Laparoscopy as a day-case procedure in patients with liver disease.
Unal G. van Buuren HR. de Man RA.
Dept. of Hepatogastroenterology, Rotterdam University Hospital, The Netherlands.
BACKGROUND AND STUDY AIMS: The present study was aimed at exploring the feasibility of diagnostic laparoscopy on a day-case basis in patients with liver disease. PATIENTS AND METHODS: Retrospective analysis was carried out of 85 consecutive day-case laparoscopies performed between January 1990 and January 1994. During this period, patients were observed in day-care facilities for a period of three hours. Patients' perception and acceptance of the procedure were assessed using a postal questionnaire. RESULTS: Laparoscopy was successful in 84 of the 85 patients; adequate liver biopsies were obtained in 83 patients. In three cases, the procedure was converted to a one-night hospital admission because of pain (1), persistent sedation (1) and collapse (1). Abdominal skin hematomas were reported by eight patients, and fever by two. Serious complications were not observed. The majority of patients experienced no complaints, or minor ones, after the procedure, and they expressed a preference for an outpatient procedure in case a renewed investigation might be indicated. Compared with in-hospital procedures, day-case laparoscopy was associated with a 33% reduction in cost. CONCLUSIONS: Diagnostic laparoscopy, with the hospital stay reduced to three hours, can be performed safely as a day-case procedure in selected patients.
Does laparoscopic cardiomyotomy require an antireflux procedure?
Kumar V. Shimi SM. Cuschieri A.
Dept. of Surgery, Ninewells Hospital and Medical School, University of Dundee, United Kingdom.
BACKGROUND AND STUDY AIMS: There is controversy concerning the need for an antireflux procedure in patients undergoing open or endoscopic cardiomyotomy for achalasia. The addition of an antireflux wrap (partial or total), while preventing reflux, may result in persistence or incomplete relief of dysphagia in patients with total oesophageal aperistalsis. The technique of laparoscopic cardiomyotomy used in Dundee preserves the lateral and posterior attachments of the gastro-oesophageal junction, and was designed to minimize the risk of gastro-oesophageal reflux. PATIENTS AND METHODS: A consecutive series of patients with achalasia (n = 19) were treated by laparoscopic cardiomyotomy using the Dundee technique, which limits the mobilization to the anterior wall of the abdominal and thoracic oesophagus. The patients were followed up prospectively to assess the long-term relief of dysphagia and the postoperative incidence of reflux symptoms, with or without oesophagitis. RESULTS: The follow-up symptoms and assessment of the patients (15-53 months, median 27 months) showed total relief (n = 12) or substantial relief (n = 5) of dysphagia in 89%. On assessment at a median follow-up of 27 months, the number of patients experiencing heartburn after this operation increased from four of 15 to five of 15, and one patient (6.6%) developed endoscopically proved oesophagitis, with a positive oesophageal pH monitoring test. CONCLUSIONS: The routine addition of an antireflux operation is not justified in patients undergoing laparoscopic cardiomyotomy, provided that the lateral and posterior attachment of the oesophagus are kept intact.
Endoscopic papillary balloon dilation for the management of common bile duct stones: experience of 226 cases.
Komatsu Y. Kawabe T. Toda N. Ohashi M. Isayama M. Tateishi K. Sato S. Koike Y. Yamagata M. Tada M. Shiratori Y. Yamada H. Ihori M. Kawase T. Omata M.
Second Department of Internal Medicine, Faculty of Medicine, University of Tokyo, Japan.
BACKGROUND AND STUDY AIMS: Endoscopic sphincterotomy is a widely accepted technique for the treatment of patients with common bile duct stones. However, it is still associated with occasional complications. The recently developed technique of endoscopic papillary balloon dilation seems to be a safe and effective procedure, and to have great potential for replacing endoscopic sphincterotomy. However, few reports have been published on the use of this technique for bile duct stones. The present study was undertaken to evaluate its safety and efficacy. PATIENTS AND METHODS: Endoscopic papillary balloon dilation was used to remove common bile duct stones in 226 consecutive patients including 41 patients of ASA classification III/IV, 41 elderly patients (> 80 years) 24 with liver cirrhosis, and 86 with periampullary diverticulum. After dilation of the papilla with a balloon diameter of 8 mm, the stones were retrieved. RESULTS: In conjunction with the use of a mechanical or/and electrohydraulic lithotriptor in 79 patients (35%) with large stones (> 10 mm in diameter), clearance of the common bile duct was achieved in 225 of 226 patients (99%) without serious complications, such as hemorrhage or severe pancreatitis; mild (n = 13) or moderate (n = 2) pancreatitis occurred in 7% of cases. CONCLUSIONS: Endoscopic papillary balloon dilation is a safe and effective technique for the treatment of common bile duct stones, even in high-risk patients.
The role of surveillance endoscopic retrograde cholangiopancreatography in preventing episodic cholangitis in patients with recurrent common bile duct stones.
Geenen DJ. Geenen JE. Jafri FM. Hogan WJ. Catalano MF. Johnson GK. Schmalz MJ.
Pancreatic Biliary Center, St. Luke's Medical Center, Milwaukee, Wisconsin, USA.
BACKGROUND AND STUDY AIMS: Approximately 2-7% of patients who have undergone previous removal of bile duct stones have recurrence often presenting as ascending cholangitis. The aim of this study was to identify the incidence, clinical presentation, and objective findings in this group of patients. Additionally, the effect of surveillance endoscopic retrograde cholangiopancreatography (ERCP) in preventing cholangitis, was studied. PATIENTS AND METHODS: Two thousand and ninety-six patients who underwent ERCP for cholelithiasis were studied with 45 of these patients being identified as having recurrent common bile duct stones. Of the 45, 13 had two or more recurrences without having any obvious predisposing factors. The mean age of the 13 patients was 57 years. The characteristics of 13 patients were reviewed, including sphincterotomy size, liver function tests, and contrast drainage time. RESULTS: All 13 patients with recurrent stones presented with ascending cholangitis. Stones were found to be soft, brown and accompanied by a large amount of sludge. The common bile duct in all 13 patients was noted to be dilated and had notable, widely patent sphincterotomes. There was significant delayed drainage in 77% of these patients. Yearly surveillance ERCPs were performed in the 13 patients, the incidence of acute cholangitis episodes per patient decreased from 2 to 0.6 with a four-year follow-up. CONCLUSION: In a subgroup of patients with multiple common bile duct stone recurrences, annual surveillance ERCP with stone removal decreases the incidence of recurrent episodes of ascending cholangitis as well as its associated morbidity and mortality.
Effect of large fundal varices on changes in gastric mucosal hemodynamics after endoscopic variceal ligation.
Tayama C. Iwao T. Oho K. Toyonaga A. Tanikawa K.
Dept. of Medicine II, Kurume University School of Medicine, Japan.
BACKGROUNDS AND STUDY AIMS: Effect of endoscopic variceal ligation (EVL) on gastric mucosal hemodynamics would differ in patients with and without large fundal varices. The aim of this study was to test this hypothesis. PATIENTS AND METHODS: Twenty-seven patients with cirrhosis and large sized esophageal varices were prospectively studied. There were eight patients with large fundal varices and 19 patients without large fundal varices. Before EVL, gastric mucosal hemodynamics were endoscopically assessed by laser-Doppler velocimetry and reflectance spectrophotometry in the antrum and the corpus. In the reflectance spectrophotometric measurements, gastric mucosal hemoglobin content (IHb) and gastric mucosal oxygen saturation (ISO2) were determined. The severity of portal-hypertensive gastropathy (PHG) was also recorded at the antrum and the corpus. For data analysis, PHG was scored (absent, 0; mild, 1; severe, 2; bleeding, 3). These measurements were repeated after initial (three days after initial session) and repeated (seven days after last session) EVL. RESULTS: At the antrum, neither PHG score nor gastric mucosal hemodynamic parameters were modified after initial and repeated EVL in patients with and without large fundal varices. In addition, no significant differences of the integrated changes in PHG score and gastric mucosal hemodynamic parameters were observed in the two groups. At the corpus, PHG score significantly increased after initial and repeated EVL in patients without large fundal varices. In these patients, laser-Doppler signal and ISO2 significantly decreased and IHb significantly increased after initial and repeated EVL. In contrast, PHG score, laser-Doppler signal, and ISO2 did not change significantly in patients with large fundal varices, although IHb transiently increased after initial EVL. Furthermore, the integrated changes in PHG score and gastric mucosal hemodynamic parameters were significantly lower in patients with large fundal varices than in those without. CONCLUSION: The aggravation of PHG after EVL is due to congestion of the gastric mucosal circulation. The presence of large fundal varices plays a protective role in the development of EVL-induced gastric mucosal hemodynamic derangement.
Endosonography-guided biopsy of mediastinal and pancreatic tumors.
Hunerbein M. Dohmoto M. Haensch W. Schlag PM.
Virchow Klinik, Robert Rossle Hospital and Tumor Institute, Humboldt University, Berlin, Germany.
BACKGROUND: Although endoscopic ultrasound (EUS) allows sensitive imaging of the upper gastrointestinal (GI) tract, it remains difficult to differentiate between benign and malignant lesions on the basis of ultrasound morphology. The purpose of this study was to determine the value of EUS-guided biopsy for the diagnosis of submucosal and extraluminal tumors. METHODS: EUS-guided biopsy was carried out in 50 patients with upper GI-tract lesions. All patients were examined using a flexible echoendoscope with a 5/7.5 MHz curved array transducer. A specially designed biopsy device (type Vilmann) with a fine needle (diameter 0.8 mm) was used for EUS-guided biopsy. RESULTS: EUS-guided biopsy was performed for evaluation of mediastinal lesions (n = 15), pancreatic tumors (n = 26) and submucosal (n = 5) or stenotic tumors of the esophagus (n = 4). Fine-needle aspiration yielded diagnostic tissue samples in 44 of 50 patients (88%). Histology demonstrated benign lesions in 20 of 44 patients and malignant tumors in the other 24 patients. EUS-guided biopsy failed in only six patients (12%): in four patients it was impossible to advance the needle into very hard pancreatic tumors; non-representative biopsy material was obtained in two further cases. The results of EUS-guided biopsy were validated by surgery (n = 21), autopsy (n = 3) or clinical follow-up (n = 20). After a mean follow-up of 16 months there is no evidence of malignancy in any of the patients with benign histology. The sensitivity and specificity of EUS-guided biopsy in the diagnosis of malignancy were 88% and 100%, respectively. None of the patients experienced complications related to endosonographic biopsy. CONCLUSIONS: EUS-guided biopsy with the Vilmann needle device is a safe and accurate method for tissue sampling of extraluminal lesions. This technique considerably improves the diagnostic value of endosonography.
The treatment of cricopharyngeal dysmotility with a transmucosal cricopharyngeal myotomy using the potassium-titanyl-phosphate (KTP) laser.
Dept. of Surgery, University of Alabama at Birmingham, USA.
Cricopharyngeal dysfunction is a relatively uncommon disorder that is misunderstood by many physicians. Cricopharyngeal dysmotility is thought to indicate abnormal function in the upper esophageal or cricopharyngeal sphincter, the etiology of which is related to uncoordinated pharyngeal swallowing, achalasia, or a combination of these factors. Unfortunately, standard diagnostic tests do not consistently show that the cricopharyngeal sphincter malfunctions; so cricopharyngeal myotomy has been suggested as a diagnostic and therapeutic tool in the treatment of dysmotility. The current report reviews trends in the diagnosis and treatment of cricopharyngeal myotomy, including the results of cricopharyngeal myotomy using the potassium-titanyl-phosphate (KTP) laser. A transmucosal cricopharyngeal myotomy with the KTP laser may be a viable alternative for patients with cricopharyngeal dysmotility compared with conventional techniques.
Iodine staining for early endoscopic detection of esophageal cancer in alcoholics.
Ban S. Toyonaga A. Harada H. Ikejiri N. Tanikawa K.
Dept. of Medicine II, Kurume University School of Medicine, Japan.
BACKGROUND AND STUDY AIMS: A retrospective epidemiological investigation has demonstrated that alcohol abuse is a major risk factor for esophageal cancer. However, prospective endoscopic screening for early detection in heavy drinkers is not available at present. PATIENTS AND METHODS: A prospective study was conducted that included 255 alcoholics (aged 52 +/- 9 years). The patients were consecutively screened using esophagoscopy with iodine staining and targeted biopsy. The study also explored whether there was a relationship between the amount of alcohol intake and the detection rate of esophageal cancer. RESULTS: Unstained lesions (larger than 5 mm) were observed on the esophageal wall in 55 patients (21.6%). Ten patients (3.9%) with 13 lesions were found to have esophageal cancer of the superficial type, with no symptoms. Cancer invasion was confined to the epithelium in three patients, to the lamina propria in seven, and to the submucosa in three. There was a direct relationship between substantial alcohol intake and the presence of esophageal cancer. CONCLUSION: Screening esophagoscopy with iodine staining is very advantageous in detecting esophageal cancer at an early stage.
Photodynamic therapy of early squamous cell carcinomas of the esophagus: a review of 31 cases.
Savary JF. Grosjean P. Monnier P. Fontolliet C. Wagnieres G. Braichotte D. van den Bergh H.
Dept. of Otolaryngology, Head and Neck Surgery, CHUV Hospital, Lausanne, Switzerland.
BACKGROUND AND STUDY AIMS: Patients with cancers of the head and neck have a strong tendency to develop early synchronous and metachronous carcinomas of the esophagus. In many of these patients, whose general condition is poor as a result of alcohol and tobacco abuse, the second primary cancers require minimally invasive treatment. The aims of this study were to evaluate the efficacy of photodynamic therapy for the treatment of early esophageal carcinomas and to compare the results obtained with three different photosensitizers (hematoporphyrin derivative), porfimer sodium (Photofrin II), and meta-(tetrahydroxyphenyl)chlorin (m-THPC). PATIENTS AND METHODS: Thirty-one early squamous cell carcinomas (Tis or T1a) of the esophagus were treated by photodynamic therapy in 24 patients. Nine tumors were treated with hematoporphyrin derivative, eight with Photofrin II and 14 with m-THPC. RESULTS: The early cancers were cured in 84% of patients after a mean follow-up period of 2 years. Because the number of cases included in each group was small, the differences in recurrence rates for the different photosensitizers could not be evaluated statistically, but m-THPC was more phototoxic, induced a shorter period of photosensitization of the skin, and had better selectivity than either of the other photosensitizers. There were four major complications: two stenoses and two esophagotracheal fistulas. CONCLUSIONS: Photodynamic therapy eradicates early squamous cell carcinomas (Tis and T1a) of the esophagus efficiently. Transmural necroses leading to fistulas can be avoided by using a low-penetrating wavelength of laser light (green light at 514.5 m instead of red light at 630 or 652 nm). Stenoses always result from circumferential irradiation of the esophageal wall, and this can be avoided by using a 180 degrees or 240 degrees windowed cylindrical light distributor.
Palliation of malignant gastric and small intestinal strictures with self-expandable metal stents.
Yates MR 3rd. Morgan DE. Baron TH.
Dept. of Medicine, University of Alabama, Birmingham Medical Center, USA.
BACKGROUND: Malignant gastrointestinal obstruction is a common preterminal event that is often treated surgically. The use of self-expandable stents to treat malignant gastric and small intestinal strictures is limited. We evaluated the feasibility, effectiveness, safety and outcome of self-expandable metal stents in providing palliative care for patients with inoperable malignant strictures of the stomach and small intestine. METHODS: Eleven consecutive patients with complete or near complete gastric or small intestinal obstruction were treated palliatively with self-expandable metal stents. Contrast radiographs were taken before and after insertion in all patients to confirm patency. Nineteen stents were placed using biliary guidewires and catheters under endoscopic and fluoroscopic guidance. Diets were modified as needed. Success was defined both technically and clinically. RESULTS: Technical and clinical success with improvement in the patient's oral diet was achieved in ten patients (91%). The one failure was caused by severe anastomotic angulation and distal luminal obstruction. During the follow-up of 5 to 294 days (mean 77 days) there were no major complications except that the stents occluded in four patients. CONCLUSION: Palliation of malignant gastric and small intestinal strictures with self-expandable metal stents is a feasible, effective, and safe alternative to operation.
Is pancreatoscopy of any benefit in clarifying the diagnosis of pancreatic duct lesions?
Jung M. Zipf A. Schoonbroodt D. Herrmann G. Caspary WF.
Innere Abteilung, St. Hildegardis-Krankenhaus, Mainz, Germany.
BACKGROUND AND STUDY AIMS: Modern fine-caliber endoscopes enable clinicians to directly visualize the pancreatic duct. They allow intraductal manipulation under optical control. We tried to evaluate the additional diagnostic potential of pancreatoscopy in assessing inconclusive intraductal pancreatic changes. PATIENTS AND METHODS: We prospectively performed 20 pancreatoscopies in 18 patients with inconclusive ductal abnormalities that had been previously investigated by computed tomography (CT) scan, abdominal ultrasound and endoscopic retrograde cholangiopancreatography (ERCP). The CHF-BP 30 (Olympus Optical Co., Japan) endoscope with an outer diameter of 3.1 mm and an instrumentation channel of 1.2 mm was used. Biopsies, cytological brushing and fluid collection were carried out, and the site of ductal abnormality was visualized. Endoscopic sphincterotomy (EST) was carried out in every patient prior to insertion of the pancreatoscope. RESULTS: Seven intraductal tumors were histologically confirmed, i.e. five intraductal papillary mucinous tumors and two adenocarcinomas. Benign appearance of the intraductal lesion plus negative histopathological examinations were confirmed by a follow-up of two years in eight patients. Five had chronic pancreatitis, and a further three had pancreatitis with strictures, blood clot obstruction, and idiopathic benign stricture, respectively. There were no complications with the exception of one bleeding episode after EST; no pancreatitis occurred. CONCLUSIONS: Pancreatoscopy is of diagnostic value in addition to CT, transabdominal ultrasound and ERCP in the differential diagnosis of poorly defined pancreatic lesions, particularly when assessing alterations of the ductal caliber without parenchymatous lesions.
Limitations of percutaneous transhepatic cholangioscopy for the diagnosis of the intramural extension of bile duct carcinoma.
Sato M. Inoue H. Ogawa S. Ohashi S. Maetani I. Igarashi Y. Sakai Y.
Third Department of Internal Medicine, Ohashi Hospital, Toho University School of Medicine, Tokyo, Japan.
BACKGROUND AND STUDY AIMS: Vascular dilatation seen on percutaneous transhepatic cholangioscopy (PTCS) is diagnostic of intramural invasive carcinoma of the bile duct, but the limitations of the technique, including biopsy, for the diagnosis of intramural extension of bile duct carcinoma have not to our knowledge been investigated before. The aims of the present study were to estimate the thickness of the specimens of bile duct wall taken by biopsy, to assess the sensitivity of PTCS for detecting intramural invasive carcinoma, and to identify the characteristics of the intramural extension of bile duct carcinoma associated with vascular dilatation. PATIENTS AND METHODS: A total of 135 biopsy, and 16 surgical specimens obtained from 25 bile duct carcinomas were examined for: the thickness of the biopsy specimens and of the mucosa and combined mucosal-fibromuscular layers in the resected common bile ducts and common hepatic ducts; the presence of muscular and neural bundles in the biopsy specimens; the number of invasive carcinomas in the biopsy specimens that had been taken from stenosed regions; and the relation between intramural extension of invasive carcinoma and vascular dilatation. RESULTS: The mean thickness of the biopsy specimens did not differ from the mean thickness of the mucosa in the resected specimens, but was significantly lower than that of the combined mucosa and fibromuscular layer. Muscular bundles were included in only 13 (14%) of the biopsy specimens, and there were no neural bundles. Carcinomas and invasive carcinomas were diagnosed histologically from the biopsy specimen in 96% and 91% of the cases, respectively. The sensitivity of a single biopsy for diagnosis for invasive carcinoma in stenosed regions was 62%, almost the same as the sensitivity in non-stenosed regions with vascular dilatation (68%). On histologic examination of 16 resected specimens, the sensitivity and specificity of vascular dilatation as a marker of the intramural extension of an invasive carcinoma were 39% and 100%, respectively, and this was significantly more common in invasive carcinomas that were invading the mucosa beyond the adventitia than in those limited to the adventitia. CONCLUSION: Histologic examinations of specimens obtained by PTCS-guided biopsy can detect invasive carcinoma in only the superficial layers of the bile duct, such as the mucosa and the shallowest fibromuscular layer. Multiple specimens are needed for the diagnosis of invasive carcinoma because the sensitivity of examination of a single specimen for detecting invasive carcinoma is low. Vascular dilatation is characteristic of carcinoma that is invading the mucosa beyond the adventitia, so the diagnosis of intramural extension of bile duct carcinoma limited to the adventitia, particularly if it has spread to the deeper fibromuscular layer and the adventitia, is difficult to make by PTCS.
Percutaneous transhepatic cholelithotripsy for difficult common bile duct stones.
Stage JG. Moesgaard F. Gronvall S. Stage P. Kehlet H.
Dept. of Surgical Gastroenterology, Hvidovre University Hospital, Denmark.
BACKGROUND AND STUDY AIMS: A study was carried out to assess the feasibility of a new rapid technique for percutaneous transhepatic access to the biliary tract with endoscopic lithotripsy (percutaneous transhepatic cholelithotripsy). PATIENTS AND METHODS: 14 patients with biliary stones resistant to endoscopic retrograde cholangiography and extracorporeal shock wave lithotripsy underwent cholelithotripsy, utilizing a new dilation kit with massive teflon dilators covered by "peel-away sheets". RESULTS: Successful lithotripsy was performed in all patients by laser lithotripsy through a choledochoscope or ureteroscope in ten patients and by stone removal by basket in the remaining four patients. The procedure was carried out using local anesthesia in the last 11 patients. Except for two patients with transient cholangitis, no complications occurred. CONCLUSIONS: Difficult bile duct and intrahepatic stones can be treated successfully with a simple percutaneous transhepatic cholelithotripsy procedure including local anesthesia, dilation and stone clearance.