Endoscopic sphincterotomy with sphincteroplasty for the management of choledocholithiasis: a single-centre experience.

BACKGROUND: Balloon dilatation of the ampulla at endoscopic retrograde cholangiopancreatography (ERCP) is increasingly utilized in the management of large bile duct stones. The aim of this study was to review and compare the outcomes of using endoscopic sphincterotomy with endoscopic balloon dilatation (sphincteroplasty) in a combined approach as a single-stage (immediate) or a two-stage procedure (delayed). METHODS: A retrospective review of medical records for all patients undergoing ERCP and balloon dilatation for choledocholithiasis between January 2010 and December 2012 was undertaken. Outcomes measured included patient demographics, stone size, degree of dilatation performed, success of stone extraction, number of procedures required for duct clearance and procedure-related complications. RESULTS: One hundred and thirty-six ERCPs were performed with balloon sphincteroplasty. One hundred and four had a previous sphincterotomy with a delayed balloon dilatation and 32 had sphincterotomy with immediate dilatation. The overall clearance rate of the common bile duct for immediate and delayed groups was 93% (28/30) and 93% (81/87), respectively. Bile duct clearance after the first procedure was achieved in 70% (21/30) of patients in the immediate group and 74% (64/87) in the delayed group. There were six complications in the delayed group and four in the immediate group. The most frequently used balloon size was 10 mm for both groups with mean sizes of 10.34 (2.93) and 11.73 (2.87) in the immediate and delayed groups, respectively. CONCLUSION: Our study suggests that use of a combined approach is safe and effective and may provide benefits over using endoscopic balloon dilatation or endoscopic sphincterotomy alone in the treatment of choledocholithiasis.

Endoscopic management of post-cholecystectomy biliary fistula.

OBJECTIVE: Bile duct injury is an uncommon but potentially serious complication in cholecystectomy. A recognized treatment for minor biliary injury is internal biliary decompression by endoscopic retrograde cholangiopancreatography (ERCP) and stent insertion. The aim of this study was to assess the effectiveness of ERCP in the management of minor biliary injuries. METHODS: A retrospective review of medical records at a tertiary referral centre identified 36 patients treated for postoperative minor biliary injuries between 2006 and 2010. Management involved establishing a controlled biliary fistula followed by ERCP to confirm the nature of the injury and decompress the bile duct with stent insertion. RESULTS: Controlled biliary fistulae were established in all 36 patients. Resolution of the bile leak was achieved prior to ERCP in seven patients, and ERCP with stent insertion was successful in 27 of the remaining 29 patients. Resolution of the bile leak was achieved in all patients without further intervention. The median time to resolution after successful ERCP was 4 days. Two patients underwent ERCP complicated by mild pancreatitis. No other complications were seen. CONCLUSIONS: This review confirms that postoperative minor biliary injuries can be managed by sepsis control and semi-urgent endoscopic biliary decompression.

Benign gastro-colic fistula in a woman presenting with weight loss and intermittent vomiting: a case report.

INTRODUCTION: Benign gastro-colic fistula is a rare occurrence in modern surgery due to the progress in medical management of gastric ulcer disease. Here we report the first case of benign gastro-colic fistula occurring whilst on proton-pump inhibitor therapy. This is a case study of benign gastro-colic fistula and review of the available literature in regards to etiology, diagnosis, management and prognosis. CASE PRESENTATION: An 84-year-old woman of Caucasian background presented with 12 months of worsening abdominal pain, nausea, vomiting, diarrhea and weight loss on a background of known gastric ulcer disease. CONCLUSION: The leading cause of gastro-colic fistulae has changed from benign to malignant due to improved medical management of gastric ulcer disease. The rarity and non-specific symptoms of gastro-colic fistula make the diagnosis difficult and it is best made by barium enema; however, computed tomography has not been formally evaluated. Surgical management with en bloc resection of the fistula tract is the preferred treatment. Benign gastro-colic fistulae are becoming exceedingly rare in the context of modern medical management of gastric ulcer disease. Surgical management is the gold standard for both benign and malignant disease.

Percutaneous cystic duct stent placement in the treatment of acute cholecystitis.

Percutaneous cholecystostomy is well established as a temporising treatment option in selected patients presenting with acute cholecystitis. However, some patients who undergo cholecystostomy will have persistent discharge, which precludes catheter removal, or may not be medically suitable for future cholecystectomy. In these circumstances, percutaneous cystic duct stenting isa novel treatment option. It may delay or avoid the need for cholecystectomy, and thereby provide definitive treatment in a subset of patients who have acute cholecystitis and a high anaesthetic risk or limited life expectancy. Current application has been limited largely to patients with pre-existing malignant common bile duct strictures, but there is potential for the application to be broadened to include other subsets of patients. In this paper, we describe the technique used for percutaneous cystic duct stenting in a patient and report on its effectiveness. We also explore the technical considerations and consider the application of the procedure on other groups of patients.

Five-year follow-up of a multicenter, double-blind randomized clinical trial of laparoscopic Nissen vs anterior 90 degrees partial fundoplication.

HYPOTHESIS: Laparoscopic 90 degrees anterior partial fundoplication for gastroesophageal reflux disease achieves equivalent results to laparoscopic Nissen fundoplication. DESIGN: A multicenter, prospective, double-blind randomized clinical trial with a minimum of 5 years' follow-up. SETTING: Nine university teaching hospitals in 6 major cities throughout Australia and New Zealand. PARTICIPANTS: One hundred twelve patients undergoing primary antireflux surgery were randomized to undergo either laparoscopic Nissen fundoplication (52 patients) or anterior 90 degrees partial fundoplication (60 patients). INTERVENTIONS: Laparoscopic Nissen fundoplication with division of the short gastric vessels or laparoscopic anterior 90 degrees partial fundoplication. MAIN OUTCOME MEASURES: Blinded assessment at 1 and 5 years' follow-up of clinical outcome for postoperative heartburn, dysphagia, gas-related symptoms, and satisfaction with the surgical outcome. Analog scales ranging from 0 to 10 were used to assess symptom severity. RESULTS: Ninety-seven patients underwent follow-up at 5 years. Three others died during follow-up, 4 refused follow-up, and 8 were lost to follow-up; 89% remained at 5-years' follow-up. At 5 years' follow-up, mean analog scores for heartburn were 2.2 for anterior fundoplication vs 0.9 for Nissen fundoplication (P=.003). There were no significant differences between the groups for dysphagia scores. The mean score for outcome satisfaction was 7.1 after anterior fundoplication vs 8.1 after Nissen fundoplication (P=.18). Eighty-eight percent reported a good or excellent outcome following Nissen fundoplication vs 77% following anterior fundoplication. CONCLUSIONS: Laparoscopic Nissen and anterior 90 degrees partial fundoplication achieve similar levels of patient satisfaction at 5 years' follow-up, with similar adverse effect profiles. However, at 5 years' follow-up, laparoscopic Nissen fundoplication achieves superior control of reflux symptoms. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Register Identifier: ACTRN12607000298415.

Oesophagectomy for tumours and dysplasia of the oesophagus and gastro-oesophageal junction.

BACKGROUND: Neoadjuvant therapy, radical lymphadenectomy and treatment in high-volume centres have been proposed to improve outcomes for resectable oesophageal tumours. The aim of the present study was to review the oesophagectomy experience of a single surgeon with a moderate caseload who uses neoadjuvant therapy selectively and performs a conservative lymphadenectomy. METHODS: A retrospective review of prospectively collected data was performed. The study included 125 consecutive attempted oesophageal resections performed by a single surgeon (RC) from 1993 to 2006. RESULTS: All patients were staged with computed tomography and also laparoscopy for lower third and junctional tumours. Endoscopic ultrasound was used in 69%. Seventy-seven per cent were adenocarcinomas. Neoadjuvant therapy was used selectively in 23%. One hundred and twenty-one resections were carried out, giving an overall resection rate of 97% with an R0 resection in 82%. In-hospital mortality was 0.8%, clinical anastomotic leak 1.7% and median length of stay 14 days. Overall median and 5-year survival were 46 months and 47%. Stage-specific 5-year survival was 100%, 71%, 41% and 21% for stages 0, I, II and III, respectively. Isolated local recurrence occurred in 8%. CONCLUSIONS: A moderate volume surgeon with specialist training in oesophageal resectional surgery can achieve a low mortality and anastomotic leak rate with good survival outcomes. The role for neoadjuvant therapy and radical lymphadenectomy is controversial and remains to be clearly defined. Accurate preoperative staging is essential for selection of patients for curative surgery with or without neoadjuvant therapy and for comparison of results.

Myotomy for achalasia: to wrap or not to wrap?

One of the potential consequences of carrying out a Heller's myotomy for achalasia is gastro-oesophageal reflux. Whether it is frequent or severe enough to warrant the routine addition of a fundoplication to the operation is debated. In this prospective series of all patients undergoing a myotomy using a minimally invasive method the incidence of gastro-oesophageal reflux disease is examined. It was found that in 124 patients who had been followed for at least 6 months, whereas mild heartburn was common (51 patients; 41%), in only 10 patients (8.2%) was a proton pump inhibitor required and there were no patients whose reflux was not controlled using standard medical treatment. Peptic oesophagitis was an infrequent endoscopic finding with only 3 of 40 patients with no or mild heartburn having mild oesophagitis and no patient on a proton pump inhibitor having active peptic oesophagitis. These findings suggest that the addition of a fundoplication to a Heller's myotomy to prevent gastro-oesophageal reflux disease is not essential.

Endoscopic management of recurrent primary bile duct stones.

BACKGROUND: The management of recurrent choledocholithiasis today remains as challenging as in the pre-endoscopic era. Between 2 and 7% of affected patients have historically required surgical intervention for the treatment of recurrent or retained choledocholithiasis and of these, as many as 24% develop biliary complications. To avoid surgery, repeated endoscopic management of the problem has been suggested. In this study, we evaluate our policy of repeated endoscopic management of recurrent primary bile duct stones. METHODS: This study examined a cohort of nine patients identified from a prospective database with recurrent choledocholithiasis. Demographic, clinical and investigative details were recorded and data were analysed. Complications were determined from a review of the patient's file. RESULTS: There were nine patients and 66 procedures were carried out. Mean age at time of first endoscopy was 70.1 years (36-91 years). Three patients were of male sex (33.3%). The mean number of endoscopies carried out per patient was 7.3 (3-13). Failure to completely clear the duct occurred in 36.4% of all endoscopies. There were no periprocedural complications. CONCLUSION: Repeated endoscopic stone extraction by endoscopic retrograde cholangiopancreatography when required is a safe policy. However, this technique will only provide temporary relief from primary duct stones and repeated endoscopic treatment, again safe, will be required.

Quality of life following laparoscopic anterior 90 degrees versus Nissen fundoplication: results from a multicenter randomized trial.

BACKGROUND: The short-term clinical outcomes from a multicenter prospective randomized trial of laparoscopic Nissen versus anterior 90 degrees partial fundoplication have been reported previously. These demonstrated a high level of satisfaction with the overall outcome following anterior 90 degrees fundoplication. However, the results of postoperative objective tests and specific clinical symptoms are not always consistent with an individual patient's functional status and general well being following surgery, and quality of life (QOL) is also an important outcome to consider following surgery for reflux. Hence, QOL information was collected in this trial to investigate the hypothesis: improvements in QOL following laparoscopic antireflux surgery are greater after anterior 90 degrees partial fundoplication than after Nissen fundoplication. METHODS: Patients undergoing a laparoscopic fundoplication for gastro-esophageal reflux at one of nine university teaching hospitals in six major cities in Australia and New Zealand were randomized to undergo either laparoscopic Nissen or anterior 90 degrees partial fundoplication. Quality of life before and after surgery was assessed using validated questionnaires - the Short Form 36 general health questionnaire (SF36) and an Illness Behavior Questionnaire (IBQ). Patients were asked to complete these questionnaires preoperatively and at 3, 6, 12 and 24 months postoperatively. RESULTS: One hundred and twelve patients were randomized to undergo a Nissen fundoplication (52) or a 90 degrees anterior fundoplication (60). Patients who underwent anterior fundoplication reported significant improvements in eight of the nine SF36 scales compared to four of the nine following a Nissen fundoplication. The majority of these improvements occurred early in the postoperative period. With respect to the illness behavior data, there were no significant differences between the two procedures. Both groups had a significant improvement in disease conviction scores at all time points compared to their preoperative scores. CONCLUSIONS: Patients undergoing laparoscopic anterior 90 degrees partial fundoplication reported more QOL improvements in the early postoperative period than patients undergoing a Nissen fundoplication. However, the QOL outcome for both procedures was similar at later follow-up.

Percutaneous cholecystostomy in the management of acute cholecystitis.

BACKGROUND: Percutaneous cholecystostomy (PC) has been used in managing acute cholecystitis in the setting of a patient with severe comorbidities where emergency cholecystectomy would carry significant mortality. The present study aims to assess the role, efficacy and complications of PC in acute cholecystitis. METHODS: Retrospective review of case notes of patients who underwent PC at Box Hill Hospital, Melbourne, Australia between July 1997 and December 2002. RESULTS: Sixteen patients (mean age 75 years; range 50-96) underwent PC. Indications for PC were significant comorbidities (n = 6), failure of conservative treatment (n = 4), bile duct malignancy (n = 2), sepsis of unknown origin (n = 2), patient declined surgery (n = 1) and local perforation (n = 1). Technical success rate was 94%. Clinical response to PC was observed in 15 patients. Overall mortality was 18% (3/16) with one death caused by PC failure. Interval cholecystectomy was performed in seven patients (44%). CONCLUSIONS: Percutaneous cholecystostomy is a useful alternative means of treating non-resolving acute cholecystitis in circumstances where emergency surgery is hazardous. It also offers effective palliation in patients not suitable for subsequent surgery.

Multicenter, prospective, double-blind, randomized trial of laparoscopic nissen vs anterior 90 degrees partial fundoplication.

HYPOTHESIS: Laparoscopic anterior 90 degrees partial fundoplication for gastroesophageal reflux is associated with a lower incidence of postoperative dysphagia and other adverse effects compared with laparoscopic Nissen fundoplication. DESIGN: A multicenter, prospective, double-blind, randomized controlled trial. SETTING: Nine university teaching hospitals in 6 major cities in Australia and New Zealand. PARTICIPANTS: One hundred twelve patients with proven gastroesophageal reflux disease presenting for laparoscopic fundoplication were randomized to undergo either a Nissen (52 patients) or an anterior 90 degrees partial procedure (60 patients). Patients with esophageal motility disorders, patients requiring a concurrent abdominal procedure, and patients who had undergone previous antireflux surgery were excluded from this study. INTERVENTIONS: Laparoscopic Nissen fundoplication with division of the short gastric vessels or laparoscopic anterior 90 degrees partial fundoplication. MAIN OUTCOME MEASURES: Independent assessment of dysphagia, heartburn, and overall satisfaction 1, 3, and 6 months after surgery using multiple clinical grading systems. Objective measurement of esophageal manometric parameters, esophageal acid exposure, and endoscopic assessment. RESULTS: Postoperative dysphagia, and wind-related adverse effects were less common after a laparoscopic anterior 90 degrees partial fundoplication. Relief of heartburn was better following laparoscopic Nissen fundoplication. Overall satisfaction was better after anterior 90 degrees partial fundoplication. Lower esophageal sphincter pressure, acid exposure, and endoscopy findings were similar for both procedures. CONCLUSIONS: At the 6-month follow-up, laparoscopic anterior 90 degrees culine partial fundoplication is followed by fewer adverse effects than laparoscopic Nissen fundoplication with full fundal mobilization, and it achieves a higher rate of satisfaction with the overall outcome. However, this is offset to some extent by a greater likelihood of recurrent gastroesophageal reflux symptoms.

Oesophagectomy for early adenocarcinoma and dysplasia arising in Barrett's oesophagus.

BACKGROUND: Oesophagectomy for high-grade dysplasia is controversial. METHODS: A prospective study was carried out on all patients who presented between 1993 and 2001 with dysplasia or early adeno-carcinoma who were considered fit for surgery. Details of endoscopic biopsies, appearance, surveillance, operative pathology and outcome were recorded. RESULTS: Of 18 patients, one had low-grade dysplasia, six had high-grade dysplasia and 11 had early adenocarcinoma. No patient had their biopsy diagnosis down-staged following final pathology, but two patients with high-grade dysplasia on biopsy were upstaged to adenocarcinoma. Our only death from disease occurred in a 39-year-old man who had undergone yearly surveillance for 86 months until adenocarcinoma was confirmed. There was no operative mortality. CONCLUSION: Oesophagectomy for early adenocarcinoma and dysplasia in Barrett's oesophagus can be done with acceptable rates of mortality and morbidity. Surveillance until adenocarcinoma is confirmed does not guarantee curable disease.