An experimental technique of laparoscopic bowel resection and reanastomosis.

With the development of laparoscopic cholecystectomy, surgeons have been stimulated to develop techniques that allow many open surgical procedures to be performed laparoscopically. Appendectomy, hernia repair, and vagotomy have already been introduced clinically. Laparoscopic bowel resection, however, is somewhat more complicated. Bowel transection, mass tissue removal, and reanastomosis in the proper geometric fashion are critical to the success of this type of operation. The introduction of the Endo-GIA stapler (United States Surgical Corp., Norwalk, CT) will make this procedure feasible on a large-scale basis. The major problem with bowel resection is not transection or tissue removal, but, rather, reanastomosis. With intracorporeal anastomosis, manipulation of the bowel with proper orientation becomes difficult. This is less of a problem when performing low-anterior resection, however, because one of the bowel limbs is fixed. The purpose of this study was to develop a technique in the laboratory that would ensure proper orientation of the two bowel limbs, with minimal manipulation prior to performance of the anastomosis. The technique that we developed and describe herein does not require manual orientation during anastomosis. Improper bowel alignment with kinking and twisting is thereby avoided. The technique appears to be useful for small- and large-bowel resections, but not for low-anterior resection. For this technique to become a reality clinically, longer endoscopic staplers with taller staple height will be required.

Experimental transperitoneal laparoscopic pyloroplasty.

Interest in laparoscopic abdominal surgery continues to grow, which has persuaded a number of centers to pursue actively laparoscopic techniques that will allow surgeons to perform additional operative procedures in a less invasive manner. Peptic ulcer surgery, because of the morbidity associated with gastric surgery as well as the pain and discomfort associated with any major abdominal operation, has been largely replaced by pharmacologic therapy. As a result, patients are often advised to continue drug therapy indefinitely. This form of therapy, however, often only partially relieves the symptoms associated with peptic ulcer disease and leaves the patient at risk to develop life-threatening complications such as bleeding and perforation. Therefore, the rapid advances occurring in the field of laparoscopic surgery provide a fertile area for the development of simple, safe, and effective procedures to treat peptic ulcer disease in selected patients. A variety of different peptic ulcer operations have already been successfully performed under laparoscopic guidance. This report describes an experimental technique of transperitoneal stapled laparoscopic pyloroplasty using a modified end-to-end anastomotic stapling device (EEA Stapler; United States Surgical Corporation, Norwalk, CT, U.S.A.). The feasibility of this procedure was documented by detailed histologic evaluation of the pyloroplasty and revealed that the pyloric musculature had been excised, resulting in a true gastroduodenostomy. Pyloroplasty, coupled with either transabdominal or transthoracic vagotomy, could be a simple alternative to more extensive open abdominal surgery. This procedure represents one additional step in providing the practicing surgeon with the ability to perform a variety of different ulcer operations in a minimally invasive (laparoscopic) fashion.

Complications of laparoscopic cholecystectomy: a prospective review of an initial 100 consecutive cases.

In order to identify problems in concept or technique with laparoscopic cholecystectomy, a prospective analysis of the initial consecutive 100 procedures was accomplished. Ongoing review of the results led to modifications in order to improve operative outcome. Minor complications such as nausea for more than 12 h (20%) and right shoulder pain (29%) were self-limiting. There were no deaths, two bile duct injuries, two abscesses, two retained common duct stones, and one case requiring transfusion, totaling a 7% major complication rate. In the subsequent 200 laparoscopic cholecystectomies, there was a 1.5% rate of major complications. Specific measures and modifications in technique that account for this improvement are detailed. Complications of laparoscopic cholecystectomy are more frequent in initial cases but can be minimized by observing specific intraoperative principles.

Cholecystcholangiography during laparoscopic cholecystectomy: cholecystcholangiography or cystic duct cholangiography.

Laparoscopic cholecystectomy is being used more frequently in the treatment of symptomatic cholelithiasis. The procedure as originally described was performed with cystic duct cholangiography. An alternate technique of performing cholangiography is cholecystcholangiography. Because of the objections that have been voiced concerning direct gallbladder injections namely, reliability of the technique, quality of the studies, and the risk of forcing stones into the common bile duct this study was performed. Subjects were 25 consecutive patients who underwent cholecystcholangiography during laparoscopic cholecystectomy. A standard technique was developed and used. Studies were graded from 0 to 5 depending upon quality with 5 being the best and 0 the worst. A 5 consisted of visualization of all of the biliary tract structures and the duodenum and a 0 consisted of visualization of only the gallbladder. Acceptable studies (graded 3, 4, or 5) were obtained in 20 patients (80%). An inability to obtain an acceptable study could usually be determined prior to contrast injection. Accordingly there would be no time delay in proceeding directly to cystic duct cholangiography. In our patients, 48% had stones in the gallbladder smaller than the caliber of the cystic duct. Based upon the results of this study we believe that cholecystcholangiography is the technique of choice for intraoperative cholangiography during laparoscopic cholecystectomy. In patients in whom this technique is not feasible the surgeon should proceed directly to cystic duct cholangiography. There was no added risk to the patient when cholecystcholangiography was performed. There was a benefit in terms of the ease of the procedure and the performance of the procedure over cystic duct cholangiography. The determination of ductal anatomy prior to cystic duct dissection may be important in minimizing the risk of ductal injury during laparoscopic cholecystectomy.

Laser laparoscopic vagotomy and pyloromyotomy.

We performed bilateral truncal vagotomy and gastric drainage procedure using standard laparoscopic instruments in five mongrel dogs. The procedure consisted of a transthoracic thoracoscopic bilateral truncal vagotomy and transperitoneal laparoscopic pyloromyotomy. A contact Nd:YAG laser fiber was used. There was no mortality, minimal morbidity, and post-operative gastric emptying was satisfactory. Pathologic studies indicated vagotomy was complete. We believe that this may be the initial step in the development of a simple, safe, and effective endoscopic procedure for the treatment of peptic ulcer disease.

Laser laparoscopic herniorraphy: a clinical trial preliminary results.

Laser laparoscopic inguinal herniorraphy represents an extension of current technology. Based on the principles of preperitoneal inguinal herniorraphy, it is performed by internal incision of the peritoneum and identification of the musculofascial defect through a laparoscope. Polypropylene mesh is then passed down the laparoscope, placed into the defect to obliterate the space, and the edges of the peritoneum are then reapproximated. Results in 20 patients with an 11 month followup indicates success in nineteen exhibiting early resumption of activity (3.3 days) and minimal pain (2.1 Tylenol #3 tablets per patient). One early recurrence suggests that anatomic identification of a direct space hernia may be difficult and that routine support of this area with additional mesh may be a requirement of a complete inguinal hernia repair.

Laser therapy of cancer of the gastrointestinal and biliary tracts.

Endoscopic laser therapy for the palliation of malignant tumors of the gastrointestinal (GI) tract has rapidly gained widespread acceptance by the medical community. This form of therapy can offer significant tumor palliation in a relatively noninvasive manner to patients who have few other therapeutic options. Since its initial use for the treatment of esophageal cancer it has been extended to the treatment of a number of other GI, tract malignancies and has in fact been utilized for the palliation of intra- as well as extrahepatic bile duct tumors. A number of advances have occurred, including improvements in lasers and laser delivery systems, refinement of treatment techniques, development of new wavelengths, and refinement of drugs that allow more specific therapy of cancer. With continued laboratory and clinical investigations, laser therapy should realize its full potential, ultimately becoming a curative treatment modality that will offer patients benefits that are equal to or greater than more invasive and disfiguring surgery without its attendant morbidity and mortality.

Technique for placement of a totally implantable venous access device.

A totally implantable venous access system is described which greatly improved the ability to gain long-term venous access in selected patients. The external jugular approach has been demonstrated to be a safe and simple technique. The only major problem associated with the implantable venous access system was the development of one-way catheter occlusions. A number of methods for restoring catheter patency have been advocated. The use of streptokinase appears to be the most reliable and was found effective in this study. Importantly, however, catheter sepsis has been virtually eliminated with this totally implantable system.

Prograde versus retrograde endoscopic laser therapy for the treatment of malignant esophageal obstruction: a comparison of techniques.

The prograde and retrograde approaches to the treatment of malignant esophageal obstruction with the Nd:YAG, or neodymium: yttrium, aluminum, garnet, laser are compared. With the prograde technique, tumor destruction proceeds from the proximal to the distal tumor margin. In retrograde treatment, the endoscope is passed to the distal tumor margin so that the treatment can proceed in the reverse direction, thereby completing therapy in a single treatment session. This is usually accomplished by passage of a guide wire down the biopsy channel of the endoscope, tumor dilatation, and then passage of the endoscope over the guide wire to the distal tumor margin, where laser destruction is begun. Twenty nonrandomly selected patients with malignant esophageal obstruction were studied. The first ten patients were treated with the prograde technique, the next ten with the retrograde technique. The two groups were similar with respect to age, sex, and tumor histologies. Patients treated retrogradely had narrower pretreatment lumens (average 2.3 vs. 4.1 mm) as well as longer tumor lengths (average 8.9 vs. 4.8 cm). The posttreatment luminal diameters were similar for each group: 18.0 mm for prograde; 16.3 for retrograde. In the retrograde group, therapy was completed in fewer treatments (1.6 vs. 2.9) and over a shorter period of time (3.6 vs. 7.8 days), despite the longer tumor lengths. All patients in both groups were able to tolerate a regular diet at the completion of therapy. The complication rate was low in both groups. It is felt that the retrograde technique (single session therapy) is the preferred method because it allows more-rapid treatment without increased complications and thereby shortens hospital stay and reduces hospital costs.

New laser technique for the treatment of malignant esophageal obstruction.

Endoscopic laser therapy for malignant esophageal obstruction is rapidly gaining widespread acceptance by the medical community. The standard approach utilizing the neodymium: yttrium, aluminum, garnet (Nd: YAG) laser was first described by Fleischer for squamous cell carcinoma of the esophagus and subsequently for adenocarcinoma of the gastroesophageal junction. According to his technique, treatment was begun at the proximal tumor margin and proceeded distally; as many as 13 treatments were necessary to complete therapy and relieve the obstruction. A new technique has been developed utilizing tumor dilatation so that treatment can be started at the distal tumor margin working retrogradely. This new technique has allowed treatment to be completed in a single session in most patients. This rapid completion of therapy has reduced the length of hospitalization and thereby hospital costs. It has also allowed patients to aliment earlier, thereby minimizing the metabolic consequences of prolonged intravenous feedings, has allowed patients to receive other forms of therapy on an outpatient basis, and has obviated the need for the chronic placement of tubes for drainage and feeding. The technique is described and discussed.

Endoscopic laser therapy for the treatment of malignant esophageal obstruction.

Malignant esophageal obstruction in 24 patients was treated using the neodymium:ytrium, aluminum, garnet laser. There were 15 males and nine females; the average age was 70.9 years. There were 17 adenocarcinomas and seven squamous cell carcinomas, with two of these being recurrent after radiation therapy. Tumor lengths ranged from 2.5-19.0 cm, with an average of 6.7 cm. The average energy delivered per centimeter of tumor was 6,309 joules for the squamous cell carcinomas and 5,598 for the adenocarcinomas. Energy delivered per treatment ranged from 3,152 to 70,527 joules. Total energy delivered per patient depended on the volume of tumor destroyed. Esophageal lumens increased from 3.4 to 16.7 mm, and 23 patients had their diets advanced, 22 to regular and one to soft solids. Reobstruction did not occur in patients who received adjunctive therapy after laser therapy. This consisted of chemotherapy in five, surgery in two, and radiation therapy in one. Complications consisted of aspiration pneumonia in three patients, including one who developed a tracheoesophageal fistula, and one documented and two suspected perforations. Hospital stay averaged 5.4 days overall and 3.5 days in those treated with the single-session technique. This increased to 8.0 days in patients with proven or suspected perforations. Endoscopic laser therapy is a safe and effective method for palliating esophageal cancer.

Cholecystitis secondary to infusion chemotherapy.

This report centers on a patient with metastatic colorectal cancer who developed acute and chronic cholecystitis secondary to the infusion of FUDR (fluoro-deoxyuridine) into the hepatic artery. This was documented by sonography, cholescintigraphy, and, ultimately, pathologically on the surgically removed specimen. Undoubtedly, with increasing cumulative treatment days made possible through technological advances in delivery systems, this complication will be seen more frequently. Prophylactic removal of the gallbladder, at the time of pump placement, which does not significantly prolong the operative time nor increase the operative mortality, should be performed to prevent this complication from occurring.

Endoscopic laser therapy of malignant esophageal obstruction.

Malignant esophageal obstruction in patients with carcinoma of the esophagus and adenocarcinoma of the distal esophagus usually indicates far-advanced disease. Palliative therapy with the neodymium-yttrium, aluminum, garnet laser has been proposed as an alternative to more invasive procedures that do little to improve the quality of life or prolong survival. Fifteen patients were treated with endoscopic laser therapy. A previously described technique was used to treat the first ten patients; the remaining five were treated with a single-session therapy method. This new technique allowed more rapid completion of therapy (1.4 treatments over 2.2 days vs 2.9 treatments over 7.8 days) without sacrificing safety. Single session therapy using this laser is recommended as the treatment of choice in patients with carcinoma of the esophagus with obstruction that is surgically or radiotherapeutically incurable.

A complication of the implantable constant infusion chemotherapy pump.

The treatment of metastatic colorectal cancer to the liver has been a significant problem for clinicians in the past. Recent technical advances in infusion systems in the form of the infusaid pump has allowed delivery of chemotherapeutic agents to the liver with great reliability. As more chemotherapy pumps are implanted, undoubtedly, new and unusual complications will occur. This report centers on a patient who developed a disrupted catheter secondary to a high pressure side port injection. It includes a description of the complication, how it occurred, was recognized, and corrected. This report will, hopefully, save other clinicians from encountering similar complications in any of their patients.