Direct endoscopic necrosectomy: a minimally invasive endoscopic technique for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris

<p><b>INTRODUCTION</b>Endoscopic transenteric stenting is the standard treatment for pseudocysts, but it may be inadequate for treating infected collections with solid debris. Surgical necrosectomy results in significant morbidity. Direct endoscopic necrosectomy (DEN), a minimally invasive treatment, may be a viable option. This study examined the efficacy and safety of DEN for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris.</p><p><b>METHODS</b>This study was a retrospective analysis of data collected from a prospective database of patients who underwent DEN in the presence of infected walled-off pancreatic necrosis or infected pseudocysts with solid debris from April 2007 to October 2011. DEN was performed as a staged procedure. Endoscopic ultrasonography-guided transgastric stenting was performed during the first session for initial drainage and to establish endoscopic access to the infected collection. In the second session, the drainage tract was dilated endoscopically to allow transgastric passage of an endoscope for endoscopic necrosectomy. Outcome data included technical success, clinical success and complication rates.</p><p><b>RESULTS</b>Eight patients with infected walled-off pancreatic necrosis or infected pseudocysts with solid debris (mean size 12.5 cm; range 7.8-17.2 cm) underwent DEN. Underlying aetiologies included severe acute pancreatitis (n = 6) and post-pancreatic surgery (n = 2). DEN was technically successful in all patients. Clinical resolution was achieved in seven patients. One patient with recurrent collection opted for surgery instead of repeat endotherapy. No procedural complications were encountered.</p><p><b>CONCLUSION</b>DEN is a safe and effective minimally invasive treatment for infected walled-off pancreatic necrosis and infected pseudocysts.</p>

Pancreatic fistula after distal pancreatectomy: incidence, risk factors and management.

BACKGROUND: Pancreatic fistulae post distal pancreatectomy still leads to significant morbidity and if not properly managed, may lead to mortality. The identification of risk factors and effective management of patients with pancreatic fistulae is important in the prevention of these complications. METHODS: There were 75 open consecutive distal pancreatectomies in the Department of Surgery, Changi General Hospital from May 2001 to May 2007. RESULTS: The indications for operation were neuroendocrine tumours (n= 15), adenocarcinoma (n= 20), Intraductal papillary mucinous tumour (IPMT) (n= 20), serous cysts (n= 15) and trauma (n= 5). There were 20 patients (27%) who developed pancreatic fistulae in the whole series. On univariate analysis, the patients with pancreatic fistulae had significantly more pre-morbidities, softer pancreas and use of staplers as a method of closure of the pancreatic remnant. On multivariate analysis, the use of staplers and soft pancreas were significant independent risk factors for the development of pancreatic fistulae in our patient population. All of the patients with pancreatic fistulae were successfully treated non-surgically with no mortality in the whole series. CONCLUSIONS: The use of stapler on soft pancreas leads to a higher risk for pancreatic fistulae after distal pancreatectomies. Most pancreatic fistulae can be managed non-surgically with good outcome.

Risk factors for conversion to open surgery in patients with acute cholecystitis undergoing interval laparoscopic cholecystectomy

<p><b>INTRODUCTION</b>Laparoscopic cholecystectomy for acute cholecystitis is associated with higher rate of conversion to laparotomy. The value of several factors that might influence the rate of conversion is analysed.</p><p><b>MATERIALS AND METHODS</b>In a retrospective analysis of a prospective database, the medical records of patients who underwent laparoscopic cholecystectomy from May 1998 to June 2004 were reviewed. Patients who had acute cholecystitis and had undergone interval laparoscopic cholecystectomy were included in this study.</p><p><b>RESULTS</b>Out of 1000 laparoscopic cholecystectomies, 201 were operated on for acute cholecystitis. One hundred and forty-five patients (72.3%) underwent successful laparoscopic cholecystectomy and 56 patients (27.7%) needed conversion to open cholecystectomy. Patient's age (P = 0.031), total white cell count (P = 0.014), total bilirubin (P = 0.002), alkaline phosphatase (P = 0.003) and presence of common bile duct stone (P = 0.001) were found to be independently associated with conversion.</p><p><b>CONCLUSION</b>Laparoscopic cholecystectomy can be performed safely for acute cholecystitis. Predictors of conversion will be helpful when planning the laparoscopic approach and for counselling patients preoperatively.</p>

Laparoscopic cholecystectomy: an audit of our training programme.

BACKGROUND: Laparoscopic cholecystectomy is a commonly performed procedure in general surgical practice but it also has an inherently steep learning curve. The training of surgeons in this procedure presents a challenge to teaching hospitals, which essentially have to strike a balance between effective training and safety of the patient. The present study aims first to assess the safety of the structured training programme for this procedure at the Department of Surgery, Changi General Hospital, Singapore. Secondly, it seeks to audit the conversion and bile duct injury rates among the laparoscopic cholecystectomies performed by the department, and the factors which influence these. METHODS: Notes of all patients who underwent laparoscopic cholecystectomy in the department over an 18-month period were reviewed retrospectively and the relevant data prospectively collected. Demographics, as well as details of cases of conversion to open operation and of bile duct injury were identified and the reasons for each recorded. RESULTS: A total of 443 patients underwent laparoscopic cholecystectomy in the 18-month period. The most common indication for surgery was biliary colic/dyspepsia (61.4%), followed by cholecystitis, cholangitis, pancreatitis and common bile duct stone. The overall conversion rate was 11.5%. Three hundred and fifty-five patients were operated on by consultant surgeons, while 88 were by registrars who had been through the structured training programme. There was no statistically significant difference found in the conversion rates between these two groups (P = 0.284). Twenty-two of the 268 female (8.2%) patients had conversion to open operation, while 29 of the 175 male patients (16.6%) underwent conversion (P = 0.007). Amongst cases of cholecystitis and cholangitis, the conversion rate for patients operated on within 7 days of onset of symptoms was 35%, while those operated on 8 or more days later had a conversion rate of 29.7% (P = 0.639). There was a solitary case of bile duct injury among the 443 cases, equating to a bile duct injury rate of 0.23%. CONCLUSION: A structured training programme involving stepwise progression of training, with close supervision by consultant surgeons and a built-in system of audit can effectively train junior surgeons in laparoscopic cholecystectomy without exposing patients to undue risks.

Endoscopic retrograde cholangiopancreatography management of common bile duct stones in a surgical unit.

BACKGROUND: Choledocholithiasis, if left untreated, can lead to significant morbidity and mortality. The management of such a problem has progressed tremendously but controversy still exists as to ideal management, laparoscopic exploration or endoscopic retrograde pancreatography with sphincterotomy. The purpose of this study is to evaluate the results of endoscopic retrograde cholangiopancreatography (ERCP) in a surgical unit. METHODS: We performed a retrospective review on 336 patients who underwent ERCP between 1997-2000. RESULTS: We achieved a successful cannulation rate of 98% and stone clearance rate exceeding 90%. Morbidity has been minimal and there was no mortality in our study. CONCLUSION: We conclude that ERCP is an effective and safe surgical alternative for the management of choledocholithiasis.