Pediatric ERCP in a multidisciplinary community setting: experience with a fellowship-trained general surgeon.

UNLABELLED: Endoscopic retrograde cholangiopancreatography (ERCP) has been used to evaluate and treat pancreaticobiliary disorders and trauma in the pediatric population. Still representing a small percentage of total pediatric endoscopies, this procedure has been performed most commonly by a small subset of adult and pediatric gastroenterologists at quaternary referral centers. METHODS: In this study, we present a review of one fellowship-trained general surgeon's experience with pediatric ERCP in a teaching community pediatric hospital for the purpose of comparison with national series. RESULTS: All ERCPs performed by one general surgeon as part of a multidisciplinary team over a 5-year period in patients aged 16 years or less were reviewed. Success and complication rates were compared between our series and published pediatric and adult series using Fisher's exact test. Comparisons were made of indications, type of anesthesia, final diagnosis, and therapeutic interventions to ensure similar study populations. A total of 26 ERCPs were performed in 19 patients ranging from 7 to 16 years old. Therapeutic procedures included sphincterotomy (11), stent placement (7), stone removal (3), and dilation (2). In one case, stone removal and stent placement were performed in conjunction with pancreatic lithotripsy. In two cases the involved duct was not visualized. There were no instances of pancreatitis, bleeding, or perforation related to ERCP. CONCLUSIONS: When compared with published series, our data demonstrated no significant difference in success or complication rates. Our study demonstrates that pediatric ERCP can be performed by fellowship-trained general surgeons with success and complication rates comparable to accepted standards. Integration of the ERCP-trained general surgeon into the pediatric team is a potential asset in the care of pediatric patients with pancreaticobiliary disorders.

Evaluation of endoscopic and laparoscopic training practices in surgical residency programs.

BACKGROUND: The ability to adequately train surgical residents in flexible and rigid endoscopy has become a difficult challenge for program directors. The American Board of Surgery requires residents to be familiar in these procedures but the methods for training have not been well defined nor formally outlined. The goals of this study were to evaluate resident experience in flexible endoscopy and laparoscopy and to investigate the specific methods used by surgical programs for the training of residents. METHODS: A survey was created by the authors and the Resident Education Committee of the Society of American Gastrointestinal Endoscopic Surgeons and was mailed to all program directors in general surgery in the United States based on the data base of the Association of Program Directors in Surgery (APDS). RESULTS: Ninety-six of 283 surveys were returned (33.9%). The surgeon played a greater role in flexible endoscopic training in 1998 as compared to 1988 (p=0.002). When analyzed by type of institution, community programs showed a similar trend but this was not seen in academic programs. Formal endoscopy rotations existed in 60% of programs but flexible endoscopy (5.2%) and laparoscopy (10.4%) fellowships were uncommon. No significant differences in the number of advanced laparoscopic procedures performed were found between academic and community programs. The presence of a laparoscopic fellow did not significantly decrease the number of cases per resident. CONCLUSION: According to our survey, surgery departments have a greater impact on flexible endoscopic training in 1998 than in 1988. This is likely due to the creation of formal endoscopy rotations and the hiring of fellowship trained endoscopic instructors. In addition, community programs have been able to provide adequate experience in both basic and advanced laparoscopic techniques as compared to academic programs. As with flexible endoscopy, however, formal laparoscopic rotations may be necessary to allow more intensive experience for each resident.

Endoscopic retrograde cholangiopancreatography in a general surgery training program.

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most complex procedures performed by endoscopists. ERCP has been performed primarily by gastroenterologists. There have been no reports in the literature regarding ERCP training within the framework of a general surgery residency program. The purpose of this study was to review ERCPs performed by surgical attendings and resident staff during a 6-year period and compare the success and complication rates with those found in published gastroenterological series. There were a total of 193 ERCPs performed on 171 patients for a success rate of 82.4 per cent and a complication rate of 6.7 per cent. A resident was the primary endoscopist in 51 procedures, with 42 (82.4%) successes and 2 complications (3.9%). There were no significant differences noted between our series and national complication rates, and between attending and resident procedures (P < 0.05, Chi-square analysis). This study has shown that surgical endoscopists can perform ERCP with success rates over 80 per cent, the currently regarded standard of expertise. The complication rates for these ERCPs were lower than accepted complication rates cited in current gastroenterological series. The results of this study support the hypothesis that ERCPs can be performed safely in a surgical residency.

A novel 5-lipoxygenase inhibitor prevents gallstone formation in a lithogenic prairie dog model.

Gallstone formation is dependent on biliary cholesterol supersaturation, the pronucleating effects of gallbladder mucin, and inflammation. We evaluated the effect of aspirin (ASA) and a 5-Lipoxygenase inhibitor (FLAPI) on cholesterol precipitation and leukotriene levels in an animal model of cholesterol gallstone formation. Male prairie dogs were divided into four dietary groups: normal chow controls, 1.2 per cent cholesterol (XOL), 1.2 per cent cholesterol plus ASA (XOL + ASA, 100 mg/kg/d), and cholesterol plus FLAPI (XOL + FLAPI, 100 mg/kg/12h). At 3 weeks the subjects were anesthetized, cholecystectomy performed, and the common duct cannulated for bile sampling. Cholesterol precipitation, lithogenic indices, and leukotriene content were analyzed. The group XOL + FLAPI did not form cholesterol crystals, whereas the group XOL + ASA did (P < 0.05, Fisher's exact test). All cholesterol-fed groups had significantly increased lithogenic indices when compared to controls. The XOL + FLAPI group showed a significant and paradoxical increase in LTB4 compared to the other groups (P < 0.05, ANOVA, Fisher's PLSD). This study has shown a significant decrease in the rate of cholesterol stone formation through the use of a novel leukotriene inhibitor at high doses, despite a high cholesterol diet.

The adverse hemodynamic effects of laparoscopic cholecystectomy.

Recent studies suggest that significant physiologic derangements can occur during laparoscopic surgery. Eighteen patients admitted for laparoscopic cholecystectomy were studied. The mean age was 46.7 (range 19-78). A standard anesthetic technique, reverse Trendelenburg positioning, and an abdominal insufflation pressure of 15 mmHg with CO2 were used with all subjects. Central venous pressure (CVP) and arterial pressures were measured invasively. Stroke volume and cardiac index were calculated using quantitative transesophageal echocardiography. Baseline measurements were taken after induction. Additional measurements were taken at 15-min intervals throughout the procedure. There was a statistically significant increase in mean arterial pressure (15.9%), systolic blood pressure (11.3%), diastolic blood pressure (19.7%), and CVP (30.0%) from control baseline values. Significant decreases in stroke volume (29.5%) and cardiac index (29.5%) occurred within 30 min of the induction of pneumoperitoneum and positioning (P < 0.05, ANOVA). Laparoscopic cholecystectomy significantly and reversibly decreases cardiac performance. Compromised patients may be at increased risk for complications not previously recognized with this procedure.

Aortic injury. A catastrophic complication of laparoscopic cholecystectomy.

Two cases of aortic injury from trocar insertion during laparoscopic cholecystectomy are described and analyzed. The literature is reviewed and suggestions are offered for avoiding and treating this major complication. Both patients survived and are normal.

Biliary extracorporeal shock wave lithotripsy: the efficacy and safety of concomitant catheter cholecystostomy during biliary lithotripsy.

The major limitations of biliary extracorporeal shock wave lithotripsy (ESWL) relate to adequate stone fragmentation and clearance of the stone fragments. We hypothesized the removal of small fragments with concomitant catheter cholecystostomy during ESWL would improve its efficacy. ESWL with aspiration or flushing through three different cholecystostomy catheters was performed on pigs with surgically implanted gallstones. Twenty-two percent and 46% of the pre-ESWL stone weight were aspirated through the 10 and 12 French catheters respectively. The clearance, size, and visualization of fragments was not significantly different between any of the groups. No significant post-mortem tissue or catheter damage was found. Catheter aspiration is a safe and effective method of removing gallstone fragments during biliary ESWL, but it does not improve stone fragmentation, stone clearance, or visualization of other fragments.

Fluorescein-assisted laparoscopy in the identification of arterial mesenteric ischemia.

Accurate identification of acute mesenteric ischemia remains a challenge. It was hypothesized that fluorescein-assisted laparoscopy (FAL) may have a role in the identification of acute arterial mesenteric ischemia. Arterial ischemic small-bowel segments were prepared in 11 dogs. Following 2.5 h of ischemia, laparoscopy was performed with a standard light source followed by FAL with an argon laser. These two techniques were immediately compared with open inspection. Standard laparoscopy correctly identified 10 ischemic segments. FAL correctly identified 9 ischemic segments and the combination of the 2 techniques allowed laparoscopy to correctly identify all 11 ischemic segments. Standard laparotomy with and without fluorescein correctly identified 10 ischemic segments. The difference between laparoscopy and laparotomy was not significant (P > 0.6, Fisher's exact test). The combination of laparoscopic evaluation with and without fluorescein allowed identification of small-bowel ischemia in all subjects in this canine model. Further studies are warranted to delineate the accuracy of laparoscopy in other patterns of mesenteric insufficiency before clinical application.

The ability of the acoustic energy/stone burden ratio to predict gallstone clearance in biliary lithotripsy.

The relationship between acoustic energy, stone burden, and stone clearance in biliary extracorporeal shock wave therapy (ESWL) is unclear. We hypothesized that there is a consistent relationship between these parameters that enables gallstone clearance to be predicted. Using a porcine model and various gallstone burdens, we performed biliary ESWL with varying energy levels and number of shock waves. The acoustic energy/stone burden ratio (AE/SB) was calculated that incorporated these variables. Stone clearance increased with higher energy settings and fewer stones present (p less than 0.005). The relationship between AE/SB ratio and stone clearance was logarithmic (r 2 = 0.82). The plateau of this curve showed optimal stone clearance at approximately 20 joules/g, beyond which point the benefit of further ESWL may not outweigh the risks. This relationship between AE/SB ratio and stone clearance may be able to predict the optimal energy required and probable outcome of biliary ESWL prior to the procedure.

Multi-institutional survey of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) is being used more frequently in patients undergoing gallbladder removal. Most initial studies have centered on the limited experience of a few select surgeons or institutions and may not accurately reflect the current state of LC. We used written and telephone survey tools to 103 community hospitals in Michigan to identify the utilization of LC, the criteria for training and credentialing, and patient outcome. Of 103 hospitals, 75 (73%) were involved with LC and 56% of these had < 100 beds. We found a large variation in the indications, contraindications, equipment, methods, and credentialing criteria. Major complications, including some not previously reported, were identified and occurred more frequently than previously described. LC is being widely applied and the majority of hospitals have < 100 beds. LC may carry higher risks than previously reported. Collected series and registry data that include community hospital experiences should better delineate the outcome of LC.

The effect of calcium on gallbladder absorption.

The absorption of water and electrolytes is an important physiologic function of the gallbladder which is altered during gallstone formation. Extracellular calcium and calcium channel antagonists are known to affect intestinal absorption, yet their effect on gallbladder absorption is less well defined. We, therefore, tested the hypothesis that changes in extracellular calcium or in calcium channels would alter gallbladder absorption. New Zealand white rabbit gallbladders were removed, filled with a modified Krebs buffer (Ca2+ = 0.7 mM), and suspended in an oxygenated bath of the same buffer. Water absorption was determined gravimetrically by obtaining serial gallbladder weights at 10-min intervals. After a 40-min control period, the serosal bathing solution was changed to one of four experimental solutions (n = 6 for each group): Ca2+ = 0.25, 0.7, or 1.2 mM or Ca2+ = 0.7 mM plus 0.1 mM verapamil. Absorption was determined during an 80-min experimental period with results expressed as the percentage change in gallbladder absorption compared to that of the control period. The 0.25, 0.7, and 1.2 mM Ca2+ groups did not show a significant change in absorption rate from their respective control rates. However, the verapamil group did demonstrate a significant (P less than 0.05) decrease in absorption rate of -69 +/- 8% by the end of the experimental period. These data demonstrate that verapamil inhibits gallbladder absorption while changes in serosal calcium concentration have no effect. We conclude that calcium channels and intracellular calcium may play an important role in modulating gallbladder absorption.

Altered bile composition during cholesterol gallstone formation: cause or effect?

Gallbladder stasis, increased gallbladder absorption, and elevated biliary levels of calcium, hydrogen ion, and bilirubin have been implicated as factors potentially critical to cholesterol crystal precipitation. Previous studies, however, have analyzed bile only when crystals or gallstones have already formed. Therefore, we tested the hypothesis that changes in bile composition are a late effect, occurring only after crystal formation. Adult male prairie dogs were fed a standard nonlithogenic control diet (n = 7) or a lithogenic 1.2% cholesterol diet for 5, 9, or 14 days to cause cholesterol saturation (n = 7), cholesterol monohydrate crystals (n = 7), or gallstones (n = 7). Gallbladder bile was examined microscopically for crystals, and analyzed for ionized calcium, bilirubin, pH, total protein, and biliary lipids. The ratio of gallbladder to hepatic bile radiolabeled cholic acid specific activity (Rsa) was calculated as an index of gallbladder stasis. Cholesterol saturation index was calculated. The results demonstrate that increased gallbladder bile cholesterol saturation and total protein concentration precede cholesterol monohydrate crystal precipitation. However, changes in gallbladder ionized calcium, unconjugated bilirubin, pH, stasis, and absorption were noted only after crystals and gallstones had already formed. These data indicate that alterations in gallbladder bile calcium, bilirubin, pH, stasis, and absorption are not early changes, but occur simultaneously with or after crystal formation. Increased biliary protein, however, which was elevated prior to nucleation, may be an important mediator of cholesterol precipitation in cholesterol-saturated bile.

Endoscopic retrograde cholangioscopy. An adjunct to endoscopic exploration of the common bile duct.

Choledochoscopy is an accepted technique in the operative exploration of the common bile duct, and is complimentary to operative cholangiography. Retrograde cholangiography can be achieved perorally in up to 97 per cent of patients and it is reasonable to assume that the use of complimentary cholangioscopy in such patients would help to improve the accuracy of bile duct examination just as it does when applied in the operative setting. We have had the opportunity to use a new technology in the endoscopic evaluation of the common bile duct. An endoscopic retrograde cholangioscopy (ERCP) is first performed and ductal anatomy outlined. When indicated, an endoscopic sphincterotomy is performed. If large stones are present they are removed with a balloon or basket. The standard side-viewing endoscope is then removed and replaced with the large channel, side-viewing scope. A "baby" scope is introduced through the "mother" scope and canulation of the common duct with the "baby" scope is performed. Biopsies and brushings of lesions may be obtained and numerous instruments are available for manipulation through the biopsy channel of the "baby" scope. The use of retrograde cholangioscopy as an adjunct to retrograde cholangiography should provide the same advantages that have been demonstrated with the use of operative choledochoscopy. Use of this instrument will allow the endoscopist to accurately identify questionable lesions seen on the cholangiogram, selectively canulate particular biliary radicals, biopsy lesions of the common duct, and perhaps intervene therapeutically in selected biliary tract lesions.

Endoscopic retrograde cholangiopancreatography in a general surgery practice.

Endoscopic retrograde cholangiopancreatography (ERCP) is performed for the diagnosis and therapy of benign and malignant biliary and pancreatic disease. There are few reports in the literature regarding the incorporation of this procedure into a general surgery practice. One hundred seven consecutive ERCPs performed by the same surgeon over a two-year period were reviewed. The most frequent indications for ERCP were jaundice, suspected common bile duct stones, and a history of pancreatitis. Successful cannulation of the ampulla of Vater was achieved in 97 per cent of the cases with the desired duct being adequately visualized in 90 per cent of the cases. Sphincterotomy was performed in 42 per cent of the procedures and common bile duct stones were removed with a balloon or basket catheter. The overall complication rate was seven per cent with no mortality. ERCP accounted for 20 per cent of all endoscopies and 12 per cent of all procedures performed by the surgeon. Twelve per cent of these patients were subsequently operated upon by the surgeon while another 16 per cent requiring surgery were returned to the referring physician. This study supports the feasibility of the incorporation of ERCP into a general surgery practice.

DRGs and outliers in surgical critical care.

The authors evaluated the charges, outcome, and characteristics of patients requiring prolonged stay in the Surgical Intensive Care Unit (SICU) as if all reimbursement was from the Medicare DRG system. The records of patients staying in the SICU longer than 20 days over an 18 month period were reviewed. Age, mortality, service, length of stay, hospital charge, and projected DRG reimbursement were recorded. Patients whose hospital stay exceeded the maximum expected for their DRG were considered day outliers. The 51 study patients had a mean age of 59 +/- 17.6 years. They comprised 1.3 per cent of all patients in the SICU and 30.7 per cent of all SICU patient days during the study period. Mortality was 39.2 per cent. Thirty-two patients (62.7%) were day outliers. The mean hospital charge per patient was $59,552 while the mean projected DRG reimbursement was $10,435, for a total projected loss in billed charges of $2,504,428. DRG reimbursement for patients requiring prolonged SICU stay is inadequate to meet their charges and may severely limit future SICU use.

Surgical treatment of peptic ulcer disease before and after introduction of H2 blockers.

This retrospective study was undertaken to determine if the advent of H2 blockers has altered the surgical treatment and outcome of patients with peptic ulcer disease (PUD). The records of patients having surgery for PUD at Butterworth Hospital, Grand Rapids, Michigan, from 1971-73 (Group 1) and 1981-83 (Group 2) were reviewed. Data recorded included patient and disease characteristics, surgical procedures, morbidity, and mortality. There was a significant difference in mean age: 54 years in Group 1 and 60 years in Group 2. Group 2 had a higher incidence of concomitant medical illnesses. Indications for operation were predominantly of an emergent nature in Group 2, with a marked decline in elective surgeries from 75 per cent to 55 per cent. There was a 15 per cent incidence of nonsurgical complications in Group 2, as opposed to 9 per cent in Group 1. This study demonstrates that the use of H2 blockers and changes in patient characteristics have altered the surgical treatment and outcome of patients with PUD.