Evolution of endoscopic therapy for esophageal varices.

Endoscopic treatment for bleeding esophageal varices was first described 65 years ago, but the technique was not widely adopted until the 1970s. Rapid progress since then has resulted in new, more effective forms of endoscopic treatment. Currently, endoscopic therapy is the primary treatment for patients with bleeding esophageal varices at most centers. This review traces the evolution of endoscopic treatment, summarizes current outcomes data, and speculates on future development.

Laparoscopic palliation of polycystic liver disease.

The role of laparoscopic surgery in the management of polycystic liver disease (PCLD) is not well defined. The authors hypothesized that laparoscopic fenestration for PCLD relieves symptoms caused by polycystic liver disease. In this study, 11 patients underwent 20 laparoscopic cyst fenestration operations as treatment for symptoms of their PCLD. Symptoms leading to surgery were pain and pressure in 15 (75%) and early satiety in 12 (60%) patients. The median hospital stay was 1 day. The symptoms resolved postoperatively in all the patients. An additional laparoscopic fenestration was required in six (55%) patients for recurrent symptoms. The average time to reoperation was 22 +/- 16 months. Two patients required hepatic transplantation. Initial symptom resolution occurred in all the patients undergoing redo fenestration. The authors conclude that laparoscopic fenestration for PCLD is safe, results in minimal "down" time and relieves the symptoms caused by PCLD. Symptomatic relief usually is temporary, and repeat surgery is required for recurring symptoms in half of the patients.

Minimally invasive surgery.

Minimally invasive surgery is replacing the traditional open surgical approach for many abdominal procedures. The benefits of reduced pain, quicker return of oral intake, shorter hospitalizations, and improved cosmetic results all support the increasing use of the laparoscopic approach. This review identifies important articles published in the literature on minimally invasive surgery from June 2002 to August 2003, with the objective of identifying future trends and directions in laparoscopic surgery. The topics of articles reviewed in detail include minimally invasive techniques applied to esophageal tumors, morbid obesity, malignant liver tumors, gallbladder disease, pancreatic pathology, colon cancer, and robotic prostatectomy.

Transoral, flexible endoscopic suturing for treatment of GERD: a multicenter trial.

BACKGROUND: A totally transoral outpatient procedure for the treatment of GERD would be appealing. METHODS: A multicenter trial was initiated that included 64 patients with GERD treated with an endoscopic suturing device. Inclusion criteria were 3 or more heartburn episodes per week while not taking medication, dependency on antisecretory medicine, and documented acid reflux by pH monitoring. Exclusion criteria were dysphagia, grade 3 or 4 esophagitis, obesity, and hiatus hernia greater than 2 cm in length. Patients underwent manometry, endoscopy, 24-hour pH monitoring, and symptom severity scoring before and after the procedure. Patients were randomized to a linear or circumferential plication configuration. Adverse procedural events were recorded. RESULTS: Mean 6-month symptom score changes demonstrated procedural efficacy. Heartburn severity and frequency as well as regurgitation all improved (p > 0.0001 for each). Twenty-four-hour pH monitoring showed improvement in number of episodes below pH of 4 at 3 and 6 months (p < 0.0007 and 0.0002) and percentage of total time the pH was less than 4 at 6 months (p < 0.011). Plication configuration did not affect symptoms or pH monitoring results. One patient had a self-contained suture perforation that was successfully treated with antibiotics. CONCLUSION: Endoscopic gastroplasty is safe. It is associated with reduced symptoms and medication use at 6 month follow-up in patients with uncomplicated GERD.

Management of major bile duct injury associated with laparoscopic cholecystectomy.

BACKGROUND: Bile duct injury is a major complication of laparoscopic cholecystectomy. The purpose of this study was to evaluate our management strategy and outcomes for the treatment of such injuries. METHODS: We studied 54 consecutive patients who had de novo bile duct injury (n = 20) or prior biliary injury repair (n = 34) associated with laparoscopic cholecystectomy. All patients were managed using a multidisciplinary approach. RESULTS: Definitive operation, almost always Roux-en-Y hepaticojejunostomy, was required in 85% of patients. We inserted external percutaneous biliary catheters in 98% of cases prior to surgery. There were no operative deaths, and the 30-day complication rate was 20%. Eight patients (15%) were managed nonoperatively. Overall, 96% of patients had no long-term, objectively definable biliary sequelae. CONCLUSIONS: Treatment of bile duct injury associated with laparoscopic cholecystectomy is optimally done using a multidisciplinary approach. Surgical reconstruction is required in most cases and can be safely accomplished with minimal morbidity and excellent long-term outcomes.

Bile duct calculi--the new challenges.

BACKGROUND: Morbidity and mortality after surgical treatment of bileduct stones increase with age and associated diseases. A proposed alternative therapy is endoscopic sphincterotomy (ES) with the gallbladder left in situ, and we elected to compare this option with standard open surgery in high-risk patients. METHODS: 98 patients (mean age 80 years) with symptoms likely to be due to bileduct stones or a recent episode of biliary pancreatitis were randomised to be treated either by open cholecystectomy with operative cholangiography and (if necessary) bileduct exploration (n = 48) or by endoscopic sphincterotomy alone (n = 50). FINDINGS: The procedure was accomplished successfully in 94% of the surgery group and 88% of the ES group, and there were no significant differences in immediate morbidity (23% vs 16%) or mortality (4% vs 6%). During mean follow-up of 17 months biliary symptoms recurred in three surgical patients, none of whom underwent repeat surgery, and in 10 ES patients, seven of whom had biliary surgery. By multivariate regression analysis endoscopic sphincterotomy was an independent predictor of recurrent biliary symptoms (odds ratio 6.9; 95% Cl 1.46 to 32.54). INTERPRETATION: In elderly or high-risk patients, surgery is preferably to endoscopic sphincterotomy with the gallbladder left in situ as a definitive treatment for bileduct stones or non-severe biliary pancreatitis.

Endoscopic variceal ligation is superior to combined ligation and sclerotherapy for esophageal varices: a multicenter prospective randomized trial.

Patients who have bled from varices remain at risk for rebleeding. There is interest in methods that would enable rapid eradication of varices. The present trial was designed to study whether combining ligation with sclerotherapy will allow quicker eradication of varices than either modality alone. Patients with bleeding esophageal varices were randomized into ligation or combination therapy groups. Patients in the ligation group were treated with endoscopic rubber band ligation alone. In combination group patients, each variceal column was ligated distally and 1 mL of ethanolamine was injected proximal to each ligated site. Subsequent treatment sessions were at 7- to 14-day intervals until varices were eradicated. The clinical and endoscopic characteristics of 25 patients in the ligation group were similar to those of 22 patients in the combination group. Follow-up was up to 30 months. Active bleeding was controlled in 100% of patients in the ligation group and 75% of those in combination group (P = NS). It took 3.3 +/- .4 (range, 1-7) sessions to eradicate varices with ligation and 4.1 +/- .6 (1-7) with combination therapy (P = NS). Survival (four deaths in ligation group, 8 in combination group), rebleeding rate (25% vs. 36%), and varix recurrence (16% vs. 23%) also were similar. There were more complications with combination therapy, including deep ulcers (65% vs. 20%; P < .05); dysphagia (30% vs. 0%; P < .05), with three strictures requiring dilation; and pain (30% vs. 10%; P = NS). Our results show that sclerotherapy combined with ligation offers no benefit over ligation alone. The higher complication rate with combination therapy does not warrant this approach.

Exposure for laparoscopic cholecystectomy dissection adversely alters biliary ductal anatomy.

BACKGROUND: Exposure for open cholecystectomy entails lateral, caudal traction on the gallbladder infundibulum, which results in opening the angle between the cystic and hepatic ducts. Laparoscopic cholecystectomy (LC), as initially described, is done with cephalad traction on the gallbladder. We hypothesized LC exposure technique narrows the angle between the cystic and hepatic ducts, placing them at increased risk of injury. METHODS: Twenty-three patients had routine LC. Cystic duct cholangiography (IOC) was done with a flexible 5-Fr catheter via a percutaneous introducer placed anterior to the gallbladder. Exposure of Calot's triangle was maintained with cephalad traction on the gallbladder fundus. IOC was repeated after allowing the organ to assume the anatomic position. The cholangiograms were inspected for significant differences, and the angle of the cystic to the hepatic duct (CDHD) was measured by a blinded radiologist. RESULTS: The mean angle of the cystic to hepatic duct was 30 degrees +/- 19 degrees in the IOCs taken with cephalad traction on the gallbladder fundus vs 59 degrees +/- 22 degrees, P < 0.001, in the cholangiograms taken without traction. A filling defect at the cystic-hepatic duct junction was present in 39% of IOC taken with traction vs none without traction. The intrahepatic ducts were seen in all films without traction, whereas the intrahepatic ducts were not visualized in 13% of IOCs taken with traction. CONCLUSIONS: From these data we conclude (1) extra-hepatic biliary ducts may be at increased risk of injury during LC because of the exposure technique and (2) imaging bile ducts in the anatomic position may convey misleading information about the relative location of important structures. Optimal exposure for dissection of Calot's triangle should utilize a second clamp on the infundibulum with lateral, caudal traction.

Photodynamic therapy with porfimer sodium versus thermal ablation therapy with Nd:YAG laser for palliation of esophageal cancer: a multicenter randomized trial.

BACKGROUND: Photodynamic therapy (PDT) is a different type of laser treatment from Nd:YAG thermal ablation for palliation of dysphagia from esophageal cancer. METHODS: In this prospective, multicenter study, patients with advanced esophageal cancer were randomized to receive PDT with porfimer sodium and argon-pumped dye laser or Nd:YAG laser therapy. RESULTS: Two hundred thirty-six patients were randomized and 218 treated (PDT 110, Nd:YAG 108) at 24 centers. Improvement in dysphagia was equivalent between the two treatment groups. Objective tumor response was also equivalent at week 1, but at month 1 was 32% after PDT and 20% after Nd:YAG (p < 0.05). Nine complete tumor responses occurred after PDT and two after Nd:YAG. Trends for improved responses for PDT were seen in tumors located in the upper and lower third of the esophagus, in long tumors, and in patients who had prior therapy. More mild to moderate complications followed PDT, including sunburn in 19% of patients. Perforations from laser treatments or associated dilations occurred after PDT in 1%, Nd:YAG 7% (p < 0.05). Termination of laser sessions due to adverse events occurred in 3% with PDT and in 19% with Nd:YAG (p < 0.05). CONCLUSIONS: Photodynamic therapy with porfimer sodium has overall equal efficacy to Nd:YAG laser thermal ablation for palliation of dysphagia in esophageal cancer, and equal or better objective tumor response rate. Temporary photosensitivity is a limitation, but PDT is carried out with greater ease and is associated with fewer acute perforations than Nd:YAG laser therapy.

Laparoscopic ultrasonography as compared with static or dynamic cholangiography at laparoscopic cholecystectomy. A prospective multicenter trial.

We compared laparoscopic ultrasonography (LICU) with static (S) or dynamic (D) cholangiography (IOC) for assessment of duct anatomy an calculi in 209 patients. LICU visualized ducts in 88% compared with 93% for IOC (P = 0.046). Nineteen patients (9%) had stones: 17 were found by LICU (89%) and 10 (53%) by IOC (P = 0.032). Time to perform LICU (7 +/- 3 min) was less than IOC (13 +/- 6 min) (P < 0.0001). Time to perform SIOC (12 +/- 5 min) and DIOC (14 +/- 6 min) did not differ (P = 0.48), nor did these tests differ in accuracy. LICU provided useful anatomical information but IOC better defined anatomic anomalies. LICU required less time but was less reliable at defining anatomy and complete duct visualization. LICU was more sensitive for stones. SIOC and DIOC did not differ objectively. LICU and IOC are complementary.

Update on laparoscopic ultrasonography.

Ultrasonography has many clinical applications and can be done with both extra- and intracorporeal techniques. Miniaturization of ultrasound transducers has opened the way for intracorporeal use of ultrasound at laparoscopy. The principles of ultrasonography are presented. Laparoscopic intracorporeal ultrasound (LICU) has proven to be useful in the differential diagnosis of liver tumours. In one series, 75 of 85 patients had positive identification of a suspected liver tumour with laparoscopic ultrasound examination. LICU has also been useful for delineation of hepatobiliary anatomy during laparoscopic cholecystectomy in both animal models and patients having cholecystectomy. LICU may detect useful anatomic information prior to dissection of the cystic duct and is accurate in detecting common bile duct stones. LICU may also be useful in the preoperative staging of pancreatic malignancy. Laparoscopic intracorporeal ultrasound may find practical application in other areas as experience evolves.

Long-term management of variceal bleeding: the place of varix injection and ligation.

Injection sclerotherapy remains the most widely used long-term management for patients after an esophageal variceal bleed. Sclerotherapy treatments should be repeated weekly until the varices are eradicated. Follow-up endoscopy every 6 to 12 months is required for life. Whenever varices recur, further weekly injection treatments are administered until re-eradication is achieved. Failure of sclerotherapy must be diagnosed early and an alternative salvage procedure performed. We currently recommend the distal splenorenal shunt. Although the complications of sclerotherapy are not great, they are cumulative with time. Unlike most surgical procedures for portal hypertension, the technique of performing sclerotherapy is not standardized, making the comparison of controlled trials difficult. The current status of controlled trials comparing sclerotherapy with other treatments is evaluated. We conclude that repeated injection sclerotherapy is at present the initial treatment of choice for patients after an esophageal variceal bleed. The technique of the new procedure of esophageal variceal ligation is described. As with sclerotherapy, weekly treatment sessions are recommended until the esophageal varices are eradicated, followed by long-term endoscopic surveillance and repeat ligation treatment when varices recur. The four controlled trials that have compared variceal ligation with sclerotherapy favor ligation. Ligation eradicated esophageal varices with fewer treatment sessions and a lower complication rate. One trial demonstrated improved survival. Complications due to the overtube are being increasingly reported but were not a problem in the controlled trials. Although esophageal variceal ligation or ligation plus sclerotherapy may ultimately prove to be superior to sclerotherapy alone, more data are required before a final conclusion can be reached.

Laparoscopic intracorporeal ultrasound. An alternative to cholangiography?

The purpose of this study was to compare laparoscopic intracorporeal ultrasound (LICU) examination of the biliary duct system with cholangiography for delineation of duct anatomy and determination of presence or absence of ductal calculi. Thirty-one patients had LICU examination of the extrahepatic bile ducts after exposure of the gallbladder but prior to dissection of the cystic duct. After LICU examination, cystic duct dissection and cholangiography were done. Evaluation of duct anatomy and decision for duct exploration were based on findings of both tests. All patients had successful LICU examination and 30 had successful cholangiography. Duct size as determined by LICU corresponded precisely with cholangiography. LICU provided useful anatomical information in two patients with aberrant anatomy and detected cholangiogram. LICU aids in delineation of biliary duct anatomy and accurately determines presence or absence of duct calculi.

Cryodestruction of hepatic tumors.

Cryodestruction of hepatic tumors is done by freezing the tumor and an appropriate amount of surrounding normal tissue in situ. The goal is complete destruction of malignant tissue. Local and systemic host mechanisms activated by the cold injury complete the process. Resorption of devitalized tissue and stabilization of the residual scar occurs during the ensuing months. Immune factors may contribute to the long-term process of cryodestruction although such effects are inconstant and ill defined. The purpose of this overview is to delineate the mechanisms of cryodestruction, briefly summarize clinical results and discuss the technique for treatment of hepatic tumors.

Laparoscopy-guided intracorporeal ultrasound accurately delineates hepatobiliary anatomy.

UNLABELLED: The purpose of this study was to develop a technique and assess the ability of a laparoscopic ultrasound probe to delineate biliary antomy and to determine the presence or absence of duct stones. METHODS: Five pigs had ultrasonography of biliary structures and liver at laparoscopy followed by cholangiograms and anatomical dissection. Five patients had ultrasonography of the biliary tract at laparoscopic cholecystectomy. RESULTS: All animals had adequate visualization of important hepatobiliary structure, and an optimal method of accessing these structures at laparoscopy was established. Patients had ultrasonography which used methods developed in the animal trial. All had adequate visualization of the entire common bile duct confirmed by cholangiography. Limitations in demonstrating the relationship of the cystic duct to the common duct were technical and can be corrected. CONCLUSION: Laparoscopic ultrasonography has significant potential for delineation of biliary anatomy and determination of presence or absence of duct calculi. Clinical implementation could minimize the risk of iatrogenic duct injury and the need for operative cholangiography.