Obstructive jaundice secondary to endoclip migration into common bile duct after laparoscopic cholecystectomy.

Obstructive jaundice is a rare condition due to foreign body in common bile. In this article we report a 69 year-old man who was diagnosed obstructive jaundice secondary to the endoscopic clip migration. The patient had been performed laparoscopic cholecystectomy 5 years ago and had recovered without any complications. He presented with abdominal pain and jaundice. The magnetic resonance cholangiopancreatography (MRCP) revealed filling defect in choledoch consistent with a bile duct stone. The endoscopic retrograde cholangiopancreatography (ERCP) exhibited an endoclip migration into the common bile duct which caused bile duct stone. Endoclips can migrate into bile duct and cause obstructive jaundice. ERCP is the first option for its treatment.

Long-term results of surgery for liver hemangiomas.

BACKGROUND: Elective surgery for liver hemangiomas is still controversial. HYPOTHESIS: Long-term results show that elective surgery for liver hemangiomas is safe and effective. SETTING: A tertiary care university hospital in Istanbul, Turkey. PATIENTS: Forty-two patients underwent surgery for liver hemangiomas between January 1988 and December 1998; 41 were symptomatic. The primary indications for surgery were abdominal pain in 33 patients, diagnostic uncertainty in 6, and enlargement in 3. The median largest dimension of the major lesion was 10 cm (range, 7-45 cm). MAIN OUTCOME MEASURES: (1) Patients' assessment of the effects of surgery on preoperative symptoms, (2) determination of whether any other pathological conditions were missed in the preoperative evaluation, (3) operative mortality and morbidity, and (4) recurrences. DESIGN: Retrospective cohort study. RESULTS: Enucleation was the most frequent operation (33 patients). Hospital mortality and morbidity were 2.4% (bleeding from the biopsy site on a lesion evaluated as inoperable at laparotomy; 1 patient) and 12% (5 patients), respectively. Thirty-three patients could be followed up for a median of 53 months (range, 6-135 months). Of the 32 preoperatively symptomatic patients, surgery was successful in symptom control in 28 (88%) (complete resolution or significant amelioration). No other cause of pain could be identified during follow-up in the other patients. Control ultrasonography revealed no recurrences. CONCLUSIONS: Elective surgery is indicated in a small subset of patients with hemangiomas because of abdominal pain, enlargement, and diagnostic uncertainty. The results of surgery in symptom control are gratifying in approximately 90% of patients. Recurrences are rare. Enucleation can be performed rapidly and safely in most patients and should be preferred to resection.

Mesoatrial shunt in Budd-Chiari syndrome.

BACKGROUND: The operations with proven effects on survival in Budd-Chiari syndrome are shunt operations and liver transplantation. PATIENTS AND METHODS: Between 1993 and 1999 (June), 13 cases of Budd-Chiari syndrome have been treated surgically. Four cases had concomitant thrombosis of the inferior vena cava; the others had marked narrowing of the lumen due to the enlarged caudate lobe. Mesoatrial (n = 12) or mesosuperior vena caval (n = 1) shunts were constructed with ringed polytetrafluoroethylene grafts. RESULTS: The median portal pressure fell from 45 (range 32 to 55) to 20 (range 11 to 27) cm H(2)O (P <0.001). Two patients died in the early postoperative period. One patient who did not comply with anticoagulant treatment had a shunt thrombosis in the second postoperative year. The other 10 patients are alive without problems during a median 42 (range 1 to 76) months of follow-up. CONCLUSION: Mesoatrial shunt with a ringed polytetrafluoroethylene graft is effective in Budd-Chiari syndrome cases with thrombosis or significant stenosis in the inferior vena cava.

Elective repair of abdominal wall hernias in decompensated cirrhosis.

BACKGROUND/AIMS: Abdominal wall hernia is a common feature of decompensated cirrhosis. However, literature on elective hernia repair in these patients is limited. Here we report the experience of our center. METHODOLOGY: Eleven hernias (seven umbilical, three inguinal and one incisional) in nine patients with decompensated cirrhosis were repaired. The indication for operation was repeated incarceration in two patients and significant pain in four; three patients with umbilical hernias had ulceration and necrosis of the overlying skin. Pre-operatively, medical therapy of ascites was conducted at the hepatology unit. Umbilical hernias were treated with the classic Mayo repair; in all cases but two, this was buttressed with a prolene graft. One inguinal hernia was repaired with the plication-darn technique; the other two and the incisional hernia were repaired with prolene grafts. RESULTS: There was no mortality. One patient had a scrotal hematoma; two patients had leakage of ascites into the wound. Seven patients were followed up. Four patients died without recurrence after a median period of 12 months (range 6-22). The other patients have no recurrence at 1, 10 and 40 months post-operatively. CONCLUSIONS: Umbilical and inguinal hernias in patients with decompensated cirrhosis may be repaired safely on an elective basis. Control of ascites is vital for success.

Laparoscopic-assisted large bowel resection.

Laparoscopic colon resection is a viable alternative to open colectomy. For non-malignant lesions, laparoscopic resection of the affected large bowel is attractive. For malignant lesions, where resection for cure is highly dependent on lymph node clearance, laparoscopic resection has met with criticisms regarding the adequacy of nodal clearance that can be achieved laparoscopically. Several published studies have shown that the operation though technically demanding, does not compromise the extent of resection. We report a series of 43 cases of laparoscopic colon resection done sequentially and successfully from January 1992 to June 1995. The operative time averaged 180 minutes (range 120 to 300 minutes). Five patients developed postoperative complications, which were mainly pulmonary and wound infections. There were no anastomotic leaks or perioperative deaths. The mean hospital stay was 5.3 days (range 4 to 9 days). By the third postoperative day, all patients were feeding and ambulatory. Long-term complications included one small bowel obstruction and one port site recurrence. In our selected group of patients, laparoscopic colon resection has not shown any adverse outcome. Prospective randomised studies are underway in various centres and their preliminary results are favourable.

Endoscopic sphincterotomy in the treatment of postoperative biliary fistulas of hepatic hydatid disease.

BACKGROUND: Ten patients with postoperative external biliary fistula treated by endoscopic sphincterotomy are reported. METHODS: Nine of these patients were operated for hepatic hydatid disease and one for a liver abscess. Mean daily output of bile through the fistulae which were present for 5-39 days was approximately 500 cc. RESULTS: Treatment was successful in nine patients with closure of the fistulae in 2-15 days (mean, 7 days). No response was obtained in one patient who was reoperated, and an intrahepatic biliary duct was found to be completely eroded by the cyst wall. CONCLUSIONS: Endoscopic sphincterotomy should be the first-line treatment for postoperative external biliary fistulae related to hepatic hydatid disease.

Pyloric channel ulcers: management and three-year follow-up.

Twenty-five patients with pyloric channel ulcers are presented. They were predominantly males (84%), with a mean age of 54 years. Four patients were operated upon in the initial admission because of gastric outlet obstruction in three and persistent bleeding in one. Twenty-one patients received H2-antagonist treatment (ranitidine 150 mg or cimetidine 400 mg twice a day). Clinical and endoscopic healing rates were 76% and 38% respectively at 6 weeks, and 91% and 85% respectively at 12 weeks of treatment. The recurrence rate at an average of 3 years of follow-up period on maintenance treatment (ranitidine 150 mg or cimetidine 400 mg nightly) was 65%. Three patients were operated upon during the follow-up period due to persistent symptoms in two and recurrence with obstruction in one Surgical procedures were vagotomy + drainage (five patients) and vagotomy + antrectomy (two patients). There were no recurrences in surgically treated patients at an average of 3.5 years of follow-up, and all were graded as Visick I or II.

Combination therapy using adrenaline and heater probe to reduce rebleeding in patients with peptic ulcer haemorrhage: a prospective randomized trial.

A prospective randomized trial was performed to assess the efficacy of the combined therapy of endoscopic injection of adrenaline and heater probe application in the management of patients with major peptic ulcer haemorrhage. Some 153 consecutive patients were randomized to receive either local injection of adrenaline (1:10,000) followed by heater probe thermocoagulation (74 patients) or no endoscopic treatment (79 patients). The two groups were well matched with regard to age, haemoglobin concentration on admission, non-steroidal anti-inflammatory drug usage and endoscopic findings. More patients in the treatment group were in shock on admission (21 versus 13). Initial haemostasis was achieved in all patients randomized to endoscopic therapy. Rebleeding occurred in fewer treated than control patients (five versus 16, P = 0.01). The treated group also had fewer deaths (zero versus two) and requirement for operation (two versus six). The results show that the combination of sclerotherapy with adrenaline and subsequent thermocoagulation reduces the rate of rebleeding in peptic ulcer haemorrhage.

Laparoscopic cholecystectomy for acute cholecystitis.

The safety and efficacy of laparoscopic cholecystectomy for acute cholecystitis were evaluated in a 2-year retrospective review. Results of laparoscopic cholecystectomy in 66 patients with acute inflammation of the gallbladder were compared with those of the standard open procedure for this condition (43 patients) and routine laparoscopic cholecystectomy (227 patients). The laparoscopic procedure for acute cholecystitis was successful in 46 of 66 patients. There was no difference in mean operating time when the inflamed gallbladder was removed laparoscopically or at open surgery (82 versus 84 min); however, each procedure took longer than did routine laparoscopic cholecystectomy (mean 69 min; P < 0.01). There was no difference in analgesic requirement between patients who underwent laparoscopic removal of an acutely inflamed gallbladder and those in the other two groups. Postoperative recovery was significantly faster than that after open surgery (P < 0.01), but took longer than that following routine laparoscopic cholecystectomy (P < 0.01). Inability to identify the cystic duct was the most common reason for conversion to open operation, which occurred in 20 cases of acute cholecystitis. Bile duct injury occurred in one of 66 patients with acute cholecystitis treated laparoscopically, two of 227 cases of routine laparoscopic cholecystectomy but in no patient who underwent open cholecystectomy. In conclusion, laparoscopic cholecystectomy is technically achievable in the majority of patients with acute cholecystitis. The conversion rate is high but, if the procedure is completed successfully, postoperative recovery is more rapid than that after open surgery. However, the method carries a higher incidence of complications and should be attempted only by experienced surgeons.

Endoscopic sphincterotomy for the treatment of cystic duct leak following laparoscopic cholecystectomy.

Two patients who underwent laparoscopic cholecystectomy had postoperative cystic duct leak from slipped metallic clips. One patient presented with biliary ascites and the other with biliocutaneous fistula. Open surgery done in the first patient was not successful in controlling the fistula. Rapid closure of the fistulae was achieved in both cases using endoscopic sphincterotomy.

Future developments in high-technology abdominal surgery: ultrasound, stereo imaging, robotics.

The surgical world is experiencing a revolution brought about by the proliferation of minimally invasive techniques. These developments have had most impact on abdominal surgery and chest surgery, but there are ramifications affecting other fields as well. One feature of this change is the increasing dependence of surgeons on technology. Developments in video imaging, ultrasound and robotics are required to make complex endoscopic procedures surgeon-friendly, just as the minimally invasive approach has made surgery more patient-friendly. In the future, integration of stereo imaging systems, computers, microrobots and robotic manipulators will result in technically sophisticated but ergonomic operating systems that will allow surgeons to perform endoscopically almost any type of surgery that can be done today.

Randomized controlled trial comparing laparoscopic and open appendicectomy.

A study was carried out of 137 patients with a diagnosis of acute appendicitis who were randomized to either laparoscopic or open appendicectomy. Patients found to have perforated or normal appendices at histological examination were excluded. Fifty-two patients undergoing laparoscopic appendicectomy and those receiving 57 open procedures were analysed. Laparoscopic appendicectomy took no longer than the open procedure (mean 43 versus 40 min). The number of doses of pethidine (1 mg per kg body-weight) required in the immediate postoperative period did not differ between the two groups but the mean number of doses of oral analgesic (naproxen sodium 550 mg twice daily) required was less in patients undergoing laparoscopic appendicectomy (2.8 versus 5.0, P < 0.05). There was no significant difference between time to resumption of fluid and diet intake and length of hospital stay. There were five (9 per cent) wound infections after open appendicectomy compared with none after the laparoscopic operation (P < 0.01). Patients who underwent laparoscopy returned to full home (17 versus 30 days, P < 0.01) and social (19 versus 32 days, P < 0.05) activities earlier than those who underwent open operation. Laparoscopic appendicectomy may allow reduction in the number of wound infections and earlier return to normal activities.

Laparoscopic-assisted right hemicolectomy--a case report.

Laparoscopic colon resection has recently attracted attention as a viable option to open colectomy due to its excellent postoperative recovery. We report the first right hemicolectomy done laparoscopically in Asia in a 62-year-old female patient with Dukes-B2 caecal carcinoma. Bowel sounds were present on the first post-operative day (POD) and diet was resumed on the third. The patient was discharged on the fourth POD. There was no complication of anastomotic leakage or wound infection.

Endoscopic hemostasis of bleeding peptic ulcers.

Developments in therapeutic endoscopy over the last decade have made it possible to perform endoscopic hemostasis for bleeding peptic ulcers. This review traces the developments in this field in the Department of Surgery of the National University of Singapore. A recently conducted prospective randomized controlled trial using intralesional adrenaline and heater probe demonstrated that initial hemostasis could be achieved in 100% of patients with actively bleeding ulcers or stigmata of recent hemorrhage. The rebleed rate was 6.6% compared with 20.3% in a well-matched control group. The recent advent of laparoscopic vagotomy and laparoscopic Billroth II gastrectomy offers a low-morbidity surgical option to long-term medical treatment for the follow-up management of patients with bleeding ulcers.

Primary repair of iatrogenic colonic perforations in unprepared colon--a report of five cases.

Primary repair of iatrogenic colonic perforations sustained during pelvic surgery was successfully undertaken in five consecutive cases who did not receive pre-operative bowel preparation. A proximal diverting colostomy was not performed following the repair. There were no instances of intra-abdominal abscess or colonic fistulation. One case developed wound infection. Post-operative recovery in all cases were mostly uneventful with a mean post-operative ileus of four days and a stay of ten days. Primary repair of iatrogenic colonic perforations in unprepared colon can be safely undertaken without a proximal diverting colostomy with acceptable morbidity.

Laparoscopic cholecystectomy in a patient with empyema of the gallbladder and situs inversus.

The successful performance of laparoscopic cholecystectomy in a patient with situs inversus viscerum and empyema of the gallbladder is reported. The 62-year-old man presented with pain in the left upper quadrant associated with fever, chills, nausea and vomiting. The abdomen was tender with guarding and a palpable globular mass in the same region. CT scan demonstrated a distended gallbladder with thick shaggy walls which contained a 2 cm gallstone in the neck and also revealed dextrocardia and situs inversus. The patient's postoperative recovery was uneventful.

Technical modification to laparoscopic appendectomy.

An alternative technique for laparoscopic appendectomy is described. The isolated appendix is exteriorized through the trocar wound, ligated, and resected. The cecum is then returned to the abdomen.