Complications of laparoscopic transgastric ERCP in patients with Roux-en-Y gastric bypass.

BACKGROUND: The altered anatomy of Roux-en-Y gastric bypass presents a challenge when duodenal access is required for ERCP. One technique, laparoscopic transgastric ERCP, was first described in 2002. Since that time, a total of 77 laparoscopic or percutaneous transgastric ERCPs have been reported. The largest case series includes 26 ERCPs, and no reports specifically address complications. We reviewed our experience with 85 transgastric ERCPs and report the limitations and complications associated with access and ERCP. METHODS: Retrospective review was conducted of gastric bypass patients who underwent transgastric ERCP in our practice from 2004-2014. RESULTS: Forty-one patients underwent 85 transgastric ERCPs during the study period. Conversion from laparoscopic to open procedure occurred in 4.8%, and selective cannulation rate was 93%. Forty-seven percent of cases were repeat ERCPs performed through a gastrostomy tube tract. During 15-month median follow-up, the overall complication rate was 19%, with 88% of complications related to access rather than ERCP. Most complications were minor; there were no deaths or cases of severe pancreatitis. Additional intervention, including repair of a posterior stomach laceration or transfusion for bleeding, occurred in 4.7% of cases. Operative intervention occurred in two cases: repair of a duodenal perforation, and debridement of an abdominal wall abscess. Post-ERCP hyperamylasemia was common but did not result in increased length of stay or significant clinical pancreatitis. CONCLUSIONS: Roux-en-Y gastric bypass eliminates the normal approach to the duodenum for ERCP. Transgastric access has a high rate of successful cannulation but is associated with complications. Conversion to open procedure occurred in 4.8%, and 16% developed a complication related to the access site, though the rate of operative intervention was low (2.4%). Our study is limited by its retrospective design, which may underestimate the complication rate, and by our homogenous patient population (94% female, 68% sphincter of Oddi dysfunction).

General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors.

OBJECTIVE: To assess readiness of general surgery graduate trainees entering accredited surgical subspecialty fellowships in North America. METHODS: A multidomain, global assessment survey designed by the Fellowship Council research committee was electronically sent to all subspecialty program directors. Respondents spanned minimally invasive surgery, bariatric, colorectal, hepatobiliary, and thoracic specialties. There were 46 quantitative questions distributed across 5 domains and 1 or more reflective qualitative questions/domains. RESULTS: There was a 63% response rate (n = 91/145). Of respondent program directors, 21% felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications. Finally, it was felt that the majority of new fellows were unable to conceive, design, and conduct research/academic projects. Thematic clustering of qualitative data revealed deficits in domains of operative autonomy, progressive responsibility, longitudinal follow-up, and scholarly focus after general surgery education.

Safe techniques for endoscopic resection of gastrointestinal lipomas.

PURPOSE: Gastrointestinal (GI) lipomas are rare, benign, slowly growing, submucosal tumors, which can either be incidentally found as silent tumors of the GI tract or be the cause for GI bleeding, anemia, intussusception, and bowel obstruction. Endoscopic removal is a valid alternative to surgical resection of these tumors. In the recent past, many submucosal lipomas were for the most part resected surgically due to the risk of perforation using endoscopy. There are newer techniques available to allow safe endoscopic removal of these lesions. We present 3 successful techniques tailored to the location of the lipoma and size. METHODS: In our unit, 3 symptomatic GI lipomas were referred to us for surgical resection, 2 originating from the duodenum and 1 from the cecum were diagnosed and resected under endoscopic ultrasound and endoscopy. We performed 3 different techniques to remove these lipomas. One of the lipomas in the duodenum was in the duodenal bulb. It was mobile and 3 cm in size. We attempted to remove this broad-based lipoma by snare and cut technique after its borders were elevated with injection of saline and epinephrine. The second duodenal lipoma was 1.5 cm. This pedunculated lipoma was located in the second portion, on the pancreatic side of the duodenum proximal to ampulla. This lipoma was lifted up with a snare and its base was cauterized resulting in successful removal. The third GI lipoma was 3.5 cm in size pedunculated and located in the cecum. The base of this pedunculated lipoma was ligated with poly loop device and endoclip resulting in ischemia and spontaneous separation of the lipoma from the colonic wall. All cases were revisited with follow-up endoscopy. All 3 methods, when used selectively, were found to be very safe and effective. RESULTS: All 3 lesions were successfully removed and histopathologically confirmed to be lipomas. After endoscopic removal, no complications were observed. CONCLUSIONS: Carefully selected GI lipomas, which in the past have required surgical resection due to high risk for perforation can be endoscopically removed with great success.

Laparoscopic transgastric endoscopic retrograde cholangiopancreatography (ERCP) after gastric bypass: case series and a description of technique.

BACKGROUND: Roux-en-Y gastric bypass excludes the biliary and pancreatic tree from traditional endoscopic evaluation and treatment. As the number of former bypass patients accrues, the need to assess and treat this subset of patients for biliary and pancreatic disease will increase. The authors describe their technique, indications, and outcomes for this group of patients. METHODS: Data were collected by a retrospective chart review of the experience two surgeons had with laparoscopically assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP) from July 2004 to October 2008 at a single institution. This review identified 22 cases. The operating surgeon performed the entire procedure. The indications were suspected sphincter of Oddi dysfunction in 18 patients and recurrent pancreatitis in four patients. Adhesions were lysed, and a purse-string suture was placed on the anterior portion of the stomach. A gastrotomy was made with monopolar electrocautery, and a 12 mm trocar was inserted. It was secured with a purse-string suture. A side-viewing duodenoscope was inserted through this port. An intestinal clamp was placed on the biliopancreatic limb. The intended interventions were sphincter of Oddi manometry, sphincterotomy, placement of a pancreatic duct stent, and injection of botulinum toxin if indicated. RESULTS: Laparoscopic access to the remnant stomach was sufficient for ERCP in 21 cases. One patient required conversion to an open procedure. A total of 12 patients had undergone prior open upper abdominal surgery. One retroperitoneal perforation was noted, with precut sphincterotomy and cannulation of the minor duodenal papilla and no clinical repercussions. Manometry was performed for 18 patients. The pancreatic duct cannulation rate for manometry was 89%, and the rate of bile duct cannulation for manometry was 94%. The manometry studies for 12 patients yielded abnormal results. Eight patients had transient improvement, and three patients had long-term improvement or resolution of symptoms after the index procedure. With additional treatment, two of the transient responders had long-term resolution of symptoms. CONCLUSIONS: The findings demonstrate that gastric bypass patients with biliary pain can be successfully evaluated endoscopically by laparoscopic transgastric ERCP for sphincter of Oddi dysfunction. The rate for technical success and complications does not appear to be significantly greater than for standard ERCP. A few helpful techniques were noted during this experience. Comparison of efficacy with that of a prior study was limited.

Management of postgastric bypass noninsulinoma pancreatogenous hypoglycemia.

INTRODUCTION: Postgastric bypass noninsulinoma hyperinsulinemic pancreatogenous hypoglycemia defines a group of patients with postprandial neuroglycopenic symptoms similar to insulinoma but in many cases more severe. There are few reports of patients with this condition. We describe our surgical experience for the management of this rare condition. METHODS: A retrospective study was performed at St. Vincent Hospital, Indianapolis. Fifteen patients were identified with symptomatic postgastric bypass hypoglycemia for the period 2004-2008. All patients were initially treated with medical therapy for hypoglycemia. Nine patients eventually underwent surgical treatment. The preoperative workup included triple-phase contrast CT scan of the abdomen, endoscopic ultrasound of the pancreas, a 72-h fast followed by a mixed meal test, and calcium-stimulated selective arteriography. Intraoperative pancreatic ultrasound also was performed in all patients. Patients then underwent thorough abdominal exploration, exploration of the entire pancreas, and extended distal pancreatectomy. RESULTS: Nine patients underwent surgery. The mean duration of symptoms was 14 months. The 72-h fast was negative in eight patients (as expected). Triple-phase contrast CT scan of the abdomen was negative in eight patients and showed a cyst in the head of pancreas in one patient. Extended distal (80%) pancreatectomy was performed in all nine patients. The procedure was attempted laparoscopically in eight patients but was converted to open in three. One patient had an open procedure from start to finish. Pathology showed changes compatible with nesidioblastosis with varying degrees of hyperplasia of islets and islet cells. Follow-up ranged from 8-54 (median, 22) months. All patients initially reported marked relief of symptoms. Over time, two patients had complete resolution of symptoms; three patients developed occasional symptoms (once or twice per month), which did not require any medication; two patients developed more frequent symptoms (more than twice per month), which were controlled with medications; and two patients had severe symptoms refractory to medical therapy (calcium channel blockers, diazoxide, octreotide). DISCUSSION: Postprandial hypoglycemia after gastric bypass surgery with endogenous hyperinsulinemia is being increasingly recognized and reported in the literature. Our experience with nine patients is one of the largest. The etiology of this condition is not entirely understood. There may be yet unknown factors involved but increased secretion of glucagon-like peptide 1 and decreased grehlin are being implicated in islet cell hypertrophy. There is no "gold standard" treatment-medical or surgical-but distal pancreatectomy to debulk the hypertrophic islets and islet cells is the main surgical modality in patients with severe symptoms refractory to medical management.

A standardized resident training program in endoscopic surgery in general and in laparoscopic totally extraperitoneal (TEP) inguinal hernia repair in particular.

The need for acquisition of specific laparoscopic skills has emphasized the role of a preclinical laboratory-training program. However, for laparoscopic inguinal hernia repair with a steep learning curve, especially for totally extraperitoneal repair, preclinical skill training remains a challenge. A standardized preclinical resident training program in endoscopic surgery is described. Also, a standardized clinical training program is proposed with systematic dissection in 10 different consecutive steps for totally extraperitoneal inguinal hernia repair. Continuous mentoring by an expert is an absolute prerequisite to the success of this training program. In this way, the learning period may be drastically reduced to approximately 30 procedures, in whom the resident progressively performs more and more of the different steps, and ultimately the complete procedure. Validation studies at different institutions are starting up to demonstrate the additional value of this training program.

The routine use of laparoscopic ultrasound decreases bile duct injury: a multicenter study.

OBJECTIVE: Laparoscopic ultrasound (LUS) has been used for over 15 years to screen the bile duct (BD) for stones and to delineate anatomy during laparoscopic cholecystectomy (LC). LUS as a modality to prevent BD injury has not been investigated in a large series. This study evaluated the routine use of LUS to determine its effect on preventing BD injury. METHODS: A multicenter retrospective study was performed by reviewing clinical outcome of LC in which LUS was used routinely. RESULTS: In five centers, 1,381 patients underwent LC with LUS. LUS was successful to delineate and evaluate the BD in 1,352 patients (98.0%), although it was unsuccessful or incomplete in 29 patients (2.0%). LUS was considered remarkably valuable to safely complete LC, avoiding conversion to open, in 81 patients (5.9%). The use of intraoperative cholangiography (IOC) varied depending on centers; IOC was performed in 504 patients (36.5%). For screening of BD stones (which was positive in 151 patients, 10.9%), LUS had a false-positive result in two patients (0.1%) and a false-negative result in five patients (0.4%). There were retained BD stones in three patients (0.2%). There were minor bile leaks from the liver bed in three patients (0.2%). However, there were no other BD injuries including BD transection (0%). Retrospectively, IOC was deemed necessary in 25 patients (1.8%) to complete LC in spite of routine LUS. CONCLUSION: LUS can be performed successfully to delineate BD anatomy in the majority of patients. The routine use of LUS during LC has obviated major BD injury, compared to the reported rate (1 out of 200-400 LCs). LUS improves the safety of LC by clarifying anatomy and decreasing BD injury.

Current status of laparoscopic ultrasound.

The purpose of this chapter is to introduce the beginning surgeon ultrasonographer to the use of ultrasound during laparoscopic surgery. The authors routinely use ultrasound in the intraoperative, endoscopic, and office settings. The importance of ultrasound in the various surgical specialties is well documented in the literature. Since the introduction of minimally invasive techniques to General Surgery, many advanced applications of ultrasonography have been developed. Confident examinations of intraabdominal anatomy, pathologic conditions, and therapeutic procedures can readily be performed. In this chapter, a comprehensive introduction to laparoscopic ultrasound is presented to the practicing General Surgeon. The basic equipment requirements and setup are explained. Fundamental techniques of laparoscopic ultrasound examination are described. The authors' method of screening for common bile duct stones during routine laparoscopic cholecystectomy is illustrated. Examination of the normal biliary tree with helpful hints is presented. The authors' systematic technique of visualizing the normal liver parenchyma is described. Common benign and malignant findings are elucidated. A brief synopsis of pancreatic ultrasonography with attention to pathologic findings is provided. Uses of ultrasound in unanticipated situations are introduced. With perseverance, the reader will discover that laparoscopic ultrasound skills can be readily attained.

Groin hernia repair by laparoscopic techniques: current status and controversies.

Laparoscopic hernia repair remains controversial, and its position in current hernia surgery remains in flux. In this article we attempt to put the laparoscopic approach in perspective by describing the rationale for its development. We summarize studies comparing it with open repairs, including recent publications, meta-analyses, and systematic reviews; and we then contrast the data with recent findings of the United States Veterans Affairs Cooperative study 456. We discuss the current and future status of the laparoscopic approach to inguinal hernia repair and present an update of our own laparoscopic totally extraperitoneal technique without mesh fixation. From 1994 to 2004 we performed 314 hernia repairs on 224 patients with no intraoperative complications, no conversions to an open procedure, and no mortality. Thirty (14%) minor postoperative complications occurred. There were three herniated lipomas (preperitoneal fat) but no true peritoneal reherniations. We evaluate critical points of laparoscopic hernia repair including extensive preperitoneal dissection, mesh configuration, size and fixation, cost reduction, and the learning curve.

Endoscopic ultrasonography.

Endoscopic ultrasound (EUS) was introduced in the early 1980s in an attempt to improve sonographic imaging of the pancreas. Its uses have been expanded to include examination of the upper and lower gastrointestinal tracts, hepatobiliary and portal systems,and the anal sphincter; diagnosis and staging of esophageal, gastric,and pancreaticobiliary tumors; and evaluation of mediastinal nodes in lung cancer. Although EUS has its limitations and is greatly dependent on operator skill, it has wide-ranging interventional and therapeutic applications that can be expected to increase in the future with technologic advances and greater educational opportunities for physicians.

Laparoscopic repair for groin hernias.

So where do things stand in 2003? Laparoscopic herniorrhaphy appears to result in less postoperative pain (acute and chronic) and in a shorter convalescence and an earlier return to work, compared with the open repair. It can be performed safely and with a low recurrence rate. However, it takes longer to do, is more difficult to learn, and costs more, all reasons why it is not more commonly performed. Currently, laparoscopic herniorrhaphy accounts for 15% to 20% of hernia operations in America and around the world. Who can blame the surgeon in a community practice for opting for the open mesh repair, operating on familiar anatomy, and using familiar techniques? Nevertheless, with efforts to cut costs by eliminating disposable equipment and honing skills to decrease operating time, laparoscopic herniorrhaphy will probably continue to be a contender, especially for the younger patient who wants to return to work quickly and for patients with bilateral and recurrent hernias. It is arguable that surgeons should possess skill in both open and laparoscopic techniques and should know the indications for each--some hernias are best repaired laparoscopically. That said, laparoscopic herniorrhaphy will most likely be performed by those with a special interest and proficiency in the technique. At the least, the laparoscopic revolution and laparoscopic hernia repair have helped elevate the study of hernia anatomy and herniorrhaphy to a position it deserves and this has made us all better hernia surgeons. What was once the stepchild of general surgery now occupies a more prominent and respectable place. With the continuing efforts of dedicated, energetic investigators, we should continue to see advances in the safe and effective repair of this most common of surgical maladies.