Long-term retention of endoscopically placed hydrogel prostheses at the lower esophageal sphincter in pigs.

BACKGROUND: Using flexible endoscopic methods, hydrogel prostheses can be safely placed, retained for long periods of time, and removed from the esophageal submucosa of pigs. This new technique may have future applications in the treatment of gastroesophageal reflux disease in selected situations. METHODS: In a controlled, prospective trial, farm pigs ( n = 28) or Sinclair mini-swine ( n = 18) underwent sequential placements of 2-13 pliable, radio-opaque hydrogel prostheses into the submucosa of the esophagus during a single endoscopy session. A novel endoscope-overtube device was used. Followup endoscopy and/or fluoroscopy sessions were video-recorded at 6-week, 12-week, 6-month, and yearly intervals. The endoscopic removal of hydrogels was tested in vivo. Necropsy specimens were inspected for signs of chronic inflammation. RESULTS: Overall, 98% of delivery attempts were successful (288/293). Only three hydrogels were lost after 6 weeks. Short-term animals ( n = 36) retained 88% of hydrogels for periods up to 6 months. Intact hydrogels ( n = 12) were easily removed from four animals at endoscopy. Long-term subjects had two or three hydrogels per animal, using either a beveled-needle device (six pigs) or a trocar design (four pigs). Trocar design: nine of nine prostheses retained at 3 years (100%). Needle design: nine of 10 prostheses retained at 3 years (90%). No significant adverse event occurred. Growth curves were similar between groups. All hydrogels remained pliable to gross inspection upon in vivo removal or necropsy. Pathology showed minimal fibrosis and no chronic inflammation. CONCLUSIONS: A novel endoscopic overtube device allows for the successful delivery of multiple hydrogel prostheses with acceptable safety and long term retention rates. These hydrogel prostheses can also be easily removed from the submucosal space of the esophagus.

Value of three-dimensional US for optimizing guidance for ablating focal liver tumors.

PURPOSE: To determine if three-dimensional ultrasound (3D US), by nature of its ability to simultaneously evaluate structures in three orthogonal planes and to study relationships of devices to tumor(s) and surrounding anatomic structures from any desired orientation, adds significant additional information to real-time 2D US used for placement of devices for ablation of focal liver tumors. MATERIALS AND METHODS: Sixteen patients underwent focal ablation of 23 liver tumors during two intraoperative cryoablation (CA) procedures, three intraoperative radiofrequency ablation (RFA) procedures, 11 percutaneous ethanol injections (PEI) procedures, and six percutaneous RFA procedures. After satisfactory placement of the ablative device(s) with 2D US guidance, 3D US was used to reevaluate adequacy to device position. Information added by 3D US and resultant alterations in device deployment were tabulated. RESULTS: 3D US added information in 20 of 22 (91%) procedures and caused the operator to readjust the number or position of ablative devices in 10 of 22 (45%) of procedures. Specifically, 3D US improved visualization and confident localization of devices in 13 of 22 (59%) procedures, detected unacceptable device placement in 10 of 22 (45%), and determined that 2D US had incorrectly predicted device orientation to a tumor in three of 22 (14%). CONCLUSIONS: Compared to conventional 2D US, 3D US provides additional relationship information for improved placement and optimal distribution of ablative agents for treatment of focal liver malignancy.

Endoscopic prosthesis augmentation of the lower esophageal sphincter in swine.

HYPOTHESIS: Endoscopically delivered prostheses are safe, durable, and may augment a defective lower esophageal sphincter (LES). METHODS: Pigs were studied as normal-LES or LES-weakened animals. A novel endoscopic delivery system was developed in order to place multiple hydrogel prostheses into the LES submucosa. Histopathology sections evaluated ultimate durability and the relationship of the prostheses to esophageal anatomy. RESULTS: Overall, 97% of 179 prosthesis delivery attempts were successful. LES-weakened animals had LES pressures return to normal or supranormal values at 2 weeks and 2 months after prosthesis augmentation. Weakened gastric yield pressures improved to normal values at 2 weeks after prosthesis augmentation. The thickness of the muscular layers and the mucosal integrity of the esophagus was unaffected by the retained prostheses. CONCLUSIONS: Endoscopically delivered hydrogel prostheses are safe and durable. These prostheses can successfully augment a defective sphincter without recognizable damage to the esophagus.

Factors influencing survival after resection for periampullary neoplasms.

BACKGROUND: The purpose of this study was to determine predictors of survival after resection for periampullary neoplasms. METHODS: Over a 15-year period, 208 patients underwent laparotomy for periampullary neoplasms. Data were analyzed to assess predictors of survival. RESULTS: Pathologic examination showed pancreatic cancer (n = 136; 65%), ampullary cancer (n = 28; 13%), distal common bile duct cancer (n = 10; 5%), duodenal cancer (n = 4; 2%), neuroendocrine tumor (n = 11; 5%), cystadenocarcinoma (n = 4; 2%), cystadenoma (n = 5; 2%), and other (n = 10; 5%). A total of 129 patients underwent pancreatic resection (71 Whipples, 35 total pancreatectomies, 21 distal pancreatectomies, and 2 partial pancreatectomies) whereas 79 patients were found to be unresectable and underwent palliative bypass and/or biopsy. Median survival was 20.4 months for resectable patients versus 4.5 months for unresectable patients (P<0.001). Of the 129 resected patients, factors significantly (P<0.05) favoring long-term survival on univariate analysis included well-differentiated histology, common bile duct or ampullary adenocarcinoma, early stage, tumor diameter <2 cm, negative margins, and absence of lymph node metastases, perineural, or vascular invasion. Age, sex, race, and type of procedure had no influence on survival. On multivariate analysis, only tumor differentiation appeared independently related to survival. Using Kendall's tau analysis, tumor type and grade correlated significantly with all other predictors. CONCLUSIONS: Of all variables studied, tumor type and poor tumor differentiation in periampullary neoplasms appear to be markers that predict a constellation of other adverse findings.

Laparoscopy-assisted endoscopic removal of a stromal-cell tumor of the stomach.

Endoscopic resection of gastrointestinal tumors is being performed with increased frequency. Submucosal mass lesions pose a particular problem, because of the risk of malignancy and the risk of complications associated with endoscopic removal. Increased incidences of both perforation and bleeding have been reported. We report here on a case in which we used a combined approach that included gastrointestinal endoscopy, laparoscopy, and laparoscopic ultrasound to resect a gastric leiomyoma. We consider that this approach enhanced our diagnostic capabilities, provided intraoperative options for resection, and enhanced the safety of the procedure.

Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature.

PURPOSE: To evaluate the effectiveness and safety of radiologic, percutaneous endoscopic (PEG), and surgical gastrostomy. MATERIALS AND METHODS: This project involved 5,752 patients (837 patients underwent radiologic gastrotomy; 4,194, PEG; and 721, surgical gastrostomy). Seventy-two (47 male, 25 female; age range, 12-94 years) underwent gastrostomy within 1 year in this series (radiologic gastrostomy, n = 33; PEG, n = 35; surgical gastrostomy, n = 4). A meta-analysis of 5,680 additional cases from literature published from 1980 to the present was also performed. RESULTS: Rates of successful tube placement were higher for radiologic gastrostomy than for PEG in our series and in the meta-analysis (99.2% vs 95.7%, P < .001). Major complications occurred less frequently after radiologic gastrostomy in our series and in the meta-analysis (5.9% vs 9.4% for PEG and 19.9% for surgery, P < .001). Thirty-day procedure-related mortality rates were highest for surgery (2.5% vs 0.3% for radiologic gastrostomy and 0.53% for PEG, P < .001). CONCLUSION: Radiologic gastrostomy is associated with a higher success rate than is PEG and less morbidity than either PEG or surgery.

Laparoscopy to correctly diagnose and stage metastatic breast cancer mimicking Crohn's disease.

We report a case of metastatic lobular breast carcinoma with extrahepatic gastrointestinal disease. On the basis of clinical findings, radiologic investigations, computerized axial tomography, gastrointestinal endoscopy, and gastric biopsy, the diagnosis of gastric and ileal Crohn's disease was made. The correct diagnosis of peritoneal carcinomatosis was made at laparoscopy. This case exemplifies the utility of laparoscopy in establishing the diagnosis and staging for abdominal disease of uncertain etiology.

Complications of laparoscopic cholecystectomy: coordinated radiologic and surgical management in 21 patients.

The authors describe their experience in management of bile duct injuries (n = 11), bile leaks or abscesses (n = 11), and bleeding (n = 1) as complications of laparoscopic cholecystectomy in 21 patients. Clinical presentations included jaundice, sepsis, pain, abdominal distention, and persistent gallstones. Twelve patients underwent operative cholangiography, three underwent conversion to open cholecystectomy, and 12 reoperations were performed in nine patients before interventional radiologic procedures, which included diagnostic percutaneous transhepatic cholangiography (n = 13), percutaneous biliary drainage (PBD) (n = 13), percutaneous stricture dilation (n = 3), stent insertion (n = 1), percutaneous abscess or biloma drainage (n = 19), and gallstone removal (n = 1). Each procedure was technically successful. Clinical improvement occurred in 18 of 19 patients. PBD was used as an operative guide before reconstructive surgery in two patients. Reoperation was unnecessary in 10 of 21 patients (48%). One patient died of fungal sepsis and pulmonary complications. This radiologic-surgical approach provided rapid and safe management of these complications.

The utility of diagnostic laparoscopy for abdominal disorders. Audit of 120 patients.

We audited our recent experience with diagnostic laparoscopy performed over a 30-month period on 131 consecutive patients. Laparoscopy was 100% accurate in the diagnosis or exclusion of intra-abdominal malignant neoplasms, and future care decisions were affected by this information. Laparoscopy in the evaluation of chronic abdominal pain yielded positive findings in 47% of cases. The majority of referrals (73%) for the investigation of chronic abdominal pain came from the medical services, whereas the majority of referrals (72%) for the investigation of cancer originated from surgeons. Laparoscopy in the setting of acute abdominal pain yielded useful information that affected patient outcomes in 71% of cases. There were no serious complications in this series. Laparoscopy is a safe and useful diagnostic tool, especially for the diagnosis, staging, or exclusion of cancer.

Laparoscopic injuries to the bile duct. A cause for concern.

The authors report six patients who had injuries to their common hepatic bile duct at laparoscopic cholecystectomy over a 16-month period. Five of the six complications could be attributed to laser injuries during dissection in the region of Calot's triangle. The authors discuss the possible mechanism of these injuries, their perioperative management, and the methods of surgical reconstruction. The follow-up period ranges from 3 months to 21 months. Liver function parameters and isotope biliary excretion scans are back to normal in all six patients. The potential hazards of laparoscopic surgery demand that extraordinary care be used not only during the actual surgical procedure, but also in the preoperative decision concerning the dissection method to be employed.

Total pancreatectomy with preservation of the duodenum and pylorus for chronic pancreatitis.

In an effort to minimize the nutritional complications that follow resection of the pancreas for severe chronic pancreatitis, the authors have performed a duodenum-preserving total pancreatectomy in eight patients for severe unremitting pain requiring large doses of opiate analgesia. Good relief of pain was obtained in six patients (75%), in whom the quality of life was undoubtedly improved. There were no problems with the control of diabetes after this procedure in any of these patients, and no patient has suffered any hypoglycemic attacks requiring medical treatment. This improved control of the diabetic state is probably related to a more physiologic state of the upper digestive tract, enabling a normal food intake. The authors found the operation to be technically difficult, however, and although there were no post-operative deaths, major complications were encountered in four patients. These consisted of postoperative bleeding requiring reoperation (two patients), sepsis, and a duodenal fistula, which progressed to stenosis.

A prospective, randomized comparison of computed tomography with conventional diagnostic methods in the evaluation of penetrating injuries to the back and flank.

We prospectively compared computed tomography with conventional diagnostic methods in the evaluation of penetrating injuries to the back and flank in 85 patients. Immediate laparotomy was performed in 24 patients because of physical findings, and these patients were not randomized. Nine unnecessary operations were performed in this group, and these nine patients had significantly higher hospital costs than patients in either randomized group. In the randomized patients, there were only three true-positive and three false-positive findings. Both computed tomographic evaluation (31 patients) and conventional evaluation (30 patients) were highly accurate and specific for injuries that required operation. Evaluation with computed tomography required a longer time to make a hospital disposition but required fewer diagnostic tests. Computed tomography can be useful in the assessment of penetrating injuries to the back and flank.

Ligation of the structures of the cystic pedicle during laparoscopic cholecystectomy.

Advances in optics, endotelevision monitoring, and instrumentation have led to the development of laparoscopic cholecystectomy. As in the open, standard operation, the crucial step is the dissection of the cystic pedicle containing the respective duct, artery, and lymph node. All the groups involved in laparoscopic cholecystectomy have to date opted for the use of applicators to clip the cystic duct and artery. As there are intrinsic disadvantages to the use of clips, we report an alternative method which involves ligation of these structures using the Roeder slip knot with dry chromic catgut. The safety margin of this knot was initially tested in vitro using a Instrom tensiometer. Under these experimental conditions, the Roeder slip knot tied with #0 dry chromic catgut ligature started to yield at 225 g. As the estimated tension on the cystic duct (1.1 g) and a 4-mm artery (6.0 g) in vivo is well below this figure, the safety of this knot with dry catgut in clinical practice is beyond question. The technique of Roeder slip-loop knotting was used to ligate the cystic artery and duct in a consecutive series of 80 patients undergoing laparoscopic cholecystectomy. This clinical experience has confirmed its safety and ease of execution. The particular advantages of Roeder loop ligation include execution through a 5.5-mm cannula and accurate placement of the knot. In addition, the technique requires less length of mobilized duct and artery, which is an important practical consideration in patients with a fibrosed gallbladder and shortened cystic pedicle.

Laparoscopic repair/peritoneal toilet of perforated duodenal ulcer.

Laparoscopic techniques have been refined to the point where exposure, haemostasis and tissue approximation by suture approach those obtained at open access surgery. We report a patient with acute perforation of an ulcer in the first part of the duodenum who was successfully treated by laparoscopic oversewing and omental patching. The clinical indications for contemplating use of laparoscopic surgery for acute ulcer perforation, techniques employed and the areas for potential improvement of instruments, needles and sutures are discussed.

Recent trends in the management of desmoid tumors. Summary of 19 cases and review of the literature.

Recent advances in the understanding of desmoid tumor biology affect therapeutic choices. This series of 19 patients and review of the literature outlines historic perspectives and discusses the options in the management of these locally aggressive tumors. Desmoid tumors tend to grow steadily, regardless of tumor location. However differences in the aggressive nature of these tumors are seen when age and sex distributions are scrutinized. Although recurrence rates are high, excisional therapy is the best first approach. An exception is the case in which tumor excision is either particularly dangerous or likely to result in significant physical handicap. Radiation or drug therapy are most often used with recurrent disease or as an alternative to mutilating surgery. Although many pharmacologic approaches have been advocated, (including antiestrogen therapy, cyclic-AMP, and prostaglandin inhibition), results are anecdotal at best.