Andreas Polydorou

Endoloop application as an alternative method for gastrotomy closure in experimental transgastric surgery

Background: Experimental studies investigating transgastric endoscopic surgery report closure of the gastric wall incision with clips. The author of this report describes endoloop placement as an alternative, equally efficient, faster method for gastrotomy closure. Methods: Eight female pigs with a mean weight of 30 kg were used. Abdominal endoscopic exploration and transgastric operations including hepatic biopsies, bilateral tubal ligation, cholecystectomy, and closure of the gastrotomy were performed. The experiment was divided into two parts. The first part included five animals, which were killed immediately after the procedure. The second part included five animals, which were kept alive and killed 15 to 20 days later. Results: The first part of the experiment, performed for technical skills acquisition, involved transgastric abdominal exploration, liver biopsies, and bilateral tubal ligation, which were successful for all five animals. The gastric wall incision was closed by applying clips in four animals and endoloops in one animal. During the autopsy at the end of the experiment, the sites of intervention were examined macroscopically. In the second part of the experiment, gastrotomy closure with endoloop application was performed in two animals and with clip application in one animal. All three animals survived, gained weight, and demonstrated no signs of infection. They were killed 15 to 20 days after the procedure, and no signs of intraabdominal infection were found. Cultures from the peritoneal cavity were negative. At necropsy, macroscopic and microscopic examination confirmed complete healing of the gastrotomy. Conclusions: Transgastric endoscopic surgery is technically feasible and effective. The application of endoloops for closure of the gastric opening is a fast, easy, and equally safe alternative to clip placement.

Significance of bile leaks complicating conservative surgery for liver hydatidosis.

Hepatic hydatidosis presents a challenge in liver surgery, and there is still controversy regarding the appropriate surgical technique. A high incidence of postoperative bile leaks is reported as a significant disadvantage of conservative surgical procedures. The purpose of this study was to examine the incidence and clinical importance of bile leakage in patients being treated exclusively by a conservative surgical technique. From January 1985 to November 2000 a total of 187 patients were operated on at our department for hepatic hydatidosis. They were subjected to the standard conservative surgical technique (wide unroofing and cyst drainage). A total of 18 complications were related to bile leakage (10%), 3 of them bile abscesses (1 drained surgically and 2 percutaneously), 1 case of bile peritonitis due to an accessory bile duct in the gallbladder bed (treated surgically), and 14 fistulas (1 bronchobiliary and 13 biliocutaneous). Five of the fistulas, including the bronchobiliary one, were treated successfully by endoscopy; and the remaining nine healed after conservative treatment. Bile leakage, representing a significant complication following conservative operations for hepatic hydatidosis, can be effectively treated conservatively or endoscopically, not justifying more aggressive surgical approaches.RésuméL’hydatitose hépatique représente un véritable challenge en chirurgie hépatique, alors que la meilleure technique chirurgicale est toujours controversée. L’incidence de fistules biliaires postopératoires est élevée: elles représentent l’inconvénient majeur des procédés chirurgicaux conservateurs. Le but de cette étude a été d’analyser l’incidence et l’importance clinique des fuites biliaires chez les patients traités exclusivement par une technique chirurgicale conservatrice. Entre janvier 1985 et novembre 2000, 187 patients ont été opérés dans notre département pour hydatitose hépatique: le procédé chirurgical, standardisé, était conservateur (résection large du dôme saillant et drainage du kyste). Il y avait au total 18 complications en rapport avec une fuite biliaire (10%), trois abcès biliaires (un drainé chirurgicalement et deux par voie percutanée), une péritonite biliaire en rapport avec un canal biliaire accessoire du lit vésiculaire (traitée chirurgicalement), et 14 fistules (une fistule biliobronchique et 13 biliocutanées). Cinq des fistules, y compris la fistule biliobronchique ont été traitées avec succès par voie endoscopique, alors que les neuf autres ont guéri par un traitement conservateur. La fuite biliaire, une des complications possibles après intervention conservatrice pour hydatose hépatique, peut être traitée efficacement de façon conservatrice et endoscopiquement, et ne justifie pas une approche chirurgicale, plus agressive.ResumenLa hidatidosis hepática constituye un desafío en el campo de la cirugía del hígado y todavía se mantiene la controversia acerca de cuál es la técnica quirúrgica más apropiada. Se informa una elevada tasa de fuga biliar postoperatoria como una desventaja significativa de los procedimientos quirúrgicos conservadores. El propósito del presente estudio fue determinar la incidencia y la importancia clínica de la fuga biliar en pacientes manejados con técnica quirúrgica conservadora exclusivamente. Entre enero de 1985 y noviembre de 2000 se operaron 187 pacientes con hidatidosis hepática en nuestro Departamento utilizando una técnica quirúrgica conservadora estandarizada (destechamiento amplio y drenaje del quiste). Se registraron 18 complicaciones relacionadas con fuga biliar (10%), tres de ellas fueron absceso (uno drenado quirúrgicamente y dos en forma percutánea), una peritonitis biliar debida a un conducto biliar accesorio en el lecho de la vesícula biliar (tratado quirúrgicamente) y 14 fístulas (una broncobiliar y 13 biliocutáneas). Cinco de las fístulas, incluyendo la bronchobiliar, fueron manejadas exitosamente mediante endoscopia, en tanto que las nueve restantes cicatrizaron con tratamiento conservador. Las fugas biliares, que representan una complicación significante de las operaciones conservadoras en la hidatidosis hepática, pueden ser efectivamente tratadas con manejo conservador o endoscópico, y no se justifican conductas quirúrgicas más agresivas.

Closure of a persistent sphincterotomy-related duodenal perforation by placement of a covered self-expandable metallic biliary stent

Retroperitoneal duodenal perforation as a result of endoscopic biliary sphincterotomy is a rare complication, but it is associated with a relatively high mortality risk, if left untreated. Recently, several endoscopic techniques have been described to close a variety of perforations. In this case report, we describe the closure of a persistent sphincterotomy-related duodenal perforation by using a covered self-expandable metallic biliary (CEMB) stent. A 61-year-old Greek woman underwent an endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy for suspected choledocholithiasis, and a retroperitoneal duodenal perforation (sphincterotomy-related) occurred. Despite initial conservative management, the patient underwent a laparotomy and drainage of the retroperitoneal space. After that, a high volume duodenal fistula developed. Six weeks after the initial ERCP, the patient underwent a repeat endoscopy and placement of a CEMB stent with an indwelling nasobiliary drain. The fistula healed completely and the stent was removed two weeks later. We suggest the transient use of CEMB stents for the closure of sphincterotomy-related duodenal perforations. They can be placed either during the initial ERCP or even later if there is radiographic or clinical evidence that the leakage persists.

Pancreatic leakage after pancreaticoduodenectomy: the impact of the isolated jejunal loop length and anastomotic technique of the pancreatic stump.

Objectives To evaluate the impact of the length of the isolated jejunal loop and the type of pancreaticojejunostomy on pancreatic leakage after pancreaticoduodenectomy. Methods One hundred thirty-two consecutive patients who underwent a pancreaticoduodenectomy were studied according to the length of the isolated jejunal loop (short loop, 20-25 cm vs long loop, 40-50 cm) and the type of pancreaticojejunostomy (invagination vs duct to mucosa). Results The use of the long isolated jejunal loop was associated with a significantly lower pancreatic leakage rate compared with the use of a short isolated jejunal loop (4.34% vs 14.2%, P < 0.05). In addition, the use of duct-to-mucosa technique was associated with significantly lower incidence of postoperative pancreatic fistula compared with the invagination technique (4.2% vs 14.5%, P < 0.05). Finally, patients with a short isolated jejunal loop compared with patients with a long loop had increased morbidity (50.7% vs 27.5%, P < 0.05) and prolonged hospital stay (16.3 ± 1.9 days vs 10.2 ± 2.3 days, P < 0.05). Overall mortality rate was 1.5%. Conclusions The use of a long isolated jejunal loop and a duct-to-mucosa pancreaticojejunostomy is associated with decreased pancreatic leakage rate after pancreaticoduodenectomy.

Treatment of hydatid liver disease.

BACKGROUND Echinococcal disease is still a serious problem in certain parts of the world. The liver is the organ affected most frequently. Over recent decades, various reports have been published comparing standard surgical and more conservative modalities for the treatment of the disease. Proper selection among the strategies reported so far could be the most appropriate part of successful patient management. METHODS A thorough review of the most recent reports on the treatment of liver Echinococcus infection, including percutaneous drainage, medical management, and laparoscopic, endoscopic and open surgical approaches has been conducted, focusing on patient outcomes. RESULTS The standard surgical approach, namely partial capsectomy, drainage, and epiploplasty, remains the most frequent operative method. Previous problems such as disease recurrence and a residual cavity seem to be managed optimally with more radical operations such as total pericystectomy. Laparoscopic and endoscopic approaches (endoscopic retrograde cholangiopancreatography and sphincterotomy) appear to have a crucial role, especially when the location of the cyst or the patients status does not permit more radical approaches. Percutaneous computed tomography- or ultrasound-guided drainage appears to be of great value in certain cases. Chemotherapeutic agents remain useful as an adjuvant treatment. CONCLUSIONS Appropriate patient selection and proper use of the various available treatments are of great importance. A tailor-made approach should be employed for each patient. The surgeons experience constitutes a principal criterion. To achieve the best possible results, an interdisciplinary approach should be used in the majority of patients.

A tailored approach to the management of perforations following endoscopic retrograde cholangiopancreatography and sphincterotomy.

BackgroundThe management of endoscopic retrograde cholangiopancreatography (ERCP)-related perforations remains controversial. Τhe aim of the study was to determine the incidence of perforations following ERCP, their characteristics, operative and non-operative management options and clinical outcome.MethodsA retrospective review of ERCP-related perforations, during a 21-year period, was performed. Each perforation was categorized into types I to IV according to the location, mechanism and radiographic evaluation of the injury. Comparisons were made between patients treated operatively and non-operatively.ResultsForty-four perforations (0.4%) occurred in 9,880 procedures. They were mainly caused by the passage of the endoscope (type I) in 7 (16%) and sphincterotomy (type II) in 30 (68%) patients. The management was non-operative in 32 (72%) and operative in 12 patients. In multivariate analysis, only the type of perforation (type I: endoscope-related) was found significant for predicting operative treatment. The hospital stay was longer for patients requiring an operation (median, 24 vs 9 days). The overall mortality was 2/44 (4.5%). There was no death in the non-operative group.ConclusionsThe need for immediate operative intervention should be based on the type of injury and clinical findings. Patients with type I perforations should be treated surgically and primary repair should be tried. Patients with type II injuries may be treated initially non-operatively. Delayed operative intervention will be required in a minority of these patients.

Two Cases of Primary Splenic Hydatid Cyst in Greece

Cystic disease of the spleen is an uncommon entity in general population. Most cases result from parasitic infection by Echinococcus granulosus, a form called splenic hydatid disease (SHD), with a reported frequency of 0.5-6.0% within abdominal hydatidosis. On the contrary, an isolated splenic involvement of hydatid disease is very uncommon even in endemic regions. Two cases of primary SHD managed with open and laparoscopic radical surgery in our department are reported herein. Primary SHD is a rare entity with non-specific symptoms underlying clinical suspicion by the physician for prompt diagnosis. Surgical treatment is the mainstay therapy, while laparoscopic approach when feasible is safe, offering the advantages of laparoscopic surgery.

A multimodal approach to acute biliary pancreatitis during pregnancy: a case series.

The treatment of acute biliary pancreatitis during pregnancy remains controversial. We present our experience of treating 7 pregnant women with acute biliary pancreatitis and verified or suspected choledocholithiasis, by using magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and sphincterotomy followed by laparoscopic cholecystectomy. MRCP was performed in all patients to confirm the presence of common bile duct stones, their size and number. ERCP and sphincterotomy were performed without the use of radiation. The procedure was terminated only when all stones (the number clarified at MRCP), were retrieved into the duodenum. All patients underwent laparoscopic cholecystectomy the following day. Neither post-ERCP nor postoperative major complications were noted. All but one patient reached a healthy natural-term labor. One patient had a planned cesarean section on 35th week. The combination of MRCP, nonradiation ERCP, and immediate laparoscopic cholecystectomy provides definite treatment and seems to put both mother and fetus at lower risk than presumed.

An ongoing dispute in the management of severe pancreatic fistula: Pancreatospleenectomy or not?

The aim of this manuscript is to review controversies in managing severe pancreatic fistula after pancreatic surgery. Significant progress in surgical technique and perioperative care has reduced the mortality rate of pancreatic surgery. However, leakage of the pancreatic stump still accounts for the majority of surgical complications after pancreatic resection. Various strategies have been employed in order to manage pancreatic fistula. Nonetheless high grade pancreatic fistula evokes controversy in relation to the choice of treatment. A Medline search was performed, with regard to conservative treatment options versus completion pancreatectomy for the management of pancreatic fistula grade C. Pancreatic fistula rates remain unchanged with an incidence ranging from 5%-20% and this is considered as the most important cause of postoperative death. Many authors claim that completion pancreatectomy has probably lost its role in favour of interventional radiology procedures, while others believe that completion pancreatectomy continues to have a place in the management of patients with severe clinical deterioration after pancreatic fistula who do not respond to non-surgical interventions. There is no agreement on the best clinical management of severe pancreatic fistula after pancreatic surgery. Completion pancreatectomy is reserved for patients not improving with conventional measures.

Esophagopericardial fistula as a rare complication after total gastrectomy for cancer

BackgroundEsophagopericardial fistula is a rare but life-threatening complication of benign, malignant or traumatic esophageal disease. It is most commonly associated with benign etiology and carries a high mortality rate which increases with delay in diagnosis.Case presentationWe present a case of an esophagopericardial fistula as a rare complication in a 53-year-old male patient, 7 months after total gastrectomy for an adenocarcinoma of the esophagogastric junction.ConclusionThe prognosis of esophagopericardial fistula is poor, especially when it is associated with malignancy.