Frederick W. Heiss

Open-label, sham-controlled trial of an endoscopic duodenojejunal bypass liner for preoperative weight loss in bariatric surgery candidates.

BACKGROUND The duodenojejunal bypass liner (DJBL) (EndoBarrier Gastrointestinal Liner) is an endoscopically placed and removable intestinal liner that creates a duodenojejunal bypass resulting in weight loss and improvement in type 2 diabetes mellitus. OBJECTIVE Weight loss before bariatric surgery to decrease perioperative complications. DESIGN Prospective, randomized, sham-controlled trial. SETTING Multicenter, tertiary care, teaching hospitals. PATIENTS Twenty-one obese subjects in the DJBL arm and 26 obese subjects in the sham arm composed the intent-to-treat population. INTERVENTIONS The subjects in the sham arm underwent an EGD and mock implantation. Both groups received identical nutritional counseling. MAIN OUTCOME MEASUREMENTS The primary endpoint was the difference in the percentage of excess weight loss (EWL) at week 12 between the 2 groups. Secondary endpoints were the percentage of subjects achieving 10% EWL, total weight change, and device safety. RESULTS Thirteen DJBL arm subjects and 24 sham arm subjects completed the 12-week study. EWL was 11.9% +/- 1.4% and 2.7% +/- 2.0% for the DJBL and sham arms, respectively (P < .05). In the DJBL arm, 62% achieved 10% or more EWL compared with 17% of the subjects in the sham arm (P < .05). Total weight change in the DJBL arm was -8.2 +/- 1.3 kg compared with -2.1 +/- 1.1 kg in the sham arm (P < .05). Eight DJBL subjects terminated early because of GI bleeding (n = 3), abdominal pain (n = 2), nausea and vomiting (n = 2), and an unrelated preexisting illness (n = 1). None had further clinical symptoms after DJBL explantation. LIMITATIONS Study personnel were not blinded. There was a lack of data on caloric intake. CONCLUSIONS The DJBL achieved endoscopic duodenal exclusion and promoted significant weight loss beyond a minimal sham effect in candidates for bariatric surgery. ( CLINICAL TRIAL REGISTRATION NUMBER NPT00469391.).

Gastric outlet obstruction secondary to pancreatic cancer

Background: Gastric outlet obstruction in patients with pancreatic cancer has a grim prognosis. Open surgical bypass is associated with high morbidity, whereas endoscopic duodenal stenting appears to provide better palliation. Methods: We reviewed the medical records of patients with gastric outlet obstruction secondary to pancreatic carcinoma who were admitted to our clinic between 1 October 1988, and 30 September 1998. The data included stage of disease, American Society of Anesthesiologists (ASA) class, surgical interventions, complications, and survival. Results: A total of 250 patients with pancreatic cancer were identified. Twenty-five of them (10%) had gastric outlet obstruction. Of these 25, 17 were treated with gastrojejunostomy, six had duodenal stenting (Wallstent), and two were resectable. There was no significant difference between the gastrojejunostomy group and the duodenal stenting group in ASA class or stage of disease. For the gastrojejunostomy group, median survival was 64 days (range, 15-167) and postoperative stay in hospital was 15 days (range, 8-39). For the duodenal stenting group, median survival was 110.5 days (range, 42-212) and postoperative stay was 4 days (range, 2-6). Ten patients (58.8%) in the gastrojejunostomy group had delayed gastric emptying. All of the patients in the duodenal stenting group were able to tolerate a soft diet the day after stent placement. Thirty-day mortality in the gastrojejunostomy group was 17.64%; in the duodenal stenting group, it was 0. Conclusion: In pancreatic carcinoma patients with gastric outlet obstruction, duodenal stenting results in an earlier discharge from hospital and possibly improved survival.

Surgical management of chronic pancreatitis.

The management of chronic pancreatitis continues to achieve only limited success. A lack of understanding of the basic pathogenic mechanism of this disease limits our therapy to treatment of symptoms, sequelae, and complications. The diagnosis of chronic pancreatitis usually is based on a history of classic pain plus some objective findings of pancreatic disease. Imaging techniques, such as ultrasonography or CT, are helpful in defining the size of the gland and the presence of masses and collections of fluid. Endoscopic pancreatography, however, remains the most helpful tool for diagnosis. The information that it provides about the pancreatic ductal system can help in selecting a procedure that achieves the best result with the lowest morbidity and mortality. The principle to follow in the surgical management of this condition is to tailor the procedure in each patient to preoperative clinical information, information provided by pancreatography, operative findings, exocrine and endocrine status of the patient, presence or absence of drug addiction and alcoholism, and the personality of the patient as well as his or her ability to manage the possible metabolic complications of surgery. Although management of pain is the main goal, the morbidity and late mortality that can result from different procedures must be a major consideration in selecting therapy. Pancreaticojejunostomy is the procedure of choice at this time for patients with a dilated pancreatic duct sphincterotomy or sphincteroplasty for the occasional patient with proved ampullary obstruction of the pancreatic duct, and internal drainage for pseudocyst. Different degrees of pancreatic resection are indicated for patients with severe disease and small pancreatic ducts, in patients in whom decompressive operations have failed, in patients with lateralized disease to the head or tail of the gland, in some instances of pseudocyst or pancreatic fistulas, and for some patients when cancer cannot be ruled out. Attempts are being made to improve the limited results of our current therapy. Endoscopic occlusion of the pancreatic duct, pancreatic segmental autotransplantation, islet cell autoimplantation, use of the pyloric-preserving operation, and use of continuous subcutaneous insulin infusion are being tried. Further experience with these techniques is required to determine their value in the management of patients with chronic pancreatitis.

Management of Cancer of the Bile Duct

Tumors of the bile duct are uncommon. Most patients will present with a syndrome of obstructive jaundice, but in a few patients the tumor can mimic benign disease of the biliary tract. Cholangiography continues to be the basis of diagnosis and gives important information for a decision on therapy. Histologic diagnosis is helpful when available, although frequently difficult to obtain and not always possible. The overall prognosis for these patients remains poor. Currently, a multidisciplinary approach is required to select for each patient the best therapy with the lowest morbidity and mortality. It should include a surgeon, gastrointestinal endoscopist, interventional radiologist, and radiotherapist. The prognosis for a patient appears to be related to the tumors location, resectability, and, in our experience, differentiation. Therapy should be tailored to each patient based on location of the tumor, extent of the disease, condition of the patient, expertise available in each institution, and morbidity and mortality associated with each procedure. At the Lahey Clinic, the resectability rate for bile duct tumor is currently 25 per cent. Resection is more frequently possible for tumor of the distal bile duct and can result in a five-year survival rate of up to 30 per cent. For patients with unresectable distal tumor at the time of operation, a proximal hepaticojejunostomy is the palliative procedure of choice. If nonresectability of a distal tumor is determined before operation, the decision to proceed with an endoscopic placement of a stent versus surgical hepaticojejunostomy or placement of a T tube needs to be an individual one. Although five-year survival for tumor of the proximal bile duct is anecdotal, those patients who undergo resection have the longest survival and may have better palliation than those who undergo strictly palliative, nonresective procedures. To warrant exploration for resection of tumor of the proximal bile duct, careful patient selection is required, and the morbidity and mortality of operation must be minimized. An increasing role of percutaneous transhepatic techniques of decompression of the biliary tract is expected as they improve and gain wider acceptance. They are the procedures of choice in very high-risk surgical patients or in patients determined before operation to have unresectable disease. Improvement in the survival of patients with cancer of the bile duct probably depends on development of better adjuvant therapy, such as new techniques of radiation therapy and new modalities of chemotherapy, in association with surgery or with a percutaneous or endoscopic intubation technique.

Segmental Pancreatic Autotransplantation with Pancreatic Ductal Occlusion after Near Total or Total Pancreatic Resection for Chronic Pancreatitis: Results at 5− to 54-month Follow-up Evaluation

Reported are eight patients with idiopathic chronic pancreatitis and two patients with alcoholic pancreatitis who had near total distal pancreatectomy for disabling pain and underwent simultaneous segmental pancreatic autotransplantation of the body and tail of the gland to the femoral area in an attempt to prevent or delay the onset of diabetes. The median follow-up period was 31 months, and follow-up study in nine patients ranged from 24 to 54 months. Patency of the grafts was determined by angiography and selected percutaneous venous assays for insulin. Islet cell function was determined by oral glucose tolerance tests, intravenous (I.V.) glucose tolerance tests, and I.V. glucagon stimulation studies. Segmental autotransplantation was technically successful in eight patients, only one of whom required insulin (at 2 years after grafting). The other seven patients with technically successful grafts have remained insulin independent, including two patients who later underwent pyloric preserving pancrcatoduodenectomy for completion pancreatectomy. Variable pain relief was observed in patients who underwent near total pancreatectomy, but pain was unrelieved in those patients who underwent limited distal resection. Patients with idiopathic pancreatitis appear to have better pain relief and preservation of endocrine function than alcoholic patients. Segmental pancreatic autotransplantation prevents or delays the onset of diabetes mellitus and should be considered as an alternative for those patients who require extensive pancreatic resection for chronic pancreatitis.

Long-term results of pancreatic resection and segmental pancreastic autotransplantation for chronic pancreatitis

Thirteen patients who underwent extensive pancreatic resection and segmental autotransplantation and who have a median follow-up of 62 months are presented. Eleven patients had technically successful grafts. Three of six patients who underwent total pancreatectomy and three of five patients who underwent near-total resection remain insulin-independent. Those patients who require insulin require small doses and have stable diabetes. Pain has recurred in 7 of the 11 patients who underwent distal subtotal resection; 5 of them required pancreatoduodenectomy and completion pancreatectomy for pain relief. Because of the high rate of recurrence of pain after distal resection, we favor pancreatoduodenectomy as the initial procedure of choice. When distal near-total or total pancreatectomy is required, the addition of segmental autotransplantation offers definitive, although at times transient, benefits in glucose homeostasis compared with no transplantation.

Acute Relapsing Pancreatitis as a Complication of Papillary Stenosis After Endoscopic Sphincterotomy

Endoscopic sphincterotomy has proven to be a safe alternative to surgery for selected types of biliary disease. Despite a relatively low morbidity, postprocedure complications are well described. This report presents an experience with three patients in whom acute relapsing pancreatitis developed as a possible complication of papillary stenosis after endoscopic sphincterotomy. None of the patients had a previous history of elevations in serum amylase levels before endoscopic sphincterotomy. After procedure, pancreatitis and subsequently acute relapsing pancreatitis with documented stricture of the pancreatic duct orifice developed in all three patients. After surgical transduodenal sphincteroplasty, no new episodes of acute relapsing pancreatitis occurred.

Carcinoma associated with achalasia: occurrence 23 years after esophagomyotomy

SummaryCarcinoma developed in a 67-year-old woman with achalasia of the esophagus 23 years after esophagomyotomy. Postoperative manometric and radiologic studies showed satisfactory relief of esophageal obstruction. The development of carcinoma after an unusually long interval after adequate surgical treatment emphasizes the need for lifelong surveillance for this complication.

Common bile duct calculi. 2. Nonsurgical therapy.

Several nonsurgical methods of therapy are available for treatment of retained common bile duct calculi. These include percutaneous extraction, endoscopic extraction, dissolution, and endoscopic sphincterotomy. The method chosen depends on location and size of calculi, size of sinus tract, patient age, surgical risks, and other factors. In most cases, procedures can be carried out safely and successfully with few or no complications.

Pancreatic pseudocyst with mediastinal extension and pleural effusion

Endoscopic retrograde cholangiopancreatography provides useful information in the diagnosis and management of patients with chronic pancreatitis. Knowledge of ductal anatomy is essential when planning operations for chronic pancreatitis. Demonstration of intraductal calculi, strictures, ductal ectasia, o r pseudocysts helps the surgeon decide which surgical approach is necessary for successful management. Our patient had chronic pancreatitis and pseudocyst with mediastinal extension and pleural effusion. Endoscopic pancreatography demonstrated an internal pancreatic fistula preoperatively.