Greg Van Stiegmann

Endoscopic esophageal varix ligation: preliminary clinical experience

Endoscopic variceal ligation (EVL) was performed in 14 consecutive patients who had recently bled from esophageal varices. None was actively bleeding at initial treatment. Ligations were accomplished using an endoscopic ligating device and an overtube. There were no procedural complications. 132 varix ligations were performed during 44 separate EVL sessions. Two patients were lost to follow-up and two died; neither death resulted from hemorrhage or treatment complications. Variceal rebleeding occurred in 2 noncompliant patients (14.3%) and was successfully controlled with emergent EVL. Ten patients achieved complete variceal eradication with from 1 to 6 (mean, 3.9) EVL sessions. No major complications (perforation, secondary bleeding, deep ulceration) resulted and there were no treatment failures. Follow-up of 10 surviving patients ranged from 240 to 370 (mean, 280) days. Endoscopic observation suggested that varices were obliterated by a process of mechanical strangulation, ischemia, superficial ulceration, and scar formation. Preliminary data indicate that EVL is a safe and effective treatment for esophageal varices.

Secretion of cytokines and growth factors into autosomal dominant polycystic kidney disease liver cyst fluid

The principal extrarenal manifestation of autosomal dominant polycystic kidney disease (ADPKD) involves formation of liver cysts derived from intrahepatic bile ducts. Autocrine and paracrine factors secreted into the cyst would be positioned to modulate the rate of hepatic cyst growth. The aim of this study was to identify potential growth factors present in human ADPKD liver cyst fluid. Cytokine array and enzyme‐linked immunosorbent assay analysis of human ADPKD liver cyst fluid detected epithelial neutrophil attractant 78, interleukin (IL)‐6 (503 ± 121 pg/mL); and IL‐8 (4,488 ± 355 pg/mL); and elevated levels of vascular endothelial growth factor compared with non‐ADPKD bile (849 ± 144 pg/mL vs. 270 pg/mL maximum concentration). ADPKD liver cyst cell cultures also released IL‐8 and vascular endothelial growth factor, suggesting that cystic epithelial cells themselves are capable of secreting these factors. Western blotting of cultured cyst cells and immunostaining of intact cysts demonstrate that cysteine‐X‐cysteine receptor 2, an epithelial neutrophil attractant 78 and IL‐8 receptor, is expressed at the apical domain of cyst lining epithelial cells. Suggesting the cystic epithelial cells may exist in hypoxic conditions, electron microscopy of the ADPKD liver cyst epithelium revealed morphological features similar to those observed in ischemic bile ducts. These features include elongation, altered structure, and diminished abundance of apical microvilli. In conclusion, IL‐8, epithelial neutrophil attractant 78, IL‐6, and vascular endothelial growth factor may serve as autocrine and paracrine factors to direct errant growth of ADPKD liver cyst epithelia. Interruption of these signaling pathways may provide therapeutic targets for inhibiting liver cyst expansion. (Hepatology 2004;40:836–846).

Laparoscopic surgery in the rat: description of a new technique

SummaryWe report a method of laparoscopic surgery in the rat. Our technique is illustrated by gastric fundoplication requiring two-handed dissection, suturing, and knot tying. This model for laparoscopic surgery is relatively inexpensive, can be extended to other operations, and makes use of an extensively studied animal. These factors may facilitate investigation of the physiologic effects of minimal access surgery.

Endoscopic esophageal varix ligation: Technique and preliminary results in children

A technique for treating esophageal variceal hemorrhage in children using endoscopically placed rubber ligatures was evaluated in six children. The method offers a major advantage over chemical obliteration of varices by sclerosants in the absence of systemic, local, or distant organ reactions and, perhaps, in the avoidance of esophageal motor dysfunction.

Management of major bile duct injury associated with laparoscopic cholecystectomy.

BackgroundBile duct injury is a major complication of laparoscopic cholecystectomy. The purpose of this study was to evaluate our management strategy and outcomes for the treatment of such injuries.MethodsWe studied 54 consecutive patients who had de novo bile duct injury (n = 20) or prior biliary injury repair (n = 34) associated with laparoscopic cholecystectomy. All patients were managed using a multidisciplinary approach.ResultsDefinitive operation, almost always Roux-en-Y hepaticojejunostomy, was required in 85% of patients. We inserted external percutaneous biliary catheters in 98% of cases prior to surgery. There were no operative deaths, and the 30-day complication rate was 20%. Eight patients (15%) were managed nonoperatively. Overall, 96% of patients had no long-term, objectively definable biliary sequelae.ConclusionsTreatment of bile duct injury associated with laparoscopic cholecystectomy is optimally done using a multidisciplinary approach. Surgical reconstruction is required in most cases and can be safely accomplished with minimal morbidity and excellent long-term outcomes.

Laparoscopic intracorporeal ultrasound

The purpose of this study was to compare laparoscopic intracorporeal ultrasound (LICU) examination of the biliary duct system with cholangiography for delineation of duct anatomy and determination of presence or absence of ductal calculi. Thirty-one patients had LICU examination of the extrahepatic bile ducts after exposure of the gallbladder but prior to dissection of the cystic duct. After LICU examination, cystic duct dissection and cholangiography were done. Evaluation of duct anatomy and decision for duct exploration were based on findings of both tests. All patients had successful LICU examination and 30 had successful cholangiography. Duct size as determined by LICU corresponded precisely with cholangiography. LICU provided useful anatomical information in two patients with aberrant anatomy and detected choledocholithiasis in five, one of whom had a negative cholangiogram. LICU aids in delineation of biliary duct anatomy and accurately determines presence or absence of duct calculi.

Neuroendocrine stress response after minimally invasive surgery in pigs

SummaryMinimally invasive operations such as laparoscopic cholecystectomy appear to result in more rapid recovery of normal function, less physiological disturbance, and presumably less stress to the organism than open operation counterparts. The purpose of this study was to determine the stress response associated with minimally invasive surgery compared to conventional laparotomy.Three groups of pigs underwent general endotracheal anesthesia. The first group had laparoscoic cholecystectomy, the second open cholecystectomy, and the last group (controls) had only general anesthesia. The neuroendocrine serum stress markers adrenocorticotropic hormone (ACTH), cortisol, insulin, and glucagon were measured prior to anesthesia and for the first 3 postoperative days.Analysis of the data showed significant elevations of both ACTH and cortisol for laparoscopic operations as well as for open operation (cortisol only) in the immediate postoperative period. No differences were found for the other serum stress markers.We conclude that minimally invasive surgery in this porcine model confers no advantage, as measured by four neuroendocrine stress hormones, over conventional surgery. Further study is required to determine the clinical implication of these findings.

Principles of endoscopic and laparoscopic ultrasound

This section is designed to bring forward some of the latest innovative technology with explanations in terms that will clarify their importance to the discipline of surgery. Through the efforts of the Innovative Technology Committee of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), leading experts in various areas will be invited to present a summary of new technology, often including their pioneering work.

Simplified endoscopic placement of nasoenteral feeding tubes.

A technique for expeditious and safe placement of nasoenteric feeding tubes under direct vision is described. Adult patients undergo feeding tube placement with intravenous sedation and topical anesthesia. Endoscopic tube placement requires an average of 10 min and eliminates many risks associated with blind passage.

Exposure for laparoscopic cholecystectomy dissection adversely alters biliary ductal anatomy

BackgroundExposure for open cholecystectomy entails lateral, caudal traction on the gallbladder infundibulum, which results in opening the angle between the cystic and hepatic ducts. Laparoscopic cholecystectomy (LC), as initially described, is done with cephalad traction on the gallbladder. We hypothesized LC exposure technique narrows the angle between the cystic and hepatic ducts, placing them at increased risk of injury.MethodsTwenty-three patients had routine LC. Cystic duct cholangiography (IOC) was done with a flexible 5-Fr catheter via a percutaneous introducer placed anterior to the gallbladder. Exposure of Calot’s triangle was maintained with cephalad traction on the gallbladder fundus. IOC was repeated after allowing the organ to assume the anatomic position. The cholangiograms were inspected for significant differences, and the angle of the cystic to the hepatic duct (CDHD) was measured by a blinded radiologist.ResultsThe mean angle of the cystic to hepatic duct was 30‡ ± 19‡ in the IOCs taken with cephalad traction on the gallbladder fundus vs 59‡ ± 22‡,P < 0.001, in the cholangiograms taken without traction. A filling defect at the cystic-hepatic duct junction was present in 39% of IOC taken with traction vs none without traction. The intrahepatic ducts were seen in all films without traction, whereas the intrahepatic ducts were not visualized in 13% of IOCs taken with traction.ConclusionsFrom these data we conclude (1) extrahepatic biliary ducts may be at increased risk of injury during LC because of the exposure technique and (2) imaging bile ducts in the anatomic position may convey misleading information about the relative location of important structures. Optimal exposure for dissection of Calot’s triangle should utilize a second clamp on the infundibulum with lateral, caudal traction.