J. Isaac

Totally intra-abdominal laparoscopic Billroth II gastrectomy

Although H2-blockers remain the first-line treatment for chronic gastric ulcers, there remain some patients who still require surgery for intractability, large ulcers, complications, or suspected malignancy. For these patients, the standard Billroth I or II gastrectomy has stood the test of time [1]. The minimally invasive surgical revolution started four years ago by the advent of laparoscopic cholecystectomy [2] has spawned the technology that now makes possible the performance of a Billroth II gastrectomy totally intraabdominally under laparoscopic control. We recently performed a laparoscopic Billroth II subtotal gastrectomy on a 76-year-old man. The patient had a 2-year history of chronic gastric ulcer and presented with the problem of episodic epigastric pain related to meals. During this time he had intermittent treatment with H2-blockers without success. Gastroscopy revealed a deep, chronic, 1.5-cm-diameter ulcer at the incisura of the stomach. Surgery was performed with total intravenous anesthesia using propofol. Nitrous oxide was omitted to reduce gas retention in the intestinal tract. Ventilation was done with a mixture of air and oxygen. Pneumoperitoneum was induced to 14 mmHg with carbon dioxide, and the operation was performed through five portals (four 12 mm and one 10 ram). The lesser and greater curves of the stomach were mobilized and vessels controlled with either Endoclip | or vascular endo GIA | stapling device applications (USSC, Norwalk, Connecticut, USA). Major vessels like the left and right gastroepiploic and the right gastric arteries were controlled with the endoGIA. The duodenal and stomach stump were simultaneously transected and closed with multiple applications of the endoGIA. A Billroth II reconstruction was similarly performed entirely intraabdominally with staples. The transected distal two thirds of the stomach was delivered through the left upper quadrant 12 mm trocar port enlarged to 25 ram. Although the surgery required 4 h and 17 applications of the 30-mm endoGIA were used, blood loss was negligible, and the patients intraoperative course was uneventful. His recovery was remarkable. He was ambulatory and pain-free without medication on the first post-operative day. Peristalsis was well established on the second day. He tolerated oral liquids on post-op day 3 and ate a normal breakfast before being discharged on his fourth day after surgery. We plan on compiling a larger series, but are pleased to forward our initial results to your publication. Based on the present case and earlier experience with laparoscopic gastrointestinal operations, we believe that laparoscopic gastric resection can offer a safe and reasonable alternative to long-term medical management.

How I do it: Laparoscopic cholecystectomy

Laparoscopic cholecystectomy, although new, has enjoyed a rapid acceptance around the world. This article describes our initial experience with this procedure. Training and credentialing, including attending of courses, are important to ensure competency in this technique prior to independent performance of this operation; our guidelines are outlined. Our indications for laparoscopic chlecystectomy are no different from those for open surgery and some previously considered contraindications to laparoscopic cholecystectomy have now been dropped. Our preoperative work up and operative technique are discussed. From June 1991 to December 1992, we performed and analyzed 304 laparoscopic cholecystectomies, including 66 cases of inflamed gallbladders in our department. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was done only in patients suspected of having bile duct stones. This resulted in 0.9% needing postoperative ERCP stone extraction. The procedure was completed in 91.4% of patients, with a conversion rate of 3% for elective and 28% for emergency patients. Bile duct injury occurred in 1.4% of patients and minor complications in 4%. The use of laparoscopic cholecystectomy is growing in our region. As experience increases and more emergency cholecystectomies are done, the proportion of all cholecystectomies done laparoscopically will increase rapidly.

Mushroom bezoar: a rare cause of small intestinal obstruction

Sir, Bezoars or masses of entangled material in the gastrointestinal tract are uncommon causes of intestinal obstruction. They are broadly of two types: phytobezoar, composed of plant material; and trichobezoar, composed of a tangle of hair. Mushrooms are a distinctly unusual type of bezoar, with only two cases being previously described in the German literature. We report an additional case of such a bezoar in the terminal ileum, presenting with small intestinal obstruction, and briefly review the literature. The patient was a 64-year-old Chinese man with a history of chronic obstructive lung disease who presented with abdominal pain and distension of 1 day’s duration. Bowel sounds were positive and there were no signs of peritonitis. An abdominal X-ray showed dilated small bowel loops consistent with small bowel obstruction. He was treated conservatively with intravenous fluids and naso-gastric suction but showed no improvement after 2 days. A colonoscopy showed cecal diverticulosis but no other identifiable large bowel lesion. A laparotomy was carried out and an intraluminal bolus mass was found in the terminal ileum about 1 m from the ileo-cecal valve. After an unsuccessful attempt at milking the bolus mass through to the cecum, an ileal enterotomy was performed and the bolus mass removed. The patient’s post-operative recovery was uncomplicated. Grossly, the specimen was a soft mass measuring 66562 cm and weighing 26 g, with a whitish central portion on the cut surface (Fig. 1). Histologically, the sections featured a poorly stained mesh of elongated cellular structures that were PAS and GMS positive. These structures showed branching and were septated (Fig. 2A, B). There were areas of gill formation, the surface of which disclosed a lining row of crowded cells (Fig. 3). Together with the corroborative staining properties, these were all features of a mushroom bezoar. The clinical features of bezoars are expectedly nonspecific. They may cause anorexia, weight loss, gastrointestinal bleeding, obstruction or perforation. Common sites of impaction are the gastric outlet, the terminal ileum as well as segments of pre-existing gastrointestinal stenosis of various aetiologies. Predisposing factors include a high fibre intake, inadequate chewing, gastric hyposecretion and hypomotility, previous gastrectomy and vagotomy. The usual culprits of bezoar formation are vegetable and fruit material, with citrus fruits and persimmons being especially implicated. Trichobezoar is another important Fig. 1 Gross appearance of the mushroom bezoar.