Joern Bernhardt

Contribution of intraoperative cholangiography to incidence and outcome of common bile duct injuries during laparoscopic cholecystectomy

Background: In the present study we examined, in a meta-analysis of the literature, the contribution of intraoperative cholangiography (IOC) to incidence, type, and time of diagnosis of common bile duct (CBD) injuries during laparoscopic cholecystectomy (LC). Materials and methods: Forty of 2104 reports were enrolled for analysis. In 26 reports we found exact information on type, location and repair of 405 major injuries and in a subgroup examination we selected 103 major injuries with detailed information as to the event and size of CBD injury in association with IOC. Results: The main incidence of CBD injuries was 0.36%. Using the method of routine IOC the incidence was 0.21% and the rate of diagnosis at the time of cholecystectomy 87% in contrast to selective use of IOC with 0.43% and 44.5%. In 405 cases of major CBD injuries, severe injuries predominated in 83.9% of the cases. Reconstruction with the help of a bilio-digestive anastomosis was necessary in 45.7% of all patients. In 34.8% of the cases a second intervention had to be made in the follow-up of 4 years after LC. The analysis of type, severity, recognition, and follow-up of CBD injuries during LC w/wo IOC showed significant advantages for doing routine IOC. Conclusions: The use of IOC can avoid severe types of CBD injuries during LC, increase the recognition at the time operation, and influence the success of repair and outcome of the patients.

NOTES—case report of a unidirectional flexible appendectomy

BackgroundNatural orifice transluminal endoscopic surgery (NOTES) refers to a new surgical procedure using flexible endoscopes in the abdominal cavity. With this procedure, access is gained by way of organs which are reached through a natural, already-existing external orifice. The hoped-for advantages associated with this method include the reduction of post-operative wound pain, shorter convalescence, avoidance of wound infection and abdominal-wall hernias as well as the absence of scars. We performed a trans-vaginal appendectomy on a human subject.Materials and methodsIn experimental operations on animals, we first evaluated the trans-vaginal access site. After them, we started first operation in human. The procedure was carried out under preventive administration of antibiotics. We used a therapeutic single-canal gastroscope. The appendix was located after exploration of the abdomen. After preparation of the mesenteriolum, ligature of the appendix base was performed by means of endoloop, followed by transsection with scissors. Recovery of the specimen was achieved by pulling it out with the instrument.ResultsOn the evening of the day on which surgery had taken place, administration of nourishment was begun. After the procedure, the patient reported slight soreness in the muscles of the abdominal wall; she felt otherwise perfectly well.InterpretationIn the space of a year, the first operations have been performed on human subjects by a few select work groups. NOTES procedures are still in the initial stages of clinical development. Until they can be introduced into surgical daily routine, further improvements are required as to equipment, technology and operative procedure.

The value of endoscopic diagnosis and the treatment of pancreas injuries following blunt abdominal trauma.

BackgroundInjuries to the pancreas following blunt abdominal trauma are rare due to its protected retroperitoneal position. Many pancreatic lesions remain unnoticed at first and only become apparent when complications arise or during treatment of other injuries. The mortality rate is between 12 and 30%, and if treatment is delayed it is as high as 60%.MethodsUsing medical records over the past 5 years, we investigated when and in what circumstances endoscopic retrograde cholangiopancreaticography (ERCP) was used in the diagnosis and treatment of pancreas injuries after blunt abdominal trauma. Penetrating injuries were not taken into consideration.ResultsAn ERCP was performed on a total of five patients with suspected injuries to the pancreas after blunt abdominal trauma. No duct participation could be determined in three of the patients with a first degree pancreatic lesion. A 44-year-old woman sustained severe internal and external injuries after a traffic accident. Because of the nature of her injuries, pancreatic left resection with splenectomy was necessary. After the operation, a pancreatic fistula diagnosed. The ductus pancreaticus (DP) was successfully treated by stenting with the use of endoscopic retrograde pancreaticography. A 24-year old woman was kicked in the epigastrium by a horse. On the day after the incident, she complained of increasing pain in the upper abdomen, and she had elevated amylase and lipase levels. Computed tomography scan showed free fluid. Less than 48 h after the accident, ERCP was performed and a leakage in the DP in the head-body region (fourth degree) was identified. We placed a stent, and during the subsequent laparoscopy the omental bursa was flushed out and a drainage laid. After 14 days, the patient was sent home. We removed the drainage 4 weeks after the accident, and the stent after 12 weeks.ConclusionThe major advantage of the prompt retrograde discription of the pancreatobiliary system after an accident in which pancreas involvement is suspected is the more precise assessment of the extent of the injuries. If a stent is placed in the same session, it is possible to carry out definitive and interventional treatment.

Laparoscopic–endoscopic rendezvous resection of gastric tumors

AbstractsBackground: Submucosal and mucosal tumors of the stomach display a wide spectrum of histopathologic and prognostic characteristics. Biopsies obtained using endoscopic techniques often do not provide the representative histologic sample needed for further therapeutic decisions. Methods: From 1999 to 2002, 18 patients with gastric tumors underwent a combined endoscopic–laparoscopic local resection of the tumors using two different procedures and were prospectively analyzed. Tumors of the posterior wall were resected using laparoscopic intragastral resection (LIR). Tumors located in the anterior wall were resected using lesion-lifting or the laparoscopic wedge resection (LWR) approach. Results: aparoscopic resections were performed in 18 patients. The mean age of the patients was 64.4 years (range, 38–81 years). Preoperative preparation included endoscopy with biopsies and histologic examination, ultrasound examination, computed tomography scan, and endoscopic ultrasonography. We performed the LWR on 10 patients and the LIR on 8 patients. After resection, the final immunohistologic examination of the specimens showed gastrointestinal stroma cell tumors in nine cases, neurinomas or benign neurofibrotic tumors in four cases, and one leiomyoma. Four additional patients with mucosal early gastric cancer and high comorbidity risks also underwent a limited full-thickness wedge resection. In all the patients, the surgical margins were tumor free, and no lymphatic or venous invasion was encountered in pathologic specimens. Method-specific complications occurred in one case (perforation of the stomach wall). No fatal outcome had to be registered. Conclusions: When selected properly, the laparoscopic–endoscopic approach is considered to be curative and minimally invasive for resection of localized gastric tumors. In cases of histopathologically unknown tumors preoperatively, definitive examination of the complete specimen provides the basis for further therapeutic decisions.

Value and consequences of routine intraoperative cholangiography during cholecystectomy.

Since the introduction of laparoscopic cholecystectomy (LC), an increase in accidental common bile duct (CBD) injuries of up to 1.2–1.6% has been reported. In the present prospective study of 1,710 patients undergoing cholecystectomy (1,241 LC procedures and 469 open cholecystectomies [OC]), we tested the predicative value of routine intraoperative cholangiography (IOC). The IOC was feasible in 92.4% of the cases in the LC group and in 83% of cases in the OC group and presented a complete depiction of the extrahepatic bile system in 98.3%. Anatomic variations of the bile duct system, which influenced the operative management, were found in 13.2% of cases (13.4% LC versus 12.8% OC). In 2.5% of the patients, preoperatively undetected CBD stones were also found. Method-specific complications did not occur in any of the patients. Additionally, in a controlled subgroup analysis of 163 patients, we evaluated preoperative intravenous cholangiography (IVC) and IOC. Intravenous cholangiography showed only 72.4% of the operation-relevant anatomic variations (vs. 100% by IOC); in 6.1% of the cases, there were reactions to the dye (vs. none in IOC), and in only 28.6% of the patients, CBD stones were detected (vs. 71.4% IOC). There were four bile duct injuries (0.29%) during LC and two (0.4%) during OC. All injuries were detected intraoperatively and fixed in the same setting without postoperative complications. In conclusion, we recommend the use of routine IOC during cholecystectomy. By this technique, anatomic variations of the bile duct system will be visualized and therefore accidental injuries will be avoided.

Caustic acid burn of the upper gastrointestinal tract: first use of endosonography to evaluate the severity of the injury.

Judging the severity of an injury after erosions of the upper gastrointestinal tract has been exclusively based on endoscopic inspection. For the first time, we used minimal probe endosonography during initial endoscopy and endoscopical progress observations to improve assessment of injury depth determining the therapy. Nine hours after admitting a patient after acid ingestion, the initial endoscopy and simultaneous endosonography with a 12-MHz minimal endosonographical probe took place. The affected wall sections with macroscopical coagulation necrosis regularly showed a richer echo, broadened first layer, and a low-echo wall edema that had developed under the necrosis. Differences existed between the breadth of the first echo-rich layer and the breadth of the edema below it. The indiscriminability of single wall layers correlated with the intensity of the edema. The initial injury depth was defined based on the depth extension of the wall edema and the discriminability of the layers. In the control examinations, a complete wall edema with limited assessability developed independently of the injurys initial severity. The assessment of injury depth was only possible during a short time span. Differences existed in the regression time of the wall edema. The initial endosonography and diagnostic findings over time showed differences between superficial and deep wall injuries after erosion. In this way, the injury depth could be correctly estimated, thus directly influencing therapy planning.

Pathophysiological Measurement and Results After Laparoscopic Fundoplication for Gastroesophageal Reflux Disease

Abstract.Purpose: Both surgical and conservative treatments for gastroesophageal reflux disorder (GERD) are controversial. The aim of this prosepective study was to examine outcomes after laparoscopic antireflux surgery. Methods: The subjects were 143 patients who underwent laparoscopic antireflux surgery. Following diagnostic procedures 126 patients were allocated to a total fundoplication group (360°C, Nissen-DeMeester) and 17, to a posterior semifundoplication group (250–270°, Toupet). All complications were registered, and pathophysiological and outcome data were examined 3, 6, and 9 months after surgery. Results: By 6 months after surgery the mean lower esophageal sphincter (LES) pressure had improved significantly, to 14.8 mmHg in the Nissen-DeMeester group, and to 12.1 mmHg in the Toupet group, corresponding to successful prevention of esophageal reflux in both groups. Dysphagia was more common in the early postoperative period after total fundic wrap (17% vs 12%), but this difference disappeared in time. All patients reported complete relief of reflux symptoms, although two of those who underwent the Nissen-DeMeester fundoplication experienced relapse of GERD and required open reconstruction (1.4%). The laparoscopic procedure was converted to open surgery in three patients (2%). There were no associated deaths and the perioperative complication rate was 4.2%. Conclusion: Laparoscopic antireflux surgery is an effective treatment for GERD. More than 93% of the patients in this series rated their outcome as good to excellent following the operation.

Update in Natural Orifice Translumenal Endoscopic Surgery (NOTES)

Purpose of review The recent developments and clinical applications of natural orifice translumenal endoscopic surgery (NOTES)-procedures and technologies are going to be presented. Recent findings In experimental as well as clinical settings, NOTES-procedures are predominantly performed in hybrid technique. Current experimental studies focus on the implementation of new surgical approaches as well as on the training of procedures. One emphasis in the clinical application is transrectal and transanal interventions. Transanal total mesorectal excision is equivalent to laparoscopic procedures but with the benefit of an even less invasive access. Transvaginal cholecystectomy can achieve results that are comparable to surgeries that are performed with laparoscopic techniques alone. An analysis of the German NOTES-Register concerning appendectomies as well as the national performance of NOTES-interventions in Switzerland is presented. Apart from intraabdominal approaches, several centers proclaim transoral thyroidectomies and transoral mediastinoscopies. Summary NOTES-procedures are performed in animal experiments as well as in clinical setting although with less frequency. At this time, hybrid techniques using rigid instruments are mainly applied.