P. C. Bornman

Long term outcome of endoscopic drainage of pancreatic pseudocysts

Objective: Nonoperative drainage either by the percutaneous or endoscopic route has become a viable alternative to surgical drainage of pancreatic pseudocysts. Endoscopic drainage has been reported in a few small series with encouraging short term results. The aim of this study was to determine the indications, suitability, and long term outcome of transmural endoscopic drainage procedures. Methods: All patients presenting over a 2-yr period to a tertiary referral hepatobiliary unit with pancreatic pseudocysts were studied. Endoscopic drainage was performed in patients with pseudocysts bulging into the stomach or duodenal lumen. Outcome measures were successful drainage of the pseudocyst, complications, and recurrence rates. Results: Of 66 patients presenting with pseudocysts, 34 were considered suitable for endoscopic drainage. Twenty-four (71%) were successfully drained. Failures were associated with thick walled pseudocysts (>1 cm), location in the tail of the pancreas, and pseudocysts associated with acute necrotizing pancreatitis. There were three recurrences (7%), two of which were successfully redrained endoscopically. The long term success rate (median follow-up, 46 months) of the initial procedure was 62%. Conclusion: Transmural endoscopic drainage is a safe procedure with minimal complications. It should be the procedure of choice for pseudocysts associated with chronic pancreatitis or trauma, with a wall thickness of <1 cm and a visible bulge into the gastrointestinal lumen. Forty percent of pseudocysts fulfilled these criteria in our study.

The Evolving Role of Endoscopic Treatment for Bleeding Esophageal Varices

The treatment of acute and recurrent variceal bleeding is best accomplished by a skilled, knowledgeable, and well-equipped team using a multidisciplinary integrated approach. Optimal management should provide the full spectrum of treatment options including pharmacologic therapy, endoscopic treatment, interventional radiologic procedures, surgical shunts, and liver transplantation. Endoscopic therapy with either band ligation or injection sclerotherapy is an integral component of the management of acute variceal bleeding and of the long-term treatment of patients after a variceal bleed. Variceal eradication with endoscopic ligation requires fewer endoscopic treatment sessions and causes substantially less esophageal complications than does injection sclerotherapy. Although the incidence of early gastrointestinal rebleeding is reduced by endoscopic ligation in most studies, there is no overall survival benefit relative to injection sclerotherapy. Simultaneous combined ligation and sclerotherapy confers no advantage over ligation alone. A sequential staged approach with initial endoscopic ligation followed by sclerotherapy when varices are small may prove to be the optimal method of reducing variceal recurrence. Overall, current data demonstrate clear advantages for using ligation in preference to sclerotherapy. Ligation should therefore be considered the endoscopic treatment of choice in the treatment of esophageal varices.

Self-expanding metal stents as an alternative to surgical bypass for malignant gastric outlet obstruction.

Gastroduodenal obstruction due to malignancy can be difficult to palliate. Self‐expanding metal stents (SEMS) are gaining acceptance as an effective alternative to surgical bypass.

Endoscopic management of bile leaks after laparoscopic cholecystectomy

BACKGROUND A bile leak is an infrequent but potentially serious complication after biliary tract surgery. Endoscopic intervention is widely accepted as the treatment of choice. This study assessed the effectiveness of endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy and biliary stenting in the management of postoperative bile leaks. METHODS An ERCP database in a tertiary referral centre was reviewed retrospectively to identify all patients with bile leaks after laparoscopic cholecystectomy. Patient records and endoscopy reports were reviewed. RESULTS One hundred and thirteen patients (92 women, 21 men; median age 47 years, range 22 - 82 years) with a bile leak were referred for initial endoscopic management at a median of 12 days (range 2 - 104 days) after surgery. Presenting features included intra-abdominal collections with pain in 58 cases (51.3%), abnormal liver function tests (LFTs) in 22 (19.5%), bile leak in 25 (22.1%), and sepsis in 8 (7.1%). Twenty-nine patients (25.7%) were found to have either major bile duct injuries without duct continuity, vascular injuries or other endoscopic findings requiring surgical or radiological intervention. Of 84 patients managed endoscopically, 44 had a cystic duct (CD) leak, 26 a CD leak and common bile duct (CBD) stones, and 14 a CBD injury amenable to endoscopic stenting. Of the 70 patients with CD leaks (group A), 24 underwent sphincterotomy only (including 8 stone extractions), 43 had a sphincterotomy with stent placement (including 18 stone extractions) and 1 had only a stent placed, while 2 patients with previous sphincterotomies required no further intervention. The average number of ERCPs in group A was 2.3 (range 1 - 7). Of the 14 patients with bile duct injuries treated endoscopically (group B), 7 had a class D, 5 an E5 and 2 a class B injury; 13 patients underwent sphincterotomy and stenting, and 1 had a sphincterotomy only. Group B required an average of 3.6 ERCPs (range 2 - 5). The 113 patients underwent a total of 269 ERCPs (mean 2.4, range 1 - 7). Seven patients had one or more complications related to the ERCP: 3 acute pancreatitis, 2 cholangitis, 2 sphincterotomy bleeds, 1 duodenal perforation and 1 impacted Dormia basket, the latter 2 requiring operative intervention. CONCLUSIONS Three-quarters of bile leaks after laparoscopic cholecystectomy were due to CD leaks (with or without retained stones) or lesser bile duct injuries and were amenable to definitive endoscopic therapy. Nineteen patients (16.8%) had major injuries that required operative intervention.

The Surgical Management of Chronic Pancreatitis

Chronic pancreatitis (CP) has been defined as a continuing inflammatory disease of the pancreas characterized by irreversible morphological changes, often associated with pain and with the loss of exocrine and endocrine function which may be clinically relevant (Clain JE Surg Clin North Am 1999). Pain is the principal cause of intractability and together with pancreatic insufficiency may have a significantly deleterious effect on a patient’s quality of life as well as their ability to work and contribute to society, often leading to loss of their’ social support network (Lankisch PG Digestion 1993). Progressive disease may culminate in severe and disabling symptoms requiring narcotic analgesia and frequent hospital admission with a consequent impact on health resources (Bornman PC W J Surg 2003; Braganza JM The Lancet 2011). The incidence and prevalence of disease has not been well documented however it is considered uncommon in Europe and the USA. This is in contrast to data available from South India where a prevalence of 114-200/100 000 people has been documented. Alcohol is the leading cause in western developed countries and some developing countries such as Brazil, Mexico and South Africa while idiopathic disease predominates in Asia and the subcontinent (Braganza JM The Lancet 2011; Garg PK J Gastroenterol Hepatol 2004).

Choosing the optimal tools and techniques for parenchymal liver transection

The modern era of safe liver resection is based on notable advances in non-invasive solid organ imaging, improved anaesthetic management, enhanced knowledge of segmental liver anatomy as described by Couinaud, better surgical technique, an appreciation of the functional reserve of the liver remnant, and the remarkable capacity of normal liver to regenerate. The evolution and development of the surgical techniques utilised during liver resection are largely an account of the efforts to minimise bleeding during hepatic parenchymal transection. Three decades ago, major liver resection was associated with mortality rates of up to 20%, and excessive bleeding was an important and common cause of operative mortality. Liver resection can now be accomplished with mortality rates of less than 3% in most specialised hepatopancreato-bilary (HPB) centres. While better patient selection and improved assessment of intrinsic liver reserve are important factors, reduced blood loss and the diminishing need for blood transfusion have been additional reasons for improved perioperative outcome. Other advances in operative technique, including improved delineation of the optimal transection plane with intra-operative ultrasound and the benefit of intermittent inflow occlusion, have also contributed to a reduction in blood loss during major liver resections.