Richard Cade

Percutaneous cholecystostomy in the management of acute cholecystitis.

Background:  Percutaneous cholecystostomy (PC) has been used in managing acute cholecystitis in the setting of a patient with severe comorbidities where emergency cholecystectomy would carry significant mortality. The present study aims to assess the role, efficacy and complications of PC in acute cholecystitis.

Diagnosis of solid pancreatic masses by endoscopic ultrasound-guided fine-needle aspiration.

Background:  Endoscopic ultrasound (EUS) with fine‐needle aspiration (FNA) is increasingly being used in the staging algorithm for pancreatic carcinoma. This allows for a tissue diagnosis, which was previously difficult to obtain. The aim of this study is to assess the utility of EUS–FNA in establishing the diagnosis of solid pancreatic mass lesions in an Australian population.

Oesophagectomy for early adenocarcinoma and dysplasia arising in Barrett's oesophagus

Background:  Oesophagectomy for high‐grade dysplasia is controversial.

Oesophagectomy for tumours and dysplasia of the oesophagus and gastro‐oesophageal junction

Background:  Neoadjuvant therapy, radical lymphadenectomy and treatment in high‐volume centres have been proposed to improve outcomes for resectable oesophageal tumours. The aim of the present study was to review the oesophagectomy experience of a single surgeon with a moderate caseload who uses neoadjuvant therapy selectively and performs a conservative lymphadenectomy.

Percutaneous cystic duct stent placement in the treatment of acute cholecystitis

Percutaneous cholecystostomy is well established as a temporising treatment option in selected patients presenting with acute cholecystitis. However, some patients who undergo cholecystostomy will have persistent discharge, which precludes catheter removal, or may not be medically suitable for future cholecystectomy. In these circumstances, percutaneous cystic duct stenting is a novel treatment option. It may delay or avoid the need for cholecystectomy, and thereby provide definitive treatment in a subset of patients who have acute cholecystitis and a high anaesthetic risk or limited life expectancy. Current application has been limited largely to patients with pre‐existing malignant common bile duct strictures, but there is potential for the application to be broadened to include other subsets of patients.

Post-oesophagectomy mortality: the centralization debate revisited.

A positive volume–outcome correlation has been well described with regard to various complex major surgical procedures. Oesophagectomy is one such procedure that has the potential for significant morbidity and mortality. Various figures for mortality following oesophagectomy have been published in the worldwide literature. In the United Kingdom, all oesophageal cancer surgery has been centralized into cancer networks, and is performed within a select number of larger volume hospitals. The national oesophagogastric cancer audit showed 30-day and 90-day mortalities of 1.7% and 3.2%, respectively. In comparison, audits of large datasets from the United States, where there is no centralization, quote in-hospital mortalities of up to 7.8%. There are publications that have analysed the volume–outcome relationship in Europe, including a study comparing Sweden, Netherlands, Denmark and the United Kingdom. It was found that an adjusted 30-day mortality rate in hospitals with an annual volume of >41 cases per year was 4.3%. Hospitals with an annual volume of <11 cases per year had a 30-day mortality of 7.2%. There was a great variation in hospital volumes among different countries. Denmark performed two-thirds of oesophagectomies in centres that did >30 cases per year, whereas in Sweden, a similar proportion was performed in centres doing <11 cases per year. It is interesting to note, however, that Sweden, despite having fewer oesophagectomies being performed in high-volume centres, had lower overall post-operative mortality than the other countries. This was attributed by the paper to high-quality health care with nationwide quality assurance programmes. Another study from the Netherlands compared oesophagectomy outcome from 1995 to 2006 – a period during which upper gastrointestinal surgery services went from 73% being performed in lowvolume (less than four cases per year) centres prior to 1999, to 63% being performed within one of two high-volume (15–20 cases per year) centres after 1999. The 3-year survival in the former period was 32%, and in the latter period was 45.1%. In the Australian context, major centres doing as little as six procedures per annum may be considered high volume. This is due to geography and relatively low population density. New South Wales has a 30-day mortality of 4.1%. There was no significant difference between lowand high-volume (six cases per year) hospitals. The Queensland audit from 2000 to 2007 showed a mortality of 1.6%. Low-volume centres (less than eight resections per year) had a mortality rate of 3.9%, or 80% of the total deaths in the state. The two high-volume centres performed a mean of 17 resections per year, just under half of all the cases within the state. Their mortality rate was only 0.7%. From 2009 onwards, oesophagectomy surgery was centralized to only 12 hospitals, with no mortalities occurring in an audit of the 2008–2009 period. Oesophagectomy surgery is not formally centralized in Victoria. Recent data released by the Surgical Outcomes Information Initiative (SOII) in association with the Victorian Surgical Consultative Council encompassed all elective oesophagectomies performed in Victorian hospitals between 1 July 2011 and 30 June 2013. There were 237 patients who underwent oesophagectomy in 26 Victorian hospitals. There were three deaths, a mortality of 1.27% with no obvious correlation between volume and mortality. There were also no significant differences between public and private hospitals (P = 0.79). A prior SOII study of all 169 elective oesophagectomy procedures performed in 16 Victorian hospitals between May 2005 and April 2007 revealed four deaths, a mortality rate of 2.37%. Ten hospitals in this period performed <10 resections with one death out of 42 cases (2%). Three hospitals with larger volumes (>20 resections) had two deaths out of 79 cases (2.5%). The concept of ‘failure to rescue’ has been proposed as an important factor in improving outcomes following complex surgery. Ghaferi et al. compared multiple centres performing complex surgery, including oesophagectomy, in the United States and classified them according to their procedural volume (from very high, to very low). Major complications were recorded, including respiratory failure, pneumonia, myocardial infarction, deep venous thrombosis/pulmonary embolism, acute renal failure, haemorrhage, surgical site infection and gastrointestinal bleeding. ‘Failure to rescue’ was measured as the number of patients out of all the patients with major complications who died. They noted very similar complication rates between hospitals; however, they found quite marked differences in ‘failureto-rescue’ rates between the very low and very high-volume centres. There are a number of factors that contribute to minimizing ‘failure to rescue’, including well-staffed intensive care and ward environments, presence of experienced staff and access to interventional radiology. These factors are less quantifiable than hospital volume, but no less important. In the Australian setting, many hospitals at which oesophagectomy is performed may never attain a large enough case load to be considered ‘high volume’. In order to optimize the best patient outcomes, it is important that these hospitals should be able to provide, at a minimum, these components for managing these complex patients in the post-operative period. There is no doubt that the higher volume hospitals achieve superior outcomes, and perhaps there is some merit to mandating centralization to high-volume centres. However, we also know that other factors also contribute to outcome, as evidenced by the excellent mortality figures in regions whose centres are comparatively low volume, such as Victoria, which demonstrate that good results

Endoscopic management of post-cholecystectomy biliary fistula.

OBJECTIVE Bile duct injury is an uncommon but potentially serious complication in cholecystectomy. A recognized treatment for minor biliary injury is internal biliary decompression by endoscopic retrograde cholangiopancreatography (ERCP) and stent insertion. The aim of this study was to assess the effectiveness of ERCP in the management of minor biliary injuries. METHODS A retrospective review of medical records at a tertiary referral centre identified 36 patients treated for postoperative minor biliary injuries between 2006 and 2010. Management involved establishing a controlled biliary fistula followed by ERCP to confirm the nature of the injury and decompress the bile duct with stent insertion. RESULTS Controlled biliary fistulae were established in all 36 patients. Resolution of the bile leak was achieved prior to ERCP in seven patients, and ERCP with stent insertion was successful in 27 of the remaining 29 patients. Resolution of the bile leak was achieved in all patients without further intervention. The median time to resolution after successful ERCP was 4 days. Two patients underwent ERCP complicated by mild pancreatitis. No other complications were seen. CONCLUSIONS This review confirms that postoperative minor biliary injuries can be managed by sepsis control and semi-urgent endoscopic biliary decompression.

GUIDELINES FOR THE MANAGEMENT OF BILE DUCT STONES

There are various ways of managing bile duct stones with the two main variables that determine management being the mode of presentation and local expertise/preference. Therefore although it is difficult to be prescriptive about the management of duct stones, there are guiding principles. If there is a suspicion that the patient may have a stone in the bile duct a decision needs to be made as to whether the stone should be removed preoperatively or intraoperatively (not postoperatively). If the decision is to remove the stone preoperatively by endoscopic retrograde cholangiopancreatography (ERCP) in some patients it is advisable to confirm the presence of the stone by magnetic resonance cholangiopancreatography (MRCP). This applies particularly if the evidence for a bile duct stone is equivocal. Patients with malignant obstruction of the bile duct frequently have coexistent gallstones. Therefore patients presenting with jaundice should have the cause of the jaundice established before surgery. Where a diagnosis of bile duct stones is made preoperatively and the decision is to remove them intraoperatively, facilities and expertise to perform that laparoscopically should ideally be available. Without entering the debate relating to routine operative cholangiography versus selective cholangiography, operative cholangiogram facilities should always be available at cholecystectomy. If the surgeon does not carry out routine operative cholangiograms, then at least his indication for carrying out an operative cholangiogram should be liberal, for example, slightly abnormal liver function tests (LFTs), mildly dilated duct on ultrasound, history of acute pancreatitis. If an unsuspected stone is diagnosed at operation removal of the stone by either laparoscopic or open exploration or postoperatively at ERCP are acceptable alternatives. This can be summarized as follows: (1) Common bile duct stones diagnosed preoperatively should be dealt with either preoperatively or intraoperatively. A decision to leave the stones for postoperative ERCP extraction is unacceptable. (2) Jaundiced patients should not be operated on without a firm diagnosis being established beforehand. (3) MRCP is a very useful and safe method of imaging the biliary tree. Where MRCP is unavailable, CT cholangiography is an alternative. (4) If operative cholangiography is carried out selectively rather than routinely the indications for it should be liberal. (5) Unsuspected bile duct stones diagnosed intraoperatively may either be dealt with at surgery or by ERCP postoperatively. ERCP is facilitated by the insertion of a transcystic biliary stent at operation. Of course, ERCP may not be possible in patients who have had previous gastric surgery.

Laparoscopy-assisted percutaneous-endoscopic gastrostomy tube insertion

Percutaneous gastrostomy insertion is a common procedure used for long-term enteral feeding, supplemental nutrition and gastric decompression in advanced malignant obstruction. Standard insertion can be carried out by percutaneous-endoscopic gastrostomy (PEG), radiologic guided gastrostomy or by open techniques. PEG is the most simple and common procedure (successful insertion rates 84–98%).1,2 Minor complications (3.6–24% of cases) include leakage, infection, minor bleeding and dislodgement.3 Major complications (0–8.4% of cases) include significant bleeding, i.p. leak requiring laparotomy and visceral perforation.3 This high rate of complication is partly due to the severity of comorbidities found in patients requiring PEG, although some complications are directly procedure related, such as inadvertent visceral perforation, i.p. haemorrhage and failed insertion. Difficulties can be anticipated in patients with large hiatus hernia, prior upper abdominal surgery, ascites, abnormal visceral rotation and obesity. We present a case of laparoscopic-assisted PEG insertion after unsuccessful PEG. This procedure has been previously described in the paediatric population, but is not used in adult patients.4 A 77-year-old man was admitted to hospital for management of a cerebral infarct on the left side resulting in right-sided paralysis and dysphagia. Because of the risk of aspiration, this man was referred for PEG. The patient was obese with a deep barrel chest and a large ptosed left lobe of liver was clinically apparent. Standard PEG insertion failed as the stomach could neither be seen with trans-illumination nor located with a percutaneous seeker needle. It was decided to proceed with laparoscopic-assisted insertion. Under general anaesthesia, a 10-mm infra-umbilical laparoscopic port was inserted followed by two 5-mm working ports (left and right upper quadrants). The peritoneal cavity was insufflated, allowing the viewing and manipulation of the stomach. The patient was noted to have a high-arched diaphragm, with the stomach covered by greater omentum and behind a large fatty left lobe of liver. The stomach was exposed and drawn caudally (Fig. 1). Gastroscopy was carried out by a second operator. Using laparoscopic guidance, the stomach was punctured by an appropriately sited percutaneous seeker needle and the loop wire passed through the needle was retrieved with the endoscopic snare and a standard pull-type gastrostomy tube attached to it. The gastrostomy tube was pulled through and its position checked both endoscopically and laparoscopically as desufflation occurred. There were no procedural complications. This simple technique allows direct viewing and manipulation of the stomach into a position where it can be safely punctured percutaneously with placement of a gastrostomy tube after standard PEG has failed. It also allows accurate siting of the gastrostomy, minimizes the risk of inadvertent visceral injury and allows for control of haemorrhage that may otherwise be missed. Laparoscopy-assisted PEG should be considered if standard PEG insertion has failed, particularly in patients with large hiatus hernias or obesity precluding safe percutaneous access to the stomach.

ENDOSCOPIC MANAGEMENT OF RECURRENT PRIMARY BILE DUCT STONES

Background:  The management of recurrent choledocholithiasis today remains as challenging as in the pre‐endoscopic era. Between 2 and 7% of affected patients have historically required surgical intervention for the treatment of recurrent or retained choledocholithiasis and of these, as many as 24% develop biliary complications. To avoid surgery, repeated endoscopic management of the problem has been suggested. In this study, we evaluate our policy of repeated endoscopic management of recurrent primary bile duct stones.