Sally A. Norton

A Randomized, Clinical Trial to Compare Endoscopic Sphincterotomy and Subsequent Laparoscopic Cholecystectomy with Primary Laparoscopic Bile Duct Exploration During Cholecystectomy in Higher Risk Patients with Choledocholithiasis

INTRODUCTION Outcomes after endoscopic sphincterotomy (ES) and subsequent laparoscopic cholecystectomy (LC) versus laparoscopic bile duct exploration (LBDE) during LC are comparable in fit patients with choledocholithiasis. This randomized, clinical trial aimed to determine the optimum treatment in patients with higher medical risk. MATERIALS AND METHODS Ninety-one higher risk patients with evidence of bile duct stones were randomized to ES/LC (group A) or LBDE during LC (group B). The primary outcome measure was duct clearance. Secondary outcome measures were complications, number of procedures per patient, conversion, and postoperative hospital stay (POS). RESULTS Forty-seven patients were randomized to ES/LC and 44 to LBDE. The median age was 74.56 years. On an intention-to-treat basis, duct clearance was achieved in 29 of 47 of group A and 44 of 44 of Group B patients (P < 0.001). Clavien Grade II-V complications occurred in 8 of 47 and 8 of 44 patients (P = 0.884), the median number of procedures was 2 (2-3) and 1 (1-1) (P < 0.001), 2 of 47 and 4 of 44 patients required conversion (P = 0.676), and the median POS was 3 (2-7) and 5 (2-7) days (P = 0.825), respectively. CONCLUSIONS There was no difference between approaches to duct clearance in terms of postoperative stay, complications, or conversion in higher risk patients, but the laparoscopic approach was more effective and efficient and avoided unnecessary procedures.

The Reporting of Gastric Band Slip and Related Complications; A Review of the Literature

Laparoscopic adjustable gastric banding is a safe and effective treatment for morbid obesity. Long-term complications include band slippage, gastric pouch dilatation and gastric erosion. Rates of band slippage reported in the literature range from less than 1% to over 20%. The aim of this review was to explore whether differences in the reporting of this complication contributed to the variability in this outcome measure. A full literature search was undertaken using EMBASE and MEDLINE search engines. Forty studies were selected for analysis based on inclusion and exclusion criteria. Each was scrutinised for outcome reporting methods and related fields. Accurate definitions for relevant terms were derived from the best available evidence. Considerable variations in device deployed, operative approach, band fixation technique, and outcome reporting mechanisms were seen between the studies. The explanation and definition of terms used within manuscripts were also seen to vary between studies. A consensus needs to be reached on how best to report complications such as gastric band slippage. We suggest which information should be included by authors to allow for accurate and reproducible reporting of such outcomes in the future.

Shared Medical Appointments for Bariatric Surgery Follow-up: a Patient Satisfaction Questionnaire

BackgroundShared medical appointments (SMAs) are group clinics where practitioners see several patients, with common health needs, at once. There is a great financial strain on the National Health Service (NHS) to provide bariatric surgery. The aim of this study was to review patient satisfaction with the SMA that is the default means of following up patients after bariatric surgery at one particular NHS trust.MethodsA patient-validated questionnaire was designed and handed out at the end of the SMAs. Patients who attended an SMA earlier in 2011 were also retrospectively sent questionnaires via post.ResultsA total of 47 patients completed the questionnaire from seven different SMAs covering the period from January to July 2011. All patients underwent laparoscopic adjustable gastric banding. After attending an SMA, patients gave an overall mean satisfaction rating of 4.13 ± 0.163 (on a scale of 1 to 5, 1 = very poor and 5 = excellent) which represented an increase (p < 0.01) compared to preconceptions before the clinic (3.59 ± 0.175). A cost analysis estimated a yearly saving of £4,617 or 65.1% made by the SMAs compared to 1:1 appointments.ConclusionsThe bariatric surgery SMA demonstrates high levels of patient satisfaction and is cost-effective.

Assuring complete laparoscopic clearance of the bile duct.

BACKGROUND The aim of this study was to evaluate and compare the use of choledochoscopy, cholangiography, and laparoscopic ultrasound in ensuring bile duct clearance and the prevention of missed stones after laparoscopic exploration. METHODS Operative details of 439 consecutive patients who underwent laparoscopic bile duct exploration between April 1994 and February 2005 were collected prospectively. Thirty-six conversions, 8 failures, and 8 patients who had a biliary enteric drainage procedure were excluded. Follow-up was by postal questionnaire or via their GP if there was no response. RESULTS One-year follow-up was complete in 95%. Patients underwent 253 transductal, 94 transcystic, and 29 radiological explorations. Laparoscopic ultrasound prompted immediate re-exploration of the bile ducts in six patients for stones missed by choledochoscopy. About 3.4% of patients presented with a missed stone within 1 year of surgery. The negative predictive values of choledochoscopy alone, choledochoscopy followed by postexploratory cholangiography and choledochoscopy followed by postexploratory laparoscopic ultrasound have been found to be 94.6%, 97.9%, and 97.4%, respectively. CONCLUSION Double checking duct clearance with laparoscopic ultrasound after choledochoscopy is worthwhile, whereas cholangiography is not.

Laparoscopic bile duct exploration seems to be safe in higher-risk patients compared to endoscopic sphincterotomy and subsequent laparoscopic cholecystectomy, in a high-volume centre

We thank the authors [1] for their comments regarding ourstudy [2]. We have indeed gone some way to show that bileduct exploration appears to be as safe as and more efficientthan the two-stage alternative approach of endoscopicsphincterotomy followed by laparoscopic cholecystectomyin higher-risk patients fit enough to undergo surgery [3].However, we recently presented some data at the AUGISannual meeting that does suggest that there is a moreprofound reduction in postoperative pulmonary function inhigher-risk patients following laparoscopic bile ductexploration than after laparoscopic cholecystectomy alone[4]. One might conclude, therefore, that higher-risk patientswith significant lung disease might best be treated bysphincterotomy.With regard to the ‘‘learning curve’’ period, it was notour intention to state a number to reach to gain competencein the procedure. In our study, this period encompassed thefirst 5 years of the series during which the technique wasrefined as described in the article. Regrettably, accuratedata regarding operation times were not collected pro-spectively so this factor was not investigated. We estimatethat with all the necessary equipment available, a surgeonwith advanced laparoscopic skills might need to performapproximately 50 procedures to be comfortable with thetechnique, but this figure would be influenced by previousexperience with open bile exploration.A controlled bile leak following choledochotomy in anumber of patients is inevitable. This is probably due to acombinationoffactors:thelatenttoneofthebiliarysphincter,the quality of the closure of the choledochotomy, and smallfragments of stones or blood clots within the duct that passspontaneously in the first few postoperative days causingtemporary obstruction. We take great care not to instrumentthe ampulla and thus avoid any episodes of procedure-relatedpancreatitis, and we would agree that any instrumentation ofthe ampulla would increase the risk of a bile leak. We areaware of some surgeon’s practice of administering hyoscine-N-butylbromide in the postoperative period to relax thesphincter but there is no evidence to suggest its efficacy.

Subcutaneous placement of access ports following laparoscopic adjustable gastric banding is a safe, cost-effective technique associated with low complication rates.

Dear Authors, We read with interest your article regarding the incidence of access port complications in your unit [1]. Our centre has a particular interest in this controversial topic, and our results have been published previously [2]. The number of patients suffering with access port complications in your cohort, namely 14.5%, is consistent with many published series [3, 4]. One thing that links the vast majority of such reports is the mechanism used to secure the access port [3, 4]. Most authors prefer to fix the port to the rectus sheath using non-absorbable sutures, with the rationale that this reduces the risk of port migration or rotation, and subsequent need to re-site the port [5, 6]. Recent advances in access port application have included the development of port fixation devices, which are growing in popularity [6]. Our preferred technique is to place the port subcutaneously, without fixation, in a snug pocket. This is simply established with gentle digital dissection prior to closure of the overlying tissues. As previously published by our group, access difficulties occurred in only 2% of our patients [2]. Approximately half of these patients ultimately required port repositioning under local anaesthesia at a later date. To date, we have operated on 340 patients at a single site. Our total access port complication rate still remains under 3%. We have had only one re-operation due to puncture of the tubing, and to date have had no abscesses or deep infections associated with the access port. It is our recommendation that surgeons performing laparoscopic adjustable gastric banding as a routine consider this simple and ultimately time-saving technical modification, to ensure low access port complication rates. We have not noted an increased risk of port rotation, migration or erosion as a result of our technique, and our methods are almost universally accepted by our patient group. Accessing the port is simplified by its subcutaneous positioning, and our negligible rate of tube fracture or disconnection is thought to be the result of removing the direct shearing forces which can occur following forceful contraction of the rectus apparatus.