Simo Laine

Laparoscopic vs conventional Nissen fundoplication. A prospective randomized study.

AbstractBackground: Laparoscopic Nissen fundoplication has gained wide acceptance among surgeons, but the results of the laparoscopic procedure have not been compared to the results of an open fundoplication in a randomized study. Methods: Some 110 consecutive patients with prolonged symptoms of grade II–IV esophagitis were randomized, 55 to laparoscopic (LAP) and 55 to an open (OPEN) Nissen fundoplication. Postoperative recovery, complications, and outcome at 3- and 12-month follow-up were compared in the two groups. Results: Five LAP operations were converted to open laparotomy due to esophageal perforation (two), technical difficulties (two), and bleeding (one). In the OPEN group (two) patients underwent splenectomy. There was no mortality. The mean hospital stay was 3.2 days in the LAP group and 6.4 in the OPEN group. Dysphagia and gas bloating were the most common complaints 3 months after the operation in both groups. These symptoms had disappeared at the 12-month follow-up examination. All patients in the LAP group and 86% in the OPEN group were satisfied with the result. Conclusions: Laparoscopic Nissen fundoplication is a safe and feasible procedure. Complications are few and functional results are good if not better than those of conventional open surgery.

Bile duct injuries during laparoscopic cholecystectomy: primary and long-term results from a single institution

BackgroundIatrogenic bile duct injury carries high morbidity. After the introduction of laparoscopic cholecystectomy the incidence of these injuries has at least doubled, and even after the learning curve, the incidence has plateaued at the level of 0.5%.MethodsA total of 32 patients sustained biliary tract injuries of the 3736 laparoscopic cholecystectomies performed in and around Turku University Central Hospital between January 1995 and April 2002. The data concerning primary treatment and long-term results were collected and analyzed retrospectively.ResultsThe overall incidence for bile duct injuries, including all the minor injuries (cystic duct leaks and bile duct strictures), was 0.86%; for major injuries alone the incidence was 0.38%. Nineteen percent of the injuries were detected intraoperatively. All the cystic duct leaks were treated endoscopically with a 90% success rate. Of the bile duct strictures 88% were treated successfully with endoscopic techniques. Ninety-three percent of the major injuries, including tangential lesions of common bile duct and total transections, were treated operatively. The operation of choice was either hepaticojejunostomy or cholangiojejunostomy in 69% of the cases; the rest were treated with simple suturing over a T-tube or an endoscopically placed stent. The long-term results, with a median follow-up period of 7.5 years, are good in 79% of the operated patients and in 84% of the whole study population. Mortality rate was 3% and acute or chronic cholangitis was seen in 13% of the patients during follow-up.ConclusionMost of the minor bile duct injuries, including cystic duct leaks and bile duct strictures, are well treatable with endoscopic techniques, whereas most of the major injuries require operative treatment, which at optimal circumstances gives good results.

Laparoscopic appendectomy—is it worthwhile? A prospective, randomized study in young women

AbstractBackground: Clinical diagnosis of acute appendicitis is most difficult in fertile-age women. In this patient group up to 50% of open appendectomies are negative for appendicitis. We conducted a randomized study to compare laparoscopic and open appendectomy in young female patients with suspected acute appendicitis. Methods: Fifty female patients between the ages of 16 and 40 years presenting with acute right lower abdominal pain were randomized, 25 to laparoscopy and 25 to an open appendectomy. Diagnostic accuracy, rate of negative appendectomies, safety, and final outcome were compared in the two groups. Results: Diagnosis was established in 96% of patients in the laparoscopic group and in 72% in the open group. There were 11 (44%) unnecessary appendectomies in the open group, but only one (4%) in the laparoscopic group (p < 0.0005). Conclusions: In young women with right lower abdominal pain, laparoscopy can give precise diagnosis and reduce the rate of negative appendectomies.

Needle-knife assisted ERCP

BackgroundDuring endoscopic retrograde cholangiopancreatography (ERCP), incising through the wall of the major papilla with an electrocautery needle-knife is a method for achieving access into the bile duct. This procedure, often referred to as a “precut,” may be used when cannulation attempts via the orifice of the papilla are unsuccessful. Potential complications include hemorrhage, duodenal perforation, and acute pancreatitis.MethodsThe 172 patients who underwent an attempt of a needle-knife assisted ERCP during the years 1997–2003 at our institution were retrospectively evaluated.ResultsA selective bile duct cannulation was achieved after needle-knife incision in 148 out of 172 patients (86%) at the primary session. In 10 additional patients (6%), a repeated procedure proved successful for cannulation. In the remaining 14 patients (8%), the biliary cannulation failed and was not attempted again. Complications after needle-knife assisted ERCP occurred as follows: three patients (2%) presented with late bleeding after the ERCP and three patients (2%) developed acute pancreatitis. None of the patients required operative treatment for complications. There was no mortality.ConclusionThe use of the needle-knife markedly improves the success rate of selective biliary cannulation in ERCP without increasing the rate of complications.

Is male gender a risk factor for bile duct injury during laparoscopic cholecystectomy

BackgroundSince its introduction in the late 1980s laparoscopic cholecystectomy has become the treatment of choice for gallstone disease. Unfortunately, the rate of iatrogenic biliary duct injuries (BDIs) has at least doubled after the adoption of the laparoscopic method. Population-based studies reporting the distribution of laparoscopic BDI patients according to gender and the severity of the BDI are mostly lacking. The purpose of the present study was to analyze the BDIs sustained during laparoscopic cholecystectomy in and around Turku University Central Hospital, with a special reference to the distribution of patients according to gender and the severity of the BDI.Patients and methodsA total of 3,736 laparoscopic cholecystectomies (2,627 female patients, 1,109 male) was performed in and around Turku University Central Hospital from 1995 to 2002 (by the end of April). The number and severity of BDIs and the gender of BDI patients were recorded, and the risk of BDI during laparoscopic cholecystectomy was calculated for the total patient population and for both genders separately.ResultsThe risk of BDI was 0.86% for the total patient population, 0.95% for female and 0.63% for male. The most conspicuous finding was that the female gender was predominant in the severe types of BDI. However, the risk of mild BDI seemed to be fairly equal in both genders.ConclusionWe conclude that female gender seems to be a risk factor for severe iatrogenic BDI during laparoscopic cholecystectomy.

Late subjective results and symptomatic outcome after laparoscopic fundoplication.

Laparoscopic fundoplication is generally accepted as a routine surgical approach in the treatment of moderate or severe gastro-esophageal reflux disease. However, there are few reports on the long-term results after this procedure. Between 1996 and 2001, 468 patients underwent laparoscopic Nissen fundoplication of which 464 patients were available for follow-up. The follow-up data were collected both from the hospital records and by a structured questionnaire, which were completed by 441 patients (95%). Eighty-nine percent (n=394) of the patients regarded the result of their surgery excellent, good, or satisfactory at a median follow-up of 51 months. With the benefit of hindsight 83% of the patients would again choose surgical treatment. Eighty-seven percent of the patients had no significant reflux symptoms. Bloating or increased flatulence were the most common side-effects. One hundred thirty-two patients (30%) had started to use antireflux medications postoperatively, but only 51 of them used it daily. Laparoscopic Nissen fundoplication provides a good and effective alternative to a life-long use of antireflux medication.

Endoscopic palliation of malignant obstructive jaundice in extremely elderly patients: plastic stent is enough

Abstract Although the price of biliary metal stents is manyfold higher when compared to plastic stents, the lower frequency of recurrent obstructions makes metal stents superior to plastic stents for endoscopic palliation of malignant biliary stricture in most patients. Is this the case in extremely elderly patients as well? A retrospective data review comprising prospective data collection and double-entry bookkeeping of therapeutic endoscopic retrograde cholangiopancreatographies (ERCP) with biliary strictures referring to malignancy in 14 patients aged 90 years or older at our institution in 1997-2007. Plastic stents were successfully inserted in 11 out of 14 patients, yielding a technical success rate of 79 %. In the remaining three patients, high biliary obstruction was relieved percutaneously in two cases while the general condition of one patient was so poor that terminal care decision was made in that case. There was no recurrent biliary obstruction in any of the patients with plastic stents prior to death which occurred after a mean of 2.8 months, giving a clinical success rate of 100 %. To be concluded, in extremely elderly patients with malignant obstructive jaundice, palliation with plastic stent is effective enough.

Feasibility of ERCP Procedures in Patients 90 Years of Age and Older

To the Editor: According to the web pages of Statistics Finland, the proportion of the elderly of the Finnish population will grow 2-fold during the next quarter century. As our population ages, the challenge for expedient miniinvasive treatment modalities in older age groups will become more and more significant, particularly in diseases common in the elderly such as pancreato-biliary diseases. With advances in equipment and expertise, the role of endoscopic procedures as mini-invasive treatment modalities has proved pivotal in the treatment of pancreato-biliary diseases during the last 2 decades. In the literature, there are numerous reports on endoscopic retrograde cholangiopancreatography (ERCP) procedures performed in the elderly including octogenarians, but only few surveys on very old patients undergoing ERCP. Here, we report our 11-year experience of ERCP procedures performed in patients aged 90 years or older.

Female gender and post-ERCP pancreatitis: Is the association caused by difficult cannulation?

Abstract Objective. Female gender is a well-known risk factor for the development of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis, but the underlying mechanism for this increased risk has remained unknown. We hypothesize that cannulation difficulty might play a part in this association. The aim of the current study was to determine whether the female papilla is more difficult to cannulate than the male papilla. Material and methods. Prospective data collection with emphasis on cannulation was conducted in 364 consecutive biliary ERCP procedures performed by very experienced ERCP endoscopists through native papilla in a tertiary referral university hospital. Results. Although the cannulation times seemed to be longer and alternative cannulation techniques seemed to be needed more frequently for successful cannulation in female than male patients, no statistically significant differences (p = 0.061 and 0.054, respectively) in the cannulation process could be found between the genders. Conclusions. The study was not able to confirm that the cannulation of the female papilla is more troublesome than the cannulation of the male papilla.

Female gender may give rise to difficulties in endoscopic and laparoscopic biliary surgery

We read with interest the fine article by Fukatsu and co-authors on unsuccessful cases of biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) in which the standard procedure was changed to a needleknife precut papillotomy [1]. ERCP is frequently challenging even for an experienced endoscopist. The most usual problem at ERCP is difficulty in achieving selective cannulation of the common bile duct. In the recent large-scale prospective survey of ERCP practice in the UK overall deep cannulation was achieved in only 2,684 of 3,210 (84%) patients undergoing their first ever ERCP [2]. In the survey by Fukatsu et al. [1] the total success rate of biliary cannulation was as high as 99% (497 out of 501 patients) in a study population in which needleknife precut papillotomy was performed in 16% (n = 80) of cases. Recently, we described our indications, techniques and results of 1,703 consecutive first-time ERCPs [3], in which the overall success rate of bile duct cannulation was 97%. The needle-knife approach was employed in 10% of cases. These figures emphasize that, although every cannulation may be challenging and the results are not satisfactory at the country level, high success rates of bile duct cannulation can be reached in high-volume centres in which needle-knife papillotomy is routine practice in difficult cases. The main purpose of the study of Fukatsu et al. [1] was to scrutinize those patients who had to undergo needleknife precut papillotomy because standard manoeuvres did not lead to successful biliary cannulation. Multivariate analysis indicated that female gender, presence of left lobe hypertrophy after hepatectomy, history of Billroth I reconstruction, and malignant biliary stricture were risk factors associated with difficult biliary cannulation. In our opinion it is not surprising that anatomic factors such as left lobe hypertrophy, Billroth I reconstruction and malignant biliary stricture are associated with difficulties in achieving access into the bile duct. Instead, we find that the association between female gender and cannulation failure reported by Fukatsu et al. is a novel, interesting and important finding. To our knowledge, there are no earlier reports on this association in the literature, which perhaps was the reason why the authors did not discuss this finding in their discussion section. This novel finding of Fukatsu et al. is in accordance with earlier reports that female gender is a risk factor for post-ERCP pancreatitis [4]. We find that difficulties in cannulation in female patients may even play a pivotal role in the development of post-ERCP pancreatitis. Moreover, earlier reports have indicated that female gender is associated with severe iatrogenic bile duct injury during laparoscopic cholecystectomy as well [5]. Traditionally, during the era of open surgery the male anatomy was known to make many abdominal operations such as bile surgery technically more demanding [6]. Nowadays, in the era of endoscopic and laparoscopic surgery, female gender seems to be a risk factor in endoscopic and laparoscopic biliary surgery. But what might be the reason for the findings that female patients seem to be more prone to difficulties in endoscopic and laparoscopic biliary surgery? A definite answer can certainly not be given, but we hypothesize that the elasticity and laxity of female J. M. Grönroos (&) S. Laine P. Salminen J. Karvonen M. Lavonius R. Gullichsen Department of Surgery, University of Turku, PB 52, 20521 Turku, Finland e-mail: juha.gronroos@tyks.fi