Argon gas embolism in the application of laparoscopic microwave coagulation therapy

Background

A major concern in the use of the argon beam coagulator system is the potential risk of argon gas embolism.

Methods

Seven cases with argon gas embolism in the English literature were reviewed along with the current case. The latter case was a 77-year-old female having laparoscopic hepatectomy after application of the microwave coagulation system on the cutting planes.

Results

Immediately following shots of an argon beam to control local bleeding at the needle hole in the liver caused by microwave coagulation, the end-tidal carbon disappeared, followed by cardiovascular collapse. After 18 min of cardiovascular resuscitation, the tumors were resected under laparotomy.

Conclusions

After reviewing the cases, pneumoperitoneum (57.1%), hepatic needle punctures (42.8%) and direct application of the argon beam to the liver (28.6%) can be considered as risky processes in such events. Caution is necessary in the use of an argon beam in liver surgery to avoid life-threatening gas embolism.     

Rendezvous gastrotomy technique using direct percutaneous endoscopic gastrostomy for transgastric cholecystectomy in hybrid natural orifice translumenal endoscopic surgery

Background/purpose

Transgastric access is a major route in natural orifice translumenal endoscopic surgery (NOTES); gastrotomy should be performed unless it would damage surrounding organs in the peritoneal cavity. This article describes a novel rendezvous gastrotomy technique over a direct percutaneous endoscopic gastrostomy (PEG).

Methods

In six live porcines, the gastrotomy involved applying a direct PEG through the abdominal wall into the stomach and exchanging to a needle trocar. An endoscopic balloon catheter was passed through the trocar by rendezvous technique. Then the inflated balloon and endoscope were advanced to the peritoneal cavity through the gastrotomy. Transgastric cholecystectomy was performed with a hybrid needle grasper through the same percutaneous site and the gastrotomy was closed with endoscopic clips.

Results

The rendezvous gastrotomy technique could reduce guidewire exchange. The success rate was 100% (6/6). Mean times for transgastric peritoneoscopy and cholecystectomy were 25.5 and 83.5 min. Mortality and morbidity was 0%. The addition of the extra trocar was unnecessary in all procedures.

Discussions/conclusions

The advantage of this introduction system includes the creation of controlled gastric perforation, which is easier to close. It provides reliable transgastric access and increases safety. It simplifies transgastric NOTES and provides less invasive hybrid NOTES procedure.     

Self-expanding metal stent insertion by colorectal surgeons in the management of obstructing colorectal cancers: a 6-year experience

Background

Placement of a self-expanding metal stent (SEMS) in patients presenting with colorectal cancer as an acute large bowel obstruction may obviate emergency surgery, potentially effectively palliating incurable cancers and acting as a bridge to surgery in patients with operable tumours. We present our experience with stenting for malignant acute large bowel obstruction over a 6-year period (2006–2011).

Methods

A prospectively compiled colorectal cancer database was reviewed to identify all patients presenting to our unit with malignant acute large bowel obstruction who had stenting carried out to achieve colonic decompression. All 44 procedures were performed by colorectal surgeons using a combined endoscopic and fluoroscopic technique.

Results

Overall, successful decompression was achieved in 42 patients by SEMS insertion (95.5 %). Technical and clinical success was achieved in all 30 patients undergoing stenting as a palliative measure (100 %). There was no clinical perforation in any of the 44 patients.

Conclusions

SEMSs insertion is a safe and effective technique for colonic decompression in the setting of acute malignant large bowel obstruction as either a palliative measure or as a bridge to subsequent resection.     

Slow Pull Versus Suction in Endoscopic Ultrasound-Guided Fine-Needle Aspiration of Pancreatic Solid Masses

Background

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of pancreatic masses is an established procedure for obtaining a pathological specimen. However, application of suction during EUS-FNA is still controversial and the efficacy of the slow-pull technique was recently reported for new core biopsy needles.

Aim

The purpose of this study was to compare the suction and slow-pull techniques using regular FNA needles.

Methods

The diagnostic yield of the suction and slow-pull techniques was retrospectively studied for patients who underwent EUS-FNA for pancreatic solid lesions.

Results

A total of 367 passes (181 by suction and 186 by the slow-pull technique) were performed during 97 EUS-FNA procedures for 93 patients with pancreatic solid lesions. The slow-pull technique resulted in lower scores for cellularity (≥2 for 37.5 % vs. 76.7 %) but scores for contamination with blood were lower (≥2 for 25.0 % vs. 66.7 %) and sensitivity of diagnosis of malignancy was higher (90.0 % vs. 67.9 %) when a 25-gauge FNA needle was used. There were no significant differences between the two techniques when a 22-gauge needle was used. In multivariate analysis of 82 cases with malignancy, the slow-pull technique (odds ratio (OR) 1.92, P = 0.028), tumor size ≥25 mm (OR 4.64, P < 0.001), and tumor location in the body or tail (OR 2.82, P < 0.001) were associated with greater sensitivity.

Conclusion

The slow-pull technique was associated with less contamination with blood and can potentially increase the diagnostic yield compared with the suction technique in EUS-FNA of pancreatic solid masses, especially with a 25-gauge FNA needle.     

The effects of isothermic and hypothermic carbon dioxide pneumoperitoneum on respiratory function test results

Background/Purpose

This study investigated the effects of isothermic and hypothermic carbon dioxide, used for pneumoperitoneum during laparoscopic cholecystectomy, on respiratory function test results.

Methods

Thirty patients who underwent elective laparoscopic cholecystectomy were enrolled in this prospective randomized study. The patients were divided into two groups. Carbon dioxide at 37?°C (isothermic) was used in the isothermic group, and carbon dioxide at 21?°C (hypothermic) was used in the hypothermic group. Respiratory function tests were performed in the preoperative period and at 12?h after the operation.

Results

Mean forced vital capacity (FVC), forced expiratory volume (FEV1), maximum peak expiratory flow (PEF), and the FEV1/FVC ratio were significantly higher in the isothermic group than in the hypothermic group (P < 0.05).

Conclusions

Using isothermic carbon dioxide for pneumoperitoneum has fewer negative effects than hypothermic carbon dioxide on respiratory function tests results. Isothermic carbon dioxide may be preferable for patients with respiratory problems.     

Rapid On-Site Evaluation Reduces Needle Passes in Endoscopic Ultrasound-Guided Fine-Needle Aspiration for Solid Pancreatic Lesions: A Risk–Benefit Analysis

Background

The effectiveness of endoscopic ultrasound-guided fine-needle aspiration increases with the number of needle passes but needle passes are also associated with increased risk of adverse events. The trade-off between needle passes and adequacy has not been well-characterized.

Aims

The purpose of this study was to compare the risk–benefit tradeoff of different sampling protocols with and without rapid onsite evaluation (ROSE).

Patients and Methods

We used a discrete-event simulation model to compare eight different sampling protocols. Each sampling protocol was simulated 10,000 times to obtain the average performance for each scenario. The per-pass adequacy rates, ROSE, accuracy of the assessor and sampling limits were varied to determine the impact of these factors on the number of needle passes and adequacy rates.

Results

Increasing per-class adequacy can be achieved at a cost of increased needle passes. Sampling with ROSE achieved higher adequacy with fewer needle passes than policies using a fixed number of needle passes without ROSE.

Conclusions

Variable sampling policies using ROSE generally achieve greater per-case adequacy with fewer needle passes than non-ROSE sampling policies using a fixed number of passes.     

Les lésions intestinales au cours des traumatismes fermés de l’abdomen : diagnostic et prise en charge en milieu défavorisé

Purpose

To report our experience of treatment for bowel injuries following blunt abdominal trauma in a rural area.

Patients and methods

This retrospective study involved nine cases of bowel injury after blunt abdominal trauma, operated in the emergency department at the Regional Hospital of Thies from January 2009 to July 2011. We analyzed the circumstances of trauma, clinical aspects, investigations, the treatment and the postoperative course.

Results

There were 8 men and 1 woman with a mean age of 27 years (14 years–65 years). The traffic accidents were the cause in 5 cases followed by sports accidents (2 cases) and a fall from a height (2 cases). Signs of peritonitis and hemoperitoneum were found respectively in 5 and 2 cases. The clinical picture consisted of a localized defense in 2 cases. Plain abdominal X-ray showed a pneumoperitoneum in 4 cases. Ultrasound found a single intraperitoneal effusion in 2 cases and was normal in 1 case. CT-scan had diagnosed a jejunal rupture in a patient and had found a pneumoperitoneum that was missed at the plain abdominal X-ray in another patient. Four patients had undergone laparotomy less than 24 hours after injury and five after 48 hours. Perforation was found in the small intestine in 8 cases, in the sigmoid in 1 case. Treatment consisted in intestinal suture (5 cases) and resection-anastomosis (2 cases). Ileostomy was performed in a patient with septic shock. Sigmoid perforation was treated by sigmoidectomy followed by colostomy. Two deaths were noted due to severe sepsis.

Conclusion

Intestinal lesions secondary to blunt abdominal trauma are difficult to diagnose. They require an early surgical treatment because it determines the prognosis.     

Large dilating balloon to allow endoscope insertion for successful endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy (with video)

Background and purpose

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy can be present unique challenges. One of the major obstacles preventing successful ERCP is acute angulation and long afferent loops in patients with Billroth II gastrectomy or Roux-en-Y anastomosis. Here, we described a novel technique for successful endoscope insertion using a large dilating balloon.

Methods

The large dilating balloon (maximum diameter 20 mm) is used as an anchor for endoscope insertion (hooking method) in patients with Billroth II gastrectomy in whom no other endoscopes could be advanced into the end of the duodenum or the Roux-en-Y anastomosis.

Results

The hooking method allows the endoscope to be advanced into the proximal afferent loop, even in patients with sharp angulation of the Y limb.

Conclusions

To the best of our knowledge, this is the first report on the use of a large dilating balloon for endoscope insertion in patients with surgically altered anatomy, in particular Roux-en-Y anastomosis. We believe this technique may be effective for difficult cases like the present case.     

Single-Operator Wire-Guided Cannulation Technique Enables Easier Cannulation of Endoscopic Retrograde Cholangiopancreatography

Background

The single-operator wire-guided cannulation technique in endoscopic retrograde cholangiopancreatography (ERCP) has been rarely reported.

Aims

This study was undertaken to determine the safety and efficiency of a single-operator wire-guided cannulation technique.

Methods

Four hundred sixty-five consecutive patients referred for ERCP were included in this prospective study and randomly divided into two groups. A new single-operator wire-guided cannulation technique was performed by the same experienced endoscopist, with experienced assistants (group A) and inexperienced ones (group B). The number of attempts at cannulation, cannulation time, success rate, and procedure-related complications were compared between the two groups.

Results

Successful cannulation was achieved in 460 out of the 465 patients (98.92?%). The incidences of post-ERCP pancreatitis, bleeding, infection, and perforation were 5.16, 0.64, 1.08, and 0?%, respectively. There were no severe complications or death. The cannulation time, number of attempts at cannulation and complications were not significantly different between the two groups (all P?>?0.05).

Conclusions

The single-operator wire-guided cannulation technique was feasible, safe and efficient. It doesn??t require an experienced assistant and precise coordination between the assistant and endoscopist during cannulation.     

Endoscopic double-metallic stenting for malignant biliary and duodenal obstructions

Background

Endoscopic metallic stenting is a safe, effective treatment for malignant biliary obstructions, but can be technically difficult when combined malignant biliary and duodenal obstructions exist. Available duodenal metallic stents feature a tight mesh unsuitable for transpapillary biliary stenting. We evaluated the feasibility and usefulness of new endoscopic procedures for endoscopic double-stent placement in managing such obstructions.

Methods

The through-the-scope duodenal metallic stent has a central cross-wired, unfixed structure that allows insertion of the biliary stent through the mesh wall of a duodenal stent. Transpapillary endoscopic placement of a biliary stent was performed through the lumen of this duodenal stent. Endoscopic ultrasound (EUS)-guided biliary drainage was performed successfully through the duodenal bulb after puncturing with a 19G needle. Biliary metallic stenting through the choledochoduodenal tract and effective drainage were achieved.

Conclusions

Use of a combined endoscopic biliary and duodenal stent inserted through the mesh of the new duodenal metallic stent is feasible and effective in managing the aforementioned obstructions. EUS-guided biliary metal stenting is a therapeutic option for endoscopic management when a failed transpapillary approach through the lumen of the duodenal stent occurs. The continued development of endoscopic procedures and devices should resolve issues associated with complicated strictures.     

Prevention of iatrogenic bile duct injuries in difficult laparoscopic cholecystectomies: is the naso-biliary drain the answer?

Background

Prevention of iatrogenic injuries is of paramount importance in difficult laparoscopic cholecystectomies (LC). The objective of this study was to analyze the effectiveness of cholangiography using a pre-inserted endoscopic naso-biliary drain (ENBD) for navigation during difficult cholecystectomies.

Methods

The study design was a retrospective case analysis. In 508 patients who underwent LC in a tertiary referral university hospital from 1996 through 2007, difficult cholecystectomy was anticipated in 26 patients due to possibly aberrant biliary anatomy (four patients), unclear cystic duct anatomy during magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic retrograde cholangiopancreatography (ERCP) (three patients), and acute cholecystitis (19 patients). An ENBD was inserted during ERCP prior to LC for cholangiography (ENBDC) to facilitate safe dissection during LC. Prevalence of biliary complications was assessed as the main outcome measurement.

Results

The majority (68%) of the patients who underwent ENBDC had complicated cholecystitis. Advanced technical expertise was not required for insertion of an ENBD. In retrospect, ENBDC was useful in prevention of a possible catastrophe in 69% of cases. Open conversion was necessary in five patients and biliary complications occurred in five patients only in the non-ENBD group. There were no procedure-related complications. One limitation of the study was that it was not randomized and there was no comparison with patients without ENBDC.

Conclusions

ENBDC is a useful and safe tool in the prevention of iatrogenic bile duct injuries in LC.     

A case report: endoscopic enucleation of gastrointestinal stromal tumor of the ampulla of Vater

Objective

To report a case of endoscopic enucleation of a gastrointestinal stromal tumor of the ampulla of Vater.

Design

The tumor resection was performed by needle knife endoscopic submucosal dissection.

Results

The tumor was resected completely without serious complications and the patient recovered rapidly.

Conclusion

Endoscopic enucleation may be an alternative treatment for gastrointestinal stromal tumors of the ampulla of Vater for patients who fulfill certain requirements.     

Isolated sling suspension during resection of the Spiegel lobe of the liver: a safe alternative technique for difficult cases

Background/purpose

The Spiegel lobe is located deep in the dorsal portion of the liver, and isolated resections of this region are technically demanding, especially in bulky and/or invasive lesions or in hypertrophied cirrhotic livers.

Methods

Anterior approach using the isolated hanging maneuver of the Spiegel lobe was attempted in patients in whom the conventional method of mobilizing the Spiegel lobe prior to liver transection would have been difficult. Clinical outcomes were compared with the conventional approach performed during the same period.

Results

Of 42 consecutive isolated resections of the Spiegel lobe, the presently reported technique was required in 12 patients (28.6%). The median diameter of the tumors was 33 mm, and tumor invasion to the retrohepatic inferior vena cava was observed in four patients. Although minor vascular injury was observed in one patient during retrohepatic dissection, the isolated sling suspension of the Spiegel lobe was successfully conducted in all cases. No remarkable inferiority of the present technique compared with the conventional approach was noted either in operation data or clinical outcomes.

Conclusion

Anterior approach using the isolated sling-suspension technique may be a safe alternative surgical option for bulky and/or invasive lesions located in the Spiegel lobe of the liver.     

Appendectomy in Germany—an analysis of a nationwide survey 2011/2012

Introduction

Although appendectomies are frequently performed and new procedural techniques have emerged, no nationwide analysis exists after the cessation of the German quality control in 2004.

Methods

One thousand eight hundred seventy surgical hospitals in Germany were asked to answer questions anonymously concerning the size of the department, applied procedural techniques, various technical details, as well as the approach to the intraoperative finding of an inconspicuous appendix.

Results

We received 643 questionnaires (34.4 %) for evaluation. Almost all hospitals (95.5 %) offer laparoscopic appendectomy (LA), 15.4 % offer single-port (SPA), and 2.2 % (hybrid-) NOTES technique (NA). LA is the standard procedure in 85.2 % of male and in 89.1 % for female patients. In an open procedure (OA), the appendix and mesoappendix are mostly ligated (93.8 and 91.5 %). A Veress needle and open access are employed equally for LA. In 66.6 % of LA, the appendix is divided using an Endo-GIA, the mesoappendix in 45.5 % with bipolar coagulation. Almost half of the hospitals routinely flush the site in OA and LA. In open surgery with an inconspicuous appendix but a pathological finding elsewhere in the abdomen, it is resected “en principe” in 64.7 % and in the absence of any pathological finding in 91.2 %. For laparoscopic procedures, the numbers are 54.8 and 88.4 %.

Conclusions

Most German hospitals perform appendectomies laparoscopically regardless of patients’ gender. Usage of an Endo-GIA is widely established. SPA has not gained much acceptance, nor is NA widely used yet. In the absence of any pathological findings in particular, the macroscopically inconspicuous appendix results in an appendectomy “en principe” in most German hospitals.     

Rarity of Severe Bleeding and Perforation in Endoscopic Ultrasound-Guided Fine Needle Aspiration for Submucosal Tumors

Background

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an established procedure for the pathological diagnosis of gastrointestinal submucosal tumors (SMTs). Although bleeding and perforation are potentially severe complications of EUS-FNA, the incidences and severities of these complications have not yet been fully evaluated because of their relative rarity.

Aim

The purpose of this study was to evaluate the incidences and mortality of severe bleeding and perforation in patients who underwent EUS-FNA for SMTs.

Methods

The records of 1,135 consecutive patients who underwent EUS-FNA for SMTs at 219 hospitals, with low- to high-volume, were reviewed using a Japanese nationwide administrative database.

Results

Of the targeted lesions 73.5 % were located in the stomach, 13.4 % in the esophagus, 8.2 % in the duodenum, and 4.9 % at other sites. Five patients (0.44 %) experienced severe bleeding requiring red blood cell transfusion or endoscopic treatment, with none experiencing perforation. Only one patient (0.09 %) died in-hospital within 30 days of EUS-FNA (0.09 %), with death not associated with bleeding or perforation.

Conclusions

EUS-FNA is safe in evaluating SMTs, with low risks of bleeding and perforation.     

Factors Affecting Colonoscope Insertion Time in Patients With or Without a Colostomy After Left-Sided Colorectal Resection

Background/Aims

We examined whether the insertion time for colonoscopies performed after left-sided resection was different in patients with a colostomy from that in patients without a colostomy and identified factors that could impact colonoscopy performance.

Methods

We included consecutive patients who underwent colonoscopy between July 2005 and March 2011 after left-sided colorectal resection for colorectal cancer. We classified surgical methods according to the presence or absence of a colostomy and evaluated colonoscope insertion time retrospectively. Furthermore, we analyzed factors that might affect insertion time.

Results

A total of 1,041 patients underwent colonoscopy after left-sided colorectal resection during the study period. The colonoscopy completion rate was 98.6?%, and the mean insertion time was 6.1?±?4.6?min (median 4.7?min, range 0.3?C35.8?min). A shorter resection length of colon, the presence of a colostomy, and a lower endoscopist case volume were found to be independent factors associated with prolonged insertion time in patients with left-sided colorectal resection. Among experienced colonoscopists, no colonoscopy-associated or clinical factors were found to affect insertion time. However, a shorter resection length of colon, the presence of a colostomy, and poor bowel preparation were associated with prolonged insertion time among inexperienced endoscopists.

Conclusions

We identified three factors that affect colonoscope insertion time after left-sided colorectal resection, including the presence of a colostomy. Inexperienced endoscopists were much more affected by the presence of a colostomy after left-sided colorectal resection. These findings have implications for the practice and teaching of colonoscopy after left-sided colorectal resection.     

Short-term outcomes of local correction of stoma prolapse with a stapler device

Background

The aim of the present study was to classify the short-term outcomes of local correction of stoma prolapse with a stapler device.

Methods

The medical records of 11 patients undergoing local correction of stoma prolapse using a stapler device were retrospectively reviewed.

Results

No mortality or morbidity was observed after the surgery. Median operative time was 35 min (range 15–75 min), and blood loss was minimal. Median duration of follow-up was 12 months (range 6–55 months). One of the 11 patients had a recurrent stoma prolapse.

Conclusions

This technique can be a feasible, safe and minimally invasive correction procedure for stoma prolapse.     

Safety Analysis of a Hemostatic Powder in a Porcine Model of Acute Severe Gastric Bleeding

Background

Non-variceal upper gastrointestinal (UGI) bleeding is a common condition that requires prompt lifesaving therapy and traditional endoscopic treatments require high technical proficiency to perform.

Aims

This study was conducted to identify any local or systemic histopathologic effects of a hemostatic powder in a porcine model of active, severe, non-variceal UGI hemorrhage.

Methods

This prospective, non-blinded animal study was performed in accordance with Good Laboratory Practice and Animal Care and Use Guidelines. Six animals underwent gastrotomy and creation of a looped vascular bundle, which was placed into the stomach lumen. The transplanted vascular bundle was punctured with an endoscopic needle–knife to create Forrest grade Ia or Ib bleeding. The hemostatic powder was then applied until hemostasis was achieved.

Results

Initial hemostasis was achieved in all animals. Results of pre- and post-treatment coagulation studies were similar. All animals survived at least 9 days post-procedure. The hemostatic powder was not found in any local, regional, or systemic tissues. Gross and histologic analysis of systemic organs showed no infarct, particulate, or embolic effects. No gross or microscopic necropsy findings were treatment-related.

Conclusions

The hemostatic powder achieved initial hemostasis (even in animals with spurting arterial bleeding) with no bowel obstruction or unintended luminal effects, no local or regional particulate effects, no systemic embolic effects, and no systemic coagulopathic effects.     

Endoscopic ultrasonography-guided gallbladder drainage: actual technical presentations and review of the literature (with videos)

Background/purpose

Endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) has been developed as an alternative drainage method in patients with acute cholangitis. Here, we describe two successful EUS-GBD cases and review the literature on this topic.

Methods

EUS-GBD was conducted using a curved linear array echoendoscope and a 19-gauge needle.

Results

A 7-Fr double pigtail stent was successfully placed transgastrically in one patient and transduodenally in the other patient, without any serious early adverse events in either patient. No late complications or relapse of acute cholecystitis have been seen during the 3- to 6-month follow-up period.

Conclusions

EUS-GBD holds high potential as an alternative gallbladder decompression procedure. However, because current experience is limited, multicenter trials for the accurate evaluation of this procedure appear to be necessary in the near future.     

Treatment of acute decompensation of maple syrup urine disease in adult patients with a new parenteral amino-acid mixture

Background

Acute decompensation of maple syrup urine disease (MSUD) is usually treated by enteral feeding with an amino-acid mixture without leucine (Leu), valine or isoleucine. However, its administration is ineffective in cases of gastric intolerance and some adult patients refuse enteral feeding via a nasogastric tube. We developed a new parenteral amino-acid mixture for patients with MSUD.

Methods

Seventeen decompensation episodes in four adult patients with MSUD treated with a parenteral amino-acid mixture (group P) were compared to 18 previous episodes in the same patients treated by enteral feeding (group E).

Results

The mean Leu concentration at presentation was similar in the groups P and E (1196.9 μmol/L and 1212.2 μmol/L, respectively). The mean decrease in the Leu concentration during the first 3 days of hospitalisation was significantly higher in group P than group E (p?=?0.0026); there were no side effects. The mean duration of hospitalisation was similar (4 vs. 4.5 days, p?=?NS). No patient in group P deteriorated whereas one patient in group E required dialysis.

Conclusion

This new parenteral amino-acid mixture is safe and allows efficient Leu concentration decrease during acute MSUD decompensation episodes in adults. Its use avoids the need for nasogastric tube insertion.