Initial experience with laparoscopic bypass for upper gastrointestinal malignancy: a new option for palliation of patients with advanced upper gastrointestinal tumors

Double Stenting for Malignant Biliary and Duodenal Obstruction: A Systematic Review and Meta-Analysis

Data about the efficacy of palliative double stenting for malignant duodenal and biliary obstruction are limited.

Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: A personal series and systematic review of the literature

The major symptoms of advanced hepatopancreatic-biliary cancer are biliary obstruction, pain and gastric outlet obstruction (GOO). For obstructive jaundice, surgical treatment should de consider in recurrent stent complications. The role of surgery for pain relief is marginal nowadays. On the last, there is no consensus for treatment of malignant GOO. Endoscopic duodenal stents are associated with shorter length of stay and faster relief to oral intake with more recurrent symptoms. Surgical gastrojejunostomy shows better long-term results and lower re-intervention rates, but there are limited data about laparoscopic approach. We performed a systematic review of the literature, according PRISMA guidelines, to search for articles on laparoscopic gastrojejunostomy for malignant GOO treatment. We also report our personal series, from 2009 to 2017. A review of the literature suggests that there is no standardized surgical technique either standardized outcomes to report. Most of the studies are case series, so level of evidence is low. Decision-making must consider medical condition, nutritional status, quality of life and life expectancy. Evaluation of the patient and multidisciplinary expertise are required to select appropriate approach. Given the limited studies and the difficulty to perform prospective controlled trials, no study can answer all the complexities of malignant GOO and more outcome data is needed.

Role of the laparoscopic approach to biliary bypass for benign and malignant biliary diseases: a systematic review

BACKGROUND

The laparoscopic approach for biliary bypass surgery is a contemporary management option. This article reviews the evidence available for its role and effectiveness.

METHODS

A computerised search was made of the MEDLINE, PubMed, and EMBASE databases for English language publications from the first report of laparoscopic biliary bypass in 1992 to January 2010.

RESULTS

Some 89 patients featured in 19 reports underwent 89 laparoscopic biliary bypass procedures for benign (n=17) and malignant (n=72) indications. Of those, 52 patients underwent biliary bypass alone, while 37 patients underwent biliary bypass combined with gastric bypass. The procedures included cholecystojejunostomy (n=64), hepaticojejunostomy (n=14), and choledochoduodenostomy (n=11). The overall success rate in achieving resolution of jaundice was 98.9%, with a morbidity rate of 12.3% and a mortality rate of 5.6%. More than one procedure was required in 1.1% of patients to achieve resolution of obstructive jaundice. During a reported median follow-up period of 13 months, obstructive jaundice recurred in none of the patients.

CONCLUSION

The laparoscopic approach to biliary bypass surgery is safe and has a high initial success rate, low reintervention rate, and low morbidity and mortality rates. Longer follow-up data and comparative studies with open surgery and endoscopic stenting are needed.

Laparoscopic surgery for pancreatic tumors

The rapid growth of minimally invasive technology and experience in recent decades has revolutionized many aspects of oncologic surgery. Adoption of laparoscopic pancreatectomy has been slow due to the inherent anatomic complexity of pancreatic surgery, as well as concerns of perioperative complications and compromised oncologic results. With increasing surgeon experience and growing data, laparoscopic pancreatic resection is generating considerable attention and enthusiasm. This article provides an overview of laparoscopic pancreatic tumor surgery with respect to tumor biology and technical approaches. Current applications of laparoscopic approaches to left pancreatectomy, tumor enucleation, central pancreatectomy, and pancreaticoduodenectomy for treatment of pancreatic tumors are considered in light of available evidence demonstrating feasibility, safety, and oncologic efficacy. Future directions in minimally invasive pancreatic surgery are explored.

Surgical bypass vs. endoscopic stenting for pancreatic ductal adenocarcinoma

BACKGROUND

The majority of patients with pancreatic cancer are non-resectable and jaundiced at presentation. Methods of palliation in such patients with locally advanced disease comprise endoscopic placement of a biliary endoprosthesis or surgical bypass.

METHODS

This retrospective study compared morbidity, mortality, hospital stay, readmission rate and survival in consecutive patients with incurable locally advanced pancreatic ductal adenocarcinoma.

RESULTS

We identified a total of 56 patients, of whom 33 underwent endoscopic stenting and 23 underwent a surgical bypass consisting of a hepaticojejunostomy-en-Y and a gastrojejunostomy. There were no significant differences in complication or mortality rates between patients undergoing palliative stenting and those undergoing palliative surgery. However, after excluding admissions for chemotherapy-related problems, the number of readmissions expressed as a percentage of the group population size was greater in stented patients compared with biliary bypass patients (39.4% vs. 13.0%, respectively; P < 0.05). Overall survival amongst patients undergoing palliative bypass was significantly greater than in stented patients (382 days vs. 135 days, respectively; P < 0.05).

CONCLUSIONS

On analysis of these data and the published literature, we conclude that surgical bypass represents an effective method of palliation for patients with locally advanced pancreatic cancer. Patients need to be carefully selected with regard to both operative risk and perceived overall survival.

Transgastric gastro-jejunal anastomosis with flexible endoscope on a biosynthetic model

Introduction: In the last few years the rapid development of flexible endoscopies has opened new possibilities in minimal invasive procedures. With the help of these techniques the exposure, the risk of complications and the healing period of the patient might be reduced. One of these procedures is the transgastric intervention. Through an incision on the wall of the stomach, the endoscope could be led into the abdominal cavity, where several interventions can be performed. The aim of the study was to examine the technical feasibility and the success of the formation of gastro-jejunal anastomosis. Meanwhile the difficulties of the method could be explored in order to introduce this method in human use. Method: A lifelike biosynthetic model was made from a slaughtered domestic pig’s gastrointestinal tract (stomach and the first few jejunum loops) which was fixed onto a plastic frame. Two single-channel gastroscopes were inserted into the stomach. On the wall of the stomach an approximately 2 centimetres wide incision was made by the electrocoagulator with a needle-knife. Through it the first jejunum loop was grasped by a foreign-body forceps and then was retracted into the stomach. Subsequently the jejunum loop was held safely with the first endoscope. Parallel to it an incision was made on the jejunum by the electrocoagulator. The authors managed to securely unite the open edges of the gastric wall and the jejunum with endoclips. Result: The model was good for practising. The anastomosis is technically feasible and was successfully made on biosynthetic porcine model using the transgastric route. Although the incisions both on the gastric wall and on the jejunum loop were made easily, the fixing of the anastomosis might be questionable. Conclusion: It was revealed that more experiments and the development of new, special instruments are needed in order to conduct the anastomosis safely.