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Troncone E, Amendola R, Moscardelli A, De Cristofaro E, De Vico P, Paoluzi OA, Monteleone G, Perez-Miranda M, Del Vecchio Blanco G. Endoscopic Gallbladder Drainage: A Comprehensive Review on Indications, Techniques, and Future Perspectives. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:633. [PMID: 38674279 PMCID: PMC11052411 DOI: 10.3390/medicina60040633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024]
Abstract
In recent years, therapeutic endoscopy has become a fundamental tool in the management of gallbladder diseases in light of its minimal invasiveness, high clinical efficacy, and good safety profile. Both endoscopic transpapillary gallbladder drainage (TGBD) and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD) provide effective internal drainage in patients with acute cholecystitis unfit for cholecystectomy, avoiding the drawbacks of external percutaneous gallbladder drainage (PGBD). The availability of dedicated lumen-apposing metal stents (LAMS) for EUS-guided transluminal interventions contributed to the expansion of endoscopic therapies for acute cholecystitis, making endoscopic gallbladder drainage easier, faster, and hence more widely available. Moreover, EUS-GBD with LAMS opened the possibility of several cholecystoscopy-guided interventions, such as gallstone lithotripsy and clearance. Finally, EUS-GBD has also been proposed as a rescue drainage modality in malignant biliary obstruction after failure of standard techniques, with encouraging results. In this review, we will describe the TBGD and EUS-GBD techniques, and we will discuss the available data on clinical efficacy in different settings in comparison with PGBD. Finally, we will comment on the future perspectives of EUS-GBD, discussing the areas of uncertainty in which new data are more strongly awaited.
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Affiliation(s)
- Edoardo Troncone
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Rosa Amendola
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | | | - Elena De Cristofaro
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Pasquale De Vico
- Department of Anaesthesia, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | | | - Giovanni Monteleone
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Manuel Perez-Miranda
- Department of Gastroenterology and Hepatology, University Hospital Rio Hortega, 47012 Valladolid, Spain
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Teoh AYB. Don't forget the gallbladder if you cannot access the bile ducts! Dig Endosc 2024; 36:359. [PMID: 37644903 DOI: 10.1111/den.14661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/13/2023] [Indexed: 08/31/2023]
Affiliation(s)
- Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
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Rimbaș M, Crinò SF, Rizzatti G, Larghi A. Endoscopic ultrasound-guided gallbladder drainage: a backdoor for biliary decompression? Endoscopy 2021; 53:873. [PMID: 34315186 DOI: 10.1055/a-1299-1495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Mihai Rimbaș
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania.,Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CERTT, Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,CERTT, Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
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Teoh AYB. Outcomes and limitations in EUS-guided gallbladder drainage. Endosc Ultrasound 2019; 8:S40-S43. [PMID: 31897378 PMCID: PMC6896429 DOI: 10.4103/eus.eus_49_19] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 07/08/2019] [Indexed: 12/19/2022] Open
Abstract
EUS-guided gallbladder drainage (EUS-GBD) is gaining popularity as an option for drainage of the gallbladder in patients suffering from acute cholecystitis but at high risk for cholecystectomy. It allows internal drainage of the gallbladder and avoidance of the external tube as used in percutaneous cholecystostomy (PT-GBD). It may also provide additional benefits, including reduced re-admissions and re-interventions. In this chapter, we review the indications and outcomes of EUS-GBD. Furthermore, the follow-up management of patients that received EUS-GBD would be outlined.
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Affiliation(s)
- Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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Affiliation(s)
- Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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Biliary bypass redux: lessons for the therapeutic endoscopist from the archives of surgery. Gastrointest Endosc 2017; 85:428-432. [PMID: 28089036 DOI: 10.1016/j.gie.2016.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 08/23/2016] [Indexed: 02/08/2023]
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Nakai Y, Matsubara S, Isayama H, Koike K. Cystic duct patency in EUS-guided gallbladder drainage as a rescue treatment for malignant biliary obstruction. Gastrointest Endosc 2016; 83:1302-3. [PMID: 27206594 DOI: 10.1016/j.gie.2016.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 01/09/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Advances in the Surgical Management of Resectable and Borderline Resectable Pancreas Cancer. Surg Oncol Clin N Am 2016; 25:287-310. [PMID: 27013365 PMCID: PMC10181830 DOI: 10.1016/j.soc.2015.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Successful surgical resection offers the only chance for cure in patients with pancreatic cancer. However, pancreatic resection is feasible in less than 20% of the patients. In this review, the current state of surgical management of pancreatic cancer is discussed. The definition of resectability based on cross-sectional imaging and the technical aspects of surgery, including vascular resection and/or reconstruction, management of aberrant vascular anatomy and extent of lymphadenectomy, are appraised. Furthermore, common pancreatic resection-specific postoperative complications and their management are reviewed.
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Abstract
Peri-ampullary and hepatic malignancies will frequently present with obstructive jaundice. For unresectable tumors, effective and lasting decompression of the biliary tree is essential to improve quality of life and survival. An overview of present treatment modalities for palliation of obstructive jaundice is provided, including a systematic review of the English literature regarding the optimum choice of palliation.
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Intraductal US in the assessment of tumor involvement to the orifice of the cystic duct by malignant biliary obstruction. Gastrointest Endosc 2008; 68:78-83. [PMID: 18402956 DOI: 10.1016/j.gie.2007.12.063] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Accepted: 12/30/2007] [Indexed: 01/22/2023]
Abstract
BACKGROUND Tumor involvement to the orifice of the cystic duct (OCD) is a risk factor for cholecystitis after metallic stent (MS) placement. OBJECTIVE ERCP and intraductal US (IDUS) were used to assess tumor involvement to the OCD. DESIGN A prospective consecutive study. SETTING The University of Tokyo Hospital, Japan. PATIENTS AND INTERVENTIONS Between January 2003 and May 2007, 34 patients with resectable malignant biliary obstruction underwent an ERCP and an IDUS before preoperative biliary drainage. MAIN OUTCOME MEASUREMENTS ERCP and IDUS findings were confirmed via a histopathologic analysis of surgical specimens. RESULTS An ERCP showed that the cystic duct was opacified in 22 of 34 patients (64.7%). Eight patients were diagnosed with OCD tumor involvement. In the remaining 12 patients, tumor involvement was impossible to evaluate via an ERCP. An IDUS identified tumor involvement to the OCD in all 34 patients. Tumor involvement to the OCD was diagnosed in 12 patients, including 4 patients with previously negative results during an ERCP. Tumor involvement was confirmed by histopathology of surgical specimens. The sensitivity and specificity of detection were 66.7% (8/12) and 63.6% (14/22), respectively, via ERCP, and 100% (12/12) and 100% (22/22), respectively, via IDUS. LIMITATION The small sample size. CONCLUSIONS IDUS, in addition to ERCP, provides an accurate evaluation of tumor involvement to the OCD in patients with malignant biliary obstruction.
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Köninger J, Wente MN, Müller MW, Gutt CN, Friess H, Büchler MW. Surgical palliation in patients with pancreatic cancer. Langenbecks Arch Surg 2006; 392:13-21. [PMID: 17103000 DOI: 10.1007/s00423-006-0100-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2006] [Accepted: 08/11/2006] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aim of palliative strategies in patients with pancreatic cancer is the relief of tumor-associated symptoms such as biliary and duodenal obstruction and tumor growth. Due to high mortality and morbidity rates of surgery, treatment of patients with advanced pancreatic cancer is mainly in the hand of gastroenterologists. RATIONALE In recent years, surgery of pancreatic cancer in specialized centres developed strongly, which makes it a viable option even in the treatment of advanced disease. CONCLUSION We advocate for an aggressive strategy in the treatment of pancreatic cancer with surgical exploration and tumor resection whenever possible.
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Affiliation(s)
- Jörg Köninger
- Department of General Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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Hamade AM, Al-Bahrani AZ, Owera AMA, Hamoodi AA, Abid GH, Bani Hani OI, O'Shea S, Lee SH, Ammori BJ. Therapeutic, prophylactic, and preresection applications of laparoscopic gastric and biliary bypass for patients with periampullary malignancy. Surg Endosc 2005; 19:1333-40. [PMID: 16021372 DOI: 10.1007/s00464-004-2282-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2004] [Accepted: 05/10/2005] [Indexed: 12/27/2022]
Abstract
BACKGROUND Laparoscopic bypass surgery for the palliation of gastric and biliary obstruction is associated with a rapid recovery. This study aimed to extend its application to other aspects in the management of patients with periampullary cancer. METHODS Between 2001 and 2004, 21 patients (median age, 68 years) underwent laparoscopic gastric (n = 8), biliary (n = 5), and combined gastric and biliary (n = 8) bypass. In addition to its therapeutic role (n = 12), indications included a concomitant prophylactic gastric (n = 3) and biliary (n = 2) bypass as well as pre- 1 Whipple's relief of deep jaundice at the time of staging laparoscopy (n = 3). Construction of the biliary bypass to the gallbladder (n = 11) or bile duct (n = 2) was based on preoperative imaging. RESULTS All procedures were completed laparoscopically. The median operating times for gastric, biliary, and combined bypass were 75, 60, and 130 min, respectively. The addition of a prophylactic bypass did not significantly prolong the operating time, as compared with a single therapeutic bypass. One patient died postoperatively of aspiration pneumonia. The postoperative hospital stay (median, 4 days) was not significantly influenced by the type of bypass. No recurrence of or new obstructive symptoms developed during the follow-up period after a therapeutic or prophylactic bypass. CONCLUSIONS Applications of laparoscopic gastric and biliary bypass can safely be expanded to include a prophylactic role and preresection relief of obstructive jaundice. Prophylactic bypass surgery does not prolong operating time or hospital stay significantly and prevents future onset of obstructive symptoms.
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Affiliation(s)
- A M Hamade
- Department of Surgery, Manchester Royal Infirmary, M13 9WL, Manchester, UK
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13
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Date RS, Siriwardena AK. Current status of laparoscopic biliary bypass in the management of non-resectable peri-ampullary cancer. Pancreatology 2005; 5:325-9. [PMID: 15980662 DOI: 10.1159/000086533] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In patients with non-resectable peri-ampullary cancer, optimization of quality of life is an important goal. Although endoscopic palliation is widely used, the proponents of laparoscopic biliary bypass claim that this procedure alters management towards surgery. However, the evidence base for selection of laparoscopic bypass is limited and the aim of this report is to scrutinize the available evidence in order to assess the current role of this procedure. METHODS A computerised literature search was made of the Medline database for the period from January 1966 to December 2004. Searches identified 12 reports of laparoscopic palliation for peri-ampullary cancer. These reports were retrieved and data analysed in the following categories: type of bypass; combination with other procedures; complication and outcome. RESULTS Laparoscopic cholecystoenterostomy is the commonest form of laparoscopic biliary bypass practiced. Of the 52 reported cases undergoing laparoscopic biliary bypass, 40 underwent laparoscopic cholecystojejunostomy, 6 laparoscopic choledochoduodenostomy and 6 underwent laparoscopic hepaticoje- junostomy. CONCLUSION Current evidence does not justify the incorporation of laparoscopic biliary bypass techniques into contemporary evidence-based management algorithms for patients with non-resectable periampullary cancer.
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Affiliation(s)
- Ravindra S Date
- Hepatobiliary Unit, Department of Surgery, Manchester Royal Infirmary, Manchester, UK
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14
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Affiliation(s)
- Jennifer G Hall
- Department of General Surgery, Duke University Medical Center, Durham, NC 27710, USA.
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Date RS, Siriwardena AK. Laparoscopic Biliary Bypass and Current Management Algorithms for the Palliation of Malignant Obstructive Jaundice. Ann Surg Oncol 2004; 11:815-7. [PMID: 15313739 DOI: 10.1245/aso.2004.12.925] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Petelin JB. Laparoscopic common bile duct exploration. Surg Endosc 2003; 17:1705-15. [PMID: 12958681 DOI: 10.1007/s00464-002-8917-4] [Citation(s) in RCA: 157] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2002] [Accepted: 12/03/2002] [Indexed: 12/16/2022]
Abstract
BACKGROUND Herein I describe my >12-year experience with laparoscopic common bile duct exploration (LCBDE). METHODS From 21 September 1989 through 31 December 2001, 3,580 patients presented with symptomatic biliary tract disease. Laparoscopic cholecystecomy (LC) was attempted in 3,544 of them (99.1%) and completed in 3,527 (99.5%). Laparoscopic cholangiograms (IOC) were performed in 3,417 patients (96.4%); in 344 cases (9.7%), the IOC was abnormal. Forty-nine patients (1.4%) underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP), and 33 patients (0.9%) underwent postoperative ERCP. LCBDE was attempted in 326 cases and completed in 321 (98.5%). It was successful in clearing the duct in 317 of the 344 patients with abnormal cholangiograms (92.2%). RESULTS The mean operating time for all patients undergoing LC with or without cholangiograms or LCBDE or other additional surgery was 56.9 min. Mean length of stay was 22.1 h. The mean operating time for LC only patients ( n = 2530)--that is, those not undergoing LCBDE or any other additional procedure--was 47.6 min; their mean postoperative length of stay was 17.2 h. Ductal exploration was performed via the cystic duct in 269 patients, (82.5%) and through a choledochotomy in 57 patients (17.5%). T-tubes were used in patients in whom there was concern for possible retained debris or stones, distal spasm, pancreatitis, or general poor tissue quality secondary to malnutrition or infection. In cases where choledochotomy was used, a T-tube was placed in 38 patients (67%), and primary closure without a T-tube was done in 19 (33%). There were no complications in the group of patients who underwent choledochotomy and primary ductal closure without T-tube placement or in the group in whom T-tubes were placed. CONCLUSIONS Common bile duct (CBD) stones still occur in 10% of patients. These stones are identified by IOC. IOC can be performed in >96.4% of cases of LC. LCBDE was successful in clearing these stones in 97.2% of patients in whom it was attempted and in 92.2% of all patients with normal IOCs. Most LCBDEs in this series were performed via the cystic duct because of the stone characteristics and ductal anatomy. Selective laparoscopic placement of T-tubes in patients requiring choledochotomy (67%) appears to be a safe and effective alternative to routine T-tube drainage of the ductal system. ERCP, which was required for 5.8% of patients with abnormal cholangiograms, and open CBDE, which was used in 2.0%, still play an important role in the management of common bile duct pathology. The role of ERCP, with or without sphincterotomy, has returned to its status in the prelaparoscopic era. LCBDE may be employed successfully in the vast majority of patients harboring CBD stones.
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Affiliation(s)
- J B Petelin
- Department of Surgery, University of Kansas School of Medicine, Kansas City, KS 66104, USA.
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Urbach DR, Bell CM, Swanstrom LL, Hansen PD. Cohort study of surgical bypass to the gallbladder or bile duct for the palliation of jaundice due to pancreatic cancer. Ann Surg 2003; 237:86-93. [PMID: 12496534 PMCID: PMC1513963 DOI: 10.1097/00000658-200301000-00012] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare patterns in mortality and the use of subsequent biliary drainage interventions (surgical, endoscopic, and percutaneous) associated with the different types of biliary bypass. SUMMARY BACKGROUND DATA Surgical palliation of obstructive jaundice due to pancreatic cancer is often accomplished with an intestinal bypass to either the gallbladder or the bile duct. It is not known whether a gallbladder bypass, which is a simpler operation and more amenable to laparoscopic surgery, performs as well as a bypass to the bile duct. METHODS The authors conducted a retrospective cohort study of 1,919 patients 65 years of age or older who had a surgical biliary bypass for pancreatic cancer diagnosed between 1991 and 1996 using Medicare claims data and the Surveillance, Epidemiology and End Results (SEER) database. RESULTS At 1, 2, and 5 years, 7.5%, 17.4%, and 26.0% of 945 patients initially treated with a gallbladder bypass had additional biliary interventions, as compared with 2.9%, 11.0%, and 13.3% of 974 patients initially treated with a bile duct bypass. Patients who initially had a gallbladder bypass were 4.4 times as likely to have additional biliary surgery and 2.9 times as likely to have any subsequent biliary intervention as were patients who initially had a bile duct bypass. Median survival was longer following bile duct bypass. The adjusted hazard ratio for death associated with gallbladder bypass was 1.2. CONCLUSIONS Compared to patients whose initial biliary bypass was to the bile duct, the risk of having one or more additional surgical, endoscopic, or percutaneous biliary drainage procedures is substantially greater in patients whose initial bypass was to the gallbladder.
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Affiliation(s)
- David R Urbach
- Department of Surgery, Toronto General Hospital Research Institute, Ontario, Canada.
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Abstract
Very few patients with a periampullary neoplasm present with resectable disease. Consequently, various operative and non-operative techniques have been developed to palliate patients with unresectable periampullary disease. Laparoscopic biliary (cholecystojejunostomy) and enteric bypass (gastrojejunostomy) are reasonable options as compared to their open counterparts for operative palliation. However, only a limited number of carefully selected patients meet selection criteria for laparoscopic palliation.
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Affiliation(s)
- E G Chekan
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.
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Luque-de Leôn E, Tsiotos GG, Balsiger B, Barnwell J, Burgart LJ, Sarr MG. Staging laparoscopy for pancreatic cancer should be used to select the best means of palliation and not only to maximize the resectability rate. J Gastrointest Surg 1999; 3:111-7; discussion 117-8. [PMID: 10457331 DOI: 10.1016/s1091-255x(99)80018-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Staging laparoscopy, based on the assumption that endobiliary stenting is the best palliation, allegedly saves an "unnecessary" laparotomy for incurable pancreatic cancer. Our aim was to determine survival of patients with clinically resectable pancreatic cancer that is found to be unresectable intraoperatively and thereby infer appropriate utilization of staging laparoscopy. A retrospective analysis was undertaken of 148 patients with ductal adenocarcinoma (1985 to 1992) with a clinically resectable lesion based on current imaging techniques. All were considered candidates for resection but were deemed unresectable at operation because of metastases to the liver (group I; 29 patients), the peritoneum (group II; 22 patients), or distant lymph nodes (group III; 44 patients) or because of vascular invasion (group IV; 53 patients). Overall median survival was 9 months (range 1 to 53 months), but by group was as follows: group I, 6 months; group II, 7 months; group III, 11 months; and group IV, 11 months. Individual comparisons showed shorter survival for patients with distant nodal, liver, or peritoneal metastases than with nodal or vascular involvement (P<0.03). Staging laparoscopy should be performed to identify patients with liver or peritoneal metastases who have an expected survival of approximately 6 months, in whom short-term endoscopic palliation is satisfactory. Extended laparoscopy to identify lymph node or vascular involvement is contingent upon which palliation (operative vs. endoscopic) is considered most appropriate. Because we believe operative bypass provides better, more durable palliation in this latter group, we have not adopted extended laparoscopy.
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Affiliation(s)
- E Luque-de Leôn
- Department of Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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20
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Abstract
BACKGROUND Potential applications for laparoscopic surgery in pancreatic disease include (1) staging of pancreatic malignancies; (2) palliation of pancreatic malignancies; (3) pancreatic resections for benign and malignant disease; and (4) pancreatic drainage procedures. METHODS A review of the literature is presented. In addition, original data on a series of 5 laparoscopic pancreatic distal resections and 10 laparoscopic cystogastrostomies are presented. RESULTS AND CONCLUSIONS Laparoscopy may have a role in the staging of patients with pancreatic malignancies; however, with high-quality preoperative imaging, the percentage of patients who will benefit from laparoscopy may be as low as 5%. For palliation, both cholecystoenterostomy and choledochoenterostomy can be performed laparoscopically. The former is technically straightforward but has a higher failure rate; the latter is technically difficult and currently not suitable for widespread adoption. Laparoscopic gastroenterostomy is a straightforward means of palliating gastrointestinal obstruction. Patients appear to benefit from laparoscopic distal pancreatic resection but not from laparoscopic pancreaticoduodenectomy. Patients appear to benefit from laparoscopic pseudocyst decompression.
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Affiliation(s)
- A Park
- Department of Surgery, University of Kentucky Chandler Medical Center, Lexington 40536-0298, USA
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21
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Slavin J, Ghaneh P, Jones L, Sutton R, Hartley M, Neoptolemos J. The future of surgery for pancreatic cancer. Ann Oncol 1999. [DOI: 10.1093/annonc/10.suppl_4.s285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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22
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SWANSTROM LEEL. Endoscopic Surgery for Pancreato-Biliary Cancer. J Laparoendosc Adv Surg Tech A 1998. [DOI: 10.1089/lap.1998.8.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Affiliation(s)
- F H Chae
- Department of Surgery, University of Colorado Health Sciences Center, Denver, USA
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Schirmer B. SSAT/SAGES minimally invasive surgeryAdvanced laparoscopic hepatobiliary surgery. Surg Endosc 1998; 12:361. [PMID: 9543532 DOI: 10.1007/s004649900673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- B Schirmer
- Department of Surgery, University of Virginia Health Science Center, Box 181, Charlottesville, VA 22908, USA
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26
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Holzman MD, Reintgen KL, Tyler DS, Pappas TN. The role of laparoscopy in the management of suspected pancreatic and periampullary malignancies. J Gastrointest Surg 1997; 1:236-43; discussion 243-4. [PMID: 9834353 DOI: 10.1016/s1091-255x(97)80115-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Laparoscopic evaluation of patients with suspected periampullary malignancies has been utilized more frequently in recent years. Its exact role with regard to staging and surgical bypass for palliation have yet to be clearly defined. To better define the role of laparoscopy in the evaluation and palliation of periampullary malignancy, a retrospective review of the Duke experience was carried out. Fifty-three patients with suspected pancreatic or periampullary malignancies were referred for surgical evaluation at Duke University Medical Center between 1993 and 1995. All patients underwent CT scanning and lesions were classified as resectable or unresectable based on previously established criteria. Patients either underwent laparoscopic evaluation (n = 30; 11 with laparoscopic palliation) or proceeded directly to celiotomy (n = 23). Charts were reviewed for postoperative course including complications, length of stay, and hospital costs. Although laparoscopy had a sensitivity of 93.3% for metastatic disease, CT scans accurately staged 86.8% of patients missing only one patient with peritoneal/hepatic disease. Based on these results, laparoscopy may not be beneficial for every patient with a suspected pancreatic malignancy. Retrospectively an attempt was made to determine which patients benefited from laparoscopy and which patients are best served by proceeding directly to open exploration. From these data we devised an algorithm that outlines an efficient and cost-effective approach for this patient population.
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Affiliation(s)
- M D Holzman
- Department of General Surgery, Duke University Medical Center, Durham, NC, USA
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Abstract
OBJECTIVE Although surgical biliary bypass for nonresectable periampullary tumors is superior to endoscopic stent placement, the latter has become popular because of the "minimally invasive" approach. Laparoscopic biliary bypass would appear to offer the advantages of both. However, this technique remains technically difficult using existing instrumentation. This study investigates the efficacy of a new endoscopic device designed for rapidly completing a small-diameter intestinal anastomosis under laparoscopic guidance. METHODS Eighteen female pigs (mean weight 35 kg, range 31 to 44) were randomly divided into three groups: animals undergoing handsewn (group H) or instrumental transient endoluminally stented anastomosis (TESA; groups P and D) laparoscopic Roux-en-Y choledochojejunostomy. For TESA two different reabsorbable stents were used, polyglycolic acid (PGA; group P) and polyurethane ester (Degrapol; group D). Blood chemistry, weight gain, and abdominal X-rays were taken weekly to document any possible migration or reabsorption of the radio-opaque stents. After 3 months, necropsy was performed. Patency of the biliary bypass and choledochojejunostomy were examined using fluoroscopy and measured by introducing graduated dilators into the anastomosis. RESULTS Fluoroscopy revealed immediate passage of contrast through the anastomosis in all animals. Weight gain, bilirubin, and alkaline phosphatase were within normal range in all groups. Diameter of the bile duct (group H 10.7 +/- 2.9 mm/group P 9.5 +/- 3.6 mm/group D 11.0 +/- 4.6 mm) and choledochojejunostomy (group H 4.5 +/- 1.1 mm/group P 4.7 +/- 1.8 mm/group D 3.6 +/- 1.9 mm) did not differ. The time required to complete the biliary bypass was significantly decreased when TESA was applied (group H 152 +/- 13 min/group P 86 +/- 14 min, P <0.001/group D 110 +/- 20 min, P <0.002). CONCLUSIONS Applying TESA, laparoscopic choledochojejunostomy can be performed rapidly and safely, revealing good bypass function over a period of 3 months. With regard to treatment for nonresectable periampullary tumors, TESA may offer a new therapeutic approach combining the benefits of minimally invasive endoscopic stent placement with the functional results and lower readmission of conventional Roux-en-Y choledochojejunostomy.
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Affiliation(s)
- O M Schöb
- Department of Surgery, University of Zürich Hospital, Switzerland
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Schmidt J, Zirngibl H, Heinmöller E, Schückel E, Jauch KW. Pankreaskarzinom — Bedeutung der Laparoskopie und der intraoperativen Spülzytologie für das perioperative Staging. ACTA ACUST UNITED AC 1997. [DOI: 10.1007/bf02619751] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tagge EP, Tarnasky PR, Chandler J, Tagge DU, Smith C, Hebra A, Hawes RH, Cotton PB, Othersen HB. Multidisciplinary approach to the treatment of pediatric pancreaticobiliary disorders. J Pediatr Surg 1997; 32:158-64; discussion 164-5. [PMID: 9044114 DOI: 10.1016/s0022-3468(97)90171-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A multidisciplinary approach using traditional open surgery, endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic surgery has revolutionized the care of the adult with pancreaticobiliary disease. This study focuses on a similar collaborative effort to diagnose and treat children with pancreaticobiliary disorders. Charts of all patients treated on the pediatric surgery service between June 1990 and May 1995, who also underwent ERCP, were abstracted for disease process, presenting symptoms, laboratory evaluation, surgical or endoscopic procedures, and eventual outcome. Twenty-six children were identified, ranging from 6 months to 19 years of age. Pancreaticobiliary disorders included pancreas divisum (n = 1), choledochal cyst (n = 4), pancreaticobiliary trauma (n = 4), cholelithiasis and choledocholithiasis (n = 17). The pancreaticobiliary tree was successfully visualized by ERCP in 25 of 26 (96%) patients. Fifteen of these patients also underwent attempted therapeutic endoscopic procedures, with 13 (87%) performed successfully. Three patients with choledochal cyst had stents placed preoperatively for cholangitis, all of whom have undergone successful choledochal cyst excision. Two trauma patients underwent attempted stenting of a bile leak and bile duct stricture, respectively, both of which were unsuccessful, necessitating surgical correction. Seventeen patients with cholelithiasis underwent ERCP to rule out choledocholithiasis. Ten patients were found to have common duct stones, and all stones were endoscopically extracted, including those in a 6-month-old child. Overall survival rate was 96% (25 of 26), with the one death occurring in a trauma patient unrelated to his pancreaticobiliary disorder. A multidisciplinary approach using traditional open surgery, ERCP and laparoscopic surgery can successfully treat even young children with pancreaticobiliary disorders. In experienced hands, diagnostic ERCP and therapeutic endoscopic intervention can be performed successfully in most pediatric patients, greatly simplifying the surgical management of these potentially complex problems.
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Affiliation(s)
- E P Tagge
- Department of Surgery, Medical University of South Carolina, Charleston 29425, USA
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