Is Endoscopic Sphincterotomy Sufficient in the Treatment of Sump Syndrome? A 25-Year Experience

Background: Sump syndrome is one of the rare long-term complications of side-to-side choledochoduodenostomy (CD) leading to attacks of cholangitis due to accumulation of food and debris in the common bile duct distal to the anastomosis is one of the rare long-term complications after CD. Methods: Fifteen patients treated with the Sump syndrome in our institution between 1996 and 2023 were retrospectively evaluated for long-term outcome. Results: Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and bile duct clearance was done in 11 patients, while four were subjected to revisional surgery in the form of a Roux-en-Y hepaticojejunostomy. No complications were recorded. There were 5 (38%) recurrences in a median follow-up period of 8 years (10 months-23 years). Of those, 3 patients were treated surgically and two with repeat ERCP. None of the patients developed any cholangiocarcinoma during follow-up. Conclusion: We conclude that although a high recurrence rate was observed, endoscopic treatment may be a valid approach in the treatment of Sump syndrome, with revisional surgery in the form of a Roux-en-Y hepaticojejunostomy as salvage therapy in recurrences.

Surgical reconstruction of major bile duct injuries: Long-term results and risk factors for restenosis

BACKGROUND

A single-institution retrospective analysis was undertaken to assess long-term results of definitive surgical reconstruction for major bile duct injuries and risk factors for restenosis.

METHODS

Patients treated between January 1995 and October 2020 were reviewed retrospectively. The primary outcome measure was patency.

RESULTS

Of 417 patients referred to a tertiary center, 290 (69.5%) underwent surgical reconstruction; mostly in the form of a hepaticojejunostomy (n = 281, 96.8%). Major liver resection was undertaken in 18 patients (6.2%). There were 7 postoperative deaths (2.4%). Patency was achieved in 97.4% of primary repairs and 88.8% of re-repairs. Primary patency at three months (including postoperative deaths and stents removed afterwards) in primary repairs was significantly higher than secondary patency attained during the same period in re-repairs (89.3% vs 76.5%, p < 0.01). The actuarial primary patency was also significantly higher compared to the actuarial secondary patency 10 years after reconstruction (86.7% vs 70.4%, p = 0.001). Vascular disruption was the only independent predictor of loss of patency after reconstruction (OR 7.09, 95% CI 3.45-14.49, p < 0.001), showing interaction with injuries at or above the biliary bifurcation (OR 9.52, 95% CI 2.56-33.33, p < 0.001).

CONCLUSIONS

Long-term outcome of surgical reconstruction for major bile duct injuries was superior in primary repairs compared to re-repairs. Concomitant vascular injury was independently associated with loss of patency requiring revision.

Malignant Tumors Misdiagnosed as Liver Hemangiomas

Background and Aim: To derive lessons from the data of patients who were followed for various periods with the misdiagnosis of liver hemangioma and eventually found to have a malignancy.

Material and Methods: The records of 23 patients treated between 2003 and 2018 were analyzed retrospectively.

Results: Twelve patients were men and 11 were women; median (range) age was 55 (35–80). The principal diagnostic modality for the initial diagnosis was ultrasonography (n:8), magnetic resonance imaging (MRI) (n:13), and computed tomography (CT) (n:2). At our institution, MRI was performed in 16 patients; the diagnosis was made with the available MRI and CT studies in five and two patients, respectively. In other words, the ultrasonography interpretations were not confirmed on MRI; in others, the MRI or CT examinations were of low quality or they had not been interpreted properly. Fifteen patients underwent surgery; the other patients received chemotherapy (n:6) or chemoembolization (n:2). The misdiagnosis caused a median (range) 10 (0–96) months delay in treatment. The final diagnoses were hepatocellular carcinoma in 12 patients, cholangiocarcinoma in four patients, metastatic mesenchymal tumor, metastasis of colon cancer, metastatic neuroendocrine carcinoma, sarcomatoid hepatocellular carcinoma, angiosarcoma, thoracic wall tumor, and metastatic tumor of unknown primary in one patient each.

Conclusions: High-quality MRI with proper interpretation and judicious follow up are vital for the accurate differential diagnosis of liver lesions.

Dramatic response to albendazole in transplantation candidates with unresectable hepatic alveolar hydatid disease

Long-term albendazole treatment should be given to all patients with unresectable hepatic alveolar echinococcosis as dramatic regression is possible in 15%-20%. It may be prudent to prepare a living donor for possible salvage transplant in case of a severe complication. Preemptive transplantation in mildly symptomatic patients should be discouraged.

Incomplete or inappropriate endoscopic and radiologic interventions as leading causes of cholangitis

BACKGROUND

Iatrogenic factors persist as leading mechanisms of cholangitis at a referral center.

METHODS

The records of 51 patients treated for cholangitis due to incomplete or inappropriate nonoperative biliary interventions between 2005-2016 were evaluated retrospectively.

RESULTS

Twenty-nine patients were men; median (range) age was 60 (30-90). An incomplete or inappropriate ERCP and percutaneous transhepatic biliary drainage (PTBD) had been performed in 45 and 6 patients respectively. Inappropriate endoscopic stenting for hilar obstruction (perihilar cholangiocarcinoma: 22 and gallbladder carcinoma:3) was the most common scenario (n: 25, 49%). Twenty other patients had undergone an ERCP with incomplete (n: 12) or no (n:8) drainage. The errors in the PTBD group were passage of the catheter to the duodenum in patients with hilar obstruction (n: 4) and incomplete drainage in patients with perihilar cholangiocarcinoma (n: 2). Two patients (4%) died of infection. The surgery of 6 operable tumor patients was delayed for median (range) 5 (1-7) months.

CONCLUSIONS

Incomplete or inappropriate nonoperative biliary interventions put patients' lives at risk and delay radical treatments.

Choledochal cysts: Management and long-term follow-up

BACKGROUND

Choledochal cysts are congenital anomalies that can occur at any level of the biliary tree. They carry long-term risk of biliary complications and cancer development. Complete excision of all involved bile ducts is recommended.

METHODS

Patients treated between 1995 and 2019 were reviewed retrospectively.

RESULTS

Sixty patients; 46 female and 14 male with a median age of 41 years (range 13-83) were included in the study. Mild abdominal pain was the most common presenting symptom (60%). Majority of the patients had Todani type I cysts (67%). Concomitant biliary malignancy was diagnosed in five patients (9%). Eight patients were followed-up conservatively (13%). Twenty-five patients were treated by excision of the extrahepatic bile ducts and Roux-en-Y hepaticojejunostomy, liver resection was added in seven, pancreatoduodenectomy was done in three and liver transplantation in one. There was no perioperative mortality. Postoperative complications developed in 17 patients (34%), two requiring surgical treatment. Four of the five patients with malignancies died at a median 42 months (range 6-95) following surgery. Median 62 months (range 8-280) follow-up was available in 45 surgically treated patients, 19 followed-up for more than 10 years. None of the patients developed malignancy during follow-up. Four patients (17%) were readmitted for anastomotic strictures requiring treatment.

CONCLUSION

The majority of choledochal cysts are Todani type-I and early cyst excision is the mainstay of management, which may decrease the risk of malignant transformation.

Endoscopic retrograde cholangiopancreatography in children: Retrospective series with a long-term follow-up and literature review

BACKGROUND/AIMS

To investigate the safety and long-term results of endoscopic retrograde cholangiopancreatography (ERCP) in children with a literature review.

MATERIALS AND METHODS

All patients within the age range of 6-17 years who underwent ERCP between 1994 and 2014 at our institution were retrospectively evaluated.

RESULT

Twenty-four patients with a median age of 15 years underwent ERCP. Cannulation of the papilla was achieved in all patients (100%) without the use of needle-knife papillotomy. Before 1999, ERCP was used as a diagnostic method only in 7 patients (29%). In 17 (71%) patients, the procedure was used for therapeutic purposes. The indications were choledocholithiasis (10 cases, 42%), postoperative complications (5 patients, 21%), and recurrent pancreatitis (2 cases, 8%). In 2 patients (8%), the therapeutic effect was not achieved, thus requiring subsequent operations. There were no major complications. Mild pancreatitis occurred in only 1 patient (4%). Long-term follow-up information was obtained in 16 (67%) patients (median, 18 years; range, 3.5-22.5 years), and no long-term complications were detected.

CONCLUSION

Endoscopic retrograde cholangiopancreatography is a valuable tool in the diagnosis and treatment of pancreatobiliary disorders in the pediatric population. Large-scale studies are required to create evidence-based guidelines specific to children.

Prevention and acute management of biliary injuries during laparoscopic cholecystectomy: Expert consensus statement

Gallstone disease is very common and laparoscopic cholecystectomy is one of the most common surgical procedures all over the world. Parallel to the increase in the number of laparoscopic cholecystectomies, bile duct injuries also increased. The reported incidence of bile duct injuries ranges from 0.3% to 1.4%. Many of the bile duct injuries during laparoscopic cholecystectomy are not due to inexperience, but are the result of basic technical failures and misinterpretations. A working group of expert hepatopancreatobiliary surgeons, an endoscopist, and a specialist of forensic medicine study searched and analyzed the publications on safe cholecystectomy and biliary injuries complicating laparoscopic cholecystectomy under the organization of Turkish Hepatopancreatobiliary Surgery Association. After a series of e-mail communications and two conferences, the expert panel developed consensus statements for safe cholecystectomy, management of biliary injuries and medicolegal issues. The panel concluded that iatrogenic biliary injury is an overwhelming complication of laparoscopic cholecystectomy and an important issue in malpractice claims. Misidentification of the biliary system is the major cause of biliary injuries. To avoid this, the "critical view of safety" technique should be employed in all the cases. If biliary injury is identified intraoperatively, reconstruction should only be performed by experienced hepatobiliary surgeons. In the postoperative period, any deviation from the expected clinical course of recovery should alert the surgeon about the possibility of biliary injury.

Obstructive jaundice secondary to endoclip migration into common bile duct after laparoscopic cholecystectomy

Obstructive jaundice is a rare condition due to foreign body in common bile. In this article we report a 69 year-old man who was diagnosed obstructive jaundice secondary to the endoscopic clip migration. The patient had been performed laparoscopic cholecystectomy 5 years ago and had recovered without any complications. He presented with abdominal pain and jaundice. The magnetic resonance cholangiopancreatography (MRCP) revealed filling defect in choledoch consistent with a bile duct stone. The endoscopic retrograde cholangiopancreatography (ERCP) exhibited an endoclip migration into the common bile duct which caused bile duct stone. Endoclips can migrate into bile duct and cause obstructive jaundice. ERCP is the first option for its treatment.

Intrahepatic biliary cystic neoplasms: Surgical results of 9 patients and literature review

AIM: To investigate the eligible management of the cystic neplasms of the liver.

METHODS: The charts of 9 patients who underwent surgery for intrahepatic biliary cystic liver neoplasms between 2003 and 2008 were reviewed retrospectively. Informed consent was obtained from the patients and approval was obtained from the designated review board of the institution.

RESULTS: All patients were female with a median (range) age of 49 (27-60 years). The most frequent symptom was abdominal pain in 6 of the patients. Four patients had undergone previous laparotomy (with other diagnoses) which resulted in incomplete surgery or recurrences. Liver resection (n = 6) or enucleation (n = 3) was performed. The final diagnosis was intrahepatic biliary cystadenoma in 8 patients and cystadenocarcinoma in 1 patient. All symptoms resolved after surgery. There has been no recurrence during a median (range) 31 (7-72) mo of follow up.

CONCLUSION: In spite of the improvement in imaging modalities and increasing recognition of biliary cystadenoma and cystadenocarcinoma, accurate preoperative diagnosis may be difficult. Complete surgical removal (liver resection or enucleation) of these lesions yields satisfying long-term results.

Bile duct injury during cholecystectomy requiring delayed liver transplantation: a case report and literature review

Major bile duct injury during cholecystectomy represents potentially severe complications with unpredictable long-term results. If these lesions are not treated adequately, they can lead to hepatic failure or secondary biliary cirrhosis therefore requiring liver transplantation. We report a patient who required liver transplantation 15 years after open cholecystectomy. A l0-year old girl underwent open cholecystectomy and duodenal repair for cholelithiasis and cholecystoduodenal fistula. She required two surgical interventions, hepaticojejunostomy which was performed in another center and portoenterostomy for biliary stricture at our institution seven years after the cholecystectomy. Eight years after the third operation, she required recurrent hospitalization for treatment of hepatic abscesses. The extremely short intervals between the three life threatening episodes and the rapid progression to severe sepsis were taken into consideration and liver transplantation was performed at the age of 25. She is leading a healthy life at 4 years post transplantation. Although iatrogenic biliary injury can usually be treated successfully by a combination of surgery, radiological and endoscopic techniques, patients with severe injuries develop irreversible liver disease. This case report and review of the literature suggest that liver transplantation is a treatment modality for a selected group of patients with end-stage liver disease secondary to bile duct injury.

Hepatic atrophy-hypertrophy complex due to Echinococcus granulosus

Obstruction of a major hepatic vein, or major portal vein, or biliary tree branch causes atrophy of the related hepatic region, and frequently, hypertrophy in the remaining liver-the atrophy-hypertrophy complex (AHC). Whether hydatid cysts can cause AHC is controversial. The records of 370 patients who underwent surgery for hepatic hydatid disease between August 1993 and July 2002 were evaluated retrospectively. Excluding six patients with previous interventions on the liver, AHC had been recorded in the operative notes of 16 patients (4.4%); for all patients, a cyst located in the right hemiliver had caused atrophy of the right hemiliver and compensatory hypertrophy of the left hemiliver. The computed tomography images of seven patients were suitable for volumetric analysis. The median (range) right and left hemiliver volumes were 334 (0-686) ml and 1084 (663-1339) ml, respectively. The median (range) cyst volume was 392 (70-1363) ml. AHC due to Echinococcus granulosus was confirmed by objective volumetric analysis. The presence of AHC should alert the surgeon to two implications. First, pericystectomy may be hazardous due to association with major vascular and biliary structures. Second, in patients with AHC, the hepatoduodenal ligament rotates around its axis; this should be considered to avoid vascular injury if a common bile duct exploration is to be performed.

Endoscopic and radiologic interventions as the leading causes of severe cholangitis in a tertiary referral center

BACKGROUND

Iatrogenic factors became the leading mechanisms of severe cholangitis in a referral center.

PATIENTS AND METHODS

The records of the 58 patients treated for severe cholangitis between 1996 and May 2004 (inclusive) were evaluated.

RESULTS

The most frequent underlying diseases were periampullary tumors and mid-bile duct carcinomas (22), followed by proximal cholangiocarcinomas (14). The triggering mechanism was an incomplete endoscopic retrograde cholangiopancreatography (ERCP) in 32 patients, incomplete or inappropriate percutaneous transhepatic biliary drainage (PTBD) in 6, apparently successful ERCP and stenting in 1, and percutaneous transhepatic cholangiography in 1. PTBD was the treatment of choice (38). Mortality was 29% (17/58); the major causes were refractory sepsis (8) and incomplete biliary drainage (advanced tumor, technical failure, or hemobilia) (8).

CONCLUSIONS

In this series composed predominantly of patients referred after development of sepsis, ERCP and PTBD complications were the leading mechanisms of severe cholangitis. Nonoperative biliary manipulations are invasive procedures with potentially fatal complications. The decisions to perform such procedures and periprocedural management are responsibilities of an experienced multidisciplinary team.

Oncolytic adenoviral therapy in gallbladder carcinoma

BACKGROUND

Oncolytic adenoviral therapy is a promising new approach for cancer treatment. The aim of this study was to improve the conditionally replicative adenoviruses (CRAds) for gallbladder cancer therapy by modifying the fiber-knob region for infectivity enhancement and by incorporating tumor-specific promoters (TSPs) for enhanced specificity.

METHODS

For promoter-controlled replication, in vitro efficacy of eight TSPs was investigated in two gallbladder cancer cell lines (NOZ and OCUG-1). Infectivity enhancement was analyzed by two different fiber modifications: Arg-Gly-Asp (RGD) incorporation into the HI loop (RGD modification) and a chimeric construct with a serotype 5 shaft and a serotype 3 knob (5/3 fiber modification). Comparisons were made by infectivity analysis and cytotoxicity assays in vitro, followed by tumor suppressive effects tested in vivo.

RESULTS

Among TSPs, highest potency was exhibited by the cyclooxygenase-2 (COX-2), Midkine, and vascular endothelial growth factor promoters in both cell lines tested. Fiber chimera (Ad5/3Luc1) conferred significant enhancement of Ad infectivity in comparison with unmodified and RGD-modified vectors. COX-2 CRAds demonstrated selective cytocidal effect in gallbladder cancer cells in vitro. COX-2 promoter-based Ad5/3 CRAds showed significantly enhanced tumor-suppressive effect compared with nonreplicative and RGD-modified CRAd vectors in vivo.

CONCLUSIONS

The 5/3 fiber-modified, COX-2 promoter-driven CRAds may prove to be a new agent for the treatment of gallbladder carcinoma.

Definitive treatment of traumatic biliary injuries

BACKGROUND

We presented our experience with definitive treatment of traumatic biliary injuries.

METHODS

Six male patients (mean age 13 years; range 2 to 32 years) who were referred to our unit for definitive treatment of traumatic biliary injuries were retrospectively evaluated. Data were analyzed in terms of demographic characteristics, mechanisms of injuries, associated injuries, previous treatments, symptoms on admission, treatment at our unit, and the results of treatment. Outcome was assessed using modified Schweiser and Blumgart criteria.

RESULTS

The injuries were due to blunt abdominal trauma in all the patients but one who had a gunshot wound. In three patients, biliary injuries were missed at the initial operation. On admission, three patients had external biliary fistulas, two had biliary strictures. One patient was sent following inadvertent ligation of the hepatoduodenal ligament during attempts to control hemorrhage. Roux-en-Y hepaticojejunostomy was performed in three patients. Percutaneous biloma drainage was performed in two patients, resulting in fistula closure in 13 and 40 days, respectively. One patient was treated by endoscopic retrograde cholangiopancreatography and papillotomy, which enabled fistula closure in three days. One patient was lost to follow-up. One patient died from hepatic failure 11 years after the trauma. At the end of a mean follow-up of 49 months (range 15 to 75 months), three patients were in excellent condition, while one patient experienced occasional attacks of cholangitis.

CONCLUSION

In patients with undetected biliary injuries and in those with unsuccessful repair attempts, biliary reconstruction should be performed in experienced hepatopancreatobiliary surgery units.

Alveolar echinococcosis in Turkey. Experience from an endemic region

BACKGROUND

Radical resection is the only potentially curative treatment for hepatic alveolar echinococcosis (AE). Although Turkey is an endemic region, population screening is not performed and early diagnosis is rare. Consequently, surgeons are compelled to explore possibilities such as near-total resection and biliodigestive anastomosis for palliation of jaundice.

METHODS

Surgery was performed in 32 patients with hepatic AE with the following indications: (1) resection; (2) palliation of jaundice; (3) definite assessment of operability; (4) failure in the management of cavity infection by percutaneous methods. Curative resection (R0 = complete resection of all parasitic mass [n = 9], and R1 = a resection in which a small remnant was left on a vital structure [n = 8]) were performed in 17 patients, intrahepatic cholangiojejunostomy in 7, laparotomy-external drainage in 7, and debulking in 1.

RESULTS

Perioperative mortality rates were 2/17, 0/7, 2/7 and 1/1, respectively. Twelve patients in the curative resection group are alive without recurrence/progression of the small remnant during a median follow-up of 59 (range 27-116) months. One patient developed an inoperable recurrence that was treated with albendazole. One patient was lost to follow-up. Long-term albendazole treatment was effective in all R1 patients except a patient who had slow asymptomatic progression. Successful palliation of jaundice was achieved in 5 of the 7 intrahepatic cholangiojejunostomy patients.

CONCLUSIONS

The results of R1 resection in alveolar hydatid disease are similar to those of R0 resection; a small remnant is successfully controlled by albendazole. In patients with jaundice due to hilar invasion, biliary diversion from segment 3 or 5 is effective for palliation of the jaundice and facilitates albendazole treatment.

The effect of concomitant vascular disruption in patients with iatrogenic biliary injuries

BACKGROUND AND AIMS

To evaluate treatment results in iatrogenic biliary injuries with concomitant vascular injuries.

PATIENTS/METHODS

Between January 1998 and May 2002 (inclusive), angiography was performed in 45 of the 105 patients treated for iatrogenic biliary tract injury. The charts of these 45 patients and 5 other patients in whom vascular injury was diagnosed at operation were evaluated retrospectively. Twenty-nine patients had concomitant vascular injury, the biliovascular injury group (BVI), and the remaining 21 patients had isolated biliary tract injury (IBTI).

RESULTS

The most frequent initial operation was a cholecystectomy. The frequency of high-level (Bismuth III or IV) strictures was 90% in the BVI group and 62% in the IBTI group ( P<0.05). Perioperative mortality was 7% in the BVI group and 5% in the IBTI group ( P>0.05). The morbidity in the BVI group was significantly higher ( P<0.05). Two patients in each group were lost to follow up. During a median (range) follow up of 31 months (5-51 months), a successful functional outcome was achieved in 96% of the BVI group and 100% of the IBTI group with a multimodal approach ( P>0.05).

CONCLUSIONS

The frequency of high-level biliary injury and morbidity were significantly higher in the BVI group. However, concomitant vascular injury had no significant effect on mortality and medium-term outcome of biliary reconstruction. Thus, routine preoperative angiography is not recommended.

Long-term results of surgery for liver hemangiomas

BACKGROUND

Elective surgery for liver hemangiomas is still controversial.

HYPOTHESIS

Long-term results show that elective surgery for liver hemangiomas is safe and effective.

SETTING

A tertiary care university hospital in Istanbul, Turkey.

PATIENTS

Forty-two patients underwent surgery for liver hemangiomas between January 1988 and December 1998; 41 were symptomatic. The primary indications for surgery were abdominal pain in 33 patients, diagnostic uncertainty in 6, and enlargement in 3. The median largest dimension of the major lesion was 10 cm (range, 7-45 cm).

MAIN OUTCOME MEASURES

(1) Patients' assessment of the effects of surgery on preoperative symptoms, (2) determination of whether any other pathological conditions were missed in the preoperative evaluation, (3) operative mortality and morbidity, and (4) recurrences.

DESIGN

Retrospective cohort study.

RESULTS

Enucleation was the most frequent operation (33 patients). Hospital mortality and morbidity were 2.4% (bleeding from the biopsy site on a lesion evaluated as inoperable at laparotomy; 1 patient) and 12% (5 patients), respectively. Thirty-three patients could be followed up for a median of 53 months (range, 6-135 months). Of the 32 preoperatively symptomatic patients, surgery was successful in symptom control in 28 (88%) (complete resolution or significant amelioration). No other cause of pain could be identified during follow-up in the other patients. Control ultrasonography revealed no recurrences.

CONCLUSIONS

Elective surgery is indicated in a small subset of patients with hemangiomas because of abdominal pain, enlargement, and diagnostic uncertainty. The results of surgery in symptom control are gratifying in approximately 90% of patients. Recurrences are rare. Enucleation can be performed rapidly and safely in most patients and should be preferred to resection.

Mesoatrial shunt in Budd-Chiari syndrome

BACKGROUND

The operations with proven effects on survival in Budd-Chiari syndrome are shunt operations and liver transplantation.

PATIENTS AND METHODS

Between 1993 and 1999 (June), 13 cases of Budd-Chiari syndrome have been treated surgically. Four cases had concomitant thrombosis of the inferior vena cava; the others had marked narrowing of the lumen due to the enlarged caudate lobe. Mesoatrial (n = 12) or mesosuperior vena caval (n = 1) shunts were constructed with ringed polytetrafluoroethylene grafts.

RESULTS

The median portal pressure fell from 45 (range 32 to 55) to 20 (range 11 to 27) cm H(2)O (P <0.001). Two patients died in the early postoperative period. One patient who did not comply with anticoagulant treatment had a shunt thrombosis in the second postoperative year. The other 10 patients are alive without problems during a median 42 (range 1 to 76) months of follow-up.

CONCLUSION

Mesoatrial shunt with a ringed polytetrafluoroethylene graft is effective in Budd-Chiari syndrome cases with thrombosis or significant stenosis in the inferior vena cava.

Elective repair of abdominal wall hernias in decompensated cirrhosis

BACKGROUND/AIMS

Abdominal wall hernia is a common feature of decompensated cirrhosis. However, literature on elective hernia repair in these patients is limited. Here we report the experience of our center.

METHODOLOGY

Eleven hernias (seven umbilical, three inguinal and one incisional) in nine patients with decompensated cirrhosis were repaired. The indication for operation was repeated incarceration in two patients and significant pain in four; three patients with umbilical hernias had ulceration and necrosis of the overlying skin. Pre-operatively, medical therapy of ascites was conducted at the hepatology unit. Umbilical hernias were treated with the classic Mayo repair; in all cases but two, this was buttressed with a prolene graft. One inguinal hernia was repaired with the plication-darn technique; the other two and the incisional hernia were repaired with prolene grafts.

RESULTS

There was no mortality. One patient had a scrotal hematoma; two patients had leakage of ascites into the wound. Seven patients were followed up. Four patients died without recurrence after a median period of 12 months (range 6-22). The other patients have no recurrence at 1, 10 and 40 months post-operatively.

CONCLUSIONS

Umbilical and inguinal hernias in patients with decompensated cirrhosis may be repaired safely on an elective basis. Control of ascites is vital for success.

Laparoscopic-assisted large bowel resection

Laparoscopic colon resection is a viable alternative to open colectomy. For non-malignant lesions, laparoscopic resection of the affected large bowel is attractive. For malignant lesions, where resection for cure is highly dependent on lymph node clearance, laparoscopic resection has met with criticisms regarding the adequacy of nodal clearance that can be achieved laparoscopically. Several published studies have shown that the operation though technically demanding, does not compromise the extent of resection. We report a series of 43 cases of laparoscopic colon resection done sequentially and successfully from January 1992 to June 1995. The operative time averaged 180 minutes (range 120 to 300 minutes). Five patients developed postoperative complications, which were mainly pulmonary and wound infections. There were no anastomotic leaks or perioperative deaths. The mean hospital stay was 5.3 days (range 4 to 9 days). By the third postoperative day, all patients were feeding and ambulatory. Long-term complications included one small bowel obstruction and one port site recurrence. In our selected group of patients, laparoscopic colon resection has not shown any adverse outcome. Prospective randomised studies are underway in various centres and their preliminary results are favourable.

Endoscopic sphincterotomy in the treatment of postoperative biliary fistulas of hepatic hydatid disease

BACKGROUND

Ten patients with postoperative external biliary fistula treated by endoscopic sphincterotomy are reported.

METHODS

Nine of these patients were operated for hepatic hydatid disease and one for a liver abscess. Mean daily output of bile through the fistulae which were present for 5-39 days was approximately 500 cc.

RESULTS

Treatment was successful in nine patients with closure of the fistulae in 2-15 days (mean, 7 days). No response was obtained in one patient who was reoperated, and an intrahepatic biliary duct was found to be completely eroded by the cyst wall.

CONCLUSIONS

Endoscopic sphincterotomy should be the first-line treatment for postoperative external biliary fistulae related to hepatic hydatid disease.

Pyloric channel ulcers: management and three-year follow-up

Twenty-five patients with pyloric channel ulcers are presented. They were predominantly males (84%), with a mean age of 54 years. Four patients were operated upon in the initial admission because of gastric outlet obstruction in three and persistent bleeding in one. Twenty-one patients received H2-antagonist treatment (ranitidine 150 mg or cimetidine 400 mg twice a day). Clinical and endoscopic healing rates were 76% and 38% respectively at 6 weeks, and 91% and 85% respectively at 12 weeks of treatment. The recurrence rate at an average of 3 years of follow-up period on maintenance treatment (ranitidine 150 mg or cimetidine 400 mg nightly) was 65%. Three patients were operated upon during the follow-up period due to persistent symptoms in two and recurrence with obstruction in one Surgical procedures were vagotomy + drainage (five patients) and vagotomy + antrectomy (two patients). There were no recurrences in surgically treated patients at an average of 3.5 years of follow-up, and all were graded as Visick I or II.

Combination therapy using adrenaline and heater probe to reduce rebleeding in patients with peptic ulcer haemorrhage: a prospective randomized trial

A prospective randomized trial was performed to assess the efficacy of the combined therapy of endoscopic injection of adrenaline and heater probe application in the management of patients with major peptic ulcer haemorrhage. Some 153 consecutive patients were randomized to receive either local injection of adrenaline (1:10,000) followed by heater probe thermocoagulation (74 patients) or no endoscopic treatment (79 patients). The two groups were well matched with regard to age, haemoglobin concentration on admission, non-steroidal anti-inflammatory drug usage and endoscopic findings. More patients in the treatment group were in shock on admission (21 versus 13). Initial haemostasis was achieved in all patients randomized to endoscopic therapy. Rebleeding occurred in fewer treated than control patients (five versus 16, P = 0.01). The treated group also had fewer deaths (zero versus two) and requirement for operation (two versus six). The results show that the combination of sclerotherapy with adrenaline and subsequent thermocoagulation reduces the rate of rebleeding in peptic ulcer haemorrhage.

Laparoscopic cholecystectomy for acute cholecystitis

The safety and efficacy of laparoscopic cholecystectomy for acute cholecystitis were evaluated in a 2-year retrospective review. Results of laparoscopic cholecystectomy in 66 patients with acute inflammation of the gallbladder were compared with those of the standard open procedure for this condition (43 patients) and routine laparoscopic cholecystectomy (227 patients). The laparoscopic procedure for acute cholecystitis was successful in 46 of 66 patients. There was no difference in mean operating time when the inflamed gallbladder was removed laparoscopically or at open surgery (82 versus 84 min); however, each procedure took longer than did routine laparoscopic cholecystectomy (mean 69 min; P < 0.01). There was no difference in analgesic requirement between patients who underwent laparoscopic removal of an acutely inflamed gallbladder and those in the other two groups. Postoperative recovery was significantly faster than that after open surgery (P < 0.01), but took longer than that following routine laparoscopic cholecystectomy (P < 0.01). Inability to identify the cystic duct was the most common reason for conversion to open operation, which occurred in 20 cases of acute cholecystitis. Bile duct injury occurred in one of 66 patients with acute cholecystitis treated laparoscopically, two of 227 cases of routine laparoscopic cholecystectomy but in no patient who underwent open cholecystectomy. In conclusion, laparoscopic cholecystectomy is technically achievable in the majority of patients with acute cholecystitis. The conversion rate is high but, if the procedure is completed successfully, postoperative recovery is more rapid than that after open surgery. However, the method carries a higher incidence of complications and should be attempted only by experienced surgeons.

Endoscopic sphincterotomy for the treatment of cystic duct leak following laparoscopic cholecystectomy

Two patients who underwent laparoscopic cholecystectomy had postoperative cystic duct leak from slipped metallic clips. One patient presented with biliary ascites and the other with biliocutaneous fistula. Open surgery done in the first patient was not successful in controlling the fistula. Rapid closure of the fistulae was achieved in both cases using endoscopic sphincterotomy.

Randomized controlled trial comparing laparoscopic and open appendicectomy

A study was carried out of 137 patients with a diagnosis of acute appendicitis who were randomized to either laparoscopic or open appendicectomy. Patients found to have perforated or normal appendices at histological examination were excluded. Fifty-two patients undergoing laparoscopic appendicectomy and those receiving 57 open procedures were analysed. Laparoscopic appendicectomy took no longer than the open procedure (mean 43 versus 40 min). The number of doses of pethidine (1 mg per kg body-weight) required in the immediate postoperative period did not differ between the two groups but the mean number of doses of oral analgesic (naproxen sodium 550 mg twice daily) required was less in patients undergoing laparoscopic appendicectomy (2.8 versus 5.0, P < 0.05). There was no significant difference between time to resumption of fluid and diet intake and length of hospital stay. There were five (9 per cent) wound infections after open appendicectomy compared with none after the laparoscopic operation (P < 0.01). Patients who underwent laparoscopy returned to full home (17 versus 30 days, P < 0.01) and social (19 versus 32 days, P < 0.05) activities earlier than those who underwent open operation. Laparoscopic appendicectomy may allow reduction in the number of wound infections and earlier return to normal activities.

Future developments in high-technology abdominal surgery: ultrasound, stereo imaging, robotics

The surgical world is experiencing a revolution brought about by the proliferation of minimally invasive techniques. These developments have had most impact on abdominal surgery and chest surgery, but there are ramifications affecting other fields as well. One feature of this change is the increasing dependence of surgeons on technology. Developments in video imaging, ultrasound and robotics are required to make complex endoscopic procedures surgeon-friendly, just as the minimally invasive approach has made surgery more patient-friendly. In the future, integration of stereo imaging systems, computers, microrobots and robotic manipulators will result in technically sophisticated but ergonomic operating systems that will allow surgeons to perform endoscopically almost any type of surgery that can be done today.

Laparoscopic-assisted right hemicolectomy--a case report

Laparoscopic colon resection has recently attracted attention as a viable option to open colectomy due to its excellent postoperative recovery. We report the first right hemicolectomy done laparoscopically in Asia in a 62-year-old female patient with Dukes-B2 caecal carcinoma. Bowel sounds were present on the first post-operative day (POD) and diet was resumed on the third. The patient was discharged on the fourth POD. There was no complication of anastomotic leakage or wound infection.

Primary repair of iatrogenic colonic perforations in unprepared colon--a report of five cases

Primary repair of iatrogenic colonic perforations sustained during pelvic surgery was successfully undertaken in five consecutive cases who did not receive pre-operative bowel preparation. A proximal diverting colostomy was not performed following the repair. There were no instances of intra-abdominal abscess or colonic fistulation. One case developed wound infection. Post-operative recovery in all cases were mostly uneventful with a mean post-operative ileus of four days and a stay of ten days. Primary repair of iatrogenic colonic perforations in unprepared colon can be safely undertaken without a proximal diverting colostomy with acceptable morbidity.

Endoscopic hemostasis of bleeding peptic ulcers

Developments in therapeutic endoscopy over the last decade have made it possible to perform endoscopic hemostasis for bleeding peptic ulcers. This review traces the developments in this field in the Department of Surgery of the National University of Singapore. A recently conducted prospective randomized controlled trial using intralesional adrenaline and heater probe demonstrated that initial hemostasis could be achieved in 100% of patients with actively bleeding ulcers or stigmata of recent hemorrhage. The rebleed rate was 6.6% compared with 20.3% in a well-matched control group. The recent advent of laparoscopic vagotomy and laparoscopic Billroth II gastrectomy offers a low-morbidity surgical option to long-term medical treatment for the follow-up management of patients with bleeding ulcers.

Laparoscopic cholecystectomy in a patient with empyema of the gallbladder and situs inversus

The successful performance of laparoscopic cholecystectomy in a patient with situs inversus viscerum and empyema of the gallbladder is reported. The 62-year-old man presented with pain in the left upper quadrant associated with fever, chills, nausea and vomiting. The abdomen was tender with guarding and a palpable globular mass in the same region. CT scan demonstrated a distended gallbladder with thick shaggy walls which contained a 2 cm gallstone in the neck and also revealed dextrocardia and situs inversus. The patient's postoperative recovery was uneventful.

Technical modification to laparoscopic appendectomy

An alternative technique for laparoscopic appendectomy is described. The isolated appendix is exteriorized through the trocar wound, ligated, and resected. The cecum is then returned to the abdomen.

The technique of laparoscopic Billroth II gastrectomy

This report describes the technique of totally intra-abdominal Billroth II gastrectomy. Because the procedure is minimally invasive, patient recovery is remarkable compared with the conventional open technique. The development of this procedure completes the minimally invasive revolution in the management of peptic ulcer disease, which began with the introduction of laparoscopic vagotomy.

Peroral tunable-dye laser lithotripsy of intrahepatic stones in oriental cholangitis

This case report details the use of a pulsed tunable-dye laser lithotripter in the endoscopic management of recurrent intrahepatic stones in a patient with Oriental cholangitis. A 42-year-old Chinese man had a cholecystectomy and choledochoduodenostomy in 1980. Subsequently he had three episodes of recurrent cholangitis which responded to medical treatment. The patient presented in April 1989 with a fourth attack of cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) and ultrasound demonstrated a large mass of stones in the right intrahepatic ductal system. A flexible upper gastrointestinal endoscope was passed into the right hepatic duct via the choledochoduodenostomy. The stones were fragmented with a tunable-dye laser and the residual fragments were removed endoscopically.

A multimodality approach to endoscopic treatment of bleeding peptic ulcers

The role of endoscopic haemostasis in the treatment of bleeding peptic ulcers is widely studied. Many trials to date have compared one or more modalities against a medical control with variable results. To date, no single modality has been shown conclusively to be superior to others. As such, in this study we have not confined the endoscopist to one modality of treatment but allowed him to customize the method of endoscopic haemostasis according to the configuration, accessibility and rate of bleeding in any particular patient. Seventy-three patients with non-variceal upper gastrointestinal (GI) bleeding were admitted to the National University Hospital in Singapore between May 1, 1988 and April 30, 1989. All were gastroscoped and 48 were found to have chronic peptic ulcer. Twenty-nine (60%) with actively bleeding peptic ulcer or stigmata of recent haemorrhage (SRH) were treated endoscopically. Initial haemostasis was achieved in 27 (93%) patients. Seven patients rebled (26%) of which four underwent repeat endoscopic treatment. Of these four patients only one rebled again and required surgery. Permanent haemostasis was achieved in 23 of 29 patients (79%). The multimodality approach for the treatment of bleeding peptic ulcers gives the endoscopist flexibility in deciding on the best way to deal with a bleeding gastric or duodenal ulcer. Each instrument has its strengths and weaknesses and the right choice of instrument is often a critical factor especially in treating a bleeding ulcer in a situation where access poses a problem.

Endoscopic management of bleeding peptic ulcers in Singapore: a multimodality approach

Endoscopic haemostasis is becoming increasingly important in the management of bleeding peptic ulcers. In this study, rather than being confined to one modality of treatment, the endoscopist was allowed to customize the treatment according to the configuration of the ulcer, accessibility, and rate of bleeding in any particular patient. Fifty patients with actively bleeding peptic ulcers or stigmata of recent haemorrhage were treated endoscopically. Initial haemostasis was achieved in 48 (96%) patients. Eleven patients rebled of whom eight underwent repeat endoscopic treatment. Of these eight patients, three rebled of whom two required surgery. Permanent haemostasis was achieved in 43 of 50 patients (86%). The rate of surgery in the endoscopically treated group was 10%. There was one death due to causes not related to bleeding. The multimodality approach is a useful method of treatment in bleeding peptic ulcers, giving flexibility to the endoscopist in deciding on the best way to deal with the problem.

The surgical treatment of squamous cell carcinoma of the oesophagus in Singapore

In a retrospective study, we reviewed 97 consecutive cases of squamous cell carcinoma collected over a five-year period (1978-1983). Resection of the tumour was possible in 30 out of 40 patients subjected to surgery. Of these 30 patients, five died within 30 days of surgery. Eight patients who underwent oesophageal resection were still alive after five years and apparently cured. Bypass surgery for unresectable lesions in six patients were complicated by anastomotic leakage in three patients. Patients unsuitable for surgical resection were treated using Celestin tube insertion or radiation. Mean survival in 13 patients with Celestin tube insertion was 4.1 months. Of 48 patients who were treated by radiotherapy, two lived beyond five years. Surgical resection restores swallowing effectively and offers a 25% chance of cure and should be done in fit patients. In unfit patients with advanced disease, palliation from the use of radiotherapy and Celestin tube insertion were poor. Newer techniques such as endoscopic laser recanalisation and bicap hyperthermia may need to be considered for palliation in this group of patients.