Management of synchronous tumours of the oesophagus and pancreatic head: a novel approach.

Synchronous tumours of the oesophagus and pancreatic head are very rare. This report describes a unique case of an adenocarcinoma of the distal oesophagus and a neuroendocrine tumour of the pancreatic head diagnosed synchronously but successfully managed metachronously. Initially, the patient underwent an oesophagectomy, with a colonic reconstruction following some months later by pylorus-preserving pancreaticoduodenectomy. A staged resection was performed after a review of the literature suggested increased morbidity with synchronous major abdominal operations.

Diagnosis of solid pancreatic masses by endoscopic ultrasound-guided fine-needle aspiration.

BACKGROUND: Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) is increasingly being used in the staging algorithm for pancreatic carcinoma. This allows for a tissue diagnosis, which was previously difficult to obtain. The aim of this study is to assess the utility of EUS-FNA in establishing the diagnosis of solid pancreatic mass lesions in an Australian population. METHODS: A retrospective review of the EUS databases of St Vincent's Hospital Melbourne and Western Hospital, Melbourne from November 2002 to May 2006 was undertaken. The focus was on patients with a solid pancreatic mass who underwent EUS-FNA. Surgical pathology or long-term follow up was used to identify false-positive or false-negative results. RESULTS: EUS was undertaken to investigate a solid pancreatic or distal common bile duct mass lesion in 155 patients. Seventy-two of these underwent EUS-guided FNA. Mean age was 68 years. A positive tissue diagnosis of malignancy could be made in 55 (76%). Nine (13%) had benign histology, with 8 (11%) having inadequate tissue obtained from FNA. A later tissue diagnosis of carcinoma was made in eight of those with either benign or inadequate histology, although in all cases there were EUS features diagnostic of malignancy, with FNA limited by technical difficulties. The overall utility of EUS-FNA showed a sensitivity of 87%, specificity 100%, positive predictive value 100%, negative predictive value 52% and overall accuracy 89%. CONCLUSION: EUS-FNA gives a high return for histological diagnosis of solid pancreatic mass lesions and should be part of the standard management algorithm for pancreatic carcinoma.

Phaeochromocytoma in pregnancy.

Hypertension during pregnancy is a common problem, causing significant maternal and fetal morbidity and mortality. Pre-eclampsia is by far the most common cause, affecting 5-10% of primigravid women. Phaeochromocytoma is a rare endocrine tumour causing hypersecretion of noradrenaline, adrenaline and/or dopamine. It is extremely rare during pregnancy and may be misdiagnosed with potentially catastrophic consequences. Delayed diagnosis remains a significant source of maternal and fetal morbidity and mortality. Recognition is critical, as the majority of maternal deaths have occurred when the diagnosis has been overlooked. Diagnosis of phaeochromocytoma is achieved by detecting increased catecholamines and metabolites (metanephrine and normetanephrine) on 24-h urine collection, as these levels are unaffected by pregnancy or pre-eclampsia. Definitive treatment of phaeochromocytoma is surgical and the laparoscopic approach has been shown to be safe and is preferred for most phaeochromocytomas. Medical preparation and treatment of hypertension is essential for safe surgery. Timing of adrenalectomy is either during the second trimester or as a staged procedure after Caesarean section delivery.

A comparison of open and laparoscopic approaches to adrenalectomy in patients with phaeochromocytoma.

We compared the perioperative profiles of patients undergoing unilateral phaeochromocytoma resection performed by open adrenalectomy with those performed by laparoscopic adrenalectomy. Data was collected prospectively on 24 patients (12 open, 12 laparoscopic). All patients underwent extensive preoperative medical preparation with phenoxybenzamine and beta-blockers. The final preoperative dose of phenoxybenzamine was similar in each group (laparoscopic 119+/-60 mg/day, open 100+/-25 mg/day). Intraoperative haemodynamic instability was assessed by the requirement for therapeutic intervention. More haemodynamic instability was observed in the laparoscopic group but the differences were not statistically significant. Sodium nitroprusside use to treat hypertension (systolic blood pressure >180 mmHg) was more frequent and the duration of the infusions longer in the laparoscopic group; high dose beta-blocker therapy with atenolol and/or esmolol to treat intraoperative tachycardia (heart rate >90) was also more frequent in the laparoscopic group. The small sample size of the study limited the ability to detect a true difference. Blood loss was greater in the open adrenalectomy group but the difference was not significant. The operating time was significantly longer (236+/-78 vs 147+/-47 min, P<0.01) but the duration of postoperative hospitalization was significantly shorter (5+/-2 vs 11+/-4 days, P<0.01) in the laparoscopic group. Postoperative complications were not significantly different. There were no perioperative deaths. Overall, we observed more haemodynamic instability in patients undergoing laparoscopic resection but were unable to demonstrate a statistically significant difference. In our experience, laparoscopic adrenalectomy has the advantage of a shorter time to discharge from hospital.

Pancreatic trauma: Universities of Melbourne HPB Group.

BACKGROUND: Pancreatic trauma is uncommon, but carries high morbidity and mortality rates, especially when diagnosis is delayed or inappropriate surgery is attempted. Although the retroperitoneal position of the pancreas confers it some immunity to injury, the force required to do so often results in severe associated injuries to other organs, which may be life threatening. Diagnosis may be difficult and surgery can be a considerable technical challenge. METHODS: All patients with pancreatic trauma who attended one of three Melbourne teaching hospitals from 1977 to 1998 were identified. Injuries were graded and the method of diagnosis and treatment studied. The incidence and causation of postoperative morbidity and mortality was identified. RESULTS: Thirty-eight patients (26 men and 12 women) were studied. Blunt trauma was responsible in 30 patients, stab wounds in five, gunshot wounds in two and iatrogenic injury in one. Injuries to other organs occurred in 30 patients. Surgical procedures were undertaken in 34 patients, resulting in the death of five and complications in 25. CONCLUSION: Complications and death are related to the associated injuries, as much as to the pancreatic injury itself. In this study, we review the experience of the management of pancreatic trauma in three large teaching hospitals in Melbourne over a 21-year period, and suggest a strategy for dealing with these difficult patients. Adherence to the basic concepts of control of bleeding from associated vascular injury, minimization of contamination, accurate pancreatic assessment, judicious resection and adequate drainage can diminish the risk. By approaching the problem in a systematic way and adopting a generally conservative management plan, complications and deaths can be minimized in these complex cases.

The anatomical basis for segment III cholangiojejunostomy with analysis of 13 cases.

BACKGROUND: The majority of patients who require palliation for jaundice and pruritus resulting from malignant hilar obstruction are treated by stenting. Stenting is usually achieved from below after performing an endoscopic retrograde cholangiopancreatography. In some cases the rendezvous technique is employed, negotiating the passage through a malignant stricture from above and stenting from below. A minority of cases, such as those who had a previous polyagastrectomy and those in whom attempts at stenting have failed, are considered to be suitable for a Segment III cholangiojejunostomy. We have investigated the anatomical basis for Segment III duct bypass and have critically analysed the results in 13 patients. Ten patients were treated by Segment III duct bypass alone, and three patients had a Segment III duct bypass combined with stenting of the right liver. METHODS: The anatomy of the biliary tree was investigated by dissection of 54 normal livers removed at autopsy. Clinical details of the 13 patients who had Section III cholangiojejunostomy were obtained from hospital records and by contacting treating practitioners. RESULTS: In 64.8% of the anatomical dissections, the findings were favourable for a Section III cholangiojejunostomy. In these specimens the Segment III duct bypass would have drained Segments II, III and IV. In 35.2% of the specimens the anatomical disposition was potentially unfavourable, mainly due to the Segment II or IV ducts joining close to the confluence and therefore liable to obstruction by the tumour. In nine of the 54 specimens the true left hepatic duct was less than 6 mm in length, making it unsuitable for a bypass procedure to drain the left hemi liver. Of the 10 patients who were subjected to a palliative Section III cholangiojejunostomy only, there was one postoperative death. Of the nine patients who survived, six obtained excellent palliation of jaundice and pruritus. CONCLUSIONS: In carefully selected cases, Section III cholangiojejunostomy achieves excellent palliation in patients with unresectable hilar malignancies that have been unable to be stented pre-operatively or who have unresectable tumours at the time of laparotomy.

Segment III cholangiojejunostomy for palliation of malignant hilar obstruction.

Between 1984 and 1992, 26 patients with obstructive jaundice due to malignancy at the liver hilum were treated by segment III Roux-en-Y cholangiojejunostomy. Twenty-two patients had hilar cholangiocarcinoma, one carcinoma of the gallbladder, one pancreatic carcinoma, one recurrent gastric carcinoma and one lymphoma. Seventeen patients had no complications in the postoperative period and six had complications; there were three postoperative deaths. Eighteen of the 23 surviving patients experienced complete resolution of jaundice for at least 3 months. Four developed recurrent jaundice and three had episodes of cholangitis before death. Segment III cholangiojejunostomy offers effective palliation for most patients with irresectable hilar malignancy.

Intraoperative cholangiography during laparoscopic cholecystectomy. Routine vs selective policy.

An audit of routine intraoperative cholangiography in a consecutive series of 496 patients undergoing laparoscopic cholecystectomy has been performed. Cannulation of the cystic duct was possible in 483 patients (97%). The use of portable, digitized C-arm fluorocholangiography was vastly superior to the employment of a mobile x-ray machine and static films in terms of reduced time to carry out the procedure and total abolition of unsatisfactory radiological exposure of the biliary tract. Repeat of the procedure was necessary in 22% of cases when the mobile x-ray equipment was used. Aside from the detection of unsuspected stones in 18 patients (3.9%), routine intraoperative cholangiography identified four patients (0.8%) whose management would undoubtedly have been disadvantaged if intraoperative cholangiography had not been performed.

Laparoscopic prosthesis fixation rectopexy for complete rectal prolapse.

Five women aged 64-81 years with complete rectal prolapse and incontinence were treated by laparoscopic mobilization of the rectum and posterior fixation to the presacral fascia using Marlex mesh. Mobilization was carried out with standard straight laparoscopic instruments in the first two patients (operating times 3.5 and 4.5 h) and with coaxial curved instruments and ultrasonic dissection in the succeeding three (operating times 2.5, 2.0 and 2.5 h). Restoration to full continence (grade 1) was observed in two patients and to grade 2 in a further two. No recurrence of the prolapse occurred during follow-up of 4-27 months.

Coaxial curved instrumentation for minimal access surgery.

New coaxial curved and bayonet instruments have been designed which permit controlled dissection and directional change of the functional tip, blunt dissection and lift retraction. The instruments are introduced into the peritoneal and thoracic cavities through flexible re-usable metal cannulae. The excellent ergonomic properties of the new instruments have been confirmed by their use in major laparoscopic and thoracoscopic operations. Coaxial instruments enhance the scope of minimal access surgery and have distinct advantages over the traditional straight instruments.

Endoscopic ultrasonic dissection for thoracoscopic and laparoscopic surgery.

A specifically designed handpiece has been developed for ultrasonic dissection of tissues and organs during minimal-access surgery. The experimental prototype has been evaluated in major endoscopic operations on the esophagus, colon, and rectum (n = 19). The benefits documented by this initial experience include increased dissection efficiency of extensive fibroareolar attachments, safe exposure of major vascular pedicles (especially those located in mesocolic fat), greatly reduced risk of major hemorrhage, and decreased operating time.

Abdominal wall lift. Low-pressure pneumoperitoneum laparoscopic surgery.

A method of abdominal wall lift has been developed and evaluated clinically in this unit during the past 18 months. It permits the conduct of laparoscopic procedures at an intraabdominal pressure of 6-8 mm Hg. The technique was introduced for laparoscopic surgery in patients with preexisting cardiac disease and chronic bronchitis. The procedure, by lifting both the abdominal wall and the falciform ligament together, also elevates the central portion of the liver (segments 3-5), thereby improving the surgical exposure. For this reason it is now also used in fit patients with ptotic livers or hypertrophied quadrate lobes undergoing laparoscopic cholecystectomy and common bile duct exploration, and to facilitate left subhepatic exposure in patients during laparoscopic antireflux surgery and vagotomy.

Extracorporeal shock wave lithotripsy combined with litholytic therapy in the treatment of patients with symptomatic gallstones--the Melbourne experience.

OBJECTIVE: To investigate the role of extracorporeal shock wave lithotripsy using the Dornier MPL9000 lithotripter and adjuvant litholytic therapy in the treatment of symptomatic gallbladder stones. PATIENTS AND METHODS: Between August 1989 and March 1991, 399 patients had their one to three gallbladder stones fragmented by the Dornier MPL9000 lithotripter. Chenodeoxycholic acid alone was used as adjuvant litholytic therapy in the majority. A minority received a combination of chenodeoxycholic acid and ursodeoxycholic acid or ursodeoxycholic acid alone. Patients who died, had cholecystectomies or failed to complete the treatment program were excluded from analysis, leaving a cohort of 287 patients with a follow-up of at least 12 months. This cohort comprised 173 patients with single small stones (20 mm or less in diameter), 32 patients with single large stones (21 mm to 30 mm in diameter) and 82 patients with two to three stones. OUTCOME MEASURES: Patients were followed up by repeated ultrasound examination to monitor the disappearance of fragments from the gallbladder. Stone-free rates, recurrences and complications of treatment were determined. RESULTS: The stone-free rate 12 months after treatment was 37.6% for patients with a single small stone, 3.1% for patients with a single large stone and 18.3% for patients with two to three stones. Of 70 patients with a single small stone who had become stone free at some time during the 12 months after treatment, five (7.1%) experienced recurrence, as did one of the 16 patients (6.9%) with two to three stones. Some 179 patients (44.9%) experienced biliary colic after lithotripsy. Most attacks were mild. Eleven patients (2.8%) developed cholecystitis and nine (2.3%) became jaundiced. Five patients (1.3%) suffered from pancreatitis, of whom one died from severe necrotising pancreatitis. Treatment mortality was 0.25%. Cholecystectomy was needed in 44 patients (11.9%). CONCLUSIONS: Only about 15%-20% of all patients with symptomatic gallbladder stones are suitable for lithotripsy. In this study, only about 28% were stone free after 12 months. As the gallbladder is not removed, stones may re-form. Laparoscopic cholecystectomy and open cholecystectomy by comparison will produce a "stone-free state" in 100% of patients, no matter how many stones are present in the gallbladder, their size, or whether the gallbladder is non-functioning. Consequently, lithotripsy and litholytic therapy are now reserved for those few patients who are unable to tolerate general anaesthesia and cholecystectomy and those who refuse surgery. Even in centres showing the most favourable results, lithotripsy and litholytic therapy will have at best a minor role to play in the overall management of symptomatic gallbladder stones.

Laparoscopy in the management of pancreatic cancer: endoscopic cholecystojejunostomy for advanced disease.

Following a period of animal experimentation in pigs, a laparoscopic technique for sutured gastrointestinal and bilioenteric anastomoses was developed and its safety and efficacy tested in chronic experiments. The method involves the construction of a preformed external jamming loop knot and continuous suturing using a specially developed Endoski needle. The technique was used to construct a cholecystojejunostomy in five patients with advanced cancer of the pancreas (four hand-sutured and one stapled/sutured). Four of the patients recovered from the procedure with no complications, minimal postoperative discomfort and complete relief of their jaundice. In one patient relief of jaundice was slow due to blockage of the anastomosis by debris and blood clot; this resolved following removal of the inspissated material. This minimally invasive procedure has the potential for complete palliation with short hospital stay and avoids the hazards of endoscopic stenting such as encrustation and cholangitis.

Endoscopic oesophagectomy through a right thoracoscopic approach.

A technique of subtotal endoscopic oesophagectomy through the right thoracoscopic approach is described. It has been used in five patients, four with cancer and one with benign motility disorder. The operative blood loss during the endoscopic dissection stage was unmeasurable in four patients and amounted to 300 ml in one. The mean (range) duration of the endoscopic dissection was 3.3 (3.0-4.0) h and of the total procedure was 5.5 (4.5-7.5) h. After the operation, the mean (range) duration of stay in the intensive care unit was 19.5 (16-26) h. From the time of the operation, the mean (range) hospital stay was 11 (8-18) days. One patient developed left vocal cord palsy which prolonged this.