Lesser sac endoscopy and laparoscopy in pancreatic carcinoma definitive diagnosis, staging and palliation.

Laparoscopy with lesser sac endoscopy (LSE) were used in combination from 1987 to 1992 in 103 patients for differentiation between pancreatic carcinoma and other peripancreatic pathology, staging, and palliation. LSE identified pancreatic carcinoma in 38 patients; pancreatic cystadenocarcinoma in 2 patients; pancreatic cystadenoma in 3 patients; pancreatic adenoma in 1 patient; pancreatic metastases from liver in 2 patients; and pancreatic cysts in 5 patients. False negative diagnosis of pancreatic carcinoma occurred in two cases. Nontumor pancreatic pathology was revealed in 10 patients. Specifically, acute pancreatitis was found in four patients, and chronic pancreatitis was found in six patients. Extrapancreatic cancers were identified in 15 patients: retroperitoneal extraorgan tumors were found in 2 patients; extrahepatic biliary tract cancer in 6 patients; gallbladder cancer in 1 patient; liver cancer in 3 patients; and stomach cancer in 1 patient. In five cases no pathology was found. Overall correct definitive diagnosis was established in 101 patients. Sensitivity of laparoscopy with LSE for pancreatic carcinoma diagnosis proved to be 95 per cent (38 of 40 patients), for pancreatic tumors diagnosis 96.22 per cent (51 of 53 patients); specificity of the method 100 per cent; and accuracy of diagnosis 98 per cent (101 of 103 patients). Thus, the accuracy of the method was as high as the accuracy of combination of all known modalities. Criteria of unresectability were revealed with the combination of LSE and laparoscopy in 75 per cent (30 of 40 cases) of pancreatic carcinoma. Moreover, laparoscopy allowed palliation of pancreatic carcinoma. Laparoscopic cholecystostomy was performed in 10 patients, and laparoscopic cholecystojejunostomy with enteroenterostomy was performed in 6 patients.

Laparoscopy and lesser sac endoscopy in gastric carcinoma operability assessment.

The results of 502 laparoscopy and 200 lesser sac endoscopy applications in 502 patients with gastric carcinoma for operability assessment are studied. Laparoscopy demonstrated a 94.74 per cent sensitivity for diagnosis of peritoneal disseminations and liver metastases. However, laparoscopy failed to establish inoperability in any cases of carcinoma spread to areas not accessible to laparoscopic visualization. Of these latter cases, 95.74 per cent were caused by tumor spread to the lesser sac retroperitoneum. Thus, the resultant sensitivity of laparoscopy in gastric carcinoma inoperability diagnosis was only 42.35 per cent. Lesser sac endoscopy made it feasible to inspect all of the organs and tissues forming the lesser sac. Of 200 patients assessed by lesser sac endoscopy, invasion of gastric posterior wall serosa was found in 89, retroperitoneal tumor invasion in 97, and retroperitoneal metastases in 42. The sensitivity of gastric carcinoma inoperability diagnosis by lesser sac endoscopy was 93.44 per cent and in combination with laparoscopy, 96.7 per cent. Utilization of lesser sac endoscopy in patients with gastric carcinoma minimized the number of exploratory laparotomies 6.4 times in comparison with only laparoscopy use and was responsible for diminishing this number to 5 per cent of the total number of examined patients.

Appendiceal intussusception as a manifestation of mucinous cystadenoma of the appendix: an interesting clinical entity.

In children, intussusception is a common cause of intestinal obstruction. In contrast, intussusception in the adult is an infrequent cause of intestinal obstruction and in the majority of instances has some obvious cause such as a tumor forming the lead point of the intussusceptum. Diagnosis is suggested by chronic, intermittent symptoms of intestinal obstruction, the presence of an abdominal mass, and the passage of blood per rectum. In contrast to children, treatment is invariably surgical resection without reduction. We have encountered an appendiceal intussusception as a manifestation of a mucinous cystadenoma of the appendix. There was no evidence of pelvic visceral involvement. This unique presentation is rarely reported. The patient underwent uneventful laparoscopy-assisted segmental ileocolonic resection with stapled anastomosis. An analysis of our diagnostic and therapeutic approach, as well as a review of appendiceal pathology as a cause of intussusception are presented to better understand this rare clinical entity.

Small bowel carcinoid: review of a single institution experience and review of the literature.

We have undertaken a review of the small bowel carcinoids treated at Georgia Baptist Medical Center during the last 27 years in order to evaluate the clinical behavior, diagnostic approaches, treatment options, and prognosis of these neoplasms. A retrospective analysis of the tumor registry at Georgia Baptist Medical Center was undertaken. A total of 148 cases of carcinoid tumors were identified. Of these, 34 were located in the small bowel. Twenty-eight of these cases were diagnosed at our institution. The others were referred for oncology care. The patient records were reviewed for sex, race, age at presentation, location, 5-HIAA status, coexistent neoplasms, multifocality, size, metastatic status, clinical presentation, diagnostic intervention, extension, adjuvant therapy, treatment intervention, and survival. A review of the available literature was undertaken to analyze the historical results in the aforementioned categories. In retrospect, many of these tumors had been clinically active for some time. The authors outline a more aggressive workup in order to avoid acute, in extremis, and late stage presentation. We present an analysis of traditional views on survival and prognosis as related to the size and spread of small bowel carcinoid. We expect that this information will assist in the development of definitive treatment, effective adjuvant therapy, and symptomatic relief for this often frustrating neoplasm.

An institutional review of the management of choledocholithiasis in 1616 patients undergoing laparoscopic cholecystectomy.

At Georgia Baptist Medical Center, 1616 patients underwent laparoscopic cholecystectomy between December 1989 and December 1992; and 103 perioperative endoscopic retrograde cholangiopancreatography (ERCP) procedures were performed, 79 preoperative and 24 postoperative. Endoscopic sphincterotomy with stone extraction was performed in 49 patients (4.7%). Normal ERCP was noted in 46 patients (44%), four patients failed stone extraction preoperatively, and two patients failed extraction postoperatively (5.7%). Four patients had small stones (< 2 mm) managed expectantly without sphincterotomy. Ten laparoscopic common bile duct explorations and eight open common bile duct explorations were performed without retained stones after these procedures. The incidence of detected choledocholithiasis requiring intervention was 4.4 per cent, which is significantly lower than the published incidence of 8 to 15 per cent. It is assumed that a higher percentage of stones may have been detected with liberal or routine use of cholangiography. The clinical significance of these potentially missed stones have not been manifest in our series to date. The authors believe that although improved patient selection may lower the percentage of normal ERCP, this combination of minimally invasive techniques provides a satisfactory approach to choledocholithiasis.

Adult rhabdomyoma: presentation as a cervicomediastinal mass (case report and review of the literature).

The adult rhabdomyoma (ARM) is an unusual and extremely uncommon tumor. Only 96 cases have been reported. Adult rhabdomyomas are found most often in the region of the base of the tongue, floor of the mouth, larynx, and pharynx. Uncommon locations include the soft palate, uvula, lip and cheek, orbit, and stomach. One prior case of extension of an ARM from the supraclavicular region into the mediastinum has been described as an incidental finding at autopsy. It is important to be aware of and correctly identify this tumor because total excision may be curative. Follow-up must be long-term, as recurrence can occur after 35 years. The authors present a case of an ARM diagnosed during the evaluation and treatment of a symptomatic mediastinal mass. This ARM was found to involve the esophagus and trachea from the inferior constrictors in the neck to the azygous vein in the mediastinum. This case represents a previously undescribed presentation of an ARM. We present a review of ARM and outline our diagnostic, therapeutic, and follow-up plans.

Nonoperative management for intra-abdominal abscesses.

Percutaneous drainage of an intra-abdominal abscess is utilized frequently. To evaluate its effectiveness at our institution over 16 months, 18 patients (mean age 49 years) who underwent radiologically directed percutaneous drainage of intra-abdominal abscesses were retrospectively reviewed. The abscesses were postoperative in 14 patients (laparotomy, 5; appendectomy, 4; colectomy, 3; hysterectomy, 2). Primary abscesses were due to diverticular disease (3), perforated appendicitis (3), perforated colon carcinoma (1), and perforated peptic ulcer (1). Percutaneous drainage was ultimately established in all patients with complete resolution of the abscesses occurring in 12 patients (67%). The average duration for drainage was 5.5 days (range 1-23). Average length of hospital stay after the establishment of drainage was 14.6 days (range 1-48). Six patients required surgical procedures because of inadequate abscess drainage (4) or continued clinical deterioration (2). There were no deaths. A major complication (colon perforation, enteric fistula) occurred in two patients (11%). Catheter-related problems were common (7/18 patients), and included drain migration (3), inadequate drainage, and catheter obstruction(2). Four patients required multiple percutaneous drainage procedures. Despite technical feasibility and clinical success in the majority of patients, percutaneous drainage of these intra-abdominal abscesses had frequent catheter-related complications. One-third of patients (31.8%) required surgical intervention despite a prolonged period (average 15 days) of percutaneous drainage. Patients demonstrated to have nonresolving abscesses by computer tomography (CT), abscesses associated with colonic diverticular disease of colon cancer, and abscesses localized to the left lower quadrant were noted to have less successful percutaneous abscess drainage. Patients with a persistent of rising leukocyte count and/or an elevated APACHE II score prior to drainage should be routinely reevaluated at 4 days. Earlier surgical intervention is felt to be warranted because these two factors in this study were indicative of a low nonoperative success rate. Post-appendectomy abscesses uniformly demonstrated prompt response to percutaneous drainage. CT-directed percutaneous drainage of intra-abdominal abscesses provides an alternative to immediate surgical intervention. The preliminary findings from this study suggest a limited application of this intervention in one-third of patients. Further detailed analysis of this patient group is required to delineate guidelines for identifying those patients where percutaneous drainage is unlikely to be successful.

An early review of 800 laparoscopic cholecystectomies at a university-affiliated community teaching hospital.

Laparoscopic cholecystectomy (LC) was first performed at Georgia Baptist Medical Center (GBMC) in December 1989, subsequently becoming the treatment of choice for most patients with symptomatic gallbladder disease. Early in the authors' series, all patients evaluated for cholecystitis were treated laparoscopically, unless the third party refused reimbursement or the attending surgeon was not trained in LC. Indications for LC were no different than for standard open cholecystectomy (OC). Eight hundred patients from December 1989 to March 1991 had an attempted LC at GBMC. The procedure was completed in 782 patients (97.7%) and required conversion to OC in 18 patients, (2.3%) primarily because of technical difficulties such as dense adhesions or gangrenous changes. No patient sustained a trocar injury to the intra-abdominal viscera, bile ducts injury, or major vascular injury. Overall morbidity was 3.1 per cent and mortality 0.13 per cent. Selective cholangiography (SIOC) was used in 14 per cent. Endoscopic retrograde cholangiopancreatography (ERCP), choledochoscopy, and Fogarty catheter techniques were used for common bile duct stone management. Average hospitalization was 0.89 days, with 85 per cent discharged in less than 24 hours. Average operative time was 86 minutes (range: 25 to 353). Patients returned to full activities at home in 8.4 days. Savings on hospital charges to patients averaged $1,100 for inpatient LC and $2,500 for outpatient LC when compared to 1989 costs for OC. Laparoscopic cholecystectomy is the current surgical procedure of choice for most patients with cholecystitis and can be done at least as safely as standard open cholecystectomy. The morbidity appears to be significantly less with LC, but longer follow-up is needed to confirm these preliminary findings.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of previous lower abdominal surgery on performing the total extraperitoneal approach to laparoscopic herniorrhaphy.

At Georgia Baptist Medical Center in Atlanta, GA, we adopted the total extraperitoneal approach (TEPA) to laparoscopic herniorrhaphies because of the concerns of potential early and late complications associated with entering the abdominal cavity. In our institution, the TEPA has compared favorably with the transabdominal approach, with lower complication and recurrence rates. There has been concern, however, in performing the TEPA in patients with previous lower abdominal surgery. The question has been raised that there is increased risk of complications in these patients. From June 1993 to May 1994, we performed 247 laparoscopic herniorrhaphies in 192 patients using the TEPA. Of these, 55 hernias were repaired in 45 patients with previous lower abdominal surgery. Overall retrospective results showed a slightly higher complication rate (23.1% vs 11.3%) and slightly higher recurrence rate (1.8% vs 0%) in the patients with previous surgery over those without. Although these differences are not statistically significant, it is important to keep these risks in mind when selecting the appropriate hernia repair for each patient.

1525 laparoscopic cholecystectomies without biliary injury: a single institution's experience.

Laparoscopic Cholecystectomy (LC) has become the preferred treatment of gallbladder disease. The indications for LC remain unchanged from those for open cholecystectomy (OC). A total of 1525 patients underwent LC at Georgia Baptist Medical Center between December 1989 and December 1992. The procedure was completed in 1,492 patients (97.8%) and required conversion to OC in 33 patients (2.2%). Selective intraoperative cholangiography was used in 165 patients (10.8%). Overall morbidity was 4.06%, and there were four deaths not operatively related, for a 0.26% mortality rate. There have been no biliary ductal injuries. The average hospital stay was 0.82 days, with 37.4% of the patients going home as true outpatients and 44.5% going home on postop Day one. Most published series on LC report a small incidence of biliary injury. We feel that with meticulous dissection of the cystic duct and use of selective intraoperative cholangiography to define unsure anatomy, biliary injury can be minimized.

A comparison of transabdominal preperitoneal (TAPP) and total extraperitoneal approach (TEPA) laparoscopic herniorrhaphies.

There are a variety of accepted techniques for herniorrhaphy. With the advent of laparoscopic general surgery, laparoscopic transabdominal and total extraperitoneal techniques have been added to the many options for repair of the inguinal hernia. From 5/91 to 6/93 we had performed 290 transabdominal preperitoneal (TAPP) laparoscopic herniorrhaphies on 244 adult patients. Due to concerns of potential early and late complications associated with entering the abdominal cavity, we adopted the total extraperitoneal approach (TEPA) for laparoscopic herniorrhaphies in 6/93. Between 6/93 and 12/93, 118 hernias have been repaired in 95 patients using the total extraperitoneal approach. In a retrospective comparison between these two procedures, the recurrence rate is 1.7% (5/290) for TAPP herniorrhaphies and 0% (0/118) for the TEPA. The overall complication rate for TAPP herniorrhaphies was 11.1% and included thigh paresthesias (6), inferior epigastric artery injuries (4), enterotomy (1), bowel obstruction (1), bladder injury (1), and urinary retention (14). The overall complication rate for the TEPA was 3.2% and included bladder injury (1), and urinary retention (2). Mean operative time was similar between these groups (TAPP-81.2 minutes, TEPA-92.9 minutes).

Laparoscopic herniorrhaphy: technical concerns in prevention of complications and early recurrence.

Laparoscopic herniorrhaphy continues to gain popularity, but should be subjected to proper scrutiny before widespread acceptance. From 5/91 to 6/93, 290 transabdominal preperitoneal (TAPP) laparoscopic herniorrhaphies were performed on 244 adult patients at Georgia Baptist Medical Center. Procedures consisted of indirect (164), direct (73), femoral (5), obturator (7), and recurrent (41) hernia repairs, with a mean operative time of 81.2 minutes (range 30-193 min). The overall technical complication rate was 5.3% and includes lateral thigh paresthesias (6), inferior epigastric artery injury (4), enterotomy during adhesiolysis (1), bowel obstruction secondary to herniation through a lateral trocar site (1), and bladder injury (1). The recurrence rate is 1% (3/290), with a mean follow up of 11 months (range 2-27 months). The authors present herein a discussion of technical considerations in an attempt to help decrease complications and recurrence as others incorporate laparoscopic hernia repair into their surgical armamentarium.

Technical considerations of the different approaches to laparoscopic herniorrhaphy: an analysis of 500 cases.

Between April 1991 and April 1994, 500 laparoscopic herniorrhaphies have been performed at our institution. The transabdominal preperitoneal approach was used for 290 repairs, and the total extraperitoneal approach was used for 210 repairs. Although both repairs resulted in acceptable recurrence and complication rates, we adopted the total extraperitoneal approach in June 1993, with a resulting lower recurrence rate (0.5% versus 2.1%) and lower complication rate (3.1% versus 11.1%) when compared with the transabdominal approach. In this retrospective review, four epigastric vessel injuries (1.6%) and one bowel obstruction from a port hernia (0.5%) were attributed to the lateral port placement in the transabdominal approach. There were also two visceral injuries (1.0%) from entering the abdominal cavity in the transabdominal approach. The one visceral injury (0.6%) in the total extraperitoneal approach was a result of the balloon dissection in a patient with multiple previous lower abdominal operations. Better exposure and lateral visualization of the extraperitoneal space has led to less incidence of nerve injury (0.0% versus 2.4%) and a lower recurrence rate (0.5% versus 2.1%) in the total extraperitoneal approach. The total extraperitoneal approach to laparoscopic herniorrhaphy compares favorably to the transabdominal approach in our institution. The improved results may have been due to the technical differences between these approaches.

Comparison of laparoscopic and open ventral herniorrhaphy.

The repair of large and/or recurrent ventral hernias is associated with significant complications and a recurrence rate that can be more than 50 per cent. Laparoscopic ventral herniorrhaphy, a recent development, has been shown to be safe and effective in the repair of ventral hernias. This study retrospectively reviews all ventral hernia repairs over a 3-year period, November 1995 through December 1998, at a community-based teaching hospital. The purpose of the study was to compare open and laparoscopic repairs. A total of 253 ventral hernia repairs were performed during this time, 174 open and 79 laparoscopic. The age, weight, and sex distribution was similar for each group. The hernias in the open group averaged 34.1 cm2 in size, and mesh used averaged 47.3 cm2. In the laparoscopic group, the hernia defect averaged 73.0 cm2, and the mesh size averaged 287.4 cm2. Operative time was longer in the open group, 82.0 versus 58.0 minutes. In the open group, there were 38 (21.8%) minor and 8 (4.6%) major complications, compared with 13 (16.5%) minor and 2 (2.5%) major complications in the laparoscopic group. Hospital stay was shorter for the laparoscopic group, 1.7 versus 2.8 days. At an average follow-up of 21 months (range, 2-40 months), there have been 36 recurrences in the open group (20.7%) compared with 2 recurrences in the laparoscopic group (2.5%). In this series, laparoscopic ventral herniorrhaphy compares favorably to open ventral herniorrhaphy with respect to wound complications, hospital stay, operative time, and recurrence rate.

500 total extraperitoneal approach laparoscopic herniorrhaphies: a single-institution review.

At Georgia Baptist Medical Center, a community-based, university-affiliated hospital, we adopted the total extraperitoneal approach (TEPA) to laparoscopic herniorrhaphy due to potential complications in entering the abdominal cavity reported previously with the transabdominal preperitoneal technique (Am Surg 1996;62:69-72). We have also employed regional anesthesia (epidural) in 108 patients in whom the TEPA was utilized. In our institution, the TEPA has compared favorably to the transabdominal preperitoneal technique, with lower complication and recurrence rates. In patients with previous lower abdominal surgery, the TEPA is considered a relative contraindication due to the increased risk of complications (Am Surg 1997, in press). Since June 1993, we have performed 503 laparoscopic herniorrhaphies using the TEPA, with encouraging early results. To date, two recurrences have been reported, one with previous lower abdominal surgery and another whose recurrence was noted to be secondary to incomplete reapproximation of the mesh with staples around the cord structures. Four major complications include two bowel perforations and two cystotomies noted during balloon dissection of the preperitoneal space. Three of these patients had previous lower abdominal surgery. Epidural anesthesia was used in 108 patients, 4 of whom required conversion to general anesthesia due to peritoneal tears and pain associated with pneumoperitoneum. All four of these patients had previous lower abdominal surgery. In summary, the TEPA remains a viable technique for laparoscopic herniorrhaphy with acceptable complication and recurrence rates. Epidural anesthesia is well tolerated by the patients undergoing this particular repair. We feel that lower abdominal surgery may be a mitigating factor in selection of the TEPA. Continued re-evaluation of the procedure is warranted before definitive conclusions can be made.

Diagnostic laparoscopy for suspected appendicitis.

One hundred consecutive patients who underwent diagnostic laparoscopy for suspected appendicitis were evaluated to assess the appropriate clinical setting for laparoscopic appendectomy. The usefulness of diagnostic laparoscopy in the setting of acute abdominal pain has been well documented. However, there is debate about the use of laparoscopy for definitive therapy. The purpose of this study is to evaluate the decision making process during diagnostic laparoscopy for suspected appendicitis. When pathology is identified other than in the appendix, the majority of patients can be treated without converting to an open procedure. In patients found to have no obvious pathology, incidental appendectomy can be performed laparoscopically. When appendicitis was identified, the majority of patients could be treated safely without converting to an open technique. However, there were certain clinical situations that necessitated conversion to an open operation. Involvement of the cecum or perforation at the base of the appendix puts the appendiceal stump at risk for leak and abscess formation. Evaluation of the cecum by palpation for a mass should also be performed in this situation. Another situation in which conversion to an open technique is warranted is an appendiceal abscess with adherent small bowel. The friability of bowel wall greatly increases the risk for bowel injury in this setting. Laparoscopy is a useful technique for the diagnosis and treatment of abdominal pain even if the appendix is normal on inspection. Conversion to an open operation should be employed when inflammation or perforation occurs at the base of the appendix and when bowel is found to be adherent to an appendiceal abscess.

Successful management of post-cesarean-section acute pseudoobstruction of the colon (Ogilvie's syndrome) with colonoscopic decompression. A case report.

Although acute pseudoobstruction of the colon is a rare entity, a large percentage of the reported cases have occurred following obstetric and gynecologic surgical procedures. Early recognition is mandatory to avoid severe and potentially fatal complications and can allow successful decompression by means of colonoscopy, thus avoiding surgical intervention, as in the case reported on here.

Management of hemophilia in colon and rectal surgery. Report of a patient with factor VIII inhibitors and review of the literature.

With the introduction of Factor VIII concentrates, surgery on patients with hemophilia has become possible. The mortality in recent large series is zero. The morbidity has been variable, with postoperative hemorrhage the most common complication. There is a dramatic change in therapeutic strategy with the development of Factor VIII inhibitors. In reviewing the literature, there are no reports discussing this patient population with respect to the subspecialty of colon and rectal surgery. The authors present a report of a patient with hemophilia who, after hemorroidectomy, developed Factor VIII inhibitors and continued hemorrhage. This article also reviews the literature and centralizes the management of colon and rectal surgery patients with hemophilia.

A complex ileovaginal fistula with associated obstructive uropathy in a patient with Crohn's disease: technical considerations and review of the literature.

A high index of suspicion of an ileogenital fistula should be aroused by a patient with Crohn's disease, weight loss, malnutrition, and a persistent vaginal discharge. Preoperative gastrointestinal and genitourinary evaluation should be used in an attempt to localize the fistulous origin as well as concomitant fistulae. The principles of surgical therapy include preoperative ureteral catheters, resection of the diseased bowel and fistulous segment of bowel, and interposition of healthy tissue (ie, omentum) between the bowel anastomosis and the vaginal cuff.

Esophageal perforation caused by coin ingestion.

Esophageal perforation and acquired tracheoesophageal fistulae (ATEF) are rare sequelae of foreign body ingestion in the pediatric population. Here we discuss the cases of two patients with esophageal perforation caused by prolonged impaction of a coin; in one case, a tracheoesophageal fistula developed. The presence of aerodigestive symptoms and signs in infants and small children should prompt physicians to consider foreign body ingestion and the presence of an ATEF. Clinical presentation, diagnostic modalities, and technical considerations for surgical management are outlined.