Concomitant laparoscopic gastric and biliary bypass and bilateral thoracoscopic splanchnotomy: the full package of minimally invasive palliation for pancreatic cancer

Cholecyst-jejunostomy for palliative surgery

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Many cases of unresectable cancer that cause obstructive jaundice require treatment.

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Biliary reconstruction can be difficult to perform safely and quickly due to many factors.

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Cholecyst-jejunostomy may be completed within 10 min.

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Cholecyst-jejunostomy is an appropriate palliative surgery.

Introduction and importance

Many cases of unresectable cancer that cause obstructive jaundice require treatment. Depending on the patient's condition in these cases, surgery may be performed to treat jaundice. The main goal of palliative surgery is to improve the quality of life. Therefore, palliative surgery for obstructive jaundice must be performed safely and quickly.

Case presentation

This case presents a 45-year-old man with fever and back pain who was diagnosed with pancreatic head cancer and multiple liver metastases. Chemotherapy was initiated; however, during the course of treatment, the patient developed hemorrhage from pancreatic cancer that had invaded the duodenum caused hematemesis and melena. Therefore, the chemotherapy could not be continued. Because the patient also developed obstructive jaundice and cholangitis, a gastrojejunostomy and cholecyst-jejunostomy was performed. The surgery was successful; however, the cancer continued to progress, and patient died 31 days after surgery.

Clinical discussion

Biliary reconstruction can be difficult to perform safely and quickly due to many factors.

This study shows that cholecyst-jejunostomy is effective for patients with end-stage cancer. In the long term, cholecyst-jejunostomy is not suitable for biliary reconstruction due to the possibility of bile congestion and cholecystitis. However, this easy and quick procedure is well indicated for emergency patients with a short life expectancy.

Conclusion

As an easy and quick procedure for emergency patients with a short life expectancy, jejunal anastomosis of the gallbladder is an appropriate palliative surgery that is indicated for jaundice treatment.

Surgical palliation of pancreatic cancer

The surgical palliation of pancreatic cancer remains an important component of the treatment of this disease. The introduction of a new aggressive and effective chemotherapy regimen (FOLFIRINOX), interdisciplinary palliative care, and minimally invasive approaches for providing palliation are all factors that expand the role of the surgeon in the care of patients with unresectable disease. Currently, the role of the surgeon in the palliation of pancreatic cancer is (1) to identify patients with incurable disease (either preoperatively or intraoperatively), (2) to determine the optimal palliative technique to optimize results and preserve resources, and (3) to perform palliation of symptoms with low morbidity and mortality. The 3 most common symptoms of pancreatic cancer requiring surgical palliation are obstructive jaundice, gastric outlet obstruction, and tumor-associated pain. It is important that the surgeon recognizes the full range of surgical and nonoperative techniques available and contributes to the decision making as to the most appropriate method for each individual patient.

Laparoscopy in gastrointestinal malignancies

This paper presents an update of the role of minimally invasive surgery (MIS) in gastrointestinal malignancy. A review of indications, surgical technique, and radicality of laparoscopy in the field of gastrointestinal cancer surgery is discussed. The feasibility and safety of laparoscopic procedures are compared with established and implemented standards in the diagnosis and treatment of oncological disorders. It is important to appreciate that only the "access" is different with all its attendant advantages. The use of laparoscopy in tumor staging and palliative and curative resection is evaluated on review of the literature, and special indications for a laparoscopic approach in gastrointestinal malignancy in different organs are discussed. In conclusion, MIS is safe and feasible, with many short-term advantages; long-term results should be further assessed in randomized controlled studies. Until the outcomes of such studies are available MIS for malignant disease should be performed by experienced surgeons in specialized centers.

Laparoscopic Resection of Type I Choledochal Cyst in an Adult and Roux-en-Y Hepaticojejunostomy: A Case Report and Literature Review

Choledochal cysts are rare cystic dilatations of the extrahepatic biliary tree, the intrahepatic bile ducts, or both and carry a substantial risk of malignant transformation. Type I choledochal cysts, which involve the entire common hepatic and common bile ducts, represent 80% to 90% of these lesions. We report laparoscopic excision of symptomatic type I choledochal cyst in a 37-year-old woman, and review the literature. Laparoscopic excision of the extrahepatic biliary tree from the hepatic confluence to the anomalous pancreatobiliary junction with en bloc cholecystectomy and reconstruction with a Roux-en-Y hepaticojejunostomy was accomplished. Postoperative recovery was uneventful with a hospital stay of 3 days. She remains well and asymptomatic at 6 months of follow-up. Laparoscopic excision of choledochal cysts may be safely accomplished with a prompt recovery. Further experience with this approach in larger number of patients is justified and long-term follow-up data are needed.

Laparoscopic pancreatic surgery

In the past, in the pancreas, a minimally invasive technique was only used for diagnostic laparoscopy in evaluating periampullary malignancy. Recent advances in operative techniques and instrumentation have empowered surgeons to perform virtually all procedures in the pancreas, including the Whipple procedure. Some of these procedures represent the most sophisticated application of minimally invasive surgery, and their outcomes are reportedly better than those of conventional open approaches. In addition to the evaluation of resectability in periampullary malignancy, palliative procedures, including biliary bypasses and gastrojejunostomy, can be performed laparoscopically. Although it is reportedly feasible to perform a Whipple procedure laparescopically, no benefit of the laparoscopic approach over the conventional open approach has been documented. Laparoscopic distal pancreatectomy, with or without preserving the spleen, is technically easier than the Whipple procedure, and is more widely accepted. Indications for laparoscopic distal pancreatectomy include cystic neoplasms and islet-cell tumors located in the pancreatic body or tail. Complications of acute and chronic pancreatitis may be treated with the use of surgical laparoscopy. When infected necrotizing pancreatitis is identified, surgical intervention for drainage and debridement is required. According to the type and location of infected necrotizing pancreatitis, three laparoscopic operative approaches have been reported: infracolic debridement, retroperitoneal debridement, and laparoscopic transgastric pancreatic necrosectomy. When internal drainage is indicated for a pseudocyst, a minimally invasive technique is a promising option. Laparoscopic pseudocyst gastrostomy, cyst jejunostomy, or cyst duodenostomy can be performed, depending on the size and location of the pseudocyst. Especially when a pseudocyst is located in close contact with the posterior wall of the stomach, it is best drained by a pseudocyst gastrostomy, which can also be done with the use of an intragastric operative technique.

Laparoscopic gastric bypass for gastric outlet obstruction is associated with smoother, faster recovery and shorter hospital stay compared with open surgery

BACKGROUND/PURPOSE

Laparoscopic gastric bypass for relief of gastric outlet obstruction (GOO) is feasible and safe. However, comparative data to confirm the benefits of the laparoscopic approach remain scarce.

METHODS

Between 1998 and 2003, 26 patients underwent 15 laparoscopic (surgeon A) and 12 open (surgeon B) gastrojejunostomies (GJs) for GOO. The indications for surgery included malignant (n = 17) and benign (n = 10) diseases.

RESULTS

There were no conversions to open surgery in the laparoscopic group, and no operative mortality occurred in either group. The groups were comparable for age, sex, American Society of Anesthesiology (ASA) score, frequencies of previous abdominal surgery and of malignant or benign disease, and type of GJ fashioned. There were no differences between the laparoscopic and open groups with regard to the operating time (median, 90 vs 111 min; P = 0.113), and patients receiving intraoperative blood transfusion. However, laparoscopic surgery was associated with significantly shorter durations of postoperative intravenous hydration (60 vs 234 h; P = 0.001), opiate analgesia (49 vs 128 h; P = 0.025), and hospital stay (3 vs 15 days; P = 0.005). Operative morbidity occurred more frequently following open surgery (33% vs 13%; P = 0.219).

CONCLUSIONS

Laparoscopic GJ for the relief of GOO is associated with a smoother and more rapid postoperative recovery and shorter hospital stay compared with open surgery. In experienced hands, the laparoscopic approach to GJ should become the new gold standard.

Endoscopic approaches for palliation of luminal gastrointestinal obstruction

Much of the workload of a typical gastroenterologist is devoted to screening patients for gastrointestinal malignancies. Efforts such as colorectal cancer screening via colonoscopy and endoscopic surveillance of patients with Barrett's esophagus are widespread and widely endorsed. In recent years, the armamentarium of endoscopy has broadened considerably and now affords physicians a variety of nonsurgical means to palliate malignant obstruction of the gastrointestinal tract. This article reviews endoscopic techniques to treat malignant esophageal, biliary, small bowel, and colonic obstruction.

Therapeutic, prophylactic, and preresection applications of laparoscopic gastric and biliary bypass for patients with periampullary malignancy

BACKGROUND

Laparoscopic bypass surgery for the palliation of gastric and biliary obstruction is associated with a rapid recovery. This study aimed to extend its application to other aspects in the management of patients with periampullary cancer.

METHODS

Between 2001 and 2004, 21 patients (median age, 68 years) underwent laparoscopic gastric (n = 8), biliary (n = 5), and combined gastric and biliary (n = 8) bypass. In addition to its therapeutic role (n = 12), indications included a concomitant prophylactic gastric (n = 3) and biliary (n = 2) bypass as well as pre- 1 Whipple's relief of deep jaundice at the time of staging laparoscopy (n = 3). Construction of the biliary bypass to the gallbladder (n = 11) or bile duct (n = 2) was based on preoperative imaging.

RESULTS

All procedures were completed laparoscopically. The median operating times for gastric, biliary, and combined bypass were 75, 60, and 130 min, respectively. The addition of a prophylactic bypass did not significantly prolong the operating time, as compared with a single therapeutic bypass. One patient died postoperatively of aspiration pneumonia. The postoperative hospital stay (median, 4 days) was not significantly influenced by the type of bypass. No recurrence of or new obstructive symptoms developed during the follow-up period after a therapeutic or prophylactic bypass.

CONCLUSIONS

Applications of laparoscopic gastric and biliary bypass can safely be expanded to include a prophylactic role and preresection relief of obstructive jaundice. Prophylactic bypass surgery does not prolong operating time or hospital stay significantly and prevents future onset of obstructive symptoms.

Current status of laparoscopic biliary bypass in the management of non-resectable peri-ampullary cancer

BACKGROUND

In patients with non-resectable peri-ampullary cancer, optimization of quality of life is an important goal. Although endoscopic palliation is widely used, the proponents of laparoscopic biliary bypass claim that this procedure alters management towards surgery. However, the evidence base for selection of laparoscopic bypass is limited and the aim of this report is to scrutinize the available evidence in order to assess the current role of this procedure.

METHODS

A computerised literature search was made of the Medline database for the period from January 1966 to December 2004. Searches identified 12 reports of laparoscopic palliation for peri-ampullary cancer. These reports were retrieved and data analysed in the following categories: type of bypass; combination with other procedures; complication and outcome.

RESULTS

Laparoscopic cholecystoenterostomy is the commonest form of laparoscopic biliary bypass practiced. Of the 52 reported cases undergoing laparoscopic biliary bypass, 40 underwent laparoscopic cholecystojejunostomy, 6 laparoscopic choledochoduodenostomy and 6 underwent laparoscopic hepaticoje- junostomy.

CONCLUSION

Current evidence does not justify the incorporation of laparoscopic biliary bypass techniques into contemporary evidence-based management algorithms for patients with non-resectable periampullary cancer.

New approaches to the minimally invasive treatment of pancreatic cancer

Advances in minimally invasive surgery have revolutionized the field of surgery. Despite the great strides in equipment and experience, operative conduct remains confined by the limits of exposure. Retroperitoneal fat can be abundant and can contribute greatly to difficulty in exposure. Visceral organs ventral to the retroperitoneum preclude direct access and require optimal patient positioning to operate. Additionally, the major vascular pedicles all originate in the retroperitoneum off of the abdominal aorta or enter the inferior vena cava. The pancreas, in particular, is surrounded by the portal vein, celiac axis, superior mesenteric vein and artery, and splenic vein and artery. If injured during surgery, these vessels can present a life-threatening emergency. The issues related to the vasculature, coupled with the difficulty in resecting portions of the pancreas and the relative paucity of pancreatic procedures, have greatly concentrated these cases at tertiary care centers staffed by experienced laparoscopists. However, as surgical technology improves and fellowships train more surgeons with advanced laparoscopic skills, minimally invasive pancreatic surgery may diffuse with more community-based health care networks.

Pancreatic neoplasms

PURPOSE OF REVIEW

This review includes a summary of articles that have affected the study and treatment of pancreatic neoplasms over the past year.

RECENT FINDINGS

Over the past year, there have been several reports of new animal models of pancreatic cancer that recapitulate the human disease and hold promise for preclinical studies. The hope of proteomic and DNA technologies for detecting pancreatic cancer and new genes involved in the biology of this disease are described. New studies examining neoadjuvant and adjuvant treatment of pancreatic cancer show some promise. The surgical treatment and palliation of pancreatic cancer continues to advance. Experiences of the treatment of intraductal pancreatic mucinous neoplasms shed some light on the management of this entity. Two large series of cystic neoplasms point to the evolving management of these often asymptomatic lesions.

SUMMARY

The treatment of pancreatic neoplasm continues to change and improve as more is learned about these diseases. A renewed clinical and scientific focus on this organ will certainly shape the management of pancreatic neoplasm and holds the promise of improved outcomes.