Gastric endo-organ access: technique and complications

Since laparoscopic cholecystectomy was introduced in 1987 by Phillipe Mouret, a variety of gastrointestinal operations such as laparoscopic Nissen fundoplication, herniorrhaphy, splenectomy, vagotomy, adrenalectomy, appendectomy, nephrectomy, staging of intra-abdominal neoplasms, and laparoscopic colectomy have gained popularity. The minimal invasive nature of these procedures and the reported benefits of a short hospital stay, reduced postoperative pain, and better cosmesis have encouraged investigation of new methods of access for gastric and colonic pathology untreatable by endoscopic or standard laparoscopic techniques.

Endoscopic valvuloplasty for GERD

BACKGROUND

The transoral, endoscopic route has been suggested as a possible approach for the correction of severe gastroesophageal reflux. Such a procedure would involve no mobilization of the cardia or other structures. The optimal placement, number, and configuration of sutures remains undefined.

METHODS

With the use of a previously developed endoscopic sewing machine, this study was undertaken in baboons with two suture arrangements immediately below the lower esophageal sphincter. A linear arrangement (group I) and a circular arrangement (group II) were compared. During the 6 months after the procedure, the animals were evaluated using manometry, fluoroscopic barium swallow, upper gastrointestinal endoscopy, and a pressure volume test.

RESULTS

A significant increase in lower esophageal sphincter length was demonstrated only in group II (p = 0. 010). A significant increase in lower esophageal sphincter pressure was demonstrated only in group I animals (p = 0.008). The abdominal length increased in group I (p = 0.004) and group II (p = 0.004). The yield pressure and yield volume did not differ significantly from those measured previously in control animals. No evidence of reflux, stricture formation, esophagitis, or other pathology was noted.

CONCLUSIONS

Some manometric parameters associated with gastroesophageal reflux are altered by the endoscopic placement of sutures below the gastroesophageal junction, with no associated serious complications.

Symptom priority ranking in the care of gastroesophageal reflux: a review of 1,850 cases

BACKGROUND

Clinical history remains an important part of the medical evaluation of patients with gastroesophageal reflux disease (GERD). Heartburn, regurgitation, and dysphagia are considered typical symptoms of GERD. Priority rankings of these symptoms can be determined with a standardized questionnaire.

OBJECTIVE

To determine whether symptom priority ranking and symptom severity grading can provide useful information in the evaluation of patients with GERD.

METHODS

From 1,850 patients that were analyzed retrospectively, patients with dysphagia unrelated to GERD were excluded. A standardized questionnaire was applied before each patient underwent any esophageal diagnostic study. Priority of symptoms was determined to be primary, secondary, tertiary, or none based on the patient response to the questionnaire. Presence of a stricture was determined either by endoscopy, esophagraphy, or both studies. Stationary esophageal manometry and 24-hour pH monitoring were performed on all patients. Through bivariate and multivariate analysis, the relationships among typical GERD symptoms, esophageal reflux-related stenosis, lower esophageal sphincter pressure, and composite score were established.

RESULTS

High priority ranking of the symptom dysphagia is predictive of the presence of an esophageal stricture, but has a negative association with abnormal manometric and pH studies. In contrast, high priority ranking of the symptom heartburn and regurgitation are positively associated with abnormal manometric and pH results.

CONCLUSIONS

Priority ranking can be a valuable adjunct to objective testing in the evaluation of GERD. In certain clinical situations it can obviate the need for 24-hour pH monitoring.

Eight years' experience with the use of a transcystic common bile duct duodenal double-lumen catheter for the treatment of choledocholithiasis

BACKGROUND

We have previously reported an alternative technique for treatment of choledocholithiasis found at laparoscopic cholecystectomy (LC) that can be considered with selected patients. This study was undertaken to update our experience with this alternative technique, which makes serial postoperative cholangiograms possible and facilitates stone extraction by assuring access to the common bile duct so that a guidewire-assisted endoscopic retrograde sphincterotomy can be performed.

METHODS

In the period between 1989 and 1997, prospective data were maintained on 1043 consecutive patients who underwent LC by a single surgeon. Fifty-two patients with abnormal cholangiograms were managed with a percutaneously placed double-lumen catheter threaded through the cystic duct and advanced into the duodenum.

RESULTS

Five attempts failed, 3 because of failure to pass the catheter and 2 because of catheter dislodgement. Of the 47 remaining patients, 2 underwent intraoperative endoscopic sphincterotomies using this alternative technique and 45 had cholangiograms repeated at 10 to 14 days. Twenty-three had negative cholangiograms, thus avoiding further procedures or unnecessary sphincterotomies because of spontaneous stone passage or initial false-positive cholangiograms. The remaining 22 had positive cholangiograms. Eighteen ultimately underwent sphincterotomies with stone extraction using a guidewire placed through the catheter. The other 4 had negative cholangiograms after serial follow-up, presumably because of spontaneous stone passage.

CONCLUSIONS

The use of a transcystic double-lumen catheter passed through the ampulla of Vater is an effective and safe alternative for the management of choledocholithiasis discovered during LC.