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A new technique for jejunal feeding tube placement: A marriage of enteroscope and laparoscope
LAPAROSCOPY ~'541 MANAGEMENT OF BILE DUCT INJURIES AFTFR LAPAROSCOPIC CHOLFCYSTFCTOMY (LC); REPORT ON 53 PATIENTS.
.IA=.G.H.M. 8ergman ~, G. van den Brink ~, E.A.J. Rauws~, L.T, de Wit ;, H. Obertop 2, K. Huibregtse ~, G.N.J. Tytgat *, D.J. Gouma 2, Department of Gastroenterology~ and Department of Surgery~, Academic Medical Center, Amsterdam , The Netherlands. From January 1990 to June 1994, 53 patients who sustained bile duct injuries during LC were managed at our hospital. Patients: There were 16 males and 37 females with a mean age of 47 years (range 22-89). Follow-up was available in all patients for a median of 17 months (range 1-3g). Four types of ductal injury were identified. Type A (18 patients) had leakage from cystic ducts or peripheral hepatic radicles, type B (I 1 patients) had major bile duct leakage, type C (9 patients) had an isolated ductal stricture, and type D (15 patients) had complete transection of the bile duct, Results: ERCP established the diagnosis in all type A, B, and C lesions. In type D lesions PTC was required to delineate the proximal extent of the injury. Thirty-four of the 38 patients with type A, B and C lesions were treated endoscopically. Endoscopic management was possible and successful in 89% of type A lesions, 71% of type B lesions, and 38% of type C lesions. The majority of failures were due to inability to pass strictures or leaks at the initial endoscopy. After endoscopic treatment early complications occurred in five patients: fever (n=2), bleeding (n~ 1), myocardial infarction (n=l), and ongoing sepsis (n=l). Two patients died during the initial treatment. During follow-up two patients developed restenosis and one patient had a second gallbladder removed. All patients with complete transection of the duct eventually underwent reconstructive surgery. Postoperative bile leakage occurred in 7 patients and 4 patients developed stenosis of the anastomosis during follow-up. There was no mortality. Conclusions: The majority of type A and B bile duct injuries after LC can be managed endoscopically. In patients with more severe ducta[ injury (types C arid D) surgery !s often required. Multidisciplinary approach to these lesions is advocated.
1543 A NEW TECHNIQUE FOR JEJUNAL FEEDING TUBE PLACEMENT: A MARRIAGE OF ENTEROSCOPE AND LAPAROSCOPE. ~ , D. Resnick, J. Vitello, J.L. Watkins, and D.E. McGuire, Departments of Medicine and Surgery, University of Illinois at Chicago, Chicago, IL Jejunal feeding tubes (Jb-'T)are the preferred access in selected patients requiring long-term enteral feedings. AIM. The aim of this study was to see whether determine newly developed needle by CORPAC (CORPAC MEDSYSTEMS, Wheeling, K,) could be used in con}unction with an entemscope in the placement of JFT under laparoscopie guidance. METHODS. Five patients were identified as ideal candidates for JFr. In the Operating Room and under general anesthesia, a push enteroscope utilizing an overtube was advanced to the proximal jejunum. At the same time, pneumoperitoneum was established and a 10 mm laparoscope placed into the abdomen. The speeially designed needle was then advanced through the entemscope and out into the lumen of the small bowel. The needle was then advanced tlamugh the serosa and into the abdominal cavity, while beIng visualized by the laparoscope. Through a second trocar site, a forceps assisted the needle to the peritoneum and out the anterior abdominal wall. The enteroscope was then removed with the needle system remaining extruded from the abdominal wall and exiting the mouth. A standard 16 Fr feeding tube (CORPAC) was attached to the end of the needle exiting the mouth. The entire assembly was then pulled through for proper placement into the small bowel. RESULTS. All 5 patients had successful endoscopic laparoscopic assisted JFT placement. There were no serious complications. One patient developed mild ilens after the procedure lasting for approximately 4 days with resolution. CONCLUSIONS. 1) Utilizing this new technique, enteroseopie assisted feeding tube placement with laparoscopy is feasible, 2) This procedure may potentially shorten the time required for JFT placement in the Operating Room. 3) This technique could potentially be performed under conscious sedation.
542
544
LAPAROSCOPIC FENESTRATION OF A MASSIVE RIGHT HEPATIC CYST: A CASE REPORT D. W. Dexter, G. T. Verazin, D. P. McKellar, Department of Surgery, Wright Patterson Medical Center, Wright Patterson AFB, OH Surgical management of symptomatic hepatic cysts has traditionally been performed by either fenestration or excision, both of which require celiotomy. We h y p o t h e s i z e d that laparoscopic fenestration of symptomatic hepatic cysts could be performed safely and with no added risk when compared with standard celiotomy. A 61 year old female presented with a 16 cm right hepatic cyst diagnosed by CT scan after complaints of abdominal pain and distention, early satiety, and dyspnea secondary to an elevated right hemidiaphragm. Preoperative endoscopic retrograde c h o l a n g i o g r a p h y showed no communication of the cyst with the biliary tree. She had undergone emergency celiotomy for a ruptured left hepatic cyst five years earlier. Using video laparoscopy the cyst was visualized in the right hepatic lobe and percutaneously aspirated with a thoracentesis catheter under direct vision. A large portion of the cyst wall was then excised to fenestrate the cyst. A I cm Jackson:Pratt drain was placed in the cyst cavity. She was discharged home on the fourth postoperative day after removing the drain. Her postoperative course has been uneventful and she remains asymptomatic at three months follow up. We r e c o m m e n d laparoscopic f e n e s t r a t i o n of symptomatic hepatic cysts as an alternative to celiotomy.
LAPAROSCOPIC HEPATIC RESECTION FOR FOCAL NODULAR HYPERPLASIA G. Fink, D. Parkus, C. Murphy, L. Grossbard Univ. of South Florida, Tampa Florida Hepatic resection has traditionally required celiotomy, however, peripheral hepatic lesions may lend themselves to laparoscopie resection, This was performed for focal nodular hyperplasia of the liver in a 31yo. female who presented with an abdominal mass and associated abdominal pain. The patient under,vent standard diagnostic laparoscopy, at which time she was noted to have a peripheral left lobe lesion measuring 5era x 6.5cm. Biopsyof the lesion revealed focal nodular hyperplasia. The patient subsequently underwent laparoseopic hepatic resection of the tumor. The resection was accomplished through two 12ram ports placed in the right and left lateral positions after insufflation to 15ram of mercury. Three applications of an endo GIA stapler were required to resect the lesion. Intraoperativeblood loss was approximately 50cc and the operative lime was 30 minutes. Surgical margins were free of tumor and the final pathology was consistent with focal nodular hyperplasia. The post operative course was unremarkab|e and the patient was discharged on post operative day two. The patiem underwent laparoseopic resection of focal nodular hys irtvolving the left hepatic lobe negating the need for ccilotomy. Laparosenpic hepatic resection should be considered in a limited patient population, primarily influenced by tumor size and location.
VOLUME 41, NO. 4, i995
G A S T R O I N T E S T I N A L ENDOSCOPY
431
.IA=.G.H.M. 8ergman ~, G. van den Brink ~, E.A.J. Rauws~, L.T, de Wit ;, H. Obertop 2, K. Huibregtse ~, G.N.J. Tytgat *, D.J. Gouma 2, Department of Gastroenterology~ and Department of Surgery~, Academic Medical Center, Amsterdam , The Netherlands. From January 1990 to June 1994, 53 patients who sustained bile duct injuries during LC were managed at our hospital. Patients: There were 16 males and 37 females with a mean age of 47 years (range 22-89). Follow-up was available in all patients for a median of 17 months (range 1-3g). Four types of ductal injury were identified. Type A (18 patients) had leakage from cystic ducts or peripheral hepatic radicles, type B (I 1 patients) had major bile duct leakage, type C (9 patients) had an isolated ductal stricture, and type D (15 patients) had complete transection of the bile duct, Results: ERCP established the diagnosis in all type A, B, and C lesions. In type D lesions PTC was required to delineate the proximal extent of the injury. Thirty-four of the 38 patients with type A, B and C lesions were treated endoscopically. Endoscopic management was possible and successful in 89% of type A lesions, 71% of type B lesions, and 38% of type C lesions. The majority of failures were due to inability to pass strictures or leaks at the initial endoscopy. After endoscopic treatment early complications occurred in five patients: fever (n=2), bleeding (n~ 1), myocardial infarction (n=l), and ongoing sepsis (n=l). Two patients died during the initial treatment. During follow-up two patients developed restenosis and one patient had a second gallbladder removed. All patients with complete transection of the duct eventually underwent reconstructive surgery. Postoperative bile leakage occurred in 7 patients and 4 patients developed stenosis of the anastomosis during follow-up. There was no mortality. Conclusions: The majority of type A and B bile duct injuries after LC can be managed endoscopically. In patients with more severe ducta[ injury (types C arid D) surgery !s often required. Multidisciplinary approach to these lesions is advocated.
1543 A NEW TECHNIQUE FOR JEJUNAL FEEDING TUBE PLACEMENT: A MARRIAGE OF ENTEROSCOPE AND LAPAROSCOPE. ~ , D. Resnick, J. Vitello, J.L. Watkins, and D.E. McGuire, Departments of Medicine and Surgery, University of Illinois at Chicago, Chicago, IL Jejunal feeding tubes (Jb-'T)are the preferred access in selected patients requiring long-term enteral feedings. AIM. The aim of this study was to see whether determine newly developed needle by CORPAC (CORPAC MEDSYSTEMS, Wheeling, K,) could be used in con}unction with an entemscope in the placement of JFT under laparoscopie guidance. METHODS. Five patients were identified as ideal candidates for JFr. In the Operating Room and under general anesthesia, a push enteroscope utilizing an overtube was advanced to the proximal jejunum. At the same time, pneumoperitoneum was established and a 10 mm laparoscope placed into the abdomen. The speeially designed needle was then advanced through the entemscope and out into the lumen of the small bowel. The needle was then advanced tlamugh the serosa and into the abdominal cavity, while beIng visualized by the laparoscope. Through a second trocar site, a forceps assisted the needle to the peritoneum and out the anterior abdominal wall. The enteroscope was then removed with the needle system remaining extruded from the abdominal wall and exiting the mouth. A standard 16 Fr feeding tube (CORPAC) was attached to the end of the needle exiting the mouth. The entire assembly was then pulled through for proper placement into the small bowel. RESULTS. All 5 patients had successful endoscopic laparoscopic assisted JFT placement. There were no serious complications. One patient developed mild ilens after the procedure lasting for approximately 4 days with resolution. CONCLUSIONS. 1) Utilizing this new technique, enteroseopie assisted feeding tube placement with laparoscopy is feasible, 2) This procedure may potentially shorten the time required for JFT placement in the Operating Room. 3) This technique could potentially be performed under conscious sedation.
542
544
LAPAROSCOPIC FENESTRATION OF A MASSIVE RIGHT HEPATIC CYST: A CASE REPORT D. W. Dexter, G. T. Verazin, D. P. McKellar, Department of Surgery, Wright Patterson Medical Center, Wright Patterson AFB, OH Surgical management of symptomatic hepatic cysts has traditionally been performed by either fenestration or excision, both of which require celiotomy. We h y p o t h e s i z e d that laparoscopic fenestration of symptomatic hepatic cysts could be performed safely and with no added risk when compared with standard celiotomy. A 61 year old female presented with a 16 cm right hepatic cyst diagnosed by CT scan after complaints of abdominal pain and distention, early satiety, and dyspnea secondary to an elevated right hemidiaphragm. Preoperative endoscopic retrograde c h o l a n g i o g r a p h y showed no communication of the cyst with the biliary tree. She had undergone emergency celiotomy for a ruptured left hepatic cyst five years earlier. Using video laparoscopy the cyst was visualized in the right hepatic lobe and percutaneously aspirated with a thoracentesis catheter under direct vision. A large portion of the cyst wall was then excised to fenestrate the cyst. A I cm Jackson:Pratt drain was placed in the cyst cavity. She was discharged home on the fourth postoperative day after removing the drain. Her postoperative course has been uneventful and she remains asymptomatic at three months follow up. We r e c o m m e n d laparoscopic f e n e s t r a t i o n of symptomatic hepatic cysts as an alternative to celiotomy.
LAPAROSCOPIC HEPATIC RESECTION FOR FOCAL NODULAR HYPERPLASIA G. Fink, D. Parkus, C. Murphy, L. Grossbard Univ. of South Florida, Tampa Florida Hepatic resection has traditionally required celiotomy, however, peripheral hepatic lesions may lend themselves to laparoscopie resection, This was performed for focal nodular hyperplasia of the liver in a 31yo. female who presented with an abdominal mass and associated abdominal pain. The patient under,vent standard diagnostic laparoscopy, at which time she was noted to have a peripheral left lobe lesion measuring 5era x 6.5cm. Biopsyof the lesion revealed focal nodular hyperplasia. The patient subsequently underwent laparoseopic hepatic resection of the tumor. The resection was accomplished through two 12ram ports placed in the right and left lateral positions after insufflation to 15ram of mercury. Three applications of an endo GIA stapler were required to resect the lesion. Intraoperativeblood loss was approximately 50cc and the operative lime was 30 minutes. Surgical margins were free of tumor and the final pathology was consistent with focal nodular hyperplasia. The post operative course was unremarkab|e and the patient was discharged on post operative day two. The patiem underwent laparoseopic resection of focal nodular hys irtvolving the left hepatic lobe negating the need for ccilotomy. Laparosenpic hepatic resection should be considered in a limited patient population, primarily influenced by tumor size and location.
VOLUME 41, NO. 4, i995
G A S T R O I N T E S T I N A L ENDOSCOPY
431