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Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity
NEW METHODS & MATERIALS Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity Anthony N. Kalloo, MD, Vikesh K. Singh, MD, Sanjay B. Jagannath, MD, Hideaki Niiyama, MD, PhD, Susan L. Hill, DVM, Cheryl A. Vaughn, RN, BSN, Carolyn A. Magee, MS, Sergey V. Kantsevoy, MD, PhD Background: A novel endoscopic peroral transgastric approach to the peritoneal cavity was tested in a porcine model in acute and long-term survival experiments. Methods: Transgastric peritoneoscopy was evaluated in 50-kg pigs. After upper endoscopy, the peritoneal cavity was accessed by needle-knife puncture of the gastric wall, followed by extension of the incision either with a pull-type sphincterotome or by balloon dilation. The peritoneal cavity was examined, and a liver biopsy specimen was obtained. The gastric wall incision was closed with clips. Observations: Twelve acute and 5 survival experiments were performed. Both techniques of gastric wall incision were without complication. The acute experiments demonstrated the technical feasibility of the approach. In the survival experiments, all pigs recovered and gained weight. Conclusions: The peroral transgastric approach to peritoneal cavity technically is feasible and has the potential to be an alternative to laparoscopy and laparotomy.
Laparoscopic access to the peritoneal cavity has many advantages over traditional open surgery.1 Smaller incisions of the abdominal wall reduce postoperative pain and the risk of ventral herniation, decrease local and systemic complications, and provide an excellent cosmetic result compared with open surgery.2,3 Patients also have less postoperative ileus and recover quickly after laparoscopic procedures.1,4 Theoretically, the peroral transgastric Received September 30, 2003. For revision December 22, 2003. Accepted February 13, 2004. Current affiliations: Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland. Vikesh K. Singh’s research is supported by a research fellowship from the Four Schools Physician-Scientist Program in Internal Medicine. Reprint requests: Anthony N. Kalloo, MD, Johns Hopkins Hospital, Division of Gastroenterology, 1830 East Monument St., Rm. 422, Baltimore, MD 21205. Copyright Ó 2004 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(04)01309-4 114
GASTROINTESTINAL ENDOSCOPY
Figure 1. Endoscopic view of gastric wall incision being made with sphincterotome.
approach to the peritoneal cavity may further reduce the invasiveness of surgery by completely eliminating anterior abdominal wall incisions.5 A peroral endoscopic approach to the peritoneal cavity via a gastric-wall incision was developed and tested in a porcine model. MATERIALS AND METHODS Transgastric peritoneoscopy was evaluated in 50-kg pigs (Sus scrofus domesticus). The aim of the study was to determine the technical feasibility and the safety of an endoscopic approach to the peritoneal cavity, with liver biopsy, in a porcine model. All procedures were performed with the animal under general anesthesia by endotracheal intubation. Survival experiments were performed after a series of acute experiments. Acute experiments A forward-viewing endoscope (GIF-160; Olympus America Corp., Melville, N.Y.) was inserted perorally into the stomach. Access to the peritoneal cavity was created as follows: a needle-knife (KD-10Q-1.A; Olympus) was used to create an initial 2-mm incision in the anterior wall of the stomach (Fig. 1). A flexible-tip guidewire (Jagwire 5658; Microvasive Endoscopy, Boston Scientific Corp., Natick, Mass.) then was advanced through the incision into the peritoneal cavity under fluoroscopic guidance. The incision was enlarged, either by extending it with a pull-type sphincterotome (210Q-0720; Olympus) to 20 mm (n = 6) or by dilation with an 8-mm dilation balloon (CRE esophageal balloon 5838; Microvasive) inserted over the guidewire (n = 6). The endoscope then was advanced into the peritoneal cavity, which was insufflated with air to lift the anterior abdominal wall and to expose the intra-abdominal viscera. The peritoneal cavity then was examined endoscopically (Fig. 2), after which the air was aspirated and the endoscope was withdrawn into the stomach. The VOLUME 60, NO. 1, 2004
Flexible transgastric peritoneoscopy: an approach to peritoneal cavity
Figure 2. Endoscopic view of peritoneal cavity, showing small bowel.
A Kalloo, V Singh, S Jagannath, et al.
Figure 3. Endoscopic view of peroral transgastric liver biopsy specimen.
gastric-wall incision was closed with jumbo clips (Endoclips; Olympus Optical Co., Ltd., Tokyo, Japan). Closure was by applying clips first to both ends of the incision and then sequentially toward the center of the incision (Fig. 3). The pigs were euthanized immediately, and the peritoneal cavity was examined grossly, with particular attention to the site of the gastric incision. Long-term survival experiments For the long-term survival experiments, all endoscopes and accessories were processed by high-level disinfection, followed by gas sterilization. The oral cavity of the pig (n = 5) was cleaned and disinfected with Betadine (Purdue, Stanford, Conn.), and the pig then was draped with sterile drapes. A sterile overtube (Olympus) was introduced perorally into the stomach, and the endoscope (GIF-160; Olympus) was advanced through the overtube into the stomach. In 3 pigs, the stomach was lavaged with 1000 mL of an antibiotic solution (neomycin 40 mg and polymyxin B sulfate 2 HTU/mL in 1000 mL saline solution). A peritoneal access opening was created as described for the acute experiments by using the balloon dilation technique. The endoscope was advanced into the peritoneal cavity, which then was insufflated with air. The peritoneal cavity was examined, and biopsy specimens were obtained from the right liver lobe with an endoscopic biopsy forceps (FB-24K-1; Olympus) (Fig. 4). The endoscope was withdrawn after decompressing the peritoneal cavity by aspiration of the air, and the gastric-wall incision was closed with clips, as described above. The pigs were fed the day after the transgastric peritoneoscopy. Upper endoscopy was repeated to evaluate the healing of the gastric wall incision. All pigs survived for 14 days, at which time the animals were euthanized, and necropsies were performed, with gross and histologic examination of the peritoneal cavity; samples were obtained from the peritoneal cavity for cultures. Particular attention was given to the area of the gastric incision. VOLUME 60, NO. 1, 2004
Figure 4. Endoscopic view showing closure of gastric wall incision with clips.
RESULTS Acute experiments All gastric incisions were performed without complication. There was no injury to adjacent structures or internal organs, nor was there significant bleeding from the gastric wall puncture or the incision. Regardless of the way the gastric wall incision was performed, the insufflation of air into the peritoneal cavity was performed without incident; the abdomen was easily distended and the view of the internal organs was spectacular. The endoscope could be advanced to different parts of the peritoneal cavity by using standard endoscopic techniques such as torquing, retroflexion, and endoscope shortening. On withdrawal of the endoscope after examination of the peritoneal cavity, pronounced contraction of the gastric wall incision GASTROINTESTINAL ENDOSCOPY
115
A Kalloo, V Singh, S Jagannath, et al.
was observed such that it was sometimes difficult to locate the incision. From 4 to 6 clips usually were required to close the gastric wall incision.
Flexible transgastric peritoneoscopy: an approach to peritoneal cavity
In the second series, of longer-term experiments, needle-knife puncture of the gastric wall followed by balloon dilation was performed in 6 pigs. Dilation of the puncture up to 2 cm in diameter was easily achieved in all pigs. There was no complication as a result of puncture or dilation of the gastric wall. When the examination of the peritoneal cavity was completed, a liver biopsy specimen was successfully obtained in all pigs (Fig. 3). After obtaining the biopsy specimen, minor bleeding occurred in two pigs and was stopped by endoscopic electocoagulation. After withdrawal of the endoscope, the gastricwall incision was easily closed in all pigs by application of 4 to 6 clips. All pigs tolerated a regular diet within 24 hours after the procedure, ate heartily, and thrived over the next 14 days. There was a mean weight gain of 7.1 (2.6) pounds (confidence interval 3.87). Upper endoscopy at day 14 revealed normal-appearing gastric mucosa, with complete healing of the gastric wall incision. There were no clips found in the stomach at endoscopy. At necropsy, the liver biopsy sites were completely healed. Cultures from the peritoneal cavity were negative in 4 of 5 pigs. A culture of tissue from the peritoneal cavity of pig no. 1 grew Proteus species. On necropsy 2 weeks after the peritoneoscopy, intraperitoneal microabscesses were found in the first two pigs. To prevent contamination of the peritoneal cavity in the last 3 survival experiments, the stomachs were lavaged with the antibiotic solution before the gastric wall incision was made. No animal exhibited any sign of infection, and peritoneal cultures obtained at necropsy 2 weeks after peritoneoscopy were negative. No other post-procedure complication was found at necropsy.
Laparoscopic procedures also eliminate the risk of abdominal wall hernia, decrease the rate of local and systemic complications, and provide excellent cosmetic results.2,3 To further minimize the invasiveness of peritoneal access, the next logical step may be to completely avoid an anterior abdominal wall approach. Thus, a peroral route to the peritoneal cavity by gastric wall incision was developed by us. The aim of the present study was to determine the technical feasibility and safety of a peroral endoscopic approach to the peritoneal cavity with liver biopsy in a porcine model, including an assessment of long-term survival. The acute and survival experiments demonstrate that the gastric wall incision could be performed safely without injury to intraperitoneal organs. The incision can be made by using combinations of readily available endoscopic accessories: a needle-knife, pull-type sphincterotome, and dilation balloons. Regardless of the way the gastric wall incision was made, air could be insufflated into the peritoneal cavity without difficulty; the abdomen was easily distended with air and the view of the internal organs was excellent. Liver biopsy was performed, and the gastric wall incision was closed with clips after the examination was completed. In long-term survival experiments, transgastric peritoneoscopy was not associated with serious infection or other complications in the peritoneal cavity. The peroral transgastric approach to the peritoneal cavity should be regarded as an alternate to laparoscopy or laparotomy and not as an adjunct to standard diagnostic endoscopy. Further laboratory and clinical trials will be necessary to determine whether this approach offers any advantage compared with standard laparoscopy or laparotomy. This is the first study to show, in an animal model, that peroral transgastric endoscopic access to the peritoneal cavity is feasible and safe. The transgastric endoscopic approach may potentially have a wide range of diagnostic and therapeutic interventions.
DISCUSSION
ACKNOWLEDGMENTS
For many centuries, the approach to the peritoneal cavity has been through incisions of the anterior abdominal wall. This approach may be associated with limits on physical activity after surgery, postoperative incisional pain, large scars, and potential operative wound complications (e.g., hematoma, infection, postoperative hernia).6-8 Laparoscopic access to the peritoneal cavity has many advantages over traditional surgery.1 The small incision of the abdominal wall decreases postoperative pain and results in a shorter hospital stay and a faster return to normal physical activity.1,4
The authors would like to acknowledge the support of the Apollo Group and Olympus Optical, Ltd. Tokyo, Japan in the success of this project.
Long-term survival experiments
116
GASTROINTESTINAL ENDOSCOPY
REFERENCES 1. Beger HG, Schwarz A, Bergmann U. Progress in gastrointestinal tract surgery: the impact of gastrointestinal endoscopy. Surg Endosc 2003;17:342-50. 2. So JB, Chiong EC, Chiong E, Cheah WK, Lomanto D, Goh P, Kum CK. Laparoscopic appendectomy for perforated appendicitis. World J Surg 2002;26:1485-8. 3. Rassweiler J, Seemann O, Schulze M, Teber D, Hatzinger M, Frede T. Laparoscopic versus open radical prostatectomy: a comparative study at a single institution. J Urol 2003;169:1689-93. VOLUME 60, NO. 1, 2004
Malignant biliary obstruction: percutaneous transhepatic biliary drainage
M Wiedmann, A Dietrich, J Mo¨ssner, et al.
4. Semm K. Endoscopic intraabdominal surgery in gynecology [German]. Wien Klin Wochenschr 1983;95:353-67. 5. Kalloo AN, Kantsevoy SV, Singh VK, Magee CA, Vaughn CA, Hill SL. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity [abstract]. Gastroenterology 2000;118:A1039. 6. Killingback M, Barron P, Dent O. Elective resection and anastomosis for colorectal cancer: a prospective audit of mortality and morbidity 1976-1998. ANZ J Surg 2002;72:689-98.
7. Raffetto JD, Cheung Y, Fisher JB, Cantelmo NL, Watkins MT, Lamorte WW, et al. Incision and abdominal wall hernias in patients with aneurysm or occlusive aortic disease. J Vasc Surg 2003;37:1150-4. 8. Pessaux P, Msika S, Atalla D, Hay JM, Flamant Y. Risk factors for postoperative infectious complications in noncolorectal abdominal surgery: a multivariate analysis based on a prospective multicenter study of 4718 patients. Arch Surg 2003;138:314-24.
Combined percutaneous transhepatic biliary drainage with port implantation for management of patients with malignant biliary obstruction
jaundice caused by hepatobiliary malignancies or metastases of other tumors, such as pancreatic cancer or gastric cancer. Percutaneous drainage and bypass surgery are alternatives, although the latter is associated with a high procedure-related early mortality and has been almost completely abandoned.1 In addition, for complex hilar tumors, it remains controversial whether stent placement should be unilateral or bilateral and whether stents should be plastic or metallic.2-6 Unfortunately, bacterial colonization and encrustation frequently result in occlusion of plastic stents and, consequently, recurrent cholangitis and, thus, the necessity for frequent stent exchange in terminally ill patients.7 There have been numerous attempts to prolong patency, including the use of new materials and stent designs and the prophylactic administration of antimicrobial agents and bile salts. Despite regular stent exchange, cholangitis recurs frequently during the later stages of the disease, requiring percutaneous transhepatic biliary drainage with regular irrigation of the catheter to maintain patency.8 This study describes another approach, the use of a modified external-internal Yamakawa-type endoprosthesis in combination with a titanium port that is implanted subcutaneously.
Marcus Wiedmann, MD, Arne Dietrich, MD, Joachim Mo¨ssner, MD, Helmut Witzigmann, MD, Karel Caca, MD Background: Endoscopic biliary stent insertion has become a standard palliative treatment for patients with obstructive jaundice caused by malignancies of the hepatobiliary system or metastases of other tumors, such as pancreatic or gastric cancer. Unfortunately, bacterial colonization and encrustation frequently leads to occlusion of plastic stents and, consequently, recurrent cholangitis. Methods: An external-internal Yamakawa-type endoprosthesis was modified and combined with a titanium, subcutaneously implanted port. This technique was evaluated as a new approach to prolongation of stent patency and prevention of cholangitis. Two patients with obstructive jaundice, one with recurrent gastric carcinoma and the other with invasive gallbladder cancer, underwent treatment with this new method. Results: Effective biliary drainage was established and cholangitis was prevented in both patients for 6 and 2 months, respectively. Conclusions: A new method of percutaneous transhepatic drainage combined with port implantation was effective and safe in two patients. This technique may be a reasonable treatment option for selected patients, but further evaluation in a larger series is required to establish efficacy and safety.
Since its introduction in the late 1970s, endoscopic biliary stent insertion has become a standard palliative treatment for patients with obstructive Received September 17, 2003. For revision December 8, 2003. Accepted January 20, 2004. Current affiliations: Department of Internal Medicine II, Department of Surgery II, University of Leipzig, Leipzig, Germany. Reprint requests: Karel Caca, MD, Department of Medicine II, University of Leipzig, Philipp-Rosenthal Str. 27, 04103, Leipzig, Germany. Copyright Ó 2004 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(04)01308-2 VOLUME 60, NO. 1, 2004
PATIENTS AND METHODS Case reports Case 1. A 78-year-old woman was hospitalized because of the gradual onset of jaundice without pain. One year earlier, she underwent gastrectomy with esophagojejunostomy for gastric carcinoma (pT2 N1 M0) followed by 6 cycles of adjuvant chemotherapy (5-fluorouracil and folic acid). CT 1 week before admission disclosed peripheral and central intrahepatic cholestasis because of local tumor recurrence in the liver hilum and along the hepatoduodenal ligament. In addition, there was evidence of a widespread intraperitoneal tumor. Examination was unremarkable except for scleral and skin icterus and an enlarged liver. The Karnovsky index was 70%. Pertinent initial laboratory test results were the following: alanine aminotransferase, 2.0 lkat/L (normal: 0.17-0.6 lkat/L); aspartate aminotransferase, 2.27 lkat/L (0.17-0.6 lkat/L); alkaline phosphatase, 7.93 lkat/L (0.58-1.74 lkat/L); GASTROINTESTINAL ENDOSCOPY
117
Laparoscopic access to the peritoneal cavity has many advantages over traditional open surgery.1 Smaller incisions of the abdominal wall reduce postoperative pain and the risk of ventral herniation, decrease local and systemic complications, and provide an excellent cosmetic result compared with open surgery.2,3 Patients also have less postoperative ileus and recover quickly after laparoscopic procedures.1,4 Theoretically, the peroral transgastric Received September 30, 2003. For revision December 22, 2003. Accepted February 13, 2004. Current affiliations: Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland. Vikesh K. Singh’s research is supported by a research fellowship from the Four Schools Physician-Scientist Program in Internal Medicine. Reprint requests: Anthony N. Kalloo, MD, Johns Hopkins Hospital, Division of Gastroenterology, 1830 East Monument St., Rm. 422, Baltimore, MD 21205. Copyright Ó 2004 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(04)01309-4 114
GASTROINTESTINAL ENDOSCOPY
Figure 1. Endoscopic view of gastric wall incision being made with sphincterotome.
approach to the peritoneal cavity may further reduce the invasiveness of surgery by completely eliminating anterior abdominal wall incisions.5 A peroral endoscopic approach to the peritoneal cavity via a gastric-wall incision was developed and tested in a porcine model. MATERIALS AND METHODS Transgastric peritoneoscopy was evaluated in 50-kg pigs (Sus scrofus domesticus). The aim of the study was to determine the technical feasibility and the safety of an endoscopic approach to the peritoneal cavity, with liver biopsy, in a porcine model. All procedures were performed with the animal under general anesthesia by endotracheal intubation. Survival experiments were performed after a series of acute experiments. Acute experiments A forward-viewing endoscope (GIF-160; Olympus America Corp., Melville, N.Y.) was inserted perorally into the stomach. Access to the peritoneal cavity was created as follows: a needle-knife (KD-10Q-1.A; Olympus) was used to create an initial 2-mm incision in the anterior wall of the stomach (Fig. 1). A flexible-tip guidewire (Jagwire 5658; Microvasive Endoscopy, Boston Scientific Corp., Natick, Mass.) then was advanced through the incision into the peritoneal cavity under fluoroscopic guidance. The incision was enlarged, either by extending it with a pull-type sphincterotome (210Q-0720; Olympus) to 20 mm (n = 6) or by dilation with an 8-mm dilation balloon (CRE esophageal balloon 5838; Microvasive) inserted over the guidewire (n = 6). The endoscope then was advanced into the peritoneal cavity, which was insufflated with air to lift the anterior abdominal wall and to expose the intra-abdominal viscera. The peritoneal cavity then was examined endoscopically (Fig. 2), after which the air was aspirated and the endoscope was withdrawn into the stomach. The VOLUME 60, NO. 1, 2004
Flexible transgastric peritoneoscopy: an approach to peritoneal cavity
Figure 2. Endoscopic view of peritoneal cavity, showing small bowel.
A Kalloo, V Singh, S Jagannath, et al.
Figure 3. Endoscopic view of peroral transgastric liver biopsy specimen.
gastric-wall incision was closed with jumbo clips (Endoclips; Olympus Optical Co., Ltd., Tokyo, Japan). Closure was by applying clips first to both ends of the incision and then sequentially toward the center of the incision (Fig. 3). The pigs were euthanized immediately, and the peritoneal cavity was examined grossly, with particular attention to the site of the gastric incision. Long-term survival experiments For the long-term survival experiments, all endoscopes and accessories were processed by high-level disinfection, followed by gas sterilization. The oral cavity of the pig (n = 5) was cleaned and disinfected with Betadine (Purdue, Stanford, Conn.), and the pig then was draped with sterile drapes. A sterile overtube (Olympus) was introduced perorally into the stomach, and the endoscope (GIF-160; Olympus) was advanced through the overtube into the stomach. In 3 pigs, the stomach was lavaged with 1000 mL of an antibiotic solution (neomycin 40 mg and polymyxin B sulfate 2 HTU/mL in 1000 mL saline solution). A peritoneal access opening was created as described for the acute experiments by using the balloon dilation technique. The endoscope was advanced into the peritoneal cavity, which then was insufflated with air. The peritoneal cavity was examined, and biopsy specimens were obtained from the right liver lobe with an endoscopic biopsy forceps (FB-24K-1; Olympus) (Fig. 4). The endoscope was withdrawn after decompressing the peritoneal cavity by aspiration of the air, and the gastric-wall incision was closed with clips, as described above. The pigs were fed the day after the transgastric peritoneoscopy. Upper endoscopy was repeated to evaluate the healing of the gastric wall incision. All pigs survived for 14 days, at which time the animals were euthanized, and necropsies were performed, with gross and histologic examination of the peritoneal cavity; samples were obtained from the peritoneal cavity for cultures. Particular attention was given to the area of the gastric incision. VOLUME 60, NO. 1, 2004
Figure 4. Endoscopic view showing closure of gastric wall incision with clips.
RESULTS Acute experiments All gastric incisions were performed without complication. There was no injury to adjacent structures or internal organs, nor was there significant bleeding from the gastric wall puncture or the incision. Regardless of the way the gastric wall incision was performed, the insufflation of air into the peritoneal cavity was performed without incident; the abdomen was easily distended and the view of the internal organs was spectacular. The endoscope could be advanced to different parts of the peritoneal cavity by using standard endoscopic techniques such as torquing, retroflexion, and endoscope shortening. On withdrawal of the endoscope after examination of the peritoneal cavity, pronounced contraction of the gastric wall incision GASTROINTESTINAL ENDOSCOPY
115
A Kalloo, V Singh, S Jagannath, et al.
was observed such that it was sometimes difficult to locate the incision. From 4 to 6 clips usually were required to close the gastric wall incision.
Flexible transgastric peritoneoscopy: an approach to peritoneal cavity
In the second series, of longer-term experiments, needle-knife puncture of the gastric wall followed by balloon dilation was performed in 6 pigs. Dilation of the puncture up to 2 cm in diameter was easily achieved in all pigs. There was no complication as a result of puncture or dilation of the gastric wall. When the examination of the peritoneal cavity was completed, a liver biopsy specimen was successfully obtained in all pigs (Fig. 3). After obtaining the biopsy specimen, minor bleeding occurred in two pigs and was stopped by endoscopic electocoagulation. After withdrawal of the endoscope, the gastricwall incision was easily closed in all pigs by application of 4 to 6 clips. All pigs tolerated a regular diet within 24 hours after the procedure, ate heartily, and thrived over the next 14 days. There was a mean weight gain of 7.1 (2.6) pounds (confidence interval 3.87). Upper endoscopy at day 14 revealed normal-appearing gastric mucosa, with complete healing of the gastric wall incision. There were no clips found in the stomach at endoscopy. At necropsy, the liver biopsy sites were completely healed. Cultures from the peritoneal cavity were negative in 4 of 5 pigs. A culture of tissue from the peritoneal cavity of pig no. 1 grew Proteus species. On necropsy 2 weeks after the peritoneoscopy, intraperitoneal microabscesses were found in the first two pigs. To prevent contamination of the peritoneal cavity in the last 3 survival experiments, the stomachs were lavaged with the antibiotic solution before the gastric wall incision was made. No animal exhibited any sign of infection, and peritoneal cultures obtained at necropsy 2 weeks after peritoneoscopy were negative. No other post-procedure complication was found at necropsy.
Laparoscopic procedures also eliminate the risk of abdominal wall hernia, decrease the rate of local and systemic complications, and provide excellent cosmetic results.2,3 To further minimize the invasiveness of peritoneal access, the next logical step may be to completely avoid an anterior abdominal wall approach. Thus, a peroral route to the peritoneal cavity by gastric wall incision was developed by us. The aim of the present study was to determine the technical feasibility and safety of a peroral endoscopic approach to the peritoneal cavity with liver biopsy in a porcine model, including an assessment of long-term survival. The acute and survival experiments demonstrate that the gastric wall incision could be performed safely without injury to intraperitoneal organs. The incision can be made by using combinations of readily available endoscopic accessories: a needle-knife, pull-type sphincterotome, and dilation balloons. Regardless of the way the gastric wall incision was made, air could be insufflated into the peritoneal cavity without difficulty; the abdomen was easily distended with air and the view of the internal organs was excellent. Liver biopsy was performed, and the gastric wall incision was closed with clips after the examination was completed. In long-term survival experiments, transgastric peritoneoscopy was not associated with serious infection or other complications in the peritoneal cavity. The peroral transgastric approach to the peritoneal cavity should be regarded as an alternate to laparoscopy or laparotomy and not as an adjunct to standard diagnostic endoscopy. Further laboratory and clinical trials will be necessary to determine whether this approach offers any advantage compared with standard laparoscopy or laparotomy. This is the first study to show, in an animal model, that peroral transgastric endoscopic access to the peritoneal cavity is feasible and safe. The transgastric endoscopic approach may potentially have a wide range of diagnostic and therapeutic interventions.
DISCUSSION
ACKNOWLEDGMENTS
For many centuries, the approach to the peritoneal cavity has been through incisions of the anterior abdominal wall. This approach may be associated with limits on physical activity after surgery, postoperative incisional pain, large scars, and potential operative wound complications (e.g., hematoma, infection, postoperative hernia).6-8 Laparoscopic access to the peritoneal cavity has many advantages over traditional surgery.1 The small incision of the abdominal wall decreases postoperative pain and results in a shorter hospital stay and a faster return to normal physical activity.1,4
The authors would like to acknowledge the support of the Apollo Group and Olympus Optical, Ltd. Tokyo, Japan in the success of this project.
Long-term survival experiments
116
GASTROINTESTINAL ENDOSCOPY
REFERENCES 1. Beger HG, Schwarz A, Bergmann U. Progress in gastrointestinal tract surgery: the impact of gastrointestinal endoscopy. Surg Endosc 2003;17:342-50. 2. So JB, Chiong EC, Chiong E, Cheah WK, Lomanto D, Goh P, Kum CK. Laparoscopic appendectomy for perforated appendicitis. World J Surg 2002;26:1485-8. 3. Rassweiler J, Seemann O, Schulze M, Teber D, Hatzinger M, Frede T. Laparoscopic versus open radical prostatectomy: a comparative study at a single institution. J Urol 2003;169:1689-93. VOLUME 60, NO. 1, 2004
Malignant biliary obstruction: percutaneous transhepatic biliary drainage
M Wiedmann, A Dietrich, J Mo¨ssner, et al.
4. Semm K. Endoscopic intraabdominal surgery in gynecology [German]. Wien Klin Wochenschr 1983;95:353-67. 5. Kalloo AN, Kantsevoy SV, Singh VK, Magee CA, Vaughn CA, Hill SL. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity [abstract]. Gastroenterology 2000;118:A1039. 6. Killingback M, Barron P, Dent O. Elective resection and anastomosis for colorectal cancer: a prospective audit of mortality and morbidity 1976-1998. ANZ J Surg 2002;72:689-98.
7. Raffetto JD, Cheung Y, Fisher JB, Cantelmo NL, Watkins MT, Lamorte WW, et al. Incision and abdominal wall hernias in patients with aneurysm or occlusive aortic disease. J Vasc Surg 2003;37:1150-4. 8. Pessaux P, Msika S, Atalla D, Hay JM, Flamant Y. Risk factors for postoperative infectious complications in noncolorectal abdominal surgery: a multivariate analysis based on a prospective multicenter study of 4718 patients. Arch Surg 2003;138:314-24.
Combined percutaneous transhepatic biliary drainage with port implantation for management of patients with malignant biliary obstruction
jaundice caused by hepatobiliary malignancies or metastases of other tumors, such as pancreatic cancer or gastric cancer. Percutaneous drainage and bypass surgery are alternatives, although the latter is associated with a high procedure-related early mortality and has been almost completely abandoned.1 In addition, for complex hilar tumors, it remains controversial whether stent placement should be unilateral or bilateral and whether stents should be plastic or metallic.2-6 Unfortunately, bacterial colonization and encrustation frequently result in occlusion of plastic stents and, consequently, recurrent cholangitis and, thus, the necessity for frequent stent exchange in terminally ill patients.7 There have been numerous attempts to prolong patency, including the use of new materials and stent designs and the prophylactic administration of antimicrobial agents and bile salts. Despite regular stent exchange, cholangitis recurs frequently during the later stages of the disease, requiring percutaneous transhepatic biliary drainage with regular irrigation of the catheter to maintain patency.8 This study describes another approach, the use of a modified external-internal Yamakawa-type endoprosthesis in combination with a titanium port that is implanted subcutaneously.
Marcus Wiedmann, MD, Arne Dietrich, MD, Joachim Mo¨ssner, MD, Helmut Witzigmann, MD, Karel Caca, MD Background: Endoscopic biliary stent insertion has become a standard palliative treatment for patients with obstructive jaundice caused by malignancies of the hepatobiliary system or metastases of other tumors, such as pancreatic or gastric cancer. Unfortunately, bacterial colonization and encrustation frequently leads to occlusion of plastic stents and, consequently, recurrent cholangitis. Methods: An external-internal Yamakawa-type endoprosthesis was modified and combined with a titanium, subcutaneously implanted port. This technique was evaluated as a new approach to prolongation of stent patency and prevention of cholangitis. Two patients with obstructive jaundice, one with recurrent gastric carcinoma and the other with invasive gallbladder cancer, underwent treatment with this new method. Results: Effective biliary drainage was established and cholangitis was prevented in both patients for 6 and 2 months, respectively. Conclusions: A new method of percutaneous transhepatic drainage combined with port implantation was effective and safe in two patients. This technique may be a reasonable treatment option for selected patients, but further evaluation in a larger series is required to establish efficacy and safety.
Since its introduction in the late 1970s, endoscopic biliary stent insertion has become a standard palliative treatment for patients with obstructive Received September 17, 2003. For revision December 8, 2003. Accepted January 20, 2004. Current affiliations: Department of Internal Medicine II, Department of Surgery II, University of Leipzig, Leipzig, Germany. Reprint requests: Karel Caca, MD, Department of Medicine II, University of Leipzig, Philipp-Rosenthal Str. 27, 04103, Leipzig, Germany. Copyright Ó 2004 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(04)01308-2 VOLUME 60, NO. 1, 2004
PATIENTS AND METHODS Case reports Case 1. A 78-year-old woman was hospitalized because of the gradual onset of jaundice without pain. One year earlier, she underwent gastrectomy with esophagojejunostomy for gastric carcinoma (pT2 N1 M0) followed by 6 cycles of adjuvant chemotherapy (5-fluorouracil and folic acid). CT 1 week before admission disclosed peripheral and central intrahepatic cholestasis because of local tumor recurrence in the liver hilum and along the hepatoduodenal ligament. In addition, there was evidence of a widespread intraperitoneal tumor. Examination was unremarkable except for scleral and skin icterus and an enlarged liver. The Karnovsky index was 70%. Pertinent initial laboratory test results were the following: alanine aminotransferase, 2.0 lkat/L (normal: 0.17-0.6 lkat/L); aspartate aminotransferase, 2.27 lkat/L (0.17-0.6 lkat/L); alkaline phosphatase, 7.93 lkat/L (0.58-1.74 lkat/L); GASTROINTESTINAL ENDOSCOPY
117