LAPAROSCOPY

ENDOSCOPIC ULTRASOUND/LAPAROSCOPY 533 CLINICAL SIGNIFICANCE OF ENDOSCOPIC ULTRASONOGRAPHY (EUS) IN PREOPERATIVE STAGING OF RECTAL CANCER.

535 MECHANICAL LAPAROSCOPIC CHOLEDOCHODUODENOSTOMY

N.Yoshikawa, Y.Akita, KKonishi, KMitamura, A.Tsunoda and M.Kusano. Second Department of Internal Medicine and Second Department of Surgery, Showa University School of Medicine, Tokyo, Japan Aim: To evaluate clinical significance of EUS in staging of rectal cancer before operation. Methods: EUS examination was performed for 32 patients with rectal cancer (mean age of 63 years from 40 to 85; 24 males and 8 females) before surgical treatment. Depth of invasion and regional lymph node metastasis of rectal cancers were examined by EUS. The accuracy of EUS findings was evaluated on the basis of histological findings of resected specimens after operation. Stages of tumors were determined using TNM classification. Results: The rectal tumors consisted of21 advanced cancers (3 elevated type, 17 ulcerated type, 1 undifferentiated type) and 11 early cancers. The mean size of the tumors was 34.5 mm. The histopathological examination revealed 23 well, 6 moderately and 2 poorly differentiated adenocarcinoma and one unclassified carcinoma due to preoperative radiation. Stages after resection were 9 for la, 15 for Ib, 7 for II, 0 for III and 1 for IV. The accuracy of EUS examination in detecting depth of invasion was 84.3% (27 out of 32 cancers; 6/11 for Tl, 21/21 for T2, 0 for T3 or T4). We assessed the depth of submucosal invasion in early cancer as muscularis propria invasion in all of 5 patients. In addition we found the accuracy of 70.8% (17/24) for NO and 50.0% (4/8) forNI in N stage. Low accuracy was found in N staging because we could not assess lymph node metastasis in patients having tumors with ulcerated or depressed lesion (59.1%, 13/22; 17 advanced and 5 early cancers). Conclusion: The accuracy in assessment of T staging of rectal cancer by EUS examination was very high, however, EUS examination was not so accurate for regional lymph node metastasis of tumors with ulcerated or depressed lesion.

J.B.Algayer, KHashiba, H.A.Brasil, A.F.Silva, W.R.Freitas Jr., R. Kikawa, D.Birolini, S.Paulo University - Department of Surgery - General Surgery. S.Paulo Brazil The authors report two elderly patients with residual choledocholithiasis who underwent videolaparoscopic side-to-side choledochoduodenostomy with mechanical suture. The first presented signs ofbiliary obstruction. The common bile duct (CBD) was 2.9cm in diameter. The second, who had 2.0cn had a CBD 2,Ocm-diameter CBD, had undergone unsucessful endoscopic treatment of choledocholithiasis. In both cases two thirds of the anastomosis was performed by laparoscopic cutting linear stapler. The parts of choledochotomy and of duodenotomy that remained open were closed by interrupted manual suture with absorbable stitch. The first patient presented a duodenal fistula in the postoperative course which solved with clinical treatment, the second had no complications. The hospital stay was thirty days for the first case and five days for the second. At follow-up two months after operation, both patients were assymptomatic. They had normal hepatobiliary tests and the endoscopy showed wide and permeable anastomoses. In conclusion, videolaparoscopic side-to-side choledochoduodenostomy with mechanical suture is a reliable alternative technique, mainly for elderly patients with distal CBD obstruction.

*534 ENDOSCOPIC ULTRASOUND (EUS) DIRECTED THERAPY IMPROVES SURVIVAL OF PATIENTS WITH LOCOREGIONALLY ADVANCED (LRA) ESOPHAGEAL CANCER

*536 EVALUATION OF BLEEDING COMPLICATIONS IN CIRRHOTIC PATIENTS UNDERGOING DIAGNOSTIC LAPAROSCOPY USING A 2MM LAPAROSCOPE

G Zuccaro, TW Rice, JJ Vargo, JP Ciezki, JR Goldblum, LA Rybicki, DJ Adelstein. The Cleveland Clinic Foundation, Cleveland, Ohio Purpose To determine: 1) if preoperative EUS improves survival in patients (pts) with esophageal cancer, 2) which pts might receive the greatest survival benefit and 3) what factors account for the survival benefit. Methods: All pts undergoing esophagectomy over a nine year period were staged preoperatively with physical exam, blood work, EGD, CXR, and CT scan. Kaplan Meier survival(KMS) estimates were calculated for pts with LRA disease (T3 and/or Nl), and for those with tumor limited to the wall (TL) (TI-2, NO). Survival for patients where EUS was performed in preoperative staging was compared to those where EUS was not performed. Predictors of improved survival were identified by multivariable Cox proportional hazards regression. Results: Of 449 surgical pts, 344 (77%) had LRA disease, and 105 (23%) had TL disease. 199 (58%) ofLRA and 59 (56%) of TL pts had EUS. For all groups, pts were not different in age, cell type/differentiation, or 30 day post operative mortality. The KMS estimates:

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In TL disease, EUS did not affect survival. However, in LRA disease, pts undergoing EUS had improved survival. Multivariable analysis identifies preoperative chemoradiotherapy (CRT) and negative Burgical margin5 (NSM) a5 prediciors of improved survival. Pis who had EUS were more likely to receive CRT (p<.OOI) and have NSM (p<.OOI) compared to the non-EUS group. Conclusions: Preoperative EUS is associated with improved survival in LRA esophageal cancer. EUS most accurately identifies those pts with LRA disease, who will benefit from preoperative CRT, resulting in a greater likelihood ofNSM. These data strongly support the use of EUS in the staging of all patients with esophageal cancer.

VOLUME 47, NO.4, 1998

SUTURE

FOR

S. Badalamenti, L.J.Jeffers, E. Molina, MJ Rodriguez, P.Rassam, P.Mendez, R.Khan, ER. Schiff, Ctrfor Liver Dis. UnivofMia Sch ofMed, Miami, Fl. and VA Medical Center Miami, Fl. Background: Patients with cirrhosis and portal hypertention are more at risk for bleeding during diagnostic laparoscopy either from the trocar site or at the biopsy site in the liver. Aim: The purpose of the study was to evaluate bleeding complications from the 5 mm trocar site during laparoscopy or any prolong bleeding from the biopsy site in the liver in patients with cirrhosis. Patients and methods: Retrospectively we reviewed the records of 50 patients with cirrhosis that underwent diagnostic laparoscopy with biopsy of the liver, from January 96 to October 97. The procedures were done by the same group of physicians. The study population consisted of 29 males /21 females with a mean age of 53: the underlying risk factors were: HCV in 29 patients (58%), HBV in 4 patients (8%), Cryptogenic in 5 patients (10%) and HCC in 12 patients (24%). The procedure was done in the laparoscopy suite under local anaesthetic, conscious sedation and pneumoperitoneum was induced with nitrous oxide. A 5 mm laparoscope with a 30 degree angle was used (Storz, Germany) and a 2 mm laparoscope with 0 degree optic lens (Auto Suture Company, Norwalk, CT) was utilized to observe the 5mm trocar site. Liver biopsy was done with a 16 gauge tru cut automatic needle (Mannan Medical, North Brook, IL.) Results: Bleeding from the 5 mm trocar site was observed in four patients (8%) 2 males / 2 females: one male with underlying HB, one male with HCV and 2 females both with HCV. Three patients required the use of one avitene plug, and one patient required the use of two avitene plugs. None of the patients showed prolonged bleeding from the biopsy site. Bleeding at the biopsy site was well controlled in a standard fashion by applying pressure with a probe. Blood transfusions were not required. Conclusion: The study population of 8% had bleeding complications from the trocar site, none of the patients had complications from the biopsy site. The 2 mm laparoscope was valuable in identifying the bleeding at the trocar site. It appears that laparoscopy can be safely performed in patients with cirrhosis and the 2mm laparoscope is useful to visualize the trocar site to rule out bleeding prior to termination of the procedure. AlBO. complication~ can be detected early and managed immediately without any further interventions.

GASTROINTESTINAL ENDOSCOPY AB157

LAPAROSCOPY *537 ENDOSCOPIC·LAPAROSCOPIC ESOPHAGEAL MYOTOMY FOR ACHALASIA: DESCRIPTION OF A NEW TECHNIQUE. Patrick Brady. Alex Rosemurgy, Zahid Baig, and Blaine Nease. Departments of Medicine and Surgery, University of South Florida, Tampa, Florida. Esophageal myotomy offers the most definitive treatment of achalasia. Recently, thoracoscopic and laparoscopic approaches to esophageal myotomy have been developed. However, lack of tactile perception renders these procedures more difficult than open surgery and may lead to incomplete myotomy or perforation. This study was done to determine if endoscopic guidance could overcome these difficulties. Methods: 38 consecutive patients undergoing thoracoscopic (n = 11) or laparoscopic (n = 27) myotomy were studied. Endoscopic transillumination was used to identify the location and length of the esophageal high pressure zone (HPZ). Myotomy was performed using a hook cautery, and obliteration of the HPZ was documented endoscopically to confirm completeness ofthe myotomy. A leak test was done by instilling water intraabdominally covering the myotomy site, followed by endoscopic insufflation of air. Perforation was manifested by bubbling from the leak site. Endoscopy was terminated when both surgeon and endoscopist were satisfied with the results. Results: The myotomy was easily recognized by the endoscopist as a translucent, linear esophageal wall defect associated with relaxation of the HPZ. Modifications in the length of the myotomy were frequently made on the basis of endoscopic assessment. Overall patient outcome was excellent in 81% (no dysphagia), good in 8%, fair in 3%, and poor in 8% (daily dysphagia). 3 perforations occurred, 2 diagnosed by endoscopic leak testing. The thoracoscopic group had a longer hospital stay than the laparoscopic group, 5.8 vs 2.4 days (p<0.001). Operation time decreased from 182 min. in 1992 to 98 min in 1996. Conclusions: Intraoperative endoscopy plays a critical role in laparoscopic myotomy. It allows immediate localization of the HPZ, intraoperative diagnosis of small perforations, and determination of the completeness of myotomy. It provides instantaneous feedback for the surgeon shortening operative time and decreasing complications.

AB158 GASTROINTESTINAL ENDOSCOPY

*538 TREATMENT OF GASTRO·DUODENAL ULCER PERFORATION BY LAPAROSCOPY AND GASTROSCOPY USING AN OMENTAL PLUG. N.Halkic, J-M.Calmes, M.Gillet, P.Pescatore*. Departments of Surgery and Gastroenterology*, C.H.U.V. University Hospital Lausanne, Switzerland. Open surgical therapy by oversewing or closure with an omental patch and peritoneal lavage is admitted as a "gold standard" of gastro-duodenal ulcer perforation. A laparoscopic approach may reduce hospital stay and need for analgesics. Immediate gastroduodenal endoscopy allows to put down the diag. nosis, to be very acute on ulcer topography, to rule out neoplasia, to secure perforation closure and to perform Helicobacter pylori (HP) diagnosis. Aims: To evaluate the feasability of a new combined laparoscopic - gastroscopic technique of perforated ulcer closure, using an omental plug. Methods: Prospective study between 04.1997 and 11.1997 of all patients treated with this technique. The omentum was plugged into the ulcer perforation by laparoscopy and grabbed through with a gastroscopic forceps. Stitching of the omentum and peritoneal lavage were done secondarily. Gastroscopic biopsies were taken for histology and rapid HP diagnosis. HP infection was treated by omeprazole, metronidazole and clarithromycine during 10 days; omeprazole was continued for 1 month. Results: Five patients (3 men, 2 women), mean age 43 years (23 . 71 years) were included in the study. There were 4 duodenal and 1 gastric ulcer perforations (all anterior). The mean diameter of the ulcer perforations was 0.8 em (0.5 - 1.5 em). The mean operative time was 72 min (45 - 90 min). Gastroscopy allowed in four cases to diagnose HP infection. No conversions were necessary. There was no surgical morbidity, in particular no leak. The mean hospital stay was 5.5 days. There was no mortality. All patients underwent control endoscopy 1 month after perforation closure with confirmation of ulcer healing. Conclusions: A combined laparoscopic-gastroscopic approach with omental plug repair is a safe endoscopic technique for treatment of gastro-duodenal ulcer perforation. Our experience suggests that this technique associated with immediate HP therapy allows optimal therapy of the perforation and the ulcer disease. The limits of this type of intervention depend on the size, the topography and pathogeny (Helicobacter vs. tumor) of the ulcer. Prospective studies comparing simple laparoscopic patching technique to the omental plug technique are warranted.

VOLUME 47, NO.4, 1998