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The role of diagnostic laparoscopy in the diagnosis of cirrhosis
LAPAROSCOPY ?545
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ARE KNOTS TIED AT LAPAROSCOPY AS SECURE AS HAND TIED KNOTS?. S S Kadirkamanathan, J G Laufer, C C Hepworth, J C Shelton, C P Swain. The Royal London Hospital, London, UK. Tying knots at laparoscopy is an essential step in surgical operations such as Nissen fundoplication. This study compares the strength and security of hand-tied knots with knots tied at laparoscopic surgery. Knots commonly used at open and laparoscopic surgery (3 and 4 halfhitches(HH), surgical knots & Roeder loop) were tested. All knots were tied on fresh post-mortem human stomachs and knot types verified before they were drawn fight. Intra-corporeal knot tying at laparoscopy was mimicked using a laparoscopic simulator and laparoscopic needle. The force needed to undo or break the knot was measured using an Instron Mechanical Testing machine. Ten tests were carried out for each type of knot. Nylon, polydiaxone, p01yglactin 910 and braided polyamide were the materials used to test the knots. Knots were tested at two different speeds (36 & 360 mm/min) to simulate strains experienced during retching or vomiting and normal physiological activities. The surface of the suture materials were studied using a scanning electron microscope. RESULTS Four HH and surgical knots tied at laparoscopy using nylon and polydiaxone were significantly weaker than the hand tied knots[p<0.05]. However, no difference was noted when vicryl or polyamide was used to tie knots by hand and at laparoscopy [p=ns]. The RSeder loop, commonly used slip knot at laparoscopic surgery, proved to be relatively weak irrespective of the suture material when compared to 3 and 4 HH [p<0.01]. CONCLUSION Slip knots are weak and should be used with care when tying important structures. Knots tied at laparoscopy using monofilament materials such as nylon and polyamide were weak and are not recommended. Conversely, knots tied using braided suture materials were strong and secure and were as good as the hand tied knots and are recommended for laparoscopic surgery.
THE ROLE OF DIAGNOSTIC LAPAROSCOPY IN THE DIAGNOSIS OF CIRRHOSIS. J. Poniachik S. Munnangi, S. Jonnalagadda, M. Bartholomew, T. Banks, T. Comell, D.E. Bernstein, K.R. Reddy, E.R. Schiff, L.J. Jeffers, Division of Hepatulogy, University of Miami School of Medicine and VA Medical Center, Miami, FL. A definitive diagnosis of cirrhosis is important in prognosis and management of patients (pts). The diagnosis of cirrhosis can be made by histological or gross appearance of the liver. Sampling error with percutaneous liver biopsy is greatest in patients (pts) with cirrhosis. Aim: To determine the discordance between the macroscopic and histologic appearances of the liver in pts with chronic liver disease. Patients and Methods: Paired laparoscopy and histology reports of 434 pts were retrospectively reviewed between 1992-1994. (M:F 1.3:1, mean age 48 + 14 yrs). Etiology: 52% hepatitis C, 8% hepatitis B, 8% fatty liver, 4% PBC, 3% autoimmune, 25% miscellaneous (cancer pts were excluded). The laparoscopic diagnosis of cirrhosis was defined as the presence of distinct nodules on the surface of the liver and hardness on palpation. Histological diagnosis of cirrhosis was based on the presence of at least one regenerative nodule with perinodular fibrosis or with fibrosis surrounding the greater part of tissue (hematoxylin and eosin and trichrome stains were prepared). Results: 169 pts had laparoscopic evidence of cirrhosis, of these 115 were confirmed by histology, this represents a 32% sampling error (if the diagnosis of cirrhosis by laparoscopy is considered to be the standard). Thirty of the 169 pts had macronodular cirrhosis by laparoscopy, in 8 of these 30, cirrhosis was not confirmed by biopsy (sampling error 26%). The length of the biopsy sample did not differ between the cirrhotics who showed concordance between laparoscopy an histology and those that did not (14 + 6mm vs 14 + 5mm). 265 pts did not have macroscopic evidence of cirrhosis, but only two had histologic evidence of cirrhosis. Conclusions: 1) There was a 32% histological sampling error among pts documented to have cirrhosis by laparoscopy. 2) The results of this study demonstrate the value of laparoscopy in the documentation of cirrhosis, often missed on liver biopsy.
546
t548
LAPAROSCOPY: ITS USE IN DIAGNOSTICALLY CHALLENGING CASES OF PEDIATRIC LIVER DISEASE. P. Kazlow, A. DeFelice, S. Narwal, D. Kaluski and S. Stylianos, Department of Pediatrics. Columbia University, New York, NY Laparoscopy is now being performed on infants and children for a wide variety of indications, including abdominal trauma, chronic abdominal pain and possible appendicitis, We report three children with chronic liver disease who presented diagnostic challenges. The laparoscope proved to be an invaluable tool, both diagnostically and therapeutically, in these instances. Patient #1 was a 10 year old female with multiple auto-immune phenomena, including Hashimoto's thyroiditis, idiopathic thrombocytopenic purpura and liver disease. The platelet abnormalities led to a prolonged bleeding time ( > 15 minutes) and precluded a routine percutaneous liver biopsy. A percutaneeus liver biopsywas performed under laparoscopic guidance. Hemostasis was established via the laparoscope by applying direct pressure to the biopsy site. There was no significant blood loss. Auto-immune hepatitis was diagnosed. Patient #2 was a 6 year old male suffering from chronic liver disease of unknown etiology, despite an extensive work-up, which included 2 previous percutaneous biopsies of the right hepatic lobe. Under laparoscopic vision, a disparity was noted between the left and right hepatic lobes. Biopsy of the left lobe was diagnostic for congenital hepatic fibrosis. Patient #3 was a 20 year old male suffering from severe combined immune deficiency. Ultrasound of the liver revealed numerous liver nodules. Under laparoscopic guidance, direct biopsy of these nodules revealed the presence of sclerosing cholangitis. There were no complications in any of these cases. Although pereutaneous liver biopsy remains the procedure of choice in most cases requiring a tissue diagnosis, there are problems of sampling error, and in some cases, hemostasis may be difficult to establish. The laparoscope provides a safe, effective alternative to open liver biopsy in diagnosticallychallenging cases, particularly when percutaneous liver biopsy is relatively contraindicated.
THE ROLE OF ERCP IN THE MANAGEMENT OF BILIARY COMPLICATIONS AFTER LAPAROSCOPIC CHOLECYSTECTOMY (LC). F. Prat, G. Pelletier, T. Ponchon, J. Boyer, B. Person, LF. Bretagne. Bic~tre, Lyon, Angers and Rennes, France.
432
GASTROINTESTINAL ENDOSCOPY
The aim of this multicenter retrospective study was to assess the interest and efficacy of biliary endoscopy in the diagnosis and treatment of biliary complications following LC. Seventy-two patients were referred to our 4 centers between 1990 and 1994 for suspected biliary complications. There were 17 men and 55 women (mean age 57+18.9 years). The mean timespan between LC and ERCP was 105+21 days. We excluded common bile duct (CBD) stones deliberately left in place at the time of LC. 6 patients (8.3%) had undergone an attempt at surgical repair before ERCP. Four different types of complications were diagnosed at ERCP: 1) 31 patients had residual stones (25 cases) or cystic duct clip migration (6 cases) into the CBD revealed 121+66 days after LC. All of them were successfully treated with endoscopic sphincterotomy (ES). 2 mild pancreatitis occurred after ES. 2) 8 complete transecti0ns or occlusions of the CBD were diagnosed 35+20 days after LC. All of them were operated on. 3) CBD partial strictures were observed in 14 patients and treated as follows: hepaticojejunostomy = 5; transhepatic stenting = 1; endoscopic stenting = 6 (1 patient developed a severe sepsis after partial drainage of a complex hilar stenosis and died 3 days after stenting; another patient died 3 months after stenting without biliary complications; 4 patients are asymptomatic -stent in place: 2; stent removed: 2, with 1 and 7 months of follow-up-). 4) 19 patients had bile leakage (cystic duct = 16, gallbladder bed = 3), revealed 13+__2days after LC. ES was performed in 16 patients and clearly induced rapid recovery in 10; ES failed to improve 3 other patients; the influence of ES on the outcome was unclear in 3 patients. One patient developed severe hemorrhage after ES, and was treated medically. Three patients were treated conservatively. We conclude that ERCP is indicated when a biliary complication is suspected after LC. ES appeared to be effective for the treatment of retained stones, clip migration and bile leakage. Long term follow-up is needed to assess the efficacy of endoscopic stenting in partial CBD strictures.
V O L U M E 41, NO. 4, 1995
t547
ARE KNOTS TIED AT LAPAROSCOPY AS SECURE AS HAND TIED KNOTS?. S S Kadirkamanathan, J G Laufer, C C Hepworth, J C Shelton, C P Swain. The Royal London Hospital, London, UK. Tying knots at laparoscopy is an essential step in surgical operations such as Nissen fundoplication. This study compares the strength and security of hand-tied knots with knots tied at laparoscopic surgery. Knots commonly used at open and laparoscopic surgery (3 and 4 halfhitches(HH), surgical knots & Roeder loop) were tested. All knots were tied on fresh post-mortem human stomachs and knot types verified before they were drawn fight. Intra-corporeal knot tying at laparoscopy was mimicked using a laparoscopic simulator and laparoscopic needle. The force needed to undo or break the knot was measured using an Instron Mechanical Testing machine. Ten tests were carried out for each type of knot. Nylon, polydiaxone, p01yglactin 910 and braided polyamide were the materials used to test the knots. Knots were tested at two different speeds (36 & 360 mm/min) to simulate strains experienced during retching or vomiting and normal physiological activities. The surface of the suture materials were studied using a scanning electron microscope. RESULTS Four HH and surgical knots tied at laparoscopy using nylon and polydiaxone were significantly weaker than the hand tied knots[p<0.05]. However, no difference was noted when vicryl or polyamide was used to tie knots by hand and at laparoscopy [p=ns]. The RSeder loop, commonly used slip knot at laparoscopic surgery, proved to be relatively weak irrespective of the suture material when compared to 3 and 4 HH [p<0.01]. CONCLUSION Slip knots are weak and should be used with care when tying important structures. Knots tied at laparoscopy using monofilament materials such as nylon and polyamide were weak and are not recommended. Conversely, knots tied using braided suture materials were strong and secure and were as good as the hand tied knots and are recommended for laparoscopic surgery.
THE ROLE OF DIAGNOSTIC LAPAROSCOPY IN THE DIAGNOSIS OF CIRRHOSIS. J. Poniachik S. Munnangi, S. Jonnalagadda, M. Bartholomew, T. Banks, T. Comell, D.E. Bernstein, K.R. Reddy, E.R. Schiff, L.J. Jeffers, Division of Hepatulogy, University of Miami School of Medicine and VA Medical Center, Miami, FL. A definitive diagnosis of cirrhosis is important in prognosis and management of patients (pts). The diagnosis of cirrhosis can be made by histological or gross appearance of the liver. Sampling error with percutaneous liver biopsy is greatest in patients (pts) with cirrhosis. Aim: To determine the discordance between the macroscopic and histologic appearances of the liver in pts with chronic liver disease. Patients and Methods: Paired laparoscopy and histology reports of 434 pts were retrospectively reviewed between 1992-1994. (M:F 1.3:1, mean age 48 + 14 yrs). Etiology: 52% hepatitis C, 8% hepatitis B, 8% fatty liver, 4% PBC, 3% autoimmune, 25% miscellaneous (cancer pts were excluded). The laparoscopic diagnosis of cirrhosis was defined as the presence of distinct nodules on the surface of the liver and hardness on palpation. Histological diagnosis of cirrhosis was based on the presence of at least one regenerative nodule with perinodular fibrosis or with fibrosis surrounding the greater part of tissue (hematoxylin and eosin and trichrome stains were prepared). Results: 169 pts had laparoscopic evidence of cirrhosis, of these 115 were confirmed by histology, this represents a 32% sampling error (if the diagnosis of cirrhosis by laparoscopy is considered to be the standard). Thirty of the 169 pts had macronodular cirrhosis by laparoscopy, in 8 of these 30, cirrhosis was not confirmed by biopsy (sampling error 26%). The length of the biopsy sample did not differ between the cirrhotics who showed concordance between laparoscopy an histology and those that did not (14 + 6mm vs 14 + 5mm). 265 pts did not have macroscopic evidence of cirrhosis, but only two had histologic evidence of cirrhosis. Conclusions: 1) There was a 32% histological sampling error among pts documented to have cirrhosis by laparoscopy. 2) The results of this study demonstrate the value of laparoscopy in the documentation of cirrhosis, often missed on liver biopsy.
546
t548
LAPAROSCOPY: ITS USE IN DIAGNOSTICALLY CHALLENGING CASES OF PEDIATRIC LIVER DISEASE. P. Kazlow, A. DeFelice, S. Narwal, D. Kaluski and S. Stylianos, Department of Pediatrics. Columbia University, New York, NY Laparoscopy is now being performed on infants and children for a wide variety of indications, including abdominal trauma, chronic abdominal pain and possible appendicitis, We report three children with chronic liver disease who presented diagnostic challenges. The laparoscope proved to be an invaluable tool, both diagnostically and therapeutically, in these instances. Patient #1 was a 10 year old female with multiple auto-immune phenomena, including Hashimoto's thyroiditis, idiopathic thrombocytopenic purpura and liver disease. The platelet abnormalities led to a prolonged bleeding time ( > 15 minutes) and precluded a routine percutaneous liver biopsy. A percutaneeus liver biopsywas performed under laparoscopic guidance. Hemostasis was established via the laparoscope by applying direct pressure to the biopsy site. There was no significant blood loss. Auto-immune hepatitis was diagnosed. Patient #2 was a 6 year old male suffering from chronic liver disease of unknown etiology, despite an extensive work-up, which included 2 previous percutaneous biopsies of the right hepatic lobe. Under laparoscopic vision, a disparity was noted between the left and right hepatic lobes. Biopsy of the left lobe was diagnostic for congenital hepatic fibrosis. Patient #3 was a 20 year old male suffering from severe combined immune deficiency. Ultrasound of the liver revealed numerous liver nodules. Under laparoscopic guidance, direct biopsy of these nodules revealed the presence of sclerosing cholangitis. There were no complications in any of these cases. Although pereutaneous liver biopsy remains the procedure of choice in most cases requiring a tissue diagnosis, there are problems of sampling error, and in some cases, hemostasis may be difficult to establish. The laparoscope provides a safe, effective alternative to open liver biopsy in diagnosticallychallenging cases, particularly when percutaneous liver biopsy is relatively contraindicated.
THE ROLE OF ERCP IN THE MANAGEMENT OF BILIARY COMPLICATIONS AFTER LAPAROSCOPIC CHOLECYSTECTOMY (LC). F. Prat, G. Pelletier, T. Ponchon, J. Boyer, B. Person, LF. Bretagne. Bic~tre, Lyon, Angers and Rennes, France.
432
GASTROINTESTINAL ENDOSCOPY
The aim of this multicenter retrospective study was to assess the interest and efficacy of biliary endoscopy in the diagnosis and treatment of biliary complications following LC. Seventy-two patients were referred to our 4 centers between 1990 and 1994 for suspected biliary complications. There were 17 men and 55 women (mean age 57+18.9 years). The mean timespan between LC and ERCP was 105+21 days. We excluded common bile duct (CBD) stones deliberately left in place at the time of LC. 6 patients (8.3%) had undergone an attempt at surgical repair before ERCP. Four different types of complications were diagnosed at ERCP: 1) 31 patients had residual stones (25 cases) or cystic duct clip migration (6 cases) into the CBD revealed 121+66 days after LC. All of them were successfully treated with endoscopic sphincterotomy (ES). 2 mild pancreatitis occurred after ES. 2) 8 complete transecti0ns or occlusions of the CBD were diagnosed 35+20 days after LC. All of them were operated on. 3) CBD partial strictures were observed in 14 patients and treated as follows: hepaticojejunostomy = 5; transhepatic stenting = 1; endoscopic stenting = 6 (1 patient developed a severe sepsis after partial drainage of a complex hilar stenosis and died 3 days after stenting; another patient died 3 months after stenting without biliary complications; 4 patients are asymptomatic -stent in place: 2; stent removed: 2, with 1 and 7 months of follow-up-). 4) 19 patients had bile leakage (cystic duct = 16, gallbladder bed = 3), revealed 13+__2days after LC. ES was performed in 16 patients and clearly induced rapid recovery in 10; ES failed to improve 3 other patients; the influence of ES on the outcome was unclear in 3 patients. One patient developed severe hemorrhage after ES, and was treated medically. Three patients were treated conservatively. We conclude that ERCP is indicated when a biliary complication is suspected after LC. ES appeared to be effective for the treatment of retained stones, clip migration and bile leakage. Long term follow-up is needed to assess the efficacy of endoscopic stenting in partial CBD strictures.
V O L U M E 41, NO. 4, 1995