EndoScope." world literature reviews Surgical l Endoscopy Surg Endosc (1996) 10:354-357 © Springer-Verlag New York Inc. I996

Original articles from a wide range of international surgical journals are selected by our editors and presented here as a structured summary and critical review. EndoScope serves as a quick and comprehensive survey of the expansive endoscopic literature from all the corners of the globe.

Section Editor: J. M. Sackier

Intraoperative choledochoscopic electrohydraulic lithotripsy for difficultly retrieved impacted common bile duct stones

Sheen-Chen, SM, Chou, FF Arch Surg (1995) 130:430-432

The authors explore the feasibility, efficacy, and safety of electrohydraulic lithotripsy for impacted distal common bile duct (CBD) stones. Between 1991 and 1993, ten consecu- tive patients who met the criteria for the procedure were described in the study. The criteria were (1) impacted distal CBD stone found during supraduodenal CBD exploration and (2) failure to retrieve or dislodge the stone by conven- tional methods during supraduodenal choledochotomy (i.e., forceps, basket, saline flush, Fogarty catheter).

Under direct visualization, an electrohydraulic probe was introduced through the channel of a choledochoscope, and shock waves were applied until the stone fragmented. The fragments were then retrieved using the basket or flushed out with saline solution. This particular portion of the operation took approximately 20 min to perform. Rou- tine postoperative management followed as with any CBD exploration. These patients were compared to another set of ten patients who had the same problem prior to this time period but underwent transduodenal sphincteroplasty for stone extraction.

All ten patients were successfully treated using this technique. One patient had "mild oozing" (hemobilia) that spontaneously resolved, which the authors admit could have been avoided with more careful manipulation. The trans- duodenal sphincteroplasty group had four complications which included a mild hemobilia, two bile leakages found in subhepatic drains, and one wound infection. By compari- son, the lithotripsy approach had a shorter operative time than the sphincteroplasty approach (73.0 + 5.0 vs 90.0 + 11.8). Although statistically not significant, the lithotripsy group had shorter hospital stays (7.6 days vs 11.6 days). Postoperative studies included T-tube cholangiography, choledochoscopies, and then abdominal ultrasonography every 6 months for the 1 st year and every year thereafter. There were no residual stones or postoperative complaints at a mean follow-up time of 22 months.

According to the authors' presentation, the impacted distal CBD stones were encountered during supraduodenal CBD exploration. For a geographic region where hepato-

biliary disease is common, readers cannot help wonder if preoperative liver enzyme studies had predicted ductal ob- struction and if ERCP with sphincterotomy was ever pro- posed as an option for stone extraction. The hospitalization days, complications, and success rates are similar to pre- liminary experiences as reported by others.

Surgeons are always cautious with intrabiliary manipu- lation of any type. Choledochoscopy may require ductal dilatation, further traumatizing the ductal lining. Hemobilia itself can either resolve spontaneously or be disastrous in severity. Even with uneventful use of the electrohydraulic probe, it can conceivably cause delayed problems; the un- known depth of energy penetration has been implicated in delayed biliary strictures after choledochal surgeries.

Finally, the number of patients in this study reflects the relative rarity of having to perform this procedure. The au- thors have done well in the thoroughness of follow-up.

Laparoscopic cecopexy for cecal volvulus

Bhandarkar, DS, Morgan, WP Br J Surg (1995) 82:323

The authors report a case of a 46-year-old woman present- ing with abdominal pain, distention, and vomiting. Exami- nation revealed nothing untoward and she was well until a few months later when she presented as an emergency with obvious signs, symptoms, and radiographic features of cecal volvulus. Conservative measures were instituted and she later underwent laparoscopic exploration. At operation a healthy, mobile, right colon was noted, and the cecum was fixed to the peritoneum of the right lower qua&ant with three polypropylene sutures. Recovery was uneventful. Discussion: The authors discuss the role of right hemico- lectomy in treating this disease and maintain that cecopexy is a satisfactory therapeutic option as it has a low morbidity rate. However, they fail to note that cecopexy has a much higher recurrence rate than right hemicolectomy, as has been documented previously in the literature. They fail to comment on the length of follow-up in this patient, stating merely, "no symptoms or signs (clinical or radiological) suggesting recurrence of volvulus were noted at follow up." This is clearly not detailed enough. Additionally, readers of this journal may recall an article [Shoop S, Sackier JM (1993) Laparoscopic cecopexy: case report and review of the literature. Surg Endosc 7:450-454] in which a similar case was presented in a patient who was HIV positive. In this article it was noted that although the technique was

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feasible, the disease returned approximately 1 year after surgery. Clearly, although this technique is possible, it is not the standard of care and almost certainly right hemicolec- tomy should be performed in most cases to prevent recur- rence.

Patient satisfaction following laparoscopic and open antireflux surgery

mind that the ultimate measure of patient satisfaction, re- gardless of technique, should be the long-term correction of GERD symptoms.

A prospective, randomized comparison of laparoscopic appendectomy with open appendectomy

Rattner, DW, Brooks, DC Arch Surg (1995) 130:289-294

The results of this study parallel the previously reported works of other centers involved with minimally invasive surgical management of gastroesophageal reflux disease (GERD). In a 2-year period, 86 patients of the Massachu- setts General Hospital and Brigham and Women's Hospital with documented GERD underwent surgical management; 74 had laparoscopic Nissen fundoplication (LNF) and 12 had the open (ONF) procedure. This study is notable for its prospective (but nonrandomized) fashion, consistency in preoperative patient interviews and postoperative follow-up to determine symptom alleviation, study of cost, and deter- mination of the patient's ability to return to work.

Only patients followed for more than 2 months (n = 64) were eligible for the patient satisfaction interview. How- ever, only 56 of them responded (87.5%). Eighty-eight per- cent (88%) were either satisfied or very satisfied with the result of surgery. Although recovery and hospital stay were shorter for the LNF group (4 days) than in the ONF group (8 days), there was no difference in patient satisfaction be- tween the two groups in terms of symptoms. Statistically significant facts of recovery include earlier oral intake of clear fluids for the LNF group (2 days vs 5 days), earlier return to work (10 days vs 26 days), and earlier return to full function (24 days vs 44 days).

Operating room time was similar in the LNF and ONF groups (173 rain and 169 min, respectively). The use of disposable instruments increased the operation cost in the LNF group. However, the overall charge for the LNF group was $11,673 vs $18,394 for the ONF group. The disparity is the result of longer hospitalization in the ONF group. In this study, eight of the last ten patients were discharged 2 days after the LNF procedure, which will further decrease its overall cost should the trend continue.

As much as this study is welcomed, the implications should be received with some caution (and the authors are quite cognizant of this). First, patient personalities contrib- ute to the outcome of a study such as this. Second, the report may be somewhat premature given that 30 out of the orig- inal 86 patients could not or did not contribute to the final result analysis. Lastly, the emerging success of LNF does not make medical therapy obsolete. Patients should con- tinue to complete a trial of medical therapy before exploring surgical options.

Readers may be interested in following this series for long-term results (to include most of the 30 not presently accounted for), patient satisfaction, cost of additional med- ical therapy, possible complications, and failures. Keep in

Ortega, AE, et al Am J Surg (1995) 169:208-213

Despite the rapid advancement of laparoscopic surgical techniques, laparoscopic appendectomy (LA) has not achieved the widespread acceptance of laparoscopic chole- cystectomy. An evaluation of the advantages and disadvan- tages of LA in patients with presumed appendicitis a mul- ticenter, prospective, randomized comparison of LA with open appendectomy (OA) was performed by Ortega et al. (1995). The techniques of LA using catgut ligature (LAL) and an endoscopic linear stapler (LAS) applied at the base of the appendix were also evaluated. OA was performed using a 5-6-cm transverse muscle-splitting incision in the right lower quadrant. Most of the LA cases were performed using a three-trocar technique.

Two hundred fifty-three patients with a preoperative di- agnosis of acute appendicitis were randomized at ten cen- ters. Seventy-eight patients were randomized to LAS, 89 to LAL, and 86 to OA. The three groups were comparable in age (mean 25 years), sex ratio (66-78% males), height (mean 165 cm), weight (mean 72 kg), and history of pre- vious abdominal surgeries (6-7 patients in each group).

The groups did not differ significantly in preoperative clinical presentation, WBC count, and operative findings. Acute appendicities was noted in 65.6% of cases, perforated appendicitis in 17.4%, and normal appendix in 16.4%. Six LAS and five LAL patients were converted to OA (conver- sion rate 6.6% for both LA groups) due to excessive inflam- mation or inability to visualize the appendix.

An evaluation was made for operative time, intra- and postoperative complications, postoperative pain, hospital stay, readmission, and resumption of activities in all three groups. Postoperative pain was evaluated in a subgroup of 134 patients using a visual-analogue pain scale of 1 to 4 (4 -- worst pain patient had ever experienced; 3 = severe pain analogous to worst headache or toothache; 2 = pain upon moving to coughing; 1 = mild incisional pain only). The patient and nursing staff both were blinded to the surgical approach. All data were analyzed by analysis of variance (ANOVA). The criteria for statistical significance was P < 0.05.

The mean operative times for LAS, LAL, and OA were 66 _+ 24, 68 _+ 25, and 58 _+ 27 rain (P > 0.01, OA vs LA). There were no statistically significant differences in hem- orrhage (defined as blood loss >50 ml) and fragmentation of appendix. Fecal soilage occurred more frequently during LAL (12.3%) than LAS 6% or OA (1%) (P < 0.01 for LAL vs OA). Postoperatively, the incidence of vomiting was higher following LAL (13%) than after LAS (2%) or OA (1%) (P < 0.05 for both LAS and OA vs LAL). Postoper-

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ative ileus occurred in LAS (6%), LAL (16%), and OA (7%) cases (P -- NS). Intraabdominal abscess developed in 2 LAS, 4 LAL, and none of the OA patients (P = NS). Wound infections were more common after OA (11 pa- tients) than LAS (n = 0) and LAL (n = 4) (P < 0.001 and <0.05 for LAS and LAL vs OA). The mean hospital stays for LAS, LAL, and OA were 2.16 _+ 3.2, 2.98 + 2.7, and 2.83 + 1.6 days, respectively. LAS permitted earlier release than OA (P < .05). Regardless of length of stay the number of days preceding resumption of full activity was 9 + 9 fol- lowing LAS, 9 + 8 after LAL, and 14 + 11 after OA (P = 0.001 for OA vs both LAS and LAL). The mean duration of analgesic requirement was the same in all three groups but the mean total pain score (visual analogue pain scale) for LA (LAS and LAL) at 24 and 48 h was 6.1 -+ 4.7 and 7.2 + 7.4 as compared to 9.6 _+ 5.1 and 12.3 _+ 10.9 for OA patients (P < 0.001 and P = 0.01).

From the above data it is clear that LA, particularly LAS, has distinct advantages over OA. Less postoperative pain, earlier resumption of normal activity, shorter hospital stay, and lower incidence of wound infection were noted with LA. The disadvantages of LA were slightly increased operative time (10 rain in this series), which could be at- tributed to the "learning curve" of resident surgeons. As well, more frequent postoperative vomiting was seen with LAL. Although intraabdominal abscess formation occurred in six patients following LA (two LAS and four LAL pa- tients) and none after OA, the difference was not statisti- cally significant. There were ten readmissions to the hospi- tal including one LAS, six LAL, and three OA patients (P = NS). The reason for these readmissions was not discussed in the article.

This study also did not assess cost issues. It is well known that laparoscopic technology is more expensive. A cost-effectiveness study of LA will need to include not only hospital costs but the costs associated with treatment of wound complications and low productivity during conva- lescence.

Intraoperative cholangiography is not essential to avoid duct injuries during laparoscopic cholecystectomy

Lorimer, JW, et al. Am J Surg (1995) 169:344-347

To remove the myth that intraoperative cholangiogram (IOC) is essential to avoid duct injuries during laparoscopic cholecystectomy (LC), a study was done at the University of Ottawa, Ontario, Canada, by John W. Lorimer and Robert J. Fairfield-Smith. In this study 525 patients underwent LC from March 1991 to September 1993 without IOC. There were no CBD injuries during this study. The indications for LC were chronic cholecystitis (82.1%), acute cholecystitis (9.l%), gallstone pancreatitis (5.6%), and jaundice (3.2%). Gallstones were present in 98.3% of cases. The median operative time was 79.5 min. Twenty-five patients (4.8%) were converted to open cholecystectomy. The reasons for

conversion were dense adhesions (20 cases), inadequate ex- posure of gallbladder due to obesity (3 cases), small-bowel injury (1 case), and cystic artery bleeding (1 case).

Based on clinical criteria of history of jaundice, acute pancreatitis, elevated liver enzymes, and ultrasound-proven or suspicion of common duct stone, preoperative endo- scopic retrograde cholangiography (ERC) was performed in 33 patients. Out of these 33 cases, 13 patients were diag- nosed as having CBD calculi (diagnostic accuracy of 40%) and treated with endoscopic sphincterotomy (ES).

In the postoperative period (up to 15 months after LC), ERC was done in 14 patients and 5 patients required ES for removal of their CBD stones. It was believed that three other patients in the postoperative group had passed duct stones before ERC (episodic biliary pain and elevated liver enzymes). One patient with an asymptomatic duct stone refused a second attempt at ES. Thus the incidence of CBD stones (22 out of 525 cases) was 4.2% and the incidence of retained or missed stones (9 out of 525) was 1.66%.

Out of 47 patients (9%) (33 preop and 14 postop) sub- jected to ERC/ES, four patients developed a complication. Duodenal perforation occurred in one patient and pancre- atitis occurred in the other three. Out of 525 patients un- dergoing LC, 28 complications (1 fatal) occurred in 25 pa- tients with morbidity of 4.8% and mortality of 0.19%.

Based on these data the authors recommend the selec- tive use of preoperative ERC/ES based on clinical, bio- chemical, and ultrasound evidence of CBD stone. As well, they argue that routine IOC is unnecessary, citing a study in which IOC was routinely employed yet ERC/ES was still required in 11% of patients as compared to 9% in this series, suggesting that IOC may not reduce the dependence on ERC/ES. Comments: That there were no common bile duct injuries in this series is insufficient evidence that IOC is unneces- sary. In fact, if you assume a bile duct injury rate of 2 in 1,000, the average surgeon only has a 50% chance of in- juring a bile duct in 500 cases. Thus the lack of a bile duct injury in 525 cases does not mean that these surgeons are immune.

A more interesting aspect of the paper is the use of ERC rather than IOC for imaging the bile duct. Unsurprisingly, the lack of practice with IOC resulted in a 66% failure rate when it was attempted! That IOC is cost-ineffective cannot be argued here as there are no comparative data supplied. All that can be argued is that ERCP/ES is an effective way to manage bile duct stones with laparoscopic cholecystec- tomy. The problems with this approach have been pointed out before and are reiterated in this manuscript. Sixty per- cent of all preoperative ERCs were unnecessary, a waste of money, and associated with patient discomfort and a 9% morbidity rate. It is hard to justify the performance of so many unnecessary, potentially dangerous, and expensive procedures. ERCP/ES was used only when stones are clin- ically apparent and these authors found that only 4.2% of their patients harbored bile duct stones. These numbers are very similar to those generated by other authors with similar algorithms. What is clear from a series utilizing routine IOC is that these authors have missed half of the common bile duct stones. Perhaps some of them have passed without causing symptoms, but it is likely, based on earlier work by Dunphy and Way, that the majority of these stones are still

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residing in the common bile duct. The median time to pre- sentation of the retained or recurrent stone after cholecys- tectomy is 9.2 years! While these authors' approach is not without merit, it will take a prospective randomized trial from a center with excellent biliary endoscopists and sur- geons who are competent with cholangiography and bile duct exploration to determine the best way to manage com-

mon bile duct stones in an era of minimally invasive sur- gery.

Reviewers for this issue: Drs. Cosgrove, Hunter, Lin, Walia