2001 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) St
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Surg Endosc (2001 ) 15: S 104-S 176 DOI: 10.1007/s00464-001-0015-5 Surgical Endoscopy Ultrasound and Interventional Techniques 9 Spnngcr-VerlagNew York Inc. 2001 2001 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) St. Louis, Missouri, USA, 18-21 April 2001 Poster presentations* LAPAROSCOPIC "RADICAL APPENDECTOMY" IS AN EFFECTIVE LAPAROSCOPIC RESECTION OF A BLEEDING ILEAL ALTERNATIVE TO ENDOSCOPIC REMOVAL OF CECAL POLYPS LYMPHANGIOMA Gina L. Adrales, M.D., Sharon L. Goldstein, M.D., Brent D. Matthews, Gina Adrales, M.D., Sharon Goldstein, M.D., Brent Matthews, M.D., Richard L. Sigmon, Jr., M.D., Kent W. Kercher, M.D., B. Todd M.D., Robert T. Yavorski, M.D., William C. Sugg, M.D., B. Todd Heniford, M.D., Department of Surgery and Charlotte Clinic for Heniford, M.D., Gastrointestinal and Liver Diseases, Carolinas Medical Center, Department of Surgery and Charlotte Medical Clinic, Carolinas Charlotte, North Carolina Medical Center, Charlotte, North Carolina. The endoscopic approach to cecal polyp resection harbors several possible complications, including the risks of perforation and bleeding. Gastrointestinal lymphangioma is a rare entity. These benign In addition, failure to remove the polyp in its entirety frequently requires tumors are composed of abnormally dilated lymphatic channels. multiple endoscopies for resection and confirmation of resection. Though often asymptomatic, small intestinal lymphangiomas may Laparoscopic "radical appendectomy" represents a safe alternative to become clinically significant as the cause of intestinal obstruc- endoscopic treatment with the potential to reduce the risk of recurrence tion, intussusception, or hemorrhage. We present an unusual and subsequentmalignancy. case of laparoscopic resection of a bleeding ileal lymphangioma Four I~atientswith edenomatous polyps of the cecum were treated with and a review of the literature. laparoscopic resection of the appendix and cecum to the level of the ileocecal valve ("radical appendectomy") and intraoperative A 33 year-old man presented with progressive fatigue and syn- colonoscopy. Three of the four patients had villous adenomas of the cope. The finding of severe microcytic anemia prompted an cecum (3 to 4.5 cm). One patient had a 3 cm tubulovillous adenoma. upper and lower endoscopic evaluation, which were both nega- There were two male and two female patients, ages 46 to 61 years, tive. Subsequent enteroclysis revealed a 3.0 cm ileal tumor sug- (mean 54). Two patients presented with occult gastrointestinalbleeding. gestive of a hemangioma. Exploratory laparoscopy, intraopera- Three of the four patients had significant co-morbidities, including dia- tive liver ultrasound and resection of a mid-ileal nodular tumor betes and coronary atheroscterotic disease. One patient, with a history were performed. The pathologic findings were consistent with of alcoholic cirrhosis, underwent intraoperative liver ultrasound and liver benign lymphangioma of the ileum. The patient remains stable biopsy and had the longest operative time. Operative time ranged from at two months follow-up. 53 to 184 minutes. Length of hospital stay (1 to 3 days) was consider- ably short. Final pathology revealed carcinoma in situ in two specimens Lymphangioma of the small intestine are highly unusual with adequate margins. There have been no postoperative complica- tumors. However, the frequency of diagnosis is increasing with tions observed during the 2 to 12 month follow-up. the expanding role of endoscopy in patient care. There are Laparoscopic "radical appendectomy" can be a safe and effective reports of resection of these tumors endoscopically in the litera- alternative to endoscopic removal in the treatment of cecal adenoma- ture. Lymphangiomas are often sessile and widely-based neo- tous polyps. This procedure can attain definitive resection, allow com- plasms, which may limit endoscopic evaluation and resection. As plete and accurate pathologic evaluation, and negate the need for illustrated in this case presentation, laparoscopy provides an repeated endoscopiesand piecemeal removal of polyps. Our brief oper- effective method of diagnosis and curative resection of intestinal ative times and absence of complications support this laparoscopictech- lymphangiomas. nique as a reasonableapproach in the managementof cecal polyps. A,s'w~na'~rl in ~lnh~hPt;r:~l nrrlPr S105 LAPAROSCOPIC SURGERY OF THE DISTAL PANCREAS: AN INITIAL EXPERIENCE OF LAPAROSCOPIC PSEUDOCYST EXPERIENCE ON THE LEARNING CURVE DRAINAGE. William G Ainslie, MBChB, Basil Ammori MD, Michael Larvin MD, Michael J William G Ainslie, MBChB, Basil Ammori MD, Michael Larvin McMahon, MD., Leeds Institute for Minimally Invasive Therapy (LIMIT) and MD, Michael J McMahon, MD., Leeds Institute for Minimally Academic Surgical Umt, Leeds General Infirmary, Leeds, UK Invasive Therapy (LIMIT) and Academic Surgical Unit, Leeds General Infirmary, Leeds. UK Fourteen consecutive patients (age 28-75 years, median 51.5) with symp- tomatic pseudocysts were treated laparoscopically.(Table) When present, Laparoscopic surgery for distal pancreatic pathology presents necrosis was debrided. Cyst-gastrestomy was initially performed through a longitudinal gastrostomy but is now performed by an intreluminal approach new challenges. These have been evaluated in a review of our to minimise trauma to the anterior stomach wall. The patients have been fol- initial experience. lowed for a median of 9 months (range 1-63). Seventeen patients underwent laparoscopic distal pancreatec- Excellent visualisation of the interior of the cavity was obtained, allowing tomy and two had enucleations of benign tumours, age range removal of necrotic tissue and clipping of a large, potentially troublesome 14-82 yrs (median 60). Indications included cystadenomas, vessel under direct vision. There were two recurrences, both in the drainage endocrine tumours, chronic or familial pancreatitis and a pseudo- group (p=O.005), which were managed successfully by interventional radiolo- gy. There was one minor chest infection and an episode of acute urinary cyst. Operative times ranged from 130-550 mins (median 300) retention among the cyst-gastrostomy group. One wound infection occurred and the median postoperative stay was 11 days (range 3-63). in a patient who was converted to laparotomy. Patients have been followed for 5-78 months (median 27). Although endoscopic or percutaneous methods for pseudocyst drainage There were five conversions, due to intra-operative bleeding have been advocated, the surgical approach of effective drainage and (n=2), unsuspected malignancy (n=2) and uncertain anatomy debridement of necrotic tissue remains the gold standard with lower recur- (n=l). Four collections required interventional radiology. There rence and infection rates. Intra-luminal, laparoscopic cyst-gastrestomy com- bines these principles with a safe, minimally invasive approach. It provides were also two pancreatic fistulae, two wound infections and two excellent visuahsation of the cavity and is superior to drain insertion. subsequent laparotomies; one for bleeding and one for a splenic infarct. One patient with chronic obstructive airway disease died lirne Converted Diet Dischazge. from MRSA pneumonia. (min) (day) (day) Collections and fistulae ceased when oversewing of the pan- Cy~~ creatic stump was abandoned. Serious wound infections were - Gast~ (n=3) 270 0 6 9 eliminated by the introduction of a totally waterproof bag. Cyst~ Troublesome bleeding due to fibrosis, obesity and access has -Intraluminal(n=7) 180 1 4 7 become less of a problem with use of the Harmonic Scalpel and lately, the Ligasure. Drain (n=4) 180 1 5.5 25.5 With experience and appropriate equipment, laparoscopic dis- tal pancreatic surgery is both feasible and safe. Cyst-jejunostomy(n= 1) 250 I 5 10 LAPAROSCOPIC GASTROJEJUNOSTOMY FOR BENIGN AND LAPAROSCOPIC CHOLECYSTOJEJUNOSTOMY FOR MAUGNANT DISEASE. AN INITIAL EXPERIENCE MALIGNANT DISEASE. AN INITIAL EXPERIENCE William G Ainslie, MBChB, Basil Ammori MD, Michael Larvin MD, William G Ainslie, MBChB, Basil Ammod MD, Michael Larvin MD, Michael J McMahon, MD., Leeds Institute for Minimally Invasive Michael J McMahon, MD., Leeds Institute for Minimally Invasive Therapy (LIMIT) and Academic Surgical Unit, Leeds General Infirmary, Therapy (LIMIT) and Academic Surgical Unit, Leeds General Leeds, UK Infirmary, Leeds, UK Objective. To evaluate the outcome and problems of laparoscopic Patients with obstructive jaundice due to pancreatic and hepatobil- gastro-jejunostomy. iary malignancies have a poor prognosis. Palliation should be mini- Method. Review of our experience mally invasive to optimise quality of life. The purpose of this review is Results. Twelve gastrojejunostomies were performed on eleven to evaluate the outcome and problems encountered during our initial patients, age range 50-83 years (median 78), with gastric outlet experience of laparoscopic cholecystojejunostomy. obstruction due to malignancy (n=9) or chronic pancreatitis (n=2). Both Fourteen patients with obstructive jaundice secondary to cholangio- antecolic (n---8) and retrocolic (n=4) anastomoses were performed. Two carcinoma (n=2), pancreatic cancer (n=11) or an islet cell tumoux patients also had a concomitant cholecystojejunostomy. Eight anasto- (n=l) had a laparoscopic cholecystojejunostomy. Two patients had moses were stapled and the remainder, were sutured. The method of concomitant gastrojejunostomy for gastric outlet obstruction. Five