Early Postoperative Endoscopy Research Articles

Early Post-Operative Endoscopy Is Associated with Lower Surgical Recurrence of Crohn's Disease: A Retrospective Study of Three Successive Cohorts.

The severity of endoscopic recurrence during the first year after intestinal resection for Crohn's disease is predictive of clinical recurrence. The aim of our study was to assess the impact of the implementation of an ileocolonoscopy during the first year after surgery on surgical recurrence. All patients who underwent a first intestinal resection for Crohn's disease between 1992 and 2018 at the University Hospital of Liège were retrospectively included. The time to surgical recurrence was compared in three successive groups of patients operated on in the period 1992-2001 (group A), 2002-2011 (group B), and 2012-2020 (group C) using the Kaplan-Meier method and the Log-Rank test. To identify independent prognostic factors, a multivariate analysis was used via the Cox model. 223 patients (group A = 69, group B = 94, group C = 60) were included. Probabilities of surgical recurrence were significantly lower in group C (2.2% and 4.7% at 3 and 5 years, respectively) compared with group B (4.2% and 7.6% at 3 and 5 years, respectively) and with group A (9% and 18.2% at 3 and 5 years, respectively) (p = 0.0089). Ileocolonoscopy during the year after surgery was associated with a significantly reduced surgical recurrence rate in univariate and multivariate analysis (HR = 0.31, p = 0.0049). The implementation of an early ileocolonoscopy after surgery for Crohn's disease since early 2000 has been associated with a reduced surgical recurrence over the last 30 years.

Early postoperative endoscopic evaluation of rectal anastomoses: a prospective cross-sectional study

BackgroundReported incidence of anastomotic leakage (AL) of rectal anastomoses is up to 29% with an overall mortality up to 12%. Nevertheless, there is no uniform evidence-based diagnostic procedure for early detection of AL.The objective of this prospective clinical trial was to demonstrate the diagnostic value of early postoperative flexible endoscopy for rectal anastomosis evaluation.MethodsFlexible endoscopy between 5 and 8th postoperative day was performed consecutively in 90 asymptomatic patients. Sample size calculation was made using the two-stage Simon design. Diagnostic value was measured by management change after endoscopic evaluation. Anastomoses were categorized according to a new classification. Study is registered in German Clinical Trials Register (DRKS00019217).ResultsOf the 90 anastomoses, 59 (65.6%) were unsuspicious. 20 (22.2%) were suspicious with partial fibrin plaques (n = 15), intramural hematoma and/or local blood coagulum (n = 4) and ischemic area in one. 17 of these anastomoses were treated conservatively under monitoring. In three a further endoscopic re-evaluation was performed and as consequence one patient underwent endoscopic vacuum therapy. 11 (12.2%) AL were detected. Here, two could be treated conservatively under monitoring, four with endoscopic vacuum therapy and five needed revision surgery. No intervention-related adverse events occurred. A change in postoperative management was made in 31 (34.4%) patients what caused a significant improvement of diagnosis of AL (p < 0.001).ConclusionsEarly postoperative endoscopic evaluation of rectal anastomoses is a safe procedure thus allows early detection of AL. Early treatment for suspicious anastomoses or AL could be adapted to avoid severe morbidity and mortality.Graphical abstract

Early endoscopic assessment after esophagectomy can predict anastomotic complications: a novel scoring system.

Anastomotic leakage after esophagectomy is a serious and demanding complication. Early detection and treatment can probably prevent clinical deterioration of the patient. We have used early endoscopic assessment and a novel endoscopy score to predict anastomotic complications. 57 patients planned for Ivor Lewis esophagectomy were included. Endoscopy videos were recorded and biopsies were taken from the gastric conduit on day 7 or 8 after esophagectomy. A scoring system based on the endoscopic appearance, the combined endoscopy score (0-6), was developed. Scoring of the videos was done blinded. Patient outcome with regards to anastomotic complications was registered on postoperative day 30 in accordance with the ECCG definitions and compared to histopathology assessment and the combined endoscopy score retrospectively. The rate of anastomotic defect (necrosis and leakage, ECCG definitions) was 19%. 7 out of 8 patients with a combined endoscopy score of ≥ 4 developed anastomotic defects. The combined endoscopy score was the only predictor for anastomotic complications. Prediction of anastomotic complications enables early detection and treatment which often limits the clinical extent of the complication. Early postoperative endoscopy is safe and a relatively simple procedure. The combined endoscopy score is an accurate tool to predict anastomotic complications.

Colorectal anastomosis dehiscence: a call for more detailed morphological classification.

IntroductionA proactive approach is recommended in colorectal anastomosis leak treatment, and early diagnosis is very important. Early postoperative endoscopy would allow rapid diagnosis of anastomotic pathologies and consequent prompt intervention according to anastomotic disruption morphology.AimTo evaluate the effectiveness of close endoscopic follow-up of all patients (including asymptomatic ones) in improving diagnosis of acute leak (AL) and reducing its complications.Material and methodsThis study included 124 patients who had undergone rectum resection for rectal cancer with stapled anastomosis. Endoscopy was performed between the 7th and 10th postoperative day and 1 month postoperatively. For defect morphology assessment, a classification system was created based on four levels of severity. Photographic findings were evaluated by an independent, experienced gastroenterologist.ResultsPostoperative endoscopy revealed 28 (22.6%) patients with acute leakage. Initial endoscopy confirmed AL in 18 patients. Six (31.6%) patients were asymptomatic and 13 (68.4%) were symptomatic. The second endoscopy revealed another 9 (32.1%) leaks (4 (44.5%) asymptomatic and 5 (55.5%) symptomatic). Sixteen (57.1%) patients had grade A leakages, 7 (25.0%) had grade B leakages, and 5 (17.9%) had grade C leakages. Furthermore, 22 of 27 (81%) defects were located posterior and posterior-laterally. Fifteen (55.5%) defects were smaller than 1/3 the circumference, 7 (25.9%) affected 1/3–1/2 of the circumference, and 5 (18.5%) affected more than 1/2 of the circumference.ConclusionsIncorporation of early endoscopy in postoperative management allows rapid diagnosis of AL and allows faster intervention, even in leaks that are clinically silent.

Postoperative Endoscopic Recurrence on the Neoterminal Ileum But Not on the Anastomosis Is Mainly Driving Long-Term Outcomes in Crohn's Disease.

Early ileocolonoscopy within the first year after surgery is the gold standard to evaluate recurrence after ileocolonic resection for Crohn's disease (CD). The aim of the study was to evaluate the association between the presence and severity of anastomotic and ileal lesions at early postoperative ileocolonoscopy and long-term outcomes. The REMIND group conducted a prospective multicenter study. Patients operated for ileal or ileocolonic CD were included. An ileocolonoscopy was performed 6 months after surgery. An endoscopic score describing separately the anastomotic and ileal lesions was built. Clinical relapse was defined by the CD-related symptoms, confirmed by imaging, endoscopy or therapeutic intensification; CD-related complications; or subsequent surgery. Among 225 included patients, long-term follow-up was available in 193 (median follow-up: 3.82 years [interquartile range: 2.56-5.41]). Median clinical recurrence-free survival was 47.6 months. Clinical recurrence-free survival was significantly shorter in patients with ileal lesions at early postoperative endoscopy whatever their severity was (I(1) or I(2,3,4)) as compared to patients without ileal lesions (I(0)) (I(0) vs I(2,3,4): P = 0.0003; I(0) vs I(1): P = 0.0008 and I(1) vs I(2,3,4): P = 0.43). Patients with exclusively ileal lesions (A(0)I(1,2,3,4)) had poorer clinical long-term outcomes than patients with exclusively anastomotic lesions (A(1,2,3)I(0)) (P = 0.009). A score describing separately the anastomotic and ileal lesions might be more appropriate to define postoperative endoscopic recurrence. Our data suggest that patients with ileal lesions, including mild ones (I(1)), could beneficiate from treatment step-up to improve long-term outcomes.

OP04 Long-term outcomes after ileocolonic resection in Crohn’s disease according to the severity of early endoscopic recurrence

Abstract Background Early ileocolonoscopy within the first year after surgery is the gold standard to evaluate post-operative recurrence after ileocolonic resection for Crohn’s disease (CD). The aim of the study was to evaluate the association between lesions at ileocolonoscopy 6 months after surgery and long-term outcomes. Methods The REMIND group conducted a prospective multicentre study. Patients operated for ileal or ileocolonic CD were included. An ileocolonoscopy was performed 6 months after surgery. An endoscopic classification separating anastomotic and ileal lesions was built (Ax for anastomotic lesions; Ix for neo-terminal ileum lesions evaluated according to the Rutggerts score). Clinical relapse was defined by CD-related symptoms confirmed by imaging, endoscopy or therapeutic intensification, CD-related complication or subsequent surgery. Results A total of 225 patients were included. Long-term data were available for 193 patients (86%). Median follow-up was 3.82 years (IQR:2.56–5.41) from surgery. Median clinical recurrence-free survival was 47.6 months. Clinical recurrence-free survival was significantly shorter in patients with ileal lesions at early post-operative endoscopy whatever their severity (I1 or I2I3I4) compared with patients without (I0) (median survivals: 68.5, 33.0 and 39.1 months, respectively, for I0, I1 and I2I3I4; I0 vs. I2I3I4: p = 0.0003; I0 vs. I1: p = 0.0008 and I1 vs. I2I3I4: p = 0.43). Patients with at least semi-circumferential anastomotic ulcerations (A2 or A3) had more anastomotic occlusive manifestations than patients without (A0 or A1) (A0 vs. A2A3: p = 0.01; A0 vs. A1: p = 0.83; A1 vs. A2A3: p = 0.05). Conclusion A classification separating anastomotic and ileal lesions might be more appropriate to define post-operative endoscopic recurrence. Patients with ileal lesions, including mild ones (I1), could beneficiate from treatment step up to improve long-term outcome.

Ultrathin endoscopy versus computed tomography in the detection of anastomotic leak in the early period after esophagectomy

BackgroundAnastomotic leak after esophagectomy is a major postoperative complication that leads to significant mortality. The aim of this study was to evaluate the safety of early postoperative ultrathin endoscopy in detecting anastomotic leaks and compare diagnostic performance of ultrathin endoscopy and computed tomography (CT) scan in identifying anastomotic leak after esophagectomy. Materials and methodsA prospective trial of 71 patients undergoing esophagectomy was conducted between January 2016 to December 2017. A contrast CT was performed prior to ultrathin endoscopy on postoperative day 5–7. ResultsAll 71 patients underwent ultrathin endoscopy and CT scan safely without complications. Among the 71 patients, transoral ultrathin endoscopy was performed on 51 patients and 20 patients with hypertension and coronary artery disease received transnasal ultrathin endoscopy. Overall, 14 leaks (20%) were identified. Endoscopy not only correctly identified the 2 patients of false-positive evaluations by CT, but also determined 4 leaks that were missed on CT. In addition, ultrathin endoscopy accurately identified 3 potential leaks based on pathological findings of anastomosis: ischemia and much fibrin coverings. One patient with normal postoperative CT findings showed healthy anastomosis but an ulcer on gastric conduit on endoscopy. Both sensitivity and specificity of endoscopy were 100%, while sensitivity and specificity of CT were 71.4% and 96.5%. ConclusionsUltrathin endoscopy after esophagectomy is safe and provides more accurate and reliable identification of anastomotic leak than CT scan. Ultrathin transnasal endoscopy may be a more appropriate diagnostic test to detect anastomosis for patients with hypertension and coronary artery disease.

Early prediction of complex benign anastomotic stricture after esophagectomy using early postoperative endoscopic findings.

Benign anastomotic stricture after esophagectomy and reconstruction adversely affects oral intake and can increase the risk of aspiration pneumonia. Some patients experience relapse that requires frequent endoscopic dilatations. This study aimed to investigate whether the endoscopic appearance of anastomosis during the early postoperative period is associated with the complexity of subsequent anastomotic strictures. Data of 213 patients who underwent esophagectomy with gastric tube reconstruction and early postoperative endoscopy between July 2008 and September 2018 were prospectively collected. Relationships among various risk factors, including the severity of mucosal degeneration of the anastomosis and complexity of anastomotic stricture, were studied using multivariate logistic regression analysis. Fifty-three patients (25%) developed anastomotic strictures at a median of 55days after surgery, requiring a median of 5 endoscopic dilations. In multivariate analysis, severe mucosal degeneration was the only significant risk factor for any type of anastomotic stricture (P < 0.001). Twenty-seven patients (51%) developed refractory anastomotic strictures. In multivariate analysis, younger age (< 65years) (P = 0.01), lack of neoadjuvant therapy (P = 0.02), severe mucosal degeneration (P = 0.03), and stricture development within 55days (P = 0.01) were the risk factors for refractory stricture. The analysis of the risk factors for severe mucosal degeneration revealed that comorbidities and anastomotic techniques were independently correlated (P < 0.01). Early postoperative severe mucosal degeneration of esophagogastrostomy was the only predictor of strictures, regardless of their type. Mucosal degeneration, early postoperative stricture, younger age, and front surgery were associated with refractory anastomotic strictures.

"Virtual ileostomy" combined with early endoscopy to avoid a diversion ileostomy in low or ultralow colorectal anastomoses. A preliminary report.

Despite the benefits of a loop ileostomy after total mesorectal excision (TME), it carries a significant associated morbidity. A "virtual ileostomy" (VI) has been proposed to avoid ileostomies in low-risk patients, which could then be converted into a real ileostomy (RI) in the event of anastomotic leak (AL). The aim of the present study is to evaluate safety and efficacy of VI associated with early endoscopy in patients undergoing rectal surgery with anastomosis to detect subclinical AL prior to the onset of clinical symptoms for sepsis. This is a single-center, retrospective study of a consecutive series of patients undergoing elective or emergent colorectal surgery with low or ultralow colorectal or ileorectal anastomosis between September 2015 and September 2016. We included 44 consecutive, unselected patients. Eight patients (18.2%) required conversion into RI and one required terminal colostomy because of AL, of whom 44.4% were asymptomatic and AL was detected with early endoscopy. Fashioning of RI was not associated with further morbidity. All patients with AL converted into RI (n = 8/9) (88.9%), had adequate healed anastomosis, and later underwent stoma closure with no complications. A stoma was avoided in 79.6% of VI. Endoscopy was associated with 55% sensitivity and 100% specificity, with a global accuracy of 88%. The combination of VI with early postoperative endoscopy could avoid unnecessary ileostomies in patients with low or ultralow anastomoses and reveal AL before the onset of symptoms, thus reducing associated morbidity.

Early Postoperative Endoscopy for Evaluation of the Anastomosis after Esophageal Reconstruction.

Anastomotic leaks significantly affect hospital stay after esophageal surgery. Here, we investigated the efficacy of early endoscopy for predicting anastomotic healing and leaks after esophageal reconstruction. A total of 65 consecutive esophageal cancer patients treated by cervical esophagogastrostomy underwent routine endoscopy between postoperative days 5 and 7. The anastomosis was scored for the degree of ischemia, stenosis, and torsion of the anastomotic axis. Independent associations between ischemia, stenosis, and torsion of the proximal esophagus and the risk of the anastomotic leak were examined using Spearman's rank correlation method. Assessment of the degree of mucosal ischemia in 65 patients shows well healing in 35, patch ischemia in 20, diffuse ischemia in 10, no necrosis in any patient. Stenosis was classified as 0 to 10% in 40 patients, 11 to 20% in 12, 21 to 80% in 11, and 81 to 100% in 2. The degree of torsion of the anastomotic axis was classified as 0 to 10 degrees in 52 patients, 11 to 90 degrees in 8, and 91 to 180 degrees in 5. With rising endoscopy scores, there was an increase in risk for leaks (score > 4.5, sensitivity 100%, and specificity 83.8%). Early postoperative endoscopy facilitates the management of esophagogastrostomy anastomosis to predict leaks.

Upper gastrointestinal endoscopy is safe and feasible in the early postoperative period after Roux-en-Y gastric bypass

Surgeons may be reluctant to perform upper gastrointestinal (UGI) endoscopy in the early post-operative period due to concern for anastomotic disruption. The aim of this study was to determine the safety and feasibility of early (≤ 30 days) post-operative UGI endoscopy after roux-en-y gastric bypass (RYGB). A retrospective data analysis of a prospectively maintained database was completed between May 2002 and March 2015 for patients that had undergone UGI endoscopy within 30 days of theirRYGB. Data analysis included baseline patient demographics, Charlson Comorbidity Index, perioperative parameters, indications for endoscopy; indications for any further endoscopic evaluation, interventions performed, and post-endoscopy complications. 190 patients underwent early postoperative UGI endoscopy after RYGB during the study period. Nineteen patients (10 %) had undergone revisional surgeries. The median duration to postoperative endoscopy was 22 days [IQR 16-26]. The most common indications included dysphagia (n = 74, 39%), abdominal pain (n = 53, 28%), nausea (n = 55, 29%), and vomiting (n = 47, 25%). Therapeutic interventions were performed in 79 patients (42%). These included balloon dilation (n=66, 84%), feeding tube placement (n = 7, 9%), evacuation of clot (n = 2, 3%), epinephrine injection (n = 2, 3%) and coagulation of bleeding (n = 1, 1%). There were no post-UGI endoscopy anastomotic disruptions or leaks. Endoscopy is helpful for the diagnosis and management of complications after RYGB. Despite the perceived risks, our study demonstrated no complications for both diagnostic and therapeutic endoscopy when performed in the early postoperative period.

Early postoperative endoscopy for targeted management of patients at risks of anastomotic complications after esophagectomy

Early postoperative endoscopy after esophagectomy is assumed to be effective in detection and prediction of anastomotic complications, but overall effects of early postoperative endoscopy remain uncertain. The aim of this study was to investigate whether mucosal status assessed by early postoperative endoscopy could offer an approach to individualized management after esophagectomy. Endoscopy was performed in 176 of 214 patients who underwent esophagectomy at either 1week or 2weeks postoperatively. Mucosal damage in the proximal region of the graft was classified as follows: intact mucosa, mild mucosal degeneration, and severe mucosal degeneration. We examined the association of the severity of mucosal damage and the incidence of anastomotic complications. Twenty-eight patients (16%) developed anastomotic stricture. Symptomatic anastomotic leaks occurred in 15 patients (8.5%), including 6 with stricture. The frequency of intact mucosa, mild mucosal degeneration, and severe mucosal was 7%, 20%, and 73% for leaks; 4%, 11%, and 85% for strictures; and 28%, 62%, and 10% for no complications, respectively (P <.001). Asymptomatic leaks were found in 4 patients in the 1-week endoscopy group. Sensitivity and specificity for the development of stricture in 1-week/2-week were 0.88/0.83 and 0.85/0.98, respectively. Positive and negative predictive values were 0.52/0.91 and 0.97/0.96, respectively. Early postoperative endoscopy could be carried out without any adverse events in all patients. Assessment of the anastomosis and graft with early postoperative endoscopy was safe and resulted in a high predictive value for subsequent anastomotic complications. Early postoperative endoscopy may lead to targeted management for a subset of patients undergoing esophagectomy.

Wrapping of the omental pedicle flap around the T-tube for the early postoperative biliary endoscopic intervention

Background: The placement of t-tube and postoperative biliary endoscopic intervention through T-tube tract is not an uncommon practice in the management of residual choledocholithiasis. In this study, we have evaluated the safety and feasibility of artificial T-tube tract for the early postoperative biliary endoscopy and early intervention through it, which was made by wrapping of the omental pedicle flap around the T-tube. Methods: A total of 230 cases of choledocholithiasis who underwent open common bile duct exploration and t-tube insertion according to new surgical technique in our hospital from January 2009 to January 2014 were analyzed retrospectively. T-tube imaging was taken after 2 weeks and for normal imaging T-tube was removed and biliary endoscopy was performed at 2-3 weeks. Results: Of 230 patients, 78 (33.9%) were male and 152 (66.1%) were female; 68 (29%) patients were with comorbidity. All groups underwent early postoperative endoscopy and early intervention at 2-3 weeks (an average of 17.9 ± 2.2 days). The result was statistically significant at (P <0.05). The residual stone were found in 27 patients (11.7%) and also noticed firmed, matured t-tube tract without any incidence of bile leakage. Conclusions: Wrapping of the omental pedicle flap around the T-tube is a simple, practical and safe procedure to make strong artificial T-tube tract for the early biliary endoscopic intervention, It has shortened the time of postoperative biliary endoscopy from 4-6 to 2-3 weeks without any incidence of intraperitoneal bile leakage.

Gastroesophageal Reflux after Vertical Banded Gastroplasty is Alleviated by Conversion to Gastric Bypass

Conversion operations after vertical banded gastroplasty (VBG) are sometimes performed because of vomiting and/or acid regurgitation. Primary operation with gastric bypass (GBP) is known to reduce gastroesophageal reflux (GERD). Previous studies have not been designed to differentiate between the effects of the altered anatomy and of the ensuing weight loss. No series has reported data on acid reflux before and after conversion from VBG to GBP. We invited eight VBG patients with current symptoms of GERD. All had intact staple lines as assessed by barium meal and gastroscopy. Acid reflux was quantified using 48-h Bravo capsule measurements. Conversion operations were performed creating an isolated 15-20-ml pouch; the previously banded part of gastric wall was excised. Gastrojejunostomy was made end to end with a 28-mm circular stapler. The study is based on five patients consenting to early postoperative endoscopy and pH measurement. All patients were women with a mean age of 49.5 years and BMI of 36.3. Time since VBG was 132.1 months. Time from conversion to second measurement was 46.6 days and BMI at that time 32.7. There was no mortality and no serious morbidity. All patients improved clinically and no patient had to go back on proton pump inhibition or antacids. Total time with pH < 4.0 was reduced from 18.4% to 3.3% (p < 0.05). DeMeester score was reduced from 58.1 to 15.9 (p < 0.05). The effect of converting VBG-operated patients to GBP results in a near-normalisation of acid reflux parameters and a discontinuation of proton pump inhibitor medication.

Detection of gastric conduit ischemia or anastomotic breakdown after cervical esophagogastrostomy: the use of computed tomography scan versus early endoscopy

Concern over potential injury to the anastomosis has limited the use of early postoperative endoscopy to diagnose conduit ischemia or anastomotic breakdown. Alternatively, a computed tomography (CT) scan has been suggested as a noninvasive means for identifying these complications. This study aimed to compare CT scan with early endoscopy for diagnosing gastric conduit ischemia or anastomotic breakdown after esophagectomy with cervical esophagogastrostomy. Between 2000 and 2007, 554 patients underwent an esophagectomy and gastric pull-up with cervical esophagogastrostomy at the University of Southern California. Records were reviewed to identify patients who had undergone endoscopy and CT scan within 24 h of each other during the first three postoperative weeks for suspicion of an ischemic conduit or anastomotic breakdown. The accuracies of CT scan and endoscopy in diagnosing an ischemic conduit were compared. A total of 76 patients had endoscopy and CT scan for clinical suspicion of conduit ischemia or anastomotic breakdown. Endoscopy was performed without complications in all 76 patients. The postoperative endoscopic findings were normal in 24 of the patients, and none subsequently experienced an ischemic conduit or anastomotic breakdown. Evidence of ischemia was present in 28 patients, 7 of whom had black mucosa throughout the gastric conduit with the anastomosis still intact and required removal of their conduit. The remaining 24 patients had partial or complete anastomotic breakdown. On the CT scan, 23 of the 76 patients showed evidence of conduit ischemia (n = 9) or anastomotic breakdown (n = 14). There was no evidence of ischemia or anastomotic breakdown on CT scan for the 24 patients with normal endoscopy or for 3 of the 7 patients who had their conduit removed for graft necrosis. A normal CT scan does not rule out the possibility of an ischemic gastric conduit after esophagectomy. Early endoscopy is a safe and accurate method for assessing conduit ischemia.

Management of acute bleeding after laparoscopic Roux-en-Y gastric bypass.

The authors reviewed the incidence of hemorrhage after laparoscopic Roux-en-Y gastric bypass (LRYGBP). The purpose of this study was to determine the incidence of this complication and to evaluate various treatment options. The records for 450 consecutive patients who had undergone LRYGBP over a 30-month period, were retrospectively reviewed. In all patients, the abdominal cavity had been drained with 2 19-Fr closed suction drains. The charts of patients who had developed an intraluminal or an intraabdominal bleed were chosen for further review. 20 patients (4.4%) developed an acute postoperative hemorrhage. The bleeding was intraluminal in 12 cases (60%), manifested by a drop in hematocrit, tachycardia and melena. The other 8 patients (40%) developed intra-abdominal hemorrhage, confirmed by large bloody output from the drains. 3 patients (15%) with intraluminal bleeding were unstable and required a reoperation. All others were successfully treated with observation, and 15 patients (75%) required blood transfusions. The diagnosis and treatment of acute intraluminal bleeding after LRYGBP represents a surgical dilemma, mainly due to the inaccessibility of the bypassed stomach and the jejuno-jejunostomy, as well as the risks associated with early postoperative endoscopy. The presence of large intra-abdominal drains allows for bleeding site localization (intraluminal vs intraabdominal) and for more accurate monitoring of the bleeding rate. Most cases respond to conservative therapy. Failure of conservative management of intraluminal bleeding, however, is more problematic and may require operative intervention. A treatment algorithm is proposed.

Early post-operative endoscopy after biliary tract surgery.

Immediate post-operative complications such as obstructive jaundice, biliary fistulae or gastrointestinal hemorrhage, occurring after biliary tract surgery can be diagnosed endoscopically. The causes of bile flow obstruction and leakage from the common bile duct can be identified using ERC. In many cases the diagnosis can be followed by endoscopic treatment, therefore obviating re-laparotomy. Between 1972 and 1979 we carried out early post-operative ERC or esophago-gastro-duodenoscopy in a total of 94 patients after biliary tract surgery. In 75 patients with residual gallstones and 4 cases with overlooked stenoses of the papilla, successful papillotomies were carried out. The procedure was unsuccessful in one case with an extremely narrow papilla. Complete removal of stones was achieved in 72 cases. In two other patients with gastroduodenal stress ulcers, bleeding was stopped by submucosal infiltration.

Early postoperative endoscopy in the operated stomach.

Early endoscopy in the upper alimentary tract after surgical operations on the stomach reveals multifarious diagnostic and therapeutic possibilities to give decisive help to patients when applied critically and rationally. The possibilities of endoscopy can differentiate between active and arrested bleeding episodes, can induce hemostasis, can diagnose and overcome sutureline insufficiencies, can differentiate the different kinds of stenosis in the lower esophageal junction. It can treat postoperative atony, diagnose perforation at an earlier stage, localize obstructive jaundice, remove intestinal foreign bodies and characterize unexpected postoperative histological findings.