Endoluminal Access Research Articles

Retrospective analysis of surgical management options of hepatolithiasis in a tertiary care centre in Bangladesh

Background: Hepatolithiasis (HL) is the presence of stones in the bile ducts proximal to the confluence of the hepatic ducts. It is endemic in the Asia-Pacific region. The etiology of hepatolithiasis is not fully understood but genetic, dietary and environmental factors are thought to be contributory. Malnutrition and low socioeconomic conditions are associated with a high incidence of intrahepatic stones. This study aimed to analyze the demographic and clinicopathological factors, appraise the role of surgical management and analyse the postoperative outcomes of HL in a tertiary care centre in Bangladesh. Methods: This study was conducted in the Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplant (HBPS & LT), BIRDEM General Hospital, Dhaka, Bangladesh. Retrospective data of all patients operated for HL from January 2011 to December 2022 were analyzed with regard to clinical parameters, biochemical parameters and different types of surgical management. Results: A total of 52 patients underwent surgical treatment for HL. Of the patients, 65.4% were female and 34.6% were male. Of the patients, 94.2% had abdominal pain, 57.7% had fever and 28.8% presented with jaundice. A total of 30.8% of patients had a history of previous biliary surgery. Liver atrophy was present in 38.5% of cases. Hepaticojejunostomy (HJ) alone was done in 36 (69.2%) patients, hepatic resection with bilioenteric anastomosis was done in 10 (19.2%) patients and hepatic resection with T-tube placement in common bile duct (CBD) done in 6 (11.5%) patients. Endoluminal access loop was done in 2 (3.8%) patients. On followup visits, 60% of patients were asymptomatic. There was no postoperative mortality. Conclusion: Results from present study revealed encouraging results with minimal post operative complications and no mortality. BIRDEM Med J 2024; 14(3): 137-142

EGS P17 Expanding the technical armamentarium to treat complex oesophageal perforations with Endoluminal Vacuum Therapy

Abstract Background Endoluminal vacuum therapy (EVT) is increasingly the default treatment modality for oesophageal leaks. If the leak cavity is large or has a dependent element, placement of the endoluminal vacuum device within the leak cavity facilitates healing. However, accessing the leak cavity can be challenging when the oesophageal defect communicating with the leak cavity is small, and it is tempting to default to luminal EVT. This can lead to a EVT failure. We present a case where luminal EVT in the presence of an established leak cavity with a narrow inlet resulted in stagnation of therapy requiring an alternative technical approach. Methods An 80-year-old high-risk female with Boerhaave's syndrome presented with a 4cm esophageal defect and a large mediastinal leak cavity. An ad-hoc endovacuum therapy (EVT) device, consisting of V.A.C granufoam (KCI) attached to a 14Fr nasogastric (NG) tube, was placed in the leak cavity at -125mmHg pressure. The EVT device was replaced every 3-8 days. After 101 days, luminal EVT was adopted due to cavity narrowing. Partial closure of the esophageal defect was achieved, but a persistent mediastinal abscess communicated through a residual pinhole defect. Additional luminal EVT and image-guided drainage couldn't resolve the persistent esophageal fistula, confirmed by contrast-enhanced CT. Results Endoluminal access to the leak cavity was re-established by dilating the fistula using a TTS 12mm radial expansion wire-guided balloon catheter enabling re-establishment of intra-cavity EVT. Having regained access, further intra-cavity EVT using an ad-hoc EVT device fashioned from black granufoam (KCI) sutured to a 10Fr or 12Fr ng tube with 125mmHg negative pressure was applied. The EVT device was changed every 3-6 days. After further 25 days of EVT complete healing was observed. Conclusions Whilst intraluminal EVT has a role in oesophageal leaks associated with small leak cavities which have no dependent element, larger leak cavities require intra-cavity EVT. If access to the leak cavity is challenging due to the small size of the oesophageal defect, endoscopic measures to facilitate endoluminal access to the leak cavity such as dilation of the defect can be safely employed to enable delivery of intra-cavity EVT. This should be considered when endoluminal access to the leak cavity is prevented due to the small size of the defect obviating the need for other more invasive interventions such as surgery.

Hepatolithiasis: A Retrospective Analysis of Surgical Management Options in a Tertiary Care Centre in Southern India.

Introduction: Hepatolithiasis (HL) is the presence of stones in the bile ducts proximal to the confluence of the hepatic ducts. This study aims to analyse the case presentations of HL in a tertiary care centre in South India and define the role of hepatic resection in these cases and their outcomes.Methods: Retrospective data of all patients operated on for HL from 2012 to 2021 were analysed with regard to clinical parameters, biochemical parameters, and different types of surgical management. Descriptive data analyses were done.Results: A total of 42 patients underwent surgical treatment for HL between 2012 and 2021 in our institution. Of the patients, 64% were females. A total of 50% of patients were affected by bilateral HL. Of the patients, 95% had abdominal pain, 57% had a fever, and 29% presented with jaundice. A total of 38% of patients had a history of previous biliary surgery. Atrophy was present in 38% of cases. Choledochoduodenostomy was performed in 26%, and hepatic resection with bilio-enteric anastomosis was done in 36% of patients. Endoluminal access loop was done in 21%. Hepaticojejunostomy alone was done in 14%. On follow-up visits (mean: 61.5 months), 60% of patients were asymptomatic with no recurrence. There was nil 30-day postoperative mortality.Conclusion: The treatment options for HL were based on the extent of liver involvement. The bilio-enteric anastomosis was done after the clearance of stones for uncomplicated HL. Complicated HL may need liver resection with hepaticojejunostomy, with an endoluminal access loop for a good outcome.

Transvaginal rigid-hybrid NOTES cholecystectomy: evaluation in routine clinical practice

Cholecystectomy using a rigid-hybrid transvaginal natural orifice transluminal endoscopic surgery (NOTES) approach (tvNCC) reduces abdominal wall incisions and might decrease surgical trauma by combining endoluminal access and laparoscopic techniques. We assessed the feasibility and safety of rigid-hybrid tvNCC in routine practice for symptomatic cholecystolithiasis or acute cholecystitis in a patient population with low selection. From September 2008 to July 2009, all female patients with cholecystectomy indications were evaluated for tvNCC. Exclusion criteria were: refusal of tvNCC; inability to give informed consent; gynecological or urological contraindications; lack of preoperative gynecological examinations; need for cholangiography/choledochus revision; anesthesiological contraindications to pneumoperitoneum; liver failure; or coagulopathy. Age, obesity, previous surgery, or degree of gallbladder inflammation were not exclusion criteria. Preoperative and 2-weeks' postoperative gynecological examinations were performed. Sexual function was assessed preoperatively and at 6 weeks postoperatively. 102 of 137 consecutive patients (74.5 %) with symptomatic cholecystolithiasis (n = 74) or cholecystitis (n = 28) were scheduled for rigid-hybrid tvNCC with nine different surgeons. Patient mean age was 52.3 +/- 17.8 years (range 18 - 87) and mean body mass index 27.3 +/- 6.3 kg/m (2) (17.6 - 43.8). Two patients had conversion to conventional laparoscopic cholecystectomy. There were no intraoperative complications. Two major complications occurred: one stroke and one herniation within the transumbilical access. Minor complications were reported in 13 patients (12.7 %) and there were no serious postoperative gynecological findings. At 6 weeks postoperatively, there were fewer dyspareunia symptoms than preoperatively ( P = 0.049). Rigid-hybrid tvNCC is feasible and safe in routine practice for symptomatic cholecystolithiasis and acute cholecystitis.

A Laparoscopic Endovascular Aortobifemoral Conduit That Can Be Retained as a Long-term Bypass: A Solution for Patients With Inadequate Iliac Access

To present a laparoscopic technique for placing a partially stented aortobifemoral (ABF) conduit that can be used for more proximal endovascular manipulations and then be retained as a permanent bypass of occlusive iliac disease. Ethical approval was obtained to use a fresh frozen cadaver. The left common iliac artery, distal aorta, and proximal right common iliac artery were dissected laparoscopically. A curved hollow needle was inserted into the distal aorta, and wire access was obtained. A partially stented bifurcated Dacron bypass graft was deployed under fluoroscopic guidance into the distal aorta. The limbs of the bypass were then used as conduits for endovascular access before being tunneled behind the ureters and anastomosed to the femoral arteries in the usual way, retaining the stented graft as an ABF bypass. This novel technique combines laparoscopic access with endovascular manipulation to place an ABF conduit, which can be retained as a permanent bypass without the need for an abdominal incision. This technique could provide a minimally invasive solution for pelvic occlusive disease that hinders endovascular repairs, as well as a minimally invasive means of securing endoluminal access in patients with iliac arteries of inadequate caliber.

Double-balloon Endoscopy for Retrograde Cholangiography in Patients with Choledochojejunostomy and Roux-en-Y Reconstruction

Choledochojejunal anastomoses with Roux-en-Y reconstruction excludes the biliary tract from conventional endoscopic retrograde cholangiography (ERC) with standard endoscopes due to the length of the interposed small bowel segment. Double-balloon enteroscopy (DBE) facilitates deep insertion into the small bowel and may be used to perform ERC in these patients. In the present case series we report our experience with diagnostic and therapeutic double-balloon ERC in patients with choledochojejunostomy to a long Roux-en-Y loop previously unavailable for standard length endoscopes. Between December 2004 and May 2008 15 patients (mean age: 60.2 years) with choledochojejunal anastomosis underwent a total of 25 DBE-ERC procedures. Cannulation of the bile ducts was achieved in 22 / 25 procedures (84 %). Twenty-one therapeutic interventions, including stone removal, biliary duct dilation, stent placement and removal of previously placed stents were performed during 16 procedures in 8 patients. The mean total duration time of the procedures was 74.6 +/- 25.0 minutes. Postinterventional self-limiting fever occurred after 4 procedures in 3 patients with cholangitis. After therapeutic interventions all patients had a significant drop of bilirubin levels and all except one patient were free of complaints (follow-up 10.4 +/- 8.6 months). The DBE system permits diagnostic and therapeutic ERC in surgically modified anatomy, previously unavailable for endoluminal access. In our experience this procedure is safe and has a high success rate with a favourable patient outcome.

Minimally Invasive Therapy of Pseudoaneurysms of the Trunk: Application of Thrombin

Thrombin injection has been proven to be successful in postcatheterization pseudoaneurysms. However, there are only a few reports on the treatment of pseudoaneurysms of the trunk. We report our first experiences using a percutaneous as well as an endovascular access. Eight iatrogenic pseudoaneurysms of the trunk (aorta, n = 4; pulmonary artery, n = 1; gastroduodenal artery, n = 1; left gastric artery, n = 1, renal artery, n = 1) were treated either percutaneously using CT guidance (n = 3) or via an endovascular access (n = 5). Noninvasive control angiograms were performed at day 1 and weeks 1 and 3 by either CT or MR angiography. The total volume of the pseudoaneurysms was 31.2 +/- 23.1 ml on average, with a mean volume of the perfused aneurysmal lumen of 12.9 +/- 7.2 ml. The maximum diameter was 4.1 +/- 1.39 cm on average. In each case, the aneurysmal neck was not wider than 2 mm. One pseudoaneurysm occluded spontaneously following selective catheterization. The remaining pseudoaneurysms were successfully treated by injection of 765 +/- 438.1 IU thrombin. In one individual, a nontarget embolization occurred, as well as an intervention-associated rupture of a pseudoaneurysm. High-grade stenoses of the donor artery were found in a different case. Only once was the endoluminal access converted to a percutaneous one. Thrombin injection might be a future first-line treatment of vascular lesions such as pseudoaneurysms of the trunk. In our experience both percutanous and endoluminal access are technically feasible and safe. However, further experiences are mandatory, especially concerning the question of dosage and long-term results.

Endoscopic full-thickness resection of the stomach

Endoluminal endoscopic resections of the gastrointestinal (GI) tract have had increasing significance in recent years. Except for the extraperitoneal part of the rectum, endoscopic resections are restricted to the mucosal and submucosal layer to preserve the integrity of the GI tract wall. The SurgAssist is the first flexible stapling device consisting of a 2,000-mm-long flexible shaft and a stapling magazine that can be positioned intraluminally and used with a remote control. To prove the principle, we investigated the endoluminal application of an endoscopically assisted and intraluminally visualized full-thickness resection of the gastric wall in a pilot study of three pigs and a series of three human exenterates. Full-thickness resection of the gastric wall in pigs can be performed with the SurgAssist flexible stapling device from an endoluminal access. However, due to the small lumen of the esophagus, the simultaneous transesophageal introduction of the stapler shaft and gastroscope is not possible in pigs. The same procedure in three human exenterates showed that the simultaneous introduction of the flexible stapler and a standard gastroscope could be achieved without damaging the esophageal wall. Full-thickness resections of up to 4 x 4 cm were carried out with the use of two or three stapler magazines. The resulting sutures were found to be airtight upon endoscopic inflation of the stomach. The clinical use of the SurgAssist intraluminal stapling device for endoscopic full-thickness resection of the gastric wall seems applicable for lesions in suitable locations of the stomach. Gastrointestinal stroma tumors and T1 tumors of the lower gastric corpus and antrum region are possible indications.

Full thickness resection device (FTRD) for endoluminal removal of large bowel tumours: development of the instrument and related experimental studies

We describe a novel device for full thickness resectioning of large bowel lesions. The device has been assessed in experimental studies. Tumours of the large bowel are a frequent disease with increasing incidence figures. If detected at an early stage, local treatment of colon tumours is possible through an endoluminal access. Currently, full thickness resection can only be performed in the rectum with the TEM technique, while snare resection through the flexible endoscope will only allow mucosa resection. We have developed a new device which allows full thickness bowel wall resections up to the splenic flexure. The device, called full thickness resection device (FTRD) has a flexible shaft and a multifunctional front-end. It can be inserted into the colon over a flexible endoscope. After the device is advanced to the tumour, the head can be opened and the tumour, including safety margins, is pulled into the resection chamber inside the device head by means of two tissue graspers. The bowel wall invagination can be visualised with the endoscope to ensure that the tumour is completely pulled into the resection head. The head is then closed and the resection mechanism is activated. A semicircular stapling suture is fired through the bowel wall and a rotary knife is used to cut the tissue. Specimens of > 3 cm can be harvested with FTRD. Prototypes of the device have been successfully tested in a series of animal experiments in parallel to the technical development of the instrument. These experiments could demonstrate that full thickness bowel wall resection is feasible using a flexible instrument and endoscopic visualisation.