Biomedical subjects
Publications and source records attributed to J L Ponsky.
Hepatic portal venous gas is easily diagnosed radiographically by the appearance of tubular lucencies branching horizontally from the porta hepatis and extending to within 2cm of the liver capsule. Associated conditions vary from benign to potentially lethal diseases which require emergency operations. A case of hepatic portal venous gas secondary to small bowel obstruction is presented and a review of the literature is also provided.
BACKGROUND: The gastric pouch to jejunum anastomosis is a critical step in the performance of an isolated Roux-en-Y gastric bypass. When performing this procedure laparoscopically, intracorporeal suturing of the gastric pouch to Roux-en-Y jejunum anastomosis is technically demanding, time consuming, and perhaps the most prohibitive part of the operation. We devised a unique, effective, and simple method to perform this anastomosis using an EEA stapler. This report describes this technique and its follow-up in our series of patients undergoing a laparoscopic isolated Roux-en-Y gastric bypass utilizing this technique. METHODS: A prospective analysis was performed identifying the technical success, leak rate, and postoperative incidence of anastomotic stenosis and its management in a consecutive series of patients undergoing a laparoscopic isolated Roux-en-Y gastric bypass with a gastrojejunal anastomosis constructed with a 21-mm or 25-mm EEA stapler. RESULTS: Forty-eight patients underwent laparoscopic isolated Roux-en-Y gastric bypass. Mean age was 40.9 years (range 22 to 64) and mean body mass index was 52.3 kg/m(2) (range 31 to 76 kg/m(2)). There were no mortalities. Three patients (6.3%) were converted to an open procedure, but only 1 because of an inability to perform the gastrojejunal anastomosis (short jejunal mesentery). There was 1 leak (2.1%) from the gastrojejunal anastomosis. It was successfully managed nonoperatively. Thirteen patients (27.1%) patients developed an anastomotic stenosis requiring endoscopic balloon dilatation. Seven of the 13 patients required only a single dilatation and have had no recurrence of dysphagia. Six of the 13 patients needed 2 to 4 dilatations, and all are swallowing normally. None have required surgical revision. After 12 months of follow-up, the mean weight loss was 115 pounds and mean decrease in body mass index was 18.5 kg/m(2). CONCLUSIONS: The stapled EEA gastrojejunal anastomosis for the laparoscopic isolated Roux-en-Y gastric bypass is safe and effective. Anastomotic stenosis occurs in approximately one quarter of patients, but it can be managed well with endoscopic balloon dilatation.
BACKGROUND: No objective measure of the level of sedation is universally accepted. However, bispectral index monitoring is currently used to objectively measure sedation levels in several clinical settings. This study compares the temporal relationship of bispectral index levels versus the Observer's Assessment of Alertness/Sedation (OAA/S) scale for sedation during endoscopy and proposes a functional bispectral index range for endoscopic procedures. METHODS: Fifty consecutive adults undergoing endoscopic retrograde cholangiopancreatography, colonoscopy, or esophagogastroduodenoscopy by a single endoscopist were studied. Intravenous sedation was achieved with diazepam and meperidine. Bispectral index levels (0 to 100) and OAA/S scores (1 to 5) were recorded every 3 minutes by a single trained observer. RESULTS: There were significant temporal correlations between bispectral index levels and OAA/S scores (r = 0.59, p < 0.0001). Bispectral index levels and OAA/S scores corresponded with the need for additional sedation as determined clinically by the endoscopist. An OAA/S score of 3 corresponded to a bispectral index level of 81.49 +/- 9.78. CONCLUSIONS: Bispectral index monitoring temporally correlates with the OAA/S scale and therefore provides an objective measure of sedation during endoscopy. This preliminary, observational study suggests that a bispectral index level near 82 corresponds with sufficient and functional sedation levels for endoscopy.
In the era of open cholecystectomy, common bile duct stones were approached by traditional choledocholithotomy. Retained or recurrent stones discovered after cholecystectomy were approached by endoscopic extraction techniques or repeat surgery. With the advent of laparoscopic cholecystectomy, the approach to choledocholithiasis became more problematic as techniques for laparoscopic extraction were rudimentary. Preoperative endoscopic retrograde cholangiopancreatography rapidly became an adjunct to laparoscopic cholecystectomy when common duct stones were likely. Experience, however, revealed that many of these procedures were unnecessary. With developing sophistication of laparoscopic techniques, a variety of approaches to common duct stones developed. These included: transcystic extraction, direct laparoscopic choledocholithotomy, intraoperative endoscopic retrograde cholangiopancreatography, antegrade sphincterotomy, and transcystic placement of a common duct stent with subsequent endoscopic sphincterotomy and stone extraction. It is the purpose of this article to define the current role of each of these methods in the laparoscopic approach to choledocholithiasis.
This study reports the histologic changes seen in the biliary ductal system and pancreas as a result of endobiliary stenting. Ten mini pigs underwent endoscopic placement of suprapapillary endobiliary stents. The animals were killed and the liver, biliary tree, and pancreas were resected en bloc and prepared for histologic examination. Endobiliary stenting was found to result in significant chronic inflammation in the biliary system within 4 weeks of stent placement. These changes were present throughout the entire extrahepatic biliary ductal system and persisted throughout the 15-week study period. There was no significant acute inflammation in the biliary tree nor acute or chronic inflammation in the pancreatic duct. Further study is indicated to determine whether these changes will result in fibrosis and stricture.
BACKGROUND: Missed lipoma of the spermatic cord is a pitfall unique to the transabdominal preperitoneal (TAPP) laparoscopic hernia repair. This problem occurs when a palpable inguinal mass is noted preoperatively, but no identifiable hernia defect is found at time of laparoscopy and the procedure is terminated. METHODS: Our group encountered six patients without intraperitoneal defects that had large cord lipomas on preperitoneal exploration. Two of these patients had undergone previous intraabdominal laparoscopy for a proposed TAPP repair, which was aborted when no defect was seen. RESULTS: Both patients were referred for continued symptomatic groin masses, which were subsequently treated by lipoma resection in conjunction with inguinal floor repair. CONCLUSIONS: When patients present with a groin mass, exploration of the preperitoneal space and cord structures is indicated during TAPP repair, even in the presence of a normal-appearing abdominal floor. Abandoning a transabdominal approach without exploration of the preperitoneal structures may lead to a failure to identify symptomatic and/or palpable cord lipomas.
Large sessile lipomas, adenomas, and other tumors are often not amenable to endoscopic excision, due to the risk of bleeding or perforation. Resection of these lesions has traditionally required laparotomy with enterotomy for complete removal. A novel technique, described here, is the combination of laparoscopy and simultaneous endoscopy, allowing for complete removal of these lesions while preserving the benefits of minimally invasive surgery.
BACKGROUND: Biliary fistulae may occur following surgical injury, abdominal trauma, or inadequate closure of a cystic duct stump. These leaks are most often managed by drainage of the associate biloma and either endoscopic sphincterotomy or placement of a biliary endoprosthesis to decrease the pressure gradient between the bile duct and the duodenum created by the muscular contraction of the ampullary sphincter. In a previous study, we demonstrated a statistically significant reduction in ductal pressures following stent placement as compared to sphincterotomy. The goal of this present study was to determine if reduction in ductal pressures correlates clinically with the resolution of biliary leaks in an animal model. METHODS: Fourteen mongrel dogs underwent laparotomy, cholecystectomy without closure of the cystic stump, and a lateral duodenotomy to identify the major papilla. The dogs were then randomized into three groups. Group I (n = 5) was a control group undergoing closure of the duodenotomy only. Group II (n = 4) underwent sphincterotomy. Group III (n = 5) underwent placement of a 7 Fr x 5 cm biliary endoprosthesis prior to duodenotomy closure. A drain was placed adjacent to the cystic duct stump in all groups. Drain output was recorded daily. The biliary leak was considered resolved when the output was < 10 cc/day. Regardless of suspected fistula closure, the drains were not removed until 2 weeks postprocedure. Necropsy was performed to identify undrained intraperitoneal bile. Statistical analysis was performed using Student's paired t test. RESULTS: All dogs had bile leaks identified on postoperative day 1. The number of days required for resolution of bile leak in group I (mean +/- SEM) was 7.60 +/- 0.87 days, as compared to 6.75 +/- 0.80 days for group II and 2.60 +/- 0.24 days for group III. There was no significant difference in the duration of bile leak between groups I and II (p = 0.445). Group III, however, had a significant reduction in the duration of biliary fistulae as compared to both groups I and II (p < 0.005). At autopsy, persistent bilomas were identified in 80% of group I, 25% of group II, and 0% of group III. None of the dogs showed evidence of dehisence of the duodenotomy closure site as a source of bile leak. CONCLUSION: Biliary stenting significantly reduces the time to resolution of cystic duct leaks as compared to sphincterotomy in a canine model. The results obtained in this study support the use of biliary endoprostheses in the management of biliary leaks and fistulae.
The incidence of pseudocysts in patients with chronic pancreatitis ranges from 20-40%. Unlike pseudocysts associated with acute pancreatitis, these do not usually resolve spontaneously. Traditionally, these cysts were drained surgically. More recently, however, they have been successfully managed with endoscopic drainage. This report reviews the history and results of nonsurgical pseudocyst management and describes a case of drainage obtained using an alternative method of ultrasound-directed percutaneous endoscopic cyst-gastrostomy.
BACKGROUND: The role of oxygen-derived free radicals in the pathogenesis of pancreatitis has been supported by data from previous studies using animal models. This study was conducted to determine whether prophylaxis with the xanthine oxidase inhibitor allopurinol would decrease the incidence and severity of pancreatography-induced pancreatitis in a canine model. METHODS: Thirty-two dogs were randomized to receive either placebo or oral allopurinol 1 hour before the procedure. A laparotomy and duodenotomy were performed and a pancreatogram was obtained. Postoperatively, pancreatic enzymes were drawn for 5 days. The animals were then euthanized, and the pancreas was weighed and evaluated histologically. RESULTS: The histologic incidence of pancreatitis was significantly reduced in the allopurinol pretreatment group (6.7%) as compared with the placebo group (41.2%, p < 0.01). A significant decrease in postoperative serum amylase levels among dogs pretreated with allopurinol was also noted. A similar trend was observed in lipase levels. The pancreas weight index was decreased in the allopurinol pretreatment group as well (control = 0.00246 vs. allopurinol = 0.00195, p < 0.02). CONCLUSIONS: Pretreatment with oral allopurinol decreases the incidence of pancreatography-induced pancreatitis. These results support the role of xanthine oxidase inhibitors in the prevention of endoscopic retrograde cholangiopancreatography-induced pancreatitis.
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Laparoscopic procedures are increasingly performed in patients who have undergone prior abdominal surgery. Safe entry into the peritoneum includes avoidance of underlying viscera often tethered to the abdominal wall from surgical adhesions. Our group describes an alternative site technique utilizing the open Hasson procedure in a previously unoperated field, thus avoiding potential underlying adhesions. During the past 24 months this technique has been performed successfully in 95 patients, and no open conversions due to visceral or vascular injuries were necessary. Previous abdominal surgery should not be an absolute contraindication to minimally invasive procedures.
Laparoscopic ventral herniorraphy is an attractive alternative to conventional open repair. It preserves the benefits of minimally invasive surgical procedures by offering decreased discomfort and hospital stay while affording a low recurrence rate. Although technically feasible, unrolling a large piece of prosthetic mesh within the peritoneal cavity is often time consuming and the most frustrating step in the procedure. Our group describes a simplified technique for unrolling mesh that is quick, easy to perform, and requires no specialized equipment.
OBJECTIVE: Pancreatitis remains the major complication of endoscopic retrograde cholangiopancreatography (ERCP). Uncontrolled data suggest a lower incidence of pancreatitis in patients with a history of iodine sensitivity when given pretreatment with corticosteroids. We conducted a clinical trial to assess the efficacy of a commonly prescribed corticosteroid, methylprednisolone, to prevent ERCP-induced pancreatitis. METHODS: Patients were entered into a randomized, multicenter, double-blind, placebo-controlled study of intravenous methylprednisolone (125 mg) versus a saline placebo immediately before the ERCP. All patients were evaluated for early and late complications. RESULTS: Two hundred eighty-six patients were randomized. Thirty-one randomized patients were excluded for technical reasons at the time of ERCP. Overall, the incidence of pancreatitis was 16 of 129 (12.4%, 95% CI: 6.7-18.1%) in the methylprednisolone group and 11 of 126 (8.7%, 95% CI: 4.4-15.1%) in the placebo group, which was not significantly different (p = 0.34). Although there was a higher rate of sphincterotomy performed in the methylprednisolone group compared to the control group (31.8% vs 16.8%, p = 0.005), the incidence of pancreatitis was not different when patients undergoing sphincterotomy were analyzed separately (13.6% in the methylprednisolone group and 9.6% in the placebo group,p = 0.50). There was no significant difference between the two groups for those with ERCP-induced pancreatitis in hospital length of stay (p = 0.22), days of parenteral analgesia (p = 0.09), or days of parenteral nutrition (p = 0.15). CONCLUSION: Intravenous methylprednisolone is not beneficial in preventing ERCP-induced pancreatitis.
Accessing the stomach via a gastrostomy is the preferred method for providing enteral nutritional support when supplementation is required for more than three or four weeks. Since its introduction in the early 1980s, percutaneous endoscopic gastrostomy has become the most popular method for creating a gastrostomy. It is a quick and cost-effective method and has supplanted open gastrostomy for the establishment of a gastrocutaneous fistula to provide access to the stomach for numerous indications. It is associated, however, with serious and potentially lethal complications which must be completely understood by the endoscopist. In addition, patient selection and thorough attention to details are paramount to the performance of a safe percutaneous endoscopic gastrostomy.