2005 SAGES Abstracts

ABSTRACTS Thursday, April 14, 2005
tive day #1. There were two post-operative complications. One
patient required stimulator repositioning due to discomfort
and another required stimulator explantation for overlying skin
erosion after abdominal wall trauma. Patients experienced a
significant decrease in nausea and vomiting as measured by
the GI symptomatology questionnaire. Half of all patients no
longer require prokinetic medications, and there was a subjective
reduction of GERD symptoms, early satiety and epigastric
pain. A significant increase in quality of life as measured by
the Rand 36 Health Survey was seen, and six of eight patients
no longer demonstrated gastroparesis on GES.
CONCLUSION: Laparoscopic implantation of an electrical stimulation
device is a safe and effective treatment for the management
of medically refractory gastroparesis.
S035
ENDOSCOPIC RETROGRADE CHOLAGIOPANCREATOGRAPHY
AND GASTRODUODENOSCOPY AFTER ROUX-EN-Y GASTRIC
BYPASS, Larissa Guerrero BS, Jose Martinez MD,Patricia
Byers MD,Peter Lopez MD,Brian J Dunkin MD, University of
Miami Department of Surgery
Background: One concern in performing Roux-en-Y gastric
bypass (RYGB) for morbid obesity is that subsequent endoscopic
evaluation of the gastric remnant and duodenum is difficult.
By gaining percutaneous access to the gastric remnant,
however, gastroduodenoscopy as well as endoscopic retrograde
cholangiopancreatography (ERCP) can be easily performed.
This report describes the results of a novel technique
for performing ?trans-gastrostomy? gastroduodenoscopy and
ERCP.
Methods: Four patients with a RYGB for morbid obesity underwent
trans-gastric remnant endoscopic evaluations. The
patients had gastrostomy tubes placed into their gastric remnants
by interventional radiology. The tube tracts were then
sequentially dilated over time to 24F. At the time of endoscopy,
the gastrostomy tube was removed, skin anesthetized, and
either a pediatric duodenoscope (outer diameter 7.5 mm) or a
transnasal gastroscope (outer diameter 5.9 mm) was inserted
through the gastrostomy tube tract.
Results: All patients were successfully evaluated. The first
patient had a dilated common bile duct after RYGB; ERCP and
sphincterotomy was done for papillary stenosis. The second
patient presented with a dilated gastric remnant on CT scan;
endoscopic evaluation of the gastric remnant and duodenum
ruled out recurrence of a duodenal tumor which had been previously
resected. The third patient had a nuclear medicine
scan with a localized bleed to the gastric remnant; a healing
pre-pyloric ulcer was seen and biopsied during endoscopy.
The fourth patient necessitated endoscopy to evaluate a prepyloric
ulcer with history of bleeding; endoscopy was successful
and the ulcer was biopsied.
Conclusion: The trans-gastrostomy endoscopic route assures
access to the excluded stomach and proximal small bowel
post RYGB. Studies of transoral endoscopic access to the duodenum
after gastric bypass have reported 60-80% success
rates when using a retrograde approach; the success rate is
even less as the alimentary and biliopancreatic limbs become
longer. Another disadvantage of the retrograde approach is
the use of an enteroscope or pediatric colonoscope without an
elevator for performing ERCP. These longer scopes also render
a number of ERCP tools useless. By contrast, the trans-gastrostomy
endoscopic route is safe and effective and the use of
standard duodenoscopes should improve the cannulation success
rate during ERCP in these patients.
S036
DEVELOPMENT OF A TOTAL COLONOSCOPY MODEL IN RATS
FOR THE STUDY OF COLORECTAL CANCER, Chris Haughn
MD, Miro Uchal MD,Sam Rossi MD,Yannis Raftopoulos
MD,Yunus Yavuz MD,Ronald Mårvik PhD,Roberto Bergamaschi
PhD, Minimally Invasive Surgery Center, Allegheny General
Hospital, Pittsburgh, PA
Experimental models of solid colorectal tumor either require
laparotomy for induction and/or an anastomosis following
resection. The long murine cecum avoids the need for an
anastomosis making cecum the preferred site for induction.
This study aims to evaluate total colonoscopy with sub mucosal
injection of cecal wall (TC) in rats in terms of failure rates
(FR), complication rates (CR) and reproducibility (R).
This protocol was approved by IACUC. A gastric bolus of
bowel prep was given. Anesthesia was injected s.c.. A video
fiberscope (5.9-mm outer diameter, 180°/90° up/down bending,
100°/100° right/left bending, 103-cm working length, 120° view
field, 2.0-mm channel) (GIF-XP160, Olympus) allowed for irrigation,
and suction. 1-ml saline was injected in cecal wall thru
a 2-mm 23-G needle placed on a 2-mm wire (NM 23L,
Olympus) resulting in a visible blister. FR was defined as failure
to reach and inject the cecum. Rats were allowed to recover.
CR was measured at necropsy. R was assessed by comparing
TC time, FR and CR for 3 operators. The sample size of 120
(type I error = 0.05 , power=80%) was based on the outcome of
a pilot study of TC in 152 rats. Data were presented as median
(range). Chi square, Fisher?s exact, or Student?s t-tests were
used for analysis.
2 of122 rats (1.6%) died after prep or anesthesia. Bowel prep
resulted in a 99.3% evacuation of solid feces. 120 male
Sprague-Dawley retired breeders weighing 592 (349-780) gr
underwent TC. Scope depth was 28 (20-36) cm. Irrigating fluid
was 290 (100-600) ml. TC time was 7 (4-28) min. FR was 4%. In
3 failed cases the scope reached the ascending colon. TC was
re-attempted with success in these 3 failed cases 1 week after
failed TC. CR was 2%. There were 2 perforations in the ascending
colon. In these 2 rats bowel perforation accounted for FR.
All 3 operators had similar TC time (p = 0.673), FR (p > 0.1) and
CR (p > 0.1). 98.3% of rats survived to planned sacrifice. No
other complications were found at necropsy.
A reproducibile in vivo rat model has been achieved. This total
colonoscopy model with sub mucosal injection of cecal wall
should provide a valuable tool in the future for studies of solid
colorectal tumors.
S037
LAPAROSCOPIC-ASSISTED TRANSGASTRIC ERCP AFTER
ROUX-EN-Y GASTRIC BYPASS: TECHNIQUE AND RESULTS,
Brian Lane MD, Samer Mattar MD,Faisal Qureshi MD,Joy
Collins MD,Paul Thodiyil MD,Tomasz Rogula MD,Pandu
Yenumula MD,Laura Velcu MD,Guilherme Costa MD,George
Eid MD,Ramesh Ramanathan MD,Adam Slivka MD,Philip
Schauer MD, Department of MIS Surgery, University of
Pittsburgh Medical Center
INTRODUCTION: An emerging dilemma is the difficulty in
obtaining endoscopic access to the biliary tract after Roux-en-y
gastric bypass. Patients who undergo LRNYGB and resultant
weight loss are at risk for gallstone formation and gallbladder/biliary
disease, with a reported combined incidence of
30%. The anatomic changes of current LRNYGB techniques
preclude standard ERCP. There have been isolated case reports
of transgastric and transjejunal intraoperative ERCP in
LRNYGB patients. The purpose of this study is to review our
results and technique in a series of lap-assisted ERCP.
METHODS: All consecutive post LRNYGB patients having a
lap-assisted ERCP from 9/2001 to 7/2004 were included. The
clinical indications for ERCP, success of biliary tree cannulation,
therapeutic interventions employed, operative technique
details, and complications were reviewed.
RESULTS: 7 patients were identified (6 female, 1 male), ranging
in age from 45 to 58. The time interval from LRNYGB was
9 months to 4 years. Indications were: obstructive jaundice (5
patients), gallstone pancreatitis (2 patients), and bile leak (1
patient). Preoperative workup included MRCP in each case. All
patients underwent successful lap-assisted transgastric ERCP.
Technical details will be presented and therapeutic maneuvers
included: 4 sphincterotomies, 3 stone retrievals and one stent
placement for a post-op bile leak. Complications included a
peri-gastrostomy wound infection and a GI bleed that resolved
with expectant treatment.
CONCLUSIONS: Although technically complex, Laparoscopicassisted
transgastric ERCP is feasible and safe after LRNYGB.
These procedures will have a growing need as the national
population of LRNYGB patients increases.
SAGES 2005
http://www.sages.org/
91