Oesophageal and gastric bile exposure after gastroduodenal surgery with Henley's interposition or a Roux-en-Y loop

Background: The degree which the various reconstruction techniques prevent bile reflux after gastroduodenal surgery has been poorly studied. Methods: Bile exposure in the intestinal tract just proximal to the jejunal loop was measured with the Bilitec 2000(R) device for 24 h after gastroduodenal surgery in three groups of patients. Group 1 comprised 24 patients,with a 60-cm Henley's loop after total gastrectomy. Group 2 included 31 patients with a 60-cm Roux-en-Y loop after total (22 patients) or subtotal (nine) gastrectomy. Group 3 contained 21 patients with a 60-cm Roux-en-Y loop anastomosed to the proximal duodenum as part of a duodenal switch operation for pathological transpyloric duodenogastric reflux. Bile exposure, measured as the percentage time with bile absorbance greater than 0.25, was classified as nil, within the range of a control population of healthy subjects, or pathological (above the 95th percentile for the control population). Reflux symptoms were scored and all patients had upper gastrointestinal endoscopy. Results: Bile was detected in the intestine proximal to the loop in none of 24 patients in group 1, eight of 31 in group 2 and 12 of 21 in group 3 (P < 0.001). The mean reflux symptom score increased with the degree of bile exposure, and the proportion of patients with oesophagitis or gastritis correlated well with the extent of bile exposure (P < 0.001). Conclusion: A long Henley's loop was more effective in preventing bile reflux than a long Roux-en-Y loop. Bilitec(R) data correlated well with the severity of reflux symptoms and the presence of mucosal lesions

[Drainage-lavage and closure of a late esophageal perforation with esophagopleural fistula and encysted pleural effusion after endoscopic injection sclerotherapy for varices]

We report a case of late perforation of the thoracic esophagus with an esophagopleural fistula after endoscopic sclerotherapy for esophageal varices in a Child-Pugh 89 cirrhotic patient. The existence of a thoracic empyema without diffuse mediastinitis allowed management of the fistula by percutaneous drainage-lavage and antibiotic therapy with subsequent closure of the esophageal wall defect and recovery from sepsis. This observation indicates that minimally invasive management of an esophageal perforation complicated by an esophago-pleural fistula is possible in highly selected patients

Laparoscopic pancreatic resection: a preliminary experience of 15 patients

Background/Aims: Worldwide experience with laparoscopic pancreatic resection remains limited. The aim of the study was to assess the feasibility, safety and outcome of laparoscopic pancreatic resection. Methodology: 15 consecutive patients suffering from benign cystic pancreatic (n=6), neuroendocrine tumors (n=8) or pancreatic metastasis from renal carcinoma (n=1) undergoing laparoscopic pancreatic resection were retrospectively collected from 5 academic hospitals. Results: Laparoscopic procedure was completed in 10 patients, including 7 distal pancreatectomies (with 5 spleen preservation), 2 tumor enucleations and 1 partial cystic resection. Conversion was due to inappropriate operative finding for laparoscopic approach in 2 patients and for uncontrollable bleeding in 3 patients. Postoperative pancreatic-related complications included pancreatic fistula in 20% and peripancreatic collection in 13% of the patients. Conclusions: Laparoscopic pancreatic resection is feasible for distal pancreatic tumors. However, successful management of the pancreatic stump remains the challenge of this procedure, in order to achieve a clear benefit in the patient outcome