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Treatment Using the SpyGlass Digital System in a Patient with Hepatolithiasis after a Whipple Procedure.

ABSTRACT: An 89-year-old man was referred to our hospital for treatment of hepatolithiasis causing recurrent cholangitis. He had undergone a prior Whipple procedure. Computed tomography demonstrated left-sided hepatolithiasis. First, we conducted peroral direct cholangioscopy (PDCS) using an ultraslim endoscope. Although PDCS was successfully conducted, it was unsuccessful in removing all the stones. The stones located in the B2 segment were difficult to remove because the endoscope could not be inserted deeply into this segment due to the small size of the intrahepatic bile duct. Next, we substituted the endoscope with an upper gastrointestinal endoscope. After positioning the endoscope, the SpyGlass digital system (SPY-DS) was successfully inserted deep into the B2 segment. Upon visualizing the residual stones, we conducted SPY-DS-guided electrohydraulic lithotripsy. The stones were disintegrated and completely removed. In cases of PDCS failure, a treatment strategy using the SPY-DS can be considered for patients with hepatolithiasis after a Whipple procedure.

SUBMITTER: Harima H

PROVIDER: S-EPMC6283764 | biostudies-literature | 2018 Nov

REPOSITORIES: biostudies-literature

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Treatment Using the SpyGlass Digital System in a Patient with Hepatolithiasis after a Whipple Procedure.

Harima Hirofumi H Hamabe Kouichi K Hisano Fusako F Matsuzaki Yuko Y Itoh Tadahiko T Sanuki Kazutoshi K Sakaida Isao I

Clinical endoscopy 20180523 6

An 89-year-old man was referred to our hospital for treatment of hepatolithiasis causing recurrent cholangitis. He had undergone a prior Whipple procedure. Computed tomography demonstrated left-sided hepatolithiasis. First, we conducted peroral direct cholangioscopy (PDCS) using an ultraslim endoscope. Although PDCS was successfully conducted, it was unsuccessful in removing all the stones. The stones located in the B2 segment were difficult to remove because the endoscope could not be inserted ...[more]

PMID: 29788693

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Project description:IntroductionWhipple procedure is one of the major surgeries performed in tertiary care centers. Once considered a high mortality procedure is now being practicing with mortality declining to less than 5%. This study describes our five-year experience of the Whipple procedure in terms of preoperative, operative, and postoperative parameters of patients undergoing surgery in a local tertiary care setting.Material and methodsThis was a non-randomized interventional study that was conducted at the Surgical Department of Services Hospital Lahore from January 2014 to December 2018. A total of 57 Whipple procedures were performed during this period. Demographic data, presenting symptoms, physical signs, past medical history, preoperative stenting details, intra-operative duration of surgery, postoperative course and complications, pathology, and causes of postoperative death were collected on a pre-designed questionnaire. Data were entered and analyzed by using SPSS 22 (IBM Corp., Armonk, USA).ResultsOut of 57 patients, 19 were females and 38 were males. The mean age of patients was 53±05 years. The most common presenting symptom was jaundice 39 (68.4%), followed by abdominal pain 32 (56.1%). The mean size of the tumor on CT-scan was 2.8±1.4 cm, the mean operation time was 315±38.3 min, mean blood loss during surgery was 500±130 ml, and mean hospital stay was 10±6 days. The major postoperative complication was the pancreatic fistula (12%). Twenty-one out of 39 patients presented with jaundice had undergone preoperative biliary stenting by endoscopic retrograde biliary stenting. The most common histological diagnosis was adenocarcinoma of pancreas 19 (33.3%). Out of 57 patients, nine (15.8%) patients expired in the first 30 days and the most frequent cause of mortality was septic shock.ConclusionIn this study, the most common presentation of patients undergoing Whipple procedure was obstructive jaundice, the most frequent operative complication was pancreatic fistula, and the most prevalent histopathology was carcinoma of the pancreas. Perioperative parameters such as mean operative time, mean blood loss during surgery, and mean length of hospital stay were comparable with other studies. However, mortality in this study was slightly higher. It can be concluded that with meticulous surgical technique, securing hemostasis strictly and standard critical care postoperatively can decrease morbidity and mortality after the Whipple procedure.

Project description:Interventions: All patients will follow the RPA Whipple’s protocol for oral diet progression. Oral diet: NBM day 0-1, Clear Fluid diet day 2-4, Full Fluid diet day 3-5, Post Gastrectomy diet day >4. Where clear diet is clear liquids only, full fluid diet is opaque liquids only and post gastrectomy diet is a diet and meal frequency appropriate for patients in the early post-operative phase after a gastrectomy or oesophagogastrectomy, and to minimise risk of dumping syndrome or oesophageal blockage (as per NSW Agency of Clinical Innovation diet specifications] . The intervention group (n = 10) patients will be placed on TPN within 24hrs post pancreaticoduodenectomy with oral diet progression. TPN will be calculated to meet patient’s estimated nutritional requirements using Schofield Equation. TPN will be titrated to goal rate using existing practice as per hospital policy Parental Nutrition (ICU patients)”.TPN will be given via pre-existing central line inserted pre-op. IV fluids given to intervention arm as per RPA Hospital Pancreaticoduodenectomy Checklist [IVT Day 0 post-operatively use Hartman’s Solution. Chart rate at 150mls/hour and on the ward if a fluid bolus is required, the preference is to use 100mls 20% Albumin] Diet progression: Day 0-1: NBM + TPN goal rate Day 2-4: Clear Fluid diet + TPN goal rate Day 3-5: Full Fluid diet + TPN half goal rate Day > 4: Post Gastrectomy diet + TPN half goal rate or ceased In addition to the above as deeded appropriate by the medical team, the patients may receive: IV fluids to meet hydration needs, oral nutritional supplements as appropriate (if oral intake is inadequate to meet estimated nutritional requirements alone). The number of days from initial surgery to when the TPN is ceased will be recorded. Primary outcome(s): The primary aim of this study is to determine the feasibility of providing total parenteral nutrition meeting estimated nutritional requirements versus standard diet progression post pancreaticoduodenectomy. [Composite primary outcome: The retention rate will be defined as the percentage of individuals who completed the intervention. This will be determined post discharge of the patient from Royal Prince Alfred Hospital. Adherence will be defined as the percentage of TPN goal rate reached. Adherence will be calculated at day 4 post randomisation, and will be determined by number of patients in the intervention group who had reached goal rate TPN and the number of days at goal rate. The goal rate of TPN will be determined in ICU and will be calculated using Schofield Equation specific for the individuals age and gender, with activity factor of 1.0-1.1 and injury factor of 1.2-1.25 and estimated protein requirements using protein targets of 1.2-1.5g/kgBW/day as per ESPEN guideline on clinical nutrition in the intensive care unit. ] Study Design: Purpose: Treatment; Allocation: Randomised controlled trial; Masking: Open (masking not used);Assignment: Parallel;Type of endpoint: Efficacy

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Treatment Using the SpyGlass Digital System in a Patient with Hepatolithiasis after a Whipple Procedure.

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Treatment Using the SpyGlass Digital System in a Patient with Hepatolithiasis after a Whipple Procedure.

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