Welcome to the August issue of the Surgeons’ Lounge. I hope all of our readers enjoyed the stories relating to current issues in colorectal surgery and surgery of the foregut from our three previous issues. We are interested in receiving stories and updates regarding all areas of surgery, and welcome our readers’ suggestions for future issues of Surgeons’ Lounge.
In this issue, our guest expert is Eduardo A. Souchon, MD, FACS, professor of surgery, Department of Surgery at The University of Texas Medical School at Houston, discusses the cas e of a patient with a pseudocyst. We also present “The Latin Quarter” section this month with guest expert, Fernando Dip, MD, chief of research surgery, Surgical Oncology, Hospital de Clinicas Jose de San Martín in Buenos Aires, who discusses the use of fluorescence-guided surgery. Our next guest expert will be Andreas G. Tzakis, MD, PhD, director, Transplant Center at Cleveland Clinic Florida, in Weston.
Finally, our Surgeon’s Challenge presents a case of a 44-year-old woman with a symptomatic ventral hernia.
I look forward to your questions, comments and feedback.
Samuel Szomstein, MD, FACS
Editor, The Surgeons’ Lounge
Dr. Szomstein is associate director, Bariatric Institute, Section of Minimally Invasive Surgery, Department of General and Vascular Surgery, Cleveland Clinic Florida, Weston.
A55-year-old man with a history of alcoholism and recurrent pancreatitis was admitted for acute-onset abdominal pain and nausea. He had multiple previous workups for upper gastrointestinal (GI) bleeding that showed no gastric or duodenal source. At this admission, he was found to have an infected pancreatic pseudocyst. A computed tomography (CT) scan showed a large, multiloculated pseudocyst with complex fluid (Figures 1 and 2). An endoscopic retrograde cholangiopancreatography (ERCP) and a stented minor papilla did not alleviate the symptoms. Via interventional radiology, a drain was placed in the pseudocyst and the patient was given antibiotics based on fluid culture results. One week later, the patient’s hemoglobin had significantly dropped and he was found to have active extravasation from the gastroduodenal artery (Figure 3). He underwent angiography with interventional radiology and a stent was placed across the hepatic artery proper (Figures 4 and 5). The patient became hemodynamically stable, but still had greater than a 500 cc daily output from the pseudocyst, despite the pancreatic stent.
Question 1. Given the history of multiple episodes of upper GI bleeding, with no source, in the setting of a pseudocyst and chronic pancreatitis, do you think earlier angiography would have been warranted?
Question 2. Would you consider a surgical drainage procedure for management of this pseudocyst in the acute setting? How long after resolution of the hemorrhage would you wait?
Question 3. Is there any additional workup you would have recommended early in this patient’s care?
Question 1. Yes. Given that the patient had multiple recurrent episodes of upper GI bleeding with no source noted on endoscopy, angiography would have been indicated in this specific patient. With pancreatic pseudocysts—especially when they are large and in close proximity to major vessels—erosions and hemorrhage may occur. Such complications from pancreatitis are well published, and usually involve the gastroduodenal artery, splenic artery or inferior pancreaticoduodenal artery. Although acute hemorrhage requires immediate surgical intervention, angiography has become widely available and should be used in both an acute and nonacute setting and if possible, treatment via embolization or stenting also should be used.1
Question 2. I would not recommend a surgical drainage procedure in the acute setting. Assuming the hemorrhage has been dealt with, the psuedocyst is likely filled with hard, clotted blood and would not be easy to isolate and operate on. Although a cystenterostomy is indicated in a staged manner, it would be most prudent to wait for the clot to soften, and most importantly, for the pseudocyst wall to mature. It is important to keep in mind that a pseudocyst is so named because it is an inflammatory reaction. I would recommend waiting, rescanning the patient, and confirming that the pseudocyst has matured with a wall thickness of 4 to 5 mm before attempting a surgical drainage procedure. It also is key to isolate which organ is in closest proximity to the cyst in order to plan the appropriate anastomosis. Of note, newer modalities, including endoscopic ultrasound (EUS), have been used to drain and treat pancreatic pseudocysts.2 However, the negatives include a failure rate of almost 25% and complications such as perforation that require emergent surgery. Although EUS drainage may be criticized as a short-term solution, current case reviews show near resolution in a clear majority of the patients.3,4 In a high-risk surgical patient, or one in whom isolating the pseudocyst or the anastomosis would be difficult, EUS-guided treatment should be considered as a viable option.
Question 3. The specific description of this pseudocyst included multiple loculations with different fluid densities. This should always trigger a workup for pancreatic malignancy, specifically cystadenocarcinoma of the pancreas. Fluid and cyst wall cytology and pathology should be reviewed. Although the history of alcoholism and chronic pancreatitis suggests a pseudocyst, one should always rule out malignancy where appropriate.
The Use of Fluorescence-Guided Surgery
When performing surgery, accurate recognition of the anatomy is essential. New technologies have been developing to facilitate the dissection and identification of structures. Fluorescence-guided surgery is a new and promising method. Using adequate fluorescent dye and appropriate laparoscopic equipment, the specific tissue can be illuminated. We focus our discussion here on the application of this new technology in laparoscopic cholecystectomy.
Minimally invasive surgery has become the procedure of choice for cholecystectomies.1 It is essential to have a thorough knowledge of the anatomy of the biliary ducts including the multiple variations of the biliary tree.2,3 Experience is essential, but not sufficient to protect surgeons and patients from biliary injury.4 Bile duct injuries are estimated to occur at a rate of 0.5%.5 The rate of injury remains stable but the frequency has increased because of the rising numbers of cholecystectomies performed. Injury occurs mainly from the misidentification of ducts. Inexperience, inflammation and aberrant anatomy are key risk factors.6
For many years, intraoperative cholangiography (IOC) was used to define the biliary anatomy and also to mitigate the severity of bile duct injury. Recently, the routine use of IOC has become controversial.7 Radiation exposure, high cost and prolonged operative time are disadvantages of the procedure.8,9 The development of new imaging methods is necessary because standard cholangiography requires incision of the cystic duct before definitive identification of the biliary structures. Fluorescent cholangiography is a new technique that creates illumination of the biliary structures using a fluorescent dye that is injected intravenously, and a special light source.10
The fluorescent imaging system consists of a light source and a filter that emits infrared and xenon light. This system is incorporated into the charge-coupled device, camera and scope that can filter out light with wavelengths below 810 and above 800 nm (Figure 1a). The light of the laparoscope can easily be changed to the infrared view using a pedal.
Indocyanine green is a fluorescent dye that has been approved for multiple clinical purposes. It is used in cardiac, hepatic and ophthalmic angiography.11 When illuminated by infrared light, the dye manifests fluorescence. The dye has 0.003% toxicity level in a dose of 0.5 mg/kg. The main pathway for excretion is hepatic.
The procedure begins with administration of a single dose of 0.05 mg/kg of indocyanine green dye one hour before surgery. A Storz® xenon light source and a laparoscope with a charge-coupled device that filters out light wavelengths (except 830 nm with a specific 780 nm infrared light source), are used intraoperatively. Abdominal inspection with standard trocar placement is performed while the dye is excreted through the liver (Figures 1b and 1c). The fluorescence system is then easily activated using a pedal, thus creating luminance from the biliary structures. The fluorescence provides visualization of the trajectory of a cystic duct. Localization of the hepatic ducts or accessory ducts also is possible.
Fluorescent cholangiography is a novel technique that does not require further training. A pedal conveniently activates the fluorescent system, therefore making it easy for the surgeon to switch between the standard and the fluorescent view. The dye can be administered in a shorter time frame before surgery although it is preferable that the dye is injected one hour preoperatively. In the case of symptomatic cholelithiasis, the dye can even be administered during anesthesia induction. The fluorescent dye is still visible two hours after the time of injection. The degree of fluorescent illumination of biliary structures varies due to different tissue types and the extent of tissue inflammation. When the depth of the tissue is increased, such as in acute or chronic cholecystitis, the quality of luminance is lowered. However, the fluorescence would continue to guide further dissection. Fluorescence from the liver illuminates the abdominal cavity to show the movements of the laparoscopic instruments during dissection. The cost and the risk for radiation exposure of the procedure are lessened because fluoroscopic imaging is unnecessary.
In some cases where the cystic and choledochal junction are not visible (as with a long and parallel cystic duct), compression of the main bile duct with a grasper can show reflux of the dye to the gallbladder, thereby delineating the structures. In another maneuver, lifting the liver enhances the appearance of the hepatic duct bifurcation. Injuries related to the cannulation of biliary structures are avoided because no invasive maneuvers are performed with fluorescent cholangiography.
Data were obtained from 65 patients who underwent laparoscopic cholecystectomy with fluorescent cholangiography. During the procedure, alternate exposure from xenon to infrared lights was used to identify the biliary structures before and after dissection (Figures 2a, 2b and 2c). Standard cholangiography was performed in all cases. A questionnaire to assess the surgeon’s visibility with and without fluorescent-guided identification of extrahepatic bile ducts was distributed.
In the study cohort, 42 patients were diagnosed with symptomatic cholelithiasis: 15 with acute cholecystitis and 12 with chronic cholecystitis. Fluorescence alone, without any dissection, identified the cystic duct in 47 cases. In all cases, the surgeons confirmed biliary anatomy with fluorescence before catheterization and transection of the cystic duct. Results from the questionnaire showed that surgeons found the technique convenient relative to traditional cholangiography and without a significant increase in length of operation time (estimated increase was two minutes).
Fluorescent cholangiography with indocyanine green appears to be a viable method for real-time detection of the extrahepatic structures without catheterization of the bile duct.
An international group dedicated to the study and implementation of fluorescent imaging techniques in surgery was recently formed. The International Study Group of Fluorescence Imaging in Surgery was created in association with Cleveland Clinic Florida, Hospital de Clinicas Buenos Aires and University of Tokyo. The group’s main objective is to share knowledge and experience, and to bring surgeons together from around the globe who are working on fluorescence imaging or are interested in learning more about its application. Our readers are invited to join this group.
A44-year-old woman with a past medical history of idiopathic thrombocytopenic purpura had a symptomatic ventral hernia from a previous midline incision. She underwent a partial hysterectomy and a concomitant ventral hernia repair with synthetic mesh in January 2012. Her postoperative recovery was complicated by severe bleeding for which she needed a blood transfusion. She developed a seroma and had 1.3 L of serosanguineous fluid percutaneously drained in March 2012, and another 600 mL percutaneously drained in April 2012. In December 2012, she was found to have leukocytosis of 20 K and an abdominal computed tomography (CT) showed that the hernias had recurred, and also confirmed an inflammatory process. She was taken to the operating room and the synthetic mesh was replaced by a biological mesh. She was discharged with multiple drains. After the drains were removed, the seroma recurred. A subsequent CT scan in April 2013 showed that the seroma was now loculated and only 400 mL of fluid was removed percutaneously (figures 1 and 2).
Challenge question: What is the best course of action at this time?