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Biomedical subjects

C R Voyles

Publications and source records attributed to C R Voyles.

At least 19 recordsLinked to original sources
PubMed1997

Selection criteria for laparoscopic cholecystectomy in an ambulatory care setting.

BACKGROUND: The ambulatory care center offers patient convenience and reduced costs after uneventful laparoscopic cholecystectomy. METHODS: A prospectively accumulated database of 1,750 cholecystectomies performed by one surgeon in a hospital setting was analyzed to test criteria for ambulatory cholecystectomy. Proposed criteria included age less than 65, absence of upper abdominal operations, and elective operations in healthy patients at low risk for common bile duct stones. RESULTS: Of 1,750 cholecystectomies, only 605 patients met all criteria for outpatient care. Discharge (from the in-hospital setting) was accomplished within 24 h of operation in 92% (first 3 years) and 98% (last 4 years) of selected cases. Only one patient (0.2%, 1/605) was converted to an open procedure; another was readmitted 30 h postoperatively with hemorrhage from the liver bed. CONCLUSIONS: Laparoscopic cholecystectomy can be performed safely in an ambulatory care setting, given careful selection and education of patients and documented experience of the surgical team.

Abdomen↗
PubMed1995

Laparoscopic electrosurgical complications and their prevention.

Insulation failures, direct coupling, and capacitive coupling around active electrodes may cause serious burns and tissue damage to patients undergoing laparoscopic procedures. A coordinated team effort between perioperative nurses and surgeons can prevent life-threatening complications from laparoscopic electrosurgical procedures. Knowledge of the biophysics of electrosurgery, the mechanisms of electrosurgery complications, and prevention of patient injuries will empower surgical team members to provide quality outcomes for patients undergoing laparoscopic procedures.

Adult↗
PubMed1995

Steam sterilization of laparoscopic instruments.

Because of the intricate internal parts of laparoscopic instruments, questions have been raised about the efficacy of cleaning and sterilization techniques. To assess these risks, hamburger meat was inoculated with high concentrations of vegetative pathogens and packed into laparoscopic cannulas. All openings of the cannulas were sealed during steam sterilization cycles ranging from 3 to 10 min in different experiments; cultures were obtained after cooling. Experiments were then performed using heat-resistant spore forms. Our studies showed that both the standard 10-min cycle and the 3-min "flash" were uniformly successful in killing all pathogenic microorganisms. A 7-min steam sterilization was necessary to kill spores within sealed cannulas. We conclude that a standard 10-min cycle within the steam autoclave provides complete sterilization of laparoscopic instruments; the 3-min "flash" sterilization is appropriate and safe for instruments that have been inadvertently contaminated or dropped during a surgical procedure.

Equipment Contamination↗
PubMed1994

Unrecognized hazards of surgical electrodes passed through metal suction-irrigation devices.

Surgical electrodes, passed through metal suction-irrigation devices, pose significant risks for unrecognized visceral burns through capacitively coupled current using monopolar electrosurgery. Plastic cannulas (and reducers) should be avoided with the metal suction-irrigation electrode; an all-metal trocar cannula confers limited safety. With surgeon education and advances in engineering, the potential for unrecognized visceral injury with capacitive coupling can be eliminated.

Burns↗
PubMed1994

Common bile duct evaluation in the era of laparoscopic cholecystectomy. 1050 cases later.

OBJECTIVE: The authors documented the evolution of common bile duct (CBD) evaluation after the development of laparoscopic cholecystectomy (LC) and CBD exploration. Emphasis was placed on stratification of CBD stone risk so that subgroups could be selected appropriately for no further studies, preoperative endoscopic retrograde cholangiogram (ERC), or intraoperative intervention. METHODS: Data were accumulated by the authors on presentation, findings, and outcomes of 1050 patients who underwent cholecystectomies. Risk stratification was based on the history, ultrasound findings, biochemical derangements, and operative findings. RESULTS: Fifty-seven per cent of patients met criteria to be "no/low" risk for CBD stones (CBD diameter < 5 mm, normal liver enzymes, and no history of acute cholecystitis, jaundice, or pancreatitis); in these patients, cholangiograms were not obtained, and there was no clinical evidence of CBD stones observed in follow-up at 45 months (sensitivity = 100%). As techniques developed for laparoscopic CBD exploration, there was a decreased incidence of open cholecystectomy (p < 0.05) and preoperative ERC (p < 0.05). The rate of operative cholangiogram increased from 13% to 23% during the series (p < 0.01). There were no CBD injuries or late strictures. The only bile leak occurred from a peripheral segmental duct in the gallbladder bed and was resolved with a laparotomy and suture. There were no transfusions. Three retained stones were documented in patients who had false-normal operative cholangiograms. CONCLUSIONS: Criteria were defined that delineate a "no/low" risk group of LC patients for whom operative cholangiograms were not indicated for excluding CBD stones. The routine use of operative cholangiography as a means of preventing CBD injury was not substantiated by this study. The indications for preoperative ERC should continue to decrease as laparoscopic techniques evolve.

Adolescent↗
PubMed1992

Multipractice analysis of laparoscopic cholecystectomy in 1,983 patients.

We analyzed the results of laparoscopic cholecystectomy in 1,983 patients from a variety of practice settings in order to evaluate a large, cross-sectional experience for this new procedure. Twenty general surgeons from 9 clinics in 4 states examined the records and outcome of their laparoscopic cholecystectomy patients through March 1991. In 88 patients (4.5%), the operation was converted to an open procedure, usually because of marked inflammation and unclear anatomy. A total of 644 cases were performed with laser dissection and 1,339 with cautery, and the results of these 2 methods were similar. There were 41 complications. Reoperation for repair was necessary in 18 patients, including 5 with common duct injuries, and, to date, the outcome has been good in each patient. Seventy-six patients (3.8%) have had recognized common duct stones; these were removed preoperatively by endoscopic sphincterotomy (ERS) in 20 patients, during cholecystectomy in 46 patients, and postoperatively by ERS in 4 patients. In six patients, common duct stones became apparent 1 to 4 months after cholecystectomy. We conclude that trained general surgeons can perform laparoscopic cholecystectomy safely with risks comparable to those for conventional open cholecystectomy.

Adolescent↗
PubMed1992

Education and engineering solutions for potential problems with laparoscopic monopolar electrosurgery.

The potential problems of monopolar electrosurgery relate to unrecognized energy transfer ("stray current") outside the view of the laparoscope. Mechanisms of stray current and unrecognized tissue injury include: (1) insulation breaks in electrodes; (2) capacitive coupling, or induced currents through the intact insulation of the active electrode to surrounding cannulas or other instruments; and (3) direct coupling (or unintended contact) between the active electrode and other metal instruments or cannulas within the abdomen. Capacitive coupling poses the greatest risk for injury when the outer conductor (trocar cannula or irrigation cannula) is electrically isolated from the abdominal wall by a plastic nonconductor. Capacitive coupling is increased by the coagulation mode (versus cut), open circuit (versus tissue contact with the electrode), 5-mm cannulas (versus 11 mm), and higher voltage generators. The safety of electrosurgery can be enhanced by surgical education regarding the biophysics of radio frequency electrical energy, technical choices in instruments using all-metal cannula systems, and engineering developments with a dynamically monitored system for insulation failure and capacitive coupling.

Electric Conductivity↗
PubMed1991

A practical approach to laparoscopic cholecystectomy.

A prospective study of 500 consecutive cholecystectomies was initiated with the introduction of laparoscopic cholecystectomy. Laparoscopic cholecystectomy was attempted in 96% of patients presenting with primary gallbladder disease and was completed in 95%. There were no deaths or bile duct injuries. Two patients undergoing laparoscopic cholecystectomy were transfused for postoperative bleeding, and only one patient required reoperation for any reason. A prospective study showed reduced operating time (20 minutes) and patient charges ($546) using electrosurgical dissection compared with laser. Reusable trocars were used without any associated injury or morbidity. An effective strategy for selective cholangiography was developed based on patient history, liver enzymes, and common duct diameter. In conclusion, laparoscopic cholecystectomy appears to be a safe operation. The cost-effectiveness of laparoscopic cholecystectomy can be enhanced ($1,271) with no loss of patient benefit using the combination of electrosurgery, reusable trocars, and selective cholangiograms in low-risk patients.

Adolescent↗
PubMed1989

Hepatic resection using stapling devices to control the hepatic veins.

Limiting blood loss is a primary concern in hepatic resection. Torrential hemorrhage occasionally occurs and is often related to loss of control or injury to the hepatic veins or vena cava. Stapling devices, carefully applied, are presented as a safe and expedient means for controlling hepatic veins within the hepatic parenchyma.

Hemostasis, Surgical↗
PubMed1985

The exoendoprosthesis in proximal bilioenteric anastomoses.

The exoendoprosthesis is a completely indwelling anastomotic stent with the external end fixed to a reservoir in the subcutaneous tissue. With local anesthesia, cholangiography and tube exchange are possible. The exoendoprosthesis was used in 15 patients with obstruction to the proximal bile duct. The obstructive lesions included cholangiocarcinoma (six patients), pancreatic cancer (two patients), gallbladder cancer (two patients), sclerosing cholangitis (three patients), and benign stricture (two patients). The postoperative course was comparable to similar series with external tubes. In one patient, a persistent bile fistula necessitated early exteriorization of the tube and biliary decompression. If cholangitis or jaundice recurred, the tube was exteriorized and exchanged to be managed conventionally. However 12 months postoperatively, eight patients had indwelling tubes without any incidence of cholangitis or jaundice. The indwelling location of the tube relieved the patients of the burden of tube management and may have reduced the incidence of cholangitis.

Bile Duct Neoplasms↗
PubMed1983

Carcinoma in choledochal cysts. Age-related incidence.

We examined a case of malignant degeneration that occurred as a long-term complication of a choledochal cyst. Analysis of the literature shows the incidence of carcinoma varies with age at the initial appearance of symptoms. The child with a choledochal cyst that appears before 10 years of age carries a minimum risk (0.7%) of subsequent malignant degeneration compared with the patient in the second decade (6.8%) and older (14.3%). Data suggest that carcinoma may be readily overlooked at the time of choledochal cyst exploration. In light of the findings, an age-adjusted strategy for management should be used.

Adenocarcinoma, Papillary↗
PubMed1983

Carcinoma of the proximal extrahepatic biliary tree radiologic assessment and therapeutic alternatives.

Preoperative cholangiography and angiography have been used in a series of 37 patients with hilar cholangiocarcinoma investigated over a 17-month period in a single specialist unit. Twelve lesions were judged to be irresectable on the basis of the cholangiographic findings: this was confirmed at laparotomy in nine patients and at autopsy in one. Angiography was performed in 21 patients, and suggested irresectability in eight: this was confirmed by laparotomy in seven. The eighth patient had compression of the left portal vein which had been interpreted as tumor invasion on angiography, and it was possible to perform a curative extended right hepatic lobectomy. Of the 13 potentially resectable patients, three were unfit for major resectional surgery. Five were found to be irresectable at laparotomy because of vena cava involvement in two and distant metastases in three. Five patients underwent resection with histologically clear margins. The combined use of cholangiography and angiography is recommended as a means of selecting appropriate therapy for patients with hilar cholangiocarcinoma.

Adenoma, Bile Duct↗