Biomedical subjects

Donald R Czerniach

Publications and source records attributed to Donald R Czerniach.

9 recordsLinked to original sources

PubMed2006

Immunologic effects of hand-assisted surgery on peritoneal macrophages: comparison to open and standard laparoscopic approaches.

BACKGROUND: Exaggerated activation of peritoneal immunity after major abdominal surgery activates peritoneal macrophages (PMs), which may lead to a relative local immunosuppression. Although laparoscopy (L) is known to elicit a smaller attenuation of peritoneal host defenses, compared with open (O) surgery, effects of the hand-assisted (HA) approach have not been investigated to date. METHODS: Eighteen pigs underwent a transabdominal nephrectomy via O, HA, or L approach. PMs were harvested at 4, 12, and 24 hours through an intraperitoneal drain and stimulated in vitro with lipopolysaccharide. The production of interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) by the purified macrophage cultures was measured with the use of a standard enzyme-linked immunosorbent assay technique. Statistical comparison was performed by using analysis of variance and Student t test. RESULTS: In vitro lipopolysaccharide-induced IL-6 and TNF-alpha production by PMs increased over the 24-hour period in all 3 groups. Stimulated PMs harvested at 12 and 24 hours postoperatively secreted higher levels of IL-6 in the O group, compared with both the HA group (P = .02, P = .01) and L group (P = .04, P = .001). PMs harvested at 4, 12 and 24 hours postoperatively also produced more TNF-alpha in O group, compared with both the HA group (P = .03, P = .03, and P = .01) and L group (P = .01, P = .05 and P = .03). There was no significant difference between H and L groups in production of either cytokine. CONCLUSIONS: Abdominal surgery attenuates peritoneal host defenses regardless of the surgical approach employed. However, for the first time, we demonstrated that the HA approach, similar to laparoscopy, is superior to open surgery in the degree of PM activation. Overall, in addition to clinical benefits of minimal access, HA surgery may confer an immunologic advantage over laparotomy.

Abdomen↗

PubMed2006

Benefits of laparoscopic adrenalectomy: a 10-year single institution experience.

INTRODUCTION: We aimed to compare the outcomes of laparoscopic and open adrenalectomies and to assess the impact of the availability of advanced laparoscopy on adrenal surgery at our institution. MATERIALS AND METHODS: A retrospective analysis of data of all patients who underwent adrenalectomy at the University of Massachusetts Medical Center over a 10-year period. RESULTS: Sixty-four consecutive patients underwent adrenalectomy during the study periods. There were 19 open (OA) and 45 laparoscopic (LA) adrenalectomies performed. There was no significant difference between the average size of adrenal masses removed for the LA and the OA groups [4.3 vs. 5.5 cm, respectively (P=0.23)]. LA proved superior to OA, resulting in shorter operative times (171 vs. 229 min, P=0.02), less blood loss (96 vs. 371 mL, P<0.01), shorter time to regular diet (1.9 vs. 4.4 d, P<0.001), and shorter hospital stay (2.5 vs. 5.8 d, P=0.02). In addition, the average annual number of adrenalectomies increased significantly since the establishment of our advanced laparoscopic program (10.0 vs. 2.0, P=0.02). CONCLUSIONS: LA offers superior results when compared to OA in terms of operative time, blood loss, return of bowel function, duration of hospital stay, and functional recovery. The availability of advanced laparoscopy has resulted in a significant increase in the number of adrenalectomies performed at our institution without a shift in surgical indications.

Adrenal Gland Neoplasms↗

PubMed2005

Advantages of mini-laparoscopic vs conventional laparoscopic cholecystectomy: results of a prospective randomized trial.

HYPOTHESIS: The use of smaller instruments during laparoscopic cholecystectomy (LC) has been proposed to reduce postoperative pain and improve cosmesis. However, despite several recent trials, the effects of the use of miniaturized instruments for LC are not well established. We hypothesized that LC using miniports (M-LC) is safe and produces less incisional pain and better cosmetic results than LC performed conventionally (C-LC). DESIGN: A patient- and observer-blinded, randomized, prospective clinical trial. SETTING: A tertiary care, university-based hospital. PATIENTS: Seventy-nine patients scheduled for an elective LC who agreed to participate in this trial were randomized to undergo surgery using 1 of the 2 instrument sets. The criteria for exclusion were American Society of Anesthesiologists class III or IV, age older than 70 years, liver or coagulation disorders, previous major abdominal surgical procedures, and acute cholecystitis or acute choledocholithiasis. INTERVENTION: Laparoscopic cholecystectomy performed with either conventional or miniaturized instruments. MAIN OUTCOME MEASURES: Patients' age, sex, operative time, operative blood loss, intraoperative complications, early and late postoperative incisional pain, and cosmetic results. RESULTS: Thirty-three C-LCs and 34 M-LCs were performed and analyzed. There were 8 conversions (24%) to the standard technique in the M-LC group. No intraoperative or major postoperative complications occurred in either group. The average incisional pain score on the first postoperative day was significantly less in the M-LC group (3.9 vs 4.9; P = .04). No significant differences occurred in the mean scores for pain on postoperative days 3, 7, and 28. However, 90% of patients in the M-LC group and only 74% of patients in the C-LC group had no pain (visual analog scale score of 0) at 28 days postoperatively (P = .05). Cosmetic results were superior in the M-LC group according to both the study nurse's and the patients' assessments (38.9 vs 28.9; P<.001, and 38.8 vs 33.4; P = .001, respectively). CONCLUSIONS: Laparoscopic cholecystectomy can be safely performed using 10-mm umbilical, 5-mm epigastric, 2-mm subcostal, and 2-mm lateral ports. The use of mini-laparoscopic techniques resulted in decreased early postoperative incisional pain, avoided late incisional discomfort, and produced superior cosmetic results. Although improved instrument durability and better optics are needed for widespread use of miniport techniques, this approach can be routinely offered to many properly selected patients undergoing elective LC.

Analgesia↗

PubMed2003

Predictors of complication and suboptimal weight loss after laparoscopic Roux-en-Y gastric bypass: a series of 188 patients.

HYPOTHESIS: An analysis of patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) may identify factors predictive of complication and of suboptimal weight loss. DESIGN: Inception cohort. SETTING: Metropolitan university hospital. PATIENTS: One hundred eighty-eight consecutive patients with severe obesity who met National Institutes of Health consensus guidelines for bariatric surgery. INTERVENTIONS: Laparoscopic RYGB. MAIN OUTCOME MEASURES: Complications requiring therapeutic intervention and percentage of excess body weight lost at 1 year after surgery. RESULTS: Of the 188 patients who underwent laparoscopic RYGB, 50 (26.6%) developed complications that required an invasive therapeutic intervention, including 2 deaths. The average follow-up was 351 days (range, 89-1019 days). Multivariate analysis by stepwise logistic regression identified surgeon experience, sleep apnea (P =.003; odds ratio, 3.0; 95% confidence interval, 1.3-7.1), and hypertension (P =.07; odds ratio, 2.0; 95% confidence interval, 1.0-4.0) as predictors of complications. The most common complication requiring therapeutic intervention was stricture at the gastrojejunal anastomosis, occurring in 27 patients (14.4%). Of the 115 patients who underwent surgery more than 1 year previously, 1-year follow-up data were available for 93 (81%). The body mass index (weight in kilograms divided by the square of height in meters) decreased from 53 +/- 8 preoperatively to 35 +/- 6 at 1 year. The mean +/- SD percentage of excess body weight lost at 1 year was 61% +/- 14%. Diabetes mellitus was negatively correlated with percentage of excess body weight lost at 1 year (P =.06). CONCLUSIONS: Surgeon experience, sleep apnea, and hypertension are associated with complications after laparoscopic RYGB. Diabetes mellitus may be associated with poorer postoperative weight loss.

Adult↗

PubMed2003

Feasibility of laparoscopic adrenalectomy for large adrenal masses.

Laparoscopic adrenalectomy (LA) is a preferred method for the removal of small adrenal masses. However, the role of LA for surgical treatment of large adrenal masses is less established. We evaluated the outcomes of LA for large (>/=5 cm) adrenal masses. We retrospectively reviewed 24 consecutive patients who underwent LA for large adrenal masses at a tertiary care university hospital. The average age of the 24 patients was 49 years, and each underwent laparoscopic resection of a large adrenal mass. All LAs were performed via a lateral transperitoneal approach. The average (+/- standard deviation) size of the masses was 6.8 +/- 1.5 cm (range, 5-11). Pathologic diagnoses included adrenal cortical adenoma (10 cases), pheochromocytoma ( 7), cyst/pseudocyst ( 3), myolipoma ( 2), and adrenal cortical hyperplasia ( 2). Statistical analysis was performed with a two-sample t test. The average operating time was 178 +/- 55 minutes (range, 120-300), and average blood loss was 87 +/- 69 mL (range, 20-300); the averages were nonsignificantly greater in the right LA group than in the left LA group (203 vs. 166 minutes, P = 0.89; 124 vs. 77 mL, P = 0.14). The average duration of nothing-by-mouth (NPO) status was 0.7 days (range, 0-4), and the average time until return to a regular diet was 1.74 +/- 0.9 days (range, 1-5). The average length of stay was 2.5 +/- 1.9 days (range, 1-10). One patient had a transient episode of pseudomembranous colitis. There were no conversions to open adrenalectomy and no major morbidities or mortalities. LA is safe and effective for surgical treatment of large adrenal masses. Both right and left large adrenal masses can be approached laparoscopically with equal success. The role of minimally invasive approaches to adrenal malignancies necessitates further investigation.

Adrenal Gland Neoplasms↗

PubMed2003

Staple line bleeding following laparoscopic splenectomy: intraoperative prevention and postoperative management with splenic artery embolization.

Laparoscopic splenectomy (LS) has become the procedure of choice for a variety of hematologic disorders and non-traumatic splenic pathology. Perioperative hemorrhage remains one of the most feared complications. We report 2 cases of postoperative splenic artery hemorrhage following vascular division using 2.5-mm Endo-GIA stapling cartridges. In this paper we identify and discuss important technical aspects of obtaining hilar vascular control during LS and report the first use of postoperative splenic artery embolization to control staple line bleeding following LS.

Embolization, Therapeutic↗

PubMed2003

Hand-assisted laparoscopic surgery.

The introduction of hand-assisted laparoscopic surgery (HALS) has occurred in several surgical specialties. It allows the laparoscopic surgeon to insert a hand into the peritoneal cavity, through a small incision, while maintaining pneumoperitoneum. This technique has been made possible through the engineering of several unique devices. By returning the hand to the peritoneal cavity, the surgeon is allowed the return of tactile sensation, atraumatic retraction, blunt dissection, and digital vascular control. Proper device placement is mandatory. The principles include port-site triangulation, conversion to a convenient open incision if necessary, location away from bony prominences, and placement to minimize hand fatigue. Application and advantages of HALS can be shown in several procedures; specifically, laparoscopic splenectomy in cases of splenomegaly, laparoscopic live-donor nephrectomy, and laparoscopic sigmoid colectomy for diverticular disease. Its use in these procedures does not appear to be detrimental to the benefits associated with a completely laparoscopic technique, and may offer advantages. It may alter the learning curve regarding advanced laparoscopic procedures for the neophyte laparoscopic surgeon, and allow them to perform operations they otherwise would not attempt. For the experienced laparoscopic surgeon, it may allow them to complete operations laparoscopically they might otherwise have to convert. In time, HALS may have a larger role in many advanced surgical procedures.

Equipment Design↗

PubMed2002

Is the use of a bougie necessary for laparoscopic Nissen fundoplication?

HYPOTHESIS: Esophageal intubation with a bougie during laparoscopic Nissen fundoplication (LNF) is commonly used to prevent an excessively tight wrap. However, a bougie may cause intraoperative gastric and esophageal perforations. We hypothesized that LNF is safe and effective when performed without a bougie. DESIGN: Retrospective review of 102 consecutive patients who underwent LNF without a bougie. SETTING: Tertiary care university hospital. PATIENTS: All patients presented with symptoms of reflux disease. Mean (+/- SD) percentage of time with pH of less than 4 was 12.6% +/- 9.4%. Mean DeMeester score was 47.8. Mean (+/- SD) resting lower esophageal sphincter pressure was 15.0 +/- 9.4 mm Hg. Mean (+/- SD) distal esophageal amplitude was 69.4 +/- 39.2 mm Hg. INTERVENTION: During LNF, we obtained 2 to 3 cm of intra-abdominal esophagus, divided all short gastric vessels, reapproximated the crura, and performed a loose 360 degrees fundoplication without a bougie. MAIN OUTCOME MEASURES: Postoperative rates of dysphagia, gas bloat, and recurrent reflux. RESULTS: In the early postoperative period, 50 patients (49.0%) complained of mild, 11 (10.8%) of moderate, and 7 (6.9%) of severe dysphagia. Average (+/- SD) duration of early dysphagia was 4.6 +/- 2.1 weeks. Dysphagia resolved in 61 (89.7%) of 68 patients within 6 weeks. Late resolution of dysphagia was noted in 4 (5.8%) patients. Three patients were successfully treated with esophageal dilatations. Persistent dysphagia was found in 1 patient. Thirty patients (29.4%) had transient gas bloat. Mild persistent reflux, requiring daily medication, was noted in 5 (4.9%) patients. CONCLUSIONS: Performance of LNF without a bougie offers a safe and effective therapy for gastroesophageal reflux disease. While avoiding the potential risks for gastric and esophageal injury, it may provide low rates of long-term postoperative dysphagia and reflux recurrence.

Deglutition Disorders↗

PubMedDate not supplied

Watermelon stomach: pathophysiology, diagnosis, and management.

Watermelon Stomach (WS) has been increasingly recognized as an important cause of occult gastrointestinal blood loss. Clinically, patients develop significant iron deficiency anemia and are frequently transfusion dependent. The histologic hallmark of WS is superficial fibromuscular hyperplasia of gastric antral mucosa with capillary ectasia and microvascular thrombosis in the lamina propria. Endoscopic findings of the longitudinal antral folds containing visible columns of tortuous red ectatic vessels (watermelon stripes) are pathognomonic for WS. Trauma to the mucosal epithelium overlying engorged vessels by gastric acid or intraluminal food results in bleeding. Treatment options for WS include endoscopic, pharmacologic, and surgical approaches. Endoscopic therapy, including contact and non-contact thermal ablations of the angiodysplastic lesions, is the mainstay of conservative therapy. However, many patients fail endoscopic therapy and develop recurrent acute and chronic GI bleeding episodes. Surgical resection may be the only reliable method for achieving a cure and eliminating transfusion dependency. Traditionally, surgery was used only as a last resort after patients failed prolonged medical and/or endoscopic therapy. However, based on the experience garnered from the literature we recommend a more aggressive surgical approach in patients who fail a short trial of endoluminal therapy.

Algorithms↗