Biomedical subjects

J R Bessell

Publications and source records attributed to J R Bessell.

At least 19 recordsLinked to original sources

PubMed2005

A randomised trial of ultrasonic dissection versus electrocoagulation to reduce lymphatic complications after surgery for recurrent sapheno-femoral incompetence.

OBJECTIVE: Prospectively to compare lymphatic drainage after ultrasonic dissection, an electrocoagulation technique and sharp dissection in the groin during surgery for recurrent sapheno-femoral incompetence. DESIGN: Prospective, randomised study comparing three surgical techniques. METHODS: Thirty-six consecutive patients undergoing surgery for recurrent sapheno-femoral incompetence were randomised. Twelve patients underwent dissection with ultrasound, 12 with electrocoagulation and 12 controls had sharp dissection with ligation of scar and lymphatic tissue using absorbable suture material. RESULTS: The mean drain output per patient was 13.5 ml in the ultrasonic group, 15.4 ml in the electrocoagulation group and 8.3 ml in the suture ligation group. Six minor cases of lymphatic leakage occurred in the ultrasonic group. This resulted in no clinical problem. There were no other significant differences between the three groups. CONCLUSIONS: There is no detectable advantage for the use of ultrasound or electrocoagulation in recurrent saphenous high ligation compared to sharp dissection.

Adult↗

PubMed2004

Chemoradiation therapy is effective for the palliative treatment of malignant dysphagia.

Between 1993 and 2001, 106 patients with esophageal cancer were reviewed at a multidisciplinary clinic and treated with palliative intent by chemoradiation therapy. This study assesses the palliative benefit on dysphagia and documents the toxicity of this treatment. The study population comprised 72 men and 34 women with a median age of 69 years. Patients were treated with a median radiation dose of 35 Gy in 15 fractions with a concurrent single course of 5 FU-based chemotherapy. Dysphagia was measured at the beginning and completion of treatment and at monthly intervals until death, using a modified DeMeester (4-point) score. Treatment was well tolerated, with only 5% of patients failing to complete therapy. The treatment-related mortality was 6%. The median survival for the study population was 7 months. The median baseline score at presentation was 2 (difficulty with soft food). Following treatment, 49% of patients were assessed as having a dysphagia score of 0 (no dysphagia). Seventy-eight per cent had an improvement of at least one grade in their dysphagia score after treatment. Only 14% of patients showed no improvement with treatment. Fifty-one per cent maintained improved swallowing until the time of last follow-up or death. This single-institution study shows that chemoradiation therapy administered for the palliation of malignant dysphagia is well tolerated and produces a sustainable normalization in swallowing for almost half of all patients.

Adult↗

PubMed2002

Early reoperation for acute dysphagia following laparoscopic fundoplication.

BACKGROUND: A small number of patients develop acute severe dysphagia for which reoperation is necessary within 10 days of laparoscopic fundoplication. The aim of this study was to identify clinical variables that might predict the likelihood of this condition occurring, such that it could be avoided in the future. METHODS: This was a prospective cohort study from three tertiary referral centres, using reoperation for acute dysphagia as the main outcome variable. Gastrointestinal symptom rating scale, and psychological well-being index questionnaires were undertaken before laparoscopic fundoplication, and dysphagia scores were determined before operation and 1 year later. Standard preoperative assessment included gastroscopy, oesophageal manometry and pH studies. RESULTS: Twelve (1.9 per cent) of the 617 patients suffered acute dysphagia, which was predicted by older age and female sex, and resulted in a longer duration of hospital stay. This condition was not predicted by any other demographic, clinical, investigative or operative variables. CONCLUSION: The study did not identify useful criteria by which severe acute dysphagia could be anticipated and thereby avoided following laparoscopic fundoplication.

Acute Disease↗

PubMed2001

A randomized controlled trial to determine the effect of humidified carbon dioxide (CO2) insufflation on postoperative pain following thoracoscopic procedures.

BACKGROUND: It has previously been shown that the insufflation of humidified gas during laparoscopy results in less postoperative pain than is observed following the use of dry gas. Experimental evidence also suggests that dry gas insufflation during thoracoscopy results in greater structural injury to the pleura than occurs with the use of humidified gas. The present study was designed to determine the effect of humidified gas insufflation on postoperative pain following thoracoscopic procedures. METHODS: Forty consecutive patients were prospectively randomized. Twenty patients were insufflated with humidified carbon dioxide (CO(2)), and 20 control patients received standard dry CO(2). RESULTS: The patients' analogue pain score was significantly lower following humidified gas insufflation compared to dry gas insufflation when assessed at 6 h postoperatively, as well as on the 1st, 2nd, 3rd, and 14th postoperative days. The postoperative morphine consumption was lower in the humidified group than it was in the control group. The incidence of respiratory complications was identical for both groups. CONCLUSION: The use of humidified gas appears to reduce postoperative pain but not the rate of respiratory complications.

Anesthesia, Inhalation↗

PubMed2000

Chronic dysphagia following laparoscopic fundoplication.

BACKGROUND: Many surgeons practise tailored laparoscopic antireflux surgery in an attempt to prevent postoperative dysphagia. The aim of this study was to determine the effect of 360 degrees fundoplication (Nissen) or 270 degrees fundoplication (Toupet), and the influence of abnormal oesophageal peristalsis, upon postoperative dysphagia. METHODS: This was a cohort study from three tertiary referral centres, using dysphagia before laparoscopic fundoplication and 1 year after operation as the main outcome variable. Preoperative oesophageal manometry was performed on all patients. RESULTS: Some 761 patients underwent Nissen and 85 underwent Toupet fundoplication. Only 2 per cent reported severe postoperative dysphagia. There was a significant selection bias towards the Toupet operation for patients with abnormal oesophageal motility (P < 0.001). For patients whose oesophageal manometric findings were normal there was a significant improvement in dysphagia after Nissen fundoplication (P = 0.02), and no significant change following Toupet fundoplication. There was no significant change in the rate of dysphagia following either method of fundoplication amongst other subgroups in which oesophageal manometry was stratified as non-specific motor disorder, low-amplitude peristalsis, or aperistalsis. CONCLUSION: A tailored approach to the degree of fundoplication is unnecessary as patients with dysmotility suffer no more dysphagia after full laparoscopic Nissen fundoplication than those who have a partial Toupet wrap.

Chronic Disease↗

PubMed2000

Study of venous blood flow changes during laparoscopic surgery using a thermodilution technique.

BACKGROUND: Many modalities exist to analyse those factors that contribute to venous stasis and deep venous thrombosis (DVT) during laparoscopic surgery. To the authors' knowledge intraoperative measurement of femoral venous blood flow has not yet been performed nor has the influence of sequential compression devices been assessed using this parameter. METHODS: The thermodilution technique similar to that employed in cardiac output measurement was used to determine changes in blood flow in the right femoral vein during laparoscopic cholecystectomy. Deep venous thrombosis prophylaxis involved perioperative use of sequential compression devices and subcutaneous heparin 5000 U. RESULTS: Pneumoperitoneum and the Trendelenburg position reduced femoral venous return in four of the six patients studied, but sequential compression devices failed to return blood flow to baseline in a predictable fashion. CONCLUSIONS: Although the measurement of blood flow using thermodilution is regarded as a reliable technique, during general anaesthesia the results may be susceptible to haemodynamic variations related to the anaesthetic agents as well as to the laparoscopic procedure. In addition sequential compression devices (when used alone) may not provide adequate prophylaxis against DVT because they do not predictably increase femoral blood flow.

Adult↗

PubMed1999

Bronchial anatomy and single-lung ventilation in the pig.

PURPOSE: To explore why two pigs died in the course of a study in which a double-lumen tube (DLT) was used to achieve single-lung ventilation, the bronchial anatomy of all six pigs involved in the study was examined at autopsy. METHODS: Autopsy involved examination of the lungs in situ and subsequent dissection of the lung tissue from the lobular bronchi. RESULTS: All six pigs were found to have an apical lobe (or lobular) bronchus arising from the trachea. In three it was on the right, as is usual in pigs, and in three, including the two that died, it was on the left. The mainstem bronchi to both lungs were short in all pigs, with major segmental bronchi arising just distal to the carina. CONCLUSION: The bronchial anatomy of the pig is such that the inflated cuffs of commercially available DLTs may cause partial or complete obstruction of the apical bronchi of one or both lungs, regardless of the side of the tracheal bronchus. The transmission of the resulting breath sounds across the narrow pig thorax can make auscultation unhelpful in assisting with optimal tube placement.

Animals↗

PubMed1999

Humidified gas prevents hypothermia induced by laparoscopic insufflation: a randomized controlled study in a pig model.

BACKGROUND: This experimental study evaluated whether humidification of warmed insufflated CO2 during laparoscopic procedures would resolve the problem of laparoscopy-induced hypothermia. METHODS: Changes in core temperature were quantified over a 3-h period of high-flow CO2 insufflation in a randomized, controlled trial of five pigs. Each animal was anesthetized and studied on three occasions under standardized conditions, acting as its own control by insufflation with no gas compared with insufflation by cool dry gas and heated humidified gas. RESULTS: Core temperatures after insufflation with heated humidified gas were no different from that of controls. After insufflation with cool dry gas, core temperature dropped by 1.8 degreesC, which was significantly more than the 0.6 degreesC drop experienced by control animals and those insufflated with heated humidified gas (p < 0.01). Calculations of the heat expended in evaporation of water were also performed. The temperature drop due to water evaporation alone in pigs insufflated with cool dry gas was calculated to be 1.5 degreesC. This compares favorably with the measured 1.2 degreesC temperature difference between these animals and the control group. CONCLUSIONS: The majority of heat lost during laparoscopic insufflation is due to water evaporation, and laparoscopic hypothermia may be prevented by using heated and humidified gas insufflation.

Analysis of Variance↗

PubMed1999

A randomized controlled trial assessing the benefit of humidified insufflation gas during laparoscopic surgery.

BACKGROUND: We conducted a randomized controlled trial during laparoscopic cholecystectomy to determine the extent of heat preservation and postoperative pain reduction using humidified carbon dioxide (CO2) gas insufflation instead of standard dry insufflation gas. METHODS: Forty consecutive patients were randomized. Twenty patients received humidified CO2, and 20 control patients received standard CO2 insufflation. A sample of 16 patients from each group was evaluated for postoperative pain levels. RESULTS: No adverse effects from the humidification of insufflated gas were observed. There was no significant difference in core body temperature between the two groups for this brief operation. Pain, as assessed by the Analogue Pain Score (APS) was significantly less for the group with humidified gas insufflation than for the control group at 6 h postoperatively as well as on the 1st, 2nd, and 3rd postoperative day and at follow-up 10 days after the operation. In the humidified group, the mean time to return to normal activities was significantly less-5.9 days, as compared to 10.9 days in the control group. CONCLUSIONS: The use of humidified insufflation gas reduces postoperative pain following laparoscopic cholecystectomy, but except for these relatively brief procedures, the heat-preserving effect of humidified gas insufflation is not significant.

Adult↗

PubMed1999

A randomized controlled trial to determine the effects of humidified carbon dioxide insufflation during thoracoscopy.

BACKGROUND: The humidification of gas insufflated during laparoscopy can reduce the degree of postoperative hypothermia and may result in less peritoneal reaction and less postoperative pain. The present study was designed to determine whether the beneficial effects of humidified gas insufflation also applied to thoracoscopy. METHODS: Six pigs were each studied on three separate occasions with insufflation into the right thoracic cavity of either humidified gas, standard dry gas, or with no insufflation (control procedure). Core body temperature was recorded every 15 min, and biopsies of the parietal pleura were taken at the end of each study for electron microscopy. RESULTS: Humidification of insufflated gas significantly minimized the fall in core temperature during the procedure. Electron microscopy showed that dry gas insufflation resulted in greater structural injury to the pleura than humidified gas insufflation. CONCLUSIONS: The potential benefits of humidifying insufflation gas during thoracoscopy warrant its evaluation in the clinical setting.

Analysis of Variance↗

PubMed1999

Pain after laparoscopy.

BACKGROUND: In the context of the much-heralded advantages of laparoscopic surgery, it can be easy to overlook postlaparoscopy pain as a serious problem, yet as many as 80% of patients will require opioid analgesia. It generally is accepted that pain after laparoscopy is multifactorial, and the surgeon is in a unique position to influence many of the putative causes by relatively minor changes in technique. METHODS: This article reviews the relevant literature concerning the topic of pain after laparoscopy. RESULTS: The following factors, in varying degrees, have been implicated in postlaparoscopy pain: distension-induced neuropraxia of the phrenic nerves, acid intraperitoneal milieu during the operation, residual intra-abdominal gas after laparoscopy, humidity of the insufflated gas, volume of the insufflated gas, wound size, presence of drains, anesthetic drugs and their postoperation effects, and sociocultural and individual factors. CONCLUSIONS: On the basis of the factors implicated in postlaparoscopy pain, the following recommendations can be made in an attempt to reduce such pain: emphathically consider each patients' unique sociocultural and individual pain experience; inject port sites with local anesthesia at the start of the operation; keep intra-abdominal pressure during pneumoperitoneum below 15 mmHg, avoiding pressure peaks and prolonged insufflation; use humidified gas at body temperature if available; use nonsteroidal anti-inflammatory drugs at the time of induction; attempt to evacuate all intraperitoneal gas at the end of the operation; and use drains only when required, rather than as a routine.

Humans↗

PubMed1998

Looking back to the advent of modern endoscopy: 150th birthday of Maximilian Nitze.

This year, 1998, marks the 150th anniversary of the birthday of Maximilian Nitze (1848-1906), a German scientist responsible for the initiation of modern endoscopy: He integrated two of his ideas in the construction of the first functional cystoscope. Nitze realized that the field of view during endoscopy could be enlarged by the use of an optical system, and that the light source should be placed on the tip of the instrument. He presented this cystoscope on October 2, 1877 for the first time, at age 28 years.

Cystoscopes↗

PubMed1996

A randomized controlled trial of laparoscopic extraperitoneal hernia repair as a day surgical procedure.

BACKGROUND: A randomized controlled trial was conducted in a day surgery setting comparing a standardized variant of the Shouldice hernioplasty with extraperitoneal laparoscopic herniorrhaphy. METHODS: The laparoscopic repair was technically challenging, evidenced by conversion from extraperitoneal to transabdominal repairs in 6.25% of patients. It was free from the inherent dangers of intraperitoneal laparoscopy. Surgical morbidity was low and comparable to that for patients randomized to the open repair. RESULTS: Outcome following laparoscopic extraperitoneal herniorrhaphy varied depending on the parameter measured. It was comparable to the open repair with respect to postoperative activity levels and the number of days required for return to work but inferior to the open repair in terms of operation time and time to hospital discharge. The extraperitoneal approach was superior to the open repair with respect to postoperative pain levels and analgesic requirements. No attempt was made to compare recurrence rates due to the short follow-up period. CONCLUSIONS: Laparoscopic extraperitoneal herniorrhaphy should not supercede conventional hernia repair until subjected to further trials with the aid of larger study populations and greater technical expertise; the results of long-term recurrence rates are awaited.

Adolescent↗

PubMed1996

Thirty years experience with heart valve surgery: isolated aortic valve replacement.

BACKGROUND: Thirty years have elapsed since the commencement of open-heart surgery in South Australia. A retrospective study was performed to evaluate mortality and complication rates and to identify factors associated with poor outcomes in all patients who underwent prosthetic aortic valve replacement during this period. METHODS: Questionnaires and personal contact have been used to generate a combined database of pre-operative and post-operative information and long-term follow-up on 1322 patients who underwent isolated prosthetic aortic valve replacement at the Cardio-Thoracic Surgical Unit of the Royal Adelaide Hospital between 1963 and 1992. RESULTS: Complete survival follow-up data were obtained for 94% (1241) of the patients. The Bjork-Shiley valve was used in 66% (875) of the patients, a Starr-Edwards prosthesis in 31% (412), a St Jude prosthesis in 2% (26), and only 0.7% (9) bioprosthetic valves were inserted. The hospital mortality rate for the 30-year period was 2.9%. Progressively older and less fit patients have undergone surgery in recent years. The long-term survival of patients with aortic stenosis and aortic incompetence was not significantly different. Long-term survival was significantly shorter for patients with higher New York Heart Association (NYHA) functional classifications, and for patients in pre-operative atrial fibrillation. Pre-operative dyspnoea was significantly improved following aortic valve replacement. The rates of postoperative haemorrhagic and embolic complications were low by comparison with other published series. CONCLUSIONS: Aortic valve replacement can be performed with low hospital mortality and complication rates, and significant symptomatic improvement can be expected. Aortic valve recipients have a favourable prognostic outcome compared with an age- and sex-matched population, and risk factors that determine long-term survival can be identified pre-operatively.

Adolescent↗

PubMed1996

Thirty years experience with heart valve surgery: isolated mitral valve replacement.

BACKGROUND: Thirty years have elapsed since the commencement of open-heart surgery in South Australia. A retrospective study was performed to evaluate mortality and complication rates and to identify factors associated with poor outcomes in all patients who underwent prosthetic mitral valve replacement during this period. METHODS: Questionnaires and personal contact have been used to generate a combined database of pre-operative and post-operative information and long-term follow-up on 938 patients who underwent isolated prosthetic mitral valve replacement at the Cardio-Thoracic Surgical Unit of the Royal Adelaide Hospital between 1963 and 1993. RESULTS: Complete survival follow-up data were obtained for 92% (865) of the patients. The Starr-Edwards valve was used in 95% (891) of the patients, a Bjork-Shiley prosthesis in 2.5% (23) of the patients, and only 24 (2.5%) other valves were inserted. The hospital mortality rate for the 30-year period was 4.7%. The mean age of the patients who underwent surgery was greater in each of the three successive decades. A long-term survival advantage was observed for patients with mitral stenosis, however, survival was significantly shorter for patients with higher New York Heart Association (NYHA) functional classifications and for patients in pre-operative atrial fibrillation. Pre-operative dyspnoea was significantly improved following mitral valve replacement. The rates of postoperative haemorrhagic and embolic complications were low by comparison with other published series. CONCLUSION: Mitral valve recipients do not regain a normalized life expectancy, but risk factors that determine long-term survival can be identified pre-operatively to aid appropriate patient selection.

Adolescent↗

PubMed1996

Changes in fibrinogen levels in patients undergoing open and laparoscopic Nissen fundoplication.

BACKGROUND: Venous thromboembolic complications may be more common after laparoscopic surgical techniques, possibly due to changes in venous flow and blood coagulability. METHODS: This study assessed fibrinogen, cross-linked fibrin degradation products (D-dimer), prothrombin international normalized ration (INR), activated partial thromboplastic time (APTT) and platelets, during and after both open and laparoscopic Nissen fundoplication to determine whether coagulability is increased by the laparoscopic approach. RESULTS: Seven patients underwent open and thirteen underwent laparoscopic Nissen fundoplication. Fibrinogen levels following open fundoplication fell from 2.8 +/- 0.3 g/L pre-operatively to 2.0 +/- 0.3 g/L following skin incision, and then increased to 4.1 +/- 0.4 g/L on the first postoperative day. Similar changes in fibrinogen occurred following laparoscopic fundoplication (2.7 +/- 0.2, 2.5 +/ 0.2 and 3.8 +/- 0.4 g/L, respectively). No significant changes in the other coagulation indices were observed. CONCLUSIONS: These results demonstrate hypercoagulability on the first postoperative day, irrespective of the operative technique. No differences between the results following laparoscopic and open fundoplication were demonstrated.

Adult↗

PubMed1996

Prolonged survival follows resection of oesophageal SCC downstaged by prior chemoradiotherapy.

BACKGROUND: The poor survival rate of surgically treated patients with oesophageal cancer has not improved substantially over the last 25 years, but combined modality therapy has shown early promising results. METHODS: A prospective study was undertaken to determine the effect of pre-operative synchronous chemoradiotherapy followed by oesophagectomy in 53 patients with squamous cell carcinoma (SCC) of the oesophagus. The patient group was unselected, other than by fitness for surgery. RESULTS: In 25% of patients, complete pathological regression of the tumour was achieved. All but one of the patients in this subgroup had T2 tumours on pre-operative clinical staging and two had evidence of lymph node involvement, but postoperative pathological examination revealed that pre-operative chemoradiotherapy had downstaged their disease to T0N0. There was no hospital mortality in this subgroup and the actuarial 7 year survival was 69%. CONCLUSIONS: For squamous oesophageal tumours deep to the submucosa this is an extremely good survival. For the present, this form of therapy for SCC of the oesophagus appears capable of achieving results comparable to, or better than, those reported for 3-field lymphadenectomy.

Adult↗

PubMed1995

Hypothermia induced by laparoscopic insufflation. A randomized study in a pig model.

Hypothermia is a common postsurgical problem, yet information documenting the impact of laparoscopy on perioperative heat balance is scarce. This paper quantifies the changes in core temperature over a 3-h period of high-flow CO2 insufflation in a randomized, controlled trial of six pigs. Each animal was anesthetized and studied on three occasions under standardized conditions, acting as its own control via insufflation with no gas compared with insufflation by cold gas and warmed gas. Insufflation of CO2 gas at high-flow rates over a prolonged period of time results in a significant fall in core temperature. The provision of warmed rather than cold insufflated gas confers no protection against changes in core temperature during laparoscopic surgery due to the small amount of heat required to warm the gas to body temperature. A much greater effect is the latent heat required to saturate the insufflated gas. Most of the hypothermic effect is due to this, and could be minimized by humidifying the flow.

Animals↗