Should intraoperative cholangiography be routinely attempted during laparoscopic cholecystectomy?
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Comment↗
Biomedical subjects
Michael J Rosen
Publications and source records attributed to Michael J Rosen.
Laparoscopic versus open colostomy reversal: a comparative analysis.
Open colostomy reversal carries significant rates of wound infection, anastomotic leak, and incisional hernia which often limit its acceptance. We hypothesized that the laparoscopic approach to the restoration of intestinal continuity may result in lower perioperative morbidity and faster postoperative recovery. Twenty-two cases of laparoscopic colostomy reversals performed at a single institution were identified and compared to 22 randomly selected open colostomy closures performed during the same time period. Patients were compared based on demographics, previous indications for colostomy procedures, and perioperative outcomes. A total of 152 patients underwent reversal of left-sided colostomies during the study period. The laparoscopic approach was successful in 20 of 22 cases; there were 2 conversions to open (9%) secondary to inability to adequately mobilize the rectal stump. The laparoscopic and open groups were comparable based on mean age (54 years versus 49 years; P = 0.23), BMI (26 kg/m(2) versus 27 kg/m(2); P = 0.66), gender (9% males versus 13% males; P = 0.23), ASA Class (2.6 versus 2.3; P = 0.07), and history of previous intra-abdominal sepsis (17 versus 16 cases). Operative times were similar (158 versus 189 minutes; P = 0.16), and estimated blood loss was significantly less in the laparoscopic group (113 versus 270 ml; P = 0.01). No intraoperative complications occurred in the laparoscopic group and two enterotomies occurred in the open group. The laparoscopic group had earlier passage of flatus (3.5 versus 5.0 days; P = 0.001) and shorter hospitalization (4.2 versus 7.3 days; P = 0.001). Perioperative complications occurred in 3 (14%) laparoscopic and 13 (59%) open cases (P = 0.01). There was no mortality in this series. The laparoscopic approach can be safely used in the restoration of intestinal continuity. It results in a decreased perioperative morbidity and faster recovery, and it offers distinct advantages over the open approach to colostomy reversal.
Adult↗
Management of acute gastrointestinal hemorrhage.
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Acute Disease↗
A primer on natural orifice transluminal endoscopic surgery: building a new paradigm.
Access to the abdominal cavity is required for diagnostic and therapeutic endeavors for a variety of medical and surgical diseases. Historically, abdominal access has required a formal laparotomy to provide adequate exposure. Natural orifice transluminal endoscopic surgery (NOTES) is an emerging experimental alternative to conventional surgery that eliminates abdominal incisions and incision-related complications by combining endoscopic and laparoscopic techniques to diagnose and treat abdominal pathology. During NOTES, commercially available flexible video endoscopes are used to create a controlled transvisceral incision via natural orifice access to enter the peritoneal cavity. Common incision-related complications such as wound infections, incisional hernias, postoperative pain, aesthetic disdain, and adhesions could be minimized or eliminated by NOTES. NOTES has evolved from more than 2 centuries of technological innovations and continued growth in the field of surgical endoscopy. Innovative surgical endoscopists have slowly developed means to surpass the constraints of the gastrointestinal lumen by using a flexible endoscope. The future of surgical endoscopy may be the shared entity of NOTES, which further integrates endoscopy, gastroenterology, and minimally invasive and general surgery. Although the promise of NOTES is electrifying to surgeons and endoscopists, several key issues need to be characterized prior to the incorporation of NOTES into routine practice. This article reviews the status, contemporary body of literature, limitations, and potential future implications accompanying the development of NOTES.
Abdominal Cavity↗
Advantages of laparoscopic appendectomy in the elderly.
Laparoscopic appendectomy (LA) has gained in popularity in recent years. The number of elderly patients undergoing appendectomy has increased as that segment of the population has increased in number; however, the utility and benefits of LA in the elderly population are not well established. We hypothesized that LA in the elderly has distinctive advantages in perioperative outcomes over open appendectomy (OA). We queried the 1997 to 2003 North Carolina Hospital Association Patient Data System for all patients with the primary ICD-9 procedure code for OA and LA. Patients > or = 65 years of age (elderly) were identified and reviewed. Outcomes including length of stay (LOS), charges, complications, discharge location, and mortality were compared between the groups. There were 29,244 appendectomies performed in adult patients (>18 years old) with 2,722 of these in the elderly. The annual percentage of LA performed in the elderly increased from 1997 to 2003 (11.9-26.9%, P < 0.0001). When compared with OA, elderly patients undergoing LA had a shorter LOS (4.6 vs 7.3 days, P = 0.0001), a higher rate of discharge to home (91.4 vs 78.9%, P = 0.0001) as opposed to a step-down facility, fewer complications (13.0 vs 22.4%, P = 0.0001), and a lower mortality rate (0.4 vs 2.1%, P = 0.007). When LA was compared with OA in elderly patients with perforated appendicitis, LA resulted in a shorter LOS (6.8 vs 9.0 days, P = 0.0001), a higher rate of discharge to home (86.6 vs 70.9%, P = 0.0001), but equivalent total charges (dollars 22,334 vs dollars 23,855, P = 0.93) and mortality (1.0 vs 2.98%, P = 0.10). When elderly patients that underwent LA were compared with adult patients (18-64 years old), they had higher total charges (dollars 16,670 vs dollars 11,160, P = 0.0001) but equivalent mortality (0.37 vs 0.15%, P = 0.20). The use of laparoscopy in the elderly has significantly increased in recent years. In general, the safety and efficacy of LA is demonstrated by a reduction in mortality, complications, and LOS when compared with OA. The laparoscopic approach to the perforated appendix in the elderly patient has advantages over OA in terms of decreased LOS and a higher rate of discharge to home as opposed to rehabilitation centers, nursing homes, or skilled nursing care. When compared with all younger adults, the laparoscopic approach in the elderly was associated with equal mortality rates even though hospitalization charges were higher. Laparoscopy may be the preferred approach in elderly patients who require appendectomy.
Aged↗
Asymptomatic thrombus trapping in vena cava filters: a case series.
The prophylactic use of vena cava filters (VCFs) remains controversial. Class I data supporting the placement of prophylactic VCFs are lacking. In addition, there are concerns regarding the long-term effects of permanent VCF placement in patients with a relatively brief period of thromboembolic risk. Venous thromboembolism can be a lethal event, occurring without a prodrome. Yet, this condition is potentially preventable. The efficacy of VCFs is difficult to determine, as it is likely that when a VCF actually traps a thrombus, the event is clinically asymptomatic. We present three cases of asymptomatic thrombus trapping in VCFs, recognized through incidental radiographic studies.
Adolescent↗
Intra-abdominal placement of antimicrobial-impregnated mesh is associated with noninfectious fever.
The antimicrobial, silver/chlorhexidine, when impregnated on mesh has been demonstrated to resist mesh infection in in vitro and in vivo models. The clinical, human systemic response to intraperitoneal placement of silver/chlorhexidine-impregnated mesh has not been investigated to date. Between October 2002 and November 2004, all in-patients undergoing laparoscopic ventral hernia repair were retrospectively analyzed. All repairs used expanded polytetraflouroethylene (ePTFE) Dual Mesh (DM) or ePTFE impregnated with silver/chlorhexidine, Dual Mesh Plus (DM+). Patient demographics, hernia characteristics, mesh type, operative details, and hospital course data were collected. Noninfectious fevers were defined as a temperature greater than 100.4 F without an identified source. Standard statistical methods were used. During the 2-year study period, 120 patients underwent laparoscopic ventral hernia repair (DM = 55, DM+ = 65). The two groups were similarly matched in terms of age, body mass index, American Society of Anesthesiologists score, defect size, and mesh size. Postoperative fever without an identified source occurred in 10 (18.2%) patients with DM and in 25 (38.5%) patients using DM+ (P = 0.015). A multivariant analysis revealed that only mesh type and body mass index predicted postoperative fever. All fevers resolved within the first 72 hours in the DM patients; however, 16 per cent of the DM+ group had persistent fevers of unknown origin after 72 hours. Within the DM+ group, patients with postoperative fevers had significantly longer postoperative stays (4.8 days vs 3.0 days; P = 0.009). The use of antimicrobial-impregnated ePTFE mesh with silver/chlorhexidine in laparoscopic ventral hernia repair is associated with noninfectious postoperative fever. In our patients, the evaluation and management of these fevers resulted in a significantly longer hospital stay.
Adult↗
Laparoscopic restoration of intestinal continuity after Hartmann's procedure.
BACKGROUND: Colostomy closure after a Hartmann's procedure typically requires a laparotomy. It also carries the risk of significant morbidity including anastomotic leak, wound infection, and incisional hernia. The aim of this study was to review our experience with laparoscopic restoration of intestinal continuity after Hartmann's procedure. METHODS: After institutional review board approval, we retrospectively reviewed the medical records of patients undergoing laparoscopic colostomy reversal between July 1997 and July 2004. RESULTS: Twenty-two patients were identified; all patients had left colon colostomies. A laparoscopic technique was used in 21 patients, and 1 patient underwent hand-assisted colostomy reversal concurrently with right radical nephrectomy. The laparoscopic approach was successful in 20 cases, and there were 2 conversions to open (9%) secondary to dense adhesions around the rectal stump. The mean time to closure of the colostomy was 168 days (range 69-385 days). The mean operative time was 158 minutes (range 84-356 minutes). The estimated blood loss averaged 114 mL (range 30-250 mL). The average length of hospitalization was 4.2 days (range 2-6 days). Bowel function returned on an average of 3.5 days (range 2-5 days). Three patients (14%) developed postoperative wound infections. There were no anastomotic leaks and no mortality. At a mean follow-up of 14.7 months, the only long-term complication has been a small hernia at a colostomy site. CONCLUSIONS: Laparoscopic colostomy reversal after Hartmann's procedure can be performed with low morbidity and a short hospital stay. The need for conversion to open surgery is uncommon despite patients' previous surgeries. A laparoscopic approach to colostomy takedown is safe and feasible and may result in a reduction in complications and length of stay as has been seen with other minimally invasive procedures.
Adult↗
Guide wire entrapment by inferior vena cava filters: an experimental study.
BACKGROUND: In situ vena cava filters are at risk for complications with the use of J-tipped guide wires. The purpose of this study was to evaluate the impact of two commonly used J-tipped guide wires on the stability of the four most recently released vena cava filters in an in vitro flow model. STUDY DESIGN: Four filters (OptEase [F1], Günther Tulip [F2], Vena Tech LP [F3], and Recovery [F4]) were inserted into an in vitro flow model. Two J-tipped guide wires (0.032-inch [GW-1], 0.035-inch [GW-2]) were passed through each filter (n = 50 passes per wire) for a distance of 10 cm. The inserter was blind as to the effects of the wire. The filters were monitored by an independent observer for adverse events occurring between the filters and the guide wires. These were defined as: migrations (>1 cm), change of position (tilt>10 degrees), and entrapment of the wire (unable to remove wire). Descriptive statistics, chi-square, and Fisher's exact test were used (p < 0.05 considered significant). RESULTS: GW-1 resulted in a lower incidence of entrapment, migration, and tilt for all filters compared with GW-2 (F1, p = 0.003; F2, p < 0.0001; F3, p < 0.0001; F4, p = 0.0004). GW-1 resulted in entrapment in 0%, migration in 7.5%, and tilt in 10.5% of insertions. GW-2 resulted in entrapment in 1%, migration in 26.5%, and tilt in 5.5% of insertions. The incidence of adverse events for GW-1 was significantly different compared with all filters (F1, 0%; F2, 46%; F3, 4%; and F4, 22%; p < 0.0001). Similarly, the incidence of adverse events for GW-2 was significantly different when evaluating all filters (F1, 12%; F2, 48%; F3, 22%; F4 60%; p < 0.0001). CONCLUSIONS: The smaller-diameter guide wire resulted in a decreased incidence of adverse events for all filters, but there is still risk for complications. Knowledge of potential complications associated with vena cava filters and the postinsertion use of guide wires are essential to avoid potential mishaps.
Catheterization↗
Endoluminal gastric surgery: the modern era of minimally invasive surgery.
Laparoendoluminal techniques are the next frontier in modern surgery. They provide a minimally invasive approach to gastric diseases that enables organ preservation while maintaining open surgical principles. Laparoscopic direct access to the stomach provides a magnified, high-resolution image for precise excision using widely available laparoscopic instrumentation. Further improvements in flexible endoscopic equipment, combined with the infusion of robotic instrumentation, will aid in overcoming the technical demands of this procedure and fuel the growth of endo-luminal gastric surgery. Based on the currently available data, inappropriately selected patients, endoluminal gastric surgery affords the patients a definitive surgical procedure with all the advantages of a minimally invasive approach.
Digestive System Surgical Procedures↗
Clinical outcomes of laparoscopic adrenalectomy for lateralizing nodular hyperplasia.
BACKGROUND: Nodular adrenal hyperplasia (NAH) may mimic the biochemical characteristics of an aldosterone-producing adenoma. The authors evaluated the outcomes of unilateral laparoscopic adrenalectomy in the setting of lateralizing aldosterone hypersecretion by NAH. METHODS: Retrospective review of consecutive patients who underwent a laparoscopic adrenalectomy for primary hyperaldosteronism owing to NAH was performed. Patient demographics, perioperative symptoms, medications, radiographic findings, and serum chemistries were analyzed. Response to operation was classified according to postoperative control of hypertension and hypokalemia as resolved, improved, or refractory. RESULTS: From January 1999 to October 2004, 15 patients underwent a laparoscopic unilateral adrenalectomy for hyperaldosteronism owing to lateralizing NAH. Nine (60%) patients presented with > or =5 years of hypertension, including 8 (53%) patients with labile or malignant hypertension. Ten (67%) patients had hypokalemia. Abdominal imaging results were normal in 9 (60%) patients. All patients underwent adrenal venous sampling (94% successfully), which revealed an average adjusted aldosterone ratio of 17.6 (range, 1.2 to 75.9). At a mean follow-up of 26 (range, 4 to 58) months, hypertension had resolved in 4 (27%), improved in 8 (53%), and was refractory in 3 (20%) patients. Hypokalemia resolved in all patients. There were no complications, conversions, or mortalities. CONCLUSION: This series shows that unilateral adrenalectomy for lateralizing NAH results in eradication of hypokalemia and resolution or significant improvement in hypertension in 80% of patients at long-term follow-up. When lateralization of aldosterone production is noted, laparoscopic adrenalectomy provides significant clinical improvement even in patients with a pathologic diagnosis of NAH.
Adrenal Glands↗
Evaluation of the efficacy of the electrosurgical bipolar vessel sealer (LigaSure) devices in sealing lymphatic vessels.
Various sources of ultrasonic and thermal energy have been developed to facilitate blood vessel ligation. However, their efficacy in sealing lymphatics has not been clearly established to date. We hypothesized that the electrosurgical bipolar vessel sealer (EBVS) produces reliable and durable sealing of large lymphatic vessels in a porcine model. Thoracic ducts from 4 adult pigs were explanted and sealed at multiple levels by using 3 different EBVS devices: LigaSure Atlas, XTD, and V. Fifteen seals (5 per group) were analyzed for sealing time and visual quality. Seal burst strength was measured by using a graduated pressure saline injection system. Twelve intact seals also underwent a histologic analysis. The mean overall burst strength of the seals was 271+/-78 mm Hg (127 to 360 mm Hg). The burst pressures in the 3 groups were not statistically different. The overall mean time to achieve a seal was 5.1+/-2.2 seconds (3 to 10 seconds). Seals were achieved significantly faster in the V group (4.1+/-0.6 seconds) compared with the Atlas (6.3+/-2.3 seconds) and XTD (6.4+/-2.6 seconds) groups. Qualitative seal assessment revealed minimal sticking and charring, a favorable degree of seal tissue clarity, and desiccation in the 3 groups. Histologic analysis demonstrated a fusion of lymphovascular channels with a complete obliteration of the lumens. We demonstrated that the use of EBVS results in a fast and effective sealing of large porcine lymphatic vessels. The seals created by all 3 devices burst at markedly supraphysiologic intraluminal pressures. Ongoing randomized human trials may prove the clinical benefits of the routine use of EBVS devices for various tissue dissections.
Animals↗
Acute appendicitis following colonoscopy.
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Acute Disease↗
Initial evaluation of Cyberknife technology for extracorporeal renal tissue ablation.
OBJECTIVES: To determine whether Cyberknife technology can be applied to renal tissue safely and effectively. The goal was to achieve the high efficacy of a surgical treatment, with the low morbidity of a noninvasive intervention. METHODS: The Cyberknife is a frameless, image-guided radiosurgical device. This innovative extracorporeal treatment combines a linear accelerator mounted on a highly maneuverable robotic arm. The Cyberknife is unique in that it divides the high-dose radiation necessary to ablate the lesion completely into up to 1200 beams. Each one of these beams of radiation has a significantly reduced dose. Therefore, the individual dose of each beam is essentially benign to the pathway and surrounding tissue. However, at the focal point of these beams, the dose is additive, and the desired ablative dose is attained. Predetermined "lesions" in 16 kidneys were treated in vivo in the porcine model. Complete treatment was accomplished in one session per animal, with no complications. Gross and histologic evaluations were completed at 4, 6, or 8 weeks. RESULTS: The degree of radiation changes correlated with longer treatment intervals. After 8 weeks, the lesions showed complete fibrosis. The zones of complete fibrosis were characterized by dense, paucicellular connective tissue completely devoid of all normal kidney elements, including tubules and glomeruli. CONCLUSIONS: This initial preclinical evaluation of the Cyberknife for extracorporeal renal tissue ablation appears to be very promising and demonstrated its ability to ablate a targeted area precisely and completely with relative sparing of the surrounding tissue. This innovative technology introduces an exciting approach as a potential treatment option of renal masses in the future.
Animals↗
Risk of early surgery for Crohn's disease: implications for early treatment strategies.
OBJECTIVES: In this study we aimed to define the rate of early surgery for Crohn's disease and to identify risk factors associated with early surgery as a basis for subsequent studies of early intervention in Crohn's disease. METHODS: We assembled a retrospective cohort of patients with Crohn's disease diagnosed between 1991 and 1997 and followed for at least 3 yr, who were identified in 16 community and referral-based practices in New England. Chart review was performed for each patient. Details of baseline demographic and disease features were recorded. Surgical history including date of surgery, indication, and procedure were also noted. Risk factors for early surgery (defined as major surgery for Crohn's disease within 3 yr of diagnosis, exclusive of major surgery at time of diagnosis) were identified by univariate analysis. Multiple logistic regression was used to identify independent risk factors. RESULTS: Of 345 eligible patients, 69 (20.1%) required surgery within 3 yr of diagnosis, excluding the 14 patients (4.1%) who had major surgery at the time of diagnosis. Overall, the interval between diagnosis and surgery was short; one half of all patients who required surgery underwent operation within 6 months of diagnosis. Risk factors identified by univariate analysis as significantly associated with early surgery included the following: smoking; disease of small bowel without colonic involvement; nausea and vomiting or abdominal pain on presentation; neutrophil count; and steroid use in the first 6 months. Disease localized to the colon only, blood in the stool, use of 5-aminosalicylate, and lymphocyte count were inversely associated with risk of early surgery. Logistic regression confirmed independent associations with smoking as a positive risk factor and involvement of colon without small bowel as a negative risk factor for early surgery. CONCLUSIONS: The rate of surgery is high in the first 3 yr after diagnosis of Crohn's disease, particularly in the first 6 months. These results suggest that improved risk stratification and potent therapies with rapid onset of action are needed to modify the natural history of Crohn's disease.
Adolescent↗
Teleassessment compared with live assessment of pressure ulcers in a wound clinic: a pilot study.
OBJECTIVE: To compare teleassessment of pressure ulcers in individuals with spinal cord injury in a simulated remote setting with in-person assessments in a wound clinic. DESIGN: Pressure ulcers were assessed using a 3-megapixel digital camera; images of each ulcer were forwarded to a laptop in a separate room. Nurses completed a medical history and wound database form. A plastic surgeon reviewed the images and database and completed a questionnaire concerning the "remote" teleassessment or teleconsultation. When needed, the plastic surgeon obtained additional information using live audio-video interaction with the participant or nurse. After the teleassessment was completed, the plastic surgeon then assessed the individual and wound live and completed the same questionnaire used for the teleassessment. SETTING: Wound clinic of a rehabilitation hospital. PARTICIPANTS: Individuals with a spinal cord injury and 1 or more pressure ulcers who were seen for initial or follow-up evaluations. MAIN OUTCOME MEASURES: Percentage of agreement for teleassessment versus live responses to 4 yes/no questions regarding the need to change wound management, satisfaction with teleassessment, need for referral, and need for additional information. MAIN RESULTS: Seventeen individuals with 20 wounds were evaluated. The total percentage of agreement for teleassessment versus live decisions was 89% (80% to 95%). The highest percentages of agreement were for the need to change wound management and the need for referral (both 95%); the lowest percentages of agreement were for satisfaction with teleassessment for making treatment decisions (85%) and the need to obtain additional information (80%). CONCLUSIONS: Teleassessment of pressure ulcers in individuals with a spinal cord injury using digital images and a standard database compared well with in-person assessment, which is similar to results reported for other pathologic conditions.
Adult↗