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Biomedical subjects

N J Soper

Publications and source records attributed to N J Soper.

At least 19 recordsLinked to original sources
PubMed1992

Laparoscopic cholecystectomy. The new 'gold standard'?

Laparoscopic cholecystectomy has rapidly been adopted by surgeons, but concerns remain about its safety, the management of common bile duct stones, and the means of appropriate training. Of 647 patients referred for cholecystectomy, preoperative endoscopic retrograde cholangiography was performed in 49 (7.6%), with 27 patients (4%) undergoing sphincterotomy and stone extraction. Traditional cholecystectomy was performed in 29 patients (4.5%). Laparoscopic cholecystectomy was attempted in 618 patients and completed successfully in 600 (97.1%). Surgical trainees functioned as the primary surgeon in 70% of cases. Technical complications occurred in three patients (0.5%), including one patient with a common bile duct laceration (0.2%). Major complications occurred in 10 patients (1.6%), with no perioperative mortality. Mean postoperative hospital stay was 1 day, with return to work or full activity a mean of 8 days after surgery. Two cases of retained common bile duct stones (0.3%) were identified. We now regard laparoscopic cholecystectomy as the "gold standard" therapy for management of symptomatic cholelithiasis.

Adolescent↗
PubMed1992

Influence of sleep on anal sphincteric pressure in health and after ileal pouch-anal anastomosis.

Fecal incontinence at night may be a disturbing consequence of ileal pouch-anal anastomosis (IPAA). The hypothesis was that decreases in anal canal resting pressure occur as sleep deepens and that the decreases are more profound in pouch patients with incontinence than in controls. Using a sleeve catheter assembly for recording intraluminal and canal pressure and polysomnographic recordings of sleep stages, progressive decreases in anal canal resting pressure with deepening sleep occurred in 11 healthy controls (mean +/- SEM: 57 +/- 3 mm Hg to 43 +/- 3 mm Hg: P less than 0.05) and in 11 patients after IPAA (55 +/- 3 mm Hg to 42 +/- 4 mm Hg; P less than 0.05). Minute-to-minute variations in mean pressure were also found in both controls and IPAA patients, and they were greater at night in patients (P less than 0.05), except during rapid eye movement (REM) sleep. In three patients, resting pressure during REM sleep decreased markedly to 31 +/- 8 mm Hg. This decrease plus the variations in pressure during REM sleep led to incontinence. In conclusion, decreases in anal resting pressure coupled with marked minute-to-minute variations in pressure during sleep occurred in controls and in patients after IPAA and, when profound, led to nocturnal fecal incontinence in some patients.

Adult↗
PubMed1992

Laparoscopic ureterolysis.

We report a case of an obstructed right kidney due to retroperitoneal fibrosis. Ureterolysis, biopsy of the retroperitoneal tissue and intraperitonealization of the ureter were accomplished laparoscopically.

Adolescent↗
PubMed1992

Laparoscopic management of bile duct stones.

Although it may seem that laparoscopic cholecystectomy has revolutionized the way we approach the patient with stones in the gallbladder and bile ducts, only a few rules have really changed. Fluoroscopic cholangiography, a requirement for radiologists and gastroenterologists performing percutaneous transhepatic cholangiography and ERCP, is slowly finding its way into the operating room. No longer is a "palpable stone" a common indication for common bile duct exploration. Most importantly, it is not necessary to make an incision into the bile duct to remove the majority of bile duct stones. The transcystic approach will clear the duct in 85% to 90% of all patients, sparing them extra hospitalization, a T-tube, and the risk of creating a bile duct stricture during sutured closure of the choledochotomy.

Cholangiography↗
PubMed1992

Suturing and knot tying in laparoscopy.

Laparoscopic surgery is evolving, and its applications are growing to include most abdominal operations. Tissue approximation by means other than mechanical clips or staples will be increasingly important. Laparoscopic surgeons must learn and apply basic suturing and knot-tying skills in this remote, two-dimensional operating theater. The authors advocate practice of these skills using inanimate and animate training models prior to application in the clinical setting.

General Surgery↗
PubMed1992

Laparoscopic nephrectomy: a review of 16 cases.

Laparoscopic nephrectomy is a new procedure in which the entire kidney is removed via an endoscopic technique using a surgical sack entrapment method in combination with a recently developed high-speed 10-mm electrical tissue morcellator. Since June 25, 1990, this procedure has been successfully accomplished in 16 consecutive patients. The average operating room time was 5.6 h. Two patients received a blood transfusion (one and three units, respectively). The average hospital stay was 4.6 days, and convalescence was completed within an average of 12 days. We believe the methods developed for laparoscopic nephrectomy will allow surgeons in other disciplines to broaden their indications for laparoscopic surgery as the entrapment sack and morcellator can potentially be applied to the removal of many other solid intraabdominal and pelvic tissues.

Adolescent↗
PubMed1992

Comparison of early postoperative results for laparoscopic versus standard open cholecystectomy.

Alternative (nonresective) therapies of symptomatic cholelithiasis have been followed by frequent recurrence of gallstones. Great interest has been generated by the recent development of laparoscopic cholecystectomy, which in addition to preventing recurrence, may be associated with less patient discomfort, shorter hospital stays and more rapid return to work than standard cholecystectomy. We compared the first 25 patients who underwent laparoscopic cholecystectomy at our institution to the most recent 25 patients undergoing standard cholecystectomy by the same surgeon. The results of analysis of the two patient groups showed that they were similar in age, weight and gallstone burden. A slightly longer operative time (mean plus or minus S.E.M., 122 +/- 9 minutes versus 95 +/- 5 minutes, p) was required to perform laparoscopic cholecystectomy than standard cholecystectomy during this early experience. However, patients undergoing laparoscopic cholecystectomy had a markedly diminished usage of parental narcotic analgesia during the first 24 hours postoperatively (1.7 +/- 0.5 milligrams of morphine sulfate versus 34.5 +/- 4.1 milligrams of morphine sulfate). They also were discharged from the hospital (1.0 +/- 0 days versus 4.1 +/- 0.3 days) and returned to work or unrestricted activity (8.5 +/- 1.1 days versus 35.6 +/- 4.5 days) much sooner postoperatively than those treated by standard open cholecystectomy. Based on these favorable results, we conclude that laparoscopic cholecystectomy should be the procedure of choice for most patients with symptomatic cholelithiasis.

Adult↗
PubMed1992

Laparoscopic cholecystectomy and choledochoscopy for the treatment of cholelithiasis and choledocholithiasis.

A 33-year-old woman with symptomatic cholelithiasis underwent laparoscopic cholecystectomy. Preoperative evaluation did not suggest the presence of choledocholithiasis, but intraoperative cholangiography showed a totally obstructing stone in the distal common bile duct. Laparoscopically directed, transperitoneal choledochoscopy was performed by passing a 9.4 F flexible ureteroscope through the cystic duct into the distal common bile duct. A single calculus was visualized and removed with a basket. The patient was discharged the next day, returned to full activity within 1 week, and has done well in the subsequent postoperative interval. The management of incidentally discovered common bile duct stones during performance of laparoscopic cholecystectomy is discussed.

Adult↗
PubMed1991

Influence of in situ neural isolation of jejunoileum on postprandial pancreatobiliary secretion and gastric emptying.

Our aims were to examine the influence of neural isolation of the jejunoileum on postprandial pancreatobiliary secretion. In four dogs, duodenal perfusion and aspiration catheters were implanted, and serosal electrodes were placed along the proximal small bowel. Control studies of gastric emptying, output of bile acids and amylase, and plasma concentrations of peptide YY and neurotensin were performed on three occasions following ingestion of a 340-kcal mixed-nutrient liquid meal. The dogs then underwent our model of in situ jejunoileal neural isolation, and the meal studies were repeated. Neural isolation, when compared to control, did not affect either postprandial conversion of intestinal myoelectric activity to the "fed" pattern, gastric emptying (T1/2, X +/- SE of the liquid meal (74 +/- 6 vs 79 +/- 7 min; P greater than 0.05), or cumulative amylase output (373 +/- 59 vs 305 +/- 66 kU; P greater than 0.05). Neural isolation decreased cumulative postprandial bile acid output from 6.6 +/- 0.9 mM to 3.4 +/- 1.1 mM (P less than 0.05) and increased postprandial plasma concentrations of peptide YY and neurotensin. Our findings suggest that the jejunoileal denervation that accompanies the in situ neural isolation of the jejunoileum is not associated with changes in postprandial motility patterns, gastric emptying, or pancreatic amylase secretion. Loss of this innervation, however, may decrease postprandial output of bile acids and lead to a compensatory increase in the postprandial release of neurotensin and peptide YY.

Amylases↗
PubMed1991

Laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is a newly developed technique for removing the gallbladder. Its future is very promising and this operation will probably become the preferred method of cholecystectomy for most patients. However, the limitations of laparoscopic cholecystectomy should be realized and great care must be taken to avoid technical complications. If laparoscopic cholecystectomy is associated with a much higher incidence of injuries to the bile duct than is traditional open cholecystectomy, its promise of decreasing pain, disability, and costs to patients undergoing cholecystectomy will be unfulfilled. The practicing general surgeon should learn laparoscopic techniques, since much of the future of abdominal surgery will ultimately reside in applying "less invasive" methods to perform standard operations. When embarking on a new procedure such as laparoscopic cholecystectomy, it is imperative that the surgeon remember the basis of his or her craft, primum non nocere.

Cholecystectomy↗
PubMed1991

Laparoscopic nephrectomy: initial case report.

A tumor-bearing right kidney was completely excised from an 85-year-old woman using a laparoscopic approach. A newly devised method for intra-abdominal organ entrapment and a recently developed laparoscopic tissue morcellator made it possible to deliver the 190 gm. kidney through an 11 mm. incision.

Adenoma↗
PubMed1991

Laparoscopic cholecystectomy: evaluation with sonography.

To determine the normal postoperative appearance of gallstones in the common duct at ultrasound (US) examination, the significance of fluid collections after surgery, and the usefulness of routine postoperative scanning, US of the right upper quadrant was performed in 106 consecutive patients 24 hours after laparoscopic cholecystectomy. The location, volume, and appearance of fluid collections were recorded. The maximum diameter of the common duct was measured in all patients and compared with preoperative measurements in 58 patients. Small fluid collections were identified in the gallbladder fossa in 56 patients (53.0%). Fluid collections did not correlate with fever or white blood cell count. In 15 of 58 patients, the diameter of the common duct had increased on the postoperative scan. This did not correlate with alkaline phosphatase or bilirubin levels. One hundred one patients (95.3%) were discharged the day after surgery. Routine US performed the day after surgery did not alter management; the authors conclude that it is unwarranted in their group of patients.

Adult↗
PubMed1991

Inhibitory effect of ileal oleate on postprandial motility of the upper gut.

To determine the effect of ileal oleate on postprandial gastrointestinal motility, duodenal and paired perfusion-aspiration ileal catheters and bipolar duodenal and jejunal electrodes were surgically implanted in five dogs. The ileum was perfused with either saline or an isotonic oleic acid emulsion at 2 ml/min. A 205-kcal mixed meal containing 120 ml liquid nutrient labeled with 111In-diethylenetriamine pentaacetic acid (DTPA) and solid food labeled with 99mTc was then administered orally. Gastric emptying was assessed by a gamma camera, myoelectric activity was continuously monitored, and duodenal-ileal transit of phenol red was determined over the ensuing 240 min. Ileal oleate reduced duodenal spikeburst frequency by 50% (P less than 0.05) and delayed gastric emptying of liquids and solids. Four hours after ingesting the meal, 62% of solids and 34% of liquids were retained in the stomach during oleic acid perfusion compared with 25 and 4%, respectively, when saline was perfused (P less than 0.05). Duodenal-ileal transit was markedly slowed by ileal perfusion with the oleic acid emulsion (P less than 0.001). Ileal oleate therefore exerted a profound inhibitory effect on proximal gut motility in the early period after ingestion of a mixed-nutrient meal in dogs.

Animals↗
PubMed1991

Safety and efficacy of laparoscopic cholecystectomy using monopolar electrocautery in the porcine model.

Recent reports suggest that laparoscopic laser cholecystectomy may become the preferred therapy for symptomatic cholelithiasis. To assess the efficacy and safety of this technique, using monopolar electrocautery instead of laser for the gallbladder dissection, laparoscopic cholecystectomy was performed on 11 pigs. Under general anesthesia, a pneumoperitoneum was established, and four sheaths were placed into the abdomen for introduction of instruments. Using video laparoscopic guidance, the cystic duct and artery were isolated, clipped, and divided. Monopolar electrocautery was used to dissect the gallbladder from its fossa. Five animals were sacrificed immediately, without visible evidence of injury to the bile ducts, liver, or intestine. The remaining six pigs were allowed to recover. One animal died 10 days postoperatively due to adhesive small bowel obstruction. The remainder survived in good health until sacrifice at 1 month. Histologic examination of the gallbladder bed and liver revealed no evidence of ongoing local hepatocyte destruction or chronic cholestasis. Cholangiography demonstrated the bile ducts to be intact. Mean (+/- SEM) total serum bilirubin (TB), alkaline phosphatase (AP), and glutamic oxalacetic transaminase (SGOT) at the time of sacrifice were similar to nonoperated swine (n = 10): TB, 0.12 +/- 0.02 versus 0.11 +/- 0.01 mg/dl; AP, 175 +/- 23 versus 162 +/- 10 IU/L; SGOT, 37 +/- 4 versus 55 +/- 7 IU/L, respectively (p > 0.05). We conclude that laparoscopic cholecystectomy can be performed using monopolar electrocautery without significant acute injury to the liver, bile ducts, or surrounding viscera. Furthermore, the porcine model can be utilized by surgeons to attain competence in this technique prior to instituting clinical application in humans.

Alkaline Phosphatase↗
PubMed1991

Does intraoperative gallbladder perforation influence the early outcome of laparoscopic cholecystectomy?

Laparoscopic cholecystectomy is rapidly becoming the preferred therapy for symptomatic cholelithiasis. It was our impression that the necessary traction exerted on the gallbladder during this procedure would frequently lead to intraoperative perforation with bile leak. We sought to determine prospectively the incidence of gallbladder perforation during laparoscopic cholecystectomy and to ascertain whether or not intraoperative bile leak resulted in overt complications. Laparoscopic cholecystectomy was performed successfully on 250 patients between November 1989 and December 1990. Gallbladder perforation occurred in 80 patients (32%). Compared with those without a bile leak, there was a larger percentage of men (p < 0.05), and the average weight was greater (p < 0.01) in those developing a bile leak. Operating time was significantly longer in patients with gallbladder perforation (mean +/- SEM, 104 +/- 4 min) than in those without a bile leak (94 +/- 3 min, p < 0.01), presumably because of the increased time spent irrigating the abdomen and retrieving gallstones. There was no difference in postoperative serum liver enzymes, amount or type of analgesia administered, interval to return to work or to full activity, or the development of postoperative infections. A wound infection requiring antibiotic therapy developed in only one patient who had not suffered a bile leak. The incidence of bile leak during the performance of laparoscopic cholecystectomy is therefore appreciable, occurring in approximately a third of our patients. Gallbladder perforation does not lead to any other adverse complications and should not cause the surgeon to convert to an open cholecystectomy.

Adolescent↗