Haemorrhoidectomy: painful choice.
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Anal Canal↗
Biomedical subjects
Q A Eijsbouts
Publications and source records attributed to Q A Eijsbouts.
[Same-day diathermic hemorrhoidectomy in 48 patients; few complications and tolerable pain].
OBJECT: To measure pain characteristics and to ascertain patient satisfaction and level of complications after day-care haemorrhoidectomy. DESIGN: Prospective. METHOD: Diathermic haemorrhoidectomy was performed in daytime care in 40 successive patients in hospital De Heel, Zaandam in 1997-1998. The operation was part of a package of measures, such as extensive counseling, preoperative bulking agents, surgery performed by colorectal surgeon, dedicated anaesthesiological techniques, adequate pain medication, and frequent outpatient clinic visits. RESULTS: The 40 patients were 21 men and 19 women with a mean age of 43 years (range: 27-67). One male patient was admitted for 24 hours because of urinary retention and 1 female patient developed a wound infection. No other serious complications were seen. During the first 5 postoperative bowel movements 75% of the total pain score was obtained. Postdefaecatory pain lasted on average 81 min on day 1 to 8 min on day 7. Time away from work was on average 6.4 days (range: 0-12). In between clinic visits 5 patients consulted their general practitioners. After 6 weeks 95% of the patients would again have consented to day-care haemorrhoidectomy. CONCLUSION: Diathermic haemorrhoidectomy has a low complication rate and tolerable pain and can be performed in day care.
Adult↗
Laparoscopic elective treatment of diverticular disease. A comparison between laparoscopic-assisted and resection-facilitated techniques.
BACKGROUND: Because of the presence of significant inflammatory reaction, elective surgical laparoscopic-assisted treatment of complicated diverticular disease can be difficult, leading to a high conversion and complication rate. Laparoscopic alternatives to this assisted approach consist of the hand-assisted method and the more conventional facilitated laparoscopic sigmoid resection. Facilitated laparoscopic sigmoid resection implies laparoscopic mobilization of the sigmoid as much as possible and splenic flexure when called for. Through a Pfannenstiel incision, the difficult steps of the operation-such as the dissection of the inflammatory process and taking down the fistula, but also resection and manual anastomosis-can be performed. In this study, we compare the operating time, conversion rate, complications, and costs of both assisted and resection-facilitated techniques. METHODS: We compared two consecutive series of 35 patients with diverticular disease who underwent a sigmoid resection by laparoscopy. Both groups were comparable in terms of age, gender, and kind of complicated diverticular disease. RESULTS: The operating time, conversion rate, and costs were all less in the laparoscopic-facilitated group. The fact that there were no conversions in this group is the most important finding of this study. Not only was it possible to convert from the assisted laparoscopic approach to laparotomy (five patients of 35), it was also possible to convert from the assisted to the facilitated form (seven of 35 patients). CONCLUSIONS: Laparoscopic-facilitated sigmoid resection is a feasible intervention for all forms of complicated diverticular disease and yields marked reductions in operating time, conversion rate, and operative and general costs.
Aged↗
Laparoscopic surgery preserves monocyte-mediated tumor cell killing in contrast to the conventional approach.
BACKGROUND: Experimental animal research shows that immunologic defenses against tumor cells are disturbed by surgical trauma, resulting in an increased rate of tumor implantation and the growth of subsequent metastases. Minimally invasive surgery is associated with a preservation of postoperative immunologic functions and, in animal models, with decreased tumor growth. The objective was to study the influence of several surgical procedures, approached conventionally and laparoscopically, on interleukin-6 (IL-6) and monocyte-mediated cytotoxicity (MMC). METHODS: Five groups of five patients each were included in this prospective study: laparoscopic cholecystectomy (minor trauma) group, Nissen fundoplication (laparoscopic and conventional as moderate trauma) groups, and sigmoid colectomy (laparoscopic and conventional as major trauma) groups. Preoperatively, 1 and 4 days after surgery, IL-6 and MMC against SW948 colon cancer cell line were determined. RESULTS: The IL-6 levels differed significantly between the three laparoscopic procedures (p = 0.004) and increased according to the degree of trauma. There was no significant difference in MMC between the three laparoscopic procedures. However, MMC was suppressed after conventional procedures and preserved after laparoscopic procedures (p = 0.001). There was no correlation between IL-6 levels and changes in MMC. CONCLUSIONS: More extensive laparoscopic procedures induce increased levels of IL-6, reflecting higher levels of trauma. Conventional surgical procedures result in depressed MMC in the postoperative period. After laparoscopic procedures, MMC is preserved. These findings may be of importance in preventing implantation and growth of cancer cells spread by surgical manipulation.
Adult↗
Laparoscopic treatment of large paraesophageal hernias: both excision of the sac and gastropexy are imperative for adequate surgical treatment.
BACKGROUND: We set out to evaluate the results of the laparoscopic treatment of large paraesophageal hernias in 22 patients. METHODS: Between 1993 and 1998, we operated on 22 consecutive patients. Preoperative assessment consisted of endoscopy, barium esophagogram, 24-h pH testing, manometry, and gastric emptying times. RESULTS: In the first three patients, the sac was not excised and gastropexy was not performed. Because of recurrences, we decided to change the technique in an attempt to avoid further complications. During middle- to long-term follow-up, only three recurrences were seen in the subsequent 19 patients. There were no deaths in this series. CONCLUSIONS: Laparoscopic treatment of large paraesophageal hernias is feasible. Because recurrences may occur after successful laparoscopic treatment, both resection of the sac and some form of gastropexy are imperative.
Adult↗
The influence of laparoscopic surgery on postoperative polymorphonuclear leukocyte function.
BACKGROUND: Laparoscopic surgery is thought to result in a better preservation of patients' immunological defenses. Polymorphonuclear leukocytes (PMN) are the most important effector cells in the elimination of pathogenic microorganisms. Because little is known about their function after laparoscopic surgery, we studied PMN phagocytosis, antigen expression, and oxygen radical production. METHODS: In this study, 17 patients scheduled for Nissen fundoplication were randomly assigned to undergo either a laparoscopic or conventional procedure. To study phagocytic capacity, PMN were incubated with fluorescein isothiocyanate (FITC)-labeled Staphylococcus aureus. Plasma opsonic capacity was measured by comparing PMN phagocytosis in the presence of patients' own plasma with phagocytosis in the presence of control plasma. Cellular activation was measured by the expression of various cell surface markers and by assessment of PMA-stimulated oxidative burst. RESULTS: Phagocytosis by PMN in the presence of patients' plasma was significantly lower 2 h after the conventional operation. No decrease in phagocytosis was observed when control plasma was used, indicating a decreased opsonic capacity of plasma after conventional surgery. No changes were observed after laparoscopic surgery. Furthermore, CD11b expression was significantly lower after the laparoscopic approach, indicating a blunted cellular activation. A significantly lower PMA-stimulated oxidative burst further confirmed the tempered stimulation after laparoscopic surgery. CONCLUSIONS: Laparoscopic surgery results in a preservation of the plasma opsonic capacity, and thereby the ability of PMN to phagocytose bacteria. Moreover, the postoperative cellular activation is reduced. The preserved phagocytosis and the blunted activation may prevent the development of postoperative infectious complications.
Adult↗
Laparoscopically assisted bowel surgery for inflammatory bowel disease. The combined experiences of two academic centers.
BACKGROUND: Laparoscopic bowel surgery was evaluated in 44 consecutive patients who underwent surgery for inflammatory bowel disease (IBD). We studied feasibility, results, and final outcome. METHODS: At two academic institutes, 44 laparoscopically assisted colectomies and laparoscopic ileostomies or colostomies were attempted. All patients had histologically proven IBD and no prior surgery for IBD. Loop ileostomy (n = 4), end colostomy (n = 1), ileocecal resection (n = 26) and (procto)colectomy (n = 13) were performed. All resections were laparoscopically assisted with extracorporal resection and anastomosis. RESULTS: Only in two patients (ileocecal resection in both) was conversion to open surgery necessary. Two patients with laparoscopic ileocolic resection had intra-abdominal abscesses, which were drained percutaneously in both. One patient in the laparoscopically assisted colectomy group had a subphrenic abscess that was drained percutaneously, and one patient had a generalized candidiasis. CONCLUSIONS: Laparoscopically assisted colectomies can be performed safely in treating IBD. The laparoscopic method with use of a small vertical umbilical or Pfannenstiel's incision seems acceptable with regard to operating time and overall costs, also allowing superior cosmesis to be maintained.
Adolescent↗
Assessment of the biliary tract by ultrasonography and cholangiography during laparoscopic cholecystectomy: a prospective study.
OBJECTIVE: The introduction of laparoscopic cholecystectomy (Lap-chol) has induced routine cholangiography to map the biliary tree and identify common bile duct (CBD) stones. However, the use of more selective criteria for performing intraoperative cholangiography (IOC), drawbacks of IOC and experience with laparoscopic ultrasonography (LU) re-introduced intraoperative ultrasonography for the CBD. The purpose of this study was to compare the accuracy of LU and IOC to identify the anatomy of the CBD and the presence of stones. METHODS: A total of 50 unselected patients undergoing elective laparoscopic cholecystectomy were evaluated by LU and IOC. Stones were found in three patients by IOC and could be confirmed by ultrasonography and CBD exploration in two. RESULTS: Anatomic definition of the biliary tract and success of the procedure was better for LU (90 and 98%) than IOC (86 and 72%). CONCLUSION: For Surgical groups with experience in LU this technique appears to become the standard technique to identify the anatomy of the CBD and assessment of CBD stones.
Adolescent↗
Laparoscopic surgery in the treatment of colonic polyps.
BACKGROUND: Benign colonic polyps that are impossible to remove with the aid of the flexible colonoscope because of their size or location must be removed surgically. METHODS: Twenty patients with colonic adenomatous polyps that could not be resected by colonoscopy because of size or difficult location (n = 18) or polyps in combination with diverticulitis (n = 2) underwent polyp removal through a small 'assisted' incision in the abdominal wall using a standard 'dissection-facilitated' laparoscopic approach to the affected colonic segment. RESULTS: In six patients the polyp was removed through a colotomy, in three through a limited resection (two ileocaecal and one limited sigmoid resection) and in 11 through a standard colectomy (four right hemicolectomy, one left hemicolectomy, four sigmoid and two anterior resections) because of suspicion of cancer. In only one patient could the polyp not be found during laparoscopy, resulting in a second conventional surgical intervention. In four patients carcinoma was diagnosed in the specimen. CONCLUSION: Precise preoperative localization of the polyp and the use of dissection-facilitated laparoscopic colonic surgery make laparoscopic removal of benign colonic polyps an alternative to an open procedure.
Aged↗
A prospective randomized study of the systemic immune response after laparoscopic and conventional Nissen fundoplication.
BACKGROUND: Laparoscopic techniques are thought to reduce the postoperative immunologic and metabolic changes of conventional operations. Until now, the only clinical data available were obtained from patients operated on for symptomatic gallstones; moreover, few studies were randomized. This randomized prospective study compares the systemic immune response after laparoscopic and conventional Nissen fundoplication. METHODS: Seventeen patients scheduled for Nissen fundoplication were randomly assigned to undergo either a laparoscopic or a conventional procedure. Postoperative inflammatory response was assessed by measuring the white blood cell count, C-reactive protein, and soluble tumor necrosis factor receptors p55 and p75. Postoperative immune function was assessed by measuring monocyte HLA-DR expression and the stress response was assessed by measuring plasma cortisol concentrations. RESULTS: Laparoscopic surgery resulted in significantly lower plasma CRP levels 1 day after surgery. Both approaches resulted in a significant decrease in HLA-DR expression within 2 hours after surgery. After the laparoscopic approach, postoperative expression was restored to preoperative values within 1 day after surgery. However, after conventional surgery HLA-DR expression remained suppressed and did not return to preoperative values until the fourth postoperative day. No significant differences between the 2 procedures were observed in white cell blood count, sTNFr-p55 and p75, nor in postoperative cortisol levels. CONCLUSIONS: Although both laparoscopic and conventional Nissen fundoplication result in an activation of the systemic immune response, this study suggests that this response could be less after the laparoscopic approach. The differences found may reflect a lower risk for postoperative infective complications.
Adult↗
Laparoscopic rectosigmoid colpopoiesis: does it benefit our transsexual patients?
When inversion of the combined penile and scrotal skin flaps for vaginoplasty in male-to-female transsexuals has not led to functional results, rectosigmoid colpopoiesis offers an immediate solution to a complicated and difficult problem. However, open colocolpopoiesis involves major surgery, and it may be associated with substantial extended morbidity and hospitalization, short- and long-term unfavorable results, and extensive scarring of the abdomen. To reduce this associated morbidity, we employ a laparoscopically assisted approach and a total laparoscopic rectosigmoid colpopoiesis. This procedure has been performed safely in the series presented herein, with no apparent compromise in the adequacy of the dissections. We conclude that our patients benefited from this procedure, and we advocate considering a total or partial laparoscopic approach whenever secondary rectosigmoid colpopoiesis is indicated in male-to-female transsexuals.
Adult↗
Hydrogen peroxide-enhanced transanal ultrasound in the assessment of fistula-in-ano.
UNLABELLED: Appropriate classification of the fistulous tracts in patients with fistula-in-ano may be of value for the planning of proper surgery. Conventional transanal ultrasound has limited value in the visualization of fistulous tracts and their internal openings. Hydrogen peroxide can be used as a contrast medium for ultrasound to improve visualization of fistulas. PURPOSE: This prospective study evaluates hydrogen peroxide-enhanced ultrasound in comparison with physical examination, standard ultrasound, and surgery in the assessment of fistula-in-ano. METHODS: Twenty-one consecutive patients (4 women; mean age, 42 years) with fistula-in-ano were evaluated by local physical examination (inspection, probing, and digital examination), conventional ultrasound, and hydrogen peroxide-enhanced ultrasound before surgery. Ultrasound was performed using a B&K Diagnostic Ultrasound System with a 7-MHz rotating endoprobe. Hydrogen peroxide (3%) was infused via a small catheter into the fistula. The results of physical examination, ultrasound, and hydrogen peroxide-enhanced ultrasound were compared with surgical data as the criterion standard. The additive value of standard ultrasound and hydrogen peroxide-enhanced ultrasound compared with physical examination was also determined. RESULTS: At surgery, 8 intersphincteric and 11 transsphincteric fistulas and 2 sinus tracts (without an internal opening) were found. During physical examination, probing was incomplete in 13 patients, the diagnosis being correct in the other 8 patients (38%) as a low (intersphincteric or transsphincteric) fistula. With conventional ultrasound, the assessment of fistula-in-ano was correct in 13 patients (62%); defects in one or both sphincters could also be found (n = 8). With hydrogen peroxide-enhanced ultrasound, the fistulous tract was classified correctly in 20 patients, the overall concordance with surgery being 95%. The internal opening was found at physical examination in 15 patients (71%), with hydrogen peroxide-enhanced ultrasound in 10 patients (48%), and during surgery in 19 patients (90%). Secondary extensions, confirmed during surgery, were found in five cases. In two patients, a secondary extension with hydrogen peroxide-enhanced ultrasound was not confirmed during surgery. Both patients developed a recurrent fistula. CONCLUSION: Hydrogen peroxide-enhanced ultrasound is superior to physical examination and standard ultrasound in delineating the anatomic course of perianal fistulas. It makes accurate preoperative assessment of the fistula possible and may be of value for the surgeon in planning therapeutic strategy.
Adult↗
Diagnostic laparoscopy in patients with an acute abdomen of uncertain etiology.
BACKGROUND: There are acute abdominal conditions in which it is difficult to establish an indicative diagnosis before laparotomy. A diagnosis is important in planning the right abdominal incision or to avoid an unnecessary laparotomy. Diagnostic noninvasive procedures such as X-ray studies do not always appear conclusive. Diagnostic laparoscopy is the only technique which can visualize the abdomen and, by establishing an adequate diagnosis, permits the surgeon to plan the right abdominal approach. METHODS: In a prospective study, 65 patients with a generalized acute abdomen (no intestinal obstruction or perforation) underwent a diagnostic laparoscopy under general anesthesia previous to the planned median laparotomy. RESULTS: In 46 patients (70%) diagnostic laparoscopy permitted the establishment of an adequate diagnosis, whereas in seven patients (10%) no cause for the acute abdomen could be found and an explorative laparotomy was avoided. In another 12 patients (20%) insufficient information was obtained during laparoscopy and an explorative laparotomy was performed. CONCLUSIONS: A conclusive diagnosis was established in 53 patients. This information led to a change in the surgical approach in 38 patients (e.g., limited, well-placed approach, laparoscopically, or avoidance of an unnecessary laparotomy). Diagnostic laparoscopy in this category of patients is a useful technique with important therapeutic consequences.
Abdomen, Acute↗
Laparoscopic Nissen fundoplication for the treatment of gastroesophageal reflux disease (GERD). Surgery after extensive conservative treatment.
BACKGROUND: A prospective study was conducted to evaluate the physiologic and clinical consequences of laparoscopic Nissen fundoplication (LNF), using strict indications for surgery. METHODS: From 1992 to 1997, 50 patients underwent LNF. Indications for operative treatment were either failure of conservative treatment or foresight to see long-term use of strong acid suppressive therapy. Patients were evaluated by barium esophagogastric study (BES), esophagoscopy, 24-h pH monitoring (pHM), stationary esophageal manometry, gastric-emptying studies (GES), pancreatic polypeptide stimulation test (PPT) and clinical evaluation using questionnaires. RESULTS: Perioperative complications necessitated conversion to laparatomy in two cases, and there was no mortality. Severe dysphagia resulted in reoperation in two patients. The average maximum lower esophageal sphincter pressure (MLESP) increased from 6. 1 mmHg to 12.7 mmHg. Endoscopy showed improved grading of the esophagitis, and the total percentage of pH less than 4 during 24 h decreased from a mean of 9.2 to 0.95. Three patients demonstrated impaired PPTs postoperatively; two had (mild) diarrhea. The overall success rate after the operation was 90%. CONCLUSIONS: The results of LNF in a limited number of patients with severe and/or resistant gastroesophageal reflux disease (GERD) receiving continuous medical treatment with proton pump inhibitors (PPIs) on a maintenance base are comparable with LNF results in centers with a more liberal policy concerning indications for LNF surgery.
Adult↗
Elective laparoscopic repair of type II paraesophageal hernias.
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Hernia, Hiatal↗
Transgastric endoluminal laparoscopic resection of a duodenal polyp.
Transgastric endoluminal surgery is a laparoscopic procedure used to treat gastric lesions such as polyps and carcinoma in situ. This approach can also be used to treat proximal duodenal problems such as bleeding and polyps. Our case was a young patient with bleeding from a benign duodenal polyp, localized 3 cm from the papilla of Vater. Two trocars were introduced by laparoscopy into the stomach. Guided by the flexible gastroscope, the polyp (a 6-cm Brunner's benign hamartoma) was resected by means of the endostaplers. Transgastric endoluminal surgery can be used to extirpate benign lesions in the proximal duodenum. The use of a flexible gastroscope can be very useful because of its adaptability to the anatomy.
Adult↗
Elective laparoscopic-assisted sigmoid resection for diverticular disease.
BACKGROUND: Although the laparoscopic-assisted approach to colorectal cancer remains controversial, its use for benign diseases can have important advantages. The purpose of this study is to determine the feasibility of this approach for the treatment of elective diverticular disease and to identify preoperative and perioperative factors which can help to select the best procedure for each patient: either assisted laparoscopic resection (ALR) or dissection-facilitated laparoscopic resection (DLR). METHODS: From November 1991 to the present, we conducted a prospective study of 41 patients approached electively for diverticular disease. RESULTS: Twenty-nine patients underwent an ALR, seven were approached by DLR, and another five patients were converted to laparotomy (15%). Morbidity was 17.5% and there was no mortality in this series. The mean hospital stay after operation was 6.5 days. CONCLUSIONS: Because of the complexity of this inflammatory process, choice of either an assisted or a more invasive laparoscopic facilitated approach is necessary. The decision is based on the technical difficulty as determined by data collected both preoperatively and during laparoscopy.
Colon, Sigmoid↗
Acute appendicitis--a clear-cut case in men, a guessing game in young women. A prospective study on the role of laparoscopy.
BACKGROUND: The aggressive surgical approach to patients suspected of having acute appendicitis for fear of perforation, and the inaccuracy of available diagnostic methods lead to an unacceptably high negative appendicectomy rate, especially in young women, in whom gynecological disorders frequently mimic appendicitis. Our objectives were to determine the value of diagnostic laparoscopy in women of child-bearing age to reduce the number of negative laparotomies and establish the correct diagnosis to allow prompt and appropriate treatment. METHODS: 161 consecutive adult female patients under 50 years of age with a clinical diagnosis of acute appendicitis underwent diagnostic laparoscopy prior to the planned appendicectomy. If an inflamed appendix was found, appendicectomy was usually done through a muscle-splitting McBurney incision. Other diagnoses were treated accordingly. A normal appendix was not removed. Results were compared to a group of 42 similar patients in whom the laparoscopy was omitted for various reasons, to 23 postmenopausal women, and to all 137 male adults, directly operated by the McBurney approach. RESULTS: After laparoscopy, 55% of the patients required appendicectomy for appendicitis while in 23% a gynecological diagnosis was made in spite of previous examination by a gynecologist. Fourteen percent had a negative laparoscopy. There were no false-negative results. The negative appendicectomy rate after laparoscopy was 5% due to two false positives and eight laparoscopy failures. In the group of fertile females who escaped laparoscopy the negative appendicectomy rate was 38%. The respective rates for postmenopausal women and men were 4% and 8%. CONCLUSIONS: All women of child-bearing age suspected of having acute appendicitis should undergo diagnostic laparoscopy prior to the planned appendicectomy, regardless of the certainty of the preoperative diagnosis. This is currently the only way to reduce the negative appendicectomy rate and establish a correct diagnosis allowing prompt and appropriate treatment. In male patients and postmenopausal women one may proceed directly to emergency appendicectomy.
Acute Disease↗