Reuse of single-use devices: Looking back, looking forward.

The reuse of medical devices marked as ‘single use’ by manufacturers has been going on for several decades. The process has been rationalized and legislated in the West as well as in Japan. However, the practice continues in an unregulated manner in India due to a paucity of guidance from the Food and Drug Administration in India. We trace the evolution of reuse policies, look at the prevalent practices in the Indian and international contexts, analyse the available Indian literature and address the ethical and economic implications of reuse. We also suggest some guidelines which may be adopted to formulate policies.

Laparoscopic surgery for reflux esophagitis and paraesophageal hernia.

BACKGROUND: Laparoscopic surgery has become the standard for treatment of several abdominal diseases. We analyzed our data on laparoscopic treatment of reflux esophagitis and paraesophageal hernia. METHODS: Twenty patients (mean age 61 y; 14 men) - 18 with reflux esophagitis and sliding hiatus hernia, and two with paraesophageal and sliding hernia - were operated on using laparoscopy between March 1999 and March 2001. All patients were investigated by upper GI endoscopy, barium study and routine pre-operative work-up. Nineteen patients underwent a modified Nissen fundal wrap along with repair of the diaphragmatic crura; one patient had only crural repair with no fundal wrap. RESULTS: All procedures were completed laparoscopically. The mean operating time was 140 min (range 90 to 240). Eighteen patients were discharged on the third postoperative day and two on the fifth day. One patient had perforation of intrathoracic part of the esophagus during passage of an esophageal bougie; he presented with empyema 10 days after discharge and was treated by intercostal drainage. There were no other complications. All patients have been followed up on an outpatient basis for 3 months to 2 years. All are presently off acid-suppressive therapy. Seventeen patients are free of symptoms; two patients have gas bloat-like symptoms and one has occasional grade I dysphagia. CONCLUSIONS: Laparosopic surgery is a safe and effective method of treating esophagitis and paraesophageal hernia.

Complicated sigmoid diverticulosis.

BACKGROUND: To evaluate the outcome of patients treated for complications of sigmoid diverticular disease. METHODS: Fifteen patients (11 women; aged 54-80 years) were treated over a 6-year period in a community hospital. Five patients presented with perforation and peritonitis, 3 with colovesical fistula, 2 with colovaginal fistula, 2 with recurrent phlegmon and 3 with bleeding. Six patients (5 with perforation, 1 colovesical fistula with hematuria) underwent emergency surgery. Six patients (2 with colovesical fistula, 2 colovaginal fistula and 2 recurrent phlegmon) underwent planned sigmoid resection. All 3 patients with bleeding were treated conservatively. RESULTS: One patient with a colovesical fistula and severe hematuria died 72 hours later with septicemia. All 5 patients with peritonitis survived; two had an eventful post-operative period and were in hospital for nearly 3 months. All 5 developed wound sepsis. Six patients who had a planned procedure had uneventful recovery. The 3 patients who presented with bleeding recovered. CONCLUSION: Complicated diverticular disease carries a high morbidity and mortality especially when operated on as an emergency. Interval sigmoid resection should be offered to patients who have recovered from an acute complication.

Endoscopic retrograde cholangiography in the era of laparoscopic cholecystectomy.

OBJECTIVE: To assess the value of endoscopic retrograde cholangiography (ERC) as an adjunct in patients undergoing laparoscopic cholecystectomy (LC). METHODS: Four hundred and sixty consecutive patients with cholelithiasis were evaluated for LC over a four-year period (January 1991 to January 1995). Forty four (9.6%) patients underwent pre-operative ERC on a suspicion of harboring common bile duct (CBD) stones. Ten other patients who presented with acute gallstone pancreatitis also had pre-operative ERC as soon as the acute attack had settled. Endoscopic sphincterotomy (ES) and stone extraction were done if indicated. After LC, four patients underwent ERC for cystic or CBD related complications. RESULTS: Cannulation was possible in all patients undergoing ERC. Of 44 patients with suspected CBD stones, 33 (75%) actually had stones. In 30 patients the stones could be extracted. Three patients had large stones which could not be extracted. Of 10 patients with acute gallstone pancreatitis, CBD stones were found in only one. In the 4 patients who developed ductal complications, ERC was used to place stents in three and to extract a missed CBD stone in one. Three patients developed fever after ERC and three others had transient hyperamylasemia. There were no other ERC related problems. CONCLUSION: In patients undergoing LC, ERC is a useful adjunct both pre- and post-operatively.

Laparoscopic cholecystectomy: analysis of 100 cases.

OBJECTIVE: To study the efficacy and safety of laparoscopic cholecystectomy. METHODS: One hundred patients with symptomatic cholelithiasis were subjected to laparoscopic cholecystectomy. Preoperative ERCP and sphincterotomy were performed to detect and treat patients suspected to have associated common bile duct (CBD) stones on clinical, biochemical and imaging methods. RESULTS: Ninety patients underwent successful laparoscopic cholecystectomy. The mean operating time was 90 minutes. There were no deaths and morbidity was minimal (6%). Eighty five patients were discharged within 48 hours of surgery. In ten patients the procedure was converted to open surgery. Previous upper abdominal surgery; associated CBD stones; empyema gall bladder; and shrunken, non distensible gall bladder could make the laparoscopic procedure difficult and forewarn the surgeon about a possible conversion to open surgery. CONCLUSION: Laparoscopic cholecystectomy is a safe and effective method of gall bladder removal.