A producer survey of knowledge and practises on gastrointestinal nematode control within the Australian goat industry.

Gastrointestinal nematodes (GINs) have been identified in Australia as a major problem in goat production, with few anthelmintics registered for use in goats. Therefore, anecdotally many producers use anthelmintics that have not been registered for goats. Using unregistered products could increase selection pressure for anthelmintic resistance as well as safety and/or meat or milk chemical residues of products from treated goats. This producer survey was conducted in 2014 to establish Australian goat producer knowledge, perception and practises of GIN treatment and control. Eighty-eight producers responded to the survey. Of these respondents, 90% thought that GINs were a problem for the Australian goat industry, and 73% considered GINs had caused production losses or health impacts for their goats during the 5 years prior to the survey. With regard to anthelmintic resistance, 7% believed that anthelmintic resistance was not a problem at all, 93% acknowledged anthelmintic resistance was a problem in Australian goats herds, with 25% of these reporting their properties as being affected. The majority (81%) of respondents believed the number of anthelmintics registered for goats was inadequate for effective GIN control. Of the 85% of producers who used an anthelmintic during the survey period, 69% had used a treatment not registered for use in goats. Fifty respondents listed the anthelmintic dosage used, and 50% of those had used a dose rate greater than the recommended label dose. The average frequency of administration of anthelmintic was 2.5 times per annum. Of the 51% of respondents who listed the frequency of their treatments given during the survey period, 16% administered four or more treatments annually to the majority of their goats and 8% administered treatments on an "as needed" basis. Faecal egg count (FEC) had been performed on 72% of properties in at least one of the six years covered by the survey. These results indicated that the majority of surveyed producers use anthelmintics that are not registered for use in goats and at different dose rates to label. These practises have the potential for increasing the spread of anthelmintic resistance in the GIN populations of goats and sheep. Further, giving dose rates in excess of label recommendations could impact goat safety and/or product residues. Further research is needed to investigate these risks and evaluate more sustainable GIN control options for goat herds. In addition more effective dissemination of information is necessary for the improvement of the Australian goat industry.

Hybrid ventral hernia repair: technique and results.

BACKGROUND: Open and laparoscopic approaches to ventral hernia repair are generally exclusive of each other. However, select patients with difficult hernias may benefit from combined open/laparoscopic hybrid techniques to avoid dissection of large subcutaneous flaps. METHODS: Seven patients underwent combined laparoscopic and open approaches for ventral hernia repair. Records were reviewed for technical details, demographics, hernia and mesh characteristics, and postoperative outcomes. RESULTS: Two hybrid techniques were used: (1) initial laparoscopic approach converted to open adhesiolysis followed by totally laparoscopic mesh fixation and (2) open repair and adhesiolysis with laparoscopic-assisted mesh fixation. In the first approach, after conversion to open adhesiolysis, mesh with four quadrant sutures was placed intraabdominally. Pneumoperitoneum was re-established, and the mesh was fixed laparoscopically with sutures and tacks in standard fashion. For the second hybrid approach, after hernia reduction and adhesiolysis, mesh was anchored with sutures placed at 3-4 cm intervals with a Reverdin needle and further secured posteriorly with a hernia tacker over 180° circumference. Prior to tying the contralateral transfascial sutures, two 5-mm laparoscopic ports were placed lateral to the mesh under direct vision on the opposite side. Once the facial sutures were tied, pneumoperitoneum was established, and the contralateral side of mesh was tacked laparoscopically. Mean patient age was 65 years and BMI 38. Mean defect size was 10.6 cm × 8.3 cm and mean mesh size was 25 cm × 19 cm. Operative time was 318 min (210-405 min). Hospital stay was 5 days (4-7 days). Morbidity was 57 % including one deep wound infection and a chronic sinus requiring reoperation. There were no hernia recurrences with average follow-up of 15 months (3-63 months). CONCLUSIONS: Hybrid laparoscopic and open techniques may be used in obese patients with difficult incisional hernias requiring open adhesiolysis. Further studies need to be done to better delineate hernia characteristics of patients that may benefit from this approach.

Esophageal manometric characteristics and outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication for epiphrenic diverticula.

PURPOSE: The purpose of this study is to characterize the esophageal motor and lower esophageal sphincter (LES) abnormalities associated with epiphrenic esophageal diverticula and analyze outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication. METHODS: The endoscopic, radiographic, manometric, and perioperative records for patients undergoing laparoscopic esophageal diverticulectomy, anterior esophageal myotomy, and partial fundoplication from 8/99 until 9/06 were reviewed from an Institutional Review Board (IRB)-approved outcomes database. Data are given as mean +/- standard deviation (SD). RESULTS: An esophageal body motor disorder and/or LES abnormalities were present in 11 patients with epiphrenic diverticula; three patients were characterized as achalasia, one had vigorous achalasia, two had diffuse esophageal spasm, and five had a nonspecific motor disorder. Presenting symptoms included dysphagia (13/13), regurgitation (7/13), and chest pain (4/13). Three patients had previous Botox injections and three patients had esophageal dilatations. Laparoscopic epiphrenic diverticulectomy with an anterior esophageal myotomy was completed in 13 patients (M:F; 3:10) with a mean age of 67.6 +/- 4.2 years, body mass index (BMI) of 28.1 +/- 1.9 kg/m2 and American Society of Anesthesiologists (ASA) 2.2 +/- 0.1. Partial fundoplication was performed in 12/13 patients (Dor, n = 2; Toupet, n = 10). Four patients had a type I and one patient had a type III hiatal hernia requiring repair. Mean operative time was 210 +/- 15.1 min and mean length of stay (LOS) was 2.8 +/- 0.4 days. Two grade II or higher complications occurred, including one patient who was readmitted on postoperative day 4 with a leak requiring a thoracotomy. After a mean follow-up of 13.6 +/- 3.0 months (range 3-36 months), two patients complained of mild solid food dysphagia and one patient required proton pump inhibitor (PPI) for gastroesophageal reflux disease (GERD) symptoms. CONCLUSION: The majority of patients with epiphrenic esophageal diverticula have esophageal body motor disorders and/or LES abnormalities. Laparoscopic esophageal diverticulectomy and anterior esophageal myotomy with partial fundoplication is an appropriate alternative with acceptable short-term outcomes in symptomatic patients.

Laparoscopic splenectomy for splenic masses.

BACKGROUND: This study aimed to evaluate the perioperative outcomes and pathology of patients undergoing laparoscopic splenectomy for splenic masses. METHODS: The records for 174 patients who underwent laparoscopic splenectomy from May 1994 to August 2006 were reviewed. Patient demographics, preoperative imaging, American Society of Anesthesiologists (ASA) score, body mass index (BMI), estimated blood loss (EBL), operative time, spleen size, complications, hospital length of stay (LOS), pathology, and mortality were extracted from the records. Data are expressed as means +/- standard deviation. Statistical significance (p < 0.05) was determined using a two-tailed t-test and Fisher's exact test. RESULTS: A splenic mass was diagnosed preoperatively for 18 patients (10.3%) (7 males and 11 females). The mean patient age was 51.4 +/- 13.7 years. The mean ASA was 2.3 +/- 0.8, and the mean BMI was 27.3 +/- 5.8 kg/m(2). Computed tomography scans demonstrated splenic masses in all the patients. The mean mass size was 4.3 +/- 3.3 cm (range, 1.0-11.0 cm), and the mean spleen length was 14.6 +/- 7.5 cm (range, 5.5-40.2 cm). Total laparoscopic splenectomy was completed for 15 patients, and hand-assisted splenectomy was performed for 3 patients (2 converted). The mean operative time was 128.3 +/- 38.5 min, and the mean EBL was 110 +/- 137.5 ml. There were no intraoperative complications or 30-day mortalities. The postoperative complication rate was 11.1%, and the mean LOS was 1.9 +/- 1.0 days. The pathology for six patients (33.3%) was malignant (5 lymphomas and 1 adenocarcinoma). There were three false-positive positron emission tomography (PET) scans. Compared with 73 patients undergoing laparoscopic splenectomy for idiopathic thrombocytopenic purpura, there was no significant difference in mean EBL, operative time, conversion rate, complication rate, LOS, or 30-day mortality rate (p > 0.05). CONCLUSIONS: Laparoscopic splenectomy is appropriate for patients whose indication for surgery is splenic mass. Suspicious splenic masses should be removed due to the relatively high incidence of malignant pathology, most commonly lymphoma.

Evaluation of acellular human dermis reinforcement of the crural closure in patients with difficult hiatal hernias.

BACKGROUND: Biologic prosthetics may circumvent mesh-related complications at the esophageal hiatus by becoming remodeled by native cells. We present our experience with acellular human dermal matrix in the repair of difficult hiatal hernias (HH). METHODS: Records of 17 patients who underwent laparoscopic HH repair using acellular human dermis to buttress the crural closure were analyzed. Hernias were paraesophageal (PEH) in 12 patients, large type 1 in 1 patient, and recurrent after prior HH repair in 4 patients. Barium swallow (BAS) was obtained 6-12 months after surgery. (Data are presented as mean +/- standard deviation.) RESULTS: Mean patient age was 65 +/- 12 years and BMI was 31 +/- 4. Mean gastroesophageal (GE) junction distance above the diaphragm in the PEHs was 4.9 +/- 1.5 cm; 9 of 12 patients with PEH had more than 50% of the stomach in the chest. Mean operating time was 273 +/- 48 min. Average hiatal defect size was 4.7 x 2.7 cm, with 4.2 +/- 1.2 sutures used to close the crura. Nissen fundoplication was performed in all patients, esophageal lengthening in four patients, and anterior gastropexy in three patients. Mean hospital length of stay (LOS) was 2.3 +/- 0.8 days. Mean followup was 14.4 +/- 4.4 months. Postoperatively, only one (6%) patient had heartburn/regurgitation, one (6%) had mild dysphagia, and two (12%) take proton pump inhibitors. Followup BAS at 10.3 +/- 4.9 months after surgery showed small recurrent hernias in two patients (12%), but only one was symptomatic. In addition, there was one symptomatic failure of a redo Nissen in an obese patient. Reoperative gastric bypass 15 months later showed an intact crural closure with a remodeled buttress site. CONCLUSIONS: Acellular human dermal matrix may be an effective method to buttress the crural closure in patients with large hiatal hernias. Longer followup in larger numbers of patients is needed to assess the validity of this approach.

Outcomes analysis of laparoscopic resection of pancreatic neoplasms.

BACKGROUND: Experience with laparoscopic resection of pancreatic neoplasms remains limited. The purpose of this study is to critically analyze the indications for and outcomes after laparoscopic resection of pancreatic neoplasms. METHODS: The medical records of all patients undergoing laparoscopic resection of pancreatic neoplasms from July 2000 to February 2006 were reviewed. Data are expressed as mean +/- standard deviation. RESULTS: Laparoscopic pancreatic resection was performed in 22 patients (M:F, 8:14) with a mean age of 56.3 +/- 15.1 years and mean body mass index (BMI) of 26.3 +/- 4.5 kg/m2. Nine patients had undergone previous intra-abdominal surgery. Indications for pancreatic resection were cyst (1), glucagonoma (1), gastrinoma (2), insulinoma (3), metastatic tumor (2), IPMT (4), nonfunctioning neuroendocrine tumor (3), and mucinous/serous cystadenoma (6). Mean tumor size was 2.4 +/- 1.6 cm. Laparoscopic distal pancreatectomy was attempted in 18 patients and completed in 17, and enucleation was performed in 4 patients. Laparoscopic ultrasound (n = 10) and a hand-assisted technique (n = 4) were utilized selectively. Mean operative time was 236 +/- 60 min and mean blood loss was 244 +/- 516 ml. There was one conversion to an open procedure because of bleeding from the splenic vein. The mean postoperative LOS was 4.5 +/- 2.0 days. Seven patients experienced a total of ten postoperative complications, including a urinary tract infection (UTI) (1), lower-extremity deep venous thrombosis (DVT) and pulmonary embolus (1), infected peripancreatic fluid collection (1), pancreatic pseudocyst (1), and pancreatic fistula (6). Five pancreatic fistulas were managed by percutaneous drainage. The reoperation rate was 4.5% and the overall pancreatic-related complication rate was 36.4%. One patient developed pancreatitis and a pseudocyst 5 months postoperatively, which was managed successfully with a pancreatic duct stent. There was no 30-day mortality. CONCLUSIONS: Laparoscopic pancreatic resection is safe and feasible in selected patients with pancreatic neoplasms. With a pancreatic duct leak rate of 27%, this problem remains an area of development for the minimally invasive technique.

Minimal access adrenal surgery.

Laparoscopic adrenalectomy has become the preferred method for removal of most adrenal tumors. An important component in selecting patients for this operation is to understand the clinical presentation and diagnostic workup for the various functioning and nonfunctioning adrenal tumors. In this review, an overview of the key clinical and diagnostic aspects of the most common adrenal tumors is presented. The indications and contraindications for a laparoscopic approach are discussed and the technique for laparoscopic adrenalectomy is then presented with inclusion of video links to demonstrate the technique. A review of the results of laparoscopic adrenalectomy is then considered with regard to common outcome measures and complications. A current controversy in adrenal surgery is the role of laparoscopic adrenalectomy in the management of patients with large tumors and malignant or potentially malignant adrenal lesions and the literature on this topic is reviewed in detail. The article concludes with a discussion of the indications and technique for partial adrenalectomy.

Experience with laparoscopic gastric resection: results and outcomes for 37 cases.

BACKGROUND: This study aimed to review the authors' technique, results, and outcomes for laparoscopic gastric wedge and segmental resections in patients with benign gastric diseases. METHODS: A retrospective clinical chart review was performed for all the patients who underwent laparoscopic gastric resection at the Washington University Medical Center from 1997 through March 2004. The surgical approach, operative results, complications, and subsequent clinical course were analyzed. Data are expressed as mean +/- standard deviation. RESULTS: Laparoscopic gastric resection was attempted in 37 cases involving 21 women and 16 men with a mean age of 61 +/- 13 years. The indications for surgery included suspected gastric stromal tumor (GIST) or carcinoid (n = 22), other benign gastric lesions (n = 6), benign gastric outlet obstruction (n = 4), and nonhealing peptic ulcer (n = 5). Segmental resection using gastroenteric anastomosis, with or without vagotomy, was performed in 14 patients, wedge resection in 22 patients, and laparoscopic enucleation in 1 patient. Resection was totally laparoscopic in 25 cases and laparoscopically assisted (with an accessory incision) in 12 cases. The mean operative time was 165 +/- 58 min, and the blood loss was 84 +/- 77 ml. Two patients (5.4%) underwent conversion to open resection. Intraoperative gastroscopy was performed in 16 cases (44%) as an aid to the resection. Regular diet was resumed at a mean of 3.0 +/- 1.7 days, and the mean length of hospital stay was 3.9 +/- 2.1 days. Four patients (10.8%) experienced major complications including subphrenic abscess (n = 1), pneumonia with respiratory failure (n = 1), splenic vein injury requiring splenectomy (n = 1), and gastric outlet obstruction (n = 1) that required reoperation 1 year later. Minor complications included intraabdominal fluid collection (n = 1), postoperative gastroparesis (n = 1), urinary retention (n = 1), and incisional hernia (n = 1). CONCLUSIONS: Laparoscopic gastric resections can be performed safely in patients with a variety of benign gastric disorders. The use of an accessory incision for reanastomosis and specimen extraction facilitates the procedure in difficult cases.

Perioperative outcomes and complications of open vs laparoscopic extraperitoneal inguinal hernia repair in a mature surgical practice.

BACKGROUND: Although the laparoscopic totally extraperitoneal (TEP) approach to hernia repair has been associated with less pain and a faster postoperative recovery than traditional open repair, many practicing surgeons have been reluctant to adopt this technique because of the lengthy operative times and the learning curve for this procedure. METHODS: Data from all patients undergoing TEP repair since 1997 and open mesh repair (OPEN) since 1999 were collected prospectively. Selection of surgical approach was based on local hernia factors, anesthetic risk, previous abdominal surgery, and patient preference. Statistical analyses were performed using unpaired t-tests and chi-squared tests. Data are mean +/- SD. RESULTS: TEP repairs were performed in 147 patients and open repairs in 198 patients. Patients in the OPEN group were significantly older (59 +/- 19 years OPEN vs 51 +/- 13 years TEP) and had a higher ASA (1.9 +/- 0.7 OPEN vs 1.5 +/- 0.6 TEP; p < 0.01). TEP repairs were more likely to be carried out for bilateral (33% TEP, 5% OPEN) or recurrent hernias (31% TEP, 11% OPEN) than were open repairs ( p < 0.01). Concurrent procedures accompanied 31% of TEP and 12% of OPEN repairs ( p < 0.01). Operative times (min) were significantly shorter in the TEP group for both unilateral (63 +/- 22 TEP, 70 +/- 20 OPEN; p = 0.02) and bilateral (78 +/- 27 TEP, 102 +/- 27 OPEN; p = 0.01) repairs. Mean operative times decreased over time in the TEP group for both unilateral and bilateral repairs ( p < 0.01). Patients undergoing TEP were more likely ( p < 0.01) to develop urinary retention (7.9% TEP, 1.1% OPEN), but were less likely ( p < 0.01) to have skin numbness (2.8% TEP, 35.8% OPEN) or prolonged groin discomfort (1.4% TEP, 5.3% OPEN). CONCLUSIONS: Despite a higher proportion of patients undergoing bilateral repairs, recurrent hernia repair, and concurrent procedures, operative times are shorter for laparoscopic TEP repair than for open mesh repair. TEP repairs can be performed efficiently and without major complications, even when the learning curve is included.

Wound complications of laparoscopic vs open colectomy.

BACKGROUND: This study was conducted to determine if laparoscopic colon surgery has changed the incidence of wound complications after colon resection. METHODS: Eighty-three patients were randomized to undergo either laparoscopic (LCR) or open colon resection (OCR) for cancer at our institution as part of a multicenter trial. Data were tabulated from review of the prospective database and physician records. RESULTS: Thirty-seven patients were randomized to LCR and 46 to OCR. Seven patients in the LCR group were converted to OCR. LCR was performed using a limited midline incision for anastomosis and specimen extraction. Incision length was significantly greater (p <0.001) in the OCR group (19.4 +/- 5.6 cm) compared to the LCR extraction site (6.3 +/- 1.4 cm). Wound infections occurred in 13.5% of patients after LCR (2.7% trocar, 10.8% extraction sites) and in 10.9% of patients after OCR. Over a mean follow-up period of 30.1 +/- 17.8 months, incisional hernias developed in 24.3% of patients after LCR and 17.4% after OCR. In the LCR group, extraction sites accounted for 85.7% of all wound complications. CONCLUSIONS: The extraction site for LCR is associated with a high incidence of complications, comparable to open colectomy. Strategies to alter operative technique should be considered to reduce the incidence of these complications.

The positive impact of laparoscopic adrenalectomy on complications of adrenal surgery.

BACKGROUND: This study was conducted to determine whether laparoscopic adrenalectomy (LA) has had a positive impact on the incidence and nature of adrenalectomy-related complications, as compared with the prelaparoscopic era. METHODS: All English language reports of patients undergoing either open adrenalectomy (OA) or LA from 1980 to 2000 were identified by Medline search. Reports were analyzed for the frequency and type of complications, with a minimum of 10 cases or studies required for inclusion. Complications were stratified by type and/or organ system involved, and groups were compared statistically using generalized linear model methods. RESULTS: Complications were tabulated from 50 studies of LA involving 1,522 patients and 48 studies of OA comprising 2,273 patients. Among the reports, 22 compared LA and OA within a single institution. The total reported complication rate was 25.2% with LA versus 10.9% with OA (p < or = 0.0001). The incidence of bleeding complications was higher with LA (4.7%) than OA (3.7%) (p < or = 0.0001). As compared with LA, OA had a significantly higher incidence of associated organ injury (2.4% vs 0.7%), mainly to the spleen, and more wound (6.9% vs 1.4%), pulmonary (5.5% vs 0.9%), cardiac (1.6% vs 0.3%), and infectious (5.8% vs 1.6%) complications (p < or = 0.0001). No significant differences in gastrointestinal, thromboembolic, or neurologic complications were seen. The mortality rate was 0.3% after LA and 0.9% after OA. The difference was not significant. CONCLUSIONS: Laparoscopic adrenalectomy has resulted in fewer adrenalectomy-related complications than seen historically with OA. Fewer wound and pulmonary complications and a reduced incidence of incidental splenectomy are primarily responsible for this improved outcome.

Risk of malignancy in thyroid incidentalomas identified by fluorodeoxyglucose-positron emission tomography.

BACKGROUND: Thyroid tumors often exhibit increased metabolic activity, as evidenced by enhanced glucose uptake on positron emission tomography (PET) with use of (18)F-fluorodeoxyglucose (FDG). The incidence of new thyroid lesions found on routine FDG-PET has not been previously reported. METHODS: A retrospective review of all patients who underwent FDG-PET imaging at our institution from June 1, 1996, through March 15, 2001, identified patients with a newly diagnosed thyroid lesion. Thyroid incidentaloma was defined as a thyroid lesion seen initially on FDG-PET in a patient without a history of thyroid disease. Available follow-up data were documented. RESULTS: One hundred and two of 4525 FDG-PET examinations (2.3%) demonstrated thyroid incidentalomas. Eighty-seven of 102 patients had no thyroid histology because of other malignancies. Fifteen patients had thyroid biopsy: 7 (47%) with thyroid cancer, 6 (40%) with nodular hyperplasia, 1 with thyroiditis, and 1 with atypical cells of indeterminate origin. The average standardized uptake values were higher for malignant compared with benign lesions. CONCLUSIONS: Thyroid incidentaloma identified by FDG-PET occurred with a frequency of 2.3%. Of the thyroid incidentalomas that underwent biopsy, 47% were found to be malignant. Given the risk of malignancy, patients with new thyroid lesions on PET scan should have a tissue diagnosis if it will influence outcome and management. Standardized uptake values may be helpful in predicting benign versus malignant histology.

Outcomes analysis in patients undergoing laparoscopic adrenalectomy for hormonally active adrenal tumors.

BACKGROUND: Laparoscopic adrenalectomy (LA) has become the preferred method of removal of most adrenal neoplasms, but few studies have evaluated the functional outcomes of this approach. The purpose of this study was to analyze our operative results and the clinical and biochemical responses to LA in patients with various hormonally active adrenal tumors. METHODS: From 1993 through November 2000, 72 patients with functional adrenal tumors underwent attempted LA. Data were obtained retrospectively by review of medical records, during routine follow-up, and by patient questionnaire. RESULTS: Indications for adrenalectomy were pheochromocytoma (n = 35), aldosteronoma (n = 29), cortisol-producing adenoma (n = 5), and adrenocorticotropic hormone-dependent Cushing's syndrome (n = 3). LA was completed in 70 of 72 patients, with 2 conversions (3%) to open adrenalectomy. Mean operative time for unilateral LA was 176 +/- 60 minutes, and postoperative length of hospital stay averaged 3.0 +/- 1.7 days. Complications, most of which were minor, occurred in 19% of patients; there were no serious complications or perioperative deaths. Two patients were unavailable for follow-up. At a mean follow-up interval of 37.6 months after LA (range, 2-90 months), resolution of clinical and biochemical signs of adrenal hyperfunction was accomplished in 34 of 34 patients with pheochromocytomas, 25 of 26 patients with aldosteronomas, 5 of 5 patients with cortisol-producing adenomas, and 3 of 3 patients with andrenocorticotropic hormone-dependent Cushing's syndrome. Two patients with multiple endocrine neoplasia (MEN) type 2 had contralateral pheochromocytomas removed 4 and 5 years after the initial surgery. Persistent hypertension necessitating medication was present in 72% of patients with aldosteronomas, although 92% of these patients had improved blood pressure control after LA. Recurrent hypokalemia developed in 1 patient (4%) with a cortical nodule in the contralateral adrenal. No local or distant tumor recurrences have occurred. CONCLUSIONS: LA results in an excellent clinical outcome in patients with various functional endocrine tumors. LA is associated with few major complications, and clinical and biochemical cure rates are comparable with those of open adrenalectomy during long-term follow-up.

Outcomes analysis of laparoscopic cholecystectomy in the extremely elderly.

BACKGROUND: A study was conducted to determine whether extremely elderly patients, age 80 years or older, were at higher risk for adverse outcomes from laparoscopic cholecystectomy than patients younger than 80 years. METHODS: Laparoscopic cholecystectomy was attempted in 421 patients age 65 years or older from 1989 through 1999. The patients were divided into two groups: group 1 (age 65-79 years; n = 351) and group 2 (age, 80-95 years; n = 70). A prospective database was analyzed for mean +/- standard deviation and using Student's t-test and chi-square analysis. RESULTS: Advanced age (group 2) was associated with a higher mean American Society of Anesthesiology (ASA) class (2.7 vs 2.3; p < 0.001) and a greater incidence of common bile duct stones (43% vs 26%; p < 0.01), as compared with those of younger age (group 1). Mean operative times in group 2 were 106 +/- 45 min as compared with 96 +/- 38 min in group 1, a difference that is not significant. The extremely elderly (group 2) had a four-fold higher rate of conversion to open cholecystectomy (16% vs 4%) and a longer mean postoperative hospital stay (2.1 vs 1.4 days). Grades 1 and 2 complications also were more common in group 2: grade 1: group 1, 8.8% vs group 2, 17% and grade 2: group 1, 4.3% vs group 2, 7.1% (p < 0.05). One patient in group 1 had a myocardial infarction 13 days postoperatively, and two deaths occurred in the extremely elderly group within 30 days postoperatively. CONCLUSIONS: Laparoscopic cholecystectomy in the extremely elderly is associated with more complications and a higher rate of conversion to open cholecystectomy than in elderly individuals younger than 80 years. The greater chance of encountering a severely inflamed or scarred gallbladder and common bile duct stones as well as increasing comorbidities likely account for these differences in outcome.

Adrenal incidentaloma.

Because of the frequent use of computed tomography and other abdominal imaging modalities, clinicians more frequently see the incidentally discovered, clinically silent adrenal mass. Most adrenal incidentalomas should be evaluated for hormonal activity and assessed for their risk of malignancy. Adrenalectomy is indicated for hyperfunctioning tumors and for any potential primary malignant adrenal lesion. Nonfunctioning cortical adenomas < 4 to 5 cm in size should be followed clinically and radiographically. Laparoscopic adrenalectomy has been used increasingly as the preferred approach in patients who require surgical resection whereas open adrenalectomy is reserved for patients with large, malignant tumors. The indications for adrenalectomy in patients with nonfunctioning adrenal tumors should not be liberalized because of the laparoscopic approach.

Evaluation of the performance and clinical impact of a rapid intraoperative parathyroid hormone assay in conjunction with preoperative imaging and concise parathyroidectomy.

BACKGROUND: (99m)Tc-sestamibi scans and rapid, intraoperative intact parathyroid hormone (PTH) assays allow preoperative identification of diseased glands and intraoperative confirmation of diseased gland removal, respectively. Use of these two new technologies may facilitate simpler, more concise surgery, shorter hospital stays, and decreased costs for frozen-section analysis. One major drawback to this new strategy has been the high cost of rapid point-of-care PTH assays. METHODS: We performed rapid PTH assays with the DPC Turbo PTH assay on the DPC IMMULITE automated analyzer. The number of intraoperative frozen sections, type of anesthesia, surgical approach, length of hospital stay, and pre- and postoperative calcium values were compared between a group of 49 patients undergoing parathyroidectomy where the intraoperative PTH assay was used in conjunction with preoperative imaging, and a historical control group of 55 patients before the use of these two technologies in our institution. RESULTS: Comparison of the Turbo PTH assay to the standard IMMULITE PTH assay gave the following: y = 1.08 x - 4.36 (r = 0.97; n = 48). For the 49 patients, the median turnaround time for each intraoperative PTH determination was 19 min (range, 14-40 min). The median decrease in PTH values from baseline was 88% (range, 33-99%). Thirty-seven patients required two PTH determinations, 7 required three, 4 had four, and 1 required five determinations. The average laboratory cost for the rapid intraoperative PTH assays was < $100 per patient (range, $55 to $113). Compared with the control group, the experimental group had significantly fewer frozen sections (1.4 vs 2.5; P < 0.0001), shorter hospital stays (17 discharged on the day of surgery vs none discharged on the day of surgery; P < 0.0001), greater use of local anesthesia (33% vs 0%; P < 0.001), and more unilateral, rather than bilateral neck explorations (65% vs 0%; P < 0.001). CONCLUSIONS: The combination of intraoperative Turbo PTH assay and preoperative (99m)Tc-sestamibi scans can lead to significant decreases in laboratory and surgical pathology costs, hospital stays, and exposure to general anesthesia by facilitating concise parathyroidectomy surgery.

Laparoscopic excision of mesenteric cysts: a report of two cases.

The authors report two cases of mesenteric cysts that were excised laparoscopically. Resection was accomplished with standard minimally invasive techniques and use of an ultrasonic scalpel. Both patients recovered promptly with minimal morbidity and returned to full activity within a short time. This reveals the suitability of minimally invasive surgery for this particular disease process.

Development of a laparoscopic approach to neurolytic celiac plexus block in a porcine model.

BACKGROUND: Neurolytic celiac plexus block (NCPB) is an effective method of palliative pain control in cases of inoperable pancreatic cancer. This study was undertaken to evaluate the feasibility of a laparoscopic approach to NCPB in an experimental animal model. METHODS: The laparoscopic technique for NCPB was developed in an acute study of six domestic swine followed by a chronic study of nine domestic swine that were monitored 3-21 days after surgery for adverse neurologic, gastrointestinal, or other sequelae. Using a four-port laparoscopic technique, the esophageal hiatus was dissected to expose the aorta at the level of the diaphragmatic crura. Under combined endoscopic and laparoscopic ultrasound (LUS) guidance, 5 ml of sclerosant dye (95% ethanol mixed with India ink) was injected into either side of the para-aortic soft tissue via a percutaneously placed 18-gauge spinal needle. After the animals were killed, the aorta and periaortic tissue were harvested from each animal for gross and histologic analysis. RESULTS: Under LUS guidance, sclerosant was injected successfully into the para-aortic soft tissue in all animals. There were no intraoperative complications in the acute animal group. Placement of sclerosant injection was successful in all nine chronic cases. Two pigs in the chronic study group died in the immediate postoperative period secondary to pneumothorax. No adverse neurologic, gastrointestinal, or other sequelae were observed in the remaining seven animals at 3-21 days postoperatively. After the animals were killed, we found no injuries to the aorta or esophagus, and histologic analysis demonstrated good placement of dye-labeled sclerosant with no compromise of aortic structural integrity. CONCLUSION: A laparoscopic approach to the aortic hiatus and NCPB is feasible. Further studies are warranted to evaluate this approach in patients who undergo staging laparoscopy for pancreatic cancer and are found to have unresectable disease.