Esophageal perforations.

The incidence of esophageal perforation (EP) has risen with the increasing use of endoscopic procedures, which are currently the most frequent causes of EP. Despite decades of clinical experience, innovations in surgical technique and advances in intensive care management, EP still represents a diagnostic and therapeutic challenge. EP is a devastating event and mortality hovers close to 20%. Ambiguous presentations leading to misdiagnosis and delayed treatment and the difficulties in management are responsible for the high morbidity and mortality rates. A high variety of treatment options are available ranging from observational medical therapy to radical esophagectomy. The potential role of interventional endoscopy and the use of stents for the treatment of EP seem interesting but remain to be evaluated. Surgical primary repair, with or without reinforcement, is the preferred approach in patients with EP. Prognosis is mainly determined by the cause, the location of the injury and the delay between perforation and initiation of therapy.

[Iatrogenic perforation of the gallbladder during laparoscopic cholecystectomy does not influence the prognosis. Prospective study]. / L'effraction de la vésicule lors des cholécystectomies laparoscopiques n'influence pas la morbidité. Etude prospective.

BACKGROUND: Perforation of the gallbladder and spillage of gallstones frequently occur in laparoscopic cholecystectomy. As stones may be lost and as spilled bile is known to be contaminated, influence on morbidity may be expected. AIMS: To evaluate the immediate and late consequences on morbidity of peroperative gallbladder perforation during laparoscopic cholecystectomy (LC) in an universitary hospital center. PATIENTS AND METHODS: One hundred and twenty one LC were prospectively evaluated with a mean follow-up of 30 months. Elective operations on 30 men and 91 women with a mean age of 56.4 years (18-85) were carried out for symptomatic cholecystolithiasis in 97 cases (80%), and in 24 cases for complicated cholecystolithiasis. The "french technique" was used for all LC, with systematic intra-operative cholangiography and ultra Sonography. Thirty-seven (30.5%) LC were performed by surgical trainees, 84 LC by confirmed surgeons. The consequences of ultra-operative gallbladder perforation were evaluated in the immediate postoperative period, especially for septic complications, and thereafter, patients were followed up 1, 6, 12 and 24 months postoperatively. RESULTS: Ultra-operative gallbladder perforation occurred in 24 cases (20%), in 83.3% during gallbladder dissection. Gallstone spillage occurred six times, and all spilled stones were removed. Gallbladder perforation was more frequent (but non significant) in acute cholecystitis (25 vs 19%, ns). A clear correlation to the skill and experience of the surgeon is shown (32.4 vs 14.2%, P =0.01). Gallbladder perforation is accompanied by an elevated (nonsignificant) postoperative morbidity (16.6 vs 7.2%, P =0.62) which is, in fact related to older patient and more acute cholecystitis in this group. No reoperations were necessary. One and two years follow-up revealed no long-term complications specially due to lost gallstones. CONCLUSION: Peroperative gallbladder perforation during LC carries no morbidity, provided a total and complete recuperation of gallstones spilled and local treatment of bile contamination with local irrigation and antibiotics. This complication is correlated to the surgeon's skill and experience.

[Can the time between interventions be reduced in the operating theater? Prospective study]. / Peut-on réduire le délai entre deux interventions au bloc opératoire ? Etude prospective.

UNLABELLED: BACKGROUND AND AIM OG THE STUDY: The interval between two surgical interventions is increasing because of the introduction of successive safety measures. Our aims were to prospectively evaluate the different intervals between two elective abdominal surgical interventions and to determine which factors were associated with a decrease in the inter-operative time delay. MATERIALS AND METHODS: Between November 2001 and July 2002, 102 inter-operative periods were prospectively analyzed. All the interventions involved either an elective, planned laparotomy or a laparoscopic procedure, under general anesthesia. The interval between two operations was divided into three periods: the departure of the patient operated on; the empty theatre; the entry of the next patient. The collected data were compared to retrospective data from 90 days and 10 years prior to the study. RESULTS: The average time delay between two interventions was 63.5 min (40-107) vs. 72.3 min (30-91) 3 months earlier and 32 min (10-105) (P = 0.001) 10 years earlier. The average time from skin closure to the departure of the patient from the operating room was 15.7 min (5-35), of which 3.5 min (1-15) was surgically related, 7.7 min (1-26) was anesthetic time (waking the patient) and 4.5 min (2-15) for taking the patient out of theatre. The average duration of the period called 'empty theatre' was 13.7 min (7-65), of which 8.9 min (4-15) was for cleaning the operating room. Finally, the last period lasted, on average, 32.1 min (11-69), of which 16.7 min (3-49) was anesthetic time, 2.3 min (2-15) for positioning the patient and 9.9 min was surgically related. In this study, the shortest time between interventions was 40 min and the longest was 107 min. The theoretical shortest time possible (summing the lowest values for each period) was 19 min, while the longest (summing the largest values) was 169 min. Anesthetic time represented 38% of the entire inter-operative period, while surgical time represented 21%. Laparoscopic procedures did not significantly effect the inter-operative interval. CONCLUSIONS: Because of the multiple safety measures required, the inter-operative delay is continuously increasing and, in this study, was equivalent to the actual operative time of the surgical procedures. The inter-operative period cannot be shortened below 20 min or so. The reduction of this period would only be possible by involving and coordinating the different personnel that contribute to performing an operation, by optimizing the procedures and by harmonizing materials. The lack of interest and the lack of concern for the most efficient use of resources within the public hospitals, as well as the recent legal and social constraints introduced in France, are the main factors preventing progress in these areas.

Low-cost laparoscopic cholecystectomy.

BACKGROUND: Hospital managers are continually trying to decrease the cost of patient care. The aim of this prospective study was to propose changes that would decrease the operating room costs of laparoscopic cholecystectomy without affecting clinical results. METHODS: The study included 112 consecutive patients who underwent an elective cholecystectomy between January 1997 and December 2000. The procedure was changed in eight ways: the American position, open laparoscopy, reusable trocars, reusable instruments, bipolar coagulation of the cystic artery, intracorporeal ligature of the cystic duct, no use of suction lavage apparatus, and use of a surgical glove as a bag to extract the gallbladder. Complete compliance with the procedure, whether any abnormal operative events or complications occurred, the duration of hospitalization, and the material and labour costs of the procedure were recorded. RESULTS: There were no abnormal operative events. Only two patients suffered from postoperative complications. The mean duration of hospitalization was 55.8 h. Fifteen patients (13.4 per cent) were not hospitalized overnight. The operating costs fell from 560 euros before the study to 330 euros in 2000. CONCLUSION: By applying simple measures, it is possible to decrease the operating room cost of laparoscopic cholecystectomy whilst maintaining good results. Such measures should be applied to other laparoscopic procedures.

Cytokinin contents and specific characteristics of tissue strains from three sexual genotypes of Mercurialis annua : Evidence for sex-gene involvement at callus-tissue level.

Analyses of the endogenous cytokinin contents of established tissue strains of Mercurialis annua are reported. The strains were derived from three individuals (strong male, weak male, female), differing by one of the three genes determining sex. The data are compared with the endogenous cytokinins of male and female shoot apices. Tissue strains are characterized by the disappearance of natural cytokinin metabolites in the female; in both males, Δ(2)-isopentenyl-adenosine and only trans-ribosylzeatin exist but in different quantities. Benzyladenine and ribosylbenzyladenine were identified in the three strains but the quantities also differed as a function of the genotype. The marked differences in cytokinin metabolism of tissue strains indicate that sex genes continue to function in the dedifferentiated state. Each strain also exhibited persistent morphological and histological characteristics, and a different sensitivity to the withdrawal of 2-4-dichlorophenoxyacetic acid or benzyladenine from the medium. Each had a specific and characteristic effect on the organogenesis of nodes cultivated in close proximity to callus pieces. These data complement the above results and show that sex genes act at the callus-tissue level. The possibility that these genes act at the early stages of embryogenesis of male and female individuals is also discussed.