Short-term outcomes in open vs. laparoscopic herniorrhaphy: confounding impact of worker's compensation on convalescence.

Over a 28-month period, 123 patients with a unilateral inguinal hernia were recruited into a randomized controlled trial comparing open herniorrhaphy (OH) to laparoscopic inguinal herniorrhaphy (LH). The primary end point was duration of convalescence. Sixty-five patients underwent OH and 58 underwent LH. Both groups were well matched for all baseline parameters, although LH patients anticipated a shorter convalescence than OH patients (14.3 +/- 9.4 days vs. 18.5 +/- 10.8 days; P = 0.021). The median duration of hospital stay was one day in both groups. No difference was observed in the duration of convalescence (LH 9.8 +/- 7.4 days; OH 11.6 +/- 7. 7 days) across groups. However, when the data were analyzed after removing patients receiving disability ("worker's") compensation (21 patients), patients undergoing LH recovered on average 3 days faster (LH 7.8 +/- 5.6 days; OH 10.9 +/- 7.5 days; P = 0.02). Patients not receiving worker's compensation appear to have a shorter convalescence after LH compared to OH. Disability compensation is a major confounding variable in determining convalescence and needs to be controlled for in any future trial design.

Laparoscopic versus open inguinal herniorrhaphy: preliminary results of a randomized controlled trial.

BACKGROUND: Benefits of laparoscopic herniorrhaphy (LH) over open hernia repair (OH) remain unproved. METHODS: Interim analysis of a prospective randomized controlled trial compared OH with LH where study outcomes were measured by third-party evaluators through patient interviews. RESULTS: Both groups were well matched for all baseline parameters, although LH patients anticipated a quicker postoperative recovery than OH (p = 0.014). No significant difference was noted in operating time or surgeon operative satisfaction. The median duration of hospital stay was 1 day in both groups; LH patients made use of significantly less postoperative narcotics than OH (p = 0.02). No difference was observed in the durations of convalescence (LH, 9.6 +/- 7.6 days; OH, 10.9 +/- 7.4 days). Greater improvements in quality of life were exhibited in LH patients than OH patients 1 month after operation (p = 0.035), with one of the two measures used. A greater percentage of LH patients seemed "very satisfied with their operation" (p = 0.07). Complication rates were similar, and a single recurrence, in a patient in the OH group, has been observed after a median follow-up of 14 months. CONCLUSIONS: Direct cost measurements showed LH to be 40% more expensive than OH in the context of a Canadian-type health care system. To date, benefits in postoperative pain and possibly quality of life have been detected in the LH group.

Bilirubin conjugate changes in the bile of gallbladders containing gallstones.

Gallbladder bile was obtained at laparoscopic cholecystectomy from 31 patients with gallstones, and duodenal aspirates from 18 normal controls. Bile pigments (9 conjugates and unconjugated bilirubin) were analyzed by high-performance liquid chromatography. The average proportional composition of the bile pigments from the patients with gallstones was characteristically different from the controls. Whereas the average values for the principal conjugates in the controls were bilirubin diglucuronide 83.4%, bilirubin monoglucuronide 10.1%, bilirubin monoglucuronide monoglucoside 4.5%, and bilirubin monoglucuronide monoxyloside 1.0%, the corresponding values in the biles from the patients with gallstones were 66.3%, 20.6%, 6.5%, and 2.8%, respectively. Values from the more minor conjugates and unconjugated bilirubin were less than 2% in either data set. In samples obtained in 9 of the gallstone patients early and late in the procedure, no significant change was found. Over the spectrum of findings in the gallstone patients, as the proportion of bilirubin diglucuronide became smaller, that of bilirubin monoglucuronide increased substantially, whereas those of bilirubin monoglucuronide monoglucoside and bilirubin monoglucuronide monoxyloside increased to a small extent. The findings suggest that bilirubin diglucuronide hydrolysis occurs in the gallbladder bile of gallstone patients, with the production of bilirubin monoglucuronide, and that if further hydrolysis of bilirubin monoglucuronide occurs with the formation of unconjugated bilirubin, the latter does not ordinarily increase because it is being absorbed. Stasis with increased gallbladder residence time was likely present in some of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Pseudoaneurysm of the cystic artery: a rare cause of hemobilia.

Aneurysms are a rare cause of hemobilia. The arteries most frequently involved are branches of the hepatic or gastroduodenal arteries. The authors report the case of a patient with hemobilia secondary to a pseudoaneurysm of the cystic artery. Only six other cases have been reported in the literature, and in all of them the condition was associated with inflammation of the gallbladder. Selective hepatic arteriography is the procedure of choice for diagnosis. Colour-Doppler ultrasonography aided in the diagnosis in the patient described in this report and may prove to be useful in equivocal cases. Cholecystectomy and ligation of the cystic artery with proximal control of the hepatic artery should be performed as soon as the diagnosis is made.

Factors determining conversion to laparotomy in patients undergoing laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) has been performed increasingly in an outpatient setting. Conversion from LC to open cholecystectomy (OC) is sometimes required. To predict conversion to OC, a single institutional study of 1,676 consecutive patients in whom LC was attempted was performed. Factors evaluated were age, sex, history of acute cholecystitis, pancreatitis, or jaundice, previous abdominal surgery, abnormalities of liver function tests, thickened gallbladder wall identified by preoperative ultrasound, obesity or morbid obesity, and cumulative institutional experience in LC. Conversion to OC was required in 90 of 1,676 (5.4%) patients. Significant preoperative predictors of conversion were acute cholecystitis, increasing age, male sex, obesity, and thickened gallbladder wall found by ultrasound. Nonobese women younger than age 65 years with symptoms of biliary colic and normal gallbladder wall thickness found by preoperative ultrasound required conversion only 1.9% of the time. These predictors may be useful in planning a program of ambulatory or short stay surgical units for patients undergoing LC and for comparing data between series.

Cholecystectomy without operative cholangiography. Implications for common bile duct injury and retained common bile duct stones.

OBJECTIVE: This study evaluated the selective use of endoscopic retrograde cholangiopancreatography (ERCP) in the context of laparoscopic cholecystectomy (LC) while minimizing the use of operative cholangiography. SUMMARY BACKGROUND DATA: There has been a long-standing debate between routine and selective operative cholangiography that has resurfaced with LC. METHODS: Prospective data were collected on the first 1300 patients undergoing LC at McGill University. Preoperative indications for ERCP were recorded, radiologic findings were standardized, and technical points for a safe LC were emphasized. RESULTS: A total of 106 patients underwent 127 preoperative ERCPs. Fifty patients were found to have choledocholithiasis (3.8%), and clearance of the common bile duct (CBD) with endoscopic sphincterotomy was achieved in 45 patients. The other five patients underwent open cholecystectomy with common duct exploration. Intraoperative cholangiography (IOC) was attempted in only 54 patients (4.2%), 6 of whom demonstrated choledocholithiasis. Forty-nine postoperative ERCPs were performed in 33 patients and stones were detected in 17 (1.3%), with a median follow-up time of 22 months. Endoscopic duct clearance was successful in all of these. The incidence of CBD injury was 0.38%, and a policy of routine operative cholangiography might only have led to earlier recognition of duct injury in one case. The rate of complication for all ERCPs was 9% and the associated median duration of the hospital stay was 4 days. The median duration of the hospital stay after open CBD exploration was 13 days. CONCLUSIONS: LC can be performed safely without routine IOC. The selective use of preoperative and postoperative ERCP will clear the CBD of stones in 92.5% of patients.

In vivo study of bleeding time and arterial hemorrhage in hypothermic versus normothermic animals.

This in vivo study confirmed impaired hemostasis during hypothermia in a swine model. Group I (normothermic, n = 8) and group II (hypothermic, n = 8) animals were anesthetized and instrumented for continuous peritoneal irrigation and monitoring of heart rate and blood pressure. The effects of hypothermia, hypotension, and inotrope on bleeding time and bleeding from two types of arterial injuries were evaluated. Our findings were that (1) bleeding time was significantly prolonged in hypothermic animals; (2) the differences in blood loss from partially torn artery (PTA) and completely cut artery (CCA) at both normothermic and hypothermic temperatures did not reach statistical significance; and (3) blood loss from PTA was greater than CCA when norepinephrine (Levophed) was infused to elevate blood pressure in hypotensive animals at normal core temperature.

Risks of blind versus open approach to celiotomy for laparoscopic surgery.

Patients undergoing laparoscopic cholecystectomy had celiotomy either by a blind (Veress needle) approach (n = 781) or by fascial and peritoneal incision with insertion of a 10-mm sheath under direct vision (n = 247). The blind approach was associated with three small bowel injuries and one tear of the left common iliac artery. No intestinal or vascular injuries occurred in the open insertion group. The difference was not statistically significant. The mean duration of surgery was 81.4 +/- 1.3 min in the blind group compared with 72.6 +/- 2.0 min in the open group (p < 0.001). There was no significant difference in postoperative stay or in return to normal activity between the two groups. It is recommended that blind access to the peritoneal cavity for laparoscopy be abandoned in favor of an open approach because the blind approach confers no advantages and places the patient at risk for unrecognized visceral or vascular injury even though these injuries may not occur at a statistically significant frequency.

Canadian laparoscopic surgery survey.

OBJECTIVE: To assess the status of laparoscopic general surgery in Canada and the training experience and educational needs of Canadian surgeons, particularly with laparoscopic cholecystectomy (LC). DESIGN: All of Canada's practising general surgeons were surveyed by mail approximately 15 months after the general availability of laparoscopic video equipment. Questionnaires completed by 736 surgeons form the basis of the analysis. SETTING: The respondent profile produced a good sample distribution to assess differences related to age, experience, location and type of practice; 30% practised in communities of 50,000 or less; 38% in hospitals with 250 or fewer beds and 57% in community hospitals. RESULTS: Eighty-four percent had already learned LC, and 51% of them had performed more than 25 LCs. The number performed correlated directly with the number of cholecystectomies usually performed yearly before laparoscopy. Age and lack of relevance to practice were reasons for not learning. Ninety-one percent took formal training courses, usually university sponsored and in Canada. Complications were experienced by 44% of respondents. Bile leak (26%), hemorrhage (15%) and bile-duct injury (9%) were the most common and increased as the number of cholecystectomies usually performed prior to LC increased. Age, sex, type and location of hospital and size of city were not significant factors. The data show a consistent (p < 0.001) increase in the proportion of surgeons who encountered a complication as the number of LCs performed increased. CONCLUSIONS: LC has been introduced in Canada in an unpredicted, rapid and seemingly orderly and responsible fashion in all areas, types and sizes of communities. It has been equally well applied by surgeons of all ages and size of practice whether practising in the smaller community or in the university centre. The dogma of complications related to a "learning curve" is not supported by the author's data, and experience with complications is not restricted to the occasional biliary surgeon. Continued vigilance is necessary.

Effects of hypothermia on hemodynamic responses to dopamine and dobutamine.

Hemodynamic characteristics, arrhythmogenicity, and dose-related hemodynamic responses to intravenous dopamine (group I) and dobutamine (group II) were examined in 16 swine at three different core body temperatures (38.5 degrees C, 35 degrees C, and 30 degrees C). The animals were anesthetized with isoflurane and mechanically ventilated. Cooling and re-warming were accomplished by a femoral-jugular A-V shunt. The animals were cooled down to 30 degrees C and stabilized for 1 hour before intravenous infusion of dopamine (group I, n = 8) or dobutamine (group II, n = 8) was started at 2, 5, 10, 15, 20, and 30 micrograms/kg/min. Hemodynamic responses to the two inotropes were continuously monitored with a bedside monitor equipped with a PC mode for customized data collection and analysis. Computerized arrhythmia detection was performed. Our findings were: (1) profound hypothermia (30 degrees C) causes significant depression of hemodynamic functions; (2) IV infusion of dopamine and dobutamine can be used safely and effectively for inotropic support during profound hypothermia, and the optimal dosage for improving cardiac output is 10-20 micrograms/kg/min; (3) no risk of inducing arrhythmia was noted with IV infusion of both inotropes up to a maximum dosage of 30 micrograms/kg/min, even though significant sinus tachycardia was consistently seen at 30 micrograms/kg/min.

Role of the teaching hospital in the development of a laparoscopic cholecystectomy program.

Laparoscopic cholecystectomy was introduced at McGill University-affiliated hospitals in a planned manner to evaluate the safety and results of this new procedure while training attending and resident surgeons. Laparoscopy was performed with the intent of carrying out cholecystectomy in 500 consecutive patients (70% female, 30% male), whose age averaged 48 years (range from 7 to 93 years). Thirty-seven percent had undergone intra-abdominal surgery previously, and 9.1% had had acute cholecystitis. There were two common-bile-duct injuries and one major small-bowel injury. The procedure had to be converted to open cholecystectomy in 25 (5%) patients. There were no deaths. The mean duration of surgery was 88 minutes. Fifty-five percent of patients were discharged home in 24 hours or less after surgery, and 75% were back to normal activity within 1 week of discharge. Fourteen attending staff and 8 senior residents achieved competence to carry out laparoscopic cholecystectomy independently.

Neomycin prevents indomethacin-induced gastric peristalsis and mucosal injury in the rat.

Inhibition of prostaglandin synthesis together with vagally mediated peristaltic contractions are essential if mucosal injury is to occur in the stomach of indomethacin-treated rats. The neomycin group of antibiotics has been shown to interfere with acetylcholine release. Agents blocking peristalsis have been demonstrated to prevent mucosal injury. We postulated that neomycin might inhibit peristalsis and prevent lesion formation. The effect of oral neomycin and bacitracin on gastric wall tone and peristaltic response to indomethacin were assessed and related to the lesion score. Bacitracin had no effect on either response and severe injury occurred. Neomycin did not block the tonal response to indomethacin but abolished peristalsis and no injury occurred. Induction of peristalsis with insulin in neomycin-indomethacin treated rats restored mucosal injury. It is concluded that neuromuscular blockade by neomycin prevented mucosal lesions by preventing peristalsis and not by impairing the ability of indomethacin to inhibit prostaglandin synthesis.

Factors in formation and prevention of bandlike gastric lesions in the rat.

The etiology of the deep bandlike necrotic gastric mucosal lesions induced by the oral administration of corrosive agents in the rat is unclear. An understanding of why the lesions are so precisely localized and how they develop should increase our understanding of the mechanisms by which the prostaglandins prevent them. This study utilizes an innocuous dye to demonstrate that the initial mucosal contact by orally administered agents is restricted to the crests of mucosal folds. A sequential study of lesion development at the fold crest indicates that coagulative necrosis occurs on contact and that the vascular defects, hemorrhage and congestion, are secondary to deep corrosion injury. Exogenous prostaglandin and 0.35 N HCl were found to abolish mucosal folding and hence prevent the fold-related lesions. Inhibition of prostaglandin synthesis was found to sensitize the mucosal fold crest to injury by 0.35 N HCl, and hence the use of indomethacin as a proof that endogenous prostaglandin synthesis plays a role in preventing bandlike lesions by such agents is questioned. It is concluded that the gastric mucosal fold plays a major role in localizing mucosal injury to parallel bands and that the obliteration of these sensitive sites may explain the protective effect of an ever-expanding number of agents. As lesions genesis appears to be the result of a contact artifact, the use of this model in the study of the physiological role played by gastric prostaglandins is seriously questioned.(ABSTRACT TRUNCATED AT 250 WORDS)

Relative roles of acid and mucosal compression in ulcerogenesis in indomethacin-insulin-treated rat.

We have proposed that gastric peristaltic activity is primarily responsible for ulcerogenesis in the phenylbutazone-treated rat and that acid plays only a synergistic role. This study examines the effect of graded doses of the H2 blocker cimetidine on acid secretion and ulcerogenesis occurring during insulin-induced peristalsis in the indomethacin (Indo) -pretreated rat. The second part of the study utilizes graded gastric distension with exogenous acid to examine the role of the forceful apposition of the mucosal folds during peristalsis in lesion genesis. It is demonstrated that the inhibition of acid secretion by cimetidine reduces but does not prevent ulceration. Gastric inflation with acid obliterates mucosal folding, prevents mucosal apposition during peristalsis, and abolishes ulcerogenesis. It is concluded that mucosal compression is the primary cause of the linear lesions along the base of the mucosal folds but that acid is necessary to extend the lesions once initiated.

The future of general surgery in Canada.

Manpower studies carried out by the Canadian Association of General Surgeons revealed a need for approximately 70 new general surgeons to enter practice each year to replace those who will discontinue practice for various reasons. The Royal College of Physicians and Surgeons of Canada certifies about 70 general surgeons each year; however, two-thirds of these pursue further specialty training, leaving only 20 to 25 to continue in general surgery. Training programs in Canada are of variable length and content. Less than half the trainees have substantial research experience. Programs designed to train the comprehensive community general surgeon are lacking in Canadian medical schools and reductions in residency training posts and other governmental constraints may worsen the anticipated shortage of general surgeons. Strong leadership is needed to bring together organized medicine, the surgical specialties, universities and government to address the training and manpower requirements for general surgeons in Canada.

Relationship between the gastric myoelectric and mechanical activity in the genesis of ulcers in indomethacin-insulin-treated rats.

We have proposed that gastric contractile activity mechanically induces ulcers in the nonsteroid antiinflammatory drug (NSAID)-treated rat. This study examines first the relationship between number (dose) of peristaltic contractions applied to the mucosa and the ulcer score. Second, it examines the relative roles of: altered gastric myoelectrical activity (MEA) resulting from indomethacin (Indo) pretreatment, insulin-induced gastric peristalsis, and a combination of the two in the generation of mucosal lesions. Third, it examines the effect of exogenous prostaglandin on the Indo-altered MEA and relates it to ulcerogenesis. Indo pretreatment increased gastric tone and MEA. In such animals, the dose of peristaltic contractions applied to the gastric wall was related to the ulcer score in a dose-dependent manner. Exogenous prostaglandin (PG) reversed the MEA effect of Indo and reduced ulceration. It is postulated that an altered smooth muscle state secondary to inhibition of prostaglandin synthesis (PG-S) renders the mucosa vulnerable to injury by peristaltic action.

Moxalactam as single-agent prophylaxis in the prevention of wound infection following colon surgery.

A single agent systemic antibiotic (moxalactam) when used prophylactically in patients undergoing colon surgery was associated with a wound infection rate comparable to that achieved by a combination of oral neomycin and intravenous metronidazole. The data obtained demonstrated that the reduced infection rate was not the result of a reduction in the bacterial content of the colon alone but due to the prophylactic agents used for elective colon surgery.

Does splenectomy predispose to meningococcal sepsis? An experimental study and clinical review.

Splenectomy is a recognized factor predisposing to the late complication of serious sepsis. The meningococcus has been listed as an important organism in postsplenectomy infection. A survey of the literature, however, revealed a total of only 13 documented case reports over a 31-year period, including ten pediatric cases. No documented cases of meningococcal sepsis in children following splenectomy for trauma were found. In an experimental mouse meningococcal infection model, the intraperitoneal LD50 was similar between normal and splenectomized mice (4 X 10(8) v 4 X 10(7) cfu, respectively; P = not significant). Bacteremic patterns were similar in both groups. Uniform survival was seen in normal and splenectomized mice after various intravenous challenge doses of meningococci up to 10(6) cfu. This was associated with efficient bacterial clearance in both groups. It appears unlikely that the defect resulting from splenectomy alone is an important predisposing factor in meningococcal sepsis.

Influence of splenectomy on lethal effects of pneumococcal infection.

To determine whether the splenectomized host is more sensitive to the toxic effects of pneumococcal infection and whether the known clearance defect accounts for the early, increased mortality seen in postsplenectomy infection, the authors studied 8-week-old C57B1 mice. They were divided into two groups: seven control nonsplenectomized mice and six splenectomized mice. All animals were inoculated intravenously with 10(3) colony forming units of Streptococcus pneumoniae. Microaliquots of blood were drawn from the tail of all mice into sterile, heparinized, capillary tubes at 1, 4, 8 and 16 hours. Blood bacteria were quantitated using a drop dilution method. The time to death was recorded. A form of survival analysis using the Cox proportional hazards model was performed on the data. The infection was uniformly fatal. An early decrease in the numbers of blood bacteria was seen in nonsplenectomized mice followed by a logarithmic linear increase. In splenectomized mice, there was early rapid bacterial growth greater than that in control mice. Splenectomized mice died earlier than control mice (p less than 0.05 at 24 hours, Fisher's exact test). The bacterial count had a highly significant effect upon mortality overall (p = 0.0017). A function describing the risk of dying versus bacterial numbers was generated and was the same for both groups. The splenectomized host does not appear to be more susceptible to the toxic effects of pneumococcal infection. Early mortality in bacteremic pneumococcal infection can be attributed to impaired bacterial clearance alone.

The pulmonary effects of opiate blockade in septic shock.

Sepsis remains the most common associated factor in acute respiratory failure (ARF). Endogenous opiates are known to have both respiratory and cardiovascular depressant effects. Because there is a high level of circulating endogenous opiates in sepsis, the possible role of opioids in the ARF syndrome seen in sepsis was studied. Sixteen piglets were infused with an LD100 dose (7.5 X 10(10) organisms/kg) of live Escherichia coli (Type 09-41). The pigs were hemodynamically monitored. Serial blood samples were taken for arterial blood gases and lactate. Serial lung biopsies were taken for determining wet/dry lung weight ratios and for histology. Group I (n = 8): septic shock controls without naloxone; group II (n = 8): naloxone treated, given as 2 mg/kg/hr intravenous boluses, starting within 1 min of E. coli infusion. All animals died of septic shock. Survivors at 150 min in group II had a higher blood pressure than group I (67.7 +/- 5.33 SEM vs 39.0 +/- 9.39) and cardiac output was also greater (1.07 +/- 0.23 vs 0.25 +/- 0.25). By 210 min, group I had no survivors (0/8) while 3/8 in group II survived. Pulmonary vascular resistance in group II at 90 and 120 min (870.8 +/- 274.1 and 942.5 +/- 12.9, respectively) was lower than in group I (2868.3 +/- 843.6 and 4156 +/- 1067). The PO2 was markedly better in group II and at 90 min; controls had a PO2 70.7 +/- 13.0, while group II had a PO2 111.4 +/- 8.4 (P less than 0.05). PCO2 levels showed a progressive rise in group I from 39.25 +/- 1.4 to 49.4 +/- 8.57.(ABSTRACT TRUNCATED AT 250 WORDS)