A nickel-titanium memory-shape device for colonic anastomosis in laparoscopic surgery.

BACKGROUND: Minimally invasive surgery is used increasingly for colonic resection. With this procedure, the involved colon is dissected laparoscopically and exteriorized through a small incision, and the segment containing the tumor is resected. The anastomosis is performed extraperitoneally either by hand suture or with a stapler. This study was designed to evaluate the feasibility of using a memory-shape compression anastomosis clip (CAC) to perform laparoscopically assisted colonic anastomosis. The study was prompted by the authors' successful experience with the CAC in an animal model and in 10 patients with diverse colonic cancers. METHODS: The sample consisted of 10 patients who underwent laparoscopic colonic surgery at the authors' center. The anastomosis was performed with the CAC for five patients and with a stapler for five patients. To perform anastomosis with the CAC, the two edges of the resected colon are aligned. Two 5-mm incisions are made near the edges, through which the CAC, after cooling in ice water, is introduced in an open position using a special applier. In response to body temperature, the clip resumes its original (closed) position, thereby clamping the two bowel loops together. At the same time, the small scalpel incorporated in the applier makes a small incision through the clamped walls for the passage of gas and feces, and the clip is released into the intestine. The two 5-mm incisions are sutured. The clip is expelled with the stool within 5 to 7 days, creating a perfect uniform anastomosis. RESULTS: Neither group had complications, except one patient from the control group who experienced a small bowel obstruction attributable to a wound suture problem, which required laparotomy. His recovery was uneventful. CONCLUSIONS: The use of the CAC for colonic laparoscopic surgery is simple and very efficient, shortening operation time. It creates a uniform anastomosis, approximating the no-touch concept in surgery, and may prevent infection. It also is lower in cost than the stapler.

Gastrointestinal anastomosis with the nickel-titanium double ring.

We used a dog model to test the safety and effectiveness of sutureless gastrointestinal anastomoses (n = 23) (end-to-end, end-to-side, or side-to-side) with the nickel-titanium double ring with temperature-dependent shape memory. Results were compared to conventional hand-sutured anastomoses (n = 5). Examination performed after 2 weeks' follow-up showed no leaks and no difference in return of bowel function between the experimental groups and the control group. Microscopic studies showed a complete epithelial lining and perfectly functioning anastomoses. We conclude that the nickel-titanium double-ring device may have an important place in the armamentarium of the gastrointestinal surgeon.

Laparoscopic extraperitoneal inguinal hernia repair with spinal anesthesia and nitrous oxide insufflation.

BACKGROUND: Laparoscopic repair of inguinal hernia is traditionally performed under general anesthesia mainly because of the adverse effects that carbon dioxide pneumoperitoneum has on awake patients. Since a mandatory use of general anesthesia for all hernia repairs is questionable, the feasibility of laparoscopic extraperitoneal herniorraphy using spinal anesthesia combined with nitrous oxide insufflation was investigated. METHODS: Over a 4-month period, February to May 1998, we performed 35 consecutive total extraperitoneal inguinal hernia procedures (24 unilateral, 11 bilateral) using spinal anesthesia and nitrous oxide extraperitoneal gas. Data on operative findings, self-reported operative and postoperative pain and discomfort (visual analog pain scale), procedure-related hemodynamics, and complications were collected prospectively. RESULTS: All 35 procedures were completed laparoscopically without the need to convert to general anesthesia. Mean operative time was 39 +/- 7 min for unilateral hernia and 65 +/- 10 min for bilateral hernia. Incidental peritoneal tears occurred in 22 patients (63%) resulting in nitrous oxide pneumoperitoneum, which was well tolerated. The patients remained hemodynamically stable throughout the procedure, and operative conditions and visibility were excellent. Complications at a mean of 4 months after the procedure included seven uninfected seromas (20%), three patients with transient testicular pain, and one (3%) recurrence. CONCLUSIONS: Laparoscopic total extraperitoneal hernia repair can be safely and comfortably performed using spinal anesthesia with extraperitoneal nitrous oxide insufflation gas. This method provides a good alternative to general anesthesia.

[129 liver surgeries--five years of experience in a surgery department].

Major hepatic resections have been associated with significant morbidity and mortality. In the past decade or so this has changed and such procedures are now done in increasing numbers. In the past 5 years we operated on 129 patients with benign or malignant hepatic lesions (75 females, 54 males; age-range 14-84). The reason for surgery was malignancy in 94 (72.9%) and benign lesions in 35 (27.1%). The most common indication for surgery was liver metastases secondary to colorectal cancer in 45% of all patients or 61.7% of those operated for malignancy. Primary liver cancer was the cause for liver resection in 13.2% of all patients or 18.1% for those with malignancy. Of the 35 patients with benign lesions the leading causes for surgery included: giant cavernous hemangioma, simple liver cysts, echinococcus cysts and focal nodular hyperplasia (11%, 22.8%, 20% and 14.3%, respectively). 76 patients underwent anatomical resection and 63 had either a nonanatomical resection or a different operation. Among the former the most common procedure was right hepatectomy (36) and among the later a nonanatomical resection equal to 1-3 Couinod segments (44). Operating time ranged from 55 min. to 8:41 hours with a mean of 3:31 +/- 1:37. Mean hospital stay was 8.7 +/- 5.8 days and 86.8% received between 0-2 units of blood. Overall mortality was 6.2% and 31.2% of the fatalities had cirrhosis. Overall mortality in noncirrhotic patients was 2.6%. The complication rate was 16.3% and only 7 patients (4.4%) were hospitalized in the intensive care unit. This indicates that major liver resections can be done safely, with morbidity and mortality similar to that of other major abdominal operations.

Minimally invasive surgery for axillary dissection. Cadaveric feasibility study.

Axillary dissection is the major cause of morbidity in breast cancer and primary cutaneous melanoma of the extremity. In the present study, we examine the potential benefits and advantages of endoscopic axillary lymph node dissection over conventional surgery. Twenty endoscopic axillary dissections and 10 lymph node samplings were performed in 10 cadavers (four male, six female). A preperitoneal distention balloon (PDB) system was used to dissect the axilla. In four of the cadavers, the procedure was followed by open surgery. The axillary contents were examined for lymphatic tissue by a pathologist. The endoscopic technique offered easy access to the axilla and clear visualization of the axillary vein, as well as the long thoracic and thoracodorsal nerves. Results were comparable to those achieved with the classic surgical dissection. Endoscopy is feasible for axillary lymph node dissection and sampling in cases of breast cancer and primary cutaneous melanoma of the extremity. Further studies in patients are needed to reach definitive conclusions.

Incidental cholecystectomy in the over-70 age group. A 19-year retrospective, comparative study.

OBJECTIVES: To analyse the outcome of incidental cholecystectomy in the over 70 age-group during surgery for gastrointestinal malignancies. DESIGN: Nineteen-year retrospective, comparative study. SETTING: Department of Surgery B, Belinson Campus, Rabin Medical Center. SUBJECTS: The hospitalization records of 4,072 patients who underwent cholecystectomy between 1975 and 1994 were reviewed. The incidental cholecystectomy cases for this period were identified and those performed during surgery for gastrointestinal malignancy were analysed separately. A sex- and age-matched control group was identified for comparison. MAIN OUTCOME MEASURES: Postoperative complications, overall morbidity and mortality, postoperative hospitalization days. Statistical differences in gallbladder-related complications and mortality among groups. RESULTS: Mortality and overall morbidity were significantly increased in the no-cholecystectomy group. Hospitalization days were increased significantly in the group not under-going cholecystectomy and although it didn't reach statistical significance, there was a clear trend for increased number of pulmonary complication in this same group. Sepsis and multiorgan failure, as an expression of acutely, postoperative symptomatic gallbladder were the major cause of death in the no-incidental-cholecystectomy group. CONCLUSIONS: Incidental cholecystectomy is safe and should be considered in every case of abdominal surgery, regardless of the age of the patient. In the over 70 age group, complication and mortality rates increase significantly and dreadfully when the gallbladder is left in situ after surgery for gastrointestinal tumors. Incidental cholecystectomy is not warranted in patients undergoing palliative procedures or in whom life expectancy is less than 6 months.

Agenesis of the gallbladder found at laparoscopy for cholecystectomy: an unpleasant surprise.

Gallbladder agenesis is a rare condition that results from the failure of the cystic bud to develop in the 4th wk of intrauterine life. Agenesis is usually discovered at laparotomy for cholecystectomy since ultrasound examination of a patient with suggestive symptoms not visualizing the gallbladder is compatible with chronic cholecystitis (shrunken gallbladder). The surgeon must prove agenesis by thoroughly examining the most common sites for ectopic gallbladders and by performing intraoperative cholangiograms. For unexplained reasons, most of the patients become asymptomatic after the operation. We present a new case of adult agenesis of the gallbladder in a patient who was taken to laparoscopic cholecystectomy for presumptive cholelithiasis.

The role of percutaneous transhepatic cholecystostomy in the management of acute cholecystitis in high-risk patients.

A method recently developed that may be an appropriate solution for high-risk patients with acute cholecystitis is percutaneous sonography-guided cholecystostomy. We report our experience in 10 high-risk elderly patients with clinical and sonographic diagnosis of acute cholecystitis. Immediate regression and resolution of septic symptoms was achieved in all cases. One patient was operated on as soon as his clinical condition stabilized, with uneventful postoperative recovery. The other nine were considered inoperable; of these, two were readmitted within a few months with recurrence of symptoms who underwent surgery, with a long and complicated postoperative course. The only complication we observed was temporary septicemia in one patient immediately after completion of the procedure. In view of these findings, we consider percutaneous transhepatic cholecystostomy an effective and safe method of treatment for acute cholecystitis in critically ill patients. However, this procedure should be regarded as a preliminary measure only, to render the patient more suitable for a formal cholecystectomy. We report our results and discuss technical and principal matters concerning percutaneous transhepatic cholecystostomy in the light of the current literature.

Multifactorial analysis of prognostic factors in major abdominal surgery in patients over 80.

OBJECTIVE: The principle aim of the study was to identify by multifactorial analysis the combination of factors predictive of mortality after major laparotomy in patients over 80 years old. DESIGN: A computer held data base established by the authors in 1978 was used to register all relevant information of all major laparotomies performed in patients above 80. RESULTS: Unifactorial analysis of mortality disclosed the following factors associated with increased postoperative mortality: 1. Age 85 or more; 2. ASA fitness status 4 or 4; 3. Emergency procedure; 4. Presence of advanced malignant disease; 5. Diagnostic group 5 or 9 (mesenteric occlusion, pancreato biliary malignancy). Multifactorial analysis disclosed low mortality (2.5%) in cases with no gravity factors and very high mortality (above 70%) in those with 3 or more gravity factors.

Surgical problems in octogenarians: epidemiological analysis of 1,083 consecutive admissions.

Patients older than 80 years of age are the most rapidly increasing group among surgical admissions and patients visiting emergency rooms. Epidemiological data of this group are of enormous medical and economic relevance. The principle aim of this study was to determine factors predictive of operative mortality in octagenarians, their clinical profiles, and length of stay compared to younger patients in similar diagnostic categories. A computer-based registry of geriatric surgery was used to record and analyze all relevant clinical and epidemiological data. The rate of admissions in octogenarians increased during the 18-year period (1973-1989) from 0.7% to 7.5% of all admissions. The number of patients undergoing surgery was 700. Three hundred and seventy-one of the procedures were elective and 329 were emergencies. Operations in octagenarians as a percentage of all operative procedures increased during the period considered from 1.1% to 5.1%. The operative mortality in this series was 10.5% prior to 1984 and decreased to 6% during the last 5 years. The average hospital stay of octagenarians was 9.8 days as opposed to 4.9 days in patients less than 70 years of age. The prognostic classification described by the authors proved very helpful in predicting mortality.

Sensitivity to new generation of antibiotics in biliary surgery.

The treatment of septic complications of cholecystectomy patients requires special attention. In a prospective study of 1009 consecutive cholecystectomy patients (including all acute and elective patients, excluding cases of malignancy), we routinely took cultures from the cystic duct and the gallbladder, and checked the strain for sensitivity. Positive cultures were found in 31.4% of the series, the most frequent bacteria being E. coli (50.3%). The aminoglycosides and the second and third generations of cephaloridins were found more specific for the strains that were cultured. While the new cephaloridins are the first choice for prophylaxis, the combination of aminoglycosides with ampicillin is to be preferred from the medical and cost effective standpoint while the aim is therapeutic.

Choledochoduodenostomy an important surgical tool in the management of common bile duct stones. A review of 126 cases.

Of 2,000 patients who underwent cholecystectomy between 1965-1984, 457 had their common bile ducts explored and of these 126 had choledochoduodenostomies. There were 70 women and 56 men and a third were over 70 years old. Forty-three also had acute cholecystitis or pancreatitis, and 73 had an increased serum concentration of bilirubin. Of the 126, 103 had stones in the common duct, and 16 had benign strictures of the sphincter of Oddi. Morbidity included wound infections in 18 (14%) and bile discharge from the drain for over 14 days in four (3%). Five patients died (4%), and they were all over 70 years old. Ninety-seven of 103 patients followed-up over 1-19 years were symptom free (94%). Two patients required re-operation for a narrow anastomosis. Three patients developed a "sump" syndrome; two were treated with antibiotics, and the third responded to endoscopic sphincterotomy. Choledochoduodenostomies should be considered during operation for benign biliary disease, when stones or a stricture in the common bile duct are anticipated.

Bilateral versus unilateral high ligation and stripping of the greater saphenous vein for varicose veins.

The problem of long waiting list of patients for varicose vein surgery may be eased by bilateral operation when both limbs are involved and not in two separate operations as is the practice in many surgical centers. We found that patients undergoing unilateral high ligation and stripping did not differ from patients who had bilateral limb operation in terms of complications, morbidity and length of hospitalization. Most of our patients were released after one day of hospitalization. Therefore, we recommend bilateral operation when there is an indication, rather than two unilateral operations.

Changing trends in surgery for acute cholecystitis.

Surgery for acute cholecystitis has become the most frequent abdominal surgery in most hospitals, yet aspects of its management remain controversial. The aim of this study was to focus on the recent trends by demonstrating the principal differences between 2 series of patients operated on during 10-year intervals. Two hundred fifty-six consecutive operations for acute cholecystitis were performed from 1970 to 1977 (group O) and were compared to 260 cases operated from 1980 to 1987 (group N). Thirty-six variables were recorded in each case. All data obtained were computer recorded and analyzed. Several trends were observed in group N: 1. The population was significantly older with a higher proportion of males and diabetics. 2. There was a marked increase in common bile duct stones, acalculous cholecystitis, and gangrenous changes in the gallbladder. 3. There was a significant increase in patients operated on within 48 hours of admission. 4. There was a significant increase in the number of patients without previous history of biliary symptoms. 5. There was a significant decrease in the rate of wound infections and no statistically significant differences in mortality (N: 3.0%, O: 2.7%). 6. A decrease of the average postoperative hospital stay of 3.2 days was observed. In spite of the older and sicker population in group N, no significant increase in mortality occurred and the postoperative hospital stay was reduced.

Multifactorial analysis of prognostic factors in emergency abdominal surgery in patients above 80 years. Analysis of 154 consecutive cases.

Patients above 80 have been the most rapidly growing group in the surgical department. The number of major laparotomies in this segment of the population has grown by 15% in the last two decades and is expected to grow by another 100% by the end of the century. The principal aim of the study was to identify by multifactorial analysis the combination of factors predictive of mortality in abdominal emergencies in this age group. A computer-held data base established by the Authors in 1978 was used to register all relevant information in 1327 major laparotomies performed in patients above 70. Of the base of 1327 patients, 219 (16.5%) were above 80. Of this group, 154 cases (70.3%) underwent emergency procedures and are the focus of this study. The principal conclusions of the Authors are as follows: A. The main differences between the two age groups 70-79 (Group A) and above 80 (Group B) are as follows: 1. Emergency laparotomies are much more frequent in Group B (70% versus 33%). 2. The overall mortality is over two and a half times as high (21.4% versus 8%). 3. The diagnostic profile and the mix of cases is different with an increased number of intestinal obstructions and malignancies in Group B. B. Unifactorial analysis of postoperative mortality disclosed the following factors associated with increased mortality: 1. Vital System Category III (Table 6-A). 2. Presence of generalized peritonitis or gangrenous bowel. 3. Presence of widespread malignant disease. 4. Belonging to the following diagnostic groups: carcinoma of pancreas, mesenteric thrombosis. 5. Age 85 or above.(ABSTRACT TRUNCATED AT 250 WORDS)

Anal pressure measurements in the study of hemorrhoid etiology and their relation to treatment.

The etiology of hemorrhoids has been explained in the past based on anatomic principles, but this study examines the relationship of resting anal pressures to hemorrhoid etiology in 38 patients with hemorrhoids and 29 controls with no perianal symptoms. Three months after treatment by elastic band ligation, anal pressures were again measured in the hemorrhoid group. Anal pressures were significantly higher in the hemorrhoid group before treatment (102 +/- 26.33 mmHg) as compared with the controls (76.75 +/- 19.56 mmHg) (P less than .001). Three months following elastic band ligation there was a small drop in anal pressure (100 +/- 26.84 mmHg) but it remained significantly higher than the control group. There was also a significant correlation between symptoms and level of anal pressures. The results indicate that persons with hemorrhoids have higher anal pressures than controls. Elastic band ligation relieves the symptoms but should not affect the anal sphincter pressure. The fact that the anal pressures remained high after treatment could imply that higher pressures are an etiologic component in the formation of hemorrhoids.

Primary hyperparathyroidism due to mediastinal parathyroid adenoma.

Of the 90 cases of primary hyperparathyroidism surgically treated in our department over the last decade (1975-1985), ten cases had a mediastinal parathyroidal adenoma. In only two of these patients was a median sternotomy required for excision of the mediastinal adenoma. Three of the ten patients underwent the initial operation in other institutions, having undergone a previous neck exploration. There were seven males and three females, ages ranging from 41-68 years. Six patients had nephrolithiasis, four had both renal stones and bone disease and two had peptic ulcer disease. One of them was operated on as an emergency because of hyperparathyroidism crisis with calcium levels of 15/16 mg%. Four patients were asymptomatic and had hypercalcemia detected by SMA screening. The calcium level ranged from 11.5-16.2 mg%. The phosphorus ranged from 1.6-2.8 mg% with a mean of 2.0 mg%. All ten patients had plasma PTH determination by radioimmunoassay, the values ranged from 1.5-3 times normal. In seven of the ten cases, the mediastinal parathyroid adenoma was localized within the thymus, the other three were adjacent to the great vessels, two to the aortic arch and one to the pulmonary artery-size ranging from 1.2-5.4 cm. Preoperative localization techniques: venous sampling in four cases; technetium scanning in three cases. No preoperative localization techniques were used in the other three cases. There was no mortality nor other significant postoperative complications.(ABSTRACT TRUNCATED AT 250 WORDS)