Microlaparoscopic vs conventional laparoscopic cholecystectomy: a prospective randomized double-blind trial.

BACKGROUND: Downsizing the port incisions may reduce pain after laparoscopic cholecystectomy. METHODS: In a double-blind controlled study, 60 patients were randomized to undergo either microlaparoscopic cholecystectomy using one 10-mm and three 3.5-mm trocars (3.5-mm LC) or traditional laparoscopic cholecystectomy using two 10-mm and two 5-mm trocars (LC). Incisional pain at each port incision and overall pain were recorded for 1 week after the operation. Fatigue, nausea and vomiting, pulmonary function, and cosmetic results were also measured. RESULTS: Data from 52 patients were analyzed; eight patients were excluded from the study for various reasons. One patient was converted from 3.5-mm LC to LC due to technical problems with the 3.5-mm optic. In the 3.5-mm LC group (n = 25), incisional pain was significantly decreased in the 1st postoperative week as compared with the LC group (n = 27) (p <0.01). In both groups, pain scores at the supraumbilical 10-mm port were significantly higher compared with other port sites (p <0.05). The cosmetic results were significantly better in the 3.5-mm LC group (p <0.01). There were no significant differences in any of the other variables. CONCLUSION: The use of 3.5-mm trocars is feasible in LC, and it both reduces incisional pain and improves the cosmetic result.

[Laparoscopic cholecystectomy in outpatient surgery]. / Laparoskopisk kolecystektomi i dagkirurgisk regi.

INTRODUCTION: The aim of the study was to describe the organisation of laparoscopic cholecystectomy in outpatient surgery and to discuss whether the method should be the future treatment of choice. MATERIAL AND METHODS: A retrospective descriptive study was carried out on 133 consecutive patients in the period 1 October 1999 to 30 September 2000. RESULTS: Seventy-seven per cent of the patients were discharged directly from the Department of Outpatient Surgery and 121 (97%) who underwent laparoscopy were discharged within 23 hours of the operation. The postoperative complication rate was 1.5% and the frequency of readmittance was 5%. DISCUSSION: Laparoscopic cholecystectomy is suitable for outpatient surgery and appears to be a recommendable setting for this operation. The method is safe and associated with few complications and readmittances.

[Transnasal gastroscopy]. / Transnasal gastroskopi.

The use of transnasal endoscopy has not been reported earlier in Denmark. This study describes the preliminary experiences with transnasal gastroscopy using the Olympus XGIF-N200 prototype. Patients scheduled for diagnostic gastroscopy were examined transnasally. The patients answered questions regarding anxiety and discomfort, and the endoscopist commented on the quality of the procedure. Of sixty patients included, 56 (93%) were examined transnasally. Two patients did not have nasal passage and were examined orally, and two patients were examined with standard gastroscope because of technical difficulties. Sixty-eight percent of the procedures were unsedated, 55% of the patients did not experience gag-reflexes. The procedure was described by most patients as "slightly uncomfortable". Twenty-five percent had uncomplicated epistaxis. Pulse rate and saturation levels were stable. Transnasal gastroscopy seems to be well tolerated by the patients, as both subjective and objective criteria were better than those for conventional gastroscopy.

[Planned second-look gastroscopy in patients with bleeding ulcer]. / Planlagt kontrolgastroskopi ved forekomst af blødningsstigmatiseret ulcus.

Preliminary studies have suggested a beneficial effect of second look endoscopy in patients with bleeding peptic ulcer. We have performed a retrospective survey of 70 patients with bleeding peptic ulcer admitted to our department. Planned second look endoscopy and repeated sclerotherapy was standard care. We found 15 of the 70 patients to rebleed after initial sclerotherapy. Overall success rate of endoscopic therapy was 63/70 patients (90%). The most important factor predicting rebleeding was the occurrence of active bleeding at the initial endoscopy. Compared with an expected rebleeding rate derived from the literature of 20-25 patients, the present study suggests a beneficial effect on rebleeding rate of planned second look endoscopy. Future controlled trials should verify this hypothesis.

Planned second look endoscopy in patients with bleeding duodenal or gastric ulcers.

INTRODUCTION: Preliminary studies have suggested a beneficial effect of second look endoscopy in patients with bleeding peptic ulcers. METHODOLOGY: We have performed a retrospective survey of seventy patients with bleeding peptic ulcers admitted to our unit in the period 1 September 1996-31 March 1998. Planned second look endoscopy and repeated sclerotherapy were standard care. The effects were evaluated by comparing the expected number of rebleeders with actual rebleeders. At the same time we assessed predicting factors for rebleeding. RESULTS: Fifteen of the admitted seventy patients were found to rebleed after initial sclerotherapy. The overall success rate of endoscopic therapy was 63/70 patients (90%). Six patients (9%) had to undergo surgery to obtain haemostasis, and one patient died suddenly after the second endoscopic sclerotherapy. Perforation was seen in two patients (3%) and the total mortality (30 days) was 4% (three patients). The most important factor predicting rebleeding was the occurrence of active bleeding at the initial endoscopy. CONCLUSION: From the literature we could expect that twenty to twenty-five patients would rebleed, comparing this with the findings of the present study suggests a beneficial effect on rebleeding rate of patients treated with planned second look endoscopy. Future controlled trails should verify this hypothesis.

Transnasal gastroscopy.

INTRODUCTION: The use of transnasal gastroscopy (TNG) has not previously been described in a Danish hospital. The method seems to be better tolerated compared with conventional oral gastroscopy. METHODOLOGY: Patients scheduled for diagnostic gastroscopy were included, and examined with a thin endoscope transnasally (Olympus XGIF-N200 prototype, diameter 6 mm). RESULTS: Sixty patients were included, and transnasal gastroscopy was possible in 56 patients (93%). Two patients were examined transorally, as there were no passage through the nose. One patient had fluid retention in the stomach, and in another patient the endoscope looped continuously in the esophagus, preventing introduction into the stomach. The quality in 48 examinations (80%) was satisfactory. Unsedated examination was possible with 38 patients (68%), and 55% of patients did not have gag-reflexes or nausea. The unpleasantness of TNG was rated on a scale from 1 to 4, and the median score was 2 (slightly unpleasant). TNG would be the method of choice in 88% of patients, if they should undergo another gastroscopy in the future. Fifteen patients had uncomplicated epistaxis as the only complication. Pulse rate and oxygen saturation values were stable during the TNG examinations. CONCLUSION: TNG with a thin endoscope seems to be well tolerated by the patients, this is supported by the subjective experience of the patients, and also by the stable values of oxygen saturation and heart rate during the examinations.

Pain after microlaparoscopic cholecystectomy. A randomized double-blind controlled study.

BACKGROUND: Laparoscopic cholecystectomy (LC) is traditionally performed with two 10-mm and two 5-mm trocars. The effect of smaller port incisions on pain has not been established in controlled studies. METHODS: In a double-blind controlled study, patients were randomized to LC or cholecystectomy with three 2-mm trocars and one 10-mm trocar (micro-LC). All patients received a multimodal analgesic regimen, including incisional local anesthetics at the beginning of surgery, NSAID, and paracetamol. Pain was registered preoperatively, for the first 3 h postoperatively, and daily for the 1st week. RESULTS: The study was discontinued after inclusion of 26 patients because five of the 13 patients (38%) randomized to micro-LC were converted to LC. In the remaining 21 patients, overall pain and incisional pain intensity during the first 3 h postoperatively increased in the LC group (n = 13) compared with preoperative pain levels (p<0.01), whereas pain did not increase in the micro-LC group (n = 8). CONCLUSIONS: Micro-LC in combination with a prophylactic multimodal analgesic regimen reduced postoperative pain for the first 3 h postoperatively. However, the micro-LC led to an unacceptable rate of conversion to LC (38%). The micro-LC instruments therefore need further technical development before this surgical technique can be used on a routine basis for laparoscopic cholecystectomy.

Severe and fatal complications after diagnostic and therapeutic ERCP: a prospective series of claims to insurance covering public hospitals.

BACKGROUND AND STUDY AIMS: Increasing numbers of patients are undergoing endoscopic retrograde cholangiopancreatography (ERCP) prior to laparoscopic cholecystectomy, and more departments and doctors are performing ERCP, while new data from large prospective series have documented the risks of both diagnostic and therapeutic ERCP. The establishment in Denmark of a Patient Insurance Association, which has covered injury caused during investigation and treatment in public hospitals since July 1992, has made it possible to collect and analyze a large prospective series of ERCP complications for which compensation has been claimed. PATIENTS AND METHODS: Thirty-nine consecutive claims for compensation due to complications after ERCP occurring between 1 July 1992 and 31 December 1996 were investigated. Case notes were reviewed, along with laboratory reports and radiographs. The complications were classified according to the international consensus. RESULTS: Claims for compensation were made in 39 cases from 25 hospitals. The indication for ERCP was appropriate in 31. Precut papillotomy for access had been performed in seven. The severity of the complications was mild in one patient, moderate in three patients, severe in 24, and fatal in nine; in two cases, the severity was not classifiable. The complications were: pancreatitis in 23 patients (seven cases fatal, one of which had involved a precut procedure), bleeding in two, perforation in nine (six had a precut procedure, one died), and other reasons in five (including one fatal case). Among the nine fatal cases, cannulation had not been achieved in two and the endoscopic retrograde cholangiogram was normal in four, one of whom underwent a sphincterotomy. One patient with a previous adenoma had an endoprosthesis removed, developed gangrenous cholecystitis afterward, and died. Thirty patients were eligible for compensation. The rejected cases included mild and moderate pancreatitis, a case of fatal hemorrhagic pancreatitis in which the patient had refused blood transfusion, and one patient who had pancreatitis prior to ERCP. CONCLUSIONS: ERCP, even for diagnostic purposes, may be associated with very serious and even fatal complications. The use of the precut procedure for access should still be considered dangerous. Other means of investigating the bile ducts should be developed. If endoscopic ultrasonography and magnetic resonance cholangiography prove to have the same diagnostic value as ERCP, which must be considered the gold standard for visualizing the ducts today, they might replace ERCP as the primary investigation in patients with an intermediate or low risk of bile duct stones; this would reduce the numbers of patients exposed to the risks of ERCP.

Granuloma annulare localized to the shaft of the penis.

A case of granuloma annulare localized to the shaft of the penis is reported. The differential diagnoses are discussed. Penile granuloma annulare is a rare disorder and it is concluded that biopsies of penile lesions are recommended to verify the correct diagnosis.

[Infertility and a mild degree of endometriosis]. / Infertilitet og mild grad af endometriose.

Laparoscopy of barren women in whom no other causes of impaired fertility can be demonstrated frequently reveals minimal areas of endometriosis. This review of the literature on infertility and mild endometriosis shows that there is no convincing study of the effectiveness of either surgical or specific forms of medical therapy for infertility and mild endometriosis. Continual treatment with gestagen may be tried. If this does not succeed the GIFT method may be applied.

[The nonoxynol content in condoms is insufficient to inhibit the human immunodeficiency virus (HIV)]. / Nonoxynol-indholdet i kondomer er utilstraekkeligt til haemning af. Human immundefekt virus (HIV).

The seven makes of condom which are marketed in Denmark were examined for the nonoxynol content with the object of assessing whether the content of nonoxynol in the condoms is sufficient to present HIV spread in connection with use of the condom and assessed in relation to the defects in effectivity (tearing, holes, overflow of semen, sliding off). Compared with the declared content of nonoxynol of 40 mg (100%) per condom, the following nonoxynol quantities could be demonstrated by methanol/water extraction and subsequent high-performance liquid chromatography: One make of condom contained 65%, two 50-55% and four 25-33%. The nonoxynol content was found to be evenly distributed between the outer and inner surface of the condoms. With a theoretical distribution volume of 6 ml (tearing during vaginal coitus), it was found that three of the makes of condoms examined did not achieve the HIV-inhibiting nonoxynol concentration of 0.05%, by means of measuring the quantity of nonoxynol on the distal 5 cm of the condoms. In anal sex, the distribution volume is greater resulting in lower nonoxynol concentrations and thus increased risk for HIV infection. It is concluded that the nonoxynol content in the condoms marketed in Denmark should be increased in order to inactivate HIV in case of condom failure.

PIP: The brands of condom which are marketed in Denmark were examined for nonoxynol content with the object of assessing whether such content is sufficient to prevent HIV spread and in relation to defects in its potential effectiveness. Using the methods of methanol/water extraction and subsequent high performance liquid chromatography (with the standard nonoxynol content being 40 mg [100%] per condom), 1 brand of condom contained 65%, 2 contained 50-55%, and 4 between 25-33%. The nonoxynol content was found to be evenly distributed between the outer and inner surfaces of the condom. With a theoretical distribution volume of 6 ml (tearing during vaginal coitus), it was found that 3 brands of condom did not achieve the HIV-inhibiting nonoxynol concentration of 0.05%. This was ascertained by measuring the quantity of nonoxynol on the distal 5 cm of the condoms. During anal sex, the distribution volume is greater which results in lower nonoxynol concentrations and thus increased risk for HIV infection. It is concluded that nonoxynol content in the condoms marketed in Denmark should be increased in order to inactivate HIV in the event of condom failure. (author's modified)

Evaluation of the amount of nonoxynol available in condoms for the inhibition of HIV using a method based on HPLC.

A method is described for detection of nonoxynol in condoms, based on methanol-water extraction followed by reverse-phase high-performance liquid chromatography. Using this method, we found that approximately 50% of the nonionic surfactant lubricant nonoxynol migrated into elastomers (rubber latex), resulting in a concentration of nonoxynol insufficient to inhibit human immunodeficiency virus (HIV) (less than 0.05%). In order to minimize the risk of sexual transmission of HIV, and to ensure spermicidal effect and optimal rubber properties, the concentration of nonoxynol in condoms, therefore, should either be increased, or nonoxynol should be packed separately. Further studies are needed to clarify and determine the solubility and migration of nonoxynols into elastomers.

[Hydrofluoric acid injuries: pathogenesis and treatment]. / Flussyreskader: patogenese og behandling.

On the basis of two case histories, the most recent literature concerning hydrofluoric acid injuries is reviewed with particular attention to the pathogenesis and the therapeutic possibilities. It is concluded that washing with water is the primary and most important treatment. Depending upon the extent of the injury, surface treatment with 2.5% calcium gluconate solution or gel may then be employed and/or infiltration treatment with a 5-10% calcium solution. Possibly combined with local analgesia and hyaluronic acid. Intravenous or intra-arterial infusion of calcium compounds and surgical excision may be considered as specialist treatment.

Premature rupture of the fetal membranes, the phases of the moon and barometer readings.

Over a 2-year period, 1,516 births were investigated to determine whether the onset of parturition could be correlated with the phases of the moon or to barometric height. 1,269 births started spontaneously, and of these, 254 (20%) started with premature rupture of the fetal membranes (PROM). No association was observed between the phases of the moon and deliveries beginning with PROM or with deliveries beginning without PROM. 1,302 of the women had regular menstrual cycles before pregnancy, and among these no specific relationship was found between the phases of the moon and the first day of the last menstruation before pregnancy. No relationship was found between the frequency of PROM and the barometric height. Variations in barometric height up to 9 h before the fetal membranes ruptured did not influence the frequency of PROM. Deliveries with PROM occurred significantly more often among primipara than among multipara. PROM occurred more frequently during night-time in the 8-hour period between 10 p.m. and 6 a.m. These results suggest that the causes of PROM are not correlated to the phases of the moon or to meteorological variations.