On-site evaluation of bus drivers with coronary heart disease.

BACKGROUND: Bus drivers with ischemic heart disease have been denied normal employment, although they satisfy Canadian Cardiovascular Society (CCS) Guidelines. To show the safety of their reemployment, we compared their responses when driving buses with those seen during graded exercise testing. METHODS: Twenty-two male city bus drivers, aged 48.1 +/- 5.6 years (19 had a myocardial infarction, 2 had coronary artery bypass graft, 1 had documented ischemic heart disease) were referred for work evaluation. After a CCS cardiopulmonary exercise test, they were accompanied by a physician and a therapist/technician on a normal shift. Note was kept of symptoms, signs, electrocardiogram (telemetry), blood pressure (ambulatory recording unit), and Borg rating of effort throughout. RESULTS: Average values for peak heart rate (101 +/- 12.5 versus 148.2 +/- 17.2 beats/min), peak systolic pressure (150.0 +/- 20.8 versus 198.9 +/- 25.7 mm Hg), peak rate-pressure product (15,259 +/- 3,369 versus 29,500 +/- 5,283 units), peak Borg RPE (9.9 +/- 1.4 versus 17.4 +/- 3.0 units), and peak ST-segmental depression (-0.03 +/- 0.07 versus -0.07 +/- 0.09 mV) during the shift were only about a half of average values reached during the graded stress test. Moreover, peak values were reached at the end of the shift, when carrying the loaded fare box, rather than when driving. CONCLUSIONS: Cardiovascular strain during bus driving is much less than during the CCS stress test for drivers. Using CCS methodology, the risk that a sudden cardiovascular incident will cause injury or death of others in the first year after recovery from myocardial infarction is estimated at 1 in 50,000 driver-years. Thus, those satisfying CCS requirements can return to full driving duties promptly, with minimal risk to themselves, passengers, or other road users.

Laparoscopic cholecystectomy: an analysis of 777 cases.

Born in secret in 1987 and developed in an atmosphere of scepticism throughout 1988, laparoscopic cholecystectomy triumphed in 1989 and 1990, causing a veritable revolution in the world of general surgery. The 777 consecutive cases that are reported in this chapter reflect the spirit of these various periods. From conservatively restrictive, our indications widened to include 90% of gallstone cases. For us the sclero-atrophic gallbladder still constitutes the greatest endoscopic challenge and should be reserved for the most experienced operators. The rates for mortality (0.1%) and complications (3.3%), which include three common bile duct injuries (0.4%), are comparable to, if not better than, those for traditional cholecystectomy. The quality of recovery is markedly better: near absence of pain, short hospitalization, return to normal physical activity within 10 days, rapid return to work and preservation of the abdominal musculature in sportspeople. These advantages are unavailable to the 5.5% of patients for whom an intraoperative conversion to an open procedure is necessary. Their recovery is that of traditional cholecystectomy, which itself is far from being poor. The large multicentre studies, such as those carried out in France and Belgium recently, reporting 3708 cases, have reached identical conclusions. Laparoscopic cholecystectomy is set to become the gold standard for treatment of gallstones and is the first step towards surgical techniques of the 21st century which will be performed within the musculocutaneous envelope of the intact human body.

Laparoscopic cholecystectomy: the state of the art. A report on 700 consecutive cases.

Born in secret in 1987, developed in an atmosphere of skepticism and even hostility throughout 1988, the laparoscopic cholecystectomy triumphed in 1989-90 and caused a veritable revolution in the world of general surgery. The 700 consecutive cases that we report here reflect the spirit of these various periods. From prudently restrictive, our indications widened to include 90% of all patients with gallbladder lithiasis. Sclero-atrophic gallbladders constitute the greatest challenge for endoscopic maneuvers. This group of patients should be treated by the most experienced operators only. The figures for mortality (0.1%) and complications (3%) are very comparable and even better than those for traditional cholecystectomy. The quality of recovery is infinitely better; there is absence of pain, a short period of hospitalization, return to normal physical activity within 10 days, rapid return to work, and total preservation of the abdominal muscles for participation in sports activities. All these advantages are assets of the laparoscopic cholecystectomy which are not available to the 6% of patients for whom an intra-operative conversion to open surgery is necessary. These patients recover within the conditions of a traditional cholecystectomy which are far from being poor. The large multicenter studies, such as those carried out in France and Belgium recently involving 3,708 patients, arrive at identical conclusions. The laparoscopic cholecystectomy is on its way to becoming the gold standard of treatment for gallbladder lithiasis. It is the first successful step towards surgical techniques of the 21st century which will be carried out inside the musculo-cutaneous envelope of the unopened human body.

Laparoscopic surgery for gallbladder stones.

The radical treatment of gallstones consists of removal of the calculi and prevention of their recurrence, and cholecystectomy is at present the common solution. Since Langebuch's first operation in 1882, Calot reporting the first French case in 1889, cholecystectomy has reached a high level of technical perfection. With a small access route and complete exploration of the common bile duct, the results are well known: global mortality is less than 0.1%. Frequently, specialised teams report series of patients under 50 years of age with zero mortality. Are there other techniques that permit the removal of calculi and the removal of the gallbladder with results comparable or better than the classic cholecystectomy? We have perfected an operative technique using laparoscopy that destroys the calculi with an ultrasonic lithotriptor followed by drainage or removal of the gallbladder. Our initial results are favourable.

Laparoscopic cholecystectomy using intracorporeal lithotripsy.

Over a 13-month period (November 1988 to December 1989), we performed our first 104 laparoscopic cholecystectomies using an intracorporeal ultrasonic lithotripsy technique. The procedure in three of these patients was converted to an open operation because of hemorrhage with unexpected findings of cirrhosis in two patients and dense subhepatic adhesions in a third. Endoscopic retrograde cholangiopancreatography was successfully used in three other patients in whom common bile duct stones were identified. We encountered only three postoperative complications out of all the laparoscopic cholecystectomies performed. One complication was a biliary fistula that closed spontaneously 1 week after surgery. The remaining complications were attributable to abscesses, one subhepatic and one pelvic, which were aspirated and drained laparoscopically. There were no deaths. Advantages of the laparoscopic approach included decreased perioperative pain, shortened hospitalization, absence of scar, and more rapid return to prehospitalization activities.

[Cholecystectomy by laparoscopy. Operative technic. Results of the first 100 cases]. / Cholécystectomie par laparoscopie. La technique opératoire. Les résultats des 100 premières observations.

The authors describe their own technique for the treatment of gallbladder stones using a laparoscopic approach. They squeletonsie the cystic artery and duct. Their clamp them by clips. Next they introduce into the gallbladder an ultrasonic lithotriptor which fragments the stones into powder evacuated by aspiration. The empty and clear gallbladder is severed off the liver and extracted out of the abdomen through an 8 mm orifice formerly used for the introduction of the lithotriptor. Among the 104 first cases performed between November 1988 to December 1989 the mortality is zero. On three patients the laparoscopic procedure has had to be stopped and replaced by a traditional open cholecystectomy. 3 complications occurred postoperatively: 1 biliary fistula which cured spontaneously within 7 days and 2 intra abdominal abscess which were treated by a secondary laparoscopic drainage. In the other cases the postoperative time has been uneventful. The patients appreciate mostly the painless postoperative time the absence of skin scar the short hospital stay 4 days and the possibility to go working one week later.

Gallstones: laparoscopic treatment--cholecystectomy, cholecystostomy, and lithotripsy. Our own technique.

The authors describe their own technique for the treatment of gallbladder stones using a laparoscopic approach. They first evacuate the stones with the aid of an intracorporal ultrasonic lithotriptor (Olympus, LTUS). Next they perform a cholecystostomy (17 cases) or a cholecystectomy (25 cases). The first 42 cases are reported, and the results have been good.

[Laparoscopic surgery of gallstones--report of treatment of 157 patients]. / Laparoskopische Chirurgie der Gallensteine--Behandlungsbericht von 157 Patienten.

From November 1988 to February 1990 157 patients with gallbladder stones haven been treated by a laparoscopic surgical procedure. They are 28 males and 129 females from 13 to 81 years old. 18 have had a cholecystostomy after intracorporeal lithotripsy (Lus Ultrasonic Olympus). They were placed on bue acids during 3 months. The average follow up time is 11 months. The mortality is zero and 2 mild complications occurred medically cured. 3 patients have a recurrent stone 6 months after surgery. 139 patients have had a cholecystectomy 89 after the same lithotripsy procedure seen above, 50 without prior lithotripsy. In 3 cases the laparoscopic procedure was abandoned, twice because of a sever bleeding, one for too compact surrounding adhesions. The mean follow up is 9 months. 123 were drained 1 day 16 had no drain. The mortality is zero. 2 patients without drainage developed a sub hepatic and douglas pouch abscess. They were cured by a lavage drainage laparoscopically made. 1 patient with drainages had a 7 days bile leak, which disappeared spontaneously. The 136 others have had a short stay in the hospital (2-4 days) a painless post operative time. They could go back to work and sport within 1 week. They have minimal scars and no danger of incisional herriae. The magnification of the optical system enables the dissection of the cystic duct and artery easier and safer than it is by mini laparotomy mostly in obese people. At the beginning of our experience only the patients with frequent biliary colics have been selected for the laparoscopic procedure. At that time 13 patients with subacute cholecystitis and 9 patients with stones in the commun bile duct have had a laparoscopic cholecystectomy associated with an endoscopic sphincterotomy in the last cases without complications.

Laparoscopic treatment for gallbladder stones and the place of intracorporeal lithotripsy.

An ultrasonic lithotriptor (U.S. Olympus) introduced into the gallbladder under visual control of a laparoscope permits fragmentation of the stones and complete clearance of the gallbladder in one session of 10-20 min. The empty, clean gallbladder can be drained (cholecystostomy) or removed (cholecystectomy) by passing it through an 8-10 mm orifice of the abdominal wall. A series of 18 cholecystostomies and 200 cholecystectomies shows that intracorporeal lithotripsy prior to these procedures is efficient, safe, and elegant. It is the guarantee of a real laparoscopic procedure in cases of cholecystectomy.

[Cholelithiasis. Laparoscopic treatment with intracorporeal lithotripsy followed by cholecystostomy or cholecystectomy. Personal technique]. / Lithiase vésiculaire. Traitement laparoscopique par lithotritie intra-corporelle (LIC) suivie de cholécystostomie ou cholécystectomie. Technique personnelle.

From November 1988 to February 1990 157 patients with gallbladder stones have been treated by a laparoscopic surgical procedure. They are 28 males and 129 females from 13 to 81 years old, 18 have had a cholecystostomy after intracorporeal lithotripsy (Lus Ultrasonic Olympus). They were placed on bile acids during 3 months. The average follow up time is 11 months. The mortality is zero and 2 mild complications occurred medically cured. 3 patients have a recurrent stone 6 month after surgery. 139 patients have had a cholecystectomy 89 after the same lithotripsy procedure seen above, 50 without prior lithotripsy. In 3 cases the laparoscopic procedure was abandoned, twice because of a sever bleeding, one for too compact surrounding adhesions. The mean follow up is 9 months. 123 were drained 1 day 16 had no drain. The mortality is zero. 2 patients without drainage developed a sub hepatic and douglas pouch abscess. They were cured by a lavage drainage laparoscopically made. 1 patient with drainage had a 7 days bile leak which disappeared spontaneously. The 136 others have had a short stay in the hospital (2-4 days) a painless post operative time. They could go back to work and sport within 1 week. They have minimal scars and no danger of incisional herniae. The magnification of the optical system enables the dissection of the cystic duct and artery easier and safer than it is by mini laparotomy mostly in obese people. At the beginning of our experience only the patients with frequent biliary colics have been selected for the laparoscopic procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Gallstones: laparoscopic treatment, intracorporeal lithotripsy followed by cholecystostomy or cholecystectomy--a personal technique.

The authors describe a personal technique for the treatment of gallbladder stones using a laparoscopic approach. They first evacuate the stones with the aid of an intracorporeal ultrasonic lithotriptor (L.U.S. Olympus). They next perform a cholecystostomy or a cholecystectomy. The first 40 cases are reported, and good results were obtained.

[Easily closed gun-barrel enterostomy. A new technique]. / Entérostomie cutanée en canon de fusil de fermeture simple. Description d'une technique originale.

The availability of continuous low rate enteral and parenteral feeding has enlarged the indications of enterostomy, notably in patients with multiple operations. However, closing an enterostomy, which may be high up in the small bowel, rises technical problems and is not always without risk. In this study a new technique of gun-barrel enterostomy easily closed with automatic sutures and without reopening of the abdominal wall is presented.