Pelvic fat volume reduction with preoperative very low energy diet (VLED): implications for rectal cancer surgery in the obese.

BACKGROUND: Obese patients have higher complication rates after pelvic surgery. Laparoscopic rectal surgery may not be possible in the obese individual due to mesorectal, total pelvic and general visceral fat volumes. Very low energy diets reduce visceral fat but the changes within the pelvis and mesorectum are unknown. The aim of the present study was to quantify the proportion of fat lost from total pelvic and mesorectal fat with a very low energy diet (VLED) and define simple, accessible measurements that correlate with expected volume reduction. METHODS: A study was conducted on proportion change in mesorectal and intrapelvic fat volumes in patients on a VLED prior to bariatric surgery at the Alfred Hospital in Melbourne. The VLED was a standardized 4-week meal replacement. Proportion change in mesorectal and intrapelvic fat volumes were measured. Patients had standardized pre-diet and post-diet magnetic resonance imaging (MRI) of the pelvis. Body mass index, weight and girth measures were obtained. Adipose quantification analysis was performed using Q-Fat. RESULTS: Nine patients were included in this study, who were preparing for bariatric (not colorectal) surgery (5 females, median age 42 years, range 27-59 years) pre-protocol body mass index was 55.8 (range 39.5-60.6 kg/m2); median weight was 163 kg. Median mesorectal fat reduction was 29.9% (range 11.6-66.6%). Linear regression showed a relationship between the amount of mesorectal fat reduction and two variables: patient height and the distance from S1 to the posterior aspect of the rectum on MRI. The relationship predicted response to the diet (R2 67%, p = 0.040). CONCLUSIONS: Very low energy diets result in a clinically significant reduction in mesorectal fat with a lesser change in total pelvic fat, suggesting that very low energy diets may be useful for preparation for pelvic surgery in the obese. The distance from S1 to the posterior rectum correlates well with mesorectal reduction, making this a valuable clinical tool when volumetric analysis is not possible. This analysis is limited to the quantification of the effect of the diet and cannot comment on the safety of this approach before pelvic cancer surgery.

Correction to: Pelvic fat volume reduction with preoperative very low energy diet (VLED): implications for rectal cancer surgery in the obese.

Due to substantial contributions by Dr. Phillip Malouf and Dr. Stephen Bell.

Laparoscopic management of blunt diaphragmatic injury.

BACKGROUND: Diaphragmatic injury is difficult to diagnose using current radiological modalities, and missed diagnosis has been associated with a mortality of 20-36%. Laparotomy is the most sensitive of the standard diagnostic tools, but its unnecessary use can be up to 25% and carries a morbidity of 20%. METHODS: The use of the laparoscope in three cases of blunt diaphragmatic injury is reported here. Two cases were non-acute. The diagnosis of diaphragmatic injury could not be confirmed pre-operatively in any of the cases. RESULTS: One, a left-sided injury, was easily diagnosed and repaired laparoscopically. The second, right-sided, was confirmed laparoscopically but had to be repaired by open due to difficulty with liver retraction. The third case, an acute injury, was not diagnosed at laparoscopy. Findings of free blood and distended small bowel warranted laparotomy and prevented the establishment of a safe, satisfactory pneumoperitoneum. Repair was performed open. None of the cases was complicated by pneumothorax. CONCLUSIONS: Laparoscopy is a useful tool for diagnosis of non-acute blunt diaphragmatic injury but has limitations in the acute setting. Left-sided injuries can be repaired laparoscopically but right-sided injuries proved difficult and may be better dealt with thoracoscopically.

Laparoscopic management of small bowel obstruction caused by a retrocaecal hernia.

Laparoscopy is not commonly used in the management of small bowel obstruction (SBO). We report the first documented case of laparoscopic diagnosis and treatment of a retrocaecal hernia, a type of internal abdominal hernia. An 86-year-old woman with a chest infection was referred with features of a well-established SBO. At laparoscopy, the hernia was quickly diagnosed and easily reduced, the bowel assessed for viability, and the sac treated by widely laying open its neck, thereby marsupializing the defect. A laparotomy was avoided, and she recovered promptly and without complication. We conclude that laparoscopy can play a useful role in the management of SBO and that its use should be considered in patients with no obvious external hernia and a virgin abdomen in whom an unusual cause is suspected.

Preoperative screening for common bile duct stones with infusion cholangiography: review of 1000 patients.

OBJECTIVE: The authors aimed to study the safety and accuracy of infusion cholangiography in patients undergoing laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA: Intravenous cholangiography is a theoretically attractive method of screening the common bile duct for stones. However, there still remain serious reservations regarding its safety and accuracy, despite some reports in the literature to the contrary. METHODS: A personal series of 1000 patients undergoing routine preoperative infusion cholangiography was reviewed. RESULTS: The cholangiograms detected bile duct stones with a sensitivity of 93.3% and a specificity of 99.3%. There were no serious contrast reactions, and the minor contrast reaction rate was 0.7%. CONCLUSIONS: The authors conclude that infusion cholangiography is indeed safe and accurate and should play a substantial role in preoperative screening for incidental common bile duct stones.

Cholecystokinin (CCK)-HIDA scintigraphy in patients with suspected gall-bladder dysfunction.

Cholecystokinin hepatobiliary (CCK-HIDA) scintigraphy is used to triage patients with chronic abdominal pain and suspected gall-bladder dysfunction. This study evaluates the predictive value of CCK-HIDA for clinical outcome after surgical and medical therapy. Fifty-six patients (45 females), mean age 43 +/- 9 years, with otherwise normal investigations, including normal ultrasound, fasted for more than 8h and then had 70MBq technetium-99m-EHIDA injected. One and a half hours later 15 ng/kg CCK was infused over 45 min. Seventy minutes dynamic imaging commenced 5 min prior to infusion. An abnormal gall-bladder ejection fraction (GBEF) was defined as < 50%. Patients were treated medically, or by cholecystectomy, depending on the surgeon's overall assessment, including results of the CCK-HIDA study. Patient status was then obtained in 51/56 patients at least 3 months after the scan or at least 1 month after surgery. All surgical specimens were reviewed independently for pathological changes of chronic acalculous cholecystitis. Of the 11 patients with an abnormal gall-bladder ejection fraction, nine (82%) underwent cholecystectomy, all of whom achieved total symptomatic cure, while two patients underwent other therapy, both of whom remained symptomatically unchanged. Of the 40 patients whose gall-bladder ejection fraction was normal, only five (12.5%) underwent cholecystectomy, of whom four were cured and one partially improved at follow up. Of the 35 patients with a normal gall-bladder ejection fraction and who underwent forms of therapy other than cholecystectomy, nine were cured symptomatically, 13 improved, 10 remained unchanged and three were symptomatically worse at follow up.(ABSTRACT TRUNCATED AT 250 WORDS)

Carbon dioxide, temperature and laparoscopic cholecystectomy.

Laparoscopic procedures have previously been shown to interfere little with respiratory homeostasis. This study was designed to determine whether respiratory homeostasis, as well as temperature, is maintained with longer laparoscopic procedures and cold carbon dioxide insufflation. This study examined 21 American Society of Anesthesiologists status I and II patients undergoing laparoscopic cholecystectomy. A constant minute ventilation (80 mL/kg per min) was instituted prior to peritoneal insufflation and end-tidal carbon dioxide measurements were followed throughout the procedure. Although they showed a small statistically significant increase (32.3 +/- 3.8 to 38.9 +/- 6.0 mmHg, P = 0.0001) they were not of clinical significance. Similarly, rectal temperature measurements showed a statistically, but not clinically, significant fall in temperature over the course of the procedures (36.4 +/- 0.46 to 36.2 +/- 0.35 degrees C, P = 0.0001). The changes in end-tidal carbon dioxide and temperature showed no correlation with the volume or carbon dioxide used. The above findings will, however, require further investigation in both longer procedures and patients with more significant disease.

Percutaneous laparoscopic cholecystectomy: indications, contraindications and complications.

The indications, contraindications and complications of percutaneous laparoscopic cholecystectomy (PLC) were established from a group of 308 patients referred for cholecystectomy. Of the 308 patients 86% underwent PLC, 5% were commenced laparoscopically, but converted to open cholecystectomy and 9% were performed as open cholecystectomy from the outset. Complications included two bile leaks from the gall-bladder bed, one cystic duct stump leak and three retained stones. Pre-operative rather than intra-operative duct imaging was used so that common duct stones could be removed before operation. PLC is a safe procedure that has now become the standard technique for cholecystectomy.

Percutaneous laparoscopic cholecystectomy: the first fifty.

A series of 50 percutaneous laparoscopic cholecystectomies was performed by one surgeon between 7 June and 25 October 1990 using a modified technique as described by Dubois. There were 42 females and 8 males, the average age being 44 years with a range of 14-76 years. The average operating time was 80 min, ranging from 35 to 210 min. Postoperative stay averaged 2.9 days and there was an average of 11 days to return to work. Complications consisted of a subhepatic bile collection requiring open drainage, one minor wound infection and one minor abdominal wall haematoma. Laparoscopic cholecystectomy is a safe technique for removing the gall-bladder resulting in a rapid convalescence and early return to work. The initial learning curve is long and careful case selection should be carried out in this phase.

Total and subtotal colectomy for colonic obstruction.

Colectomy (total or subtotal) is not the operation of choice for elective colonic cancer unless the patient is under 50 years of age, is undergoing curative resection, and has associated adenomatous polyps. Routine colectomy is not supported when a partial obstruction prevents preparation of the colon and interferes with proximal colonic examination. Colectomy (especially subtotal) is acceptable for the acutely obstructed colon but it is technically demanding and requires experience in patient selection.

Synchronous carcinomas of the large intestine.

Sixty-one (3.0%) of 2029 patients managed operatively for carcinoma of the large intestine had synchronous carcinomas. In 47 (77.0%) of the 61 patients the carcinomas were in the same or adjacent segment(s) of large intestine. Adenomatous polyps were present in 18 (30%) patients compared to 269 (14%) of 1968 patients with a single cancer. A curative resection was performed in 40 of 61 patients, palliative resection in 16 and a non-resection palliative operation in five. Two patients required proctocolectomy and eight subtotal colectomy with ileorectal anastomosis. Cancer specific survival for the entire group and for those treated by curative resection did not differ significantly from that of patients with a single carcinoma. It is concluded that: (1) the presence of a second carcinoma does not significantly alter the survival prospects; (2) both pre-operative large intestinal examination and careful operative palpation of the entire large intestine should be performed, and (3) the significantly higher incidence of adenomatous polyps in patients with synchronous carcinomas is consistent with the polyp/cancer sequence hypothesis.

Cholecystectomy without routine operative cholangiography.

A series of 1575 consecutive patients with cholelithiasis managed by cholecystectomy without operative cholangiography is presented. All operations were performed by one of our authors. Exploration of the bile ducts was performed in 185 (12%) patients. During the postoperative period there was evidence of retained calculi in three (1.6%) of the 185 patients. The incidence of remote calculi (those presenting at a time distant from cholecystectomy) was determined for patients undergoing cholecystectomy between 1963 and 1967. Follow up information was available on 258 (80%) of 321 patients. Clinical evidence of remote calculi was found in seven (2.7%) patients. The incidence of both retained and remote calculi was similar to that found in series where operative cholangiography was routine.

Colonic infarction and pancreatitis: a case report.

A case of almost total colonic infarction secondary to pancreatitis is described. This appears to be a very rare complication of acute pancreatitis and is a result of mesenteric venous thrombosis secondary to the acute inflammatory process. The clue to the diagnosis was the passage of bright blood per rectum and a rapid deterioration in the condition of a patient with severe pancreatitis. Subtotal colectomy with ileostomy and mucous fistula formation was the treatment of choice. Ileosigmoid anastomosis was performed six months later.