The laparoscopic option in the management of peritoneal dialysis catheter revision.

BACKGROUND: Long-term functioning of peritoneal dialysis catheters (PDCs) depends on maintenance of pelvic positioning and prevention of the formation of adhesions. The purpose of this study was to evaluate the validity of laparoscopy as a tool for the correction of malfunctioning PDCs and to introduce our specially designed technique. METHODS: The charts of 12 patients who underwent laparoscopic revisions of malfunctioning PDCs between May 1997 and June 2000 were reviewed for perioperative complications and long-term outcomes. We describe the causes of malfunction of PDCs and the laparoscopic technique for their revision. RESULTS: Of the 12 patients studied, the malfunction of eight catheters resulted from migration of the catheter into the upper abdomen. In 4 patients, formation of adhesion of either small bowel or omentum resulted in the malfunction of the PDC. The only complication we encountered was bleeding. It occurred in 3 patients, 1 of whom needed reoperation in order to achieve hemostasis. Over a median follow-up of 21 months all PDCs treated this way are functioning. CONCLUSIONS: The laparoscopic management of malfunctioning PDCs is a valid option for the treatment of such a complication.

[Costs and benefits of laparoscopic inguinal hernia repair--is there an economic justification?].

BACKGROUND: With the recent accelerated development of laparoscopic surgery, it has been applied in all fields of surgery. The main issue today is not the technical ability of performing laparoscopic procedures but rather their justification while considering the disease and cost-benefit aspects. OBJECTIVES: The present study surveys the experience accumulated in recent years concerning the economical aspects of laparoscopic inguinal hernia repair. Issues like length of the surgical procedure, cost, typical complications and recuperation time are being addressed. METHODS: We reviewed controlled clinical trials that compare laparoscopic and open repair of inguinal hernia. Trials that included at least 100 patients and were published in peer-reviewed journals since 1996 were included. Various operative techniques were compared using clinical and economical parameters. RESULTS: Most studies examined the issues from an institutional or health care system viewpoint and not from a comprehensive societal perspective. Therefore, indirect costs were seldom included. Operative times were longer and direct costs were significantly higher in the laparoscopic approach as compared to conventional open surgery. However, recovery time and return to work were found to occur earlier in patients who underwent laparoscopic surgery. CONCLUSIONS: A shorter recovery time and shorter off-work period after laparoscopic hernia repair could compensate for the increased hospital expenditures. However, this contribution has not yet been completely established and needs further validation by supplementary studies. Other aspects that will have to be evaluated include quality of life and patient satisfaction.

Reimbursement policies, incentives and disincentives to perform laparoscopic surgery in Israel.

The introduction of laparoscopic surgery was believed to bestow great advantages to patients and health services. Health services and societal costs may also be affected by changes in length of hospital stay, operating room costs and return to normal activity. The aim of this paper is to examine the influence of two different reimbursement methods (per diem and DRG) on the incentives and disincentives given to different role players in the Israeli health-care system regarding two common surgical procedures: appendectomy and inguinal hernia repair. Three different perspectives are discussed: society, the hospitals and the sick funds. From the hospital's perspective, laparoscopic surgery is usually more expensive compared to open procedures, mainly due to higher operating room costs. We suggest that as far as current reimbursement methods are preserved, hospitals have no economic incentive to adopt the laparoscopic technology as benefits occur only to society. In general, sick funds would encourage hospitals to perform laparoscopic appendectomy, where the payment is per diem and would be economically indifferent regarding laparoscopic inguinal hernia repair, where hospitals are compensated on a DRG basis. It has been suggested that economic advantages to society may arise from a faster return to work after laparoscopic appendectomy and laparoscopic inguinal hernia repair. In this case, new payment arrangements should be set to give proper incentives for the adoption of laparoscopic procedures.

Desmoid tumor (aggressive fibromatosis) of the neck.

Desmoid tumors are histologically benign fibrous neoplasms arising from the musculoaponeurotic structures throughout the body. There is similar biological behaviour between benign fibrous proliferations and fibrosarcoma. These neoplasms have the tendency to locally invade and erode adjacent muscular tissue and bone. Within the head and neck area they also tend to encase vital structures. We present a case of a 28-year-old white female with a five-month history of a painful mass in her left posterior cervical triangle who was treated by excisional biopsy of the lesion with preservation of the accessory nerve and post-operative radiation. The histopathologic characteristics of desmoid tumors and treatment of these lesions are also reviewed.

Outpatient management of acute mastoiditis with periosteitis in children.

Children with acute mastoiditis with periosteitis are conventionally hospitalized for parenteral antibiotics and/or surgical treatment. However, if possible, effective and safe outpatient treatment is desirable. During a 36-month period, outpatient parenteral antibiotic therapy (once daily i.m. ceftriaxone) was evaluated in 32 children with acute mastoiditis, with clinical evidence of periosteitis. Inclusion criteria included otomicroscopic evidence of acute otitis media (AOM), displacement of the pinna, retroauricular swelling, erythema and tenderness. The treatment consisted of wide myringotomy and administration of i.m. antibiotics. Daily visits, by a combined team of an otolaryngologist and pediatric infectious disease specialist, were considered essential. Fourteen children (43%) were treated initially in the hospital (and subsequently as outpatients) and 18 (57%) children were treated entirely as outpatients. Mean duration of outpatient treatment was 7 days (range: 4-10). The overall clinical cure rate was 96.8%. One child underwent simple mastoidectomy. No serious side effects were observed. Our data suggests that many children with acute mastoiditis with periosteitis can be managed successfully and safely as outpatients by a combined team of otolaryngologists and infectious disease specialists.

Colorectal tumourigenesis.

Colorectal cancer is significant because of its lethality and high incidence in the Western world. Furthermore, it is a particularly suitable model for studying the events involved in the progression from normal tissue to invasive cancer. There is a great deal of epidemiological and histopathologic evidence to implicate the adenomatous polyp as the precursor to colorectal cancer. Moreover in recent years investigators have uncovered some of the molecular genetic events that underlie the progression from normal epithelium to polyp to cancer. It is hoped that an increased understanding of the molecular changes will afford opportunities for new diagnostic, prognostic and therapeutic strategies in the management of this disease.

Basal cell carcinoma of the male nipple. Case report and review of the literature.

BACKGROUND: Basal cell carcinoma (BCC) of the nipple is a very unusual occurrence, often mistaken for Paget's disease. OBJECTIVE: By reporting a further case of BCC of the nipple in a 57-year-old man and by reviewing the sixteen previously reported cases, we mean to characterize further a common lesion arising at an unusual site. We also wish to stress the lack of agreement regarding the treatment of BCC of the nipple. METHODS: Review of the literature was based on a search in Medline. CONCLUSIONS: We appeal to compile all cases of BCC arising at unusual locations in order to gain a better understanding of these lesions.

[Nutritional disturbances after Roux-en-Y gastric bypass].

200 patients after Roux-en-Y gastric bypass were nutritionally followed for an average of 6.7 years. They were randomly selected out of 450 patients operated on during 1980-1985. They had lost a mean of 56 +/- 22% of their excess weight and had remained stable in weight for the preceding 5 years with limited nutritional caloric restriction. Iron saturation, hemoglobin and mean corpuscular volume declined gradually and significantly (p less than 0.0001, p less than 0.0001 and p less than 0.001, respectively). However, mean serum concentration of vitamin B12, which also had decreased significantly during the preceding 5 years (p less than 0.0004), increased during recent years, but still was lower than before the bypass. Albumin and transferrin levels remained normal. There was no correlation between weight change and serum concentration of iron or vitamin B12. We conclude that 6.7 years after surgery, while there is no caloric or protein deficiency, there has been gradual development of iron deficiency, but not correlated with weight loss.

Avulsion fracture of the medial epicondyle caused by arm wrestling.

Fractures occurring in teenagers during arm wrestling usually involve the distal humerus and appear as a fracture of the medial epicondyle. We studied eight male patients, aged 13 to 15 years, with such fractures. All fractures involved the right hand and occurred while the patients were in the final stages of winning a match in a formal competition. Three fractures occurred during an official competition and the other five occurred during a match between friends. One patient suffered from ulnar nerve paresis that eventually recovered spontaneously. All of the patients were immobilized for 10 to 21 days, and progressed gradually to motion of the elbow. At 1-year followup, clinical and functional results were satisfying. Therefore, we recommend conservative management for fractures of the medial epicondyle sustained during arm wrestling.

[Anaphylactic shock after traumatic rupture of a splenic echinococcal cyst].

Anaphylactic shock as a result of trauma is very rare. We describe a 20-year-old Druze soldier who presented with anaphylactic shock due to rupture of a splenic echinococcal cyst induced by blunt trauma to the left chest wall and upper abdomen. The main clinical manifestations, which developed within minutes of the trauma, were high fever, pruritus, edema of the lips and eyelids, dyspnea, stridor and rhinorrhea. Eosinophilia was not present on admission but appeared 4 days later. Surgery revealed an intact echinococcal cyst in the left lobe of the liver and another in the spleen. The splenic cyst was torn, filled with blood and its contents had spread throughout the splenic tissue, but without peritoneal spillage. Recovery was complete after splenectomy and resection of the hepatic hydatid cyst.

Bariatric surgery in morbidly obese sleep-apnea patients: short- and long-term follow-up.

Forty-seven obese sleep-apnea patients were investigated in the sleep laboratory before and after a massive weight reduction achieved by bariatric surgery. The first postoperative sleep investigations were performed approximately 1 y after surgery and revealed a highly significant decrease in the number of apneic episodes per hour of sleep and a significant improvement in all sleep-quality-related measures. A second postoperative sleep study was performed approximately 7 y postoperatively and revealed that regaining of weight was associated with the reappearance of sleep apnea syndrome, although the great majority of the patients still felt, subjectively, that they were well and did not suffer from recurrence of the sleep apnea syndrome.

Liposarcoma of the perineum and scrotum.

A case of liposarcoma of the perineum and scrotum, which presented as a huge haematoma and was left in place for three years prior to excision, is presented. The patient was treated by wide excision of the tumour, orchiopexy to the inguinal region and radiotherapy. To date, 30 months following surgery, the patient is completely asymptomatic and no tumour recurrence is evident either on physical and rectal examinations or on chest X-rays, ultrasonography and abdominal and pelvic computerized tomography.

[Nutritional habits after Roux-en-Y gastric bypass for morbid obesity].

The nutrition of 200 patients after Roux-en-Y gastric bypass for morbid obesity was followed for 6.7 years. During the first 2 years their food intake was severely restricted, resulting in an excess weight loss of 69 +/- 14%. At an average of 3 years after surgery they began to regain weight significantly (p less than 0.04) due to nutritional adaptation. In the following years caloric consumption stabilized at an excess weight loss of 48-56%. However, they had continuing meat intolerance with 51.0, 60.3, 59.5 and 55.1% of them avoiding meat during 0-12 months, 13-24 months, 25-72 months and 73-96 months after surgery, respectively. We conclude that after Roux-en-Y gastric bypass there is nutritional adaptation lasting as long as 2 years, when a characteristic nutritional behavior is adopted which persists for years.

Perinephric inflammatory process following extracorporeal shock wave lithotripsy.

A patient with large branched staghorn calculi was treated with ESWL. She suffered from recurrent urinary tract infections. Following ESWL she developed a perinephric abscess, which necessitated percutaneous drainage. The clinical course is described and a possible pathogenesis of perinephric abscess following ESWL is suggested.