Amitai Bickel

The impact of patient delay and physician delay on the outcome of laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND Laparoscopic cholecystectomy is now used in the management of acute cholecystitis. Under these circumstances unfavorable conditions may result in conversion and complications. Information about these conditions may help in planning the laparoscopic approach or in proceeding directly to open cholecystectomy. This study was initiated to evaluate perioperative factors associated with conversion and complications of laparoscopic cholecystectomy in acute cholecystitis. Special attention was paid to the duration of complaints until surgery, to the delay on the part of the patient, and to the delay on the part of the physician. METHODS Between January 1994 and December 1997, we attempted to perform laparoscopic cholecystectomy on 348 patients with acute cholecystitis. All perioperative data were collected on standardized forms. RESULTS There were 182 cases (52%) of acute uncomplicated cholecystitis, 90 (26%) of gangrenous cholecystitis, 33 of hydrops (9.5%), and 43 of empyema of the gallbladder (12.5%). Seventy six patients (22%) needed conversion to open cholecystectomy and complications occurred in 57 cases. Advanced cholecystitis was associated with significant patient delay (P = 0.01), and it had a significantly higher conversion rate (39%) compared with early cholecystitis (14.5%); (P <0.00001). Conversion rates were also associated with male gender (P = 0.0017), a history of biliary disease (P = 0.0085), and a patient delay of >48 hours (P = 0.028). The total and infectious complication rates were associated with an age older than 60 years (P = 0.023 and 0.007, respectively) and male gender (P = 0.026 and 0.014, respectively). CONCLUSIONS In acute cholecystitis, patient delay is associated with a high conversion rate. Early timing of laparoscopic cholecystectomy tends to reduce the conversion rate, as well as the total and the infectious complication rates. Male gender, a history of biliary disease, and advanced cholecystitis are associated with conversion. Male and older patients are associated with a high total and infectious complication rates.

Perioperative Hyperoxygenation and Wound Site Infection Following Surgery for Acute Appendicitis: A Randomized, Prospective, Controlled Trial

OBJECTIVE To assess the influence of hyperoxygenation on surgical site infection by using the most homogeneous study population. DESIGN A randomized, prospective, controlled trial. SETTING Department of surgery in a government hospital. PATIENTS A total of 210 patients who underwent open surgery for acute appendicitis. In the study group, patients received 80% oxygen during anesthesia, followed by high-flow oxygen for 2 hours in the recovery room. The control group received 30% oxygen, as usual. INTERVENTION Open appendectomy via incision in the right lower quadrant of the abdomen. MAIN OUTCOME MEASURES Surgical site infection, mainly assessed by the ASEPSIS (additional treatment, serous discharge, erythema, purulent discharge, separation of deep tissues, isolation of bacteria, and stay in hospital prolonged >14 days) system score. RESULTS Surgical site infections were recorded in 6 of 107 patients (5.6%) in the study group vs 14 of 103 patients (13.6%) in the control group (P = .04). Significant differences in the ASEPSIS score were also found. The mean hospital stay was longer in the control group (2.92 days) compared with the study group (2.51 days) (P = .01). CONCLUSION The use of supplemental oxygen is advantageous in operations for acute appendicitis by reducing surgical site infection rate and hospital stay. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01002365.

Laparoscopic management of lumbar hernia

Abstract. We describe (for the first time) a laparoscopic approach to repair an acquired superior triangle lumbar hernia in a morbidly obese woman by using prosthetic mesh. Such a technique provides an excellent anatomic view, thus avoiding injury to structures in proximity to the hernia during repair; eventually the well-known advantages of such approach result.

Validation and Reduction of the Oxidative Stress Following Laparoscopic Operations: A Prospective Randomized Controlled Study

Objective:To validate ischemia-reperfusion mechanism during laparoscopic cholecystectomy, and to assess the reduction of oxidative stress by an intermittent sequential pneumatic compression (ISPC) device. Summary Background:Increased intraperitoneal pressure during laparoscopic operations may lead to decreased cardiac output and visceral perfusion, and possible ischemia-reperfusion effects. Using the ISPC device was shown to improve cardiac output and visceral perfusion during pneumoperitoneum (PP). Methods:Twenty patients undergoing elective laparoscopic cholecystectomy were enrolled in a randomized prospective controlled study and divided into 2 groups: 1) study group (10 patients), activation of ISPC together with creation of PP; and 2) control group, without ISPC. Lipid peroxidation and glutathione levels (as indicators of oxidative stress) as well as liver and renal function tests, were measured before and at the end of PP, and again at 30 minutes, 4 hours, and 24 hours afterward, together with hemodynamic and respiratory parameters. Results:There was no significant difference between both groups concerning liver enzymes and bilirubin, nor in hemodynamic parameters. In the control group, increased lipid peroxide levels were noted 4 hours after PP termination, in comparison to pre-PP levels (590.4–649.2 mmol/L, P = 0.002). In the study group (ISPC), such changes were not inspected. Decreased total glutathione levels were noted in the control group, 30 minutes following CO2 evacuation. Conclusions:Our study validates the ischemia-reperfusion mechanism following laparoscopic surgery. The use of an ISPC device decreased the oxidative stress (secondary to relative ischemia-reperfusion insult) following PP, probably due to improved cardiac output and visceral perfusion.

A simplified laparoscopic technique for mesh placement in ventral hernia repair.

Abstract. The use of a large synthetic mesh for laparoscopic repair of significant ventral abdominal wall defects may be accompanied by technical difficulties resulting from improper orientation and positioning of the mesh over the defect. We suggest a technique based on initial fixation of the mesh center to the central point of the defect, and subsequent centrifugal attachment of the mesh to the abdominal wall. This technique is advantageous because it leads to precise orientation and positioning of the synthetic patch and to significant reduction of the time needed for its reinforcement over and around the defect.

Use of endoscopic trocar-cannula for chest drain insertion in trauma patients and others.

BACKGROUND The insertion of a chest drain into the pleural space is a common procedure used for treatment in various intrathoracic abnormalities. Recently, a new technique for chest-tube insertion for pleural cavity drainage, using the disposable endoscopic trocar-cannula, was described for the treatment of some pathologic conditions. METHODS In a prospective study, we used this technique in the treatment of patients with chest trauma, spontaneous and iatrogenic pneumothorax, and various kinds of pleural effusion. RESULTS One hundred twelve patients were treated by using the endoscopic trocar-cannula for tube insertion into the pleural cavity. Among them, 39 patients were treated after blunt and penetrating chest trauma. Most cannulae were of 10 to 11 mm in diameter, which enabled the insertion of large-bore drain tubes. In five trauma patients, chest-tube insertion was done successfully without antecedent chest x-ray films. The complication rate was 0.89% for intrapulmonary positioning of a chest tube in a patient who had previous ipsilateral thoracic surgery. CONCLUSION The use of endoscopic trocar-cannulae for chest-tube insertion is a safe, simple, and effective technique for management of trauma and other diverse intrathoracic abnormalities. Its use outside the hospital should be further studied.

Monitoring Cardiac Stress Using Features Extracted From

It is known that acoustic heart sounds carry significant information about the mechanical activity of the heart. In this paper, we present a novel type of cardiac monitoring based on heart sound analysis. Specifically, we study two morphological features and their associations with physiological changes from the baseline state. The framework is demonstrated on recordings during laparoscopic surgeries of 15 patients. Insufflation, which is performed during laparoscopic surgery, provides a controlled, externally induced cardiac stress, enabling an analysis of each patient with respect to their own baseline. We demonstrate that the proposed features change during cardiac stress, and the change is more significant for patients with cardiac problems. Furthermore, we show that other well-known ECG morphology features are less sensitive in this specific cardiac stress experiment.

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BACKGROUND Pneumatic sleeves are widely used in surgery to prevent venous stasis and to improve cardiac function. The aim of this study was to assess the underlying cardiovascular mechanism induced by the activation of intermittent sequential pneumatic compression (ISPC) in healthy volunteers. METHODS Twenty male subjects underwent transthoracic echocardiographic and tissue Doppler imaging evaluation before and during the activation ISPC devices. Each patient served as his own control. RESULTS Following ISPC activation, there were significant increases in cardiac output (from 5.1 to 5.5 L/min, P < .05) and stroke volume (from 72 to 78 mL, P < .002), as well as ejection fraction, the velocity-time integral of aortic flow, and fractional shortening of the left ventricle. There was no increase in heart rate. Tissue Doppler imaging was compatible with normal cardiac responses. Total peripheral resistance was significantly reduced during ISPC activation. CONCLUSIONS The activation of ISPC devices in normal volunteers augmented cardiac output because of increased preload as well as decreased afterload.

Heart Sounds

BACKGROUND The laparoscopic approach to incisional hernia repair is already well established because of its advantages. We evaluated the possibility of using a laparoscopically assisted approach whenever conversion to open repair was considered. PATIENTS AND METHODS We operated laparoscopically on 62 patients for postoperative ventral hernia (POVH), seven of whom had undergone laparoscopically assisted repair. The reasons for considering conversion were mainly technical difficulties in adhesiolysis and hernia reduction, and the suspected possibility of intestinal injury during dissection. The assisted approach included creation of a short incision over the fascial defect, exploration of the hernia contents and correction of any intestinal injury, completion of adhesiolysis, closure of the abdominal cavity, and laparoscopic accomplishment of the repair. RESULTS Following open exploration, two iatrogenic intestinal perforations and one serosal injury were found and repaired. In four cases, only the completion of adhesiolysis was necessary. The postoperative convalescence was uneventful, and no recurrence has been recorded to date. CONCLUSIONS The laparoscopically assisted approach to difficult POVH repair is feasible and safe, and it helps to preserve the advantages of the laparoscopic approach. We recommend this approach whenever conversion to open surgical repair is under consideration during laparoscopic repair.

The physiological impact of intermittent sequential pneumatic compression (ISPC) leg sleeves on cardiac activity

Hormone receptor status is of significant value when deciding on anti-estrogenic adjuvant therapy for breast cancer tumors. However, while estrogen receptor (ER) regulation was intensively studied, the regulation of progesterone receptor (PR) levels has not been extensively investigated. MicroRNAs (miRNAs, miRs) are post-transcriptional negative regulators of gene expression involved in diverse cellular processes. The aim of this study was to identify miRNAs that regulate PR in breast cancer.We mapped potential miRNA binding sites for miR-181a, miR-23a and miR-26b on PR mRNA and demonstrated a direct regulation of PR by these three miRNAs by in-vitro Luciferase binding assays. Over-expression of each miRNA in MCF-7 cells resulted in a reduction in the expression levels of PR mRNA. Then, expression levels of these miRNAs were measured in Formalin-Fixed, Paraffin-Embedded (FFPE) samples of 29 ER-positive breast cancer tumors and adjacent normal breast tissues. A significant reciprocal correlation between PR mRNA and the miRNA levels were identified suggesting a role for miR-181a, miR-23a and miR-26b in PR regulation in breast cancer. Moreover, the average expression fold-changes of the three miRNAs between cancerous and normal tissues displayed an opposite trend when analyzing according to Immuno-histochemistry(IHC) status. Furthermore, miR-181a and miR-26b were found to be over-expressed in most tumor tissues supporting their role in ER-positive breast cancer development. We conclude that miR-181a, miR-23a and miR-26b act as negative regulators of PR expression in ER-positive breast cancer. The diagnostic and prognostic potential of these miRNAs in breast cancer should be further evaluated.