Arie Eitan

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.

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.

Are the morphology of papillary thyroid carcinoma and the tumour's behaviour correlated?

Six cases of papillary thyroid carcinoma showing clinically highly aggressive behaviour by invading the upper airway and digestive tract structures were retrospectively reviewed to evaluate the morphological variants of the tumours. Four of them were found to be pure papillary and one was a mixed-papillary and follicular-variants regarded as non-aggressive. Only one case was found to be tall cell variant-regarded as an aggressive variant of papillary thyroid carcinoma. The findings suggest that the prognosis of papillary thyroid carcinoma cannot be predicted from its morphological variant and attention should be given to other clinical parameters.

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 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.

Heart Sounds

BackgroundInduction of pneumoperitoneum (PP) may lead to adverse cardiac functions secondary to changes such as decreased venous return and hypercarbia. The assessment of cardiac electrical activity by signal averaging may reflect various hemodynamic derangements and serve as a prognostic marker for arrhythmias. The aim of the study is to examine characteristic electrocardiographic changes that may occur during PP, by using signal-averaged P-wave analysis.MethodsTwenty healthy (ASA I and II) patients were enrolled in a prospective paired control study, and underwent elective laparoscopic cholecystectomy. A standard ECG together with computerized filtered signal-averaged P-wave duration measurement (leads X, Y, Z) were carried out during awareness, under anesthesia before and during PP, and after CO2 evacuation. Depth of anesthesia was controlled by bi-spectral index (BIS).ResultsAn increased duration of P-wave was observed during PP in comparison to the anesthesia phase before PP (111 versus 115 ms, t-test and Wilcoxon signed rank test). A significant increase was also detected in the maximal value of P-wave duration between these phases of the operation. The difference in the number of patients in whom the duration increased by at least 5 ms was also found to be significant.ConclusionsPrimarily, a decreased P-wave duration was expected, due to cardiac autonomic sympathetic predominance during PP. Its prolongation during PP may reflect some cardiac pathophysiological (structural and functional) changes, including influence on cardiac ion channels during depolarization. Usually, clinical consequences related to laparoscopic cholecystectomy are absent, but clinical awareness should be maintained for cardiac diseased patients undergoing prolonged laparoscopic procedures.

Laparoscopically Assisted Approach for Postoperative Ventral Hernia Repair

Papillary carcinoma is the most common malignant tumour of the thyroid gland, accounting for at least two-thirds of newly diagnosed carcinomas. This tumour may be occasionally multicentric in origin. It frequently spreads to regional lymph nodes in the neck and mediastinum, but uncommonly metastasizes outside these regions. Local invasion of this tumour to the upper airway or digestive tract structures is infrequent. However, when that occurs, it is a source of significant morbidity and mortality. In the last two years four patients suffering from invasive papillary carcinoma to the aerodigestive tract were treated in our department. A short case history of one of them is presented and current trends in management of the disease are reviewed.