Bruce V. MacFadyen

Bile duct injury after laparoscopic cholecystectomy: The United States experience

AbstractBackground: Forty series reporting experience with laparoscopic cholecystectomy in the United States from 1989 to 1995 were reviewed. A total of 114,005 cases were analyzed and 561 major bile duct injuries (0.50%) and 401 bile leaks from the cystic duct or liver bed (0.38%) were recorded. Intraoperative cholangiography (IOC) was attempted in 41.5% of the laparoscopic cholecystectomies and was successful in 82.7%. In major bile duct injuries, the common bile duct/common hepatic duct were the most frequently injured (61.1%) and only 1.4% of the patients had complete transection. Methods: When reported, most of the bile duct injuries were managed surgically with a biliary-enteric anastomosis (41.8%) or via laparotomy and t-tube or stent placement (27.5%). The long-term success rate could not be determined because of the small number of series reporting this information. The management for bile leaks usually consisted of a drainage procedure (55.3%) performed endoscopically, percutaneously, or operatively. Results: The morbidity for laparoscopic cholecystectomy, excluding bile duct injuries or leaks, was 5.4% and the overall mortality was 0.06%. It was also noted that the conversion rate to an open procedure was 2.16%. Conclusions: It is concluded based on this review of laparoscopic cholecystectomies that the morbidity and mortality rates are similar to open surgery. In addition, the rate of bile duct injuries and leaks is higher than in open cholecystectomy. Furthermore, bile duct injuries can be minimized by lateral retraction of the gallbladder neck and careful dissection of Calot’s triangle, the cystic duct–gallbladder junction, and the cystic duct–common bile duct junction.

Intravenous hyperalimentation as an adjunct to cancer chemotherapy

A 36 per cent response rate was obtained in fifty-eight nutritionally depleted patients with cancer who would otherwise have been denied adequate antitumor therapy because of the fear of complications from malnutrition and inanition. A positive correlation between the nutritional status of the patient and the chemotherapeutic tumor response was identified. Intravenous hyperalimentation can be a valuable adjunct to cancer chemotherapy by improving the nutritional status, increasing the total deliverable dose of anticancer agent per unit of time, and reducing the incidence and severity of the toxic gastrointestinal side effects without adversely stimulating malignant cell growth or producing septic complications.

Complications of laparoscopic herniorrhaphy

SummaryAnterior inguinal hernia repair is the second-most-commonly performed abdominal operation and has been associated with low morbidity and mortality rates. The principle of laparoscopy has been applied to this surgical problem in a series of 762 patients with 841 inguinal hernias. Four types of laparoscopic repairs were conducted: (1) high ligation of the indirect inguinal hernia sac and closure of the internal ring (87 patients with 89 hernias); (2) plug and patch of the internal ring (74 patients with 87 hernias); (3) transperitoneal suture repair of the transversalis fascia to the iliopubic tract or Coopers ligament (28 patients with 30 hernias); and (4) placement of a large prosthesis over the myopectoneal orifice (563 patients with 635 hernias). These early results indicate that the overall complication rates were low, especially when a large prosthesis was used to reinforce the myopectoneal orifice. It is concluded that laparoscopic inguinal herniorrhaphy is a safe and effective procedure with which to manage this surgical problem.

Gallbladder cancer and trocar site recurrences

BACKGROUND Critics of laparoscopic surgery cite an increased incidence of tumor recurrence at the trocar sites following laparoscopic cholecystectomy in patients incidentally found to have carcinoma of the gallbladder. The purpose of this review was to determine if laparoscopic cholecystectomy performed in patients with gallbladder cancer results in an increased incidence of abdominal wall recurrences. METHODS The charts of all patients with gallbladder cancer registered at the University of Texas M. D. Anderson Cancer Center from January 1991 through April 1996 were retrospectively reviewed. Data were collected on initial and subsequent surgical procedures, tumor grade and histology, T stage, adjuvant therapy, and survival. These data were analyzed with regard to abdominal wall recurrences and outcome. RESULTS Ninety-three patients with gallbladder cancer were seen during this period; 79 patients with complete follow-up information comprised the study population. Comparison of the incidence of abdominal wall recurrences among the categories of surgical procedure (laparoscopic versus open versus laparoscopic converted to open) did not reveal any statistically significant differences. Overall 5-year survival was 10%. CONCLUSIONS Gallbladder cancer is an aggressive malignancy with few long-term survivors. In addition, these data show that the incidence of abdominal wall implantation is not increased with laparoscopic surgery but is more likely a manifestation of the aggressive nature of this tumor.

Intravenous hyperalimentation as an adjunct to radiation therapy

Radiation therapy may induce anorexia with resultant weight loss and inanition that can limit the dose of radiation therapy administered. The purpose of this study was to evaluate 39 nutritionally‐depleted patients who had a variety of malignant diseases treated with radiation therapy and concomitant nutritional support with intravenous hyperalimentation (IVH). The average dose of radiation delivered was 3827 rads in an average of 3.5 weeks. Ninety‐five percent of the patients completed their planned course of radiation therapy and improved symptomatically. Fifty‐four percent of the patients responded with a greater than 50% reduction in tumor size. Responding patients gained an average weight of 13.0 ± 6.5 lbs. during IVH (av. 36.2 days) and radiation therapy (av. 3832 rads), whereas non‐responding patients gained only 4.9 ± 8.8 lbs. (p < 0.001) during IVH (av. 42.8 days) and radiation therapy (av. 3819 rads). Serum albumin concentrations rose from 3.12 ± 0.49 gm/100 ml to 3.51 ± 0.68 gm/100 ml (p < 0.05) during treatment in responding patients but did not rise significantly from 3.09 ± 0.48 gm/100 ml in non‐responding patients. In conclusion, IVH allowed a planned course of radiation therapy to be delivered to a group of poor‐risk, malnourished cancer patients, and a positive correlation between tumor response and nutritional status was identified. Moreover, IVH was a valuable adjunct in the treatment of six patients who had enteric fistulas that originated from radiated bowel.

Endoluminal and transluminal surgery: Current status and future possibilities

The field of minimally invasive surgery has seen tremendous growth since the first laparoscopic cholecystectomy was performed in 1987. The key question is not how successful these techniques are currently, but rather where may they lead in the future? New technologies promise to usher in an era of even less invasive procedures. The terms being coined in the literature include “incisionless,” “endoluminal,” “transluminal,” and “natural orifice” transluminal endoscopic surgery. These techniques certainly have the potential to become the next wave of minimally invasive procedures. A recent editorial in Surgical Endoscopy by Macfadyen and Cuschieri highlighted the ongoing developments in endoscopic surgery and stressed the critical importance of surgeons being involved in future applications and permutations of these techniques [1]. There are early signs of such involvement. The work of numerous investigators in the field was presented recently at the 2005 Digestive Disease Week. The American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), in collaboration with the American College of Surgeons, recently organized a postgraduate course in endoluminal therapy at the spring 2005 meeting held in Hollywood, Florida. The course is being offered again at the 2006 SAGES annual meeting. Similar courses are being offered at other regional and national meetings. This review attempts to highlight some of the available and evolving endoluminal therapies reviewed at that forum, including techniques for the management of gastroesophageal reflux disease, endoscopic mucosal resection, endoluminal bariatric surgery, transanal endoscopic microsurgery, and transgastric endoscopic surgery, as well as new technologies and possible future directions in luminal access surgery.

Face and construct validity of a computer-based virtual reality simulator for ERCP

BACKGROUND Currently, little evidence supports computer-based simulation for ERCP training. OBJECTIVE To determine face and construct validity of a computer-based simulator for ERCP and assess its perceived utility as a training tool. DESIGN Novice and expert endoscopists completed 2 simulated ERCP cases by using the GI Mentor II. SETTING Virtual Education and Surgical Simulation Laboratory, Medical College of Georgia. MAIN OUTCOME MEASUREMENTS Outcomes included times to complete the procedure, reach the papilla, and use fluoroscopy; attempts to cannulate the papilla, pancreatic duct, and common bile duct; and number of contrast injections and complications. Subjects assessed simulator graphics, procedural accuracy, difficulty, haptics, overall realism, and training potential. RESULTS Only when performance data from cases A and B were combined did the GI Mentor II differentiate novices and experts based on times to complete the procedure, reach the papilla, and use fluoroscopy. Across skill levels, overall opinions were similar regarding graphics (moderately realistic), accuracy (similar to clinical ERCP), difficulty (similar to clinical ERCP), overall realism (moderately realistic), and haptics. Most participants (92%) claimed that the simulator has definite training potential or should be required for training. LIMITATIONS Small sample size, single institution. CONCLUSIONS The GI Mentor II demonstrated construct validity for ERCP based on select metrics. Most subjects thought that the simulated graphics, procedural accuracy, and overall realism exhibit face validity. Subjects deemed it a useful training tool. Study repetition involving more participants and cases may help confirm results and establish the simulators ability to differentiate skill levels based on ERCP-specific metrics.

Modifications of coagulation and fibrinolytic parameters in laparoscopic cholecystectomy

Background: The incidence of deep vein thrombosis and pulmonary embolism following laparoscopic surgery is unknown and studies on alterations of hemostasis after laparoscopy are inconclusive. Methods: In this study we prospectively evaluated changes in prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen (Fg), antithrombin III (ATIII), prothrombin fragment F 1 + 2, beta-thromboglobulin (bTG) and D-dimer (D-D), preoperatively and 24 h after laparoscopic surgery in 16 patients. Results: Comparing pre- and postoperative values, no statistical differences were observed in aPTT, F1 + 2, and ATIII measurements. Postoperative PT values increased slightly (p ~ 0.05) after surgery. Conversely, Fg, bTG, and D-D values were statistically higher in the 24-h evaluation (p = 0.008, 0.01, and 0.045, respectively). Conclusions: These data suggest that laparoscopic surgery induces activation of coagulation and fibrinolytic pathways and, additionaly, bTG elevation, which has never been reported and might account for postoperative platelet activation and a greater risk of thrombogenicity. Therefore, routine thromboembolic prophylaxis in patients undergoing laparoscopic surgery is recommended.

New Concepts of Ambulatory Home Hyperalimentation

Various infusion systems have been devised to allow long-term administration of total parenteral nutrition solutions on an ambulatory basis to patients who are unable to maintain adequate enteral nutrition and/or who might benefit from a period of bowel rest. During the past 3 yr, the intravenous hyperalimentation team of The Hermann Hospital and The University of Texas Medical School at Houston has gained considerable experience in developing a specially designed patient vest which is comfortable, attractive and practical for continuous or intermittent central venous or enteral feeding on an ambulatory basis. The system is described together with the results of its use. in 25 patients ranging in age from 23 mo to 66 yr for a cumulative total ambulatory home hyperalimentation experience equivalent to 12.4 man-years. Complications related to the technique have been minimal, and clinical results have been most gratifying. It is anticipated that further advances in this vital field will contribute to increas...

Laparoscopic common bile duct exploration.

Abstract. In recent years, laparoscoscopic common bile duct exploration has become the procedure of choice in the management of choledocholithiasis in several laparoscopic centers. The increasing interest for this laparoscopic approach is due to the development of instrumentation and technique, allowing the procedure to be performed safely, and it is also the result of the revised role of endoscopic retrograde cholangiopancreatography, which has been questioned because of its cost, risk of complications and effectiveness. Many surgeons, however, are still not familiar with this technique. In this article we discuss the technique and results of laparoscopic common bile duct exploration. Both the laparoscopic transcystic approach and choledochotomy are discussed, together with the results given in the literature. When one considers the costs, morbidity, mortality and the time required before the patient can return to work, it would appear that laparoscopic cholecystectomy with common bile duct exploration is more favorable than open surgery or laparoscopic cholecystectomy with preoperative or postoperative endoscopic sphincterotomy. However, the technique requires advanced laparoscopic skills, including suturing, knot tying, the use of a choledochoscope, guidewire, dilators and balloon stone extractor. Although laparoscopic common bile duct exploration appears to be the most cost-effective method to treat common bile duct stones, it should be emphasized that this procedure is very challenging, and it should be performed by well-trained laparoscopic surgeons with experience in biliary surgery.