Danny Rosin

Colon and rectal surgery without mechanical bowel preparation: a randomized prospective trial.

ObjectiveTo assess whether elective colon and rectal surgery can be safely performed without preoperative mechanical bowel preparation. Summary Background DataMechanical bowel preparation is routinely done before colon and rectal surgery, aimed at reducing the risk of postoperative infectious complications. However, in cases of penetrating colon trauma, primary colonic anastomosis has proven to be safe even though the bowel is not prepared. MethodsPatients undergoing elective colon and rectal resections with primary anastomosis were prospectively randomized into two groups. Group A had mechanical bowel preparation with polyethylene glycol before surgery, and group B had their surgery without preoperative mechanical bowel preparation. Patients were followed up for 30 days for wound, anastomotic, and intra-abdominal infectious complications. ResultsThree hundred eighty patients were included in the study, 187 in group A and 193 in group B. Demographic characteristics, indications for surgery, and type of surgical procedure did not significantly differ between the two groups. Colo-colonic or colorectal anastomosis was performed in 63% of the patients in group A and 66% in group B. There was no difference in the rate of surgical infectious complications between the two groups. The overall infectious complications rate was 10.2% in group A and 8.8% in group B. Wound infection, anastomotic leak, and intra-abdominal abscess occurred in 6.4%, 3.7%, and 1.1% versus 5.7%, 2.1%, and 1%, respectively. ConclusionsThese results suggest that elective colon and rectal surgery may be safely performed without mechanical preparation.

Laparoscopic cholecystectomy performed under regional anesthesia in patients with chronic obstructive pulmonary disease

Background: Laparoscopic cholecystectomy has been successfully performed using epidural anesthesia. We evaluated our experience with this surgical approach in high-risk patients. Methods: We present the results of 29 patients with gallstones who, between 1998 and 1999, underwent laparoscopic cholecystectomy with epidural anesthesia. All but 1 patient had chronic obstructive pulmonary disease. Results: All 29 surgeries were successfully completed via laparoscopy and with the patients under epidural anesthesia. No patient required endotracheal intubation during surgery or pain medication afterward. Postoperatively, 1 patient developed a wound infection and 3 patients developed urinary retention. Atlast follow-up (12 months postop), all patients were in good health. Conclusion: In this series, laparoscopic cholecystectomy was feasible under epidural anesthesia and it eliminated the need for postoperative analgesia. We believe that this approach should be considered for patients who require biliary surgery but who are not good candidates for general anesthesia due to cardiorespiratory problems.

Laparoscopic colectomy without mechanical bowel preparation

BackgroundMechanical bowel preparation prior to colorectal surgery may reduce infectious complications, facilitate tumor localization, and allow intraoperative colonoscopy, if required. However, recent data suggest that mechanical bowel preparation may not facilitate a reduction in infectious complications. During laparoscopic colectomy, manual palpation is blunt, thereby potentially compromising tumor localization. The aim of this study was to assess the utility of mechanical bowel preparation in laparoscopic colectomy.Materials and methodsA retrospective medical record review of all patients who underwent laparoscopic colectomy was performed. Patients were divided into two groups: those who had preoperative mechanical bowel preparation (Group A) or those who did not (Group B). All relevant perioperative data were reviewed and compared.ResultsTwo hundred patients underwent laparoscopic colectomy; 68 (34%) were in Group A and 132 (66%) were in Group B. Sixteen (8%) patients required intraoperative colonoscopy for localization and were evenly distributed between the two groups. The incidence of conversion to laparotomy was slightly higher in Group B (14 vs 9%) due to difficult localization in some cases; however, this difference did not reach statistical significance. Furthermore, there was no significant difference in the postoperative complication rate between the two groups. Specifically, an anastomotic leak and a wound infection were recorded in 4 and 12% of patients in Group A compared to 3 and 17% in Group B, respectively.ConclusionsLaparoscopic colectomy may be safely performed without preoperative mechanical bowel preparation, although difficult localization may lead to a slightly higher conversion rate. Appropriate patient selection for laparoscopic colectomy without mechanical bowel preparation is essential. Furthermore, bowel preparation should be considered in cases of small and nonpalpable lesions.

Closure of Laparoscopic Trocar Site Wounds with Cyanoacrylate Tissue Glue: A Simple Technical Solution

Cyanoacrylate-based tissue glue has been widely used for many years around the world, and was recently approved for use in the United States, mainly for skin cuts and lacerations. Other applications were described, in different surgical situations. Although ideal for small, clean incisions, its use in laparoscopic surgery is currently limited. Over a year period, 100 patients with more 250 trocar site wounds had their wounds glued using histoacryl. Infection rate was extremely low (one case), and partial dehiscence of the wound happened in two patients, where wound edge approximation was not optimal. Cosmetic results were excellent and patient satisfaction was high, as no sutures had to be removed. Glue application is easy and quick, with no risk of needle sticks, and it is a viable option for laparoscopic wound closure.

Die laparoskopische Splenektomie: Neue Techniken und Indikationen

Abstract. Over the recent years laparoscopic splenectomy has become the preferred approach for the treatment of many conditions requiring splenic removal. At first limited to small spleens and to benign hematologic disorders, this procedure is now used for a variety of indications. Enlarged spleens are possible to be removed laparoscopically, although this is still a demanding procedure. Two factors facilitated the technique and contributed to its wide acceptance: 1) Change in the technique originally used, by positioning the patient in right lateral decubitus, and approaching the spleen from a postero-lateral direction. 2) The development of new technologies to dissect and divide tissues and vessels, including the ultrasonic shears and the laparoscopic linear stapler. In this article we review the current indications for laparoscopic splenectomy, as well as the techniques to accomplish this procedure.Zusammenfassung. Im Laufe der letzten Jahre wurde die laparoskopische Splenektomie zum bevorzugten operativen Verfahren bei Erkrankungen, bei denen die Milz entfernt werden muss. Zunächst war die laparoskopische Splenektomie auf Milzen kleiner Größe und benigne hämatologische Erkrankungen beschränkt; mittlerweile ist diese Methode auf eine Vielzahl anderer Indikationen ausgeweitet worden. Auch vergrößerte Milzen können bereits laparaskopisch entfernt werden, obwohl dies nach wie vor eine Herausforderung für den Chirurgen darstellt. Zwei Faktoren haben die laparoskopische Splenektomie vereinfacht und so zu der steigenden Akzeptanz und Attraktivität dieser Technik beigetragen: 1. Abwandlung der ursprünglichen laparoskopischen Technik durch veränderte Lagerung des Patienten in Rechtsseitenlage mit einem postero-lateralen Zugang. 2. Die Entwicklung von neuen Schneide- und Dissektionstechniken, wie z. B. das Ultraschallmesser (Ultracision) und laparoskopische Linearstapler. In dieser Übersichtsarbeit stellen wir sowohl die gegenwärtigen Indikationen zur laparoskopischen Splenektomie als auch die neue Operationstechnik und die dafür benötigten Instrumente dar.

Gastric MALT lymphoma in a Helicobacter pylori-negative patient: a case report and review of the literature.

Helicobacter pylori (H. pylori), a gram-negative spiral bacterium only recently recognized, has been associated with many gastric pathologies, including peptic ulcer disease, chronic gastritis, gastric lymphoma, and gastric adenocarcinoma. Eradication of H. pylori is now considered essential for the treatment of these pathologies, and usually consists of antibiotic therapy, combined with acid suppression by a proton pump inhibitor. This simple treatment can often obviate the need for surgical intervention. In the case of gastric mucosa-associated lymphoid tissue (MALT) lymphoma, it can replace the use of radiotherapy or chemotherapy. In a small percentage of the above-mentioned gastric pathologies, no evidence of H. pylori is found. In these cases, H. pylori eradication therapy seems to be irrelevant, and other therapeutic modalities are required. We present a case of gastric MALT lymphoma in an H. pylori-negative patient, in whom partial gastric resection was carried out. We review the literature and discuss the possible therapeutic options in this situation.

Laparoscopic Surgery of the Liver and Biliary Tract

Laparoscopic treatment of liver and biliary tract disease is growing in popularity but requires extensive experience. Among the lesions now managed with minimally invasive methods are simple cysts, polycystic liver disease, hydatid cysts, biliary stones, and benign solid tumors. Patient selection, surgical techniques, and outcomes are described.

Bedside laparoscopy in the ICU: report of four cases.

BACKGROUND Patients in the intensive care unit (ICU) may suffer from life-threatening abdominal pathologies, which may necessitate a surgical intervention. Diagnosis may be difficult, as deep sedation and analgesia often mask symptoms, and physical examination is unreliable. Imaging studies are not accurate enough, and exploratory laparotomy carries significant morbidity and mortality rates in this patient population. The unstable patient is difficult to mobilize to the imaging department or to the operating room. Bedside laparoscopy may overcome these difficulties. PATIENTS AND METHODS We describe our initial experience with the use of bedside laparoscopy in critical patients with suspected abdominal pathology. The procedure was performed in four patients over a 4-month period and completed in all four. RESULTS The findings were: turbid fluid consistent with viscus perforation in a patient with unexplained sepsis after cardiac surgery, sterile hemorrhagic fluid in a patient with malignancy and thrombotic thrombocytopenia purpura, a retroperitoneal mass from which biopsies were taken in a patient with sudden respiratory failure, and abdominal abscess in a patient after bowel resection for mesenteric embolism. None of these patients had a laparotomy after the laparoscopy. Patients 1 and 4 died a few hours after the procedure from sepsis, and patients 2 and 3 died several days later. CONCLUSION Bedside laparoscopy in the ICU is feasible, informative, and accurate. It has a role in diagnosing abdominal pathologies and planning further treatment. It may avert a nontherapeutic laparotomy. Unfortunately, the prognosis in these patients is poor. Earlier use of this diagnostic modality may improve patient outcome.

Diverticulitis: does age matter?

Acute diverticulitis has been traditionally associated with worse outcome in young patients, indicating a more aggressive surgical approach is required for them. The aim of this study was to assess whether acute diverticulitis was more virulent in young patients.

Preoperative Nutritional Optimization for Crohn’s Disease Patients Can Improve Surgical Outcome

Background: Preoperative preparation of patients with Crohn’s disease is challenging and there are no specific guidelines regarding nutritional support. The aim of this study was to assess whether preoperative nutritional support influenced the postoperative outcome. Methods: A retrospective, cohort study including all Crohn’s disease patients who underwent abdominal surgery between 2008 and 2014 was conducted. Patients’ characteristics and clinical and surgical data were recorded and analyzed. Results: Eighty-seven patients were included in the study. Thirty-seven patients (42.5%) received preoperative nutritional support (mean albumin level 3.14 vs. 3.5 mg/dL in the non-optimized group; p < 0.02) to optimize their nutritional status prior to surgery. Preoperative albumin level, after adequate nutritional preparation, was similar between the 2 groups. The 2 groups differ neither in demographic and surgical data, overall post-op complication (p = 0.85), Clavien-Dindo score (p = 0.42), and length of stay (p = 0.1). Readmission rate was higher in the non-optimized group (p = 0.047). Conclusion: Nutritional support can minimize postoperative complications in patients with low albumin levels. Nutritional status should be optimized in order to avoid hazardous complications.