David C. Wherry

An external audit of laparoscopic cholecystectomy in the steady state performed in medical treatment facilities of the Department of Defense

OBJECTIVE This study provides the first objective assessment of a complete patient population undergoing laparoscopic cholecystectomy in the steady state. The authors determined the frequency of complications, particularly bile duct, bowel, vascular injuries, and deaths. SUMMARY BACKGROUND DATA This retrospective study, conducted for the Department of Defense healthcare system by the Civilian External Peer Review Program, is the second complete audit of laparoscopic cholecystectomy. Data were collected on 9130 patients undergoing laparoscopic cholecystectomy between January 1993 and May 1994. METHODS The study sample consisted of clinical data abstracted from the complete records of 9054 (99.2%) of the 9130 laparoscopic cholecystectomies performed at 94 military medical treatment facilities. RESULTS Of 10,458 cholecystectomies performed in the Military Health Services System, 9130 (87.3%) were laparoscopic and 1328 (12.7%) were traditional open procedures. Seventy-six medical records were incomplete: however, there was sufficient data to determine mortality and bile duct injury rates. Of the remaining 9054 cases, 6.09% experienced complications, including bile duct (0.41%), bowel (0.32%), and vascular injuries (0.10 percent). The mortality rate was 0.13%. Access via Veress technique was used in 57.6% and Hasson technique in 42.4% of patients. Intraoperative cholangiograms were performed in 42.7% of the cases with a success rate of 86.2%. Eight hundred ninety-two (9.8%) patients were converted to open cholecystectomies. CONCLUSIONS In the steady state, despite an increase in the percentage of laparoscopic cholecystectomies performed for nonmalignant gallbladder disease, there continues to be minimal complications and low mortality.

PROSPECTIVE EVALUATION OF THORACOSCOPY FOR DIAGNOSING DIAPHRAGMATIC INJURY IN THORACOABDOMINAL TRAUMA: A PRELIMINARY REPORT

Diagnosis of diaphragmatic injury (DI) can be difficult in patients with penetrating trauma because physical examination, computed tomographic scan, chest x-ray films, and diagnostic peritoneal lavage may miss these injuries. Mandatory exploration has been recommended because of the increased mortality associated with missed DI. Thoracoscopy was prospectively evaluated as a less invasive method for diagnosing DI in patients with penetrating trauma. Over a 14-month period, 14 patients were evaluated by thoracoscopy; video thoracoscopy was used in the last 9. Findings of thoracoscopy were confirmed by laparotomy or laparoscopy. Thoracoscopy correctly identified the presence or absence of DI in nine and five patients, respectively (all patients). Video thoracoscopy was easier and faster to perform than non-video thoracoscopy. This is the first reported series in which video thoracoscopy has been used for trauma. We found this procedure to be safe, accurate, and less invasive than laparotomy for diagnosing DI.

Arterial Reconstruction with Vascular Clips is Safe and Quicker Than Sutured Repair

BACKGROUND Non-penetrating, arcuate-legged vascular-closure staple clips made of titanium were initially developed for microvascular anastomoses with little experience of their use in larger vessels. The purpose of this study was to compare vascular-closure staple clips to sutured anastomoses in common iliac arteries in a porcine model. METHODS In an experimental study, transected iliac arteries on both sides of 11 pigs were randomly assigned to end-to-end anastomosis performed with vascular-closure staple clips or interrupted 6-0 polypropylene sutures. Angiographic, macroscopic and microscopic results were assessed after 2 months. RESULTS There was no significant difference in the patency rate, tensile strength of the anastomoses, vessel diameter at the repair site, intimal thickness or wall thickness of the arteries after either method of closure. The mean (s.d.) clamp time was 19.8 (6.1) minutes for clip repair, and 36.0 (6.9) seconds for suture repair (P < 0.001). The times required for the reconstruction of the anastomoses were 17.4 (6.1) and 35.5 (7.1) minutes, respectively (P < 0.001). CONCLUSIONS Arterial anastomoses performed with vascular-closure staple clips are faster than sutured anastomoses, and result in comparable wound healing when assessed for patency, tensile strength, degree of narrowing and intimal reaction.

An external audit of laparoscopic cholecystectomy performed in medical treatment facilities of the department of Defense.

ObjectiveThis study provided an objective survey by an outside auditing group of a large, complete patient population undergoing laparoscopic cholecystectomies, determined the frequency of complications, especially bile duct injuries, and presented a system for classifying and comparing the severity of bile duct injuries. Summary Background DataThis is the first study of laparoscopic cholecystectomy to encompass a large and complete patient population and to be based on objectively collected data rather than self-reported data. The Civilian External Peer Review Program (CEPRP) of the Department of Defense health care system conducted a retrospective study of 5642 patients who underwent laparoscopic cholecystectomies at 89 military medical treatment facilities from July 1990 through May 1992. MethodsThe study sample consisted of the complete records of 5607 (99.38%) of the 5642 laparoscopic cholecystectomy patients. ResultsOf the sample, 6.87% of patients experienced complications within 30 days of surgery, 0.57% sustained bile duct injuries, and 0.5% sustained bowel injuries. Among 5154 patients whose procedures were compteled laparoscopically, 5.47% experienced complications. Laparoscopic procedures were converted to open cholecystectomies in 8.08% of cases. Intraoperative cholangiograms were attempted in 46.5% of cases and completed in 80.59% of those attempts. There were no intraoperative deaths; 0.04% of the patients died within 30 days of surgery. ConclusionsThe frequency of complications found in this study is comparable to the frequency of complications reported in recent large civilian studies and earlier, smaller studies. The authors present a system for classifying bile duct injuries, which is designed to standardize references to such injuries and alow for accurate comparison of bile duct injuries in the future.

Arterial and venous repair with vascular clips: comparison with suture closure.

PURPOSE Nonpenetrating, arcuate-legged titanium vascular closure staple (VCS) clips were initially developed for microvascular anastomoses with little experience of their use in larger vessels. The purpose of this study was to compare the VCS clips with standard suture closure of arteriotomies and venotomies in common iliac vessels of pigs. METHODS In nine pigs, longitudinal 1 cm iliac arterial and venous incisions were repaired with VCS clips on one side and continuous 6-0 polypropylene suture on the other, and the macroscopic and microscopic results were assessed after 3 months. RESULTS The time required for vessel repair was significantly shorter with clips than with sutures both in arteries (51 +/- 9 vs 414 +/- 36 seconds) and in veins (100 +/- 32 vs 439 +/- 45 seconds). There was no significant difference in the inner diameter, intimal thickness, or intima-to-media height ratios of the arteries or veins after either method of closure. CONCLUSIONS Repair of 1 cm incisions in small-diameter arteries and veins with VCS clips results in wound healing as good as that achieved with standard suture closure, when assessed for patency, leakage, degree of narrowing, and intimal reaction. The time required for clip closure is considerably shorter than for suture closure.

Rapid Arterial Anastomosis with Titanium Clips

BACKGROUND The obvious advantages of rapid arterial anastomoses have prompted the continuing search for more rapid anastomotic techniques to complement the standard sutured anastomosis. Nonpenetrating, arcuate-legged titanium vascular closure staple (VCS) clips were initially developed for microvascular anastomoses. The purpose of this study was to compare VCS clips with sutured arterial end-to-end anastomosis in larger vessels. METHODS In 6 pigs, transacted iliac arteries were reanastomosed with VCS clips on one side and continuous 6-0 polypropylene suture on the other. RESULTS The reconstruction time was 8.4+/-5.2 minutes for clip closure and 12.0+/-6.6 minutes for suture closure (P = 0.033). All vessels were patent half an hour after completing the anastomoses with no signs of early thrombosis. CONCLUSIONS Arterial end-to-end anastomosis can be performed more rapidly with VCS clips than continuous sutures, and are potentially useful in situations where the clamp time of the vessel is critical.

Valproic acid prevents hemorrhage-associated lethality and affects the acetylation pattern of cardiac histones.

ABSTRACT Pharmacological inhibitors of histone deacetylases (HDAC) demonstrate cytoprotective effects both in vitro and in vivo. In this study, we investigated whether valproic acid (VPA), a known mood stabilizer and anticonvulsant with HDAC-inhibiting activity, improves survival following otherwise lethal hemorrhage in rats. We found that preinsult injection of VPA (300 mg/kg, twice) prolonged the survival of severely hypotensive animals up to 5 times. VPA treatment increased the acetylation of nonhistone and histone proteins in the rat heart. The pattern of modifications of individual histones revealed hyperacetylation of histones H2A, H3, and H4, indicating the presence of active genes. Expression of HSP70 and superoxide dismutase, implicated in the modulation of vitality, was increased by VPA. Our results reveal that VPA offers considerable protection in the hemorrhagic shock model and suggest a role for HDAC inhibition in mediating VPA actions.

Late-presenting appendicitis

Background: Acute appendicitis is the most common abdominal condition necessitating urgent surgical intervention in the United States. The objective of this study was to determine if interval laparoscopic appendectomy after initial nonoperative treatment for late appendicitis presenting as an appendiceal mass is a safe alternative to immediate appendectomy. Methods: Thirty two consecutive patients (aged 16–74 years) during a 5-year period presented with appendiceal mass. Seventeen received initial nonsurgical treatment followed by interval laparoscopic appendectomy (aged 16–60 years; group 1). Fifteen underwent immediate appendectomy (aged 16–74 years; group 2). Results: All patients in the interval laparoscopic appendectomy group improved with initial therapy and underwent surgery an average of 4.9 months later. Although the operative time and the complication rate were similar between groups 1 and 2, the time to return to baseline activities was significantly less in group 1 after adjusting for age (p = 0.02 or less). Conclusions: Interval laparoscopic appendectomy is safe in patients with chronic appendicitis and allows for judicious diagnostic evaluation of the appendiceal mass and planned surgery under controlled conditions.

Potential of a hand-held ultrasound in assessment of the injured patient

Current studies indicate that portable ultrasound used by trained trauma surgeons in the emergency room can be performed using the focused abdominal sonogram for trauma technique in approximately 2 minutes to evaluate patients with blunt torso trauma. It has been shown to be as accurate as DPL and computed tomography (CT) in the detection of hemoperitoneum following abdominal trauma. It is also very accurate in detecting pericardial fluid and may have a role in the evaluation of penetrating injuries of the thorax, either from stab or gunshot wounds. The examination is best performed early on in the secondary survey of the injured patient. Miniaturization and hand-held ultrasound units are on the horizon. The faculty of the University of Washington in Seattle in conjunction with the Advanced Technology Laboratories in Seattle and the Advanced Research Project Agency of the Department of Defense are producing a battlefield hand-held ultrasound with the ultimate goal to have an ultrasound unit that will fit in the trauma surgeons pocket. With the use of this new technology, the potential for early diagnosis of victims of trauma and prompt treatment is at hand. One of the greatest challenges remaining is that of training surgeons in the use of ultrasound. The authors experience in conducting ultrasound courses for surgeons at the Uniformed Services University of the Health Sciences is described.

A quick and simple method to close vascular, biliary, and urinary tract incisions using the new Vascular Closure Staples

Traditional suture reconstruction of tubular organs creates a perforating needle injury, leaves suture material on the endothelial or mucosal surfaces, and is cumbersome when done endoscopically. One alternative method of reconstruction of tubular organs could use the new non-penetrating clip to create an everted closure. In five pigs, a longitudinal incision of the infrarenal aorta, inferior vena cava, left ureter, gallbladder, and the common bile duct (in two) was closed with Vascular Closure Staples (VCS-clips). Four weeks after surgery, all ten blood vessels remained patent with no thrombosis. There was a well-healed wound with continuous intimal layer. The ureteral, gallbladder, and common bile duct wounds healed without leakage or obstruction in all animals. There was complete mucosal bridging of the wound, although in some specimens one or two clips were exposed to the lumen. The VCS-clips are easily and quickly applied and are safe insofar as can be determined by short-term follow-up.