F. Berrevoet

Outpatient Laparoscopic Cholecystectomy in Belgium: What Are we Waiting for?

Abstract Background: The current advances and expertise in minimally invasive surgery and the present importance of cost containment have encouraged the performance of laparoscopic cholecystectomy (LC) as an ambulatory procedure. A retrospective study was carried out to assess the feasibility, outcome and patients’ preference and satisfaction after performing true day-case LC in a university teaching hospital. Methods: All patients admitted consecutively between January 2003 and March 2005 for LC were considered for inclusion in the study. Patients were offered ambulatory treatment if they were ASA class 1 or 2, had no clinical signs of acute cholecystitis or pancreatitis, and had a responsible carer at home. All others underwent a routine LC. Reasons for refusing day-surgery LC were analyzed. Postoperative complications, conversion rate, overnight stay and patient satisfaction were all evaluated. Results: A total of 249 LCs were performed. Only 15 (6%) were performed in an ambulatory setting. Reasons for refusing day-surgery were medical (42%), doubt about reimbursement by insurance companies (15%) or psychological (49%). All patients were treated for symptomatic cholecystolithiasis. Unplanned admission was 13% because of excessive nausea and vomiting. Outpatient follow-up showed that overall patient satisfaction was over 80%. Conclusion: Considering an increasing trend towards reduced hospital stay, ambulatory LC is feasible and safe, showing high levels of patient satisfaction. Adequate prophylaxis of postoperative nausea, vomiting and pain management is necessary. However, the provision of adequate information to the patient by the referring physician is essential to avoid refusal of ambulatory treatment. Insurance companies have to be more liberal with their policies for day-case surgery.

Die Lebertransplantation mit Erhalt der Vena cava und einem temporären portocavalen Shunt

Summary. The experience with laterolateral cavocavostomy for hepatovenous reconstruction in liver transplantation is reviewed with and without the use of a temporary portocaval shunt. A total of 65 liver transplantations were analyzed. In 49 transplantations a laterolateral cavocaval anastomosis was performed (group I). In group II (n = 16) the same technique was used after a temporary portal caval shunt was constructed. Mean arterial pressure (mmHg): group I 128 ± 34; group II 109 ± 32. Cardiac output (l/min) decrease during the anhepatic phase was 2.3 ± 1.9 and 1.2 ± 1.5, respectively (P < 0.05). The peroperative blood loss measured as the number of packed cells transfused was 16.4 ± 15.8 versus 1.2 ± 2.3 (P < 0.04) and fresh frozen plasma 19.0 ± 14.7 versus 3.7 ± 4.0 (P < 0.02). Course on ICU (days), liver function tests, renal function and the need for reoperation because of bleeding were not statistically significantly different between the groups. One-year patient survival was 82.7 and 85.7 %, respectively. In conclusion, we found that despite preservation of the caval flow during hepatectomy, the additional use of a temporary portocaval shunt was advantageous with regard to peroperative hemorrhage and hemodynamic stability and can potentially facilitate implantation of the liver graft.Zusammenfassung. Die laterolaterale Cavocavostomie zur hepatovenösen Rekonstruktion bei der Lebertransplantation wird vorgestellt, mit und ohne Anlage eines temporären portocavalen Shunts. Insgesamt 65 Lebertransplantationen wurden analysiert. Bei 49 Transplantationen wurde eine laterolaterale cavocavale Anastomose angelegt (Gruppe I). Bei 16 weiteren Patienten (Gruppe II) wurde ein temporärer portocavaler Shunt während der Hepatektomie durchgeführt. Der gemittelte arterielle Blutdruck betrug in mmHg für Gruppe I 128 ± 34, in Gruppe II 109 ± 32. Das Herzzeitvolumen (l/min) reduzierte sich während der anhepatischen Phase bei Gruppe I um 2,3 ± 1,9 bei Gruppe II um 1,2 ± 1,5 (p < 0,05). Der perioperative Blutverlust gemessen an der Anzahl Erythrocytenkonzentrate betrug 16,4 ± 15,8 in Gruppe I versus 1,2 ± 2,3 in Gruppe II (p < 0,04) an der Anzahl Einheiten Frischplasma 19,0 ± 14,7 vs. 3,7 ± 4,0 (p < 0,02). Der Verbleib auf der Intensivstation in Tagen, die Leberfunktionsteste sowie die renale Funktion und die Häufigkeit erforderlicher Reoperationen wegen Blutung waren nicht statistisch signifikant unterschiedlich zwischen den beiden Gruppen. Die 1-Jahres-Überlebensrate betrug 82,7 % bzw. 85,7 %. Schlußfolgerung: Die Anlage eines temporären portocavalen Shunts kann bei der Cava-erhaltenden Hepatektomie und Spender-zu-Empfänger-Cavocavostomie zu besserer hämodynamischer Stabilität, weniger Blutverlust und vereinfachter Transplantatimplantation beitragen.

Open intraperitoneal mesh repair for umbilical hernias. A technical note.

Abstract Background: Mesh techniques are the preferable methods for repair of small ventral hernias, including umbilical and epigastric hernias, as primary suture repair shows high recurrence rates. Recently, the Ventralex™ (Davol Inc., C.R.Bard, Inc., RI, USA) hernia patch was introduced with promising preliminary short-term results. Methods: In this short technical note we describe both the surgical technique for adequate patch placement and the material characteristics of this device with associated pro’s and con’s. Conclusion: For small ventral hernia repair the Ventralex™ patch is a very elegant and quick to use mesh device. Although it is meant to be used intraperitoneally, it is also possible to place the patch in the preperitoneal space. However, probably due to the less controllable mesh deployment, and the interaction between the different materials, especially in the preperitoneal space, extra attention and some caution during placement is warranted using this device.

Klinik, Diagnostik und Therapie von Komplikationen an der hepato-venösen Anastomose nach orthotoper Lebertransplantation mit verschiedenen Anastomosierungs- techniken bei Erwachsenen und Kindern

Die cavo-cavale End-zu-End Anastomose nach orthotoper Lebertransplantation ist seltener mit Komplikationen behaftet als die arterielle oder portalvenose Anastomose aufgrund der Grose der Anastomose und des uneingeschrankten Blutflusses. Mit zunehmender Verwendung modifizierter Lebertransplantate sind auch veranderte Anastomosentechniken am hepatovenosen Ubergang in jungster Zeit beschrieben worden [1, 2, 3, 4, 7], uber deren Komplikationen wenig bekannt ist. Im folgenden soll die eigene Erfahrung mit derartigen Anastomosen im Hinblick auf Komplikationshaufigkeit und Therapiemoglichkeiten dargestellt und mit der klassischen End-zu-End Cavostomie verglichen werden.