Franklin H. G. Bridgewater

A systematic review of laparoscopic live-donor nephrectomy

Background. A systematic review was undertaken to assess the safety and efficacy of laparoscopic live-donor nephrectomy (LLDN) compared with open live-donor nephrectomy (OLDN). Methods. Literature databases were searched from inception to March 2003 inclusive. Comparative studies of LLDN versus OLDN (randomized and nonrandomized) were included. Results. There were 44 included studies, and the quality of the available evidence was average. There was only one randomized controlled trial and six nonrandomized comparative studies with concurrent controls identified. In terms of safety, for donors, there did not seem to be any distinct difference between the laparoscopic and open approaches. No donor mortality was reported for either procedure, and the complication rates were similar although the types of complications experienced differed between the two procedures. The conversion rate for LLDN to an open procedure ranged from 0% to 13%. In terms of efficacy, LLDN seemed to be a slower operation with longer warm ischemia times than OLDN, but this did not seem to have resulted in increased rates of delayed graft function for recipients. Donor postoperative recovery and convalescence seemed to be superior for LLDN, making it a potentially more attractive operation for living donors. Although in the short-term, graft function and survival did not seem to differ between the two techniques, long-term complication rates and allograft function could not be determined and further long-term follow-up is required. Conclusions. LLDN seems to be at least as safe and efficacious as OLDN in the short-term. However, it remains a technique in evolution. Further high-quality studies are required to resolve some of the outstanding issues surrounding its use, in particular, long-term follow-up of donor complications and recipient graft function and survival.

Safety and Efficacy of Nontherapeutic Male Circumcision: A Systematic Review

PURPOSE We wanted to assess the safety and efficacy of nontherapeutic male circumcision through a systematic review of the literature. METHODS We systematically searched The York Centre for Reviews and Disseminations, Cochrane Library, PubMed, and EMBASE databases for randomized controlled trials published between January 1997 and August 2008. Studies reporting on circumcision in an operative setting in males of any age with no contraindications to or medical indications for circumcision were eligible for inclusion. The main comparator was intact genitalia. From 73 retrieved studies, 8 randomized controlled trials were ultimately included for analysis. RESULTS Severe complications were uncommon. Analgesia/anesthesia during circumcision was promoted. The prevalence of self-reported genital ulcers was significantly lower in circumcised men than uncircumcised men (3.1% vs 5.8%; prevalence risk ratio 0.53; 95% confidence interval [CI], 0.43–0.64; P<.001). Circumcised sub-Saharan African men were at significantly lower risk of acquiring human immunodeficiency virus/acquired immune deficiency syndrome than were uncircumcised men (random effects odds ratio = 0.44, 95% CI, 0.32–0.59; P <.001). The evidence suggests that adult circumcision does not affect sexual satisfaction and function. CONCLUSIONS Strong evidence suggests circumcision can prevent human immunodeficiency virus/acquired immune deficiency syndrome acquisition in sub-Saharan African men. These findings remain uncertain in men residing in other countries. The role of adult nontherapeutic male circumcision in preventing sexually transmitted infections, urinary tract infections, and penile cancer remains unclear. Current evidence fails to recommend widespread neonatal circumcision for these purposes.

Useless and dangerous—fine needle aspiration of hepatic colorectal metastases

Fine needle aspiration cytology (FNAC) is an established tool for diagnosing liver tumours. It has recognised complications, however. Use of the procedure in abdominal tumours is fatal in 0.006 to 0.031% of cases.1 2 Most deaths occur with liver tumours and are due to haemorrhage. Another complication is that metastases can seed along biopsy needle tracts, although this has been reported to be rare, with an incidence of 0.003% to 0.07%, mostly from pancreatic tumours.1 2 More recently, much higher rates (0.4% to 5.1%) of needle tract metastases have been reported when FNAC is used in liver lesions, usually for primary liver tumours.3–7 Only 13 cases of needle tract colorectal metastases caused by FNAC in liver lesions are described in journals listed in Medline.7–13 Several authors have commented that the procedure should be avoided because of the risk of this complication. A further similar case is reported here, extending the contraindication of FNAC in hepatic tumours to include lesions for which no primary malignancy has been found. Therefore in Western populations, in which primary liver malignancy is rare, the diagnosis of apparently malignant liver lesions should centre on searching for the primary tumour, rather than on FNAC of the lesion. A 78 year old man presenting with back pain was found on computed tomography of his abdomen to have a lesion in the right lobe of his liver. FNAC of the lesion was done without referral to a surgeon, …

Systematic review of congenital and acquired portal-systemic shunts in otherwise normal livers.

Portal‐systemic shunts (PSSs) are rarely seen in healthy individuals or patients with non‐cirrhotic liver disease. They may play an important role in hepatic metabolism as well as in the spread of gastrointestinal metastatic tumours to specific organs. Small spontaneous PSSs may be more common than generally thought. However, epidemiological data are scarce and inconclusive. This systematic review examined the prevalence of reported PSSs and the associated detection methods.

Technical Note: Facilitating Laparoscopic Liver Biopsy by the Use of a Single-Handed Disposable Core Biopsy Needle

Despite the use of advanced radiological investigations, some liver lesions cannot be definitely diagnosed without a biopsy and histological examination. Laparoscopic Tru-Cut biopsy of the liver lesion is the preferred approach to achieve a good sample for histology. The mechanism of a Tru-Cut biopsy needle needs the use of both hands to load and fire the needle. This restricts the ability of the surgeon to direct the needle into the lesion utilising the laparoscopic ultrasound probe. We report a technique of laparoscopic liver biopsy using a disposable core biopsy instrument (BARD (R) disposable core biopsy needle) that can be used single-handedly. The needle can be positioned with laparoscopic graspers in order to reach posterior and superior lesions. This technique can easily be used in conjunction with laparoscopic ultrasound.

Painless Obstructive Jaundice Secondary to a Common Bile Duct Abscess: A Delayed Sequela of Cholecystectomy

Complications related to cholecystectomy are well described. Most occur in the early postoperative period and are recognised either at the time of, or shortly after surgery. Clinical sequelae occurring years following cholecystectomy are rare and infrequently reported. In addition, most delayed complications are related to the continuing presence or new formation of gallstones. In this paper we present a unique case of an abscess of the common bile duct wall, presenting with painless obstructive jaundice more than 30 years following an open cholecystectomy, without the presence of gallstones. The clinical presentation, investigations, and treatment are discussed with a review of other relevant reported cases in the literature.

Acute upper gastrointestinal haemorrhage resulting in transient hepatic failure following liver resection

BACKGROUND Both acute stress ulcer and liver failure are well-known complications of hepatic resection. This case study documents how an episode of postoperative gastrointestinal haemorrhage can provoke transient hepatic failure. CASE OUTLINE A 66-year-old woman with no previous history of reflux oesophagitis or peptic ulcer disease underwent a right liver resection for a solitary metastasis. On the fifth postoperative day, with a small premonitory haematemesis, she was started on omeprazole intravenously. She subsequently required blood transfusion and endoscopy; a bleeding acute gastric ulcer was injected with adrenalin. She then progressed to acute liver failure with associated hepatic encephalopathy but made a full recovery. DISCUSSION Adverse effects of prophylactic H(2) receptor antagonists have included liver failure and hepatitis, and animal studies have shown inhibition of liver regeneration after hepatectomy. Proton pump inhibitors (PPIs) have an acceptable profile of adverse events and their effect on liver regeneration appears to be favourable. Given the serious potential for liver failure in the event of significant bleeding, a PPI is advocated for routine prophylaxis against acute stress ulceration in all major liver resections.