Gary C. Vitale

Multipractice analysis of laparoscopic cholecystectomy in 1,983 patients

We analyzed the results of laparoscopic cholecystectomy in 1,983 patients from a variety of practice settings in order to evaluate a large, cross-sectional experience for this new procedure. Twenty general surgeons from 9 clinics in 4 states examined the records and outcome of their laparoscopic cholecystectomy patients through March 1991. In 88 patients (4.5%), the operation was converted to an open procedure, usually because of marked inflammation and unclear anatomy. A total of 644 cases were performed with laser dissection and 1,339 with cautery, and the results of these 2 methods were similar. There were 41 complications. Reoperation for repair was necessary in 18 patients, including 5 with common duct injuries, and, to date, the outcome has been good in each patient. Seventy-six patients (3.8%) have had recognized common duct stones; these were removed preoperatively by endoscopic sphincterotomy (ERS) in 20 patients, during cholecystectomy in 46 patients, and postoperatively by ERS in 4 patients. In six patients, common duct stones became apparent 1 to 4 months after cholecystectomy. We conclude that trained general surgeons can perform laparoscopic cholecystectomy safely with risks comparable to those for conventional open cholecystectomy.

Interruption of professional and home activity after laparoscopic cholecystectomy among French and American patients

With a laparoscopic approach, patients can undergo cholecystectomy with a shorter hospitalization, minimal pain, and quicker recovery. It has not been demonstrated, however, that patients actually return to work after laparoscopic cholecystectomy faster than the traditional 4- to 6-week absence from work after a standard open procedure. A survey of 104 French and 84 American patients undergoing laparoscopic cholecystectomy revealed that postoperative discomfort was completely resolved in 2 weeks in 73% of French and 93% of American patients. All but 11 French and 5 American patients were back to normal home activities by 2 weeks after the operation. Of the 35 American and 40 French patients who had professional activity outside the home, 63% and 25%, respectively, returned to work within 14 days. Five (14%) of the American patients and 12 (30%) of the French patients returned to work 4 weeks or more after the operation. The amount of physical activity on the job correlated with the period off work, but, interestingly, at least six patients with very hard physical activity at work (including construction workers) were able to return to full work activity within 1 week. These data suggest that early return to work is possible and that pain resolves quickly after laparoscopic cholecystectomy. The economic benefit of having patients back on the job quickly, however, may be less than expected until cultural norms change with regard to leave of absence after major surgery.

Peritoneal host defenses are less impaired by laparoscopy than by open operation.

There is a growing body of evidence that laparoscopic surgery is physiologically less injurious than open surgery. We hypothesized that the open technique results in a greater impairment of peritoneal and systemic defense mechanisms than does the laparoscopic technique. Nissen fundoplication, standardized in technique and duration, was performed in 16 pigs. The procedure was performed through a standard midline incision (OPEN, n=8) or with laparoscopic technique and CO2 pneumoperitoneum (LAP, n=8). The peritoneal cavity was instilled with 400 cc of normal saline, either alone (not contamined, n=8) or containing 109E. coli/ml (contaminated, n=8). Quantitative cultures, cell count, and flow cytometry were performed on blood and peritoneal fluid samples obtained at timed intervals. We found that host defense processes were better preserved after LAP than by OPEN surgery. Peritoneal and systemic monocyte class II antigen expression, and serum tumor necrosis factor-alpha activity was greater in the OPEN group compared with the LAP group, but peritoneal bacterial clearance was more efficient in the LAP group. These data may illustrate a potential benefit of laparoscopic surgery in cases of peritoneal contamination.

Computerized 24-hour ambulatory esophageal pH monitoring and esophagogastroduodenoscopy in the reflux patient. A comparative study.

Ambulatory 24-hour esophageal pH monitoring and esophagogastroduodenoscopy were performed in 72 patients with symptoms suggestive of gastroesophageal reflux. Additionally, 22 asymptomatic healthy volunteers underwent pH monitoring. In patients with classic reflux symptoms and endoscopic esophagitis, a mean of 5.41 minutes/hour of reflux below pH 4 was found compared to 0.70 minutes/hour in controls (p less than 0.0001). The mean number and duration of reflux events in this group were 1.51 events/hour and 4.0 minutes/event, compared with 0.31 events/hour and 2.26 minutes/event in volunteers (p less than 0.001, p less than 0.01). A new system for ambulatory esophageal pH monitoring is presented using a pH-sensitive radiotelemetry pill or a pH probe and computerized methods for ambulatory data collection, analysis, and storage. An overall sensitivity of 76% was obtained with a 91% selectivity for detection of acid reflux in 51 patients having classic symptoms of gastroesophageal reflux. Ambulatory pH monitoring was positive for acid reflux in seven of 11 patients with normal endoscopic findings. Conversely, eight of 12 patients with normal pH monitoring had endoscopic esophagitis. In 19 patients presenting with atypical symptoms or previous gastric surgery, endoscopic findings were normal in 15. Nine of these 15 were identified as acid refluxers by pH monitoring. A combined approach using both pH monitoring and endoscopy is warranted for maximal detection and quantification of disease. A clear clinical role for pH monitoring is seen in the early diagnosis of acid reflux, particularly in patients having normal endoscopic findings with nonspecific gastrointestinal complaints or previous gastric operations.

Prophylactic postoperative nasogastric decompression. A prospective study of its requirement and the influence of cimetidine in 200 patients.

To determine the need for prophylactic nasogastric decompression following laparotomy and the influence of cimetidine, 200 consecutive patients who underwent major abdominal procedures were prospectively randomized into one of four limbs: no tube-placebo; no tube-cimetidine; tube-placebo; and tube-cimetidine. Patients were evenly distributed among these groups with respect to age, sex, alcohol and tobacco use, previous operations, and types of operations. There was significantly longer time until passage of flatus, bowel movement, and cessation of intravenous fluids in the tube group (p less than 0.05). Duration of postoperative stay increased from 11.4 to 14.1 days in the intubated patients (p less than 0.05). There was also significantly more pain with and frequency of swallowing, and nose/throat discomfort in the tube group. Nasogastric tubes reduced the incidence of vomiting from 28 in the no-tube group to 10 in the tube group (p less than 0.05), but most had only one or two episodes. Cimetidine did not affect either the incidence of vomiting or the duration of intubation, but was associated with a significant increase in pneumonias (p less than 0.05). Five patients without tubes initially, and seven patients with tubes had to have them inserted or replaced for vomiting or abdominal distention, which occurred equally in the placebo and cimetidine limbs. There were no cases of aspiration pneumonia, gastric dilatation, or wound dehiscence in the trial, and the four anastomotic leaks were divided equally between the tube and no-tube groups. The results indicated that prophylactic decompression was unnecessary in most patients and associated with increased morbidity and delayed return of gastrointestinal function. Cimetidine lowered nasogastric output on the first postoperative day (p less than 0.05), but did not prevent vomiting.

Endoscopic treatment of distal bile duct stricture from chronic pancreatitis

AbstractBackground: Endoscopic placement of biliary stents is an effective initial treatment for jaundice and cholangitis caused by common bile duct (CBD) strictures secondary to chronic pancreatitis; however, the role of endoscopic treatment for long-term management of these strictures is less clear. In 1992, we designed a protocol of balloon dilatation and stenting for ≥12 months. This study evaluates endoscopic therapy as a definitive long-term treatment for these strictures. We have treated 25 patients with this protocol. Methods: All patients had an endoscopic sphincterotomy, balloon dilatation of the stricture, and then placement of a polyethylene stent (7–11.5 F). Stents were exchanged at 3–4-month intervals to avoid the complications of clogging and cholangitis. We were particularly interested in how many patients would achieve resolution of the stricture and tolerate removal of the stent. Results: The length of the CBD strictures ranged from 8 to 40 mm. Within days of stenting, all patients achieved relief of jaundice and cholestasis. Complications consisted of six episodes of cholangitis and nine episodes of pancreatitis. There were no deaths. Twenty of the 25 patients are now stent-free after an average stenting period of 13 months (range, 3–28). To date, there has been no recurrence of stricture, for a mean of 32 months. Three patients still have stents in place, and two patients required operation—one for persistent stricture and recurrent cholangitis after 8 months of stenting, and one for a mass in the head of the pancreas that was thought to be cancer. Conclusions: Our results indicate that these strictures will respond and dilate after a course of stenting in 80% of patients, with an acceptable morbidity. Although these are medium-term results at 32 months, we would expect most recurrences within the 1st year following stent removal. In some cases, stenting is necessary for >12 months. Thus, the data suggest that endoscopic stenting provides definitive treatment in most patients with CBD stricture due to chronic pancreatitis and may be considered a viable alternative to standard surgical bypass.

The injured colon: relationships of management to complications.

One hundred thirty-seven patients who sustained intraperitoneal colon wounds were admitted to the University of Louisville Hospital during the three-year period ending December 31, 1979. One hundred twenty penetrating wounds and 17 blunt injuries were treated. An intraoperative classification system was employed, in which Grade 1 injuries were characterized by minimal contamination, the absence of associated organ injuries, minimal shock, and no significant delay between injury and definitive operation. All of these were managed by single-layer closure. More severe wounds were treated by colostomy or exteriorization. The overwhelming majority of the patients (116) sustained Grade 2 injuries. Twenty-two patients (16%) died. Nine deaths (6% of the patients) were directly attributable to the colon wounds. Twenty-five Grade 1 injuries were treated by primary suture closure with a single complication (3% of the patients). Nine wounds were exteriorized for later reinsertion into the peritoneal cavity, but only two patients were spared colostomy by this method. Right colon injuries were, clearly, more severe than left or sigmoid colon wounds. Intraoperative classification allowed selection of a group of patients in whom suture repair was safe. Colostomy was associated with the lowest complication rate for Grade 2 and 3 wounds.

Endoscopic drainage of the pancreatic pseudocyst

BACKGROUND Pancreatic pseudocyst is a common complication of chronic pancreatitis occurring in 20% to 40% of cases. Pseudocysts can be treated by endoscopic cystenterostomy or transpapillary drainage, percutaneously with computed tomography guidance or operatively. METHODS A total of 36 endoscopic pancreatic pseudocyst drainage procedures were performed in 29 patients with 34 pseudocysts. Eighty percent presented with chronic pain, 25% had recurrent pancreatitis, and approximately one half of the patients had either gastric outlet obstruction or a palpable abdominal mass. RESULTS Thirty-six endoscopic drainage procedures were performed, 27 cystenterostomies and 9 transpapillary drainages. Endoscopic treatment achieved complete resolution of the pseudocyst in 24 of 29 patients (83%), and the other 5 (17%) eventually required surgery. Two patients required distal pancreatectomy because of their pancreatic pathology, 2 cystgastrostomies for persistence of the pseudocyst, and 1 external drainage of an infected pancreatic cyst. The mean follow-up after the initial drainage was 16 months. There were no deaths attributed to the procedures and no complication that required surgery. Only 1 nonadherent pseudocyst (cystadenoma) required immediate operation after attempted endoscopic drainage. CONCLUSIONS The conclude that endoscopic drainage of pancreatic pseudocysts can be both safe and effective, and definitive treatment. It should be considered as an alternative option before standard surgical drainage in selected patients.

Selective role for endoscopic retrograde cholangiopancreatography in abdominal trauma

AbstractBackground: Emergency endsocopic retrograde cholangiopancreatography (ERCP) is rarely indicated in trauma patients; however, in cases of suspected pancreatic or bile duct injury or bile leak, it may be useful. The purpose of this paper is to review our ERCP experience in trauma patients. Our Level I Trauma Center admits 1800 patients annually. Methods: Since January 1991, we have performed ERCP in 12 trauma patients, nine after blunt injury and three after penetrating injury. Results: ERCP was used as a diagnostic tool to evaluate the pancreatic duct in six stable patients with equivocal CT scans and unexplained abdominal pain, fever, and an elevated amylase or a peripancreatic pseudocyst. Based on their ERCP findings—one intact pancreatic duct, one transected duct, and four pseudocysts—five of the six patients had operations.We performed ERCP in six patients for persistent bile leaks (five cases) or jaundice (one case). The findings were one case of bilemia (intrahepatic biliovenous fistula), one case of common bile duct disruption, and four cases of persistent bile leaks from the liver after liver injuries. Endobiliary stents placed in five patients successfully stopped the four bile leaks and closed the biliovenous fistula. The one case of ductal disruption required an open choledochojejunostomy. The only ERCP complication was an episode of cholangitis treated with antibiotics. The earliest ERCP was 3 days after injury, and most were performed within 2 months. Conclusions: ERCP is a helpful procedure for diagnosing biliary and pancreatic duct injury in a select group of trauma patients who do not have obvious indications for exploration. In addition, ERCP techniques are also effective for treating most bile leaks.

The use of ERCP in the management of common bile duct stones in patients undergoing laparoscopic cholecystectomy.

SummaryThe purpose of this study was to evaluate the indications and results of endoscopic retrograde cholangiopancreatography (ERCP) for gallstone disease since the advent of laparoscopic cholecystectomy. In our personal series of 410 consecutive cases of laparoscopic cholecystectomy, we found 17 common bile duct (CBD) stones; seven were identified by preop ERCP, nine at laparoscopy by intraoperative cholangiography, and one postop by ERCP. We have performed preop ERCP in 21 patients (5.1%); CBD stones were found in seven. Our indications for preop ERCP were elevated liver function tests, dilatation of the common duct by ultrasound, or a history of jaundice/pancreatitis, and all stones were successfully removed by endoscopic sphincterotomy. At laparoscopic cholecystectomy nine patients were found to have stones; one was treated with laparoscopic methods, four with open CBD exploration, and four by postop endoscopic sphincterotomy. Post-laparoscopic cholecystectomy, five patients underwent ERCP for pain or increased liver function tests suggestive of common duct stones. One of the five was found to have stones and these were successfully removed by endoscopic sphincterotomy. ERCP is very useful as a diagnostic and therapeutic modality in laparoscopic cholecystectomy patients with suspected CBD stones. Elevated liver function tests and dilated CBD by ultrasound are the most accurate predictors of stones. Endoscopic sphincterotomy is a more effective route, at present, for stone removal than a laparoscopic approach.