Gerald M. Larson

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.

Plastic Mesh Repair of Incisional Hernias

During eight years polypropylene mesh was used in fifty-three patients for the repair of difficult incisional hernias. There was no operative mortality, and the mesh has been uniformly well tolerated. To date, recurrences have been observed in six patients (11.3%), a distinct improvement over the era before mesh was used. Greater attention to the details of mesh fixation may further lower the recurrence rate.

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.

Approaches to Repair of Ventral Hernia and Full-Thickness Losses of the Abdominal Wall

This article describes the causes, course, and treatment options for surgical repair of umbilical epigastric and incisional hernias. Special attention is paid to the full-thickness abdominal wall defects, which are particularly difficult wounds to close. A method of closure with Marlex mesh, followed by myocutaneous flap coverage, is discussed.

Delayed gastric emptying after gastric surgery

BACKGROUND The reported incidence of delayed gastric emptying (DGE) after gastric surgery is 5% to 25% and usually is based on operations for peptic ulcer disease. Ongoing improvements in perioperative care, nutritional support, and new prokinetic drugs may have had a beneficial effect on the frequency and course of postoperative DGE. METHODS We therefore studied our recent experience with DGE in 416 patients who had gastric surgery for ulcer disease (283), cancer (92), or trauma and other indications (41) between January 1985 and December 1993. DGE was defined as inability to eat a regular diet by postoperative day 10. RESULTS DGE occurred in 99 of 416 patients (24%). In 75 of these 99 patients, a postoperative contributing factor for DGE was identified. These factors were sepsis (32), anastomotic edema and leaks (23), obstruction (4), pancreatitis (3), multiple system organ failure (5), and miscellaneous conditions (8). In 24 patients there was no obvious cause for DGE; these patients recovered with nutritional support and time. Re-operation specifically for gastric stasis was not performed. Among the 99 patients with DGE, 67% were eating by day 21, 92% by 6 weeks, and 100% by 10 weeks. Significant risk factors for DGE were diabetes (55%), malnutrition (44%), and operations for malignancy (38%). The Whipple procedure had the highest incidence of DGE (70%), highly selective vagotomy the lowest (0%), while truncal vagotomy had no significant effect. The response to metoclopramide was 20% and unpredictable. CONCLUSION DGE continues to affect a considerable number of our patients (24%) after gastric surgery and is particularly common in patients with diabetes, malnutrition, and gastric or pancreatic cancer. However, gastric motility does return in 3 to 6 weeks in most patients and the need for re-operation for gastric stasis is rare.

Impact of multiple risk factors and ranitidine prophylaxis on the development of stress-related upper gastrointestinal bleeding : a prospective, multicenter, double-blind, randomized trial

OBJECTIVES To evaluate the impact of risk factors on the development of stress-related upper gastrointestinal bleeding in severe head injury patients randomized to treatment with a 6.25 mg/hr continuous ranitidine infusion or placebo. DESIGN Prospective, multicenter, randomized, double-blind, placebo-controlled, parallel-group study. SETTING Ten intensive care units in the United States. PATIENTS Patients with severe head injury, defined as having a Glasgow Coma Score of < or = 10, were eligible for enrollment. INTERVENTIONS Ranitidine 6.25 mg/hr or saline placebo was administered by continuous infusion for a maximum of 5 days. MEASUREMENTS AND MAIN RESULTS Patients were evaluated every 8 hrs for the presence of stress-related upper gastrointestinal bleeding. Bleeding developed in 15 (19%) of 81 placebo-treated patients vs. three (3%) of 86 ranitidine-treated patients (p = .002). None of the individual risk factors had a significant effect on bleeding frequency. No bleeding occurred in the four patients with one risk factor. Placebo bleeding rates in patients with 2, 3 to 5, and > 5 risk factors were 20%, 20%, and 18%, respectively. For the ranitidine-treated patients, bleeding was reported in 0%, 5%, and 0% in the 2, 3 to 5, and > 5 risk factor subgroups, respectively. Pneumonia occurred in 19% of the placebo-treated patients vs. 14% in the ranitidine treatment group. CONCLUSIONS The full risk to develop stress-related upper gastrointestinal bleeding was realized when two risk factors were present concomitantly. The presence of additional risk factors did not increase the occurrence of bleeding. A continuous infusion of ranitidine at 6.25 mg/hr provided significant protection from bleeding, regardless of the number of risk factors present.

VENTRAL HERNIA REPAIR BY THE LAPAROSCOPIC APPROACH

An analysis of these results indicates that laparoscopic hernia repair can be performed safely by experienced laparoscopic surgeons, and with lower perioperative complication rates than for open hernia repair. Although the follow-up period for the laparoscopic repair is only 2 or 3 years, the recurrence rate is likely lower than with open repair. Most patients with ventral hernias are candidates for this laparoscopic repair if safe access and trocar placement can be obtained. The choice of mesh often provokes a debate among surgeons, but little practical difference in the results seems to exist between the two types of mesh available. Although the ePTFE mesh has a good theoretic basis for promoting tissue ingrowth on the parietal side of the mesh and minimizing adhesions to the bowel side of the mesh, data indicate that no difference in outcome exists related to adhesions or fistula formation (Tables 1 and 2), so surgeon preference and cost of the prosthesis should be the deciding variables. Fistulas are of concern because of the experience with mesh in the trauma patient and in the treatment of severe abdominal wall infections, when abdominal wall reconstruction often is performed in contaminated wounds in the acute phases and leaves the mesh exposed without soft tissue coverage. These conditions do not apply for most cases of elective hernia repair. Laparoscopic ventral hernia repair offers advantages over the conventional open mesh repair and may decrease the hernia recurrence rate to 10% to 15%. When properly performed, the laparoscopic approach does not and should not compromise the principles for successful mesh repair of ventral hernias.

Intrathoracic fundoplication for shortened esophagus: Treacherous solution to a challenging problem

Intrathoracic fundoplication was used in 12 patients with acquired shortening of the esophagus secondary to gastroesophageal reflux. While several patients had excellent results using this approach, five major complications occurred. One patient developed a paraesophageal hernia, while four had ulceration within the wrap itself. One had serious hemorrhage, while another required reoperation to dismantle the intrathoracic wrap. One patient developed a gastrobronchial fistula and eventually died from pulmonary sepsis. The cause of these problems is unknown, but delayed gastric emptying was implicated in two patients. Even though leaving a Nissen fundoplication in the chest seems to be an attractive alternative when the surgeon cannot reduce the wrap below the diaphragm, this alternative is fraught with treacherous complications in a large percentage of patients.

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.