Ioannis Baloyiannis

Is there a role for drain use in elective laparoscopic cholecystectomy? A controlled randomized trial

BACKGROUND Although the issue of drain use in open cholecystectomy has been adequately addressed by prospective randomized trials, there is lack of evidence on the usefulness of drains in elective laparoscopic cholecystectomy, and the surgeons follow their beliefs and bias on this debate. Therefore, a controlled randomized trial was designed to assess the value of drains in elective laparoscopic cholecystectomy. METHODS During a 5-year period (January 2002 to December 2006), 284 patients were randomized to have a drain placed (group A), whereas 281 patients were randomized not to have a drain (group B) placed in the subhepatic space. End points of this trial were to detect any differences in morbidity, postoperative pain, and hospital stay between the 2 groups. RESULTS There was no mortality in either group and no statistically significant difference in morbidity or hospital stay between the 2 groups. However, postoperative pain was significantly increased in patients who had a drain placed; median visual analog scale (VAS) score was 5 (range 1 to 8) versus 3 (range 1 to 8), in the non-drained group (P < .0001). Interestingly, in 2 of 3 patients in whom a drain was placed against randomization because of bile leak suspicion, a bile leak occurred. CONCLUSIONS The routine use of a drain in elective laparoscopic cholecystectomy has nothing to offer; in contrast, it is associated with increased pain. It would be reasonable, however, to leave a drain if there is a worry about an unsolved or potential bile leak, bearing in mind that drain placement, although sometimes providing a false sense of security, does not guarantee either prevention or treatment of postoperative bile collections, bleeding, or bile peritonitis.

Laparoendoscopic rendezvous versus preoperative ERCP and laparoscopic cholecystectomy for the management of cholecysto-choledocholithiasis: interim analysis of a controlled randomized trial.

Background:Although the ideal management of cholecysto-choledocholi-thiasis is controversial, the 2-stage approach [endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and common bile duct (CBD) clearance followed by laparoscopic cholecystectomy] remains the standard way of management worldwide. One-stage approach using the so-called laparoendoscopic rendezvous (LERV) technique offers some advantages, mainly by reducing the hospital stay and the risk of post-ERCP pancreatitis. Objective:To compare the LERV 1-stage approach with the standard 2-stage approach consisting of preoperative ERCP followed by laparoscopic cholecystectomy for the treatment of cholecysto-choledocholithiasis. Setting:Controlled randomized trial, University/Teaching Hospital. Methods:Patients with cholecysto-choledocholithiasis were randomized either to LERV or to the 2-stage approach. Both elective and emergency cases were included in the study. Primary endpoint was to detect difference in overall hospital stay, whereas secondary endpoints were (i) to detect differences in morbidity (especially post-ERCP pancreatitis) and (ii) success of CBD clearance. This is an interim analysis of the first 100 randomized patients. Results:Hospital stay was significantly shorter in the LERV group; median 4 (2–19) days versus 5.5 (3–22) days, P = 0.0004. There was no difference in morbidity and success of CBD clearance between the 2 groups. Post-ERCP amylase value was found significantly lower in the LERV group: median 65 (16–1159) versus 91 (30–1846), P = 0.02. Conclusions:Interim analysis of the results suggests the superiority of the LERV technique in terms of hospital stay and post-ERCP hyperamylasemia.

Laparoscopic appendectomy : Differences between male and female patients with suspected acute appendicitis

BackgroundThe role of laparoscopy in the management of patients with suspected acute appendicitis remains controversial. It has been suggested that laparoscopy is useful mainly in young women of reproductive age because of the high incidence of wrong diagnosis in these patients.MethodsDifferent management protocols for patients with suspected acute appendicitis were prospectively used in male and female patients; women of reproductive age were treated laparoscopically, while men were randomised to open or laparoscopic appendectomy.ResultsFrom September 2002 to September 2005, 132 patients—54 women and 78 men—with suspected acute appendicitis were treated according to the protocol. The incidence of wrong diagnosis in female patients was high (26% and the conversion rate low (5.5%). In contrast, in the laparoscopic male subgroup, these rates showed a reverse relationship (5.2% and 18.5%, respectively). Morbidity did not differ between female and male patients or between the 2 arms of the male group. Laparoscopic appendectomy took longer to perform without affecting significantly the needs for postoperative analgesia, the duration of hospital stay and the time to return to normal activities when compared with open appendectomy in men.ConclusionLaparoscopic appendectomy is at least as safe as the open procedure in the male population, although it does not appear to offer any obvious advantage over the open procedure. The diagnostic advantage that laparoscopy offers to fertile women makes the procedure attractive for this population.

Laparoscopic transabdominal preperitoneal repair of inguinal hernia under spinal anesthesia: a pilot study

BACKGROUND The laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is an evolving technique associated with the well-known advantages of a minimally invasive approach. However, general anesthesia is routinely required for the procedure. Based on our previous experience in regional anesthesia for laparoscopic procedures, we designed a pilot study to assess the feasibility and safety of performing laparoscopic TAPP repair under spinal anesthesia. METHODS Forty-five American Society of Anesthesiologists I or II patients with a total of 50 inguinal hernias underwent TAPP repair under spinal anesthesia, using a low-pressure CO(2) pneumoperitoneum. Five patients had bilateral hernias, and 4 patients had recurrent hernias. Thirty hernias were indirect and the remaining direct. Intraoperative incidents, postoperative pain complications, and recovery in general as well as patient satisfaction at the follow-up examination were prospectively recorded. RESULTS There was 1 conversion from spinal to general anesthesia and 2 conversions from laparoscopic to the open procedure at a median operative time of 50 minutes (range 30-130). Ten patients complained of shoulder pain during the procedure, and 6 patients suffered hypotension intraoperatively. The median pain score (visual analog scale) was 1 (0-5) at 4 hours after the completion of the procedure, 1.5 (0-6) at 8 hours, and 1.5 (0-5) at 24 hours, and the median hospital stay was 1 day (range 1-2). Sixteen patients had urinary retention requiring instant catheterization. At a median follow-up of 20 months (range 10 months-28 months), no recurrence was detected. CONCLUSIONS TAPP repair is feasible and safe under spinal anesthesia. However, it seems to be associated with a high incidence of urinary retention. Further studies are required to validate this technique.

Current status of laparoendoscopic rendezvous in the treatment of cholelithiasis with concomitant choledocholithiasis.

The current evidence in favor of the laparoendoscopic rendezvous is promising and demonstrates the main advantages of this technique in regard to shorter hospital stay and selective cannulation of the common bile duct (CBD), avoiding thus the inadvertent cannulation of the pancreatic duct. In addition, in the rendezvous technique the contrast medium is not injected retrogradely as during the traditional endoscopic retrograde cholangiopancreatography (ERCP), when the medium accidentally could be injected under pressure into the pancreatic duct. The RV technique minimizes that risk. Both these main advantages of the RV technique over the classic ERCP, are related with a significant lower incidence of hyperamylasemia and post-ERCP pancreatitis, compared with the traditional two stage procedure. Choledocholithiasis is present in 10% to 15% of patients undergoing cholecystectomy. To date, the ideal management of CBD stones remains controversial. Prospective randomized trials have shown that laparoscopic management of the CBD stones, as a single stage procedure, is the most efficient and cost effective method of treatment. Laparoendoscopic rendezvous has been proposed as an alternative single stage approach. Several studies have shown the effective use of this technique in the treatment of CBD stones by improving patient compliance and clinical results including shorter hospital stay, higher success rate and less cost. The current evidence about the use of this technique presented in this review article is promising and demonstrates the main advantages of the procedure.

Loop stomas with a subcutaneously placed bridge device

AimTo describe and evaluate a new technique for supporting a loop stoma with a simple removable subcutaneous bridge device.MethodsFifty-five patients underwent a procedure resulting in a loop stoma. Thirty patients had a loop colostomy and twenty-five a loop ileostomy. In all cases, the stoma was supported with a removable subcutaneous redivac drain fixed to the skin.ResultsThere was no incidence of mechanical obstruction, stenosis, retraction, mucosal erosion or subcutaneous infection. Daily cleaning and care of the stoma was very simple, and the removal of the bridge device was carried out without opening the collecting bag.ConclusionOur proposed technique is safe and feasible without considerable complications.

Spontaneous expulsion from rectum: a rare presentation of intestinal lipomas

Lipomas are rare, subserosal, usually solitary, pedunculated small lesions appearing mainly in the large intestine with a minimal malignancy potential. They usually run asymptomatic and become symptomatic when they become enlarged or complicated causing intestinal obstruction, perforation, intusucception or massive bleeding. In rare cases they can be self-detached and expulsed via the rectum as fleshy masses. This event mainly occurs in large, pendunculated lipomas which detach from their pedicle. The reason for this event remains in most of cases unclear although in some cases a predisposing factor does exist. Abdominal pain and obstructive ileus may be observed while in many cases bleeding occurs. The expulsed mass sets the diagnosis and in most of the cases all symptoms subside. Diagnosis is rarely established before surgery with the use of barium enema, computed tomography and colonoscopy which additionally provides measures of treatment and diagnosis. In atypical cases though, in cases where the malignancy can not be excluded or in complicated cases, surgery is recommended. Usually the resection of the affected intestinal part is adequate. If during surgery a lipoma is encountered simple lipomatectomy seems also to be adequate.

Laparoscopic ventral hernia repair in obese patients under spinal anesthesia

PURPOSE The aim of the present study was to evaluate the feasibility and efficacy of laparoscopic ventral hernia repair under spinal anesthesia in obese patients (BMI > 30 kg/m(2)). METHODS From January 2007 to February 2010, 23 obese patients had their elective laparoscopic ventral hernia repair under spinal anesthesia. We looked primarily for intra-operative incidences as well as immediate postoperative complications. Long term results and especially recurrences were also to be evaluated. RESULTS Median operative time was 55 min (range 20-100). Intraoperatively, six patients (26%) complained of shoulder pain, three patients (13%) developed bradycardia and two (8.7%) hypotension. Postoperatively, nausea and/or vomiting were recorded in four patients (17.4%), four patients (17.4%) experienced urinary retention and one patient developed wound infection. Median pain score at 4th, 8th and 24th postoperative hour was 0.5 (0-5), 1.5 (0-6), and 1.5 (0-5) respectively. The median length of hospital stay was one day (1-2). At a median follow up of 39 months, one patient was diagnosed with a recurrence. CONCLUSION Spinal anesthesia for LVHR in obese patients (BMI > 30 kg/m(2)) proved an efficient and safe alternative to general anesthesia in the given patient sample.

Ingested Fish Bone: An Unusual Mechanism of Duodenal Perforation and Pancreatic Trauma

Ingestion of gastrointestinal foreign bodies represents a challenging clinical scenario. Increased morbidity is the price for the delayed diagnosis of complications and timely treatment. We present a case of 57-year-old female patient which was admitted in the emergency room department complaining of a mid-epigastric pain over the last twenty-four hours. Based on the patients history, physical examination and elevated serum amylase levels, a false diagnosis of pancreatitis, was initially adopted. However, a CT scan confirmed the presence of a radiopaque foreign body in the pancreatic head and the presence of air bubbles outside the intestinal lumen. The patient was unaware of the ingestion of the foreign body. At laparotomy, after an oblique duodenotomy, a fish bone pinned in the pancreatic head after the penetration of the medial aspect of the second portion of the duodenal wall was identified and successfully removed. The patient had an uneventful postoperative recovery. Wide variation in clinical presentation characterizes the complicated fish bone ingestions. The strategically located site of penetration in the visceral wall is responsible for the often extraordinary gastrointestinal tract injury patterns. Increased level of suspicion is of paramount importance for the timely diagnosis and treatment.

Rib fractures with heamothorax after labor: a case report

IntroductionMaternal thoracic trauma during labor is extremely rare.Case presentationA woman was presented at the Accident and Emergency Department complaining of pain over the lower thorax bilaterally which started after a difficult delivery when the obstetrician forced her lower thorax. Small right-sided haemothorax and rib fractures bilaterally were diagnosed and she was admitted to hospital. Her in-hospital stay and follow up was uneventful.ConclusionManeuvers during labor should be applied from trained personnel and should be performed safely.