P. M. Y. Goh

Predictive factors for conversion of laparoscopic cholecystectomy.

Abstract Reliable predictive factors for conversion of laparoscopic cholecystectomy (LC) would be extremely useful in the preparation and planning of admission for patients with symptomatic cholelithiasis. Data from 783 patients in whom LC was attempted in a university clinic from June 1990 to December 1995 were retrospectively analyzed. The aim of this study was to determine preoperative indicators that can be useful for predicting conversion to open cholecystectomy (OC). Conversion was required in 58 (7.4%) patients, of which 48 (83%) were elective and 10 (17%) emergency. Factors evaluated were age, sex, obesity, duration of gallstone disease, co-morbid factors, indication for surgery, previous abdominal surgery, fever, physical examination findings, white blood cell (WBC) count, liver function tests, ultrasound findings, and the experience of the surgeon. Acute cholecystitis, rigidity in the right upper abdomen, fever, thickened gallbladder wall on ultrasonography, elevated alkaline phosphatase (ALP), liver transaminases and the WBC count were significant predictors of conversion in the univariate analysis. Multivariate logistic regression analysis on these significant predictors showed that acute cholecystitis [odds ratio (OR) = 3.12], thickened gallbladder wall on ultrasonography (OR = 3.75), elevated ALP (OR = 2.23), and WBC count (OR = 3.69) were jointly significant.

Expression of nitric oxide synthase, cyclooxygenase, and p53 in different stages of human gastric cancer

The present study evaluated the significance of nitric oxide synthase (NOS), cyclooxygenase (COX) expression and p53 status in 55 patients with gastric adenocarcinoma and relationship of these molecular markers to tumor characteristics and metastatic potential. Immunohistochemical technique was used to identify the cellular location and distribution of the enzymes in the specific cells of gastric tumors. In gastric cancer tissue, the expression of inducible enzymes, iNOS and COX-2, increased significantly with increasing tumor stage (P=0.015, P=0.001, respectively), size (P=0.025, P=0.001, respectively) and the presence of metastases (P=0.002, P=0.015, respectively). The expression of constitutive enzymes, ecNOS and COX-1, followed the opposite pattern. COX-1 was significantly reduced in advanced gastric tumors (P=0.007) and tumors larger than 5 cm (P=0.007). Reduced expression of ecNOS was also observed in advanced gastric tumors; however, this did not reach statistical significance. 53% of gastric tumors showed accumulation of p53. This was significantly higher in advanced tumors (P=0.004), larger than 5 cm (P=0.015) with metastases (P<0.001). Gastric tumors positive for accumulation of p53 had significantly stronger expression of iNOS (P=0.018) and COX-2 (P=0.01) enzymes than tumors negative for this nucleophosphoprotein. We conclude, that tumor-associated nitric oxide production, as well as COX-2 overexpression, may promote gastric cancer progression by providing a selective growth advantage to tumor cells with non-functioning p53.

Trends of diverticular disease of the large bowel in a newly developed country

Five hundred twenty four consecutive barium enemas done over an 18-month period were reviewed in Singapore to ascertain the prevalence and distribution of diverticular disease in the large bowel. In this study, the prevalence rate was 20 percent, which is comparable to European and American studies but higher than similar studies in Asian countries. However, the distribution of the disease showed a predominance of right-sided disease (70 percent). This is a pattern that is markedly different from that seen in Europe and North America, where the disease involves largely the left side of the large bowel. The high prevalence rate in this series is at variance with the widely held belief that diverticulosis occurs less frequently in oriental communities.

Comparison between laparoscopic and conventional omental patch repair for perforated duodenal ulcer

AbstractBackground: The aim of the study is to evaluate the safety and efficacy of laparoscopic omental patch repair. Method: This is a retrospective review of 53 consecutive patients with omental patch repair for perforated duodenal ulcer; 38 underwent conventional open approach and 15 underwent laparoscopic patch repair. The only selection criterion was availability of expertise for laparoscopic repair on the day of admission. By chance, the open group had poorer ASA scores. There were four deaths and five postoperative complications in the open group. Results: Laparoscopic repair was successful in 14 cases with one postoperative complication. Operative time was longer in the laparoscopic group (80 vs 65 min in open group, p= 0.02). Patients required less postoperative analgesics in the laparoscopic group (median amount of pethidine was 75 mg vs 175 mg in the open group, p= 0.03). There was no statistically significant difference in terms of hospital stay and return to normal activities between the two procedures. Follow-up Visick scores were comparable in both groups. Conclusions: Laparoscopic omental patch repair offers a safe alternative to the conventional method and causes less postoperative pain.

Early experience with laparoscopic radical gastrectomy for advanced gastric cancer.

Use of the laparoscopic approach for the management of gastric cancer is still in the developmental phase. The authors present their experience with laparoscopic radical gastrectomy for advanced gastric cancer. Between September 1997 and August 1999, four laparoscopic gastrectomies for gastric carcinoma were performed on two male and two female patients (mean age, 61.5 years). One D2 total radical gastrectomy and three D2 subtotal distal gastrectomies were performed, using a totally laparoscopic approach. Mean operative time was 210 minutes. There were no intraoperative complications. All four patients recovered uneventfully from surgery and began oral feeding on the third postoperative day. Median postoperative stay was 7 days (range, 6–9). All patients were alive 8 months to 3 years after the operation, with no cancer recurrences. This series shows that laparoscopic radical gastrectomy for moderately advanced cancers can produce good results in terms of safety and oncologic adequacy.

Laparoscopic appendectomy for perforated appendicitis

Although laparoscopic appendectomy for uncomplicated appendicitis is feasible and safe, its application to perforated appendicitis is uncertain. A retrospective study of all patients with perforated appendicitis from 1992 to 1999 in a university hospital was performed. A series of 231 patients were diagnosed as having perforated appendicitis. Of these patients, 85 underwent laparoscopy (LA), among whom 40 (47%) required conversion to an open procedure. An open appendectomy (OA) was performed in 146 patients. The operating time was similar for the two groups. Return of fluid and solid diet intake were faster in LA than OA patients (p<0.01). Postoperative infections including wound infections and abdominal abscesses occurred in 14% of patients in the laparoscopy group and in 26% of those with OA (p<0.05). The surgeon’s experience correlated with the conversion rate. Laparoscopic appendectomy is associated with a high conversion rate for perforated appendicitis. If successful, it offers patients faster recovery and less risk of infectious complications.RésuméAlors que l’appendicectomie par laparoscopic pour appendicite non compliquée est faisable et sûre, son rôle dans l’appendicite perforée reste incertain. On a analysé rétrospectivement les résultats chez tous les patients traités pour appendicite perforée entre 1992 et 1999 dans un service de chirurgie d’un hôptial universitaire: 231 patients ont ainsi été inclus dans cette étude. Quatre-vingt-cinq patients ont eu une laparoscopic (LA): 40 patients (47%) ont nécessité une conversion à la voie tradtionnelle. Une appendicectomie par voie traditionnelle (OA) a été réalisée chez 146 patients. La durée de l’intervention était similaire entre les deux groupes. La reprise d’alimentation orale et solide a été plus rapide dans le groupe LA par rapport au groupe OA (p<0.01). On a noté des complications infectieuses, y compris des infections pariétales et des abcès intra-abdominaux chez 14% dans le groupe L, comparé à 26% pour le groupe O (p<0.05). L’expérience du chirurgien a été corrélée directement avec le taux de conversion. L’appendicectomie laparoscopique est associée à un taux élevé de conversion en raison de l’appendicite perforée. En cas de succès, la récupération est plus rapide et il y a moins de risque de complications infectieuses.ResumenMientras que la apendicectomía laparoscópica es posible y segura en las apendicitis no complicadas, el papel de la laparoscópia en el tratamiento de la apendicitis perforada está muy controvertido. En un hospital universitario se efectuó un estudio retrospectivo de todos aquellos casos de apendicitis perforada, intervenidos entre 1992 y 1999. 231 pacientes ftieron diagnosticados de perforación apendicular. 85 fueron tratados por laparoscópia (LA) pero 40 (47%) requirieron reconversión a cirugía abierta. Con apendicectomía abierta (OA) se trataron 146 enfermos. La duración de la operación fue similar en ambos grupos. La iniciación de la ingesta de líquidos y sólidos fue más precoz en el grupo LA que en el OA (p<0.01). Infección postoperatoria que comprende tanto la de la herida como abscesos abdominales, se constató en el 14% de los pacientes del grupo LA y en el 26% de los del grupo OA (p<0.05). La experiencia del cirujano se correlacionó directamente con la tasa de reconversión. Ésta es mucho más frecuente en el tratamiento laparoscópico de las apendicitis perforadas. Si la apendicectomía laparoscópica puede realizarse satisfactoriamente el paciente se recuperará con más rapidez y el riesgo de complicaciones infecciosas será menor.

Randomized trial of periportal peritoneal bupivacaine for pain relief after laparoscopic cholecystectomy

The aim of this study was to determine whether injection of a long‐acting local anaesthetic, in relation to the port sites at the level of the parietal peritoneum, would reduce postoperative pain following laparoscopic cholecystectomy. Patients were entered into a randomized, prospective, double‐blind study comparing the effects of a standard technique, in which bupivacaine (total of 20 ml, 0–5 per cent) was injected into the subcutaneous periportal tissue around the four port sites, and a technique in which bupivacaine (total of 20 ml, 0.25 per cent) was injected into the subcutaneous periportal tissue as above with the addition of periportal parietal peritoneal injection of bupivacaine (total of 20 ml, 0–25 per cent). Two scores for pain, with the patient at rest, and on movement, were assessed 6 and 18 h after surgery using a visual analogue pain scale. Median pain score was significantly higher in patients who received standard technique (n = 40) than in those given peritoneal injection (n = 40) at both 6 (rest = 3.0 versus 1.0, movement = 5.0 versus 2.9) and 18 h (rest =1.9 versus 0, movement = 3.2 versus 1.2). Both opiate and oral analgesic requirements were reduced in patients administered peritoneal injection, although this was not statistically significant. The addition of periportal injection of bupivacaine at the level of the parietal peritoneum, performed under direct vision, reduces pain after laparoscopic cholecystectomy.

Totally intra-abdominal laparoscopic Billroth II gastrectomy

Although H2-blockers remain the first-line treatment for chronic gastric ulcers, there remain some patients who still require surgery for intractability, large ulcers, complications, or suspected malignancy. For these patients, the standard Billroth I or II gastrectomy has stood the test of time [1]. The minimally invasive surgical revolution started four years ago by the advent of laparoscopic cholecystectomy [2] has spawned the technology that now makes possible the performance of a Billroth II gastrectomy totally intraabdominally under laparoscopic control. We recently performed a laparoscopic Billroth II subtotal gastrectomy on a 76-year-old man. The patient had a 2-year history of chronic gastric ulcer and presented with the problem of episodic epigastric pain related to meals. During this time he had intermittent treatment with H2-blockers without success. Gastroscopy revealed a deep, chronic, 1.5-cm-diameter ulcer at the incisura of the stomach. Surgery was performed with total intravenous anesthesia using propofol. Nitrous oxide was omitted to reduce gas retention in the intestinal tract. Ventilation was done with a mixture of air and oxygen. Pneumoperitoneum was induced to 14 mmHg with carbon dioxide, and the operation was performed through five portals (four 12 mm and one 10 ram). The lesser and greater curves of the stomach were mobilized and vessels controlled with either Endoclip | or vascular endo GIA | stapling device applications (USSC, Norwalk, Connecticut, USA). Major vessels like the left and right gastroepiploic and the right gastric arteries were controlled with the endoGIA. The duodenal and stomach stump were simultaneously transected and closed with multiple applications of the endoGIA. A Billroth II reconstruction was similarly performed entirely intraabdominally with staples. The transected distal two thirds of the stomach was delivered through the left upper quadrant 12 mm trocar port enlarged to 25 ram. Although the surgery required 4 h and 17 applications of the 30-mm endoGIA were used, blood loss was negligible, and the patients intraoperative course was uneventful. His recovery was remarkable. He was ambulatory and pain-free without medication on the first post-operative day. Peristalsis was well established on the second day. He tolerated oral liquids on post-op day 3 and ate a normal breakfast before being discharged on his fourth day after surgery. We plan on compiling a larger series, but are pleased to forward our initial results to your publication. Based on the present case and earlier experience with laparoscopic gastrointestinal operations, we believe that laparoscopic gastric resection can offer a safe and reasonable alternative to long-term medical management.

Needlescopic Thoracic Sympathectomy: Treatment for Palmar Hyperhidrosis

BACKGROUND Open thoracic sympathectomy has been the established option for patients with essential hyperhidrosis. Recently, video-assisted endoscopic sympathectomy has provided a simple, safe, reliable, and cost-effective alternative to the earlier technique. With advances in instrumentation, performing the procedure through 2-mm and 3-mm needlescopic ports is now possible. The authors evaluate the effectiveness of so-called needlescopic thoracic sympathectomy for the treatment of primary hyperhidrosis. METHODS Thirty five consecutive patients with a mean age of 24 years, including 23 men and 12 women, underwent bilateral needlescopic thoracic sympathectomies at the National University Hospital of Singapore. RESULTS The mean operative duration was 56 minutes, and the mean hospital stay was 1.2 days. In no patient did Horners syndrome or significant pneumothorax develop. The rate of success, defined as completely dry hands, was 97%. Two patients had unilateral recurrences that responded well to repeat needlescopic sympathectomies. We performed a total of 72 sympathectomies. CONCLUSIONS Our study demonstrates that the use of miniature port access sites produces excellent medical and cosmetic results and is associated with a short hospital stay and low risk of complications.

Predictive factors for synchronous common bile duct stones in patients with cholelithiasis

AbstractBackground: To determine the predictive factors of synchronous common bile duct (CBD) stones, data from 878 consecutive patients who underwent cholecystectomy in a university clinic from June 1991 to June 1996 were retrospectively analyzed. Methods: Based on clinical, biochemical, and ultrasonographic criteria, 194 patients were selected for ERCP, 180 preoperative and 14 postoperative. Results: Cannulation of CBD was successful in 192 (99%) patients. Stones were identified in 62 (32%) patients and sphincterotomy was performed in 56 (90%). Duct clearance was achieved in 43 (77%) cases. There was a high predictive value for the presence of CBD stones in patients with cholangitis, present jaundice, and dilated CBD with evidence of stones on ultrasound (75%, 72%, and 67% respectively). A dilated CBD without stone on ultrasound and elevated liver enzymes had less than 40% positive predictive value. History of previous jaundice, pancreatitis, previously raised liver enzymes, and present pancreatitis was predictive in less than 20% of the cases. Univariate analyses revealed that clinical findings of cholangitis and obstructive jaundice, elevated liver enzymes (previous and present), and ultrasonographic findings of stones in a dilated CBD were significant positive predictors. Subanalysis of each elevated liver enzyme revealed that alanine transaminase, aspartate transaminase, alkaline phosphatase, and gamma glutamyl transpeptidase were significant predictors. Both elevated conjugated and total bilirubins were also significant predictors for CBD stones. Conclusion: Multivariate logistic regression analysis on these significant predictors showed that cholangitis (odds ratio [OR]: 10.5), dilated CBD with evidence of stones on ultrasound (OR: 7.4), elevated aspartate transaminase (OR: 2.9), and conjugated bilirubin (OR: 5.3) were jointly significant. The likelihood of having stones in the duct without any of these predictors was 7%, but 99% when all the predictors were positive.