Value of segmental limb blood pressures in predicting results of aortofemoral bypass

The efficacy of segmental limb blood pressure measurements, assessed noninvasively by Doppler ultrasound, in predicting the result of aortofemoral reconstruction was evaluated in fifty-two extremities with varying extent of aortoiliac and more distal arterial occlusive disease. Three prognostic correlates were analyzed: (1) preoperative proximal thigh/arm pressure index (TPI); (2) preoperative pressure gradient between adjacent leg segments (proximal thigh, above-knee, below-knee, and ankle), normally less than 30 mm Hg; and (3) early postoperative increase in the ankle/arm pressure index (API). After aortofemoral bypass, forty-one limbs (79 per cent) were asymptomatic or improved and eleven were unimproved. The mean TPI in extremities benefiting from aortofemoral bypass, 0.82 +/- 0.17 (+/-1SD) was significantly less than that of unimproved limbs, 1.01 +/- 0.09 (p less than 0.01). Aortofemoral bypass was beneficial in all twenty limbs with normal leg pressure gradients. Conversely, six of twenty-five legs with one abnormal gradient and five of seven with two abnormal gradients failed to improve. The postoperative increase in API was 0.1 or more in all forty-one improved extremities and was less than 0.1 in all eleven failures. Although eleven of thirty-two limbs (34 per cent) with arteriographic evidence of combined aortoiliac and subinguinal occlusive disease were not improved after proximal bypass, the result of operation could not be predicted from the angiographic pattern or severity of distal disease. Segmental limb blood pressures provide useful predictive indices of the efficacy of aortofemoral bypass and the potential need for more distal reconstruction in multisegmental disease.     

Acute hemodynamic effects of lumbar sympathectomy

Lumbar sympathectomy increases total limb blood flow after aortofemoral bypass in a high percentage of cases. This was true in eleven of fourteen extremities (78.6 per cent) in our series even though no specific selection criteria for entry into the study, other than the need for aortofemoral bypass, were used: that is, patients were entered into the study irrespective of preoperative ankle/arm pressure indexes or results of hyperemia testing. Overall, flow rates after sympathectomy was added to aortofemoral bypass were 1.55 times greater than after aortofemoral bypass alone. This degree of augmentation of flow may be important, particularly in cases of limited outflow.     

Other laparoscopic bariatric procedures

Laparoscopic surgery is regarded as a major improvement reflected by a rapid recovery and low perioperative and postoperative morbidity. In obese patients the gains of this new technique may be affected by obesity-related problems, such as impaired respiratory function, high intraabdominal pressure, thick abdominal wall, and liver steatosis. This review describes the development of laparoscopic vertical banded gastroplasty (VBG) and gastric bypass procedures; and it addresses questions such as feasibility, comparability to open procedures, procedure-related problems, and recovery. The clinical outcome after laparoscopic VBG and gastric bypass is also updated. Up to May 1997 we have operated on 105 patients with laparoscopic VBG and another 26 completed laparoscopic gastric bypass procedures. The weight loss after both procedures are in accordance with the weight loss seen with open surgery. Procedure-related complications are described in detail in this paper. It is concluded that laparoscopic bariatric surgery will remain an area of importance for clinical practice, research, and development.     

Patient rights, provider rights: balancing the conflict

Laparoscopic cholecystectomy is a minimally invasive and highly effective technique for gallstone disease. The authors report their experience of laparoscopic cholecystectomy. Between September 1992 and December 1994 we performed laparoscopic operations on 212 patients with gallstone disease. Our series included 149 female and 63 male patients; 29 patients was converted intraoperatively to the open procedure. Laparoscopic cholecystectomy is the best surgical approach for the treatment of cholelithiasis: it reduces postoperative pain and hospital stay, has cosmetical and financial benefits.     

Challenging the future: impact of information technology on dietetics practice, education, and research

PURPOSE: We retrospectively evaluated balloon angioplasty with intraluminal stenting to define applicability, early results, cost, and length of stay. METHODS: Seventy-three patients underwent 94 aorto-iliac angioplasties with intraluminal stents from October 1991 through July 1993. All had disabling claudication or rest ischemia. RESULTS: Mean follow-up was 10.2 months and was 90.4% complete. Ninety percent of procedures were immediately successful. There were no deaths within 30 days of surgery. Complications occurred in 13%. The ankle:brachial indices improved in all groups. Functional class improved in all groups. In class 4, limb salvage or a benefit on level of amputation was universal. Length of stay ranged 33% to 82% less than when aorto-iliac or aortofemoral bypass were undertaken (diagnosis-related group 39.25). Hospital charges for stent procedures ranged 25% to 66% less than for aorto-iliac or aortofemoral bypass (diagnosis-related group 39.25). CONCLUSION: The procedure is widely applicable, with an apparent initial advantage in mortality, morbidity, charges, and length of stay. Durability is unproven.     

Laparoscopic adrenalectomy. A new standard of care

OBJECTIVE: The authors review their experience with laparoscopic adrenalectomy in patients with benign adrenal neoplasms. Efficacy, safety, and cost effectiveness of the procedure are examined. BACKGROUND: Laparoscopic adrenalectomy is replacing open adrenalectomy in some medical centers as the standard surgical approach for uncomplicated tumors. However, laparoscopic adrenalectomy often is considered more difficult and more expensive than traditional "open" surgery. METHODS: Perioperative and postoperative records as well as hospital charges from the first 19 patients undergoing laparoscopic unilateral adrenalectomies at the authors' medical institutions were examined and compared with 19 patients who underwent open unilateral adrenalectomies. RESULTS: None of the 19 patients undergoing unilateral laparoscopic adrenalectomy required conversion to open adrenalectomy. Mean operative times as well as total hospital charges were similar in those patients undergoing either laparoscopic or open adrenalectomy. However, the morbidity and postoperative length of hospital stay were significantly less in those patients undergoing laparoscopic adrenalectomy. CONCLUSIONS: Laparoscopic adrenalectomy can be performed safety and with the benefits associated with minimally invasive surgery. In addition, the procedure is cost effective. These factors suggest that laparoscopic adrenalectomy should be the preferential surgical technique for benign adrenal disease.     

Laparoscopic appendectomy in the adult

AIM OF THE STUDY: The benefits of laparoscopic appendectomy remain controversial. The aim of the study was to evaluate the advantages and disadvantages of this technique. MATERIAL AND METHODS: Four hundred and forty-eight patients operated on for suspected appendicitis during a 5-year period were analysed in a retrospective study. The preoperative diagnosis was corrected in 21.4% of the cases (8.1% for males and 28.7% for females) and the conversion rate was 9.7%. There were 17 patients with generalized peritonitis and 28 with localized peritonitis. During the past year, this surgical method was introduced in another hospital and a prospective study included 92 consecutive patients operated on for appendicitis. The operating time was 53 minutes and the conversion rate was 7.6%. There were five patients with generalized peritonitis and eight with localized peritonitis. RESULTS: There were no postoperative deaths. In the first period, the morbidity rate was 2.3% in the laparoscopic group without conversion. After pathological examination, there was a 14.2% rate of normal appendix. The mean hospital stay was 4.3 days. In the second period, there were only three minor complications and the mean hospital stay was 4.19 days. CONCLUSION: The choice of laparoscopic approach is associated with some advantages: corrections of the diagnosis (mainly in young women) and simplification of the postoperative course, provided that the surgeon has sufficient experience.     

Elective laparoscopic splenectomy for hematologic disorders

Laparoscopic splenectomy has been reported to be the procedure of choice in selected patients with hematologic disorders. The purpose of this study is to review our experience with laparoscopic splenectomy in this patient population. The charts of all patients with hematologic disorders who presented for laparoscopic splenectomy over a 17-month period were reviewed. Fifteen patients, nine males and six females, aged 12 to 80 years (mean, 49 years) presented for laparoscopic splenectomy. Surgical indications included 13 cases of idiopathic thrombocytopenic purpura and one each of hemolytic anemia and Hodgkin's disease. Splenectomy was performed utilizing a four- or five-puncture laparoscopic technique. For completed laparoscopic splenectomies, the mean operative time was 129 minutes, and the mean estimated blood loss was 232 cc. Mean splenic weight was 210 g. There were no operative deaths. There was a single intraoperative complication, a 1700-cc hemorrhage, and two postoperative complications: pneumonitis and deep venous thrombosis. Overall morbidity was 20 per cent. A single patient (7%) required conversion to laparotomy for completion due to hemorrhage. For patients completed laparoscopically, the mean hospitalization was 1.5 days, and none required parenteral narcotics for pain control after the first 36 hours. Laparoscopic splenectomy for patients with hematologic disorders is a safe and technically feasible procedure. Decreased hospitalization and discomfort are the primary benefits. This technique should be added to the repertoire of surgeons treating patients with hematologic disorders.     

Aortic corset syndrome

The majority of proximal anastomotic complications of aortofemoral bypass grafts are related to the formation of pseudoaneurysms or true proximal aneurysmal dilation of the residual infrarenal aorta. The late development of occlusive disease at the proximal anastomosis is an extremely rare event. We report two patients in whom symptomatic stenoses developed involving the proximal anastomoses of aortofemoral bypass grafts originally placed for aortoiliac occlusive disease. Surgical exploration demonstrated the presence of a constricting prosthetic corset wrapped around the proximal suture line of each graft. Exuberant neointimal hyperplasia was responsible for both stenoses.     

Introduction of video endoscopic vascular surgery of the pelvic area

The fact that operative lethality and other typical postoperative complications following surgical treatment of aortoiliac atherosclerotic disease are mainly related to the surgical trauma (derived from the extensive abdominal incision and dissection), but not to the classical arterial reconstruction itself, has led us to develop a videoendoscopic aortoiliacal surgical method which is supposed to diminish the potential postoperative complications. Thus, a new endoscopic instrument set for vascular surgery has been developed in close cooperation with Aesculap AG Tuttlingen, Germany. After evaluating the basic techniques of videoendoscopic patching and end-to-side anastomosis with the newly designed instruments on a training model (n = 50), the feasibility of videoendoscopic vascular surgery on aortoiliacal vessels was tried out on human corpses (n = 8). The positive results of the initial survey have finally encouraged us to conduct our first series of animal studies on piglets (n = 25). The investigation regarding ultrasonically monitored blood flow in the femoral arteries after videoendoscopic aortofemoral bypass grafting and other systemic, hemodynamic parameters showed positive results. No complications were encountered in any of the standardized animal studies. Favorable activity levels were recorded. Meanwhile we have performed 5 extraperitoneal videoendoscopic aortofemoral artery bypasses in patients with aortoiliac occlusive diseases. One patient in whom we had occluded the inferior mesenteric artery died due to an ischaemic colitis. The other patients had an uneventful postoperative course. The videoendoscopic vascular procedures were carried out according to the rules of conventional vascular surgery. Nevertheless, further experimental research and development of endoscopic instruments have yet to be done, to optimize the new surgical method and to clarify the advantages of videoendoscopic vascular surgery.     

Controlled trial of laparoscopic-assisted vs open colon resection in a porcine model

BACKGROUND: Several series of laparoscopic colon resection have been reported in the literature with varied results; however, no controlled series of laparoscopic vs open colon resection has been reported. The purpose of this study was to determine the relative safety and adequacy of laparoscopic colon resection in a controlled trial using a porcine model. METHODS: Domestic pigs (n = 23) were randomly divided into two groups. Animals underwent either an open or laparoscopic-assisted segmental resection of the sigmoid colon. The open resections were performed through a 20-cm midline incision and the laparoscopic technique utilized five 12-mm ports. Laparoscopic resection took twice as long to complete as open resection (P < 0.001). Return of gastric function was significantly faster in the laparoscopic group than in the open group (P < 0.032). RESULTS: No significant differences were found in total length of resection, proximal or distal margins, number of lymph nodes recovered, length of mesenteric vessel resected, or time to return of bowel function. At vivisection, more adhesions to the abdominal wall were noted in the open group (P < 0.002). One death occurred in the laparoscopic group 2 h postoperatively (8.3% mortality) while all open group pigs survived. However, there was no statistically significant difference in mortality rates by chi-square analysis (P > 0.5). CONCLUSIONS: Despite longer operative time, laparoscopic intervention is technically feasible, safe, and may offer significant postoperative benefits due to fewer abdominal adhesions.     

A randomised controlled trial of a low-molecular-weight heparin (Enoxaparin) to prevent deep-vein thrombosis in patients undergoing vascular surgery

The incidence of postoperative deep vein thrombosis (PDVT) after aortic surgery and lower limb revascularisation has not been assessed by a large prospective study. In a prospective randomised trial the effect of a low-molecular-weight heparin fragment, Enoxaparin (ENX) 4200 anti factor Xa IU once daily was compared to that of unfractionated heparin (UFH) 7500 IU twice daily. Two hundred and thirty-three consecutive patients were classified into three groups, aortic or aortoiliac and aneurysmectomy (n = 75), aorto-femoral bypass for atherosclerotic disease (n = 71), and femoropopliteal or femorodistal bypass (n = 87). Patients were analysed for development of deep vein thrombosis by Duplex scanning and, if positive, by venography between the seventh and tenth postoperative day. PDVT was present in 10 patients in the ENX group and in four patients in the UFH group (8.2 and 3.6% respectively, NS). The incidence of PDVT was 8% after aortic or aortoiliac aneurysmectomy, 7% after aortofemoral revascularisation, and 3.4% after femoropopliteal or femorodistal bypass. The overall incidence of PDVT after aortic surgery was 7.5% (95% CI 5.4-9.7). There was no pulmonary embolism. Intra-operative blood loss and postoperative bleeding events did not differ significantly between the ENX and UFH groups. After 1 month follow-up, no clinical event or death could be related to PDVT or pulmonary embolism. In conclusion, in vascular surgery ENX is as safe and effective in the prevention of PDVT as is UFH.     

Should laparoscopic appendectomy be avoided for complicated appendicitis in children?

BACKGROUND/PURPOSE: Laparoscopic appendectomy is becoming the preferred technique for treating acute appendicitis. However, recent literature on adults suggests that laparoscopic appendectomy may increase the risk for postoperative infectious complications in complicated (gangrenous or perforated) cases. This study was undertaken to compare the results of open versus laparoscopic appendectomy for complicated appendicitis in children. METHODS: A retrospective review from two institutions was performed for all children treated operatively for complicated appendicitis from January 1994 through November 1996. RESULTS: Fifty-six cases were identified. Twenty-seven children underwent laparoscopic appendectomy, whereas 22 underwent open appendectomy. Seven children underwent conversion from laparoscopic to open surgery. Operating times and length of hospital stay did not differ significantly between the laparoscopic and open groups. Postoperative complications developed in 24 children (42.8%). Complications were more frequent after laparoscopic appendectomy compared with open appendectomy (56% v 18%, P = .002). A postoperative intraabdominal abscess (IAA) developed in 14 children (25%). An IAA occurred in two children after open appendectomy compared with 11 children after laparoscopic appendectomy (9% v 41%, P = .01). CONCLUSION: The findings suggest that laparoscopic appendectomy should be avoided in children who have complicated appendicitis because of the increased risk for postoperative intraabdominal abscesses. The authors propose a prospective, randomized trial to verify this finding.     

Bedtime administration of lansoprazole does not modify its greater efficacy vs ranitidine in the acute and long-term treatment of duodenal ulcer. Results from a multicentre, randomised, double blind clinical trial

OBJECTIVE: Although surgical biliary bypass for nonresectable periampullary tumors is superior to endoscopic stent placement, the latter has become popular because of the "minimally invasive" approach. Laparoscopic biliary bypass would appear to offer the advantages of both. However, this technique remains technically difficult using existing instrumentation. This study investigates the efficacy of a new endoscopic device designed for rapidly completing a small-diameter intestinal anastomosis under laparoscopic guidance. METHODS: Eighteen female pigs (mean weight 35 kg, range 31 to 44) were randomly divided into three groups: animals undergoing handsewn (group H) or instrumental transient endoluminally stented anastomosis (TESA; groups P and D) laparoscopic Roux-en-Y choledochojejunostomy. For TESA two different reabsorbable stents were used, polyglycolic acid (PGA; group P) and polyurethane ester (Degrapol; group D). Blood chemistry, weight gain, and abdominal X-rays were taken weekly to document any possible migration or reabsorption of the radio-opaque stents. After 3 months, necropsy was performed. Patency of the biliary bypass and choledochojejunostomy were examined using fluoroscopy and measured by introducing graduated dilators into the anastomosis. RESULTS: Fluoroscopy revealed immediate passage of contrast through the anastomosis in all animals. Weight gain, bilirubin, and alkaline phosphatase were within normal range in all groups. Diameter of the bile duct (group H 10.7 +/- 2.9 mm/group P 9.5 +/- 3.6 mm/group D 11.0 +/- 4.6 mm) and choledochojejunostomy (group H 4.5 +/- 1.1 mm/group P 4.7 +/- 1.8 mm/group D 3.6 +/- 1.9 mm) did not differ. The time required to complete the biliary bypass was significantly decreased when TESA was applied (group H 152 +/- 13 min/group P 86 +/- 14 min, P <0.001/group D 110 +/- 20 min, P <0.002). CONCLUSIONS: Applying TESA, laparoscopic choledochojejunostomy can be performed rapidly and safely, revealing good bypass function over a period of 3 months. With regard to treatment for nonresectable periampullary tumors, TESA may offer a new therapeutic approach combining the benefits of minimally invasive endoscopic stent placement with the functional results and lower readmission of conventional Roux-en-Y choledochojejunostomy.     

Severe muscle weakness secondary to paraneoplastic hypophosphatemia in neuroblastoma

OBJECTIVES: To evaluate the influence of the use of a bypass on the results of thoracoabdominal aortic aneurysm surgery. METHODS: The results of the repair of 224 thoracoabdominal aortic aneurysms operated upon between 1981 and the end of 1996 were evaluated retrospectively. In 122 cases we used simple cross-clamping (clamp and sew technique) and in 102 cases a left heart bypass (atrio-femoral or aorto-femoral) was the preferred method. Except for the use of cerebrospinal fluid drainage over the last years, the methods of spinal protection were the same in both groups. Renal protection was also identical in both groups. All aneurysms were repaired using the inlay technique. RESULTS: Hospital mortality was 11.2%: 14.7% in cross-clamp group versus 6.8% in the bypass group (p = 0.04). Postoperative dialysis was necessary in 9.8%: 12.7% in the cross-clamp group versus 6.8% in the bypass group (p = 0.108). Paraplegia occurred in 8.4%: 7.4% in the cross-clamp group versus 9.8% in the bypass group (p = 0.517). Using the highly predictive model of Acher, there would have been 33% spinal cord lesions in the bypass group. CONCLUSIONS: Hospital mortality, postoperative dialysis and postoperative spinal cord problems are lowered by the use of a bypass during the repair of thoracoabdominal aortic aneurysms. These results evidence that the use of a bypass is indicated in this complex operation.     

When to ambulate the patient with a vascular graft in the groin

Ankle blood pressure studied pre- and postoperatively in 60 patients after aortofemoral and femoral distal bypass surgery showed no adverse effect after major positional changes (supine, sitting, and standing). Early ambulation was not harmful to graft dynamics in this group of patients.     

Laparoscopic splenectomy. How to make it easier using an innovative atraumatic suction grasper

BACKGROUND: With the evolution of laparoscopic surgery comes the need for specific instruments that apply traction to parenchymal tissue, like the spleen, without exposing the organ to the associated high risk of bleeding. To meet this need, we designed and developed a suction-cup grasper that allows easy grasping and manipulation of the spleen. Some of the difficulties usually encountered during laparoscopic splenectomy may be overcome by using this device. MATERIALS: The instrument consists of a cone-shaped, silicone rubber suction cup designed with an antislip internal surface. The cup is connected to a support arm with a flexible distal end that can be rotated. Traction is exerted with a commonly available suction system. The device is inserted through a 12-mm-diameter guide sheath. RESULTS: The two interventions performed with the atraumatic device were completed with laparoscopic technique. No complications arose during or after the operations. The average operating time was 110 min. The patients were discharged after 4 and 5 days postoperative, respectively. CONCLUSIONS: As a device specifically designed for grasping parenchymal organs, the atraumatic suction grasper affords the operator a faster and safer technique in laparoscopic splenectomy.     

Combined effect of nisin and high hydrostatic pressure on destruction of Listeria innocua and Escherichia coli in liquid whole egg

BACKGROUND: Thrombosis is the most frequent late complication of surgical procedures in the aortofemoral area. In the presence of aortobifemoral bypass, graft limb occlusion generally occurs within the first two years. Various techniques have been proposed to revascularize the ischemic limb. Personal experience in the treatment of occlusions of aorto-femoral bypasses branch by femoro-femoral bypasses is reported and the immediate and long-term results are analyzed. METHODS: The study was retrospective and the medium follow-up was 51 months (1-14 years). The patients were all operated from 1976 to 1995 in the Division of Vascular Surgery of the University of Bari. The group consisted of 40 patients affected by unilateral occlusion that occurred after aorto-femoral bypass. The femoro-femoral bypass was performed using non-ringed 6 or 8 mm Dacron prostheses; the proximal anastomosis was made a few cm above the femoral anastomosis of the permeable branch of the existing aorto-bifemoral bypass and the distal anastomosis on the cross-leg profunda femoris. Postoperative follow-up consisted of clinical examination, continuous wave Doppler examination or US-color-Doppler scan in order to assess the permeability of the graft. RESULTS: The immediate results showed 2 and long-term results 9 occlusions of the bypass. No perioperative mortality was observed. CONCLUSIONS: In conclusion the authors consider the use of femoro-femoral bypass indicated in a high number of patients affected by unilateral occlusion of the aorto-bifemoral bypass.     

Laparoscopic enucleation of a renal cell carcinoma

The purpose of this study was to report on the feasibility of laparoscopic excision of renal cell carcinoma. An 81-year-old female with renovascular disease underwent a laparoscopic excisional operation for a 2-cm tumor localized in the left kidney. Pathological evaluation showed a low-grade tumor without any extension through the renal capsule (grade I Hand Broder, stage I Robson). The postoperative course was uneventful; there was minimal postoperative pain. The patient was discharged home on the sixth day. Laparoscopic excision would appear to be a safe and effective technique in selected cases.     

Open compared with laparoscopic approach to Burch colposuspension: a cost analysis

OBJECTIVE: To compare postoperative course and hospital charges of an open versus laparoscopic approach to Burch colposuspension for the treatment of genuine stress urinary incontinence. METHODS: A retrospective chart review was performed to identify all patients undergoing open or laparoscopic Burch colposuspension by the same surgeon over a 2-year period. Patients undergoing additional surgical procedures at the time of colposuspension were excluded from the study. Twenty-one patients underwent open Burch colposuspension and 17 patients underwent laparoscopic colposuspension. Demographic data including age, parity, height, and weight were collected for each group. Both groups also were compared with regard to operative time, operating room charges, estimated blood loss, intraoperative complications, change in postoperative hematocrit, time required to resume normal voiding, length of hospital stay, and total hospital charges. RESULTS: The laparoscopic colposuspension group had significantly longer operative times (110 versus 66 minutes, P < .01) and increased operating room charges ($3479 versus $2138, P < .001). There was no statistical difference in estimated blood loss or change in postoperative hematocrit between the two groups. No major intraoperative complications occurred in either group. Mean length of hospital stay was 1.3 days for the laparoscopic group and 2.1 days for the open group (P < .005). However, total hospital charges for the laparoscopic group were significantly higher ($4960 versus $4079, P < .01). CONCLUSION: Laparoscopic colposuspension has been described as a minimally invasive, cost-effective technique for the surgical correction of stress urinary incontinence. Although the laparoscopic approach was found to be associated with a reduction in length of hospital stay, it had significantly higher total hospital charges than the traditional open approach because of expenses associated with increased operative time and use of laparoscopic equipment.