Laparoscopic anterior resection: a consecutive series of 84 patients

Laparoscopic colorectal surgery is in its infancy. From a series of over 200 colorectal procedures undertaken over the last 30 months, we have performed 84 anterior resections. In 55 women and 29 men, median age 64 years (range 32-86), median weight 72 kg (range 36-125), surgery was undertaken for benign pathology (n = 57) and adenocarcinoma (n = 27). Anterior resection was completed laparoscopically in 75 cases (89%) with a median operating time of 210 min (range 85-420). Minor morbidity occurred in 17 patients (20%) with major morbidity in 10 cases (12%). There was one post-operative death. Flatus was passed a median of two days (range 1-7) after surgery and feces at a median of four days (range 2-9). Total hospital stay was six days (range 2-33). Delayed morbidity during a maximum of 30 months' follow-up included two anastomotic strictures but no evidence of malignant seeding. Laparoscopic anterior resection appears both feasible and safe for both benign and malignant disease, with the caveat that long-term outcome in malignant disease is not yet available.

Alcohol level at head injury and subsequent psychotropic treatment during trauma critical care

Alcohol intoxication at the time of traumatic brain injury (TBI) presents many complications for critical care treatment. This is the first reported data on psychotropic dosages administered to TBI patients in the critical care setting. In this study, the blood alcohol level (BAL)-positive patients (n = 14) tended to be older (P = 0.095), have lower admission Glascow Coma Scores (P = 0.031), and spent more days on respirators (P = 0.125) than the BAL-zero patients (n = 21). The BAL-positive group received more days of narcotics and benzodiazepines with markedly higher average daily doses, not statistically significant. These results are a basis for studying relationships between medication, treatment variables, and outcomes for TBI patients and then developing specific medication guidelines.

Laparoscopic Nissen fundoplication--200 consecutive cases

PATIENTS

Laparoscopic Nissen fundoplication was undertaken in 200 patients between 1991 and 1994.

METHODS

Pre-operative assessment included symptom score, endoscopy, manometry, and 24 hour pH monitoring of the oesophagus. Patients were evaluated at three and 12 months after surgery with symptom scoring and 96 patients also underwent 24 hour pH studies at three to six months postoperatively.

RESULTS

In the first 100 patients median duration of operation was 155 minutes (range: 70-330), conversion rate to laparotomy was 7%, median hospital stay was three days (range: 2-57), and total morbidity was 16%. This compared with a median operation time of 120 minutes (60-240) (p = 0.0003, 95% CI 10, 40), a conversion rate of 2% (p = 0.2), a hospital stay of three days (1-18) (p = 0.0016, 95% CI 0, 1), and total morbidity of 7% (p = 0.15) in the second 100 patients. Median total symptom scores fell from 5/9 to 0/9 after fundoplication (< 0.0001) while median 24 hour oesophageal acid exposure in 96 patients was reduced from 10% to 1% (p < 0.001).

CONCLUSIONS

Laparoscopic Nissen fundoplication is a safe and effective procedure for gastro-oesophageal reflux disease. With experience, the duration of operation falls and the hospital stay is shorter. Shortterm symptomatic and pH results are consistently improved by surgery.

Obsessive-compulsive disorder, tattooing and bizarre sexual practices

BACKGROUND

A case is presented describing an association between obsessive-compulsive disorder, tattooing and unusual sexual practices.

METHOD

A single case report.

CONCLUSIONS

Tattooing and unusual sexual practices are compulsive behaviours associated with the subject's obsessive-compulsive disorder. Such associations have not previously been described in the literature.

Laparoscopic-assisted colorectal surgery. Lessons learned from 240 consecutive patients

PURPOSE

To audit the development and outcomes of laparoscopic colorectal surgery at the Royal Brisbane Hospital.

METHODS

Since July 1991, laparoscopic-assisted colectomy for benign and malignant colorectal disease has been performed on more than 300 patients at the Royal Brisbane Hospital. This paper summarizes the outcome for the first 240 patients who underwent a laparoscopic colorectal procedure. All laparoscopic data were collected prospectively, and for selected studies, data were compared with open surgical controls.

RESULTS

Nineteen patients required open conversion (7.9 percent). There was a significant decrease in wound infection rates in patients having a laparoscopic-assisted colectomy (3.6 percent) compared with historical controls (7.9 percent) (P < 0.05; chi-squared). There were five anastomotic leaks, five laparotomies for postoperative adhesive obstruction, and four perioperative deaths. A total of 103 patients had a procedure for colorectal cancer. Of the 79 potentially curative procedures, there have been 5 (6.3 percent) recurrences to date.

CONCLUSION

The overall morbidity and mortality in this series seem to be acceptable compared with that of open procedures.

Laparoscopic antegrade biliary stenting

BACKGROUND AND STUDY AIMS

Laparoscopic common bile duct exploration is successful in 90% of patients, but 10% of patients may have retained stones or impaired biliary drainage at the end of surgery. This study presents the results of laparoscopic biliary stenting in three such patients.

PATIENTS AND METHODS

Three patients with choledocholithiasis, aged 51, 82, and 100 were treated by laparoscopic antegrade placement of biliary stent.

RESULTS

Biliary drainage was established in all three cases. Follow-up at six months revealed all patients to be asymptomatic, with two aged 82 and 101 with the stents still in place.

CONCLUSIONS

Laparoscopic antegrade biliary stenting deserves consideration when the surgeon encounters impaired biliary drainage after laparoscopic exploration of the common bile duct.

Chromosomal location of murine protein tyrosine phosphatase (Ptprj and Ptpre) genes

It is now widely accepted that protein tyrosine phosphatases (PTPases) play important or even critical roles in cell growth, differentiation, and development. Our recent experiments suggested that specific PTPases, PTP beta 2 and PTP epsilon, are involved in the early molecular events for in vitro differentiation of mouse erythroleukemia (MEL) as well as embryonic carcinoma (F9) cells. Using mouse cDNA for PTP beta 2 and PTP epsilon, which we have cloned recently, we attempted to locate the genes to mouse chromosomes. Interspecific backcross analysis indicated that the gene for PTP beta 2, Ptprj, is located in the middle region of chromosome 2, and the gene for PTP epsilon, Ptpre, was mapped in the vicinity of the imprinted regions in the distal part of chromosome 7. Possible biological roles of these PTPases are discussed.

Laparoscopic splenectomy and lymph node biopsy for hematologic disorders

OBJECTIVE

The authors audit the introduction of laparoscopic splenectomy and laparoscopic intra-abdominal lymph node biopsy and compare outcomes with a parallel cohort of patients undergoing open splenectomy.

SUMMARY BACKGROUND DATA

Laparoscopic splenectomy was first reported in 1992. It was introduced into clinical practice at the Royal Brisbane Hospital in 1991. Between June 1991 and March 1994, 24 patients have undergone laparoscopic splenectomies and 23 patients have had laparoscopic intra-abdominal lymph node biopsies.

METHODS

Laparoscopic splenectomy was performed using a four- or five-port technique. The splenic hilum was secured using a linear stapler cutter, and the spleen was removed after placing it in a laparoscopic bag. Lymph node biopsy was performed using a three- or four-port technique, depending on the site and size of the lymphadenopathy.

RESULTS

Laparoscopic splenectomy was completed in 22 patients (92%). Median hospital stay was 3 days (range 2-7 days) and morbidity occurred in two patients (8%). Lymph node biopsy was completed laparoscopically in 21 of 23 patients (91%), with morbidity in two cases (9%). Median hospital stay was 2 days (range 1-6 days), with a diagnostic accuracy of 90%. Comparison with open splenectomy revealed that the laparoscopic approach took significantly longer to perform (p = 0.0002), but resulted in a significantly shorter hospital stay (p = 0.0005).

CONCLUSIONS

Both laparoscopic splenectomy and laparoscopic lymph node biopsy currently are used as the treatments of choice for hematologic disease in our institution.

Laparoscopic biliary and gastric bypass: a useful adjunct in the treatment of carcinoma of the pancreas

Over 90% of patients with inoperable carcinoma of the pancreas are successfully palliated by endoscopic retrograde cholangiopancreatography and stent insertion. Treatment of the residual 10% of patients often entails a laparotomy, which is difficult to justify when median survival of these patients is only 150 days. Laparoscopic biliary and gastric bypass offers a less invasive alternative than open surgery with shorter hospital stay and more rapid return to normal activity. Between August 1991 and March 1994, 16 patients (median age 69 years, range 31-85) had laparoscopic bypass surgery. The indications for surgery were gastric outlet obstruction at initial presentation (n = 4), blocked biliary stent (n = 8), and metastatic tumour at laparoscopy (n = 4). Surgery took the form of cholecystjejunostomy (n = 7), gastroenterostomy (n = 5), both procedures (n = 3), and failed operation (n = 1). Operative duration was 75 minutes (range 45-190) and hospital stay four days (range 3-33) and all apart from two patients were discharged from hospital in seven days or less. Morbidity occurred in two patients (13%) in the form of a cerebrovascular accident and delayed gastric emptying. Median survival in 10 patients who have died is 201 days (range 20-525). Laparoscopic biliary and gastric bypass is possible in most patients in whom endoscopic stenting has failed and in those who subsequently develop gastric outlet obstruction. Hospital stay is shorter than after open surgery and recovery more rapid.

Laparoscopic exploration of the common bile duct: lessons learned from 129 consecutive cases

Since the introduction of laparoscopic cholecystectomy there has been widespread debate about the best way to manage common bile duct (CBD) calculi. Between August 1991 and July 1994, 129 patients underwent laparoscopic exploration of the CBD. Fifteen patients of median age 52 years were managed by glucagon-induced relaxation of the sphincter of Oddi and saline flushing of the bile duct through a cholangiogram catheter. This had a success rate of 73 per cent and took a median of 90 min including cholecystectomy. The technique has now been replaced by Dormia basket exploration of the CBD. Transcystic common duct exploration using a Dormia basket was used in 79 patients of median age 47 years. Duct clearance was achieved in 96 per cent of cases with a median operating time of 55 min. Thirty-five patients of median age 52 years were managed by choledochotomy and T tube placement, with a 91 per cent duct clearance rate and a median operating time of 120 min. Overall duct clearance was achieved in 92 per cent of patients with an operative morbidity rate of 5.4 per cent. Duct clearance using either a Dormia basket or choledochotomy and T tube placement was obtained in 95 per cent of patients. Laparoscopic exploration of the CBD is an important alternative in the management of common duct calculi.

Identification and chromosomal mapping of a third mouse runt-like locus

The Drosophila runt gene, which controls early events in embryogenesis, has been shown to have homologues in human and mouse. The human gene on 21q22 is involved in the t(8;21) associated with acute myeloid leukemia. Two mouse runt-like loci encoding DNA-binding proteins have been identified. We report here the isolation and partial sequence of a molecular clone of a third mouse runt-like locus. By using a panel of somatic cell hybrids and interspecific backcross mice, we map the novel locus to the telomeric region of mouse chromosome 4.

Endoscopic retrograde cholangiopancreatography (ERCP) and stent placement in the management of large common bile duct stones

Management of large common bile duct (CBD) calculi is controversial. Endoscopic treatment is fraught with difficulty, particularly when stones are over one centimetre in diameter and the patient's coagulation is deranged. Between 1988 and 1993, 56 patients have been managed by endoscopic retrograde cholangiopancreatography (ERCP) and stent placement as the initial treatment for large CBD calculi. Complete follow up has been possible in 50 cases (89.3%). The median age was 73.5 years (range 29-92) and primary presenting symptoms were jaundice (n = 39), cholangitis (n = 6) or abdominal pain (n = 5). Median bilirubin was 99 mumol/L (range 7-926) and 60% of the patients had deranged clotting with a median thrombotest of 61%. Stones ranged in size from 0.9 to 4.5 cm (median 1.6 cm). Treatment was with a 7F 'pigtail' stent in 39 cases and a 10F straight stent in 11 patients. Morbidity occurred in 12% of cases with two deaths (4%). Stents remained in place for a median of 1 month (range 0.2-59). Definitive treatment of CBD stones, once the jaundice and sepsis had settled, involved surgery in 24 patients and repeat ERCP with sphincterotomy +/- mechanical lithotripsy in 17 cases. Nine patients remain alive and well with their stents still in place. Initial management of large CBD calculi by ERCP and stent placement carries a low morbidity and mortality and is a useful adjunct in the management of a difficult clinical problem.

Intramuscular diclofenac sodium for postoperative analgesia after laparoscopic cholecystectomy: a randomised, controlled trial

Laparoscopic cholecystectomy is the surgical treatment of choice for symptomatic gallstones. Nonsteroidal antiinflammatory drugs offer effective analgesia, avoiding the central side effects of opiate drugs. To assess intramuscular diclofenac sodium (Voltarol; Ciba-Geigy) after laparoscopic cholecystectomy, 55 consecutive patients (41 female; 14 male; mean age: 50 years) were randomised to receive either diclofenac or placebo in double-blind fashion. Six patients were withdrawn from study (three conversions to open cholecystectomy; three incomplete documentation). Pain scores were assessed at 4, 24, and 48 h using a linear analogue scale; opiate consumption and time to first oral fluid and food were recorded. In 26 patients receiving diclofenac, median scores at 4 h were 1.6 (range 0-7.6) as compared with 4.1 (range 0-7.6) in 23 control patients (p = 0.05, 95% confidence limits 3.2, 0; Mann-Whitney U test). Nausea scores, return to diet, and time to discharge did not differ significantly between the groups. Intramuscular diclofenac significantly reduces early postoperative pain after laparoscopic cholecystectomy and is worthy of consideration if the procedure were ever undertaken as day case surgery.

Long-term pain: less common after laparoscopic than open cholecystectomy

Persistent symptoms after cholecystectomy are common, occurring in up to 40 per cent of patients. Severe pain persists in 10 per cent of cases. A total of 450 patients were studied, 200 after open cholecystectomy and 250 after the laparoscopic operation. Patient notes were reviewed and a postal questionnaire was circulated. Responses were obtained from 155 patients (77.5 per cent) undergoing open cholecystectomy and 205 (82.0 per cent) having the laparoscopic operation. Mean (s.d.) follow-up was 32(23) months after open cholecystectomy and 15(7) months after the laparoscopic procedure. Right upper quadrant pain was more common after open cholecystectomy (9.7 versus 3.4 per cent, P < 0.05). Indigestion and heartburn were equally prevalent in the two groups. Some 59.4 per cent of patients were free from symptoms after open cholecystectomy compared with 63.4 per cent following the laparoscopic operation; there was symptomatic improvement in 30.3 and 31.7 per cent respectively. Symptoms were the same or worse in 10.3 per cent of patients after open cholecystectomy compared with 4.9 per cent after the laparoscopic operation (P < 0.05). Patients report significantly less right upper quadrant pain after laparoscopic than after open cholecystectomy.

Immunocytochemical staining of pS2 protein in fine-needle aspirate from breast cancer is an accurate guide to response to tamoxifen in patients aged over 70 years

Fine-needle aspirates from 52 breast cancers in 50 patients over 70 years of age were immunocytochemically stained for pS2 protein. All patients were treated with tamoxifen 40 mg/day and followed up at intervals of 2 months. The size of the tumour was serially assessed with calipers and portable ultrasonography. Change in tumour size was confirmed mammographically. Clinical monitoring was performed bind of the pS2 status. Twenty-five tumours were pS2 positive, of which 23 showed a significant response; ten went into complete remission (mean time to complete remission 6.8 (range 2-14) months) and 13 demonstrated partial remission (mean follow-up 8.9 (range 6-19) months). Two tumours remained static. Twenty-seven tumours were pS2 negative and none of these responded to tamoxifen; six remained static (mean follow-up 11.5 (range 6-14) months) and 21 progressed (mean time to progression 7.0 (range 3-14) months) (P < 0.001). Immunocytochemical assessment of fine-needle aspirates from elderly women with breast cancer accurately predicts a worthwhile response to tamoxifen.

Imaging of the common bile duct in patients undergoing laparoscopic cholecystectomy

Options for managing the common bile duct during laparoscopic cholecystectomy include routine peroperative cholangiography and selected preoperative endoscopic retrograde cholangiopancreatography (ERCP). The use of these methods was reviewed in 350 patients with symptomatic gall stones referred for laparoscopic cholecystectomy. Unit A (n = 114) performed routine cystic duct cholangiography but undertook preoperative ERCP in patients at very high risk of duct stones only; unit B (n = 236) performed selected preoperative ERCP on the basis of known risk factors for duct stones. The detection rate for common bile duct stones was similar for units A and B (16% v 20%). In unit A, five of seven patients who had preoperative ERCP had duct stones. Operative cholangiography was technically successful in 90% of patients and duct stones were confidently identified in 13, one of whom went on to immediate open duct exploration. Postoperative ERCP identified duct stones in only four patients, indicating spontaneous passage in eight. In unit B, preoperative ERCP was undertaken in 76 of 236 (32%) patients and duct stones were identified in 47 (20%). Duct clearance was successful in 42 (18%) but failed in five (2%), necessitating elective open duct exploration. Both protocols for imaging the common bile duct worked well and yielded satisfactory short term results.

Thickness of adherent mucus gel on colonic mucosa in humans and its relevance to colitis

The thickness of adherent mucus gel on the surface of colonic mucosa was measured in surgically resected specimens from 46 'control' patients most of whom had carcinoma of the colon; 12 were from right colon, 17 left colon, and 21 from rectum. In addition specimens were examined from 17 patients with ulcerative colitis and 15 patients with Crohn's disease. In controls a continuous layer of mucus was readily seen on specially prepared sections viewed by phase contrast illumination. Mean values for right and left colon and rectum were 107 (48), 134 (68), and 155 (54) microns respectively with a significant difference between right colon and rectum (p = 0.015). Values in ulcerative colitis showed greater variation and in those areas with acute inflammation mucosa was denuded of the mucus layer. In contrast, values for Crohn's disease were normal or greater than normal in thickness--right colon 190 (83) microns compared with 107 48 microns, p = 0.0093. A series of validation experiments are described for the method used to measure mucus thickness. The possible role of mucus in the pathogenesis of inflammatory bowel disease is discussed.

Effect of nicotine on rectal mucus and mucosal eicosanoids

Because ulcerative colitis is largely a disease of non-smokers and nicotine may have a beneficial effect on the disease, the effect of nicotine on rectal mucosa in rabbits was examined. Nicotine was given subcutaneously by an Alzet mini-pump in doses of 0.5, 1.25, and 2 mg/kg/day for 14 days to three groups of eight animals and compared with eight controls. Mean (SD) serum nicotine concentrations (ng/ml) were 3.5 (1.1), 8.8 (2.3), and 16.2 (5.2) respectively in the treated groups. The thickness of adherent mucus on rectal mucosa in controls (median 36 microns) was significantly reduced by low dose (22 microns, p = 0.0011), and increased by high dose nicotine (48 microns, p = 0.035). Incorporation of radioactive glucosamine into papain resistant glycoconjugates was unchanged, indicating that mucin synthesis was unaltered. Prostaglandins (PG) were reduced, in some cases significantly (6-keto PGF1 alpha, PGF2 alpha, and hydroxy-eicosatetraenoic acid), by nicotine, which showed an inverse dose dependence--with greatest inhibition in relation to the lowest dose. Nicotine, and possibly smoking, may affect colitis by an action on mucosal eicosanoids and on adherent surface mucus secretion in the rectum and large bowel.

Pediatric trauma patients in an 'adult' trauma center

The injury patterns, age distribution, and outcome of pediatric patients (age < 15 years) treated in an "adult" trauma center is incompletely defined. A total of 1115 pediatric trauma patients (9.6% total trauma admissions) treated over a 6-year period in a level I suburban trauma center without a pediatric trauma service or a pediatric surgeon were reviewed for age distribution; injury mechanism, injury pattern, and injury severity; surgical procedures; disposition; and mortality. All charts were subject to internal and external peer review, including five site surveys. Resuscitation, surgery, critical care, and stepdown management were provided by a trauma team led by in-house attending trauma surgeons (mean PGY = 20). Of the patients 22% were preschool (age 0-4 years), and 34% were adolescent (age 12-14 years); the mechanism was blunt (96%), with motor vehicular crash being the most frequent; the mean ISS was 11.1, with 39% of ISSs > 9; significant injuries (AIS score > or = 3) of the head and extremities were dominant; 3.9% of patients underwent laparotomy, primarily for injuries to the bowel, spleen, and liver. There was only one laparotomy in the 0-4 year age group. The mean length of stay of patients was 6.2 days, with 38% requiring time in the ICU. Of the patients, 90% were discharged home; the treated trauma patient mortality rate was 25 of 988, or 2.5%; 92% of these died of nonsurvivable head injuries. No deaths were judged preventable. There was no significant difference of noncompliance for the pediatric patients when compared with the adult population in five trauma audit filters.(ABSTRACT TRUNCATED AT 250 WORDS)