Closure of trocar wounds using a suture carrier

We developed a hook suture carrier for closure of trocar wounds, making use of the vertical rather than the horizontal space, which is limited in small wounds. The technique is simpler than all the laparoscopically assisted devices currently available, and it has no learning curve. No complications developed in 6 months of use.

Laparoscopic resection of accessory spleen for recurrent immune thrombocytopenic purpura 19 years after splenectomy

Routine identification and resection of accessory splenic tissue, an integral part of splenectomy for immune thrombocytopenic purpura (ITP), is not necessarily a "blind spot" of the laparoscopic technique. This case report of laparoscopic resection of accessory spleen for recurrent ITP 19 yr after splenectomy supports this view.

Closure of trocar wounds in laparoscopic operations. The threading technique

A method of fascial closure utilizing a hypodermic needle as a conduit for threading the suture through the fascia is described. This technique is designed to make use of vertical space rather than horizontal space, which is lacking in the small trocar wounds. The technique is easy to master and teach and has resulted in secure closures in over 150 wounds.

Pancreas-sparing duodenectomy: indications, surgical technique, and results

BACKGROUND

Pancreatoduodenectomy, originally performed for malignancy of the pancreas and duodenum, is also commonly used for potentially malignant lesions. Because a normal pancreas should be spared, we investigated the concept of duodenectomy alone with the pancreas intact for diseases such as familial adenomatous polyposis syndrome.

METHODS

Five patients underwent pancreas-sparing duodenectomy for nonmalignant lesions performed by means of meticulous detachment of the duodenum from the pancreas, transecting the bile and pancreatic ducts outside the duodenum. Reconstruction was accomplished by advancing the jejunum to anastomose end-to-end with the juxtapyloric duodenal cuff, implanting the bile and pancreatic ducts in a location corresponding to the native papilla. The hospital course, complications, and long-term follow-up status of all patients are reviewed in detail.

RESULTS

No deaths occurred in this series. Delayed gastric emptying was seen in one patient and transient pancreatic fistula in another. Long-term endoscopic follow-up showed no stenosis of the ductal anastomoses. Endoscopic surveillance, including endoscopic retrograde cholangiopancreatography, was not hampered by this technique of reconstruction.

CONCLUSIONS

Pancreas-sparing duodenectomy is a practical operation for nonmalignant duodenal lesions where the pancreas is not involved by the disease process.

Incomplete excision of the gallbladder during laparoscopic cholecystectomy

Dissection and transection of the cystic duct close to the gallbladder has been advocated as a means of avoiding common bile injury during laparoscopic cholecystectomy (LC). We present three cases in which inadequate identification of the gallbladder-cystic duct junction resulted in incomplete cholecystectomy. In two patients an unsecured gallbladder infundibulum presented as cystic duct leaks and one patient developed recurrent symptomatic cholelithiasis. These cases emphasize the need for complete dissection and visualization of the cystic duct at the gallbladder prior its division and secure ligation during LC.

Endoscopic treatment of biliary leakage after laparoscopic cholecystectomy

Laparoscopic cholecystectomy is an effective and safe treatment for uncomplicated symptomatic cholelithiasis. However, biliary tract injury may be more common with this procedure than with open cholecystectomy. We have encountered 17 patients with a biliary leak among 465 patients undergoing laparoscopic cholecystectomy, the diagnosis being established by clinical and radiographic parameters. The most common site of leakage was the cystic duct stump. Patients underwent endoscopic sphincterotomy and biliary stent placement, with an overall success rate of 96%. No morbidity or mortality related to the endoscopic procedures was encountered. We conclude that biliary leakage after laparoscopic cholecystectomy is uncommon. When it occurs, it can be treated safely and efficaciously by endoscopic means.

Surgical decisions in the management of duodenal perforation complicating endoscopic sphincterotomy

The management of duodenal perforation associated with endoscopic sphincterotomy is controversial. Despite the fact that many patients recover without surgery, surgical opinion tends to favor immediate operation upon diagnosis since the mortality is high when sepsis is advanced. To refine the criteria for operative management, all duodenal perforations after endoscopic sphincterotomy over a 5-year period were studied. In a series of 464 consecutive endoscopic sphincterotomies, 8 duodenal perforations occurred; additionally, 4 patients with duodenal perforation were referred from elsewhere for management. Six patients were managed initially with nonoperative treatment (group I), and six underwent exploratory surgery upon diagnosis or hospital transfer (group II). One patient in group I was operated on 4 days after diagnosis. Of the seven surgically treated patients, three had repair of the duodenal perforation and drainage of the abscess or phlegmon, but four had no gross inflammation or visible duodenal perforation requiring repair at exploration. The clinical features of abdominal pain with physical signs significantly correlated with operative findings of pus or phlegmon (p < 0.05). Improvement in symptoms within 24 hours is correlated with spontaneous recovery (p < 0.01). Neither the presence of retroperitoneal air nor contrast leak is predictive of the need for surgery, and neither correlated with the size of the perforation. It is concluded that duodenal perforation may be treated successfully without surgery when the symptoms are mild and improve rapidly with medical treatment, but surgery should be undertaken if pain and abdominal signs are prominent, if suppuration is suspected, or if symptoms do not improve after a brief period of nonoperative management.

Thiamin and vitamin B6 intakes and erythrocyte transketolase and aminotransferase activities in morbidly obese females before and after gastroplasty

To assess the need for postoperative vitamin supplements, intakes and nutritional status of thiamin (B1) and vitamin B6 were studied in 18 female gastroplasty patients who received a placebo or different levels of supplemental vitamins. Postoperative erythrocyte transketolase basal (BA) and thiamin pyrophosphate-stimulated (SA) activities and activity coefficients (AC) correlated significantly with B1 intake. Despite a decrease in apotransketolase, low thiamin intakes were associated with increased AC values during the first 3 months. With return to low B1 intakes following repletion during month 4, the AC values remained normal with low total activities. Both alanine (EALT) and aspartate (EAST) aminotransferase apoenzyme levels declined and AC values increased significantly during the first 3 months. Although the EALT-indices were more sensitive to changes in B6 intake than the EAST-indices, the EASTBA and SA correlated most consistently with the intake. Postoperative dietary intakes of both vitamins were inadequate for maintenance of normal activities of these erythrocyte enzymes. Although B1 intake of greater than or equal to 1.0 mg/day was adequate for maintenance of normal thiamin status in most subjects of this study, supplementation with greater than or equal to 1.5 mg/day is prudent even though it may not prevent the early postoperative loss of apotransketolase. Vitamin B6 intake at the current recommended dietary allowance (1.6 mg) was not adequate to maintain coenzyme saturation of the erythrocyte aminotransferases. Marginal intake of other nutrients may have affected the utilization of both thiamin and vitamin B6.

The phenomenal growth of laparoscopic cholecystectomy: a review

The widespread use of laparoscopic cholecystectomy 2 years after its introduction suggests that the procedure is a viable therapeutic option for uncomplicated gallstone disease. Early results seem to support a shorter convalescence for this procedure compared to open cholecystectomy. However, the actual complication rate is unknown. The outcome appears to be highly dependent on the skill and experience of the surgeon. How this operation is ranked against the classical cholecystectomy remains to be assessed.

Gastric perforation after endoscopic treatment of a Dieulafoy's lesion

Dieulafoy's vascular malformation is an underdiagnosed cause of massive, often recurrent upper gastrointestinal hemorrhage. Attempted endoscopic treatment of Dieulafoy's lesion has been recommended prior to surgery in many instances, but may occasionally be employed as primary therapy in patients that are not considered good "operative risks." Although generally considered safe and effective therapy for nonvariceal hemorrhage, combination therapy by injection and thermocoagulation techniques may result in perforation. We present a patient with a Dieulafoy's lesion of the stomach that illustrates both the efficacy and risks of combination endoscopic therapy for nonvariceal gastrointestinal hemorrhage.

Retrograde dilation of esophageal strictures with balloon dilators

Balloon dilators may be safely applied for retrograde dilation of esophageal strictures without the use of fluoroscopy or a pressure-gauge attachment. The turgidity of the dilating balloon is preferred to that of other materials such as polyvinyl, rubber, or metal. The technique enables endoscopic monitoring and can be adapted for strictures elsewhere in the gastrointestinal tract.

Giant cerebral aneurysm repair. Incorporating cardiopulmonary bypass and neurosurgery

Since our initial experience on April 28, 1989, a total of nine patients have received treatment for giant cerebral aneurysm using cardiopulmonary bypass with deep hypothermia and circulatory arrest. The following data summarize our findings associated with these patients. The average patient's age was 46 years (range: 16 to 59 years of age). Seven patients were female, two were male. The procedure required approximately eight hours to complete with an average cardiopulmonary bypass time of 104 minutes (range: 60 to 140 minutes). Circulatory arrest time averaged 26 minutes (range, 12 to 45 minutes) with an average of 30 minutes (range: 10 to 62 minutes) required to cool the patient to below 18 degrees C (64 degrees F). An average of 54 minutes (range: 28 to 81 minutes) was required to warm the patient to a bladder temperature of 36 degrees C (96.8 degrees F). During the cooling period, five patients went into asystole spontaneously, four patients required bolus of 20 mEq of potassium chloride, and upon rewarming, spontaneous defibrillation occurred in six patients. Three patients were defibrillated without difficulty with external shock. The average number of blood products administered in each of the nine patients was 3.6 units of packed red blood cells, 3 units of fresh frozen plasma, and 6.5 units of platelets. Six patients recovered postoperatively without complication, and the recovery of three patients was affected by the complex anatomical location of the giant aneurysm. Cardiopulmonary bypass with deep hypothermia and circulatory arrest offers an alternative approach to the treatment of giant cerebral aneurysms considered inoperable by conventional techniques. The effectiveness of each procedure depends on the collaborative efforts of every member of the perioperative nursing team, the neurosurgical team, the cardiac surgical team, the neuroanesthesiology team, and the perfusionists. Careful planning and anticipation at every stage of the surgery can reduce surgical time, cardiopulmonary bypass time, and most importantly, circulatory arrest time.

Effect of Wound Closure Technique on Wound Infection in the Morbidly Obese: results of a randomized trial

The effect of suture obliteration of the subcutaneous dead space in morbidly obese abdominal wounds was studied in a randomized trial, comparing a pre-fascial retention suture technique (utilized for approximated of the thick panniculus) to controls where the skin was simply closed with staples. The wound infection rates were similar (11.8% for the sutured group versus 12.3% for controls, p 0.4), as were the total wound complication rates (26.5% for sutured group versus 21.9% for controls, p 0.4). Ultrasound study of the wounds closed without suturing the panniculus demonstrated no dead spaces. We conclude that no advantage is to be gained by suturing the subcataneous fat, however thick. The finding is of general application in wound closures involving thick layers of fat.

Riboflavin intakes and status of morbidly obese females during the first postoperative year following gastroplasty

Eighteen women participated in a prospective study to assess the need for supplemental riboflavin after gastroplasty. Three groups of five patients received either a placebo or 0.6 or 1.2 mg riboflavin daily for up to 12 months, except during months 4 and 7 when all participants were given a "one-a-day" supplement containing 1.7 mg riboflavin. Dietary intakes of riboflavin decreased from 1.43 +/- 0.17 mg before the operation to 0.70 +/- 0.07 mg at 3 months, and then increased to 1.02 +/- 0.17 mg by 6 months. Even at 12 months, only 33% of the subjects had dietary intakes greater than or equal to 1.2 mg. All those with total intakes less than or equal to 1.7 mg at 3 months had impaired riboflavin status, as indicated by an erythrocyte gluthatione reductase activity coefficient greater than 1.40 and an erythrocyte riboflavin concentration less than 372 nmol/L. In contrast, 62% of the same subjects had urinary riboflavin excretion in the acceptable range. Supplemental intake of 1.7 mg riboflavin appeared to prevent tissue depletion in all subjects.

Pathogenesis of complications of percutaneous endoscopic gastrostomy. A lesson in surgical principles

In two comparable series of percutaneous endoscopic gastrostomy differing in only one technical detail, complications were significantly reduced by omitting traction on the gastrostomy tube to approximate the gastric to the abdominal wall. Radiologic studies show that traction shortened the tract (4.9 +/- 1.1 cm with traction, 11.6 +/- 2.3 cm without traction). In two patients with fasciitis, gross pericatheter leak of contrast into a short and patulous tract was observed. Tube extrusion and gastrointestinal bleeding from gastric ersion ulcers were eliminated when traction was not used. No peritonitis occurred as a result of not attempting to approximate the stomach to the abdominal wall. The data suggest that traction on the gastrostomy tube is not only unnecessary, but is the cause of many of the complications reported.

Effect of energy restriction on riboflavin retention in normal and deficient tissues of the rat

We investigated the effects of energy restriction on tissue riboflavin depletion and subsequent repletion of deficient tissues. Groups of male Sprague Dawley rats with average body weights between 268 and 275g were placed on energy-restricted diets consisting of 8g (31kcal or 130kJ) per day of a basal diet adequate in all other nutrients and either 12mg of riboflavin/kg or no added riboflavin. The ad libitum controls received additional energy as a mixture of sucrose, starch, and corn oil (10:3:1 by wt). No significant difference in the degree of riboflavin deficiency was detected between energy-restricted and ad libitum-fed rats as assessed by riboflavin concentrations in the liver and gastrocnemius and soleus muscles and by the erythrocyte glutathione reductase activity coefficient (EGRAC). Additional energy-restricted riboflavin-deficient rats were subsequently repleted by feeding either the supplemented basal diet with no additional energy or with ad libitum energy. Repletion of liver riboflavin concentration and reduction of the EGRAC values to control levels occurred regardless of energy intake. Muscle riboflavin concentrations were normal in the ad libitum-fed group but decreased in the energy-restricted rats despite 4 weeks of supplementation. The latter group had muscle riboflavin levels similar to those in the rats fed the riboflavin-deficient diet for 8 weeks. The results suggest that energy restriction impairs flavo-protein synthesis in muscle but not in the liver.

Plasma pyridoxal phosphate as indicator of vitamin B6 status in morbidly obese women after gastric restriction surgery

Plasma pyridoxal phosphate (PLP) concentrations were determined in 15 morbidly obese women before and after gastric restriction surgery for weight reduction. The subjects received a daily vitamin-mineral supplement containing 2 or 3 mg of vitamin B6 for 9 days before the operation and either a placebo or a multivitamin supplement containing 0.4, 0.8 or 2 mg of vitamin B6 for 3 months postoperatively. During the fourth month, all subjects received 2 mg of supplemental vitamin B6 per day. Dietary intakes of the vitamin were calculated from 3-day intake records kept by the subjects. Blood samples for PLP determination were obtained preoperatively and twice between weeks 4 and 8 and at 3 and 4 months postoperatively. The mean concentration of plasma PLP increased significantly from preoperation to 4 to 5 weeks postoperation and returned to the preoperative level by 6 to 8 weeks, with no further changes during the rest of the experimental period. There was no correlation between plasma PLP and either total or supplemental intakes of vitamin B6 at any of the time periods studied. Significant positive correlations were found between the preoperative and the first two postoperative plasma PLP levels (r = 0.93 and 0.67, p less than 0.001 and 0.005, respectively) and between the rate of weight loss and plasma PLP at 4-5 weeks and at 4 months postoperatively. Muscle PLP reserve may be mobilized during the early postoperative period and complicate the use of plasma PLP as a measure of vitamin B6 status.

Videoendoscopy for difficult anastomoses

To determine whether intra-operative videoendoscopy provides useful information on the integrity of gastrointestinal anastomoses, laboratory and clinical studies were undertaken. In the dog model, the videoendoscope was inserted per orum to visualize side-to-side (gastrojejunostomy) and end-to-end (jejunojejunostomy) anastomoses and to establish endoscopic criteria of normal anastomosis, verified by examination of the specimen. Technically faulty anastomoses were then constructed and inspected endoscopically to determine the signs of poor technique. In clinical application, the videoendoscope was used to inspect the anastomoses after low anterior resection, revision of gastric bypass, and choledochoduodenostomy. The laboratory results indicate that direct visualization of a defect in suture-line with the end-viewing endoscope is difficult, although indirect signs of trouble are helpful. Conversely, the appearance of a perfect anastomosis without any indirect signs of poor technique is accurate in the assurance of a trouble-free anastomosis. The best clinical use is in low anterior resection of the rectum and the worst is in choledochoduodenostomy. It is concluded that videoendoscopic inspection of anastomosis is only of limited help in determining the integrity of a difficult anastomosis, and much work is required to perfect both the instrument and technique before general use is recommended.

Prediction of post-cardiopulmonary bypass cardiac output

The ability to predict cardiac output (CO) before termination of cardiopulmonary bypass (CPB) allows identification of potential complications once the patient is off bypass. We have previously demonstrated that CO early after CPB can be reliably predicted by a plot of venous oxygen saturation at various flow rates on CPB, based on in-line monitoring of venous oxygen saturation. In this study, we evaluated a simplified technique for predicting CO with a series of 50 patients on CPB. When CPB weaning began, patients were normothermic, anesthetized, and paralyzed. Venous oxygen saturation and arterial blood flow were recorded. At low pump flow just before termination of CPB, the final venous oxygen saturation was recorded. Assuming a proportional relationship between venous oxygen saturation and arterial blood flow, CO early after CPB was predicted. The simplified CO prediction was compared with the thermodilution CO immediately after CPB. The simplified technique reliably predicted CO early after CPB compared with the thermodilution technique. The simplicity and reliability increase the clinical value of the CO prediction.

The role of tissue ischemia in the pathogenesis of anastomotic stricture

In a chronic dog model, colocolostomies with intact blood supplies were constructed with the circular stapler. By means of "tight" stapling, an ischemic suture line was induced (suture line blood flow reduced to less than 10% of baseline mucosal blood flow). Under these conditions, only one of 20 anastomoses resulted in stenosis at 1 month. Correctly stapled colocolostomies were then performed in bowels rendered ischemic by removal of all mesenteric arcades for 4 to 6 cm. Mucosal blood flow in such ischemic bowels was reduced to 30% and 16% of control, respectively, and suture line blood flow was as low as that of the tightly stapled anastomoses. Significant stenosis (more than 68% reduction of the lumen) was observed in the group with 6 cm of mesenteric clearance. In no dogs did peritonitis or colonic gangrene develop. Gross and histologic revascularization was evident when dogs were killed at 6 weeks. These findings suggest that it is ischemia of the bowel, rather than ischemia at the suture line itself, that leads to anastomotic stricture. In view of the known susceptibility of the human intestine to ischemia, the model may have overstated the degree of ischemia necessary to produce strictures in clinical practice. Since the induced acute ischemia did not persist in the chronic state, we conclude that it is the adequacy of collateral development that determines the outcome in this model.

The sources of recurrent hemorrhage during long-term sclerotherapy

The sources of recurrent hemorrhage during long-term sclerotherapy undertaken by a single surgeon were studied prospectively in a consecutive series of 53 patients for a period of 2 to 6 years. Recurrent hemorrhage, defined as upper gastrointestinal bleeding requiring transfusion or hospitalization or both, in the course of chronic sclerotherapy was investigated aggressively by means of endoscopy and the findings archived with videotape recording. In 24 patients 51 episodes of recurrent hemorrhage developed in the entire series. On the basis of endoscopic findings and serial comparison of videotape recordings, the most common source of recurrent hemorrhage was the original varices, which accounted for rebleeding in 18 patients. The risk of such bleeding was highest in the first month, diminishing thereafter until total variceal eradication. Rebleeding after eradication of varices was always from sources other than varices, as regenerated vessels were small and infrequent and never the source of bleeding. Continued sclerotherapy ultimately achieved total variceal eradication in 15 of 18 patients with variceal rebleeding. Sclerotherapy alone was successful in eradicating all varices in a total of 38 patients in this series, the mean time required being 13 +/- 4.1 months. Rebleeding from sources not amenable to sclerotherapy was treated with porto-azygos disconnection (6 patients) or distal splenorenal shunts (3 patients). There were 12 deaths: four attributed to hemorrhage (3 after surgery), five from liver failure, and three late deaths from causes not due to liver disease. Recurrent hemorrhage per se during the course of sclerotherapy may not be taken as a sign of treatment failure but must be vigorously investigated, since findings profoundly affect management and outcome.

Endoscopic measurement of gastric mucosal blood flow by laser Doppler velocimetry: effect of chronic esophageal variceal sclerosis

A technique of endoscopic measurement of gastric mucosal blood flow using laser Doppler velocimetry was described. The technique was validated in the laboratory by performing endoscopic measurement of gastric mucosal blood flow in the dog simultaneously with application of a second probe at open operation, utilizing the same laser Doppler flowmeter. Probe pressure causing minor dimpling (less than 20 gm/cm2) was found to cause insignificant alteration of mucosal blood flow. Criteria were developed to aid separation of artifacts introduced by probe motion. A conversion factor was established for converting the readout of the instrument (Hertz x 10(2] into ml/100g/min by synchronously measuring mucosal blood flow by hydrogen gas clearance technique and laser Doppler velocimetry in the gastric and duodenal mucosa. In patients with portal hypertension gastric mucosal blood flow was determined before and after sclerotherapy, and compared to the gastric mucosal blood flow in subjects without portal hypertension. Gastric mucosal blood flow was elevated in portal hypertensives, but sclerotherapy did not appear to cause changes in blood flow. Endoscopic mucosal blood flow measurement is non-invasive, practical and of potential value in clinical investigation of gastrointestinal pathophysiology.