Background: Tokyo Guidelines for the management of acute cholangitis and cholecystitis

There are no evidence-based-criteria for the diagnosis, severity assessment, of treatment of acute cholecystitis or acute cholangitis. For example, the full complement of symptoms and signs described as Charcot's triad and as Reynolds' pentad are infrequent and as such do not really assist the clinician with planning management strategies. In view of these factors, we launched a project to prepare evidence-based guidelines for the management of acute cholangitis and cholecystitis that will be useful in the clinical setting. This research has been funded by the Japanese Ministry of Health, Labour, and Welfare, in cooperation with the Japanese Society for Abdominal Emergency Medicine, the Japan Biliary Association, and the Japanese Society of Hepato-Biliary-Pancreatic Surgery. A working group, consisting of 46 experts in gastroenterology, surgery, internal medicine, emergency medicine, intensive care, and clinical epidemiology, analyzed and examined the literature on patients with cholangitis and cholecystitis in order to produce evidence-based guidelines. During the investigations we found that there was a lack of high-level evidence, for treatments, and the working group formulated the guidelines by obtaining consensus, based on evidence categorized by level, according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence of May 2001 (version 1). This work required more than 20 meetings to obtain a consensus on each item from the working group. Then four forums were held to permit examination of the Guideline details in Japan, both by an external assessment committee and by the working group participants (version 2). As we knew that the diagnosis and management of acute biliary infection may differ from country to country, we appointed a publication committee and held 12 meetings to prepare draft Guidelines in English (version 3). We then had several discussions on these draft guidelines with leading experts in the field throughout the world, via e-mail, leading to version 4. Finally, an International Consensus Meeting took place in Tokyo, on 1-2 April, 2006, to obtain international agreement on diagnostic criteria, severity assessment, and management.

Need for criteria for the diagnosis and severity assessment of acute cholangitis and cholecystitis: Tokyo Guidelines

The Tokyo Guidelines formulate clinical guidance for healthcare providers regarding the diagnosis, severity assessment, and treatment of acute cholangitis and acute cholecystitis. The Guidelines were developed through a comprehensive literature search and selection of evidence. Recommendations were based on the strength and quality of evidence. Expert consensus opinion was used to enhance or formulate important areas where data were insufficient. A working group, composed of gastroenterologists and surgeons with expertise in biliary tract surgery, supplemented with physicians in critical care medicine, epidemiology, and laboratory medicine, was selected to formulate draft guidelines. Several other groups (including members of the Japanese Society for Abdominal Emergency Medicine, the Japan Biliary Association, and the Japanese Society of Hepato-Biliary-Pancreatic Surgery) have reviewed and revised the draft guidelines. To build a global consensus on the management of acute biliary infection, an international expert panel, representing experts in this area, was established. Between April 1 and 2, 2006, an International Consensus Meeting on acute biliary infections was held in Tokyo. A consensus was determined based on best available scientific evidence and discussion by the panel of experts. This report describes the highlights of the Tokyo International Consensus Meeting in 2006. Some important areas focused on at the meeting include proposals for internationally accepted diagnostic criteria and severity assessment for both clinical and research purposes.

Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines

This article discusses the definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis. Acute cholangitis and cholecystitis mostly originate from stones in the bile ducts and gallbladder. Acute cholecystitis also has other causes, such as ischemia; chemicals that enter biliary secretions; motility disorders associated with drugs; infections with microorganisms, protozoa, and parasites; collagen disease; and allergic reactions. Acute acalculous cholecystitis is associated with a recent operation, trauma, burns, multisystem organ failure, and parenteral nutrition. Factors associated with the onset of cholelithiasis include obesity, age, and drugs such as oral contraceptives. The reported mortality of less than 10% for acute cholecystitis gives an impression that it is not a fatal disease, except for the elderly and/or patients with acalculous disease. However, there are reports of high mortality for cholangitis, although the mortality differs greatly depending on the year of the report and the severity of the disease. Even reports published in and after the 1980s indicate high mortality, ranging from 10% to 30% in the patients, with multiorgan failure as a major cause of death. Because many of the reports on acute cholecystitis and cholangitis use different standards, comparisons are difficult. Variations in treatment and risk factors influencing the mortality rates indicate the necessity for standardized diagnostic, treatment, and severity assessment criteria.

Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines

Diagnostic and therapeutic strategies for acute biliary inflammation/infection (acute cholangitis and acute cholecystitis), according to severity grade, have not yet been established in the world. Therefore we formulated flowcharts for the management of acute biliary inflammation/infection in accordance with severity grade. For mild (grade I) acute cholangitis, medical treatment may be sufficient/appropriate. For moderate (grade II) acute cholangitis, early biliary drainage should be performed. For severe (grade III) acute cholangitis, appropriate organ support such as ventilatory/circulatory management is required. After hemodynamic stabilization is achieved, urgent endoscopic or percutaneous transhepatic biliary drainage should be performed. For patients with acute cholangitis of any grade of severity, treatment for the underlying etiology, including endoscopic, percutaneous, or surgical treatment should be performed after the patient's general condition has improved. For patients with mild (grade I) cholecystitis, early laparoscopic cholecystectomy is the preferred treatment. For patients with moderate (grade II) acute cholecystitis, early laparoscopic or open cholecystectomy is preferred. In patients with extensive local inflammation, elective cholecystectomy is recommended after initial management with percutaneous gallbladder drainage and/or cholecystostomy. For the patient with severe (grade III) acute cholecystitis, multiorgan support is a critical part of management. Biliary peritonitis due to perforation of the gallbladder is an indication for urgent cholecystectomy and/or drainage. Delayed elective cholecystectomy may be performed after initial treatment with gallbladder drainage and improvement of the patient's general medical condition.

Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines

Because acute cholangitis sometimes rapidly progresses to a severe form accompanied by organ dysfunction, caused by the systemic inflammatory response syndrome (SIRS) and/or sepsis, prompt diagnosis and severity assessment are necessary for appropriate management, including intensive care with organ support and urgent biliary drainage in addition to medical treatment. However, because there have been no standard criteria for the diagnosis and severity assessment of acute cholangitis, practical clinical guidelines have never been established. The aim of this part of the Tokyo Guidelines is to propose new criteria for the diagnosis and severity assessment of acute cholangitis based on a systematic review of the literature and the consensus of experts reached at the International Consensus Meeting held in Tokyo 2006. Acute cholangitis can be diagnosed if the clinical manifestations of Charcot's triad, i.e., fever and/or chills, abdominal pain (right upper quadrant or epigastric), and jaundice are present. When not all of the components of the triad are present, then a definite diagnosis can be made if laboratory data and imaging findings supporting the evidence of inflammation and biliary obstruction are obtained. The severity of acute cholangitis can be classified into three grades, mild (grade I), moderate (grade II), and severe (grade III), on the basis of two clinical factors, the onset of organ dysfunction and the response to the initial medical treatment. "Severe (grade III)" acute cholangitis is defined as acute cholangitis accompanied by at least one new-onset organ dysfunction. "Moderate (grade II)" acute cholangitis is defined as acute cholangitis that is unaccompanied by organ dysfunction, but that does not respond to the initial medical treatment, with the clinical manifestations and/or laboratory data not improved. "Mild (grade I)" acute cholangitis is defined as acute cholangitis that responds to the initial medical treatment, with the clinical findings improved.

Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines

The aim of this article is to propose new criteria for the diagnosis and severity assessment of acute cholecystitis, based on a systematic review of the literature and a consensus of experts. A working group reviewed articles with regard to the diagnosis and treatment of acute cholecystitis and extracted the best current available evidence. In addition to the evidence and face-to-face discussions, domestic consensus meetings were held by the experts in order to assess the results. A provisional outcome statement regarding the diagnostic criteria and criteria for severity assessment was discussed and finalized during an International Consensus Meeting held in Tokyo 2006. Patients exhibiting one of the local signs of inflammation, such as Murphy’s sign, or a mass, pain or tenderness in the right upper quadrant, as well as one of the systemic signs of inflammation, such as fever, elevated white blood cell count, and elevated C-reactive protein level, are diagnosed as having acute cholecystitis. Patients in whom suspected clinical findings are confirmed by diagnostic imaging are also diagnosed with acute cholecystitis. The severity of acute cholecystitis is classified into three grades, mild (grade I), moderate (grade II), and severe (grade III). Grade I (mild acute cholecystitis) is defined as acute cholecystitis in a patient with no organ dysfunction and limited disease in the gallbladder, making cholecystectomy a low-risk procedure. Grade II (moderate acute cholecystitis) is associated with no organ dysfunction but there is extensive disease in the gallbladder, resulting in difficulty in safely performing a cholecystectomy. Grade II disease is usually characterized by an elevated white blood cell count; a palpable, tender mass in the right upper abdominal quadrant; disease duration of more than 72 h; and imaging studies indicating significant inflammatory changes in the gallbladder. Grade III (severe acute cholecystitis) is defined as acute cholecystitis with organ dysfunction.

Massive Fecal Impaction Presenting with Megarectum and Perforation of a Stercoral Ulcer at the Rectosigmoid Junction

A 25-year-old male with lifelong constipation presented to the emergency department with an acute abdomen. Initial resuscitation was performed, and the patient underwent urgent laparotomy. He was found to have feculent peritonitis with megabowel involving the rectum and sigmoid colon and a stercoral ulcer with full thickness erosion, and perforation was also identified on the anti-mesocolic surface at the rectosigmoid junction. Abdominal irrigation and subtotal colectomy with proximal fecal diversion was performed. This case illustrates that recognition of severe, chronic constipation should lead to interventions including disimpaction and aggressive medical management. When indicated, megabowel can be managed surgically in an elective setting based on anatomic findings and physiologic studies. Peritonitis is an ominous late finding in patients with severe constipation.

Tailgut Cyst (Retrorectal Cystic Hamartoma): Report of a Case and Review of the Literature

Tailgut cysts are rare congenital lesions arising from remnants of normally regressing postanal primitive gut. They often present in middle-aged women with perirectal symptoms and a retrorectal multicystic mass. These cysts have occasionally shown malignant transformation. We report a case of a tailgut cyst occurring in a 25-year-old African-American female. The differential diagnosis of a retrorectal mass is briefly explored, and the etiology, diagnostic strategy, and surgical approach for tailgut cysts is examined. We also report an extensive literature review to examine clinical characteristics and surgical data for 43 cases of tailgut cysts spanning 16 years.

A Survey of the Work Effort of Full-time Surgeons of the Southeastern Surgical Congress

This is a survey research project to determine the work hours of practicing surgeons and compare those hours with hours that have been mandated for graduate medical education programs by the Accreditation Council for Graduate Medical Education (ACGME). The survey conducted of the membership of the Southeastern Surgical Congress focused on the amount of time devoted to professional activity. Although several categories of membership were surveyed, those surgeons in full-time practice were used for this report. Five hundred ninety-two general surgeons and some surgical specialties from 17 states reported a total professional work effort of 65 hours per week averaged over a month. Twenty per cent reported working more than 80 hours per week. Statistically significant ( P < 0.05) factors that characterized these individuals included years in practice (1 to 10 years), more clinical hours per week, fewer administrative hours per week, fewer teaching hours per week, fewer continuing medical education (CME) hours per year, and an increase in recent clinical practice. Interestingly, there was no significant difference in CME over a 2- or 5-year period. Other factors such as type of practice did not have statistical significance. There was no difference between states and no difference in time commitment to political or community activities. This survey indicates that surgeons going into practice in the Southeast from general surgery graduate medical education programs can expect to have a mean work week of 65 hours, and 20 per cent can expect to exceed an 80-hour work week.

Tailgut cyst (retrorectal cystic hamartoma): report of a case and review of the literature

Tailgut cysts are rare congenital lesions arising from remnants of normally regressing postanal primitive gut. They often present in middle-aged women with perirectal symptoms and a retrorectal multicystic mass. These cysts have occasionally shown malignant transformation. We report a case of a tailgut cyst occurring in a 25-year-old African-American female. The differential diagnosis of a retrorectal mass is briefly explored, and the etiology, diagnostic strategy, and surgical approach for tailgut cysts is examined. We also report an extensive literature review to examine clinical characteristics and surgical data for 43 cases of tailgut cysts spanning 16 years.

A survey of the work effort of full-time surgeons of the Southeastern Surgical Congress

This is a survey research project to determine the work hours of practicing surgeons and compare those hours with hours that have been mandated for graduate medical education programs by the Accreditation Council for Graduate Medical Education (ACGME). The survey conducted of the membership of the Southeastern Surgical Congress focused on the amount of time devoted to professional activity. Although several categories of membership were surveyed, those surgeons in full-time practice were used for this report. Five hundred ninety-two general surgeons and some surgical specialties from 17 states reported a total professional work effort of 65 hours per week averaged over a month. Twenty per cent reported working more than 80 hours per week. Statistically significant (P < 0.05) factors that characterized these individuals included years in practice (1 to 10 years), more clinical hours per week, fewer administrative hours per week, fewer teaching hours per week, fewer continuing medical education (CME) hours per year, and an increase in recent clinical practice. Interestingly, there was no significant difference in CME over a 2- or 5-year period. Other factors such as type of practice did not have statistical significance. There was no difference between states and no difference in time commitment to political or community activities. This survey indicates that surgeons going into practice in the Southeast from general surgery graduate medical education programs can expect to have a mean work week of 65 hours, and 20 per cent can expect to exceed an 80-hour work week.

A changing culture in interpersonal and communication skills

In summary it is essential that we improve our interpersonal and communication skills. We can learn and be taught better skills. We will be evaluated on these skills in the future, and it is important for us to establish ourselves as good role models for the future surgeons who will be entering our profession. It is of benefit to our patients and will give them a better understanding of their disease and elevate their level of healthcare. It is also important to us to help reduce our stress and to eliminate burnout. We can improve our interpersonal and communication skills in many ways. First we must be aware that there is a problem and recognize this as a problem that can be solved and that we do need to improve our current skills. This can be done through multiple educational tools such as lectures, videos, and self-assessments. The responsibility for this culture change ranges from top to bottom, but really begins at the bottom. It is important for all of us especially individuals such as myself, who is not only a practicing surgeon but also a surgeon in a leadership position, a surgeon who teaches medical students and residents, and a chairman who develops the careers of young faculty members. It is important for organizations such as the Southeastern Surgical Congress to recognize this need of our members and to conduct seminars, luncheons, and courses in helping us acquire better skills and also giving us some assessment of the current status of our skills. The American College of Surgeons has already addressed this issue by forming the Task Force on Communication and Educational Skills. Various examining boards have already incorporated this into requirements and expectations of future physicians and surgeons. We must establish ourselves as good role models. Being a good role model cannot be overemphasized. We are very fortunate in being good role models in medical knowledge and mastering phenomenal technical feats; however, this is not enough. It is also important that we also improve our interpersonal and communication skills. We must establish goals and outcomes for ourselves and work on ways of assessing these to ensure that we are effective in improving our skills. We must incorporate interpersonal and communication skills into our training programs, postgraduate courses, and all aspects of lifelong continuing education. Addressing the improvement of our interpersonal and communication skills will have many beneficial effects including improved patient outcomes, a better healthcare status for our patients, and a high level of confidence that patients have in us as physicians and surgeons. We do at times have a less than ideal collegial relationship with other disciplines in medicine. This faulty relationship needs to be rectified. We need to restore and maintain a high collegial relationship with everyone in medicine not only other physicians, but also nurses, paramedical personnel, and others. These changes will require a great deal of effort and will take some considerable time. Initially laparoscopic cholecystectomy and laparoscopic skills were not adequately learned but with recognition of its importance, education, and time, we became master surgeons. We are very fortunate to have residents and practitioners with superb laparoscopic skills that they acquired during their training and in structured postgraduate courses. Likewise it is important to incorporate interpersonal and communication skills into our training programs and our continuing medical educational programs. Finally, this is not just a touchy-feely issue, but it is one of surgical professionalism. It is critical for us to address this as an important issue since it will enhance the good qualities that we already possess. Let's start today. I have enjoyed this year being your President, and wish to thank you for the opportunity of addressing you this morning.

Update on laparoscopic cholecystectomy, including a clinical pathway

Laparoscopic cholecystectomy is a minimally invasive procedure in which the gallbladder is removed. Patients with symptomatic gallstones or biliary dyskinesis are eligible for this procedure. No specific contraindications exist except for poor surgical risk factors. The rate of conversion to an open technique is increased in patients with acute disease, pancreatitis, bleeding disorders, unusual anatomy, and prior upper abdominal surgery. Complications occur even with experienced laparoscopists, and the important technical aspects of surgery have been identified. The length of the hospital stay and postoperative recovery time is markedly shortened compared with that of standard cholecystectomy. This procedure offers sufficient advantages to patients that it has become the standard of practice in most cases.

Challenges to academic surgery. Life cycles in chairmanship: the first decade

A chair is a coordinator who is responsible for channeling the talents, dedication, and enthusiasm of the faculty and residents to strengthen the department. I believe that I have started down this path and realize the importance of the support of the faculty, residents, and other members in the institution. I have been fortunate to work in a department of surgery with superb faculty, residents, and students. The next decade will consist of the challenges of changes, chaos, and significant adverse external pressures. These challenges must be met with a commitment to our core values of patient care, teaching, and research, and allow the mission of the program to grow and change with the times.

Leiomyosarcoma of the colon: a second malignant neoplasm after treatment for a Wilms' tumor

Leiomyosarcoma of the colon is a rare malignancy. We report the case of a 33-year-old woman with a leiomyosarcoma of the colon occurring as an intussusception 30 years after receiving abdominal irradiation for a Wilms' tumor. A review of the prior and current treatment for Wilms' tumor is discussed, as well as the association between second malignancies and abdominal irradiation. Leiomyosarcoma of the colon usually presents in the fifth and sixth decades of life and is more common in men. The most common symptom is pain. Ninety per cent are diagnosed at surgery for treatment of bleeding, perforation, or obstruction. Surgery remains the primary treatment. Leiomyosarcomas of the gastrointestinal tract are radioresistant, and adjuvant chemotherapy has shown no survival benefit. The overall prognosis is poor, with mean 5-year survival of 28 per cent. General surgeons need to be aware of the possibility of second malignant neoplasms after primary treatment of childhood cancers. Proper reporting is essential to study the long-term effects of early treatment of childhood cancers and in predicting the best treatment outcomes for these patients.

Leiomyosarcoma of the Colon: A Second Malignant Neoplasm after Treatment for a Wilms’ Tumor

Leiomyosarcoma of the colon is a rare malignancy. We report the case of a 33-year-old woman with a leiomyosarcoma of the colon occurring as an intussusception 30 years after receiving abdominal irradiation for a Wilms’ tumor. A review of the prior and current treatment for Wilms’ tumor is discussed, as well as the association between second malignancies and abdominal irradiation. Leiomyosarcoma of the colon usually presents in the fifth and sixth decades of life and is more common in men. The most common symptom is pain. Ninety per cent are diagnosed at surgery for treatment of bleeding, perforation, or obstruction. Surgery remains the primary treatment. Leiomyosarcomas of the gastrointestinal tract are radioresistant, and adjuvant chemotherapy has shown no survival benefit. The overall prognosis is poor, with mean 5-year survival of 28 per cent. General surgeons need to be aware of the possibility of second malignant neoplasms after primary treatment of childhood cancers. Proper reporting is essential to study the long-term effects of early treatment of childhood cancers and in predicting the best treatment outcomes for these patients.

Nonoperative management of liver and/or splenic injuries: effect on resident surgical experience

Changes in the management of trauma over the past few years are significantly affecting postgraduate surgical education, with the lack of operative trauma experience being a major concern in some programs. This problem is accentuated in residency programs that obtain their trauma caseload primarily from blunt injury. Our experience over the past 6 years confirms that the growing trend toward nonoperative management of blunt liver and spleen injuries in adults is likely to exacerbate this problem. Blunt trauma admissions to our Level I trauma center increased from 2888 from 1991 through 1993 (group A) to 3587 from 1994 through 1996 (group B). Liver and/or splenic injuries occurred with equal frequency in both groups. Whereas diagnostic peritoneal lavage was used in 26 per cent of group A, its use dropped to 2 per cent in group B as abdominal computerized tomography was used more frequently to evaluate these patients. Nonoperative management increased from 10 per cent of group A to 54 per cent of group B. As a result, therapeutic laparotomies dropped from 85 in group A (58% of patients with liver/splenic injuries) to 74 (35%) in group B and nontherapeutic laparotomies from 48 (33%) to 23 (11%). While the evolution in the management of blunt liver and splenic injuries has resulted in the avoidance of nontherapeutic laparotomies, the operative caseload available to surgical housestaff has been adversely affected. Although the Residency Review Committee has stressed the importance of the critical care management of these patients, the criteria used to evaluate the number of trauma cases in postgraduate surgical education may need to be revised.

Malignant rhabdoid tumor of the duodenum

A polypoid malignant rhabdoid tumor of the duodenum is presented. The pattern of metastatic spread in this 58-year-old man included multiple duodenal and small intestinal transmural tumor implants and a large peribronchial lymph node causing superior vena cava syndrome. Microscopically, the tumor was composed of a diffuse population of rhabdoid cells characterized by homogeneous globular cytoplasmic inclusions that tended to indent or displace eccentric, vesicular nuclei with nucleoli. No glandular features were noted. Immunohistochemical and ultrastructural evaluation revealed that these inclusions contained vimentin, an intermediate filament of the mesenchymal cytoskeleton. Phenotypic features of a rhabdoid tumor have been reported in 10 poorly differentiated malignancies of the gastrointestinal tract. This is the first case report of a malignant rhabdoid tumor of the small intestine. Regardless of the site of the lesion, tumors showing these features are generally associated with a poor prognosis.

General surgical clinical pathways: an introduction

With increasing pressures to reduce the cost of health care, protocols and practice guidelines are being developed to streamline the practice of medicine. Many of these guidelines have been developed by health care workers who are not involved in the daily care of patients and who do not have clinical expertise in the specific diseases. The Southeastern Surgical Congress appointed a committee to develop clinical pathways for common surgical diseases. These clinical pathways have been developed by practicing surgeons with expertise in common surgical diseases and reviewed for their applicability by other surgeons with clinical expertise. The types of guidelines are reviewed and the need for guidelines are discussed. This paper presents the purpose, development, essential elements, and the dissemination and implementation of clinical pathways for common surgical diseases. It is critical that surgeons and surgical organizations participate in developing clinical guidelines and clinical pathways.

Comparison of CO2 laser, electrocautery, and scalpel incisions on acute-phase reactants in rat skin

Lasers and electrocautery devices have been applied as an alternative to the scalpel because of better hemostasis and lymphatic sealing. However, previous studies have demonstrated conflicting data regarding the effects of these modalities on the inflammatory response, the first reaction by tissue during wound healing. The purpose of this study is to quantitate inflammatory responses in rat skin following laser, electrocautery, and scalpel injury by measuring T-kininogen (T-KGN), a major acute-phase protein in the rat and its endogenous substrate, cathepsin B, an important inflammatory mediator. Full-thickness wounds (6 cm) were created on the dorsum of Sprague Dawley rats by using a laser, electrocautery, or scalpel. Tissue samples were harvested at 1 hour to 21 days after injury. T-KGN levels were radioimmunoassayed; cathepsin B activity was assayed by using a synthetic substrate Z-Arg-Arg-MCA. Data were analyzed by analysis of variance. T-KGN levels peaked at 3 days for all modalities, although the laser group was statistically (P < or = 0.01) higher at 1, 3, and 7 days after injury. In contrast, cathepsin B activity was significantly (P < or = 0.01) lower at 3 days in the laser group. CO2 laser ablation incites a greater inflammatory response than electrocautery or scalpel injuries. High levels of T-KGN may provide protection from proteolytic damage associated with cathepsins.

The effects of octreotide on healing of small bowel anastomosis

Octreotide (OCT) is a somatostatin analog used for its inhibitory action on multiple GI functions. Although octreotide has numerous clinical benefits, it has also been shown to inhibit postresectional hyperplasia of small bowel and hepatic regeneration. Because octreotide inhibits both trophic and anabolic hormones, we hypothesize that the use of octreotide may be detrimental in patients with a recent bowel anastomosis. To test this hypothesis, 60 male rats were randomized to four equal groups following small bowel anastomosis. Group I = control; Group II = 10 mg/day of hydrocortisone succinate; Group III = 2.5 micrograms/kg/day octreotide (equivalent of a clinical dose); Group IV = 25 micrograms/kg/day octreotide. Hydrocortisone was used as a negative control because it is known to have inhibitory effects on small bowel anastomotic healing. On postoperative Day 7, bursting pressures were measured. Serum T-kininogen levels, as a marker for systemic inflammation, and hydroxyproline content from the anastomotic segments were obtained. These results indicate that in the rat small bowel model, octreotide did not have any deleterious effect on anastomotic strength, systemic inflammation, and collagen content, even at high doses. Hydrocortisone, as expected, showed significant detrimental effects on bursting strength, as well as decreasing systemic inflammation. These findings have significant clinical implications, as octreotide could be used without jeopardizing the intestinal anastomosis.

Laparoscopic management of peptic ulcer disease

Laparoscopic surgery has heralded a new era for the operative management of peptic ulcer disease. With a mean hospital stay of 3.5 days,22 a recurrence rate of 4% to 11%,1,3 and a morbidity from dumping and diarrhea of 1% to 2%,21 laparoscopic proximal gastric vagotomy can truly provide a good alternative to medical therapy. Despite the high cost of medical care and surgical equipment, a laparoscopic vagotomy should be cost effective compared with life-long pharmacologic management of peptic ulcer disease. Several different operative procedures have been discussed, with similar outcomes. The surgeon has a choice of several approaches, depending on his or her training and level of skill. As surgeons gain experience with laparoscopic surgery, we are able to offer consistently good results with low recurrence rates and negligible morbidity and mortality. Minimally invasive surgery has rekindled the operative treatment of peptic ulcer disease.

Management of choledocholithiasis encountered during laparoscopic cholecystectomy

To evaluate the prevailing methods of management and assess the safety of laparoscopic treatment of choledocholithiasis, a retrospective review of all common bile duct explorations (CBDE) initiated during laparoscopic cholecystectomy at the Medical College of Georgia was performed. From December 1990 until December 1994, 604 laparoscopic cholecystectomies were performed. In 28 of these patients (26 female, 2 male) with an age range of 17 to 60 years, CBDE was initiated; 21 were performed laparoscopically, and 7 were converted to open CBDE. The procedure was successful in completely clearing the duct of stones in 24 of 28 cases (17 laparoscopic, 7 open). Postoperative endoscopic retrograde cholangiopancreatography was successfully employed in three of the cases of retained stones, and in the fourth, the stone was felt to be small enough to pass without further intervention. Biliary balloon catheters were successfully used to clear the duct in 8 of 17 laparoscopic CBDEs, and a laparoscopic choledochoscope introduced through the cystic duct was used in 7 cases; both were used in 2 cases. The open CBDEs were performed in standard fashion utilizing balloon catheters and choledochoscopy. The only operative complications were the four above-mentioned cases of retained stones. In summary, choledocholithiasis encountered during the course of laparoscopic cholecystectomy can frequently be managed with a laparoscopic CBDE.

The subxiphoid laparoscopic approach for resection of mediastinal parathyroid adenoma after successful localization with TC-99m-sestamibi radionuclide scan

Primary hyperparathyroidism is caused by an ectopically located parathyroid adenoma in a small percentage of cases. Parathyroid adenomas located within the retrosternal area of the anterior mediastinum account for a large proportion of failed initial cervical explorations. Current surgical approach to these lesions is via median sternotomy, with the discomfort, hospitalization, and morbidity associated with a major thoracic operation. We report a new technique for the resection of these ectopic parathyroid adenomas after successful radiologic localization: a minimally invasive subxiphoid laparoscopic approach. The procedure was performed in a symptomatic patient with documented primary hyperparathyroidism who had failed three previous neck operations. The ectopic parathyroid adenoma was successfully resected endoscopically, with resolution of the hypercalcemia. The patient was discharged on the third postoperative day, avoiding completely the morbidity of a median sternotomy.

Prospective evaluation of the safety and efficacy of laparoscopic jejunostomy

We prospectively assessed the safety and efficacy of laparoscopic jejunostomy done by 11 surgeons in 8 medical centers using the T-fastener technique. In all, 23 men and 13 women aged 19 to 84 (mean, 59) years required enteral feeding, but could not undergo gastrostomy and had no contraindication to laparoscopy. Of these patients, 12 had head and neck cancer and 11 had neurologic swallowing dysfunction. The procedure took 25 to 180 minutes (mean, 75). Three (8%) early cases were converted to open jejunostomy because of accidental enterotomies caused by inappropriate techniques that were avoided in later cases. Minor technical problems, such as passing a needle through the back wall of the jejunum, occurred in 7 patients, but they were easily corrected and produced no complications. Feedings were routinely begun within 24 hours of the surgical procedure. All jejunostomy catheters functioned well. This is a safe and effective technique when done by experienced laparoscopic surgeons, and serious complications are rare.

Crucial anatomic lessons for laparoscopic herniorrhaphy

Laparoscopic herniorrhaphy is generally performed using a transabdominal approach, an approach to hernia repair that is unfamiliar to most general surgeons. There is sufficient published anecdotal experience to indicate that the relationships of structures near the internal ring are not generally known and that this may predispose to their injury. There is considerable variability of nerves that pass through, or deep to, the iliopubic tract lateral to the internal inguinal ring, making it potentially hazardous to place staples or sutures in this region. Medially, the surgeon must be conscious of the possible presence of an aberrant obturator artery or vein and unexpected iliopubic vessels and take appropriate precautions to avoid unexpected sources of hemorrhage. The human cadaver, especially in the unfixed state, can be an ideal model to learn the surgical anatomy for laparoscopic hernia repair and to avoid neurovascular injuries.

Laparoscopic cholecystectomy in children with sickle cell disease

Since 1991, laparoscopic cholecystectomy has been utilized in children with sickle cell disease, predominantly because of the decreased pain and shorter hospitalization. We believe that outpatient laparoscopic cholecystectomy or even a 24 hour hospitalization is not indicated in the patient with sickle cell disease. Perioperative complications include bleeding diathesis, vaso-occlusive phenomena, and delayed hemolytic transfusion reactions, although clotting parameters can be normal.

An experimental model for laparoscopic common bile duct exploration

The development of an effective and reliable technique for laparoscopic common bile duct exploration has been limited by the technical difficulty of the procedure and the lack of a suitable animal model with a bile duct diameter large enough to accommodate the fiberoptic choledochoscope and other instruments used for stone extraction. Short-term bile duct ligation in the dog provides a simple and reproducible animal model that enables the surgeon to gain experience with laparoscopic common bile duct exploration in a laboratory setting. This model will enable the surgeon to develop the technical skills necessary to perform laparoscopic common bile duct exploration. In addition, the model may facilitate the development and refinement of new techniques and instruments that will facilitate laparoscopic common bile duct exploration in the clinical setting.

Comparison of adhesion formation in transperitoneal laparoscopic herniorrhaphy techniques

Two techniques of transperitoneal laparoscopic inguinal hernia repair were studied to evaluate the incidence of short term adhesion formation. Two methods were evaluated in thirty pigs with induced bilateral inguinal hernia defects. Half of the defects were repaired by incising the peritoneum, placing the mesh over the muscle defect, securing the mesh with staples, and reapproximating the peritoneum over the defect with staples. The other hernias were repaired by positioning the mesh over the defect and securing the mesh with staples, with no reapproximation of the peritoneum. The animals were allowed to recover and were killed at the end of two weeks. At autopsy, the animals were examined for the presence of adhesions to bowel. A statistically greater number of adhesions were formed with peritoneal reapproximation, 43 per cent (13/30), compared with 10 per cent (3/30) when the peritoneum was not reapproximated. The simpler method of repair, with no reapproximation, resulted in a statistically lower incidence of adhesions.

Laparoscopic anatomy of the biliary tree

A thorough knowledge of the anatomy of the extrahepatic biliary tree and its frequent anatomic variations is essential for performance of a safe laparoscopic cholecystectomy. The surgeon should have an appreciation for the distortions in the anatomy as a result of retraction on the gallbladder and how the direction of retraction alters the spatial relationships between the cystic duct and common bile duct. The steps in the operative procedure have been outlined to provide good exposure and optimize the identification of structures. Good exposure will enable the surgeon to identify anatomic variants; however, a thorough knowledge of these variants is necessary for safe performance of the operation.

Laparoscopically harvested omental free flap to cover a large soft tissue defect

OBJECTIVE

The omentum has been a very important tool in the armamentarium of the reconstructive surgeon. It has lost much of its value because of the morbidity associated with laparotomy. Laparoscopic surgery has become a popular technique and allows operations to be performed with minimal morbidity. The possibility of harvesting the omental free flap with the laparoscope and its use in reconstructive surgery has been demonstrated.

SUMMARY BACKGROUND DATA

Since the first laparoscopic cholecystectomy was performed, many surgeons have learned the procedure. Other surgical specialties have also benefited from this technique. The omentum provides a large amount of vascularized tissue and excellent wound coverage. It can be transferred as a pedicle flap, or as a free flap, using microvascular technique.

METHODS

The procedure was developed and refined in an animal model. One team harvested the omentum with laparoscopic assistance, while the other team prepared the recipient vessels. After completion of the microvascular transfer, the dogs were observed for 14 days. At that time, the omental tissue was examined for gross and histologic changes. A clinical case is also presented.

RESULTS

Gross and microscopic studies documented the viability of this approach. The patient tolerated the procedure well and had an unremarkable postoperative course.

CONCLUSIONS

Experimental and clinical evidence shows that the omentum can be successfully harvested as a free flap using laparoscopic assistance. This technique may prove to be of clinical significance and very useful for reconstructive surgery with less morbidity.

Complications of laparoscopic surgery

The potential complications of a laparoscopic procedure include those related to laparoscopy and those related to the specific operative procedure. The majority of these complications occur during the early learning phase for laparoscopy. They also may occur, however, during procedures performed by surgeons who have considerable laparoscopic experience. As new applications for laparoscopy continue to emerge, it is important for the surgeon to be familiar with the possible complications associated with the various laparoscopic procedures. Only through an appreciation of the potential complications of a procedure can their overall incidence be reduced to a minimum.

U.S. experience with laparoscopic cholecystectomy

Thirteen published series concerning laparoscopic cholecystectomy performed in the United States were reviewed. The review was based on reports that included at least 100 patients. Three of the series are surveys of surgery chairpersons and multiple hospitals. The other 10 series are based on the experience of the investigators. The operation was performed by trained and qualified surgeons, usually in females with early gallbladder and gallstone disease. The patient profiles were similar, and the outcomes were favorable. The incidence of complications and deaths was very low, but the rate of injury to the common bile duct was slightly higher in laparoscopic cholecystectomy than in open cholecystectomy. Intraoperative cholangiography can be performed selectively. The major benefits to the patient are a short hospital stay, early return to activity, and a reduced hospital bill.

Selective cholangiography. Current role in laparoscopic cholecystectomy

The initial 22-month experience with laparoscopic cholecystectomy in 400 patients employing an algorithm of selective cholangiographic evaluation is reported. Preoperative or postoperative endoscopic retrograde cholangiography was performed whenever stones were suspected clinically. Preoperative endoscopic retrograde cholangiography was performed in 44 patients (11%), in whom 14 (3.5%) had an endoscopic sphincterotomy with extraction of common bile duct stones. Intraoperative cholangiography was performed in only eight patients (2%) almost exclusively to acquire experience with the technique, and all cholangiograms were normal. Laparoscopic cholecystectomy was successfully completed in 96% of the patients. There were no deaths in this series, and major complications occurred in only 5% of patients. Two patients (0.5%) had a significant common bile duct injury that was recognized and successfully repaired at the initial operation. No late common bile duct strictures have been recognized. Six patients (1.5%) underwent postoperative endoscopic retrograde cholangiography for suspected common bile duct stones, with three patients requiring endoscopic sphincterotomy and stone extraction. This experience suggests that the use of preoperative and postoperative endoscopic retrograde cholangiography can be based on clinical presentation and laboratory evaluation and does not need to be performed routinely. Routine intraoperative cholangiography is not necessary in most patients undergoing laparoscopic cholecystectomy. The authors conclude that laparoscopic cholecystectomy can be performed safely with the selective use of cholangiography.

Cost-effectiveness of extracorporeal shock-wave lithotripsy versus cholecystectomy for symptomatic gallstones

To evaluate the cost-effectiveness of extracorporeal shock-wave lithotripsy vs. cholecystectomy for symptomatic gallstones, a model was constructed that projects charges and survival for both treatments. For a 45-year-old woman with one small stone, treatment with extracorporeal shock-wave lithotripsy rather than cholecystectomy is projected to result in an average gain of only 3 days of life and an average increase in direct medical charges of $1729 over 5 years of follow-up. The resulting marginal cost-effectiveness of extracorporeal shock-wave lithotripsy vs. cholecystectomy is $216,000 of extra charges per year of life gained with extracorporeal shock-wave lithotripsy. Extracorporeal shock-wave lithotripsy is projected to be much more cost-effective for elderly than for young patients (10-20-fold difference), but considerably less cost-effective for multiple stones than a single stone (2-4-fold difference), and less cost-effective for women than men (twofold difference). Adjusting for effects of morbidity on quality of life, extracorporeal shock-wave lithotripsy is projected to have slightly better quality-adjusted survival than cholecystectomy for the small subset of patients with one stone (by 8 to 43 days at 5 years) but not for young patients with multiple stones. It is concluded that decisions about appropriate use of extracorporeal shock-wave lithotripsy should consider the effects of patient characteristics on clinical and economic outcomes.

Traditional versus laparoscopic cholecystectomy

Laparoscopic cholecystectomy is a minimally invasive procedure whereby the gallbladder is removed using laparoscopic techniques. The indications are similar to those for elective traditional cholecystectomy, but selection of patients is important for success. Contraindications are currently evolving. Patients with advanced cholecystitis, abdominal sepsis, ileus, bleeding disorders, pregnancy, and morbid obesity should not undergo this procedure. The procedure requires good traditional surgical skills, as well as additional laparoscopic (and laser) skills. Operative time is slightly longer than for traditional cholecystectomy, but decreases with experience. Morbidity is low, but there is a concern about bile duct injuries. Mortality is very low (0%) and is comparable to traditional cholecystectomy (0.4%). The major advantages of laparoscopic cholecystectomy are the short hospital stay (average: 2 days) and early return to normal activity (7 days). This results in a reduction in hospital costs. Adequate training and credentialing are important processes to foster good patient outcomes.

Laparoscopic guided cholecystectomy

Cholecystectomy remains the most effective form of therapy for patients with symptomatic cholelithiasis. An alternative method of gallbladder removal, laparoscopic guided cholecystectomy, was attempted in 100 patients. Five patients required conversion of the laparoscopic procedure to an open laparotomy for the following reasons: discovery of a pancreatic malignancy in one patient, extensive adhesions in one, presence of an aberrant accessory right hepatic duct in one, common hepatic duct injury in one, and avulsion of the cystic duct in one. Both ductal injuries occurred during the early phase of the clinical program. In those patients undergoing laparoscopic cholecystectomy, 93 were discharged within 24 hours of surgery and 94 returned to normal activity within 1 week. Laparoscopic guided cholecystectomy appears to offer a number of advantages in patient care as well as a significant reduction in health care expenses for gallbladder disease. Appropriate training in laparoscopic surgery is necessary in order to avoid operative complications.

Laparoscopic cholecystectomy

Laparoscopic cholecystectomy is a combined endoscopic-operative technique for removing the gallbladder. Patients with symptomatic gallstones are eligible for this procedure. Contraindications include pregnancy, acute cholangitis, advanced cholecystitis, acute pancreatitis, peritonitis, significant bleeding disorder, portal hypertension, and a prior major upper abdominal operation. The procedure does require experience and specialized training. It is guided by an endoscope, camera, and video monitor, and is performed through four cannulas. The gallbladder is dissected from the hepatic bed under observation on a monitor. The possible complications are bleeding, injury to the common bile duct, and technical problems, such as perforation of the gallbladder. The length of the hospital stay and the postoperative recovery time are markedly shortened compared with standard cholecystectomy. The procedure has an advantage over stone dissolution and biliary lithotripsy in that the gallbladder is removed, and additional or continued treatment is not necessary. This procedure offers sufficient advantages to the patient that it will likely become a standard for qualified abdominal surgeons.

Gallstone dissolution

Many methods are available for gallstone dissolution, including oral bile salts; cholesterol solvents such as mono-octanoin or methyl tert-butyl either; and calcium or pigment solvents such as EDTA and polysorbate. Which of these approaches will be appropriate for an individual patient depends on the type of stones; whether they are in the gallbladder or the bile ducts; whether access to the biliary tree is available; the patient's age and general medical condition; and the availability of necessary expertise. In the US, both chenodeoxycholate and ursodeoxycholate are now available. Ursodeoxycholate is more expensive but appears to produce fewer side effects and may be more efficacious. These agents are most effective in thin women with small floating, radiolucent cholesterol stones in a functioning gallbladder. Only about half of the small subset of patients will experience partial or complete dissolution of stones within a year. Stone recurrence and the potential toxicity of long-term therapy are problems with this approach. Therefore, for most patients, cholecystectomy, either in the traditional fashion or using a laparoscopic approach (see article later in this issue by Gadacz et al), is the most cost-effective and perhaps the safest option. Intragallbladder instillation of methyl tert-butyl ether probably will be applicable only to a small subset of patients, and treatment is likely to be followed by a high recurrence rate. In patients with retained common duct cholesterol stones and access to the biliary tree, mono-octanoin therapy is advantageous in that it can be initiated as soon as cholangiography demonstrates no extravasation. In properly selected patients, a 90% success rate with this technique can be expected within 7 days.

Adenocarcinoma of the ileostomy: the latent risk of cancer after colectomy for ulcerative colitis and familial polyposis

A case of a primary adenocarcinoma of an ileostomy is reported along with 15 other cases collected from the literature. These rare tumors are seen on the average 24 years after colectomy with ileostomy and in all cases are associated with a past history of ulcerative colitis or familial polyposis. Most of the reported cases of these tumors have appeared in the literature within the past 5 years, suggesting that there is a rising incidence of this disease corresponding to completion of a biologic latency period that began when the Brooke ileostomy was introduced for ulcerative colitis in 1951. In our case a mucinous adenocarcinoma occurred at the ileostomy site 34 years after colectomy. Adjacent to the tumor was mucosa showing colonic metaplasia and focal dysplasia. Subsequent biopsy specimens of the revised stoma showed inflammatory lesions morphologically suggestive of inflammatory (pseudo) polyps. The clinical and morphologic features in this case suggest that there is transition from ileal mucosa to colonic mucosa to colonic dysplasia to adenocarcinoma. Annual evaluation of the ileostomy for colonic metaplasia, inflammatory lesions consistent with ulcerative colitis and dysplasia, is recommended. In the presence of dysplasia, stomal revision is advised. Wide local excision is advised for adenocarcinoma.