The reality of general surgery training and increased complexity of abdominal wall hernia surgery

INTRODUCTION

The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required 'tailored' approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature.

METHODS

A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated.

RESULTS

All present guidelines for abdominal wall surgery recommend the utilization of a 'tailored' approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50-100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures.

CONCLUSION

A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.

Accreditation and certification requirements for hernia centers and surgeons: the ACCESS project

INTRODUCTION

There is a need for hernia centers and specialist hernia surgeons because of the increasing complexity of hernia surgery procedures due to new techniques, more difficult cases and a tailored approach with an increasing public awareness demanding optimal treatment results. Therefore, the requirements for accredited/certified hernia centers and specialist hernia surgeons should be formulated by the international and national hernia societies, while taking account of the respective health care systems.

METHODS

The European Hernia Society (EHS) has appointed a working group composed of 18 hernia experts from all regions of Europe (ACCESS Group-Hernia Accreditation and Certification of Centers and Surgeons-Working Group) to formulate scientifically based requirements for hernia centers and specialist hernia surgeons while taking into consideration different health care systems. A consensus was reached on the key questions by means of a meeting, a telephone conference and the exchange of contributions. The requirements formulated below were deemed implementable by all participating hernia experts in their respective countries.

RESULTS

The ACCESS Group suggests for an adequately equipped hernia center the following requirements: (a) to be accredited/certified by a national or international hernia society, (b) to perform a higher case volume in all types of hernia surgery compared to an average general surgery department in their country, (c) to be staffed by experienced hernia surgeons who are beyond the learning curve for all types of hernia surgery recommended in the guidelines and are responsible for education and training of hernia surgery in their department, (d) to treat hernia patients according to the current guidelines and scientific recommendations, (e) to document each case prospectively in a registry or quality assurance database (f) to perform follow-up for comparison of their own results with benchmark data for continuous improvement of their treatment results and ensuring contribution to research in hernia treatment. To become a specialist hernia surgeon, the ACCESS Group suggests a general surgeon to master the learning curve of all open and laparo-endoscopic hernia procedures recommended in the guidelines, perform a high caseload and additionally to implement and fulfill the other requirements for a hernia center.

CONCLUSION

Based on the above requirements formulated by the European Hernia Society for accredited/certified hernia centers and hernia specialist surgeons, the national and international hernia societies can now develop their own programs, while taking account of their specific health care systems.

Thoracoscopic sympathectomy for palmar hyperhidrosis

BACKGROUND

Upper thoracoscopic sympathectomy, obtained either by ablation or resection of the appropriate ganglia, is now the preferred treatment for primary palmar hyperhidrosis. Therefore, we undertook a review to compare the relative efficacy of these two techniques.

METHODS

A Medline search was performed for the years 1974-99 to identify all published studies of thoracoscopic sympathectomy for hyperhidrosis.

RESULTS

In all, 33 studies were identified and divided into two groups-ablation and resection. When the resection method was used, the immediate success rate was 99.76%, whereas the ablation method achieved dry hands in 95.2% of cases (p = 0.00001). Palmar sweating recurred in 0% of patients treated via resection and -4.4% treated with ablation. Ptosis was noted in 0.92% of cases after ablation and in 1.72% after resection (p = 0.017).

CONCLUSIONS

Resection yields superior results, yet the majority of surgeons ablate, probably because it is easier, requires a shorter operating time, leads to fewer cases of Horner's syndrome, and because resympathectomy eventually overcomes initial failure.

Video-assisted open supraclavicular sympathectomy following air embolism

This report suggests that laparoscopic technology and instrumentation can be used to improve open procedures, especially when exposure and visibility are limited.

Background:

Air embolism is a relatively rare complication of thoracoscopic surgery.

Methods:

Open supraclavicular sympathectomy was indicated to overcome the risk of re-embolization. A novel video-assisted technique was performed.

Conclusions:

The previously prevalent open supraclavicular sympathectomy is a good choice for avoiding air embolism. Laparoscopic instrumentation and technology can be used to improve open procedures, especially when exposure and visibility are limited. Sometimes we should remember to use the experience of our teachers.

Magnetic resonance guided focused ultrasound surgery. Ablation of soft tissue at bone-muscle interface in a porcine model

BACKGROUND

Pain management treatments of patients with bone metastases have either efficacy problems or significant side effects. Percutaneous radiofrequency ablation has recently proved to be of palliative value. Magnetic resonance guided focused ultrasound surgery (MRgFUS) uses focused ultrasonic energy to non-invasively create a heat-coagulated lesion deep within the body in a controlled, accurate manner. The surgeon can monitor and control energy deposition in real time. This technology represents a potential treatment modality in oncological surgery. We investigated the ability of two MRgFUS methods to accurately and safely target and ablate soft tissue at its interface with bone.

MATERIALS AND METHODS

Heat-ablated lesions were created by MRgFUS at the bone-muscle interface of 15 pigs. Two different methods of energy delivery were used. Temperature rise at the target adjacent to bone was monitored by real time MR thermal images. Results were evaluated by MRI (magnetic resonance imaging), nuclear scanning and by histopathological evaluation.

RESULTS

Soft tissue lesion sizes by both methods were in the range of 1-2 cm in diameter. Targeting the focus 'behind' the bone, achieved the same result with a single sonication only. Follow up MRI and histopathological examination of all lesions showed focal damage at its interface with bone and localized damage to the outer cortex on the side closer to the targeted tissue. There was no damage to non-targeted tissue.

CONCLUSION

MRgFUS by both energy deposition methods can be used to produce controlled well-localized damage to soft tissue in close proximity to bone, with minimal collateral damage.

MR-guided focused ultrasound surgery (MRgFUS) for the palliation of pain in patients with bone metastases--preliminary clinical experience

BACKGROUND

Magnetic resonance-guided focused ultrasound surgery (MRgFUS) is a noninvasive thermal ablation technique, shown to be clinically effective in the treatment of uterine fibroids and is being evaluated as a method of thermal ablation of benign and malignant breast tumors. To evaluate the safety and initial efficacy of MRgFUS for the palliation of pain caused by bone metastases, in patients for whom other treatments are either not effective or not feasible.

MATERIALS AND METHODS

Thirteen patients suffering from symptomatic bone metastases underwent MRgFUS procedure. Treatment safety was evaluated by assessing the incidence and severity of device-related complications up to 6 months after treatment. Effectiveness of pain palliation was evaluated by visual analog scale, pain questionnaires and changes in the patients' medication.

RESULTS

Fifteen procedures were carried out. Mean follow-up was 59 days. Twelve patients received adequate treatment and were available for follow-up. Two patients died due to disease progression during the first month after treatment. No severe adverse events were recorded. The remaining 10 patients reported prolonged improvement in pain score and/or reduced analgesic dosage.

CONCLUSION

MRgFUS may provide a safe and effective noninvasive alternative for the palliation of pain, caused by bone metastases.

History of sympathetic surgery

The first reported operation on the upper sympathetic system was performed by Alexander in 1889. The initial indications (epilepsy, exophthalmic goiter, idiocy, glaucoma) are obsolete. For some subsequent indications (angina pectoris, vasospastic disorders, and painful conditions) sympathectomy has still a limited application. The main indications today are hyperhidrosis (since 1920) and blushing. Renewed attempts to perform the operation for psychological conditions have been reported. The technique of sympathectomy has been modified over the century, with a trend to minimize the extent of surgery: from open to endoscopic approaches; from resection of ganglia to thermoablation, thermotransection, and clipping. The sequelae of the operation (mainly compensatory hyperhidrosis) present a major problem in a small percentage of operated patients. Techniques of reversal (by nerve grafting and unclipping) have been proposed. Meticulous follow-up studies are required to evaluate the merits of these techniques. Improved knowledge of the functions and interrelations of the autonomic nervous system is required to understand the mechanism of these sequelae and learn how to avoid or treat them.

The pathophysiology of cervical and upper thoracic sympathetic surgery

The main effect of upper thoracic sympathectomy is sudomotor. To abolish sweating of the palms, T(2) ganglionectomy (often with the addition of T(3)) was invariably performed. To prevent axillary sweating, additional T(4) ablation was recommended. Sympathectomy produces a vasodilatatory cutaneous effect. The circulation in the muscles, however, is unaltered or may even be reduced. It also appears that improved skin blood flow is on the thermoregulatory, not nutritive level. It seems that chronic surgical sympathectomy does not cause major changes in the vascular function of the forearm. Although the exact pathophysiological mechanism of blushing is still obscure, bilateral upper dorsal sympathectomy alleviates this phenomenon. T(2)-T(3) ganglionectomy significantly decreases pulse rate and systolic blood pressure, reduces myocardial oxygen demand, increases left ventricular ejection fraction and prolongs Q-T interval. A certain loss of lung volume and decrease of pulmonary diffusion capacity for CO result from sympathectomy. Histomorphological muscle changes and neuro-histochemical and biochemical effects have also been observed.

Upper thoracic sympathetic surgery

Four open surgical approaches have been used to perform upper thoracic sympathectomy. The posterior approach requires access through the posterior muscles of the back, and rib transection. It is a painful operation that has been practically abandoned in favor of the other techniques. The anterior transthoracic approach consists of a formal thoracotomy and never gained popularity. The supraclavicular approach involves dissection of several important anatomical structures. It requires excellent surgical dexterity, but ensures the easiest postoperative recovery. The last approach involves a small transaxillary thoracotomy. Technically, it is the easier procedure. Both the supraclavicular and the transaxillary approaches were widely used until the advent of thoracoscopic surgery. The results (rate of success, recurrences, and sequelae) were similar for all techniques, depending on the procedure performed on the sympathetic chain, not on the access route. Open approaches for upper dorsal sympathectomy are not used any more except in the very rare cases in which thoracoscopy is unfeasible.

Intrapleural analgesia following thoracoscopic sympathectomy for palmar hyperhidrosis: a prospective, randomized trial

BACKGROUND

Reports on intrapleural analgesia (IPA) are conflicting. The current study assessed the effect of a single-dose thoracoscopic bilateral intrapleural anesthetic administration on the immediate postoperative recovery room and 24-h pain control.

METHODS

Fifty patients with primary palmar hyperhidrosis were randomly classified into two groups to receive either 20 ml of 0.5% bupivacaine and 5 mg/ml epinephrine or 0.9% NaCl in each thoracic cavity at the end of thoracoscopic T2-T3 sympathectomy. The degree of early postoperative pain was estimated by visual analog scale (VAS). The 24-h parenteral opioid analgesic requirement was recorded.

RESULTS

The immediate postoperative VAS score (1.46 +/- 0.41 vs 2.0 +/- 0.61, p = 0.03), opioid consumption (0.42 +/- 0.36 vs 0.65 +/- 0.28, p = 0.0133), and 24-h opioid consumption (1.02 +/- 0.80 vs 1.48 +/- 0.84, p = 0.05) were significantly reduced following IPA compared to those of the control group.

CONCLUSION

IPA is a simple and effective means for postoperative pain control following thoracoscopic upper dorsal sympathectomy.

Upper dorsal thoracoscopic sympathectomy for palmar hyperhidrosis. The use of harmonic scalpel versus diathermy

BACKGROUND

Upper dorsal thoracoscopic sympathectomy, the treatment of choice for primary palmar hyperhidrosis, is not devoid of long-term complications, like Horner's syndrome and postoperative neuralgia. It has been postulated that propagation of heat induced by diathermy may be responsible for some of these sequelae. To assess this hypothesis, a study was undertaken to evaluate the use of harmonic scalpel, which does not dissipate heat.

METHOD

Sixteen patients with primary palmar hyperhidrosis underwent upper dorsal thoracoscopic sympathectomy using the harmonic scalpel on one side and diathermy on the other. Follow-up was made two years postoperatively.

RESULTS

The length of the procedure with each instrument was similar. There was no localization of postoperative pain, which could be attributed to either device. No Horner's syndrome or postoperative neuralgia occurred.

CONCLUSION

The present study proved the safe use of harmonic scalpel for upper dorsal thoracoscopic sympathectomy, but did not detect any important advantage of either instrument over diathermy.

Impact of intraoperative sonography on resection and cryoablation of liver tumors

PURPOSE

We retrospectively analyzed the impact of intraoperative sonography (IOUS) on the management of patients referred for resection of liver tumors.

METHODS

Forty patients underwent IOUS with a 7-MHz curved-array sector transducer; in selected cases, a 5-MHz linear-array transducer attached to a color Doppler unit was also used. The number, size, and location of tumors on IOUS, including tumor proximity to or invasion of major vessels or invasion of the diaphragm, were compared to findings on preoperative imaging studies. The effect of these findings on surgical management was assessed. Unresectable lesions were treated by cryoablation under ultrasound guidance.

RESULTS

IOUS detected preoperatively unsuspected lesions in 7 patients (18%). Metastases suspected on CT arterial portography were ruled out in 2 patients (5%), and indeterminate lesions were diagnosed as cysts by IOUS in 2 other patients (5%). Vascular proximity or vascular or diaphragmatic invasion detected by IOUS rendered lesions unresectable in 4 patients (10%). Cryoablation under IOUS guidance and monitoring was attempted in 11 patients (28%) and performed successfully in 10.

CONCLUSIONS

IOUS changed the management in 38% of patients and guided cryoablation in 28% of patients. IOUS performed by an experienced sonologist is invaluable for the accurate assessment of liver tumor resectability; the detection of additional, preoperatively unknown lesions; and the guidance of cryoablation of unresectable tumors.

The effect of upper dorsal thoracoscopic sympathectomy on the total amount of body perspiration

Thoracoscopic T2-T3 sympathectomy is the treatment of choice for primary palmar hyperhidrosis (PPH); however, compensatory hyperhidrosis (CH) is a disturbing sequela of this operation, the mechanism of which is poorly understood. This study was conducted to evaluate the effect of heat stress on total body perspiration after thoracoscopic T2-T3 sympathectomy, and determine its correlation with CH. A total of 17 patients with PPH who underwent bilateral T2-T3 sympathectomy were subjected to heat stress induced by a 10-min sauna bath (ambient temperature 70 degrees C), 1 day before and 1 month after surgery. The naked body weight was recorded before and immediately following the sauna bath, and the patients were followed up to assess whether CH had developed and the degree of its severity. Postoperatively, the amount of perspiration increased in 13 patients and decreased in 1. The amount of perspiration induced by the sauna bath ranged from 60 to 480 g, with a mean value of 185.29 +/- 125.80 g, before the operation, and from 60 to 540 g, with a mean value of 265.88 +/- 154.05 g, after the operation (P = 0.0113). There was no correlation between the degree of alteration in total body perspiration and the development of CH. Performing thoracoscopic T2-T3 sympathectomy for PPH affects the total body sweating response to heat; however, the development of CH does not correlate with this alteration.

The treatment of primary palmar hyperhidrosis: a review

Primary palmar hyperhidrosis (HH) is a pathological condition of overperspiration caused by excessive secretion of the eccrine sweat glands, the etiology of which is unknown. This disorder affects a small but significant proportion of the young population all over the world. Neither systemic nor topical drugs have been found to satisfactorily alleviate the symptoms. Although the topical injection of botulinum has recently been reported to reduce the amount of local perspiration, long-term results are required before a definitive evaluation of this method can be made. Hypnosis, psychotherapy, and biofeedback have been beneficial in a limited-number of cases. While radiation achieves atrophy of the sweat glands, its detrimental effects prohibit its use. Iontophoresis has attained some satisfactory results but it has not been assessed long term. Percutaneous computed tomography-guided phenol sympathicolysis achieves excellent immediate results, but its long-term failure rate is prohibitive. Furthermore, percutaneous radiofrequency sympathicolysis may be an effective procedure, but its long-term results are not superior to surgical sympathectomy. On the other hand, surgical upper dorsal (T2-T3) sympathectomy achieves excellent long-term results and the thoracoscopic approach has supplanted the open procedures. Despite some sequelae, mainly in the form of neuralgia and compensatory sweating which cannot be predicted and may be distressing, surgical sympathectomy remains the best treatment for palmar hyperhidrosis.

Cryohemostasis of uncontrolled hemorrhage from liver injury

Uncontrolled hemorrhage is the primary cause of death in both blunt and penetrating liver trauma. Cryohemostasis was attempted in the past for elective liver surgery but did not gain popularity. During past decades, cryoequipment was refined and successfully used for tumor ablation. The purpose of the present study was to assess the efficacy of cryosurgery as a potential adjuvant hemostatic technique in the treatment of grades III-IV liver injuries. A standard liver crush-evulsion injury was created in pigs. In the control group, the liver was left to bleed freely. In the experimental group, the severed liver surface was immediately frozen to -160 degrees C for 10 min, spontaneously thawed, and left to bleed thereafter. Blood pressure, pulse rate, urine output, and serum lactate were monitored. The total blood loss was measured 180 min after liver injury was inflicted. The volume of frozen liver parenchyma was measured. For further laboratory evaluation, three additional experimental animals were not sacrificed and recovered. Cryohemostasis significantly reduced blood loss and substantially attenuated hemorrhagic shock. The frozen liver parenchyma underwent necrosis but did not jeopardize survival. Cryosurgery may be an efficient adjuvant technique in the early control of hemorrhage in grades III-IV liver injury.

Postoperative suction drainage of the axilla: for how long? Prospective randomised trial

OBJECTIVE

To define the correct time to remove the drain after axillary dissection for carcinoma of the breast.

DESIGN

Prospective randomised trial.

SETTING

Two public hospitals, Israel.

SUBJECTS

90 women who required axillary dissection for carcinoma of the breast.

INTERVENTIONS

42 were randomised to have the drain removed on postoperative day 3, and 48 to keep the drain in until discharge had decreased to less than 35 ml/24 hours.

MAIN OUTCOME MEASURES

Formation of seromas or wound infections, need to reinsert the drain, and duration of hospital stay.

RESULTS

Early removal of the axillary drain was associated with a significantly higher incidence of seromas (9/42 compared with 2/48, p = 0.02) unless the total amount of fluid drained during the first three postoperative days was less than 250 ml.

CONCLUSION

Drains should be removed after axillary dissection only when the daily amount of fluid discharged is low, unless the drainage during the first three days is less than 250 ml.

Thoracoscopic sympathectomy for hyperhidrosis: is there a learning curve?

The aim of this study was to evaluate the learning curve of upper dorsal thoracoscopic sympathectomy. From June 1993 to December 1996, we performed 232 sympathectomies on 116 patients with primary palmar hyperhidrosis. The T2-T3 ganglia were resected by electrocuting and were removed for histologic examination. The series was divided into two groups of 58 patients each, and operations in each group occurred during a period of 21 months. Follow-up was obtained on 111 patients for a mean of 25.06+/-12.62 months. All limbs were dry after the operation, and hyperhidrosis did not recur. The anesthesia time was reduced, but the operating time, the difficulty in identifying and in resecting the ganglia, compensatory hyperhidrosis, postoperative neuralgia, and subjective satisfaction with the procedure were similar in both groups. The learning curve in the present study was mainly reflected by a reduction in the incidence of Horner's syndrome.

Prevention of limb loss in critical ischaemia by arterialization of the superficial venous system: an experimental study in dogs

The possibility of ischaemic limb salvage by arterializing the superficial venous system was examined in a canine study. The experiment was carried out on four healthy dogs in three stages. In the first stage, collateral circulation to the hind limb was abolished. In the second stage, all branches of the common femoral artery were ligated, which created a model of ischaemia incompatible with limb survival. Revascularization was achieved by anastomosing the valvulotomized long saphenous vein to the common femoral artery, proximal to its ligation. The dogs were monitored for 2 weeks. All limbs maintained tissue oxygenation similar to that of the control contralateral limb. In the third stage, the artery was ligated proximal to the femoro-saphenous anastomosis and the limb monitored for 7 hours. Acute loss of motor function of the limb resulted. In the present study, arterialization of the valvulotomized long saphenous vein prevented limb loss in critical ischaemia.

[Combined treatment of hepatic tumors by cryosurgery and resection: first results]

Cryosurgery is an old technique which is being used for hepatic tumors as an adjuvant to hepatic resection. We recently treated 7 patients with multiple malignant liver tumors, 5 of whom had colorectal metastases, 1 carcinoid metastases, and 1 multiple hepatic lesions of hepatocellular carcinoma. 6 underwent combined liver resection and cryoablation of lesions in the remaining liver. In the 7th patient, only cryoablation was performed because hepatic resection was rejected and there was an extrahepatic metastasis. The advantages of this treatment are removal or destruction of all liver lesions found by any method, including intraoperative ultrasound examination, maximal preservation of normal liver parenchyma and that it is curative in patients inoperable by standard criteria.

Primary palmar hyperhidrosis presenting with unilateral symptoms: a report of two cases and review of the literature

Two cases of primary palmar hyperhidrosis are presented. T2-T3 sympathetic ganglionectomy of the affected side completely alleviated perspiration of the palms, but oversweating of the contralateral palms appeared a few weeks later. A similar sympathetic ganglionectomy of the second side, 1 month and 1 year later, resulted in renewed oversweating of the palm on the first operated side within 3 months of the second operation. During the same period, 127 other patients with primary palmar hyperhidrosis underwent a bilateral upper dorsal sympathectomy, though the condition did not recur in any of these patients. The possible mechanism(s) of why overperspiration of the second hand developed after the first sympathectomy in these two patients, and why it recurred in the first hand after the second operation are examined, but remain obscure.

Emergency minilaparotomy cholecystectomy for acute cholecystitis: prospective randomized trial--implications for the laparoscopic era

This prospective controlled trial evaluates the efficacy of minicholecystectomy (MC) in cases of acute cholecystitis compared to that of conventional cholecystectomy (CC) and discusses its implications in the laparoscopic era. Sixty consecutive patients with acute cholecystitis were prospectively randomized into two groups: MC group (30 cases) and CC group (30 cases). The two groups were well matched with regard to age, sex, weight/height index, previous upper abdominal surgery, and APACHE II scores. The mean length of incision was 5.5 cm (range 4.5-9.0 cm) in the MC group compared to 13.5 cm (range 12-16 cm) in the CC group. No significant differences were found between MC and CC with regard to operative time (69.1 +/- 17.0 and 68.1 +/- 15.4 minutes, respectively; p = 0.82), operative difficulty on a 1 to 10 scale (5.2 +/- 1.5 versus 4.6 +/- 1.6, respectively; p = 0.177), and complication rate (11% and 17%, respectively; p = 0.19). Significantly lower analgesia requirements were noted in the MC group: 27.5 +/- 14.6 mg of morphine sulfate compared to 44.5 +/- 13.2 mg in the CC group (p < 0.001). In addition, the duration of hospital stay was significantly shorter for MC patients (3.1 +/- 1.0 days) than in CC patients (4.7 +/- 1.2 days) (p < 0.001). Twenty-two patients (73.3%) in the MC group were reported to return to normal daily activities 2 weeks after the operation, compared to only 12 (40%) in the CC group (p = 0.0028). MC is safe and applicable as an emergency procedure for acute cholecystitis. It is superior to CC in terms of convalescence and cosmesis. The results of MC in the setting of acute cholecystitis compare favorably with the published results of laparoscopic cholecystectomy.

[Gastrografin for mechanical partial, small bowel obstruction due to adhesions]

The therapeutic effect of gastrografin is occasionally mentioned in the literature. However, this effect has not been objectively evaluated. We studied prospectively the effect of Gastrografin in cases of adhesive, simple, partial, small bowel obstruction (SBO) compared to conventional management. During 3 years, a total of 137 episodes of simple, partial SBO in 127 patients (10 recurrent episodes) were treated. The episodes were randomized into a control group (80 episodes), treated conventionally, and a trial group (77 episodes), which received in addition 100 ml of Gastrografin administered through the nasogastric tube. The two groups were well-matched with regard to age, gender, weight, medical and surgical background and duration of complaints before admission. Time to first stool and resolution of obstruction, complications, need for surgery, and hospital stay were noted. Mean time to first stool was significantly shorter in the trial group: 6.2 +/- 3.9 hours vs 23.5 +/- 12.7 (p < .0001). Mean hospital stay for unoperated patients was also shorter in the trial group: 2.7 +/- 2 days vs 5.5 +/- 2 days, (p < .0001). In addition, significantly fewer episodes in the trial group required operation, 10.4 vs 26.7% (p < 0.013). 1 patient in each group dies following operation. There were no Gastrografin-related complications and it was effective and safe for adhesive, partial, simple SBO. It significantly speeds resolution of obstruction, reduces the need for operation, and shortens convalescence.

Upper dorsal thoracoscopic sympathectomy for palmar hyperhidrosis: improved intermediate-term results

PURPOSE

The purpose of this study was to examine the immediate and mid-term results of thoracoscopic upper dorsal (T2-T3) sympathectomy for primary palmar hyperhidrosis.

METHODS

From June 1993 to October 1994 we performed 106 sympathectomies on 53 patients with palmar hyperhidrosis. Thirty-four female patients and 19 male patients ranging in age from 15 to 44 years, (mean 23.1 years) were studied. Both sides were operated during the same surgical procedure. The T2-T3 ganglia were resected by electrocuting with a hook and were removed for histologic examination. Follow-up for a mean of 19.25 months was obtained on 52 patients (104 operated limbs).

RESULTS

All limbs were completely dry at the end of the procedure, and hyperhidrosis did not recur during the whole follow-up period. Short-term postoperative complications (mainly atelectasis, pneumonia, pneumothorax, and hemothorax) occurred in six (11.3%) patients. Long-term sequelae were observed in 43 (81.1%) patients and included Horner's syndrome (9 patients, 17.3%, one side only in each patient), neuralgia (7 patients, 13.5%), and compensatory hyperhidrosis (35 patients, 67.3%). These sequelae were not permanent in all cases, and the degree of severity was variable. Six (11.5%) patients, three of whom regretted being operated, were dissatisfied with their results: one because of Horner's syndrome, one because of persisting neuralgia, and four because of compensatory sweating.

CONCLUSIONS

Despite the large number of postoperative long-term sequelae, 88.5% of patients expressed subjective satisfaction from the procedure. Obtaining 100% of dry hands on mid-term follow-up makes this approach rewarding.

Carcinoid tumor of the common bile duct

A case of primary carcinoid tumor of the common bile duct is presented. Diagnostic and therapeutic uncertainties of this extremely rare cause of jaundice are discussed.

An anomaly of the extrahepatic biliary system

An anomaly of the extrahepatic biliary system is reported in which the common hepatic duct was found to enter the gallbladder, whereas the cystic duct drained the whole biliary system into the duodenum. Review of the literature revealed only eight previously reported similar cases. To ascertain such anatomy, a choledochal cyst and the Mirizzi syndrome must be excluded. In the past, the rarity of the configuration described herein led to transection of the common hepatic duct during cholecystectomy in most cases. The concomitant presence of other abdominal anomalies, as in our case, or severe inflammation in the porta hepatis should prompt suspicion of biliary anomalous anatomy. In that case, dissection of the gallbladder from the fundus downward will allow timely discovery of such an anomaly. Maintenance of continuity between the common hepatic duct and cystic-common biliary duct by preserving part of the gallbladder permits easy repair on a T tube.

Small bowel obstruction following laparoscopic cholecystectomy: diagnosis of incisional hernia by computed tomography

As laparoscopic cholecystectomy has become the procedure of choice for symptomatic gallstones, specific complication related to this technique have been noted. We report a case of small bowel obstruction in the trocar puncture site following uneventful laparoscopic cholecystectomy in an extremely obese woman. Diagnosis was made by computed tomography, and reduction was possible by local approach, avoiding explorative laparotomy.

Therapeutic effect of oral Gastrografin in adhesive, partial small-bowel obstruction: a prospective randomized trial

BACKGROUND

Previous published clinical observations claim that Gastrografin, a hyperosmolar gastrointestinal water-soluble contrast agent, speeds the resolution of postoperative ileus, barium impaction ileus, adhesive small-bowel obstruction, and intestinal obstruction caused by parasites and bezoars. However, no objective data exist that support the therapeutic effects of Gastrografin in these situations.

METHODS

A total of 107 episodes of adhesive, partial small-bowel obstruction in 99 patients were randomized into a control group (48 episodes), who were treated with conventional methods, and a trial group (59 episodes), who were treated with 100 ml of Gastrografin administered through the nasogastric tube. The following variables were examined: time to resolution of partial small-bowel obstruction, the need for operation, complications, and hospital stay.

RESULTS

Mean timing of the first stool was 23.3 hours in the control group and 6.2 hours in the patients receiving Gastrografin (p < 0.00001). Ten obstructive episodes (21%) in the control group required operative treatment compared with six (10%) in the trial group (p = 0.12). Mean hospital stay for the patients who responded to conservative treatment was 4.4 days and 2.2 days in the control and trial groups, respectively (p < 0.00001). One patient in each group died after operation. No Gastrografin-related complications were observed.

CONCLUSIONS

Orally administered Gastrografin is safe and has a therapeutic role in adhesive, partial small-bowel obstruction. It significantly prompts the resolution of the obstructive episodes and shortens hospital stay. However, further studies are necessary to confirm the significance of our observation that it may reduce the need for operation.

Thoracoscopic versus open supraclavicular upper dorsal sympathectomy: a prospective randomised trial

The purpose of the present study was to compare the short term results of the "open" supraclavicular approach with the thoracoscopic access for T2-T4 sympathetic ganglionectomy in patients with palmar hyperhidrosis. Patients were randomly allocated into two groups of 12 each, and were operated on: one by the open supraclavicular access; the other by the transthoracoscopic approach. The effect on palmar perspiration, operative data, postoperative complications and patients's satisfaction on short term follow up were examined. All operations achieved dry hands. Only two significant differences were observed: longer anaesthesia and poorer patient satisfaction in the thoracoscopic group one week after surgery (probably because a higher proportion of cases developed prolonged postoperative chest pain). Both techniques similarly achieve dry hands. The open method is not longer or more difficult, is possibly associated with less morbidity, and gives a higher subjective satisfaction.

[Posttraumatic superficial temporal artery pseudoaneurysm]

The etiology of superficial temporal artery aneurysm (STAA) is usually blunt trauma. This type of aneurysm is more prevalent in young men and is also probably more common than estimated from the literature. We present 3 males and 1 female with STAA, ranging in age from 8 to 30 years, who were successfully treated. 3 were operated on under local anesthesia, while the aneurysm of the fourth was obliterated by continuous local pressure. Application of local pressure is the best measure for preventing the development of pseudoaneurysm following blunt temporal trauma. We consider surgery the treatment of choice for STAA.

Minicholecystectomy vs conventional cholecystectomy: a prospective randomized trial--implications in the laparoscopic era

The objective of this study was to compare results of elective "open" conventional cholecystectomy (CC) to those of minicholecystectomy (MC). A clinical prospective, randomized trial was designed. The setting was an academic general surgical unit. In the CC group were 26 patients; in the MC group were 24 patients. In the CC group a conventional open cholecystectomy was performed through a subcostal incision; in the MC group operation through an initial 5-cm subcostal incision was done. Mean length of wound was 14.4 cm and 5.4 cm in the two groups, respectively (p < 0.001). Mean operative time was 60 and 59 minutes, respectively. Mean operative difficulty, estimated on a 1-10 scale, was 3.4 and 5.6, respectively (p < 0.05). Mean postoperative analgesia requirements (number of doses of 10 mg morphine sulphate) were 5.8 and 4.0, respectively (p = 0.002). Mean duration of hospitalization was 4.7 and 3.0 days, respectively (p < 0.001). Mean "overall patient satisfaction," estimated on 1-10 scale, was 6 and 8.3, respectively (p = 0.002). We conclude that Minicholecystectomy offers less pain, earlier recovery, and better cosmetic results than the conventional "open" procedure. Published results of MC compare favorably with those of laparoscopic procedures. The implications of these results in the "laparoscopic era" are discussed.

[Thoracoscopic resection of upper dorsal sympathetic chain for palmar hyperhidrosis]

During the past year we have used the thoracoscopic approach in performing bilateral upper dorsal sympathectomies for the treatment of palmar hyperhidrosis. We present our first 16 patients. Histological examination proved that sympathetic ganglia had been resected in all 32 procedures. Immediately after operation all hands were completely dry and 31 of them remained so on follow-up 5 months later (97% success rate). The main operative complications were bleeding in 3 cases (9.4%; only 1 severe), and chest and back pain for more than 1 week in 8 (50%). The main late sequela was compensatory hyperhidrosis of the chest and back in 10 cases (62%).

[Temporal artery biopsy--required or superfluous?]

Temporal arteritis is a systemic disease affecting large and medium-sized arteries in the elderly. The incidence of the disease increases with age and its major complications are blindness, cerebrovascular accidents and aortic dissection. Diagnosis is mainly based on clinical signs and symptoms. Temporal artery biopsy is a popular and simple diagnostic procedure and if positive confirms the diagnosis. However, a negative biopsy cannot exclude temporal arteritis due to its segmental nature, and the specific signs and symptoms still require treatment with corticosteroids. During the years 1982-1991 we performed 206 temporal artery biopsies, of which only 21 (10.2%) confirmed the presence of temporal arteritis. Our experience is presented with regard to the usefulness of temporal artery biopsy in particular. In view of the low biopsy yield we recommend more selective referral for this purpose.

[Isolated iliac aneurysm]

The incidence of isolated iliac artery aneurysm is 1-2% of that of abdominal aortic aneurysms. The natural history is of gradual enlargement, with rupture the most common clinical presentation. The signs and symptoms of such an aneurysm are influenced by its concealed location within the bony pelvis. Awareness of these special characteristics improves the chances of early diagnosis and proper surgical treatment before possible rupture. We report 2 cases which demonstrate the spectrum of the clinical presentation.

[Total colectomy and mucosal proctectomy with J-pouch anal anastomosis for ulcerative colitis and familial colonic polyposis]

Total colectomy and mucosal proctectomy with ileal pouch-anal anastomosis is the accepted surgical procedure for ulcerative colitis and familial polyposis of the colon. During 1981-1990, 25 patients with ulcerative colitis or familial polyposis underwent this operation in our department. In the majority a J-pouch was performed. In the early years, an 8 cm rectal muscular sleeve was left. In later cases, in accordance with opinions expressed in the medical literature, the length of the sleeve was shortened to about 3 cm. We present the functional results and the early and late complications on follow-up of up to 10 years (mean 3.5 years). Although this operation is not the ideal solution, it is better than the alternatives and is the surgical procedure of choice.

[Subtotal cholecystectomy: an emergency procedure for the difficult gallbladder and high-risk patient]

Emergency cholecystectomy in high-risk patients is still associated with significant morbidity and mortality. Occasionally technical difficulties and bleeding diathesis are complicating factors. Our prospective experience with subtotal cholecystectomy in 23 consecutive patients is presented. All presented as increased surgical risks (APACHE II above 10) and suffered from acute cholecystitis with empyema or perforation. 1 patient died (4.4%), but overall, surgical complications were minimal. We conclude that subtotal cholecystectomy combines the advantages of cholecystectomy and cholecystostomy. We believe that this short, simple and safe procedure is a logical choice for emergency situations in critically ill patients.