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Biomedical subjects

A Cuschieri

Publications and source records attributed to A Cuschieri.

At least 145 records · Page 8Linked to original sources
PubMed1996

Hepatobiliary anatomy in patients with transposition of the gallbladder: implications for safe laparoscopic cholecystectomy.

The surgical anatomy of six patients with sinistroposition of the gallbladder is described. Five of these were encountered in a consecutive series of 1764 patients undergoing laparoscopic cholecystectomy for symptomatic gallstone disease in two hospitals between 1989 and 1994, a prevalence of 0.3 per cent in patients undergoing this operation. Despite the left-sided transposition of the gallbladder, the biliary pain experienced by these patients was always on the right side. Preoperative diagnosis of this anomaly was made in only one of six patients despite routine preoperative external ultrasonography and selective preoperative cholangiography. In sinistroposition the cystic artery always crosses in front of the common bile duct from right to left. The cystic duct may open on the left or right side of the common hepatic duct. The anomaly does not preclude safe laparoscopic cholecystectomy but modifications of the port sites and use of the falciform lift facilitate the procedure in these cases. The anatomical features of the sixth case encountered in a patient undergoing resection of hilar cholangiocarcinoma indicate that sinistroposition of the gallbladder may be due to failure of development of segment IV of the liver.

Adult↗
PubMed1996

Percutaneous endoscopic external ring (PEER) hernioplasty.

This pilot study was conducted to determine if percutaneous endoscopic external ring (PEER) hernioplasty would be a viable alternative to the conventional and laparoscopic methods of tension-free repair. The procedure consists of (1) a 2.0-2.5-cm incision over the external inguinal ring to reach the emerging spermatic cord structures, and ligation and excision of the hernia sac and (2) insertion of an endoscope-attached retractor through the external ring, into the inguinal canal for visualization, dissection of posterior inguinal wall, and placement of mesh to complete tension-free repair. PEER hernioplasty was used to treat 48 patients with 60 primary hernias (bilateral in 12 patients) between January 1993 and December 1994. Median follow-up was 12 months and ranged from 5 to 22 months. All patients were discharged within 24 h after surgery except for one. All patients resumed their normal activity within 2-3 weeks. Only three complications were encountered (two scrotal hematomas and one inguinal seroma). To date, there has been recurrence of two hernias in one patient. We conclude that PEER hernioplasty is an effective method of repair of primary hernias that is less invasive than the conventional approach and both less invasive and more cost-effective than laparoscopic approaches.

Adult↗
PubMed1996

A microprocessor-controlled psychomotor tester for minimal access surgery.

BACKGROUND: There is little reported information on psychomotor performance in relation to minimal access surgery (MAS). METHODS: A microprocessor-controlled endoscopic psychomotor tester (the Dundee Endoscopic Psychomotor Tester-DEPT) has been developed to evaluate psychomotor aspects of MAS. Experiments were conducted on 20 medical undergraduates to evaluate accuracy and reliability of the tester. RESULTS: The study demonstrated a significant difference between subjects (p < 0.01). It also identified three individuals who enacted 16, 22, and 40 errors while the majority (85%) sustained less errors with a median of 4.5. CONCLUSIONS: DEPT provides a standard, reproducible, objective real-time scoring system. It identifies individuals who cannot adjust to endoscopic viewing and therefore manipulate from endoscopic images.

Clinical Competence↗
PubMed1996

EAES ductal stone study. Preliminary findings of multi-center prospective randomized trial comparing two-stage vs single-stage management.

BACKGROUND: The current management of patients with ductal calculi and gallstone disease consists of endoscopic stone extraction (ESE) followed by laparoscopic cholecystectomy (LC). The advent of techniques of laparoscopic ductal stone clearance has introduced an alternative single stage laparoscopic treatment for these patients. The EAES ductal stone trial was set up to compare the relative efficacy and outcome of these two management options. METHODS: The study consists of a prospective randomized controlled clinical trial comparing two management options of patients undergoing LC and suspected of harbouring common duct stones. Patients registered into the trial are randomized to one of two arms: (i) Group A-preoperative ERC with ESE followed by LC during the same hospital admission. (ii) Group B-single stage laparoscopic management consisting of LC and laparoscopic stone extraction either by the trans-cystic duct route or by direct supraduodenal common duct exploration. RESULTS: This preliminary analysis was carried out on 207 randomized patients with comparisons being made on the intention to treat principle. The two groups (A = 106, B = 101) were comparable with respect to clinical features. ASA grade, serum biochemistry and ultrasound findings. CONCLUSIONS: These preliminary findings indicate equivalent success rates and patient morbidity between the two management options but a shorter hospital stay (cost benefit) with the single stage laparoscopic treatment. Trans-cystic duct extraction is a more benign procedure than laparoscopic supraduodenal CBD exploration and is accompanied by a significantly shorter hospital stay. The higher incidence of conversion in the single stage laparoscopic group compared to the two-stage arm is due to the preference for open common duct exploration when the laparoscopic attempt failed by the majority of participating surgeons. The results to-date suggest that in fit patients, single stage laparoscopic treatment is the better option and the role of ESE should change to selective use in those patients in whom laparoscopic ductal stone extraction has failed.

Adolescent↗
PubMed1996

Preface.

Explore the source record for details and available documents.

Journal Article↗
PubMed1996

Laparoscopic Pancreatic Resections.

Resection of the pancreas by the laparoscopic approach is still in its infancy and the reported experience is very limited. Despite its retroperitoneal location, exposure and mobilisation of the pancreas can be achieved in the vast majority of patients and does not usually pose major technical problems provided the surgeon is experienced in advanced laparoscopic techniques and in pancreatic surgery. Based on our experience, laparoscopic enucleation of islet-cell tumours constitutes an ideal indication. Both the precise location (by contact ultrasonography of the pancreas) and the enucleation (by ultrasonic dissection) are facilitated by the laparoscopic approach. Laparoscopic distal 70-80% pancreatectomy for chronic pancreatitis and cystic tumors appears to confer benefit over the equivalent open operation by accelerating recovery and return to full activity of the patient after surgery. By contrast, our experience with laparoscopic pancreaticoduodenectomy for periampullary cancer has been disappointing and we have not documented any benefit from this approach. In addition, there are real concerns that an oncologically adequate operation (with extended lymphadenectomy) for cancer of the head of the pancreas is not possible by the laparoscopic approach.

Journal Article↗
PubMed1996

Laparoscopic distal 70% pancreatectomy and splenectomy for chronic pancreatitis.

OBJECTIVE: The authors performed an initial clinical evaluation of laparoscopic pancreatectomy with splenectomy for chronic pancreatitis. SUMMARY BACKGROUND DATA: Severe intractable pain is the most common indication for resection in chronic pancreatitis. Localized accentuation of the pathology, usually in the head of the organ, is the basis for localized proximal resection, often with preservation of a rim of pancreas and the duodenum, although some favor total pancreatectomy. The reported results for distal pancreatectomy have been variable. Distal resections are limited to those patients in whom the gross pathology is maximal in the left hemipancreas. METHODS: A consecutive series of five patients with intractable pain due to chronic pancreatitis have been treated with laparoscopic 70% distal pancreatectomy and splenectomy using a 5-port technique. RESULTS: The procedure was completed in all with an average operating time of 4.5 hours and a mean intraoperative blood loss of 400 mL. There was one minor pancreatic leak, which resolved spontaneously. The median postoperative hospital stay was 6 days. CONCLUSIONS: Laparoscopic distal pancreatectomy for chronic pancreatitis is feasible, the procedure appears to be safe, and it is accompanied by an accelerated recovery.

Adult↗
PubMed1996

Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy in Scotland.

This survey determined the effect of the introduction of laparoscopic cholecystectomy on the rates of cholecystectomy (total and laparoscopic) in Scotland. From 1977 to 1990, the Scottish cholecystectomy rate fell by an average of almost 1% per annum. With the advent of laparoscopic cholecystectomy, the total cholecystectomy rate (open and laparoscopic) rose considerably--by 18.7% from 1989-93 (p < 0.05). The largest increase (25%) was observed in the 45-64 years age group but it was also particularly evident (19%) in elderly patients (65-74 years). Subjects were more likely to undergo laparoscopic cholecystectomy than open cholecystectomy if they were young and female. The increased cholecystectomy rate observed merits careful scrutiny and health economic evaluation.

Adolescent↗
PubMed1996

Stereologic study of splenic tissue compartments from traumatically injured and cancer patients.

Carefully age-matched groups of patients, surgically treated for either traumatic injury (n = 5; mean = 71.2 years) or for early stage carcinoma (n = 5; mean = 74.2 years), were used to investigate all the splenic tissue compartments applying model-based stereology. The point-counting method was utilized to study the volume densities of following tissue compartments: red pulp, perifollicular zone, white pulp (this compartment was divided into two subcompartments: follicles and periarteriolar lymphatic sheath), marginal zone and connective tissue. The following stereologic parameters of lymphoid follicles were determined: areal numerical density (the number of follicles per mm2 of tissue section), the numerical density (number of follicles per mm3 of tissue), and the mean follicle diameter. The identity of tissue compartments was verified using immunohistochemical staining for B- and T- lymphocytes. Significantly increased volume densities of perifollicular zone and periarteriolar lymphatic sheath were registered in patients treated for traumatic spleen injury. On the other hand, the significantly increased number of lymphoid follicles per mm2 and per mm3 of splenic tissue were registered in the group of cancer patients. The differences observed, whether attributable to the immune stimulation of the ruptured spleen or the alterations of the immune system due to malignant disease, suggest that this issue deserves further attention.

Aged↗
PubMed1996

Stereological study of tissue compartments of the human spleen.

Morphometric reports on animal and human spleen are very few and no studies have been carried out using stereological methods to investigate all of the tissue compartments of the human spleen. Eighteen samples of spleens, which were either surgically removed after traumatic injury or during treatment for early stage carcinoma or gastric ulcer, were investigated. The point-counting method was used to study the volume densities of the following tissue compartments: red pulp, perifollicular zone, white pulp (this tissue compartment was divided in two subcompartments: follicles and periarteriolar lymphatic sheath), marginal zone and connective tissue of trabeculas. The following stereological parameters of the follicles were investigated: the number of follicles per mm2 of spleen section, numerical density, volume density, and the mean follicular diameter. The identity of spleen tissue compartments was verified using immunohistochemical staining for B- and T-lymphocytes. The volume densities of tissue compartments, as well as stereological parameters of lymphoid follicles, were similar in both groups of splenic samples, except for the volume densities of perifollicular zone and periarteriolar lymphatic sheath, where a statistically significant difference was registered.

Animals↗
PubMed1995

Ultrasonographic characterization of hepatic cryolesions. An ex vivo study.

OBJECTIVE: To determine the physical basis for the ultrasonographic characteristics of the hepatic ice ball produced by cryotherapy and the size correlation between the actual hepatic ice ball and the ultrasonographic cryolesion. DESIGN: Experimental ex vivo study involving controlled freezing with liquid nitrogen recirculating probes of fresh porcine livers immersed in various solutions at ambient temperatures (20.2 degrees C to 22.6 degrees C), together with measurements of the impedance of frozen and unfrozen liver. RESULTS: First, the hyperechoic rim is caused by reflection of 34% of ultrasound waves at the interface between unfrozen and frozen liver as a consequence of an increased acoustic impedance of frozen liver that was calculated to be approximately 3.8 times that of unfrozen liver tissue. The increased acoustic impedance is due to the decrease in elasticity of hepatic tissue as it freezes. Second, the posterior acoustic shadowing is partly due to the attenuation of the incident ultrasound waves by reflection at the interface between unfrozen and frozen liver. It is also dependent on the crystalloid-protein content of hepatic parenchyma, which ensures a homogeneous lesion by preventing "shattering" within the cryolesion. This is in sharp contrast to the ultrasonographic appearance of an ice ball formed in ionized water, in which the hyperechoic rim overlies an area of posterior acoustic enhancement. Third, the correlation of the size between the ultrasonographic cyrolesion and the measured hepatic ice ball approached unity (r = .99), and the two measurements were identical for cryolesions less than 50 mm in diameter. CONCLUSION: Ultrasound is an accurate method for depicting the actual diameter of frozen solid hepatic tissue in cryotherapy for liver tumors, but the present technology does not provide accurate assessments of the volume of frozen tissue.

Animals↗
PubMed1995

Comparative evaluation of contact ultrasonography and transcystic cholangiography during laparoscopic cholecystectomy: a prospective study.

BACKGROUND: The role of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) is controversial. While many advocate its routine use, others argue for a selective approach. Recent reports showed laparoscopic contact ultrasonography (LCU) as a viable alternative to IOC. However, no prospective data were available to compare the accuracy, efficacy, and safety of the two diagnostic procedures. OBJECTIVE: To evaluate the benefits and disadvantages of LCU and IOC during LC. METHODS: Seventy-eight patients who underwent LC at Pisa (Italy) and Dundee (Scotland) university hospitals were entered in a prospective data registry. Details of operative technique and results of LCU and IOC were analyzed by reviewing videotape recordings of each procedure. RESULTS: Laparoscopic cholecystectomy was achieved in 73 patients, with five requiring conversion to the open procedure. The success rate of IOC was 90% (64/71). Performance of IOC demanded more than twice the time needed for LCU. Eleven percent (8/71) of cholangiograms were abnormal, with a false-positive rate of 1% (1/71). Laparoscopic contact ultrasonography detected all four instances of unsuspected ductal stones but none of the three cases of anomalous biliary anatomy. Clinically relevant incidental findings were picked up by LCU in six patients. CONCLUSIONS: Laparoscopic contact ultrasonography proved to be extremely accurate in the detection of ductal stones but less reliable in the disclosure of anomalous biliary anatomy. The essential role of IOC in providing a clear spatial display of the biliary tract was confirmed. Since the two procedures are complementary, their combined use is advisable in difficult LC to avoid retained common bile duct stones and prevent iatrogenic complications.

Adenoma↗
PubMed1995

Comparison of direct vision and electronic two- and three-dimensional display systems on surgical task efficiency in endoscopic surgery.

Task efficiency and knot strength was evaluated under standardized conditions using direct vision and electronic imaging with two-dimensional (2-D) and three-dimensional (3-D) systems. Three operators with different endoscopic surgical experience tied a surgeon's knot with standard endoscopic instruments using the three different visual systems in random order. Each operator tied 20 knots with each visual system. Median task efficiency (defined as the time to complete the knot) was 35.0 (interquartile range (i.q.r.) 30.3-43.8) s for direct vision and 53.0 (i.q.r. 45.3-62.8) s and 53.5 (i.q.r. 45.0-64.8) s for 2-D and 3-D imaging respectively (P < 0.05). With respect to direct vision, this represented an overall degradation of task efficiency with the use of electronic imaging of 52 per cent, with no detectable difference between 2-D and 3-D imaging. The knot strength, representing the degree of tightening, was weaker with electronic imaging but the difference was not significant due largely to variation between the three operators.

Clinical Competence↗