Biomedical subjects
Publications and source records attributed to A Darzi.
Umbilical endometriosis should be considered in the differential diagnosis of an umbilical swelling. The diagnosis is made by histological examination as clinically there may be no relationship between the swelling and menstruation.
We report three cases of emphysematous cholecystitis managed by laparoscopic cholecystectomy. The diagnosis was made by ultrasound in all cases. Two patients developed postoperative infections. There were no fatalities. The mean postoperative stay was 6 days. In experienced hands, laparoscopic removal of the gallbladder in emphysematous cholecystitis is feasible with good results.
We report our initial experience of laparoscopic ligation of varicocele in 13 patients with a mean age of 34 years (range 18-39). Eight patients were subfertile, and the rest complained of dragging pain and discomfort in the left scrotum. At laparoscopy the peritoneum overlying the spermatic vessels was divided, and the spermatic veins were mobilized, clipped, and divided. The spermatic artery was identified and preserved in 11 of the 13 cases. The patients were discharged within 24 h of hospital admission. Semen quality improved in seven of the eight subfertile patients studied with a mean follow-up of 8 months. Four patients who were operated on for pain and discomfort had symptomatic improvement by the time of their first outpatient visit at 3 months. One patient complained of paresthesia along the anterior aspect of his thigh, which resolved in 6 weeks. There were no other complications. Laparoscopic varicocelectomy is a safe and effective minimally invasive procedure for treatment of clinical varicocele.
The recent introduction of laparoscopic cholecystectomy (LAPC) has revolutionised the surgical treatment of gallstone disease. However, it has also raised doubts about the future role of extracorporeal shock wave lithotripsy (ESWL) in the treatment of gallstones. In this study, we compared patients treated successfully with ESWL and dissolution therapy with patients treated by LAPC. Out of 67 patients, 50 had successful clearance with ESWL while 50 out of 54 had successful LAPC. We evaluate treatment duration, recurrence rate (ESWL) and cost of treatment in both groups. All patients had uncomplicated symptomatic gallstones. The inclusion criteria were similar in both groups with the exception of patients with non-functioning gallbladders who were excluded from ESWL. The results of the study show that although ESWL is noninvasive and associated with minimal morbidity, it is also costly and has a high failure and recurrence rate. In contrast, laparoscopic cholecystectomy, while requiring short-term hospital stay and debility, seems to be a safe and effective alternative with an advantage in terms of cost and duration of treatment.
The authors performed Heller's myotomy using an endothoracoscopic technique on two patients with swallowing difficulties that were clinically demonstrated to be oesophageal achalasia. At 12 and 18 months' followup, respectively, both patients were asymptomatic. Extramucosal cardiomyotomy, as reported by Heller in 1913, is the most common approach to repair achalasia of the oesophagus. The advantages of the laparoscopic technique (less pain, small scars, reduced hospital stay) are given, as well as the disadvantages (possible mobilization of left lateral liver segment, possible splenic damage, difficulty retracting abdominal contents). More studies are needed to determine the rate of pulmonary complications caused by the extended degree of pulmonary collapse in the thoracoscopic approach and to compare the laparoscopic and thoracoscopic approaches to Heller's myotomy.
Rectal mobilization during abdominoperineal or low anterior resection involves careful dissection between the rectum and the sacrum. Inadvertent manipulation outside the avascular presacral space may damage presacral veins, causing troublesome and potentially life-threatening bleeding. We reviewed the current management of presacral bleeding, including the use of an endoscopic stapling device to control presacral bleeding.
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High-intensity shock waves (HISW) waves can produce rapid and intense tissue heating. We have studied a novel device capable of simultaneous shock wave generation, focusing and extracorporeal delivery along with imaging of the proposed target. Shock waves are generated by piezo-electric crystals and target a focal point of 10 x 2 mm. In a preliminary study, three groups of land race pigs received HISW to discrete points on the liver parenchyma. There was no mortality in any group. Cardiovascular monitoring revealed that HISW did not induce any haemodynamic changes during treatment and that core temperatures and liver function tests were unaffected by this therapy. Ultrasound monitoring during treatment demonstrated discreet hyperechoic areas with acoustic shadowing suggesting cavitation. Animals killed immediately after 48 h of HISW therapy had discrete necrotic cylinders within the liver with a mean diameter of 2 cm (+0.21 SD). Histological examination revealed a pattern of necrosis and vascular changes suggestive of ischaemia. In addition, there were areas of coagulative necrosis consistent with thermal injury. Animals killed at 2 months had necrotic cavities which had become surrounded by mature fibrosis. These early results indicate that high energy shock waves delivered extracorporeally can cause specific destruction of liver tissue by focused hyperthermia and cavitation. Clinical studies of this device are required to assess the possible virtue of HISW in the treatment of liver and other tumours.
Laparoscopic or laparoscopic-assisted surgery for colorectal cancer was attempted in 59 patients suffering from malignant disease of the anus, rectum and colon over a 20-month period. Conversion to open surgery was necessary in 5 patients (8.4%). The peroperative (30-day) mortality was 5.8%, and in two of the three patients who died this was attributable to thrombo-embolic complications. The cancer-related mortality was 8%. There were 5 Dukes' A, 21 Dukes' B and 25 Dukes' C lesions resected, and thus far all recurrences were in patients who had Dukes' C lesions. The resection margins and lymph node yield in these specimens were similar to those achieved with conventional open surgery. Six patients also had hepatic metastases recognized at the time of primary surgery. These preliminary data indicate the feasibility of performing laparoscopic-assisted resection of colorectal cancer without compromising the accepted principles of excisional surgery for malignant disease. However, a number of important issues such as thrombo-embolic prophylaxis, specimen retrieval and the long-term recurrence rates require further study before these procedures are widely adopted for colorectal cancer.
Thoracoscopic lung biopsy provided diagnostic histologic material with minimal patient discomfort in an HIV-positive man with diffuse pulmonary Kaposi's sarcoma. This minimally invasive procedure will have an increasing role in providing a histologic diagnosis in patients with diffuse lung disease.
Laparoscopic cholecystectomy is the most common major abdominal operation performed endoscopically. Other surgical procedures performed endoscopically include hysterectomy, hernia repair, Nissen fundoplication, and vagotomy. More recently, laparoscopic colectomy has been described (1,2). We have performed over fifty laparoscopic assisted colonic procedures, the results of which have been published (2). In this paper we describe the technique of two laparoscopic assisted procedures in colonic surgery--right and left hemicolectomy.
A consecutive series of six patients admitted with perforated anterior duodenal ulcer were operated on using a laparoscopic technique. Only one operation was unsuccessful and required conversion to conventional open laparotomy. The remaining five patients had a completed laparoscopic omental patch repair with peritoneal washout. There was no mortality, and two patients developed a chest infection postoperatively. Early mobilisation and discharge from the hospital (mean, 6 days) were notable features in this series. In conclusion, laparoscopic repair of uncomplicated perforated duodenal is a safe and effective technique.
Laparoscopic technology is likely to have an increasing impact on surgical procedures that have previously required an open approach. We have prospectively evaluated laparoscopic colectomy in 40 patients requiring elective colonic excision mainly for malignant disease. 33 of 40 patients had a successfully completed laparoscopic colectomy, although there was one postoperative death. Seven operations were unsuccessful and required conversion to conventional open laparotomy. Morbidity was low with no wound infections and only two chest infections in the 32 survivors. Early mobilisation and discharge from hospital (mean 8 days) was a notable feature. Previous abdominal surgery was not an absolute contraindication to laparoscopic colectomy. However, the inability to palpate the colon directly to confirm the site of laparoscopically impalpable lesions leads us to recommend contrast radiology to confirm the location of colonoscopically diagnosed lesions before laparoscopically assisted colectomy. Preliminary pathological assessment of resected tumour specimens revealed a satisfactory tumour clearance. We conclude that laparoscopic colectomy is a feasible operation in most patients and leads to a substantial patient benefit without compromising the chance of a surgical cure of cancer.
Extracorporeal shock wave lithotripsy (ESWL) is successful in fragmenting gallstones, but less than 28 per cent of patients with gallstone disease fulfil the conventional criteria for treatment. However, no data exist to substantiate these selection criteria. In this study, the selection criteria were broadened to include patients with radiolucent stones of any size and number, and radio-opaque stones less than 3 cm in diameter. To date; 108 symptomatic patients with gallstones have received treatment. All patients received up to six outpatient sessions of ESWL (6000 shock waves per session) without sedation or analgesia. The dissolution therapy consisted of combined bile salt and terpene administration. The clearance rates were 9 per cent within 2 months, 21 per cent at 2-4 months, 38 per cent at 4-8 months, 60 per cent at 8-12 months, and 78 per cent at 12-18 months. Of patients with a successful outcome only 19 (18 per cent) would have satisfied traditional selection criteria. There have been no significant complications except in one patient who developed mild acute pancreatitis, which settled on conservative treatment, and two patients who developed acute cholecystitis. This study would suggest that the previously accepted selection criteria underestimate the number of patients suitable for gallstone ESWL and dissolution therapy.
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'Chemical cholecystectomy' has been proposed as an alternative to removal of the gallbladder. This study assessed cystic duct obliteration using bipolar electrocoagulation (with sham cannulation controls) and gallbladder mucosal treatment with tetracycline (or saline controls) in 29 mongrel dogs. Cystic duct obstruction was assessed by tube cholecystography at day 14, and epithelial damage by histology at day 42. Electrocoagulation by duct diathermy effectively occluded the cystic duct in 14 of 19 animals; however, this was associated with mucocele formation unless mucosal treatment with tetracycline was also performed. Immediate instillation of tetracycline after duct electrocoagulation produced only partial epithelial damage. The combination of duct electrocoagulation and delayed tetracycline instillation at 14 days produced complete destruction of all gallbladder epithelium and an effective chemical cholecystectomy.