Biomedical subjects

A E Park

Publications and source records attributed to A E Park.

9 recordsLinked to original sources

PubMed2000

Endoscopic retrograde cholangiopancreatography in the management of choledocholithiasis.

Surgeons today have a wide range of therapeutic options for the management of patients with choledocholithiasis. Endoscopists, interventional radiologists, and surgeons employ a variety of techniques to access and remove common bile duct stones (CBDS) successfully. Although earlier studies have been done to assess the relative merits of laparoscopic and endoscopic management of CBDS, few of them have employed a randomized prospective trial for the comparison. Without recognized parameters for comparison, no definitive conclusions can be drawn. Herein, we examine the role of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) as an important adjunct to laparoscopic cholecystectomy (LC) in the management of CBDS. The three main scenarios in which this modality is employed for CBDS removal are selective preoperative ERCP, intraoperative ERCP, and postoperative ERCP. We conclude that an appropriate balance must be struck to maintain a high yield of positive or therapeutic ERCP, avoid unnecessary ERCP, and not miss CBDS, while ensuring acceptably low rates of morbidity and mortality and controlling costs. As we await the publication of prospective data, we may look for direction from decision analysis in order to develop optimal management strategies and define the "best practice" results that should be expected of operators before new procedures and innovative technology are accepted on a widespread basis.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed2000

Minilaparoscopically assisted placement of ventriculoperitoneal shunts.

BACKGROUND: Ventriculoperitoneal (VP) shunting remains the preferred treatment for hydrocephalus. Laparoscopic techniques to aid in the placement of the peritoneal portion of the catheter have been reported previously. We describe a minilaparoscopic VP shunt (MLVPS) insertion technique that facilitates directed placement of the peritoneal portion of the catheter in most patients, including those with obese abdomens previously subjected to surgery. In this study we review our experience with MLVPS placement. METHODS: All cases of MLVPS insertions at the University of Kentucky Medical Center and Lexington VA Hospital performed between February 1998 and March 1999 were reviewed retrospectively. A total of 27 patients (13 males and 14 females) ranging in age from 4 to 81 years (mean, 41 years) underwent VP shunting. The MLVPS insertion was performed via a 2-mm laparoscope and a separate 2-mm incision for catheter insertion using a venous introducer kit. In patients who had prior abdominal surgery, a 5-mm direct-view trocar was used. RESULTS: The MLVPS procedure was successful in 27 patients (100%). The mean number of prior shunts was 2 (range, 0-28). Of the 27 patients, 16 (59%) had undergone previous abdominal surgery. The mean operative time was 76 min (range, 19-155 min). There were no intra- or postoperative complications, and no mortalities. The follow-up period extended from 1 to 12 months. CONCLUSIONS: Findings show MLVPS placement to be safe and feasible. It allows accurate, directed placement of the VP shunt with a 2-mm laparoscope and a second 2-mm incision for shunt insertion. The procedure is associated with reduced trauma to the abdominal wall and minimal postoperative ileus. Long-term follow-up assessment of shunt function is planned.

Adolescent↗

PubMed2000

Laparoscopic splenectomy: outcomes and lessons learned from over 200 cases.

BACKGROUND: In this study of laparoscopic splenectomy (LS), we evaluate prospectively gathered perioperative patient data and review lessons learned in the evolution of this procedure. METHODS: At 2 university medical centers between November 1993 and March 2000, there were 203 patients (122 female patients and 81 male patients) who underwent LS after preoperative evaluation. RESULTS: LS was successfully completed in 197 patients (97%). The mean operative time was 145.5 minutes and the length of stay averaged 2.7 days with 143 (70.4%) staying less than 48 hours. The most common indication was idiopathic thrombocytopenic purpura (ITP). Six patients required conversion to open splenectomy (OS), with only 2 conversions in the last 163 cases. No deaths were attributed to the procedure. Complications occurred in 19 patients (9.3%). Thirty accessory spleens were identified in 25 patients (12.3%). Seventeen patients (8.4%) underwent concomitant procedures, most commonly cholecystectomy. CONCLUSIONS: LS by the lateral approach is both safe and feasible in patients of all ages.

Adolescent↗

PubMed1999

Incisional hernia.

Explore the source record for details and available documents.

Hernia, Ventral↗

PubMed1999

Randomized, controlled trial of bupivacaine injection to decrease pain after laparoscopic cholecystectomy.

OBJECTIVES: To determine if intraoperative instillation of bupivacaine would decrease early postoperative pain after laparoscopic cholecystectomy, if the patients would consequently require less narcotic postoperatively and if such patients would elect to be discharged on the day of operation if given the choice. DESIGN: Double-blind, randomized, controlled trial. SETTING: A tertiary care hospital in Hamilton, Ont. PATIENTS: Fifty patients underwent laparoscopic cholecystectomy. Day-surgery patients had the choice of staying overnight for discharge the following day. They were compared with a control group of 47 patients who had laparoscopic cholecystectomy but did not receive bupivacaine. INTERVENTION: Instillation of 20 mL of 0.5% bupivacaine with epinephrine into laparoscopic cholecystectomy port sites intraoperatively before closure. MAIN OUTCOME MEASURES: Visual analogue scale (VAS) pain scores assessed 4 times postoperatively, the choice of patients to leave hospital the same day or to remain in the hospital overnight; the level of postoperative narcotic usage. MAIN RESULTS: Mean VAS pain scores (range 0 [no pain] to 5 [severe pain]) at less than 2 hours and at 6 hours after surgery were 2.9 and 2.9, respectively, in the bupivacaine group compared with 4.5 and 4.0, respectively, in the control group (p = 0.001 and 0.025). VAS scores at 10 hours postoperatively and the next morning did not differ between the groups. More patients in the bupivacaine group elected to go home on the day of surgery (p = 0.034). Narcotic usage was not significantly different. CONCLUSION: Instillation of bupivacaine into port sites should be standard practice for elective laparoscopic cholecystectomy.

Adult↗

PubMed1998

Prospective, multicenter study of laparoscopic ventral hernioplasty. Preliminary results.

BACKGROUND: A standard technique for laparoscopic ventral hernioplasty (peritoneal onlay using an expanded polytetrafluoroethylene [ePTFE] patch for hernias >/=4 cm2) is being used in a prospective, multicenter, long-term study. METHODS: Demographic, operative, and postoperative data were collected and analyzed. Follow-up clinical evaluations were conducted 7-10 days, 4 weeks, 6 months, 1 year, and then annually after surgery in all patients. RESULTS: In the first 2 years of the study, 144 patients were enrolled; nine were lost to follow-up. The mean operating time was 120 min. The mean follow-up was 222 days (range 5-731). Postoperative complications were five infections, three cases of prolonged ileus, one bowel obstruction, 23 seromas (15 resolved without intervention), and six hernia recurrences. Hospital discharge occurred a mean of 2.3 days after surgery and return to normal activity a mean of 15 days postoperatively. CONCLUSIONS: Laparoscopic prosthetic ventral hernioplasty avoids the large wound required in open repairs, with attendant complications and recurrences, and appears safe, especially if an ePTFE mesh is used. Compared with conventional open ventral hernioplasty, the laparoscopic technique may also allow shorter hospitalization and a quicker return to normal activities after surgery.

Adult↗

PubMed1998

Carotid plaque morphology correlates with presenting symptomatology.

PURPOSE: In carotid artery disease, correlation of carotid plaque morphology with the patient's presenting symptoms has drawn conflicting conclusions. The purpose of this series was to correlate carotid plaque characteristics with the presenting symptoms from a large cohort of patients who underwent operation for carotid artery disease. METHODS: From a series of 1252 consecutive patients who underwent carotid endarterectomy, presenting symptoms were divided into three groups: transiently symptomatic (transient ischemic attack [TIA] or amaurosis fugax), prior stroke, and asymptomatic. Plaque characteristics, including ulceration, intraplaque hemorrhage, and degree of stenosis, were recorded prospectively for 1008 procedures. All endarterectomy specimens were inspected during the procedure, and plaque characteristics were recorded immediately after operation. RESULTS: There was a higher incidence of plaque ulceration in the transiently symptomatic and prior stroke groups (391 of 508 [77%] and 91 of 115 [79%]) than in the asymptomatic cohort (231 of 385 [60%]; p < 0.0001, chi2 test). There was no significant difference in the incidence of plaque hemorrhage between the transiently symptomatic and prior stroke patients compared with the asymptomatic patients. There was no statistical difference for ulcerated plaque or plaque hemorrhage between the transiently symptomatic and prior stroke group. Intraplaque hemorrhage occurred more frequently in patients with high-grade stenosis (90% to 99%) than in those with less than 90% stenosis (202 of 299 [68%] versus 97 of 299 [32%]; p = 0.01, chi2 test). CONCLUSIONS: On gross examination of the carotid specimen in the operating room, plaque ulceration correlates with an initial presentation of amaurosis fugax, TIA, or prior stroke compared with patients operated on for asymptomatic disease. The presence of intraplaque hemorrhage is associated with more advanced stenosis of the internal carotid artery. These findings suggest that plaque morphology does play an important role in the presentation of carotid artery disease.

Adult↗

PubMed1996

Pediatric laparoscopic splenectomy using the lateral approach.

Laparoscopic splenectomy in children has been shown to be safe, to reduce postoperative pain and hospital stay, and to accelerate return to full activities. We describe our experience with a four-port "lateral" approach in 18 patients. Patients were placed in the lateral decubitus position and the table was flexed to separate the left subcostal margin and iliac crest. The camera port was inserted at the umbilicus and additional ports were placed in the epigastrium and left lower quadrant. After mobilization of the splenic flexure a port was inserted in the left flank below the 12th rib for elevation of the spleen. A 30 degrees laparoscope was used and the splenic vessels were controlled with an endo-GIA and/or clips. The spleens were placed in a bag, morcellated, and extracted through a port site. Eight females and 10 males with a median age of 12.5 years (5-17 years) and weight of 55.5 kg (17-124 kg) underwent splenectomy of idiopathic thrombocytopenia purpora (10), spherocytosis (6), elliptocytosis (1), and Hodgkin's disease (1). The median operating time was 160 min (90-300 min) and median blood loss was 105 ml (5-350 ml). Accessory spleens were removed in four cases. Three patients required extensions of a port site to remove large spleens which could not be placed in a bag. The sole complication was a transient pancreatitis with associated pleural effusion. The median postoperative hospital stay was 2 days (1-11 days) and time to full activities was 8 days (3-25 days). The lateral approach affords excellent visualization of the splenic vessels, pancreas, and accessory spleens. This approach is safe and reliable and is our preferred approach for laparoscopic splenectomy in children.

Adolescent↗

PubMed1996

Carotid endarterectomy. Lessons from intraoperative monitoring--a decade of experience.

OBJECTIVE: The authors analyzed a single institution's 10-year experience with intraoperative monitoring during 709 primary carotid endarterectomies and investigated the impact of contralateral internal carotid artery stenosis on carotid artery stump pressure (SP). SUMMARY BACKGROUND DATA: Stump pressure reflects the combination of contralateral carotid artery anatomy, collateral intracranial vasculature, and systemic blood pressure. By controlling for blood pressure with a stump index (SI) (SI = [SP/mean arterial pressure] x 100), a correlation between pressure and contralateral carotid artery anatomy can be demonstrated. Although the use of SP has long been advocated as an indicator of adequate cerebral perfusion, its correlation with perioperative complications while using an intraluminal shunt has not been evaluated completely. METHODS: From a series of 886 primary carotid endarterectomy cases, SP and mean arterial pressure were measured prospectively in 709 procedures. Temporary intraluminal shunts were used in cases with demonstrated contralateral carotid occlusion, prior cerebrovascular accident (CVA), or SPs less than 35 mmHg. Ipsilateral and contralateral angiographic degree of carotid stenosis was recorded at the time of the operation. Neurologic status was recorded prospectively for all 709 procedures. Operative electroencephalogram (EEG) changes and SP then were compared with the neurologic status of the patient in the perioperative period. RESULTS: The mean SP for the group (n = 709) was 46.7 +/- 15.3 mmHg (mean +/- standard deviation [SD]) with a mean SI of 54.9 +/- 22.6. The distribution for the SI is a more gaussian curve than that for SP. There were 19 ipsilateral CVAs (2.7%). The mean SP in the nonstroke group was 47.1 +/- 15.2 mmHg (mean SI = 54.7 +/- 16.5) compared with 31.9 +/- 13.2 mmHg (mean SI = 38.8 +/- 18.2) in the stroke group (P < 0.0001). Stroke rate for SP < or = 35 mmHg was 7% (13/185) versus 1.1% (6/524) for SP > 35 (p < 0.0001). Stump index and SP are related to contralateral carotid artery stenosis. The pattern of SI or SP versus contralateral stenosis is biphasic, with an increase at 75%. If SI is < or = 40, the mean contralateral stenosis is 55.1%; if SI is > 40, the mean contralateral stenosis is 35.1% (p < 0.05). Continuous EEG monitoring was completed for the 549 most recent operations. Patients who had a perioperative stroke had EEG changes observed during the procedure in only 6 of 12 cases (50% sensitivity), with 76% specificity. Using SP < or = 35 mmHg, sensitivity was 68% and specificity was 75%.

Aged↗