Biomedical subjects
Publications and source records attributed to B C Manegold.
Endoscopic sphincterotomy (EST) is a useful alternative to re-intervention of the bile ducts in cases of choledocholithiasis in the aged patient. The rate of success of EST is 87.7%, the rate of complications 8.4%, and the rate of mortality 1.1%. Mortality from EST is lower than that from transduodenal papillotomy or reoperation of the bile ducts. Late complications after EST are unknown and not to be expected.
Results of exfoliative gastric cytology from two periods were compared (779 examinations in the first period, 598 in the second). In 85% of cytological examinations, a histologic diagnosis was available. 64% of histologically verified carcinoma were diagnosed by cytology, too. In the second period the percentage of false positive findings decreased from 4,7% to 1,1% and the rate of suspicious findings from 3,7% to 1,5%. The proportion of carcinomas not detected by cytology increased from 32% to 35%. The rate of correct diagnosis of two contributors remained constant (53% resp. 71%). Improvement of diagnostic accuracy depends upon better technique of yield of material by endoscopists.
From August 1974 to December 1977 a total of 155 endoscopic papillotomies were performed. Endoscopic papillotomy (EPT) has proven to be an acceptable alternative to surgical reintervention at the biliary tree especially in aged and cholecystectomized patients where obstructive jaundice is caused by a concrement. The rate of all complications (9%) is comparatively low. In our own series 3 patients died after endoscopic papillotomy. EPT may be justified in jaundiced patients without previous cholecystectomy when there is a high risk for laparotomy. Preoperative drainage of massive hyperbilirubinaemia caused by a carcinoma of the papilla of Vater and treatment of the blind sack syndrome in cases of choledochoduodenostomy are further indications of this method. Late complications after EPT are not known until now.
Foreign bodies of the upper GIT are regularly extracted with endoscopes, provided, that they have neither left the pylorus, changed their form, nor perforated the wall. Endoscopic extraction is recommended when safe and spontaneous discharge is uncertain. Impacted rectal foreign bodies usually need proctologic or abdominal surgery. Intraoperative endoscopy should be limited to those organs that are not attainable by preoperative inspection like cholangioscopy and peroral jejunoileoscopy.
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Cytological smears from 779 cases were examined over a three-year period, cell collection and cytological diagnosis being in separate hands (material sent in from outside). Three quarters of the cytological findings could be compared with the histological diagnosis: 68% of 194 histologically proven malignant tumours were diagnosed cytologically. The diagnostic accuracy varied between 53 and 74.4%, depending on experience and precision of the endoscopist. In 18 cytologically positive cases results were different from the histological diagnosis. Initial diagnosis of malignant tumour by cytology was made in 3.6% of cases. Subsequently repeated biopsies or histological examination of surgical specimens confirmed the diagnosis.
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In an effort to ensure proper training and to establish a routine amongst the surgical team right from the start, we began practicing laparoscopic techniques with the lap simulator. After having acquainted ourselves with the fundamentals of this minimal-invasive method, we applied our newfound experience to the animal model. Even though the subsequent studies with pigs were the best learning model in which to practice different surgical techniques--e.g., ureter clipping and renal vessel triple stapling with the Endo-GIA--various problems can arise in a true clinical situation since anatomical diversity exists between an animal and human situs. We found that a compromise could be reached by simulating laparoscopic conditions during open surgery without endangering the safety of the patient during any point of the operation. After open surgical exposure of the Gerota fascia was carried out, the operative site was completely covered with the Laptent. From this moment on, all operative steps were performed with laparoscopic instruments under continuous video monitoring. Our step-by-step training program has exposed the surgeon and OR staff to the complexity of this new surgical technique. The use of the Laptent has successfully bridged the gap between open and laparoscopic surgery. Most important of all, those surgical centers without access to extensive experimental studies will realize that Laptent-assisted surgery can be of benefit and facilitate the clinical introduction of this minimal-invasive method.
During 7057 conventional cholecystectomies (1972-1991), 16 bile duct injuries occurred, amounting to a risk of 0.22%. A total of 1022 laparoscopic cholecystectomies were performed without such a complication since April 1990. In a retrospective study, 64 patients (16 of our patients and 48 referrals) with an injury or stricture due to conventional cholecystectomy were investigated. In 14 of our 16 patients the injury was recognized and immediately repaired with a good long-term result of 93%, including one successful repair of a subsequent stricture. Two cases of unrecognized injury were managed by nonoperative means. The group of 48 referred patients comprised 10 early postoperative complications (21%) and 38 strictures after an "uneventful" cholecystectomy. Of the 64 total patients, 10 (16%) underwent nonoperative treatment, and 54 required surgery. The mean follow-up period after surgery was 7.4 +/- 4.9 years. Most cases (93%) were repaired by bilioenteric anastomosis (i.e., foremost hepaticojejunostomy) with an 18% restricture rate. Including second and third repairs for restricture, a total of 60 operations (14 primary and 46 secondary reconstructions) were performed without hospital mortality. A good long-term result after stricture repair was achieved in 75% of the patients, whereas 17% had a poor outcome owing to restricture or death (10% had related mortality within 10 years). The other 8% had a moderate result due to recurrent cholangitis. Thus immediate repair of a bile duct injury offers the better chance of a favorable prognosis compared to secondary stricture repair.
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A rare case of life-threatening hemorrhage from a vascular neoplasm of the esophagus is presented. The exact nature of the lesion remained obscure in spite of careful histomorphologic analysis. After tumor extirpation no signs of recurrence were observed during a four-year follow-up period.