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D I Watson

Publications and source records attributed to D I Watson.

At least 19 recordsLinked to original sources
PubMed2007

MicroRNAs and cancer.

BACKGROUND: MicroRNAs (miRNAs) are small sequences of RNA, 21 to 22 nucleotides long, that have been discovered recently. They are produced from areas of the human genome that were previously thought to have no function. These sequences now appear to be important in the regulation of many fundamental processes. Evidence has recently emerged that deregulated miRNA activity is associated with human cancers. METHODS: The English literature was searched using PubMed for publications relevant to miRNAs and cancer. Relevant references from identified publications were also sourced. These publications were reviewed to identify existing evidence for the role of miRNAs in cancer. RESULTS: miRNAs inhibit the translation of mRNA from many target genes involved in cancer development. This leads to changes in the levels of protein encoded by these target genes and drives the development of cancer. The genes that produce miRNAs are frequently located in regions of the genome that are either lost, or amplified, in cancer cells. CONCLUSION: Determination of the miRNA expression profile in cancer tissues should lead to a better understanding of the genetic pathways involved in tumour development.

Gene Expression Profiling↗
PubMed2006

Laparoscopic fundoplication in patients with an aperistaltic esophagus and gastroesophageal reflux.

A minority of patients with severe gastroesophageal reflux who present to surgeons for antireflux surgery have absent esophageal peristalsis when investigated before surgery with esophageal manometry. Some of these patients also have systemic sclerodema. While conventional wisdom suggests that these patients are at risk of a poor outcome if they proceed to fundoplication, some will have severe reflux symptoms, which are poorly controlled by medical therapy, and surgery will therefore offer the only chance of 'cure'. We performed this study to determine the outcome of laparoscopic fundoplication in the subset of patients with gastroesophageal reflux and an aperistaltic esophagus. From 1991 to 2003, the operative and follow-up details for all 1443 patients who underwent a laparoscopic fundoplication in our Departments have been prospectively collected on a database. These patients were then followed yearly using a standardized symptom assessment questionnaire. A subset of patients whose preoperative esophageal manometry demonstrated complete absence of esophageal body peristalsis and absent lower esophageal sphincter tone (aperistaltic esophagus) were identified from this database, and their outcome following laparoscopic fundoplication was determined. Twenty-six patients with an aperistaltic esophagus who underwent a laparoscopic fundoplication were identified. Six of these had a systemic connective tissue disease (scleroderma), and 20 had an aperistaltic esophagus without a systemic disorder. A Nissen fundoplication was performed in four patients, and an anterior partial fundoplication in 22. Follow-up extended up to 12 years (median, 6). A good overall symptomatic outcome was achieved in 88% at 1 year, 83% at 2 years and 93% at 5-12 years follow-up. Reflux symptoms were well controlled by surgery alone in 79% at 1 year, and 79% at 5-12 years. At 2 years, 87% were eating a normal diet. Two patients underwent further surgery - one at 1 week postoperatively for a tight esophageal hiatus, and one at 1 year for recurrent reflux. Patients with troublesome reflux and an aperistaltic esophagus can be effectively treated by laparoscopic fundoplication. An acceptable outcome will be achieved in the majority of patients.

Adult↗
PubMed2005

Thoracoscopic and laparoscopic esophagectomy: initial experience and outcomes.

BACKGROUND: Although surgical resection currently is the preferred treatment for fit patients with resectable esophageal cancers, it is associated with a relatively high risk of morbidity and significant perioperative mortality. Currently, a range of open surgical approaches are used. More recently, minimally invasive approaches have become feasible, with the potential to reduce perioperative morbidity. This study investigated the outcomes from one such approach. METHODS: Outcome data were collected prospectively for 36 consecutive patients who underwent a minimally invasive esophagectomy for esophageal cancer. A three-stage approach was used, with all the patients undergoing a thoracoscopic esophageal mobilization, combined with either open or hand-assisted laparoscopic abdominal gastric mobilization, and open cervical anastomosis. An open abdominal approach was used for 15 of the patients and a hand-assisted laparoscopic approach for 21. A total of 34 patients had invasive malignancy, whereas 2 had preinvasive disease. A group of 23 patients (68%) who had invasive malignancies also received neoadjuvant chemotherapy and radiotherapy. RESULTS: The mean operating time ranged from 190 to 360 min (mean, 263 min). The median postoperative hospital stay was 16 days. In-hospital mortality was 5.5% (2/36), and perioperative morbidity was 41%. The perioperative outcomes for patients undergoing an open abdominal approach and those who had hand-assisted laparoscopic surgery were similar. For the patients who underwent a hand-assisted laparoscopic abdominal procedure, the total operating time was shorter (248 vs 281 min), and the blood loss was less (223 vs 440 ml). The median follow-up period was 30 months. The 4-year survival predicted by Kaplan-Meir for the 34 patients with invasive malignancy was 44%. CONCLUSION: The outcome for esophagectomy using thoracoscopic esophageal mobilization, with or without hand-assisted laparoscopic abdominal surgery, was comparable with data from conventional open surgical approaches. These approaches can be performed with an acceptable level of perioperative morbidity. Further application of these techniques, with close scrutiny of outcome data, is appropriate.

Adult↗
PubMed2005

Endoscopic ultrasound for preoperative staging of esophageal carcinoma.

BACKGROUND: Endoscopic ultrasound (EUS) is potentially the best method for pretreatment staging of esophageal carcinoma once distant metastases have been excluded by other methods. However, its apparent accuracy might be influenced by the use of neoadjuvant therapy. To determine the accuracy of EUS in patients undergoing esophageal resection, the authors reviewed their experience with EUS. METHODS: A total of 73 patients with esophageal carcinoma who underwent an esophagectomy between April 2000 and February 2005 were examined using preoperative EUS and computed tomography (CT). Of these patients, 39 also underwent preoperative neoadjuvant chemoradiotherapy. Both EUS and CT scan were used to determine the depth of tumor penetration (T-stage) and the presence of lymph node metastases (N-stage). These results then were compared with staging determined after pathologic examination of the resected surgical specimen. RESULTS: For patients not undergoing neoadjuvant therapy, T-stage was accurately determined by EUS in 79%, N-stage in 74%, and tumor node metastasis (TNM) classification in 65% of the cases. However, when patients who had undergone neoadjuvant chemoradiotherapy were included, the overall accuracy of EUS was 64% for T-stage, 63% for N-stage, and 53% for TNM classification. For the patients who underwent neoadjuvant therapy, EUS indicated a more advanced T-stage in 49%, N-stage in 38%, and TNM classification in 51% of the cases, as compared with pathology. The overall accuracy of EUS for T- and N-stage carcinomas was superior to that of CT scanning. CONCLUSION: For patients who do not undergo preoperative neoadjuvant chemotherapy and radiotherapy, EUS is a more accurate method for determining T- and N-stage resected esophageal carcinomas. Neoadjuvant therapy, however, results in apparent overstaging, predominantly because of tumor downstaging, and this reduces the apparent accuracy of EUS (and CT scanning) in this patient group. Nevertheless, EUS staging before neoadjuvant therapy could be more accurate than pathologic staging after treatment, thereby providing better initial staging information, which can be used to facilitate treatment.

Adult↗
PubMed2005

Five-year follow-up of a randomized clinical trial of laparoscopic total versus anterior 180 degrees fundoplication.

BACKGROUND: Total fundoplication for gastro-oesophageal reflux disease may be followed by unwanted side-effects. A randomized trial demonstrated that an anterior 180 degrees partial fundoplication achieved effective reflux control and was associated with fewer side-effects in the short term than total fundoplication. This paper reports longer-term (5 year) outcomes from that trial. METHODS: Between December 1995 and June 1997, 107 patients were randomized to undergo either laparoscopic total fundoplication or a laparoscopic anterior 180 degrees fundoplication. After 5 years, 101 of 103 eligible patients (51 total, 50 anterior) were available for follow-up. Each patient was interviewed by a single blinded investigator and a standardized questionnaire was completed. The questionnaire focused on symptoms and overall satisfaction with the results of fundoplication. RESULTS: There were no significant differences between the two groups with regard to control of heartburn or patient satisfaction with the overall outcome. Dysphagia, measured by a visual analogue score for solid food and a composite dysphagia score, was worse at 5 years after total fundoplication. Symptoms of bloating, inability to belch and flatulence were also more common after total fundoplication. Reoperation was required for dysphagia in three patients after total fundoplication and for recurrent reflux in three patients after anterior fundoplication. CONCLUSION: Anterior 180 degrees partial fundoplication was as effective as total fundoplication for managing the symptoms of gastro-oesophageal reflux in the longer term. It was associated with a lower incidence of side-effects, although this was offset by a slightly higher risk of recurrent reflux symptoms.

Deglutition Disorders↗
PubMed2005

Laparoscopic repair of large hiatal hernias.

BACKGROUND: The repair of large hiatal hernias can be technically challenging. Most series describing laparoscopic repair report only symptomatic outcomes and the true recurrence rate, including asymptomatic recurrence, is not well documented. This study evaluated the long-term outcome of laparoscopic repair of large hiatal hernias. METHODS: All patients who had undergone laparoscopic repair of a large hiatus hernia (more than 50 per cent of the stomach in the hernia) with a minimum 2-year clinical follow-up were identified from a prospectively maintained database. A standardized questionnaire was used to assess symptoms and a barium swallow radiograph was performed to determine anatomy. Multivariate analysis was used to identify factors associated with recurrence. RESULTS: Of 100 eligible patients, clinical follow-up was available in 96. Follow-up ranged from 2 to 8 (median 4) years. In patients with preoperative reflux symptoms, there were significant improvements in heartburn and dysphagia scores after surgery. Overall, 80 per cent of patients rated their outcome as good or excellent. Sixty patients underwent a postoperative barium meal examination that identified 14 radiological hernia recurrences (eight small, three medium and three large). Four other patients in this group of 60 had previously undergone reoperation for early and late recurrence (two of each), giving an overall recurrence rate of 18 of 60 (30 per cent). One third of patients with recurrence were totally asymptomatic and the presence of postoperative symptoms did not reliably predict the presence of anatomical recurrence. Younger age and increased weight at operation were independent risk factors contributing to recurrence. CONCLUSIONS: Laparoscopic repair of large hiatal hernias yields good clinical outcome. Recurrence after laparoscopic repair seems to be more common than previously thought. Objective anatomical studies are required to determine the true recurrence rate. The majority of recurrences are not large and do not cause significant symptoms.

Adult↗
PubMed2005

Dissection efficiency during laparoscopic oesophageal dissection.

Advanced techniques in laparoscopic surgery have led to an increased need for appropriate training in instrument handling and dissection. Recent developments in computer video technology have facilitated critical analysis of surgical technique. Video deconstruction of oesophageal hiatal dissection during six laparoscopic fundoplication procedures was undertaken. The procedures were performed by surgeons with a wide range of surgical experience, and the investigators analysing performance were blinded to their level of training. Sequential five-second video segments were analysed in detail by 3 investigators. A taxonomy list was developed to describe individual types of movement. The number and time per movement was assessed and a degree of efficiency was assigned. An efficient movement was defined as one that advances the dissection towards a recognised goal. The total oesophageal dissection time varied from 10 minutes (min) to 25 min (mean 16 min). The mean number of actions performed was 173 (range 120-272). A mean of 7 min was spent separating tissues (range 5-13), with 6 min spent grasping and positioning tissue (range 3-8). The amount of time spent in inefficient movement varied from 3 to 14 min (mean 7 min). The greatest variation between operators was seen in the efficiency of tissue separation when using dissecting instruments. Inexperienced operators spent a lot more time performing additional movements such as scope cleaning, observation and instrument exchange. This technique of video deconstruction can identify key areas for improvement. This could be used for trainee assessment and to provide constructive feedback. Future development in this area could enhance training in advanced laparoscopic techniques.

Journal Article↗
PubMed2005

Neoadjuvant chemoradiotherapy for esophageal carcinoma.

SUMMARY. Neoadjuvant chemoradiotherapy is often administered to patients with esophageal carcinoma in the belief that this will improve survival. However, its role in the management of esophageal carcinoma remains controversial. In this study we evaluated our experience with neoadjuvant chemoradiotherapy for the treatment of esophageal carcinoma. The study group was 115 patients who underwent esophagectomies between January 1999 and January 2004. Eighty-nine patients had adenocarcinoma and 26 had squamous cell carcinoma. Fifty-six patients underwent neoadjuvant chemoradiotherapy (two cycles of cisplatin and 5-fluorouracil with 45 Gy radiation) followed by esophagectomy. The other 59 patients proceeded directly to esophagectomy. Outcomes were determined prospectively, and follow-up was available for all patients. Neoadjuvant chemoradiotherapy achieved down-staging of the esophageal cancer in 43%, 43% and 46% of patients, according to T, N and TNM classifications, respectively. Neoadjuvant chemoradiotherapy resulted in a complete pathological response in seven (13%) patients. The surgical morbidity rate was 37% (42/115), and in-hospital mortality was 5% (6/115). There were no differences between patients who did and did not undergo neoadjuvant chemoradiotherapy in regard to completeness of resection, perioperative mortality and postoperative morbidity. Four-year survival was 33% following neoadjuvant chemoradiotherapy, compared with 19% for patients undergoing surgery alone. The administration of neoadjuvant chemoradiotherapy in patients with esophageal carcinoma down-staged nearly 50% of tumors, and a complete pathological response occurred in some of these patients. It was not associated with any increase in postoperative morbidity or perioperative mortality. In this non-randomized study, it was also associated with a trend towards a better survival outcome.

Adenocarcinoma↗
PubMed2004

Pneumoperitoneum and peritoneal surface changes: a review.

BACKGROUND: Recent evidence suggests that the use of carbon dioxide to create a pneumoperitoneum during laparoscopy can lead to adverse structural, metabolic, and immune derangements within the peritoneal cavity, and that these can be dependent on the specific insufflation gas used. These changes include structural alterations in the mesothelial lining, pH disturbances, and alterations in peritoneal macrophage responsiveness. This contrasts with an apparent systemic benefit associated with laparoscopic, as compared with open, surgery. METHODS: Recently published clinical and experimental studies related to the effect of pneumoperitoneum on the peritoneal surface are reviewed, and their relevance is discussed. RESULTS: Structural changes in the peritoneal mesothelial surface layer such as widening of the intercellular junctions can be demonstrated with electron microscopy. Acidification of the peritoneum in response to carbon dioxide insufflation occurs not only at the peritoneal surface, but also in the underlying connective tissue, resulting in disturbances in the electrical surface charge and the release of various immune mediators such as endotoxin. Pneumoperitoneum also affects the local peritoneal immune environment resulting in alterations in cytokine production and phagocytic function, as well as diminished antitumor cell cytotoxicity. CONCLUSIONS: Ultrastructural, metabolic, and immune alterations are observed at the peritoneal surface in response to a pneumoperitoneum. Experimental evidence suggests that these changes are carbon dioxide-specific effects. The consequences of these alterations to the local peritoneal environment are not well understood, but they may facilitate tumor implantation within the peritoneal cavity and adversely affect the ability to clear intraperitoneal infections. Further investigation into this area is warranted.

Animals↗
PubMed2004

Aspirin and indomethacin for the prevention of experimental port-site metastases.

BACKGROUND: Nonsteroidal antiinflammatory drugs have been shown to have antitumor and chemopreventative effects. We investigated the potential of these drugs to inhibit port-site and intraperitoneal metastases. METHODS: The antiproliferative effect of aspirin and indomethacin on tumor cells was measured in vitro and in vivo. The in vivo experiments used DA rats to measure the effects of aspirin and indomethacin on the development of port-site metastases and the proliferation of intraperitoneal tumor cells after laparoscopy. RESULTS: In vitro, aspirin and indomethacin had an antiproliferative effect on tumor cells, inhibiting cell division and killing cells in a concentration and time-dependent manner. Orally administered aspirin and indomethacin, at the maximum tolerated dose, did not reduce the rate of intraperitoneal tumor cell division and had no effect on peritoneal metastases, or the number or size of port-site metastases. CONCLUSIONS: Despite promising in vitro studies, this study does not suggest there will be any clinical therapeutic value associated the use of aspirin or indomethacin for the prevention of the spread of tumor following the spillage of cells into the peritoneal cavity at laparoscopic surgery.

Animals↗
PubMed2004

Randomized clinical trial of laparoscopic versus open fundoplication for gastro-oesophageal reflux disease.

BACKGROUND: The aim of this study was to compare laparoscopic and open Nissen fundoplication for gastro-oesophageal reflux disease in a randomized clinical trial. METHODS: Ninety-nine patients were randomized to either laparoscopic (52) or open (47) Nissen fundoplication. Patients with oesophageal dysmotility, those requiring a concurrent abdominal procedure and those who had undergone previous antireflux surgery were excluded. Independent assessment of dysphagia, heartburn and patients' satisfaction 1, 3, 6 and 12 months after surgery was performed using multiple standardized clinical grading systems. Objective measurement of oesophageal acid exposure and lower oesophageal sphincter pressure before and after surgery, and endoscopic assessment of postoperative anatomy, were performed. RESULTS: Operating time was longer in the laparoscopic group (median 82 versus 46 min). Postoperative pain, analgesic requirement, time to solid food intake, hospital stay and recovery time were reduced in the laparoscopic group. Perioperative outcomes, postoperative dysphagia, relief of heartburn and overall satisfaction were equally good at all follow-up intervals. Reduction in oesophageal acid exposure, increase in lower oesophageal sphincter tone and improvement in endoscopic appearances were the same for the two groups. CONCLUSION: The laparoscopic approach to Nissen fundoplication improved early postoperative recovery, with an equally good outcome up to 12 months.

Adult↗
PubMed2004

Cyclo-oxygenase-2 expression in esophageal adenocarcinoma as a determinant of clinical outcome following esophagectomy.

The aim of this study was to determine if cyclo-oxygenase-2 (COX-2) expression in adenocarcinoma of the esophagus affects survival outcome in patients undergoing esophagectomy. Ten patients surviving more than 3 years following an esophagectomy for adenocarcinoma of the esophagus were identified from an esophagectomy database maintained by the University of Adelaide Department of Surgery. An additional group of 10 patients, who underwent esophagectomy for adenocarcinoma, but who died within 12 months of surgery due to recurrent disease, were also identified. Pieces of the original formalin fixed carcinoma tissue embedded in paraffin blocks from all of these patients were obtained, and slices of the tumor specimens underwent immunohistochemical staining with COX-2 protein. The extent of staining was then graded by a single 'blinded' pathologist: grade 0, no staining; grade 1 +, limited staining; and grade 2 +, strong staining. Kaplan-Meier survival curves were then constructed and used to determine correlations between survival and COX-2 staining, tumor T-stage, local lymph node metastases, and tumor vascular invasion. Ninety-five percent (19/20) of patients stained positively for COX-2. Patients with grade 2 + staining had a significantly poorer survival outcome compared to grade 1 + patients (P = 0.03). There were also trends towards shorter survival with worsening T-stage, lymph node metastasis and vascular invasion. COX-2 protein appears to be expressed by most esophageal adenocarcinomas. An increased level of expression of COX-2 was associated with a poorer survival outcome in this study. COX-2 protein expression association could be a better prognostic indicator for esophageal adenocarcinoma than traditional histopathological staging.

Adenocarcinoma↗
PubMed2004

Diaphragmatic hernia after minimally invasive esophagectomy.

Diaphragmatic hernia is an uncommon complication that can follow transhiatal esophagectomy. It has not been reported after minimally invasive esophagectomy. We report such a case presenting with features of small bowel obstruction. The paucity of adhesions following the combined laparoscopic and thoracoscopic approach may confer an increased risk of this complication.

Adenocarcinoma↗
PubMed2003

Pneumothorax during laparoscopy.

BACKGROUND: Pneumothorax is a known complication of laparoscopy, with most pneumothoraces diagnosed postoperatively with conventional chest x-ray. Electrocardiogram (ECG) conduction changes are associated with pneumothorax. In a sheep model, ECG changes were evaluated as a potential indicator of intraoperative pneumothorax. Additionally, resolution rates of helium (He) and carbon dioxide (CO2) pneumothorax were also evaluated in this model. METHODS: Under general anesthesia, 10 sheep had known volumes (20-100 cc) of either He or CO2 introduced into the left hemithorax. A 12-lead ECG recorded changes associated with the induced pneumothorax. After changes in the ECG plateaued, the gas volume in the hemithorax was increased to 2 L and the resultant pneumothorax was followed for a 2-h period using fluoroscopy to determine resolution rates for the different gas pneumothoraces. Gas volumes were aspirated after 2 h and ECGs were again recorded. RESULTS: Pneumothorax volumes as low as 20 cc produced consistent ECG changes. The amplitude of the precordial QRS complex was seen to diminish, and this lowering of the QRS amplitude continued as pneumothorax volume increased up to 100 cc. The ECG returned to prepneumothorax patterns with aspiration of the left chest. For different gas pneumothoraces, CO(2) pneumothorax showed almost complete resolution in the 2-h period, whereas He pneumothorax was unchanged. CONCLUSIONS: Precordial ECG changes appear to be a very sensitive indicator of pneumothorax, with very small pneumothorax (<100 cc) consistently being detected by reduction of the QRS complex amplitude. Intraoperative use of precordial ECG leads could result in rapid identification of pneumothorax during laparoscopic surgery. Carbon dioxide pneumothorax shows near 100% resolution in a 2-h period. This supports recommendations of expectant management in asymptomatic patients with CO(2) pneumothorax. However, He pneumothorax does not resolve spontaneously quickly and may require aspiration even in asymptomatic patients.

Absorption↗
PubMed2002

Excision of laparoscopic port sites increases the likelihood of wound metastases in an experimental model.

BACKGROUND: Case reports of patients developing tumor metastases at port sites following laparoscopic surgery have prompted the development of preventive strategies to address this potential problem, including local excision of the port sites. While it has been suggested that this strategy could be used clinically, its efficacy has not been established. METHODS: Twenty four immune-competent Dark Agouti rats underwent laparoscopy and standardized intraperitoneal laceration of an implanted abdominal flank tumor, using an established laparoscopic cancer model. Rats were randomized to either control (n = 12) or wound excision (n = 12) groups. Both groups underwent laparoscopy using carbon dioxide (CO2) insufflation and two mini-laparoscopy ports. In the wound excision group, one of the port site wounds was excised following desufflation of the abdominal cavity. One week later, the port site wounds were excised for histological examination. RESULTS: Wound involvement with tumor was significantly more common following wound excision than with untreated control wounds (nine of 12 vs two of 12, p = 0.002). In the wound excision group, tumor metastases arose preferentially in the excised port site wound. CONCLUSION: This study suggests that excision of laparoscopy port site wounds following laparoscopic surgery for cancer does not prevent the subsequent development of port site tumors. Furthermore, the excision of port sites may actually increase the risk of tumor metastases arising in port sites, suggesting that the clinical application of this strategy should be avoided pending further evaluation.

Abdominal Neoplasms↗
PubMed2002

A further modification of fundoplication. 90 degrees anterior fundoplication.

BACKGROUND: Laparoscopic Nissen fundoplication is the most widely applied procedure for the surgical treatment of gastroesophageal reflux. However, it can be followed by adverse outcomes, including dysphagia and "wind-related" problems. To reduce the likelihood of side effects, we have progressively modified this procedure to an anterior 90 degrees partial fundoplication. METHODS: The procedure entails posterior hiatal repair, posterior esophagopexy, accentuation of the angle of His, and construction of a 90 degrees anterior partial fundoplication. Clinical follow-up was performed prospectively using a standardized questionnaire. RESULTS: From February 1999 to June 2001, 83 patients underwent 90 degrees anterior fundoplication for gastroesophageal reflux disease. In 45 the procedure was chosen because of specific patient or surgeon preference, and in 38 it was performed within the context of an ongoing randomized trial. Operating time ranged from 20 to 140 minutes (median, 52 min), and all but one of the procedures were completed laparoscopically. One patient experienced a major postoperative complication--small bowel injury from Veress needle. Follow-up extends up to 2 years (median, 1 year). Two patients have undergone further surgery, both for recurrent reflux. Control of reflux has been acceptable, with a reduction in heartburn symptom scores and high overall satisfaction. Postoperative dysphagia measured using a visual analog scale was less following surgery compared with preoperative scores. Eighty-two percent of patients could belch normally 3 and 12 months after surgery. CONCLUSIONS: Ninety-degree anterior fundoplication achieves good control of reflux and a low incidence of side effects. To further evaluate its potential, we are currently undertaking a prospective randomized trial.

Adult↗
PubMed2002

Helium vs carbon dioxide gas insufflation with or without saline lavage during laparoscopy.

BACKGROUND: Helium is an inert gas that, if used for insufflation during laparoscopy, may be followed by less postoperative pain than carbon dioxide (CO2) insufflation, due to a more limited effect on intraabdominal pH and metabolism. Saline lavage has also recently been shown to reduce postoperative pain following laparoscopic surgery. To evaluate these possibilities and to better define the clinical safety of helium insufflation, we undertook a prospective randomized trial comparing CO2 and helium insufflation with or without saline lavage in patients undergoing elective laparoscopic upper abdominal surgery. METHODS: From January to November 2000, 173 patients undergoing elective laparoscopic cholecystectomy or fundoplication were randomized to undergo laparoscopy with either CO2 or helium insufflation. Within each group, patients were further randomized to undergo peritoneal lavage with 2 L of 0.9% saline at the end of the surgical procedure. This yielded the following four patient groups; CO2 (group 1, n = 47), CO2 + saline lavage (group 2, n = 43), helium (group 3, n = 43) and helium + saline lavage (group 4, n = 40). Patients were blinded to their randomization, and post-operative assessment was also performed by a blinded investigator, who applied a standardized scoring system to assess postoperative pain. RESULTS: The study groups were well matched for age, sex, weight, American Society of Anesthesiologists (ASA) status, duration of surgery, and volume of gas utilized, and 81% of patients were discharged within 48 h. There were no differences in the incidence of postoperative complications among the study groups, and postoperative pain scores were not significantly different when all four groups were compared. When helium (groups 3 and 4) was compared with CO2 (groups 1 and 2), no differences in pain score were seen. When no lavage (groups 1 and 3) was compared with lavage (groups 2 and 4), less pain was found in the group undergoing saline peritoneal lavage (mean 4-h pain score, 5.9 vs 5.2; 24-h pain score, 4.8 vs 4.1; p > 0.05). CONCLUSIONS: The use of helium insufflation for laparoscopic surgery, while not associated with any significant adverse sequelae, was not associated with less postoperative pain in this trial. The use of saline peritoneal lavage was associated with less pain in the early postoperative period.

Abdominal Pain↗