Biomedical subjects
Publications and source records attributed to D I Watson.
A case of a choledochal cyst occurring in a 21-year-old woman is presented. The spectrum of congenital dilatation of the biliary tree and the contributions of various imaging modalities and procedures in the condition are discussed, including the use of nuclear medicine biliary imaging.
A case of emphysematous cholecystitis with gall-bladder perforation, resulting in free intraperitoneal gas, is presented. It adds to only nine previous reports. A successful outcome was achieved by early surgery, combined with appropriate antibiotic therapy.
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The initial teaching and learning experience of four surgeons performing a laparoscopic Nissen fundoplication is reported. A total of 33 patients underwent the laparoscopic approach for Nissen fundoplication. Two patients also underwent concomitant cholecystectomy. A loose 360 degrees fundoplication secured by three or four sutures was performed, with 29 patients also undergoing posterior crural repair. Three operations were converted to open procedures. Two patients required subsequent surgery, one when the fundoplication and proximal stomach slipped into the chest and one for oesophageal obstruction. No other complications occurred. All patients are well and free of reflux symptoms at follow-up ranging up to 10 months (median 5 months). Operating time ranged from 47 min to 154 min (median 81 min) for fundoplication alone. The laparoscopic fundoplications with cholecystectomy required 145 and 170 min. Postoperative stay ranged from 3 to 12 days (median 3 days). Laparoscopic Nissen fundoplication is feasible in the management of gastro-oesophageal reflux disease. These early results demonstrate that this new technique may reduce some of the morbidity associated with open antireflux surgery. A prospective randomised study has been started to assess efficacy and benefits more thoroughly.
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It is possible to achieve satisfactory palliation for most patients with malignant oesophageal obstruction by endoscopic means, surgical resection or radiotherapy. Despite these options, a small group of patients remains for whom another alternative should be considered. Fifteen patients presenting with extensive tumour, a non-dilatable stricture, or a tracheo-oesophageal fistula, not suitable for any of the standard methods of palliation, underwent palliative surgical bypass using stomach or colon. The hospital mortality was 33% and the median survival 6 months. Anastomotic leakage occurred in six patients and the median postoperative stay was 28 days (range 20-42 days). All patients who survived surgery, except one, achieved satisfactory palliation. The nature of these patients is such that whatever is done, mortality will almost inevitably be high. The authors believe that all patients in this series were better off than they would have been if left untreated, and oesophageal bypass should be considered for patients with distressing dysphagia due to disease not amenable to standard palliative methods.
A review of all patients with liver trauma admitted to the Royal Adelaide Hospital during the period 1983-86 was undertaken. Twelve of the 63 patients died. Liver trauma was responsible in eight (giving a mortality rate of 12.7%). The overall mortality rate was 19.0%. Most of the liver injuries (83%) were due to blunt trauma. All the deaths occurred in this group and were related directly or indirectly to blood loss. A high mortality (83%) was associated with hepatic vein injury. Right hepatectomy was unsuccessful in preventing death in any of these patients. The management of major venous injuries is discussed. A significant number of the liver injuries was minor. Analysis of these suggests that a more conservative approach to the management of haemodynamically stable patients might be appropriate.
Although Nissen fundoplication controls gastroesophageal reflux disease effectively, it is associated with an incidence of side effects. For this reason we have investigated the use of a laparoscopic 180-degree anterior fundoplication as a technique that has the potential to control reflux, but with less associated postoperative dysphagia and fewer gas-related side effects. Good short-term (6-month) outcomes have been previously reported within the content of a randomized trial. This report details the technique we used and describes the outcome of this procedure with longer follow-up in a much larger group of patients. The outcome for patients with gastroesophageal reflux disease who underwent a laparoscopic anterior 180-hemifundoplication was determined. Clinical follow-up was carried out prospectively by an independent scientist who applied a standardized questionnaire yearly following surgery. This questionnaire evaluated symptoms of reflux, postoperative problems including dysphagia, gas bloat, ability to belch, and overall satisfaction with clinical outcome. From July 1995 to May 1999, a total ofc107 patients underwent a laparoscopic anterior hemifundoplication. Four patients underwent further surgery for recurrent heartburn, and persistent troublesome dysphagia occurred in one. At 1 year 89% of patients remained free of reflux symptoms, and at 3 years 84% remained symptom free. Of those with symptoms of reflux, approximately half of them had only mild symptoms. The overall incidence and severity of dysphagia for liquids and solids was not altered by partial fundoplication. Epigastric bloating that could not be relieved by belching was uncommon, and only 11% of the patients at 1 year and 10% at 3 years following surgery were unable to belch normally. Overall satisfaction with the outcome of surgery remained high at 3 years' follow-up. Laparoscopic anterior partial fundoplication is an effective operation for gastroesophageal reflux, with a low incidence of side effects and a good overall outcome.
A wide variety of disposable and reusable trocars have been designed and marketed for use in laparoscopic surgery. The performance of these instruments varies considerably. Disposable trocars usually contain valve designs which allow the easy passage of instrumentation and safety mechanisms which reduce the likelihood of visceral injury from the trocar point. Whilst most reusable trocars have not provided safety mechanisms, and have been less user-friendly, newer designs are beginning to bridge the gap. The choice of a trocar for laparoscopic surgery will depend on each surgeon's perception of the advantages and disadvantages of competing instrumentation, which may need to be balanced against the budgetary requirements of their practice location.