Quality of life after repair of bile duct injury.
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Bias↗
Biomedical subjects
D J Gouma
Publications and source records attributed to D J Gouma.
Efficiency of manual versus robotical (Zeus) assisted laparoscopic surgery in the performance of standardized tasks.
BACKGROUND: The objective of this study was to compare the efficiency of manual and robotically assisted laparoscopic surgery. METHODS: To evaluate the surgical efficiency in a set of basic endoscopic movements, 20 medical students without any surgical experience were selected to perform at random a set of laparoscopic tasks either manually or robotic assisted (Zeus). This task consisted of dropping beads into receptacles, running a 25-cm rope, capping a hypodermic needle, suturing, and performing a laparoscopic cholecystectomy on a cadaver liver of a pig. A quantitative time-action analysis was performed to evaluate the efficacy and skill performance in terms of time and the number of actions. RESULTS: The dropping beads exercise and the laparoscopic cholecystectomy required more time when performed with robotic assistance, as compared with manual performance (respectively, median, 78.5 s; range, 63 - 122 s vs median, 144.5 s; range, 100 - 169 s; p <0.01 and median, 34.0 min; range 11-44 min vs median, 46.5 s; range, 21 - 79 min; p = 0.05). A tendency toward fewer total actions in all the robotically assisted exercises was observed. However, significance was shown only in the rope-passing task (median, 71; range, 59 - 87 vs median, 62; range, 57-80; p = 0.05). Grasping the beads, the rope, and either the needle or the cap were tasks that required fewer actions to complete when performed with robotically assistance (respectively, median, 11; range, 10 - 14 vs median, 12.5; range, 11 - 15; p <0.01; median, 56; range, 55 - 60 vs median, 60.5 min; range, 55 - 65; p = 0.03, and median, 6; range, 4 - 21 vs median, 10.5; range, 6 - 38; p = 0.02). As compared with the robotically assisted rope-passing exercise, more failures were made in the manually performed procedure (p = 0.03), mainly caused by unintentional dropping of the rope (p = 0.02). CONCLUSIONS: Robotically assisted laparoscopic surgery by participants without any surgical experience might require more time, but actions can be performed equally or more precisely as compared with manual laparoscopic surgery.
Animals↗
Peroperative analysis of the surgical procedure.
The increased technological complexity of surgery and the growing importance of quality assessment demand objective analysis of the surgical process. However, until now no standard method existed for analyzing the peroperative process. In this article, a methodology is discussed to describe and to analyze the surgical process. A method is given to measure the correctness and efficiency of task performance, protocols, and instruments used. In addition, reference values are defined so as to compare new instruments, alternative protocols, and the performance of new tasks with a standard. Finally, recommendations are given for improving new surgical tasks, the development of clinically driven instrument design, and new protocols.
Algorithms↗
[Diagnosis and treatment of pancreatic carcinoma in the region of Amsterdam Comprehensive Cancer Care Center in 1997].
OBJECTIVE: To describe the diagnostic work-up and treatment of patients with a pancreatic carcinoma in the Amsterdam area, the Netherlands, particularly in general hospitals. DESIGN: Retrospective, descriptive. METHOD: During 1997, 286 patients with a pancreatic carcinoma were diagnosed in 20 hospitals in the Amsterdam area. Diagnostic work-up and treatment data were collected from the medical records and analysed. RESULTS: Ninety percent of the patients presented in one of the 17 general hospitals (n = 252; 132 men and 154 women; mean age: 70 years). Thirty-five percent of them underwent diagnostic investigations which did not focus directly on pancreatic pathology. Ultrasound was performed in 97% of patients (4% in combination with Doppler) and CT in 60% (4% spiral CT). Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 39% of these patients and endoprostheses were only inserted in half the cases. Thirty-five percent of the patients who underwent both CT and ERCP underwent ERCP first. Ninety-nine patients (39%) were referred to a reference hospital for further investigation or treatment. The period between the first investigation and the histological diagnosis was 4 weeks. CONCLUSION: In the diagnostic work-up of patients with a pancreatic carcinoma, invasive diagnostic procedures were often performed before the non-invasive tests. Spiral CT was used minimally and ERCP was frequently performed without subsequent biliary drainage. The mean duration of diagnostic work-up was relatively long.
Adult↗
[Diagnostics and treatment of distal bile duct or pancreatic carcinoma; guidelines of the Amsterdam and Twente Comprehensive Cancer Centers].
A project on the diagnostic work-up and treatment of distal bile duct and pancreatic carcinoma was carried out in the region covered by the Comprehensive Cancer Centre in Amsterdam, the Netherlands. It consisted of (a) describing the diagnostic work-up in the area, (b) developing the guidelines, (c) spreading the recommendations. The implementation and application of the guidelines are currently being evaluated.
Bile Duct Neoplasms↗
IL-10-deficient mice demonstrate multiple organ failure and increased mortality during Escherichia coli peritonitis despite an accelerated bacterial clearance.
To determine the role of endogenous IL-10 in local antibacterial host defense and in the development of a systemic inflammatory response syndrome during abdominal sepsis, IL-10 gene-deficient (IL-10(-/-)) and wild-type (IL-10(+/+)) mice received an i.p. injection with Escherichia coli. Peritonitis was associated with a bacterial dose-dependent increase in IL-10 concentrations in peritoneal fluid and plasma. The recovery of E. coli from the peritoneal fluid, blood, and lungs was diminished in IL-10(-/-) mice, indicating that endogenous IL-10 impaired bacterial clearance. Despite a lower bacterial load, IL-10(-/-) mice had higher concentrations of TNF, macrophage inflammatory protein-2 and keratinocyte in peritoneal fluid and plasma, and demonstrated more severe multiple organ damage as indicated by clinical chemistry and histopathology. Furthermore, IL-10(-/-) mice showed an increased neutrophil recruitment to the peritoneal cavity. To examine the role of elevated TNF levels in the altered host response in IL-10(-/-) mice, the effect of a neutralizing anti-TNF mAb was determined. Anti-TNF did not influence the clearance of E. coli in either IL-10(+/+) or IL-10(-/-) mice. Furthermore, anti-TNF did not affect leukocyte influx in the peritoneal fluid, multiple organ damage, or survival in IL-10(+/+) mice. In IL-10(-/-) mice, anti-TNF partially attenuated neutrophil recruitment and multiple organ damage, and prevented the increased lethality. These data suggest that although endogenous IL-10 facilitates the outgrowth and dissemination of bacteria during E. coli peritonitis, it protects mice from lethality by attenuating the development of a systemic inflammatory response syndrome by a mechanism that involves inhibition of TNF release.
Animals↗
Analysis of the quality and efficiency in learning laparoscopic skills.
OBJECTIVES: This study demonstrates the application of time-action analysis to the evaluation of task performance of diagnostic laparoscopy with laparoscopic ultrasonography. METHODS: The first 25 diagnostic laparoscopies with laparoscopic ultrasonography performed by a surgical resident were analyzed and compared with the outcomes of these procedures performed by an experienced surgeon. The time, actions, and correctness of task performance were evaluated. Furthermore, outcome correctness and postoperative complications were assessed. RESULTS: No postoperative complications occurred. The resident made one wrong diagnosis, for which the cause was detected by peroperative analysis. Additionally, 1% of the subtasks were performed only partially, 4% not at all, and 2% using the wrong technique. The efficiency for most diagnostic tasks remained significantly lower than that of the experienced surgeon (p < 0.001). CONCLUSIONS: Time-action analysis can be used to provide detailed insight into the quality and efficiency of learning surgical skills. It enables objective measurement of correctness in task performance as well as time and action efficiency.
Ampulla of Vater↗
Hand-assisted laparoscopic donor nephrectomy. Ascending the learning curve.
BACKGROUND: The hand-assisted approach to laparoscopic donor nephrectomy (LDN) might minimize the learning curve and shorten both the operation and the warm ischemia time. Our initial results from hand-assisted LDN are presented and compared with data from the literature. METHODS: From January to September 2000, ten hand-assisted LDNs of the right kidney were performed. RESULTS: The median operation time was 140 min (range, 120-400 min), and the warm ischemia time was 2.5 min (range, 1-4 min). There were no conversions. Postoperative morbidity included one urinary tract infection. All but one patient returned to a normal diet within 48 h. Opiates were needed a maximum of 48 h. One recipient experienced initial loss of graft function as a result of unknown causes. CONCLUSIONS: Even at the beginning of the learning curve, operation time and warm ischemia time are significantly reduced by the hand-assisted approach, as compared with conventional LDN.
Adult↗
Functional outcome, quality of life, body image, and cosmesis in patients after laparoscopic-assisted and conventional restorative proctocolectomy: a comparative study.
PURPOSE: The aim of this study was to assess the functional outcome and the quality of life of laparoscopic-assisted ileal pouch-anal anastomosis compared with conventional ileal pouch-anal anastomosis. Further, body image and cosmesis were evaluated in both groups. METHODS: Sixteen patients who underwent a laparoscopic-assisted ileal pouch-anal anastomosis between March 1996 and September 1999 were matched with 19 patients who had a conventional ileal pouch-anal anastomosis. Patients were matched for the time period after surgery, distribution of familial adenomatous polyposis/ulcerative colitis, and one/two-stage procedure. Thirty-two patients agreed to fill out a set of questionnaires that assessed functional outcome, quality of life, body image, and cosmesis. Quality of life was measured with the Short Form 36 Health Survey questionnaire and the Gastrointestinal Quality of Life Index. The Body Image Questionnaire was used to measure patients' perceptions of and satisfaction with their own body and their attitude toward their bodily appearance (body image) and the degree of satisfaction of patients with respect to the physical appearance of the scar (cosmesis). RESULTS: Patients in the conventional group were older than patients in the laparoscopic-assisted group (mean 39.2 +/- 8.4 vs. 30.6 +/- 7.1 years; P < 0.01). No differences were found in functional outcome and quality of life. Satisfaction with the cosmetic result of the scar was significantly higher in the laparoscopic-assisted group compared with the conventional group. Body image score was higher in the laparoscopic-assisted group when compared with the conventional group, although not significant. CONCLUSIONS: The functional outcome and quality of life of laparoscopic-assisted ileal pouch-anal anastomosis is not different from conventional ileal pouch-anal anastomosis. In the long-term, better cosmesis is the most important advantage after laparoscopic surgery.
Adenomatous Polyposis Coli↗
Bile duct injury: new aspects of diagnosis and treatment.
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Bile Ducts↗
Urine interleukin-8 is a marker for urinary tract infection in postoperative patients.
BACKGROUND: Urine of patients with urinary tract infection (UTI) contains high levels of interleukin (IL)-6 and IL-8. However, knowledge of the kinetics of their release in urine is limited. We therefore compared the appearance of IL-6 and IL-8 in urine after uncomplicated surgery and surgery complicated by UTI. PATIENTS AND METHODS: 165 patients undergoing abdominal surgery who received a urinary catheter were studied. Urine IL-6 and IL-8 were prospectively measured in patients who did (n = 10) or did not (n = 20) develop UTI. Statistical analysis was done by one-way ANOVA and the Mann-Whitney test. RESULTS: Although urine IL-6 increased in the 2 to 4 days preceding the bacteriological documentation of UTI, a similar increase was observed in patients who did not develop UTI. Urine IL-8 was elevated on the day UTI was diagnosed, while remaining low in controls. CONCLUSION: In this patient group with postoperative UTI, urine IL-8 was a better marker for the early host response than urine IL-6.
Abdomen↗
The effect of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy.
BACKGROUND: The benefit of preoperative biliary drainage in jaundiced patients undergoing pancreaticoduodenectomy for a suspected malignancy of the periampullary region is still under debate. This study evaluated preoperative biliary drainage in relation to postoperative outcomes. STUDY DESIGN: At the Academic Medical Center, Amsterdam, the Netherlands, a cohort of 311 patients undergoing pancreaticoduodenectomy from June 1992 up to and including December 1999 was studied. Of this cohort 21 patients with external or surgical biliary drainage were excluded and 232 patients who had received preoperative internal biliary drainage were divided into three groups corresponding with severity of jaundice according to preoperative plasma bilirubin levels: < 40 microM (n = 177), 40 to 100 microM (n = 32), and > 100 microM (n = 23) were designated as groups 1, 2, and 3, respectively. These groups were compared with patients who underwent immediate surgery (n = 58) without preoperative drainage. RESULTS: The median number of stent (re)placements was 2 (range 1 to 6) with a median drainage duration of 41 days (range 2 to 182 days) and a stent dysfunction rate of 33%. Although patients in group 1 were better drained than patients in groups 2 and 3 (median reduction of bilirubin levels 82%, 57%, and 37%, respectively, p < 0.01), there was no difference in overall morbidity among the drained groups (50%, 50%, and 52%, respectively). There was no significant difference in overall morbidity between patients with and without preoperative biliary drainage (50% and 55%, respectively). CONCLUSIONS: Preoperative biliary drainage did not influence the incidence of postoperative complications, and although it can be performed safely in jaundiced patients it should not be used routinely.
Adult↗
Major liver resection results in a changed plasma amino acid pattern as reflected by a decreased Fischer ratio which improves by bactericidal/permeability increasing protein.
BACKGROUND/AIMS: Major liver resection results in a high morbidity and mortality, and endotoxin plays a role in post-resection hepatic failure. Severe hepatic failure as seen in hepatitis and cirrhosis may be accompanied by hepatic encephalopathy and is characterized by a typical plasma amino acid pattern reflected by a decreased Fischer ratio. This study was performed to evaluate the plasma amino acid pattern in patients undergoing major liver surgery receiving placebo or the endotoxin-neutralizing agent bactericidal/permeability-increasing protein (rBPI21). PATIENTS AND METHODS: Forty-eight patients were randomized in this phase II, dose escalation, multicenter trial. Plasma amino acid profiles were determined preoperatively, and on the first (day 1) and third (day 3) postoperative day. RESULTS: In the placebo group the Fischer ratio decreased significantly on both postoperative days. Administration of rBPI21 also resulted in a decreased Fischer ratio on day 1, but not on day 3. Highly elevated alanine plasma levels were observed on day 1 in placebo-treated patients, whereas rBPI21 prevented this elevation. Plasma alanine levels on day 1 correlated with the duration of post-resection hepatic failure. CONCLUSIONS: Major liver resection results in a decreased Fischer ratio and a rise in plasma alanine levels. Plasma levels of alanine on the first postoperative day correlated with the duration of the post-resection hepatic failure. rBPI21 improved the Fischer ratio and prevented the rise of plasma alanine levels.
Adult↗
Readmissions after pancreatoduodenectomy.
BACKGROUND: Readmission after pancreatoduodenectomy because of tumour recurrence or surgery-related complications can adversely affect patient outcome. METHODS: From October 1992 to June 1999, 283 consecutive resections were performed (243 for malignant disease and 40 for benign disease). The hospital mortality rate was 1 per cent (three of 283). All readmissions were analysed with regard to indication, treatment and outcome. RESULTS: One hundred and six patients (38 per cent) were readmitted, 64 (60 per cent) because of tumour recurrence and indications such as gastrointestinal obstruction (n = 19), biliary obstruction (n = 15) and pain (n = 21), of whom 30 patients (47 per cent) were in a preterminal condition. Median hospital stay and hospital-free survival after discharge were 14 and 51 days respectively. Median survival after surgical treatment (n = 14) was 58 days, and ascites was significantly associated with poor survival. Forty-seven (44 per cent) of the patients were readmitted for surgical complications such as abscess (n = 11), fistula (n = 8) and gastrointestinal obstruction (n = 8). Median hospital stay was 15 days and median hospital-free survival after discharge was 1035 days. CONCLUSION: Readmission after pancreatoduodenectomy was common (38 per cent), 60 per cent for tumour recurrence and 44 per cent for surgery-related complications. Survival after surgical bypass procedures for tumour recurrence was limited, particularly when ascites was present. Patients readmitted for complications of surgery had a good prognosis.
Adult↗
Incidence of benign lesions in patients resected for suspicious hilar obstruction.
BACKGROUND: The differentiation between benign and malignant strictures at the hepatic hilum is difficult. The aim of this study was to assess the clinical and radiographical features of hilar lesions in a series of patients resected for a presumed cholangiocarcinoma. METHODS: Of 132 consecutive patients undergoing resection for a suspicious lesion at the hepatic hilum, 20 (15 per cent) had a histopathologically proven benign tumour, diagnosed as chronic fibrosing or erosive inflammation, sclerosing cholangitis, or a granular cell tumour. All medical files and radiological examinations of the patients were reassessed. RESULTS: Clinical symptoms were considered suspicious in 16 of 19 patients. At ultrasonography only one of 16 patients had an unsuspicious examination. In 14 of 18 patients cholangiographic images were considered suspicious. Overall reassessment confirmed a suspicious lesion in all 20 patients. CONCLUSION: Because of the limitations of current diagnostic tools, a false-positive preoperative diagnosis of malignancy resulted in a 15 per cent resection rate of benign lesions in this series of suspicious hilar strictures.
Abdominal Pain↗
A normal appendix found during diagnostic laparoscopy should not be removed.
BACKGROUND: Diagnostic laparoscopy has been introduced as a new diagnostic tool for suspected appendicitis. While the normal appendix used to be removed routinely, laparoscopy allows us to leave a normal looking appendix in place. This latter strategy is, however, not generally accepted. The long-term results of not removing a normal looking appendix were evaluated. METHODS: This was a prospective evaluation of 109 diagnostic laparoscopies for suspected appendicitis in which a normal looking appendix was left in place. After a median follow-up of 4.4 years a telephone questionnaire was performed. RESULTS: There were no false-negative laparoscopies. In 65 patients (60 per cent) another diagnosis was obtained (group 1). In 44 patients (40 per cent) no diagnosis was obtained (group 2). After a median interval of 8 months, 15 patients presented to the emergency department for symptoms possibly involving the appendix, during the median follow-up of 4.4 years. This resulted in readmission of nine patients, of whom eight were reoperated. In only one patient (1 per cent) was a histologically proven appendicitis found and the appendix removed. Some 105 patients were eligible for follow-up. Of the 100 patients interviewed (95 per cent), nine patients (9 per cent) (six in group 1 and three in group 2) still had recurrent pain in the right lower abdominal quadrant. There were no differences between patients with or without another diagnosis obtained during preceding laparoscopy. CONCLUSION: It is safe to leave a normal looking appendix in place when a diagnostic laparoscopy for suspected appendicitis is performed, even if another diagnosis cannot be found at laparoscopy.
Adult↗
Interferon-gamma administration after abdominal surgery rescues antigen-specific helper T cell immune reactivity.
Antigen-induced activation of T cells is determined by many factors. Among these factors are (i) the number of T-cell receptors (TCRs) triggered by TCR ligands on antigen-presenting cells (APCs), and (ii) the intrinsic cellular threshold for activation. T-cell receptor triggering is optimized by adhesion molecules that form the interaction site between T cells and APCs, i.e. the immunological synapse. In addition, signals through co-stimulatory molecules lower the intrinsic T-cell activation threshold. Immunosuppressive agents and traumatic events such as major operative procedures change physiological T-cell responses. Depressed immune functions after surgery are presumed to render patients more susceptible to pathogens. Interferon-gamma (IFNgamma) is a type II homodimeric cytokine with multiple immunostimulatory properties. Several studies have been performed to assess the effects of IFNgamma treatment in patients in need of increased immune reactivity. However, until now, the effect of IFNgamma on human antigen specific CD4(pos) T-cell reactivity after surgically-induced immunosuppression has not been reported. Therefore, a comparative trial of recombinant human (rh) IFNgamma versus placebo in patients after abdominal surgery was initiated. Antigen-specific helper T cell immune reactivity was assessed by antigen-induced cytokine production, intracellular cytokine staining and flow cytometry. A single dose of rhIFNgamma rescued down-modulation of antigen-specific CD4(pos) T-cell reactivity, concomitant with an up-regulation of TCR-ligands on antigen-presenting cells. Selected patients may benefit from the immunostimulatory properties of rhIFNgamma administration in vivo.
Abdomen↗
Survival after pancreaticoduodenectomy for periampullary adenocarcinoma: an update.
AIM: Survival after pancreaticoduodenectomy for periampullary tumours is limited. Over the last decade peri-operative management has improved and morbidity and mortality decreased. The aim of the study was to analyse recent survival data after pancreaticoduodenectomy and to determine factors that influence survival. METHODS: From October 1992 to September 1998, 204 patients with a ductal adenocarcinoma in the pancreatic head (108), distal bile duct (32), and ampulla (64) who underwent standard pancreaticoduodenectomy, were analysed with regard to histology and tumour status. Survival was calculated by using the Kaplan-Meier method. Risk factors were identified in a univariate and multivariate analysis. RESULTS: Median survival after resection for carcinoma of the pancreatic head, distal bile duct, and ampulla were 16, 25 and 24 months, respectively (P=0.008). In the univariate analysis vein resection, blood transfusion of more than four packed red cells, the presence of tumour positive resection margins, lymph-node metastases and poor tumour differentiation significantly decreased survival. In the multivariate analysis positive resection margins, lymph-node metastases, and poor tumour differentiation independently influenced survival. CONCLUSIONS: Resection margins, lymph-node status and tumour differentiation are independent prognostic factors. Survival after standard pancreaticoduodenectomy for periampullary tumours has not improved.
Adult↗