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Biomedical subjects

J Toouli

Publications and source records attributed to J Toouli.

At least 73 records · Page 4Linked to original sources
PubMed1997

Laparoscopic fenestration of symptomatic non-parasitic cysts of the liver.

BACKGROUND: Some 5-10 per cent of patients with congenital 'solitary' liver cysts develop symptoms (pain, gastric outlet obstruction or jaundice), and require treatment. METHODS: Ten consecutive patients with symptomatic non-parasitic liver cysts have been treated by laparoscopic fenestration. RESULTS: There were no postoperative complications. During a median follow-up of 25.5 months with ultrasonographic examination there has been no recurrence of the cysts and the patients remain asymptomatic. CONCLUSION: The minimal access surgical approach by laparoscopic fenestration could become standard treatment for simple liver cysts.

Adult↗
PubMed1996

EAES ductal stone study. Preliminary findings of multi-center prospective randomized trial comparing two-stage vs single-stage management.

BACKGROUND: The current management of patients with ductal calculi and gallstone disease consists of endoscopic stone extraction (ESE) followed by laparoscopic cholecystectomy (LC). The advent of techniques of laparoscopic ductal stone clearance has introduced an alternative single stage laparoscopic treatment for these patients. The EAES ductal stone trial was set up to compare the relative efficacy and outcome of these two management options. METHODS: The study consists of a prospective randomized controlled clinical trial comparing two management options of patients undergoing LC and suspected of harbouring common duct stones. Patients registered into the trial are randomized to one of two arms: (i) Group A-preoperative ERC with ESE followed by LC during the same hospital admission. (ii) Group B-single stage laparoscopic management consisting of LC and laparoscopic stone extraction either by the trans-cystic duct route or by direct supraduodenal common duct exploration. RESULTS: This preliminary analysis was carried out on 207 randomized patients with comparisons being made on the intention to treat principle. The two groups (A = 106, B = 101) were comparable with respect to clinical features. ASA grade, serum biochemistry and ultrasound findings. CONCLUSIONS: These preliminary findings indicate equivalent success rates and patient morbidity between the two management options but a shorter hospital stay (cost benefit) with the single stage laparoscopic treatment. Trans-cystic duct extraction is a more benign procedure than laparoscopic supraduodenal CBD exploration and is accompanied by a significantly shorter hospital stay. The higher incidence of conversion in the single stage laparoscopic group compared to the two-stage arm is due to the preference for open common duct exploration when the laparoscopic attempt failed by the majority of participating surgeons. The results to-date suggest that in fit patients, single stage laparoscopic treatment is the better option and the role of ESE should change to selective use in those patients in whom laparoscopic ductal stone extraction has failed.

Adolescent↗
PubMed1996

Galanin modulates sphincter of Oddi function in the Australian brush-tailed possum.

The neuropeptide galantin (GAL) is found in neurons in the biliary tract of several species. We mapped the distribution of GAL-like immunoreactive nerve (GAL-LI) fibers in the sphincter of Oddi of the Australian brush-tailed possum by immunohistochemistry. The pharmacological effects of GAL in vitro and in vivo were studied by measuring sphincter of Oddi muscle strip contractility and transsphincteric flow, respectively. Muscle layers, and ganglionated and perivascular plexuses, contained GAL-LI nerve fibers. Exogenous GAL caused a concentration-dependent (10(9)-10(-6)M) increase in the spontaneous longitudinal but not circular muscle contractions. At 10(-6) M GAL, contractile activity was elevated two- to fourfold. This response was tetrodotoxin insensitive but competitively inhibited by galantide (10(-8)-10(-7) M). In vivo, intra-arterial bolus injections of GAL (1001000 ng/kg), decreased transsphincteric flow, with a maximum reduction to 80.2 +/- 6.8% of control. In conclusion, GAL appears to selectively stimulate longitudinally oriented sphincter of Oddi smooth muscle via a direct mechanism, which results in a modest reduction in transsphincteric flow.

Animals↗
PubMed1996

Division of the sphincter of Oddi for treatment of dysfunction associated with recurrent pancreatitis.

Increasing evidence suggests that motility disorders of the sphincter of Oddi may lead to episodes of recurrent pancreatitis in a small proportion of patients with the diagnosis of idiopathic recurrent pancreatitis. Over 10 years, 35 patients have been identified and treated for this condition. The aim of the study was to assess symptomatic outcome in these patients. Following the exclusion of common causes of pancreatitis the patients underwent sphincter of Oddi manometry. Patients with manometric abnormalities and three with normal manometric findings underwent treatment. Twenty-six patients with persistent symptoms underwent total division of the sphincter via open sphincteroplasty and septectomy. Patients were followed up according to symptoms and classed as having a cure, mild symptoms or no change. At a median follow-up of 24 (range 9-105) months, 15 of the 26 patients were cured, eight had only mild symptoms and three remained unchanged. In the majority of patients with a good clinical outcome, manometry had demonstrated sphincter of Oddi stenosis. Total division of the sphincter of Oddi is associated with good symptomatic outcome in patients with recurrent episodes of pancreatitis and documented sphincter of Oddi stenosis.

Adult↗
PubMed1996

Coordination of biliary and upper gastrointestinal motility in the fasted conscious pig.

A chronic pig model was developed which permits the simultaneous measurement of integrated biliary motility as resistance to flow (CBD inflow), gallbladder, duodenal and gastric motility in addition to collection of venous blood samples for gut hormones estimations. Animals displayed a duodenal interdigestive cycle of 55.4 +/- 3.4 min (mean +/- SEM, n = 6), consisting of phase I, II and III (21.2 +/- 2.1, 70.5 +/- 2.0, 8.7 +/- 0.5% of the cycle, respectively). A gastric interdigestive cycle of 60.2 +/- 6.5 min (n = 4) was similarly demonstrated consisting of three phases which corresponded to the three duodenal phases. The gastric phases I, II and III comprised 26.3 +/- 3.0, 71.2 +/- 2.7 and 2.5 +/- 0.8% of the cycle, respectively. The gastric phase III immediately preceded the onset of the duodenal phase III. The gallbladder likewise displayed an interdigestive cycle of 54.5 +/- 7.2 min (n = 6) consisting of a quiescent period (37.2 +/- 3.7% of the cycle) corresponding temporally to duodenal phase III and phase I. This quiescent phase was followed by a period of rhythmic contractions (64.5 +/- 4.1% of the cycle) which corresponded temporally to duodenal phase II. The onset of the gallbladder quiescent period coincided with the onset of duodenal phase III. The CBD inflow similarly demonstrated an interdigestive cycle of 53.4 +/- 9.6 min (n = 4) duration, consisting of three phases. The initial phase was evident as a period of rapid inflow, the onset of which coincided with the onset of duodenal phase III and the gallbladder quiescent period, and occupied 12.0 +/- 0.8% of the cycle. The second phase which occupied 18.0 +/- 7.4% of the cycle, was typified as a period of declining inflow which reached a relatively stable level at a time corresponding to the end of duodenal phase I. The third phase consisted of the maintenance of the inflow rate achieved at the end of the previous phase (60% of maximum inflow), corresponding in onset and duration with duodenal phase II and occupied 70.0 +/- 8.6% of the cycle. Plasma motilin levels fluctuated in relation to the duodenal interdigestive cycle, peaking during phase III relative to phase I (36.9 +/- 8.5 vs 25.4 +/- 7.7 pg mL-1, respectively, n = 5, P < 0.05). Cholecystokinin levels did not fluctuate, remaining low (2.3 +/- 2.1 pM cholecystokinin octapeptide equivalents, n = 5) throughout the duodenal interdigestive cycle, but increased about two fold after ingestion of solid food. Feeding disrupted the gastric, duodenal, gallbladder and CBD inflow cycles.

Animals↗
PubMed1996

Laparoscopic cholecystectomy in cirrhotic patient.

Cholecystectomy is associated with increased risk in patients with liver cirrhosis. Moreover, cirrhosis and portal hypertension have been considered relative or absolute contraindication to laparoscopic cholecystectomy. As experience with laparoscopic cholecystectomy increased, we decided to treat cirrhotic patients via this approach. Between January 1994 and April 1995, nine patients with a Child-Pugh's stage A cirrhosis underwent elective laparoscopic cholecystectomy with intraoperative cholangiography. There was no significant per- or post-operative bleeding and no blood transfusion was necessary. There was no mortality and very low morbidity. Median hospital stay was 3 days. This series suggests that well-compensated cirrhosis can not be considered a contraindication to laparoscopic cholecystectomy.

Adult↗
PubMed1996

Sphincter of Oddi.

It has been more than 100 years since Rugero Oddi described the sphincter that bears his name. In that time, investigators have determined its precise anatomy and they have demonstrated its independence from the duodenal muscle wall. Modern manometric techniques have defined the motor activity of the sphincter and motility abnormalities in patients presenting with either recurrent biliary-type pain or idiopathic recurrent pancreatitis. The term Sphincter of Oddi dysfunction is used to describe motility disorders of the sphincter. Clinical studies have shown that in patients with manometrically determined stenosis, division of the sphincter is associated with cure of the symptoms in more than 70%. For patients with biliary-type pain, division of the bile duct sphincter is all that is required, whereas in patients with idiopathic recurrent pancreatitis, division of the septum between the bile duct and the pancreatic duct is mandatory.

Biliary Dyskinesia↗
PubMed1995

Laparoscopic surgery in women with a clinical diagnosis of acute appendicitis.

OBJECTIVES: To assess the routine use of diagnostic laparoscopy and laparoscopic appendicectomy in women with a clinical diagnosis of acute appendicitis. METHODS: Women who presented with a clinical diagnosis of acute appendicitis between 1 January 1992 and 31 August 1993 were prospectively assessed and 107 underwent diagnostic laparoscopy. RESULTS: Appendicitis was confirmed in 63 women (59%) and no diagnosis could be made in seven (6%). An alternative diagnosis, most commonly a gynaecological disorder, was made in 37 women (35%). Twenty-eight women with an alternative diagnosis (76%) did not require a laparotomy. Seventy-three patients had a laparoscopic appendicectomy, with an 8% conversion rate to an open operation. The morbidity rate for laparoscopic procedures was 3%, the median inpatient stay was two days and the median time to return to normal activities was eight days. CONCLUSIONS: Diagnostic laparoscopy should be performed in women who present with a clinical diagnosis of acute appendicitis to confirm the diagnosis, reduce the rate of unnecessary appendicectomy and avoid an unnecessary laparotomy. When acute appendicitis is confirmed, appendicectomy may be performed laparoscopically.

Activities of Daily Living↗
PubMed1995

Peroperative endoscopic sphincterotomy during laparoscopic cholecystectomy for choledocholithiasis.

The development of laparoscopic cholecystectomy has created a dilemma in the management of choledocholithiasis. A number of options exist, including endoscopic sphincterotomy (ES) before laparoscopic cholecystectomy in patients with suspected common bile duct (CBD) calculi, laparoscopic bile duct exploration, open CBD exploration and postoperative ES. None of these options has emerged as ideal or universally acceptable. An alternative technique, peroperative ES, has been developed. A prospective assessment of the use of peroperative ES in 13 patients in whom choledocholithiasis was demonstrated with operative cholangiography is presented. Eleven patients had successful ES and clearance of stones. The CBD could not be cannulated in one patient, and an adequate ES for stone extraction could not be performed in the remaining patient. Both procedures were converted to open CBD exploration. Complications were mild postoperative pancreatitis (two patients) and pulmonary atelectasis (one). The median total operating time was 165 min and the median postoperative hospital stay was 3 days. Peroperative ES at the time of laparoscopic cholecystectomy provides a safe technique for clearance of the CBD.

Adult↗
PubMed1995

Preface.

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Journal Article↗
PubMed1995

Peroperative Endoscopic Sphincterotomy.

A major aim in the treatment of bile duct stones detected at the time of laparoscopic cholecystectomy should be to remove the stones during the same operation. In most instances, and for patients with small stones, this aim can be achieved using techniques through the cystic duct. In patients in whom these techniques failed, the role of a duodenal approach for removing the stones was evaluated by performing perendoscopic sphincterotomy (PES) and clearing the bile duct via this route. In an initial series of 13 patients, it was demonstrated that perendoscopic sphincterotomy and extraction of stones from the bile duct can be effectively performed in patients in the supine position with minimal interference to the laparoscopic cholecystectomy operation. The perendoscopic approach does not add to the complication rate of the operation, and short-term follow-up of patients indicates no significant postoperative sequalae. This approach adds to the various techniques being developed for the minimal-access approach to the treatment of bile duct stones.

Journal Article↗
PubMed1995

Port-Site Recurrence of Cancer Associated With Laparoscopic Diagnosis and Resection: The European Experience.

Port-site recurrences of cancer have drawn attention to the potential risks of laparoscopy for the diagnosis and treatment of digestive cancers. The first observations concerned unsuspected gallbladder cancers shown by laparoscopic cholecystectomy for lithiasis. Seventeen cases in patients with advanced or early colon cancer followed. It eventually became clear that all cancers could be the origin of such recurrences, which present as apparently isolated nodules embedded in the wall. These parietal recurrences were well known in open surgery, having been reported for most cancers, but they drew little attention because they usually occur in the context of carcinosis. It must be remembered that digestive cancers in general have a high potential for dissemination and that nearly 30% of patients have micrometastases in the bloodstream, the lymph nodes, the peritoneum, or even the bone marrow. The mechanism of tumor implantation is analogous to development of an inflammatory reaction. Under these conditions, laparoscopic surgery is susceptible to cause neoplastic dissemination for a number of mechanical reasons: CO2 insufflation, tumor manipulation, failure to isolate the tumor, forceful extraction of the surgical specimen, and exsufflation. Multiinstitutional trials of well-defined laparoscopic protocols based on the same oncologic principles as in open surgery should reduce the frequency of tumor cell dissemination and the incidence of port-site recurrences.

Journal Article↗
PubMed1995

Gastric devascularization and splenectomy for bleeding gastric varices.

Gastric varices may be associated with oesophageal varices in patients with portal hypertension. Control of haemorrhage from gastric varices is often difficult. Between June 1988 and February 1990, six patients underwent gastric devascularization in an effort to control life-threatening haemorrhage from bleeding gastric varices after non-operative measures failed. In all six patients the bleeding was controlled. There was one peri-operative death due to hepatic failure. Four patients experienced postoperative respiratory or urinary tract infections that responded to appropriate antibiotic and respiratory support measures. After a mean follow-up period of 44 months, eradication of gastric varices was achieved in all five survivors. Gastric devascularization is an effective surgical measure for good palliation and control of life-threatening haemorrhage from bleeding gastric varices.

Adult↗
PubMed1995

99mTechnetium labelled leucocyte scanning in acute lower abdominal pain: can it reduce the negative appendectomy rate?

While the incidence of 'negative' appendectomy has long been justified as a necessary evil in the management of acute appendicitis, attempts to improve diagnostic accuracy have met with mixed results. In a prospective study of 34 selected patients who presented with acute lower abdominal pain the potential role of 99mTechnetium labelled leucocyte scanning in the diagnosis of acute appendicitis has been evaluated. Patient management was not based on the result of the nuclear scan. The clinical outcome was correlated with the scan diagnosis. There was one false positive and one false negative scan result with respect to the clinical diagnosis of appendicitis yielding a sensitivity of 90% and a specificity of 96%. 99mTechnetium labelled leucocyte scanning may have an important role in the assessment of selected patients presenting with acute lower abdominal pain.

Abdomen, Acute↗