Biomedical subjects

M J Fallas

Publications and source records attributed to M J Fallas.

15 recordsLinked to original sources

PubMed1999

Laparoscopic common bile duct exploration: long-term outcome.

HYPOTHESIS: Transcystic laparoscopic common bile duct exploration (LCBDE) with biliary endoscopy results in excellent long-term clinical outcome and patient satisfaction. DESIGN: Prospective cohort study of unselected patients found to have common bile duct stones during laparoscopic cholecystectomy between October 1989 and April 1998. A mailed survey assessed symptoms, outcome, and satisfaction. SETTING: A large community teaching hospital. PATIENTS: Two hundred seventeen patients with common bile duct stones. INTERVENTION: Transcystic LCBDE with choledochoscopy. MAIN OUTCOME MEASURES: Success of LCBDE, morbidity, postoperative symptoms, and satisfaction. RESULTS: One hundred sixteen surveys (54%) were returned. Mean follow-up was 60 months. The LCBDE procedure failed in 6 patients and endoscopic retrograde cholangiopancreatography was performed in 4 patients (3%). One patient had unsuspected retained stones. No patient had late recognition of retained stones or a bile duct stricture. Abdominal pain was present in 90 patients (89%) preoperatively and in 29 patients (26%) postoperatively (P = .001). The LCBDE procedure reduced 3 specific pain profiles: epigastric, from 47% (n = 54) to 7% (n = 8); back, from 31% (n = 36) to 6% (n = 7); and shoulder, from 18% (n = 21) to 2% (n = 2). When pain persisted, it was different in character in 15%. All nonpain symptoms (such as nausea, bloating, indigestion, and gas) were reduced from 78% (n = 91) to 34% (n = 39) (P = .001) except diarrhea. Diarrhea was present in 24 patients (22%) preoperatively and postoperatively, though it was a new postoperative symptom in 11 patients (11%). One hundred two patients (95%) were satisfied or mostly satisfied with LCBDE. CONCLUSIONS: Pain and nonpain symptoms, while reduced significantly after LCBDE, may persist. The LCBDE procedure does not result in common bile duct strictures or a significant rate of retained stones. This relatively new treatment for common bile duct stones is safe and effective.

Cholecystectomy, Laparoscopic↗

PubMed1996

Laparoscopic splenectomy for ITP. The gold standard.

BACKGROUND: A comparison of safety, efficacy, and cost of laparoscopic splenectomy (LS) vs open splenectomy (OS) for idiopathic thrombocytopenic purpura (ITP) was performed. METHODS: The records of 49 consecutive patients who underwent splenectomy for ITP (31 LS and 18 OS) at a large metropolitan teaching hospital between 3/91 and 8/95 were reviewed. Morbidity, mortality, hospital stay, operative time, blood loss, time to oral fluid intake, direct costs, and operating room (OR) costs were analyzed. RESULTS: Age, sex, comorbidity, and spleen size were similar in both groups. LS was successful in 94% of patients in whom it was attempted. Operative times showed a learning curve for LS, with average times for the last ten cases (94 +/- 35 min) significantly shorter than for the first ten (p = 0.01) and also shorter than for OS (103 +/- 45 min). Postsurgical hospital stay was 2.9 +/- 1.3 days for LS and 6.9 +/- 3. 0 days for OS (p < 0.001). Patients tolerated an oral diet 1.2 +/- 0. 5 days after LS and 3.2 + 0.7 days after OS (p < 0.001). Direct hospital cost was $5,509 +/- 3,636 for LS and $9,031 +/- 12,752 for OS. In the LS group, six patients (21%) had accessory spleens identified and removed, compared with two patients (11%) in the OS group. Platelet counts did not respond in two (7%) patients in the LS group, but no accessory spleens were identified by nuclear scan. One major complication occurred in the LS group. There were no cases of splenosis or mortality in either group. CONCLUSIONS: LS is a safe and effective treatment for ITP, with significantly shorter postoperative hospital stay than OS.

Adolescent↗

PubMed1996

Cost-effective management of complicated choledocholithiasis: laparoscopic transcystic duct exploration or endoscopic sphincterotomy.

BACKGROUND: In the United States of America, approximately 700,000 patients undergo laparoscopic cholecystectomy (LC) each year and at least 10 percent of these patients will have common bile duct stones (CBDS). The purpose of this study was to evaluate patients with choledocholithiasis and compare the economic and clinical results obtained by LC with endoscopic sphincterotomy (ES) with those of LC with laparoscopic transcystic common bile duct exploration (LTCBDE). STUDY DESIGN: From June 1991 to September 1994 patients undergoing LC plus LTCBDE and those undergoing LC plus ES at a single institution were compared where cost data were available. Of the 76 patients with choledocholithiasis, 59 patients underwent LC plus LTCBDE (group 1) and 17 patients underwent LC plus ES (group 2). A subset of group 1 patients undergoing urgent LC plus LTCBDE (group 3) for cholecystitis, cholangitis, or pancreatitis plus laparoscopy were examined separately. RESULTS: Laparoscopic cholecystectomy plus LTCBDE, whether including all-comers (group 1) or just urgent cases (group 3), was associated with a significantly decreased length of hospital stay (6.1 and 6.9 days, respectively, compared with group 2, 12.4 days) (p < 0.001). The morbidity of patients in group 1 was also markedly lower than for patients in group 2; 12 percent compared with 41 percent, respectively. Patients in group 1 had a significantly decreased cost of hospitalization (+13,151), when compared with patients in group 2 (+18,712) (p = 0.05). This difference is even more pronounced when professional fee reimbursement is considered. The cost of treatment for patients in group 1 was +14,732 compared with +21,125 for patients in group 2 (p < 0.05). The total hospital cost for patients in group 3 was only +13,564 compared with +18,712 for patients in group 2. When professional reimbursement was considered, the cost was +15,150 for patients in group 3 compared with +21,125 for patients in group 2. CONCLUSIONS: Patients undergoing LC plus LTCBDE for CBDS, whether urgently or electively, have markedly decreased morbidity rates, length of hospital stay, and costs when compared with patients undergoing LC plus ES.

California↗

PubMed1995

Bile duct stones in the laparoscopic era. Is preoperative sphincterotomy necessary?

OBJECTIVE: To evaluate treatments for common bile duct stones (CBDS). DESIGN: Retrospective review of authors' case series. SETTING: Large private metropolitan teaching hospital. PATIENTS: All patients with CBDS (N = 145) from a series of 1231 patients who underwent laparoscopic cholecystectomy, 99% with intraoperative fluorocholangiography. INTERVENTIONS: Treatments for CBDS included one or more of the following: laparoscopic transcystic duct exploration (n = 123), laparoscopic choledochotomy (n = 10), open choledochotomy (n = 7), preoperative endoscopic sphincterotomy (ES) (n = 9), intraoperative ES (n = 2), post-operative ES (n = 11), or observation (n = 10). MAIN OUTCOME MEASURES: Success of various interventions for CBDS, morbidity and mortality, frequency of retained stones, operative time, and length of postoperative hospitalization. RESULTS: Laparoscopic transcystic duct exploration was successful in 91% of attempts and resulted in the shortest postoperative stay (3.4 days), least morbidity (5%), and fewest retained stones (5%). Endoscopic sphincterotomy was successful in 56% of preoperative attempts, 50% of intraoperative attempts, and 91% of postoperative attempts. There were no reoperations and one death. CONCLUSIONS: For patients requiring cholecystectomy, laparoscopic transcystic duct exploration is safe and effective, treats CBDS in one session, and if unsuccessful still allows for open choledochotomy or postoperative ES. Preoperative endoscopic retrograde cholangiography and ES should be reserved for patients with serious illness or possible malignant disease.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed1995

Incidence of complications following laparoscopic hernioplasty.

Smaller individual series on the outcome of laparoscopic hernioplasty techniques have been reported. This study reports on the complications of 3,229 laparoscopic hernia repairs performed by the authors in 2,559 patients. The TAPP (transabdominal preperitoneal) technique was the most frequently performed: 1,944 (60%). The totally preperitoneal technique was performed 578 (18%) times. The IPOM (intraperitoneal onlay mesh) repair was performed 345 (11%) times. The plug-and-patch technique was used 286 (9%) times and simple closure of the hernia defect without mesh was used in 76 (2%) repairs. Overall, there were 336 (10%) complications: 17 (0.5%) major and 265 (8%) minor. There were 54 (1.6%) recurrences, with a mean follow-up of 22 months. The TAPP technique had 19 (1%) recurrences and 141 (7%) complications. There were four bowel obstructions in this subgroup from herniation of small bowel through the peritoneal closure and trocar sites. The totally preperitoneal technique had no recurrence and 60 (10%) complications. The IPOM group had 7 (2%) recurrences and 47 (14%) complications. The plug-and-patch technique had 26 (9%) recurrences and 24 (8%) complications. The simple closure of the internal ring had 2 (3%) recurrences and 10 (13%) complications. Laparoscopic hernioplasty is not without complications. Laparoscopic hernioplasty is not without complications. Training, experience, and attention to technique will prevent some of these complications.

Hernia, Inguinal↗

PubMed1994

Laparoscopic trans-cystic-duct common-bile-duct exploration.

One thousand seventy-one consecutive laparoscopic cholecystectomies were performed. Routine cholangiography was employed with a 99% success rate. One hundred thirty patients were found to have common duct stones (CBDS). In 48 (37%) patients they were unsuspected. One hundred eleven patients underwent attempted trans-cystic-duct extraction techniques (TCD-CBDE). One hundred three (93%) were successful. The following techniques were employed: 101--biliary endoscopy, 23--ampullary balloon dilation, 2--fluoroscopic basket retrieval. The average operative time was 136 min. The average postsurgical stay was 3.7 days. There were 19 (17%) complications--6 (5%) major. There were 4 retained stones (2 intentional) and 1 death. Patients over 65 years of age had more complications and patients with unsuspected CBDS under 65 years of age had the fewest. TCD-CBDE is a safe, effective way to extract common duct calculi. Endoscopy and basket stone retrieval was the primary technique employed.

Cholecystectomy, Laparoscopic↗

PubMed1994

Laparoscopic transcystic choledochoscopy.

Preoperative prediction of common bile duct stones (CBDS) is imprecise. Cholangiography during laparoscopic cholecystectomy (LC) is the best method for detection of CBDS. Treatment of most stones detected at LC can be safely accomplished using transcystic choledochoscopy and stone extraction. This technique is applicable in nearly 90% of patients with CBD calculi. It may be preferable to endoscopic sphincterotomy (ES) in younger patients and is probably equivalent to ES in patients over 65 years of age.

Adolescent↗

PubMed1994

Laparoscopic splenectomy.

Laparoscopic splenectomy was attempted in 16 patients and was performed successfully in 13 (81%) patients with the diagnosis of idiopathic thrombocytopenic purpura (ITP), AIDS-related thrombocytopenia, Hodgkin's disease, or lymphoma. The operative time averaged 157 min, and autologous transfusion was required in four patients. The postsurgical stay averaged 3 days in patients with completely laparoscopic splenectomies and 4 days in patients whose spleens were removed through small counterincisions. No major complications secondary to the procedure itself occurred postoperatively. Conversion to open operation was necessary in three (19%) patients because of bleeding or splenomegaly. With careful selection of patients and mastery of the technique, laparoscopic splenectomy can be safely performed on normal or slightly enlarged spleens. The advantages are less pain, shorter hospitalization, and reduced disability as compared to "open" splenectomy.

Acquired Immunodeficiency Syndrome↗

PubMed1994

Laparoscopic inguinal herniorrhaphy.

Traditional open hernia repairs are usually performed as outpatient procedures under local anesthesia, with minimal morbidity and low recurrence rates. To be widely accepted, any new procedure must at least match current standards of performance. This review summarizes the most widely used techniques for laparoscopic inguinal herniorrhaphy. Early results of over 1700 cases using these techniques are reported. Recurrence was lowest using the total extraperitoneal repair. In selected patients, laparoscopic inguinal herniorrhaphy is a safe and comparable alternative to standard open repairs.

Hernia, Inguinal↗

PubMed1994

Comparison of laparoscopic cholecystectomy in obese and non-obese patients.

Results of laparoscopic cholecystectomy in obese and non-obese patients were analyzed prospectively. Laparoscopic cholecystectomy was performed in 841 patients-179 obese (Group I) and 662 non-obese (Group II). Operative time averaged 73.1 minutes in Group I and 73.7 minutes in Group II. There were no statistically significant differences in the ability to perform cholangiography (99.4% Group I; 97.9% Group II), conversion rate (1.1% Group I; 1.5% Group II), or complications (4.5% Group I; 3.8% Group II). In Group I no pulmonary complications were noted, nor any cases of venous thromboembolic disease. Risk of laparoscopic cholecystectomy appears comparable in obese and non-obese patients. Based on historical comparisons, laparoscopic cholecystectomy may be safer than traditional cholecystectomy in obese patients.

Adolescent↗

PubMed1993

Laparoscopically guided cholecystectomy: a detailed report of the first 453 cases performed by one surgical team.

This study reports outcome data from a diverse population undergoing laparoscopic cholecystectomy. Our technique differs from other laparoscopic methods in its use of electrocautery, blunt hilar dissection, and routine intraoperative cholangiography. This study includes 453 consecutive surgeries performed between August 1989 and March 1991. Only the first 20 patients were screened to exclude those with common bile duct stones, prior upper abdominal surgery, pregnancy, or acute cholecystitis. Patients had the following conditions: current acute cholecystitis (9%), a history of acute cholecystitis (16%), jaundice (5%), pancreatitis (4%), and prior abdominal surgery (38%). Nine per cent had common bile duct stones which were treated with either laparoscopic transcystic common bile duct exploration (69%), laparoscopic choledochotomy (5%), open choledochotomy (10%), endoscopic retrograde cholangiopancreatography (10%), or observation (7%). Operative time averaged 78 minutes. One patient died, and 6% developed complications. Seventy-one per cent were discharged on the first postoperative day. Our experience demonstrates that LC can be performed safely, even in difficult cases, although considerable endoscopic experience and skill are required.

Cholangiography↗

PubMed1992

Laparoscopic colectomy.

Fifty-one laparoscopic colectomies were attempted at two institutions. The clinical results and methods are presented. Seven cases (14%) were converted to facilitated procedures, and four cases (8%) were converted to "open." Cases of cancer, diverticulitis, endometriosis, regional enteritis, villous adenomas, and sessile polyps were operated. Right, transverse, left, low anterior, and abdominoperineal colectomies were performed. Colotomies and wedge resections were also performed. Laparoscopic suturing was required in five cases of incomplete anastomosis by circular stapler (18%). Suturing was required in all right, transverse colectomies and colotomies. Operative time averaged 2.3 hours. Hospitalization averaged 4.6 days. Four patients had complications (8%), and one 95-year-old died of pneumonia (2%). Laparoscopic colectomies can be performed safely, but require two-handed laparoscopic coordination, as well as suturing and knot-tying skills.

Adult↗

PubMed1992

Laparoscopic cholecystectomy in acute cholecystitis.

Between August 1989 and December 1990, twenty-five patients with a preoperative diagnosis of acute cholecystitis underwent laparoscopic cholecystectomy. Twenty-one patients (84%) had abdominal tenderness, 16 (64%) had leukocytosis, and 10 (40%) had fever. Eleven patients (44%) came to the hospital with only one of these previously mentioned clinical signs. Six patients (24%) had two clinical signs. Eight patients (32%) came to the physician with all three findings. The length of surgery correlated directly with the number of presenting clinical signs. The average operating time was 119 minutes. Intraoperative cholangiograms were routinely performed on all patients. Four patients (16%) had common bile duct stones. The average hospitalization was 3.8 days and patients returned to work or routine physical activity between 3 days and 2 weeks (average 8 days) after surgery. There were three wound infections and two cases of hyperamylasemia. One patient developed urinary retention and another had a CO2 embolus. There were no intra-abdominal abscesses and no mortality. Laparoscopic cholecystectomy in acute cholecystitis is technically difficult. The incidence of common bile duct stones is greater than in elective cases, and routine cholangiography is crucial. With sufficient experience and skill, laparoscopic cholecystectomy can be performed safely in patients with acute cholecystitis.

Academic Medical Centers↗

PubMedDate not supplied

Laparoscopic preperitoneal inguinal hernia repair without peritoneal incision. Technique and early clinical results.

More than 500,000 hernia procedures are performed annually in the United States alone. The authors have devised a new technique for laparoscopic hernia repair. The peritoneum is not incised, as the space between the abdominal wall and the peritoneum is developed with CO2 and blunt dissection. The trocars and laparoscope are placed within this preperitoneal space. Mesh is stapled to Cooper's ligament and the underside of the abdominal wall. From November 1990 to January 1992, 68 herniae have been repaired in 35 patients. The first 25 patients were kept overnight for observation and discharged the following day. Thirty-two patients (92%) were able to resume full physical activity within 1 week. Average follow-up was only 12 months, but there were no recurrent or retained herniae.

Female↗

PubMedDate not supplied

Laparoscopic choledochoscopy and extraction of common bile duct stones.

Various strategies have been proposed for the treatment of common bile duct stones encountered during laparoscopic cholecystectomy (LC). Eighty-three patients who had choledocholithiasis discovered during or just prior to LC are included in this study. These patients were treated by various modalities including preoperative, intraoperative, and postoperative endoscopic retrograde cholangiopancreatography and sphincterotomy, laparoscopic choledochotomy, transcystic duct-common bile duct (TCD-CBD) exploration, and conventional "open" common duct exploration. Sixty-six patients were successfully treated with TCD-CBD exploration. They were discharged on average 2.6 days postoperatively and were able to return to normal physical activities within 7 days of discharge. There was minimal morbidity and no mortality. The technique of TCD-CBD exploration is described in detail. The role of laparoscopic choledochotomy and endoscopic sphincterotomy for management of common duct stones in patients undergoing laparoscopic cholecystectomy appears limited.

Common Bile Duct↗