Biomedical subjects
Publications and source records attributed to R Sefr.
The authors present an incidental finding of intraabdominal testicle during laparoscopic operation for another diagnosis in an adult man. The surprising finding was managed by laparoscopy without conversion to an open procedure, adhering to rules of oncologic prevention because possible testicular cancer. Had an open approach been chosen in this patient, the intraabdominal testicle would have remained undetected.
The authors present their experience with biofragmentable anastomosis in the area of the colon in 42 patients where they used a biofragmentable ring Valtrac, Davis-Geck Co. to restores continuity after resection. The authors focus their attention on the peroperative technical difficulty of construction of the anastomosis proper and on complications encountered during the immediate postoperative course. The most serious among them is, no doubt, dehiscence of the anastomosis. Based on this experience, the authors express their opinion on the simplicity of the implementation proper of a BAR anastomosis and problems of postoperative complications.
The authors present information on the use of a modern sutureless anastomotic connection by means of a biofragmentable ring--BAR (Biofragmentable Anastomotic Ring) which was used in patients to restore the continuity of the GIT after resections in the upper portions of the digestive tract. The authors present their initial clinical experience and emphasize the importance of visualization of biofragmentable anastomoses by gastroscopic examination in case of postoperative complications with the possibility of therapeutic provisions, if necessary.
In a group of 23 patients with suspected malignant disease in the abdominal cavity laparoscopy was indicated and 11 times positive findings were obtained--six time a primary tumourous process and five times secondaries. The authors demonstrate on case-histories the advantages of laparoscopy when other examination fail or give dubious results. In their group of patients it always helped to establish a definite diagnosis.
The incidence of bile leaks increased with the introduction of laparoscopic cholecystectomy in surgery. The present paper is focused on biliary leaks-their diagnosis and treatment in a large group of patients, with special emphasis on a miniinvasive approach. Nine biliary leaks were found (i.e. 0.72%). Four leaks resolved spontaneously, five were treated surgically with good results.
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Laparoscopic cholecystectomy is now a method of choice in treating symptomatic cholelithiasis. The aim of this study was to assess an early integration of surgical residents into performing laparoscopic cholecystectomies and the significance of the integration for their training. Since February 1992 laparoscopic cholecystectomy (LC) has been performed in our institutions. During the 1st year 253 LCs were done by 4 surgeons--2 residents (in postgraduate years 3 and 4) and 2 staff surgeons; the 2nd year the team was extended and 301 LCs were performed. The residents operated on 364 cases (66%); the overall conversion rate was 5.4%; in the group of patients operated by residents (R) it was 3.8%; in the group operated by staff surgeons (SS) it was 8.4%. The complication rates did not exceed literature reports. The overall complication rate was 3.4%, in the "R" group 3.0% and in the "SS" group 4.2%. It may be concluded that surgical residents can perform LC without additional complications after initial experience with the open technique and appropriate hands-on laboratory training period before starting LC. Continuous training in advanced open biliary procedures should be assured for senior surgical residents.
The authors treated during the past three years 312 patients with oesophageal varices after the first haemorrhage. All patients were treated by endoscopic sclerotization of oesophageal varices and drugs which reduce the excessive portal pressure. After a minimum of two sclerotherapeutic sessions, following control of acute haemorrhage, the authors observed a relapse of haemorrhage from the upper gastrointestinal tract in 38 patients. In 20 of them the relapse of haemorrhage was again from oesophageal varices, but in 18 patients it was of different origin and would not be affected by classical treatment with a Sengstaken tube. The authors draw attention to the necessity of emergency endoscopy in these patients and to the fact that possible postponement of rational treatment, e.g. in duodenal ulcers insertion of a tube, may threaten the patient's life.
The authors submit their experience and data from the literature on the problem of oesophageal varices. In haemorrhage of varices at present the most successful procedure is endoscopic haemostasis concurrently with intensive treatment focused on the basic disease and replacement of blood losses. In patients with a history of haemorrhage from varices endoscopic sclerotization is generally recommended. The authors supplement it with the promising medicamentous reduction of the portal pressure. Other procedures, i.e. surgery, are indicated only in a minority of patients whose varices do not reposed to haemostasis and medicamentous reduction of high portal pressure. The problem how to proceed in varices which did not bleed so far is still unresolved. The authors recommend individual evaluation and submit their own procedure.
The authors discuss in a brief review the mighty development of invasive endoscopy in the next few years. Based on their own findings as well as data in the literature, they assume that it will be necessary to prepare theoretical as well as practical material for this quite newly developing discipline. It penetrates already at present to all European surgical and gastroenterological departments and changes fundamentally the approach to diagnosis and treatment of diseases of the gastrointestinal tract.
The haemodynamic action of long-term (3 months) therapy with enalapril, a potent inhibitor of angiotensin convertase was investigated in 12 patients selected at random, all suffering from portal hypertension and a previous episode of haemorrhage from oesophageal varices. In all these patients after one-week intervals sclerotization of oesophageal varices was made. As controls served a group of 13 patients treated only by sclerotherapy and placebo. In the enalapril treated group after three months the pressure in the wedged hepatic vein (25 +/- 4.8 vs. 21.3 4.8 mm Hg) and the pressure gradient wedged free hepatic vein (17.0 +/- 6.0 vs. 12.6 +/- 3.4 mm Hg) were significantly lower than the initial values (p less than less than 0.01) in the enalapril treated group. A very marked decline (greater than 3 mm Hg) of this pressure was recorded in 50% of the patients. In the group treated by sclerotherapy and placebo the pressure gradient did not decline. During treatment no changes in the systemic haemodynamics and liver tests occurred. None of the patients died during the investigation and the subsequent 6-month period. The authors provided evidence that enalapril reduces the portal pressure in patients with hypertension, although not in all, and can be successfully used for the treatment of patients with oesophageal varices in combination with sclerotherapy.
The authors submit the results of 1061 endoscopic sclerotizations of oesophageal varices in 183 patients. For sclerotization they used endoscopes of Olympus Co. at two-week intervals. Treatment was supplemented by administration of drugs reducing portal pressure. The number of complications associated with this treatment is very low. Serious life-threatening complications occur in much less than 1%. The authors consider endoscopic sclerotization of oesophageal varices after the first haemorrhage as the method of choice, in particular in combination with medicamentous treatment for reduction of portal pressure. They emphasize the necessity to perform these procedures in a department with adequate experience with sclerotizations where at least 100-200 sclerotization per year are performed. In the discussion other therapeutic possibilities are suggested. The problem of preventive sclerotization of varices has not been resolved so far. The authors recommend it in their department and use it in patients who according to the endoscopic finding or the level of the portocaval gradient are at risk of haemorrhage.
The authors describe, based on an analysis of 2970 patients subjected to endoscopy, the advantages of urgent endoscopy performed within six hours after admission to the surgical department. They refute former statements that urgent endoscopy is endoscopy performed within 24 or 48 hours. They discuss the different approach of endoscopists to different types of haemorrhage and to the time factor and emphasize the prognostic considerations of the endoscopist.
The incidence of bile leaks has increased with the advent of laparoscopic cholecystectomy. The present paper is focused on bile leaks--their diagnosis and management approaches with special consideration to relaparoscopy. From February 1992 to May 1995 a total of 1223 laparoscopic cholecystectomies were performed in two hospitals. Eight biliary leaks were found in the series under study (i.e. 0.65%). The diagnosis was confirmed by means of ultrasound, CT scans and ERCP. Three leaks resolved spontaneously on external drains placed during the operation. Two and three patients underwent laparotomy and relaparoscopy, respectively. The etiology of the leakage included three cases of ducts of Luschka, one cystic duct leak, and one retained CBD stone. the source of the remaining leaks was not determined. In all cases the management approaches comprised relaparoscopy and laparotomy. It may be concluded that an early diagnosis and management of bile leaks after laparoscopic cholecystectomies would prevent further complications.
Laparoscopic cholecystectomy is an accepted part of the training of surgical residents at present. Further procedures performed by residents include laparoscopic appendectomy, herniorrhaphy and others. This report analyzes the first 22 months of operative laparoscopy in Bakes Surgical Hospital and the impact on the training of residents. From September 1993 through May 1995 four residents performed 179 laparoscopic operations. Their operative experience has been shifted especially towards laparoscopic cholecystectomy but education in open cholecystectomy and open biliary tract procedures has not been jeopardized. It may be concluded that surgical residents can master essential laparoscopic operations without additional complications in a manner standard for training of other procedures.