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PubMed2003

Serum levels of macrophage colony-stimulating factor after cesarean section, vaginal delivery, or laparotomy in normal pregnant women and gynecologic patients.

BACKGROUND: Macrophage colony-stimulating factor (M-CSF) is located in villous cells lining the vessels in the placenta in the third trimester and has been implicated in placental growth and development. Macrophage colony-stimulating factor levels in peripheral blood increased significantly with progression of pregnancy in uncomplicated pregnancies. The serum levels of M-CSF appear to be altered after laparotomy in normal pregnant women and nonpregnant gynecologic patients. Thus, the present study examined changes in serum levels of M-CSF before and after laparotomy and compared these findings between the two groups. Macrophage colony-stimulating factor levels before and after vaginal delivery were also examined. METHODS: Peripheral blood was collected before, 1 day, and 10 days after laparotomy or vaginal delivery from 38 subjects, of whom 14 were normal pregnant women who underwent cesarean section (group 1), 12 were gynecologic patients (group 2), and 12 were normal pregnant women who delivered vaginally (group 3). The M-CSF level was determined by the sandwich ELISA method using three antibodies. RESULTS: In all groups, the serum levels of M-CSF increased significantly 1 day after laparotomy or vaginal delivery, but then decreased significantly after 10 days. The net increase 1 day after laparotomy was significantly lower in group 1 than in group 2. Before and 1 day after laparotomy, the M-CSF levels were significantly higher in group 1 than in group 2, but not 10 days after laparotomy. Changes in M-CSF levels in group 3 were relatively similar to those in group 1. CONCLUSIONS: Serum levels of M-CSF were significantly higher in groups 1 and 3 than in group 2, before laparotomy or vaginal delivery. The M-CSF level increased moderately 1 day after cesarean or vaginal delivery, and it increased remarkably after gynecologic laparotomy. The increases in M-CSF levels postlaparotomy may occur via different mechanisms between groups 1 and 2. Placental removal and termination of pregnancy might contribute to the decrease in M-CSF levels, leading to only a moderate increase in M-CSF levels 1 day after laparotomy in group 1.

Adult↗
PubMed2001

Determining the need for laparotomy in penetrating torso trauma: a prospective study using triple-contrast enhanced abdominopelvic computed tomography.

BACKGROUND: The nontherapeutic laparotomy rate in penetrating abdominal trauma remains high and the morbidity rate in these cases is approximately 40%. Selective management, rather than mandatory laparotomy, has become a popular approach in both stab wounds and gunshot wounds. The advent of spiral technology has stimulated a reassessment of the role of computed tomography (CT) in many aspects of trauma care. We prospectively investigated the current utility of triple-contrast CT as a diagnostic tool to facilitate initial therapeutic management decisions in penetrating torso trauma. METHODS: We studied hemodynamically stable patients with penetrating injury to the torso (abdomen, pelvis, flank, back, or lower chest) without definite indication for laparotomy, admitted to our trauma center during the 1-year period from 7/99 through 6/00. Patients underwent triple-contrast enhanced spiral CT as the initial study. A positive CT scan was defined as any evidence of peritoneal violation (free air or fluid, contrast leak, or visceral injury). Patients with positive CT, except those with isolated solid viscus injury, underwent laparotomy. Patients with negative CT were observed. RESULTS: There were 75 consecutive patients studied: mean age 30 years (range 15-85 years); 67 (89%) male; 41 (55%) gunshot wound, 32 (43%) stab wound, 2 (3%) shotgun wound; mean admission systolic blood pressure 141 mm Hg (range 95-194 mm Hg); 26 (35%) had positive CT and 49 (65%) had negative CT. In patients with positive CT, 18 (69%) had laparotomy: 15 therapeutic, 2 nontherapeutic, and 1 negative. Five patients had isolated hepatic injury and 2 had hepatic and diaphragm injury on CT and all were successfully managed without laparotomy. Of these seven patients, three had angioembolization and two had thoracoscopic diaphragm repair. In patients with negative CT, 47/49 (96%) had successful nonoperative management and 1 had negative laparotomy. The single CT-missed peritoneal violation had a left diaphragm injury at laparotomy. CT accurately predicted whether laparotomy was needed in 71/75 (95%) patients. CONCLUSION: In penetrating torso trauma, triple-contrast abdominopelvic CT can accurately predict need for laparotomy, exclude peritoneal violation, and facilitate nonoperative management of hepatic injury. Adjunctive angiography and investigation for diaphragm injury may be prudent.

Abdominal Injuries↗
PubMed2005

Inflammatory response of interleukin-1beta and interleukin-6 in septic rats undergoing laparotomy and laparoscopy.

It is generally accepted that greater inflammatory response is observed after laparotomy than laparoscopy in animal models. However, in a previous study, we reported there are no significant differences in the systemic response of tumor necrosis factor (TNF)-alpha between the laparotomy and laparoscopy groups in a rat model of endotoxic shock. The present study extends this investigation to the inflammatory response of 2 additional proinflammatory mediators, interleukin (IL)-1beta and IL-6, in septic rats after laparotomy and laparoscopy in the same animal model. Rats received lipopolysaccharide (LPS) intraperitoneally and underwent laparotomy (n = 5), laparoscopy (n = 5), or no surgical intervention (n = 5). A control group received anesthesia only (n = 5). Serum IL-1beta and IL-6 levels were significantly higher at 2, 4, and 8 hours after LPS injection and were equally suppressed in the laparotomy and laparoscopic groups (P < 0.05). Liver IL-1beta mRNA and protein levels were significantly inhibited at 2, 4, and 8 hours in the laparotomy and laparoscopic groups. Liver IL-6 mRNA (2 and 4 hours) and protein (4 hours) levels were also suppressed significantly in both the laparotomy and laparoscopic groups (P < 0.05). There were no significant differences in hepatic levels of mRNA and protein of IL-beta and IL-6 in both the laparotomy and laparoscopic groups. These results extend our previous finding demonstrating the suppression of TNF-alpha in both the laparotomy and laparoscopic groups. The behavior of the markers used in our study demonstrated that the inflammatory response does not differ between laparotomy and laparoscopic surgery in our rat model of endotoxic shock.

Animals↗
PubMed2005

Is laparotomy necessary in the diagnosis of fever of unknown origin?

Fever of unknown origin (FUO) is a diagnostic challenge for the practising physician. Detailed medical history, physical examination, non-invasive laboratory tests, and radiologic examinations compose the first level in the diagnostic approach to the FUO. When a diagnosis cannot be established with these procedures, some invasive diagnostic techniques and finally exploratory laparotomy are performed. Although advanced diagnostic measures and imaging-guided less invasive procedures have decreased the need, laparotomy remains as a final diagnostic method for FUO cases. In this study we evaluate the role and importance of laparotomy in the diagnosis of our FUO cases. In 17 out of 126 patients (8 male, 9 female, the median age 35.8 years) hospitalized in our clinic between 1982 and 2002 with the diagnosis of FUO, the diagnosis was established by laparotomy. The diagnosis was made directly in 13 patients, and indirectly (by excluding other diseases) in 2 patients. In several FUO series, the contribution of laparotomy to the diagnosis of FUO was reported as 27-100%. This rate was found to be 88% in the present study. During laparotomy on 17 cases, tissue samples were taken from spleen, liver, intra-abdominal and mesenteric lymph nodes. Pathologic examination of these tissue samples revealed miliary tuberculosis in 4; non-Hodgkin's lymphoma in 3; Hodgkin's lymphoma in 3; liver tumour in 1; hairy cell leukemia in 1; peritonitis carcinomatosis in 1. In the patients with miliary tuberculosis, the liver (3) and/or spleen (2), and/or lymph node (3) revealed caseating granulomas. Laparotomy diagnosed 3 of 5 cases whose abdominal ultrasonography and computerized tomography were normal. In conclusion, although advanced diagnostic methods decreased the need for laparotomy in FUO, if non-invasive and invasive diagnostic measures fail, laparotomy may contribute to the diagnosis. The selection of the patient and the timing are important for laparotomy.

Adolescent↗
PubMed2006

Decompressive laparotomy for abdominal compartment syndrome--a critical analysis.

INTRODUCTION: Abdominal compartment syndrome (ACS) is increasingly recognized in critically ill patients, and the deleterious effects of increased intraabdominal pressure (IAP) are well documented. Surgical decompression through a midline laparotomy or decompressive laparotomy remains the sole definite therapy for ACS, but the effect of decompressive laparotomy has not been studied in large patient series. METHODS: We reviewed English literature from 1972 to 2004 for studies reporting the effects of decompressive laparotomy in patients with ACS. The effect of decompressive laparotomy on IAP, patient outcome and physiology were analysed. RESULTS: Eighteen studies including 250 patients who underwent decompressive laparotomy could be included in the analysis. IAP was significantly lower after decompression (15.5 mmHg versus 34.6 mmHg before, p < 0.001), but intraabdominal hypertension persisted in the majority of the patients. Mortality in the whole group was 49.2% (123/250). The effect of decompressive laparotomy on organ function was not uniform, and in some studies no effect on organ function was found. Increased PaO2/FIO2 ratio (PaO2 = partial pressure of oxygen in arterial blood, FiO2 = fraction of inspired oxygen) and urinary output were the most pronounced effects of decompressive laparotomy. CONCLUSION: The effects of decompressive laparotomy have been poorly investigated, and only a small number of studies report its effect on parameters of organ function. Although IAP is consistently lower after decompression, mortality remains considerable. Recuperation of organ dysfunction after decompressive laparotomy for ACS is variable.

Abdomen↗
PubMed1995

Increased tumor establishment and growth after laparotomy vs laparoscopy in a murine model.

OBJECTIVE: To test our hypothesis that tumors would be more easily established and grow more aggressively after laparotomy than after laparoscopy. This hypothesis was based on studies that have demonstrated that surgery can suppress immune function and facilitate tumor growth and that have shown preservation of immune function after laparoscopic procedures. DESIGN: Double-blinded, randomized, control trial. SETTING: Research laboratory and animal care facility. ANIMALS: One hundred forty 5- to 6-week-old C3H/He female mice. INTERVENTIONS: Three experiments with three groups each: laparotomy, insufflation, and anesthesia controls. All animals received an intradermal inoculation of tumor cells in the dorsal skin. The anesthesia control cohort underwent no procedure. The laparotomy cohort underwent a midline laparotomy from the xiphoid process to the pubis, which was closed after 30 minutes. The insufflation cohort underwent peritoneal insufflation with carbon dioxide for 30 minutes. MAIN OUTCOME MEASURES: Tumor volume, tumor mass, and incidence of tumor establishment. RESULTS: In the first experiment, the tumor volumes of the anesthesia control and insufflation groups followed a similar pattern of plateau and regression. The tumor volumes of the laparotomy group followed a different pattern and were significantly larger than those of the control and insufflation groups on postoperative days 6 and 12 (P < .05 for all comparisons). In the second experiment, tumors in the laparotomy group were approximately three times larger than those of the control group (P < .01) and almost twice as large as insufflation group tumors (P < .01) by mass. In the third experiment, there was a significantly higher incidence of tumor establishment in the laparotomy group than in the insufflation (P < .04) or control (P < .01) groups. The incidence was not different between the control and insufflation groups. CONCLUSIONS: Tumors were more easily established and grew more aggressively after laparotomy than after insufflation. These results, coupled with those that demonstrate an immune advantage to laparoscopy over laparotomy, suggest that the difference in observed tumor growth may be related to immune function. While much work remains to be done, we believe these data provide evidence of a previously undemonstrated benefit of laparoscopic intervention.

Animals↗
PubMed2005

Pfannenstiel versus vertical laparotomy in patients undergoing radical retropubic prostatectomy with spinal anesthesia: results of a prospective, randomized trial.

OBJECTIVE: To evaluate the impact of a standard vertical laparotomy versus a Pfannenstiel transverse laparotomy on intra-, peri-operative, and 6-month follow-up outcome in patients undergoing radical retropubic prostatectomy with pelvic lymphadenectomy with spinal anesthesia. METHODS: Between January 2003 and June 2003, 69 age-matched consecutive patients with clinically localized prostate cancer underwent radical retropubic prostatectomy with pelvic lymphadenectomy with spinal anesthesia and were randomized into Group 1 (vertical laparotomy: 35 patients) and Group 2 (Pfannenstiel laparotomy: 34 patients). An extensive analysis of the critical intra-, peri-operative, and 6-month follow-up clinical parameters was performed. RESULTS: Both the hemodynamics and the biochemical balance were not significantly different between the two groups. Overall blood loss (p = 0.78), autologous (p = 0.88) and homologous (p = 0.36) blood transfusions were similar regardless of the type of laparotomy. Surgical time was not significantly (p = 0.27) different between the two groups. Similarly, the two forms of laparotomy did not differ regarding the length of the surgical incision (p = 0.21), as measured at the end of the procedure. Post-operative oxygen saturation percentage by pulse oximetry, as well as post-op sedation score, were not significantly different (p = 0.06 and p = 0.97, respectively). Waiting time in the post-operative holding area (p = 0.15), and pain score in the post-operative holding area (p = 0.9) as well as on post-operative day 1 (p = 0.1) were not significantly different between the two groups. The rate of first flatus passage and of unassisted ambulation were similar regardless of the type of laparotomy during post-operative day day 1. The two types of incision made it possible to remove a similar (p = 0.34) number of pelvic lymph nodes and were associated to a similar rate of positive surgical margins among pT2 patients. At the 6-month follow-up the occurrence of a pelvic lymphocele and of deep venous thrombosis was similar in the two groups (p = 0.6 and p = 0.16, respectively). Complete urinary continence and spontaneous erectile function recovery was reported in a similar number of patients regardless of the type of surgical incision (p = 0.59 and p = 0.40, respectively). CONCLUSIONS: These results suggest that a Pfannenstiel transverse suprapubic laparotomy does not result in a significantly different outcome from a standard vertical laparotomy in patients undergoing a radical retropubic prostatectomy with pelvic lymphadenectomy with L2-L3 spinal anesthesia for clinically localized prostate cancer.

Aged↗
PubMed1999

[Laparoscopy or laparotomy in acute cholecystitis (200 cases). Comparison of the results and factors predictive of conversion].

STUDY AIM: The aim of this prospective study was to compare the results of cholecystectomy for acute cholecystitis through laparoscopic and open approach and to assess factors responsible for conversion into laparotomy. PATIENTS AND METHODS: From January 1991 to October 1997, 200 patients with calculous acute cholecystitis were operated on in the same center, 100 through laparoscopy and 100 through laparotomy. Choice between these two procedures was only dependent on the disresponsibility of videolaparoscopic material. Comparison between laparoscopy and laparotomy groups concerned postoperative mortality and morbidity rates, hospital stay duration and late results. Intraoperative conversion into laparotomy occurred in 24 patients and factors responsible for conversion were assessed with univaried and multivaried analysis. RESULTS: Both groups were comparable with regard to sex ratio, age, ASA score but associated diseases incidence, plastron, fever above 38 degrees C and leucocytosis were significantly more frequent in the laparotomy group and delay between diagnosis and surgery was significantly longer in the laparoscopic group. There were two postoperative deaths in the laparotomy group, 0 in the laparoscopic group (NS). Morbidity rate was higher (32% versus 10%) (p = 0.0002) and hospital stay longer (12 +/- 10 days, versus 5 +/- 3) in the laparotomy group (p = 0.00005). Late results were similar in both groups. Conversion rate into laparotomy was 24%. Factors predisposing significantly to conversion were in univaried analysis: plastron, fever above 38 degrees C, leucocytosis, delay between diagnosis and surgery above 4 days, presence on ultrasonography of pericholecystic liquid and gallbladder wall edema, presence of "Klebsiella" in gallbladder bile. With multivaried analysis, leucocytosis and delay between diagnosis and surgery were the only independent factors. CONCLUSION: Videolaparoscopic cholecystectomy is a safe and efficient technique in the treatment of acute cholecystitis, with a lower postoperative morbidity rate and a shorter hospital stay. Conversion rate into laparotomy is significantly dependent on leucocytosis and delay between diagnosis and surgery. Laparoscopic cholecystectomy should be performed as soon as possible in acute cholecystitis.

Acute Disease↗
PubMed1999

Complications and long-term outcomes after adnexal surgery by laparotomy and laparoscopy.

STUDY OBJECTIVE: To assess complications and subjective outcomes after adnexal surgery by laparotomy and laparoscopy. DESIGN: Observational study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Two-hundred twenty-eight women requiring adnexal surgery for benign indications. INTERVENTIONS: The 114 patients who underwent laparotomy and 114 having laparoscopy were followed prospectively for 1 year. Two questionnaire-based evaluations were undertaken to determine subjective outcomes. To evaluate possible later surgical procedures, hospital records were reviewed 4 years after operation. MEASUREMENTS AND MAIN RESULTS: No major complications occurred in the laparotomy group. The two (1.8%) in the laparoscopy group were intestinal injury and aortal injury, both in women who had previously undergone laparotomy. Rates of minor complications were 11.4% for laparotomy and 7.0% for laparoscopy. Two patients in both groups were readmitted. No difference was found between groups in need for additional adnexal procedures up to 4 years after operation. After 1 year, frequencies of subjective complaints and satisfaction with surgical procedure did not differ significantly. Mean hospital cost per patient was less for laparoscopy than for laparotomy. CONCLUSION: No statistically significant differences were seen after adnexal surgery by laparoscopy and laparotomy with regard to frequency of complications and subjective outcomes. Laparoscopy in women who have previously undergone laparotomy may be associated with a slightly greater risk of major complications than another laparotomy.

Adnexa Uteri↗
PubMed2000

Salvage laparotomy for failure of peritoneal drainage in necrotizing enterocolitis in infants with extremely low birth weight.

BACKGROUND/PURPOSE: Peritoneal drainage is a temporizing procedure for infants with extremely low birth weight (ELBW) who have perforated necrotizing enterocolitis (NEC). "Salvage" laparotomy is advocated when patients worsen after drainage. Some patients have survived with intact gastrointestinal functional after drainage alone. The purpose of this study is to determine if these salvage laparotomies are beneficial. METHODS: The authors reviewed the records of ELBW infants treated at Stanford University with perforated NEC from 1993 through 1998. Data collected included demographic makeup, type of operation, survival rate, postoperative complications, length of stay (LOS), and cost. RESULTS: The authors treated 26 patients, 9 with laparotomy and 17 with peritoneal drainage. The peritoneal drainage group had lower birth weight and more comorbid conditions. Survival rate was similar between laparotomy and drainage: 55.6% versus 41.2%. Four patients in the drainage group underwent salvage laparotomy for perceived clinical deterioration. All of these patients died. The clinical status of patients who had salvage laparotomy and died was similar to those who did not and lived. Seven of 13 patients treated with drainage followed only by supportive care and antibiotics survived. Cost and LOS for patients undergoing salvage laparotomy were much greater than for nonsurviving patients undergoing only peritoneal drainage: 84 +/- 20 days and $660,000 compared with 34 +/- 11 days and $306,000. CONCLUSIONS: Both primary peritoneal drainage and laparotomy should be considered primary therapy for perforated NEC. Patients undergoing peritoneal drainage typically experience clinical deterioration after operation. In this limited experience, salvage laparotomy did not appear beneficial.

Drainage↗
PubMed1998

Laparoscopy and laparoscopic ultrasonography avoid exploratory laparotomy in patients with hepatocellular carcinoma.

OBJECTIVE: This prospective study evaluates the value of laparoscopy and laparoscopic ultrasonography (USG) in avoiding exploratory laparotomy in patients with hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA: Laparotomy and intraoperative USG is the gold standard to determine the resectability of HCC. No palliation can be offered to patients found to have unresectable disease, and the surgical exploration causes morbidity. METHODS: From June 1994 to June 1996, 110 of 370 patients (30%) with HCC were considered candidates for possible hepatic resection. Preoperative liver function was assessed using Child-Pugh grading and indocyanine green retention test. The extent of disease was evaluated with radiologic studies, including percutaneous USG, computerized tomography scan, and hepatic angiogram. Nineteen patients were excluded from the study because of previous upper abdominal surgery (n = 12), ruptured tumors (n = 4), refusal by patients (n = 2), and instrument failure (n = 1). Laparoscopy and laparoscopic USG was performed on 91 patients immediately before a planned laparotomy aiming at hepatic resection. Laparotomy was aborted when definite evidence of unresectable disease was found on laparoscopic examination. RESULTS: The median time required for laparoscopy and laparoscopic USG was 30 minutes (range, 10 to 120 minutes). Fifteen patients had evidence of unresectable disease on laparoscopic examination. Among the remaining 76 patients who underwent laparotomy, 9 had exploration only and 67 underwent hepatic resection. Thus, exploratory laparotomy was avoided in 63% of patients with unresectable disease. The laparoscopic examination failed to confirm unresectable disease more often when the tumor was >10 cm in diameter. The procedure accurately assessed the adequacy of the liver remnant and the presence of intrahepatic metastases, but it was less sensitive in determining the presence of tumor thrombi in major vascular structures and the extent of invasion of adjacent organs. When unresectable disease was detected without the need for a laparotomy, the postoperative recovery was faster, and the nonoperative treatment for the tumor could be initiated earlier. CONCLUSIONS: Laparoscopy with laparoscopic USG avoids unnecessary laparotomy in patients with HCC and should precede a planned laparotomy aiming at hepatic resection.

Adolescent↗
PubMed2001

Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care?

OBJECTIVE: To evaluate the safety of a policy of selective nonoperative management (SNOM) in patients with abdominal gunshot wounds. SUMMARY BACKGROUND DATA: Selective nonoperative management is practiced extensively in stab wounds and blunt abdominal trauma, but routine laparotomy is still the standard of care in abdominal gunshot wounds. METHODS: The authors reviewed the medical records of 1,856 patients with abdominal gunshot wounds (1,405 anterior, 451 posterior) admitted during an 8-year period in a busy academic level 1 trauma center and managed by SNOM. According to this policy, patients who did not have peritonitis, were hemodynamically stable, and had a reliable clinical examination were observed. RESULTS: Initially, 792 (42%) patients (34% of patients with anterior and 68% with posterior abdominal gunshot wounds) were selected for nonoperative management. During observation 80 (4%) patients developed symptoms and required a delayed laparotomy, which revealed organ injuries requiring repair in 57. Five (0.3%) patients suffered complications potentially related to the delay in laparotomy, which were managed successfully. Seven hundred twelve (38%) patients were successfully managed without an operation. The rate of unnecessary laparotomy was 14% among operated patients (or 9% among all patients). If patients were managed by routine laparotomy, the unnecessary laparotomy rate would have been 47% (39% for anterior and 74% for posterior abdominal gunshot wounds). Compared with patients with unnecessary laparotomy, patients managed without surgery had significantly shorter hospital stays and lower hospital charges. By maintaining a policy of SNOM instead of routine laparotomy, a total of 3,560 hospital days and $9,555,752 in hospital charges were saved over the period of the study. CONCLUSION: Selective nonoperative management is a safe method for managing patients with abdominal gunshot wounds in a level 1 trauma center with an in-house trauma team. It reduces significantly the rate of unnecessary laparotomy and hospital charges.

Abdominal Injuries↗
PubMed2005

Treated ovarian cancer: MR imaging, laparotomy reassessment, and serum CA-125 values compared with clinical outcome at 1 year.

PURPOSE: To compare retrospectively the use of magnetic resonance (MR) imaging, laparotomy reassessment, and serum CA-125 values in predicting the presence of residual tumor in women who have been treated for ovarian cancer. MATERIALS AND METHODS: This study was approved by the institutional review board, and informed consent was waived. The study was compliant with the Health Insurance Portability and Accountability Act. Seventy-six women (mean age, 59 years) with treated ovarian cancer underwent preoperative MR imaging of the abdomen and pelvis with intravenous gadolinium-based and intraluminal barium contrast material. MR findings were compared with surgical and histopathologic findings, serial and static serum CA-125 values, and clinical follow-up results. Tumor absence was proved with normal surgical results and by following up patients for at least 1 year, with no evidence of residual tumor at serial CA-125 analysis or subsequent laparotomy. McNemar test for correlated proportions was used for statistical analysis. RESULTS: Sixty-eight women had residual tumor proved at laparotomy and biopsy or at clinical follow-up. Eight patients had no evidence of residual tumor. Gadolinium-enhanced MR imaging depicted residual tumor in 61 patients (sensitivity, 90%; specificity, 88%; accuracy, 89%) compared with laparotomy, which demonstrated residual tumor in 60 patients (sensitivity, 88%; specificity, 100%; accuracy, 89%) and CA-125 values, which demonstrated residual tumor in 44 patients (sensitivity, 65%; specificity, 88%; accuracy, 67%) (P < .01). The positive predictive values for MR imaging, laparotomy, and serum CA-125 values were 98%, 100%, and 98%, respectively, whereas the corresponding negative predictive values were 50%, 50%, and 23%, respectively. In 14 patients, there was a discrepancy between the results of MR imaging and those of laparotomy. In seven patients, MR imaging depicted residual tumor that was not found at laparotomy but was proved at subsequent biopsy or clinical and imaging follow-up, with an increasing serum CA-125 level. In six patients, MR findings were normal, and subsequent laparotomy revealed small-volume residual tumor. Residual tumor was incorrectly predicted with MR imaging in one patient who had no surgical or clinical evidence of residual tumor for 1 year. CONCLUSION: Gadolinium-enhanced spoiled gradient-echo MR imaging depicts residual tumor in women with treated ovarian cancer, with an accuracy, positive predictive value, and negative predictive value that are comparable to those of laparotomy and superior to those of serum CA-125 values alone.

Adult↗
PubMed1995

Repeat laparotomy for gastrointestinal disorders in cattle: 57 cases (1968-1992).

A study was conducted to investigate indications for, typical findings during, and outcome of repeat laparotomies in 57 cattle with gastrointestinal disorders. Cattle were grouped according to the reason the initial laparotomy had been performed. Group-1 cattle (n = 46) had had left or right displacement of the abomasum (LDA or RDA) or right volvulus of the abomasum. Group-2 cattle (n = 10) had had ruminal, reticular, or abomasal obstruction or perforation. Group-3 cattle (n = 7) had had obstruction, volvulus, distention, or perforation of the small or large intestine. Median interval between laparotomies was 1 month (range, 1 day to 38 months). Intraoperative findings during repeat laparotomy in group-1 cattle included LDA (n = 18), RDA (9), right volvulus of the abdomen (5), pneumoperitoneum (1), diffuse abdominal adhesions (1), cecal adhesions (1), adhesions of the rumen to the body wall (1), abscess in the cranial portion of the abdomen (1), reticular adhesions (1), localized necrosis (1), and idiopathic rumen distention (1). Intraoperative findings during repeat laparotomy in group-2 cattle included abscess in the cranial portion of the abdomen (4), no abnormalities (1), distended rumen (1), ruptured abomasum (1), recurrent abomasal impaction (1), diffuse abdominal adhesions (1), and pyloric fat necrosis (1). Intraoperative findings during repeat laparotomy in group-3 cattle included LDA (3), RDA (1), cecal volvulus (1), anastomotic rupture (1), and impacted colocolostomy (1). Seven cows and 1 calf underwent additional repeat laparotomies. Forty-four (77%) of the 57 cattle were discharged following final laparotomy. Fourteen of the 20 group-1 cattle, 1 of the 6 group-2 cattle, and 2 of the 3 group-3 cattle for which follow-up information was available were productive after repeat laparotomy.

Abomasum↗
PubMed1993

Second-look laparotomy in stage I ovarian cancer following comprehensive surgical staging.

OBJECTIVE: To evaluate the role of second-look laparotomy in patients with comprehensively staged stage I epithelial ovarian cancer. METHODS: We reviewed the medical records and obtained long-term follow-up on 54 stage I patients who had second-look laparotomies following complete surgical staging and chemotherapy. RESULTS: The distribution by stage was as follows: stage IA 18 (33%), stage IB two (4%), and stage IC 34 (63%). Eighteen patients (33%) had endometrioid tumors, 12 (22%) clear cell, 13 (24%) mucinous, eight (15%) serous, and three (6%) undifferentiated. Forty-four patients (82%) had grade 2 or 3 tumors. Thirty-eight (70%) were treated with platinum-based regimens and 16 (30%) received non-platinum regimens. At second-look laparotomy, tumor was identified in three women (5.5%). Stage, cell type, and grade did not predict the second-look laparotomy result, although no patient with a grade 1 tumor had a positive second-look laparotomy. With a mean follow-up of 48 months from second-look laparotomy, 11 women (22%) have had recurrences following negative second looks. Tumor grade was a strong predictor of recurrence following negative second-look laparotomy (P < .0001), with the risk of recurrence being 0% for grades 1 and 2 and 52% for grade 3. Substage, cell type, and chemotherapy type and duration did not predict recurrence. CONCLUSIONS: The likelihood of a positive second-look laparotomy is about 5% in well-staged stage I ovarian cancer. Patients with stage I, grade 3 tumors have a risk of recurrence of approximately 50% following negative second-look laparotomy.

Adult↗
PubMed1996

ACOG Committee opinion. Second-look laparotomy for epithelial ovarian cancer. Number 165, December 1995 (replaces no. 100, November 1991). Committee on Gynecologic Practice. American College of Obstetricians and Gynecologists.

The Committee on Gynecologic Practice makes the following recommendations: Second-look laparotomy is the most accurate method of assessing disease status in a patient who has completed initial therapy for ovarian cancer and who is clinically free of disease. It serves as a useful early endpoint in assessing the effectiveness of treatments in prospective randomized clinical trials. There are, however, no prospective clinical trials that demonstrate an advantage in survival for patients who have undergone second-look laparotomy. A negative second-look laparotomy is associated with improved survival rates and may be used to justify either discontinuing therapy altogether or using an investigational consolidation therapy. In patients with stage I or II ovarian cancer who have had complete surgical staging and appropriate adjuvant therapy and who are asymptomatic, a second-look laparotomy is rarely positive (5%) and is not thought to be of value. Retrospective studies suggest that maximal cytoreduction (to nodules < 5 mm) of tumors in patients with stage III or IV ovarian cancer who are clinically free of disease prior to secondlook laparotomy is associated with improved median survival rates despite the lack of evidence that current second-line therapies are effective. Second-look laparotomy usually should be performed by a gynecologic oncologist who has a complete understanding of ovarian cancer and has defined the goals of second-look laparotomy for an individual patient. The surgeon must have the surgical skills to perform a complete operation as described in the "Assessment" section. Second-look laparotomy is not considered a "standard" or "mandatory" operation for all women with ovarian cancer. The additional morbidity and cost of the procedure must be weighed against the expected benefit for the individual patient. A second-look laparotomy may be appropriate based on the goals of treatment for an individual patient or as part of a clinical protocol.

Carcinoma↗
PubMed2002

Is delayed laparotomy for blunt abdominal trauma a valid quality improvement measure in the era of nonoperative management of abdominal injuries?

BACKGROUND: Review of hemodynamically stable patients who undergo laparotomy for trauma greater than 4 hours after admission is an American College of Surgeons quality improvement filter. We reviewed our recent experience with patients who underwent laparotomy for trauma greater than 4 hours after admission to evaluate the reasons for delay, and to determine whether they were because of failure of nonoperative management or other causes. METHODS: The registry at our Level I trauma center was searched from January 1998 through December 2000 for patients who required a laparotomy for trauma greater than 4 hours after admission. Of 3,369 admitted blunt trauma patients, 90 (2.7%) underwent laparotomy for trauma, of which 26 (29%) were identified as delayed laparotomies greater than 4 hours after admission. RESULTS: The most common mechanism of injury was motor vehicle crash, the mean Injury Severity Score was 18, and 65% of the patients had significant distracting injuries. Five patients had laparotomy greater than 24 hours after admission. The average time to the operating room in the remaining patients was 8.6 hours. Clinical examination (61%) findings were the most common indication for operation. Gastrointestinal (GI) tract injury was the most common injury associated with delay in laparotomy (58%). CONCLUSION: GI tract injuries are the predominant injury leading to delayed laparotomy for blunt trauma (58%). Failed nonoperative management of solid organ injuries occurred less frequently (15%). Future efforts should concentrate on earlier identification of GI tract injury. Delayed laparotomy for blunt abdominal trauma is a valid quality improvement measure.

Abdominal Injuries↗
PubMed1994

Endoscopic versus laparotomy management of endometriomas.

OBJECTIVE: To compare the surgical management and follow-up of patients with endometriomas managed by endoscopic surgery versus laparotomy using a retrospective case control format. DESIGN: Endoscopic oophorocystectomies were performed on 36 patients. Chart review of laparotomy oophorocystectomies from 21 patients was conducted. Six-week and 12-month follow-up for evaluation of symptoms, evidence of recurrence, and fertility was available on all subjects. RESULTS: In the endoscopy group, 39 patients had screening laparoscopy for possible endoscopic surgery. Three of this group required laparotomy and 36 patients underwent endoscopic surgery. Chart review identified 21 patients who had undergone primary laparotomy for endometriomas. Patient groups were matched for age, severity of disease, presence of other infertility factors, and absence of perioperative medical suppression. Outcome parameters for each group were: operating time--endoscopy 2.8 hours (+/- 1.2), laparotomy 3.1 hours (+/- 1.8); estimated blood loss--endoscopy 40 cc (+/- 45); laparotomy, 240 cc (+/- 107); recovery time--endoscopy, 6.2 days (+/- 2.5), laparotomy 30 days (+/- 6.8); endometrioma recurrence rate--endoscopy 11.1%, laparotomy 19%; and pregnancy rate--endoscopy 42.8%, laparotomy 46.6%. CONCLUSION: A high percentage of patients with endometriomas associated with advanced endometriosis can be managed effectively by endoscopic surgery.

Adult↗