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PubMed1993

Video-assisted thoracoscopic stapled wedge excision for indeterminate pulmonary nodules.

Between June 1991 and July 1992, 118 patients (57 men and 61 women) underwent video-assisted thoracoscopy for indeterminate pulmonary nodules. Median age was 64 years (range 30 to 85 years). Thoracotomy was performed in 33 patients (28.0%) after thoracoscopy only because the nodule could not be located in 17 patients, was too large to safely resect in 5, appeared malignant in 4, and for technical reasons in 7. Eighty-five patients underwent thoracoscopic wedge excision. Twenty-one (24.7%) of these 85 patients also had thoracotomy--15 to perform formal lung resection for bronchogenic carcinoma, 3 for nondiagnostic abnormalities, 2 to locate a second nodule, and 1 for stapler malfunction. The remaining 64 patients (54.2%) had only video-assisted thoracoscopic wedge excision. A single wedge excision was performed in 56 patients, two in 6, and three in 2. Pathologic examination of these 74 nodules revealed a granuloma in 30, metastatic cancer in 25, hamartoma in 7, lymphoma in 1, and other benign lesions in 11. There were no deaths and only 4 (6.3%) complications in these 64 patients. The 64 patients treated by thoracoscopy only were compared with a similar group of 64 patients who had wedge excision via thoracotomy without prior thoracoscopy. Postoperative analgesic requirements were less in the patients treated by thoracoscopy. Median hospitalization in the thoracoscopy group was 3 days compared with 6 days in the thoracotomy group (p < 0.05). Median total charge for the thoracoscopy-only group was $12,898 as compared with $12,502 for patients undergoing wedge excision via thoracotomy. We conclude that thoracoscopic wedge excision is a safe and effective procedure in selected patients with an indeterminate pulmonary nodule. A significant number of patients (45.8%), however, required a thoracotomy to accomplish a safe operation or to ensure adequate staging and resection for malignancy. Although thoracoscopy reduces postoperative analgesia requirements and shortens hospital stay, total hospital charges were similar to charges for a wedge excision via thoracotomy.

Adult↗
PubMed1999

Comparison of arcuate-legged clipped versus sutured hepatic artery, portal vein, and bile duct anastomoses.

Attempts at improving anastomoses have included the development of stapling techniques. Our purpose was to evaluate arcuate-legged clipped versus standard sutured anastomoses of the hepatic artery (HA), portal vein (PV), and bile duct in a porcine liver transplantation model. Two groups of pigs were studied intraoperatively and 1 day after liver transplantation. A control group underwent sutured anastomosis of PV and HA with polypropylene and of bile duct with polydioxanone (n = 8). An experimental group underwent anastomoses with arcuate-legged clips (n = 8). We analyzed the time to perform anastomosis and flows before and at various time points after anastomosis. In addition, patency and histology of the anastomoses were evaluated 1 day after operation, including a fibrin-thrombosis score, medial injury, and inflammation score. Times to complete HA and PV anastomoses were not different between clipped and sutured groups. However, the time was shorter to complete bile duct anastomosis with clips than with sutures (6.3 +/- 1.1 minutes and 13.3 +/- 2.0 minutes, respectively). Flows through HA anastomoses were not different between groups, but flow through the PV was higher in clipped compared with sutured anastomosis (P = 0.06). Patency was 100 per cent with no leaks for all three anastomoses in both groups. Histologic data were similar between vascular anastomotic groups. Sutured bile duct anastomoses revealed mild smooth muscle injury in 75 per cent whereas clipped bile duct anastomoses displayed no smooth muscle injury. We conclude that arcuate-legged clipped anastomosis represents a viable option to sutured anastomoses of the PV, HA, and bile duct anastomoses. Bile duct anastomoses were completed in less than half the time and with less tissue damage documented histologically.

Anastomosis, Surgical↗
PubMed2003

Endoscopic staple diverticulostomy for recurrent Zenker's diverticulum.

OBJECTIVES: The purpose of this study was to evaluate the technical feasibility, effectiveness, and morbidity of using endoscopic staple diverticulostomy (ESD) as treatment for Zenker's diverticulum (ZD) recurring after either prior endoscopic treatment or external diverticulectomy or diverticulopexy. STUDY DESIGN: A retrospective review of a case series of 18 patients with recurrent ZD. METHODS: All patients cared for with ZD were evaluated to identify those patients with recurrent ZD. The clinical records of patients with recurrent ZD were reviewed for: demographics, prior treatment, time to recurrence, factors associated with recurrence, technical feasibility of treatment, complications, effectiveness and duration of symptom relief. RESULTS: Between March 1995 and July 2001, a total of 127 consecutive patients with ZD received care. Eighteen of these patients were treated for recurrent ZD: nine treated originally by ESD, and nine by external approach (seven by diverticulectomy and two by diverticulopexy), with three of these patients treated twice. Seventeen patients had partial or complete relief of symptoms after their initial treatment, with recurrence of symptoms noted 0 to 60 months later. Specific factors associated with recurrence of symptoms were identified in only one patient. Treatment of recurrent ZD by ESD was technically feasible in 16 of the patients. Complete or improved symptom relief has been reported by 16 of the patients after revision ESD, with follow-up from 9 to 69 months. No significant treatment complications occurred. Fifteen patients resumed clear liquid diet on the day of surgery, and one on the day after surgery. All patients were discharged from the hospital by the second postoperative day (mean = 0.6 d). CONCLUSIONS: ESD is an effective, technically feasible, and safe treatment for patients with ZD recurring after prior endoscopic or external treatment, and it should be the initial treatment of choice for these patients.

Adult↗
PubMed2006

A retrospective review of bone tunnel enlargement after anterior cruciate ligament reconstruction with hamstring tendons fixed with a metal round cannulated interference screw in the femur.

PURPOSE: To assess bone tunnel enlargement after anterior cruciate ligament (ACL) reconstruction with the use of hamstring tendons fixed with a round cannulated interference (RCI) screw in the femur. METHODS: A consecutive series of 30 ACL reconstructions performed with hamstring tendons fixed with an RCI screw in the femur and with staples via Leeds-Keio ligament in the tibia was retrospectively reviewed. The clinical outcome was evaluated through the Lysholm score. Anterior instability was tested by Telos-SE (Telos Japan, Tokyo, Japan) measurement. The location and angle of each femoral and tibial tunnel were measured with the use of plain radiographs, and bone tunnel enlargement greater than 2 mm detected any time 3, 6, 12, and 24 months postoperatively was defined as positive. Each factor (location and angle of the tunnels, sex, affected side, age, Lysholm score, and Telos-SE measurement) was compared between enlarged and nonenlarged groups. RESULTS: Positive enlargement of the bone tunnel (>2.0 mm) was observed in 36.7% (11 of 30) on the femoral side and 33.3% (10 of 30) on the tibial side, and in 6 knees of both sides. Half of patients (15 of 30) had an enlarged tunnel on the femoral or the tibial side until 1 year postoperatively. In most cases, enlargement reached maximum at 6 months postoperatively. Female patients tended to have an enlarged tunnel, especially on the femoral side (P < .05). Tunnel enlargement was not correlated with location and angle of the tunnels. Moreover, no difference was found in Lysholm score and Telos-SE measurement between enlarged and nonenlarged groups, although the nonenlarged group tended to exhibit higher Lysholm score and lesser instability. CONCLUSIONS: Bone tunnel enlargement of the femoral or tibial side was observed in half of patients (6 in both sides, 5 only in the femur, and 4 only in the tibia) after ACL reconstruction was performed with a hamstring tendon fixed with an RCI screw. Female patients had a greater chance for enlargement of the femoral tunnel than did males. This enlargement had no significant impact on patient activity and on anterior instability of the knee 1 year after surgery. LEVEL OF EVIDENCE: Level IV, Therapeutic case series.

Adolescent↗
PubMed2003

Double stapled ileal pouch anal anastomosis (DS-IPAA) for mucosal ulcerative colitis (MUC): is there a correlation between the tissue type in the circular stapler donuts and in follow-up biopsy?

PURPOSE: This study aims to assess the correlation between the tissue types found in the circular stapler donut at the time of initial double-stapled ileal pouch-anal anastomosis (DS-IPAA) and during subsequent periodic routine random biopsy. Secondarily, we sought to assess the risk of dysplasia, carcinoma or mucosal ulcerative colitis (MUC) recurrence in the retained mucosa. METHODS: The pathology reports of 91 patients (48 males, 43 females) who were operated upon for MUC from September 1988 to June 1997 and were reviewed and had two follow up visits for biopsy. The histological features of the distal donuts and biopsies of retained mucosa obtained at yearly interval follow-up were assessed in order to determine the epithelial tissue type (columnar, transitional and squamous), inflammation, recurrence of MUC and presence of dysplasia or malignancy. RESULTS: Median age at surgery was 43 (range 15-71) years and duration of MUC was 9.6 (range 0.3-42) years prior to surgery. The anastomosis was performed at a median height of 1.0 (range 0-2.5) cm cephalad to the dentate line and biopsy follow-up was undertaken at median 34 (range 2-110) months after DS-IPAA. The distal donuts were analysed in all cases, as were 305 follow-up biopsies (median 3.4; range 1-7 per patient). Although columnar epithelium (CE) was found in 62 (68%) donuts, it was absent on follow-up biopsy in 16 (26%) of these patients. Conversely, although no CE was identified in 29 (32%) donuts, it was identified in 11 (38%) of these patients during follow-up biopsy. CE in the donut was a significant predictor of CE in subsequent biopsies (P = 0.0012). The histological features consistent with MUC were seen in the biopsies from the retained mucosa in 15 (16%) patients from 0.3 to 7.6 years after DS-IPAA. While eight (9%) patients exhibited dysplasia or adenocarcinoma in the excised colon or rectum, none of the patients had either dysplastic changes or carcinoma within the retained mucosal biopsies. CONCLUSION: The correlation between CE in the circular stapler donut and at follow-up biopsy was high. However since CE developed in some patients in whom no CE was present in the distal donuts, regardless of the epithelial tissue type finding at the time of DS-IPAA, periodic follow-up biopsy should be obtained.

Adolescent↗
PubMed2003

Roux-en-Y gastric bypass leak complications.

HYPOTHESIS: Enteric leakage is a significant complication of the Roux-en-Y gastric bypass (RYGB) procedure that can be treated successfully. DESIGN: Retrospective study of 400 consecutive RYGB patients from 1999-2002. SETTING: Community hospital with a university surgical residency. PATIENTS: Hospital records of 400 morbidly obese patients who underwent gastric bypass surgery were reviewed. MAIN OUTCOME MEASURES: Time of discovery of leak, location of leak, treatment, hospital stay, and mortality. RESULTS: Twenty-one patients (5.25%) developed leaks. The mean body mass index (calculated as weight in kilograms divided by the square of height in meters) was 54.2. Thirteen patients were noted to develop a leak at the gastrojejunal anastomosis, with an average time to diagnosis of 7.0 days. Five of these patients underwent reexploration, and 8 were successfully treated with percutaneous drainage alone. Four patients developed leaks at the jejunojejunal anastomosis (mean time to diagnosis, 2.0 days). All of these patients required exploration, and 2 patients died. Four patients were noted to have leaks in other areas (average time to diagnosis, 3.5 days). Two patients were treated with drainage, and 2 underwent exploration. The average hospital stay of all patients was 33 days. CONCLUSIONS: Enteric leakage is a significant complication of the RYGB. Patients who are suspected of having an enteric leak because of signs of sepsis or hemodynamic instability require emergent exploration. Leaks that are more insidious may be treated successfully with percutaneous drainage. Aggressive exploration of patients who appear to be septic, and percutaneous drainage of insidiously developing leaks may decrease patients' morbidity and mortality.

Adult↗
PubMed2007

Laparoscopic appendectomy in children: use of the endoloop vs the endostapler.

HYPOTHESIS: Two techniques are used for laparoscopic appendectomy (LA): division of the mesoappendix with the harmonic scalpel and ligation of the appendix with an endoloop (EL), or division of the mesoappendix and appendix with an endostapler (ES). Using an ES is a cost-effective technique that provides an outcome benefit in children who require appendectomy. DESIGN: Case series. SETTING: Academic, tertiary care children's hospital. PATIENTS: Seventy-five children who underwent LA from January 1, 2002, to March 31, 2004. INTERVENTION: Laparoscopic appendectomy. MAIN OUTCOME MEASURES: Age, diagnosis, length of stay, surgical time, total operating room time, complications, and instrumentation costs were compared between the EL and ES groups. RESULTS: There was no significant difference in age, length of stay, perforated, gangrenous, or acute appendicitis diagnoses, or complications between the groups. The surgical time and total operating room time for LA in children in the ES group were significantly shorter than in children in the EL group by 15% and 17%, respectively (P<.05). The disposable equipment costs for LA were $201 per case in the ES group vs $400 per case in the EL group. The mean 14.9-minute increase in total operating room time in children in the EL group resulted in $373 of additional operating room and anesthesia costs. The decreased disposable equipment costs and shorter surgical time of LA in the ES group led to cost savings of $572 per case as compared with children who underwent LA with an EL. CONCLUSIONS: There is no significant difference in outcome between children who undergo LA with an EL or with an ES. However, this study supports the use of the ES for LA as a more cost-effective technique that is associated with reduced surgical time.

Adolescent↗
PubMed1994

A prospective comparison of laparoscopic and tension-free open herniorrhaphy.

OBJECTIVE: To compare results and outcomes following laparoscopic and tension-free open inguinal herniorrhaphy. DESIGN: A prospective, nonrandomized trial of a single surgeon's experience. SETTING: A large university hospital. PATIENTS: The study included 100 patients with 116 hernias. Patients were offered open hernia repair or, if medically suitable for general anesthesia, a laparoscopic hernia repair. Fifty-seven patients underwent open repair and 43 patients underwent laparoscopic repair. INTERVENTION: Laparoscopic repair was performed using a transabdominal preperitoneal mesh technique. Open hernia repair was performed using a mesh-plug technique in which the hernia sac was reduced and held in place by a cone of mesh. The floor was covered with a second piece of mesh that encircled the cord and was sutured at the internal ring; it was held in place under the external oblique without sutures. RESULTS: Patients undergoing open repair were older than those undergoing laparoscopic repair. The distribution of hernia types was similar. The laparoscopic operation took longer than the open operation (mean [+/- SD], 1.9 +/- 0.4 hours vs 1.6 +/- 0.4 hours; P < .05), was more expensive ($4165 +/- $1154 vs $2985 +/- $1682; P < .05), and required more postoperative admissions (28% vs 3.5%). There were three recurrences in the laparoscopic group and none in the open group. Patients undergoing laparoscopic repair consumed the same amount of narcotic analgesics as did the group undergoing open repair and had discomfort for the same amount of time. Patients undergoing laparoscopic repair returned to work sooner than did patients undergoing open repair (5.6 days vs 10.3 days; P < .05). CONCLUSIONS: Laparoscopic hernia repair returns patients to the workplace faster than open hernia repair despite a similar analgesic requirement. The laparoscopic repair costs more and has a higher recurrence rate than open repair. Laparoscopic repair is most suitable for bilateral hernias. Further investigation of this technique is required before its wide-scale application can be recommended.

Adult↗
PubMed1995

The ability of laparoscopic clips to withstand high intraluminal pressure.

OBJECTIVE: To determine if commercially available clips for laparoscopic surgery become displaced with high intraluminal pressures. DESIGN: In vivo model in which the splenic, renal, and mesenteric vessels together with the gallbladder of anesthetized living pigs were individually occluded using titanium and absorbable clips and then subjected to pressures of 300 mm Hg; and in vitro model in which the procedure was repeated on freshly removed human gallbladders with the attached segment of cystic duct. INTERVENTION: The intraluminal pressure of the occluded segment was increased until (1) the clip was released, (2) the vessel burst, or (3) the predetermined pressure (300 mm Hg) was obtained. RESULTS: A total of 90 clips were examined. No clip could be displaced from any porcine vessel at intraluminal pressures of up to 300 mm Hg. One vessel burst before the predetermined pressure was obtained, the clips remaining intact. Clips placed on the porcine and human models also could not be displaced by a pressure of 300 mg Hg. CONCLUSION: Commercially available titanium and absorbable clips do not disrupt when subjected to high intraluminal pressures. Postoperative bile leaks are more likely to result from necrosis of the cystic duct than displacement of the clip by the pressure within the biliary system.

Animals↗
PubMed1994

Intestinal anastomosis with a skin stapler: a safe and efficient method in humans.

A method of intestinal anastomosis with a skin stapler has been used successfully in 39 patients to form 40 anastomoses. The method has been employed in elective and emergency surgery, in small and large intestine, for a variety of pathological conditions and in the presence of obstruction, sepsis and soiling. Bowel anastomosis with a skin stapler is safe, simple and efficient in time and materials.

Adult↗