Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “LAPAROTOMY”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 19 recordsLinked to original sources
PubMed1999

Laparotomy versus no laparotomy in the management of early-stage, favorable-prognosis Hodgkin's disease: a decision analysis.

PURPOSE: To perform a decision analysis that compared the life expectancy and quality-adjusted life expectancy of early-stage, favorable-prognosis Hodgkin's disease (HD) managed with and without staging laparotomy, incorporating data on treatment outcomes of HD in the modern era. METHODS: We constructed a decision-analytic model to compare laparotomy versus no laparotomy staging for a hypothetical cohort of 25-year-old patients with clinical stages I and II, favorable-prognosis HD. Markov models were used to simulate the lifetime clinical course of patients, whose prognosis depended on the true pathologic stage and initial treatment. The baseline probability estimates used in the model were derived from results of published studies. Quality-of-life adjustments for procedures and treatments, as well as the various long-term health states, were incorporated. RESULTS: The life expectancy was 36.67 years for the laparotomy strategy and 35.92 years for no laparotomy, yielding a net expected benefit of 0.75 years for laparotomy staging. The corresponding quality-adjusted life expectancies for the two strategies were 35.97 and 35.38 quality-adjusted life years (QALYs), respectively, resulting in a net expected benefit of laparotomy staging of 0.59 QALYs. Sensitivity analysis showed that the decision of laparotomy versus no laparotomy was most heavily influenced by the quality-of-life weight assigned to the postlaparotomy state. CONCLUSION: Our model predicted that on average, for a 25-year-old patient, proceeding with staging laparotomy resulted in a gain in life expectancy of 9 months, or 7 quality-adjusted months. These results suggest that a role remains for surgical staging in the management of early-stage HD.

Adult↗
PubMed1982

Collaborative clinical trial for stage I and II Hodgkin's disease: significance of mediastinal and nonmediastinal disease in laparotomy- and non-laparotomy-staged patients.

In this study, 460 eligible patients with stage I and II Hodgkin's disease were randomized to treatment with involved field (IF) and extended field (EF) radiotherapy. Lymphangiogram was a requisite of the study. One hundred and seventy-seven patients were staged by laparotomy. The value of EF radiotherapy in improving survival over a 10-year followup was studied. This effect was considered separately for patents staged by laparotomy, for patients staged by lymphangiogram alone, and for patients with and without initial mediastinal involvement. A substantial benefit was seen for the subgroup staged by lymphangiogram alone and without mediastinal disease, with 10-year survival rates of 80% for EF and 56% for IF. For all other groups staged by laparotomy or having mediastinal presentations 10-year survival rates were essentially the same, differing by less than ten percentage points for IF and EF regimens. The advantage of EF treatment in lymphangiogram-staged nonmediastinal disease was realized only when the extended fields included the abdominal para-aortic area.

Hodgkin Disease↗
PubMed2001

Impact of second look laparotomy and secondary cytoreductive surgery at second-look laparotomy in ovarian cancer patients.

OBJECTIVE: Currently, no prospective study supports or refutes the value of secondary cytoreductive surgery in patients with ovarian cancer. We therefore reviewed the surgical data of patients who underwent second-look laparotomy (SLL) with or without secondary cytoreductive surgery at our department. METHODS: Analysis is based on the data of 179 patients who had FIGO stage II (suboptimally staged), stage III or IV ovarian cancer, who received a platinum-based first-line chemotherapy, who were clinically considered to be tumor-free or had at least a clinically partial response to first-line chemotherapy, and who underwent SLL. In patients with macroscopic tumor the diagnostic SLL was followed by a secondary cytoreductive surgery in order to remove as much tumor as possible. Patients with a positive SLL were given second-line chemotherapy. Survival from SLL until death was considered the primary statistical endpoint. RESULTS: In 78 out of 179 (43.5%) a negative SLL could be confirmed pathologically. Patients with negative findings, with microscopic, and macroscopic disease at SLL had a median survival of 66.6, 57.2, and 19.0 months, respectively (p=0.0001). In patients who underwent a secondary cytoreductive operation and in whom residual tumor was none, less than 2 cm, or more than 2 cm, the median survival was 22.9, 17.8, and 15.5 months, respectively (p=0.325). CONCLUSIONS: The presence of macroscopic tumor at SLL is an adverse prognostic factor whereas the role of secondary cytoreductive surgery at SLL appears to be limited in the routine management of ovarian cancer patients.

Adult↗
PubMed1998

Laparoscopy versus laparotomy: an evaluation of adhesion formation after pelvic and paraaortic lymphadenectomy in a porcine model.

OBJECTIVE: Our purpose was to determine whether there is a difference in adhesion formation after pelvic and paraaortic lymphadenectomy with transperitoneal laparoscopy compared with both extraperitoneal laparotomy and transperitoneal laparotomy in a porcine model. STUDY DESIGN: Ninety female hogs underwent pelvic and paraaortic lymphadenectomy: 40 with transperitoneal laparoscopy, 40 with extraperitoneal laparotomy, and 10 with transperitoneal laparotomy. Three weeks after the initial surgery, a laparotomy was performed to assess adhesion formation. RESULTS: The transperitoneal laparotomy group had significantly higher adhesion formation, with a 100% (10 of 10) adhesion rate. In the transperitoneal laparoscopy group, 12 of 40 hogs (30%) had adhesions develop versus 8 of 38 (21%) in the extraperitoneal laparotomy group (p = not significant). Also no differences were found in the transperitoneal laparoscopy and extraperitoneal laparotomy groups when comparing adhesion thickness or the total surface area of adhesions. More anterior abdominal wall adhesions were noted in the extraperitoneal laparotomy group (5 of 38) than in the transperitoneal laparoscopy group (0 of 40, p = 0.02). CONCLUSIONS: Pelvic and paraaortic lymphadenectomy performed with transperitoneal laparoscopy does not increase adhesion formation when compared with extraperitoneal laparotomy in a porcine model. The transperitoneal laparoscopy (and extraperitoneal laparotomy) approach also induces significantly fewer adhesions than transperitoneal laparotomy.

Animals↗
PubMed2000

Lymphocyte proliferation in mice after a full laparotomy is the same whether performed in a sealed carbon dioxide chamber or in room air.

PURPOSE: Our laboratory has demonstrated that significantly more cell-mediated immunosuppression occurs after full laparotomy than after either anesthesia control or carbon dioxide (CO2) pneumoperitoneum. We further demonstrated that the postoperative immunosuppression is related to the length of the incision. Other investigators believe that the immunosuppression observed after laparotomy is caused by peritoneal exposure to small amounts of lipopolysaccharide found in circulating air. They believe that the better-preserved immune function associated with laparoscopic surgery results from the avoidance of air contamination of the peritoneal cavity. To investigate this hypothesis, we determined and compared postoperative lymphocyte proliferation rates after (a) laparotomy in room air, (b) laparotomy in a CO2 chamber, (c) CO2 insufflation in a murine model, and (d) anesthesia alone. METHODS: Female C3H/He mice (n = 21) were divided randomly into four groups: (a) anesthesia control, (b) air laparotomy, (c) CO2 laparotomy, and (d) CO2 insufflation. The control mice underwent no procedure. The group 2 animals underwent a full midline incision (xiphoid to pubis) and exposure to room air for 20 min and then were clipped closed. The group 3 mice underwent a full midline incision in a sealed CO2 chamber for 20 min, and the group 4 mice insufflation with CO2 gas at 4 to 6 mm Hg for 20 min. Splenocytes were harvested from all the animals on day 2 after the interventions. Lymphocyte proliferation then was assessed using the nonradioactive colorimetric MTS/PMS system 72 h after concanavalin-A stimulation. RESULTS: There was no significant difference in lymphocyte proliferation between the air and CO2 laparotomy groups. Lymphocyte proliferation in the anesthesia control and CO2 insufflation groups was significantly higher than in both the air laparotomy (p<0.05) and CO2 laparotomy (p<0.05) groups (p values by Tukey-Kramer test). There was no significant difference between the anesthesia control and CO2 pneumoperitoneum groups. CONCLUSIONS: Our results suggest that full laparotomy performed in a sealed CO2 chamber compared to room air laparotomy resulted in similar suppression of lymphocyte proliferation. Furthermore, no significant suppression of lymphocyte proliferation was observed in the CO2 pneumoperitoneum group. These results, with regard to lymphocyte proliferation rates, refute the hypothesis that postoperative immunosuppression is related to air exposure and support the alternative hypothesis that immunosuppression is related to incision length.

Air↗
PubMed1998

Influence of delayed staging laparotomy after laparoscopic removal of ovarian masses later found malignant.

OBJECTIVE: To determine whether delayed laparotomy after attempted laparoscopic excision of an ovarian mass later found to be malignant has an impact on the stage of disease. METHODS: A questionnaire regarding laparoscopic management of ovarian masses later found to be malignant was mailed to all gynecologic departments in Austria. Of the 70 cases reported, laparotomy was performed after laparoscopy in 48 cases. In 24 of these cases, laparotomy was performed within 17 days of laparoscopy, whereas 24 cases involved a delay of more than 17 days. Twenty-two patients in whom laparotomy was performed immediately after laparoscopy were used as controls. RESULTS: In patients with borderline tumors who underwent laparotomy more than 17 days after laparoscopy, the odds ratio (OR) for International Federation of Gynecology and Obstetrics (FIGO) stage IIB-IV disease was 5.3 (95% confidence interval [CI] 0.40, infinity), compared with patients undergoing immediate laparotomy (multivariate analysis). Patients with invasive ovarian cancer who underwent laparotomy more than 17 days after laparoscopy had an OR of 9.2 (CI 0.92, 481) for stage IIB-IV disease compared with patients undergoing immediate laparotomy (multivariate analysis). In patients with borderline tumors, multivariate analysis showed that the timing of laparotomy is an independent prognostic factor for the stage of disease. In invasive ovarian cancer, none of the factors evaluated by multivariate analysis was found to be an independent prognostic factor for the distribution of disease stage. A delay between laparoscopy and laparotomy may affect adversely the distribution of disease stage. CONCLUSION: The timing of subsequent laparotomy was found to be a factor predictive of the distribution of disease stage.

Adolescent↗
PubMed1986

Diagnostic laparotomy for abdominal trauma. A university hospital experience.

Following the experience of World War II, exploratory laparotomy in all patients with penetrating abdominal trauma was deemed mandatory until 1960 when Shaftan reported his experience with selective laparotomy. In 1973, Nance et al. reported on selective observation of abdominal stab wounds. There seems to be little controversy over mandatory laparotomy for abdominal gunshot wounds. Blunt trauma is generally managed expectantly with the adjunctive use of peritoneal lavage, CT scanning, and serial examinations of the abdomen. Despite the selective approach and the use of adjunctive diagnostic methods, exploratory laparotomy continues to be the most accurate method used to diagnose the presence of intra-abdominal injury. In order to examine our experience with diagnostic laparotomy for trauma, both blunt and penetrating, a retrospective study of 494 consecutive patients undergoing exploratory laparotomy over the past 4 years was undertaken. Abdominal stab wounds were explored under local anesthesia, and, if found to penetrate the posterior fascia, laparotomy was accomplished. All patients with abdominal gunshot wounds underwent exploration. Exploratory laparotomy in patients with blunt abdominal trauma was mandated by clinical signs, positive peritoneal lavage, or positive CT scan. All patients with unexplained shock and/or signs of peritoneal irritation underwent urgent laparotomy. In this series of 494 patients, 99 or 20 per cent of the entire group had a negative exploration (30% for stab wounds, 16% for gunshot wounds, and 19% for blunt abdominal trauma). The morbidity for the negative laparotomy group was limited to five patients with postoperative atelectasis. There were no anesthesia complications, iatrogenic intraoperative injuries, or wound infections. There were five deaths but none were laparotomy-related.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Injuries↗
PubMed1996

Second-look operation for epithelial ovarian cancer: laparoscopy or laparotomy?

OBJECTIVES: To compare the results, complications, and hospital charges associated with laparoscopy versus laparotomy in second-look operations for epithelial ovarian cancer. METHODS: We conducted a retrospective chart review of 109 patients with invasive epithelial ovarian cancer who underwent a second-look operation between July 1, 1992, and June 30, 1995. RESULTS: Thirty-one patients (28.4%) underwent laparoscopy, 70 patients (64.2%) underwent laparotomy, and eight patients (7.3%) underwent both procedures at the same operation. The majority of patients (60.6%) presented with stage IIIC disease. Persistent ovarian cancer was found in 65 of 109 (59.6%) patients, including 17 of 31 (54.8%) evaluated by laparoscopy, 43 of 70 (61.4%) by laparotomy, and five of eight (62.5%) by both procedures. Significantly lower mean blood loss was noted in patients undergoing laparoscopy (27 mL) compared with laparotomy (208 mL) (P < .01). In addition, the mean operating time for laparoscopy (129 minutes) was significantly shorter than that for laparotomy (153 minutes) (P < .01), and mean hospital stay was shorter for patients undergoing laparoscopy (1.6 days) compared with laparotomy (6.8 days) (P < .01). All intraoperative and immediate postoperative complications were noted in patients who underwent laparotomy. There was no difference in day of surgery charges between the two procedures; however, total hospital charges were significantly lower for patients undergoing laparoscopy ($ 9448) compared with laparotomy ($ 17,969) (P < .01). With a median follow-up of 22.0 months, recurrence after negative second-look surgery was noted in four of 27 (14.8%) patients evaluated by laparotomy and two of 14 (14.3%) patients evaluated by laparoscopy. CONCLUSION: Laparoscopy may be an acceptable alternative to second-look laparotomy for interval evaluation of epithelial ovarian cancer. Second-look laparoscopy probably results in less morbidity, shorter operating time, shorter hospital stay, and lower total hospital charges. These results require confirmation in a randomized clinical trial.

Adult↗
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↗
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↗
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↗