Medical Library

[Analgesic intolerance (AI). Key position of ENT physicians for early detection of this condition]

The clinical manifestation of analgesic intolerance (AI) is frequently associated with symptoms examined by ear-nose-throat (ENT) specialists. The prevalence of AI is reported in the literature to be 0.6-2.5%. Even though there are no concluding results concerning its pathogenesis, an altered arachidonic acid metabolism is most likely the underlying pathomechanism. The symptoms include chronic rhinosinusitis with nasal polyps, asthma, gastrointestinal ulcers, angioedema, and urticaria. Clinical reactions after ingestion of nonsteroidal anti-inflammatory-drugs (NSAIDs) are often obvious in the progress of disease. In order to initiate early therapy and therefore prevent the progress of disease, the diagnosis of AI should occur before the complete picture of AI is obvious. Adaptive desensitization is currently the single causal therapy. Frequency of endonasal revision surgery is reduced after desensitization; severe asthma and reactions after ingestion of NSAIDs are avoided. ENT specialists are particularly in a key position for early detection of AI.

Förster U, Olze H.

Klinik für Hals-Nasen-Ohren-Heilkunde, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353 Berlin. ul.foerster@web.de

Diagnostic laparoscopy guidelines : This guideline was prepared by the SAGES Guidelines Committee and reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), November 2007.

Hori Y.

Society of American Gastrointestinal and Endoscopic Surgeons, 11300 West Olympic Blvd, Suite 600, Los Angeles, CA, 90064, USA, sagesweb@sages.org.

Incorporation of proficiency criteria for basic laparoscopic skills training: how does it work?

BACKGROUND: It is desirable that surgical trainees are proficient in basic laparoscopic motor skills (eye-hand coordination). The present study evaluated the use of predefined proficiency criteria on a basic virtual reality (VR) simulator in preparation for a laparoscopic course on animal models. METHODS: Twenty-eight surgical trainees who enrolled for a basic laparoscopic course were trained on a basic (VR) simulator until their performance met predefined criteria. Two different criteria were defined, based on the performance of experienced laparoscopic surgeons on the simulator. In the first group (n = 10), the criteria were set at the 75th percentile of the laparoscopic surgeons\’ performance on the simulator and in the second group, at the 50th percentile (n = 18). Training time and number of attempts needed until the performance criteria were met were measured. RESULTS: In the first group, training time needed to pass the test ranged from 29 to 77 min (median: 63 min) with a range of 43-90 attempts (median 61 attempts). In the second group, training time ranged from 38 to 180 min (median 80 min) with a range of 55-233 attempts (median 95 attempts). Experience with assisting or performing laparoscopic procedures varied widely and was not correlated with the training time and number of attempts needed to pass the criteria. CONCLUSIONS: The performance criteria for training laparoscopic motor skills on a (VR) simulator resulted in wide variation between surgical trainees in time and number of attempts needed to pass the criteria. This demands training courses with a flexible time span tailored to the individual level of the trainee.

Verdaasdonk EG, Dankelman J, Lange JF, Stassen LP.

Faculty of Mechanical, Marine and Materials Engineering, Department of BioMechanical Engineering, Delft University of Technology, Mekelweg 2, Delft, 2628 CD, The Netherlands, e.g.g.verdaasdonk@tudelft.nl.

Cytokine responses following laparoscopic or open pyeloplasty in children.

BACKGROUND: The present study evaluated the cytokine response in children following laparoscopic pyeloplasty (LP) or open pyeloplasty (OP). A series of cytokines were measured postoperatively, including interkin1-beta (IL-1beta), interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-10 (IL-10), tumor necrosis factor-alpha (TNF-alpha), and C-reactive protein (CRP). METHODS: A total of 31 patients, with an average age of 9.1 +/- 3.0 years (range 2.5-14 years) were studied. Fourteen patients underwent LP and 17 underwent OP. Blood serum concentrations of IL-1beta, IL-6, IL-8, IL-10, TNF-alpha, and CRP were measured via enzyme-linked immunosorbent assay (ELISA) before surgery as well as 4, 24, and 48 h following the operation. In addition, the procedure duration, hospital stay, incidence of wound infection, and the recurrence rate of stenosis in both groups were compared. RESULTS: Serum IL-6 and CRP concentrations were significantly elevated in both groups at 4, 24, and 48 h relative to preoperative levels. However, the rise in IL-6 and CRP in OP group was significantly more robust than in LP group. No significant changes were observed in serum levels of IL-1beta, IL-8, IL-10, or TNF-alpha in either group. The procedure duration was significantly longer for LP (193.6 +/- 74.7 min, range 120-360 min) versus OP (120.1 +/- 27.5 min, range 90-165 min, p < 0.05), but the hospital stay following LP was shorter (LP group: 5.3 +/- 1.1 days versus OP group: 9.3 +/- 2.1 days, p < 0.05). No severe complications were noted in either group, however, one child experienced wound infection following OP procedure. An incident of recurrent stenosis following the operation occurred in both groups. There was no postoperative morbidity or severe implications at 12 month follow-up in either group. CONCLUSIONS: Both OP and LP are safe and effective procedures for the treatment of ureteropelvic junction obstruction in the pediatric population. However, the shorter hospital stay and decreased cytokine response following LP indicates potential benefits over traditional invasive procedures.

Wang L, Qin W, Tian F, Zhang G, Yuan J, Wang H.

Department of Urology, Xijing Hospital, Fourth Military Medical University, Chang Le West Road 15, Xi’an, 710032, China.

Correlation of CO(2) pneumoperitoneal pressures between rodents and humans.

INTRODUCTION: Many studies have reported on the effects of pneumoperitoneum in a rat model, using a wide range of intra-abdominal pressures. The correlation between pneumoperitoneal pressures in rodents to pressures in humans has not been established. This study evaluates changes in various physiological parameters in different pneumoperitoneum pressures in the rat model with a comparison to known data in humans. MATERIALS AND METHODS: Three groups of eight Wistar rats each were anesthetized, tracheostomized, and mechanically ventilated with fixed tidal volume and respiratory rate. After a stabilization phase, CO(2) pneumoperitoneum was established to 12, 8, and 5 mmHg in the different groups. Changes in blood pressure, heart rate, peak ventilatory pressure, and end-tidal CO(2) (ETCO(2)) were recorded throughout the experiment. RESULTS: There were no significant changes in blood pressure and heart rate in all groups. No increase in ETCO(2) was demonstrated following induction of pneumoperitoneum in the 12 and 8 mmHg groups. A statistical significant increase in ETCO(2) occurred only in the 5 mmHg group (39.4 to 41.3 mmHg, p = 0.023). Ventilatory pressures increased after induction of pneumoperitoneum in all groups. The increase reached a maximal level in the 8 and 12 mmHg groups (from 3 to 12 mmHg) and was lower in the 5 mmHg group (from 3 to 7 mmHg) CONCLUSIONS: The neglected increase in ETCO(2) in pressures >/=8 mmHg, in the rat correlates to high pressures in humans (above 14-20 mmHg) when CO(2) diffusion through the peritoneum declines due to pressure occlusion of peritoneal capillaries. The maximal ventilatory pressures generated in the rat in intra-abdominal pressures >/=8 mmHg correlate to pressures, which are higher than the standard working pressures in humans. Thus, pneumoperitoneal pressures >8 mmHg in the rat do not simulate routine working pressures employed in humans. A pressure of 5 mmHg is optimal in a rat model to simulate laparoscopy in humans.

Avital S, Itah R, Szomstein S, Rosenthal R, Inbar R, Sckornik Y, Weinbroum A.

Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, shmuelavital@hotmail.com.

Clinical models are inaccurate in predicting bile duct stones in situ for patients with gallbladder.

BACKGROUND: The probability that a patient has common bile duct stones (CBDS) is a key factor in determining diagnostic and treatment strategies. This prospective cohort study evaluated the accuracy of clinical models in predicting CBDS for patients who will undergo cholecystectomy for lithiasis. METHODS: From October 2005 until September 2006, 335 consecutive patients with symptoms of gallstone disease underwent cholecystectomy. Statistical analysis was performed on prospective patient data obtained at the time of first presentation to the hospital. Demonstrable CBDS at the time of endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiography (IOC) was considered the gold standard for the presence of CBDS. RESULTS: Common bile duct stones were demonstrated in 53 patients. For 35 patients, ERCP was performed, with successful stone clearance in 24 of 30 patients who had proven CBDS. In 29 patients, IOC showed CBDS, which were managed successfully via laparoscopic common bile duct exploration, with stone extraction at the time of cholecystectomy. Prospective validation of the existing model for CBDS resulted in a predictive accuracy rate of 73%. The new model showed a predictive accuracy rate of 79%. CONCLUSION: Clinical models are inaccurate in predicting CBDS in patients with cholelithiasis. Management strategies should be based on the local availability of therapeutic expertise.

Topal B, Fieuws S, Tomczyk K, Aerts R, Van Steenbergen W, Verslype C, Penninckx F.

Department of Abdominal Surgery, University Hospital Gasthuisberg, Herestraat 49, Leuven, 3000, Belgium, baki.topal@med.kuleuven.be.

Delayed laparoscopic subtotal cholecystectomy in acute cholecystitis with severe fibrotic adhesions.

BACKGROUND: Conversion rate to open surgery is higher for patients with acute cholecystitis than in those without acute cholecystitis. We attempted to develop a laparoscopic subtotal cholecystectomy to decrease this conversion rate. METHODS: From 2000 to 2005, laparoscopic cholecystectomy for acute cholecystitis was performed in 60 patients (22 women, 38 men). Patients were divided into two groups: group A (2000 to 2002, n = 22) and group B (2003 to 2005, n = 38). When significant difficulty was encountered dissecting the gallbladder from its bed, we incised the gallbladder wall leaving the posterior wall and cauterizing the remnant mucosa (subtotal cholecystectomy, SC-1). When dissection of the gall bladder neck and triangle of Calot was difficult, the neck of the gallbladder was sutured despite clipping (SC-2). RESULTS: Mean duration from onset of symptoms to operation was 55.3 +/- 52.0 days. SC-1 was performed in 8 patients in group A and 18 patients in group B. SC-2 was performed in three patients in Group B. Conversion rate was 18.1% (4/22) in group A and 0% (0/38) in group B, compared to 0.4% (1/221) for patients without acute cholecystitis. No complications were associated with ablated gallbladder mucosa. CONCLUSION: Laparoscopic subtotal cholecystectomy offers safe and effective treatment for acute cholecystitis. The conversion rate in group B is decreased by avoiding hazardous dissection of the cystic duct.

Horiuchi A, Watanabe Y, Doi T, Sato K, Yukumi S, Yoshida M, Yamamoto Y, Sugishita H, Kawachi K.

Department of Surgery 2, Ehime University School of Medicine, Shitsukawa, Toon City, Ehime, 791-0295, Japan, atsushi@m.ehime-u.ac.jp.

Use of a colonoscope for distal duodenal stent placement in patients with malignant obstruction.

BACKGROUND: Stent placement in the distal duodenum or proximal jejunum with a therapeutic gastroscope can be difficult, because of the reach of the endoscope, loop formation in the stomach, and flexibility of the gastroscope. The use of a colonoscope may overcome these problems. OBJECTIVE: To report our experience with distal duodenal stent placement in 16 patients using a colonoscope. METHODS: Multicenter, retrospective series of patients with a malignant obstruction at the level of the distal duodenum and proximal jejunum and treated by stent placement using a colonoscope. Main outcome measurements are technical success, ability to eat, complications, and survival. RESULTS: Stent placement was technically feasible in 93% (15/16) of patients. Food intake improved from a median gastric outlet obstruction scoring system (GOOSS) score of 1 (no oral intake) to 3 (soft solids) (p = 0.001). Severe complications were not observed. One patient had persistent obstructive symptoms presumably due to motility problems. Recurrent obstructive symptoms were caused by tissue/tumor ingrowth through the stent mesh [n = 6 (38%)] and stent occlusion by debris [n = 1 (6%)]. Reinterventions included additional stent placement [n = 5 (31%)], gastrojejunostomy [n = 2 (12%)], and endoscopic stent cleansing [n = 1 (6%)]. Median survival was 153 days. CONCLUSION: Duodenal stent placement can effectively and safely be performed using a colonoscope in patients with an obstruction at the level of the distal duodenum or proximal jejunum. A colonoscope has the advantage that it is long enough and offers good endoscopic stiffness, which avoids looping in the stomach.

Jeurnink SM, Repici A, Luigiano C, Pagano N, Kuipers EJ, Siersema PD.

Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center Rotterdam, ’s Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands, s.jeurnink@erasmusmc.nl.

Mechanical versus suture fixation of the port in adjustable gastric banding procedures: a prospective randomized blinded study.

BACKGROUND: Laparoscopic adjustable gastric band port placement can require 9-25% of total implantation time. Prolonged port fixation combined with extended wound manipulation results in an elevated incidence of port-related complications (infection, port tension, pain, rotation). This study compared port fixation using a novel applier to traditional fixation using nonresorbable sutures. METHODS: From Dec 2005 to March 2006, 50 patients were enrolled into a prospective randomized study. Intra- and postoperative outcomes of placing the Swedish Adjustable Gastric Band((R)) (SAGB) Realize(TM) with Velocity(TM) port and fixation device (group A) were compared to those of the SAGB with its titanium suture-fixation port (group B). Patient characteristics, port implantation duration, incision length, postoperative port-site pain [via visual analogue scale (VAS)], pain medication, and complications were recorded. Minimum follow-up was 12 months (three visits). Postoperative evaluation was performed by an investigator not involved in the surgery. RESULTS: Patient groups were comparable in age, sex, and body mass index. In group A versus group B, mean port implantation time was lower (53.5 +/- 13.1 versus 451.3 +/- 84.9 s, p < 0.0001), port-site skin incision was longer (mean 4.1 +/- 0.2 versus 3.1 +/- 0.2 cm, p < 0.0001), and postoperative opioid consumption was less (mean 1.3 versus 3.0 units, p < 0.01). Group A reported less mean pain on the VAS (3.2 versus 3.8, p < 0.01); 0/25 group A versus 3/25 group B patients required hypnotics. There were no discernible differences between groups in hospitalization (mean 2.9 days), nursing requirements, or pain at 3, 6, and 12 months. In group A, no patient required reoperation for a port complication; two port rotations occurred in group B (NS). CONCLUSION: Velocity mechanical port applier fixation is superior in efficiency to port suture fixation, safely increasing the speed to port implant from nearly 8 min to under 1 min and decreasing total operative time by 19%. Port applier fixation trends to reduction of major complications and statistically significantly lessens the minor complication of port-site pain.

Miller KA, Pump A.

Surgical Department, General Austrian Hospital Hallein, Buergermeister Str. 34, Hallein, 5400, Austria, karl.miller@kh-hallein.at.

Minimally invasive surgery for colorectal cancer: quality of life, body image, cosmesis, and functional results.

BACKGROUND: The aims of this cross-sectional study were to assess the long-term quality of life, the body image, and the cosmetic and functional results in patients who had laparoscopic-assisted for colorectal cancer. METHODS: Forty-two patients were enrolled in this study: 21 consecutive patients who had undergone laparoscopic-assisted colonic resection and 21 patients who had open colonic resection, selected according to stage, gender, age, cancer site, and type of resection. The patients answered four questionnaires about their quality of life, body image, functional, and cosmetic results. Nonparametric tests were used for statistical analysis. RESULTS: Postoperative hospital stay was shorter in patients who had laparoscopic-assisted resection. The cosmetic score was significantly better in the laparoscopic-assisted group than in the open group (p < 0.01). In spite of similar overall body image score, patients who had a laparoscopic-assisted resection reported a significantly better satisfaction with their own body (p = 0.05). Quality-of-life and functional results were similar in both groups. CONCLUSIONS: The cosmetic results and the consequent satisfaction with the body were significantly better after laparoscopic assisted resection compared to equivalent open procedure. These effects seemed to be temporary but they could help patients to accept the burden of surgery.

Scarpa M, Erroi F, Ruffolo C, Mollica E, Polese L, Pozza G, Norberto L, D\’Amico DF, Angriman I.

Department of Surgical and Gastroenterological Sciences, sez. di Clinica Chirurgica I, University of Padova, Padova, Italy, marcoscarpa73@yahoo.it.