RESUMO
AIM: Preclinical studies have suggested that nitinol-based compression anastomosis might be a viable solution to anastomotic leak following low anterior resection. A prospective multicentre open label study was therefore designed to evaluate the performance of the ColonRing(™) in (low) colorectal anastomosis. METHOD: The primary outcome measure was anastomotic leakage. Patients were recruited at 13 different colorectal surgical units in Europe, the United States and Israel. Institutional review board approval was obtained. RESULTS: Between 21 March 2010 and 3 August 2011, 266 patients completed the study protocol. The overall anastomotic leakage rate was 5.3% for all anastomoses, including a rate of 3.1% for low anastomoses. Septic anastomotic complications occurred in 8.3% of all anastomoses and 8.2% of low anastomoses. CONCLUSION: Nitinol compression anastomosis is safe, effective and easy to use and may offer an advantage for low colorectal anastomosis. A prospective randomized trial comparing ColonRing(™) with conventional stapling is needed.
Assuntos
Anastomose Cirúrgica/instrumentação , Fístula Anastomótica/terapia , Colo/cirurgia , Reto/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Ligas/uso terapêutico , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Colectomia/métodos , Europa (Continente) , Feminino , Humanos , Israel , Masculino , Pessoa de Meia-Idade , Vigilância de Produtos Comercializados , Estudos Prospectivos , Sepse/epidemiologia , Sepse/etiologia , Estados Unidos , Adulto JovemRESUMO
PURPOSE: Reconstruction of large abdominal-wall defects (AWD) in patients after massive weight loss (MWL) can be challenging. Patients are left with a sizeable amount of excess skin and subcutaneous tissue which can serve as a natural and readily available source of mesh coverage. In this article, we present our experience in the reconstruction of large AWD in patients after MWL, using autogenous dermal flaps combined with a synthetic mesh. METHOD: All patients with large AWD and MWL, diagnosed between January 2012 and December 2016, were considered to be candidates for the procedure. During the operation, an attempt was made to attain full closure of the defect above the mesh. In those patients for whom such closure was not possible, a dermal flap technique was used. Patients were closely monitored for at least 1 year. Outcome measures included early and late postoperative complications. Data are presented as mean ± standard deviation (SD). RESULTS: Over the study period, a total of 14 patients underwent a surgery involving combined mesh and dermal flap technique. Early post-operative complications included three patients who suffered from minor wound disruption and were treated with local dressings. One patient had an abdominal-wall hematoma that required an evacuation. Two patients suffered from an epidermal cyst and chronic sinuses that required surgical debridement. None of the patients experienced intra-abdominal complication, respiratory failure, or required ICU treatment. No mesh contamination or hernia recurrence was observed during the follow-up period of 22.25 ± 6.4 months. CONCLUSION: Autologous dermal flap combined with mesh technique may serve as an effective surgical alternative in patients after MWL with large AWD for whom full muscular coverage of the underlying prosthesis is not possible.
Assuntos
Hérnia Ventral/cirurgia , Herniorrafia/métodos , Obesidade , Procedimentos de Cirurgia Plástica/métodos , Retalhos Cirúrgicos , Telas Cirúrgicas , Parede Abdominal/cirurgia , Abdominoplastia/efeitos adversos , Abdominoplastia/métodos , Adulto , Bariatria/métodos , Derme/transplante , Feminino , Hérnia Ventral/complicações , Herniorrafia/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Obesidade/terapia , Procedimentos de Cirurgia Plástica/efeitos adversos , Estudos Retrospectivos , Retalhos Cirúrgicos/irrigação sanguínea , Transplante Autólogo , Redução de PesoRESUMO
The difficult airway constitutes a continuous challenge for anesthesiologists. Guidelines and algorithms are key to preserving patient safety, by recommending specific plans and strategies that address predicted or unexpected difficult airway. However, there are currently no "gold standard" algorithms or universally accepted standards. The aim of this article is to present a synthesis of the recommendations of the main guidelines and difficult airway algorithms.
Assuntos
Manuseio das Vias Aéreas/normas , Manuseio das Vias Aéreas/métodos , Algoritmos , Anestesia Geral , Humanos , Intubação Intratraqueal , Guias de Prática Clínica como AssuntoRESUMO
BACKGROUND: Bariatric surgery has increased in popularity, with Roux-en-Y Gastric Bypass (RYGB) being one of the most frequently performed. This leads to many cases in which the stomach is removed from routine gastroscopy access, sometimes being a major source of concern. Performing enteroscopy in these patients is technically difficult. We present our experience with 24 cases in which the aim was to access the detached stomach. METHODS: Retrospective analysis on RYGB enteroscopy procedures aimed to access the detached stomach. Data recorded: demographic parameters, indication, gas insufflation, time to bypass stomach, total procedure and recovery times, and endoscopic and pathological findings. RESULTS: This study included 24 patients who underwent RYGB in the previous 3-36 months. Indications were chronic abdominal pain, refractory anemia, or unexplainable weight loss. Detached stomach was accessed in 79% of patients. Access time ranged from 25 to 55 min. Recovery time for all procedures was 86.66 min on average and shorter with CO2 insufflation (42.5 min). All detached stomachs showed macroscopic gastritis; four of them were Helicobacter pylori positive. Significant findings included three patients with jejunojejunostomy stenosis and one patient with a marginal gastrojejunal ulcer, which was later diagnosed with Signet ring cell carcinoma of the proximal anastomosis. CONCLUSIONS: We present the feasibility and importance of enteroscopy of the detached stomach and believe that this procedure should be performed more frequently. A high index of suspicion is needed for postoperative symptoms in order to exclude significant pathologies and reassure symptomatic patients that there is no abnormality in the bypassed stomach.
Assuntos
Endoscopia Gastrointestinal/métodos , Derivação Gástrica/efeitos adversos , Laparoscopia/métodos , Estômago/cirurgia , Adulto , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has been used more frequently over the past 10 years. As the population ages, a larger number of older people will suffer from weight-related comorbidities, resulting in bariatric surgery becoming a dominant solution for improving health and quality of life. We assessed the long-term outcomes of LSG in elderly patients. METHODS: We conducted a retrospective chart review of patients who underwent LSG between January 2007 and August 2009. We subdivided 123 patients into <35 (n = 43), 35-55 (n = 59), and >55 (n = 21) age groups. RESULTS: The respective mean excess body mass index loss and excess weight loss were 42.5% ± 3.1% and 41.3% ± 12.3% for the <35 age group, 48.7% ± 4.1% and 45.6% ± 10.6% for the 35-55 age group, and 53.6% ± 4.6% and 52.1% ± 11.1% for the >55 age group. The follow-up compliance rates at the 5-year visit were 23.85, 31.11, and 47.61% for the <35, 35-55, and >55 age groups, respectively. The corresponding Bariatric Analysis and Reporting Outcome System scores were 3.7 ± 1.1, 4.0 ± 0.7, and 5.3 ± 1.3. The comorbidities of all the patients improved significantly, with a non-significant distribution between the three groups for each comorbidity. CONCLUSIONS: LSG is a useful tool for people who want to modify their eating habits and lose weight healthily. This study suggests that long-term weight loss, improvements in comorbidity, and compliance to follow-up are significant for patients >55 years old.
Assuntos
Gastrectomia/métodos , Obesidade/cirurgia , Adolescente , Adulto , Fatores Etários , Idoso , Cirurgia Bariátrica , Feminino , Seguimentos , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Estudos Retrospectivos , Redução de Peso , Adulto JovemRESUMO
BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is currently being widely accepted for its role in the treatment of morbid obesity. Staple-line leakage is one of the most reported complications found in 0.5-7 % of the population, in which the Over-the-Scope Clip (OTSC) (Ovesco Endoscopy, Tübingen, Germany), a novel device, is employed. We present our experience with this system in LSG leaks. METHODS: A retrospective analysis of prospectively collected data from patients with LSG leakage was performed, and these patients were treated with the OTSC system. Efficiency was defined as complete oral nutrition without any evidence of additional leakage. RESULTS: Overall, 26 patients underwent endoscopic OTSC treatment. The median age was 39 years (range 26-60), and 12 were male patients (46.15 %). The mean body mass index (BMI) was 42.89 kg/m(2), and 10 patients (38.46 %) came from a revisional bariatric procedure (SRVG or LAGB). Twenty-two patients (84.61 %) had upper staple-line leaks (near the GEJ), and the remaining 4 (15.38 %) had lower antral leaks. Number of endoscopy sessions ranged from 2 to 7 (median 3). There were five failures: 2 of them had an antral leak, and the remaining 3 had an upper staple-line leak. Twenty-one (80.76 %) leaks were successfully treated within 32 days' median time till complete oral nutrition was attained (range 14-70). CONCLUSIONS: The success rate was high with the OTSC system, and it is concluded to be a safe and effective treatment for LSG leaks.
Assuntos
Fístula Anastomótica/prevenção & controle , Gastrectomia , Obesidade Mórbida/cirurgia , Grampeamento Cirúrgico , Adulto , Anastomose Cirúrgica/instrumentação , Anastomose Cirúrgica/métodos , Fístula Anastomótica/epidemiologia , Índice de Massa Corporal , Feminino , Gastrectomia/instrumentação , Gastrectomia/métodos , Humanos , Laparoscopia/instrumentação , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/epidemiologia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Instrumentos Cirúrgicos , Grampeamento Cirúrgico/instrumentação , Grampeamento Cirúrgico/métodos , Resultado do TratamentoRESUMO
Spleen exposure to ultrasound has been reported to influence antibody response to sheep red blood cell injection in mice (decreased hemagglutination and hemolytic titers and IgM, IgG2a and IgG2b levels and elevated IgG1 levels). In a controlled clinical trial, we investigated the possible immunosuppressive side-effect of splenic exposure (2.0 mW/m2, 3.5 MHz, 5 minutes) to ultrasound on the immune response to Rubella vaccination in 41 anti-Rubella antibody-negative volunteers. The measured parameters (blood cell count, IgA, IgM, IgG including subclasses IgG1-IgG4, isoagglutinins, anti-Rubella hemagglutinin and hemolysin titers, complement C3, skin tests to mumps and tuberculin, T, B and O lymphocytes, esterase-positive and negative T-cell subsets) suggest changes dependent on the time of vaccination, but provide no evidence of an immunosuppressive effect of ultrasound in man.
Assuntos
Imunidade , Baço/imunologia , Ultrassom/efeitos adversos , Adolescente , Adulto , Anticorpos Antivirais/biossíntese , Feminino , Humanos , Imunidade Celular , Imunoglobulinas/biossíntese , Terapia de Imunossupressão , Testes Intradérmicos , Linfócitos/imunologia , Vacina contra Rubéola/imunologia , Vírus da Rubéola/imunologiaRESUMO
BACKGROUND AND OBJECTIVES: It is generally assumed that delayed diagnosis of acute appendicitis results in higher morbidity but this assumption is not strongly supported in the literature. We attempt to define the effect of patient and physician delay on the outcome of patients with acute appendicitis. PATIENTS AND METHODS: We studied 486 patients admitted between 1980 and 1992. Patient delay in presenting to a physician and surgeon delay from hospital admission to operation were studied in relation to stage of disease at operation as well as to postoperative complications. RESULTS: Postoperative complications occurred in 10% of cases with simple acute appendicitis versus about 20% of cases with gangrenous or perforated appendicitis (P <0.001). The mean patient delay from onset of symptoms to presentation to a physician was 1.7 days in simple acute appendicitis versus 2.3 days in gangrenous or perforated appendicitis (P <0.001). Mean surgeon delay was 13.6 hours in simple acute appendicitis versus 14.5 hours in advanced appendicitis (P = NS). CONCLUSION: Delay in patient presentation adversely affects the stage of disease in acute appendicitis and leads to increased incidence of infectious complications and to prolonged hospital stay. Conversely, physician delay does not affect the stage of disease. A surgeon's decision to observe patients in hospital in order to clarify the diagnosis is justified, as it does not adversely affect outcome.
Assuntos
Apendicite/cirurgia , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Apendicite/diagnóstico , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Fatores de TempoRESUMO
BACKGROUND: Laparoscopic cholecystectomy is now used in the management of acute cholecystitis. Under these circumstances unfavorable conditions may result in conversion and complications. Information about these conditions may help in planning the laparoscopic approach or in proceeding directly to open cholecystectomy. This study was initiated to evaluate perioperative factors associated with conversion and complications of laparoscopic cholecystectomy in acute cholecystitis. Special attention was paid to the duration of complaints until surgery, to the delay on the part of the patient, and to the delay on the part of the physician. METHODS: Between January 1994 and December 1997, we attempted to perform laparoscopic cholecystectomy on 348 patients with acute cholecystitis. All perioperative data were collected on standardized forms. RESULTS: There were 182 cases (52%) of acute uncomplicated cholecystitis, 90 (26%) of gangrenous cholecystitis, 33 of hydrops (9.5%), and 43 of empyema of the gallbladder (12.5%). Seventy six patients (22%) needed conversion to open cholecystectomy and complications occurred in 57 cases. Advanced cholecystitis was associated with significant patient delay (P = 0.01), and it had a significantly higher conversion rate (39%) compared with early cholecystitis (14.5%); (P <0.00001). Conversion rates were also associated with male gender (P = 0.0017), a history of biliary disease (P = 0.0085), and a patient delay of >48 hours (P = 0.028). The total and infectious complication rates were associated with an age older than 60 years (P = 0.023 and 0.007, respectively) and male gender (P = 0.026 and 0.014, respectively). CONCLUSIONS: In acute cholecystitis, patient delay is associated with a high conversion rate. Early timing of laparoscopic cholecystectomy tends to reduce the conversion rate, as well as the total and the infectious complication rates. Male gender, a history of biliary disease, and advanced cholecystitis are associated with conversion. Male and older patients are associated with a high total and infectious complication rates.
Assuntos
Colecistectomia Laparoscópica , Colecistite/cirurgia , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Colecistectomia Laparoscópica/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
Adult intussusception is a rare condition, chronic and recurring in nature, and presenting as intermittent intestinal obstruction. Surgeons generally have limited experience with it. We present 13 cases that have been treated in our department over a period of 19 years. In most of the cases there is an identifiable cause and it is often a malignancy. Awareness, plain abdominal films, barium enema and CT are valuable tools for diagnosis. Resection without reduction is the treatment of choice in most cases. In instances where resection would necessitate a permanent stoma, attempts at manual reduction are justified. Timely treatment, properly carried out, should result in a good prognosis.
Assuntos
Intussuscepção/etiologia , Intussuscepção/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Neoplasias Intestinais/complicações , Obstrução Intestinal/complicações , Masculino , Pessoa de Meia-IdadeRESUMO
We performed 75 laparoscopic cholecystectomies during July and September 1996. In 3 men and 4 women, aged 32-87 years, there was obstructive jaundice caused by choledocholithiasis. During laparoscopy in the jaundiced patients, calculi were identified by cholangioscopy and intra-operative cholangiography. They were washed into the duodenum (confirmed cholangiographically) after intravenous glucagon injections and dilation of the papilla of Vater. Serum bilirubin and liver enzyme levels returned to normal within a few days. There was no operative or postoperative morbidity, nor any biliary-related systemic complications. Average postoperative hospitalization was 3 days.
Assuntos
Colecistectomia Laparoscópica/métodos , Cálculos Biliares/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Colestase/etiologia , Feminino , Glucagon/uso terapêutico , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Although bactibilia is an important condition of acute cholecystitis, its effect on the course and outcome of the infectious gallbladder disease has rarely been studied, particularly in relation to the laparoscopic procedure. The current study attempts to learn more about the inter-relationship between bactibilia and laparoscopic cholecystectomy during acute cholecystitis. Demographic, preoperative, operative, and postoperative data were prospectively collected in every patient with acute cholecystitis treated in the department of surgery at the Bnai Zion Medical Center, Israel. Intraoperative biliary samples were collected under aseptic conditions at the time of operation for bacteriologic examination and were routinely cultured in aerobic and anaerobic media for 3 days. The study population was divided into culture-positive and culture-negative groups, and the collected parameters were compared between the groups. Age over 60 years, a palpable gallbladder, temperature over 37.5 degrees C, a white blood cell (WBC) count of more than 12,000/cc(3), and serum alkaline phosphatase higher than 100 U/dL were all found to be factors capable of predicting bactibilia. Bactibilia was a significant factor associated with total, as well as infectious, operative complications. Bactibilia is considered to indicate an advanced stage of acute cholecystitis. In cases of laparoscopic cholecystectomy for infectious gallbladder disease, bactibilia is strongly associated with total, as well as local, infectious complications. Preoperative conditions such as older age, elevated temperature, a palpable gallbladder, elevated WBC count, and elevated serum levels of alkaline phosphatase can serve as predictors of bactibilia and its consequent complications. Although the sensitivity and specificity of the predictive factors for bactibilia are limited to 63% and 67%, respectively, in their presence during acute cholecystitis, conservative wide-spectrum antibiotics as the first-line therapy is appropriate, and, upon regimen failure, laparoscopic surgery by an experienced surgeon is indicated as the adjusted therapy.
Assuntos
Bile/microbiologia , Colecistectomia Laparoscópica , Colecistite Aguda/microbiologia , Colecistite Aguda/cirurgia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Criança , Colecistite Aguda/complicações , Colecistite Aguda/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Adulto JovemRESUMO
BACKGROUND: Laparoscopic cholecystectomy (LC) in acute cholecystitis is associated with a relatively high rate of conversion to an open procedure as well as a high rate of complications. The aim of this study was to analyze prospectively whether the need to convert and the probability of complications is predictable. METHODS: A total of 215 patients undergoing LC for acute cholecystitis were studied prospectively by analyzing the data accumulated in the process of investigation and treatment. Factors associated with conversion and complications were assessed to determine their predictive power. RESULTS: Conversion was indicated in 44 patients (20.5%), and complications occurred in 36 patients (17%). Male gender and age >60 years were associated with conversion, but these factors had no sensitivity and no positive predictive value. The same factors, together with a disease duration of >96 h, a nonpalpable gallbladder, a white blood count (WBC) of >18,000/cc(3), and advanced cholecystitis, predicted conversion with a sensitivity of 74%, a specificity of 86%, a positive predictive value of approximately 40%, and a negative predictive value of 96%. However, these data became available only when LC was underway. Male gender and a temperature of >38 degrees C were associated with complications, but these factors had no sensitivity and no positive predictive value. Progression along the stages of admission and therapy did not add predictive factors or improve the predictive characteristics. Male gender, abdominal scar, bilirubin >1 mg%, advanced cholecystitis, and conversion to open cholecystectomy were associated with infectious complications. Their sensitivity and positive predictive value remained 0 despite progression along the stages of admission and therapy. CONCLUSION: Although certain preoperative factors are associated with the need to convert a LC for acute cholecystitis, they have limited predictive power. Factors with higher predictive power are obtained only during LC. The need to convert can only be established during an attempt at LC. Preoperative and operative factors associated with total and infectious complications have no predictive power.
Assuntos
Colecistectomia Laparoscópica , Colecistite/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/economia , Colecistectomia Laparoscópica/métodos , Colecistite/classificação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias , Valor Preditivo dos Testes , Estudos Prospectivos , Sensibilidade e Especificidade , Fatores Sexuais , Falha de TratamentoRESUMO
This prospective study determines the indications for and the optimal timing of laparoscopic cholecystectomy (LC) following the onset of acute cholecystitis. It also evaluates preoperative and operative factors associated with conversion from laparoscopic cholecystectomy to open cholecystectomy in the presence of acute cholecystitis. Having been established as the procedure of choice for elective cholelithiasis, LC is now also used for management of acute cholecystitis. Under these circumstances the procedure may be difficult and challenging. Certain favorable and unfavorable conditions may be present that influence the conversion and complication rates. Information about these conditions may be helpful for elucidating the optimal circumstances for LC or when the procedure is best avoided. We performed LC on an emergency basis as soon as the diagnosis was made on all patients presenting with acute cholecystitis from January 1994 to December 1995. All preoperative, operative, and postoperative data were collected on standardized forms. Of the 137 patients registered, 130 were eligible for the audit. Seven patients found by laparoscopic intraoperative cholangiography to have choledocholithiasis were converted for common bile duct exploration and were excluded from the study. Altogether 83 patients (72%) underwent successful LC and 37 (28%) needed conversion to open cholecystectomy. The conversion rate of acute gangrenous cholecystitis (49%) was significantly higher than that for uncomplicated acute cholecystitis (4.5%) (p < 0.00001) and for hydrops (28.5%) and empyema of the gallbladder (28.5%) (p = 0.004). The difference in conversion between the group with acute necrotizing (gangrenous) cholecystitis and the two groups with hydrops and empyema of the gallbladder was not statistically significant (p = 0.07). The complication rates of acute cholecystitis, hydrops, empyema of the gallbladder, and gangrenous cholecystitis were 9.0%, 9.5%, 14.0%, and 20.0%, respectively (p = NS). Patients with an operative delay of 96 hours or less from the onset of acute cholecystitis had a conversion rate of 23%, whereas a delay of more than 96 hours was associated with a conversion rate of 47% (p = 0.022). The complication rate was 8.5% in the laparoscopic group and 27% in the converted group (p = 0.013). Patients over 65 years of age, with a history of biliary disease, a nonpalpable gallbladder, WBC count over 13,000/cc, and acute gangrenous cholecystitis were independently associated with a high LC conversion rate; male patients, finding large bile stones, serum bilirubin over 0.8 mg/dl, and WBC count over 13,000/cc were independently associated with a high complication rate following laparoscopic surgery with or without conversion. Generally, LC can be performed safely for acute cholecystitis, with acceptably low conversion and complication rates. Different forms of cholecystitis carry various conversion and complication rates in selected cases. LC for acute cholecystitis should be performed within 96 hours of the onset of disease. Predictors of conversion and complications may be helpful when planning the laparoscopic approach to acute cholecystitis.
Assuntos
Colecistectomia Laparoscópica/métodos , Colecistite/cirurgia , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Distribuição de Qui-Quadrado , Colangiografia , Colecistectomia/efeitos adversos , Colecistectomia/métodos , Colecistectomia Laparoscópica/efeitos adversos , Colecistite/diagnóstico , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Prospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: To ascertain the incidence of obstruction after various operations and find out if the index operation influenced the course and outcome of adhesive small bowel obstruction. DESIGN: Retrospective study. SETTING: Teaching hospital, Israel. SUBJECTS: 190 of 248 patients who presented with small bowel obstruction between January 1980 and December 1994. INTERVENTIONS: All patients were treated conservatively and operated on only if they did not improve or deteriorated. MAIN OUTCOME MEASURES: Incidence of obstruction depending on site of index operation, and response to treatment. RESULTS: 46 Patients (24%) had undergone upper abdominal operations, 26 (14%) small bowel resection, 47 (25%) appendicectomy, 27 (14%) gynaecological operations, and 44 (23%) colonic resections. The annual incidence of obstructive complications among the 190 patients in the groups studied was highest after appendicectomy (3.1/year) and colonic resections (2.9/year) and lowest after operations on the gallbladder and pancreas (1.1/year). Postoperative adhesive obstruction presented earlier after operations on the small bowel (median 1 year, range 5.4-20) and colon (median 1 year, range 2.2-40) than after the other operations. 60 (32%) of patients with acute small bowel obstruction had a history of abdominal malignancy, and obstruction was more likely to be complete after small bowel resection (20/26, 77%) compared with 39/74 (53%) after appendicectomy or gynaecological surgery, 17/46 (37%) after upper abdominal surgery, and 15/44 (34%) after colonic resection. Patients who developed obstruction after colonic resection had the longest period of conservative treatment (median 60 hours, range 24-216) and had the highest morbidity (8/44, 18%) although only 2 required bowel resection. Two patients died, both after obstruction following upper abdominal operations. CONCLUSIONS: Patients who present with obstruction after small bowel resection are extremely likely to be completely obstructed. Perhaps the morbidity associated with obstruction after colonic resection could be reduced if patients were operated on earlier.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Obstrução Intestinal/epidemiologia , Adolescente , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Feminino , Hospitais de Ensino/estatística & dados numéricos , Humanos , Incidência , Obstrução Intestinal/etiologia , Obstrução Intestinal/terapia , Intestino Delgado/cirurgia , Israel/epidemiologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Probabilidade , Estudos Retrospectivos , Fatores de Risco , Distribuição por Sexo , Taxa de Sobrevida , Aderências Teciduais/epidemiologia , Aderências Teciduais/etiologia , Aderências Teciduais/terapiaRESUMO
Elective laparoscopic cholecystectomy is established as the treatment of choice for symptomatic cholecystolithiasis and is now proposed for the treatment of acute cholecystitis. We initiated the present study in order to clarify the question of safety of the procedure in the presence of an inflamed gallbladder, and to compare the results with those of a traditionally treated group with acute cholecystitis. We compared the preoperative, operative, and postoperative courses of 146 patients with acute cholecystitis, managed laparoscopically between 1994 and 1996, with those of 97 patients, treated traditionally by open cholecystectomy for the same diagnosis between 1992 and 1993. In the acute cholecystitis cases, when laparoscopic cholecystectomy was successfully performed, the operative and postoperative courses were superior to those of open cholecystectomy. The use of drains and NG tubes, the need for antibiotics and analgesia, the associated morbidity, and the hospital stay were significantly reduced. Following conversion, the postoperative course was similar to that of open cholecystectomy. Of the group of acute cholecystitis cases laparoscopically approached 39 (27%) needed conversion. Twenty-five complications occurred in 24 (16.5%) patients of the laparoscopic group, whereas 30 complications occurred in 25 (26%) patients of the traditionally operated group. Male sex, older patients, and larger bile stones were found to be associated with a higher conversion rate as well as a higher complication rate. A nonpalpable gallbladder and gangrenous cholecystitis were associated with conversion while fever was associated with complications. Laparoscopic cholecystectomy can be performed safely in selected cases of acute cholecystitis, with acceptable conversion and low complication rates. When laparoscopic cholecystectomy is successfully performed, the operative and postoperative courses are superior to those of open cholecystectomy. Following conversion, the postoperative course is similar to that of open cholecystectomy. According to this study, male sex, older age, large bile stones, a nonpalpable gallbladder, and gangrenous cholecystitis may be regarded as predictors of conversion, while male sex, older age, large bile stones, and fever may be regarded as predictors of complications. The timing of laparoscopic cholecystectomy should be within 96 h from onset of the inflammation.
Assuntos
Colecistectomia Laparoscópica , Colecistite/cirurgia , Doença Aguda , Colecistectomia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-OperatóriasRESUMO
In a prospective audit of our first 213 laparoscopic cholecystectomies (LC), we compared the results obtained by qualified surgeons to those obtained by residents. The first group started performing LC after undergoing formal laboratory laparoscopic courses. The second group was introduced to LC by standard attending-resident teaching in the operating room. In all, 137 LC wer performed by qualified surgeons and 76 by residents. Patients' clinical and laboratory characteristics were not significantly different in the two groups. The conversion rate to laparotomy (11.5% and 12.5%), mean duration of surgery (88 and 83 min), iatrogenic perforation of the gallbladder (16% and 18.5%), "lost stones" (7% and 4%), use of drains (12% and 13%), and extension of the umbilical port incision (about 30% in both groups) were similar in the two groups. The incidence of biliary (3% and 4%) and infectious (3.5% and 4%) complications was equivalent in both groups. We conclude that with the traditional attending-resident approach to surgical education, residents safely and quickly acquire the necessary skills to perform LC without jeopardizing the safety of patients.
Assuntos
Colecistectomia Laparoscópica , Cirurgia Geral/educação , Auditoria Médica , Adulto , Idoso , Colecistectomia Laparoscópica/métodos , Competência Clínica , Feminino , Humanos , Internato e Residência , Masculino , Corpo Clínico Hospitalar , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Avaliação de Programas e Projetos de Saúde , Estudos Prospectivos , Resultado do TratamentoRESUMO
Laparoscopic cholecystectomy (LC), the procedure of choice for elective cholelithiasis, is now also used in the management of acute cholecystitis. In the various types of gallbladder disease, favorable and unfavorable conditions may influence the conversion and complication rates. Information about these conditions may help elucidate the optimal circumstances for LC or indicate when the procedure is best avoided. We attempted to perform emergency LC on 215 patients with acute cholecystitis. The procedure was successful in 171 patients (79.5%), and conversion to open cholecystectomy (OC) was needed in 44 (20.5%). Complications occurred in 37 patients (17%). Uncomplicated acute cholecystitis was associated with age <50 years, duration of complaint <48 h, temperature <38.5 degrees C, a nonpalpable gallbladder, and an alkaline phosphatase >100 U/L. Acute gangrenous cholecystitis was associated with a negative gallbladder history, other associated diseases, temperature >38.5 degrees C, a palpable gallbladder, and serum bilirubin levels <1 mg/dl. Hydrops was associated with a temperature <38 degrees C and a leukocyte count of >12,000/cc3, and empyema of the gallbladder was associated with duration of complaint >48 h and a palpable gallbladder. The conversion rate of acute gangrenous cholecystitis (40%) was significantly higher than that of uncomplicated acute cholecystitis (8%) (p < 0.00001, odds ratio=7.7), as well as that of empyema of the gallbladder (12.5%) (p=0.005, odds ratio=4.7). The conversion from LC to OC in uncomplicated acute cholecystitis was associated with male sex and with duration of complaint >24 h, and in gangrenous cholecystitis with age >60 years, a nonpalpable gallbladder, and a leukocyte count of >15,000/cc3. The complication rates of acute cholecystitis, hydrops, empyema of the gallbladder, and gangrenous cholecystitis were 16%, 7%, 22%, and 21%, respectively (p = NS). The total complication rate in acute cholecystitis tended to be associated with a duration of complaint >48 h and in gangrenous cholecystitis with male sex, age >60 years, other associated disease, larger bile stones, and elevated serum bilirubin levels. Generally, LC is safe in all forms of cholecystitis, with acceptably low conversion and complication rates, excluding gangrenous cholecystitis. In gangrenous cholecystitis, a conversion rate of approximately 40% is expected. Predictors of conversion and complications may be particularly helpful in planning the laparoscopic approach to acute gangrenous cholecystitis. Patients >60 years of age, with a nonpalpable gallbladder and with a leukocyte count >15,000/cc3, frequently need conversion. In men >60 years old, with other associated disease, with larger bile stones, and with elevated serum bilirubin levels, complications are frequently expected. Under these conditions, laparoscopic approach should be undertaken by especially experienced teams, or OC should be considered.
Assuntos
Colecistectomia Laparoscópica , Colecistite/cirurgia , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Distribuição de Qui-Quadrado , Colangiografia , Colecistectomia Laparoscópica/efeitos adversos , Colecistite/classificação , Colecistite/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Probabilidade , Prognóstico , Estudos Prospectivos , Fatores de Risco , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Fatores SexuaisRESUMO
OBJECTIVE: To find out whether fever and raised white cell count (WCC) are associated with conversion and complications of laparoscopic cholecystectomy in acute cholecystitis, and whether their presence could help in deciding the place of laparoscopic procedures. DESIGN: Prospective study. SETTING: Teaching hospital, Israel. SUBJECTS: 256 patients who were treated for clinical acute cholecystitis between January 1994 and November 1997. INTERVENTIONS: Emergency laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: Raised temperature and WCC; incidence of conversion and complications. RESULTS: Raised temperature (>38 degrees C) was independently associated with advanced cholecystitis (p = 0.002, odds ratio [OR] 2.7) and a palpable gallbladder preoperatively (p = 0.02, OR 2.1). Total complications correlated with a temperature of >38 degrees C. Raised WCC (>15 x 10(9)/L) was independently associated with age >45 years (p = 0.02, OR 2.4), a palpable gallbladder preoperatively (p = 0.001, OR 2.9), and a raised temperature (>38 degrees C) (p < 0.0001, OR 6.2). Conversion was associated with a WCC >18 x 10(9)/L (p = 0.0, OR 3.2). CONCLUSION: A WCC of >18 x 10(9)/L may assist in predicting conversion, and fever of >38 degrees C may assist in predicting the development of complications.
Assuntos
Colecistectomia Laparoscópica/efeitos adversos , Colecistite/cirurgia , Febre/etiologia , Leucocitose/etiologia , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
OBJECTIVE: To study the factors associated with accidental perforation of the gallbladder and spillage of bile and stones and to assess the consequences of these mishaps. DESIGN: Prospective study with retrospective bacteriological evaluation. SETTING: Teaching hospital, Israel. SUBJECTS: 189 Patients who were treated for clinical acute cholecystitis between January 1994 and August 1996. INTERVENTIONS: Emergency laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: Incidence of accidental perforation of gallbladder and spillage of bile and stones and of conversion and complications in relation to preoperative and operative findings. RESULTS: Bile was spilt in 65 (34%) and gall-stones were "lost" in 27 (14%), 44 (23%) required conversion to an open approach and 36 (19%) developed complications. Preoperative duration of symptoms >96 hours and a palpable gallbladder were associated with accidental perforation of the gallbladder and spillage of bile. A palpable gallbladder, gangrenous cholecystitis, and WBC > 15 x 10(9)/L were associated with stones "lost" in the peritoneum. A history of biliary disease was inversely related to "lost" stones. Conversion of laparoscopic to open cholecystectomy was associated with male sex, age >60 years, a non-palpable gallbladder, WBC > 15 x 10(9)/L, and a gangrenous gallbladder. Complications of surgery were more common among men and associated with fever of >38 degrees C. Neither the conversion nor the complications were associated with perforation of the gallbladder or "lost" stones. CONCLUSION: Perforation of the gallbladder and intraperitoneal spillage of bile or stones during laparoscopic cholecystectomy for acute cholecystitis are not associated with undesirable events, are not indications for conversion, and are not associated with further complications. When patients are given appropriate antibiotics perioperatively and the spilt bile is properly aspirated and the peritoneum irrigated, the operative and postoperative courses are similar to those of patients with unperforated gallbladder.