H1-antagonism improves intestinal mucosal pH and heart function in porcine hypodynamic endotoxic shock.

Porcine hypodynamic shock was induced by continuous infusion of 5 micrograms lipopolysaccharide/kg per hour. This resulted in a decrease of cardiac output from baseline values of 3.5 +/- .9 L/min to 1.5 +/- .8 L/min and a reduced left ventricular stroke work index in the endotoxin-group (n = 6 animals). Pretreatment with the H1-antagonist dimethindene (2 mg/kg) in a second group (n = 6) significantly prevented these effects. Furthermore animals pretreated with the H1-antagonist showed a stable mean arterial blood pressure, whereas the control endotoxin-treated group revealed a drastic reduction in mean arterial blood pressure (99 +/- 4.7 mmHg versus 65.8 +/- 10 mmHg after 240 min, respectively). Pulmonary function and systemic vascular resistance were not ameliorated by the H1-antagonist in hypodynamic shock. Gastrointestinal mucosal pH (pHi), which indicates oxygenation of the mucosa, was decreased by endotoxin-infusion (7.45 +/- .32 baseline value to 6.92 +/- .24 after 120 min). This parameter as well as base excess values and lactate levels were significantly improved by dimethindene-pretreatment (p < .05). These results may indicate a beneficial effect of H1-antagonist-pretreatment on endotoxin-induced deterioration of the microcirculation. Furthermore our results clearly demonstrated that only pretreatment before endotoxemia with H1-antagonism is effective, since infusion of H1-antagonist in hypodynamic shock 45 min after addition of endotoxin (n = 6 animals) did not improve the cardiovascular system or the microcirculation.

Laparoscopic Billroth II gastrectomy: a review.

The operation of Billroth II gastrectomy has not changed substantially in concept or technique since it was first performed in 1885 by Theodor Billroth. The advent of stapling has made the procedure faster for the surgeon but the operation has remained as painful and as traumatic for the patient. The totally intra-abdominal laparoscopic Billroth II gastrectomy offers a minimally invasive option that is remarkably less traumatic and more 'patient friendly'. Initial experience in this operation around the world has largely concentrated on resection for benign gastric ulcer but the possibility of resection for cancer is not inconceivable. Experience with a small experimental series of eight cases showed that this operation has many advantages over open surgery in terms of postoperative pain, quicker mobilization, fewer wound problems, better cosmesis and quicker discharge. No anastomotic leak, chest or wound complications were encountered. The main problem remains the cost of disposable stapling devices.

Evaluation of a head-mounted display (HMD) in the performance of a simulated laparoscopic task.

BACKGROUND: Head-mounted display (HM) units are used in various industries, but they have been tried only recently in surgery. In this study, we evaluated whether a commercially available HMD would improve or impede a laparoscopic task-in this case, suturing. METHODS: Six participants performed a total of 120 laparoscopic suture knots in an experimental model. The Olympus FMD011 model with a two-dimensional image was used. The order of each task with or without the head display unit was random. The time to complete each knot was recorded, and the results were analyzed. RESULTS: The display unit prolonged the suturing times of the subjects by 10% (p < 0.04). CONCLUSIONS: In this experimental model, the HMD we utilized did not appear to improve laparoscopic suturing. More developments, such as improved depth perception and better resolution, may increase its usefulness for laparoscopic tasks.

Combined resection of hepatoblastoma and intracaval right atrial extension with profound hypothermia and circulatory arrest.

Hepatoblastoma is an uncommon liver neoplasm in children but its intraatrial extension through the inferior vena cava is extremely rare. The case described is a 3-year-old boy in whom profound hypothermia and circulatory arrest were used to resect a hepatoblastoma and its extension to the right atrium. This technique allows maximal resection and relief of venous obstruction from atrial extension of hepatoblastoma.

Evaluation of percutaneous endoscopic gastrostomy in a university hospital.

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy (PEG) has become a commonly performed procedure to provide nutritional support for chronically ill patients. The aim of this study was to review the safety and results of PEG in a teaching hospital. METHODOLOGY: A retrospective review of 44 patients who underwent PEG procedure. The indication was long-term enteral feeding in patients who were unable to maintain adequate nutrition by mouth with an otherwise functioning gut. The most common primary diagnosis was cerebrovascular accident (17 patients). All patients were unable to swallow. RESULTS: There were six (13.6%) minor complications, and two mortalities from peritonitis (4.5%). The most common complication was gastrostomy site infection, which did not require exchange of the feeding tube. CONCLUSIONS: PEG is a useful means of providing nutrition in patients unable to swallow without the necessity for laparotomy and general anesthesia. This method provides an adequate avenue for enteral alimentation in selected patients and is relatively safe. Careful attention to the technique of insertion is important to prevent leakage or bowel perforation.

Traumatic posterior dislocation of the hip--a local experience and review of the literature.

The results of 30 patients who sustained traumatic posterior dislocation of the hip treated in both Departments of Orthopaedic Surgery in the Singapore General Hospital from January 1980 to May 1987 were analysed. The most common cause was motorcycle accidents. Young adult males formed the majority of affected cases. 90% of the dislocations were of the Types I and II. Associated injuries were common. The primary treatment was closed reduction under anaesthesia. The subsequent period of traction and non-weight bearing was variable, but it did not seem to affect the final results. Avascular necrosis of the femoral head and secondary osteoarthritis were the major complications. The overall functional results were good.

Laparoscopic posterior truncal vagotomy and anterior highly selective vagotomy--a case report.

Laparoscopic vagotomy provides a viable alternative to expensive long-term treatment with H2 antagonists in patients with intractable peptic ulcer disease. The minimally invasive procedure offers reduced postoperative discomfort and improved cosmesis. Here, we report our first case of a posterior truncal vagotomy and anterior highly selective vagotomy performed laparoscopically for the first time in Asia. The surgery was uneventful. Diet was resumed on day 3 and the patient was discharged on day 4. Post-vagotomy acid secretion tests on the third week revealed a dramatic decrease in acid production. With further experience, laparoscopic vagotomy can be an attractive alternative to long term medication in peptic ulcer disease.

A multimodality approach to endoscopic treatment of bleeding peptic ulcers.

The role of endoscopic haemostasis in the treatment of bleeding peptic ulcers is widely studied. Many trials to date have compared one or more modalities against a medical control with variable results. To date, no single modality has been shown conclusively to be superior to others. As such, in this study we have not confined the endoscopist to one modality of treatment but allowed him to customize the method of endoscopic haemostasis according to the configuration, accessibility and rate of bleeding in any particular patient. Seventy-three patients with non-variceal upper gastrointestinal (GI) bleeding were admitted to the National University Hospital in Singapore between May 1, 1988 and April 30, 1989. All were gastroscoped and 48 were found to have chronic peptic ulcer. Twenty-nine (60%) with actively bleeding peptic ulcer or stigmata of recent haemorrhage (SRH) were treated endoscopically. Initial haemostasis was achieved in 27 (93%) patients. Seven patients rebled (26%) of which four underwent repeat endoscopic treatment. Of these four patients only one rebled again and required surgery. Permanent haemostasis was achieved in 23 of 29 patients (79%). The multimodality approach for the treatment of bleeding peptic ulcers gives the endoscopist flexibility in deciding on the best way to deal with a bleeding gastric or duodenal ulcer. Each instrument has its strengths and weaknesses and the right choice of instrument is often a critical factor especially in treating a bleeding ulcer in a situation where access poses a problem.

Palliation of advanced gastric cancer by laparoscopic gastrojejunostomy.

Palliation of unresectable gastric carcinoma by conventional gastrojejunostomy is associated with significant morbidity and mortality. Laparoscopic gastrojejunostomy may be an alternative as it can achieve the same results with less morbidity. This is a case report of a 68-year-old man with an obstructed, unresectable gastric carcinoma that has metastasized to the lungs and liver. Attempt at laser boring was unsuccessful. Laparoscopic assessment revealed an immobile tumour fixed to the pancreas. A totally intraabdominal laparoscopic gastrojejunostomy was fashioned with endoGIAs (USSC Norwalk, CT). Operation time was 85 minutes. He was able to tolerate feeds on the 3rd postoperative day (POD), diet on the 5th POD and was discharged on the 8th POD. Satisfactory palliation at home was achieved for ten weeks before death. Laparoscopic gastrojejunostomy is thus a good option for palliation of obstructed advanced gastric cancer.

A rare wandering splenic cyst removed with laparoscopic assistance.

This is a report of the first case of a true cyst arising in a wandering spleen. Laparoscopic splenectomy was attempted. The spleen was mobilized under laparoscopic control and the cyst aspirated. Dissection of the pedicle was technically feasible. However, the procedure was aborted due to uncontrollable bleeding from a moderate-sized artery. Although the whole procedure was not completed laparoscopically, laparoscopic assistance facilitated extirpation of the spleen through a 5-cm oblique left iliac fossa incision in a minimally invasive fashion.

Laparoscopic-assisted right hemicolectomy--a case report.

Laparoscopic colon resection has recently attracted attention as a viable option to open colectomy due to its excellent postoperative recovery. We report the first right hemicolectomy done laparoscopically in Asia in a 62-year-old female patient with Dukes-B2 caecal carcinoma. Bowel sounds were present on the first post-operative day (POD) and diet was resumed on the third. The patient was discharged on the fourth POD. There was no complication of anastomotic leakage or wound infection.

Management of acute cholecystitis in the era of laparoscopic surgery.

Laparoscopic cholecystectomy for acute cholecystitis is a feasible but difficult operation that should only be performed by experienced laparoscopists. Specific modifications to the standard technique of laparoscopic cholecystectomy is described in this review. The conversion to open surgery rate is high, mostly due to dense adhesions obscuring Calot's triangle. However, if successfully completed without complications, the postoperative recovery is superior to the conventional procedure.

Management of fetal sacroccocygeal teratoma.

With the advent of antenatal ultrasound, the focus on sacroccocygeal teratoma has shifted from management at birth to management in the antenatal period. Multidisciplinary approach involving the obstetrician, neonatologist and paediatric surgeon is necessary to achieve good results. Two cases of antenatally detected sacrococcygeal teratomas are reported, one at 24 weeks and the other at 26 weeks of gestation. The tumour was benign in both cases and in both cases, delivery was done at full term. In one case, it was a normal vaginal delivery and in the other, an elective lower segment caesarean section was performed. Close ultrasound follow-up during pregnancy had excluded cardiac failure, hydropic changes and other congenital anomalies which could have altered the management of the pregnancy. Accurate diagnosis of such tumours during antenatal periods may in future allow intrauterine fetal interventional surgery for a premature fetus. The tumour was surgically dealt with successfully in each case on the third day after birth with good clinical results at the end of one year and eight months respectively.

A descriptive study of emergencies admitted to a surgical department.

A study was undertaken to evaluate the pattern of emergency admissions and their management by the surgical firm in a medium size (700 beds) general hospital. Over a three month period, 258 patients were admitted to one surgical team that was on take every third day. All patients were entered into a protocol that was updated daily by a registrar. In four (13.3%) of the 30 days on take, patients had to be referred to a nearby hospital due to shortage of emergency beds. The accuracy of diagnosis by the Accident and Emergency (A&E) resident, surgical resident and surgical team were 75.7, 77.2 and 88.4% respectively. The mean delay before attendance by an intern after admission was 47 (SD +/- 29) mins. Forty-four (17%) of these admissions were probably unnecessary. A further 22 (8.5%) patients had to be referred to other disciplines, indicating an initial wrong diagnosis. A substantial number of investigations were unnecessarily done on an emergency basis. Ninety-three (36.0%) patients required surgery. The median duration of hospital stay was three days. The overall morbidity was 4.2% and mortality 1.2%. The study was valuable in revealing the deficiencies in the existing emergency service; leading to new proposals to achieve our ultimate aim of providing high quality patient care.

Laparoscopic exploration of the common bile duct-report on two cases and literature review.

The optimal management of the common bile duct stone in the era of laparoscopic surgery is not certain. The common policy is selective preoperative endoscopic retrograde cholangio-pancreatography (ERCP) followed by laparoscopic cholecystectomy. When ERCP fails, the common bile duct is explored via open surgery. New techniques of laparoscopic trancystic exploration of the common bile duct and laparoscopic choledochotomy exploration of the common bile duct are now being tried. The results of two case reports are discussed.

Deep vein thrombosis complicating colorectal surgery in the Chinese in Singapore.

It has been reported that the risk of thromboembolism after general surgery in Chinese is negligible, thus, prophylaxis has not been used. This study examined the incidence in the high risk subgroup of patients undergoing colorectal operations. In a two-year retrospective review, 35 rectum resections for cancer, 72 colon resections for cancer, and 22 colon resections for benign disease were analysed. The clinical incidence of deep vein thrombosis (DVT) in patients with malignancy was 4.7% (5/107). None of the patients with benign disease had DVT. Three of the five patients with DVT had pulmonary embolism, of which one died. Rectal surgery incurred a higher risk (11.4%) compared to colonic resection (1.4%) (p = 0.038). Postoperative wound infection was an important predisposing factor (p = 0.027). In view of these findings, a prospective trial has been planned to further evaluate the need for prophylaxis in selected high risk patients.

Laparoscopic-assisted large bowel resection.

Laparoscopic colon resection is a viable alternative to open colectomy. For non-malignant lesions, laparoscopic resection of the affected large bowel is attractive. For malignant lesions, where resection for cure is highly dependent on lymph node clearance, laparoscopic resection has met with criticisms regarding the adequacy of nodal clearance that can be achieved laparoscopically. Several published studies have shown that the operation though technically demanding, does not compromise the extent of resection. We report a series of 43 cases of laparoscopic colon resection done sequentially and successfully from January 1992 to June 1995. The operative time averaged 180 minutes (range 120 to 300 minutes). Five patients developed postoperative complications, which were mainly pulmonary and wound infections. There were no anastomotic leaks or perioperative deaths. The mean hospital stay was 5.3 days (range 4 to 9 days). By the third postoperative day, all patients were feeding and ambulatory. Long-term complications included one small bowel obstruction and one port site recurrence. In our selected group of patients, laparoscopic colon resection has not shown any adverse outcome. Prospective randomised studies are underway in various centres and their preliminary results are favourable.

Probability of adverse events that have not yet occurred: a statistical reminder.

The probability of adverse and undesirable events during and after operations that have not yet occurred in a finite number of patients (n) can be estimated with Hanley's simple formula, which gives the upper limit of the 95% confidence interval of the probability of such an event: upper limit of 95% confidence interval = maximum risk = 3/n (for n > 30). Doctors and surgeons should keep this simple rule in mind when complication rates of zero are reported in the literature and when they have not (yet) experienced a disastrous complication in a procedure.

The surgical treatment of multiple small bowel strictures in Crohn's disease by combined resection and stricturoplasty.

Crohn's disease is extremely rare among Asians. Resection of strictures causing obstruction has traditionally been the accepted choice in surgical therapy. This may lead to problems such as iatrogenic short bowel syndrome and its sequelae. Stricturoplasty is an acceptable and safe alternative. We report a case where combined stricturoplasty and resection was performed safely and advocate its use.

Preoperative ERCP in the management of common bile duct stones before laparoscopic cholecystectomy.

OBJECTIVE: To evaluate the effectiveness of a policy of preoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) before laparoscopic cholecystectomy. DESIGN: Retrospective review. SETTING: University hospital, Singapore. SUBJECTS. From January 1991 to December 1992, 303 patients underwent elective laparoscopic cholecystectomy, of which 46 (15%) were selected to have ERCP preoperatively because they had clinical, biochemical, and ultrasound signs of the presence of stones in the common bile duct (CBD). MAIN OUTCOME MEASURES: Effectiveness and efficiency of ERCP. RESULTS: Successful cannulation of the CBD was achieved in 45/46 cases (98%). In 19 patients (42%) stones were found, of which 18 (95%) were removed endoscopically. There were no major complications from the ERCP or the sphincterotomy. One patient developed symptoms from an unsuspected common duct stone two weeks after cholecystectomy and it was removed endoscopically. CONCLUSION: Selective preoperative ERCP is an effective and safe way of clearing the CBD before laparoscopic cholecystectomy, but its efficiency can be improved further by widening the criteria for preoperative ERCP and by doing operative cholangiography for patients with a low risk of stones in the CBD.