Randomized clinical trial comparing radially expanding trocars with conventional cutting trocars for the effects on pain after laparoscopic cholecystectomy.

BACKGROUND: Trocar incisions are important sources of pain the first days after laparoscopic cholecystectomy. Radially expanding trocars may cause less pain than conventional cutting trocars. METHODS: In a patient- and observer-blinded trial, 80 patients were randomized to undergo laparoscopic cholecystectomy using either radially expanding trocars (radial group) or conventional cutting trocars (cutting group). Two 10-mm and two 5-mm trocars were used in both treatment groups. All the patients received standardized anesthetic and analgesic treatment. The primary outcome was incisional pain. Pain was registered during mobilization using a visual analog scale (VAS) and a verbal rating scale (VRS) before and 6 h after the operation, and at postoperative days 1 and 2. The needs for a fascial incision to retract the gallbladder, active surgical hemostasis, and supplementary requirements of opioids during the hospital stay were registered. In addition, 2 days after the operation, the incidence and severity of suggilations at the trocar incisions were measured. RESULTS: Data from 77 patients were available for statistical analysis. In the radial group, 23 patients needed fascial incision for gallbladder retraction compared with 11 patients in the cutting group (p = 0.006). No significant intergroup differences in VAS or VRS pain scores or any other variable were found. CONCLUSIONS: The use of radially expanding trocars has no effect on incisional pain after laparoscopic cholecystectomy.

Pancreaticoduodenectomy for periampullary cancer in patients more than 70 years of age.

BACKGROUND/AIMS: To assess the indications for and results of pancreaticoduodenectomy in patients more than 70 years old with periampullary cancer. METHODOLOGY: Thirty-four consecutive patients older than 70 years with periampullary cancer. The surgical procedure was pancreaticoduodectomy (Whipple's operation) with an extensive dissection of lymph nodes and the connective tissue in the peripancreatic region. Main outcome measures were postoperative morbidity and mortality, median and 5-year survival rates. RESULTS: Postoperative medical complications occurred in 24% and surgical complications in 53% of the patients. Four patients (12%) died in the postoperative period (within 30 days), and 3 patients (9%) died later in the postoperative course. The cumulative and age corrected 5-year survival rate for the remaining patients was 26%. Fifteen patients died of recurrence, and 7 patients of other causes. Five patients are still alive more than 5 years after surgery. In patients with noncurative operation the median survival time was 1 1/2 years, which is longer than would be expected from other palliative procedures. Apart from a moderately increased postoperative mortality the results were similar to those reported for younger patients. CONCLUSIONS: Pancreaticoduodenectomy should be considered in patients older than 70 years with resectable periampullary cancer. A 5-year survival rate of 20-35% can be obtained. Palliative resection may be indicated in patients in good general condition, as resection gives the best palliation and longer survival than other palliative methods.

Deformity after fracture of the lateral humeral condyle in children.

We studied 28 displaced (Jacob types II and III) fractures of the lateral humeral condyle in 28 children. There were only two Milch type I fractures. Twenty-one fractures were treated by open reduction and internal fixation with K-wires, Palmer nails, or sutures. Seven patients were treated with a plaster cast, five following closed reduction, and the primary displaced position being accepted in two. Anatomic reduction was obtained in 18 patients. All but one fracture were united at review 2 years to 16 years later. The distal humerus was wider on the injured side in all patients. Six patients had a visible varus deformity, and three patients had a visible valgus deformity. The radiologic tilt of the joint surface and the depth of the trochlear groove were measured in patients more than 10 years old at review. All patients with a final varus tilt of the joint surface on the injured side were less than 9 years of age at injury, and all but one of the patients with Milch type II fractures had a deepening of the trochlear groove. Two patients developed avascular necrosis of the trochlea. One of these had a concomitant fracture of the medial humeral epicondyle, and the other suffered a lateral condylar fracture preceded by a supracondylar fracture. We conclude that a reduced growth potential at the trochlear groove is a regular complication of the Milch type II fracture, and that the Jacobs classification is the most useful in the assessment of the method of treatment.

[Pancreaticoduodenectomy--Whipple's operation--for periampullary cancer in patients over 70 years of age]. / Pankreatikoduodenektomi--Whipples operation--for periampullaer cancer hos patienter over 70 år.

Thirty-four consecutive patients with an age over 70 years with periampullary cancer were operated on with pancreaticoduodenectomy (Whipple's procedure). The operative procedure included an extensive dissection of the regional connective tissue and lymph nodes including the retroperitoneum. Postoperative medical complications occurred in 24% and surgical complications in 53% of the patients. Four patients (12%) died in the postoperative period (within 30 days), and three patients (9%) died later in the postoperative course. The cumulative and age corrected five-year survival for the remaining patients was 26%. Fifteen patients died from recurrence, and seven patients from other causes. In patients with a non-radical operation the median survival was 1 1/2 years, which is longer than could be expected with other palliative procedures. Apart from a moderately increased postoperative mortality the results were similar to those reported for younger patients. In conclusion, pancreaticoduodenectomy may be considered in patients with an age over 70 years with operable periampullary cancer. A five-year survival rate of 20-35% can be obtained. Palliative resection is indicated in patients in good general condition, as resection gives the best palliation and longer survival than other palliative methods.