Laparoscopic appendectomies: results of a monocentric prospective and non-randomized study.

BACKGROUND/AIMS: Appendicitis is one of the most frequent causes of abdominal pain in western countries. It occurs in 6 to 7% of the United States population. Despite laboratory and imagery tests, 15 to 40% appendices removed by laparotomy appear to be normal at histological examination. Thus, others pathologies beside appendicitis may be found in patients with right lower quadrant pain. This had led some to advocate laparoscopy for patients suspected to have acute appendicitis. The aim of this study is to determine the contribution of laparoscopy in patients with right lower quadrant pain and the implications of removing a macroscopic normal appendix. Rates of all pathologies and normal appendices were found at laparoscopy. Morbidity, mortality rates and length of hospital stay linked to laparoscopic appendectomy. DESIGN: Prospective non-randomized study. METHODOLOGY: Between January 1995 and September 2004, 615 patients have been approached by laparoscopy for acute, subacute or chronic abdominal right-lower-quadrant pain in our Department of Digestive and Laparoscopic Surgery. Thirteen patients have not been hold and the study involves 602 patients including 311 men and 291 women with a mean age of 33 years. All removed tools have been analyzed histologically. During the same period, only 5 patients have been approached by laparotomy. RESULTS: Five hundred and thirty patients (88%) had appendicitis, 39 patients (6.5%) had another pathology and no disease was found in 33 patients (5.5%). According to the sex, appendicitis was found in 242 women (83.2%) versus 288 men (92.6%). Thirty-four women (11.7%) versus 5 men (2%) had another pathology. The local morbidity was 4.3%, the general morbidity 1% and the mortality was 0%. The average length of postoperative hospital stay was 4 days (range: 1-27). Oral intake was assumed on average 1.5 days postoperatively (range: 0-13). There were 10 reoperations (1.6%). CONCLUSIONS: Laparoscopy is a reliable technique, safe and reproducible. It is an effective and relatively atraumatic tool to investigate abdominal cavity. This allows an accurate decision-making, which is especially advantageous in young women who have a high rate of non-appendicular pathologies. Laparoscopy also reduces the rate of unnecessary abdominal exploration while realizing a correct diagnosis of others possible pathologies. We therefore advocate laparoscopy in patients with abdominal right-lower-quadrant pain, especially women.

Computer-controlled stapling system for lung surgery.

PURPOSE: Current disposable hand-actuated staplers may pose reliability problems, especially with respect to the measurement of tissue thickness. We have evaluated a newly developed stapler with a computer-controlled placement of staples. DESCRIPTION: The SurgAssist system (Power Medical Interventions, New Hope, PA) is comprised of a console that houses a computer, a remote control unit, a flexible shaft, and a cartridge. The remote control unit has two uses: (1) controlling the accurate placement of the cartridge by orientating the tip of the flexible shaft, and (2) controlling the closure of the stapler and the firing. Each cartridge contains a programmed electronic device that triggers the activation of the appropriate program in the main microprocessor. The compression level on the tissue is determined by the computer. EVALUATION: The system was used in a consecutive series of 38 patients, 26 times during open lung surgery and 12 times during video-assisted thoracic surgery. The following open procedures were performed: three pneumonectomies, 15 lobectomies, three segmentectomies, and five wedge resections. The following video-assisted thoracic surgery procedures were performed: eight wedge resections and four bullectomies for pneumothorax. There was no stapling failure and no complication related to the use of the stapler. During video-assisted thoracic surgery, some ergonomic problems were encountered that will be overcome by redesign. CONCLUSIONS: The computer-controlled stapling system may significantly improve tissue approximation during open and video-assisted thoracic surgery.

10-year experience with the ATS mechanical valve in the mitral position.

BACKGROUND: The ATS Medical Open Pivot mechanical heart valve was introduced in 1992. Previous reports have focused on the low rate of thromboembolic complications in the aortic position. The purpose of this retrospective study is to analyze the rate of midterm thromboembolic events and other valve-related complications when the ATS Open Pivot valve is implanted in the mitral position. METHODS: Between June 1992 and June 2002, 177 patients (63 male and 114 female; mean age 57.5 years) underwent mitral replacement with an ATS Open Pivot mechanical heart valve. Preoperatively, 17 patients (10%) were in New York Heart Association functional class II, 117 patients (66%) in class III, and 43 patients (24%) in class IV. Seventy-four patients (42%) were in chronic atrial fibrillation. Seventy-four mitral valve replacements (42%) were associated with other cardiac procedures. Etiologies included degenerative disease (56%), rheumatic disease (38%), and endocarditis (6%). On the second postoperative day, 100 mg acetylsalicylic acid and oral acenocoumarol (Sintrom) was introduced to obtain a target INR of 2.0 to 3.0. All patients were followed up by one cardiologist and underwent annual transthoracic echocardiographic examination. RESULTS: Percent follow-up was 90.4%. Data represent 724 total patient-years. Mean follow-up was 48 +/- 34 months (range, 1 to 119). Operative morbidity was 15%. Overall hospital mortality was 2.8% (5 patients). At hospital discharge, the mean INR for all the patients was 2.38 +/- 0.68 (range, 1.32 to 6.44). Five early neurologic complications occurred: 3 transient cerebrovascular accidents and 2 strokes. Three late transient cerebrovascular ischemic accidents occurred at 3, 4, and 6 years, respectively. No other complications such as paravalvular leak, valve dysfunction, thrombosis, or valve explant occurred. Postoperative echocardiographic data revealed low mean pressure gradient as related to the valvular size. CONCLUSIONS: The ATS Medical Open Pivot mitral valve demonstrates low rates of bleeding, thromboembolic, and other valve-related complications.

Esophageal perforation by echoprobe during cardiac surgery: treatment by endoscopic stenting.

The usefulness and safety of transesophageal echocardiography during cardiac surgery have been well described in the literature. However, rare complications of this procedure can occur and should be familiar to surgeons and anesthesiologists. A case of esophageal perforation by echoprobe during coronary artery bypass grafting treated successfully by endoscopic stenting is reported.