Outcomes and interventions in patients transported to hospital with ongoing CPR after out-of-hospital cardiac arrest - An observational study.

INTRODUCTION: The main objective was to present characteristics and outcome of patients without sustained field return of spontaneous circulation (ROSC) transported to hospital with ongoing cardiopulmonary resuscitation (CPR). Our secondary objectives were to investigate hospital-based interventions and the performance of the universal Termination of Resuscitation-rule (uTOR). METHODS: In this retrospective observational cohort study, out-of-hospital cardiac arrest (OHCA) patients arriving to the emergency department of a university hospital in Sweden during a six-year period (2010-2015) were identified using a prospectively recorded hospital-based registry. Additional data were retrieved from medical records and from the Swedish cardiopulmonary resuscitation registry. RESULTS: Among 409 patients transported with ongoing CPR, 7 survived to hospital discharge (1.7%). Hospital-based interventions against a suspected cause of arrest were attempted during ongoing resuscitation in 34 patients (8.3%), of whom 3 survived to hospital discharge. The remaining 4 survivors had spontaneous in-hospital ROSC. Survivors presented with either a shockable rhythm (n = 4) or pulseless electrical activity (n = 3). The uTOR identified non-survivors with a positive predictive value (PPV) of 98.4% and a specificity of 71.4% for termination. CONCLUSION: Survival after OHCA where sustained prehospital ROSC is not achieved is rare and available in-hospital interventions are rarely utilised. No patient with asystole as the first recorded rhythm survived. The uTOR identified non-survivors with a PPV of 98.4% but showed poor specificity.

Out-of-hospital cardiac arrest termination of resuscitation with ongoing CPR: An observational study.

INTRODUCTION: Termination of resuscitation guidelines for out-of-hospital cardiac arrest can identify patients in whom continuing resuscitation has little chance of success. This study examined the outcomes of patients transferred to hospital with ongoing CPR. It assessed outcomes for those who would have met the universal prehospital termination of resuscitation criteria (no shocks administered, unwitnessed by emergency medical services, no return of spontaneous circulation). METHODS: A retrospective cohort study of consecutive adult patients who were transported to hospital with ongoing CPR was conducted at three hospitals in the West Midlands, UK between September 2016 and November 2017. Patient characteristics, interventions and response to treatment (ROSC, survival to discharge) were identified. RESULTS: 227 (median age 69 years, 67.8% male) patients were identified. 89 (39.2%) met the universal prehospital termination of resuscitation criteria. Seven (3.1%) were identified with a potentially reversible cause of cardiac arrest. After hospital arrival, patients received few specialist interventions that were not available in the prehospital setting. Most (n = 210, 92.5%) died in the emergency department. 17 were admitted (14 to intensive care), of which 3 (1.3%) survived to hospital discharge. There were no survivors (0%) in those who met the criteria for universal prehospital termination of resuscitation. CONCLUSION: Overall survival amongst patients transported to hospital with ongoing CPR was very poor. Application of the universal prehospital termination of resuscitation rule, in patients without obvious reversible causes of cardiac arrest, would have allowed resuscitation to have been discontinued at the scene for 39.2% of patients who did not survive.

Outbreak of Mycobacterium bovis infection in a wild animal park.

An outbreak of tuberculosis due to Mycobacterium bovis occurred in a wild animal park. Three pot-bellied pigs (Sus scrofa vittatus), one red deer (Cervus elaphus), one buffalo (Bison bonasus) and two European lynxes (Lynx lynx) were affected and showed clinical signs including weight loss, enlarged lymph nodes and paralysis of the hindlimbs. Postmortem examinations revealed multifocal granulomatous lesions in various organs, including the lymph nodes, lungs, intestines, kidneys and the central nervous system. Acid-fast organisms were demonstrated in various organs histologically and bacteriologically. Spoligotyping of 17 isolates from various organs of the affected animals confirmed an infection by M bovis and revealed an identical pattern indicating a common origin. The spoligotype was different from the pattern of M bovis recorded in the cattle population in Germany between 2000 and 2006. Investigations of sentinel animals such as an aged silver fox (Vulpes vulpes), a badger (Meles meles), a ferret (Mustela putorius) and rodents, and tuberculin skin tests of the animal attendants and randomly collected faecal samples from the enclosures were all negative for M bovis.

Percutaneous lung biopsy in the horse: comparison of two instruments and repeated biopsy in horses with induced acute interstitial pneumopathy.

The aim of the study reported here was to compare complications of lung biopsy in horses and the quality of the lung specimens after biopsy using the manual Tru-Cut biopsy needle (TC) and an automated biopsy needle (ABN). For experiment 1, lung biopsy was performed in 50 horses with one instrument on one side of the thorax, and then with the other instrument on the other side. Postmortem examination was performed in 20 of the 50 horses. Coughing was detected in 10 of 50 horses and epistaxis was observed in 6 of the 50 horses. Endoscopy revealed bleeding into the airways in 16 of 49 horses and in 5 of 49 horses after biopsy with the TC or the ABN, respectively. Use of the ABN induced a significantly smaller amount of bleeding. Pneumothorax was detected by radiography in 1 of 50 horses. Hematoma diameter determined in 7 of 20 horses at postmortem examination, was significantly larger after biopsy with the TC than with the ABN. The quality of the lung specimen was good. In experiment 2, complications after repeated and multiple lung biopsies in 6 horses were evaluated. Moderate epistaxis was observed on 13 of 104 occasions. Bleeding into the airways was detected at endoscopy on 41 of 104 occasions, and pneumothorax was detected during 4 of 104 occasions. Complications such as hematoma at the biopsy site and bleeding into the airways were greater after biopsy with the TC than after use of the ABN. Lung biopsy specimens obtained with the ABN were fairly safe for the animal.

Heavy-weight versus low-weight polypropylene meshes for open sublay mesh repair of incisional hernia.

BACKGROUND: The introduction of retromuscular, preperitoneal sublay technique using polypropylene (PP) meshes had significantly decreased the recurrence rates after open incisional hernia repair. Nevertheless, recent data of single institutions reported about non-acceptable high hernia recurrences. The objective of this study was to determine early complications and the long-term course of patients who underwent open sublay hernia repair using heavy-weight versus low-weight PP meshes. METHODS: Between January 1996 and December 1997, all consecutive patients received large pore-sized, monofilament heavy-weight PP meshes (Prolene); from January 1998 to December 2001, only large pore-sized, low-weight PP meshes (Vypro) composed of multifilaments were used. The clinical course of all patients was registered during the hospital stay as well as 3 months and at least 12 months after surgery. RESULTS: Sixty-nine patients (mean age 56 +/- 13 years) underwent sublay hernia repair with heavy-weight PP meshes, 106 patients (mean age 60 +/- 14 years) with low-weight PP meshes. No significant differences were determined concerning age, gender, BMI, ASA score, hernia size 25 - 99 cm(2) and number of primary midline incisions. In contrast, mean hernia size and number of hernia size > or = 100 cm(2) were significantly higher, whereas number of hernia size < 25 cm(2), ratio of recurrent hernia and length of hospital stay were lower in the low-weight PP mesh group. Minor complications (17%) appeared more frequently in the heavy-weight than in the low-weight PP mesh group (13%). One patient each with major bleeding required re-operation in both groups. One patient with lethal pulmonary embolism in the heavy-weight PP mesh group and one patient with unrecognised enterotomy and re-operation in the low-weight PP mesh group were registered. In the long-term run (mean follow-up 92 +/- 20 months), patients of the heavy-weight PP mesh group complained significantly more frequently about chronic pain and "stiff abdomen" than those of the low-weight PP mesh group (46 +/- 14 months). Two hernia recurrences occurred in each study group. Two of them were found after midline hernia repair at the edge of the mesh, the remainder were detected after lateral hernia repair. CONCLUSION: Large pore-sized low-weight PP meshes composed of multifilaments are clearly to be favoured over large pore-sized, monofilament heavy-weight PP meshes because of better abdominal wall compliance and less chronic pain. However, both types of meshes are convincing due to high tensile strength and low recurrence rates in the long-term run.

Periventricular and subcortical leukoencephalopathy in two dachshund puppies.

Two wirehaired dachshund puppies were presented with generalized tremor and gait abnormalities characterized by mild ataxia, tetraparesis and slightly abnormal proprioception. Neurological examination led to the suspicion of a diffuse generalized white matter lesion. Computerized tomography and pathological examination revealed a remarkable unilateral dilatation of the lateral ventricles in each dog. Histopathological examination showed a severe reduction of stainable myelin, widespread mild perineuronal oedema with vacuolations and multifocal reactive astrocytosis affecting the subcortical and deep periventricular white, and to a lesser degree, grey matter of the cerebral hemispheres, most prominently at the level of the optic chiasm. Axons showed a moderately reduced packing density; some axons were irregularly shaped and slightly thickened. There was no evidence of myelin breakdown products and neurones appeared to be well preserved. Brain stem, cerebellum and spinal cord were normal, as was the peripheral nervous system. This leukoencephalopathy in two dachshund puppies most closely resembles human periventricular leukomalacia caused by pre- or perinatal hypoxia-ischaemia.

Compensated overexpression of procollagens alpha 1(I) and alpha 1(III) following perilla mint ketone-induced acute pulmonary damage in horses.

Interstitial lung disease with chronic fibrosis is a frequent cause of reduced performance in horses. The aim of this study was to establish a model of acute alveolar damage and interstitial lung disease in horses that could be used to monitor the histopathological lesions and changes in expression levels of genes relevant to pulmonary fibrosis. Six adult horses were given a single intravenous injection (6 mg per kg body weight) of perilla mint ketone (PMK). Transthoracic lung biopsy samples (1 x 0.2 x 0.2 cm) were collected before and after (days 1, 4, 8, 11, 15, 18, 22, 25 and 29) the administration of PMK. Light and electron microscopy revealed severe acute alveolar damage (days 1 to 4), proliferation of type II pneumocytes (days 4 to 11) and finally complete healing at about day 18. However, unexpectedly severe clinical signs necessitated euthanasia in two horses on days 9 and 11. The expression levels of the collagen genes COL1AI and COL3AI as well as transforming growth factor (TGF)-beta were examined in the biopsy samples by reverse transcription-real time quantitative polymerase chain reaction. COL1AI and COL3AI gene expressions were upregulated (3- and 17-fold, respectively) between days 1 and 29 in all six horses, whereas TGF-beta was upregulated in two horses (2- and 4-fold, respectively), between days 4 and 18. Although the gene expression analyses indicated a strong activation of the pro-fibrotic pathway, no interstitial fibrosis was seen in any horse. A complete necropsy performed on day 60 revealed complete recovery of the lungs of the four surviving horses, with no evidence of fibrosis. Unidentified compensatory mechanisms may have prevented pulmonary fibrosis, despite strong upregulation of pro-fibrotic genes.

Laparoscopic lateral adrenalectomy versus open posterior adrenalectomy for the treatment of benign adrenal tumors.

BACKGROUND: Minimally invasive techniques play an important role in adrenal gland surgery. The objective of this study was to compare laparoscopic transabdominal adrenalectomy in the lateral position to the open posterior adrenalectomy with respect to the intraoperative and the short-term postoperative course. METHODS: Forty laparoscopic adrenalectomies (LA) carried out between July 1998 and August 2001 were compared to 30 open posterior operations (PA) performed between July 1994 and June 1998. In all cases the indications for surgery was a benign lesion smaller than 8 cm. RESULTS: Age, gender, tumor size, and distribution of the tumor histology were comparable in both groups (LA vs PA). In favor of LA, statistically significant differences (p <0.05) were observed regarding the intraoperative blood loss (260 vs 380 mL), the postoperative narcotic equivalents (2.9 vs 6.4 mg), the morbidity rate (13 vs 27%), and the length of hospital stay (7 vs 10 days). Average operating time was significantly longer for LA (135 vs 106 min). There were two conversions to open adrenalectomy due to diffuse bleeding. Following LA, we observed one major complication (postoperative bleeding from the spleen making a laparotomy necessary) and four minor complications (one small retroperitoneal hematoma, two subcostal nerve irritations, one pleural effusion). PA resulted in one major (wound infection) and seven minor complications (two subcutaneous hematomas, two nerve irritations, two pleural effusions, one dystelectasis). CONCLUSIONS: Laparoscopic adrenalectomy proved as a safe and reliable procedure, displaying all advantages of minimal access surgery. In our institution, it has become the standard technique employed for benign adrenal disease. However, the operation is technically demanding, and as adrenal surgery is rare, it should be restricted to centers with special interest in laparoscopic and endocrine surgery.

[Chronic appendicitis as an independent clinical entity]. / Die chronische Appendizitis als eigenständige klinische Entität.

INTRODUCTION: Chronic appendicitis is not generally accepted as an independent clinical entity. The diagnosis is often made only after histological analysis when the patient has undergone appendectomy in a case of persistent or recurrent pain. The objectives of this prospective study were to analyse the incidence of chronic appendicitis among our patients, to compare demographic and clinical data with histological results and to evaluate long-term follow-up after appendectomy. METHODS: Between November 1995 and February 1998, 322 patients underwent appendectomy due to typical symptoms of appendicitis. All appendices were analysed macroscopically by the surgeon and histologically by two independent pathologists. Furthermore, demographic data, standard blood results, Alvarado score, body mass index, operation time, complications, and length of hospital stay were evaluated. In April 2001, a long-term follow-up survey evaluated the present complaints of all operated patients. RESULTS: A total of 112 patients showed clinical signs of non-acute appendicitis. However, 26.8% of these appendices histologically revealed an acute inflammation. In the subgroup of histologically non-acute appendicitis, 4.9% of the appendices were inconspicuous, 42.0% chronically inflamed and 50.6% fibrotic. Compared to that, the macroscopic examination by the surgeon resulted in a 93.5% specificity and a 77.8% sensitivity. The preoperative period of pain was significantly longer (7 days) compared to patients with acute appendicitis (0.5 days). White blood count (8.700 versus 13.400) and preoperative Alvarado score (4 versus 7 points) were significantly lower, the hospital stay significantly shorter (3 versus 4 days). A specificity of 89.9% and a positive likelihood ratio of 4.64 were calculated for an optimal cut-off value of 7 days for preoperative pain. At a median of 50.2 months after the operation, 93.1% of the patients were asymptomatic, and five patients reported persistent pain in the right lower quadrant. CONCLUSIONS: Three quarter of all patients with pain in the right lower quadrant but no significant signs of inflammation showed the histological criteria for chronic appendicitis. However, histology revealed signs of an acute inflammation in 25% of patients. An optimal cut-off value of 7 days preoperative period of pain was able to suggest a histologically non-acute appendicitis with a high specificity and a high positive predictive value. More than 93% of these patients were asymptomatic in their long-term follow-up. Chronic appendicitis must be assumed in cases of recurrent or persistent pain longer than 7 days and an elective appendectomy has to be recommended.

[Laparoscopic colostomy: experience in patients with ovarian or ano-rectal cancer, non-operable or with rectovaginal fistula]. / Colostomia per via laparoscopica: esperienze con pazienti affetti da carcinoma ovarico o ano-rettale inoperabile o con fistole retto-vaginali.

Between August 1995 and May 2001 laparoscopic colostomy was successfully carried out in 23 patients with advanced ovarian cancer, inoperable carcinoma of the anorectum or rectovaginal fistulas. There were no intraoperative or postoperative complications and postoperative recovery was rapid with all patients having function of the colostomy within 24 hrs and regaining their preoperative state of mobility on the second postoperative day. The laparoscopic approach allows the careful selection of the colostomy site, easy mobilisation of the colon, causing only little disruption to the intestinal function hence improving postoperative recovery. From Authors' experience, laparoscopic colostomy is a simple and safe operation in most cases and can be used as the preferred technique of intestinal diversion.

Minimally invasive video-assisted parathyroidectomy and intraoperative parathyroid hormone monitoring. The first 36 cases and some pitfalls.

BACKGROUND: The success of parathyroid surgery depends on the identification and removal of all hyperactive parathyroid tissue. At this writing, bilateral cervical exploration and identification of all parathyroid glands represent the operative standard for primary hyperparathyroidism (pHPT). However, improved preoperative localization techniques and the availability of intraoperative parathyroid hormone monitoring prepare the way for minimally invasive procedures. METHODS: Patients with pHPT and one unequivocally enlarged parathyroid gland on preoperative ultrasound and 99mTc-SestaMIBI scintigraphy underwent minimally invasive video-assisted parathyroidectomy by an anterior approach. Intraoperatively, a rapid chemiluminescense immunoassay was used to measure intact parathyroid hormone (iPTH) levels shortly before and then 5, 10, and 15 min after excision of the adenoma. The operation was considered successful when more than a 50% decrease in preexcision iPTH levels was observed after 5 min. RESULTS: Between October 1999 and November 2001, 36 of 82 patients with pHPT were eligible for a minimally invasive approach. A conversion to open surgery became necessary in five patients because of technical problems. In three cases, intraoperative iPTH monitoring showed no sufficient decrease in iPTH values. In these cases, subsequent cervical exploration showed one double adenoma and two hyperplasias, respectively. In two patients we had difficulty interpreting intraoperative iPTH values, resulting in persistent pHPT. CONCLUSIONS: Despite the use of high-resolution ultrasound and 99mTc-SestaMIBI scintigraphy, the presence of multiple glandular disease cannot be ruled out completely. Intraoperative iPTH monitoring to ensure operative success is indispensible for a minimally invasive approach. Despite our problems with iPTH monitoring in two patients, we believe that in selected cases, minimally invasive parathyroidectomy represents an attractive alternative to conventional surgery.

[Duodenosigmoidal fistula in a patient with Crohn's disease]. / Duodenosigmoidale Fistel bei Morbus Crohn.

The development of enteral fistulas - internal and external - is common in Crohn's disease with a frequency of about 45 % in large series of patients. Most internal fistulas arise in the small bowel, but internal large bowel fistulas occur in about one fourth of all patients with fistulas in Crohn's disease. Colonic gastroduodenal fistulas do occur, but are very rare. Of the 35 cases of colonic-duodenal fistulas that we found in the literature, most have been described to involve either a previous ileocolostomy site or the ascending or transverse colon. There are only three cases displaying sigmoidoduodenal fistulas. To these we add a fourth case with this report. A 42-year-old woman presented with upper abdominal pain, loss of appetite and regurgitations with a foul smell as well as abdominal gas complaints. A duodenosigmoidal fistula was diagnosed by local application of contrast and the fistula tract was excised in typical fashion by resection of the colonic fistula and primary closure of the duodenum. The patient experienced a good recovery with relief of symptoms.

[Surgical and adjuvant therapy of neuroendocrine tumors of the gastrointestinal tract and their metastases. A retrospective analysis of personal patient group]. / Die operative und adjuvante Therapie neuroendokriner Tumoren des Gastrointestinaltrakts und ihrer Metastasen. Eine retrospektive Analyse des eigenen Patientenguts.

INTRODUCTION: Carcinoid tumors are the most common neuroendocrine tumors of the gastrointestinal tract. Surgical treatment and prognosis depend on the location of the tumor. METHOD: Between 01.01.1985 and 31.12.1999 25 patients with neuroendocrine tumors of the gastrointestinal tract or their metastases were treated in our institution. The records of these patients were reviewed retrospectively. Patients still alive were reexamined clinically. RESULTS AND CONCLUSIONS: The most frequent primary sites were the ileum and jejunum (36%), appendix (36%), stomach (12%), pancreas (8%), colon (4%) and bronchus with hepatic metastasis (4%). A malignant carcinoid syndrome was present in 8 patients. In patients with neuroendocrine tumors, curative, radical tumor removal should be attempted. Some patients with advanced disease needed some surgery for tumor debulking and resection of metastases. In non-resectable liver metastases hepatic arterial chemotherapy and chemoembolization after implantation of port catheters seem to be very beneficial therapeutic options. A fixed part of the therapeutic regime in progressive disease is adjuvant chemotherapy with 5-fluorouracil and streptozotocin and symptomatic therapy with octreotide.

[The use of an underlay polypropylene mesh in complicated incisional hernias: sucessful French surgical technique]. / Il trattamento dei laparoceli complicati con rete di poliprolilene nella tecnica "underlay": metodo provato della chirurgia francese.

BACKGROUND: Incisional hernia repair with conventional techniques is associated with high recurrence rates of 30-50%. Surgical repair using different prosthetic biomaterials is becoming increasingly popular. On the basis of the favourable results by French surgeons, the results of underlay prosthetic mesh repair using polypropylene mesh in complicated and recurrent incisional hernias have been studied. METHODS: After preparation and excision of the entire hernia sac, the peritoneum and posterior rectus sheath are closed with a continuous looped polyglyconate suture. The prosthesis used for the midline hernias is positioned on the posterior rectus sheath and extends far beyond the borders of the myoaponeurotic defect. The prosthesis for lumbar and subcostal hernias is placed in a prepared space between the transverse and oblique muscles. Intraperitoneal placement of the mesh must be avoided. Between January 1997 and September 1998 a total of 57 incisional hernia repair (25 primary hernias, 32 recurrent hernias) have been performed using this technique (28 women, 29 men, mean age 56+/-13 years). RESULTS: Local complications occurred in 6 patients (11%). One patient suddenly died on the 3rd postoperative day from severe pulmonary embolism (mortality 1,7%). Thirthy-seven patients with a minimum follow-up of 6 months were reexamined clinically (follow up time 6-33 months). Till now one recurrent hernia has been observed. There were only minor complaints like a feeling of tension in the abdominal wall (n = 3) and slight pain under physical stress (n = 9). CONCLUSIONS: The aforementioned technique of underlay prosthetic repair allows an anatomical and consolidated reconstruction of the damaged abdominal wall with excellent results and low complication rates especially in high risk patients and complicated hernias.

[Laparoscopic adrenalectomy with lateral approach--a comparison with the conventional dorsal technique]. / Laparoskopische Adrenalektomie in Seitenlage--ein Vergleich mit der konventionellen dorsalen Technik.

OBJECTIVES: Minimal invasive techniques are gaining more and more acceptance in adrenal gland surgery. In a matched case control study laparoscopic transabdominal adrenalectomy in the lateral position (LA) was compared to the conventional open dorsal technique (DA) with resection of the 11th or 12th rib. METHODS: Between July 1998 and March 2000, 26 LA in 24 patients (two bilateral) were prospectively documented and compared to 25 DA in 23 matched patients (two bilateral), who had been operated on between January 1995 and June 1998. Indications for adrenalectomy in all patients were benign adrenal lesions < 6 cm. RESULTS: Age, gender, average tumor size (3.5 cm/3.6 cm) and tumor types (Conn adenoma: 10/7; Cushing: 8/7, including 2 bilateral in each group; pheochromocytoma: 3/6, incidentaloma: 2/2; others: 3/3) were distributed in both groups (LA/DA) without statistical differences. However, statistically significant differences (P < 0.05) were present (LA vs DA) comparing intraoperative blood loss (200 vs 360 ml), postoperative narcotic equivalents (1.1 vs 6.2), morbidity (8 vs 30%), and length of hospital stay (5.5 vs 9 days). Average operating time was significantly longer in LA (130 vs 105 min), but decreased during the last LA cases to the DA level. One LA had to be converted to open surgery due to diffuse bleeding. Following LA we observed two minor complications (small retroperitoneal hematoma, nerve irritation below the 12th rib); following DA there were 6 minor (2 dorsal subcutaneous hematomas, 2 nerve irritations, dystelectasis, pleural effusion) and one major complication (wound infection). CONCLUSION: LA represents a safe procedure with all the common advantages of minimal access surgery. Based on our experience and that of others, laparoscopic adrenalectomy has become the gold standard for adrenalectomy in most cases of benign adrenal disease. As adrenal surgery is rare, at present LA should be restricted to centers with a special interest in endocrine and laparoscopic surgery.

[Timely management of bile duct complications after laparoscopic cholecystectomy]. / Zeitgerechtes Management von Gallengangkomplikationen nach laparoskopischer Cholecystektomie.

INTRODUCTION: Bile duct complications after laparoscopic cholecystectomy occur twice to three times more frequently than after an open procedure. Four different types of lesions may be differentiated by the Siewert classification: postoperative bile fistulas (type I), late strictures (type II), tangential injuries of the bile duct (type III) and defect lesions (type IV). The diagnostic and therapeutic management is demonstrated in relation to our own experience and the literature. METHODS: Eleven patients (median age 43.8 +/- 17.2) with bile duct complications after laparoscopic cholecystectomy were operatively treated between November 1993 and December 1998. Nine patients (four type-II lesions, five type-IV lesions) were referred from another hospital; 2 defect lesions out of 410 laparoscopic cholecystectomies (0.5%) were documented in our own patient group. RESULTS: Four patients with late strictures were operatively treated with a hepaticocholedochostomy (n = 2) or hepaticojejunostomy (n = 2) after 14.3 +/- 8.4 months and were discharged from hospital after 10.6 +/- 3.8 days. In both cases with type-IV lesion and a short defect, an end-to-end anastomosis was successful (hospital stay 11.6 +/- 1.0 days). However, a retrocolic Roux-Y end-to-side hepaticojejunostomy was performed in all cases with a larger defect (n = 5; hospital stay 14.8 +/- 2.0 days). The two defect lesions in our own group were detected by intraoperative cholangiography and immediately treated after conversion either with hepaticocholedochostomy or hepaticojejunostomy (hospital stay 11.2 +/- 0.6 days). CONCLUSIONS: The incidence of bile duct complications after laparoscopic cholecystectomy might be kept down by anatomic preparation, selective intraoperative cholangiography and early consideration of conversion to open procedure. The clinical course after biliary tract injury can be positively influenced only by a standard diagnostic and operative procedure and by an early transfer to a specialized center.

Laparoscopic loop colostomy for advanced ovarian cancer, rectal cancer, and rectovaginal fistulas.

OBJECTIVES: The objectives of this study were to present a minimal invasive technique of intestinal diversion for selected cases of advanced inoperable ovarian cancer, rectal cancer, and rectovaginal fistulas, and to discuss indications, pitfalls, and potential complications. METHODS: The technical features of laparoscopic colostomy are described. RESULTS: Between August 1995 and July 1997 laparoscopic colostomy was successfully carried out in 12 patients with advanced ovarian cancer, inoperable carcinoma of the rectum, or rectovaginal fistulas. There were no intraoperative or postoperative complications and postoperative recovery was rapid, with all patients having function of the colostomy within 24 h and regaining their preoperative state of mobility on the second postoperative day. CONCLUSION: The laparoscopic approach allows careful selection of the colostomy site and easy mobilization of the colon, causing only little disruption to intestinal function and, hence, improving postoperative recovery. From our experience, laparoscopic colostomy is in most cases a simple and safe operation and can be used as the preferred technique of intestinal diversion.