Laparoscopic vs open appendectomy. Prospective randomized study of outcomes.

OBJECTIVE: To compare open appendectomy (OA) with laparoscopic appendectomy (LA) for length of the operation, complications, postoperative pain control, length of hospitalization, postdischarge recovery time, and hospital charges. DESIGN: Prospective randomized clinical trial of patients with acute appendicitis. SETTING: Tertiary care, urban teaching hospital. PATIENTS: A population-based sample of patients (aged > or = 12 years; weight, > 49.7 kg) admitted to a surgical teaching service with a clinical diagnosis of acute appendicitis. Patients were prospectively randomized to either OA or LA during a 20-month period (from April 1, 1994, to December 31, 1995). Fifty-seven patients were initially enrolled in the study; 7 did not complete the study because of a protocol violation. All remaining patients completed the study, including postdischarge follow-up. INTERVENTIONS: Two (7.4%) of the 27 patients in the LA group required conversion to OA because of technical difficulties. One patient (in the OA group) underwent a second surgical procedure for drainage of a pelvic abscess. Three patients (in the LA group) required second surgical procedures. For analysis, no crossovers were allowed and all patients remained in their originally randomized group. MAIN OUTCOME MEASURES: Length of the operation, intraoperative and postoperative complications, postoperative pain control, length of hospitalization, postdischarge recovery time, and hospital charges. RESULTS: Fifty patients (19 women and 31 men) were examined. Twenty-seven patients underwent LA, 2 requiring conversion to an OA. Twenty-three patients underwent an OA. Patient demographics were similar between groups. Statistical differences between the 2 groups were found for (1) length of the operation (median, 81.7 vs 66.8 minutes, LA vs OA groups: P < .002), (2) operating room charges (median, $3191 vs $1514, LA vs OA group; P < .001), and (3) total hospital charges (median, $5430 vs $3673, LA vs OA group; P < .001). No statistical differences between the 2 groups were found for (1) length of hospitalization (median, 1.1 vs 1.2 days, LA vs OA group), (2) pain control (mean, 4 vs 3.7 of 10 [0 indicates least pain; 10, most pain], LA vs OA group), (3) recovery time (time necessary before returning to work or school) (median, 14.0 days for both groups), and (4) complications (5 vs 1, LA vs OA group). CONCLUSIONS: Laparoscopic appendectomies and OAs are comparable for complications, postoperative pain control, length of hospitalization, and recovery time. Patients who underwent an OA had a shorter operative time and lower operating room and hospital charges. Laparoscopic appendectomy does not offer any proved benefits compared with the open approach for the routine patient with acute appendicitis.

Prophylactic antibiotics for elective laparoscopic cholecystectomy: are they necessary?

HYPOTHESIS: Prophylactic antibiotic treatment in elective laparoscopic cholecystectomy does not lower the already low infection rate associated with this procedure. DESIGN AND SETTING: Prospective double-blind randomized trial at a community-based training hospital. PATIENTS: Four hundred fifty patients undergoing elective laparoscopic cholecystectomy were randomized into 1 of 3 treatment arms: (1) preoperative cefotetan disodium, 1g intravenously; (2) preoperative cefazolin, 1g intravenously; and (3) intravenous placebo. There were no demographic differences between groups in age, smoking history, American Society of Anesthesiologists score, infection risk class, time of antibiotic administration prior to surgery, and type of skin preparation. INTERVENTIONS: Laparoscopic cholecystectomy was attempted in all cases; however, 10 patients required conversion to an open cholecystectomy and they were included in the statistical analysis. Preoperatively, all patients were randomized in a blinded manner and received cefotetan, cefazolin, or placebo intravenously. RESULTS: There were 10 postoperative infections. In the cefotetan group, there were 3 cases of superficial surgical site infections. In the cefazolin group, there were 2 superficial surgical site infections-1 pneumonia and 1 rhinosinusitis. In the placebo group, there were 2 superficial surgical site infections and 1 urinary tract infection. The overall infection rate in this series was 2.4%. Follow-up was performed at routine postoperative visits and by telephone contact. Data were evaluated using the chi2 test and analysis of variance with Duncan post hoc test (P<.05). CONCLUSION: Based on our data, use of prophylactic antibiotics does not decrease the rate of wound infections in elective laparoscopic cholecystectomy.

Thoracoscopic excision of mediastinal parathyroid adenomas: a report of two cases and review of the literature.

BACKGROUND: Most abnormal parathyroid glands can be removed through a standard cervical incision; even those in the superior mediastinum. Those located in certain areas of the mediastinum, for example posteriorly or in the aortopulmonic window, historically have required excision through a median sternotomy or thoracotomy. Angioablation is a nonsurgical alternative to management of these lesions. STUDY DESIGN: We present two case reports of mediastinal parathyroid adenomas that were excised thoracoscopically, and review the literature regarding the management of mediastinal parathyroid adenomas. RESULTS: Both patients who underwent precise localization and thoracoscopic excision of their mediastinal parathyroid adenomas had resolution of their hypercalcemia with minimal associated morbidity and shortened recovery periods. CONCLUSIONS: We suggest that thoracoscopic excision of mediastinal parathyroid adenomas is the better means of controlling hypercalcemia secondary to parathyroid adenoma in those patients considered for either median sternotomy, thoracotomy or angiographic ablation where the exact location of the lesion can be established preoperatively.

Axillary lymph node dissection: is it required in T1a breast cancer?

BACKGROUND: Several authors have questioned the need for axillary lymph node dissection in T1a breast cancer (primary tumors 5 mm or less in diameter), although current practice typically includes routine axillary lymph node dissection. STUDY DESIGN: We retrospectively reviewed the records of 2,242 breast cancers in our tumor registries from 1987 to 1994. The incidence of axillary lymph node metastases was determined according to primary breast cancer size. The objective was to determine the need for axillary lymph node dissection in T1a breast cancers, and our data included 74 T1a cancers. Axillary lymph node dissection was performed in 66 of these patients. RESULTS: Axillary lymph node metastases were found in 3 of 66 cases (4.5 percent). We also reviewed several other institutional series of T1a breast cancers and found no statistical difference in the reported axillary lymph node metastases and our data (p < .10). The combined single-institution data included 256 T1a breast cancers and had a 3.9 percent incidence of axillary lymph node metastases. The Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute published data statistically different from ours. From 1977 to 1982, 339 T1a lesions had a 21 percent incidence of axillary lymph node metastases (p < .005), and from 1983 to 1987, 1,491 T1a lesions had an 11 percent metastatic rate (p < .001). We believe that the SEER data is flawed, because SEER results do not require histologic confirmation of axillary lymph node status. CONCLUSIONS: We believe the single-institution rate of 3.9 percent axillary lymph node metastases in T1a breast tumors results from state-of-the-art breast cancer screening and detection of earlier and smaller lesions. Our data support abandoning routine axillary lymph node dissection in T1a breast cancer.

Does peer-reviewed publication change the habits of surgeons?

BACKGROUND: From April 1994 to December 1995 a prospective randomized trial was conducted at our institution comparing outcomes of laparoscopic and open appendectomy. It demonstrated no significant advantage to laparoscopic appendectomy. Our current study evaluates whether surgeon's habits at our hospital have been influenced by our previously published study. METHODS: Charts were reviewed for patients who underwent appendectomy from August 1998 to December 1998. In addition, a formal survey was conducted of all staff surgeons to ascertain their procedure of choice for appendicitis, and the reasons for their preference. RESULTS: Seventy-nine percent of the appendectomies were attempted laparoscopically. The median operative time was longer for laparoscopic appendectomy, and median hospital charges were higher. Survey results showed that most staff surgeons prefer laparoscopic appendectomy. CONCLUSION: Despite our own published paper supporting open appendectomy over laparoscopic appendectomy, laparoscopic appendectomy has become the standard of care at our institution for the treatment of appendicitis.

Use of fine needle aspiration for solid breast lesions is accurate and cost-effective.

BACKGROUND: Palpable breast tumors have traditionally been diagnosed with open biopsy or core biopsy. We propose fine needle aspiration biopsy (FNA) as a reliable, cost-saving initial procedure in these patients. METHODS: Eighty-five palpable solid breast masses of the breast in 85 patients were classified by a combination of physical examination, mammography, and/or ultrasound as probably benign, indeterminate, or highly suspicious for cancer. All tumors had FNA biopsies. All patients had either a confirmatory open biopsy (55) or close clinical follow-up (30) with a mean follow-up of 29 months (range 6 to 36). RESULTS: Thirty-four patients classified as clinically benign had a benign FNA biopsy. No cancers were detected in this group by either open surgical biopsy or clinical follow-up. Twenty patients were classified clinically as indeterminate. All had FNA biopsies, and 6 were either positive for cancer or suspicious for cancer. Fourteen patients had negative FNA biopsies. Five of the 6 abnormal biopsies had cancer on open biopsies. The 1 false-positive result occurred in a lactating patient. Thirty-one patients were classified clinically as highly suspicious for cancer. Twenty-three were confirmed as cancer with FNA biopsy. Eight needed open surgical biopsy to confirm cancer. All 31 patients clinically suspicious for cancer had cancer. In patients classified clinically as highly suspicious or probably benign, FNA was a reliable first diagnostic step (100% positive predictive value, 100% specificity, 87% sensitivity, and 89% negative predictive value). CONCLUSIONS: Fine needle aspiration biopsy of solid palpable breast lesions should be the diagnostic procedure of choice for those patients classified clinically as probably benign or clinically as highly suspicious for cancer. Cost analysis revealed elimination of an open biopsy in such cases would save $1,100 per patient. For highly suspicious cases, a negative fine needle aspiration should not deter an open surgical biopsy. For patients classified as indeterminate, fine needle aspiration biopsy results are not reliable enough to determine treatment.

Prophylactic antibiotics are not indicated in clean general surgery cases.

BACKGROUND: In assigning risk of infection, the traditional wound classification system has been replaced by the National Nosocomial Infection Surveillance (NNIS) system. NNIS classification is determined by procedure length, wound cleanliness, and ASA status. To date, no prophylactic antibiotic guidelines have been proposed for the NNIS system. METHODS: Clean general surgery cases were retrospectively reviewed in our hospital for infection and prophylactic antibiotic use. These cases were then stratified per the NNIS system. RESULTS: One thousand twenty-three clean general surgery cases had 16 (1%) surgical site infections. The infection rate in NNIS class 0, 1, and 2 cases not given prophylactic antibiotics was 1.21%, 3.03%, and 0%, respectively. The infection rate in NNIS class 0, 1, and 2 cases given prophylactic antibiotics was 0.94%, 2.44%, and 6.67%, respectively. CONCLUSIONS: No statistically significant decrease in infection rate was demonstrated by us using prophylactic antibiotics, regardless of the NNIS classification in clean general surgery cases.

Recurrent common bile duct stones containing metallic clips following laparoscopic common bile duct exploration.

A case of recurrent common bile duct stones 2 years following laparoscopic cholecystectomy and laparoscopic common bile duct exploration in a 52-year-old man is reported. Surgical material as a nidus for recurrent stone formation has been reported and occurred in the present case. Factors influencing metallic clip migration after biliary surgery are discussed, with recommendations for decreasing recurrent stones caused by foreign material.

Laparoscopic paraesophageal hernia repair.

BACKGROUND AND OBJECTIVE: Paraesophageal hernias are uncommon yet potentially lethal conditions. Their repair has now been facilitated by laparoscopic technology. We present a series of 20 patients with paraesophageal hernias repaired laparoscopically. METHODS: Twenty patients with paraesophageal hernias had laparoscopic repairs. Eighteen patients had primary repair of their hiatal defect. Two required mesh reinforcement. Fifteen patients had a fundoplication procedure performed concomitantly. RESULTS: Long-term follow-up is available on 17 patients. There was no in-hospital morbidity or mortality. Average length of stay was 2.3 days. One patient recurred in the immediate postoperative period. There were no other recurrences. The only death in the series occurred in the oldest patient 18 days postoperatively. He had been discharged from the hospital and died of cardiac failure. No patients have had complications from a paraesophageal hernia postoperatively. CONCLUSION: Laparoscopic repair of paraesophageal hernias is possible. Preoperative work-up should include motility evaluation to assess esophageal peristalsis as the majority of these will need a concomitant anti-reflux procedure. This data helps the surgeon to determine whether or not a complete or partial wrap should be done. Repair of the diaphragmatic defect can be accomplished in the majority of patients without the use of prosthetic material with excellent results.

Laparoscopic colon surgery for benign disease: a comparison to open surgery.

BACKGROUNDS AND OBJECTIVES: There remains a debate in the literature about the advisability of laparoscopic surgery for malignant disease of the colon. Current prospective studies will hopefully answer this question. However, for benign diseases of the colon, we believe laparoscopic surgery offers many advantages including decreased postoperative pain, early discharge from the hospital, and early return to normal activities. We retrospectively reviewed our experience with laparoscopic colectomies for benign disease to see whether these procedures could be done safely and if the proposed advantages could be realized. METHODS: Thirty-eight laparoscopic colon resections performed for benign disease were compared to 39 open colon resections with respect to operating times, length of hospital stay, estimated blood loss, days until first postoperative bowel movement, and complications. RESULTS: The laparoscopic colon resection group had decreased length of stay, less blood loss, earlier return of bowel function, and an equivalent number of complications. Laparoscopic cases did take an average of 24 minutes longer. CONCLUSION: The use of laparoscopic colon surgery for benign disease not only affords the patient the advantage of the laparoscopic approach, but also allows the surgeon to gain experience while awaiting the results of ongoing trials for laparoscopic colon surgery in malignant disease.

Supplemental dietary arginine accelerates intestinal mucosal regeneration and enhances bacterial clearance following radiation enteritis in rats.

BACKGROUND: Arginine is a dibasic amino acid with significant metabolic and immunologic, effects especially in trauma and stress situations. Arginine supplementation has been shown to promote wound healing and improve immune system. We designed a study to evaluate the effects of supplemental dietary arginine on intestinal mucosal recovery and bacterial translocation and bacterial clearance after induction of radiation injury in rats. METHODS: Twenty-one male Sprague-Dawley rats were subjected to a single dose of 1100 rads of abdominal X radiation. Rats were divided into three groups; the first group received diet enriched with 2% arginine, the second group with 4% arginine, and the third group with isonitrogenous 4% glycine. Rats were sacrificed 7 days after the radiation. Blood was drawn for arginine levels and mesenteric lymph nodes were harvested for quantitative aerobic and anaerobic cultures. Segments of ileum and jejunum were evaluated for villous height, number of villi per centimeter of intestine, and the number of mucous cells per villous. RESULTS AND CONCLUSIONS: Arginine is absorbed reliably from the gut following oral administration. Dietary 4% arginine supplementation enhanced bacterial clearance from mesenteric lymph nodes compared to 2% arginine and 4% glycine supplemented diet following radiation enteritis in rats. Four percent arginine resulted in clear improvement in intestinal mucosal recovery when compared to 2% arginine and 4% glycine after abdominal irradiation in rats.