Laparoscopic surgery in children and adolescents with suspected appendicitis: results of medical technology assessment.

Laparoscopy has been performed in 43 patients aged up to 18 years with suspected appendicitis; 20 were children 8-15 years and 23 adolescents 16-18 years of age. Diagnostic laparoscopy was successful in 36 (84%) patients; in 7 (16%) subsequent laparotomy was necessary to establish the diagnosis, in 4 (9%) because the appendix was not visualized. Laparoscopic appendectomy was done in 33 (77%) patients, additional laparoscopic adhesiolysis in four and inversion of a diverticulum in one. Changing to laparotomy during the laparoscopic operation was necessary in one patient because of a technical problem and in another because of bleeding of the appendicular artery. Laparoscopy was totally free of complications in 33 (77%) patients; another 9 (21%) had surgical or technical problems without negative outcome for the patient. In one (2%) patient a wound infection led to a negative outcome; there were no other laparoscopy-related events. The mean intensity of pain on the first day after laparoscopic appendectomy was 31 points (Visual Analogue Scale with 100 points) and decreased to nearly zero on the third day; 37% of patients needed opioids on the first and none on the third day. There was no statistical difference for pain intensity and consumption of analgesics after appendectomy via laparoscopy versus laparotomy. We conclude that diagnostic and therapeutic laparoscopy in children and adolescents with suspected appendicitis is a safe and effective procedure.

[Laparoscopic and conventional suture of perforated peptic ulcers--a comparison]. / Laparoskopische und konventionelle Ubernähung perforierter peptischer Ulcera--eine Gegenüberstellung.

After the first successful laparoscopic closure of a perforated peptic ulcer in 1990, 13 consecutive patients with laparoscopic closure were compared to 8 previous patients with conventional surgery. The endpoints adverse advents (complications), pain intensity, fever, leucocytosis and hospital stay showed no clinically relevant differences. Consumption of analgesics was lower in the laparoscopy group. Laparoscopic closure of perforated peptic ulcer is technically feasible. The safety of the method and the benefit for the patient need proof by a randomized controlled trial.

[Laparoscopic or classical appendectomy? A prospective randomized study]. / Laparoskopische oder klassische Appendektomie? Eine prospektiv randomisierte Studie.

Though laparoscopic appendectomy started endoscopic surgery in general surgery, it has yet not reached the acceptance as is the case with cholecystectomy. The application of this technique in possibly bland appendices and reports that the technique was accompanied by severe complications, increases the scepticism about it. This made us decide to start a randomized controlled trial: laparoscopic vs. conventional appendectomy. More than 1000 endoscopic interventions mainly performed at the gallbladder and the stomach and 165 prospectively documented and partly treated patients with acute appendicitis were the basis to start this trial. "Acute Appendicitis" was diagnosed on the basis of clinical symptoms by means of the computer-aided questionnaire of the EC-study "Acute Abdominal Pain", a self-developed validated diagnostic score, the macroscopic findings and the careful assessment of the histology of the resected appendix. Beside the technical feasibility, principle end-points were mainly intensity and course of postoperative pain measured by means of the Visual Analogue Scale (VAS) in lying, standing and moving position and the postoperative consumption of analgesics. We assessed a difference of 15 points on the VAS as clinically relevant. Of 57 patients with acute appendicitis we performed open appendectomy in 23 and laparoscopy in 34 patients according to randomization. In 9 patients of the laparoscopy group it was necessary to change over to open appendectomy for different reasons resulting in a direct comparison of 25 laparoscopies versus 23 open appendectomies. There were no differences between sociodemographic and preclinical data in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluating endoscopy]. / Bewertung der Endoskopie.

Endoscopy is a safe technique with a sensitivity and specificity superior to those of conventional diagnostic procedures, which it has consequently replaced. In doing so, it has also altered many diagnostic and therapeutic concepts. Moreover, endoscopy has positively influenced the previously unaffected course of certain diseases, e.g. upper G. I. bleeding. Endoscopy benefits both the patient and the physician. Although no complete cost-benefit analysis is available, preliminary reports have been favourable. These aspects indicate that endoscopy is highly valuable in a clinical setting. It must be pointed out, however, that endoscopy as a whole has not yet been fully analyzed in any single given clinical study.

[Laparoscopic cholecystectomy--initial experiences and results]. / Laparoskopische Cholecystektomie--Erste Erfahrungen und Ergebnisse.

In a prospective pilot study on 100 consecutive patients with symptomatic cholelithiasis the laparoscopic cholecystectomy shows to be a safe technic without mortality and a low complication rate (3%). The time of operation is influenced by a learning curve of the operation-team and depends on the technical equipment. The postoperative hospital stay is 3 days in median. Postoperatively the pain-intensity is low and decreased very fast. These increased the patients perioperative comfort.

[Indications for construction of stoma pouches]. / Indikation für die Anlage von Stomata.

Despite the advances of reconstructive surgical techniques, there are still indications for enterostoma constructions. Terminal colostomies are constructed after abdominoperineal rectal amputations. The terminal ileostomy is the procedure of choice after total colectomies for Crohn's disease. Loop colostomies are still a possibility for stool diversion procedures and for decompression in acute colonic obstruction. Loop ileostomies reduce load before ileal anastomoses and are increasingly used as diverting stomas in cases of colonic anastomoses. The cecal tube fistula, which does not divert the fecal stream completely, has the special advantage of easy, spontaneous closure.

[Conservative surgery--choice of procedure and strategy: invasive versus minimally invasive surgery]. / Schonendes Operieren--Verfahrenswahl und Strategie: Invasives versus minimal invasives Operieren.

From the patient's view conservative surgery means less stress and strain through therapeutic interventions. Important criteria for assessment are freedom of pain, preservation of health or quick recovery from bodily impairments as well as reestablishment of integrity and fitness. The surgeon meets the patient's expectations through a careful interview, an operation with a minimally traumatizing access, a rather reliable technique and a careful follow-up. Endoscopic surgery most likely complies with this conception. This is shown in a prospective observational study on laparoscopic cholecystectomies in 500 patients and can also be expected for future indications.

Evaluation of routine upper digestive tract endoscopy before laparoscopic cholecystectomy.

Endoscopy of the upper digestive tract was performed in 376 patients with symptomatic gallstone disease before elective laparoscopic cholecystectomy. Abnormalities were found in 60 patients (16.0 per cent); these included peptic ulcer (n = 14), gastric erosions (n = 15) and oesophagitis (n = 11). Thirty patients were treated medically and two by endoscopic polypectomy. In four patients endoscopy led to cancellation of cholecystectomy; in two the complaints have persisted. Statistical analysis of 28 variables showed few significant differences in symptoms between patients with normal and those with abnormal appearances at endoscopy. It is concluded that routine endoscopy before laparoscopic cholecystectomy is neither clinically useful nor cost effective in patients with symptomatic gallstone disease. This conclusion is related exclusively to patients with typical gallstone symptoms according to the definition used in this department.

[Score systems, their importance for the intensive care patient]. / Score-Systeme, ihre Bedeutung für den Intensivpatienten.

Scoring systems are a technique for defining patients for scientific and management purposes. A hypothetical, severely ill patient with cirrhosis, peritonitis, renal insufficiency and coagulation problems can be precisely classified: Child C, Mannheim-Peritonitis-Index 34 and APACHE II score 27 which results in a mortality of at least 70% of patients. At our own hospital, the continuous APACHE score (CAPS) has been developed and tested. The CAPS performed better than daily APACHE scores and provided useful trend information for the individual patient.

[Routine gastroscopy before laparoscopic cholecystectomy: evaluation of the technology in 376 patients]. / Routine-Gastroskopie vor laparoskopischer Cholezystektomie: Technologiebewertung bei 376 Patienten.

We performed endoscopy of the upper digestive tract in 376 patients before elective laparoscopic cholecystectomy. Abnormalities were found in 60 (15.9%); 14 patients had peptic ulcers, 15 gastric erosions, and 11 oesophagitis. Because of endoscopic findings 30 patients were treated medically and 2 by endoscopic polypectomy. Endoscopy lead us to cancel cholecystectomy in 4 patients; in 2 the complaints have persisted. Patients with abnormal endoscopic findings showed few significant differences in 40 variables (history and symptoms) compared with patients with normal findings. The incidence of ulcers, erosions or oesophagitis in patients over 72 years of age without loss of weight was 28.6%, compared with an overall incidence of 10.6%. Endoscopy confined to this group of patients, however, would have shown only 15% of all lesions. Consequently these predictors for endoscopic abnormalities had no practical benefit. Technology assessment according to the criteria of Fineberg et al. showed a health improvement for only 2 patients (0.5%). We conclude that routine endoscopy before laparoscopic cholecystectomy is not clinically useful in patients with symptomatic gallstone disease. This is exclusively related to patients with typical gallstone symptoms according to our definition.

Laparoscopic and conventional closure of perforated peptic ulcer. A comparison.

BACKGROUND: After the first successful laparoscopic closure of a perforated peptic ulcer in 1990, 18 patients with laparoscopic closure were compared to 16 patients with conventional surgery. METHODS: The endpoint adverse events (complications), pain intensity, operation time, fever, leucocytosis, and duration of hospital stay showed no clinically relevant differences. RESULTS: Consumption of analgesics was lower in the laparoscopic group. CONCLUSIONS: Laparoscopic closure of perforated peptic ulcer is technically feasible. The safety of the method and the benefit for the patient need proof by means of a randomized controlled trial.

Conventional versus laparoscopic cholecystectomy and the randomized controlled trial. Cholecystectomy Study Group.

We considered using a randomized trial to assess the value of laparoscopic cholecystectomy in the treatment of symptomatic gallstones. The pros and cons for the timing of such a trial were in favour of not beginning the trial until surgeons learned to use the new procedure safely and effectively, and until key endpoints and outcome indices could be identified and assessed using valid measures. Instead an observational study was implemented to monitor the learning curve of surgeons as they mastered the laparoscopic equipment and procedures, and to assess the responses of the patients to the procedure. In the first 100 patients, the procedure proved to be as safe and feasible to use as conventional surgery, and there were strong benefits in terms of quicker recovery of the patients with less pain, discomfort, and a reduced length of hospital stay. The responses of the surgeons and the patients to the new procedure now place ethical constraints on the planning of a randomized controlled trial. Currently, comprehensive surveillance and monitoring of laparoscopic cholecystectomy is the only realistic method with which to assess the impact of this new technology in our clinic.

Pain after laparoscopic cholecystectomy. Intensity and localization of pain and analysis of predictors in preoperative symptoms and intraoperative events.

It is postulated that laparoscopic cholecystectomy as "patient-friendly surgery" leads to more comfort and in particular to less pain. A prospective study on pain was performed on all patients undergoing the operation over the period of 1 year (n = 382) out of a series of more than 1,000 patients who have undergone the operation in our clinic. Pain was measured by a 100-point visual analogue scale (VAS), by a five-point verbal rating scale, and by the consumption of analgesics. Pain was the most frequent symptom, both before and after the operation. The mean level of pain was 37 VAS points 5 h after the operation and declined to 16 points on the third day. In 106 patients (27.8%) the intensity of pain was higher than 50 VAS points. Analgesics were used by 282 patients (73.8%), opioids by 112 (29.3%). Pain was significantly higher in female than male patients (P < 0.05), but consumption of analgesics was similar in both groups. The most severe pain was localized to the abdominal wall wounds by 157 (41.1%) and to the right upper abdomen by 138 patients (36.1%) on the first postoperative day. Patients who needed opioids and/or had a pain level of > 50 VAS points (n = 138) had higher preoperative pain levels (P = 0.018) and preoperatively complained more frequently about nausea, vomiting, bloating, and a feeling of abdominal pressure (P = 0.003-0.031). However, predictive values of these variables were too small to be of clinical benefit.(ABSTRACT TRUNCATED AT 250 WORDS)

The stress response to laparoscopic cholecystectomy: investigation of endocrine parameters.

Laparoscopic cholecystectomy, as a typical example of minimal invasive surgery, is associated with low complication rates and minimal patient discomfort, and provides the same safety as conventional cholecystectomy. In the present prospective observational study, endocrine parameters as indicators for stress response were measured. We investigated 53 patient with laparoscopy cholecystectomy and 12 patients with conventional cholecystectomy. Blood samples were taken pre-, peri-, and postoperatively for measurement of ACTH, cortisol, prolactin, and growth hormone. General anesthesia followed a standardized protocol. The increase in all stress hormones did not differ between patients in the two groups, and was comparable with that reported in the literature and the findings of our own previous studies in patients undergoing conventional cholecystectomy and elective colon resection. We conclude that laparoscopic cholecystectomy is associated with a pronounced endocrine stress response that does not account for the observed differences in the peri- and postoperative complication rate or patient comfort.

Preincisional local anesthesia with bupivacaine and pain after laparoscopic cholecystectomy. A double-blind randomized clinical trial.

The aim of this study was to investigate whether local anesthesia of abdominal wall wounds prior to laparoscopic cholecystectomy leads to decreased pain beyond the immediate postoperative period and thus improves the comfort of the patient. In a randomized, double-blind study 50 patients scheduled for laparoscopic cholecystectomy were divided into two groups. In one group (n = 25) the skin, subcutis, fascia, muscle, and preperitoneal space were infiltrated with 8 ml of bupivacaine 0.5% 5 min before each abdominal wall incision. The control group (n = 25) received normal saline. The intensity of pain was assessed by a 100-point visual analogue scale (VAS) at rest and during movement and by the consumption of analgesics. Analgesic therapy was provided by on-demand analgesia with piritramide intravenously for 24 h and continued by ibuprofen orally on request. The mean intensity of pain at rest and during movement was lower but not statistically significant in patients who received bupivacaine compared to the control group up to the second postoperative day. The difference was between 4 and 9 VAS points and therefore of doubtful clinical relevance. Similar statistically nonsignificant results were found for the mean consumption of piritramide up to 16 h after the operation. Three patients (12%) in the bupivacaine group localized the most severe pain up to the second postoperative day to the right lower abdominal wall wound where the gallbladder had been extracted compared to 11 patients (44%) of the control group (P = 0.012). These results indicate that bupivacaine was effective at the site where it was administered.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic cholecystectomy: technical performance, safety and patient's benefit.

Laparoscopic cholecystectomy seems to be the most promising new technique for the treatment of symptomatic gallstone disease. For different reasons, controlled clinical trials comparing comfort and trauma for the patient of conventional versus laparoscopic cholecystectomy are difficult to perform at our institution. We therefore report on the results of our first 400 laparoscopic cholecystectomies using a strict and detailed protocol on technical performance, safety and benefit for the patient. Data was obtained immediately after the operation and after a short-term follow-up. To analyze the technical performance and the safety of the procedure, we developed a new classification system (I-V) of adverse events, including both the patients' and the surgeons' viewpoints. Our results show that in nearly 80% of the cases an optimal result (no adverse events in any respect) was obtained. For different reasons, the surgical procedure had to be changed during the operation in 20 cases (5%). In 3 cases (0.8%), an injury of the common bile duct occurred; 2 patients died (mortality 0.5%). On the first post-operative day, vomiting occurred in only 8% and nausea in 19% of the patients. Pain intensity was always below the level where patients demand analgesic medication and declined near zero the day after the operation. Patients fatigue was measured on a scale from 0-10 and rose from 2.2 preoperatively to 3.3 postoperatively. Only a short hospital stay of 3 days median was required. At short-term follow-up 6 weeks after the operation, pain was only rarely reported, the patients were fit and only 20% avoided some kind of food. We conclude that laparoscopic cholecystectomy is the treatment of choice for this precisely defined patient population with symptomatic gallstone disease.

Long-term results after laparoscopic cholecystectomy.

As part of a continuing audit of patients undergoing laparoscopic cholecystectomy (which now numbers over 1500) 468 of the 508 patients (92.1 per cent) operated on between October 1989 and March 1991 were studied between 350 and 988 days after the operation (mean 19 months). A questionnaire was filled in by each patient before operation and at the late follow-up visit. Eight specific symptoms were sought-non-colicky pain, colic, abdominal distension, nausea, vomiting, loss of appetite, flatulence, and dietary restriction. The result of each operation was assessed by two surgeons and by the patient. In 453 patients (96.8 per cent) the symptoms had improved as a result of the operation, but 260 patients (55.6 per cent) had some abdominal symptoms. The result was assessed as excellent in 310 patients (66.2 per cent); 143 (30.5 per cent) still had abdominal complaints but they were willing to cope with those symptoms. In 15 patients (3.2 per cent) the result was unsatisfactory. Statistical analysis of 26 preoperative variables showed few significant differences between patients with excellent results and patients with persisting or new symptoms. The percentage of patients with biliary colic was reduced from 82.9 per cent before to 6.4 per cent after laparoscopic cholecystectomy (P < 0.05), and of those with flatulence from 62.6 per cent to 45.3 per cent (P < 0.05). Flatulence persisted in 147 (50.2 per cent) of the 293 patients who had complained of flatulence before the operation, and of the 175 patients who had not complained of flatulence before surgery, 65 (37.1 per cent) reported the symptom for the first time after the operation. It appears that 'flatulent dyspepsia' after cholecystectomy has many causes, one of which may be removal of the gallbladder. It is concluded that the long-term results of laparoscopic cholecystectomy in patients with symptomatic gallstone disease were excellent but the prognosis in individual patients was unpredictable.