Comparison of early outcome from transperitoneal versus transhepatic percutaneous cholecystostomy.

BACKGROUND/AIMS: To determine whether there is a statistically significant difference in the short-term clinical outcome in patients undergoing percutaneous cholecystostomy based on the anatomic route of gallbladder puncture that is, transhepatic versus transperitoneal. METHODOLOGY: Our population consisted of 132 patients who: 1) presented with acute cholecystitis, 2) were at high risk for surgery because of comorbid conditions, 3) underwent percutaneous cholecystostomy either using computed tomography guidance or ultrasound guidance and whose anatomic route was known: the transhepatic percutaneous cholecystostomy group comprised 59 patients, the transperitoneal group 73 patients. Demographic characteristics and clinical parameters of the groups were compared statistically, as were postprocedure hospital course, complications and time to hospital discharge. RESULTS: The two groups were similar in demographic characteristics. There was a statistically significant tendency for computed tomography-guided percutaneous cholecystostomy to be transhepatic, and for ultrasound-guided percutaneous cholecystostomy to be transperitoneal. There were no differences in short-term postprocedure complications between the two groups. There was a tendency for shorter time to hospital discharge following transperitoneal percutaneous cholecystostomy. CONCLUSIONS: Transperitoneal and transhepatic percutaneous cholecystostomy are similar in short-term safety, with no significant difference in complication rate. The interventional radiologist can feel secure in performing percutaneous cholecystostomy using either approach.

Filtered signal-averaged P-wave duration during pneumoperitoneum in patients undergoing laparoscopic cholecystectomy: A reflection of pathophysiological cardiac changes.

BACKGROUND: Induction of pneumoperitoneum (PP) may lead to adverse cardiac functions secondary to changes such as decreased venous return and hypercarbia. The assessment of cardiac electrical activity by signal averaging may reflect various hemodynamic derangements and serve as a prognostic marker for arrhythmias. The aim of the study is to examine characteristic electrocardiographic changes that may occur during PP, by using signal-averaged P-wave analysis. METHODS: Twenty healthy (ASA I and II) patients were enrolled in a prospective paired control study, and underwent elective laparoscopic cholecystectomy. A standard ECG together with computerized filtered signal-averaged P-wave duration measurement (leads X, Y, Z) were carried out during awareness, under anesthesia before and during PP, and after CO(2) evacuation. Depth of anesthesia was controlled by bi-spectral index (BIS). RESULTS: An increased duration of P-wave was observed during PP in comparison to the anesthesia phase before PP (111 versus 115 ms, t-test and Wilcoxon signed rank test). A significant increase was also detected in the maximal value of P-wave duration between these phases of the operation. The difference in the number of patients in whom the duration increased by at least 5 ms was also found to be significant. CONCLUSIONS: Primarily, a decreased P-wave duration was expected, due to cardiac autonomic sympathetic predominance during PP. Its prolongation during PP may reflect some cardiac pathophysiological (structural and functional) changes, including influence on cardiac ion channels during depolarization. Usually, clinical consequences related to laparoscopic cholecystectomy are absent, but clinical awareness should be maintained for cardiac diseased patients undergoing prolonged laparoscopic procedures.

Overcoming reduced hepatic and renal perfusion caused by positive-pressure pneumoperitoneum.

HYPOTHESIS: Use of the intermittent sequential pneumatic compression (ISPC) device may improve splanchnic and renal perfusion caused by positive-pressure pneumoperitoneum (PPP) in patients undergoing laparoscopic cholecystectomy. DESIGN: Prospective controlled study. SETTING: University hospital. PATIENTS: Twenty-two consecutive patients undergoing elective laparoscopic cholecystectomy whose cardiac output decreased at least 10% on induction of PPP. INTERVENTION: The ISPC device was activated over the lower limbs 15 minutes after PPP was established for the remainder of surgery. MAIN OUTCOME MEASURES: Urine output, cardiovascular functions, and hepatic and renal perfusion were measured during the surgical phases; urine output was quantified in a matched control group (n = 30). RESULTS: Induction of PPP significantly decreased cardiac output and stroke volume, while ISPC significantly reversed these changes. Increased systemic vascular resistance during PPP was reversed by ISPC. Activation of the pneumatic sleeves during PPP increased the mean +/- SD portal venous and hepatic arterial blood flows from 0.86 +/- 0.30 to 1.33 +/- 0.44 L/min (P<.001) and from 0.26 +/- 0.10 to 0.38 +/- 0.19 L/min (P = .002), respectively; the mean renal segmental arterial index decreased with ISPC from 0.68 +/- 0.05 to 0.63 +/- 0.08 (P = .003). During PPP, urine output decreased from 1.10 to 0.28 mL/min per meter squared (P = .001) but improved markedly with ISPC to 0.61 mL/min per meter squared (P = .01). Such improvement was absent in the control group. CONCLUSIONS: Use of ISPC significantly improves hepatic and renal blood flows during PPP. Its application is recommended during prolonged laparoscopic procedures, including laparoscopic live donor nephrectomy.

Monitoring cardiac stress using features extracted from S1 heart sounds.

It is known that acoustic heart sounds carry significant information about the mechanical activity of the heart. In this paper, we present a novel type of cardiac monitoring based on heart sound analysis. Specifically, we study two morphological features and their associations with physiological changes from the baseline state. The framework is demonstrated on recordings during laparoscopic surgeries of 15 patients. Insufflation, which is performed during laparoscopic surgery, provides a controlled, externally induced cardiac stress, enabling an analysis of each patient with respect to their own baseline. We demonstrate that the proposed features change during cardiac stress, and the change is more significant for patients with cardiac problems. Furthermore, we show that other well-known ECG morphology features are less sensitive in this specific cardiac stress experiment.

Reversal of adverse hemodynamic effects of pneumoperitoneum by pressure equilibration.

HYPOTHESIS: The creation of positive-pressure pneumoperitoneum during laparoscopic operations can lead to adverse hemodynamic changes, mainly decreased cardiac output. We hypothesized that pneumatic compression sleeves worn on the legs during pneumoperitoneum could abolish the pressure gradient between the abdominal cavity and the legs and so eliminate these adverse hemodynamic changes. DESIGN: Prospective, randomized, controlled clinical trial with an additional calibration group. SETTING: A regional referral center. PATIENTS: Forty-five consecutive patients undergoing laparoscopic cholecystectomy who developed hemodynamic changes on induction of positive-pressure pneumoperitoneum were randomized to 3 groups. INTERVENTIONS: Low-pressure, nonsequential pneumatic compression sleeves, wrapped around the legs, were used to equilibrate the pressure gradient in the study group and to gradually exceed it in the calibration group. In the control group, no sleeves were used. MAIN OUTCOME MEASURES: Transesophageal Doppler cardiac output, stroke volume, and systemic vascular resistance were monitored noninvasively. RESULTS: The creation of positive-pressure pneumoperitoneum caused a significant decrease of cardiac output and stroke volume and increased systemic vascular resistance. In the experimental groups of patients, pressurizing the sleeves to the pneumoperitoneal pressure caused a significant increase of cardiac output (from 4.82 to 6.74 L/min), increased stroke volume, and decreased systemic vascular resistance (P<.001). This was not seen in the control group. Additional gradual pressure increase in the sleeves of the calibration group produced no further improvement. Releasing the pressure abolished the hemodynamic advantages. CONCLUSIONS: Applying pressure on the legs equivalent to the positive-pressure pneumoperitoneum improves hemodynamic performance during pneumoperitoneum by nullifying the pressure gradient that is responsible for the adverse consequences. This might be of major practical value, especially for cardiac patients undergoing prolonged laparoscopic operations.

Improving the adverse changes in cardiac autonomic nervous control during laparoscopic surgery, using an intermittent sequential pneumatic compression device.

BACKGROUND: The creation of positive pressure pneumoperitoneum (PP) may lead to adverse cardiovascular effects during laparoscopic operations. It can also lead to increased sympathetic cardiac activity, that might have serious consequences. We hypothesized that by reversing the hemodynamic effects, the use of intermittent sequential pneumatic compression device (Lympha-press) on the lower extremities would lead to improved cardiac autonomic control. METHODS: This was a prospective cohort study, in which patients served as their own control. Fifteen patients without cardiorespiratory disease undergoing elective laparoscopic cholecystectomy were enrolled prospectively. The activity of the cardiac autonomic nervous system was evaluated by using spectral analysis of heart rate variability, with the Del Mar Avionics 363 (Irvine, California), based on the fast Fourier transformation. The Lympha-press was manipulated several minutes after induction of PP. In each frequency band we measured and compared the power values during anesthesia against those of PP, as well as those of PP against those recorded during activation of Lympha-press. RESULTS: Creation of PP caused increased sympathetic activity, as was manifested by increased power of the low frequency band. Manipulation of the Lympha-Press compression device caused increased parasympathetic activity, as was evident by significant increased power of the high frequency band in all patients. CONCLUSIONS: Using an intermittent sequential pneumatic compression device during laparoscopic cholecystectomy may improve cardiac autonomic control by enhancing protective parasympathetic activity. That may have clinical significance, especially in patients suffering from cardiac disease, by improving heart rate variability and elevating the threshold of the occurrence of ventricular arrhythmia.

Laparoscopically assisted approach for postoperative ventral hernia repair.

BACKGROUND: The laparoscopic approach to incisional hernia repair is already well established because of its advantages. We evaluated the possibility of using a laparoscopically assisted approach whenever conversion to open repair was considered. PATIENTS AND METHODS: We operated laparoscopically on 62 patients for postoperative ventral hernia (POVH), seven of whom had undergone laparoscopically assisted repair. The reasons for considering conversion were mainly technical difficulties in adhesiolysis and hernia reduction, and the suspected possibility of intestinal injury during dissection. The assisted approach included creation of a short incision over the fascial defect, exploration of the hernia contents and correction of any intestinal injury, completion of adhesiolysis, closure of the abdominal cavity, and laparoscopic accomplishment of the repair. RESULTS: Following open exploration, two iatrogenic intestinal perforations and one serosal injury were found and repaired. In four cases, only the completion of adhesiolysis was necessary. The postoperative convalescence was uneventful, and no recurrence has been recorded to date. CONCLUSIONS: The laparoscopically assisted approach to difficult POVH repair is feasible and safe, and it helps to preserve the advantages of the laparoscopic approach. We recommend this approach whenever conversion to open surgical repair is under consideration during laparoscopic repair.

Evaluation of liver enzymes following elective laparoscopic cholecystectomy: are they really elevated?

BACKGROUND: Studies made on a small number of patients have demonstrated significant modifications in liver function tests (LFT) following laparoscopic cholecystectomy. AIM: To assess retrospectively, post-operative LFT in a large group of patients undergoing elective uneventful laparoscopic cholecystectomy. METHODS: Between 1999 and 2007, 1,997 patients were scheduled for laparoscopic cholecystectomy. In 1,034 patients (the study group), the surgery was elective and normal LFT were measured a day prior to surgery. Exclusion criteria included acute cholecystitis, acute pancreatitis, pre-operative endoscopic retrograde cholangio-pancreatography, medication that may affect liver metabolism, and intra-operative complications. Liver function tests were evaluated pre-operatively and 20-24 h post-operatively. RESULTS: The mean post-operative value of liver function tests and amylase were well within normal limits, although mild increase was inspected in part of it. We observed post-operative mild hepatic enzyme increase only in 41 patients (3.9%), in nine of these, choledocholithiasis was found. CONCLUSIONS: In contrary to previously published data, we have validated, in light of our broad sampling, that the induction of CO(2) pneumoperitoneum does not cause deranged liver function tests.

Fecal impaction in children: report of 53 cases of rectal seed bezoars.

BACKGROUND: Rectal seed bezoars in children seem to present an uncommon problem that necessitates some operative intervention. PURPOSE: Our objective is to determine the occurrence and clinical characteristics of rectal seed bezoars in children with fecal impaction. METHODS: A retrospective review of hospital records of children with discharge diagnosis of fecal impaction was conducted from 1996 to 2005 in a university-affiliated general hospital RESULTS: The study group is composed 59 children. A total of 53 had rectal seed bezoars: watermelon seeds in 43 children, prickly pear seeds in 6, sunflower seeds in 3, and pumpkinseeds in 1. Six children had seedless fecal impaction. All the children with seed bezoars were of Arab origin. Fifty children were treated under general anesthesia. Of the remaining 9 children, 5 underwent digital disimpaction without general anesthesia: 3 with seedless feces and 2 with rectal seed bezoars. Four children with rectal seed bezoars evacuated spontaneously without digital disimpaction. There was summer seasonal preference for watermelon and prickly pear seed bezoars, whereas sunflower seed bezoars occurred in the spring. CONCLUSIONS: Fecal impaction owing to rectal seed bezoars is more common than previously believed. Its occurrence among Arab children alone in this study might indicate a high proportion of fecal seed bezoars throughout the Middle East. We propose that the preferred treatment should include disimpaction and irrigation of the rectal content under anesthesia. Greater awareness by primary care practitioners and parents might be beneficial in its prevention in the future.

Validation and reduction of the oxidative stress following laparoscopic operations: a prospective randomized controlled study.

OBJECTIVE: To validate ischemia-reperfusion mechanism during laparoscopic cholecystectomy, and to assess the reduction of oxidative stress by an intermittent sequential pneumatic compression (ISPC) device. SUMMARY BACKGROUND: Increased intraperitoneal pressure during laparoscopic operations may lead to decreased cardiac output and visceral perfusion, and possible ischemia-reperfusion effects. Using the ISPC device was shown to improve cardiac output and visceral perfusion during pneumoperitoneum (PP). METHODS: Twenty patients undergoing elective laparoscopic cholecystectomy were enrolled in a randomized prospective controlled study and divided into 2 groups: 1) study group (10 patients), activation of ISPC together with creation of PP; and 2) control group, without ISPC. Lipid peroxidation and glutathione levels (as indicators of oxidative stress) as well as liver and renal function tests, were measured before and at the end of PP, and again at 30 minutes, 4 hours, and 24 hours afterward, together with hemodynamic and respiratory parameters. RESULTS: There was no significant difference between both groups concerning liver enzymes and bilirubin, nor in hemodynamic parameters. In the control group, increased lipid peroxide levels were noted 4 hours after PP termination, in comparison to pre-PP levels (590.4-649.2 mmol/L, P = 0.002). In the study group (ISPC), such changes were not inspected. Decreased total glutathione levels were noted in the control group, 30 minutes following CO2 evacuation. CONCLUSIONS: Our study validates the ischemia-reperfusion mechanism following laparoscopic surgery. The use of an ISPC device decreased the oxidative stress (secondary to relative ischemia-reperfusion insult) following PP, probably due to improved cardiac output and visceral perfusion.

Fecal impaction in adults: report of 30 cases of seed bezoars in the rectum.

PURPOSE: Seed bezoars in the rectum have been considered an uncommon cause of fecal impaction in adults. Although there have been several reports on sunflower seed bezoars, seed bezoars from the fruit of the prickly pear cactus and watermelon have received little notice. This study was designed to determine the frequency of fecal impaction by seed bezoars in the rectum and their clinical characteristics in adults. METHODS: A retrospective review of the medical records of patients hospitalized with the diagnosis of fecal impaction during a ten-year period. RESULTS: During the study period (January 1996 to December 2005), 55 patients were hospitalized at the Western Galilee Hospital, in northern Israel, with the diagnosis of fecal impaction. Phytobezoars were found in 30 patients (55 percent). The seed bezoars were composed of prickly pear seeds in 12 patients, watermelon seeds in 10 patients, sunflower seeds in 4 patients, popcorn kernels in 1 patient, and pomegranate seeds in 1 patient. The Jew:Arab ratio for seed bezoars was 7:23. Seventy-three patients had seedless fecal masses with a Jew:Arab ratio of 58:15. All 30 patients with bezoar underwent digital disimpaction under general anesthesia. Only 21 of 73 patients with seedless fecal masses were treated under general anesthesia. CONCLUSIONS: Seed bezoars found in the rectum were the most common cause of fecal impaction requiring hospitalization, probably to the result of the eating habits in the Middle East. The consumption of seeds with shell fragments or fruits containing many seeds (such as the prickly pear) should be accompanied by the awareness that large quantities may cause fecal impaction.

Interposition of a jejunal segment as an alternative one-stage operation for acute left colon obstruction.

PURPOSE: Much debate surrounds the one-stage surgical management of acute left colon obstruction. Many surgeons are still reluctant to perform primary anastomosis in unprepared bowel fearing the risk of anastomotic dehiscence. Although intraoperative lavage and subtotal colectomy have recently proved effective for preventing fecal loading, both of these procedures have drawbacks and the search for additional alternative surgical procedures continues. We conducted an experimental study to examine a new one-stage operation, consisting of the interposition of a jejunal segment to the resection site of the colon, to manage acute left colon obstruction. METHODS: The colons of 20 domestic pigs were obstructed, and 2 days later, segmental resection and either primary colo-colonic anastomosis or interposition of a jejunal segment was performed. Autopsies were done 6 weeks after the operations and the anastomotic regions were subjected to bursting pressure analysis. RESULTS: The operating time was longer in the interposition group at 49 +/- 14 vs 38 +/- 12 min ( P < 0.01). There was no mortality or clinical signs of anastomotic dehiscence in either group. A perianastomotic abscess was detected on autopsy in one animal from the primary colo-colonic anastomosis group. The bursting pressures of the jejunocolic anastomoses were significantly higher ( P < 0.001) than those of the primary colo-colonic anastomoses. CONCLUSIONS: These experimental results suggest that jejunal interposition may be a feasible alternative to primary colonic anastomosis to create intestinal continuity after resection for acute obstruction of the left colon.