Is there a role of preservation of the spleen in distal pancreatectomy?

BACKGROUND: The spleen may be preserved during distal pancreatectomy (DP) for benign disease. The aim of this retrospective study was to compare the postoperative course of DP with or without splenectomy. STUDY DESIGN: From June 1992 to June 1997, 40 adult patients without chronic pancreatitis underwent elective DP for benign lesions. Fifteen underwent spleen-preserving DP (Conservative Group) and 25 DP with splenectomy (Splenectomy Group). In spleen-preserving DP, we attempted to preserve the splenic artery and vein. RESULTS: Spleen-preserving DP was successfully performed in all 15 cases. Patient groups were comparable for clinical features, indication for DP, and surgical procedure. There were no postoperative deaths. The overall incidence of pancreatic fistula was 23%, but was significantly higher in the Conservative Group (40%) than in the Splenectomy Group (12%; p < 0.05). Subphrenic abscesses were more frequently observed in the Conservative Group than in the Splenectomy Group (p < 0.05). The mean duration of postoperative hospital stay was 19 days (range 6 to 46 days) in the Conservative Group and 12.5 days (range 7 to 45 days) in the Splenectomy Group (p < 0.05). At the end of mean followup of 30 months (range 8 to 40 months), no severe postsplenectomy sepsis was observed in the Splenectomy Group. CONCLUSIONS: In our experience, DP with splenectomy has a lower morbidity rate and we consider it to be the best procedure for benign pancreatic disease.     

Is there any benefit of preservation of the spleen in distal pancreatectomy?

For a pancreatic body or tail tumor, distal pancreatectomy with splenectomy (DPS) is a standard operation. Spleen-preserving distal pancreatectomy (SPDP) was introduced in order to preserve the organ and thus provide the patient with a better quality of life. Clinical data were compared between 38 Japanese patients with DPS and 9 with SPDP for benign tumors or tumor-like lesions at the body or tail of the pancreas at preoperative, early postoperative (< 3 months after operation), and late postoperative periods (>6 months after operation). The preoperative findings were not different between the two groups except for the significantly higher serum amylase levels in the SPDP group. Operation time, operative blood loss, and length of postoperative hospital stay were not different between the two groups. Pancreatic fistula occurred in 3 (8%) of the 38 patients in the DPS group and in 1 (11%) of the 9 patients in the SPDP group, abdominal abscess in 5 (13%) of the 38 patients in the DPS group and none (0%) in the 9 patients in the SPDP group. At short-term, clinical findings were not different between the two groups except for a significantly greater platelet count in the DPS group than in the SPDP group (46.8 x 10(4)/microl versus 29.6 x 10(4)/microl, P = 0.0081). At long-term after the operation, clinical findings, including the platelet count, were not different between the two groups. Computed tomography revealed a pseudocyst in 9 (53%) of 17 patients examined in the DPS group and in 3 (75%) of 4 patients examined in the SPDP group at short-term after operation. All patients with pseudocysts were asymptomatic. Two asymptomatic patients (one in the DPS group and one in the SPDP group) first developed a pseudocyst at long-term after the operation. The alteration of glucose tolerance was similar between the two groups. Postoperative pancreatic exocrine function (the N-benzol-L-tyrosyl-p-aminobenzoic acid test) was not different between the two groups. These data suggest that SPDP with preservation of the splenic vessels can be satisfactorily performed without elongating operative time and postoperative hospital stay or increasing risk of postoperative complications, with the exception of increased platelet count in the DPS group at short-term after the operation. Thus, SPDP is worth considering as one of the options for the treatment of benign lesions of the body or tail of the pancreas.     

Is laparoscopic approach to lumbar spine fusion worthwhile?

BACKGROUND: Laparoscopic lumbar spine fusion has been recently described. The aim of this study is to evaluate the safety and efficacy of this procedure for single- and multiple-level degenerative disc disease. METHODS: Twenty-four consecutive laparoscopic interbody lumbar fusions were evaluated prospectively (18 single-level were compared with 6 multiple-level procedures). Results of the laparoscopic multiple-level procedures were further compared with 12 open multiple-level operations. RESULTS: Twenty procedures were completed laparoscopically. The conversions were related to iliac vein lacerations (3 cases) and a mesenteric tear. Single-level cases had lower morbidity (22% versus 83%), shorter hospital stay (2 versus 10 days), and higher fusion rate (88% versus 50%) than multiple-level procedures. Overall results in the latter group were worse than in the matched open group. CONCLUSIONS: Laparoscopic single-level fusion (L5-S1) is safe and carries the benefits of minimal access surgery. Morbidity after multiple level approach is high, and this procedure cannot be advocated at this time.     

Is it worthwhile to screen the hip in infants born with clubfeet?

Purpose

There is some disagreement about whether idiopathic congenital talipes equinovarus (CTEV) increases the risk of neonatal developmental dysplasia of the hip (DDH). This study aimed to investigate the incidence of DDH in our infants with idiopathic CTEV.

Methods

We conducted an observational cohort study over a three-year period to assess the relationship between idiopathic CTEV and DDH. All neonates younger than six weeks with idiopathic CTEV who were treated in our medical centre were admitted to this study. Each subject underwent hip ultrasound examination using the Graf method at the age of six weeks. DDH was diagnosed when a hip was type IIa(−) or worse according to the Graf classification of sonographic hip type.

Results

A total of 184 patients were diagnosed with idiopathic CTEV and underwent hip sonography. In total, seven hips of five individuals underwent treatment (four girls and one boy). The results indicated that 2.7 % of babies (five of 184) with idiopathic CTEV had DDH. However, we did not find any statistically significant difference (p = 0.5776) in the Pirani scores between the DDH group and group with normal hips.

Conclusions

This study revealed that the idiopathic CTEV group had a greater incidence of DDH in comparison with the general population. It is recommended that hip sonography be undertaken particularly in patients with idiopathic CTEV.     

Manipulation and injection for hallux rigidus. Is it worthwhile?

Manipulation of the metatarsophalangeal joint and injection with steroid and local anaesthetic are widely practised in the treatment of hallux rigidus, but there is little information on the outcome. We report the results of this procedure carried out on 37 joints, with a minimum follow-up of one year (mean, 41.2 months). Patients with mild (grade-1) changes gained symptomatic relief for a median of six months and only one-third required surgery. Two-thirds of patients with moderate (grade-2) disease proceeded to open surgery. In advanced (grade-III) hallux rigidus, little symptomatic relief was obtained and all patients required operative treatment. We recommend that joints are graded before treatment and that manipulation under anaesthetic and injection be used only in early (grades I and II) hallux rigidus.     

Revision hip surgery in the elderly: Is it worthwhile?

We prospectively analyzed the outcome in 103 consecutive patients undergoing revision hip replacement, dividing the patients into 2 groups according to their age at the time of surgery. There were 45 patients aged 75 years or older and 58 patients aged younger than 75 years. The results of revision hip replacement in terms of pain relief, functional improvement, and patient satisfaction did not differ between the 2 groups. There was a significantly higher death rate among the elderly patients (13.3% versus 1.7%; P = .0202) and a significantly higher rate of dislocation (20% versus 1.7%; P = .0019). We conclude that revision hip replacement is an effective operation in the elderly, but that patient and surgeon must be aware of the risks that such surgery entails.     

Is it safe to reuse disposable laparoscopic trocars?rid=""

BACKGROUND: The reuse of disposable laparoscopic instruments carries a risk of transmitting infectious diseases such as hepatitis and HIV. We evaluated the safety of reusing disposable trocars by studying the chances of their harboring infectious viruses after resterilization in an in vitro setting. METHODS: Disposable laparoscopic trocars were exposed to horse blood contaminated with high or low viral concentrations of herpes simplex virus type 1 (HSV1) and attenuated polio virus type 1 at room temperature for 2 h. HSV1 was chosen as the surrogate for lipid viruses that include hepatitis B and HIV virus; polio virus represented the nonlipid viruses that cause infections in immunocompromised patients and are more resistant to sterilization. The trocars were subsequently cleaned and resterilized by low-temperature steam and formaldehyde at 80 degrees C for 3 h. Viral cultures were then repeated after sterilization. RESULTS: A cytopathic effect (CPE) was demonstrated at both concentrations for HSV1 in all trocars before but not after sterilization. For the polio virus, CPE was evident in 50% of the trocars (two of four) exposed to high viral concentration after sterilization. CONCLUSION: Disposable trocars are difficult to resterilize and may harbor infectious viruses after their initial use. Therefore, the reuse of disposable trocars in laparoscopic surgery cannot be recommended.     

Is it possible to perform a laparoscopic assisted Hartmann's procedure and a subsequent laparoscopically assisted reversal in complicated diverticulitis?

Surgery of complicated sigmoid diverticulitis should be as gentle as possible. Serious time pressure, unpredictable operation fields and unprepared bowel determine the surgical strategy. Hence, we examine whether minimal invasive surgery (MIS) (i. e., Hartmann procedure) is suited for emergency conditions in selected patients. Furthermore, the objective of the study was to -assess the feasibility of the reversal of Hartmann procedure in appropriate patients after a preceding classical or laparoscopic intervention. -Between 2005 and 2009 128 patients with sigma diverticulitis were operated, 72 patients of them with complicated sigmoid diverticulitis (peritonitis, haemorrhage, ileus, perforation), The classical Hartmann procedure was performed in 45 (35 %) patients, 39 of them being treated within 24 hours. The laparoscopically assisted Hartmann procedure was realised in 15 patients and could be successfully completed in 13 cases. The cor-responding mortality rate was 0 %. A Hartmann reversal could be performed in 26 patients (58 %). A laparoscopic approach was chosen in 16 patients and could be successfully completed in 14 cases. 12 patients were operated with classical Hartmann reversal. The respective mortality rates in both groups were 0 %. We therefore conclude that in cases of peritonitis due to sigmoid diverticulitis laparoscopic surgery, like laparoscopically assisted Hartmann procedure and a subsequent laparoscopically assisted reversal could be recommended in selected patients.     

Is antegrade stenting superior to retrograde stenting in laparoscopic pyeloplasty?

PURPOSE: We describe a simple and timesaving technique of antegrade stenting. We compared it with retrograde stenting in laparoscopic pyeloplasty. MATERIALS AND METHODS: From December 2002 to August 2003, 24 patients with mean age of 24.29 years (range 5 to 57) had a Double-J (Medical Engineering Corp., New York, New York) stent placed laparoscopically after finishing the posterior suture line. The stent and ureteral catheter straightened over the guide wire were introduced through the lumen of a 5 mm hook or suction canula via a subcostal port. This technique was compared with retrograde stenting in 21 consecutive patients with mean age of 24.45 years (range 6 to 65) in terms of stenting time and failure to stent leading to conversion. RESULTS: In 23 of 24 cases laparoscopic stenting could be completed in a mean time of 5.2 minutes. In case 1 the stent was lying outside the pelvis because it was placed after ureteropelvic anastomosis was completed. The stent was retrieved after placing the ports again and reinserted with retrograde technique. In subsequent cases the stent was inserted successfully after completing the posterior suture line and visualizing the ureteral lumen. Mean time of retrograde stenting was 39.35 minutes. One case was converted to open pyeloplasty after retrograde stenting failed and in another 5Fr ureteral catheter was left instead. However, this patient required percutaneous stenting on postoperative day 5. With retrograde stenting stent severance and upward migration into the ureter occurred in 1 patient each, while none of the patients with laparoscopic stenting showed such problems. CONCLUSIONS: Laparoscopic stenting is a simple technique that obviates the need for an additional procedure and decreases the risk of the stent being cut or migrating upward. It also provides better anatomical delineation and dissection around the ureteropelvic junction since the pelvis remains distended. In addition, it makes suture placement and knot tying easy.