Influence of "liberal" versus "restrictive" intraoperative fluid administration on elimination of a postoperative fluid load

BACKGROUND: Previously, the authors found "liberal" fluid administration (approximately 3 l Ringer's lactate [RL]) to improve early rehabilitation after laparoscopic cholecystectomy, suggesting functional hypovolemia to be present in patients receiving "restrictive" fluid administration (approximately 1 l RL). Because volume kinetic analysis after a volume load may distinguish between hypovolemic versus normovolemic states, the authors applied volume kinetic analysis after laparoscopic cholecystectomy to explain the difference in outcome between 3 and 1 l RL. METHODS: In a prospective, nonrandomized trial, the authors studied 20 patients undergoing laparoscopic cholecystectomy. Ten patients received 15 ml/kg RL (group 1) and 10 patients received 40 ml/kg RL (group 2) intraoperatively. All other aspects of perioperative management were standardized. A 12.5-ml/kg RL volume load was infused preoperatively and 4 h postoperatively. The distribution and elimination of the fluid load was estimated using volume kinetic analysis. RESULTS: Patient baseline demographics and intraoperative data did not differ between groups, except for intraoperative RL, having a median of 1,118 ml (range, 900-1,400 ml) in group 1 compared with a median of 2,960 ml (range, 2,000-3,960 ml) in group 2 (P<0.01). There were no significant preoperative versus postoperative differences in the size of the body fluid space expanded by infused fluid (V), whereas the clearance constant kr was higher postoperatively versus preoperatively (P=0.03). The preoperative versus postoperative changes in volume kinetics including V were not different between the two groups. CONCLUSIONS: Elimination of an intravenous fluid load was increased after laparoscopic cholecystectomy per se but not influenced by the amount of intraoperative fluid administration.     

Influence of Liberal versus Restrictive Intraoperative Fluid Administration on Elimination of a Postoperative Fluid Load

Background: Previously, the authors found "liberal" fluid administration (approximately 3 l Ringer's lactate [RL]) to improve early rehabilitation after laparoscopic cholecystectomy, suggesting functional hypovolemia to be present in patients receiving "restrictive" fluid administration (approximately 1 l RL). Because volume kinetic analysis after a volume load may distinguish between hypovolemic versus normovolemic states, the authors applied volume kinetic analysis after laparoscopic cholecystectomy to explain the difference in outcome between 3 and 1 l RL.

Methods: In a prospective, nonrandomized trial, the authors studied 20 patients undergoing laparoscopic cholecystectomy. Ten patients received 15 ml/kg RL (group 1) and 10 patients received 40 ml/kg RL (group 2) intraoperatively. All other aspects of perioperative management were standardized. A 12.5-ml/kg RL volume load was infused preoperatively and 4 h postoperatively. The distribution and elimination of the fluid load was estimated using volume kinetic analysis.

Results: Patient baseline demographics and intraoperative data did not differ between groups, except for intraoperative RL, having a median of 1,118 ml (range, 900-1,400 ml) in group 1 compared with a median of 2,960 ml (range, 2,000-3,960 ml) in group 2 (P < 0.01). There were no significant preoperative versus postoperative differences in the size of the body fluid space expanded by infused fluid (V), whereas the clearance constant kr was higher postoperatively versus preoperatively (P = 0.03). The preoperative versus postoperative changes in volume kinetics including V were not different between the two groups.     

Effect of prolonged pneumoperitoneum on intraoperative urine output during laparoscopic gastric bypass

BACKGROUND: Intraoperative oliguria is common during laparoscopic operations. The objective of this study was to evaluate the effects of prolonged pneumoperitoneum during laparoscopic gastric bypass (GBP) on intraoperative urine output and renal function. METHODS: 104 patients with a body mass index between 40 and 60 kg/m2 were randomly assigned to laparoscopic (n = 54) or open (n = 50) GBP. Intraoperative urine output was recorded at 30-min intervals. Blood urea nitrogen and creatinine levels were measured at baseline and on postoperative days 1, 2, and 3. Levels of antidiuretic hormone, aldosterone, and plasma renin activity were also measured in a subset of laparoscopic (n = 22) and open (n = 24) GBP patients at baseline, 2 hours after surgical incision, and in the recovery room. RESULTS: The laparoscopic and open groups were similar in age, gender, and body mass index. There was no significant difference in amount of intraoperative fluid administered between groups (5.4 +/- 1.6 L, laparoscopic versus 5.8 +/- 1.7 L, open), but operative time was longer in the laparoscopic group (232 min versus 200 min, p < 0.01). Urinary output during laparoscopic GBP was 64% lower than during open GBP at 1 hour after surgical incision (19 mL versus 55 mL, p < 0.01) and continued to remain lower than that of the open group by 31-50% throughout the operation. Postoperative blood urea nitrogen and creatinine levels remained within the normal range in both groups. Serum levels of antidiuretic hormone, aldosterone, and plasma renin activity peaked at 2 hours after surgical incision with no significant difference between the two groups. CONCLUSION: Prolonged pneumoperitoneum during laparoscopic gastric bypass significantly reduced intraoperative urine output but did not adversely alter postoperative renal function.     

Selective intraoperative cholangiography during laparoscopic cholecystectomy: how selective?

The necessity for intraoperative cholangiography during laparoscopic cholecystectomy has been debated for some time. Numerous retrospective studies favor selective intraoperative cholangiography. Surgeons in favor of the selective policy differ in their personal selective criteria. The aim of this prospective study was to evaluate whether intraoperative cholangiography can be safely omitted during laparoscopic cholecystectomy on all patients who fit a standard set of criteria: normal liver function tests, common bile duct diameter less than 10 mm, and no history of gallstone pancreatitis or jaundice. We undertook a prospective study on 155 consecutive patients treated in a county teaching hospital with symptomatic gallbladder disease who met the above standard set of criteria. One hundred and fifty-five patients meeting these criteria underwent laparoscopic cholecystectomy during a 2-year period from February 1996 through February 1998. Data analyzed included patient history, laboratory and ultrasound findings, operative results, postoperative stay, and intraoperative and postoperative complications. The patients were followed by periodic interviews, physical examination, liver function tests, and/or biliary ultrasound for up to 3 1/2 years with a mean follow-up of 26 months for retained common bile duct stones. Intraoperative cholangiography was performed in only one of the 155 patients studied to confirm common bile duct injury. There were four postoperative complications (2.6%) and one common bile injury (0.6%). Postoperative stay averaged one day. No patients, by history, biliary ultrasound, liver function tests or endoscopy, were found to have retained common bile duct stones during the follow-up period. Our study shows that intraoperative cholangiography is not necessary for patients undergoing laparoscopic cholecystectomy who have normal liver functions tests, common bile duct diameter less than 10 mm, and no history of gallstone pancreatitis or jaundice.     

Physiologic effects of intravenous fluid administration in healthy volunteers

Dose regimens in perioperative fluid management are rarely evidence based. Therefore, we investigated responses to an IV fluid infusion in healthy volunteers to assess basic physiologic effects of a fluid infusion per se. In a prospective, double-blinded, cross-randomized study, 12 healthy volunteers with a median age of 63 yr (range, 59-67 yr) received an infusion of lactated Ringer's solution 40 mL/kg (median, 2820 mL) or 5 mL/kg (median, 353 mL; background infusion) in random order on two separate occasions. The study was designed to mimic the perioperative course with preoperative fasting, infusion of the fluid over 3 h in the morning, and additionally 24-h hospitalization under standardized conditions. Primary outcome assessments were pulmonary function (spirometry), exercise capacity (submaximal treadmill test), balance function (BalanceMaster), and weight. Infusion of 40 mL/kg of lactated Ringer's solution compared with the background infusion (5 mL/kg) resulted in a significant decrease in pulmonary function and a significant weight gain of median 0.85 kg (range, -0.2-1.6 kg; P = 0.003) persisting 24 h after the infusion. Exercise capacity and balance function were not influenced by fluid administration. These findings may serve as a basis for clinical studies applying the same type of fluid in different amounts to determine the optimal amount of perioperative fluid in various surgical procedures. IMPLICATIONS: Infusion of 40 mL/kg of lactated Ringer's solution in volunteers led to a significant decrease in pulmonary function and a significant weight gain for 24 h but without effects on exercise capacity. These findings may serve as basis information for clinical studies of perioperative fluid management.     

Normal saline versus lactated Ringer's solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair: an outcome study

Metabolic acidosis and changes in serum osmolarity are consequences of 0.9% normal saline (NS) solution administration. We sought to determine if these physiologic changes influence patient outcome. Patients undergoing aortic reconstructive surgery were enrolled and were randomly assigned to receive lactated Ringer's (LR) solution (n = 33) or NS (n = 33) in a double-blinded fashion. Anesthetic and fluid management were standardized. Multiple measures of outcome were monitored. The NS patients developed a hyperchloremic acidosis and received more bicarbonate therapy (30 +/- 62 mL in the NS group versus 4 +/- 16 mL in the LR group; mean +/- SD), which was given if the base deficit was greater than -5 mEq/L. The NS patients also received a larger volume of platelet transfusion (478 +/- 302 mL in the NS group versus 223 +/- 24 mL in the LR group; mean +/- SD). When all blood products were summed, the NS group received significantly more blood products (P = 0.02). There were no differences in duration of mechanical ventilation, intensive care unit stay, hospital stay, and incidence of complications. When NS was used as the primary intraoperative solution, significantly more acidosis was seen on completion of surgery. This acidosis resulted in no apparent change in outcome but required larger amounts of bicarbonate to achieve predetermined measurements of base deficit and was associated with the use of larger amounts of blood products. These changes should be considered when choosing fluids for surgical procedures involving extensive blood loss and requiring extensive fluid administration. IMPLICATIONS: Predominant use of 0.9% saline solution in major surgery has little impact on outcome as assessed by duration of mechanical ventilation, intensive care unit stay, hospital stay, and postoperative complications, but it does appear to be associated with increased perioperative blood loss.     

Prospective, double-blinded, randomized, placebo-controlled comparison of local anesthetic and nonsteroidal anti-inflammatory drugs for postoperative pain management after laparoscopic surgery

Compared with the open approach, laparoscopy has been shown to significantly reduce postoperative pain. Improving postoperative analgesia in laparoscopic surgery is an area of continued interest. The goal of this study was to compare the efficacy of local anesthetic infiltration with or without preoperative nonsteroidal anti-inflammatory drugs. Patients undergoing elective laparoscopic cholecystectomy were enrolled in an Institutional Review Board-approved, prospective, double-blinded, randomized, placebo-controlled comparison study. Patients were randomized into four groups: Group I, preoperative oral administration of a placebo medication and preincision local infiltration of 40 mL of 0.5 per cent bupivicaine at trocar sites; Group II, preoperative oral administration of 50 mg of rofecoxib; Group III, preoperative oral administration of 50 mg of rofecoxib and preincision local infiltration of 40 mL of 0.5 per cent bupivicaine into skin, muscle, and peritoneum; and Group IV, preoperative oral administration of a placebo medication. Postoperative pain scores were assessed at 4 hours, 8 hours, 12 hours, and 24 hours using a visual analog scale. Postoperative analgesic use, complications, and length of stay were recorded. Statistical significance was defined as P < 0.05. Fifty-five patients (46 women and 9 men) were enrolled in this study and underwent a standardized, elective, laparoscopic cholecystectomy for mild, symptomatic cholelithiasis (96.4%) and gallbladder polyps (3.6%). No patient had pain immediately before surgery. Postoperative analgesic requests, visual analog scale results, incidence of postoperative vomiting at 4 hours, 8 hours, 12 hours, and 24 hours, in addition to length of stay, were not statistically different between the four groups. No complications occurred. The use of preoperative rofecoxib, 0.5 per cent bupivicaine infiltration, or both for postoperative analgesia did not decrease postoperative pain or decrease length of stay after laparoscopic cholecystectomy compared with placebo. Preoperative administration of an oral anti-inflammatory pain medication, infiltration of a local anesthetic, or both had no greater effect than placebo in controlling discomfort after a laparoscopic cholecystectomy. The challenge of preempting postoperative pain continues and will require further investigation.     

Preliminary results of transumbilical single-port laparoscopic cholecystectomy

Single-port laparoscopic cholecystectomy was developed with the aim of reducing the invasiveness of traditional laparoscopy, diminishing postoperative pain and morbidity. The aim of this prospective study was to assess the feasibility and the efficacy of this new approach. Between April and December 2009, a total of 21 patients underwent single-port laparoscopic cholecystectomy for symptomatic gallbladder stone disease. Single surgeon, elective patient, no preoperative diagnosis of common bile duct stone and no previous upper abdominal surgery were the selection criteria chosen for the study. Attempt to reproduce the standard technique (routine intraoperative cholangiography) was considered. Twenty patients (95.2%) successfully completed single-port surgery, and the median operative time was 65 min (range 40–122). Conversion to standard laparoscopic cholecystectomy was required for one patient (4.8%) for a difficult haemostasis. Intraoperative cholangiography was performed for 14 patients (66.7%). Seven patients (33.3%) were discharged on the same day of the operation; median hospital stay was 1 day (range 1–4). No postoperative complications were observed; one patient was reoperated on the same day of surgery because of unexplained abdominal pain and leucocytosis, but relaparoscopy demonstrated no fluid collection. On the 1st postoperative day, median VAS was 3. Most patients declared to be satisfied with the result of the operation and the resulting scar. Transumbilical single-port access cholecystectomy is feasible using standard laparoscopic instruments. It may reduce morbidity, postoperative pain and may offer cosmetic advantages compared with standard laparoscopic approach. However, presently the procedure may be performed only by surgeons with wide experience with this operation through standard laparoscopic access.     

腹腔镜与开腹胆总管切开取石术应激反应差异分析

目的比较两种手术术式应用于结石患者治疗时应激反应差异。方法选取胆总管结石患者80名,随机分为腹腔镜组和开腹组,每组40例,均接受胆囊切除术和胆总管切开取石术;应用SPSS 20.0软件包进行数据处理,术中出血量、手术时间、术后胃肠道功能恢复时间、术后住院时间、Cor、C-P、FT3水平等计量资料以(x珋±s)表示,采用t检验;不良反应发生率等计数资料采用χ2检验,P0.05为差异具有统计学意义。结果腹腔镜组患者术中出血量、肠道功能恢复时间和住院时间显著低于开腹组(t=12.019,t=6.757,t=10.343,P0.01)。腹腔镜组患者术后3 d内血清皮质醇(Cor)、C-肽(C-P)和游离三碘甲状腺原氨酸(FT3)水平显著优于开腹组(t=6.296,t=11.030,t=7.408,P0.01)。腹腔镜组患者术后并发症发生率显著低于开腹组(χ2=15.313,P0.01)。结论腹腔镜胆总管切开取石术术中损伤小、术后恢复快患者应激反应小并发症发生率低,具有临床应用价值。     

Single access cholecystectomy using standard laparoscopic instruments

The aim of this study was to verify feasibility and safety of single incision laparoscopic cholecystectomy using conventional surgical instruments. Twenty patients underwent single incision laparoscopic cholecystectomy. Indications for cholecystectomy were symptomatic cholelithiasis. Operative time, postoperative length of stay, intraoperative and postoperative complications, postoperative pain (by visual analogue scale), and patient cosmetic satisfaction were considered. All 20 procedures were successfully concluded without additional skin incisions. The mean operative time was 69 ± 16 min with a trend toward a reduction in operating time with increasing surgical experience. Intraoperative bile leakages for gallbladder rupture were observed in only three cases. No postoperative complications were recorded. The median pain scale value was 3 and the median value of cosmetic satisfaction was 3. The mean postoperative length of stay was 1.3 ± 0.9 days. Single incision laparoscopic cholecystectomy with conventional surgical instruments is a feasible and safe procedure, but additional studies in larger series are needed to confirm our results.     

A prospective randomized pilot study of near-infrared spectroscopy-directed restricted fluid therapy versus standard fluid therapy in patients undergoing elective colorectal surgery

There are substantial data supporting the concept that algorithms that effectively limit fluid volumes to patients undergoing elective surgery, particularly intraoperatively, significantly reduce perioperative morbidity. We hypothesized that intraoperative fluid limitation could be safely accomplished when guided by near-infrared spectroscopy (NIRS) monitoring, and that this fluid restriction regimen would result in a reduction in postoperative morbidity when compared with standard monitoring and fluid therapy. The intent of this pilot study was to demonstrate the feasibility and ease of conduct of this study protocol before expanding to the multicenter pivotal trial. We performed a prospective, (2:1) randomized, pilot study at two centers. A total enrollment of 24 fully evaluable patients undergoing elective open colorectal surgery (16 restricted, 8 standard) was planned. After providing informed consent, patients were randomized to standard fluid resuscitation (500 LR induction bolus, then LR 7 mL/kg/h x 1 h, then 5 mL/kg/h) or restricted fluid resuscitation (no induction bolus, then LR 2 mL/kg/h). Subsequent fluid bolus infusions were guided by physiologic parameters (systolic blood pressure < 90 mm Hg, heart rate > 100 bpm, or oliguria) in the standard group, and by tissue oxygen saturation from NIRS (tissue oxygen saturation (StO2) < 75%, or 20% below baseline; or the same physiologic parameters) in the restricted group. Primary endpoints were major postoperative complications. A total of 27 patients were randomized (18 restricted, 9 standard). Age, gender, ethnicity, past medical history, and body mass index were similar. American Society of Anesthesiologists class was somewhat higher in the restricted group (American Society of Anesthesiologists class 3 in 77% of restricted vs 44% of standard patients; P = 0.194). Median total intraoperative fluids were less in the restricted group (1300 mL) when compared with the standard group (3014 mL) (P = 0.021). Total fluids for the hospitalization were also statistically significantly decreased in the restricted group. Complications occurred in about two-thirds of patients, and complication rates were not statistically different between groups (1.6/restricted patient vs 2.1/standard patient; P = 0.333). Primary indications for boluses (n = 93) given to study patients were: hypotension (69%); oliguria (15%); and tachycardia (14%), with multiple indications per bolus. In only two instances did the StO2 drop to less than 75 per cent, or decrease by 20 per cent from baseline in the 3 minutes before bolus as an indication for fluid administration. Patients undergoing elective colorectal surgery with a fluid restricted strategy had only rare episodes of decreased StO2, suggesting that adequate tissue perfusion was maintained in this group. As a result, NIRS monitoring did not significantly influence intraoperative fluid management of patients undergoing colorectal surgery.     

Preemptive ketamine during general anesthesia for postoperative analgesia in patients undergoing laparoscopic cholecystectomy

AIM: Preemptive analgesia is currently in use in the management of postoperative pain and no more under search. The administration of ketamine as intraoperative analgesic agent is well-known since a long time; the analgesic properties of this drug are related to its actions as a non-competitive N-methyl-D-aspartate receptors antagonist; these receptors present an excitatory function on pain transmission and this binding seems to prevent or reverse the central sensitisation of every kind of pain, including postoperative pain. In literature, the use of this anesthetic for the preemptive analgesia in the management of postoperative pain is controversial; for this reason the aim of our study was the clinical evaluation of preemptive perioperative analgesia with low-doses ketamine. METHODS: This trial involved 40 patients undergoing laparoscopic cholecystectomy, with the same surgical operator; postoperative analgesia was performed with the intraoperative administration of ketamine (0.7 mg/kg) or tramadol (15 mg/kg). A randomized, double-blind study was performed; after an inhalatory/analgesic general anesthesia (sevofluorane + remifentanyl) the postoperative-pain control was clinically evaluated through algometric measurements (Visual Analog Scale, Verbal Rating Scale, Pain Intensity Difference); supplemental doses of tramadol were administered if required, also to quantify the adequacy of analgesia, and adverse effects were evaluated. RESULTS: The results show that preemptive intraoperative analgesia with ketamine produces a good analgesia at the awakening, despite low duration (approximately 1 hour), and upgrades the analgesic effect of tramadol in the postoperative period. Among the adverse effects, some (for example nausea) were related to the administration of both analgesics and to the kind of surgery, others (hallucinosis, nystagmus, photophobia, psychomotor excitation, psychotic symptoms) were due to ketamine, and others (respiratory depression and hypotension) could be related to tramadol. Although the adverse effects due to ketamine are more numerous than those related to tramadol, the second could potentially be more dangerous. CONCLUSION: Our study suggests that preemptive low-doses ketamine is able to produce an adequate postoperative analgesia and increases the analgesic effect of tramadol; furthermore, ketamine adverse effects could be reduced by intraoperative administration of benzodiazepines and/or antiemetic drugs, or by the association of ketamine and a peripheral analgesic (ketorolac).     

The role of endoscopic retrograde cholangiopancreatography and cholangiography in the laparoscopic era.

OBJECTIVE: The authors reviewed the results of endoscopic retrograde cholangiopancreatography (ERCP) and intraoperative cholangiography in a series of patients who underwent laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA: The indications for preoperative and postoperative ERCP and intraoperative cholangiography as adjuncts to laparoscopic cholecystectomy are evolving. The debate regarding the use of selective or routine intraoperative cholangiography has intensified with the advent of laparoscopic cholecystectomy. METHODS: The authors reviewed the records of 343 consecutive patients who underwent laparoscopic cholecystectomy during a 1-year period. Historical, biochemical, and radiologic findings for the patients who underwent ERCP and intraoperative cholangiography were analyzed. RESULTS: Three hundred forty- three patients underwent laparoscopic cholecystectomy during the period reviewed. Preoperative ERCP was performed in 42 patients. Twenty-seven of these patients (64%) had common bile duct (CBD) stones, which were cleared with a sphincterotomy. Intraoperative cholangiography was performed for 101 patients (29%). Three cholangiograms had false- positive results (3%), leading to two CBD explorations, in which no CBD stones were found, and one normal ERCP. Six patients underwent postoperative ERCP, three for the removal of retained CBD stones (0.9%), all of which were cleared with a sphincterotomy. Fifteen patients had gallstone pancreatitis, six of whom had CBD stones (40%) that were cleared by ERCP. There were 33 complications (10%) and no CBD injuries. CONCLUSION: The use of routine intraoperative cholangiography is discouraged in view of its low yield and the significant rate of false positive cholangiogram results.     

Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection

BACKGROUND: Protocolized fluid administration using oesophageal Doppler monitoring may improve the postoperative outcome in patients undergoing surgery. METHODS: A total of 108 patients undergoing elective colorectal resection were recruited into a double-blind prospective randomized controlled trial. An oesophageal Doppler probe was placed in all patients. The control group received perioperative fluid at the discretion of the anaesthetist, whereas the intervention group received additional colloid boluses based on Doppler assessment. Primary outcome was length of postoperative hospital stay. Secondary outcomes were morbidity, return of gastrointestinal function and cytokine markers of the systemic inflammatory response. Standard preoperative and postoperative management was used in all patients. RESULTS: Demographic and surgical details were similar in the two groups. Aortic flow time, stroke volume, cardiac output and cardiac index during the intraoperative period were higher in the intervention group (P<0.050). The intervention group had a reduced postoperative hospital stay (7 versus 9 days in the control group; P=0.005), fewer intermediate or major postoperative complications (2 versus 15 percent; P=0.043) and tolerated diet earlier (2 versus 4 days; P=0.029). There was a reduced rise in perioperative level of the cytokine interleukin 6 in the intervention group (P=0.039). CONCLUSION: A protocol-based fluid optimization programme using intraoperative oesophageal Doppler monitoring leads to a shorter hospital stay and decreased morbidity in patients undergoing elective colorectal resection.     

单孔腹腔镜在深部浸润型子宫内膜异位症中的应用及初步探讨

目的初步探讨单孔腹腔镜手术在深部浸润型子宫内膜异位症(deeply infiltrating endometriosis,DIE)中的可行性、安全性及围手术期结局。 方法回顾性分析空军军医大学西京医院妇产科于2017年5月至2018年8月共完成的6例单孔腹腔镜DIE病灶切除术。记录患者年龄、体质量指数、手术时间、术中出血量、病灶直径、术中及术后相关并发症,手术前后血红蛋白差值,术后排气时间、术后疼痛模拟评分、住院时间、术后随访情况等指标。 结果6例患者的手术均成功完成,无中转传统腹腔镜手术或开腹手术,无并发症发生。年龄(32.3±6.3)岁,体质量指数(23.8±5.6)kg/m^2,手术时间(106.5±47.3)min,术中出血量(27.6±35.4)ml,术后排气时间(12.4±6.7)h,住院时间(3.5±2.7)d。 结论单孔腹腔镜对于孤立的界限相对清楚的DIE病灶的手术是安全、可行的,但需进一步扩大病例数证实其可靠性。     

Laparoscopic splenectomy for hematologic disorders: experience with the first fifty patients

BACKGROUND: Splenectomy is increasingly being performed by various minimal access surgical modalities for select hematologic disorders. METHODS: A retrospective analysis was performed on the first 50 patients on whom laparoscopic splenectomy (LS) was attempted. The data studied included indications for surgery, patient demographics, intraoperative parameters, and patient outcomes. A total laparoscopic approach (TLS) was employed in 38 patients and a hand-assisted technique (HALS) was used in 12 patients with massive splenomegaly. Eight patients had concomitant surgical procedures: 7 patients underwent laparoscopic cholecystectomy and 1 patient received a kidney transplant. The most common indications for LS were idiopathic thrombocytopenic purpura (ITP) (50%) and hereditary spherocytosis (24%). RESULTS: LS was successfully completed in 48 patients (96%). Thirty-four patients (68%) required perioperative blood or platelet transfusions. The mean spleen diameter was 17.1 cm (range, 11.2-28.4 cm) on imaging study and mean intact splenic weight was 1019 gm. The mean operative time was 188 minutes (range, 90-340 minutes) in the TLS group and 171 minutes (range, 120-240 minutes) in the HALS group. The mean intraoperative blood loss was 306 mL (range, 40-640 mL) in the TLS group and 163 mL (range, 100-300 mL) in the HALS group. The mean postoperative hospital stay was 3.2 days (range, 2-5 days). CONCLUSION: TLS is safe and feasible in patients with nonpalpable spleens. A concomitant laparoscopic procedure for treating coexisting abdominal pathology may be performed without additional morbidity. The HALS technique may be preferable in patients with splenomegaly (palpable spleens), as it appears to offer intraoperative advantages for retraction, dissection, hemostasis, and organ retrieval.     

A balanced approach to choledocholithiasis

Background: We set out to review and evaluate the results of an algorithm for managing choledocholithiasis in patients undergoing laparoscopic cholecystectomy. Methods: We performed retrospective review of patients with choledocholithiasis at the time of laparoscopic cholecystectomy (LC) between March 1993 and August 1999. All patients were operated on under the direction of one surgeon (M.E.A), following a consistent algorithm that relies primarily on laparoscopic transcystic common bile duct exploration (TCCBDE) but uses laparoscopic choledochotomy (LCD) when the duct and stones are large or if the ductal anatomy is suboptimal for TCCBDE. Intraoperative endoscopic retrograde sphincterotomy (ERS) is done if sphincterotomy is required to facilitate common bile duct exploration (CBDE). Postoperative endoscopic retrograde cholangiopancreatography (ERCP) is utilized when this fails. Preoperative ERCP is used only for high-risk patients. Results: A total of 728 LC were performed, and there were 60 instances (8.2%) of choledocholithiasis. Primary procedures consisted of 47 TCCBDE; 37 of them required no other treatment. In five cases, the stones were flushed with no exploration. Intraoperative ERS was performed three times as the only form of duct exploration. LCD was utilized twice; one case also required intraoperative ERS, and the other had a postoperative ERCP for stent removal. One patient with small stones was observed, with no sequelae. Preoperative ERCP was done twice as the primary procedure. Of the 10 cases that were not completely cleared by TCCBDE, three had a postoperative ERCP and seven had an intraoperative ERS, one of which required a postoperative ERCP. There were three complications (6%) related to CBDE, with no long-term sequelae. There were four postoperative complications (6.7%) and no deaths. The mean number of procedures per patient was 1.12. The average postoperative hospital stay was 1.8 days (range, 0-14). Conclusions: Choledocholithiasis can be managed safely by laparoscopic techniques, augmenting with ERCP as necessary. This protocol minimizes the number of procedures and decreases the hospital stay.     

Does intraoperative fluid management in spine surgery predict intensive care unit length of stay?

STUDY OBJECTIVE: To determine whether intraoperative fluid management in spine surgery predicts postoperative intensive care unit length of stay (ICU LOS). DESIGN: Retrospective case series. SETTING: University-affiliated medical center. PATIENTS: 103 adult ASA physical status I, II, and III patients undergoing spine surgery. INTERVENTIONS: Patients were divided into three LOS groups: no ICU stay (LOS0) (n = 26), 1 day ICU stay (LOS1) (n = 48), and ICU stay > 1 day (LOS2) (n = 29). Measurements were analyzed by groups using the Kruskal-Wallis and Mann-Whitney tests, and linear regression. MEASUREMENTS: Demographics, comorbidity, length of surgery, surgical procedure, and intraoperative fluids were recorded. MAIN RESULTS: The important differences in perioperative fluid management among the three groups included estimated blood loss (612 +/- 480 mL, 1853 +/- 1175 mL, 2702 +/- 1771 mL, means +/- SD); total crystalloid administration (2715 +/- 1396 mL, 5717 +/- 2574 mL, 7281 +/- 3417 mL); and total blood administration (92 +/- 279 mL, 935 +/- 757 mL, 1542 +/- 1230 mL) in LOS0, LOS1, and LOS2, respectively. The mixture of surgical procedures was similar in LOS1 and LOS2; and differed from LOS0. Predictors of ICU LOS included age, ASA physical status, surgical procedure, total crystalloid administration, and platelet administration. Surgical procedure and total crystalloid administration correlated (Pearson correlation coefficient = 0.441; p = 0.000) and were not related to age or ASA physical status. CONCLUSIONS: Total crystalloid administration during spine surgery does predict ICU LOS. In addition, total crystalloid administration is closely related to the surgical procedure. Given that the mixture of surgical procedures was similar in LOS1 and LOS2, but differed in estimated blood loss, total crystalloid administration, and total blood administration; intraoperative fluid management during spine surgery only predicts ICU LOS insofar as total crystalloid administration is related to the surgical procedure.     

Evaluation of Intra-abdominal Pressure after Laparoscopic and Open Gastric Bypass

Background: Increased intra-abdominal pressure (IAP) postoperatively can adversely affect cardiovascular, pulmonary,and renal function. In this prospective, randomized trial, we compared the IAP in morbidly obese patients after laparoscopic and open gastric bypass (GBP) surgery. Methods: 64 patients with a body mass index of 40 to 60 kg/m² were randomized to undergo laparoscopic or open GBP.IAPs were obtained at baseline (after induction of anesthesia), immediately after the operation, and on post-operative day (POD) 1, 2, and 3. Intraoperative and postoperative fluid requirements, urine output, and creatinine clearance were recorded. Results: Demographics of the two groups were similar. IAP increased from baseline immediately after laparoscopic and open GBP (p < 0.05). IAP returned to baseline by POD 2 after laparoscopic GBP but remained elevated through POD 3 after open GBP. In fact, IAP was lower after laparoscopic _{GBP than after open GBP on POD 1, 2 and 3 (p <} 0.05).The amount of intraoperative IV fluid was similar between groups, but laparoscopic GBP required less IV fluid and facilitated higher urine output post-operatively than open GBP.There was no significant difference in creatinine clearance between groups. Conclusions: Laparoscopic GBP resulted in significantly lower IAP, less postoperative fluid required, and greater postoperative urine output than open GBP.     

Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery

BACKGROUND: Intraoperative hypovolemia is common and is a potential cause of organ dysfunction, increased postoperative morbidity, length of hospital stay, and death. The objective of this prospective, randomized study was to assess the effect of goal-directed intraoperative fluid administration on length of postoperative hospital stay. METHODS: One hundred patients who were to undergo major elective surgery with an anticipated blood loss greater than 500 ml were randomly assigned to a control group (n = 50) that received standard intraoperative care or to a protocol group (n = 50) that, in addition, received intraoperative plasma volume expansion guided by the esophageal Doppler monitor to maintain maximal stroke volume. Length of postoperative hospital stay and postoperative surgical morbidity were assessed. RESULTS: Groups were similar with respect to demographics, surgical procedures, and baseline hemodynamic variables. The protocol group had a significantly higher stroke volume and cardiac output at the end of surgery compared with the control group. Patients in the protocol group had a shorter duration of hospital stay compared with the control group: 5 +/- 3 versus 7 +/- 3 days (mean +/- SD), with a median of 6 versus 7 days, respectively ( = 0.03). These patients also tolerated oral intake of solid food earlier than the control group: 3 +/- 0.5 versus 4.7 +/- 0.5 days (mean +/- SD), with a median of 3 versus 5 days, respectively ( = 0.01). CONCLUSIONS: Goal-directed intraoperative fluid administration results in earlier return to bowel function, lower incidence of postoperative nausea and vomiting, and decrease in length of postoperative hospital stay.