Laparoscopic enucleation or wedge resection of benign gastric pathology: analysis of 44 consecutive cases

Laparoscopic resection of gastric submucosal tumors has been described, but the role of laparoscopy for tumors within the esophagus or near the gastroesophageal junction is not clearly defined. The aim of this study was to examine the outcomes of laparoscopic or thoracoscopic enucleation or wedge resection of benign gastric tumors. The charts of 44 patients who underwent minimally invasive resection of benign esophagogastric tumors were reviewed. Surgical approaches included thoracoscopic enucleation (n = 2), laparoscopic enucleation (n = 6), transgastric enucleation (n = 2), and laparoscopic gastric wedge resection (n = 34). There were 23 males with a mean age of 57 years. There was one conversion (2.5%) to laparotomy. Mean operative time was 97 ± 52 minutes. The mean length of hospital stay was 2.6 ± 2.0 days. One patient developed gastric outlet obstruction requiring Roux-en-Y reconstruction. There were no leaks and the 90-day mortality was zero. Pathology demonstrated gastrointestinal stromal tumor (n = 31), leiomyoma (n = 6), and other benign pathology (n = 7). There has been one tumor recurrence at a mean follow-up of 4.3 years. The laparoscopic approaches to local resection of gastric tumors are safe and feasible. The type of minimally invasive surgical approaches should be tailored based on the location and size of the lesion.     

Ileal pouch-anal anastomosis. A single surgeon's experience with 100 consecutive cases.

Between August 1982 and November 1985, 100 patients underwent ileal "J" pouch-anal anastomosis (IPAA) at the University of Utah. All operations were performed in a standard fashion by a single surgeon. Seventy-eight patients were operated on for chronic ulcerative colitis and 22 for familial polyposis coli. Sixty of the patients were male and 40 were female with a mean age of 33.2 years and a range of 11-63 years. Mean +/- SEM operating time was 5.9 +/- 0.4 hours, blood loss was 666 +/- 49 ml, and total hospitalization was 10.1 +/- 0.3 days. No operative deaths occurred. The overall operative morbidity was 13% after IPAA. Clinical "pouchitis" was observed in 18 patients, all of whom were operated on for chronic ulcerative colitis. No patients had frank incontinence. Twenty per cent of patients experienced frequent nocturnal leakage in the early postoperative period with a significant improvement over the ensuing 6 months. Stool frequency at 1, 3, 6, 12, and 24 months was 7.5 +/- 0.2, 6.5 +/- 0.1, 6.2 +/- 0.3, 5.4 +/- 0.1, and 5.4 +/- 0.2, respectively. Stool frequency at 12 months correlated inversely with ileal pouch capacity and the diagnosis of familial polyposis. It is concluded that ileal pouch-anal anastomosis is a safe and effective operation for patients with chronic ulcerative colitis and familial polyposis coli.     

Hand-assisted laparoscopic sigmoid resection for diverticular disease: 100 consecutive cases

BACKGROUND: Hand-assisted laparoscopic surgery (HALS) has been proposed as a useful alternative to conventional laparoscopic and open surgery. As compared with conventional laparoscopic surgery, it offers the advantages of tactile feedback, better exposure, and a shorter learning curve. There is increasing evidence that HALS retains the advantages of minimal-access surgery. The aim of this study was to analyze the feasibility as well as the short- and medium-term outcomes of HALS sigmoid resection for diverticular disease. METHODS: The study included 100 consecutive patients between July 1999 and August 2004. Data were prospectively recorded. Follow-up evaluation was performed by standardized telephone interview after a mean postoperative period of 19 months (range, 2-55 months). RESULTS: Two major intraoperative complications occurred: splenic laceration requiring splenectomy and ureteral injury requiring suture. There were only three conversions: one case of pararectal incision and two cases of extended lower Pfannestiel incision. There was no single case of conversion to midline laparotomy. One patient died postoperatively of myocardial infarction. The postoperative complications included intraabdominal hematoma (2%), anastomotic leakage (3%), wound infection (11%) and bladder dysfunction (1%). The reoperation rate was 5%. The median hospital stay was 8 days. In terms of satisfaction with the results, 97% of patients would choose HALS again. CONCLUSIONS: When used for diverticular disease, HALS sigmoid resection has a low intra- and postoperative complication rate. The satisfaction rate among patients is high. Even in technically difficult cases, conversion to midline laparotomy can be avoided.     

Brachial plexus injury: a survey of 100 consecutive cases from a single service

OBJECTIVE: We analyzed the epidemiology, preoperative management, operative findings, operative treatment, and postoperative results in a group of 99 patients who sustained 100 injuries to the brachial plexus. METHODS: The charts of 100 consecutive surgical patients with brachial plexus injuries were reviewed. RESULTS: The patient group comprised 80 males and 19 females ranging from 5 to 70 years of age. One male patient had bilateral brachial plexus palsy. Causes of injury were largely sudden displacement of head, neck, and shoulder and included 27 motorcycle accidents. There were 23 open wounds, including 8 gunshot wounds, 6 other penetrating wounds, and 9 wounds caused by operative or iatrogenic trauma. Loss was exhibited at C5-C6 in 19 patients, at C5-C7 in 15 patients, and at C5-T1 in 39 patients, and 8 patients had another spinal root pattern of injury. Nineteen patients had injury at the cord or the cord to nerve level. Associated major trauma was present in 59 patients. Emergency surgery for vessel or nerve repair was necessary in 18 patients. Myelography (n = 57) or magnetic resonance imaging (n = 7) revealed at least one root abnormality in 52 patients. The median interval from trauma to operation was 7 months. Operative exposures used included anterior supraclavicular, infraclavicular, combined supra- and infraclavicular, or a posterior approach in 5, 14, 77, and 4 patients, respectively. The surgical procedures performed included neurolysis alone in 12 patients and nerve grafting, end-to-end anastomosis, and/or neurotization in 81, 5, and 47 patients, respectively. Postoperative follow-up of at least 36 months was conducted in 78% of the patients. Grade 3 recovery according to Louisiana State University Medical Center criteria means contraction of proximal muscles against some resistance and of distal muscles against at least gravity. Among the 18 patients with open wounds, 14 (78%) recovered to a Grade 3 or better level, as did 35 (58%) of 60 patients with stretch injuries. In all cases of C5-C6 stretch injuries repaired by nerve grafting (n = 10), the patients recovered useful arm function. CONCLUSION: Brachial plexus injury represents a severe, difficult-to-handle traumatic event. The incidence of such injuries and the indications for surgery have increased during recent years. Graft repair and neurotization procedures play an important role in the treatment of patients with such injuries.     

Thoracoscopic lobectomy for benign disease--a single centre study on 64 cases.

OBJECTIVE: Chronic lung infection is the main indication for lobectomy in benign pulmonary disease and may be technically demanding due to inflammatory changes such as adhesions, lymph node enlargement and neovascularization. The role of the thoracoscopic operation in these indications is yet ill-defined. METHODS: We retrospectively analyzed the results of patients who underwent thoracoscopic lobectomy (TL) between 1992 and June 1999 and compared this study group with patients who underwent open lobectomy (OL), all for benign disease. Data were not normally distributed, therefore, the median and range is given and nonparametric statistical analysis was applied. RESULTS: A total of 117 lobectomies for benign disease (64 TL) were analyzed. Indications included bronchiectasis (36 TL; 18 OL), chronic infections (13 TL; eight OL), tuberculosis (five TL; 15 OL), emphysema (five TL; one OL), AV-malformations (two TL; one OL), severe haemoptysis (four OL), and others (three TL; six OL). Twelve conversions to thoracotomy were necessary due to severe adhesions. One patient in the open lobectomy group died within 30 days postoperative. Drainage time was 5.0 (1-32) days in TL and 6.0 (3-21) days in OL, hospital stay was 8.5 (4-41) days and 10.0 (5-52) days, respectively. Blood loss was 0 (0-2000) ml in TL and 300 (0-6000) ml in OL.Operation time for thoracoscopic lobectomies significantly decreased from 2.5 (1-6) h for cases between 1992 and 1997 (n=49) to 1.5 (0.5-2.5) h for recent cases (n=15) (P<0.01). In addition, a trend towards less blood loss was noted (100 (0-2000) ml vs. 0 (0-400) ml; P=0.06). Drainage time and hospital stay did not differ significantly. CONCLUSIONS: Thoracoscopic lobectomy in chronic inflammatory disease can be performed safely in selected patients, especially with bronchiectasis. Conversion rate to thoracotomy is low. Operation time with this approach declined significantly over time.     

Cytologically malignant margin without continuous pulmonary tumor lesion: cases of wedge resection, segmentectomy and lobectomy

The surgical margin is usually investigated during the operation using a pathological method, though cytological methods are also used to identify remaining malignant cells. We reviewed cases of pulmonary resection for a malignant tumor. At our institution, an on-site surgical margin examination using a cytological method is mandated for cases of wedge resection and segmentectomy, and an option in lobectomy cases. We examined 21 wedge resection (3 primary lung cancer, 18 metastasis), 17 segmentectomy (13 primary lung cancer, 4 metastasis), and 4 lobectomy (all primarily lung cancer) cases. Six cases showed malignant cells in the surgical margin, of which one had a microscopic skip lesion pattern and five an 'occult' pattern (positive cytology, negative pathology). Cytological malignancy occurred even in cases of wedge resection of a tiny (4 mm in diameter) lesion metastasized from colon cancer, as well as segmentectomy with a sufficient gross margin containing microscopic skip lesions and right middle lobectomy with an additional right upper lobectomy due to two previous cytological malignancies in a residual lobe. Surgical margin cytology revealed remaining malignancy in the residual lobe, which provided important information for deciding additional procedures during surgery.     

Morbidity of iliac bone grafts. A study apropos of 100 consecutive cases]

A study of the real morbidity after iliac bone graft harvesting was conducted on a homogenous series of 100 consecutive cases. Functional and aesthetic consequences were evaluated in relation to the immediate post-operative course and the long-term follow-up and in relation to the indication, the technique used and the amount of bone removed. Considering the small number of sequelae observed, autogenous iliac bone graft remains the best material for craniomaxillofacial reconstruction. The main disadvantage consists of the resorptions noted; which raises the possibility of using other types of bone grafts or bio-materials in some indications.     

The Mitchell bunionectomy: a prospective study of 60 consecutive cases utilizing single K-wire fixation.

The authors prospectively evaluated 45 patients (60 feet) affected by hallux valgus and treated with a distal metatarsal osteotomy. The surgical procedure consisted of a modified Mitchell osteotomy, in which fixation was achieved with a Kirschner wire that was driven into the proximal osteotomy fragment and buttressed the distal one. Early weightbearing was allowed without a cast. Follow-up averaged 25 months. The mean American Orthopedic Foot and Ankle Society clinical hallux score increased from 44.6/100 preoperatively to 83.2/100. Radiographic evaluation showed that mean metatarsophalangeal and intermetatarsal angles decreased respectively from 31.7 degrees to 16.9 degrees, and from 15.4 degrees to 8.6 degrees. Short-term loss of correction occurred in three cases (4%). Six feet (10%) had unrelieved metatarsalgia that was related to excessive shortening of the first metatarsal and/or inappropriate orientation of the metatarsal head. Stabilization of the Mitchell osteotomy with a Kirschner wire proved safe and effective for the surgical correction of mild to moderate hallux valgus.     

The effectiveness of palliative resection for advanced esophageal carcinoma: analysis of 24 consecutive cases

Purpose: In some patients who already have advanced esophageal cancer at the time of presentation, symptoms like the inability to eat, and complications such as bronchoesophageal fistula are so debilitating that palliative resection may be beneficial. However, resection of the esophagus is associated with significant risk, and whether this operation should be performed for palliation remains controversial. Because few reports have been published on this subject, we retrospectively analyzed 24 patients with esophageal cancer who underwent palliative resection. Methods: Esophageal resection was performed with palliative intent in 12 patients and with curative intent in another 12 who were left with residual cancer. Results: There was no operative death. All of the ten patients who had been unable to eat preoperatively were able to eat after the operation, and four patients with a life-threatening bronchoesophageal fistula were free of symptoms after the operation. Two patients died in hospital during the postoperative chemotherapy but the other 22 were discharged. The mean survival period was 264 days. Conclusions: With improved postoperative care, the risk of palliative esophageal resection is no longer considered unacceptable. Received: July 2, 2001 / Accepted: March 5, 2002     

Cholecystectomy: to drain or not to drain. A randomized prospective study of 200 patients.

During the 24-month period commencing January 1975, 200 patients underwent elective cholecystectomy for chronic cholecystitis. According to a prospective randomized protocol, 100 patients were drained and an identical number were not drained. The two groups were similar with respect to age, weight, diabetic history, and all other measured clinical parameters.Patients who were not drained had less postoperative fever in terms of actual temperature elevation and duration of fever and were discharged from the hospital earlier. There was no difference in the incidence of wound infection or other complications between the two groups.This study confirms that elective cholecystectomy without drainage of the subhepatic space can be done safely and that less postoperative fever and shorter hospitalization can be expected.     

Comparison of the immediate postoperative outcome of using the conventional two drains versus a single drain after lobectomy

BACKGROUND: We compared the immediate postoperative outcome and cost-effectiveness of using a single chest drain in the midposition to the conventional apical and basal drains after lobectomy. METHODS: Of the 120 consecutive patients who underwent thoracotomy and lobectomy for lung cancer at our center between January 2001 and December 2002, 60 had the conventional 28 French apical and basal drains (group A), whereas the remaining 60 had a single 28 French chest drain placed in the midposition before closure (group B). The assessed outcomes included length of stay, amount and duration of drainage, subcutaneous emphysema, postremoval hemothorax and pneumothorax, drain reinsertion, patient controlled analgesia duration, maximum pain scores, and analgesic usage. RESULTS: Both groups matched in terms of age (group A vs group B mean, 65 years old vs 66 years old, respectively; p = not significant [NS]) and gender (M:F, 4:1 for group A vs 4:1 for group B). There was no significant difference in the length of stay (mean, 7.7 days for group A vs 7.8 days for group B; p = NS), amount of drainage (mean, 667 mL for group A vs 804 mL for group B; p = NS), duration of drainage (mean, 4 days for group A vs 4.3 days for group B; p = NS), duration of patient controlled analgesia (mean, 3.7 days for group A vs 4.2 days for group B; p = NS) and analgesic combinations used (nonsteroidal antiinflammatory drugs +/- oral opioids +/- paracetamol) between the two groups. There were no clinically significant postdrain removals of hemothorax or pneumothorax in either group. Group A patients had a significantly higher maximum pain score compared with group B patients (mean, 1.4 vs 1.02, respectively; p = 0.02). Cost savings per patient in group B was more than or equal to 55 US dollars, which added up to a total cost savings of approximately more than or equal to 3,300 US dollars. CONCLUSIONS: A single chest drain in the midposition is just as effective, significantly less painful, and much more cost effective than the conventional use of two drains after lobectomy.     

Value of wide-margin wedge resection for solitary pulmonary nodule: a single center experience.

OBJECTIVE: Despite refinements of the diagnostic procedures, often surgery remains the only option to ascertain the histopathological nature of solitary pulmonary nodules (SPN). Aim of the present study was to ascertain the value of wide-margin wedge resection (WMWR) with curative intent in a consecutive cohort of patients afflicted by SPN. METHODS: From January 1995 to January 2002, 129 patients (74 male, mean age 60.5+/-14.4 years) underwent WMWR of a SPN. In-hospital outcome was prospectively collected and retrospectively analyzed. Incidence of malignancy was obtained by histology. Patients found to be afflicted by primary lung cancer (PLC) were sub-grouped according to their preoperative cardiopulmonary status (CPS). In-hospital and mid-term clinical outcome of all the patients is presented. RESULTS: There were 3 (2.3%) in-hospital deaths. Distribution of histology included 61 (47.3%) PLC (41 poor CPS), 20 (15.5%) secondary lung cancer (SLC), and 48 (37.2%) miscellaneous benign lesions. Twenty patients with PLC were fit and underwent completion lobectomy within 2 weeks following WMWR. Hospital length of stay was longer in patients with PLC as compared to patients with SLC (P=0.04). There were 17/61 (27%) recurrences in the PLC group. Of these, 2 occurred in fit patients undergone previous WMWR-lobectomy, and 15 in patients with poor baseline CPS. All these patients were referred for adjuvant therapy. Overall 5-year survival of the PLC group was 66% (61.1% for those with poor CPS and 82.5% for those with good CPR (P=NS). Seven out of 20 (35%) patients with SLC had late recurrent disease, leading to 1 re-operation. The overall 5-year survival in this group was 58.8%. There was only 1 non-related late death in the benign group. CONCLUSIONS: The WMWR resection of a primarily malignant SPN determines a valuable 5-year survival but a relatively high incidence of late recurrence. WMWR is a safe and effective surgical option for patients presenting with poor cardiopulmonary reserve.     

Opioid-free spine surgery: a prospective study of 244 consecutive cases by a single surgeon

BACKGROUND CONTEXTThere have been no reported efforts to eliminate opioid use for elective spine surgery, despite its well-known drawbacks.PURPOSEWe sought to test the hypothesis that opioid-free elective spine surgery, including lumbar fusions, can be performed with satisfactory pain control.STUDY DESIGN/ SETTINGThis study analyzes prospectively collected data from a single surgeon's patients who were enrolled into an institutional spine registry.PATIENT SAMPLEWe enrolled every consecutive surgical patient of author RAB between January 1, 2018 and July 13, 2019.OUTCOME MEASURESThe postsurgical opioid use, pain scores, emergency room visits, and readmissions were tracked.METHODSWe developed a comprehensive program for opioid-free pain control after elective spine surgery. In the initial stage, opioids were given “PRN” only, while in the second stage, they were avoided altogether. Student's t tests were performed to compare pain scores, and regression analyses were performed to understand drivers of opioid use and pain.RESULTSTwo hundred forty-four patients were studied, a third of whom underwent lumbar fusions. In the initial stage, 47% of patients took no opioids from recovery room departure until 1-month follow-up. During the second stage, 88% of patients took no opioids during that period. Pain scores were satisfactory, and there was no association between postoperative opioid use and either procedural invasiveness or pain scores. However, preoperative opioid use was associated with a nearly fivefold increased risk of postoperative use. Ninety-three percent of lumbar fusion patients who were opioid-free before surgery did not take a single opioid in the postoperative period.CONCLUSIONOpioid-free elective spine surgery, including lumbar fusions, is feasible and effective. We suggest that opioid-free spine surgery be offered to patients who are opioid-naïve or who can be weaned off before the operation.     

自身免疫性胰腺炎14例临床分析

目的 探讨自身免疫性胰腺炎(AIP)的特征性表现,以提高对其的认识程度和诊治水平.方法 对2002年2月至2008年4月间收治的14例AIP患者的临床表现以及影像学、实验室、病理学资料和治疗效果进行回顾性分析,其中男性13例,女性1例,年龄35～71岁,平均53岁.临床表现为进行性皮肤巩膜黄染11例,持续性或间歇性上腹胀痛不适3例.结果 CT检查表现为胰腺弥漫性肿大伴胰管弥漫性不规则狭窄11例,胰头局灶性肿大伴胰头处胰管狭窄3例,全部病例均有胆总管胰腺段狭窄.共有12例患者接受免疫球蛋白G(IgG)和自身抗体检测,其中7例IgG浓度升高,6例自身抗体阳性.14例AIP患者中,9例就诊时存在或随访中出现胰腺外其他自身免疫性疾病.病理检查显示3例胰腺导管周围有致密的淋巴细胞和浆细胞浸润伴间质纤维化.因怀疑胰腺恶性肿瘤而行手术治疗7例,给予皮质类固醇激素治疗7例,治疗结果满意.随访中有4例复发.结论 MP应该作为胰腺癌的一种鉴别诊断,避免因误诊而进行不必要的手术治疗.