Are the current difficulty scores for laparoscopic liver surgery telling the whole story? An international survey and recommendations for the future

Background

Recent studies have suggested that the difficulty of laparoscopic liver resections are related to both patient and tumour factors, however the available difficulty scoring systems only incorporate tumour factors. The aim of this study was to assess the opinion of laparoscopic liver surgeons regarding the factors that affect the perceived difficulty of laparoscopic liver resections.

The discharge of primary and secondary granules during immune phagocytosis by normal and chronic granulocytic leukaemia polymorphonuclear neutrophils

S ummary . The two types of granule in polymorphonuclear neutrophils may have distinct functions. The primary granule enzymes are responsible for killing and digesting ingested micro-organisms while the secondary granule constituents may have regulatory functions outside the cell. This hypothesis is supported by finding that during immune phagocytosis of a yeast, nearly all of the neutrophil's secondary granule vitamin B₁₂-binding protein is lost from the cell and 80% can be accounted for in the medium. Much less of the primary granule enzymes, β-glucuronidase and acid phosphatase, are lost from the cells and very little can be detected in the medium. Lysozyme is a constituent of both types of granule and its behaviour is intermediate. There is no difference in the release of these granule constituents from chronic granulocytic leukaemia neutrophils compared with normal neutrophils.     

Implementation of enhanced recovery programme after pancreatoduodenectomy: A single-centre UK pilot study

IntroductionData on enhanced recovery programmes after pancreatoduodenectomy (ERP-PD) is limited. The aim of this pilot study was to evaluate the feasibility, safety and clinical outcomes of ERP-PD when implemented at a high-volume UK university referral centre.MethodsThis was an observational single-surgeon case-control study (before-and-after pathway). A total of 20 consecutive patients were prospectively enrolled for the ERP-PD and compared with 24 consecutive patients previously treated during an equal time frame.ResultsPatients in the ERP-PD group had a significant shorter time to remove naso-gastric tube (median of 5 vs. 7 days, p = 0.0001), start liquid diet (median of 2 vs. 5 days, p < 0.0001), start solid food (median of 4 vs. 9 days, p < 0.0001), pass stools (median of 6 vs. 7 days, p = 0.002), and had shorter length of stay (median of 8.5 days vs. 13 days, p = 0.015) compared to the pre-pathway group. Postoperative complications were overall less frequent but not significantly different in the ERP-PD group (p = 0.077). No difference in mortality and readmission rates was found.ConclusionsOur findings support the feasibility and safety of ERP-PD. Improved patients' outcomes, significant bed day savings and increase National Health Service productivity are anticipated with implementation of ERP-PD on a larger scale.     

European experience of laparoscopic major hepatectomy

Background/purpose

Laparoscopic hepatectomies have seen a worldwide proliferation. Major anatomic resections, which were initially considered unsuitable for laparoscopy, are currently confined to a few centers of expertise. The aim of this study was to discuss the current trends and techniques in laparoscopic major hepatectomy in Europe.

Methods

The prospective databases of ten European centers were combined to provide answers to a questionnaire that had been addressed to all European teams known to perform laparoscopic liver surgery.

Results

Between 1996 and 2011 a total of 2245 laparoscopic liver resections have been carried out, of which 495 (22 %) were major resections. The proportion of laparoscopic right and left hepatectomies varied between 4 and 40 % of all major hepatectomies of the same type. Benign, primary malignant and metastatic lesions were, respectively, 22.4, 19.6 and 58 % of all indications. The different techniques and approaches, as regards hand assistance, hepatic inflow and outflow control, liver mobilization and concomitant colectomies, are discussed.

Conclusions

To date, an important level of experience of laparoscopic liver resection has been accumulated in Europe, and experience of major hepatectomies is constantly increasing. However, they remain technically very demanding procedures which should be confined to expert surgeons who have already acquired considerable experience with simpler laparoscopic liver resections.     

Efficacy of radiotherapy in optic gliomas

Twenty-five children with optic gliomas were evaluated over a seven year period by sequential computed axial tomography in order to determine the efficacy of radiotherapy as a treatment modality. Indices of tumor progression or regression included both size and contrast enhancement characteristics. Twenty of 25 patients followed during this period received radiotherapy. Of these patients, ten had tumor regression, nine were stable, and one was worse. This result contrasts with five untreated patients, four of whom had tumor progression and one who was stable (x2 = 18.37, p less than .001). One of the children with tumor progression later received radiotherapy and demonstrated marked tumor regression. Of the 18 treated patients who could be tested reliably, visual function and/or regression occurred in seven children. None of the untreated patients improved. There were no definite complications of radiotherapy in this small group.     

Relationships Between Serum Free Fatty Acids and Zinc, and Attention Deficit Hyperactivity Disorder: A Research Note

The purpose of this study is to evaluate the relationships between serum free fatty acids (FFA) and zinc, and attention deficit hyperactivity disorder (ADHD). Forty eight children with ADHD (33 boys, 15 girls) were included in the patient group and 45 healthy volunteer children (30 boys, 15 girls) constituted the control group. The mean serum FFA level in the patient group was 0.176 ± 0.102 mEq/L and in control group, 0.562 ± 0.225 mEq/L ( p < .001). The mean serum zinc level of patient group was 60.6 ± 9.9 μg/dl and that of the control group. 105.8±13.2 μg/dl (p < .001). A statistically significant correlation was found between zinc and FFA levels in the ADHD group. These findings indicate that zinc deficiency may play a role in aetiopathogenesis of ADHD. Although we observed decreased FFA levels in ADHD cases, it is necessary to determine whether this condition is a principal cause of ADHD or is secondary to zinc deficiency.     

Management of intrabiliary rupture of hydatid cyst of the liver

Thirty-six patients with intrabiliary rupture of hepatic echinococcal cysts were managed between 1974 and 1993. Clinical findings, skin tests, serologic tests, and imaging techniques were used to establish the diagnosis. Twenty-five (69.4%) patients had pain, 24 (66.6%) jaundice 22 (61.1%) fever, 20 (55.5%) chills, 10 (27.7%) malaise, and 7 (19.4%) other symptoms as the major causes of admission. All patients underwent choledochotomy and T-tube drainage. Treatment directed to the cyst was cystectomy and capittonage, cystectomy and drainage, and partial hepatectomy in 22, 12, and 2 patients, respectively. Omentoplasty was added to the treatment in 10 patients. Seven (19.4%) patients had complications. The period of hospitalization for patients with and without complications was 34.6±18.1 and 15.1±2.7, days, respectively. This study indicates that better results are obtained in patients with cystic lesions of the liver by avoiding percutaneous puncture or biopsy, the early use of ultrasonography and computed tomography, evacuation of the cyst together with its germinative membrane and the involved biliary tract under adequate care to avoid spillage into the peritoneal cavity, treating the remaining cavity according to its location, size, and the presence of infection, and decreasing the pressure in the biliary tract by T-tube drainage.

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Resumen Treinta y seis pacientes con ruptura intrabiliar de un quiste equinocóccico fueron manejados entre 1974 y 1993. Se utilizaron los hallazgos clínicos, pruebas cutáneas, pruebas serológicas y técnicas de imagenología para establecer el diagnóstico. Como causa principal de la hospitalización, 25 (69.4%) pacientes presentaban dolor, 24 (66.6%) ictericia, 22 (61.1%) fiebre, 20 (55.5%) escalofríos, 10 (27.7%) malestar general y 7 (19.4%) otros síntomas. La totalidad de los pacientes fue sometida a coledocotomía y drenaje con tubo en T. El tratamiento específico contra el quiste consistió en cistectomía y capitonaje, cistectomía y drenaje y hepatectomía parcial en 22,12 y 2 pacientes, respectivamente. Se añadió omentoplastia en 10 pacientes; 7 (19.4%) de los casos desarrollaron complicaciones. El período de hospitalización en los pacientes con y sin complicaciones fue de 36.6±18.1 y 15.1±2.7 días, respectivamente. El presente estudio indica que se logran mejores resultados en el manejo de las lesiones quísticas del hígado evitando la punción o biopsia percutáneas; utilizando precozmente el ultrasonido y la tomografía computadorizada; practicando la evacuación del quiste junto con su membrana germinativa y del tracto biliar afectado bajo con meticuloso cuidado para evitar la contaminación de la cavidad peritoneal; haciendo tratamiento de la cavidad residual de acuerdo con su ubicación, tamaño y la presencia de infección; y disminuyendo la presión en el tracto biliar mediante drenaje con tubo en T.

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Résumé Trente-six patients ayant une rupture dans les voies biliaires d'un kyste hydatique ont été traités entre 1974 et 1993. Les données cliniques, les tests cutanés, sérologiques et des techniques d'imagerie ont été utilisées pour arriver au diagnostic. Vingt-cinq (69.4%) patients se sont plaints de douleur, 24 (66.6%) d'ictère, 22 (61.1%) de fièvre, 20 (55.5%) de frissons, 10 (27.7%) de malaise et 7 (19.4%) d'autre symptômes comme motif d'hospitalisation. Tous les patients ont eu une cholédochotomie et un drainage par drain de Kehr. Le traitement du kyste a été une kystectomie associé à un capitonnage, une kystectomie associé à un drainage et une hépatectomie partielle chez 22, 12 et deux patients, respectivement. On a ajouté une omentoplastie chez 10 patients. L'évolution a été compliquée chez sept (19.4%) patients. La durée d'hospitalisation avec et sans complications a été de 3.6±18.1 et 15.1±2.7 jours, respectivement. Cette étude indique que de meilleurs résultats sont obtenus lorsque l'on s'abstient de la ponction percutanée ou de biopsie percutanée, lorsque l'on utilise l'échographic et la tomodensitométrie pour le diagnostic à un stade précoce, lorsque l'on évacue le kyste et enlève la membrane germinative et la portion de la voie biliaire intéressée, sans déversement du contenu dans la cavité péritonéale, lorsque l'on traite la cavité résiduelle selon son site, la taille du kyste et la présence d'infection, et lorsque l'on diminue la pression dans la voie biliaire par un drainage externe.

     

The effect of watching live arthroscopic views on postoperative anxiety of patients

Surgery is a stressful experience. Many minor interventions have been shown to cause considerable anxiety in patients, but whether arthroscopy leads to such anxiety is not well-known. Methods for lowering perioperative anxiety have been sought and listening to music or watching a movie have been recommended. The method of permitting patients to watch their own endoscopy has been studied infrequently. Our aim in this study was to find out the effect of watching simultaneous arthroscopic views on postoperative anxiety. A total of 63 patients were randomly divided into two groups: those watching their own arthroscopy formed group W, while patients that were only verbally informed formed group NW. The mean age of patients in both groups were 33 and 34, respectively. Meniscal surgery was the most commonly performed procedure (49/63 patients). The patients filled in state scale of State-trait anxiety inventory (STAI) forms and the study questionnaire (SQ) prepared for this study, just before and after the arthroscopy. Group W had significantly lower postoperative scores of STAI-S, whole questionnaire (Q-score) and all but one of individual statements in SQ. Having a previous operation history did not affect STAI scores. Age and level of education was not correlated with any of the studied parameters either. The ratio of patients that were pleased with the arthroscopy experience in group W and NW were 94 and 63%, respectively. Watching live arthroscopic views has led to a significant decrease in postoperative anxiety and worries about the surgery and the postoperative period, while increasing overall understanding and satisfaction of the patient.