Laparoscopic adnexectomy for benign tubo-ovarian disease using abdominal wall lift: a comparison to laparotomy.

OBJECTIVES: To evaluate the results of laparoscopic adnexectomy using an abdominal wall-lifting device compared to laparotomy. METHODS: From February 1997 to December 2001, laparoscopic adnexectomy was performed in 68 cases of benign diseases in a university hospital. Three cases (4.4%) were converted to laparotomy due to poor visualization. The control group was a similar cohort of 65 patients who underwent the same procedures using laparotomy. RESULTS: There were 59 ovarian cysts and six tubal pregnancies in each group. Mean analgesic used, hospital stay, recovery period and blood loss were 11.5 mg, 2.0 days, 1.0 week and 49 ml, compared with 151.8 mg, 4.0 days, 3.0 weeks, and 122 ml in the laparotomy group (P<0.0005). Mean operating times and hospital charges were 81.7 min and 293.9 dollars (US), compared with 77.1 min (P=0.108) and 272.7 dollars (US) (P=0.033) in the laparotomy group. No serious complications were found in either group. CONCLUSIONS: Gasless laparoscopic adnexectomy is a safe and effective technique to provide laparoscopic benefit with minimal increase in hospital charges.     

Stability,permeation, and cytotoxicity reduction of capsicum extract nanoparticles loaded hydrogel containing wax gourd extract

The aim of this study was to develop hydrogel loaded with capsicum extract nanoparticles and wax gourd extract for transdermal delivery of capsaicin. The addition of wax gourd extract was supposed to reduce cytotoxicity of capsaicin in capsicum extract against HaCaT keratinocyte cell line. Capsicum extract nanoparticles were prepared by solvent displacement method using hyaluronic acid as a stabilizer. The physical and chemical stability of capsicum extract nanoparticles were investigated by dynamic light scattering technique and UV–Visible spectrophotometry, respectively. Hydrogel loaded with capsicum extract nanoparticles and wax gourd fruit extract was then formulated by using Carbopol 940® as a gelling agent for transdermal delivery. The skin permeability of capsaicin from the hydrogel was evaluated by Franz diffusion cell approach. The cytotoxicity reduction of capsicum extract nanoparticles and capsicum extract nanoparticles by mixing with wax gourd extract was determined by MTT assay The results showed that capsicum extract nanoparticles exhibited an average diameter of 168.4 ± 5.3 nm with a polydispersity index and zeta potential value of 0.26 ± 0.01 and −45.7 ± 7.1 mV, respectively. After two month-storage, particle size, polydispersity index, and zeta potential values of capsicum extract nanoparticles stored at 4° C, 30° C, and 45 °C did not significantly change. The capsaicin content decreased to 78%, 71%, and 72% when stored at 4 °C, 30 °C, and 45 °C for three months, respectively. The pH values of hydrogel containing capsicum extract nanoparticles were found to be in the range of 5.58–6.05 indicating good stability. The hydrogel exhibited a pseudoplastic character. The rate of permeation flux of capsaicin from hydrogel was 7.96 µg/cm²/h. A significant increase in cell viability was observed when the cells were incubated with capsicum extract nanoparticles mixed with wax gourd, compared to capsicum extract nanoparticles alone. The wax gourd extract in the hydrogel protected HaCaT cells from capsaicin cytotoxicity, thus may provide a new approach for delivery of capsaicin to reduce cytotoxicity to skin cells.     

Gasless laparoscopic hysterectomy: a comparative study with total abdominal hysterectomy

AIM: To evaluate the short-term results of gasless laparoscopic hysterectomy (GLH) compared to total abdominal hysterectomy. METHODS: A comparative study of GLH using an abdominal wall-lifting device (n = 31) and total abdominal hysterectomy (TAH) (n = 31) was carried out between July 1999 and July 2001. RESULTS: One patient (3.2%) in the GLH group required conversion to TAH. The operative time was 168 +/- 38 min and 112 +/- 29 min (P < 0.001) for the GLH and TAH groups, respectively. Gasless laparoscopic hysterectomy cases had a shorter hospital stay and convalescent period (2.6 +/- 0.9 days vs 5.0 +/- 1.3 days, P < 0.001 and 8.0 +/- 3.0 days vs 15.8 +/- 2.4 days, P < 0.001, respectively). Postoperative meperidine use and estimated blood loss were lower for GLH (P < 0.001). Complications were comparable in the two groups. Hospital charges were 8.5% higher for GLH (P = 0.02). CONCLUSIONS: Gasless laparoscopic hysterectomy may be an alternative technique for hysterectomy which provides laparoscopic benefit with minimal increase in hospital charges.     

Evaluating the accuracy of American Society for Gastrointestinal Endoscopy guidelines in patients with acute gallstone pancreatitis with choledocholithiasis

BACKGROUNDAcute gallstone pancreatitis (AGP) is the most common cause of acute pancreatitis (AP) in the United States. Patients with AGP may also present with choledocholithiasis. In 2010, the American Society for Gastrointestinal Endoscopy (ASGE) suggested a management algorithm based on probability for choledocholithiasis, recommending additional imaging for patients at intermediate risk and endoscopic retrograde cholangiopancreatography (ERCP) for patients at high risk of choledocholithiasis. In 2019, the ASGE guidelines were updated using more specific criteria to categorize individuals at high risk for choledocholithiasis. Neither ASGE guideline has been studied in AGP to determine the probability of having choledocholithiasis. AIMTo determine compliance with ASGE guidelines, assess outcomes, and compare 2019 vs 2010 ASGE criteria for suspected choledocholithiasis in AGP. METHODSWe conducted a retrospective cohort study of 882 patients admitted with AP to a single tertiary care center from 2008-2018. AP was diagnosed using revised Atlanta criteria and AGP was defined as the presence of gallstones on imaging or with cholestatic pattern of liver injury in the absence of another cause. Patients with chronic pancreatitis and pancreatic malignancy were excluded as were those who went directly to cholecystectomy prior to assessment for choledocholithiasis. Patients were assigned low, intermediate or high risk based on ASGE guidelines. Our primary outcomes of interest were the proportion of patients in the intermediate risk group undergoing magnetic resonance cholangiopancreatography (MRCP) first and the proportion of patients in the high risk group undergoing ERCP directly without preceding imaging. Secondary outcomes of interest included outcome differences based on if guidelines were not adhered to. We then evaluated the diagnostic accuracy of 2019 in comparison to the 2010 ASGE criteria for patients with suspected choledocholithiasis. We performed the t test or Wilcoxon rank sum test, as appropriate, to analyze if there were outcome differences based on if guidelines were not adhered to. Kappa coefficients were calculated to measure the degree of agreement between pairs of variables. RESULTSIn this cohort, we identified 235 patients with AGP of which 79 patients were excluded as they went directly to surgery for cholecystectomy without prior MRCP or ERCP. Of the remaining 156 patients, 79 patients were categorized as intermediate risk and 77 patients were high risk for choledocholithiasis according to the 2010 ASGE guidelines. Among 79 intermediate risk patients, 54 (68%) underwent MRCP first whereas 25 patients (32%) went directly to ERCP. For the 54 patients with intermediate risk who had MRCP first, 36 patients had no choledocholithiasis while 18 patients had evidence of choledocholithiasis prompting ERCP. Of these patients, ERCP confirmed stone disease in 11 patients. Of the 25 intermediate risk patients who directly underwent ERCP, 18 patients had stone disease. One patient with a normal ERCP developed post ERCP pancreatitis. Patients undergoing MRCP in this group had a significantly longer length of stay (5.0 vs 4.0 d, P = 0.02). In the high risk group, 64 patients (83%) had ERCP without preceding imaging, of which, 53 patients had findings consistent with choledocholithiasis, of which 13 patients (17%) underwent MRCP before ERCP, all of which showed evidence of stone disease. Furthermore, all of these patients ultimately had an ERCP, of which 8 patients had evidence of stones and 5 had normal examination.Our cohort also demonstrated that 58% of all 156 patients with AGP had confirmed choledocholithiasis (79% of the high risk group and 37% of the intermediate group when risk was assigned based on the 2010 ASGE guidelines). When the updated 2019 ASGE guidelines were applied instead of the original 2010 guidelines, there was moderate agreement between the 2010 and 2019 guidelines (kappa = 0.46, 95%CI: 0.34-0.58). Forty-two of 77 patients were still deemed to be high risk and 35 patients were downgraded to intermediate risk. Thirty-five patients who were originally assigned high risk were reclassified as intermediate risk. For these 35 patients, 26 patients had ERCP findings consistent with choledocholithiasis and 9 patients had a normal examination. Based on the 2019 criteria, 9/35 patients who were downgraded to intermediate risk had an unnecessary ERCP with normal findings (without a preceding MRCP).CONCLUSIONTwo-thirds in intermediate risk and 83% in high risk group followed ASGE guidelines for choledocholithiasis. One intermediate-group patient with normal ERCP had post-ERCP AP, highlighting the risk of unnecessary procedures.     

Assessment of the physical properties of laparoscopic myoma-fixation devices

Background The physical properties of three commercial 5-mm myoma-fixation devices available for clinical use (short-pitch corkscrew, long-pitch corkscrew, buttress-thread screw) and a standard wood screw were examined.Methods Fresh specimens of uterine leiomyoma masses were used to test the maximum traction force obtained from each device on 31 occasions. The myoma tissue at each traction site was evaluated histologically to determine its density. The maximal traction forces in each myoma density group were compared using a generalized estimating equations approach to linear regression based on repeated measures within each myoma. The bending strength also was determined for each device.Results A wide range of maximum traction forces with a mean of 130.8 ± 71.5 N (range, 21.6–341.6 N) over all devices and tissue densities was recorded. The mean maximum traction force provided by the short-pitch corkscrew (159.2 ± 12.2 N) was significantly higher (p < 0.01) than that of the other devices in medium-density myomas, and not significantly lower than that of other devices in low-density myomas. The mean maximum traction force provided by the buttress-thread screw was significantly lower than that of the short-pitch corkscrew only in medium density myomas, and did not differ significantly from that of the wood screw in any density group. The wood screw provided the highest bending strength (6.73 × 10⁴ N/m) (whereas the short- and long-pitch corkscrew provided the lowest (9.70 × 10² N/m and 1.95 × 10³ N/m, respectively) and the buttress-thread screw an intermediate (2.24 × 10⁴ N/m) strength (p < 0.0005 for all comparisons except for the two corkscrews).Conclusions Screw-type myoma-fixation devices can provide comparable traction force with high bending strength. A long-pitch corkscrew should not be used for laparoscopic myomectomy because of its low traction force and bending strength. When a commercial screw is not available, a standard wood screw can be used with acceptable traction force and very high strength for bending.     

Effect of thread pitch on pull-out strength of laparoscopic myoma screws

AIM: The purpose of this study was to evaluate the effect of thread-pitch on pull-out strength and bending strength of buttress-thread screws designed for laparoscopic myoma extraction. METHODS: The ultimate failure load of four 5-mm diameter buttress-thread screws with 3-, 4-, 5-, and 6-mm thread pitch, 40 mm in thread-length were examined on fresh myoma specimens. The myoma tissue at each traction site was evaluated histologically to determine its density. The critical minimal pull-out strength based on moderate-density myoma group was estimated. The bending strength was also determined for each screw. RESULTS: A wide range of ultimate failure loads with a mean +/- SE of 129.3 +/- 5.5 N (range, 30.4-255.7 N) for all screws and tissue densities was recorded. In moderate-density myomas, the mean ultimate failure loads decreased linearly with increasing thread-pitch from 3 mm (148.0 +/- 9.5 N) to 6 mm (119.8 +/- 9.4 N) (test for trend: P < 0.05). Based on the criterion of a minimum pull-out strength of at least 50 N in not less than 95% of tractions in medium-density myomas, the 3-mm and 5-mm pitch screws were found to have acceptable properties. The 5-mm pitch screw had less thread-turn than the 3-mm pitch for the same thread-length and would need less application time. The bending strength also decreased with increasing thread pitch from 3 to 5 mm, then became stable at around 15 N. CONCLUSIONS: The pull-out strength of soft tissue buttress-thread screws decreased linearly with increasing thread-pitch. Thread-pitch should be considered when designing laparoscopic myoma-screws.