Diagnosis and Treatment of Lyme Carditis: JACC Review Topic of the Week

The incidence of Lyme disease, a tick-borne bacterial infection, is dramatically increasing in North America. The diagnosis of Lyme carditis (LC), an early disseminated manifestation of Lyme disease, has important implications for patient management and preventing further extracutaneous complications. High-degree atrioventricular block is the most common presentation of LC, and usually resolves with antibiotic therapy. A systematic approach to the diagnosis of LC in patients with high-degree atrioventricular block will facilitate the identification of this usually transient condition, thus preventing unnecessary implantation of permanent pacemakers in otherwise healthy young individuals.     

Single-incision laparoscopic cholecystectomy (SILC): a refined technique

Background

Reports of decreasing the number of incisions in laparoscopic procedures began appearing in the 1990s. A recent spark in pursuing such an approach has been accelerated by natural-orifice transluminal endoscopic surgery.

Method

Several modifications in performing single-incision laparoscopic cholecystectomy (SILC) were introduced until it was possible to develop a simple and safe technique.

Results

SILC was completed in 61 of 71 operated patients. Fifty-five patients had SILC without cholangiography (average operative time, 49 minutes). Thirteen patients had SILC with cholangiography, 11 with negative results (average operative time, 67 minutes). Three patients needed additional trocars (bi-incision access surgery [BIAS]). None were converted to open procedures. Of the 69 patients with SILC or BIAS, 66 had same-day discharge, and 3 were discharged the following day.

Conclusion

SILC or BIAS is effective for gallbladder removal, with comparable lengths of stay, operative times, and safety as the traditional method, with better cosmetic results.     

针式组合式器械在新式单孔腹腔镜胆囊切除术中的应用

目的总结针式组合式器械在新式单孔腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中的应用效果。 方法回顾性分析接受新式单孔LC治疗的24例患者资料。术中将显露器针杆从右肋缘下锁骨中线穿刺进入腹腔,在腹腔内与操作头连接后向上牵引胆囊底浆膜层进行显露。将电钩针杆经剑突下穿刺进入腹腔,在腹腔内与操作头连接后进行胆囊三角分离及剥离胆囊。 结果开展24例新式单孔LC,其中需要增为2孔者3例,增孔率12.5%;无中转开腹。顺利完成21例(87.5%)新式单孔LC,手术时间(55.2±21.5)min,术中出血量(6.4±12.3)ml,无胆漏、出血、胆管损伤等并发症。 结论针式组合式显露器和针式组合式电钩结合使用可顺利完成新式单孔LC。     

Patient views through the keyhole: new perspectives on single-incision vs. multiport laparoscopic cholecystectomy

Objectives

Single-incision laparoscopic cholecystectomy (SILC) may be associated with less pain, shorter hospital stay and better cosmetic results than multiport laparoscopic cholecystectomy (MLC). Advocates suggest that patients prefer SILC, although research directly addressing the question of patient preferences is limited. This study aimed to assess patient preferences using currently available evidence.

Methods

Patients awaiting elective cholecystectomy were shown a series of postoperative images taken after SILC or MLC and asked which procedure this led them to prefer. This was repeated after patients had completed a questionnaire constructed using published objective data comparing patient-reported outcomes of SILC and MLC.

Results

The study was completed by 113 consecutive patients. After their initial viewing of the images, 16% of subjects preferred MLC. Younger age, lower body mass index and female sex were associated with choosing SILC. After completing the questionnaire, 88% of patients preferred MLC (P < 0.001). Patients ranked the level of risk for complications and postoperative pain above cosmetic results in determining their choice of procedure.

Conclusions

Patients'' initial preference when presented with cosmetic appearance was for SILC. When contemporary outcome data were included, the majority chose MLC. This underlines the need to fully inform patients during the consent process and indicates that patient views of SILC may differ from the views of those introducing the technology.