Abstract: Intraperitoneal adhesions are a common problem in abdominal surgery. The aim of this study was to compare the effectiveness of Statofilm, a novel antiadhesive film based on cross-linked carboxymethylcellulose and atorvastatin, with that of sodium hyaluronate-carboxymethylcellulose (Seprafilm(®)) in the prevention of postoperative intraperitoneal adhesions in rats.
Abstract: BACKROUND: Xanthogranulomatous cholecystitis is a rare but severe presentation of cholecystitis characterized by extensive inflammation of the gallbladder wall with characteristic histopathological features. Frequently, the inflammatory mass resembles gallbladder cancer macroscopically, which further complicates therapeutic decisions. CASE PRESENTATION: We report a case of xathogranulomatous cholecystitis with characteristic computed tomography findings, which was managed by percutaneous drainage of the gallbladder, giving the opportunity for a delayed elective cholocystectomy with an excellent postoperative outcome. DISCUSSION: Recent studies give emphasis on certain criteria for the differential diagnosis of xanthogranulomatous cholecystitis against carcinoma. Characteristic computed tomography features are usually sufficient to establish the diagnosis with safety and decide a nonoperative management of the disease in the acute phase. Percutaneous gallbladder drainage is regarded as a safe and an efficient method for the initial treatment of severe cases.
Abstract: Bevacizumab is a monoclonal antibody targeted at vascular endothelial growth factor (VEGF) to treat advanced colorectal cancer as well as other malignancies, but the ideal time point for its administration in patients scheduled for surgery is not well defined due to serious concerns regarding possible side effects on wound healing. Therefore, we conducted an experimental study in rats to clarify this issue.
Abstract: Adenocarcinoma of the pancreas exhibits aggressive behavior in growth, inducing an extremely poor prognosis with an overall median 5-year survival rate of only 1%-4%. Curative resection is the only potential therapeutic opportunity.
Abstract: The management of metastatic disease in pancreatic endocrine tumors (PETs) demands a multidisciplinary approach and the cooperation of several medical specialties. The role of surgery is critical, even when a radical excision cannot always be achieved.
Abstract: Autoimmune pancreatitis (AIP) is a rare form of chronic pancreatitis with a discrete pathophysiology, occasional diagnostic radiological findings, and characteristic histological features. Its etiology and pathogenesis are still under investigation, especially during the last decade. Another aspect of interest is the attempt to establish specific criteria for the differential diagnosis between autoimmune pancreatitis and pancreatic cancer, entities that are frequently indistinguishable.
Abstract: Sigmoidorectal endometriosis accounts for 70% of the cases of intestinal endometriosis. Symptoms are non-specific, frequently resembling adenocarcinomas.
Abstract: Retractile mesenteritis is a rare, fibrosing, inflammatory disease affecting the adipose tissue of the intestinal and colonic mesentery. So far, about 300 cases have been reported in the literature. We present a case of retractile mesenteritis.
Abstract: The medical treatment plays the first role in the vast majority of cases. Severe acute diverticulitis requires hospitalization and supporting care with intravenous fluids and antibiotics such as ciprofloxacin and metronidazole. Emergency operative intervention is necessary if complication occurs. Laparoscopic surgery has a well-defined place and such colectomy has been gaining, nowadays, more popularity.
Abstract: elderly patients are steadily becoming a growing part of the population. The aim of this study is to evaluate the outcome of open inguinal hernia repair in patients aged over 65 years.
Abstract: PURPOSE: The aim of the study was to investigate the effect of angiogenesis inhibition by bevacizumab, a monoclonal anti-vascular endothelial growth factor (VEGF) antibody, on the healing process of colonic anastomoses in rats, assessing some specific involved factors. This new agent is used mainly in metastatic colorectal cancer. The angiogenesis plays an important role in both wound healing and metastatic invasion and spread of malignant cells. There has not been any evidence assessing the optimal time for its safe use in operated patients. MATERIALS AND METHODS: Forty Wistar rats were randomly allocated into four equal groups. A colonic anastomosis was performed in all rats. Half of them received intraoperatively a single dose of bevacizumab 5 mg/body weight and the rest received placebo. The animals were sacrificed on the 7th (Avastin 7th, placebo 7th) and 14th (Avastin 14th, placebo1 4th) postoperative day. The anastomosis was resected and sent for histological study and for tissue biochemical assays (VEGF, endothelin-1 (ET-1), C-reactive protein (CRP), pro-oxidant-antioxidant balance (PAB), carbonylated proteins, hydroxyproline) using specific enzyme-linked immunosorbent assay kits. For statistical analysis, the Mann-Whitney U test was used (of statistical significance when P < 0.05). RESULTS: No complication or anastomotic dehiscence was observed. Histology did not reveal statistically significant differences between groups concerning degree of inflammation, fibroblasts, collagen, and fibrosis. Likewise, hydroxyproline levels did not differ. However, some statistically significant differences were found in VEGF, CRP and carbonyl proteins (Avastin 7th vs placebo 7th, placebo 14th vs placebo 7th), ET-1, and PAB (Avastin 14th vs Avastin 7th), which did not finally affect the collagen synthesis marker hydroxyproline, nor did the anastomotic strength. CONCLUSIONS: Bevacizumab, when administered intraoperatively, has no significant effect on colon anastomotic healing in rats despite a transient mild ischemia.
Abstract: Early assessment of the severity of acute pancreatitis is essential to the proper management of the disease. It is dependent on the criteria of the Atlanta classification system.
Abstract: BACKGROUND: The indications and benefits of laparoscopic cholecystectomy (LC) in patients with liver cirrhosis and symptomatic cholelithiasis have not been satisfactorily documented. The aim of this study was to investigate its efficacy and safety in such patients. METHODS: Medical records of 38 patients with liver cirrhosis (stages Child-Pugh A and B) who underwent LC were retrospectively reviewed. Demographic characteristics and other parameters including initial presentation, conversion rate, complication rate, mortality, and duration of hospital stay were investigated and compared with noncirrhotic patients' parameters in our database. RESULTS: Cirrhotic patients who underwent LC were older than noncirrhotic patients (P=0.021). Both the conversion rate (15.78%) and the duration of hospital stay were increased in the cirrhotic group, but without significant differences. Major complications occurred more often in the cirrhotic group (P=0.027), increasing morbidity; however, the mortality was zero. CONCLUSIONS: LC can be safely performed in Child-Pugh A and B cirrhotic patients with symptomatic gallstone disease, with acceptable complication and conversion rates. The increased risk for a major complication, however, demands more attention than usual.
Abstract: The Ewing sarcoma family of tumors (ESFT) includes classic Ewing sarcoma of the bone, extraosseous or soft tissue Ewing sarcoma, Askin tumors of the chest wall, and peripheral primitive neuroectodermal tumors of the bone and soft tissues. They share a common neural histogenesis, tumor genetics and biology. The genetic hallmark of the ESFT is the presence of t(11;22)(q24;q12), which creates the EWS/FLI1 fusion gene and results in the expression of a chimeric protein. Although Ewing tumors can occur at any age, the great majority are found in individuals less than 20 years of age. We herein report a case of gastric Ewing sarcoma in a 68-year-old male. This patient illustrates the second reported occurrence of primary Ewing sarcoma in the stomach and the first reported with the t(11;22)(q24;q12) gene translocation.
Abstract: BACKGROUND AND AIMS: Variceal bleeding is the most serious complication of portal hypertension associated with high mortality. This study was conducted to investigate any protective effect of early propranolol administration in the development and degree of esophageal varices in cirrhotic rats with portal hypertension. This topic is controversial in the literature. METHODS: For the development of liver cirrhosis and esophageal varices, 60 rats underwent ligation of the left adrenal vein and complete devascularization of the left renal vein, followed by phenobarbital and carbon tetrachloride (CCl(4)) administration. This operation enhances the development of cephalad collaterals, responsible for the induction of esophageal varices. After 2 weeks of CCl(4) administration, the rats were randomly separated into 2 groups. In group I, propranolol was continuously administered intragastrically throughout the study, whereas in group II normal saline (placebo) was administered instead. Cirrhosis was detected clinically by ascites development. Hemodynamic studies and morphometric analysis of the lower esophagus were performed after complete induction of cirrhosis, measuring the following parameters: portal pressure, total number of submucosal veins, total submucosal vessel area, mean cross-sectional submucosal vessel area, relative submucosal area (percentage) occupied by vessels and area of the single most dilated submucosal vein. RESULTS: The statistical analysis revealed no statistically important difference between the 2 groups for the morphometrically studied parameters. However, portal venous pressure was lower in group I. CONCLUSION: Early propranolol administration did not protect rats from developing esophageal varices, despite the fact that a significant decrease in portal pressure was detected.
Abstract: Mirizzi's syndrome accounts for an important risk for bile tree injury during surgery, since preoperative diagnosis is missed in half of the cases and is often difficult to differentiate from carcinoma. A 79-year-old male, with a known history of cholelithiasis, was admitted with a progressive obstructive jaundice over 20 days, without pain, fever, or other symptoms. Magnetic resonance cholangiopancreatography described possible microlithiasis of the distal bile duct, but on endoscopic retrograde cholangiopancreatography (ERCP), an irregular stenosis was detected under the junction of hepatic ducts, which was described as possibly neoplastic. A temporary stent was placed and the patient was referred for surgery. On first view the gallbladder appeared hard, embedded in adhesions, giving the impression of an unresectable tumor and the bile duct was not approachable. After a fundus-down incision of the gallbladder multiple stones were extracted. Frozen biopsies from the gallbladder wall were negative. The incision was extended towards the gallbladder neck and a large communication with the common bile duct (CBD) was revealed. A difficult partial cholecystectomy was performed, followed by cholecystojejunostomy with a Roux-en-Y jejunal loop. The patient had a totally uneventful postoperative course. Stent removal was succeeded endoscopically 1 month later. The importance of preoperative ERCP and CBD stenting is highlighted in this article. ERCP may have failed to distinguish Mirizzi's syndrome from carcinoma, however the stent placement saved the cardiologically compromised patient from further surgical manipulations. Therefore, in ambiguous cases, whatever the final diagnosis turns to be, either carcinoma or Mirizzi's syndrome, CBD stenting can be useful for the final management of the patient.
Abstract: BACKGROUND: The advantages of laparoscopic surgery have been well documented. However, the impact of pneumoperitoneum on sepsis sequelae is still equivocal. This study aimed to evaluate the effect of CO(2) pneumoperitoneum, applied under different pressures and exposure times, on sepsis cascade and mortality. MATERIAL AND METHODS: In 42 New Zealand rabbits, peritonitis was induced by the cecum ligation and puncture model. After 12 h, the animals were randomized in seven groups: a control group, four groups with pneumoperitoneum (10-15 mmHg for 60-180 min), and two groups with laparotomy (for 60 and 180 min). Blood samples were collected before cecum ligation and puncture, 12 h later and 1, 3, and 6 h after pneumoperitoneum desufflation or abdominal trauma closure to evaluate bacteremia, endotoxemia, white blood cells count, C-reactive protein, and procalcitonin levels. Furthermore, the mortality time was recorded in all animals. RESULTS: Bacteremia and endotoxemia were induced in all groups. Endotoxemia levels were significantly more elevated in the group where pneumoperitoneum was performed under 15 mmHg for 180 min compared with all other groups at 1 and 3 h after pneumoperitoneum desufflation (P < 0.05), except when compared with the group where pneumoperitoneum was performed under 10 mmHg for 180 min. White blood cell and C-reactive protein levels showed similar trends for all groups. However, serum procalcitonin reached statistically higher levels (P < 0.05) in groups with laparotomy compared with groups with pneumoperitoneum and with the control group at 6 h. Survival was lower in the laparotomy groups compared with the pneumoperitoneum groups and with the control group (P < 0.05). CONCLUSIONS: In the presence of peritonitis, CO(2) pneumoperitoneum applied in clinically standard pressures, even for extended time intervals, reduces the severity of sepsis and prolongs survival.
Abstract: To present our experience with unexpected findings during hernia surgery, either unusual hernial contents or pathologic entities, like neoplastic masses, masquerading as a hernia.
Abstract: Afferent loop syndrome is a relatively rare complication after subtotal gastrectomy. We present a late onset of afferent loop obstruction, in a patient who underwent Billroth II gastrectomy with Roux-Y reconstruction for a gastric ulcer 27 years ago. A 60-year-old male was admitted to the hospital with an 8-hour history of acute epigastric pain, associated with vomiting, fever and signs of sepsis. Laboratory tests revealed leukocytosis, elevated liver function tests and high serum amylase. An obstructed afferent loop appeared on CT as a fluid filled tubular mass, crossing the middle line between the aorta and the mesenteric vessels. Advanced sepsis was also seen in the peripancreatic and retroperitoneal region. Although the patient was operated on immediately after diagnosis with reconstruction of Roux-Y anastomosis, he died 12 hours later. Afferent loop syndrome is quite uncommon, and must be suspected in patients who have undergone subtotal gastrectomy. Clinical manifestations of the syndrome are usually non-specific. CT is the examination of choice and surgery the first choice treatment.
Abstract: An enlarging soft tissue mass was resected from the leg of a young man with neurofibromatosis type 1. Rhabdomyosarcomatous elements admixed with islands of osteoid and chondroid matrix was seen on microscopy. Based on immunohistochemistry, a malignant triton tumor, an uncommon subtype of peripheral nerve sheath tumor with rhabdomyosarcomatous elements, was diagnosed. The important feature of this neoplasm was that it showed pluridirectional differentiation to osteosarcoma and chondrosarcoma. This pathologic finding is rare and seen in only a few cases of all malignant triton tumors.
Abstract: Malakoplakia represents a chronic inflammatory disease associated with a broad spectrum of bacterial infections. On histopathology, Michaelis-Gutmann bodies are considered as pathognomonic histopathological findings. Rarity of the disease and wide variety of clinical presentation makes its diagnosis very challenging. We report herein the case of a 66-year-old woman who, having undergone lower anterior resection for rectal adenocarcinoma 3 and a half years ago, presented with urinary frequency and dull abdominal pain. CT scan revealed a soft tissue tumour infiltrating the preperitoneal fat over the urinary bladder, which was considered as recurrence of the rectal carcinoma. On laparotomy, a tumour invading the bladder, small intestine and the anterior abdominal wall was resected and the patient recovered uneventfully. On histopathology, malakoplakia of urinary bladder was revealed. Overstaging of patients' malignancy due to malakoplakia is not uncommon, so its early identification can help avoid incorrect treatment.
Abstract: To investigate any protective effect of early propranolol administration in the development of portal hypertensive gastropathy in cirrhotic rats.
Abstract: Foreign body ingestion is a commonly seen accident in emergencies, usually in children (80%), elderly, mentally impaired, or alcoholic individuals, whereas it may occur intentionally in prisoners or psychiatric patients. According to the literature, 90% of ingested foreign bodies pass through the gastrointestinal tract without complications, 10% to 20% necessitate endoscopic removal, whereas only 1% of them will finally need surgical intervention. In clinical practice, we often face the dilemma of choosing the appropriate treatment modality. We present 13 cases treated in our department, emphasizing in a "waiting and close observation" policy. Among these cases, only 1 patient needed to be operated because of obstruction of ileocecal valve by a large coin. Indications for treatment where applicable are also being discussed.
Abstract: BACKGROUND: This study was conducted to investigate the effect of chronic bosentan administration on the development of esophageal varices in carbon tetrachloride-induced cirrhosis in rats. METHODS: For the development of liver cirrhosis and esophageal varices, 60 rats underwent ligation of the left adrenal vein, followed by phenobarbital and carbon tetrachloride administration. Two weeks after the beginning of carbon tetrachloride administration, rats were separated into two groups. In group I, comprising 30 rats, bosentan was continuously administered throughout the study, whereas in group II, also 30 rats, placebo instead of bosentan was continuously administered. Hemodynamic studies and morphometric analysis of the lower esophagus were performed after complete induction of cirrhosis. The total number of veins counted in the submucosa, the number of submucosal veins/mm(2) of submucosa, the total submucosal area occupied by vessels, the mean cross-sectional vessel area, the relative submucosal area (percentage) occupied by vessels, and the area of the single most-dilated submucosal vein were studied. RESULTS: Bosentan induced a significant (P < 0.05) decrease in portal pressure, while morphometric analysis revealed a significant reduction (P < 0.05) of all parameters studied in bosentan-treated rats, except in the total and relative number of submucosal veins. CONCLUSIONS: Bosentan administration seemed to significantly attenuate dilation of submucosal veins in the lower esophagus of cirrhotic rats. This effect was mainly attributed to a decrease in the portal pressure induced by chronic bosentan administration.
Abstract: BACKGROUND: Wound healing in liver cirrhosis is known to be impaired possibly due to liver insufficiency and subsequent malnutrition status; however, there is no study to examine healing effectiveness of the tooth socket following an extraction in such patients. MATERIALS AND METHODS: Irreversible cirrhosis was induced in 30 Wistar rats by repetitive weekly doses of CCl(4) and continuous administration of phenobarbital in a 12-week course was monitored by body weight measurement and ascites development, and was proved histologically. One week later, cirrhotic and control rats were subjected to extractions of two maxillary grinders on each side, one side by simple method, the other by surgical method. Half of the animals of each subgroup were sacrificed on the 10th post-extraction day, whereas the other half on the 30th post-extraction day, and histological sections were examined from all tooth sockets for wound-healing activity. RESULTS: A malnutrition status was detected in cirrhotic rats with significant difference in their body weight. Several histological parameters of socket healing were not statistically different between cirrhotic and control animals. However, a significant delay on epithelialization and cancellous bone formation was detected on the 10th post-extraction day for either simple or surgical extractions in cirrhotic animals. CONCLUSIONS: Liver cirrhosis in rats provokes a significant delay on epithelialization and mature cancellous bone formation and consecutively on early socket wound healing after a tooth extraction.
Abstract: Complications of flexible endoscopy-though still rare-are increasing in frequency lately as more invasive procedures are routinely performed. Perforation, hemorrhage, coagulation disorders, thrombophlebitis, and splenic rupture have all been reported to complicate colonoscopy and colorectal polypectomies. In this paper, we report on a case of retroperitoneal, mediastinal, and neck surgical emphysema, complicating colonoscopy and rectal polypectomy, presented initially as a change in the voice and facial swelling.
Abstract: OBJECTIVE: Emergency surgery for colorectal cancer is common in daily practice, and is mainly implied by bowel obstruction. It is related to increased morbidity and mortality. Its relation with the stage and respectability of the disease is uncertain. This study aims to further clarify these parameters. PATIENTS AND METHODS: Over the past 24-year period 121 patients had an emergency operation (12%) from a total of 1009 patients with colorectal carcinoma. There were 59 men (48.8%) and 62 women (51.2%) with a mean age of 68 years (range 21-93); 61 patients (50.4%) were > or = 70-years-old. The data of all these patients were studied retrospectively in comparison with those who underwent elective surgery. Emergency cases were further divided into two age groups (> or = 70 and < 70 years) and compared. The tumour location was mainly in the left colon, whereas obstruction was the predominant reason for acute presentation. RESULTS: On operation, absence of macroscopic spread was noted in 57.8% of emergency cases and 72% of elective cases (p < 0.05). The resectability rates were 75% and 90% respectively (p < 0.05), and were not significantly affected by the age factor. There were no differences in the grade of malignant cell differentiation or in the depth of microscopic invasion (p > 0.05) in either group. For emergency operations, the morbidity was 20% (24 patients) and the 30-day mortality rate was 5.8% (7 patients). Both parameters were higher in patients > or = 70-years-old. CONCLUSION: Emergency surgery for colorectal carcinoma is related to lower resectability and to higher--but acceptable--postoperative morbidity and mortality rates, when compared with elective surgical management.
Abstract: ABSTRACT Background: Since octogenarians become a growing part of the population and surgical care is possible in them, this study was conducted to evaluate the outcome of laparoscopic cholecystectomy in patients 80 years of age and over. Methods: From June 1993 to May 2006, a total of 1263 patients underwent a laparoscopic cholecystectomy, applying the four-trocar American technique; 21 among them were >/=80 years. We retrospectively reviewed patients' age, gender, indication for surgery, comorbid conditions, American Society of Anesthesiologists (ASA) score, conversion to open procedure, postoperative complications, and length of hospital stay. Results: The mean age in the >/=80 group was 82.5+/-3 and 57% were women, while in the <80 group 72% of patients were women. Recurrent biliary colic was the most frequent (62%) indication for surgery among the elderly patients. Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy were performed preoperatively in 6 elderly patients (29%); there were 4 cases of acute calculus pancreatitis and 2 cases of acute cholangitis. A high surgical risk (ASA score of III and IV) was estimated in 11 patients (52%) from the >/=80 group versus 32% in the <80 group (P =0.047). Conversion rate was higher (19%) and hospital stay was longer (4.9 days) in the >/=80 group, compared to younger patients (P =0.01). Mortality was zero and morbidity was 14% versus 3% in the <80 group (P =0.03), including 1 case of postoperative bleeding, 1 case of wound infection, and 1 case of pulmonary atelectasis, respectively. Conclusions: Laparoscopic cholecystectomy in the extremely elderly is safe and well tolerated; however, it is associated with a higher conversion rate, increased morbidity, and a longer hospital stay.
Abstract: Situs inversus totalis is an inherited condition characterized by a mirror-image transposition of thoracic and abdominal organs. It often coexists with other anatomical variations. Transposition of the organs imposes special demands on the diagnostic and surgical skills of the surgeon. We report a case of a 34-year-old female patient presented with left upper quadrant pain, signs of acute abdomen, and unknown situs inversus totalis. Severe acute cholecystitis was diagnosed, and an uneventful laparoscopic cholecystectomy was performed. A posterior cystic artery was identified and ligated. Laparoscopic cholecystectomy is feasible in patients with severe acute calculus cholecystitis and situs inversus totalis; however, the surgeon should be alert of possible anatomic variations.
Abstract: BACKGROUND: Conversion of laparoscopic to open cholecystectomy is required in certain cases for the safe completion of the operation. Some factors contribute more to the need for conversion. METHODS: Over a 13-year period, the laparoscopic cholecystectomy procedure was attempted in 1263 patients whose mean age was 54 years and 28% being male. The conversion was necessary in 98 cases whose mean age was 60 years, with 42% being male. All data were studied retrospectively. Six factors were examined statistically for a possible correlation with the conversion rate, as well as the trend of it over time. RESULTS: The main reason for conversion was the unclear anatomy owing to previous inflammation, followed by bleeding and choledocholithiasis suspicion, gallbladder carcinoma, bile duct injury, or spilled gallstones. The overall conversion rate was 7.75%. It was significantly increased in males (11.6%) and the elderly (12.4 %), gallbladder inflammation (29%), and morbid obesity (50%). Conversion rate did not change significantly in the first half period (8.1%) of the study, the second half-period (7.6%), in patients with diabetes mellitus (6.7%), or hematological disorders (6%). CONCLUSIONS: The risk for the conversion of laparoscopic cholecystectomy increases significantly in males, the elderly, obese patients, and when inflammation is present. This observation remains unchanged over time. Diabetes mellitus and hematologic disorders do not predispose in a higher risk for conversion.
Abstract: Epidermoid splenic cysts are very rare. Symptoms emerge because of enlargement, infection, haemorrhage or rupture. Although splenectomy is indicated for large cysts, minimally invasive and preservation procedures, such as partial splenectomy or total cystectomy with splenorrhaphy, have been increasingly used during the last decade. We report herein the case of a 16-year old female presented with left upper abdominal quadrant pain, fever and abdominal distention treated in our department.
Abstract: Laparoscopic cholecystectomy may lead to serious complications, some of which can be disastrous if they are not recognized and managed immediately. Over the past 12-year period, 1225 laparoscopic cholecystectomies were performed. Totally, major complications occurred in 19 cases (1.5%). The conversion rate was 7.4%. Complications included common bile duct injury in 2 cases (0.16%), vessel injury by trocar or Veress needle in 4 cases (0.32%) including 1 case of aorta injury (0.08%), bleeding from the gallbladder bed or the cystic artery in 10 cases (0.8%), bile leak in 1 case (0.08%), duodenum injury in 1 case (0.08%), and transient liver ischemia in 1 thalassanemic patient (0.08%). The complication was recognized during the operation in 11 cases. Reoperation was necessary in five cases (0.4%), and conservative management was applied in three cases. Although infrequent, major complications may occur during laparoscopic cholecystectomy. Immediate recognition and management is critical and may lead to a safe outcome.
Abstract: Gangrenous cystitis is an extremely rare condition. During the last 70 years, only 30 cases have been reported in the literature. We report a case of gangrenous cystitis in a 70-year-old woman presented with symptoms of acute abdomen. Main causative factor was overdistension of the bladder due to catheter obstruction. She underwent debridement and drainage of the cystic remnant. The pathogenesis, diagnosis, and management of gangrenous cystitis are discussed.
Abstract: BACKGROUND: The influence of laparoscopic cholecystectomy on coagulation and fibrinolysis is debatable. There have been a few but controversial studies and the need for routine antithrombotic prophylaxis is unclear. MATERIALS AND METHODS: In this prospective study we investigated changes in coagulation and fibrinolysis parameters in laparoscopic cholecystectomy. Blood samples taken before, during, and after surgery from 38 consecutive patients were analyzed. Measured parameters included the international normalized ratio, prothrombin time, partial thromboplastin time, antithrombin III activity, platelet count, mean platelet volume, fibrinogen, and D-dimers. RESULTS: Statistically significant changes included increased perioperative international normalized ratio and D-dimers, and postoperative antithrombin III, fibrinogen, and D-dimers, as well as decreased perioperative antithrombin III and fibrinogen and postoperative international normalized ratio, platelet count, and mean platelet volume. Values of partial thromboplastin time had no statistically significant changes. CONCLUSION: Reduced coagulation activity and increased fibrinolytic activity occur during and after laparoscopic cholecystectomy.
Abstract: Parastomal hernia represents a common complication of colostomy formation. Surgical techniques such as facial repair and stoma relocation have almost been abandoned because of high recurrence rates. Extraperitoneal prosthetic mesh repair had better results but was accompanied by high rates of mesh contamination. A new technique, with intraperitoneal onlay position of expanded polytetrafluoroethylene (ePTFE) was therefore established. We report herein two cases of symptomatic large parastomal hernias treated in our department.
Abstract: OBJECTIVE: Colorectal emergency requiring radical surgery is becoming increasingly frequent in the elderly and problems remain as regards the best management policy. Our long-time experience is presented in this study. PATIENTS AND METHODS: In the last 23 years, 105 elderly patients, aged > or = 65 years, with colorectal disease underwent an emergency operation in our Surgical Department. Forty-five patients (mean age 72 years) had benign disease and 60 patients (mean age 76.5 years) colorectal carcinoma. RESULTS: The carcinoma was located in the left colon (68%), right colon (18%) and rectum (14%). Mostly, patients with malignant cancer presented with obstructive ileus, and patients with benign tumours with perforation and peritonitis, with a predominance of diverticulitis. A resection operation either with primary anastomosis or Hartmann's procedure was performed in 75% of cases; in the rest, only palliation was resorted to. Forty-three percent of the patients with colorectal cancer emergency were > or = 80 years of age. The mean morbidity was 25% and mortality 17%, which make up to 33% and 26.6% for benign disease, and 20% and 10% for malignant cancer, respectively. The mortality rate was higher in patients with perforation than those with obstruction. CONCLUSION: Advanced age is not a contraindication to radical surgery in case of colorectal emergency in the elderly. In the majority, a resection operation is feasible. In high-risk patients, colostomy is a life-saving alternative.
Abstract: We report the case of a 17-year-old male with a rupture into the biliary tract. The patient was urgently admitted to the surgical department with the clinical diagnosis of cholangitis. Modern imaging techniques and specific serologic tests established the diagnosis of intrabiliary rupture of a liver hydatid cyst due to E. granulosus. Despite the fact that surgery remains the cornerstone of treatment, conservative management was preferred, due to the location of the echinococcal cyst in the right lobe of the liver adjacent to the inferior vena cava and the age of the patient. Endoscopic sphincterotomy was performed with subsequent evacuation of the biliary tree, followed by a sixcycle treatment with albendazole. At one-year follow-up, the patient is in good health, with no radiologic or serologic evidence of relapse.
Abstract: BACKGROUND/PURPOSE: Surgery is the cornerstone in the treatment of echinococcosis. The purpose of this study is to report the long-term results of partial cystectomy and omentoplasty in the management of hepatic hydatid disease. MATERIAL AND METHODS: In a retrospective survey over the past 20 years (1982-2001) there were 36 patients (13 men and 23 women, with a mean age of 50 years) with hepatic echinococcosis, treated by partial cystectomy and omentoplasty. All patient data were carefully studied and short-term as well as long-term results were assessed. The cystic lesion was single in all but two cases (5.6%), located in the right lobe of the liver (69.4%), the left lobe (25%) or both lobes (5.6%). The mean size of the cyst was 12 cm in diameter (range 3 to 25 cm). The follow-up was achieved at regular intervals and recently in all, including computed tomography and specific immunological test ELIZA. It has completed a mean 12-year period (range 2 to 21 years) and in 75% of cases up to 10 years. RESULTS: The mean hospital stay was 23 days (range 9 to 51 days). The morbitity was 8/36 (22%) due mainly to septic complications. The 30-day mortality was 1/36 (2.7%). The residual cavity remained for a mean of 8 months (range 4 to 18 months), while fistula formation was seen in 1/36 (2.7%). There was cure in 29 cases (80.6%) without any serological or imaging evidence of residual disease. However, recurrence was documented in 7 cases (19.4%) requiring further treatment. CONCLUSIONS: Following the experience of the authors, partial cystectomy and omentoplasty may be an acceptable alternative to more radical procedures, especially in high risk cases and in developing countries.
Abstract: BACKGROUND: Colonic polyps are usually removed endoscopically. Surgical intervention is reserved for large, inaccessible colorectal polyps that have underdone malignant transformation. Laparoscopic management of colonic polyps has gained a well-defined role. METHODS: Since 1993, 650 laparoscopic colectomies have been performed in our department. Twenty-eight patients with large, sessile, polyps that have undergone malignant transformation underwent elective laparoscopic colectomy. Operative procedures included 14 sigmoidectomies, 10 low anterior recto-sigmoid resections, 3 right colectomies, and 1 left colectomy. Central ligation of vessels and lymph node dissection were preformed in all patients. RESULTS: The main outcome measures include conversion rate (11%), morbidity (11%), and mortality (3.5%). The mean return of bowel function was 3.1 days, liquid intake 1.4 days, solid food intake 2.5 days, and mean hospital stay 8 days. The mean specimen length was 23 cm, and the mean number of retrieved lymph nodes was 15. Malignancy according to Dukes classification was in situ, n=4; A, n=15; B, n=4; C, n=4; and D, n=1. During follow-up, 2 patients developed liver metastases. CONCLUSION: Laparoscopic colectomy is a technically feasible and effective method for treating large colorectal polyps that have undergone malignant transformation.
Abstract: Accurate placing of securely tied knots in laparoscopic surgery is technically demanding and time consuming. Surgeons must face difficulties arising from 2-dimensional vision, spatial limitations, and restricted movement. Issues to be taken into account include security, virtuosity, and cost effectiveness. The authors believe that in spite of advances in instrumentation and optics, training should aim at manual skill development and application of the basic principles of general surgery.
Abstract: BACKGROUND/AIMS: The spleen is the third most common location of hydatid disease after liver and lung. The aim of this study was to analyse the long-term outcome of surgical treatment of patients with splenic echinococcosis comparing splenectomy with spleen-preserving surgery. METHODS: During a period of 25 years (1976-2001), 19 (5.4%) patients with splenic echinococcosis were treated in our department out of 349 patients with abdominal hydatid disease. In 16 patients the spleen was the only organ involved, while in 3 patients the liver was also affected. RESULTS: Eleven patients had splenectomy and in the other 8 the spleen was preserved: enucleation (n = 4), partial cystectomy and omentoplasty (n = 2) and cystojejunal Roux-en-Y anastomosis (n = 2). One (6%) patient died in the early postoperative period and 5 (29%) patients had postoperative complications. There was no significant difference between the splenectomy and spleen-preserving groups concerning median hospital stay and postoperative complication rate. The median follow-up in 15 patients was 52 (range 6-300) months. Two patients (13%) developed recurrence of the disease requiring re-operation at 2 and 3 years, respectively. Recurrence occurred in 1 (12%) patient in the splenectomy group and in 1 (14%) out of 7 patients in the spleen-preserving group. CONCLUSION: In the present series it was possible to preserve the spleen in 8 (42%) of 19 patients, without significant increase of recurrent echinococcosis.
Abstract: BACKGROUND AND OBJECTIVES: It is essential to minimize pain after laparoscopic surgery. This study examined the effect of wound infiltration by a long-acting local anesthetic. METHODS: This prospective, randomized study includes 190 laparoscopic procedures carried out by the same surgeon. The patients were randomly allocated into 2 groups. The control group comprised 75 cases of laparoscopic cholecystectomy (LC) and 20 cases of laparoscopic inguinal hernia repair (LIHR) without the use of a local anesthetic; only saline was used. The study group comprised 75 cases of LC and 20 cases of LIHR with preincisional periportal infiltration with 20 mL of ropivacaine (10 mg/mL). The postoperative pain scores at 3, 6, 12, and 24 hours determined with a visual analogue scale (VAS), nausea, and the kind and amount of analgesic drugs were assessed. RESULTS: In the study group in 41% of LC cases and 85% of LIHR cases, no analgesia was required at all; likewise, in the control group in 20% of LC cases and 44% of LIHR cases, no analgesia was required. The difference was statistically significant (P<0.05). In the remainder, pain at 3 and 6 hours and total analgesic requirements in the study group were less than that in the control group (P<0.05). The postoperative nausea and shoulder pain remained statistically unchanged (P>0.05). CONCLUSIONS: It seems that wound infiltration with ropivacaine in laparoscopy provides satisfactory postoperative analgesia, diminishing or reducing the need for opioids.
Abstract: Despite progress, intra-abdominal sepsis is associated with a high morbitity and mortality rate. Although, much effort has been made in basic research, there have not been any therapeutic applications as yet. The peritoneal defense system (innate and specific) represents the first local reaction to inflammation caused by bacterial invasion. It includes lymphatic absorption of bacteria, phagocytosis, entrenchment of inflammation and lymphocyte production (humoral and cellular immune). Also, the fibrin formation and degradation by intraperitoneal activation of coagulation and fibrinolysis plays an important role in this local response. The endotoxin from Gram-negative or exotoxins from Gram-positive bacteria cause the release of proinflammatory cytokines (TNF-alpha, IL-1betha, IL-6) by macrophages. They act as mediators resulting in the initiation of systemic inflammatory response syndrome (SIRS) at first and cellular damage with multiple organ dysfunction syndrome (MODS) ultimately. There are two different, but communicated, functional departments, i.e. peritoneal and systemic compromising the host inflammatory response to bacterial infection. Cytokine production occurs in both of them.
Abstract: BACKGROUND/PURPOSE: Gallstone ileus is an uncommon complication of cholelithiasis in the elderly with a high morbidity and mortality rate. This study aims to clarify the current surgical management. METHODS: In a retrospective survey over the past 11 years there were 9 patients with gallstone ileus, all elderly (mean age, 77 years), among 2242 cholecystectomies (0.4%) and 243 operated small intestinal obstructions (3.7%). Urgent laparotomy confirmed gallstone obstruction and a cholecystoduodenal (89%) or cholecystocolonic (11%) fistula. The operation included enterolithotomy alone (3 high-risk cases) or plus fistula repair and cholecystectomy (6 cases). There were 3 postoperative complications including wound dehiscence, wound infection, and obstructive jaundice (morbidity, 37.5%) and 1 death due to myocardial infarction (mortality, 11%). On follow-up (mean, 5 years), 6 patients with cholecystectomy (in 1 case it was performed 2 months after the initial operation) and 1 patient with enterolithotomy alone are well; there was 1 death from an unrelated cause after 1 year. CONCLUSION: It seems that a one-stage procedure (enterolithotomy plus fistula repair and cholecystectomy), when feasible, should be the first choice. Enterolithotomy alone should be reserved for only unstable and difficult cases.
Abstract: Malignant fibrous histiocytoma (MFH) is a soft-tissue sarcoma originating from fibroblast cells, characterized by a high rate of metastasis or recurrence. This tumor rarely develops in the gastrointestinal tract, with no more than 30 cases described in the literature. We report a case of MFH of the abdominal cavity in a 45-year-old woman who presented with epigastric pain, anorexia, and weight loss. A computed tomography (CT) scan of the abdomen revealed multiple solid tumors in the peritoneal cavity. We performed exploratory laparotomy and found at least 15 solid whitish tumors attached to the wall of the small intestine, as well as to the parietal peritoneum. There were three metastases in the liver. All of the tumors were excised, most of which were about 10 cm in diameter. Histopathological findings indicated a stromal tumor consisting of spindle cells, and immunohistochemical examination of the resected specimens established the definite diagnosis of a pleomorphic MFH. The patient had an uneventful postoperative course and was given adjuvant chemotherapy. She is currently well 2 years after her operation. We review the clinical picture of this tumor in the abdominal cavity, and discuss its diagnosis, pathogenesis, and treatment.
Abstract: BACKGROUND: Obstructive jaundice is often accompanied by bacterial translocation and subsequent sepsis. The effect of lactulose in preventing that process was evaluated in an experimental model. Obstructive jaundice was induced in 23 rabbits after common bile duct ligation. METHODS: Animals were divided into two groups. Group A of 11 animals-controls and group B of 12 rabbits, which received 2 ml/kg of lactulose p.o. by a nasogastric tube. Blood was sampled daily, before and after operation. Samples were applied for culture and for estimation of endotoxins (LPS), tumor necrosis factor (TNFa), and malondialdehyde (MDA). RESULTS: Mean (+/-SD) survival of animals of group A was 3.08+/-0.19 days compared to 5.36+/-0.41 days of animals of group B. Serum concentrations of LPS and TNFa of each day of treatment remain constant in animals of group A; they were steadily decreased in animals of group B reaching statistical significance on the fourth day. Similar changes were not found for MDA. CONCLUSION: The administration of lactulose may prevent systemic endotoxaemia and the subsequent inflammatory response in an experimental model of obstructive jaundice, so as to extend survival. These results merit further clinical evaluation.
Abstract: Plummer-Vinson syndrome is characterized by dysphagia, iron deficiency, anemia and the presence of esophageal web or webs. Two cases of this syndrome are reported in middle-aged women, which were treated over the last eight years. Both patients presented with dysphagia, anemia, sideropenia, glossitis and cheilitis. Radiological examination of the pharynx showed the presence of webs in both cases. The patients were treated with iron supplementation, which resulted in elimination of the symptoms. Both patients remain in good general condition and without any dysphagic complaints, 5 and 8 years after the diagnosis, respectively.
Abstract: The Peutz-Jeghers syndrome is an autosomal dominant inherited disease, characterized by the presence of hamartomatous polyposis of the gastrointestinal tract and perioral mucocutaneous pigmentation. The incidence of surgical complications in these patients is relatively rare, and correlates with the size and location of the polyps. We report on two complications of the Peutz-Jeghers syndrome which occurred in two generations of the same family. There was a perforation and an invagination of the small intestine. Both cases were treated by resection of the small intestine.
Abstract: BACKGROUND: The objectives of the study were to compare the tension-free mesh repair with non-meash conventional repair of groin hernia. METHODS: In the past two years in 299 consecutive unselected patients 339 inguinal hernia repairs were carried out. They randomly allocated to undergo either a non-meash modified Bassini's repair (n=164) or a tension-free mesh repair (n=175). The latter group consisted of laparoscopic TAPP repair (n=46) and open onlay patch repair (n=64) or plug and patch repair (n=65). Operation time, postoperative pain and complications, hospital stay, return to work and recurrence were assessed. Statistical analysis was made using the "t"-Student test. RESULTS: The characteristics of the patients in each group and the operation time did not differ significantly. The planned procedure was completed in all and no death occurred. The analgesic requirements (none 2.5 vs 56.4%, opiods 77 vs 23.6%), complication rate (9.4 vs 4.3%), hospital stay (4.2 vs 1.8 days), return to work (17.2 vs 7.3 days) and recurrence rate (5.5 vs 1.2%) in non-mesh group were more than in the mesh group. All differences were statistically significant (p<0.05). Among the three subgroups of mesh group no statistically significant differences (p>0.05) were found. CONCLUSIONS: The tension-free mesh repair either open or laparoscopic provides excellent results with better short-term outcome and lower recurrence rate than non-mesh modified Bassini's repair.
Abstract: During laparoscopic cholecystectomy, perforation of the gallbladder can occurs in < or = 20% of cases, while gallstone spillage occurs in < or = 6% of cases. In most cases, there are no consequences. Gallstones can be lost in the abdominal wall as well as the abdomen during extraction of the gallbladder. The fate of such lost gallstones, which can lead to the formation of an abscess, an abdominal wall mass, or a persistent sinus, has not been studied adequately. Herein we report the case of a persistent sinus of the abdominal wall after an emergent laparoscopic cholecystectomy in an 82-year-old woman with gangrenous cholecystitis and perforation of the friable wall in association with an empyema of the gallbladder. The culture of the obtained pus was positive for Escherichia coli. After a small leak of dirty fluid from the wound of the epigastric port site of 4 months' duration, surgical exploration under local anesthesia revealed that the sinus was caused by spilled gallstones impacting into the abdominal wall between the posterior sheath and left rectus abdominalis muscle. The removal of the stones resulted in complete healing. Long-term complications after laparoscopic cholecystectomy involving the abdominal wall are rare but important possible consequences that could be avoided.
Abstract: AIMS: Helicobacter pylori has been found in the upper gastrointestinal tract; it is incriminated as aetiological factor in various pathological conditions. This prospective study assesses the presence of this microorganism in the appendix flora and the possible role of its infection in the pathogenesis of acute appendicitis. METHODS: H. pylori was investigated in 46 consecutive patients undergoing emergent appendectomy for presumed acute appendicitis. Blood sample for serological test of H. pylori infection was drawn before operation. The removed appendix specimen was stained for H. pylori; confirmation was made by PCR (Polymerase Chain Reaction) analysis. The intensity of inflammation was determined pathologically grading from no inflammation to gangrenous appendicitis. Statistical analysis was made using the chi-square test. RESULTS: Seropositivity for H. pylori infection was found in 18 patients (39%), but the microbe was detected in just two appendix specimens (4%). In all seropositive patients acute appendicitis was confirmed by the pathology study; serous (33%) and purulent or gangrenous (67%). The latter incidence in the seronegative patients was 50%. There were found eight specimens (17%) negative for inflammation dealing all with seronegative patients. CONCLUSIONS: It seems that H. pylori colonizes the appendix in small proportion and is unlikely to be associated in direct correlation with acute appendicitis. However, seropositive patients with acute inflammation are likely to suffer from purulent or gangrenous form.
Abstract: The small intestine is the most common site of gastrointestinal (GI) metastases from cutaneous malignant melanoma; however, primary malignant melanoma originating in the small intestine is extremely rare. We report the case of a 72-year-old man found to have a primary malignant melanoma in the ileum. The patient presented with anorexia, weight loss, diffuse colicky abdominal pain, and episodic rectal bleeding. A preoperative diagnosis of a small intestinal tumor was based on the findings of enteroclysis and computed tomography scanning. This diagnosis was confirmed at laparotomy and an enterectomy was performed. Histopathological examination of the resected specimen clarified the exact nature of the lesion, confirming the diagnosis of melanoma. A thorough postoperative investigation did not reveal a primary lesion in the skin, anus, oculus, or any other location. Thus, we diagnosed this tumor as a primary lesion. One year after his operation, the patient remains well without any evidence of recurrence. Primary malignant melanoma of the small intestine is an extremely rare lesion, which must be differentiated from other intestinal tumors.
Abstract: Congenital web formations are extremely rare anomalies of the extrahepatic biliary tree. The age at presentation and the clinical symptomatology of these anomalies depend on the grade of the biliary obstruction. We report a case of a common bile duct septum in association with cholelithiasis in a 30-year-old woman. The diagnosis was made on preoperative magnetic resonance cholangiopancreatography (MRCP) and confirmed with intraoperative cholangiography. Because all known causes of acquired web formation were excluded, a congenital origin of the web was assumed. The patient was treated with a hepaticoduodenostomy above the level of the septum. The embryological aspects of this rare anomaly are described.
Abstract: BACKGROUND: Postoperative nausea and vomiting are observed in increased frequency after laparoscopic surgery. This study was performed in order to compare the efficacy of two 5-hydroxytryptamine-3 (5-HT3) receptor antagonists, ondansetron and tropisetron, in preventing postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy. METHODS: Using a randomized, double-blind study design, 87 ASA I and II patients scheduled for laparoscopic cholecystectomy were randomly assigned to receive 4 mg ondansetron (Group A, n = 29), 5 mg tropisetron (Group B, n = 31), or placebo (Group C, n = 27) intravenously (IV) before induction of anesthesia. The end points evaluated were frequency of nausea, nausea intensity rated on a scale from 1 (mild) to 5 (most severe), frequency of vomiting, and need for rescue antiemetics. These parameters were measured immediately after surgery (0 h), at 3 h, 6 h, and 12 h postoperatively. RESULTS: The frequency of nausea was significantly higher in group A (31.2%) compared to group B (14%) at 12 h postoperatively (p <0.01). However, patients of group A had significantly lower nausea scores at 3 h postoperatively compared to group B. Postoperative vomiting occurred in 13.8% of patients in group A and 9.6% of patients in group B throughout the whole study period (p = n.s.). The need for rescue antiemetics was similar between groups A and B. Both groups were superior to placebo concerning all studied parameters. CONCLUSION: Our results show that ondansetron may be more effective in controlling nausea intensity during the first 3 h after laparoscopic cholecystectomy, while tropisetron has a longer-acting activity, with a major impact on nausea frequency at 12 h postoperatively.
Abstract: BACKGROUND: The safety of laparoscopic procedures has been studied broadly. The effects on cardiopulmonary function and reliable methods of monitoring concentrate more interest. METHODS: A prospective study in 22 consecutive patients with ASA I and II was designed. The continuous assessment of alterations of arterial blood gases, pH, arterial pressure and heart rate during laparoscopic cholecystectomy by carbon dioxide pneumoperitoneum American technique was achieved using an intra-vascular multi-parameter sensor Paratrend. RESULTS: Statistically significant increase of both PaCO2 and PE.CO2 in parallel and a corresponding decrease of pH were found in correlation with the duration of the pneumoperitoneum. The values of PaO2, Sat O2, base excess, H-CO3, mean arterial pressure and heart rate showed no statistically significant alterations at any time throughout the procedure. No differences were noted between younger patients and in the elderly or between patients with ASA I and II. CONCLUSIONS: Intra-arterial blood-gas sensor ensures continuous on-line monitoring, but no abnormal and threatening changes occur during laparoscopic cholecystectomy in otherwise healthy people.
Abstract: BACKGROUND AND AIMS: Postoperative pain is the most distressing sequela of conventional hemorrhoidectomy. A modern alternative of circumferential mucosectomy has been proposed to reduce the pain in this procedure. PATIENTS AND METHODS: This controlled trial included 80 patients with second to fourth degree hemorrhoidal disease operated on over a 2-year period. The patients were randomly allocated to undergo either the stapled Longo procedure (group 1) or Milligan-Morgan hemorrhoidectomy (group 2) under epidural anesthesia. The operating time, postoperative pain scores at 3, 6, 12, and 24 h, analgesic consumption, hospital stay, and complication rate were recorded. At follow-up the outcome and patient satisfaction were evaluated. RESULTS: The mean operating time in group 1 was shorter than in group 2, postoperative pain scores at all time points and the mean epidural morphine requirement was lower, and mean hospital stay was shorter. The complication rate did not differ (three cases of postoperative bleeding in group 1 and two cases in group. At follow-up no recurrence or complains were recorded except three cases of mild incontinence (one in group 1 and two in group 2). The patients in group 1 (95%) were more satisfied than in group 2 (89%). CONCLUSION: The Longo procedure is thus a simple, safe, and effective method that entails less postoperative pain, more satisfaction, and shorter hospital stay than the standard Milligan-Morgan hemorrhoidectomy.
Abstract: Open Nissen fundoplication has been established as an effective treatment in the management of gastroesophageal reflux disease (GORD). Progress in minimally invasive surgery has given the chance of performing laparoscopic Nissen fundoplication. The short-term results are encouraging and its outcome promising. The need for long-term medication ceases and it has already widely replaced the open procedure. Furthermore, the laparoscopic procedure can achieve the repair of any hiatal defect present. Thorough preoperative evaluation is imperative, because it determines the indication for surgery as well as the sort of operation. The laparoscopic procedure ensures a meticulous dissection and full mobilization of the lower oesophagus. These preconditions are of great importance in performing safely a floppy wrap. The method could be followed by complications or failure. Appropriately designed modern equipment is necessary. Thus, much experience and adequate training are required for the perfect application of laparoscopic Nissen fundoplication.
Abstract: BACKGROUND: The preincisional use of ketamine combined with local tissue infiltration with Ropivacaine may reduce noxious input during surgery. The goal of this study was to examine whether this combination improves postoperative pain control after laparoscopic cholecystectomy. METHODS: A total of 55 patients were randomly assigned to one of three groups. Group 1 received placebos preincisional. Group 2 received preincisional saline IV and local infiltration with 20 ml ropivacaine (10 mg/ml). Group 3 received preincisional ketamine 1 mg/kg IV and local infiltration with 20 ml ropivacaine (10 mg/ml). Postoperative pain was rated at 0, 3, 6, 12, 24, and 48 h postoperatively by visual analogue scale scores (VAS). Cumulative analgesic consumption and time until first analgesic medication request were recorded. RESULTS: Group 3 experienced significantly (p < 0.05) less pain than group 2 at 6 h and 12 h postoperatively. Groups 2 and 3 did not differ significantly by VAS at 0 h, 3 h, 24 h, and 48 h. Group 1 had significantly higher VAS scores than groups 2 and 3 at 0 h, 3 h, 6 h, 12 h, and 24 h postoperatively. The consumption of analgesics was significantly higher in group 1 than in groups 2 and 3. Although the consumption of analgesics was higher in group 3 than in group 2, this difference did not reach statistical significance. The time to first request for analgesics was significantly longer in groups 2 and 3 than in group 1, with no statistical difference between groups 2 and 3. Conclusion: Preincisional treatment with low-dose IV ketamine and local infiltration with ropivacaine 1% reduces postoperative pain after laparoscopic cholecystectomy.
Abstract: OBJECTIVE: To find out the causes of abdominal wound dehiscence. DESIGN: Retrospective study. SETTING: University hospital, Greece. SUBJECTS: Abdominal wound dehiscence occurred in 89 cases out of 19,206 major abdominal operations including 4671 emergencies during the past 15 years (0.5%). INTERVENTIONS: In the study group 14 local and systemic risk factors were analysed and compared with those in a control group of 89 patients who had similar procedures without dehiscence. MAIN OUTCOME MEASURES: Statistical analysis using the chi square test. RESULTS: Significant factors (p < 0.05) included age over 65 years, emergency operation, cancer, haemodynamic instability, intra-abdominal sepsis, wound infection, hypoalbuminaemia, ascites, obesity, and steroids. Risk factors that were not significant included sex, anaemia, diabetes mellitus and pulmonary disease. Overall morbidity and mortality were 30% and 16%, respectively. The mortality and the possibility of dehiscence seem to correlate directly with the number of risk factors. CONCLUSION: Patients with these risk factors require more attention and special care to minimise the risk of its occurrence.
