Showing papers by "Guy J. Maddern published in 1995"

Hypothermia induced by laparoscopic insufflation. A randomized study in a pig model

Abstract: Hypothermia is a common postsurgical problem, yet information documenting the impact of laparoscopy on perioperative heat balance is scarce. This paper quantifies the changes in core temperature over a 3-h period of high-flow CO2 insufflation in a randomized, controlled trial of six pigs. Each animal was anesthetized and studied on three occasions under standardized conditions, acting as its own control via insufflation with no gas compared with insufflation by cold gas and warmed gas. Insufflation of CO2 gas at high-flow rates over a prolonged period of time results in a significant fall in core temperature. The provision of warmed rather than cold insufflated gas confers no protection against changes in core temperature during laparoscopic surgery due to the small amount of heat required to warm the gas to body temperature. A much greater effect is the latent heat required to saturate the insufflated gas. Most of the hypothermic effect is due to this, and could be minimized by humidifying the flow.

Peri‐operative outcome for day‐case laparoscopic and open inguinal hernia repair

Abstract: Summary This study documents the results obtained in 30 day patients undergoing open hernia repair under local infiltration block with patient-controlled sedation (group A) and 29 day patients undergoing laparoscopic hernia repair under general anaesthesia (group B). The mean operating time was less in group A (44.8min) compared with group B (66.6min) (p < 0.0001). Similarly, stage 1 recovery room times were longer in group B (98.1 min) than group A (45.1 min) (p < 0.0001). Time to discharge for group A (139.1 min) was significantly shorter than group B (224.2 min) (p < 0.002), with more peri-operative complications occurring in group B and greater analgesic requirements. An open inguinal hernia repair under local infiltration block is the optimal approach for unilateral non-recurrent herniae as a day surgical procedure. These results have important cost and efficiency implications.

Intrahepatic anastomoses for malignant and benign biliary obstruction.

Abstract: Objective: To assess the role, techniques, and outcome of intrahepatic biliary anastomoses in patients undergoing resective or palliative surgery at the hepatic hilum. Design: A retrospective review over a 23-year period of all patients undergoing intrahepatic bilioenteric anastomoses. Setting: A major university teaching hospital in France. Patients and Interventions: Over a 23-year period, 59 patients (19 with palliative, 35 with curative, and five with benign disease) underwent intrahepatic bilioenteric anastomoses. Measurements and Results: There was a hospital mortality of six for the palliative group and four for the curative group. A significant fall in both the serum bilirubin and alkaline phosphate levels occurred after surgery ( P Conclusions: Despite the advent of modern endoscopic and percutaneous intubation techniques, intrahepatic anastomoses after tumor resection offer the only chance of cure for obstructing hilar malignant disease. (Arch Surg. 1995;130:137-142)

Clinical experience with the intrahepatic posterior approach to the portal triad for right hepatectomy and right segmental resection.

Abstract: An intrahepatic posterior approach to the portal triad has been used over a 2-year period to perform right hepatectomies and right segmental resections in 29 patients (20 men, 9 women; median age 63 years, range 22–82 years). Two resections were palliative for cholangiocarcinomas; the remainder included 9 hepatocellular carcinomas, 12 colorectal metastases, 2 adenomas, 3 cancers of the gallbladder, and one case of chronic hepatic fibrosis. The median operative time was 3 hours 40 minutes (3:40; range 2:20–7:00) with a median period of hepatic ischemia of 87 minutes (range 27–152 minutes). Median blood transfused was 0 unit (range 0–12 units) with only three patients requiring intensive care admission. There was one hospital death. All but one patient was followed up after surgery (median period 24 months; range 1–36 months) at which time there had been three deaths from metastatic disease; the remaining patients were free of clinical recurrence. This operative approach allows minimally resective surgery to be performed safely with excellent shortand medium-term results.

Venous allografts: a useful alternative to venous autografts in digestive surgery

Abstract: Over a 16 month period seven patients underwent surgery using venous allografts either to reconstruct the portal vein, or to construct a mesocaval 'H' graft or a shunt between the coronary vein and the subhepatic inferior vena cava. The allografts were harvested during multiorgan procurement from the bifurcation of the inferior vena cava, the common iliac vein and the external iliac vein and kept in a preservation solution at 4 degrees C for a mean time of 6 days (range 1-29) before use. Subsequent thrombosis was clinically evident in only two patients. The use of venous allografts appears to be a useful alternative to other venous replacements.

Hemangiopericytoma of the pancreas: report of a case and review of the literature

Abstract: Hemangiopericytoma is an uncommon vascular tumor with variable malignant potential. The origin, structure and function of pericytes remains controversial. Intra-abdominal hemangiopericytomas are highly aggressive soft tissue tumors with a great propensity for malignant transformation. We report on a case of hemangiopericytoma of the pancreas in a 53-year-old female presenting with abdominal pain. Ultrasonography and CT scan revealed a cystic tumor of the head of the pancreas. The patient underwent successful pancreaticoduodenal resection and is alive with no signs of recurrence 25 months following surgery. Ultrastructural studies are necessary to differentiate hemangiopericytomas from other sarcomas. Malignancy may be ascertained only in the presence of metastases or local recurrence. Routine surveillance is advocated.

What should I do about my patient's gall stones?

Abstract: The problem of benign biliary disease is one that causes significant morbidity and social economic strain in the western world. The classical treatment, cholecystectomy, has been challenged by various medical and surgical techniques in a seemingly random nature. The development of the treatment of gall stone disease is reviewed by analysis of published studies over the last 20 years. The advantages and disadvantages are discussed as an overview and summary of the current management of gall stone disease in the light of our knowledge of its malignant potential.

Physiological outcome following laparoscopic highly selective vagotomy : a controlled study in a pig model

Abstract: Open highly selective vagotomy (HSV) has withstood the rigors of objective evaluation to become the optimal surgical treatment for chronic duodenal ulcer refractory to medical therapy in many centers. Laparoscopic HSV has not been subjected to the same scrutiny before entering clinical practice. A controlled animal study was conducted to demonstrate the physiological validity of laparoscopic HSV. Experimental groups underwent laparoscopic and open highly selective vagotomies, and control groups underwent a sham laparoscopic gastric mobilization or no operative procedure. Gastric acid output was measured by an aspiration technique, liquid gastric emptying was calculated by the double sampling technique of George, and gastroesophageal reflux was assessed by 8-h ambulatory pH monitoring. Laparoscopic HSV was as effective as its open counterpart in reducing basal acid output, and laparoscopic HSV did not interfere with liquid gastric emptying in contrast to open HSV. Neither open nor laparoscopic HSV was observed to precipitate gastroesophageal reflux. These data suggest that the continued use of laparoscopic HSV in clinical practice is appropriate.