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“Unexplained” disturbances in liver function are common following laparoscopic cholecystectomy. Is intraabdominal hypertension the reason?
LAPAROSCOPY 647
~'645 "Unexplained" disturbances in liver function ere common following laparoscopic cholecystectomy, ls intruabdominal hypertension the reason? Valeriu Andrei. Mosbe Schein, Marc Mergolis, James Rueinski, Sayed Gerdezi and Leslie Wise. New York Methodist Hospital and Comall University Medical College, Brooklyn, New York.
LAPAROSCOPIC APPENDECTOMY : OUR EXPERIENCE P Esposito, D Cerbonr G Rotondano, A Del Prete, R Pisano and G Cerbone
Background: A previous study (Halevy A e t al. Ann Surg 1994; 219:362364) disclosed "unexplained" disturbances in postoperative liver function tests (LFT) in more than two-thirds of 67 patients undergoing laperosenpic cholecystectomy (LC). No cause for these elevations was documented. Objective: To assess the incidence, cause and clinical significance of "unexplained" disturbances in post LC LFT. Methods: A retrospective chart review of 270 and 64 patients who underwent LC and open cholecystectomy (OC), respectively, was conducted. Exclusion criteria: any pre-operative abnormality in bilirubin or liver enzyme levels, history of chronic liver disease, gallbladder empyema, gangrene or perforation, any evidence or suggestion of choledocholithiasis or other duetal pathology on pre-operative or intra-opei'ative imaging or surgical exploration. Thus, patients undergoing pre-operative ERCP or intra-operative cholangiogram were also excluded. Blood was collected on postoperative day l for SGOT, Alk. Phos, bilirubin, and albumin. "Unexplained" disturbances were defined as 40% increase frmn preoperative valued and beyond normal range in any oftbe latter. At LC the pneumo- peritoneum was maintained at a pressure not exceeding 15 mm Hg. All data were entered and analyzed using EPI INFO, version 6.0. Results: The groups undergoing LC and OC were well matched concerning age, sex, BMI, associatd medical conditions, alcohol, smoking or drug abuse and length of operation. Abnormal of LFT's were observed in 108 (40%) and 13 patients (20%) undergoing LC and OC, respectively (p=0.003). "Unexplained" LFT disturbances resolved spontaneously and were not associated with any morbidity. Conclusions: "Unexplained" disturbances in LFT following LC occurs in 40% oftbe patients and appears to be clinically non-significant. It is speculated that the reason for this phenomenon is the pneumoperiotnenmrelated intra-abdominal hypertension-the only variable not present in the OC group.
Appendectomy is one of the most frequent operation in the world, often performed without reason. Aim of this study was to evaluate the impact of leparoscopy on unnecessary appendectomy, and comparison of laperotomic and laparoscopic appendectomy in patients with proven acute appendicitis. From Januery 1995 to January 1996 220 patients (140 M, 80 F ; mean age 22 , range 10 - 46) were operated on for snspected appendicitis in our deparmaent. One-hundred-fifty patients (82 M, 68 F ; mean age 17, range 10 - 40) were randomized to either conventioual-(75 patients) or lsperoseopic (75 patients) appendectomy. Two patients in the group with lsperoscopic approach were converted to open lsparotomy because was disclosed a cecal neoplasm while another patient was converted for adhesions. In the group with conventional treatuient eight appendectomies were proven unnecessary, compered to three in the laperoscopic group. One patient died after embolism in die group treated with laparoscopy. The postoperative hospital stay was twelve days (range 5 - 38) for conventional appendectomy, and ten days (range 3 - 20). The duration of operation was shorter in the conventional approach (20 vs 55 minutes). In the conventional group there were fewer minor complications (7 vs 14). The major complications were similar in die two groups. Nonetheless less unnecessary appendectomy with laperoscopic approach, data ere not statistically sigulficative. So we can conclude that laperoscopic approach determines a reduction in postoperative convalescence and an increase in duration o f operation but nothing about the impact of lsperoscopy on the management of unnecessary appendectomies.
t646
~648
FUNCTIONAL OUTCOME AFTER LAPAROSCOPIC POSTERIOR RECTOPEXY FOR RECTAL PROLAPSE. P Esposito, D Cerboue,'S Verde, F Russo, S Perrotta and G Cerbone
LAPAROSCOPY AND ACUTE ABDOMEN IN CRITICALLY ILL PATIENT P Esposito. D Cerboue, G Rotondano, R Pisano, A Del Prete and G Cerbone
Dept. of Surgery - University of Naples - Italy Dept. of Emergency- New Pellegrini Hb~pieal-Naples, Italy The term Rectal prolapse implies a full thickness circumferential descent of the rectum through the anus often associated with weakness of the anal sphincter that can require a postanal repair for incontinence especially in elderly patients. Aim o f this study was to determine whether the difference in functional outcome niter lsperoseopic posterior rectopexy is associated with changes in anal endosonographic and manometric findings. From January 1993 to December 1995 fifteen patients (4 M 11 F, mean age 76 range 5485) with complete rectal prolapse underwent laperoscopic posterior rectopexy in our department. Eight patients (53,3 %) had complaints of incontinence. All patients were evaluated preoperatively and postoperatively (three months after operation). This protocol of evaluation included anorectal manometry and anal endosonography. One patient developed systemic sepsis in fifth postoperative day treated with antibiotic therapy. In the remaining no major complications occurred. Mean time of follow-up was 22 months ranging from 10 months to 40. No recurrence of rectal prolapse was found. Three patients became fully continent and in seven there was an improving of continence. Three patients developed, Instead, constipation that was treated with laxatives. Two patients dida't note improvement in sphincter function. At ano-rectal manometry there was an increase in the maxlmem basal pressure. Rectal capacity did not change significantly after operation. At anal endosonography preoperatively, the thickness of the internal sphincter and of the submucosa were significantly increased as compared to healthy controls. Also, the thickness of the Internal sphincter decreased after operation. Laperoscopic rectopexy is a technically feasible method which resulted in improved continence in the majority of our patients. This improvement was associated with a significant increase o f maximum basal pressure and a significant stronger positive distention reflex, suggesting a partial recovery o f the internal sphincter. This is sustained by the decrease of the internal sphincter thickness after operation.
AB186
GASTROINTESTINAL
ENDOSCOPY
Dept. of Surgery- University of Naples - Italy Dept. of Emergency- New Pellegrinr FIospttal -Naples, Italy
Dept. of Surgery- University of Naples - Italy Dept. of Emergency- New Pellegrini Hospital-Naples, Italy The evaluation of the acute abdomen is still occasionally problematical, especially in patients critically ill with multi-organ system failure. In these patients clinical history and physical findings ere oftan of poor value and surgical exploration may be very dangerous. In these cases laperoscopy may be an useful insaatment for a correct diagnosis. Aim of this study was to evaluate the usefulness of laparoscopy in seriously ill patient. From March 1989 to April 1993 twenty seriously ill patients (9 M. 11 F : mean age 73, range 42-82) were submitted to laperoscopy for acute abdomen in our department. The most part of them was suspected to be affected ~ o m infercted b o w d with abdominal distention, pain. renal failure and coagulopathy. The examination was negative in eight cases, thereby avoiding laperotomy. The examination was. on the contrary, positive in twelve cases and In those cases laperntomy was reconunended. Results of physical examination and leperoscopy were verified with autopsy and / or clinical follow-up. In our series in three cases (15 %) there was no accordance between laparoscopy findings and antoptic diagnosis. All of thc~n had been considered negative at laperoscopy. In two of these three cases there was a Cmtis-Fitz-Hngh Syndrome while in the third case there was a neoplasm. Two patients in the group submitted to laparotomy died for myocardial inferction respectively in second and third postoperative day. On the basis of this small series we believe that laparoscopy can be done with reasonable safety even in the most critically ill of patients. The examination can be done in the intensive cere unit setting without delay and hazard of ttasporting these very ill and often unstable patients to other parts of the hospital. Nonetheless on the base of our experience we believe that a negative fmding doesn't relieve the surgeon of the continued necessity for close clinical following of die patient.
V O L U M E 45, N O . 4, 1 9 9 7
~'645 "Unexplained" disturbances in liver function ere common following laparoscopic cholecystectomy, ls intruabdominal hypertension the reason? Valeriu Andrei. Mosbe Schein, Marc Mergolis, James Rueinski, Sayed Gerdezi and Leslie Wise. New York Methodist Hospital and Comall University Medical College, Brooklyn, New York.
LAPAROSCOPIC APPENDECTOMY : OUR EXPERIENCE P Esposito, D Cerbonr G Rotondano, A Del Prete, R Pisano and G Cerbone
Background: A previous study (Halevy A e t al. Ann Surg 1994; 219:362364) disclosed "unexplained" disturbances in postoperative liver function tests (LFT) in more than two-thirds of 67 patients undergoing laperosenpic cholecystectomy (LC). No cause for these elevations was documented. Objective: To assess the incidence, cause and clinical significance of "unexplained" disturbances in post LC LFT. Methods: A retrospective chart review of 270 and 64 patients who underwent LC and open cholecystectomy (OC), respectively, was conducted. Exclusion criteria: any pre-operative abnormality in bilirubin or liver enzyme levels, history of chronic liver disease, gallbladder empyema, gangrene or perforation, any evidence or suggestion of choledocholithiasis or other duetal pathology on pre-operative or intra-opei'ative imaging or surgical exploration. Thus, patients undergoing pre-operative ERCP or intra-operative cholangiogram were also excluded. Blood was collected on postoperative day l for SGOT, Alk. Phos, bilirubin, and albumin. "Unexplained" disturbances were defined as 40% increase frmn preoperative valued and beyond normal range in any oftbe latter. At LC the pneumo- peritoneum was maintained at a pressure not exceeding 15 mm Hg. All data were entered and analyzed using EPI INFO, version 6.0. Results: The groups undergoing LC and OC were well matched concerning age, sex, BMI, associatd medical conditions, alcohol, smoking or drug abuse and length of operation. Abnormal of LFT's were observed in 108 (40%) and 13 patients (20%) undergoing LC and OC, respectively (p=0.003). "Unexplained" LFT disturbances resolved spontaneously and were not associated with any morbidity. Conclusions: "Unexplained" disturbances in LFT following LC occurs in 40% oftbe patients and appears to be clinically non-significant. It is speculated that the reason for this phenomenon is the pneumoperiotnenmrelated intra-abdominal hypertension-the only variable not present in the OC group.
Appendectomy is one of the most frequent operation in the world, often performed without reason. Aim of this study was to evaluate the impact of leparoscopy on unnecessary appendectomy, and comparison of laperotomic and laparoscopic appendectomy in patients with proven acute appendicitis. From Januery 1995 to January 1996 220 patients (140 M, 80 F ; mean age 22 , range 10 - 46) were operated on for snspected appendicitis in our deparmaent. One-hundred-fifty patients (82 M, 68 F ; mean age 17, range 10 - 40) were randomized to either conventioual-(75 patients) or lsperoseopic (75 patients) appendectomy. Two patients in the group with lsperoscopic approach were converted to open lsparotomy because was disclosed a cecal neoplasm while another patient was converted for adhesions. In the group with conventional treatuient eight appendectomies were proven unnecessary, compered to three in the laperoscopic group. One patient died after embolism in die group treated with laparoscopy. The postoperative hospital stay was twelve days (range 5 - 38) for conventional appendectomy, and ten days (range 3 - 20). The duration of operation was shorter in the conventional approach (20 vs 55 minutes). In the conventional group there were fewer minor complications (7 vs 14). The major complications were similar in die two groups. Nonetheless less unnecessary appendectomy with laperoscopic approach, data ere not statistically sigulficative. So we can conclude that laperoscopic approach determines a reduction in postoperative convalescence and an increase in duration o f operation but nothing about the impact of lsperoscopy on the management of unnecessary appendectomies.
t646
~648
FUNCTIONAL OUTCOME AFTER LAPAROSCOPIC POSTERIOR RECTOPEXY FOR RECTAL PROLAPSE. P Esposito, D Cerboue,'S Verde, F Russo, S Perrotta and G Cerbone
LAPAROSCOPY AND ACUTE ABDOMEN IN CRITICALLY ILL PATIENT P Esposito. D Cerboue, G Rotondano, R Pisano, A Del Prete and G Cerbone
Dept. of Surgery - University of Naples - Italy Dept. of Emergency- New Pellegrini Hb~pieal-Naples, Italy The term Rectal prolapse implies a full thickness circumferential descent of the rectum through the anus often associated with weakness of the anal sphincter that can require a postanal repair for incontinence especially in elderly patients. Aim o f this study was to determine whether the difference in functional outcome niter lsperoseopic posterior rectopexy is associated with changes in anal endosonographic and manometric findings. From January 1993 to December 1995 fifteen patients (4 M 11 F, mean age 76 range 5485) with complete rectal prolapse underwent laperoscopic posterior rectopexy in our department. Eight patients (53,3 %) had complaints of incontinence. All patients were evaluated preoperatively and postoperatively (three months after operation). This protocol of evaluation included anorectal manometry and anal endosonography. One patient developed systemic sepsis in fifth postoperative day treated with antibiotic therapy. In the remaining no major complications occurred. Mean time of follow-up was 22 months ranging from 10 months to 40. No recurrence of rectal prolapse was found. Three patients became fully continent and in seven there was an improving of continence. Three patients developed, Instead, constipation that was treated with laxatives. Two patients dida't note improvement in sphincter function. At ano-rectal manometry there was an increase in the maxlmem basal pressure. Rectal capacity did not change significantly after operation. At anal endosonography preoperatively, the thickness of the internal sphincter and of the submucosa were significantly increased as compared to healthy controls. Also, the thickness of the Internal sphincter decreased after operation. Laperoscopic rectopexy is a technically feasible method which resulted in improved continence in the majority of our patients. This improvement was associated with a significant increase o f maximum basal pressure and a significant stronger positive distention reflex, suggesting a partial recovery o f the internal sphincter. This is sustained by the decrease of the internal sphincter thickness after operation.
AB186
GASTROINTESTINAL
ENDOSCOPY
Dept. of Surgery- University of Naples - Italy Dept. of Emergency- New Pellegrinr FIospttal -Naples, Italy
Dept. of Surgery- University of Naples - Italy Dept. of Emergency- New Pellegrini Hospital-Naples, Italy The evaluation of the acute abdomen is still occasionally problematical, especially in patients critically ill with multi-organ system failure. In these patients clinical history and physical findings ere oftan of poor value and surgical exploration may be very dangerous. In these cases laperoscopy may be an useful insaatment for a correct diagnosis. Aim of this study was to evaluate the usefulness of laparoscopy in seriously ill patient. From March 1989 to April 1993 twenty seriously ill patients (9 M. 11 F : mean age 73, range 42-82) were submitted to laperoscopy for acute abdomen in our department. The most part of them was suspected to be affected ~ o m infercted b o w d with abdominal distention, pain. renal failure and coagulopathy. The examination was negative in eight cases, thereby avoiding laperotomy. The examination was. on the contrary, positive in twelve cases and In those cases laperntomy was reconunended. Results of physical examination and leperoscopy were verified with autopsy and / or clinical follow-up. In our series in three cases (15 %) there was no accordance between laparoscopy findings and antoptic diagnosis. All of thc~n had been considered negative at laperoscopy. In two of these three cases there was a Cmtis-Fitz-Hngh Syndrome while in the third case there was a neoplasm. Two patients in the group submitted to laparotomy died for myocardial inferction respectively in second and third postoperative day. On the basis of this small series we believe that laparoscopy can be done with reasonable safety even in the most critically ill of patients. The examination can be done in the intensive cere unit setting without delay and hazard of ttasporting these very ill and often unstable patients to other parts of the hospital. Nonetheless on the base of our experience we believe that a negative fmding doesn't relieve the surgeon of the continued necessity for close clinical following of die patient.
V O L U M E 45, N O . 4, 1 9 9 7