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ABSTRACT: A 23-year-old man with extensive blunt trauma to the right lobe of the liver in whom adequate haemostasis could not be achieved by selective suturing and packing was encountered. Contributing factors to poor haemostasis included massive transfusion, hypothermia and acidosis.
Hepatic haemostasis was achieved by selective intrahepatic ligation of the right hepatic pedicle and packing.
After resuscitation and stabilization in the intensive care unit, a right hemihepatectomy was performed 14 h later.
The present case describes a modification of the Pringle manoeuvre, termed 'selective Pringle manoeuvre'. This technique is a useful additional strategy for the management of uncontrollable bleeding in massive hepatic trauma.
Australian and New Zealand Journal of Surgery 08/2000; 70(7):503-5.
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ABSTRACT: The present study characterized the histopathological nature of laparoscopic grasper trauma during laparoscopic cholecystectomy in a prospective, blinded trial in order to establish a model for laparoscopic grasper trauma. The null hypothesis that graspers cause no histologically distinct tissue injury was tested.
The gall bladders of 19 patients undergoing laparoscopic cholecystectomy were examined. The area of gall bladder that had been grasped by Debakey laparoscopic forceps was excised (sample), along with an area of gall bladder that had not been grasped (control). Paired specimens were examined by a pathologist (blinded) to identify which was 'sample' and which was 'control' and to assess for histological markers of crushed tissue injury. The data were analysed by chi-squared or Fisher's exact tests.
The pathologist was able to identify the sample (gripped) specimen in 13 of the 19 cases. In the remaining six cases the pathologist was unable to determine the specimen that had been gripped due to either absence of damage (four cases), or severe inflammation precluding assessment (two cases). The ability of the pathologist to distinguish the sample from the control specimen was significant (chi-squared test, P = 0.003). Of the histological markers of crushed tissue injury, focal thinning of the gall bladder wall and epithelial loss were present in significantly more sample (gripped) specimens than control specimens (chi-squared test, P = 0.0002 and P < 0.0001, respectively).
Laparoscopic graspers cause tissue trauma that can be assessed histologically. The current study presents a relevant, reproducible, ethically acceptable human model for assessing the interaction between laparoscopic graspers and soft tissues.
Australian and New Zealand Journal of Surgery 08/2000; 70(8):578-81.
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Australian and New Zealand Journal of Surgery 07/1999; 69(6):466-7.
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ABSTRACT: Curative oesophageal resection for carcinoma may be carried out by either the transhiatal or the Ivor-Lewis transthoracic technique. The aims of this study were to compare the morbidity, 30-day mortality and long-term survival of the two techniques in the treatment of oesophageal carcinoma and to provide data to calculate the sample sizes for a prospective randomized trial.
Results from 44 series published between January 1986 and December 1996 were reviewed. Thirty-three papers reported results on 2675 patients having transhiatal (THO) and 29 papers reported results on 2808 patients having Ivor-Lewis oesophagectomy (ILO).
The two groups were comparable in terms of age, sex and stage of the disease. There was no apparent difference in postoperative morbidity between the two groups with respect to respiratory complications (24% for THO, 25% for ILO), cardiovascular complications (12.4% for THO, 10.5% for ILO), wound infection (8.8% for THO, 6.2% for ILO) and chylothorax (2.1% for THO, 3.4% for ILO). The transhiatal group appeared to have a higher incidence of anastomotic leaks (16% for THO, 10% for ILO), anastomotic strictures (28% for THO, 16% for ILO) and recurrent laryngeal nerve injuries (11.2% for THO, 4.8% for ILO). The 30-day mortality was 6.3% for transhiatal and 9.5% for Ivor-Lewis oesophagectomy. Overall long-term survival at 5 years was similar (24% for THO, 26% for ILO).
The surgical approach to oesophagectomy was not an important determinant of morbidity and long-term survival in patients with oesophageal carcinoma. Transhiatal oesophagectomy was associated with a higher incidence of anastomotic complications and recurrent laryngeal nerve injury. Ivor-Lewis oesophagectomy had a higher mortality. In order to demonstrate a significant difference in morbidity or long-term survival between the two techniques 3100 patients would be required in each arm of a prospective randomized trial.
Australian and New Zealand Journal of Surgery 04/1999; 69(3):187-94.
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Australian and New Zealand Journal of Surgery 12/1998; 68(11):811-2.
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ABSTRACT: Somatostatin, a neuropeptide and hormone, is found in the biliary tract of several species. The aim of this study was to map the distribution of somatostatin-like immunoreactive nerve fibers in the extrahepatic biliary tract of the Australian possum and to determine the pharmacological effects of somatostatin 1-14 on sphincter of Oddi activity in vitro and in vivo.
Tissue was harvested for immunohistochemistry and sphincter of Oddi for circular or longitudinal muscle contractility. In anesthetized possums, sphincter of Oddi motility was measured by manometry, and transsphincteric flow was measured gravimetrically.
Somatostatin immunoreactivity was evident in gallbladder ganglia nerve cell bodies and in nerve fibers of the common bile duct and sphincter of Oddi. Somatostatin 1-14 increased circular and longitudinal muscle contraction amplitude 3-4-fold (P < 0.05), but only the longitudinal muscle contraction amplitude was tetrodotoxin sensitive. Somatostatin 1-14 stimulated spontaneous sphincter of Oddi motility in a tetrodotoxin-insensitive manner, increasing basal pressure, contraction frequency, and amplitude 2-4-fold (P < 0.05) and reducing transsphincteric flow to 25% of control (P < 0.0001).
Somatostatin-like immunoreactivity is present in the extrahepatic biliary tree, and somatostatin 1-14 stimulates sphincter of Oddi smooth muscle and nerves. The major action is direct stimulation of sphincter of Oddi circular muscle, which reduces transsphincteric flow.
Gastroenterology 09/1998; 115(3):672-9. · 11.68 Impact Factor
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ABSTRACT: The neural distribution and action of gastrin-releasing peptide in the extrahepatic biliary tree of the Australian brush-tailed possum was investigated. Immunohistochemical staining of fixed specimens demonstrated gastrin-releasing peptide-containing nerves throughout the neural plexuses of the gallbladder, sphincter of Oddi, and mucosa of the common bile duct. Gastrin-releasing peptide (5-2000 ng/kg) increased gallbladder tone to a level equivalent to that produced by cholecystokinin octapeptide (160 ng/kg). This action was tetrodotoxin-insensitive. Sphincter of Oddi motility and transsphincteric flow were not altered. Possible mediation of the gallbladder response by gastrin was examined. Gastrin (50-2500 ng/kg) stimulated gastric acid secretion, elevated gallbladder motility to 64% of that produced by gastrin-releasing peptide, and did not alter sphincter of Oddi motility. In conclusion, gastrin-releasing peptide-containing nerves are found in the neural plexus of the possum extrahepatic biliary tree. Gastrin-releasing peptide induces gallbladder contraction in part by a direct action on gallbladder smooth muscle and also via release of gastrin.
Digestive Diseases and Sciences 07/1998; 43(6):1275-84. · 2.12 Impact Factor
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ABSTRACT: Substance P containing nerves are widely distributed throughout the gastrointestinal tract. The aims of this study were to determine the distribution of substance P containing nerves in the extrahepatic biliary tree of the Australian brush-tailed possum and to characterize the effect of exogenous substance P on the sphincter of Oddi (SO) motility and transphincteric flow in vivo. Immunohistochemical staining of fixed specimens (n = 8) found moderate numbers of substance P containing nerve cell bodies and fibres throughout the neural plexuses of the SO, in particular in the serosal and intraluminal nerve trunks of the SO and gallbladder. Synthetic porcine substance P (1-2000 ng kg-1), administered by close intra-arterial injection (i.a.; n = 7), produced a dose-dependent elevation in basal pressure [P < 0.01] and an associated dose-dependent reduction in trans-sphincteric flow [P < 0.0001]. Substance P had no significant dose-dependent effect on SO phasic contraction amplitude or frequency. Tetrodotoxin (9 micrograms kg-1, i.a.) did not inhibit the effect of substance P on SO motility and trans-sphincteric flow (n = 5). In conclusion, substance P containing nerves are found throughout the possum extrahepatic biliary tree. Exogenous substance P stimulates SO motility and reduces trans-sphincteric flow in vivo by acting directly on the sphincter smooth muscle.
Neurogastroenterology and Motility 05/1998; 10(2):165-73. · 3.41 Impact Factor
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ABSTRACT: Laparoscopic exploration of the common bile duct (CBD) with a choledochoscope or a stone basket during laparoscopic cholecystectomy was attempted in 60 patients and was successful in 56. The cystic duct was used for entry to the CBD in 46 patients and in 14 a choledochotomy was performed. Of 51 patients with confirmed common duct stones, 38 had complete laparoscopic clearance (75 per cent). In 13 patients the duct was not cleared or was only partially cleared, of whom four went on to have clearance by postoperative percutaneous choledochoscopy down a cystic duct or T-tube track. Two patients with cystic duct tubes passed their remaining stones spontaneously. One patient had open exploration and six required endoscopic retrograde cholangiopancreatography. Of nine patients without stones, choledochoscopy was impossible in three patients whose cholangiogram was later considered to be normal. In five patients stones were excluded by choledochoscopy and in one patient laparoscopic choledochoscopy was undertaken to better define abnormal biliary anatomy; this helped to avoid major bile duct injury. Choledochoscopy was easier with the smaller 3.6-mm ureteroscope but stone removal was more difficult when the basket was too small for the stones, the cystic duct too small relative to stone size or the number of stones was too great. Successful stone clearance was proportional to the level of effort expended, and was limited by operating time and equipment.
British Journal of Surgery 04/1996; 83(3):341-6. · 4.61 Impact Factor
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ABSTRACT: In the last 5 years, surgery of the gastrointestinal tract has been revolutionized by the application of minimal access techniques. Following initial enthusiasm, which suggested that most abdominal surgery would ultimately be done via this approach, there is now need for appraisal and evaluation of the role of a number of these minimal access techniques when compared with open surgery. Undoubtedly, the most convincing and total application of minimal access techniques has been in the treatment of gallstone disease. Laparoscopic cholecystectomy is now standard therapy for cholelithiasis and endoscopic sphincterotomy with stone extraction is standard therapy for choledocholithiasis. Where the two conditions co-exist, operative cholangiography allows for the recognition of stones in the bile duct at the time of laparoscopic cholecystectomy and provides the potential avenue for treatment. Most major centres also would recommend routine operative cholangiography during laparoscopic cholecystectomy for the detection of unsuspected stones and as an extra safety procedure in the early identification of potential bile duct injuries. The efficacy of laparoscopic appendicectomy and laparoscopic or thoracoscopic treatment of achalasia of the oesophagus also is supported by data from well conducted prospective studies. Doubt remains regarding the advantage of laparoscopic surgery over other approaches in the treatment of gastro-oesophageal reflux, inguinal hernias and jaundice due to non-resectable cancer. For all three of these conditions, prospective trials are underway and the results of these trials should be assessed prior to widespread adoption of the laparoscopic techniques.(ABSTRACT TRUNCATED AT 250 WORDS)
Australian and New Zealand Journal of Surgery 08/1995; 65(7):525-32.
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ABSTRACT: To assess the routine use of diagnostic laparoscopy and laparoscopic appendicectomy in women with a clinical diagnosis of acute appendicitis.
Women who presented with a clinical diagnosis of acute appendicitis between 1 January 1992 and 31 August 1993 were prospectively assessed and 107 underwent diagnostic laparoscopy.
Appendicitis was confirmed in 63 women (59%) and no diagnosis could be made in seven (6%). An alternative diagnosis, most commonly a gynaecological disorder, was made in 37 women (35%). Twenty-eight women with an alternative diagnosis (76%) did not require a laparotomy. Seventy-three patients had a laparoscopic appendicectomy, with an 8% conversion rate to an open operation. The morbidity rate for laparoscopic procedures was 3%, the median inpatient stay was two days and the median time to return to normal activities was eight days.
Diagnostic laparoscopy should be performed in women who present with a clinical diagnosis of acute appendicitis to confirm the diagnosis, reduce the rate of unnecessary appendicectomy and avoid an unnecessary laparotomy. When acute appendicitis is confirmed, appendicectomy may be performed laparoscopically.
The Medical journal of Australia 03/1995; 162(3):130-2. · 2.81 Impact Factor
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ABSTRACT: The development of laparoscopic cholecystectomy has created a dilemma in the management of choledocholithiasis. A number of options exist, including endoscopic sphincterotomy (ES) before laparoscopic cholecystectomy in patients with suspected common bile duct (CBD) calculi, laparoscopic bile duct exploration, open CBD exploration and postoperative ES. None of these options has emerged as ideal or universally acceptable. An alternative technique, peroperative ES, has been developed. A prospective assessment of the use of peroperative ES in 13 patients in whom choledocholithiasis was demonstrated with operative cholangiography is presented. Eleven patients had successful ES and clearance of stones. The CBD could not be cannulated in one patient, and an adequate ES for stone extraction could not be performed in the remaining patient. Both procedures were converted to open CBD exploration. Complications were mild postoperative pancreatitis (two patients) and pulmonary atelectasis (one). The median total operating time was 165 min and the median postoperative hospital stay was 3 days. Peroperative ES at the time of laparoscopic cholecystectomy provides a safe technique for clearance of the CBD.
British Journal of Surgery 03/1995; 82(2):257-9. · 4.61 Impact Factor
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ABSTRACT: Local recurrence (LR) continues to be a major problem following surgical treatment for rectal cancer, and proposed ways of reducing this remain controversial. The aim of this study was to review results from published surgical series in which adjuvant therapies were not used. A Medline search identified series published between January 1982 and December 1992 with follow-up on at least 50 patients with rectal cancer treated surgically for cure, without adjuvant therapy. Fifty one papers reported follow-up on 10,465 patients with a median LR rate of 18.5%. LR was 8.5%, 16.3% and 28.6% in Dukes' A, B and C patients respectively, 16.2% following anterior resection and 19.3% following abdominoperineal resection. Nine papers (1,176 patients) reported LR rates of 10% or less. LR was 7.1% in 1,033 patients having total mesorectal excision and 12.4% in 476 patients having extended pelvic lymphadenectomy. Routine cytocidal stump washout in 1,364 patients was associated with 12.2% LR, however a higher proportion (41%) also underwent total mesorectal excision. In 52% of cases, LR was reported to have occurred with no evidence of disseminated disease. Surgical technique is an important determinant of LR risk. LR rates of 10% or less can be achieved with surgery alone in expert hands.
International Journal of Colorectal Disease 02/1995; 10(3):126-32. · 2.38 Impact Factor
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ABSTRACT: Laparoscopic cholecystectomy is the preferred method of treatment for symptomatic choledocholithiasis. Since its introduction there has been an increase in postoperative diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to assess the indications and results of ERCP following laparoscopic cholecystectomy. Sixty-one patients had an ERCP following laparoscopic cholecystectomy. Two broad groups were identified: Group 1 (35 patients) had filling defects (consistent with stones) noted on operative cholangiography, which were not successfully flushed or extracted at the time of laparoscopic cholecystectomy; Group 2 consisted of patients who developed problems following laparoscopic cholecystectomy. Nine patients had post-laparoscopic cholecystectomy pain with abnormal liver function tests (LFT), four of whom had common bile duct (CBD) injuries and three had CBD stones. Eleven patients had post-laparoscopic cholecystectomy pain with a normal diameter common bile duct on ultrasound and normal LFT; only one had a CBD stone. Five patients with a persisting bile leak following laparoscopic cholecystectomy had an ERCP and endoscopic sphincterotomy. In three the leak ceased, while two required subsequent open surgery to drain bile collections and ligate the cystic duct. One patient presented with an episode of transient jaundice but had a normal ERCP. There were six post-ERCP complications; three patients had mild pancreatitis, two had a minor haemorrhage and one an asymptomatic duodenal perforation. Endoscopic retrograde cholangiopancreatography post-laparoscopic cholecystectomy was most valuable for the management of retained stones and the diagnosis and management of post-laparoscopic cholecystectomy pain in association with abnormal LFT. The diagnostic yield was low (9%) when the LFT were normal.
Australian and New Zealand Journal of Surgery 07/1994; 64(6):407-12.
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ABSTRACT: Duodenal injury following blunt abdominal trauma is uncommon. The severity of injury can vary from an intramural haematoma to a duodenal rupture with associated transection of the pancreatic duct. A case of duodenal rupture with avulsion of the ampulla of Vater is presented and discussed.
HPB Surgery 02/1994; 7(3):225-9.
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ABSTRACT: Postoperative adhesions account for 64-79% of admissions with small bowel obstruction (SBO). The aim of this study was to identify the operative procedures and the types of adhesions that cause SBO. A retrospective analysis of all patients with an admission diagnosis of acute adhesive SBO between January 1982 and December 1990 was performed. One hundred and nineteen patients had 144 admissions with an initial diagnosis of acute SBO due to adhesions. The previous operations were: appendicectomy 23.3%; colorectal resection 20.8%; gynaecological surgery 11.7%; upper gastrointestinal (gastric, biliary or splenic) surgery 9.2%; small bowel surgery 8.3%; and more than one previous abdominal operation 23.6%. Sixty-one admissions required surgery to relieve the SBO. Eighteen patients had strangulated small bowel. All but two of these patients had a single band adhesion causing the SBO and associated strangulation. Band adhesions were commonly found following appendicectomy, colorectal resections or gynaecological operations. Seventeen of the 21 patients with previous surgery for a colorectal malignancy had benign adhesions causing the SBO, while four of the six patients with either previous ovarian or previous gastric carcinoma had recurrent malignancy causing the SBO. Five patients had previously undiagnosed carcinomas (three ovarian and two caecal) as the cause of the SBO.
Australian and New Zealand Journal of Surgery 12/1993; 63(11):848-52.
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ABSTRACT: The aim of this study was to prospectively assess the results of laparoscopic cholecystectomy in patients with acute inflammation of the gallbladder.
Laparoscopic cholecystectomy has become the standard treatment for symptomatic gallbladder disease. Its role in the surgical treatment of acute cholecystitis has not been defined, although a number of recent reports suggest that there should be few contraindications to an initial laparoscopic approach.
All patients presenting with symptomatic cholelithiasis from October 1990 until June 1992 were evaluated at laparoscopy with intention of proceeding to a laparoscopic cholecystectomy. The gross appearance of the gallbladder was categorized as acute inflammation, chronic inflammation, or no inflammation. Ninety-eight (23.4%) of 418 patients had acute inflammation of the gallbladder: 55 were edematous, 10 were gangrenous, 15 had a mucocele, and 18 had an empyema.
The authors assessed outcome in these patients. The frequency of conversion to an open operation was 33.7% for acute inflammation, 21.7% for chronic inflammation (p < 0.05), and 4% for no inflammation (p < 0.001). The conversion rate was highest for empyema (83.3%) and gangrenous cholecystitis (50%), while the conversion rate for edematous cholecystitis was 21.8% and for acute inflammation with a mucocele it was 7%. The median operation time for successful laparoscopic cholecystectomy for acute inflammation was 105 minutes, which was longer than that with no inflammation (90 minutes). However, the incidence of complications was not different from that for chronic or no inflammation. The median postoperative stay for patients with acute gallbladder inflammation was 2 days for successful laparoscopic cholecystectomy and 7 days for patients converted to an open operation.
Laparoscopic cholecystectomy for acute inflammation of the gallbladder is safe and is associated with a significantly shorter postoperative stay compared to open surgery. A greater number of patients required conversion to open operation compared to those with no obvious inflammation. Conversion to open operation was most frequent for empyema and gangrenous cholecystitis, suggesting that once this diagnosis is made, excessive time should not be spent in laparoscopic trial dissection before converting to an open operation.
Annals of Surgery 12/1993; 218(5):630-4. · 7.49 Impact Factor
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ABSTRACT: The potential advantages of laparoscopic surgery for a number of abdominal operations including appendicectomy have been heralded. In this study the aims were to assess prospectively the role of routine diagnostic laparoscopy in the diagnosis of acute appendicitis and determine the efficacy of laparoscopic appendicectomy. Patients with suspected acute appendicitis had diagnostic laparoscopy. When the diagnosis was confirmed laparoscopic appendicectomy was performed. Where an alternative diagnosis was made the appropriate treatment was instituted. If no diagnosis could be made the macroscopically normal appendix was removed by laparoscopic appendicectomy. Eighty-one patients (50 female, 31 male) had an initial diagnostic laparoscopy; 53 had appendicitis and proceeded to laparoscopic appendicectomy. A diagnosis could not be established at diagnostic laparoscopy in six patients and they also proceeded to laparoscopic appendicectomy. An alternative diagnosis was made in the remaining 22 patients (19 female and 3 male), with five proceeding to laparotomy and one patient with mesenteric adenitis having laparoscopic appendicectomy. Seven patients having laparoscopic appendicectomy required conversion to an open operation due to a retrocaecal or perforated appendix. The median operating time for successful laparoscopic appendicectomy was 55 min (range 30-95). Morbidity occurred in five of 53 patients having a successful laparoscopic appendicectomy. The median postoperative hospital stay was 2 days. The median time before return to normal activities was 8 days. Diagnostic laparoscopy is a useful diagnostic technique in women with suspected acute appendicitis, as it improves diagnostic accuracy, reduces the negative appendicectomy rate and avoids unnecessary laparotomy.(ABSTRACT TRUNCATED AT 250 WORDS)
Australian and New Zealand Journal of Surgery 12/1993; 63(11):840-7.
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ABSTRACT: Cystogastrostomy or cystojejunostomy at open operation has been the usual treatment for symptomatic pancreatic pseudocyst. The aim of this study was to assess prospectively the results of percutaneous cystogastrostomy (PCG) for the treatment of symptomatic pseudocysts. The technique of PCG comprised initially of drainage of the pseudocyst with a 10 Fr percutaneous, transgastric catheter. This initial drainage catheter had two components; the first, between the pseudocyst and the stomach, drained the pseudocyst and the second, between the stomach and exterior, acted as a percutaneous gastrostomy. The initial drain was left in situ for 14 days, at which time it was exchanged percutaneously for the definitive PCG; a double ended Mallecot type catheter that drained between the pseudocyst and the stomach. The latter catheter was left in situ until there was no residual pseudocyst demonstrated on computerized tomography scan and was removed endoscopically. Eleven patients with large (> 6 cm), symptomatic pseudocysts have been treated with PCG. All patients were treated successfully without the need for surgical intervention. The median time to radiological resolution was 24 days. There were four episodes of sepsis, two related to central venous line infections nad two related to catheter blockage. Percutaneous, cystogastrostomy blockage was managed by either replacing the initial drain or inserting a second catheter. The median follow up after successful treatment was 9 months (range 2-17). There were no symptomatic recurrences and one small (2 cm) asymptomatic recurrent pseudocyst. This preliminary experience with PCG demonstrates the efficacy of this procedure for treating symptomatic pancreatic pseudocysts.
Australian and New Zealand Journal of Surgery 09/1993; 63(9):693-8.
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ABSTRACT: The advent of laparoscopic cholecystectomy (LC) has led to a reassessment of the approach to the management of choledocholithiasis. In a consecutive series of 418 patients undergoing LC, common bile duct (CBD) stones were suspected pre-operatively in 130 patients. Forty-five of the patients (35%) were found to have CBD stones on either pre-operative endoscopic retrograde cholangiopancreatography (ERCP; 20) or on operative cholangiography (OC; 25). Common bile duct stones were detected on OC in a further 12 of 288 patients (4.2%) without pre-operative suspicion of choledocholithiasis. Of the total of 57 patients with CBD stones, the duct was cleared by pre-operative ERCP and endoscopic sphincterotomy (ES) in 15 patients. In 13 patients, two of whom had had a pre-operative ERCP and ES, duct clearance was achieved by relaxing the sphincter pharmacologically and flushing the CBD via the OC catheter. One patient had an on-table ERCP and ES with successful stone extraction during LC. Eleven patients were converted to open operation with bile duct exploration. Sixteen patients had a postoperative ERCP. In five patients the CBD stones had passed spontaneously in the time between LC and ERCP. Ten patients required ES to clear the duct of stones. One patient had a failed ERCP and is still awaiting a repeat. The remaining patient was scheduled, but did not return for follow-up ERCP. In summary, pre-operative ERCP was indicated in less than 10% of patients in this series.(ABSTRACT TRUNCATED AT 250 WORDS)
Australian and New Zealand Journal of Surgery 07/1993; 63(6):443-50.
