bluuebunny/crossref_metadata_2025 huggingface dataset:
Preoperative Chemoradiation Therapy and Anal Sphincter Preservation with Locally Advanced Rectal Adenocarcinoma
Authors: Luna‐Pérez Pedro , Rodríguez‐Ramírez Saúl , Rodriguez‐Coria Darío F. , Fernández Armando , Labastida Sonia , Silva Alejandro , López Marvin J.
Published: October 2003

Preoperative irradiation has been used to produce tumor regression and allow complete resection of rectal cancer with a sphincter‐saving procedure. To evaluate the associated toxicity, the response in the primary tumor, and the postsurgical morbidity in a group of patients with locally advanced rectal cancer treated with preoperative chemoradiation therapy and low anterior resection, 120 patients were treated with 45 Gy of preoperative radiotherapy and a bolus infusion of 5‐fluorouracil 450 mg/m2 on days 1 to 5 and 28 to 32 of radiotherapy. Four to six weeks later, 16 lesions were found unresectable; 36 patients underwent abdominoperineal resection or pelvic exenteration, and in the remaining 68 a low anterior resection was performed. For the purpose of this study only the latter group was included. There were 38 men and 30 women, with a mean age of 54.7 ± 13.1 years. Gastrointestinal and hematologic acute toxicity grade 3 to 4 occurred in 12 and 7 patients, respectively. The mean distance of the tumor above the anal verge was 8.2 ± 2.6 cm. In 10 patients the surgical resection included neighboring pelvic organs; 16 patients (23.5%) required a temporary diverting colostomy. The main causes of surgical morbidity were clinical anastomotic leakage in seven (10%), abdominal wall infection in five (7.4%), anastomotic stenosis in three (4.5%), and intraabdominal abscess in one (1.5%). No operative deaths occurred. The postsurgical stages were as follows: no tumor in the specimen, 17 (25%); T1, 4 (6%); T2, 12 (17%); T3, 17 (25%); T4, 5 (7%); any T with N+, 9 (13%); and any T, N with M+, 4 (6%). The median and mean follow‐ups were 30.0 months and 37.4 ± 25.0 months, respectively. The local recurrence rate was 2.9%, and the distant recurrence rate was 17%. The administration of preoperative chemoradiation therapy for locally advanced rectal cancer is associated with tolerable toxicity, a high rate of response in the primary tumor that allowed anal sphincter preservation, and a low rate of local recurrence.
Ernst Ferdinand Sauerbruch: Rise and Fall of the Pioneer of Thoracic Surgery
Authors: Cherian Sanjay M. , Nicks Rowan , Lord Reginald S.A.
Published: October 2003

Ferdinand Sauerbruch (1875–1951) was a pioneer of thoracic and cardiac surgery and is undoubtedly one of the twentieth century's most outstanding surgeons. Before 1904 operations on the thorax met with fatal complications due to pneumothorax. Sauerbruch developed a pressure‐differential chamber that maintained normal respiration and enabled safe operations to be undertaken on the thorax. Together with von Mikulicz, he initiated intrathoracic operations and later developed various surgical procedures on the mediastinum, lungs, pericardium, heart, and esophagus. The simple yet effective techniques of positive‐pressure ventilation replaced the expensive, cumbersome negative‐pressure chamber. Sauerbruch's latter years were marred by dementia that adversely affected his personality, intellect, and capacity as a surgeon. The unjustifiable toll of increasing patient morbidity and mortality forced authorities to dismiss him in 1949. He died at the age of 76 in Berlin. After almost a century since the advent of the first safe thoracic surgery, the advances in technique and technology have been enormous. A great deal is owed to the inspiration and contributions of Ferdinand Sauerbruch.
Guidelines for Neurosurgical Trauma in Brazil
Authors: Ferreira de Andrade Almir , Marino Raul , Ciquini Orildo , Gadelha Figueiredo Eberval , Guelman Machado André
Published: October 2003

This chapter emphasizes some aspects of the Brazilian Guidelines for the Assessment of Head Injury Patients, written based on the experience of the Emergency Service, Neurosurgical Division of the University of São Paulo Medical School Hospital, and sponsored by the Brazilian Society of Neurosurgery. These guidelines approach the management of head‐injury patients from their initial assessment in the Emergency Room until the final suggested clinical or surgical management. The Brazilian Guidelines represents our efforts to provide the basis for a common unified data collection system, which may allow cooperative studies in the future.
Present Status of Neurosurgical Trauma in Germany
Authors: Firsching Raimund , Woischneck Dieter
Published: October 2003

Exact epidemiological data on head injury in Germany are limited and based on data from death certificates, the Federal Board of Statistics (Bundesamt für Statistik), small regional cohort studies, and health insurance. With a population of 82
million people there had been 279,029 head injuries admitted to hospital in Germany in 1996. The majority had the diagnosis.
"concussion," which refers to completely reversible lesions. Head injury caused the deaths of 9415 patients in 1996, which amounts to a mortality of 11.5 per 100,000 inhabitants. At the same time there were
135 independent neurosurgical units, all of which had a computerized tomography scanner available. Of all fatal cases, however, 68.4% died before they reached a hospital. The exact cost is difficult to assess,
because head injury causes more costs than only the hospital stay and rehabilitation.
Surgical Management of Benign Strictures of the Biliary Tract
Authors: Quintero Gustavo A. , Patiño José Felix
Published: October 2003

Benign strictures of the biliary tract are difficult to treat surgical complications. Most biliary strictures result from injuries during cholecystectomies, and their initial management is a major determining factor of the long‐term outcome. Only surgeons well trained and experienced in their management should treat this entity. The affected patients present various signs and symptoms depending on the time the lesion is detected, and the treatment modality largely depends on such timing. The success of surgical treatment with its attendant low morbidity and mortality makes it the preferred modality over transhepatic image‐guided or endoscopic balloon dilatation, with or without the insertion of stents. Surgical treatment is based on three principles: good exposure for internal drainage of the intrahepatic biliary tract, mucosa‐to‐mucosa anastomosis, and prevention of the risk of reoperation for recurrent stenosis. Roux‐en‐Y hepaticojejunostomy with a blind subcutaneous jejunal loop seems to comply with these three principles. Transanastomotic stents are not necessary. We have analyzed our experience from 1988 to 1999 with 65 consecutive patients referred to us for biliary reconstruction. We used the Roux‐en‐Roux‐en‐Y hepaticojejunostomy with a blind subcutaneous jejunal loop, performed by the same surgical group in all cases.
Dilatation of Biliary Strictures through the Afferent Limb of a Roux‐en‐Y Choledochojejunostomy in Patients with Sclerosing Cholangitis
Authors: Hutson Duane G. , Russell Edward , Levi Joe U. , Jeffers Lennox J. , Reddy K. Rajender , Yrizarry Jose M. , Scagnelli Tomas , Sleeman Danny , Schiff Eugene R. , Livingstone Alan S.
Published: October 2003

Repeated dilatation of biliary strictures in patients with sclerosing cholangitis through a subcutaneously placed afferent limb of a choledochojejunostomy is technically feasible and safe. This study is a prospective 15‐year evaluation of 36 patients treated by repeat dilatation through this jejunal limb. There was one operative death and one major complication of dilatation. The 5‐year survival of all patients was 74%. If patients with cirrhosis or unproven cholangiocarcinoma at the time of operation are not included, the 5‐year survival is 86%. The 15‐year survival of all patients was 30%; it was 64% if those with cirrhosis and unproven cholangiocarcinoma at the time of operation are not included. Six patients are presently alive with an average survival of 159 months. The study suggests that a combination of repeated dilatations combined with transplantation is the approach of choice in selected patients.
Long‐term Biliary Complications after Liver Surgery Leading to Liver Transplantation
Authors: Loinaz Carmelo , Moreno González Enrique , Jiménez Carlos , García Ignacio , Gómez Ramón , González‐Pinto Ignacio , Colina Francisco , Gimeno Alberto
Published: October 2003

Chronic biliary obstruction with repeated bouts of cholangitis adversely affects quality of life and may lead to secondary biliary cirrhosis with liver failure. We reviewed our experience with chronic biliary complications after surgical treatment of various diseases that at the end needed a liver transplantation. Twelve patients with previous biliary surgery developed secondary biliary cholangitis, secondary biliary cirrhosis, or both. Seven had surgery for liver hydatid disease by Echinococcus granulosus, another four had complicated biliary surgery unrelated to hydatid disease, and one had a history of a traffic accident with liver trauma and hepatectomy with chronic biliary fistula. The repeated cholangitis attacks and in two cases of hydatid disease the development of biliary‐bronchial fistulas made these patients' lives miserable. All had had previous surgical procedures that made the transplantation procedure more difficult. Nevertheless, patient survival and graft actuarial survival after liver replacement were 75.0% and 69.2%, respectively, at 5 years.
Management of Biliary Duct Confluence Injuries Produced by Hepatic Hydatidosis
Authors: Vicente Emilio , Meneu Juan C. , Hervás Pedro L. , Nuño Javier , Quijano Yolanda , Devesa Manuel , Moreno Alberto , Blazquez Luis
Published: October 2003

From 1978 to 1999 a total of 850 patients underwent surgical treatment for hydatid disease of the liver at our surgical department. Biliary duct confluence injuries produced by hepatic hydatidosis (HH) were founded in six patients (0.7%). Surgical intervention was undertaken to relieve the obstructive jaundice and clinical manifestations of cholangitis and to treat the hydatid cyst. A partially open cystopericystectomy technique was used in three patients with a double bilioenteric Roux‐en‐Y reconstruction. The remaining three patients (two with prehepatic portal hypertension and one with triple hepatic duct confluence) were subjected to a cystojejunostomy. There were no hospital deaths. Two cases of anastomotic leakage following a high bilioenteric anastomosis occurred but did not require surgical treatment. During the follow‐up (5–19 years) one patient suffered local recurrence of the hydatid disease 7 years after cystojejunostomy. The site of intrahepatic biliary and vascular involvement, the presence of biliary duct anomalies, and the presence of portal hypertension are decisive factors when choosing the “ideal” procedure for reconstruction. Conservative surgical approaches (partial cystectomy and cystojejunostomy) are the treatments of choice. Radical surgery is often a serious matter.
Choledocholithiasis: New Approach to an Old Problem
Authors: Cervantes Jorge , Rojas Guillermo
Published: October 2003

The old problem of diagnosis and treatment of choledocholithiasis is analyzed in light of recent developments in the field of radiology and surgery. The traditional indications for common bile duct (CBD) exploration resulted in a large number of unnecessary manipulations of the bile ducts. The same is now true of the widespread use of endoscopic retrograde cholangiopancreatography. With the advent of magnetic resonance imaging cholangiography, which can clearly demonstrate CBD calculi by means of a noninvasive, complication‐free technology, we should abandon the old indications for CBD exploration and be more conservative regarding the diagnosis and management of this condition. In an era of minimally invasive surgery we are seeing a significant reduction in the number of patients with choledocholithiasis.
Biliary Complications during Liver Resection
Authors: Lam Chi‐Ming , Lo Chung‐Mau , Liu Chi‐Leung , Fan Sheung‐Tat
Published: October 2003

Biliary complications after hepatectomy may lead to sepsis, liver failure, and death. Measures to detect biliary injury after liver transection may reduce such morbidity. The aim of this study was to investigate the trend of biliary complications after hepatectomy during the last 10 years and assess the efficacy of intraoperative measures (methylene blue test, cholangiography, fibrin glue application) for reducing postoperative biliary complications. This is a retrospective study of 616 consecutive patients who underwent hepatectomy in our institution from January 1989 to September 1998. The study period was divided into the first 5 years and the second 5 years for comparison. The hospital mortality rate was 6%. It was significantly reduced during the second 5‐year period (3.3% vs. 10.6%; p= 0.0002). The postoperative biliary leakage rate was 5.5% and was also reduced during the second 5‐year period (3.5% vs. 9.8%; p= 0.004). Postresection methylene blue tests were performed more frequently during the second 5‐year period than the first (63% vs. 28%; p= 0.0001). The postoperative biliary leakage rate was reduced by the methylene blue test (3.6% vs. 7.3%; p < 0.05) but not by application of fibrin glue (7.2% vs. 4.2%) or postresection cholangiography. However, among the 60 patients with a positive methylene blue test, postoperative biliary leakage still occurred in 10% of them after the leakage sites were sutured. In conclusion, the biliary complication rate is decreasing. Only the postresection methylene blue test, but not postresection cholangiography or application of fibrin glue, helps to reduce the postoperative biliary leakage rate.
Surgical Complications and Treatment during Resection for Malignancy of the High Bile Duct
Authors: Meunier Bernard , Lakehal Mohamed , Tay Khoon‐Hean , Malledant Yannick , Launois Bernard
Published: October 2003

From January 1968 to January 1997 a series of 50 of 109 patients had undergone resection for high bile duct cancer in our institution in Rennes, France. The overall operative mortality was 12%, but there were no deaths among those who had only tumor resection or those with hepatectomy with vascular reconstruction. The early complications were biliary fistula (four cases) and subphrenic abscess (three cases), of which two of the biliary fistulas resulted in mortality. There were three gastrointestinal hemorrhages; one was due to gastritis related to hepatorenal insufficiency and was fatal. Two other deaths were due to respiratory failure and ascites associated with hepatic insufficiency. In one patient after liver transplantation with cluster resection, a biliary leak and ileocolic fistula were the cause of postoperative mortality. Another patient suffered a ruptured mycotic aneurysm after pretransplant transtumoral intubation, which emphasizes the risk of infection in an immunosuppressed patient. The main late complication was cholangitis (8 cases). This complication is most often a symptom of recurrence (four cases). Some are due to benign causes (intrahepatic lithiasis, intrahepatic foreign body granuloma). Surgical exploration is mandatory to exclude benign complications, which can then be treated palliatively. Four patients presented with recurrence but without cholangitis. In conclusion, the causes of complications after resection of high bile duct cancer should be carefully assessed to choose the correct treatment. Late cholangitis is a symptom of recurrence, but it should be explored and managed precisely.
Endoscopic Stenting for Malignant Biliary Obstruction
Authors: Lai Edward C.S. , Lo Chung‐Mau , Liu Chee‐Leung
Published: October 2003

Use of endoscopic stents to manage patients with malignant obstructive jaundice is a well accepted measure. Interpretation of the results of endoscopic stenting must be made with reference to the level of the bile duct obstruction. Results were generally unsatisfactory for hilar lesions, especially when the intrahepatic ducts were segregated into multiple isolated systems. After deployment, stent dysfunction due to clogging by biliary sludge is apparently an inevitable process for the conventional plastic stent. Considerable efforts had been made to prolong the stent patency by changing its physical configuration, coating the inner lumen, and the choice of material but with little success. The development of a self‐expandable metal stent is a major advance, but the benefits derived from a larger stent lumen are compromised by the initial expense and the tumor ingrowth through the wires for all models available commercially. Current data failed to substantiate the value of routine preoperative biliary decompression, as there is no reduction in the morbidity and mortality rates after surgery. Although biased patient selection may have resulted in the negative observations made, repeated clinical trials should probably focus on patients with distal bile duct tumors who are preparing for a major pancreatic resection. As a definitive palliative measure, endoscopic stenting is a more cost‐effective option than surgery for patients with limited life expectancy based on data regarding plastic stents. The recommendations are evolving however, as there is progressive refinement of laparoscopic surgery techniques and designs of endoscopic stents.
Biliary Anastomotic Complications in 400 Living Related Liver Transplantations
Authors: Egawa Hiroto , Inomata Yukihiro , Uemoto Shinji , Asonuma Katsuhiro , Kiuchi Tetsuya , Fujita Shiro , Hayashi Michihiro , Matamoros Maria A. , Itou Kyo , Tanaka Koichi
Published: October 2003

The purpose of this study was to evaluate the cause and outcome of biliary anastomotic complications occurring after living related liver transplantation (LRLT). A database of 391 patients undergoing 400 LRLT from June 1990 to August 1998 was reviewed. The overall incidence of biliary anastomotic complications was 18.2% (71 patients). There were 45 bile leaks, 35 anastomotic strictures, and the bile duct was ligated inadvertently in 3 cases. Univariative analysis revealed that the manner of stent usage, intrapulmonary shunting, and gender of recipients were significant risk factors for leakage. Anastomotic leaks, cytomegalovirus infection, hepatic artery complications, and gender of recipients were significant risk factors for stricture. In pediatric patients older than 2 years old, ABO blood type compatibility was another risk factor for leakage and stricture. Choice of stent usage and earlier transplantation for patients with intrapulmonary shunting should reduce the rate of biliary leaks, and prophylaxis of leaks for patients with intrapulmonary shunting, and minimizing hepatic artery complications should reduce the rate of biliary stricture after LRLT. Avoidance of ABO‐incompatible donors or innovative immunosuppression in ABO‐incompatible transplantation should be considered in children.
Choledochocholedochostomy Conversion to Hepaticojejunostomy due to Biliary Obstruction in Liver Transplantation
Authors: Gómez Ramón , Moreno Enrique , Castellón Camilo , González‐Pinto Ignacio , Loinaz Carmelo , García Ignacio
Published: October 2003

Choledochocholedochostomy with tutor (CC‐T) or without (CC) is the technique of choice for biliary reconstruction in orthotopic liver transplantation (OLT), however, its rate of complications is high and does not decrease significantly over the years. Biliary obstruction is the most frequent complication and surgical treatment frequently involves conversion to hepaticojejunostomy (H‐J). Out of 412 patients (448 OLTs) analyzed retrospectively, 74 (18%) presented biliary complications and 25 (6%) required conversion to H‐J because of biliary obstruction, generally due to anastomotic stenosis (17 patients, 68%). Sixteen out of the 25 presented after the first 3 months, and in two patients, stenosis was secondary to arterial thrombosis. Anastomotic stenosis was more frequent in the CC group than in the CC‐T group (9.9% versus 2.6%, p < 0.05). Sixteen patients (64%) underwent percutaneous dilatations, but the response was only transitory. There were no postoperative deaths. At the follow‐up, three (12%) of the 17 surviving patients presented episodes of cholangitis which required percutaneous dilatations (1), revision of the H‐J (1), or conversion to hepaticojejunoduodenostomy (1). Mean survival of patients with H‐J was 70.9%, and the actuarial survival rate was 68% at 5 years. This does not differ from the actuarial survival in our series of transplanted patients (65%). CC or CC‐T (in selected cases) is an adequate biliary reconstruction for OLT, in spite of the fact that a small number of patients will require conversion to H‐J. H‐J is an excellent technique of rescue in cases of biliary obstruction that are not possible to resolve by percutaneous dilatations.
Laparoscopic Surgeon and the Common Bile Duct
Authors: Fitzgibbons Robert J. , Gardner Glenn C.
Published: October 2003

Many biliary tract surgeons have now reached a level of sophistication with laparoscopic cholecystectomy that they are now able to deal with the common bile duct at the same time. Preoperative endoscopic cholangiography can be reserved for cases where choledocholithiasis has a high degree of probability. This has served to decrease the number of negative studies. The surgeon has five choices regarding stones confirmed by operative cholangiography during laparoscopic cholecystectomy: (1) do nothing, hoping the stones will pass spontaneously or that a postoperative sphincterotomy with stone extraction will be successful; (2) perform a transcystic laparoscopic common bile duct exploration (best for stones less than 1 cm and distal to the cystic duct); (3) perform a laparoscopic common bile duct exploration by choledochotomy (best for large stones in patients with common bile ducts greater than 1 cm. It is also the preferred approach with stones proximal to the insertion of the cystic duct.); (4) perform an intraoperative sphincterotomy with stone extraction, either retrograde or antegrade (this approach has some proponents but has not gained popularity among the majority of surgeons); and (5) place a double lumen catheter through the cystic duct with a proximal lumen in the common bile duct and the distal lumen in the duodenum. This can be used for serial postoperative cholangiography to confirm spontaneous stone passage or falsely positive operative cholangiograms. It is useful in situations when laparoscopic common bile duct exploration equipment or surgeon expertise is not available. If stones persist, a guidewire can be introduced through the distal lumen of the catheter for a guidewire‐assisted sphincterotomy. Other CBD interventions that have been reported include laparoscopic biliary bypass and resection of choledochal cysts. Malignant lesions should not be approached by a laparoscopic method except in unusual circumstances.
Is There a Place for Laparoscopy in Management of Postcholecystectomy Biliary Injuries?
Authors: Azagra Juan Santiago , De Simone Paolo , Goergen Martine
Published: October 2003

Despite its minimal invasiveness, laparoscopic cholecystectomy (LC) carries unquestionably higher morbidity and mortality rates when compared with the open counterpart (OC). Among the iatrogenic injuries, biliary tract lesions are the most clinically relevant because of their potential for patient's disability and long‐term sequelae. No universal agreement exists for classifying these lesions, but numerous authors have advocated a distinction between bile leaks and bile injuries. Even if not entirely correct, bile leaks refer to fistulas from minor ducts in continuity with the major ductal system or from accessory ducts (as the duct of Luschka). Biliary injuries are major complications consisting of leaks, strictures, transection, or ligation of major bile ducts. While bile leaks are typically treated by percutaneous and/or endoscopic drainage and stenting, biliary injuries often require a combined radiology‐assisted and endoscopic approach or even conventional surgery. The role of laparoscopy in the management algorithm of biliary lesions is still anecdotal. To date, a total of 25 cases of laparoscopic drainage of post‐cholecystectomy bilomas have been reported in the literature, whereas there is no mention of laparoscopic primary repair of biliary injuries detected at or after cholecystectomy. The main reasons depend on the excellent results achieved by the ancillary techniques; the emergency settings that accompany more complex biliary lesions; the technical challenges posed by the presence of inflammation, collections, and obscured anatomy; and the potential for malpractice litigation. However, a sound laparoscopic technique and a strict adherence to basic surgical tenets are crucial in order to avoid the incidence of iatrogenic biliary injuries and reduce their still unknown impact on long‐term patient disability.
Surgical Repair after Bile Duct and Vascular Injuries during Laparoscopic Cholecystectomy: When and How?
Authors: Bachellier Philippe , Nakano Hiroshi , Weber Jean‐Christophe , Lemarque Pascal , Oussoultzoglou Elie , Candau Christophe , Wolf Philippe , Jaeck Daniel
Published: October 2003

Recent collective reviews have outlined when and how surgeons should treat patients with bile duct injuries after laparoscopic cholecystectomy (LC). However, little is described about other injuries combined with bile duct injuries, for example, hepatic arterial injury and secondary biliary cirrhosis. Fifteen patients with bile duct injuries following LC were referred and surgically treated from 1990 to 1998 in our institution. We report how patients with hepatic arterial injury combined with bile duct injuries during LC were treated. The present study also reports unusual complicated situations: one patient with biliary cirrhosis referred 4 years after LC, another treated with internal biliary metallic stent referred 2.5 years after LC, and another with isolated right hepatic ductal injury. Short‐ and long‐term surgical outcomes after biliary repair were compared between simply referred patients and those with complicated history. Patients who were referred several years after LC and who were referred after primary hepaticojejunostomy were included with patients with complicated history (n= 4, group B), and the other patients were included with patients with simple history (n= 11, group A). Simultaneous right hepatic arterial occlusion was observed in 3 of these 15 patients, and arterial reconstruction was performed in 2 of the 3 patients in addition to biliary reconstruction. No postoperative complication occurred in these three patients. The patient with isolated injury of the right hepatic duct and the other with biliary cirrhosis were successfully treated with hepaticojejunostomy. The other patient treated with biliary stent underwent hepaticojejunostomy but a second operation was required because of later stenosis. Mean hospital stay was significantly longer in group B (30.3 ± 6.9 days) than in group A (18.5 ± 2.5 days, p< 0.05). Rehospitalization was more frequent in group B than in group A (p < 0.01). However, long‐term outcome was successful in both groups. The present results showed that arterial reconstruction should be performed when the distal right hepatic artery can be exposed and reconstructed, and suggested that patients with bile duct injuries during LC should be immediately referred to surgical institutions in which surgeons have adequate experience of bile duct repair and hepatic arterial reconstruction.
Safety of Laparoscopic Approach for Acute Cholecystitis: Retrospective Study of 609 Cases
Authors: Navez Benoît , Mutter Didier , Russier Yves , Vix Michel , Jamali Faek , Lipski David , Cambier Emmanuel , Guiot Pierre , Leroy Joël , Marescaux Jacques
Published: October 2003

Laparoscopic cholecystectomy (LC) is now widely accepted as the modality of choice for the treatment of symptomatic uncomplicated cholelithiasis. The application of the laparoscopic technique in the setting of acute cholecystitis (AC) is more controversial. The precise role as well as the potential benefits of LC in the treatment of the acutely inflamed gallbladder have not been clearly established through large clinical series. The aim of our study was to assess the feasibility, safety, benefits, and specific complications of the laparoscopic approach in patients with AC. A retrospective chart analysis involving the patients admitted to two busy emergency digestive surgical units between October 1990 and December 1997 was carried out. Six hundred and nine patients meeting our criteria for AC were identified and evaluated. Overall complication rate was 15% with 12 postoperative bile leakages (1.97%) and 4 biliary tract injuries (BTI) (0.66%). The overall mortality rate was 0.66%. Local and overall complication rates were significantly correlated with the delay between the onset of acute symptoms and the operation but not the rate of general complications nor deaths. Our results demonstrate the safety and feasibility of LC in the setting of AC. Early cholecystectomy within 4 days is strongly recommended to minimize complications and increase the chances of a successful laparoscopic approach.
Transduodenal Sphincterotomy in Laparoscopic Era
Authors: Carboni Manlio , Negro Paolo , D'Amore Linda , Proposito Delia
Published: October 2003

Indications for transduodenal sphincterotomy have been reduced in recent years, mainly because of the development of endoscopic sphincterotomy and laparoscopic procedures. Endoscopic treatment is effective, but it is necessary to carefully evaluate its indications because the incidence of early and late complications is not negligible. Laparoscopic procedures require advanced and expensive technologies and considerable laparoscopic experience. Transduodenal sphincterotomy is safe and effective, if correctly performed. Some risk factors appear to be related to the incidence of complications that do not significantly differ from those following endoscopic sphincterotomy. Transduodenal sphincterotomy may be still indicated in selected cases, and for this reason it should be considered an essential part of the knowledge of a general surgeon.
Telesensor Integrated Circuits
Authors: Ferrell Thomas L. , Britton Charles L. , Bryan William L. , Clonts Lloyd G. , Emery Michael S. , Ericson M. Nance , Merraudeau Fabrice , Morrison G. Wayne , Passian Ali , Smith Steven F. , Threatt Tim D. , Turner Gary W. , Wintenberg Alan L.
Published: October 2003

Progress in personal computing has recently permitted small research programs to design and simulate application‐specific integrated circuits (ASICs). Inexpensive fabrication of silicon chips can then be obtained using chip foundries,
and quite complex circuits can be greatly reduced in size with an accompanying increase in certain performance characteristics. Within the past 5 years it has also become possible to design ASICs which can transmit and receive radio signals and which thus may be employed in applications in which wired connections for input and output of signals are not practicable. We are currently developing research‐grade prototype ASICs for the monitoring of human vital signs. In this case one or more sensors placed on an ASIC provides a signal to be transmitted a distance of 2‐3 meters to a receiver/display unit. The use of ASIC telesensors provides the possibility of wireless monitoring, including long‐term monitoring, with inexpensive and unencumbering devices. Their self‐contained nature permits a number of potential uses in future biomedical applications as new sensors are devised which are amenable to deployment on silicon.
Image Display Technology and Image Processing
Authors: Hanna George , Cuschieri Alfred
Published: October 2003

Significant developments in video imaging have taken place but further progress is needed to provide images with the right characteristics for optimal interpretation by the operator.
The nature and location of the image display in relation to the surgeon and operating field are also important in facilitating image‐guided surgery/interventions, and several new technologies are being explored.
In the diagnostic field, virtual reality surface anatomical and internal luminal rendering has opened a new chapter in diagnosis,
screening, and treatment planning, the potential of which is only just being realized.
Telementoring and Teleproctoring
Authors: Rosser James C. , Gabriel Nick , Herman Bjorn , Murayama Michinori
Published: October 2003

Telemedicine has previously been defined as "live two‐way interactive video communication between a physician and a patient and/or another physician, where all participants are able to see and hear one another much like a face to face encounter." This concept has gained recent notoriety because of the great advances in telecommunications and the potential future increased cost‐effectiveness associated with its utilization. We have developed a telementoring deployment protocol that can be effectively used to introduce a student to telementoring processes. The strict protocol uses military commands to facilitate smooth information transfer. The use of a concept called tactical information deployment provides the surgeon with rapid access to reference information in the operating suite. Multimedia interactive CD‐ROMs, with digitized movie clips,
illustrations, sound bits, and the latest academic review of the literature arm the surgeon with a database that establishes an unprecedented clinical adaptive capability (CAC). The availability of this information is invaluable to surgeons in their initial advanced laparoscopic procedural efforts. Telementoring simulator opportunities are included to acclimate the participant to the process. If the process seems comprehensive, it is meant to be. This is a high‐risk situation, and a patient's welfare is on the line. If this concept is to reach its maximal healthcare delivery potential, responsible and academically credible training programs should be established with directional guidelines.
Tissue Engineering and Its Potential Impact on Surgery
Authors: Lalan Sonal , Pomerantseva Irina , Vacanti Joseph P.
Published: October 2003

The loss or failure of an organ or tissue is one of the most frequent, devastating, and costly problems in healthcare. Current treatment modalities include transplantation of organs, surgical reconstruction, use of mechanical devices, or supplementation of metabolic products. A new field, tissue engineering,
applies the principles and methods of engineering, material science,
and cell and molecular biology toward the development of viable substitutes which restore, maintain, or improve the function of human tissues. In this review, we outline the opportunities and challenges of this emerging interdisciplinary field and its attempts to provide solutions to tissue creation and repair. Within this context, we present our experience using the basic tools of tissue engineering to guide regeneration of diverse tissues that include the liver, small intestine, cardiovascular structures, nerve, and cartilage. And in addition, we discuss the necessity of finding new strategies to achieve vascularization of complex tissues for transplant and present our approaches utilizing MicroElectroMechanical Systems (MEMS) technology and three‐dimensional printing.
Importance of Delayed Imaging for Blunt Renal Trauma
Authors: Blankenship John C. , Gavant Morris L. , Cox Clair E. , Chauhan Ravi D. , Gingrich Jeffrey R.
Published: October 2003

The advent of noninvasive computed tomography of the abdomen and pelvis for evaluation of blunt renal trauma has led to the practice of expectant management for hemodynamically stable patients. Although expectant management of higher grade injuries (American Association for the Surgery of Trauma Renal Injury Scale) would intuitively result in an increased frequency of urologic complications, this has not been previously examined in a large series of patients utilizing contemporary radiologic imaging techniques. A retrospective review of patients from a single institution within a recent 4‐year period revealed 4 grade I, 13 grade II, 21 grade III, 7 grade IV, and 4 grade V injuries. None of grade I, 15% of grade II, 38% of grade III, 43% of grade IV, and 100% of grade V injuries had one or more (15 major and 11 minor) urologic complications. The incidence of urinary complications correlated significantly with increasing grade (0%, 15%, 38%, 43%, and 100% for grades I to V, respectively; r = 0.94, p = 0.0158). Of the delayed urologic complications, 50% were diagnosed on follow‐up imaging studies and 33% of them required intervention. Therefore we advocate repeat imaging 2 to 4 days after trauma resulting in grade III to V blunt renal lacerations to identify delayed complications that may require intervention.
Management of Penile Amputation Injuries
Authors: Jezior James R. , Brady Jeffrey D. , Schlossberg Steven M.
Published: October 2003

Penile amputation is an uncommon injury resulting from self‐mutilation, felonious assault, or accidental trauma. Management requires resuscitation and stabilization of the patient with particular attention to underlying psychiatric illness.
Amputated tissue can be preserved under hypothermic conditions in preparation for surgical replantation. Current replantation techniques rely on microsurgical approximation of the dorsal structures and cavernosal arteries with uniformly good results. Phallic replacement may be necessary when the amputated segment is lost. Microsurgical free forearm flap phalloplasty is the current mainstay of penile replacement surgery. Although urethral complications remain problematic, the results continue to be acceptable with regard to appearance and function. A unique subset of patients sustaining amputation injury is children. Both replantation and phallic construction have been successful in children and represent an alternative to gender reassignment.
Changes in Bacterial Concentration in the Liver Correlate with That in the Hepaticojejunostomy after Bile Duct Reconstruction: Implication in the Pathogenesis of Postoperative Cholangitis
Authors: Chuang Jiin‐Haur , Lee Shin‐Yi , Chen Wei‐Jen , Hsieh Chie‐Song , Chang Nyuk‐Kong , Lo Sing‐Kai
Published: October 2003

Postoperative cholangitis is a frequent and unpredictable complication of unknown etiology following bile duct reconstruction (BDR), particularly for biliary atresia. This study was undertaken to correlate the growth of bacteria in the hepaticojejunostomy with that in the liver after BDR. Quantitative bacterial culture was done on the specimens taken from the liver and from the hepaticojejunostomy at 1 week (group 1, n = 7), 1 month
(group 2, n = 7), and 2 months (group 3, n = 7) following BDR with Roux‐en‐Y hepaticojejunostomy in piglets after 2 weeks of common bile duct ligation. The histological examination of the liver and the hepaticojejunostomy, as well as serial monitoring of hemogram and liver function tests, were performed to correlate the findings with the bacterial concentration of the liver and the hepaticojejunostomy following BDR. The bacterial concentration of the hepaticojejunostomy,
expressed as log10 colony‐forming units per gram
(log10 CFU/g) of the hepaticojejunostomy, showed a progressive decrease from 8.38 ± 1.36 in group 1, 7.07 ±
2.54 in group 2, to 3.56 ± 1.31 in group 3 (p =
0.001). The log10 CFU/g of the liver also showed a progressive decrease from 5.02 ± 1.59 in group 1, 3.16 ±
1.56 in group 2, to 2.19 ± 1.09 in group 3 (p =
0.006). There was a significant positive correlation of the log10 CFU/g of the liver (n = 21) with that of the hepaticojejunostomy (n = 21) following BDR (r = 0.600,
p = 0.004). Most of the infectious pathogens isolated from the liver were also isolated from the hepaticojejunostomy. The changes in hemoglobin, bilirubin, albumin, and ammonia significantly correlated with the changes of the bacterial concentration of the liver. The results of the study suggests that hepatic bacterial proliferation after BDR is significantly affected by microbial overgrowth in the bilioenteric anastomosis and is associated with deteriorated liver function and hemogram.
Total Pelvic Exenteration for Primary Local Advanced Colorectal Cancer
Authors: Chen Han‐Shiang , Sheen‐Chen Shyr‐Ming
Published: October 2003

Total pelvic exenteration (TPE) is an ultraradical operative procedure for locally advanced pelvic tumors with high morbidity and mortality rates. We retrospectively reviewed the results of TPE for primary locally advanced colorectal cancer in terms of mortality, morbidity, and long‐term survival. Of 2952 patients with colorectal cancer, 50 underwent TPE for primary locally advanced colorectal cancer between 1986 and 1995. There was one operative death
(2%). The other 49 cases were entered into a retrospective study.
Thirty‐two cases (65%) showed involvement of one or more adjacent organs. Thirty‐one patients (97%) had urologic organs invaded by tumor. The overall 5‐year survival rate was 49% and the overall morbidity was 37%. The survival rate for stage II was 62%, and that for stage III was 35%; there was no survival in stage IV. Early morbidity was noted in 24% of patients; late morbidity, in 15%. TNM stage appeared to be the only independent factor for survival
(p = 0.022). Our study showed that TPE can be performed with relatively low operative mortality and acceptable morbidity. With thorough preoperative evaluation and adequate surgical dissection, satisfactory outcomes for a primary locally advanced colorectal cancer can be achieved, especially at the earlier stages.
Arrow Wounds: Major Stimulus in the History of Surgery
Authors: Karger Bernd , Sudhues Hubert , Brinkmann Bernd
Published: October 2003

To illustrate how the high incidence of arrow wounds provided a major stimulus for the development of surgery until a century ago, we conducted a literature search. Our research shows that archaic peoples developed considerable surgical skill for extraction of arrows, including thoracotomy and trephination. A classical Hindu veda describes a variety of extraction methods, and Homer's Iliad introduces the term iatros,
which means "he who extracts arrows." Hippocrates of Kos and Galen,
representatives of the humoral doctrine, both shunned surgical intervention and considered purulence a drainage of materia peccans (spoiled humors). Cornelius Celsus was the first to systematically differentiate removal of arrows per extractionem and per expulsionem. Celsus recommended the spoon of Diocles, an ancient surgical instrument specially designed for extraction of arrows. Paulus of Aegina favored rapid extraction,
aggressive therapy, and ligature on both sides of a vessel before extraction efforts. Paulus was the first to describe a special instrument for the removal of detached arrowheads per expulsionem
(propulsorium). In medieval Europe, the standard of surgery declined drastically. The classical procedure under the dominant influence of the humoral concept was to await pus before extraction and to burn the wound with boiling oil and a branding iron. Arab authors had conserved the knowledge of Celsus and Paulus, and in Europe a renewal was achieved by Ambroise Paré, who has been called the creator of modern surgery. The incidence of arrow wounds increased once more in the American West. Joseph H. Bill, a famous U.S. Army Surgeon preoccupied with arrow wounds, favored rapid extraction and aggressive therapy, and he taught recruits not to apply traction on the shaft. The principles established by Celsus, Paulus, Paré, and Bill not only mark important landmarks in the evolution of surgery but can also serve as the basis for modern treatment of arrow wounds, which still occur,
although on a small scale.
Incidence of Umbilical Hernia in African Children: Redefinition of “Normal” and Reevaluation of Indications for Repair
Authors: Meier Donald E. , OlaOlorun David A. , Omodele Rachael A. , Nkor Sunday K. , Tarpley John L.
Published: October 2003

This study was undertaken to assess the degree of ubiquity of umbilical hernias (UHs) in Nigerians and to determine if a laissez faire approach to the presence of UHs is justified. A prospective evaluation was conducted of the umbilical area of 4052 Nigerians living in the vicinity of the Baptist Medical Centre (BMCO) in Ogbomoso, Nigeria. The diameter of the fascial defect was measured with the subject supine and the protrusion of the umbilical skin with the subject erect. Subjects were divided into three groups: group 1 (1 month to 18 years old); group 2 (older than 18 years); and group 3 (pregnant women in an antenatal clinic). “Outies” (defined as any protrusion of the umbilical tip past the periumbilical skin) were present in 92% of group 1, 49% of group 2, and 90% of group 3 subjects. UHs (defined as protrusion of at least 5 mm and diameter of at least 10 mm) were present in 23% of group 1, 8% of group 2, and 15% of group 3 subjects. Spontaneous closure of UHs seems to occur until age 14. A retrospective analysis identified 11 patients undergoing emergency operations for UH‐related problems during the past 15 years. With a low incidence and 0% mortality rate associated with management of these emergencies, a policy of prophylactic repair is not justified at BMCO. Because most of the children we examined had outies, repair for cosmetic reasons is rarely requested. The only logical indication for repair of UHs at BMCO is incarceration, and this rarely occurs.
Esophageal Shortening during the Era of Laparoscopic Surgery
Authors: Awad Ziad T. , Mittal Sumeet K. , Roth Terese A. , Anderson Peter I. , Wilfley William A. , Filipi Charles J.
Published: October 2003

An effective method for determining the presence of a short esophagus preoperatively would be helpful to surgeons. In this study 260 patients underwent primary laparoscopic antireflux surgery; 44 of them were suspected to have esophageal shortening on the basis of: (1) Barrett's esophagus or evidence of peptic stricture formation on endoscopy; (2) an irreducible hiatal hernia ≥ 5 cm in length on upright barium esophagram; or (3) a short esophagus on manometric analysis, defined as 2 SD below normal for height. Six patients without preoperative criteria required extensive esophageal mobilization and intraoperative endoscopic/laparoscopic assessment. Preoperative results were then compared with intraoperative esophageal length assessments. Altogether, 13 patients (5% of the whole series) underwent a lengthening procedure: left thoracoscopically assisted laparoscopic Collis gastroplasty (n= 11) or open transthoracic Collis gastroplasty (n= 2) plus antireflux repair (Nissen fundoplication in 9 and Toupet repair in 4). Among the preoperative tests, endoscopy had the highest sensitivity rate (61%); a combination of tests resulted in an increase in the specificity (63–100%) without a corresponding increase in sensitivity (28–42%). Preoperative testing is thus useful for predicting the need for an esophageal lengthening procedure. Endoscopy is the best screening test for the short esophagus. A well planned prospective trial to test the reliability of each test is needed.