Rate Of Unnecessary Laparotomies Research Articles

ThTP1.7 Staging laparoscopy in bilio-pancreatic malignancies compared to radiological staging: A comparative study

Abstract Introduction The study was to compare the accuracy of laparoscopy in staging and selecting patients diagnosed with malignant obstructive jaundice, to the traditional investigation. Methods A prospective study conducted in the period between September 2017 and December 2018.30 patients, having malignant jaundice, were divided into two groups for cancer staging to assess their resectability and operability. Staging of 15 patients in group A was limited to conventional diagnostic methods, while 15 patients were in group B, Where Laparoscopy was added. Results Results showed that the accuracy of routine investigations in staging was 73%, while that of laparoscopy was 93%. The number of cases under staged by imaging were 8 cases(these were 3 in Group A and 5 in group B) thus they were diagnosed as operable. On the other hand, just 1 case was misdiagnosed by the laparoscopy. Regarding the morbidity and mortality, there were variable complications among those who had unrequired laparotomies including one mortality case. On the other side, the incidence of complications were markedly decreased in group B, with no mortality incidence. Conclusion Diagnostic laparoscopy has a crucial role in staging people with malignant jaundice and may decrease the rate of unnecessary laparotomy in people found to have resectable disease by conventional imaging.

153 Staging Laparoscopy in Bilio-Pancreatic Malignancies Compared To Radiological Staging: A Comparative Study

Abstract Introduction The study was to compare the accuracy of laparoscopy in staging and selecting patients diagnosed with malignant obstructive jaundice, to the traditional investigation. Method a prospective study conducted in the period between September 2017 and December 2018.30 patients, having malignant jaundice, were divided into two groups for cancer staging to assess their resectability and operability. Staging of 15 patients in group A was limited to conventional diagnostic methods, while 15 patients were in group B,where Laparoscopy was added. Results Results showed that the accuracy of routine investigations in staging was 73%, while that of laparoscopy was 93%.The number of cases under staged by imagings were 8 cases(these were 3 in Group A and 5 in group B) thus they were diagnosed as operable. On the other hand, just 1 case was misdiagnosed by the laparoscopy. Regarding the morbidity and mortality, there were variable complications among those who had unrequired laparotomies including one mortality case.on the other side,the incidence of complications were markedly decreased in group B,with no mortality incidence. Conclusions Diagnostic laparoscopy has a crucial role in staging people with malignant jaundice and may decrease the rate of unnecessary laparotomy in people found to have resectable disease by conventional imagings.

A prospective study on the diagnostic pathway of patients with stage IIIC-IV ovarian cancer: Exploratory laparoscopy (EXL) + CT scan VS. CT scan

ObjectiveTo compare the diagnostic power of CT scan to a combination of exploratory laparoscopy (EXL) and CT scan in patients with stage IIIC-IV Ovarian Cancer (OC) by anatomic areas. To investigate if adding EXL to CT can reduce unnecessary laparotomy. MethodsIn the period 2009–2017, 350 consecutive patients with FIGO Stage IIIC-IV OC underwent CT and EXL prior to Visceral-Peritoneal debulking (VPD) and were included in the study. Radiologist and surgeons filled an ad-hoc form to report CT scan and EXL of eleven key anatomic areas. The decision to proceed to EXL was based on the CT scan and the decision to proceed to laparotomy (LPT) on CT and EXL. Setting LPT findings as the gold standard, positive and negative predictive value (PPV/NPV), sensitivity, specificity, and accuracy of CT, EXL and CT + EXL were calculated. We broke down the diagnostic outcomes by anatomic areas and determined the rate of unnecessary laparotomy avoided with the findings of EXL. ResultsMedian time for the EXL was 14 min (SD +/− 3). No complication related to EXL occurred. At EXL, 325 out of 350 patients (93%) proceeded to LPT and 25 patients (7.1%) did not because of exclusion criteria. In 307 patients out of 325 (94.4%) EXL was followed by VPD. Eighteen patients had exclusion criteria found at LPT and had no VPD. EXL reduced the rate of unnecessary/futile laparotomy from 12.2% to 5.1%. CT + EXL showed a significantly higher sensitivity for all anatomic areas except for the lymph nodes. Specificity was not significantly improved. PPV was significantly improved for small bowel, porta hepatis and stomach. NPV displayed a statistical improvement in all anatomic areas except lymph nodes, stomach, and liver. ConclusionThe combination CT + EXL has a higher diagnostic power than CT alone, particularly on diaphragm, small bowel serosa and mesentery. The rate of unnecessary laparotomy decreased by almost 60%.

Role of ultrasound in the diagnosis of acute appendicitis: A prospective study

Background and Aim: Although the clinical presentation of acute appendicitis is typical in 70% of the cases, about 30%of the patients have an uncertain pre-operative diagnosis. Consequently the rate of unnecessary laparotomy is as high as 20-25%. The aim of the study was, to evaluate the role of ultrasound in the diagnosis of acute appendicitis in clinically equivocal cases. Materials and Methods: 100 patients clinically suspected to be acute appendicitis were referred for ultrasound examination. Presence of appendicoliths, loculated collections, complex masses in the right iliac fossa were also considered in the diagnosis of acute appendicitis. The sonological findings were correlated with surgical findings. In patients, who had negative graded compression US examination, abdomen and pelvis were assessed with curvilinear transducer of 3.5-7.0MHz Results: Of the 100 patients who formed the study population, 76 patients had acute appendicitis. Ultrasound was sensitive in detecting acute appendicitis in 66 patients. 10 patients were falsely diagnosed as acute appendicitis on ultrasound. One patient was false positively diagnosed as having acute appendicitis. US could detect normal appendix in 8 cases. Ultrasound provided alternate diagnosis in 6 patients, thus influencing the management. The overall accuracy of ultrasound in the diagnosis of acute appendicitis was 86.36%. The sensitivity, specificity, predictive value of a positive test and predictive value of a negative test were 86.64%, 83.33%, 97.05% and 50% respectively. Conclusion: Ultrasound being non-invasive, non-traumatic, readily available modality is a result-oriented examination in clinically equivocal cases of acute appendicitis.

Routine MRI With DWI Sequences to Detect Liver Metastases in Patients With Potentially Resectable Pancreatic Ductal Carcinoma and Normal Liver CT: A Prospective Multicenter Study.

The purpose of this study was to evaluate the performance of systematic MRI with DWI for the detection of liver metastases (LM) in patients with potentially resectable pancreatic ductal carcinoma and normal liver findings at CT. Patients with potentially resectable pancreatic ductal carcinoma and a normal liver at CT were enrolled in a prospective multicenter study between March 2011 and July 2013 and underwent preoperative MRI. The reference standard was pathologic analysis of detected hepatic lesions. A total of 118 patients were enrolled. MRI depicted liver lesions that were not visible at CT in 16 patients. All lesions were visualized both with and without DWI. Lesions were LM in 12 (10.2%) patients and were confirmed in seven patients by preoperative biopsy, four by intraoperative frozen section, and one at 6-month follow-up evaluation after pancreatic resection. All but one liver metastatic lesion diagnosed with MRI were smaller than 10 mm. Four of 118 (3.4%) patients had a false-positive diagnosis of LM at MRI and remained LM free after a follow-up period of 24 months or longer. Three of 102 (2.9%) patients with normal MRI findings had subcapsular LM that were diagnosed intraoperatively. At follow-up, 99 of 118 (83.9%) patients were LM free after a mean of 24 months. The patient-based sensitivity of MRI for the detection of LM was 80.0% (95% CI, 51.9-95.7%); specificity, 96.1% (95% CI, 90.4-98.9%); positive predictive value, 75.0% (95% CI, 47.6-92.7%); and negative predictive value, 97.1% (95% CI, 91.6-99.4%). Compared with CT, preoperative MRI improves the detection of LM in patients with potentially resectable pancreatic ductal carcinoma and may change management and the rate of unnecessary laparotomy and pancreatectomy for 10% of patients.

Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer.

Surgical resection is the only potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Laparoscopy can detect metastases not visualised on CT scanning, enabling better assessment of the spread of cancer (staging of cancer). This is an update to a previous Cochrane Review published in 2013 evaluating the role of diagnostic laparoscopy in assessing the resectability with curative intent in people with pancreatic and periampullary cancer. To determine the diagnostic accuracy of diagnostic laparoscopy performed as an add-on test to CT scanning in the assessment of curative resectability in pancreatic and periampullary cancer. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, EMBASE via OvidSP (from inception to 15 May 2016), and Science Citation Index Expanded (from 1980 to 15 May 2016). We included diagnostic accuracy studies of diagnostic laparoscopy in people with potentially resectable pancreatic and periampullary cancer on CT scan, where confirmation of liver or peritoneal involvement was by histopathological examination of suspicious (liver or peritoneal) lesions obtained at diagnostic laparoscopy or laparotomy. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies. Two review authors independently performed data extraction and quality assessment using the QUADAS-2 tool. The specificity of diagnostic laparoscopy in all studies was 1 because there were no false positives since laparoscopy and the reference standard are one and the same if histological examination after diagnostic laparoscopy is positive. The sensitivities were therefore meta-analysed using a univariate random-effects logistic regression model. The probability of unresectability in people who had a negative laparoscopy (post-test probability for people with a negative test result) was calculated using the median probability of unresectability (pre-test probability) from the included studies, and the negative likelihood ratio derived from the model (specificity of 1 assumed). The difference between the pre-test and post-test probabilities gave the overall added value of diagnostic laparoscopy compared to the standard practice of CT scan staging alone. We included 16 studies with a total of 1146 participants in the meta-analysis. Only one study including 52 participants had a low risk of bias and low applicability concern in the patient selection domain. The median pre-test probability of unresectable disease after CT scanning across studies was 41.4% (that is 41 out of 100 participants who had resectable cancer after CT scan were found to have unresectable disease on laparotomy). The summary sensitivity of diagnostic laparoscopy was 64.4% (95% confidence interval (CI) 50.1% to 76.6%). Assuming a pre-test probability of 41.4%, the post-test probability of unresectable disease for participants with a negative test result was 0.20 (95% CI 0.15 to 0.27). This indicates that if a person is said to have resectable disease after diagnostic laparoscopy and CT scan, there is a 20% probability that their cancer will be unresectable compared to a 41% probability for those receiving CT alone.A subgroup analysis of people with pancreatic cancer gave a summary sensitivity of 67.9% (95% CI 41.1% to 86.5%). The post-test probability of unresectable disease after being considered resectable on both CT and diagnostic laparoscopy was 18% compared to 40.0% for those receiving CT alone. Diagnostic laparoscopy may decrease the rate of unnecessary laparotomy in people with pancreatic and periampullary cancer found to have resectable disease on CT scan. On average, using diagnostic laparoscopy with biopsy and histopathological confirmation of suspicious lesions prior to laparotomy would avoid 21 unnecessary laparotomies in 100 people in whom resection of cancer with curative intent is planned.

Assessment of Extent and Severity of Pellet Induced Abdominal Injuries, a Rare Variant of Weapon Violence: A Prospective Study

Background: The use of a Pellet gun, a form of short gun used for mob control in many conflict zones, has posed a serious challenge to the surgeons in assessing the extent of trauma caused by these pellets. Objectives: To study the role of conventional available investigations for trauma like ultrasonography and computed tomography scans in assessing the severity of the injuries caused by the pellets. Methodology: 50 patients having pellet injuries predominantly in abdomen without other associated trauma were included in the study. The decision for surgery was taken on the basis of clinical and CECT (Contrast Enhanced Computed Tomography) findings and these findings were then compared with intra-operative findings. Results: 30/50 patients were decided to be operated on the basis of Clinical and CECT findings. On exploration, it was observed that 18/33 patients really needed exploration while as 15/33 patients could have been managed conservatively. This was observed in next 20/50 patients who were put on conservative management with similar CECT findings. Of these 20 patients, 17 did well while as 3 were explored later in view of developing peritonitis and were found to have small bowel perforations. Conclusion: Conventional investigations for trauma like FAST and CECT abdomen are not ideal for assessing the severity of pellet induced abdominal visceral injuries which result in high rate of unnecessary laparotomies. Also the abdominal pellet trauma patients can be well managed conservatively until hemodynamically stable even though CT scan shows pellet penetration into peritoneal cavity or bowel lumen.

Assessment of the management and outcomes of penetrating abdominal shotgun injuries

Background: Lately in Egypt, the incidence of abdominal shotgun injuries has greatly increased especially after the 25 th of January 2012 revolution. There is a controversy that exists over whether patients with penetrating abdominal shotgun wounds should have selective or mandatory exploration. This work aims to put a clear management plan for patients with penetrating abdominal shotgun injuries and to determine the role and indications of exploratory laparotomy to avoid unnecessary explorations and their complications. Methods: The study was conducted on 40 patients presented to Kasralainy medical school with penetrating abdominal shotgun injuries, who were randomly allocated into two groups, Group (1): the patients were treated conservatively for 72 hours and Group 2: the patients were explored. Results: In group (2), it was found that most of the patients (13 out of 18 which is 72.2%) had negative or non-significant injuries and only 5 out of 18 patients (27.8%) showed significant injuries which demanded repair. So, they were explored with no benefit but on the contrary they had the chance of developing complications of abdominal explorations and this truely occurred because the complications in group 2 were significantly higher than group (1) regarding postoperative wound infection and paralytic ileus. Also, incisional hernia and burst abdomen occurred in group 2. While in group (1), only 3 patients (13.6%) out of 22 had deteriorated during the follow up. which is a low percent especially that these patients could be detected early and managed. Conclusions: Conservative management for patients with intra-abdominal pellets who are vitally stable with no massive hemoperitonium or pneumoperitoniumon is feasible and safe with the ability of identification and management of patients who will require surgery by close follow up without increase in the major morbidities or mortalities. This strategy significantly reduces the rate of unnecessary laparotomies and related complications. Although the main drawback is the small number of the study group.

Conservative Management of Anterior Abdominal Penetrating Trauma

Background Selective conservative management of abdominal penetrating trauma can significantly minimize the morbidity and length of hospitalization by decreasing the rate of unnecessary laparotomies. Objectives In the present study, we reported the outcome of newest guidelines of our trauma center in one year. Patients and Methods All patients with anterior abdominal stab wounds who were referred to Rajaiee trauma center between September 2012 and September 2013 were enrolled. Patients without shock, peritonitis, and evisceration who did not require emergency operation were planned for nonoperative management with serial physical examinations, blood cells count, and radiographic investigations. Outcome of nonoperative management was described in order to reveal the advantages and disadvantages of our current guideline. Results Among 45 patients who underwent nonoperative management, 27 cases (60%) required laparotomy due to peritonitis or shock. Rate of unnecessary nontherapeutic operations was 49.2%. Conclusions Minimizing diagnostic procedures such as diagnostic peritoneal lavage and computed tomography can significantly increase the rate of unnecessary operations leading to longer hospitalizations and operation-related morbidity. To reduce the failure rate of nonoperative management and nontherapeutic surgeries, modifications in current guidelines should be made.

To Scan or Not to Scan, That is the Question

Background Selective conservative management of abdominal penetrating trauma can significantly minimize the morbidity and length of hospitalization by decreasing the rate of unnecessary laparotomies. Objectives In the present study, we reported the outcome of newest guidelines of our trauma center in one year. Patients and Methods All patients with anterior abdominal stab wounds who were referred to Rajaiee trauma center between September 2012 and September 2013 were enrolled. Patients without shock, peritonitis, and evisceration who did not require emergency operation were planned for nonoperative management with serial physical examinations, blood cells count, and radiographic investigations. Outcome of nonoperative management was described in order to reveal the advantages and disadvantages of our current guideline. Results Among 45 patients who underwent nonoperative management, 27 cases (60%) required laparotomy due to peritonitis or shock. Rate of unnecessary nontherapeutic operations was 49.2%. Conclusions Minimizing diagnostic procedures such as diagnostic peritoneal lavage and computed tomography can significantly increase the rate of unnecessary operations leading to longer hospitalizations and operation-related morbidity. To reduce the failure rate of nonoperative management and nontherapeutic surgeries, modifications in current guidelines should be made.

Clinical Features and Comprehensive Diagnosis of Autoimmune Pancreatitis in China

Aim: To search for the key factors of autoimmune pancreatitis (AIP) in China and to improve the early identification of AIP in order to avoid misdiagnosing it as pancreatic carcinoma. Methods: Clinical, imaging, laboratory, and pathological data about AIP were collected and analyzed from 1996 to 2011 in The Chinese People's Liberation Army General Hospital. Results: A total of 33 patients (male 29, female 4) aged 35-76 years (52.3 ± 9.3 years) meeting the International Consensus Diagnostic Criteria for type 1 (n = 32) or type 2 (n = 1) AIP were included. With improved understanding of AIP, the misdiagnosis rate and unnecessary laparotomy rate was decreased from 95.7% (22/23) and 91.3% (21/23) before 2006, to 20.0% (2/10) (p = 0.001) and 0.0% (p = 0.001) respectively after 2006. The major symptoms were jaundice in (24/33, 72.7%) and abdominal pain (12/33, 36.4%). Half of the patients had other accompanied autoimmune disorders. Laboratory tests showed an elevated level of serum IgG in 9 out of 11 patients (81.8%) and an increased eosinophil count in 16 out of 33 patients (48.5%). The serum IgG4 levels were twice the upper limit of the normal value. CT scan showed a low-contrast margin characterized by a capsule-like rim in 24 of 32 patients (75.0%). Pathologic examinations showed fibrosis and infiltration of massive lymphocytes and plasma cells in the pancreas. Prednisone was given to the patients and proved to be quite effective for all of them (12/12, 100%). Conclusion: Type 1 AIP shows a sex predilection compared with type 2 AIP in China. In order to diagnose AIP exactly, a comprehensive strategy, especially including imaging and pathological examination, should be used. With growing awareness, fewer AIP patients with this diagnosis would be misdiagnosed and incorrectly treated.

Challenges of managing paediatric abdominal trauma in a Nigerian setting.

The management of abdominal trauma (particularly blunt trauma) has undergone tremendous revolution in the last 30 years with significant reduction in morbidity and mortality in developed countries. The aim of this report is to highlight the challenges of managing abdominal trauma in children in Nigeria based on our experience in Zaria, northern Nigeria. This is a retrospective review of 82 children managed for abdominal trauma from 1991 2002 at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Information regarding demographics, mechanism of injury, haemodynamic status at presentation, clinical and radiologic evaluation, management, intraoperative findings and outcome, were extracted from case notes, operation notes and discharge summary notes. Fifty seven (69.5%) children had blunt trauma, mostly from traffic accidents (32, 57%) and falls (20, 36%), and 25 (30.5%) penetrating trauma mainly from falls onto sharp objects (7 of 18 patients) and animal-related injuries (5 of 18 patients). In the management of those with blunt trauma, advanced imaging modalities were usually not available and this resulted in an unnecessary laparotomy rate of 51% (laparotomy considered unnecessary because the patients remained haemodynamically stable after resuscitation and any intraperitoneal bleeding had stopped by the time oflaparotomy and no active operative measure was required to control bleeding). The management of penetrating trauma was more straightforward as this was guided by evidence of peritoneal penetration. Mortality from blunt trauma was 14.5% (8 of 55 patients) from exsanguinations before surgery 2, gastric perforation 3, hepatic laceration 2 and splenic injury one. Mortality from penetrating trauma was 12% (3 of 25 patients) from tetanus, overwhelming infection and haemorrhage respectively. The overall mortality from abdominal injury was 13.8% (11 of 80 patients) and were mostly avoidable if the patients presented early, and received some resuscitation before arrival at our hospital. The management of blunt abdominal trauma in children in Nigeria is faced with several challenges, which are mainly absence of an organised trauma system and lack of appropriate facilities. These need to be addressed in order to improve the care of these injuries.

Nonoperative management of penetrating abdominal trauma

Penetrating abdominal trauma is prevalent in most urban settings in the United States; for instance, 25% of trauma cases in Los Angeles are penetrating. Selective nonoperative management is practiced routinely for blunt abdominal trauma, but in most institutions laparotomy is still considered the standard of care for abdominal gunshot wounds. The traditional treatment of these injuries has been exploratory laparotomy for all gunshot wounds to the abdomen and for all stab wounds where peritoneal violation has been proven. Nonoperative versus surgical management The implementation of selective nonoperative management of penetrating abdominal trauma can decrease the rate of unnecessary laparotomy and thus avoid the complications associated with nontherapeutic surgery. In addition, it significantly shortens hospital length of stay, resulting in cost savings. 1 One reason cited for aggressive surgical management has been the high incidence of intra-abdominal injuries in cases of penetrating trauma, previously reported to be as high as 98%. 2 However, the studies reporting this number do not distinguish between therapeutic and nontherapeutic laparotomies, making it difficult to accurately assess which cases could have been managed without surgery. 2,3 In addition, other studies have found the incidence to be only about 70% to 80%, leaving 20% to 30% of cases that can be managed nonoperatively. 4-7 Clinicians have been hesitant to move to nonoperative management because many consider negative exploratory laparotomy to be a harmless procedure. However, it is not without complications. Any surgery involves exposure to anesthesia, whose risks include idiosyncratic reactions and aspiration; other risks of surgery are bleeding, infection, iatrogenic injuries, and

Laparoscopy in developing countries in the management of patients with an acute abdomen.

Surgeons in developing countries see a need to improve diagnosis and decision making in patients with an acute abdomen. Without the benefit of diagnostic aids such as computers and high-resolution ultrasonography, the rate of unnecessary laparotomy is often unacceptably high. The laparoscope is usually available in a developing country and its use easily acquired. Using laparoscopy in doubtful situations the unnecessary laparotomy rate was significantly reduced from 14.0 to 6 per cent (P < 0.05). Laparoscopy achieved a diagnostic accuracy of 86 per cent and prevented unnecessary laparotomy in 57 per cent of those in whom it was used.

Abdominal trauma

Blunt abdominal trauma is much more frequent than penetrating abdominal trauma in Europe. As a consequence of improved quality of computed tomography, even complex liver injuries are increasingly being treated conservatively. However, missed hollow viscus injuries still remain a problem, as they considerably increase mortality in multiply injured patients. Laparoscopy decreases the rate of unnecessary laparotomies in perforating abdominal trauma and helps to diagnose injuries of solid organs and the diaphragm. However, the sensitivity in detecting hollow viscus injuries is low and the role of laparoscopy in blunt abdominal injury has not been defined. If intra-abdominal bleeding is difficult to control in hemodynamically unstable patients, damage control surgery with packing of the liver, total splenectomy, and provisional closure of hollow viscus injuries is of importance. Definitive surgical treatment follows hemodynamic stabilization and restoration of hemostasis. Injuries of the duodenum and pancreas after blunt abdominal trauma are often associated with other intra-abdominal injuries and the treatment depends on their location and severity.

Early laparoscopy as a routine procedure in the management of acute abdominal pain: a review of 1,320 patients

Acute abdominal pain is a common cause for presentation to the emergency room and hospital admission. Many of these patients will undergo exploration for suspected appendicitis, but in 20-35% of cases a normal appendix is found. Because of the limited access provided by the gridiron incision, a definitive diagnosis may not be found. Other patients may be treated conservatively and discharged, only to return with recurrent pain or more definitive symptoms of pathology. In patients with acute abdominal pain, early laparoscopy is an accurate means of both making a definitive diagnosis and avoiding a delay in the diagnosis. We performed a retrospective analysis of 1,320 consecutive patients with acute abdominal pain over a 62-month period. All patients underwent diagnostic laparoscopy within 48 h of admission. We evaluated the initial clinical diagnosis, the laparoscopic diagnosis, and the subsequent outcome in this group of patients. Individuals with abdominal trauma were excluded from the study, and all patients were >12 years of age. A definitive diagnosis was made in 90% of patients after diagnostic laparoscopy. Laparoscopy changed the clinical diagnosis in 30% of cases. (83%) of patients underwent a laparoscopic operation for management of their condition at the time of diagnosis. In 92 patients (7%), conversion to laparotomy was required to manage their condition. Peritonitis was present in 180 patients; of 110 of them had appendicitis. Twelve patients developed complications related to the diagnostic laparoscopy or the laparoscopic operation, and there was one postoperative death due to a perforated gastric malignancy. Mean operating time was 30 min (range, 17-90). Early diagnostic laparoscopy and treatment results in the accurate, prompt, and efficient management of acute abdominal pain. This technique reduces the rate of unnecessary laparotomy and right iliac fossa gridiron incisions and increases the diagnostic accuracy in these patients. This treatment method is feasible where facilities are available to accommodate the workload and there are practitioners with the requisite expertise.

Modern management of pancreatic carcinoma.

Pancreatic cancer remains a fearsome disease. New insights into the molecular pathogenesis may influence choice of treatment modalities and provide avenues for novel therapeutic strategies for testing in the clinic. The survival rate of patients with all stages of disease is poor and clinical trials are appropriate alternatives for treatment and should be considered. Surgical resection, when possible, remains the primary treatment modality and can result in long-term cure. Less invasive techniques such as laparoscopy may reduce the rate of unnecessary laparotomies. The role of adjuvant therapy is re-emerging. Patients with unresectable and metastatic disease are incurable and optimal palliation is the goal. These patients may benefit from palliative bypass of biliary or duodenal obstruction if symptomatic. Pain associated with local tumour infiltration may be palliated with radiation, with or without chemotherapy, or with coeliac nerve blocks or local neurosurgical procedures. Chemotherapy with gemcitabine has modest objective response rates but has been shown to improve symptoms.

Selective use of diagnostic laparoscopy prior to planned hepatectomy for patients with hepatocellular carcinoma

Background Patients with hepatocellular carcinoma (HCC) are frequently found to be inoperable at surgical exploration. Laparoscopy may reduce the rate of unnecessary laparotomy in these patients. However, there are no criteria for selective use of laparoscopy. Methods Sixty patients with potentially operable HCC underwent laparoscopy prior to planned partial hepatectomy. Intraoperative findings and postoperative course were analyzed, and factors for the selective use of laparoscopy were identified. Results Fourteen of 19 inoperable patients (74%) were identified by means of laparoscopy, which increased the resectability rate from 68% to 89%. Compared with patients undergoing exploratory laparotomy only, patients determined to be inoperable on laparoscopy had significantly less intraoperative blood loss, a shorter operating room time, and a briefer hospital stay. In a multivariate analysis, clinically apparent liver cirrhosis and radiologic evidence of major vascular invasion or bilobar tumors predicted the likelihood of finding inoperable disease at laparoscopy. The initial use of laparoscopy avoided unnecessary laparotomy in almost 30% of patients with—but only 5% of patients without—these features. Conclusions If high-risk patients with HCC are selectively targeted, the yield of laparoscopy is increased and unnecessary laparotomy may be avoided. In patients without cirrhosis, major vascular invasion, or bilobar tumors, the yield of laparoscopy is low and is therefore not generally recommended.

Emergency laparoscopy for abdominal stab wounds.

Management strategies for abdominal stab wounds (ASW) in initially asymptomatic patients range from mandatory explorative laparotomy (EL) to conservative approaches with observation alone. Emergency diagnostic laparoscopy (DL) may play a potential role between these two extremes-hence lowering the rate of unnecessary laparotomies and keeping the rate of missed injuries to a minimum. At our institution mandatory EL was carried out in every patient with ASW until 1992. In a retrospective study the charts of 43 patients with ASW were reviewed in terms of initial diagnostic procedures, intraabdominal injuries, and course and length of hospital stay. Between 5/1993 and 4/1995 DL was performed in a prospective study in 15 patients with suspected peritoneal penetration (PP) after ASW according to a standardized diagnostic and therapeutic algorithm. In 17 patients (40%) EL showed no PP; 15 (35%) had significant intraabdominal injuries, while 11 patients with PP didn't have lacerations of intraabdominal organs, resulting in an overall rate of nontherapeutic laparotomy of 65%. Mortality was 6% (n = 3), average hospital stay 8 days. Primary DL could exclude PP in 10 out of 15 patients (66%). The remaining five patients (33%) showed PP: In two patients with ASW to the right upper quadrant, intraabdominal injuries could be excluded by DL, and in one patient a low-grade liver injury was treated laparoscopically, thus avoiding laparotomy in a total of 87% (n = 13). In two patients with PP laparoscopy was converted to laparotomy: no pathological finding in one case, splenectomy for spleen laceration in the second patient, resulting in a rate of nontherapeutic laparotomies of 7%. All patients in this series had an uneventful course; average hospital stay was 2.4 days. DL offers an important diagnostic tool in excluding peritoneal penetration in ASW, hence lowering the rate of unnecessary laparotomies. Given experience and skills, laparoscopy may be used therapeutically in selected cases of ASW.

Value of helical computed tomography, angiography, and endoscopic ultrasound in determining resectability of periampullary carcinoma

Background High-quality preoperative radiographic evaluation is crucial in selecting patients with periampullary carcinomas who are candidates for surgical exploration and tumor resection while minimizing the rate of unnecessary laparotomy. Methods Twenty-one consecutive patients were prospectively investigated using helical computed tomography (CT) scanning, endoscopic ultrasonography (EUS), and selective visceral angiography (SVA) to determine tumor resectability. All patients were explored and resectability determined. Results Helical CT had a sensitivity of 63%, a specificity of 100%, and an overall accuracy of 86%. EUS had a sensitivity of 75%, a specificity of 77%, and an overall accuracy of 76%. SVA had a sensitivity of 38%, a specificity of 92%, and an overall accuracy of 71%. Conclusions Helical CT scanning is the best preoperative imaging test to determine tumor resectability. EUS is more sensitive than CT for tumor detection, but underestimates resectability. SVA is no longer helpful in the preoperative evaluation of these malignancies.