Early conversion for gangrenous cholecystitis: impact on outcome.

BACKGROUND: Early conversion from laparoscopic to open cholecystectomy for patients with gangrenous cholecystitis has been advocated. This study investigated the impact of early conversion on patient outcome. METHODS: Data from all patients with gangrenous cholecystitis undergoing laparoscopic cholecystectomy between 1992 and 2002 whose procedure had been converted to open surgery were prospectively collected and analyzed. Morbidity, length of stay, intensive care unit admission, and operative time served as outcome measures. RESULTS: Of the 97 patients in the study, 33 underwent conversion to open cholecystectomy. The conversion was early for 24% of the patients, after the initial dissection, for 33% and after an extended attempt at completion of the laparoscopic cholecystectomy for 37%. There was no difference in the overall morbidity among the groups, whereas the length of hospital stay appeared to be longer in the early conversion group. The operative time was significantly shorter after early conversion (p < 0.01, chi-square test). CONCLUSION: Laparoscopic cholecystectomy is not feasible for all patients with gangrenous cholecystitis. However, a concerted effort to perform the cholecystectomy with the minimally invasive approach does not have an adverse impact on patient outcome and is likely to benefit patients although it poses a moderate risk of conversion.

Open Rives-Stoppa ventral hernia repair made simple and successful but not for everyone.

BACKGROUND: The Rives-Stoppa (RS) repair of ventral incisional hernias (VIHR) is technically difficult. It involves the retromuscular placement of mesh anterior to the posterior fascia and the primary closure of the anterior fascia. Recurrence rates are 0-8%. We proposed that the operation could be done with equal success by placing the mesh in an intraperitoneal position and primarily closing the fascia anterior to the mesh. METHODS: 81 patients who had undergone an open RS-VIHR with intraperitoneal mesh were evaluated for hernia recurrence and factors associated with recurrence. RESULTS: 55 women and 26 men (mean BMI 38+/-9) underwent RS-VIHR (mean age 49+/-11 years). Of these patients, 44 (54%) had a prior VIHR, 30 (37%) had an incarcerated hernia and 34 (42%) had multiple fascial defects. PTFE was used in 83% and Prolene in 12%. Average LOS was 5.8+/-12 days. All received perioperative intravenous antibiotics and 28% were discharged on oral antibiotics. Follow-up averaged 30+/-24 months. Recurrent VIH developed in 12/81 (15%), with three occurring after removal of infected mesh and one after a laparotomy. Excluding these four, the recurrence rate was 10%. There was no correlation between hernia recurrence and age, BMI, hernia size, number of prior repairs, or LOS (t-test p>0.05). Hernia recurrence did not correlate with gender, prior peritoneal contamination, incarceration, multiple defects, adhesions, mesh type, oral antibiotics, cardiac disease, diabetes, tobacco use, or seroma (X(2) p>0.05). Those with a wound infection and/or abscess formation had a significantly higher recurrent hernia rate (60% vs. 8%, X(2) p<0.001). Patients with pulmonary disease had a significantly higher recurrence rate (50% vs. 12%, X(2) p=0.01). CONCLUSIONS: RS-VIHR with intraperitoneal mesh is a successful and less technically challenging method of repair than prior modifications. Aggressive efforts to identify infection and treat early may prevent abscess formation and subsequent recurrent hernia. Patients with chronic pulmonary disease have an unacceptably high recurrence rate and should not be considered as candidates for elective RS-VIHR.

Traumatic injury to the proximal superior mesenteric vessels.

Twenty-one patients were treated for 25 injuries to the proximal superior mesenteric vessels (eight, superior mesenteric artery; nine, superior mesenteric vein; four, superior mesenteric artery plus superior mesenteric vein). Mechanisms of injury were stab wounds (11 cases), motor vehicle accidents (9 cases), and iatrogenic (one case). Ten patients (48%) arrived at the emergency room in shock (two with no obtainable case blood pressure). Superior mesenteric artery repair was performed by lateral suture (seven cases), end-to-end anastomosis (three cases), autogenous vein graft (one case), and no repair (one case). All 13 venous injuries were repaired by lateral suture. Four patients (19%) died in the operating room secondary to acute blood loss and irreversible shock. There were no late deaths and no second-look operations. Further improvement in survival depends on rapid transportation from injury site to operating room.

The physiology of postvagotomy duodenal ulcer healing: a prostaglandin connection.

This study evaluated the type and mode of action exerted by truncal vagotomy on mucosal prostaglandin content in the rat. Ninety-six rats were equally divided into sham-operated, vagotomy, atropine-treated, and cimetidine-treated groups. Each group was subdivided into stressed (cold-restraint) and nonstressed cells. Gastric mucosal injury was graded, and duodenal mucosa was processed for determination of prostaglandin content. Results included: (1) significant increases in duodenal mucosal prostaglandins in all experimental groups compared with sham-operated controls, (2) decreases in duodenal mucosal prostaglandin content associated with stress in all groups, and (3) significantly less gastric mucosal injury in all stressed, experimentally treated rats compared with sham-operated animals. These results demonstrate that attenuation of gastric acid-secretion, achieved either surgically or pharmacologically and proved by decrease in stress gastric injury, is associated with an increase in the content of duodenal mucosal prostaglandins. Such augmentation of mucosal prostaglandins could account for, along with the direct acid-lowering effect of vagotomy, the success of truncal vagotomy in the surgical cure of duodenal ulcer disease.

The asymptomatic pancreatic islet cell tumor: a novel presentation.

Pancreatic islet cell tumors that secrete one or several polypeptide hormones have been suspected and diagnosed secondary to their systemic manifestations. This case report details the diagnosis and treatment of an 62-year-old man with a large pancreatic islet cell tumor without symptoms in whom the mass was found as a direct result of blunt trauma to the abdomen. The tumor contained high concentrations of both vasoactive intestinal polypeptide (VIP) and somatostatin. A discussion of VIP-containing tumors is included.

Adverse cardiodynamic effects of vasopressin not avoided by selective intra-arterial administration.

In this study, lysine-vasopressin, administered either as a continuous, intravenous infusion (1 unit/kh/hour) or as a selective infusion into the superior mesenteric artery (0.2 unit/minute), produced equal (25%), significant (p less than 0.05), and sustained (60 minute) reductions in portal pressure. Compared to intravenous administration, selective intra-arterial infusion of vasopressin resulted in similar reductions incardiac output (38%), myocardial contractility (23%), and coronary flow (53%). Since these adverse cardiodynamic effects were not avoided by selective intra-arterial infusion, it would appear that administration of vasopressin as a continuous infusion through a peripheral vein remains the most rapid and practical method of administering the drug.

Lack of sustained vagal control of gastric mucosal blood flow. Why vagotomy is not effective in preventing recurrent hemorrhage from stress ulcers.

Vagotomy with drainage or resection has been advocated for control of hemorrhage from stress-related gastric erosions despite the high rate of associated rebleeding. The object of this study was to evaluate the effect of truncal and selective vagotomy on gastric mucosal blood flow under both normotensive and ischemic conditions to ascertain why rebleeding occurs. Fifteen miniature swine were divided into three groups according to the surgical procedure they underwent: (1) pyloroplasty alone, (2) truncal vagotomy and pyloroplasty, and (3) selective vagotomy and pyloroplasty. Four weeks postoperatively the animals were studied in three phases--during a normotensive period, during 5 minutes of shock (50 mm Hg), and during 90 minutes of shock (50 mm Hg). Cardiac output and mean arterial pressure values as well as gastric mucosal blood flow (measured by 15 microspheres) were determined during each phase. The following values were similar in all three groups: shock-related decreases in cardiac output and mean arterial pressure (60% decrease), total gastric mucosal blood flow during normotension, and gastric mucosal blood flow decreases at 5 and 90 minutes of shock (60% decrease). Identical reductions in gastric mucosal blood flow occurred in the gastric fundus, corpus, and antrum as well. These results demonstrate that the elimination of gastric vagal tone does not alter either the normotensive gastric mucosal blood flow or the gastric mucosal vascular response to ischemia and suggest that there is no physiologic basis for the long-term protective effect of vagotomy in preventing either rebleeding or the gastric mucosal ischemia that may lead to stress ulcers. These factors may explain the high failure rate associated with this procedure.

Prostacyclin-mediated gastric cytoprotection is dependent on mucosal blood flow.

Although prostacyclin (PGI2) causes an increase in resting gastric mucosal blood flow, this effect is not thought to be correlated with its cytoprotective action. This study questions that hypothesis by assessing whether PGI2 cytoprotection occurs in the presence of decreased gastric mucosal blood flow. Twenty-four miniature swine were anesthetized with chloralose, ventilated, and catheterized to measure cardiac output and arterial pressure and to inject microspheres. An orogastric tube was placed for infusion of 2.5% autogenous bile in isotonic HCl (2 ml/kg/hr). Four experimental groups were used: I, control (no drugs); II, vasopressin (0.25 U/min intravenously); III, PGI2 (0.1 micrograms/kg/min intravenously); and IV, vasopressin and PGI2 combined. Gastric mucosal blood flow was documented at baseline and at 1, 2, and 3 hours of drug infusion by radiolabeled-microsphere technique. Stomachs were harvested and photographed, and lesions were scored (0 to 3) by blinded observers. Gastric mucosal blood flow was decreased (50%) in both groups that received vasopressin, increased (300%) in animals that received PGI2 alone, and unchanged in controls. All animals that received vasopressin, whether alone or with PGI2, developed mucosal injury (mean score 2.5 versus (2.2). Group I and group III animals did not develop lesions. The results of this study demonstrate that PGI2 failed to elevate gastric mucosal blood flow, which was already depressed to vasopressin, and that PGI2 failed to protect the gastric mucosa from injury in the presence of reduced blood flow. This suggests that PGI2 cytoprotection is linked to its effect on gastric mucosal blood flow.

Cimetidine affords protection equal to antacids in prevention of stress ulceration following thermal injury.

A prospective, randomized, double-blind, endoscopic study is described in which the efficacy of cimetidine (13 patients) is compared to that of antacids (14 patients) in the prevention of stress ulceration following severe thermal injury. Each treatment modality was equally effective in the prevention of acute gastroduodenal disease and its associated complications. Both cimetidine and antacids produced a near elimination of duodenal disease and markedly reduced the severity of gastric disease when compared to that of untreated historical controls. Lack of major side effects and ease of administration make cimetidine an attractive alternative to antacid therapy in the prophylaxis of stress-induced gastroduodenal disease in the thermally injured patient.

von Hippel-Lindau syndrome presenting as pancreatic endocrine insufficiency: a case report.

The visceral manifestations of von Hippel-Lindau syndrome rarely are clinically significant until late in the disease process. Pancreatic endocrine insufficiency in the syndrome is extremely uncommon. We report a case of a 32-year-old woman with von Hippel-Lindau syndrome whose initial diagnosis came to light because of a clinical presentation with complications related to pancreatic endocrine insufficiency.

Hyperinsulinism, glucose-dependent insulinotropic polypeptide, and the enteroinsular axis in morbidly obese patients before and after gastric bypass.

The role of glucose-dependent insulinotropic polypeptide (GIP) in the hyperinsulinism of morbid obesity and its correction after gastric bypass was studied in 12 morbidly obese (150 +/- 15 kg) patients. After oral glucose, significant increases in serum glucose, insulin, and GIP levels occurred both before and after gastric bypass. Compared with preoperative values, fasting concentrations and integrated incremental areas for glucose, insulin, and GIP were decreased after a 25% weight loss after gastric bypass. The hyperinsulinism of morbid obesity and its amelioration after gastric bypass may be caused by markedly elevated levels of GIP before surgery and its reduced release after bypass. Reduced release of GIP after gastric bypass may partly occur because of exclusion of ingested glucose from contact with the mucosa of the duodenum and proximal jejunum, sites with the highest concentration of GIP.

Exclusion angiography for patients with possible vascular injuries of the extremities--a better use of trauma center resources.

In this study we evaluated the capacity of selective angiography to reduce the number of exploratory procedures with negative results for suspected peripheral vascular injury. During the 4-year period ending December 1982, 316 trauma patients were evaluated for possible vascular injuries of the extremities. Exploration alone was performed for 124 patients, and 61 had vascular injuries; 192 patients were considered to be in stable condition and underwent selective angiography. Of these, 50 had vascular injuries and required operation. There were two false positive angiograms and one false negative angiogram (missed arteriovenous fistula). The overall diagnostic accuracy for angiography was 98%. The overall positive yield rate for operation was 64%. Selective angiography for the stable trauma patient to exclude vascular injury is safe, sensitive, and specific. Exclusion angiography has increased the overall positive yield rate for exploration of suspected vascular injury at our institution by 49%. Thus the selective use of exclusion angiography for patients who are stable and who do not have other indications for wound exploration is a reasonable and necessary mode of diagnosis for more effective use of operating room facilities.

Cimetidine prevents reduction in gastric mucosal blood flow during shock.

This study evaluated Cimetidine's possible role in regulating gastric mucosal blood flow in the anesthetized, stressed miniature swine. Stress consisted of hemorrhagic shock to a mean arterial pressure of 50 mm Hg. Twenty-one animals were divided into three experimental groups: untreated controls, preshock Cimetidine treatment group, and postshock Cimetidine treatment group. Gastric mucosal blood flows were determined (microsphere method) during a stabilization period and after 90 minutes of shock. Central hemodynamic indices were monitored throughout each experiment. In the fundus, mucosal blood flow decreased 59% in the controls, 11% in the preshock, and 28% in the postshock Cimetidine groups. Antral mucosal blood flow decreased 57% in controls, 19% in the preshock, and 33% in the postshock Cimetidine groups. In the corpal mucosa, blood flow decreased 53% in controls, 11% in the preshock group, and 41% in the postshock Cimetidine group. Cimetidine administration, both before and after shock, conferred significant protection on mucosal blood flow changes related to shock. Preshock drug administration had a significantly greater protective effect than postshock treatment on blood flow in the corpal mucosa.

Pulmonary function after laparoscopic cholecystectomy.

BACKGROUND: The purpose of this study was to prospectively compare the effect of laparoscopic cholecystectomy (LC) versus open cholecystectomy (OC) on postoperative pulmonary function. METHODS: Forty consecutive patients (20 in each group) who were evenly matched in terms of pulmonary risk factors were assigned to either elective LC or OC. Pulmonary function studies, oxygen saturation, and chest radiography were performed on both groups before and after the operation until baseline levels were reached. Narcotic requirements and pulmonary complications were compared. The t test, ANOVA, and chi-squared analysis were used. RESULTS: Compared to the patients who underwent OC, patients who underwent LC had a significant reduction in postoperative pulmonary impairment (30% to 38%) in all areas studied including forced vital capacity; forced expiratory volume in 1 second; forced expiratory flow, mid-expiratory phase; maximum forced expiratory flow; maximum voluntary ventilation; total lung capacity; and oxygen saturation. Pulmonary function returned to baseline levels 4 to 10 days sooner after LC. Pulmonary complications including atelectasis and hypoxia were less frequent after LC. An eight-fold decrease was noted in postoperative pain medication requirement in the LC group. CONCLUSIONS: Compared to OC, laparoscopic cholecystectomy results in a significantly reduced compromise in pulmonary function and narcotic requirement leading to fewer postoperative pulmonary complications. Laparoscopic cholecystectomy should be considered the procedure of choice for elective cholecystectomy.

Biliary sludge formation during enteral nutrition: prevalence and natural history.

BACKGROUND: Total parenteral nutrition is an etiologic factor in the formation of biliary sludge. We studied whether enteral nutrition is also a risk factor for sludge. METHODS: Fifty patients with a needle catheter jejunostomy (NCJ) placed during a major abdominal operation underwent preoperative and weekly postoperative ultrasonography until NCJ feedings were discontinued (1 to 6 weeks). RESULTS: All patients were men. The mean age was 63.2 +/- 1.6 years. Fourteen asymptomatic patients (28.0%) had biliary sludge within 2 weeks of beginning enteral feedings through a NCJ. Complete ultrasonographic resolution of sludge was observed in 13 of the 14 positive patients within 1 to 2 weeks of resuming an oral diet. One patient was lost to follow-up after 14 week; a positive sonogram had persisted but the patient remained asymptomatic. During the period of observation, no other patient had signs of biliary tract disease. CONCLUSIONS: (1) Biliary sludge may form in some patients during enteral feeding with NCJ. (2) Sludge is cleared by the gallbladder once an oral diet is resumed. (3) There appears to be little risk of complications during postoperative enteral feeding.

Renal effects on serum gastric inhibitory polypeptide (GIP).

Fasting and meal-stimulated serum immunoreactive gastric inhibitory polypeptide (GIP) concentrations were measured in normal subjects and in uremic patients undergoing chronic hemodialysis. Mean fasting GIP was higher in the uremic patients (1006 +/- 145 (SE) pg/ml) than in the normal control subjects (132 +/- 31 pg/ml, p less than 0.001). Also, postcibal absolute and incremental serum GIP concentrations between 15 and 180 min were greater (p less than 0.05) in the uremic patients than in the control subjects; in the former they failed to return to fasting levels 180 min after the meal. In a second study, using anesthetized normal dogs, simultaneous renal arterial and venous serum GIP concentrations were measured during an intraduodenal perfusion of glucose. The renal arterial-venous (A-V) GIP gradient became greater as serum arterial GIP concentrations increased. The correlation between renal A-V GIP gradient and renal arterial GIP concentration was quite good (r = 0.85), with a 39% maximum mean A-V reduction in serum GIP concentrations observed across the kidney. This large renal A-V GIP gradient observed under nonsteady conditions suggests that the kidney may be an important site for the removal of GIP from the circulation. Thus, the higher than normal fasting and stimulated serum GIP concentrations observed in uremic patients can be attributed, at least in part, to a loss of the renal extraction mechanism for GIP.

High-dose vasopressin for acute variceal hemorrhage. Clinical advantages without adverse effects.

Based on laboratory and clinical data from our institution, 113 patients with cirrhosis, portal hypertension, and acute hemorrhage from esophageal varices were treated with high-dose vasopressin arginine (1 to 1.5 U/min) to control the acute bleeding and reduce blood loss during portosystemic shunt operations. Compared with patients receiving a lower dose of vasopressin infusion, these patients had a reduction in both postoperative mortality (21% vs 6%) and the proportion of patients requiring emergency operation (40% vs 18%). A decrease in operative blood loss (1340 vs 793 mL) was also seen. Adverse effects of vasopressin were increased by high-dose infusion, but no significant morbidity occurred. These results suggest that high-dose vasopressin infusion can reduce the mortality of acute variceal hemorrhage and porto-systemic shunting primarily by allowing patients to improve hepatic function prior to an elective operation and by decreasing intraoperative blood loss.

Percutaneous transhepatic cholangiography and biliary decompression. Invasive, diagnostic, and therapeutic procedures with too high a price?

To investigate and/or treat the causes of jaundice, 221 patients underwent the following procedures over 7 years: percutaneous transhepatic cholangiography (PTC) alone (104 patients), PTC with external biliary drainage (69 patients), or PTC with external/internal biliary drainage (48 patients). Forty-nine procedure-related complications occurred in 39 patients (18%). Three patients (1.5%) required an emergency operation for hepatic hemorrhage (2 patients) and a perforated gallbladder (1 patient). Two patients (1%) died as a direct result of the procedure secondary to hemorrhage (1 patient) and sepsis (1 patient). Preoperative biliary decompression, although technically (95%) and physiologically (82%) successful in the majority of patients, had no therapeutic benefit when compared (nonrandomized) with those patients without alleviation of jaundice prior to surgical intervention.

Topical prostaglandin E2 in the treatment of acute upper gastrointestinal tract hemorrhage. A prospective, randomized, double-blind study.

We performed a prospective, randomized, double-blind study to assess the efficacy of topical prostaglandin E2 (PGE2) in altering the course of patients with severe upper gastrointestinal tract hemorrhage. Forty-four patients with life-threatening, endoscopically proven hemorrhage were randomly allocated to receive either PGE2 or placebo for seven days. Severity of mucosal injury, determined by endoscopy, was scored both before and after completion of treatment. There were no significant differences between groups in either transfusion requirements or successful outcomes. However, the PGE2 group had significantly improved endoscopic injury scores while the placebo group did not. Therefore, topical PGE2 does not control acute hemorrhage from established upper gastrointestinal tract lesions, but it does result in an accelerated healing of established lesions.

Improving survival in patients with cirrhosis undergoing major abdominal operations.

Fifty-one patients with cirrhosis underwent 65 major abdominal procedures, with an 8% mortality and a 28% complication rate. Preoperative and perioperative management was comparable to that rendered patients with cirrhosis undergoing portosystemic shunting procedures. Emergency operation, persistent coagulation defects (prothrombin time and partial thromboplastin time prolonged greater than 2 s), blood loss greater than 4 U, and exploration of the common bile duct were factors associated with increased mortality. Major surgical procedures can be safely performed in critically ill patients with cirrhosis with intensive preoperative care and with minimizing intraoperative blood loss.