The use of bioimpedance spectroscopy to monitor therapeutic intervention in patients treated for breast cancer related lymphedema.

We performed a multi-institutional analysis to evaluate the ability of bioimpedance spectroscopy (BIS) to capture the impact of lymphedema treatment compared with observation alone in the management of breast cancer related lymphedema (BCRL). We utilized a retrospective review of 50 patients with breast cancer who were evaluated with BIS at baseline and following loco-regional treatment. An analysis was performed comparing changes in L-Dex scores for those patients undergoing treatment for BCRL (n=13) versus those not undergoing intervention (n=37). A second (subset) analysis was also performed on all patients with elevated L-Dex scores compared to baseline prior to undergoing loco-regional treatment (n=32). When comparing the cohort treated for BCRL to those not treated, L-Dex scores were significantly reduced (-4.3 v. 0.1, p=0.005) in the period following intervention (for treated patients). For the subset of patients with elevated L-Dex scores postoperation, the change in L-Dex score following BCRL treatment was significantly reduced (-5.8 v. 0.1, p=0.001) compared with the group observed that had elevated postsurgical L-Dex scores. In this analysis, BIS was able to detect early onset lymphedema and subsequently significant changes (reductions) in L-Dex scores directly related to intervention for BCRL compared with observation alone.

Immune thrombocytopenic purpura during pregnancy: laparoscopic treatment.

BACKGROUND AND OBJECTIVES: Laparoscopic surgical techniques in pregnancy have been accepted and pose minimal risks to the patient and fetus. We present the first reported case of a pregnant woman with immune thrombocytopenia purpura who underwent laparoscopic splenectomy during the second trimester. METHODS AND RESULTS: The anesthesia, hematology, and obstetrics services closely followed the patient's preoperative and intraoperative courses. After receiving immunization, stress close steroids, and prophylactic antibiotics, she underwent a successful laparoscopic splenectomy. After a short hospital stay, the patient was discharged home. CONCLUSION: Immune thrombocytopenia purpura can be an indication for splenectomy. As demonstrated in appendectomy, cholecystectomy, and our case presentation, laparoscopic splenectomy can be safely performed during pregnancy.

Breast and cervical carcinoma screening services: physicians' perceptions of need.

The Mississippi Breast and Cervical Cancer Control Coalition conducted a survey of health care professionals to assess current practices in the areas of breast and cervical cancer screening. A 22% response rate was obtained, with family practitioners having the highest response rate. Cost was cited as a major barrier to access to screening mammography. Some discrepancies between provider perceptions and currently accepted guidelines were identified.

Familial juvenile polyposis: patterns of recurrence and implications for surgical management.

BACKGROUND: Familial juvenile polyposis predisposes to the development of carcinoma of the colon. Optimum surgical management and recommended surveillance of affected individuals are still being defined. STUDY DESIGN: A retrospective review of experience with a kindred identified in 1988 was carried out. RESULTS: Of 34 living members, 15 have been investigated, and histologically typical juvenile polyps were found in 11. In each instance, polyps were most numerous in the right colon, with few polyps in the descending colon and none in the rectum. Eight patients have had subtotal colectomies with ileorectal anastomoses; the remaining patients were managed by polypectomy (with one recurrence after ten years). In addition to juvenile polyps, polyps with adenomatous or villous elements were identified in three patients. One of these patients had invasive adenocarcinoma in a large mixed polyp of the cecum. Two patients with polyps had coexisting carcinoma of the stomach. All patients have been followed up with periodic upper and lower gastrointestinal endoscopy. Polyps have recurred in the rectal remnants of three patients at a mean of 36 months after subtotal colectomy. Two patients have undergone conversion to total proctocolectomy with ileoanal anastomosis and J pouch; one patient was found to have juvenile polyps in the pouch 40 months after surgery. CONCLUSIONS: Despite the preponderance of right-sided polyps at initial diagnosis, the rapid recurrence of polyps after subtotal colectomy argues in favor of performing proctocolectomy with preservation of anal sphincter function (restorative proctocolectomy) at the time of initial surgery. Patients with a small number of polyps may choose instead to undergo periodic colonoscopy with colonoscopic polypectomy. An algorithm for surveillance and follow-up is proposed.

Laparoscopic plication of perforated ulcer: results of a selective approach.

We reviewed our experience with laparoscopy for perforated ulcer from April 1, 1992, to March 31, 1993. All patients admitted to the gastrointestinal surgery service with a diagnosis of perforated viscus had evaluation for possible laparoscopic Graham plication (LGP). Of eight patients considered, five had successful diagnostic laparoscopy. Two patients with anterior duodenal ulcers had LGP. Operative times were 85 and 106 minutes; postoperative stays were 5 and 8 days. Three procedures were converted to formal laparotomy when laparoscopy revealed gastric or prepyloric ulcers. Three patients had immediate laparotomy because of known disease process. Two additional patients were treated with open plication by other surgeons; their operative times were 98 and 110 minutes and postoperative stays, 6 and 4 days. Hospital charges averaged $6,573 for the two laparoscopic plications, $7,511 for the four plications not done laparoscopically, and $20,995 for the two cases converted to open plication. A selective approach allowed two Graham patch closures to be done laparoscopically without complications, at a cost comparable to that of open surgery.

The integration of laparoscopy into a surgical residency and implications for the training environment.

Although laparoscopic cholecystectomy is now an accepted part of resident training, the impact of operative laparoscopy (OL) upon the residency environment has not been examined in detail. We reviewed the first 3 years' experience with OL and the process by which it was introduced into our residency program. Data were obtained from our prospective computerized surgical laparoscopic registry as well as from a survey conducted midway in this experience. At that time, a questionnaire was sent to current residents in the program and residents who graduated after the inception of the OL program were interviewed by telephone. OL cases increased each year and comprised a progressively greater percentage of total cases. Residents performed over 97% of cases, with attending surgeons as first assistants. Initially, only senior-level residents participated as surgeons; however, after the first year we noted a significant tendency for cases to filter down the ranks. Junior-level residents have already participated in more laparoscopic than open cholecystectomies and expressed considerable concern about training in open procedures. Graduated residents without exception were able to obtain privileges to perform OL without additional training. They did not feel that resident education was compromised by the advent of laparoscopy. Both current and graduated residents considered didactic sessions including animal laboratories and simulators an important part of training.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic appendectomy: is it worth it?

Data on all laparoscopic appendectomies (LA) were collected prospectively from June 1990 through July 1992 and compared retrospectively with all open appendectomies (OA) done at the same hospital during the same time period. Laparoscopic appendectomies were performed in 29 patients (ages 15-47, mean 25.3 years) and OA in 77 patients (ages 18-71, mean 31.9 years, P < 0.01). Preoperative findings were similar in the two groups. Acute appendicitis was confirmed in 22 (76%) LA and in 57 (74%) OA; of these, 9/22 (41%) LA and 23/57 (40%) OA were gangrenous or perforated. A normal appendix was removed in seven (24%) LA and in 20 (26%) OA. Three patients (10%) required conversion of LA to an open procedure. Operative time was significantly longer for LA (mean 105 minutes) compared with OA (mean 69 minutes; P < 0.001). Postoperative complications requiring further intervention (wound infection or intraabdominal abscess) occurred in three LA (10%) and in 23 OA (30%, P < 0.05). Wound morbidity as measured by number of wounds left open at surgery or opened for infection was significantly less after LA (14% LA, 39% OA, P < 0.001). Hospital stay was significantly shorter after LA (mean 4.2 days) compared with OA (mean 6.3 days; P < 0.05). Hospital charges and professional fees were not significantly different between the two groups. In selected patients, LA is a safe, effective alternative to OA, with fewer complications and shorter hospital stay. In addition, hospital charges are similar, making an investment of more time in the operating yield an outcome equal or superior to OA.

Laparoscopic appendectomy. Initial experience in a teaching program.

From February 1990 to December 1991, 16 laparoscopic procedures were performed for right lower quadrant pain. There were nine men and seven women, aged 16 to 47 years (mean, 27.2 years). All procedures were performed by surgical chief residents with prior experience in laparoscopic cholecystectomy, first-assisted by an attending surgeon. The appendix was visualized and a definitive diagnosis was made in all patients. One patient with acute salpingitis underwent diagnostic laparoscopy only; two patients underwent laparotomy (perforated appendicitis, perforated diverticulitis). A fourth patient had an acute torsion of an ovarian cyst managed laparoscopically. Laparoscopic appendectomy was successfully performed in 12 patients (acute appendicitis, 9; fibrosis or chronic inflammation, 2; normal appendix, 1). Mean operative time for laparoscopic appendectomy was 95.7 minutes, and mean postoperative stay was 2.5 days. The authors conclude that operative time, diagnostic accuracy, and complication rates for laparoscopic appendectomy are acceptable. Within the context of a training program, laparoscopic appendectomy provides an opportunity for surgical residents to expand laparoscopic skills.