Laparoscopy: the preferred method of cholecystectomy in the morbidly obese.

BACKGROUND: Morbid obesity has been considered a contraindication to laparoscopic cholecystectomy (LC). METHODS: To evaluate this we reviewed our first 201 patients undergoing LC and compared the operative procedure and outcome in morbidly obese (greater than or equal to 100 pounds over ideal body weight [IBW]) and nonobese patients. We also compared a group of morbidly obese patients who underwent standard open cholecystectomy (n = 11) with the obese group undergoing LC (n = 21). All groups were comparable in terms of age, sex, and symptoms (acute vs chronic). The obese groups undergoing LC and open cholecystectomy had similar weights (134.0 +/- 9.4 pounds over IBW [range, 100 to 286 pounds] and 133.8 +/- 6.0 pounds over IBW [range, 108 to 170 pounds], respectively) and were significantly different from the nonobese group undergoing LC (28.3 +/- 2.0 pounds over IBW [range, 23 to 98 pounds]). Parameters evaluated included operative time, resumption of normal diet, length of postoperative hospitalization, complications, conversion to open procedure, and ability to perform cholangiography. RESULTS: There were no statistically significant differences between the obese and nonobese groups undergoing LC in any parameters studied (operative time, 151.7 +/- 4.0 minutes vs 160.7 +/- 9.9 minutes; tolerance of diet, 1.2 +/- 0.1 days vs 1.1 +/- 0.1 days; time to discharge, 2.0 +/- 0.1 days vs 1.8 +/- 0.2 days; complications, 7.0% vs 0.0%). Operative time (117.6 +/- 11.6 minutes) was shorter (p = 0.45) in obese patients undergoing open cholecystectomy. However, time to normal diet and length of postoperative hospitalization were significantly longer (3.1 and 4.6 days, respectively; p less than 0.01), and there were more complications (18.2%). CONCLUSIONS: Rather than being contraindicated in the morbidly obese, LC appears to be the preferred method of cholecystectomy.

In vivo crushing of an aortic stent enables endovascular repair of a large infrarenal aortic pseudoaneurysm.

PURPOSE: To report an unusual approach to endovascular exclusion of a large aortic pseudoaneurysm. METHODS AND RESULTS: A 63-year-old male had an unsuccessful endovascular repair of an aortic anastomotic pseudoaneurysm that left an expanded, uncovered Palmaz stent lying obliquely within the aorta. After nearly 3 years, the pseudoaneurysm enlarged to 7 cm, and the patient became symptomatic. Repair of the pseudoaneurysm was accomplished by crushing the indwelling stent to allow placement of a stent-graft. CONCLUSIONS: Malpositioned stents that are hindering an endoluminal procedure may be crushed against the arterial wall in vivo to facilitate passage of endovascular instruments or devices.

An outcome analysis of carotid endarterectomy: the incidence and natural history of recurrent stenosis.

PURPOSE: This report identifies the incidence of recurrent carotid stenosis after carotid endarterectomy (CEA) and records the natural history of the disease process to gain further insight into its proper management. METHODS: A prospective surveillance protocol with duplex imaging and velocity spectral analysis was used to detect recurrent stenosis ( > 50% diameter reduction) and to document the clinical outcomes of patients who underwent CEA. Between 1984 and 1993, 619 consecutive CEAs were performed in 587 patients. RESULTS: Recurrent carotid stenosis developed in 48 CEA sites (7.8%) during a mean follow-up interval of 34 months (range, 2 to 118 months). Normal results on intraoperative assessment correlated with a 5.6% incidence of recurrent stenosis, compared with a 19% incidence when a residual hemodynamic abnormality was present (p < 0.0003). In the first year after surgery, there were no transient ischemic attacks, strokes, or carotid occlusions from recurrent stenosis, compared with a 27% morbidity rate in later follow-up (p < 0.01). Three patients with recurrent stenosis subsequently had occlusion at the CEA site, two of whom had severe ipsilateral strokes. CONCLUSIONS: The incidence of recurrent carotid stenosis is low. Patients are at significant risk for neurologic morbidity when a recurrent stenosis occludes. With a 0.3% incidence of late stroke resulting from carotid bifurcation disease, these data confirm that CEA does provide long-term protection from stroke.

Using dipyridamole-thallium imaging to reduce cardiac risk in aortic reconstruction.

UNLABELLED: Cardiac morbidity and mortality remain the major operative risk following aortic reconstruction (AR) performed for aneurysmal and occlusive disease. We reviewed the preoperative cardiac evaluation and outcome in 209 patients who had AR between 1987 and 1992. Dipyridamole-thallium stress test (DTST) was performed in 147 (70.3%) patients. Fifty-six of these patients had a normal DTST and only 1 (1.8%) had a perioperative myocardial infarction (MI). Forty-six patients had a fixed defect on their DTST and 3 (6.5%) had perioperative MI. Forty-five patients had reversible defects on their DTST and 2 (4.4%) had perioperative MI with 1 cardiac death. Following DTST, 29 coronary catheterizations were performed. Ten catheterizations were normal or had minimal one-vessel coronary artery disease with an associated postoperative death in 1 patient due to cardiac dysrhythmia. Nineteen patients had abnormal coronary angiography, 1 of whom had a perioperative myocardial infarction and 5 of whom underwent coronary artery revascularization (CABG) (3) or percutaneous transluminal angioplasty (2) prior to AR without subsequent cardiac events. Forty-three (20.6%) had either no cardiac symptoms (40) or prior CABG (3) precluding invasive cardiac evaluation. There was one fatal perioperative myocardial infarction (2.3%), resulting in a cardiac mortality of 2.3% in this group. The remaining 19 patients who did not have a DTST (9.1%) had coronary angiography based on evidence of significant cardiac disease resulting in one CABG and one percutaneous transluminal angioplasty. There was one (5.3%) perioperative myocardial infarction in this group and no cardiac deaths. Thirty-day mortality was 3.8%, perioperative MI rate was 3.8%, and perioperative cardiac mortality was 1.0%. During the follow-up period (median, 18 months; range, 1-89), there were 19 deaths (10%) and the 5-year cumulative survival was 76%. CONCLUSION: Selective use of DTST can direct further evaluation, intervention, and subsequent perioperative care. This algorithm has enabled us to perform AR even in patients with defined perfusion abnormalities with acceptable morbidity. The true sensitivity, specificity, and predictive value of DTST can only be determined by a prospective trial.