Technical elements of successful laparoscopic cholangiography as defined by radiographic criteria.

OBJECTIVE: To define the elements of successful laparoscopic cholangiography. DESIGN: Retrospective review of 130 consecutive patients who underwent laparoscopic cholangiography. SETTING: Community hospital with a surgical residency. PATIENTS: Thirty-four males and 96 females, aged 16 to 86 years, with acute and chronic cholecystitis. INTERVENTION: Laparoscopic cholecystectomy during intraoperative cholangiography. MAIN OUTCOME MEASURE: A cholangiogram that satisfactorily delineates biliary anatomy as defined by accepted radiologic criteria. RESULTS: A successful laparoscopic cholangiogram was obtained in 98.5% of the study group. CONCLUSION: A safe and reliable technique to obtain a laparoscopic cholangiogram is described and validated using accepted radiologic criteria.

An improved double-lumen biliary catheter for cholangiography.

A double-lumen biliary catheter was developed to aid in the performance of cholangiography and bile duct stone extraction. A prototype catheter was used in four cadavers. Excellent cholangiograms were obtained and a cryoprecipitate coagulum easily formed in the bile ducts without waste. Extraction of the coagulum from the bile ducts was aided by use of the catheter. The catheter also can aid in routine balloon catheter bile duct stone extraction, and thus is useful for both diagnosis and treatment of bile duct stones.

Cholangiographic demonstration of relief of narcotic-induced spasm of the sphincter of Oddi.

Narcotics are known to cause spasm of the sphincter of Oddi. This spasm may be difficult to distinguish from obstruction of the distal common bile duct on operative cholangiograms in cases where narcotics are used perioperatively. A case is presented in which narcotic-induced spasm of the sphincter of Oddi, clearly demonstrated in an operative cholangiogram, is reversed by a narcotic antagonist, thereby avoiding an unnecessary common duct exploration.

Paradoxical embolism to the superior mesenteric artery.

Paradoxical embolism occurs when venous thrombi embolize into the systemic arterial circulation by passage of clots through an intracardiac septal defect. This paper describes a case of paradoxical embolism to the superior mesenteric artery in a patient with recent myocardial infarction and pulmonary embolism. This phenomenon was first described in 1877 (Cohnheim, 1877) and many case reports have followed but most of these have been autopsy findings. We emphasize that this diagnosis should be suspected in all patients who suffer systemic arterial emboli without any evidence of left heart origin and/or in association with pulmonary emboli. One author has reviewed 19 cases since 1930, most of which were reported in the past 15 years (Johnson, 1951). This probably reflects an increased awareness of the diagnosis and more sophisticated diagnostic modalities. It also raises the possibility that paradoxical embolism may be more common than originally believed.

Failure of conservative management of splenic rupture in a patient with mononucleosis.

"Conservative" management of splenic rupture in patients with mononucleosis has not been adequately evaluated because of its infrequent occurrence. Splenic rupture can be lethal in this setting and is the most common cause of death from mononucleosis. We report a case of spontaneous splenic rupture in a young girl with mononucleosis. The initial management was nonoperative but because of recurrent pain and rebleeding, a splenectomy was later performed. We do not recommend observation of splenic rupture in patients with mononucleosis because of the danger of delayed hemorrhage.

Spontaneous pneumothorax complicating pregnancy--case report and review of the literature.

Patients with a spontaneous pneumothorax frequently present for care in the emergency department. The occurrence of spontaneous pneumothorax during parturition occurs rarely. We describe a case of spontaneous pneumothorax during the first trimester of pregnancy, which resolved with tube thoracostomy. The patient delivered vaginally a healthy 4.3 kg male at term under epidural anesthesia. We discuss spontaneous pneumothorax and review reported cases during pregnancy.

Genetic identification of five strongyle nematode parasites in wild african elephants (Loxodonta africana).

African savannah elephants (Loxodonta africana) are an ecologically and economically important species in many African habitats. However, despite the importance of elephants, research on their parasites is limited, especially in wild populations. Currently, we lack genetic tools to identify elephant parasites. We present genetic markers from ribosomal DNA (rDNA) and mitochondrial DNA (mtDNA) to identify five elephant-specific nematode parasites in the family Strongylidae: Murshidia linstowi, Murshidia longicaudata, Murshidia africana, Quilonia africana, and Khalilia sameera. We collected adult nematodes from feces deposited by wild elephants living in Amboseli National Park, Kenya. Using both morphologic and genetic techniques, we found that the internal transcribed spacer (ITS) region in rDNA provides a reliable marker to distinguish these species of strongyles. We found no evidence for cryptic genetic species within these morphologic species according to the cox-1 region of mtDNA. Levels of genetic diversity in strongyles from elephants were consistent with the genetic diversity seen within other strongyle species. We anticipate that these results will be a useful tool for identifying gastrointestinal nematode parasites in elephants.

Laparoscopic-assisted abdominal aortic aneurysmectomy.

PURPOSE: The technical elements and early results of laparoscopic-assisted abdominal aortic aneurysmectomy are described. METHODS: From February 1997 to May 1999, 60 patients underwent elective laparoscopic surgery for infrarenal abdominal aortic aneurysm. Patients ranged in age from 53 to 87 years (mean age, 70.6 years). The mean aneurysm size was 5.7 cm (range, 4.4-8.0 cm). All patients underwent aortography and computed tomography scanning preoperatively. Patients were not deemed candidates for the procedure when visceral arterial abnormalities requiring surgical treatment were present or an aortic aneurysm neck shorter than 0.5 cm was found. A risk-stratification system was used as a means of quantitating risk factors and excluding high-risk patients. Aortic reconstruction was performed with retroperitoneal laparoscopy, with the patient in a modified right lateral decubitus position. An Endo TA 30 and an Endo TA 60 laparoscopic staplers (US Surgical, Norwalk, Conn) were used in occluding the common iliac arteries and aneurysm sac. Laparoscopic hemoclips were used as a means of occluding the lumbar arteries and other branches of the aneurysm sac. An aortobifemoral or aortobi-iliac bypass grafting procedure was performed by means of the laparoscope to position the graft and visualize the end-to-end aorta-to-graft anastomosis, with distal anastomoses performed through counter incisions. RESULTS: Three patients died within 30 days of surgery (mortality rate, 5.0%). Complications included left ureteral injury (1), postoperative myocardial infarction (1), ileofemoral deep venous thrombosis (1), acute renal failure (2), colon ischemia (1), and infected graft limb requiring revision (1). The mean operative time was 7.7 hours, and the mean aortic cross-clamping time was 112 minutes. Compared with a contemporary consecutive series of 100 patients undergoing open transabdominal or retroperitoneal aneurysmectomy performed by the same group of surgeons, the laparoscopic patients had decreased length of stays in the intensive care unit and the hospital, with less need for ventilator support, earlier resumption of a regular diet, and an earlier return to normal activity. At the follow-up examinations, all bypass grafts were patent. CONCLUSION: Laparoscopic-assisted aneurysmectomy is safe and effective and can be performed with good results. The longer operation time required is well tolerated in patients who are at good and moderate risk. Prior training in laparoscopic aortic surgery is necessary for surgeons to obtain the required level of expertise needed to perform these procedures. With these caveats, the results of our study suggest that laparoscopic-assisted aortic aneurysmectomy is appropriate for moderate-to-good risk (American Society of Anesthesiologists class of III or lower) operative candidates meeting standard criteria for aneurysm resection in whom preoperative computed tomography scan and biplane arteriography demonstrate a proximal aneurysm neck of 0.5 cm or larger and no need for visceral or internal iliac artery reconstruction. A randomized trial would be required to confirm the benefits of this procedure over open aneurysmectomy.

Peripheral migration of pacemaker electrodes.

A 55-year-old male was admitted with right ileo-femoral phlebitis caused by an unused pacemaker electrode fragment which had migrated from the right subclavian vein to the right iliac vein. Vena cava plication was followed by removal of the electrode fragment and complete resolution of the phlebitis. The exposed metal coil may have contributed to the severe inflammatory reaction.