Emergent laparoscopic repair of incarcerated incisional and ventral hernia.

BACKGROUND: The role of laparoscopy in the repair of incarcerated incisional or ventral hernia is not yet established. This presentation reviews the authors' experience with patients who underwent laparoscopic surgery in presence of incarceration. METHODS: Patients who had surgery during the years 1997 to 2001 were included in the study. All patients underwent surgery immediately after their admission. In all cases, Gore-Tex Dual Mesh was used. RESULTS: The review included 25 patients (21 women and 4 men). Ten of these patients (40%) had undergone at least one earlier repair, and one patient (4%) underwent conversion to open repair because of small bowel injury. The mean operation time was 63 min (range, 15-20 min). The median postoperative hospital stay was 3.2 days (range, 2-7 days). There were no noteworthy postoperative complications. During the follow-up period, no patient experienced recurrent hernia. CONCLUSIONS: The authors' current has experience demonstrated that laparoscopic repair is feasible and can be attempted for patients presenting with incarcerated incisional or ventral hernia.

Laparoscopic repair of poststernotomy subxiphoid epigastric hernia.

BACKGROUND: The repair of a subxyphoid hernia is a difficult procedure that nonetheless results in a high rate of recurrence. The laparoscopic approach is a promising new technique for more efficacious treatment of this condition. This is the first report in the English-language literature to describe the use of this approach for the correction of poststernotomy subxiphoideal hernia. METHODS: Information was retrieved from the patients' hospitalization and outpatient clinic files. Of 984 patients who had a median sternotomy, 10 developed a substernal subxiphoid epigastric hernia. These patients had all been treated laparoscopically using Gore-Tex mesh. RESULTS: Nine patients were admitted electively and one urgently. The fascial defect sizes were 4-15 cm (mean, 8.5) in length. Intraabdominal content was adherent to the hernia in six patients; in the other four cases, the defect was adhesion free. In four patients, an incidental surgical procedure was performed (three cholecystectomies and one inguinal hernia repair using the trans abdominal preperitoneal [TAPP] technique). The operations lasted 25-120 min (average, 55). No death occurred as a result of the operations, and none of the operations was converted to an open procedure. Three patients had minor postoperative complications. During 20-42 months of follow-up, one patient suffered a recurrence. CONCLUSIONS: Laparoscopic repair of a poststernotomy subxiphoideal epigastric hernia is feasible and has a low rate of minor complications. Our review of the literature indicates that this technique produces a better outcome than the conventional open repair.

Use of adjustable silicone gastric banding for revision of failed gastric bariatric operations.

BACKGROUND: Revision of gastric bariatric operations is sometimes technically difficult and may fail to achieve prolonged weight reduction. The use of the adjustable silicone gastric banding (ASGB) offers a new approach for these revisions. METHODS: ASGB was performed as a revisional procedure on 37 patients whose initial bariatric operations were as follows: silastic ring vertical gastroplasty (21), gastric bypass (12), horizontal gastroplasty (3) and vertical banded gastroplasty (1). RESULTS: The length of the procedure varied from 55 to 145 minutes (mean 83 minutes). Intraoperative complications included two fundic tears which were sutured without any postoperative sequelae. Five patients needed reoperation during the first postoperative year due to gastric volvulus (1), tubing tear (1) and development of postoperative ventral hernia (3). BMI fell from 44.8+/-SD 8.07 to 33.4+/-6.9 kg/m2 for patients operated with BMI higher than 35 kg/m2 and from 29.2+/-3.32 to 25.4+/-2.8 kg/m2 for patients operated with BMI lower than 35 kg/m2. CONCLUSIONS: ASBG can be performed with revisions with an acceptable complication rate and postoperative weight reduction.

The role of laparoscopy in the diagnosis and treatment of missed diaphragmatic rupture.

BACKGROUND: Diaphragmatic rupture is one of the most commonly missed injuries in trauma cases. Traditionally, laparotomy or thoracotomy has been the treatment of choice for this condition. METHODS: During the last 2 years, we treated three patients laparoscopically to address neglected diaphragmatic ruptures that caused herniation of the intraabdominal contents. RESULTS: In all three cases, laparoscopy succeeded in identifying the diaphragmatic defect, so that the herniated viscera could be released and the defect repaired primarily or with a prosthesis. The intraoperative and the postoperative courses were uneventful; there were no significant complications. CONCLUSION: Laparoscopy has an important role in the surgical treatment of missed diaphragmatic ruptures.

Pseudomembranous colitis: report of a severe case with unusual clinical signs in a young nurse.

We describe the case of a young and otherwise healthy nurse who developed pseudomembranous colitis ten days after receiving oral clindamycin for dental infection. Her clinical course was particularly stormy and was characterized by severe diarrhea and vomiting, profuse ascites, pleural effusion, abdominal tenderness, peritoneal irritation, and systemic toxicity. The Clostridium difficile assay was negative on two occasions. Features compatible with pseudomembranous colitis were seen at sigmoidoscopy, and the diagnosis was confirmed by biopsies.

Sarcoidosis and giant midesophageal diverticulum.

Traction diverticula of the midesophagus result from granulomatous inflammation of mediastinal lymph nodes. Tuberculosis and histoplasmosis are known etiologies of this condition. To the best of our knowledge, this is the first report of a traction diverticulum caused by sarcoidosis.

Antiproliferative and differentiating effects of benzodiazepine receptor ligands on B16 melanoma cells.

In this study, we evaluated the effect of several ligands active at the central-type and peripheral-type benzodiazepine receptor (BzR) (clonazepam, diazepam, PK11195 and Ro5-4864) on the growth and differentiation of B16 melanoma cells. All tested BzR ligands were able to suppress proliferation of the cells at the micromolar range and in a concentration-dependent manner. However, agents selectively active at the peripheral-type BzR (PK11195 and Ro5-4864) exhibited more potent antiproliferative activity. In addition, the BzR ligands were demonstrated to affect the cell cycle by reducing the percent of cells in the S phase and increasing the percent in the G2/M phase. BzR ligands induced cellular phenotypic alterations, which have been previously shown to be associated with melanoma cell differentiation. These alterations included: marked morphological changes, enhancement of melanogenesis, lipid accumulation and increase in the activity of gamma glutamyl transpeptidase. All BzR ligands induced a marked reduction in the concentration of UTP and most of them did the same in GTP and CTP, while ATP levels were not significantly altered. In summary, BzR ligands (clonazepam, diazepam, PK11195 and Ro5-4864) were found to exert antitumor effects in B16 melanoma cells. These findings encourage further studies of a possible therapeutic potential of BzR ligands in treatment of melanoma.

The secrets of the unknown trauma patient. The hazards of undiagnosed subclavian steal syndrome in the chest trauma patient: a case report.

Chest trauma can be complicated, among others, with cardiac tamponade. This life-threatening condition should be treated promptly and adequately to assure a positive outcome. During the rapid events that take place in the emergency room with the arrival of a polytrauma patient, anamnestic data are not always available, especially if dealing with a non-cooperative, unaccompained traumatized patient. The following case report describes our experience with a chest trauma patient after a vehicle accident, who was admitted to our ward exhibiting a constellation of signs compatible with a cardiac tamponade. The only demonstrable objective signs included distended mediastinum and heart shadow on the chest X ray and muffled heart sounds. However, despite the impressive clinical picture, the patient continued to exhibit constant, though low blood pressure measurements and after a short period of observation, given the homodynamic stability, it was decided against pericardiocenthesis. The "secret" of our patient was finally discovered at angiography, when a left subclavian steal was diagnosed. The literature in this matter is discussed, stressing the importance of anamnestic data in the trauma patient. Most importantly, we address the significance of relying on hard clinical data (homodynamic stability) rather than on isolated signs (widened mediastinum/heart shadow) to reach as accurate a diagnosis as possible before pursuing invasive, usually not-innocuous procedures (pericardiocenthesis).

Of balloon axilloscopy and avoidance of iatrogenic injury to the long thoracic nerve.

BACKGROUND: Laparoscopic removal of axillary lymph nodes is possible and affords an excellent view of all structures, allowing preservation of vessels and nerves. The technique uses pediatric trocars and a lifting device to maintain the newly created axillary space. OBJECTIVE: To prove that a newly developed technique of balloon axilloscopy can be performed using only one 10-mm and two 5-mm standard trocars and constant carbon dioxide flow to preserve the axillary space and that preservation of all nerves and vessels is possible with this approach. DESIGN: Prospective study on 4 fresh-frozen human cadavers and 7 live porcine models. SETTING: A hospital department of minimal surgery access and a university department of anatomy. RESULTS: The balloon dissection consistently revealed and preserved the nerves and vessels, and exposure and dissection of the first rib could similarly be accomplished. An alternative route to the apex of the axilla has been developed--between the pectoralis minor and pectoralis major muscles--after their careful separation. The axillary content of surgical interest (lymph nodes) is easily separated from the other anatomical elements and is simply dissected under complete visualization and preservation of all vital axillary structures. CONCLUSIONS: Balloon axilloscopy was easy to perform, provided the surgeon with constant visualization of vital anatomical structures, and allowed easy separation and dissection of the axillary lymph nodes and the first rib. As a technical aid prior to a conventional axillary dissection, or as part of a pure endoscopic procedure in the axilla, balloon axilloscopy is 100% reliable in identifying the long thoracic nerve and moving it out of the way, separating the lymph nodes from it and from the intercostobrachial nerve and axillary vein and artery, rendering the whole dissection process safer for both the surgeon and the patient.

Esophageal motility abnormalities in cirrhotic patients before and after endoscopic variceal treatment.

Esophageal motility abnormalities in patients treated endoscopically for variceal hemorrhage are rarely studied and usually are not addressed in the clinical setting. However, a review of the literature revealed that esophageal varices reduce the mean amplitude and increase the mean duration of peristaltic waves but have little effect on lower esophageal sphincter function. Transit time is delayed and gastroesophageal reflux disease is common in up to 64% of the patients. Whereas band ligation appears to have little impact on esophageal motility, data are limited and are hampered by lack of standardization, rendering conclusions about safety rather premature. Injection sclerotherapy spares the lower esophageal sphincter, as well, but it significantly reduces mean amplitude contractions, mainly in the lower one-third to one-half of the esophagus. In addition, normal peristalsis may be occasionally or completely replaced by nonpropagating simultaneous contractions that may result in chest pain and/or dysphagia in the absence of stricture. Transient prolongation of acid clearance usually resolves within a week, except in patients who have developed stricture. Pathogenesis of the abnormal motility remains poorly understood, and treatment has been empirical. However, a short course of anti-reflux treatment after each therapeutic session is justified, as well as long-term treatment for patients with stricture. The choice of treatment for esophageal motility abnormalities is less clear and requires future studies.

Mediastinal parathyroid cysts.

BACKGROUND: Mediastinal parathyroid cysts are a relatively rare clinical entity. The clinical presentation can be quite varied, although most are found incidentally during investigations for esophageal or respiratory symptoms. METHODS: We present a review of the literature and describe two instructive cases showing specific clinical findings. The clinical presentation, radiologic and pathologic findings, and treatment of mediastinal parathyroid cysts are discussed. RESULTS: In the first patient, the presenting symptom was increasing hoarseness resulting from paresis of the right recurrent laryngeal nerve. This case illustrates the rare association of a benign mediastinal parathyroid cyst with unilateral vocal cord palsy. The second patient presented with the more classic findings of progressive dyspnea and stridor related to tracheal compression. CONCLUSIONS: Although mediastinal parathyroid cysts are rare and can have varied presentations, thorough investigation can reveal the underlying cyst. Surgical excision is the treatment of choice and can be expected to produce excellent results.

Incidental cholecystectomy in the over-70 age group. A 19-year retrospective, comparative study.

OBJECTIVES: To analyse the outcome of incidental cholecystectomy in the over 70 age-group during surgery for gastrointestinal malignancies. DESIGN: Nineteen-year retrospective, comparative study. SETTING: Department of Surgery B, Belinson Campus, Rabin Medical Center. SUBJECTS: The hospitalization records of 4,072 patients who underwent cholecystectomy between 1975 and 1994 were reviewed. The incidental cholecystectomy cases for this period were identified and those performed during surgery for gastrointestinal malignancy were analysed separately. A sex- and age-matched control group was identified for comparison. MAIN OUTCOME MEASURES: Postoperative complications, overall morbidity and mortality, postoperative hospitalization days. Statistical differences in gallbladder-related complications and mortality among groups. RESULTS: Mortality and overall morbidity were significantly increased in the no-cholecystectomy group. Hospitalization days were increased significantly in the group not under-going cholecystectomy and although it didn't reach statistical significance, there was a clear trend for increased number of pulmonary complication in this same group. Sepsis and multiorgan failure, as an expression of acutely, postoperative symptomatic gallbladder were the major cause of death in the no-incidental-cholecystectomy group. CONCLUSIONS: Incidental cholecystectomy is safe and should be considered in every case of abdominal surgery, regardless of the age of the patient. In the over 70 age group, complication and mortality rates increase significantly and dreadfully when the gallbladder is left in situ after surgery for gastrointestinal tumors. Incidental cholecystectomy is not warranted in patients undergoing palliative procedures or in whom life expectancy is less than 6 months.

Zenker's diverticulum: reappraisal.

For more than 2 centuries, the nature and pathophysiology of pharyngoesophageal (Zenker's) diverticulum has been a matter of argument. The intrinsic or extrinsic forces and structures that might play a role in the development of this disorder have been repeatedly scrutinized, and still today the different theories of muscular incoordination and/or spasm, cricopharyngeal achalasia, gastroesophageal reflux, or neuromuscular abnormalities try to find their way as the final word regarding etiology remains to be told. Options for treatment follow a similar pattern although myotomy and diverticulopexy seem to have yielded the best results. In this review, historical and current data gathered from the world literature are compiled in an attempt to give a clear overview of the pathophysiology surrounding the genesis of Zenker's diverticulum and the clinical manifestations, diagnosis, and different alternatives for definite treatment of this disorder.

Successful treatment of anal tumors with CO2 laser in elderly, high-risk patients.

The central issue in elderly surgery remains the operative risk, which is usually a direct factor of age, ASA classification, and other pathologies, especially cardiovascular diseases. It is the surgeon's role to define properly the risks involved with a patient and to anticipate the involved operative mortality. Based on this, we performed CO2 laser fulguration of anal canal tumors in 10 patients suffering from either squamous cell or adenocarcinoma localized up to 4 cm from the anus. The rationale was to avoid prohibitive operative and anesthetic risk, achieve local control of disease and improve quality of life by avoiding surgical convalescence and an otherwise certain colostomy. All patients underwent fulguration (25-30 W) every 3-4 months. Complications included minor pain and bleeding. Three patients required operation (Hartman's pouch) within 2 1/2 years due to continuous tumor bleeding and stricture of the anal canal. The remaining 7 patients were treated regularly and satisfactorily by fulguration and the mean survival in this group was 8 years (in all cases the causes of death were unrelated to the procedure or the tumor). We conclude that CO2 laser fulguration of anal canal tumors in elderly, high-risk patients represents an invaluable option of treatment, while avoiding major operative risk, controlling the local spread of disease, maintaining physiological bowel function, and avoiding colostomy. Most importantly, the main dividends of the study are patient satisfaction and maintenance of good quality of life.

The use of CO2 laser for inguinal hernia repair in elderly, pacemaker wearers.

Interference of electrical current with pacemaker activity is well known and has long been described. Almost every surgical procedure is now performed with the electrical knife, or electrocautery. In patients wearing a pacemaker this poses a problem, because of the danger of electronic interference within the pacemaker with consequent firing-frequency changes and the higher risk of intra- and postoperative bleeding and oozing when using a scalpel instead of cautery. We have performed 25 hernioplasties in elderly patients with permanent pacemakers using the CO2 laser technique. All operations were technically successful, and the immediate and long term (1 year) follow-up proved uneventful. Additionally normal pacemaker function was maintained during surgery and through the follow-up period. CO2 laser surgery is advantageous over electrocautery in patients with pacemakers because it does not interfere with pacemaker activity. Moreover, the laser produces normal hemostasis and does not stimulate muscle and nerve activity during surgery.

Novobiocin modulates colchicine sensitivity in parental and multidrug-resistant B16 melanoma cells.

The effect of the antibiotic agent novobiocin on the sensitivity of melanoma cells to colchicine and vinblastine was examined in drug-sensitive and drug-resistant B16 melanoma cells. A cell line COL/R was selected for colchicine resistance. The COL/R cell line (resistant to 80 ng/ml colchicine) was found to possess the multidrug-resistant (MDR) phenotype. The cells were shown to be cross-resistant to vinblastine and Adriamycin and to overexpress P glycoprotein. P glycoprotein activity was assessed by using the rhodamine 123 accumulation test. Rhodamine accumulation was markedly decreased in COL/R cells as compared to the parental B16 cells. Verapamil reversed drug resistance and increased rhodamine accumulation in COL/R cells. Novobiocin in combination with colchicine or vinblastine synergistically inhibited the proliferation of parental B16 cells. In COL/R cells, novobiocin markedly decreased colchicine resistance and increased rhodamine accumulation. These data show that novobiocin increases the sensitivity of both parental and MDR melanoma cells to microtubule-disrupting cytotoxic drugs.

Rejection of a gelatin-impregnated Dacron graft.

Sealing of the synthetic vascular graft is important to solve problems of leakage. The use of a new vascular graft--Dacron impregnated by gelatin--is described. After operation the patient developed a febrile reaction, and in spite of a thorough investigation no septic foci could be identified. It is believed that the fever was immunological in origin.

Amino acid alcohols: growth inhibition and induction of differentiated features in melanoma cells.

The effects of a series of D- and L-amino acid alcohols on the proliferation and phenotypic expression of B16 mouse melanoma cells were evaluated. B16 melanoma cells were incubated for different time intervals in the presence of D- or L-phenylalaninol (PHE), D- or L-alaninol (AL), D- or L-leucinol (LE), L-histidinol (HIS), L-tyrosinol (TYR) and L-methioninol (MET). All agents, including the D or L configuration, induced an anti-proliferative effect, although of considerably different magnitude. D-PHE was the most active growth inhibitor. The growth inhibitory effects were accompanied by phenotypic alterations, which included morphological changes and enhancement in the activities of NADPH cytochrome c reductase and tau-glutamyl transpeptidase. These phenotypic alterations correlated with the growth inhibitory effects of the different agents and seem to reflect a higher differentiated state.

[Aortocaval fistula].

Aortocaval fistula is a rare phenomenon which has both acute and chronic clinical presentations. Its diagnosis and treatment are difficult and it presents a surgical challenge of the first degree, requiring intensive perioperative care. A patient with an aortocaval fistula is described. It was found during emergency operation for a ruptured abdominal aortic aneurysm.

The risk of cholecystectomy for acute cholecystitis in diabetic patients.

In order to evaluate the risk of acute cholecystitis in diabetic patients, we analyzed 2,700 consecutive cholecystectomies, 566 of which were performed in the presence of acute cholecystitis. Of these patients 123 had diabetes mellitus (DM) and 433 had no diabetes (ND). The aim of this study was to establish the comparative risks in the two groups. We found that diabetics are more likely to be operated on in the acute stage of their disease (22% vs. 12%). The DM group had a higher rate of septic bile, gangrenous changes and perforations of the gallbladder wall. The morbidity rate was higher in the DM group (21% vs. 9%), and mortality was slightly higher in the DM group. The degree of additional operative risk does not in our view justify recommending cholecystectomy in diabetic patients with asymptomatic gallstones. Early surgery however, is highly recommended in diabetics with symptomatic gallstones and acute cholecystitis.