Open and laparoscopic cholecystectomy in acquired immunodeficiency syndrome: indications and results in fifty-three patients.

BACKGROUND: Although acute cholecystitis is one of the most common indications for abdominal surgery in patients with acquired immunodeficiency syndrome (AIDS), previous studies have reported disappointingly high morbidity and mortality among those patients who have undergone cholecystectomy. The aims of this study were to analyze the indications for and the outcome of cholecystectomy performed for acute cholecystitis in patients with AIDS. METHODS: We retrospectively reviewed the hospital charts of 53 patients with AIDS who underwent open or laparoscopic cholecystectomy from 1992 to 1997. Statistical analysis using the chi-square, Student's t, and Fisher exact tests was conducted to determine whether cause of cholecystitis, type of surgical approach, and CD4+ T-lymphocyte count influenced outcome. RESULTS: The clinical findings and imaging by ultrasonography were always reliable in establishing diagnosis and guiding treatment of acute cholecystitis. Open cholecystectomy was performed in 24 patients (45%). The procedure was begun laparoscopically in 29 patients (55%) and converted to open in 4 (14%). The pathologic findings showed acalculous cholecystitis in 19 patients (36%) and cholelithiasis in 32 (60%). Morbidity was 34% and mortality was 2%. Type of operative approach, cause of cholecystitis, and CD4+ T-lymphocyte count (greater or less than 50 cells/mm3) did not significantly affect morbidity and mortality. The length of hospital stay was significantly influenced by the CD4+ T-lymphocyte count. CONCLUSIONS: These findings suggest that in most patients with AIDS, laparoscopic or open cholecystectomy may be performed with significant but acceptable morbidity and low mortality.

Correlation between low neuraminidase blood levels and a predisposition toward family-related breast cancer.

It has been shown that high sialic acid levels are often found in conjunction with breast cancer, and these high concentrations are thought to be due to deficiency of the enzyme neuraminidase. The study proposes to elicit a relationship between low levels of blood neuraminidase and a family history of breast cancer. Neuraminidase blood levels were measured in 30 healthy women between the ages of 35 and 65 years with no evidence of a family history of breast cancer (control group), and in 33 healthy women between the ages of 35 to 65 years, all of whom had immediate members of their families with breast cancer (study group). The mean level of the blood neuraminidase was found to be 1.375 units in the control group. On the other hand, the mean level for the study group was 1.256 units. The difference between the two groups is statistically significant, (P value < 0.01). It is important to note that in the study group 20 of the 33 participants, 60.6 per cent, had neuraminidase levels below the mean of the study group, whereas only 3 of the 30, 10 per cent, in the control group had neuraminidase levels below the mean of the study group. Deficiency of the enzyme neuraminidase may suggest an elevated risk for breast cancer.

Foregut duplication cyst: a report of a case.

During the early embryonal stage of foregut development, malformations may be encountered. Foregut duplications are considered to be due to abnormal cannulization of the gastrointestinal tract and may be communicating or non-communicating cystic or tubular. They are lined by mucosal membrane. The case herein records the first instance of a foregut duplication cyst that contained both gastric and bronchial mucosa. The patient was a 35-year-old female complaining of epigastric pain and nausea for the past several months. Physical examination revealed no abnormal findings, but an upper gastrointestinal X-ray series demonstrated an irregularity of the greater curvature of the stomach. On CT scan, a left upper quadrant mass was noted. At laparotomy, a soft, retroperitoneal mass was seen between the stomach and the left adrenal gland, measuring 5.5 x 2.5 x 2 cm. It was excised and sent for histopathology. Pathology showed the mass to be of a cystic nature, containing both gastric and bronchial mucosa. After surgery the patient made an uneventful recovery.

Elective cholecystectomy and carcinoma of the gallbladder.

The incidence of carcinoma of the gallbladder has been reputed to be approximately 1.5 per cent among those who undergo surgery for chronic cholecystitis. The incidence at Cabrini Medical Center coincides rather well with that from other studies but has shown a marked decline, 21.5 per cent, within recent years. A report from the American Cancer Society projects an even greater decline to 0.65 per cent in the incidence of this almost incurable disease within the next 1-2 years. The decrease in the incidence of cancer of the gallbladder is attributed to the great increase in the performance of elective cholecystectomy for chronic cholecystitis among people 50 years of age or younger, before they have reached the age when carcinoma of the gallbladder is most prevalent. Early surgery is advocated not only as an effective and safe form of therapy but also as a valuable preventive measure.

The incidence of intra-abdominal surgery in acquired immunodeficiency syndrome: a statistical review of 904 patients.

This communication concerns the incidence of intra-abdominal surgery in 904 patients with acquired immunodeficiency syndrome who were admitted to the Cabrini Medical Center during a 3-year period from January 1985 to January 1988. It was found that 36, or 4.2%, of the patients underwent surgery, including 12 cholecystectomies, 7 splenectomies, 7 appendectomies, 6 laparotomies, and 6 other operations for miscellaneous conditions. It was pointed out that the high incidence of inflammatory involvement of the gallbladder, appendix, and intestines in AIDS patients was in all probability due to the nature of the blood supply to these organs. All receive blood from terminal arteries or vessels with few anastomoses, and therefore when vasculitis ensues it is often followed by gangrene or ulceration of mucosal surfaces. Surgical intervention was deemed advantageous for those patients with splenomegaly and accompanying pancytopenia, acute appendicitis, and lesions of the gastrointestinal tract, but not for those with cholecystitis. The high postoperative mortality rate, 22.2%, was attributed primarily to the immunodeficient state of the patients rather than to complications of their surgery.

The surgical treatment of the Zollinger-Ellison syndrome: an update.

Forty-six professors of surgery in answers to a questionnaire reported that 143 patients with Zollinger-Ellison syndrome had been admitted to their hospitals within the last 2 years. The bed capacity of these hospitals totaled 27,019. In extrapolating these figures, it is seen that the capacity of the 46 institutions averaged 587 beds per hospital, and that an average 71.5 patients with Zollinger-Ellison syndrome were admitted each year. In other words, a hospital with 587 beds might expect 1.55 yearly admissions of patients suffering from this disease. Two surgical methods have emerged as today's main treatment choices for Zollinger-Ellison syndrome that is unaccompanied by isolated gastrinoma. These are 1) preoperatively administered H2 blockers followed by less-than-total gastrectomy, truncal vagotomy, and postoperative H2-blocker therapy; and 2) preoperatively administered H2 blockers followed by highly selective vagotomy plus postoperative H2-blocker therapy. Only seven of 46 respondents still maintain that total gastrectomy should be carried out to cure the disease. All respondents advocate excision of an isolated gastrinoma as the treatment of choice if one is found at surgery.

Cold nodules of the thyroid: current treatment.

Within recent years differing approaches to the treatment of cold nodules of the thyroid gland have evolved. To assess these differences and to discover whether a general consensus exists, questionnaires were sent to professors of surgery and endocrinology and to chiefs of head and neck sections at various medical colleges and university hospitals throughout the country. Fifty-three surgeons and 13 endocrinologists answered the questionnaires and their responses are analyzed and recorded here.

Coexistence of abdominal aortic aneurysm and carcinoma of the colon: a dilemma.

The incidence of colonic cancer coexisting with an aneurysm of the abdominal aorta is approximately 2%. Such a coexistence presents a true dilemma to the surgeon for it is often difficult to decide whether to treat the carcinoma or the aneurysm first. This report summarizes the opinions of 46 Professors of General Surgery and Vascular Surgery who gave their response as to which condition should receive priority of treatment. Approximately one third of the respondents favored excision of the carcinoma first; one third stated they would excise the aneurysm first; and the remaining third said they would withhold a decision until laparotomy was performed. Two surgeons replied that they would attempt to perform aneurysmectomy and colectomy simultaneously.

Peritoneal lavage as an aid to diagnosis of peritonitis in debilitated and elderly patients.

Twenty-seven debilitated or obtunded patients were subjected to peritoneal lavage to determine the presence or absence of peritonitis. Fourteen lavages were found to be positive, revealing peritonitis in 12 patients. Two of the 14 patients refused surgery and subsequently died. Thirteen patients had negative lavages, none of whom subsequently developed any evidence of peritonitis or required surgical intervention. Peritoneal lavage is an extremely reliable procedure, both in establishing the diagnosis of peritonitis or in ruling out its presence in debilitated or obtunded, elderly patients. The procedure can be performed quickly, without prolonged preparation, and without fear of complications. In addition, there is little cost to the procedure, especially when compared to the cost of more sophisticated time-consuming tests such as x-ray studies, gallium or CT-scanning.

Carcinoma of the breast in three siblings.

Reported are three siblings, a sister and 2 brothers, who had breast cancer. The paternal grandmother of the proband was known to have had breast cancer. It is our belief that this report supports further the genetic etiology of certain breast cancers. The study examines the literature with regard to genetically transmitted female breast cancer and also implies a genetic etiology of male breast cancer. Of special interest is the fact that the female sibling had bilateral breast cancer during her premenopausal years and that one of the two brothers also developed his lesion at an early age, 41 years.

Carcinoma of the pancreas in nonjaundiced patients. A silent disease.

This report deals with the study of 25 patients with carcinoma of the pancreas without jaundice. Carcinoma of the pancreas is the fourth most common cause of death among men who suffer from cancer. The extremely high mortality associated with pancreatic cancer is due to failure of early diagnosis. Those cases associated with obstructive jaundice can be diagnosed much earlier than those in which jaundice is absent. In the absence of jaundice, symptoms and signs of pancreatic cancer are so vague that they may be confused with those of other conditions. Routine laboratory tests aid little in the definitive diagnosis of the disease. Sophisticated new modalities of diagnosis such as ultrasonography, endoscopic retrograde cholangiopancreatography (ERCP), and CT-scanning frequently will lead to a correct diagnosis, but these tests are seldom performed unless there is a strong suspicion that carcinoma of the body of the pancreas exists. When pancreatic carcinoma without jaundice is ultimately diagnosed, it is found to be less amenable to surgery than lesions located in the head where early jaundice is more often encountered. Most patients with cancer of the body of the pancreas suffer from persistent unexplained abdominal pain, marked anorexia, and weight loss. Such patients must be subjected to sophisticated diagnostic tests in order to arrive at an early diagnosis.