Prospective comparison of intraoperative angiography with duplex scanning in evaluating lower-extremity bypass grafts in a community hospital.

The gold standard for intraoperative evaluation of lower-extremity bypass grafts has been angiography. Limitations of this technique include inability to measure flow dynamics, violation of graft integrity, cost, and length of assessment time. The goal of this study was to evaluate duplex scanning as an alternative modality for intraoperative graft assessment. Our study group comprised of 19 consecutive patients undergoing infrainguinal bypass procedures at our institution between March 1999 and March 2000. Intraoperative angiography was compared with duplex scanning by evaluating parameters of assessment time, graft flow velocities, serum creatinine levels, and 30-day graft patency rates. Mean study times were the following: cut-film angiography, 22 +/- 1.8 minutes; real-time fluoroscopy, 17 +/- 2.5 minutes; and duplex imaging, 10.4 +/- 1.1 minutes. As noted duplex imaging times as compared with radiographic modalities were significantly shorter (P < 0.05). There was a substantial cost difference between angiography ($650) and duplex scanning ($350). A 100 per cent correlation of study findings was noted between angiography and duplex scanning. No significant change in pre- versus postoperative creatinine levels was found. We conclude that duplex scanning is an effective modality and provides reliable intraoperative vascular graft assessment data in a community hospital setting. Advantages include a shorter study time, lower cost, flow dynamic data acquisition, and avoidance of mechanical graft trauma.

The forehead lift: endoscopic versus coronal approaches.

Rejuvenation surgery of the upper one-third of the face can be accomplished by a number of well-known techniques and approaches. The objectives of this study were to: (1) determine if endoscopic-assisted forehead lifts achieve the same degree of correction as the coronal/pretrichial forehead lifts, (2) to assess the effect of concurrent blepharoplasty on brow elevation, and (3) to evaluate long-term results of coronal/ pretrichial forehead lifts. The study was a retrospective blinded comparison of pre- and postoperative photographs of patients who underwent forehead lifts. In order to control for the differences in photographs, ratios of distances were measured utilizing standard anthropometric sites of the brow, medial canthus, and subnasale. All reviewed cases were operated on by the same surgeon (S.W. Perkins, M.D.). A total of 140 patients having undergone forehead lift procedures and with 12-month postoperative photographic documentation were included in the study. Of these 121 patients had coronal forehead lifts and 19 had endoscopic-assisted forehead lifts. Results revealed that at 1 year follow-up both methods achieved brow elevation without a significant difference in the approach. Concomitant blepharoplasty had no statistical effect on brow position. Additionally, long-term follow-up on the coronal/pretrichial lifts revealed a gradual drop in brow position over 5 years. We conclude that both endoscopic and coronal/pretrichial forehead lifts provide for comparable elevation at 1-year follow-up. Concomitant blepharoplasty has minimal to no significant effect on brow position. Brow elevation in coronal/pretrichial forehead lifts may be temporary.

Laparoscopic cholecystectomy and appendectomy in situs inversus totalis.

Situs inversus totalis is an uncommon anatomic anomaly that complicates diagnosis and management of acute abdominal pain. Expedient diagnosis of common intraperitoneal disease processes such as biliary colic, acute appendicitis and diverticulitis is often delayed as a result of seemingly incongruous physical findings. We present the case of a young woman with prior emergency room visits for complaints of a vague left upper quadrant abdominal pain. An ultrasound performed on her third presentation revealed visceral situs inversus with cholelithiasis and dilated intra- and extrahepatic biliary ducts. Standard laparoscopic cholecystectomy and cholangiography with a mirror-image surgical approach was performed successfully and without complication.

Thoracic blastomycosis and empyema.

Blastomycosis is endemic in river valley areas of the southeastern and Midwestern United States. Pulmonary manifestations include chronic cough and pleuritic pain. Radiographic appearance of the infection can mimic bronchogenic lung carcinoma. Pleural effusion is rarely associated with this pulmonary infection, and empyema has not been previously reported. We report a case of pulmonary and pleural Blastomyces dermatitidis infection presenting as empyema thoracis. Diagnosis and treatment were attained with video-assisted thoracoscopic (VATS) pleural and lung biopsy and debridement.

Pulmonary artery pseudoaneurysm after tube thoracostomy.

Pulmonary artery pseudoaneurysm has been described as a complication of Swan-Ganz catheterization and right heart catheterization. Isolated cases of this condition occurring in blunt and penetrating chest trauma have been reported. In this communication, we describe the case of a patient with intracranial hemorrhage who required positive-pressure ventilation and in whom subsequent pneumothorax developed, necessitating tube thoracostomy. A persistent opacification of the lung field resulted in evaluation with computed chest tomography and color-flow Doppler ultrasonography. A pseudoaneurysm of the lingular segmental artery was identified and successfully obliterated by Gelfoam coil embolization.