Surgical considerations in the contemporary management of biliary tract disease in the postpartum period.

BACKGROUND: Excluding sterilization procedures, no experience with laparoscopic procedures in the postpartum period has been reported. The postpartum patient may have unique characteristics that must be recognized for safe management. METHODS: The authors prospectively studied 1,100 consecutive biliary patients in a private surgical practice since the introduction of laparoscopic cholecystectomy (LC). The group includes 34 patients who presented with biliary tract disease and were operated upon within 6 weeks of obstetrical delivery. Laparoscopic procedures were performed on these 34 patients 1 to 42 days following vaginal (26) or Cesarean (8) deliveries. RESULTS: All patients had calculous cholecystitis. Choledocholithiasis was documented in 10 (29%) patients, including 3 patients (9%) with missed common duct stones, and strongly suggested in 5 (15%) others. Open biliary procedures were required for 2 patients. One patient returned to surgery for an ERCP-related complication. Follow up is known for all patients. There were no delayed complications. CONCLUSIONS: The laparoscopic approach to biliary tract disease in the postpartum period is safe. Recent vertical Cesarean incisions can withstand the strain of a reduced pneumoperitoneum. The high incidence of choledocholithiasis calls for routine cholangiography in the postpartum patient.

Thoracoscopic assisted pneumonectomy.

A lung carcinoma with tumor involving more than one lobe or in close proximity to the mainstem bronchus often requires pneumonectomy for surgical cure. Inflammation, bulky tumors, and dense adhesions limit the operative field of vision and may result in the abandonment of procedures with potential for complete extirpation. This case illustrates the utility of thoracoscopy in visualization of the hilum and other neurovascular structures in a patient with a proximal tumor and dense intrathoracic adhesions. Successful resection was made possible by use of combined open and thoracoscopic modalities.

Laparoscopic surgery for HIV-infected patients: minimizing dangers for all concerned.

As the number of patients infected with the human immunodeficiency virus (HIV) increases and their life-expectancy grows, more patients will present with conditions that require surgical intervention. Laparoscopic procedures provide several specific advantages over traditional (open) procedures in this population. For the patient, the extent of invasiveness is diminished; incisions are limited; healing time and wound complications can be decreased; pulmonary function is optimized; and the patient rapidly returns to regular activity. For the surgical team, risk of exposure to body fluids is minimized. For the general population, the exclusive use of readily available disposable instruments addresses infection control issues. Of 62 procedures performed on HIV-infected patients prior to the availability of laparoscopic surgery in the general surgery department, 27 (43.6%) could have been approached laparoscopically. Two patients with HIV infection are described who recently underwent successful laparoscopic procedures. In one case, this approach was the only option the patient would consent to. More widespread use of the approach should be specifically encouraged in patients with HIV infection.

A growing spectrum of surgical disease in patients with human immunodeficiency virus/acquired immunodeficiency syndrome. Experience with 120 major cases.

One hundred twenty major general surgical procedures were performed on 88 adult patients harboring the human immunodeficiency virus. Fifty-eight (48%) of the procedures were performed on patients who fulfilled the criteria for acquired immunodeficiency syndrome. The patients were predominantly male (94%). Single risk factors included homosexuality (73% of cases), intravenous drug abuse (8%), and previous blood transfusions (8%). Four patients (5%) had multiple risk factors; risk factors were denied by seven patients (8%). The mean age at surgery was 41.6 years (range, 22 to 67 years). Surgical conditions that rarely affect the population without the human immunodeficiency virus presented diagnostic challenges. Altered physiologic responses to even routine conditions were observed. Thirty-day morbidity rates for emergency (group A) and elective (group B) procedures were 19% and 9%, respectively. This included seven surgical deaths (13%) in group A and one in group B (2%). Patients undergoing 92 of 112 procedures (82%) not associated with surgical mortality were followed up. Patients who were dead at follow-up had mean procedure-survivals of 19 weeks (group A) and 21 weeks (group B) for 33 procedures. Those who remained alive had a mean procedure-survival of 86 weeks for 59 procedures. No single prognosticator could be correlated with outcome, although the combination of hypoalbuminemia with a history of opportunistic infection(s) was associated with short survival. Emergency and elective procedures can be performed in the patient with human immunodeficiency virus/acquired immunodeficiency syndrome with acceptable morbidity and mortality. Procedures are indicated to extend patient life or to improve quality of life.

The consequences of current constraints on surgical treatment of appendicitis.

In this study, we sought to identify changes in the picture of a selected surgical condition during an interval of time that has brought about radical departures from previously established policies and programs. As a direct consequence, the patients take a more circuitous route to the surgeon. A significant number of patients with acute appendicitis in 1986 (37 percent) and 1987 (29 percent) suffered a prolonged delay in hospitalization or surgical referral compared with patients in 1980. This delay was accompanied by a more advanced stage of disease that ultimately caused a markedly increased morbidity (13 percent in 1986 and 24 percent in 1987, compared with 5 percent in 1980) and subsequent extended length of stay. This deterioration in patient care and failure at cost containment had previously been examined for conditions that can be operated electively. This study documents that the constraints also affect the treatment of patients whose initial condition requires urgent operative treatment. With specific relation to patients with acute appendicitis, surgeons recognize the value of the negative appendectomy. It appears the so-called gatekeepers must find a way to accept a certain negative hospitalization to referral rate. If current constraints will not allow this, the policies and programs behind the constraints should be changed.

Massive gastrointestinal hemorrhage caused by rupture of a jejunal branch artery aneurysm.

Aneurysms located in the arterial tree that directly supplies the alimentary tract account for a small percentage of all aneurysms. Jejunal branch artery aneurysms are an uncommon component of this group, and gastrointestinal hemorrhage from such an aneurysm has rarely been described. We report a case of a jejunal branch artery aneurysm appearing as sudden and massive gastrointestinal bleeding in a 28-year-old man. Diagnosis was made by selective superior mesenteric artery angiography, and the patient underwent successful segmental resection of the involved area of jejunum. The pertinent literature is reviewed.

The vanishing elective cholecystectomy. Trends and their consequences.

During the 1980s, there have been ongoing changes in the policies and programs that govern the health care provision system. To assess the effect of these changes on patient care, the charts of patients undergoing cholecystectomy in 1980 (132 patients) and 1986 (108 patients) were reviewed and compared. The patients are increasingly over 60 years of age. The elective cholecystectomy is being replaced by procedures for more advanced disease as referrals of patients to the surgeon are delayed. The morbidity more than doubled. Compared with 1980, the policies and programs in effect during 1986 allowed fewer patients to undergo cholecystectomy (-18%), but required a markedly increased cost for those patients (+22%).

Postgastrectomy phytobezoars--endoscopic diagnosis and treatment.

Thirty-three consecutive patients with 38 bezoars were identified since 1975. Twenty-nine patients (87.8%) had undergone previous gastric surgery. The average interval between surgery and bezoar diagnosis was 7.7 years. There were 14 men and 19 women (mean age, 61.5 years). Epigastric distress (84%) and weight loss (31%) were the most common complaints. Twenty-two (75.9%) of 29 barium studies were falsely negative. Attempts at prior enzymatic dissolution had failed in three patients. Three (13.6%) of 22 patients available for follow-up had multiple episodes of bezoar formation. All patients underwent esophagogastroduodenoscopy for diagnosis and concomitant fragmentation and "flushing" of the bezoar for resolution. The success rate was 100%; no complications occurred.