The hemodynamics of steal syndrome and its treatment.

A 61-year-old man developed steal syndrome after creation of a transposed basilic vein arteriovenous fistula (AVF) resulting in rest pain and ischemic ulcers in the fingertips. Our initial surgically created stenosis reduced the diameter by 32% and the area by 56%, and increased the radial artery pressure from 52 to 78 mmHg, with relief of symptoms. Within 3 weeks his symptoms reappeared. Repeat measurements did not explain his return of symptoms. A second area of stenosis was created in the AVF, with a diameter reduction of 75%, and an area reduction of 94%. His symptoms resolved, and his ulcers healed. The hemodynamics of the AVF and the steal syndrome were evaluated by duplex imaging and Doppler pressure assessment. A greater stenosis increased the radial artery pressure from 78 to 140 mmHg while maintaining flow through the AVF. Rather than increasing the degree of stenosis at the first site, we created a second area of stenosis. Hemodynamically, this would be additive to the first without the risk of creating a high-grade stenosis that could thrombose the AVF. Increasing the resistance in the AVF will decrease flow in the AVF and, ultimately, increase flow to the hand.

The treatment of gastric mucosal prolapse syndrome with laparoscopic nissen fundoplication.

Gastric mucosal prolapse occurs when a portion of the mucosa of the stomach herniates into the esophagus, resulting in massive hemorrhage. A 19-year-old man presented on two occasions with an upper gastrointestinal hemorrhage as a result of this syndrome. He was definitively treated with a laparoscopic Nissen fundoplication. This case report outlines his presentation, defines and details gastric mucosal prolapse, and discusses the treatment of this syndrome with laparoscopic Nissen fundoplication.

Prospective, multicenter study of laparoscopic ventral hernioplasty. Preliminary results.

BACKGROUND: A standard technique for laparoscopic ventral hernioplasty (peritoneal onlay using an expanded polytetrafluoroethylene [ePTFE] patch for hernias >/=4 cm2) is being used in a prospective, multicenter, long-term study. METHODS: Demographic, operative, and postoperative data were collected and analyzed. Follow-up clinical evaluations were conducted 7-10 days, 4 weeks, 6 months, 1 year, and then annually after surgery in all patients. RESULTS: In the first 2 years of the study, 144 patients were enrolled; nine were lost to follow-up. The mean operating time was 120 min. The mean follow-up was 222 days (range 5-731). Postoperative complications were five infections, three cases of prolonged ileus, one bowel obstruction, 23 seromas (15 resolved without intervention), and six hernia recurrences. Hospital discharge occurred a mean of 2.3 days after surgery and return to normal activity a mean of 15 days postoperatively. CONCLUSIONS: Laparoscopic prosthetic ventral hernioplasty avoids the large wound required in open repairs, with attendant complications and recurrences, and appears safe, especially if an ePTFE mesh is used. Compared with conventional open ventral hernioplasty, the laparoscopic technique may also allow shorter hospitalization and a quicker return to normal activities after surgery.

Diagnosis of postoperative urinary ascites using renal scintigraphy.

Nuclear medicine biliary studies have been routinely used to identify bile leaks that occur after laparoscopic cholecystecomy. The use of a Tc-99m mercaptoacetyltriglycine (MAG3) renal scan to diagnose a case of urinary leakage that occurred after a laparoscopic-assisted colectomy is shown in this report. Laparoscopic surgery is widely used in place of conventional laparotomy to minimize recovery time and discomfort after surgery. The complication rate for laparoscopic colectomy has been reported as approximately 6% to 10%. In particular, ureteral leak has been reported in 2% of procedures. Ascites of unknown origin can become a diagnostic dilemma. We present a case of postoperative ascites of unknown origin that was successfully diagnosed as urinary leakage using renal scintigraphy.

Technical considerations in endoscopic cervicothoracic sympathectomy.

OBJECTIVE: To evaluate the technique and results of videoendoscopic cervicothoracic sympathectomy in patients who have reflex sympathetic dystrophy or hyperhidrosis of the upper extremity. DESIGN: Clinical case series. The cohort underwent diagnostic evaluation and surgical intervention, and had a mean postoperative follow-up of 14 months. SETTING: An urban, university-affiliated tertiary referral medical center. PATIENTS: A consecutive, referred sample. Seven of the nine patients had reflex sympathetic dystrophy and two had bilateral upper extremity hyperhidrosis. Five were women and four were men, with a mean age of 44 years. INTERVENTIONS: Ten thoracoscopic sympathectomies, encompassing the lower third of the stellate ganglion to the fourth thoracic ganglion, in nine patients. The technique is performed under general anesthesia, using three 1-cm incisions for instrument placement. Patients had bilateral hand temperature probes intraoperatively. Six of the procedures were in the left hemithorax, four in the right. MAIN OUTCOME MEASURES: Relief of the symptoms for which the patient was referred. Perfection and alteration of the technique also were measured. RESULTS: The average operating time was 91 minutes. The average length of hospital stay was 3.5 days. The mean increase in skin temperature was 2.4 degrees C. Nine of 10 patients had partial or complete relief of symptoms. One patient with severe dystrophic reflex sympathetic dystrophy has persistent symptoms. One patient had a pneumothorax for 48 hours. Horner's syndrome did not develop in any patient. CONCLUSION: Endoscopic cervicothoracic sympathectomy is an effective, minimally invasive therapy for upper extremity reflex sympathetic dystrophy and hyperhidrosis.

Changes in intracranial pressure associated with apneumic retractors.

OBJECTIVE: To investigate the effect of apneumic retraction on intracranial pressure (ICP) using a live porcine model. DESIGN: Five 25- to 30-kg pigs had a fiber-optic ICP bolt inserted under general endotracheal anesthesia and were monitored for ICP, mean arterial pressure, arterial blood gas measurements, and intra-abdominal pressure before, during, and after pneumoperitoneum, with each period 30 minutes long. These series of measurements were repeated after artificially raising ICP with an epidural balloon to create a head-injured model. The mean (+/- SE) ICP in the noninjured model at baseline was 13.46 +/- 1.01 mm Hg; during pneumoperitoneum, 18.72 +/- 1.50 mm Hg (P = .0001). Similarly, in the head-injured model, ICP was raised artificially to a new baseline of 22 +/- 1.75 mm Hg with an epidural balloon, and pneumoperitoneum increased ICP to 27.40 +/- 0.93 mm Hg (P = .0001). Pneumoperitoneum was then released, and an apneumic retractor was inserted while maintaining the inflated epidural balloon. MAIN OUTCOME MEASURE: Changes in ICP. RESULTS: Applying anterior wall retraction equivalent to 20 mm Hg was not associated with changes in ICP. These observations were independent of any changes in arterial PCO2 or arterial pH. Following the release of pneumoperitoneum, abdominal wall retraction, and epidural balloon, all measurements reverted to baseline. CONCLUSION: Pneumoperitoneum adversely affects ICP, while apneumic retraction may not affect animals with raised ICP. These findings suggest that pneumoperitoneum should be used with caution in patients with raised ICP, and apneumic retraction may be a safer alternative for laparoscopic evaluation in this population.

Characteristics of patients at risk for perioperative myocardial infarction after infrainguinal bypass surgery: an exploratory study.

Patients requiring infrainguinal bypass surgery often have diffuse atherosclerotic disease, and perioperative myocardial infarction (MI) is a potentially lethal complication that is not uncommon in these patients. To establish additional clinical characteristics that might be useful in identifying patients who require more extensive cardiac evaluation, we conducted an exploratory case-control study comparing 22 patients who had a perioperative MI following elective infrainguinal bypass surgery with 191 control subjects whose bypasses were uneventful. In addition to previously recognized risk factors (e.g., history of angina or prior MI), we examined the association of perioperative MI with (1) results of common preoperative laboratory tests and ECG, (2) preoperative use of certain medications, and (3) intraoperative factors that might be anticipated prior to surgery (e.g., duration of surgery or type of anesthesia). Perioperative MI was associated not only with a history of angina, prior MI, or coronary artery disease but also with the need for certain cardiac medications, higher white blood cell (WBC) counts, ST-segment depression, left bundle branch block, and lengthy surgical procedures. Multiple logistic regression analysis identified the following factors as being independently associated with perioperative MI: preoperative antiarrhythmic agents (odds ratio [OR] = 26.4, p = 0.006), nitrates (OR = 8.4, p = 0.006), calcium channel blockers (OR = 5.5, p = 0.04), and aspirin (OR = 6.8, p < 0.01) and ST-segment depression (OR = 11.8, p = 0.01), WBC count (OR = 1.27/1000, p = 0.005), and duration of surgery (OR = 2.2/hr, p = 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

A new 3-D laparoscope in gastrointestinal surgery.

This study was set up to compare three-dimensional imaging of a new three-dimensional laparoscope with two-dimensional imaging in the inanimate and clinical settings. In the clinical setting the laparoscope was used in a total of 50 different laparoscopic operations. It provided excellent depth perception, definition, and resolution. The relationships of structures were more easily defined, and instrument manipulation was easier, doing away with the need for "touch and feel" to determine instrument position. Three-D imaging made cannulation of the cystic duct for cholangiography or with a flexible choledochoscope easier. In the inanimate setting basic simple tasks took the same time in 2-D as in 3-D, whereas a more complicated procedure of passing a needle and suture through a series of hoops was 25% faster when performed in 3-D compared to 2-D. Three-D imaging may reduce operative time for laparoscopic procedures, particularly the more complicated operations.

The retroperitoneal incision. An evaluation of postoperative flank 'bulge'.

OBJECTIVES: To determine if intercostal nerve injury is related to postoperative flank "bulge" and to determine whether the extent of the retroperitoneal incision is related to the incidence of flank bulge following abdominal aortic aneurysm repair. DESIGN: Bilateral dissection of the 11th intercostal nerve on seven cadavers; neurophysiological evaluation of five patients, three with a flank bulge and two without; and retrospective analysis of the extent of retroperitoneal incision and incidence of postoperative flank bulge in 63 consecutive patients. SETTING: Urban academic medical center. PATIENTS: Sixty-three consecutive patients who underwent retroperitoneal repair of an abdominal aortic aneurysm and neurophysiological evaluation of five volunteer patients. INTERVENTIONS: Retroperitoneal repair of abdominal aortic aneurysms. MAIN OUTCOME MEASURE: Reduction of injury to the 11th intercostal nerve by avoiding extension of the retroperitoneal incision into the intercostal space. RESULTS: Of 14 dissections of 11th intercostal nerves, there were bifurcations of the main trunk within the intercostal space in four, at the tip of the 11th rib in seven, and at least 2 cm distal to the tip of the rib in three. Neurophysiological evaluation revealed iterative discharges, polyphasia, fibrillation potentials, and altered recruitment patterns compatible with intercostal nerve injury in patients with a bulge but not in the opposite abdominal wall musculature or in patients without a bulge. Seven (11.11%) of 63 patients had a bulge. Thirty-one of 63 patients had incisions into the 11th intercostal space in which a bulge developed in six (19.35%). Thirty-two patients had incisions that avoided extension into the intercostal space; a bulge developed in one (0.03%) (P = .53). CONCLUSIONS: Postoperative bulge is related to intercostal nerve injury with subsequent paralysis of abdominal wall musculature. Intercostal nerve injury can be reduced by avoiding extension of the incision into the 11th intercostal space.

Diagnostic laparoscopy increases intracranial pressure.

There are numerous reports in the literature concerning the use of laparoscopy for evaluation of abdominal trauma victims. The safety of laparoscopic evaluation in trauma patients with potentially severe intracranial injuries has not yet been analyzed. This study investigates the effect of pneumoperitoneum on intracranial pressure (ICP) and cerebral perfusion pressure. Five 30-kg pigs were monitored for ICP, mean arterial pressure (MAP), arterial blood gases (ABGs), and intra-abdominal pressure (IAP) for 30 minutes before, during, and after pneumoperitoneum. These series of measurements were repeated after artificially elevating the ICP with an epidural balloon. The mean ICP at baseline was 13.46 +/- 1.01 mm Hg. The mean ICP during pneumoperitoneum was 18.72 +/- 1.50 mm Hg (p = 0.0001). The ICP increased to 27.40 +/- 0.93 mm Hg (p = 0.0001) after the ICP was raised artificially to a new baseline of 22 +/- 1.75 mm Hg with the epidural balloon. These increases were independent of changes in arterial PCO2 or arterial pH. Pneumoperitoneum during laparoscopy may increase ICP and must be used cautiously in evaluating patients with severe head injuries.

Do infected inguinal lymph nodes increase the incidence of postoperative groin wound infection?

PURPOSE: Risk factors for postoperative wound infection in patients undergoing vascular surgery may include age, comorbid conditions, wound classification, use of prosthetic grafts, and repeat operations. Groin incisions, in particular, pose substantial risk during placement of prosthetic grafts. METHODS: To investigate the role of infected inguinal lymph nodes (LN) in groin wound infection (GWI), we excised an inguinal LN from 69 consecutive patients (89 groins) undergoing 36 infrainguinal reconstructions, 24 aortobifemoral bypasses, 12 extra-anatomic femoral bypasses, 11 vein stripping, and 6 femoral pseudoaneurysm repairs. LN Gram staining was performed, and aerobic and anaerobic cultures were obtained. In addition cultures were taken from any ulcerated or gangrenous lesion on the ipsilateral open extremity lesion. RESULTS: Bacteria were isolated from 10 of 89 LN (11.2%) and included Staphylococcus species, gram-negative rods, diphtheroids, and Peptostreptococcus. Three of the 10 LN were taken from extremities with open lesions; seven were not. In no case did organisms cultured from a groin LN correlate with its corresponding open extremity lesion. Four GWI developed after operation (4%). In each case results of the groin LN cultures were negative. Three of the GWI were associated with an ulcerated or gangrenous lesion on the ipsilateral extremity (p = 0.08, odds ratio = 7.6), but in only one case did the organisms from the GWI correspond to that in the open lesion. The development of a GWI was strongly associated with insulin-dependent diabetes mellitus (p = 0.009, odds ratio = 22.9). CONCLUSION: In conclusion, 11% of groin LN harbored bacteria, but none of these were associated with subsequent development of a wound infection. Instead, insulin-dependent diabetes mellitus and the presence of an open skin lesion on the ipsilateral extremity seemed to be associated with an increased risk of wound infection.

Inferior pancreaticoduodenal artery aneurysm: report of a case and review of the literature.

Inferior pancreaticoduodenal artery aneurysms are rare, with only 34 cases reported in the literature. Most cases reported have begun with variations of abdominal or epigastric pain. We report a unique case of aneurysm of the inferior pancreaticoduodenal artery that began with intestinal angina and weight loss.

Laparoscopic highly selective vagotomy.

Although the prevalence of peptic ulcer disease has not decreased, the number of surgical procedures for definitive treatment of peptic ulcer disease has diminished. While H-2 blockers are effective in healing ulcers, the incidence of recurrence, particularly in patients who have specific risk factors and do not use life-long maintenance therapy, may range from 50-90%. In an attempt to minimize the morbidity of definitive ulcer surgery, this study was undertaken to perform and evaluate highly selective vagotomy performed laparoscopically in the porcine model. Sixteen swine underwent laparoscopic highly selective vagotomy. The acute group (n = 10) underwent immediate celiotomy after the surgery. The chronic group underwent barium studies and celiotomy 6 months following surgery. In 70% of the acute group and 100% of the chronic group, nerve identification and division were accurate. Bleeding, when encountered, could be managed laparoscopically. In the chronic group, the postoperative weight gain was appropriate and barium studies were normal. This paper details the technique and results of laparoscopic highly selective vagotomy in an animal study and shows that this procedure can be safely and accurately performed. Based on this study, a clinical trial, which includes studies of acid production, long-term follow-up, and intraoperative endoscopic Congo red testing has been undertaken on recipients of laparoscopic highly selective vagotomy.

Laser lithotripsy for the management of retained stones.

The morbidity of reoperation for retained biliary stones is not significant. Many techniques have been developed to avoid reoperation. This study analyzes T-tube tract choledochoscopy and lithotripsy using a 504-nm pulsed dye laser for treatment of retained stones. A flexible choledochoscope is passed into the biliary tract and laser energy is delivered under endoscopic visualization after passing a 320-microns laser fiber through the instrument channel. Eight patients were treated in nine sessions. The mean number of pulses was 1512.33, delivered at 3 to 5 Hz with an energy of 100 to 120 mJ. In all patients, the biliary tract was cleared. A single patient's treatment was complicated by transient bacteremia. Mean follow-up was 10 months. Choledochoscopic laser lithotripsy is a safe, effective technique that may also play a major role in laparoscopic common duct surgery.

Variation in the size and number of stone fragments after gallbladder lithotripsy.

Ninety-four gallbladder ultrasound examinations were carried out in 11 patients at intervals for the first 40 days after lithotripsy. No dissolution or other active therapy was carried out during this time. Fragment size and number were measured to determine the postlithotripsy variability. Analysis of variance (ANOVA) showed no significant changes in fragment size or number over time. The changes in fragment size and number compared to the previous measurements were then evaluated. Again, ANOVA showed no significant changes between times. The average change in absolute size was 3.1 +/- 0.6 mm, and the average change in absolute number was 1.4 +/- 0.5. We conclude that fragment size and number as determined by ultrasound do not vary significantly with time during the first 40 days. The absolute size change measured to the nearest millimeter should be at least 4 mm to surpass the 95% confidence interval. Similarly, the absolute change in number should be at least 2 to be regarded as significant.

Cholecystcholangiography during laparoscopic cholecystectomy: cholecystcholangiography or cystic duct cholangiography.

Laparoscopic cholecystectomy is being used more frequently in the treatment of symptomatic cholelithiasis. The procedure as originally described was performed with cystic duct cholangiography. An alternate technique of performing cholangiography is cholecystcholangiography. Because of the objections that have been voiced concerning direct gallbladder injections namely, reliability of the technique, quality of the studies, and the risk of forcing stones into the common bile duct this study was performed. Subjects were 25 consecutive patients who underwent cholecystcholangiography during laparoscopic cholecystectomy. A standard technique was developed and used. Studies were graded from 0 to 5 depending upon quality with 5 being the best and 0 the worst. A 5 consisted of visualization of all of the biliary tract structures and the duodenum and a 0 consisted of visualization of only the gallbladder. Acceptable studies (graded 3, 4, or 5) were obtained in 20 patients (80%). An inability to obtain an acceptable study could usually be determined prior to contrast injection. Accordingly there would be no time delay in proceeding directly to cystic duct cholangiography. In our patients, 48% had stones in the gallbladder smaller than the caliber of the cystic duct. Based upon the results of this study we believe that cholecystcholangiography is the technique of choice for intraoperative cholangiography during laparoscopic cholecystectomy. In patients in whom this technique is not feasible the surgeon should proceed directly to cystic duct cholangiography. There was no added risk to the patient when cholecystcholangiography was performed. There was a benefit in terms of the ease of the procedure and the performance of the procedure over cystic duct cholangiography. The determination of ductal anatomy prior to cystic duct dissection may be important in minimizing the risk of ductal injury during laparoscopic cholecystectomy.

Electrohydraulic lithotripsy (EHL) for the treatment of large retained common duct stones.

Retained biliary stones may be too large for extraction through the existing T-tube tract. It may be necessary to dilate the tract, crush the stones or use endoscopic papillotomy. There are reports of stones and the extracting basket becoming stuck in the T-tube tract and tract ruptures caused by extracting large stones. In this study electrohydraulic lithotripsy (EHL) is used in combination with T-tube tract choledochoscopy for the fragmentation of large stones prior to basket extraction. T-tube choledochoscopy was performed under IV sedation and sterile conditions no sooner than one month following common bile duct exploration. The Olympus 4.9-mm choledochoscope was passed through the T-tube tract to visualize the stone. A #5 Fr EHL probe was passed through the endoscope and advanced to within 1 mm of the surface of the stone. EHL discharge was started at a low energy level being increased until the spark discharges caused stone fragmentation. The resultant stone fragments were basket extracted under direct vision. The procedure was used in twelve patients with removal of all stones in eleven patients. Eight patients were treated with one endoscopic session. Because of multiple stones, two patients required two sessions and one patient four sessions. In one patient stone position prevented adequate fragmentation and endoscopic papillotomy also failed. Repeat choledochoscopy and EHL were successful. There were no complications of EHL or choledochoscopy in any of the patients. EHL was both effective and safe for fragmentation of large common duct stones when performed under direct vision using a choledochoscope.