Internal hernia caused by epiploic appendices successfully treated by single-incision laparoscopic surgery (SILS).

Internal hernia is a rare and often overlooked cause of small bowel obstruction. We report a case of internal hernia with an orifice composed of epiploic fat, successfully diagnosed and treated by single-incision laparoscopic surgery. This is the second report of this type of internal hernia and the first reported case addressed laparoscopically. Although the use of laparoscopy for the treatment of small bowel obstruction is not firmly established today, it may be beneficial for both its diagnostic value and as a less invasive treatment.

Optimal timeline for emergency surgery in patients with strangulated groin hernias.

PURPOSE: This retrospective study evaluates the clinical course and outcomes of patients who underwent surgery for strangulated hernias. METHODS: Among 520 groin hernias from 2001 to 2012, 51 inguinal and 42 femoral hernias were strangulated and operated emergently at a tertiary referral center. Perioperative factors, patient profiles, and time interval to surgery (T total = time from onset to surgery, T 1 = time from onset to initial evaluation, T 2 = time from the first hospital to the tertiary center, T 3 = time from admission at the tertiary center to surgery, T total = T 1 + T 2 + T 3) were analyzed in patients with strangulation, then compared between two groups, the bowel resection (BR) group and the non-bowel resection (NBR) group. RESULTS: T 1, T 2 and T total in the bowel resection group were significantly longer than those in the non-bowel resection group (P < 0.05). Patients who presented initially to the tertiary center (T 2 = 0) had a significantly lower resection rate than patients transported from other hospitals (24 vs. 44 %, P = 0.048). There was no significant difference in morbidity between the BR and NBR groups (35 vs. 24 %, P = 0.231). CONCLUSIONS: The elapsed time from onset to surgery, especially T 1 and T 2, is the most important prognostic factor in patients with strangulated groin hernias. Early diagnosis and transportation are essential for good outcomes.

Three-step method for ultrasound-guided central vein catheterization.

BACKGROUND: The long-axis view and in-plane needle approach (LAX-IP) for ultrasound-guided central vein catheterization is considered ideal because of the quality of real-time imaging. We describe a novel technique, using a step-by-step procedure, to overcome the pitfalls associated with the LAX-IP. This study was undertaken to demonstrate the clinical utility of this approach. METHODS: All operators underwent training before participation in this study. One hundred patients were enrolled in this study and underwent central venous catheterization using this method. Using a portable ultrasound and vein catheterization kit, patients were appropriately positioned and a straight portion of the vein identified (Step 1). A needle guide was used (Step 2) and the vein imaged in real time in two directions (Step 3), to identify the true long axis and prevent damage to surrounding tissues. RESULTS: The overall success rate for catheterization was 100% with a median of one puncture for each patient. All catheterizations were performed within three punctures. Problems with the first puncture included difficult insertion of the guide-wire due to coiling, difficult anterior wall puncture, less experience with the procedure, and other reasons. There were no complications associated with the procedure. CONCLUSIONS: This three-step method is not dependent on an operator's ability to proceed based on spatial awareness, but rather depends on logic. This method can prevent difficulties associated with a two-dimensional ultrasound view, and may be a safer technique compared with others. Further clinical trials are needed to establish the safety of this technique.

Laparoscopic splenectomy using pneumoperitoneum or gasless abdominal wall lifting: a 15-year single institution experience.

INTRODUCTION: Laparoscopic splenectomy using pneumoperitoneum has been performed since 1992. The gasless abdominal wall-lifting method for laparoscopic splenectomy was introduced as an alternative. This retrospective study was undertaken to compare results using the two techniques. METHODS: Between 1995 and 2010, 54 patients underwent laparoscopic splenectomy at a single institution; 30 underwent the procedure using the gasless technique and 24 using pneumoperitoneum. There were no significant differences between the two groups regarding age, sex or BMI, but more patients underwent concurrent operations in the pneumoperitoneum group. The abdominal wall-lift system with subcutaneous K-wires was used for the gasless method. RESULTS: Intraoperative blood loss was similar in the two groups (193.0 ± 196.7 mL gasless, 217.3 ± 296.6 mL pneumoperitoneum; P > 0.05), but operative time (182.1 ± 92.1 min, 135.1 ± 46.1 min; P < 0.05), and resected spleen weight (306.1 ± 297.7 g, 138 ± 81.0 g; P < 0.05) were significantly different. In the gasless group, additional procedures included conversion (n = 1), mini-laparotomy (n = 2), and CO(2) insufflation (n = 2). Excluding the concurrent living-related kidney donor patients, hospital stay was similar (6.9 ± 2.5 days, 6.3 ± 2.0 days, P > 0.05). CONCLUSION: Although gasless laparoscopic splenectomy is feasible, there are disadvantages, particularly the restricted operative working space in some patients. These results suggest that either technique may be used on an individual basis in patients undergoing laparoscopic splenectomy.

A quantitative evaluation of fluid leakage around a polyvinyl chloride tapered endotracheal tube cuff using an in-vitro model.

INTRODUCTION: This study was designed to quantitatively evaluate the sealing effect of a polyvinyl chloride tapered endotracheal tube cuff and to compare the tapered cuff with cylindrical endotracheal tube cuffs using an in vitro viscous fluid model. METHODS: Five types of 8.0 mm inner diameter endotracheal tubes (TaperGuard, PortexSacett, PortexSoftseal, Sheridan HVT, Sheridan CF) were fixed in vertically placed 20mm internal diameter acrylic tubes. The cuffs were inflated to 25 mmHg pressure and water was added to the top of the cuff. The amount of water leaking around the cuff at five minutes was measured. Afterwards a viscous fluid was poured above the cuff and the amount of fluid passing around the cuff at five minutes and four hours was measured. Each determination was repeated five times and the data analyzed. RESULTS: The median (range) amount (ml) of dyed water passing around the cuff at 5 minutes was TaperGuard tube 0 (0-0.2), PortexSacett 81.1 (44.6-107.9), PortexSoftseal 95.4 (91.4-113.7), Sheridan HVT 46.5 (32.7-74.6) and Sheridan CF 52.6 (31.9-62.2), suggesting that TaperGuard significantly (P<0.05) reduced fluid leakage. The viscous fluid leakage at 5 minutes was not significantly different among the groups while the amount of leaked viscous fluid at 4 hours was 0.2 (0-1.1) for the TaperGuard, 57.6 (11.9-117.4) for the PortexSacett, 23.2 (13.8-33.0) for the PortexSoftseal, 5.5 (2.7-15.4) for the Sheridan HVT and 5.6 (1.8-7.9) for the Sheridan CF. CONCLUSION: An endotracheal tube with a tapered polyvinyl chloride cuff had significantly less fluid leakage compared to four tubes with cylindrical cuffs.

The role of laparoscopy in the treatment of intra-abdominal malignancies.

The role of laparoscopy in the care of patients with cancer is currently evolving. Numerous experimental and clinical studies have attempted to elucidate the nature and cause of port-site metastases--particularly to discern whether they simply are a marker of advanced disease, or if they are a result of the laparoscopic intervention. Laparoscopy has a role in establishing the diagnosis of cancer in some situations by allowing biopsy of intraperitoneal and retroperitoneal masses, lymph nodes, and visceral lesions, as well as examination of abdominal contents under direct vision or with ultrasound probes. Laparoscopy is useful in the staging of established malignancies such as pancreatic cancer, hepatic lesions, lymphoma, and esophageal cancer. Laparoscopy also has a role in the surgical treatment of a variety of malignancies, including gastric carcinoma, pancreatic cancer, splenic malignancies, adrenal cancers, and colon cancer. The safety of laparoscopy for the definitive resection of colon cancer has not yet been proven, and until the results of a randomized prospective trial currently underway are known, should be performed only in the context of a clinical trial. Lastly, laparoscopy can play an important role in the palliative care of the cancer patient in performing procedures such as feeding-tube placement or intestinal stoma creation. It is imperative that using laparoscopy in the care of patients with malignancies be carefully and thoroughly evaluated since this technique can either benefit or adversely affect survival or quality of life.

Laparoscopic interventions in lymphoma management.

The widespread use of laparoscopy has been made possible by the exponential improvements in imaging technology as well as the development of specialized instruments. Although the use of laparoscopy for procedures such as cholecystectomy has become commonplace, its applicability in the management of malignancies remains in evolution. The role of the surgeon in the care of the patient with lymphoma is limited mostly to obtaining a diagnosis. Laparoscopy can play a significant role in the care of the patient requiring accurate intra-abdominal staging. The staging procedure is conducted in a fashion identical to the open procedure, including multiple liver biopsies, a splenectomy, and multiple lymph node biopsies. Patients with non-Hodgkin's lymphoma almost never require staging, and laparoscopy may play a role in obtaining tissue for diagnosis in a small fraction of patients. Patients with Hodgkin's disease who have diffuse disease (stages III and IV) never need staging because they will all receive chemotherapy. Likewise, patients with limited disease (stage I) are usually treated with radiation therapy alone. Some patients with stage II disease will require surgical staging, which should be performed laparoscopically. The laparoscopic approach to this procedure may afford benefits to the patient including decreased hospitalization, morbidity, and reduced delays in obtaining definitive treatment.

Perioperative management of the patient with cancer.

There are a number of conditions that present commonly in patients with cancer that may have a significant effect on the preoperative, intraoperative, and postoperative treatment of these patients. These effects can be broadly categorized into anatomic and physiologic effects and may be examined as direct effects of the tumor or as effects of therapy administered for the tumors. Tumors that cause anatomic effects of importance to perioperative management include head and neck tumors with airway obstruction, mediastinal masses with respiratory compromise, pericardial effusion and cardiac tamponade, and superior vena cava syndrome. Some tumors that cause physiologic effects include pheochromocytomas and carcinoid tumors. Anatomic effects of tumor therapy are important after radiation therapy to the head and neck and after radiation therapy to the abdomen. Tumor therapy has important physiologic effects in such areas as the cardiopulmonary complications of chemotherapy, hematologic effects of chemotherapy, steroid administration, and wound healing. While the list of topics is not exhaustive, this is a useful framework for discussing the effects of tumors and their therapy on the cancer patient, especially in regard to perioperative management. Most importantly, these examples demonstrate the importance of close cooperation among surgeon, anesthesiologist, and referring physician to assure the conduct of surgical procedures on the patient with cancer with maximal safety.

Laparoscopic evaluation of lymphoma.

Surgeons are involved in the diagnosis and staging of patients with lymphoma. Treatment requires accurate information about histologic classification and the extent of disease. While most patients with non-Hodgkin's lymphoma are treated with systemic chemotherapy, the exact stage of disease in patients with Hodgkin's lymphoma may determine the therapy to be used. The use of minimally invasive surgery in surgical staging of patients with Hodgkin's disease has the potential to decrease the morbidity and mortality of the staging procedure in these patients. All of the components of a staging procedure (liver biopsies, splenectomy, lymph node biopsies, and oophoropexy) can be performed laparoscopically. The procedure is performed with the patient in the supine position. After obtaining several liver biopsies, the splenectomy is completed. Lymph nodes are then sampled from the celiac, portal, iliac, and peri-aortic regions. Lymph nodes identified as abnormal on pre-operative imaging studies are identified and excised. While each of these procedures is technically challenging, the laparoscopic conduct of this diagnostic procedure may afford patients decreased post-operative morbidity and mortality.

Enhanced cytolytic activity of tumor infiltrating lymphocytes (TILs) derived from an ICAM-1 transfected tumor in a murine model.

BACKGROUND: Tumors transfected with intercellular adhesion molecule-1 (ICAM-1), a known activator of resting T-cells, show an increased response to adoptive immunotherapy in vivo. This salutary effect may be due to increased sensitivity of the transfected tumor cells to cell-mediated cytotoxicity or an increased activity of the effector cells in the presence of increased amounts of ICAM-1. MATERIALS AND METHODS: MCA105 fibrosarcoma cells were transfected with the gene for ICAM-1, and a clone (Cl149) demonstrating significantly increased expression of ICAM-1 by fluorescent-activated cell sorter (FACS) and enzyme-linked immunosorbent assay (ELISA) compared to parental tumor was selected and cultured. Tumor infiltrating lymphocytes (TILs) were cultured in vitro from MCA105 and Cl149 tumors. K562 tumor cells were used as controls. RESULTS: TILs derived from MCA105 tumors lysed MCA105 (32% at 40:1) and Cl149 (52% at 40:1) target cells but not K562 (3%) demonstrating TIL specificity. TILs derived from Cl149 showed increased lysis of both target cells tested: MCA105 (62% at 40:1, P < 0.05) and Cl149 (98%) compared to lysis of the same target cells by MCA105 TILs as well as being specific (K562, 1%). CONCLUSIONS: These studies demonstrate that increased expression of ICAM-1 by a tumor cell results in increased lysis by TILs derived from either a tumor with enhanced ICAM-1 expression or a parental tumor, compared to the lysis of parental tumor target cells. In addition, TILs derived from a tumor with enhanced expression of ICAM-1 have significantly increased antitumor efficacy compared to TILs from the parental tumor, suggesting a possible mechanism for previously observed in vivo antitumor effects. These results suggest a new strategy for improving the efficacy of adoptive immunotherapy, by using lymphocytes derived from genetically altered tumors. The study of lymphocytes from genetically modified tumor cells may enable the elucidation of properties of various molecules believed important in cellular cytotoxicity.

Gastric outlet obstruction secondary to post cholecystectomy biloma: case report and review of the literature.

BACKGROUND: Postcholecystectomy bilomas are relatively uncommon with a reported incidence of about 2.5%, and most often present with right upper quadrant pain and fever within seven days of the operation. There are a number of approaches to the treatment of this uncommon lesion. CASE REPORT: The authors report a case of a cholecystectomy performed in a 35-year-old female which resulted in a biloma, presenting 11 days postoperatively with gastric outlet obstruction. The literature is reviewed to suggest the optimal management and treatment plans for this complication. RESULTS: This patient was successfully managed with radiologic intervention for the treatment of a biloma and resulting gastric outlet obstruction after open cholecystectomy. CONCLUSION: Although uncommon, bilomas may present in an unusual manner such as with gastric outlet obstruction. As with early bilomas, they may be treated successfully with interventional radiologic techniques.

Expression of ICAM-1 enhances in vivo lymphocyte adhesion in a murine fibrosarcoma.

BACKGROUND AND OBJECTIVES: ICAM-1 is essential for lymphocyte-endothelial cell interactions. We have demonstrated that increased expression of ICAM-1 in tumors results in an enhanced response to adoptive immunotherapy. We undertook this study to determine whether increased expression of ICAM-1 results in increased lymphocyte adhesion in vivo. METHODS: Parental MCA-105 tumor cells were cotransfected with ICAM-1 and the NeoR plasmid. A neomycin resistant clone (Cl149) was selected and increased expression of ICAM-1 confirmed by FACS analysis. Tumor fragments (MCA-105 or Cl149) were placed in a dorsal skin-fold chamber on day 0 in C57BL/6 mice. Lymphocytes were fluorescently labeled using 0.5% acridine orange and activity recorded on videotape at 700x magnification. Lymphocyte activity was quantitated over 30 second intervals in postcapillary venules as either passing or rolling/sticking (R/S). The % R/S was calculated for each category and evaluated using chi 2 analysis. RESULTS: Whereas 38% of lymphocytes were classified as R/S in normal tissue, 32% were classified as R/S (P > .05) in the MCA-105 tumor. However, in the ICAM-1 transfected CL149, there was significantly greater R/S at 53% (P < .05). CONCLUSIONS: These data demonstrate increased lymphocyte adhesion in tumors with enhanced expression of ICAM-1 by direct in vivo observations and may partially explain the salutary effect of increased ICAM-1 expression on adoptive immunotherapy. This suggests the possible application of adhesion molecule expression in the cellular therapy of cancer.

General management of gastrointestinal fistulas. Recognition, stabilization, and correction of fluid and electrolyte imbalances.

Gastrointestinal fistulas are unfortunate complications of a number of disease states, such as inflammatory bowel disease and tumors, or may result from complications of surgical intervention. Fistulas may be associated with significant morbidity and mortality, much of which is a result of fluid losses and electrolyte imbalances. Thus, attention to these issues is a critical component of the management of patients with gastrointestinal fistulas. The management of gastrointestinal fistulas is divided into three phases: diagnosis/recognition, stabilization/investigation, and treatment. The major goal of the stabilization phase is the correction of fluid losses and electrolyte abnormalities. This phase must be carried out expeditiously to reduce the associated complications. Knowledge of the electrolyte content of various secretions of the gastrointestinal tract is essential to guide this phase of management. Early control of infectious foci, with drainage of abscesses if present, is of great importance. Esophageal fistulas most commonly result from instrumentation of the esophagus and are diagnosed by radiographic imaging studies. Nonoperative therapy is an option in select patients, but aggressive surgical intervention is often required. Dehydration is often associated with these injuries and must be corrected. Gastric and duodenal fistulas are most commonly iatrogenic and may be associated with significant fluid losses. Careful measurement of the fistula effluent is important. Nutritional support is begun following correction of fluid and electrolyte abnormalities. Pancreatic fistulas are often high volume fistulas and are associated with significant skin breakdown if they are cutaneous. The use of a somatostatin analogue may decrease the volume of the fistula to allow healing. Small intestinal fistulas often result from postoperative complications and require careful attention to electrolyte abnormalities. Spontaneous closure often obviates surgical intervention. Colonic fistulas are less often associated with complications than are other fistulas of the gastrointestinal tract. The stabilization phase in the management of patients with gastrointestinal fistulas is a critical time during which careful attention to fluid and electrolyte losses can result in reduced morbidity and mortality from these difficult management problems.

Laparoscopic splenectomy in patients with hematologic diseases.

OBJECTIVE: The authors review their initial experience with laparoscopic splenectomy in patients with hematologic diseases. Efficacy, morbidity, and mortality of the technique are presented, and other patient recovery parameters are discussed. SUMMARY BACKGROUND DATA: Laparoscopic splenectomy is performed infrequently and data regarding its safety and efficacy are scarce. Factors such as a high level of technical difficulty, the potential for sudden, severe hemorrhage, and slow accrual of operative experience due to a relatively limited number of procedures are responsible. The potential patient benefits from the development of a minimally invasive form of splenectomy are significant. METHODS: Clinical follow-up, a prospective longitudinal database, and review of medical records were analyzed for all patients referred for elective splenectomy for hematologic disease from March 1992 to March 1995. RESULTS: Laparoscopic splenectomy was attempted in 43 patients and successfully completed in 35 (81%). Therapeutic platelet response to splenectomy occurred in 82% of patients with immune thrombocytopenic purpura and hematocrit level increased in 60% of patients with autoimmune hemolytic anemia undergoing successful laparoscopic splenectomy. The morbidity rate was 11.6% (5 of 43 patients), and the mortality rate was 4.7% (2 of 43 patients). Return of gastrointestinal function occurred in patients 23.1 hours after laparoscopic splenectomy and 76 hours after conversion to open splenectomy (p < 0.05). Mean length of stay was 2.7 days after laparoscopic splenectomy and 6.8 days after conversion to open splenectomy (p < 0.05). CONCLUSION: Laparoscopic splenectomy may be performed with efficacy, morbidity, and mortality rates comparable to those of open splenectomy for hematologic diseases, and it appears to retain other patient benefits of laparoscopic surgery.

ICAM-1 increases in vitro adhesion and cytotoxicity in a murine fibrosarcoma.

Cellular adhesion and specific cytotoxicity are two essential components for the successful cellular therapy of cancer. Intercellular adhesion molecule-1 (ICAM-1) is an essential participant in lymphocyte-endothelial cell adhesion and may also play a role in lymphocyte-mediated cytotoxicity. To study the effect of ICAM-1 on adhesion and cytotoxicity in vitro, MCA-105 tumor cells were cotransfected with ICAM-1 and the gene for neomycin resistance (NeoR). Two clones (Clones 81 and 149) with confirmed enhancement of ICAM-1 expression were selected. Studies were performed examining adhesion of lymphocytes to HUVECs, MCA-105, Clone 81 or Clone 149 alone, or combinations of the three tumor cell lines with HUVECs. Peripheral blood lymphocytes labeled with 51Cr were used and adhesion was determined by counting in a gamma-counter after rinsing away nonadherent cells. Cytotoxicity was performed using 51Cr-labeled MCA-105, NeoR, Clone 81, and Clone 149 target cells. LAK cells cultured from splenocytes of normal mice were used as the effector cells and a chromium release assay was performed. Adhesion data showed significant increases in adhesion (P < 0.05) for Clones 81 and 149 compared to MCA-105. However, the combination of HUVECs and tumor cells to mimic the in vivo condition had a variable effect on adhesion compared to tumor cells alone. Cytotoxicity experiments demonstrated that Clone 149 was significantly (P < 0.05) more susceptible to lysis by normal LAK cells compared to MCA-105, NeoR, and Clone 81. These results suggest that increased ICAM-1 expression enhances the susceptibility of tumor cells to lysis by LAK cells.