Aortitis with multiple aneurysms mimicking infective endocarditis.

Aortitis usually produces aortic insufficiency by aortic root dilation. In rare cases the inflammation may involve the aortic valve cusps, causing valvular insufficiency. A patient in whom aortitis produced valvular masses, with aortic and peripheral arterial aneurysms, embolic episodes and aortic insufficiency is described. Valve replacement for suspected infective endocarditis was complicated by homograft dehiscence and multiple false aneurysms. Although immunosuppression was successful in decreasing the patient's vasculitis, he became infected and died of complications of aspergillus infection.

Management of choledocholithiasis in the time of laparoscopic cholecystectomy.

BACKGROUND: The best way to detect and manage common duct stones in conjunction with laparoscopic cholecystectomy is not agreed upon at the present time. PATIENTS AND METHODS: Our experience with choledocholithiasis in a consecutive series of 1,123 cholecystectomies (94% by laparoscopy) has been reviewed. Suspected duct stones were investigated preoperatively or postoperatively by endoscopic retrograde cholangiography (ERC), and if necessary, duct clearance was attempted by endoscopic sphincterotomy (ES). No attempt was made to identify choledocholithiasis intraoperatively. RESULTS: Endoscopic retrograde cholangiography was performed in 11% of patients, and 32% of these required ES. The complication rate of ERC and ES was 8%, without mortality. Two patients required a second operation for missed choledocholithiasis, for a reoperation rate of 0.2%. CONCLUSION: We believe that primary or secondary open surgery is only occasionally necessary for the management of choledocholithiasis. Preoperative ERC and ES for suspected duct stones, with the same strategy employed as a salvage for stones presenting after cholecystectomy, was safe and efficient.

Is prophylactic resection valid as an indication for elective surgery in diverticular disease?

OBJECTIVE: To determine whether interval resection in asymptomatic patients after 1 or 2 episodes of acute diverticulitis (prophylactic resection) is justified as a means of preventing late inflammatory complications of diverticular disease. DESIGN: A retrospective analysis. SETTING: A university-affiliated tertiary care hospital. PATIENTS: Those requiring hospitalization from 1987 to 1995 for treatment of acquired diverticular disease of the colon. Twenty-eight patients underwent elective resection and 154 were treated for inflammatory complications (perforation, fistula, complete large-bowel obstruction). INTERVENTIONS: Standard surgical management for diverticular disease, but only 3 prophylactic resections were undertaken during this period. OUTCOME MEASURES: Type of operation, stoma creation and closure, hospital death. In those treated for complicated disease, the effects on outcome of all previous outpatient treatment and hospitalizations. RESULTS: Only 10% of those presenting with complications had been treated conservatively for acute diverticulitis and only 5% had been hospitalized for this reason. CONCLUSIONS: Prophylactic resection is unlikely to prevent late major complications of diverticular disease; therefore, as an elective indication for surgery in this disease its use is questionable.

Management of splenic injuries in a Canadian trauma centre.

OBJECTIVES: To document the current practice pattern for the treatment of splenic injuries in one Canadian trauma centre and to identify factors that determined which method was employed. DESIGN: A cohort study. SETTING: A Canadian lead trauma centre. PATIENTS: A cohort of 100 patients with splenic injury treated at one trauma hospital over 5 years was identified from a prospective trauma database. MAIN OUTCOME MEASURES: The success rate and failure rate for splenic salvage by splenectomy, splenorrhaphy or observation. Volume of blood transfused, injury severity score (ISS) and method of diagnosis. RESULTS: The median ISS for the cohort was 34 (36 for splenectomy, 38 for splenorrhaphy and 35 for observation). A blunt mechanism of injury was present in 96%. The diagnosis was made by computed tomography (CT) in 55%. Splenic salvage was accomplished in 51 patients; of these, 44 (86%) were in the observation group, and the success rate was 90% (within the range reported in the literature). Only seven patients underwent splenorrhaphy. CT was performed more frequently in the observation group than in the splenectomy group (82% v. 25%, p < 0.0001). The splenectomy group had more blood transfused than the successful observation group (mean units 15 v. 3, p = 0.0001) and had a higher median ISS (36 v. 29, p = 0.02). Multivariate analysis revealed that the method of diagnosis (CT v. diagnostic peritoneal lavage) was the strongest factor associated with how the splenic injury was treated. CONCLUSIONS: The finding in this report of an increase in observational treatment of splenic injuries represents a shift in practice from a previous Canadian report and is in keeping with recent published trends from the United States. Future studies are needed to assess whether any strong regional practice pattern variations in the management of blunt splenic injuries exists in other trauma centres across Canada.

Primary aortogastric fistula: a complication of ruptured aortic aneurysm.

An aortogastric fistula which resulted from rupture of an atherosclerotic aneurysm of the descending and supraceliac aortic segments is reported. The diagnosis was suspected preoperatively on the basis of CT and angiographic examinations. Vascular replacement was accomplished without difficulty, but a fatal outcome eventually occurred because of failure of local repair of the gastric defect. Relevant literature on primary aortoenteric fistulas has been reviewed, with particular emphasis on reports detailing management of the alimentary tract perforations. We now believe that resection should be strongly considered in situations where both resection and local repair of the enteric defect are options.

Hemobilia complicating elective laparoscopic cholecystectomy: a case report.

Iatrogenic injury to the hepatic or cystic arteries can occur during laparoscopic cholecystectomy and can be seen in isolation or in association with bile-duct injury. The most common manifestation of arterial injury is intraoperative hemorrhage; also, interruption of the right hepatic artery can occur without hemorrhage, and this can be clinically insignificant or associated with hepatic ischemia. A less common manifestation of arterial injury during laparoscopic cholecystectomy is presented. A 48-year-old woman had a pseudoaneurysm of the major anterior branch of the right hepatic artery in association with an injury to the common hepatic duct. This complication presented as massive hemobilia after she had been discharged from the hospital. Definitive repair of the pseudoaneurysm was carried out at the time of Roux-en-Y hepaticojejunostomy for correction of the associated duct injury. This unusual vascular complication should be considered in patients after laparoscopic cholecystectomy who demonstrate evidence of late occult or obvious hemorrhage.

Intraoperative cholangiography is not essential to avoid duct injuries during laparoscopic cholecystectomy.

BACKGROUND: Whether or not to perform intraoperative cholangiography (IOC) with laparoscopic cholecystectomy is controversial. The decision to perform IOC should depend on the individual surgeon's preference for the management of choledocholithiasis. PATIENTS AND METHODS: An initial experience of 525 patients undergoing laparoscopic cholecystectomy done without IOC is reviewed. RESULTS: Suspected or proven choledocholithiasis was managed by endoscopic retrograde cholangiography with sphincterotomy if necessary. There were no bile duct injuries or bile leaks, and 9% (47) of patients underwent endoscopic investigation or treatment. There have been no secondary operations for duct stones. CONCLUSION: We think that the use of IOC to avoid bile duct injuries is not essential, and that the key to avoiding such injuries is meticulous demonstration of anatomic detail at operation. We have been satisfied with selective use of endoscopic cholangiography and sphincterotomy for the management of choledocholithiasis.

Venous gangrene of the extremities.

OBJECTIVE: To review the rare clinical condition of venous gangrene of the extremities, particularly in association with malignant disease; to develop a treatment scheme for this difficult condition. DATA SOURCES: Surgical articles on phlegmasia cerulea dolens, venous gangrene and other forms of noninfectious, nonarterial gangrene of the extremities from 1937 to the present were identified from published indexes and computer databases; experience with four additional cases treated by the authors is incorporated. STUDY SELECTION: Studies selected for detailed review include those involved directly with venous gangrene and its investigation and treatment, and those relating to investigation of clinically similar conditions. DATA EXTRACTION: Because of the rarity of venous gangrene, much of the available literature is descriptive, involves small numbers of cases and describes only limited experience with investigation and treatment; data extraction was done by a single reviewer. DATA SYNTHESIS: Because of advances in diagnostic technology and thrombosis research, the assessment of suspected venous gangrene has changed significantly in recent years. Despite these advances, the prognosis for patients with this condition continues to be poor. The possible confounding roles of paradoxical reactions to anticoagulants and of primary hypercoagulable states are considered. CONCLUSIONS: Objective demonstration of extensive thrombosis of the large veins of the involved extremity remains central to the diagnosis. The presence and stage of any associated malignant lesion must be rapidly determined to allow planning for further treatment. Because conventional anticoagulation frequently fails, it may be necessary to consider less well-established modes of therapy.

Invasive Clostridium septicum infection in association with colorectal carcinoma.

The association between invasive Clostridium septicum infection and colorectal carcinoma is examined by the presentation of three cases and a review of the literature. In the first two cases the patients presented with nontraumatic metastatic clostridial gas gangrene. In the third case a patient with chemotherapy-induced myelosuppression from concomitant multiple myeloma had a necrotizing transmural infection of the right colon. The apparent portal of entry of Clostridium septicum was an occult carcinoma of the ascending colon. The increasing evidence for a strong link between this organism and some cases of neutropenic enterocolitis is reviewed.

Blunt extraperitoneal rupture of the right hemidiaphragm: case report.

A case of blunt extraperitoneal rupture of the right hemidiaphragm and an accompanying abnormal hepatobiliary scan that revealed the rupture are presented. Associated major injuries, the fact that right-sided ruptures have less immediate herniation, and plugging of the defect by the liver are difficulties that can be encountered in establishing the diagnosis. Most diagnostic tests are not helpful and about half of these ruptures are found at laparotomy or thoracotomy. All should be closed surgically.

A comparison between expanded polytetrafluoroethylene and plasma tetrafluoroethylene grafts for hemodialysis access.

Animal studies have indicated that plasma tetrafluoroethylene (TFE) may be a better prosthetic material than expanded polytetrafluoroethylene (ePTFE) for arteriovenous access in patients who require hemodialysis because it combines the advantages of both Dacron and Teflon. A randomized clinical trial to compare the two materials was conducted between May 1987 and January 1989. Forty-four patients were enrolled, 22 in each group. The status of the grafts was monitored for at least 18 months. The patency rate for plasma TFE was 59% and for ePTFE was 64%. Kaplan-Meier analysis and Wilcoxon testing revealed no statistical differences between the two groups. Four grafts became infected, two in each group, and one aneurysm developed. Despite its theoretical advantages, plasma TFE was found to be similar to ePTFE as a graft material for hemodialysis.

Small-bowel carcinoid presenting in association with a phytobezoar.

An unusual case of a recurrent, postoperative, small-bowel obstruction is presented. The obstruction was due to a phytobezoar proximal to the site of a primary carcinoid of the small bowel. The radiologic findings of a mobile, intraluminal filling defect and a more distal, fixed mural mass are reviewed. The cause of the recurrent obstruction was likely a "ball-valve" effect of the phytobezoar at the site of stenosis caused by the carcinoid. This case emphasizes the value of small-bowel imaging in repeated small-bowel obstruction.