Neuroprotective effect of mild hypothermia in patients undergoing coronary artery surgery with cardiopulmonary bypass: a randomized trial.

BACKGROUND: Neuropsychological deficits occur in 30% to 80% of patients undergoing heart surgery and are due in part to ischemic cerebral injury during cardiopulmonary bypass. We tested whether mild hypothermia, the most efficacious neuroprotective strategy found in laboratory studies, improved cognitive outcome in patients undergoing coronary artery surgery. METHODS AND RESULTS: Patients 60 years or older scheduled for coronary artery surgery were enrolled. During cardiopulmonary bypass, patients were initially cooled to 32 degrees C then randomly assigned to rewarming to 37 degrees C (control) or 34 degrees C (hypothermic), with no further intraoperative warming. Testing was scheduled preoperatively and 1 week and 3 months postoperatively. Eleven tests were combined into 3 cognitive domains: memory, attention, and psychomotor speed and dexterity. A patient was classified as having a cognitive deficit if a decrease of >/=0.50 SD was realized in 1 or more domains. The incidence of cognitive deficits 1 week after surgery, which was the primary outcome, was 62% () in the control group and 48% () in the hypothermic group (relative risk 0.77, P=0.048). In the hypothermic group, the magnitude of deterioration in attention and in speed and dexterity was reduced by 55.6% (P=0.038) and 41.3% (P=0.042), respectively. At 3 months, the hypothermic group still performed better on one test of speed and dexterity (grooved pegboard). There was no difference in morbidity or mortality. CONCLUSIONS: Our findings support a neuroprotective effect of mild hypothermia in patients undergoing coronary artery surgery and should encourage physicians and perfusionists to pay careful attention to brain temperature during cardiopulmonary bypass.

Laparoscopic repair of ureterosciatic hernia.

Ureterosciatic herniation is a rare benign event that can mimic diverticulosis or irritable bowel syndrome. This entity has been managed by a number of open surgical techniques. Laparoscopic repair of this entity enabled us to identify the defect, interpose mesh, and obliterate the hernia defect with minimal morbidity. This represents the first report of laparoscopic repair of a ureterosciatic hernia.

Minimally invasive management of low-grade and benign gastric tumors.

BACKGROUND: Benign gastric tumors and tumors of low-grade malignancy can be safely removed laparoscopically. METHODS: Seven patients were considered candidates for laparoscopic resection of gastric tumors. Inclusion criteria included small tumor size (less than 6 cm), exophytic or endophytic tumor morphology, and benign characteristics. Indications for surgical intervention included bleeding, weight loss, and need for tissue diagnosis. Patients ranged in age from 38 to 70. There were five female and two male patients. All patients underwent preoperative upper GI endoscopy. The procedures were performed using a four- or five-port technique. An Endo-GIA (US Surgical Company, Norwalk, Connecticut) was used to amputate those tumors located on the serosal surface of the stomach. Tumors on the mucosal surface were exposed via a gastrotomy, then likewise amputated using an Endo-GIA. The gastrotomy closure was then either hand sewn or stapled. Operating time ranged from 95 to 225 min. RESULTS: Final pathologic diagnoses included lipoma, lymphoma, leiomyoma, and leiomyosarcoma. There was a 28% conversion rate. There were no complications. Length of postoperative stay ranged from 4 to 7 days. There have been no tumor recurrences in 6-38-month follow-up. CONCLUSIONS: Minimally invasive management of benign and low-grade gastric tumors can be performed safely with excellent short- and long-term results.

Consequences of lost gallstone.

Laparoscopic cholecystectomy has become the treatment of choice in the management of calculus gallbladder disease. Intraperitoneal gallstone loss is not uncommon; it occurs in up to 40% of cases. Often, the stones are left unretrieved and are thought to be inconsequential. We present a series of patients who have had serious sequela from gallstones in the peritoneal cavity. We performed a retrospective study of the management of six patients with complications from intraperitoneal gallstones. The patients presented with a variety of complaints, from fevers to pneumonia to a colo-cutaneous fistula. Presentation ranged from immediately postoperatively to 18 months after surgery. Diagnosis included perihepatic abscesses and colo-biliary fistula. General anesthesia was usually necessary for removal of the stones. All patients have resolved following the removal of the gallstones. Our recommendation is to attempt to avoid spillage through careful dissection and retrieve any lost stones. The defect in the gallbladder can be closed with a clip. Whether the procedure should be converted to an open one to retrieve all the stones remains open to debate. The surgeon should be aware of the possible consequences of the lost gallstone.

Missing T-cell receptor V beta families following blood transfusion. The role of HLA in development of immunization and tolerance.

Previously, we showed that donor-specific CTL nonresponsiveness occurs in transfused recipients sharing one HLA haplotype (or at least one HLA-B and one HLA-DR antigen) with the blood donor. The aim of the present study was to disclose the distinct effects of BT on the T-cell receptor repertoire and to analyze which factors determine the tolerizing versus immunizing properties of BT. We show here that recipients of HLA-sharing BT develop not only donor-specific CTL nonresponsiveness posttransfusion, but also a significant decrease in the usage of one to three V beta families as shown by PCR. In contrast, recipients of non-HLA-sharing BT remained donor-specific CTL responders and did not decrease the usage of V beta families. In addition, these patients generated high-affinity CTL for donor antigens which could not be blocked by anti-CD8 mAb. Our results show that major alterations occur in the CTL and TCR V beta repertoire following BT. We hypothesize that the fate of transfused allogeneic lymphocytes in the host is based on the degree of sharing of HLA antigens with the host. This relationship determines the ultimate outcome of BT: immunization versus tolerization.

Ductal carcinoma in situ of the male breast.

BACKGROUND: Ductal carcinoma in situ (DCIS) of the male breast is an uncommon disease, accounting for approximately 7% of all male breast carcinomas. Compared with invasive carcinomas of the breast, the prognosis associated with DCIS in men is excellent; however, clinical features, pathology, and treatment of this disease are not well defined in the literature. METHODS: Records of 23 men with carcinoma of the breast treated at the Lahey Clinic from 1968 to 1991 were reviewed, revealing 4 patients with pure DCIS (17%). The reported management of DCIS in women is discussed in comparison with that of DCIS in men. RESULTS: Of the four patients with DCIS, the presenting complaint was a retroareolar mass in three patients and a bloody nipple discharge in one patient. The pathologic subtype was papillary in one patient and intracystic papillary in three patients. Two patients were treated with partial mastectomy alone. Disease recurred locally as DCIS in both patients, requiring mastectomy at 30 and 108 months. No lymph node metastases were found in the three patients who underwent axillary dissection. All four patients were alive without disease at 133, 120, 36, and 32 months of follow-up, respectively. CONCLUSIONS: Although the sample size was small, our patients and a review of the literature suggest that most DCIS in men is of the papillary type and that mastectomy without axillary dissection is the preferred treatment.

Cholecystectomy. Open cholecystectomy revisited.

We have presented a basic set of rules to follow in the performance of cholecystectomy. We do not wish to convince the reader that these methods are the only ones, but they are a safe starting point for the novice surgeon working in the right upper quadrant. Each of us takes part of what we are taught, amplifies what we find works best for us, and tries to impart to others the experience we have gained.

Cholangiocarcinoma and Crohn's disease.

Cholangiocarcinoma is an infrequent complication of inflammatory bowel disease. Although increasing numbers of cholangiocarcinomas are being reported in association with ulcerative colitis, the occurrence of this disease in patients with Crohn's disease is rare. To understand this complication better, we have reported the case of a patient with Crohn's disease in whom cholangiocarcinoma subsequently developed and reviewed the literature.

Bile duct injury during laparoscopic cholecystectomy: mechanism of injury, prevention, and management.

Although several studies have shown a low incidence of bile duct injuries during laparoscopic cholecystectomy, concerns remain because of the sustained increase in the number of referrals for biliary reconstruction after the procedure. Twenty-one patients have been referred to our institution because of major bile duct injuries after laparoscopic cholecystectomy. The injury was recognized during the laparoscopic procedure in only 6 of the 21 (29%). Nineteen patients underwent hepaticojejunostomy at least once, one patient required hepaticojejunostomy and repair of a choledochoduodenal fistula, and one patient needed repair of a biliary colonic fistula. Hepaticojejunostomy above the bifurcation was required in 10 patients (50%), at the bifurcation in 3, and below the bifurcation in 7. Nine of the eleven patients in whom the initial repair was performed at the local hospital presented with early stricture (median 7 months). The common denominator of the development of bile duct injuries during laparoscopic cholecystectomy is the failure to identify the structures of the triangle of Calot. Specific steps during laparoscopic cholecystectomy to avoid bile duct injuries are described. Expertise in hepatobiliary surgery appears to optimize results of biliary reconstruction.

Local resection for ampullary tumors. Is there a place for it?

Two of 14 patients with adenomas were without disease 25 and 43 months after ampullary resection. Two patients with an initial diagnosis of malignant neoplasm had no recurrence at 75 and 40 months; one underwent pancreatoduodenectomy at 8 months because of recurrence. Six of nine patients with initial diagnoses of villous adenoma were without disease at 1, 2, 16, 23, 46, and 51 months; three underwent conversion to pancreatoduodenectomy because of invasive carcinoma. Frozen-section studies revealed adenocarcinoma in two patients with villous adenoma but failed to show invasion in one patient. One patient with villous adenoma was mistakenly thought to have carcinoma based on results of frozen-section studies. Local ampullary resection is valuable in treating benign and selected premalignant and malignant ampullary lesions. The threshold for conversion to pancreatoduodenectomy should be low unless ampullectomy is performed with palliative intent.

A case control study of renal transplantation in patients with type I diabetes.

A case control study was undertaken comparing the outcome of 208 renal allografts transplanted into diabetic recipients with those transplanted into an appropriately matched group of non-diabetic recipients. In each group there were 151 cadaver, 21 two-haplotype identical, 35 one-haplotype identical, and one zero-haplotype identical living-related grafts. For the entire group of diabetics, 1- and 5-year graft survivals were 71.3% and 46%. Graft survivals for the non-diabetic recipients at 1 and 5 yr were 81.8% and 57.8% (p less than 0.05). In all patient subgroups divided according to the donor source, the graft and patient survival rates for the non-diabetic recipients exceeded those of the diabetic recipients. One- and 5-yr diabetic patient survivals were 90% and 70%, and for the non-diabetics they were 97% and 95%, respectively (p less than 0.001). There were 40 deaths among diabetics and 15 among the non-diabetics. Cardiovascular disease was the major cause of death in the diabetics, accounting for 40% of the deaths. In addition, allograft loss due to patient death was a significant cause of graft loss in the diabetic group, 24 grafts (28%). Seven grafts (10%) were lost due to patient death in the non-diabetic group (p less than 0.05). Post-transplant, diabetic recipients had a greater incidence of stroke, angina, myocardial infarction, peripheral vascular disease, urinary tract infections (p less than 0.01 for each), and wound infections (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Primary adenocarcinoma of third and fourth portions of duodenum. Favorable prognosis after resection.

Duodenal adenocarcinoma, a rare malignant lesion, is associated with a poor 5-year survival. Few series have addressed differences between resectable tumors of the proximal and distal duodenum. We reviewed records of 17 consecutive patients with adenocarcinoma of the duodenum who underwent resection: 10 had adenocarcinoma of the proximal duodenum, and seven had tumors of the distal duodenum. Most patients underwent pancreatoduodenectomy. Five patients with adenocarcinoma of the distal duodenum underwent segmental resection. No perioperative deaths occurred. Six of 10 patients with proximal tumors died of metastatic disease. Of the seven patients with tumors of the distal duodenum, five are alive without evidence of disease, and two died of unrelated causes. The survival of patients with adenocarcinoma of the distal duodenum is surprisingly good, and segmental resection is the procedure of choice.

Laparoscopic bile duct injuries. Risk factors, recognition, and repair.

Records of 11 patients undergoing biliary reconstruction after laparoscopic cholecystectomy are reviewed. Ductal injuries resulted from failure to define the anatomy of Calot's triangle. Risk factors include scarring, acute cholecystitis, and obesity. Presenting findings included anorexia, ileus, failure to thrive, pain, ascites, and jaundice. All patients required hepaticojejunostomies, which were multiple and above the hepatic bifurcation in four patients. Given the extensive nature of these injuries and the frequent need for intrahepatic anastomosis and early stenosis of repairs by referring physicians, we recommend reconstruction be undertaken by an experienced hepatobiliary surgeon. To avoid injuries, a greater appreciation of risk factors and anatomic distortion and variance and strict adherence to principles of dissection and identification of anatomic structures are suggested. The use of cholangiography and a low threshold for conversion to the open procedure are advised.

Midgut volvulus in an elderly patient.

In adults, congenital anomalies of intestinal rotation are usually incidental findings. Any symptoms present may be the result of intermittent volvulus of the small bowel. We report classic fluoroscopic, computed tomographic, and angiographic findings in what is believed to be the oldest reported patient with this entity.

Management of intra-abdominal sepsis.

The management of intra-abdominal sepsis includes drainage of septic foci, debridement of devitalized tissue, and prevention of continuing peritoneal contamination. An algorithm is presented as an aid to the thought process.

Common operative problems in hepatobiliary surgery.

The pace of change in hepatobiliary surgery requires a sound foundation in basic surgical principles. Further reductions in morbidity and mortality rates and appropriate use of alternative therapies require careful attention to preoperative risk assessment and patient selection. To operate safely and successfully on the liver and bile ducts, the surgeon must be well versed in normal and variant hepatobiliary anatomy, understand the underlying disease and therapeutic alternatives, and known techniques of reoperative biliary surgery. Surgeons who operate on the gallbladder must be prepared to confront a host of unexpected and difficult operative problems. Bile duct injuries must be repaired properly at the first attempt. Complex biliary operations require a great level of technical expertise and judgment to obtain successful results and should only be undertaken by experienced hepatobiliary surgeons. As proficiency with the more routine procedures improves, increasingly complex and extensive procedures become possible. We must constantly police ourselves to be certain that these more extensive procedures truly benefit our patients.

Surgical management of nonparasitic cystic liver disease.

We report clinical features, surgical management, recurrences, and follow-up study of 12 patients with simple hepatic cyst, 11 patients with polycystic liver disease, and 19 patients with cystadenoma who were surgically treated over a 25-year period. The median age of patients was 48 years, and 37 women and 5 men were in the series. The most common presenting symptom and physical finding were chronic abdominal pain and tenderness in the right upper quadrant. The most commonly associated disease was polycystic kidney disease, which was an associated finding in 5 of the 11 patients with polycystic liver disease (45%). The most valuable diagnostic studies in all groups were computed tomography and ultrasonography. The location of the disease was bilobar in patients with polycystic liver disease, with a right lobe predominance in 18% of patients. The right lobe was also predominant in 83% of patients with simple hepatic cyst and 58% of patients with cystadenoma. Of all solitary cystic lesions in the left lobe, 75% of them were cystadenomas. Of the 66 surgical procedures performed, aspiration was associated with a failure rate of 100%; partial excision, a failure rate of 61%; and total excision and liver resection, a failure rate of 0%. Orthotopic liver transplantation was performed in three patients and was associated with two early deaths. Partial excision relieved symptoms in three patients (43%) with polycystic liver disease. Total excision, enucleation, or liver resection with cyst(s) is the treatment of choice for non-parasitic cystic lesions of the liver.

Hepatobiliary anomalies associated with polysplenia syndrome.

The report of a 29-year-old woman with polysplenia syndrome, Crohn's disease, and bilateral cataracts is presented. The patient was noted to have a right-sided stomach and small bowel, Crohn's ileitis, and a left-sided colon. Results of roentgenography of the chest and echocardiography were consistent with a diagnosis of hypoplasia of the inferior vena cava with azygos continuation. The patient underwent laparotomy with cholecystectomy, exploration of the common bile duct, and choledochoscopy for cholelithiasis, choledocholithiasis, and chronic cholecystitis. Laparotomy revealed a liver that had two lobes, each with the morphologic appearance of the left lobe. The gallbladder was centrally located. T-tube cholangiography revealed a quadruplication of the intrahepatic biliary ducts. To our knowledge, this patient is the only known adult with this syndrome in whom cholangiography demonstrated isomerism of the biliary tree. A review of the literature on this subject is given with emphasis on biliary anomalies.