The ovarian hyperstimulation syndrome.

OBJECTIVE: To review the up-to-date literature concerning the pathogenesis of, risk factors for, prevention of, and therapy for the ovarian hyperstimulation syndrome, and to provide suggestions for management of this syndrome. DESIGN: Literature review combined with on-site clinical experiences at the authors' institution of practice. PATIENT(S): Women who have risk factors for or manifest the ovarian hyperstimulation syndrome. INTERVENTION(S): Intravenous fluid management, thrombosis prevention techniques, paracentesis techniques, and critical care management protocols. MAIN OUTCOME MEASURE(S): Staging system of the ovarian hyperstimulation syndrome, criteria for outpatient versus hospitalization management, and indications for varying levels of interventional management. RESULT(S): The ovarian hyperstimulation syndrome, unique to the field of assisted reproductive technology, remains a largely elusive and unpredictable iatrogenic physiologic complication in the course of pharmacologic ovarian stimulation. Reliable information on risk factors, possible physiologic mechanisms, prevention techniques, and management is fortunately progressing, and overall advances are being made in this field. The present review is an attempt to summarize the modern literature regarding this syndrome and to use this current knowledge to provide a basis for acceptable management regimens. CONCLUSION(S): Ovarian hyperstimulation syndrome is a serious complication of assisted reproductive technology, with potential for critical morbidity and death. Physicians who prescribe medications known to be associated with this syndrome should be familiar with identifiable risk factors, means of prevention, and a system for staging and treating the disease and have a current knowledge base for putative models of pathogenesis.

Susceptibility testing of biliary bacteria obtained before bile duct manipulation.

Over a 3 3/4-year period, bile culture and susceptibility studies were performed on 41 patients before any instrumentation or manipulation of the biliary tract for retained biliary stone extraction. At least one bile bacterium was identified in 90% of the patients examined. As many as seven organisms were identified in one patient. Of the organisms, 62% were Gram-negative aerobes, the most representative being Klebsiella pneumonia; 27% were Gram-positive aerobes, the Enterococcus grouping being the most representative. Nine percent of the isolates were anaerobic bacteria and 2% yeast. Fifteen percent of the patients developed signs of sepsis. Three of these patients had manipulation of their bile ducts with a choledochoscope and grew out positive blood cultures; all were treated successfully and recovered uneventfully. Susceptibility testing on all aerobic bacteria was performed, indicating 97% effective coverage of both Gram-positive and Gram-negative bacteria using synergistic antibiotics of ampicillin and an aminoglycoside. Even with 9% of the isolated bacteria being anaerobes, the effective coverage using the same two drug combinations was about 88%. Because of the relatively high percentage (15%) of patients developing signs and symptoms of sepsis, synergistic prophylactic antimicrobial therapy is recommended in patients who are debilitated, in instrumentation of obstructed bile ducts, or with choledoschoscopy.

Postoperative choledochoscopy through the T-tube tract.

The present management of retained biliary calculi utilizing irrigation with heparin and other agents through the T tube has proved disappointing. The use of basket catheters under fluoroscopy is more successful but has limited usefulness in extraction of impacted and certain other stones. The preliminary use of postoperative choledochoscopy utilizing a choledochofiberscope passed through the T-tube tract has been consistently effective in 17 patients for evaluation of filling defects on the postoperative cholangiogram and for the removal of difficult or multiple retained stones. Introduction of the endoscope may require dilation of the T-tube tract. This is accomplished with ease. Use of the recently available T tube with a larger external limb will improve postoperative access to the common bile duct for direct visual examination and removal of stones.

Herniation of the gallbladder through the foramen of Winslow.

A rare case of herniation of the gallbladder through the foramen of Winslow is presented. There are only six surgically proven previously reported cases. This condition should be suspected where symptoms suggest gallbladder disease in the presence of normal functioning gallbladder. A simultaneous cholecystogram and an upper gastrointestinal study is necessary to confirm the diagnosis. A cholecystectomy with plication of the foramen of Winslow is the suggested treatment.

Bilary tract exploration via T-tube tract: improved technique.

A total of 40 cases referred for postoperative reexploration of the biliary tract via the T-tube trace was reviewed. In selected cases, a modified technique of dilatation of the T-tube tract or bile ducts and endoscopy via the T-tube tract was used. Dilatation of the T-tube tract is a relatively simple procedure that was necessary in over one-half of our cases, since the retained stone was larger than the T-tube inserted during surgery. A new T-tube with a larger external limb was developed in order to reduce the necessity for dilatation of the biliary-cutaneous fistulous tract. Fiberoptic endoscopy of the biliary system via the T-tube tract offers another means for removing large or impacted stones and for investigating mucosal defects. This modified technique has reduced the number of patients requiring surgical reexploration.

Unsuccessful postoperative extraction of retained common duct stones: an analysis.

An analysis of unsuccessful extractions of retained biliary calculi using basket catheters reveals more than half the failures are related to the selection, placement, and size of the T tube. A new T tube has been developed which will improve postoperative access to the common duct and facilitate removal of retained calculi.

Angiographic and radionuclide characteristics of hepatic angiosarcoma found in vinyl chloride workers.

Hepatic angiosarcoma, recently discovered in a large series of vinyl chloride workers, demonstrates characteristic angiographic and radionuclide changes. Tumors exhibiting central hypovascularity with puddling are usually surrounded by a peripheral stain. A negative peripheral defect is demonstrated on hepatic scan. Healing hepatic infarction secondary to wedged hepatic venography creates a false-positive lesion on angiography similar to angiosarcoma. Splenomegaly and systemic venous hypertension develop in a number of these patients.