Am Surg

Outcome after laparoscopic cholecystectomy for chronic acalculous cholecystitis.

Adams DB. Tarnasky PR. Hawes RH. Cunningham JT. Brooker C. Brothers TE. Cotton PB.
Department of Surgery, Medical University of South Carolina, Charleston 29425, USA.
Patients with typical symptoms of biliary tract disease but no gallstones on ultrasonography may benefit from cholecystectomy for presumed chronic acalculous cholecystitis. We retrospectively analyzed the outcome of 50 patients with a preoperative diagnosis of chronic acalculous cholecystitis based upon history (chronic or recurrent, postprandial right upper quadrant abdominal pain), the absence of acid-peptic disease, and normal biliary sonography treated with laparoscopic cholecystectomy (LC) and transcholecystic cholangiography from 1991 to 1996. All patients had preoperative cholecystokinin-stimulated hepatobiliary scintigraphy (CCK-HBS). There were 42 women and 8 men with a mean age of 43 years. CCK-HBS was abnormal in 45 patients (< or = 35 per cent gallbladder ejection fraction or nonfilling of the gallbladder). There was no postoperative mortality and one morbidity (urinary retention). All patients had microscopic evidence of chronic cholecystitis. At mean follow-up of 30 months, (range, 7-62 months) 39 patients (78%) were free of abdominal pain. Thirty-five of 45 patients with abnormal CCK-HBS were pain free (positive predictive value, 0.78). Four of five patients with normal CCK-HBS were pain free (negative predictive value, 0.20). The positive and negative likelihood ratios for CCK-HBS were 0.99 and 1.13, respectively, confirming that this test was not useful for predicting benefit from LC. Seven patients with persistent right upper quadrant pain had abnormal postoperative sphincter of Oddi manometry; they improved after endoscopic sphincterotomy. Patients with symptoms typical of biliary colic with normal gallbladder sonography and absence of acid-peptic disease benefit from LC in the majority of cases. Those who remain symptomatic after LC may benefit from endoscopic retrograde cholangiopancreatography with sphincter of Oddi manometry and endoscopic sphincterotomy when manometry is abnormal.

When its not appendicitis.

Velanovich V. Harkabus MA. Tapia FV. Gusz JR. Vallance SR.
Division of General Surgery, Henry Ford Hospital, Detroit, Michigan, USA.
Other pathology besides appendicitis may be found in patients with right lower quadrant pain. This has led some to advocate diagnostic laparoscopy/laparoscopic appendectomy for all such cases. This policy would substantially raise the costs of care without a priori proof of its efficacy. However, a selective approach on when to proceed with diagnostic laparoscopy will depend on the frequency of finding unexpected, nonappendiceal pathology. To determine this, we reviewed our experience with 202 appendectomies. For females < 50 years old, 33 per cent had normal appendices, 12 per cent had periappendicitis, 47 per cent had acute appendicitis, 12 per cent had perforated appendicitis, and 26 per cent had other nonappendiceal pathology. For males < 50 years old, 13 per cent had normal appendices, 8 per cent had periappendicitis, 67 per cent had acute appendicitis, 15 per cent had perforated appendicitis, and 5 per cent had other pathology. For patients > 50 years old, 7 per cent had normal appendices, 13 per cent had periappendicitis, 33 per cent had acute appendicitis, 60 per cent had perforated appendicitis, and 20 per cent other pathology. Other nonappendiceal pathology was found in 42 per cent of females < 50 with normal appendices, 57 per cent with periappendicitis, and 14 per cent with acute/perforated appendicitis. In males < 50 years, 50 per cent of those with normal appendices, 10 per cent of those with periappendicitis, and 0.7 per cent of those with acute appendicitis had nonappendiceal pathology. In conclusion, women of childbearing age and patients > 50 years old have a significant incidence of nonappendiceal pathology. In this group of patients, a diagnostic laparoscopy appears justifiable to identify the cause of the abdominal pain.

Laparoscopic abdominoperineal resection for anorectal cancer.

Iroatulam AJ. Agachan F. Alabaz O. Weiss EG. Nogueras JJ. Wexner SD.
Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale 33309, USA.
The use of the laparoscopic technique in treating colorectal malignancies for cure is still a controversial issue. The aim of this study was to evaluate the outcome of laparoscopic abdominoperineal resection (APR) in treating malignancies of the lower rectum and anus and to compare the results with patients of matched age and diagnosis treated by conventional open APR by the same surgeon during the same time period. Between August 1991 and December 1996, we performed 235 laparoscopic colorectal procedures, including 8 laparoscopic APRs for malignancies of the lower rectum or anus. There were 6 female and 2 male patients of a mean age of 67 years. Pathologies included 4 adenocarcinomas, 2 melanomas, 1 leiomyosarcoma, and 1 squamous cell carcinoma. Four procedures were laparoscopically completed, and 3 were laparoscopic-assisted. One was converted to an open procedure due to dense adhesions. Five procedures were performed with palliative intent, whereas 3 were performed with curative intent. These patients were evaluated for procedural safety, distal and lateral resection margins, number of lymph nodes harvested, operative time, postoperative ileus, length of hospital stay, morbidity, and mortality. Results were compared with 7 conventional APRs performed between 1991 and 1996, 5 of which were performed for palliation. Histologic studies of the specimen demonstrated free lateral resection margins in all cases in both groups. No differences were noted in the mean free distal resection margins among the four groups: laparoscopic, 2.5 cm; laparoscopic-assisted, 3 cm; converted, 6 cm; and open, 3.6 cm. Mean lymph node harvest was 9, 9, 9, and 10 nodes, respectively. Mean length of surgery was 181, 198, 240, and 131 minutes, respectively. The length of postoperative ileus was 3.2, 7, 3, and 5.9 days, respectively. Mean postoperative length of stay was 6.5, 7, 6, and 12.5 days, respectively. Morbidity was 25 per cent in the laparoscopy group and 43 per cent in the open group. There was no 30-day postoperative mortality recorded in any group. Laparoscopic APR is associated with a 50 per cent reduction in the length of hospitalization without any compromise to lateral or distal resection margins, number of lymph nodes harvested, or morbidity.

The etiology of intestinal obstruction in patients without prior laparotomy or hernia.

McCloy C. Brown TC. Bolton JS. Bowen JC. Fuhrman GM.
Department of Surgery, Ochsner Clinic, New Orleans, LA 70121, USA.
Patients with clinical features of intestinal obstruction without a history of prior laparotomy or physical evidence of a hernia can be a diagnostic challenge. We attempted to evaluate our preoperative diagnostic accuracy, to assess the effectiveness of our diagnostic tools, and to determine the incidence of various causes of intestinal obstruction in this select group. Medical records of all patients admitted to our institution and taken to surgery with a diagnosis of intestinal obstruction from 1975 through 1995 were reviewed. Patients with a history of prior laparotomy, evidence of hernia, or emergent indications for surgery on admission were excluded. The most common cause of intestinal obstruction in this select group of patients was malignancy. The ability to detect malignancy preoperatively is significantly better than the ability to detect benign causes of obstruction (Pearson Chi square = 4.09 with a P value of 0.04). Preoperative detection of malignancy in these patients is critical for optimal treatment planning and counseling for patients and their families.

Leiomyosarcoma: a 45-year review at Charity Hospital, New Orleans.

Hill MA. Mera R. Levine EA.
Section of Surgical Oncology, Louisiana State University Medical Center, New Orleans 70112, USA.
Approximately 2 to 9% of all soft tissue sarcomas are leiomyosarcomas (LMS). LMS arises nearly exclusively as tumors in adults, with peak incidence occurring in the fifth and sixth decades. The purpose of this study was to analyze disease-specific survival and define prognostic factors in patients with this disease who were treated and followed at a single institution. Fifty-eight cases of LMS were identified in the Tumor Registry of the Medical Center of Louisiana at New Orleans (charity Hospital) from 1950 to 1995. Charts were reviewed and tissue blocks reexamined to confirm the diagnosis. Follow-up information was available for 56 of 58 (96%) patients. Univariate and multivariate analyses were performed to analyze which factors predict outcome. The median survival time was 138 months. Univariate analysis identified age (> 48 years), location (retroperitoneal vs other sites), and extent of disease as prognostic factors. Multivariate analysis revealed that only age and the extent of disease at presentation are independent prognostic indicators. Race, sex, and adjuvant therapy were not significant prognostic factors. Surgical resection remains the therapeutic mainstay for patients with LMS. The value of other treatment modalities is largely limited to surgical failures. The data show that the age of the patient and the extent of disease at presentation are the best predictors of long-term survival. LMS has a good prognosis when complete resection of localized lesions can be achieved.

Prosthetic patch stabilization of crural repair in antireflux surgery in children.

Simpson B. Ricketts RR. Parker PM.
Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
Nissen fundoplication is a frequently performed procedure by pediatric surgeons for the treatment of gastroesophageal reflux. Reoperation for failed fundoplication is necessary in 10 per cent of children and in 25 per cent of neurologically impaired children. In an attempt to reduce the postoperative recurrence of gastroesophageal reflux and wrap herniation, we have modified our Nissen fundoplication by reinforcing the crural repair with a horseshoe-shaped prosthetic patch. Between 1993 and 1995, 38 children underwent a Nissen fundoplication with prosthetic patch crural repair. Tension-free crural repair was performed over an esophageal dilator by suturing a horseshoe-shaped Dacron patch posterior to the esophagus. After crural repair, the standard Nissen 360 degrees wrap was constructed. Of the 38 children, 56 per cent (n = 21) were neurologically impaired. In 18 per cent of patients, the operation was performed for recurrent reflux due to wrap herniation after a Nissen fundoplication without prosthetic patch repair. One child required esophageal dilatation postoperatively for dysphagia related to esophageal stenosis. After a mean follow-up of 15 months, all patients were without symptomatic reflux or had no radiographic evidence of recurrent reflux or wrap herniation. Tension-free crural repair with a prosthetic patch may decrease postoperative reflux and wrap herniation, particularly in neurologically impaired children and in children requiring reoperation for recurrent reflux.

Small-diameter H-graft portacaval shunt reduces portal flow yet maintains effective hepatic blood flow.

Zervos EE. Goode SE. Rosemurgy AS.
Department of Surgery, College of Medicine, University of South Florida, Tampa, USA.
Small-diameter H-graft portacaval shunts (HGPCSs) effectively treat bleeding varices due to cirrhosis, although the effects of such shunts on hepatic blood flow are not well established. Proponents of HGPCS believe that portal flow diverted through the shunt is regained through increased hepatic arterial inflow while others argue that this flow is never recovered; resulting in compromised nutrient flow. In this study, we sought to determine the effects of HGPCS on effective hepatic and portal blood flow. Patients undergoing HGPCS had portal pressures and flow (via color-flow Doppler ultrasound) measured intraoperatively before and after placement of HGPCS. Effective hepatic blood flow was determined utilizing low-dose galactose clearance 1 day preoperatively and 5 days postoperatively. Over a 7-year period, 64 patients (42 male and 22 female), average age 54 +/- 13.6 years (SD), were studied. Cirrhosis was due to alcohol in 37 patients, hepatitis in 9, alcohol and hepatitis in 5, and assorted other causes in 13. Child's class was A in 11 patients, B in 35, and C in 18. Both portal flow and pressures decreased significantly postoperatively (15 +/- 14.2 to 10 +/- 15.1 mL/min [P < 0.05] and 29 +/- 13.0 to 18 + 6.2 mm/Hg [P < 0.05]), whereas effective hepatic blood flow decreased insignificantly (1441 +/- 1719 to 1332 +/- 863 mL/min). Small-diameter HGPCS significantly reduce portal pressures and portal blood flow while maintaining effective hepatic flow. These findings suggest that hepatic arterialization occurs as early as 5 days after shunting and thus support the application of HGPCS.

Laparoscopic cholecystectomy in pregnancy.

Gouldman JW. Sticca RP. Rippon MB. McAlhany JC Jr.
Department of Surgical Education, Greenville Hospital System, SC 29605, USA.
Laparoscopic cholecystectomy has been performed in the United States since 1989 and currently is the procedure of choice for the management of symptomatic cholelithiasis. Its utility in the pregnant patient has been controversial. Concerns have been expressed for a number of potential problems, including trocar injury to uterus and fetus, effect of pneumoperitoneum on both mother and fetus, induction of preterm labor, teratogenic effects on the fetus, and long-term effects on fetal and neonatal development. We describe the Greenville Hospital System experience with laparoscopic cholecystectomy in pregnancy. From 1992 to 1996, eight laparoscopic cholecystectomies were performed in pregnant females, one during the first trimester and seven during the second trimester. Mean maternal age was 23.8 years (range, 18-31). All procedures were performed for recurrent and intractable symptoms with the average length of symptoms 3.5 weeks (range, 2-4 weeks). Two patients were diagnosed preoperatively with gallstone pancreatitis, two had acute cholecystitis, and four patients were felt to have hyperemesis gravidarum before their diagnosis of gallstones. All procedures were performed under general endotracheal anesthesia with CO2 insufflation pressures of 12 mm Hg. Postoperatively, all patients had uneventful recoveries with complete resolution of their symptoms and were discharged home in an average of 3 days (range, 1-7 days). No postoperative complications to mother or fetus were documented. Eight patients have delivered full-term healthy fetuses with no documented neonatal morbidity or mortality. Long-term follow-up of the infants at a mean of 23 months (range, 2.5-47 months) reveals that all eight infants have progressed to normal healthy children. Our experience and the current world literature demonstrate that laparoscopic cholecystectomy in pregnancy can be performed safely and effectively for symptomatic cholelithiasis, especially when symptoms are recurrent and persistent and may endanger fetal and maternal livelihood. The diagnosis of symptomatic cholelithiasis should be considered in the pregnant patient with recurrent episodes of nausea and vomiting.

Whats black and white and red (read) all over? The bedside interpretation of diagnostic peritoneal lavage fluid.

Bellows CF. Salomone JP. Nakamura SK. Choe EU. Flint LM. Ferrara JJ.
Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana 70112, USA.
Diagnostic peritoneal lavage (DPL) is often used to determine whether a blunt trauma victim has significant intra-abdominal hemorrhage. One bedside test (BT) historically recommended to evaluate DPL fluid is the ability to read newsprint through the fluid contained within intravenous (i.v.) tubing. Few experimental data support this practice. Two hundred eighteen traumatologists were queried regarding their use of BTs. In a related clinical study, blinded volunteers were asked to read print through various unmarked containers filled with simulated DPL fluid, created by adding aliquots of whole human blood to liter bags of lactated Ringer's solution. Of the 97 traumatologists who completed our preliminary survey, 60 per cent reported using a visual BT to assess DPL fluid. Of these surgeons, 44 per cent attempted to read newsprint through i.v. tubing. Our clinical study showed that more volunteers could read print through a red top tube (95%) when it contained a red cell concentration of 827 +/- 41/mm3 than the i.v. bag (4%). Nearly 70 per cent of volunteers were able to read print through the tubing containing 41,429 +/- 2,967 red blood cells (RBCs)/mm3. Regardless of the receptacle, readability was lost at RBC counts far below 100,000/mm3. Many traumatologists utilize BTs as an adjunct to clinical decision making. We conclude that, if the clinician can read print through lavage fluid within an i.v. bag, Vacutainer tube, or i.v. tubing, the DPL will be negative at cell count. However, inability to read print through i.v. tubing requires laboratory confirmation to document an RBC count > 100,000/mm3.

A prospective, randomized comparison of traditional and laparoscopic inguinal exploration in children.

Rogers DA. Hatley RM. Howell CG Jr.
Section of Pediatric Surgery, Medical College of Georgia, Augusta 30912-4070, USA.
The indications for routine exploration of the asymptomatic contralateral groin during pediatric herniorrhaphy remain controversial. Laparoscopy through the open hernia sac has been described as an alternative to this traditional approach and appears to offer some advantages. In deciding whether this technique should be introduced into our clinical practice, we sought to discover whether there was a significant time difference between these two methods and if there were unique complications associated with this approach. We elected to answer this question in a prospective, randomized study. A total of 18 patients completed the study. There were no significant complications in either group. The average total surgical procedure time in the laparoscopy group was 47.5 minutes versus 41 minutes in the traditional group, which is not a statistically significant difference. We conclude from this prospective, randomized pilot study that laparoscopic exploration can be introduced into a pediatric surgical practice without a significant time penalty, and we currently offer it as a reasonable and safe alternative to our patients.

Primary gastrointestinal non-Hodgkins lymphoma: increasingly AIDS-related.

Whooley BP. Bernik S. Sarkis AY. Wallack MK.
Department of Surgery, St. Vincents Hospital and Medical Center of New York/New York Medical College, New York 10011, USA.
A retrospective study was conducted to determine the influence of the acquired immunodeficiency syndrome (AIDS) epidemic on the incidence, clinical presentation, and outcome of primary gastrointestinal lymphoma (stages I and II) over a 20-year period at a single institution. Between 1971 and 1981, there were seven cases. Fifty-eight patients were diagnosed between 1983 and 1993, and 81 per cent were AIDS-related. The mean age overall was 50 years; 81 per cent were male, and 35 per cent presented with acute complications. All tumors were high or intermediate grade B cell lymphomas, and 48 per cent had bulky or advanced disease at presentation. The overall actuarial 5-year survival was 9 per cent. Human immunodeficiency virus status and stage were significant independent prognostic factors. The AIDS-related subgroup had a mean age of 43 years, and 91 per cent were male. Tumor resection was performed in 38 per cent, and the 5-year survival was 2 per cent. The mean age for the non-AIDS-related subgroup was 71 years, and 55 per cent were male. Resection was performed in 39 per cent, and 5-year survival was 28 per cent. AIDS-related disease accounted for the dramatic increase in incidence of primary gastrointestinal lymphoma since 1983. The prognosis for these patients is poor and is dominated by the underlying immunocompromise.

Endorectal advancement flap in perianal Crohns disease.

Joo JS. Weiss EG. Nogueras JJ. Wexner SD.
Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale 33309, USA.
The aim of this study was to evaluate the outcome of patients undergoing endorectal advancement flap repair for perianal Crohn's disease relative to the primary site of intestinal Crohn's disease. From January 1991 to December 1995, 31 consecutive endorectal advancement flap repairs were performed in 26 patients. The results relative to surgical outcomes, length of hospitalization, and recurrence were analyzed. The mean patient age was 40.2 years (range, 16-70). Type of fistulas included: rectovaginal: 20 (64.5%), fistula in ano: 8 (25.8%), rectourethral: 1 (3.2%) and others: 2 (6.5%). The mean length of follow-up was 17.3 (range 3-60) months. The mean length of hospitalization was 3.7 (range 2-5) days. A temporary diverting stoma was created in 6 patients with a 66.7% (4/6) surgical success rate. Twenty-one of the 26 patients had previous procedures consisting of 12 (38.7%) bowel resections, 6 (19.4%) seton placements, 4 (12.9%) drainages, and 6 (19.4%) diverting ileostomies. Eleven patients had multiple procedures. Ultimately, fistulas were eradicated in 22 (71%) cases, including 15 (75%) of the 20 with rectovaginal fistulas and 7 (63.6%) of the 11 with other fistulas. There was no mortality; morbidity included a flap retraction in 1 patient, who required antibiotics for 5 days and bleeding in 1 patient, who required reoperation. Success was noted in 2 of 8 (25%) patients with small bowel Crohn's disease as compared to 20 of 23 (87%) patients without small bowel Crohn's disease (P < 0.05). Endorectal advancement flap is an effective surgical modality for the treatment of fistulas due to perianal Crohn's disease but is less apt to succeed in patients with concomitant small bowel Crohn's disease.

Laparoscopy and lesser sac endoscopy in gastric carcinoma operability assessment.

Charukhchyan SA. Lucas GW.
Georgia Oncological Research Center, Tbilisi, USA.
The results of 502 laparoscopy and 200 lesser sac endoscopy applications in 502 patients with gastric carcinoma for operability assessment are studied. Laparoscopy demonstrated a 94.74 per cent sensitivity for diagnosis of peritoneal disseminations and liver metastases. However, laparoscopy failed to establish inoperability in any cases of carcinoma spread to areas not accessible to laparoscopic visualization. Of these latter cases, 95.74 per cent were caused by tumor spread to the lesser sac retroperitoneum. Thus, the resultant sensitivity of laparoscopy in gastric carcinoma inoperability diagnosis was only 42.35 per cent. Lesser sac endoscopy made it feasible to inspect all of the organs and tissues forming the lesser sac. Of 200 patients assessed by lesser sac endoscopy, invasion of gastric posterior wall serosa was found in 89, retroperitoneal tumor invasion in 97, and retroperitoneal metastases in 42. The sensitivity of gastric carcinoma inoperability diagnosis by lesser sac endoscopy was 93.44 per cent and in combination with laparoscopy, 96.7 per cent. Utilization of lesser sac endoscopy in patients with gastric carcinoma minimized the number of exploratory laparotomies 6.4 times in comparison with only laparoscopy use and was responsible for diminishing this number to 5 per cent of the total number of examined patients.

Recurrent Zenkers diverticulum: treatment with crycopharyngeal myotomy.

Skinner KA. Zuckerbraun L.
University of California, Los Angeles, School of Medicine, Department of Surgery, USA.
Recurrence following treatment of Zenker's diverticulum (ZD) occurs in up to 16 per cent of patients. We have reviewed our experience with cricopharyngeal myotomy (CM) to determine its safety and efficacy in the treatment of recurrent ZD. Eight patients were treated, five with early recurrence (symptoms persisting or recurring within 6 months of their initial surgery) and three with late recurrence. Most patients with early recurrence did not have an adequate CM as part of their initial therapy, suggesting that adequate myotomy is important for early relief of dysphagia. Seven patients underwent CM alone, and one patient underwent CM with diverticulectomy. All patients experienced immediate relief of their dysphagia, with good to excellent results persisting at last follow-up (mean follow-up 53 months). Complications were seen only in the patient who underwent combined myotomy with diverticulectomy. We have found CM alone to be quite safe and effective in the treatment of recurrent ZD.

Surgical and nonsurgical management of primary and metastatic liver tumors.

Year 1998
Zibari GB. Riche A. Zizzi HC. McMillan RW. Aultman DF. Boykin KN. Gonzalez E. Nandy I. Dies DF. Gholson CF. Holcombe RF. McDonald JC.
Louisiana State University Medical Center, Department of Surgery, Shreveport 71130, USA.
The medical records of 267 patients who had liver tumors, primary and metastatic, from 1988 to 1995 were retrospectively reviewed. Two hundred thirteen patients (80%) had metastatic disease, and 54 patients (20%) had primary liver disease. Their clinical manifestations and laboratory values were evaluated as factors predictive of diagnosis and survival. There was a significant increase in the occurrence of upper abdominal pain, weight loss, extrahepatic symptoms due to the metastatic origin, and hepatomegaly. Metastases from colorectal primary lesions were synchronous in 34 patients and metachronous in 31 patients. Stomach, lung, and pancreatic primaries were more commonly synchronous. Breast metastases were more commonly metachronous. Elevated serum glutamic-oxaloecetic transaminase and alkaline phosphatase and decreased albumin were the most common liver test abnormalities at diagnosis. Carcinoembryonic antigen values were elevated in the majority of colon cancer patients. Eighty-one percent of patients with primary liver cancer had elevated levels of alpha-fetoprotein, 40 per cent were seropositive for hepatitis B, and 23 per cent were seropositive for hepatitis C. Seventy-nine patients (30%) underwent surgery for their cancer, 37 (47%) had resections, 38 (48%) were unresectable, and 4 (5%) underwent liver transplantation. The patients who underwent surgery had a 32 per cent 5-year survival rate compared to a 0 per cent 5-year survival in the patients who did not have surgery (p = 0.0001). The patients who had resections had a better survival rate than those deemed unresectable at surgery (62% versus 0% at 5-years with p = 0.0008). The perioperative morbidity rate was 16 per cent, with lobectomies having the best rate and trisegmentectomies having the worst. Perioperative mortality rate was zero for all liver resections. Hepatic resection and, in selected patients, liver transplantation are the only two available therapeutic modalities that produce long-term survival with a possible cure in patients with primary and metastatic liver tumor.

Should a laparoscopic appendectomy be done?

Year 1998
Fallahzadeh H.
Department of Surgery, University of Louisville, Columbia Lake Cumberland Regional Hospital, Somerset, USA.
For a laparoscopic appendectomy to be part of a surgical armamentarium, it should: 1) decrease hospital stay, 2) lessen narcotic requirement, 3) speed return to normal activity, 4) be cost effective, and 5) have fewer complications. To this end, we reviewed 60 consecutive cases of each appendectomy performed, laparoscopically and by open technique, during the period of 1993-1996. We looked not only at the above criteria, but also at the type of employment. Laparoscopic appendectomy did not decrease hospital stay (2.1 versus 1.4 days), or morphine equivalent narcotic requirement (38.5 mg versus 19.8 mg). However, laparoscopic appendectomy did carry a hospital bill of $3650.00 more than the open technique ($7923 versus $4273). This results not only from chargeable disposable items, but also from an increase in operative time (47 vs. 36 minutes) and room and anesthesia time (88 vs. 63 minutes), because of the increased length of preparation time. In only one category, patients involved in heavy manual activity (17 patients), the return to normal activity decreased by 1 week. There was no difference in complication rate in each category. Based on these findings, laparoscopic appendectomy cannot be recommended in suspected cases of appendicitis.

Imipramine overdose complicated by toxic megacolon.

Year 1998
Ross JP. Small TR. Lepage PA.
Spartanburg Regional Medical Center, South Carolina, USA.
Tricyclic antidepressants are a class of drugs commonly used for the treatment of depression. Tricyclic antidepressants account for approximately 20 to 25 per cent of drug overdoses that require acute medical admission. The most common cause of mortality is cardiovascular toxicity (e.g., arrhythmia, heart block, or hypotension). Other morbidities include conditions secondary to anticholinergic effects (central and peripheral) and respiratory complications. Ileus, constipation and urinary retention are common peripheral anticholinergic sequelae, whereas unusual complications include pancreatitis, intestinal pseudo-obstruction with cecal perforation, and sigmoid colon gangrene. We report a case of imipramine overdose that was complicated by toxic megacolon with an associated perforation.

Long-term survival after locally aggressive anorectal melanoma.

Year 1998
Whooley BP. Shaw P. Astrow AB. Toth IR. Wallack MK.
Department of Surgical Oncology, St. Vincent's Hospital, New York, New York, USA.
Anorectal melanoma is a rare disease and, unlike cutaneous melanoma, there are few guidelines regarding optimal management. It has a reputation for having a poor prognosis, which has been attributed to a delay in diagnosis and to a lack of effective systemic therapy. It has also been suggested that the biology of this tumor may differ from that of cutaneous melanoma. An interesting case of anorectal melanoma is presented which highlights the unique considerations and challenges encountered by medical oncologists and surgeons who treat this disease.

The outcome of intestinal fistulae: the Louisiana State University Medical Center--Shreveport experience.

Year 1998
Martinez D. Zibari G. Aultman D. McMillan R. Mancini MC. Rush BM. McDonald JC.
Department of Surgery, Louisiana State University Medical Center, Shreveport 71130, USA.
Fistulae arising from the intestinal tract are associated with significant morbidity and mortality rates. Most contemporary studies of fistulae report mortality rates between 6 and 20 per cent. The major causes of death in these patients are sepsis, electrolyte imbalance, and malnutrition. A total of 48 patients with either external or internal intestinal fistulae were reviewed in this study over a 5-year period at the Louisiana State University Medical Center at Shreveport. Intestinal fistulae were classified into three types, anatomic site, physiologic type, and etiology, to evaluate morbidity and mortality rates. We also attempted to evaluate the role of parenteral nutrition in this patient population, but our data were inconclusive because of the limited number of patients. There was no difference in mortality rates associated with anatomical sites. High-output fistulae were associated with a higher mortality rate compared to low-output fistulae. Fifty-six per cent of the patients achieved closure. The overall mortality rate was 21 per cent. Spontaneous closure rates were lower when compared to those in other studies. This was attributed to sepsis, malignancy, and history of previous radiation therapy. Management of intestinal fistulae includes control of sepsis, correction of electrolyte disturbances, nutritional support, and operative intervention if necessary.

Reconstruction of replaced right hepatic artery, to implant a single-catheter port for intra-arterial hepatic chemotherapy.

Year 1998
Eid A. Reissman P. Zamir G. Pikarsky AJ.
Department of General Surgery and Transplantation, Hadassah University Hospital, Kiryat Hadassah, Jerusalem, Israel.
Intra-arterial hepatic chemotherapy using an implantable subcutaneous port with a catheter inserted into the gastroduodenal artery is an acceptable treatment for patients with isolated, nonresectable liver metastases from colorectal cancer. Because of the common variations of hepatic arterial anatomy occurring in about one-half of the patients, this technique will result in complete perfusion of both hepatic lobes only in those with "classical" arterial anatomy (Michels type I). Many techniques have been described in these situations, usually using a dual-catheter port with the attendant risk of hepatic misperfusion and arterial thrombosis. We herein describe an alternative technique applicable to patients with a right hepatic artery arising from the superior mesenteric artery. In this technique the right hepatic artery is anastomosed end-to-end with the gastroduodenal artery, followed by implantation of a single-catheter port that is inserted into the splenic artery.

U tubes and rare hepatobiliary complications.

Year 1998
Brevetti GR. Brevetti LS. Giangobbe MJ. Ukah FO.
Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City 52242, USA.
U tubes have been used for a wide variety of hepatobiliary problems. We report a patient with multiple complications possibly related to the use of a U tube. These include secondary biliary cirrhosis, intrahepatic bilomas, and enterocutaneous fistula. The relatively rare entities of intrahepatic biloma and enterocutaneous fistula are reviewed.

Factors affecting wound complications in repair of ventral hernias.

Year 1998
White TJ. Santos MC. Thompson JS.
Department of Surgery, University of Nebraska Medical Center, Omaha 68198-3280, USA.
Wound-related complications are common after incisional hernia repair. Prophylactic antibiotic use, placement of subcutaneous drains, and technical factors such as mesh implantation reportedly influence the incidence of these complications. Our aim was to study the incidence of wound complications in incisional hernia repairs and to determine whether use of antibiotics, drains, or mesh influence these rates. Two hundred fifty hernias were repaired in 206 patients over a 14-year period. Simple repair was performed in 151 patients while mesh was used in 99 repairs. Mesh repair was used in larger hernias, required longer operating time, and had greater blood loss than simple repair. Twenty-eight per cent of repairs with mesh were for recurrent hernias compared with 14 per cent for simple repair (P < .05). Overall, 34 per cent of patients had wound-related complications. Chronic obstructive pulmonary disease, obesity, steroid therapy, and previous wound infection were not associated with increased risk for wound complications. The use of mesh and hernia defect > 10 cm were associated with significantly more wound complications. The incidence of seroma was increased in mesh repairs (21% vs 7%), as were total wound complications (44% vs 26%; P < 0.05). A suprafascial onlay mesh technique resulted in more frequent seroma formation. Patients undergoing mesh repair were more likely to receive antibiotics (91% vs 71%) and have subcutaneous drains placed (57% vs 25%; P < 0.05) compared to simple primary repair. Neither antibiotics nor drains had an effect on the incidence of wound complications within each group. Overall, wound infections were more frequent when drains were placed. We conclude that repair of incisional hernias is associated with substantial risk of wound-related complications. Mesh is used for repair of larger and more complex hernias and is associated with increased risk of wound complications. Abnormal fluid collections are the most frequent problem, but the use of drains does not reduce the incidence of these complications.

Aortoiliac occlusive disease and gastrointestinal malignancy: changing therapeutic options.

Year 1998
Neuzil DF. Meszoely I. Tarpley JL. Naslund TC.
Vanderbilt University Medical Center, Division of Vascular Surgery, Nashville, Tennessee 37232-2735, USA.
Treatment of gastrointestinal malignancy encountered unexpectedly during procedures involving the abdominal aorta continues to be debated. Previously, simultaneous vascular procedures with intra-abdominal malignancy were rare. Most underwent vascular reconstruction followed by a delayed aortic procedure. With recent improvement in axillobifemoral graft patency, a one-stage procedure for aortoiliac disease should be entertained. We recently encountered a small bowel lymphoma while beginning an aortic replacement for aortic occlusion. Resection of a near-obstructing small bowel tumor immediately after axillofemoral reconstruction provided treatment of both entities at one time. Since the early description of axillofemoral bypass in 1963, varying success with extra-anatomic bypass has been reported. Early data for axillofemoral bypass were dismal, but with recent technical and graft improvements patency has been improved. Occult malignancy during aortic procedures is uncommon, about 2 to 4 per cent, but when met is usually dealt with after the patient recovers from the vascular procedure. With improvements in extra-anatomic bypass results, a single operative period can be entertained.

Gallbladder diverticulum: a case report and review of the literature.

Year 1998
Kramer AJ. Bregman A. Zeddies CA. Guynn VL.
Delner Community Hospital, Geneva, Illinois, USA.
Gallbladder diverticulum is an unusual and uncommon disease process rarely discussed in the literature. This disorder may not be diagnosed until surgically resected. The presentation may entail nonspecific complaints over a prolonged period as highlighted in a case report of a 17-year-old woman with this disease. The incidence and pathophysiology of this disease process is correlated to the symptoms and signs of this patient. The surgical findings, procedure, and outcome are described.

Successful management of visceral Klippel-Trenaunay-Weber syndrome with the antifibrinolytic agent tranexamic acid (cyclocapron): a case report.

Year 1998
Katsaros D. Grundfest-Broniatowski S.
Department of Surgery, Fairview General Hospital, Cleveland, Ohio, USA.
Klippel-Trenaunay-Weber syndrome (KTWS) is a rare, congenital disorder characterized by vascular nevus formation, deep venous thrombosis, varicosities, and hypertrophy of affected tissues. A patient with known thrombosis of his splanchnic circulation and visceral KTWS presented with life-threatening hemorrhage from rectosigmoid varices. Portosystemic shunting was not feasible. Endoscopic sclerosis, variceal ligation, and proctocolectomy were not possible due to the size and number of the varices. Previous treatment with epsilon-aminocaproic acid had been unsuccessful and complicated by thrombophlebitis. Conservative treatment with blood transfusions, cryoprecipitate, fresh frozen plasma, vitamin K, propanolol, and somatostatin analog failed to stop the bleeding. The patient was given the antifibrinolytic agent, tranexamic acid, with cessation of his hemorrhage. Serial thromboelastograms confirmed improved reaction time, coagulation time, clot formation rate, and maximum amplitude. We conclude that tranexamic acid may be a useful adjunct in the medical treatment of high-risk patients with KTWS and other vascular nevi complicated by coagulopathy.

Ectopic thyroid nodular goiter presenting as a porta hepatis mass.

Year 1998
Jamshidi M. Kasirye O. Smith DJ.
Department of Surgery, Western Reserve Care System, Youngstown, Ohio, USA.
An ectopic thyroid goiter was found in a 58-year-old woman who presented with abdominal and low back pain, diarrhea, and generalized weakness. Initial workup, including abdominal CT scan, revealed a mass extending from the duodenum to the porta hepatis. After resection and upon pathologic examination of the tissue, nodular arrangement of thyroid follicles and colloid lakes with focal hyperplastic and nodular goiter changes were identified.

Small-bowel perforation secondary to metastatic carcinoma of the breast.

Year 1998
Cornu-Labat G. Ghani A. Smith DJ. McDonald AD. Kasirajan K.
Department of Surgery, Western Reserve Care System, Youngstown, Ohio, USA.
Perforation from a solitary metastatic lesion of the small bowel is rare. We report a case of acute perforation with no evidence of metastatic disease within the abdomen. Resection of the small bowel was performed.

Nonsurgical pneumoperitoneum: a case report and a review.

Year 1998
Rowe NM. Kahn FB. Acinapura AJ. Cunningham JN Jr.
Department of Surgery, Lutheran Medical Center, Brooklyn, New York 11220, USA.
The finding of extraluminal gas on plain radiographs is usually associated with a perforated viscus. But, as this case shows, the finding of pneumoperitoneum is not pathogenic of a perforated viscus or even of a surgical emergency, because there are many benign explanations for a pneumoperitoneum. Perhaps the most important maneuver for differentiating between the two is by performing a through history and physical examination. This in conjunction with either a diagnostic peritoneal lavage, contrast studies, or endoscopic evaluation can help prevent a patient from having needless surgery. The causes of a nonsurgical pneumoperitoneum are described as well as a treatment plan for patients presenting with a nonsurgical pneumoperitoneum.

Adenocarcinoid tumor of the ampulla of Vater.

Year 1998
Alex WR. Auerbach HE. Pezzi CM.
Department of Surgery, Abington Memorial Hospital, Pennsylvania, USA.
We report a rare case of adenocarcinoid tumor of the ampulla of Vater. The tumor contained an intermixture of adenocarcinoma and carcinoid tumor and was removed successfully by pancreaticoduodenectomy. The characteristics of these rare tumors are reviewed.

The role of liver transplantation in the subacute trauma patients.

Year 1998
Ginzburg E. Shatz D. Lynn M. Pombo H. Diaz M. Martin L. Livingstone A. Khan MF. Nery J. Tzakis A.
Department of Surgery, University of Miami School of Medicine, Florida 33101, USA.
Two case reports are presented involving complex liver traumas requiring the need for liver transplantation. Both of these patients were designated unsalvageable until the transplant team was consulted. It is imperative that surgeons involved with complex hepatic trauma not give up hope and include these patients as potential liver recipients when irreversible liver failure occurs.

A Muir-Torre syndrome family.

Year 1998
Serleth HJ. Kisken WA.
Department of Surgery, Gundersen/Lutheran Medical Center, La Crosse, Wisconsin 54601, USA.
The Muir-Torre syndrome is a rare autosomal-dominant disease involving sebaceous neoplasms as markers for multiple internal malignancies. Diagnostic criteria include at least one sebaceous gland adenoma, epithelioma, or carcinoma and at least one internal malignancy. The world literature contains 162 cases with 316 internal malignancies. Colorectal and urogenital malignancies predominate, and nearly half the patients had two or more internal cancers. The discovery of a Muir-Torre syndrome-associated sebaceous lesion is rare and should prompt an evaluation for internal malignancies. We report a family over five generations displaying this syndrome. The proband is a 44-year-old man with two skin and two colon malignancies who presented to our clinic with the chief complaint of an infected sebaceous cyst. The world literature is reviewed, and an emphasis on the surgeon's role in evaluation and treatment is discussed.

Biliary dyskinesia: natural history and surgical results.

Year 1998
Goncalves RM. Harris JA. Rivera DE.
General Surgery Service, D. D. Eisenhower Army Medical Center, Ft. Gordon, Georgia 30805, USA.
Patients with biliary dyskinesia have symptoms consistent with biliary colic and an abnormal gallbladder ejection fraction (GEF) in the absence of cholelithiasis. Cholecystokinin hepatobiliary scan quantifies gallbladder function and may assist in selecting patients with acalculous biliary pain who would benefit from cholecystectomy. Seventy-eight patients with an abnormal GEF (< 35%) on cholecystokinin hepatobiliary scan without cholelithiasis were studied retrospectively. Patients were divided into groups based on diagnosis and treatment. In Group I, the patients who underwent cholecystectomy, 80 per cent (35 of 44) had complete symptomatic resolution whereas the remaining 20 per cent (9 of 44) had symptomatic improvement. Pathology reports demonstrated chronic cholecystitis in 95 per cent of specimens. Group II were patients with symptoms attributable to biliary dyskinesia, but did not undergo cholecystectomy. Persistence of symptoms was noted in 75 per cent (18 of 24) of patients whereas 25 per cent (6 of 24) had symptomatic resolution without any treatment. Group III consisted of patients with an abnormal ejection fraction who had improvement of symptoms after treatment for an alternative diagnosis (n = 10). These findings suggest that an abnormal ejection fraction does not always indicate gallbladder disease. Alternative diagnoses must be investigated and treated. Patients with persistent biliary type symptoms in combination with an abnormal GEF in the absence of other attributable causes can expect a favorable response to cholecystectomy.

Quality of life and antireflux medication use following laparoscopic Nissen fundoplication.

Year 1998
Bloomston M. Zervos E. Gonzalez R. Albrink M. Rosemurgy A.
University of South Florida, College of Medicine, Tampa, USA.
With the advent of minimally invasive techniques, the surgical treatment of gastroesophageal reflux disease has received renewed interest. The efficacy of laparoscopic Nissen fundoplication in eliminating reflux has been documented. This study was undertaken to determine changes in quality of life and cost of antireflux medications after laparoscopic Nissen fundoplication. One hundred patients undergoing laparoscopic Nissen fundoplication between 1992 and 1997 completed questionnaires assessing changes in pre- and postoperative cost and number of antireflux medications, reflux symptoms, and quality of life. The average number of antireflux medications was significantly reduced (1.8 versus 0.3, P < 0.0001) as was the average monthly cost ($170 versus $30, P < 0.0001). Patients reported significant (P < 0.05) symptomatic improvement in postprandial heartburn, nocturnal heartburn, postprandial nausea, postprandial vomiting, dysphagia, and gas/bloating. Patients in this series noted fewer symptoms and used fewer antireflux medications at less cost after laparoscopic Nissen fundoplication. Symptoms commonly thought of as complications of fundoplication (vomiting, dysphagia, gas/bloating) were less common after fundoplication. This report documents the efficacy of laparoscopic fundoplication in improving quality of life and reducing use and cost of antireflux medications.

The outcome of laparoscopic Heller myotomy without antireflux procedure in patients with achalasia.

Year 1998
Wang PC. Sharp KW. Holzman MD. Clements RH. Holcomb GW. Richards WO.
Department of General Surgery, Vanderbilt University, Nashville, Tennessee, USA.
We retrospectively reviewed 30 patients with achalasia (18 males, 12 females) undergoing laparoscopic Heller myotomy without antireflux procedure to determine relief of dysphagia and prevalence of postoperative gastroesophageal reflux. Preoperative symptoms were obtained by history alone before 1996 and by standardized questionnaire after September 1996. Twenty-nine patients (97%) had dysphagia, 22 patients (73%) had regurgitation, 21 patients (70%) had weight loss, 7 patients (23%) had heartburn, and 4 patients (13%) had nocturnal aspiration. The first 3 patients were done thoracoscopically, with the subsequent 27 patients performed laparoscopically; 4 cases (13%; 1 thoracoscopic and 3 laparoscopic) were converted. The mean postoperative stay was 1.9 days (1-6 days). One patient underwent repeat laparoscopic myotomy for persistent dysphagia. Twenty-eight patients (93%) were available for follow-up. Patients were asked on a standardized questionnaire to grade their relief of dysphagia, regurgitation, and heartburn. Good to excellent relief of dysphagia was obtained in 25 patients (89%), whereas 3 patients (11%) continued to have significant dysphagia postoperatively. Twenty-four patients (86%) had little or no regurgitation. Four patients (14%) had frequent regurgitation. Twenty-four patients (89%) reported little or no heartburn. Three patients (11%) reported significant postoperative heartburn. Laparoscopic Heller esophagomyotomy without antireflux procedure provides excellent symptomatic relief of dysphagia in patients with achalasia. Early follow-up suggests that minimal occurrence of symptomatic postoperative reflux can be achieved without performing an antireflux procedure.

Early gastric cancer and Helicobacter pylori: 34 years of experience at Charity Hospital in New Orleans.

Year 1998
Eckert MW. McKnight CA. Lee JA. Araya J. Correa P. Cohn I Jr. Levine EA.
Department of Surgery, Louisiana State University, New Orleans, USA.
Good survival rates have been reported for resected early gastric adenocarcinoma (EGC) in patients found via screening procedures. However, the prevalence of Helicobacter pylori in EGC in unscreened populations is unclear. The major purpose of this investigation was to analyze the clinical experience and incidence of H. pylori in unscreened patients presenting with EGC at Charity Hospital over a 34-year period. From 1963 through 1997, the tumor registry at Charity Hospital compiled data on 2497 patients evaluated for gastric carcinoma. Of these patients, 26 (1%) had lesions that were confined to the mucosa or submucosa, i.e., T1N0M0 (American Joint Commission on Cancer classification). Pathology specimens and medical records were retrieved for confirmation of diagnosis and retrospective analysis for H. pylori. H. pylori was analyzed by Steiner staining and immunohistochemistry using a polyclonal antibody. EGC was detected in 12 men and 14 women with a mean age of 62 years. Upper gastrointestinal X-ray studies were performed on 19 of the 26 patients and failed to conclusively demonstrate a lesion in any case. Endoscopy was performed on 22 patients, and preoperative biopsies were positive in 95 per cent of these. Operative procedures included 2 local excisions and 22 subtotal and 2 total gastrectomies. No extended nodal dissections were performed. Microscopic evaluation revealed lesions limited to the mucosa in 63 per cent of cases and involving the submucosa in 37 per cent of the cases. Of the 14 patients evaluable of H. pylori, 79 per cent were positive for the bacterium. The status of 2 patients is unknown, and only 1 patient died of the original gastric cancer, for a disease-free survival of 96 per cent. The 5-year and 10-year overall survival rates were calculated to be 50 per cent and 21 per cent, respectively, when all causes of death were taken into consideration. Median follow-up of the survivors was 64 months. Resection of early gastric carcinoma in unscreened patients without extended lymphadenectomy yielded excellent results. H. pylori was present in 79 per cent of cases. These data suggest an association between H. pylori and EGC. Whether H. pylori infection is an etiologic factor in gastric cancer remains an area of active research.

The clinical complexity of splenic vein thrombosis.

Year 1998
Han DC. Feliciano DV.
Division of Cardiothoracic Surgery, Carlyle Fraser Heart Center, Crawford Long Hospital, Emory University School of Medicine, Atlanta, Georgia, USA.
Upper gastrointestinal hemorrhage secondary to splenic vein thrombosis is a curable form of localized portal hypertension when treated with splenectomy. A high index of suspicion is necessary in order to promptly diagnose and treat this underrecognized condition that is most commonly caused by inflammation or neoplasm of the pancreas. The triad of isolated gastric varices, splenomegaly, and normal hepatic function is classic; it is not uncommon, however, for patients to have only some or even none of these conditions. Mesenteric angiography with venous phase imaging is the gold standard of diagnosis. Ultrasound and CT may identify splenic vein thrombosis, but are most helpful in delineating concomitant upper abdominal pathology. Early recognition and intervention allow associated underlying conditions to be treated under the same anesthetic with minimal morbidity and mortality.

Colorectal cancer in patients under forty: presentation and outcome.

Year 1998
Parramore JB. Wei JP. Yeh KA.
Department of Surgery, Medical College of Georgia, Augusta 30912, USA.
Colorectal cancer is the third most frequent malignancy in adults of both sexes in this country, with 90 per cent of patients diagnosed after age 50 years. This disease is unusual in patients under 40 years of age, and controversy persists as to prognosis in this subset of patients. Patients diagnosed with invasive adenocarcinoma of the colon and rectum from 1985 to 1997 were identified. They were then grouped according to age (< 40 or > or = 40). Charts were reviewed with respect to patient epidemiologic characteristics, clinical presentation, tumor staging, and survival. Twelve women and 24 men less than 40 years of age (median, 31 years/range, 13-39 years) were diagnosed with colorectal adenocarcinomas. This represented 8.6 per cent of the total patients diagnosed with colorectal cancers during this time. Thirty-five (97%) had symptoms (pain, blood per rectum, weight loss, or alteration in bowel habits) before diagnosis, and 23 (64%) had multiple symptoms. Younger patients had more poorly differentiated tumors (28%) and more mucinous adenocarcinomas (26%) than the older group. Younger patients were more likely to present with stage III or IV disease (78%) as well. Despite these findings, the median survival for younger patients was no different than the older patients when compared by stage. Colorectal cancer in young adults is rare, but should be considered in the differential diagnosis for all patients with gastrointestinal symptomatology. The presentation of these patients is not unlike that of older patients. Those patients with early-stage disease should be treated aggressively, as long-term survival may be anticipated, whereas the outcome for those with metastatic disease is poor.

Recurrent inguinal hernia: preferred operative approach.

Year 1998
Janu PG. Sellers KD. Mangiante EC.
Department of Surgery, University of Tennessee at Memphis, USA.
Inguinal herniorrhaphy remains one of the most common general surgical operations, with approximately 10 to 20 per cent performed for recurrence. Subsequent repairs provide considerable technical challenge, as well as substantially greater risk of developing further recurrence. Mesh repair is advocated by several specialized hernia centers, demonstrating re-recurrence rates less than 2 per cent. Detractors of this repair include cost, technical difficulty, and risk for infection. The purpose of this study was to compare results of mesh and nonmesh repairs for recurrent inguinal hernia, either using an anterior or posterior approach, at a large teaching institution. From January 1, 1985, to December 31, 1994, 146 patients underwent repair for recurrent inguinal hernia at the Veterans Administration Hospital at Memphis, Tennessee. Patients were stratified by type of repair: Lichtenstein (Mesh), open anterior (OA), Bassini, Marcy, McVay, Shouldice, and preperitoneal with or without mesh. Patient ages and weights were similar between groups. Mean operative time for Mesh repair (104 +/- 4 minutes) was longer than that for OA repairs (80 +/- 5 minutes, P < 0.05) or preperitoneal without mesh repairs (92 +/- 5 minutes, P < 0.05). Mesh-based posterior repairs had the longest operative times (116 +/- 5 minutes). Hospital stay averaged 2.8 +/- 0.3 days, similar among all groups. One wound infection (1.0%) occurred in patients undergoing Mesh repair, which required operative drainage. No patient required removal of mesh. Two patients in the Mesh group (5.9%) developed recurrence compared with four recurrences (18.0%) in patients undergoing OA repairs. Only one patient with a mesh-based posterior repair recurred (1.9%) compared to eight without mesh (21.6%, P < 0.01). Follow-up ranged from 2 to 12 years. Repair of recurrent inguinal hernia using either an anterior or posterior mesh repair technique, performed at a teaching facility, provides superior recurrence rates without increasing risk for infection or length of stay. Preperitoneal mesh based repair is the preferred technique.

Neonatal necrotizing enterocolitis: the long-term perspective.

Year 1998
Patel JC. Tepas JJ 3rd. Huffman SD. Evans JS.
Department of Surgery, University of Florida Health Science Center Jacksonville 32209, USA.
Ten years' experience with neonatal necrotizing enterocolitis (NNEC) was reviewed retrospectively to determine long-term survival and quality of life and to analyze risk factors associated with in-hospital mortality. Institutional records were queried to identify all neonates who required emergent surgical intervention for NNEC. These records were then reviewed and survivors' families interviewed by phone to determine patient status, persistent gastrointestinal problems, and overall quality of life. Once identified, long-term survivors (LTSs) were compared to in-hospital deaths by the analysis of birth weight, gestational age, time interval from birth to diagnosis, indications for laparotomy, and extent of intestinal involvement. Between 1986 and 1996, 69 patients required surgical intervention for NNEC. Eleven patients were lost to follow-up. Of the remaining 58 patients, 31 were ultimately discharged home, with 28 patients having survived an average of 4.18 years. The acute, or in-hospital, mortality rate was 39.1 per cent. Infants who died did so within an average of 23 days postoperatively, and those who were discharged home required an average of 121 days of inpatient convalescence. Twenty-one of the 28 LTSs achieved a normal quality of life with no persistent health problems. One patient required a hepatic-intestinal transplant, and another six had minor problems with frequent diarrhea. Average birth weight, age at NNEC diagnosis, and gestational age were not significantly different between LTSs and those with acute deaths. Aggressive in-hospital care is warranted for infants with NNEC. The excellent quality of life achieved in 75 per cent of survivors implies that the expense of heroic surgical care for these seriously ill premature infants is a worthwhile investment.

Impact an anatomical site on bacteriological and clinical outcome in the management of intra-abdominal infections.

Year 1998
Wilson SE. Faulkner K.
Department of Surgery, University of California, Irvine, USA.
The clinical and bacteriological results of treatment for 429 patients who had intra-abdominal infection were analyzed to determine whether the anatomical origin of peritonitis influenced outcome. All patients had received effective broad spectrum antimicrobial therapy and operation in four multicenter trials. The diagnoses of infection were categorized into three sites: upper gastrointestinal tract, complicated appendicitis, and lower gastrointestinal tract. Clinical response rates were excellent for complicated appendicitis and were lowest for infections related to the upper gastrointestinal tract. Bacteriological response rates were also lower for upper gastrointestinal tract organisms and were highest for isolates associated with complicated appendicitis. There were no deaths in the 213 patients who had infection associated with appendicitis. Seven deaths occurred in the 86 patients (81%) with an upper gastrointestinal site of infection, and nine deaths occurred in the 130 patients (6.5%) with lower gastrointestinal site of infection. Mortality was related to recurrent intra-abdominal infection after an unsuccessful primary operation and a serum albumin less than 25 g/l. Clinical trails of antimicrobials for intra-abdominal infection should consider stratification of patients according to these three levels of alimentary tract perforation when the site is known preoperatively. Patients who have infection secondary to previous surgery or who are malnourished represent a higher risk group even with appropriate antibiotics.

Comparison of liver function tests after hepatic lobectomy and hepatic wedge resection.

Year 1998
Pelton JJ. Hoffman JP. Eisenberg BL.
Section of Surgical Oncology, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, USA.
Prior studies have suggested that changes in liver function tests may vary with the postoperative time interval and may be related to the extent of hepatic resection. This study describes characteristic profiles in parenchymal liver enzymes and other serum liver function tests over a 4-week course comparing anatomic to nonanatomic hepatic resections. The records of 48 patients undergoing successful major hepatic resection during a 3-year period were retrospectively reviewed. Of these 48 patients, 28 underwent formal anatomic resection (hepatic lobectomy), and 20 underwent nonanatomic resections (wedge resection). Routine postoperative management in lobectomy patients included drawing liver function tests and enzymes daily for the first week, then at approximately 2 and 4 weeks postoperatively. These tests included: prothrombin time (PT), partial thromboplastin time, total serum bilirubin, total protein (TP), aspartate transaminase, lactate dehydrogenase (LDH), alkaline phosphatase, albumin (A), and glucose. Patients undergoing wedge resections had these values checked less frequently, approximately 3 to 5 days, 2 weeks, and 4 weeks postoperatively. Profiles of these values were plotted over the 4-week postoperative time course for each group of patients. Patients undergoing hepatic lobectomy showed a characteristic laboratory value profile. PT elevated within 48 hours to a mean high of 16.0 seconds, then returned to normal by postoperative day 4. Partial thromboplastin time levels remained normal throughout the entire perioperative course. Total bilirubin rose slightly, to a mean high of 2.6 mg/100 cc, then returned to normal by postoperative day (POD) 14. Parenchymal liver enzymes aspartate transaminase and LDH rose abruptly to very high levels, then returned abruptly to normal (by POD 5). TP and A both fell to approximately 50 per cent of normal, gradually rising to normal by POD 14. Glucose rose to a mean high of 199 mg/100 cc within the first 5 days, then returned to normal by POD 7. Alkaline phosphatase remained normal initially, then showed a progressive rise to a high of 288 mg/100 cc on POD 14. Patients undergoing wedge resections did not show the same changes in total serum bilirubin, but showed similar trends in all other tests, although the magnitude of these changes was smaller. TP and A levels fell acutely after resection, then began a slow rise toward normal by POD 21. TP and A profiles were similar for both lobectomy patients and those undergoing wedge resection. The only tests that may have altered clinical management were the PT and total bilirubin. Patients undergoing major hepatic resection have characteristic postoperative profiles of liver enzymes and liver function tests. These laboratory profiles differ with the extent of hepatic resection. The profiles reflect changes in volume status, parenchymal liver destruction, transient hepatic insufficiency, and postoperative hepatic regeneration. However, except possibly for PT and bilirubin, the routine use of these tests is not recommended, given that the results do not alter clinical management.

Prognostic factors for adenocarcinoma of the gallbladder: an analysis of 162 cases.

Year 1998
North JH Jr. Pack MS. Hong C. Rivera DE.
Department of Surgery, Eisenhower Army Medical Center, Fort Gordon, Georgia 30905, USA.
Carcinoma of the gallbladder is a rare neoplasm and is associated with a dismal prognosis. To analyze the natural history of this disease and prognostic factors, a large tumor registry database was accessed. During the period 1972 to 1995, 214 patients were entered. Adequate follow-up was available on 162 patients, and this group forms the basis of this review. There were 54 males and 108 females with a median age of 62 years. Median follow-up was 7 months. Right upper quadrant abdominal pain was the most frequent presenting symptom. Fifteen patients had an incidental finding of carcinoma after cholecystectomy. Overall, 5-year survival was 25 per cent, with a median survival time of 9.7 months. Survival was improved for patients with local disease compared with those with regional or metastatic disease. One hundred nine patients underwent surgical therapy. Complete resection was possible in 36 patients, whereas 44 patients had residual disease. Median survival time for patients with no residual disease was 67.2 months, whereas those for patients with microscopic residual tumor and gross residual tumor were 8.9 and 3.8 months, respectively (P < 0.000001). Gallbladder cancer is often diagnosed at an advanced stage and is associated with a poor prognosis. In patients with localized disease, surgical treatment provides the opportunity for long-term survival only when a complete resection can be performed. Prognosis for patients with microscopic residual and gross residual disease is similar.

Gallbladder hypokinesia: an unusual cause of duodenal obstruction.

Year 1998
Bunyaratavej K. Trisal V. Penney DG. Silapaswan S.
Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan, USA.
Gallbladder hypokinesis is an uncommon condition and a potential etiologic factor in the formation of gallstones and the development of cholecystitis. It is associated with a number of different conditions, but gallbladder hypokinesia as a cause of small bowel obstruction is unreported. In the case presented below, we saw a postoperative partial upper small bowel obstruction due to hypokinesia of the gallbladder. The investigations, management, and subsequent recovery are described. A review of the literature failed to reveal any similar occurrence.

Solitary scapula mass: atypical presentation of esophageal adenocarcinoma.

Year 1998
Cuomo J. Warren FH. Sanders LM. Beech DJ.
Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana 70112, USA.
Adenocarcinoma of the esophagus is an aggressive malignancy that frequently occurs with lymph node involvement. Current management strategies may incorporate adjuvant therapeutic modalities in an attempt to improve the typical dismal outcome. There is frequent association of esophageal adenocarcinoma with Barret's metaplasia. Isolated bone and soft tissue metastases are rare and may present a diagnostic challenge in asymptomatic patients.

Acute acalculous cholecystitis: incidence, risk factors, diagnosis, and outcome.

Year 1998
Kalliafas S. Ziegler DW. Flancbaum L. Choban PS.
Department of Surgery, Ohio State University, Columbus 43210, USA.
The objective of this study was to review the incidence, risk factors, methods of diagnosis, and outcome of acute acalculous cholecystitis (AAC) and to identify the sensitivity and limitations of current radiographic modalities used to establish the diagnosis. Our study was a retrospective chart review in a tertiary-care university hospital. Over a 53-month period, 27 cases of AAC (17 males, 10 females; mean age 50 years; mean Acute Physiology and Chronic Health Evaluation II score, 17) were encountered. Of these, 14 (52%) occurred in critically ill patients and 17 (63%) in patients recovering from non-biliary tract operations. AAC occurred in 0.19 per cent of surgical intensive care unit admissions and accounted for 14 per cent (27 of 188) of all cases of acute cholecystitis. Presenting symptoms and laboratory values were nonspecific. Twenty patients had radiographic studies before surgery. Among the various radiological studies used for AAC, morphine cholescintigraphy had the highest sensitivity (9 of 10; 90%), followed by computed tomography (8 of 12; 67%) and ultrasonography (2 of 7; 29%). Ten of the 20 patients had more than one study done preoperatively. All 27 patients had an open cholecystectomy. AAC was associated with a high incidence of gangrene (17 of 27 cases; 63%), perforation (4 of 27; 15%), and abscess (1 of 27; 4%). The mortality rate was 41 per cent (11 of 27). We conclude that AAC is a rare, but potentially lethal, disease occurring in critically ill patients and those recovering from non-biliary tract operations. The clinical presentation is nonspecific, and significant delays in diagnosis result in a high incidence of gangrene, perforation, abscess, and death. To improve outcome, a high index of suspicion with early radiographic evaluation, often employing multiple studies, is necessary. An algorithm for the evaluation of patients for suspected AAC is proposed.