Laparoscopic vascular surgery: four case reports.

PURPOSE: We report four cases of laparoscopic vascular procedures (two iliofemoral bypasses, one aortobifemoral bypass, and one aortoiliac endarterectomy) performed with a technique that does not require insufflation of the peritoneal cavity with gas. METHODS: Initially in the porcine model and later in patients, we developed a laparoscopic technique with a mechanical arm used to mechanically elevate the abdominal wall, creating a working cavity. Conventional vascular instruments were used in combination with laparoscopic devices. Five to seven ports were needed for the procedures (four to six ports of 0.5 to 1.5 cm and one incision of 4.0 cm). Exposure was maintained by use of roticulating fan retractors and laparotomy sponges. End-to-side technique was used for all graft anastamoses (cross-clamp time of 40 to 70 minutes). Distal anastamoses were performed through an open femoral incision. Operative time was 5 hours (iliac procedure) and 7 hours (aortic procedure). RESULTS: All patients were ambulating and tolerating a regular diet within 24 hours (iliac procedures) or 48 hours (aortic procedures) after operation. They were discharged home on the second (iliac procedures) or third (aortic procedures) postoperative day. Within 1 week they had resumed normal daily activities. No complications occurred, and no blood bank products were transfused. When compared with the standard surgical approach, gasless laparoscopic technique gave a faster postoperative recovery with less pain and decreased the risk of wound herniation, dehiscence, and infection. From a laparoscopic standpoint, the use of disposable instruments was minimized and the theoretical risk of CO2 embolism eliminated. CONCLUSION: These four cases demonstrate that laparoscopic vascular bypass procedures are feasible and that the accepted advantages of laparoscopy can be extended to patients undergoing vascular surgery.

Preoperative carotid artery screening in elderly patients undergoing cardiac surgery.

The role of preoperative screening for carotid artery disease in elderly patients undergoing cardiac surgical procedures is not clearly established. This prospective study was designed to determine the prevalence of carotid disease in this population and to identify preoperative risk factors for carotid artery stenosis. During a 54-month interval, 1087 patients of a consecutive series of 1184 patients 65 years of age and older who underwent cardiac surgical procedures (91% had coronary artery disease) were evaluated before operation with carotid duplex ultrasonography. The prevalence of disease was 17.0% for 50% or greater stenosis and 5.9% for 80% or greater stenosis. With use of a stepwise, logistic regression model of 12 preoperative variables, five variables were found by multivariate analysis to be significant (p less than or equal to 0.05) predictors of 80% or greater stenosis: female sex, peripheral vascular disease, history of transient ischemic attack or stroke, smoking history, and left main coronary artery disease. If all patients with at least one risk factor were screened, then this model predicts that 95% of patients with 80% or greater stenosis and 91% of patients with 50% or greater stenosis would be identified before operation. The probability of carotid disease in a given patient can also be estimated (range, 5% to 65%). Carotid endarterectomy combined with cardiac surgical procedures was performed on 46 patients who were either symptomatic (16) or had 80% or greater stenosis (30). The overall stroke rate for the 1087 patients was 2.0% (22 patients), and the 30-day mortality rate was 5.2% (56 patients).(ABSTRACT TRUNCATED AT 250 WORDS)

Identification of beta-endorphin-6(16-17) as the principal metabolite of des-tyrosin-gamma-endorphin (DTgammaE) in vitro and assessment of its activity in neurotransmitter receptor binding assays.

Des-tyrosine-gamma-endorphin (beta-endorphin-(2-17); DTgamma E) lacks direct in vitro activity at dopaminergic receptors, but does inhibit in vivo [3H]spiperone binding in various rat brain areas. The principal objective of these studies was to test the hypothesis that DTgammaE may exert its selective, neuroleptic-like activity through an active metabolite. Accordingly, DTgammaE was incubated at 37 degrees C in a whole rat brain homogenate of neutral pH after which samples were prepared for HPLC analysis. The major, heat-stable metabolite of DTgammaE was identified as the clinically active, beta-endorphin related fragment, beta-endorphine-(6-17). The beta-endorphin sequences 4-17, 5-17, l0-17, 12-17 and 2-16 were also present but in minor amounts. Identical results were obtained studying DTgammaE metabolism using rat striatal tissue slices. Neurotransmitter receptor binding experiments showed that beta-endorphin-(6-17) was inactive at central dopaminergic, serotonergic, muscarinic, benzodiazepine and opiate receptors measured in vitro. Thus, like DTgammaE, beta-endorphin-(6-17) differs from classical neuroleptics in that it does not inhibit in vitro [3H]spiperone binding in the corpus striatum, frontal cortex or mesolimbic areas of the rat brain. It may be that DTgammaE and beta-endorphine-(66-17) exert their selective neuroleptic-like activity through an indirect inhibition of central dopaminergic activity, possibly in combination with an in vivo antagonism of the postsynaptic dopamine receptor.

A comparison of multiple and single electroconvulsive therapy.

In a retrospective study of 30 patients receiving either single ECT (N = 17) or multiple monitored ECT (N = 13), no difference in effectiveness or safety was seen between treatments. However, patients who received multiple monitored ECT had fewer sessions of general anesthesia and a significantly more rapid course of treatment.

Multiple monitored electroconvulsive therapy in the elderly.

Twenty patients aged 45 or older with the diagnosis of endogenous depression were evaluated in terms of safety and efficacy in their response to multiple monitored electroconvulsive therapy (MMECT) versus single electroconvulsive therapy (SECT). The MMECT group (10 patients) when compared retrospectively with the control SECT group (10 patients) showed a similar record for safety and efficacy. However, the MMECT group required shorter overall duration of treatment, fewer sessions of general anesthesia, and lower dosages of anesthetic agents. The chief benefit of MMECT probably is in the reduction of the time the patient is at risk for suicide.