The adverse hemodynamic effects of laparoscopic cholecystectomy.

Recent studies suggest that significant physiologic derangements can occur during laparoscopic surgery. Eighteen patients admitted for laparoscopic cholecystectomy were studied. The mean age was 46.7 (range 19-78). A standard anesthetic technique, reverse Trendelenburg positioning, and an abdominal insufflation pressure of 15 mmHg with CO2 were used with all subjects. Central venous pressure (CVP) and arterial pressures were measured invasively. Stroke volume and cardiac index were calculated using quantitative transesophageal echocardiography. Baseline measurements were taken after induction. Additional measurements were taken at 15-min intervals throughout the procedure. There was a statistically significant increase in mean arterial pressure (15.9%), systolic blood pressure (11.3%), diastolic blood pressure (19.7%), and CVP (30.0%) from control baseline values. Significant decreases in stroke volume (29.5%) and cardiac index (29.5%) occurred within 30 min of the induction of pneumoperitoneum and positioning (P < 0.05, ANOVA). Laparoscopic cholecystectomy significantly and reversibly decreases cardiac performance. Compromised patients may be at increased risk for complications not previously recognized with this procedure.

Long bone fractures in the polytrauma patient. The role of early operative fixation.

The role of early operative fixation in polytrauma patients with long bone fractures was analyzed by comparing length of stay, intensive care unit days and ventilator days, incidence of pulmonary complications, infectious complications, orthopedic complications, and mortality in three groups: traction only, operative fixation later than 48 hours after admission, and operative fixation within 48 hours of admission. Patients in all groups were similar in mode of injury, age, and Injury Severity Scores. Patients with early operative fixation of long bone fractures had significantly (P less than .05) fewer pulmonary complications than either the traction or the late operative fixation group. No group routinely required ventilator support, even with attendant abdominal and chest trauma. Operative fixation of long bone fractures within 48 hours of admission in the multiply injured patient reduces pulmonary complications.

Primary appendiceal adenocarcinoma.

Primary appendiceal adenocarcinoma is rare, with fewer than 300 reported cases. This report reviews 23 cases of appendiceal adenocarcinoma at Butterworth Hospital from 1968 to 1985. Clinical presentation, operative findings, treatment, and length of survival were recorded. Common clinical presentations included acute appendicitis and progressive abdominal distention. This disease was frequently an incidental finding during unrelated elective surgery and was often associated with other primary malignancies. Surgical treatment included appendectomy, right hemicolectomy, and interval hemicolectomy after initial appendectomy. Improved survival was noted in patients who had localized and noninvasive disease. Prognosis was most closely related to tumor grade. No patient who had localized, well-differentiated tumor died from the disease or had evidence of tumor recurrence after surgical treatment. All patients with poorly differentiated tumors died from widespread carcinomatosis. Appendectomy appears to be sufficient treatment for well-differentiated, localized, mucus secreting adenocarcinomas of the appendix.

Pulmonary artery catheterization: a prospective study of internal jugular and subclavian approaches.

We compared complications of pulmonary artery catheter (PAC) insertion and maintenance at internal jugular (IJ) vs. subclavian (SC) sites. Patients were randomized into groups using an IJ or SC route, and insertions were timed. An air-permeable dressing and anticontamination shield were used. Catheters were removed 72 h after insertion. If PAC monitoring was still needed, a new catheter was either inserted over a guidewire at the initial insertion site or inserted at a new site. On removal, the catheter tip, introducer-sheath tip, and catheter within the shield were submitted for semiquantitative culture. Sixty-six catheters were initially inserted, and 26 were changed. No determinative differences in the time for venous cannulation were found, but the IJ route was slightly faster. In 3% of the catheterizations, serious complications arose. The infection rate was 2% for initial catheters, 8% for second catheters placed over a guidewire, and 15% for second catheters placed at a new site. These differences were not consequential. No local infection or catheter-related sepsis occurred. Thus, using a standard, sterile-insertion technique and a catheter-maintenance protocol yielded a low risk of insertion and infectious complications at either the IJ or SC site. Our data indicated that PACs can be changed safely over a guidewire at 72 h, avoiding further insertion risks without increasing infectious complications.