Bioavailability of medication after laparoscopic cholecystectomy.

Bioavailability of medication after laparoscopic cholecystectomy has not been studied previously. There is concern about the ability of patients to tolerate oral medication postoperatively and the optimal timing of hospital discharge. In this study, each subject received 20 mg/kg acetaminophen (po) preoperatively, with a repeat dose at 6 (group 1), 12 (group 2), or 24 h (group 3) postoperatively. Serum levels were obtained 40 and 90 min after each ingestion. Bioavailability of medication was significantly decreased (p < 0.01) 6 h (group 1) and 12 h (group 2) postoperatively. Bioavailability returned to baseline by 24 h after laparoscopic cholecystectomy (group 3). This study indicates that oral medication should be used judiciously during the first 12 h after laparoscopic surgery.

Trocar site tumor recurrence after laparoscopic-assisted colectomy.

As a variety of procedures become technically feasible with laparoscopic techniques, it becomes increasingly important to appropriately select the patients who will benefit from the laparoscopic approach. We report the case of a patient with Dukes C2 colon cancer treated by laparoscopic-assisted sigmoid colectomy who subsequently developed an abdominal wall recurrence at a trocar site scar. The case raises some concerns about the use of the laparoscopic technique in the surgical management of colon cancer.

Bioavailability of medication delivered via nasogastric tube is decreased in the immediate postoperative period.

BACKGROUND: A study was performed to determine bioavailability of medication delivered via nasogastric tube in patients after abdominal surgery. METHODS: Acetaminophen (20 mg/kg) was administered to each patient per os at least 48 hours prior to abdominal surgery and via nasogastric tube 3 hours postoperatively. The nasogastric tube was clamped for 30 minutes after drug administration, prior to resuming suction. Serum levels of acetaminophen were measured 0, 40, and 90 minutes after each dose. RESULTS: Acetaminophen levels were significantly lower (P < 0.001) when the drug was administered via nasogastric tube postoperatively. CONCLUSIONS: Decreased bioavailability of medications delivered via nasogastric tube may have important clinical implications and should be taken into consideration during the postoperative period.

Documentation of abdominal exploration during laparoscopic cholecystectomy.

UNLABELLED: To assess the documentation of intraperitoneal exploration and events during laparoscopic cholecystectomy, we reviewed 200 dictated operative reports from eight different institutions. The 200 laparoscopic cholecystectomies were performed by 40 different surgeons on 158 female patients and 42 male patients. A description of the gallbladder was included in 134 (67%) reports and not mentioned in 66 (33%) reports. Fifty-four (27%) reports did not mention any intraperitoneal findings away from the gallbladder. Another 36 (18%) of the reports contained only a general comment indicating that no abnormalities were seen in the abdomen (excluding the gallbladder). The other 110 (55%) reports mentioned at least one specific site or finding in the abdomen other than the gallbladder. The most commonly mentioned sites were the liver, bowel, and stomach. Only 42 (21%) operative notes described what happened to the gallbladder contents: 30 described spillage of bile and/or gallstones and 12 stated that no spillage occurred. CONCLUSIONS: Laparoscopic cholecystectomy operative notes have often lacked a description of gallbladder appearance, documentation of abdominal exploration, and/or documentation of complete removal of the gallbladder and its contents.

Erythropoetin accelerates hematocrit recovery in post-surgical anemia.

UNLABELLED: We evaluated the role of recombinant human erythropoietin (RHE) for treatment of severe postsurgical anemia (Hct < 25%) in 40 Jehovah's Witness (JW) patients refusing transfusion. Twenty patients (group E) received RHE either at a loading dose of 300 U/kg iv 3 times/week for 1 week followed by 150 U/kg 3 times/week in accordance with an IRB approved protocol (N = 13), or at a dose of 100 U/kg 3 times/week for humanitarian reasons (N = 7). This group was compared to 20 similar JW patients who did not receive RHE (group C). All patients received iron restoration and nutritional support. Non-parametric analysis (Mann-Whitney) was used because of sample size. Entry hematocrit was similar for both groups: H(E)(0) = 15.8% +/- 1.1 SEM (8.5-23.4) vs HC (0) = 12.8% +/- 0.9 SEM (7.3-20.6), P = 0.09. After one week, hematocrit was significantly higher in group E (H(E)(1)) = 19.3 +/- 1.1 vs HC(1) = 12.5% +/- 0.9, P < 0.0005) as was the increase in hematocrit for group E (3.6% +/- 0.9 for E vs -0.4% +/- 0.8 for C, P < 0.005). Hematocrit change in Week 2 showed an increase for both groups (2.9 +/- 0.6 for E vs 4.9% +/- 1.2 for C, P = 0.12). CONCLUSIONS: Hct recovery shows a 1-week lag in severely anemic postsurgical patients treated without RHE. Exogenous RHE appears to accelerate hematocrit recovery in the first week. Use of RHE in the immediate postoperative period may help avoid or reduce homologous blood transfusion.

Preoperatively assessing and planning blood use for elective vascular surgery.

Few guidelines exist for determining transfusion needs and strategies, namely, the appropriate use of autologous versus homologous blood for elective vascular surgery. To address this deficiency, we have developed and used an algorithm based on an analysis of the procedure, maximum surgical blood ordering schedule, patient status, and patient suitability for autologous alternatives. Data were derived from consecutive major vascular procedures done at our hospital from 1991 to 1992. The algorithm helps the surgeon assess transfusion need and patient suitability for autologous predonation and aids in selecting appropriate transfusion alternatives. Using this algorithm during the past year with 120 patients, we simplified transfusion decisions, reduced homologous blood use (to only 4.2%), and reduced wasting of autologous blood to less than 5% of the units predonated. We believe that the use of this algorithm will aid the vascular surgeon in choosing appropriate alternatives to allogeneic blood transfusion, thereby reducing the patient's exposure to risk. The algorithm should also reduce wasting of autologous blood.

A survey of preferred approach to inguinal hernia repair: laparoscopic or inguinal incision?

The recent interest in laparoscopic surgery has raised some concerns that large numbers of surgeons were recommending this "minimally invasive" approach in procedures such as inguinal herniorrhaphy before the availability of adequate data regarding safety and benefits. To determine current experience and preference levels for laparoscopic inguinal herniorrhaphy (LH), we conducted a mail survey of New Jersey surgeons. Of 531 respondents, 430 (81%) preferred a traditional inguinal incision approach over a laparoscopic approach (8%). Of 344 general surgeon respondents, 227 (66%) had experience with laparoscopic cholecystectomy, but only 56 (16%) had experience with LH. This latter group had performed only an average of 9.2 laparoscopic herniorrhaphies, with a median of five cases. Most of these 56 surgeons with LH experience indicated a preference for inguinal incision herniorrhaphy although 19 surgeons who had performed 10 or more LH cases showed a slight preference for LH (11 to 8). The primary reasons for choosing LH included "less pain" and "quicker recovery." The primary reasons for choosing inguinal incision herniorrhaphy included having a "better known procedure" and avoiding general anesthesia. Our survey indicates that the laparoscopic approach to inguinal hernia repair has currently accumulated few proponents in the surgical community since many surgeons are waiting for more data on the procedure.

Perfluorocarbons as blood substitutes: the early years. Experience with Fluosol DA-20% in the 1980s.

Clinical testing of perfluorocarbons (PFC) as blood substitutes began in the early 1980's in the form of Fluosol DA-20% (FDA), a mixture of perfluorodecalin and perfluorotripropylamine emulsified with Pluronic F68. We have treated 55 patients (Treatment (T) = 40; Control (C) = 15) with intravenous infusions of 30 cc/kg of FDA as part of either a randomized, clinical trial or a humanitarian protocol. All patients were Jehovah's Witnesses who refused blood transfusion and were severely anemic (mean hemoglobin = 4.6 g/d). FDA successfully increased dissolved or plasma oxygen content (P1O2 in ml/dl), but not overall oxygen content (T group: P1O2 baseline = 1.01 +/- .27, P1O2 12hrs = 1.58 +/- .47 [p = < .0001, t-test]; P1O2 12 hrs: T = 1.58 +/- .47, C = 1.00 +/- .31, p = < .0002, t-test). This effect persisted for only 12 hours post infusion, and had no apparent effect on survival. FDA is an ineffective blood substitute because of low concentration and short half-life. Improved emulsion design may resolve these problems, thereby producing a more effective agent. Our discussion will include a review of our data plus a summary of other reports of FDA efficacy as a blood substitute.

Pancreatic cystogastrostomy by combined upper endoscopy and percutaneous transgastric instrumentation.

Minimally invasive endoscopic and radiologic techniques have been reported for internal gastric drainage of pancreatic pseudocysts but these have significant technical limitations. A purely endoscopic approach to cystogastrostomy provides limited access for instrumentation and hemostasis. Radiologically-guided percutaneous techniques cannot regularly provide an adequately wide cystogastrostomy opening. Reported is a patient who had a pancreatic cystogastrostomy performed using a minimally invasive surgical approach combining upper endoscopy and percutaneous transgastric surgical instrumentation. The upper endoscope essentially served as a camera. A percutaneous endoscopic gastrostomy tube served as a port for inserting laparoscopic instruments into the stomach. The laparoscopic instruments were used to create a 1.5 cm cystogastrostomy opening similar in size to what could be created by an open abdominal approach. The laparoscopy instruments provided good tactile feedback and excellent hemostatic control. Avoiding an open abdominal procedure shortened postoperative recovery and reduced patient discomfort. Although the pseudocyst recurred once, the same procedure was performed again and there has not been a recurrence for 10 months. The authors conclude that this minimally invasive surgical procedure provides an excellent alternative approach for internal drainage of selected pancreatic pseudocysts.

A surgical approach to chronic aortomyoplasty in the goat model.

The left latissimus dorsi skeletal muscle of seven male goats was prepared and applied circumferentially to the descending aorta just below the subclavian artery. Stimulation of the neural pedicle of the latissimus dorsi was performed in an attempt to convert it to a fatigue-resistant cardiac-like muscle. Timing of the stimulus was in diastole. Biochemical assays established the conversion, and echocardiography demonstrated aortic compressions in the area of the muscle wrap. Although limited in numbers, the converted latissimus dorsi muscle in the extra-aortic position appears to provide diastolic augmentation.

Immediate breast reconstruction after mastectomy.

Immediate breast reconstruction after mastectomy can be performed safely with a low incidence of complications. There is no evidence that reconstruction with a submuscular implant interferes with subsequent oncologic care, followup, or outcome for patients.

Safety of teaching laparoscopic cholecystectomy to surgical residents.

As laparoscopic cholecystectomy evolves into the "standard" method for gallbladder removal, it has become necessary for surgical residents to safely acquired the necessary skills to perform the procedure. To determine the safety of this procedure in the hands of residents, the authors evaluated the first 100 attempted laparoscopic cholecystectomies performed by a resident in the role of "surgeon." Ninety-one of the 100 procedures were successfully completed laparoscopically and 9 required conversion to laparotomy: 5 technically difficult cases, 2 common duct explorations, and 2 for intraoperative complications. At Cooper Hospital in New Jersey, essentially all patients requiring cholecystectomy are first attempted laparoscopically. Seventy-seven patients had chronic cholecystitis and 23 had acute disease. Twenty-two patients had intraoperative cholangiograms and two had laparoscopic common bile duct exploration. For the laparoscopically-completed procedures, average operative time was 91 min and showed a downward trend as each resident gained experience. Three (3%) major complications occurred: one colon laceration, one common bile duct injury, and one postoperative bile collection. For the 91 laparoscopically-completed procedures, 53 patients were discharged on postoperative day 1 and 20 on postoperative day 2. Average postoperative hospitalization was 1.7 days. Overall, these results were comparable to those reported in the literature by attending and private surgeons. The authors conclude that laparoscopic cholecystectomy can be performed safely by supervised residents acting as primary surgeon with outcomes similar to those obtained by trained attending surgeons.

Arterial vasopressin for control of bleeding from a stapled intestinal anastomosis. Report of two cases.

Postoperative bleeding from a stapled intestinal anastomosis is a rare complication. In previously reported cases, the bleeding either ceased spontaneously or required reoperation for direct control. We report two cases in which the bleeding was controlled using an intra-arterial vasopressin infusion. To our knowledge, this technique has not been previously reported for management of this problem. We had initial concerns about creating ischemia at the anastomosis, which could lead to disruption. Neither patient demonstrated subsequent problems with the anastomosis. Intra-arterial vasopressin infusion appears to be an effective method for controlling bleeding from a stapled intestinal anastomosis and can avert the need for reoperation.

Transfusion guidelines for cardiovascular surgery: lessons learned from operations in Jehovah's Witnesses.

Patients undergoing cardiovascular surgery are among the top users of homologous blood transfusion (HBT). Awareness of the risks of disease transmission and immune system modulation from HBT has prompted us to find alternatives such as autologous predonation (APD) and intraoperative autotransfusion (IAT). However, these latter options are not appropriate for all patients. We reviewed our experience with 59 Jehovah's Witness patients who underwent 63 elective cardiovascular procedures without either HBT or APD to determine the safety of operation without these modalities and to develop revised maximum surgical blood-ordering schedule guidelines for cardiovascular surgery. Estimated blood loss averaged 870 ml, but one third to one half of losses were replaced by IAT. IAT was not needed in lower extremity bypass operations in which the estimated blood loss was less than 150 ml. Three of 59 patients died (5.1%), but only one died of operative bleeding complications. We conclude that (1) elective cardiovascular operations can be done safely without the use of either HBT or APD, (2) HBT is not necessary in leg bypass procedures, and (3) maximum surgical blood-ordering schedule guidelines for HBT in major cardiovascular operations can be reduced to near zero by the use of intraoperative autotransfusion and acceptance of a postoperative hemoglobin nadir of 7.0 gm/dl.

Upper extremity occlusive arterial disease after radiotherapy for breast cancer.

Upper extremity arterial occlusive disease is a rare complication of radiation therapy for breast cancer. We present the case of a 74 year old woman who developed upper extremity ischemia 32 years after mastectomy and radiation therapy. Arteriography identified a stenotic proximal brachial artery lesion within the previous radiation field. Balloon angioplasty was unsuccessful. An axillo-brachial bypass relieved the ischemia and is still patent after 24 months. The previous literature shows that arterial bypass procedures have been uniformly successful in this circumstance. Little experience has been reported with balloon angioplasty for these lesions.

Is hemoglobin level alone a reliable predictor of outcome in the severely anemic surgical patient?

The relationship between outcome and hemoglobin (Hgb), oxygen extraction ratio (ER), history of cardiac, renal, pulmonary, and/or hepatic disease, diabetes, malignancy, sepsis, hypertension, and active bleeding was analyzed in 47 patients with severe anemia (Hgb less than 7.0 gm/dl, mean = 4.6 +/- .2 gm/dl) to evaluate the effect of Hgb on survival and to look for other predictors of outcome. All patients had refused blood transfusion on religious grounds and were participants in a randomized, controlled study of the blood substitute Fluosol DA-20 per cent. Patients were analyzed as a group and after stratifying by Hgb into four levels: (Hgb less than 3.0 gm/dl, N = 7; Hgb less than 3.5 gm/dl, N = 12; Hgb less than 4.0 gm/dl, N = 17; Hgb less than 4.5 gm/dl, N = 23) and by ER into two levels of less than 50 per cent and greater than 50 per cent. Only Hgb, ER, sepsis and active bleeding were predictors of outcome, with sepsis being the only significant, independent predictor of outcome at all levels (P less than .01). Active bleeding was a predictor for levels of Hgb below 4.0 gm/dl. Hgb level alone was a significant predictor only at levels below 3 gm/dl (P less than .05). Extraction ratio interacted with Hgb only below 3 gm/dl (P less than .05). Multiple independent factors influence outcome in the severely anemic patient, the strongest being sepsis and active bleeding. Prevention of sepsis and early intervention to stop bleeding should improve survival in the patient who refuses transfusion.

Hemoductal pancreatitis.

Gastrointestinal tract hemorrhage from rupture of the splenic artery into the pancreatic duct is unusual. This obscure cause of intermittent gastrointestinal tract bleeding should be suspected when the more common causes of bleeding have been ruled out. Duodenoscopy carried out during active hemorrhage may reveal blood coming from the papilla of Vater. Coeliac arteriography will show the pathognomonic findings and confirm the diagnosis. We have treated three patients who had chronic pancreatitis and who developed pseudocyst formation and pseudoaneurysms of the splenic artery. The pseudoaneurysm ruptured into the duct of Wirsung, causing obscure upper-gastrointestinal bleeding. Treatment was distal pancreatectomy and splenectomy, including the pseudoaneurysm and pseudocyst. A review of the literature suggests that three different types of bleeding into the pancreatic duct can occur. The cause of each is described.

Serial duplex scans elucidate the evolving hemodynamics of distal arteriovenous fistulas.

Arteriovenous fistulas at the distal anastomosis have been suggested to improve the patency of prosthetic femorocrural bypasses. We have followed nine patient with bypasses to the crural vessels and distal arteriovenous fistulas using physical examination, pulse volume recordings, and segmental pressure indices. Duplex scans of the distal anastomosis were employed to determine the contribution of arterial and venous outflow to total graft flow. Early graft patency was achieved in all patients. One patient went on to amputation at one week postoperatively for progressive ischemia despite a patent graft. The other eight patients achieved successful revascularization. Healing of ulcers, relief of rest pain, the presence of palpable pulses, good pulse wave amplitude, and normal pressure indices are consistent findings as long as the bypass is patent. One patient died on the fourth postoperative day from a myocardial infarction. The remaining patients have been followed from one to 23 months with follow-up examination every three to four months. Sequential duplex scans show that flow continues into distal arteries while venous outflow diminishes. This corresponds to a reduction in the diameter of the outflow veins while the caliber of arterial runoff is maintained. Patency has been achieved up to 23 months with a mean of 12 months. Venous outflow occlusion precedes graft thrombosis by two to 15 months. Graft occlusion has uniformly necessitated amputation. It may be possible to improve long-term graft patency and limb salvage by surgical revision of the distal anastomosis to reestablish venous outflow.

Traumatic disruptions of the thoracic aorta: treatment and outcome.

Of 27 patients admitted to our level I trauma center with acute disruption of the thoracic aorta, two patients died of exsanguination before aortic repair. One patient had massive leakage from the aneurysm after aortography and died during surgery. All patients suffered from multiple injuries. Eighty-three percent of the patients had major operations in addition to the aortic repair. "Clamp and sew" technique was used in 18 patients (75%), two of whom had multiple tears of the aortic arch. Heparin-coated shunts were used in five patients (20.8%), and a cardiopulmonary bypass was performed in one patient who had multiple tears. Three postoperative deaths were related to polytrauma, cardiogenic shock, and sepsis. Paraplegia developed in three patients, two of whom had multiple aortic lesions necessitating longer ischemia time during the repair. Only one patient had complete neurologic deficit at the 1-year follow-up. In our series, neither surgical procedure proved superior. We conclude that the "clamp and sew" technique for repair of the disrupted thoracic aorta may allow for a more favorable outcome.

Fluosol DA-20 in the treatment of severe anemia: randomized, controlled study of 46 patients.

We evaluated the safety and efficacy of Fluosol DA-20% (FDA) as a blood substitute in the treatment of severe anemia. Thirty-six patients received either FDA (n = 21) or crystalloid/hydroxyethyl starch (CHS) (n = 15) as part of a randomized, controlled trial. Ten patients received FDA as part of a humanitarian protocol. All were Jehovah's Witnesses who refused transfusion, had bled recently, and had average Hgb levels of 4.3 g/dl. After pulmonary artery catheter insertion, each patient was infused with CHS to attain a pulmonary artery wedge pressure (WP) of 10 to 18 mm Hg. FDA was given as a one-time dose of 30 ml/kg. Data were collected at baseline, 12, 24, and 48 h. None of the patients with negative reactions to a 0.5-ml test dose of FDA had adverse reactions to the subsequent infusion. The plasma or dissolved component of oxygen content was significantly higher in the FDA group at 12 h (FDA group 1.58 +/- 0.47 ml/dl, control group 1.01 +/- 0.31 ml/dl, p less than .02, t-test). Nineteen patients died: 12 (37.5%) FDA, seven (46.6%) control. The difference was not significant. We conclude the following: a) FDA can be given safely to severely anemic patients in doses of 30 ml/kg; b) FDA significantly increased the dissolved component of oxygen content after 12 h but the effect did not persist; c) severely anemic patients can survive without transfusion although mortality is high. In this study, inability of FDA to sustain increased oxygen content was due in part to the rapid elimination of FDA and also to the limited amount given.(ABSTRACT TRUNCATED AT 250 WORDS)