Combined intraoperative laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography: lessons from 29 cases.

BACKGROUND: The role and timing of endoscopic retrograde cholangiopancreatography (ERCP) in patients with suspected choledocholethiasis remains a controversial subject. There have been few studies exploring the role of intraoperative ERCP. Therefore, we set out to perform a retrospective review of 29 patients who underwent combined laparoscopic cholecystectomy (LC) and intraoperative ERCP (LC/ERCP). Our objective was to assess the feasibility of a one-stage approach using intraoperative ERCP. METHODS: We identified 29 patients in whom LC/ERCP was attempted between January 1996 and November 1998 at a university-affiliated hospital with a large private faculty. Parameters reviewed included preoperative diagnosis, liver function tests (LFT), finding on transcystic cholangiogram (TCC), ERCP, stone retrieval, failure of ERCP, length of stay, morbidity, and mortality. RESULTS: Twenty-eight of 29 patients (97%) underwent successful combined LC/ERCP. Successful TCC followed by ERCP was performed in 21 of 26 patients (81%). Five TCC were technically unsuccessful; in these patients, ERCP was performed on the basis of preoperative criteria. In three patients, TCC was not attempted. Stones were successfully retrieved from 20 of 21 patients (95%) with abnormal finding on TCC, one of five patients (20%) with failed TCC, and two of three patients (67%) with ERCP but without TCC. Overall morbidity was 14%, comprising two patients with postoperative hyperamylasemia and two with cystic duct leaks. There were no deaths in the group. The mean time for the combined procedure was 173 min (range, 50-290). Mean length of hospitalization was 3.4 days, and mean postoperative stay was 2.2 days. CONCLUSIONS: LC/ERCP can be performed safely. The advantages of the combined procedures include one-stage treatment of cholelithiasis and choledocholithiasis, avoidance of unnecessary preoperative ERCP and their concomitant complications, and elimination of potential return to the operating room when postoperative ERCP is technically impossible.

Radiologic gastrojejunostomy and percutaneous endoscopic gastrostomy: a prospective, randomized comparison.

PURPOSE: To compare the efficacy of radiologic guided placement of percutaneous gastrojejunostomy (PGJ) and percutaneous endoscopic gastrostomy (PEG). MATERIALS AND METHODS: Patients were randomized to PGJ (n = 66) or PEG (n = 69). Indications for gastrostomy were need for prolonged enteral nutrition (97%) or gastrointestinal decompression (3%), with etiologies of neurologic impairment (81%), head and neck neoplasm (12%), bowel obstruction (3%), or other (4%). Mean follow-up was 202 days and 30-day follow-up was obtained for 85% of patients. RESULTS: PEG was successful in 63 of 69 (91%) patients, while PGJ established access in all of 66 attempts (100%) (P = .014). Average procedural time was 53 minutes for PGJ and 24 minutes for PEG (P = .001). At 30-day follow-up, there were 33 and 45 complications in the PGJ and PEG groups, respectively. This difference was due to the greater incidence of pneumonia in the PEG group (P = .013). Long-term tube-related complications occurred with 17 PGJs and four PEGs (P = .007). The PGJ cost more than PEG, but this advantage was offset by the cost of complications. CONCLUSION: PGJ had higher success rate and fewer complications, due to a lower incidence of pneumonia. PEG took less time to perform, cost less, and required less tube maintenance.

Antitumor activity of the novel human breast cancer growth inhibitor, mammary-derived growth inhibitor-related gene, MRG.

A novel human tumor growth inhibitor was identified by differential cDNA sequencing. The predicted amino acid sequence of this tumor-suppressing factor has a significant sequence homology to mouse mammary-derived growth inhibitor and thus was named mammary-derived growth inhibitor-related gene (MRG). MRG was found to be expressed in normal and benign human breast tissues but not in breast carcinomas. In situ hybridization analysis demonstrated a stage-specific MRG expression as follows. MRG was barely detectable in breast carcinomas, showed partial and weak expression in benign hyperplasia, but was expressed at a high level in normal breast epithelial cells. To determine if MRG can modulate in vivo growth of human breast cancers, we transfected a full-length MRG cDNA into MDA-MB-231 human breast cancer cells and studied the orthotopic growth of MRG transfectants versus control transfectants in the mammary fat pad of athymic nude mice. Overexpression of MRG in human breast cancer cells significantly suppressed cell proliferation in vitro and tumor growth in an orthotopic nude mouse model. These results suggest that MRG has tumor-suppressing activity, and the loss of MRG expression may be involved in the development and progression of breast cancer.

Free radial forearm flap to the foot after a shotgun injury: the day I became a patient.

This is a personal account of a General Practitioner who suffered a shotgun injury to his right foot. Reconstruction involved the use of a free radial forearm flap to fill a defect distal to the heel. The case is illustrated and the feelings of the patient described.

Early laparoscopic cholecystectomy for acute cholecystitis.

BACKGROUND: The timing of laparoscopic cholecystectomy for acute cholecystitis remains controversial. METHODS: One hundred ninety-four patients with acute cholecystitis were reviewed. The conversion rates for the various number of days of symptoms before surgery were analyzed. The conversion rate dramatically increased from 3.6% for those patients with 4 days of symptoms to 26% for those patients with 5 days of symptoms. The mean number of days of symptoms prior to surgery in those patients who underwent successful laparoscopic cholecystectomy was 4.1 as compared to 8.0 in those patients who required open cholecystectomy (p < 0.0001). Based on this data the patients were divided into two groups. Group 1 consisted of 109 patients who underwent laparoscopic cholecystectomy within 4 days of onset of symptoms and group 2 consisted of 85 patients who underwent laparoscopic cholecystectomy after more than 4 days following onset of symptoms. RESULTS: The conversion rate from laparoscopic to open cholecystectomy was 15%. The conversion rate for group 1 was 1.8% as compared to 31.7% for group 2 (p < 0.0001). Indications for conversion were inability to identify the anatomy secondary to inflammatory adhesions (68%), cholecystoduodenal fistula (18%), and bleeding (14%). The major complication rate for group 1 was 2.7% as compared to 13% for group 2 (p = 0.007). The mortality rate for all patients with attempted laparoscopic cholecystectomy for acute cholecystitis was 1.5%. The average procedure time for group 1 was 100 +/- 37 min vs 120 +/- 55 min in group 2. The average number of postoperative hospital days in group 1 was 5.5 +/- 2.7 days as compared to 10.8 +/- 2.7 days in group 2. CONCLUSIONS: We advocate early laparoscopic cholecystectomy within 4 days of onset of symptoms to decrease major complications and conversion rates. This decreased conversion rate results in decreased length of procedure and hospital stay.

Endoscopy training during general surgery residency.

The endoscopic experience of surgical residents was evaluated following the introduction of a formal surgical endoscopy program, which consisted of a 2-month rotation, generally at the postgraduate year 2 level. The resident was assigned to one attending surgeon and also had a formal laboratory session. There were many benefits, including a significant increase in endoscopic encounters. Program directors should seriously consider setting up a rotation with an experienced surgeon-endoscopist.

Laparoscopic-assisted abdominal aortic aneurysm repair.

Since the advent of laparoscopy, the sweeping changes seen in general surgery have not been paralleled in vascular surgery. There have been case reports of laparoscopic-assisted aortobifemoral bypass for occlusive disease. Because aneurysmal disease comprises the majority of aortic surgery, we pursued animal and cadaveric feasibility studies for laparoscopic-assisted abdominal aortic aneurysm (AAA) repair. We present a case report of the first clinical case performed under Institutional Review Board protocol using this technique. The patient was a 62-year-old male with a 6-cm infrarenal AAA. After obtaining a pneumoperitoneum, a modified fish retractor was used to exclude the bowel. Ten 11-mm ports provided access to laparoscopically dissect the neck of the aneurysm and the iliac vessels. Then, a 10-cm minilaparotomy was performed and standard vascular clamps were inserted via the port incisions. Standard aneurysmorraphy was performed with a polytetrafluoroethylene (PTFE) tube graft. Laparoscopy conferred three major benefits: better visualization of the aneurysm neck, less bowel manipulation, and avoidance of hypothermia. This case report illustrates the feasibility of laparoscopic-assisted aneurysm repair. Controlled human studies will define the role of laparoscopy in AAA surgery.

Formal endoscopy training for senior and junior house staff.

The upper endoscopic experience of junior and senior surgical residents was analyzed before (period 1) and after (period 2) creating a 2-month rotation with a dedicated surgical endoscopist. Three hundred sixty-two endoscopies were performed during the study period, with 295 (81%) being performed after formalizing training. A chi-square analysis was performed and found to be statistically significant for each group when compared to a control experience with colonoscopy. We conclude that a dedicated block of time and a committed surgical attending physician will have a significantly positive impact on resident caseload. Furthermore, the added benefits of being more closely involved with the patient rather than relying on another discipline will add to the resident's educational experience.

Percutaneous gastrostomy made simple.

The use of percutaneous endoscopic gastrostomy has obviated the necessity of laparotomy for enteral access. The authors propose a new technique for introduction of the gastrostomy tube. It entails use of the laparoscopic trocar to gain entrance into the gastric lumen.

Malignant peripheral nerve sheath tumor arising spontaneously from retroperitoneal ganglioneuroma: a case report, review of the literature, and immunohistochemical study.

We report a case of a malignant peripheral nerve sheath tumor arising from a retroperitoneal ganglioneuroma in an adult male. There was no known previous history of a childhood neuroblastoma or of radiation therapy. In addition, the patient had no stigmata or family history of von Recklinghausen's neurofibromatosis. This case provides evidence that, although rare, spontaneous malignant transformation of ganglioneuroma can occur. Immunohistochemical studies supported that the spindle cell component was of nerve sheath origin.

Membranolytic and nucleolytic activities of cytolytic T lymphocyte clones.

In an attempt to see if the nucleolytic and membranolytic activities of cytolytic T lymphocytes (CTL) were totally independent and could be expressed independently, we cloned CTL and determined their membranolytic and nucleolytic activities. If the two lytic mechanisms were completely independent and could be independently expressed by individual CTL, we anticipated that we would find CTL clones exhibiting only one or the other activity. Initial examination of membranolytic and nucleolytic activities in 99 newly established CTL clones revealed a poor correlation (r = 0.4) between the two activities. In addition, some clones expressed membenolytic activity without nucleolytic activity, and others, nucleolytic activity without membenolytic activity. The results suggest that CTL have 2 or more separate and independent mechanisms that lead either to the membranolytic or to the nucleolytic lesions in target cells.

An appraisal of small and diminutive colonic polyps.

A retrospective review of all colonoscopic polypectomies performed in a busy surgical endoscopy unit over a 6-month period was undertaken. All patients were included who presented with colonic polyps measuring less than 1 cm in diameter for which sufficient specimens were available for histopathologic examination. In all, 262 were polyps removed from 206 patients; of these, 158 (60%) were neoplastic. There was a statistically significant predilection for polyps in the right colon to be neoplastic. Worrisome histologic patterns (severe dysplasia, carcinoma in situ, or invasive carcinoma) were seen in 18 specimens (6.5%). In two patients, polypoid carcinoma could be identified; in one case it involved a lesion measuring 0.2 cm in diameter. Since these lesions exhibit no distinctive gross features, only their endoscopic removal and histologic study can ensure proper diagnosis and treatment.

Motivating adolescents to reduce their fines in a token economy.

Adolescents on a 16-bed token economy ward of a state hospital were subjected to four interventions in a seven-phase experiment to reduce the number of fines they received each day. Phase I was a four-week baseline period. Phases II and III were four- and five-week periods, respectively, in which residents were awarded tickets for a weekly $10 lottery each day they were at or below a changing criterion of daily fines. In Phase IV, residents received coupons, exchangeable for money, for days with zero fines. Phase V was a return to baseline. Phase VI was a one-week period in which daily lotteries for $1 were held, with the criterion for receiving a ticket being zero fines on the previous day. Phase VII was a one-week return to baseline. No significant differences in average fines per day, number of residents meeting criteria, or mean number of zero-fine days per week were found across phases. Results are discussed in terms of amount and immediacy of reinforcement, other opportunities to gain money, possible rebelliousness of the residents against the increased aversiveness of fines, and implications for further research.

An appeals system for fines received by adolescents in a token economy.

A system is described wherein adolescents participating in a token economy at a state hospital were allowed to appeal fines received from staff. Appeals were heard by a board composed of three residents and a psychology intern. The board met weekly and had full power to rescind or uphold fines. Before initiation of the appeal system, residents complained vigorously about fines received and about the "unfairness" of the staff and the token system, frequently denying responsibility for the infractions involved. Although almost half the fines were upheld, there were practically no more complaints of unfairness, and denials of responsibility declined drastically. The number of residents appealing fines fell from an average of four per week to less than one per week after the system had been in effect for one and one-half months. When asked why the system was not being used more often, residents grudgingly volunteered that most of the fines received were fair. It was not possible to determine whether this was due to changes in residents' attitudes or to actual changes in fining behavior by staff. Results are discussed in terms of effects on residents, acceptance by staff, and implications for further research.

Protein kinase C (PKC) inhibitors inhibit primary (1-0) but not secondary (1-1) or cloned cytotoxic T lymphocytes.

The isoquinolinesulfonamide PKC inhibitors H-7 and H-8 inhibit primary, in vivo generated cytotoxic T lymphocyte (CTL) activity by 50% at concentrations approximating their reported Ki values for PKC, 6 uM and 15 uM respectively. However, a greater than ten-fold higher concentration of H-7 (100 uM) is required to reduce secondary or clone 8F CTL-mediated cytotoxicity by 50%. At this concentration H-7 is also reported to inhibit calmodulin (CaM)-dependent enzymes. To distinguish between the effect of 100 uM H-7 on PKC versus CaM the napthalenesulfonamide CaM antagonist W-7 was investigated. W-7 inhibited primary, secondary and clone 8F CTL-mediated cytolysis by 50% near its reported Ki value for CaM-dependent kinase activity, 12 uM. We conclude that W-7 and 100 uM H-7 reduce cytolysis by inhibiting CaM-dependent reactions and not PKC. Thus, these findings indicate that primary killers require both PKC- and CaM-dependent activation pathways for lethal hit delivery, whereas highly lytic cultured CTL use only one pathway dependent upon CaM.

Gastrointestinal neurofibroma in a patient with von Recklinghausen's disease.

A 47-year-old woman underwent surgery because of a nonhealing gastric ulcer. An interesting pathologic finding followed.

Combined hamartoma of the retina and retinal pigment epithelium: the clinical spectrum.

Combined Hamartoma of the Retina and Retinal Pigment Epithelium is a rare ocular condition that has occasionally been mistaken for a more sinister lesion. Although there are wide clinical variations within the spectrum of the disorder, they are characterised by a number of distinctive ophthalmoscopic and angiographic features.