Ultrasonography incorrectly diagnoses gallbladder polyps.

To determine the accuracy of ultrasound-diagnosed polypoid lesions of the gallbladder in their institution, the authors reviewed the records of 41 patients with polypoid lesions of the gallbladder who underwent cholecystectomy, and collected data concerning age, sex, symptoms, and histopathologic diagnosis. Histopathologic evaluation confirmed polyps in only two patients (4.9%) categorized as having polypoid lesions of the gallbladder. Most specimens from patients with ultrasonography reports suggesting small polyps manifested cholesterolosis (17 of 41) or cholelithiasis (15 of 41). No specimen harbored malignancy. Mean patient age was 47.4 years, and the most common symptoms were pain (85%), nausea (44%), vomiting (29%), and abnormal liver function test results (14%). The accuracy of sonography for diagnosing polypoid lesions of the gallbladder was poor. Many of the small polyps seen on sonography most likely represented a stone embedded in the gallbladder wall or other abnormality. Because of the likelihood of cholelithiasis, the authors recommend that patients with biliary symptoms and ultrasonography findings suggesting polypoid lesions of the gallbladder undergo cholecystectomy.

Laparoscopic postmortem examination: a minimally invasive approach to the autopsy.

Laparoscopic and thoracoscopic autopsies have previously only been performed on an experimental basis to determine their potential usefulness as a substitute for a conventional postmortem examination. We present the case of a patient with an unusual variant of malignant melanoma (diffuse melanosis) in whom the immediate cause of death clinically was thought to be fulminant hepatic failure, the etiology of which was unknown. The family was unwilling to consent to a conventional autopsy, but would permit a postmortem examination limited to a 2-cm abdominal incision and removal of a sample of liver. In view of the unanswered clinical questions regarding the cause of the acute hepatic failure and its possible relationship to the diagnosis of diffuse melanosis, we decided that more extensive examination of the abdominal cavity, specifically the liver, was required and that the only way that this could be accomplished was by laparoscopic techniques. Laparoscopic examination of the abdominal cavity revealed multiple melanotic nodules on the surface of the liver and studding the omentum. Multiple liver samples were easily obtained; these revealed massive diffuse necrosis of the liver parenchyma with scattered nodular deposits of dark pigment consistent with melanin. We report the first known case in which a laparoscopic autopsy was used to obtain valuable information that answered clinically relevant questions. Laparoscopic autopsy can offer the a family that is unwilling to consent to a conventional postmortem examination an alternative that can potentially provide answers to clinical questions that otherwise would have been unresolved.

Transmission of live laparoscopic surgery over the Internet2.

BACKGROUND: Video broadcasting of surgical procedures is an important tool for education, training, and consultation. Current video conferencing systems are expensive and time-consuming and require preplanning. Real-time Internet video is known for its poor quality and relies on the equipment and the speed of the connection. The Internet2, a new high-speed (up to 2,048 Mbps), large bandwidth data network presently connects more than 100 universities and corporations. We have successfully used the Internet2 to broadcast the first real-time, high-quality audio/video program from a live laparoscopic operation to distant points. METHODS: Video output of the laparoscopic camera and audio from a wireless microphone were broadcast to distant sites using a proprietary, PC-based implementation of H.320 video conferencing over a TCP/IP network connected to the Internet2. The receiving sites participated in two-way, real-time video and audio communications and graded the quality of the signal they received. RESULTS: On August 25, 1998, a laparoscopic Nissen fundoplication was transmitted to Internet2 stations in Colorado, Pennsylvania, and to an Internet station in New York. On September 28 and 29, 1998, we broadcast laparoscopic operations throughout both days to the Internet2 Fall Conference in San Francisco, California. Most recently, on February 24, 1999, we transmitted a laparoscopic Heller myotomy to the Abilene Network Launch Event in Washington, DC. CONCLUSIONS: The Internet2 is currently able to provide the bandwidth needed for a turn-key video conferencing system with high-resolution, real-time transmission. The system could be used for a variety of teaching and educational programs for experienced surgeons, residents, and medical students.

The role of cyclooxygenase-1 and cyclooxygenase-2 in lipopolysaccharide and interleukin-1 stimulated enterocyte prostanoid formation.

Lipopolysaccharide is an inflammatory agent and interleukin-1 is a cytokine. Their pro-inflammatory effects may be mediated by prostanoids produced by inducible cyclooxygenase-2. The aim of this study was to determine the prostanoids produced by lipopolysaccharide and interleukin-1 stimulated enterocytes through the cyclooxygenase-1 and 2 pathways. Cultured enterocytes were stimulated with lipopolysaccharide or interleukin-1beta with and without cyclooxygenase inhibitors. Low concentrations of indomethacin and valerylsalicylic acid (VSA) were evaluated as cyclooxygenase-1 inhibitors and their effects compared with the effects of a specific cyclooxygenase-2 inhibitor, SC-58125. Prostaglandin E2, 6-keto prostaglandin F1alpha, prostaglandin D2 and leukotriene B4 levels were determined by radioimmunoassay. Immunoblot analysis using isoform-specific antibodies showed that the inducible cyclooxygenase enzyme (COX-2) was expressed by 4 h in LPS and IL-1beta treated cells while the constitutive COX-1 remained unaltered in its expression. Interleukin-1beta and lipopolysaccharide stimulated the formation of all prostanoids compared with untreated cells, but failed to stimulate leukotriene B4. Indomethacin at 20 microM concentration, and VSA inhibited lipopolysaccharide and interleukin 1beta stimulated prostaglandin E2, but not 6-keto prostaglandin F1alpha formation. SC-58125 inhibited lipopolysaccharide and interleukin-1beta stimulated 6-keto prostaglandin F1alpha but not prostaglandin E2 release. The specific cyclooxygenase-2 inhibitor also inhibited lipopolysaccharide produced prostaglandin D2 but not interleukin-1beta stimulated prostaglandin D2. While SC-58125 inhibited basal 6-keto prostaglandin-F1alpha formation it significantly increased basal prostaglandin E2 and prostaglandin D2 formation. As SC-58125 inhibited lipopolysaccharide and interleukin-1beta induced 6-keto prostaglandin F1alpha production but not prostaglandin E2 production, it suggests that these agents stimulate prostacyclin production through a cyclooxygenase-2 mediated mechanism and prostaglandin E2 production occurs through a cyclooxygenase-1 mediated mechanism. Prostaglandin D2 production appeared to be variably produced by cyclooxygenase-1 or cyclooxygenase-2, depending on the stimulus.

Prospective evaluation of a new through-the-scope nasoduodenal enteral feeding tube.

BACKGROUND: With present techniques, transpyloric feeding tube placement is unreliable. This study evaluated a new nasoduodenal tube placed through a gastroscope. METHODS: A therapeutic gastroscope was advanced into the distal duodenum, and through the 3.7-mm channel this feeding tube was advanced under direct vision into the small bowel. The tube/guidewire combination was then advanced with the concomitant equidistant retraction of the scope until the wire could be grasped at the lips and exchanged to the nose using a nasal transfer tube. The guidewire was removed, and a "Y" connector was then attached to the end of the tube. RESULTS: Successful tube placement in all 21 patients (14M/7F) required an endoscopy time of 31 +/- 3.3 min and the tubes were utilized for 9.24 +/- 0.94 days. Tube tips were confirmed in the distal duodenum (10) or proximal jejunum (11) by radiographic contrast injection. CONCLUSION: This new through-the-scope tube can be placed in the distal duodenum quickly, safely, and consistently.

Congenital intestinal malrotation causing gestational intestinal obstruction. A case report.

BACKGROUND: Intestinal obstruction in pregnancy is rare. The mortality rate is higher during pregnancy than in the general population and applies to fetal as well as maternal survival. Major causes of intestinal obstruction in the pregnant women include adhesions, volvulus and intussusception. CASE: A 27-year-old woman, gravida 2, para 1, estimated gestational age approximately 26 weeks, with a high-level, complete small bowel obstruction. The patient failed a trial of conservative management and required laparotomy, at which time a congenital malrotation was found. She was treated successfully with a modified Ladd's procedure. There was no maternal or fetal morbidity. CONCLUSION: This case represents an extremely rare cause of bowel obstruction in pregnancy; a paucity of such cases have been reported.

Colonoscopic perforations. Etiology, diagnosis, and management.

Since its introduction into clinical medicine, flexible fiberoptic colonoscopy has had a great impact on diagnosis and management of diseases of the colon and rectum. There are three mechanisms responsible for colonoscopic perforation: specifically, mechanical perforation directly from the colonoscope or a biopsy forceps, barotrauma from overzealous air insufflation, and, finally, perforations that occur during therapeutic procedures. Perforation of the colon, which requires surgical intervention more frequently than bleeding, occurs in less than 1 percent of patients undergoing diagnostic colonoscopy and may be seen in up to 3 percent of patients undergoing therapeutic procedures such as polyp removal, dilation of strictures, or laser ablative procedures. Management of colonic perforation secondary to colonoscopy remains a controversial issue in that it can be effectively managed by operative and nonoperative measures. If a perforation does occur, signs and symptoms that the patient will experience will be related to both the size and site of the perforation, adequacy of the bowel preparation, amount of peritoneal soilage, underlying colonic pathology (where a thin walled colon from colitis or ischemia, for example, may result in a larger perforation than a healthy colon), and, finally, overall clinical condition of the patient. Radiology often establishes diagnosis. Plain films of the abdomen and an upright chest x-ray may reveal extravasated air confined to the bowel wall, free intraperitoneal air, retroperitoneal air, subcutaneous emphysema, or even a pneumothorax. A localized perforation may demonstrate lack of pneumoperitoneum. Some surgeons recommend surgery for all colonoscopic perforations; however, there does appear to be a role for conservative management in a select group of patients such as those with silent asymptomatic perforations and those with localized peritonitis without signs of sepsis that continue to improve clinically with conservative management. Finally, conservative management works well in those patients with postpolypectomy coagulation syndrome. Surgery is most definitely indicated in the presence of a large perforation demonstrated either colonoscopically or radiographically and in the setting of generalized peritonitis or ongoing sepsis. The presence of concomitant pathology at time of colonoscopic perforation such as a large sessile polyp likely to be a carcinoma, unremitting colitis, or perforation proximal to a nearly obstructing distal colonic lesion may force immediate surgery. Finally, in the patient who deteriorates with conservative management, one should proceed to surgery.