Laparoscopic cholecystectomy in pregnancy.

It has been stated that pregnancy is an absolute contraindication to laparoscopic cholecystectomy. After failed medical management, five gravid patients underwent successful laparoscopic cholecystectomy with single-film intraoperative cholangiography. One patient was in the first trimester, three were in the second trimester, and one was in the third trimester. All carried the pregnancy to term and delivered normal children. Laparoscopic cholecystectomy can be safely performed during pregnancy and offers the potential of significant cost savings compared with traditional medical management of cholecystitis complicating pregnancy.

A feasibility study of computer aided diagnosis in appendicitis.

In this study, the hypothesis that computer aided diagnosis could enable a more accurate differentiation between patients with acute appendicitis and those with abdominal pain but normal appendixes was examined. A data base was established by analyzing the records of 476 patients having an emergency measure appendectomy during a five year period. There were 360 or 76 per cent with acute appendicitis, 98 or 20 per cent with normal appendixes and 18 or 4 per cent with other diseases requiring operation. The records were analyzed with regard to history, physical examination and laboratory findings. The data base was then divided randomly into two parts. Part 1 was subjected to univariate discriminant analysis, using the chi-square test. The only quantities which were significantly different between appendicitis and a normal appendix were sex, duration of symptoms, anorexia and vomiting. Multivariate discriminant analysis was used to derive an abdominal pain index which discriminated between appendicitis and a normal appendix with a sensitivity of 0.82 and a specificity of 0.39. Using the abdominal pain index to evaluate the patients in part 2 of the data base, 23 or 40 per cent of the 58 patients with a normal appendix would have avoided operation. However, 31 or 18 per cent of the 169 patients with appendicitis would have not been operated upon; three of those 31 had perforated appendixes. Computer aided diagnosis was no more effective than unaided clinical diagnosis in appendicitis.

The unnecessary laparotomy for appendicitis-can it be decreased?

There has been no decrease in the incidence of negative appendectomies in the adult population over the past two decades. Review of 484 appendectomies over a five-year period revealed that females between the ages of 13 to 40 have the lowest appendiceal perforation rate and the highest diagnostic error rate. More thorough preoperative assessment is indicated in this group. A program utilizing intensive observation, diagnostic barium enema, and laparoscopy may produce a reduction in negative laparotomies for appendicitis.

Carotid artery disease following external cervical irradiation.

A retrospective study of 910 patients surviving at least five years after cervical irradiation for Hodgkin's disease, non-Hodgkin's lymphoma, or primary head an neck neoplasms showed the incidence of stroke following cervical irradiation was 63 of 910 patients (6.3%) during a mean period of observation of nine years. This represents a trend toward an increased risk for this population observed over the same period of time (p = 0.39). A prospective study of 118 similar patients currently living five years after cervical radiotherapy was performed to determine the incidence of carotid artery disease occurring as a consequence of neck irradiation. Abnormal carotid phonangiograms (CPA) were found in 25% of the patients and abnormal oculoplethysmographs (OPG) were found in 17%. These studies represent significant carotid lesions that are not expected in such a population. It is concluded that the carotid stenoses demonstrated are most likely a consequence of prior irradiation. Patients that are five-year survivors of cervical irradiation should have noninvasive vascular laboratory studies performed as part of their routine follow-up examinations in order to detect these carotid lesions while they are occult.

Outcome of operations for upper gastrointestinal tract bleeding.

The outcome of operations for upper gastrointestinal tract bleeding during a six-year period was compared with that of the previous four years, in which indications for operation and guidelines for surgical procedures were similar. Between 1973 and 1978, 392 patients were hospitalized for hemorrhage. Endoscopy diagnosed a bleeding lesion in 92% of 234 patients studied. Of 75 patients (19%) who required operation for uncontrollable hemorrhage, 20 (27%) died and two (3%) rebled postoperatively. Most deaths (80%) were caused by esophageal variceal bleeding. Among 47 patients with nonvariceal hemorrhage, mortality was only 9%. No patient with stress ulcer bleeding was encountered. Compared with our 1969 to 1972 experience, the present study shows no improvement in overall mortality. Rebleeding was less frequent than earlier. The most significant differences in outcome were decreased mortality in alcoholic gastritis patients, no deaths from stress ulcer, and increased mortality after portosystemic shunting. Endoscopy, used frequently from 1973 to 1978, helped to improve preoperative diagnostic rates (85% vs 65%). Combined with innovations in nonoperative treatment, such as infusion of vasopressin, it did not appear to decrease the proportion of patients requiring operation.

A reappraisal of penetrating neck injury management.

Seventy-five patients with penetrating neck injuries were reviewed. A policy of routine neck exploration for all wounds violating the platysma resulted in a 56% negative exploration rate. All patients with serious injuries had overt clinical signs preoperatively. A policy of selective exploration is discussed.

Recent experience with trauma of the liver.

Surgeons must be intimately familiar with the alternatives available in managing hepatic trauma. Although the vast majority of injuries of the liver can be managed by a simple operative technique, the occasional severe injury demands instant recognition and the precise application of surgical skill for successful treatment. Exsanguination associated with hepatic trauma remains an unsolved problem.

Fatal hepatic hemorrhage after trauma.

Two hundred twenty-five cases of acute hepatic trauma were reviewed. Thirty-four patients died, 28 (82 per cent) as a direct result of exsanguination. The successful management of hemorrhage associated with severe liver injuries requires early diagnosis, prompt hemostasis and restoration of blood volume, close attention to coagulation factors, and the precise application of surgical techniques.

Diagnostic peritoneal lavage.

A technique for peritoneal lavage which has increased accuracy and eliminated complications is described. A curved incision is made to one side of the umbilicus at the level of the infraumbilical ring extending over the linea alba for 4 cm. The advantages of the site are its avascularity, paucity of peritoneal fat, and adherence of the peritoneum. By placing the incision at the infraumbilical ring, the rectus muscle is avoided. By adhering to the technique described, false lavage results and iatrogenic injuries to abdominal structures have been significantly decreased.