Increased transperitoneal bacterial translocation in laparoscopic surgery.

BACKGROUND: The indications for laparoscopic surgery have expanded to include diseases possibly associated with peritonitis such as appendicitis, perforated peptic ulcers, and diverticulitis. The safety of carbon dioxide (CO2) pneumoperitoneum in the presence of peritonitis has not been proved. Our previous investigations demonstrated increased bacteremia associated with CO2 insufflation. In effort to clarify the relative effects of intraabdominal pressure and type of gas, this study was designed to measure bacterial translocation with different gases at different pressures of pneumoperitoneum. METHODS: For this study, 110 rats were given intraperitoneal bacterial innoculations with Escherichia coli and equally divided into five groups of 20 animals each. The study groups included a control group with no pneumoperitoneum administered (n = 30), insufflation at a commonly used pressure of 14 mmHg with helium (n = 20) and CO2 (n = 20), and low insufflation at 3 mmHg with helium (n = 20) and CO2 (n = 20) in an effort to minimize influences related to pressure. Blood cultures were checked at 15-min intervals for the first 45 min, then hourly thereafter for a total of 165 min after peritoneal inoculation with 2 x 10(7) E. coli. RESULTS: There is increased risk of bacterial translocation in comparing groups that underwent pneumoperitoneum with those that did not in the rat peritonitis model. Furthermore, these findings are dependent on the presence or absence of gas, but not necessarily on the type of gas used for insufflation. In the low-pressure groups of both gases (helium and CO2), bacterial translocation was significantly increased, as compared with the control group. Low pressure also was associated with increased bacterial translocation, as compared with high pressure, but beyond 30 min of insufflation, no significant differences were apparent. CONCLUSIONS: The risk of bacterial translocation in the E. coli rat peritonitis model is increased with insufflation using CO2 or helium, and this effect is more significant at lower pressures (3 mmHg) than at higher pressures (14 mmHg). However, no clinically applicable conclusions regarding the relative effects from type of gas or insufflation pressures could be confirmed.

Disseminated brown tumors from hyperparathyroidism masquerading as metastatic cancer: a complication of parathyroid carcinoma.

Osteitis fibrosa cystica (brown tumors) can be a skeletal manifestation of advanced hyperparathyroidism, including parathyroid cancer. Severe osteitis fibrosa cystica can mimic metastatic bone diseases especially in patients with a history of cancer. Because the treatment and prognosis of these two problems differ greatly considering hyperparathyroidism in the differential diagnosis of patients found to have osteolytic lesions is critical for the appropriate management of these patients. In this case report we describe a patient with a history of renal cell cancer and presumed osteolytic bone metastases. During prophylactic intramedullary rodding to prevent pathologic fracture of her femur she was found to have a benign lesion related to her previously undiagnosed hyperparathyroidism caused by an underlying parathyroid cancer. A detailed review of this disease and the associated bone changes is also included to underscore the importance of an adequate differential diagnosis as well as optimal management. Patients with hypercalcemia or bony lesions should not automatically be treated palliatively for metastatic disease just because of a past medical history of cancer. Hyperparathyroidism is a readily curable problem if properly diagnosed.

Changing concepts in long-term central venous access: catheter selection and cost savings.

BACKGROUND AND OBJECTIVES: Long-term central venous access is becoming an increasingly important component of health care today. Long-term central venous access is important therapeutically for a multitude of reasons, including the administration of chemotherapy, antibiotics, and total parenteral nutrition. Central venous access can be established in a variety of ways varying from catheters inserted at the bedside to surgically placed ports. Furthermore, in an effort to control costs, many traditionally inpatient therapies have moved to an outpatient setting. This raises many questions regarding catheter selection. Which catheter will result in the best outcome at the least cost? It has become apparent in our hospital that traditionally placed surgical catheters (ie, Hickmans and central venous ports) may no longer be the only options. The objective of this study was to explore the various modalities for establishing central venous access comparing indications, costs, and complications to guide the clinician in choosing the appropriate catheter with the best outcome at the least cost. METHODS: We evaluated our institution's central venous catheter use during a 3-year period from 1995 through 1997. Data was obtained retrospectively through chart review. In addition to demographic data, specific information regarding catheter type, placement technique, indications, complications, and catheter history were recorded. Cost data were obtained from several departments including surgery, radiology, nursing, anesthesia, pharmacy, and the hospital purchasing department. RESULTS: During a 30-month period, 684 attempted central venous catheter insertions were identified, including 126 surgically placed central venous catheters, 264 peripherally inserted central catheters by the nursing service, and 294 radiologically inserted peripheral ports. Overall complications were rare but tended to be more severe in the surgical group. Relative cost differences between the groups were significant. Charges for peripherally inserted central catheters were $401 per procedure, compared with $3870 for radiologically placed peripheral ports and $3532 to $4296 for surgically placed catheters. CONCLUSIONS: Traditional surgically placed central catheters are increasingly being replaced by peripherally inserted central venous access devices. Significant cost savings and fewer severe complications can be realized by preferential use of peripherally inserted central catheters when clinically indicated. Cost savings may not be as significant when comparing radiologically placed versus surgically placed catheters. However, significant cost savings and fewer severe complications are associated with peripheral central venous access versus the surgical or radiologic approach.

Determinants of efficacy of immunotherapy with tumor-derived heat shock protein gp96.

Immunotherapy with gp96 was highly effective in mice bearing methylcholanthrene-induced fibrosarcomas (Meth A tumors) when treatment began 7 days or less after tumor challenge, but significantly less effective if the treatment began 9 days after challenge. Immunotherapy of pre-existing tumors showed all the hallmarks of specificity of gp96 and dose-restriction observed previously with prophylactic studies. When mice with large primary Meth A tumors were treated with surgery alone, or with surgery followed by therapy with Meth A-derived gp96, the mice that received surgery and immunotherapy did significantly better than those receiving surgery alone. The relationship between the time of initiation of immunotherapy with gp96 and its efficacy was also tested in a metastatic model of the Lewis lung carcinoma. In this model, immunotherapy with gp96 was very effective if treatment began up to 31 days after tumor challenge, but significantly less so if therapy was initiated day 33 post-tumor challenge. These observations suggest that the regulatory phenomena that interfere with immunotherapy gather momentum with surprising speed.

Gallbladder duplication and laparoscopic management.

Gallbladder duplication can present a significant challenge to the laparoscopic surgeon, primarily due to difficulties with diagnosis and recognition. Previous reports of attempted laparoscopic cholecystectomy in patients with gallbladder duplication resulted in incomplete or staged multiple procedures. The case report of a 35-year-old woman with successful laparoscopic management of symptomatic gallbladder duplication is described, emphasizing several important considerations. Preoperatively when evaluating radiologic studies a high index of suspicion is necessary in interpreting atypical findings. To further evaluate these abnormalities, liberal use of preoperative ERCP is helpful, and specific endoscopic techniques may be necessary as well. Intraoperatively, the findings may be confusing, and cholangiography can help clarify ductular anomalies, especially if the gallbladder duplication is contained within a common serosal coat. Missing a second gallbladder can result in persistent symptoms postoperatively necessitating further surgery. Laparoscopic cholecystectomy in the management of gallbladder duplication can be safely done and an awareness is necessary to avoid complications or multiple procedures.

Perioperative vasopressin secretion treated by demeclocycline.

The purpose of this study was to evaluate the perioperative effects of demeclocycline on vasopressin (VP) in patients undergoing surgery, specifically coronary artery bypass grafting (CABG). This was a prospective, double-blind placebo-controlled clinical study using human subjects in a 575-bed tertiary care teaching community hospital. Thirty patients (20 males and 10 females) undergoing elective CABG over a 6-month period were randomized preoperatively to receive either demeclocycline or a placebo. Each patient received either a total of 1200 mg daily of demeclocycline or a placebo beginning 5 days preoperatively and continuing through postoperative day 2. Urine and serum osmolality, electrolytes, and VP levels were measured daily. Perioperative VP levels were significantly higher (P = 0.05) in the demeclocycline group despite decreased VP activity. The postoperative serum sodium and osmolality remained normal in the demeclocycline group and significantly decreased in the placebo group (P < 0.01). The urine osmolality increased significantly in the placebo group (P = 0.04) on postoperative day 1. We conclude that perioperative administration of demeclocycline reliably inhibits the effects of increased VP secretion commonly seen in patients undergoing CABG procedures. Applying these findings to surgical patients who are at increased risk of complicated fluid and electrolyte problems requires further study.

Colorectal carcinoma and the relationship of peritoneal cytology.

BACKGROUND: This study was designed to investigate the frequency of the association between colorectal cancer and peritoneal cytology as well as the impact of surgical resection on conversion of cytology from benign to malignant cells being present. Furthermore, increasingly frequent reports of port site recurrences with laparoscopic colectomy for limited stage colon carcinoma prompted us to evaluate the incidence of tumor cell spillage with traditional "open" colonic surgery. METHODS: Fifty random patients undergoing surgery for colorectal carcinoma were prospectively evaluated with peritoneal washings prior to and following colon resection. RESULTS: Five patients (10%) were found to have malignant cytology, with no patients converting from negative to positive cytology. All five positive cytologies were associated with stage IV disease and poorly differentiated colon cancer. CONCLUSION: Intraoperative peritoneal cancer dissemination could not be demonstrated by cytologic washings of the abdominal cavity before and after colorectal resection utilizing standard cytomorphological criteria.

Does pneumoperitoneum during laparoscopy increase bacterial translocation?

BACKGROUND: To evaluate the impact of laparoscopy in the presence of peritonitis, this study was designed to assess bacteremia caused by E. coli-induced peritonitis with a carbon dioxide pneumoperitoneum in a rat model. METHODS: Sixty Sprague-Dawley rats were divided into inoculum groups (no E. coli, 10(6) colony-forming units [CFU] E. coli, and 10(8) CFU E. coli), followed by induction of a carbon dioxide pneumoperitoneum or no pneumoperitoneum. Fifteen-minute-interval blood cultures were obtained to determine time of bacteremia development. Statistical assessment to determine significant differences among groups was done using ANOVA and t-test analysis. RESULTS: A total of 20 animals with E. coli introduced into the peritoneum and a carbon-dioxide-induced pneumoperitoneum had more frequent positive blood cultures at all time intervals compared to identical inoculum subgroups without a pneumoperitoneum. ANOVA revealed a significant difference in bacteremia within the same concentration inoculum groups in animals receiving a pneumoperitoneum vs none (p < 0.01). Bacteremia increased significantly as inoculum concentrations increased (25% with 10(6) E. coli inoculum vs 80% with 10(8) E. coli), especially among the insufflated subgroups (45% with 10(6) E. coli vs 100% with 10(8) E. coli) over 180 min (p < 0.01). CONCLUSION: Carbon dioxide pneumoperitoneum increases the incidence of E. coli bacterial translocation from the peritoneum into the bloodstream in this rat model.

Modern concepts in nonsurgical management of traumatic biliary fistulas.

The management of traumatic biliary fistulas is controversial. New ideas in nonsurgical treatment have recently evolved, in part because of the rapid advancement of laporoscopic surgery. Three major concepts are important in managing biliary fistulas: diagnosis, drainage, and decompression. These concepts were applied to a trauma patient, then reviewed in detail.

A new and simple approach to open laparoscopy.

This new and simple approach to laparoscopy should be in the armamentarium of every laparoscopic surgeon. Similar to the dissection involved with an open peritoneal lavage, the peritoneal cavity is entered. After placement of a pursestring fascial suture, the introducer and laparoscope are inserted. The suture is used to provide an airtight seal and close the defect at the termination of the procedure. We believe that this is a safe, rapid, effective technique that is easy to learn.

Managing appendicitis in the elderly patient.

The incidence of acute appendicitis in the elderly will continue to increase as the elderly population enlarges. Because appendicitis is much more serious in elderly patients compared to younger patients, the care we render to elderly individuals must be optimal, and recent improvements in care have dropped mortality rates significantly.

A reappraisal of appendicitis in the elderly.

Historically, appendicitis in the elderly is associated with higher morbidity and mortality. Ninety-six patients over 60 years of age with appendicitis treated over a 10-year period were reviewed. Only 20% presented classically with anorexia, fever, right lower quadrant pain, and an elevated white blood cell count. One third of the patients had greater than 48 hours delay to admission. Objective diagnostic testing was often confusing and unreliable. At the time of admission, only 51% were diagnosed as having possible appendicitis. Eighty-three percent of our patients underwent surgery within 24 hours, and 72% had frank perforation. Thirty-two percent of those surviving developed complications, and 83% of these patients had perforated appendicitis. Complications were twice as likely in patients with perforation. Despite the relatively high morbidity, there were only four deaths in patients with coexistent carcinoma. Because of the later and atypical presentation of appendicitis in this age group, a high index of suspicion and early operation are important in avoiding perforation and subsequent morbidity.

Changing concepts of deep venous thrombosis of the upper extremity--report of a series and review of the literature.

Deep venous thrombosis (DVT) of the upper extremity has recently been recognized as being more common than previously reported (probably because of the increasingly frequent use of subclavian venous access). A retrospective review of patients in whom subclavian or axillary DVT had developed in the past 6 years (1980 to 1986) was conducted at the Akron General Medical Center. The major cause identified was related to subclavian venous catheterization, which accounted for 39% of all instances of subclavian and axillary DVT. Our results are correlated with a review of the literature. In our review of studies in which subclavian venous catheterizations were prospectively examined with use of objective means of diagnosis, we found that 28% of all subclavian catheterizations had venous thrombosis develop, often subclinically. This is not an innocuous disease, as suggested in the past; in our series 12% of upper-extremity DVT had pulmonary embolization (PE). In reviewing the recent literature, we found an average 12.4% incidence of PE, which often occurs during anticoagulation treatment. Diagnostic modalities are discussed and treatment regimens are reviewed along with an extensive literature review.

Cardiopulmonary needle embolization: a complication of central venous drug abuse.

A great variety of complications secondary to drug abuse have been reported in the literature. We report a case of multiple cardiopulmonary needle embolization. A drug addict who had resorted to central venous drug abuse was found on chest roentgenograms to have multiple asymptomatic needle fragments within her chest. In this instance chest roentgenograms and tomographs were more helpful in needle localization than computed tomography. Complications of intracardiac foreign bodies are also briefly reviewed. In attempts to diagnose this complication, a high index of suspicion is necessary as central venous drug abuse becomes increasingly more prevalent.

Hickman catheter dislodgement due to pendulous breasts.

Dislodgement of Hickman, Broviac, and Mediport catheters is a rare but recognized complication. To date, no specific etiology for this has been cited. We present five cases of dislodgement due to positional changes in large-breasted women and one man with gynecomastia. Apparently, motion in the subcutaneous tissue secondary to gravitational forces on large breasts causes downward and outward traction on the subcutaneous portion of the catheter. Variations in placement technique to help avoid this complication are described.