[Peritoneal tuberculosis simulating advanced ovarian carcinoma: a case report]. / Tuberculose péritonéale disséminée simulant un cancer ovarien: à propos d'un cas.

Disseminated peritoneal tuberculosis accounts for 1-3% of tuberculosis disease, represented by high frequency of lung defects in endemic countries. The authors report one case in a 43-year-old woman, the initial interpretation of which, based on pleural and peritoneal exudate, showed suspected latero-uterine mass and significant elevated serum CA 125 level, mimicking disseminated ovarian carcinoma. Only after exploring laparotomy with biopsy was disseminated peritoneal tuberculosis identified, thus correcting the diagnosis. Symptomatology, X-ray defect, and cynetic of serum CA 125 level were left in totality after 3 months of antituberculosis multidrugs. This is a diagnostic trap, which presents a new interest for such pathology as tuberculosis, which is on the increase again in the West.

Gastric tonometry and direct intraabdominal pressure monitoring in abdominal compartment syndrome.

BACKGROUND/PURPOSE: Abdominal compartment syndrome (ACS) may complicate abdominal closure in patients with abdominal wall defects, abdominal trauma, intraperitoneal bleeding, and infection. Increased intraabdominal pressure (IAP) leads to respiratory compromise, organ hypoperfusion, and a high mortality rate. This study evaluates the efficacy of continuous direct monitoring of IAP and gastric tissue pH in detecting impending ACS. METHODS: Ten mongrel puppies weighing 2.8 to 6.4 kg underwent general endotracheal anesthesia, placement of an intraabdominal inflatable balloon to simulate ACS and a Swan-Ganz catheter to measure direct IAP. A gastric tonometer, nasogastric tube, foley catheter, and arterial catheter also were inserted. Half-hourly inflation's of the intraabdominal balloon were used to simulate the development of ACS. Direct intraabdominal (IAP), gastric (GP), bladder (BP), and peak airway pressures (PAP) were measured. Gastric tonometry fluid and arterial blood gas levels were obtained during inflation, and the gastric tissue pH level was calculated. Data were statistically analyzed using Pearson's correlation coefficients. RESULTS: Baseline pressures were 2 to 5 cm H(2)O in the stomach and bladder catheters, 1 to 3 mm Hg in the intraabdominal catheter, and correlated with a gastric tissue pH level of 7.4. Significantly high correlation coefficients (cc) were observed between IAP versus BP (cc, 0.77; P <.002). IAP versus GP (cc, 0.79; P <.002) and IAP versus PAP (c, 0.83; P <.0004). A high negative correlation coefficient was noted between gastric pH and IAP (cc, 0.61; P <.026). The pH level dropped to 7.0 with BP and GP of 20 cm H(2)O and IAP of 10 mm Hg, to 6.8 at 30 cm H(2)O and 20 mm Hg, and 6.5 at 40 cm H(2)O and 30 mm Hg, respectively. However, correlation coefficients between gastric tissue pH and BP, GP, or PAP were not significant. CONCLUSIONS: These data suggest that continuous direct intraabdominal pressure monitoring is a simple and effective method that correlates well with indirect bladder or gastric pressure measurement. Changes in gastric tissue pH in association with increased intraabdominal pressure may be an early indicator of impending abdominal compartment syndrome. These observations indicate that these techniques may be more sensitive than current methods of indirect measurement, which may be associated with delayed recognition of ACS.

Patch esophagoplasty using AlloDerm as a tissue scaffold.

BACKGROUND/PURPOSE: Anastomotic leak and stricture are common causes of morbidity after esophageal repair. The authors describe a technique of patch esophagoplasty using decellularized human skin. METHODS: Twelve conditioned dogs underwent a cervical 2.0- x 1.0-cm esophagoplasty with AlloDerm. A gastrostomy tube was used for feedings until an esophagram was performed on the 10th to 14th postoperative day. Dogs were then given oral chow and followed up for leak and dysphagia. Animals were killed at 1-, 2-, and 3-month intervals and evaluated for stricture, diverticula formation, and patch histology. RESULTS: All animals survived, and none had sepsis or dysphagia. All esophagrams were without evidence of leak or stricture. At death there were no strictures or diverticula. Histologic examination of 1-month specimens showed partial reepithelialization of the patch with neovascularization. Control staining of AlloDerm was strongly positive for elastin. This was decreased in the region of the patch at 1 month. Two-month specimens showed intact epithelium and an increase in the caliber of new blood vessels. Three-month specimens showed no significant variation from 2-month animals. CONCLUSION: Decellularized human skin (AlloDerm) provides a temporary collagen framework on which esophageal healing can occur and function can be maintained.

Risk factors for leg wound complications following endoscopic versus traditional saphenous vein harvesting.

BACKGROUND: Risk factors for leg wound complications following traditional saphenectomy have included: obesity, diabetes, female gender, anemia, age, and peripheral vascular disease. Use of an endoscopic saphenectomy technique may modify the risk factor profile associated with a traditional longitudinal incision. METHODS: From September 1996 to May 1999, 276 consecutive patients who underwent elective isolated coronary artery bypass grafting performed by a single surgeon (K.B.A.) had their greater saphenous vein harvested endoscopically. During the period from January 1999 to May 1999, the surgical records of 643 patients who underwent the same operation and had a traditional longitudinal saphenectomy were reviewed for postoperative leg wound complications. Group demographics were similar regarding preoperative risk stratification and traditionally identified wound complication risk factors (diabetes, gender, obesity, preoperative anemia, and peripheral vascular disease). Leg wound complications were defined as: hematoma, dehiscence, cellulitis, necrosis, or abscess requiring dressing changes, antibiotics and/or debridement prior to complete epithelialization. Follow-up was 100% at six weeks. RESULTS: Leg wound complications following endoscopic harvest occurred in 3% (9/276) of patients versus 17% (110/643) of traditional harvest patients (p < 0.0001). No univariate risk factors for wound complications were associated with endoscopic saphenectomy. Univariate predictors of wound complications following traditional saphenectomy included: diabetes (p = 0.001), obesity (p = 0.0005), and female gender (p = 0.005). Multivariable risk factors for leg wound complications following saphenectomy were traditional harvest technique (OR 7.56, CI 3.8-17.2, p < 0.0001), diabetes (OR 2.10, CI 1.4-3.2, p = 0.0006) and obesity (OR 1.82, CI 1.2-2.8, p = 0.007). CONCLUSIONS: Traditional longitudinal saphenectomy is a multivariable risk factor for development of leg wound complications. Endoscopic saphenectomy modifies the risk factor profile for wound complications and should be the standard of care, particularly for obese and/or diabetic patients who require venous conduit during coronary artery bypass grafting.

The development of gastroesophageal reflux after percutaneous endoscopic gastrostomy.

The relationship between percutaneous endoscopic gastrostomy (PEG) and subsequent development of gastroesophageal reflux (GER) is complex and not well understood. The authors retrospectively reviewed 82 children over a 5-year period who underwent PEG tube (n = 64) or PEG button (n = 18) placement. Children were evaluated preoperatively for clinical evidence of GER (C-GER) or radiographic GER (R-GER) with upper gastrointestinal contrast study or Tc99m gastric scinitiscan. Seventy-five patients were evaluated for clinical evidence of postoperative GER by direct family contact. Eleven of 39 (28%) patients with no GER preoperatively developed GER postoperatively, eight (20%) of whom required Nissen fundoplication (NF) or gastrojejunostomy (GJ) tube. Ten of 19 (53%) with preoperative C-GER but no R-GER continued to have GER after PEG, but only three required NF or GJ. Only one of nine children who had R-GER only developed clinical GER after PEG placement. Of the eight children with both C-GER and R-GER, only two (25%) required NF or GJ and two (25%) had no postoperative GER. The authors conclude that PEG tubes are useful in infants and children and are associated with a relatively low incidence of postoperative GER. If C-GER is absent, a PEG is a reasonable procedure to consider even in the presence of R-GER.

Cardiac myxoma: the Indiana Heart Institute experience.

Surgical resection of a cardiac myxoma was performed in 14 patients at the Indiana Heart Institute at St. Vincent Hospital and Health Care Center in Indianapolis from 1974 to 1989. Thirteen were located in the left atrium and one in the right atrium. The 10 women and four men ranged in ages from 28 to 75 years. Surgical complications included one perioperative death, one late death and one late recurrence requiring reoperation. Physicians must be highly suspicious to correctly diagnose this unusual but surgically correctable entity. Two-dimensional echocardiography is the diagnostic technique of choice for both early diagnosis of a cardiac myxoma and late follow-up after resection.

Long-term follow-up of unusual ball-valve aortic substitute.

On March 19, 1962, prior to the availability of Starr-Edwards ball-valve prostheses for aortic substitution, a mitral valve turned upside down was implanted for marked calcific aortic stenosis. It worked well and the patient was in good health for 15 years. Late annular calcification and loosening of sutures with marked perivalvular regurgitation made valve replacement necessary 16 years after operation. The original valve was perfectly preserved.

The management of stenotic and obstructive lesions of the aortic arch branches.

The stenotic internal carotid can be managed in a variety of ways and number of tests can be utilized for assessing the collateral blood flow. Except in unusual situations, carotid thromboendarterectomy with or without a patch graft is generally employed. Although some surgeons use no protective shunt at all, or only upon specific indications, intraluminal shunting is utilized extensively. Our preference is to employ the customary Javid shunt technic except in unusual circumstances that suggest that added safety may be assured by shortening to a matter of seconds the period of interruption of carotid flow. In such cases, we believe the temporary axillary-internal carotid intraluminal shunt is of considerable value. Although mediastinal and thoracic procedures and bypass grafts delivering blood from the ascending aorta are not needed nearly as often as they were formerly, they are essential in certain cases. They yield excellent results and carry small risk. Carotid-subclavian grafts have proved quite valuable in restoring pulsatile flow to the subclavian and carotid systems. Our preference, however, because of technical simplicity, is the carotid-axillary bypass procedure. Subclavian-subclavian and axillary-axillary grafts have been employed successfully. When a carotid-axillary bypass is feasible, we would choose this method instead and reserve the others for unusual anatomic-pathologic situations.

Embolization of caval umbrella. Discussion and report of successful removal from the right ventricle.

The first case of successful diagnosis and operative removal of a vena caval umbrella which had become detached and migrated to the right ventricle is reported. Complications from the employment of this device are discussed. In all cases of umbrella embolization to the right heart and pulmonary arterial tree, immediate operative removal is indicated. Precautions regarding umbrella insertion which minimize the likelihood of dislodgment and embolization are also mentioned.

Temporary axillary-carotid shunting for unusual instances of carotid stenosis.

A method has been developed which entails the introduction of the larger end of a Javid shunt tube in the axillary artery and the other in the internal carotid with only momentary interruption of blood flow. The method of closing the incision after the thromboendarterectomy almost entirely eliminates a second period of carotid occlusion. This procedure may be useful in unusual instances in which it is believed advantageous to avoid even the relatively short occlusion periods usually necessary when using the standard intraluminal shunt technique.

Stenotic and obstructive lesions in acute dissecting thoracic aortic aneurysms.

The present study of 33 operatively treated patients, 88 per cent of whom survived the procedure, is concerned with an important problem associated with acute thoracic aortic dissection, the stenotic and obstructive lesions of the aorta and its branches. Their variety and nature are described, as are the additional operative procedures deemed necessary at the time of the operation, immediately thereafter, or later on. Much has been learned about these difficulties from clinical and autopsy observations and especially from careful arteriographic surveys. They seem to be generally well withstood following resectional and grafting procedures upon the affected segment of the thoracic aorta. Occasionally, additional operative manipulations may be necessary at the same time, for example, interpolation of grafts between the ascending aortic graft and a coronary when the origin of the latter is sheared off by the dissection, and distal arterial manipulations when the patient still has ischemic lower extremities immediately after the primary procedure. Later operations must sometimes be performed because of persistence of complaints such as intermittent claudication. It is extremely rare that immediate reoperation is advisable because of indications of intra-abdominal ischemia. Much more can be learned from careful pre- and postoperative arteriographic study.

Left carotid steal. A new observation.

A patient had an occlusion of the left subclavian artery just proximal to the takeoff of a previously placed subclavian-carotid graft. This caused reversal of flow in the graft and a symptomatic steal of blood via to the intracranial arteries. An axilloaxillary graft restored forward flow. In a second patient, a steal occurred from the right carotid and vertebral systems into the distal carotid system of the left side that has been isolated by a proximal carotide artery occlusion from arteriosclerosis. A saphenous vein, used as a bypass from the subclavian to the carotid artery, restored normal flow. Thus, the carotide system may be the low-pressure area responsible for the steal, although this is rarer than the subclavian.