Comparison of desflurane with propofol in outpatients undergoing peripheral orthopedic surgery.

This study was undertaken to compare desflurane with propofol anesthesia in outpatients undergoing peripheral orthopedic surgery. Data were combined from two institutions participating in a multicenter study. Ninety-one patients, ASA physical status I or II, were each randomly assigned to one of four groups. After administration of fentanyl (2 micrograms/kg) and d-tubocurarine (3 mg), intravenous propofol was administered to induce anesthesia in groups I and II and desflurane in groups III and IV. Maintenance was provided by desflurane/N2O in groups I and III, propofol/N2O in group II, and desflurane/O2 in group IV. Emergence and recovery variables, psychometric test results, and side effects were recorded by observers unaware of the experimental treatment. Patients in group II experienced less nausea than other groups (P = 0.002) despite this group having required more intraoperative fentanyl supplementation than groups III and IV (P = 0.01). Time to emergence, discharge, and psychometric test results were similar in all groups. Desflurane appears to be comparable with propofol as an outpatient anesthetic, facilitating rapid recovery and discharge home.

Changes in extrahepatic bile duct caliber in liver transplant recipients without evidence of biliary obstruction.

To better understand changes in the size of the extrahepatic bile duct after liver transplantation, we retrospectively studied the luminal diameter of the extrahepatic bile duct on serial cholangiograms in 40 liver transplant recipients with choledochocholedochostomy biliary anastomoses and without biliary complications. Forty operative and 105 postoperative cholangiograms were reviewed. The average interval between operative and last postoperative cholangiogram was 5 weeks (range, 1-17 weeks). The mean diameter of the donor common hepatic duct increased from 5.5 +/- 2.1 mm to 6.3 +/- 2.4 mm (p = .015). The mean diameter of the native common bile duct increased from 5.1 +/- 1.4 mm to 6.8 +/- 2.4 mm (p less than .001). The diameter of the donor common hepatic duct increased by 3 mm or more in six patients (15%); the diameter of the native common bile duct increased by 3 mm or more in nine (23%). Increased diameter of the native common bile duct was associated with T-tube migration into the duct in four cases. The size of the extrahepatic bile duct on cholangiograms is stable or increases slightly in most liver transplant recipients. Mild increases unassociated with a specific cause of obstruction or hepatic dysfunction do not portend biliary obstruction and are clinically benign.

Obstructive dilatation of extrahepatic recipient and donor bile ducts complicating orthotopic liver transplantation: imaging and laboratory findings.

Biliary obstruction in liver transplants is most commonly due to stricture at the biliary anastomosis. The native common bile duct typically is normal. We retrospectively studied 28 patients with choledochocholedochostomy anastomoses who had marked native and donor extrahepatic bile duct dilatation associated with clinical evidence of biliary obstruction. Operative cholangiograms were compared with postoperative cholangiograms obtained a mean of 50 weeks (range, 2-246 weeks) later. Mean caliber of the native common bile duct increased from 7.5 +/- 2.0 mm on operative cholangiograms to 14.8 +/- 3.9 mm on postoperative cholangiograms (p less than .001). Mean caliber of the donor common hepatic duct increased from 5.9 +/- 1.3 mm on operative cholangiograms to 12.8 +/- 3.8 mm on postoperative cholangiograms (p less than .001). Dilatation of the cystic duct remnant was seen in 15 patients. All patients had surgical revision to choledochojejunostomy with improved results of liver function studies in most cases. Diffuse dilatation of native and donor extrahepatic bile ducts may develop in liver transplant recipients. Typical features include native and donor extrahepatic ducts greater than 12 mm in diameter and a dilated cystic duct remnant on postoperative cholangiography in a patient with otherwise unexplained hepatic dysfunction.

Unanticipated admission to the hospital following ambulatory surgery.

We conducted a case-control study to identify clinical and demographic risk factors for admission to the hospital following ambulatory surgery. Of 9616 adult patients who underwent ambulatory surgery at a university-affiliated hospital between 1984 and 1986, one hundred were admitted. The most common reasons for admission were pain (18), excessive bleeding (18), and intractable vomiting (17). The mean age (+/- SD) of patients who were admitted was 37 +/- 13 years, and 96% had American Society of Anesthesiologists' physical status scores of 1 or 2. Factors that were independently associated with an increased likelihood of admission were general anesthesia (odds ratio, 5.2), postoperative emesis (odds ratio, 3.0), lower abdominal and urologic surgery (odds ratio, 2.9), time in the operating room greater than 1 hour (odds ratio, 2.7), and age (odds ratio, 2.6). Our results indicate that the likelihood of unanticipated admission is related more to the type of anesthesia and surgical procedure rather than to the patient's clinical characteristics.

The intravenous pyelogram in acute pyelonephritis.

In a cohort of 67 otherwise healthy patients with acute pyelonephritis that was severe enough to warrant hospitalization and uroradiography, 8% had a genitourinary abnormality that influenced management. Consequently, over 90% of patients had studies that did not alter their care. In an attempt to identify clinical clues that might increase specificity without compromising sensitivity of the intravenous pyelogram in acute pyelonephritis, only the fever curve was statistically useful. Confined to patients who were febrile through 72 hours of appropriate antibiotic treatment, the yield of urography in demonstrating anomalies of immediate clinical significance rose from 8% to 36%. The likelihood of an acutely important abnormality was also increased fivefold in both diabetic patients and patients with a urinary pathogen other than ampicillin-sensitive Escherichia coli, but small numbers precluded statistical significance. Bacteremia was common (27%), but not helpful other than in confirming the microbiological diagnosis. Nonacute structural abnormalities were present in 43% of the patients, three to nine times more frequently than in reported cases without upper tract infection.

Hospital resources used for inpatient and ambulatory surgery.

New hospital and physician payment schemes encourage physicians to participate actively in efforts to minimize hospital resource use. As an example of the type of evaluations anesthesiologists may conduct, we examined hospital resources used for comparable groups of inpatients (INPTs) and day surgery unit (DSU) patients. Although INPTs and DSU patients undergoing surgical arthroscopy of the knee or diagnostic laparoscopy were similar with regard to age, physical status, and staff surgeon, more preoperative tests were performed for INPTs than for DSU patients (P less than .05). Hospital costs for these tests were four times greater for INPTs than for DSU patients. Operating room time was from 20 to 45 min longer for INPTs than for DSU patients (P less than .05). Recovery room time was from 25 to 52 min longer for DSU patients (P less than .05). Per patient nursing labor costs paralleled operating and recovery room times. These kinds of analyses are important in identifying opportunities to improve resource use, in assessing institutional costs for surgical care, and in designing strategies that allow institutions and physicians to respond to cost containment pressures.

Cerebral CT scan abnormalities in cholestatic and hepatocellular disease and their relationship to neuropsychologic test performance.

Forty-nine nonalcoholic cirrhotic patients, on whom cranial CT scans were available, were administered a battery of neuropsychological tests. Although none of the subjects exhibited clinical signs or symptoms of hepatic encephalopathy, quantification of the CT scan image implicated cerebral edema and cortical atrophy. In addition numerous significant correlations were observed between the CT variables and neuropsychological test performance. The findings are conjectured to reflect previously unrecognized cerebral morphologic changes associated with chronic subclinical portal-systemic encephalopathy.

Takayasu arteritis: radiographic and angiographic findings in 59 patients.

Fifty-nine patients (57 females, two males) with Takayasu arteritis were retrospectively evaluated. Chest radiographs were abnormal in 68% of patients in whom they were obtained (n = 49). Aortic contour changes and calcification were frequent findings. Sixty-eight percent of patients who underwent total aortography (n = 50) had panaortitis, and 28% had involvement confined to the thoracic aorta and/or its branches. Stenosis was the most common angiographic finding in the aorta and its branches, but occlusion (n = 4), aneurysm (n = 3), and dilatation (n = 15) were not infrequent. Adventitial vascular structures (the vasa vasorum) were seen in three cases. Eighty-six percent (n = 21) of pulmonary arteriograms showed abnormalities. Occlusion was by far the most common finding. There was no predilection for any lobe nor correlation with systemic arteritis. It was concluded that Takayasu arteritis characteristically involves the systemic and the pulmonary arteries independently. Total aortography and pulmonary arteriography are necessary to diagnose and evaluate the extent of the disease.

A departmental policy addressing chemical substance abuse.

Substance abuse is a major socioeconomic problem. However, the ready availability of potent narcotic and sedative drugs probably constitutes a unique risk for anesthesiologists. Until recently, few anesthesia departments were prepared to recognize or safely manage afflicted colleagues. Because we felt it important to educate our staff and residents and to have a response mechanism established prior to the advent of a substance abuse problem, a departmental committee was formed to develop a Substance Abuse Policy. The policy has served to increase our general awareness and to direct our actions effectively when dealing with physician impairment. It is presented here in the belief that other departments might find it useful in tailoring their approach to this problem.

Radiographic features of liver allograft rejection.

The radiographic features of 19 transplanted patients with failure of the liver allograft were evaluated. These features were: poor filling, stretching, attenuation of intrahepatic biliary ducts documented by T-tube cholangiogram, attenuation of branches of the hepatic artery seen on angiogram as well as a decrease of blood flow through the liver seen on angiogram and nuclear medicine dynamic scintigram. These findings were secondary to swelling of the transplanted liver and were not specific for rejection; they may also be present in hepatic infarction or infection.

Cholangiography and interventional biliary radiology in adult liver transplantation.

Radiographic assessment of the biliary tract is often essential in patients who have undergone liver transplantation. T- or straight-tube cholangiography, percutaneous transhepatic cholangiography, and endoscopic retrograde cholangiography all may be used. A total of 264 cholangiograms in 79 adult liver transplant patients (96 transplants) was reviewed. Normal radiographic features of biliary reconstructive procedures, including choledochocholedochostomy and choledochojejunostomy, are demonstrated. Complications diagnosed by cholangiography included obstruction, bile leaks, and tube problems, seen in eight, 24, and 12 transplants respectively. Stretching and incomplete filling of intrahepatic biliary ducts were frequently noted and may be associated with rejection and other conditions. Transhepatic biliary drainage, balloon catheter dilatation of strictures, replacement of dislodged T-tubes, and restoring patency of obstructed T-tubes using interventional radiologic techniques were important in avoiding complications and additional surgery in selected patients.

Diabetes mellitus: the predominant cause of bilateral renal enlargement.

The authors reviewed 102 cases of bilateral renal enlargement seen on excretory urography (excluding hydronephrosis and duplex kidneys) to determine the clinical significance of this finding. Associated abnormalities were found in 48 patients, including diabetes mellitus in 29; nondiabetic obesity, large body structures, or chronic steroid use in 16; acromegaly in 1; and unknown etiology in 37, 2 of whom were found to have diabetes five years later. Because of the striking preponderance of diabetes in this study, a fasting blood glucose analysis is recommended for patients with unexplained bilateral renal enlargement on excretory urography.

Postmenopausal ureteral endometriosis with atypical adenomatous hyperplasia following hysterectomy, bilateral oophorectomy, and long-term estrogen therapy.

Endometriosis of the ureter is rare. The authors describe a case of ureteral endometriosis presumed on clinical and radiologic grounds to be a primary ureteral malignancy. The unique feature of the present case is the development, after long-term estrogen therapy, of postmenopausal ureteral endometriosis with extensive atypical adenomatous hyperplasia. The present case demonstrates that reactivation of endometriosis and the development of atypical hyperplasia may occur after menopause with prolonged estrogen therapy.

Catamenial pneumothorax: the roles of diaphragmatic defects and endometriosis.

The diagnosis of catamenial pneumothorax should be suspected whenever a women in the third or fourth decade of life has recurrent right-sided chest pain temporally associated with menstruation. This entity was first described in 1958 and since then, 59 cases have been reported in the English literature. There is no universally accepted explanation for the pathogenesis of the pneumothorax. Four additional cases are presented which support the significant role that diaphragmatic defects and endometriosis play in the pathogenesis of catamenial pneumothorax. At thoracotomy, numerous small perforations of the right diaphragm were found in three patients, two of whom had associated endometriosis of that diaphragm. The fourth patient had indirect evidence of diaphragmatic defects proven by a diagnostic pneumoperitoneum. On the basis of the hypothesis of transfallopian passage of air, this patient was treated by tubal ligation only and has not had a recurrence of pneumothorax since. This form of therapy has not been reported previously for this disorder.

The mechanical aspects of anesthetic pollution control.

Reduction of anesthetic contamination in the operating room requires removal of excess circuit gases (scavenging), elimination of anesthetic equipment leakage, and avoidance of anesthetic technics which allow unopposed spill of gas into the operating room. Scavenging and disposal of excess anesthetic gases can present hazards to the patient; means to protect the breathing circuit from elevated positive and negative pressures should be of prime consideration in selecting a scavenging system. Leakage from anesthic equipment occurs in the high-pressure (central and tank N2O sources to the machine flowmeters) and the low-pressure portions (from the machine flow-meters to the patient) of the system and can be of sufficient magnitude to virtually negate effective scavenging. These leakage points can be readily detected and corrected using periodic simple test procedures.