Laparoscopic cholecystectomy in pregnancy.

Laparoscopic cholecystectomy has been performed in the United States since 1989 and currently is the procedure of choice for the management of symptomatic cholelithiasis. Its utility in the pregnant patient has been controversial. Concerns have been expressed for a number of potential problems, including trocar injury to uterus and fetus, effect of pneumoperitoneum on both mother and fetus, induction of preterm labor, teratogenic effects on the fetus, and long-term effects on fetal and neonatal development. We describe the Greenville Hospital System experience with laparoscopic cholecystectomy in pregnancy. From 1992 to 1996, eight laparoscopic cholecystectomies were performed in pregnant females, one during the first trimester and seven during the second trimester. Mean maternal age was 23.8 years (range, 18-31). All procedures were performed for recurrent and intractable symptoms with the average length of symptoms 3.5 weeks (range, 2-4 weeks). Two patients were diagnosed preoperatively with gallstone pancreatitis, two had acute cholecystitis, and four patients were felt to have hyperemesis gravidarum before their diagnosis of gallstones. All procedures were performed under general endotracheal anesthesia with CO2 insufflation pressures of 12 mm Hg. Postoperatively, all patients had uneventful recoveries with complete resolution of their symptoms and were discharged home in an average of 3 days (range, 1-7 days). No postoperative complications to mother or fetus were documented. Eight patients have delivered full-term healthy fetuses with no documented neonatal morbidity or mortality. Long-term follow-up of the infants at a mean of 23 months (range, 2.5-47 months) reveals that all eight infants have progressed to normal healthy children. Our experience and the current world literature demonstrate that laparoscopic cholecystectomy in pregnancy can be performed safely and effectively for symptomatic cholelithiasis, especially when symptoms are recurrent and persistent and may endanger fetal and maternal livelihood. The diagnosis of symptomatic cholelithiasis should be considered in the pregnant patient with recurrent episodes of nausea and vomiting.

Laparoscopic inguinal hernia repair: is the enthusiasm justified?

One surgeon repaired 72 inguinal hernias in 61 patients by a transabdominal preperitoneal laparoscopic placement of prosthetic mesh. There were 58 male and 3 female patients; the mean age was 47.9 years. Thirty-six unilateral inguinal hernias (either direct or indirect), 11 bilateral inguinal hernias, 12 recurrent inguinal hernias, and 2 unilateral pantaloon inguinal hernias were repaired. There were no operative mortalities. The mean follow-up was 21 months, with a range of 6 to 42 months. Ten hernia recurrences (13.8%) were documented 3 to 24 months postoperatively (mean, 12 months). There were six direct hernia recurrences, two indirect hernia recurrences, and two recurrences of recurrent hernia repairs. Thirteen patients (21.3%) experienced morbidity: seromas in eight, a hematoma in one, an ileus in one, hematuria in one, and neuropathy in two. In our opinion, the significant morbidity and early recurrence rate of a laparoscopic inguinal hernia repair are unacceptable. Enthusiasm for laparoscopic technique to repair inguinal hernias is not justified if similar morbidity and recurrence rates are documented within the surgical community.

Results and complications of arteriovenous access dialysis grafts in the lower extremity: a five year review.

Virtually no objective data exist regarding the natural history of arteriovenous (AV) dialysis access grafts placed in the lower extremity for routine hemodialysis. From March 1988 until October 1993, 45 consecutive lower extremity AV dialysis access grafts were placed in 39 patients (16 males; 23 females; mean age 58 years) at a large teaching community hospital. All 39 patients had long-standing end stage renal disease and had required chronic hemodialysis from 7 to 237 months mean, 72 months) prior to leg graft placement. Polytetrafluorethylene (n=39) or bovine (n=6) loop lower extremity dialysis grafts were placed after multiple upper extremity dialysis graft failures (mean, 2.7 previous grafts with 9.6 thrombectomies and/or access revisions per patient). There were no operative deaths; however, in follow-up (1-132 months; mean 20 months; median 18 months), 33 percent of the patients had died from systemic complications of their renal disease, and only 20 (44%) leg grafts are currently patent [correction of patient] . Graft complications, excluding graft thromboses, occurred in 20 grafts including graft infection (n=8; 18%), severe ipsilateral leg ischemia (n=7; 16%), graft aneurysmal degeneration requiring revision (n=3; 7%), fistula-induced congestive heart failure (n=2; 4%), and major lower extremity amputation (n=3; 7%). Primary patency by life-table analysis was 47 percent at 24 months. Fifteen (33%) grafts thrombosed at least once, and all but one were salvaged with thrombectomy. The need for lower extremity AV dialysis access appears to be a significant marker for late mortality in this group of chronically ill patients. They are associated with multiple complications and should probably be placed only if significant patient morbidity can be accepted and justified.

Carcinoma of the ampulla of Vater: a community hospital experience.

Carcinoma of the ampulla of Vater is an uncommon malignancy often treated at tertiary referral centers. Most published series are derived from these centers and show resectability rated of 80 to 90 percent, with overall 5 year survival rates of 25 to 60 per cent. Twenty cases of ampullary carcinoma treated in a community hospital setting were reviewed. The mean age at diagnosis was 69 years (range, 49-89), and 65 per cent of the patients were female. The most common presenting symptoms were jaundice (85%) and abdominal pain (50%). Stages at diagnosis included stage II, 12 patients; stage III, 5 patients; and stage IV, 3 patients. Nine patients underwent curative resections (resectability rate, 45%), of which five were pylorus-preserving pancreaticoduodenectomies and four were standard pancreaticoduodenectomies. There were no operative mortalities. Overall survival was 23 per cent, while survival in the resected patients was 60 per cent at 2 years. The majority of the patients not resected were felt to be poor candidates for major surgery either because of significant comorbid disease or advanced age. Three patients presented with advanced disease, and two patients died within 7 days of presentation. This review demonstrated a significantly lower resectability rate for carcinoma of the ampulla of Vater, with comparable survival rates. Differences from published studies at tertiary referral centers reflect a selection bias of patients referred to these centers.

Long-term follow-up of patients with Roux-en-Y gastrojejunostomy for gastric disease.

OBJECTIVE: A consecutive series of Roux-en-Y gastrojejunostomies with a mean follow-up of 11.9 years was reviewed to characterize the long-term results of patients having this operation to treat or prevent bile reflux gastritis. SUMMARY BACKGROUND: Development of postprandial abdominal discomfort, nausea, vomiting, or bezoar formation (Roux stasis syndrome) in the postoperative follow-up period has prompted questions about the role of Roux-en-Y gastrojejunostomy to treat or prevent bile reflux gastritis. METHODS: Long-term clinical follow-up (mean, 11.9 years) data for 24 patients was collected by reviewing medical records, interviewing patients directly through telephone contact, or both. All patients who had symptoms in the follow-up period were evaluated by upper gastrointestinal series, endoscopy, or both. A modified Visick scale was used for clinical ratings. RESULTS: Of the 22 evaluable patients, follow-up was complete in 20; the clinical condition that prompted surgery was corrected in 21 (95%). Roux-en-Y gastrojejunostomy was successful for treating or preventing bile reflux gastritis in all 22 patients. Despite this success, clinical failure (Visick scale III or IV) was documented in 8 patients (36%). Seven of the 8 patients had clinical failure within 6 months of operation, with the Roux stasis syndrome developing in 6 of them (27%). CONCLUSION: This consecutive series of Roux-en-Y gastrojejunostomies performed by one surgeon has the longest follow-up to date. Although the Roux-en-Y gastrojejunostomy is safe and often successful, the procedure appears to be limited by a substantial rate of clinical dissatisfaction. Surgeons should be cautious in using it to treat primary or remedial gastrointestinal disease.

Does arterial inflow failure cause distal vein graft thrombosis? A prospective analysis of 450 infrainguinal vascular reconstructions.

Classically, inadequate arterial inflow, diseased runoff, and poor bypass conduit quality have all been cited as causes of infrainguinal vein graft failure. To examine the role of arterial inflow failure as a specific cause of vein graft thrombosis, we prospectively analyzed 450 consecutive infrainguinal vascular reconstructions by means of a strict duplex scan surveillance protocol at three teaching institutions from 1986 to 1993. Sixteen incidences of arterial inflow failure (11 occlusions and five high-grade stenoses) above previously placed infrainguinal vein grafts were identified in 14 patients and confirmed by arteriography. Despite these inflow failures, all 14 autogenous vein infrainguinal reconstructions remained patent on arteriography. These inflow failures were observed from 2 to 72 months (mean 16 months) after infrainguinal reconstruction. Immediate successful inflow repair was performed in 13 of the 16 failures. Conversely, among 450 grafts followed, 37 acute graft occlusions occurred-all with arteriographically or noninvasively documented normal inflow. Thus no graft in the series has yet failed as a result of inflow occlusion (mean follow-up 22 months; range 1 to 78 months). We thus conclude that properly constructed infrainguinal saphenous vein bypass grafts with an intact endothelium often remain patent through low-flow collateral vessels despite total arterial inflow occlusion. These data thus challenge the premise that arterial inflow disease is a major cause of infrainguinal vein bypass occlusion.

Laparoscopic cholecystectomy in a community hospital setting.

Recently, laparoscopic cholecystectomy has become the preferred surgical procedure for removal of the gallbladder. However, many surgeons believe that the safety and efficacy have yet to be proved in the community hospital setting. To address this concern, a retrospective chart review of the initial 271 instances of inpatient laparoscopic cholecystectomy within a community hospital was undertaken. All procedures were performed by 15 general surgeons in private practice and residents in general surgery. Of the 271 patients, 11 were converted to open cholecystectomy. Surgical complications occurred in six of the 260 instances of laparoscopic cholecystectomy (2.3 percent), with only one injury to the common bile duct. Major postoperative complications occurred in 23 patients, including severe postoperative pain (nine patients), prolonged ileus (seven patients), bile leakage (three patients), retained common duct stones (two patients), respiratory failure (one patient) and postoperative myocardial infarction (one patient). The period of hospitalization ranged from one to 64 nights with a median of one night. The operative mortality rate was zero percent. Multivariate analysis identified two factors associated with an increased risk of postoperative complications. Patients 70 years of age or older and patients whose operating times were greater than one hour and 45 minutes were at increased risk for postoperative complications. We believe that these data represent the general outcomes of the laparoscopic procedure in a community hospital setting and lend support to the argument that the procedure can be performed safely and effectively in this setting.

Antacid control of complications from acute gastroduodenal disease after burns.

To determine the effectiveness of hydrogen ion neutralization in preventing the clinical complications (hemmorrhage and perforation) of acute gastroduodenal disease after thermal injury, 48 patients with burns of greater than 35% total body surface were evaluated within 72 hours after injury. In a prospective, randomized fashion, patients were chosen to receive antacid or no-antacid therapy. An established lithiumflux technique was utilized to determine the integrity of the gastric mucosal barrier (GMB) before group selection. Only one of the 24 patients receiving antacid developed significant upper gastrointestinal bleeding; however, seven of 24 patients receiving no antacid experienced hemorrhage and gastric ulcer perforation (p less than 0.02). None of seven patients with GMB disruption who received antacid developed a clinical complication; however, six of 15 patients with GMB disruption receiving no antacid experienced clinical complications (p less than 0.05). Neutralization of gastric acid offers protection against the development of clinically significant ulcer complications in the burn patient.

Gastric acid secretion and acute gastroduodenal disease after burns.

Total titratable acidity of fasting gastric secretion was determined in 34 hemodynamically stable patients within five days after burn. Acid output was not predictive of disease; acute duodenal ulcers, however, were not discovered in patients with acid secretion of less than 3.11 mEq/hr. Patients with both gastric and duodenal disease secreted significantly (P less than .05) more acid than patients without duodenal involvement and complications were more likely to develop, especially from acute ulcerations. Hemorrhage or perforation occurred in nine patients whose acid output was significantly (P less than .05) greater than that of asymptomatic patients. Duodenal regulation and neutralization of acid secretion may be impaired in patients with early duodenal injury, resulting in a relative increase in acid output and enhanced potential for complications. A controlled evaluation of antacid therapy in the prevention of disease complications seems justified in these patients.

Histochemical study of gastric mucosubstances after thermal injury: correlation with endoscopic evidence of acute gastroduodenal disease.

Gastroduodenoscopy with biopsy was performed in nine patients within 5 days after major thermal injury. Biopsies were evaluated by special histochemical techniques to visualize and differentiate cellular mucosubstances. Acute gastroduodenal lesions were encountered early and frequently in 78% of adult burn patients. The early occurrence, morphology, and histology of these lesions suggest that alterations in gastric mucosal blood flow may play an important etiologic role. A decreased production of gastric mucus does not appear to be an etiologic factor since acute gastric mucosal disease was encountered in most patients despite normal quantities of cellular mucosubstances.

Acute duodenitis and duodenal ulceration after burns. Clinical and pathological characteristics.

The clinical and pathological characteristics of Curling ulcer were defined by early and serial endoscopic examination of the duodenum in 37 burned patients. Duodenal disease was present in 27 patients and occurred only in patients with burns involving more than 38 percent of the total body surface. Erosive "duodenitis" could occur within 12 hours after injury and was usually associated with acute gastric disease. Isolated duodenitis occurred only in patients with pancreatitis. Contrast roentgenograms did not reliably show the superficial mucosal disease. Duodenal ulcerations were present in 12 patients and developed on a background of diffuse superficial mucosal injury. Other complications in the patient's postburn course influenced disease progression. Hemorrhage occurred in six patients with duodenal disease, usually originating from a posterior duodenal ulcer. Uncomplicated ulcers invariably healed within five weeks after diagnosis.

Acute gastric disease after cutaneous thermal injury.

Diffuse erosive "gastritis" was discovered as early as five hours postinjury in 45 of 54 burn patients (83.5%) evaluated by gastroduodenoscopy. Acute ulcers were identified in 14 patients (26%); concomitant duodenal disease was present in 34 patients (76%). Microvascular fibrin thrombi were not demonstrated even though five patients had disseminated intravascular coagulation. Seven patients were examined before nasogastric intubation; four, with a mean burn size of 59.6% total body surface, had diffuse "gastritis." Low total serum protein levels were measured in 81% of tested patients, but were not predictive of mucosal disease. Hemorrhage followed the clinical deterioration of six patients (11.1%); one ulcer perforated. Whereas coagulation abnormalities, nasogastric intubation, and hypoproteinemia may augment mucosal injury, the morphologic and histologic examinations of the lesions suggested a primary ischemic cause resulting from the opening of submucosal shunts or local vasoconstriction.

Histochemical changes in gastric mucosubstances in patients with acute and chronic ulcer disease.

The several types of epithelial cells in human gastric mucosa produce different mucosubstances. The surface epithelium largely forms a neutral mucosubstance except that in about two-thirds of the specimens the deep foveolar cells produce a slight to moderate amount of a mucosubstance apparently containing sulfate esters and carboxyl groups. Mucous neck cells often exhibit a neutral mucosubstance but in about onehalf of the stomachs reveal a slight to moderate reactivity indicative of sulfated mucosubstance. Chief cells contain a sulfated mucosubstance with unique histochemical properties. Mast cells vary widely in prevalence but those in the gastric mucosa appear depleted of stored mucosubstances when compared with those in the gastric submucosa or the esophagus. The sulfated mucosubstance normally abundant in human as in canine chief cells appears consistently depleted in patients with stress ulcer or hemorrhagic gastritis. In addition, mucus often appears depleted in the surface epithelium and interstitial edema is present in the superficial mucosa of these patients. These findings appear consistent with the view that biosynthetic activity in chief cells and surface epithelial cells is impaired perhaps secondary to shock-induced circulatory changes in gastric mucosa of patients with stress ulcer or hemorrhagic gastritis.