Bioavailability of medication after laparoscopic cholecystectomy.

Bioavailability of medication after laparoscopic cholecystectomy has not been studied previously. There is concern about the ability of patients to tolerate oral medication postoperatively and the optimal timing of hospital discharge. In this study, each subject received 20 mg/kg acetaminophen (po) preoperatively, with a repeat dose at 6 (group 1), 12 (group 2), or 24 h (group 3) postoperatively. Serum levels were obtained 40 and 90 min after each ingestion. Bioavailability of medication was significantly decreased (p < 0.01) 6 h (group 1) and 12 h (group 2) postoperatively. Bioavailability returned to baseline by 24 h after laparoscopic cholecystectomy (group 3). This study indicates that oral medication should be used judiciously during the first 12 h after laparoscopic surgery.

Trocar site tumor recurrence after laparoscopic-assisted colectomy.

As a variety of procedures become technically feasible with laparoscopic techniques, it becomes increasingly important to appropriately select the patients who will benefit from the laparoscopic approach. We report the case of a patient with Dukes C2 colon cancer treated by laparoscopic-assisted sigmoid colectomy who subsequently developed an abdominal wall recurrence at a trocar site scar. The case raises some concerns about the use of the laparoscopic technique in the surgical management of colon cancer.

Bioavailability of medication delivered via nasogastric tube is decreased in the immediate postoperative period.

BACKGROUND: A study was performed to determine bioavailability of medication delivered via nasogastric tube in patients after abdominal surgery. METHODS: Acetaminophen (20 mg/kg) was administered to each patient per os at least 48 hours prior to abdominal surgery and via nasogastric tube 3 hours postoperatively. The nasogastric tube was clamped for 30 minutes after drug administration, prior to resuming suction. Serum levels of acetaminophen were measured 0, 40, and 90 minutes after each dose. RESULTS: Acetaminophen levels were significantly lower (P < 0.001) when the drug was administered via nasogastric tube postoperatively. CONCLUSIONS: Decreased bioavailability of medications delivered via nasogastric tube may have important clinical implications and should be taken into consideration during the postoperative period.

Recall of informed consent after endoscopic procedures.

PURPOSE: The aim of this study was to determine if recall of informed consent is affected by the timing of obtaining informed consent before endoscopic procedures. METHODS: Sixty patients scheduled for colonoscopy or esophagogastroduodenoscopy were enrolled in this prospective, randomized study. Each patient received informed consent 24 to 72 hours or immediately before the procedure, and follow-up occurred one to three days postprocedure. RESULTS: There was no statistically significant difference in recall of informed consent or the individual elements of informed consent (indication, risks, benefits, alternatives) between the two groups. CONCLUSION: Recall of informed consent is similar whether consent is obtained immediately or several days before endoscopic procedures.

Erythropoetin accelerates hematocrit recovery in post-surgical anemia.

UNLABELLED: We evaluated the role of recombinant human erythropoietin (RHE) for treatment of severe postsurgical anemia (Hct < 25%) in 40 Jehovah's Witness (JW) patients refusing transfusion. Twenty patients (group E) received RHE either at a loading dose of 300 U/kg iv 3 times/week for 1 week followed by 150 U/kg 3 times/week in accordance with an IRB approved protocol (N = 13), or at a dose of 100 U/kg 3 times/week for humanitarian reasons (N = 7). This group was compared to 20 similar JW patients who did not receive RHE (group C). All patients received iron restoration and nutritional support. Non-parametric analysis (Mann-Whitney) was used because of sample size. Entry hematocrit was similar for both groups: H(E)(0) = 15.8% +/- 1.1 SEM (8.5-23.4) vs HC (0) = 12.8% +/- 0.9 SEM (7.3-20.6), P = 0.09. After one week, hematocrit was significantly higher in group E (H(E)(1)) = 19.3 +/- 1.1 vs HC(1) = 12.5% +/- 0.9, P < 0.0005) as was the increase in hematocrit for group E (3.6% +/- 0.9 for E vs -0.4% +/- 0.8 for C, P < 0.005). Hematocrit change in Week 2 showed an increase for both groups (2.9 +/- 0.6 for E vs 4.9% +/- 1.2 for C, P = 0.12). CONCLUSIONS: Hct recovery shows a 1-week lag in severely anemic postsurgical patients treated without RHE. Exogenous RHE appears to accelerate hematocrit recovery in the first week. Use of RHE in the immediate postoperative period may help avoid or reduce homologous blood transfusion.

Preoperatively assessing and planning blood use for elective vascular surgery.

Few guidelines exist for determining transfusion needs and strategies, namely, the appropriate use of autologous versus homologous blood for elective vascular surgery. To address this deficiency, we have developed and used an algorithm based on an analysis of the procedure, maximum surgical blood ordering schedule, patient status, and patient suitability for autologous alternatives. Data were derived from consecutive major vascular procedures done at our hospital from 1991 to 1992. The algorithm helps the surgeon assess transfusion need and patient suitability for autologous predonation and aids in selecting appropriate transfusion alternatives. Using this algorithm during the past year with 120 patients, we simplified transfusion decisions, reduced homologous blood use (to only 4.2%), and reduced wasting of autologous blood to less than 5% of the units predonated. We believe that the use of this algorithm will aid the vascular surgeon in choosing appropriate alternatives to allogeneic blood transfusion, thereby reducing the patient's exposure to risk. The algorithm should also reduce wasting of autologous blood.

Perfluorocarbons as blood substitutes: the early years. Experience with Fluosol DA-20% in the 1980s.

Clinical testing of perfluorocarbons (PFC) as blood substitutes began in the early 1980's in the form of Fluosol DA-20% (FDA), a mixture of perfluorodecalin and perfluorotripropylamine emulsified with Pluronic F68. We have treated 55 patients (Treatment (T) = 40; Control (C) = 15) with intravenous infusions of 30 cc/kg of FDA as part of either a randomized, clinical trial or a humanitarian protocol. All patients were Jehovah's Witnesses who refused blood transfusion and were severely anemic (mean hemoglobin = 4.6 g/d). FDA successfully increased dissolved or plasma oxygen content (P1O2 in ml/dl), but not overall oxygen content (T group: P1O2 baseline = 1.01 +/- .27, P1O2 12hrs = 1.58 +/- .47 [p = < .0001, t-test]; P1O2 12 hrs: T = 1.58 +/- .47, C = 1.00 +/- .31, p = < .0002, t-test). This effect persisted for only 12 hours post infusion, and had no apparent effect on survival. FDA is an ineffective blood substitute because of low concentration and short half-life. Improved emulsion design may resolve these problems, thereby producing a more effective agent. Our discussion will include a review of our data plus a summary of other reports of FDA efficacy as a blood substitute.

Safety of teaching laparoscopic cholecystectomy to surgical residents.

As laparoscopic cholecystectomy evolves into the "standard" method for gallbladder removal, it has become necessary for surgical residents to safely acquired the necessary skills to perform the procedure. To determine the safety of this procedure in the hands of residents, the authors evaluated the first 100 attempted laparoscopic cholecystectomies performed by a resident in the role of "surgeon." Ninety-one of the 100 procedures were successfully completed laparoscopically and 9 required conversion to laparotomy: 5 technically difficult cases, 2 common duct explorations, and 2 for intraoperative complications. At Cooper Hospital in New Jersey, essentially all patients requiring cholecystectomy are first attempted laparoscopically. Seventy-seven patients had chronic cholecystitis and 23 had acute disease. Twenty-two patients had intraoperative cholangiograms and two had laparoscopic common bile duct exploration. For the laparoscopically-completed procedures, average operative time was 91 min and showed a downward trend as each resident gained experience. Three (3%) major complications occurred: one colon laceration, one common bile duct injury, and one postoperative bile collection. For the 91 laparoscopically-completed procedures, 53 patients were discharged on postoperative day 1 and 20 on postoperative day 2. Average postoperative hospitalization was 1.7 days. Overall, these results were comparable to those reported in the literature by attending and private surgeons. The authors conclude that laparoscopic cholecystectomy can be performed safely by supervised residents acting as primary surgeon with outcomes similar to those obtained by trained attending surgeons.

Arterial vasopressin for control of bleeding from a stapled intestinal anastomosis. Report of two cases.

Postoperative bleeding from a stapled intestinal anastomosis is a rare complication. In previously reported cases, the bleeding either ceased spontaneously or required reoperation for direct control. We report two cases in which the bleeding was controlled using an intra-arterial vasopressin infusion. To our knowledge, this technique has not been previously reported for management of this problem. We had initial concerns about creating ischemia at the anastomosis, which could lead to disruption. Neither patient demonstrated subsequent problems with the anastomosis. Intra-arterial vasopressin infusion appears to be an effective method for controlling bleeding from a stapled intestinal anastomosis and can avert the need for reoperation.

Transfusion guidelines for cardiovascular surgery: lessons learned from operations in Jehovah's Witnesses.

Patients undergoing cardiovascular surgery are among the top users of homologous blood transfusion (HBT). Awareness of the risks of disease transmission and immune system modulation from HBT has prompted us to find alternatives such as autologous predonation (APD) and intraoperative autotransfusion (IAT). However, these latter options are not appropriate for all patients. We reviewed our experience with 59 Jehovah's Witness patients who underwent 63 elective cardiovascular procedures without either HBT or APD to determine the safety of operation without these modalities and to develop revised maximum surgical blood-ordering schedule guidelines for cardiovascular surgery. Estimated blood loss averaged 870 ml, but one third to one half of losses were replaced by IAT. IAT was not needed in lower extremity bypass operations in which the estimated blood loss was less than 150 ml. Three of 59 patients died (5.1%), but only one died of operative bleeding complications. We conclude that (1) elective cardiovascular operations can be done safely without the use of either HBT or APD, (2) HBT is not necessary in leg bypass procedures, and (3) maximum surgical blood-ordering schedule guidelines for HBT in major cardiovascular operations can be reduced to near zero by the use of intraoperative autotransfusion and acceptance of a postoperative hemoglobin nadir of 7.0 gm/dl.

Upper extremity occlusive arterial disease after radiotherapy for breast cancer.

Upper extremity arterial occlusive disease is a rare complication of radiation therapy for breast cancer. We present the case of a 74 year old woman who developed upper extremity ischemia 32 years after mastectomy and radiation therapy. Arteriography identified a stenotic proximal brachial artery lesion within the previous radiation field. Balloon angioplasty was unsuccessful. An axillo-brachial bypass relieved the ischemia and is still patent after 24 months. The previous literature shows that arterial bypass procedures have been uniformly successful in this circumstance. Little experience has been reported with balloon angioplasty for these lesions.

Is hemoglobin level alone a reliable predictor of outcome in the severely anemic surgical patient?

The relationship between outcome and hemoglobin (Hgb), oxygen extraction ratio (ER), history of cardiac, renal, pulmonary, and/or hepatic disease, diabetes, malignancy, sepsis, hypertension, and active bleeding was analyzed in 47 patients with severe anemia (Hgb less than 7.0 gm/dl, mean = 4.6 +/- .2 gm/dl) to evaluate the effect of Hgb on survival and to look for other predictors of outcome. All patients had refused blood transfusion on religious grounds and were participants in a randomized, controlled study of the blood substitute Fluosol DA-20 per cent. Patients were analyzed as a group and after stratifying by Hgb into four levels: (Hgb less than 3.0 gm/dl, N = 7; Hgb less than 3.5 gm/dl, N = 12; Hgb less than 4.0 gm/dl, N = 17; Hgb less than 4.5 gm/dl, N = 23) and by ER into two levels of less than 50 per cent and greater than 50 per cent. Only Hgb, ER, sepsis and active bleeding were predictors of outcome, with sepsis being the only significant, independent predictor of outcome at all levels (P less than .01). Active bleeding was a predictor for levels of Hgb below 4.0 gm/dl. Hgb level alone was a significant predictor only at levels below 3 gm/dl (P less than .05). Extraction ratio interacted with Hgb only below 3 gm/dl (P less than .05). Multiple independent factors influence outcome in the severely anemic patient, the strongest being sepsis and active bleeding. Prevention of sepsis and early intervention to stop bleeding should improve survival in the patient who refuses transfusion.

Hemoductal pancreatitis.

Gastrointestinal tract hemorrhage from rupture of the splenic artery into the pancreatic duct is unusual. This obscure cause of intermittent gastrointestinal tract bleeding should be suspected when the more common causes of bleeding have been ruled out. Duodenoscopy carried out during active hemorrhage may reveal blood coming from the papilla of Vater. Coeliac arteriography will show the pathognomonic findings and confirm the diagnosis. We have treated three patients who had chronic pancreatitis and who developed pseudocyst formation and pseudoaneurysms of the splenic artery. The pseudoaneurysm ruptured into the duct of Wirsung, causing obscure upper-gastrointestinal bleeding. Treatment was distal pancreatectomy and splenectomy, including the pseudoaneurysm and pseudocyst. A review of the literature suggests that three different types of bleeding into the pancreatic duct can occur. The cause of each is described.

Fluosol DA-20 in the treatment of severe anemia: randomized, controlled study of 46 patients.

We evaluated the safety and efficacy of Fluosol DA-20% (FDA) as a blood substitute in the treatment of severe anemia. Thirty-six patients received either FDA (n = 21) or crystalloid/hydroxyethyl starch (CHS) (n = 15) as part of a randomized, controlled trial. Ten patients received FDA as part of a humanitarian protocol. All were Jehovah's Witnesses who refused transfusion, had bled recently, and had average Hgb levels of 4.3 g/dl. After pulmonary artery catheter insertion, each patient was infused with CHS to attain a pulmonary artery wedge pressure (WP) of 10 to 18 mm Hg. FDA was given as a one-time dose of 30 ml/kg. Data were collected at baseline, 12, 24, and 48 h. None of the patients with negative reactions to a 0.5-ml test dose of FDA had adverse reactions to the subsequent infusion. The plasma or dissolved component of oxygen content was significantly higher in the FDA group at 12 h (FDA group 1.58 +/- 0.47 ml/dl, control group 1.01 +/- 0.31 ml/dl, p less than .02, t-test). Nineteen patients died: 12 (37.5%) FDA, seven (46.6%) control. The difference was not significant. We conclude the following: a) FDA can be given safely to severely anemic patients in doses of 30 ml/kg; b) FDA significantly increased the dissolved component of oxygen content after 12 h but the effect did not persist; c) severely anemic patients can survive without transfusion although mortality is high. In this study, inability of FDA to sustain increased oxygen content was due in part to the rapid elimination of FDA and also to the limited amount given.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative transcutaneous oxygen tension criteria for completion arteriography.

During the past three years, we studied the value of transcutaneous oxygen monitoring in 28 lower extremity vascular bypass procedures. In 21 reconstructions, a rapid rise in the transcutaneous oxygen tension following reperfusion was indicative of a patent graft and patent runoff vessels. Inadequate revascularization was identified in three of four patients in whom transcutaneous oxygen tension failed to rise following femorodistal arterial bypass (positive predictive value 75%). A normal intraoperative transcutaneous oxygen tension study following femorodistal bypass had a negative predictive value of 95%. The overall accuracy was 91%. Transcutaneous oxygen tension monitoring during lower extremity vascular bypass procedures is useful in assessing the success of revascularization and may be used to select which patients should undergo completion arteriography as opposed to those in whom an arteriogram is not essential.

Exsanguinating upper extremity vascular injury: is an initial approach by clavicular resection adequate?

Clavicular resection has been recommended by some as an acceptable approach to the repair of subclavian and axillary vascular injuries. We believe this may not be the best approach in patients with severe trauma and exsanguinating injuries. During the last 5 years, we have treated 11 patients with trauma to the subclavian or axillary vessels, four of whom presented in shock from exsanguinating injuries. After initial fluid resuscitation, we operated on each patient by resecting the medial portion of the clavicle. Three of the four patients required further surgery or extension of the incision to control bleeding. In our experience, clavicular resection as a primary approach to exsanguinating injuries did not provide either adequate tamponade of bleeding or the exposure needed to repair injured vessels safely. Clavicular resection may be acceptable for hemodynamically-stable patients with minimal soft tissue damage and simple, right-sided vessel lacerations, but we cannot recommend it as an initial approach in patients with severe, exsanguinating injuries.

Hemorrhoidectomy in the patient with multiple or circumferential hemorrhoids.

A technique is presented that allows complete removal of hemorrhoids even when large hemorrhoids exist between the classic three major hemorrhoidal locations. Since the anorectal mucosa overlying these "interval" hemorrhoids is preserved, there is no increased tendency for stricture formation to occur.

Transanal excision of large sessile villous adenomas using an endorectal traction flap.

A technique is presented herein which allows a local transanal excision of large sessile villous adenomas with minimal morbidity and excellent preservation of specimen for complete histologic analysis. This technique is particularly applicable to elderly, poor risk patients and those patients with villous adenomas which extend so low in the rectum that anterior resection would be difficult or impossible.

Colon operations without wound infection. Principles and techniques in 101 cases.

A total of 101 consecutive elective colon operations were performed with no postoperative wound infection. Patients with a wide variety of diagnoses and procedures were included in the series. Many factors contribute to the formation of postoperative wound infections. A comprehensive approach with attention to preoperative nutritional assessment, bowel preparation, wound protection, sterile technique, closure of the incision, and systemic prophylactic antibiotics contributed to the overall good results.