Laparoscopic orchiectomy for unilateral intra-abdominal testis.

We present 2 cases of laparoscopic removal of a unilateral intra-abdominal testis. Removal of a unilateral intra-abdominal testis is indicated in patients more than 10 years old because the malignant potential of an intra-abdominal testis outweighs any cosmetic benefit of orchiopexy. Laparoscopic orchiectomy is a safe and effective surgical procedure for adolescents and adults with this disease entity providing outpatient therapy and prompt rehabilitation.

Outpatient open cholecystectomy.

A prospective study to evaluate discharge of patients from the hospital the day of open cholecystectomy was performed. Patients were selected for outpatient operation if they were less than 55 years of age, did not undergo exploration of the common bile duct and had no significant co-morbidity. During a six month period, 94 consecutive patients underwent cholecystectomy. Forty-four of 64 eligible patients were discharged the day of operation. Patients were walking and receiving oral liquids soon after operation. Marcaine (bupivacaine hydrochloride) was injected subfascially in all patients and vertical incisions were used in 34 of 44. One patient required readmission for 12 hours, three days after operation. The satisfaction rate was high and the patients returned to their usual activity in seven to 21 days. Outpatient open cholecystectomy is safe, and appropriate therapy and the data established a standard with which to compare that of laparoscopic cholecystectomy.

Twenty-four hour hospitalization after cholecystectomy.

To evaluate the likelihood that patients can be discharged from the hospital the day after open cholecystectomy, a prospective study of 500 consecutive patients undergoing cholecystectomy was undertaken. The study group included patients with associated acute and gangrenous cholecystitis, biliary pancreatitis and choledocholithiasis as well as those with diabetes, hypertension and obesity. Approximately one-fourth of the total group were discharged within 24 hours and over one-half in 48 hours. There was a significant correlation between advancing age and increasing length of stay. Almost one-half of the patients less than 35 years of age without acute or complicated disease were discharged within 24 hours, more than 80 per cent within 48 hours, and the mean length of postoperative stay (MLS) for these patients was 1.9 days. The presence of choledocholithiasis and fever greater than 101 degrees F. increased MLS, while acute cholecystitis, hyperamylasemia and leukocytosis did not. Early discharge from the hospital after open cholecystectomy, even in sick patients, is safe and cost-effective.

Common bile duct distensibility after cholecystectomy.

To assess the possibility of common bile duct distensibility after cholecystectomy, we made a retrospective study of patients who had ultrasonography and endoscopic retrograde cholangiopancreatography (ERCP). The study comprised 52 patients without extrahepatic biliary obstruction; 19 had had cholecystectomy, 18 of whom complained of biliary colic similar to that they had had originally. The other 33 patients had intact, well visualized gallbladders; 15 of these patients had pain in the right upper quadrant or epigastrium, but none had chronic pancreatitis. The average diameter of the common bile duct at its widest point by ultrasonography was 4.8 mm (range, 4.0 to 9.0 mm) in the 33 patients with intact gallbladders, and 5.7 mm (range, 4.0 to 8.0 mm) in the 19 patients who had had cholecystectomy. The diameter by ERCP was 4.4 mm (range, 2.9 to 6.3 mm) in the patients with intact gallbladders, and 11.17 mm (range, 6.9 to 14.7 mm) in the patients who had had cholecystectomy. In each patient who had had cholecystectomy the diameter as measured by ERCP was larger than it appeared by ultrasonography. The results suggest that the common bile duct is distensible, and that this distensibility may be related to the postcholecystectomy syndrome.

Perforated or gangrenous appendicitis treated with aminoglycosides. How do bacterial cultures influence management?

To study the influence of bacterial culture data on the clinical management of gangrenous or perforated appendicitis, we reviewed records of 104 patients who had been treated empirically with aminoglycoside antibiotics. Culture results appeared to influence antibiotic therapy in only 7 patients (7%). The routine cultures obtained at appendectomy affected therapy in only 2 patients. Discriminant analysis identified postoperative infectious complications and related factors as the principal determinants of culture utility. We conclude that, in patients with perforated appendicitis treated empirically with aminoglycoside combination regimens, culture results were seldom used for clinical management except in instances of postoperative infectious complication. Routine cultures and Gram's stains of perforated appendicitis, however, should still be obtained (1) to allow epidemiologic tracking in the hospital; (2) to identify organisms that are recovered infrequently but may cause serious disease (eg, Clostridium); and (3) because newer antibiotics are replacing aminoglycosides in the treatment of perforated appendicitis.

Cefamandole versus cefoxitin prophylaxis in patients undergoing cholecystectomy.

A prospective, randomized, double-blind study of three different antibiotic prophylaxis regimens in 150 patients undergoing cholecystectomy was conducted. Group I patients received a 1-gram preoperative dose of cefamandole followed by 4 additional postoperative doses at 6-hour intervals. Group II received a similar regimen except that 2-gram doses of cefamandole were used. Group III received a comparable cefoxitin regimen in 2-gram doses. The patients were deemed to be at high risk for postoperative infection by virtue of the fact that most (almost 70%) were obese and all had had a recent attack of cholecystitis. There were no significant differences among the 3 groups with respect to postoperative infectious complications. It is concluded that perioperative cefamandole and cefoxitin are both effective in reducing the postoperative infectious complications of cholecystectomy. A 5-gram course of cefamandole is as effective as either a 10-gram course of cefamandole or a 10-gram course of cefoxitin and could provide a substantial savings in cost.

Rapid resolution of high level hyperamylasemia as a guide to clinical diagnosis and timing of surgical treatment in patients with gallstones.

We reviewed the charts of 78 patients with acute hyperamylasemia (25 with gallstones, 38 alcoholic patients and 15 other), looking for early patterns of serum amylase flux that could distinguish gallstone associated disease. Patients with gallstones had average serum amylase levels of 1,848 +/- 289 International units per liter and 911 +/- 233 International units per liter at hospital admission and on hospital day 2, respectively; these levels were significantly greater than those in either the alcoholic or other patients. In the group of patients with gallstones, there were also dramatic decreases in serum levels of amylase at 24 hours (1,425 +/- 286 International units) after hospital admission; these decreases were not seen in the other groups of patients. At operation, the patients with gallstones had mild or no pancreatitis. All of them underwent uneventful cholecystectomy within 48 hours of hospitalization; only three patients required exploration of the common duct, and only one patient had ampullary obstruction. We conclude that rapid resolution of high level hyperamylasemia within 24 hours of hospitalization in symptomatic patients with gallstones can help to identify patients whose amylase fluctuations are indeed gallstone related, who have either mild pancreatitis or none at all, are good candidates for early cholecystectomy and are not likely to have common duct stones.

Radiolucent Cholangioclip.

Use of the absorbable and radiolucent Cholangioclip in the performance of intraoperative cholangiography has been found to be rapid, technically simple, effective, complication-free and avoids radiopaque materials within the operative field.

Demographic characteristics of gallbladder cancer in an area endemic for biliary calculi.

A 10 year retrospective study of 134 patients in whom gallbladder cancer developed in El Paso County was undertaken. Improved survival was noted in younger, female, and Hispanic patients, which appears to be a unique demographic characteristic of gallbladder cancer in an area endemic for biliary calculi. These prolonged survival data may all be explained by early diagnosis. In addition, there is suggestive evidence that a multidisciplinary approach of operation plus adjuvant chemotherapy and radiotherapy results in greater length of survival.

CT diagnosis of duodenal lipoma.

A case of duodenal lipoma presenting as chronic abdominal pain is reported. The value of CT scanning and endoscopy in the diagnosis of duodenal lipomas is emphasized.

Early surgery for biliary pancreatitis.

Herein, we documented our successful experience in performing definitive biliary tract surgery on patients with biliary pancreatitis as soon as the diagnosis was made and within 48 hours of admission. Early surgery reduced the length of hospital stay and did not result in associated morbidity, death, or complications of acute pancreatitis. The results of the study support the concept that removing obstruction of the pancreatic duct prevents progression of edematous pancreatitis to hemorrhagic pancreatitis. We conclude that patients with acute pancreatitis should be evaluated urgently for the presence of biliary tract stone disease and should be operated on as soon as the diagnosis of biliary pancreatitis is made, that early definitive surgery can be performed safely on patients with biliary pancreatitis, that cholecystectomy with intraoperative cholangiography and common duct exploration as necessary should be performed in all patients, and that length of stay for patients with biliary pancreatitis is reduced and morbidity and mortality possibly may be reduced by early surgery as compared with delayed surgery.

Parathyroid carcinoma in a child: unusual presentation with seizures.

The second reported case of carcinoma of the parathyroid gland in a child 15 years of age or younger is presented. This case is also remarkable in its extremely unusual presentation with seizures, theorized to be associated with hypercalcemia and/or a negative magnesium balance.

Traumatic hernia of the anterior abdominal wall.

Despite an increase in incidence of blunt abdominal trauma and despite the variations in compressive forces that occur, very few cases of traumatic hernia of the anterior abdominal wall have been recorded. Two recently treated cases of traumatic disruption of the musculature and fascia of the anterior abdominal wall with herniation of intestine into the subcutaneous space are herein reported. The occurrence of blunt abdominal trauma associated with an extra-abdominal mass believed to contain intestine signifies a severe compressive force and probable extensive associated injury. It represents an acute emergency and requires prompt resuscitative measures and surgical intervention.

Amebic liver abscess. Differential diagnosis of cholecystitis.

Among patients presenting with pain and tenderness in the right upper quadrant were 75 with cholelithiasis (13 male, 2 under age 50) and 9 with amebic hepatic abscess (6 male, all under age 45). The differential diagnosis of cholelithiasis versus liver abscess was accurately made by prompt sonography and hepatobiliary scintigraphy. Amebic abscess was confirmed by positive serum ameba titers. Presenting symptoms and results of laboratory studies of patients with amebic abscess were indistinguishable from those of patients with cholecystitis. It is concluded that an accurate diagnosis of amebic liver abscess in the differential diagnosis of cholecystitis can be made by sonography and hepatobiliary imaging. Also, in endemic areas of the southwestern United States, amebic abscess should be strongly considered in the differential diagnosis of patients presenting with pain and tenderness in the right upper quadrant and is more common than cholecystitis in young men.

Early operation for acute biliary tract stone disease.

A prospective study to evaluate the accuracy of early diagnosis and the efficacy of early operation for biliary tract stone disease was performed. One hundred fifty-two consecutive patients with signs and symptoms compatible with biliary colic or acute cholecystitis were admitted to the hospital and promptly evaluated with ultrasonography and hepatobiliary (Pipida) scanning. Patients with demonstrable stones or a nonvisualized gallbladder underwent operation within 48 hours of admission. Of 75 patients who underwent operation, 64 had acute and/or severe chronic cholecystitis. Associated biliary pancreatitis was present in 14 of 75 patients. Cholecystectomy with intraoperative cholangiography was performed for 73 of the 75 patients. One patient underwent cholecystectomy only and one patient underwent cholecystostomy. There were 18 common duct explorations. No transfusions were required and there were no deaths. The average duration of hospital stay for all patients who underwent operation was 6.5 days. The results indicate that an accurate diagnosis of acute biliary tract stone disease can be made rapidly with use of sonography and hepatobiliary scanning, that cholecystectomy with intraoperative cholangiography and common duct exploration as necessary can be performed safely (including cases of biliary pancreatitis) in the acute setting, and that with early operation the duration of stay is decreased and morbidity and mortality rates compare favorably with those of elective cholecystectomy. It is concluded that operation performed within at least 48 hours of admission is the treatment of choice for acute biliary tract stone disease.

Preoperative bilirubin, alkaline phosphatase and amylase levels as predictors of common duct stones.

The predictive value of the preoperative level of bilirubin, alkaline phosphatase and amylase as indicators of choledocholithiasis was determined by prospectively evaluating 304 consecutive patients undergoing cholecystectomy. Elevated levels of bilirubin and alkaline phosphatase are associated with an increased incidence of common duct stones, and the percentage incidence of stones increases with rising bilirubin and alkaline phosphatase levels. Alkaline phosphatase levels as great as 200 are associated with common duct stones in a low percentage of instances, being equivalent to that for unsuspected stones. Levels of 200 or greater are associated with a marked increase in the incidence of common duct stones. An elevated serum or urine amylase level, or both, is of little, if any, value as a predictor of common duct stones. Alkaline phosphatase appears to be a better indicator of common duct stones than does bilirubin, but neither bilirubin nor alkaline phosphatase in themselves are statistically significant indicators. Bilirubin and alkaline phosphatase in combination is a statistically significant predictor of common duct stones at all levels. The combination of a bilirubin level of greater than 3.0 and an alkaline phosphatase level of greater than 250 has a 76.2 per cent probability of an associated common duct stone. The quite important role of operative cholangiography in demonstrating unsuspected stones and in preventing unnecessary common duct explorations is reinforced.

Rupture of a giant non-functioning pancreatic islet cell tumor following minimal trauma.

The interesting occurrence of a previously asymptomatic giant non-functioning islet cell tumor of the pancreas identified following rupture secondary to relatively insignificant abdominal trauma is reported. Despite the rarity of the condition, this circumstance underscores the need to be aware of the possibility of pre-existing pathology in evaluating and treating patients for blunt abdominal trauma. To our knowledge, this is the first reported instance of this rare disease entity presented secondary to blunt abdominal trauma.

Gastric bypass for morbid obesity: preoperative and postoperative psychological evaluation of patients.

Twenty consecutive patients undergoing gastric bypass for morbid obesity were evaluated psychologically preoperatively and postoperatively by Minnesota Mulitphasic Personality Inventory (MMPI) assessment, a Problem Index designed for the study, and semistructured interviews. Patients were classified into categories based on the extent of psychopathology demonstrated preoperatively, and into categories based on the presence or absence of postoperative complications. Eighty percent of the patients continue to do well or improve psychologically. Patients with postoperative complications showed no significant change in psychological status. Patients who did not experience postoperative complications showed significant improvement in depression, hysteria, poor morale, psychoticism, phobias, and health concerns. Psychological changes with surgery did not correlate with weight loss. All patients with complications were unmarried and more likely to be moderately or severely disturbed on preoperative MMPI assessment.

Breast carcinoma in a young man.

Breast carcinoma occurred in a 25-year-old man. This is to our knowledge, the seventh reported instance of this extremely rare cancer. Despite its infrequent occurrence, high cure rates can be obtained if it is detected and treated early. Breast masses in young men must not be ignored.