Laparoscopic versus conventional appendectomy.

BACKGROUND: The results of recent series suggest remarkable advantages of laparoscopic appendectomy over the conventional open appendectomy. To determine if clear advantages could be established, the charts of all patients admitted to our institution with a presumptive diagnosis of acute appendicitis and subsequent appendectomy were retrospectively reviewed. STUDY DESIGN: From January 1990 through June 1992, there were 300 conventional open appendectomies and 66 laparoscopic appendectomies performed. Data from both groups were compared with respect to anesthesia time, operative time, postoperative morbidity, postoperative pain, time to regular diet, hospitalization period, cost, and return to normal activities. RESULTS: There were no significant differences between the laparoscopic and open appendectomy groups with respect to operative complications, postoperative morbidity, pain medication requirements, and time to regular diet. There were significantly longer anesthesia times, operative times, and operating room costs in the laparoscopic group. For complicated appendicitis, the laparoscopic technique resulted in infectious complications that required readmission in 45.5 percent of the patients. CONCLUSIONS: Laparoscopic appendectomy is a safe alternative to conventional open appendectomy for simple acute appendicitis. However, laparoscopic appendectomy is not superior to the conventional method with regard to operative time, postoperative morbidity, pain medication requirements, time to regular diet, length of stay, cost, or return to normal activity. Laparoscopic appendectomy may be contraindicated in complicated appendicitis (gangrene, perforated with abscess, or peritonitis) due to an increased rate of infectious complications requiring readmission.

Pulmonary arterial histology and morphometry in systemic sclerosis: a case-control autopsy study.

Morphometric measurements were performed on pulmonary arteries in 58 patients with systemic sclerosis (20 limited cutaneous and 38 diffuse cutaneous involvement [21 with and 17 without renal crisis]) and age, race, and sex matched autopsy controls. Matched pairs analysis was employed. For arteries of all sizes, the area of the intima and percent luminal occlusion were greater in the limited and diffuse (no renal crisis) groups than in controls, and these differences were statistically significant for large and medium sized vessels. The greatest luminal occlusion was found in limited cutaneous patients, and especially those with clinical evidence of pulmonary arterial hypertension, providing a rationale for the poor response to vasodilator therapy in these patients.

Renal vascular histology and morphometry in systemic sclerosis. A case-control autopsy study.

An autopsy case-control study of renal vascular histology and morphometry in systemic sclerosis (scleroderma) was performed. Thirty-five of 70 systemic sclerosis cases had renal tissue available for study: 26 had diffuse cutaneous involvement (9 with "renal crisis" and 17 without) and 9 had limited cutaneous disease (CREST syndrome [calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias]). Age-matched (within 10 years) and sex-matched controls with renal specimens were obtained. New sections were cut from tissue blocks, and morphometry was completed using a Zeiss Image Analyzer. Using analysis of variance, the intimal area (Ai) was significantly increased (intimal thickening) in small and medium-sized arteries of patients with diffuse scleroderma and in small arteries of CREST patients, compared with those in controls, while a decreased medial area (Am) was seen consistently in all groups. The proportion of the vessel wall occupied by intima (Ai:[Ai + Am]) was significantly greater in all vessel size groups in patients with diffuse scleroderma compared with that in controls. The percentage of luminal occlusion was greatest in patients with diffuse disease with renal crisis. These same patients had severe edematous and mucinous intimal thickening in small and medium vessels, often in association with fibrinoid necrosis. We conclude that renal vascular structural changes are an integral part of systemic sclerosis. However, the significant differences between diffuse scleroderma patients and CREST syndrome patients, for both intimal thickening and percentage of luminal occlusion, suggest that the arterial disease in these 2 patient subsets is distinctive.

Lipid microspherule-associated acute monarticular arthritis.

We describe the fifth reported case of acute monarthritis associated with lipid microspherules. A 33-year-old obese man developed acute knee arthritis with a synovial fluid white blood cell count of 11,700/mm3 (97% polymorphonuclear leukocytes). The fluid contained numerous strongly positively birefringent intra- and extracellular spherules that measured 2-6 microns in diameter and had the appearance of Maltese crosses. No systemic lipid disorder or local trauma could account for the attack, which responded promptly to the administration of colchicine.

Early definitive surgery for acute pancreatitis associated with cholelithiasis.

Since the natural history of pancreatitis associated with cholelithiasis is one of recurrence, surgery for the biliary tract disease is mandatory. But appropriate timing of the surgery remains controversial. Seventy-eight patients have been treated with early surgery once a diagnosis of cholelithiasis associated pancreatitis was made. Eighteen patients had previous episodes of nonalcoholic pancreatitis. Utilizing Ranson's prognostic signs, 52 patients had mild pancreatitis and 26 severe. Sixty-eight patients (87%) had surgery within 72 hours after admission and ten patients (13%) within 5 days. All patients had a cholecystectomy and operative cholangiogram performed. Fifty-six (72%) positive operative cholangiograms were obtained and common bile duct exploration revealed choledocholithiasis in 42 patients (75%). No mortality occurred, and four had six complications including mild persistent pancreatitis (two), wound infection (one), urinary tract infection (one), cardiac arrhythmia (one) and heart block requiring permanent pacemaker (one). The average hospital stay was 10.4 days. T-tube cholangiogram done prior to discharge was normal in all patients, and there have been no episodes of recurrent pancreatitis. Early definitive surgery for pancreatitis associated with cholelithiasis is recommended and can be accomplished with minimal morbidity and mortality coupled with judicious utilization of hospital resources.

Bilateral amyloidosis of the ureter associated with carcinoma.

We report a case of coexisting amyloid and neoplasm in a localized ureteral lesion. This case also represents the third reported instance of sequential bilateral ureteral amyloidosis. Right nephroureterectomy revealed amyloid and an in situ focus of low grade transitional cell carcinoma. Three years later amyloid in the distal left ureter was resected and the gap was bridged by a bladder hitch and Boari flap. Subsequent followup has been uneventful.

Operative risk of general surgical procedures in patients with previous myocardial revascularization.

Eighty general surgical procedures with general anesthesia were performed upon 73 patients who had undergone previous myocardial revascularization for significant coronary artery disease. No deaths occurred in this group of patients. Cardiac complications occurred in two patients. A silent myocardial infarction occurred in one patient while another required a permanent cardiac pacemaker for complete heart block. Six noncardiac complications developed in four patients. We concluded that patients with significant coronary artery disease who have undergone previous myocardial revascularization can tolerate subsequent general surgical procedures with limited risk.

Excisional breast biopsy and roentgenographic examination for mammographically detected microcalcification.

Sixty-two women had excisional breast biopsy for areas of microcalcification detected by mammography with no associated palpable mass. Carcinoma was discovered in 20 patients (32 percent). These cancers ranged in size from 0.6 to 14 mm in greatest diameter. Six patients had multicentric carcinoma, including one synchronous bilateral lobular carcinoma. Axillary metastasis was present in three patients (15 percent), each with multicentric lesions. Chronic cystic mastopathy (55 percent) was the most common finding associated with microcalcification. In six patients (30 percent) with carcinoma, the microcalcification was present only in adjacent tissue and ducts. Generous excisional biopsy, verification of excision of the site of microcalcification by roentgenographic examination of the specimen, and thorough histologic examination by paraffin section are mandatory to detect these early and potentially curable breast carcinomas.