Portal vein thrombosis.

Portal vein thrombosis (PVT) is a complication of hepatic disease and a potentially lethal complication of splenectomy. The reported incidence of this complication is low (approximately 1%). However, its true incidence may have been underestimated due to difficulty in making the diagnosis. Herein we report the case of a 19 year-old woman who presented with a 2-year history of idiopathic thrombocytopenic purpura (ITP). Because she had become refractory to medical therapy, she underwent laparoscopic splenectomy. She was discharged on postoperative day 2 after an uncomplicated procedure. She did well, complaining only of mild backache, until postoperative day 21, when she presented with nausea, vomiting, and leukocytosis. CT showed PVT and superior mesenteric vein thrombosis. Despite heparin and fluid administration, her condition worsened. At laparotomy, she had diffuse small bowel edema and congestion. At a second-look procedure 24 h later, nearly all her jejunum and ileum were necrotic. After three procedures, she was left with 45 cm of proximal and 10 cm of distal small bowel. Bowel continuity was restored 8 weeks later. She continued on warfarin anticoagulation therapy for 1 year. Postsplenectomy PVT is most often seen following splenectomy for myeloproliferative disorders and almost never after trauma. The large splenic vein stump and the hypercoagulable state in patients with splenomegaly are thought to be contributory. The presentation of PVT is vague, without defining signs or symptoms. Color-flow Doppler and contrast-enhanced CT scans are the best methods for the nonoperative diagnosis of PVT. Aggressive thrombolysis offers the best hope for clot lysis and maintenance of bowel viability. Even vague symptoms must be considered seriously following splenectomy.

The need for training opportunities in advanced laparoscopic surgery.

BACKGROUND: There is controversy regarding the amount of training necessary to safely perform advanced laparoscopic surgery. General surgical residency often provides only a low volume of advanced laparoscopic cases and there is growing interest in nonaccredited fellowships focused on laparoscopic surgery. OBJECTIVE: To assess surgical residents' perception of the need for training in advanced laparoscopic surgery in addition to that provided in a standard general surgical residency. METHODS: A 15-item questionnaire was mailed to 985 physicians who either were Society of American Gastrointestinal Endoscopic Surgeons (SAGES) candidate members or had attended a SAGES resident course in 1998 or 1999. For the purposes of the survey, laparoscopic Nissen fundoplication, laparoscopic herniorrhaphy, laparoscopic splenectomy, and laparoscopic colectomy were chosen as advanced procedures. RESULTS: Of the 85 responses obtained, 81% were from respondents who were at the postgraduate fourth-year (PG4) level or higher. Furthermore, 58% of the respondents had taken a course in advanced laparoscopic surgery outside their residency program. The respondents believed that to perform the procedures safely and with confidence on entering practice, they needed to do at least eight each of the selected laparoscopic procedures. As reported, 45% of the respondents had performed three or fewer laparoscopic hernias; 60% had performed three or fewer laparoscopic Nissen fundoplications; 81% had performed three or fewer laparoscopic colectomies; and 86% had performed three or fewer splenectomies. Only 32% of the residents expected to perform more than 10 laparoscopic Nissen fundoplications, only 10% expected to perform more than 10 colectomies, and only 4% expected to perform more than 10 splenectomies before completing their residency. Many respondents (65%) said they would pursue an additional year of advanced laparoscopic training if it were available. In programs unaffiliated with a fellowship in advanced laparoscopic surgery, 65% of the residents were concerned that such a fellowship would interfere with residency training in laparoscopic surgery. In comparison, only 24% of the residents in programs affiliated with a fellowship in advanced laparoscopic surgery believed that the fellowship interfered with their training, whereas 47% of the residents in programs affiliated with a fellowship in advanced laparoscopic surgery thought that the fellowship had no impact on their training. CONCLUSIONS: Residents clearly perceive a need for additional training in advanced laparoscopic surgery. Residents from programs without a laparoscopic fellowship are concerned about a negative impact on their experience from a laparoscopic fellow, but residents from programs with a laparoscopic fellowship are neutral about the impact of a fellow.

Laparoscopic appendectomy and the management of gynecologic pathologic conditions found at laparoscopy for presumed appendicitis.

A laparoscopic approach to patients with possible appendicitis has increased in popularity. In this article it is compared to the traditional open appendectomy, and the management of frequently found gynecologic pathology masquerading as appendicitis is described.

Laparoscopic is not better than open appendectomy.

Laparoscopic appendectomy is increasingly being used by general surgeons. The advantages of the procedure over open appendectomy are not as obvious as the advantages of laparoscopic cholecystectomy over open cholecystectomy. This study was a retrospective review of nonrandomized patients of two attending surgeons over the time period 4/11/91 to 2/15/93. Parameters examined included patient age, gender, operating room time, hospital cost, hospital stay, negative appendectomy rate, and wound infection rate. Results showed that there was no difference in the patient age. Gender was significantly different, with the laparoscopic group containing 68% females, whereas the open group contained only 39% (P < 0.01). Operating room time was significantly longer for the laparoscopic group by approximately 18 minutes (P < 0.05). Hospital cost was $1400.00 more expensive for the laparoscopic group (P < 0.05). Hospital stay and wound infection rates were not significantly different. The negative appendectomy rate was 37% for the laparoscopic group and 12% for the open group (P < 0.05). We conclude that laparoscopic is not superior to open appendectomy.

Aortic injury. A catastrophic complication of laparoscopic cholecystectomy.

Two cases of aortic injury from trocar insertion during laparoscopic cholecystectomy are described and analyzed. The literature is reviewed and suggestions are offered for avoiding and treating this major complication. Both patients survived and are normal.

Reusable instruments are more cost-effective than disposable instruments for laparoscopic cholecystectomy.

Health care costs are rising rapidly, and surgeons can play a role in limiting costs of operations. Of the 600,000 cholecystectomies performed each year in the United States, approximately 80% are performed with laparoscopic technique. The purpose of this study was to compare the costs of reusable vs disposable instruments used during laparoscopic cholecystectomy. The costs to the hospital of reusable and disposable instruments were obtained. Instruments studied were the Veress needle, trocars and sleeves (two 10 mm and two 5 mm), reducers, clip appliers, and clips. In addition, the costs of sterilization and sharpening for reusable instruments were calculated. The cost of reusable instruments was based on an assumed instrument life of 100 cases. Data from three private hospitals and a Canadian university hospital were collected and examined. Data from the four hospitals revealed that the costs of reusable instruments per case were $46.92-$50.67. The comparable costs for disposable instruments were $330.00-$460.00 per case. Theoretical advantages of disposable instruments such as safety, sterility, and better efficiency are not borne out in literature review. In addition, the environmental impact of increased refuse from disposable instruments could not be exactly defined. With the consideration of significant cost savings and the absence of data demonstrating disadvantages of their use, reusable instruments for laparoscopic cholecystectomy, are strongly recommended.

Is laparoscopic better than open appendectomy?

Laparoscopic appendectomy is becoming increasingly popular as surgeons strive to manage surgical problems via minimally invasive techniques. We reviewed our early experience in 38 patients with laparoscopic appendectomy and compared it to open appendectomies done during the same time period. We found no difference in hospital costs, stay, or wound infection rate. There was a significant difference in OR time: the laparoscopic approach took longer. We conclude that this new approach is not clearly superior to open appendectomy despite theoretical advantages. Newer instruments and further studies are needed.

Intraoperative flexible videocholedochoscopy. An improved technique for evaluating the common duct.

At the conclusion of common duct exploration, a T-tube cholangiogram is usually performed. Recently, flexible choledochoscopy has become available to evaluate the interior of the common duct. We compared four cases, using the videocholedochoscope with completion T-tube cholangiography, both in our four patients and historically. We used the Olympus CHF-P20 flexible choledochoscope, which is 4.8 mm in diameter, hooked to an Olympus S-4 videoadapter. We found that flexible choledochoscopy enabled us to evaluate the biliary tree directly from the ampulla to the third branch radicle within the liver. In all cases, the common ducts were normal after stone removal. Both the preexploration and completion T-tube cholangiograms yielded less information. We conclude that flexible choledochoscopy is an improved technique that allows a more thorough evaluation of the common duct, obviates more extensive procedures, i.e., sphincteroplasty, by removing stones through the scope, and negates the need for a completion T-tube cholangiogram. We encourage all biliary tract surgeons to consider this technique for their own use.

Distal colonic impaction requiring laparotomy in an adult with cystic fibrosis.

A sigmoid fecal impaction leading to colonic obstruction in an adult with cystic fibrosis was evacuated at laparotomy by manual compression of the inspissated stool through the rectum. In cystic fibrosis beyond infancy, constipation is a common management problem. Intestinal obstruction caused by inspissated stool in the terminal ileum and cecum has been well documented; however, distal colonic obstruction requiring operation has not been previously reported.

Is percutaneous better than open gastrostomy? A clinical study in one surgical department.

Percutaneous endoscopic gastrostomy (PEG) has become an acceptable alternative to open gastrostomy since its inception in 1981. The PEG procedure has been assumed by most to have lesser associated morbidity and mortality and to be more cost effective. Only a few studies have compared the two procedures, and even fewer cost comparisons have been performed. A review of the literature and a retrospective study was performed over a three-year period examining eighty-eight consecutive patients who underwent either PEG (48) or gastrostomy (4) for feeding purposes only by the same group of surgeons. Patients undergoing PEG or gastrostomy tube placement in association with other procedures were excluded from the study. The results of our experiences with PEG versus open gastrostomy revealed no difference in age or gender. Intraoperative morbidity was higher (50%) for PEG than for gastrostomy (2.5%). Six-month follow-up mortality was 30 per cent and 32 per cent for PEG and gastrostomy. The cost for PEG ($1360) was approximately half the cost for gastrostomy ($2448). This study demonstrates that PEG has a significantly higher intraoperative morbidity rate relative to open gastrostomy, whereas both carry a substantial percentage of late complications. Problems often encountered with PEG included suture breakage, inadvertent colon puncture, local peritonitis, and inability to keep the stomach inflated. Late complications seen with open gastrostomy were wound infection, wound dehiscence, and respiratory complications. No deaths were a direct result of either procedure, and long-term mortality rates were comparable. PEG was clearly more cost effective.(ABSTRACT TRUNCATED AT 250 WORDS)

Scrotal incarceration of the ureter with crossed renal ectopia: case report and literature review.

To our knowledge only 18 cases of ureteral herniation into the groin have been reported in the literature. We encountered a patient with crossed renal ectopia and ureteral incarceration into a right indirect inguinal hernia. Based on analysis of the presentation and management of our patient combined with a review of the literature we conclude that patients with urinary symptoms and a groin hernia should undergo preoperative urological evaluation, all hernias containing a ureter should be repaired and ureteral resection rarely is necessary during the hernia repair.

Pitfalls in the role of standardized preadmission laboratory screening for ambulatory surgery.

We conducted a one-year retrospective analysis to determine the effect of a standardized preadmission screening (PAS) program on the cancellation rate of ambulatory surgery. Patients were divided into two groups. Group One patients had selective PAS lab work based on history and physical examination. Group Two patients underwent a standardized PAS consisting of history, physical examination, biochemical profile, complete blood count, and urinalysis. Patients in both groups received a prothrombin/partial thromboplastin time (PT/PTT) if one anticoagulation therapy, an electrocardiogram (EKG) with age greater than 40 years, and a chest X ray with age greater than 50 years. We found that the frequency of surgery cancellation before and after instituting a standardized PAS remained the same (6.9% vs 6.4%); furthermore, only 38.5 per cent of the cancellations in Group One and 16.4 per cent in Group Two were due to laboratory, EKG, or chest X-ray results. The rest were due to intercurrent illness, scheduling conflicts, and other uncontrollable factors. A closer analysis of Group Two shows that of 4,058 standardized preadmission screens performed, 4,015 (99%) were normal; only 43 (1%) had abnormal results that led to cancellation of ambulatory surgery. Similarly, 99.93 per cent of all EKGs and 99.97 per cent of all chest X-rays performed in both groups were normal, having no influence on operational performance or patient management. We suggest that selective use of laboratory and diagnostic studies, in conjunction with a thorough history and physical examination, is as effective as a standardized PAS in identifying patients at risk for ambulatory surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

All terrain vehicles (ATVs). A recreational gamble.

Over the period September 1985 to July 1986, the authors reviewed 28 admissions to the Level I trauma center as a result of all-terrain vehicle (ATV) accidents. The patients ranged in age from 6 to 71 years, with nearly 33 per cent (9), under age 16. There were 22 (78.6%) male and 6 (21.4%) female patients. All suffered multiple abrasions, lacerations, and contusions. In addition, 21 (75%) patients had a fracture of some type. Eight (28.6%), had head injuries and 3 (10.7%) sustained spinal cord injuries with a permanent neurologic deficit. Intrathoracic injury occurred in 2 patients (7.1%) and intraabdominal injuries occurred in 1 (3.6%). Moreover, death occurred in 3 (10.7%). Simultaneously reviewed were admissions resulting from motor vehicle accidents (MVA) and motorcycle accidents (MCA) during the same period. By comparison, the death rates (DR), fracture rates (FR), and spinal cord lesions with deficit (SLR) were significantly higher in accidents with ATVs than with MVAs or MCAs. The death rates for ATVs, MVAs, and MCAs were 10.7 per cent, 4.6 per cent, and 1.2 per cent, respectively, with significance between the MCA and ATV groups, P = .0395. The FR were 75 per cent, 53 per cent, and 65 per cent, respectively, with P = .265. SLR was found in 10.7 per cent, 2.3 per cent, and 4.4 per cent of these same groups, with P = .0001. These data suggest that ATV riders are at a higher risk for sustaining fractures, significant spinal cord injuries, or death. ATVs clearly present a health hazard to riders of all ages.

Colonoscopic extraction of foreign bodies from above the rectum.

There has been a considerable amount of experience with removal of rectal foreign bodies inserted transanally. Until recently removal of objects above the rectosigmoid junction has required laparotomy. A literature review reveals that since 1975 there have been 29 cases of colonoscopic removal of a variety of objects reported in fourteen publications. The authors have had experience with three cases of retained colonic foreign bodies (greater than 7 days) extracted using the colonoscope. All patients received preprocedure antibiotics and bowel preparation from below. All objects were removed using either the Olympus CF LB3R colonoscope or the Fujinon EVC-M videocolonoscope. The authors conclude that colonoscopic retrieval of foreign bodies is technically feasible, safe, less morbid, and less costly than laparotomy. This technique should be considered as the first step in management of these patients by endoscopic surgeons.

Answering the fat emulsion contamination question: three in one admixture vs conventional total parenteral nutrition in a clinical setting.

Fat emulsions (FE) support microbial growth when inoculated in vitro; dextrose/amino acid solutions (D/AA) do not. Can FE be safely added to D/AA when delivered over 24 hrs? We attempted to answer this question by culturing both conventional (C) total parenteral nutrition (TPN), in which the FE and D/AA are given separately, and the 3-in-1 admixture TPN, in which all components are delivered in one bag. Two-hundred TPN fluid cultures were obtained serially by collecting 1 ml of fluid from the distal-most connection when the TPN was changed every 24 hrs. Quantiative and qualitative cultures were obtained. One hundred sixty-six (83%) were negative. Of the 34 (17%) positive cultures, 15 (17% of 88) were from the conventional system whereas 19 (17% of 112) were from the 3-in-1 system. Six clinically septic patients furnished 11 TPN fluid specimens which grew greater than 400 colonies/ml. Seven (8% of 88) of these were from the conventional system whereas four (3.6% of 112) were from the 3-in-1 system. All had distant sites of sepsis. The 23 remaining positive TPN fluid cultures grew less than 25 colonies/ml, with 20 growing Staphylococcus epidermidis. All of these patients were clinically well and there was no significant difference in the distribution of positive cultures between the conventional system (9%) and the 3-in-1 system (13%).(ABSTRACT TRUNCATED AT 250 WORDS)