Laparoscopy for the Acute Abdomen.

The application of laparoscopy for therapy is well established in biliary tract disease, inguinal herniorrhaphy, and fundoplication. Frequently, the diagnostic capability of laparoscopy is overlooked. A review of the literature and an institution's experience in laparoscopy for the acute abdomen is presented. Therapy was completed laparoscopically in a substantial number of cases.

Infected pancreatic necrosis and peripancreatic fluid collections: serendipitous response to antibiotics and medical therapy in three patients.

Three patients with clinical and radiologic evidence of pancreatic necrosis or peripancreatic fluid collections/inflammatory masses who were advised to have surgery on the basis of bacterial infection on skinny-needle aspiration of the pancreas but were deemed medically unstable or refused operative intervention were treated with intensive antibiotic therapy. All three patients survived the attack of acute pancreatitis with infection on medical therapy alone. This suggests that occasional patients with infected necrosis and/or peripancreatic collections/inflammatory masses may respond to antibiotics, especially those antibiotics that have recently been shown to have a high penetration into pancreatic tissue.

Exploratory laparoscopy for perforation following colonoscopy.

Colonoscopy is being increasingly used for the diagnosis and therapy of colonic diseases. Bleeding and perforation are two major complications. The management of patients with perforation is undergoing evolution. There is evidence to support conservative management in selected patients with perforation without clinical signs of peritonitis. There is, however, a subset of patients with perforation where a considerable doubt exists about the choice between surgical and conservative management. We report one such patient, a 50-year-old woman with free air under the diaphragm and peritoneal signs following a therapeutic colonoscopy in whom an exploratory laparoscopy was performed. Exploratory laparoscopy is proposed for such patients when there is a question in choosing between surgical and conservative management.

Cardiovascular changes during laparoscopic cholecystectomy.

Although the technique of laparoscopic cholecystectomy has increasing appeal, physiologic data to support the safety of this procedure are lacking. We studied the cardiovascular changes in 16 patients undergoing laparoscopic cholecystectomy, using impedance cardiography as a noninvasive means of continuous monitoring of cardiac output. Serial measurements of mean arterial pressure (MAP), heart rate (HR), intraperitoneal pressure and expired carbon dioxide tension (PECO2) were also recorded. Results revealed a decrease of 30 percent (p < 0.001) in cardiac index and 5 percent (p = 0.089) in HR, along with increases of 15 percent (p < 0.001) in MAP and of 79 percent (p < 0.001) in the calculated total peripheral resistance index. This elevation in afterload could lead to both an increase in myocardial oxygen consumption and to the potential risk of myocardial ischemia and possibly infarction or congestive heart failure, or both, in patients who are susceptible. The data suggest that patients with a history of cardiac disease should have preoperative cardiac evaluation and be closely monitored during laparoscopic cholecystectomy, as in any other extensive operation.

Is colonoscopy safe in the early postcolectomy period?

Colonoscopy was performed preoperatively and 1, 2, 3 and 7 days following a left hemicolectomy with a primary anastomosis in 11 dogs. The remaining colon and anastomosis were adequately visualized. Maximal intraluminal pressures achieved were from 15 to 35 mmHg. No leakage of air or intra-abdominal abscesses were present. In ten patients undergoing colonoscopy for lower gastrointestinal symptoms, the pressures were similarly measured. Although pressures were slightly higher in patients, averaging 30 mmHg, the results suggest that colonoscopy can be safely performed during the early postcolectomy period.

Massive rectal bleeding from a Dieulafoy's type ulcer of the rectum: a review of this unusual disease.

Dieulafoy's ulcer is an uncommon lesion that usually presents with massive bleeding. Although it has been observed, for the most part, in the stomach, it has also been identified in the small bowel and colon. Both endoscopy and angiography have been used for diagnosis; however, endoscopy has had a high failure rate for localizing colonic disease during active bleeding. Treatment has been primarily surgical, but endoscopic coagulation and sclerotherapy have been recently employed. A 20-year-old male presented with massive lower gastrointestinal bleeding, which was found to be caused by a Dieulafoy's ulcer in the rectum. Observation of Dieulafoy's ulcer in the rectum has not been reported previously. Diagnosis was by rigid sigmoidoscopy. This lesion was treated by widely oversewing the vessel after endoscopic therapy failed. The etiology of this lesion is most likely congenital. Hemorrhage probably occurs as a result of mechanical damage of the mucosa, combined with erosion of the vessel by fecal flow. Unlike colonic Dieulafoy's ulcers, it should be possible to diagnose rectal lesions by rigid sigmoidoscopy. This diagnosis may be difficult with high rectal ulcers, and angiography may have to be employed. Endoscopic therapy failed here, as in other reports on colonic disease. Thus, we would recommend widely oversewing rectal lesions as the primary treatment. Resection should be reserved for cases that have failed this therapy.

Role of reactive oxygen metabolites in early cardiopulmonary changes of acute hemorrhagic pancreatitis.

The role of reactive oxygen metabolites in extrapancreatic organ dysfunction associated with acute hemorrhagic pancreatitis was studied in dogs. Experimental pancreatitis was induced by the intraductal infusion of activated trypsin and taurocholate. Cardiac output, pulmonary and systemic blood pressure, pulmonary wedge pressure, central venous pressure, heart rate, blood gases and serum amylase were measured. Cardiac index, pulmonary and systemic vascular resistance, and the right and left stroke work were calculated. Systemic arterial and venous blood pressure and cardiac index gradually declined over 6 hr, while pulmonary mean blood pressure and pulmonary vascular resistance increased. Pretreatment of pancreatitis with catalase and superoxide dismutase prevented the rise in mean pulmonary blood pressure, moderated the rise in pulmonary vascular resistance, and decreased the rate and extent of the fall in cardiac index. These data suggest that reactive oxygen metabolites may play some role in the extraabdominal organ manifestations of acute pancreatitis.

A modified retention suture technique with external and internal "booties" to close difficult abdominal wounds.

In a patient with acute hemorrhagic pancreatitis complicated by pancreatic abscess, closure of the abdominal wall 7 days following marsupialization was difficult owing to the marked distension and edema of the bowel wall, especially the transverse colon. A simple technique using retention sutures with internal and external rubber "booties" above and below the fascia was used to prevent injury to the edematous bowel. The rubber catheters, or "booties," were removed at the bedside, thus making it a simple procedure in a difficult situation.

Safety of endoscopy in the immediate postoperative period following gastric anastomosis.

The safety of gastrointestinal endoscopy in the immediate postoperative period following partial gastrectomy was assessed in ten dogs. Endoscopy was performed preoperatively and at 1, 2, 3, and 7 days postoperatively. The mean pressures required to perform an adequate endoscopy varied from 17 to 20 mm Hg. Following partial gastrectomy, the abdominal wall was closed with a zipper to facilitate inspection of the gastric anastomosis. No leakage of air or intra-abdominal abscesses were seen following endoscopy. The results of this study suggest that endoscopy can be safely performed in the immediate postgastrectomy period.

Comparison of intraoperative ultrasonography and cholangiography in detection of small common bile duct stones.

High-resolution intraoperative ultrasonography was compared with conventional radiographic imaging in the detection of small common bile duct (CBD) stones (less than 5 mm in diameter). Sixteen mongrel dogs had laparotomy and ligation of distal CBD; 1 week to 10 days later, 0-3 gallstones of varying sizes (2-5 mm) were introduced into the dilated CBD (6-16 mm). High-resolution intraoperative ultrasonography of the CBD and a conventional intraoperative cholangiogram were performed to detect the presence and number of stones. The results of these two tests were evaluated independently by two ultrasonographers and two surgeons. There were 21 true-positive and five false-negative readings by sonogram compared with 17 and 9, respectively, by cholangiogram. Sensitivity of the sonogram was 81% and 65.4% by cholangiogram. Score of accuracy was 1.06 and 1.62 by cholangiogram and 0.81 and 0.87 by ultrasound (p less than 0.05). Intraoperative ultrasonography was found to be more sensitive in detecting small CBD stones when compared with intraoperative cholangiogram.

Factors affecting recurrence following resection for Crohn's disease.

The records of 187 patients with Crohn's disease who underwent resectional surgery were analyzed to evaluate the effect of several clinical and histologic features on the recurrence rate. Recurrence was defined as the need for re-resection. The data were analyzed by the life-table method. Age, sex, age at onset of disease and at time of resection, family history, presence of granuloma, and microscopic involvement at the line of resection did not affect the recurrence rate. The distribution of the disease and duration of symptoms before primary resection did influence the rate of re-resection. Patients with predominantly large bowel disease (N = 56) were found to have a higher rate of re-resection (45 percent) when compared with 32 percent in patients with small bowel involvement (N = 94) and with 35 percent in patients with both small and large bowel involvement (N = 37) (P = 0.04). A detailed review, an analysis of the literature, and a comparison with our results are made.

Comparison of antacid and sucralfate in the prevention of gastrointestinal bleeding in patients who are critically ill.

In a randomized open trial, a regimen consisting of sucralfate administered every six hours was shown to be as effective as a regimen consisting of an antacid given hourly in the prevention of upper gastrointestinal bleeding in 155 patients who were critically ill. Two of 75 (2.6 percent) patients receiving antacid and three of 80 patients (3.8 percent) receiving sucralfate showed evidence of bleeding. In no case was bleeding severe enough to necessitate blood transfusions or surgery. The cost-effectiveness, ease of administration, reduced nursing hours, greater compliance, and fewer side effects make sucralfate a useful substitute for antacid in preventing upper gastrointestinal bleeding in patients who are critically ill.

Antacid versus sucralfate in preventing acute gastrointestinal bleeding. A randomized trial in 100 critically ill patients.

A randomized, controlled trial of sucralfate versus antacid as prophylaxis against upper gastrointestinal bleeding was carried out in 100 critically ill intensive care unit patients. Both groups were comparable with regard to sex, age, duration of prophylaxis, and the number of risk factors per patient. There was no gross bleeding in any of the patients. Three of the 48 sucralfate patients and 2 of the 52 antacid patients showed strongly positive results of Gastroccult tests of three successive hourly samples of gastric aspirate and were considered treatment failures. We conclude that sucralfate therapy is as effective as an antacid regimen in the prevention of gastrointestinal bleeding in critically ill patients. In view of a considerable savings in nursing time, it offers the opportunity for considerable reduction in the cost of intensive care while providing effective protection.

Microbiologic efficacy of a surgically constructed nipple valve.

The efficacy of a surgically constructed nipple valve in preventing reflux of colonic bacteria into the small bowel was evaluated. The nipple valve significantly decreased the number of S. marcescens, a marker bacterium, in the small bowel when compared with plain ileocolic anastomosis. In this study, the nipple valve prevented the reflux of bacteria similar to an intact ileocecal valve which suggests that the nipple valve is an effective bacteriologic barrier and may be used as a substitute for the ileocecal valve in patients with short bowel syndrome.