Spilled gallstone mimicking right middle lobe pulmonary nodule.

Laparoscopic cholecystectomy is the standard of care for the surgical management of symptomatic gallstone disease. Gallstone spillage at laparoscopic cholecystectomy is common, with a reported incidence of 0.2-20%. In the majority of cases there are no complications associated with this spillage, but a series of studies report patients with complications of free peritoneal gallstones. We present a case of migration of gallstone to the lung resulting in an inflammatory mass in the right middle lobe as a complication of spillage at laparoscopic cholecystectomy.

Spilled gallstone mimicking right middle lobe pulmonary nodule.

Laparoscopic cholecystectomy is the standard of care for the surgical management of symptomatic gallstone disease. Gallstone spillage at laparoscopic cholecystectomy is common, with a reported incidence of 0.2-20%. In the majority of cases there are no complications associated with this spillage, but a series of studies report patients with complications of free peritoneal gallstones. We present a case of migration of gallstone to the lung resulting in an inflammatory mass in the right middle lobe as a complication of spillage at laparoscopic cholecystectomy.

Mitral valve repair for active culture positive infective endocarditis.

OBJECTIVE: To describe the clinical and echocardiographic outcome after mitral valve (MV) repair for active culture positive infective MV endocarditis. PATIENTS AND METHODS: Between 1996 and 2004, 36 patients (mean (SD) age 53 (18) years) with positive blood culture up to three weeks before surgery (or positive culture of material removed at operation) and intraoperative evidence of endocarditis underwent MV repair. Staphylococci and streptococci were the most common pathogens. All patients had moderate or severe mitral regurgitation (MR). Mean New York Heart Association (NYHA) class was 2.3 (1.0). Follow up was complete (mean 38 (19) months). RESULTS: Operative mortality was 2.8% (one patient). At follow up, endocarditis has not recurred. One patient developed severe recurrent MR and underwent valve replacement and one patient had moderate MR. There were two late deaths, both non-cardiac. Kaplan-Meier five year freedom from recurrent moderate to severe MR, freedom from repeat operation, and survival were 94 (4)%, 97 (3)%, and 93 (5)%, respectively. At the most recent review the mean NYHA class was 1.17 (0.3) (p < 0.0001). At the latest echocardiographic evaluation, left atrial diameters, left ventricular end diastolic diameter, and MV diameter were significantly reduced (p < 0.05) compared with preoperative values. CONCLUSIONS: MV repair for active culture positive endocarditis is associated with low operative mortality and provides satisfactory freedom from recurrent infection, freedom from repeat operation, and survival. Hence, every effort should be made to repair infected MVs and valves should be replaced only when repair is not possible.

Contribution of pain to inspiratory muscle dysfunction after upper abdominal surgery: A randomized controlled trial.

Upper abdominal surgery causes respiratory muscle dysfunction. Multiple factors have been implicated in the occurrence of such dysfunction; however, the role of pain remains unclear. To elucidate the role of pain, we studied 50 patients undergoing elective upper abdominal surgery in a randomized, controlled investigation. Inspiratory and expiratory muscle function were assessed through sniff mouth pressure (Psniff) and maximal expiratory pressure (MEP), respectively. Pain during the pressure maneuvers was assessed with a visual analog scale (VAS). Measurements were made before surgery (Session 1), 24 h after surgery (Session 2), and 1 h later, after intramuscular administration of pethidine (analgesia group) or placebo (placebo group) (Session 3). To evaluate the effect of pain, we used a mixed-effects model with random intercept, having either Psniff or MEP as the dependent variable and both surgical operation and the level of pain as fixed effects. Upper abdominal surgery decreased Psniff in both the analgesia and placebo groups (from 70 +/- 15 to 42 +/- 11 cm H(2)O [p < 0.05] in the analgesia group, and from 69 +/- 15 to 42 +/- 10 cm H(2)O [p < 0.05] in the placebo group). Intramuscular pethidine caused an increase in Psniff to 56 +/- 14 cm H(2)O (p < 0.05), whereas placebo had no effect. Pain increased comparably after upper abdominal surgery in both groups (from 0.3 +/- 0.6 to 4.4 +/- 1.5) [p < 0.05] in the analgesia group and from 0.4 +/- 0.5 to 4.3 +/- 1.5 [p < 0.05] in the placebo group). Intramuscular pethidine decreased pain as measured by VAS score to 2.1 +/- 1.0 (p < 0.05) in the analgesia group, whereas placebo had no effect. Psniff had a statistically significant relationship to pain (p < 0.001). Adjusting for the occurrence of surgical operation did not affect this result. MEP showed the same tendency as Psniff, but the observed changes did not reach statistical significance. We conclude that pain contributes to inspiratory muscle dysfunction after upper abdominal surgery.