Thoracoscopic exposure of intervertebral discs.

Video-assisted thoracic surgical techniques provide access to the anterior thoracic spine without the morbidity of open thoracotomy. Improved diagnostic methods now give better awareness of the incidence and clinical significance of thoracic herniated nucleus pulposus. We present video-assisted thoracic surgical exposure techniques that have been used successfully to treat thoracic disc disease from T-2 to T-12.

Combining laparoscopic cholecystectomy and (peri) umbilical herniorrhaphy.

Clinically significant umbilical hernias are frequently encountered in patients needing laparoscopic cholecystectomy. It is safer and quicker to first expose and reduce the hernia in a standard fashion rather than endoscopically. Cholecystectomy can then be done with a Hasson trocar, as camera port, in the hernia defect. Herniorrhaphy is performed after gallbladder extraction.

A study of rib biopsy.

A retrospective study of one decade of rib biopsy in four hospitals in Nashville, Tenn, showed 61 biopsies were done in 60 patients. The typical patient was a male in his seventh decade. Preferred operative technique was open biopsy with general anesthesia. One half of the patients had metastatic malignancy; most of the known primary tumors were lung cancer. About one fifth of specimens were normal ribs. Biopsy was done in nine of these because of false-positive scintigraphy. Accurate preoperative chest wall localization is critical in order to minimize intraoperative decision-making problems. Yield of rib biopsy should be increased by more careful clinical observation, including critical evaluation of bone scans, avoiding overinterpretation of physical findings and observing for healing of possible rib fractures.

Gallstones, cholecystitis and diabetes.

Findings from studies showing an increased incidence of gallstones in diabetic patients do not control for other variables, such as obesity. There is no proof that diabetic patients have more gallstones. Gallstones do not cause diabetes mellitus. The principal gallbladder pathologic feature in diabetic patients is a functional deficit of uncertain etiologic factors, creating a large, flaccid, poorly emptying organ. Bile acid and lipid composition are usually increased in diabetic patients. Cholecystitis seems to be a more serious disease in diabetic patients, with worse infectious sequelae and more rapid disease progression. This conclusion has not been examined statistically. Even with modern care, the complication rate for operations upon the biliary tract in patients with diabetes is increased. Those with diabetes are generally older than other patients requiring cholecystectomy. Systemic changes of aging partly explain increased morbidity and mortality. Diabetic patients with symptomatic gallbladder disease usually require operation. Risk of cholecystectomy in diabetic patients is similar to that in nondiabetics. Prophylactic cholecystectomy for diabetic patients with "silent" gallstones was formerly recommended because of an apparent high risk of cholecystitis. Until the natural history of gallstones in those with diabetes has been defined, such patients should be considered in danger of serious illness. The risk of acute cholecystitis in diabetic patients with stones is probably significant enough to warrant the performance of early cholecystectomy.

The Y anastomosis of César Roux.

RYA was designed to avoid biliary reflux, which complicated earlier forms of gastrojejunostomy. The emerging popularity of the procedure was squelched by the frequent complication of gastrojejunal stomal ulceration. RYA returned from surgical oblivion after World War II in its use in replacing the esophagus and stomach. It is now commonly used to drain other organs, mainly the biliary system, and in various remedial operations for complications from gastrectomy. Conversion to RYA is efficacious for the treatment of inflammation of the stomach and esophagus caused by alkaline reflux. The main complication of RYA is Roux Y syndrome, secondary to gastric or efferent jejunal stasis, or both. Peptic ulceration is much less a problem since the advent of vagotomy. Better understanding of the physiologic characteristics of various forms of RYA should soon better define the limits of its clinical application.

Clinical efficacy of temporal artery biopsy in Nashville, Tennessee.

A retrospective study of temporal artery biopsies done over one decade in four Nashville hospitals yielded 412 procedures on 394 patients. Diagnosis was obtained in 17%, and the procedure was helpful in 21% of patients. Only two complications were recorded. There was no correlation between length of biopsy specimen and diagnostic yield. The Nashville experience with temporal artery biopsy is probably representative. Some refinement of procedure application appears necessary.

Prospective analysis of the effect of incidental appendectomy on infection rate after cholecystectomy.

I prospectively studied 100 patients to see whether "incidental appendectomy" with cholecystectomy affects wound infection rate. Randomization resulted in groups similar in age, habitus, and sex. Forty-seven patients had appendectomy. The most frequent gallbladder disease was chronic calculous cholecystitis. Positive cultures were obtained from 11% of gallbladders. The mean age of patients with gallbladder bacteria was 14.5 years older than that of the series. True pathologic changes were seen in 6% of appendices. Average operative time was extended six minutes by appendectomy. Length of postoperative hospital stay was unchanged by the addition of appendectomy. There were no infections in the patients without appendectomy and one (2%) in the group with appendectomy. The total 1% infection rate is considerably below most reported rates. There was no difference in infection rate between groups with and without appendectomy (P = .47). Unless the procedure is technically difficult, appendectomy with elective cholecystectomy does not increase the chance of infection.

A comparison of Levin and sump nasogastric tubes for postoperative gastrointestinal decompression.

Prospective analysis of the relative postoperative efficacy of Levin and sump nasogastric tubes was performed. One hundred cases using each tube were randomly selected. Operations in the two groups were similar. Mean output per hour from the tubes was close: 25.29 cc from Levin, and 26.56 cc from sump tubes. Analysis of variance showed no significant difference. There was a difference (P = .05 level) in hourly drainage from women patients, 20.49 cc from Levin, and 25.14 cc from sump tubes. There were no major complications attributable to the tubes. Output from tubes was usually low in early postoperative hours, rising steadily for the first 3 days. Drainage per nursing shift decreased throughout the day. Fever is associated with nasogastric tube use. In the absence of other etiology, a diagnosis of "tube fever" can be made. There is no difference in the clinical efficacy of Levin and sump tubes. There is no scientific basis for the prevalent use of sump tubes.

Hemopneumothorax: complication of tunneler use in axillofemoral bypass.

Two cases of accidental entrance of the thorax with a vascular tunneler are reported. Passage of this instrument when performing axillofemoral bypass is probably safer when done in a cephalad-to-caudad direction. A counterincision at the costal margin may be helpful in avoiding the complication, especially when the tunneler is passed from the groin.