Laparoscopic appendectomy for Amyand's hernia: a modern approach to a historic diagnosis.

OBJECTIVES: This study seeks to discuss the management and diagnosis of Amyand's hernia, an exceedingly rare diagnosis. METHODS: The case of a 60-year-old female found to have inguinal appendicitis on preoperative computed tomography imaging is presented. RESULTS: The patient underwent concomitant laparoscopic inguinal hernia repair and appendectomy. DISCUSSION: Laparoscopic management of Amyand's hernia should be strongly considered for repair and resection.

A 2-minute pre-extubation protocol for ventilated intensive care unit patients.

BACKGROUND: Clinicians often are challenged with safely predicting the optimal time of extubation for ventilated patients. Commonly used weaning parameters have poor positive predictive value for successful extubation. METHODS: A total of 213 intubated patients in our 20-bed surgical intensive care unit were enrolled in a trial to test a prospective, observational, 2-minute extubation protocol (TMEP). Daily measurements were obtained on all intubated patients who met criteria, which included adequate oxygenation, systolic blood pressure, heart rate, hemoglobin, Glasgow Coma Score greater than 10t, absence of significant metabolic/respiratory acidosis, and absence of therapeutic or neurologic paralysis. During TMEP, endotracheally intubated patients were physically disconnected from the ventilator for a 2-minute period of observation while spontaneously breathing room air. Patients were extubated if they tolerated the trial without clinically significant desaturation or alteration of vital signs or mental status. RESULTS: The TMEP reliably predicted successful extubations in 203 of 213 patients (95.3%). Patients who required reintubation had a longer intensive care unit stay and a longer hospital stay. CONCLUSIONS: TMEP is a simple and reliable method of predicting successful extubation.

Noninvasive Doppler ultrasonography for assessing cardiac function: can it replace the Swan-Ganz catheter?

BACKGROUND: Cardiac function, including cardiac index (CI), traditionally has been measured by a pulmonary artery catheter (PAC). A noninvasive alternative for measuring cardiac function would offer obvious advantages. METHODS: A prospective study of trauma and nontrauma patients was performed in a surgical intensive care unit over a 3-month period. CI was determined using both a standard PAC and a continuous-wave Doppler ultrasound (UTS). The study had 2 phases: phase I was nonblinded and phase II was blinded; the correlation between UTS- and PAC-derived CI was assessed. RESULTS: A total of 120 paired measurements of CI were observed in 31 patients. The UTS-derived CI measurements showed agreement with PAC measurements in both phase I and phase II of the study with a bias of .06 L/min/m(2) +/- .4 L/min/m(2). Paired measurements correlated well in both phase I (r = .97, R2 = .95, P < .0001) and phase II (r = .93, R2 = .86, P < .0001) of the study. CONCLUSIONS: Doppler UTS correlates well with PAC measurements of CI. This noninvasive modality is an accurate and safe alternative to PAC.

Laparotomy for visceral ischemia and gangrene.

In the six centuries since mesenteric ischemia was first described, multiple factors have been investigated as predictors of bowel viability with little consensus. We retrospectively examined all cases of exploratory laparotomy for suspected bowel ischemia over an 8.5-year period. Patients were grouped into those who had a "positive laparotomy" with findings of bowel ischemia, bowel gangrene, or both (PL) and those who had a "negative laparotomy" with no evidence of compromised bowel (NL). Of the 114 patients, 86 (75%) were in the PL group and 28 (25%) in the NL group. The significant differences between the two groups were the higher prevalence of females in the PL group versus the NL group [71% vs. 50% (P = 0.04)] and the younger age in the NL group versus the PL group [64 +/- 19 vs. 76 +/- 14 (P = 0.0002)]. The groups did not significantly differ with respect to preoperative comorbidities and results of laboratory studies. Two patients in NL group had pneumatosis intestinalis on abdominal CT. One patient in PL group had a negative visceral angiogram. There was no difference in mortality between the groups. No single preoperative study reliably predicted positive findings at laparotomy in our series.

Early pneumoperitoneum after percutaneous endoscopic gastrostomy in intensive care patients: sign of possible bowel injury.

BACKGROUND: Although percutaneous endoscopic gastrostomy may be complicated by iatrogenic bowel injury, most clinicians consider a small pneumoperitoneum on radiographs obtained after the procedure a benign finding of little clinical consequence. The possibility of a relationship between findings of early pneumoperitoneum after percutaneous endoscopic gastrostomy and subsequent iatrogenic bowel injury was examined. METHODS: Charts of 85 patients in a surgical intensive care unit who had undergone percutaneous endoscopic gastrostomy between 2000 and 2005 were retrospectively reviewed. All patients had a follow-up upright chest radiograph obtained after percutaneous endoscopic gastrostomy. The charts of 4 patients with radiographs that showed early pneumoperitoneum were reviewed. RESULTS: Findings were clinically significant in 1 of the 4 patients. That patient had a perforated transverse colon that required surgical repair. The other 3 patients had no complications. CONCLUSION: Pneumoperitoneum after percutaneous endoscopic gastrostomy may be a sign of possible bowel injury and requires further evaluation. It should not be dismissed as benign. Obtaining a chest radiograph after a patient has undergone percutaneous endoscopic gastrostomy is essential.