Laparoscopically assisted abdominal aortic aneurysm repair: first 20 cases.

PURPOSE: Laparoscopic surgery decreases postoperative pain, shortens hospital stay, and returns patients to full functional status more quickly than open surgery for a variety of surgical procedures. This study was undertaken to evaluate laparoscopic techniques for application to abdominal aortic aneurysm (AAA) repair. METHODS: Twenty patients who had AAAs that required a tube graft underwent laparoscopically assisted AAA repair. The procedure consisted of transperitoneal laparoscopic dissection of the aneurysm neck and iliac vessels. A standard endoaneurysmorrhaphy was then performed through a minilaparotomy using the port sites for the aortic and iliac clamps. Data included operative times, duration of nasogastric suction, intensive care unit days, and postoperative hospital days. Pulmonary artery catheters and transesophageal echocardiography were used in seven patients. For these patients data included heart rate, pulmonary artery systolic and diastolic pressures, mean arterial pressure, central venous pressure, pulmonary capillary wedge pressure, cardiac index, and end diastolic area. Data were obtained before induction, during and after insufflation, during aortic cross-clamp, and at the end of the procedure. RESULTS: Laparoscopically assisted AAA repair was completed in 18 of 20 patients. Laparoscopic and total operative times were 1.44 +/- 0.44 and 4.1 +/- 0.92 hours, respectively. Duration of nasogastric suction was 1.3 +/- 0.7 days. Intensive care unit stay was 2.2 +/- 0.9 days. The mean length of hospital stay was 5.8 days excluding three patients who underwent other procedures. There were two minor complications, one major complication (colectomy after colon ischemia), and no deaths. For the eight patients who had intraoperative transesophageal echocardiographic monitoring, no changes were noted in heart rate, pulmonary artery systolic pressure, pulmonary capillary wedge pressure, and cardiac index. Pulmonary artery diastolic pressure and central venous pressure were greatest during insufflation without changes in end-diastolic area. Volume status, as reflected by end-diastolic area and pulmonary capillary wedge pressure, did not change. CONCLUSIONS: Laparoscopically assisted AAA repair is technically challenging but feasible. Potential advantages may be early removal of nasogastric suction, shorter intensive care unit and hospital stays, and prompt return to full functional status. The hemodynamic data obtained from the pulmonary artery catheter and transesophageal echocardiogram during pneumoperitoneum suggest that transesophageal echocardiography may be sufficient for evaluation of volume status along with the added benefit of detection of regional wall motion abnormalities and aortic insufficiency. Further refinement in technique and instrumentation will make total laparoscopic AAA repair a reality.

Utility of transesophageal echocardiography and pulmonary artery catheterization during laparoscopic assisted abdominal aortic aneurysm repair.

BACKGROUND: Advanced laparoscopic procedures are more commonly performed in elderly patients with cardiac disease. There has been limited data on the use of pulmonary artery catheters (PAC) and transesophageal echocardiography (TEE) to monitor hemodynamic changes. METHODS: We prospectively studied eight patients undergoing laparoscopic assisted abdominal aortic aneurysm repair. All patients had a PAC and all but one had an intraoperative TEE. Data included heart rate (HR), temperature (temp), pulmonary artery systolic (PAS) and diastolic (PAD) pressures, mean arterial pressure (MAP), central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), cardiac index (CI), mixed venous oxygen saturation (MVO2), and oxygen extraction ratio (O2Ex) and was obtained prior to induction, during insufflation, after desufflation, during aortic cross-clamp, and at the end of the procedure. End diastolic area (EDA), a reflection of volume status, was measured on TEE. ANOVA was used for data analysis. RESULTS: No changes were noted in HR, temp, PAS, PCWP, CI, MVO2, and O2Ex. PAD and CVP were greater during insufflation compared with baseline and aortic cross-clamp without associated changes in EDA. MAP was higher at baseline compared with all other times during the procedure. CONCLUSIONS: Insufflation increased PAD and CVP. However, volume status as suggested by EDA and PCWP did not change. These data question the reliability of hemodynamic measurements obtained from the PAC during pneumoperitoneum and suggest that TEE may be sufficient for evaluation of volume status along with the added benefit of timely detection of ventricular wall motion abnormalities.

Is preoperative cardiac evaluation for abdominal aortic aneurysm repair necessary?

PURPOSE: It is reported that 25% to 50% of patients with abdominal aortic aneurysms (AAA) have severe coronary artery disease (CAD) and should undergo an aggressive cardiac workup before AAA repair. In contrast, it has been our policy that patients referred for AAA repairs undergo no cardiac testing before surgery. METHODS: This report reviews the last 113 consecutive patients who underwent elective AAA repair by the senior author using this policy. Seventy-four patients (group A) had only an electrocardiogram before surgery. The remaining 39 patients (group B) were referred having already had additional testing that included a thallium stress test (n = 20), echocardiogram (n = 18), multiple gated acquisition (MUGA) scan (n = 3), cardiac catheterization (n = 8), or some combination of these. RESULTS: There was no statistical difference between group A and group B with regard to age, sex, tobacco use or history of coronary artery disease, diabetes mellitus, stroke (CVA), hypertension, peripheral vascular disease, or chronic obstructive pulmonary disease. Group B more commonly had a history of myocardial infarction (41% vs 19%, p < 0.03) and congestive heart failure (23% vs 7%, p < 0.03). During surgery there was no significant differences in blood loss, transfusion requirements, or operative times. There were no myocardial infarctions in group A and two (5.1%) in group B, which was not significantly different. Other complications, such as CVA, renal failure, pulmonary failure, pneumonia, wound infection, and hemorrhage, were not significantly different between the two groups. Postoperative hospital stay was not significantly different. There were three deaths in the entire series (2.7%), and only one in group B was cardiac-related in a patient with known end-stage cardiac disease and a symptomatic 8 cm AAA. CONCLUSIONS: These data indicate that most patients with AAA can safely undergo repair with no cardiac workup and that cardiac workup before AAA repair contributes little information that impacts on treatment or final clinical outcome. We conclude that cardiac testing in preparation for AAA repair is not usually necessary and that intraoperative hemodynamic management may be the most important variable in determining outcome.

Factors that affect the survival rate of patients with ruptured abdominal aortic aneurysms.

PURPOSE: There has been much discussion in the literature of factors that affect the mortality rate of patients who undergo repair of ruptured abdominal aortic aneurysms. Some studies have suggested restricting patient selection for repair on the basis of certain preoperative factors including age, increased creatinine level, low hemoglobin level, loss of consciousness, electrocardiographic changes, and preoperative cormorbid medical conditions. A retrospective review of 96 patients who underwent repair of a ruptured abdominal aortic aneurysm was performed to determine whether these factors would necessarily be applicable to all populations. METHODS: A retrospective chart review of all patients who underwent repair of a ruptured abdominal aortic aneurysm was performed over a study period of 20 years. Data was analyzed by both univariate and multivariate analysis. RESULTS: The mean age of the patients was 73 years. The intraoperative mortality rate was 23%. The in-hospital mortality rate was 60.4%, with a 30-day mortality rate of 56.3%. By univariate analysis of various factors associated with the mortality rate, hemoglobin level, creatinine level, lowest preoperative and average intraoperative systolic blood pressure, packed red blood cells transfused, estimated blood loss, intraoperative urine output, and temperature were statistically significant. A history of loss of consciousness was also statistically significant. No preoperative comorbid medical conditions were significant, nor was age. On a multivariate analysis, preoperative factors of loss of consciousness, a lowest preoperative systolic blood pressure less than 90 mm Hg, a hemoglobin level less than 10 g/dl, and a creatinine level greater than 1.5 mg/dl were predictive of death. The effects of the hemoglobin level, creatinine level, and loss of consciousness on the mortality rate were strongest in patients who had a lowest preoperative systolic blood pressure greater than 90 mm Hg. In patients who had the sets of preoperative factors that were associated with a 100% mortality rate, there were intraoprative factors that influenced their death. CONCLUSIONS: These findings suggest that the factors (loss of consciousness, creatinine level, hemoglobin level) that are predictive of death may be a reflection of shock in this patient population. Further studies should be directed to optimizing preoperative resuscitation. Patients who have a ruptured abdominal aortic aneurysm should not be denied therapy on the basis of any specific set of preoperative factors.

Laparoscopically assisted abdominal aortic aneurysm repair. A report of 10 cases.

BACKGROUND: Laparoscopic surgery decreases postoperative pain and length of hospital stay. Whether laparoscopically assisted abdominal aortic aneurysm (AAA) repair can be safely and reliably performed is unknown. This prospective study was designed to establish the feasibility of laparoscopically assisted AAA repair and its effects on intraoperative and postoperative variables. METHODS: With IRB approval, 10 patients with infrarenal AAA requiring a tube graft underwent laparoscopically assisted AAA repair. The procedure consisted of laparoscopic dissection of the aneurysm neck and iliac vessels. Then, through an 8-11-cm minilaparotomy, a standard endoaneurysmorrhaphy was performed. Data included laparoscopic and total operative times, blood loss, fluid requirements, duration of nasogastric suction (NGT), and lengths of intensive care unit (ICU) and postoperative hospital stays. RESULTS: Laparoscopically assisted AAA was completed in nine of 10 patients. The first patient was converted to a standard incision because the aneurysm neck could not be adequately dissected. Laparoscopic and total operative times were 1.8 +/- 0.4 and 4.5 +/- 0.7 h, respectively. Mean blood loss was 1 +/- 0.6 l. Intraoperative fluid requirement was 6.6 +/- 1.3 l. The duration of NGT suction was 1.8 +/- 1.0 days. The ICU stay was 2.1 +/- 0.8 days and hospital stay was 6.7 +/- 2.5 days. There were two minor complications and no deaths. CONCLUSIONS: Laparoscopically assisted AAA repair is technically feasible with acceptable blood loss, operative time, morbidity, and mortality. Potential advantages may be early removal of the NGT and shorter ICU and hospital stays. Prospective randomized trials are needed to determine if laparoscopically assisted AAA repair is advantageous.

Cytokines in Crohn's colitis.

BACKGROUND: Increasing evidence points to a pathologic role for cytokines in Crohn's colitis. Levels of cytokines are increased in diseased segments of colon in Crohn's colitis, but no one has studied the concentration of cytokines in clinically and histologically nondiseased segments. METHODS: Mucosal biopsies were obtained from 7 patients with active segmental Crohn's colitis and from 7 controls without inflammatory bowel disease. The concentration of Interleukin (IL)-1 beta, IL-2, IL-6, and IL-8 in patients and controls were determined using enzyme linked immunosorbent assay and compared. Histologic sections were also performed to confirm diseased and nondiseased segments of colon. RESULTS: The concentrations of IL-1 beta, IL-6, and IL-8 were significantly higher in the involved segments of colon (10.3 +/- 4.1, 3.7 +/- 1.0, 34.4 +/- 6.9 picograms [pg] per mg) when compared to controls (1.8 +/- 0.5, 1.1 +/- 0.5, 5.3 +/- 1.0 pg/mg). The concentrations of IL-1 beta, IL-2, and IL-8 (8.5 +/- 2.9, 5.3 +/- 1.2, 26.3 +/- 8.8 pg/mg) in normal appearing segments of colon of patients with Crohn's colitis were also significantly higher than in controls, whose IL-2 level was 2.0 +/- 0.5 pg/mg. IL-1 beta and IL-8 were significantly more concentrated in both the involved and uninvolved colonic segments of patients with Crohn's colitis compared to controls. IL-2 and IL-6 were also more concentrated in Crohn's patients than in controls, but not significantly. The differences in interleukin concentrations between involved and uninvolved segments of colon in patients with segmental Crohn's colitis were not significant. CONCLUSIONS: Although Crohn's colitis is often a segmental disease, concentrations of IL-1 beta and IL-8 are increased throughout the entire colon. These observations reinforce the hypothesis that Crohn's colitis involves the whole colon even when this is not apparent clinically or histologically.

Surgical patients with pseudomembranous colitis: factors affecting prognosis.

BACKGROUND: Although several studies have identified the factors that contribute to the development of antibiotic-associated colitis (AAC), little data are available in regard to those factors that may affect the prognosis of patients with the disease. Therefore we conducted a retrospective analysis of 201 surgical patients with AAC to identify risk factors predictive of increased morbidity or mortality. METHODS: We conducted a review of the charts of 201 surgical patients hospitalized between Jan. 1, 1991, and June 30, 1993, in whom AAC developed. AAC was defined as the presence of diarrhea associated with a positive latex agglutination or toxin assay for Clostridium difficile. An additional 52 procedure-matched charts of patients admitted to a surgical service during the same period were also reviewed and constituted the control group. We analyzed the contribution of 21 variables to prognosis in both groups. RESULTS: There was no difference between the two groups in the preoperative length of stay, the number of antibiotics per patient and the number of antibiotic-days, number of patients receiving preoperative bowel preparation, total parenteral nutrition, and overall mortality rate. Patients in the control group were at increased risk of death if they had a history of preexisting renal dysfunction, prolonged preoperative hospital stay, and a poor nutritional status. AAC developed 10.0 +/- 13.8 days after operation in the study group. All patients were receiving multiple antibiotics at the time of diagnosis (3.6 +/- 7.5 antibiotic), with a mean of 14.3 +/- 20.7 antibiotic-days. The overall mortality rate in the study group was 8%. In five patients (2%) toxic megacolon developed; four deaths occurred among these patients (80% mortality rate). A 25% mortality rate was directly attributable to complications of AAC. Six variables were identified as predictive of increased mortality rate: steroids, laxatives, length of preoperative stay, postoperative interval before the onset of symptoms, use of total parenteral nutrition, and abdominal distention. CONCLUSIONS: AAC carries a significant mortality rate in surgical patients; therefore the diagnosis of AAC should be aggressively pursued and patients with the disease should be promptly treated. Patients receiving steroids, total parenteral nutrition, and multiple antibiotics in whom signs and symptoms of AAC develop late in their postoperative course, and patients with abdominal distention and marked leukocytosis, are at increased risk of dying of AAC and should be aggressively treated.

Inverted papilloma of the nose and paranasal sinuses in children.

Inverted papillomas are rare nasal and sinus neoplasms in children. The disturbing biological characteristics of these tumors seen in adults, including malignant degeneration and the high frequency of recurrence, have been similarly observed in the pediatric population. Therefore, inverted papilloma in children mandates similar treatment to that proven effective in adults, including wide excision and careful histopathological examination of any tissue excised. Radiation therapy should be reserved for those tumors associated with carcinoma. Since recurrences can occur after long periods of time, life-long follow-up is warranted.

Adult supraglottitis due to herpes simplex virus.

Changes in the concepts regarding epiglottis have occurred over the last two decades. Supraglottis, once thought to occur exclusively in the pediatric population, is now recognized in adults. Supraglottis is a well-defined syndrome usually caused by a bacterial infection by Haemophilus influenzae type B. Recently, other organisms have been implicated as etiologic agents in cases of supraglottitis. Documented viral supraglottitis is very rare, and adult supraglottitis due to herpes simplex virus-I has not been reported to our knowledge.

The laryngeal mucocele. Imaging analysis of a rare lesion.

Four patients with laryngeal mucocele (fluid-filled laryngocele) are described. Two laryngeal mucoceles were external, lying outside the thyrohyoid membrane, and two were combined, lying both internal and external to the membrane. The combined laryngeal mucoceles presented with both neck mass and hoarseness. The external lesions and one combined lesion were diagnosed using computed tomography (CT) and ultrasound. Another combined lesion had the benefit of CT and magnetic resonance imaging (MRI) prior to exploration. All were homogeneously hypodense at CT with rim enhancement only in the case of the laryngopyocele. The mucocele evaluated with MRI had homogeneously long T1 and T2 relaxation times similar to cerebrospinal fluid.

Respiratory failure as the initial presentation of myasthenia gravis.

A number of reports describe the otolaryngologic manifestations of myasthenia gravis. Symptoms such as dysphagia, dysarthria, and dysphonia are quite common to myasthenia gravis, yet the usual onset of this disorder is insidious in nature. We report a case of an 18-year-old woman, previously undiagnosed, who presented with acute dysphagia followed by the rapid onset of respiratory failure. The diagnosis and treatment of myasthenia gravis are discussed.

The Indian Health Service record of achievement.

The Indian Health Service (IHS) was transferred from the Department of Interior to the Public Health Service in the Department of Health, Education, and Welfare in 1955. At that time, the general health of Indian people substantially lagged behind the rest of the U.S. population. This gap was reflected in mortality rates which were several-fold higher for Indians, or reflected in time; there were decades between the dates when the U.S. population achieved certain lower death rates compared with the dates when similar reductions were achieved by Indians. As a result of preventive health programs, improvements in sanitation, and the development of a number of medical advances, substantial progress has been achieved in improving the health of American Indians and Alaska Natives. Life expectancy of Indians has increased 20 years between 1940 and 1980. From 1955 through 1982, the death rate for Indian infants dropped by 82 percent. Also, the age-adjusted death rate for tuberculosis decreased from 57.9 per 100,000 population in 1955 to 3.3 in 1983. These and other improvements are summarized in this paper.

The carbon dioxide laser in podiatric medicine.

The CO2 laser has several distinct advantages in its application to soft tissue lesions of the foot. A dry field is obtained with good hemostasis and clear vision, with easy access in confined areas. The laser beam sterilizes as it cuts, reducing the incidence of infection. In sealing lymphatic channels, it may theoretically diminish the risk of metastasis in malignant lesions. Healing occurs with minimal postoperative swelling, scarring, or pain, leading to increased patient comfort. Other areas in which the laser can be helpful are porokeratosis, keloids, spider web varicosities, and tattoos.