Primary resection and anastomosis for perforated left colon lesions.

The records of 33 patients with perforated left colon lesions over a 6-year period from 1992 to 1998 were examined retrospectively for clinical course and complications. All patients had a free perforation, feculent or purulent peritonitis, and/or a large inflammatory mass. All patients had primary resection and anastomosis without a protective colostomy or ileostomy. Indications included diverticulitis in 28 patients, obstructing colorectal carcinoma in 3, and iatrogenic perforations in 2. Complications occurred in 10 patients, including atelectasis in 1, urinary retention in 2, urinary tract infections in 2, wound infections in 3, line catheter sepsis in 1, and acute tubular necrosis in 1. There was one anastomotic dehiscence, which was successfully converted to a Hartmann procedure. Patients were discharged an average of 7 days after surgery. Two patients required surgery after discharge: one had a fascial dehiscence and the other an incisional ventral hernia. There was no mortality. Primary resection and anastomosis of selected perforated left colon lesions can be performed with a morbidity and mortality rate lower than that usually reported for the Hartmann procedure.

Gallstone pancreatitis in the era of laparoscopic cholecystectomy.

This study focused on the management of all patients admitted with a diagnosis of gallstone pancreatitis (GP) since the advent of laparoscopic cholecystectomy in our institution. The inpatient and outpatient medical records of all 172 patients with GP admitted from November 1990 to June 1995 were retrospectively reviewed. The main outcome measures were the effectiveness of and complications associated with surgical and endoscopic treatment of GP, including the incidence and management of common bile duct stones. One hundred fifty-four patients underwent cholecystectomy (89 laparoscopic and 65 open), usually within 3 to 5 days after admission when the amylase had returned to normal or nearly normal. There was a progressive increase in the use of laparoscopy, with 6 per cent of cholecystectomies in 1991 performed laparoscopically and 88 per cent in the first half of 1995. Overall conversion rate was 16 per cent. A total of 33 patients (19.2%) underwent endoscopic retrograde cholangiopancreatography (ERCP): 9 preoperatively and 12 postoperatively, and in 12 patients it served as definitive treatment due to advanced age and/or serious associated medical problems. Of the 24 positive intraoperative cholangiograms, 14 had common bile duct (CBD) stones. CBD stones were found in a total of only 32 patients (18.6%). Laparoscopic CBD exploration was not performed during this time period. There were 16 (8.6%) complications and two deaths (1.2%). Six patients refused all treatment. There were no unsuccessful postoperative ERCPs, and no patient underwent reoperation. In conclusion, our approach to patients with GP is safe and effective, with a low rate of complications. Considering the relatively low incidence of CBD stones in GP (18.6% in this series), routine preoperative ERCP is not indicated, because it has some risk and the vast majority of studies would be negative. In certain highly selected patients with multiple medical problems and/or advanced age, endoscopic sphincterotomy may be considered the definitive treatment. The optimal management of GP and CBD stones, however, depends on the skills and resources available as well as patient preference.

Selective operative cholangiography in laparoscopic cholecystectomy.

At the Kaiser Foundation Hospital in Los Angeles, 1344 patients underwent laparoscopic cholecystectomy from December 1990 through April 1994. Intraoperative cholangiography was done selectively at the discretion of the surgeon in only 98 (7%) of patients. The most common indications were a history of jaundice, abnormalities of liver function tests, or gallstone pancreatitis. Patients with increasing or persistent liver function test abnormalities and/or ultrasound identification of stones in a dilated common bile duct underwent either preoperative endoscopic retrograde cannulation of the common duct (ERCP) and endoscopic sphincterotomy or open common bile duct exploration, according to their wishes. Laparoscopic common bile duct exploration was not performed. Postoperative ERCP was performed in seven patients with suspected retained stones, but was normal in six. The single patient with a retained stone was successfully treated with endoscopic sphincterotomy. No patient had an unsuccessful ERCP or endoscopic sphincterotomy, and none required reoperation for a retained stone. There were no major common duct injuries. Six patients with small stones in nondilated ducts on intraoperative cholangiography have been followed without intervention and remain clinically well. Routine intraoperative cholangiography is not essential to prevent common bile duct injury or retained stones in laparoscopic cholecystectomy patients.

Outpatient laparoscopic appendectomy.

Laparoscopy has allowed surgeons the ability to perform procedures which result in less postoperative discomfort, earlier return to daily activities, and better cosmesis. For example, laparoscopic cholecystectomy has virtually replaced open cholecystectomy, and many of these operations are performed in the outpatient setting. The role of laparoscopic appendectomy is yet to be defined, however. Over an 18-month period from February 1992 to July 1993, 75 laparoscopic appendectomies were performed at Kaiser Permanente Medical Center in Los Angeles. Thirty-five of the patients undergoing this procedure were outpatients. While there were a total of three complications, including two intraabdominal abscesses, there were no complications in the outpatient appendectomy group. Laparoscopic appendectomy may be safely performed in the outpatient setting in patients with acute nonperforated appendicitis.

Thrombosis of abdominal aortic aneurysms.

The usual complication of abdominal aortic aneurysms is rupture. Although thrombosis of peripheral aneurysms is common, thrombosis of abdominal aortic aneurysms is rare. Sudden thrombosis of abdominal aortic aneurysms constitutes a surgical emergency, with a mortality of 50 percent. The patient often presents with cool and mottled skin, and with severe pain from the umbilicus to the lower extremities. Femoral pulses are rarely present, and neurologic deficits below the level of occlusion are common. We reviewed four recent patients with thrombosed abdominal aortic aneurysms. They presented with a range of symptoms that included impotence, abdominal pain, lower extremity pain, coolness, and weakness. Angiography in three of the patients revealed complete occlusion of the aorta. The fourth patient did not undergo angiography because of hemodynamic instability. Three of the four patients underwent thrombectomy, aneurysmectomy, and bypass grafting. The other patient underwent axillofemoral bypass grafting in lieu of aneurysmectomy because of severe coronary arteriosclerotic heart disease. All patients did well postoperatively. Our limited experience suggests that prompt diagnosis and surgical management of patients with thrombosed aortic aneurysms can lead to a successful outcome.

Long-term follow-up of asymptomatic carotid bruits.

Ninety-seven patients with asymptomatic carotid bruits were followed up 5 to 13 years or until the occurrence of transient ischemic attacks, stroke or death. In 11% of the patients transient ischemic attacks developed and in 19%, strokes. Symptoms that developed in more than half of the patients did so within 2 years and 90% within 6 years of detection of the bruit. Seventeen of 18 strokes occurred without antecedent transient ischemic attacks. Fifty-three of the patients underwent 94 major noncarotid operations with no postoperative strokes. Death occurred in 37% of the patients during the follow-up period, and 90% of the deaths were due to cardiac problems or stroke.

Operative choledochoscopy. Results of a prospective study in several institutions.

A prospective study from six surgical units utilizing choledochoscopy in conjunction with primary choledocholithotomyand cholangiography resulted in an incidence of less than 2 per cent unsuspected residual biliary calculi. Total reliance on choledochoscopy without associated operative cholangiography is not justified and fraught with error. When there are no calculi in the common duct, the choledochoscope allows the surgeon to shorten exploration time with confidence that the postexploratory cholangiogram will confirm his negative findings. The choledoschoscope is of additional value in the extraction of calculi. Certain considerations in the management of biliary tract tumors also can be helped by the addition of choledochoscopy. The simultaneous presence of calculous disease and biliary tract neoplasm can coexist can be brought to light by the use of the choledochoscope. The incorporation of choledochoscopy, using a rigid Berci-Shore choledochoscope, as part of routine common duct exploration, appears to be warranted.

Arteriointestinal fistula: report of a case following surgery for trauma.

A case of an arteriointestinal fistula following surgery for trauma is reported. In prevention of this complication, it is suggested that temporary ileostomy and mucous fistula be considered in cases of combined right colon and intra-abdominal vascular injuries to eliminate a leaking bowel anastomosis as a source of contamination of the vascular repair.

Occult breast carcinomas detected by xeroradiography: clinical considerations.

One hundred and eighty-five breast cancers were demonstrated by xeroradiography in 6,238 patients. Sixty-two cancers were occult, and constituted one-third of the demonstrable breast cancers. Some of the patients with clinically nonpalpable carcinomas had high risk factors known to be associated with the development of breast cancer. The diagnosis was usually established and confirmed by wide excisional biopsy of the area containing the suspicious lesion. In some instances the lesion was localized preoperatively by xeroradiography using a technique of skin markings. Specimen xeroradiography was utilized if there were calcifications seen on the preoperative xeroradiograph. There was a significantly decreased incidence of axillary node metastases in the occult cases when compared to the dominant mass cases.