Iatrogenic "respiratory acidosis" during laparoscopic preperitoneal hernia repair.

This is the first report, to our knowledge, of a case of massive subcutaneous emphysema during totally preperitoneal laparoscopic hernia repair causing a "respiratory acidosis" with a systemic pH 7.20 and a pCO2 of 64 and PO2 of 84. The acidosis was corrected by increased mechanical ventilation. It appears that because of its lack of defined borders, the preperitoneal space is particularly vulnerable to the formation of massive subcutaneous emphysema. Thus, there is a large potential surface area for CO2 absorption. The complication may be prevented by increased attention to the length of fascial incisions, inflation of balloon expanding devices, and securing gripping devices in the port sites.

Surgery of the sympathetic nervous system.

This article reviews the innervation of the arterial system of the lower extremity, lumbar sympathectomy in vascular surgery, lumbar sympathectomy for digital gangrene and in the prevention of major amputation of the lower extremity and substance P's role in neurogenic inflammatory modulation. Long-term results of lumbar sympathectomy and direct arterial bypass surgery have also been reviewed. In addition to the pilomotor, sudomotor and vasomotor actions of the sympathetic nervous system via its neurotransmitters, the molecular basis of the chronic neurogenic inflammatory reaction have been addressed with special attention to the discovery of substance P in the lumbar sympathetic chain and ganglia of human beings.

Pulmonary blastoma presenting as a solitary lip metastasis: case report and review of the literature.

Pulmonary blastoma (PB) is an uncommon primary lung malignancy. This neoplasm was first described by Barrett and Barnard in 1945. The tumor is composed of immature epithelial and mesenchymal tissues which may recapitulate early embryological lung development. Under the microscope, the globular component resembles immature bronchus and connective tissue as seen in embryonic lung. More than one hundred cases have been reported in the literature. PB is more frequent in older people and in males and tends to affect blacks at younger ages. Symptomatology varies from asymptomatic to symptoms of a non-specific pulmonary disease. Cough, hemoptysis, dyspnea, chest pain, respiratory distress, fever, anorexia and weight loss are the most common presenting features. The most common roentgenologic pattern is a well-demarcated peripheral lesion, encapsulated by compression or atelectatic lung tissue, although in some cases there is a tendency to lobulation and cavitation. The size of the mass varies from a small peripheral nodule to a mass occupying the entire lobe or hemithorax. The treatment of choice has been surgical excision, radiation and, in selected cases, a combination of chemotherapy with radiation. The prognosis of this malignancy is poor; overall five-year survival is approximately 16 percent. No correlation has been established between histopathologic criteria and survival. The factors that indicate poor prognosis are tumor recurrence, metastasis at initial presentation, tumor size over 5 cm and lymph node metastasis. Liver, central nervous system and bones are the most frequent location of distant metastases. A rare case is presented of a pulmonary blastoma with an upper lip metastasis occurring in a paraplegic male. Diagnosis was confirmed by autopsy findings.(ABSTRACT TRUNCATED AT 250 WORDS)

Autonomic dysreflexia revisited.

Autonomic dysreflexia (AD) is a clinical phenomenon that affects patients with spinal cord injury (SCI) above the major sympathetic outflow tract. The lesion is most often at or above the T-6 level. Any noxious stimuli below this level initiate reflex sympathetic activity resulting in life threatening hypertension uncontrollable by the feedback parasympathetic activity. The episodes of hypertension generally persist until the offending stimulus is removed. Absence of higher control over reflex sympathetic activity due to transection of the cord is an anatomical explanation of the phenomenon. Current evidence suggests additional factors such as supersensitivity and possibly increased numbers of spinal alpha adrenoreceptors and peripheral microvascular adrenoreceptors as well as accumulation of substance P below the lesion. It has been suggested that substance P acts as a modulator, initiating the sympathetic event to produce a strong, slow and prolonged excitatory action. Autonomic dysreflexia is further accentuated by the absence of gamma amino benzoic acid (GABA), norepinephrine (NE) and 5-hydroxytryptamine (5-HT) below the lesion. GABA is an inhibitory neurotransmitter. It has been suggested that either NE or 5-HT may also act as an inhibitory neurotransmitter. Resetting of the baroreceptors at a lower level also plays an important role. The anatomical transection at or above T-6 then helps in maintaining and accentuating the biochemical changes that develop in patients with high spinal cord lesions. The current article reviews the pathophysiology and management of this potentially life threatening, yet easily treatable, phenomenon.

The learning curve for laparoscopic cholecystectomy.

The introduction of laparoscopic cholecystectomy (LC) in 1987 has resulted in its wide acceptance by surgeons in the United States. Questions about proper training and learning curve for surgeons wishing to perform laparoscopic procedures have been raised during this period. We retrospectively evaluated 416 consecutive cholecystectomy cases that were performed by eight surgeons in a community teaching hospital. In this report, 374 patients had LC and 42 patients (10%) had an attempted LC, which had to be converted to an open cholecystectomy (CONV). Surgeons A and B performed 40% and 18% of all LC cases, respectively, and were classified as the surgeons with the highest volume of cases. Parameters, including conversion rate, operative time, and complications, were evaluated to define the learning curve. Surgeons A and B experienced 17% and 14% initial conversion rates for the first 35 cases, respectively. These rates dramatically dropped to an acceptable level (4% and 3%) with increased experience. The operative time for surgeon A for the first and last 35 cases improved from 97 +/- 25 min to 74 +/- 32 min (p = 0.01). Although the procedure time for surgeon B improved by 4 min, this difference was not statistically significant. The operative time for all cases was 81 +/- 31 min and 87 +/- 27 min, respectively, for surgeons A and B, which was significantly less than that for other surgeons (p = 0.01). A total of 12 patients experienced complications related to LC. Most of the complications (75%) occurred in the first 30 cases for all surgeons.(ABSTRACT TRUNCATED AT 250 WORDS)

A retrospective analysis of laparoscopic and open cholecystectomies.

A total of 686 consecutive cases were reviewed for comparison between open cholecystectomy (OC) and laparoscopic cholecystectomy (LC). The procedures were performed by the teaching surgical service of a community hospital. Between March 1989 and December 1992, 381 patients had LC, 262 had OC, and 43 patients had attempted LC that was converted to open cholecystectomy (CONV). Postoperative hospital stay for LC was 2.9 +/- 3.7 days (range 12 h to 28 days) and was significantly less than those for OC (12.4 +/- 23.6 days) or CONV (8 +/- 8.3 days) (p < 0.0001). Patients who had LC revealed meaningfully decreased perioperative or postoperative antibiotic use, postoperative temperature elevations, and hospitalization when compared to OC or CONV (p < 0.0001). Bile duct injury was 0.26% with LC and 0.38% with OC. The percentage of postoperative bile leakage was 0.79% and 0.38% for LC and OC, respectively. LC cases were associated with lower complication rates when compared to OC or CONV (p < 0.005). No deaths were observed with LC (0%). However, the mortality rate for OC was 1.5%. The results of LC were more favorable than those of OC and CONV with respect to complications, morbidity, mortality, and length of hospital stay. Based on our experience, the patient outcome for LC was superior to OC.

Aortic blebs: an indication for urgent surgery.

A blister on an aortic aneurysm represents the final stage before rupture, regardless of patient symptoms or aneurysm size. The mechanisms of rupture are unclear but probably involve defects in the elastin and collagen matrices.

Relationship of estrogen and progesterone receptors to prognosis in breast cancer.

To ascertain the role of estrogen (ER) and progesterone (PR) receptors as prognostic indicators of resectable breast cancer, the records of 204 patients were analyzed whose receptor studies were done at the Maimonides Medical Center from 1975 to 1983. All patients had radical or modified radical mastectomies and did not show any evidence of distant metastases at the time of operation. Median follow-up was 37 months. An additional 117 patients received some form of adjuvant therapy, mainly chemotherapy, and were analyzed separately. Life table analysis using the log rank test for measuring significance, and a Cox multivariate analysis was performed. At 48 months, 22% of the ER positive (ER+) group versus 33% of the ER negative (ER-) group had recurred as compared to 16% and 35% for the PR+ versus PR- groups, respectively. Life table analysis of the disease free interval (DFI) showed that the difference between the ER+ and ER- groups was not significant (p greater than 0.1), while the difference in DFI between the PR+ and PR- groups was significant (p less than 0.05). Multivariate analysis revealed that the most important factors in predicting the DFI were nodal status (p less than 0.001), tumor size (p less than 0.025), and progesterone receptor status (p less than 0.05). Estrogen receptor status was not found to be significant. In conclusion, PR- patients have a shorter DFI than PR+ patients and that PR status is a more valuable predictor of DFI than ER status.

Colonic anastomotic disruption in myasthenia gravis. Report of two cases.

Anticholinesterases are the mainstay in the treatment of myasthenia gravis. They are also used in the reversal of neuromuscular blocking agents used during general anesthesia. Their use in gastrointestinal surgery, especially involving anastomosis of the distal ileum or colon, has been implicated in anastomotic disruptions. This paper discusses the controversy in the use of reversal agents (anticholinesterases) in colon surgery and specifically in patients with myasthenia gravis.