Results of laparoscopically assisted colon resection for carcinoma.

BACKGROUND: Surgical resection is the primary treatment for colorectal carcinoma. Laparoscopically assisted colon resection technically is feasible for both benign and malignant disease. However, the role of laparoscopically assisted colon resection for carcinoma is controversial. METHODS: We prospectively studied our first 100 patients with colorectal carcinoma who successfully underwent laparoscopically assisted colon resection for the carcinoma. RESULTS: The pathologic stages were Dukes' categories A-16, B-52, C-25, and D-7. Operative mortality and morbidity were 2% and 22%, respectively. During a mean follow-up period of 40.3 months, recurrence by stage was zero patients with stage A disease, five patients with stage B disease, nine patients with stage C disease. Thirteen of these patients died as a result of their disease. At this writing, 60 patients are alive without evidence of disease, and 23 have completed the study disease free after more than 60 months. The 5-year survival probabilities by stage were 100% for stage A, 76.8% for stage B, and 51.7% for stage C. CONCLUSIONS: Laparoscopically assisted colectomy for cancer can be performed safely. The recurrence rate after laparoscopically assisted resection appears to be at least as good as after open resection. Results from ongoing prospective, randomized trials are needed to confirm these findings.

Acute cholecystitis treated urgently by nonselective laparoscopic cholecystectomy.

Beginning in 1990, all patients encountered by the author requiring cholecystectomy were attempted by laparoscopy. This study reports the results of 83 patients with acute cholecystitis who were urgently treated, nonselectively, by laparoscopic cholecystectomy. Acute cholecystitis was diagnosed clinically by the presence of right upper quadrant peritoneal pain, gallbladder phlegmon and fever, and/or increased white blood cell count. In addition, a confirming pathology report and/or elevated white blood cell count was present in all 83 patients. Age ranged from 18 to 82 years with an average of 39.4 years. Fifteen patients were male and 68 female. Insufflation was obtained in all patients without a complication. Discharge occurred by postoperative Day one for 24 patients, Day two for 66 and by Day three for 75 patients (range 19-300 hours). No patient had common duct stones. Most patients had stones impacted in the cystic duct, including one patient who had Mirizzi's syndrome. Operative time ranged from 28 to 300 minutes, with an average of 106.3 minutes. No conversion to open cholecystectomy was required. Complications included bile spillage in five patients, stone spillage in ten, and ileus in three patients. One patient with Mirizzi's syndrome required a postoperative radiological procedure for removal of a cystic duct stone remnant that was not completely removed at the time of operation. The high complication rate initially associated with laparoscopic cholecystectomy probably resulted from violating cardinal principles of surgery, not from the inappropriateness of laparoscopy. In conclusion, it is recommended that urgent laparoscopy is an appropriate initial approach for patients with acute cholecystitis.

Breast biopsy for nonpalpable lesions: a worthwhile endeavor?

The purpose of this study was to determine our yield of carcinoma in patients with a nonpalpable mammographic abnormality and to identify which mammographic criteria will most likely yield a positive biopsy. We conducted a review of all patients with nonpalpable mammographic abnormality who underwent needle-localized breast biopsy at our institution from 1988 to 1991. Charts of 295 patients who underwent 332 needle-localized breast biopsy were reviewed for age, family history, cancer history, mammographic findings, operative time, volume of excised breast tissue, and histology. Mammographic abnormalities were categorized as suspicious (clustered) microcalcification, stellate mass, ill-defined mass, well-circumscribed mass, developing density, or asymmetric density. The overall yield of cancer positive biopsies was 48 of 332 (14.5%). The frequency of diagnosed cancers was DCIS (8), LCIS (1), Stage I (31) and Stage II (8). The frequency that each single mammographic criteria resulted in a cancer diagnosis was: suspicious calcification (12%), stellate mass (22%), ill-defined mass (14%), well-circumscribed mass (11%), developing density (9%) and asymmetric density (0%). However, patients with both a stellate mass and microcalcifications formed the highest risk subgroup, with cancer detected 66 per cent of the time (P = 0.03).

Hypertension in pregnancy: preeclampsia-eclampsia.

Diagnosis of preeclampsia involves consideration of many different factors. It is desirable to make the diagnosis early in the disease course for the best possible outcome for mother and fetus. Overdiagnosis may occur in some cases; however, given the severe maternal and fetal morbidity in cases of untreated disease, it is best to monitor and treat symptoms before they become severe. Overall goals of treatment include prolonging the pregnancy as long as possible without compromise of maternal health, while monitoring the fetus for signs of distress. Treatment for the mother is symptomatic, with seizure prophylaxis and hypertension control. In gestations less than 32 weeks, it is desirable to expose the fetal lungs to at least 48 hours of corticosteroids before delivery to enhance lung maturity. Studies of preeclampsia have demonstrated high fetal morbidity/mortality for gestations less than 24 weeks. With expectant management, decreased fetal morbidity and mortality are shown for both 24- to 27- and 28- to 34-week gestations. Secondary to excellent fetal survival, immediate delivery is indicated for severe disease at gestation greater than 34 weeks.