Acute hemiballismus after carotid endarterectomy--a case report.

A 72-year-old woman who experienced a postoperative stroke after a carotid endarterectomy with the presenting symptom of hemiballismus is described. This unusual presentation was likely the result of a hypotensive episode coupled with a predisposing anatomic variant in the circle of Willis, which compromised blood flow in the posterior cerebral circulation. She responded well to treatment with haloperidol with complete resolution of hemiballistic movements.

Intraoperative sentinel lymph node mapping in patients with colon cancer.

BACKGROUND: The sentinel lymph node (SLN) mapping technique has been used in breast cancer and melanoma, and was recently described for colon cancer. METHODS: Thirty-five patients with colon cancer underwent intraoperative SLN mapping. One milliliter of 1% isosulfan blue was injected subserosally around the tumor. The first nodal area that was highlighted with blue was identified as the SLN. All lymph nodes underwent examination with hematoxylin and eosin (H&E) stain. SLNs underwent additional sectioning and were stained with CAM 5.2. RESULTS: Lymphatic mapping adequately identified the SLN in 25 patients (71%). In the 15 cases where the SLNs were negative for metastases, all other non-SLNs were also negative (0% false negative rate). The SLN was the only site of metastases in 6 (17%) of 35 patients. CAM 5.2 staining provided the only evidence of micrometastases in 4 (11%) of 35 patients. CONCLUSIONS: Intraoperative SLN mapping is a feasible technique with a reasonable SLN identification rate (71%). The absence of metastases in the SLNs accurately predicts the status of the non-SLNs. Tumors in 11% of patients were upstaged by the demonstration of micrometastatic involvement, and these patients may benefit from further adjuvant chemotherapy.

Microlaparoscopic cholecystectomy. Less invasive gallbladder surgery.

BACKGROUND: We set out to compare a prospective evaluation of microlaparoscopic cholesystectomy (MLC) using 5-mm ports for the scope and operating ports and two 2-mm ports for retracting to the historic results of standard laparoscopic cholecystectomy (SLC). METHODS: Fifty-six consecutive patients were operated electively for symptomatic gallstones between June 1997 and July 1998. Demographics, history of prior abdominal surgery, operative time, resident level, need to convert, length of stay, and postoperative analgesia were recorded for each case. In all, 43 women and 13 men aged 21 to 89 (average, 51 years) underwent MLC. Average weight was 78 kg (range, 48-119) and average height was 163 cm. RESULTS: Operative time for MLC was 72+/-25 min (range, 35-140), somewhat less than the referenced standard of 79+/-27 min (p = 0.1). The skin-to-trocar time (6+/-2 vs. 13+/-77 min) and intraoperative cholangiogram time (9+/-8 vs. 11+/-6 min) were significantly shorter (p<0.01 and p<0.05, respectively) for MLC. Other partial times were not significantly different. PGY2 residents averaged 74+/-21 min (range, 44-118) compared to 75+/-27 min (range, 35-140) for PGY3 and 53+/-5 (range, 43-59) for PGY5. Patient weight influenced time. Patients <65 kg averaged 56 +/-12 min; 66-80 kg, 72+/-24 min; 81-95 kg, 78+/-26 min; and >95 kg, 85+/-22 min. Previous abdominal surgery did not affect operative time. Nine patients (16%) required conversion from 2- to 5-mm ports because of adhesions, wall thickening, or need for better retraction. Time in these patients was 95+/-26 min vs. 68+/-21 min in other patients (p<0.01). No patient was converted to an open procedure. Three patients (5%) had a positive cholangiogram and common bile duct exploration that required placement of an extra 5-mm trocar. Five patients (9%) required insertion of an additional 2-mm port. All patients received patient-controlled analgesia (PCA). Morphine use was 0.21+/-0.19 mg/kg (range, 0-0.8). Hospital stay was 1.31 days (range, 0.5-4). Subjective satisfaction was excellent because of smaller incisions. No additional morbidity was seen with MLC. CONCLUSION: MLC is a feasible and safe approach that provides similar times to SLC with better cosmesis, a less painful recovery, and possibly an earlier return to normal activity.

Dynamic CT in the preoperative evaluation of patients with gastric cancer: correlation with surgical findings and pathology.

BACKGROUND: The use of diagnostic techniques in the preoperative staging of patients with gastric cancer must be better defined. To further clarify which technique is indicated, we applied a new modality of computed tomography (CT) scanning for patients with gastric cancer. METHODS: Dynamic CT of the abdomen using water as oral contrast agent was performed in 30 patients with gastric adenocarcinoma. Patients without evidence of metastatic disease underwent exploratory laparotomy and intraoperative staging. Resectable patients had surgical excision and definitive pathologic staging. RESULTS: Two patients (7%) had metastatic disease by CT and were considered inoperable. The remaining 28 underwent laparotomy. Of these, six (21%) were unresectable and 22 (79%) had surgical resection. Dynamic CT adequately suggested advanced stage disease in four (67%) of the 6 unresectable patients. Wall thickness in dynamic CT correlated with the risk of serosal involvement (P < .001). Both CT and surgery had an accuracy of 64% (P > .05) in predicting pathologic staging. CT overstaged only 4% of cases. CONCLUSIONS: Dynamic CT is a useful modality that can indicate inoperable disease, obviating the need for laparotomy in patients with gastric adenocarcinoma. CT can modify the surgical approach by suggesting unresectable or advanced disease. The low percentage of patients that are overstaged by CT, combined with its similar staging accuracy when compared with laparotomy, support its preoperative use in these patients.