Delayed Gastric Emptying after Laparoscopic Anterior Highly Selective and Posterior Truncal Vagotomy

We describe a case of gastroparesis after laparoscopic highly selective anterior and posterior truncal vagotomy in a 30-yr-old male with gastric ulcer disease. Motility studies confirmed the diagnosis, and a pancreatic polypeptide sham feeding study suggested that a complete vagotomy may have been inadvertently performed. The experience with this procedure in gastric ulcer disease is extremely limited; review of the literature of laparoscopic highly selective vagotomy describes only two cases with delayed gastric emptying as defined by radiological examination. In view of the paucity of reports, caution is warranted, and this procedure should be undertaken only in the setting of a controlled trial.     

Primary care referrals for lumbar spine radiography: diagnostic yield and clinical guidelines.

BACKGROUND: Primary care requests for radiographs of the lumbar spine have come under increasing scrutiny. Guidelines aiming to reduce unnecessary radiographs by limiting referrals to patients at high risk of serious disease have been widely distributed. Trial evidence suggests that guidelines can reduce radiography referrals. It is not clear whether this reduction has been achieved in routine practice. AIM: This study, using routine data, was conducted to measure trends in pnmary care referrals for lumbar spine radiography at two hospitals between 1994 and 1999. DESIGN OF STUDY: Analysis of primary care requests for lumbar spine radiography from computerised records. SETTING: Addenbrooke's Hospital, Cambridge (1 July 1994 to 30 June 1999), and Ipswich General Hospital (1 July 1995 to 30 June 1999), United Kingdom. METHOD: All primary care requests for lumbar radiography were identified electronically from computerised information systems. A random sample of 2100 radiography reports were classified according to clinical importance. These classifications were used to examine whether the proportion of radiographs demonstrating potentially more serious findings had increased between 1994 and 1999. RESULTS: There was no evidence that primary care referrals for radiography of the lumbar spine had decreased between 1994 and 1999 at either hospital. General practitioners did not progressively refer more high-risk patients for lumbar radiography. Only a small proportion of patients had important radiographic findings that might warrant specialist referral or specific therapy. CONCLUSION: The implementation of diagnostic guidelines offers much to the NHS. However in these two hospitals, the reduction in radiograph utilisation evident in trials was not achieved. Guideline development is a resource intensive process; distribution must be supported by more effective implementation strategies.     

A comparison of endotracheal intubation and use of the laryngeal mask airway for ambulatory oral surgery patients.

PURPOSE: This study compared current experience with the laryngeal mask airway (LMA) to previous experience with endotracheal intubation for ambulatory patients receiving general anesthesia. PATIENTS AND METHODS: A retrospective comparison of 157 patients (50 endotracheal intubation [ET] and 107 LMA cases) was conducted. The subjects were American Association of Anesthesiologist (ASA) Class I and II patients who underwent outpatient general anesthesia for dentoalveolar surgery. Procedure time, recovery time, and cost of techniques were compared. RESULTS: The patients undergoing a variety of outpatient dentoalveolar surgical procedures under general anesthesia in the LMA group had a shorter procedure time than the ET group (40 vs 44 minutes) and had a significantly shorter recovery time (54 vs 67 minutes). In addition, compared with the cost of delivering care with ET, the LMA provided slightly lower cost per case ($20 to $30 per case compared with $35 to $80 per case), depending on the anesthetic technique used. Comparing the 2 techniques for removal of 4 impacted third molars (25 patients ET and 68 patients LMA) revealed a similar procedure time of 39 minutes for both groups, but a shorter recovery time for the LMA group (54 vs 68 minutes). CONCLUSIONS: Use of the LMA has advantages over endotracheal intubation for outpatients receiving general anesthesia for dentoalveolar surgery.     

Estrogen and progesterone receptor expression in uterine and extrauterine leiomyosarcomas: an immunohistochemical study.

The authors have noted anecdotal cases of extrauterine leiomyosarcomas (LMS) with estrogen receptor (ER) and progester-one receptor (PR) immunoreactivity. However, there are few studies that have compared ER and PR immunoexpression in LMS of uterine and extrauterine origin. The authors obtained a representative formalin-fixed, paraffin-embedded tissue block from cases of uterine LMS (n = 15) and extrauterine LMS (n = 16) from the archives of the Cleveland Clinic Foundation and performed immunohistochemical staining for ER and PR. Staining was evaluated by 2 observers in a semiquantitative manner using the following scale: 0, no nuclear staining; 1+, 1 to 25% of nuclei stained; 2+, 26 to 50% of nuclei stained; 3+, 51 to 75% of nuclei stained; 4+, 76 to 100% of nuclei stained. The majority of uterine LMS stained for ER (13 of 15, 87%), PR (12 of 15, 80%), or both ER and PR (12 of 15, 80%), with most cases showing 3+ or 4+ positive staining. For the extrauterine LMS cases, staining for ER was seen in 4 of 16 cases (25%), staining for PR was observed in 2 of 16 cases (13%), and staining for both ER and PR was seen in 2 of 16 cases (13%). One extrauterine LMS showed 4+ coexpression of ER and PR, but the remaining extrauterine cases showed only 1+ ER and/or PR immunoreactivity. These data suggest that most uterine LMS coexpress ER and PR, and most extrauterine LMS do not stain for these antigens. However, a subset of extrauterine LMS are ER and/or PR immunoreactive. This raises the possibility that hormonal manipulation may be beneficial in the treatment of these therapeutically recalcitrant tumors.     

Renal, cerebral, and pulmonary effects of hypertonic resuscitation in a porcine model of hemorrhagic shock

To determine the safety and efficacy of a hypertonic solution for hypovolemic resuscitation, we compared the acute and delayed effects of hypertonic sodium lactate solution (514 mOsm) to Ringer's lactate solution (274 mOsm) in a porcine model of hemorrhagic shock. Cardiovascular, pulmonary, renal, and cerebral functions were examined in mature swine after their blood volume had been reduced by 40%. Hemorrhage produced significant decreases in blood pressure, cardiac output, and creatinine clearance, which were reversed with resuscitation. Resuscitation with Ringer's lactate solution required significantly more fluid and produced a significantly greater increase in intracranial pressure than did hypertonic sodium lactate solution. HSL produced significant increases in serum sodium and osmolality, which resolved within 48 hours. Hypernatremia and hyperosmolality were not associated with renal or cerebral dysfunction and were corrected through increased sodium excretion, free water intake, and a negative free water clearance.     

Short-Ti inversion-recovery pulse sequence: analysis and initial experience in cancer imaging

Inversion recovery (IR), commonly considered a pulse sequence capable of producing T1-weighted images with excellent display of normal anatomy, is versatile: The null point and peak time provide a useful, succinct summary of the properties of IR and its capacity for producing both T1- and T2-weighted images. Shortening of the inversion time (TI) and creation of a short-TI inversion-recovery (STIR) pulse sequence increases sensitivity to malignancy and other abnormalities by making the effects of prolonged T1 and T2 on signal intensity additive and by nulling the signal from fat. The authors examined over 300 patients with various malignancies and compared STIR images with T1- and T2-weighted images obtained at 0.5 T. In 43 cases, signal-difference-to-noise ratios (SD/Ns) were calculated between tumor, fat, and muscle. In general, STIR images demonstrated tumor as a conspicuously high-intensity area in a background of muted, discernible anatomic detail. The good contrast achieved with STIR sequences between tumor and fat (SD/N = 18.1) and tumor and muscle (SD/N = 12.9) consolidated into a single image the information contained separately on T1- and T2-weighted images, which facilitates efficient detection and localization of malignancy.     

Effects of intra-ischemic blood pressure on outcome from 2-vessel occlusion forebrain ischemia in the rat.

Halothane anesthetized Sprague-Dawley rats underwent 10 min of bilateral carotid artery occlusion with mean arterial pressure (MAP) held at 30, 50 or 60 mmHg. Sham rats did not undergo ischemia. A 7-day recovery interval was allowed. Intra-ischemic electroencephalographic (EEG) changes, behavioral function (Days 5-7), and histologic injury (Day 7) were evaluated. Under similar conditions, cerebral blood flow was determined after 10 min ischemia by the [3H]nicotine indicator fractionation technique. EEG isoelectricity was observed in 11 of 11, 5 of 10, and 2 of 11 rats in the 30 mmHg, 50 mmHg, and 60 mmHg groups respectively. Neither passive avoidance cross-over latencies nor general motor scores were affected by intra-ischemic MAP and no differences from sham performance were observed. The per cent of CA1 neurons counted as dead (left and right hemispheres combined) was significantly affected by intra-ischemic MAP (72, 46 and 28% in the 30 mmHg, 50 mmHg, and 60 mmHg groups, respectively; P less than 0.001). A greater than 50% CA1 neuronal mortality rate was present only in those rats exhibiting EEG isoelectricity. However, the number of rats demonstrating greater than a 25% interhemispheric difference in CA1 neuronal loss was greatest in the 50 mmHg group (P less than 0.02). Hippocampal blood flow decreased in association with severity of hypotension (8 +/- 1, 35 +/- 8, and 48 +/- 2 ml/100 g/min (mean +/- S.E.M.) for 30, 50, and 60 mmHg, respectively; P less than 0.01). Again, however, the greatest variability in blood flow was observed at MAP = 50 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)