Intestinal obstruction from midgut volvulus after laparoscopic cholecystectomy

Congenital midgut malrotation, a rare anatomic anomaly that can lead to duodenal or small bowel obstruction, rarely is recognized beyond the first year of life. We report a case of unrecognized congenital midgut malrotation that resulted in midgut volvulus, causing intestinal obstruction and requiring emergent reoperation after laparoscopic cholecystectomy. This unusual complication, first reported in 1994, involved a 56-year-old man and resulted in cecal infarction recognized and treated on the second postoperative day. This second case describes a less acute postoperative course, with multiple bouts of partial bowel obstruction leading to two readmissions and finally resulting in a reexploration and definitive treatment on the 19th postoperative day. Received: 16 February 1999/Accepted: 22 March 1999     

Sphenoidal sinus mucocele after transsphenoidal surgery for acromegaly

This report concerns one case of a sphenoid sinus mucocele occurring 17 years after transsphenoidal surgery for acromegaly. In 1979, a 51-year-old man was successfully operated by the transnasal transsphenoidal approach for a growth hormone (GH) adenoma 1 cm in diameter. In 1996, the patient was hospitalized for headaches and diplopia. He presented a loss of right visual acuity with paralysis of the right oculomotor nerve. The basal GH level was normal with a satisfactory decrease after oral glucose ingestion. Pituitary sellar radiography showed a disappearance of the posterior clinoid while magnetic resonance imaging revealed the existence of a bilocular, circular, homogeneous lesion of the sphenoid sinus 3 cm in diameter with a posterior and lateral extension. The diagnosis of mucocele was confirmed by surgical treatment, allowing drainage of the mucocele through a transsphenoidal approach. The drained material was composed of sinus epithelium containing many polynuclear and resorptive cells. Postoperatively, the symptoms decreased dramatically, leading to full recovery of visual function and disappearance of the headaches. Apart from the tumor recurrence, the mucocele of the sphenoid sinus can be evoked as a possible long term complication of transsphenoidal sugery for pituitary adenoma. Received: 2 June 1998 / Accepted: 23 February 1999     

Patterns of success and failure with laparoscopic Toupet fundoplication

Background: Advocates of the Toupet partial fundoplication claim that the procedure has a lower rate of the side effects of dysphagia and gas bloat than a complete Nissen fundoplication. However, there is increasing recognition that reflux control is not always as good with the Toupet procedure as with the Nissen. Therefore, we set out to evaluate the factors contributing to success and failure in patients who underwent laparoscopic modified Toupet fundoplication (LTF). Methods: A total of 143 patients undergoing LTF for documented gastroesophageal reflux disease (GERD) were evaluated prospectively in regard to their outcomes over a 4-year period. All patients had preoperative esophagogastroduodenoscopy (EGD) and manometry; 24-h pH testing was used selectively. Esophageal manometry was requested of all patients 6 weeks postoperatively. Clinical follow-up was by office visit or questionnaire every 6 months after surgery; patients with significant problems were investigated further. Failure was defined as the development of recurrent reflux documented by endoscopy, 24-h pH test, or wrap disruption on barium swallow, or severe dysphagia persisting >3 months and requiring surgical revision. Results: At a mean follow-up of 30 months (range, 3–51), 21 of 143 patients failed LTF; two had dysphagia and 19 had recurrent reflux. Failure was associated with preoperative findings of a defective lower esophageal sphincter (LES) (14/21), complicated esophagitis (13/21), and failure to divide short gastric vessels (12/19) (chi-square p < 0.05). Defective esophageal body peristalsis, present in 14 patients, resulted in failure in six cases. Presence of either complicated esophagitis or a defective LES was associated with a 3-year 50% success rate, whereas presence of mild esophagitis and a normal LES was reflected in a 96% 3-year success rate. Conclusion: Laparoscopic Toupet fundoplication should be reserved for milder cases of GERD, as assessed by manometry and endoscopy. Received: 29 June 1998/Accepted: 2 July 1999     

The origins of surgery: 1. From prehistory to Renaissance*

The art, craft and science of surgery is a highly interpersonal skill, central to a variety of traditions and cultures throughout human history. The development of surgery parallels the evolution of the human race from prehistory to the present time. This review attempts to examine the changing concepts and practices in surgery from the earliest era, enshrouded in mysticism and magic, through a manual craft performed by barbers and artisans, to a dignified profession based on science and technology. The evolution of surgery in the previous millennia is reviewed against the culture and morals, the politics and religion, and the philosophy and science of its period; in so doing assessing its perspective on the threshold of a new millennium.      

Subarachnoid anesthesia in young patients: a comparative analysis of two needle bevels

BACKGROUND AND OBJECTIVES: This prospective, randomized, double-blind study compares the efficacy of two spinal needles in terms of their performance characteristics and associated perioperative complaints in young patients. METHODS: ASA I and II patients aged from 20 to 40 years undergoing lower limb orthopedic surgery were included during a 12-month period. After application of the protocol, 158 patients were recruited. The patients were randomized to two groups: group I: 26-gauge Atraucan (n = 79) and Group II: 27-gauge Whitacre (n = 79). A study was made of the demographic parameters, technical characteristics, and peri- and postoperative complications. RESULTS: No significant differences were found in the technical handling of the needles, number of attempts made to achieve the puncture, or the time required to perform the technique. No technical failures (spinal anesthesia inadequate for the planned surgery) were reported, and the frequency of complications during the procedure was identical in both groups. Frequency of postdural puncture headache (3.8%) or severity and duration showed no difference between the two groups. The overall assessment of postoperative complications revealed similar scores for both needles. CONCLUSIONS: Technical handling (ease with which block was performed) of the needles analyzed was extremely easy, showing a high success rate which associated with the similar incidence of complications. Type of bevel does not appear to be a determining factor in the quality or morbidity associated with subarachnoid block when fine-gauge needles are used in young patients.     

Prevention of postoperative vomiting with granisetron in paediatric patients with and without a history of motion sickness

A history of motion sickness is one of the patient-related factors associated with postoperative emesis. This prospective, randomized, double-blind, placebo-controlled study was undertaken to assess the efficacy of granisetron, a selective 5-hydroxytryptamine type 3 receptor antagonist, for preventing postoperative vomiting after tonsillectomy in 120 children with (n = 60) and without (n = 60) a history of motion sickness. Patients received a single dose of granisetron (40 micrograms.kg-1) or placebo (saline) (n = 30 of each) intravenously after an inhalation induction of anaesthesia. A complete response, defined as no vomiting, no retching and no need for another rescue medication, during the first 24 h after anaesthesia was 77% and 13% in patients with a history of motion sickness who had received granisetron or placebo, respectively; the corresponding incidence was 83% and 40% in those without it (P < 0.05; chi 2 test with Yates' continuity correction). No clinically serious adverse effects due to the study drug were observed in any of the groups. In conclusion, prophylactic antiemetic therapy with granisetron is effective for preventing postoperative emesis in children with a history of motion sickness as well as in those without it.     

Increased extracellular brain water after coronary artery bypass grafting is avoided by off-pump surgery

OBJECTIVE: To determine if coronary artery bypass graft (CABG) surgery without cardiopulmonary bypass (CPB) avoids the brain swelling known to occur after CPB, to quantify these brain water compartment changes, and to identify the water shifts as due to intracellular or extracellular water. DESIGN: Prospective, controlled, and blinded. SETTING: Cardiac surgical unit in a university teaching hospital. SUBJECTS: Patients scheduled for CABG who were assigned to conventional (n = 10) or off-pump (n = 7) surgery according to their coronary anatomy. INTERVENTIONS: Magnetic resonance imaging (MRI) examinations were performed 1 day before surgery and 1 hour and 1 week after CABG surgery. MAIN OUTCOME MEASURES: Extracellular and intracellular water homeostasis was described quantitatively by calculating the averaged apparent diffusion coefficient of brain water using diffusion-weighted MRI. Blinded visual ordering of the images from the three examinations was performed according to brain size using conventional MRI. RESULTS: The average diffusion coefficient of brain water increased 4.7%+/-1.5% immediately after CABG with CPB and normalized after 1 week but did not change after CABG without CPB. No focal ischemic changes were seen in either group, and no gross neurologic deficits were observed. Visual analysis showed consistent brain swelling after CPB and variable changes in those operated without CPB. CONCLUSION: Changes consistent with increased extracellular brain water seen after CABG with CPB were not observed in patients undergoing CABG without CPB. The clinical significance of brain water changes and increased brain water content after surgery with CPB remains undefined.     

111例血管损伤的诊治体会

回顾分析10年间我院收治的血管损伤病例的病因、临床表现和经验。方法和结果:111例(12～55岁)血管损伤的原因有钝性损伤、刀刺伤、枪弹伤。下肢50例,上肢36例,颈部13例,腹部12例。67例(60％)合并有骨和周围神经损伤。20例(18％,四肢17例,腹部3例)行血管造影和超声多普勒检查。17例(15％)在清创手术时未发现血管损伤,日后形成假性动脉瘤,4例伤后形成动-静脉瘘而再度就诊。动脉损伤的治疗:侧壁修补43例,损伤段动脉切除吻合25例,自体静脉移植8例,人工血管移植5例和动脉结扎1例。静脉损伤治疗:侧壁修补10例,损伤段静脉切除吻合6例,静脉补片1例,静脉结扎2例及非手术治疗1例,腹主动脉和腔静脉损伤者死亡3例(3％)。四肢血管损伤肢体存活率为97％。结论:手术探察是目前急诊诊断血管损伤的主要方法;术前血管造影检查对血管损伤的诊断具有决定意义;术式选择和合并脏器损伤的处理应根据伤情而定。     

区域动脉灌注治疗重症急性胰腺炎116例报告

目的为探讨提高重症急性胰腺炎的疗效。方法应用Ｓｅｌｄｉｎｇｅｒ法,置导管于胰腺病变供血动脉内,灌注抑酶制剂和抗生素,以提高进入胰腺组织内的药物浓度,达到控制胰腺病变和预防继发性感染的目的。结果通过１１６例区域动脉灌注的方法和综合疗法,明显减少了坏死胰腺组织的感染,降低了死亡率。结论该法是治疗重症急性胰腺炎的新疗法,特别适合于胰腺早期病变的治疗。     

Criteria and benchmarks for laparoscopic cholecystectomy in a free-standing ambulatory center.

BACKGROUND AND OBJECTIVES: Keys to economic survival in an era of decreasing reimbursement include controlling costs and avoiding complications. In an effort to reduce costs, laparoscopic cholecystectomy has been performed with same-day discharge from a hospital setting. The free-standing ambulatory surgery center offers even greater cost savings if safety can be assured. Facility charges, surgical technique and instrument selection influence the costs of the procedure. METHODS: A database was accumulated prospectively on the first 100 laparoscopic cholecystectomies performed in a free-standing ambulatory surgery center to assess costs, logistical constraints, and safety. RESULTS: Laparoscopic cholecystectomies were accomplished in 99 of 100 patients. One patient was suspected of having cancer during laparoscopy and was transferred to a nearby hospital for open cholecystectomy. There were no other postoperative hospitalizations for complications. The fixed facility charge for the procedure was $2,990, and the total costs for all routinely disposable items (gowns, gloves, instruments, and adhesive bandages was $98. The mean OR time was 29 minutes (standard deviation 13.7). CONCLUSIONS: The free-standing ambulatory surgery center is an appropriate facility for an experienced operating team to perform laparoscopic cholecystectomy in selected patients. The surgeon's selection of appropriate energy sources and instruments is essential to complete the operation in a most cost-effective manner.