Variant arterial anatomy in laparoscopic cholecystectomy.
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Arteries↗
Biomedical subjects
C E Scott-Conner
Publications and source records attributed to C E Scott-Conner.
Pregnancy complicated by carcinoma of the colon above the rectum.
Although rare during pregnancy, colorectal carcinoma is one of the leading three types of cancer in women. In the medical literature, there are only 28 reports of carcinoma of the colon above the rectum concurrent with pregnancy. During the last 8 years in our community, four pregnant women have received care by us for this usually lethal disease. These cases are presented and the pertinent considerations of this pregnancy complication based on the entire collected experience are reviewed. The possibility of this disease must be considered in the obstetric as well as the gynecologic patient.
Adenocarcinoma↗
Laparoscopic appendectomy. Initial experience in a teaching program.
From February 1990 to December 1991, 16 laparoscopic procedures were performed for right lower quadrant pain. There were nine men and seven women, aged 16 to 47 years (mean, 27.2 years). All procedures were performed by surgical chief residents with prior experience in laparoscopic cholecystectomy, first-assisted by an attending surgeon. The appendix was visualized and a definitive diagnosis was made in all patients. One patient with acute salpingitis underwent diagnostic laparoscopy only; two patients underwent laparotomy (perforated appendicitis, perforated diverticulitis). A fourth patient had an acute torsion of an ovarian cyst managed laparoscopically. Laparoscopic appendectomy was successfully performed in 12 patients (acute appendicitis, 9; fibrosis or chronic inflammation, 2; normal appendix, 1). Mean operative time for laparoscopic appendectomy was 95.7 minutes, and mean postoperative stay was 2.5 days. The authors conclude that operative time, diagnostic accuracy, and complication rates for laparoscopic appendectomy are acceptable. Within the context of a training program, laparoscopic appendectomy provides an opportunity for surgical residents to expand laparoscopic skills.
Adolescent↗
Effects of the lithotomy position on arterial blood flow in the lower extremities.
The lithotomy position is known to decrease venous blood flow and predispose to lower extremity venous thrombosis. However, arterial thrombosis secondary to surgical positioning has rarely been discussed. One hundred patients underwent measurements of their ankle-arm index, the ratio of their ankle systolic pressure compared to their brachial blood pressure, preoperatively (AAI); immediately after being placed in the lithotomy position (AAII); and immediately prior to returning to the supine position (AAIII). Comparison of all the ankle-arm indexes revealed significant drops between preoperatively and immediately after being placed in the lithotomy position, and between preoperatively (p less than .01) and immediately prior to the supine position (p less than .05). When only preoperative ankle-arm indexes of 0.99 were examined, a very significant drop of p less than .005 was obtained. No significant drop was seen in the group with preoperative ankle-arm indexes less than 0.99. In view of this pressure drop, standard lithotomy stirrups, such as those usually utilized for OB procedures, should be used with caution for procedures requiring prolonged lithotomy position.
Aged↗
Peritoneal neutrophil chemotaxis is impaired in biliary obstruction.
Previous studies have shown impaired reticuloendothelial function in biliary obstruction. The chemotactic response of polymorphonuclear leukocytes from peripheral blood and peritoneal fluid of jaundiced rats (Group 1) was compared to that of sham operated controls (Group 2) and normal rats (Group 3). Male Sprague-Dawley rats underwent bile duct ligation or sham celiotomy. Studies were performed from 1 to 3 weeks after surgery. Mean serum bilirubin was 6.8 mg percent in Group 1 and normal in Groups 2 and 3. Peritoneal neutrophils were induced by intraperitoneal injection of 10 ml of 10 percent peptone broth 16 hours before the study, harvested from peritoneal fluid and peripheral blood, and isolated on Ficoll-Hypaque. F-met-leu-phe (FMLP) chemoattractant (10(-7) M) was used to induce migration of neutrophils across 3 mu filters. The filters were removed, mounted on slides, stained, and counts averaged for five oil immersion fields for each of three wells. Data were expressed as number of neutrophils per oil immersion field. Peritoneal neutrophil chemotaxis was significantly decreased in Group 1 (10.3 +/- 8.1) compared with Groups 2 (17.0 +/- 7.3) and 3 (20.2 +/- 6.4). A similar trend was noted in polymorphonuclear leukocytes from peripheral blood (Group 1: 13.1 +/- 7.8, Group 2: 18.2 +/- 6.7, Group 3: 17.4 +/- 5.9; P = 0.1). This impairment in neutrophil chemotaxis may contribute to the high rate of septic complications observed in the jaundiced host.
Animals↗
Bacterial phagocytosis in obstructive jaundice. A microbiologic and electron microscopic analysis.
Reticuloendothelial system dysfunction has been suggested as an explanation for the increased susceptibility to infection in patients with obstructive jaundice. In the present study, the response of cholestatic rats to a bacterial challenge was investigated and the uptake of bacteria by their Kupffer cells was examined with the electron microscope. Rats underwent bile duct ligation (BDL, n = 8) of sham celiotomy (SC, n = 8) and were allowed to recover for 10 days. They were then injected with 10(9) Staphylococcus aureus IV and killed at intervals of 15, 30, 60, and 180 minutes after injection. Two from each group were killed at each interval. Quantitative blood cultures were performed, and specimens of liver and lung were obtained for quantitative bacterial culture and processed for electron microscopy. Bacteria were rapidly cleared from the bloodstream of SC animals but persisted in BDL rats. Electron microscopy consistently demonstrated bacteria within Kupffer cell phagocytic vesicles of both SC and BDL animals at each interval selected. There was no morphologic difference in these vesicles between the two groups. Bacteremia persists in BDL rats subjected to a bacterial challenge despite rapid uptake of bacteria in apparently normal phagocytic vesicles. This study suggests a defect in intracellular killing of bacteria, an impairment of delivery of bacteria to RE cells, or a combination of these factors.
Animals↗
Does rapid wound closure improve survival in older patients with burns?
Seventy-five patients more than fifty years of age were admitted for treatment of burns from January 1, 1986, to December 31, 1987, to two community-hospital-based burn units. Patients were managed by a team of burn surgeons at each unit and early excision and grafting was used whenever possible in deep partial-thickness and full-thickness burns. The extent of burn was charted weekly during hospitalization and rate of wound healing was calculated using linear regression analysis. The mean total percent burn was 26.2 per cent (range, 4-85%). The overall mortality rate was 40 per cent. Mortality rate increased sharply by decade from 17.4 per cent for those aged 50-59 years to 100 per cent for the five patients age 90 and more. Excision and grafting were performed in 40 patients; 35 patients were not operated upon. Although hospitalization was somewhat longer in patients treated surgically, survival was better. Excision and grafting should be used when needed to achieve rapid wound closure in patients more than fifty years of age.
Accidents, Home↗
Major hepatic resections: a 10-year experience with emphasis on special problems.
From 1976-1985, 32 patients underwent major hepatic resection at the University of Mississippi Medical Center. This experience was reviewed to determine the relationship of blood loss, postoperative hyperbilirubinemia, and the performance of concomitant surgical procedures to operative mortality, local tumor recurrence, and long-term survival. There were no deaths among 16 elective resections. Of 16 patients undergoing emergency resections, seven died (43.8%). The mortality rate correlated strongly with intraoperative transfusion of more than 10 units of blood and with postoperative hyperbilirubinemia. Performance of additional procedures increased mortality significantly after emergency, but not elective, hepatic resection. Median survival was 53.4 months in patients resected for hepatoma and 33.5 months in those patients resected for metastatic colon lesions. Local recurrence in a patient with hepatoma was managed by resection at 13 months, with no evidence of further recurrence at 69 months.
Adolescent↗
Impaired clearance of Escherichia coli bacteremia in early biliary obstruction.
Adult male rats underwent common bile duct ligation or sham celiotomy. At intervals of 7 and 14 days postoperatively, bacteremia was induced by intravenous injection of 10(9) Escherichia coli or intraperitoneal injection of 10(6) E. coli. Serial quantitative blood cultures and quantitative whole organ cultures were obtained. One week after surgery, clearance of bacteremia was impaired in all of the animals. Clearance of intraperitoneally injected E. coli was less efficient in the duct ligation rats. Fourteen days postoperatively, clearance of bacteremia induced by intravenous or intraperitoneal injection had improved in the sham celiotomy rats but was still significantly impaired in the duct ligation rats. An increased number of viable E. coli were recovered from the lungs of duct ligation rats after intravenous administration. We found that rats with obstructive jaundice do not respond normally to a bacteremia challenge. This impairment in reticuloendothelial function can be noted as early as 1 week after common duct ligation.
Animals↗
Technical considerations in distal pancreatectomy with splenic preservation.
Splenic preservation may be attempted when distal pancreatectomy is performed for nonmalignant disease. The splenic artery and vein can be preserved with meticulous control of the multiple small, thin-walled branches that tether these vessels to the pancreas, allowing splenic salvage. Mobilization of the spleen into the operative field, ligation of the short gastric vessels and splenectomy are not performed. Thus, the operative procedure may be accomplished in carefully selected patients with little increase in operative time or blood loss over conventional distal pancreatectomy with splenectomy.
Humans↗
Thrombotic thrombocytopenic purpura and pancreatitis.
Abdominal pain is frequently encountered in patients with thrombotic thrombocytopenic purpura (TTP). Often the pain is secondary to inflammation of the pancreas. A case is presented in which the usual signs of TTP developed well after the clinical and laboratory demonstration of pancreatitis, raising the possibility that the pancreatic inflammation triggered the onset of TTP. Treatment with plasmapheresis resulted in prompt improvement. TTP should be considered in patients with abdominal pain or pancreatitis in whom thrombocytopenia, microangiopathic hemolytic anemia, neurologic changes, fever, and renal disease are present.
Female↗
Distal pancreatectomy with and without splenectomy. A comparative study.
Twenty-one patients undergoing distal pancreatectomy from January 1980 through April 1987 were studied retrospectively. Group I (n = 10) had distal pancreatectomy with splenectomy, and Group II (n = 11) had distal pancreatectomy with splenic preservation. The groups were comparable in mean age and extent of pancreatic resection. Operative time in Group I patients who did not require additional major procedures was 3.74 +/- 1.01 hours, compared with 2.86 +/- 1.68 hours for similar Group II patients. The overall complication rate in Group I was 40 per cent, including two pancreatic fistulas, one subphrenic abscess, and one gastric fistula. In Group II the overall complication rate was 36.4 per cent, with one pancreatic fistula, one subphrenic abscess, and one colonic fistula. Splenic infarction occurred in only one patient (Group II), in whom both splenic vessels were ligated. No patient developed insulin-dependent diabetes. There were no deaths. The mean hospitalization time was 18.8 days in Group I, and 17.5 days in Group II. Splenectomy should not be considered a routine part of distal pancreatic resection. Splenic preservation can be achieved in selected cases with no increase in complication rate, operative time, or length of postoperative hospitalization.
Adult↗
Quantitation of rate of wound closure and the prediction of death following major burns.
Data were obtained from 100 consecutive patients requiring hospitalization for 2 weeks or more for treatment of major burns. Age, total percentage burn, mechanism of injury, presence or absence of inhalation injury, and outcome were recorded. Serial weekly burn wound maps were used to calculate the wound closure index (WCI), previously defined as the slope of a straight line fitted to percentage burn as a function of time by linear regression analysis. Logistic regression analysis was used to construct an equation incorporating age, percentage burn and WCI. Addition of the WCI significantly improved the discriminant ability of the logistic regression model. The composite index correctly predicted survival in 97 percent of patients. Rapid wound closure, as measured by the WCI, correlated with survival.
Adolescent↗
Effect of cephalosporins on fascial healing after celiotomy.
A 7 day course of either cefonicid or cefazolin significantly reduced mean wound breaking weight after midline celiotomy in Sprague-Dawley rats compared with control animals. This detrimental effect was not seen when each drug was administered as a single preoperative dose. Even a 3 day course of cefonicid was associated with a significant reduction in the weight required to disrupt a healing abdominal closure. An increased incidence of incisional hernias was also noted among animals treated for 7 days with cefonicid or cefazolin. Shorter antibiotic regimens were not associated with an increased frequency of incisional herniation.
Animals↗
Profound suppression of lymphocyte function in early biliary obstruction.
The blastogenic response to mitogens was studied in spleen and lymph node cells from four groups of Lewis rats at 1 to 2, 3 to 5, 6 to 9 and 10 to 14 days, respectively, after common bile duct ligation (CBD) or sham celiotomy (SC). Suppression in the splenocytes' mitogenic response to concanavalin A and phytohemagglutinin was noted as early as 3 days after common bile duct ligation. The response remained suppressed during the period of observation. Lymph node cells manifested a suppressed response to concanavalin A and phytohemagglutinin after 4 days of jaundice. No alteration in splenocyte response to lipopolysaccharide was observed. There was no correlation with the level of serum bilirubin.
Animals↗
Burn area measurement by computerized planimetry.
A microcomputer system was developed which allows the user to draw the contour of a burn on a diagram on the computer screen. The per cent body surface area is then determined by direct area measurement by the computer. A total of 148 weekly burn diagrams ranging from 1% to 71% (mean, 23.7%) body surface area burn in 59 patients were analyzed using this system. Excellent correlation between the computer system and the manual Lund and Browder chart method (correlation coefficient, 0.962; p less than 0.0001) was obtained. Computerized planimetry provides a rapid, simple method of recording data and calculating total per cent burn which compares well with the manual Lund and Browder diagram.
Burns↗
Obstruction of defunctionalized loop ten years after jejunoileal bypass for morbid obesity.
We have reported a case of obstruction due to volvulus of the ileosigmoid anastomosis ten years after jejunoileal bypass. Revision of the ileosigmoid anastomosis with drainage of the defunctionalized limb into the cecum relieved the obstruction.
Female↗
Implications of emergency operations on the colon.
The records of 137 patients undergoing elective colonic operations and 45 patients requiring emergency large bowel operations were reviewed. The mortality rate was 37.8 percent after emergency operations compared with 5.1 percent after elective operations (p less than 0.001). Patient age was not a significant prognostic variable although physiologic status of the patient had a high correlation with both morbidity and mortality. Complications followed 86.7 percent of the emergency operations and 57.7 percent of the elective operations (p less than 0.001). Respiratory failure, renal and hepatic dysfunction, and cardiac events more frequently followed emergency colonic operations. Intraabdominal complications developed after 57.8 percent of the emergency operations compared with 29.9 percent of the elective operations (p less than 0.005). Colonic resection and primary anastomosis in the elective setting was associated with a 7.9 percent mortality rate. A large bowel anastomosis during an emergency operation resulted in a 70 percent mortality rate (p less than 0.001). When emergency colonic operation included creation of a colostomy the mortality rate was 34.4 percent. Although this mortality rate was substantial, it was significantly better than the 70 percent rate that followed attempted anastomosis under unfavorable circumstances (p less than 0.02).
Age Factors↗