Biomedical subjects
Publications and source records attributed to C H Andrus.
A case report of a congenital posterolateral diaphragmatic hernia in an adolescent is presented and a technique for thoracoscopic repair of Bochdalek hernia is described. Postoperative discomfort was minimal and the hospital stay was less than 24 hours. Video-assisted thoracic surgery may be the technique of choice for repair of certain congenital diaphragmatic hernias when identified after infancy.
BACKGROUND: Early case reports suggest more frequent and rapid recurrences of carcinoma of the gallbladder after laparoscopic cholecystectomy (LC) than after open cholecystectomy. This cancer has a poor prognosis and occurs in 1 percent of patients who undergo cholecystectomies. STUDY DESIGN: A recent community hospital series of gallbladder carcinoma (GBC) was reviewed and the total reported experience of GBC after LC was compiled. Diagnostic findings were compared for patients with GBC and a consecutive series of 24 patients who had LC for benign disease. RESULTS: Nine patients with GBC were found among 928 patients who had undergone cholecystectomy (0.97 percent incidence). Compared to patients without GBC, patients with carcinoma were older, had thicker gallbladder walls, and had more abnormalities detected intraoperatively (all p < or = 0.05). Recurrence of GBC occurred more rapidly after LC, and in diffuse peritoneal and port sites when compared with recurrence patterns after open cholecystectomy. CONCLUSIONS: In patients with GBC, LC may be sufficient when the disease is confined to the gallbladder mucosa and the gallbladder is excised intact without bile spillage. However, patients whose gallbladders are torn during dissection or patients who have invasive tumors should undergo laparotomy and local reexcision. In situ GBC can be implanted if the organ is torn during dissection. When gallbladders with suspicious wall thickening or adhesions are noted at LC, especially in older patients, the procedure should be converted to open cholecystectomy.
OBJECTIVE: To determine the incidence of jaundice and hyperamylasemia in the absence of common bile duct abnormalities or clinical pancreatitis in patients undergoing cholecystectomy. DESIGN: A continuous, prospective analysis of a consecutive case series was performed on all patients undergoing cholecystectomy. SETTING: An urban, tertiary care university hospital. PATIENTS: Adult patients with gallbladder disease. INTERVENTION: All patients underwent cholecystectomy. MAIN OUTCOME MEASURES: The presence or absence of common bile duct abnormalities was evaluated by cholangiography, and pancreatitis was identified by clinical signs, imaging studies, and direct visual inspection during cholecystectomy. RESULTS: All patients (N = 1746) undergoing cholecystectomy were prospectively categorized as having chronic calculous (n = 1410), acute calculous (n = 217), chronic acalculous (n = 70), or acute acalculous (n = 49) gallbladder disease. It was uncommon for patients with chronic calculous cholecystitis to have an elevated bilirubin level with no choledocholithiasis and a normal common bile duct or to have hyperamylasemia without pancreatitis. Twenty-five percent of the patients with acute calculous cholecystitis had a serum bilirubin level between 34 and 86 mumol/L (2.0 and 5.0 mg/dL) with no common bile duct abnormality and 4% had hyperamylasemia without pancreatitis. Over one third of the patients with acute acalculous cholecystitis had an elevated bilirubin level with a normal common bile duct or an elevated amylase level without pancreatitis. CONCLUSION: Jaundice and hyperamylasemia can be produced by gallbladder disease alone.
Laparoscopic pelvic lymph node dissection has proven to be a reliable, less-invasive method for staging prostate cancer. Presently, no clear indications for its performance prior to radical retropubic prostatectomy are available. With the purpose of identifying clinical parameters by which to better select patients who would benefit from laparoscopic pelvic lymph node dissection, we chose to perform the procedure only in patients considered at high risk for nodal metastasis: clinical stages B2 or C, poorly differentiated tumors, and/or a serum prostatic-specific antigen level of more than 20 ng/dL. We compared the results with those of patients not meeting such parameters. Of 80 men receiving treatment for clinically localized disease, 30 (38%) fulfilled one or more of the criteria. When considering the individual clinical parameters, clinical stage was predictive of nodal involvement in five (26%) of 19 patients, grade was predictive in three (37.5%) of eight patients, and prostatic-specific antigen level was predictive in six (40%) of 15 patients. Statistical analysis confirmed that the prostatic-specific antigen level was the single best predictor of nodal involvement. However, better predictive values were obtained when the different criteria were combined. Nodal involvement was predicted most consistently by a combination of clinical stage and prostatic-specific antigen level.
Patients with cardiopulmonary insufficiency undergoing laparoscopic surgery with carbon dioxide (CO2) pneumoperitoneum may retain CO2 resulting in clinically significant respiratory acidosis. A canine model of pulmonary emphysema induced by papain inhalation was utilized to evaluate the respiratory effects of both CO2 and helium pneumoperitoneum. Prior to papain inhalation and 5 and 8 weeks after initial treatment under general anesthesia, mechanical ventilation was adjusted to maintain the end-tidal CO2 (ETCO2) at 40 mm Hg during baseline and pneumoperitoneum physiologic monitoring periods. Utilizing an analysis of variance, hemodynamic and respiratory physiologic parameters were compared. In this canine model, all dogs demonstrated consistent hypercarbia during CO2 pneumoperitoneum prior to papain treatments, but CO2 retention was significantly increased in the emphysematous state. The occurrence of hypercarbia during CO2 pneumoperitoneum may be underestimated by ETCO2 monitoring as was revealed by an increased PaCO2 (arterial carbon dioxide pressure)-ETCO2 gradient with an increasing time interval between papain exposure and period of physiologic monitoring. Irrespective of the pulmonary condition of the dog, helium pneumoperitoneum did not produce any hypercarbic or acidic changes when compared with the concomitant baseline period of dogs prior to the induction of pneumoperitoneum, thus suggesting that helium pneumoperitoneum may be a reasonable alternative in patients at risk for CO2 retention.
Over the past 22 months, 51 laparoscopic internal vein ligations have been performed to determine its application and practicality in treating the infertile male with varicoceles. Of the 33 cases available for a follow-up of greater than 6 months, 16 pregnancies are reported. Five patients reporting pregnancies refused to submit a postoperative semenogram. Of the reportable series, 17 of 33 had significant improvement in sperm density (51%), 15 of 33 (45%) in sperm viability, and 15 of 33 (45%) in sperm motility. No major complications were seen and minor complications were few and transient. Morbidity was extremely low. Laparoscopic internal spermatic vein ligations would appear to be a reasonable, practical, and effective method to correct varicoceles.
Laparoscopic techniques have expanded the possibilities of endo-surgically approaching urological abnormalities that would otherwise be managed via an open operation. We report on another useful application of the laparoscope, bladder diverticulectomy. A large bladder diverticulum, responsible for incomplete bladder emptying and recurrent urinary tract infections in an 87-year-old man, was successfully excised endoscopically. The technique and possible future indications are described.
The retained bladder of a 27-year-old paraplegic woman suffering from recurrent pyocystis was removed laparoscopically. Operative time was 130 minutes. Postoperative hospital stay was 5 days, which was significantly less than that in 5 similar patients undergoing open cystectomy for vesical empyema in whom the mean hospital stay was 20.6 days. We believe that laparoscopic cystectomy represents a plausible, minimally invasive alternative to standard cystectomy for the symptomatic bladder left behind after supravesical urinary diversion.
The use of varicocelectomy for the treatment of subfertility seems to be incontrovertible. However, there is a difference of opinion as to the proper surgical method of varicocele ablation. The inguinal and high retroperitoneal approaches are the most commonly accepted methods to date. However, significant postoperative morbidity is common and return to normal activity often is prolonged. Also, bilateral operations are being performed more commonly. These considerations have prompted many to search for alternative techniques. We developed a laparoscopic procedure that is as simple and effective as more traditional methods. In addition, it offers lower morbidity, allows for microscopic dissection with preservation of the spermatic artery and is amenable to bilateral ligation without a second incision. Ten patients 16 to 54 years old underwent laparoscopic ligation of the spermatic veins at the internal inguinal ring. The diagnosis was based on physical examination. Indications for the operation were infertility with a stress sperm pattern in 5 patients, testicular atrophy in 4 and scrotal pain in 1. Four patients underwent bilateral ligation. Preliminary followup showed resolution of the varicocele in all patients and disappearance of pain in the patient treated for this symptom. No morbidity related to this procedure has been encountered and all patients resumed normal activity within 2 days. We believe that this new method is a viable alternative for varicocelectomy.
We report on the concomitant removal of an atrophic intrascrotal left testicle secondary to mumps orchitis and a right varicocelectomy for athenospermia done laparoscopically. The procedure proved to be quite simple to complete, avoiding the need for secondary incisions, which would have been required otherwise if a standard open approach was chosen. The convalescence period was uneventful with the patient returning to regular activities within 72 h of the procedure. We feel that in selected cases a laparoscopic orchiectomy offers distinct advantages to conventional open surgical approaches.
BACKGROUND: Parietal cell vagotomy (PCV) is an accepted therapy for peptic ulcer disease. Traditional operative PCV results may be obtained laparoscopically or endoscopically. The purpose of this study was to quantitatively evaluate newer methods of PCV. METHODS: Variations in PCV, gastroscopic chemoneurolysis and laparoscopic photoneurolysis, were evaluated in 20 to 25 kg pigs. Traditional operative PCV was performed by laparotomy and served as the operative control. With a posterior truncal vagotomy, a PCV was performed laparoscopically by an anterior seromyotomy with either operative division of the neurovascular bundles with titanium clips or with a defocused CO2 laser. Transesophageal gastroscopic PCV was performed by transmucosal injections of the chemoneurolytic agents, 0.75% cobaltous chloride or 0.1% benzalkonium chloride. Adequacy of PCV at the time of operation was assessed by endoscopic Congo red testing. Two weeks later, repeat Congo red testing was performed by open gastrotomy. Quantitation of completeness of PCV and statistical comparison was determined by photographing the pentagastrin-stimulated gastric mucosa 5 minutes after Congo red application and subsequent comparison of innervated area versus total gastric mucosal area by a computer-driven digitized area-calculation program. RESULTS: All PCV techniques studied produced significant acid-secretory reduction, and both laparoscopic and gastroscopic PCV denervated the parietal cells in a manner comparable with operative PCV. Laser photoneurolysis could only be accomplished by producing full-thickness necrosis of the gastric wall. Submucosal injection of cobaltous chloride produced granulomatous nodules with foreign body crystals. Unlike operative and laparoscopic PCV, transmucosal gastroscopic benzalkonium PCV did not produce gross gastroparesis. CONCLUSIONS: All evaluated laparoscopic and endoscopic PCV techniques effectively denervated the parietal cells of the porcine stomach when evaluated at 2 weeks after treatment. Gastroscopic submucosal injection of benzalkonium chloride produced effective denervation with no evident histologic tissue changes and suggestive evidence of normal gastric emptying. Further evaluation with more extended periods of observation of these new techniques of performing PCV appear warranted.
From October 1986 to January 1991, 47 patients with esophageal cancer (29 squamous, 18 adenocarcinoma) were treated with simultaneous radiotherapy (3000 or 3600 cGy) and chemotherapy (infusional 5-fluorouracil, cisplatin) delivered during a 5-week period. This treatment was well tolerated; 44 patients (94%) completed a full course of therapy, 40 (85%) had relief from dysphagia, and 21 (45%) noted either weight gain or no net weight loss. One patient (2%) died of complications (tracheoesophageal fistula, perforated ulcer) during chemotherapy and radiotherapy. The remaining 46 patients were referred for operation. Six refused because of excellent relief of their dysphagia, and one was denied operation. Thirty-nine patients went to operation, and 34 (83%) had lesions that were resectable. Eight of the 39 surgically treated patients (21%) had no evidence of residual tumor identified in the resected specimens. One of these complete responders died 7 weeks postoperatively after multiple complications (3% operative mortality rate). Three of the remaining seven have also died since the operation, one of recurrent cancer and two with no known recurrent disease. Actuarial survival in this present series was significantly better than that of our 1980 to 1985 historical control patients (p less than 0.005). There was no difference between patients with squamous carcinoma and those with adenocarcinoma with regard to the prevalence of complete response or long-term survival. Survival of the seven patients who did not undergo operation was comparable with that of the 34 patients in whom esophagectomy was performed. This study suggests that combined preoperative chemotherapy plus radiotherapy for esophageal cancer is well tolerated, provides excellent palliation of symptoms, allows for a high rate of resectability, is equally effective for squamous carcinoma and adenocarcinoma, and provides encouraging early results with regard to long-term survival. The data also call into question the role of esophagectomy, particularly in patients who have a complete response to preoperative therapy.
At present, there is no consensus regarding the routine use of intraoperative cholangiography during cholecystectomy. We describe a reliable technique for performing cystic duct cholangiography during laparoscopic cholecystectomy. Using this technique, we were able to cannulate the cystic duct in 97% of patients, completely visualize the biliary tree and duodenum in 93% of patients, and identify unsuspected choledocholithiasis in 3% of patients. Treatment options for the management of choledocholithiasis demonstrated by cholangiograms during laparoscopic cholecystectomy include conversion to an open cholecystectomy and common duct exploration, or endoscopic sphincterotomy and common duct stone extraction following laparoscopic cholecystectomy.
Laparoscopic cholecystectomy uses carbon dioxide, a highly diffusable gas, for insufflation. With extended periods of insufflation, patient arterial carbon dioxide levels may be adversely altered. Patients were selected for laparoscopic cholecystectomy using the same criteria as for open cholecystectomy. Twenty patients (group 1) had normal preoperative cardiopulmonary status (American Society of Anesthesiologists class I), while 10 patients (group 2) had previously diagnosed cardiac or pulmonary disease (class II or III). Demographic, hemodynamic, arterial blood gas, and ventilatory data were collected before peritoneal insufflation and at intervals during surgery. Patients with preoperative cardiopulmonary disease demonstrated significant increases in arterial carbon dioxide levels and decreases in pH during carbon dioxide insufflation compared with patients without underlying disease. Results of concurrent noninvasive methods of assessing changes in partial arterial pressures of carbon dioxide (end-tidal carbon dioxide measured with mass spectrographic techniques) may be misleading and misinterpreted because changes in partial arterial pressures of carbon dioxide are typically much smaller than changes in arterial blood levels and, unlike arterial gas measurements, do not indicate the true level of arterial hypercarbia. During laparoscopic cholecystectomy, patients with chronic cardiopulmonary disease may require careful intraoperative arterial blood gas monitoring of absorbed carbon dioxide.
Although minimally surgically invasive, laparoscopic surgery has yet to be proven safe in patients receiving anticoagulants. Retrospectively, the laparoscopic management of four patients requiring anticoagulation for cardiac valvular prostheses or chronic atrial fibrillation was reviewed with regard to potential hemorrhagic complications. Warfarin was discontinued preoperatively in all cases. Heparin anticoagulation was individualized according to each patient's risk for thrombosis. Laparoscopic cholecystectomy and intraoperative cholangiography were completed in each patient without resulting hemorrhagic complications. The operative management of patients exhibiting cholecystitis may be complicated by anticoagulation therapy required for preexisting conditions/diseases such as cardiac valve prostheses, chronic atrial fibrillation, deep venous thrombosis, and pulmonary embolism. The minimally invasive nature of laparoscopic surgery lends itself well to cholecystectomy required in the face of anticoagulation treatment. This limited initial series of selected patients demonstrates the feasibility and efficacy of laparoscopic cholecystectomy in patients receiving anticoagulants.
In this era of occurrence screening, increased documentation of surgical resident supervision, and overall efforts to alter quality of patient care through increased documentation, an in-house quality assurance data base can greatly facilitate these activities. To establish a data base, 6241 operative procedures over a 15-month interval were logged into a StatView II Database using the patient's name and record number, diagnosis, and operative information available from the standard operation report worksheet. Additional information, including the name of the supervising staff and level of supervision, had also been recorded concurrently on this form. Each month, after this demographic information has been entered into the data base for each surgical service, it is reviewed, ensuring 100% surveillance of all cases. The subsequent morbidity and mortality (M & M) information is then added to the data base. Using the contingency table option of the StatView II Database, quarterly and annual reviews have been done to study individual services, types of cases, staff attending, individual supervision, levels of staff involvement, and incidence of complications. Our Surgical Service has reported an overall morbidity of 306 cases (4.9%) and mortality of 71 (1.14%). Average numerically coded levels of resident supervision have been compiled with regard to individual services and staff surgeons. This data base has proved helpful in the recredentialling process of our surgical staff, resident logs, identification of necessary reviews of certain case types, and formation of a computerized operative log.
Eleven patients with parathyroid carcinoma and 186 patients with parathyroid adenoma were seen between 1958 and 1990. Significant differences (p less than 0.01) were found between the two groups in calcium and parathormone levels, lesion size, presence of palpable mass, and severity of clinical presentation. Initial operative management consisted of parathyroidectomy alone in three patients, all of whom experienced recurrence of disease. Of the eight patients who underwent aggressive surgical management (parathyroidectomy and resection of thyroid or thymus), only one experienced recurrence. Three of the four patients with recurrence underwent multiple thoracic and cervical procedures for control of disease; one patient was treated with medical therapy alone. The mean survival in the surgical group was 17 years; the patient treated with medical therapy survived 10 years. In all four patients, however, treatment was palliative rather than curative. We conclude that patients with primary hyperparathyroidism characterized by markedly elevated serum calcium and parathormone, palpable mass, and severe clinical presentation should be suspected of harboring a parathyroid carcinoma. An aggressive initial surgical approach was considered in these patients. This experience emphasizes the importance of aggressive surgical extirpation in reducing disease recurrence and also for palliation and prolongation of life when recurrence does occur.
The prevention of anesthetic mishaps during endoscopic procedures is of great importance to physicians in training. With the large number of such procedures performed each year, even infrequent adverse anesthetic reactions may result in a significant number of problems. To establish the safety and efficacy of an anesthetic regimen using intravenous meperidine and diazepam, all endoscopic procedures performed at one teaching institution in a 4-month period were retrospectively analyzed with regard to: (1) type and dosage of sedation/anesthesia, (2) endoscopic procedure involved, (3) effect of any underlying disease state, (4) side effects, (5) endoscopic complications, and (6) overall patient acceptance. A total of 716 patients underwent 913 endoscopic procedures with 876 separate anesthetic/intravenous sedations. General anesthesia was utilized in 44% of the 155 pediatric procedures. In the adult patients, intravenous sedation was administered by a physician-in-training under supervision except in 9% of cases (66 patients) when intravenous sedation utilizing alternative agents was given by the anesthesia department. The dose of sedation used (per body weight) declined with increasing age in the pediatric group (0-19 years). The adult dose remained constant for the next eight decades of life (meperidine 0.76 +/- 0.33 mg/kg: diazepam 0.12 +/- 0.08 mg/kg). In the adult group, 758 procedures were performed: 371 patients underwent esophago-gastroduodenoscopy, 258 colonoscopy, 36 endoscopic retrograde cholangiopancreatography, 40 flexible sigmoidoscopy, and 51 percutaneous endoscopic gastrostomy. Anesthetic-related complications (transient apnea and itching), were noted in two patients, and naloxone was utilized to reverse oversedation in a further 17 (2.56%).(ABSTRACT TRUNCATED AT 250 WORDS)