Biomedical subjects
Publications and source records attributed to L Morgenstern.
Dr. George Berci's contributions to the art and science of endoscopy and laparoscopy have continued unabated for nearly half a century. Fundamental advances in optics, illumination, television application, instrumentation, and operative radiology were either fostered or initiated by him, culminating in the advanced state of the technology as it is known today. As a creative force and catalytic influence, he has been a true pioneer.
Percutaneous endoscopic gastrostomy (PEG) is a widely used procedure for patients who cannot swallow. Although it is mostly performed for valid indications, its use in terminally ill patients is questionable. In this study, more than 30% of patients died in hospital after PEG placement and 16% died less than 30 days after placement. Strict guidelines and oversight or PEG placement are recommended.
BACKGROUND: Obesity is a growing health problem that contributes to numerous life-threatening or disabling disorders, including coronary artery disease, hypertension, type 2 diabetes mellitus, hyperlipidemia, degenerative joint disease, and obstructive sleep apnea. Significant weight reduction in the morbidly obese improves or reverses associated illness and benefits well-being. The purpose of the SAGES Appropriateness Conference was to summarize the state of the art for open and laparoscopic operations for the morbidly obese. METHODS: The English literature comparing bariatric procedures was reviewed and grouped by level of evidence by three surgeons (BS, LV, and CC). From more than 1,500 articles, all conference participants were provided with reprints and table summaries of no less than 50 selected manuscripts. Ten experts were requested to present reviews and make evidence-based arguments for and against the open and laparoscopic approaches in written format. An expert panel of six surgeons, including an ethicist and patient, commented on implications of data presented. The finalized statement was e-mailed to all participants for approval and comment. RESULTS: Consensus statements were achieved on various aspects of morbid obesity, including indications for surgery, resolution of comorbid illnesses with significant weight loss, and the importance of committed bariatric program. Our panel of experts agreed, in general, to the advantages of laparoscopic approaches compared to open operations in skilled hands. CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass (RYGB) affords improved short-term recovery compared to open gastric bypass. Laparoscopic adjustable banding can be performed with lower average mortality than either RYGB or any of the malabsorptive operations, and it produces variable degrees of short-term weight loss. Prospective randomized trials are needed to compare gastric bypass, malabsorptive, and restrictive procedures.
Splenosis represents the autotransplantation of splenic tissue after splenic trauma or surgery. Disruption of the splenic capsule causes fragments of splenic tissue to be seeded mainly throughout the peritoneal cavity, where they are characterized by diffusely scattered bluish implants. Extraperitoneal locations are very rare and mainly include the thoracic cavity after thoracoabdominal trauma with simultaneous splenic rupture and diaphragmatic laceration. We retrospectively identified all patients in the pathology registry with the diagnosis of splenosis between December 1974 and July 2003 at our urban teaching hospital. Data collected included presenting signs and symptoms, history, imaging studies, treatment, pathology, and outcome. Five cases of splenosis were identified and described. Location of the splenosis was intraperitoneal in two and intrahepatic, intrathoracic, and subcutaneous in one each. In these cases, there was an average interval of 29 years between splenic injury and diagnosis, and most were found incidentally. One of the cases was managed entirely laparoscopically and another thoracoscopically.
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With modern medical technology, it is now possible to sustain life for prolonged periods in critically ill patients, even when there is no reasonable hope of improvement or achieving the goals of therapy. Such futile and medically inappropriate interventions may violate both the ethical and medical precepts generally accepted by patients, families, and physicians. In this study, we sought to determine who was primarily responsible for such interventions, the nature of their motivation, and the role of a timely bioethical consultation. In a retrospective review, we identified 100 patients of 331 bioethical consultations who had futile or medically inappropriate therapy. The average age of patients was 73.5 +/- 32 years (mean +/- 2 SD) with 57% being male. Fifty-seven percent of the patients were admitted to the hospital with a degenerative disorder, 21% with an inflammatory disorder, and 16% with a neoplastic disorder. The family was responsible for futile treatment in 62% of cases, the physician in 37% of cases, and a conservator in one case. Unreasonable expectation for improvement was the most common underlying factor. Family dissent was involved in 7 of 62 cases motivated by family, but never when physicians were primarily responsible. Liability issues motivated physicians in 12 of 37 cases where they were responsible but in only 1 of 62 cases when the family was (chi(2) 5 degrees of freedom = 26.7, p < 0.001). When the bioethics consultation resulted in cessation of the therapy, patients died in a median of 2 days as opposed to 16 days if therapy continued (p < 0.001).
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Splenic metastases from solid tumors are unusual with only scattered case reports of patients treated with splenectomy before 1987. We conducted a retrospective chart review at our large tertiary-care private teaching hospital between January 1990 and September 1999 and found splenic metastases in 31 patients. In eight patients (26%), the spleen was the only site of metastatic disease. Of the 31 splenectomies for metastases, 23 were performed for ovarian neoplasms, five during primary operative procedures, and 18 during secondary cytoreductive procedures or explorations for late recurrences at an average of 3.9 years after the original operation. Nearly half of the metastases (15 of 31) appeared entirely within the splenic parenchyma, representing probable hematogenous spread, whereas seven involved both the splenic parenchyma and capsule and nine involved the capsule only. Between 1990 and 1999 we identified a statistically significant increase in use of splenectomy for treatment of metastatic tumor with a Spearman rank correlation value of 0.86 (P < 0.05). Most of this increase was attributable to ovarian cancer cases and may be due to expansion of treatment options or improved imaging methods. We report the largest series of splenectomy for splenic metastases and the ninth case report in the world literature of splenectomy for isolated splenic metastasis due to colorectal cancer.
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Two recent cases of splenic infarction of unusual cause stimulated a review of our experience with this condition. We conducted a retrospective chart review of selected patients with pathologic diagnosis of splenic infarction seen at a large metropolitan private teaching hospital during the past 30 years. Variables analyzed included sex, age, etiology of infarction, underlying diseases, diagnostic tests, splenic pathology, and complications. Splenic infarction occurred in 59 patients (33 male and 26 female; average age, 55 years; range, 2-87 years). Etiologies included hematologic disorders (n = 35), thromboembolic disorders (n = 17), and other diseases (n = 7). Symptoms were present in 69 per cent of the patients and included abdominal pain, fever and chills, and constitutional symptoms; 18 patients were asymptomatic. Patients with nonmalignant hematologic conditions were often asymptomatic (55%); abdominal pain was common in all groups, and fever was especially common in patients with embolic conditions (70%). CT scan was the most frequent radiologic study. Patients with hematologic conditions usually were explored for complications of those conditions (69%), while complications of splenic infarction were a frequent indication for operation in patients with emboli (60%). Overall morbidity was 36 per cent, with pulmonary complications most frequent, and mortality was 5 per cent. We conclude that splenic infarction must be suspected in patients with known hematologic or thromboembolic conditions who develop left upper quadrant pain and signs of localized or systemic inflammation. CT scan is currently the preferred diagnostic test, but ultimate diagnosis depends on pathologic examination of the spleen. Surgical complications of splenic infarction include abscess and rupture.
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Bile duct injury is one of the most serious complications of laparoscopic cholecystectomy (LC). In open cholecystectomy (OC) the reported incidence of injury is less than 0.2 per cent. In LC, the aggregate reported experience, in many thousands of cases, is three or four times this number. Although "the learning curve" has been considered the principal factor in the heightened incidence of this complication with LC, there are hazards inherent in this new surgical modality that may never allow elimination of the increased risk of bile duct injury. As a sequel to an earlier report of 1200 cases of OC before the laparoscopic era from a single institution, this report deals with the next 2427 consecutive cases of LC from the same institution. In the first 1284 cases of LC, there were seven bile duct injuries (0.58%); in the ensuing 1143 cases there were six bile duct injuries (0.50%). The overall incidence nationwide is even higher, as evidenced by widespread reports of repair of bile duct injuries referred to major tertiary care centers. Routine operative cholangiography is of the utmost importance in the early recognition and immediate repair of ductal injuries. In 12 of the 13 cases reported here, early recognition and repair during the primary surgery resulted in a successful outcome.