Biomedical subjects
Publications and source records attributed to N J Soper.
Chronic mesenteric venous thrombosis without involvement of the splenic or portal veins may lead to gastrointestinal hemorrhage from mesenteric varices. Three cases are presented in this report; 1 patient died secondary to blood loss and 2 patients have experienced a benign clinical course. The presentation, methods of diagnosis, and therapeutic options for this disorder are described.
Since 1978, the operation chosen for patients with variceal hemorrhage has been based on preoperative hemodynamic and clinical factors. One hundred sixteen consecutive patients were managed with the following operations: distal splenorenal shunt (75 patients), nonselective shunts (33 patients), and nonshunting operation (8 patients). Emergency surgery was required in 19 percent of patients. The selection criteria used resulted in the majority of high risk patients receiving nonselective shunts. This selective operative approach resulted in an overall operative mortality of 12 percent, a median survival of 3 years, and postoperative encephalopathy, ascites, and recurrent variceal hemorrhage in 20, 23, and 11 percent of patients, respectively. Operative mortality for the total group was closely related to Child's class. Whereas encephalopathy was most frequent after nonselective shunts, ascites was more common after the distal splenorenal shunt. Recurrent hemorrhage rarely occurred after a shunting procedure, but was a frequent complication of nonshunting operations. Neither the type of procedure selected nor the cause of liver disease influenced long-term survival.
A rat model was used to investigate the effects of starvation and protein depletion on serum fibronectin levels and reticuloendothelial function. Serum fibronectin levels decreased significantly following both test diets. The uptake of opsonin-independent test agents was minimally affected by starvation and protein depletion. Clearance of gelatinized colloidal carbon, which is dependent on circulating opsonins, was significantly reduced in the malnourished animals. This clearance defect was corrected by incubation of colloidal carbon with normal serum. These data suggest that reticuloendothelial dysfunction secondary to malnutrition is primarily mediated by a deficiency of circulating opsonins.
Hypersplenism frequently accompanies cirrhosis with portal hypertension. In this series of 76 patients, 36 percent had thrombocytopenia, 41 percent had leukopenia, and 25 percent had both thrombocytopenia and leukopenia. However, hypersplenism was severe enough to necessitate splenectomy in only two patients (3 percent). Nonalcoholic cirrhotic patients exhibit hypersplenism more frequently and to a greater magnitude than do alcoholic cirrhotic patients. Fourteen and 44 percent of alcoholic and nonalcoholic cirrhotics, respectively, had both thrombocytopenia and leukopenia. Distal splenorenal shunts and nonselective shunts are equally effective in relieving preoperative hypersplenism. Approximately two thirds of the patients were relieved of thrombocytopenia or leukopenia after either of these procedures. Splenectomy invariably corrects hypersplenism associated with cirrhosis and should be included as part of the operative procedure in patients requiring surgery for control of variceal hemorrhage.
Gallbladder removal using laparoscopic techniques has rapidly been adopted by surgeons around the world. Questions have been raised concerning laparoscopic cholecystectomy, including the safety of the operation, its implications for management of common bile duct stones, and the means by which surgeons should be trained. In the present series, 424 patients were referred to a single surgeon for cholecystectomy during a 22-month period. A traditional open cholecystectomy was performed in 9 patients (2.1%) because of presumed contraindications to laparoscopic cholecystectomy. Laparoscopic cholecystectomy was attempted in the remaining 415 patients (97.9%). On the basis of preoperative investigations, 19 patients (4.6%) underwent endoscopic retrograde cholangiopancreatography. Endoscopic sphincterotomy and stone extraction were performed in the 13 patients (3.1%) demonstrating choledocholithiasis. Laparoscopic cholecystectomy was converted to an open operation in 8 patients (1.9%) owing to dense adhesions, obscure anatomy, or cholangiographic abnormalities. Laparoscopic cholecystectomy was successfully performed in 407 patients (96%) in 95 +/- 2 minutes (mean +/- SEM). Surgical trainees were involved in all operations and performed 68% of the procedures under supervision. Cystic duct cholangiograms were obtained selectively in 129 patients (30.4%). Intraoperative complications occurred in 3 patients, including 1 patient with a minor injury to the common bile duct (0.2%). There was no perioperative mortality, and major complications occurred in 6 patients (1.4%). Minor complications were seen in 12 others (2.8%), and one patient required reoperation for a trocar injury to the jejunum. Prolonged follow-up has revealed one case of asymptomatic retained common bile duct stones (0.2%). Laparoscopic cholecystectomy can therefore be performed in more than 95% of patients with no mortality and minimal morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)
We assessed the effect of previous abdominal colectomy on functional results after ileal "J" pouch-anal anastomosis (IPAA) in patients with ulcerative colitis. Twenty-five patients with colectomy prior to IPAA were compared with 22 patients who underwent noncolonic abdominal operations prior to IPAA. No differences were observed in pre- or postoperative resting anal sphincter pressure, squeeze pressure, or rectal inhibitory reflex. Previous colectomy was associated with a greater incidence of postoperative small bowel obstruction. Mean +/- SEM daily stool frequency at 1 and 12 months postoperatively, respectively, was 8.9 +/- 0.8 and 5.7 +/- 0.3 for patients who had undergone previous colectomy, and 8.2 +/- 0.7 and 6.0 +/- 0.5 for the no-previous colectomy group (p = not significant). At the same postoperative intervals, nocturnal stool frequency was 1.9 +/- 0.3 and 1.1 +/- 0.2 for the colectomy group and 1.5 +/- 0.3 and 0.6 +/- 0.1 for the no colectomy group (p = 0.05 at 1 year). More patients in the previous colectomy group had greater than or equal to 1 nocturnal stool after 1 year (71% versus 33%, p = 0.03). Although pouch capacity at 1 year was not different in the 2 groups, pouch capacity was directly related to stool frequency in the no colectomy group (r2 = 0.48, p = 0.01), but not in the previous colectomy group (r2 = 0.08, p = not significant). We conclude that previous abdominal colectomy may be associated with a higher overall incidence of small bowel obstruction. Moreover, previous colectomy is a determinant of postoperative nocturnal stool frequency after IPAA, most likely due to altered ileal pouch function.(ABSTRACT TRUNCATED AT 250 WORDS)
Opinion is divided whether intra-operative cholangiography should be performed routinely or on a selective basis during laparoscopic cholecystectomy. We therefore performed the first prospective randomized trial of static cholangiography in patients who did not have indications for cholangiograms. Laparoscopic cholecystectomy was attempted on 164 consecutive patients, of whom 49 (30%) patients were excluded from the trial due to indications for or against cholangiography. In the remaining 115 (70%) patients, 56 were randomized to the cholangiography group while 59 patients did not receive cholangiograms. Duration of postoperative hospitalization and interval to return to full activity were identical in the two groups. Static cholangiograms added 16 +/- 1 min (mean +/- SEM) to the procedures (p < 0.01). Cholangiography increased the total charges for the operation by almost $700 (p < 0.01). Cholangiograms were performed successfully in 94.6% of the patients and changed the operative management in 4 (7.5%) patients. There was 1 (1.9%) false negative study. Intra-operative cholangiography did not reveal aberrant bile ducts at risk of injury from the operative dissection. There was no mortality or cholangiogram-related morbidity in either group. In follow-up ranging from 2-12 months, there has been no clinical evidence of bile duct injury or retained common bile duct stones. In summary, in patients without indications for cholangiography, the performance of static cholangiograms markedly increased the operative time and cost of laparoscopic cholecystectomy. The operative management of a minority of patients was changed by the information obtained, but laparoscopic cholecystectomy may be performed safely in the absence of cholangiograms with little risk of injury to the major ductal system or retained calculi.
There is a strong association between pregnancy and gallstones. When acute cholecystitis or recurring bouts of biliary colic occur during pregnancy, medical therapy is usually initiated but occasionally fails. Laparoscopic cholecystectomy has recently been described for the treatment of symptomatic cholelithiasis, but many authors consider pregnancy to be an absolute contraindication to this operation. We herein describe the management of markedly symptomatic cholelithiasis during the second trimester of pregnancy using laparoscopic techniques in five patients. Tocolytic medications were administered perioperatively in two patients, and open laparoscopy or the use of an alternative site for insertion of the initial port was used in all patients. Laparoscopic cholecystectomy without cholangiograms was successful in all five patients and postoperative hospitalization ranged from 24 to 48 h. Uncomplicated term delivery has occurred in three of the five patients; in the other two patients, normal pregnancies are continuing. Laparoscopic cholecystectomy can be performed safely during pregnancy, as long as the patient is monitored carefully and specific precautions are observed.
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A rare case of parahiatal hernia with gastric volvulus and incarceration is reported. An anatomically distinct diaphragmatic defect was present adjacent to a structurally normal esophageal hiatus. Laparoscopic repair was performed with excellent results.
Among the potential hazards of laparoscopic surgery using electrocautery is the release of chemical by-products of incomplete tissue combustion into the pneumoperitoneum with subsequent transperitoneal absorption into the bloodstream and/or release into the operating room. The purpose of this study of patients undergoing laparoscopic cholecystectomy (LC) was twofold: (1) to assess the relationship between intraperitoneal concentration of carbon monoxide (CO) and blood levels of carboxyhemoglobin (COHb) and methemoglobin (MetHb), and (2) to assess the surgeon's inhalation of CO resulting from ambient smoke exposure. During LC with monopolar electrocautery, 21 patients were evaluated intraoperatively for intraperitoneal [CO] by sampling gas from a trocar, whereas arterial [COHb) and [MetHb] were determined perioperatively. The surgeon's venous blood was drawn pre- and postoperatively to assay [COHb] and [MetHb]. Patients completed visual analogue questionnaires 6 hours and 24 hours postoperatively to assess for adverse symptoms. Mean (+/- SEM) patient age and weight were 45 +/- 3 years and 84 +/- 4 kg, respectively. Mean duration of the operation was 69 +/- 5 minutes, and electrocautery was used for 3.0 +/- 0.3 minutes. Intraperitoneal [CO] rose to peak levels of 209 +/- 19 ppm at 50 minutes, whereas systemic [COHb] and [MetHb] were unchanged. The surgeon's systemic [COHb] and [MetHb] did not increase postoperatively. Nausea, abdominal pain, and fatigue scores decreased significantly between 6 and 24 hours postoperatively; however, there were no correlations between these symptoms and peak intraperitoneal [CO]. Although LC using electrocautery increases intraperitoneal [CO] to "hazardous" levels, systemic [COHb] and [MetHb] are not elevated by generation of intraperitoneal smoke. The surgeon's exposure to CO by the evacuation of smoke through laparoscopic ports is negligible. Production of smoke during LC using monopolar electrocautery, therefore, does not appear to pose a threat to either the patient or the surgeon.
Different strategies and imaging modalities have been used to detect common bile duct (CBD) stones during laparoscopic cholecystectomy. We prospectively compared fluoroscopic intraoperative cholangiography (FIOC) and laparoscopic intracorporcal ultrasonography (LICU) in patients undergoing laparoscopic cholecystcctomy for this purpose. In a consecutive series of 607 laparoscopic cholecystectomics, FIOC was used in the first 407 patients, whereas LICU was preferentially applied to the subsequent 200 patients. When LICU documented CBD stones, the duct was flushed with saline solution after intravenous administration of glucagon, and stone persistence or absence was confirmed by FIOC and/or repeat LICU. In the FIOC group, 10 patients were converted to open cholecystectomy and 16 patients did not undergo FIOC. Among the remaining 381 patients, FIOC was successful in 370 (97%). In the LICU group, two patients were converted and LICU was not performed in 26 patients. In the remaining 172 patients, the cystic duct (CBD) junction and the CBD were visualized in all cases (P <0.05 vs. FIOC). The mean (+/- SEM) times required to complete FIOC and LICU were 15. 1 +/- 0.4 minutes and 5.3 +/- 0.2 minutes, respectively (P <0.0001). Choledocholithiasis was detected in 25 patients (7%) undergoing FIOC and in 22 patients (13%) undergoing LICU (P <0.05). In the LICU group, the mean sizes of the stones cleared by ampullary dilatation and flushing (17 of 22, 77%) and those requiring more invasive methods (5 of 22, 23%) were 1.6 +/- 0.2 mm and 2.7 +/- 0.3 mm, respectively (P <0.01). Sludge seen in the CBD by LICU in 10 patients (6%), which disappeared with flushing in all cases. LICU is accurate, safe, and permits more rapid evaluation of bile duct stones than FIOC during laparoscopic cholecystectomy. LICU may be overly sensitive in detecting small stones and sludge, which are of questionable significance. Stones 2 mm or less can usually be cleared by flushing, whereas larger ones often require invasive techniques for removal.
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