Bruce P. Brown

Laparoscopic Partial Nephrectomy: Initial Experience and Comparison to the Open Surgical Approach

During an 18-month period, 6 laparoscopic partial nephrectomies were attempted, 4 of which were successful. The surgical technique was modified and improved between cases aided by new laparoscopic instrumentation, such as the argon beam coagulator and the 7.5 MHz. ultrasonic sector scanning system. In a retrospective comparison between laparoscopic and open partial nephrectomy, estimated blood loss was 525 ml. for the former versus 708 ml. for the latter procedure. However, operating time was more than 2 hours longer with the laparoscopic approach. The major advantages of the laparoscopic procedure appear to be a more rapid return to full diet, less postoperative pain and less requirement for parenteral narcotics. Despite the small size of this series and limited followup data, convalescence may be shortened by 4 weeks after laparoscopic partial nephrectomy. Patients with benign diseases of the kidney, especially with a duplicated collecting system, who require partial nephrectomy may be considered candidates for the laparoscopic approach. The advantages to the patient, however, may be offset by the technical demands on the surgeon.

Midgut volvulus as a complication of intestinal malrotation in adults

Seven adults with midgut volvulus as a complication of malrotation are presented. All patients were men with an average age of 33 years. Four presented with long histories of intermittent abdominal pain. In three patients, the twisted, corkscrew appearance of the barium column in the duodenum and proximal jejunum in an upper gastrointestinal series made the diagnosis. In the remaining patient, small-bowel follow-through performed three years before surgery showed intestinal malrotation. Three patients presented with the acute onset of severe abdominal pain. Plain films showed small-bowel obstruction and pneumatosis intestinalis in two patients and only nearly complete small-bowel obstruction in the third. Barium studies were not done in this group because of the need to proceed to exploratory laparotomy and the risk of perforation. In one patient, abdominal angiography suggested the diagnosis by showing abnormal courses of the mesenteric vessels to the volvulized segment of small bowel. All three of these patients showed ischemic segments of bowel at laparotomy.

Sonography of acute appendicitis in pregnancy

Background:Clinical evaluation of acute appendicitis is difficult in pregnant patients. Delay in diagnosis is associated with increased fetal mortality. The purpose of our study was to assess the value of sonography in the diagnosis of acute appendicitis in pregnant women.Methods:We obtained sonograms in 22 pregnant women suspected of acute appendicitis. All sonograms were performed using graded-compression to detect an enlarged appendix. The sonographic criteria for acute appendicitis were detection of a noncompressible blindended and tubular multilayered structure of maximal diameter greater than 6 mm.Results:The sonographic findings were correlated with surgical findings in seven cases and clinical follow-up in 15 cases. Acute appendicitis was diagnosed by sonography in three of 22 patients, and in all but one was confirmed by surgical and pathologic findings. In the remaining 19 patients, 15 improved on clinical follow-up; three were shown to have a normal appendix at surgery and one had focal acute inflammation at the tip of the appendix.Conclusions:Our experience suggests that graded-compression sonography is a useful procedure in pregnant patients suspected of acute appendicitis and has a similar accuracy as in nonpregnant women, especially in the first and second trimester.

Paraovarian and paratubal cysts: preoperative diagnosis using transabdominal and transvaginal sonography.

Paraovarian and paratubal cysts constitute about 10% of adnexal masses. Our purpose was to determine whether pathologically proven examples of these lesions were correctly identified during preoperative transabdominal and transvaginal sonographic evaluations.

Straightening the colon with curved cross sections: An approach to CT colonography

RATIONALE AND OBJECTIVES The purpose of this study was to straighten digitally and consistently the colon with curved cross sections and to compare the results with planar cross-section-based processing for computed tomographic (CT) colonography. MATERIALS AND METHODS In electric field-based straightening, curved cross sections are formed along electric force lines because of electric charges digitally distributed along the colon central path. Four straightening experiments were conducted on CT scans of a colonoscopy phantom. Representative images were studied for polyp detectability and feature distortion. Two further trials involved patient data to demonstrate the clinical feasibility of this method. RESULTS In colon straightening with planar sections, a polyp was counted multiple times in both phantom and patient studies where the polyps were in central path turns with substantial curvature. Furthermore, opposite the central path turns, the colon walls were undersampled with planar sections. Straightening with curved sections produced consistent mappings. Image distortion was present in straightening with curved sections, but the conspicuity of polyps was maintained. In the soft-straightening process, trilinear interpolation greatly suppressed the surface- or volume-rendering noise associated with nearest neighbor interpolation. CONCLUSION Straightening with curved sections outperforms straightening with planar sections in terms of polyp detectability. This approach eliminates the navigation difficulties of current CT colonography and may have clinical use.

Strenuous exercise decreases motility and cross-sectional area of human gastric antrum. A study using ultrasound.

Gastric emptying in humans is delayed with strenuous exercise. We used ultrasound imaging in six healthy volunteers to determine whether changes in motility and configuration of the gastric outlet contribute to this delay. After fasting, all individuals ingested chicken broth and garbanzo beans. With subjects sitting upright, transverse and longitudinal real-time views of the gastric antrum were recorded on video tape. In the exercise studies, subjects pedaled an ergometer for 10 min to attain a heart rate of 85% predicted maximum. On a different day, all subjects had an identical study without exercise. The order of performance of exercise and no-exercise studies was randomized. After exercise, contraction frequencies and antral areas were significantly reduced compared to the studies without exercise. In addition, after exercise there was closure of the pylorus and tubular narrowing of the gastric antrum. Closure of the pylorus and decreased gastric antral area and motility may be important in explaining the decrease in gastric emptying that occurs with strenuous exercise.

Utility of Tc-99m mebrofenin scintigraphy in the assessment of infantile jaundice.

Technetium-99m mebrofenin hepatobillary excretory patterns were assessed in 36 infants with hyperbilirubhnemia. Phenobarbital was administered to 22 patients before imaging. Final diagnoses included: intrahepatic chotestasis (14 patients), neonatal hepatitis (nine patients), biliary atresia (eight patients), alpha-1-antitrypsin deficiency (two patients), Ategilles syndrome (two patients), and cystic fibrosis (one patient). No patient with biliary atresia showed bowel activity by 24 hours. Of the 28 infants without biliary atresia, 23 (82%) had bowel activity visualized by 6–8 hours and 26 (90%) had bowel activity by 24 hours. Two had no bowel activity at 24 hours: one had cystic fibrosis and one had neonatal hepatitis. Of the 26 patients with bowel visualization, the time to visualize bowel did not differ between patient groups with and without phenobarbital induction. All of the patients with hepatitis, including those with marked dysfunction, showed good hepatic uptake. Mebrofenin scintigraphy is an important imaging technique in the diagnostic evaluation of infants with hyperbilirubinemia. In addition to biliary atresia, intrahepatic chotestasis due to cystic fibrosis and severe neonatal hepatitis may also cause bowel nonvisualization up to 24 hours. The results of this study suggest phenobarbital induction may not be needed when Tc-99m mebrofenin scintigraphy is used for the assessment of infantile jaundice.

Preoperative sonographic diagnosis of gallbladder torsion : report of two cases

Acute torsion of the gallbladder is increasingly seen in clinical practice in the elderly population. Delay in surgical treatment may be fatal. In this report, we describe two cases of torsion of the gallbladder in elderly women, in which sonographic diagnosis was made preoperatively, leading to prompt surgical intervention. In both cases the clinical findings were nonspecific. We also describe the color Doppler findings in one case. Preoperative diagnosis of this condition was suggested in an earlier report. l

Colon unraveling based on electrical field: recent progress and further work

CT colonography (CTC) is a new technology, which permits endoscopic-like evaluation of the mucosal surface. Recently, an electrical field based approach was developed to unravel the colon in spiral CT image volumes, that is to digitally straighten then flatten the colon using curved cross-sections. In this paper, we report (1) an exact and computation- intensive algorithm for straightening the colon using curved cross-sections, and (2) an approximate but computationally efficient straightening algorithm. In the direct straightening algorithm, each curved cross-section of the colon is defined by electrical force lines due to charges distributed along the colon path, and constructed by directly tracing the force lines. In the fast straightening algorithm, only representative force lines are traced that originate equiangularly from the current colon path position, while other force lines are interpolated from the traced force lines. The experiments are performed with both phantom and patient data. It is demonstrated that straightening the colon with curved cross-sections facilitates visualization and analysis, has potential for use in CTC; and the speed of the interpolation based straightening algorithm is practically acceptable, which is about 40 times faster than that of the direct algorithm.

PENICILLIN TREATMENT OF EMPYEMA: REPORT OF 24 CASES AND REVIEW OF THE LITERATURE

Excerpt It is generally conceded that the sulfonamide drugs have not been successful in effecting cures in cases of empyema once frank pus has developed in the pleural cavity. The most that can be ...