Fred Silvestri

Laparoscopic management of acute small-bowel obstruction.

AbstractBackground: A retrospective review is given of the authors’ experience with a consecutive series of acute small-bowel obstruction unresponsive to medical management. Methods: There were 33 exploratory laparoscopies. The etiology was accurately diagnosed in 100% of the cases. Twenty-five (76%) were secondary to postoperative adhesions, of which 18 (72%) were successfully treated by laparoscopic lysis of adhesions. Minilaparotomy was needed to treat iatrogenic perforation (two), gangrenous bowel (one), and Meckel’s diverticulectomy (one). Formal laparotomy was utilized for small-bowel resection (two), malignant adhesions (two), and intolerance of pneumoperitoneum (one). Four cases of incarcerated hernias were treated by conventional herniorrhaphy. Results: Overall, 67% of our cases were spared formal laparotomy. Conclusion: We conclude that laparoscopy is an excellent diagnostic modality in acute small-bowel obstruction, the majority of which can be simultaneously managed laparoscopically. Laparotomy should be reserved for malignant adhesions, surgical misadventure, or when the pathology dictates.

Laparoscopic resection of posterior gastric leiomyoma

Abstract. Laparoscopic gastric surgery is gaining momentum, especially in the treatment of benign disease. Simultaneous endoscopy and laparoscopy allow precise localization of lesions. Because of the stomachs size, mobility, and distensibility, relatively large lesions can be safely excised. Wedge resection for anterior lesions and a transgastric or intragastric approach for posterior lesions are feasible laparoscopically. Two cases of posterior gastric leiomyomas successfully resected laparoscopically are presented. The use of stapling devices greatly facilitates this procedure.

Clinical experience with everted cervical vein as patch material after carotid endarterectomy

PURPOSE The aim of this study was to evaluate the clinical efficacy of everted cervical veins used as patches after carotid endarterectomy. METHODS A prospective nonrandomized comparative analysis was performed on patients with either everted cervical veins or saphenous veins as patches after carotid endarterectomy. Two hundred ninety-six patients underwent 329 carotid endarterectomies during an 8 1/2-year period (1987 to 1995). Saphenous vein patches were used in 125 (38%) cases and everted cervical veins in 167 (51%). These two groups were compared clinically and by sonographic surveillance. The mean follow-up of patients in this study was 27 +/- 11 months. RESULTS No significant differences were noted regarding postoperative morbid events between the everted cervical and saphenous vein patch groups. Even at 5 years the percentage of patients without stroke for both groups exceeded 95%. Duplex surveillance studies also showed comparable percentages of recurrent moderate (50% to 69%) and severe (70% to 99%) stenosis, 5.6% and 6.9%, respectively, for everted cervical vein and 5.4% and 6.5%, respectively, for saphenous vein. Cumulative recurrent stenosis-free rates at 5 and 6 years exceeded 82% for each of the patch study groups. CONCLUSIONS Based on the results of this study everted cervical veins are useful adjuncts to carotid endarterectomy, when patch angioplasty is necessary or desirable. Their performance is comparable to that of saphenous veins. Cervical veins are usually available, even when the saphenous vein is absent or inadequate. In addition, good saphenous veins can be spared and lower extremity excisions avoided.

Pelvic radiation therapy as a risk factor for ischemic colitis complicating abdominal aortic reconstruction

Ischemic colitis is an infrequent but potentially devastating complication of abdominal aortic reconstruction. Identification of patients with predisposing risk factors for the development of ischemic colitis can guide intraoperative measures to preserve or restore colonic blood flow during aortic surgery. Previous radiation therapy for pelvic malignancy may be one such predisposing risk factor. Two cases are presented in which ischemic colitis complicated abdominal aortic reconstruction in the setting of previous pelvic irradiation. In the months after radiation therapy for prostate cancer, one patient underwent infrarenal abdominal aortic aneurysm repair. Ischemic infarction of the sigmoid colon developed acutely after surgery and required emergent sigmoid colectomy. The second patient underwent reconstruction of an infrarenal abdominal aortic aneurysm after having had radiation therapy for a bladder tumor. Despite an initial satisfactory result, the patients abdominal pain and diarrhea progressively worsened and he eventually required sigmoid colectomy for severe ischemic colitis. In both of these patients, the inferior mesenteric arteries were patent and had not been reimplanted. The association of pelvic radiation therapy with ischemic colitis after aortic reconstruction should focus attention to the operative details for maintaining the colonic circulation in these patients. Reimplantation of the inferior mesenteric artery in particular may prevent both the acute and the insidious variants of this complication in patients who undergo aortic surgery and decrease the incidence of this complication in patients with a history of radiation therapy to the pelvis.

Endovascular treatment of mycotic hepatic artery aneurysm in the hostile abdomen--a case report.

Mycotic hepatic artery aneurysms are rare. This report documents a case in which a mycotic hepatic artery aneurysm was associated with Crohns disease, renal adenocarcinoma, and a urinary tract infection. Endovascular management of this mycotic hepatic artery aneurysm was successful in the setting of a hostile abdomen based on multiple previous operations, a stoma, and a scarred abdomen.

Experience with a new valvulotome for lower-extremity revascularization procedures by the in situ method☆

Between November 1990 and November 1992, 50 consecutive cases requiring lower-extremity revascularization by the in situ method were compared with regard to use of two different valve cutters, the Hall valvulotome and the Insitucat. There were no amputations in patients with patent grafts, nor were any infections or false aneurysms noted during the course of this study. In the Insitucat group (n = 25), primary patency was achieved in 19 cases. Five of the six graft failures underwent additional procedures of which three remained patent, adding to the secondary patency rate (22 of 25). The greatest problem with regard to maintaining primary graft patency was that of missed or retained valves, but the incidence of this problem decreased during the course of this study as experience was gained with the catheter in conjunction with angioscopy. Experience with the Insitucat valvulotome has demonstrated its efficacy, though enhanced by monitoring the results with angioscopy. The development and discovery of focal stenotic areas and retained valves by surveillance sonography have resulted in enhanced (assisted) primary graft patency rates. The incidence of these problems appears to be comparable with that occurring with other means of producing valvular incompetence for an in situ reconstruction where valvulotomes of similar design are employed. This was confirmed by comparative analysis with another group of 25 in situ vein bypasses performed during the same time period but during the Hall valvulotome.

Portal mesenteric shunting for reconstruction of the visceral venous system1

Reconstruction of the mesenteric venous system, particularly during pancreaticoduodenectomy, is a formidable procedure. The trend of increasing the extent of resections to encompass the portal– superior mesenteric venous system with tumor adherence or ingrowth is being performed with increasing frequency worldwide. 1,2 This article was prompted by our use of a modified shunting technique to perform mesenteric venous reconstruction, preventing visceral congestion and permitting hepatic perfusion during most of the time period required for this component of a pancreaticoduodenectomy. Recent large series of pancreatic resections have reported no instances of using shunts.

Preliminary Experience with a Self-Centering, Expandable Valvulotome for in Situ Vein Reconstruction:

A self-centering, expandable valvulotome was employed to establish femoral distal in situ vein reconstructions in 41 patients. The focus of the early follow-up was to assess graft patency and the incidence of incomplete valve closure. Residual arteriovenous fistulas, clearly unrelated to the methodology of valvulotomy, were also noted. Early patency was achieved in all 41. Missed valves occurred in two instances, requiring open direct valve excision in one case and use of a Mills valvulotome in the other. One vein was injured but successfully repaired. The authors conclude that excellent patency results with complete valve cutting can be achieved in the majority of cases for in situ reconstruction in the lower extremity with a new self-centering, expandable valvulotome. The role of angioscopy is uncertain and requires further study.

Mesoportal bypass: A unique operation for mesenteric hypertension

A 47-year-old man was referred for evaluation and treatment of gastrointestinal variceal bleeding and possible transjugular intrahepatic portal-systemic shunting. Intrahepatic manometry disclosed a normal portal pressure, but selective mesenteric arteriography revealed occlusion of the superior mesenteric, splenic, and inferior mesenteric veins. Duodenal and gastric varices were noted, but no esophageal varices were seen. The portal vein was clearly patent. At surgery, a 2 cm mass was found at the superior mesenteric vein-splenic vein juncture, and subsequent pathologic examination confirmed the presence of suture material within dense fibrous tissue as the probable cause for this rare condition. The surgical procedure performed was a superior mesenteric vein-to-portal vein bypass, employing ringed expanded polytetrafluoroethylene. Graft patency and function have been confirmed postoperatively by means of both venous-phase mesenteric arteriography and duplex imaging. The surgical procedure was novel, in that it was possible to decompress the hypertensive mesenteric circulation from the distal superior mesenteric vein directly into the portal vein with a prosthetic bypass. The physiologic benefit of this operation is clear: the avoidance of the encephalopathic syndrome and the facilitation of hepatopetal blood flow.

Extraanatomic Renal Revascularization: Surgical and Anatomic Variations

A thoracic-aorta-left renal artery bypass with polytetrafluoroethylene (PTFE) and three gastroduodenal right renal artery bypasses were constructed in four patients in whom loss of renal function and the potential for dialysis were imminent. These extraanatomic bypasses showed durable patency with preservation of renal function. Gastroduodenal- renal bypass requires an appreciation of the anatomic relationship of the right renal artery to the right renal vein. Anatomic studies were performed in 80 human cadavers to assess the anatomic relationships of the right renal artery with respect to the right renal vein. In 50% of the cadavers studied, the right renal artery was superior to the right renal vein. It was located inferior to the right renal vein in 17.5% and directly posterior in 32.5%. Extraanatomic bypasses may be required for treatment of renal hypertension or parenchymal salvage. Gastroduodenal-renal and thoracorenal reconstructions are unusual variants of extraanatomic bypasses, and though uncommonly required, may be extremely useful methods to employ for renal revascularization.