Frederick L. Greene

Hemodynamic changes during laparoscopic cholecystectomy monitored with transesophageal echocardiography

Although pneumoperitoneum has been well tolerated in a predominantly healthy population, there is concern that an increased intraperitoneal pressure may be poorly tolerated in patients with marginal cardiopulmonary function. The purpose of this study was to demonstrate noninvasively the hemodynamic effects of carbon dioxide pneumoperitoneum utilizing biplane transesophageal echocardiography.Fourteen otherwise-healthy patients undergoing nonemergent laparoscopic cholecystectomy were studied using bi-plane transesophageal echocardiography under a standardized anesthetic protocol utilizing isoflurane, fentanyl, and vecuronium bromide. Endtidal CO2, oxygen saturation, cardiac rhythm, temperature, and blood pressure were monitored noninvasively. Minute ventilatory volume was adjusted as needed to keep end-tidal CO2 less than 38 mmHg. Data were recorded at baseline, following abdominal insufflation to 15 mmHg with CO2, with head-up tilt of 20°, following exsufflation, and with the patient level. Significance was determined using a paired Student t-test.Insufflation to 15 mmHg decreased cardiac index (C.I.) by 3% (3.34 to 3.23 l/min/m2) while both heart rate (HR) and mean arterial pressure (MAP) increased (by 7% and 16%), respectively, and stroke volume index decreased by 10% (from 51.6 to 46.6 ml/beat/m2). Head-up tilt of 20° further decreased CI to 2.98 l/min/m2 (−11%) and SVI to 40.3 ml/beat/m2 (−22%) while HR increased by a total of 14% and MAP by 19%.As laparoscopic techniques are applied to a broader population, the impact of small but significant decrements in cardiac function become increasingly important. This study demonstrates that the combination of CO2 pneumoperitoneum and the reverse Trendelenburg position does adversely effect cardiac output.

Increasing prostate cancer screening in African American men with peer‐educator and client‐navigator interventions

BACKGROUNDnFew African American men participate in prostate cancer screening, although they have higher prostate cancer incidence and mortality rates.nnnMETHODSnThis study documents the benefits of two educational methods; the peer-educator method and the client-navigator method, in increasing their participation.nnnRESULTSnSixty-one percent of the 1,211 African American men who received an educational program on prostate cancer participated in the free prostate cancer screening. Men who received the peer-educator method intervention, which included a testimony in support of prostate cancer screening given by an African American man, were more likely to participate, p = 0.04, than were men who received a standard educational program. Also, men who received the client-navigator method intervention, which included 1) a phone call aimed at overcoming screening barriers and 2) reminders for screening, were more likely to participate, p = 0.0001.nnnCONCLUSIONSnMore African American men will participate in prostate cancer screening following the peer-education and client-navigator interventions.

Cryptococcosis of the colon resembling Crohn's disease in a patient with the hyperimmunoglobulinemia E-recurrent infection (Job's) syndrome

A 29-yr-old woman presenting with granulomatous colitis and a chronic perirectal abscess was found to have localized cryptococcosis associated with the hyperimmunoglobulinemia E-recurrent infection (Jobs) syndrome. Similarity to previous cases of esophageal cryptococcosis and ileocecal histoplasmosis suggests an association between the hyperimmunoglobulinemia E-recurrent infection syndrome and localized fungal infections of the alimentary tract. To our knowledge, this is the first well-documented case of cryptococcosis confined to the colon and perirectal tissues.

Laparoscopy in Malignant Disease

The use of laparoscopy in patients with malignant disease is particularly helpful diagnostically and will often impact on future therapy. The indications and complications of this technique in combination with other diagnostic and therapeutic modalities in patients with malignant disease are evaluated and the accuracy of results are compared to laparotomy procedures. Future trends in laparoscopic surgery also are discussed.

Choledochocele and recurrent pancreatitis: diagnosis and surgical management

A case history has been presented that reports a rare type III choledochal cyst (choledochocele) and describes the association of a choledochocele and recurrent acute pancreatitis. The most reliable diagnostic technique, as used in our patient and supported by our literature review, is endoscopic retrograde cholangiopancreatography. This case further supports surgical correction employing transduodenal sphincteroplasty. This procedure is highly recommended for management of the intramural choledochocele (type IIIc), especially when associated with recurrent pancreatitis. Finally, patients who present with recurrent pancreatitis without the usual historical or diagnostic findings of biliary tract or alcoholic disease should have a choledochocele included in the differential diagnosis.

ROLE OF LAPAROSCOPY IN THE STAGING OF MALIGNANT DISEASE

Although diagnostic laparoscopy has been used by surgeons and gastroenterologists since the early 1900s, todays surgical oncologists have been relatively slow to embrace this technology. Together with the fervor and benefits afforded by laparoscopic therapeutic interventions in the management of patients with benign disease and the diagnostic usefulness in blunt trauma and abdominal pain, awareness has been rekindled regarding the advantages of laparoscopy for the staging of abdominal malignancy. As surgeons begin to realize that extirpative procedures are doomed to failure in curing patients with diffuse abdominal metastases disclosed on laparoscopic assessment, palliative measures, such as stent placement, ablative procedures, balloon dilatation, intraluminal high-dose radiation, and laser techniques will be used commonly by surgical endoscopists and gastroenterologists. Similarly, it is hoped that the use of systemic chemotherapy will achieve better specificity in cell destruction in patients identified laparoscopically to have uncontained disease in the abdominal cavity. The sensitivity of sonography combined with laparoscopy has been shown to approach that of celiotomy in the evaluation of solid organs, thereby avoiding unnecessary laparotomy and its associated morbidities. Using sonography as a complement to laparoscopy will extend the usefulness of both techniques. The application of laparoscopy and the advent of miniaturized laparoscopic instrumentation (Fig. 7), both diagnostic and therapeutic, in the management of patients with abdominal malignancy will be limited only by the creativity and expertise of physicians and instrument makers.

Predictors of Pap Smear Screening in Socioeconomically Disadvantaged Elderly Women

Predictors of Pap Smear Screening in Socioeconomically Disadvantaged Elderly Women

Effect of dietary copper on colonic tumor production and aortic integrity in the rat

Gastrointestinal malignancy has been associated with aortic aneurysmal disease in humans, while metabolic derangement of copper has been incriminated as a possible promotor of aneurysmal development of the aorta. An animal model utilizing the carcinogen 1,2-dimethylhydrazine (DMH) was selected to evaluate levels of dietary copper on both colonic tumor production and morphologic changes in the rat aorta. Six groups, each including 10 Sprague-Dawley rats, received 16 weekly doses (20 mg/kg) of DMH beginning at 4 weeks of age. Groups were maintained on either normal (25 ppm), low (0.6 ppm), or high (100 ppm) copper chow during the entire experimental period. After 25 weeks, all animals were sacrificed to assess colonic tumor production and to perform scanning (SEM) and transmission electron microscopic (TEM) studies of the rat aorta. Results showed a significant increase in colonic tumor production (3.14 +/- 0.39 tumors per centimeter colon) in rats treated with low-copper chow and DMH when compared with rats on normal chow and DMH (0.74 +/- 0.07 tumors per centimeter colon) and animals maintained on high-copper diets and DMH (0.76 +/- 0.08 tumors per centimeter colon). In addition, morphologic study showed disruption of the intima and media in rats maintained on low-copper diet alone, and also on low-copper diet plus DMH. The results of this study showed that DMH and low dietary copper significantly increase (P less than 0.001) the yield of colonic tumors and produce loss of aortic integrity when studied morphologically. Copper levels may be important in the association of neoplasia and aneurysm formation in the clinical setting.

Predictors of fecal occult blood screening among older socioeconomically disadvantaged Americans: a replication study.

Socioeconomically disadvantaged elderly are less likely to participate in fecal occult blood testing (FOBT). A quasi-experimental design was used in this operational replication study to determine predictors at baseline of subsequent participation in FOBT. Sixty-five percent of the 211 participants in the replication study participated in FOBT, and 47% of the 171 participants in the original study participated in FOBT. Predictors for FOBT in the replication study were male gender, age of 65-75 years old, ability to go places without assistance, history of having had a digital rectal examination and FOBT. This replication study supports targeting socioeconomically disadvantaged populations for FOBT as well as females, persons 85 years and older, persons who need assistance in travel, and person who have not had FOBT before. The results show that socioeconomically disadvantaged persons will participate in FOBT when effective educational interventions that include adaptation for aging changes are used.

Colorectal cancer in animal models—A review

Colorectal cancer remains the second leading cause of cancer death in the western hemisphere. During the past several decades information regarding epidemiology, etiology and associated factors regarding colo-rectal cancer in humans has been collected through study of experimental colonic tumors in animal models. Much of this work has been influenced by the use of 1,2-dimethylhydrazine as the inducing carcinogen in susceptible populations of animals, although other specific carcinogens have been used. Through application of this experimental model, knowledge of dietary, immunologic, and bacterial factors has been realized in the etiology of colo-rectal cancer. This review details methodology and results of developing experimental models as they pertain to human colo-rectal cancer.