Lester F. Williams

Comparison of laparoscopic cholecystectomy with open cholecystectomy in a single center

In this retrospective study, we compared the results of 1,283 open cholecystectomies (OCs) performed at our medical center during the pre-laparoscopic era with 1,107 laparoscopic cholecystectomies (LCs) performed from 1990 to 1992. There was no difference in the percentage of cases of acute and chronic cholecystitis in each time period (16.8% in each), nor were there differences in the patient characteristics for each group. The percentage of patients undergoing intraoperative cholangiography was similar for patients with chronic cholecystitis for each period, although the incidence of abnormal cholangiograms was lower in the laparoscopic era (5.8% versus 15.2%, p < 0.001). There was one bile duct injury in the OC group and three in the LC group (although one of these occurred after conversion ot an open procedure), but this difference was not statistically significant. However, there was a higher mortality rate in the patients with acute cholecystitis treated with OC (2.3% versus 0%, p = 0.03) and an increase in the overall complications in the patients with chronic cholecystitis in the OC group (7.5% versus 3.1%, p < 0.001) compared with the LC group. The increase in overall complications appeared to be primarily related to the increased rate of wound-related complications (3.6% versus 0%, p < 0.001) in the patients with chronic cholecystitis in the OC group. LC appears to be a safe procedure with a low incidence of complications including bile duct injury when performed by adequately trained surgeons.

New approaches to the management of severe acute pancreatitis

A recent experience with seventy-seven patients admitted to Boston City Hospital for acute pancreatitis permitted us to identify thirteen patients (17 per cent) whom we diagnosed as having severe protracted acute pancreatitis. These alcoholic patients obviously had fulminant pancreatitis similar to that reported by others in two instances and pancreatic abscesses in two additional instances, but nine of the patients did not fulfill the criteria usually used by others as a basic for surgical intervention. Specific preoperative diagnosis was obtained in these patients by the aggressive use of endoscopic cannulation of the pancreatic ducts, which documented the presence of surgically correctable lesions. These patients had sustained significant malnutrition, which was corrected only by protracted therapy extending an average of two months and involving all modalities currently available for nutritional support of the severely ill patient. After proper preoperative identification of a specific lesion and correction of the malnutrition, the eleven patients without fulminant disease were operated on with no deaths or significant complication. Nine of the patients had elective procedures, which included six distal pancreatectomies and one total pancreatectomy. Thus, severe protracted acute pancreatitis can be identified, and once categrorized, it can have therapeutic implications.

Lower gastrointestinal bleeding. Diagnostic approach and management conclusions.

The management of patients with lower gastrointestinal bleeding requires a systematic approach based on defined diagnostic and therapeutic methods. Although in 80 percent of patients bleeding will stop spontaneously, 25 percent will have rebleeding and 50 percent of those with rebleeding will bleed again. Angiography documents specific bleeding sites but raises questions related to the incidence, site and frequency of bleeding, as well as the necessity of demonstrating extravasation. We reviewed 49 arteriograms performed for lower gastrointestinal bleeding. We conclude from our findings that angiography identifies a presumptive cause of bleeding in 49 percent of patients; angiography identified the site of bleeding in 86 percent of the patients with active bleeding, thus allowing segmental colectomy. We believe that documentation of angiodysplasia in a patient with lower gastrointestinal bleeding is presumptive evidence for the site of bleeding. Angiography is useful and worthwhile in the work-up of patients with lower gastrointestinal bleeding in an attempt to plan localized, definitive resection, and this may lead to a lower mortality rate.

Nonocclusive mesenteric infarction

Abstract Nonocclusive mesenteric infarction is a disease of increasing surgical significance. It is manifested by abdominal pain, usually occurring in a patient with known atherosclerotic heart disease. Over the course of days gastrointestinal bleeding, peritonitis, and finally shock develop. Shock is a late reflection of the disease and usually is not a precipitating factor. The hemorrhagic mucosal necrosis is seen in the absence of obstruction to the arterial system, at least to the 50 μ. level, and is seen in other than terminal conditions. The diagnosis can be suspected on clinical grounds and supported by arteriographic studies. The principles of therapy include massive fluid volume replacement, support of cardiac function, interruption of splanchnic vasoconstriction, and control of septicemia and endotoxemia.

A Radiological Approach to the Patient with Acute, Extensive Bowel lschemia1

A radiological scheme for the diagnosis of acute, extensive bowel ischemia was developed following experience with 27 patients. In all cases, angiography successfully identified those patients with occlusive superior mesenteric vascular disease. In those without mesenteric occlusion, an immediate postangiographic barium examination indicated those patients whose abdominal disease simulated nonocclusive intestinal ischemia clinically. Mortality was high despite a rapid, accurate diagnostic workup, suggesting that new therapeutic approaches to ischemic bowel disease must be sought.

New parameters of viability in ischemic bowel disease.

Abstract 1. 1. Electromyographic patterns and an acidotic or normal serosal pH in the range of 7.30 to 7.80 are cumulatively significant guides to bowel viability. 2. 2. The lack of electromyographic activity indicates major damage which progresses to a pregangrenous phase or, in chronic preparation, is followed by a functionless stenotic area. Serosal pH in this group would have no value as an indicator. 3. 3. The presence of an alkalotic serosal pH in the presence of equivocal electromyographic tracings would suggest irreversible bowel damage in the pregangrenous phase. 4. 4. Mucosal pH merely reflected vascular hemodynamics.

Myocardial effects of intestinal ischemia

IRREVERSIBLE HEMORRHAGIC SHOCK in the dog is clearly related to intestinal ischemia [7]. Because of the emphasis on irreversibility, other investigators, focusing on the late stages of this situation, have overlooked early systemic changes directly related to the diminished splanchnic blood flow. We have previously demonstrated that after 1 hour of occlusion of the superior mesenteric artery (SMA) and before the onset of hypotension, hypovolemia, or acidosis, there is a marked decrease in cardiac output [ 91. In the present study, further evidence for a cardiac defect related to intestinal ischemia was obtained from a bioassay of peripheral plasma utilizing an isolated heart muscle preparation, and from electrocardiographic observations. In addition, plasma was assayed for vasopressor and vasodepressor activity.

Experimental nonocclusive mesenteric ischemia: Therapeutic observations

Abstract In an experimental model that simulates the clinical condition of nonocclusive mesenteric ischemia, early therapy which provides volume replacement or support of the cardiac output does not improve survival. In contrast therapy which interrupts vasconstriction, phenoxy-benzamine, improves survival and prevents hemorrhagic mucosal necrosis.

Is pulmonary angiography essential for the diagnosis of acute pulmonary embolism

The records of 158 patients who underwent pulmonary angiography for the presumed diagnosis of acute pulmonary embolism were retrospectively reviewed. Of the 111 patients in the category of high probability for pulmonary embolism based on clinical impression, 60 patients (54 per cent) had a positive pulmonary angiogram. Of the forty-seven patients in the low probability group, ten (21 per cent) had a positive angiogram. Forty-eight of the seventy-three patients (66 per cent) with a high probability lung scan had a positive pulmonary angiogram. Eleven of twelve patients (92 per cent) with a high probability ventilation-perfusion scan had a positive pulmonary angiogram, and two of eight patients (25 per cent) with a low probability ventilation-perfusion scan had a positive pulmonary angiogram. The mean PO2 of patients with a positive pulmonary angiogram was 64 mm Hg, and the mean PCO2 30 mm Hg. The mean PO2 of patients with a negative pulmonary angiogram was 63 mm Hg and the mean PCO2 34 mm Hg. Based on these data, we believe that the accuracy of pulmonary angiography in diagnosing acute pulmonary embolism is much higher than that of the clinical impression, arterial blood gas determinations, and lung scanning technics.

Penetrating wounds of the neck: Re-emphasis of the need for prompt exploration☆

Abstract Our experience with this small series of patients with penetrating wounds of the neck parallels that of several other groups and supports the dictum that all such wounds should have prompt exploration. More than half will have injury to a major structure and yet one third will not manifest such an injury. The morbidity and mortality of a neck exploration in which the findings are negative is minimal and the potential for correction of a significant injury is great. Preoperative evaluation must be complete if therapeutic difficulties are to be avoided. Finally, since any of the major structures of the neck might be damaged, the surgeon must be familiar with the principles of therapy for injury to each vital structure.