Michael Negri

Pseudoaneurysm of the dorsalis pedis artery

Two cases of post-traumatic pseudoaneurysm of the dorsalis pedis artery are presented. Both were managed by resection and vascular reconstruction with a successful result. It is suggested that this, rather than resection and ligation, is the preferred treatment in these cases.

Is male gender a risk factor for conversion of laparoscopic into open cholecystectomy

AbstractBackground: Based on a clinical observation that the conversion rate of laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) is higher in males, we decided to review our records and to verify whether a significant difference in conversion rates exists between sexes. Methods: A retrospective study on conversion rates of elective laparoscopic cholecystectomy (LC) into open cholecystectomy (LC) in relation to gender was carried out in 329 patients: 267 females and 62 males. Results: Our data revealed that the probability of conversion is fivefold greater in males than females, 21% vs 4.5%, respectively (p=0.0001). We attribute this striking difference to significantly more adhesions (p=0.0002) and anatomical difficulties (p=0.003) in males during LC, leading to conversion. Conclusions: We conclude that conversion of LC to OC is more prevalent among males and is probably attributable to a greater incidence of anatomical difficulties.

Pulse oximetry in the evaluation of the painful hand after arteriovenous fistula creation

Five patients with a side-to-side arteriovenous fistula complaining of pain, numbness, and cold sensation were evaluated by pulse oximetry. Low SaO2 was noticed in all five. Closure of a major proximal venous collateral vessel eliminated the steal and resulted in SaO2 correction and was followed by clinical amelioration. Pulse oximetry proved to be a helpful adjunct in the evaluation of the painful hand after creation of an arteriovenous fistula. By applying the pulse oximeter to the patients affected limb, we were able to determine whether the pain was a result of ischemia and if the correction of the steal improved oxygenation.

How does infected bile affect the postoperative course of patients undergoing laparoscopic cholecystectomy

OBJECTIVES To assess the rate of infected bile in patients undergoing laparoscopic cholecystectomy (LC) and to study the influence on the postoperative infective complications in this group of patients. METHODS Bile samples of 247 patients undergoing LC were collected and cultured for aerobic and anaerobic bacteria. All patients were given prophylactic antibiotics. RESULTS The overall rate of infected bile was 12.8% (56 positive cultures); of these, 54 were aerobic and 2 anaerobic bacteria. Only 2 patients developed infection at the umbilical site, and in both, the bile was sterile. None of the patients with positive bile cultures developed any signs of infection during a mean follow-up period of 26 months. CONCLUSION The overall rate of septic complications following LC is extremely low, and at least in our study no correlation was found between infected bile and septic complications.

The fate of long-standing intraperitoneal gallstone in the rat

Gallstones are occasionally spilled into the peritoneal cavity during open and laparoscopic cholecystectomy. Using the rat model, we investigated the long term effect of such retained intraperitoneal gallstones. During a follow-up period of one year, no systemic deleterious outcome could be attributed to the presence of the implanted gallstones except for mild local effects. Based on the rat model we conclude that reasonable effort should be made in order to retrieve an escaped gallstone, but there is no justification whatsoever for a conversion of the laparoscopic procedure to an open laparotomy only for the purpose of retrieving a lost stone.

The laparoscopic second look for ischemic bowel disease

AbstractBackground: Survival after acute vascular ischemia depends on a second look laparotomy to detect extending bowel compromise and to verify the integrity of the anastomosis. In a series of five consecutive patients with acute ischemic bowel desease, we used laparoscopic technique to determine if a formal laparotomy could be avoided. Methods: following the resection of ischemic bowel in five consecutive patients, two laparoscopic trocars were inserted in the lower abdominal quadrants and covered by sterile gloves. Forty-eight to 72 h following the primary operation, the abdomen was inflated via a trocar and secondary assessement done by laparoscopy. Results: In all patients, the integrity of the anastomosis and viability of the remaining bowel was accurately assessed by laparoscopy. Conclusions: Using mininally invasive techniques, a second look laparotomy was avoided in 5 patients with ischemic bowel disease.

Pulse oxymetry evaluation of oxygen saturation in the upper extremity with an arteriovenous fistula before and during hemodialysis

We noticed that some patients with arteriovenous (AV) fistula on chronic hemodialysis experience pain in the limb with the fistula a short time after being connected to the dialysis machine. We postulated that the pain is caused by relative ischemia and therefore performed this study to determine whether oxygen saturation (SaO2) of the extremities with AV fistula decreases during hemodialysis. Seventy-two patients with a side-to-side primary AV fistula were evaluated by pulse oxymetry. SaO2 was measured before hemodialysis and 20 minutes after initiation of dialysis. The contralateral arm served as a control. In 48 patients, SaO2 difference between the arms of each patient before hemodialysis was less than 4%. SaO2 values of this group of patients did not change significantly 20 minutes after initiation of dialysis. In 24 patients, SaO2 differences between the hands of each patient before hemodialysis were 4% or more. In this group of patients, SaO2 values of the hands with the AV fistula decreased significantly 20 minutes after hemodialysis from a mean of 90.85 +/- 2.84% to 81.60 +/- 3.94 (P < 0.001). SaO2 remained unchanged in the contralateral arm. Nine patients in this group complained of pain and change in sensation in the arm with the fistula during hemodialysis. One patient complained of severe pain in the arm with the fistula before hemodialysis, and SaO2 was unmeasurable. We conclude that, in some patients, SaO2 of the arm with the AV fistula decreases only during hemodialysis. This phenomenon may be symptomatic. A predialysis SaO2 difference of 4% or more between the arms predicts decreased SaO2 of the arm with the AV fistula during hemodialysis.

Laparoscopic endocorporeal mobilization followed by extracorporeal sutureless anastomosis for the treatment of carcinoma of the left colon

Surgery has become progressively more reliant on technology. The technique of colonic anastomosis utilizing the biofragmentable anastomotic ring (BAR) is one such example. The benefits of therapeutic laparoscopy have been applied to the arena of colorectal surgery. A case is presented that combines these two modalities in a patient with colon cancer, laparoscopic mobilization of the large bowel, exteriorized resection, and BAR anastomosis.

Continuous esophageal pH monitoring during laparoscopic cholecystectomy

Gastro-esophageal regurgitation (GER) and eventual aspiration is considered a major risk during general anesthesia. High intraperitoneal pressure produced during laparoscopic cholecystectomy (LC) is a possible source of increased GER. We investigated the incidence of GER using continuous esophageal pH monitoring in 14 patients undergoing elective LC. Only two brief episodes of acid reflux (pH<4) occurred during LC. Apparently the high intraperitoneal pressure during LC carries no increased risk of regurgitation and aspiration.

Intra – and Retroperitoneal Bleeding Associated with Anticoagulant Therapy

Intra- and retroperitoneal bleeding may be associated with anticoagulant therapy and presents the gastroenterological surgeon with a diagnostic and therapeutic dilemma. Although these rare types of bleeding may be spontaneous, minimal trauma cannot be ruled out. In the case of retroperitoneal hemorrhage, conservative management may suffice, but in the case of intraperitoneal bleeding, urgent laparotomy may be required. It is not possible to elicit causal factors, and elderly patients on anticoagulant therapy should be carefully monitored on the appearance of any abdominal complaints.