Oded Zamir

Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis

BACKGROUNDnThe ultimate therapy for acute cholecystitis is cholecystectomy. However, in critically ill elderly patients the mortality of emergency cholecystectomy may reach up to 30%. Open cholecystostomy performed under local anesthesia was considered to be the procedure of choice for treatment of acute cholecystitis in high-risk patients. In recent years, ultrasound- or computed tomography (CT)-guided percutaneous transhepatic cholecystostomy (PTHC) replaced open cholecystostomy for the treatment of acute cholecystitis in critically ill patients.nnnMETHODSnThe aim of the present study was to evaluate the results of a 5-year protocol using PTHC followed by delayed laparoscopic cholecystectomy for the treatment of acute cholecystitis in critically ill patients. We reviewed the charts of 55 patients who underwent PTHC at the Hadassah University Hospital Mount Scopus during the years 1994 to 1999.nnnRESULTSnThe main indications for PTHC among this group of severely sick and high-risk patients was biliary sepsis and septic shock in 23 patients (42%); and severe comorbidities in 32 patients (58%). The median age was 74 (32 to 98) years, 33 were female and 22 male. Successful biliary drainage by PTHC was achieved in 54 of 55 (98%) of the patients. The majority of the patients (31 of 55) were drained transhepaticlly under CT guidance. The rest, (24 of 55) were drained using ultrasound guidance followed by cholecystography for verification. Complications included hepatic bleeding that required surgical intervention in 1 patient and dislodgment of the catheter in 9 patients that was reinserted in 2 patients. Three patients died of multisystem organ failure 12 to 50 days following the procedure. The remaining 52 patients recovered well with a mean hospital stay of 15.5 plus minus 11.4 days. Thirty-one patients were able to undergo delayed surgery: 28 underwent laparoscopic cholecystectomy of whom 4 (14%) were converted to open cholecystectomy. This was compared with a 1.9% conversion rate in 1,498 elective laparoscopic cholecystectomies performed at the same time period (P = 0.012). Another 3 patients underwent planned open cholecystectomy, 1 urgent and 2 combined with other abdominal procedures. There was no surgery associated mortality, severe morbidity, or bile duct injury.nnnCONCLUSIONSnThe use of PTHC in critically ill patients with acute cholecystitis is both safe and effective.

Laparoscopic Nissen fundoplication in children under 2 years of age

AbstractBackground: Antireflux operations have been recommended for infants and children suffering from complications related to gastroesophageal reflux (GER). In recent years, the laparoscopic approach has been used increasingly for antireflux surgery in adult patients. This is our initial experience with Nissen fundoplication in infants and children under 2 years of age.n Patients: We operated on 11 patients weighing between 3.0 and 10.0 kg. The main indications for surgery were GER-induced aspiration pneumonia and failure to thrive, in spite of intensive conservative treatment. All patients except one had an associated neurological abnormality, including six patients with familial dysautonomia.n Results: All attempted operations were completed successfully laparoscopically, with only a few postoperative complications and acceptable short-term results. The clinical considerations and technical aspects unique to this specific group of patients are discussed.n Conclusion: Laparoscopic Nissen fundoplication is feasible, safe, and effective, even in very small babies.

A more liberal approach to the surgical treatment of Crohn's disease

BACKGROUNDnSurgery for Crohns disease is not intended for cure, but rather to relieve symptoms and treat complications. Perioperative morbidity, the fear of creating short bowel syndrome, and the tendency of the disease to recur convinced many physicians to refer their Crohns patients for surgery only when life-threatening complications occur.nnnMETHODSnThis is a retrospective analysis of 47 patients operated on for Crohns disease between 1989 and 1994. Twenty-six patients were operated on for classic indications (classic group) and the other 21 were operated on to improve their quality of life (quality group).nnnRESULTSnThere was no operative or postoperative mortality during a mean follow-up period of 50 (27 to 84) months. All major postoperative complications occurred only in patients operated on for the classic indications (four abscesses, two fistulas, one wound dehiscence, and two small bowel obstructions). During the follow-up period, a total of 13 patients (50%) in the classic group and only 5 patients (24%) in the quality group required reintroduction of medical therapy or additional operations for exacerbations and complications of Crohns disease.nnnCONCLUSIONSnOur data suggest that surgical intervention intended to improve the quality of life for Crohns disease patients is safe and effective for carefully selected patients. It does improve quality of life, may prevent life-threatening complications, and offers a lower recurrence rate following surgery.

Pyocolpos — a rare cause of neonatal sepsis

A newborn female infant presented with a lower abdominal mass and sepsis. Radiologic and ultrasonic studies established the diagnosis of pyocolpos. Surgical drainage was successfully carried out. Hydrocolpos is an uncommon anomaly resulting from imperforate hymen or atresia of the vagina. It usually presents in the first few weeks of life as an asymptomatic abdominal mass or with symptoms due to compression of adjacent structures by the enlarged vagina. Rarely, pyocolpos results from an infected hydrocolpos, usually associated with vaginal atresia rather than imperforate hymen. It may cause life-threatening sepsis; early diagnosis and prompt surgical drainage are therefore essential. The infant described demonstrates the diagnostic approach and the management of pyocolpos.

Intussusception in the premature infant

Intussusception is uncommon in the neonatal period; only a few cases have been reported in premature infants. Two such cases are described. The infants presented with abdominal distention and vomiting followed by rectal bleeding. Confusion with the diagnosis of necrotizing enterocolitis (NEC) led to a delay in operation. Pathological leading points were present in both patients. Early operation is recommended for persistent intestinal obstruction in premature infants with an atypical picture of NEC or meconium disease not relieved by meglumine diatrizoate (Gastrografin) enema.

Lymphangioma of the Pancreas Presenting as Massive Duodenal Bleeding

A 71-year-old woman underwent operation for massive duodenal bleeding. At laparotomy a large multicystic tumor arising from the pancreas was found. The bleeding was controlled by suturing of the duodenal mucosa and release of the stretched duodenum from the tumor. Histologic and ultrastructural examination confirmed the diagnosis of cystic lymphangioma of the pancreas. We discuss the clinical and pathologic aspects of this rare tumor.

Extensive Lye Injury of the Stomach and Duodenum

A 38-year-old woman was treated for extensive corrosive injury of the stomach and duodenum following ingestion of liquid lye. Nine days following admission she developed perforation and bleeding from