Rocco Orlando

Physiologic effects of pneumoperitoneum

Laparoscopy requires the establishment of pneumoperitoneum in order to provide adequate surgical exposure and maintain operative freedom. Insufflation of carbon dioxide into the peritoneal cavity, however, can affect several homeostatic systems, leading to alterations in acid-base balance, blood gases, and cardiovascular and pulmonary physiology. Although these changes may be well tolerated by healthy individuals, they may increase physiologic stress in patients with pre-existing conditions, placing them at increased risk for perioperative complications. An understanding of the physiologic changes caused by carboperitoneum is therefore essential for identification of high-risk patients and formulation of appropriate treatment plans, which may include preoperative cardiorespiratory optimization and perioperative monitoring. Under optimal conditions, debilitated patients should be able to tolerate pneumoperitoneum safely and, thereafter, reap the benefits associated with minimally invasive surgery.

Selective hepatic arterial embolization of grade IV and V blunt hepatic injuries: an extension of resuscitation in the nonoperative management of traumatic hepatic injuries.

BACKGROUND Recognizing the significant mortality and complications inherent in the operative management of blunt hepatic injuries, hepatic arterial embolization was evaluated as a bridge between operative and nonoperative interventions in patients defined as hemodynamically stable only with continuous resuscitation. METHODS Seven of 11 patients with grade IV or V hepatic injuries identified by computed tomography underwent hepatic arterial embolization. A prospective evaluation of hepatic embolization based on subsequent hemodynamic parameters was assessed by matched-pair analysis. A summary of this study populations demographic data and outcomes is presented, including age, Glasgow Coma Scale score, Injury Severity Score, Revised Trauma Score, computed tomography grade, intensive care unit and hospital length of stay, transfusion requirements, complications, and mortality. RESULTS No statistical difference was demonstrated between pre-embolization and postembolization hemodynamics and volume requirements. After embolization, however, continuous resuscitation was successfully reduced to maintenance fluids. Hepatic embolization was the definitive therapy for all seven patients who underwent embolization. CONCLUSION Results of this preliminary investigation suggest that hepatic arterial embolization is a viable alternative bridging the therapeutic options of operative and nonoperative intervention for a subpopulation of patients with hepatic injury.

Acute acalculous cholecystitis in the critically ill patient

Nine cases of acute acalculous cholecystitis were diagnosed in the surgical intensive care unit at Hartford Hospital during a 2 year period after abdominal, cardiovascular, and traumatic surgery. A tender mass in the right upper quadrant was suggestive but not diagnostic of the condition. Hyperamylasemia was seen in all patients. Ultrasonography is the most useful diagnostic tool; serial studies reveal progressive gallbladder dilatation and edema. Tube cholecystostomy was used in five patients and cholecystectomy in four. Cholecystostomy led to resolution of the inflammatory process in all five patients. Cholecystectomy should be reserved for those patients with extensive gallbladder necrosis. Six of the nine patients in the series died, all from multiple systems failure with concomitant sepsis. Hypotension is probably central to the development of acute acalculous cholecystitis. In the face of elevated intraluminal gallbladder pressure caused by ampullary edema and increased bile viscosity, hypotension may result in mucosal ischemia and necrosis with subsequent bacterial colonization. Acute acalculous cholecystitis represents another organ failure in critically ill patients who are experiencing progressive failure of multiple organ systems. An aggressive approach to the manifestations of organ failure, including acalculous cholecystitis, must be employed.

Angiographic Embolization for Gastroduodenal Hemorrhage: Safety, Efficacy, and Predictors of Outcome

OBJECTIVE To examine the safety, efficacy, and predictors of outcome of angiographic embolization in the management of gastroduodenal hemorrhage. DESIGN Retrospective record review. SETTING University-affiliated tertiary care center. PATIENTS All of the patients were referred after endoscopic treatment failure. Surgery was not immediately considered because of poor surgical risk, refusal to consent, or endoscopists decision. Patients with coagulopathy, hemobilia, and variceal or traumatic upper gastrointestinal tract bleeding were excluded from review. INTERVENTIONS Between January 1, 1996, and December 31, 2006, 70 embolization procedures were performed in 57 patients. MAIN OUTCOME MEASURES Technical success rate (target vessel devascularization), clinical success rate (in-hospital cessation of bleeding without further endoscopic, radiologic, or surgical intervention), and complications. RESULTS The technical success rate was 94% (66 of 70 angiographies). The primary clinical success rate was 51% (29 of 57 patients), and the clinical success rate after repeat embolization was 56% (32 of 57 patients). Two factors were found to be independent predictors of poor outcome by multivariate analysis: recent duodenal ulcer suture ligation (P = .03) and blood transfusion of more than 6 units prior to the procedure (P = .04). There was no predictive value for angiographic failure based on age, sex, prior coagulopathy, renal failure at presentation, immunocompromised status, multiple organ system failure, empirical (blind) embolization, and use of permanent vs temporary embolic agents. Repeat embolizations were helpful for postsphincterotomy bleeding. Major ischemic complications (4 patients [7%]) were associated with previous foregut surgery. CONCLUSIONS Angiographic embolization for gastroduodenal hemorrhage was associated with in-hospital rebleeding in almost half of the patients. Angiographic failure can be predicted if embolization is performed late, following blood transfusion of more than 6 units, or for rehemorrhage from a previously suture-ligated duodenal ulcer.

Carcinoma of the stomach after gastric operation

Seventeen cases of carcinoma of the stomach occurring late after previous gastric operation are presented. In all instances, patients had undergone gastroenterostomy, with or without gastric resection. Most patients had undergone the initial operation for peptic ulcer disease an average of 18 years before presenting with the tumor. Endoscopic biopsy of the gastroenterostomy and gastric cytologic evaluation offered a high degree of sensitivity and specificity in making the diagnosis. These tumors appeared to originate in the gastric mucosa near the stoma. Survival was poor with both curative and palliative therapy. Alkaline bile reflux, achlorhydria and bacterial colonization are discussed as possible causes. Patients who have undergone partial gastric resection are at increased risk for the development of carcinoma of the stomach remnant. We recommend that any patient in whom new upper gastrointestinal symptoms develop more than 10 hears after partial gastrectomy should undergo endoscopy with biopsy of the gastric mucosa adjacent to the anastomosis.

Gastric lymphoma: A clinicopathologic reappraisal☆

Histologic material from 42 cases diagnosed as gastric lymphoma at Hartford Hospital was reviewed, confirming the diagnosis in 37. Three cases of pseudolymphoma were found. The incidence of gastric lymphoma has increased steadily over the past 50 years: 35 percent of cases occurred during the past decade. Most patients with gastric lymphoma are in the seventh or eighth decade of life. Resection offered the best chance for long-term survival, either alone or with radiation therapy. Nodal status was correlated with length of survival of survival; 60 percent of patients with negative nodes survived 5 years or more. Cases were classified according to the Rappaport classification and the Working Formulation of Non-Hodgkins Lymphomas. The formulation was more useful than the Rappaport classification in assessing prognosis in various types of lymphoma and better reflects our current understanding of neoplasms of the lymphoid system.

Second Opinion and Transfer of Care

Surgeons are dedicated to performing technically competent and expert operations: preventing complications wherever possible. Unfortunately, adverse events do occur and must be managed efficiently and effectively. When technical surgical complications occur as a result of an operative procedure, the surgeon must decide when to seek a second opinion and when to consider transfer of the patient for additional care.

Disclosure of Complications and Error

Communication with patients about medical error is one of the most difficult issues which confront the surgeon. While surgeons strive to care for patients without mistakes, the complexity of the care process allows for the possibility of surgeon error, systems error, or error committed by any member of the care team.