The American Journal of Surgery

Published by Elsevier
Print ISSN: 0002-9610
This study was designed to investigate the role of hydroxyethyl starch (HES) 130/0.4 on the wound healing process in left colonic anastomoses in the presence of intra-abdominal sepsis. The left colonic anastomosis was performed in 40 rats that were divided into 4 groups: (1) group SHAM, laparatomy plus cecal mobilization (n = 10); (2) group SHAM + HES, HES130/.4-treated controls (n = 10); and (3) group CLP, cecal ligation and puncture (n = 10); (4) group CLP + HES, CLP plus HES130/.4 (n = 10). HES130/.4 was administrated before the construction of colonic anastomosis, 15 mL/kg/24 hours and daily for 4 postoperative days. Anastomotic bursting pressures (ABPs) were measured in vivo on day 5. Tissue samples were obtained for analyses of hydroxyproline (HP) contents, myeloperoxidase (MPO) activity, malondialdehyde (MDA), reduced glutathione (GSH) levels, and nuclear factor-kappaB (NF-kappaB) activation. The plasma levels of tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, d-dimer, and protein C (PC) were also measured. Anastomotic granulation tissues were fixed for transmission electron microscopic (TEM) analyses. Intra-abdominal sepsis led to significant decreases in colonic anastomotic bursting pressures, perianastomotic tissue HP contents, GSH levels, and plasma levels of PC, along with increases in perianastomotic tissue MPO activity, MDA levels, NF-kappaB activation, and plasma levels of TNF-alpha, IL-6, and d-dimer. However, HES130/.4 treatment significantly inhibited all these responses. TEM analyses revealed that there was a trend toward a higher density of fibroblast distribution and a higher rate of fibroblast activation in the SHAM- and HES 130/0.4-treated animals, compared with the CLP group. This study showed that moderate doses (15 mL/kg) of HES 130/0.4 administration significantly prevented this intraperitoneal sepsis-induced impaired anastomotic healing of the left colon. This beneficial effect of HES 130/0.4 can be mainly attributed to its anti-inflammatory and antioxidant properties and beneficial effects of modulating endothelial-associated coagulopathy.
This trial examines the utility of breast magnetic resonance imaging (MRI) for detection of occult breast disease and its effect on surgical treatment. Between October 2000 and March 2002, 76 of 1289 patients underwent bilateral breast MRI within 4 months of a mammogram. The MRI scan, mammogram, pathology reports, and physicians' notes were reviewed to determine impact of MRI on surgical treatment. Magnetic resonance imaging detected 23 additional lesions in 19 patients not detected by mammogram. Cancer occult to mammography was detected by MRI in 6 women, constituting 7.9%. Magnetic resonance imaging impacted surgical treatment plans in 10 of 76 (13.2%) patients. Magnetic resonance imaging is effective at identifying new subclinical breast disease not seen on mammography. Ten of 76 patients (13.2%) who underwent MRI had their surgical management altered due to MRI findings. Specific criteria should be studied to know which subgroups would benefit most from breast MRI.
A report on the use of silver nitrate cream is presented, indicating that the advantages of a solution can be combined with the facility of application of a cream. Seventy-eight patients admitted over a two year period to the Naval Hospital, Oakland, were treated with silver nitrate cream. The cream appears not to cause allergic reaction or systemic toxicity and is bacteriologically effective in protecting epidermal elements. The main advantage of silver nitrate cream over the two more popular current preparations is that it is an effective preparation for a very low cost.
In the last few decades, a great deal of progress has been made in understanding the cellular and biochemical interplay that comprises the normal wound healing response. This response is a complex process involving intricate interactions among a variety of different cell types, structural proteins, growth factors, and proteinases. The normal wound repair process consists of three phases--inflammation, proliferation, and remodeling--that occur in a predictable sequence and comprise a series of cellular and biochemical events. A review of the biochemical and physiologic processes that regulate wound healing and the cascade of cellular events that gives rise to the healing process is presented here.
Surgical results have been reported to be improved in hepatic resections for hepatocellular carcinoma (HCC) in recent years, but the detailed trends in surgical results for HCC in a single high-volume center are still not clear. Surgical results in 1,000 hepatic resections for HCC performed at a single medical center from 1989 to 2011 were analyzed. Patients were divided into 3 groups: those performed in the early period (1989 to 1995, n = 181), the middle period (1996 to 2004, n = 391), and the late period (2005 to 2011, n = 428). Hospital mortality (3.9%, 1.0%, and .5%; P = .0027) and morbidity (45%, 24%, and 15%; P < .0001) rates were significantly decreased. The overall survival rates were significantly improved (50%, 72%, and 78% at 5 years; P = .0021), but there was no significant difference in the disease-free survival (29%, 34%, and 31% at 5 years; P = .7823). Surgical results of hepatic resections for HCC were significantly improved, with the mortality rate nearly reaching 0%. The 5-year survival rate after hepatic resections for HCC was also improved to 78%, but the consistently high rate of HCC recurrence after hepatic remains a problem.
A retrospective review of 1,000 elective cholecystectomies was undertaken to identify factors associated with wound infection. The technic of wound drainage appears to influence the incidence of infectious wound complications to a significant degree.
Between 1979 and 1988, we created intestinal anastomoses in 1,000 patients using a single-layer, continuous suturing technique and a polypropylene suture. The technique is easily learned, flexible in its application, and incurs less cost than most other techniques. The anastomoses involved all levels of the colon and the upper (intraperitoneal and extraperitoneal) rectum. All patients were followed for a minimum of 1 year. The clinically suspected anastomotic leak rate was 1%. Other morbidity included would complications (2%), obstruction of the small intestine (2%), anastomotic stricture (1%), and death (1%). No death was due to anastomotic complications. These rates of complications are comparable with, and in many instances lower than, those reported with other techniques of intestinal anastomosis.
Operative cholangiography and extraductal palpation are both accurate means of demonstrating common duct stones. When used in combination, accuracy was 94.4%. Routine extraductal palpation and selective cholangiography will prevent excessive and fruitless common duct exploration.
Learning curves and efficiency concerns have slowed the integration of laparoscopy into colorectal practice. We evaluated our experience with laparoscopic colorectal (LC) surgery using enhanced recovery pathways (ERPs). One thousand consecutive LC procedures performed by 2 surgeons over a 5-year period using previously published, standardized ERPs were assessed. The mean age was 59, and the mean body mass index was 29.5. Procedures included segmental colectomy (54%), proctectomy (19%), total colectomy (11%), ostomy (5%), and other procedures (11%). Diagnoses included malignancy (41%), diverticulitis (16%), inflammatory bowel disease (13%), and other (30%). The mean operative time was 151 minutes, and the mean blood loss was 55 mL. Conversion to an open surgery occurred in 5.8%, whereas 2.3% were performed using a hand-assist procedure. The mean hospital stay was 4.1 days (median 3), with a 6% readmission rate. Complications (20%) included mortality (0.3%), wound infection (4%), and anastomotic leak (1.4%). LC surgery with ERP offers excellent outcomes with efficient use of resources.
Atomic bomb victims who were exposed under 1,000 meters and survived ; over five years were investigated. There were 619 patients who comprised a total ; sample. Mechanical, blast, burn, and radiation injuries were evaluated as to ; onset, duration, severity, body area affected, and type of healing. The modal ; patient experienced severe radiation and mild trauma. Results were compared with ; similar earlier studies. The possibility that patients exposed within 1,000 m ; with radiation and/or thermal injuries have been dying at a faster rate than ; those withmechanical or no injuries is discussed. (auth);
The finding of a normal appendix on appendectomy should occur in no more than 15 percent of patients, and in half of these some other cause of the abdominal pain will probably be found, most often gynecologic in origin. In order to achieve this rate, surgeons will have to exercise more restraint, develop greater discrimination in evaluating abdominal findings and probably spend more time palpating abdomens. This must be done while maintaining the incidence of perforation at or below 15 percent. A needless operation to remove a normal appendix is not an innocuous procedure and cannot be rationalized as such, but against this must be weighed the risks of delayed surgery when the history, physical findings and laboratory data are unequivocal. Future statistical reviews will tell how well surgeons are applying their skills in the evaluation of the troublesome vermiform appendix, and if there are any differences in the Health Maintenance Organization setting compared with the fee-for-service hospital.
An 11 year study of 1,035 elective colon resections reaffirmed the value of oral antibiotic prophylaxis. Five antibiotic regimens were used in 88 percent of the patients. The most effective and most frequently used regimen was the combination of parenteral cephalosporin with oral erythromycin and an aminoglycoside. The overall infection rate with this regimen was 11 percent and the wound sepsis rate was 2.5 percent. The use of parenteral cephalosporins alone was not effective. Furthermore, resistant bacteria were cultured from the wound infections of parenteral cephalosporin patients. A nondirective annual review of these data and each surgeon's infection rate resulted in a change in the antibiotic ordering practices and decreased infection rates. It is no longer acceptable surgical practice to omit antibiotic prophylaxis in colon operations.
In conclusion, this study shows that carcinoma of the stomach has a very high incidence when compared with other forms of cancer seen in a rural Korean mission hospital. The peak age for men is fifty-one years and for women forty-two years. Male to female ratio is three to one. There is a higher rate of stomach cancer among farmers than other segments of the population. Of 178 patients reported having hope of cure, 138 are living. Only seven have lived longer than five years. Ninety-one are living free of disease. Koreans with stomach cancer seem to ingest significantly larger amounts of soya bean paste than persons of the same age and sex without stomach cancer. The fact that Aspergillus flavus is found in soya bean cakes raises the possibility that aflatoxins produced by this mold which grows on the soya bean cakes (from which soya bean paste is made) may be a possible etiologic factor in the high incidence of stomach cancer seen in 1,079 patients with stomach cancer in a 130 bed hospital in the seven year period from 1962 through 1968 in Southwest Korea. Further investigation is necessary to delineate the role of molds as a factor in stomach cancer as observed in the Far East. Epidemiologic studies of the significance of the consumption of soya paste as a factor in the frequency of cancer of the stomach in Korea are being reported in another paper.
Background: The nickel-titanium compression anastomosis ring device (ColonRing, NiTi Surgical Solutions, Netanya, Israel) has been cleared by the Food and Drug Administration in 2006 to construct gastrointestinal anastomoses. We evaluated the anastomotic leak rate after end-to-end anastomosis using the ColonRing device. Methods: Using a multinational (16 countries), multicenter (178 centers) data registry provided by NiTi Surgical Solutions, Netanya, Israel, we retrospectively examined clinical data of patients who underwent elective laparoscopic or open left-sided colectomy and anterior resection from January 2008 to June 2010. Results: A total of 1,180 patients underwent end-to-end anastomosis using the ColonRing device during the study period. The overall anastomotic leak rate was 3.22% (38 patients). The median length of hospital stay was 6 days (range 2 to 21 days). The median ring expulsion time was 8 days. The earliest ring expulsion time was 6 days; however, in 1 patient, the ring did not expel. In 4 patients, the anastomosis had to be immediately recreated because of 1 misfiring and 3 incomplete anastomoses. Conclusions: The use of the ColonRing device is feasible and safe and could be considered an alternative technology for end-to-end colorectal anastomosis.
We hypothesized that wide-field brachytherapy (BRT) after margin negative excision would result in complication rates, local recurrence rates, and cosmesis scores equivalent to external beam radiotherapy (ERT). Patients with T(is,1,2) tumors less than or equal to 4 cm, 0 to 3 positive axillary nodes, and negative inked surgical margins were entered prospectively into BRT phase I/II trial. Patients who met the eligibility criteria for BRT but were treated with ERT during the same time period were retrospectively identified as controls. A blinded panel of healthcare professionals graded cosmetic outcome. Fifty patients with 51 breast cancers received BRT from January 1992 to October 1993. We identified 94 patients eligible for BRT but concurrently treated with ERT. At a median follow-up of 75 months, the two groups were similar for grade III treatment toxicities, local/regional recurrence rates, and cosmesis scores. For selected breast cancer patients undergoing breast-conserving therapy, BRT is an attractive alternative to ERT.
A case is reported of ten year survival after thoractomy for inoperable bronchogenic carcinoma. Apparent spontaneous regression has been followed by freedom from development of a new pulmonary tumor in spite of the patient's continued smoking. Immunologic factors affecting this course are suggested by the demonstration of immune lymphocytes in the patient's peripheral blood which depress the growth of tumor cells from a donor with lung cancer.
This study examined the clinical value of intraoperative peritoneal lavage for cytological examination in patients with gastric cancer. Peritoneal dissemination is the most frequent mode of recurrence for this tumor. A retrospective of lavage findings, other factors, and outcome was performed in 1,297 patients with gastric cancer who underwent intraoperative peritoneal lavage. The 5-year survival rate of patients with positive lavage cytology was only 2%. Patients who underwent curative resection and had negative cytology had a significantly better 5-year survival rate (P < 0.001). Even among patients with macroscopic peritoneal dissemination, the survival rate was significantly better with negative cytology, which reflected fewer free cancer cells in the peritoneal cavity. Serum concentrations of carcinoembryonic antigen and carbohydrate antigen 19-9 were significantly higher in patients with positive cytology. Multivariate analyses indicated that intraoperative cytological findings was an independent prognostic factor for survival, and was the most important factor for predicting peritoneal recurrence. Intraoperative peritoneal lavage cytology is important in predicting survival and peritoneal recurrence in gastric cancer.
Clinical results of the use of a gastroenteric anastomosis with a diameter the size of the normal pylorus (1.9 cm) in 1,300 cases between 1954 and 1971 are presented mainly in terms of prevention of the dumping syndrome. We have had no patient with clinical manifestations of any degree of the dumping syndrome in the first two years after operation. These excellent results have led us to employ the method routinely. We recommend this method for its simplicity and, above all, its effectiveness in preventing the dumping syndrome.
Experience with 1,360 primary parotid tumors seen at the Mayo Clinic during two fifteen year periods, 1940 through 1954 and 1955 through 1969, is reviewed. A comparison of histopathologic classification, type of treatment indicated, recurrence rates, and survival in the two periods reveals considerably greater understanding of all factors in the later fifteen year period. The relatively high mortality still encountered among patients with high grade malignant tumors of the parotid glands indicate the nature of the challenge still to be met. Based on the data in this study, it is our opinion that superficial or total conservative parotidectomy is best employed primarily for benign tumors and that the shift to more radical operative procedures should continue in the management of malignant tumors, especially those that are less well differentiated. For experienced surgeons, exceptions might be the small superficially located tumors or the tumors in the lower pole of the gland such as Warthin's tumors. Local excision with removal of a margin of parotid parenchyma might be justifiable in such cases.
A retrospective review was undertaken of 1,422 permanent venous access devices (PVADs) implanted from 1989 to 1991 at Hahnemann University Hospital. This included 730 single-lumen Hickman catheters, 368 double-lumen Hickman catheters, 307 single-lumen Portacath infusion ports, and 17 double-lumen Portacath infusion ports. Indications for placement were as follows: antibiotics in 28%; chemotherapy in 51%; hyperalimentation in 4%; intravenous fluids in 4%; hemodialysis in 3%; and undocumented indications in 10%. There were 60 PVADs removed and/or replaced prior to the completion of intended therapy (4% overall). Indications for removal were catheter infection in 1% of cases and catheter malfunction in 3% of cases. The percentage of Portacath infusion ports removed was significantly greater than the percentage of Hickman catheters that were removed (p < 0.001). However, there was no significant relationship between catheter infection or the malfunction rate, and the number of lumens, initial indication for placement, or number of catheters placed. Life-threatening complications associated with PVAD insertion occurred in fewer than 1% of cases. The insertion of PVADs is a safe and efficient mode of long-term venous access.
Five of the author's cases and 1,428 cases from Japan's literature are discussed. Half of the patients were infants. The ratio of men to women was 1 to 3. One hundred fifty-one patients had malformation of the pancreaticobiliary system, which is said to be a cause of congenital choledochal cyst. All of the patients have been followed up. Excision of the cyst is the best procedure for preventing ascending cholangitis and cystic cancer. Roux-Y hepaticojejunostomy is also effective for reconstruction of the bile duct because it rarely causes ascending cholangitis.
Vertical gastroplasty is a safer and simpler operation than gastric bypass for morbid obesity, but to produce permanent long-term weight loss, a permanent support is needed for the outlet of the newly created gastric pouch in vertical gastroplasty. The most important finding in this study of 1,463 patients with vertical gastroplasties was the development of a safe and practical use of a Silastic ring to permanently support the outlet. Using an uncovered Silastic ring, erosion of the ring has not been observed and long-term weight loss of 36.7 percent of original weight or 63.4 percent of excess weight has been obtained, which is equivalent to that reported for gastric bypass or other gastric reduction procedures. In addition, lower mortality and lower morbidity rates have been achieved than those reported in studies using other gastric reduction methods. Silastic ring vertical gastroplasty with an uncovered ring is the safest and most effective of the gastric reduction procedures in our experience.
From analysis of results of more than 1,500 renal transplants has evolved a plan for donor selection and immunosuppressive management whereby patients with end-stage renal disease can obtain maximum graft and patient survival. With superior results in both patient and graft survival with living-related transplantation, this modality should be considered initially. Pretreatment with third party blood transfusions appears effective in all donor categories. Donor-specific blood transfusions have afforded 1-haplotype mixed lymphocyte culture-incompatible recipients enhanced opportunity for successful transplantation. Current results with living-related transplantation suggest realistic expectations of 1 and 2 year graft survival rates of greater than 90 percent. Curtailment of steroid therapy has resulted in improved patient survival at 1 and 2 years: 98 and 97 percent for recipients of living-related grafts, and 91 and 88 percent for recipients of cadaver grafts. These results, in combination with proper donor selection and appropriate recipient pretreatment with blood transfusions, have made renal transplantation a very effective therapeutic method in patients with end-stage renal disease.
From 1979 through 1981, 64 premature infants who weighed less than 1,500 g underwent 68 operations and 52 survived (81 percent). Twenty-six of 31 infants who weighed less than 1,000 g (84 percent) and 26 of 33 infants who weighed between 1,000 and 1,500 g survived (84 and 79 percent, respectively). The most common operation was ligation of a patent ductus arteriosus in 53 infants, of whom 43 survived (81 percent). Ten infants were operated on for necrotizing enterocolitis and 7 survived (70%). Four of five infants (80 percent) survived other major operations. Factors which influence survival include appropriate timing of operation, preoperative and postoperative mechanical ventilation, and parenteral nutrition. Intraoperative management includes short-duration anesthesia, continuous monitoring of vital signs, and judicious use of small amounts of amnestic and neuromuscular blocking agents combined with low fractional inspired oxygen concentration to reduce the risk of oxygen toxicity. Utilizing these principles, the survival rate compared favorably with the survival rate of all premature infants, which establishes that major surgery can be undertaken with only moderate risk in the infant with very low birth weight.
Background: The aim of this study was to evaluate the clinical outcomes of 1,578 patients with breast benign diseases after excisions and the risk factors. Methods and results: With a median follow-up of 34 months, 69 patients were identified to have recurrence (local recurrence: 45; new lesion: 24). Univariate and multivariate analyses revealed that multiple lesions, a larger lesion size, and a hematoma were independent risk factors for recurrence. Patients with in situ recurrence tended to have fewer lesions and more samples taken per lesion. Patients with new lesions tended to have multiple lesions. After re-excisions, there was no second recurrence events observed in the patients with local recurrence (0/30), whereas 5 patients with new lesions (5/14) were noted to have second recurrence events. Conclusions: Ultrasound-guided vacuum-assisted biopsy for the complete excision of breast benign diseases is safe and effective. Local recurrence and new lesions may have different clinicopathological features and underlying mechanisms. Different management might be given to patients with a different pattern of recurrence.
Experience with laparoscopy in 1,720 cases performed for surgical diseases with elective or emergency indications is reported. It is hoped that laparoscopy, a simple and harmless technic of great diagnostic value, will be employed more frequently in routine and emergency surgery.
A questionnaire regarding details of their illness, social, educational and religious background and various aspects of rehabilitation since surgery was completed by 1,803 persons who underwent ileostomy for ulcerative colitis between 1930 and 1970. The majority of participants were operated on since 1960, reported an above-average education, lived in metropolitan areas, had surgery performed as a single stage proctocolectomy, and were chronically ill for an average of almost 7 years from the onset of disease to ileostomy. An unexplained high incidence of Jewish patients was noted; in addition, Jewish patients comprised almost half of those who had a family history of inflammatory bowel disease. Although some participants reported major postoperative problems including unfavorable alterations in stomal structure and function, bowel obstruction, delayed perineal healing and nephrolithiasis, most patients were satisfied with life with an ileostomy, presently maintaining their health, employment, marriage and sexuality.
We analyzed the results of laparoscopic cholecystectomy in 1,983 patients from a variety of practice settings in order to evaluate a large, cross-sectional experience for this new procedure. Twenty general surgeons from 9 clinics in 4 states examined the records and outcome of their laparoscopic cholecystectomy patients through March 1991. In 88 patients (4.5%), the operation was converted to an open procedure, usually because of marked inflammation and unclear anatomy. A total of 644 cases were performed with laser dissection and 1,339 with cautery, and the results of these 2 methods were similar. There were 41 complications. Reoperation for repair was necessary in 18 patients, including 5 with common duct injuries, and, to date, the outcome has been good in each patient. Seventy-six patients (3.8%) have had recognized common duct stones; these were removed preoperatively by endoscopic sphincterotomy (ERS) in 20 patients, during cholecystectomy in 46 patients, and postoperatively by ERS in 4 patients. In six patients, common duct stones became apparent 1 to 4 months after cholecystectomy. We conclude that trained general surgeons can perform laparoscopic cholecystectomy safely with risks comparable to those for conventional open cholecystectomy.
Resection represents the best treatment for potentially curable liver tumors; radiofrequency ablation (RFA) is an alternative. The curative potential of RFA may be hampered because the extent of burn is difficult to estimate by ultrasound. We postulated that intraoperative MRI (iMRI) would enable a more accurate assessment of ablation completeness. We performed open hepatic surgery in an operating room equipped with a unique, retractable 1.5-T magnet. Patients were selected because it was anticipated that RFA (with or instead of resection) was likelihood and that iMRI might be helpful in making intraoperative decisions. After baseline MRI, lesions were further assessed by ultrasound at the time of open surgery. Lesions were resected and/or ablated, and further imaging confirmed the margins of the procedure. Nine patients underwent the procedure: 1 with metastatic carcinoid, 4 with hepatocellular carcinoma, and 4 with colorectal liver metastases. In 4 patients, iMRI had an effect on decision-making. In 5 individuals, there were nonlocal recurrences, and 1 patient who was never disease-free had a local recurrence. Intraoperative MRI could potentially impact operative decision-making when ablating extensive disease. Its ability to prevent local recurrences must be determined. Moreover, the role of this technology in the overall treatment armamentarium must be defined.
A critical outcome analysis of a large, single-institution experience provides a better frame of reference for an assessment of the role of laparoscopic colectomy for colorectal pathology. Review of a prospectively gathered database was performed of a consecutive series of laparoscopic colectomy patients who were operated on by 2 surgeons at a single institution (tertiary referral center) using standardized techniques and care plans. Patients were assessed for operative indications, type of resection, operative time, conversion, complications, duration of stay, and readmission within 30 days. One thousand consecutive patients undergoing laparoscopic colectomy from January 1999 thru June 2004 were analyzed. The types of resections were right colectomy = 314, left/sigmoid colectomy/anterior resection = 435, total colectomy = 61, total proctocolectomy = 14, and other = 176. The indications for surgery were diverticular disease = 285, colorectal neoplasia = 285, inflammatory bowel disease = 172, rectal prolapse = 81, and other = 177. The conversion rate was 11.4%. The mean operative time was 112 +/- 45 minutes for all resections. The mean duration of hospitalization for all patients was 3.7 +/- 3.8. The overall complication rate was 9.9%, with the most frequent complications being ileus 2.8%, pulmonary 1.6%, cardiac 1.4%, and wound infection 2.6%. The 30-day readmission rate was 9.1%, and the most frequent reasons for readmission were ileus/small-bowel obstruction, intra-abdominal infection, and anastomotic leak. This largest single-institution experience with laparoscopic colectomy confirms the benefits of a standardized approach including shorter hospital rehabilitation and low rates of cardiopulmonary and wound complications. Efforts must be directed at improving access to training in laparoscopic colectomy techniques so that patients can benefit from this new technology.
Hepatobiliary disease in patients with acquired immunodeficiency syndrome (AIDS) has been well documented. Cytomegalovirus and Cryptosporidium are the pathogens most frequently associated. Previous reports of cholecystectomies and AIDS have had conflicting results on morbidity and mortality. Retrospective review of 101 patients with AIDS and symptomatic cholecystitis who underwent cholecystectomy from December 1989 to May 1995. All patients had symptoms characteristic of gallbladder disease, the most common being abdominal pain and fever. Thickening of the gallbladder was the most common diagnostic finding. Fifty-six patients underwent open cholecystectomy and 45 laparoscopic cholecystectomy. Pathologic examination revealed an abnormal gallbladder in all cases and gallstones in 29%. A specific pathogen or malignancy was identified as the etiologic agent in 44% of patients. Perioperative morbidity was similar (<5%) in both surgical groups. Perioperative mortality was 4% among all the patients treated. Both open and laparoscopic cholecystectomy improved the quality of life of these patients and should be considered as the treatment for persistent hepatobiliary symptoms in patients with AIDS.
Laparoscopic splenectomy (LS) is the surgical approach of choice for patients with hematologic disorders requiring splenectomy. Patients with idiopathic thrombocytopenic purpura (ITP) have normal to slightly enlarged spleens and benefit the most from LS. We reviewed the perioperative outcomes in 101 patients who underwent LS between May 1996 and December 2002. Patients were divided into three groups--ITP, other benign, and malignant hematologic disorders--and compared. The ITP patients (n = 48) had significantly smaller spleens and operative times compared with the other groups. Splenomegaly in the other benign (n = 23) and malignant hematologic disorders (n = 30) groups was responsible for higher open conversion rates and greater need for hand-assisted laparoscopic splenectomy (HALS). Laparoscopic splenectomy and HALS can be performed with good results for benign and malignant hematologic disorders. The benefits of HALS are similar to LS, so there should be a low threshold for HALS in patients with large spleens.
Top-cited authors
Jatin P Shah
  • Memorial Sloan Kettering Cancer Center
Ernest E Moore
  • University of Colorado
Richard Reznick
  • Queen's University
Frederick Alan Moore
  • University of Florida
Henry A Pitt
  • Temple University