Initial experience with laparoscopic Nissen fundoplication

In an effort to explore the utility of classic Nissen fundoplication performed laparoscopically, 16 adult patients with well documented gastroesophageal reflux underwent laparoscopic Nissen fundoplication. A full gastric fundal dissection was performed, with division of at least 2 short gastric vessels. The crura were approximated with 1-3 sutures, and a loose fundoplication was performed over an esophageal dilator (minimum 46 F) with three stitches, encompassing the esophageal wall (2.5 cm in length). All patients had symptoms of reflux refractory to medical therapy, and four had an esophageal stricture requiring preoperative dilatation. Fifteen of 16 procedures were completed laparoscopically; one patient required conversion to an open procedure to control bleeding from a posterior gastric vein. There were no other operative complications. The average operative time was 180 minutes (range 120-285). Clear liquids were begun at the passage of flatus (average 2.7 days postop), and patients were discharged an average of 4.1 days postoperatively. Postoperative complications included ileus (1 patient for 6 days), severe subcutaneous emphysema (1 patient), and dysphagia requiring dilatation (5 patients). In short follow-up (mean 4.43 mo., range 1-12 mo.) 14 of 15 patients had complete abolition of reflux symptoms, but one patient with persistent heartburn had reflux demonstrated on a postoperative upper GI series. Thirteen of 16 patients returned to full function within 14 days of surgery. We conclude that standard Nissen fundoplication is possible laparoscopically, and allows a rapid recovery from surgery. However, it is difficult, time consuming, and associated with a significant rate of recurrence in the short term (6%).(ABSTRACT TRUNCATED AT 250 WORDS)

Tumor thickness in early tongue cancer

OBJECTIVE

To review the relationship between tumor thickness and the subsequent development of cervical nodal metastases in 26 patients with stage I and II carcinomas of the oral tongue.

METHODS

The histologic features of 26 consecutive patients treated for squamous carcinoma of the oral tongue were reviewed "blindly" by a pathologist, and the variables were correlated with clinical outcome.

RESULTS

No association between tumor thickness and nodal metastases was found. Perineural infiltration was the only factor to approach statistical significance. There was also no statistically significant correlation between tumor thickness and patient survival.

CONCLUSIONS

The histologic factors considered herein probably should be controlled for when comparing results of treatment of cancer of the oral tongue.

Bile duct injury in laparoscopic cholecystectomy

Bile duct injury is an unusual complication of laparoscopic cholecystectomy. Although the exact incidence is yet to be determined, it does appear to be more common than bile duct injury during open cholecystectomy. Previous publications have attempted to document the incidence of bile duct injuries and methods to prevent it. We reviewed our experience with 11 bile duct injuries from laparoscopic cholecystectomy. Such injuries were manifested by abdominal pain, low-grade fever, and hyperbilirubinemia or biliary fistula. These patients' injuries were treated by using drainage or reexploration and ligation of cystic duct and subcholecystic duct leaks and Roux-en-Y hepaticojejunostomy for common duct strictures and lacerations.

Complications of hepatic resection for colorectal carcinoma metastasis

Hepatic resection of metastatic colorectal carcinoma is widely advocated with 5-year survival rates quoted at 20 to 25 per cent. However, concerns about the morbidity and mortality for this procedure still exist. It is estimated that only 25 per cent of patients potentially eligible for hepatic resection are actually referred for evaluation, possibly secondary to concerns about the morbidity and mortality of the surgical procedure involved. All patients undergoing such resections at the Emory University Affiliated Hospitals between January 1, 1984 and December 31, 1989 were reviewed to determine the associated morbidity and mortality. Forty-three patients were identified (23 men, 20 women, ranging in age from 32 to 80 years (mean of 60.8). The average postoperative intensive care unit (ICU) stay was 3.2 days (range 1 to 12) and the average hospital stay was 15 days (range 6 to 45). There were no postoperative deaths, and 10 patients (23%) developed significant complications (1 biliary fistula, 2 thrombophlebitis, 3 abscess/wound infections, 1 hepatic insufficiency, 1 pneumothorax, 1 pleural effusion, 1 lobar pulmonary collapse). The occurrence of complications was not related to preoperative liver enzymes, absolute tumor mass present, or associated co-morbid disease. The extent of liver resection, length of operation, and number of units of blood transfused were all correlated with the occurrence of complications (P = 0.01, 0.01, and 0.05, respectively). Likewise, the length of hospital stay and ICU stay were directly related to the extent of hepatic resection (P = 0.05 and 0.09) and number of transfusions (P = 0.05 and 0.01). The length of operation showed such a trend but was not statistically significant (P = 0.2).(ABSTRACT TRUNCATED AT 250 WORDS)

Electrosurgical laparoscopic cholecystectomy

Though laparoscopic cholecystectomy has become widespread, questions remain as to its success rate, its role in acute cholecystitis, the role of cholangiography, and whether laser use is necessary. To attempt to answer these questions, the first 100 patients undergoing laparoscopic cholecystectomy at Emory University using electrosurgical diathermy were reviewed. Patients underwent cholecystectomy for biliary colic (87), gallstone pancreatitis (1), and acute cholecystitis (12). The average length of hospital stay was 29 hours (range: 12 hours to 5 days). Laparoscopic cholecystectomy was not possible in 7 patients because of gangrenous cholecystitis (2), adhesions from previous surgery (2), equipment failure (2), and choledochoduodenal fistula found at surgery (1). Two patients developed bile leaks from accessory bile ducts that healed spontaneously. There were no other complications. The average time required to complete the laparoscopic cholecystectomy was 115 minutes (range: 45 to 238 minutes) and was not significantly different in those patients undergoing intraoperative cholangiography (117 minutes) versus those without (109 minutes). Common duct stones were uncommon in this series. Thirty-three patients underwent intraoperative cholangiogram. One patient was found to have a common duct stone, which was pushed into the duodenum using a Fogarty catheter (American Edwards Laboratories; Anasco, Puerto Rico) inserted through the cystic duct at the time of laparoscopic cholecystectomy. Twelve patients with acute cholecystitis underwent an attempt at laparoscopic cholecystectomy that was successful in nine. These procedures were difficult and lengthy (mean of 143 minutes). Causes for failure were gangrenous cholecystitis (2) and equipment failure (1). In conclusion, laparoscopic cholecystectomy can be performed with a high success rate (93%) and low morbidity (2%). No complications seemed attributable to electrosurgical dissection.

Ileal pouch-anal anastomosis. The Emory University experience

The ileal pouch-anal anastomosis has become a practical alternative to proctocolectomy for the treatment of ulcerative colitis and polyposis coli. To evaluate its success, the Emory University Affiliated Hospital experience from February 1984 to March 1989 was retrospectively reviewed. There were a total of 50 patients identified; 84 per cent had ulcerative colitis, and 16 per cent had polyposis coli (familial polyposis and Gardner's syndrome). The majority of these patients underwent a two-stage operation, but one-third required a three-stage procedure due to difficulty in mucosal proctectomy or toxic megacolon. J-pouch construction was performed in 72 per cent of patients, S-pouch construction in 14 per cent, straight ileo-anal anastomosis in 8 per cent, and lateral isoperistaltic ileo-anal anastomosis in 6 per cent. Of the 50 patients, 36 (72%) have had closure of the temporary ileostomy. Fourteen patients have not had ileostomy closure due to change in diagnosis to Crohn's disease, operative complications, or ileostomy closure pending. The combined operative morbidity per patient for the ileal pouch-anal anastomosis and the closure of the ileostomy was 32 per cent. This included bowel obstruction, 16 per cent; pelvic abscess, 6 per cent; and ileo-anal separation, 4 per cent. Follow-up on patients with ileostomy closure ranged from 6 months to 4 years (mean, 1.3 years). Stool frequency was 5.9 stools per 24 hours at 6 months and improved with time. During the follow-up period, all patients were eventually completely continent of stool during the day, and most became completely continent of stool at night.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective evaluation of diversion colitis

Numerous case reports suggest that diversion of the fecal stream results in nonspecific colitis, with abnormalities ranging from minimal friability to gross ulceration. Published reports consist largely of patients with symptomatic colitis, and there are scant data suggesting at what frequency diversion colitis actually occurs. In an attempt to identify the frequency of diversion colitis and any associated etiologic factors, 20 patients scheduled for colostomy closure at Grady Memorial Hospital between 8/1/88 and 6/15/89 underwent colonoscopy, including the excluded segment, to evaluate for diversion colitis. Colostomies were performed for the management of diverticulitis, trauma, cancer, protection of an anastomosis, and diversion of fecal fistula. Patients with ulcerative colitis or Crohn's disease were excluded. The colon was classified grossly as normal or colitis (including easy friability, edema, inflammation, and ulceration as colitis). Fourteen of the 20 patients (70%) had findings of diversion colitis (DC), while six had a normal exam (NL). Nine biopsies were performed in the DC group and all revealed microscopic abnormalities. One of the normal patients was also biopsied, revealing mild, nonspecific changes. There was no difference in mean age (DC 49.3, NL 48.2), interval from formation of colostomy (DC 9.21 +/- 7.27 months, NL 2.83 +/- 1.94 months), type of colostomy, or reason for colostomy in the two groups. None of the DC patients had symptoms of colitis (mucous or bloody discharge, tenesmus, or pain), and one of the DC patients manifested symptoms of colitis after colostomy closure. We conclude that diversion colitis is a common subclinical problem in patients with a diverting colostomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Determinants of primary therapy of early stage breast cancer

Controversy exists in the local treatment of early stage breast cancer. In an effort to determine what criteria are used in selection of therapy for patients with breast cancer, we reviewed the experience of early stage breast cancer at Crawford Long Hospital of Emory University during 1986 and 1987. One hundred eighty-three patients were identified with Stage 0, I, or II breast cancer. A total of 11% of patients were treated by lumpectomy and radiotherapy. Residence distant from the hospital was associated with a low rate of utilization of lumpectomy and radiotherapy (p = .05). The strongest predictor of therapy was the surgeon involved in the patient's care (p = 0.001). For surgeons who cared for five or more patients with breast cancer over this time period, rates of utilization of lumpectomy and radiotherapy ranged from 0 to 20% of patients. The results of this study suggest that the surgeon consulted is the major determinant of the type of therapy used in the primary management of breast cancer.

Use of omental pedicle grafts in abdominoperineal resection

Following abdominoperineal resection, the empty space of the pelvic hollow is filled by loops of small intestine, which may become fixed and cause obstruction. In patients who require adjuvant radiotherapy, such loops of intestine fixed in the pelvis may predispose the patient to radiation enteritis. Proposed methods to prevent such fixed loops of small intestine in the pelvis include closure of the pelvic peritoneum with subperitoneal drainage, fixation of the bladder to the sacrum, retroversion of the uterus, placement of prosthetic mesh, and placement of an omental pedicle graft in the pelvic hollow. The omental pedicle graft has the advantages of ease of performance, use of autologous tissue, and filling the pelvic hollow with vascularized tissue, which should decrease the risk of postoperative pelvic abscess. This study reviews the technique of omental pedicle graft closure of the pelvis and the results of it in our initial eight patients. The omental pedicle graft has become the preferred method of pelvic reconstruction following abdominoperineal resection at Grady Memorial Hospital, Atlanta, Georgia.

Current management of choledocholithiasis

Choledocholithiasis may be managed by surgical extraction of stones or endoscopic papillotomy with extraction of stones. To evaluate these methods of management, the charts of all patients with choledocholithiasis admitted to Crawford Long Hospital of Emory University between April 1, 1983, and April 30, 1988, were reviewed. One hundred patients were identified; 42 were treated by common bile duct exploration (CBDE) and 58 had endoscopic papillotomy with extraction of stones (EP) as their initial treatment. The two groups were similar in regards to age, but the CBDE group had more comorbid conditions (average 2.5/patient in CBDE vs 1.8/patient in EP) and a higher incidence of acute cholecystitis and/or cholangitis (74% of CBDE patients; 24% of EP patients). Successful extraction of all stones occurred in 79 per cent of CBDE patients and 90 per cent of EP patients. Of those patients with retained stones following CBDE, all were later extracted by EP. Of patients having EP as their initial procedure, 24 per cent required repeat endoscopic procedures for extraction of residual stones and only six patients (10.4%) required CBDE for retained stones. Morbidity was lower (10% vs 23%) and hospital stay shorter (3.6 days vs 10.4 days) in the EP than CBDE patients; thus, the two groups are not completely comparable. Mortality was similar in the two groups (1.7% EP, 2.3% CBDE).

Breast masses in young women

To better define the risk of breast cancer in young patients, a retrospective review of all breast biopsies in women under age 40 years at Grady Memorial Hospital, Atlanta, from Dec 1, 1981, to Aug 15, 1987, was performed. During this time, 751 biopsies were performed on patients aged 9 to 40 years. None of the 128 patients aged 20 years or less had carcinoma. Of 150 patients aged 21 to 25 years, two had carcinoma. At age 26, there began a steady rise in the incidence of carcinoma, such that in the 36- to 40-year age group, carcinoma was present in 24.4% of the specimens. This retrospective review confirms previous reports that suggest that carcinoma of the breast is distinctly unusual in patients under age 20 and that breast masses in these young patients should be managed conservatively. As the incidence of carcinoma increases with the age of the patient, one's threshold for excisional biopsy should decrease.

Perianal infections in acute leukemia. Second place winner: Conrad Jobst Award

Perianal infections in patients with acute leukemia and granulocytopenia are potentially lethal conditions. To evaluate the management of perianal infections in patients with granulocytopenia and acute leukemia, all such patients treated at Emory University Hospital between January 1, 1980, and December 31, 1985, were reviewed. Twenty patients were found to have severe granulocytopenia (fewer than 500 polymorphonuclear leukocytes/mm3) and perianal infection, representing 5.7 per cent of all hematology service admissions during that period. Eleven patients were managed conservatively with broad-spectrum antibiotics and supportive measures, and nine patients underwent operative drainage of the perianal infection in addition to conservative measures. The two groups were similar in respect to age, associated conditions, length of hospitalization, and degree of perianal infection, with the exception that operatively drained patients were more likely to have positive blood cultures (7/9 operatively drained; 4/11 conservatively managed). Mortality was higher in the operatively drained group (44.4% vs 9% in the conservatively managed), and three patients had progression of the local infection after drainage, two of whom required a diverting colostomy. The overall mortality attributed to perianal disease in these severely granulocytopenic patients was 25 per cent. From this review, operative drainage of perianal infection does not appear to increase survival or decrease morbidity in patients with severe granulocytopenia.

Splenectomy for immune thrombocytopenia related to human immunodeficiency virus

From 1 January 1984 to 31 August 1987, 11 patients underwent splenectomy for treatment of thrombocytopenia related to human immunodeficiency virus (HIV). Six of the patients had been previously treated with prednisone, five of whom showed some response. None of those who responded to the prednisone had a sustained response and, thus, all required splenectomy. All 11 patients had an excellent response to splenectomy. The average preoperative and postoperative platelet counts were 19,700 and 498,000, respectively. All patients have maintained normal platelet counts at an average follow-up period of 12.4 months (range of one to 37 months). There were no postoperative deaths. Morbidity was minimal; in two patients, wound seromas developed. In one patient, acquired immunodeficiency syndrome (AIDS) developed 12 months after splenectomy, but none of the other patients have evidence of AIDS. Splenectomy is a safe and effective therapy for HIV-related immune thrombocytopenia.

Surgical complications of human immunodeficiency virus infection

To assess the role of the general surgeon in the care of patients with acquired immunodeficiency syndrome (AIDS) and AIDS-related complex (ARC) the hospital records of all patients with AIDS or ARC who underwent a major operation at the General Surgical Service of Crawford W. Long Memorial Hospital were reviewed. Of 79 patients with AIDS or ARC diagnosed since 1982, 14 required major abdominal surgery. Operations performed were for gastrointestinal (GI) complications of opportunistic infections and neoplasms (four), diagnosis of major retroperitoneal lymphadenopathy (four), and treatment of AIDS-related immune thrombocytopenia (six). GI complications consisted of two cases of cytomegalovirus perforation of ileum and colon, one case of bleeding ileocolonic lymphoma, and one case of cryptosporidium cholecystitis. Laparotomy for diagnosis of retroperitoneal lymphadenopathy was performed in four patients and provided diagnostic material in three of them. Six patients underwent splenectomy for AIDS-related immune thrombocytopenia. Four of these patients had previously been treated with prednisone without impressive results. All patients had marked improvement of their platelet counts and clinical bleeding after splenectomy. Postoperative complications were common and consisted of wound infection, disseminated intravascular coagulation, GI bleeding, pneumocystis pneumonia, small-bowel obstruction, and cytomegalovirus pneumonia. One patient died after laparotomy for perforated ulcers of the ileum and colon.

Needle aspiration cytology of breast masses

Needle aspiration cytology has been reported to be a highly sensitive and specific method of evaluation of solid breast masses when used by a single individual or closely knit group of clinicians and cytopathologists. This report summarizes the experience in 86 patients in whom needle aspiration cytology and excisional biopsy of solid breast masses were performed. All clinical evaluations, including needle aspirations and excisional biopsies, were performed by surgical residents in the Breast Clinic of Grady Memorial Hospital. The cytologic and histologic interpretations were performed by members of the Department of Pathology without direct interaction with the patients. Of the entire group of 86 patients, 27 had cancer and 59 had benign breast disease. There were no false-positive findings and five (11.9%) false-negative findings. The sensitivity of fine-needle aspiration was 73.7 per cent and specificity 100 per cent. The results are compatible with previously reported studies and it is believed that needle aspiration cytology is an integral part of evaluation of breast masses.

Benign duodenocolic fistula

Three cases of benign duodenocolic fistula are presented, and the diagnosis and treatment reviewed. Patients with benign duodenocolic fistulas usually complain of diarrhea, and occasionally nausea and feculent vomiting. Physical examinations are nonspecific, revealing wasting from the chronic diarrhea. Barium enemas are usually diagnostic. Therapy consists of excision of the fistula and repair of the duodenal and colonic defects.

Esophagogastrostomy using the EEA stapling instrument

A technique of esophagogastric anastomosis using the end-to-end anastamotic (EEA) stapler following esophagectomy is described in detail. Twenty-two patients underwent esophagectomy for carcinoma at various levels. There were no anastomotic leaks and no operative mortalities. Complications included wound infection (3), pneumonia (1), and late stricture (2). The strictures resulted from use of the small (25-mm) cartridge and responded to dilatation. Technical details of the technique include complete division of the esophagus before inserting the stapler, use of the pursestring instrument, use of "guy" sutures to aid in introduction of the anvil, and use of a proximal esophageal "traction clamp" to avoid tearing the esophagus. The 31-mm cartridge is used whenever possible. It is concluded that EEA is a very safe method of esophagogastrostomy when used with strict attention to technical details.

Improved limb salvage in popliteal artery injuries

This study reviews the recent experience with popliteal artery injuries at the Massachusetts General Hospital. Twenty-two patients suffered 24 injuries. The overall limb salvage was 83%. Blunt trauma accounted for 19 of the cases and was associated with femur fractures, knee dislocations, and tibia-fibular and plateau fractures: four amputations (21%) resulted. There were five penetrating injuries from three gunshot wounds, one stab wound, and one laceration: no amputations occurred. The major factor in the amputated limbs was delay in diagnosis and therapy of the arterial injury associated with blunt trauma. Arterial disruption secondary to penetrating injuries was recognized more quickly and had a better outcome. A higher index of suspicion in blunt trauma may improve results. Recommendations for therapy are: arterial reconstruction should generally precede orthopedic operation. Venous ligation was not associated with increased limb loss, but we recommend repair if possible. Arterial repair includes thrombo-embolectomy in distal arteries. If necessary, reverse saphenous vein is grafted. When operation is unsuccessful, revision should be performed.