Complications of laparoscopic cholecystectomy

Laparoscopic cholecystectomy with lasers or cautery is a feasible, effective, and worthwhile operative procedure that is subject to morbidity and mortality. There is unequivocal evidence that the complication incidence is directly related to the training and experience of the surgeon, applicability of basic principles of gallbladder and common duct surgery, and preventive measures toward iatrogenic injuries in gallbladder surgery. Continued and sustained investigation in laparoscopic cholecystectomy, technological developments in equipment, and the continued education of the surgeon in the applicability and use of laparoscopic cholecystectomy, intraoperative cholangiography, and choledocholithotomy are essential. At the St Francis Medical Center, Pittsburgh, Pennsylvania 1009 laparoscopic cholecystectomies with lasers or cautery were performed between March 1989 and October 1991. There were 32 (3%) abandoned laparoscopic cholecystectomies with alternative open cholecystectomy. There were six extrahepatic ductal injuries and a complication incidence of 10.9%. The mortality rate was 0.38%. The average length of stay was 2 days. In comparison with standard cholecystectomy, laparoscopic cholecystectomy is a competitive and superior procedure in selected circumstances.

Surgical results and complications in elderly patients with benign lesions of the spinal canal

OBJECTIVE

To describe the long-term outcome and complications of spinal surgery in a population of elderly patients.

DESIGN

Retrospective chart review and clinical follow-up.

SETTING

A 700-bed tertiary care midwestern hospital.

PATIENTS

Patients 70 years of age or older who underwent elective surgical procedures for the treatment of benign lesions of the spinal canal.

MAIN OUTCOME MEASURES

Data obtained from chart review included age, sex, nature and duration of neurological symptoms, activities of daily living (ADL), associated illnesses, length of hospitalization, type of surgery, and complications attributable to surgery. Outcome measurements included changes in neurological symptoms and ADL and a standardized scale obtained from consecutive outpatient visits, telephone interviews, or written responses.

RESULTS

Seventy-eight patients with lumbar canal stenosis or soft disc herniations underwent laminectomies, foraminotomies or discectomies. Eleven patients underwent cervical laminectomies for multilevel spondylitic myelopathy. Limb and spine pain were the most common neurological symptoms in patients with lumbar lesions; diminished ADLs were present in eight patients with cervical myelopathies. Six patients died of unrelated causes, and 78 were followed for an average of 27.1 months. Twenty-three (85.2%) of 27 patients with lumbar disc herniations reported improvements or resolution of limb pain while 35 (81.4%) of 43 patients with lumbar canal stenosis reported fair or good results. Five of eight patients with multilevel cervical spondylosis reported improvements of myelopathic symptoms. Twenty-six (28.6%) complications were attributable to 91 surgical procedures including five severe complications and one fatality. Patients with three or more associated illnesses demonstrated a significantly higher incidence of postoperative complications.

CONCLUSIONS

Elderly patients with benign lesions of the spinal canal may achieve significant reduction in limb pain and increases in ADL following appropriate surgery, with a tolerable rate of severe complications. The preoperative physical condition of the elderly patient served as an indicator for operative morbidity.

Angiogenic activity of fibrin degradation products is located in fibrin fragment E

The source of angiogenic activity of fibrin degradation products has been sought in a series of experiments, applying degradation products from different types of fibrin and fibrinogen to the chick chorioallantoic membrane. The presence of platelets or fibronectin during clotting was not essential for activity, and neither was crosslinking. Fibrinogen degradation products were non-stimulatory, as was serum. Molecular sieve column chromatography indicated a range of active fragments. Admixture of active fibrin degradation products with antifibrin fragment E, but not D, antiserum neutralized activity. Preparations containing only fibrin fragment E retained activity. A commercial preparation of fibrinogen fragment E was inactive until treated with thrombin. These experiments point to fibrin fragment E being the source of angiogenic activity, with thrombin cleavage being the essential step in generating activity.

Fibrinogen/fibrin in atherogenesis

Fibrin is a major component of many atherosclerotic plaques. Within the intima there is continuous formation of fibrin, and continuous fibrinolysis. In aortic lesions, a lipoprotein bound to fibrin can be released by incubation with plasmin. Most of this lipoprotein is accounted for by Lp(a). The atherogenicity of Lp(a) may be more associated with lipid deposition than with inhibition of fibrinolysis. Fibrin degradation products may be chemotactic to monocyte-macrophages and stimulate smooth muscle cell proliferation.

Treatment of necrolytic migratory erythema in glucagonoma syndrome

The glucagonoma syndrome is characterized by elevated serum glucagon, a pancreatic alpha-cell tumor, anemia, hypoaminoacidemia, and necrolytic migratory erythema. Necrolytic migratory erythema may cause marked morbidity and is frequently misdiagnosed. A 42-year-old white woman with a 1 1/2-year history of refractory dermatitis (most severe on the lower extremities) had the glucagonoma syndrome. Her severe morbidity was markedly relieved with the administration of intravenous amino acids. This therapy was successful in controlling the necrolytic migratory erythema through recurrences after somatostatin (SMS 201-995), surgical debulking, and chemotherapy proved inadequate.

Does lipoprotein(a) (Lp(a)) complete with plasminogen in human atherosclerotic lesions and thrombi?

Thrombotic occlusion is the major cause of myocardial infarction (MI), and fibrin accumulation appears to play a significant role in development of atherosclerotic lesions. Any factor that reduces the lysis of fibrin may thus increase the risk of MI, and it has been suggested that this accounts for the atherogenicity of the lipoprotein variant Lp(a). The characteristic feature of Lp(a) is an apoprotein which is homologous with part of the plasminogen molecule, and experiments in vitro suggest that it interferes with uptake and activation of plasminogen on cell surfaces and fibrin. The presence of Lp(a) also seemed to offer an explanation for the apparent absence of plasminogen from 70-80% of intimal samples. We have compared the levels of Lp(a) and plasminogen in normal intima and atherosclerotic lesions. In aortic intima there was no relation between Lp(a) and plasminogen, which was absent in some samples with no Lp(a), and present in others with high levels. In intravascular thrombi plasminogen was present at a rather constant concentration (16.3 +/- 4.6 micrograms/100 mg wet tissue), whereas Lp(a) varied over a 100 fold range (0-104 micrograms/100 mg). Plasminogen binds to fibrin and is activated on the fibrin clot, so levels in extracts may not fully represent Lp(a)/plasminogen interactions. After extraction the residual tissues and thrombi were treated with 1 M epsilon-aminocaproic acid (epsilon-aca) to elute lysine-bound components. Lp(a) was eluted from all but one intimal sample, confirming previous findings on its binding to fibrin in lesions, but there was no relation between the amounts of Lp(a) and plasminogen in the tissue eluates. Paradoxically, in the thrombi there was a weak positive correlation between Lp(a) and plasminogen in epsilon-aca eluates (r = 0.504, P = 0.05). These results do not support the hypothesis that Lp(a) displaces plasminogen in vivo, but the large amount of Lp(a) eluted by epsilon-aca suggests that its atherogenicity resides in preferential binding to fibrin, leading to increased lipid accumulation in lesions.

Intestinal injury after lumbar discectomy

In a review of 5,200 lumbar discectomies performed from 1974 to 1989, two patients sustained a ventral perforation of the disc space followed by isolated small intestinal injury. Both patients underwent lumbar discectomy at the lumbosacral junction and presented with signs and symptoms of acute abdominal distress within three days after the operation. At surgical laparotomy, small tears were noted in the ileum, which were closed primarily. The patients had an uneventful recovery. The results of a review of 11 instances reported in the literature suggest that isolated intestinal injuries usually occur postoperatively at the lumbosacral junction and involve the small intestine. Factors, such as body habitus, surgical experience, patient positioning and types of instruments, as well as the use of a surgical microscope, do not appear to modify the risk of intestinal injury. After discectomy, patients may present with acute abdominal signs and symptoms or chronic wound infections. Work-up studies include evaluation of vascular structures and ureters either roentgenographically or at abdominal exploration. A high index of suspicion and adequate disc space visualization during discectomy may reduce the incidence of this complication.

Effects of general anesthetics and pressure on mammalian excitatory receptors expressed in Xenopus oocytes

The effects of general anesthetics and pressure on receptors from the mammalian central nervous system have been investigated using oocyte expression techniques. Poly A+ mRNA extracted from rat whole brain was injected into mature Xenopus oocytes producing depolarizing responses to the fast excitatory neurotransmitters NMDA and kainate and the inhibitory neurotransmitters GABA and glycine. An apparatus was constructed to allow agonist dose-response curves to be determined at high pressures using voltage-clamped oocytes. This was used to investigate the excitatory transmitter kainate. It was found that anesthetics depress the current induced by kainate whereas pressure does not appear to affect the responses associated with this transmitter. Furthermore it was found that pressure does not reverse (or modify in any way) the changes in response brought about by application of anesthetics.

Pulmonary embolism--a concept for survival

In clinical practice, the incidence, complications, and results of pulmonary embolism remain a serious challenge to medical and surgical clinicians. This article presents the historical aspects, pathophysiology, clinical features, diagnostic techniques, high risk factors, medical and surgical management, results, autopsy data, and prophylaxis of pulmonary embolism at the St Francis Medical Center for a 30-year period from 1958 to 1988, emphasizing the years 1979 to 1988. A concept for early diagnosis and prevention with improved morbidity and mortality also is presented.

Spontaneous regression of giant arteriovenous fistulae during the perinatal period. Case report

A unique case of spontaneous regression of giant arteriovenous fistulae during infancy is described in this report. A female infant, the product of normal labor and delivery, demonstrated severe ventriculomegaly and an intracranial hemorrhage at birth. Cerebral angiography at 5 days of age revealed several large fistulae fed by the anterior and middle cerebral arteries draining into the deep venous system through a dilated internal cerebral vein and ectatic vein of Galen. Two days following the angiogram, a second intracranial hemorrhage occurred. Active hydrocephalus developed over the next 6 months and was treated with ventriculoperitoneal shunting. When the child was 8 months of age, angiography failed to demonstrate the fistulae. It was postulated that pressure effects from the intracranial hematoma and long-standing intracranial hypertension as well as stenosis in the anomalous venous outflow resulted in vascular stasis, venous thrombosis, and selective arterial occlusion. Hydrocephalus was a result of the compression of the intraventricular foramina by dilated embryonic vessels. This anomaly, predominantly involving the anterior circulation, may be homologous to the vein of Galen aneurysm in the posterior circulation.

Hydroquinone-induced localized exogenous ochronosis treated with dermabrasion and CO2 laser

Exogenous localized ochronosis can result from the repeated use of hydroquinone-containing creams, many of which are available over the counter. We report a case that was managed by dermabrasion and CO2 laser. The incidence and proposed etiologies of hydroquinone-induced exogenous ochronosis are reviewed.

Factors influencing the accumulation in fibrous plaques of lipid derived from low density lipoprotein. I. Relation between fibrin and immobilization of apo B-containing lipoprotein

The lipid that accumulates in some fibrous atherosclerotic lesions appears to be derived from plasma low density lipoprotein (LDL). An early stage in lipid accumulation may be immobilization of a fraction of the LDL, and this is released by incubation with proteolytic enzymes, of which the most effective is the fibrinolytic enzyme, plasmin. We have examined the relationship between release of fibrin degradation products (FDP) and LDL in controlled plasmin incubations of 42 samples of normal intima and atherosclerotic lesions from aortas of 10 patients. In three patients (group 1) no LDL was released from any of the 11 tissue samples although they comprised lesions as well as normal intima. In 2 more patients (group 2) LDL was consistently low. However, in 5 patients (group 3) substantial amounts of LDL were released from all 21 tissue samples, and there was a significant correlation between the amounts of FDP and LDL (P less than 0.001). In spite of this correlation there were marked differences in the ratio FDP/LDL, but analysis by SDS-polyacrylamide gel electrophoresis and immuno blotting of the FDP released showed no consistent pattern related to LDL binding. Although the ratio FDP/LDL showed a 4-fold range, in 6 lesions subjected to successive 2-h incubations with plasmin the ratio within each lesion remained constant, supporting the concept that fibrin and LDL are linked.

A clinical trial of topical terbinafine (a new allylamine antifungal) in the treatment of tinea pedis

Twenty-three patients were enrolled in a randomized, double-blind trial of terbinafine 1% cream compared with placebo vehicle in the treatment of tinea pedis. Of the 20 patients who were evaluated for efficacy, 10 received terbinafine and 10 received placebo. Except for the terbinafine-treated patients being an average of 11 years older than the patients receiving placebo and the median duration of disease being 6 weeks longer in the placebo group, the two groups were demographically and clinically similar. Results of mycologic tests and clinical findings showed terbinafine to be significantly more effective than placebo in the treatment of tinea pedis. Significantly more terbinafine-treated patients than placebo-treated patients showed conversion to negative culture and microscopy at end of therapy and a significant reduction in scored signs and symptoms. Overall efficacy at follow-up (combined mycologic and clinical findings) was also significantly greater in the terbinafine group (78%) than in the placebo group (zero) (p less than 0.001). Unexplained elevation of liver function test results was noted in three placebo-treated patients and in one terbinafine-treated patient, but these changes were not considered clinically relevant or drug related.

The inter-relation of fibrin, lipoprotein(a) and plasminogen in human atherosclerotic lesions

The low density lipoprotein (LDL) variant, lipoprotein(a) (Lp(a)) is a risk factor for coronary heart disease, and in this study we have examined its interaction with the arterial wall. Samples of normal intima and atherosclerotic lesions were extracted with buffer containing EDTA and protease inhibitors and assayed for LDL and Lp(a) by radial immunodiffusion. The extract tissues were washed, then incubated with plasmin and the amounts of LDL and Lp(a) released into the digest were measured. Intimal Lp(a) concentrations were compared to Lp(a) in the patients' blood. Levels of both soluble and plasmin-releasable Lp(a) were related to type of intimal sample and blood Lp(a) level. In early proliferative lesions there was a significant correlation between plasmin-releasable Lp(a) and blood Lp(a) (r = 0.631, P less than 0.002). Highest levels of plasmin-releasable Lp(a) were found in more advanced lesions that had accumulated some lipid. In extracts the amounts of LDL were 5-20 fold greater than Lp(a) but in the plasmin digests Lp(a) could account for most of the apoB detected, suggesting that Lp(a) may bind to fibrin in the lesion through its plasminogen-like structures and thus contribute to lipid accumulation in fibrous plaques. Plasminogen cannot be detected by rocket immunoelectrophoresis in samples from about two-thirds of aortas, and it seemed possible that the large plasminogen-like apo(a) component of Lp(a) was interfering with intimal uptake or retention of plasminogen, or its immunoassay. However, in 28 samples of intima or thrombi from 16 patients there was no relation between amounts of Lp(a) and plasminogen.

History of antifungals

Until two to three decades ago, only a few drugs were available for the treatment of fungal infections. The status of antifungal therapy changed dramatically in the late 1960s with the introduction of newer broader spectrum agents, such as the iodinated trichlorophenols and the imidazoles, that acted by disruption of the fungal cell membrane. Some of the more recently developed broad-spectrum antifungal drugs include the triazoles terconazole, itraconazole, and fluconazole and the dimethylmorpholine amorolfine. The allylamines represent one of the newest classes of compounds shown to be effective in the management of fungal disorders. The two members of this unique chemical class that have been studied clinically, naftifine and terbinafine, are effective against a wide spectrum of fungal organisms. Terbinafine has the added advantage of both topical and oral activity.

Factors relevant to stimulatory activity of fibrin degradation products in vivo

Extracts of atherosclerotic lesions contain a range of fibrin degradation products (FbDP), similar fragments have been detected in extracts from human and mouse healing skin wounds and from the invasive edge of human breast carcinomas, which are all proliferating systems. We have previously shown that FbDP stimulate cell proliferation including angiogenesis in the chick chorioallantoic membrane (CAM), and sought to characterize further the active components. Fibrin prepared from platelet-rich and platelet-free plasma, and purified Kabi fibrinogen, was treated with plasmin, and the digests were all active. FbDP from platelet-rich plasma clots also increased vascularity of the CAM. Prior removal of fibronectin from plasma by gelatin-Sepharose affinity chromatography did not affect proliferative activity. Current studies showed that long digests of fibrin, in which the only major band detectable is fibrin fragment E are active. Commercial fibrinogen derived fragment E, itself inactive on the CAM, becomes active after exposure to thrombin cleavage of fibrinopeptides. Recently fragment E has been isolated from shorter digests, by simple filtration through a Millipore 0.2 microns centrifuge filter. It displayed similar activity to the fragment E obtained from long digests. Fragment E in plaque extracts has been shown consistently to lack fibrinopeptide A indicating it is of fibrin origin.

Factors influencing the accumulation in fibrous plaques of lipid derived from low density lipoprotein. II. Preferential immobilization of lipoprotein (a) (Lp(a))

The extracellular lipid that accumulates in fibrous atherosclerotic lesions appears to be derived directly from plasma low density lipoprotein (LDL). One factor that may influence the lipid deposition is immobilization of part of the LDL in lesions, and an immobilized fraction can be released by incubation with the fibrinolytic enzyme, plasmin, suggesting that it is associated with fibrin. The lipoprotein variant Lp(a) is associated with increased risk of arterial disease, and its characteristic apoprotein, apo(a), is structurally related to plasminogen, suggesting that it might bind to the plasminogen binding sites on fibrin. In this study we have compared blood Lp(a) and the soluble and plasmin-releasable Lp(a) in 45 samples of normal intima and different types of lesion. Levels of soluble and plasmin-releasable Lp(a) were dependent on both blood level and type of tissue sample. Although the amount of soluble LDL was 5-20 times higher than Lp(a) in intima, the amounts released by plasmin were similar, and Lp(a) appears to account for most of the apo B-containing lipoprotein that is immobilized in lesions.

Atherosclerotic plaque growth: presence of stimulatory fibrin degradation products

Focal smooth muscle cell proliferation is widely perceived as a key event in the formation of stenosing atherosclerotic lesions, but the stimuli for this remain uncertain. Soluble extracts of human aortic intima from proliferative gelatinous and transitional lesions, as well as surface encrusted thrombi, have been shown by us to be mitogenic for the chick chorioallantoic membrane (CAM). They have also been shown to stimulate increase in vascularity of the CAM. When active samples were passed through anti-albumin and anti-whole-serum affinity columns, mitogenic activity in the unabsorbed, fibrin related antigen fraction remained close to the original whole extract level. In contrast, when the unabsorbed fractions from anti-whole-serum columns were passed through an antifibrinogen affinity columns, the activity was reduced to insignificant levels. Similarly, whole extracts lost activity after passing through an antifibrinogen column. This has been taken one stage further by dividing the unabsorbed fraction from an anti-whole-serum column into two equal volumes and passing one half through an antifibrinogen fragment D affinity column, and the other through an antifibrinogen fragment E affinity column. The activity of the unabsorbed fraction from the fragment D column remained the same, but that from the fragment E column was significantly reduced. Most of the fibrin degradation products (FbDP) in lesion extracts are derived from fibrin, not fibrinogen, and clotting out fibrinogen and fragment X with thrombin did not remove the activity. Whole extracts of atherosclerotic lesions clotted on the CAM surface as has previously been shown with plasma.(ABSTRACT TRUNCATED AT 250 WORDS)