Ectopic pregnancy (EP) is a leading cause of maternal morbidity and mortality. Rates of EP have declined, yet ethnic, socioeconomic, and age-related disparities persist. Improved ultrasound resolution, the use of emergency transvaginal ultrasounds, and improved lab sensitivity have enabled earlier diagnosis, which could further improve outcomes for patients with EP.
This review of the literature discusses the solution of unresolved issues related to carotid endarterectomy in Russia: (1) A program has been created for choosing the tactics of revascularization of patients with simultaneous atherosclerotic lesions of the coronary and carotid arteries; (2) Using the methods of computer modeling, studying the genetics and morphology of restenosis, it was found that the classic carotid endarterectomy with plasty of the reconstruction zone with a patch is an unsafe type of revascularization; (3) An eversion carotid endarterectomy with transposition of the internal carotid artery over the hypoglossal nerve has been developed, which makes it possible to prevent damage to the latter during repeated carotid endarterectomy for restenosis; (4) It has been established that carotid endarterectomy is associated with a high risk of complications in patients over 75 years of age; (5) It has been proven that emergency carotid endarterectomy in the first hours after the development of a stroke is not safe because. combined with the maximum number of all non-favorable cardiovascular events; (6) 3 new types of carotid endarterectomy with carotid glomus preservation have been developed.
Since April 1991, we have used the eversion technique to perform carotid endarterectomy in 31 consecutive procedures. There were no operative deaths in the current series, and no neurologic complications have been observed. We believe this technique decreases the possibility of early and late restenosis and recommend it for patients requiring carotid endarterectomy.
We reviewed our experience with 69 patients with carcinoma of the ampulla of Vater admitted to the Memorial Sloan-Kettering Cancer Center, New York, from October 1983 to October 1990. Of the 69 patients, 66 were explored and 55 underwent resection (83 percent resectability). The median length of survival for the 55 patients who underwent resection was 51 months, compared with eight months for the 14 patients who did not undergo resection (p = 0.000004). Of the variables evaluated, only resectability was a statistically significant predictor of survival. Positive lymph nodes in 17 of 55 patients who underwent resection were not predictive of long term survival.
Our experience with urogenital fistulas are reviewed and three instances of complex ureterovesicovaginal fistulas, which can be mistaken for pure vesicovaginal fistulas because of diagnostic difficulties, are presented. If the ureterovaginal component of these fistulas is overlooked intraoperatively, urinary leakage will persist despite otherwise successful closure of the vesicovaginal component of the fistula. Because of the involvement of the terminal ureter in the fistulous system, operative therapy must combine the closure of the vesicovaginal fistula with reimplantation of the ureter into the bladder and interposition of omentum or a peritoneal patch between the bladder and vagina. Diagnosis and therapy are illustrated by patient reports and literature review.
Fifteen patients with severe cardiac disease (American Society of Anesthesiologists III or IV) underwent laparoscopy using radial artery and pulmonary artery catheters to determine intraoperative hemodynamic changes. Cardiac output (CO), mean arterial blood pressure (MAP), central venous pressure, heart rate, systemic vascular resistance (SVR) and mixed venous oxygen saturation (SVO2) were recorded before anesthetic induction, after induction, but before peritoneal insufflation, after insufflation and after release of pneumoperitoneum. Peritoneal insufflation led to significant elevations in MAP and SVR and reduction in CO. For seven patients, a decrease in SVO2 after peritoneal insufflation was predictive of significant worsening of hemodynamic parameters, suggesting inadequate cardiac reserve. In all patients, hemodynamic parameters returned toward baseline once pneumoperitoneum was released. There were no perioperative cardiac complications. While it is evident that laparoscopy presents serious hemodynamic stress, it can be performed safely in high-risk patients, using aggressive intraoperative monitoring.
The clinical course and pregnancy outcome of all patients undergoing extensive nonobstetric operation during pregnancy during a ten-year period was reviewed. During this time, there were 49,567 births and 78 women had nonobstetric operation; an incidence of one in 635. The most common indications for surgical treatment were appendicitis, adnexal mass and cholecystitis. The perinatal mortality rate was not increased in women undergoing nonobstetric operation, provided that fetal viability was established preoperatively. In this series, there was no measurable benefit from the use of perioperative prophylactic tocolytic agents. However, nonobstetric operation was associated with an increased risk of preterm labor. Postoperatively, patients should be monitored for contractions and treated with tocolytic agents when appropriate.
The current multicenter study was conducted at five sites using 86 patients to evaluate the safety and efficacy of piperacillin/tazobactam (4 grams per 500 milligrams every eight hours) compared with imipenem/cilastatin (1 gram every eight hours) in the treatment of patients who were hospitalized with a clinically or bacteriologically confirmed diagnosis of intra-abdominal infection. Forty-seven patients received piperacillin/tazobactam and 39 received imipenem/cilastatin. The favorable response among patients who were clinically evaluable with a valid response in the group treated with piperacillin/tazobactam was 87 percent. In the group treated with imipenem/cilastatin it was 77 percent. Bacteriologic eradication rate among bacteriologically evaluable patients with a valid response in the group treated with piperacillin/tazobactam was 100 percent. In the group treated with imipenem/cilastatin it was 89 percent. The eradication rate of pathogens isolated from patients who were evaluable by biologic factors in the group treated with piperacillin/tazobactam was 100 percent and in the group treated with imipenem/cilastatin treatment, 96 percent. In the group treated with piperacillin/tazobactam the incidence and type of adverse reactions were similar to those seen with piperacillin alone. It is concluded that piperacillin/tazobactam is safe and efficacious in the treatment of patients hospitalized with intraabdominal infections and that tazobactam extends the spectrum of piperacillin.
Gram-positive bacteria are increasingly prevalent in the postoperative patient population and are important as pathogens. As increasingly ill and elderly patients undergo surgical treatment and as increased use is made of invasive or immunosuppressive treatment modalities, this trend is likely to accelerate. The increasing use of broad-spectrum antibiotics results in the emergence of resistant pathogens or superinfections that are increasingly difficult to treat. Examples of such pathogens include methicillin-resistant Staphylococcus epidermidis, vancomycin-resistant enterococci and Clostridium difficile. No acute care setting, from large urban teaching hospital to small rural community hospital, is immune to the trend. The clinical challenge posed by these organisms is compounded by the fact that serious gram-positive infections can be impossible to distinguish on clinical grounds from their gram-negative counterparts. The host inflammatory response to gram-positive infection is quite similar to that caused by gram-negative infection, including elaboration of cytokine mediators and progression to visceral organ dysfunction. The clinician must be cognizant that serious infections, especially of nosocomial origin, may be caused by gram-positive bacteria.
Although median sternotomy was succinctly described in 1897, "Milton's procedure" was essentially unused until it was recommended in 1957. With the advent of coronary bypass operation in 1968, median sternotomy became one of the most commonly performed surgical procedures. Even with the increasing use of median sternotomy for cardiac operations, thoracic surgeons have been reluctant to apply this operative modality in their practice. This is understandable because most pulmonary problems present in a distinctly unilateral manner and the tendency of most thoracic surgeons is to avoid median sternotomy in favor of the more familiar lateral thoracotomy. However, with the increasing use of CT scans of the chest, more patients with bilateral pulmonary pathologic factors are being identified. Median sternotomy is ideally applicable to this patient group for preservation of pulmonary function and for diminishing patient discomfort. Certainly, median sternotomy is infinitely preferable to staged bilateral thoracotomy if the same therapeutic goals can be accomplished. Younger thoracic surgeons who are trained in cardiac operation are less reluctant to use median sternotomy in the treatment of noncardiac disorders. This factor may account for the recent reports of increased usage of median sternotomy. It is a very natural tendency to use that with which one is familiar. Nonetheless, median sternotomy, other than for cardiac operation, is currently underused. The situation may ultimately be corrected as the use of median sternotomy is more fully appreciated. This relatively atraumatic, nonmuscle dividing approach to the anterior mediastinum, heart, lungs, diaphragm, pleural cavities, aortic arch and great vessels and liver deserves to be seriously considered as an appropriate alternative to more familiar, but more traumatic, approaches.
Continent urinary diversion has become a common form of bladder management for the female exstrophy patient in whom primary reconstruction has failed. Reported are the results of successful pregnancies in four young adult females, who had previously undergone a flap vaginoplasty as part of earlier management and more recently a continent right colonic urinary reservoir with a perineal stoma (Indiana pouch). Pregnancy in each of these patients was characterized by several urinary tract infections, cervical prolapse and mild to severe maternal hydronephrosis. All of the patients had some degree of difficulty with clean intermittent catheterization. One patient required an indwelling catheter with prolonged bed rest. Maternal hydronephrosis resolved after delivery in all instances. All four patients delivered their infants by way of cesarean section, either emergently for maternal or fetal distress or electively. Cervical prolapse did not resolve in three patients and will require surgical repair. After delivery, all patients returned to their previous pattern of clean intermittent catheterization without loss of continence. All the infants delivered were healthy with appropriate weights and high Apgar scores (more than 8). Orthotopic (perineal stoma) continent urinary diversion is not a contraindication to pregnancy. However, our experience mandates delivery by cesarean section with close monitoring for maternal or fetal distress during gestation.
A surgical procedure performed during space flight would occur in a unique microgravity environment. Several experiments performed during weightlessness in parabolic flight were reviewed to ascertain the behavior of surgical bleeding in microgravity. Simulations of bleeding using dyed fluid and citrated bovine blood, as well as actual arterial and venous bleeding in rabbits, were examined. The high surface tension property of blood promotes the formation of large fluid domes, which have a tendency to adhere to the wound. The use of sponges and suction will be adequate to prevent cabin atmosphere contamination with all bleeding, with the exception of temporary arterial droplet streams. The control of the bleeding with standard surgical techniques should not be difficult.
The standard for surgical treatment of morbid obesity is gastric reservoir reduction (GRR). The two popular techniques for GRR are the gastric bypass (GBP) and vertical banded gastroplasty. In 1981, a new approach to GRR, namely, the gastric wrap (GW) was introduced. The GW envelops the stomach in a customized Teflon (polytetrafluoroethylene) mesh. The current study compares, for the first time, the long term efficacy of GW and GBP. One hundred and five morbidly obese patients were studied. Fifty-two patients had GBP and 53 had GW. Preoperative and ideal weights averaged 301 and 129 pounds in the GW patients versus 278 and 123 pounds in the GBP patients. The two groups had similar age, height and co-morbid conditions. All patients survived the operation. After discharge, the patients had follow-up examinations at two weeks, two months, six months and then yearly. The GW was significantly more effective than the GBP in attaining and maintaining weight loss. The increased percent excess weight loss (percent EWL) was statistically significant at 12 months when the GW patients achieved 67 percent EWL compared with 57 percent EWL in the GBP patients. After the third year, the percent of EWL declined in the GBP patients, averaging 48 percent at four years and 47 percent at five years. In contrast, the GW patients maintained a 72 percent EWL at four years and a 66 percent EWL at five years. This weight loss was accomplished without nutritional embarrassment in both groups. The superiority of the GW in achieving and maintaining weight loss is reflected by the opinions of the patients regarding the attainment of preoperative objectives and their willingness to recommend GW to others. The downside of the GW is the higher incidence of reversal and the increased technical difficulties with reversal or revision compared with the GBP.
Despite improved results in vascularized pancreatic transplantation, the incidence of technical complications continues to be high. Vascular complications are an important source of morbidity. Previously undescribed is the occurrence of an arteriovenous fistula (AVF) in the transplanted mesenteric bundle. We have identified this unusual complication in three of 90 consecutive recipients of pancreatic transplant. The first patient presented with severe and protracted endocrine insufficiency, which was effectively reversed by direct surgical ligation of the AVF. The second patient presented with hematuria, which likewise, resolved with correction of the AVF. The third instance was diagnosed immediately after transplant and was successfully corrected by direct surgical ligation. The operative approach with establishment of proximal vascular control differed in each instance. Clinical presentation was variable and diagnosis was suggested by physical examination, duplex ultrasonography and radionuclide perfusion scanning. Arteriography was confirmatory. Mesenteric AVF can be easily identified and corrected at the time of reoperation without compromising allograft function.
Impairment of the pancreatic microcirculation is a characteristic finding in experimental biliary pancreatitis. Isovolemic hemodilution with dextran 60 has been proven to maintain pancreatic capillary perfusion. To evaluate the significance of this therapeutic approach with respect to histologic changes, intravital microscopic assessment of the microcirculation was combined with a morphometric analysis of the pancreas by means of light microscopy in rabbits (n=18). Pancreatic capillary perfusion was maintained in the rabbits subjected to hemodilution 30 minutes after the induction of pancreatitis with 54 percent of the capillaries still being perfused at 12 hours, compared with only 16 percent in the control group. The improved capillary perfusion resulted in a significant reduction of those changes considered potentially reversible (cell vacuolization and interstitial edema) that surround zones of necrosis. However, because of the early establishment of necrosis in this model, hemodilution was unsuccessful in preventing all cell death. Hemodilution can limit the progressive extension of pancreatic injury in this model of biliary pancreatitis.
During a seven and one-half year period from 1984 to 1991, 106 patients admitted to a Level I trauma center had blunt vascular injury to the extremities. This subset of patients was analyzed with respect to mechanism of injury, associated injuries, method of repair, morbidity and mortality. Twenty patients sustained vascular injuries of the upper limb. Eighty percent of the patients (16 patients) underwent primary vascular repairs, 15 percent had primary amputations and 5 percent (one patient) were observed. Eighty-eight percent (14 of 16 repairs) of the vascular repairs demonstrated excellent neurologic function postoperatively. Eighty-six patients had arterial injuries of the lower extremity. Forty-eight percent (41 patients) of the injured legs were amputated, 41 percent (35 patients) underwent vascular repairs, 6 percent (five patients) underwent ligation of the primary vessel with no amputation and 24 percent (21 patients) underwent no surgical procedure. Sixty-two percent of the 37 patients (23 patients) with popliteal injuries required amputation and 57 percent (21 patients) underwent vascular repair. The overall mortality rate was 11 percent--zero percent for injuries to the upper limb and 14 percent for injuries to the lower limb.
Twelve patients were operated upon using this technique. Early results show that hyperinsulinemia has abated in these patients and that the need for postoperative bicarbonate replacement, admissions for dehydration or hematuria resulting from pancreatic exocrine drainage into the bladder are also eliminated (9). This new technique of portal pancreatic transplantation is suitable for patients undergoing combined pancreatic and renal transplantation in whom rejection of the pancreas can be monitored through the function of the renal allograft. The procedure is technically feasible and safe. However, large trials are needed to document the full benefits and continued safety of this new procedure.
