We reviewed our experience with laparoscopy for perforated ulcer from April 1, 1992, to March 31, 1993. All patients admitted to the gastrointestinal surgery service with a diagnosis of perforated viscus had evaluation for possible laparoscopic Graham plication (LGP). Of eight patients considered, five had successful diagnostic laparoscopy. Two patients with anterior duodenal ulcers had LGP. Operative times were 85 and 106 minutes; postoperative stays were 5 and 8 days. Three procedures were converted to formal laparotomy when laparoscopy revealed gastric or prepyloric ulcers. Three patients had immediate laparotomy because of known disease process. Two additional patients were treated with open plication by other surgeons; their operative times were 98 and 110 minutes and postoperative stays, 6 and 4 days. Hospital charges averaged $6,573 for the two laparoscopic plications, $7,511 for the four plications not done laparoscopically, and $20,995 for the two cases converted to open plication. A selective approach allowed two Graham patch closures to be done laparoscopically without complications, at a cost comparable to that of open surgery.

BACKGROUND:Animal studies have demonstrated fetal acidosis during carbon dioxide pneumoperitoneum. This finding suggests a potential adverse effect of CO2 pneumoperitoneum on fetal outcome in humans.PATIENTS AND METHODS:We reviewed our recent experience with laparoscopic surgery performed under general anesthesia and with the use of CO2 pneumoperitoneum, in pregnant women with appendicitis or cholecystitis. We compared these women's charts and pregnancy outcomes with those of pregnant women who underwent formal laparotomy during the same period of time.RESULTS:Seven pregnant patients underwent laparoscopic surgery, and there were 4 fetal deaths among them (3 during the first postoperative week, and another 4 weeks postoperatively). Five pregnant patients underwent formal laparotomy, of whom 4 subsequently progressed to term and 1 was lost to follow-up.CONCLUSIONS:Our recent experiences together with the available animal data suggest that caution should be used when considering nonobstetrical laparoscopic surgery in pregnant women. This experience suggests that additional clinical and laboratory investigations may be indicated to evaluate fetal risk associated with such surgery.

The Mississippi Breast and Cervical Cancer Control Coalition conducted a survey of health care professionals to assess current practices in the areas of breast and cervical cancer screening. A 22% response rate was obtained, with family practitioners having the highest response rate. Cost was cited as a major barrier to access to screening mammography. Some discrepancies between provider perceptions and currently accepted guidelines were identified.

Prior studies regarding immune function in bile-duct ligated rats have illustrated blunted immune function. The present study measures natural killer (NK) cell activity. Rats underwent bile duct ligation (BDL) or sham celiotomy (SC) and were sacrificed at 1, 2, and 3 weeks after surgery. Ficoll-Hypaque density centrifugation was used to obtain a purified preparation of splenocytes, NK cell activity was determined by incubating varying concentrations of splenocytes with chromium-labelled YAC-1 tumor cells for 4 hours. Chromium release was measured by a gamma counter and expressed as per cent activity (compared with 100 per cent activity obtained by complete lysis with detergent). The experiments were repeated after preincubation in tissue culture flasks to remove an adherent cell population. NK cell activity was decreased at all spleen cell:target cell ratios studies at 1 week after BDL. At 2 weeks after BDL, NK cell activity was decreased at all but the lowest two concentrations; and 3 weeks after BDL, NK cell activity was decreased only at the highest concentrations used. Separation of an adherent cell fraction restored NK cell activity, This suppression in NK cell activity one week after BDL may account, in part, for the poor response of BDL animals to bacterial and immune challenge, Restoration of activity after removal of an adherent cell fraction suggests that macrophages may be at least partly responsible for this inhibition.

Background: In addition to mastitis, lactational breast abscesses, and several other benign conditions unique to the puerperium, pregnant women may develop any of the other breast problems seen in the nonpregnant female population. This review deals with the diagnosis and management of breast problems during pregnancy and lactation. Data sources: A literature review of the evaluation, technique of biopsy, and treatment of cancer in pregnant women was conducted. Conclusions: The most common problems fall into a spectrum of infectious complications from milk stasis or mastitis to frank abscess formation. Galactoceles, noninfected milk-filled cysts, present as tender masses; aspiration is both diagnostic and curative. Benign fibroadenomas occasionally enlarge significantly or infarct during pregnancy. A physiologic nipple discharge is common during pregnancy, and may be bloody. Rare cases of massive breast hypertrophy during pregnancy have been reported. The mortality of breast cancer during pregnancy is related to delay: compared stage-for-stage with nonpregnant controls, the prognosis is similar. As a general rule, the cancer should be treated surgically and the pregnancy may be allowed to progress.

BACKGROUND:The present experiments were performed to determine whether serum or cellular factors are responsible for the immune suppression observed in biliary obstruction.METHODS:Male Lewis strain rats underwent bile duct ligation and division (BDL) or sham celiotomy (SC). Spleen cells (splenocytes) and lymph node cells (lymphocytes) were isolated 3 to 14 days later. Levels of direct and total serum bilirubin and total conjugated bile acids and response of BDL and SC splenocytes and lymphocytes to concanavalin A (Con A) and phytohemagglutinin were measured. Splenocytes from normal Lewis rats were then added to medium containing 20 microliters, 40 microliters, and 100 microliters BDL or SC serum and incubated with Con A. BDL or SC splenocytes were injected into normal Lewis rats, and splenocytes from those rats were studied 24 hours later (adoptive transfer). Splenocytes from BDL and SC rats were separated into nylon wool adherent and nonadherent fractions and incubated with Con A and phytohemagglutinin.RESULTS:The mitogenic response to Con A and phytohemagglutinin was depressed in BDL splenocytes but normal in BDL lymphocytes. BDL serum suppressed the proliferative response of normal splenocytes, and adoptive transfer of cells produced immunosuppression. Removal of a nylon wool adherent fraction of cells restored the lymphoproliferative response in BDL splenocytes.CONCLUSIONS:The blastogenic response to phytohemagglutinin and Con A was decreased in BDL splenocytes. This effect was transferrable by both serum and cells. Removal of a subpopulation of splenocytes corrected the defect.

BACKGROUND:In patients with known extramammary malignancies, metastatic disease should be considered in the differential diagnosis of a breast mass.STUDY DESIGN:Retrospective review.RESULTS:From January 1, 1980 to December 31, 1992, nine women (ages 25 to 67 years) were identified with breast masses, the biopsies of which proved to be metastatic from other sites. All patients presented with palpable breast masses. Mammograms were obtained in five patients; all demonstrated the palpable abnormality. Two of three mammograms showing multiple nodules were evaluated as suggestive of benign disease. In three patients, breast metastases were the presenting symptom of an occult primary tumor. The remaining six patients were diagnosed with metastatic disease in the breast from ten months to 15 years after the initial diagnosis (mean of 5.5 years) of an extramammary malignancy. One-half of the patients presented five or more years after the initial diagnosis. Breast metastases were associated with disseminated metastatic disease in eight of the nine patients. Six patients died after a mean interval of 8.2 months (range of 3.5 to 35 months) from diagnosis of breast metastases. One patient was unavailable for follow-up evaluation and is presumed dead.CONCLUSIONS:Metastatic disease should be considered in the differential diagnosis of a palpable breast mass, particularly if there is a history of extramammary malignancy. The presence of multiple or bilateral well-circumscribed nodules may suggest a benign process on mammography. Breast metastasis is usually indicative of diffuse metastatic disease and a poor prognosis. Biopsy and careful review of previous pathologic material assures prompt treatment and avoids an unnecessary radical operation.

Familial juvenile polyposis is a rare intestinal polyposis that has recently been associated with gastric and colonic adenocarcinoma. The authors report a kindred of 41 members, 11 of whom have familial juvenile polyposis. In these patients, random sections of otherwise grossly normal-appearing colonic mucosa showed a dense population of mixed inflammatory cell infiltrates in the superficial third of the lamina propria. Fine nodular mucosa was noted focally and diffusely in six of eight colons resected. These consisted of foci of dense inflammatory cell infiltrates in the mucosa with slight crypt architectural abnormalities. The majority of lesions were typical juvenile polyps. Dysplastic changes were noted in the polyps that were 1-2.9 cm or larger. The largest polyps contained foci of villous adenoma and juvenile polyp. A focus of adenocarcinoma of the colon was noted at the base of the villous adenoma portion of the largest polyp. The gastric polyps were histologically identical to hyperplastic polyps of the stomach. This report represents the largest number of patients (eight) in a single family with familial juvenile polyposis studied histologically. This is also the first time that the changes in the nonpolypoid colonic and gastric mucosa have been reported. The pattern of inheritance in this family suggests that the trait for familial juvenile polyposis segregates as an autosomal dominant.

When surgery is required for complications of inflammatory bowel disease (IBD) or for failure of medical management, numerous options exist. This review focuses on surgical alternatives, technical considerations, and complications for both routine and unusual problems associated with IBD. Restorative proctocolectomy for chronic ulcerative colitis, intestine-sparing procedures for Crohn's disease, and the management of Crohn's disease in difficult anatomic sites or with unusual complications are discussed.

Data on all laparoscopic appendectomies (LA) were collected prospectively from June 1990 through July 1992 and compared retrospectively with all open appendectomies (OA) done at the same hospital during the same time period. Laparoscopic appendectomies were performed in 29 patients (ages 15-47, mean 25.3 years) and OA in 77 patients (ages 18-71, mean 31.9 years, P < 0.01). Preoperative findings were similar in the two groups. Acute appendicitis was confirmed in 22 (76%) LA and in 57 (74%) OA; of these, 9/22 (41%) LA and 23/57 (40%) OA were gangrenous or perforated. A normal appendix was removed in seven (24%) LA and in 20 (26%) OA. Three patients (10%) required conversion of LA to an open procedure. Operative time was significantly longer for LA (mean 105 minutes) compared with OA (mean 69 minutes; P < 0.001). Postoperative complications requiring further intervention (wound infection or intraabdominal abscess) occurred in three LA (10%) and in 23 OA (30%, P < 0.05). Wound morbidity as measured by number of wounds left open at surgery or opened for infection was significantly less after LA (14% LA, 39% OA, P < 0.001). Hospital stay was significantly shorter after LA (mean 4.2 days) compared with OA (mean 6.3 days; P < 0.05). Hospital charges and professional fees were not significantly different between the two groups. In selected patients, LA is a safe, effective alternative to OA, with fewer complications and shorter hospital stay. In addition, hospital charges are similar, making an investment of more time in the operating yield an outcome equal or superior to OA.

Six adult patients were treated for tumors of the retrorectal space from 1975 to 1990 at the University of Mississippi Medical Center. All were female; ages ranged from 19 to 64 (mean, 37.8) years. Two asymptomatic tumors were discovered in the peripartum period, and two patients had symptoms of local fullness or pain. One patient presented with a pelvic abscess, and one patient had had recurrent pilonidal cyst abscesses drained. All lesions were completely excised (one by a transsacral route, two by a transanal route, and three by a combined abdominosacral approach). All were histologically benign (four tailgut cysts and two epidermoid cysts). One tailgut cyst recurred after transanal excision and was removed by a transsacral route without further recurrence. Adequate excision may be achieved by any of several approaches. Transanal excision, although convenient for small low-lying dermoid tumors, resulted in the only recurrence in our series.

The preoperative identification of a bleeding site is not always possible, particularly when bleeding originates in the small intestine. Small vascular abnormalities, such as the telangiectatic lesion described in this report, comprise about 40-60% of such cases. Preoperative location using arteriography, radionuclide bleeding scan, and enteroclysis were nondiagnostic. The lesion was demonstrated by intraoperative endoscopy. A segment of small intestine was resected, and the patient made an uneventful recovery.

Previous studies have shown impaired immune function in biliary obstruction, and our earlier investigations have demonstrated impaired response to alloantigens in the jaundiced rat host. The present study uses the graft versus host (GVH) popliteal lymph node assay to assess the ability of lymphocytes from bile duct ligated animals to elicit an immune response in normal rats. Female Lewis rats underwent bile duct ligation and transection (BDL) or sham celiotomy. A third group of rats served as normal controls. The animals were killed at intervals from 1 to 6 weeks after surgery, and spleen cell preparations were made. Splenocytes (5 x 10(6)) from BDL, sham celiotomy, or normal control rats were injected into the hind footpads of LBNF(1), hybrid rats. The contralateral hind footpads were injected with media as controls. The popliteal lymph nodes were removed and weighed 7 days after injection. The BDL, rats were clinically jaundiced. GVH response was normal at 1 week and decreased at 2 weeks, remaining depressed through 6 weeks. Contralateral control lymph node weights were similar in all groups. Obstructive jaundice not only impairs host immune defense, but also significantly decreases splenocyte GVH capability

Patients with sickle hemoglobinopathies are at risk for unique postoperative complications and increased mortality. Understanding the pathophy siology of these disorders is important for safe perioperative management. Because there is no animal model for sickle cell disease, understanding has progressed through in vitro studies and clinical observations. This review describes the clinical manifestations of the sickle hemoglobinopathies with special emphasis on current knowledge of pathophysiology. It also discusses issues of preoperative screening, transfusion. and postoperative care.

Stones are sometimes spilled at the time of cholecystectomy. Retrieval may be difficult, especially during laparoscopic cholecystectomy. Little is known about the natural history of missed stones which are left behind in the peritoneal cavity. We present a case in which a patient developed an intraabdominal abscess around such a stone. The abscess recurred after drainage and removal of the stone was needed for resolution. This case suggests that care should be taken to avoid stone spillage, and that stones which are spilled into the abdomen should be retrieved.

Male Lewis strain rats underwent bile duct ligation and division (BDL), selective hepatic duct ligation (SHL), simple ligation and recanalization (RCN), or sham celiotomy (SC). Unoperated rats served as normal controls (NC). At intervals of 1, 2, and 3 weeks postoperatively, the popliteal lymph node assay was used to study host versus graft (HVG) response. LBN-F1 splenocytes (5 × 106) were injected into the hind foot pads, and the contralateral foot pad was injected with medium as a control. The popliteal lymph nodes were removed and weighed 7 days later. In the BDL group, HVG response was significantly impaired at 1 (BDL, 12,9 ± 5.1 mg; SC, 21.6 ± 2.6; NC, 22.4 ± 9.4; P < 0.005, BDL vs SC or NC), 2 (BDL, 12.6 ± 5.6; SC, 19.1 ± 3.0; NC, 15.8 ± 5.8; P < 0.001, BDL vs SC), and 3 weeks (BDL, 8.9 ± 3,9; SC, 21.7 ± 6.3; NC, 16.7 ± 3.8; P < 0.001, BDL vs SC or NC). SHL did not cause hyperbilirubinemia or impair the HVG response at 2 weeks (SHL, 17.2 ± 4.5; NC, 16.7 ± 7.4). The serum bilirubin was normal 2 and 3 weeks after RCN, and the HVG response was normal in both groups; however, the HVG response was somewhat lower at 2 weeks (RCN, 12.1 ± 2.1) than at 3 weeks (RCN, 18.2 ± 4.4; P ± 0,01, RCN 2 weeks vs RCN 3 weeks). BDL causes significant impairment in the murine response to alloantigens as measured by the popliteal lymph node assay. Preservation of sufficient normally drained hepatic parenchyma to prevent hyperbilirubinemia also preserves the HVG response, as does incomplete obstruction (RCN).

Sprague-Dawley rats were challenged with intraperitoneal injection of 10(7) Streptococcus pneumoniae 10 days after common duct ligation (BDL) or sham celiotomy (SC). Quantitative bacterial cultures were performed on liver, spleen, lung, kidney, and heart blood samples obtained 4 hours after injection. All 13 (100%) BDL animals had positive heart blood cultures, but only 6 of 12 (50%) SC animals remained bacteremic (p < 0.05). Significantly more viable organisms were recovered from lung, liver, spleen, and kidney of BDL animals compared with SC controls. BDL impaired the host's ability to kill this encapsulated gram-positive organism. Viable bacteria remained in all organs studied, which was associated with continuing bacteremia.

Significant arterial anomalies were encountered in 4 of our first 51 laparoscopic cholecystectomies (8%). The laparoscopic appearance of normal and variant arterial anatomy is described.