Intra-abdominal abscesses following laparoscopic and open appendectomies

Recent findings in a small number of studies have suggested a trend toward increased infectious complications following laparoscopic appendectomy. The purpose of the present review was to evaluate the incidence of postappendectomy intra-abdominal abscess formation following laparoscopic and open appendectomies. Using the surgical database of the Los Angeles County-University of Southern California Medical Center, we reviewed the records of all appendectomies performed at the center between March 1993 and September 1995. Incidental appendectomies as well as appendectomies in pediatric patients under the age of 18 years were excluded. A total of 2497 appendectomies were identified; indications for these procedures included acute appendicitis in 1422 cases (57%), gangrenous appendicitis in 289 (12%), and perforated appendicitis in 786 (31%). The intraoperative diagnosis made by the surgeon was used for classification. A two-tailed P value of <0.05 was considered significant. There was no significant difference in the rate of abscess formation between the groups undergoing open and laparoscopic appendectomies for acute and gangrenous appendicitis. In patients with perforated appendicitis, a total of 26 postappendectomy intra-abdominal abscesses occurred following 786 appendectomies for an overall abscess formation rate of 3.3%. Eighteen abscesses occurred following 683 open appendectomies (2.6%), six abscesses occurred following 67 laparoscopic appendectomies (9.0%), and the remaining two abscesses occurred following 36 converted cases (5.6%). For perforated appendicitis, however, there was a statistically significant increase in the rate of abscess formation following laparoscopic appendectomy compared to conventional open appendectomy (9.0% vs. 2.6%, P = 0.015). There was no significant difference in the rate of abscess formation between open vs. converted cases or between laparoscopic vs. converted cases. A comparison of the length of the postoperative hospital stay showed no significant difference between open and laparoscopic appendectomy for perforated appendicitis (6.1 days vs. 5.9 days). Laparoscopic appendectomy for perforated appendicitis is associated with a higher rate of postoperative intra-abdominal abscess formation without the benefit of a shortened hospital stay. Given these findings, laparoscopic appendectomy is not recommended in patients with perforated appendicitis.     

Should laparoscopic appendectomy be avoided for complicated appendicitis in children?

BACKGROUND/PURPOSE: Laparoscopic appendectomy is becoming the preferred technique for treating acute appendicitis. However, recent literature on adults suggests that laparoscopic appendectomy may increase the risk for postoperative infectious complications in complicated (gangrenous or perforated) cases. This study was undertaken to compare the results of open versus laparoscopic appendectomy for complicated appendicitis in children. METHODS: A retrospective review from two institutions was performed for all children treated operatively for complicated appendicitis from January 1994 through November 1996. RESULTS: Fifty-six cases were identified. Twenty-seven children underwent laparoscopic appendectomy, whereas 22 underwent open appendectomy. Seven children underwent conversion from laparoscopic to open surgery. Operating times and length of hospital stay did not differ significantly between the laparoscopic and open groups. Postoperative complications developed in 24 children (42.8%). Complications were more frequent after laparoscopic appendectomy compared with open appendectomy (56% v 18%, P = .002). A postoperative intraabdominal abscess (IAA) developed in 14 children (25%). An IAA occurred in two children after open appendectomy compared with 11 children after laparoscopic appendectomy (9% v 41%, P = .01). CONCLUSION: The findings suggest that laparoscopic appendectomy should be avoided in children who have complicated appendicitis because of the increased risk for postoperative intraabdominal abscesses. The authors propose a prospective, randomized trial to verify this finding.     

Complications of absorbable pelvic mesh slings following surgery for rectal carcinoma

PURPOSE: To evaluate the intraoperative, postoperative, and long-term complications of an absorbable pelvic mesh sling after surgery for rectal carcinoma. METHODS: A retrospective review of medical records from April 8, 1991, through April 8, 1996. RESULTS: Twenty patients with a mean age of 57 (range, 37-79) years underwent pelvic mesh sling placement. The tumor stages were as follows: Stage I, 5; Stage II, 2; Stage III, 11; and Stage IV, 1. A recurrent perianal basal cell carcinoma was not included in the staging group. Surgery consisted of 18 abdominoperineal resections, 1 total proctocolectomy, and one Hartmann's procedure. Mean follow-up was 18 (range, 2-49) months. There were no intraoperative complications related to mesh placement. Twenty-nine complications occurred in 14 patients during the immediate postoperative period. Five were possibly mesh-related and included a pelvic abscess, perineal seroma, toxic perineal wound, pulmonary embolus, and lower extremity deep venous thrombosis, respectively. A mild postoperative ileus developed in 17 patients (85 percent), and a diet was initiated at a mean of seven (range, 4-24) days. Fourteen patients received postoperative radiotherapy with a mean dose of 5,339 (range, 2,500-7,020) cGy delivered in 180-cGy fractions. There were 14 immediate complications caused by radiotherapy in 11 patients, but only two patients required delays in treatment. Two patients had diarrhea alone, six developed perineal dermatitis alone, and three patients had both diarrhea and perineal dermatitis. All patients with diarrhea had received chemoradiation. One patient developed a partial small-bowel obstruction following radiation. CONCLUSIONS: Absorbable pelvic mesh sling placement can be performed with minimum morbidity and is recommended following surgery for rectal cancer when radiation is anticipated as part of multimodality therapy.     

Should we patch corneal erosions?

This prospective study was performed to investigate epidemiological characteristics in terms of the age- and sex-specific incidence in patients with perforated and nonperforated appendicitis. The study population comprised 1486 consecutive patients who underwent appendectomy for suspected acute appendicitis between 1989 and 1993. Two patient cohorts [n = 544 (37%)] were analyzed with regard to prehospitalization duration of symptoms and in-hospital observation time. The crude incidence of acute appendicitis was 86 per 100,000 per year. Although the incidence of nonperforated appendicitis was highest among adolescents and young adults (13-40 years of age), perforated appendicitis occurred at almost the same incidence in all sex and age groups. The diagnostic accuracy was 76%. Perforated appendicitis occurred in 19%, with higher rates in small children and the elderly, irrespective of gender. A high diagnostic accuracy was not associated with an increased rate of perforation. In small children and the elderly, the diagnostic accuracy was low and the perforation rate high. Patients with perforation had a significantly longer duration of symptoms as well as in-hospital observation time than did patients with nonperforated appendicitis. Perforated appendicitis showed a different incidence pattern than nonperforated appendicitis and was associated with a significantly longer duration of symptoms and in-hospital observation time, probably due to patient-related factors. We suggest this observation deserves attention regarding clinical diagnosis and treatment decision-making for patients with suspected acute appendicitis.     

Early appendectomy versus an interval appendectomy for appendiceal abscess in children

We retrospectively compared the results of an early appendectomy and an interval appendectomy at a later date after initial conservative treatment in children demonstrating perforated appendicitis with a localized abscess. The preoperative conditions were similar for both groups. The early group (n = 8) showed a statistically significant longer operation time and a greater but not significant blood loss were noted while a larger number of postoperative complications were also observed. On the other hand, in the late operation group (n = 6) initial conservative management including triple antibiotic therapy proved successful without the need to drain the abscess, and thus the interval appendectomy was safely completed without any complications. There were no significant differences between the two groups with respect to length of hospital stay or medical costs. Based on these findings, we thus recommend that initial conservative treatment followed by an interval appendectomy about three months later is a useful strategy for the treatment of appendiceal abscesses in children. However, whether or not an interval appendectomy is appropriate in all patients whose inflammation is suppressed with antibiotics still needs to be clarified.     

White blood cell count is a poor predictor of severity of disease in the diagnosis of appendicitis

The white blood cell (WBC) count is considered to be a useful test in the diagnosis of appendicitis. The purpose of this study was to examine the clinical features of patients with normal WBC appendicitis and also to determine whether a higher WBC count correlates with a more advanced stage of appendicitis. Patients with pathologically confirmed appendicitis from January 1989 to December 1994 were included in the study (n = 1919). The age, gender, temperature, length of hospital stay, and severity of disease (1 = acute appendicitis; 2 = gangrenous appendicitis; 3 = perforated appendicitis with abscess formation; 4 = appendicitis with diffuse peritonitis) were compared for patients with a normal WBC count (range, 3.8-10.9) versus those who had an elevated WBC count. A normal WBC count was seen in 11 per cent of patients (n = 209). There was no difference in age, temperature, gender, or severity of disease in the patients with a normal WBC count compared with those with an elevated WBC count (P > 0.05). The severity of disease of patients with a normal WBC count were: 1 = 58 per cent; 2 = 13 per cent; 3 = 7 per cent; and 4 = 22 per cent. For patients with an elevated WBC count the scores were: 1 = 57 per cent; 2 = 17 per cent; 3 = 13 per cent; and 4 = 14 per cent. The proportion of gangrenous and perforated appendicitis in the patients with a normal WBC count is the same as in the patients with an elevated WBC count.     

Subcutaneously implanted central venous access devices in cancer patients: a prospective analysis

BACKGROUND: Long term intravenous access is a common requirement for cancer patients. This analysis was designed to determine device-related morbidity and factors predictive of poor long term outcome for patients with subcutaneous single lumen intravenous access ports. METHODS: Six hundred eighty patients who underwent subcutaneous intravenous port placement between June 1987 and May 1989 at Memorial Sloan-Kettering Cancer Center were followed prospectively until port removal, death, or a maximum of 1960 days. Indications for and circumstances of placement, patient diagnoses, patient demographics, and subsequent courses of treatment were recorded, as well as technical and microbiologic device-related complications. Total, device specific, and complication free device durations were calculated. RESULTS: The median patient age was 52.4 years (range, 1.6-83.9 years). The female-to-male ratio was 1.5 to 1. Cancer diagnoses included solid organ tumors (84%), leukemia (4%), lymphoma (11%), and others (1%). Indications included access for systemic chemotherapy (98%), total parenteral nutrition (0.5%), and others (1.5%). One insertion complication and six insertion failures occurred, without mortality. The estimated mean overall actuarial device specific duration was 1191 days (range, 2-1960 days). Actuarial mean complication free, device specific duration was 952 days. Complications included sepsis (n = 31; 4.4%), site infection (n = 31; 4.4%), and accessibility failures such as thrombosis and leakage (n = 40, 5.7%). Reasons for end of port duration were patient death (72.4%), end of treatment (13.5%), functional failure or intractable infection (11.2%), and others (2.9%). Independent factors correlating with decreased port specific, complication free duration included placement site, age, tumor type, and catheter tip position. CONCLUSIONS: Subcutaneous intravenous access ports in cancer patients are safe and well tolerated. Long term device duration is primarily influenced by patient survival. In this study, 90% of patients alive at 1 year and 70% of patients alive at 4 years had a functional port.     

Communicable disease in African immigrants in Minneapolis

To perform a laparoscopic appendectomy, three trocars are usually needed. In order to reduce abdominal wall trauma, we have adopted an umbilical one-puncture laparoscopic-assisted appendectomy (UOPLAA). We did a retrospective study of UOPLAA performed during last 2 years on 200 children aged from 5 to 18 years (median, 9 years). The patients were selected after clinical examination. No child with advanced generalized peritonitis or an abscess with a palpable mass was a candidate for this technique. UOPLAA was successful in 184 patients (92%). In 16 cases (8%), an additional trocar was required to manage perforated or retrocecal appendicitis. The mean operative time was 15 min, and the mean hospital stay was 2 days. There were no intraoperative complications. There were 10 (5%) postoperative complications (three parietal and seven intraabdominal). Four patients (2%) needed reoperation under general anesthesia. The UOPLAA is our preference in cases of acute nonperforated appendicitis because it is simple and fast, with good cosmetic results; but in 8% of our cases, an intraoperative difficulty (retrocecal location, abnormal adhesive band, peritonitis, etc.) arose that required the introduction of additional devices to ensure the safety of the laparoscopic procedure.     

Treatment of malignant esophageal obstructions with covered metallic Z stents: long-term results in 52 patients

PURPOSE: To prospectively evaluate the clinical efficacy of silicone-covered Gianturco-R?sch self-expandable Z (GRZ) stents in the treatment of malignant esophageal obstruction. PATIENTS AND METHODS: GRZ stents were placed in 52 patients (39 men, 13 women) with severe dysphagia due to high-grade malignant esophageal obstruction. RESULTS: Stent placement was technically successful, and immediate relief of dysphagia was achieved in 50 of 52 patients (96%), with long-term relief in 47 patients (90%). Fifty-one patients (98%) died during follow-up (range, 1 week to 33 months; mean, 4.3 months). Late complications were most prevalent and included stent migration (n = 5), food impaction (n = 2), chest pain (n = 2), membrane disruption with tumor ingrowth (n = 1), granulomatous reaction above the stent (n = 1), esophageal perforation with mediastinitis (n = 1), and upper gastrointestinal hemorrhage (n = 4). Twelve complications were easily managed with medical, endoscopic, or radiologic intervention. Four deaths may have been related to stent placement (early mortality rate, 7.7%). CONCLUSION: GRZ stents provide relatively safe and effective long-term palliation in patients with severe, malignant esophageal obstruction.     

Update on the use of percutaneous nephrostomy/balloon dilation for the treatment of renal transplant leak/obstruction

PURPOSE: Retrospective evaluation of the efficacy of percutaneous nephrostomy and nephroureteral stent placement for treatment of post-transplant ureteral leak, and percutaneous nephrostomy and balloon dilation for treatment of post-transplant ureteral obstruction. PATIENTS AND METHODS: Data were reviewed for all patients who underwent percutaneous therapy for complications after renal transplantation between January 1985 and June 1995. A total of 61 patients with complications (leak, n = 17; obstruction, n = 44) had been treated. Patients underwent percutaneous nephrostomy followed by antegrade placement of a nephroureteral stent. In addition, all patients with obstruction also underwent ureteral balloon dilation. Follow-up ranged from 9 weeks to 24 months. Positive outcome was defined as nonsurgical closure of leak, significant improvement in renal function, and removal of the nephroureteral stent with maintenance of stable renal function. RESULTS: Regarding ureteral leak, 10 of 17 patients (59%) healed after treatment. Seven patients (41%) did not respond and went on to surgical repair. All patients with early (n = 13) ureteral obstruction (< 3 months after transplantation), had improved renal function (P < .025). Sixty-two percent of patients with early obstruction were cured (tube out with stable renal function) and 38% went to surgery for ureteral repair. In patients with late (n = 31) obstruction (> 3 months after transplantation), renal function improved in only 58% (P < .01). Only 16% of patients with late obstruction were cured (tube out with stable renal function). Ureteral obstruction was persistent in the remaining patients and did not respond to multiple balloon dilations. All complications were minor and included 23 of 61 (38%) patients with urinary tract infections and nine of 61 (14%) patients with limited hematuria. CONCLUSION: Percutaneous nephrostomy is very effective in improving renal function in patients with early obstruction. It is moderately successful in treating ureteral leak. Ureteral balloon dilatation is moderately effective for treatment of obstruction in the early (< 3 months) postoperative period. However, balloon dilation is minimally successful in curing ureteric obstruction occurring more than 3 months after transplantation.     

Is there a duty to die?

OBJECTIVE: To review appendectomy cases in children at a small community hospital and to compare with experience at larger centers. DESIGN: A five-year retrospective study. SETTING: Bartlett Regional Hospital, Juneau, Alaska. PATIENTS AND METHODS: Records of children age 14 and younger who underwent appendectomy from 1991 through 1996 were reviewed; 79 charts were found. Cases were grouped as simple appendicitis, advanced appendicitis, and appendectomy without appendicitis. Variables considered included: length of symptoms at first contact, time from onset until surgery, presence or absence of classical symptoms, post-operative complications, length of hospital stay. RESULTS AND CONCLUSION: 51 cases (64.6%) of simple appendicitis, 22 cases (27.9%) of advanced disease, and 6 cases (7.6%) of normal appendix occurred. Advanced disease was high (66.7%) in children less than 5, and low (22.7%) in ages 10-14. Parental delay > 48 hours in seeking care was a significant factor in advanced disease, professional delay (time from first exam until surgery) was not. Post-surgical complications occurred in 7 (31.8%) cases of advanced disease and in none of the cases with simple appendicitis. Advanced disease cases had an average hospital stay of 8.59 days (+/-2.92) vs. 3.86 days (+/-1.46) for simple appendicitis. Review of appendicitis in children at this hospital compared favorably with the experience at larger medical centers.     

CT of appendicitis in children

PURPOSE: Our goal was to review the CT findings and to help define the role of CT in the evaluation of appendicitis in children. METHOD: Of 730 children with surgically proven appendicitis, 22 underwent preoperative CT evaluation. Their CT scans and operative and pathology records were retrospectively reviewed. The CT scans were evaluated for appendiceal wall thickness, diameter, and location, appendicoliths, pericecal inflammation, phlegmon, abscess, free fluid, small bowel dilatation, and bowel wall thickening. Criteria for diagnosing appendicitis were (a) appendiceal wall thickening (> 1 mm) or (b) presence of abscess, phlegmon, or pericecal inflammation associated with appendicolith(s). Prospective reports of ultrasound examinations performed within 2 days of the CT scans were available in 14 children and were correlated with the CT findings. RESULTS: An abnormally thickened appendix, with a diameter ranging from 9 to 18 mm, was seen in four children. Three appendices were retrocecal and one was near the cecal tip, anterior to the iliac vessels. Appendicoliths were present in 10 children, multiple in 1. Abscesses were seen in 13 of 22 children, multiple in 5. Phlegmon was seen in five children and pericecal inflammation in two. Bowel wall thickening was present in seven children and small bowel dilatation was noted in six. Other findings included free fluid, hydronephrosis, thickening of urinary bladder wall, air in the uterus and vagina, adenopathy, and thickening of the abdominal wall musculature. CT was diagnostic of appendicitis in 11 of 22 children (50%). In 14 children with both ultrasound and CT studies, CT was slightly better in diagnosing appendicitis and visualizing the abnormal appendix and was superior in defining the presence and extent of abscess and inflammation in 9 of 14 children. CONCLUSION: CT is a useful adjunct in diagnosing appendicitis in children, with a major role in cases of complicated appendicitis.     

Outcome of palliative biliary and gastric bypass surgery for pancreatic head carcinoma in 126 patients

BACKGROUND: Recent reports of decreased morbidity and mortality following palliative surgery for patients with irresectable pancreatic head carcinoma prompted a review of the results in 126 patients (median age 64 (range 39-90) years) who had undergone palliative biliary and gastric bypass surgery. METHODS: The indication for surgical palliation was the finding of an irresectable tumour at laparotomy (n = 44), failure of endoscopic treatment (n = 43), clinical symptoms of gastric outlet obstruction (n = 28) and miscellaneous (n = 11). Biliary and gastric bypass was performed in 118 patients, biliary bypass alone in six and gastrojejunostomy alone in two. The indication for gastrojejunostomy was symptoms in 28 patients (23 per cent) and prophylaxis in 92 patients (77 per cent). RESULTS: Postoperative local complications occurred in 17 per cent of patients, general complications in 10 per cent and delayed gastric emptying in 14 per cent of patients. The 30-day mortality rate was 1 per cent and overall hospital mortality rate 2 per cent. Median hospital stay was 17 (range 5-80) days. Median overall postoperative survival was 190 (range 14-830) days. Late obstructive gastrointestinal symptoms occurred in 14 patients (11 per cent) after a median of 141 (range 21-356) days. CONCLUSION: Roux-en-Y hepaticojejunostomy combined with gastrojejunostomy offers effective palliation for irresectable pancreatic head cancer and can be performed with low mortality and acceptable morbidity rates.     

A study of 362 consecutive laparoscopic Nissen fundoplications

BACKGROUND: Open Nissen fundoplication has been shown to be a very effective operation in the treatment of intractable gastroesophageal reflux. Because of its technical rather than amputative nature, this procedure offers itself to a completely laparoscopic approach. Several studies have shown the feasibility; however, very few have dealt with the effectiveness of the laparoscopic approach. METHODS: Results of laparoscopic Nissen fundoplications performed during a 6-year period were reviewed including duration of operation, number of hospital days, number of conversions to open procedures, complications, and symptoms. All 362 patients had evidence of gastroesophageal reflux disease documented by radiographic, endoscopic, or pH monitoring testing before the operation. Patients with dysphagia or odynophagia underwent manometric evaluation before operation. Postoperative evaluation included esophagography and endoscopy at 2 to 3 months with an esophagogram yearly thereafter. Follow-up time was 6 months to 6 years. RESULTS: The mean time of operation decreased from 2.7 +/- 0.4 hours during the period from 1991 to 1994 to 1.8 +/- 0.3 hours from 1994 to 1997. During those same periods, the number of days of hospitalization decreased from 2.2 days to a mean of 1.5 days. Manometric studies done before the operation (n = 58) showed a pressure of 4 +/- 1.2 mm Hg compared with postoperative values (n = 39) of 14 +/- 1.8 mm Hg. The conversion rate was 0.8% (n = 3), and the complication rate of 1.9% (n = 7) included the 3 conversions, 2 pneumothoraces, 1 patient with postoperative bleeding, and 1 patient with a large abdominal wall hematoma. There were 5 failures of the procedure (1.2%). Thirteen patients (3.6%) described postoperative symptoms that persisted beyond 2 months, including bloating, flatulence, dysphagia, and diarrhea. CONCLUSIONS: With strict selection criteria and increasing experience and standardization of technique, laparoscopic Nissen fundoplication can provide both safe and effective results for patients with chronic symptoms of gastroesophageal reflux disease.     

Myotonic dystrophy kinase modulates skeletal muscle but not cardiac voltage-gated sodium channels

PURPOSE: To evaluate the technique used for and long-term results of percutaneous cecostomy tube placement for the treatment of fecal incontinence in children. MATERIALS AND METHODS: After an initial pilot study in 15 patients, 42 additional patients with fecal incontinence aged 2-20 (mean, 11.5) years and weighing 9.9-109.0 (mean, 39.2) kg underwent percutaneous cecostomy tube placement. Twenty-nine patients had spina bifida, nine had imperforate anus, three had cloacal anomalies, and one had Hirschsprung disease. Mean follow-up was 265 days (range, 8-503 days). RESULTS: Tube placement was successful in all patients. One patient developed local inflammation after accidental early retention-suture removal, which was treated with suture replacement and intravenous antibiotics. Another developed postprocedural ileus, which resolved. Late complications included constipation in one patient (treated with diet alteration), granulation tissue in seven patients (treated with silver nitrate cautery), and accidentally dislodged tubes in three patients (two successfully replaced at home and one replaced at the radiology suite). Vomiting related to the phosphate enema occurred in two patients. Resolution of soiling was achieved in all patients. CONCLUSION: Percutaneous cecostomy and antegrade enemas are very successful in achieving fecal continence and patient independence and acceptability, with minimal early and late complications.     

Prosthetic replacement of the inferior vena cava for malignancy

PURPOSE: Invasion of the inferior vena cava (IVC) by tumor is generally considered a criterion of unresectability. This study was designed to review the outcomes of a strategy of aggressive resection of the vena cava to achieve complete tumor resection coupled with prosthetic graft placement to re-establish caval flow. METHODS: Retrospective review of patients treated at a university referral center. Ten patients (mean age 54; eight females, two males) underwent tumor resection that involved circumferential resection of the IVC and immediate prosthetic replacement with ringed polytetrafluoroethylene (PTFE) grafts ranging in diameter from 12 to 16 mm. RESULTS: Seven patients had replacement of the infrarenal IVC, two of their suprarenal IVC, and one had reconstruction of the IVC bifurcation. Four of the 10 patients received preoperative chemotherapy, and none received radiotherapy. The most common (7/10) pathologic diagnosis was leiomyosarcoma arising from the IVC or retroperitoneum. Additional diagnoses included teratoma (one), renal cell carcinoma (one), and adrenal lymphoma (one). There were no perioperative deaths, and one complication (prolonged ileus) occurred. Mean length of stay was 8.1 days. Anticoagulation was not routinely used intraoperatively or postoperatively. Follow-up (mean duration = 19 months) demonstrated that survival was 80% (8/10) and 88% (7/8) of patients were free of venous obstructive symptoms. CONCLUSION: Resection of the IVC with prosthetic reconstruction allows for complete tumor resection and provides durable relief from symptoms of venous obstruction.     

Primary anastomosis in the treatment of acute disease of the unprepared left colon

Between June 1, 1990 and December 31, 1996, 58 consecutive patients with unprepared colons were urgently explored for nontraumatic disease with intent to proceed with primary left-sided colonic anastomosis. Unprotected anastomoses were not attempted in 15 patients. The causes of exclusion included preoperative and intraoperative shock in three patients, and three patients were on long-term high-dose steroids, four had gross fecal contamination of the peritoneal cavity, four had large pelvic abscesses, and one had ischemic colitis. All 43 patients undergoing anastomosis without protective colostomy had stapled anastomoses. Indications included complicated diverticular disease in 32 cases. There were nine cases of obstruction from colorectal carcinoma and one obstruction due to sigmoid volvulus. There was one case of perforation from pseudomembranous enterocolitis. The most common complications were: atelectasis in nine cases, wound infection in two cases, and prolonged ileus in two cases. Pelvic abscess occurred in one case. There was one wound dehiscence. There was one anastomotic dehiscence, and there was no mortality. Operative time averaged 85 minutes and hospital length of stay 9.7 days. Primary anastomosis of the unprepared left colon is safe in most urgent and emergent situations, thus avoiding the significant morbidity and cost of colostomy closure.     

Thoracic versus lumbar epidural anesthesia's effect on pain control and ileus resolution after restorative proctocolectomy

BACKGROUND: Epidural anesthesia as a perioperative adjunct has been shown to provide superior pain control and has been implicated in more rapid ileus resolution after major abdominal surgery, possibly through a sympatholytic mechanism. Studies suggest that the vertebral level of epidural administration influences these parameters. METHODS: One hundred seventy-nine patients (120 male, 59 female; average age, 36 years) underwent restorative proctocolectomy for ulcerative colitis or familial polyposis between 1989 and 1995. Patients were grouped according to type of anesthesia. Group THO (n = 53) received thoracic (T6 to T10) epidurals. Group LUM (n = 51) received lumbar (L2 to L4) epidurals, and group PCA (n = 75) received patient-controlled intravenous narcotic analgesia. Patients were compared for complications, perioperative risk factors, postoperative pain, and ileus resolution. RESULTS: Epidural narcotics, alone or combined with local anesthetics, were administered for an average of 2 (LUM) to 4 (THO) days without significant complications. Infrequent problems related to the epidural catheters included self-limited headaches or back pain (four) and site infections (two). Epidural failure, as measured by conversion to PCA for inadequate pain control, was not significantly greater for LUM (25%) than THO (23%). Average pain scores, rated daily on a visual analog scale, were significantly higher (indicating more pain) for PCA patients (4.2) during postoperative days 1 through 5 than for LUM (3.5) (p < 0.05) and for THO (2.4) (p < 0.05). Ileus resolution, as determined by stool output and return of bowel sounds, was significantly faster in THO than in LUM or PCA (p < 0.05). Resolution of ileus was not significantly different between PCA and LUM (p > 0.05). CONCLUSIONS: Thoracic epidural analgesia has distinct advantages over both lumbar epidural or traditional patient-controlled analgesia in shortening parameters measuring postoperative ileus and in reducing surgical pain. The procedure is safe and associated with low morbidity. Thoracic epidural anesthesia is also economically justifiable and may prove to impact significantly on future postoperative management by reducing length of hospitalization. Our data and those of others are most striking in these regards for patients with thoracic catheters, indicating the importance of vertebral level in epidural drug administration.     

Transient up-regulation of ciliary neurotrophic factor receptor-alpha mRNA in axotomized rat septal neurons

PURPOSE: To determine prospectively the feasibility, complications, and mid- and long-term advantages of peripheral insertion of central catheters in infants and children. MATERIALS AND METHODS: During a 15-month period between March 1995 and June 1996, a total of 285 catheter placement attempts were made to peripherally insert central catheters in 183 pediatric patients (89 boys, 94 girls). Phlebographic guidance was used, and the catheters were inserted below the elbow in 99% of cases. Catheter insertion was indicated for prolonged antibiotic therapy in 108 patients (158 catheter placement attempts), hematologic or oncologic care in 24 patients (40 attempts), total parenteral nutrition in 16 patients (46 attempts), and venous access for fluid or blood in 35 patients (41 attempts). The success rate and complications were recorded along with the indication, patient age, and duration of catheter placement. RESULTS: One hundred fifty-two of 158 (96%) catheter placement attempts were successful in outpatients (n = 108), 124 of 127 (98%) in hospitalized patients (n = 75), and 70 of 73 (96%) in patients aged less than 1 year. Infection and pericatheter venous thrombosis were the main complications and were seen in 17 of 276 (6%) and one of 276 (0.3%) catheter placement attempts, respectively. Catheter occlusion occurred in 23 of 276 (8%) catheter placement attempts. CONCLUSION: Peripheral insertion of central catheters was highly feasible in infants and children with this protocol. Such catheters were well tolerated in the pediatric population with a low frequency of complications.     

Iliofemoral venous stenoses: effectiveness of treatment with metallic endovascular stents

PURPOSE: To assess effectiveness of metallic endovascular stents in treatment of venous stenoses and occlusions. MATERIALS AND METHODS: Stents were placed intravenously in 56 patients (59 stenoses or occlusions) over a 6-year period. Stent sites included the inferior vena cava (n = 10) and common iliac (n = 31), external iliac (n = 46), common femoral (n = 27), and superficial femoral veins (n = 4). Indications for stent placement included stenoses from pelvic malignancy and its treatment; trauma, surgery, or pregnancy; and idiopathic stenoses. Patients underwent anticoagulation therapy for 3-6 months after stent placement. Follow-up was performed with duplex ultrasound. RESULTS: With use of life-table analysis, overall primary and secondary 1-year patency rates were 50% and 81%, respectively. Primary and secondary 4-year patency rates were and 50% and 75%, respectively. Five patients died of primary disease progression within 6 months after stent placement. Major complications occurred in 6.8% of cases. One-year secondary patency rates were statistically significantly lower (P = .05) for patients with malignant disease, although primary patency rates were comparable. Overall sustained decrease in symptoms (P < .0001) was observed 1 year later. CONCLUSION: Endovascular stent placement is a nonsurgical alternative for reestablishment of venous flow and sustained relief of symptoms in patients with malignant or benign pelvic venous disease.