Laparoscopic cholecystectomy: the evolution of general surgery.
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Cholecystectomy↗
Biomedical subjects
J V White
Publications and source records attributed to J V White.
The architecture of adventitial elastin in the canine infrarenal aorta.
Although the artery wall consists of three distinct layers, only the structures of the intima and media have been well characterized. The adventitia has generally been overlooked. Our examination focused on the organization of elastin and collagen which are the major components of this tunic. Canine infrarenal aortas were excised, stretched to their in vivo length, then pressure fixed in formalin. Transverse, longitudinal, and frontal sections were prepared with specific elastin and collagen stains. Areas of adventitia in these sections were examined with LM, and interconnections between collagen and elastin were photographed at various magnifications. Subsequently, the slides were fractured for attachment to SEM stubs, and the coverslips were demounted. The identical areas were then examined with SEM using the LM micrographs as a guide to identify elastin and collagen. Whole mount aortic ring preparations were digested in formic acid for 72 and 96 h at 45 degrees C to confirm adventitial elastin architecture. The adventitia was organized in alternating lamellae of collagen and elastin. The elastin lamellae consisted of continuous sheets of elastin with a longitudinal fibrillar substructure. Finer circumferential elastin fibers were also identified. These attached to both longitudinal elastin and adjacent collagen lamellae. Collagen lamellae were arranged in broad corrugated bands of fibrils. The unique architecture of the adventitia may explain some of the visco-elastic properties of the aorta in both normal and pathologic states.
Animals↗
Laparoscopic cholecystectomy registry.
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Cholecystectomy↗
Beneficial effects of dietary mineral restriction in dogs with marked reduction of functional renal mass.
Although studies in partially nephrectomized rats have identified a progressive nephropathy that is altered by dietary restriction of phosphorus intake, the response of dogs to similar perturbations has not been established. Functional renal mass was reduced by 15/16 in dogs to determine its long-term effects on renal function and to evaluate the effects of two levels of dietary mineral (calcium and phosphorus) intake (0.44% phosphorus/0.57% calcium versus 1.50% phosphorus/1.91% calcium). Following a 3-month stabilization period, dogs were fed either the lower mineral diet (group 1, N = 12) or the higher mineral diet (group 2, N = 12) for 24 months. Loss of renal function with the passage of time was observed in 10 of 12 dogs maintained on the higher mineral diet, with an average decrease in exogenous creatinine clearance of 11.1 +/- 6.3%/month, leading to a survival rate of 33% in this group. Restriction of dietary mineral intake slowed (P less than 0.05) the rate of decline of exogenous creatinine clearance in group 1 to 2.6 +/- 1.1%/month and improved 24-month survival to 75% (P less than 0.01). Deterioration of renal function was associated with renal calcium accumulation and histologic evidence of nephrocalcinosis, tubular atrophy and dilatation, and interstitial fibrosis. These events were more readily apparent in female than in male dogs. A role for glomerulosclerosis was not apparent, and neither glomerular pathology nor glomerular volume was related to the observed decrements in renal function.
Animals↗
Risk factors for poor nutritional status in older Americans.
Inappropriate dietary intake and chronic disease or disability place a substantial number of older adults at high risk of malnutrition. Malnutrition often results in considerable dysfunction and disability, reduced quality of life and, in some instances, premature or increased morbidity and mortality. Nutrition screening should prevent nutrition-related problems or allow early intervention. The elements that contribute to nutritional problems in the elderly must be clearly identified and prioritized. The desired goal of nutrition screening is a more vigorous older population able to maintain optimal nutrition, resulting in improved health and quality of life.
Aged↗
Effect of dietary protein on functional, morphologic, and histologic changes of the kidney during compensatory renal growth in dogs.
Two diets similar in caloric density and mineral content, but markedly different in protein content, were used to study the effects of dietary protein on renal function and morphologic and histopathologic changes in dogs that had functional renal tissue reduced by seven-eights nephrectomy. The effects of moderate protein intake (MPrI = 15% protein; dry-matter basis) and high-protein intake (HPrI = 31% protein; dry-matter basis) were studied for the initial 7 months (period 1 [P1]) after renal mass reduction. Diets were then switched between groups during the following 7 months (period 2 [P2]) to evaluate the effects of increased or decreased protein intake. The HPrI caused significantly (P less than 0.05) greater glomerular filtration rate (GFR) and renal growth than did MPrI during P1. Dogs that maintained HPrI during P1 and MPrI during P2 (group 1) had significant (P less than 0.05) reduction in GFR during P2. Dogs that maintained MPrI during P1 and HPrI during P2 (group 2) had significant (P less than 0.05) improvement in GFR and renal growth during P2. At the end of the study, renal reserve was evaluated in both groups of dogs before and after group 1 was returned to HPrI for 2 weeks. During this 2-week feeding trial, group-1 dogs had marked improvement in renal reserve, relative to group 2, and GFR increased to the terminal P1 values. Results indicate a possible residual benefit from HPrI during the early phase of compensatory renal growth in the form of functional compensatory memory to HPrI. The severity of renal lesions was indistinguishable between dogs of dietary groups during both study phases.(ABSTRACT TRUNCATED AT 250 WORDS)
Animal Feed↗
Consensus of the Nutrition Screening Initiative: risk factors and indicators of poor nutritional status in older Americans.
Dietetics professionals must become even more proactive in taking the lead in the nutritional screening and assessment of older Americans. They can do so by encouraging all health care providers to become familiar with each older American's circumstances and needs. In addition, as individuals and as a professional health care association, we should urge our colleagues and institutions to establish regular longitudinal surveillance and continuity of care in nutrition services delivery. The timely, appropriate, and cost-effective delivery of nutritional screening, assessment, and care will improve the health and well-being of this valued segment of the US population. Dietetics professionals are a vital part of this process.
Activities of Daily Living↗
Free vascularized tissue transfer for limb salvage in peripheral vascular disease.
In patients with tissue necrosis, higher limb salvage rates can be accomplished with free tissue transfers performed by a vascular and plastic surgeon team. We treated 10 patients with severe ischemic soft tissue defects in their legs with radical debridement and free tissue transfer alone (two patients) or after revascularization (eight patients). Arteriography was performed to plan revascularization to evaluate bypass results, and to identify appropriate recipient vessels for free tissue transfer. Soft tissue defects treated with free tissue transfer included nonhealing amputation sites in five patients and proximal skin and muscle necrosis in the remaining patients, one of which resulted in an exposed in-situ graft in one leg. One patient underwent a distal bypass specifically to provide arterial inflow for free tissue transfer, whereas seven other patients received free tissue transfers following bypass due to persistently nonhealing wounds. The remaining two patients had diabetes mellitus with necrosis near a major joint with nonhealing amputation sites. Free tissue transfers were taken from the latissimus dorsi in six patients, and from the gracilis, rectus abdominis, rectus femoris, and scapula flaps in other patients. Recipient vessels for free tissue transfers were the external iliac artery (one patient), saphenous vein bypass grafts (two patients), popliteal artery (one patient), posterior tibial (three patients), and dorsalis pedis vessels (three patients). Eight of the 10 flaps were viable at follow-up (four months-six years), with a mean follow-up of 20 months. One patient underwent above-knee amputation 15 months after operation and one underwent below-knee amputation three years later due to central flap necrosis. The remainder achieved functional limb salvage allowing patients to resume ambulation. Vascular surgeons should consider free tissue transfer in patients with nonhealing soft tissue defects following optimal revascularization to further extend our ability to salvage the threatened limb.
Adult↗
Laser assisted fusion of the rat stomach: preliminary studies.
The purpose of this study was (1) to determine whether rat gastrotomies could be securely closed without sutures by CO2 laser-induced tissue fusion alone and (2) to compare some characteristics (physical, biochemical, histological) of laser-fused gastrotomies with sutured gastrotomies. Following pentobarbital anesthesia a 1.5-cm longitudinal anterior gastrotomy was made in the forestomach of male Sprague-Dawley rats. This wound was closed using either a sutureless tissue weld created by a microscope-mounted CO2 laser (153 W/cm2) (Group I, N = 61) or with a running 6-O polypropylene suture (Group II, N = 58). Animals were sacrificed on Postoperative Days 1, 2, 4, 7, and 11 and the wounds were studied. Survival to scheduled sacrifice was 95% in Group I and 93% in Group II. Although bursting pressure of laser-fused gastrotomies was significantly lower than that of sutured controls on Postoperative Day 1, measurement on subsequent days showed comparable wound strength between the laser and suture groups. Wound hydroxyproline content was significantly higher on Postoperative Day 1 and lower on Postoperative Day 11 in the laser group. Histologic examination of the laser-fused wounds revealed less inflammation and earlier reepithelialization than the sutured wounds, giving the microscopic appearance of a "neater" healing wound. These results suggest that laser-induced fusion is a feasible method of gastrointestinal wound closure which may complement standard suture techniques.
Animals↗
Percutaneous ablation of gallstones.
The purpose of this study was to determine if gallstones could be safely and effectively ablated in the pig using a proprietary percutaneous rotor-tipped catheter, the Kensey-Nash Lithotrite (KNL). All gallstones in a single human gallbladder were defined as a gallstone set. Human gallstone sets not meeting current treatment criteria for extracorporeal shock wave lithotripsy (ESWL) were placed in the gallbladder (GB) of male pigs (N = 8; 80-100 kg). A percutaneous transhepatic guide wire was put into the GB and the abdomen closed. The KNL was then introduced under fluoroscopy using the Seldinger technique and activated. Gallstone ablation was monitored by tactile and auditory feedback to the operator and by fluoroscopy. Once completed the device was withdrawn, the GB irrigated, and the 9F sheath removed. Animals were sacrificed immediately (Group 1, N = 4) and at 28 +/- 5 days (Group 2, N = 4). Gallstones were ablated in 26 +/- 8 min. No pig had significant hemorrhage, GB perforation, or pancreatitis. One acute animal had stone fragments greater than 2 mm in the gallbladder. No other animals had any fragments greater than 1 mm present in the GB, cystic duct, common duct, ampulla, or duodenum. Histologic examination of the GB showed acute hemorrhagic mucosal injury in Group 1 and extensive mucosal regeneration with some stone fragment granulomata and mural fibrosis in Group 2. We conclude that percutaneous gallstone ablation with the KNL is safe and effective in this short-term pig model and appears to be a safe procedure for gallstone ablation. Long-term safety and effectiveness remain to be demonstrated. This device should be useful for treatment of symptomatic gallstones in patients not treatable by ESWL.
Animals↗
Venous duplex imaging: should it replace hemodynamic tests for deep venous thrombosis?
Noninvasive diagnosis of deep venous thrombosis has traditionally relied on detection of alterations in venous hemodynamics. Although phleborheography is among the most sensitive tests, it is inadequate for diagnosing infrapopliteal and nonocclusive proximal thrombi and for surveillance of patients at high risk for deep venous thrombosis. Venous duplex imaging is a new technique being rapidly accepted, however, without the same critical analysis given to previous diagnostic modalities. The purpose of this study is to evaluate the diagnostic acumen of venous duplex imaging compared to phleborheography and ascending phlebography in two distinct patient groups, and to determine whether patient selection, and thus the location or magnitude of thrombi have significant influence on these diagnostic tests. One hundred ten extremities in 103 patients were prospectively evaluated with venous duplex imaging, phleborheography, and ascending phlebography within the same 24-hour period. Patients were categorized into one of two groups: Diagnostic--patients evaluated because of clinical suspicion of acute deep venous thrombosis; and Surveillance--patients at high risk of postoperative deep venous thrombosis after total joint replacement, but not symptomatic. Patients in the diagnostic group had a greater frequency of deep venous thrombosis (p less than 0.001) and significantly more occluding above-knee thrombi (p = 0.054) compared to those in the surveillance group. Phleborheography detected 73% (27/37) of above-knee thrombi in the diagnostic group compared to 29% (2/7) in the surveillance group (p = 0.036). This difference was not noted with venous duplex imaging, which detected 100% of above-knee thrombi in both diagnostic and surveillance groups and 78% (7/9) of all below-knee thrombi.(ABSTRACT TRUNCATED AT 250 WORDS)
Humans↗
The preoperative diagnosis of the ulcerated carotid atheroma.
Arteriography and carotid duplex imaging accurately quantify the degree of stenosis caused by carotid atheroma. Since arteriography is inconsistent in identifying carotid ulceration, and controversy exists regarding the diagnostic accuracy of carotid B-mode imaging, a prospective study was performed comparing the two techniques to 126 carotid endarterectomy specimens. Sixty percent (76/126) of specimens contained ulcers. The diagnostic sensitivity for B-mode imaging and arteriography was 47% (36/76) and 53% (40/76), respectively (p = NS). Importantly, the degree of stenosis caused by the plaque significantly affected diagnostic sensitivities. B-mode sensitivity was 77% (10/13) in plaques less than or equal to 50% and 41% (26/63) for plaques greater than 50% (p = 0.03). Arteriography likewise detected 77% (10/13) of ulcers in plaques less than or equal to 50% stenosis and 48% (30/63) in plaques with greater than 50% stenosis (p = 0.07). In patients with focal symptoms, 100% (10/10) of plaques with less than or equal to 50% stenosis contained ulcers, whereas in plaques with greater than 50% stenosis 63% (36/57) contained ulcers (p = 0.02). These data indicate that the diagnostic sensitivity for carotid ulceration is not significantly different between B-mode carotid imaging and arteriography. Since most B-mode errors occur with high-grade stenoses this short-coming is unlikely to adversely affect patient care. Previous studies investigating the ability of carotid B-mode imaging to detect ulceration failed to address quantitative aspects of the carotid plaque. These data appear to resolve the previously existing controversy.
Arteriosclerosis↗
Preparation of the calcified tibial artery for bypass grafting.
This method of preparation of calcified tibial arteries for bypass grafting produces softening of the arterial wall to permit vascular control and the construction of a technically precise anastomosis. The presence of the inflated intraluminal balloon during compression of the arterial wall inhibits violent cracking of the calcific skeleton and displacement of calcium plates into the lumen. This results in fewer intimal flaps and the preservation of an undisrupted outflow tract.
Anastomosis, Surgical↗
Extraskeletal osteosarcoma in two dogs.
Extraskeletal osteosarcoma (ESOS) of the spleen and jejunum was diagnosed in 2 dogs. As an extremely uncommon type of tumor that has proven difficult to treat, ESOS is associated with high rate of local recurrence and metastatic disease. Extraskeletal osteosarcoma principally affects older dogs, has no apparent breed predilection, and may develop more frequently in males. The cause of ESOS is unknown, but may involve malignant metaplasia of pluripotential mesenchymal cells into osteoblasts. Macroscopically, ESOS usually is observed as a hard mass and may appear similar to calcified hematoma or myositis ossificans. The classic radiographic appearance of ESOS is a soft tissue mass with focal mineralization and without adjacent bone involvement.
Animals↗
Congenital pelvic arteriovenous malformation with massive prostatic hemorrhage: a case report.
Congenital arteriovenous malformations in the true pelvis are extremely rare: only 7 cases have been described in male patients. We report on a patient who presented with massive hemorrhage after transrectal prostatic biopsy and transurethral resection of the prostate. Diagnosis was established by means of magnetic resonance imaging and confirmed by arteriography. Our attempt at management by embolization and subsequent surgical ligation is described. A literature review and discussion of arteriovenous anomalies are presented.
Aged↗
Operative venodilation: a previously unsuspected factor in the cause of postoperative deep vein thrombosis.
Intraoperative venodilation in veins distant from the site of operation has been shown to occur in animals and has been directly correlated with focal venous endothelial damage. This exposure of subendothelial collagen could serve as initiation sites for thrombus formation. This study tests the hypothesis that human beings (1) significant operative venodilation occurs and that it correlates with postoperative deep venous thrombosis (DVT); (2) operative venodilation can be pharmacologically controlled; and (3) this control reduces the incidence of postoperative DVT. Twenty-one patients undergoing total hip replacement had their contralateral cephalic vein continuously monitored with modified ultrasonographic instrumentation, with a continuous on-line recorder graphing venous diameter. Patients were randomly assigned to receive 0.5 mg of dihydroergotamine and 5000 U of heparin (DHE/Hep) for prophylaxis or placebo, with investigators "blinded" Postoperatively, all patients underwent ascending phlebography. Patients in whom postoperative DVT developed (11) had a mean operative venodilation of 28.9% +/- 3.93%, and those in whom DVT did not develop (10) had a mean venodilation of 11.6% +/- 1.55% (p = 0.001). Only 17% (2/12) dilating less than 20% baseline diameter had DVT compared with 100% (9/9) dilating greater than 20% of baseline diameter (p = 0.002). Patients receiving venotonic agent DHE had significantly less venodilation and DVT (p less than 0.001) compared with patients receiving the placebo. Patients who had DVT and whose veins dilated greater than 20% were older than patients who did not have DVT and whose veins minimally dilated: p = 0.04 and p = 0.07, respectively. Although there was a trend toward increased venoconstriction in patients receiving DHE/Hep (p = 0.09), there was no correlation of venoconstriction with ultimate thrombotic outcome. Maximal venodilation occurs during handling of soft tissue (muscle), and this occurs significantly sooner than maximal venoconstriction, which occurs during bone manipulation. We conclude that excessive operative venodilation is a new and important etiologic factor that leads to postoperative DVT. Operative venodilation can be pharmacologically controlled with the venotonic agent DHE. The combination DHE/Hep reduces postoperative DVT by the reduction of operative venodilation in the presence of low doses of an anticoagulant. These findings offer a new approach for predicting postoperative DVT and an object rationale for developing effective prophylaxis.
Aged↗
Intraoperative intra-arterial thrombolytic therapy for salvage of limbs in patients with distal arterial thrombosis.
Acute arterial embolic or thrombotic occlusion of the runoff vessels is associated with an incomplete operative thromboembolectomy and an unacceptably high rate of amputation. This report presents a six year analysis of the use of intraoperative intra-arterial thrombolytic therapy, evaluating 38 patients who presented with impending loss of limb because of an acute occlusion of the runoff vessels. All of the patients had extensive thrombosis of a distal vessel and a complete distal thromboembolectomy was not possible. Fourteen patients received infusion of streptokinase, maximum dose of 50,000 units; 26 received urokinase (UK), maximum dose of 150,000 units, and two underwent an isolated limb perfusion technique using one million units of UK. Thirty-four lower and four upper extremities were treated. Twenty-eight of 38 patients had successful revascularization procedures that resulted in salvage of the limbs, and ten of the 38 underwent an extensive amputation. In 18 of the 28 who were successfully revascularized, lysis was clearly obtained, which contributed to the ultimate success; in ten of the 28, it was unclear whether or not lysis significantly contributed to salvage of the limbs. Although four of the 38 died within 30 days postoperatively and one patient had a hemorrhagic complication, neither the deaths nor the complication could be attributed to a lytic agent. There was no evidence of systemic thrombolysis in these patients. Intraoperative intra-arterial thrombolytic therapy administered by the slow bolus injection technique is safe. It can be an important adjunct to mechanical thromboembolectomy and bypass procedures in patients with limb-threatening ischemia caused by thrombosis of the distal part of the vessel. The isolated limb perfusion technique using high dose UK is particularly valuable in acute, small vessel, multiarterial occlusion. Intraoperative intra-arterial infusion of thrombolytic agents may make the difference between salvage or amputation of the limb without causing additional risk for the patient.
Acute Disease↗