Biomedical subjects
Publications and source records attributed to M Schein.
An unusual case of delayed pneumoperitoneum following a penetrating wound of the chest is presented. The mechanism of pneumoperitoneum, the diagnostic dilemma of injury to the abdomen in penetrating wounds of the lower chest, and the alternative methods used in achieving early diagnosis of diaphragmatic penetration are discussed.
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A case of acute-on-chronic acalculous cholecystitis in a 7-year-old Black child is reported. The incidence causation, differential diagnosis and management of acalculous cholecystitis in childhood and the confusion caused by the terminology are briefly discussed.
Two cases of oesophageal perforation at the thoracic inlet, due to penetrating trauma, are described. In the first case the diagnosis was established 2 weeks after injury; the second case was diagnosed within 30 hours, was treated unsuccessfully and referred to us 1 month after injury. The management of these severely ill patients is discussed. Defunctioning of the oesophagus was necessary in both cases, and later reconstruction was carried out in one of the patients.
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A case of penetrating stab wound of the cervical oesophagus is described. The early diagnosis of oesophageal injuries is discussed, emphasizing the importance of clinical symptoms and signs.
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The addition of cholecystectomy to truncal vagotomy and a drainage procedure increases the incidence and severity of postvagotomy diarrhea. This study attempts to establish whether diarrhea is more common after highly selective vagotomy (HSV) and cholecystectomy than after HSV alone. The incidence of diarrhea in 729 patients who underwent HSV without cholecystectomy was found to be 8.8% whereas, in 66 patients in whom HSV was combined with cholecystectomy, the incidence of diarrhea was 9.3%. In most patients, the diarrhea was very mild and in none was it severe. We conclude that the addition of cholecystectomy to HSV does not result in an increased incidence of diarrhea.
The objective of this study was to compare results of elective "open" conventional cholecystectomy (CC) to those of minicholecystectomy (MC). A clinical prospective, randomized trial was designed. The setting was an academic general surgical unit. In the CC group were 26 patients; in the MC group were 24 patients. In the CC group a conventional open cholecystectomy was performed through a subcostal incision; in the MC group operation through an initial 5-cm subcostal incision was done. Mean length of wound was 14.4 cm and 5.4 cm in the two groups, respectively (p < 0.001). Mean operative time was 60 and 59 minutes, respectively. Mean operative difficulty, estimated on a 1-10 scale, was 3.4 and 5.6, respectively (p < 0.05). Mean postoperative analgesia requirements (number of doses of 10 mg morphine sulphate) were 5.8 and 4.0, respectively (p = 0.002). Mean duration of hospitalization was 4.7 and 3.0 days, respectively (p < 0.001). Mean "overall patient satisfaction," estimated on 1-10 scale, was 6 and 8.3, respectively (p = 0.002). We conclude that Minicholecystectomy offers less pain, earlier recovery, and better cosmetic results than the conventional "open" procedure. Published results of MC compare favorably with those of laparoscopic procedures. The implications of these results in the "laparoscopic era" are discussed.
Open management and "planned relaparotomies" in the treatment of critical abdominal infections have recently generated interest and hope. Most studies which examine the value of these therapeutic modalities are retrospective and include poorly stratified groups of patients. Since 1985, we have consistently applied these aggressive methods of treatment in all patients presenting with intra-abdominal infections belonging to the following groups: I) diffuse postoperative peritonitis (29 cases); II) diffuse fecal peritonitis (14 cases); and III) infected pancreatic necrosis (9 cases). The overall mortality rate was 44%; it was 55%, 14% and 56%, respectively, in the 3 groups. The abdomen was closed between reoperations in 21 patients who required an average of 1.7 relaparotomies; the mortality in this group was 24%. Thirty-one patients, who required an average of 3.8 relaparotomies, were managed with the open method resulting in a mortality of 58%. Multiple organ failure was the cause of death in 87% of the patients. We conclude that "planned relaparotomies" may have been beneficial in group II. The value of open management in patients belonging to groups I and III remains unproven. The mechanical-surgical answers to severe forms of peritonitis may have reached their limit.
We classify pancreatic pseudocysts in 3 types: post-necrotic type I, related to acute pancreatitis; post-necrotic type II, related to an acute attack superimposed on chronic pancreatitis; and retention type III, due to chronic pancreatitis with ductal stricture. A prospective study on percutaneous catheter drainage of post-necrotic pseudocysts (type I and II) was undertaken from 1987 to 1990. Twenty-three pseudocysts in 21 patients were drained. Overall recurrence rate was 4%; 2 patients had fistulization of the catheter into bowel; no deaths occurred. The procedure was successful in all type I cysts; in type II cysts it was associated with prolonged drainage and increased risk of complications when cyst-duct communication was present. Percutaneous drainage has no role to play in type III retention cysts. Guidelines regarding indications for treatment and the techniques employed are described.
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To assess the efficacy of cefotaxime in the treatment of severe intra-abdominal infections, we reviewed the bacteriology of secondary peritonitis and evaluated the efficacy of cefotaxime and metronidazole in 79 patients undergoing staged abdominal repair. We were able to demonstrate that the combination of an aggressive surgical policy with an effective antimicrobial regimen eliminates pathogens from the previously infected peritoneal cavity. Additional improvement in results awaits further advances in supportive care and/or methods to reverse the cascades of the excessive inflammatory or cytokine responses.
Feeding gastrostomy is a commonly performed procedure in North America. Our aim was to study the outcome of patients undergoing feeding gastrostomy to better define patients who will benefit from the procedure as opposed to those in whom it may be futile. A cohort of the most recent 100 consecutive patients undergoing feeding gastrostomy in a community teaching hospital was retrospectively studied. The main indication for gastrostomy was neurologic disorder interfering with eating/swallowing (group A-54 patients), followed by debilitating systemic disease (group B-26 patients) and obstructive malignancy of the head and neck or esophagus (group C-20 patients). Forty-one patients died within 30 days of the procedure (41%). The overall 30-day survival rates in groups A, B, and C were 70%, 15%, and 85%, respectively. In four patients death was caused by intraperitoneal leak from the gastrostomy site; the remaining patients died of their underlying disease. Five patients required reoperation for gastric leakage around the gastrostomy within 30 days. Only nine patients could be traced who were alive and still using the gastrostomy a year after its placement: two in group A, none in group B, and seven in group C. APACHE II scores at tube insertion also predicted survival; 30-day survival rates in patients with scores of 10 and below, 11 to 15, 16 to 20, and over 20 were 96%, 71%, 48%, and 18%, respectively. No patient with an APACHE score above 15 belonging to group B (debilitating disease) survived more than 30 days. We conclude that to have a beneficial therapeutic effect feeding gastrostomy should be performed selectively. Severe debilitating systemic conditions that interfere with normal eating, when combined with a high APACHE II score, indicate the futility of gastrostomy.
BACKGROUND: Adolescent health care in family practice at times creates conflicting responsibilities for parents and their teenagers. In the context of a new adolescent preventive health program in a family practice setting, we compared attendance rates using two invitation protocols, the protocols differing in their emphasis on adolescent autonomy vs parental responsibility. METHODS: One hundred six teenagers in the seventh and tenth grades were invited for preventive health visits with the family nurse and physician using two protocols. Protocol 1 involved obtaining parental consent before approaching the adolescent. With protocol 2, an invitation letter and parental consent form were mailed to the teenager, while a letter of explanation was sent concurrently to the parents. In each case, the letter of invitation was followed up by a telephone call for those who did not respond. The spontaneous response rate (a positive response after receiving the letter), agreement to attend rate (a positive response after receiving the letter or being telephoned), and the attendance rate were determined according to grade, sex, and protocol. RESULTS: The spontaneous response rate was 21%, the agreement to attend rate was 75%, and the attendance rate was 44%. Attendance rates were higher for the girls compared with the boys (54% vs 35%, P = .08) and for the seventh graders compared with the tenth graders (53% vs 31%, P = .03). The spontaneous response rate was lower among the tenth graders using protocol 2 (8% vs 37.5% with protocol 1, P = .04), while the agreement to attend rate and attendance rate did not differ for the two protocols. CONCLUSIONS: Nearly one half of this population of adolescents attended preventive health visits at the family nurse's and physician's initiative. A follow-up telephone call after the initial written invitation resulted in increased participation, while approaching the teenager or parent initially did not make a difference in attendance. This pilot study shows the potential for initiating an adolescent health program in the family practice setting.
BACKGROUND: Double gallbladder is a rare anomaly of the biliary tract. Double gallbladder arising from the left hepatic duct was previously reported only once in the literature. CASE REPORT: A case of symptomatic cholelithiasis in a double gallbladder, diagnosed on preoperative ultrasound, computed tomography (CT) and endoscopic retrograde cholangiopancreatogram (ERCP) is reported. At laparoscopic cholangiography via the accessory gallbladder no accessory cystic duct was visualized. After conversion to open cholecystectomy, the duplicated gallbladder was found to arise directly from the left hepatic duct; it was resected and the duct repaired. CONCLUSIONS: We emphasize that a careful intraoperative cholangiographic evaluation of the accessory gallbladder is mandatory in order to prevent inadvertent injury to bile ducts, since a large variety of ductal abnormality may exist.
We report a case of complete uterine prolapse that resulted in bilateral hydroureter, hydronephrosis, and renal dysfunction. The nonoperative reduction of the prolapse with a vaginal pessary reversed the obstructive uropathy and ameliorated renal function. The lower urinary tract should be imaged in patients with complete uterine prolapse. If present, obstructive uropathy should be relieved by the reduction of the prolapse before irreversible renal damage occurs.
Cardiac metastases are uncommon and difficult to diagnose clinically; thus, they are most often found only at autopsy. Here we present a case of isolated right atrial cardiac metastasis found 7 weeks after the resection of the primary tumor, which was an adenocarcinoma of the lung. The patient presented with intractable obstructive shock, caused by a ball-valve effect of the atrial lesion that prevented forward blood flow from the right atrium. Computed tomography (CT) scans and echocardiograms failed to detect the lesion, and the patient died 2 weeks later. An autopsy revealed a large, isolated right atrial metastatic adenocarcinoma.