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Biomedical subjects

S R Klein

Publications and source records attributed to S R Klein.

At least 37 records · Page 2Linked to original sources
PubMed1996

Comparative stress hormone changes during helium versus carbon dioxide laparoscopic cholecystectomy.

Laparoscopic surgery has been termed minimally invasive surgery by advocates of this technology. It has been demonstrated previously that using carbon dioxide for insufflation produces a respiratory acidosis due to transperitoneal absorption of gas. Insufflation with helium does not create this acidosis. We questioned whether laparoscopic surgery would elicit a stress response and whether the absence of acidosis with helium might prevent or reduce the levels of stress hormones. Sixteen female patients undergoing laparoscopic cholecystectomy were randomly assigned to helium (n = 8) or CO2 (n = 8) insufflation. Serum cortisol, epinephrine, and norepinephrine were measured preoperatively, after induction of anesthesia but before insufflation, at 45 min of surgery, and after desufflation. There were increases in epinephrine, norepinephrine, plasma cortisol, and urine cortisol at 45 min and at the conclusion of the procedure over the preoperative value. With ANOVA, each variable showed significant increases from preoperative values, at 45 min, and at the end of the case. Except for the increased epinephrine when helium was used, there were no significant differences in the other variables between helium and CO2. Laparoscopic cholecystectomy produces significant increases in stress hormone levels. Prevention of acidosis with helium insufflation does not appear to protect against increases in stress hormones. Epinephrine levels with helium insufflation are higher than with CO2, and elevations in stress hormones suggest that laparoscopic cholecystectomy is not physiologically minimally invasive.

Acidosis, Respiratory↗
PubMed1995

Laparoscopic inguinal herniorrhaphy in two stallions.

Two mature stallions that were used for breeding purposes were admitted for evaluation of inguinal hernias. In 1 horse, the hernia was reduced per rectum by gentle traction applied to the intestine. In the other horse, the hernia was reduced by placing the horse in dorsal recumbency and applying external pressure over the scrotum. Both horses were observed for recurrence of the hernia. Seven days later, an elective laparoscopic technique for inguinal herniorrhaphy was performed on each horse, using polypropylene mesh. Complications did not develop, and both horses have successfully completed 2 full breeding seasons. Laparoscopic inguinal herniorrhaphy allows preservation of the testis on the affected side and precludes many complications associated with open surgical techniques used on inguinal rings.

Animals↗
PubMed1995

Adverse consequences of increased intra-abdominal pressure on bowel tissue oxygen.

OBJECTIVE: Demonstrate the effect that increased intra-abdominal pressure (IAP) has on visceral oxygen delivery and bowel tissue oxygenation (TPO2). METHODS: Six Duroch swine underwent abdominal insufflation with helium to pressures of 15 and 25 mm Hg for 1 hour. Animals were instrumented with a pulmonary artery flotation catheter to measure cardiac output and calculate systemic oxygen delivery. Fluorescence quenching optodes were implanted in the terminal ileum and the subcutaneous tissue of an axillary fold to measure bowel and systemic (control) tissue oxygen levels, respectively. RESULTS: Bowel tissue oxygen fell from 43 +/- 12 mm Hg at baseline to 31 +/- 12 mm Hg, with 15 mm Hg of abdominal pressure at 60 minutes. With 25 mm Hg IAP, bowel TPO2 fell from 24 +/- 12 to 12 +/- 8 mm Hg (p < 0.02). No change in axillary TPO2 was observed during either period of increased IAP. Cardiac output (CO), systemic oxygen delivery, and mixed-venous oxygen saturation (Svo2) also declined, although blood pressure and oxygen consumption remained constant. CONCLUSIONS: Increased IAP produces significant decreases in bowel submucosal TPO2 without similar changes in extra-abdominal (subcutaneous) TPO2. This decline is dependent on the extent and duration of the elevation in IAP. Readily accessible parameters, such as CO and Svo2, also decline with increased IAP and may be useful variables to monitor as relative indicators of bowel hypoperfusion and TPO2.

Abdomen↗
PubMed1995

Scintimammography: the complementary role of Tc-99m sestamibi prone breast imaging for the diagnosis of breast carcinoma.

PURPOSE: To evaluate the complementary role of technetium-99m sestamibi scintimammography in improvement of the sensitivity and specificity of mammography in detection of carcinoma of the breast. MATERIALS AND METHODS: At 5 and 60 minutes after intravenous injection of Tc-99m sestamibi, scintimammograms were obtained in 147 women (age range, 18-73 years; mean age, 47.9 years +/- 10.2 [standard deviation]) with 153 lesions that warranted breast biopsy (102 lesions) or fine-needle aspiration cytologic analysis (51 lesions). There were 113 palpable and 40 nonpalpable lesions. Lesion size on mammograms was 0.8 x 0.6 cm to 15.0 x 11.0 cm (mean, 2.82 cm +/- 1.71 x 2.39 cm +/- 1.56). RESULTS: Scintimammographic findings were true-positive in 47 biopsy-confirmed carcinomas, true-negative in 91 benign lesions, false-positive in 11 lesions with benign histopathologic findings (fibrocystic disease [n = 8] or fibroadenoma [n = 3]), and false-negative in four lesions of infiltrating ductal carcinoma. The sensitivity of scintimammography was 92.2%; specificity, 89.2%; positive predictive value, 81.0%; and negative predictive value, 95.8%. CONCLUSION: The authors conclude that scintimammography is a sensitive test that can improve the detection of breast carcinoma.

Biopsy, Needle↗
PubMed1995

Controversies in the management of retroperitoneal hemorrhage associated with pelvic fractures.

Pelvic fractures present major therapeutic challenge requiring systematic diagnostic and management strategies. This article describes a 50-year-old female with a massive pelvic fracture after being crushed under the wheels of a bus. All aspects of her management are presented in detail. The current indications and role of exploratory laparotomy, internal and external fixation, and diagnostic and therapeutic angiography are discussed.

Fatal Outcome↗
PubMed1994

Triage by laparoscopy in patients with penetrating abdominal trauma.

Laparoscopy was performed on 33 patients with penetrating abdominal injuries to identify those with peritoneal penetration. Diagnostic or therapeutic manoeuvres were not attempted; evidence of peritoneal penetration mandated exploratory laparotomy. Twenty-two patients had gunshot wounds and 11 stab wounds. Ten patients had multiple penetrating injuries. Intraperitoneal injury was not evident by clinical assessment in any patient and all were haemodynamically stable. Twenty-three patients underwent negative laparoscopy and no intraperitoneal injury was subsequently detected. Laparoscopy demonstrated peritoneal penetration in ten patients and subsequent laparotomy detected intraperitoneal injuries in nine. No complications of laparoscopy occurred. In stable patients with penetrating trauma and no clinical evidence of intraperitoneal injury, laparoscopy effectively and safely detects those with peritoneal penetration.

Abdominal Injuries↗
PubMed1994

Balloon dissection facilitated laparoscopic extraperitoneal hernioplasty.

BACKGROUND: With the goals of minimizing perioperative morbidity and obtaining direct inguinal access without transgressing the peritoneal cavity, we developed a balloon dissection device to facilitate laparoscopic extraperitoneal hernioplasty. PATIENTS AND METHODS: We have performed balloon facilitated dissection on 113 patients (105 males) on an outpatient basis. Some patients were repaired under regional anesthesia. A total of 150 hernias have been repaired: 72 indirect, 70 direct, 3 scrotal, 2 sliding, 2 spigelian, and 1 femoral. RESULTS: Mean operating time was 60 minutes. All patients were ambulatory on discharge. Half reported minimal or no immediate postoperative pain. Over 80% had only minimal irritation or discomfort on the third postoperative day. Nearly 60% returned to work within 2 weeks. None required hospital readmission for an immediate complication of hernioplasty. With a mean follow-up of 6.3 months, only three recurrences are reported. Except for one persistent neuropathy which resolved after staple removal, there were no significant complications. CONCLUSIONS: We conclude that balloon dissection facilitates laparoscopic extraperitoneal hernioplasty and obviates the need for general anesthesia. Our approach minimizes perioperative pain. It can be done on an outpatient basis and permits prompt return to full activity including physical work.

Adult↗
PubMed1994

Contemporary management strategy for major inferior vena caval injuries.

Injuries of the inferior vena cava (IVC) require prompt and definitive action. To evaluate our current management strategy, we reviewed 38 patients with IVC trauma treated from 1983 through 1990. Sixteen were injured by gunshots, eight by stabs, and 14 by blunt mechanisms. Thirty of the 38 survived (79%). All were awake on presentation, although 45% were hypotensive (systolic blood pressure < 90 mmHg). The mean Injury Severity Score was 27. At laparotomy all demonstrated active retroperitoneal bleeding or an expanding hematoma. The caval injury was retrohepatic in 12 (three involving the hepatic veins), suprarenal in seven, pararenal in nine, and infrarenal in ten. Among the eight deaths, five had retrohepatic injuries, two pararenal injuries, and one had an infrarenal injury. Surgical repair was accomplished in 33, 26 (79%) via lateral venorrhaphy and seven via polytetrafluoroethylene patch repair. The right chest was entered with diaphragmatic division in 8 of 12 cases with retrohepatic injuries. Two atrial-caval shunts were used and both patients survived. Twenty follow-up studies (at > or = 3 months) were performed in which three patients demonstrated IVC occlusion, and one had a Budd-Chiari-like syndrome. We conclude that inferior vena caval injury remains a highly lethal injury. Successful outcome depends on prompt volume restoration, a stratified selective management approach, and avoidance of hypothermia. Prosthetic vena caval reconstruction represents an acceptable alternative.

Adolescent↗
PubMed1994

Acute fatty liver of pregnancy: laparoscopy-assisted diagnosis.

We report a case of fatty infiltration of the liver in a 27-year-old Hispanic woman. She went to an outside hospital in her third trimester of pregnancy with abdominal pain, jaundice, peripheral edema, and diffuse intravascular coagulation. An emergent cesarean section was performed, and she developed symptoms of acute hemorrhagic pancreatitis and altered mental status. She was transferred to Harbor County Hospital, where a computed tomography scan showed a fatty liver, and a liver biopsy confirmed the diagnosis of fatty liver of pregnancy. Prompt recognition and immediate termination of pregnancy with intensive, supportive care are essentials in the management of fatty liver of pregnancy.

Acute Disease↗
PubMed1993

Tissue oxygenation in hypovolemic shock.

Bowel mucosal ischemia may be related to the development of systemic sepsis. Traditional indices of oxygen metabolism are flow-weighted averages which do not reflect tissue-specific oxygen concentration. We undertook this study to examine the relationship between systemic oxygen delivery (DO2) and tissue oxygen tension (TPO2) in hypovolemic shock. A modified Wiggers model was used to produce hypotension in five swine. TPO2 was measured continuously with fluorescence-quenching 1-mm probes placed in the submucosa of the terminal ileum and subcutaneously in an axillary fold. Shock was maintained for 1 hr, followed by resuscitation. Cardiac output, systemic and pulmonary arterial pressures, and arterial and mixed venous blood gases were measured every 15 min. Data were analyzed by nonparametric ANOVA and rank coefficients, with logarithmic curve fitting and linear regression. DO2 decreased with phlebotomy (P < 0.003) as did skin TPO2 (P < 0.001) and bowel TPO2 (P < 0.0004). Skin and bowel TPO2 varied with DO2 and each other (P < 0.05). TPO2 remained low throughout the shock period and returned to or exceeded baseline levels with resuscitation (P < 0.05). The following were concluded: (1) Hypovolemic shock produces a significant and rapid decrease in subcutaneous and bowel TPO2 with concomitant change in DO2. (2) The degree of bowel ischemia, clinically inaccessible for quantitation, is paralleled by subcutaneous TPO2. (3) TPO2 provides information about oxygen availability in shock and resuscitation not available from traditional parameters of oxygen transport.

Animals↗
PubMed1993

Omphalocaval shunt: an alternative procedure for portal decompression.

We report a case in which umbilical vein was used to construct an omphalocaval shunt in a patient with a long history of alcoholic liver disease and recurrent esophageal and gastric variceal bleeding episodes. The indication for the choice of this procedure included the presence of dense adhesions in the porta hepatis, arteriographic documentation of continuity with the portal venous system, and an umbilical vein 12 mm in internal diameter. The hypertensive portal system was successfully decompressed and proved patent 6 months postoperatively.

Adult↗
PubMed1992

Laparoscopic occlusion of testicular veins for clinical varicocele.

Surgery via the laparoscope is now a reliable and cost-effective alternative to some open surgical procedures. Advances in videoendoscopy, incorporating optical magnification combined with the development of instruments with which to dissect, ligate, and transect blood vessels provide the urologist the opportunity to surgically correct a varicocele. In the outpatient setting, 4 patients (14-26 years of age) underwent laparoscopic ligation of the left internal spermatic veins for painful left varicocele. Carbon dioxide pneumoperitoneum was obtained using a Veress needle. A 10-mm laparoscope was placed intraperitoneally through a cannula inserted in the infraumbilical border. Utilizing two additional endosurgical ports (5 mm and 10 mm) through which 5-mm dissecting instruments and vaso-occlusive endoclips were placed, three veins were individually isolated and ligated in each of the 4 patients. In all 4 patients, the left testicular artery was visualized and preserved. There was no blood loss or other intraoperative complication. In each patient the varicocele was successfully corrected. Analgesic medication was not required postoperatively. We conclude that laparoscopic ligation of the internal spermatic veins is a safe and effective way of treating a varicocele without immediate postoperative sequelae. Long-term follow-up is necessary to determine the place of the endoscopic approach.

Adolescent↗
PubMed1992

Contemporary management of amebic liver abscess.

In a retrospective review covering 16 years divided into two time periods, 133 patients with amebic liver abscess were evaluated. Most of the patients were young, Hispanic men, and one-third had coexistent disease. A reliable diagnosis can be established in 24 hours using ultrasound or computed tomography scans. Over the entire time period, antiparasitic therapy was evolved to occupy a primary role and surgery was reserved for management of abscess complications.

Academic Medical Centers↗