Laparoscopic cholecystectomy for acute cholecystitis: can the need for conversion and the probability of complications be predicted? A prospective study

BACKGROUND

Laparoscopic cholecystectomy (LC) in acute cholecystitis is associated with a relatively high rate of conversion to an open procedure as well as a high rate of complications. The aim of this study was to analyze prospectively whether the need to convert and the probability of complications is predictable.

METHODS

A total of 215 patients undergoing LC for acute cholecystitis were studied prospectively by analyzing the data accumulated in the process of investigation and treatment. Factors associated with conversion and complications were assessed to determine their predictive power.

RESULTS

Conversion was indicated in 44 patients (20.5%), and complications occurred in 36 patients (17%). Male gender and age >60 years were associated with conversion, but these factors had no sensitivity and no positive predictive value. The same factors, together with a disease duration of >96 h, a nonpalpable gallbladder, a white blood count (WBC) of >18,000/cc(3), and advanced cholecystitis, predicted conversion with a sensitivity of 74%, a specificity of 86%, a positive predictive value of approximately 40%, and a negative predictive value of 96%. However, these data became available only when LC was underway. Male gender and a temperature of >38 degrees C were associated with complications, but these factors had no sensitivity and no positive predictive value. Progression along the stages of admission and therapy did not add predictive factors or improve the predictive characteristics. Male gender, abdominal scar, bilirubin >1 mg%, advanced cholecystitis, and conversion to open cholecystectomy were associated with infectious complications. Their sensitivity and positive predictive value remained 0 despite progression along the stages of admission and therapy.

CONCLUSION

Although certain preoperative factors are associated with the need to convert a LC for acute cholecystitis, they have limited predictive power. Factors with higher predictive power are obtained only during LC. The need to convert can only be established during an attempt at LC. Preoperative and operative factors associated with total and infectious complications have no predictive power.

Laparoscopic cholecystectomy for acute cholecystitis: how do fever and leucocytosis relate to conversion and complications?

OBJECTIVE

To find out whether fever and raised white cell count (WCC) are associated with conversion and complications of laparoscopic cholecystectomy in acute cholecystitis, and whether their presence could help in deciding the place of laparoscopic procedures.

DESIGN

Prospective study.

SETTING

Teaching hospital, Israel.

SUBJECTS

256 patients who were treated for clinical acute cholecystitis between January 1994 and November 1997.

INTERVENTIONS

Emergency laparoscopic cholecystectomy.

MAIN OUTCOME MEASURES

Raised temperature and WCC; incidence of conversion and complications.

RESULTS

Raised temperature (>38 degrees C) was independently associated with advanced cholecystitis (p = 0.002, odds ratio [OR] 2.7) and a palpable gallbladder preoperatively (p = 0.02, OR 2.1). Total complications correlated with a temperature of >38 degrees C. Raised WCC (>15 x 10(9)/L) was independently associated with age >45 years (p = 0.02, OR 2.4), a palpable gallbladder preoperatively (p = 0.001, OR 2.9), and a raised temperature (>38 degrees C) (p < 0.0001, OR 6.2). Conversion was associated with a WCC >18 x 10(9)/L (p = 0.0, OR 3.2).

CONCLUSION

A WCC of >18 x 10(9)/L may assist in predicting conversion, and fever of >38 degrees C may assist in predicting the development of complications.

The impact of patient delay and physician delay on the outcome of laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

Laparoscopic cholecystectomy is now used in the management of acute cholecystitis. Under these circumstances unfavorable conditions may result in conversion and complications. Information about these conditions may help in planning the laparoscopic approach or in proceeding directly to open cholecystectomy. This study was initiated to evaluate perioperative factors associated with conversion and complications of laparoscopic cholecystectomy in acute cholecystitis. Special attention was paid to the duration of complaints until surgery, to the delay on the part of the patient, and to the delay on the part of the physician.

METHODS

Between January 1994 and December 1997, we attempted to perform laparoscopic cholecystectomy on 348 patients with acute cholecystitis. All perioperative data were collected on standardized forms.

RESULTS

There were 182 cases (52%) of acute uncomplicated cholecystitis, 90 (26%) of gangrenous cholecystitis, 33 of hydrops (9.5%), and 43 of empyema of the gallbladder (12.5%). Seventy six patients (22%) needed conversion to open cholecystectomy and complications occurred in 57 cases. Advanced cholecystitis was associated with significant patient delay (P = 0.01), and it had a significantly higher conversion rate (39%) compared with early cholecystitis (14.5%); (P <0.00001). Conversion rates were also associated with male gender (P = 0.0017), a history of biliary disease (P = 0.0085), and a patient delay of >48 hours (P = 0.028). The total and infectious complication rates were associated with an age older than 60 years (P = 0.023 and 0.007, respectively) and male gender (P = 0.026 and 0.014, respectively).

CONCLUSIONS

In acute cholecystitis, patient delay is associated with a high conversion rate. Early timing of laparoscopic cholecystectomy tends to reduce the conversion rate, as well as the total and the infectious complication rates. Male gender, a history of biliary disease, and advanced cholecystitis are associated with conversion. Male and older patients are associated with a high total and infectious complication rates.

Intron variants of the p53 gene are associated with increased risk for ovarian cancer but not in carriers of BRCA1 or BRCA2 germline mutations

Two biallelic polymorphisms in introns 3 and 6 of the p53 gene were analysed for a possible risk-modifying effect for ovarian cancer. Germline DNA was genotyped from 310 German Caucasian ovarian cancer patients and 364 healthy controls. We also typed 124 affected and 276 unaffected female carriers with known deleterious BRCA1 or BRCA2 germline mutation from high-risk breast-ovarian cancer families. Genotyping was based on PCR and high-resolution gel electrophoresis. German ovarian cancer patients who carried the rare allele of the MspI restriction fragment length polymorphism (RELP) in intron 6 were found to have an overall 1.93-fold increased risk (95% confidence internal (CI) 1.27-2.91) which further increased with the age at diagnosis of 41-60 years (odds ratio (OR) 2.71, 95% CI 1.10-6.71 for 41-50 and OR 2.44, 95% CI 1.12-5.28 for 51-60). The 16 bp duplication polymorphism in intron 3 was in a strong linkage to the MspI RFLP. In BRCA1 or BRCA2 mutation carriers, no difference in allele frequency was observed for carriers affected or unaffected with ovarian cancer. Our data suggest that intronic polymorphisms of the p53 gene modify the risk for ovarian cancer patients but not in carriers with BRCA1 or BRCA2 mutations.

The value of histomorphometric nuclear parameters in the diagnosis of well differentiated follicular carcinomas and follicular adenomas of the thyroid gland

AIMS

To explore the potential of histomorphometric analysis in distinction between follicular adenomas and well differentiated follicular carcinomas of the thyroid gland. Their differentiation on routine histological study may be a challenging exercise, being contingent upon the absence or presence of vascular invasion and penetration of neoplastic follicles through the capsule of the tumour.

METHODS AND RESULTS

Computer-assisted image analysis was performed to gauge the nuclear area, nuclear Ferret diameter, nuclear regularity factor, nuclear elongation factor, number of nuclear vesicles and total area of all nuclear vesicles in the follicles of 37 adenomas and 36 well differentiated carcinomas. By univariate analysis, these nuclear descriptors (with the exception of the elongation factor) were found to correlate with the benign or malignant nature of the tumours. By multivariate analysis, only the nuclear area, Ferret diameter and regularity factor were ascertained to be significant predictors of malignancy. A fitted logit model correctly predicted 91% of the cancers and 87% of the adenomas.

CONCLUSIONS

Histomorphometrically gauged nuclear parameters of the tumour cells may reinforce pathologists' decision-making by adding objective and unbiased criteria to their subjective assessment of follicular neoplasms in cases in which vascular or capsular invasion are not detected.

Etiology and pathophysiology of primary and recurrent groin hernia formation

The cause of primary groin hernia is multifactorial with evolutionary, hereditary, congenital, environmental aspects, and the general state of health all playing their part. Besides maintaining general body fitness and not smoking tobacco, there is little one can do to avoid this common affliction. On the other hand, recurrent groin hernia is largely due to easily controllable human factors and can be avoided by choosing an experienced surgeon with a particular interest and understanding of the subject, preferably one who specializes in and confines himself to the surgery of groin hernias, working in a unit dedicated to herniology he will select the best operation for the particular type of hernia and execute it to conform to the highest acceptable standards, using the best materials and techniques. The patient will rapidly, within a matter of days, return to his full, normal activities and can look forward to a success rate of over 99%.

No association of the I1307K APC allele with ovarian cancer risk in Ashkenazi Jews

Familial adenomatous polyposis is a dominantly inherited colon cancer syndrome associated with germ-line mutations in the APC tumor suppressor gene. An APC gene sequence alteration, the I1307K allele, occurs in 6% of the Ashkenazi Jewish population and is reported to double the risk for colorectal cancer. We screened a population of 190 Ashkenazi women who were diagnosed with epithelial ovarian carcinoma for the I1307K variant and measured the effect of this allele on the risk for cancer development in their first-degree relatives. We identified the I1307K allele in 7.9% (15 of 190) of our ovarian cancer cases. The average age of ovarian cancer diagnosis in carriers of the I1307K allele (57.5 years) was not statistically different than the age for noncarriers (56.4 years; P = 0.70). Among the 1087 first-degree relatives, there were 23 cases of colorectal cancer; 3 of 100 relatives of probands with the I1307K allele (3.0%) had a history of colorectal cancer versus 20 of 987 relatives of probands without the I1307K allele (2.1%; relative risk, 1.48; 95% confidence interval, 0.45-4.88; P = 0.462). Relatives of the I1307K carriers had a risk of 38.0% for developing any cancer to age 80, similar to the risk for relatives of noncarriers of the I1307K allele (42.1%; P = 0.86). The average age of diagnosis of cancer of any type was not different between relatives of carriers (59.0 years) and noncarriers (60.4 years). In the Ashkenazi Jewish population, the I1307K allele is unlikely to increase the risk of ovarian cancer or of cancer in general.

Laparoscopic cholecystectomy for acute cholecystitis and the consequences of gallbladder perforation, bile spillage, and "loss" of stones

OBJECTIVE

To study the factors associated with accidental perforation of the gallbladder and spillage of bile and stones and to assess the consequences of these mishaps.

DESIGN

Prospective study with retrospective bacteriological evaluation.

SETTING

Teaching hospital, Israel.

SUBJECTS

189 Patients who were treated for clinical acute cholecystitis between January 1994 and August 1996.

INTERVENTIONS

Emergency laparoscopic cholecystectomy.

MAIN OUTCOME MEASURES

Incidence of accidental perforation of gallbladder and spillage of bile and stones and of conversion and complications in relation to preoperative and operative findings.

RESULTS

Bile was spilt in 65 (34%) and gall-stones were "lost" in 27 (14%), 44 (23%) required conversion to an open approach and 36 (19%) developed complications. Preoperative duration of symptoms >96 hours and a palpable gallbladder were associated with accidental perforation of the gallbladder and spillage of bile. A palpable gallbladder, gangrenous cholecystitis, and WBC > 15 x 10(9)/L were associated with stones "lost" in the peritoneum. A history of biliary disease was inversely related to "lost" stones. Conversion of laparoscopic to open cholecystectomy was associated with male sex, age >60 years, a non-palpable gallbladder, WBC > 15 x 10(9)/L, and a gangrenous gallbladder. Complications of surgery were more common among men and associated with fever of >38 degrees C. Neither the conversion nor the complications were associated with perforation of the gallbladder or "lost" stones.

CONCLUSION

Perforation of the gallbladder and intraperitoneal spillage of bile or stones during laparoscopic cholecystectomy for acute cholecystitis are not associated with undesirable events, are not indications for conversion, and are not associated with further complications. When patients are given appropriate antibiotics perioperatively and the spilt bile is properly aspirated and the peritoneum irrigated, the operative and postoperative courses are similar to those of patients with unperforated gallbladder.

Laparoscopic cholecystectomy for the various types of gallbladder inflammation: a prospective trial

Laparoscopic cholecystectomy (LC), the procedure of choice for elective cholelithiasis, is now also used in the management of acute cholecystitis. In the various types of gallbladder disease, favorable and unfavorable conditions may influence the conversion and complication rates. Information about these conditions may help elucidate the optimal circumstances for LC or indicate when the procedure is best avoided. We attempted to perform emergency LC on 215 patients with acute cholecystitis. The procedure was successful in 171 patients (79.5%), and conversion to open cholecystectomy (OC) was needed in 44 (20.5%). Complications occurred in 37 patients (17%). Uncomplicated acute cholecystitis was associated with age <50 years, duration of complaint <48 h, temperature <38.5 degrees C, a nonpalpable gallbladder, and an alkaline phosphatase >100 U/L. Acute gangrenous cholecystitis was associated with a negative gallbladder history, other associated diseases, temperature >38.5 degrees C, a palpable gallbladder, and serum bilirubin levels <1 mg/dl. Hydrops was associated with a temperature <38 degrees C and a leukocyte count of >12,000/cc3, and empyema of the gallbladder was associated with duration of complaint >48 h and a palpable gallbladder. The conversion rate of acute gangrenous cholecystitis (40%) was significantly higher than that of uncomplicated acute cholecystitis (8%) (p < 0.00001, odds ratio=7.7), as well as that of empyema of the gallbladder (12.5%) (p=0.005, odds ratio=4.7). The conversion from LC to OC in uncomplicated acute cholecystitis was associated with male sex and with duration of complaint >24 h, and in gangrenous cholecystitis with age >60 years, a nonpalpable gallbladder, and a leukocyte count of >15,000/cc3. The complication rates of acute cholecystitis, hydrops, empyema of the gallbladder, and gangrenous cholecystitis were 16%, 7%, 22%, and 21%, respectively (p = NS). The total complication rate in acute cholecystitis tended to be associated with a duration of complaint >48 h and in gangrenous cholecystitis with male sex, age >60 years, other associated disease, larger bile stones, and elevated serum bilirubin levels. Generally, LC is safe in all forms of cholecystitis, with acceptably low conversion and complication rates, excluding gangrenous cholecystitis. In gangrenous cholecystitis, a conversion rate of approximately 40% is expected. Predictors of conversion and complications may be particularly helpful in planning the laparoscopic approach to acute gangrenous cholecystitis. Patients >60 years of age, with a nonpalpable gallbladder and with a leukocyte count >15,000/cc3, frequently need conversion. In men >60 years old, with other associated disease, with larger bile stones, and with elevated serum bilirubin levels, complications are frequently expected. Under these conditions, laparoscopic approach should be undertaken by especially experienced teams, or OC should be considered.

Effect of smoking on breast cancer in carriers of mutant BRCA1 or BRCA2 genes

BACKGROUND

Smoking has carcinogenic effects, and possibly antiestrogenic effects as well, but it has not been found to be a risk factor for breast cancer in women in the general population. However, hereditary breast cancer is primarily a disease of premenopausal women, and interactions between genes and hormonal and environmental risk factors may be particularly important in this subgroup.

METHODS

We conducted a matched case-control study of breast cancer among women who have been identified to be carriers of a deleterious mutation in either the BRCA1 or the BRCA2 gene. These women were assessed for genetic risk at one of several genetic counseling programs for cancer in North America. Information about lifetime smoking history was derived from a questionnaire routinely administered to women who were found to carry a mutation in either gene. Smoking histories of case subjects with breast cancer and age-matched healthy control subjects were compared. Odds ratios for developing breast cancer were determined for smokers versus nonsmokers by use of conditional logistic regression for matched sets after adjustment for other known risk factors.

RESULTS

Subjects with BRCA1 or BRCA2 gene mutations and breast cancer were significantly more likely to have been nonsmokers than were subjects with mutations and without breast cancer (two-sided P = .007). In a multivariate analysis, subjects with BRCA1 or BRCA2 mutations who had smoked cigarettes for more than 4 pack-years (i.e., number of packs per day multiplied by the number of years of smoking) were found to have a lower breast cancer risk (odds ratio = 0.46, 95% confidence interval = 0.27-0.80; two-sided P = .006) than subjects with mutations who never smoked.

CONCLUSIONS

This study raises the possibility that smoking reduces the risk of breast cancer in carriers of BRCA1 or BRCA2 gene mutations.

Laparoscopic versus open cholecystectomy in acute cholecystitis

Elective laparoscopic cholecystectomy is established as the treatment of choice for symptomatic cholecystolithiasis and is now proposed for the treatment of acute cholecystitis. We initiated the present study in order to clarify the question of safety of the procedure in the presence of an inflamed gallbladder, and to compare the results with those of a traditionally treated group with acute cholecystitis. We compared the preoperative, operative, and postoperative courses of 146 patients with acute cholecystitis, managed laparoscopically between 1994 and 1996, with those of 97 patients, treated traditionally by open cholecystectomy for the same diagnosis between 1992 and 1993. In the acute cholecystitis cases, when laparoscopic cholecystectomy was successfully performed, the operative and postoperative courses were superior to those of open cholecystectomy. The use of drains and NG tubes, the need for antibiotics and analgesia, the associated morbidity, and the hospital stay were significantly reduced. Following conversion, the postoperative course was similar to that of open cholecystectomy. Of the group of acute cholecystitis cases laparoscopically approached 39 (27%) needed conversion. Twenty-five complications occurred in 24 (16.5%) patients of the laparoscopic group, whereas 30 complications occurred in 25 (26%) patients of the traditionally operated group. Male sex, older patients, and larger bile stones were found to be associated with a higher conversion rate as well as a higher complication rate. A nonpalpable gallbladder and gangrenous cholecystitis were associated with conversion while fever was associated with complications. Laparoscopic cholecystectomy can be performed safely in selected cases of acute cholecystitis, with acceptable conversion and low complication rates. When laparoscopic cholecystectomy is successfully performed, the operative and postoperative courses are superior to those of open cholecystectomy. Following conversion, the postoperative course is similar to that of open cholecystectomy. According to this study, male sex, older age, large bile stones, a nonpalpable gallbladder, and gangrenous cholecystitis may be regarded as predictors of conversion, while male sex, older age, large bile stones, and fever may be regarded as predictors of complications. The timing of laparoscopic cholecystectomy should be within 96 h from onset of the inflammation.

Does the index operation influence the course and outcome of adhesive intestinal obstruction?

OBJECTIVE

To ascertain the incidence of obstruction after various operations and find out if the index operation influenced the course and outcome of adhesive small bowel obstruction.

DESIGN

Retrospective study.

SETTING

Teaching hospital, Israel.

SUBJECTS

190 of 248 patients who presented with small bowel obstruction between January 1980 and December 1994.

INTERVENTIONS

All patients were treated conservatively and operated on only if they did not improve or deteriorated.

MAIN OUTCOME MEASURES

Incidence of obstruction depending on site of index operation, and response to treatment.

RESULTS

46 Patients (24%) had undergone upper abdominal operations, 26 (14%) small bowel resection, 47 (25%) appendicectomy, 27 (14%) gynaecological operations, and 44 (23%) colonic resections. The annual incidence of obstructive complications among the 190 patients in the groups studied was highest after appendicectomy (3.1/year) and colonic resections (2.9/year) and lowest after operations on the gallbladder and pancreas (1.1/year). Postoperative adhesive obstruction presented earlier after operations on the small bowel (median 1 year, range 5.4-20) and colon (median 1 year, range 2.2-40) than after the other operations. 60 (32%) of patients with acute small bowel obstruction had a history of abdominal malignancy, and obstruction was more likely to be complete after small bowel resection (20/26, 77%) compared with 39/74 (53%) after appendicectomy or gynaecological surgery, 17/46 (37%) after upper abdominal surgery, and 15/44 (34%) after colonic resection. Patients who developed obstruction after colonic resection had the longest period of conservative treatment (median 60 hours, range 24-216) and had the highest morbidity (8/44, 18%) although only 2 required bowel resection. Two patients died, both after obstruction following upper abdominal operations.

CONCLUSIONS

Patients who present with obstruction after small bowel resection are extremely likely to be completely obstructed. Perhaps the morbidity associated with obstruction after colonic resection could be reduced if patients were operated on earlier.

Laparoscopic cholecystectomy for acute cholecystitis: prospective trial

This prospective study determines the indications for and the optimal timing of laparoscopic cholecystectomy (LC) following the onset of acute cholecystitis. It also evaluates preoperative and operative factors associated with conversion from laparoscopic cholecystectomy to open cholecystectomy in the presence of acute cholecystitis. Having been established as the procedure of choice for elective cholelithiasis, LC is now also used for management of acute cholecystitis. Under these circumstances the procedure may be difficult and challenging. Certain favorable and unfavorable conditions may be present that influence the conversion and complication rates. Information about these conditions may be helpful for elucidating the optimal circumstances for LC or when the procedure is best avoided. We performed LC on an emergency basis as soon as the diagnosis was made on all patients presenting with acute cholecystitis from January 1994 to December 1995. All preoperative, operative, and postoperative data were collected on standardized forms. Of the 137 patients registered, 130 were eligible for the audit. Seven patients found by laparoscopic intraoperative cholangiography to have choledocholithiasis were converted for common bile duct exploration and were excluded from the study. Altogether 83 patients (72%) underwent successful LC and 37 (28%) needed conversion to open cholecystectomy. The conversion rate of acute gangrenous cholecystitis (49%) was significantly higher than that for uncomplicated acute cholecystitis (4.5%) (p < 0.00001) and for hydrops (28.5%) and empyema of the gallbladder (28.5%) (p = 0.004). The difference in conversion between the group with acute necrotizing (gangrenous) cholecystitis and the two groups with hydrops and empyema of the gallbladder was not statistically significant (p = 0.07). The complication rates of acute cholecystitis, hydrops, empyema of the gallbladder, and gangrenous cholecystitis were 9.0%, 9.5%, 14.0%, and 20.0%, respectively (p = NS). Patients with an operative delay of 96 hours or less from the onset of acute cholecystitis had a conversion rate of 23%, whereas a delay of more than 96 hours was associated with a conversion rate of 47% (p = 0.022). The complication rate was 8.5% in the laparoscopic group and 27% in the converted group (p = 0.013). Patients over 65 years of age, with a history of biliary disease, a nonpalpable gallbladder, WBC count over 13,000/cc, and acute gangrenous cholecystitis were independently associated with a high LC conversion rate; male patients, finding large bile stones, serum bilirubin over 0.8 mg/dl, and WBC count over 13,000/cc were independently associated with a high complication rate following laparoscopic surgery with or without conversion. Generally, LC can be performed safely for acute cholecystitis, with acceptably low conversion and complication rates. Different forms of cholecystitis carry various conversion and complication rates in selected cases. LC for acute cholecystitis should be performed within 96 hours of the onset of disease. Predictors of conversion and complications may be helpful when planning the laparoscopic approach to acute cholecystitis.

Delay of surgery in acute appendicitis

BACKGROUND AND OBJECTIVES

It is generally assumed that delayed diagnosis of acute appendicitis results in higher morbidity but this assumption is not strongly supported in the literature. We attempt to define the effect of patient and physician delay on the outcome of patients with acute appendicitis.

PATIENTS AND METHODS

We studied 486 patients admitted between 1980 and 1992. Patient delay in presenting to a physician and surgeon delay from hospital admission to operation were studied in relation to stage of disease at operation as well as to postoperative complications.

RESULTS

Postoperative complications occurred in 10% of cases with simple acute appendicitis versus about 20% of cases with gangrenous or perforated appendicitis (P <0.001). The mean patient delay from onset of symptoms to presentation to a physician was 1.7 days in simple acute appendicitis versus 2.3 days in gangrenous or perforated appendicitis (P <0.001). Mean surgeon delay was 13.6 hours in simple acute appendicitis versus 14.5 hours in advanced appendicitis (P = NS).

CONCLUSION

Delay in patient presentation adversely affects the stage of disease in acute appendicitis and leads to increased incidence of infectious complications and to prolonged hospital stay. Conversely, physician delay does not affect the stage of disease. A surgeon's decision to observe patients in hospital in order to clarify the diagnosis is justified, as it does not adversely affect outcome.

Sclerosing encapsulating peritonitis

Sclerosing encapsulating peritonitis (SEP), idiopathic or secondary, is a form of intraperitoneal fibrosclerosis that causes intestinal obstruction. In the case of a 41-year-old man with dialysis-induced SEP presented here, we show that intraperitoneal hemorrhage may play an important pathogenetic role and that the process may develop in < or = 12 weeks. Regardless of cause, the treatment of obstruction is operative, with dissection of the encasing membrane from the intestine and separation of adherent loops of small bowel until they are laid free and returned to their normal configuration. The prognosis after appropriate operative therapy is good but depends on coexisting diseases.

The menstrual cycle and acute appendicitis

OBJECTIVE

To examine the influence of the menstrual cycle on the incidence and presentation of acute appendicitis.

DESIGN

Retrospective study.

SETTING

University hospital, Israel.

SUBJECTS

144 women of child bearing age operated on for suspected acute appendicitis and subdivided according to the menstrual phase during which they presented.

MAIN OUTCOME MEASURES

The final diagnoses, clinical presentation, and laboratory data.

RESULTS

There were no significant differences in the incidence of acute, gangrenous, or perforated appendicitis in patients operated on during the various phases of the menstrual cycle. During menstruation, however, a normal appendix not accompanied by other disease was found significantly more often (p = 0.04). Clinical presentation, physical findings, and laboratory results did not vary throughout the menstrual cycle except for the "classic shifting pain" which was significantly more common during the luteal phase.

CONCLUSIONS

Acute appendicitis occurs randomly during the various phases of the menstrual cycle. The incidence of operations for uninflamed appendixes may be higher during the menstrual phase. Significantly more negative laparotomies are done during the menstrual phase, which suggests the existence of a functional disorder that mimics acute appendicitis.

Secondary hyperparathyroidism and nonmedullary thyroid cancer

Nonmedullary thyroid carcinoma is known to occur in association with primary hyperparathyroidism. A combination of secondary, uremic, hyperparathyroidism and non-medullary thyroid carcinoma is rare and was hitherto reported in only 12 cases. We report another three patients with this parathyroid/thyroid disease combination, suggesting that it may represent not merely a coincidence. A number of factors active in secondary hyperparathyroidism may play a role in the induction and/or promotion of the thyroid cancer. These include parathyroid endocrinopathy, goiterogenic effect of prolonged hypercalcemia, and uremia. During surgery on the parathyroid glands, associated thyroid lesions demand special considerations.

Arterial occlusive disease in occult cancer

Thromboembolism frequently complicates advanced cancer. The incidence of TE as one of the initial manifestations of occult cancer and the diagnostic value of TE as a signal of a possible unrecognized tumor were the subjects of recent studies. TE may precede the diagnosis of cancer by several months or years. The polymorphism of manifestations of paraneoplastic TE has been described previously. An accelerated course of intermittent claudication and of ischemic heart disease has been described in patients with cancer and probably represents additional variants of Trousseau's syndrome. Recently, clues for the presence of occult neoplasms in patients with TE have been proposed. Their value in the stratification of patients needs to be established in prospective studies. That cancer may be responsible for a precipitated course of coronary or peripheral arterial disease raises the question of whether work-up is recommended to uncover a silent malignancy in a patient who has been referred for treatment of these severe ischemic syndromes.

Psoas abscess: case report and review of the literature

Psoas muscle abscess is rare and presents a diagnostic challenge requiring a high index of suspicion. We report an unusual case of primary psoas abscess caused by Proteus mirabilis. Primary psoas abscess is most commonly present in children and is usually caused by Staphylococcus aureus. A total of 434 cases of psoas abscess has been reported. The subject is discussed noting the differences between primary and secondary cases, and emphasizing the importance of ultrasound and computerized tomography guided drainage of psoas abscess. A flow chart for the evaluation and management of primary and secondary abscess is presented, taking into consideration the success rate of the various methods of treatment described in the literature.

Ischemic heart disease precipitated by occult cancer

The hypothesis was tested that cancer, by virtue of it being a thrombotic diathesis, may enhance ischemic heart disease. Because cancer therapy may precipitate thromboembolism, the authors focused on patients with occult neoplasia before therapy. Occult cancer was defined as a time period of 2 years before a cancer diagnosis was established. Data obtained from the files of patients with the diagnosis of malignant tumors and admitted to a general hospital during a 3-year period were reviewed for coronary risk factors, coronary events, and characteristics of cancer. Indices of coronary instability were studied: the incidence of first coronary events, the incidence of all coronary events, and the coronary events burden. These indices were calculated for 366 patients with cancer (from the Department of Medicine files of 166 consecutive patients with cancer of several primary sites and from the surgical ward files of 100 consecutive patients with colorectal cancer and 100 consecutive patients with cancer of the prostate or bladder) and for 100 patients with benign prostatic hypertrophy. The patients with benign prostatic hypertrophy served as controls. A steep and statistically significant increase in coronary instability indices was observed in all groups of patients with cancer in the 2-year period before cancer diagnosis in comparison with the coronary instability indices of control patients (P less than or equal to 0.05 to 0.0001). Patients with colorectal cancer presented the highest indices in the 2-year period before cancer diagnosis, with unstable ischemic heart disease being reported in 18% and first coronary events in 10%. The coronary events burden was 0.92. The lowest indices among patients with cancer were recorded in those with prostatic and bladder cancer. Unstable ischemic heart disease occurred in 6% and first coronary events in 4%. The coronary events burden was 0.36. The indices were several times lower for control patients than for patients with cancer. Unstable ischemic heart disease occurred in 3% of control patients, and first coronary events in 2%. The coronary events burden was 0.15. Other possible etiologic factors, particularly the known coronary risk factors and anemia, were not statistically related with an increased risk of coronary events in the 2-year period before cancer diagnosis. Based on these epidemiologic data, it appears that there may be an association between occult cancer and coronary events.

[Staging of rectal carcinoma by endorectal ultrasonography]

Staging of rectal carcinoma is essential for its management. 23 patients with rectal lesions were examined by endorectal ultrasonography. Of these 19 had rectal carcinoma and in 4 there was an abscess of the rectal wall, previously diagnosed by sigmoidoscopic biopsy. 10 of those with carcinoma were examined by computerized tomography as well, and 10 were operated on. In most cases the staging of rectal carcinoma by endorectal ultrasonography was accurate and compared well with the operative histological results. We conclude that endorectal ultrasonography is the method of choice for staging of rectal carcinoma prior to treatment.

CA-15.3, TPA and MCA as markers for breast cancer

Serum concentrations of CA-15.3, tissue polypeptide antigen (TPA) and mucinous-like carcinoma-associated antigen (MCA) were measured in 327 women: 81 controls, 93 patients with benign breast disease, 46 patients recently diagnosed with breast cancer and 107 patients during breast cancer follow-up. CA-15.3 was elevated in 16% of the controls, in 29% of the patients with benign breast disease, in 65% of the breast cancer patients and in 74% of the follow-up patients. TPA was elevated in 4%, 11%, 36% and 75%, respectively. The corresponding figures for MCA were 10%, 8%, 30% and 64%. The highest sensitivity for cancer detection (74%) was obtained with a combination of CA-15.3 and TPA, while the specificity of this panel was 75%. The negative predictive value of these combined tests was 93%. MCA scored lower values, being only 30% sensitive. The CA-15.3/TPA panel may increase sensitivity compared with single marker tests and provide additional information for clinical evaluation.

Thromboembolism. Clues for the presence of occult neoplasia

It has been stated that it is inappropriate to conduct an extensive search for occult malignancy in patients with thromboembolism, unless there is some more specific indication. The present study defines those specific indices. By analyzing the clinical features of 11 consecutive patients with occult cancer presenting with thromboembolism (TE), criteria which differentiate TE in occult cancer from TE complicating other disorders were defined. These are the absence of an apparent cause for the TE at the time of the patient's admission, age more than 50 years, multiple sites of venous TE, associated venous and arterial TE, TE resistant to therapy with oral anticoagulants, and the presence of associated paraneoplastic syndromes. The incidence of these parameters in case reports from the literature was also analyzed. The six criteria that were prevalent in our series of patients with paraneoplastic TE, were observed to occur with similar incidence in different groups of historical cases. These criteria may be useful for stratification of patients with TE with regard to the probability of the presence of an occult cancer and the indications for further investigations.

Radiation carcinogenesis in the male breast

A 53-year-old man developed cystic papillary carcinoma of the breast 30 years after radiotherapy to his chest. This rare type of carcinoma has not been previously reported following irradiation. In contrast to the comprehensive literature on irradiation as an etiological factor in carcinogenesis of the female breast, only 10 cases have been reported in males. The subject is reviewed together with the experience gained on human females and with animals. The carcinogenic characteristics of irradiation are analyzed.

Clinical significance of paraneoplastic syndrome

The prevalence, clinical presentations, and diagnostic significance of the paraneoplastic syndrome (PNS) in the setting of a department of internal medicine in a community hospital was studied. During a 7-year period (1979-1985) a total of 167 patients among 11,000 hospitalized patients were diagnosed as having a malignant neoplasia previously unknown. From this group we selected all cases who presented with one or more of the known clinical PNSs. Forty-two cases, i.e., 25% fulfilled the selection criteria. Their prevalence in our population was higher than usually found in the literature. Sixteen different categories of PNS were observed. They occurred 55 times, since more than one PNS was present in 9 cases. No significant correlation was observed between any type of PNS and any particular class of malignant neoplasia. At the time of initial evaluation, PNSs were associated with stage I malignancy in 15 cases, with stages II and III in 8 and 3 cases, respectively, and with stage IV in 22 cases. PNSs were the leading symptom or sign in 56% of the patients. In these patients the PNS determined the direction of work-up in the search for a malignant tumor. However, PNSs were essential for suspecting cancer in stage I of the disease in 6 cases only, i.e., 14%. We stress that awareness of the clinical implications of these syndromes may permit an earlier diagnosis of malignancy.

Incidence and diagnostic significance of paraneoplastic thromboembolism disorders. A survey from a community hospital

The incidence of paraneoplastic thromboembolic disorders (PTD) at first presentation of cancer and its diagnostic significance as a cancer marker are unknown. Fourteen thousand two hundred and eighty-seven patients were admitted to the department of medicine during the period 1978-1987. Nine amongst those patients had thromboembolic disorders (TE) as the initial clinical disturbance. In another 2 patients TE was the first sign of recurrence in apparently cured cancer. PTD patients were elderly (median age 70 years), the clinical variants of PTD included solitary venous thrombosis in 3, migratory thrombophlebitis in 4, pulmonary TE in 1, arterial occlusion in 2, and associated arterial and venous occlusion in 1 case. PTD antedated the diagnosis of neoplasia by 3-180 days (median 21 days). Analysis of the impact of TE on the initiation of search for occult malignancy (PTD-cancer relevance) and on patient survival (PTD-cancer prognosis) demonstrated high PTD-cancer relevance scores in 9 among 11 cases, but favorable PTD-cancer prognosis scores in only 3 cases. This is consistent with the significance of TE for the earlier diagnosis of a, usually, disseminated cancer. The present study demonstrated a higher than usually stated association of TE with occult cancer (4.6%). It differs from recent studies by including not only venous thrombosis, but a variety of venous and arterial TE disorders as well. By studying the population from a community hospital, we believe that these data would reflect the situation in the general population at large. In this way our study differs from those of tertiary care hospitals in that our patients were not preselected.

Histoplasmosis of kidneys presenting as chronic recurrent renal disease

Histoplasmosis is a well-known infectious disease that can sometimes run a mysterious and unexpected course. A case is reported that presented as a chronic renal process, with right pyelocutaneous fistula and prolonged purulent discharge as well as focal calcifications of the left kidney with recurrent stone formation. Histopathologic examination of the right kidney, removed in 1975, showed noncaseating granulomas, but the precise diagnosis was not made until 1983, when histopathologic re-examination followed partial resection of the left kidney, for recurrent stone formation. This article emphasizes the difficulty in diagnosing a noncaseating granulomatous disease in general and histoplasmosis in particular, especially when the urogenital tract is involved, with isolated local manifestations. It underlines the progressive and damaging character of this chronic disease, the variety of its manifestations, and attempts to increase awareness of this potentially treatable disease.

Acute cholecystitis after orthopaedic operations

When acute cholecystitis follows orthopaedic operations, the disease is frequently obscure and fulminating, with rapid progress to gangrene and perforation of the gallbladder, which may be fatal. Three cases are reported and the literature is reviewed. Various aspects of the disorder are discussed. It is important that orthopaedic surgeons should be aware of the condition in order to be able to make an early diagnosis and so prevent a lethal outcome.

MAPMAKER: an interactive computer package for constructing primary genetic linkage maps of experimental and natural populations

With the advent of RFLPs, genetic linkage maps are now being assembled for a number of organisms including both inbred experimental populations such as maize and outbred natural populations such as humans. Accurate construction of such genetic maps requires multipoint linkage analysis of particular types of pedigrees. We describe here a computer package, called MAPMAKER, designed specifically for this purpose. The program uses an efficient algorithm that allows simultaneous multipoint analysis of any number of loci. MAPMAKER also includes an interactive command language that makes it easy for a geneticist to explore linkage data. MAPMAKER has been applied to the construction of linkage maps in a number of organisms, including the human and several plants, and we outline the mapping strategies that have been used.

Postoperative acute cholecystitis complicating unrelated operations

The entity of postoperative acute cholecystitis has striking features that demand special attention. The process may follow intra- and extra-abdominal procedures, and the diagnosis may be especially difficult after recent abdominal operations. The course of the disease is frequently obscure and fulminant, progressing rapidly to gangrene and perforation of the gallbladder, with a high mortality rate. Six such patients, aged 69 to 83 years, were managed in our department, with one death. The cause of this complication is probably multifactorial and includes: stasis of bile of high viscosity induced by dehydration, hypovolemia, fever, and shock; obstruction at the sphincter of Oddi following starvation, anesthesia, narcotics or other possible factors such as pigment load following blood transfusion; and impaired circulation to the gallbladder secondary to sympathetic stimulation or blood-borne toxic factors induced by septicemia. The key to successful treatment is awareness, early diagnosis, intensive preoperative treatment with fluids and antibiotics, and percutaneous drainage or immediate cholecystectomy.

X-linked syndrome of branchial arch and other defects

We report on two brothers and their maternal first cousin who have branchial arch defects and other anomalies. Similar physical findings in all three include microcephaly, downslanting palpebral fissures, highly arched palate, apparently lowset, protruding ears, bilateral hearing loss, slightly webbed neck, and mild short stature. In addition, two boys had cryptorchidism, and one had subvalvar pulmonic stenosis and body asymmetry. We suggest that these cousins have an X-linked syndrome of which branchial arch defects are a component. Other pleiotropic manifestations of the mutant gene include microcephaly and cryptorchidism; body asymmetry and relatively short stature may be components as well.

Postoperative acute cholecystitis complicating urologic operations

Two cases are described of acute gangrenous cholecystitis following urologic operations. The subject is reviewed. The predominance of urologic procedures as the preceding factor for this postoperative complication is pointed out. The possible causes, the presenting features, the diagnosis, management, and serious prognosis are discussed. Awareness of the condition, early diagnosis, and operation are recommended. Its importance to the urologist is stressed.

Neuropraxis secondary to hemorrhage in a traumatic dislocation of the shoulder

A case of traumatic shoulder dislocation associated with a tear of the subscapular artery is presented. The main clinical feature was a dramatic neurologic loss of the brachial plexus, reversed by exploration, evacuation of hematoma, and ligation of the bleeding vessel. Early surgical decompression to achieve neurologic recovery is emphasized.

Hydromediastinum and hydrothorax in the neonate with central vein catheterization

A near fatal complication of central venous catheterization in a newborn infant is reported. Five days after insertion, the catheter tip eroded through the wall of the vein, causing hydromediastinum and hydrothorax with acute circulatory and respiratory distress. The diagnosis was confirmed by noting that the tip of the catheter had become curved downwards, by aspirating slightly bloodstained fluid from the pleural space and by injecting radio-opaque dye through the catheter. Recovery followed removal of the catheter, intercostal drainage, intubation and positive pressure respiration. The erosion of the vein may have been brought about by the location of the catheter tip at the junction of the left subclavian and innominate veins--a less than optimal position. The factors causing this complication are discussed. Recommendations are made about the type of catheter, its appropriate placement and maintenance. The diagnosis and management are surveyed.