Abdominal compartment syndrome after mesenteric revascularization

Abdominal compartment syndrome (ACS) results from increased pressure within the abdominal cavity leading to multisystem organ dysfunction. The most common cause of ACS is increased intraperitoneal volume from any source, but extrinsic compression can also cause increased intra-abdominal pressure. Although ACS has been well described in patients with trauma, little has been reported on ACS in postoperative patients without traumatic injuries. We report on a patient who had acute ACS 2 days after surgical revascularization for chronic mesenteric ischemia. With appropriate treatment, the patient made a rapid and complete recovery. We present this case of acute ACS in the postoperative patient without trauma to increase awareness and help minimize death caused by this devastating syndrome.

Risk neutralization in cardiac operations: detection and treatment of associated carotid disease

BACKGROUND

A screening and treatment protocol was implemented to extend the benefit of prophylactic carotid endarterectomy to patients who had open heart operations.

METHODS

Patients aged 65 or older or who at any age had left main coronary disease, transient ischemic attack, or stroke were eligible for preoperative carotid duplex screening. Carotid endarterectomies and open heart operations were planned as a staged (n = 59) or combined procedure (n = 55) for angiographically confirmed carotid stenosis of at least 80%.

RESULTS

Duplex scans were obtained in 1,719 of 7,035 open heart surgical patients over 8 years. The overall stroke rate was 1.5% (108 of 7,035). Seven of these were strokes of carotid origin (0.1%). There were 129 patients with at least 80% stenosis. One hundred fourteen had carotid endarterectomy preceding open heart operation, and none had carotid artery stroke. Twelve patients with at least 80% carotid stenosis by duplex scan had open heart operations without prophylactic carotid endarterectomies. There were four carotid strokes in these 12 patients (p = 0.0001; odds ratio, 20.2). Stroke risk remained significantly elevated (16.8%, p = 0.005) in the 50% to 79% group. The changes associated with the reduced risk afforded by this screening and treatment strategy amounted to $346 for each patient in the study.

CONCLUSIONS

The risk of carotid stroke at the time of cardiac operation can be defined by duplex screening. Prophylactic carotid endarterectomy neutralizes the risk in those with at least 80% stenosis. Consideration for lowering the threshold for assessment and treatment of carotid stenoses appears warranted. The economic investment is recouped by the savings in system resources that would have been depleted through care for carotid stroke and its sequelae.

A core breast biopsy diagnosis of invasive carcinoma allows for definitive surgical treatment planning

BACKGROUND

We reviewed our image-guided core needle breast biopsy (IGCNBB) experience with patients diagnosed with invasive carcinoma (IC) to determine the accuracy of a core biopsy diagnosis of invasion and our ability to perform a single definitive cancer operation.

METHODS

All IGCNBBs between July 1993 and July 1997 were reviewed to identify patients diagnosed with IC. Data included initial surgical treatment, surgical pathology, and subsequent surgical treatment.

RESULTS

Of the 1,676 biopsies, invasive carcinoma was diagnosed in 208 with follow-up in 204 cases. Invasive carcinoma diagnosis was confirmed in 202 of 204 cases (99%). One hundred ninety-two patients had surgical treatment. Of these 192 patients, 173 (90%) could have achieved definitive surgical treatment with a single operation.

CONCLUSIONS

An IGCNBB diagnosis of IC is accurate and allows for definitive breast cancer therapy. The potential impact on patient management is that a single operation can usually accomplish what traditionally has required at least two surgical procedures.

Image-guided core-needle breast biopsy is an accurate technique to evaluate patients with nonpalpable imaging abnormalities

OBJECTIVE

The goal was to evaluate one institution's experience with image-guided core-needle breast biopsy (IGCNBB) and compare the pathologic results with wire-localized excisional breast biopsy (WLEBB) for patients with positive cores and the mammographic surveillance results for patients with negative cores.

SUMMARY BACKGROUND DATA

IGCNBB is becoming a popular, minimally invasive alternative to WLEBB in the evaluation of patients with nonpalpable abnormalities.

METHODS

This study includes all patients with nonpalpable breast imaging abnormalities evaluated by IGCNBB from July 1993 to February 1997. Patients with positive cores (atypical hyperplasia, carcinoma in situ, or invasive carcinoma) were evaluated by WLEBB. Patients with negative cores (benign histology) were followed with a standard mammographic protocol. IGCNBB results were compared with WLEBB results to determine the sensitivity and specificity for each IGCNBB pathologic diagnosis.

RESULTS

Of 1440 IGCNBBs performed during the study period, 1106 were classified as benign, and during surveillance follow-up only a single patient was demonstrated to have a carcinoma in the index part of the breast evaluated by IGCNBB (97.3% sensitivity, 99.7% specificity). IGCNBB demonstrated atypical hyperplasia in 72 patients, 5 of whom refused WLEBB. The remaining 67 patients were evaluated by WLEBB: nonmalignant findings were found in 31, carcinoma in situ was found in 25, and invasive carcinoma was found in 11 (100% sensitivity, 88.8% specificity). IGCNBB demonstrated carcinoma in situ in 84 patients; WLEBB confirmed carcinoma in situ in 54 and invasive carcinoma in 30 (65.4% sensitivity, 97.7% specificity). IGCNBB demonstrated invasive carcinoma in 178 patients. Three were lost to follow-up. On WLEBB, 173 of the remaining 175 had invasive carcinoma; the other 2 patients had carcinoma in situ (80.8% sensitivity, 99.8% specificity).

CONCLUSIONS

An IGCNBB that demonstrates atypical hyperplasia or carcinoma in situ requires WLEBB to define the extent of breast pathology. Mammographic surveillance for a patient with a benign IGCNBB is supported by nearly 100% specificity. An IGCNBB diagnosis of invasive carcinoma is also associated with nearly 100% specificity; therefore, these patients can have definitive surgical therapy, including axillary dissection or mastectomy, without waiting for the pathologic results of a WLEBB. Based on the authors' findings, IGCNBB can safely replace WLEBB in evaluating patients with nonpalpable breast abnormalities.

Carcinoma of the male breast: analysis of prognosis compared with matched female patients

BACKGROUND

Considerable debate exists concerning the prognosis of breast cancer in male patients compared with that in female patients. Some studies have observed worse prognosis for men; others suggested the higher mortality rates were primarily due to delayed diagnosis.

METHODS

Survival time from diagnosis with invasive disease to death resulting from breast cancer of 58 men treated between 1973 and 1989 was compared with survival of 174 women treated between 1976 and 1978 who were matched by stage of disease and age at diagnosis. All patients were treated by mastectomy and axillary dissection.

RESULTS

Tumors were < or = 2 cm in 70% of cases and 55% were free of axillary metastases. The histology of the tumors differed significantly by gender (p < 0.05). Significantly more men had estrogen receptor-positive tumors (87%) than did women (55%, p < 0.001). Survival at 10 years was similar for male and female patients. Multivariate analysis controlling for tumor size, number of positive axillary lymph nodes, age at diagnosis, histology, and receptor status indicated no significant difference in survival of male compared with female patients.

CONCLUSIONS

These data conflict with the conventional wisdom that breast cancer in men carries a worse prognosis than the disease in women. Although histology of the tumor and receptor status differed by gender, these factors did not have an impact on survival in these paired patients. Our data indicate that breast carcinoma in males is not biologically more aggressive than in females.

Appropriate management of atypical ductal hyperplasia diagnosed by stereotactic core needle breast biopsy

BACKGROUND

Stereotactic core needle breast biopsy (SCNBB) is a minimally invasive technique used to sample nonpalpable mammographic abnormalities. The optimal management of atypical ductal hyperplasia (ADH) diagnosed by SCNBB is unknown. We hypothesized that ADH diagnosed by SCNBB should be evaluated by excisional breast biopsy (EBB) because of the risk of identifying carcinoma in association with ADH that would be missed if a diagnostic sampling technique alone was utilized.

METHODS

To test this hypothesis, a prospective diagnostic protocol was created which called for SCNBB instead of EBB for patients with mammographic abnormalities considered suspicious for malignancy. If ADH was noted on histologic evaluation of the cores, patients were advised to undergo an EBB.

RESULTS

A review of the initial 900 patients evaluated by SCNBB yielded 39 patients (4.3%) with ADH detected by SCNBB. Thirty-six of these 39 patients agreed to proceed with EBB: 19 patients demonstrated benign findings including atypical ductal hyperplasia, 13 patients demonstrated noninvasive ductal carcinoma, and 4 patients had evidence of invasive carcinoma.

CONCLUSIONS

A 47% rate of detecting noninvasive or invasive breast carcinoma supports the hypothesis that ADH detected by a sampling technique, such as SCNBB, should be managed by EBB.

Laparoscopic adrenalectomy in patients with primary aldosteronism

Advances in laparoscopic surgery have changed our approach to many surgical problems. We describe a technique of laparoscopic adrenalectomy in patients with primary aldosteronism using an anterior transabdominal approach. The left adrenal gland was approached through the root of the transverse mesocolon, the right adrenal gland through the subhepatic space. The patients were discharged within 24 to 48 h with normal blood pressure after discontinuation of antihypertensive medication. This technique is safe and allows the patient to return to normal activity sooner than with conventional surgery.

Management of cancer of the opposite breast following breast preservation

Breast preservation has been shown to be a good alternative to mastectomy in selected patients with breast cancer. The purpose of this study was to evaluate the characteristics of cancer developing in the opposite breast to determine if breast preservation should be attempted in that breast as well. From 1979 to 1988, 172 women underwent tylectomy, axillary dissection and irradiation for carcinoma of the breast. All had follow-up mammogram. Mean age was 55 years. Mean follow-up time was 50 months. Thirteen patients (7.6%) developed cancer in the opposite breast. Three cancers were carcinoma in situ, nine were stage I, and one was stage IIa. Nine of 13 patients had breast preservation therapy, and four had mastectomies. Ten patients are alive with no evidence of disease, two are alive with disease and one died with disease. Breast preservation for bilateral breast cancer is a safe alternative if patients can be followed closely.

Current management of male breast cancer. A review of 104 cases

Between 1975 and 1990, 104 male patients with a total of 106 breast cancers were treated at Memorial Hospital or the Ochsner Clinic and their records reviewed. The patients were followed for a median of 67 months (range, 0.5 to 14.4 years). Analysis of the frequency distribution by stage showed that 16 (17%) patients were stage 0 and 26 (27%) patients were stage I. The median duration of symptoms before diagnosis was 18 weeks (mean, 5 weeks; range, 1 to 156 weeks). Modified radical mastectomy was undertaken in 71 (67%) patients. The actuarial 5-year relapse-free survival for the entire group was 68% and the actuarial 5-year overall survival was 85%. Relapse-free survival at 5 years for axillary node-negative patients was 87% and for node-positive patients was 30% (p less than 0.001). Overall survival figures for the same subsets showed a 5-year survival of 100% for the node-negative subset and 60% for the node-positive subset. On multivariate analysis, the most powerful predictor of outcome in men was the status of the axillary lymph nodes, and the only prognostic factor that added significantly to this predictive power was the duration of symptoms. Patients who sought treatment less than 6 months after the onset of symptoms experienced a significant survival advantage when compared with patients whose symptoms were present for more than 6 months (p = 0.03). The profile of the stages at diagnosis, the treatment approach, and the survival rates approximate those reported in series of female breast cancers, and overall, the two diseases are remarkably similar.

The significance of mammographic findings after breast-conserving therapy for carcinoma of the breast

Mammographic changes after lumpectomy, axillary dissection and irradiation are common and unpredictable. To study the significance of these changes at the first follow-up mammogram, we retrospectively reviewed reports of 172 women treated in this manner between 1979 and 1988. The mean follow-up time was 50 months. Eight patients had recurrences in the same breast, while 13 patients had carcinoma develop in the opposite breast. The mean time of follow-up mammograms was 11 months (range of one to 48 months). Twenty-six patients had a normal mammogram, while 146 patients had some changes within the irradiated breast. Thirty-one patients had suspicious findings--a mass, speculation or new microcalcifications. None of these 31 patients had carcinoma confirmed by biopsy or follow-up examination. Of eight patients with recurrence in the same breast, six had a biopsy because of findings on physical examination, while two had changes from previous mammograms. The mean time to recurrence was 50 months (range of 24 to 81 months). We conclude that mammographic changes in the irradiated breast are common after lumpectomy and irradiation for carcinoma of the breast. A baseline mammogram should be done six months after irradiation is completed. Changes that occur at this time should be considered secondary to surgical treatment and irradiation and are not an indication for immediate biopsy. These findings should be reconfirmed by a mammogram performed one year after irradiation to prove that these changes are stable. Physical examination and yearly mammography of both breasts are imperative in the follow-up evaluation of patients treated in this manner.

Foreign body in the gastrointestinal tract: intraluminal migration of laparotomy sponge

We have reported a case of complete transluminal migration of a retained laparotomy sponge that caused repeated partial small bowel obstruction. Diagnosis was made when roentgenograms showed multiple positions of the laparotomy marker. The sponge was surgically removed. This is the 69th reported case of complete transluminal migration and distal movement of a laparotomy sponge.

Patterns of utilization of mammography comparison by physician specialties in 6,000 consecutive mammograms

Mammography is regarded as the most important screening test for breast cancer. The combination of physical examination of the breast by a physician and mammography can result in reduced breast cancer mortality. Evidence is mounting that mammography alone can produce similar results. Despite these facts, mammography is underutilized in the United States. In an attempt to define the utilization of mammography in the Ochsner Medical Institutions, New Orleans, Louisiana, the records of 6,000 consecutive patients who underwent mammography were reviewed with respect to the specialty of the physician ordering the test. The ratio of the number of mammograms ordered by each service to the number of eligible patients (women over age 50) visiting that service provided insight into the patterns of utilization of mammography in the Ochsner Clinic. This information will allow for efficient utilization of time and resources in planning continuing education programs geared toward mammographic screening.

Roentgenographic evaluation of the augmented breast

We performed a retrospective study to determine the sensitivity of mammography in detecting breast cancer arising in women with augmented breasts. Of eight women with breast implants in whom breast cancer developed, six had mammograms before biopsy. Only two of the six cancers were identified mammographically (sensitivity = 33%), and one of these two was seen only in retrospect. In both cases, the mammographic findings suggested a benign rather than a malignant process. All eight women had a palpable mass and early disease, and all are clinically disease-free at present. The sensitivity of mammography in detecting palpable cancers in a control group of women without implants was 92% (118 of 128). For tumors of 2 cm or less, the sensitivity was 88% (58 of 66). These results suggest that the sensitivity of mammography in detecting breast cancer is decreased when implants are present. Further investigations are needed to determine the effects of prostheses on mammographic evaluations.

Outpatient cholecystectomy simulated in an inpatient population

This prospective clinical trial evaluates the feasibility and safety of elective cholecystectomy in a simulated outpatient protocol in 40 patients. Results were compared with a 19-patient control group managed by conventional postoperative methods. Oral liquids were begun in the recovery room, intravenous fluids were discontinued 4 hours after surgery, and enteral analgesics and antiemetics were provided on the ward. Protocol patients were randomized in a double-blind fashion to receive metoclopramide or placebo after surgery to assess its influence on the early tolerance of oral intake. In the protocol group, nausea without emesis occurred in nine patients (23%); 11 others (28%) had nausea with emesis. This was not significantly different from the control group. Metoclopramide-treated patients did not demonstrate a lower incidence of nausea or emesis but did tolerate oral liquids earlier after surgery than the placebo group (P less than 0.05). After release from recovery, eight protocol patients (20%) requested parenteral narcotics for relief of pain. Postoperative urinary catheterization was required in nine protocol patients (23%) and five control patients (26%). No major complications occurred. Outpatient cholecystectomy is both feasible and safe. Metoclopramide may allow earlier tolerance of enteral liquids postoperatively.

Rupture of a previously bypassed popliteal aneurysm: a case report

A case of rupture of a previously excluded popliteal aneurysm is reported and the pertinent literature reviewed. Symptoms of aneurysm expansion with nerve compression preceded the rupture. The need for continued follow-up after treatment of popliteal aneurysms is emphasized.

Improved operative risk after myocardial revascularization

At Ochsner Medical Institutions from 1970 to 1979, 96 patients who had previously had myocardial revascularization later had a total of 136 noncardiac operations. There were no postoperative myocardial infarctions and only one noncardiac death. Transitory postoperative arrhythmias occurred in 3.6% of patients. It appears that myocardial revascularization protects the cardiac patient from myocardial infarction and cardiac-related deaths during and after noncardiac operations. Patients with cardiac disease scheduled for elective surgery should have exercise testing or coronary cineangiography or both to evaluate the severity and significance of the coronary disease. If significant coronary lesions are demonstrated that are amenable to a bypass procedure, the operative risk will be lessened by prior revascularization.

Ruptured hepatic artery aneurysm with hepatic artery-to-portal vein fistula. Preservation of portal flow by autogenous vein reconstruction

Hepatic artery aneurysms are uncommon lesions that have varied clinical presentations. Rupture into the portal vein has occasionally been reported, as has associated gastrointestinal bleeding. A case is described in which an unusually large hepatic artery aneurysm ruptured into the portal vein, destroying a major portion of its wall. Reconstruction was accomplished successfully by use of an autogenous saphenous vein patch with preservation of hepatopetal portal flow.

Techniques for operative reduction of pubic symphysis disruptions

Occasionally, a pelvic fracture is an exceedingly difficult injury to manage in the multiple trauma victim. Accompanying hemorrhage can not only be life-threatening but often confuses the evaluation as to sources of blood loss. Reduction of a Malgaigne's or open book pelvic fracture aids significantly in stemming this extraperitoneal venous bleeding. If operative intervention for associated injuries is required, reapproximation of any pubic disruption should be performed concomitantly. Use of the rib approximator for this reduction saves considerable time and can be accomplished with relatively little effort.

Current surgical management of pheochromocytoma during pregnancy

The diagnosis of pheochromocytoma during pregnancy has rarely been made correctly prior to delivery, only 42 cases having been reported. Antepartum diagnosis markedly decreases the maternal and fetal mortality. We report a case of pheochromocytoma manifesting during the third trimester of pregnancy. Preoperative control of blood pressure with phenoxybenzamine and phentolamine therapy was carried out. Simultaneous cesarean section and excision of the tumor resulted in a healthy mother and newborn infant. We review the perioperative and intraoperative management of patients with a pheochromocytoma during pregnancy.

Metastatic melanoma of the gallbladder

Metastatic involvement of the gallbladder in melanoma is rare, but constitutes the most common metastatic lesion involving this organ. Two cases of metastatic melanoma to the gallbladder with radiographic evidence of gallbladder abnormality prior to surgery are presented. These cases are compared to the nine previously reported cases of metastatic melanoma to the gallbladder with abnormal cholecystograms. All eleven cases presented with signs and symptoms compatible with cholecystitis. Nine of the eleven patients had a previous melanoma primary and most had other extrabiliary metastases. Associated cholelithiasis appeared to be only incidental. In addition, nine reported cases of "primary" biliary melanoma were reviewed. Clinical and pathologic presentations in the latter cases were similar to the former cases with metastases. Seventy-eight percent had extrabiliary sites of metastasis at some time in the course of their disease, tending to refute the impression of "primary" biliary melanoma. Melanoma in the gallbladder is much more likely to have metastasized from a regressed skin primary than to have arisen de novo. The two reported cases and the 18 cases from the literature indicate that the physician must consider gallbladder metastasis in melanoma patients presenting with symptoms compatible with cholecystitis.

Metastatic melanoma of the gallbladder

Metastatic involvement of the gallbladder in melanoma is rare, but constitutes the most common metastatic lesion involving this organ. Two cases of metastatic melanoma to the gallbladder with radiographic evidence of gallbladder abnormality prior to surgery are presented. These cases are compared to the nine previously reported cases of metastatic melanoma to the gallbladder with abnormal cholecystograms. All eleven cases presented with signs and symptoms compatible with cholecystitis. Nine of the eleven patients had a previous melanoma primary and most had other extrabiliary metastases. Associated cholelithiasis appeared to be only incidental. In addition, nine reported cases of "primary" biliary melanoma were reviewed. Clinical and pathologic presentations in the latter cases were similar to the former cases with metastases. Seventy-eight percent had extrabiliary sites of metastasis at some time in the course of their disease, tending to refute the impression of "primary" biliary melanoma. Melanoma in the gallbladder is much more likely to have metastasized from a regressed skin primary than to have arisen de novo. The two reported cases and the 18 cases from the literature indicate that the physician must consider gallbladder metastasis in melanoma patients presenting with symptoms compatible with cholecystitis.

Evaluation of mini-dose heparin administration as a prophylaxis against postoperative pulmonary embolism: a prospective double-blind study

A prospective double-blind study was instituted in a group of 150 general surgical patients to test the effectiveness of mini-dose heparinization in the pre- and postoperative periods. There was a 21 per cent reduction in the incidence of deep venous thrombosis in the heparin treated group. A radiopharmaceutical imaging technique with 99m-technetium macroaggregated albumin was used to evaluate the deep venous system. The procedure proved to be simple, safe, and painless; however, it was difficult to differentiate venous stasis from deep venous thrombosis. A negative study was good evidence that deep venous thrombosis did not exist. An additional benefit of this procedure was that a perfusion lung study could be obtained which provided additional information regarding pulmonary embolism without injecting additional radiopharmaceutical. Again, the negative perfusion lung study provided more information.