Faculty Bibliography

INTRODUCTION/BACKGROUND:Appendicolithiasis is a risk factor for perforated acute appendicitis. There is limited inpatient data on predictors of progression in appendicolithiasis-associated non-perforated acute appendicitis. METHODS:We identified adults presenting with appendicolithiasis-associated non-perforated acute appendicitis (on computed tomography) who underwent appendectomy. Logistic regression was used to investigate predictors of in-hospital perforation (on histopathology). RESULTS:296 patients with appendicolithiasis-associated non-perforated acute appendicitis were identified; 48 (16.2%) had perforation on histopathology. Mean (standard deviation [SD]) age was 39 (14.9) years. The mean (SD) length of stay (LOS) was 1.5 (1.8) days. LOS was significantly longer with perforated (mean [SD]: 3.0 [3.1] days) vs. non-perforated (mean [SD]: 1.2 [1.2] days) appendicitis (p < 0.001). On multivariate analysis, in-hospital perforation was associated with age > 65 years (OR 5.4, 95% CI: 1.4- 22.2; p = 0.015), BMI > 30 kg/m2 (OR 3.5, 95% CI: 1.3-8.9; p = 0.011), hyponatremia (OR 3.6, 95% CI: 1.3-9.8; p = 0.012). There was no significant association with age 25-65 years, gender, race, steroids, time-to- surgery, neutrophil percentage, or leukocyte count. CONCLUSION/CONCLUSIONS:Geriatric age, obesity, and hyponatremia are associated with progression to perforation in appendicolithiasis-associated non-perforated acute appendicitis.

BACKGROUND:Laparoscopy has been used for the resolution of acute abdominal surgical conditions in the second trimester of pregnancy for years. There are few case reports, however, regarding its use in rare presentations of the acute abdomen later in pregnancy. CASE/METHODS:We report a case of the use of laparoscopy in the resolution of an intussusception in the 34th week, creating a smaller incision and providing the benefits of minimally invasive surgery. CONCLUSION/CONCLUSIONS:We suggest that laparoscopy be considered for further utilization as a safe and minimally invasive alternative for surgical procedures in the third trimester of pregnancy.

There are many noninfectious disorders in the critical care unit (CCU) that mimic sepsis. Pseudosepsis is the term applied to noninfectious disorders that mimic sepsis. Fever/leukocytosis is not diagnostic of infection but frequently accompanies a wide variety of noninfectious disorders. When fever/leukocytosis and hypotension are present, sepsis is the presumptive diagnosis until proven otherwise. After empiric therapy for sepsis is initiated, the clinician should rule out the noninfectious causes of pseudosepsis. The most common causes of pseudosepsis in the CCU setting are pulmonary embolism, myocardial infarction, gastrointestinal hemorrhage, overzealous diuretic therapy, acute pancreatitis, relative adrenal insufficiency, and (rarely) rectus sheath hematoma. Rectus sheath hematoma may occur secondary to trauma/anticoagulation therapy and may present as an acute surgical abdomen mimicking sepsis. Rectus sheath hematoma should be considered when other causes of pseudosepsis or sepsis fail to explain persistent hypotension unresponsive to fluids/pressors. The diagnosis of rectus sheath hematoma is by abdominal ultrasound or computed tomography scan. If the abdominal computed tomography scan is negative for other intra-abdominal pathology and other causes of pseudosepsis are eliminated, then the diagnosis of pseudosepsis caused by rectus sheath hematoma is confirmed by demonstrating a hematoma in the rectus sheath. Treatment of rectus sheath hematoma is surgical drainage and ligation of any bleeding vessels. Evacuation of the rectus sheath hematoma rapidly reverses the patient's hypotension and is curative. We describe a case of pseudosepsis caused by rectus sheath hematoma in an elderly man with hypotension unresponsive to fluids/pressors and mimicking septic shock. Clinicians should be aware that rectus sheath hematoma is a rare but important cause of pseudosepsis in patients in the CCU.

We present the case of a 30-year-old man who developed a small bowel obstruction from an acute midgut volvulus 8 days after undergoing a laparoscopic appendectomy. There was no evidence of congenital malrotation or midgut volvulus on the initial computed tomography (CT) scan or at laparoscopy. Subsequently, a midgut volvulus developed in the absence of congenital malrotation.

Atrial myxomas are the most common primary tumor of the heart. We report an unusual case where an incidentally found right atrial myxoma was associated with a malignant lymphoma. Surgical management of the concurrent problems is discussed as well as a review of pertinent literature and efficacy of diagnostic modalities.

Currently 500,000 inguinal herniorrhaphies are performed annually in United States. Most surgeons approach the inguinal region anteriorly. Very few surgeons use the posterior approach. Cheatle in 1920 followed by Nyhus in 1960, described the preperitoneal hernia repair. The preperitoneal approach has been used for recurrent hernias and for complicated hernias. In 1975, Stoppa added the use of a prosthetic mesh to the preperitoneal herniorrhaphy to improve the recurrence rate (1.4%). In the past few years, laparoscopy has replaced the traditional open technique in certain general surgical procedures (cholecystectomy, appendectomy). In this article, we will show that laparoscopic hernia repair is a viable alternative to the open herniorrhaphy because it combines the use of a proven method (preperitoneal prosthetic hernia repair) and the advantages of laparoscopy (less pain, fast recovery, better cosmesis).

Ten successive cases of celioscopic colectomy are reported (5 right and 5 left colons). Colectomies were made for diverticular disease in 6 case and for cancer in the remaining cases. The patients ages range from 52 to 80 years, with an average of 72 years. The average duration of surgery is 92 minutes. The stay in hospital lasted from 5 to 7 days with an average of 6 days. All patients resumed fluid feeding on the 3rd postoperative day and solid feeding on the 4th to 6th day. None of them received analgesics later than 48 hours postoperatively. There was no mortality. Only one complication was noted in the form of urinary retention. In our opinion, colectomy with celioscopic video surgery currently has a definite role to play and, owing to technical and instrumental progress, colectomy can be performed without complementary laparotomy, at least for the left colon.

450 successive celioscopic cholecystectomies (May, 1990-April, 1992) are reported for 312 cases of uncomplicated gallstone (69%) operated electively and 138 cases operated in emergency, including 120 cases of acute cholecystitis, 17 cases of biliary pancreatitis and 1 case of angiocholitis. Immediate conversion into laparotomy was required in 10 cases (2.2%) either for technical reasons (1.1%) or because of lithiasis of the common bile duct (1.1%). The stay in hospital lasted an average of 2.2% days for elective admission and 3.3 days for emergent admission. The average operating time was 65 minutes (75 minutes until May, 1991, and 55 minutes between May, 1991 and April, 1992). Preoperative retrograde cholangiography was performed in 67 cases and intraoperative cholangiography in 16 cases. Second surgery was required for suture in one case because of cholerrhagia in a secondary duct of the gallbladder bed. This cholerrhagia would not have been amenable to simple aspiration. One patient (0.2%) died of myocardial infarction at D + 10. Complications include 4 cases of pulmonary embolism, 3 cases of cystic biliary fistula without second surgery and 4 cases of umbilical hernia. A more peculiar case is that of a patient admitted 5 months after surgery for gangrenous acute cholecystitis. This patient was admitted for fever and epigrastric pain. He had a very low-flow duodenocutaneous fistula of uncertain origin. This patient was not operated again. This may not be a complication connected to celioscopic surgery. Celioscopic cholecystectomy is superseding conventional cholecystectomy. Surgeons' efforts should strive at eliminating operative errors, reducing postoperative morbidity, improving techniques and instruments, teaching celioscopic surgery and extending its indications to other intraabdominal operations.