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It has been demonstrated by other investigators that central plasma clearance of amino acids accurately predicts hepatocyte function in patients with liver disease and correlates with clinical outcome. This methodology has not heretofore been studied in the trauma patient. It is our hypothesis that central amino acid clearance in trauma patients is more reflective of hepatocyte function than traditional liver function tests. We examined the plasma amino acid clearance rates using L-[1-13C]phenylalanine. Clearance rates were compared to standard liver function tests (LFTs) and the sensitivity and predictability of the technique were determined. The study was conducted on uninjured control subjects and in seriously injured patients, both with and without significant liver injuries. Compared to baseline values in the control group, initial phenylalanine breath scores were reduced in the injured, but exceeded control levels at 7 days postinjury. These changes were statistically significant. There was no difference between those with and without liver trauma. LFTs showed inconsistent and conflicting results. Thus, central amino acid clearance measured by L-[1-13C]phenylalanine oxidation is depressed immediately following injury but reaches supranormal levels at 7 days postinjury. Compared to LFTs, amino acid clearance suggests initial hepatocyte suppression followed by hyperactivity and is a more accurate determinant of hepatocyte function.

Morbid obesity (MO) is associated with diabetes mellitus-type II (DM-II). Roux-en Y gastric bypass (RNY) has been shown to normalize glucose intolerance in these patients through an incompletely understood mechanism. Gastrointestinal hormonal changes have been suggested as an explanation for resolution of DM II. Preoperatively, 20 MO patients with DM-II were evaluated for demographics and fasting levels of the following: glucose, insulin, C-peptide, glucagon, cortisol, gastric inhibitory polypeptide (GIP), and glucagon-like peptide-1 (GLP-1). Each patient underwent RNY with a 15-cc gastric pouch and 150-cm Roux limb. Postoperatively, each of the variables was measured at 2 weeks, 6 weeks, and 12 weeks and compared with the preoperative result using Student t test with significance, P = 0.05. Results are expressed as mean +/- SD. Twenty patients (5 male and 15 female), age 40.3 +/- 7.9 years, weight 146.3 +/- 34.0 kg, height 158.7 +/- 18.7 cm, and BMI 52.7 +/- 8.8, were enrolled in this IRB-approved protocol. Weight and BMI decreased progressively (117.5 +/- 26.9 kg and 47.0 +/- 7.4, P = 0.01, respectively) during the study but reached significance only at 12 weeks. Fasting plasma glucose decreased significantly within 2 weeks after RNY. Insulin and cortisol both approached, but never achieved, significant changes over 12 weeks. GLP-1 increased initially, but not significantly. GIP and C-peptide both decreased significantly. Glucagon remained essentially unchanged over 12 weeks. RNY rapidly normalizes fasting plasma glucose in morbidly obese patients with DM-II. GIP, a gactor in the enteroinsulin axis, decreases and may play a role in the correction of DM-II after gastric bypass.

Background: Laparoscopic Roux-en-Y gastric bypass is an effective treatment for morbid obesity. However, little information is available on gastrointestinal (GI) symptomatology in this population. This study compares GI symptoms in morbidly obese patients to that of control subjects., Methods: A previously validated, 19-point GI symptom questionnaire was administered prospectively to each patient seen for surgical consultation for morbid obesity. The symptoms were then grouped into 6 clusters as follows: (1) abdominal pain, (2) irritable bowel, (3) GERD, (4) reflux, (5) sleep disturbance, (6) dysphagia. The result of each cluster of symptoms expressed as mean +/- standard deviation of obese versus control is compared using student's t-test with significance p = 0.05., Results: Forty-three patients (40 female, 3 male) age 37.3 +/- 8.6 with BMI 47.8 +/- 4.9, and 36 healthy control subjects (23 female, 13 male), age 39.8 +/- 11.2, completed the questionnaire. Results of each cluster for morbid obese vs control subjects are expressed as mean +/- standard deviation: Abdominal pain 25.3 +/- 18.0 vs 12.1 +/- 11.4, p = 0.0002; irritable bowel 23.0 +/- 14.8 vs 15.6 +/- 13.3, p = 0.02; GERD 40.3 +/- 18.9 vs 22.3 +/- 16.1, p = 0.0001; reflux 29.9 +/- 19.0 vs 11.8 +/- 13.4, p = 0.0001; sleep disturbance 50.6 +/- 28.9 vs 32.9 +/- 26.8, p = 0.006; dysphagia 10.9 +/- 15.6 vs 7.2 +/- 10.6, p = NS., Conclusions: Morbidly obese patients experience more intense GI symptoms than normal subjects, whereas dysphagia is equivalent to normal subjects. These data may be important in counseling patients and understanding that their complaints are legitimate. Follow-up in the postoperative period is needed to determine if these symptoms are improved with an operation.

Laparoscopic Roux-en-Y (RY) gastric bypass is an effective treatment for morbid obesity. However, little information is available regarding the gastrointestinal symptomatic outcome after laparoscopic RY gastric bypass for morbid obesity. The purpose of this study is to identify changes occurring in gastrointestinal symptoms after laparoscopic RY gastric bypass. A previously validated, 19-point gastrointestinal symptom questionnaire was administered prospectively to each patient seen for surgical consultation to treat morbid obesity. Patients rated the degree to which each symptom affected their lives on a 0 to 100 mm Liekert scale with 0 indicating absence of a symptom, 33 indicating the symptom was present occasionally, 67 indicating the symptom occurred frequently, and 100 indicating the symptom was continuous. The same survey was readministered 6 months postoperatively. The mean of each symptom (preoperative vs. postoperative value) was compared using Student's t test with significance at P<0.05. Forty-three preoperative patients (age 37.3+/-8.6 years; body mass index 47.8+/-4.9) and thirty-five, 6 months' postoperative patients (81% follow-up; body mass index 31.6+/-5.3) completed the questionnaire. The result for each symptom is expressed as mean+/-standard deviation of preoperative vs. postoperative scores. Significantly different symptoms include the following: abdominal pain 23.3+/-26.4 vs. 8.6+/-13.5, P=0.003; heartburn 34.0+/-26.6 vs. 8.0+/-14.0, P=0.0001; acid regurgitation 28.1+/-24.0 vs. 10.7+/-21.0, P=0.001; gnawing in epigastrium 19.3+/-22.7 vs. 7.5+/-16.0, P=0.01; abdominal distention 38.2+/-31.5 vs. 11.1+/-19.2, P=0.0001; eructation 27.7+/-24.4 vs. 15.5+/-16.9, P=0.01; increased flatus 40.2+/-25.7 vs. 25.2+/-25.3, P=0.005; decreased stools 5.4+/-16.8 vs. 17.4+/-20.0, P=0.0005; increased stools 23.9+/-26.7 vs. 6.5+/-11.7, P=0.0005; loose stools 29.7+/-26.5 vs. 17.5+/-20.0, P=0.03; urgent defecation 34.3+/-26.5 vs. 14.3+/-19.3, P=0.0009; difficulty falling asleep 44.1+/-38.4 vs. 27.5+/-32.9, P=0.05; insomnia 42.4+/-36.2 vs. 21.6+/-30.5, P=0.008; and rested on awakening 65.1+/-33.8 vs. 30.5+/-28.8, P=0.0001. Symptoms that did not significantly change included the following: nausea/vomiting 17.2+/-22.7 vs. 22.1+/-19.9, P=0.33; borborygmus 28.8+/-25.2 vs. 26.8+/-29.7, P=0.75; hard stools 10.3+/-22.9 vs. 7.1+/-18.6, P=0.56; incomplete evacuation of stool 17.2+/-22.8 vs. 13.4+/-21.7, P=0.45; and dysphagia 10.9+/-15.6 vs. 17.7+/-28.4, P=0.18. Laparoscopic RY gastric bypass significantly improves many gastrointestinal symptoms experienced by morbidly obese patients without adversely affecting any of the measured parameters. This information is useful in preoperative counseling to assure patients of overall symptomatic improvement after this operation in addition to significant weight loss and improvement of comorbid conditions.

Background: Currently there are few reports comparing gastrointestinal (GI) symptoms in the morbidly obese versus control subjects or the effect of laparoscopic Roux-en-Y gastric bypass (LRYGBP) on such symptoms., Methods: A previously validated, 19-point GI symptom questionnaire was administered prospectively to each patient undergoing LRYGBP, and the questionnaire was re-administered 6 months postoperatively. Six symptom clusters (abdominal pain, irritable bowel [IBS], reflux, gastroesophageal reflux disease [GERD], sleep disturbances, and dysphagia) were compared in the following manner using Students t-test: 1) Control vs. Preop, 2) Control vs Postop, and 3) Preop vs Postop. Results are expressed as mean +/- standard deviation, significance P=0.05., Results: 43 patients (40 female and 3 male, age 37.3 +/- 8.6, BMI 47.8 +/- 4.9) completed the questionnaire preoperatively, and 36 patients (34 female, 2 male, BMI 31.6 +/- 5.3) completed the questionnaire 6 months postoperatively, for a response-rate of 84%. Abdominal pain, IBS, reflux, GERD and sleep disturbance symptoms were significantly worse in preop versus controls. Dysphagia was not different. Postop vs preop scores revealed abdominal pain, IBS, GERD, reflux, and sleep disturbance symptoms to be improved significantly. Dysphagia was not significantly different. Only dysphagia was worse when comparing postoperative to controls. No other symptom cluster was significantly different in controls vs postoperative., Conclusions: Morbidly obese patients experience more intense GI symptoms than control subjects, and many of these symptoms return to control levels 6 months after LRYGBP. Dysphagia is equivalent to control subjects preoperatively but increases significantly after LRYGBP. This data suggests another quality-of-life improvement (relief of GI symptoms) for morbidly obese patients. Further follow-up is needed to document the long-term reduction of GI symptoms.

Background: In addition to the known beneficial effects of ascorbic acid on wound healing and the immune response, it is also a potent extracellular antioxidant. Recent work in septic rats suggests that high-dose ascorbic acid total parenteral nutrition (TPN) supplementation may protect cells from free radical injury and improve survival. In this study, we determined ascorbic acid levels in the immediate post-injury/illness period and evaluated the ability of early short-term high levels of ascorbic acid in TPN to normalize plasma levels., Materials and Methods: Ascorbic acid levels were determined in 12 critically injured patients and 2 patients with severe surgical infections. Each patient received TPN supplemented with increasing doses of ascorbic acid over a 6-day period. Therapeutic responses were determined by plasma and urine measurements using high-pressure liquid chromatography., Results: The initial mean +/- SEM baseline plasma ascorbic acid concentration was depressed (0.11 +/- 0.03 mg/dl) and unresponsive following 2 days on 300 mg/day supplementation (0.14 +/- 0.03; P = 1.0) and only approached low normal plasma levels following 2 days on 1000 mg/day (0.32 +/- 0.08; P = 0.36). A significant increase was noted following 2 days on 3000 mg/day (1.2 +/- 0.03; P = 0.005)., Conclusion: We confirmed extremely low plasma levels of ascorbic acid following trauma and infection. Maximal early repletion of this vitamin requires rapid pool filling early in the post-injury period using supraphysiologic doses for 3 or more days.

Background: Among directors of general surgery residencies, there is a concern that the quality of medical students applying to surgical residencies is declining., Methods: Quality of surgical applicants was assessed by several methods including subjective opinions determined by survey and by objective data including student United States Medical Licensing Examination (USMLE) scores of matched candidates. The number of applicants interviewed, total interviews granted, proportion of Alpha Omega Alpha (AOA) students, and the rank order of the candidates matched was obtained by survey. The survey included data on postgraduate year 1 (PGY-1) residents from July 1996 to July 1999. Three mailings were made to 226 US surgical residency programs., Results: Data were obtained from 90 programs. Surgery program directors disagreed with a survey statement that overall quality of applicants had declined (P <0.01), but agreed with a statement that activities of medical schools to enroll graduating students into primary care had hurt recruitment (P <0.001). Objective data revealed no change in mean USMLE part I scores of PGY-1 residents over the 4 years (P = 0.265, power = 0.81). There was no change in proportion of matched residents who were AOA over time. The mean score of all new PGY-1 residents, the rank of the first matched resident, the rank of the last ranked resident, and proportion of AOA students was higher in programs with five or more categorical spots when compared with programs of at most four (P <0.001). Across all programs, there was a trend to go lower on the rank list to fill categorical positions over time (P <0.001)., Conclusions: There is a perception that medical school policies act to discourage recruitment of quality medical students into general surgery programs, and surgery programs are going deeper into their rank lists to fill categorical positions. However, the average USMLE part I score of applicants to surgical residencies and proportion of AOA applicants has not decreased.

Acute pancreatitis develops precipitously, changing the patient's condition from apparent good health to a critically ill status. Of patients who succumb, 80 per cent die from secondary infection in the pancreas-peripancreatic area. Infection supervenes in the second week or later after onset. Prophylactic antibiotic(s) appear to be helpful in avoiding, delaying, and/or lessening secondary sepsis. Once infection develops, treatment requires open debridement of necrotic material, drainage, and appropriate antibiotic therapy; or mortality will approach 100 per cent. Infecting organisms are commonly Escherichia coli, Klebsiella, Staphylococcus, Enterococcus, Bacteroides, and/or fungi. Antibiotics felt to be preferable for prophylactic therapy include 1) imipenem-cilastatin, 2) a quinolone + metronidazole, and 3) possibly an extended-spectrum penicillin. Treatment should be continued for 2 weeks or until recovery. Because fungus infections are occurring more often, prophylaxis with fluconazole may be warranted.

Objective: To determine if the anabolic effects of intravenous insulin on protein kinetics could be exploited in the enterally fed trauma victim., Design: Randomized, crossover control protocol., Setting: Level I trauma center., Patients: Ten trauma patients with an Injury Severity Score higher than 20. Exclusion criteria included diabetes mellitus, pregnancy, steroid use, and aged younger than 18 years or older than 65 years., Interventions: Within the first 24 hours of admission to the intensive care unit, each patient had a transpyloric feeding tube inserted radiographically. Enteral nutrition was provided with a protein supplement (Ensure, Ross Laboratories, Columbus, Ohio) and Promod, supplemented with protein powder to supply 1.5 g/kg per day of protein and 156.9 kJ/kg per day. Intravenous insulin was provided at 0.043 U/kg per hour beginning on the second or fourth day., Main Outcome Measures: Urinary nitrogen balance and 3-methylhistidine excretion rates were measured at the end of the third and fifth days. Plasma glucose, insulin, and C-peptide levels were obtained at these same times., Results: Urinary nitrogen balance was not significantly different with or without the administration of insulin (-4.58+/-50.1 mg/kg per day vs -9.38+/-50.9 mg/kg per day, respectively). 3-Methylhistidine excretion rates did not change significantly with or without the administration of insulin (5.77+/-0.67 micromol/kg per day vs 6.15+/-0.43 micromol/kg per day, respectively). Serum insulin levels did not differ significantly when exogenous infusions were added (57.8+/-17.9 microU/mL vs 82.1+/-44.9 microU/mL), but serum C-peptide levels did decrease significantly when exogenous insulin was added (5.11+/-3.2 microU/mL vs 10.28+/-3.5 microU/mL; P = .04). Serum glucose levels decreased significantly when insulin was administered (5.8+/-0.4 mmol/L [104.6+/-7.2 mg/dL] vs 7.7+/-0.4 mmol/L [138.1+/-7.4 mg/dL; P =.004)., Conclusion: The anabolic effect of intravenous insulin on protein kinetics is not evident when nutrition is provided enterally in the trauma victim.

All surgeons will encounter difficult cholecystectomies. Many trying and untenable situations can be prevented or made easier by the cautious surgeon who has a carefully thought-out plan for each potential problem. Step-by-step, this article addresses the arduous challenges that may be faced beginning with diagnosis and continuing through the operative procedure including the decision to operate, the best intervention, abdominal entry, dealing with common duct stones, intraoperative cholangiography, exposure of the biliary anatomy, avoidance of bleeding or common duct injury, spilled stones, and postoperative bile collection. Each problem is addressed with emphasis on prevention and management., (Copyright 1998 W.B. Saunders Company.)

Objective: A prospective, randomized trial was performed to determine which of two antireflux procedures, a complete wrap (Nissen) or a 200N wrap (Toupet), was more effective with fewer sequelae., Summary Background Data: Laparoscopic procedures for gastroesophageal reflux disease appear to be as effective as those done by open laparotomy. The Nissen fundoplication is used most frequently, but postoperative bloating, inability to belch, and dysphagia occur. The partial wrap has been said to be as effective with less unfavorable postoperative symptoms., Methods: Patients with reflux esophagitis were approached laparoscopically using a six-port technique. After division of the short gastric vessels and dissection of the terminal esophagus and fundus of the stomach to allow performance of either procedure, patients randomly were assigned one of the procedures by a card drawn in the operating room., Results: Forty patients underwent operation, but 1 was excluded when an open procedure became necessary. Twenty-three patients received a complete wrap and 16 received a partial wrap. The average operating time was 155 minutes for the Nissen procedures and 162 minutes for the Toupet procedures. The postoperative stay averaged 2.7 days for the Nissen procedures and 2.5 days for the Toupet procedures. There were no deaths. Including the patient converted to an open procedure, three patients had operative complications. At follow-up, Visick scores after the complete wraps were I-13, II-8, III-2 and after the partial wrap were I-12 and II-3. Two patients indicated they would not have the operation again., Conclusions: A partial or a complete wrap after division of the short gastric vessel offers effective therapy for reflux esophagitis with > 90% patient satisfaction. The authors' study shows no clear advantage of one wrap (partial or complete) over the other.

Patients with villous tumors of the ampulla Vater usually present with jaundice, intermittent or constant, but may seek care for abdominal pain, intestinal hemorrhage, or pancreatitis. Because villous tumors may harbor carcinoma in 30 to 50 per cent of cases, appropriate management may require radical resection. We have managed four patients with villous lesions of the ampulla Vater occurring in 1981, 1992, 1993, and 1995. Three were villous (two with malignant change) and one was a villoglandular adenoma. Treatment consisted of local excision with reimplantation of the ducts in one patient, Whipple resection in two patients, and biliopancreatic bypass in one who had distant nodal metastases not resectable for cure. This patient died 18 months after operation of an unrelated disease, but the others were well at last follow-up. The presentation as well as the diagnostic and therapeutic considerations in the management of villous tumors of the ampulla Vater are discussed.

Periampullary carcinoid tumors are rare; only 73 have previously been reported in the international literature. We reviewed the records of four patients with carcinoid tumor at Vater's ampulla. The findings were compared to a recent review of the previously reported 73 patients. The two groups were similar with respect to male predominance, presenting symptoms, infrequent preoperative diagnosis, tumor size, and rate of metastasis. The present study patients were older by 20 years, and none of the patients in this group had von Recklinghausen's disease, despite a 25 per cent incidence in the review group. The follow-up in the present study is too short to make conclusions, but the 5-year survival calculated in the review group was 90 per cent. Periampullary carcinoids act differently clinically from the midgut type. In particular, tumor size appears to have no correlation to metastatic potential, as in midgut carcinoids. If carcinoid syndrome does develop, as a foregut carcinoid it may have a "variant" type syndrome.

Laparoscopic cholecystectomy is usually performed via four to five cannulas; a few surgeons employing only three. A technique utilizing two entry ports, an infraumbilical Hasson 10 mm and a medial subcostal 5 mm, is described. The operation was feasible in six of seven patients. In the seventh, a third cannula was placed to allow traction on a floppy gallbladder. No complications ensued and all patients went home the day following operation. While cosmesis was impressive, the patients appeared to experience pain similar to that of patients in whom more cannulas were employed.

The relationship between precursor supply and hepatic glucose output (HGO) was examined in 8 control subjects and 12 trauma patients after a fasting period of approximately 60 hours. Glucose kinetics were measured with a primed-constant infusion of [U-14C]glucose and [6-3H]glucose. The basal rate of HGO was 5.45 +/- 0.22 micromol x kg-1 x min-1 in the controls and 13.16 +/- 0.76 micromol x kg-1 x min-1 following trauma (p < 0.001). Four hours after amino acid infusion of 1.3 g x kg-1 x 24 h-1, HGO in the controls was unchanged at 5.35 +/- 0.22 micromol x kg-1 x min-1 but it had decreased to 11.71 +/- 0.67 micromol x kg-1 after trauma (p < 0.001). We conclude that increasing the supply of gluconeogenic precursors does not stimulate HGO in normal subjects after fasting or after severe trauma and that factors other than to availability of amino acids are responsible for the enhanced rate of HGO in trauma patients.

Plasma amino acid concentrations were measured during fasting and after 3 days of enteral feeding in 16 trauma patients on a glutamine-supplemented diet and 14 patients on an isonitrogenous control diet. During fasting, total amino acids, including glutamine, were depressed by 50% and this was attributed to a reduction in both essential and nonessential amino acids. The essential amino acid concentrations increased in both groups after feeding. The nonessential amino acid concentrations also increased in the control group but not in the glutamine group during feeding. Repletion of the glutamine extracellular pool was not evident after an average intake of 27.1 g per day of glutamine for 3 days. Nitrogen balance was similar for the two groups during feeding. We conclude that in this study, enteral glutamine did not increase the glutamine plasma concentration. In addition, both formulas improved the hypoaminoacidemia of essential amino acids but only the control diet improved the nonessential amino acids plasma concentration.

Groin hernias are one of the major problems handled by the surgeon. At this time there appears to be some clear indications for open repair, pretty clear indications for laparoscopic repair, less clear indications for one type anesthesia or the other. There has been a major shift toward utilizing mesh in open repairs and in laparoscopic repairs with no significant increase in complications. Patients should usually be able to return to work, even at labor, within two weeks of the operation. Surgeons and patients should expect to experience a recurrence less than 2% of the time.

Laparoscopic cholecystectomy has become the preferred method for removal of the diseased gallbladder. While its morbidity and mortality rates are lower than those of the open technique, it does have associated complications which may cause significant morbidity. The morbidity associated with spilled gallstones is not well studied and little can be found in the literature on this subject. We encountered a patient who developed abscesses within the abdominal wall following laparoscopic cholecystectomy. We recommend that spilled gallstones be removed when possible and that surgeons be aware of this possible complication.

The Nissen fundoplication is the most common operative approach to the correction of gastroesophageal reflux disease (GERD) in the United States. This report describes our success in performing this anti-reflux procedure laparoscopically in 28 patients with symptomatic GERD refractory to conventional medical therapy. Our laparoscopic technique does not differ significantly from the traditional, open Nissen fundoplication. After surgery, all patients reported symptomatic relief, and none required medication for the control of reflux symptoms. Oral feedings were begun on the first postoperative day, and patients were typically discharged on the second day after surgery. All but two patients resumed normal eating within an average of 26 days. Two patients experienced longer term postoperative dysphagia, including one who had undergone a highly selective vagotomy concurrent with the antireflux surgery.

Dramatic advances continue to occur with video-directed endoscopic operations. This commentary will follow the same format as the one in the previous edition two years ago. Most of the predictions anticipated in our last writing have been met or exceeded. Change will continue to accelerate, though the individual innovations will be of smaller magnitude.

Objective: This article reviews the authors' experience with endoscopic management of duodenal ulcer and ulcers occurring after a previous drainage procedure., Summary Background Data: Patients with complications of duodenal ulcer and ulcers occurring after a previous drainage procedure still require surgical management. Virtually all operations for duodenal ulcer include some form of vagotomy. American surgeons in academic centers prefer highly selective vagotomy in suitable candidates. Video-directed laparoscopic and thoracoscopic operations have been done for all complications of duodenal ulcer except for acute hemorrhage., Methods: The authors have performed laparoscopic operation on eight patients with intractable chronic duodenal ulcer, seven patients with gastroesophageal reflux disease combined with duodenal ulcer, one patient with chronic duodenal ulcer and gastric outlet obstruction, and one patient with acute perforation. Operations performed included omentopexy, anterior seromyotomy plus post truncal vagotomy, and highly selective vagotomy. Seven patients had a simultaneous Nissen fundoplication; and the patient with obstruction underwent concomitant pyloroplasty and vagotomy. Six patients with intestinal ulcers occurring after a previous drainage procedure were treated with thoracoscopic vagotomy. Techniques used are shown., Results: There has been one recurrent ulcer in the laparoscopic group after anterior seromyotomy plus posterior truncal vagotomy. The patient treated by omentopexy for duodenal perforation recovered gastrointestinal function promptly with no further difficulty, but eventually died of primary medical disease. Patients undergoing thoracoscopic vagotomy have all become asymptomatic. Postoperative hospital stay after highly selective vagotomy, anterior seromyotomy plus posterior truncal vagotomy, or thoracoscopic vagotomy was 1-5 days., Conclusions: Laparoscopic management of duodenal ulcers is feasible. Larger numbers of patients with longer follow-up are essential. Ulcers occurring after a drainage procedure deserve thoracoscopic vagotomy.

This report describes a laparoscopic procedure for prosthetic repair of inguinal hernias using an extraperitoneal approach. A total of 51 primary direct and indirect hernias were repaired in this series, including 11 recurrent and 12 bilateral hernias. Operative time for this laparoscopic procedure was similar to that of the comparable open surgery and no unusual complications were noted. All patients were discharged the day following surgery and returned to work within 7 days.

Duodenal and marginal jejunal ulcers respond promptly to vagus section. When a prior gastric drainage procedure has been done, the approach of choice for these ulcers is vagectomy through the left chest. This report describes four patients who were subjected to thoracoscopic vagectomy and had prompt early benefit. A description of our technique is presented.

The current study was undertaken to evaluate the contribution of insulin and glucagon to regulation of glucose metabolism in man following severe, traumatic injury by manipulating concentrations of insulin and glucagon with infusions of somatostatin. Glucose kinetics were assessed with [U-14C, 6-(3)H]glucose in severely injured patients and compared with data obtained from patients recovering from minor, elective operative procedures. Glucose production was significantly increased in subjects with traumatic injury compared with control subjects (13.0 +/- 0.63 mumol/kg/min v 8.6 +/- 0.27 mumol/kg/min). There was no impairment in glucose oxidation by the injured patients. Modulation of insulin and glucagon with somatostatin indicated that non-insulin-mediated glucose uptake (NIMGU) was significantly elevated in injured patients (12.2 +/- 0.94 mumol/kg/min v 7.4 +/- 0.61 mumol/kg/min). Hepatic glucose output (HGO) in the absence of glucagon was also significantly elevated in injured patients (12.2 +/- 1.20 mumol/kg/min v 5.8 +/- 1.08 mumol/kg/min). Indirect calorimetry showed a 27% increase in resting energy expenditure (REE). Increased protein oxidation accounted for 56% of the increase in REE. Changes in carbohydrate and lipid oxidation accounted for 28% and 15% of the increase in REE. There was no correlation between the injury severity score of the injured patient and the degree of metabolic abnormality. It is concluded from these studies that (1) injured patients have a high rate of glucose turnover in the absence of glucagon and insulin; (2) the reliance on glucose as a source of energy is not diminished in injured subjects; and (3) increases in protein oxidation account for the majority of the increased REE found in injured patients.

Video controlled laparoscopy has dramatically changed general surgery. Further striking alteration is sure to occur in the immediate future. Not only are the surgeons who are concentrating on this area making great strides, but innovative equipment and technological innovation are certain to make more complex procedures feasible. Thus the future of laparoscopic surgery is very bright.

Diagnostic peritoneal lavage (DPL) is an established procedure in evaluation of trauma victims but is less well established for use in patients suspected of having acute intra-abdominal disease. Twenty-six seriously ill patients at our institution who had DPL for acute intra-abdominal disease form the basis of this report. Use of DPL indicated sepsis in ten patients; in seven of the ten, findings were confirmed at celiotomy or autopsy. Only one of the ten survived without laparotomy or confirmatory necropsy indicating the result of DPL had been false-positive. Sepsis was not indicated by DPL in 16 patients. Fourteen patients appeared to have true-negative results confirmed by operation (three patients), autopsy (four patients), or survival longer than two weeks (seven patients). Complications occurred in one patient whose DPL showed sepsis. Two patients with negative results of DPL died within two weeks of examination without confirmatory operation or autopsy and could not be evaluated. We therefore, consider the overall diagnostic accuracy in our patient group to be 95%. We recommend the use of DPL in patients suspected of an acute intra-abdominal disease process who are unable to undergo other evaluation for reasons such as critical illness.

Injuries of the diaphragm in 86 patients occurring over a 10-year period were retrospectively reviewed. Blunt trauma victims experienced injury on the right and left with nearly equal frequency, representing a strikingly different experience from those reporting before 1970 when left-sided injuries predominated. Patients' complaints and physical findings were not reliable indicators of diaphram injury, but were usually manifestations of associated injury. Ninety-five per cent of our acute victims had other injuries. Routine chest X-rays were the most reliable diagnostic tools, yet these were normal in 1/4 of the patients. Diagnosis depends on high index of suspicion before operation and careful inspection of the diaphragm at operation. Initial thoracotomy required subsequent laparotomy to complete management in seven of 15, whereas laparotomy required supplemental thoracotomy only once in 65 instances. The superior operative approach, therefore, for either right or left diaphragmatic injury is initial laparotomy.

We reviewed the records of 274 trauma patients who had 275 diagnostic peritoneal lavages from Feb 1, 1983 through Jan 31, 1986. Lavage was done in 271 of 560 (48%) cases of blunt trauma and three of 245 (1%) penetrating injuries (gunshot wounds to the chest). The open lavage technique was used, and results were considered grossly positive if there was 10 ml of gross blood. Results were considered microscopically positive if there were more than 100,000 RBCs or 500 WBCs/cu mm, an elevated amylase or bilirubin value, or bacteria or vegetable fibers. Lavage was negative in 193 cases, including false-negative results (1%), and positive in 78, with three false-positive results (3.8%). Open peritoneal lavage is safe, rapid, readily available, and accurate in the evaluation of blunt abdominal trauma.

Nonocclusive mesenteric ischemia, leading into intestinal infarction, frequently complicates and causes the fatal outcome in otherwise treatable instances of low cardiac output states. Once intestinal necrosis occurs in these patients, the mortality is almost 100 per cent. A high risk group of patients in whom intestinal infarction occurs because of low cardiac output can be readily identified. A high index of suspicion for the occurrence of intestinal ischemia in these patients should facilitate recognition of the disease during its early stages. The disastrous results experienced by us and others warrant the use of more aggressive methods for the diagnosis and treatment of patients with this condition. A high index of suspicion in a recognizable group of patients observed by selective mesenteric arteriography affords a method for confirmation of the diagnosis of mesenteric vasoconstriction. Once the diagnosis is established, a patient management protocol program should be followed. Sustained infusion of papaverine into the mesenteric artery is useful in reversing mesenteric vasoconstriction. Additionally, the judicious use of celiotomy and intestinal resection, preceded and followed by the sustained infusion of papaverine into the superior mesenteric artery, offers hope for the survival of some of these patients and warrants further use.

Preventable deaths from small bowel obstruction result from misdiagnosis, inappropriate delay in operation, inadequate preoperative preparation, and a poorly performed operative procedure. A systematic approach to each of the factors includes repeat physical examination, x-rays and CBC four hours after initial study in questionable cases, a pre-planned therapeutic interventions timetable, adequate intravascular volume and electrolyte levels, and a carefully designed operation which includes as little bowel manipulation and entrance as possible.

Rupture of an aneurysm of the mesentergic artery caused severe intestinal hemorrhage in a 50-year-old woman with polyarteritis nodosa. Abdominal angiography not only established diagnosis of polyarteritis nodosa by demonstrating multiple visceral aneurysms but also localized the site of bleeding.

All cases of penetrating cardiac trauma in 1985 and 1986 in Jefferson County, Alabama, where patients dying of penetrating trauma received autopsies, were retrospectively reviewed. All hospitals in the county plus the single coroner's office provided the records of the 72 patients comprising this study. Incidents occurred most often in the home or residence (70%) by a known assailant (83%) due to domestic/social disputes (73%). Frequency was greatest in the evening hours (73% between 6:00 PM and 3:00 AM), on weekends in spring and summer. Victims tended to be male (86%), black (72%), married (46%), blue collar workers (62%). There were 41 (57%) gunshot wounds, 3 (4%) shotgun wounds, and 28 (39%) stab wounds with an associated mortality rate of 97%, 100%, and 68%, respectively. Prehospital mortality rate (dead at the scene) was 54.2% (39/72), and death on arrival was 26.4% (19/72), for a combined pretreatment mortality rate of 80.6%. All patients who arrived with no vital signs died. Mortality appeared to be related to mechanism of injury, age, race, sex, vital signs on arrival, number and specific cardiac chambers injured, associated major vascular injury, hematocrit, and mode of transportation. Mortality was not related to caliber of weapon, ethanol level, transport time, time from arrival to operation, or transfusion requirements. There were only ten survivors (1 gunshot wound and 9 stab wounds), all of whom had ventricular injuries and no associated major vascular injuries. The ten survivors represented a 71.4% (10/14) salvage rate for those victims arriving with vital signs. Complications occurred in three patients. Hospitalization averaged 7.3 days in the survivors. Penetrating cardiac trauma remains a serious, socially linked disease with a high rate of mortality. Rapid transport, aggressive resuscitation and cardiorrhaphy remain the best treatment.

A retrospective review of experience with small-bowel obstruction at the University Hospital in Birmingham for a ten-year period (January 1963 through December 1972) revealed 465 episodes of obstruction in 415 patients. The mortality was 4% in obstruction due to adhesions, and 28% in obstruction caused by carcinoma; overall mortality was 8%. Intra-abdominal adhesions were the cause of 69% of cases. Malignant obstruction (mostly from metastatic disease) was the second most common cause of obstruction, and external hernia was third. Delay in diagnosis and inappropriately prolonged used of long intestinal tubes added to the mortality and can be avoided. We suggest a plan for prompt, consistent diagnosis and recommend more liberal use of the barium meal in questionable cases.

One hundred seventy-one patients received one year of melphalan or intermittent cyclophosphamide, methotrexate, and fluorouracil after mastectomy for breast cancer with involved axillary nodes. Analysis with a median follow-up of three years indicates a favorable outcome only for patients with 1-3 positive nodes who were treated with melphalan and who experienced a leukocyte count less than 3,000/mm3 (3.0 X 10(9)/l). Tumor size, average percentage of dose received, menopausal status, and type of chemotherapy were not significant factors in recurrence of disease, after adjustment for the number of positive nodes and leukocyte count nadir during treatment based on a multifactorial analysis. These data suggest that administration of a dose of melphalan which does not produce a leukocyte count of less than 3,000/mm3 is ineffective in preventing early recurrence of disease. Since oral melphalan is known to be erratically absorbed, lack of hematologic toxicity may well be due to variable absorption of the drug on a fixed-dose region. Failure to prevent recurrence of disease in this and other trials using oral melphalan may be due to chemotherapy-related as well as disease-related factors.

Superior technique necessitates effective intraoperative communication. Hand signals can convey most of the wishes of the surgeon. Pragmatic execution calls for mixing hand signals with anticipation and verbal commands.

The diagnosis of intestinal obstruction is readily made when a patient presents with typical history and signs, and when plain films of the abdomen display characteristic findings. Some patients, however, constitute diagnostic problems because abdominal roentgenograms are still equivocal, even after repetition in four hours. In the unclear case, use of a barium meal will safely, promptly, and routinely prove or disprove small bowel obstruction. Intestinal obstruction in which the initial abdominal films tend to be either unrevealing or equivocal include high obstructions, including the superior mesenteric artery syndrome; presence of strangulation; partial small bowel obstruction; and fluid-filled proximal bowel. In intestinal obstruction, characteristic roentgenographic findings with use of barium meal are normal to rather rapid transit time to the point of obstruction; homogenous dilution of barium in dilated proximal loops; and inhomogenous, scattered, and fragmented collections of barium in the distal, collapsed loops.

The right hepatic artery in a patient with traumatic liver tear was embolized with Gelfoam to stop an otherwise uncontrollable hemorrhage. The procedure was probably life saving in this patient. Transient elevated transaminase and bilirubin levels returned to normal 3 weeks after embolization. A repeat hepatic arteriogram 4 months after embolization demonstrated good revascularization of the right hepatic lobe from the left hepatic, left gastric, and gastroduodenal arteries. This case demonstrates the therapeutic value and safety of selective hepatic arterial branch embolization in massive life-threatening hemorrhage.

Seven patients with cardiac rupture from blunt trauma were encountered at the University Hospital, University of Alabama School of Medicine, in a 15-year period. Five of seven patients survived, including three with left atrial injuries and one each with right ventricular and left ventricular injuries. Useful diagnostic features included systolic hypotension, distended neck veins, and elevated central venous pressures. Associated injuries averaged four per patient. Successful management demands a high index of suspicion of cardiac injury, prompt diagnosis, and immediate median sternotomy. After repair of the heart the incision should usually be extended to allow exploratory laparotomy.

A retrospective review revealed 17 lymphomas in a 25-year period (1960-84). Presenting features did not allow differentiation from carcinoma. Preoperative diagnosis was made in 3 patients by endoscopic biopsy. Treatment included apparent complete resection of 12 patients. Incomplete removal following biopsy with or without a drainage procedure was performed on five patients. Radiation therapy was used on ten patients and chemotherapy was used on three patients. There were three 5-year survivors and four others with survival greater than 2 years. All patients surviving more than 2 years had apparent complete resection while five patients also had radiation. One also had chemotherapy. Analysis of our patients with review of other series suggests complete resection with adjacent nodes to be the best approach. Appropriate node sampling, liver biopsy, and removal of the spleen if it appears clinically involved should be done. Postoperative radiation and/or chemotherapy may be indicated only when apparent complete resection is not feasible.

One hundred and thirty splenectomies were performed at the University Hospital in Birmingham for hematologic disorders during a 12 year period. There were seven deaths of which four were related to sepsis in patients with malignant growths which probably impaired immune competence. Splenectomy was found to be uniformly satisfactory for hereditary hemolytic anemia, for hypersplenism complicating rheumatoid arthritis and for the rare instance of primary hypersplenism. Splenectomy was usually salutary in didopathic thrombocytopenic purpura and in antoimmune hemolytic anemia. When done for diagnosis, splenectomy was definitive in about 50 per cent of the instances. Individual patients with thrombotic thrombocyeosinophilia syndrome benefited. Splenectomy for hypoplastic or aplastic anemia in an actual circulation offered only questionable benefit and is rarely necessary for hyperplenism secondary to portal hypertension.

Blunt trauma to renal arteries often receives suboptimal management because of delayed diagnosis, incomplete preoperative evaluation, associated injuries, or unknown functional capacity of the contralateral kidney. We propose a rational treatment plan from an analysis of our three cases and a review of 118 cases. Two thirds of the patients were male, and left-sided injuries predominated over right 42.9% to 30.6%. In 20 cases the insult was bilateral. Associated injuries occurred in 72%, averaging 1.6 injuries per case, of which one half were intra-abdominal. Flank and/or abdominal pain was present in 73% of cases, tenderness in 65%, and gross or microscopic hematuria in 74%. Repairs were attempted on 38 renal arteries. "Successful" repairs were accomplished in 16 arteries, while repairs failed in 22. Subsequent hypertension developed in 32% of successes. Repair should be attempted in stable patients with unilateral injury of less than four hours' duration, bilateral injuries of less than 20 hours' duration, or injuries with nonocclusion on arteriogram.