Showing papers in "Journal of The American College of Surgeons in 1996"

Prevention of postoperative abdominal adhesions by a sodium hyaluronate-based bioresorbable membrane : a prospective, randomized, double-blind multicenter study

Abstract: BACKGROUND: Postoperative abdominal adhesions are associated with numerous complications, including small bowel obstruction, difficult and dangerous reoperations, and infertility. A sodium hyaluronate and carboxymethylcellulose bioresorbable membrane (HA membrane) was developed to reduce formation of postoperative adhesions. The objectives of our prospective study were to assess the incidence of adhesions that recurred after a standardized major abdominal operation using direct laparoscopic peritoneal imaging and to determine the safety and effectiveness of HA membrane in preventing postoperative adhesions. STUDY DESIGN: Eleven centers enrolled 183 patients with ulcerative colitis or familial polyposis who were scheduled for colectomy and Heal pouch-anal anastomosis with diverting-loop ileostomy. Before abdominal closure, patients were randomly assigned to receive or not receive HA membrane placed under the midline incision. At ileostomy closure eight to 12 weeks later, laparoscopy was used to evaluate the incidence, extent, and severity of adhesion formation to the midline incision. RESULTS: Data were analyzed for 175 assessable patients. While only five (6 percent) of 90 control patients had no adhesions, 43 (51 percent) of 85 patients receiving HA membrane were free of adhesions (pl0.00000000001). The mean percent of the incision length involved was 63 percent in the control group, significantly greater than the 23 percent observed in patients who received HA membrane (pl0.001). Dense adhesions were observed in 52 (58 percent) of the 90 control patients, but in only 13 (15 percent) of the 85 receiving HA membrane (pl0.0001). Comparison of the incidence of specific adverse events between the groups did not identify a difference (pg0.05). CONCLUSIONS: This study represents the first controlled, prospective evaluation of postoperative abdominal adhesion formation and prevention after general abdominal surgery using standardized, direct peritoneal visualization. In this study, HA membrane was safe and significantly reduced the incidence, extent, and severity of postoperative abdominal adhesions.

Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group.

Abstract: Background There has been a broad interest in the use of growth factors to treat patients with chronic nonischemic diabetic ulcers. Study design One hundred eighteen patients were studied in a randomized, prospective, double-blind, multicenter trial comparing treatment with topically applied recombinant human platelet-derived growth factor (rhPDGF) or placebo (vehicle) and were treated until completely healed or to 20 weeks. All patients had aggressive sharp debridement of their ulcers before randomization and repeat debridement of callus and necrotic tissue as needed. The influence of debridement was evaluated by reviewing the records of the office visits where debridement was performed. Results Forty-eight percent of patients treated with rhPDGF healed compared with 25 percent of patients who received placebo (p = 0.01). The mean percentage of office visits where debridement was performed was comparable for the two treatment groups: 46.8 percent (rhPDGF) and 48.0 percent (placebo). In general, a lower rate of healing was observed in those centers that performed less frequent debridement. The improved response rate observed with more frequent debridement was independent of the treatment group. However, for any given center, the percentage of patients who healed was greater with rhPDGF than placebo. Conclusions Wound debridement is a vital adjunct in the care of patients with chronic diabetic foot ulcers.

Male and female sexual and urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum.

Abstract: Background We performed a study to assess sexual and urinary function after total mesorectal excision with autonomic nerve preservation for primary carcinoma of the rectum. Study design We studied retrospectively postoperative sexual and urinary function in 136 (78 percent) of 175 eligible patients (82 males and 54 females) who responded to a standardized questionnaire. Results The ability to engage in intercourse was maintained by 86 percent of the patients younger than 60 years of age, and by 67 percent of patients 60 years and older. Eighty-seven percent of male patients maintained their ability to achieve orgasm. The type of surgery (abdominoperineal resection compared to low anterior resection), and age equal to or greater than 60 years were significantly associated with male sexual dysfunction. Of the female patients, 85 percent were able to experience arousal with vaginal lubrication and 91 percent could achieve orgasm. The majority of patients had few or no complaints related to urinary function. Serious urinary dysfunction such as neurogenic bladder was not encountered. Conclusions Autonomic nerve preservation in association with total mesorectal excision reduces the operative morbidity rate and is successful in minimizing sexual and urinary dysfunction in the operative treatment of patients with carcinoma of the rectum.

Quality of life scale for gastroesophageal reflux disease.

Abstract: BACKGROUND Treatment of uncomplicated gastroesophageal reflux disease (GERD) is primarily to improve the symptoms of the patient. However, measurement of symptomatic outcome is difficult because it is as the patient perceives it to be and not "objective." This creates a need to develop a simple and understandable instrument to measure symptomatic outcome. STUDY DESIGN All patients referred for evaluation of GERD were eligible for this prospective study. During the initial visit, patients were asked to complete the Gastroesophageal Reflux Data Sheet. This ten-item questionnaire included an overall assessment of satisfaction; the best possible score was 0, and the worst was 45. The evaluation included history, physical examination, and additional studies, including upper gastrointestinal series, esophagogastroduodenoscopy, esophageal manometry, and 24-hour esophageal pH monitoring as indicated. Initial treatment was medical with histamine2-blockers, omeprazole, cisapride, or both. If a patient was dissatisfied with medical treatment and had both a hypotensive lower esophageal sphincter and abnormal results of the 24-hour pH monitoring, then operative treatment with either laparoscopic or open Nissen or Toupet fundoplication was offered. After approximately three months of medical treatment or one month after operative treatment, patients were asked to complete the questionnaire again. Data were analyzed using nonparametric tests and linear regression analysis. RESULTS A total of 72 patients were assessed, and 100 percent of them completed the questionnaire. Patients who were satisfied with their condition had a median health-related quality of life (HRQL) score of five, and those who were dissatisfied had a median score of 26 (p < 0.000001). Patients who ultimately chose surgical therapy had a median preoperative score of 28, compared with 15 for patients who chose to continue medical therapy (p = 0.0001). The change in HRQL score from before treatment to after treatment for surgical patients was 27 compared with 11 for medically treated patients (p < 0.002). Items 1 through 6 of the questionnaire were individually sensitive to the effects of treatment. However, there was no correlation between HRQL and the composite pH score or with the lower esophageal sphincter pressure. CONCLUSIONS This HRQL score has advantages over standard health status instruments for GERD including simplicity for patients (and therefore a high compliance rate), ease of understanding for physicians, and sensitivity to the effects of treatment. In addition, it may help determine, early in the course of treatment, patients who may ultimately require surgical therapy, thereby avoiding prolonged, but futile, medical therapy.

Laparoscopic adrenalectomy compared to open adrenalectomy for benign adrenal neoplasms.

Abstract: BACKGROUND Laparoscopic adrenalectomy has recently been used for removing a variety of adrenal neoplasms. The purpose of the present study was to compare results and outcomes in patients who underwent either laparoscopic or open adrenalectomy at our institution from 1988 to the present. STUDY DESIGN The records of 66 consecutive patients with benign adrenal neoplasms who underwent adrenalectomy from 1988 through 1995 were retrospectively reviewed. Patients were divided into three groups based on the operative approach: group I (n = 25), open anterior transabdominal approach; group II (n = 17), open posterior retroperitoneal approach; and group III (n = 24), laparoscopic transabdominal flank approach. Various parameters were compared and statistical analyses were performed. RESULTS The three groups were similar in age, gender, American Society of Anesthesiologists class, and distribution of unilateral compared with bilateral adrenalectomy. Mean tumor size was slightly larger in group I (3.4 +/- 1.4 cm) than in group II (2.4 +/- 1.4 cm) or group III (2.7 +/- 1.4 cm) (p = NS). Mean operative times for unilateral adrenalectomy were 142 +/- 38 minutes in group I, 136 +/- 34 minutes in group II, and 183 +/- 35 minutes in group III (p < 0.001, groups I and II compared with group III). For bilateral adrenalectomy, mean operative times were 205 +/- 71 minutes (group I), 328 +/- 11 minutes (group II), and 422 +/- 77 minutes (group III). Patients who underwent laparoscopic adrenalectomy had significantly less operative blood loss (mean, 104 mL compared to 408 mL in group I and 366 mL in group II, p < 0.001) and a lower incidence of perioperative blood transfusion. Laparoscopic adrenalectomy was also associated with significantly reduced parenteral pain medication requirements (p < or = 0.001) and more rapid resumption of a regular diet (p < or = 0.01) compared to open adrenalectomy. Postoperative length of stay was significantly longer in group I (8.7 +/- 4.5 days) and in group II (6.2 +/- 3.9 days) after open adrenalectomy than after laparoscopic adrenalectomy (3.2 +/- 0.9 days) (p < 0.01). Total hospital charges were similar for groups II and III but somewhat higher for group I. Patients were able to resume 100 percent activity an average of 10.6 +/- 4.9 days after laparoscopic adrenalectomy and returned to work a mean of 16.0 +/- 6.1 days postoperatively. CONCLUSIONS Laparoscopic adrenalectomy is a safe and effective procedure and has several advantages over open adrenalectomy. Laparoscopic adrenalectomy should become the preferred operative approach for the treatment of patients with small, benign adrenal neoplasms.

A prospective randomized study of end points of resuscitation after major trauma: global oxygen transport indices versus organ-specific gastric mucosal pH.

Abstract: BACKGROUND Gastric tonometry, as a method of organ-specific monitoring of the status of the splanchnic circulation, has demonstrated prognostic and therapeutic implications in critically ill patients. The experience with this method in patients with trauma has been limited. STUDY DESIGN Fifty-seven patients were prospectively randomized into two groups: group 1, n = 30, normalization and maintenance of gastric mucosal pH (pHi) at or above 7.3 and group 2, n = 27, maintenance of oxygen delivery index of 600 or an oxygen consumption index of greater than 150. The groups had statistically similar injury severity scores, lactate levels, and base deficits. RESULTS Of the 44 patients with pHi greater than 7.3 at 24 hours, three (6.8 percent) died of multiple organ dysfunction syndrome as compared with seven (53.9 percent) of 13 in whom pHi was not optimized, p = 0.006. Optimization times for oxygen delivery index, oxygen consumption index, lactate levels, and base excess were similar between survivors and nonsurvivors. The time for pHi optimization was significantly longer in nonsurvivors. Multiple organ dysfunction syndrome points were significantly higher in patients who did not have pHi optimized within 24 hours (6.08 compared with 2.5, p = 0.03). Optimization time for pHi was predictive of mortality on multiple regression. Persistently low pHi was frequently associated with systemic or intra-abdominal complications. It was the first finding in all the nonsurvivors at least 48 to 72 hours before death. CONCLUSIONS Gastric mucosal pH may be an important marker to assess the adequacy of resuscitation. Monitoring of pHi may provide early warning for systemic complications in the postresuscitation period.

The effect of prolonged pneumoperitoneum on renal function in an animal model

Abstract: Background Prolonged, increased intra-abdominal pressure (IAP) during laparoscopic surgery has been associated with oliguria and anuria. Study design The objective of this study was to evaluate the effects of various levels of IAP on renal function. Ten groups of three adult female farm pigs were given a general anesthetic, followed by establishment of an IAP of 0, 5, 10, 15, or 20 mm Hg with CO2, 20 mm Hg with argon gas, abdominal wall lift device, renal vein occlusion (RVO), 15 mm Hg with CO2 plus dopamine administration at 2 microgram/kg/minute, or 20 mm Hg retroperitoneal CO2 insufflation. The following studies were recorded: baseline central venous pressure (CVP), pulmonary wedge pressure (PWP), cardiac output (CO), renal vein flow (RVF), renal artery pressure (RAP), selective urine output (UO), urinary osmolarity, and creatinine clearance; the parameters were repeated every 30 minutes for the four hours of the IAP study and two hours after release of the IAP. Results The results were analyzed within two main IAP groups: less than 15 mm Hg and greater than or equal to 15 mm Hg. There was no clinically significant variation in the CVP, PWP, and RAP. The CO decreased slightly and this was more significant in the greater than or equal to 15 mm Hg group. The RVF and UO decreased concomitantly and significantly in the greater than or equal to 15 mm Hg group. Even after two hours of desufflation, the RVF did not return to baseline, although the UO improved. Creatinine clearance decreased significantly in the greater than or equal to 15 mm Hg group. The RVO group exhibited similar changes in the study parameters as those seen in the greater than or equal to 15 mm Hg group, although the RVF did not improve on release of the renal vein in the RVO group. Changes were the same with an argon or CO2 IAP of 20 mm Hg. The abdominal wall lift device had an associated decrease in RVF at 15 KG force but no alteration in UO. Retroperitoneal insufflation resulted in the same decrease in RVF and UO as seen with the same IAP. Dopamine did not afford a protective effect on UO during an IAP of 15 mm Hg. Conclusions The decreased UO during prolonged IAP greater than or equal to 15 mm Hg in the animal model is associated with a corresponding decrease in RVF, but does not appear to be associated with any permanent renal derangement nor any transient histologic changes.

Vascular graft thrombosis after pancreatic transplantation: univariate and multivariate operative and nonoperative risk factor analysis.

Abstract: Background Vascular thrombosis is still the leading cause of nonimmunologic, technical pancreatic transplant graft failures. The paucity of published data--coupled with our large institutional experience with pancreatic transplantation in all recipient and transplant categories, using a wide spectrum of surgical techniques--provided the impetus for a retrospective study of graft thrombosis risk factors. Study design Four hundred thirty-eight patients with pancreatic transplants (45 percent simultaneous pancreas-kidney [SPK], 23 percent pancreas-after-kidney [PAK], and 32 percent pancreatic transplants alone [PTA] and with Type I insulin-dependent diabetes mellitus were studied retrospectively. Of 438 pancreatic transplants, 90 percent were bladder-drained and 10 percent were enteric-drained. Ninety-three percent were from cadaver donors, 90 percent were whole-organ grafts, and 20 percent were retransplantations. Quadruple immunosuppression was given. For bladder-drained, whole-organ transplantations (n=378), we performed Cox regression analyses to study the impact on pancreatic graft thrombosis of donor, recipient, mode of preservation, and surgical variables. Results The overall thrombosis rate was 12 percent (5 percent arterial, 7 percent venous). For cadaver, bladder-drained, whole-organ pancreatic transplants, the thrombosis incidence was highest in PAK recipients (20 percent). The PAK category was also found to be an independent risk factor for thrombosis by stepwise Cox regression analysis. In separate stepwise Cox regression analyses for each category, other identified risk factors for thrombosis included the following: donor age (PAK, PTA); cardiocerebrovascular cause of donor death (SPK, PAK); the use of an aortic Carrel patch (SPK); arterial pancreatic graft reconstruction using a splenic artery to superior mesenteric artery anastomosis (SPK, PTA) or an interposition graft between the splenic artery and the superior mesenteric artery (PTA); portal vein extension graft (PAK); left-sided implantation into the recipient (PAK); and graft pancreatitis (defined as hyperamylasemia exceeding five days post-transplant [PAK, PTA]). Conclusions Older donors or those who died of cardiocerebrovascular disease should not be considered for any recipient category. Preservation time needs to be minimized and strategies need to be developed to decrease graft pancreatitis. Surgically, left-sided implantation and arterial reconstructions other than the Y-graft also increase risk, as do portal vein extensions. Renal transplants alone in prospective PAK recipients with Type I diabetes mellitus should, therefore, always be implanted left-sided to allow for right-sided pancreatic graft placement.

Intestinal adaptation following massive small bowel resection in the mouse.

Abstract: BACKGROUND: Transgenic mice represent powerful tools for studying the role of genes and their expression under multiple conditions, and they may provide a unique model for studies of intestinal adaptation after massive small bowel resection (SBR). This study characterized a successful model for SBR and intestinal adaptation in the mouse. STUDY DESIGN: Sham operation (bowel transection with reanastomosis) or SBR was performed on male C57BL/6 mice. A solid or liquid diet, various sizes of monofilament suture for the anastomosis, and resection of 50 or 75 percent of the proximal small intestine were studied. In other studies, intestinal adaptation was characterized as changes in intestinal wet weight, DNA, protein, villus height, crypt depth, and crypt cell proliferation rates at 12 hours, 24 hours, three days, and one, two, and four weeks after 50 percent SBR. RESULTS: Survival was significantly improved with a liquid diet (8 percent compared with 88 percent; p < .001) and modestly improved by using the smallest suture for anastomosis (60 percent for 7-0 compared with 88 percent for 9-0; p = not significant). Mice did not tolerate more than 50 percent SBR (16 percent survival rate for 75 percent SBR compared with 85 percent survival rate for 50 percent SBR; p < .01). Small bowel resection augmented ileal wet weight, DNA and protein content, villus height, crypt depth, and crypt-cell proliferation rates. CONCLUSIONS: Provision of a liquid diet, using a small suture for anastomosis, and resection of no more than 50 percent of the proximal small intestine are important for survival. This model will permit researchers using transgenic mice to better understand critical genes during intestinal adaptation after SBR.

Retroperitoneal sarcoma: the University of Florida experience.

Abstract: BACKGROUND Retroperitoneal sarcomas are rare mesenchymal neoplasms. Analysis of their characteristics and their impact upon a particular patient population is of significant importance to the surgeon. From 1970 to 1994, 63 adult patients underwent resection of primary retroperitoneal sarcomas at the University of Florida. STUDY DESIGN A retrospective analysis was performed to determine the biologic behavior of these tumors, surgical management of primary and recurrent disease, predictive variables influencing survival, and the effect of multimodality therapy. RESULTS There were 39 females and 24 males and the mean age was 55 years. The median weight of the tumors was 1,815 g (range 25 to 10,800 g). There were 33 percent leiomyosarcomas, 30 percent malignant fibrous histiocytomas, and 22 percent liposarcomas. Low-grade tumors accounted for 46 percent of the total, and grade was a significant predictor of survival (p=0.002). Seventy-eight percent of the lesions were totally resected, and this clearly influenced outcome (p<0.0001). In 75 percent of cases, adjacent organs were resected concurrently, and 34 percent of the tumors involved local vascular structures. Survival was enhanced by multiple resections in the 40 percent of patients who had a recurrence (p=0.0001). None of the adjuvant therapy regimens demonstrated survival advantage. Thirty-one percent of the study group patients were alive and 21 percent were disease free at the conclusion of the study. Median survival has been 41 months after total resection, nine months after debulking, and five months after biopsy only. CONCLUSIONS Complete resection and low grade continue to be the most important prognostic factors for this tumor. The survival advantage of multiple resections has seldom been noted and justifies an aggressive surgical follow-up.

Intra-abdominal fungal infections after pancreatic transplantation: incidence, treatment, and outcome

Abstract: BACKGROUND Intra-abdominal infections account for 15 percent of technical failures after pancreatic transplantation. Although some data are available about intra-abdominal bacterial infections, no study has analyzed the incidence, treatment, and outcome of intra-abdominal fungal infections. STUDY DESIGN We retrospectively studied 445 consecutive pancreatic transplantations--45 percent were simultaneous pancreatic and renal, 24 percent pancreatic after renal, and 31 percent pancreatic transplantations alone--in patients with Type I diabetes mellitus. Donors were cadavers in 92 percent and living relatives in 8 percent. Primary transplantations were done in 80 percent and retransplantation in 20 percent. Of these 445 pancreatic transplantations, 90 percent were bladder-drained, 9 percent enteric-drained, and 1 percent duct-injected. Only symptomatic patients with documented culture-positive intra-abdominal fungal infections were included. RESULTS Intra-abdominal fungal infections occurred after pancreatic transplantation in 41 (9.2 percent) of 445 patients. Donor age, but not recipient age, was a significant risk factor. The rate of infections was higher for enteric-drained (21 percent) than for bladder-drained (10 percent) transplantations; for organs donated by living relatives (16 percent) than for those from cadavers (9 percent); and for pancreatic after renal (12 percent) and simultaneous pancreatic-renal (11 percent) than for pancreatic-only (5 percent) recipients. The rate of intra-abdominal fungal infections was 6 percent for recipients who were given antifungal prophylaxis (fluconazole, 400 mg/day for seven days after transplantation) compared with 10 percent for those without prophylaxis. The one-year graft survival rate for recipients with infection was 17 percent compared with 65 percent for those without (p = 0.0001); the survival rate was 70 percent compared with 92 percent for patients with and without infection, respectively (p = 0.0007). In 22 percent of recipients, the infection resolved and graft function persisted; in 58 percent, the infection resolved after transplant pancreatectomy; and in 20 percent, death occurred despite transplant pancreatectomy. Recipients with sole fungal or fungal and bacterial infection (n = 41) were 50 percent less likely to recover with a functioning graft and had a risk of death that was three times higher (p < or = 0.05) than those with sole bacterial infection (n = 48). CONCLUSIONS Intra-abdominal fungal infections after pancreatic transplants are associated with high morbidity and mortality rates, significantly higher than for sole bacterial infections. In addition to aggressive treatment, including transplant pancreatectomy and reduction of immunosuppression, efforts must be made toward better prevention of intra-abdominal fungal infections.

Transperineal repair of symptomatic rectocele with Marlex mesh: A clinical, physiological and radiologic assessment of treatment

Abstract: BACKGROUND: The aim of this study was to evaluate the operative repair of rectoceles in a defined group of women by a technique designed to deal with the cause (failure of the rectovaginal septum) rather than the effect (rectal and vaginal wall bulging). STUDY DESIGN: Only women whose defecation was aided by vaginal digitation and who had large rectoceles on proctography were included. Any other clinical symptoms in the absence of vaginal digitation, even when proctography demonstrated a rectocele, were not taken as indicators for surgery in this study. There were nine women, median age 50 years (range, 32 to 61). The rectovaginal septum was repaired with Marlex mesh through a perineal approach by one surgeon. The median follow-up period was 29 months. RESULTS: Eight of the nine women achieved successful evacuation after surgery without the need for vaginal digitation. Rectocele size, depth, and the percent of barium trapped in the rectocele on proctography were all improved. Anorectal physiology measurements were unchanged by surgery. CONCLUSIONS: Operative repair of the rectovaginal septum removes the need for vaginal digitation in most women with large rectoceles on proctography. Further studies in well-defined groups of women are needed to establish how well rectocele repair aids women with a variety of other pelvic and perineal symtoms.

Necrotizing soft tissue infections: obstacles in diagnosis.

Abstract: Background This study was done to identify obstacles in the early diagnosis and treatment of necrotizing soft tissue infections. Study design A ten-year retrospective case series was analyzed. Results Data from 29 patients were analyzed. Among patients undergoing early operation within 24 hours of admission (n = 17) there was one death (6 percent mortality rate); survivors averaged 2.9 operations per patient. By comparison, of patients with delayed operation (n = 12) three died (25 percent mortality rate) and there were 3.6 operations per patients. Positive fine-needle aspiration (FNA) of suspicious lesions, demonstrating either pus or bacteria by Gram's stain, led to early operation in 80 percent of patients tested. Patients with soft tissue gas on radiographs were more likely to undergo early operation (58 percent). Delayed operation was more common in the absence of radiographic findings. All patients admitted to nonsurgical services had delayed operations. Conclusions Suspected necrotizing soft tissue infections require prompt surgical evaluation and early operative exploration. Early operation with definitive surgical therapy initiated within 24 hours of admission is associated with decreased mortality rates. Negative FNA findings, nondiagnostic radiographs, and admission to a nonsurgical service correlate with delay in definitive operative intervention.

Comparison of a new type of polytetrafluoroethylene patch (Mycro Mesh) and polypropylene prosthesis (Marlex) for repair of abdominal wall defects.

Abstract: BACKGROUND Two types of prosthetic material used for repairing hernial defects of the abdominal wall were compared: Mycro Mesh and Marlex. Mycro Mesh (MM) is a new polytetrafluoroethylene product of layered, microporous structure. Macroscopically, it presents regularly distributed, 2-mm orifices that perforate the biomaterial. Marlex (PL) is a well-known polypropylene mesh product with a macroporous structure. STUDY DESIGN In 24 white New Zealand rabbits, a full-thickness (except skin) 5 x 7-cm defect was created in the anterior wall of the abdomen. Defects were repaired with either MM (n = 12) or PL (n = 12) implants and studied at 14, 30, 60, and 90 days after implantation. Samples of the interfaces between prosthesis and subcutaneous tissue, visceral peritoneum, and receptor tissue, respectively, were studied. Samples were processed for optical microscopy and scanning electron microscopy (SEM). An immunohistochemical study was made using RAM-11, a monoclonal antibody specific for rabbit macrophages. The tensile strength of the repairs was made using an Instron tensiometer on 2-cm wide transversal strips that included the prosthesis and its anchor zones to the receptor tissue. RESULTS The formation of adhesions between the prosthesis and intestine was important with the PL implants but not with the MM implants. Optical microscopy and SEM showed formation of an organized connective tissue surrounding the MM implants. At 90 days, compact bridges of connective tissue linked the tissue on the subcutaneous and peritoneal sides of the prosthesis. The PL implants became integrated into a disorganized, highly vascularized connective tissue. The intensity of the macrophage response was similar in both prostheses and decreased between days 14 and 90 (Student-Newman-Keuls test p = 0.01). The tensile strength of the PL implants was greater than that of the MM implants. At 90 days, the tensile strength of the PL implants was mean equals 33.11 N and of the MM implants, mean equals 22.65 N (Mann-Whitney test p < 0.001). CONCLUSIONS The tissue integration of the PL and MM implants differed; fewer visceral adhesions formed on MM than on PL; the macrophage reaction was not determinant of the success of failure of either biomaterial; and the tensile strength of the prosthesis-receptor tissue interface was much greater in the PL implants than in the MM implants.

Clinical consequences of anal sphincter rupture during vaginal delivery

Abstract: BACKGROUND:Rupture of the anal sphincters at childbirth is considered rare in obstetric literature. Long-term effects are sparingly mentioned. In clinical practice, however, it is not uncommon to m ...

Primary duodenal adenocarcinoma: a ten-year experience with 79 patients.

Abstract: BACKGROUND Duodenal adenocarcinoma is a rare malignancy with a poorly defined natural history and outcome. The factors that affect management and survival of patients with this disease remain controversial. This study analyzed the ten-year experience at one institution with primary duodenal adenocarcinoma to define factors that have an impact on patient survival. In addition, the outcome of patients with resected duodenal adenocarcinoma was compared with that of patients with gastric and pancreatic adenocarcinoma. STUDY DESIGN A retrospective review of the prospective database for patients with peripancreatic lesions treated at Memorial Sloan-Kettering Cancer Center between 1983 and 1994 identified 79 patients with a primary duodenal adenocarcinoma. Demographics, presenting symptoms, operative variables, pathologic findings, and survival data were analyzed. Multivariate comparisons and actuarial survival were calculated using these variables. RESULTS A curative resection was performed in 42 (53 percent) of the 79 patients, including 38 pancreaticoduodenectomies and four duodenal resections. The overall projected five-year survival rate was 31 percent, with resected and nonresected patient survival rates of 60 and zero percent, respectively (p < 0.0001). Nodal metastases, regardless of location, did not have an impact on survival. While stage was a significant factor in survival on univariate analysis, no survival difference was noted between stages I, II, and III. Only resectability and presence of non-nodal metastases predicted outcome on multivariate analysis. CONCLUSIONS Resectability and presence of distant metastatic disease are the strongest determinants of outcome for patients with duodenal adenocarcinoma. Staging and nodal status offer little prognostic information and nodal positivity should not preclude resection. As patients have symptoms similar to those of pancreatic adenocarcinoma but have an outlook more comparable to gastric adenocarcinoma, a vigorous approach to resection is justified.

Incidence and predictors of axillary metastasis in T1 carcinoma of the breast.

Abstract: BACKGROUND The relatively low incidence (6 to 31 percent) of axillary metastasis in patients with T1 carcinoma of the breast (20 mm or smaller) has led some surgeons to question routine axillary lymphadenectomy (ALND) for patients with no palpable axillary metastases and T1 tumors. This study was undertaken to determine the incidence and predictors of axillary lymph node metastasis in patients with T1 carcinoma of the breast and evaluate the role of sentinel lymphadenectomy (SLND) in this context. STUDY DESIGN All patients with T1 invasive carcinoma of the breast treated at the John Wayne Cancer Institute between January 1988 and June 1994 were prospectively studied. The study population was comprised of 259 women who had ALND. Of these patients, 114 were part of a pilot study examining the efficacy of SLND. RESULTS Of the 259 women, 69 (27 percent) had axillary metastasis. Hematoxylin and eosin staining identified nodal involvement in 13 percent of patients with T1a and T1b tumors (10 mm or less) and in 30 percent of patients with T1c tumors (p = 0.002). Other factors such as age, hormone receptor status, presence of ductal carcinoma in situ, histology, ploidy, and S-phase were not significant predictors of involvement. A sentinel node was identified in 73 patients: this node accurately predicted axillary status in 72 patients, was the only positive node in nine of 16 patients with axillary involvement, and was 100 percent predictive of axillary status when the primary tumor was 10 mm or less. Retrospective immunohistochemical staining revealed an additional seven patients with positive sentinel nodes. With this technique, even T1a lesions had a 15 percent incidence of axillary metastasis. CONCLUSIONS Tumor size is the only accurate predictor of axillary metastasis in patients with T1 carcinoma of the breast. The significant incidence of axillary involvement from T1 tumors mandates accurate staging, even when the tumor is 10 mm or less in size. Examination of a sentinel lymph node may accurately predict axillary metastasis.

Vaginal evisceration: presentation and management in postmenopausal women

Abstract: Background Vaginal evisceration is a rare event, often associated with previous vaginal surgery in postmenopausal women. To date, 57 cases have been described in the world literature since 1901. Study design We report three cases of vaginal evisceration and review risk factors and management described in the current literature. Results Of 60 reported cases of vaginal evisceration, 41 occurred in postmenopausal women. A common triad of previous vaginal surgery (73 percent), postmenopausal status (68 percent), and the presence of an enterocele (63 percent) was identified. Histopathologic evaluation of one case revealed a chronic vaginal-peritoneal fistula, and immunohistochemistry highlighted migration of squamous cells to multiple peritoneal serosal surfaces. This finding emphasizes the chronic nature of factors that predispose to the acute evisceration of abdominal contents. Most eviscerations were managed by primary repair of the vaginal disruption and the accompanying disorder of the pelvic floor, after assessing the viability of the prolapsed bowel and resecting any compromised segments. However, most surgeons agreed that delayed vaginal repair was preferable if the vaginal tissues appeared acutely inflamed or nonviable. Conclusions Vaginal evisceration is primarily seen with obstetrical or postcoital trauma, but in postmenopausal women it is most often associated with a history of vaginal surgery and a pelvic support disorder. Hypoestrogenism, atrophy, and devascularization from previous surgery seem to play a significant role. Management is directed toward resecting any compromised bowel, repairing the vaginal defect, and correcting the contributing defect in the pelvic floor.

A prospective randomized comparison of the metabolic and stress hormonal responses of laparoscopic and open cholecystectomy.

Abstract: BACKGROUND In a relatively short period of time, therapeutic laparoscopy has become an everyday part of the general surgeon's life. Although laparoscopy provides distinct clinical advantages, it is not yet clear that it lessens the stress response typical of elective surgical procedures, and as such, the morbidity of surgery. The hypothesis that laparoscopic cholecystectomy produces less of a metabolic and stress hormonal response than open cholecystectomy was tested in a prospective randomized trial. STUDY DESIGN Twenty otherwise healthy women between 18 and 45 years of age with a history of uncomplicated symptomatic cholelithiasis undergoing either laparoscopic (n = 10) or open cholecystectomy (n = 10) were studied. The hormonal response of the adrenocortical (serum adrenocorticotropic hormone, cortisol, and urinary free cortisol), adrenomedullary (plasma and urinary epinephrine and norepinephrine), thyroid (thyroid-stimulating hormone, thyroxine, and triiodothyronine), pituitary (antidiuretic hormone and growth hormone), and glucose (serum glucose, glucagon, and insulin) homeostatic axes were measured serially over a 24-hour period. RESULTS No difference was seen between the laparoscopic and open groups in operative time (mean plus or minus standard error of the mean, 70 +/- 6 minutes compared with 77 +/- 6.3 minutes) or hospital stay 1.3 +/- 0.2 compared with 1.1 +/- 0.1 days). Assessment of postoperative pain using an analog pain score was less in the laparoscopic group (4.9 +/- 1.3 compared with 12.3 +/- 2.5, p = 0.01). The response of the adrenocortical, adrenomedullary, thyroid, and glucose axes were similar or identical in both groups. Antidiuretic hormone levels were greater in the laparoscopic group at one hour intraoperatively (281 +/- 79 pg/mL compared with 54 +/- 18 pg/mL, p < 0.01), and at extubation (122 +/- 18 pg/mL compared with 36 +/- 7 pg/mL, p < 0.01). Serum glucose levels were greater immediately following laparoscopic cholecystectomy. Glucose and insulin levels were greater at four, 12, and 24 hours after open cholecystectomy. CONCLUSIONS Elective laparoscopic and open cholecystectomy for uncomplicated cholelithiasis result in similar degrees of perioperative hormonal stimulation. The different hormonal responses in the immediate and later postoperative periods after laparoscopic and open cholecystectomy suggest differential stressful stimuli between the two procedures.

Pedestrian-motor vehicle trauma: an analysis of injury profiles by age

Abstract: BACKGROUND: Pedestrian-motor vehicle trauma (PMVT) is a common mechanism of injury in urban populations. STUDY DESIGN: We performed a retrospective review of 273 PMVT victims (16 percent of all patients with blunt injuries) seen at a Level I trauma center over a three-year period. Patients were analyzed by age and grouped as children (age younger than 16 years), adults (age 16 to 59 years), or elderly (age older than 59 years). RESULTS: Children constituted 27 percent of the patients, adults 54 percent, and elderly 19 percent. This mixture had significantly more children and elderly than the population at large or the entire blunt trauma population at our hospital. The majority of patients (66 percent) were male, with females outnumbering males only in the elderly group. Elderly patients were more frequently admitted to the intensive care unit (ICU) and had significantly longer ICU and hospital stays. Injury Severity Scores were successively higher in each age group and significantly higher in the elderly. Extremity trauma was most common in all three groups, followed by head injuries. The elderly patients were more prone to chest and pelvic injuries and the children most often had femur fractures. Operations were performed in 22 percent of the patients; orthopedic procedures were most frequent. The mortality rate was 6 percent, with 69 percent of the deaths occurring during the initial resuscitation efforts. The mortality rate was significantly higher in the elderly patients (13 percent). The majority of accidents occurred during nighttime hours, especially in the adult group. Half of the accidents occurred on the weekend, with the greatest number on Saturday. One-third of the accidents occurred during the months of October to December. CONCLUSIONS: Pedestrian-motor vehicle trauma is a common injury, with distinct epidemiological features that may be useful in accident prevention strategies. Language: en

Effect of inferior mesenteric artery ligation on blood flow in the marginal artery-dependent sigmoid colon.

Abstract: BACKGROUND Anastomotic leakage after restorative rectal excision may develop from ischemia associated with inadequate blood flow in the marginal artery-dependent colon. STUDY DESIGN We have used laser Doppler flowmetry to measure blood flow change during mobilization of the sigmoid colon before excision of the sigmoid colon or rectum in 26 patients and proximal to the colorectal anastomosis during the first five postoperative days in five patients. RESULTS There was a significant (p < 0.005) fall (median, 50 percent interquartile range, 41 to 86 percent) in sigmoid colon serosal flow after ligation of the inferior mesenteric artery (IMA) and distal marginal artery (DMA) that was not influenced by the order of vessel ligation. No increase in perianastomotic colonic perfusion was detected during the first five postoperative days. CONCLUSIONS The significant blood flow reduction after ligation of the IMA and DMA supports the hypothesis that anastomotic leakage after restorative rectal excision may result from ischemia associated with inadequate blood flow in the marginal artery-dependent sigmoid colon. Improvement in inadequate intraoperative colonic perfusion from increased collateral circulation is unlikely to develop in the marginal artery-dependent colon during the first five postoperative days.

Survival factors in 186 patients younger than 40 years old with colorectal adenocarcinoma

Abstract: BACKGROUND We sought to determine the clinical factors and tumor characteristics associated with the reported poor prognosis in young patients with carcinoma of the colon and rectum. STUDY DESIGN A retrospective review was performed of 186 patients younger than 40 years of age who were treated for primary colorectal adenocarcinoma. The median age was 34.3 years, and the median follow-up period was 9.4 years. Clinical and tumor histopathologic parameters were analyzed. RESULTS Regional lymph node metastases, distant metastases, or both, were seen at first examination in 65.6 percent of young patients. Histopathologic indicators of more aggressive tumor biology were present at a significantly higher frequency in young patients compared with patients older than 40 years (p < 0.001). Poorly differentiated tumor grade was present in 41.0 percent, signet-ring cell tumors were found in 11.1 percent, and infiltrating tumor leading edges were present in 69.0 percent of young patients. Among young patients with stage II disease, vascular invasion was a significant negative prognostic variable (p < 0.05). CONCLUSIONS We have demonstrated an increased incidence of three biological indicators of aggressive and potentially metastatic tumor biology in 186 young patients with carcinoma of the colon and rectum: signet-ring cell carcinoma, infiltrating tumor edges, and aggressive histologic grade in the primary adenocarcinoma. The increased incidence of these three histologic measures of more aggressive carcinoma of the colon and rectum in part accounts for the higher rate of advanced disease at presentation in patients younger than 40.

The Pittsburgh randomized trial of tacrolimus compared to cyclosporine for hepatic transplantation.

Abstract: Background Tacrolimus (formerly FK 506) was first used clinically in 1989 to successfully replace cyclosporine in hepatic transplant recipients who were experiencing intractable rejection or as the baseline drug from the time of operation. After extensive pilot experience, an institutional review board-mandated clinical trial comparing cyclosporine with tacrolimus was performed.

Cost-effective management of complicated choledocholithiasis: laparoscopic transcystic duct exploration or endoscopic sphincterotomy.

Abstract: BACKGROUND In the United States of America, approximately 700,000 patients undergo laparoscopic cholecystectomy (LC) each year and at least 10 percent of these patients will have common bile duct stones (CBDS) The purpose of this study was to evaluate patients with choledocholithiasis and compare the economic and clinical results obtained by LC with endoscopic sphincterotomy (ES) with those of LC with laparoscopic transcystic common bile duct exploration (LTCBDE) STUDY DESIGN From June 1991 to September 1994 patients undergoing LC plus LTCBDE and those undergoing LC plus ES at a single institution were compared where cost data were available Of the 76 patients with choledocholithiasis, 59 patients underwent LC plus LTCBDE (group 1) and 17 patients underwent LC plus ES (group 2) A subset of group 1 patients undergoing urgent LC plus LTCBDE (group 3) for cholecystitis, cholangitis, or pancreatitis plus laparoscopy were examined separately RESULTS Laparoscopic cholecystectomy plus LTCBDE, whether including all-comers (group 1) or just urgent cases (group 3), was associated with a significantly decreased length of hospital stay (61 and 69 days, respectively, compared with group 2, 124 days) (p < 0001) The morbidity of patients in group 1 was also markedly lower than for patients in group 2; 12 percent compared with 41 percent, respectively Patients in group 1 had a significantly decreased cost of hospitalization (+13,151), when compared with patients in group 2 (+18,712) (p = 005) This difference is even more pronounced when professional fee reimbursement is considered The cost of treatment for patients in group 1 was +14,732 compared with +21,125 for patients in group 2 (p < 005) The total hospital cost for patients in group 3 was only +13,564 compared with +18,712 for patients in group 2 When professional reimbursement was considered, the cost was +15,150 for patients in group 3 compared with +21,125 for patients in group 2 CONCLUSIONS Patients undergoing LC plus LTCBDE for CBDS, whether urgently or electively, have markedly decreased morbidity rates, length of hospital stay, and costs when compared with patients undergoing LC plus ES

Therapeutic options and results for the management of minimally invasive carcinoma of the breast: influence of axillary dissection for treatment of T1a and T1b lesions.

Abstract: BACKGROUND Axillary dissection has maintained a role of primacy for the surgical therapy of invasive carcinoma of the breast for many years. More recently, early (T1) minimally invasive carcinoma of the breast has been diagnosed with increasing frequency, and the necessity of axillary dissection for sampling purposes in these small tumors has been questioned, based primarily on the finding of low rates of axillary metastases. STUDY DESIGN The Rhode Island State Tumor Registry records of 1,126 patients with T1a or T1b tumors were examined to assess the effect of axillary dissection on patient outcome. These data span 9 years (1985 to 1992) with a median follow-up duration of 64 months. Five-year overall, disease-free, and breast cancer-specific (determinate) survival were determined according to treatment modality. Axillary node positivity was calculated for patients with minimally invasive carcinoma of the breast who underwent axillary dissection. Multivariate statistical methods were used to provide adjustment for known confounding prognostic variables. RESULTS Omission of axillary dissection occurred in 157 cases and correlated with reductions in overall, disease-free, and breast cancer-specific survival (p < .001 in all cases). Nodal status significantly influenced disease-free survival in minimally invasive carcinoma of the breast (90 percent node-negative compared with 76 percent node-positive, p = .02). Nodal positivity was evident in 18.2 percent of patients undergoing axillary dissection for minimally invasive carcinoma of the breast (9.8 percent for T1a, 19.4 percent for T1b, p = .01). In multivariate analysis, the performance of axillary dissection with breast conservation or modified radical mastectomy were independent predictors of overall survival, as well as disease-free and breast cancer-specific survival. CONCLUSIONS A significant number of patients with small (less than or equal to 1 cm) invasive tumors of the breast will have axillary metastases at the time of diagnosis. Omission of axillary dissection in these patients was associated with significant impairment of overall, disease-free, and breast cancer-specific survival. Axillary dissection should continue to be a standard approach for the surgical therapy of all patients with invasive carcinoma of the breast, regardless of tumor size.

Colorectal surgery in octogenarians.

Abstract: Background Elderly patients are often viewed as high-risk surgical candidates. Recent reports, however, have recommended applying the standard surgical approach to this group. Many of these series report mortality rates that are substantially higher than those in the younger population. Therefore, the applicability of these procedures for the elderly may be questionable. Study design We retrospectively studied 140 patients older than 80 years who underwent colorectal surgery at our institution between January 1990 and January 1995. Of these, 123 underwent colon or rectal resections and 17 had diverting colostomy only. Ninety-seven (79 percent) of the colorectal resections were for carcinoma. In this study, perioperative care, operative results, and survival are analyzed. Results Elective and emergent colorectal resections totaled 80.5 and 19.5 percent, respectively. The mortality rate for elective resections was 3 percent and for emergency resections it was 21 percent. Postoperative morbidity was 27 percent and the average hospital stay was 13.1 days. Diverting colostomy was associated with a 24 percent mortality rate. The survival rate after colorectal resections for one, two, and five years was 85, 72, and 40 percent, respectively. Conclusions The results support the view that elective colorectal resection in the elderly population is worthwhile and should be performed for the same indications as in younger patients. Although emergent operations were associated with a poor outcome, the majority of the patients survived and left the hospital.

Comparative clinical study of port-closure techniques following laparoscopic surgery.

Abstract: Background Recently, a number of laparoscopic port-closure techniques have been reported to avoid the complications associated with the port closure after laparoscopic surgery. To evaluate these port-closure techniques, we compared seven new laparoscopic port-closure techniques with the standard technique of a hand-sutured closure. Study design In a prospective, randomized study, 95, 12-mm port sites in 32 patients undergoing transperitoneal laparoscopic procedures were randomized to one of eight different port-site closure techniques. The port-closure techniques included: the Carter-Thomason Needle-Point Suture Passer, Maciol suture needle set, eXit Disposable Puncture Closure device, Endoclose suture carrier, Tahoe Surgical Instruments Ligature device, a long 14-gauge angiocatheter with looped polypropylene suture, Lowsley retractor with hand-sutured closure, and the standard technique of hand-sutured closure. We evaluated the time, the security, and the auxiliary instrumentation required for each closure. Results Of the port-closure techniques, the Carter-Thomason device was faster overall, resulted in fewer port-closure-related complications and provided a leak proof closure. Conclusions The Carter-Thomason device is our preferred method for the closure of port sites after laparoscopic surgery.

Gastric carcinoma: does lymph node dissection alter survival?

Abstract: BACKGROUND Extragastric lymphadenectomy (D2 node dissection) is strongly supported by Japanese data to have survival benefit. Randomized trial data are either inconclusive or nonsupportive of this view. We have reviewed a prospectively gathered database of 18,346 cases of gastric carcinoma from a gastric cancer patient care evaluation study conducted by the American College of Surgeons to assess whether the performance of extragastric node dissection was associated with improved survival in patients who had resection with curative intent (all margins microscopically clear). STUDY DESIGN We reviewed a subgroup of patients with curatively resected gastric carcinoma and compared the outcome in patients having extragastric lymph node dissection with the outcome in patients who did not have dissection of N2 nodes. RESULTS Among the 3,804 patients having curative resection in the long-term study with more than a five-year follow-up, 695 had dissection of the nodes along the celiac axis, hepatic artery, or splenic artery (N2 nodes); 1,529 patients had removal of the adjacent nodes (N1 nodes) along the gastric tube or the gastric or perigastric nodes (N1 nodes); and 903 patients who had no nodes identified in the resection specimen (essentially N0 nodes removed). For patients having a dissection of N2 nodes, the median survival time was 19.7 months with a five-year survival rate of 26.3 percent; for patients having a dissection of N1 nodes, the median survival time was 24.8 months with a five-year survival rate of 30 percent; among patients having no nodes removed, the median survival time was 29.5 months with a five-year survival rate of 35.6 percent. CONCLUSIONS Lymph node dissection (D2) of N2 nodes did not augment survival compared with gastrectomy without node dissection or that included perigastric nodes in the resection. Subgroup analysis of patients with gastric carcinoma having a curative resection did not show benefit of the extragastric node dissection (D2). Continued study is warranted and the data from ongoing clinical trials may yield more conclusive information.

Evaluation of tissue trauma after laparoscopic and abdominal hysterectomy: measurements of neutrophil activation and release of interleukin-6, cortisol, and C-reactive protein.

Abstract: Background Trauma and major surgery stimulate a cascade of events that mediate the inflammatory response The aim of our study was to determine whether or not hysterectomy leads to release of cytokines, cortisol, and C-reactive protein (CRP), activation of neutrophils, and activation of the complement cascade A further aim was to compare laparoscopic and abdominal hysterectomy with regard to the same parameters Study design Twenty-four consecutive patients were randomized to either abdominal (n = 12) or laparoscopic hysterectomy (n = 12) Blood samples were drawn preoperatively, intraoperatively, and then at one minute, 24 hours, and seven days postoperatively Interleukin-6 (IL-6) levels were used to evaluate cytokine release, cortisol and CRP to evaluate the inflammatory response, and polymorphonuclear (PMN) elastase to detect neutrophil activation To evaluate complement activation, the terminal C5b-9 complement complex (TCC) was determined Results Interleukin-6 concentrations were significantly elevated one minute and 24 hours postoperatively in both groups Independent of the surgical technique or operative time, the highest IL-6 concentration was reached four hours after beginning the operation Cortisol levels were significantly elevated during and after the operation in both groups C-reactive peptide levels were significantly elevated in both groups 24 hours and seven days after the operation Polymorphonuclear elastase was elevated 24 hours postoperatively in both groups There were no signs of complement activation during the operative period or postoperatively in either patient group Conclusions Our results indicate serious tissue trauma during both laparoscopic and abdominal hysterectomy The extent of surgical trauma did not differ between the two operative methods

Endogenous endophthalmitis associated with pyogenic hepatic abscess.

Abstract: BACKGROUND Endogenous endophthalmitis has been associated with pyogenic hepatic abscess in several recent anecdotal reports. The purpose of this study was to determine the incidence of endophthalmitis associated with pyogenic hepatic abscess, identify the degree of association with Klebsiella pneumoniae as a causative organism, and determine the outcome of treatment. STUDY DESIGN A retrospective study was performed of 352 consecutive patients with a clinical diagnosis of pyogenic hepatic abscess who had been admitted to Chang Gung Memorial Hospital in Kaohsiung between 1986 and 1993. Findings from complete ophthalmologic evaluations and treatment results were recorded. RESULTS Eleven patients (3.1 percent) with endogenous endophthalmitis (monocular in eight and binocular in three) were found among the 352 cases of pyogenic hepatic abscess. Seven of the patients had diabetes mellitus and their blood glucose was poorly controlled. Only one patient had an intrahepatic stone as the cause of hepatic abscess, the other abscesses were of cryptogenic origin. The causative organism was mainly K. pneumoniae and the diagnosis was made by blood culture in ten patients, hepatic aspirate culture in seven, and vitreous contents culture in three. Systemic antibiotics were given in all patients with endogenous endophthalmitis. Percutaneous catheter drainage for hepatic abscess under echo guidance was performed in seven patients, medical treatment only was performed in three patients, and percutaneous tapping of abscess was done in one patient. All 11 patients were alive at the time of writing. Intravitreous culture followed by injection of antibiotics and steroids was immediately undertaken if septic endophthalmitis was suspected, except in two patients, who lost vision before any treatment was given. In five patients, cefamezin and gentamicin were given, and in four patients vancomycin, amikacin, and dexamethasone were given every three days if necessary. Finally, among the total of 14 eyes, there was blindness in ten, three of these had no light perception initially. In seven patients there had been a delay of treatment longer than one day. In one eye there was "counting fingers" vision and in three eyes there remained some vision. CONCLUSIONS Physicians should be alert to the development of endogenous endophthalmitis when a patient with pyogenic hepatic abscess or bacteremia complains of ocular symptoms. Prompt diagnosis and vigorous treatment with intravitreous injections of vancomycin, amikacin, and dexamethasone within 24 hours can save the patient's eyes and vision.