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The author questions the conventional assumption that the pneumoperitoneum must be established before insertion of the laparoscope and its trocar. Complications commonly associated with establishment of a needle-induced pneumoperitoneum include subcutaneous emphysema, blood vessel penetration, retroperitoneal emphysema, bowel distention, overdistention, gas embolism, and omental emphysema. This paper summarizes the author's experience with 301 outpatient laparoscopies performed in 1976-77 using the method of direct trocar insertion without prior pneumoperitoneum. The process of pneumoperitoneum was visualized directly through the Needlescope. 54 cases were performed under general anesthesia and 247 under local anesthesia. Complications were encountered in only 3 cases (1 uterine perforation and 2 cases requiring postoperative hospitalization for nausea and vomiting). There were no cases of technical failure. Comparison of recovery times for 250 consecutive patients treated without preliminary pneumoperitoneum and 117 patients treated with the conventional technique indicated that the recovery time was 19 minutes shorter on average in the former group because of a lessened degree of postoperative discomfort, nausea, and vomiting. Although further research is necessary to confirm the findings in this series, it seems plausible to suggest that a reduction of complications associated with needle-induced pneumoperitoneum may be possible with this technique.
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PMID:Direct laparoscope trocar insertion without prior pneumoperitoneum. 15 Nov 44

Complications of the initial 200 cases of laparoscopic cholecystectomy (LC) at the Cathay General Hospital within a period of 11 months were reviewed from video documents of the operations and clinical records. The major complication rate was 3.5%, including one common bile duct (CBD) injury (0.5%), three retained CBD stones (1.5%), one subphrenic fluid accumulation (0.5%), one liver abscess (0.5%) and one cystic duct stump bile leakage (0.5%). All major complications were cholecystectomy-related, and only one of the seven occurred in cases of acute cholecystitis. Age and sex were not related to its occurrence. The rate of minor complications ranged from 0.5% to 10%; they were: shoulder and back pain (10%), gall bladder perforation (10%), retained stones in the abdominal cavity (5%), transient nausea and diarrhea (5%), extension of umbilical port to a mini-laparotomy (3.5%), prolonged operation time > three hours (2%), subcutaneous emphysema (1.5%), wound infection (1.5%) and prolonged ileus (0.5%). The minor complications occurred largely in patients with acute cholecystitis. The complications occurred mostly during the early period of our study, indicating a learning period phenomenon. These could have been avoided if we had had a thorough knowledge of the potential complications and had strictly followed the principles of laparoscopic surgery. We conclude that LC is safe and the complication rate is not higher than that for open cholecystectomy. Most of the complications are preventable if LC is performed by qualified biliary surgeons following strict precautions.
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PMID:Complications of laparoscopic cholecystectomy: an analysis of 200 cases. 136 18

The chemistry, pharmacology, pharmacokinetics, clinical efficacy, adverse effects, and dosage of ipratropium bromide are reviewed. Ipratropium bromide, a synthetic quaternary isopropyl derivative of atropine, interrupts vagally mediated bronchoconstriction by inhibiting the cyclic guanosine 3',5'-monophosphate system at parasympathetic nerve endings. Ipratropium bromide is poorly absorbed after oral and inhaled administration but diffuses rapidly into tissue after i.v. or i.m. administration. The elimination half-life is 3.2-3.8 hours. After inhalation, the drug is eliminated in the urine and feces. The bronchodilatory effect of ipratropium bromide in stable chronic obstructive pulmonary disease appears to be comparable, and may be superior, to that of the beta-sympathomimetic agents. In acute exacerbations, ipratropium bromide is useful but may not be the preferred agent because of a delayed onset of action (within 15 minutes; mean dose-dependent duration of effect, three to five hours). Combination therapy with other bronchodilating drugs has proved useful. Ipratropium bromide may be a useful adjunctive agent in the treatment of asthma. Since the onset of action is delayed, ipratropium bromide should not be used as single-drug therapy in an acute asthmatic exacerbation. Reported adverse effects, including cough, nausea, palpitations, dry mouth, nervousness, gastrointestinal distress, and dizziness, have been mild. The usual dosage is two inhalations (36 micrograms) four times daily, and the maximum number of doses per day should not exceed 12. Although ipratropium bromide is currently indicated only for maintenance therapy in stable chronic bronchitis and emphysema, it may be useful as adjunctive therapy in asthma and in the management of acute exacerbations of chronic bronchitis and asthma. Additional experience in a variety of chronic obstructive pulmonary disorders will help to clarify the role of ipratropium bromide in the treatment of obstructive pulmonary disease.
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PMID:Use of ipratropium bromide in obstructive lung disease. 297 9

Pneumoperitoneum is most commonly caused by the perforation of a hollow viscus, in which case an emergency laparotomy is indicated. We report herein the case of a patient who presented with the signs and symptoms of peritonitis, but who was found to have idiopathic pneumoperitoneum which was successfully managed by conservative treatment. A 70-year-old man presented with epigastric pain, nausea, and a severely distended and tympanitic abdomen. Abdominal examination revealed diffuse tenderness with guarding, but no rebound tenderness. He was febrile with leukocytosis and high C-reactive protein. Chest X-ray and abdominal computed tomography demonstrated a massive pneumoperitoneum without pneumothorax, pneumomediastinum, pneumoretroperitoneum, or subcutaneous emphysema, and subsequent examinations failed to demonstrate perforation of a hollow viscus. Thus, a diagnosis of idiopathic pneumoperitoneum was made, and the patient was managed conservatively, which resulted in a successful outcome. This experience and a review of the literature suggest that idiopathic pneumoperitoneum is amenable to conservative management, even when the signs and symptoms of peritonitis are present.
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PMID:Conservative management of idiopathic pneumoperitoneum masquerading as peritonitis: report of a case. 764 Apr 58

Paraquat intoxication is a common medical problem in this country. The mortality is high, particularly in the cases of high dose ingestion. Mediastinal emphysema observed in paraquat intoxication always means mortality, however, we experienced a survivor. A 29 y/o female ingested about 10-15 c.c. of 24% (2.4-3.6 gm) paraquat to attempt suicide. Nausea and protracted vomiting occurred shortly after. During hospitalization, mediastinal emphysema developed on the 7th day and subsided 10 days later. Serum paraquat level determination revealed 185 ng/ml in 20 hours after ingestion and 34 ng/ml on the 6th day. She received general supportive treatments with the augmentation of sodium thiosulfate. Hypokalemia had been observed for 11 days and was intractable until hypomagnesemia was identified and corrected. So far, she had returned back to her work for more than 1 year, although the chest x-ray revealed slight pulmonary fibrosis. The high ingested dose, oral ulcers, high serum level and mediastinal emphysema of this patient all implicate a poor prognosis of paraquat intoxication; however, these contradict the observed survival of our patient. In conclusion, mediastinal emphysema observed in paraquat intoxication is not related to the serum level of paraquat. It does not absolutely lead to death and may simply come from the esophageal rupture after vigorous vomiting in paraquat intoxication.
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PMID:Survival of paraquat intoxication complicated with mediastinal emphysema: a case report. 783 61

A 24-year-old previously healthy man presented with a 3-week history of progressively intensifying symptoms of diabetes mellitus. He had become increasingly unwell during the night preceding his admission to hospital and had developed central pleuritic chest pains with nausea; he had vomited once. On admission, he was clinically dehydrated and acidotic with Kussmaul's respiration. A diagnosis of diabetic ketoacidosis was confirmed by laboratory tests (arterial pH 7.21; bicarbonate 11.6 mmol l-1; blood glucose 40.5 mmol l-1, and heavy ketonuria). Subcutaneous emphysema was palpable in the neck tissues and a chest X-ray revealed mediastinal emphysema. There was no clinical or radiological evidence of acute or chronic pulmonary disease and a barium swallow confirmed the integrity of the oesophagus. He made an uneventful recovery from the ketoacidosis with conventional therapy. The subcutaneous emphysema and pneumomediastinum had completely resolved at review 4 weeks later.
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PMID:Pneumomediastinum complicating diabetic ketoacidosis. 879 65

A 52-year-old-white male underwent double lung transplantation for severe emphysema due to alpha-1-antitrypsin deficiency and heavy tobacco use. Following a postoperative course complicated by renal insufficiency, pulmonary emboli, and Clostridium difficile colitis, he was discharged in stable condition. Two months later, he was admitted to a local hospital with a fever, abdominal pain, diarrhea, nausea, and dyspnea. Computerized tomography (CT) of the chest revealed bilateral pleural effusions. Sigmoidoscopy was grossly normal but biopsy demonstrated cytomegalovirus (CMV) colitis, and the patient was placed on intravenous ganciclovir. Over the next week, he became progressively hypoxemic and was transferred to the University of Pittsburgh Medical Center (post-transplant day 81) for further evaluation. His medications on transfer included: ganciclovir, prednisone, tacrolimus, dapsone, fluconazole, ondansetron, lansoprazole, digoxin, and coumadin.
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PMID:Legionellosis in a lung transplant recipient obscured by cytomegalovirus infection and Clostridium difficile colitis. 1212 25

Haemorrhage, penetration and perforation are common complications of peptic ulcers. Free intraabdominal air is seen in 80 % after perforation. Penetration into the retroperitoneum with pneumothorax and mediastinal emphysema are rarely observed. We report the case of a 85-year-old female patient with nausea, vomiting and little appetite. During endoscopy of the upper GI-tract she complained about progressive dyspnea. Chest X-ray revealed mediastinal emphysema and pneumothorax. When performing laparotomy, we found a duodenal ulcer, that had penetrated the retroperitoneal space. The patient underwent partial gastrectomy and reconstruction with Billroth-II anastomosis. The postoperative course was uneventful.
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PMID:[Duodenal ulcer presenting as pneumomediastinum and pneumothorax -- case report]. 1252 27

Adenosine with its rapid onset and brief duration of action has a number of clinical applications including treatment of paroxysmal supraventricular tachycardia and maximal coronary vasodilatation during pharmacologic stress testing. The adverse effects of adenosine include dyspnea, nausea, headache, chest pain, flushing and bronchospasam. Although there were few reports which mentioned the occurrence of bronchospam after administration of adenosine, a number of studies indicated that the use of adenosine was not contraindicated in patients with chronic obstructive pulmonary disease (COPD) or asthma. We report here a male patient with pulmonary emphysema and lung bullous disease who developed severe constriction of the main bronchi after intravenous adenosine during general anesthesia. After treatment, the patient was discharged without complications. We have reviewed the related current literature and herein discuss the reason and management of the adenosine induced bronchospasm.
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PMID:Intraoperative bronchospasm after intravenous adenosine during general anesthesia. 1567 35

Chronic obstructive pulmonary disease is characterized by a rapid decline in lung function due to small airway fibrosis, mucus hypersecretion and emphysema. The major causative factor for COPD is cigarette smoking that drives an inflammatory process that gives rise to leukocyte recruitment, imbalance in protease levels and consequently matrix remodeling resulting in small airway fibrosis and loss of alveolar tissue. Current drug treatment improves symptoms but do not alter the underlying progression of this disease. The failure of antiinflammatory drugs like glucocorticosteroids to have a major impact in this disease has hastened the need to develop novel therapeutic strategies. Phosphodiesterase (PDE) 4 inhibitors are novel anti-inflammatory drugs that have recently been show to document clinical efficacy in this disease, although their utility is hampered by class related side-effects of nausea, emesis and diarrhea. Whilst it is not yet clear whether such drugs will prevent emphysema, this is a distinct possibility provided experimental observations from preclinical studies translate to man. This review will discuss the current standing of PDE4 inhibitors like roflumilast as novel treatments for COPD and the potential for developing nonemetic anti-inflammatory drugs.
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PMID:PDE4 inhibitors as potential therapeutic agents in the treatment of COPD-focus on roflumilast. 1804 84


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