Primary Aortoenteric Fistula Secondary to Ulcerative Atherosclerosis: A Case Report.

Aortoenteric fistulae after replacement surgery of the aorta is a well-described phenom enon. Fewer than 200 cases of primary aortoenteric fistulae have, however, been reported. The vast majority of these reveal aortic or gastrointestinal pathology as etiolo gies. The authors report on the very rare occurrence of primary aortoenteric fistula caused by ulcerative atherosclerosis in the absence of aortic aneurysm. The index of suspicion in patients with gastrointestinal bleeding of unknown etiology must be high to accurately diagnose an aortoenteric fistula. With aggressive testing and early laparotomy if indicated, the diagnosis of aortoenteric fistula can be ascertained and surgical correction can be accomplished

Laparoscopic Cholecystectomy Alleviates Pain in Patients with Acalculous Biliary Disease.

Our goal was to determine whether laparoscopic cholecystectomy is a safe and effective means of treatment for patients with acalculous cholecystitis. We reviewed the charts of 243 patients diagnosed with acalculous cholecystitis or biliary dyskinesia. Follow-up telephone interviews to measure degree of patient satisfaction and relief of preoperative symptoms were conducted. Hepatobiliary scanning results and postoperative symptom resolution were compared. One hundred seventy-one patients (94.5%) reported complete or partial resolution of symptoms postoperatively. Although 99 patients had symptoms reproduced with cholecystokinin injection during scanning, there was no significant correlation between these findings and alleviation of pain with cholecystectomy. There was no significant correlation between pain resolution after cholecystectomy and abnormal pathologic findings. Patients who suffered symptoms for a longer period of time preoperatively were more likely to be satisfied with the result of laparoscopic cholecystectomy. Laparoscopic cholecystectomy alleviates symptoms in many patients with acute or chronic acalculous cholecystitis or biliary dyskinesia with minimal morbidity

Utility of Chest Radiographs After Guidewire Exchanges of Central Venous Catheters.

OBJECTIVE: To determine whether chest radiographs are warranted after uncomplicated guidewire exchanges of central venous catheters in patients admitted to a Level I trauma intensive care unit. DESIGN: Prospective study performed in two phases. SETTING: Intensive care unit in a Level I trauma center. PATIENTS: Patients admitted to a Level I trauma center intensive care unit who required central venous catheter guidewire exchanges. INTERVENTIONS: Criteria for uncomplicated guidewire exchanges were established and followed. A catheter exchange checklist was completed at each procedure, and a chest radiograph was performed after each guidewire exchange. The complications followed were catheter malposition, pneumothorax, hemothorax, and cardiac tamponade. Results were reviewed after 3 mos, and a second phase of the study was initiated in which chest radiographs were obtained selectively and were not performed for uncomplicated exchanges. If obtained, subsequent radiographs were reviewed, and patients were followed to discharge for complications. MEASUREMENTS AND MAIN RESULTS: One hundred central venous catheter exchanges with postprocedure radiographs were evaluated in phase I. The only complication identified was one malpositioned catheter. In phase II, 110 patients were followed. Eighty-four patients did not have chest radiographs performed after guidewire exchange; 69 patients had subsequent radiographs documenting good placement of the catheter, and 15 patients did not have a radiograph before death (n = 2) or discharge from the hospital (n = 13). Sixteen patients had postprocedure radiographs performed. There were no malpositioned catheters or complications related to guidewire exchanges. CONCLUSIONS: Chest radiographs are unwarranted after uncomplicated guidewire exchanges of central venous catheters in hemodynamically stable, monitored patients. Eliminating these radiographs will result in significant cost and time savings without adversely affecting patient outcome