A comparison of intraoperative ultrasound versus cholangiography in the evaluation of the common bile duct during laparoscopic cholecystectomy.

Indications for intraoperative evaluation of the common bile duct during laparoscopic cholecystectomy are controversial, as is the goal of either anatomic definition or assessing for choledocholithiasis. One hundred twenty-five consecutive patients undergoing laparoscopic cholecystectomy underwent both intraoperative ultrasound and intraoperative cholangiography. Cholangiography required slightly more time to perform; it was more sensitive (92.8% vs 71.4%) but less specific (76.2% vs 100%) for choledocholithiasis than was ultrasound. Ultrasound was somewhat more difficult to perform, and, particularly in the setting of intraabdominal obesity, was often inadequate at providing clear visualization of the intrapancreatic common bile duct. It did not provide the same anatomic definition as an adequate cholangiogram. The overall incidence of choledocholithiasis was 11.2%.

Effect of ileal oleate on interdigestive intestinal motility of the dog.

To determine the effect of ileal oleate on fasting intestinal motility, pairs of duodenal and ileal catheters and bipolar duodenal and jejunal seromuscular electrodes were surgically implanted in six dogs. The ileum was perfused with either normal saline (154 mM NaCl) or oleic acid emulsion (152 mM), while intestinal myoelectric activity was continuously monitored. For transit studies, a bolus of [3H]PEG was injected into the duodenum, and jejunal and ileal alliquots were collected every 15 min for a 6-hr study period. Plasma samples were collected for radioimmunoassays of peptide YY and enteroglucagon. Ileal oleate infusion increased the MMC cycle length and decreased the number of MMCs (P < 0.001) and the myoelectric spike-burst frequency/10 min in the duodenum (P < 0.05). Both duodenal-jejunal (P < 0.05) and duodenal-ileal transit (P < 0.01) were delayed markedly by ileal perfusion with oleic acid emulsion as compared to control studies. Ileal oleate increased plasma levels of peptide YY (P < 0.01) and enteroglucagon (P < 0.01). Ileal perfusion with oleate therefore activated the so-called "ileal brake," diminishing duodenal myoelectric spike bursts and slowing intestinal transit while concurrently increasing plasma levels of peptide YY and enteroglucagon.

Comparison of early postoperative results for laparoscopic versus standard open cholecystectomy.

Alternative (nonresective) therapies of symptomatic cholelithiasis have been followed by frequent recurrence of gallstones. Great interest has been generated by the recent development of laparoscopic cholecystectomy, which in addition to preventing recurrence, may be associated with less patient discomfort, shorter hospital stays and more rapid return to work than standard cholecystectomy. We compared the first 25 patients who underwent laparoscopic cholecystectomy at our institution to the most recent 25 patients undergoing standard cholecystectomy by the same surgeon. The results of analysis of the two patient groups showed that they were similar in age, weight and gallstone burden. A slightly longer operative time (mean plus or minus S.E.M., 122 +/- 9 minutes versus 95 +/- 5 minutes, p) was required to perform laparoscopic cholecystectomy than standard cholecystectomy during this early experience. However, patients undergoing laparoscopic cholecystectomy had a markedly diminished usage of parental narcotic analgesia during the first 24 hours postoperatively (1.7 +/- 0.5 milligrams of morphine sulfate versus 34.5 +/- 4.1 milligrams of morphine sulfate). They also were discharged from the hospital (1.0 +/- 0 days versus 4.1 +/- 0.3 days) and returned to work or unrestricted activity (8.5 +/- 1.1 days versus 35.6 +/- 4.5 days) much sooner postoperatively than those treated by standard open cholecystectomy. Based on these favorable results, we conclude that laparoscopic cholecystectomy should be the procedure of choice for most patients with symptomatic cholelithiasis.

Safety and efficacy of laparoscopic cholecystectomy using monopolar electrocautery in the porcine model.

Recent reports suggest that laparoscopic laser cholecystectomy may become the preferred therapy for symptomatic cholelithiasis. To assess the efficacy and safety of this technique, using monopolar electrocautery instead of laser for the gallbladder dissection, laparoscopic cholecystectomy was performed on 11 pigs. Under general anesthesia, a pneumoperitoneum was established, and four sheaths were placed into the abdomen for introduction of instruments. Using video laparoscopic guidance, the cystic duct and artery were isolated, clipped, and divided. Monopolar electrocautery was used to dissect the gallbladder from its fossa. Five animals were sacrificed immediately, without visible evidence of injury to the bile ducts, liver, or intestine. The remaining six pigs were allowed to recover. One animal died 10 days postoperatively due to adhesive small bowel obstruction. The remainder survived in good health until sacrifice at 1 month. Histologic examination of the gallbladder bed and liver revealed no evidence of ongoing local hepatocyte destruction or chronic cholestasis. Cholangiography demonstrated the bile ducts to be intact. Mean (+/- SEM) total serum bilirubin (TB), alkaline phosphatase (AP), and glutamic oxalacetic transaminase (SGOT) at the time of sacrifice were similar to nonoperated swine (n = 10): TB, 0.12 +/- 0.02 versus 0.11 +/- 0.01 mg/dl; AP, 175 +/- 23 versus 162 +/- 10 IU/L; SGOT, 37 +/- 4 versus 55 +/- 7 IU/L, respectively (p > 0.05). We conclude that laparoscopic cholecystectomy can be performed using monopolar electrocautery without significant acute injury to the liver, bile ducts, or surrounding viscera. Furthermore, the porcine model can be utilized by surgeons to attain competence in this technique prior to instituting clinical application in humans.

Substance P stimulates the opossum sphincter of Oddi in vitro.

We have previously shown that substance P (SP) regulates sphincter of Oddi (SO) motility in vivo. However, its mechanism of action remains unclear. Our aim was to develop an in vitro model to measure spikeburst (SB) an contractile frequency (CMC) of the SO and to characterize further SP effects. In 16 opossums, SO rings were excised, mounted within a Kreb's tissue bath with bipolar electrodes and force transducers, allowed to equilibrate, and exposed to increasing SP concentrations with washout between each test solution. Spikeburst and CMC frequencies were recorded on a polygraph, quantitated, expressed as differences before and during SP, and statistically analyzed with Student's test. Although SP induced a significant concentration-dependent increase in phasic SB frequency and CMC, the amplitude of concentrations was not affected by SP. A close correlation was found between basal and SP-stimulated SB and CMC, suggesting myoelectric and mechanical coupling. Previous exposure of SO to SP antagonist [D-Arg1, D-Pro2, D-Trp7,9, Leu11]-SP significantly decreased the response to SP. Tetrodotoxin (TTX), did not affect the delta CMC response to SP. In conclusion an in vitro preparation was developed to study the effect of SP on the SO. Substance P increased SB and CMC of the SO in a concentration-dependent fashion, thus acting as a stimulatory peptide. Perfusion of SO rings with SP antagonist had no effect on basal CMC but significantly inhibited the action of SP in a competitive manner. The effect of SP was not altered by TTX. These data suggest that the action of SP on the SO is primarily myogenic.