Spilled gall stones during laparoscopic cholecystectomy: a review of the literature.

Laparoscopic cholecystectomy is associated with spillage of gall stones in 5%-40% of procedures, but complications occur very rarely. There are, however, isolated case reports describing a range of complications occurring both at a distance from and near to the subhepatic area. This review looks into the various modes of presentation, ways to minimise spillage, treating the complications, and the legal implications.

Is antral gastrin important in the resistance of duodenal ulcers to H2 receptor antagonists or in recurrent ulceration after highly selective vagotomy?

Basal serum gastrin, integrated gastrin response to a meal, and integrated gastrin response to insulin induced hypoglycaemia were measured in 60 patients with duodenal ulcer before and after elective highly selective vagotomy to determine whether antral gastrin has a role in resistance to H2 receptor antagonist treatment which the patients had received before surgery or in the development of recurrent ulceration after vagotomy. The basal gastrin, integrated gastrin response to a meal, and the integrated gastrin response to insulin were similar in patients whose ulcers healed after H2 receptor agonist treatment or were refractory to at least three months of this treatment. The same parameters measured before or after highly selective vagotomy were similar in patients who eventually developed recurrent ulceration compared with those who did not. As expected the basal and meal stimulated (but not insulin stimulated) serum gastrin values increased after highly selective vagotomy. Ulcer patients with particularly high gastrin values (whether basal or stimulated) were not more resistant to H2 receptor antagonist treatment or prone to develop ulcer recurrence after highly selective vagotomy. This study suggests that antral gastrin is not important in 'resistance' of duodenal ulceration either to H2 receptor antagonist treatment or to highly selective vagotomy.

Implantation of a benign rectal villous adenoma in the surgical track after transsphincteric excision. Report of a case.

A 56-year-old male patient underwent excision of a rectal villous adenoma by a transsphincteric approach. Six years after surgery, an extrarectal mucinous mass was noted, which, on biopsy, had histologic features of implantation of benign villous adenoma within the operative scar. For medical reasons, surgery was avoided and the lesion enlarged until symptoms necessitated rectal excision five years later. Histologic examination of the resected mucinous tumor supported an origin from implanted adenomatous epithelium. This is apparently the first description of implantation of an adenoma in the surgical track. Care should be taken during transsphincteric and transsacral excision of rectal adenomas to prevent implantation at the time of surgery.

Mycotic aneurysm of the aorta due to group B streptococcus (Streptococcus agalactiae).

This report describes the successful treatment by excision and primary anatomic graft of a mycotic aortic aneurysm infected with a Group B Streptococcus.

'Inflammatory' abdominal aortic aneurysms.

The term 'inflammatory aneurysm' is used to describe a variant of atherosclerotic abdominal aortic aneurysms in which the wall of the aneurysm is unusually thick and surrounded by extensive fibrosis and adhesions. Repair of these aneurysms is associated with a higher mortality and morbidity than repair of those which are non-inflammatory, so that diagnosis prior to surgery is desirable. The use of computed tomography (CT) and ultrasound in this differentiation is discussed. The correct diagnosis was made in 16 out of 17 by CT, but in only three of nine cases who had ultrasound scans.

Recurrent ulceration after highly selective vagotomy for duodenal ulcer.

Recurrent peptic ulceration was diagnosed in 9 per cent of 433 patients who were treated by elective highly selective vagotomy (HSV) for duodenal ulcer (DU) between 1969 and 1980. In 233 patients followed up for 5-12 years (12 per cent being lost to follow-up), the incidence of recurrence was 10.7 per cent. The site of recurrence was duodenal in 23 patients, pyloric in 4, gastric in 6 and combined duodenal and gastric in 2 (total of 35 patients). One patient presented with a perforation, l4 with haemorrhage and 30 with epigastric pain. Asymptomatic patients were not endoscoped and so asymptomatic recurrence would have been missed. Nine patients were treated by reoperation (5 Polya partial gastrectomy, 4 vagotomy + antrectomy), the remainder with cimetidine. There was no mortality. When the 35 patients with recurrence were compared with the patients without recurrence, no preoperative factors could be identified that might be used to predict recurrence. Thus, for the two groups, the sex distribution, age, length of ulcer history, previous ulcer complications and preoperative acid outputs (basal and maximal) were very similar. This was true also when the data for patients with true recurrence in the duodenum were examined separately. Hence, contrary to some previous reports, no evidence was found that patients who are hypersecretors of acid, either basal or maximal, before operation should be treated by vagotomy combined with antrectomy. After HSV, however, patients with recurrent DU secreted more acid (basal, insulin and pentagastrin-stimulated) than patients without recurrence, the difference between the two groups being statistically significant for basal acid output (BAO) and the response to insulin. The only factor which was found to influence the incidence of recurrent ulceration after HSV strongly was the surgeon who performed the operation.

Postoperative external small bowel fistulas: a study of a consecutive series of patients treated with intravenous hyperalimentation.

A consecutive series of 25 patients who developed external small bowel fistula within 2 weeks of abdominal surgery is described. Half the patients had a primary diagnosis of inflammatory bowel disease and the fistula arose usually as a result of direct trauma to the bowel or the breakdown of an anastomosis. All the patients were treated conservatively with total bowel rest and intravenous hyperalimentation. In 15 (60 per cent) spontaneous fistula closure occurred, in an average period of 32 days. In 8 patients the fistula failed to close and surgery was performed, but was effective in only 3 cases. Thus the fistula eventually closed in 18 patients. Five patients died, all from intra-abdominal sepsis. Of the 8 patients with a primary diagnosis of Crohn's disease, 3 died, 2 have a persistent fistula, 1 has a permanent ileostomy and spontaneous closure occurred in only 2.

A prospective study of subclavian vein catheters used exclusively for the purpose of intravenous feeding.

One hundred and seventy-eight central venous catheters inserted via the subclavian vein for the purposes of intravenous feeding were studied in 77 patients. Insertion of the catheter was complicated by puncture of the subclavian artery on three occasions and by a pneumothorax on two. Catheters remained in situ for a mean period of 10 days. Ninety-two were removed because the requirement for nutrition no longer existed and 86 were removed because of suspected infection, venous thrombosis or mechanical problems. Infective organisms were grown from 17 catheters (9.5 per cent) but other unrelated causes of infection were frequently present in the population under study. Venous thrombosis of a major upper limb vein was seen in 8 patients.

A survey of protein nutrition in patients with inflammatory bowel disease--a rational basis for nutritional therapy.

The incidence of protein malnutrition was studied in 74 unselected patients with inflammatory bowel disease who were in the following categories: ileostomy (16), remission (15), elective surgery (12), acute attack (12), urgent surgery (10) and post-surgical complications (9). Compared with a control group, the patients in the urgent surgery group had low values for plasma albumin transferrin, pre-albumin and haemoglobin and these values were even lower in the patients who developed a major complication after surgery. There was no evidence of protein malnutrition in the ileostomy patients or in those in whom the disease was in remission. Nutritional therapy is strongly indicated in patients who are admitted to hospital with a severe attack of colitis and in whom urgent surgery is probable.

Early assessment of severity of acute pancreatitis using peritoneal lavage.

Diagnostic peritoneal lavage using one litre of isotonic saline was performed on 27 patients with acute pancreatitis as soon as possible after diagnosis. There were no complications. Severe attacks (defined retrosepctively according to the progress of the attack) were characterised by the presence of free peritoneal fluid and by dark-coloured and often opalescent return fluid. The concentrations of albumin, aspartate aminotransferase (SGOT) and total protein in the return fluid provided good discrimination between severe and mild attacks, and there were also significant differences in the concentrations of amylase, urea, calcium, potassium, bilirubin, alkaline phosphatase, and the white cell count. Lavage successfully predicted severe disease in five patients whose condtion had been clinically assessed as mild.

Malnutrition in surgical patients. An unrecognised problem.

Indices of nutritional state were measured in 105 surgical patients. The indices were chosen to give information on protein-calorie malnutrition, anaemia, vitamin deficiency. Abnormal values for the various indices were common in the group as a whole and most frequent (50%) in patients who were still in hospital more than a week after major surgery. These patients had a high frequency of anaemia, vitamin deficiency, weight-loss, loss of arm-muscle bulk, and low plasma levels of transferrin and albumin. These abnormalities had gone almost entirely unrecognised, even in patients with sepsis after major surgery, who would benefit from improvement in nutritional state.