Intravenous cholangiography and the management of choledocholithiasis prior to laparoscopic cholecystectomy.

The preoperative diagnosis of choledocholithiasis simplifies the laparoscopic management of biliary tract disease. Slow infusion intravenous cholangiography (SI-IVC) may be an accurate and cost-effective screening test for choledocholithiasis, and it is safer than traditional intravenous cholangiography. Forty-nine patients underwent SI-IVCs for suspected choledocholithiasis. These patients subsequently had endoscopic retrograde cholangiograms (ERC) or intraoperative cholangiograms (IOC) during laparoscopic cholecystectomies. Sixteen SI-IVCs demonstrated choledocholithiasis; 13 were confirmed by ERCs or by IOCs. The remaining 33 patients with negative SI-IVCs had negative ERCs or IOCs. The sensitivity, specificity, and accuracy of detecting choledocholithiasis by SI-IVC were 100%, 92%, and 94%. Only one patient had a mild reaction to the contrast agent. In our hospital the cost of an SI-IVC is $324, the cost of an IOC is $393 (including operating room and anesthesia costs), and the cost of an ERC is $1,085. SI-IVC is an accurate method of preoperative screening for choledocholithiasis. It is safe and cost-effective.

Nasointestinal tube for decompression or enteroclysis: experience with 150 patients.

The initial clinical experience with the use of a triple lumen long tube designed for gastrointestinal decompression and enteroclysis is reported in 150 patients. Based on clinical observations, this tube is effective in suctioning retained gastric and intestinal fluid but requires frequent irrigation of the sump port for effective decompression of distended small bowel. In all patients with a preexisting nasogastric tube, the replacement by the decompression/enteroclysis tube was considered more comfortable by the patients. Successful placement of the tube in the jejunum was achieved in 147 of 150 consecutive patients on the initial attempt. The use of this tube obviates dual intubations for decompression and enteroclysis, the attendant discomfort on the patient, and it expedites subsequent performance of enteroclysis if needed. The complications reported with other long intestinal tubes were not observed with this device.

Obstruction of the small intestine: accuracy and role of CT in diagnosis.

The reliability of abdominal computed tomography (CT) in the assessment of varying degrees of small bowel obstruction (SBO) was evaluated by using results at enteroclysis and clinical outcome as standards of reference. A blinded retrospective analysis was performed of the studies of 55 patients who underwent both CT and enteroclysis in the course of assessment for suspected SBO. Nine patients had no obstruction, 40 patients had obstruction due to adhesions, and six patients had tumor-related obstruction. CT results were used to identify correctly 63% (29 of 46) of those who had SBO and 78% (seven of nine) of the patients who did not. The overall accuracy of the CT interpretations to help establish diagnosis was 65% (36 of 55). When obstructions were classified into low- and high-grade partial obstruction, CT results could be used to identify correctly 81% (17 of 21) of high-grade SBOs and 48% (12 of 25) of low-grade SBOs. The procedure yielded two false-positive and 13 false-negative results for patients with low-grade obstruction, revealed masses in all six cases with tumor-related obstruction, and helped predict the correct cause in all true-positive cases.

Laparoscopic cholecystectomy: the Methodist Hospital experience.

This report relates our experience with laparoscopic cholecystectomy at Methodist Hospital of Indiana (Indianapolis). We began to develop a technique for this procedure in our animal laboratory in January 1988 and over the subsequent 18 months performed this procedure successfully in eight animals. Our first human cholecystectomy by the laparoscopic method was done on September 13, 1989. Since then more than 900 cholecystectomies have been completed under laparoscopic guidance at our institution. In this 1,000-bed hospital, 18 surgeons have been trained to perform laparoscopic biliary tract surgery on a regular basis. In addition, approximately 70 other surgeons from around the state have been trained in our program of "mini"-fellowships. This report reviews these 900 cases, presents some anecdotal information, and relates some of the unique features that we have developed.

New alternatives in gallstone treatment.

Within the past few years, a number of new treatment modalities for gallbladder stones have become available. Laparoscopic cholecystectomy has proved as safe as traditional surgical cholecystectomy, without the discomfort and lengthy recuperation associated with a large abdominal incision. Several other new treatments also have been investigated, including percutaneous cholecystolithotomy, peroral drug chemolysis, extracorporeal shock wave lithotripsy, and methyl-tert-butyl ether lavage. The relative merits and disadvantages of these treatments, compared to each other and to standard cholecystectomy, are described herein.

The effect of barium enemas and barium sulfate on healing of colorectal biopsy sites.

Twelve mongrel dogs had superficial and deep colon biopsies above and below the peritoneal reflection. Six of the animals were given a barium enema; two had a barium enema immediately, two in three days, and two in six days. The animals were sacrificed 48 hours after the barium enema; the sigmoid was removed and tissue was examined macroscopically and microscopically. When healing rates of the biopsy sites were compared with those of control animals, there was no difference. The results suggest that barium has no deleterious effect on the healing of superficial or deep colorectal biopsies.

Barium enema after colorectal biopsies: experimental data.

The appropriate interval between a colorectal biopsy and a barium enema is controversial. Superficial and deep biopsies, above and below the peritoneal reflection, were performed on 12 dogs. Six control dogs did not have a barium enema. Six study dogs had a barium enema at different postbiopsy time intervals: immediately, 3 days, and 6 days. After superficial biopsies, there was no barium extravasation in any study animal. Histological examination, 48 hr after enema, showed complete epithelialization of all superficial sites on both study and control dogs. When the barium enema was done after a deep biopsy, there was intramural extravasation of barium immediately after biopsy but not after 3 or 6 days. Focal ulcerations were seen microscopically at sites of deep biopsies when the barium enema was performed immediately and 3 days after the diagnostic procedure. All deep biopsy sites were reepithelialized in 6 days. There was no evidence of intraperitoneal or retroperitoneal perforation and no difference in healing of biopsy sites in subjects and control animals. This study in dogs suggests that a barium enema may be performed without hazard immediately after a superficial biopsy of nondiseased colon and 6 days after a deep biopsy.

Gastric rupture: an esophageal obturator airway complication.

The esophageal obturator airway (EOA) is in common use throughout the country. This report outlines an unexpected and serious complication: gastric rupture due to overinsufflation. A survey of the literature revealed that most of the known complications involve direct trauma to the esophagus or trachea. In our case, the patient's stomach was ruptured due to vigorous manual ventilation where air was forced into the stomach under pressure, rather than into the lungs, due to failure of the air pressure cuff utilized in the EOA.