How does infected bile affect the postoperative course of patients undergoing laparoscopic cholecystectomy?

OBJECTIVES: To assess the rate of infected bile in patients undergoing laparoscopic cholecystectomy (LC) and to study the influence on the postoperative infective complications in this group of patients. METHODS: Bile samples of 247 patients undergoing LC were collected and cultured for aerobic and anaerobic bacteria. All patients were given prophylactic antibiotics. RESULTS: The overall rate of infected bile was 12.8% (56 positive cultures); of these, 54 were aerobic and 2 anaerobic bacteria. Only 2 patients developed infection at the umbilical site, and in both, the bile was sterile. None of the patients with positive bile cultures developed any signs of infection during a mean follow-up period of 26 months. CONCLUSION: The overall rate of septic complications following LC is extremely low, and at least in our study no correlation was found between infected bile and septic complications.

Autoimmune mechanisms in thromboangiitis obliterans (Buerger's disease): the role of tobacco antigen and the major histocompatibility complex.

This study is a continuation of our previous work that showed that patients with thromboangiitis obliterans (TAO; Buerger's disease) demonstrate a cell-mediated immune response to human artery type-specific collagens. To investigate the role of cigarette smoking in patients with TAO, cellular and humoral sensitivity was tested to a tobacco glycoprotein (TGP) antigen in 13 patients with Buerger's disease, 16 healthy smokers, and 12 nonsmoking healthy young male subjects. In this study, patients with Buerger's disease and healthy smokers had the same rate of cellular response to TGP, whereas nonsmokers did not respond. All three groups had a 30% to 40% measurable antibody response to TGP. If TGP has an immunologic role in the pathogenesis of TAO, an additional factor (or factors) may be operative. A specific genetic makeup may be one such factor, although at this stage other pathogenic mechanisms cannot be ruled out. Eleven patients with Buerger's disease and two control groups of 10 young healthy smoking male subjects and 12 young nonsmokers underwent histocompatibility leukocyte antigen (HLA) typing. Patients with Buerger's disease had a statistically significantly higher frequency of HLA-DR4 and a significantly lower frequency of the HLA-DRW6 antigen than had both control groups. Because similar findings have been reported in other autoimmune diseases, this observation may serve as further evidence that an autoimmune mechanism is involved in Buerger's disease.

A prospective analysis of liver biopsies in rheumatoid arthritis patients receiving long term methotrexate therapy.

Baseline and sequential liver biopsies were performed in ten patients with rheumatoid arthritis (RA) treated with methotrexate (MTX) for more than 4 years. Liver biopsies were performed in all patients before the initiation of MTX therapy and were repeated after reaching a cumulative dose of 1500 mg or more. In four patients a third biopsy was performed 3 years after the first one. No significant worsening of hepatic architecture was found in any of our patients after 4 to 7 1/2 years of MTX therapy. No correlations between histologic findings and various clinical or pharmacological variables could be found. Our results suggested that prolonged MTX administration in RA patients did not cause severe hepatic abnormalities.

The effect of ischemia of the dog's colon on transmural migration of bacteria and endotoxin.

The purpose of this investigation was to evaluate the effect of temporary ischemia created during the surgical preparation of the colon for resection on transmural migration of bacteria and passage of endotoxin through the ischemic wall of the canine colon. Eighteen dogs were used: in fourteen the colon was devascularized by ligating all marginal vessels. Aerobic and anaerobic cultures and washings for endotoxin assay were obtained from the surface of the bowel at intervals up to 6 hr after creating the ischemia. Peripheral and portal blood samples were also obtained at equal intervals for bacteriologic cultures and endotoxin assay. Bacterial transmural migration was examined in 10 dogs. In 6 of the dogs biologically marked bacteria were introduced into the colon via a rectal catheter before producing the ischemia. In 4 dogs radioactively labeled endotoxin was introduced into the colon in a similar fashion. In all the dogs, surface cultures, both routine and specific for the marked bacteria, were negative for the whole period of up to 6 hr after creation of ischemia. All portal and peripheral vein cultures were also negative. Transmural migration of endotoxin was investigated in 8 dogs, 4 of which served as controls and underwent a sham operation. In the 4 dogs in which the colon was devascularized endotoxin was discovered in peritoneal washings, and in portal and systemic blood samples, as early as 30 min after the preparation of the bowel was completed. In the control dogs endotoxin assays were negative throughout the experiment. In this model up to 6 hr of ischemia did not result in migration of bacteria through the ischemic wall. Endotoxin, however, entered the peritoneum and the blood very soon after producing the ischemia.

Impairment of bromosulfophthalein clearance by bile salt administration in normal volunteers and patients with Dubin-Johnson syndrome.

Sodium dehydrocholate administration significantly impaired bromosulfophthalein (BSP) clearance in six normal volunteers, despite its choleretic effect. In order to determine whether the impairment is at the stage of excretion of BSP from the liver cell into the bile, patients with Dubin-Johnson syndrome were studied. In all six Dubin-Johnson patients, sodium dehydrocholate administration significantly decreased BSP clearance. Since serum bile acid levels are normal in Dubin-Johnson patients, presumably due to a final secretory pathway into the bile distinct from that of BSP and other organic anions, the interaction between BSP and bile acids cannot take place at the stage of excretion into the bile. Based on a previous study and our results, the interaction between BSP and bile salts seems to occur at the site of transport within the liver cell. This mechanism of inhibition may be responsible for the increased serum BSP retention during chemotherapy.

Infections in vascular operations.

During the period 1973-79, 26 infections occurred in 931 vascular operations. The overall infection rate was 2.8%, and 80% of the infections occurred in groin incisions. There was a significantly higher infection rate when a synthetic graft was inserted, when there was an infected foot ulcer prior to operation, or when early reoperation was necessary. Several regimens of antibiotic treatment are described. The current practice of a short perioperative course of cefazolin, combined with irrigation of the wound with 1% povidone-iodine solution before closure of the skin resulted in an acceptably low rate of infection (less than 2%) during the last three years of the study period. There is no advantage in continuing postoperative antibiotic therapy for more than one to three days.

Echocardiographic left ventricular function in mitral stenosis.

Left ventricular function was measured by echocardiography in 22 patients with pure mitral stenosis. Thirteen patients underwent closed transventricular mitral valvulotomy and nine underwent open mitral valvulotomy using cardiopulmonary bypass. Preoperative left ventricular function was normal in most patients but was depressed in older subjects (P less than 0.05) and in those undergoing a second operation on the mitral valve (P less than 0.001). The decrease in left ventricular function was probably related to the duration of mitral valve disease, with fibrosis and rigidity of the subvalvar apparatus and posterobasal left ventricular wall. There was no change in ventricular dimensions or in left ventricular function as measured by percentage shortening of the left ventricular diameter and ejection fraction 7 to 12 days after open or closed mitral valvulotomy.

Echocardiographic left ventricular function in aortic and mitral incompetence and the effect of valve replacement.

Left ventricular (LV) function was studied by echocardiography in 28 patients with volume overload of the LV before and after valve replacement. Of the 28 subjects, 19 had mitral valve disease (eight with mitral incompetence and 11 with mitral incompetence and stenosis) and nine patients had aortic incompetence. Patients with chronic mitral and aortic incompetence had marked LV enlargement with normal or slightly depressed systolic function; in those with acute mitral incompetence the degree of cardiomegaly was less and the state of LV function depended on the underlying cause of valvular incompetence. Valve replacement was followed by a decrease in LV end-diastolic volume and this occurred in the first week after operation. There was a gradual improvement in LV function in some patients, as measured by normalized mean velocity of posterior LV wall motion. Paradoxical septal motion occurred in many patients after operation but improved in the late postoperative period.