Perfoation of the gallbladder: 'bait' for the unsuspecting laparoscopic surgeon.

INTRODUCTION Cholecystectomy is one of the most common elective procedures carried out by general surgeons. Most patients present with typical biliary anatomy and simple gallstone disease. Intraoperative and postoperative courses are frequently predictable and uncomplicated. Nevertheless, a small but significant number of patients experience complicated disease with rare presentations and complex biliary anatomy. Unfortunately, consensus on appropriate care for such patients is lacking. CASE HISTORY We describe three patients who presented with complex manifestations of gallbladder perforation: acute perforation of the gallbladder; a spontaneous cholecystocutaneous fistula; a cholecystoduodenal fistula. The initial presentation, preoperative investigations, and selected surgical strategy for each case are described. CONCLUSIONS The case studies described here illustrate the need for a low index of suspicion for gallbladder perforation. Caution should be exercised in preoperative and intraoperative phases in this patient population.

Chronic transcutaneous electrical stimulation of calf muscles improves functional capacity without inducing systemic inflammation in claudicants.

OBJECTIVES: To assess whether electrical stimulation of ischaemic calf muscles in claudicants causes a systemic inflammatory response and to evaluate effects of its chronic application on muscle function and walking ability. DESIGN: Prospective randomised controlled trial of calf muscle stimulation. MATERIALS AND METHODS: Stable claudicants were randomised to receive either active chronic low frequency (6 Hz) motor stimulation (n=15) or, as a control treatment, submotor transcutaneous electrical nerve (TENS) stimulation (n=15) of calf muscles in one leg, 3 x 20 min per day for four weeks. Leucocyte activation was quantified by changes in cell morphology, vascular permeability by urinary albumin:creatinine ratio (ACR), calf muscle function by isometric twitch contractions and walking ability by treadmill performance pre- and post-intervention. RESULTS: Acute active muscle stimulation activated leucocytes less (28% increase) than a standard treadmill test (81% increase) and did not increase ACR. Chronic calf muscle stimulation significantly increased pain-free walking distance by 35 m (95% CI 17, 52, P<0.001) and maximum walking distance by 39 m (95% CI 7, 70, P<0.05) while control treatment had no effect. Active stimulation prevented fatigue of calf muscles during isometric electrically evoked contractions by abolishing the slowing of relaxation that was responsible for loss of force. CONCLUSIONS: Chronic electrical muscle stimulation is an effective treatment for alleviating intermittent claudication which, by targeted activation of a small muscle mass, does not engender a significant systemic inflammatory response.

Ultrasound guided percutaneous thrombin injection of iatrogenic femoral artery pseudoaneurysms after coronary angiography and intervention.

Ultrasound guided percutaneous thrombin injection has recently been described for the treatment of iatrogenic femoral pseudoaneurysms. Patient selection and technical aspects of this technique are still evolving and safety data, particularly after coronary intervention, remains limited. The percutaneous thrombin injection of femoral artery pseudoaneurysms in 13 consecutive patients, most of whom were receiving antiplatelet/anticoagulant treatment (aspirin 11, heparin 4, clopidogrel 6), is reported. Thrombin (1000 U/ml) was injected over several seconds until Doppler colour flow within the cavity ceased. The median dose of thrombin injected was 800 U (range 200-1000 U) and the treatment was successful in all cases without complication. In one case, thrombus was visualised within the arterial lumen immediately after thrombin injection, but this dissolved spontaneously within five minutes without evidence of embolisation. In contrast to ultrasound guided compression, percutaneous thrombin injection of femoral pseudoaneurysms is a rapid, well tolerated, and successful technique even in patients receiving antiplatelet/anticoagulant treatment.

Intravenous fluids for abdominal aortic surgery.

BACKGROUND: Surgery on the abdominal aorta, for aneurysmal and occlusive disease is a major undertaking which requires intensive support and fluid management. Blood products are often used, but the major fluid replacement is with crystalloids or colloids. There has been controversy for many years over which fluid is optimal and a number of studies have examined this subject, without any systematic review. OBJECTIVES: The objective of this review was to determine the effectiveness of different non-blood replacement fluids used in surgery on the abdominal aorta with a view to identifying the optimal fluid for use in such surgery. SEARCH STRATEGY: All publications describing (or which might describe) randomised controlled trials of non-blood replacement fluids in abdominal aortic surgery were sought using the search strategy described by the Cochrane Review Group on Peripheral Vascular Diseases. This strategy includes hand searching of relevant medical journals and extensive MEDLINE and EMBASE searches. In addition, trials have been identified from searches of references included in those trials already retrieved. SELECTION CRITERIA: Randomised controlled trials assessing the effects of one or more specific non-blood fluids used for replacement therapy in operations on, and confined to, the abdominal aorta. DATA COLLECTION AND ANALYSIS: Data were extracted to pre-prepared tables and then entered into the Review Manager software where statistical analysis and descriptive subjective analysis were performed. MAIN RESULTS: Nine trials, involving 412 patients were included. Patients undergoing aortic surgery had various physiological parameters measured before and after their operation (cardiac, respiratory, biochemical, haematological and protein). Ten fluids were studied: Ringer lactate, 5% dextrose in Ringer lactate, 5% dextrose in 0.45% saline, 5% dextrose in water, 1.8% saline, human albumin solution in Ringer lactate, human albumin solution in water, 5% dextrose with human albumin solution, Dextran 60, Hetastarch. Patients were randomised to fluid type. This review demonstrates that no single fluid has been shown to affect any outcome measure significantly more than any other across a range of outcome measures. However, each trial compared different fluids, and each fluid has not been compared against all others. The death rate in these studies was 2.9% (12 patients). REVIEWER'S CONCLUSIONS: Further studies are required, with sufficient sample size and power, to draw any further conclusions. There are no studies examining the effects of combination fluid therapy.

Regional variation in varicose vein operations in England 1989-1996.

AIM: To determine accuracy of Office of Population Censuses and Surveys (OPCS) codes for varicose vein (VV) operations and differences in regional activity over 7 years. METHODS: OPCS codes were obtained for VV operations (L85, L87) for the 8 English regions 1989/90-1995/96. Data were also obtained for the 4 districts of the old Oxford Region. Centrally collected codes for one hospital were compared with audit data from the same hospital. RESULTS: There was a marked inter-regional variation in VV activity, e.g. in 1995/96 the range of operations/100,000 population was 102 (Anglia & Oxford) to 138 (West Midlands). There was a gradual increase in the number of operations carried out nationally from 98/100,000 in 1989/90 to 121/100,000 in 1995/96. The numbers peaked in 1991/92, coinciding with a 'waiting list initiative'. When compared with audit data, accuracy of coding improved throughout the study period. There was a 55% inaccuracy in 1989/90 compared with 2% in 1995/96. In each year, codes overestimated the volume of work actually carried out. CONCLUSION: OPCS codes broadly reflect VV activity. Difference in VV activity in different parts of the country are apparent.

Iliac occlusions: stenting or crossover grafting? An examination of patency and cost.

OBJECTIVES: Percutaneous transluminal angioplasty with stenting is perceived to be a less invasive and cheaper option for the treatment of iliac artery occlusion than surgical reconstruction. We have carried out a prospective observational study of all patients undergoing an iliac stent or femorofemoral crossover graft for iliac artery occlusion to assess the cost effectiveness of the two approaches in a district general hospital. METHODS: Fifty-one patients underwent primary angioplasty with stenting and 87 patients crossover grafting. Patients were all assessed 2 months after their procedure and then at intervals over the following years. RESULTS: In 13 cases, it was impossible to place the stent successfully. In a further 10 patients, major complications occurred which were mainly thromboembolic. Fifteen patients underwent crossover grafting after failure to insert a stent, or after stent occlusion. No major complications occurred following crossover grafting. The median length of stay following successful stenting was 1 day; the following crossover grafting was 4 days. The mean stay was higher in each group (2.5 and 5.8 days) and is a more accurate parameter for estimation of cost, which for iliac stenting is estimated at pound1912 versus pound3072 for crossover grafting. The mean additional cost of those patients sustaining complications after stenting was pound2481. On an <<<>>> basis, patency following stent insertion at 6 months was 52%; patency after bypass was 100% (p <0.0001). If any complication occurs after stenting, the cost advantage of the procedure is lost. In those patients without complication, the initial cost benefit of iliac stenting is lost within 6 months, as patients require further intervention, usually as a crossover graft, when the stent occludes. Crossover grafting is a durable low-risk procedure. CONCLUSIONS: We suggest that stenting of occluded iliac arteries should be reserved for those patients with limited life expectancy. Patients who are younger and fitter should be offered femorofemoral crossover grafting as a primary procedure until research enables identification of those patients who are most likely to maintain long-term patency after stenting.

Strangulated iatrogenic diaphragmatic hernia: a late diagnosed complication.

Three cases of iatrogenic diaphragmatic herniation are reported following thoracic and high abdominal surgery. Each case presented at least 6 months after the original surgery with symptoms of acute upper gastrointestinal obstruction. Diaphragmatic herniation was not considered in the initial differential diagnosis which lead to a delay in their referral. We emphasise the importance of checking the diaphragm following upper abdominal surgery and care when closing a defect.