Surgery for gallstones in the elderly.

In a consecutive series of 349 patients undergoing surgery for gallstones, 66 patients (19%) were aged over 65 years. Within this group of elderly patients, 51 underwent laparoscopic cholecystectomy which was successful in 84% of cases. The most frequent cause for conversion to open surgery was the presence of dense pericystic adhesions. Fifteen patients (23%) underwent elective open surgery. The principal reason was co-existent duct stones. There was no operative mortality and procedure related morbidity in the elderly following laparoscopic or open surgery was similar. Laparoscopic cholecystectomy can be safely and effectively performed in the majority of elderly patients, offering them the perceived advantages of this technique. However, the presence of duct stones in 18% of cases necessitates careful evaluation of these patients pre-operatively.

The role of ERCP and endoscopic sphincterotomy in the era of laparoscopic cholecystectomy.

The advent of laparoscopic cholecystectomy (LC) has led to some controversy regarding the best method of managing bile duct calculi. This paper reviews the cases of 38 patients who underwent LC and endoscopic retrograde cholangiopancreatography (ERCP), from a series of 600 consecutive laparoscopic cholecystectomies. Twenty-nine patients had ERCP performed pre-operatively because of suspicion of choledocholithiasis. Duct stones were confirmed in eight patients. Recent or current jaundice was the best predictor of bile duct stones. Nine patients had ERCP done postoperatively because of duct stones seen on operative cholangiography. In two patients bile duct cannulation was not possible and a third procedure, open duct exploration, was necessary. Techniques in laparoscopic management of duct stones are improving and the role of ERCP and sphincterotomy should be limited to jaundiced patients or those with proven bile duct stones in whom laparoscopic procedures have been unsuccessful.

Early postoperative endoscopic sphincterotomy for retained common duct stones.

The results of endoscopic sphincterotomy in 30 patients with retained common bile duct stones and a T-tube in situ following surgical exploration of the common bile duct are presented. Successful stone extraction was achieved in 27 cases (90%). There was one death, which was not procedure related. Early postoperative T-tube cholangiography is advocated and if necessary sphincterotomy can be safely performed 1 week following surgery. This approach has advantages in shortening hospital stay and minimising patient discomfort.

Stapled marlex mesh abdominal closure for repeat laparotomy in pancreatic disease.

A series of seven cases of severe pancreatic disease have been managed by repeat laparotomy for debridement of necrotizing pancreatitis, drainage of abscesses or control of haemorrhage with stapled marlex mesh closure of the abdominal wall. The use of a stapled marlex mesh at first laparotomy provides for safe, expedient relaparotomy until sepsis or haemorrhage is controlled.

Endoscopic sphincterotomy for common bile duct calculi.

A series of 74 patients having endoscopic sphincterotomy for common bile duct calculi is reported. Complete stone extraction was achieved in 53 cases (72%). Seventeen of 21 patients with retained calculi following recent biliary surgery had successful extractions (80%). Of 30 patients having had a cholecystectomy, 21 (70%) were successful, but only 15 of 23 patients with obstructive jaundice and no previous biliary surgery had the ducts cleared of calculi. Failure was due to multiple stones in the duct, or calculi too large to pass through the sphincterotomy. Endoscopic sphincterotomy is advocated in patients with obstructive jaundice due to stones, moving to early surgery should it prove unsuccessful. The results in patients with a T-tube in situ are comparable to extraction of the calculi along the T-tube tract.

Jaundice and the effect of sodium taurocholate taken orally upon abdominal wound healing.

The effect of oral sodium taurocholate upon abdominal wound healing was assessed in an experimental study using rats. Bile duct ligation produced a significant reduction in wound bursting strength four and six days postoperatively compared with control rats, and sodium taurocholate in bile duct ligated rats resulted in a significant increase in wound strength six days postoperatively. There was no change in wound hydroxyproline concentrations between rats in the bile duct ligated and control groups. In the clinical situation, oral bile salts may be of value in the preoperative management of patients with obstructive jaundice.

Arterial embolectomy: a review of 100 cases.

The results of 100 consecutive patients undergoing arterial embolectomy at the Royal Brisbane Hospital between 1971 and 1981 are presented. Twenty-two patients died and 18 of these had unsuccessful procedures. Of the 82 patients surviving more than 30 days, 14 had a limb amputated and 12 underwent further vascular surgery. Duration of ischaemia was the most important predictive factor; 75% of cases with an ischaemia time of less than 12 h had a successful outcome whereas only 37% were successful when the ischaemia time exceeded 12 h. Anticoagulation improved the success rate, but resulted in a high incidence of wound haematoma.

Faecal mutagens and intestinal tumours in the dimethylhydrazine-injected rat.

The relationship between the development of colonic tumours and the presence of faecal mutagens has been investigated in the dimethylhydrazine (DMH) injected rat model. Subcutaneous DMH 20 mg/kg for 6 weeks in 10 rats produced colonic tumours in 8 animals and duodenal tumours in 2. Faeces were collected 6, 10, 14, 20 and 25 weeks after commencing DMH injections and were assayed using the Ames test system with both aqueous and ether extracts. All faeces were initially negative for mutagens, but all became positive at some stage following DMH injections, There was no consistent pattern of mutagen excretion or of the strain of Salmonella typhimurium detecting a positive extract. Early positive extracts tended to be with aqueous extracts, whereas later extracts (20 and 25 weeks) were predominantly with ether extracts. DMH produces a metabolic change in the rat resulting in the production of faecal mutagens. This change precedes the appearance of colonic neoplasms and persists after the withdrawal of DMH injections.

A comparison of upper abdominal wound closure with monofilament nylon and polyglycolic acid.

In a trial of 104 consecutive patients undergoing upper abdominal surgery, 62 wounds were closed with continuous layered nylon and 42 with interrupted mass PGA sutures. All wounds were closed by one surgeon. There was a significantly greater incidence of wound infection (P less than 0.01) and incisional hernia (P less than 0.05) in the group closed with PGA. Wounds closed with PGA took longer to suture (1.00 min/cm) than wounds closed with nylon (0.76 min/cm), a highly significant difference (P less than 0.001). From this study it is recommended that upper abdominal surgical wounds should be closed with a continuous nylon suture.