Laparoscopic common bile duct exploration: evolution of a new technique.

Laparoscopic exploration of the common bile duct (CBD) with a choledochoscope or a stone basket during laparoscopic cholecystectomy was attempted in 60 patients and was successful in 56. The cystic duct was used for entry to the CBD in 46 patients and in 14 a choledochotomy was performed. Of 51 patients with confirmed common duct stones, 38 had complete laparoscopic clearance (75 per cent). In 13 patients the duct was not cleared or was only partially cleared, of whom four went on to have clearance by postoperative percutaneous choledochoscopy down a cystic duct or T-tube track. Two patients with cystic duct tubes passed their remaining stones spontaneously. One patient had open exploration and six required endoscopic retrograde cholangiopancreatography. Of nine patients without stones, choledochoscopy was impossible in three patients whose cholangiogram was later considered to be normal. In five patients stones were excluded by choledochoscopy and in one patient laparoscopic choledochoscopy was undertaken to better define abnormal biliary anatomy; this helped to avoid major bile duct injury. Choledochoscopy was easier with the smaller 3.6-mm ureteroscope but stone removal was more difficult when the basket was too small for the stones, the cystic duct too small relative to stone size or the number of stones was too great. Successful stone clearance was proportional to the level of effort expended, and was limited by operating time and equipment.

Value of laparotomy in the diagnosis of obscure gastrointestinal haemorrhage.

Over a nine year period a total of 137 patients were investigated for obscure gastrointestinal bleeding on one surgical unit. In 20 patients visceral angiography strongly suggested the presence of caecal or right colonic angiodysplasia. These patients were treated by an appropriate colectomy and they are not considered further in this study. Similarly lesions of the small bowel detected by preoperative investigations are not considered here. Fifty five patients were offered diagnostic laparotomy after the failure of other investigations to establish a diagnosis. Two patients refused. A diagnostic laparotomy was performed in the remaining 53. At operation if no visible lesion was seen an on table enteroscopy was performed using a colonoscope passed per oram and, if necessary, per anum. In nine (17%) patients no cause for bleeding was found. In 18 (34%) patients there was a small bowel vascular anomaly, in 14 (26%) a small bowel tumour, in four (7.5%) a bleeding Meckel's diverticulum, and in eight (15%) other miscellaneous lesions. Laparotomy, with on table enteroscopy where indicated, elucidated the cause of bleeding in 44 patients (83%). It was associated, however, with a postoperative death rate of 7.5% (four patients). After seemingly appropriate surgery, rebleeding occurred in 14 patients (26%). Of 18 patients with small bowel vascular anomalies seven rebled (39%), at an average follow up interval of 32 months.

Is screening once at age 65 an effective method for detection of abdominal aortic aneurysms?

OBJECTIVE: To evaluate whether a single screening at 65 or screening at 65 and 70 are the methods of choice to detect the majority of abdominal aortic aneurysms (AAA) suitable for treatment. SETTING: District general hospital, district general practice and community. METHODS: Data were collated from four studies (a pilot, a control trial, and two cohorts) of abdominal ultrasound screening of an invited group of 11 666 men and women aged 65-80 to derive age related prevalence, invitation acceptance rates, and operative mortality. Deaths from AAA rupture were obtained from district registrars' returns. RESULTS: The prevalence of AAA increased with age being greater overall in men (6.8%) than in women (1.2%). From ages 65 to 80 the prevalence in men increased from 5.4% to 10.4%, and in women from 0.6% to 2.1%. In men and women 4% of patients dying from AAA rupture were aged 65 or under and 85% of deaths occurred over the age of 70. Acceptance rates for screening decreased between 65 and 80 from 80.5% to 66.2% in men and from 72.7% to 58.3% in women. In elective or symptomatic patients operative mortality was zero up to the age of 70, increasing to 7.1% in older patients. CONCLUSIONS: Men should be screened at age 65 to obtain a high acceptance rate and to identify those with AAA most likely to benefit from treatment. The prevalence is relatively low at this age so an additional screen at age 70 is recommended, which would pick up a further 3.7% of patients with AAA, at which age intervention is likely to be of benefit.

Iodostearic acid in the treatment of advanced gastrointestinal carcinoma.

This phase II non-comparative trial evaluated the efficacy of intramuscular iodostearic acid in the treatment of 30 patients with advanced carcinoma of the gastrointestinal tract. These included 17 patients with colorectal carcinoma, seven with pancreatic carcinoma, four with gastric carcinoma, one with hepatocellular carcinoma and one with cholangiocarcinoma. Iodostearic acid emulsion (2 ml/1.2 g) followed by depomedrone (0.5 ml/10 mg) was injected intramuscularly twice weekly. No serious toxic effects were observed, the main side effects being local pain at the injection site and hot flushes. There were no partial or complete responses. Stable disease was seen in six of 30 patients (20%) at 3 months and three of 30 patients (10%) at 6 months. In conclusion, intramuscular iodostearic acid is relatively non-toxic, however, it appears to be of little value in the treatment of patients with advanced gastrointestinal carcinomas.

Effects of dietary fatty acids on the early stages of neoplastic induction in the rat pancreas. Changes in fatty acid composition and development of atypical acinar cell nodules.

Diets enriched with fat, especially unsaturated fat, promote experimental pancreatic carcinogenesis, but little is known of the effects of individual fatty acids. The effect of stearic and oleic acid on pancreatic fatty acids and atypical acinar cell nodules (preneoplastic lesions) was studied in 14-day-old weanling male Leeds strain rats (n = 60) given the carcinogen azaserine. Rats were allocated to one of six groups: untreated controls (n = 10), 20% stearic acid diet (n = 10), 20% oleic acid diet (n = 10), carcinogen alone (n = 10), carcinogen plus 20% stearic acid diet (n = 10) or carcinogen plus 20% oleic acid diet (n = 10). Azaserine was administered by intraperitoneal injection in a dose of 30 mg/kg at 2, 3 and 4 weeks of age. When total lipid extracts of pancreas were examined, there was an increase in stearic acid in the stearic acid fed group and an increase in oleic acid in the oleic acid fed group, irrespective of carcinogen treatment. The relative content of all other pancreatic fatty acids was suppressed by feeding oleic acid. At 26 weeks, the number and volumetric indices of pancreatic atypical acinar cell nodules was increased only in rats given azaserine and oleic acid. The enhancing effect of oleic acid on pancreatic carcinogenesis may be associated with pancreatic fatty acid changes.

Manipulation of body fat composition with sterculic acid can inhibit mammary carcinomas in vivo.

Sterculic acid, a delta-9-desaturase inhibitor, administered to rats caused a rise in the stearic:oleic acid ratio of total lipids in peripheral red cells, serum and liver (P less than 0.001). As a reduction in the stearic:oleic acid ratio has been described in cancer cells, we investigated the effect of sterculic acid on tumour growth. Female F344 rats were injected subcutaneously with two different doses of sterculic acid for 4 weeks prior to, and 4 weeks following, implantation of a nitrosomethylurea-induced mammary tumour. Tumour growth was inhibited equally by the two doses of sterculic acid (P less than 0.001). A rise in the stearic:oleic acid ratio of tumours was observed in rats treated for only 16 days with sterculic acid. Manipulation of the tissue stearic:oleic acid ratio inhibits transplanted mammary tumour growth in rats.

Bacterial endocarditis in a transplanted heart.

A 51-year-old man presented with an abscess in his sternotomy scar 33 months after orthotopic heart transplantation. After surgical drainage he developed a febrile illness which led to renal and pulmonary failure. Twenty-three days after the illness began, blood cultures grew Staphylococcus aureus and he died 11 days later. Post-mortem examination revealed acute bacterial endocarditis with dense colonies of gram-positive cocci on the mitral valve leaflets and microabscesses in the myocardium of the transplanted heart.