Intraoperative flexible videocholedochoscopy. An improved technique for evaluating the common duct.

At the conclusion of common duct exploration, a T-tube cholangiogram is usually performed. Recently, flexible choledochoscopy has become available to evaluate the interior of the common duct. We compared four cases, using the videocholedochoscope with completion T-tube cholangiography, both in our four patients and historically. We used the Olympus CHF-P20 flexible choledochoscope, which is 4.8 mm in diameter, hooked to an Olympus S-4 videoadapter. We found that flexible choledochoscopy enabled us to evaluate the biliary tree directly from the ampulla to the third branch radicle within the liver. In all cases, the common ducts were normal after stone removal. Both the preexploration and completion T-tube cholangiograms yielded less information. We conclude that flexible choledochoscopy is an improved technique that allows a more thorough evaluation of the common duct, obviates more extensive procedures, i.e., sphincteroplasty, by removing stones through the scope, and negates the need for a completion T-tube cholangiogram. We encourage all biliary tract surgeons to consider this technique for their own use.

Abdominal aortic aneurysm repair in high-risk patients. A review of five years' surgical experience of non-ruptured abdominal aortic aneurysms in a rural tertiary referral center.

A review of 77 elective abdominal aortic aneurysms repaired over the past five years at West Virginia University Hospital in high-risk patients reveals an elevated incidence of concomitant occlusive vascular disease. We continue to perform routinely preoperative aortography with runoff films in these patients because of the valuable information it gives. This information permits us to perform vascular procedures to relieve the atherosclerotic stenotic lesions at the time of the abdominal aortic aneurysm repair. A review of risk factors, vascular anomalies, concomitant vascular procedures, complications, and mortality is given.

Is percutaneous better than open gastrostomy? A clinical study in one surgical department.

Percutaneous endoscopic gastrostomy (PEG) has become an acceptable alternative to open gastrostomy since its inception in 1981. The PEG procedure has been assumed by most to have lesser associated morbidity and mortality and to be more cost effective. Only a few studies have compared the two procedures, and even fewer cost comparisons have been performed. A review of the literature and a retrospective study was performed over a three-year period examining eighty-eight consecutive patients who underwent either PEG (48) or gastrostomy (4) for feeding purposes only by the same group of surgeons. Patients undergoing PEG or gastrostomy tube placement in association with other procedures were excluded from the study. The results of our experiences with PEG versus open gastrostomy revealed no difference in age or gender. Intraoperative morbidity was higher (50%) for PEG than for gastrostomy (2.5%). Six-month follow-up mortality was 30 per cent and 32 per cent for PEG and gastrostomy. The cost for PEG ($1360) was approximately half the cost for gastrostomy ($2448). This study demonstrates that PEG has a significantly higher intraoperative morbidity rate relative to open gastrostomy, whereas both carry a substantial percentage of late complications. Problems often encountered with PEG included suture breakage, inadvertent colon puncture, local peritonitis, and inability to keep the stomach inflated. Late complications seen with open gastrostomy were wound infection, wound dehiscence, and respiratory complications. No deaths were a direct result of either procedure, and long-term mortality rates were comparable. PEG was clearly more cost effective.(ABSTRACT TRUNCATED AT 250 WORDS)