Routine use of ultrasound 24 hours before laparoscopic cholecystectomy can predict the need for intraoperative cholangiogram: results of a 12-month prospective audit.

Intraoperative cholangiograms and exploration of the common bile duct (CBD) during laparoscopic cholecystectomy are technically more demanding than during open cholecystectomy. This has led to many surgeons using a selective policy for cholangiography. In this study we prospectively assessed whether biliary ultrasound (CBD diameter > or = 6 mm) or one or more abnormal liver function tests (LFTs) performed in the 24 hours preoperatively could predict the need for cholangiography. Forty-five patients were studied (14 male, 31 female), mean age 47.8 years. All patients with one or both tests abnormal preoperatively (19 patients) underwent intraoperative cholangiograms. Seven CBD stones were identified (16%). There was no evidence of CBD stones in patients not undergoing cholangiography at a median follow-up of 18 months. In patients with stones, three underwent open CBD exploration, and four underwent endoscopic retrograde choledochopancreatography (ERCP) and sphincterotomy in the early postoperative period without complications. CBD diameter > or = 6 mm is a useful predictor of CBD stones. These may be treated successfully by postoperative ERCP.

MRI demonstration of arachnoiditis in cauda equina syndrome of ankylosing spondylitis.

The cauda equina syndrome is a rare but well-recognised complication of longstanding ankylosing spondylitis, usually presenting when the joint disease is quiescent. The clinical and radiological findings in a patient with only a 3-year history, in whom the onset of joint and neurological symptoms was apparently simultaneous, are presented. MRI revealed characteristic expansion of the lumbar spinal canal with scalloping of the pedicles, laminae and spinous processes, related to numerous posterior dural diverticula. The quantity and extent of such diverticula are unusual. We demonstrated adherence of individual nerve roots to the arachnoid surface of these diverticula and to each other. In a second patient, with a much longer history of both ankylosing spondylitis and cauda equina syndrome, MRI again showed florid, multilocular dural ectasia, marked irregularity and thickening of nerves, and adherence to the dural diverticula. These cases provide evidence for the role of arachnoiditis in the pathogenesis of the cauda equina syndrome of ankylosing spondylitis.

A Mars bar is not an adequate fatty meal--a comparison with Calogen.

A prospective study was performed to compare the contractility of the gall bladder ultrasonically after ingestion of a 65 g Mars bar or 60 ml of Calogen. Using a repeated measure design, 27 healthy subjects were studied fasting and at 10 min intervals after ingestion of the fatty meal. Results show that there is a significant difference between Mars bar and Calogen (ANOVA, P < or = 0.01), with Calogen producing greater gall bladder contraction overall, and that the ejection fraction is greatest at 40 min (t = 2.23, P < or = 0.01). It is suggested that 60 ml of Calogen is used as the standard fatty meal to assess gall bladder contractility and that the patient is rescanned 40 min post fatty meal.

How do general practitioners compare with the outpatient department when requesting upper abdominal ultrasound examinations?

The recent re-organization of the National Health Service has placed a new emphasis on reexamining the services that hospitals provide to General Practitioners (GPs). To assess the positive findings from an existing open access ultrasound service for GPs in a metropolitan District General Hospital, a retrospective study was performed of 300 consecutive patients referred by GPs compared with 300 consecutive patients referred from the general medical, surgical and geriatric Outpatient Departments--specifically with regard to upper abdominal ultrasound. The frequency with which the clinical indication for referral was associated with an ultrasound finding which could explain the patient's symptoms was measured and the similarities and differences in the two groups are discussed. The study did not attempt to assess the complete value of this service since that would have necessitated assessment of the importance of negative findings. In the two groups the total number of ultrasound abnormalities was similar. A total of 25.3% of GP referrals had an abnormality which could account for their symptoms. The corresponding figure for hospital outpatients was 33.6%. On this criterion, the provision of open access for abdominal ultrasound to GPs is justified.

Airway obstruction associated with the use of the Guedel airway.

Soft tissue lateral neck radiography was used in 22 male patients older than 60 yr, to determine the cause of pharyngeal airway obstruction during anaesthesia, before and after insertion of a Guedel airway. In six of the patients, the airway was radiologically and clinically clear with the head in the neutral position. Nine patients showed obstruction of the airway by a "shelf" of tongue, but seven were cleared clinically by dorsiflexion at the atlanto-occipital joint, and the remaining two by the Esmarch-Heiberg manoeuvre. In four of the 22 patients, the Guedel airway was lodged in the vallecula in the neutral position. This was cleared clinically by dorsiflexion at the atlanto-occipital joint in all these patients. In three patients the Guedel airway was obstructed by the epiglottis, but this was cleared by dorsiflexion at the atlanto-occipital joint in two; in the third patient, the Guedel airway slipped into the vallecula after dorsiflexion at the atlanto-occipital joint and remained there despite the Esmarch-Heiberg manoeuvre. There was only one instance in 66 trials of a clinically obstructed airway without an apparent radiological cause. However, there were 10 instances in 66 trials of a clinically clear airway with an apparent radiological cause for obstruction.

Effect of general anaesthesia on the pharynx.

Conventional lateral radiography was used in 18 elderly male patients to investigate the changes induced by general anaesthesia in the upper airway. The effect of tongue traction under anaesthesia was studied similarly in another 11 patients. Following induction of anaesthesia, there were highly significant approximations to the posterior pharyngeal wall of the soft palate (median change 1.3 mm, 95% confidence interval (Cl) 0.3-2.6 mm; P = 0.006), tongue base (mean change 6.5 mm, 95% Cl 5.3-7.7 mm; P less than 0.001) and epiglottis (mean change 3.8 mm, 95% Cl 3.1-4.5 mm; P less than 0.001). Apparent radiographic occlusion of the airway occurred most consistently at the level of the soft palate (17 of 18 patients), sometimes at the level of the epiglottis (four patients), but the tongue base did not touch the posterior pharyngeal wall in any patient. Traction on the tongue failed to clear the nasopharyngeal obstruction. Attempted inspiration under anaesthesia caused major secondary collapse of the pharynx, with multiple sites of obstruction, similar to that found in obstructive sleep apnoea.

Radiological study of the Laryngeal Mask.

Lateral soft-tissue radiography was used to determine the location of the Laryngeal Mask (LM) in relation to the larynx and surrounding structures in 24 elderly male patients undergoing general anaesthesia. In a majority of cases (16 of 24) the epiglottis was within the cuff of the mask but without causing discernable airway obstruction in any case. One case of backfolding of the cuff occurred, and there was one case of gross misplacement (also clinically undetected). Supplementary information was obtained in 13 patients by the use of fibre-optic endoscopy, via the lumen of the LM, confirming the inclusion of the epiglottis within the mask and demonstrating a characteristic distortion by the LM of the normal laryngeal anatomy. It is concluded that inclusion of the epiglottis within the LM is commonplace, and misplacements may occur without clinical evidence of a compromised airway.

Role of estrogen and androgen in maintaining the preovulatory follicle.

The effects of nitromifene citrate (CI 628), an antiestrogen, and Flutamide, an antiandrogen, on the ultrastructure and viability of the preovulatory follicle and granulosa cells were examined both in vivo and in vitro. In vivo administration of either antihormone induced degeneration within the granulosa cells. In some of the affected granulosa cells, the nuclear material was condensed while the cytoplasm and associated organelles were unaltered. In others, the density of the cytoplasm was reduced, the smooth endoplasmic reticulum was dilated but the nucleus remained unaltered. In vitro, either antihormone reduced granulosa-cell viability but the granulosa cells were twenty times more sensitive to CI 628 than to Flutamide. In addition, exposure to CI 628 induced nuclear condensation without affecting the cytoplasm, while Flutamide induced the deterioration of the cytoplasm without altering the nucleus. These observations suggest that: (1) both estrogen and androgens control the viability of the granulosa cells and thereby the follicle, (2) the action of estrogen and androgen is mediated through receptors within the granulosa cells since these antihormones prevent the nuclear uptake of their respective hormone, (3) the granulosa cells of preovulatory follicles appears to be more dependent on estrogen than on androgen, and (4) each steroid appears to have a specific role in maintaining the granulosa cell; estrogens control the integrity of the nucleus while androgens preserve the cytoplasmic organization of the granulosa cell.

Ultrastructural alterations associated with the initiation of follicular atresia.

To identify and describe ovarian follicles committed to undergo follicular degeneration (atresia), immature rats were primed with pregnant mare serum gonadotropin (PMSG). After PMSG treatment, preovulatory follicles develop but subsequently degenerate. Prior to the appearance of pyknotic nuclei (Stage I of atresia), degenerative changes were observed in focal areas of the granulosa cell layer. These changes include "blebbing" of the cytoplasm and alterations in the shape of the granulosa cells. The appearance of these degenerative changes coincides with a decrease in ovarian concentrations of estradiol and testosterone. Since estrogens and androgens maintain the follicle, the decline in estradiol and testosterone could be responsible for the further degenerative alterations that lead to complete deterioration of the preovulatory follicle. In Stage I atretic follicles, lysosome-derived autophagic vacuoles develop and macrophages invade both the thecal and granulosa cell layers. The combined actions of the autophagic vacuoles and macrophages could destroy both the granulosa-cell and thecal layers and thereby transform the preovulatory follicle into an ovarian cyst.