Cholecystectomy in a community hospital.

Modern elective cholecystectomy, when distinguished from emergency operations and those complicated by choledocholithiasis, should be a safe procedure with a brief hospital stay. In a community hospital, 100 consecutive patients underwent cholecystectomy, with minor complications in 7 percent. The postoperative hospital stay averaged less than 4 days, and the cost was just over +2,000. Elective cholecystectomy in the community can have minimal risk and will likely remain cost-effective even when medical therapies become available.

Preoperative evaluation of the risk of common bile duct stones.

The patient with gallstones has an unknown risk of also having choledocholithiasis. To establish this risk preoperatively, several tests were studied in 167 patients, 37 of whom had common duct stones at exploration. With no previous or current jaundice, as well as normal alkaline phosphatase levels and a duct size of less than 12 mm, there was less than a 5% risk of choledocholithiasis; elevated bilirubin and/or alkaline phosphatase levels indicated intermediate risks (33% to 66%); and a duct size of 12 mm or greater, with any combination of other factors, indicated a 90% to 100% risk of choledocholithiasis. The surgeon should be aware of these probabilities in evaluating conditions of patients with cholelithiasis.

Criteria for hepatic transplantation in cirrhosis.

Among the patients considered for hepatic transplantation, cirrhosis should be theoretically the best indication. Results so far are disappointing because the patients who have undergone a transplantation had end stage liver disease. When gastrointestinal bleeding, renal failure, coagulopathy and encephalopathy are used as criteria, one can accurately select patients who will die from cirrhosis within one month. Our results for those who had a liver graft in this group are poor. Criteria were then selected to identify a less dramatically ill group of patients with cirrhosis. These patients have residual poor liver function after surviving acute severe complications and have a spontaneous survival of less than one year. The results of liver transplantation in two patients in this group are encouraging.

Individualization of treatment for hilar bile duct cancers.

Two cases of hilar bile duct cancer are presented, 1 treated with the preferred technique of left intrahepatic anastomosis, the other with tube drainage. The many factors to be considered before choosing the most appropriate procedure are stressed. A critique of several techniques is offered, with a discussion of the nuances in decision making. The surgeon who embarks upon treatment of such tumors should be thoroughly familiar with the wide range of procedures available; better selection should improve palliation.

Appendicitis over forty.

Charts of 616 patients over the age of 40 presenting to a community hospital emergency department with lower abdominal pain were reviewed to estimate the incidence and establish the profile of appendicitis in older patients. Appendicitis remains the commonest cause of undiagnosed lower abdominal pain, and retains a common presentation at all ages. Much of the pre-operative delay in patients who perforated appendices occurred in the hospital. Barium enema was a useful and safe diagnostic procedure used in 22 cases.

Operative cholangiography and overlooked stones.

In a series of 100 consecutive common bile duct explorations in which stones were present and operative cholangiography performed, 22 patients were found to have residual stones. The operative cholangiograms showed the missed stones in three fourths of the patients, even though many of the cholangiograms were of poor quality. It is concluded that operative cholangiography is an excellent technique that will demonstrate most common bile duct stones. Closer cooperation with the radiologist and more emphasis on technique should lead to consistently satisfactory films and more appropriate interpretation, thus resulting in fewer overlooked biliary calculi.

Amylase elevation attributable to an ovarian neoplasm.

An ovarian carcinoma producing amylase-rich ascites and pleural effusions is reported; salivary type amylase was identified in tumor tissue. A variety of nonpancreatic diseases and tumors of lung, parotid, ovary, and other organs have been associated with elevated amylase in serum or body fluids. Amylase isoenzyme electrophoresis is of value in differentiating pancreatic from nonpancreatic sources of increased amylase.

Long term results of Roux-en-Y hepaticojejunostomy.

One hundred and twenty-three patients with benign diseases involving the bile ducts, curable by biliary bypass, underwent a Roux-en-Y hepaticojejunostomy, and the long term results of this operation were evaluated to ascertain if hepaticojejunostomy is a safe and durable procedure. There were no operative deaths. A peptic ulcer developed postoperatively in two patients. Only one instance of anastomotic stenosis was observed at follow-up study, averaging 5.5 years. Six of the 11 patients with postoperative biliary symptoms had intrahepatic lithiasis, a possible indication that the symptoms were due to temporary obstruction of the anastomosis by residual stones. A refined operative technique has improved the results which over-all are highly satisfactory.

Improving cholecystectomy.

Bacteriologic study of bile in 100 patients undergoing cholecystectomy for various manifestations of choletithiasis yielded 36 per cent positive cultures, with greater frequency in older individuals and those with acute cholecystitis and common duct stone; these results are comparable to those in previous studies and reaffirm the septicity of the bile. Incidence of wound infection, averanging 10 per cent in published series of cholecystectomies, was 0.5 per cent in 200 patients in whom a water-impermeable wound drape was sewn to the peritoneum to prevent contamination by potentially infected bile. This result, in patients with an infectious risk comparable to that in other series, establishes the value of meticulous wound isolation in preventing wound infection.

Transient bile duct obstruction. Response of serum bilirubin and alkaline phosphatase levels in the rat.

The immediate evolution of changes in serum bilirubin and alkaline phosphatase levels during and after brief temporary occlusion (12 hours or less) of the main bile duct was studied in the rat. Transient obstruction of the main bile duct of more than one hour was characterized by a simultaneous increase in serum levels of both bilirubin and alkaline phosphatase. The time required for return to normal values was less for bilirubin than the duration of a brief obstruction and was more prolonged for alkaline phosphatase than the duration of obstruction. In obstruction of four or more hours, it was rare to find an isolated elevation of serum bilirubin; this occurred when the control value for alkaline phosphatase levels was low and their relative increase was obscured. Thus, an isolated increase in the serum bilirubin level is infrequently compatible with obstruction of the bile duct, even when transient and of brief duration. Conversely, isolated elevation of serum alkaline phosphatase levels in an acute abdominal syndrome may indicate relieved biliary obstruction.

Disconnection of the ampulla of Vater.

A patient with ampullary disconnection during gastrectomy is presented, emphasizing the chronicity and retractile scarring which exposes the bile and pancreatic ducts to simultaneous injury. As wider appreciation of this potentially lethal lesion is gained, greater use of predissection cholangiography or probe identification of the papilla should occur. Steps to detect the lesion and primary repair by duodenal advancement or, in unrecognized instances, the Hepp operation using a Roux-en-Y limb after a suitable waiting period are recommended.

Cholangitis with acute renal failure: priorities in therapeutics.

Obstructive cholangitis with acute renal failure is a dramatic syndrome which merits individual definition. Twenty-one patients with acute suppurative cholangitis complicated by rapidly developing renal insufficiency were studied, and the severity of the renal failure, an acute interstitial tubulopathy, bore no significant relationship to the serum bilirubin level. The mechanism of renal damage was clearly related to episodes of septicemia. Increasing experience has modified the approach to treatment. The dominant septic problem can often be controlled by vigorous antibiotic and fluid therapy, allowing time for spontaneous improvements in renal function. All patients thus operated at a distance from the septic episode survived. If emergency operation is required because of persistent or recrudescnet sepsis, the necessity for dialysis should be considered first; the circumstances demanding dialysis are defined. The priorities in therapy are then: 1) treatment of the infection, 2) treatment of the renal failure, and finally 3) operation. The amount of the operation depends on the evolution of the sepsis, but should be preceded by dialysis when required.

Biliobiliary fistula. A trap in the surgery of cholelithiasis.

Of 24 cases of abnormal communication between gallbladder and main bile duct occurring in a service specializing in hepatobiliary surgery, jaundice was present in all, but variable in degree and persistence. No particular clinical picture suggested this complication of cholelithiasis, and preoperative diagnosis is rare. At operation, adhesions were strikingly dense, often first suggesting a diagnosis of cancer. The gallbladder, fused to the main bile duct, should not be dissected from it because of the risk of ductal injury. Under these conditions, the gallbladder should be opened peripherally, stones extracted, and a cholangiogram performed to assess the situation. Treatment consists of partial cholecystectomy and closure of a cuff of gallbladder wall over a T tube placed into the main bile duct through the fistula.

Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver.

It is important to expand the indications for resection of tumors of the hilas, generally requiring associated hepatectomy, after careful search for metastases and biopsy of any suspicious areas makes this reasonable. One can justify such a procedure, representing a major stress and a considerable mortality rate, only if one is sure that all the tumor will be removed. If resection cannot be carried out, a unilateral intrahepatic cholangioenteric anastomosis with preference for the round ligament technique is an excellent procedure when properly applied. If a contraindication to a left sided anastomosis exists, particularly invasion of the left sided confluences, the anastomosis is made on the right to the duct of segment V. Study of the cholangiogram with attenion to the primary and secondary confluences directs a decision to perform a double anastomosis the ducts are not dilated or a poor quality anastomosis is all that can be achieved on one side and when secondary confluents are involved on both sides. The results of a variety of techniques emphasize the importance of the cholangiogram in choosing the location of an anastomosis and the role of invasion of primary and secondary conversions in choosing the technique. Many of thse patients are young and, even if no resection is possible, amy survive several years. A renewed sense of well being and prolongation of life are achievable goals even if the tumor cannot be removed. There is every reason to offer the maximum to these patients so that, if they muse eventually die, it will be from the tumor itself and not from its biliary complications.