Open cholecystectomy: its morbidity and mortality as a reference standard.

In a retrospective study of 10,471 cholecystectomies, performed between 1971 and 1990, the incidence and causes of death and morbidity of cholecystectomy were analysed. There were 47 postoperative deaths (0.4%); 6 deaths occurred in 5841 patients less than 50 years old, 23 in 3898 patients between 50 and 70 years old and 18 in 732 patients more than 70 years old. Death rates in each group were, respectively, 0.1%, 0.6% and 2.5% (p < 0.001). The death rate in 9339 patients who had cholecystectomy alone was 0.3% and the death rate in 1132 patients who had a concomitant common bile duct exploration (CBDE) was 1.6% (p < 0.001). Cardiovascular complications were the main cause of death, and biliary, pulmonary and wound complications were the most common. There were 614 complications in 529 patients; 176 of these patients were less than 50 years old, 252 were between 50 and 70 years old and 101 were more than 70 years old. Complication rates were, respectively, 3.0%, 6.5% and 13.8% (p < 0.001). For patients with cholecystectomy alone the morbidity was 3.6% and for patients who had a concomitant CBDE the morbidity was 17% (p < 0.001). The mortality and morbidity of cholecystectomy increase significantly with age and a concomitant CBDE. However, patients who underwent cholecystectomy electively or for acute cholecystitis had comparable mortality and morbidity.

Primary hyperparathyroidism in children.

Primary hyperparathyroidism is rare in children. This report describes a 15-year-old boy who had an intrathymic chief cell adenoma. The literature related to this condition in neonates and children is reviewed. Neonatal hyperparathyroidism differs from hyperparathyroidism in children. The severity of symptoms and osseous lesions, genetic inheritance in many, pathological changes in the parathyroid glands and the need for more extensive treatment in neonates and infants indicate that primary hyperparathyroidism in these patients should be considered as a different entity from that occurring in older children.

Hereditary pancreatitis: report of an affected Canadian kindred and review of the disease.

Hereditary pancreatitis is an autosomal dominant disease with no other known cause. It usually begins in childhood and is characterized by recurrent attacks of abdominal pain of variable intensity and duration, followed by symptom-free periods. The diagnosis is usually made in early adult life, when pancreatic insufficiency and calcifications appear. Complications are less frequent than in nonhereditary chronic pancreatitis. There are also differences between the two forms of chronic pancreatitis in sex incidence, etiologic factors and life expectancy. In a Canadian kindred three generations are affected with hereditary pancreatitis; there are four definite and four suspected cases. More than 40 affected kindreds, including 195 proven cases and 190 suspected cases, have now been reported in the literature. Thus, hereditary pancreatitis should be considered in the differential diagnosis of chronic relapsing pancreatitis of unknown cause as well as recurrent abdominal pain in childhood.

Retained and recurrent bile duct stones. Surgical or nonsurgical removal?

An experience with 69 patients who underwent 72 common bile duct reoperations for retained or recurrent choledocholithiasis is presented. The mean age of the patients was 57 years, and 35 patients had associated conditions. In this series six patients (8.3%) had minor complications and no patient developed major complications or died. Two (2.9%) patients developed recurrent choledocholithiasis. In recent years, nonoperative removal of retained stones through a T-tube by mechanical extraction or chemical dissolution, and removal of retained or recurrent stones by endoscopic sphincterotomy has gained widespread popularity. Retained or recurrent choledocholithiasis should be managed on an individual basis. Reoperation has a good success rate, low morbidity and mortality rates. It should be considered as the treatment of choice in low risk patients, in whom a retained stone cannot be mechanically extracted through a T-tube, and in patients with recurrent choledocholithiasis diagnosed after removal of the T-tube.