Clinical experience with heart transplantation in infants

Patients with typical symptoms of biliary tract disease but no gallstones on ultrasonography may benefit from cholecystectomy for presumed chronic acalculous cholecystitis. We retrospectively analyzed the outcome of 50 patients with a preoperative diagnosis of chronic acalculous cholecystitis based upon history (chronic or recurrent, postprandial right upper quadrant abdominal pain), the absence of acid-peptic disease, and normal biliary sonography treated with laparoscopic cholecystectomy (LC) and transcholecystic cholangiography from 1991 to 1996. All patients had preoperative cholecystokinin-stimulated hepatobiliary scintigraphy (CCK-HBS). There were 42 women and 8 men with a mean age of 43 years. CCK-HBS was abnormal in 45 patients (< or = 35 per cent gallbladder ejection fraction or nonfilling of the gallbladder). There was no postoperative mortality and one morbidity (urinary retention). All patients had microscopic evidence of chronic cholecystitis. At mean follow-up of 30 months, (range, 7-62 months) 39 patients (78%) were free of abdominal pain. Thirty-five of 45 patients with abnormal CCK-HBS were pain free (positive predictive value, 0.78). Four of five patients with normal CCK-HBS were pain free (negative predictive value, 0.20). The positive and negative likelihood ratios for CCK-HBS were 0.99 and 1.13, respectively, confirming that this test was not useful for predicting benefit from LC. Seven patients with persistent right upper quadrant pain had abnormal postoperative sphincter of Oddi manometry; they improved after endoscopic sphincterotomy. Patients with symptoms typical of biliary colic with normal gallbladder sonography and absence of acid-peptic disease benefit from LC in the majority of cases. Those who remain symptomatic after LC may benefit from endoscopic retrograde cholangiopancreatography with sphincter of Oddi manometry and endoscopic sphincterotomy when manometry is abnormal.     

Effect of altering cerebrospinal fluid pressure on spinal cord blood flow

The outcome of patients with cholesterolosis was compared with that of those with chronic cholecystitis operated on for chronic acalculous biliary pain. A total of 55 patients with acalculous biliary pain with a median symptom duration of 24 (range 6-120) months were investigated by dynamic cholescintigraphy and followed for a median of 24 (range 12-60) months. Thirty-five patients underwent cholecystectomy, of whom 22 had a low gallbladder ejection fraction (under 35 per cent), with symptomatic improvement in 21 of these (P < 0.01). All four patients with a normal ejection fraction (35-50 per cent) improved after cholecystectomy but only four of nine with a high ejection fraction (over 50 per cent) did so. Results of histological examination were available in 32 patients and revealed cholesterolosis in 20. A low ejection fraction was found in 16 patients with cholesterolosis, of whom 15 showed symptomatic improvement after cholecystectomy; the other four patients had a high fraction and all improved after cholecystectomy. Overall, symptoms in 19 of 20 patients with cholesterolosis improved after cholecystectomy compared with only seven of 12 with chronic cholecystitis (P = 0.03).     

D1 and D2 receptor regulation of preproenkephalin and preprodynorphin mRNA in rat striatum following acute injection of amphetamine or methamphetamine

From 1990 through 1993, we treated 36 patients with recurrent typical biliary colic but who showed no ultrasonic evidence of cholelithiasis by laparoscopic cholecystectomy. Associated symptoms included nausea (75%), bloating (56%), fatty-food intolerance (53%), vomiting (17%), weight loss (31%), bowel irregularity (28%), reflux or dyspepsia (25%), and fever (17%). Diagnostic evaluation included ultrasound (100%), upper gastrointestinal series (36%), oral cholecystogram (14%), computed tomographic scan (39%), endoscopic retrograde cholangiopancreatography (17%), upper gastrointestinal endoscopy (14%), and hepatobiliary scan (92%). Quantitative hepatobiliary scans in 33 patients revealed a low gallbladder ejection fraction (EF) of less than 35% in 29 patients (88%; mean EF = 9%), and 13 patients experienced reproducible pain after cholecystokinin provocation. All patients underwent attempted laparoscopic cholecystectomy; one case of unsuspected acute acalculous cholecystitis was converted to open laparotomy because of unclear anatomy. Gross and histological examination of the gallbladders revealed chronic inflammation (83%), cholesterolosis (31%), cholesterol crystals or small stones (17%), acute inflammation (8%), polyps (6%), and normal histology (6%); however, blind retrospective scoring of gallbladders revealed significant chronic inflammation in only 38%. In the 2 to 40 months (mean, 14 months) since operation, there have been no deaths (97% follow-up). Laparoscopic cholecystectomy relieved pain in 93% of patients with a low preoperative EF compared with 75% of patients with a normal EF (nonsignificant p value). Persistent abdominal or gastrointestinal complaints included flatulence (31%), loose stools or fecal urgency (29%), belching (29%), indigestion (20%), nausea (11%), and "typical" gallbladder pain (9%). We conclude that many patients with symptoms of biliary colic and scintigraphic evidence of biliary dyskinesia have histologic findings of chronic cholecystitis. Although laparoscopic cholecystectomy usually eliminates biliary colic, persistent nonbiliary complaints are frequent.     

Gallbladder ejection fraction. Nondiagnostic for sphincter of Oddi dysfunction in patients with intact gallbladders

Thirty consecutive patients with intact gallbladders and biliary pain were evaluated to determine whether gallbladder ejection fraction could identify sphincter of Oddi dysfunction. The mean gallbladder ejection fraction was 45% in patients with abdominal pain and 72% in normal controls. Gallbladder ejection fractions were then correlated with endoscopically measured sphincter of Oddi pressures in patients with abdominal pain. The mean gallbladder ejection fraction was 41% in 7 patients with elevated sphincter pressures and 46% in 23 patients with normal pressures (P = NS). Thirty-six percent of patients with elevated pressures and 33% of patients with normal pressures had abnormal gallbladder ejection fractions. Gallbladder ejection fraction had a sensitivity of 33%, a specificity of 63%, and a positive predictive value of 25% for detection of elevated pressures. Regression analysis revealed a poor correlation between sphincter pressure and gallbladder ejection fraction (r2 = 0.02). These findings suggest that gallbladder ejection fraction cannot be used to diagnose sphincter of Oddi dysfunction in patients before they undergo cholecystectomy.     

Can sincalide cholescintigraphy fulfil the role of a gall-bladder stress test for patients with gall-bladder stones?

BACKGROUND: Patients referred to general surgeons for the treatment of gall-bladder stones were studied to evaluate the role of sincalide cholescintigraphy as a gall-bladder stress test in an effort to identify a group of patients whose pain was non-biliary in origin and who would not be improved by cholecystectomy. METHODS: Ten asymptomatic controls and 57 patients with gallstones and abdominal symptoms were studied. All patients were interviewed by an independent assessor who identified a group of patients in whom the role of gallstones in their presentation was uncertain (clinically possibly biliary group). All patients and controls underwent sincalide cholescintigraphy. The surgeons remained blinded to the study results throughout the study period. All patients were re-evaluated 6-12 months later to establish the ultimate diagnosis based on their therapeutic response. RESULTS: Several parameters of gall-bladder function were studied from analysis of the sincalide cholescintigram. Lag time, ejection period, ejection rate and ejection fraction did not differ significantly among controls, patients proven to have non-biliary disease and patients proven to have biliary disease. There were significant differences in mean gall-bladder filling fraction between proven biliary and proven non-biliary groups. However, the group of patients with clinically possibly biliary symptoms could not accurately be separated into those who benefited from cholecystectomy and those who improved without surgery on the basis of this parameter. CONCLUSIONS: Significant differences in gall-bladder filling fraction between symptomatic and asymptomatic gallstone patients were identified suggesting reduced gall-bladder compliance in symptomatic patients. However, the sincalide cholescintigram failed to emerge as a useful gall-bladder stress test. Even in the 1990s, assessment by an experienced surgeon appears to be the most appropriate way to select patients for cholecystectomy.     

Biliary tract carcinomas. I. Gallbladder cancer

In three successive papers the clinical, diagnostic and surgical possibilities of biliary tract carcinoma are discussed on the base of 119 patients, undergone operation at the Chair of Abdominal Surgery for the period 1952-1979: 52 (44%) with gallbladder carcinoma, 48 (40% with biliary ducts carcinoma and 19 (16%) with duodenal papilla carcinoma. The authors report that gallbladder carcinoma is most frequent - 4.4 per cent of all biliary operations. The ratio males: females is 1:3 and the highest number of the patients is over the age of 60. The diagnosis is usually made with 6 months later due to the atypical clinical picture, progressing under the mask of cholelithiasis, found in 70-100 per cent of the cases. That is the reason in 5 per cent of the cases that carcinoma involved the whole gallbladder, metastases and infiltration of the adjacent organs being frequent. Resectable proved to be only 9 patients, the mortality rate kept high. A complex diagnostics is recommended with present-day methods and early prophylactic cholecystectomy in case of calculosis.     

Primary carcinoma of the gallbladder. The role of adjunctive therapy in its treatment

Of forty-three patients with carcinoma of the gallbladder discovered ih a twenty-five year period (during which 10,349 patients were diagnosed as having cholelithiasis), eighteen patients (42 per cent) had no obvious tumor outside of the gallbladder at the time of operation, nineteen patients (44 per cent) had local spread of the disease, and six patients (14 per cent) had abdominal carcinomatosis or distant metastasis. In the twenty-one patients who underwent surgical therapy for cure of their disease, the five year survival rate was 33 per cent. The more extensive surgical procedures (other than cholecystectomy alone) did not significantly increase survival. Neither the duration of the symptoms nor the pathologic type of the tumor altered the eventual outcome. No patients with tumor outside the gallbladder at the time of operation survived longer than two years. Compared to those who did not receive it, the fifteen patients treated postoperatively with adjunctive therapy (radiation therapy or chemotherapy or both) lived longer and also were significantly better palliated when tumor outside of the gallbladder was found at the time of operation. From these findings, the routine use of adjunctive therapy is recommended in all patients with disease outside of the gallbladder and serious consideration should be given to its use in all patients found to have carcinoma of the gallbladder.     

"The French are well, the preventologists ask themselves": tentative analysis of a chronic disease

PURPOSE: To evaluate the measurement with ultrasonography (US) of the gallbladder ejection fraction after slow-infusion cholecystokinin stimulation in patients with biliary symptoms and in individuals without symptoms. MATERIALS AND METHODS: Gallbladder volumes were calculated in 60 healthy volunteers after a 30-minute infusion of sincalide. The time to maximum response, the gallbladder ejection fraction, and the rate of initial contraction were obtained at US. A total of 100 symptomatic patients were evaluated with this technique. Reference standards included surgical outcome or results of clinical follow-up of at least 1 year. RESULTS: The average ejection fraction +/- 2 standard deviations was 80% +/- 30. A fraction greater than 60% was considered to be a normal response to cholecystokinin stimulation. There was no statistically significant sex difference. Slow infusion did not produce any side effects. A sensitivity of 75% and a specificity of 100% for determination of gallbladder ejection fraction at US were obtained in patients with surgical and histopathologic proof of disease. CONCLUSION: The slow-infusion method is reliable, safe, and reproducible in evaluating gallbladder contraction. The cholecystokinin-stimulated gallbladder ejection fraction test may be useful in determining which patients could benefit from surgery.     

Clonal expansion of T-cells in measles

Videolaparoscopic cholecystectomy is considered the treatment of choice for simple cholelithiasis. Now many surgeons consider the laparscopic procedure usable also in the complicated biliary lithiasis like acute cholecystitis and choledocholithiasis. The authors report their recent experience of the laparoscopic treatment of biliary lithiasis, regarding 221 non-selected patients (69% symptomatic cholelithiasis, 20% chronic cholecystitis, 4.5% acute cholecystitis, 4.5% coledocolithiasis, 2% hydrops). The diagnostic-therapeutic protocol and the results are described and compared with the beginning of their experience, when they treated only symptomatic gallbladder stone disease, and with the reports of the literature. The authors concluded that the laparoscopic procedure is a good chance for the surgeon in the treatment of all cases of benign biliary disease. But, in particular for patients with choledocholithiasis, he has be able to know all the diagnostic and therapeutic possibilities, to choose the best in every single case.     

A prospective experience with selective cholangiography

A prospective study of patients with symptomatic cholelithiasis was undertaken to determine the effectiveness of identifying clinically significant choledocholithiasis with selective cholangiography. Between 1991 and 1995, 262 patients presented to the senior author (K.W.M.) with acute or chronic cholecystitis. Sixteen patients had a preoperative endoscopic retrograde cholangiopancreatography (ERCP) for an elevated alkaline phosphatase or total bilirubin greater than twice the normal value or an ultrasound finding suspecting choledocholithiasis. Ten of the ERCP patients had choledocholithiasis, with eight patients having successful clearance by ERCP. Ninety other patients had intraoperative cholangiography for abnormal serum liver biochemistries, a history of jaundice or pancreatitis, or a dilated common bile duct (CBD) (>6 mm) on ultrasound. Fourteen of the intraoperative cholangiography patients and the two remaining ERCP patients had choledocholithiasis requiring CBD exploration for clearance of their stones. There were no false-positive cholangiograms, and there were no bile duct injuries in this series. With 100 per cent follow-up of at least 2 years, only one patient required ERCP clearance of a retained CBD stone 13 months after cholecystectomy. The positive predictive value and the negative predictive value for the selective cholangiography criteria are 23 per cent and 99 per cent, respectively. In conclusion, clinically significant choledocholithiasis can be found effectively with selective cholangiography. Also, utilizing selective cholangiography reduces the number of routine cholangiograms by 60 per cent.     

Management of gallstones in pregnancy

BACKGROUND: Biliary disease during pregnancy is rare and the management of cholecystitis during pregnancy is controversial. Cholecystectomy in the pregnant patient has generally been avoided because of the reported high incidence of associated fetal loss. Recent developments relating to diagnostic and anaesthetic management have altered the overall approach to symptomatic biliary tract disease in pregnant patients. METHODS: The literature was reviewed using Medline searches for cholelithiasis in pregnancy, to include pathophysiology, diagnosis and management. RESULTS AND CONCLUSION: Surgery should be performed only for complicated non-resolving biliary tract disease during pregnancy as in over 90 per cent of patients the acute process will resolve with conservative management. For patients requiring operative intervention, laparoscopic cholecystectomy has emerged as a safe and effective method of treatment.     

Congenital aortic stenosis. Experience with 43 patients

Between September, 1967, and January, 1975, 43 patients underwent intracardiac repair for congenital aortic stenosis at the Buffalo Children's Hospital. The patients ranged in age from 2 days to 24 years, 6 of them being below one year of age. Valvular aortic stenosis was found in 21 cases (4 infants [Group I-A] and 17 older patients [Group I-B]), discrete subaortic membranous diaphragm in 11 (Group II); diffuse subvalvular muscular obstruction in 3 (Group III), supravalvular stenosis in 4 (Group IV), and multiple-level obstruction in 4 (2 infants [Group V-A] and 2 older patients [Group V-B]). Preoperatively, 58 per cent of the patients were symptomatic and 67 per cent had abnormal electrocardiograms. Associated congenital cardiac defects were found in 28 per cent of the cases. The over-all hospital mortality rate was 9 per cent (3 patients in Group I-A and one in Group V-A), with no deaths occurring in patients older than 3 months of age at the time of operation. Two late deaths occurred (Groups I-B and V-B). A complete heart block developed in one patient (Group III). The average intraoperative peak systolic left ventricular-aortic gradient decreased in all groups after repair but progressively increased in the late hemodynamic studies obtained in symptomatic patients. Six patients were reoperated upon for recurrent obstruction. Late results were evaluated on the basis of symptoms, electrocardiographic findings, valve function, and hemodynamic data. They showed excellent or satisfactory results in 59 per cent of the patients in Group I-B, in 45 per cent in Group II, in 66 per cent in Group III, and in 25 per cent in Group I-V. Results were fair or poor in Groups, I-A, V-A, and V-B. In children and adolescents, effective relief of the obstruction and of the symptoms can be obtained with minimal operative risk and minimal morbidity. In symptomatic infants, despite the high operative mortality rate, surgical intervention is indicated because of the poor prognosis.     

Hoarseness

OBJECTIVE: To evaluate management and pregnancy outcomes in pregnant women with gallbladder disease. STUDY DESIGN: We reviewed the records from three teaching hospitals in central North Carolina from 1986 to 1993 to evaluate women who were admitted with gallbladder disease during pregnancy. RESULTS: Forty-two women were admitted with symptomatic cholelithiasis; 67% were white, the average age was 26 years, and the mean gestational age at presentation was 26 weeks. Conservative management with intravenous hydration, narcotics, dietary changes and antibiotics, if needed, was the first line of treatment in all 42 cases. Conservative management was successful in 17 women, with 8 requiring more than one admission. Nineteen patients failed medical management and needed cholecystectomy; three cases were laparoscopic. The diagnosis in the surgical group included 3 women with biliary colic, 14 with cholecystitis and 2 with gallstone pancreatitis. Four cholecystectomies were performed in the first trimester, 10 in the second and 5 in the third. Thirteen of 19 patients had no postoperative complications and delivered at term. Four women had uterine contractions controlled with tocolytics and delivered at 35 weeks or more. Two of 19 delivered prematurely--one at 32.5 weeks, 15 weeks after a laparoscopic cholecystectomy, and another at 34 weeks, 10 weeks after an open cholecystectomy. Of the patients who delivered prematurely, none were within the immediate postoperative period, and it appears unlikely that the cholecystectomy was causative. No maternal or perinatal mortality was noted. CONCLUSION: This review and others indicate that surgery should be reconsidered as possible primary management in pregnant women with symptomatic gallbladder disease.     

Evaluation of axis alignment system for correction of myopic astigmatism with the excimer laser

BACKGROUND: Anomalous pancreaticobiliary junction (APBJ) without congenital choledochal cyst (CCC) carries a high risk of gallbladder carcinoma development. The aim of this study was to obtain information allowing early diagnosis and appropriate management. METHODS: The clinical features, imaging findings and surgical outcome of 18 patients with APBJ without CCC were analysed retrospectively. RESULTS: Fourteen patients had symptoms, including those of acute pancreatitis (five patients). In 16 patients the gallbladder showed abnormalities, including carcinoma (eight) and mucosal hyperplasia (11). Ultrasonography detected gallbladder carcinoma with 100 per cent sensitivity and mucosal hyperplasia with 91 per cent sensitivity. A long common channel was demonstrated by endoscopic retrograde cholangiopancreatography (ERCP) in all patients, endoscopic ultrasonography in nine of ten, and magnetic resonance cholangiopancreatography (MRCP) in five of five. Five of eight patients with gallbladder carcinoma underwent extended cholecystectomy with bile duct excision. Three patients with cancer and eight with no cancer had cholecystectomy alone. None developed bile duct carcinoma or acute pancreatitis after operation. All patients without malignancy remained asymptomatic for a mean follow-up period of 4.7 years. CONCLUSION: Prophylactic cholecystectomy is recommended for patients with APBJ without CCC. For early diagnosis of APBJ, gallbladder abnormalities on ultrasonography or acute pancreatitis of unknown aetiology should prompt further investigation with ERCP or less invasive imaging modalities such as endoscopic ultrasonography and MRCP.     

Clinical and hemodynamic criteria for use of the intra-aortic balloon pump in patients requiring cardiac surgery

In order to establish criteria for elective use of the intra-aortic balloon pump (IABP) in patients having cardiac surgery, we conducted a retrospective study of 43 patients who required counterpulsation, because of inability to be weaned from cardiopulmonary bypass, between May, 1972, and June, 1974. Patients in cardiogenic shock preoperatively were excluded. The 43 patients included 23 (Group A) who had severe preoperative left ventricular dysfunction with a mean cardiac index less than 1.8 L. per minute per square meter, ejection fraction less than 30 per cent, and end-diastolic pressure greater than 22 mm. Hg; 20 patients (Group B) had a combination of moderate cardiac dysfunction (cardiac index less than 2.2, ejection fraction less than 40, end-diastolic pressure less than 18) in the presence of acute infarction or severe aortic stenosis (gradient greater than 80 mm. Hg) with or without coronary disease. An inverse relationship was noted between survival and delay from completion of operation to the use of 1ABP. Thirty-two of 43 patients were weaned off bypass and were balloon assisted for 12 to 96 hours postoperatively; 25 patients were discharged (58 per cent). In Subgroup A, 14 of 23 (60 per cent) and, in Subgroup B, 9 of 20 (45 per cent) were long-term survivors. Based on these findings, 45 patients were operated upon between June, 1974, and December, 1975, with elective use of 1ABP and were assessed by serial hemodynamic studies. Sixteen had severe preoperative left ventricular dysfunction similar to Subgroup A and 29 had moderate dysfunction in combination with pathology similar to Subgroup B. Fifteen of these patients were hemodynamically unstable at time of arrival in the operating room; 1ABP was inserted under local anesthesia. Thirty-nine patients (87 per cent) were weaned off bypass and were hospital survivors. In Subgroup A, 13 of 16 (81 per cent) and, in Group B, 21 of 29 (72 per cent) were long-term survivors. Criteria for elective use of 1ABP in cardiac surgery should include severe preoperative left ventricular dysfunction or a combination of moderate dysfunction with coronary or valvular pathology. Elective 1ABP improves the survival with trivial iatrogenic morbidity.     

Neonatology radiology casebook. Tracheal agenesis

BACKGROUND: Biliary tract diseases are frequent in heart transplant recipients, with significant morbidity and mortality. Since the first presentation of gallstones in this population is often acute cholecystitis, asymptomatic cholelithiasis should not be considered benign. PATIENTS AND METHODS: We retrospectively reviewed 18 heart transplant recipients who underwent cholecystectomy from January 1991 to June 1997. We intentionally chose to perform a straightforward open procedure when acute cholecystitis was suspected (3 patients). A laparoscopic cholecystectomy was performed in all the other cases (15 patients) without conversion to open procedure. CONCLUSION: Since no significant complications were observed in our patients, we believe that transplant recipients with cholelithiasis should undergo laparoscopic cholecystectomy in their posttransplantation course regardless of the symptomatic status of their biliary tract.     

Cystic duct syndrome and minimally invasive surgery

Cholecystectomy is an established successful operation which provides total relief of presurgical symptoms in up to 85% of patients. About 5% of patients after cholecystectomy experience severe episodes of upper abdominal pain, similar to those that they had prior to cholecystectomy. These so called postcholecystectomy syndromes may be due to biliary strictures, retained biliary calculi, cystic duct stump syndrome, stenosis or dyskinesis of the sphincter of Oddi. Postcholecystectomy symptoms caused by cystic stump and gallbladder remnant had been described early in this century and several papers have been published on the topic. During recent years laparoscopic cholecystectomy became popular but we have not found in the literature the mention of either that it could cause cystic duct stump syndrome or it could be used for its treatment. During the last seven years in 8 patients we found gallbladder remnants or cystic duct stumps causing their symptoms. Among the 8 patients 3 had laparoscopic and 5 classic cholecystectomies. After incomplete cholecystectomy we usually find that the cystic duct stump and the Calot triangle embedded in inflamed scar tissue. For this reason the surgical risk is to high with laparoscopic surgery to reoperate for these pathological changes. In all 8 cases the pathological cystic duct stumps and gallbladder remnants were removed using 3-4 cm single microlaparotomy incisions. The postoperative stay of these patients were uneventful and they were discharged home 2-3 days after surgery.     

Laparoscopic subtotal cholecystectomy in patients with complicated acute cholecystitis or fibrosis

BACKGROUND: The open subtotal cholecystectomy technique has simplified removal of the difficult gallbladder. Increasing laparoscopic experience has made laparoscopic subtotal cholecystectomy (LSC) a feasible option in patients with complicated acute or chronic cholecystitis. METHODS: LSC was performed in 29 patients with severe inflammation or fibrosis of the gallbladder associated with gallstone disease over a 23-month period. These 29 patients (mean age 53 years; 22 women) constituted 8.5 per cent of the total number of laparoscopic cholecystectomies performed (n = 340) and 15.6 per cent of 186 patients with acute cholecystitis. Eighteen patients in the latter group underwent conversion to open cholecystectomy. The indications for LSC were acute cholecystitis/empyema (n = 23) and severe fibrosis (n = 6). RESULTS: The cystic duct was either clipped before division (n = 15), sutured (n = 2) or ligated using an Endoloop (n = 10). In two patients the gallbladder bed was drained without isolating the cystic duct. The posterior wall of the gallbladder was left intact to avoid excessive bleeding or damage to bile ducts in the gallbladder bed. A suction drain was inserted in 14 cases. Median operating time was 73 (range 45-130) min. One patient died after operation from a myocardial infarction. Six patients had local complications (two haematomas, three bile leaks, one minor wound sepsis) and nine developed respiratory infections. Median hospital stay was 5 (range 2-28) days. CONCLUSION: LSC is a safe, relatively simple and definitive procedure allowing removal of a difficult gallbladder and reducing the need for open conversion or cholecystostomy in the majority of patients.     

The chronopharmacotherapy of diseases]

Peroperative cholangiography (POC) performed as a routine during cholecystectomy for cholelithiasis was evaluated in 102 patients. POC was normal 93 patients. Nine patients had abnormal POCs: 5 were true positive--CBD stones (4) and sphincteric fibrosis (1): 4 were false positive--air bubbles (2) and sphincteric spasm (2). Preoperative indication of CBD stones were present in 12 patients-5 of these had abnormal POC (4 true positive and 1 false positive). CBD exploration was avoided in 7 patients with normal POC. Ninety patients did not have any preoperative indication of CBD stones-4 of these had abnormal POC (1 true positive and 3 false positive). None of the patients with a normal POC had any clinical evidence of residual stones on follow up for one year. POC did not help in any case to delineate biliary ductal anatomy. Routine POC during cholecystectomy should be abandoned and should be performed selectively in patients suspected to have CBD stones only to avoid a negative CBD exploration.     

Solute focusing techniques for bioseparations

BACKGROUND: Hepatic lesions in sickle cell disease have been studied essentially in autopsy series. Previous reports on living patients are rare and concern a limited number of cases. The aim of the present study is to report the clinical, biochemical, and hepatic histological findings in 26 living patients with sickle cell disease and hepatobiliary disease. PATIENTS AND METHODS: Twenty-six of 510 patients with sickle cell disease, in whom liver tissue was available for histological analysis, were selected. In 21 patients, biopsy was obtained during laparotomy for cholecystectomy; 5 patients underwent needle biopsy for hepatomegaly and/or liver test abnormalities. RESULTS: Twenty of the 21 cholecystectomized patients, as well as the 5 other patients, had liver vascular lesions consisting of sinusoidal dilatation (23 cases), perisinusoidal fibrosis (19 cases), and acute ischemic necrosis (5 cases). It is of interest that the 21 cholecystectomized patients had clinical signs of complicated cholelithiasis, and that 20 of them had gallbladder stones, with common bile duct lithiasis in only 1 case. In the 25 patients without common bile duct obstruction, symptoms might have been due to vascular lesions, but it must also be noted that in the cholecystectomized patients they did not persist or recur following surgery. In one cirrhotic patient, marked sinusoidal lesions might have favored severe hepatocellular failure that led to liver transplantation. In another patient, fatal hepatocellular insufficiency was possibly due to ischemia. The nonvascular lesions that were observed, ie, chronic persistent or mildly active hepatitis (11 cases) and cirrhosis (2 cases), were always associated with vascular lesions. CONCLUSION: These results suggest that in sickle cell disease: (1) hepatic lesions are mainly vascular; (2) these lesions can be responsible for acute and/or chronic ischemia that may be severe; (3) symptoms suggestive of acute cholecystitis and/or biliary tract obstruction might be, at least in part, explained by vascular lesions; and (4) biliary tract surgery indications should be considered more carefully.