An analysis of perioperative cholangiography in one thousand laparoscopic cholecystectomies.

BACKGROUND: We undertook this retrospective study to ascertain the proper role of perioperative cholangiography in the management of 1002 patients undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis. METHODS: Nine hundred forty-one patients were categorized as being at high or low risk for choledocholithiasis according to the presence or absence of jaundice, pancreatitis, elevated bilirubin, alkaline phosphatase, serum glutamic-oxaloacetic transaminase, or radiographic evidence of common bile duct stones (CBDSs). RESULTS: Intraoperative cholangiography (IOCG) and preoperative endoscopic retrograde cholangiopancreatography (ERCP) were equivalent in the detection of CBDSs, and laparoscopic common bile duct exploration (CBDE) was successful in 12 of the 21 patients (57%) in whom it was attempted. The ducts of the other 52 patients with CBDSs were successfully cleared by preoperative or postoperative ERCP. CONCLUSIONS: Laparoscopic IOCG is successful in detecting CBDS in high-risk patients and half of these ducts can be cleared laparoscopically. The incidence of CBDS in low-risk patients is 1.7%, a risk that does not warrant routine cholangiography. These data suggest ERCP should be reserved for those at-risk individuals in whom IOCG or laparoscopic duct clearance has been unsuccessful.

Conversion of laparoscopic to open cholecystectomy. An analysis of risk factors.

BACKGROUND: Identifying patients who are at risk for conversion from laparoscopic (LC) to open cholecystectomy (OC) has proven to be difficult. The purpose of this review was to identify factors that may be predictive of cases which will require conversion to laparotomy for completion of cholecystectomy. METHODS: We reviewed 581 LCs initiated between July 1990 and August 1993 at a university medical center and recorded reasons for conversion to OC. Statistical analysis was then performed to identify factors predictive of increased risk for conversion. RESULTS: Of the 581 LC initiated, 45 (8%) required OC for completion. Reasons for conversion included technical and mandatory reasons and equipment failure. By multivariate analysis, statistically significant risk factors for conversion included increasing age, acute cholecystitis, a history of previous upper abdominal surgery, and being a patient at the Veterans Affairs Medical Center (VAMC). Factors not increasing risk of conversion included gender and operating surgeon. CONCLUSIONS: We conclude that no factor alone can reliably predict unsuccessful LC, but that combinations of increasing age, acute cholecystitis, previous upper abdominal surgery, and VAMC patient result in high conversion rates. Patients with the defined risk factors may be counseled on the increased likelihood of conversion. However, LC can be safely initiated for gallbladder removal with no excess morbidity or mortality should conversion be required.

Temporary left-sided mechanical cardiac support during acute myocarditis.

Acute myocarditis is usually a self-limiting viral illness. Rarely, however, myocardial depression can be profound leading to circulatory collapse. Mechanical cardiac support in the form of intraaortic balloon pumps or ventricular assist devices have been used in these unusual cases to maintain systemic perfusion until transplantation or left ventricular recovery occurs. We report a young patient with acute myocarditis who required left heart mechanical support and who, however, was successfully weaned despite only minimal myocardial recovery.

Lower extremity overuse in bicycling.

Overuse problems in cycling can be attributed to several factors. First, the symmetric design of the bicycle matched against the asymmetric variants of the human body produce, on occasion, abnormally directed stress loads on tendons and muscles. Second, cycling involves a high number of repetitions compared with other sports, often as high as 5000 revolutions per hour. Last, with the advent of advanced pedal systems, the cyclist has become more "fixed" to the bicycle. It is critically important that these factors be understood and addressed when treating overuse injuries in cyclists. Standard modalities and therapies are essential components of the treatment plan for cycling-related overuse injuries that should not be overlooked. Surgical intervention should only be considered after prolonged nonoperative measures have failed to relieve symptoms.

Iliotibial band syndrome in cyclists.

Iliotibial band syndrome is an overuse injury caused by repetitive friction of the iliotibial band across the lateral femoral epicondyle. Once considered an injury indigenous to runners, it is now frequently being seen in cyclists. The purpose of this paper is to identify iliotibial band syndrome as a significant problem in cyclists and to propose both operative and nonoperative measures for treating cyclists. Nonoperative measures specific to cyclists consist of bicycle adjustments and training modifications. These are adjunctive therapies to stretching, icing, rest, and oral nonsteroidal antiinflammatory drugs. For cyclists requiring operative intervention, a new surgical technique for excising or releasing the distal iliotibial band is presented. This technique, used by the senior author (JCH) since 1984, involves excision of an elliptical piece of the distal posterior band off the lateral femoral epicondyle.