Laparoscopic common bile duct exploration; a preferential pathway for elderly patients.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) has emerged as a recommended alternative to endoscopic retrograde cholangiopancreatography (ERCP) for the management of choledocholithiasis. However, its use in the elderly has been limited, and evidence of its safety and efficacy in these patients is yet to be established. This study describes our experience of LCBDE in elderly patients, analysing the safety and efficacy of this technique in comparison to younger patients. METHODS: All patients undergoing laparoscopic cholecystectomy (LC) with LCBDE for choledocholithiasis in our unit between January 2015 and January 2017 were included. Data pertaining to patient demographics, comorbidities, investigations, operative technique and outcomes were analysed. Patients were divided into 2 groups based on age (Group A:<65 years vs Group B: >/ = 65 years) for comparative analysis. RESULTS: 124 patients (Group A: 65, Group B: 59) were included. Group B were more co-morbid and had a higher ASA grade than Group A. However, there was no significant difference between groups in rates of conversion to open or complications, including bile leak (3.1% vs 5.1%, p = 0.67), retained stone (4.6% vs 1.7%, p = 0.62), or complications according to Clavien-Dindo classification (p = 0.78). Re-intervention rates were also similar between groups (7.7% vs 3.4%, p = 0.44 and 3.1% vs 3.4%, p = 1.0 respectively), as was length of stay. CONCLUSION: Despite higher frequency of comorbidities and ASA grade, LCBDE in elderly patients is safe and effective, and has similar outcomes to younger patients. Therefore elderly patients with choledocholithiasis should be offered LCBDE as an alternative to ERCP.

Evaluation of pituitary responsiveness to LHRH as a pregnancy test in ewes.

Pregnant and nonpregnant ewes were injected with luteinizing hormone-releasing hormone (LHRH). Pituitary responsiveness, based on serum luteinizing hormone (LH), and follicle stimulating hormone (FSH) concentration, 2 hr after injection was then determined for each ewe, by radioimmunoassay (RIA) and correlated with the physiological reproductive state of each ewe. The serum LH release in pregnant ewes was significantly lower than that in nonpregnant ewes. Serum LH concentrations of pregnant ewes were further categorized according to whether the ewes were multiple (ML) or single lambing (SL). The responses by ML ewes were lower for LH than the SL responses. Follicle stimulating hormone responses were not different between pregnant or nonpregnant groups. Luteinizing hormone responses between pregnant ewes which were grouped according to 3 stages of pregnancy (1 to 5, 5 to 10 and 10 to 15 weeks pregnant) were not different from each other. Pregnancy diagnoses were made based on a fixed cut-off value, to which the LH response of each ewe to 5 mug LHRH was compared. Ewes whose response fell below this cut-off were diagnosed as pregnant. Accuracy of the diagnoses were determined by known lambing data. Diagnostic accuracy ranged from a low of 60% for nonpregnant, to a high of 95% for ML ewes. Accuracy for SL ewes (64%) was lower than for the overall pregnant group (79%), as well as that for ML ewes. Doses of LHRH, higher than 5 mug per ewe, generally produced LH release in pregnant ewes which was not significantly suppressed relative to responses of nonpregnant ewes. These results lead to the conclusion that gonadotropin response to exogenous LHRH injection is not an effective tool for pregnancy diagnosis.

Effects of photoperiod and estradiol on tonic gonadotropins in ovariectomized ewes.

Estradiol-17 beta (estradiol) inhibition of tonic (basal, as opposed to cyclic or preovulatory) serum luteinizing hormone (LH) and follicle-stimulating hormone (FSH) was evaluated in ewes subjected to long or short photoperiods. Nine mature Colombia ewes were ovariectomized early in the breeding season and implanted with either Silastic capsules containing approximately .12 g of estradiol (n = 4) or with empty capsules (n = 5). Ewes were housed indoors for 43 wk under controlled lighting: 17 wk of short days (8.5 h light: 15.5 h dark), 12 wk of long days (15.5 h light: 8.5 h dark) and a second 14 wk of short days. Five intact ewes penned with a vasectomized marker ram were used to evaluate estrus under these photoperiodic conditions. Estrous cycles in intact ewes ceased approximately 10 wk after onset of the long photoperiod and resumed approximately 11 wk after return to short days. In ovariectomized ewes, estradiol dramatically depressed FSH as well as LH during the long photoperiod and, to a lesser degree, depressed FSH, but not LH, during the short photoperiod. These data support the hypothesis that sensitivity of the tonic gonadotropin regulatory mechanism to estradiol inhibition changes with photoperiod and, thereby, modulates the onset and duration of the breeding and anestrous seasons in ewes. A model accounting for seasonal changes in the inhibitory action of estradiol is proposed.

Nursing enhances the negative effect of estrogen on LH release in the cow.

Twenty-three crossbred beef cows between 4 and 5 yr of age were assigned at random to one of six treatments: (1) ovariectomized 4 d postpartum (OVX) with early weaning of calves 21 d postpartum (OVX-EW; n = 4), (2) OVX-EW and 17 beta-estradiol implants (OVX-E2-EW; n = 4), (3) OVX and normal nursing by calves throughout the experiment (OVX-NN; n = 3), (4) OVX-NN and 17 beta-estradiol implants (OVX-E2-NN; n = 4), (5) intact cows and early weaning of calves 21 d postpartum (EW), (6) intact cows and normal nursed (NN). Blood was collected at 15-min intervals over a 4-h period once weekly during the 12-wk postpartum period in the OVX cows. Early weaned intact cows exhibited estrus 23 d sooner (P less than .05) than normally nursed cows. A hormone level for each cow at each week was determined from the mean of the 17 samples collected over the 4 h period each week. There were no significant changes due to E2 treatment, for concentrations of LH, FSH or number of pulses during wk 1 through 3. However, during wk 4 through 12 the linear and quadratic contrasts of wk X estrogen X nursing were significant for serum LH, indicating there was no difference between the treatments for EW and NN without E2 but there was a large difference in the presence of E2. During nursing E2 suppressed serum LH below that of nonestrogen-treated cows while after weaning E2 stimulated LH release above that of nonestrogen-treated cows.(ABSTRACT TRUNCATED AT 250 WORDS)

A randomized, crossover comparison of various ventilation devices in a swine pneumothorax model.

OBJECTIVE: Bag-valve-mask devices (BVMs), manually triggered ventilators (MTVs), and automatic transport ventilators (ATVs) are three available options for out-of-hospital artificial ventilation. Use of the MTV and the ATVs has been limited by concern for causing or worsening a pneumothorax (PTX). The purpose of this study was to compare the effects of ventilation with a BVM, ATV, and MTV in a swine PTX model. METHODS: This was a randomized, crossover study. Six fasted swine (21.2-24.5 kg, mean = 23.5 kg) were sedated and paralyzed. The swine were intubated with a cuffed endotracheal tube. A lung injury was created with a hemostat under direct visualization after the pleural cavity was entered by sharp dissection. A 16-Fr Foley catheter was inserted and sealed in the pleural space at the injury site. Prior to each trial, a PTX was created by instilling 300 mL of air through the Foley catheter. Each swine underwent 10-minute ventilation trials, at a rate of 12-14 breaths/min, with BVM, MTV, and ATV by the same investigator following each trial; PTX size was determined by withdrawing air through the Foley catheter. Analysis of variance for repeated measures (alpha = 0.05) was used for statistical analysis. RESULTS: There was no difference in the extent of PTX expansion produced by ventilation with BVM (339.8 +/- 35.9 mL), MTV 327.8 +/- 28.9 mL), or ATV (321.8 +/- 22.2 ml). CONCLUSION: BVMs, MTVs, and ATVs do not differ in their effects on PTX volumes. Concern for excessive expansion of PTX by MTVs and ATVs is not supported. Prospective evaluation is warranted to determine the efficacy of these ventilation techniques.