Anaerobic and aerobic skin bacteria before and after skin-disinfection with chlorhexidine: an experimental study in volunteers.

The amount, composition, and localization of anaerobic and aerobic bacteria in the normal skin before and after disinfection were the subject of a volunteer study. The superficial bacterial flora were sampled by velvet pad imprints, and the deep flora were determined from whole skin biopsies. Only one anaerobic species, Propionebacterium acnes, was encountered even though other and more strict anaerobic bacteria could have been grown with the anaerobic technique employed. Staphylococcus albus dominated among the aerobic superficial bacteria, while diphtheroids, Micrococcus spp., and lactobacilli occurred sporadically. The deep aerobic bacteria were present in a significantly greater amount than the anaerobic. A two-step cleansing/disinfection procedure was evaluated in vivo in volunteers as well as in surgical patients, and aqueous cetrimide/chlorhexidine (Savlon) followed by chlorhexidine in alcohol (Hibitane) almost eradicated both the superficial and deep anaerobic and aerobic skin flora.

Fatigue and cardiac and endocrine metabolic response to exercise after abdominal surgery.

Subjective feeling of fatigue was quantified before and 20 days after elective uncomplicated abdominal surgery in 16 otherwise-healthy patients and compared with changes in heart rate and various hormonal and substrate responses to a 10-minute bicycle exercise (65% of preoperative maximal work capacity) preoperatively and postoperatively. Postoperatively, fatigue increased (p less than 0.001) from 3.0 +/- 0.5 to 5.3 +/- 0.5 arbitrary units (mean +/- SEM). Heart rate, plasma catecholamines, and serum growth hormone, lactate, alanine, and glycerol values always increased, whereas serum insulin values decreased in response to exercise (p less than 0.01). During exercise, only heart rate (p less than 0.01) and lactate (p less than 0.05) values were higher postoperatively compared with preoperatively. Increase in fatigue postoperatively correlated significantly to increase in heart rate (p less than 0.01) and correlated positively, but not significantly, to increase in plasma levels of noradrenaline (p = 0.08), growth hormone (p = 0.09), and alanine (p = 0.08) during exercise, but not to increase in serum lactate values (p greater than 0.8). Thus, after uncomplicated surgery, there was increased fatigue and amplified metabolic and cardiovascular response to a given absolute work load. These findings are similar to those observed during detraining and suggest a therapeutic role of exercise in the treatment of postoperative fatigue.

Bile duct injury during laparoscopic cholecystectomy: a prospective nationwide series.

BACKGROUND: The risk of bile duct injury in laparoscopic cholecystectomy has been a concern since the procedure became part of the surgical armamentarium. Our study assesses the incidence, types, and treatment for laparoscopic bile duct injury. STUDY DESIGN: Prospective case registration in a national database with participation by all departments of surgery performing laparoscopic cholecystectomy in Denmark since the first operation in January 1991. The case notes for bile duct injury have been reviewed. RESULTS: From 1991 through 1994, 57 of 7,654 patients sustained bile duct injury (0.74 percent; 95 percent confidence interval, 0.55 percent to 0.94 percent), including nine injuries occurring after conversion. The annual incidence did not decrease. Thirty-nine percent of the laparoscopic bile duct injuries were incisions, 39 percent were transections, and 12 percent were clip injuries or strictures. One patient, who sustained transection during open reoperation for bleeding after a converted procedure, died. Bile leaks for reasons other than bile duct injury occurred in 2.1 percent; 71 percent of these were cystic duct leaks. Acute cholecystitis was the indication for laparoscopic cholecystectomy in 968 patients, with 1.3 percent sustaining laparoscopic bile duct injury (95 percent confidence interval, 0.62 percent to 2.08 percent), while the incidence in patients with other indications for laparoscopic cholecystectomy was 0.62 percent (95 percent confidence interval, 0.44 percent to 0.82 percent) (p > 0.05). Preoperative knowledge of bile duct anatomy was available by means of preoperative endoscopic retrograde cholangiopancreatography or intravenous cholangiography in 26 percent of patients undergoing laparoscopic cholecystectomy but this did not reduce the risk of bile duct injury. The frequency of bile duct injury in patients who had intraoperative cholangiography was not significantly different from those who did not. Intraoperative cholangiography was done in 14 cases of injury (diagnostic for injury in 8, misinterpreted in 2, and normal in 4 patients). The case notes described operative difficulties in 11 of 48 cases of laparoscopic bile duct injury, most often because of fibrosis or difficulty delineating the anatomy. CONCLUSIONS: The incidence of bile duct injury in laparoscopic cholecystectomy is higher than previously generally anticipated and did not decrease from 1991 through 1994. Risk factors and possible preventive measures should be evaluated in prospective studies.

Gastrin and partial gastrectomy in duodenal ulcer patients 25 years postoperatively.

Serum gastrin concentrations were measured in 26 patients (Group A) who underwent partial gastrectomy for duodenal ulcer disease at least 25 years previously. The basal serum gastrin level was 31.6 +/- 1.5 pg/ml, increasing significantly after food stimulation to 36.8 +/- 2.4 pg/ml (p less than 0.05). In 16 of these patients (Group B), endoscopic biopsy specimens were taken from the minor and major curvatures of the stomach, from the jejunal part of the gastrojejunostomy, and from the duodenum. Mucosal gastrin concentrations measured were 0, 20.4 +/- 3 ng/g, and 30 +/- 7.1 ng/g, respectively. Ten of these patients (Group C) had a repeated gastroscopy with food stimulation of the duodenal pouch, using a balloon catheter in the lower duodenum. Serum gastrin concentrations after pouch stimulation did not differ significantly compared with basal values. No changes in the mucosal gastrin concentrations during pouch stimulation were seen. In conclusion, since no gastrin could be detected in the gastric mucosa and the mucosal gastrin concentration in the duodenum was 50 times lower than reported in other studies, the gastrin release measured after food stimulation could have been of extragastric or extraduodenal origin.

Cholescintigraphy in patients with acute cholecystitis before and after percutaneous gallbladder drainage.

OBJECTIVE: To investigate gallbladder function by use of cholescintigraphy in patients with acute cholecystitis before and after percutaneous gallbladder drainage. DESIGN: A cholescintigraphy was performed in 40 patients with acute cholecystitis before and after the performance of percutaneous gallbladder drainage. During the post-drainage cholescintigraphies, a cholecystokinin stimulation was performed to investigate gallbladder emptying in 12 selected patients. Gallbladder pressure and volume were measured before drainage in another group of 12 patients with acute cholecystitis. RESULTS: As expected, no gallbladder activity was observed in the cholescintigraphies before drainage, except in a patient with an occluding stone in the common bile duct. Cystic duct patency and gallbladder activity were seen in 80% of patients in cholescintigraphies performed after drainage but before any other treatment. Post-drainage cholescintigraphy revealed a mean gallbladder ejection fraction of 24%, which is significantly lower than the corresponding value in normal individuals and gallstone patients without cholecystitis (n = 12). Gallbladder pressure and volume were markedly increased compared with normal values. CONCLUSION: The relief of increased gallbladder pressure and volume appears to be important for the re-establishment of gallbladder function.

Assessment of the biliary tract by antegrade cholecystography after percutaneous cholecystostomy in patients with acute cholecystitis.

The diagnostic value of formal antegrade cholecystography in a consecutive series of 44 patients with scintigraphically confirmed acute cholecystitis, treated by percutaneous transperitoneal cholecystostomy, has been evaluated. A total of six patients did not have antegrade cholecystography (catheter migration in five patients and gangrenous gallbladder perforation in one). Antegrade cholecystography was performed in the remaining 38: 10 patients with persisting cystic duct obstruction and 28 patients with patent cystic ducts. In the persisting cystic duct obstruction group, antegrade cholecystography confirmed the cause of gallbladder outflow obstruction as impacted calculi in either the gallbladder neck or cystic duct in all patients. In the patent cystic duct group, antegrade cholecystography demonstrated the common ducts well in all but two patients, and common duct calculi in eight of nine patients. Three patients had common duct calculi in non-dilated ducts. Antegrade cholecystography is an easy and safe method of clarifying gallbladder pathology in all patients, and can be used to evaluate the common duct for associated common duct calculi in most patients.

Effect of laparoscopy on bacteremia in acute appendicitis: a randomized controlled study.

Laparoscopic appendectomy is increasingly used in treating acute appendicitis. Several controlled series have demonstrated the clinical benefit of the procedure. However, some basal pathophysiologic changes caused by the laparoscopy still need clarification, i.e., whether laparoscopy can give rise to bacteremia. The purpose of this randomized controlled study in 30 patients undergoing surgery due to suspected acute appendicitis, either by an open classic technique or by a laparoscopic technique, was (by collecting samples for blood culturing pre-, peri-, and postoperatively) to evaluate whether laparoscopy during carbon dioxide pneumoperitoneum could induce bacteremia. Six patients of 12 in the group treated by laparoscopy presented positive blood cultures peri- and postoperatively. No positive blood cultures were demonstrated in the open operated group. The difference was significant (P = 0.0183). The clinical significance of these findings should be clarified in further clinical investigations.

[Laparoscopic colonic surgery]. / Laparoskopisk colonkirurgi.

Eight patients were treated with laparoscopically assisted surgery for colorectal cancer. The technique, results and complications are presented. Conversion to laparotomy was necessary in two patients. There was one postoperative death, which could not be attributed to the operative procedure. It is concluded that laparoscopically assisted surgery will probably be a suitable treatment for some patients with colorectal diseases.

[Local treatment of tumors of the rectum with transanal endoscopic microsurgical technique]. / Lokalbehandlingen af tumores i rectum med transanal endoskopisk mikrokirurgisk teknik.

Nine patients were treated with transanal endoscopic microsurgery for rectal adenomas and three for incurable malignant disease of the rectum. The techniques are presented. One early complication was seen. In the median follow-up period of 6.5 months no recurrences were seen in the adenoma group. In the palliatively resected group of rectal cancers one patient has died and two patients are alive without stomas. It is concluded that the microsurgical technique is a safe treatment modality for some patients with rectal diseases.

[Percutaneous cholecystectomy in acute cholecystitis]. / Perkutan kolecystostomi ved akut kolecystit.

Seventy-two patients with acute cholecystitis were treated with initial ultrasound-guided percutaneous transperitoneal cholecystostomy (PTCS). PTCS could be performed in all 72 patients almost without procedure related complications, and subsequent elective treatment could be done in all, except three patients where acute cholecystectomy was necessary because of accidental catheter dislocation. Seven patients died of their severe underlying illness without relationship to PTCS or cholecystitis. Eight patients with acalculous cholecystitis had no further treatment after removal of the drainage catheter. It is concluded that PTCS is a safe method for acute drainage in patients with acute cholecystitis.

[Laparoscopic parietal cell vagotomy. Preliminary results]. / Laparoskopisk parietalcellevagotomi. Proeliminoere resultater.

The results from 11 laparoscopic parietal cell vagotomies are presented. The procedure could be carried out in all patients. The median day of discharge after the procedure was day 1 (range 1-16), median convalescence time 7 (range 4-50) days. One patient required re-operation due to a perforation at the lesser curvature. This complication is ascribed to the learning phase. If a sufficient reduction in gastric acid secretion can be documented in a larger series of patients, laparoscopic parietal cell vagotomy should be considered a serious alternative to conservative treatment.

[Pelvic floor reconstruction with a Prolene net in enterocele]. / Baekkenbundsrekonstruktion ved enterocele med Prolene-net.

Nine women, all of whom were multiparae with large symptom-producing enteroceles and all of whom had been submitted to operation by other methods without permanent effect, were submitted to total pelvic floor reconstruction with non-absorbable mesh. No complications of this intervention were observed and the discomfort due to enterocele disappeared in all of the patients during the follow-up period which averaged 11 months (range 1-24 months). The method is recommended in the treatment of large enteroceles where other forms of surgical treatment have failed.

[Percutaneous cholecystolithotripsy]. / Perkutan kolecystolitotripsi.

Thirty-two high-risk patients with severe complicating conditions and gall bladder symptoms requiring treatment, including acute cholecystitis in 28 of the patients, were treated with percutaneous cholecystolithotripsy (PTCL). This intervention was carried out under general, regional or local anaesthesia and resulted in fragmentation and removal of the stones in 90% of the patients. Cholecystectomy proved necessary in three patients on account of perforation in two and formation of "steinstrasse" in the cystic duct in one. No other complications of puncture or lithotripsy occurred and the postlithotripsy drainage time was, on the average, ten days. It is concluded that the PTCL technique is a realistic therapeutic offer to high-risk patients with gall bladder stones requiring treatment and in whom laparoscopic cholecystectomy or mini-cholecystectomy are not considered suitable.

[Percutaneous cholecystostomy and laser lithotripsy]. / Perkutan kolecystostomi og laser-litotripsi.

A case of acute cholecystitis in a high risk patient was treated in the acute phase with cholecystostomy guided by ultrasound and with introduction of a pig-tail catheter for drainage. Later, percutaneous laser lithotripsy was undertaken via a flexible choledochoscope. The recent percutaneous therapeutic principles and the possibilities in biliary calculous disease are reviewed.

[Minicholecystectomy]. / Minikolecystektomi.

Mini-cholecystomectomy was performed in 24 unselected patients with symptomatic gallbladder stones with pain control by intra- and postoperative epidural analgesia. Twenty three patients were discharged on the second postoperative day, while one patient who required re-laparotomy for haemostasis had recovered completely on the third day postoperatively. Median pain score (VAS) was 0 at rest, during coughing and mobilisation. Pulmonary function was not influenced significantly and postoperative fatigue normalized after 48 hours. These preliminary, uncontrolled observations suggest that mini-cholecystectomy is advantageous compared to conventional cholecystectomy, and may represent an alternative to laparoscopic cholecystectomy.

[Endoscopic percutaneous transhepatic cholelithotripsy in the treatment of complicated stones in the deep biliary tracts]. / Endoskopisk perkutan transhepatisk kolelitotripsi til behandling af vanskelige sten i de dybe galdeveje.

The results of endoscopic percutaneous transhepatic cholelithotripsy in seven patients with stones in the deep biliary passages which could not be treated by endoscopic papillotomy (EST) or extracorporeal shock wave lithotripsy (ESWL) are presented. A new dilator technique combined with mechanical or laser-lithotripsy was employed. All of the patients were relieved of the stones after uncomplicated course. It is concluded that endoscopic percutaneous cholelithotripsy which can be carried out under local anaesthesia, should be offered to patients with stones in the deep biliary passages which are not accessible to conventional treatment with EST or ESWL.

[Extracorporeal shockwave crushing of gallstones. Preliminary report]. / Ekstrakorporal galdestensknusning. En praeliminaer rapport. Hvidovre Hospitals Galdestensgruppe.

Extracorporeal shock wave lithotripsy (ESWL) was used for treatment of symptomatic x-ray negative stones in 23 patients. The number of ESWL sessions per patient was 1.8 (range 1-4). In 18 patients (78%), adequate fragmentation was seen comparable to results obtained elsewhere. Oral bile acid therapy was used after ESWL in the 18 patients mentioned and the mean follow-up period was five months (range 3-8 months). Four patients had by now passed all stones while 12 patients still had remaining stone fragments and one patient a gallstone. After ESWL, one patient was and one patient a gallstone. After ESWL, one patient was referred for cholecystectomy at his own request. Of the remaining five patients, cholecystectomy was performed in two and was scheduled for in three. Complications after ESWL were seen in two patients who developed acute pancreatitis. Thus, our preliminary experience shows that ESWL resulted in fragmentation and passing of gallbladder stones, but not without complications. Like the gallstone groups in Lyon, Montreal and Munich we are convinced that ESWL should be performed in accordance with prospectively designed protocols in order to establish optimal planning of indications and strategies for future treatment.

[Laparoscopic cholecystectomy in Denmark. A prospective registration]. / Laparoskopisk kolecystektomi i Danmark. En prospektiv registrering.

Laparoscopic cholecystectomy (LC) was introduced in Denmark in 1991, and a prospective case register was established. All departments performing LC agreed to participate. In 1991-1992, 2,415 patients underwent LC in 44 departments. The median number of procedures was 32 (interquartile range 18-58, range 1-370), performed by a median of four surgeons per department (3-5, 1-23). Two hundred and forty-two patients (10%) had acute cholecystitis. Eighteen point five percent had had an ERCP performed prior to LC. The rate of conversion to open operation was 10.5%, occurring significantly more often in acute cholecystitis (25.6%) than in patients with other indications (8.8%) (p < 0.001). Intraoperative cholangiography was used in 22.4%. The median duration of LC was 90 minutes (70-120, 25-415). The postoperative course was without complications in 90.4%. Laparotomy for complications was necessary in 43 patients (2.0%), mainly because of bile leaks. Twelve patients (0.6%) were treated endoscopically for complications. Bile duct injury occurred in 16 patients (0.66%, 95% CI 0.34-0.99%), including three transsections, one stricture, and 12 minor injuries. Six patients (0.25%, 95% CI 0-0.45%), three of whom had procedure-related complications, died postoperatively. All were > or = 72 years of age. Median time to discharge was two days, while median time to resumed work/normal activity was eight days. A comparison with the number of LC registered in the National Patient Register indicates that reporting is complete.

Effect of streptozocin on gastrin release.

As streptozocin has a toxic effect on gastrin producing cells in some patients with gastrinomas, the action of the drug upon normal gastrin release was evaluated in patients with carcinoid tumours (n=6) and malignant insulinomas (n=2). No acute effects were recorded in 22 instances where gastrin levels were followed during the first 24 hours after infusion of streptozocin. When gastrin levels were compared throughout a course of repeated infusions during months a significant increase was noted. Concentrations were doubled after 6 g streptozocin given during a four months period, and tripled after 10 g in nine months period. One patients developed bleeding duodenal ulcer after a total dose of 6 g. It is concluded that streptozocin does not damage normal G cells, but by some action seems to stimulate gastrin relase. Peptic ulceration may be an important side effect during a long term treatment.

CT scanning in patients with Zollinger-Ellison syndrome and carcinoid syndrome.

Computed tomography of the upper abdomen was performed in 11 patients with Z--E syndrome and 6 patients with carcinoid syndrome. The liver, pancreas, spleen and upper part of the retroperitoneal space were examined to localize a primary tumour and/or metastases. The CT findings were correlated to the final diagnoses obtained by operation or by other diagnostic procedures. The correlation between CT and the clinical findings was acceptable, and we are of the opinion that with further experience this new noninvasive radiological technique might be a helpful tool in the preoperative evaluation in these diseases. Furthermore, CT is an easy method in the control of a tumour or metastases during treatment.