Elective laparoscopic cholecystectomy without routine intraoperative cholangiography: a retrospective analysis of 1101 consecutive cases.

BACKGROUND: Laparoscopic cholecystectomy (LC) is today the operation of choice for symptomatic gallstone disease. Before the laparoscopic era intraoperative cholangiography (IOC) was generally considered as a fundamental step in cholecystectomy while nowadays the role of IOC is controversial: is there a need for IOC to specify anatomy of biliary tree in order to avoid bile duct injuries (BDI) and to detect possible common bile duct (CBD) stones or not? PATIENTS AND METHODS: We studied retrospectively all the elective LCs done in Turku City Hospital for Surgery during the ten years (1992-2001). Cholecystectomy was performed to 1101 patients, 874 (79%) female and 227 (21%) male patients, mean age 53y (range 15-89). LC was possible in 1022 (93%) cases while 79 (7%) had to be converted to open procedure. The number and severity of bile duct injuries were recorded. The cases with endoscopic retrograde cholangiopancreatography (ERCP) and/or magnetic resonance cholangiopancreatography (MRCP) during the follow-up and the findings in ERCP and MRCP were recorded from patient records and radiological database. RESULTS: IOC was performed in 32 operations (20 in LC and 12 after conversion) and CBD stones were found in seven patients. There were four primary BDIs: two CBD injuries and two minor bile leaks. During a mean follow-up of 72 months (range 36-144) ERCP was performed in 16 and MRCP in three patients. Three patients underwent both MRCP and ERCP. CBD stones were detected in ten patients and a postoperative late CBD stricture was found in one case. CONCLUSIONS: According to our data, both the incidence of BDIs (0.5%) and symptomatic postoperative CBD stones (0.9%) remain low without the routine use of IOC.

Serum phospholipases A2 in patients undergoing panproctocolectomy because of severe ulcerative colitis.

A major role has been proposed for group II phospholipase A2 in the pathogenesis of local and generalised inflammatory reactions. Elevated catalytic activity and mass concentrations of this enzyme have been found in serum and tissue samples of the colon in patients with active ulcerative colitis. The cellular source(s) of group II phospholipase A2 in the blood circulation is (are) unknown. In the current prospective study, we investigated the mass concentration of group II phospholipase A2 and the catalytic activity concentration of phospholipase A2 in serial serum samples of 15 consecutive patients who underwent a standard panproctocolectomy operation for severe ulcerative colitis. Both the catalytic activity concentrations of phospholipase A2 and the mass concentrations of group II phospholipase A2 increased rapidly in serum samples to maximum values on the first postoperative day and then decreased (p = 0.002 and p < 0.001, respectively) in patients who recovered uneventfully. Three patients had postoperative complications that further increased the enzyme concentrations at the time of respective complications. The pattern of group II phospholipase A2 mass concentration profiles was similar to the profiles of C-reactive protein. The results show that the removal of the large bowel does not eliminate the potential to secrete group II phospholipase A2 into the blood circulation in these patients. Secretion of group II phospholipase A2 into the circulation after surgery seems to be a normal host response to a major abdominal operation and postoperative complications. Consequently, we conclude that the large bowel is not an important source of group II phospholipase A2 in sera of patients with ulcerative colitis. The results also support the assumptions that the catalytic activity of phospholipase A2 in serum is attributable to group II phospholipase A2 and that this enzyme is an acute phase protein.

A randomised study of colostomies in low colorectal anastomoses.

OBJECTIVE: To assess the value of covering colostomy for patients undergoing low anterior resection for rectal neoplasms. DESIGN: Prospective randomised study. SETTING: Two university hospitals, Finland. SUBJECTS: 38 patients with air-tight stapled end-to-end anastomoses and complete anastomotic tissue rings were randomly allocated to have a covering colostomy (n = 19) or not. MAIN OUTCOME MEASURES: Postoperative mortality, anastomotic leaks, reoperations for leaks. RESULTS: The clinical leak rate was 24% (9/38) and six patients (16%) had radiological leaks. The total number of leaks (clinical and radiological together) was similar in the two groups, 7/19 compared with 8/19, respectively. There were fewer clinical leaks in the colostomy group (3/19; 16% compared with 6/19; 32%), but the difference was not significant. Reoperations for leaks were necessary more often in patients who did not have a covering colostomy (6/19; 32% compared with 1/19; 5%, p = 0.09). Two patients who did not have a stoma died from the infective complications of their leaks and one died of heart failure in the colostomy group. One patient who had not been given a stoma initially was left with a permanent colostomy after a leak. CONCLUSIONS: Our results suggest that a covering colostomy does not reduce the leak rate after low anterior resection, but prevents most of the severe infective consequences of the leaks.

Intraoperative sonography in patients with suspected liver metastases.

The correlation of preoperative sonography and intraoperative inspection and palpation of the liver with intraoperative sonography was studied in 77 patients. All underwent elective abdominal surgery for the treatment of verified malignant intra-abdominal tumours. Preoperative sonography findings differed from the intraoperative findings in 22 of the 77 patients (29%), intraoperative sonography being more reliable. Palpation differed from intraoperative sonography in 16 of 77 patients (21%), in three of whom the findings at intraoperative sonography altered therapy. Intraoperative sonography was most effective in detecting small previously undetected, nonpalable lesions deep in the liver parenchyma. There were no complications due to sonography. We recommend intraoperative sonography as a safe and diagnostically effective procedure for routine use in abdominal surgery.

Laparoscopic cholecystectomy. Experience of the first 150 patients.

Between April 1991 and May 1992, 150 patients were treated by laparoscopic cholecystectomy. Eleven patients (7.3%) required conversion to open laparotomy and five (3.3%) patients were operated on for postoperative complications. There were two (1.3%) patients with a hepatic duct lesion, one of which was treated with a T-tube alone but the other required a bilioenteral reconstruction. The average operation time was 72 minutes (range 30-240 minutes). The mean hospital stay of all patients was 2.1 days (range 1-28 days) and the mean time to return to work was 11.5 days (range 6-60 days).

Surgery of acute peptic ulcer haemorrhage.

During the years 1973-1985, 145 patients with acute peptic ulcer haemorrhage were treated surgically at the Department of Surgery, Turku University Central Hospital. The bleeding site was gastric ulcer in 76 patients; 58 of these were treated by gastric resection and 17 by ulcer excision combined with vagotomy and pyloroplasty. Forty-two out of 69 patients with bleeding duodenal ulcer were treated with partial gastrectomy, the remaining with transfixion and vagotomy and pyloroplasty. The rebleeding rate was 2% and reoperation rate 9% among the patients who had a resection. In contrast 19% of the transfixed and 12% of ulcer excision cases rebled. The primary overall mortality was 12%; 44% of the patients with recurrent bleeding died. Because rebleeding was the most important cause of mortality, partial gastrectomy in bleeding gastric as well as duodenal ulcer may be preferable.

Comparison of fresh, ethanol-preserved, and paraffin-embedded samples in DNA flow cytometry.

Fresh, ethanol-preserved, and formalin-fixed and paraffin-embedded samples taken from the same part of 15 human tumors, and from one normal spleen and one pancreas were analyzed for nuclear DNA content by flow cytometry. The coefficient of variation (CV) values of the G1 peaks were smaller in the fresh than in the other samples (P less than 0.001). The DNA ploidy of the tumors was the same in all types of samples. The DNA indices (DIs) measured from either ethanol-preserved or formalin-fixed tissue correlated strongly with those obtained from fresh tissue (P less than 0.001), although they tended to be somewhat smaller in the fresh samples. The S-phase fractions measured from all types of samples were of the same order of magnitude in most cases (P less than 0.001). Uninterpretable histograms were most often obtained from fresh samples. Identical DI values and rather constant S-phase fractions were obtained from ethanol-preserved samples stored at 4 degrees C for up to 5 months. It is concluded that all three types of samples are suitable for the determination of DNA ploidy, DI, and S-phase fraction and that 50% ethanol is suitable for long-term preservation of flow cytometric samples.

Second follow-up study of mucosal changes in the gastric remnant after resection for peptic ulcer disease.

Second follow-up 36-37, 26-27 and 15-18 years after gastric resection for peptic ulcer disease was performed for 72 patients who in the first screening five years earlier had severe atrophic gastritis and/or intestinal metaplasia in the gastric remnant mucosa. Of the 72 patients 60 were still alive. The death certificates revealed no gastric stump carcinomas among the 12 deceased patients. Neither were any cases of gastric stump carcinoma found among the 38 endoscopically screened patients. Severe atrophic gastritis, which was present in 37 patients in 1982-83, had regressed in 14 cases (p less than 0.01) and proceeded in one case. The extent of intestinal metaplasia had increased in 11 cases and decreased in five cases (p = 0.149, NS). Dysplasia, which was not seen five years ago, was now detected in four cases (10.5%). There was an association between dysplasia and incomplete intestinal metaplasia in three cases. Although these mucosal changes may be premalignant it is not possible to be categorical about the prognosis. Thus, endoscopic screening of all patients whose stomach has been resected for peptic ulcer disease cannot be recommended. Endoscopy, however, is always indicated when gastric symptoms appear in a patient with history of gastric resection.

Vagotomy and gastroenterostomy for stenosing duodenal ulcer.

Vagotomy and gastroenterostomy (V-GE) was performed in 41 patients with chronic stenosing duodenal ulcer and gastric retention in the years 1965-84. There was no mortality and no severe complication occurred. One patient was reoperated for dysfunction of an antecolic stoma. After a follow-up of 1-16 (mean 8) years 30 patients were interviewed and gastroscopy was performed in 21. One recurrence of ulcer was found at endoscopy. Visick classification gave the following overall results: grade I 40%, grade II 13%, grade III 30% and grade IV 17%. One case of gastric carcinoma was found five years after operation. It was concluded that V-GE is a simple and safe method and will give satisfactory early and long-term results.