Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study.

BACKGROUND: Previous studies suggest that laparoscopic cholecystectomy (LC) is associated with an increased risk of intraoperative injury involving the bile ducts, bowel, and vascular structures compared with open cholecystectomy (OC). Population-based studies are required to estimate the magnitude of the increased risk, to determine whether this is changing over time, and to identify ways by which this might be reduced. METHODS: Suspected cases of intraoperative injury associated with cholecystectomy in Western Australia in the period 1988 to 1994 were identified from routinely collected hospital statistical records and lists of persons undergoing postoperative endoscopic retrograde cholangiopancreatography. The case records of suspect cases were reviewed to confirm the nature and site of injury. Ordinal logistic regression was used to estimate the risk of injury associated with LC compared with OC after adjusting for confounding factors. RESULTS: After the introduction of LC in 1991, the proportion of all cholecystectomy cases with intraoperative injury increased from 0.67% in 1988-90 to 1.33% in 1993-94. Similar relative increases were observed in bile duct injuries, major bile leaks, and other injuries to bowel or vascular structures. Increases in intraoperative injury were observed in both LC and OC. After adjustment for age, gender, hospital type, severity of disease, intraoperative cholangiography, and calendar period, the odds ratio for intraoperative injury in LC compared with OC was 1.79. Operative cholangiography significantly reduced the risk of injury. CONCLUSION: Operative cholangiography has a protective effect for complications of cholecystectomy. Compared with OC, LC carries a nearly twofold higher risk of major bile, vascular, and bowel complications. Further study is required to determine the extent to which potentially preventable factors contribute to this risk.

Breast cancer in Western Australia in 1989. I. Presentation.

This study was designed as a population-based study of all cases of breast cancer diagnosed in Western Australia (WA) in 1989. Cases were identified from the State Cancer Registry and from computerized hospital inpatient records. Data were obtained from the records of surgeons and oncologists managing the patients, hospital medical records, and pathology and cytology reports. A total of 701 histologically proven tumours were documented in 692 women. Of these 6.8% were not known to the State Cancer Registry. Two-thirds (68%) of tumours were first detected by the woman herself, 11% were found by a doctor and 11% were detected by mammographic screening. Stage I tumours accounted for 40% of tumours and Stage II 39%. The estimated lifetime risk of a WA woman developing at least one malignant breast tumour is 10%. Passive surveillance based upon a legal obligation on doctors to notify cases of cancer may be resulting in a significant under-estimation of the incidence of cancer in WA. Mammographic screening played only a small role in the detection of breast cancer in WA in 1989, but its contribution and the proportion of stage I tumours should both increase as a population-based mammographic screening programme is established. This survey will provide a yardstick against which changes can be measured. Eighty-four per cent of tumours presently occur in women who would have access to mammographic screening although only 44% occur in the 50-69 age bracket that is to be actively recruited. The lifetime risk of breast cancer in WA women is greater than has been appreciated previously.

Breast cancer in Western Australia in 1989. II. Diagnosis and primary management.

This study was designed as a population-based study of all cases of breast cancer diagnosed in Western Australia (WA) in 1989. Cases were identified from the State Cancer Registry and from computerized hospital inpatient records. Data were obtained from the records of surgeons and oncologists managing the patients, hospital medical records and pathology and cytology reports. A total of 701 tumours in 692 women were treated by 105 different surgeons of whom 25 saw 10 or more cases. Over 70% were proven by cytology or biopsy within 2 weeks of presentation to a doctor. The first diagnostic investigation was fine needle aspiration in 45%, open biopsy in 28% and diagnostic mammogram in 24.4%. A definitive procedure involving breast conservation was performed in 31.3% of patients with operable tumours; 35.6% of those under 50 years of age. If axillary dissection or sampling was part of such treatment, 93.5% of those under 50 years and 75% of those 50 years and over had radiotherapy to the residual breast. Although less than one-third of patients were referred to a medical oncologist almost a half had adjuvant systemic therapy (92% of node positive and 23% of node negative patients). Tamoxifen was prescribed as part of adjuvant therapy in 93% of those over 50 years and cyclophosphamide, methotrexate and 5-fluorouracil in 71% of those under 50 years. Less than 10% of patients treated with mastectomy and axillary dissection had postoperative radiotherapy to the chest wall and drainage areas. The patterns of care of patients with breast cancer in WA prior to the introduction of population-based mammographic screening have been established.(ABSTRACT TRUNCATED AT 250 WORDS)

Scar formation after breast-conserving surgery for cancer. Sir Charles Gairdner Hospital Breast Cancer Group.

A study of surgery for breast cancer was performed to examine the influence of haematoma formation and radiotherapy on the development of mammographically detected scars. Fifty-nine women undergoing lumpectomy and radiotherapy were studied. Sixteen had mammographic scars 12 months after surgery. There was a correlation between postoperative haematoma formation and scarring (P = 0.03) but not between tumour size and scarring. The type of radiation therapy did not influence scar formation.

Mondor's disease of the breast resulting from jellyfish sting.

OBJECTIVE: To present two cases of Mondor's disease of the breast resulting from jellyfish stings in Western Australia. CLINICAL FEATURES: A 30-year-old Caucasian woman presented with a palpable thickened cord in her right breast. The straightness of the cord suggested a thrombosed lymphatic. A 50-year-old Caucasian woman presented with an obvious palpable cord extending most of the length of her left breast. Mammography demonstrated no abnormality. Both women reported having been stung by jellyfish a month earlier. INTERVENTION AND OUTCOME: As Mondor's disease is a benign, self-limiting disease, the patients were reassured and reviewed routinely. In each case, the condition settled spontaneously over a period of several weeks. CONCLUSION: Jellyfish stings should be recognised as an unusual variant of the numerous causes which have been described for Mondor's disease.

Liver abscess in Western Australia (1974-1983).

Over the 10 year period 1974-1983, 91 cases of liver abscess presented to the major teaching hospitals in Perth, Western Australia. Amoebic liver abscess (ALA) accounted for 37 (or 41%) of these cases, an incidence inflated by Perth's proximity to south-east Asia where amoebiasis is endemic. This frequent recent history of contact, the availability of sensitive and specific diagnostic serology and a clinical presentation usually suggesting pathology in the right upper quadrant, accounted for the consistently short delay in diagnosis of ALA. There were no deaths from ALA and a low incidence of complications such as secondary infection or rupture into the thorax. On the other hand, pyogenic liver abscess (PLA) commonly presented in a more non-specific manner and in an older age group, contributing to a long delay in diagnosis. Despite improvements in liver imaging techniques and advances in antibiotic and general supportive therapy, mortality for PLA remains high, 20% in this series. Fatal PLA was associated with multiple abscesses not amenable to drainage, increasing age, delay in diagnosis and the presence of septicaemia.

Non-seminomatous germ cell testicular tumours: residual masses after chemotherapy.

Twenty-three consecutive patients with metastatic non-seminomatous germ cell testicular tumours were treated with a combination of cisplatinum, vinblastine and bleomycin. Nineteen had elevated serum tumour marker levels (alpha-fetoprotein and beta-subunit HCG) prior to chemotherapy. In 11 of the 19, residual masses were present on the completion of induction chemotherapy despite normal serum tumour marker levels (residual mass after chemotherapy). The management of these 11 patients was based on a policy of observation rather than routine resection of residual deposits and all are currently alive (32-58 months) with ten free of active disease. Two of the eleven required additional chemotherapy when serial tumour marker levels became elevated during follow-up. Another six have been observed without further intervention and have remained well with stable or diminishing deposits. The remaining three have required resection of residual masses, in each case because of mass enlargement despite persistently negative tumour marker levels. None of the masses showed histological evidence of malignancy. A more selective approach to resection of residual masses after chemotherapy is advocated.

Fine-needle aspiration cytology in the management of breast disease.

The results of a series of fine needle aspiration biopsies of breast lumps were reviewed to evaluate the accuracy of this diagnostic method and its place in the clinical management of breast lesions. A high level of diagnostic accuracy was achieved. There were no false positive diagnoses of malignancy and fewer than 3% of diagnoses were falsely negative. Eighty per cent of carcinomas could be confidently diagnosed by means of cytological investigation. The patient with a benign cytological diagnosis can either be reassured, or her surgical management planned as a day case. For the patient with a cytological diagnosis of malignancy, discussion of the nature of her surgery and subsequent care is possible before operation. In selected cases of carcinoma, mastectomy can be performed without frozen-section confirmation. Diagnostic accuracy is dependent upon experience, especially in aspiration technique, and optimum results are obtained if the pathologist/cytologist also performs the procedure.

The comparative epidemiology of benign breast lumps and breast cancer in Western Australia.

Totals of 313 patients with breast cancer and 1,283 patients biopsied for benign breast lumps were found in Western Australia in 1978 through review of all histopathological, hospital and cancer registry records. The incidence of breast cancer rose to 146.9 per 100,000 at age 45-54 years and thereafter increased little. The biopsy rate for benign breast lumps rose more sharply to 420.2 per 100,000 at age 45-54 years and then fell. This pattern was mainly due to benign mammary dysplasia (BMD); fibroadenoma showed an earlier peak biopsy rate (30-34 years) and other (mainly non-neoplastic) benign lumps were biopsied at a relatively constant rate throughout adult life. Rates of breast cancer, BMD and fibroadenoma showed similar relationships to the other descriptive variables studied. The rates of each were higher in single than married women, in residents of the Perth area than residents of other parts of the State and in women employed in professional and related occupations than other employed women. They were lower in migrants from Europe (excluding Great Britain) than native-born Australians and in women of low socio-economic status than women of high status. Not all these differences were statistically significant. Rates of other breast lumps did not generally vary in these ways and were conversely related to country of birth, area of residence and socio-economic status. The parallels in descriptive epidemiology between breast cancer, BMD and fibroadenoma suggest that they may share aetiological factors.

Postoperative gastric emptying.

Postoperative intolerance of oral fluids in common after abdominal surgery, and their premature administration may result in abdominal distension, nausea and vomiting. The ability of the stomach to empty 100 ml of water was investigated in patients undergoing elective cholecystectomy. Patients were studied preoperatively and on the first postoperative day using a radio-isotopic method of measurement of gastric emptying. Factors such as age, electrolyte disturbance, duration of operation and the many drugs used during the perioperative period were analysed in relation to postoperative gastric emptying rates. Postoperative gastric emptying showed wide variation, being normal in some patients but absent in others. No correlation was found between postoperative gastric emptying and age, plasma potassium and the duration of operation and anaesthetic. A significant correlation was found, however, between gastric emptying and drugs administered in the perioperative period. In particular, gastric emptying was grossly retarded following an injection of opiate, but this returned to normal if more than 5 h had elapsed since the last injection of opiate. It is suggested that opiate therapy is a major factor in a patient's inability to tolerate fluids following cholecystectomy.

Occurrence of breast cancer in Australian women.

No data are available on the incidence of breast cancer for the whole of Australia. Review of published incidence data from 1972 to 1978 from New South Wales, South Australia, and Tasmania shows that the incidence of breast cancer in women aged 25 years and over ranged between 97.8/100 000 and 106.5/100 000 of these women. These rates are similar to those in other countries with high rates. Comparison of mortality rates in Australian States between 1968 and 1978 for women aged 25 years and over showed rates from 28.3/100 000 in Victoria and 44.1/100 000 in the Australian Capital Territory. The rates for Victoria and the Australian Capital Territory were significantly higher than those in the other States. Trends in mortality in Australia for women aged 25 years and over were studied in the period from 1907 to 1977. Initially, the mortality rate was 28.5/100 000 and increased to reach a peak of 41.5/100 000 in 1940-1944. Thereafter, rates fell to 37.1/100 000 in 1960-1964, but have begun to rise again since 1970. The 1940-1944 peak was largely confined to women over the age of 50 years, and further analysis of the age-specific mortality rates showed the peak to be cross-sectional in type (that is, affecting each age group in the same calendar period). The rise after 1970 occurred mainly in women aged between 30 and 44 years and 60 and 79 years.

Gastric motility and emptying in normal and post-vagotomy subjects.

The effects of proximal gastric vagotomy (PGV) and vagotomy with pyloroplasty (V and P) on gastric motility were studied using a solid meal labelled with a radiopharmaceutical agent. In having on-line computer facilities it was possible not only to record the rate of emptying but also to analyse the relative roles of the fundus and the antrum within the overall framework of gastric emptying. In normal subjects the fundus filled and then emptied in an almost linear pattern. The antrum, however, did not completely fill until well after the meal was eaten and thereafter appeared to maintain a constant volume during the study. The redistribution of contents between fundus and antrum was reflected in the total stomach emptying curve as a delay, or lag phase before gastric emptying commenced. After both types of vagotomy fundic filling was delayed, representing a slower eating time, which was presumably due to early satiety. Antral filling and volume was disturbed only after V and P, which was also reflected by a loss of the lag phase seen on the total stomach curve. PGV retained antral function but there was significant delay in the redistribution of contents between fundus and antrum, though this did not have clinical significance. The rate of emptying was unaffected by either operation. It was concluded PGV did maintain antral function and a more normal pattern of emptying compared with V and P. After V and P the changes in antral function were considerable and these changes are probably associated with some of the complications resulting from this operation.

Massive pancreatic serous effusions.

The condition of massive pancreatic serous effusion is being increasingly recognized as a specific complication of pancreatitis. It occurs as a result of leakage of pancreatic juice into the pleural or peritoneal cavity after disruption of the duct system. Five such cases are described. The difficulties in making the diagnosis are mainly due to the absence of symptoms of pancreatitis, and most patients present because of the effects of the effusion. Once suspected, the diagnosis is confirmed by the demonstration of a grossly elevated amylase level in the fluid. A rational surgical approach is usually successful, and depends on the demonstration of a leak from a pseudocyst or disruption of the pancreatic duct system.

Operative biopsy of the pancreas using the Trucut needle.

The results of 14 operative biopsies of the pancreas using the Trucut technique are presented. There was no significant complication attributable to the biopsy, and in all cases an adequate tissue specimen was obtained, facilitating either frozen or paraffin section histological diagnosis. One false negative result was obtained which was due to sampling error. This technique is recommended as a good alternative when operative pancreatic biopsy is required. It is technically simple, has an acceptably low sampling error, provides a good tissue specimen for histological examination, and has few complications.

The initial phase of gastric emptying before and after vagotomy and pyloroplasty.

The initial phase of gastric emptying of solid food was monitored with the use of a gamma camera and on-line computer facilities. In normal subjects a consistent pattern was seen comprising an early delay in the onset of emptying ("plateau"), followed by an exponential decay curve. After vagotomy the plateau was lost, and the exponential pattern of emptying commenced once the stomach was full. There was no evidence of sudden "dumping" of contents from the stomach. The overall rates of emptying as measured by the half emptying time (T 1/2) were the same in normal and postvagotomy subjects.

Drug therapy for postragotomy gastric stasis.

An unusual but well-recognized complication of truncal vagotomy with a drainage procedure is severe gastric stasis (atony). In 6 patients presenting with this problem drug therapy was initiated after mechanical obstruction of the gastric outlet was excluded by radiology. Bethanechol chloride was successful in stimulating gastric peristalsis in all the patients, with consequent improvement of symptoms in 5 out of the 6 subjects. Metoclopramide alone was of no value in starting peristalsis but of pssible benefit once gastric motility had begun.

Gastric emptying in control subjects and patients with duodenal ulcer before and after vagotomy.

The emptying of a solid meal labelled with Indium 113mDTPA from the stomach was studied with a gamma camera in 26 normal subjects, 27 patients with duodenal ulcer, on 41 occasions after truncal vagotomy and pyloroplasty and 38 times after highly selective vagotomy. Applying the method of principal component analysis to the results, differences were detected between control and duodenal ulcer subjects and two probable subgroups of duodenal ulcer were observed. Half emptying times did not reveal these patterns. After vagotomy, delayed emptying was general at one week. At one month, patients after highly selective vagotomy had a more normal result than those with truncal vagotomy and pyloroplasty (TV), but by six months no significant difference in overall emptying rate was found, although changes in the pattern of gastric emptying persisted in some patients after TV.

Multiple hyperplastic inflammatory polyps complicating quiescent ulcerative colitis.

A patient with well-controlled and currently asymptomatic ulcerative colitis had II unusually large polypoid lesions in his colon demonstrated by barium enema X-ray examination and colonoscopy. Previous histological descriptions of inflammatory polyps did not adequately describe their morphology, and the term "hyperplastic inflammatory polyp" is suggested.

Continuous monitoring of the effect of pentagastrin on gastric emptying of solid food in man.

By continuous monitoring of a solid meal labelled with a radiopharmaceutical it has been possible to determine the effects of drugs on gastric emptying and motility during a single study. Predictably hyoscine delayed, and bethanechol increased, the rate of gastric emptying. Pentagastrin initially produced marked antral activity resulting in a physiological stricture and subsequent delay in the overall rate of gastric emptying. Fundal motility was unaffected though reflux from the antrum occurred.