Squamous cell carcinoma of the gallbladder presenting with a biliary-colic fistula.

Pure squamous carcinoma of the gall bladder is a rare tumour which may present diagnostic difficulty for the histopathologist. A case presenting as a biliary-colic fistula is described and the diagnostic histological features discussed. Theories regarding aetiology and the prognosis of this rare tumour are also discussed.

Elective hepatic resection for benign and malignant liver disease: early results.

Between August 1989 and April 1992, 60 consecutive elective hepatic resections were performed by one surgeon at two hospitals. This personal series was reviewed to determine the early results of elective hepatic resection. There were 17 patients with liver metastases from colorectal cancer, 14 with hepatocellular carcinoma (three with cirrhosis), seven with cholangiocarcinoma, six with carcinoma of the gallbladder plus liver involvement, ten with liver metastases from other sites and six with benign conditions of the liver. Thirty-eight patients underwent major liver resection, seven unisegmentectomy, six bisegmentectomy, four trisegmentectomy and five non-anatomical resection. Total vascular exclusion was used in 50 cases and the Pringle manoeuvre in ten. The mean(s.d.) operative blood transfusion was 990(1260) ml packed red blood cells (range 0-13 units); 17 patients did not receive blood transfusion. There were two operative deaths; non-fatal complications developed in 16 patients. The two deaths were from postoperative liver failure and there was no other hospital death.

Life quality and psychological morbidity with an ileostomy.

The recent introduction of restorative proctocolectomy for the treatment of ulcerative colitis has reopened the debate about the effects of ileostomy on quality of life. This study analysed life quality and psychological morbidity in 113 patients with an ileostomy using a postal questionnaire which included questions about their opinion of the pouch operation. Of the questionnaires, 73 per cent were suitable for analysis. A total of 93 per cent of those responding were happy with the ileostomy and appeared to have adapted to a normal life with it. Some 87 per cent stated that they would keep the ileostomy in preference to an ileoanal pouch. In addition, psychological morbidity as assessed by the General Health Questionnaire occurred in only 5 per cent of patients.

The effect of infrarenal aortic reconstruction on glomerular filtration rate and effective renal plasma flow.

Compromised patients with aortic disease are vulnerable to various complications from aortic reconstruction. These complications are related to changes in systemic haemodynamics during aortic cross-clamping, which leads to cardiac stress and alteration in regional blood flow to different organs. One of the most important postoperative complications is renal failure which is associated with a high mortality rate. Circulatory alterations within the kidney must play a role in the pathogenesis of renal dysfunction that may follow infrarenal aortic cross-clamping and reconstruction. To study the effects of abdominal aortic reconstruction on renal function and perfusion, we measured prospectively the glomerular filtration rate (GFR, n = 59), effective renal plasma flow (ERPF, n = 38) and left ventricular ejection fraction (LVEF, n = 38) in patients undergoing elective infrarenal aortic reconstruction. Radionuclide techniques were used. The three parameters were measured at three time points: preoperatively, postoperatively and 6 months after surgery. The LVEF was measured in order to reflect the patient's cardiac status and pre-renal perfusion. We also measured the three parameters in two control groups of patients: a group of patients undergoing major colonic surgery and a group of patients with arterial disease under conservative management. Six months after surgery the GFR had decreased in 67% of aortic reconstruction patients. Overall GFR in the aortic reconstruction group decreased by a mean of 9 ml min-1 (p = 0.007). This was associated with a decrease in the ERPF in 48.5% of patients. The mean decrease in ERPF in the aortic reconstruction group was 74 ml min-1 (p = 0.05). The LVEF was unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

Technical and operative factors in infrarenal aortic reconstruction and their effect on the glomerular filtration rate in the immediate postoperative period and 6 months later.

Renal failure is an important cause of postoperative morbidity and mortality in infrarenal aortic reconstruction. Several mechanisms for this postoperative renal dysfunction have been suggested. However, biochemical testing of renal function is insensitive since it shows only gross renal changes. This study examined prospectively the effects of the technical and operative factors on renal function using radionuclide tests. The authors measured the total Glomerular Filtration Rate (GFR) using 51Cr-EDTA clearance in 59 patients undergoing elective infrarenal aortic reconstruction. We also examined the individual kidneys using 99mTc-DTPA renography and 99mTc-DMSA renal scanning. Renal scanning gives the percentage of function of each kidney, while renography gives a graphic assessment of individual renal perfusion and clearance. All tests were carried out preoperatively, 2 weeks postoperatively and 6 months later. Twelve technical factors including aortic cross clamping time, type of aortic anastomosis, forced diuresis, division of left renal vein and various others were recorded to study their effect on the GFR and the individual kidney function. The effect on renal function of these operative factors has not previously been described. GFR showed no change in the immediate postoperative period. Six months later GFR decreased, the mean decrease was 9 ml/min. (P = 0.007 Wilcoxon rank). Some of our patients showed an increased GFR, a phenomenon that was recognised recently. None of the factors studied, except division of the left renal vein, had any effect on the changes in the GFR in the immediate postoperative period or 6 months later.