Lost gallstones during laparoscopic cholecystectomy: are they really benign?

The long-term effect of stones spilled into the peritoneal cavity during laparoscopic cholecystectomy is unknown. The course of a 58-year-old man who had recurrent right subphrenic abscesses and a right empyema secondary to spilled gallstones during laparoscopic cholecystectomy is described. The authors outline techniques for minimizing the spillage of stones during laparoscopic cholecystectomy: the application of hemoclips, endoloops and sutures, and placement of the necrotic, friable gallbladder in an endoscopic bag immediately upon completion of the dissection, before extraction of the gallbladder. They conclude that spillage of stones during laparoscopic cholecystectomy may lead to serious infection and should be recorded in the operative notes so that stones may be suspected when a patient presents with abdominal infection after laparoscopic cholecystectomy.

Treatment with FK506 prevents rejection of rat colon allografts.

Colon transplantation has been proposed as a method to improve the function of an intestinal allograft. The present study examined the risk of colon rejection and the effect of FK506 on colon rejection in BN-->LEW rats with orthotopic bowel transplants. The first 4 groups included rats with untreated allografts (group 1), rats with isografts treated with 0.6 mg/kg FK506 (group 2), rats with allografts treated with 0.6 mg/kg FK506 (group 3), and rats with allografts treated with 0.4 mg/kg FK506 (group 4). In each of these groups (10-12 rats), half of the animals received a small bowel graft only (SB), while the other half received a small bowel, ascending colon, and cecum graft (SBC). The animals were followed daily until they died or were killed at 4 weeks. In group 5, an additional 18 untreated rats with SBC allografts were randomly killed on the third, fifth, seventh, and tenth postoperative days to study the sequential histopathologic and immunopathologic changes of colon rejection. There was no difference in survival, body weight, nutritional parameters, or bacterial contamination after SB and SBC transplantation. Intestinal transit was slower after SBC than SB transplantation (P < 0.05). Sequential histopathologic studies revealed that (1) the severity and time course of colon rejection was similar to small intestine rejection, and (2) the features of colon rejection were similar to ulcerative colitis. There was no evidence of graft-versus-host disease after SBC transplantation. In summary, adding a segment of large bowel to a small bowel allograft does not increase the risk of rejection or surgical complications. The transplanted colon slows intestinal transit. Treatment with FK506 effectively prevents colon rejection. These data suggest that adding a colon graft may improve the outcome of clinical small bowel transplantation.

Synergistic effects of tumour necrosis factor and morphine on gut barrier function.

OBJECTIVE: To study the effects of tumour necrosis factor (TNF) and morphine on intestinal permeability, intestinal transit and bacterial translocation in the rat. DESIGN: A randomized interventional controlled experiment. SETTING: University surgery and microbiology research laboratory. PARTICIPANTS: Forty-four rats in five groups as follows: control (n = 9); treated with morphine every 2 hours for 8 hours (n = 9); treated with TNF for 5 minutes (n = 10); treated with TNF plus morphine every 2 hours for 8 hours (n = 6); and treated with TNF plus morphine every 3 hours for 24 hours (n = 10). MAIN OUTCOME MEASURES: Intestinal permeability as measured by the uptake of chromium-51 ethylenediaminetetraacetate (51Cr-EDTA) over 8 hours, intestinal transit as measured by the amount of 51Cr-EDTA remaining in the gastrointestinal tract at the time of animal sacrifice, intestinal bacteria counts and translocation of bacteria as measured from bacterial counts of mesenteric lymph nodes, spleen and liver at the time of sacrifice. RESULTS: Morphine increased intestinal transit time and ileal bacteria counts (p < 0.05). TNF alone did not increase intestinal permeability or bacterial translocation. TNF plus morphine increased intestinal transit time, intestinal permeability, bacterial counts and bacterial translocation (p < 0.05). CONCLUSIONS: Morphine or increased intestinal transit time, or both, increases the concentration of intestinal bacteria. Morphine plus TNF increases intestinal bacteria counts, intestinal permeability and bacterial translocation. Morphine alone does not increase intestinal permeability or bacterial translocation.

Transplantation of segmental rat intestinal grafts including the ileocecal value and the ascending colon.

Extrinsic denervation and lymphatic disruption impair nutrient absorption after small bowel transplantation. The present study was undertaken to determine whether adding the ileocecal valve with or without the ascending colon would improve the function of a segmental intestinal graft. Five groups of Lewis rats (n = 10/group) were studied. Group I had a sham laparotomy. Groups II, III, IV, and V had the native jejunum, ileum, and cecum replaced with a graft. Inbred Lewis rats were used as isogeneic donors for the transplants to avoid the confounding effect of graft rejection. Group II had the entire jejunum and ileum transplanted. Group III had 20 cm of terminal ileum transplanted. Group IV had 20 cm of the terminal ileum including the ileocecal valve transplanted. Group V had 20 cm of the terminal ileum, the ileocecal valve, and the ascending colon transplanted. The terminal ileum-transplanted and terminal ileum/ileocecal valve-transplanted groups lost more than 25% of their preoperative weight by the end of the second postoperative week; most of these animals were killed because of inanition. In contrast, the sham laparotomy, jejunum/ileum-transplanted, and ascending colon-transplanted groups remained healthy until completion of the study on the 28th postoperative day. The ascending colon-transplanted group had slower intestinal transit and less bacterial contamination of the terminal ileum compared with the terminal ileum-transplanted and terminal ileum/ileocecal valve-transplanted groups (P < 0.05). Transplantation of the ascending colon and the ileocecal valve significantly improves the function of segmental small bowel isografts in rats. These data suggest that adding a colonic segment may be a simple method to improve the function of short-segment cadaveric and living-related intestinal grafts in humans.

Specialism and generalism in the future of general surgery.

The progressive specialism that has characterized the practice of medicine over the last 100 years has occurred almost entirely in a scientific context. Societal needs and social changes have had little influence. As we near the end of the 20th century the benefits of scientific specialism are being questioned. New historical studies of specialism have shown that factors other than new knowledge are the driving force for the creation of some subspecialties. The process by which a new subspecialty is established requires both a national institute and a certification examination. Certification is intended to identify those with specific knowledge and skill by inclusion, but is being perceived increasingly as a process that works by exclusion. General surgery, one of the few "generalist" disciplines, finds itself at a crossroads. Further subspecialization with certification will fragment and destroy the discipline. There are cogent arguments, based on economics and care-delivery issues, to preserve general surgery. Making this choice will commit general surgeons to accept the concept of scientific generalism and to the development of the specialty of general surgery in a social context.

Biliary tract reconstruction in liver transplantation.

Refinements in biliary tract reconstruction and the frequent use of cholangiography have produced a marked decline in the number of deaths from biliary complications after liver transplantation. The authors' method of reconstruction differs from those of others in that it employs no stents or T tubes and retains the donor gallbladder, allowing access to the biliary tract for radiologic purposes in the post-transplant period. In a series of 161 consecutive liver transplants, the frequency of biliary complications was 13.6% (15 anastomotic and 7 gallbladder-related). Of three deaths that occurred in patients with biliary complications, one was due to the complication itself. A Roux-en-Y reconstruction with anastomosis to the donor duct was associated with the lowest anastomotic complication rate (2.2%). Upper abdominal surgery before transplantation, especially shunting, was a major risk factor for biliary complications.

Denitrification in a sand and gravel aquifer.

Denitrification was assayed by the acetylene blockage technique in slurried core material obtained from a freshwater sand and gravel aquifer. The aquifer, which has been contaminated with treated sewage for more than 50 years, had a contaminant plume greater than 3.5-km long. Near the contaminant source, groundwater nitrate concentrations were greater than 1 mM, whereas 0.25 km downgradient the central portion of the contaminant plume was anoxic and contained no detectable nitrate. Samples were obtained along the longitudinal axis of the plume (0 to 0.25 km) at several depths from four sites. Denitrification was evident at in situ nitrate concentrations at all sites tested; rates ranged from 2.3 to 260 pmol of N(2)O produced (g of wet sediment) h. Rates were highest nearest the contaminant source and decreased with increasing distance downgradient. Denitrification was the predominant nitrate-reducing activity; no evidence was found for nitrate reduction to ammonium at any site. Denitrifying activity was carbon limited and not nitrate limited, except when the ambient nitrate level was less than the detection limit, in which case, even when amended with high concentrations of glucose and nitrate, the capacity to denitrify on a short-term basis was lacking. These results demonstrate that denitrification can occur in groundwater systems and, thereby, serve as a mechanism for nitrate removal from groundwater.

Multiorgan failure in critically ill patients.

Of 1136 patients admitted consecutively to two medical-surgical intensive care units, 100 were found to have multiorgan failure, defined as failure of more than two organ systems. The average duration of stay in the intensive care units was 13.4 days. The overall death rate was 78% compared with 12.8% for patients without multiorgan failure. The most common initiating illnesses or insults were sepsis, surgery, accidental trauma and cardiogenic shock. Of potential risk factors studied, shock, sepsis, surgery, pre-existing organ disease and age over 65 years were the most common. Although sepsis occurred before or during the course of multiorgan failure in 78 patients, in only 34 was sepsis judged to be the prime insult leading to multiorgan failure. Surgery during the course of multiorgan failure had neither an adverse nor beneficial effect on outcome. The mean number of organ systems failing was 4.36 for survivors and 5.03 for nonsurvivors. The most common systems to fail were central nervous, cardiovascular and respiratory.

Liver transplantation: the University Hospital-Children's Hospital of Western Ontario experience.

Patients who currently benefit the most from liver transplantation are those with end-stage, non-malignant liver disease. Primary biliary cirrhosis and cirrhosis from chronic active hepatitis (hepatitis B negative) have been the most common indications in our experience. Overall survival rates in excess of 70% at 1 year are now common and those patients who live the first year have a very good prospect of long-term survival. Complete rehabilitation occurs in about 80% of survivors. Patients on life support systems before transplantation and those awaiting urgent retransplantation have the highest mortality rates. Modern anesthetic and surgical techniques have made the operation much safer and more straightforward. Biliary tract complications remain common, especially in patients with a history of previous upper abdominal surgery. Cyclosporine has had a major impact, but in the context of its use in combination with other immunosuppressive agents (antilymphocyte globulin, steroids, azathioprine and OKT3).

Sporadic hemorrhagic colitis associated with Escherichia coli, type O157:H7: unusual presentation mimicking ischemic colitis.

Hemorrhagic colitis is a bacterial infection of the colon, associated with a verotoxigenic strain of Escherichia coli, commonly serotype O157:H7. This recently described disease is usually self-limiting. Because fecal cultures are negative for the usual pathogens and the clinicopathologic features closely mimic ischemic colitis, the patient is exposed to the risk of unnecessary surgery. One such situation is described and differentiation between hemorrhagic and ischemic colitis is discussed.

Liver transplantation without venous bypass.

Fifty consecutive orthotopic liver transplants were performed without venous bypass in 41 recipients. Seven patients were transplanted twice and one patient received 3 transplants. The average age of the recipients was 37 years. The commonest indications for transplantation were primary biliary cirrhosis and cirrhosis from chronic active hepatitis. Fifty-eight percent of the recipients had undergone previous upper abdominal surgery. During the anhepatic period systolic blood pressure decreased by 21% to an average of 98 mm. of mercury. Cardiac output decreased by 52% to a mean (+/- SEM) of 3.89 +/- 0.21 L/min., and there was a doubling of the systemic vascular resistance. The hemodynamic alterations promptly returned to preclamping levels following hepatic revascularization. The average intraoperative transfusion requirements were 13 units of packed red blood cells, 9.6 units of platelets, 14.5 units of plasma and 6.6 L of crystalloid. Patients with previous surgery and retransplants required an average of 13 and 17 units of packed red blood cells, respectively. There was no deterioration in renal function in the postoperative period and no patient required hemodialysis. The 30 day survival was 87.8%. The 90-day and one-year actuarial survival is 80.5% and 68.8%, respectively. It is concluded that venous bypass is not necessary as a routine in orthotopic liver transplantation.

A simplified method for metabolic studies in conscious swine.

Reliable short-term blood access in conscious swine was provided by implanting multiple silastic catheters. Catheters were inserted into the aorta, hepatic vein, portal vein, and inferior vena cava through a midline laparotomy incision. Multiple catheters also were placed into the external jugular vein through a separate cervical incision. Catheter patency rates for blood withdrawal on the sixth post-operative day were: arterial 100%, hepatic 91%, portal 86%, inferior vena cava 71%. No animal had major wound or catheter infection on the seventh post-operative day. The methods described allow metabolic studies, including measurements of splanchnic blood flow, to be carried out either acutely or for up to at least 7 days post-operatively.

Insulin decreases muscle protein loss after operative trauma in man.

Seventy-two hours after major operative trauma, nine patients receiving a constant infusion of calories (1460 kcal/m2/day) and protein (75 gm of amino acid/m2/day) showed a negative nitrogen balance, increased muscle catabolism, as measured by 3-methylhistidine excretion, increased amino acid efflux from muscle, and decreased circulating levels of insulin. When 5 U of insulin/hr were added to the infusate, arterial insulin levels rose significantly from 39.7 +/- 4.1 microU/ml to approximately the pretrauma levels (74.6 +/- 7.7 microU/ml). Despite this normalization of insulin levels, excretion of nitrogen and 3-methylhistidine and the efflux of amino acids from forearm muscle fell but did not return to pretraumatic levels, suggesting some insulin resistance. Visceral gluconeogenesis from amino acids appeared to decrease, since insulin infusion decreased the efflux of alanine from skeletal muscle with no change in its arterial level. Insulin also significantly reduced the efflux of isoleucine, tyrosine, phenylalanine, glutamine, and total amino acid nitrogen from forearm muscle. These findings, along with the partial reduction in the excretion of 3-methylhistidine and nitrogen, suggest that insulin, in combination with infused calories and protein, decreases the loss of muscle protein after trauma.

Major operative trauma increases peripheral amino acid release during the steady-state infusion of total parenteral nutrition in man.

The effect of major operative trauma on skeletal muscle metabolism was examined in nine patients receiving a constant infusion of calories (1460 kcal/m2/day) and protein (75 gm of amino acids/m2/day) for 5 days before and 4 days after an operation. Compared with the preoperative state, 72 hours after the operation there was a significant rise in arterial levels of glucagon, cortisol, norepinephrine, and inactive triiodothyronine and a drop in concentrations of insulin, active triiodothyronine, and amino acids. Forearm blood flow increased, as well as the efflux from forearm muscle of lactate, taurine, serine, glycine, valine, methionine, isoleucine, leucine, phenylalanine, lysine, arginine, and total amino acid nitrogen (440%). This loss of muscle protein after trauma is associated with increased muscle proteolysis, as measured by increased urinary 3-methylhistidine excretion (83%), and accounts for increased nitrogen loss (54%) from the body. Increased activity of the sympathetic nervous system is manifested by increased levels of epinephrine and norepinephrine, a relative lack of insulin, and increased levels of glucagon. This hormonal milieu plays an important role in the production of hypoaminoacidemia, increased efflux of amino acids and lactate from muscle, and negative nitrogen balance observed in these traumatized patients.

Renal function after nephrectomy for donor organs.

Thirty-three living related kidney donors were investigated at a mean of 5.8 years after donor nephrectomy (range 3-18 years) to detect late adverse effects. They were evaluated for hypertension, the presence of proteinuria and renal dysfunction as assessed by serum creatinine value and creatinine clearance. There was a significant rise in both diastolic blood pressure and serum creatinine levels and a trend towards significance in the decline in creatinine clearance. Eleven individuals had diastolic blood pressure greater than or equal to 90 mmHg but only 1 required treatment. Although the rise in serum creatinine reached significance the mean serum creatinine (104.91 mumol/l) remained within the normal range. Two patients showed a minimal rise in proteinuria. The overall results confirm that kidney donation is safe and indicate that there are no significant late sequelae.

2,3-Dihydroxybenzoic acid. Effect on mortality rate in a septic rat model.

Neutrophil-derived oxygen-free radicals may play a role in organ dysfunction associated with generalized sepsis. A rat model was used to test the effects of two free radical scavengers, dimethyl sulfoxide (DMSO) and 2,3-dihydroxybenzoic acid (2,3-DHB), on mortality from intra-abdominal sepsis produced by cecal ligation and perforation. Being an iron-chelating agent, 2,3-DHB may have an additional bacteriostatic effect. Therapeutic regimens included no treatment; gentamicin sulfate (2 mg given intraperitoneally [IP] every eight hours); DMSO (2 g/24 hr given IP every eight hours in divided doses); 2,3-DHB (35 mg/kg given IP every eight hours); and combinations of gentamicin with each free radical scavenger. No statistically significant improvement in survival was obtained by therapeutic intervention with gentamicin alone, DMSO alone, 2,3-DHB alone, or gentamicin in combination with DMSO. When used in combination with gentamicin, 2,3-DHB yielded a statistically significant improvement in survival when compared with gentamicin alone or with no treatment. These results show that 2,3-DHB when used in combination with gentamicin has a beneficial effect on mortality following intra-abdominal sepsis in this model.