Bilio pancreatic diversion following failure of laparoscopic adjustable gastric banding

BACKGROUND

This study examines the failure rate with laparoscopic adjustable gastric banding (LABG) and results of band removal with synchronous biliopancreatic diversion without (BPD) or with duodenal switch (BPDDS).

METHODS

Failure of LAGB was defined as removal of the band due to insufficient weight loss or a complication.

RESULTS

The band was removed in 85 of 1,439 patients (5.9%), most commonly for persistent dysphagia and recurrent slippage. The removal rate and slippage rate decreased from 10.8 and 14.2% to 2.8 and 1.3%, respectively, following introduction of the pars flaccida technique. Fifteen of 27 patients with previous open vertical banded gastroplasty (VBG) required removal of the band. Mean percentage excess weight loss 12 months following open BPD, laparoscopic BPD, open BPDDS, and laparoscopic BPDDS was 44, 37, 35, and 28%, respectively.

CONCLUSION

LAGB fails in 6% of patients and removal of the band with synchronous BPD or BPDDS can be performed laparoscopically. Patients with failed primary VBG have a high failure rate with LAGB.

A comparison of laparoscopic adjustable gastric banding in adolescents and adults

BACKGROUND

Laparoscopic adjustable gastric banding (AGB) induces effective weight loss in adults, but its efficacy in adolescents has yet to be determined.

METHODS

Since 1996, data have been collected prospectively on all patients undergoing laparoscopic AGB procedures performed at our hospital by a single surgeon (G.F.). Patients <20 years old at surgery (adolescents) were compared with- patients >20 years old (adults) who were matched for sex and body mass index (BMI).

RESULTS

Seventeen adolescents with a median age of 17 years (range, 12-19) and a BMI of 42.2 kg/m2 (range, 30.3-70.5) were compared to 17 adults with a median age of 41 years (range, 23-70) and a BMI of 41.8 kg/m2 (range, 30.1-71.5). There were no significant differences between the adolescents and the adults in complications or weight loss. The BMI dropped to 30.1 kg/m2 (range, 22.6-39.4) in adolescents and 33.1 kg/m2 (range, 28.4-41.3) in adults at 2-month follow-up.

CONCLUSION

Laparoscopic AGB is as effective in adolescents as it is in adults.

Laparoscopic Gastric Banding and Crural Repair in the Obese Patient with a Hiatal Hernia

BACKGROUND

A hiatal hernia is present in up to 50% of patients undergoing bariatric surgery. It has been claimed that laparoscopic adjustable gastric banding (LAGB) can both improve and induce reflux symptoms. The effect of a simultaneous crural repair and gastric banding has not yet been reported.

METHODS

Since 1999, all patients undergoing LAGB have a simultaneous crural repair if a hiatal hernia is present. Gastroesophageal reflux disease and dysphagia were assessed preoperatively and postoperatively using the modified DeMeester symptom-scoring system and the use of anti-reflux medication.

RESULTS

62 patients with a hiatal hernia have undergone simultaneous LAGB and crural repair, with a median follow up of 14 (3-38) months. There was no mortality, and complications occurred in 3 patients, namely pulmonary embolus, slippage requiring repositioning of the band and persistent dysphagia requiring band removal. 24 months following LAGB and crural repair, median BMI had fallen from 43 to 31 kg/m2 and median excess weight loss was 53%. Modified DeMeester symptom-score fell from a preoperative median of 3 (0-5) to a postoperative median of 0 (0-2) (P < 0.01, Mann Whitney U), and the number of patients on anti-reflux medication decreased from 44 to 6 (P < 0.01, Chi-squared).

CONCLUSION

Crural repair in addition to LAGB does not increase the risk of slippage or dysphagia, significantly improves reflux symptoms and decreases the need for anti-reflux medication.

Symptomatic vitamin A deficiency following biliopancreatic diversion

BACKGROUND

Biliopancreatic diversion (BPD) is an effective operation for morbid obesity. Fat-soluble vitamin deficiencies are known complications of this procedure, with incidence rates reported as high as 6%.

CASE REPORT

A-36-year old morbidly obese female with BMI 60.6 kg/m(2) underwent laparoscopic adjustable gastric banding, followed 2 years later by BPD in an attempt to control her weight. Following BPD, she failed to attend outpatient appointments and was poorly compliant with daily multivitamins and monitoring of serum vitamin and mineral levels. She developed symptomatic vitamin A deficiency, with vitamin A levels <0.1 micromol/L, and night blindness, as well as deficiencies of vitamins D, E and K, zinc and selenium. Her vitamin deficiencies were corrected with appropriate supplements and her night blindness resolved.

DISCUSSION

This case raises the issues of preoperative screening of patients and compliance, as well as life-long postoperative monitoring of serum vitamin and mineral levels. With better compliance with outpatient appointments, prescribed multivitamins and oral vitamin A tablets, as well as regular monitoring of serum vitamin and mineral levels, vitamin deficiencies and their consequences, such as night blindness, may be avoided.

Massive splenomegaly is associated with significant morbidity after laparoscopic splenectomy

OBJECTIVE

To evaluate the impact of spleen weight on operative and clinical outcome in a series of 108 consecutive laparoscopic splenectomies.

BACKGROUND

Laparoscopic splenectomy as an alternative to open splenectomy for splenomegaly is regarded as controversial.

METHODS

Patients underwent laparoscopic splenectomy for a range of hematological disorders between November 1992 and February 2000. Multiple linear and logistic regression analysis were used to assess the effect of massive splenomegaly (>1000 g) on perioperative mortality and morbidity, after adjusting for the joint effects of patient age, weight, pre- and postoperative full blood counts, operating time, estimated blood loss, conversion rate, reoperation rate, and duration of hospital stay.

RESULTS

Massive splenomegaly was recorded in 27 of 108 (25%) cases. In this group, splenic weight ranged from 1000 to 4750 g (median, 2500 g). Patients with splenic weight >1000 g had a significantly longer median operating time (170 vs. 102 minutes, P < 0.01), conversion rate (5/27 vs. 4/81, P < 0.05), postoperative morbidity (15/27 vs. 4/81, P < 0.01), and median postoperative stay (5 vs. 3 days, P < 0.01). Multivariate analysis found splenic weight to be the most powerful predictor of morbidity (P < 0.01). Patients with splenomegaly (>1000 g) were 14 times likely to have post operative complications. One patient died 3 days after surgery, following a pulmonary embolus (spleen weight 500 g, mortality 1/108, 0.9%).

CONCLUSIONS

Laparoscopic splenectomy is feasible in patients with giant spleens. However, it is associated with greater morbidity, and the advantages of minimal access surgery in this subgroup of patients are not so clear.

Treating diabetes in the morbidly obese by laparoscopic gastric banding

BACKGROUND

Remission of diabetes following Roux-en-Y gastric bypass has been postulated to occur partly by bypass of the foregut. Laparoscopic adjustable gastric banding (LAGB) also reduces food intake but does not bypass the foregut, and its effects on diabetes have yet to be elucidated.

METHODS

Patients with diabetes or a history of diabetes and >6 months follow-up after LAGB were studied. Follow-up was conducted separately by a surgeon with regard to weight loss and potential morbidity and by a physician with regard to diabetic control.

RESULTS

14 patients had had gestational diabetes, and diabetes was controlled by diet in 25, oral hypoglycemics in 38 and insulin in 11 patients. Reduction in body mass index (BMI) and percentage of excess weight loss (%EWL) were similar in these 4 subgroups, with a median reduction in BMI of 11.7 kg/m(2) and %EWL of 51.1% at 24 months. 26 of 38 patients controlled with oral hypoglycemic medication and 6 of 11 insulin-dependent diabetics had all medication stopped at a median of 6.5 months following LAGB. Univariate and multivariate analyses identified %EWL > or = 30.6% at 6 months as the only significant predictor of remission of diabetes.

CONCLUSION

Two-thirds of the diabetic patients have had remission of diabetes following LAGB. LAGB is an effective treatment for diabetes in obese patients.

Laparoscopic gastric banding in morbidly obese adolescents

BACKGROUND

4% of adolescents in the U.S.A. are obese, 80% of whom will become obese adults. Obesity in adolescence is associated with increased mortality and morbidity in adulthood. Is laparoscopic adjustable silicone gastric banding a safe and effective method of weight loss in morbidly obese adolescents?

METHODS

Since 1996, data has been prospectively collected on all patients undergoing laparoscopic adjustable gastric banding (LAGB) by a single surgeon. Patients are reviewed at 6 and 12 weeks following surgery, then at 3 monthly intervals. Weight loss is measured in absolute terms, reduction in body mass index (BMI) and as percentage of excess weight loss.

RESULTS

17 patients with a median age of 17 (12 to 19) years underwent LAGB. Median follow-up was 25 (12 to 46) months. 2 complications occurred, 1 slipped band and 1 leaking port. BMI fell from a preoperative median of 44.7 to 30.2 kg/m2 at 24 months following surgery, corresponding to a median loss of 35.6 kg or 59.3% of excess weight. 13 of 17 patients (76.5%) lost at least 50% of their excess weight, and 9 of 11 patients (81.8%) had a BMI < 35 kg/m2 at 24 months following surgery.

CONCLUSION

LAGB is a safe and effective method of weight loss in morbidly obese adolescents, at least in the medium term. Its role in preventing obesity and obesity-related disease in adulthood remains to be determined as part of our long-term study.

Treatment of non-resectable hepatocellular carcinoma with autologous tumor-pulsed dendritic cells

BACKGROUND

The response of hepatocellular carcinoma (HCC) to therapy is often disappointing and new modalities of treatment are clearly needed. Active immunotherapy based on the injection of autologous dendritic cells (DC) co-cultured ex vivo with tumor antigens has been used in pilot studies in various malignancies such as melanoma and lymphoma with encouraging results.

METHODS

In the present paper, the preparation and exposure of patient DC to autologous HCC antigens and re-injection in an attempt to elicit antitumor immune responses are described.

RESULTS

Therapy was given to two patients, one with hepatitis C and one with hepatitis B, who had large, multiple HCC and for whom no other therapy was available. No significant side-effects were observed. The clinical course was unchanged in one patient, who died a few months later. The other patient, whose initial prognosis was considered poor, is still alive and well more than 3 years later with evidence of slowing of tumor growth based on organ imaging.

CONCLUSIONS

It is concluded that HCC may be a malignancy worthy of DC trials and sufficient details in the present paper are given for the protocol to be copied or modified.

Laparoscopic colorectal surgery for cancer: intermediate to long-term outcomes

PURPOSE

Since 1991, a laparoscopic-assisted resection has been used at the Royal Brisbane Hospital selectively for patients with colorectal cancer. This article audits the intermediate to long-term postoperative complications and cancer follow-up data.

METHODS

All patients undergoing a laparoscopic resection for cancer were prospectively followed up with regard to long-term outcomes.

RESULTS

One hundred eighty-one patients have been studied. One hundred fifty-four patients had potentially curative procedures performed in the study period. Median follow up was 71 (range, 7-108) months. The overall recurrence rate in this group was 6 percent (21 recurrences). There was one port site recurrence after a potentially curative procedure (0.6 percent) and one port site recurrence after a palliative resection. Perioperative mortality was 1 percent (2 patients). Only six patients suffered an adhesive small-bowel obstruction postoperatively. There was one incisional hernia. Unadjusted five-year median survival data for Australian Clinico-pathological Staging A was 91 percent (3.5 percent recurrence); for Australian Clinico-pathological Staging B, 83 percent (15 percent recurrence); and for Australian Clinico-pathological Staging C, 74 percent (26 percent recurrence).

CONCLUSION

In selected patients a laparoscopic resection for colorectal cancer produces acceptable intermediate to long-term oncologic outcomes and a low long-term complication rate.

Glucose uptake and insulin action in human adipose tissue--influence of BMI, anatomical depot and body fat distribution

OBJECTIVE

To examine and compare in vitro basal and insulin-stimulated glucose uptake in human omental and subcutaneous adipose tissue derived from lean, overweight or obese individuals, and in those with central or peripheral obesity.

DESIGN

In vitro study of basal and insulin-stimulated 2-deoxyglucose uptake in human omental and subcutaneous adipose tissue explants derived from patients undergoing elective abdominal surgery.

SUBJECTS

Fourteen lean (average age 47 y, average body mass index (BMI) 22 kg/m(2)), 12 overweight (average age 51 y, average BMI 27 kg/m(2)), and 15 obese subjects (average age 45 y, average BMI 39 kg/m(2)). Ten peripherally obese (average age 43 y, average WHR 0.76) and 17 centrally obese (average age 50 y, average waist-to-hip ratio (WHR) 0.92).

MEASUREMENTS

Fatness and fat distribution parameters (by anthropometry), basal and insulin stimulated [(3)H]-2-deoxyglucose uptake in omental and subcutaneous adipose tissue explants.

RESULTS

In adipose tissue from lean subjects transport of 2-deoxyglucose over basal was stimulated approximately two-fold by insulin. In contrast, 2-deoxyglucose transport in adipose tissue of obese or overweight subjects was not responsive to insulin. Following incubation with 100-nM insulin for 35 min, insulin-stimulated 2-deoxyglucose transport was significantly lower in both omental and subcutaneous adipose tissue of obese and overweight compared to lean subjects. Basal 2-deoxyglucose uptake was also significantly reduced in omental and subcutaneous tissue in obese compared to lean subjects. Depot-specific differences in 2-deoxyglucose uptake were also seen. Overall 2-deoxyglucose uptake was greater in omental than subcutaneous adipose tissue but this was due to increased basal levels rather than increased insulin action. The reduction in insulin-stimulated 2-deoxyglucose uptake seen in overweight and obese subjects was relatively similar in both depots. However, insulin responsive 2-deoxyglucose transport was significantly lower in the omental adipose tissue of subjects with central obesity, as compared to that of subjects with peripheral obesity. No difference in insulin induced 2-deoxyglucose transport was observed in the subcutaneous adipose tissue explants of subjects with either central or peripheral obesity.

CONCLUSION

In lean individuals insulin responsiveness of omental and subcutaneous adipose tissue was similar, but basal glucose uptake was significantly higher in omental adipose tissue. Adipose tissue obtained from overweight as well as obese individuals is insulin resistant. This insulin resistance occurs at a lower BMI than previously expected and is not adipose-depot specific. However, in obese subjects with a central distribution of adiposity insulin resistance occurs at the site of omental adipose tissue, in contrast to those with peripheral obesity.

Signature authentication by forensic document examiners

We report on the first controlled study comparing the abilities of forensic document examiners (FDEs) and laypersons in the area of signature examination. Laypersons and professional FDEs were given the same signature-authentication/simulation-detection task. They compared six known signatures generated by the same person with six unknown signatures. No a priori knowledge of the distribution of genuine and nongenuine signatures in the unknown signature set was available to test-takers. Three different monetary incentive schemes were implemented to motivate the laypersons. We provide two major findings: (i) the data provided by FDEs and by laypersons in our tests were significantly different (namely, the hypothesis that there is no difference between the assessments provided by FDEs and laypersons about genuineness and nongenuineness of signatures was rejected); and (ii) the error rates exhibited by the FDEs were much smaller than those of the laypersons. In addition, we found no statistically significant differences between the data sets obtained from laypersons who received different monetary incentives. The most pronounced differences in error rates appeared when nongenuine signatures were declared authentic (Type I error) and when authentic signatures were declared nongenuine (Type II error). Type I error was made by FDEs in 0.49% of the cases, but laypersons made it in 6.47% of the cases. Type II error was made by FDEs in 7.05% of the cases, but laypersons made it in 26.1% of the cases.

Systematic errors in optical-flow velocimetry for turbulent flows and flames

Optical-flow (OF) velocimetry is based on extracting velocity information from two-dimensional scalar images and represents an unseeded alternative to particle-image velocimetry in turbulent flows. The performance of the technique is examined by direct comparison with simultaneous particle-image velocimetry in both an isothermal turbulent flow and a turbulent flame by use of acetone-OH laser-induced fluorescence. Two representative region-based correlation OF algorithms are applied to assess the general accuracy of the technique. Systematic discrepancies between particle-imaging velocimetry and OF velocimetry are identified with increasing distance from the center line, indicating potential limitations of the current OF techniques. Directional errors are present at all radial positions, with differences in excess of 10 degrees being typical. An experimental measurement setup is described that allows the simultaneous measurement of Mie scattering from seed particles and laser-induced fluorescence on the same CCD camera at two distinct times for validation studies.

Towards T-tube free laparoscopic bile duct exploration: a methodologic evolution during 300 consecutive procedures

OBJECTIVE

To establish a simple, reproducible, and safe technique of laparoscopic common bile duct exploration (CBDE) with high clearance rates and low morbidity and mortality rates.

SUMMARY BACKGROUND DATA

For most general surgeons, laparoscopic CBDE appears an unduly complex and demanding procedure. Since the introduction of laparoscopic cholecystectomy, many surgeons use endoscopic cholangiography (ERC) and endoscopic sphincterotomy as their only option in treating bile duct stones. ERC is more specific if used after surgery, but it carries an appreciable morbidity rate and has the disadvantage of requiring a second procedure to deal with bile duct stones. To this end, various methods of laparoscopic CBDE have been developed.

METHODS

Between August 1991 and February 1997, 300 consecutive unselected patients underwent laparoscopic CBDE.

RESULTS

Of 300 laparoscopic CBDE procedures, 173 (58%) were managed using a transcystic approach and 127 (42%) with choledochotomy. Successful laparoscopic stone clearance was achieved in 271 (90%). Of the 29 (10%) patients not cleared laparoscopically, 10 had an elective postsurgical ERC, 12 were converted to an open procedure early in the series, and 7 had unexpected retained stones. There was one death (mortality rate 0.3%) and major morbidity occurred in 22 patients (7%). The last 100 procedures were performed from July 1995 to February 1997, and stone clearance was unsuccessful in only two patients.

CONCLUSIONS

Laparoscopic transcystic basket extraction of common duct stones under fluoroscopic guidance is a relatively quick, successful, and safe technique. Choledochotomy, when required, is associated with a higher morbidity rate, particularly with T-tube insertion, and the authors advocate primary bile duct closure with or without insertion of a biliary stent as a more satisfactory technique for both surgeon and patient. Most patients with gallbladder and common duct calculi should expect a curative one-stage laparoscopic procedure without the need for external biliary drainage or ERC.

Laparoscopic underrunning of bleeding duodenal ulceration: a minimalist approach to therapy

Surgical management of bleeding duodenal ulcer has traditionally included a procedure to reduce gastric acid production to enable ulcer healing and reduce the likelihood of rebleeding. The availability of intravenous proton pump inhibitors in the peri-operative period may promote rapid ulcer healing and as a component of anti-Helicobacter eradication therapy greatly reduces the incidence of ulcer recurrence. Using this approach, six patients with actively bleeding duodenal ulcer underwent laparoscopic duodenotomy and attempted suturing of the bleeding site. One patient required conversion to open surgery and subsequently re-bled at 60 h, necessitating a partial (Billroth II) gastrectomy. In the remaining five patients suture control of bleeding and luminal closure were completed laparoscopically without complications. Laparoscopic repair of acutely bleeding duodenal ulcers is technically feasible and had a low complication rate in this small series.

Laparoscopic management of acute small bowel obstruction

BACKGROUND

Laparoscopic management of acute small bowel obstruction is hypothetically attractive but little is known of its clinical potential.

METHODS

A retrospective study was undertaken of patients with acute small bowel obstruction requiring surgery, managed by a laparoscopic unit (LU; n = 69) and a general unit (GU; n = 70).

RESULTS

Laparoscopy was performed in 55 patients (80 per cent) in the LU compared with ten (14 per cent) in the GU. Laparoscopic surgery completed treatment in 31 patients (45 per cent) in the LU and assisted in a further 15 (22 per cent). Patients treated laparoscopically were discharged earlier than those treated by laparotomy (median 3 (range 1-15) versus median 8 (range 1-46) days). Patients treated laparoscopically had a higher chance of early unplanned reoperation than those treated by laparotomy (five of 35 versus four of 88) (P < 0.05).

CONCLUSION

Laparoscopy can be performed in a high percentage of patients requiring surgery for acute small bowel obstruction. Hospital stay was reduced but the risk of early unplanned reoperation was increased in patients managed laparoscopically.

Laparoscopic anterior resection: a consecutive series of 84 patients

Laparoscopic colorectal surgery is in its infancy. From a series of over 200 colorectal procedures undertaken over the last 30 months, we have performed 84 anterior resections. In 55 women and 29 men, median age 64 years (range 32-86), median weight 72 kg (range 36-125), surgery was undertaken for benign pathology (n = 57) and adenocarcinoma (n = 27). Anterior resection was completed laparoscopically in 75 cases (89%) with a median operating time of 210 min (range 85-420). Minor morbidity occurred in 17 patients (20%) with major morbidity in 10 cases (12%). There was one post-operative death. Flatus was passed a median of two days (range 1-7) after surgery and feces at a median of four days (range 2-9). Total hospital stay was six days (range 2-33). Delayed morbidity during a maximum of 30 months' follow-up included two anastomotic strictures but no evidence of malignant seeding. Laparoscopic anterior resection appears both feasible and safe for both benign and malignant disease, with the caveat that long-term outcome in malignant disease is not yet available.

Laparoscopic antegrade biliary stenting

BACKGROUND AND STUDY AIMS

Laparoscopic common bile duct exploration is successful in 90% of patients, but 10% of patients may have retained stones or impaired biliary drainage at the end of surgery. This study presents the results of laparoscopic biliary stenting in three such patients.

PATIENTS AND METHODS

Three patients with choledocholithiasis, aged 51, 82, and 100 were treated by laparoscopic antegrade placement of biliary stent.

RESULTS

Biliary drainage was established in all three cases. Follow-up at six months revealed all patients to be asymptomatic, with two aged 82 and 101 with the stents still in place.

CONCLUSIONS

Laparoscopic antegrade biliary stenting deserves consideration when the surgeon encounters impaired biliary drainage after laparoscopic exploration of the common bile duct.

Laparoscopic splenectomy and lymph node biopsy for hematologic disorders

OBJECTIVE

The authors audit the introduction of laparoscopic splenectomy and laparoscopic intra-abdominal lymph node biopsy and compare outcomes with a parallel cohort of patients undergoing open splenectomy.

SUMMARY BACKGROUND DATA

Laparoscopic splenectomy was first reported in 1992. It was introduced into clinical practice at the Royal Brisbane Hospital in 1991. Between June 1991 and March 1994, 24 patients have undergone laparoscopic splenectomies and 23 patients have had laparoscopic intra-abdominal lymph node biopsies.

METHODS

Laparoscopic splenectomy was performed using a four- or five-port technique. The splenic hilum was secured using a linear stapler cutter, and the spleen was removed after placing it in a laparoscopic bag. Lymph node biopsy was performed using a three- or four-port technique, depending on the site and size of the lymphadenopathy.

RESULTS

Laparoscopic splenectomy was completed in 22 patients (92%). Median hospital stay was 3 days (range 2-7 days) and morbidity occurred in two patients (8%). Lymph node biopsy was completed laparoscopically in 21 of 23 patients (91%), with morbidity in two cases (9%). Median hospital stay was 2 days (range 1-6 days), with a diagnostic accuracy of 90%. Comparison with open splenectomy revealed that the laparoscopic approach took significantly longer to perform (p = 0.0002), but resulted in a significantly shorter hospital stay (p = 0.0005).

CONCLUSIONS

Both laparoscopic splenectomy and laparoscopic lymph node biopsy currently are used as the treatments of choice for hematologic disease in our institution.

Laparoscopic biliary and gastric bypass: a useful adjunct in the treatment of carcinoma of the pancreas

Over 90% of patients with inoperable carcinoma of the pancreas are successfully palliated by endoscopic retrograde cholangiopancreatography and stent insertion. Treatment of the residual 10% of patients often entails a laparotomy, which is difficult to justify when median survival of these patients is only 150 days. Laparoscopic biliary and gastric bypass offers a less invasive alternative than open surgery with shorter hospital stay and more rapid return to normal activity. Between August 1991 and March 1994, 16 patients (median age 69 years, range 31-85) had laparoscopic bypass surgery. The indications for surgery were gastric outlet obstruction at initial presentation (n = 4), blocked biliary stent (n = 8), and metastatic tumour at laparoscopy (n = 4). Surgery took the form of cholecystjejunostomy (n = 7), gastroenterostomy (n = 5), both procedures (n = 3), and failed operation (n = 1). Operative duration was 75 minutes (range 45-190) and hospital stay four days (range 3-33) and all apart from two patients were discharged from hospital in seven days or less. Morbidity occurred in two patients (13%) in the form of a cerebrovascular accident and delayed gastric emptying. Median survival in 10 patients who have died is 201 days (range 20-525). Laparoscopic biliary and gastric bypass is possible in most patients in whom endoscopic stenting has failed and in those who subsequently develop gastric outlet obstruction. Hospital stay is shorter than after open surgery and recovery more rapid.

Laparoscopic exploration of the common bile duct: lessons learned from 129 consecutive cases

Since the introduction of laparoscopic cholecystectomy there has been widespread debate about the best way to manage common bile duct (CBD) calculi. Between August 1991 and July 1994, 129 patients underwent laparoscopic exploration of the CBD. Fifteen patients of median age 52 years were managed by glucagon-induced relaxation of the sphincter of Oddi and saline flushing of the bile duct through a cholangiogram catheter. This had a success rate of 73 per cent and took a median of 90 min including cholecystectomy. The technique has now been replaced by Dormia basket exploration of the CBD. Transcystic common duct exploration using a Dormia basket was used in 79 patients of median age 47 years. Duct clearance was achieved in 96 per cent of cases with a median operating time of 55 min. Thirty-five patients of median age 52 years were managed by choledochotomy and T tube placement, with a 91 per cent duct clearance rate and a median operating time of 120 min. Overall duct clearance was achieved in 92 per cent of patients with an operative morbidity rate of 5.4 per cent. Duct clearance using either a Dormia basket or choledochotomy and T tube placement was obtained in 95 per cent of patients. Laparoscopic exploration of the CBD is an important alternative in the management of common duct calculi.

Rectal bleeding associated with chronic pancreatitis

Pseudocyst formation, with its attendant complications of compression, rupture, bleeding and fistula formation, is a well known complication of chronic pancreatitis. In 1966 Berne and Edmondson drew attention to the often fatal outcome of pancreatico-colonic fistula complicated by hemorrhage. We present two cases of this rare complication of chronic pancreatitis as defined by the Marseille classification.

Morbidity and mortality of operative intubation for malignant oesophageal obstruction

In 33 patients who underwent operative intubation of carcinoma of the oesophagus or gastric cardia, there were nine postoperative deaths (mortality 27%). Only 15 patients (46%) had no further operative procedure or anaesthetics, but their mean survival was only 3.7 months. Nine patients (27%) required a total of 17 procedures after the placement of their original tube. Operative intubation has a similar mortality to resection but the survival times are short. Whenever possible palliative resection or endoscopic intubation is to be recommended.