No abstract

The advent of laparoscopic cholecystectomy (LC) has led to some controversy regarding the best method of managing bile duct calculi. This paper reviews the cases of 38 patients who underwent LC and endoscopic retrograde cholangiopancreatography (ERCP), from a series of 600 consecutive laparoscopic cholecystectomies. Twenty‐nine patients had ERCP performed pre‐operatively because of suspicion of choledocholithiasis. Duct stones were confirmed in eight patients. Recent or current jaundice was the best predictor of bile duct stones. Nine patients had ERCP done postoperatively because of duct stones seen on operative cholangiography. In two patients bile duct cannulation was not possible and a third procedure, open duct exploration, was necessary. Techniques in laparoscopic management of duct stones are improving and the role of ERCP and sphinc‐terotomy should be limited to jaundiced patients or those with proven bile duct stones in whom laparoscopic procedures have been unsuccessful.

In a consecutive series of 349 patients undergoing surgery for gallstones. 66 patients (19%) were aged over 65 years. Within this group of elderly patients. 51 underwent laparoscopic cholecystectoiny which was successful in 84% of cases. The most frequent cause for conversion to open surgery was the presence of dense pericystic adhesions. Fifteen patients (23%) underwent elective open surgery. The principal reason was co‐existent duct stones. There was no operative mortality and procedure related morbidity in the elderly following laparoscopic or open surgery was similar. Laparoscopic cholecystectoiny can be safely and effectively performed in the majority of elderly patients. offering thein the perceived advantages of this technique. However. the presence of duct stones in 18% of cases necessitates careful evaluation of these patients pre‐operatively.

One hundred patients with persistent or recurrent pneumothorax treated by parietal pleurectomy are described. There was one known recurrence and no postoperative deaths. Six patients required further surgery for complications. In the uncomplicated cases the average stay in hospital following operation was 11-5 days. Parietal pleurectomy should be regarded as the treatment of choice for patients with recurrent pneumothorax who are fit to undergo surgery.

A survey of the nutritional state of surgical patients using haematological and biochemical measurements has demonstrated a higher frequency of abnormal values in patients following major surgery. Anthropometrtc measurements in patients did not differ from non-hospitalised controls. The routine use of multi-channel biochemical analysls to estimate plasma albumin, and the estlrnation of haernoglobin levels are of value in the postoperative management of surgical patients. Consideration of early intravenous feeding should be given to those patients who do not make a rapid recovery from major surgery.

Rectus sheath haematomas are unusual, and it is very rare to find associated rectus muscle necrosis. The aetiological factors are discussed. Non‐surgical treatment is preferred, but if surgery is indicated, evacuation of the haematoma with ligation of the feeding vessels is an effective method of treatment.

A series of 74 patients having endoscopic sphincterotomy for common bile duct calculi is reported. Complete stone extraction was achieved in 53 cases (72%). Seventeen of 21 patients with retained calculi following recent biliary surgery had successful extractions (80%). Of 30 patients having had a cholecystectomy, 21 (70%) were successful, but only 15 of 23 patients with obstructive jaundice and no previous biliary surgery had the ducts cleared of calculi. Failure was due to multiple stones in the duct, or calculi too large to pass through the sphincterotomy. Endoscopic sphincterotomy is advocated in patients with obstructive jaundice due to stones, moving to early surgery should it prove unsuccessful. The results in patients with a T‐tube in situ are comparable to extraction of the calculi along the T‐tube tract.

TABLE II-Mean (± SE of mean) plasma urate concentrations (mmol/l) in patients who suffered AMI according to whether they were given diuretics Day: 1 4 7 14 Diuretics given (n = 38) 0-354 ± 0-015 0 409 ±0-021 * 0-392 +0-018 0-382 ±0-016 Diuretics not given (n = 32) 0 340 ±0-012 0-327 0-015* 0-368 ±0-018 0-368 0-018 *P<0-01. ate concentrations, may play a part in altering the renal handling of urate. These organic acids are thought to share a common secretory mechanism with urate and produce hyperuricaemia by competing with urate for this secretory site.11 12 Possibly also a more rapid turnover of preformed purines or increased de novo synthesis may have produced hyperuricaemia in the AMI group. Further study is in progress to elucidate the mechanism. We thank the physicians of Addenbrooke's Hospital, Cambridge, for allowing us to study patients under their care and Professor H Lehmann for the laboratory facilities. P G was the holder of the Grimshaw-Parkinson Research Studentship at the University of Cambridge and is at present receiving a grant from the Wellcome Trust. Requests for reprints should be addressed to P G