Search

True left-sided gallbladder (sinistroposition) is a rare anatomic anomaly in which the gallbladder is found to the left of the falciform ligament, under the left lobe of the liver. Though uncommon, it is important for the surgeon to recognize this finding because the ductal anatomy is unique and the mechanics of the operation provide a technical challenge. Multiple case reports have documented safe management of sinistroposition encountered during conventional laparoscopic cholecystectomy. We present a case of sinistroposition encountered during a single-incision laparoscopic cholecystectomy. We believe that the single-site laparoscopic technique is not only a safe option but may actually provide certain benefits in approaching this difficult anatomy in the properly selected patient and the experienced single-site surgeon's hands.

Large sliding inguinal hernias involving the urinary bladder are rare. We present the relevant clinical data, radiographic images, and the intraoperative findings of a sliding inguinoscrotal herniation of the urinary bladder. A 67-year-old male presented with a scrotal mass and the need to manually compress his scrotum in order to void. Diagnosed with a large sliding inguinal hernia with significant bladder involvement (scrotal cystocele), the patient underwent an inguinal herniorraphy and replacement of the bladder in the retroperitoneal space. Surgery proved to be successful in the management of the inguinal hernia and voiding dysfunction.

Bouveret syndrome is a rare complication of cholelithiasis occurring when a gallstone passes through a cholecystoduodenal or choledochoduodenal fistula and lodges in the pylorus or proximal duodenum causing a gastric outlet obstruction. The case of a 70-year-old male who developed Bouveret syndrome is presented, and the management of this presentation of gallstone ileus by Roux-en-Y duodenojejunostomy is discussed in detail.

Background: The unexpected intraoperative finding of a cancerous gallbladder has become particularly problematic, because cancer recurs rapidly after laparoscopic cholecystectomy. It would be desirable to identify the patients of greatest risk for gallbladder cancer before operation. After several elderly patients presenting with acute cholecystitis were found to have gallbladder cancer, we performed the following study., Methods: Records of patients (60 years of age or older, 1987 to 1995) with an admitting diagnosis of acute cholecystitis and symptoms including right upper quadrant pain, nausea, vomiting, fever, and leukocytosis were reviewed., Results: Eighty patients were included in the study. Carcinoma involving the gallbladder was found in seven patients; six had primary and one had metastatic carcinoma. The 73 patients without cancer underwent cholecystectomy. The differences between the noncancer and cancer patients included age (68 +/- 7 versus 74 +/- 8 years, p < 0.05), total bilirubin (mg/dl, 1.5 +/- 1.5 versus 3.7 +/- 3.4, p < 0.01), alkaline phosphatase (IU/L, 179 +/- 132 versus 369 +/- 226, p < 0.01), and aspartate aminotransferase (IU/L, 77 +/- 93 versus 158 +/- 157, p < 0.05)., Conclusions: Additional work-up and open cholecystectomy should be considered in elderly patients presenting with apparent acute cholecystitis, especially when liver functions are abnormal.

Background: The occurrence of postvagotomy complications was initially considered an unavoidable but acceptable consequence of duodenal ulcer surgery. Following the description of "selective" vagotomy procedures, however, it became apparent that effective ulcer surgery might be accomplished without unpleasant sequellae., Methods: In 1957 the experimental basis for "highly" selective vagotomy (HSV), which preserved antral innervation, was reported. HSV was performed in several European centers between 1960 and 1968, and was widely accepted there. Surgeons in the United States, in contrast, were largely reluctant to use HSV, an operation which had an excessive ulcer recurrence rate compared to vagotomy-antrectomy. More recently, HSV is recognized as a successful operation, due to more complete division of preganglionic gastric vagal nerves ("extended" HSV) and the liberal use of pyloric reconstruction in patients with juxtapyloric ulcers., Results: HSV is performed with minimal morbidity, with an incidence of recurrent ulcer which is less than 5%. Complications such as dumping, diarrhea, and gastric atony are quite rare., Conclusions: HSV is an ideal procedure for most patients with duodenal ulcer. Because most operations for ulcer are performed for urgent or life-threatening problems, the most common operation performed in the United States today is truncal vagotomy combined with pyloroplasty or gastric resection. Earlier operation for chronic ulcer has many potential advantages.

Computerized axial manometry (CAM) of the lower esophagus measures squeeze pressure at multiple points in each segment of the lower esophageal sphincter (LES), calculates several unique parameters of LES function, and constructs a 3-D display of the LES. Whether parameters derived from CAM, such as the radial mean pressure (LESrmp), Asymmetry (Asym), and Vector Volume (VV), have relevance to function of the LES remains undefined. This study compares the results of CAM in patients with gastroesophageal reflux disease (GERD) and controls. There were 54 patients with GERD and 21 volunteers; all underwent CAM as part of their evaluation; GERD was defined by clinical and endoscopic examinations, and all patients had abnormal 24-hour pH tests. Statistical evaluation was performed. The LESrmp and the Vector Volume were significantly correlated in both groups of patients and differed significantly in both. Asymmetry of the LES was a significant negative factor in LES strength as shown by VV and LESrmp. Asymmetry alone, however, did not show a strong correlation with reflux. Asymmetry is indirectly correlated with the major determinants of LES strength; in patients with low VV, asymmetry might be a critical factor. When a high VV is present, asymmetry has no particular relevance. CAM provides invaluable measurements of the LES.

Twenty-four guinea pigs with third degree burns over 70% of the body surface area were divided equally into four groups. At 0.5 hours postburn, all groups received Ringer's lactate solution (R/L) according to the Parkland formula. The infusion rate was then reduced to 25% of the Parkland formula at 1.5 hours postburn. Group 1 received only R/L, and groups 2, 3 and 4 received adjuvant vitamin C (14.2 mg/kg/hr) until 4, 8, and 24 hours postburn, respectively. The volume of R/L was reduced by that of vitamin C solution so that the hourly sodium and fluid intake in each group was the same. Groups 1 and 2 demonstrated higher hematocrit and lower cardiac output values than did group 3, suggesting hypovolemia and hemoconcentration in these groups. Group 3 showed hematocrit and cardiac output values equivalent to those in group 4. We conclude that high dose vitamin C infusion maintains hemodynamic stability in the presence of a reduced resuscitation fluid volume provided vitamin C is administered for a minimum of 8 hours postburn.

Background: Effective surgical treatments for achalasia of the esophagus facilitate swallowing by division of muscles that fail to relax normally during swallowing. If esophagocardiomyotomy is performed, a complementary antireflux procedure is mandatory to prevent postoperative gastroesophageal reflux. We evaluated patients who had undergone a circumferential antireflux procedure after esophagocardiomyotomy to determine the effects of this procedure in patients with an aperistaltic esophagus., Methods: During the past 15 years we treated 94 patients with achalasia by use of pneumatic dilation (66), esophageal myotomy (19), or esophagocardiomyotomy with floppy Nissen fundoplication (24). Achalasia was defined by radiographic and manometric criteria until 1986 when computerized axial manometry of the esophagus was initiated, providing information about the three-dimensional contour and "volume" of the lower esophageal sphincter in addition to the usual manometric data., Results: Dysphagia was effectively relieved in all, and neither postoperative reflux nor esophageal obstruction was observed after esophagocardiomyotomy followed by floppy Nissen fundoplication. The measured lower esophageal sphincter pressures and sphincter volume were markedly reduced., Conclusions: Esophagocardiomyotomy with floppy Nissen fundoplication is an effective treatment for achalasia; clinical evidence of obstruction of the esophagus was not seen, and manometric data were typical of a weakened sphincter.

Operations for peptic ulcer have evolved to minimize physiologic disturbance while ulcer recurrence is prevented. Nevertheless, all operations disturb gastrointestinal motility to some extent, and these changes correlate with postoperative side effects. In particular, the pattern of gastric emptying is altered, but small bowel emptying is largely preserved. Alterations in biliary motility increase the risk of gallstone formation after most, but not all, ulcer operations.

There is a sound basis for performing EHSV with reference to the "areas of vagotomy" as described and for wider application of EHSV. Most patients with complications of duodenal ulcer disease can be treated successfully by EHSV, with a small incidence of recurrent ulcers. The liberal use of pyloroplasty or drainage procedures is justified, since the potential problems of perioperative infection and postoperative alkaline reflux are not clinically significant. Post-gastrectomy syndromes can be largely avoided if gastric resection is reserved only for the few patients with deep ulcers of the lesser curvature. Intraoperative testing for completeness of vagotomy is a useful adjunct in the performance of EHSV, especially by those who are learning the technique. If the principles of EHSV are followed, routine use of intraoperative testing is superflous.

The source and fate of sulfoconjugated catecholamines present in plasma are not known. Sulfated norepinephrine has been shown to overflow together with free norepinephrine from a typical peripheral neuroeffector junction. Some released free norepinephrine is removed via the lymphatic system, but it is not known whether sulfated catecholamines are removed similarly. Serotonin, another biogenic amine, is released from the enterochromaffin cells into portal blood. The aims of the present study were to determine whether conjugated catecholamines and serotonin could be detected in thoracic duct lymph of dogs and to compare concentrations in lymph with those in samples of portal blood collected before and after the dogs were fed. A method is described for the extraction and purification of free and conjugated catecholamines and serotonin from lymph. In lymph and in plasma, there were similar concentrations of free (0.2-0.4 ng/ml) and conjugated (0.1-0.2 ng/ml) norepinephrine and of conjugated dopamine (0.2-1.0 ng/ml). The concentrations of free serotonin were much lower in lymph (0.1-0.2 ng/ml) than in portal blood (100-200 ng/ml). Small amounts of conjugated serotonin (0.1-0.4 ng/ml) were detected in lymph but were not detected in plasma. Feeding caused increases in concentration of conjugated dopamine in lymph and in plasma and small increases in the output of free norepinephrine and free and conjugated serotonin in lymph.

An ideal operation for a benign disease, such as duodenal ulcer, must be effective, relatively free of serious postoperative complications and standardized for effective performance. Highly selective vagotomy, an operation known to have few side effects, has not been adopted by many surgeons because of the concerns about postoperative recurrent ulcers, as well as by concerns about the technical performance of the operation. Recurrent ulcers may be the result of incomplete denervation of the parietal cell mass; based upon the results of intraoperative testing, we suspected that previously unrecognized sites supplied preganglionic vagus nerves to the parietal cell mass. Nerve tracing studies identified four areas in the stomach that are not adequately denervated in the "standard" highly selective vagotomy. Based on these data, we defined and performed "extended highly selective vagotomy" upon 180 patients with ulcers. Herein, the results of follow-up examinations of 113 patients for a mean of at least 4.5 years postoperatively are reported. Recurrent duodenal ulcers occurred in 2.9 percent (two of 69) after extended vagotomy alone, and in none of 44 in whom a drainage procedure was used; the overall recurrence rate was 1.8 percent. Serious postoperative complaints were found in one patient in each group. The use of extended highly selective vagotomy for duodenal ulcer has a rational experimental basis and acceptable clinical results. Pyloroplasty, in conjunction with extended highly selective vagotomy, does not increase the incidence of serious postoperative side effects.

Distention of the gastric antrum with an alkaline fluid normally results in the secretion of gastrin. Following gastrocystoplasty in humans, however, hypergastrinemia has not been observed. We explored the possibility that a component of urine may suppress antral gastrin activity in the dog. Partial cystectomy and antral transposition to the bladder (ATB) was performed in five animals and antral transposition to the colon (ATC) was performed in five other dogs to serve as a hypergastrinemic controls. At four and eight weeks after surgery the mean serum gastrin levels in the ATC dogs were significantly greater than the mean preoperative levels (p less than 0.05). In contrast, at four and eight weeks after surgery the mean serum gastrin levels in the ATB animals were significantly less than the mean preoperative levels (p less than 0.05). The antral G-cell density as determined by immunohistochemical study at eight weeks after surgery was greater than normal in the ATC dogs but less than normal in the ATB dogs; but the differences did not achieve statistical significance. In another series of experiments using four other dogs a 4% aqueous peptone solution and a 4% peptone solution in concentrated dog urine were instilled into exteriorized antral pouches. The mean serum gastrin levels at 60 and 90 minutes after instillation of the former were significantly increased (p less than 0.05), but there was little or no change after instillation of the latter. Urine, or a component of urine, appears to suppress canine antral gastrin secretion and may explain the absence of hypergastrinemia following gastrocystoplasty in humans.

The endoscopic Congo red test allows accurate and rapid evaluation of the completeness of vagotomy and may result in a lower incidence of postoperative incomplete vagotomy. This report describes 44 patients tested during proximal gastric vagotomy. Evidence of incomplete vagotomy was found in over 95% at the conclusion of the conventional operation. Importantly, the test was a guide to further operative maneuvers which abolished the evidence of incomplete vagotomy upon subsequent testing. The endoscopic Congo red test satisfies the requirements for an ideal test for complete vagotomy: it is easily performed, does not require special equipment, and can be repeated several times if necessary to verify that desired effects have been achieved. The wider use of this test, therefore, appears justified.

The role of insulin in control of bile secretion is uncertain. To study the mechanism of choleresis produced by large doses of insulin, bile was collected through modified Thomas cannulas from dogs anesthetized with pentobarbital. Animals received pipenzolate methylbromide, sodium taurocholate, and [14C]erythritol. After bile flow had stabilized three animals received infusions of insulin at 2, 4, 13, 26, 35, and 70 mU . kg-1 . min-1 for 40 min each. Bile and [14C]erythritol clearance increased (P less than 0.005), but bile salt output remained constant, suggesting that the choleresis was mainly due to enhanced bile salt-independent canalicular flow. Plasma insulin and glucagon levels also rose when insulin was infused. To exclude the possible effects of glucagon three additional animals received somatostatin (800 ng . kg-1 . min-1) along with infusions of insulin. Bile flow and [14C]erythritol clearance again increased significantly, but glucagon levels remained low, suggesting that the effects on bile flow were due to insulin alone. To determine whether physiological doses of insulin altered bile flow dogs were anesthetized with pentobarbital and received pipenzolate methylbromide, taurocholate, [14C]erythritol, and somatostatin (800 ng . kg-1 . min-1). Insulin (0.2 and 0.8 mU . kg-1 . min-1) was infused through the portal vein for 1 h each. Bile flow and [14C]erythritol clearance increased with insulin (0.8 mU . kg-1 . min-1; P less than 0.02), suggesting that the choleresis may have been due to bile salt-independent canalicular flow. Plasma insulin rose to physiological postprandial levels. These studies demonstrate that pharmacological and physiological levels of insulin administered to dogs produce a significant choleresis. Thus insulin may play an important role in the regulation of bile secretion.

The aim of this study was to determine whether transection and pacing alter the frequency of the human jejunal pacesetter potentials (PPs). In 8 patients undergoing Roux gastrectomy, three temporary bipolar electrodes were implanted on the jejunal seromuscularis at sites 5 cm proximal to and 10 and 20 cm distal to the jejunal transection. Three other patients not undergoing Roux transection (controls) had electrodes applied at similar sites. After recovery, the mean +/- SEM frequency of the jejunal PPs in Roux patients was slightly slower distal to the jejunal transection (11.0 +/- 0.2 cpm) than proximal to the transection (11.3 +/- 0.2 cpm, p less than 0.05), whereas the PP frequency in the two areas in control nontransected patients was identical (proximal, 12.0 +/- 0.3 cpm; distal, 12.0 +/- 0.3 cpm). In contrast to the change in frequency with transection, pacing with electric pulses (strength, 15 mA; duration, 50 ms; frequency, 0.2-1.0 cpm faster than native PP frequency) speeded the jejunal PP frequency in only 1 of 9 patients tested. We conclude that transection decreased the frequency of the human jejunal PPs, but only slightly. Pacing did not readily entrain the PPs in either intact or transected jejunum.

The aim of this study was to determine whether mucosal antrectomy, which preserves antropyloric motility, would enhance the antiulcer properties of proximal gastric vagotomy (PGV). Hydrochloric acid and gastrin secretion were studied in five dogs before and after PGV and mucosal antrectomy, while the response to the Mann-Williamson operation (an ulcer-producing operation) was evaluated in four control dogs with intact stomachs, five dogs with PGV alone, and six dogs with PGV plus mucosal antrectomy. Proximal gastric vagotomy and mucosal antrectomy decreased mean +/- SEM basal and pentagastrin-stimulated acid secretion from 4.3 +/- 1.3 to 0.4 +/- 0.3 mEq/hr and from 21 +/- 0.7 to 7.4 +/- 1.8 mEq/hr, respectively (p less than 0.05). Basal plasma gastrin was altered little by the operation (68 +/- 9.7 pg/ml before, 58 +/- 11 pg/ml after; p greater than 0.05) but the 4-hour integrated plasma gastrin response to a 200 gm meat meal decreased from 13 +/- 1.8 to 3.3 +/- 0.7 ng X min/ml (p less than 0.05). Only one of six dogs with mucosal antrectomy and PGV developed peptic ulcer after the Mann-Williamson operation, whereas four of five with PGV alone and three of four controls developed ulcers (p less than 0.05, PGV alone versus PGV and mucosal antrectomy). In conclusion, PGV and mucosal antrectomy decreased acid secretion and postcibal gastrin response and provided greater protection against peptic ulcer than PGV alone.

The optimal treatment for obstructing duodenal ulcer is controversial because of questions about the efficacy of proximal gastric vagotomy (PGV) in controlling the primary ulcer diathesis. Impressed with the theoretic advantages of PGV with drainage as a primary treatment for this problem, we have treated 37 suitable patients by this approach. All patients underwent endoscopic examination and barium meal study that proved the diagnosis. PGV, including division of the gastroepiploic nerves as indicated by intraoperative testing, was followed by Jaboulay gastroduodenostomy (18), Finney pyloroplasty (12), Heineke-Mikulicz pyloroplasty (3), anterior hemipylorectomy (2), duodenoplasty (1), and gastroenterostomy (1). No recurrent ulcers were seen during a mean follow-up of 4.6 years. Three patients had mild early dumping at infrequent intervals. Bilious vomiting, alkaline gastritis, and other postgastrectomy complaints were recorded infrequently. PGV with drainage is a good treatment for the obstructing ulcer and does not have as many morbid risks as alternative operative procedures.

Additional data are presented in support of the earlier observation that in nonendemic countries 2-mercaptoethanol (2-ME) resistant vibriocidal antibodies better reflect antibacterial immunity against cholera following vaccination than does total vibriocidal activity. It can be shown that in more than half of the cases even after at least three subsequent vaccinations in six to eight months intervals 2-ME resistant vibriocidins would not last as long as six months. Following intradermal inocculations of vaccine only one in a group of five demonstrated faint 2-ME resistant antibody response. All sera were tested with and without dialysis following 2-ME treatment revealing corresponding results.