Intraoperative cholangiography revisited.

The charts of 1351 patients undergoing cholecystectomy at our institutions from 1985 through 1989 were reviewed retrospectively to evaluate the indications for and the success of intraoperative cholangiography. A total of 800 patients underwent intraoperative cholangiography. They were divided into two groups based on the absence (CR-) or presence (CR+) of clinical and/or operative criteria suggestive of the existence of common bile duct stones. Intraoperative cholangiography in CR- patients was of limited benefit, being negative (normal) in 95.7%, true-positive (abnormal) in 3.3%, and false-positive in 1%. False-positive intraoperative cholangiography resulted in unnecessary common bile duct explorations. Intraoperative cholangiography in CR+ patients proved useful, avoiding unnecessary common bile duct exploration in 55%. In those select CR+ patients with palpable common bile duct stones or cholangitis, little additional information was gained by the intraoperative cholangiography. We conclude that routine screening intraoperative cholangiography in CR- patients be reconsidered, as should the use of intraoperative cholangiography in CR+ patients with a palpable common bile duct stone or cholangitis. Intraoperative cholangiography in the remainder of CR+ patients proved beneficial and should be continued.     

Laparoscopic cryosurgery for hepatic tumors

Background: Hepatic cryosurgery has been shown to be a safe technique that may be well suited to a laparoscopic approach. Methods: The technical feasibility and safety of laparoscopic cryosurgery was explored first in a pig model. Thereafter we performed the first successful case of laparoscopic hepatic cryosurgery at our institution. Results: In the animal model, we found that it is possible to safely identify, target, and cryoablate specific lesions in the liver. Temperature in the peritoneal cavity remained above 35°C, and pathologic examination of the abdominal wall around the cryoprobe site revealed no damage. We also successfully treated a 62-year-old man with a metastatic colorectal carcinoma deep in the right lobe of the liver with laparoscopic cryosurgery using a transpleural approach. Conclusion: We conclude that laparoscopic cryosurgery is feasible for lesions anywhere in the liver. For lesions high on the dome of the liver, a transpleural approach may provide better access.     

FM sonography in diffuse liver disease: prospective assessment and blinded analysis

FM sonography - a signal-processing technique that uses frequency and phase information as well as amplitude data - shows promise in evaluation of patients with diffuse liver disease. In a prospective blinded review of 37 patients with biopsy-proved liver disease and 42 healthy volunteers, FM sonography was clearly superior to traditional amplitude-based (AM) sonography in distinguishing healthy from diseased subjects. Statistically significant differences were seen in accuracy (FM, 98.7%; AM, 84.8%), sensitivity (FM, 97.3%; AM, 70.3%), and negative predictive value (FM, 97.7%; AM, 78.8%). Our data also suggest that current FM sonographic techniques cannot differentiate among histologic findings associated with different hepatic parenchymal abnormalities. It is unclear, therefore, whether FM imaging can reduce the numbers of patients who require biopsy for diagnosis or the frequency of biopsy procedures in patients with known disease.     

Frequency of adverse reactions to influenza vaccine in the elderly. A randomized, placebo-controlled trial

Concern about side effects constitutes a major deterrent to patient compliance with influenza vaccination, yet there is a paucity of data about the occurrence of adverse reactions in the population targeted for immunization. We conducted a randomized, double-blind, crossover trial to compare the frequency of adverse reactions following administration of 1988-1989 trivalent split-antigen influenza vaccine and saline placebo. Outpatient veterans 65 years of age or over (n = 336) were recruited by mail and were randomly assigned to receive vaccine followed 2 weeks later by placebo injection or placebo followed 2 weeks later by vaccine. There was no significant difference between influenza vaccine and placebo with respect ot the proportion of subjects reporting disability or systemic symptoms.     

Test-retest reliability of the pain drawing instrument

Test-retest reliability of a pain drawing instrument was investigated. Pain drawings of chronic pain patients (n = 51) were scored for percentage of total body surface in pain and location of pain. A test-retest reliability coefficient of r = 0.85 was calculated for a time interval that averaged 71 days. In addition, a percentage of agreement based on distribution of pain over time was calculated at 88.2%. The effect on reliability of age, gender and time-interval differences was investigated. The utility of the pain drawing instrument as a measure of extent of pain and location of pain over time is discussed.