Optimal surgical technique, use of intra-operative cholangiography (IOC), and management of acute gallbladder disease: the results of a nation-wide survey in the UK and Ireland

INTRODUCTION

There is debate on optimal techniques that reduce bile duct injury during laparoscopic cholecystectomy (LC). A national survey of Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS) members was carried out to determine current surgical practice for gallstones, including the use of intra-operative cholangiography (IOC) or critical view of safety to reduce the risk of bile duct injury.

SUBJECTS AND METHODS

An anonymous postal survey was sent to all 417 AUGIS members. Data on grade of surgeon, place of work (district general hospital, teaching), subspecialty, number LC per year, use of IOC, critical view of safety, and management of stones detected during surgery were collated.

RESULTS

There was a 36% (152/417) response – 134 (88%) from consultant surgeons (36, HPB; 106,OG; 64, DGH; 88, teaching hospital). Of these, 38% performed > 100 LC per year, 36% 50–100 LC per year, and 22% 25–50 LC per year. IOC was routine for 24%; and selective for 72%. Critical view of Calot''s triangle was advocated by 82%. Overall, 55% first clip and divide the cystic artery, whereas 41% first clip and divide the cystic duct. Some 39% recommend IOC and 23% pre-oper-ative MRCP if dilated common bile duct (CBD) is noted on pre-operative ultrasound. When bile duct stones are identified on IOC, 61% perform laparoscopic CBD exploration (LCBDE), 25% advise postoperative ERCP, and 13% perform either LCBDE or ERCP. Overall, 88% (n = 134) recommend index cholecystectomy for acute pathology, and this is more likely in a teaching hospital setting (P= 0.003). Laparoscopic CBD exploration was more likely to be performed in university hospitals (P< 0.05).

CONCLUSIONS

A wide dissection of Calot''s triangle to provide a critical view of safety is the technique most commonly recommended by AUGIS surgeons (83%) to minimise risk of bile duct injury, in contrast to 24% that recommend routine IOC. The majority (88%) of AUGIS surgeons advise index admission cholecystectomy for acute gallbladder disease.     

Characterization of a novel HTLV-infected cell line

A man from Chile developed an aggressive mature T cell leukemia associated with marked eosinophilia. The neoplastic lymphocytes were of T helper surface phenotype, and they expressed the p24 and p19 antigens of human T cell leukemia virus (HTLV). A cell line (ME) was established from the patient's peripheral blood cells that was initially composed of eosinophils and T and B lymphocytes. The B lymphocytes of the cell line are polyclonal and contain Epstein-Barr virus (EBV) DNA. Many of the T lymphocytes, a few of the B lymphocytes, and none of the eosinophils express HTLV p19 and p24 antigens. By 6 months of culture, the ME line no longer contained eosinophils. A variant line of ME was established; this variant (ME-2) is notable because the cells (greater than 80%) adhere tightly to the bottom of the culture flask; they do not express T lymphocyte markers, but 30% of the cells contain cytoplasmic mu heavy immunoglobulin chains. These pre-B and null lymphocytes contain p19 and p24 antigens (80% of cells), have the HTLV- I genome, and are able to transform normal T lymphocytes in vitro. We isolated a B lymphocyte clone (11A) from ME that expresses cytoplasmic immunoglobulin (70% of cells) and p19 and p24 antigens (75% of cells), contains the EBV and HTLV genomes, and can transform T lymphocytes from normal volunteers. These data show that B lymphocytes can be infected with HTLV, although no disease of HTLV-infected B lymphocytes has been reported. The T lymphocytes from normal adult peripheral blood were easily immortalized (about 70% efficiency) by cocultivation with lethally irradiated ME cells. Twenty-five of 27 of the transformant lines were composed of T lymphocytes with helper antigens, and two of the lines were of T suppressor antigen phenotype. All the cell lines that were tested constitutively produce lymphokines, including colony- stimulating factor (CSF), erythroid-potentiating activity (EPA), macrophage migration-inhibitory factory (MIF), neutrophil-inhibitory factor (NIF), and differentiation-inducing factor (DIF).     

Comparison of milk and maize based diets in kwashiorkor

The dual sugar test of intestinal permeability is a reliable non-invasive way of assessing the response of the small intestinal mucosa to nutritional rehabilitation. AIM: To compare a local mix of maize-soya-egg to the standard milk diet in the treatment of kwashiorkor. DESIGN: The diets were alternated three monthly in the sequence milk-maize-milk. There were a total of 533 kwashiorkor admissions of at least five days during the study who received either milk or maize. Intestinal permeability was assessed at weekly intervals by the lactulose-rhamnose test in 100 kwashiorkor cases, including 55 on milk and 45 on the maize diet. RESULTS: Permeability ratios (95% confidence interval) on the milk diet improved by a mean of 6.4 (1.7 to 11.1) compared with -6.8 (-16.8 to 5.0) in the maize group. The improved permeability on milk occurred despite more diarrhoea, which constituted 34.8% of hospital days (29.8 to 39.8) compared with 24.3% (17.8 to 30.8) in the maize group. Case fatality rates for all 533 kwashiorkor admissions were 13.6% v 20.9%, respectively, giving a relative risk of death in the maize group of 1.54 (1.04 to 2.28). The maize group also had more clinical sepsis (60% v 31%) and less weight gain (2.9 v 4.4 g/kg/day) than the milk group. IMPLICATIONS: Milk is superior to a local maize based diet in the treatment of kwashiorkor in terms of mortality, weight gain, clinical sepsis, and improvement in intestinal permeability.     

A new model to predict final height in constitutionally tall children

In order to develop new height prediction models for children with constitutionally tall stature, 55 such boys and 88 girls were recalled for measurement of adult final height (FH). Data on height (H), age (CA), and target height (TH) were collected from the hospital charts and radiographs of the left hand and wrist were retrieved and used for bone age (BA) determination [BA according to the methods of Greulich and Pyle (BA_GP) and Tanner and Whitehouse (BA_RUs)]- Standard multiple regression techniques were used to develop prediction equations for FH. In addition, to test the validity of the new equations, FH was measured in a second group of constitutionally tall children (n = 32) and compared with the predicted FH according to our models. In addition, a comparison was made with other prediction methods. Mean (SD) FH was 196.0 (4.9) cm in boys and 180.5 (3.8) cm in girls. The ultimate regression equation was FH (cm) = 216.07 + 0.75 × H + 0.25 × TH - 11.09 × CA - 14.02 × BA_OP+ 0.74 × (CA × BA_GP) for boys and FH = 161.42 + 0.73 × H + 0.15 × TH - 8.41 × CA - 8.83 × BA_RUS - 2.45 × M + 0.55 × (CA × BA_RUS) for girls. The models showed satisfying accuracy: the mean (SD) errors were −1.4 (3.2) cm for boys and −0.5 (3.1) cm for girls with corresponding mean (SD) absolute errors of 2.7 (2.2) cm and 2.0 (2.4) cm, respectively. Compared with the current prediction methods, the new models were quite promising. Their clinical validity has to be ascertained in larger groups of tall children.     

Inclusion body beta-thalassemia trait in a Swiss family is caused by an abnormal hemoglobin (Geneva) with an altered and extended beta chain carboxy-terminus due to a modification in codon beta 114

We have analyzed the sequence of the beta globin gene of a chromosome that is linked to the occurrence of an inclusion body beta-thalassemia characterized in the heterozygote by moderate anemia, severe red cell abnormalities, splenomegaly, inclusion body formation, elevated Hb A2 levels, and an increased in vitro alpha/beta chain synthetic ratio. The data indicate a change in codon 114 from CTG (Leu) to -GG that resulted in a frameshift and the presumed synthesis of an abnormal beta chain that is 156 residues long with a completely different C-terminal amino acid sequence. The change in codon 114 gives a -GGGCCC- sequence that creates a new ApaI site; the resulting 2.6-kilobase fragment has been observed in all subjects with this thalassemia condition. Protein structural analyses failed to demonstrate any trace of the abnormal beta chain, even in reticulocytes and nucleated red cells that were isolated by density gradient centrifugation. The inclusion bodies appear to contain mainly normal alpha chains. It is assumed that the structure of the beta-Geneva chain prevents it from combining with normal alpha chains; this results in a rapid breakdown of the abnormal protein during the early stages of red cell maturation and an accumulation of free alpha chains.     

CEFUROXIME AXETIL IN THE TREATMENT OF BRONCHITIS: COMPARISON WITH AMOXYCILLIN IN A MULTICENTRE STUDY IN GENERAL PRACTICE PATIENTS

SUMMARY Cefuroxime axetil 250 mg twice daily and amoxycillin 250 mg three times daily were compared in an investigator-blind, randomised, parallel group, multicentre study of acute or acute-on-chronic bronchitis. The two compounds had broadly similar efficacy. Analysis of patients on an intention-to-treat basis 24-72 hours after completion of the course of study medication showed that amoxycillin afforded clinical cure or improvement in 123/153 (80.4%) of patients and cefuroxime axetil in 109/143 (76.2%). This result was not significantly different, but the amoxycillin cure rate was not sustained and there were significantly more clinical relapses during the 4-week follow-up period following the end of treatment. Only 4/68 (5.9%) of patients receiving cefuroxime axetil relapsed and required further treatment, whereas 16/77 (20.8%) of those receiving amoxycillin needed further treatment (P=0.016). These were all patients who had initially responded to treatment and had been adjudged clinically cured or improved. The significant difference in relapse rates suggests that the apparent clinical success with amoxycillin was not sustained. There were no differences between the two treatments in the numbers of patients experiencing adverse events, which were generally mild and transient.     

Reintoxication: the release of fat-stored Δ9-tetrahydrocannabinol (THC) into blood is enhanced by food deprivation or ACTH exposure

Background and purpose:

Δ⁹-tetrahydrocannabinol (THC), the main psychoactive constituent of cannabis, accumulates in adipose tissue where it is stored for long periods of time. Here we investigated whether conditions that promote lipolysis can liberate THC from adipocytes to yield increased blood levels of THC.

Experimental approach:

In vitro studies involved freshly isolated rat adipocytes that were incubated with THC before exposure to the lipolytic agent adrenocorticotrophic hormone (ACTH). A complementary in vivo approach examined the effects of both food deprivation and ACTH on blood levels of THC in rats that had been repeatedly injected with THC (10 mg·kg⁻¹) for 10 consecutive days. Lipolysis promoted by ACTH or food deprivation was indexed by measurement of glycerol levels.

Key results:

ACTH increased THC levels in the medium of THC-pretreated adipocytes in vitro. ACTH also enhanced THC release from adipocytes in vitro when taken from rats repeatedly pretreated with THC in vivo. Finally, in vivo ACTH exposure and 24 h food deprivation both enhanced the levels of THC and its metabolite, (-)-11-nor-9-carboxy-Δ⁹-tetrahydrocannabinol (THC-COOH) in the blood of rats that had been pre-exposed to repeated THC injections.

Conclusions and implications:

The present study shows that lipolysis enhances the release of THC from fat stores back into blood. This suggests the likelihood of ‘reintoxication’ whereby food deprivation or stress may raise blood THC levels in animals chronically exposed to the drug. Further research will need to confirm whether this can lead to functional effects, such as impaired cognitive function or ‘flashbacks’.