Sedimentation of biliary sludge: effect on composition of gallbladder bile from patients with cholesterol, mixed, or pigment stones

BACKGROUND

Ultracentrifugation of bile has been used extensively to remove insoluble material such as sludge from bile before further studies of cholesterol nucleation. Although it has been recognized that this procedure may affect the composition of gallbladder bile, it has not been studied systematically in different gallstone populations. Therefore, we investigated the concentration of biliary lipids, protein, mucin, and bilirubin before and after ultracentrifugation.

METHODS

Gallbladder bile samples were aspirated during laparoscopic surgery from 66 patients (35 with cholesterol, 16 with mixed, and 15 with pigment stones).

RESULTS

Whereas the concentrations of bile acids, phospholipids, protein, and bilirubin in gallbladder bile did not change significantly after ultracentrifugation, cholesterol (20.6 +/- 1.6 to 14.8 +/- 1.2 mmol/l) and mucin concentrations (0.99 +/- 0.2 to 0.67 +/- 0.1 mg/ml) and the cholesterol saturation index (1.68 +/- 0.12 to 1.31 +/- 0.10) decreased significantly in gallbladder bile from patients with cholesterol stones.

CONCLUSIONS

Sedimentation of biliary sludge may profoundly affect the composition of gallbladder bile, which has to be considered in studies of cholesterol saturation and nucleation. The cholesterol concentration difference between native and ultracentrifuged bile reflects the insoluble crystalline fraction of cholesterol and may be useful for quantitation of the mass of cholesterol crystals in gallstone-associated bile samples.

Correlation between biliary alpha 1-acid glycoprotein concentration and cholesterol crystal nucleation time in gallstone disease

A biliary form of the alpha 1-acid glycoprotein (AAG) promotes cholesterol crystallization in the lower-molecular-weight, concanavalin A-bound fraction of gallbladder bile. In addition, bile AAG concentration is higher in cholesterol gallstone patients with multiple stones than in control patients without gallstone disease. In this study we sought to determine whether the increased biliary concentration of AAG in cholesterol gallstone patients is accompanied by a more rapid nucleation time in patients with multiple stones. AAG concentration in native biles was measured by ELISA. Nucleation time was measured using a standard microscopy method. The concentration of biliary AAG was then related to nucleation time in biles from the same patients. Nucleation times were significantly shorter (< or = 5 days) in cholesterol gallstone patients with raised AAG concentrations (P < 0.03). There was a significant (P = 0.004) negative correlation (r = -0.53) between nucleation time and the AAG concentration in cholesterol gallstone patients with multiple stones. The concentration of biliary AAG appears to exert an important influence on the speed of cholesterol nucleation in bile in many patients with cholesterol gallstone disease.

Transesophageal echocardiographic determinants of embolism in nonrheumatic atrial fibrillation

The purpose of the study was to determine the relation of transesophageal echocardiographic findings to symptoms of systemic embolism in patients with nonrheumatic atrial fibrillation. Transthoracic and transesophageal echocardiography were used to study 107 patients with atrial fibrillation including 49 patients without embolic complications and 58 patients who had suffered from previous cerebral or peripheral embolism. A multiple logistic regression analysis revealed that left atrial thrombi (odds ratio 9.0, 95% CI 2.4-33.6, p < 0.005) and the presence of dense left atrial spontaneous contrast (odds ratio 8.4, 95% CI 1.3-53.1, p < 0.05) were independently related to embolic symptoms. Intensive left atrial spontaneous contrast was associated with an increased left atrial diameter (odds ratio 2.0, 95% CI 1.1-3.6, p < 0.05), the presence of chronic atrial fibrillation (odds ratio 6.9, 95% CI 1.6-29.8, p < 0.01) and aortic atherosclerosis (odds ratio 2.6, 95% CI 1.2-5.5, p < 0.05). It was further negatively correlated to mitral regurgitation (odds ratio 0.4, 95% CI 0.2-0.9, p < 0.05). In conclusion, dense spontaneous echo contrast and left atrial thrombi are associated to thromboembolic complications in patients with nonrheumatic atrial fibrillation. Classifying of spontaneous contrast seems to be useful when estimating the thromboembolic risk in atrial fibrillation.

Intraperitoneal versus interpleural morphine or bupivacaine for pain after laparoscopic cholecystectomy

BACKGROUND

Opioids can produce peripheral analgesic effects by activation of opioid receptors on sensory nerves. This study was designed (1) to examine a novel route of opioid administration, the intraperitoneal injection; (2) to compare this to interpleural application, and (3) to compare opioid with local anesthetic effects under both conditions.

METHODS

At the end of laparoscopic cholecystectomy, 110 patients received the following injections in a double-blind, randomized manner: Group 1 (n = 18) was given intraperitoneal morphine (1 mg in 20 ml saline) and 20 ml intravenous saline. Group 2 (n = 17) received intraperitoneal saline and 1 mg intravenous morphine. Group 3 (n = 15) received 20 ml 0.25% intraperitoneal bupivacaine and intravenous saline. Group 4 (n = 20) received interpleural morphine (1.5 mg in 30 ml saline) and 30 ml intravenous saline. Group 5 (n = 20) received interpleural saline and 1.5 mg intravenous morphine. Group 6 (n = 20) received 30 ml 0.25% interpleural bupivacaine and intravenous saline. Postoperative pain was assessed using a visual analog scale, a numeric rating scale, and the McGill pain questionnaire. Pain localization, supplemental analgesic consumption, vital signs, and side effects were recorded for 24 h.

RESULTS

Neither intraperitoneal nor interpleural morphine produced significant analgesia after laparoscopic cholecystectomy (P > 0.05, Kruskal-Wallis test), whereas interpleural bupivacaine was effective (P < 0.05, Kruskal-Wallis test, up to 6 h postoperatively) but not intraperitoneal bupivacaine (P > 0.05, Kruskal-Wallis test). Shoulder pain was not prevalent in the majority of patients during the first 6 h. By 24 h, about half of the patients complained of shoulder pain, which was rated "low" by about one-third of all patients. No significant side effects occurred.

CONCLUSIONS

Interpleural bupivacaine (0.25%) produces analgesia after laparoscopic cholecystectomy. We attribute the lack of effect of intraperitoneal injections to the small dose and to a rapid dilution within the peritoneal cavity. The fact that interpleural morphine (0.005%) is ineffective may be due to an intact perineurial barrier in the noninflamed pleural cavity, which restricts the transperineurial passage of morphine to opioid receptors on intercostal nerves.

Different techniques of laparoscopic end-to-end small-bowel anastomoses

The aim of the study was to prove that laparoscopic stapling devices can be used to create a bowel anastomosis. Three groups with n = 6 pigs each were subjected to different techniques of small-bowel anastomoses. In groups I and II anastomosing of the bowel ends was carried out with singly placed staples using a hernia stapler. (Group I: Two-thirds of the circumference became inverted and one-third everted. Group II circumferentially everted). In group III triangular everted anastomoses were produced using a linear noncutting stapler. All animals survived the observation period of 14 days and were postmortally examined. Average construction time was 59 min for groups I and III and 47 min for group II. Average diameters were 14 mm, 16 mm, and 18 mm for groups I, II, and III, respectively. There were no significant differences between the techniques concerning the stability of the anastomoses as expressed by bursting pressures. There were two stenoses in group I animals caused by electrocautery during preparation of the bowel ends prior to anastomosing. Anastomotic insufficiencies or fistulas were not observed clinically or with Gastrografin studies. We conclude that anastomoses in the pig can laparoscopically be constructed by employing singly placed staples as well as a linear stapler. Further investigations of these techniques on large bowel and human specimens are required prior to their clinical use in humans.

[Conventional or laparoscopic cholecystectomy in treatment of acute cholecystitis?]

Elective laparoscopic cholecystectomy has become established as the procedure of choice for the treatment of symptomatic cholecystolithiasis while the application of this method for acute cholecystitis has been propagated with restrainment. In a prospective study 114 conventional (right subcostal incision) and 102 laparoscopic cholecystectomies for this indication were compared. The overall complication rate amounted 10.7% for conventional cholecystectomy and 8.9% for laparoscopic cholecystectomy. The rate of conversion was 9.2%. Due to the fact that intraoperative cholangiography was carried out in 60% of conventional cholecystectomies and in only one of laparoscopic procedures the arithmetic advantage of minimally invasive technique with respect to blood loss and operating time does not allow final conclusions. These patients however recovered clearly faster and could be discharged after an average of 5.2 +/- 4.2 postoperative days, while the hospitalisation after conventional operations amounted to 7.6 +/- 3.8 days (p < 0.001).

Laparoscopic repair of a Morgagni hernia

Laparoscopic repair of a diaphragmatic hernia through the right sternocostal foramen of Morgagni in an obese 42-year-old man is described. The indications for surgery were symptoms of strain-induced dyspnea and tightness in the chest. The technique was carried out by incorporating a marlex mesh into the defect and fixing it in place with hernia staples. The patient had an immediate recovery after repair of the hernia and has remained free of recurrence or complaints 9 months after surgery.

Extracorporeal shock-wave lithotripsy prior to laparoscopic cholecystectomy. Does it make sense?

The extraction of large gallstones in laparoscopic cholecystectomy either requires the enlargement of one of the incisions or intraoperative lithotripsy. Preoperative extracorporeal shock-wave lithotripsy (ESWL) might theoretically solve the problem and facilitate the extraction of the gallbladder. Ten patients with at least one gallstone larger than 20 mm in diameter underwent ESWL treatment within 24 h prior to laparoscopic surgery. Complete pulverization of stones was achieved in one patient. Fragmentation into pieces smaller than 10 mm could be observed in another three cases. Additional mechanical fragmentation employing forceps was necessary in seven and an enlargement of the incision in five of the 10 patients. Compared to a matched group of 10 control patients with gallstones of corresponding size receiving mechanical lithotripsy, the ESWL did not show an advantage, but rather an increase in costs. It therefore cannot be recommended.

Ultrastructural studies of acute rejection following single lung transplantation in the rat--histological and immunohistological findings

Nowadays the acute and especially chronic lung rejection are the major problems after lung transplantation (L-Tx) with relevant influence on longterm survival. We performed lung transplantation in rats to study a possible role of ultrastructural lesions in the graft during the acute rejection process, concerning their reversibility/irreversibility and influence of the chronic rejection. Based on histologic and immunohistologic studies after L-Tx in MHC-different and strong reactive rat strain combination AVN-LEW and filial generation (AVN-LEW)F1-LEW (n = 57 and n = 32) electronmicroscopic studies (TEM, SEM) were performed in the combination AVN-LW (n = 20) on postoperative day 0, 1, 2 and 5, all without immunsuppressive therapy. Syngenic grafts (LEW-LEW; n = 12) served as controls. Histologically the allografts were classed according to the proven acute rejection phases latent, vascular, alveolar and destructive. The immunhistological and electronmicroscopic results correlated with these rejection phases. There was no difference between the rat strain combinations. All allografts developed acute rejection on postoperative day 2 and were destroyed on postoperative day 5/6. Initially T-helper-cells, later cytotoxic-T-cells and macrophages played the predominent role in the acute rejection process. In the ultrastructural specimens alterations of the blood vessels, pneumocytes type-II, and surfactant gave more information. Initially flattening of endothelial cells and circumscribed lesions of graft vessels occur, increasing in the allografts up to extensive vascular wall destructions, accompanied by total thrombotic occlusion. Disturbances of surfactant production observed in the grafts of all strain combinations are not homogenous.(ABSTRACT TRUNCATED AT 250 WORDS)

Fibronectin in human gallbladder bile: cholesterol pronucleating and/or mucin "link" protein?

Some biliary proteins (pronucleators) seem to be essential factors for cholesterol crystal formation and crystal growth in bile. A recent study suggests that fibronectin is such a pronucleator in bile. Fibronectin also seems to closely interact with intestinal mucin. Since biliary mucin plays an important role in gallstone formation, such an interaction in bile may be of relevance in cholesterol gallstone formation. To more clearly elucidate the role of fibronectin in cholesterol gallstone disease, we measured the concentration of fibronectin in native bile of cholesterol gallstone patients and checked its influence on the cholesterol nucleation time of model bile. We further looked for a molecular interaction between biliary fibronectin and gallbladder mucin. We found that fibronectin is present in gallbladder bile of gallstone patients in low concentrations (2.6 +/- 1.2 micrograms/ml). Bile fibronectin did not interact with gallbladder mucin. Moreover, in a wide range of concentrations fibronectin had no influence on the nucleation time of model bile. We conclude that fibronectin does not seem to play a major role in cholesterol gallstone disease.

[Safety and tolerance of a new dipeptide-containing amino acid solution DP-Gln 20 versus a conventional amino acid solution Vamin 18EF in patients after elective colon surgery]

OBJECTIVE AND METHODS

Recent studies have demonstrated the important role of glutamine in postoperative metabolism. Using dipeptide-containing amino acid solutions it is possible to enhance glutamine supply. Safety and tolerance of DP-Gln 20 (gly-gln, gly-tyr) and Vamin 18EF were investigated in an open, prospective, randomised study. 16 patients received isonitrogenous parenteral nutrition over 4 days.

RESULTS

There was no difference in clinical and biochemical patterns between both groups. Complications and adverse events due to the infused amino acid solutions were not observed.

[Laparoscopic single staple suture--initial clinical experiences]

Based on the results of our own animal experimental investigations, the first clinical employment of single titanium staples in the creation of suture lines on the gastrointestinal tract was carried out. These staple lines are most favorably adapted for laparoscopic use. First experiences with 10 staple lines, 6 of which were anastomoses, are reported. Neither insufficiencies nor stenoses were detected. Until now there are no long-term observations. The technique seems to allow open or laparoscopically the creation of standardized suture lines in any segment of the gastrointestinal tract.

Laparoscopic deroofing of post-transplant lymphoceles

Lymphocele is a most common surgical complication following renal transplantation. The indication for treatment is given when the lymphocele becomes symptomatic. We succeeded in laparoscopically deroofing large lymphoceles in nine patients that were causing ureter compression in eight and ipsilateral leg edema in six cases. The postoperative course was uneventful, and the surgery-related hospitalization did not exceed 7 days. Severe adhesions and a thick lymphocele wall, which made preparation difficult, resulted in the transection of the transplant ureter in one case. Techniques and prerequisites that would help to avoid this type of complication are discussed. According to CT scan or sonography, there was no recurrence in any of the patients after a mean follow-up of 11 months. This technique seems to be superior to other methods of treatment because not only is a cure obtained with a single intervention, but there is also a low risk of infection and a short hospitalization.

Collagen gel immobilisation provides a suitable cell matrix for long term human hepatocyte cultures in hybrid reactors

An easy to apply culture technique is presented that protects a monolayer configuration of liver cells within an extracellular matrix. The Immobilising Gel (IG)-Technique not only preserves hepatocyte morphology and supports a variety of differentiated cell functions over long term periods, but also offers higher resistance of IG-culture systems against shear forces of fluids in a hybrid reactor device, as compared to other culture techniques. Human hepatocyte cultures in IG-Technique: DNA-normalised levels for the total production of cholinesterase, albumin, urea and lactate remained high throughout the investigational period (50 days). Glutamic-Pyruvic-Transaminase (GPT) release decreased after peak values during early culture adaptation. Electron Microscopic (EM) findings after the shear forces experiment revealed undisturbed subcellular structures and a preserved intercellular morphology, including bile canaliculi and desmosomes. We conclude that the IG-technique is of considerable advantage as compared to other culture systems, especially in the field of dynamic applications, e.g. hybrid reactors for artificial organ development.

Laparoscopic stenting for protection of common bile duct sutures

Laparoscopic common bile duct exploration is comparable with the open operation and it is usually finished with the insertion of external bile drainage such as a T-tube. We performed an antegrade placement of a biliary stent with primary suture of the common bile duct following common bile duct exploration. We thereby avoided the acquisition of the additional expensive equipment required for the transcystic approach and the placement of a T-tube, which in our eyes contradicts the idea of minimized discomfort in minimally invasive surgery.

[Laparoscopic cholecystectomy of large gallbladder calculi]

Laparoscopic cholecystectomy is more laborious in patients with large gallbladder stones in that they can only be removed safely after an enlargement of one incision or intraoperative lithotripsy. Preoperative extracorporeal shock-wave lithotripsy (ESWL) might theoretically solve this problem and facilitate the extraction of the gallbladder. Ten patients with minimum one stone > 20 mm of diameter received ESWL treatment within 24 h before operation. Complete pulverization of stones was achieved in only one patient. Additional mechanical fragmentation by forceps was necessary in 7 and an enlargement of the incision in 5 of 10 patients. Compared to 10 patients with corresponding stones and mechanical lithotripsy ESWL showed no advantage and cannot be recommended because of increase of costs.

Indomethacin decreases viscosity of gallbladder bile in patients with cholesterol gallstone disease

There is experimental evidence that inhibition of cyclooxygenase with nonsteroidal anti-inflammatory drugs may decrease cholesterol gallstone formation and mitigate biliary pain in gallstone patients. The mechanisms by which NSAIDs exert these effect are unclear. In a prospective, controlled clinical trial we examined the effects of oral indomethacin on the composition of human gallbladder bile. The study included 28 patients with symptomatic cholesterol or mixed gallstones. Of these, 8 were treated with 3 x 25 mg indomethacin daily for 7 days prior to elective cholecystectomy while 20 received no treatment and served as controls. Bile and tissue samples from the gallbladder were obtained during cholecystectomy. Indomethacin tissue levels in the gallbladder mucosa, as assessed by HPLC, were 1.05 +/- 0.4 ng/mg wet weight, a concentration known to inhibit effectively cyclooxygenase activity. Nevertheless, no differences between the treated and untreated groups were found in the concentrations of biliary mucus glycoprotein (0.94 +/- 0.27 versus 0.93 +/- 0.32 mg/ml) or total protein (5.8 +/- 0.9 versus 6.4 +/- 1.3 mg/ml), cholesterol saturation (1.3 +/- 0.2 versus 1.5 +/- 0.2), or nucleation time (2.0 +/- 3.0 versus 1.5 +/- 2.0 days). However, biliary viscosity, measured using a low-shear rotation viscosimeter, was significantly lower in patients receiving indomethacin treatment (2.9 +/- 0.6 versus 5.6 +/- 1.2 mPa.s; P < 0.02). In conclusion, in man oral indomethacin decreases bile viscosity without alteration of bile lithogenicity or biliary mucus glycoprotein content.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of phospholipids and bile acids on cholesterol nucleation time and vesicular/micellar cholesterol in gallbladder bile of patients with cholesterol stones

Supersaturation and rapid nucleation of cholesterol in bile are of key importance in the pathogenesis of cholesterol gallstones. While the effects of bile acids and phospholipids on cholesterol saturation of bile have been extensively studied, their influence on the cholesterol nucleation time has not been compared. We, therefore, investigated whether increases of bile acid or phospholipid concentrations in bile by in vitro supplementation affect the cholesterol nucleation time. Bile samples were obtained at surgery from patients with cholesterol gallstones. Prior to the nucleation assay the bile samples were divided into 0.5-ml aliquots and supplemented with 1.25, 2.5, 5.0, and 10.0 mumol/ml of different phosphatidylcholines (PC-dimyristoyl, PC-dipalmitoyl, PC-distearoyl, and extracted biliary PCs) or with 5.0, 10.0, and 20.0 mumol/ml of bile acids (glycine or taurine conjugates of cholic acid, deoxycholic acid, or chenodeoxycholic acid). The increase of phosphatidylcholine or bile acid concentration decreased the mean cholesterol saturation index to a similar extent (PC: 0.1-0.3; BA: 0.1-0.2). Supplementations of bile with increasing amounts of synthetic or biliary PCs caused a marked prolongation of the nucleation time in bile from 1.5 +/- 0.2 up to > or = 21 days or 2.5 +/- 0.7 up to > or = 21 days. Concurrently, biliary cholesterol was shifted from vesicles to mixed micelles and the cholesterol/phospholipid ratio of the remaining vesicles was progressively lowered. In contrast, the addition of bile acids to gallbladder bile did not affect the cholesterol nucleation time (2.2 +/- 0.3 days), the percentage of vesicular cholesterol, or the cholesterol/phospholipid ratio of vesicles and micelles.(ABSTRACT TRUNCATED AT 250 WORDS)

[Various techniques for laparoscopic small intestinal anastomosis. A preliminary report]

Three groups with n = 6 pigs were subjected to different techniques of endoscopic small bowel anastomosis. In Group I connection of the gut endings was done, using an all layer stapler-device, otherwise employed as hernia-stapler. Two thirds of the circumference became inverted, one third was everted. Anastomosis of Group II was done with the same stapler device, but all clips were set to evert the wound-endings. Group III consisted of triangularly shaped anastomosis, for which a linear stapler device was being used. All animals survived the investigation period (14 days) and were postmortally examined. Technical aspects and clinical results are being discussed.

[Current status of gallstone surgery in Germany. Results of a survey and retrospective analysis of 27,403 interventions--open vs. laparoscopic surgery]

Based on a representative poll, which included a retrospective data analysis, the current surgical approach to gallstone disease in Germany is presented. A total of 25,955 procedures in 1991 is analysed. 24.9% of all cholecystectomies were done laparoscopically. In 1992, already 81.4% of all surgeons reported own experiences with this new technique. Comparing open procedures with laparoscopic cholecystectomy the latter showed a lower incidence of complications (6.8 vs 8.7%) and perioperative death (0.14 vs. 0.43%). In contrast, relaparotomies were more frequent in the laparoscopy group (1.48 vs. 0.84%). The diagnostic and therapeutic approach for common bile duct stones is currently changing. There is a tendency towards less invasive endoscopic and laparoscopic procedures and towards their combination, respectively.

Headache--defined

Headache is one of man's most common afflictions. Increasing interest from the general population has contributed to the recent surge in research. This research relates to etiology or pathophysiology, treatment and impact of society. Headache can be a minor symptom or a symptom of serious underlying disease. As nurses, either in a health care facility or in our communities, we have a responsibility to keep abreast of current theories and treatments. Both presenters are currently involved in clinical trials of new headache medications for both children and adults. Behavioural Objectives: 1. Understand when a headache is a serious symptom and warrants further investigation. 2. Identify the different types of headache. 3. Describe the etiology of headache and its physical and psychological manifestations in child and adults with a particular emphasis on migraine. 4. Gain appreciation for the role of the clinical trials nurse.