How safe is internal iliac artery embolisation prior to EVAR? A 10-year retrospective review

PURPOSE

Internal iliac artery (IIA) embolisation is commonly performed prior to endovascular aneurysm repair (EVAR) of aortoiliac aneurysms to prevent type 2 endoleaks via the internal iliac arteries. The safety of this procedure is controversial due to the high incidence of pelvic ischaemic complications.

METHODS

We undertook a retrospective review of all patients undergoing IIA embolisation before EVAR from 2002 to 2012, to determine incidence of, and factors associated with pelvic ischaemia.

RESULTS

Eight of 25 patients (32 %) experienced new-onset ischaemia, including erectile dysfunction (4 %), and buttock claudication (28 %) that persisted >6 months in only four patients (16 %). Both bilateral IIA embolisation and a shorter time interval to EVAR correlate with increased risk (p = 0.006 and p = 0.044). No co-morbidities or demographic factors were predictive.

CONCLUSIONS

We conclude that IIA embolisation remains a beneficial procedure, however, to minimise the risk of buttock claudication we advise against both bilateral IIA embolisation and short time intervals between embolisation and subsequent EVAR.

Concurrent colorectal malignancy and abdominal aortic aneurysm: a multicentre experience and review of the literature

OBJECTIVES

There is lack of consensus regarding concurrent vs. staged approaches, and the prioritisation of staged procedures in cases presenting with colorectal carcinoma (CRC) and abdominal aortic aneurysm (AAA) synchronously. We aim to present our experience, review the literature on this therapeutic dilemma and examine the role of endovascular aortic repair (EVAR).

DESIGN, MATERIALS AND METHODS

An observational study of the experience of two centres and a systematic review of the published literature.

RESULTS

Twenty-four patients were identified from the prospective databases of two tertiary referral centres between 2001 and 2006. Intervention for both malignancy and aneurysm was performed in 13 patients. In 10 patients, cancer resection was performed initially and was followed by open aneurysm repair (n=3) or EVAR (n=7). Two patients (AAA diameters: 7.0 and 8.0cm) underwent EVAR prior to colonic resection. One patient was selected for synchronous surgery. There were no interval AAA ruptures, graft infection or postoperative mortalities. Literature review identified 269 such cases; of these 101 were treated by combined surgery. In staged surgery, there were nine interval aneurysmal ruptures and one aortic graft infection.

CONCLUSIONS

In our experience, staged management can be undertaken, without interval aneurysmal rupture. EVAR has an evolving role in preventing delay in CRC management, in high-risk patients, and during combined intervention.

Perforation of a retrocaecal appendix presenting clinically as a right lumbar abscess

Presentations of acute appendicitis represent an ongoing challenge to surgeons. This case of retrocaecal perforated appendicitis presented clinically as a right lumbar abscess, with the concomitant new diagnosis of type 2 diabetes mellitus in a 66-year-old male. This case emphasises the importance of an abdominal CT scan in any patient presenting with unusual sepsis near the abdomen.

Traumatic inferior gluteal artery pseudoaneurysm and arteriovenous fistula managed with emergency transcatheter embolization

We present a case of blunt trauma to the buttock resulting in an inferior gluteal artery pseudoaneurysm and arteriovenous fistula. The characteristic diagnostic features on CT angiography and digital subtraction angiography (DSA), along with the emergency percutaneous management of this traumatic vascular injury, are described. A review of the literature demonstrates inferior gluteal artery pseudoaneurysm is a rare condition, while successful treatment with glue embolization is previously unreported.

Synchronous appendiceal tumours

Primary appendiceal neoplasms are a rare clinical and pathological entity. We report a case of synchronous appendiceal tumours of different histological types which presented as a symptomatic palpable and radiologically apparent mass in the right iliac fossa. This case demonstrates the importance of pre-operative diagnosis of these neoplasms, as it may alter the surgical approach and obviate the need for additional surgery. Furthermore, some of the controversies associated with the management of an appendix mass in the elderly population are discussed.

Perforated retrocaecal appendix presenting as right lumbar abscess

BACKGROUND

Acute appendicitis is common in older patients, however, the presentation may differ from the younger population and it is often complicated by coexistent disease and delays in presentation.

AIMS

This case report describes an unusual presentation of acute appendicitis in an elderly patient and also demonstrates a unique anatomical pathway of disease extension. In addition, this case report highlights the advantages of CT in preoperative evaluation and subsequent management of these protean presentations of acute appendicitis.

METHODS

This report describes a case of an asymptomatic retrocaecal perforated appendicitis which presented clinically as a right lumbar abscess with surrounding cellulitis, and was further complicated by a concomitant new diagnosis of type 2 diabetes mellitus in a 66-year-old male.

CONCLUSION

Elderly or immunocompromised patients presenting with cellulitis or a cutaneous abscess of the abdominal wall or lumbar region may benefit from an abdominal CT to demonstrate an intraperitoneal source of sepsis.

A new look at an under-diagnosed poorly treated condition: Restless legs syndrome

Restless legs syndrome (RLS) is a common condition that is difficult to diagnose. However, once correctly diagnosed, its management is straightforward and evidence-based. The purpose of this article is to familiarise clinicians with both the symptoms and diagnostic criteria for RLS and to elucidate secondary and often curable causes of this prevalent condition. There is also a concise review of its pathophysiology and current management strategies. The authors hope this article will raise awareness of this condition among clinicians and in doing so improve the quality of life for the patients affected by it.

Adult intussusception--need for en-bloc resection

BACKGROUND

Adult intussusception is an uncommon surgical presentation

AIMS

We report a case of adult intussusception, review the literature and discuss the optimal management.

METHODS

We describe a woman who presented with severe abdominal pain and a large supra-umbilical mass. Ileocolic intussception was confirmed on CT, and a laparotomy and en-bloc resection were carried out. Postoperatively she made an uneventful recovery.

CONCLUSION

Adult intussusception is a rare clinical presentation. En-bloc resection should be the surgical treatment of choice in the majority of cases due to the high percentage of malignant lead points.

Transient reduction in gastric acid secretion following gastric mucosal laser irradiation

This study assessed a novel approach using defocused carbon dioxide (CO2) laser irradiation on the gastric mucosal surface to reduce gastric acid output. Ninety-six Sprague-Dawley rats were randomised to three groups: control, surgical highly selective vagotomy (surgical-HSV), and gastric mucosal irradiation (laser-M). Cysteamine-induced peptic ulceration was studied, including ulcer index (product of the total number of ulcers by the sum of the ulcer length), at 4 weeks and 20 weeks. The mean ulcer index in the surgical-HSV group was significantly reduced compared with controls at 4 weeks and at 20 weeks. The mean ulcer index in the laser-M group was significantly reduced compared with controls at 4 weeks but not at 20 weeks. Histologic analysis did not reveal any mucosal changes in parietal cell mass at 4 weeks and at 20 weeks. The results show a transient antiulcer effect produced by the gastric mucosal irradiation seen at 4 weeks and abolished by 20 weeks. This data supports the feasibility of endoscopic management of peptic ulcer disease.

The patients' perception of quality in surgery

The benefits of measuring patient satisfaction have been increasingly acknowledged in recent years. A range of techniques has been used including analysis of complaints made by patients and/or relatives, focus group interviews following discharge, postal and telephone surveys, face-to-face interviews and critical incident analysis. Both quantitative and qualitative methodologies are often employed in patient-satisfaction research. It is suggested that a two-tier approach of methods can increase validity and reliability (i.e. utilizing qualitative approaches in order to develop a quantitative tool). Surgery will benefit through the identification of quality benchmarks based on this type of research. There must be an emphasis on incorporating the results of patient satisfaction studies into practice and the monitoring of improvements based on the identified benchmarks.

Beneficial effects of taurolidine in experimental pancreatitis

Taurolidine has potent antiendotoxin and antimicrobial effects in vitro. This study assessed the effect of taurolidine in a well-described model of acute pancreatitis. Ninety-five male Wistar rats (250 g) were studied. Pancreatitis was induced by intraductal injection of 50 microliters of a 4% sodium taurocholate solution at a pressure of 25 cm water. Animals were randomly allocated to 1 of 10 groups: 4 groups were used to characterize the model and there were 6 treatment groups. Taurolidine (100 mg/kg) or saline was administered intravenously at Time 1, 4 hr, or 4 and 24 hr following induction of pancreatitis. Serum amylase, endotoxin levels, and blood cultures were assessed at 4 and 24 hr. Survival was documented at 1 week. Serum amylase levels were elevated in animals in whom acute pancreatitis was induced; however, there was no difference in serum amylase between animals treated with taurolidine and those treated with saline. Positive blood cultures were more numerous in saline-treated groups. Treatment with taurolidine was associated with significantly (P < 0.01) lower endotoxin levels (14 +/- 8 pg/ml) compared with saline-treated animals (350 +/- 87 pg/ml). Taurolidine administration significantly improved survival compared with controls, when given at 4, 24, and 4/24 hr postinduction of pancreatitis (P < 0.05). Taurolidine was beneficial in this model of acute pancreatitis.

Oxygen free radicals and acute pancreatitis: fact or fiction?

The effect of oxygen free radical suppression was studied in the taurocholate model of acute pancreatitis in the rat using systemic allopurinol, superoxide dismutase (S.O.D.) and catalase. None of the treatments were beneficial which suggests that oxygen free radical suppression is unlikely to be clinically beneficial in acute pancreatitis.

ERCP in the management of patients having laparoscopic cholecystectomy: re-appraising current indications

This study assessed the ability of biochemical tests and ultrasound to predict the presence of ductal calculi, and thereby refine the indications for ERCP, in patients before or after laparoscopic cholecystectomy. Thirteen of fifty-three patients investigated before laparoscopic cholecystectomy, and four of seventeen investigated after had stones confirmed at ERCP. The most sensitive indices for stones were raised serum alkaline phosphatase (0.76), aspartate transferase (0.75) and alanine transferase (0.76). The most specific indices were an abnormal ultrasound (0.92), raised serum amylase (0.78) and raised bilirubin (0.75). Serum bilirubin, amylase and ultrasound were all normal in twenty-seven patients and all of these had normal ERCPs. If patients with normal bilirubin, amylase and ultrasound were not referred for ERCP, no stones would have been overlooked and the number of ERCPs could have been reduced by 39%.

Post-cholecystectomy symptoms after laparoscopic cholecystectomy

Abdominal symptoms persist in up to 40% of patients after laparotomy cholecystectomy and biliary lithotripsy. Laparoscopic cholecystectomy is now the treatment of choice for symptomatic gallstone disease. However, no data exist as to the influence of laparoscopic cholecystectomy on symptoms. We analysed 100 patients who had undergone laparoscopic cholecystectomy at a median of 12 months (range 10-19 months) previously. Pre- and postoperative symptoms were compared and patient satisfaction was graded from 1 (best) to 5 (worst). Time to resumption of full activity (mean +/- SD) was recorded. All patients had more than two symptoms preoperatively. Postoperatively, 61 patients had complete absence of symptoms, 14 patients complained of only one symptom during the postoperative period and 25 patients continued to have at least two symptoms. The mean time taken to return to full activity was 2.4 +/- 1.7 weeks. In patients without any symptoms postoperatively, time taken to return to full activity was 2.3 +/- 1.5 weeks, 2.7 +/- 1.4 weeks for patients with one symptom postoperatively, while patients with two or more symptoms returned to full activity in 2.3 +/- 1.3 weeks and 2.6 +/- 1.7 weeks, respectively. Notwithstanding that 25% of patients reported two or more symptoms postoperatively, most patients (n = 84) considered the procedure to be a complete success. A further 10 patients had significant improvement after laparoscopic cholecystectomy. Five patients considered themselves only slightly improved, while a single patient was no better off postoperatively. These data indicate that after laparoscopic cholecystectomy most patients return to full activity within 3 weeks. Thus, the incidence of post-cholecystectomy symptoms is similar after laparoscopic and laparotomy cholecystectomy and biliary lithotripsy.Patients should be advised of the risk of persistent symptoms after these procedures.

Early experiences of laparoscopic cholecystectomy in five Irish hospitals. Irish Laparoscopic Group

There are many concerns about the widespread introduction of laparoscopic cholecystectomy. The initial experience of five hospitals in introducing laparoscopic cholecystectomy was reviewed. Three hundred and eight patients were operated upon, and the operations were completed laparoscopically in 279 (91 percent). One patient sustained a diathermy injury to the right hepatic duct. There was no mortality and the overall morbidity was 10 percent. Mean postoperative stay was 3.6 days. The participating surgeons considered training workshops to be desirable and felt that trainees should be supervised for at least ten cases. Laparoscopic cholecystectomy can be safely introduced and performed, and it should be considered in all patients undergoing cholecystectomy.

Local beneficial effect of coumarin in experimental peritonitis

Coumarin, a potent immune stimulant and macrophage activator, has been used to treat brucellosis and as an immune suppressor. The effect of Coumarin and systemic antibiotics on septicaemia, survival and peritoneal contamination in experimental peritonitis was assessed. Four groups of male Sprague-Dawley rats were inoculated with Clostridium perfringens, Escherichia coli and Bacteroides fragilis. Group A received saline alone, Group B received Coumarin alone, Group C received antibiotics (Clindamycin and Cephradine) alone and Group D received both Coumarin and antibiotics. Septicaemia, confirmed by blood culture, occurred in all animals. Coumarin did not improve survival whether given alone or in combination with antibiotics. Animals given Coumarin (Groups B and D) had significantly less peritoneal soiling (54%, 0%) (P less than 0.02, P less than 0.001) than their controls (Groups A and C: 92%; 29%). While Coumarin did not improve resistance to septicaemia it did exert a local beneficial effect.

Transcatheter hepatic arterial therapy for symptomatic liver malignancy

Transcatheter hepatic arterial chemoembolization was performed in ten patients with symptomatic unresectable liver malignancy. Nine patients experienced control of symptoms for 52-100% of the duration of their survival, although one patient died 10 days after the procedure. No objective evidence of decrease in tumour size was seen at review but three cases showed selective decrease in tumour vasculature or tumour necrosis.

Cystic duct obliteration and gallbladder mucosal destruction: a feasible alternative to cholecystectomy

'Chemical cholecystectomy' has been proposed as an alternative to removal of the gallbladder. This study assessed cystic duct obliteration using bipolar electrocoagulation (with sham cannulation controls) and gallbladder mucosal treatment with tetracycline (or saline controls) in 29 mongrel dogs. Cystic duct obstruction was assessed by tube cholecystography at day 14, and epithelial damage by histology at day 42. Electrocoagulation by duct diathermy effectively occluded the cystic duct in 14 of 19 animals; however, this was associated with mucocele formation unless mucosal treatment with tetracycline was also performed. Immediate instillation of tetracycline after duct electrocoagulation produced only partial epithelial damage. The combination of duct electrocoagulation and delayed tetracycline instillation at 14 days produced complete destruction of all gallbladder epithelium and an effective chemical cholecystectomy.

A safe new procedure for high-risk patients with symptomatic gallstones

Cholecystectomy is associated with an appreciable mortality rate in elderly high-risk patients. Patients aged over 60 years with symptomatic gallstones, at high operative risk, underwent cholecystotomy under local anaesthesia through a 3-cm incision. Stones were removed and clearance was demonstrated endoscopically and by tube cholecystography. Catheter drainage was continued for 7 days until a further cholecystogram confirmed clearance. The procedure was attempted in 26 patients with concomitant cardiovascular, respiratory or malignant disease. Successful removal of all gallbladder stones was possible in 24 patients. Four patients had common bile duct stones demonstrated on cholecystography, all of which were successfully treated by endoscopic sphincterotomy. All patients are symptom-free at a mean follow-up of 36 weeks with no recurrent stones on ultrasonography.

Biliary intervention via minicholecystostomy

Minicholecystostomy was performed in 24 elderly patients, under local anaesthesia. All had symptomatic gallstones removed utilizing endoscopy and fluoroscopy. These procedures were well tolerated, with no significant complications, despite severe coexistent disease. One patient has had recurrent problems due to gallstones and one has died from disseminated malignancy. The remaining 22 are well and symptom-free. This combined surgical and radiological approach is a useful alternative procedure for patients with gallstones who are a poor risk for general anaesthesia.

Ingrowing toenails: improving treatment

Sixty-six patients with ingrowing toenails were randomly assigned to one of two treatment groups and followed up for 16 to 30 months after surgery. In group A 39 nail edges in 32 patients were treated by excision of the nail edge and chemical ablation of germinal matrix edge with 70% aqueous phenol. There were 34 patients in group B, in whom 46 nail edges and germinal matrix edges were surgically excised. In group A recurring symptoms developed in four (10%) nail edges, necessitating further surgery, and asymptomatic spicules developed in seven (18%) nail edges. Two (4%) nails in group B required reoperation and spicules developed in 10 (22%). Both procedures were performed as outpatient surgery, relieved pain and infection, and were acceptable to patients. At an average 2-year follow-up, both procedures yielded comparable results that were superior to those of simple avulsion.

Renal injury and recovery in partial ureteric obstruction

Partial ureteric obstruction was produced by insertion of an obstructing stent into the left ureter of 21 mongrel dogs and the duration of obstruction was varied as follows: Group A (n = 7) for 60 days; Group B (n = 7) for 28 days; Group C (n = 7) for 14 days. Intrapelvic pressure monitoring confirmed that obstruction had been produced by stent insertion and relieved by reimplantation of the left ureter following the designated obstruction period. The extent of recovery of renal function was assessed by creatinine clearance, with group C maintaining normal function, group B recovering 31% and group A recovering 8% of control function. Methyl-methacrylate extrusion casts of the renal microvasculature were made in group B and C kidneys and studied by scanning electron microscopy. During obstruction there was evidence of arteriolar constriction. These changes provide a morphological basis for the renal functional alterations and support the concept that post-obstructive renal failure is a vascular injury.

Duplex ultrasonography and selection of patients for carotid endarterectomy: plaque morphology or luminal narrowing?

Percentage of carotid stenosis and plaque morphology as determined by duplex scanning were correlated with symptoms and CT evidence of infarction in 108 patients. Severity of carotid stenosis less than 49% or greater than 50% narrowing was not associated with an increased risk of ipsilateral symptoms or CT infarction. However, a heterogeneous plaque appearance, suggesting intraplaque hemorrhage, did correlate with ipsilateral cerebral symptoms. Heterogeneous plaque appearance may be a more reliable indication for carotid endarterectomy than a hemodynamically significant stenosis.

Variable results of calcium blockade in post-ischaemic renal failure

The effects of three chemically dissimilar calcium-blocking drugs were studied in experimental post-ischaemic renal failure, in the rat. After 45 min unilateral clamping and contralateral nephrectomy, post-ischaemic verapamil administration protected renal function (p less than 0.025), but flunarizine, either before or after ischaemia, was not beneficial. Following 60 min bilateral renal pedicle clamping, nifedipine administration was not beneficial. Verapamil was the only calcium-blocking drug which attenuated the post-ischaemic renal dysfunction. Calcium blockers which differ in their modes of action, differ in their ability to protect the kidney from ischaemia.

Duplex scanning for noninvasive assessment of both carotid luminal diameter and atheromatous plaque morphology

The value of Duplex scanning in 50 consecutive patients with symptomatic carotid stenosis was evaluated. Compared with contrast arteriography, the sensitivity of Duplex scanning, for a greater than 50% internal carotid diameter reduction, was 90% (66/73) with a specificity of 96% (26/27). The overall agreement between Duplex and contrast arteriography as measured by the Kappa value was K = 0.561. One of the 13 arteries felt to be occluded on Duplex scanning was radiologically found to be patent. Excluding the six normal and 13 occluded arteries, 81 carotid plaques were defined as either heterogeneous, suggestive of intraplaque hemorrhage or as homogeneous. Twenty-four of the 32 asymptomatic cerebral hemispheres were associated with ipsilateral homogeneous plaques, while 30 of the 49 symptomatic hemispheres had heterogeneous plaques in the ipsilateral carotid, (p less than 0.001). This study confirms the accuracy of duplex scanning in detecting internal carotid stenosis as well as in identifying plaques which are morphologically heterogeneous and more likely to be associated with ipsilateral cerebral hemispheric symptoms.

The canine kidney in haemorrhagic shock: effect of verapamil

Recent evidence suggests that verapamil administration reduces myocardial and small intestinal damage in canine haemorrhagic shock, and verapamil has also been shown to reduce renal dysfunction in clamp models in post-ischaemic renal failure. The effects of high-dose verapamil and hypovolaemia on renal haemodynamics and function in a canine haemorrhagic shock model were studied. Anaesthetized mongrel dogs were divided into three groups. Animals of group I (n = 5) were not subjected to shock but given a 90-min verapamil infusion (2.28 micrograms/kg); animals of group II (n = 5) were subjected to shock (mean blood pressure 40 mm Hg) for 2 h and given a 90-min 0.9% saline infusion, and animals of group III (n = 7) were both subjected to a 2-hour shock and given verapamil. The electrocardiograph was monitored, and general haemodynamic parameters were measured before shock (period 1), at the end of shock (period 2), after reinfusion of shed blood (period 3) and 1 h after shock (period 4). Total renal and cortical zonal blood flow was estimated by radioactively labelled microsphere injection during each period. Creatinine and osmolar clearance were estimated before and after shock. Verapamil administration caused heart block in groups I and III which lowered heart rate and blood pressure and exacerbated the haemodynamic effects of shock in group III. Despite this, no measurable difference in renal function was recorded between groups II and III. Total renal blood flow fell during shock, and this was exacerbated in animals given verapamil, suggesting a cumulative deleterious effect of shock and verapamil in renal blood flow.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiographically-induced infection of the aorta

We present three cases of infection of the native aorta following angiography. The infection was an incidental finding at operation in two patients, while a third presented with fulminant sepsis. All had debridement of the retroperitoneum and underwent successful extraanatomic bypass. We feel caution is warranted in placing a retroperitoneal graft even in suspected aortic sepsis. Prophylactic antibiotics may be advisable to protect against infection of atherosclerotic plaque during angiography.

Verapamil attenuates stress-induced gastric ulceration

Since many of the proposed etiologic factors leading to gastric stress ulceration involve stimulation of calcium influx, the effect of verapamil, a potent calcium channel blocker, on the gastric mucosa in cold-restrained inbred rats was assessed. Twenty-nine rats received intraperitoneal normal saline (2 ml) while the experimental group (N = 29) received 1 mg/kg verapamil in an equal volume of normal saline intraperitoneally. All animals were then stressed at 4 degrees C for 4 hr and sacrificed. Gastrin and fatty acid levels were measured and blinded ulcer scoring of the gastric mucosa was carried out. Verapamil-treated animals had decreased frequency and severity of gastric stress ulceration as assessed by ulcer index, ulcer grade, and number of ulcers/animal. In addition, the plasma gastrin levels tended to be lower in the verapamil group. Fatty acid levels were similarly depressed following cold restraint in both groups. Pretreatment with verapamil significantly decreased gastric ulcerative response to cold-restraint stress in the rat. This effect of verapamil pretreatment may be secondary to cytoprotection of the gastric mucosa, preservation of gastric mucosal blood flow, or blockade of calcium-mediated ulcerogenic stimuli.

High fibre diet in symptomatic diverticular disease of the colon

Over the past decade fibre supplementation has achieved widespread acceptance in the management of symptomatic diverticular disease, although the efficacy of this treatment has been debated. We have conducted a retrospective review of 72 patients admitted to hospital with symptomatic diverticular disease over a ten year period in order to determine whether or not high fibre diet afforded protection against the development of complications, necessity for surgery or persistence of symptoms. Fifty-six patients were treated non-operatively, of these 43 received advice concerning a high fibre diet but only 31 patients complied. The 12 patients who failed to take additional fibre and the 13 patients who never received dietary advice (25 patients) formed the non high fibre group. Those treated with fibre supplementation fared significantly better in developing fewer complications and required less surgery (P less than 0.05). At the time of follow-up review patients on a high fibre diet reported significantly fewer symptoms (P less than 0.05).

Ultrasonography, HIDA scintigraphy or both in the diagnosis of acute cholecystitis?

The benefit of early surgery for patients with acute cholecystitis is now accepted but rapid accurate pre-operative diagnosis is important and the single best investigation has not yet been clearly established. All 47 patients with suspected acute cholecystitis admitted to a district general hospital during a 6 month period underwent ultrasonic examination and scintigraphy with HIDA within 48 h of admission. In 23 patients acute cholecystitis was proven. Ultrasound correctly diagnosed this in 21 patients but in 2, changes attributed to chronic cholecystitis only were detected. Two false positive ultrasound results also occurred, one in a patient with adenomyomatosis and acute pancreatitis, the other in a case of duodenitis. HIDA scan was diagnostic in 19 patients but in the remaining 4 the presence of abnormal liver function tests accounted for non-visualization of the biliary tree (a non-diagnostic result). In the absence of jaundice a HIDA scan is the more specific test for confirming acute cholecystitis.

Choledochoscopy? Post-exploratory fluorocholangiography? Or both?

Per-operative, post-exploratory fluorocholangiography and choledochoscopy were evaluated prospectively in 59 consecutive patients undergoing bile duct exploration for calculus disease. Fluorocholangiography showed filling defects in 13 cases and was valuable in localisation of stones, assessment of ampullary patency and visualisation of intrahepatic radicles. Choledochoscopy confirmed stones in nine cases, gave immediate confirmation of four false positive X-rays, enabled removal of five residual stones and biopsy of one benign stricture. This study suggests that fluorocholangiography should be performed routinely after duct exploration. Choledochoscopy is a useful adjunct but need only be performed in patients with abnormal X-ray findings; to confirm residual stones and aid in their removal or to permit biopsy of strictures.