Charles K. McSherry

The incidence and causes of death following surgery for nonmalignant biliary tract disease.

In the 46-year period from September 1, 1932 to September 1, 1978, 11,808 patients were operated on for nonmalignant biliary tract disease. In 80.1% of these patients, the disease was considered chronic, and in 19.9%, acute inflammation was superimposed on the existing condition. There were 207 postoperative deaths, a mortality rate of 1.7%. Advanced age, acute cholecystitis and common duct stones were the principal determinants of operative mortality. Cholecystectomy for chronic cholecystitis was performed in 7,413 patients with an operative mortality of 0.5%. Choledochotomy in search of residual or recurrent common duct calculi was performed in 341 patients with a mortality of 2.1%. Detailed analysis of the causes of death in 105 patients who died during the years 1962 through 1978 revealed that cardiovascular disease, especially myocardial infarction, was the most frequent cause of death. Liver disease, most commonly cirrhosis, was also a major factor in operative mortality.

Cholecystectomy: The gold standard ☆

There were 14,232 patients operated on for non-malignant biliary tract disease at a single medical center from 1932 through 1984. During this period, there were 237 postoperative deaths. Of the total number of patients, 10,749 underwent cholecystectomy with 60 postoperative deaths. Cholecystostomy was performed in 599 patients with 60 deaths. Cholecystectomy or cholecystostomy in conjunction with common duct exploration was performed in 2,226 patients with 89 deaths. Choledochotomy alone as a secondary procedure to search for stones was performed in 374 patients with 21 deaths. Procedures for strictures and miscellaneous conditions were performed in 284 patients with 21 deaths. Cholecystectomy for chronic cholecystitis was performed in 8,910 patients with 38 deaths. The data from the last 6 years of this study disclosed 30 postoperative deaths; only one of these patients might have been a candidate for lithotripsy or bile acid dissolution therapy. Nonsurgical alternative therapies for gallstone disease are unlikely to decrease the mortality from calculous biliary tract disease. Furthermore, stone recurrence will continue to be the major limiting factor for those techniques that fail to remove the gallbladder.

Chenodeoxycholic acid induced liver injury in pregnant and neonatal baboons.

The prolonged feeding of chenodeoxycholic acid produces hepatic injury in both pregnant and non-pregnant baboons. CDC feeding does not adversely affect ovarian function and no teratogenic effects of this bile acid were noted in 16 live birth and two stillborn progeny of CDC fed animals. However, 10 of the 16 live birth neonates and one stillborn had focal hepatic lesions histologically similar to those observed in the adult animals. In addition one neonate had gross hepatic necrosis. The severity of the liver damage was related to the content of lithocholic acid in the bile of both the neonates and their mothers. Experiments with 14C-chenodeoxycholic and 14C-lithocholic acid demonstrate that the lithocholate in the enterohepatic circulation of the neonate is derived from the CDC fed to the pregnant adult. In the gallbladder bile of the neonate most, but not all, of the lithocholate is conjugated but unsulfated. Both newborn and adult baboons sulfate lithocholic acid but to an extent less than that reported for man. Less efficient sulfation of lithocholic acid in the baboon may exaggerate the toxicity of CDC feeding in this species compared to man. Nevertheless, the potential for adverse effects on the fetal liver must be recognized as a risk associated with the use of chenodeoxycholic acid in women of child-bearing age.

The Elective Surgery Second Opinion Program.

The results of the Cornell Elective Surgery Second Opinion Program are presented. From February 1972 to January 1978, 7053 patients were evaluated for proposed elective surgery, and in 27.6% of these, the operations were not approved. The subspecialties of orthopedics and gynecology demonstrated the highest rates of non-confirmation, while that for general surgery was 18%. A group of 318 patients with general surgical diagnoses are reviewed. The percentage of nonconfirmed surgery for this group was 15 percent. The most common reasons for not approving the operations were absence of pathology and failure to utilize medical therapy when indicated.

An animal model of pigment cholelithiasis

Pigment stones of high calcium content were induced in male hamsters of the Harlan Sprague-Dawley strain fed a nutritionally adequate semipurified diet for a period of 14 weeks. The diet contained moderate amounts of cholesterol (0.30 percent) and ethinyl estradiol (15 micrograms/day per animal). At sacrifice, the incidence of pigment stones was 50 percent. When stones were present, they were in the form of numerous black amorphous rods about 0.1 to 0.4 mm in length. Infrared analysis of the dried stones indicated the following composition: calcium phosphate 26.7 percent, calcium bilirubinate 12.8 percent, cholesterol 15.1 percent, and protein 45.4 percent. Pigment stones were associated with an elevated biliary total calcium level (probably induced by the dietary cholesterol) and a paradoxic decrease in the biliary total bilirubin level. The lithogenic diet produced marked elevations in liver and plasma cholesterol levels and cholesterol saturation of bile, but no cholesterol crystals or stones were observed. The accumulation of elevated levels of cholesterol in the livers of the experimental animals produced mild to moderate hepatotoxicity. The precise mechanism of the dietary induction of pigment stones in this hamster model remains to be elucidated.

Endoscopic retrograde cholangiopancreatography and sphincterotomy.

Endoscopic retrograde cholangiopancreatography (ERCP) is an important diagnostic technique to evaluate patients with biliary and pancreatic disease. Since 1970, over 1000 ERCPs in the Surgical Endoscopy Unit of Beth Israel Medical Center have been performed; this report summarizes the most recent 300 cases. This paper will document the indications and methodology as well as the improved morbidity and mortality rates associated with this procedure. In contrast to earlier reports, the incidence of hyperamylasemia is now 8.3% and clinical pancreatitis, 2.3%. Cholangitis occurred in less than 1% of patients. In addition, 40 patients had endoscopic sphincterotomy. Retained and recurrent common duct stones were the most frequent indications for this procedure. There was one death. In another patient, a duodenal perforation was treated successfully by antibiotics and parenteral fluids. We believe this technique has many advantages over choledochotomy in properly selected patients.

The significance of splenic abscess

Abstract Twelve patients with splenic abscesses encountered at The New York Hospital-Cornell Medical Center between 1932 and 1960 are presented. Data concerning age, sex distribution, underlying disease processes, bacteriologic studies and autopsy observations are presented. Ninety-one and seven-tenths per cent (91.7 per cent) of the abscesses were thought to result from blood stream infection, so-called “metastatic abscesses” and 8.3 per cent from perforation of an adjacent abdominal viscus. The presence of coexisting serious illness and the questionable value of operation are stressed.

Contribution of endoscopy to diagnosis and treatment of gastric cancer

The contribution of fiberoptic endoscopy to the diagnosis and treatment of gastric cancer was evaluated in 174 patients. For the purpose of staging, they were compared with 99 patients admitted to the same institution in the pre-endoscopy era. The frequency of minimal gastric cancer (stages I and II) was 16.5 percent in the patients who had esophagogastroduodenoscopy in contrast with only 4 percent in the patients without endoscopy. Fiberoptic endoscopy was superior to barium gastrography in the diagnosis of minimal gastric cancer. The effect of early diagnosis on survival was such that at 3 year follow-up, the cumulative proportion of stage I and II patients still alive was 85 percent compared with only 17.5 percent of stage III patients and none of the stage IV patients.

Surgical aspects of biliary tract disease

Abstract Presented here is a review of selected topics of mutual interest to both gastroenterologist and surgeon. Statistics concerning the mortality and morbidity of biliary tract surgery indicate that associated cardiovascular disease is a principal cause of fatal complications. On the basis of these data, elective cholecystectomy is advised in patients with “silent” gallstones and symptomatic hyperplastic cholecystoses. The approach in patients with obstructive jaundice is reviewed, using case reports to illustrate the management of common duct calculi and sclerosing choledochitis.

Liver hematoma after blunt injury

Abstract A case report of a patient with blunt liver injury who had a demonstrated lesion of an intrahepatic branch of the left hepatic artery is presented. A large expanding parenchymal hematoma resulted in thrombosis of the hepatic vein, pulmonary emboli, and death. This case illustrates the elusiveness of intrahepatic injury caused by external blunt forces, the seriousness of intrahepatic bleeding uncontrolled by ligature of the vessel, and the tendency of hepatic veins to become thrombosed when there is an expanding intrahepatic lesion.