David L. Nahrwold

The effect of ursodiol on the efficacy and safety of extracorporeal shock-wave lithotripsy of gallstones: The dornier national biliary lithotripsy study

BACKGROUND In the treatment of gallstones with extracorporeal shock-wave lithotripsy, the bile acid ursodiol is administered to dissolve the gallstone fragments. We designed our study to determine the value of administering this agent. METHODS At 10 centers, 600 symptomatic patients with three or fewer radiolucent gallstones 5 to 30 mm in diameter, as visualized by oral cholecystography, were randomly assigned to receive ursodiol or placebo for six months, starting one week before lithotripsy. RESULTS The stones were fragmented in 97 percent of all patients, and the fragments were less than or equal to 5 mm in diameter in 46.8 percent. On the basis of an intention-to-treat analysis of all 600 patients, 21 percent receiving ursodiol and 9 percent receiving placebo (P less than 0.0001) had gallbladders that were free of stones after six months. Among those with completely radiolucent solitary stones less than 20 mm in diameter, 35 percent of the patients receiving ursodiol and 18 percent of those receiving placebo (P less than 0.001) were free of stones after six months. Biliary pain, usually mild, occurred in 73 percent of all patients but in only 13 percent of those who were free of stones after three and six months (P less than 0.01). There were few adverse events. Only diarrhea occurred with a significantly different frequency in the two groups: 32.6 percent were affected in the ursodiol group, as compared with 24.7 percent in the placebo group (P less than 0.04). Severe biliary pain occurred in 1.5 percent of all patients, acute cholecystitis in 1.0 percent, and acute pancreatitis in 1.5 percent; endoscopic sphincterotomy was performed in 0.5 percent, and cholecystectomy in 2.5 percent. CONCLUSIONS Extracorporeal shock-wave lithotripsy with ursodiol was more effective than lithotripsy alone for the treatment of symptomatic gallstones, and equally safe. Treatment was more effective for solitary than multiple stones, radiolucent than slightly calcified stones, and smaller than larger stones.

Opioid drugs cause bile duct obstruction during hepatobiliary scans

Hepatobiliary scans using Tc-IDA are reliable in making the diagnosis of acute cholecystitis. Commonly, opioid drugs are administered in patients with acute cholecystitis to relieve pain. Opioid drugs cause biliary sphincter spasm. Whether these drugs adversely affect hepatobiliary scans is unknown. We studied 13 healthy volunteer subjects, performing three hepatobiliary scans in each one. Scans were performed without opioid drugs and 30 minutes after intramuscularly administered meperidine, morphine, hydroxyzine, hydroxyzine plus meperidine, butorphanol, and nalbuphine. Opioid drugs markedly delayed clearance of Tc-IDA from the common bile duct, simulating common bile duct obstruction. Hydroxyzine alone caused an insignificant delay. We have concluded that opioid drugs cause bile duct obstruction in healthy persons. If opioid drugs are administered before a diagnostic hepatobiliary scan, delayed clearance of Tc-IDA from the common bile duct might lead to an erroneous diagnosis and indicate a potentially unnecessary common bile duct exploration. Opioid drugs should not be administered for several hours before a diagnostic hepatobiliary scan.

One-stage resection and anastomosis in the management of colovesical fistula☆

Thirty-four patients with colovesical fistulas seen over a recent 10 year period were reviewed. Diverticulitis was the most common cause of colovesical fistula, accounting for 71 percent of patients in our series. The majority of patients present electively, and most have urinary tract complaints. In those patients in our study who presented with systemic infection, urinary obstruction was present in 70 percent. Although proctosigmoidoscopy and barium enema examination are essential in the preoperative assessment, cystoscopy is the most useful test in suggesting or confirming the diagnosis of colovesical fistula. Intravenous urography is not necessary in the evaluation of these patients. The surgical treatment depends on the cause of the fistula. For patients with an inflammatory cause of the fistula, one-stage operative treatment is associated with low morbidity and decreased length of stay compared with operative treatment in more than one stage. In the presence of severe inflammation or inadequate bowel preparation, two-stage operative treatment is safe and effective. Operations in three stages for colovesical fistula are not indicated. The primary objectives in the management of colovesical fistulas due to unresectable malignancy are relief of intestinal and urinary obstruction and fecal diversion. Resection of the malignancy should be performed whenever possible.

Abnormalities in gallbladder morphology and function in patients with cholelithiasis.

Thirty-seven symptomatic cholelithiasis patients who had cholecystectomy were studied to determine the relationships between clinical manifestations, histologic findings and gallbladder absorptive capability. A clinical score was calculated from clinical data which we thought might be predictive of abnormal gallbladder histology. Histologic parameters indicative of gallbladder disease were used to calculate a histologic score. Short-circuit current measurements, which reflect gallbladder sodium absorption, were used to assess absorptive function. Patients with very high clinical scores, indicative of pronounced clinical findings, had high histologic scores and low short-circuit current values, indicative of marked histologic changes and poor absorptive function, respectively. For the remainder of patients, the clinical score was not predictive of histologic findings or absorptive function. There was linear correlation between histologic scores and short-circuit current values, which suggests that absorptive function of the gallbladder is directly related to the degree of histologic abnormality, and that absorptive capability is not an all-or-none phenomenon. The data also show that visualization on oral cholecystography is an unreliable measure of gallbladder absorptive capability.

United states research published in major surgical journals is decreasing.

ObjectiveThe authors hypothesized that less research performed in the United States was reported in the five major general surgical journals in 1993 than in 1983. Summary Background DataAcademic surgeons believe they have less time and fewer funds for research than previously. MethodsFive journals were analyzed for the number of pages and articles devoted to basic and clinical research in 1983 and 1993 and for the country in which the research was performed. ResultsThe number of U.S. research pages and articles decreased over the past decade, and the number of non-U.S. pages and articles increased. ConclusionsThe reason(s) for the decrease in U.S. research reported in the general surgical journals should be studied, identified, and, if possible, rectified.

Continuing medical education reform for competency-based education and assessment.

&NA; The development of competency‐based education and evaluation for residents and practicing physicians by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties (ABMS), respectively, includes the competency of practice‐based learning and improvement. Efforts to implement this and the other competencies have been a powerful stimulus for continuing medical education (CME) reform, the goal of which is to improve the outcomes of care. The ABMS member boards and their counterpart specialty societies, members of the Council of Medical Specialty Societies (CMSS), have formed dyads to set standards and provide education to that end. Focused on the patient, the report of the Conjoint Committee on Continuing Medical Education contains the recommendations necessary to deliver competency‐based continuing education to physicians. To implement them will be a major challenge. The CME community must consider the need to provide CME across the major health professions to address the fact that most care is delivered within systems composed of many health professionals. The use of microsystems as a model for the delivery, study, and validation of this interdisciplinary CME holds great promise.

Rectus sheath hematoma complicating an exacerbation of asthma

Hematoma of the rectus sheath is a rare complication of asthma. We describe a case of rectus sheath hematoma precipitated by a paroxysm of cough during an exacerbation of asthma. Diagnosis and management of this clinical entity is discussed.

Supersaturation of canine gallbladder bile with calcium bilirubinate during formation of pigment gallstones

Analogous to cholesterol gallstones forming in bile supersaturated with cholesterol, pigment gallstones may form in bile supersaturated with calcium bilirubinate. We tested this hypothesis in a dietary model of pigment gallstones. The concentration of ionized calcium (Ca++) and unconjugated bilirubin (UCB) was measured in 15 normal dogs and in 15 dogs with pigment gallstones induced by 6 weeks of a methionine-deficient diet. Although there was minimal change in the gallbladders ability to acidify or concentrate bile, both [Ca++] and [UCB] markedly increased. These values were compared with equilibrium concentrations in model bile solutions. In all normal bile, the [UCB] was equal to or lower than the mean [UCB] concentration of model bile solutions with comparable [Ca++]. However, in all but one bile sample from dogs with pigment gallstones, the [UCB] exceeded this concentration and was therefore supersaturated with calcium bilirubinate. This supports the hypothesis that calcium bilirubinate precipitation is important in the formation and growth of pigment gallstones.

Physician competency? Teaching old dogs new tricks.

The public policy committee of the Society for Surgery of the Alimentary Tract (SSAT) held a panel on “Physician Competency” during Digestive Disease Week in New Orleans on May 18, 2004. Developing and assessing physician competencies, particularly surgeon competencies, is a challenge and a subject of many discussions worldwide. The goal of surgical training in any system is to produce competent professionals capable of meeting the health care needs of the society. A surgeon must learn to operate safely and skillfully. The traditional way of teaching has been in the operating room, is based on an exemplary role model, and is monitored through subjective assessments. “See one, do one, teach one” has been the adage of many generations. The operating room is no longer the ideal learning environment because of (a) increasing time constraints, (b) cost, stress, and ethical considerations, (c) hours and shift restrictions for residents, (d) a shift from inpatient to ambulatory surgery, (e) the use of more complex (laparoscopic) procedures, and (f) the public’s attention. These constraints have resulted in a shift towards a more objective measurement of outcome and surgeon abilities, and, thereby, decreased interaction between residents and senior role models.

Cholecystokinin antagonist prevents hyperamylasemia and improves pancreatic exocrine function in cerulein-induced acute pancreatitis.

Supramaximal cerulein administration induces acute pancreatitis, which markedly impairs pancreatic secretion in conscious rats. We hypothesized that pretreatment with the potent cholecystokinin antagonist, L-364,718, improves the pancreatic secretory impairment associated with cerulein-induced acute pancreatitis. Rats were surgically prepared with gastric, duodenal, bile, and pancreatic fistulas and jugular vein catheters. On postoperative day 4, groups of rats were administered (a) L-364,718 1 mg/kg intraduodenally, (b) cerulein 5 μg/kg/h for 6 h intravenously, (c) L-364,718 1 mg/kg intraduodenally followed by cerulein 5 μg/kg/h for 6 h intravenously, and (d) safflower oil carrier intraduodenally. On postoperative day 5, we studied cholecystokinin (CCK)-stimulated pancreatic secretion. Plasma amylase was measured at the time of surgery and at the conclusion of experiments on postoperative days 4 and 5. The duodenally administered CCK antagonist had no effect, 24 h later, on CCK-evoked protein secretion and prevented the pancreatic exocrine impairment and hyperamylasemia caused by supramaximal cerulein administration. These observations suggest that cerulein-induced acute pancreatitis is mediated by a CCK-receptor mechanism.