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Background: Primary gastric lymphomas are distinct entities with an indolent clinical course and biologic behavior. They account for 2-8% of all gastric malignancies. We conducted this study to evaluate the role of gastroscopy as the principal diagnostic method in detecting gastric MALT lymphomas.Methods: Sixty-three consecutive patients with gastric MALT lymphomas, who were evaluated and treated at our institution between January 1978 and December 1997, are retrospectively reviewed. There were 36 males and 27 females, with a mean age of 53 years (range 20-80 years). All patients underwent the standard diagnostic evaluation, including gastroscopy and biopsy. Patients were staged according to revised Musshof modification of the Ann Arbor classification system, whereas histological evaluation was made according to the Isaacson classification system for gastric MALT lymphomas.Results: According to endoscopic findings, the antrum harbored the neoplasm in 31 patients (49%), the body in 38% (24 patients), and the fundus in 4% (3 patients), whereas in 5 patients (8%) the neoplasm occupied the entire stomach. The macroscopic appearance was not in most cases pathognomonic of the disease. Three macroscopic patterns were recognized at endoscopy: (a) the ulcerative in 51% (32 patients), (b) the polypoid in 33% (21 patients) and (c) the diffuse infiltrative in 16% (10 patients). The neoplasm was characterized as a benign disease in 24 patients (38%), with malignancy being suspected in 62% (39 patients). Endoscopy displayed a sensitivity of 61% in detecting malignancy; however, the sensitivity dropped to 27% when endoscopic diagnosis of non-Hodgkin's lymphoma was hypothesized.Conclusions: Although the impact of gastroscopy as a diagnostic tool in the patients of our study was of limited value, due to the nonspecific gross pattern of gastric MALT lymphomas, it should be maintained in the diagnostic intervention of the upper GI tract pathologies. [ABSTRACT FROM AUTHOR]

The application of laparoscopic technique has gained popularity in the past decade. Numerous studies have qualified and quantified the systemic impact of acutely elevated intra-abdominal pressure during pneumoperitoneum at time of laparoscopy. The major hemodynamic effects are increased central venous pressure, increased systemic vascular resistance and systemic hypertension. Reductions in splanchnic and renal blood flow have also been documented, but the clinical significance of these observations is not clear and required further investigation. In our previous work we demonstrated intracranial hypertension secondary to acute elevation in intra-abdominal pressure and described the pathophysiology. Elevated intra-abdominal pressure during induced pneumoperitomeum can serve as a basic model for other disease processes which are characterized by acute or chronic abdominal hypertension. Here we review the current literature and describe our own experience to suggest a unifying model, with emphasis on the key role of the central nervous system in mediating the systemic response to increased intra-abdominal pressure. [ABSTRACT FROM AUTHOR]

Background: The effects of pneumoperitoneum on intracranial pressure (ICP) have received relatively little attention. This study was undertaken to investigate the changes in ICP occurring as a result of increased intraabdominal pressure (IAP) and positioning in animals with normal and elevated ICP. Method: Five pigs (average weight 60 lb) were studied. A subarachnoid screw was placed for ICP monitoring. End tidal CO2 was monitored. Ventilation was performed to keep PCO2 between 30 and 50 mmHg. Measurements of arterial blood gases, mean arterial blood pressure, and ICP were recorded at four different levels of intraabdominal pressure (IAP 0, 8, 16, and 24 mmHg), both in the supine and Trendelenburg positions. A Foley catheter was introduced into the subarachnoid space to elevate the intracranial pressure, and the same measurements were performed. Results: There was a significant and linear increase in ICP with increased IAP and Trendelenburg position. The combination of increased IAP of 16 mmHg and Trendelenburg position increased ICP 150% over control levels. Conclusions: Patient positioning and level of IAP should be taken into consideration when performing laparoscopy on patients with head trauma, cerebral aneurysms, and other conditions associated with increased ICP. [ABSTRACT FROM AUTHOR]

We report a case of ectopic pancreas tissue in the gastric wall that was removed using a minimally invasive approach. The patient was a 46-year-old obese woman who presented with fatigue, weakness, abdominal discomfort, and guaiac-positive stools. Laboratory analysis showed iron deficiency anemia. Preoperative endoscopy revealed a submucosal lesion in the gastric antrum. Intraoperative upper endoscopy clearly located the lesion at the antrum. The lesion was marked with India ink, allowing it to be identified easily at laparoscopy. A laparoscopic wedge resection of the gastric antrum was performed. The patient had an uneventful recovery. We believe that this is a valid treatment option for this benign condition. [ABSTRACT FROM AUTHOR]

Background: Fluorescence-guided surgery (FGS) has emerged as an innovative technique with promising applications in various surgical specialties. However, clinical implementation is hampered by limited availability of evidence-based reference work supporting the translation towards standard-of-care use in surgical practice. Therefore, we developed a consensus statement on current applications of FGS., Methods: During an international FGS course, participants anonymously voted on 36 statements. Consensus was defined as agreement ≥70% with participation grade of ≥80%. All participants of the questionnaire were stratified for user and handling experience within five domains of applicability (lymphatics & lymph node imaging; tissue perfusion; biliary anatomy and urinary tracts; tumor imaging in colorectal, HPB, and endocrine surgery, and quantification and (tumor-) targeted imaging). Results were pooled to determine consensus for each statement within the respective sections based on the degree of agreement., Results: In total 43/52 (81%) course participants were eligible as voting members for consensus, comprising the expert panel (n = 12) and trained users (n = 31). Consensus was achieved in 17 out of 36 (45%) statements with highest level of agreement for application of FGS in tissue perfusion and biliary/urinary tract visualization (71% and 67%, respectively) and lowest within the tumor imaging section (0%)., Conclusions: FGS is currently established for tissue perfusion and vital structure imaging. Lymphatics & lymph node imaging in breast cancer and melanoma are evolving, and tumor tissue imaging holds promise in early-phase trials. Quantification and (tumor-)targeted imaging are advancing toward clinical validation. Additional research is needed for tumor imaging due to a lack of consensus., Competing Interests: Declaration of competing interest Statement: One author has disclosed the following potential conflicts of interest: S. Gioux (SG) is a full-time employee of Intuitive Surgical. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Published by Elsevier Ltd.)

Background and Aims: Bariatric surgery is considered the only long-lasting treatment for morbid obesity. Techniques and procedures have changed dramatically. We report on some of the major changes in the field., Materials and Methods: We reviewed some of the major changes in trends in bariatric surgery based on some landmark paper published in the literature., Results: We identified three major phases in the evolution of bariatric surgery. The pioneer phase was mostly characterized by discovery of weight loss procedures serendipitously from procedures done for other purposes. The second phase can be identified with the advent of laparoscopic techniques. This is considered the phase of greatest expansion of bariatric surgery. The metabolic phase derives from the improved understanding of the mechanisms of actions of the bariatric operations at the hormonal and molecular level., Conclusions: Bariatric surgery has changed significantly over the years. The safety of the laparoscopic approach, along with the better understanding of the metabolic changes obtained postoperatively, has led to a more individualized approach and also an attempt to expand the indications for these procedures., (© The Finnish Surgical Society 2014.)

Reports of nutritional deficiencies after Bariatric surgery have lead investigators to inquire about the preoperative nutritional status of morbidly obese patients. Interestingly, numerous reports demonstrated a pattern of low levels of various micronutrients among overweight and obese patients, even in comparison with normal weight population. In this article we reviewed the literature for micronutrient deficiencies in obese patients prior to weight reduction surgery.

Background: In the morbidly obese, laparoscopic Roux-en-Y gastric bypass (RYGB) effectively achieves weight loss with the resolution of co-morbidities. The goal is to create a small-volume gastric pouch with a narrow gastrojejunal anastomosis (GJA). The procedure is associated with a GJA stricture rate of approximately 3%. The use of a compression anastomotic device to create a sutureless gastrointestinal anastomosis, replacing sutures or staples, might reduce tissue trauma and improve the GJA patency rate. A temperature-dependent, memory-shape, Nitinol Compression Anastomosis Clip (CAC) has been successfully used in intestinal anastomoses. Compression of the entrapped bowel leads to necrosis, with device expulsion after 7-10 days., Methods: We designed a pilot animal model study of open RYGB to examine the clip's safety in the performance of upper gastrointestinal anastomoses. Six 40-kg female pigs underwent RYGB. Group 1 (n = 3) underwent GJA with the CAC and a stapled jejunojejunal anastomosis (JJA). Group 2 (n = 3) underwent GJA and JJA with the CAC. One pig from each group was euthanized at 1, 4, and 8 weeks postoperatively., Results: Two pigs, one from each group, developed gastroparesis. At autopsy, all anastomoses were patent; the mean GJA diameter with the CAC was 1.6 cm (range 0.6-3), the mean JJA diameter with the stapler was 3.8 cm (range 35-40), and the mean JJA diameter with the CAC was 3 cm (range 3-3.2). Anastomotic burst pressures were similar between the stapled and CAC anastomoses. The device was passed per rectum by postoperative day 9 (range 8-12). Histologic examination of the CAC anastomoses demonstrated a complete mucosal lining with no evidence of stricture formation at 2 months., Conclusion: The results of this small animal study have demonstrated the safety of sutureless compression anastomoses in an animal model of open RYGB.

Background: Laparoscopic cholecystectomy has been successfully performed using epidural anesthesia. We evaluated our experience with this surgical approach in high-risk patients., Methods: We present the results of 29 patients with gallstones who, between 1998 and 1999, underwent laparoscopic cholecystectomy with epidural anesthesia. All but 1 patient had chronic obstructive pulmonary disease., Results: All 29 surgeries were successfully completed via laparoscopy and with the patients under epidural anesthesia. No patient required endotracheal intubation during surgery or pain medication afterward. Postoperatively, 1 patient developed a wound infection and 3 patients developed urinary retention. At last follow-up (12 months postop), all patients were in good health., Conclusion: In this series, laparoscopic cholecystectomy was feasible under epidural anesthesia and it eliminated the need for postoperative analgesia. We believe that this approach should be considered for patients who require biliary surgery but who are not good candidates for general anesthesia due to cardiorespiratory problems.

Background: Patients in the intensive care unit (ICU) may suffer from life-threatening abdominal pathologies, which may necessitate a surgical intervention. Diagnosis may be difficult, as deep sedation and analgesia often mask symptoms, and physical examination is unreliable. Imaging studies are not accurate enough, and exploratory laparotomy carries significant morbidity and mortality rates in this patient population. The unstable patient is difficult to mobilize to the imaging department or to the operating room. Bedside laparoscopy may overcome these difficulties., Patients and Methods: We describe our initial experience with the use of bedside laparoscopy in critical patients with suspected abdominal pathology. The procedure was performed in four patients over a 4-month period and completed in all four., Results: The findings were: turbid fluid consistent with viscus perforation in a patient with unexplained sepsis after cardiac surgery, sterile hemorrhagic fluid in a patient with malignancy and thrombotic thrombocytopenia purpura, a retroperitoneal mass from which biopsies were taken in a patient with sudden respiratory failure, and abdominal abscess in a patient after bowel resection for mesenteric embolism. None of these patients had a laparotomy after the laparoscopy. Patients 1 and 4 died a few hours after the procedure from sepsis, and patients 2 and 3 died several days later., Conclusion: Bedside laparoscopy in the ICU is feasible, informative, and accurate. It has a role in diagnosing abdominal pathologies and planning further treatment. It may avert a nontherapeutic laparotomy. Unfortunately, the prognosis in these patients is poor. Earlier use of this diagnostic modality may improve patient outcome.

A limited number of access ports used in laparoscopic surgery may impair the ability of the surgeon to achieve adequate retraction and exposure, or to stabilize "moving targets" while operating on nonfixed organs. Solutions such as adding more ports or using a hand-assisted technique have the disadvantages of being more invasive, possibly creating a cumbersome situation of multiple instruments in a limited working space. We describe a useful technique for retraction and stabilization with the use of temporary sutures that pass through the abdominal wall. Although not new, this technique is not widely known or used, and laparoscopic surgeons may find it useful for a variety of applications.

A decade after the introduction of therapeutic laparoscopy, the use of laparoscopic gastric surgery is becoming accepted. While still evolving, currently available techniques and equipment are already sufficient for performing most ablative and reconstructive procedures. Despite feasibility, problems such as procedural complexity, long operative time, and high cost may negate the advantages of earlier and easier recovery. At present, these procedures are limited to highly trained laparoscopic surgeons, but they may become more prevalent among the next generations of surgeons, due to constant changes in surgical training and education. The question of laparoscopic curative treatment of malignant gastric tumors has not been answered. Diagnostic laparoscopy for staging is effective and widely practiced, but gastric resections are mostly limited to benign lesions. Currently, early malignant lesions are laparoscopically treated mainly in Japan, whereas more advanced lesions are laparoscopically resected in only a few centers around the world. Full endorsement of these procedures, by randomized controlled trials, although desirable, is unlikely soon, due to the technical complexity and low prevalence of these pathologies in western countries.

Cyanoacrylate-based tissue glue has been widely used for many years around the world, and was recently approved for use in the United States, mainly for skin cuts and lacerations. Other applications were described, in different surgical situations. Although ideal for small, clean incisions, its use in laparoscopic surgery is currently limited. Over a year period, 100 patients with more 250 trocar site wounds had their wounds glued using histoacryl. Infection rate was extremely low (one case), and partial dehiscence of the wound happened in two patients, where wound edge approximation was not optimal. Cosmetic results were excellent and patient satisfaction was high, as no sutures had to be removed. Glue application is easy and quick, with no risk of needle sticks, and it is a viable option for laparoscopic wound closure.

Over the recent years laparoscopic splenectomy has become the preferred approach for the treatment of many conditions requiring splenic removal. At first limited to small spleens and to benign hematologic disorders, this procedure is now used for a variety of indications. Enlarged spleens are possible to be removed laparoscopically, although this is still a demanding procedure. Two factors facilitated the technique and contributed to its wide acceptance: 1) Change in the technique originally used, by positioning the patient in right lateral decubitus, and approaching the spleen from a postero-lateral direction. 2) The development of new technologies to dissect and divide tissues and vessels, including the ultrasonic shears and the laparoscopic linear stapler. In this article we review the current indications for laparoscopic splenectomy, as well as the techniques to accomplish this procedure.

Background: Elevated intraabdominal pressure (IAP) is observed in various clinical situations, the most common of which are severe abdominal trauma and laparoscopic surgery. Extreme pressures may lead to Abdominal Compartment Syndrome (ACS), but even with lower pressures adverse effects are apparent. The cardiovascular system, the respiratory system, the kidneys and the visceral circulation are all affected, but the exact physiological mechanism is not well defined., Aims: To discuss possible mechanisms which explain the observed hemodynamic effects of increased IAP., Methods: Large animal model observations and review of current literature regarding the correlation between IAP and intracranial pressure (ICP)., Results: It was shown that the elevation of abdominal pressure leads to elevation of ICP. Transfer of pressure through the central venous system or by the cerebrospinal fluid (CSF) has been proposed as an explanation. In response to elevated ICP, various stress hormones are secreted by the central nervous system, including vasoconstricting agents such as vasopressin and catecholamines. It is hypothesized that the central nervous system is the link between the increased abdominal pressure and its adverse hemodynamic effects. This may be a protective mechanism of the brain, aimed to increase the mean arterial pressure when the ICP is elevated, in order to preserve the cerebral perfusion pressure., Conclusion: ICP is elevated in response to IAP elevation, and may be responsible for its adverse hemodynamic effects. Antagonists to vasopressin may have a role in the treatment of this condition.

Objective: This paper reviews the current use of laser techniques for the treatment of biliary stones., Background Data: Biliary stones may pose a special problem when access to them is limited, when previous attempts of removal have failed, or when a less invasive option than surgery is needed. The availability of various laser sources and the adaptation of the technology for safe use in the biliary system make the use of laser energy for stone fragmentation possible., Methods: Current literature is reviewed concerning the use of laser for biliary lithotripsy, including experimental data and experience with human series. Technology, indications, alternatives, and cumulative world experience are discussed., Conclusions: Recent technical advances have made the use of laser energy for fragmentation of biliary calculi possible. It is a valid option for treatment of "difficult" stones, when other methods have failed or as a primary treatment in certain situations. The technical complexity and the high cost limit its use for specialized centers.

Introduction: In previous studies we described mechanisms by which acute elevation of the intraabdominal pressure (IAP) induces intracranial hypertension (ICHTN). Here we sought to define the role of ICHTN in mediating systemic hypertension (HTN) during CO(2) pneumoperitoneum (PNP)., Methods: Six large animals (swine) were hyperventilated to buffer hypercarbia. Intracranial pressure (ICP) was monitored with a Camino intraparenchymal ICP monitoring system. A Foley catheter was introduced intracranially via a separate burr hole. At phase 1, changes in ICP, central venous pressure (CVP), and mean arterial pressure (MAP) were recorded during periods of CO(2) PNP at IAP levels of 15, 20, 25, and 30 mm Hg. At phase 2, ICHTN was produced directly by inflating the intracranial balloon to the same ICP levels that had been measured in phase 1 for each degree of IAP. CVP and MAP were recorded. Repeated measures analysis of variance was applied., Results: At phase 1, the mean DeltaCVP, DeltaICP, and DeltaMAP increased relative to the degree of IAP (P = 0.0001, 0.0004, and 0.024, respectively). At phase 2, the increments in DeltaMAP were significant (P = 0.024) and in the same direction and amplitude as at phase 1., Conclusions: In this study, increasing the IAP with CO(2) PNP with a consequent increase of ICP and direct manipulation of the ICP produced a comparable systemic HTN. We believe that this further supports our hypothesis: Elevated IAP produces an immediate increase in the CVP, which impairs venous drainage from the central nervous system (CNS), increases the ICP, and initiates a CNS-mediated response and systemic HTN., (Copyright 2000 Academic Press.)

Prior studies have reported an association between the presence of the 7 repeat allele of the 48 bp repeat polymorphism of the third cytoplasmic loop of the dopamine D4 receptor gene (DRD4) and novelty seeking behaviors, attention deficit hyperactivity disorder (ADHD), Tourette syndrome (TS), pathological gambling, and substance abuse. However, other studies have failed to replicate some of these observations. To determine whether we could replicate these associations we genotyped 737 individuals from four different groups of control subjects, and 707 index subjects from four different groups of impulsive, compulsive addictive behaviors including substance abuse, pathological gambling, TS, and ADHD. Chi-square analysis of those carrying the 7 allele versus non-7 allele carriers was not significant for any of the groups using a Bonferroni corrected alpha of.0125. However, chi-square analysis of those carrying any 5 to 8 allele versus noncarriers was significant for pathological gambling (p <.0001), ADHD (p

The introduction of laparoscopic techniques for the management of biliary stone disease has expanded the therapeutic choices for surgeons confronted with choledocholithiasis. As new strategies emerge, the treatment of cholelithiasis and choledocholithiasis remains controversial. This paper discusses the options available for the treatment of common bile duct stones. Diagnostic and therapeutic algorithms are proposed. The treatment of these patients must be individualized, taking into consideration the condition of the patient, associated diseases, secondary complications of the gallstones, and the surgical expertise and resources of the institution.

In previous studies we reported that an acute elevation in intra-abdominal pressure (IAP) is responsible for the elevation in intracranial pressure (ICP) and mean blood pressure (MBP). Thus far, the reasons for the increased ICP during an acute elevation in IAP and the combined effects of increased IAP and ICP on hemodynamics have not been reported. Five large animals (swine) were studied. Each animal served as its own control. A subarachnoid screw was placed for ICP monitoring. The jugular vein, femoral vein, and femoral artery were cannulated. ICP, MBP, central venous pressure above (CVPA) and below (CVPB) the diaphragm, and PaC02 were monitored after a pneumoperitoneum with C02 was established at 5, 15, and 30 mm Hg of IAP. Cavography was performed to evaluate the morphology of the inferior vena cava at different increments of IAP. Measurements were obtained in reverse Trendelenburg (group 1), supine (group 2), and Trendelenburg (group 3) positions. Multiple regression analysis was used to examine the effects of IAP and positioning in separate models with different blood pressures as dependent variables. Increased IAP significantly increased CVPA, CVPB, ICP, and MBP. There were no changes in cerebral perfusion pressure. The change in position (from group 1 to group 3) significantly increased CVPA and decreased the CVPB. Cavograms performed on animals in the supine position with increased IAP showed a narrowing of the IVC at the level of the diaphragm. Increases in IAP will increase ICP and MBP without altering the cerebral perfusion pressure. A mechanical effect mediated by compression of the inferior vena cava at the level of the diaphragm with increased central venous pressure and decreased drainage from the lumbar plexus and central nervous system is responsible for this effect.

Background: The side effects of acute elevations in intraabdominal pressure (IAP) are related to a multifactorial etiology. Previous studies have reported that acute elevations in IAP produce an immediate increase in intracranial pressure (ICP). This study was designed to analyze the reasons for increased ICP during acute elevations of IAP and to determine the combined effects of IAP and changes in ventilation indices on ICP and hemodynamic indices., Study Design: Five pigs were studied. A subarachnoid screw was placed for ICP monitoring. The jugular vein, femoral vein, and femoral artery were cannulated. Mean arterial pressure (MAP), central venous pressure (CVP), ICP, and arterial pressure of carbon dioxide (PaCO2) were monitored before and after carbon dioxide pneumoperitoneum was established at 0, 10, and 20 mmHg of IAP Effects of hyperventilation and hypoventilation were recorded and compared with baseline ventilation. Cavography was performed to evaluate the morphology of the inferior vena cava (IVC) at different levels of IAP. Multiple regression and Student's t-test were used to examine the effects of IAP and ventilation on dependent variables., Results: The IVC showed a progressive narrowing at the level of the diaphragm as IAP was increased. There was a simultaneous increase in CVP, MAP, and ICP. The mean changes in ICP with hypoventilation were significantly larger than with hyperventilation., Conclusions: Acutely increased IAP displaces the diaphragm cranially, narrowing the IVC and increasing intrathoracic pressure. This increases CVP and increases ICP by venous stasis and increased pressure in the sagittal sinus with decreased resorption of cerebrospinal fluid. Hemodynamic changes are directly related to the rise in ICP. Hypoventilation and hypercarbia significantly increase ICP when compared with hyperventilation and hypocarbia. Hyperventilation does not significantly decrease ICP during acute elevations of IAP.

Defects in serotonin metabolism, and abnormalities in both blood serotonin and tryptophan levels, have been reported in many psychiatric disorders. Tryptophan 2,3-dioxygenase (TDO2) is the rate limiting enzyme for the breakdown of tryptophan to N-formyl kenurenine. Functional variants of this gene could account for the observed simultaneous increases or decreases of both serotonin and tryptophan in various disorders. We have identified four different polymorphisms of the human TDO2 gene. Association studies show a significant association of one or more of these polymorphisms and Tourette syndrome (TS), attention deficit hyperactivity disorder (ADHD) and drug dependence. The intron 6G-->T variant was significantly associated with platelet serotonin levels. Only the association with TS was significant with a Bonferroni correction (p = 0.005). Our purpose here is not to claim these associations are proven, but rather to report preliminary results and show that easily testable polymorphisms are available. We hope to encourage additional research into the potential role the TDO2 gene in these and other psychiatric disorders.

Pathological gambling has been termed both the 'pure' and the 'hidden' addiction. 'Pure' because it is not associated with the intake of any addicting substance, and 'hidden' because it is an extension of a common, socially accepted behaviour. The Taq A1 variant of the human DRD2 gene has been associated with drug addiction, some forms of severe alcoholism, and other impulsive, addictive behaviours. We have sought to determine if there is a similar association with pathological gambling. A total of 222 non-Hispanic Caucasian pathological gamblers from multiple sites across the US participated in the study. Of these 171 donated a sample of blood, 127 filled out several questionnaires, and 102 did both. Of the 171 pathological gamblers 50.9% carried the D2A1 allele versus 25.9% of the 714 known non-Hispanic Caucasian controls screened to exclude drug and alcohol abuse, p < 0.00000001, odds ratio (OR) = 2.96. For the 102 gamblers who filled out the questionnaires, 63.8% of those in the upper half of the Pathological Gambling Score (more severe) carried the D2A1 allele (OR versus controls = 5.03), compared to 40.9% in the lower half (less severe). Of those who had no comorbid substance abuse, 44.1% carried the D2A1 allele, compared to 60.5% of those who had comorbid substance abuse. Forty-eight controls and 102 gamblers completed a shorter version of the Pathological Gambling Score. Of the 45 controls with a score of zero, 17.8% carried the D2A1 allele. Of the 99 gamblers with a score of 5 or more, 52.5% carried the D2A1 allele (chi 2 = 15.36, p = 0.00009). These results suggest that genetic variants at the DRD2 gene play a role in pathological gambling, and support the concept that variants of this gene are a risk factor for impulsive and addictive behaviours.

Objective: To evaluate treatments for common bile duct stones (CBDS)., Design: Retrospective review of authors' case series., Setting: Large private metropolitan teaching hospital., Patients: All patients with CBDS (N = 145) from a series of 1231 patients who underwent laparoscopic cholecystectomy, 99% with intraoperative fluorocholangiography., Interventions: Treatments for CBDS included one or more of the following: laparoscopic transcystic duct exploration (n = 123), laparoscopic choledochotomy (n = 10), open choledochotomy (n = 7), preoperative endoscopic sphincterotomy (ES) (n = 9), intraoperative ES (n = 2), post-operative ES (n = 11), or observation (n = 10)., Main Outcome Measures: Success of various interventions for CBDS, morbidity and mortality, frequency of retained stones, operative time, and length of postoperative hospitalization., Results: Laparoscopic transcystic duct exploration was successful in 91% of attempts and resulted in the shortest postoperative stay (3.4 days), least morbidity (5%), and fewest retained stones (5%). Endoscopic sphincterotomy was successful in 56% of preoperative attempts, 50% of intraoperative attempts, and 91% of postoperative attempts. There were no reoperations and one death., Conclusions: For patients requiring cholecystectomy, laparoscopic transcystic duct exploration is safe and effective, treats CBDS in one session, and if unsuccessful still allows for open choledochotomy or postoperative ES. Preoperative endoscopic retrograde cholangiography and ES should be reserved for patients with serious illness or possible malignant disease.

A psychodynamic approach emphasizes the meaning and consequences of one's behavior. After a brief review of the literature, the authors present the first of a two-part model for psychodynamic psychotherapy with pathological gamblers. In this first phase, the immediate goal is abstinence, and five strategies for obtaining it are discussed. These consist of 1.) breaking through the denial 2.) confronting omnipotent defenses 3.) interrupting the chasing cycle 4.) identifying reasons for gambling, and 5.) motivating the patient to become an active participant in treatment. An argument is made for integrating a traditional psychodynamic approach with an addictions model.