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Data on the incidence, nature and management of early laparoscopic biliary injury up to January 1993 were obtained by a postal questionnaire sent to all New Zealand general surgeons (n = 214; response rate 71 percent) and to all endoscopists who perform endoscopic retrograde cholangiography (n = 16; response rate 100 percent). A total of 41 injuries (surgeons' survey, 22; endoscopists' survey, 19) occurred in an estimated 4000 laparoscopic cholecystectomies; 16 involved the common bile and hepatic ducts, and 25 the cystic and segment V ducts. Operative cholangiography was performed in one patient. The diagnosis of injury was made after operation in 31 of 41 patients and after discharge in 21. Conservative management was undertaken in only 19 patients. This prospective audit documents an increase in the incidence of early biliary injury after the introduction of laparoscopic cholecystectomy in New Zealand. The results highlight the need for further study to determine the best way to ensure early and accurate diagnosis of biliary injury and to define optimal conservative and operative management.

The clinical and economic impact of minimally invasive surgery in New Zealand, especially laparoscopic cholecystectomy, has been profound but uncharted. A postal questionnaire was sent to all general surgeons in New Zealand (n = 214), in order to document the current levels of experience, adequacy of training, levels of equipment and sources of funding. In the case of laparoscopic cholecystectomy, further details were obtained relating to operative technique, complication rates and approaches to the management of choledocholithiasis. The response rate was 71%. From 27 centres, 71 of 106 active general surgeons were performing minimally invasive surgery. Of the 34 different procedures audited, cholecystectomy (3056), herniorrhaphy (178), and appendicectomy (141) were performed most often. Primary funding came from Area Health Boards (71%) and private hospital funds (25%) with 4% coming from other sources. Ten different camera/insufflator systems were used. Training was perceived to be adequate by the majority of surgeons (89%), although seven surgeons had received no specific training. Laparoscopic cholecystectomy technique included: prophylactic antibiotics (89% of surgeons), patients supine (80%), wound infiltration (80%), routine use of diathermy within triangle of Calot (36%) and a routine peritoneal drain (13%). Routine operative cholangiography was used rarely (7%) and 72% of surgeons had deliberately changed their policy with respect to its use. Twenty-two cases of laparoscopic biliary injury were identified by the survey, none of whom had operative cholangiography. The conversion rate was 13% for acute and 4% for elective laparoscopic cholecystectomy. This survey indicated the broad scope of minimally invasive surgery that is being undertaken, and highlights potentially important variations in surgical practice.

A prospective study was undertaken to evaluate selective visceral angiography (SVA) in the management of patients with pancreatic and periampullary cancer. Over a 30-month period 52 patients with potentially resectable pancreatic or periampullary cancer underwent SVA; 4 patients had obvious angiographic evidence of widely disseminated disease and were not subjected to laparotomy while 2 further patients were eventually considered too frail for resection. The remaining 46 patients (median age 58 years, range 37-73 years, males 26, females 20) had no evidence of disseminated disease on ultrasonography and/or CT scanning and had both SVA and surgery and form the basis of this study. Vascular anomalies were detected in 16/46 (35%) patients. Hepatic metastases were wrongly diagnosed by angiography in 7 out of 9 patients (77%). SVA correctly predicted resectability or irresectability in 28/46 patients (overall predictive value 61%). Of the 27 patients who proved to have irresectable disease at operation, 11 were correctly identified by SVA (sensitivity 41%). Of the 13 patients reported to have irresectable disease, 2 underwent resection (false-positive rate 15%). Of the 33 patients reported to have resectable disease, 16 were irresectable (false-negative rate 48%). Overall there was a poor relationship between resectability and the angiographic features. On the basis of these data, SVA cannot be considered a sufficiently accurate means of assessing resectability. Its use for this purpose in patients with pancreatic and periampullary cancer is not justified.

It has been proposed that endotoxin contributes to the development of multiple organ failure (MOF) in acute pancreatitis. Endotoxaemia is transient and may not be detected by intermittent blood sampling. By contrast, not only can changes in the patient's endogenous antiendotoxin core antibody pool persist for many days, but depletion of this pool may be a key event in determining the physiological significance of endotoxaemia. A series of 33 patients with acute pancreatitis had daily measurement of Acute Physiology Score (APS) and levels of C-reactive protein, interleukin 6, endotoxin, immunoglobulin (Ig) G and IgM antiendotoxin core antibodies, and prospective documentation of complications. Endotoxin was detected in the serum of 13 patients, while a significant change in levels of endogenous antiendotoxin core antibodies was detected in all those with severe pancreatitis and in 28 overall. MOF developed in seven patients, five of whom died. The combination of a rising APS over the first 48 h of admission and a significant fall in endogenous IgG antibody level was observed in all patients who developed MOF (seven of seven), but in only one of 16 without MOF (P = 0.00003; overall predictive value 91 per cent). This study suggests that measuring the initial trend in APS and the concentration of endogenous IgG antiendotoxin core antibody provides a means of identifying patients with acute severe pancreatitis who are at high risk of developing MOF. This group might benefit from passive immunotherapy with antiendotoxin antibodies.

A 7.5-MHz linear array ultrasound probe has been developed for the evaluation of solid organs at laparoscopy. Twelve patients with suspected carcinoma of the head of the pancreas, considered at initial investigation to have resectable disease, were submitted to laparoscopy. In 4 patients, diagnostic laparoscopy revealed hepatic metastases (4 patients), peritoneal dissemination of tumor (2), and malignant ascites (1). Laparoscopic ultrasonography demonstrated hepatic metastases in four patients and hepatic cysts in two further patients. Ultrasound evaluation of the pancreas revealed lymphadenopathy (4 patients), local infiltration (2), and portal vein displacement or invasion (4). An anomalous right hepatic artery arising from the superior mesenteric artery was identified in one patient. Overall, laparoscopy identified advanced disease in four patients. Laparoscopic ultrasonography, while detecting advanced disease in a further two patients. predicted resectable disease in six patients (50%). Only one of the six patients submitted to laparotomy was found to have irresectable disease due to lymph-node metastases. Laparoscopic ultrasound examination of the pancreas and liver has improved the early staging of pancreatic carcinoma and should be undertaken at an early stage in the management of such patients.

The relation between weight loss and the risks of major surgery have been investigated for more than 50 years. It can now be said, with some confidence, that the underweight patient has an increased risk of complications following major surgery. This understanding, however, is based on methods of nutritional assessment that are of limited relevance to hospitalized patients whose malnutrition might be due to sepsis, neoplasia, trauma, or starvation. A consequence is the widespread belief that protein-energy malnutrition (PEM) has been overemphasized as a surgical risk factor, and that the many nonnutritional risk factors ought to be implicated more often. An argument is made for a fresh approach to nutritional assessment in order to better identify the individual patient who, by virtue of PEM, stands an increased risk of a complicated postoperative course. It is suggested that an evaluation of the impact PEM has on vital physiologic function provides a clinically relevant defect to identify and treat and a means of monitoring response to nutritional intervention.

It has been usual practice to manage gallstone pancreatitis conservatively over the acute phase and to perform an elective cholecystectomy after an interval of 2-3 months. Because of the risks of recurrent pancreatitis, and in an effort to reduce the high morbidity and mortality associated with severe pancreatitis, there has been a trend towards early surgical intervention and, more recently, endoscopic sphincterotomy. From the Greenlane Hospital experience during 1979-1987, and from a review of recent literature, a strategy is proposed for the management of acute gallstone pancreatitis.

Pulmonary complications remain the most important cause of postoperative morbidity and mortality. The many advances of modern surgical care over the last 30 years have not appreciably altered the incidence of these complications. Many risk factors have been shown to contribute to this problem, but no studies have examined the impact of preoperative protein depletion on respiratory function and related this to the development of postoperative pulmonary complications. 80 patients (42 men, 38 women, median age of 64 years, with a range of 15-91 years) awaiting major elective gastrointestinal (G.I.) surgery were divided into two categories on the basis of a direct measurement of protein depletion: nonprotein-depleted patients (n = 41, mean protein loss, 2% +/- 1.7 SEM) and protein-depleted patients (n = 39, mean protein loss, 36% +/- 3.5 SEM). There was no significant difference between these two categories in regard to age, height, sex, surgical diagnosis, the presence of chronic lung disease, smoking, proportion of upper abdominal incisions, degree of obesity, the duration of anesthesia, and the use of prophylactic antibiotics and physiotherapy. There was a significant difference between these two categories of patients in regard to respiratory muscle strength (p less than .025), vital capacity (p less than .05), and peak expiratory flow rate (p less than .005). Pneumonia developed in a significantly higher proportion of protein-depleted patients with atelectasis (p less than .05), and their stay in the hospital after surgery was longer (p less than .05). These data show that protein depletion is associated with an impairment of respiratory function, and is in itself a significant risk factor in the development of postoperative pneumonia.

This study was designed to test the hypothesis that protein depleted surgical patients are at an increased risk of postoperative complications following major surgery; 101 patients and 59 normal volunteers had measurements of nutritional status (weight loss (%), midarm muscle circumference, plasma transferrin and prealbumin concentration and a direct measurement of pre-operative protein depletion, the protein index) and the patient's postoperative course was carefully monitored from the time of operation until discharge. The patients were divided into two categories on the basis of the extent of protein depletion: non-protein depleted patients (4% mean protein loss) and protein depleted patients (39% mean protein loss). The protein depleted patients had a significantly higher incidence of major complications, pneumonia and stayed in hospital longer (both overall stay and postoperatively).

A case of halothane induced hepatitis is reported in a middle aged woman who underwent gastric surgery for morbid obesity. The abnormalities in her liver function tests included a progressive rise in bilirubin level over five weeks. Prompt resolution of her jaundice followed the initiation of methionine therapy.

We have recently found that an impairment of the wound healing response (WHR) occurs in surgical patients with protein-energy malnutrition before there are any measurable changes in body fat and protein stores. The hypothesis of this study was that the patients' recent food intake is more important in determining the WHR than the patients' overall nutritional status. We have measured the recent food intake (by dietary recall), the WHR (by hydroxyproline accumulation in subcutaneous GORE-TEX implants), the pre-operative weight loss (per cent), and body fat and protein stores (by in vivo neutron activation analysis) in 83 patients awaiting a major elective gastrointestinal resection, and divided them into two groups: adequate recent food intake (n = 59) and inadequate recent food intake (n = 24). There was no significant difference between these two groups for age, sex, diagnosis, surgical procedure, weight loss (per cent), or the amount of body fat and protein stores but there was a significant difference in the WHR (1.81 +/- 0.16 s.e.m. versus 1.04 +/- 0.22 s.e.m. nmol hydroxyproline/mg GORE-TEX, P less than 0.005). These results show that pre-operative food intake has a greater influence over the wound healing response than absolute losses of protein and fat from body stores and they suggest that the maintenance of a normal food intake up until the time of surgery is of importance in preventing an impairment of the wound healing response.

It is a long held belief that weight loss is a basic indicator of surgical risk. Many experienced surgeons, however, think otherwise. We have investigated the proposition that weight loss is a risk factor for postoperative complications but only when associated with clinically obvious physiologic impairment. Before major surgery, 102 patients had a careful history taken to ascertain if there had been recent weight loss and a reduction in the capacity for activity. Physical examination included assessment of mood, skeletal muscle function, respiratory muscle function, and wound healing. Plasma albumin was also measured. Using this information the patients were placed into one of three groups. Group I (N = 43) were normal, group II (N = 17) had weight loss greater than 10% but no clinical evidence of physiologic impairment, and group III (N = 42) had weight loss greater than 10% with clear evidence of dysfunction of two or more organ systems. The patients in group III had significantly more postoperative complications (p less than 0.05). They also had more septic complications (p less than 0.02) including a higher incidence of pneumonia (p less than 0.05) and a longer hospital stay (p less than 0.05) than patients in each of the other two groups. Objective measurements of body stores of protein and liver, and psychologic, respiratory, and skeletal muscle function, confirmed the validity of the clinical classification into the risk groups. The results demonstrate that weight loss is a basic indicator of surgical risk in modern practice providing it is associated with clinically obvious impairment of organ function. They suggest that adequate body protein stores are necessary for normal body function and for minimizing the risks of surgery.

Measurements of voluntary hand grip strength (GS) are a sensitive predictor of postoperative complications. The loss of body protein is thought to be important in the development of these postoperative complications, but the relationship between GS and body protein status has not been studied. We have measured GS (by hand dynamometry), total body protein (indirectly by mid-arm muscle circumference, and directly by in vivo neutron activation analysis) and the proportion of protein loss (protein index) in 80 patients with gastrointestinal disease and 87 normal volunteers. Using regression analysis, a matched study and clinical decision analysis, it has been demonstrated that GS is a sensitive measurement of the degree of protein loss. The results support more widespread use of GS measurements in the identification of patients at high risk of postoperative complications and in the monitoring of patient response to nutritional intervention.

Yersinia hepatic abscesses are rare, and are more likely to occur in patients with iron overload. A diabetic patient with haemochromatosis presented with a hepatic abscess due to Yersinia enterocolitica, which was treated successfully by the use of a single antibiotic.