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In this work the deposition of particles onto the surface of a textile-type fiber was investigated using a novel experimental system in which thin, bare monofilaments are used as light guides. This method was previously developed as a tool for investigating the deposition of oil droplets from an emulsion, the extent of deposition being measured via changes in the attenuation of light transmitted down the fiber. The present system studies the deposition and subsequent evaporation of a droplet of an aqueous suspension containing 1.9 μm tracer particles. The dynamics of the evaporation of such a droplet from a flat surface are known to involve a build up of deposited particles at the drop periphery to form a ring stain, the rate of deposition increasing during the evaporation process due to a diverging flux. In this report the deposition characteristics on a flat surface are confirmed and a systematic sequence of experiments for the evaporation of droplets of suspensions containing tracer particles from a polyester fiber surface is reported. The experiments use both video-microscopy and the change in attenuation along the fiber caused by droplet deposition which is related to the wetted area. An initial loss is followed by a period where only a slow change in attenuation occurs and finally by a rapid and large change as the droplet completes its evaporation and a large number of particles are deposited. The relationship between the initial loss and wetted area and the final loss and total number of particles deposited is discussed.

Background: Iatrogenic common bile duct injury is the worst complication of laparoscopic cholecystectomy. The goal of this study is to increase awareness of the problem and educate surgeons about the consequences of these injuries.

The role of intraoperative fluorocholangiography (IOC) in laparoscopic cholecystectomy (LC) is controversial. We evaluated the use of IOC at an institution where the study is performed routinely.Records of all patients undergoing LC during a 3-year period ending January 1, 1996 were reviewed.A total of 1207 patients received IOC, whereas 116 patients did not. IOC findings were categorized as follows: normal, 1016 cases (84%); CBD stone, 149 cases (12.3%); anomalies, 23 cases (1.9%); duodenal diverticula, 10 cases (0.8%); ductal strictures, four cases (0.3%); and CBD diverticula, 5 cases (0.4%). In the 116 patients who did not receive IOC, 35 of the procedures could not be performed, whereas 81 were not attempted. Of the 149 IOC that showed CBD stones, two were false positives. Anomalies included accessory right hepatic ducts (11 cases), cystic ducts joining the right hepatic duct (seven cases), and abnormal cystic duct entries (five cases). Duct injuries occurred in 5 cases (0.4%), three before and two after IOC. Four injuries were minor; IOC prevented CBD transection.Routine IOC is feasible, safe, accurate, and provides critical information of immediate use during LC. By treating ductal stones at operation and identifying patients without CBD stones, IOC minimizes need for postoperative studies, including endoscopic retrograde cholangiography (ERC).

The purpose of this study was to investigate the possibility of detecting bile duct injuries using laparoscopic intraoperative ultrasound (LIOU).Fifty bile duct injuries were created using laparoscopic techniques in ten farmer pigs. The lesions created were: (1) partial occlusion, (2) complete occlusion (1 clip), (3) complete occlusion (2 clips), (4) transection between clips, (5) excision between clips.All injuries were easily visualized using LIOU. The relation of clips impinging upon or occluding the bile duct was readily visualized on LIOU in all cases. In some cases it was difficult to distinguish between partial and complete occlusion. It was also difficult to distinguish between transection and excision due to retraction of the severed bile duct.In cases of iatrogenic occlusion of the bile duct involving hemoclips (including transection or excision between clips), LIOU is a potentially useful modality that may allow earlier recognition and repair. Further studies are needed to evaluate the efficacy of LIOU in detection of bile duct injuries that do not involve hemoclips.

Background: In 100 consecutive patients who underwent laparoscopic cholecystectomy, the feasibility, reliability, and cost of routine laparoscopic cholangiography were prospectively studied. Methods: Fluoroscopic cholangiograms with multiple exposures were successfully completed in all patients in an average time of 6.9 min. Results: Twenty-one percent were abnormal, and 15 common duct stones and 6 significant anatomic anomalies detected. Thirteen out of 15 patients with common duct stones had preoperative suspicion of common duct stones. Two out of 15 were completely unsuspected. The average cost of cholangiography was $768, and there were no complications related to the procedure. There were no false interpretations. Conclusions: When compared with selective preoperative endoscopic retrograde cholangiopancreatography (ERCP), routine laparoscopic cholangiography is safer, more accurate, and less costly, and may have the added benefit of potentially reducing iatrogenic injuries in patients with anatomic variations. Routine laparoscopic cholangiography should be considered by all surgeons.

The management of symptomatic cholelithiasis during pregnancy remains a serious and difficult problem. This condition may be further complicated by the presence of common bile duct stones (CBDS). Two cases of CBDS in pregnancy are presented. During the period from August 1990 to June 1994, 1127 consecutive patients underwent LC by a single surgical team. Two (0.2%) of these patients were pregnant and both were found to have choledocholithiasis. One patient's stones were lavaged into the duodenum via the cystic duct and the other patient had transcystic choledochoscopy and transcystic duct tube drainage. The patients were discharged from the hospital on postoperative days 4 and 6, respectively. There were no complications and both successfully carried their pregnancies to term. Laparoscopic cholecystectomy (LC) with transcystic common bile duct exploration (TCDE) was advantageous in both patients. Neither patient required an abdominal incision or choledochotomy. Laparoscopic TCDE with or without cystic tube drainage is a viable option in the management of CBDS in the pregnant patient.

We retrospectively evaluated the results of laparoscopic cholecystectomy in patients infected with the human immunodeficiency virus (HIV) with and without acquired immunodeficiency syndrome (AIDS). One thousand one hundred twenty-seven consecutive patients underwent laparoscopic cholecystectomy by our surgical group. Eighteen of these patients were known to be infected with the HIV virus; 6 were asymptomatic and 12 had AIDS. We reviewed the medical records of all HIV-positive individuals with regard to morbidity, mortality, and postoperative outcome following laparoscopic cholecystectomy. In the six HIV-patients without AIDS, five (83%) had improvement of symptoms postoperatively. There was one minor complication (17%). In contrast, only one of the 12 patients with AIDS had postoperative improvement of symptoms and eight (66%) had complications after surgery. There were four deaths (33%) within 30 days of surgery in this group. Only a small percentage of AIDS patients benefit from laparoscopic cholecystectomy. There is a significantly morbidity and mortality following this procedure in this group. Strategies to improve outcome are presented.

Smaller individual series on the outcome of laparoscopic hernioplasty techniques have been reported. This study reports on the complications of 3,229 laparoscopic hernia repairs performed by the authors in 2,559 patients. The TAPP (transabdominal preperitoneal) technique was the most frequently performed: 1,944 (60%). The totally preperitoneal technique was performed 578 (18%) times. The IPOM (intraperitoneal onlay mesh) repair was performed 345 (11%) times. The plug-and-patch technique was used 286 (9%) times and simple closure of the hernia defect without mesh was used in 76 (2%) repairs. Overall, there were 336 (10%) complications: 17 (0.5%) major and 265 (8%) minor. There were 54 (1.6%) recurrences, with a mean follow-up of 22 months. The TAPP technique had 19 (1%) recurrences and 141 (7%) complications. There were four bowel obstructions in this subgroup from herniation of small bowel through the peritoneal closure and trocar sites. The totally preperitoneal technique had no recurrence and 60 (10%) complications. The IPOM group had 7 (2%) recurrences and 47 (14%) complications. The plug-and-patch technique had 26 (9%) recurrences and 24 (8%) complications. The simple closure of the internal ring had 2 (3%) recurrences and 10 (13%) complications. Laparoscopic hernioplasty is not without complications. Laparoscopic hernioplasty is not without complications. Training, experience, and attention to technique will prevent some of these complications.

Various methods for performing laparoscopic hernia repair are being developed, and although follow-up is still generally too short to reach definitive conclusions or establish universal guidelines, a significant experience is accumulating. The laparoscopic approach appears to be most advantageous in the repair of recurrent herniae and least advantageous for small unilateral herniae that can be repaired under local anesthesia without using mesh.

Transcystic duct choledochoscopy is a safe and effective modality for clearing the common bile duct of stones encountered during laparoscopic cholecystectomy. The authors present early clinical experience with this new technique as developed at Cedars-Sinai Medical Center in Los Angeles.

More than 500,000 hernia procedures are performed annually in the United States alone. The authors have devised a new technique for laparoscopic hernia repair. The peritoneum is not incised, as the space between the abdominal wall and the peritoneum is developed with CO2 and blunt dissection. The trocars and laparoscope are placed within this preperitoneal space. Mesh is stapled to Cooper's ligament and the underside of the abdominal wall. From November 1990 to January 1992, 68 herniae have been repaired in 35 patients. The first 25 patients were kept overnight for observation and discharged the following day. Thirty-two patients (92%) were able to resume full physical activity within 1 week. Average follow-up was only 12 months, but there were no recurrent or retained herniae.

With increasing acceptance of routine cholangiography during laparoscopic cholecystectomy (for confirmation of anatomy) there has been increased identification of common duct calculi. A technique of laparoscopic transcystic common duct stone extraction is described and early clinical results are presented. Successful stone extraction was accomplished in 39 out of 41 consecutive attempts by one surgical team. Two cases required choledochotomy. There were four complications including hyperamylasemia (2), minor wound infection (1), and incidental pneumothorax (1). Recommendations regarding safety and indications are presented. Initial evaluation suggests laparoscopic transcystic stone extraction is safe and effective.

The drop volume technique for interfacial tension measurement uses relatively small amounts of liquids, but, nevertheless, is capable of high precision. It is, therefore, especially attractive when the substrate phases are limited in quantity. — The introduction of a newly-available micrometer head and alterations to the glass syringe has enabled the traditional technique to be improved on in two ways: first, the effective syringe capacity has been doubled without any loss in accuracy; second, it has been possible to semiautomate the system with considerable time-saving in the calculation of the tension. — The modified technique has been applied to the measurement of the interfacial tension in aqueous/silicone oil systems in situations where the oil, extracted from systems in vivo, had a total volume of about 1 ml. The small density difference in these systems made for large drop volumes, which in certain cases exceeded the capacity of the conventional technique. The modified technique worked well in these systems.

A survey is made of published work on the location of oily soil on textile fabrics. There is evidence that such soil tends to build up at certain preferred sites in the fabric, such as between parallel fibres in the yarn. A theoretical explanation is developed which correlates these observations. Because the shape of a droplet of oil of given volume depends upon the local geometry and contact angle at the site where it is located, different sites are associated with different Laplace internal pressures in the drop. It is shown that differences in these internal pressures between sites can bring about a thermodynamically favored movement of the droplet towards sites where the Laplace excess pressure is least. On this basis, a heirarchy of sites can be constructed and this is found to parallel the observed favor of sites for oily soil in fabrics.

An investigation into the evaporation of sessile droplets of latex and clay particle suspensions is presented in this work. The quartz crystal microbalance (QCM) has been used to study the interfacial phenomena during the drying process of these droplets. Characteristic changes of the crystal oscillating frequency and crystal resistance (damping of the oscillating energy) have been observed and related to the different stages of the evaporation process. Measurements have been made for latex particle sizes from 1.9 to 10 microm and for rough and polished crystals using drops from 0.3 to 1.5 microL. The behavior of the QCM is shown to depend strongly on the size of particles present and on the morphology of the crystal surface. One of the most striking features is a drastic damping of the oscillation energy and corresponding rise in frequency observed during the final stages of evaporation, particularly for the clay suspensions.

Associations of both overt thyroid disease as well as subclinical thyroid abnormalities with affective disorders have been well established. Similar associations have been reported with mixed mania and rapid cycling bipolar disorder. We tested for differences in overt and subclinical thyroid disease and subclinical differences in a large series of bipolar patients examined during mixed or pure manic episodes.Rates of previously diagnosed thyroid disease were compared by sex, race and manic subtype (mixed versus pure) in 443 patients. Serum thyroid stimulating hormone (TSH) and free thyroxine (FT4) concentrations obtained from patients with no clinical thyroid disease collected during manic and mixed bipolar episodes were compared using ANOVA statistics. Race was also included in the model and age was covaried.Rates of thyroid disease, in particular hypothyroidism, were higher in females and white people, and increased with advancing age. No differences were noted between subjects sampled during mixed or pure manic episodes. In patients with no history of thyroid disease, serum TSH and FT4 concentrations did not differ between manic subtypes or between sexes. TSH levels however, were significantly lower in African Americans.We did not confirm past reports of associations of overt or subclinical thyroid disease with mixed manic episodes. African Americans had significantly lower serum TSH concentrations than white people, while FT4 levels did not differ.

latrogene Gallengangsverletzungen nach laparoskopischer Cholezystektomie sind schwerwiegende, potentiell lebensbedrohliche Komplikationen. Neben den verursachenden Fehlern wahrend der Primar-OP fuhren aber auch insbesondere Fehler im Management der Komplikationen haufig zu einem Schlichtungsverfahren oder gar einem Gerichtsprozess. Ziel der Untersuchung ist es die Aufmerksamkeit des Chirurgen auf operativ-technische und Managementfehler zu richten, um das Outcome der Verletzungen zu verbessern.

Existing procedures for the generation of polymorphic DNA markers are not optimal for insect studies in which the organisms are often tiny and background molecular information is often non-existent. We have used a new high throughput DNA marker generation protocol called randomly amplified DNA fingerprints (RAF) to analyse the genetic variability in three separate strains of the stored grain pest, Rhyzopertha dominica. This protocol is quick, robust and reliable even though it requires minimal sample preparation, minute amounts of DNA and no prior molecular analysis of the organism. Arbitrarily selected oligonucleotide primers routinely produced approximately 50 scoreable polymorphic DNA markers, between individuals of three independent field isolates of R. dominica. Multivariate cluster analysis using forty-nine arbitrarily selected polymorphisms generated from a single primer reliably separated individuals into three clades corresponding to their geographical origin. The resulting clades were quite distinct, with an average genetic difference of 37.5 +/- 6.0% between clades and of 21.0 +/- 7.1% between individuals within clades. As a prelude to future gene mapping efforts, we have also assessed the performance of RAF under conditions commonly used in gene mapping. In this analysis, fingerprints from pooled DNA samples accurately and reproducibly reflected RAF profiles obtained from individual DNA samples that had been combined to create the bulked samples.

High rates of substance abuse have been reported in the general population, with males more often affected than females. Although high rates of substance abuse have also been reported in bipolar patients, the relationship between substance abuse and bipolar disorder has not been well characterized.Substance abuse histories were obtained in 392 patients hospitalized for manic or mixed episodes of bipolar disorder and rates of current and lifetime abuse calculated. Analyses comparing sex, subtype (manic vs. mixed) and clinical history variables were conducted.Rates of lifetime substance abuse were high for both alcohol (48.5%) and drugs (43.9%). Nearly 60% of the cohort had a history of some lifetime substance abuse. Males had higher rates of abuse than females, but no differences in substance abuse were observed between subjects in manic and mixed bipolar states. Rates of active substance abuse were lower in older age cohorts. Subjects with a comorbid diagnosis of lifetime substance abuse had more psychiatric hospitalizations.Substance abuse is a major comorbidity in bipolar patients. Although rates decrease in older age groups, substance abuse is still present at clinically important rates in the elderly. Bipolar patients with comorbid substance abuse may have a more severe course. These data underscore the significance of recognition and treatment of substance abuse in bipolar disorder patients.

Few large clinical epidemiological studies have been undertaken comparing subjects meeting criteria for mixed and pure states of bipolar disorder. In part, the difficulty comparing these states emanates from confusion in their diagnostic separation. In the current report, we use a definition derived from receiver operating characteristic (ROC) curve analysis as an alternative to the DSM-IIIR/IV definition, and we compare the two subtypes of manic episodes.Three hundred and sixty-six patients meeting DSM-IIIR criteria for bipolar disorder, manic or mixed, were categorized using newly described criteria for mixed states. The two subtypes were compared on demographic variables and clinical history variables, using multiple analysis of variance with post hoc univariate F tests. The same analyses were conducted using the DSM-IIIR-defined subtypes.Using the ROC criteria, 79 subjects (21.6%) were characterized as mixed, in contrast to 51 subjects (13.9%) using DSM-IIIR criteria for bipolar disorder, mixed. The ROC-defined mixed manic group comprised more Caucasians and more females. Age of first psychiatric hospitalization was earlier and duration of illness longer in the mixed group. First episodes were unlikely to be categorized as mixed (5%). When the DSM-IIIR definition was employed, differences were not demonstrated.An earlier age of first psychiatric hospitalization and increased duration of illness, as well as a lower frequency of mixed subtype of manic episode during first hospitalization, are compatible with the view that mixed manic episodes occur more frequently later in the course of bipolar disorder. Moreover, differences in race, sex, and clinical histories of subjects in mixed episodes tend to support the separation of mixed mania as a diagnostic subtype of bipolar disorder.

Erianthus arundinaceus has great potential as a germplasm source for better ratoonability, vigour, tolerance to environmental stresses, and disease resistance in sugarcane. Many unsuccessful attempts have been made to introduce these characters into modern sugarcane cultivars. We report on significant progress made since molecular tools were implemented. Sequence-tagged PCR, revealing size variation in the 5S rDNA cluster, was performed on intact leaf tissue to identify genuine hybrids six weeks after germination. This early screening of seedlings avoids the loss of genuine hybrids due to competition with selfed progeny. Of 96 crosses made involving female Saccharum officinarum or sugarcane cultivars (Saccharum spp.) and male E. arundinaceus, 26 were fertile producing 1328 seedlings. Thirty-seven genuine hybrids were unequivocally identified but only 19 have survived. Genuine hybrids were produced from only three crosses, all involving S. officinarum as the female parent. Chromosome elimination was observed in all seven hybrids analyzed using genomic in situ hybridization (GISH). Very little cross-hybridization was observed between the genomes of the two species after GISH, confirming recent molecular studies which showed that E. arundinaceus is quite distant from the genus Saccharum. The major limitation in the introgression of E. arundinaceus resides now in the apparent sterility of the hybrids.

Background: Staging laparotomy provides useful information for management of Hodgkin disease but has fallen into disfavor because procedure-related morbidity exceeds that of new chemotherapeutic regimens. Objective: To determine the feasibility, effectiveness, and safety of laparoscopic staging for Hodgkin disease compared with those of open staging. Patients: Fifty-five patients with Hodgkin disease of cell types including nodular sclerosis in 43 (78%), mixed cellularity in 9 (16%), and lymphocyte predominance in 3 (5%). Study Design: Concurrent evaluation of laparoscopic staging (n= 15) and retrospective review of open staging (n=40). Interventions: Laparoscopic and open techniques of surgical staging for Hodgkin disease, including splenectomy, liver biopsies, and lymph node sampling. Main Outcome Measures: Operative time, duration of postoperative ileus and of postoperative hospitalization, morbidity, number of lymph nodes retrieved, alteration in pathologic stage, recurrence, and survival. Results: For laparoscopic staging vs open staging groups, mean operative time was 202 vs 144 minutes (P=.001); mean postoperative ileus was 1.9 vs 3.2 days (P

Dysregulation of the hypothalamus-pituitary-adrenal axis (HPA) is more common in elderly patients with depression than in younger depressed patients, and glucocorticoids are known to influence serotonergic function. Elderly depressed patients are also reportedly more resistant to therapeutic effects of antidepressants. In the current study, we measured platelet serotonin transporter binding sites and transport function in young and elderly depressed patients and determined the relationship to HPA status as assessed with the dexamethasone suppression test (DST). The density and affinity of transporter molecules showed no differences between young and elderly depressed patients, regardless of DST results. Nevertheless, transporter function showed a substantial interaction of aging with DST: elderly DST suppressors showed a deficit in [3H]serotonin uptake capabilities and resistance to imipramine inhibition of uptake. No such defects were seen in the young depressed cohort, regardless of DST status, nor in elderly depressed DST non-suppressors. These results are consistent with the view that depression in the elderly exhibits basic biological differences from depression in earlier life, and that such distinctions may account in part for therapeutic ineffectiveness of antidepressants in specific subgroups, associated with the presence or absence of appropriate HPA regulation.

An effort was made to determine whether a policy of routine cholangiography affects the incidence, morbidity, and cost of bile duct injuries.A retrospective review of consecutive 3,242 laparoscopic cholecystectomies was performed. Most patients had routine intraoperative cholangiography.There were 12 bile duct injuries (0.37%). All injuries were Bismuth levels 1 and 2. Eleven of 12 injuries were recognized intraoperatively. Ten were repaired primarily and one required hepaticojejunostomy. All repairs were successful. Average hospital charges were $26,669. One of 12 patients had delayed recognition of a bile duct injury and underwent primary repair over a T-tube on postoperative day 7. Hospital charges were $43,957.Routine cholangiography did not appear to decrease the absolute incidence of bile duct injuries compared to previously published reports. Injury severity, morbidity, late sequelae, and costs were reduced by a policy of routine cholangiography.

In the United States of America, approximately 700,000 patients undergo laparoscopic cholecystectomy (LC) each year and at least 10 percent of these patients will have common bile duct stones (CBDS). The purpose of this study was to evaluate patients with choledocholithiasis and compare the economic and clinical results obtained by LC with endoscopic sphincterotomy (ES) with those of LC with laparoscopic transcystic common bile duct exploration (LTCBDE).From June 1991 to September 1994 patients undergoing LC plus LTCBDE and those undergoing LC plus ES at a single institution were compared where cost data were available. Of the 76 patients with choledocholithiasis, 59 patients underwent LC plus LTCBDE (group 1) and 17 patients underwent LC plus ES (group 2). A subset of group 1 patients undergoing urgent LC plus LTCBDE (group 3) for cholecystitis, cholangitis, or pancreatitis plus laparoscopy were examined separately.Laparoscopic cholecystectomy plus LTCBDE, whether including all-comers (group 1) or just urgent cases (group 3), was associated with a significantly decreased length of hospital stay (6.1 and 6.9 days, respectively, compared with group 2, 12.4 days) (p0.001). The morbidity of patients in group 1 was also markedly lower than for patients in group 2; 12 percent compared with 41 percent, respectively. Patients in group 1 had a significantly decreased cost of hospitalization (+13,151), when compared with patients in group 2 (+18,712) (p = 0.05). This difference is even more pronounced when professional fee reimbursement is considered. The cost of treatment for patients in group 1 was +14,732 compared with +21,125 for patients in group 2 (p0.05). The total hospital cost for patients in group 3 was only +13,564 compared with +18,712 for patients in group 2. When professional reimbursement was considered, the cost was +15,150 for patients in group 3 compared with +21,125 for patients in group 2.Patients undergoing LC plus LTCBDE for CBDS, whether urgently or electively, have markedly decreased morbidity rates, length of hospital stay, and costs when compared with patients undergoing LC plus ES.

This study examines the relationship of serum prolactin changes (delta PRL) to variations in electrode placement after controlling for differences in the convulsive threshold. Previous studies showing greater release of PRL with bilateral (BL) compared with right unilateral (RUL) electrode placement were conducted without knowledge of the convulsive threshold. Twenty-two patients each received threshold RUL, threshold BL, 2.25 times threshold RUL, and 2.25 times threshold BL ECT. Serum PRL was collected 5 min before and 15 min after each electroconvulsive therapy (ECT). The convulsive threshold was greater for BL than RUL electrode placement. delta PRL was greater with BL than RUL ECT at comparable relative stimulus intensities. delta PRL was not correlated with seizure duration or absolute stimulus dose.

The aim of this study was to evaluate the outcome of patients undergoing laparoscopic colectomy for diverticulitis.Fourteen consecutive patients undergoing laparoscopic sigmoid colectomy (LSC) for diverticulitis were evaluated. Medical records from a control group of 14 matched patients undergoing traditional open sigmoid colectomy (OSC) for diverticulitis were reviewed for comparison.Mean age, operative time, morbidity, and mortality of the LSC and OSC groups were not significantly different. However, the mean estimated blood loss (171cc vs 321cc), days to p.o. liquids (2.9 vs 6.1), and postoperative stay (6.3 vs 9.2 days) were all significantly less in the LSC patients. Although the mean operating room charges were greater in the LSC patients ($10,589 vs $8,207) the mean total hospital charges ($29,981 vs $36,745) and costs ($11,528 vs $13,426) were markedly less.Compared with OSC for diverticulitis, LSC results in a more rapid return of bowel function and shortened hospital stay. Despite the greater operating room charges of LSC, the total hospital charges and costs are lessened.

Bile duct injury is one of the most serious complications of laparoscopic cholecystectomy (LC). In open cholecystectomy (OC) the reported incidence of injury is less than 0.2 per cent. In LC, the aggregate reported experience, in many thousands of cases, is three or four times this number. Although "the learning curve" has been considered the principal factor in the heightened incidence of this complication with LC, there are hazards inherent in this new surgical modality that may never allow elimination of the increased risk of bile duct injury. As a sequel to an earlier report of 1200 cases of OC before the laparoscopic era from a single institution, this report deals with the next 2427 consecutive cases of LC from the same institution. In the first 1284 cases of LC, there were seven bile duct injuries (0.58%); in the ensuing 1143 cases there were six bile duct injuries (0.50%). The overall incidence nationwide is even higher, as evidenced by widespread reports of repair of bile duct injuries referred to major tertiary care centers. Routine operative cholangiography is of the utmost importance in the early recognition and immediate repair of ductal injuries. In 12 of the 13 cases reported here, early recognition and repair during the primary surgery resulted in a successful outcome.

The incidence and reasons for early recurrences following laparoscopic hernioplasty have not been studied. Because the incidence is small and the follow up is short, a multi-institutional study was performed among the pioneers in the field. The incidence figures were obtained by survey of surgeons who had significant experience (over 100 cases) and kept concurrent records. Fifty-four recurrences (1.7%) occurred after 3229 laparoscopic hernia repairs. There were 1944 transabdominal preperitoneal (TAPP) repairs with 19 recurrences (1%) and 578 preperitoneal repairs with no recurrences. There were 345 onlay mesh (IPOM) repairs with seven recurrences (2%), and 286 plug and patch repairs with 26 recurrences (9%). Simple closures were performed 76 times with two recurrences (2.6%). Fifty-seven patients (three cases were referred to the author without incidence data but complete records for analysis) had 60 recurrent hernias. Recurrences were noted, on average, 5.1 months postoperatively (range 0–30 months). The most common reason for recurrence was that the mesh was too small — 36 (60%). The mesh was never stapled in 19 instances (32%), and the hernia was never repaired in three cases (20%). The clips pulled through the tissue in six cases (8%), and in 10 cases (15%) the repair has not yet been undertaken because the etiology was unclear. There was more than one reason in 19 patients. Technical factors were responsible for nearly all recurrences.

Laparoscopic cholecystectomy has become the standard treatment for symptomatic cholelithiasis since its introduction in March 1987 by Mouret in France. Currently there are no absolute contraindications for laparoscopic cholecystectomy, but there are some relative contraindications, the determination of which depends on the operator’s experience. These include generalized peritonitis, septic shock from cholangitis, shock from severe acute pancreatitis, cirrhosis with portal hypertension, severe coagulopathies, cancer of the gallbladder, and third-trimester pregnancy.

One thousand seventy-one consecutive laparoscopic cholecystectomies were performed. Routine cholangiography was employed with a 99% success rate. One hundred thirty patients were found to have common duct stones (CBDS). In 48 (37%) patients they were unsuspected. One hundred eleven patients underwent attempted trans-cystic-duct extraction techniques (TCD-CBDE). One hundred three (93%) were successful. The following techniques were employed: 101--biliary endoscopy, 23--ampullary balloon dilation, 2--fluoroscopic basket retrieval. The average operative time was 136 min. The average postsurgical stay was 3.7 days. There were 19 (17%) complications--6 (5%) major. There were 4 retained stones (2 intentional) and 1 death. Patients over 65 years of age had more complications and patients with unsuspected CBDS under 65 years of age had the fewest. TCD-CBDE is a safe, effective way to extract common duct calculi. Endoscopy and basket stone retrieval was the primary technique employed.

Laparoscopic splenectomy was attempted in 16 patients and was performed successfully in 13 (81%) patients with the diagnosis of idiopathic thrombocytopenic purpura (ITP), AIDS-related thrombocytopenia, Hodgkin's disease, or lymphoma. The operative time averaged 157 min, and autologous transfusion was required in four patients. The postsurgical stay averaged 3 days in patients with completely laparoscopic splenectomies and 4 days in patients whose spleens were removed through small counterincisions. No major complications secondary to the procedure itself occurred postoperatively. Conversion to open operation was necessary in three (19%) patients because of bleeding or splenomegaly. With careful selection of patients and mastery of the technique, laparoscopic splenectomy can be safely performed on normal or slightly enlarged spleens. The advantages are less pain, shorter hospitalization, and reduced disability as compared to "open" splenectomy.

Results of laparoscopic cholecystectomy in obese and non-obese patients were analyzed prospectively. Laparoscopic cholecystectomy was performed in 841 patients-179 obese (Group I) and 662 non-obese (Group II). Operative time averaged 73.1 minutes in Group I and 73.7 minutes in Group II. There were no statistically significant differences in the ability to perform cholangiography (99.4% Group I; 97.9% Group II), conversion rate (1.1% Group I; 1.5% Group II), or complications (4.5% Group I; 3.8% Group II). In Group I no pulmonary complications were noted, nor any cases of venous thromboembolic disease. Risk of laparoscopic cholecystectomy appears comparable in obese and non-obese patients. Based on historical comparisons, laparoscopic cholecystectomy may be safer than traditional cholecystectomy in obese patients.

Preoperative prediction of common bile duct stones (CBDS) is imprecise. Cholangiography during laparoscopic cholecystectomy (LC) is the best method for detection of CBDS. Treatment of most stones detected at LC can be safely accomplished using transcystic choledochoscopy and stone extraction. This technique is applicable in nearly 90% of patients with CBD calculi. It may be preferable to endoscopic sphincterotomy (ES) in younger patients and is probably equivalent to ES in patients over 65 years of age.

Manic depressive illness (bipolar disorder) is the mood disorder classically considered to have a strong biological basis. During manic depressive cycles, patients show dramatic fluctuations of mood, energy, activity, information processing, and behaviors. Theories of brain function and mood disorders must deal with the case of bipolar disorder, not simply unipolar depression. Shifts in the nosologic concepts of how manic depression is related to other mood disorders are discussed in this overview, and the renewed adoption of the Kraepelinian "spectrum" concept is recommended. The variable clinical presentations of manic depressive illness are emphasized. New genetic mechanisms that must be considered as candidate factors in relation to this phenotypic heterogeneity are discussed. Finally, the correlation of clinical symptom clusters with brain systems is considered in the context of a three-component model of manic depression.

From August 1989 to January 1993, the authors performed laparoscopic biliary operations in 900 patients, 13 of whom had severe cardiac dysfunction. Nine patients were Goldman Class IV, and four patients were Goldman Class III. Three patients had recent myocardial infarction, five patients were known to have low left ventricular ejection fractions (10%, 21%, 25%, 26%, and 30%), one had severe myocardial ischemia, one had severe congestive heart failure, and one was in profound shock. Nine patients underwent successful laparoscopic cholecystectomy. Laparoscopic cholecystostomies were performed in three patients. One operation was converted to an open cholecystectomy. There was one death within 30 days of surgery. With appropriate hemodynamic monitoring and adequate perioperative support of cardiac function, laparoscopic cholecystectomy can be performed safely for acute cholecystitis in patients with severe cardiac disease. When compared with historical controls, laparoscopic cholecystectomy appears to be safer than open cholecystectomy.

Balloon dilatation of the sphincter of Oddi has been performed via a laparoscopic transcystic duct technique. Small common duct stones and stone debris have been successfully lavaged into the duodenum in 17 of 20 cases (85%) by this method. Postoperative hyperamylasemia was noted in four patients. Mild clinical pancreatitis was observed in three patients (15%). Further evaluation of this technique as an adjunct to laparoscopic common bile duct stone extraction is warranted.

We investigated various energy sources and delivery systems suitable for fragmentation of common duct calculi by a laparoscopic technique. We evaluated electrohydraulic lithotripsy (EHL) using 1.9-Fr probe delivering 80 W and laser lithotripsy using a 200-micron(s) fiber delivering 30-70 mJ/pulse at 5-20 Hz. In vitro biliary stone fragmentation analysis suggested that the laser lithotripsy produced a more controllable fragmentation than EHL. Initial attempts to employ EHL techniques in animal models resulted in common bile duct injury or inadequate fragmentation of stones. In contrast, biliary lithotripsy was accomplished in pigs using the pulsed-dye laser at 10 Hz and 60 mJ/pulse. Histologic evaluation revealed no evidence of ductal injury related to laser stone fragmentation. Subsequently, laser common duct lithotripsy was used in two human subjects. One patient had a 1.8-cm impacted ampullary stone and one patient had a 3-cm intrahepatic stone. In both cases, the stones were removed laparoscopically after laser fragmentation. Our experience suggests that the laser lithotripsy may facilitate laparoscopic common duct stone extraction procedures.

This study reports outcome data from a diverse population undergoing laparoscopic cholecystectomy. Our technique differs from other laparoscopic methods in its use of electrocautery, blunt hilar dissection, and routine intraoperative cholangiography. This study includes 453 consecutive surgeries performed between August 1989 and March 1991. Only the first 20 patients were screened to exclude those with common bile duct stones, prior upper abdominal surgery, pregnancy, or acute cholecystitis. Patients had the following conditions: current acute cholecystitis (9%), a history of acute cholecystitis (16%), jaundice (5%), pancreatitis (4%), and prior abdominal surgery (38%). Nine per cent had common bile duct stones which were treated with either laparoscopic transcystic common bile duct exploration (69%), laparoscopic choledochotomy (5%), open choledochotomy (10%), endoscopic retrograde cholangiopancreatography (10%), or observation (7%). Operative time averaged 78 minutes. One patient died, and 6% developed complications. Seventy-one per cent were discharged on the first postoperative day. Our experience demonstrates that LC can be performed safely, even in difficult cases, although considerable endoscopic experience and skill are required.