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Although the surgical advantages of laparoscopic cholecystectomy (LC) have been reported, the anaesthetic problems associated with this new technique have not been well described. For the first 101 patients undergoing laparoscopic cholecystectomy at our institution, we prospectively documented intraoperative critical observations and adverse outcomes in the PACU (Post-Anaesthetic Care Unit). In order to put the magnitude of these problems into perspective, we compared, in an identical manner, the anaesthetic management and outcomes of two more familiar surgical groups, cholecystectomy by laparotomy (C), and laparoscopy for gynaecological examination (LG). For this new procedure LC, intraoperative hypotension (12.9%), and PACU hypothermia (31.4%), nausea and vomiting (12.9%) and desaturation (10.9%) were common but excessive pain (4.0%) was rare. Patients undergoing C, who were older and less healthy, tended to have fewer incidents of OR hypotension (3.4%) but in the PACU experienced more desaturation (25.9%) and excessive pain (12.9%) (P < or = 0.05). The younger and healthier LG group had fewer problems, less OR hypotension (0.4%), and less PACU nausea and vomiting (5.7%) and desaturation (1.3%) (P < or = 0.05). However, the LG group had a similar incidence of excessive pain (4.4%). We have documented considerable postoperative anaesthetic benefits for patients undergoing laparoscopic cholecystectomy compared with conventional cholecystectomy. However, there is still considerable perioperative morbidity compared with gynaecological laparoscopies. Now that specific problems have been identified, they may be amenable to specific anaesthetic interventions.

We report a rare case of a patient with blastomycosis who presented with splenic abscess and peritoneal involvement. This case is unique in that no historical or radiographic evidence of antecedent pulmonary infection was apparent and therapy with orally administered ketoconazole was effective. We reviewed the English-language literature on blastomycotic splenic abscess and compared findings from other cases with findings from the current case.

Treatment for systemic candidiasis has often been withheld because of the nephrotoxicity of standard amphotericin B therapy, particularly in immunodepressed patients. The authors describe their experience between 1981 and 1983 with 29 such patients in the intensive care unit who were treated with low-dose amphotericin B. The diagnosis was made when endophthalmitis or persistent fungemia was present, or when Candida was cultured from three or more body sites. The daily dose of amphotericin B was 0.3 to 0.5 mg/kg. Treatment was accompanied by a mean increase in the serum creatinine value of 26% in patients who did not undergo dialysis before therapy, but this did not lead to renal failure. The overall death rate was 72.4%. Non-survival appeared to be associated with an inadequate total dosage (less than 6 mg/kg); survivors received a mean total dose of 570 mg. A retrospective analysis of positive peritoneal cultures failed to support their previously reported significance. The authors conclude that, in some instances, low-dose amphotericin B will effectively treat systemic candidiasis, resulting in little renal impairment, and that the criteria for such treatment require re-evaluation.

Pneumatosis cystoides intestinalis is an uncommon condition in which pockets of gas occur intramurally in the gastrointestinal tract. The authors describe the case of a 76-year-old man in whom this condition caused low colonic obstruction, simulating a rectal carcinoma. The patient was successfully treated with high-flow oxygen therapy. This form of therapy has not previously been reported in obstructing lesions, but in this case it successfully relieved the obstruction and thus avoided a colostomy that might have been necessary.

Despite the best conservative measures available for the control of major variceal hemorrhage, some patients either continue to bleed, or rebleed early, and require emergency surgery. One hundred patients with cirrhosis and uncontrolled bleeding were treated with emergency portasystemic shunts between 1968 and 1983. Fifty eight patients had end-to-side portacaval shunts and 42 had Dacron interposition mesocaval shunts. Both groups were comparable with respect to age, sex and prevalence of alcoholism. There was an increased severity of liver disease as assessed by Child's class in the mesocaval group of patients. Overall in-hospital mortality was 31% with no significant difference demonstrated between the mesocaval group (28%) and the portacaval group (33%), nor between alcoholic cirrhotics (34%) and non-alcoholic cirrhotics (21%). Mortality rates based on severity of liver disease were: Child's A (1/6) 17%, Child's B (9/48) 19%, and Child's C (21/46) 46%. There was a statistically significant difference between Child's A & B and Child's C (p less than 0.01). Four patients were lost to follow-up. No significant differences were found in 5 year survival by life table analysis comparing portacaval (39%) vs. mesocaval (28%) groups or alcoholic cirrhotics (36%) vs. non-alcoholic cirrhotics (29%). Encephalopathy in survivors was absent in 46%, mild in 28% and severe in 26% of patients. There was no significant difference in encephalopathy rates following portacaval or mesocaval shunting. Neither operation was clearly superior and choice of operation can be made on the basis of technical and anatomical factors and surgeon experience. Emergency shunting remains a useful option for patients with variceal bleeding refractory to other more conservative therapy, and is associated with acceptable early mortality and long term survival rates.