Spontaneous extrusion of gallstones after percutaneous drainage

There have been reports of late discharge of gallstones through operative wounds after spillage into the peritoneal cavity during laparoscopic cholecystectomy and after the development of spontaneous cholecystocutaneous fistulae. However, spontaneous discharge of gallstones from the tract of a percutaneous cholecystostomy or percutaneous drainage of a perforated gall bladder has not, to the best of our knowledge, been reported previously. We report a case in which a patient who had a percutaneous drain inserted for a perforated gall bladder discharged 34 gallstones from the tract after removal of the 7-F pigtail catheter

Should chloride-rich crystalloids remain the mainstay of fluid resuscitation to prevent ‘pre-renal’ acute kidney injury?: con

The high chloride content of 0.9% saline leads to adverse pathophysiological effects in both animals and healthy human volunteers, changes not seen after balanced crystalloids. Small randomized trials confirm that the hyperchloremic acidosis induced by saline also occurs in patients, but no clinical outcome benefit was demonstrable when compared with balanced crystalloids, perhaps due to a type II error. A strong signal is emerging from recent large propensity-matched and cohort studies for the adverse effects that 0.9% saline has on the clinical outcome in surgical and critically ill patients when compared with balanced crystalloids. Major complications are the increased incidence of acute kidney injury and the need for renal replacement therapy, and that pathological hyperchloremia may increase postoperative mortality. However, there are no large-scale randomized trials comparing 0.9% saline with balanced crystalloids. Some balanced crystalloids are hypo-osmolar and may not be suitable for neurosurgical patients because of their propensity to cause brain edema. Saline may be the solution of choice used for the resuscitation of patients with alkalosis and hypochloremia. Nevertheless, there is evidence to suggest that balanced crystalloids cause less detriment to renal function than 0.9% saline, with perhaps better clinical outcome. Hence, we argue that chloride-rich crystalloids such as 0.9% saline should be replaced with balanced crystalloids as the mainstay of fluid resuscitation to prevent ‘pre-renal’ acute kidney injury

Physiological aspects of fluid and electrolyte balance

The intake of water and electrolytes is inseparable from feeding by natural or artificial means and careful attention to salt and water balance is a vital component of perioperative care and of nutritional support. Nutritional support with water and sodium restriction in post-intensive care patients with oedema, dilutional hypoalbuminaemia and fluid excess of 10 L, cleared oedema over 7-10 days, with a 1 g/L rise in serum albumin for every kg loss in weight. Return of gastrointestinal function was also observed. Accordingly, 20 patients, undergoing colonic surgery, were randomised to receive standard (>3 L water and 154 mmol sodium/day) or restricted postoperative fluids (<2 L water and 77 mmol sodium/day). Solid (72.5 vs 175 min) and liquid phase (73.5 vs 110 min) gastric emptying times were significantly longer in the standard group on the 4th postoperative day and associated with a three day longer hospital stay. In volunteers receiving 2 L of 0.9% saline and 5% dextrose infusions, on separate occasions over one hour, haematocrit and serum albumin concentration fell, mainly due to dilution. While dextrose was rapidly excreted, two-thirds of the saline was retained after 6 h. Following 1 L infusions, plasma renin and angiotensin concentrations decreased more after saline than dextrose (P<0.04). Responses of aldosterone, atrial natriuretic peptide and vasopressin were not significantly different. Comparing 2 L infusions of saline and Hartmann's solution, volunteers excreted more water (median 1000 vs 450 mL) and sodium (122 vs 73 mmol) after Hartmann's. Hyperchloraemia and reduced bicarbonate were noted after saline alone. Whereas fluctuations in water balance are dealt with efficiently through osmoreceptors and vasopressin, and sodium deficiency by volume receptors and the renin angiotensin aldosterone system, the mechanism for dealing with sodium and chloride excess appears relatively inefficient. Natriuretic peptide responds to volume expansion rather than sodium gain

Physiological aspects of fluid and electrolyte balance

The intake of water and electrolytes is inseparable from feeding by natural or artificial means and careful attention to salt and water balance is a vital component of perioperative care and of nutritional support. Nutritional support with water and sodium restriction in post-intensive care patients with oedema, dilutional hypoalbuminaemia and fluid excess of 10 L, cleared oedema over 7-10 days, with a 1 g/L rise in serum albumin for every kg loss in weight. Return of gastrointestinal function was also observed. Accordingly, 20 patients, undergoing colonic surgery, were randomised to receive standard (>3 L water and 154 mmol sodium/day) or restricted postoperative fluids (<2 L water and 77 mmol sodium/day). Solid (72.5 vs 175 min) and liquid phase (73.5 vs 110 min) gastric emptying times were significantly longer in the standard group on the 4th postoperative day and associated with a three day longer hospital stay. In volunteers receiving 2 L of 0.9% saline and 5% dextrose infusions, on separate occasions over one hour, haematocrit and serum albumin concentration fell, mainly due to dilution. While dextrose was rapidly excreted, two-thirds of the saline was retained after 6 h. Following 1 L infusions, plasma renin and angiotensin concentrations decreased more after saline than dextrose (P<0.04). Responses of aldosterone, atrial natriuretic peptide and vasopressin were not significantly different. Comparing 2 L infusions of saline and Hartmann's solution, volunteers excreted more water (median 1000 vs 450 mL) and sodium (122 vs 73 mmol) after Hartmann's. Hyperchloraemia and reduced bicarbonate were noted after saline alone. Whereas fluctuations in water balance are dealt with efficiently through osmoreceptors and vasopressin, and sodium deficiency by volume receptors and the renin angiotensin aldosterone system, the mechanism for dealing with sodium and chloride excess appears relatively inefficient. Natriuretic peptide responds to volume expansion rather than sodium gain

Impact of mechanical bowel preparation in elective colorectal surgery: a meta-analysis

AIM: To analyse the effect of mechanical bowel preparation vs no mechanical bowel preparation on outcome in patients undergoing elective colorectal surgery. METHODS: Meta-analysis of randomised controlled trials and observational studies comparing adult patients receiving mechanical bowel preparation with those receiving no mechanical bowel preparation, subdivided into those receiving a single rectal enema and those who received no preparation at all prior to elective colorectal surgery. RESULTS: A total of 36 studies (23 randomised controlled trials and 13 observational studies) including 21568 patients undergoing elective colorectal surgery were included. When all studies were considered, mechanical bowel preparation was not associated with any significant difference in anastomotic leak rates (OR = 0.90, 95%CI: 0.74 to 1.10, p = 0.32), surgical site infection (OR = 0.99, 95%CI: 0.80 to 1.24, p = 0.96), intraabdominal collection (OR = 0.86, 95%CI: 0.63 to 1.17, p = 0.34), mortality (OR = 0.85, 95%CI: 0.57 to 1.27, p = 0.43), reoperation (OR = 0.91, 95%CI: 0.75 to 1.12, p = 0.38) or hospital length of stay (overall mean difference 0.11 d, 95%CI: -0.51 to 0.73, p = 0.72), when compared with no mechanical bowel preparation, nor when evidence from just randomized controlled trials was analysed. A sub-analysis of mechanical bowel preparation vs absolutely no preparation or a single rectal enema similarly revealed no differences in clinical outcome measures. CONCLUSION: In the most comprehensive meta-analysis of mechanical bowel preparation in elective colorectal surgery to date, this study has suggested that the use of mechanical bowel preparation does not affect the incidence of postoperative complications when compared with no preparation. Hence, mechanical bowel preparation should not be administered routinely prior to elective colorectal surgery

Safety and efficacy of antibiotics compared with appendicectomy for treatment of uncomplicated acute appendicitis: meta-analysis of randomised controlled trials

Objective To compare the safety and efficacy of antibiotic treatment versus appendicectomy for the primary treatment of uncomplicated acute appendicitis. Design Meta-analysis of randomised controlled trials. Population Randomised controlled trials of adult patients presenting with uncomplicated acute appendicitis, diagnosed by haematological and radiological investigations. Interventions Antibiotic treatment versus appendicectomy. Outcome measures The primary outcome measure was complications. The secondary outcome measures were efficacy of treatment, length of stay, and incidence of complicated appendicitis and readmissions. Results Four randomised controlled trials with a total of 900 patients (470 antibiotic treatment, 430 appendicectomy) met the inclusion criteria. Antibiotic treatment was associated with a 63% (277/438) success rate at one year. Meta-analysis of complications showed a relative risk reduction of 31% for antibiotic treatment compared with appendicectomy (risk ratio (Mantel-Haenszel, fixed) 0.69 (95% confidence interval 0.54 to 0.89); I2=0%; P=0.004). A secondary analysis, excluding the study with crossover of patients between the two interventions after randomisation, showed a significant relative risk reduction of 39% for antibiotic therapy (risk ratio 0.61 (0.40 to 0.92); I2=0%; P=0.02). Of the 65 (20%) patients who had appendicectomy after readmission, nine had perforated appendicitis and four had gangrenous appendicitis. No significant differences were seen for treatment efficacy, length of stay, or risk of developing complicated appendicitis. Conclusion Antibiotics are both effective and safe as primary treatment for patients with uncomplicated acute appendicitis. Initial antibiotic treatment merits consideration as a primary treatment option for early uncomplicated appendicitis

A pen in the liver

A 24-year-old woman with anxiety, depression, and emotionally unstable personality disorder was referred to a tertiary center 2 weeks after ingesting multiple foreign bodies. She had undergone a laparoscopic cholecystectomy and a laparotomy for extraction of ingested foreign bodies several years ago. A sagittal CT scan view showed a ballpen and a hair clip in the stomach. A coronal view demonstrated that a second ballpen had penetrated the duodenal wall to enter the liver parenchyma. There was no free intraperitoneal air or fluid or evidence of abscess formation. At laparotomy, a toothbrush, a broken spoon and a ballpen were extracted from the stomach via an anterior gastrotomy. The duodenum was adherent to the liver but the second ballpen had migrated into the distal duodenum, with the tip in the proximal jejunum. This was extracted via an enterotomy and the fistula was not interfered with. The enterotomy and gastrotomy were closed with 3-0 polydioxanone sutures. The hair clip had passed spontaneously and was not detected on intraoperative fluoroscopy. She made an uneventful recovery and postoperative liver function tests remained in the normal range. This is only the fourth reported case of a pen fistulizing between the upper gastrointestinal tract and the liver

A dangerous loop

Key Clinical Message: A 76-year-old man developed a hemoperitoneum after ERCP for choledocholithiasis. He underwent a laparotomy and splenectomy for a capsular tear at the splenic hilum, a rare complication of ERCP. “Bowing” of the endoscope with torsion on the greater curvature of the stomach may lead to shear forces causing splenic injury