Ann R Coll Surg Engl 2007; 89: 238-241 238Adenocarcinoma of the gall bladder is a rare but aggressive gastrointestinal malignancy. It carries a dismal prognosis, with a reported overall 5-year survival rate not exceeding 5%.1 According to a large multicentre survey commissioned by the French Surgical Association, the overall median survival is just 3 months, 2 the main reason being late presentation. It mainly affects patients in their 7th and 8th decade and is about 5 times more common in females. It is estimated that in 85% of cases it is associated with gallstones 3 but the only recognised pre-malignant condition is a 'porcelain gall bladder'. In the vast majority of patients who are diagnosed with gall bladder carcinoma, the first suspicion of malignancy arises during operation and is confirmed on histological examination of the specimen. Despite advances in radiological imaging, accurate preoperative diagnosis is the exception rather than the rule. At present, all specimens, regardless of their macroscopic appearance, are being sent for histological examination. It seems questionable whether the result of the histopathological examination of each gall bladder would alter management when it provides no advantage to the surgeon, patient or pathologist.The aim of the study was to assess the necessity of routine histological examination of the gall bladder following simple cholecystectomy and its impact on the further management of the patients. Patients and MethodsWe analysed, retrospectively, the electronic database of histological reports of all gall bladder specimens after cholecystectomy in the last 5 years. In all cases of confirmed malignancy, we retrieved and reviewed, from patients notes and, when missing, from the hospital electronic database, results of pre-operative investigations such as: liver function tests, ultrasound scans or computed tomography Gall bladder carcinoma is a rare malignancy that carries a very poor prognosis. Laparoscopic cholecystectomy (LC) is established as the gold-standard treatment for symptomatic gall stones. The aim of the study was to assess the incidence of gall bladder carcinoma and the possibility of reducing the routine histological examination of gall bladder specimens.

INTRODUCTION The aim of this study was the assessment of patient outcome, peri-operative complications, length of stay and duration of operation after laparoscopic primary closure of the common bile duct (CBD) compared with choledochotomy with T-tube drainage and trans-cystic exploration. PATIENTS AND METHODS Analysis of prospectively collected data on 71 explorations of the common bile duct between July 2001 and March 2006. RESULTS A total of 71 patients had exploration of the CBD. Within this group, 12 were referred after failed endoscopic retrograde cholangiopancreatography (ERCP). The methods of exploration included trans-cystic (9 cases), choledochotomy with Ttube (12), and choledochotomy with primary closure (50). CBD stones were found in 66 patients. In the remaining cases, we found a stricture in 1, debris in 2, and dilatation of the CBD without a stone in 2. There were 5 conversions to open technique and 3 patients required postoperative ERCP (1 with permanent stenting). Peri-operative complications included T-tube (3), primary closure group (9), and trans-cystic (0). There was no statistical significant difference (Chi-square test, P = 0.296) between the groups. There was a trend towards a shorter length of stay in the primary closure group as compared with the trans-cystic and T-tube groups of 4.16, 4.44, and 6.33 days, respectively. However, it did not reach statistical significance (one-way analysis of variance with Boneferroni correction, mean difference between groups 1.89, 0.28, 2,17, statistical significance at P < 0.05). The shortest operating time was in the primary closure group (95.92 min) which was statistically significant (P < 0.001). We did not use a biliary drain in the last 48 patients. CONCLUSIONS Primary laparoscopic closure of the CBD is safe and results in a reduction in operating time. Choledochoscopy ensures clearance of the CBD and eliminates the need for T-tube.

Postoperative adhesion formation is a significant health-care problem with no universally accepted method of prevention. Barrier methods of prevention have been extensively tested and licensed, and this article examines the evidence.

Endoscopic duodenal polypectomy is a routine procedure particularly useful for obtaining histological diagnosis but it is not without serious complications. This is a case report of severe necrotising pancreatitis after duodenal polypectomy. We suggest that experienced endoscopists should carry out polypectomies and that clear guidelines for the management of duodenal polyps are required. Patients undergoing endoscopic duodenal polypectomies should be placed at the beginning of the endoscopy list and observed for at least 4 h.

No abstract