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BACKGROUND: Mirizzi Syndrome (MS) is an important but uncommon complication of gallstones characterized by narrowing of the common hepatic duct (CHD) due to mechanical compression or inflammation. This study aimed to assess the impact of preoperative and intraoperative diagnosis of MS on the performance, safety and efficacy of laparoscopic cholecystectomy. METHODS: From a consecutive series of 1,281 patients having surgery for gall bladder disease between 1990 and 1998, nine patients with MS were identified from a prospective database and their clinical progress examined. RESULTS: Five out of the nine patients with MS presented with pain (2/5 were also jaundiced), and four presented with acute cholecystitis. Liver function tests were abnormal in all patients. Preoperative diagnosis of MS based on ultrasound was made in only two patients, and in a third on findings of a nasobiliary cholangiogram. In six patients, the diagnosis was intraoperative. In seven patients cholecystectomy was completed by laparoscopy. Two patients needed conversion to open cholecystectomy. In two patients the common bile duct was mistaken for the cystic duct and the error was recognized on relaxation of traction on the gall bladder in one, but in the other a duct injury occurred that was not recognized until the postoperative period. CONCLUSIONS: Preoperative diagnosis of MS is difficult, and a high index of suspicion is necessary to avoid serious complications. Once the diagnosis is known, successful laparoscopic management is possible but care should be taken to avoid duct injury.

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BACKGROUND: In a small proportion of patients presenting with metastases to cervical lymph nodes the primary cancer remains occult despite thorough evaluation. The present report examines patterns of failure and outcome following an initial treatment strategy directed principally at the clinically involved side of the neck. METHODS: From a prospectively compiled computerized database 38 patients were identified with metastatic squamous cell carcinoma from an occult primary site. These patients were evaluated with respect to initial treatment, subsequent detection of a primary tumour, neck recurrence and survival characteristics. RESULTS: Thirty-seven of 38 patients were treated with curative intent and all had neck dissection. Adjuvant radiotherapy was given to 34 of the 37 (90%; 32 postoperatively and two pre-operatively). Radiotherapy was directed at the ipsilateral neck alone in 24 patients while 10 received comprehensive treatment to both sides of the neck and potential occult primary sites. The rate of control of disease in the ipsilateral neck was 91% while the failure rate in the contralateral neck was 16% (six patients). A primary cancer was ultimately identified in five patients (13%). Disease-specific survival was 63% at 4 years. Clinical N3 stage, extracapsular tumour extension and involved surgical margins predicted for poorer survival on univariate analysis. Analysis using multiple risk factors found that only involved surgical margins predicted for treatment failure. CONCLUSIONS: Despite generally advanced disease at presentation, patients presenting with cervical metastasis from an unknown primary carcinoma have a reasonable survival expectation and aggressive treatment is warranted, but approximately half will develop recurrent disease. Careful follow-up is required if effective salvage treatment is to be instituted.

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BACKGROUND: As Australia's population ages, the number of elderly patients presenting for surgery of abdominal aortic aneurysms (AAA), both elective and ruptured, will increase. The aim of the present study was to compare the costs of treatment of patients with AAA, under and over the age of 80, in the elective and emergency settings in a hospital with a divisional structure in which the true costs can be accurately obtained. METHODS: A total of 40 patients were selected at random from a series of 267 patients treated with open surgery for AAA between January 1987 and December 1994, 10 in each of four groups: group A, elective repair in patients aged < 80 (171/267); group B, elective AAA repair in patients aged > 80 (25/267); group C, emergency AAA repair in patients aged < 80 (50/267); and group D, emergency AAA repair in patients aged > 80 (11/267). A retrospective analysis of the hospital costs of treatment of these patients at St George Hospital was conducted. These true costs were then compared to Australian National Diagnostic Related Group (AN-DRG) costs. RESULTS: Group A and B had no mortality. In Group C and D the mortality was 20 and 60%, respectively. The emergency treatment groups also had longer lengths of stay. A statistically significant difference in cost of AAA repair between elective and emergency groups in both age groups was seen; that is, group A cost less than group C and group B cost less than group D. Costs per survivor, however, showed a dramatic difference between the cost of group C patients ($30000) and group D patients ($60000). In comparison with AN-DRG calculated costs, the true costs of groups A and B were equivalent to AN-DRG costs. In the emergency groups, however, there were marked discrepancies between the true cost ($61000) and that calculated by the DRG ($25000) in group D, with similar differences seen in group C to a lesser extent. CONCLUSION: Emergency repair of AAA is significantly more expensive and has a high mortality in the over-80 age group. Also, there is a substantial shortfall between the true costs of treating these patients and the funds allocated for treatment in this group.

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Cryoshock is a syndrome of coagulopathy, renal, and pulmonary injury following cryotherapy, and its etiology is unknown. The aim of this study was to assess the impact of hepatic cryotherapy on renal function, and whether this effect is related to volume of cryotherapy, and to identify any predictors of renal impairment in patients who undergo cryotherapy. A retrospective analysis of all patients with primary or secondary hepatic malignancy treated with cryotherapy from April 1990 to October 1996 was conducted. Ten of 204 patients with renal impairment (elevation in creatinine of greater than 0.02 mmol/L for more than 2 days postprocedure) were identified. One patient has postoperative pancreatitis with late renal impairment (20 days) and was excluded. The severity of renal impairment was usually modest (mean rise in creatinine of 0.31 mmol/L; SD, 0.19). Two patients required temporary hemodialysis. Only one patient, who had significant cardiac disease, had associated pulmonary injury and shock. Demographic data in both groups were comparable, except for a trend toward more noncolorectal cancer patients in the renal impairment group (4/9 vs 33/194). Patients in the renal impairment group had a greater number of lesions than those of the nonrenal impairment group (3.4 vs 2.1, p < 0.01), as well as larger lesion diameter (2.9 vs 1.9, p < 0.01), increased freezing time (74.7 vs 44.3, p < 0.01), and a higher aspartate transaminase (AST) (2254 vs 1157, p < 0.01). This study suggests that renal impairment is more likely to be seen in patients undergoing more extensive cryotherapy. The number and diameter of lesions together with AST data link renal injury with magnitude of liver injury--all renal impairment patients had an AST > 1000, compared with only 28% of patients who did not.

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