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Laparoscopic subtotal cholecystectomy (LSC) is considered to be a safe option in severe cholecystitis with non-discernible anatomy within the Calot's triangle where there is a potential risk of causing injury to the common bile duct. Here we present two cases of gallstone pancreatitis associated with use of an endoscopic stapler during LSC.

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Most ingested foreign bodies will pass through the gastrointestinal tract without any problems. On the other hand long, slender objects such as a toothbrush will rarely be able to negotiate the angulated and fixed retroperitoneal duodenal loop. Spontaneous toothbrush passage has never been described and therefore endoscopic or surgical removal is always required. Here we describe an asymptomatic young female presenting to out-patient clinic with a history of unintentional toothbrush ingestion 4 years prior. Endoscopic removal was unsuccessful because the toothbrush was partially embedded in to the gastric mucosa. We describe the second case to date of laparoscopic removal of a toothbrush via a gastrotomy with subsequent intra-corporeal repair of the defect.

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Acid and bile acids form important constituents of the refluxed substances in patients who suffer from gastroesophageal reflux disease. Whilst 24h ambulatory pH monitoring using antimony or glass pH electrodes measures acid levels 5 cm above the gastroesophageal junction, there are no reliable methods of measuring other constituents of duodenal juices such as bile acids. Past studies in detection of bile acids have included esophageal aspiration studies with detection of bile acids with HPLC or indirect methods using fiber-optic bile sensor "Bilitec" to detect bilirubin in the bile. These methods have either been impracticable or unreliable for routine and accurate measurement of bile acid. More recently, impedance technology has been used to define "weakly" acid or alkaline reflux. There are many potential applications of biosensors of various types, and it is envisaged that a biosensor specific for bile acid would be a more practical tool for routine measurement. This paper looks at a model for development of a biosensor for bile acid based on molecular imprinted polymers.

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OBJECTIVE: To quantitate and characterize the motility abnormalities present in patients with epiphrenic diverticula and to assess the outcome of surgical treatment undertaken according to these abnormalities. SUMMARY BACKGROUND DATA: The concept that epiphrenic diverticula are complications of esophageal motility disorders rather than primary anatomic abnormalities is gradually becoming accepted. The inconsistency in identifying motility abnormalities in patients with epiphrenic diverticula is a major obstacle to the general acceptance of this concept. METHODS: The study population consisted of 21 consecutive patients with epiphrenic diverticula. All patients underwent videoesophagography, upper gastrointestinal endoscopy, and esophageal motility studies. The diverticula ranged in size from 3 to 10 cm and were predominantly right-sided. Seventeen patients underwent transthoracic diverticulectomy or diverticulopexy with esophageal myotomy and an antireflux procedure. The length of the myotomy was determined by the extent of the motility abnormality. Transhiatal esophagectomy was performed in one patient with multiple diverticula. Two patients declined surgical treatment and another patient died of aspiration before surgery. Symptomatic outcome was assessed via a questionnaire at a median of 24 months after surgery. RESULTS: The primary symptoms were dysphagia in 5 (24%) patients, dysphagia and regurgitation in 11 (52%) patients, and pulmonary symptoms in 5 (24%) patients. The median duration of the primary symptoms was 10 years. Esophageal motility abnormalities were identified in all patients. An esophageal motor disorder was diagnosed only by 24-hour ambulatory motility testing in one patient, and 24-hour ambulatory motility testing clarified the motility diagnosis in five other patients. The most common underlying disorder was achalasia, which was detected in nine (43%) patients. A hypertensive lower esophageal sphincter was diagnosed in three patients, diffuse esophageal spasm in five, "nutcracker" esophagus in two, and a nonspecific motor disorder in two patients. One patient had an intraoperative myocardial infarction and died. Two patients had persistent mild dysphagia after surgery. The remaining patients had complete relief of their primary symptoms. CONCLUSIONS: There is a high prevalence of named motility disorders in patients with epiphrenic diverticula, and this condition is associated with the potential for lethal aspiration. Twenty-four-hour ambulatory motility testing can be helpful if the results of the stationary examination are normal or indefinite. Resection of the diverticula and a surgical myotomy of the manometrically defined abnormal segment results in relief of symptoms and protection from aspiration.

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