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PubMed1994

[Two-stage minimally invasive therapy of cholecysto- and choledocholithiasis].

Therapeutical splitting consisting of endoscopic sphincterotomy, stone removal and laparoscopic cholecystectomy is a valuable alternative method compared to open cholecystectomy with common bile duct exploration. In our prospective study we performed this procedure in 89 patients (28.7.1990-28.7.1993). Morbidity was 4.5% and mortality was 0. A follow-up study of 50 patients shows residual stones in 2% and papillary stenosis in 2%.

Adult↗
PubMed1993

Intracorporeal retrograde choledocholithotripsy or ESWL as a therapy for choledocholithiasis.

More than 90% of all common bile duct stones can be removed endoscopically following endoscopic sphincterotomy aided by the use of baskets, balloon catheters and mechanical lithotripsy. Oversized, very hard or impacted stones, however, often resist conventional endoscopic therapy. Promising new or improved approaches to the treatment of these stones are intracorporeal or extracorporeal shockwave lithotripsy. Shockwave lithotriptors for ESWL are currently available worldwide. However, to treat with the water-bath first generation devices general anaesthesia is required, since shockwaves are painful. Furthermore, an X-ray localization system is essential to visualize the stones after opacification of the bile duct via a nasobiliary catheter. On average, two shockwave treatments with a further one to four endoscopic sessions are required. Intracorporeal lithotripsy promises more comfort and less effort for the patient. Shockwaves are generated either by means of the spark gap principle (electrohydraulic probes) or by laser-induced plasma generation. Laser-induced shockwave lithotripsy appears to be the safer procedure, since with solid state lasers (Q-switched Nd: YAG, alexandrite) athermal, well controlled shockwaves can be generated without the risks of duct perforation (as described for the electrohydraulic system). Furthermore, a recently developed stone-tissue detection system integrated in a new dye laser system (Lithognost) enhances the safety of laser-induced lithotripsy. In consequence, laser lithotripsy without direct endoscopic control appears possible in selected cases.

Endoscopy, Digestive System↗
PubMed1993

[Laparoscopic cholecystectomy in cholecysto-choledocholithiasis. "Therapeutic splitting" or conventional surgical procedure?].

In a prospective study the impact of preoperative, selective endoscopic cholangiography (ERC/P) and therapy was evaluated in 586 consecutive patients with symptomatic gallstone disease in respect of biliary pathology and laparoscopic cholecystectomy (n = 520). Exclusion criteria for the admission to the study were previous gastric surgery, necrotizing cholecystitis and gallbladder perforation. Because of presumed pathology on ultrasound, suggestive for common bile duct stones or papillary stenosis 59 patients (11.3%) had preoperative ERC/P. In all patients with calculi (n = 40) endoscopic stone removal was successfully performed with/without sphincterotomy (EPT), in three cases of clinically relevant stenosis EPT was indicated. Morbidity was 1.6% after ERC/EPT, in the endoscopic group operative morbidity and mortality was zero. In the non-endoscopic group (n = 461) sixteen complications occurred, although none could have been avoided by preoperative cholangiography. Two patients showed retained calculi (0.3%), missed by preoperative diagnostics. Both cases were successfully treated by ERC. Intraoperative cholangiograms were not done routinely (11%). In conclusion, we think, that selective, preoperative ERC/P, EPT and stone removal--if necessary--facilitate a very low morbidity and mortality in the laparoscopic treatment of complicated gallstone disease. By means of the "therapeutical splitting" the conversion to open bile duct surgery with all its higher morbidity and mortality can be eradicated. Also, only a few of the endoscopically operating hospitals already provide equipment for laparoscopic bile duct revision, not to talk about the gifted and experienced surgeons.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1993

[Laparoscopic cholecystectomy and choledocholithiasis].

Laparoscopic operations are a revolution in surgery. So far they were developed most in surgery of the biliary pathways. The authors emphasize the necessity to extend diagnostic and therapeutic examination methods of the biliary pathways pre-, intra- and postoperative ERCP, pre- and intraoperative cholangiography, choledochotomy, choledochoscopy, concrement extraction. Only then laparoscopic operations attain their full importance with all advantages--postoperative comfort, reduced period of treatment, hospitalization and convalescence, cosmetic effect. The authors present in the submitted paper their own experience and world-wide trends--mainly in the USA and France.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1993

Choledocholithiasis attributable to a foreign body in a horse.

Cholelithiasis is the most common cause of biliary obstruction in horses. Proposed mechanisms include ascariasis, biliary stasis, ascending biliary infection, and changes in bile composition. In this horse, a foreign body acted as the nidus for bile-salt deposition and ascending cholangitis. Clinical signs (intermittent abdominal pain, icterus, and pyrexia) in conjunction with high serum activity of enzymes indicative of obstructive biliary disease led to a tentative diagnosis of cholelithiasis. Ultrasonography was used to confirm the diagnosis. Postmortem examination revealed a 7-cm wooden stick to be the core of a cholelith found in the common bile duct.

Animals↗
PubMed1993

[Cholecystolithiasis and choledocholithiasis cured by methyl tert butyl ether (MTBE) combined with EST].

A 70-year old male patient was admitted to hospital with fever and right upper quadrant pain. Ultrasonography and cholecystography revealed acute cholecystitis associated with multiple stones not only in the gallbladder but also in the common bile duct. Percutaneous trans-gallbladder drainage (PTGBD) was performed because of his persisting complaints and severe inflammatory change of the gallbladder. Operation was not considered due to his cardiac problem, so we tried direct dissolution treatment of the gallstones by using Methyl tert butyl ether (MTBE) through the percutaneous transhepatic catheter. Following maximal aspiration of the gallbladder contents, same amount of MTBE was infused into and the patient was kept in the right-side-down position for an hour. After 30 times of MTBE treatment, all stones in the gallbladder were thoroughly dissolved without any side effect. A residual stone in the common bile duct was easily taken out by endoscopic sphincterotomy.

Aged↗
PubMed1995

[Spontaneous rupture of aberrant bile ducts in choledocholithiasis].

It is reported on 4 patients aged 69 to 79 years suffering from rupture of aberrant subserosal bile ducts. In the first patient the gallbladder did not obtain stones, the common duct stones causing increased pressure in the intrahepatic ducts and rupture were not diagnosed, the supposed "cyst" was excised, followed by suture of the liver tissue. Due to peritonitis relaparotomy had to be done. Since now intrahepatic obstruction was supposed a hepatojejunostomy was performed. The patient died from peritonitis following insufficiency of the anastomosis and bronchopneumonia. The other patients were cured by cholecystectomy, revision of the duct, T-tube and suture at the site of perforation, in one case with additional endoscopic papillotomy.

Aged↗