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PubMed2001

Patient evaluation and management with selective use of magnetic resonance cholangiography and endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy.

OBJECTIVE: To assess the utility of triage guidelines for patients with cholelithiasis and suspected choledocholithiasis, incorporating selective use of magnetic resonance cholangiography (MRC) and endoscopic retrograde cholangiopancreatography (ERCP) before laparoscopic cholecystectomy (LC). SUMMARY BACKGROUND DATA: ERCP is the most frequently used modality for the diagnosis and resolution of choledocholithiasis before LC. MRC has recently emerged as an accurate, noninvasive modality for the detection of choledocholithiasis. However, useful strategies for implementing this diagnostic modality for patient evaluation before LC have not been investigated. METHODS: During a 16-month period, the authors prospectively evaluated all patients before LC using triage guidelines incorporating patient information obtained from clinical evaluation, serum chemistry analysis, and abdominal ultrasonography. Patients were then assigned to one of four groups based on the level of suspicion for choledocholithiasis (group I, extremely high; group 2, high; group 3, moderate; group 4, low). Group 1 patients underwent ERCP and clearance of common bile duct stones; group 2 patients underwent MRC; group 3 patients underwent LC with intraoperative cholangiography; and group 4 patients underwent LC without intraoperative cholangiography. RESULTS: Choledocholithiasis was detected in 43 of 440 patients (9.8%). The occurrence of choledocholithiasis among patients in the four groups were 92.6% (25/27), 32.4% (12/37), 3.8% (2/52), and 0.9% (3/324) for groups 1, 2, 3, and 4, respectively (P <.001). MRC was used for 8.4% (37/440) of patients. Patient triage resulted in the identification of common bile duct stones during preoperative ERCP in 92.3% (36/39) of the patients. Unsuspected common bile duct stones occurred in six patients (1.4%). CONCLUSIONS: The probability of choledocholithiasis can be accurately assessed based on information obtained during the initial noninvasive evaluation. Stratification of risks for choledocholithiasis facilitates patient management with the most appropriate diagnostic studies and interventions, thereby improving patient care and resource utilization.

Algorithms↗
PubMedDate not supplied

[Endoscopic cholangiography in mild acute biliary pancreatitis: when and for whom?].

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP), with or without sphincterotomy, has been widely used in patients with severe biliary acute pancreatitis (BAP) or those with cholangitis and/or obstruction of the biliary tree. Its use in subjects with mild BAP is more controversial. AIM: To optimize use of ERCP in patients with mild pancreatitis due to gallstones by identifying clinical and biochemical predictors of choledocholithiasis. MATERIAL AND METHOD: The clinical and biochemical data, images, and outcomes of 83 patients with mild BAP hospitalized at the Instituto Nacional de Ciencias Medicas y Nutricion "Salvador Zubiran" from January 1, 1988 to May 30, 2000 were retrospectively analyzed. All patients received elective cholecystectomy at hospital admission. In 35 cases, ERCP was performed before cholecystectomy (group A). The remaining 48 were operated on without ERCP (group B). In 30, transcystic-cholangiography was done. Forty-seven (57%) were female. Mean age was 47 years (19-90). Mean time between onset of AP and hospital admission was 2.2 days (1-15), and between clinical onset and cholecystectomy, eight days (1-26). Statistical differences were evaluated by non-parametric methods. An univariated and multivariated analysis was performed looking for data to identify choledocholithiasis. RESULTS: Choledocholithiasis was found in 27 cases (32%), 18 from group A (51%), and nine for group B (19%) (RR = 4.58, IC 95% = 1.7-12.25, p = 0.004). ERCP was performed in all cases because of clinical suspicion of choledocholithiasis (jaundice, bilirubin, and alkaline phosphatase alteration and/or choledochal dilation); however, none of the patients of group B in whom choledocholithiasis was operatively diagnosed showed biochemical or radiologic alterations. Subjects with choledocolithiasis presented more frequently a history of biliary pain (RR = 5.75, IC 95% = 1.76-18.7), jaundice (RR = 3.07, IC 95% = 1.15-8.16) and/or alkaline phosphatase elevation (RR = 4.11, IC 95% = 1.3-12.7). CONCLUSION: The high frequency of choledocholithiasis in subjects with mild biliary pancreatitis warranted radiologic exploration of the biliary tree in all patients submitted to cholecystectomy. In those with jaundice, alkaline phosphatase elevation and/or a history of biliary pain, ERCP should be performed prior to the operation; in others, choledocholithiasis can be discharged by operative transcystic cholangiography. Therapeutic measures for treating choledocholithiasis should be adapted to hospital facilities.

Acute Disease↗
PubMed1984

[Preoperative and postoperative lengths of extrahepatic biliary duct measured by direct cholangiography].

The lengths of extrahepatic duct of 110 cases of cholecystolithiasis and 108 cases of choledocholithiasis were compared by direct cholangiography. An average length of the former was 11.0 +/- 1.45 cm, while that of the latter was 12.5 +/- 1.50 cm. There was remarkable change in length between cholecystolithiasis and choledocholithiasis. The length of 75 postoperative choledocholithiasis was 10.4 +/- 1.06 cm. The postoperative length of extrahepatic duct of choledocholithiasis was shorten significantly. There was no significant postoperative change in length in cholecystolithiasis and post-operative significantly. There was no significant postoperative change in length in choledocholithiasis. Because almost same length as that of cholecystolithiasis. As for the location of duodenal entry of the choledochus, there was no remarkable difference between cholecystolithiasis group and choledocholithiasis group. Remarkable difference of the length of extrahepatic duct between cholecystolithiasis group and choledocholithiasis group was not observed after surgery. These data suggested that the length of the extrahepatic bile duct is not the cause of stone formation, but the result of choledocholithiasis.

Adult↗
PubMed2005

Laparoscopic approach as primary treatment of common bile duct stones in children.

BACKGROUND: Preoperative endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy (ES) are an effective strategy for choledocholithiasis, but complications such as pancreatitis and outcome in children are unknown. The laparoscopic cholecystectomy became the new gold standard in children for cholelithiasis. For the choledocholithiasis in children, the attitude is more controversial. We analyzed our series of laparoscopic approach for the management of choledocholithiasis in children to determine if it is an effective procedure. PATIENTS AND METHOD: Between 1996 and 2001, 126 children were treated for cholelithiasis in our institution; 13 children (10.3%) were managed for a choledocholithiasis. We reviewed age at symptom onset results of paraclinical examinations, the type of laparoscopic management, and postoperative outcome. RESULTS: The mean age at clinical signs was 9.9 years (range, 3 months-15.5 years). One child was excluded because he had a preoperative ES. Twelve children had a laparoscopic cholecystectomy and cholangiogram at the same time. A choledocholithiasis was found in 10 cases. A flush of the common bile duct (CBD) was performed in all cases with a 3F or 5F ureteral catheter; the stone was pushed into the duodenum in 3 cases and successfully extracted in 3 with a 4F Dormia or Fogarty catheter. One child needed a conversion to open surgery. Three times, an ES was necessary in postoperative course in each case for clinical and biologic signs of CBD obstruction or pancreatitis (30%). All children are symptom-free with an average follow-up of 28 months. CONCLUSION: Laparoscopic CBD exploration for choledocholithiasis can be performed safely in children at the time of cholecystectomy and can clear all of the stones in the CBD in two thirds of cases. If there is residual obstruction, a postoperative ES can be performed. We suggest primary treatment of choledocholithiasis by laparoscopic approach in children.

Adolescent↗
PubMed2005

The detection of bile duct stones in suspected biliary pancreatitis: comparison of MRCP, ERCP, and intraductal US.

OBJECTIVES: Early ERCP and endoscopic sphincterotomy for stone extraction can benefit the prognosis in patients with severe biliary pancreatitis, but are associated with complications. The ability to identify choledocholithiasis by noninvasive means in biliary pancreatitis is limited. The aim of this study was evaluation of the ability of MRCP to detect choledocholithiasis in patients with acute biliary pancreatitis. In addition, we investigated whether intraductal US (IDUS) could help manage these patients. METHODS: Thirty-two patients with suspected biliary pancreatitis were studied prospectively. MRCP was performed immediately before ERCP by separate blinded examiners within 24 h of admission. Wire-guided IDUS was performed during ERCP within 72 h of admission, regardless of the results of MRCP. Using endoscopic extraction of a stone as the reference standard, the diagnostic yield of MRCP was compared with transabdominal US, CT, ERCP, and IDUS. RESULTS: The sensitivity of US, CT, MRCP, ERCP, and IDUS for identifying choledocholithiasis was 20.0%, 40.0%, 80.0%, 90.0%, and 95.0%, respectively. The overall agreement between MRCP and ERCP was 90.6% for choledocholithiasis (kappa= 0.808, p < 0.01). The sensitivity of MRCP for detecting choledocholithiasis decreased with dilated bile ducts (bile duct diameter > 10 mm, 72.7% vs 88.9%). The combination of ERCP and IDUS improved accuracy in the diagnosis of choledocholithiasis. CONCLUSIONS: MRCP can be used to select patients with biliary pancreatitis who require ERCP. IDUS may be applied in the management of biliary pancreatitis if ERCP is performed.

Adult↗
PubMed2001

Follow-up of selective endoscopic ultrasonography and/or endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy: a prospective study of 300 patients.

BACKGROUND AND STUDY AIMS: This prospective study evaluated the selective use of endoscopic retrograde cholangiography (ERC) and endoscopic ultrasonography (EUS) in the context of laparoscopic cholecystectomy (LC). PATIENTS AND METHODS: Between 1993 and 1998, LC for symptomatic gallstones was indicated in 300 consecutive patients. In order to diagnose and treat choledocholithiasis preoperatively, we performed, on the basis of preoperative criteria, ERC in "high-risk" patients and EUS in "intermediate-risk" patients. Choledocholithiasis was treated by preoperative biliary endoscopic sphincterotomy (BES). LC was performed either after the endoscopic procedure or directly in "low-risk" patients. RESULTS: A total of 104 patients (35%) had 118 preoperative procedures: a) EUS (n = 68; feasibility 100%): choledocholithiasis was observed in 14/68 patients (21%); b) ERC (n = 50; feasibility 94%): 36 ERC were indicated on on preoperative criteria, and 14 on the basis of EUS results. Choledocholithiasis was found in 41/ 50 patients (82%) (13/14 patients with positive EUS), 19% of "intermediate-risk" patients, and 78% of "high-risk" patients; ERC failed in three patients who had no choledocholithiasis on subsequent intraoperative cholangiography (IOC). Clearance of the common bile duct (CBD) was achieved after BES in 41/41 patients. There was no mortality; complications occurred in 4/ 300 patients (1%). No retained stones were found in patients of any of the three groups, after a mean follow-up of 32 months. CONCLUSIONS: Combined endoscopic and laparoscopie management of cholecystolithiasis and choledocholithiasis is a viable option and is optimized by the use of EUS.

Adolescent↗
PubMed1999

[The role of intravenous cholangiography in the era of laparoscopic cholecystectomy: is there a renaissance?].

BACKGROUND AND OBJECTIVE: The preoperative investigation for choledocholithiasis in patients undergoing elective laparoscopic cholecystectomy is still a matter of debate. PATIENTS AND METHODS: In a prospective clinical trial the accuracy of intravenous cholangiography (IVC), ultrasonography and liver function tests in the preoperative diagnosis of choledocholithiasis was assessed in 98 patients undergoing elective cholecystectomy. Only patients with uncomplicated cholecystolithiasis considered to be at low risk for having bile duct stones were investigated. A 2-year follow-up clinical survey (mean) was performed in 92 of the 98 patients to investigate the occurrence of postoperative choledocholithiasis (gold standard: clinically manifest choledocholithiasis). RESULTS: In this patient cohort the incidence of choledocholithiasis was found to be 5.1%. Among the three diagnostic tests IVC proved to be more accurate with higher sensitivity and a better positive predictive value than ultrasonography and liver function tests. The sensitivity for IVC was 100% compared to 20% for ultrasonography and 40% for liver function tests, respectively. The positive predictive value for IVC was 83.3% in comparison to 20% for ultrasonography and 25% for liver function tests. Mild side effects caused by intravenous contrast media were observed in 2.0%. During a mean postoperative follow-up of 2 years no clinically manifest and initially overlooked choledocholithiasis could be detected in the 92 investigated patients. CONCLUSION: IVC is a reliable method to detect unsuspected common bile duct stones and should be used in the preoperative diagnosis prior to elective laparoscopic cholecystectomy. IVC may play a role in decreasing the rate of preoperative ERCP or intraoperative cholangiography in these patients.

Adolescent↗
PubMed2003

Prospective study of scoring system in selective intraoperative cholangiography during laparoscopic cholecystectomy.

AIM: To evaluate of scoring system in predicting choledocholithiasis in selective intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC). METHODS: The scoring system of predicting choledocholithiasis was developed during the retrospective study in 264 cases, and was tested in 184 to evaluate its predictive value in choledocholithiasis. RESULTS: The scoring system was developed in a retrospective study of 264 cases, the statistical analyses showed the predictive factors included sex, transaminase levels, alkaline phosphatase level, bilirubin level, and common bile duct diameter on ultrasonography. The scoring system was used in 184 cases prospectively, of which, 3 of 162 (1.9 %) cases scoring <3 had choledocholithiasis, 17 of 22 (77.3 %) cases scores >=3 had choledocholithiasis. A case of scores >=3 or more prospectively should be considered highly intraoperative cholangiography during laparoscopic cholecystectomy. CONCLUSION: The scoring system can predict choledocholithiasis and is helpful in selection patients for intraoperative cholangiography.

Cholangiography↗
PubMed2000

[Helical CT compared to ERCP in obstructive biliary pathology].

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is the examination of choice in the diagnosis of biliary tract pathology although newer, less invasive techniques with high diagnostic sensitivity should be evaluated. The aim of this study was to evaluate the diagnostic efficacy of helical computed tomography (CT) in bile duct obstruction, particularly in choledocholithiasis. PATIENTS AND METHODS: Forty-four patients with suspected bile duct obstruction were prospectively evaluated. Helical TC was carried out 12 hours before ERCP and patients were grouped according to risk of choledocholithiasis. RESULTS: Choledocholithiasis was found in 20 patients (45.4%). Helical TC identified this pathology in 17 and correctly ruled it out in 18 of 24 patients (S: 85%, E: 75%, positive predictive value 74%, negative predictive value 85.7%. Of the patients with choledocholithiasis, bile duct dilatation was found in 18. Helical TC correctly diagnosed this pathology in 16 of the 18 patients (88.8%). Helical TC correctly diagnosed one of two patients (50%) with choledocholithiasis and normal bile ducts. CONCLUSIONS: Helical TC is effective in the diagnosis of choledocholithiasis but is not sufficiently accurate to be used in the screening of this entity.

Adult↗
PubMedDate not supplied

Laparoscopic cholecystectomy and perioperative ERCP.

BACKGROUND/AIMS: Study of acceptance of simultaneous laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography for treatment of cholelithiasis with choledocholithiasis. METHODOLOGY: There were 25 patients. Ten patients had acute pancreatitis of biliary etiology, accompanied by transitory icterus. In 15 patients, choledocholithiasis was suspected preoperatively both on ultrasonography and i.v. cholangiography. In all patients laparoscopic cholecystectomy with perioperative endoscopic retrograde cholangiopancreatography and sphincterotomy were performed for the treatment of cholelithiasis and choledocholithiasis. RESULTS: Simultaneous laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography was successfully done in all patients. The patients were discharged home on the 4th day after the surgery. Concerning early complications, there where 3 early complications, e.g., prolonged hemorrhage after papillotomy in a patient with choledocholithiasis with stenotic papillitis. Conservative therapy (fresh frozen plasma, local hemostats) was used in this patient. In 4 patients with choledocholithiasis, transitory hyperamylasemia was observed, with no clinical symptoms of pancreatitis. The symptoms disappeared with conservative therapy 3 days after the beginning of treatment. CONCLUSIONS: Simultaneous laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography for treatment of cholelithiasis and choledocholithiasis is a safe and acceptable treatment.

Ampulla of Vater↗
PubMed2006

Duodenal EUS to identify thickening of the extrahepatic biliary tree wall in primary sclerosing cholangitis.

BACKGROUND: Diagnosing primary sclerosing cholangitis (PSC) is problematic and requires meeting a burden of proof through clinical, biochemical, radiologic, and histological features. Endoscopic ultrasound yields detailed images of the extrahepatic biliary tree, but its value in contributing to the diagnosis of this condition is unknown. OBJECTIVES: To determine the potential for transduodenal EUS to detect common bile duct wall thickening in PSC. DESIGN: A prospective, controlled study with retrospective, blinded data analysis. SETTING: Single tertiary referral center for inflammatory bowel disease and EUS. PATIENTS: Four groups of patients were assessed with radial endosonography: PSC (n = 9); inflammatory bowel disease (IBD) with abnormal liver blood tests (n = 21); choledocholithiasis (n = 15); and normal controls (n = 50). Measurements were made of the common bile duct diameter and wall thickness. INTERVENTIONS: Transduodenal radial EUS of the biliary tree. MAIN OUTCOME MEASUREMENTS: Common bile duct diameter and wall thickness. RESULTS: The mean diameter (SD) of the common bile duct for the PSC, IBD, choledocholithiasis, and normal control groups measured 8.9 mm (2.8), 5.4 mm (1.7), 7.2 mm (2.2), and 5.0 mm (1.9), respectively (PSC and choledocholithiasis groups compared to the IBD group, P < .05 for a single test of hypothesis, but correction for the multiple testing of data removed this significance; normal control group P < .005). Mean ductal wall thickness (SD) was 2.5 mm (0.8) for the PSC group, 0.7 mm (0.4) for the IBD group, 0.8 mm (0.4) for the choledocholithiasis group, and 0.8 mm (0.4) for the normal control group, respectively (PSC group compared to the other 3 groups, P < .005). LIMITATIONS: Assessment of intrahepatic PSC is problematic. CONCLUSION: Thickening (>1.5 mm) of the common bile duct wall is seen in patients with PSC but not in those with apparently uncomplicated IBD or choledocholithiasis. The results of this study suggest that standard endosonography contributes to the imaging and potentially to the diagnosis of PSC.

Adult↗
PubMed2002

Dynamic MR cholangiography after fatty meal loading: cystic contractility and dynamic evaluation of biliary stasis.

PURPOSE: Dynamic MR cholangiography was conducted on patients with cholelithiasis or choledocholithiasis who had consumed a fatty test meal (Molyork) and the cystic contractility and dynamics of biliary stasis was evaluated. SUBJECTS AND METHOD: The subjects were 25 with intracystic cholelithiasis, 10 with choledocholithiasis and 10 normal controls. For an imaging sequence, the rapid acquisition with relaxation enhancement (RARE) method was employed and imaging was conducted for 40 min (every 30 s following Molyork administration) without breath-holding. The gallbladder contraction ratio was computed and the contractile ratio for the common bile duct was calculated. To determine the bile flow to the duodenum, the high-intensity signal, indicating the flow from the lower common bile duct, and perfusion of the duodenum were observed in dynamic mode on the monitor with the naked eye and interpreted as positive bile flow. The frequency of this flow was visually monitored. RESULTS: The gallbladder contractile ratio was significantly reduced in patients with cholelithiasis or choledocholithiasis compared with the controls. In a comparison with the normal controls, no sequential changes were noted in the mean contractile ratio of the common bile duct of the patients with cholelithiasis or choledocholithiasis. The mean frequency of bile flow observed for each 40 min period was 13+/-2.4, 6+/-2.2, and 4+/-1.3 times for the controls, those with intracystic cholelithiasis, and those with choledocholithiasis, respectively. Compared with the controls, the latter two patient groups showed evident reductions in the frequency of bile flow to the duodenum (p<0.001). CONCLUSION: Dynamic MRC combined with Molyork loading makes it possible to compute cystic contractile ratios and perform a dynamic examination of bile flow under non-invasive, near-physiological conditions.

Adult↗
PubMedDate not supplied

Endoscopic sphincterotomy in 100 patients scheduled for laparoscopic cholecystectomy: ultrasound evaluation.

BACKGROUND/AIMS: The aim of the study was to determine to what extent ultrasonography may monitor the process of sphincterotomy and its effectiveness. The study also aimed at determining the sensitivity and specificity of ultrasonography in detecting choledocholithiasis, in comparison with the results of endoscopic retrograde cholangiopancreatography. METHODOLOGY: Between January 1995 and June 2001, endoscopic sphincterotomy was performed on 100 patients with suspected synchronous choledocholithiasis in preparation for laparoscopic cholecystectomy. The main parameters evaluated in the ultrasonography image included the breadth of the common bile duct and absence or presence of concrements in bile ducts before and after sphincterotomy. RESULTS: Applied before the endoscopic operation, ultrasonography revealed choledocholithiasis in 58 patients and dilatation of the common bile duct in 95 patients. Endoscopic retrograde cholangiopancreatography confirmed choledocholithiasis in 74 patients, after sphincterotomy concrements were removed in 63 persons. In 26 patients sphincterotomy was performed for stenosis of Vater's papilla. Patients with the breadth of the duct > 10 mm, were referred to a check-up examination. CONCLUSIONS: Compared with endoscopic retrograde cholangiopancreatography, ultrasonography correctly specifies the breadth of the bile duct and properly monitors the process of endoscopic sphincterotomy, but is less accurate in determining the occurrence of choledocholithiasis, and sensitivity in the test amounted to 73%, and specificity of the examination--84.5%.

Adolescent↗
PubMedDate not supplied

Management of common bile duct stones: the state of the art in 2000.

Biliary lithiasis is a widespread disease all over the world; one-third of the white population presents with stones in the biliary ducts. In Chile, it is present in 47% of adult females. The most common complications of this pathology are acute cholecystitis, choledocholithiasis, acute pancreatitis, retained common bile duct (CBD) stones, and gallbladder cancer; these constitute a serious health problem in Chile. The aim of this study was to update the information related to choledocholithiasis after 10 years of laparoscopic biliary surgery. To achieve this objective, we retrospectively analyzed the last 100 cases of choledocholithiasis admitted to the University of Chile Clinical Hospital in 2000. Prevalence by sex and age was determined. Clinical diagnosis was demonstrated to be effective in 92.3% of the cases; laboratory tests and ultrasound were effective in 81% and 90% of the cases, respectively. Diagnosis of cholelithiasis and choledocholithiasis as one unique entity corresponded to 53% of the sample; 47% of the remaining choledocholithiasis cases corresponded to retained CBD stones in patients previously cholecystectomized. Time of appearance of symptoms of this residual pathology was reviewed. All methods or procedures employed to treat this pathology were studied, and it was found that endoscopic cholangiography (ERCP) was the most frequently used procedure. Also, results of other alternative procedures, such as open surgery or ERCP combined with laparoscopic cholecystectomy, were considered. Finally, this study was complemented with a thorough bibliographic review of more than 100 publications on the subject that were published in high-impact surgical reviews, emphasizing the course of treatment followed during the last 7 years.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1989

Anergy in patients with biliary lithiasis.

A prospective study was carried out in 428 subjects (212 controls and 216 patients) to evaluate the delayed cell-mediated immune response preoperatively in patients with biliary lithiasis. The delayed hypersensitivity response was assessed by a Multitest and subjects were classified as immunocompetent, relatively anergic or anergic. Significant differences were found between control subjects and patients with cholelithiasis compared with those with acute cholecystitis (P less than 0.01), non-icteric choledocholithiasis (P less than 0.01) and choledocholithiasis with jaundice (P less than 0.05). There were also differences between patients with icteric and non-icteric choledocholithiasis (P less than 0.02). Seven possible causative factors for anergy were evaluated: a haemoglobin concentration of less than or equal to 12 g/l and a haematocrit of less than or equal to 35 per cent were related to the appearance of anergy and relative anergy in patients with acute cholecystitis. Bilirubin levels greater than or equal to 34 mumol/l were found in 60 per cent of patients with choledocholithiasis and relative anergy and in 80 per cent of those who were anergic (P less than 0.001). These results show a high incidence of failure of the cell-mediated immune response in patients with acute cholecystitis (71 per cent) and icteric choledocholithiasis (82 per cent). In the latter, jaundice appears to be associated with this failure. A close correlation between relatively anergic and anergic state and the development of postoperative septic complications was found.

Adult↗
PubMed1993

Anatomical variation of pancreatobiliary ducts in biliary stone diseases.

Endoscopic retrograde cholangiopancreatography examinations were prospectively analyzed to determine whether anatomical variations of ductal systems have a role in the pathogenesis of cholecystolithiasis and choledocholithiasis. Included were 140 normal examinations (control group), 102 patients with cholecystolithiasis, and 68 patients with choledocholithiasis (primary stones in the common bile duct). Low entry of the cystic duct was observed frequently in patients with cholecystolithiasis (15.7% vs. 2.1% in control, p < 0.01). No preferential type of course of the cystic duct was observed in patients with cholecystolithiasis and choledocholithiasis. Separate openings of the bile and pancreatic ducts were significantly prevalent in patients with choledocholithiasis (53.5% vs. 30.6% in control, p < 0.01). Common channel was significantly short in patients with cholecystolithiasis. Incidence of juxtapapillary duodenal diverticula was significant in patients with choledocholithiasis. These observations suggest that some of the pancreatobiliary ductal anatomy may be closely implicated in the development of gallstone diseases.

Aged↗
PubMed1985

[Pragmatic status determination of transduodenal sphincterotomy].

Of a total of 1791 biliary tract operations from 1977-1984 transduodenal sphincterotomy was performed in 6.3% of 1720 primary and in 63.4% of 71 secondary operations, altogether in 154 cases. In primary operations papillary and suprapapillary choledocholithiasis was the indication in 83.5% of sphincterotomies. In these cases papillary stenosis is not considered separately because sphincterotomy is the preferred approach to stone removal in retroduodenal choledocholithiasis. Without retroduodenal choledocholithiasis and irreversible, organic papillary stenosis was found in 0.7%, a reversible, functional papillary stenosis in 2.8% of primary cases. However, in secondary operations isolated papillary stenosis without choledocholithiasis was the indication in 24.4% of sphincterotomies. The mean age of these patients was 68, the mean interval to the first operation 26 years. Operative mortality was 1.9% for sphincterotomy, 0.6% for all operations. Late results were satisfactory in 96.3% of sphincterotomies. Endoscopic papillotomy is considered the treatment of choice for residual papillary stenosis after cholecystectomy. When the comparative risks and intraoperative findings are well accounted for, transduodenal sphincterotomy becomes a safe and reliable procedure for the serious and tangible condition of retroduodenal choledocholithiasis.

Ampulla of Vater↗
PubMed2001

Intraoperative cholangiography in laparoscopic cholecystectomy during residency in general surgery.

BACKGROUND: The role of laparoscopic intraoperative cholangiography (IC) in the diagnosis of asymptomatic choledocholithiasis is still controversial. The aim of this study was to evaluate the diagnostic-therapeutic impact and the educational implications of this method for residents specializing in general surgery. METHODS: We reviewed the records of 835 patients who underwent laparoscopic cholecystectomy for cholecystolithiasis without choledocholithiasis. IC was routinely performed by both expert surgeons and residents in general surgery. RESULTS: The cholecystectomy was completed laparoscopically in 804 cases, but conversion to open surgery was required in 31 cases. IC was not completed in 140 cases (17.4%), and in 44 cases it revealed a suspected choledocholithiasis. The stones were treated via laparoscopy in 36 cases, laparotomy in six cases, and endoscopic retrograde cholangiopancreatography (ERCP) in two cases. Five patients were not diagnosed wit h choledocholithiasis. In one case, a lesion of the choledochus was discovered and treated laparoscopically. A total of 610 IC were done by expert surgeons and 225 by residents. The duration of the cholecystectomy with IC was significantly different between the two groups (76.9 +/- 12 vs 92.4 +/- 11), as was the feasibility index (88.6% vs 80.6%). CONCLUSIONS: Laparoscopic IC is a safe and accurate procedure for the diagnosis of unrecognized choledocholithiasis. Teaching of this procedure as part of the specialization in general surgery would be opportune because it would provide surgical residents with an additional tool for the diagnosis and treatment of this pathology of the common bile duct.

Adolescent↗