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Management of Gallstone Cholangitis in the Era of Laparoscopic Cholecystectomy
Abstract
Hypothesis
The combined endoscopic and laparoscopic approach is safe and effective in managing gallstone cholangitis in the era of laparoscopic cholecystectomy (LC).Design
Retrospective case series.Setting
University teaching hospital.Patients
One hundred eighty-four consecutive patients with gallstone cholangitis treated between January 1995 and December 1998.Interventions
The main treatments were endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) followed by interval LC. Open or laparoscopic common bile duct exploration (OCBDE or LCBDE) was used when ERCP or ES failed.Main Outcome Measures
Success of various interventions, morbidity and mortality, and long-term incidence of recurrent biliary symptoms.Results
Endoscopic retrograde cholangiopancreatography was successful in 175 patients (95%), with bile duct stones found in 147 (84%). Endoscopic stone clearance by ES was achieved in 132 patients (90%). Morbidity rate after ERCP or ES was 4.0% (n = 7), and overall mortality rate from cholangitis was 1.6% (n = 3). After bile duct stone clearance, 82 patients underwent LC with a conversion rate of 9.8% (n = 8) and a morbidity rate of 3.6% (n = 3). Eighteen patients underwent OCBDE with a morbidity rate of 33% (n = 6), and 3 underwent LCBDE with 1 conversion and no morbidity. There was no operative mortality. Seventy-eight patients were managed conservatively after endoscopic clearance of bile duct stones. Follow-up data were available in 101 patients with cholecystectomy and 73 patients with gallbladder in situ. During a median follow-up of 24 months, recurrent biliary symptoms occurred in 5.9% (n = 6) and 25% (n = 18), respectively (P = .001). In both groups, the most common recurrent symptom was cholangitis (n = 5 and n = 14, respectively). Gallbladder in situ (risk ratio, 4.16; 95% confidence interval, 1.39-12.50; P = .01) and small-size papillotomy (risk ratio, 2.94; 95% confidence interval, 1.07-8.10; P = .04) were significant risk factors for recurrent biliary symptoms.Conclusions
Endoscopic sphincterotomy for biliary drainage and stone removal, followed by interval LC, is a safe and effective approach for managing gallstone cholangitis. Patients with gallbladder left in situ after ES have an increased risk of recurrent biliary symptoms. Laparoscopic cholescystectomy should be recommended after endoscopic management of cholangitis except in patients with prohibitive surgical risk.
... [1][2][3] Approximately 4-15% of patients with gall stones have common bile duct stones (cholecystocholedocholithiasis). 4 Many treatment modalities are currently available for cholecystocholedocholithiasis such as ERCP + LC, laparoscopic common bile duct exploration and open common bile duct exploration. 5 Among these treatment modalities ERCP + LC has fewer complications and is minimally invasive. 6 Several studies have shown that approximately 4-24% of patients who do not undergo cholecystectomy after ERCP will develop biliary complications. ...
Background: Endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) remains the cornerstone of treatment worldwide for coexisting CBD and gall bladder calculi. The interval between ERCP and LC is disputed. In our study, LC is performed at or more than 6 weeks after ERCP keeping in view by allowing the gall bladder to recover from the acute inflammatory changes if operated upon earlier.Methods: We conducted a prospective observational study in the postgraduate department of general surgery government medical college Srinagar J and K India over a period of 2 years. The 25 patients above age of 18 years and with cholecysto-choledocholithiasis who underwent ERCP and LC at or more than 6 weeks were included.Results: In our study the mean age was 45.3 years. Male: female ratio was 1:3.2. the distribution of patients as per Nassar grading scale 1 (4%) patient had grade I,12 (48%) patients had grade II, 5 (20%) patients had grade III and 7 (28%) patients had grade IV. In patients with grade I, the mean duration of surgery was 36.0 minutes, in grade II the duration of surgery ranged from 34-60 minutes with mean duration of surgery of 43.4 min (SD±8.9), in grade III duration of surgery ranged from 42-68 minutes with mean duration of surgery of 55.2 min (SD±10.06) and in grade IV duration of surgery ranged from 68-116 minutes with mean duration of surgery of 91.3 min (SD±17.66). We observed a definite relationship between the intraoperative Nassar grading scale and the post ERCP interval, 1 patient of grade I scale operated at 12 weeks post ERCP. 12 patients were between the post ERCP interval of 8-12 weeks (mean 10.1 weeks) and they had grade II. In grade III we had 5 patients with post ERCP interval of 7-11 weeks (mean 9.2 weeks). In grade IV we had 7 patients with post ERCP interval of 6-10 weeks (mean 7.9 weeks). p=0.008.Conclusions: Interval LC after ERCP is safe but challenging, longer the interval time between ERCP and LC lesser the chances of encountering intra-operative complications. We recommend LC more than 6 weeks after ERCP is safe.
... However, LC with simultaneous CBD exploration can only be implemented if the necessary surgical expertise is available [8] and is related to a higher postoperative bile leakage rate [9]. Therefore, endoscopic retrograde cholangiopancreatography (ERCP) followed by LC remains the mainstay for managing coexisting gallbladder (GB) and CBD stones [10][11][12]. In addition, inpatient ERCP in conjugation with cholecystectomy is widely accepted because it is the most efficient treatment algorithm which shortens the length of hospital stay [13]. ...
Background:
About 10% of patients with gallbladder (GB) stones also have concurrent common bile duct (CBD) stones. Laparoscopic cholecystectomy (LC) after removal of CBD stones using endoscopic retrograde cholangiopancreatography (ERCP) is the most widely used method for treating coexisting gallbladder and common bile duct stones. We evaluated the optimal timing of LC after ERCP according to clinical factors, focusing on preoperative relief of jaundice.
Methods:
A total of 281 patients who underwent elective LC after ERCP because of choledocholithiasis and cholecystolithiasis from January 2010 to April 2018 were retrospectively reviewed. We compared the hospital stay, perioperative morbidity, and rate of surgical conversion to open cholecystectomy according to the relief of jaundice before surgery. These enrolled patients were divided into two groups: relief of jaundice before surgery (group 1, n = 125) or not (group 2, n = 156).
Results:
The initial total bilirubin level was higher in group 1; however, there were no significant differences in the other baseline characteristics including age, sex, American Society of Anesthesiologists score, previous surgical history, white blood cell count, C-reactive protein, and operative time between the two groups. There was also no significant difference in postoperative hospital stay between the two groups (4.5 ± 3.3 vs. 5.5 ± 5.6 days, p = 0.087). However, after ERCP, the waiting time until LC was significantly longer in group 1 (5.0 ± 4.9 vs. 3.5 ± 2.4 days, p < 0.001). There were no statistical differences in the conversion rate (3.2% vs. 3.8%, p = 0.518) or perioperative morbidity (4.0% vs. 5.8%, p = 0.348), either.
Conclusions:
LC would not be delayed until the relief of jaundice after ERCP since there were no significant differences in perioperative morbidity or surgical conversion rate to open cholecystectomy. Early LC after ERCP may be feasible and safe in patients with cholangitis and cholecystolithiasis.
... Delaying cholecystectomy or discharging patients without cholecystectomy was shown to be associated with a high risk of development of recurrent biliary pathologies close to 25%. 6 Indeed, Poon et al 6 reported a 25% rate of recurring biliary concerns at 24 months in patients who did not have LC after an episode of cholangitis. Moreover, Schiphorst et al reported a 20% recurrence rate of biliary symptoms as early as 22 days. ...
Background and aims:
The pathogenesis of acute cholangitis (AC) occurs with biliary obstruction followed by bacterial growth in the bile duct. The leading cause of AC is obstructing gallstones. There have been conflicting theories about the optimal timing for cholecystectomy following AC. The aim of this study is to assess the impact of early cholecystectomy on the 30-day readmission rate, 30-day mortality, 90-day readmission rate and the length of hospital stay.
Methods:
This retrospective study was performed between January 2015 and January 2021 in a high-volume tertiary referral teaching hospital. Included patients were 18 years or older with a definitive diagnosis of acute gallstone cholangitis who underwent endoscopic retrograde cholangiopancreatography (ERCP) with complete clearance of the bile duct as an index procedure. We divided the patients into two groups: patients who underwent ERCP alone and those who underwent ERCP with laparoscopic cholecystectomy (LC) on the same admission (ERCP+LC). Data were extracted from electronic medical records. The primary endpoint of the study was the 30-day readmission rate.
Results:
A total of 114 patients with AC met the inclusion criteria of the study. The ERCP+LC group had significantly lower rates of 30-day readmission (2.2% vs 42.6%, p<0.001), 90-day readmission (2.2% vs 30.9%, p<0.001) and 30-day mortality (2.2% vs 16.2%, p=0.017) when compared with the ERCP group. In a multivariate logistic regression analysis, patients in the ERCP+LC group had 90% lower odds of 30-day readmission compared with patients who did not undergo LC during admission (OR=0.1, 95% CI (0.032 to 0.313), p<0.001).
Conclusion:
Performing LC on same day admission was associated with a decrease in 30-day and 90-day readmission rate as well as 30-day mortality.
... One concern regarding discharging patients prior to cholecystectomy after an episode of acute cholangitis is development of recurrent biliary complications, including cholecystitis, choledocolithiasis, gallstone pancreatitis, and cholangitis. The literature reports a high risk of recurrent [4]. Our study likely underestimates the incidence of recurrent cholangitis as it only examined patients with acute cholangitis who underwent LC and did not look at patients who never went on to have surgery. ...
Background
Early cholecystectomy following an episode of gallstone pancreatitis is data supported, however, there is minimal literature regarding the optimal timing for cholecystectomy following an episode of acute cholangitis. Our study aims to determine the ideal timing for laparoscopic cholecystectomy following an episode of acute cholangitis.
Methods
A retrospective chart review was done on cholecystectomies performed for cholangitis at our institution from 2008 to 2015. Patients were compared based on timing of cholecystectomy (i.e., index admission versus delayed) and Tokyo severity grade (I–III).
Results
We identified 151 patients who underwent cholecystectomy for cholangitis at our institution from 2008 to 2015. Cholecystectomy was performed during the index admission for 61.6% of patients and Tokyo grade (TG) did not affect the rate of cholecystectomy during index admission (TG1 65.2%, TG2 64.1%, TG3 52.8%; p = 0.46). There was no difference in average operative time (89.0 min vs. 96.6 min; p = 0.36) or conversion to open cholecystectomy (5.4% vs. 10.3%; p = 0.34) between early and late cholecystectomy groups. There was also no statistically significant difference in intra-operative complications (9.7% vs. 15.5%; p = 0.28) or overall complication rates (16.1% vs. 29.3%; p = 0.05) based on timing of cholecystectomy; however, post-operative complications were significantly higher for the delayed cholecystectomy group (20.7% vs. 6.5%; p = 0.01).
Conclusions
Early cholecystectomy after cholangitis is safe to perform and is not associated with higher operative times or rate of conversion to open, regardless of Tokyo grade. Due to the risk of developing recurrent cholangitis and a higher rate of post-operative complications seen with delayed cholecystectomy, our recommendation is to perform cholecystectomy during the index admission.
... or severe acute cholangitis: Urgent biliary drainage should be done. Following endoscopic management of acute cholangitis, laparoscopic cholecystectomy is recommended in patients with gallstone disease [36] . The various techniques of performing laparoscopic cholecystectomy safely have been described over the last few decades [37][38][39] . ...
Acute cholangitis is bacterial infection of the extra-hepatic biliary system. As it is caused by gallstones blocking the common bile duct in most of the cases, its prevalence is greater in ethnicities with high prevalence of gallstones. Biliary obstruction of any cause is the main predisposing factor. Diagnosis is established by the presence of clinical features, laboratory results and imaging studies. The treatment modalities include administration of intravenous fluid, antibiotics, and drainage of the bile duct. The outcome is good if the treatment is started early, otherwise it could be grave.
... This choice allows for the extraction of stones via the duodenum or, if this is not possible, for the placement of an internal stent or nasobiliary tube to drain the biliary tree obstructed by stones. An aggressive management with early endoscopic biliary drainage has been shown to be associated with a very low mortality rate [57]. On the other hand, delay in ERCP for patients with severe cholangitis has resulted in increased mortality and morbidity [58]. ...
Although stones in the biliary tree (and especially in the gallbladder) are an extremely common (and many times asymptomatic) disorder, they may even be the cause of insidious infections. Acute cholecystitis (AC) is a bacterial infection (most likely preceded by an inflammation of the gallbladder wall) produced by an obstruction of the cystic duct by gallstones. The obstruction results in gallbladder distension, wall edema, inflammation, ischemia, and ultimately bacterial infection, causing necrosis, gangrene, and eventually perforation of the gallbladder wall, with the development of a local abscess or generalized peritonitis. The obstruction is usually caused by gallstones (>90 %), thereby identifying the acute calculous cholecystitis (ACC), but AC may infrequently be acalculous (acute acalculous cholecystitis, AAC) [1]. Instead acute cholangitis is a bacterial infection caused by an obstruction of the biliary tree most commonly from gallstones, independent of the gallbladder and cystic duct (termed choledocholithiasis, CL), resulting in elevated intraluminal pressure and bile infection. CL in many cases can be even associated to AC.
Gallbladder disorders encompass a wide breadth of diseases that vary in severity. We present a comprehensive review of literature for the clinical presentation, pathophysiology, diagnostic evaluation, and management of cholelithiasis-related disease, acute acalculous cholecystitis, functional gallbladder disorder, gallbladder polyps, gallbladder hydrops, porcelain gallbladder, and gallbladder cancer.
Introduction
Guidelines recommend early endoscopic retrograde cholangiopancreatography for the management of acute cholangitis, but the definition of the term “early” remains debatable. This study analyzed national trends in the timing of endoscopic retrograde cholangiopancreatography and identified the ideal time to perform preoperative endoscopic retrograde cholangiopancreatography in patients with acute cholangitis.
Methods
The 2005 to 2016 National Inpatient Sample was used to identify patients undergoing cholecystectomy for acute cholangitis. Severity of cholangitis was defined using the 2013 Tokyo Grading Criteria, where Tokyo grade III patients were defined as having organ dysfunction and non-Tokyo grade III patients were defined as grades I and II. Multivariable regressions (accounting for patient and hospital characteristics) were used to identify the timing of preoperative endoscopic retrograde cholangiopancreatography associated with the least mortality risk.
Results
Of 91,051 patients undergoing cholecystectomy for cholangitis, 55% underwent preoperative endoscopic retrograde cholangiopancreatography: 24% of patients received endoscopic retrograde cholangiopancreatography on the day of admission, 41% on hospital day 2, and the use of endoscopic retrograde cholangiopancreatography decreased gradually thereafter. Mortality rates remained under 1% if endoscopic retrograde cholangiopancreatography was performed during the first 3 days and increased as endoscopic retrograde cholangiopancreatography was performed during days 4 to 7 (P < .001). On multivariable regression, endoscopic retrograde cholangiopancreatography performed >72 hours after admission was associated with increased mortality (adjusted odds ratio 1.80, P = .01). Receiving endoscopic retrograde cholangiopancreatography P > 72 hours increased risk of death among Tokyo grade III patients (adjusted odds ratio 1.88, P = .01). Overall, during the study period, the utilization of preoperative endoscopic retrograde cholangiopancreatography for all grades of acute cholangitis increased from 39% of patients in 2005 to 51% in 2016 (P < .001).
Conclusion
There has been an increase in the use of endoscopic retrograde cholangiopancreatography for acute cholangitis. Although endoscopic retrograde cholangiopancreatography on the day of admission was not associated with a decrease in mortality in patients with Tokyo grade III disease, endoscopic retrograde cholangiopancreatography within 72 hours of hospitalization was associated with decreased in-hospital mortality.
Objectives
Laparoscopic cholecystectomy (LC) following acute gallstone cholangitis reduces the recurrence of biliary symptoms; however, the timing of LC has not been determined yet. The aim of our study was to evaluate the impact of performing LC during admission on the 30-day readmission rate.Methods
We conducted a retrospective cohort study of acute gallstone cholangitis patients who underwent endoscopic clearance (EC) of the bile duct through endoscopic retrograde cholangiopancreatography between April 2013 and May 2018. Patients were classified into two groups: EC only group and EC followed by LC during admission (EC + LC) group. The primary outcome was the 30-day readmission rate.ResultsA total of 95 patients with acute cholangitis were included in the analysis. Of these patients, 35 patients (36.8%) underwent LC during admission. The 30-day readmission rate was significantly lower in the EC + LC group compared to the EC group (2.9% vs. 26.7%, P 0.003). In a multivariate regression analysis, patients who underwent LC during admission had 90% lower odds of readmission within 30 days compared to patients who did not (OR 0.1, 95% CI (0.01–0.9), P 0.04).Conclusions
Performing laparoscopic cholecystectomy during admission for acute gallstone cholangitis patients following endoscopic clearance of the bile duct significantly reduced the 30-day readmission rate without affecting the length of stay.
Objective
This study was performed to compare the effect of different time intervals between endoscopic retrograde cholangiopancreatography (ERCP) and early laparoscopic cholecystectomy (LC) on the operation duration, postoperative hospitalization, and postoperative complications.
Materials and methods
We retrospectively reviewed data for 105 patients with cholecystocholedocholithiasis who underwent ERCP and LC from January 2016 to May 2019. The patients were divided into three groups. In Group A, the interval from ERCP to LC was 0–3 days; in Group B, the interval was 4–6 days; and in Group C, the interval was >6 days. We compared operation duration, blood loss volume, postoperative hospitalization, and rate of biliary complications among the three groups and analyzed the risk factors for postoperative complications.
Results
Operation duration differed significantly among the three groups (Group A, 47.5 min; Group B, 60.0 min; Group C, 47.5 min), the blood loss volume differed significantly between Group A and Group B (8 ml vs 10 ml, p = 0.033), the postoperative hospitalization and rate of postoperative complications did not differ significantly.
Conclusion
The best time for patients with cholecystocholedocholithiasis to undergo LC is 0–3 days after ERCP. If the operation cannot be performed within 3 days, we recommend 6 days after ERCP.
Debate remains regarding the timing of laparoscopic cholecystectomy after emergent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis. We hypothesized that patients undergoing early laparoscopic cholecystectomy would have fewer operative complications and a lower conversion rate. This study is a retrospective review of an ERCP database from 2012 to 2016 of adults with a diagnosis of cholangitis secondary to choledocholithiasis who underwent ERCP followed by a laparoscopic cholecystectomy. Patient demographics, ERCP details, timing of operation (<72 hours vs >72 hours after ERCP), complications, and mortality were recorded. Analysis included chi-square, Fisher's exact, and Wilcoxon rank-sum tests, where appropriate. In the 127 patients (65 per cent male; median age, 67 years; 48 (38%) early surgery), there were no differences in demographics, BMI, vital signs, or laboratory values. Patients in the late surgery group were more likely to have a Charlson Comorbidity Index > 3 (P = 0.002), require pre-operative endoscopic sphincterotomy (P < 0.002), need pre-operative insertion of a ductal stent (P < 0.03), and had more postoperative complications (P = 0.04). Patients in the late laparoscopic cholecystectomy group had more comorbidities and suffered more complications.
Approximately twenty per cent of adults have gallstones making it one of the most prevalent gastrointestinal diseases in Western countries. About twenty per cent of gallstone patients requires medical, endoscopic, or surgical therapies such as cholecystectomy due to the onset of gallstone-related symptoms or gallstone-related complications. Thus, patients with symptomatic, uncomplicated or complicated gallstones, regardless of the type of stones, represent one of the largest patient categories admitted to European hospitals.
This review deals with the important critical care aspects associated with a gallstone-related disease.
Background
This study investigated the optimal timing and usefulness of early cholecystectomy for acute cholecystitis in patients with comorbid acute cholangitis.
Materials and methods
In 2011–2016, 252 patients who underwent early cholecystectomy for acute cholecystitis and 7 who underwent delayed cholecystectomy were enrolled and compared. Patients with comorbid acute cholangitis were then divided into those who underwent urgent cholecystectomy (within 72 h after symptom onset), semi-urgent cholecystectomy (3–14 days after symptom onset), or delayed cholecystectomy (3 months after symptom onset).
Results
There were no significant intergroup differences in postoperative complication rate (p = 0.561), operation time (p = 0.496), or intraoperative blood loss (p = 0.151) between those with and those without acute cholangitis. Postoperative stays were significantly longer in the comorbid acute cholangitis group (p = 0.004). In the patients with acute cholangitis, the urgent cholecystectomy, semi-urgent, and delayed cholecystectomy groups had comparable intra- and postoperative outcomes.
Conclusion
Early cholecystectomy within 14 days after symptom onset was safely performed for patients with concomitant acute cholecystitis and acute cholangitis after the successful treatment of acute cholangitis.
Gallstone disease is one of the most prevalent and costly digestive diseases in Western countries. The mechanisms underlying the formation of either cholesterol or pigment stones must take into account the role of epidemiological factors, risk factors, abnormalities in hepatic cholesterol and bilirubin metabolism and their biliary secretion, genetic factors and LITH genes. This chapter reviews current understanding of the molecular pathogenesis, natural history, clinical presentation, diagnosis, and treatments of gallstone disease and its complications. Aspects related to the prevention and protective mechanisms are discussed. Several critical clinical issues are summarized with the currently available grading of strength of recommendation and quality of evidence.
Gallstone disease is prevalent in western society, with 10–15 % of adults having gallstones (Stinton and Shaffer, Gut Liver 6(2):172–87, 2012). In the USA, 500,000–750,000 cholecystectomies are performed annually. Given the prevalence of biliary disease, it is important to understand the spectrum of gallstone-related pathologies and how to treat them. The major problems caused by gallstones are symptomatic cholelithiasis; acute cholecystitis; choledocholithiasis; cholangitis; and biliary pancreatitis. In addition, the surgeon may encounter a patient with acute acalculous cholecystitis or gallstone ileus. This chapter offers an overview of each of these clinical entities and outlines a diagnostic and treatment strategy for each.
During 2002 the International Association of Pancreatology developed evidenced-based guidelines on the surgical management of acute pancreatitis. There were 11 guidelines, 10 of which were recommendations grade B and one (the second) grade A. (1) Mild acute pancreatitis is not an indication for pancreatic surgery. (2) The use of prophylactic broad-spectrum antibiotics reduces infection rates in computed tomography-proven necrotizing pancreatitis but may not improve survival. (3) Fine-needle aspiration for bacteriology should be performed to differentiate between sterile and infected pancreatic necrosis in patients with sepsis syndrome. (4) Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for intervention including surgery and radiological drainage. (5) Patients with sterile pancreatic necrosis (with negative fine-needle aspiration for bacteriology) should be managed conservatively and only undergo intervention in selected cases. (6) Early surgery within 14 days after onset of the disease is not recommended in patients with necrotizing pancreatitis unless there are specific indications. (7) Surgical and other forms of interventional management should favor an organ-preserving approach, which involves debridement or necrosectomy combined with a postoperative management concept that maximizes postoperative evacuation of retroperitoneal debris and exudate. (8) Cholecystectomy should be performed to avoid recurrence of gallstone-associated acute pancreatitis. (9) In mild gallstone-associated acute pancreatitis, cholecystectomy should be performed as soon as the patient has recovered and ideally during the same hospital admission. (10) In severe gallstone-associated acute pancreatitis, cholecystectomy should be delayed until there is sufficient resolution of the inflammatory response and clinical recovery. (11) Endoscopic sphincterotomy is an alternative to cholecystectomy in those who are not fit to undergo surgery in order to lower the risk of recurrence of gallstone-associated acute pancreatitis. There is however a theoretical risk of introducing infection into sterile pancreatic necrosis. These guidelines should now form the basis for audit studies in order to determine the quality of patient care delivery. Copyright (C) 2002 S. Karger AG, Basel and IAP.
Objective: Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course requiring only brief hospitalization to a rapidly progressive, fulminant illness resulting in the multiple organ dysfunction syndrome (MODS), with or without accompanying sepsis. The goal of this consensus statement is to provide recommendations regarding the management of the critically ill patient with severe acute pancreatitis (SAP). Data Sources and Methods: An international consensus conference was held in April 2004 to develop recommendations for the management of the critically ill patient with SAP. Evidence-based recommendations were developed by a jury of ten persons representing surgery, internal medicine, and critical care after conferring with experts and reviewing the pertinent literature to address specific questions concerning the management of patients with severe acute pancreatitis. Data Synthesis. There were a total of 23 recommendations developed to provide guidance to critical care clinicians caring for the patient with SAP. Topics addressed were as follows. 1) When should the patient admitted with acute pancreatitis be monitored in an ICU or stepdown unit? 2) Should patients with severe acute pancreatitis receive prophylactic antibiotics? 3) What is the optimal mode and timing of nutritional support for the patient with SAP? 4) What are the indications for surgery in acute pancreatitis, what is the optimal timing for intervention, and what are the roles for less invasive approaches including percutaneous drainage and laparoscopy? 5) Under what circumstances should patients with gallstone pancreatitis undergo interventions for clearance of the bile duct? 6) Is there a role for therapy targeting the inflammatory response in the patient with SAP? Some of the recommendations included a recommendation against the routine use of prophylactic systemic antibacterial or antifungal agents in patients with necrotizing pancreatitis. The jury also recommended against pancreatic debridement or drainage for sterile necrosis, limiting debridement or drainage to those with infected pancreatic necrosis and/or abscess confirmed by radiologic evidence of gas or results or fine needle aspirate. Furthermore, the jury recommended that whenever possible, operative necrosectomy and/or drainage be delayed at least 2-3 wk to allow for demarcation of the necrotic pancreas. Conclusions. This consensus statement provides 23 different recommendations concerning the management of patients with SAP. These recommendations differ in several ways from previous recommendations because of the release of recent data concerning the management of these patients and also because of the focus on the critically ill patient. There are a number of important questions that could not be answered using an evidence-based approach, and areas in need of further research were identified.
INTRODUCTION: Smallpox is caused by variola viruses, which are large, enveloped, single-stranded DNA viruses of the Poxvirus family and the Orthopoxvirus genus. Variola major strains cause three forms of disease (ordinary, flat type, and hemorrhagic), whereas variola minor strains cause a less severe form of smallpox. Vaccination with vaccinia virus, another member of the Orthopoxvirus genus, protects humans against smallpox because of the high antibody cross-neutralization between orthopoxviruses. The Working Group for Civilian Biodefense considers smallpox a dangerous potential biological weapon because of “its case-fatality-rate of 30% or more among unvaccinated persons and the absence of specific therapy.” Of the potential ways in which smallpox could be used as a biological weapon, an aerosol release is expected to have the most severe medical and public health outcomes because of the virus's stability in aerosol form, low infectious dose, and high rate of secondary transmission. A single case of smallpox would be a public health emergency. EPIDEMIOLOGY: Smallpox as a Biological Weapon: Smallpox has been used as a biological weapon in the distant past and has recently been a focus of bioweapons research. In the 18th century, British troops in North America gave smallpox-infected blankets to their enemies, who went on to suffer severe outbreaks. Defecting Russian scientists describe covert Russian operations during the 1970s and 1980s that focused on the development of more virulent smallpox strains and of missiles and bombs that could release smallpox.
Biliary infection is common. Antibiotics comprise the initial therapy. Infections of the gallbladder, with the exception of empyema of the gallbladder or gangrenous cholecystitis, most often involve a single organism. Most infections are due to gram-negative coliforms. Infection of the bile ducts, or cholangitis, is usually more serious, and more often involves multiple organisms. Cholangitis frequently is associated with bile duct obstruction, and relief of this obstruction can be accomplished with endoscopic, percutaneous, or surgical techniques. Prompt appropriate antibiotic therapy along with treatment of the underlying cause of obstruction leads to successful management of most biliary tract infections.
In the treatment of patients with symptomatic cholelithiasis and possiblecholedocholithiasis (CBDS) there is not an algorithm that is fully accepted. Therefore themanagement of these patients depends upon the availability, capability and skill of thesurgical and endoscopic teams involved in the process. There is consensus to performpreoperative ERCP if the patient can be classified as a high risk for CBDS following theASGE guideline 2010. There is also complete agreement to not perform any otherdiagnostic or therapeutic radiologic or endoscopic studies if the patient has a low risk ofCBDS. However when the patient has an intermediate risk of CBDS, and in order toavoid risky and unnecessary procedures (such as preoperative ERCP) there are a range oftherapeutic options available to use (Intraoperative ERCP, Postoperative ERCP,Laparoscopic management of CBDS) whenever an intraoperative cholangiography(IOC) shows the CBDS. Magnetic resonance cholangiopancreatography (MRC) forimaging the biliary tract and endoscopic ultrasound (EUS) are very helpful to diagnoseCBDS in this setting. However not every hospital in the world has these facilitiesavailable and nor have they easy or timely access to them. It is important to know that inspite of the fact of their availability there are patients with contradictory radiological andclinical results (normal MRCP with persistently pathologic liver tests not justifiable byother reasons). In these cases we can use IOC during Laparoscopic Cholecistectomy as adefinitive radiological test to determine whether or not it will be necessary to useIntraoperative or postoperative ERCP or laparoscopic management of CBDS.Postoperative ECP is a good choice with some drawbacks such as it is a two-stagetreatment that in case of failure can be followed by another surgical operation. The laparoscopic management of CBDS is a single-stage treatment which needs a very goodand experienced surgical team, and in order to reach this skill it requires a long learningcurve. Intraoperative ERCP has the advantage of being a single-stage treatment that canbe used all over the world, that has a significant success rate, an easy learning curve, lowmorbidity involving a shorter hospital stay and lower costs than the two-stage treatments(postoperative and preoperative ERCP). Intraoperative ERCP is also a good salvagetreatment when preoperative ERCP fails or when total laparoscopic management is notsuccessful thereby avoiding open cholecystectomies. It also has some drawbacks such asthe need for good coordination between surgical and endoscopic teams and thatcholecistectomy must be practically completed before the ERCP is performed.
Acute cholangitis is an infectious disease of the biliary tract with a wide spectrum of presentations, ranging in severity from a mild form, characterised mainly by fever and jaundice, to a severe form with septic shock. Reported mortality rates vary from 13 to 88% [1].
ACUTE CALCULOUS CHOLECYSTITIS: Epidemiology: The prevalence of gallstones in the general population is approximately 10–15%, and is higher in people with the following risk factors: female gender, multiparity, obesity, recent pregnancy, and hemolytic diseases (e.g., sickle cell disease). Of people with gallstones, 10–20% will develop complications such as biliary colic, cholecystitis, cholangitis, or gallstone pancreatitis. Acute calculous cholecystitis is defined by sustained obstruction of the cystic duct or neck of the gallbladder with gallstones or sludge. In contrast, biliary colic is pain secondary to transient obstruction of the gallbladder. Acute cholecystitis is primarily a localized acute inflammatory process caused by gallbladder obstruction and subsequent distension, but is clinically managed as an infection. The pathophysiologic role of bacteria cultured from bile remains unknown. Clinical Features: Although most patients with acute cholecystitis present with right upper quadrant tenderness, few actually present with the classic triad of fever, right upper quadrant pain, and leukocytosis. The pain of acute cholecystitis may radiate to the back and the right shoulder due to secondary irritation of the diaphragm. Acute cholecystitis can be distinguished from biliary colic by constant pain in the right upper quadrant and the presence of Murphy's sign, defined as inspiration limited by pain on palpation of the right upper quadrant.
Late laparoscopic cholecystectomy (LC) after endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy (ES) for common bile duct (CBD) stone clearance, two-stage LC (TSLC), is associated with difficult surgical dissection and an increased rate of conversion to open procedure. The purpose of the study was to evaluate whether the interval between ERCP/ES and LC is associated with major bile duct injury (BDI) and determine an optimal period for TSLC.
This was a retrospective cohort study of adult patients who underwent LC. The exclusion criteria were absence of CBD stones on imaging or ERCP, surgical treatment of choledocholithiasis, post-operative endoscopic CBD stone clearance and open cholecystectomy.
The eligibility criteria were met by 183 patients. There were six major BDIs (3%). Comparisons of the early and late TSLC showed statistically significant difference in major BDI at 16-week cut-offs. Binomial regression analysis demonstrated that late (≥16 weeks) TSLC was associated with 10-fold increase in major BDI (95% confidence interval: 1.1-95.7, P = 0.043). Survival analysis comparing early (<16 weeks) with late (≥16 weeks) TSLC demonstrated that both groups had similar survival time (log-rank test: 0.317).
General surgeons should be aware of the increasing risk of major BDI with delaying TSLC and perform interval LC before week 16.
© 2015 Royal Australasian College of Surgeons.
To investigate the safety and feasibility of our original single-incision laparoscopic cholecystectomy (SILC) for acute inflamed gallbladder (AIG).
One hundred and ten consecutive patients underwent original SILC for gallbladder disease without any selection criteria and 15 and 11 of these were diagnosed with acute cholecystitis and acute gallstone cholangitis, respectively. A retrospective review was performed not only between SILC for AIG and non-AIG, but also between SILC for AIG and traditional laparoscopic cholecystectomy (TLC) for AIG in the same period.
Comparison between SILC for AIG and non-AIG revealed that the operative time was longer in SILC for AIG (97.5 min vs 85.0 min, P = 0.03). The open conversion rate (2/26 vs 2/84, P = 0.24) and complication rate (1/26 vs 3/84, P = 1.00) showed no differences, but a need for additional trocars was more frequent in SILC for AIG (5/24 vs 3/82, P = 0.01). Comparison between SILC for AIG and TLC for AIG revealed no differences based on statistical analysis.
Our original SILC technique was adequately safe and feasible for the treatment of acute cholecystitis and acute gallstone cholangitis.
Elective laparoscopic cholecystectomy is recommended after endoscopic clearance of choledocholithiasis for patients with acute cholangitis, according to Tokyo guidelines. However, the optimal timing remains uncertain.
Perioperative outcomes were retrospectively reviewed and compared between patients with early (< 6 weeks) and late (> 6 weeks) surgeries, while risk factors for postoperative complications were assessed using multivariate analysis.
One hundred twelve patients (mean age, 64 years; range, 30-85 years) were analyzed. Rate of conversion and intraoperative and postoperative complications (classified per Dindo et al) were 21.4% (24 of 112), 23.2% (26 of 112), and 34.8% (39 of 112), respectively. The late surgery group had significantly more intraoperative (28.8% vs 9.4%, P = .029) and postoperative (42.5% vs 15.6%, P = .007) complications compared with the early surgery group. Multivariate analysis showed both late surgery (95% confidence interval, 1.47-12.5; P = .008) and a history of endoscopic sphincterotomy (95% confidence interval, 1.06-8.26; P = .038) to be independent risk factors for postoperative complications.
Patients with endoscopic clearance of choledocholithiasis, especially after endoscopic sphincterotomy, should receive elective laparoscopic cholecystectomy within 6 weeks after a cholangitic attack.
The development of laparoscopic cholecystectomy as a minimally invasive approach to eliminate gallstones, in conjunction with increasingly sophisticated techniques for removal of common bile duct (CBD) stones by endoscopic sphincterotomy, has revolutionized the treatment of choledocholithiasis. We describe a new technical approach to laparoscopic exploration of the CBD after unsuccessful endoscopic stone extraction.
Eleven patients were subjected to laparoscopic exploration of the CBD with choledochotomy using a rigid scope (24-Fr nephroscope) during the last 2 years. Of these patients, 10 had unsuccessful preoperative (7 cases) or intraoperative (3 cases) stone extraction, and 1 case had a single impacted stone 2.3 cm in diameter. Five patients had a single bile duct stone and 6 patients had multiple stones. The size of the stones ranged from 9.5 to 24 mm (mean = 12.6 +/- 4 mm).
Balloon dilation of the papilla of Vater was done in all patients. Most of the stones were fractured and pushed into the duodenum with rigid grasping forceps but a lithotripter was required in 2 patients. Stone clearance was 100%; complications related to the procedure were not observed. After CBD clearance, primary closure of the choledochotomy was achieved in 10 patients. In 1 patient who had CBD perforation during a previous procedure, choledochotomy was closed over a T-tube. The mean operative time was 124 +/- 26.7 min (range = 84-165 min) and the mean postoperative hospital stay was 4 +/- 1.7 days (range = 3-7 days).
Laparoscopic exploration of the CBD with a rigid scope is an efficacious procedure in dealing with unsuccessful endoscopic stone extraction.
Infectious cholangitides encompass a wide spectrum of infectious processes affecting the biliary tree. They can have protean clinical and imaging appearances. Some manifest as an acute medical emergency with high mortality if not properly and emergently managed. Others are chronic processes that may predispose a patient to liver failure or cholangiocarcinoma. The clinical and imaging features and the subsequent therapy are dictated by the pathogens involved, the immune status of the host, and the degree and distribution of biliary obstruction. Bacteria cause most cases of infectious cholangitis in Western countries. In other parts of the world, parasites play an important role, either as causative agents or in predisposing the host to bacterial superinfection. Viral cholangitides primarily affect immunocompromised patients. The clinical and imaging features of cholangitis differ between immunocompetent and immunocompromised patients. Imaging plays a pivotal role in diagnosis of infectious cholangitis, helps identify predisposing causes, and demonstrates complications. Moreover, interventional radiology provides tools to treat acute life-threatening biliary infections, chronic entities, and complications.
To evaluate the results of laparoscopic exploration of the common bile duct (LECBD) in patients with previous gastrectomy.
This study is a retrospective review of a prospectively maintained database of LECBD during the period 1994-2005. Those cases of LECBD with previous open gastrectomy were sorted out and analyzed. Indications of operation included unsuccessful endoscopic extraction due to altered anatomy and some explorations were performed together with side-to-side choledochoduodenostomy so as to eliminate biliary stasis and decrease stone recurrence. The operation steps involved open insertion of trocar and creation of pneumoperitoneum, meticulous adhesiolysis, direct choledochotomy followed by clearance of biliary stones. After confirmed ductal clearance, the common bile duct was routinely closed with t-tube diversion. The perioperative parameters of these patients were analyzed and compared to those receiving open exploration of common bile duct due to previous gastrectomy during the same study period.
Of the 184 LECBD performed between 1994 and 2005, 33 patients had previous open upper gastrointestinal operations and among them 18 LECBD were performed in post-gastrectomy patients (2 with previous classical Whipple's operation). There were 10 male and 8 female patients with mean age of 77.5 (58-97 years). Of the 14 patients undergoing preoperative endoscopic retrograde cholangiopancreatography, there were 10 failed cannulations and 4 failed extractions. Altogether 17 choledochotomies and 1 transcystic duct exploration was performed whereas 4 patients with recurrent primary stones received additional choledochoduodenostomy. Median operating time was 120 min (60-390 min). Open conversion was required in 3 patients (16.6%) because of jammed basket, extensive adhesion and "through & through" bile duct injury respectively. Postoperative complications occurred in 4 patients (22.2%), which included 3 bile leaks and also the previously mentioned bile duct injury. The median hospital stay was 9 days (4-82 days). Upon a median follow-up of 17.5 months, there was only 1 patient found to have recurrent common bile duct stone and he was managed by laparoscopic exploration and choledochoduodenostomy. When the results were compared to those 12 open explorations because of previous open gastrectomy, longer operation time (120 vs. 75 min, p=0.004) and slightly shorter hospital stay (9 vs. 14 days, p=0.104) were noted in the LECBD group but without increased complication rate (22.2 vs. 25%, p=1).
These results suggest that LECBD is worth attempting even in patients with previous open gastrectomy.
The onset of morphological differentiation in Streptomyces lividans is intrinsically delayed in comparison to Streptomyces coelicolor, but can be advanced by adding extra copper to the medium. Copper-specific chelators block aerial hyphae formation in both strains illustrating the crucial role of copper in morphogenesis. The S. coelicolor ram cluster was isolated as a clone that complements the copper-dependent differentiation of S. lividans. The S. lividans ram cluster was cloned and shown to be 99.6% identical to the S. coelicolor clone. The difference in development between S. lividans and S. coelicolor could neither be related to functional differences between the two ram clusters nor to differences in the transcription level. In both strains the low level of ramAB transcription correlated with aerial mycelium formation and was coupled to the upstream ORF ramS. An increased ramAB expression level in S. lividans by the introduction of an extra copy of ram stimulated the development. In S. lividans disruption of ramABR resulted in the inability to produce aerial hyphae. Conversely, the identical mutant of S. coelicolor retained its developmental capacities, indicating the presence of a ram-independent developmental route that is not present or not activated in S. lividans. Aerial hyphae and spore formation in the S. lividans ramABR mutant was restored when grown near wild-type strains, suggesting that the ram gene products are involved in transport of a factor essential for normal development. In addition, an elevated copper concentration in the medium also relieved the developmental block of these mutants. These findings suggest that higher copper concentrations render this ram-associated factor obsolete.
To investigate the diagnostic standard for early identification of severe acute cholangitis in order to lower the incidence of morbidity and mortality rate.
A diagnostic standard was proposed in this study as follows:documented biliary duct obstruction by ultrasound or computerized tomography or other imaging tools with the manifestation of systemic inflammatory response syndrome (SIRS). The surgical procedures included emergency common bile duct exploration with T tube insertion or cholecystostomy with secondary common bile duct exploration. And incidence of postoperative multiple organ dysfunction syndrome (MODS), duration of systemic inflammatory response and hospital mortality were analyzed.
Fourty-three patients conforming to the diagnostic standard described above were employed in this study. 1 patient was admitted in acutely ill condition and complicated with acute relapse of chronic bronchitis, cholecystostomy procedure was performed but the patient was complicated with postoperative acute lung injury which was treated by assisted mechanical ventilation for 5 d; 2 wk later, two-stage common bile duct Exploration and T tube insertion were performed. The remaining 42 patients underwent primary common bile duct exploration and T tube insertion, 1 developed acute lung injury and recovered 3 d later, 2 patients developed acute renal dysfunction, 1 of which recovered 2 d later and the other died on d 4. For all patients, the postoperative systemic inflammatory response persisted for 2 to 8 d with median of 3 d.
Early diagnosis of severe acute cholangitis can be made using this diagnostic standard, further development of systemic inflammatory response could be prevented and incidence of MODS as well as hospital mortality decreased.
Laparoscopic common bile duct (CBD) exploration is a well-established treatment option in dedicated centers. However, few data are available on the results in elderly patients.
The outcome after laparoscopic CBD exploration in elderly patients (age <70 years) was compared with that in a concurrent control group of younger patients (age, <70 years).
There were 77 elderly patients in group A and 207 younger patients in group B. American Society of Anesthesiology (ASA) III and IV patients and prior abdominal operations were more frequent in group A (p <0.001). Two patients from each group underwent conversion to open surgery. There was no significant difference frequency of use between the transcystic and choledochotomy approaches, although the latter tended to be more frequent in the group A because of larger stones, (group A 53.4%; group B, 37.6%). Minor and major morbidity (group A, 12%; group B, 13.6%), rate of recurrent stones (group A, 1.3%; group B, 1.9%), and mortality (group A, 1.3%; group B, 0%) were not significantly different between the two groups. The single death in group A involved a patient with acute toxic cholangitis who underwent emergency surgery after multiple failed attempts at endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy performed elsewhere. No CBD stenosis was observed at follow-up assessment.
Elective laparoscopic CBD exploration is safe and effective. It may become the standard of care in both elderly and younger patients.
Background:
To date, no procedure has yet been identified as the gold standard for the treatment of gallstone cholangitis in the laparoscopic era.
Methods:
The data of 109 consecutive patients with acute cholangitis were prospectively entered into a computerized database. All patients were managed according to a standard protocol. The main treatments were endoscopic retrograde cholangiography (ERC) combined with endoscopic sphincterotomy (ES), followed by interval laparoscopic cholecystectomy (LC). Patients in whom ERC or endoscopic stone clearance failed were managed by emergency open common bile duct exploration. LC was performed with a standardized four-cannula technique. The mean duration of surgery, conversion rate, and postoperative outcome of these patients were evaluated.
Results:
ERC was successful in 103 patients (94.5%). In five of these patients (4.8%), no bile duct stones were found. The 98 patients (95.2%) with common bile duct stones were referred for ES. The bile duct stones were successfully removed after ES in 93 cases (94.9%). The overall failure rate of ERC and ES for choledocholithiasis was 10.1%. Self-limiting pancreatitis occurred in four patients (4.3%). Overall, two of the 109 patients died (1.8%). After ES, 81 patients underwent LC. LC was performed successfully in 74 patients (91.3%). Conversion to open surgery was required in seven patients (8.7%). The morbidity rate after cholecystectomy was 7.4%; the morbidity rate after open bile duct exploration was 36.4% (p<0.05). Fifteen patients were managed conservatively after initial endoscopic management of their cholangitis. The overall incidence of recurrent biliary symptoms was significantly higher among patients with gallbladder in place than for patients who underwent cholecystectomy (38.5% vs 1.5%, p<0.001).
Conclusions:
ES followed by LC is a safe and effective approach for the management of gallstone cholangitis; cholecystectomy should be performed in patients with gallstone cholangitis unless the operative risk is extremely high. These high operative risk patients and those who refuse surgery after ES should be warned that they are at high risk for recurrent biliary symptoms.
Symptomatic gallstones are generally accepted as being the indication for cholecystectomy. Generally, severe abdominal pain in epigastrium and in the right upper abdominal quadrant, and lasting for more than 15 min, is thought to be caused by gallstones. However, many patients with other abdominal complaints undergo cholecystectomy and are satisfied with the outcome of surgery. Possible ways to improve the results of cholecystectomy are discussed.
Review of previous work by the authors.
The introduction of laparoscopic cholecystectomy has even led to an increase in cholecystectomies; in a higher complication rate; and in increased costs of the treatment of gallstone disease. Because of faster recovery, 70% of symptomatic gallstone patients are able and willing to undergo laparoscopic cholecystectomy in day care. Cholecystectomy after sphincterotomy and stone extraction in patients who have stones in the gallbladder was demonstrated to prevent gallstone-related symptoms in at least 40% of patients. If the gallbladder had to be removed later for symptomatic disease, however, this did not result in a higher rate of conversions and complications. Because of shortage in operation capacity in The Netherlands, there is a considerable delay between the diagnosis of symptomatic stones and cholecystectomy. Better selection of patients for cholecystectomy will not only improve the results of cholecystectomy, it will also reduce the number of cholecystectomies and patients on waiting lists. Delay of cholecystectomy is associated with more complications, longer operative times, higher conversion rates to open cholecystectomy and prolonged hospitalization. The efficacy of the bile salt ursodeoxycholic acid in preventing gallstone-related pain attacks and complications in patients with contraindications for operation or waiting to undergo cholecystectomy should be investigated further, since two retrospective studies have demonstrated favourable outcomes for this strategy.
The results of cholecystectomy are likely to be improved by better selection of patients, prevention of delay of the procedure and possibly treatment with ursodeoxycholic acid.
During 2002 the International Association of Pancreatology developed evidenced-based guidelines on the surgical management of acute pancreatitis. There were 11 guidelines, 10 of which were recommendations grade B and one (the second) grade A. (1) Mild acute pancreatitis is not an indication for pancreatic surgery. (2) The use of prophylactic broad-spectrum antibiotics reduces infection rates in computed tomography-proven necrotizing pancreatitis but may not improve survival. (3) Fine-needle aspiration for bacteriology should be performed to differentiate between sterile and infected pancreatic necrosis in patients with sepsis syndrome. (4) Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for intervention including surgery and radiological drainage. (5) Patients with sterile pancreatic necrosis (with negative fine-needle aspiration for bacteriology) should be managed conservatively and only undergo intervention in selected cases. (6) Early surgery within 14 days after onset of the disease is not recommended in patients with necrotizing pancreatitis unless there are specific indications. (7) Surgical and other forms of interventional management should favor an organ-preserving approach, which involves debridement or necrosectomy combined with a postoperative management concept that maximizes postoperative evacuation of retroperitoneal debris and exudate. (8) Cholecystectomy should be performed to avoid recurrence of gallstone-associated acute pancreatitis. (9) In mild gallstone-associated acute pancreatitis, cholecystectomy should be performed as soon as the patient has recovered and ideally during the same hospital admission. (10) In severe gallstone-associated acute pancreatitis, cholecystectomy should be delayed until there is sufficient resolution of the inflammatory response and clinical recovery. (11) Endoscopic sphincterotomy is an alternative to cholecystectomy in those who are not fit to undergo surgery in order to lower the risk of recurrence of gallstone-associated acute pancreatitis. There is however a theoretical risk of introducing infection into sterile pancreatic necrosis. These guidelines should now form the basis for audit studies in order to determine the quality of patient care delivery.
With advances in noninvasive radiologic technology, additional adjunctive techniques are developing, and the roles for ERCP and EUS are continuously changing. In a diagnostic setting, ERCP is currently best reserved for patients with a high likelihood of needing endoscopic therapy, and EUS is especially useful for cases in which other imaging techniques have been inconclusive or are of inferior diagnostic capability. In a therapeutic setting, ERCP and EUS retain important roles in the management of both benign and malignant pancreatic and biliary disease. Certainly, technological advances also directly affect these modalities and expanded applications for ERCP and EUS for the pancreas and biliary tract are anticipated.
Emergency common bile duct exploration (CBDE) is still required in patients acutely ill with complicated biliary tract stone disease when endoscopic decompression fails to reverse their condition. This study looks at the clinical profile of patients requiring emergency CBDE and examines the various factors influencing the postoperative outcome.
Clinical records of patients with emergency CBDE in Singapore General Hospital from January 1991 to December 1998 were reviewed. Factors influencing postoperative outcomes, for example, pre-existing medical problems, hepatic parameters, the impact of endoscopic procedures (if any) and indications for surgery, were correlated with postoperative morbidity and 30-day mortality.
The records of 100 patients were available for review. Major indications for emergency CBDE were cholangitis (51%) and intraoperative findings of common bile duct obstruction during emergency laparotomy (23%). Six patients had emergency CBDE because of iatrogenic complication of attempted therapeutic endoscopic retrograde cholangiopancreaticography (ERCP) for biliary stones. Overall mortality was 14.0% and 8.0% had retained stones. Mortality was significantly influenced by age, prior biliary disease, preoperative endoscopic biliary decompression in acute cholangitis (33.3%vs 9.4%, P = 0.035) and endoscopic complications.
Among patients requiring emergency CBDE, uncomplicated preoperative endoscopic biliary decompression benefits patients with acute cholangitis.
Cholelithiasis is a prevalent condition in Western populations. Most cases are asymptomatic but complications can occur. Acute cholangitis, cholecystitis, and gallstone pancreatitis are the most common biliary tract emergencies and are usually caused by biliary calculi. Whenever possible, acute cholecystitis should be treated with early LC. AAC is an uncommon condition usually affecting patients with significant comorbidities. Treatment is usually with percutaneous cholecystostomy, which often is also the only required therapy. Endoscopic drainage is the preferred form of biliary decompression in acute cholangitis and these patients should subsequently undergo elective LC unless unfit for surgery. Effective and optimal management of biliary tract emergencies relies on close cooperation between gastroenterologist, surgeon, and radiologist.
It has been more than 30 years since the introduction of endoscopic sphincterotomy for the management of choledocholithiasis. Once introduced, this endoscopic intervention subsequently enabled clinicians to witness the natural history of leaving the gallbladder in situ once the common duct calculi were removed. Because many people were free of symptoms once the common bile duct was cleared of stones, patients and physicians alike soon questioned whether it was necessary to remove the gallbladder at all. Despite more than two decades of clinical research and numerous published reports, the answer to this question remains elusive. Similarly, the management algorithm for choledocholithiasis in patients with an intact gallbladder remains controversial. We review the available key data regarding this question. Importantly, there are only three prospective, randomized trials that have examined the need for cholecystectomy after endoscopic sphincterotomy, with case studies constituting most of the published reports. Consequently, the literature on this topic remains inconclusive, weakened by its retrospective approach, considerable variability between the patients studied, inconsistent inclusion and exclusion criteria, and frequently poor patient follow-up. Nonetheless, the preponderance of data favor removing the gallbladder after endoscopically clearing the common bile duct of gallstones because an estimated 25% of patients will experience recurrent symptoms within a 2-year follow up period. Recognizing the existence of various mitigating clinical factors, we advocate adopting a selective wait-and-see approach for high-risk patients, especially those with a life expectancy of less than 2 years or severely debilitating comorbidities.
New investigations, evaluation of controversial issues, and advances in technology continue to shape the endoscopic management of biliary disorders. This article discusses recent literature related to the diagnosis and therapy of biliary tract disease. Specifically, the diagnosis and management of choledocholithiasis, complications of biliary endoscopy and potential preventive measures, roles for endosonography in the evaluation of biliary disease, and endoscopic therapy of postoperative liver transplantation complications are reviewed. Recent advances in biliary stents and the use of cholangioscopy in biliary disorders are also assessed.
Cholangitis, infection of the bile ducts, is a serious condition that necessitates prompt and efficacious treatment for a good clinical outcome. A single center retrospective study of cholangitis was conducted to better define the spectrum of responsible pathogens and their antibiotic sensitivities.
We studied all patients at our hospital who had cholangitis from January 1998 to June 2004. Patients were identified by ICD-9 codes and the cause of the cholangitis, the treatment and culture data were noted by review of the medical record.
Thirty patients presented with cholangitis as noted by the clinical symptoms of jaundice, fever and abdominal pain. The cause of the biliary obstruction was gallstones in 18 patients, benign biliary strictures in 5 and malignant obstruction in 7. All the patients with malignant obstruction with cholangitis had stents; there were no cases of cholangitis in malignant obstruction unless prior instrumentation had been performed. The most common isolates were Enterococcus>E. coli>Enterobacter>Klebsiella. Sixty-four percent of blood cultures and all but one of the bile cultures grew organisms. Seventy-two percent of patients had positive blood cultures with at least one resistant organism present and 36% had organisms resistant to multiple antibiotics. Fifty percent of patients with benign biliary disease and positive blood cultures had multiple organisms growing in their blood. Three-quarters of the isolates were resistant to one or more antibiotics and one-quarter of isolates were resistant to three or more antibiotics. Resistant organisms were found regardless of the cause of the biliary obstruction.
For all causes of cholangitis, there is a high incidence of positive blood cultures and a high rate of antibiotic resistance. For optimal treatment, blood and/or bile cultures should be routinely performed to optimize antibiotic therapy.
Endoscopic sphincterotomy (ES) was attempted in 106 patients with common bile duct (CBD) calculi and gall bladders present, who were considered unfit for surgery on the grounds of age and frailty alone (35%) and/or the presence of major medical problems (65%). Endoscopic sphincterotomy was successful in 105 patients (99%). Early ES related complications occurred in 21 patients (19.8%). Twelve hospital deaths occurred (11.3%), although this was due to biliary causes in only five (4.7%) and one of these was moribund on admission. Complications were more frequent in those in whom initial ES did not clear the common bile duct (30.4%) compared with those in whom this was (11.7%; p = 0.0164). The mortality was also greater in patients in whom there was no ERCP proof of CBD clearance (p = 0.01) unless operated upon. Twelve patients developed gall bladder complications (11.3%) including five with empyema (4.7%). Analysis of clinical, haematological, and biochemical factors together with ERCP findings showed that the only factor which had any value in predicting gall bladder complications was pre-existing cholangitis. The present series was compared with another using ES as a definitive procedure, and with a surgical series. Although there were significant differences in outcome, differences with respect to medical risk factors and the incidence of complications of CBD stones (jaundice, cholangitis, and acute pancreatitis) were striking. Further analysis of these factors may allow a clearer definition of patients most likely to benefit from either ES or surgery.
Objective:
To review the results of laparoscopic cholecystectomy (LC) in patients with acute cholecystitis with attention to cost and clinical outcome.Design:
Retrospective study.Setting:
Large private metropolitan teaching hospital.Patients:
Four hundred forty-six patients had LCs at our institution between January 1993 and February 1995. Acute cholecystitis, confirmed by clinical, laboratory, operative, and histopathological findings, was present in 60 patients.Main Outcome Measures:
The medical history, laboratory findings, gallbladder ultrasounds, timing of operation from the onset of symptoms, conversion rates to open procedures, operative times, intraoperative findings, complications, postoperative length of stay, cost of operative procedures and hospitalizations, and convalescence times were collected.Results:
Laparoscopic cholecystectomy was attempted in 16 patients within 72 hours of the onset of symptoms of acute cholecystitis (group 1), in 19 patients with symptoms between 4 and 7 days (group 2), and in 25 patients with symptoms lasting more than 7 days (group 3). The only factor (eg, preoperative laboratory and ultrasound findings) that affected the outcome of the operation was duration of symptoms prior to operation. Patients who had LC done within 72 hours of the onset of symptoms had lower rates of conversion to open procedures, less difficult operations, shorter operative times, less costly procedures, and a shorter convalescence than those with symptoms for longer than 72 hours prior to operation. The conversion rates in patients operated within and after 72 hours were 12% and 30%, respectively. There were no bile duct injuries and no mortalities.Conclusions:
Laparoscopic cholecystectomy can be performed safely in most patients with acute cholelithiasis. However, we found that the duration of symptoms prior to LC affected the outcome; the conversion rates, hospital costs, and convalescence times increased in operated-on patients with symptoms for more than 72 hours. In our opinion, interval cholecystectomy may be a superior option in this latter group of patients.(Arch Surg. 1996;131:540-545)
p
< 0.05), a higher incidence of intercurrent diseases (
p
< 0.05), and a higher serum urea level (
p
< 0.001). The proportions of patients who underwent early or delayed surgery were comparable. There was no difference in operation
time, postoperative analgesic requirements, or complications. Elderly patients, however, had a significantly higher conversion
rate (23.3% versus 2.5%;
p
< 0.05). Even after successful laparoscopic cholecystectomy, there was a longer delay before ambulation (
p
< 0.05) and resumption of normal diet (
p
= 0.08) with resulting prolonged postoperative (
p
= 0.08) and total hospital stay (
p
< 0.05). Laparoscopic cholecystectomy is a safe, effective treatment for acute cholecystitis in the elderly. When compared
to younger patients, elderly patients are at greater risk for conversion, delayed recovery, and prolonged hospital stay.
Of 402 patients admitted with biliary disease over the last three years, cholangitis has been diagnosed in 36. This represents an 8.8 per cent overal incidence and a 33.8 per cent incidence among patients who have undergone operation or manipulation involving the common duct. Based on this experience, a program of prophylaxis and treatment of cholangitis has been devised with special emphasis on the management of elderly patients in the initial postoperative period.
Twenty patients with suppurative cholangitis were seen at the Massachusetts General Hospital over a nine year period. Fifteen patients had acute obstructive suppurative cholangitis due to complete obstruction of the common duct, many with coma, hypotension, and positive blood cultures. Sixty per cent of patients were older than seventy years, and most had a history of biliary tract disease. Although most had jaundice, abdominal pain, and fever, clinical symptoms were variable. The diagnosis of cholangitis was made in only 30 per cent of patients before autopsy or surgery. Eighteen patients had calculi in the common duct, and two had primary fibrosis of the ampulla. Patients explored less than 24 hours after admission or deterioration died less often than those operated on after some delay. Most patients underwent common duct exploration and four had a concomitant sphincterotomy. In one instance, cholecystostomy only was performed and this patient died because of ongoing sepsis. The overall mortality was 40 per cent; of those subjected to operation, 25 per cent died in the hospital. Recovery was dramatic among most survivors, and calculous disease did not recur, except for two patients with retained stones. Prophylactic cholecystectomy is recommended to prevent the occurrence of this subtle and highly dangerous syndrome.
Emergency surgery for patients with severe acute cholangitis due to choledocholithiasis is associated with substantial morbidity and mortality. Because recent results suggested that emergency endoscopic drainage could improve the outcome of such patients, we undertook a prospective study to determine the role of this procedure as initial treatment.
During a 43-month period, 82 patients with severe acute cholangitis due to choledocholithiasis were randomly assigned to undergo surgical decompression of the biliary tract (41 patients) or endoscopic biliary drainage (41 patients), followed by definitive treatment. Hospital mortality was analyzed with respect to the use of endoscopic biliary drainage and other clinical and laboratory findings. Prognostic determinants were studied by linear discriminant analysis.
Complications related to biliary tract decompression and subsequent definitive treatment developed in 14 patients treated with endoscopic biliary drainage and 27 treated with surgery (34 vs. 66 percent, P greater than 0.05). The time required for normalization of temperature and stabilization of blood pressure was similar in the two groups, but more patients in the surgery group required ventilatory support. The hospital mortality rate was significantly lower for the patients who underwent endoscopy (4 deaths) than for those treated surgically (13 deaths) (10 vs. 32 percent, P less than 0.03). The presence of concomitant medical problems, a low platelet count, a high serum urea nitrogen concentration, and a low serum albumin concentration before biliary decompression were the other independent determinants of mortality in both groups.
Endoscopic biliary drainage is a safe and effective measure for the initial control of severe acute cholangitis due to choledocholithiasis and to reduce the mortality associated with the condition.
105 patients with acute calculous cholangitis who did not respond to conservative management underwent urgent endoscopic drainage of the biliary system at a mean of 1.5 days after admission. Treatment was successful in 102 (97%) patients. 3 of the patients in whom drainage was not successful underwent emergency surgery, with 1 death. 3 patients died of uncontrolled sepsis despite successful endoscopic drainage. 1 patient died of a stroke. The overall mortality was 4.7%. Among those in shock 2 out of 4 drained after 72 h died, compared with 3 out of 38 drained before 72 h. There were no deaths in the group without shock irrespective of the timing of drainage.
Endoscopic sphincterotomy was undertaken in 186 patients with common bile duct stones and an intact gall bladder who were considered unfit for surgery. One hundred and seventy one patients had jaundice of whom 18 also had clinical cholangitis. The mean age of treated patients was 79.7 years (range 27-92) and only 13 were aged less than 60. Sphincterotomy was successful in 185 (99%) and complete clearance achieved in 172 (92.5%). Early complications occurred in nine patients (4.8%) of whom three died (1.6%). The patients have been followed on average for 32 months (range six to 72 months). Eighteen patients have subsequently required cholecystectomy (9.6%), with six major complications, but no deaths. There have been 27 natural deaths and 156 patients remain alive and symptom free. Endoscopic treatment alone is safe and effective in the majority of frail and elderly patients and can reduce the need for surgery in this high risk group.
Endoscopic sphincterotomy is an accepted treatment for retained common bile duct stones, but there is little specific information available regarding its application in acute suppurative obstructive cholangitis with sepsis due to choledocholithiasis. Thirteen patients with this condition were referred to the authors for consideration of urgent endoscopic common bile duct decompression. All had been judged to be poor surgical candidates. Pus was released from the common bile duct by sphincterotomy within 24 hours of admission in all 13. Stones were removed endoscopically in 10 patients (77%) without complications. After endoscopic stone removal, symptoms, signs, and abnormal laboratory values returned to normal rapidly; follow-up endoscopic retrograde cholangiography did not show retained stones. Three patients whose large stones precluded endoscopic removal underwent operative choledocholithotomy. Urgent endoscopic sphincterotomy offers an important alternative in the treatment of acute suppurative obstructive cholangitis secondary to choledocholithiasis.
One hundred twenty-two patients with common bile duct stones and intact gallbladders underwent endoscopic sphincterotomy without cholecystectomy and were followed for 6 months to 9 years (mean 3 years). Nineteen patients died from unrelated causes. One hundred of 103 surviving patients (97 percent) were asymptomatic, whereas 3 had complaints. Acute cholecystitis did not occur in 91 patients without gallstones, whereas it did occur in 5 of 31 patients (16 percent) with gallstones (25 patients) or nonvisualization of the gallbladder (6 patients). Two patients in the former subgroup had formation of new gallstones. We conclude that cholecystectomy should be advocated whenever possible in patients with gallstones or nonvisualization of the gallbladder after endoscopic sphincterotomy due to the high incidence of acute cholecystitis in this subgroup and that operation is not necessary in patients without gallstones; however, one should be aware of possible formation of new stones in the gallbladder.
Ninety episodes of acute cholangitis in 66 patients have been analyzed. In 71% of the episodes, an operation was performed. Eight deaths occurred, for a patient mortality rate of 12%. Sixty-seven per cent of the operations were performed after at least 72 hours of antibiotic therapy, whereas only 17% had to be done as life-threatening emergencies within 24 hours of admission to the hospital. Although 86% of the operative deaths occurred in the group operated on more than 72 hours after admission, this was not statistically significant. However, death did correlate with failure to respond to antibiotic therapy (p less than 0.001) irrespective of time of operation. Biliary cancer and congenital lesions were etiologic for 31% of the operative cases in this series, but were responsible for 71% of the postoperative deaths (p less than 0.05). We conclude that acute cholangitis has a wide spectrum of severity and that most cases will respond to antibiotic therapy, affording the surgeon the luxury of operating in an elective fashion. Moreover, acute cholangitis complicated by failure to respond to antibiotic therapy is more likely to occur in biliary cancer and congenital lesions, and subsequently will have a poorer prognosis.
The features of cholangitis were analyzed in 99 consecutive cases treated in the last ten years. The disease was severe and refractory in half the cases due to malignant stricture, and in 20% of those due to gallstones. Benign strictures, sclerosing cholangitis, and most cases of choledocholithiasis were associated with less severe cholangitis, which responded promptly to antibiotic therapy. High fever, a serum bilirubin level above 4 mg/dl, and hypotension characterized the most severe refractory cases in which emergency surgery was mandatory. Patients without manifestations were nearly always controlled successfully with antibiotics. We conclude that the term "suppurative cholangitis" is an unsatisfactory synonym for severe cholangitis, because the correlation between biliary suppuration and clinical manifestations in cholangitis is inexact; some patients with severe sepsis do not have pus in the bile duct, and a few patients with suppurative bile are only moderately ill.
Morbidity and mortality after surgical treatment of bileduct stones increase with age and associated diseases. A proposed alternative therapy is endoscopic sphincterotomy (ES) with the gallbladder left in situ, and we elected to compare this option with standard open surgery in high-risk patients.
98 patients (mean age 80 years) with symptoms likely to be due to bileduct stones or a recent episode of biliary pancreatitis were randomised to be treated either by open cholecystectomy with operative cholangiography and (if necessary) bileduct exploration (n=48) or by endoscopic sphincterotomy alone (n=50).
The procedure was accomplished successfully in 94% of the surgery group and 88% of the ES group, and there were no significant differences in immediate morbidity (23% vs 16%) or mortality (4% vs 6%). During mean follow-up of 17 months biliary symptoms recurred in three surgical patients, none of whom underwent repeat surgery, and in 10 ES patients, seven of whom had biliary surgery. By multivariate regression analysis endoscopic sphincterotomy was an independent predictor of recurrent biliary symptoms (odds ratio 6.9; 95% Cl 1.46 to 32.54).
In elderly or high-risk patients, surgery is preferable to endoscopic sphincterotomy with the gallbladder left in situ as a definitive treatment for bileduct stones or non-severe biliary pancreatitis.
Conventionally, acute cholangitis is managed by placing a nasobiliary drainage catheter. We have attempted to place a biliary endoprosthesis in such patients as an alternative to using nasobiliary catheter drainage.
Twenty-seven patients with acute cholangitis were managed by placement of 7-Fr straight biliary endoprostheses instead of using nasobiliary drainage catheters to decompress the biliary system. The procedure was carried out without sphincterotomy and without image intensification.
Biliary endoprosthesis placement was successfully carried out in all the patients. Definitive treatment was then provided to all but four patients, who either had inoperable cancer or were at high risk for surgery. Early stent occlusion occurred in one patient, and in another patient the Dormia basket became entrapped while stones were being removed from the common bile duct. There were no mortalities.
Biliary endoprosthesis placement is safe, easy to perform, and is a cheaper alternative to endoscopic nasobiliary drainage.
Advanced age with its concomitant comorbid conditions may be associated with increased postoperative laparoscsopic cholecystectomy (LC) complications and more frequent conversion to open cholecystectomy (OC). The purpose of this study was to evaluate the outcome of LC in patients age 65 and older.
Ninety consecutive patients were studied age 65 and older, of whom 39 (43%) were males and 51 (57%) were females, mean age 74 years (range 65-98), with 20 patients (22%) >/= 80. Indications for surgery included biliary colic 55 (61%), acute cholecystitis 22 (24%), pancreatitis 10 (11%), and cholangitis 3 (4%). Seventeen patients (19%) had preoperative ERCP, 12 of which were normal; five had sphincterotomy with stone extraction. Comorbid conditions included hypertension (44%), CAD (17%), cardiac arrhythmias (18), CHF (9%), and COPD (7%).
Operative time-mean 1 h 51 min +/- SD 43 min. Conversion to OC-three patients (3%). Length of stay-mean 5 days (range 1-26). Mortality-two patients (2%) >80 years old, one patient with septicemia and multiorgan failure whose comorbid diseases included CAD, C.F., COPPED, and elevated BP, one patient with MI postsurgery, morbid diseases included DM and CAD. Complications-five patients (5%): bile leak from cystic duct stump (one), postsurgery MI (two), incarcerated incisional hernia (one), septicemia (one).
Morbidity rates for LC in the elderly population are not different from that reported for patients less than 65 years of age. (5% vs 6%, Fried et al., Surg Clin North Am 1994;74 [2]: 375-387). Our 2% mortality rate is statistically different from previously reported in a series of patients of all ages (0.6%, Fried et al.). The 3% rate of conversion to OC in this older population is not significantly different from the patients in Fried et al. series (4%).
Although recent reports suggest an initial laparoscopic approach to acute cholecystitis, the risk factors and consequences of the failure of an attempt remained unknown.
A retrospective study of 557 laparoscopic cholecystectomies was undertaken to identify 70 patients (13%) with a clinical diagnosis of acute cholecystitis confirmed by ultrasonography. Patients who required conversion to laparotomy (conversion group) were compared to those with successful laparoscopic cholecystectomy (successful group).
Eight of 70 patients (11%) required conversion. The conversion group had significantly more elderly (< or =65 years) patients (88% vs 37%; P = 0.02) and larger gallstones as shown on ultrasonography (25 mm vs 15.5 mm; P = 0.03). Other preoperative factors associated with severe inflammation were not predictive. Conversion was associated with the intraoperative finding of severe adhesions and not with those of empyema of gallbladder or gangrenous cholecystitis. Conversion was made after a median laparoscopic surgery time of 50 minutes. The conversion group required more operation time, more analgesics, a longer recovery time, and a longer hospital stay. In addition, the postoperative complication rate was significantly higher (63% vs 16%; P = 0.009).
Patients who required conversion from laparoscopic to open cholecystectomy for acute cholecystitis are at risk for postoperative complications. In elderly patients with large gallstones, the surgeon should made an early decision to convert if severe adhesions are encountered.
The aim of this study was to analyse characteristics of patients who survived more than 5 years after liver resection of colorectal metastases.
A multicentre retrospective study collected 1818 patients who underwent curative resection of hepatic metastases between 1959 and 1991. Among the 747 patients operated on before 1987, 102 survived longer than 5 years, and were compared with patients who survived less than 5 years.
Three risk factors proved independently significant in multivariate analysis between the two groups: serosa infiltration (P = 0.003), involvement of peritumoral lymph nodes around the primary colorectal tumour (P = 0.04), and a liver resection margin of less than 1 cm (P = 0.02). There was no significant difference for other parameters studied (location of primary tumour, location, number and size of metastases, type of resection). A trend towards a shorter survival of patients with increased carcinoembryonic antigen serum level was observed.
Resection of colorectal hepatic metastases can provide long-term survival even in patients with poor prognostic factors. It seems justified to undertake resection of colorectal liver metastases whenever it may be performed safely as a curative treatment.
A prospective randomized study was undertaken to compare early with delayed laparoscopic cholecystectomy for acute cholecystitis.
Laparoscopic cholecystectomy for acute cholecystitis is associated with high complication and conversion rates. It is not known whether there is a role for initial conservative treatment followed by interval elective operation.
During a 26-month period, 99 patients with a clinical diagnosis of acute cholecystitis were randomly assigned to early laparoscopic cholecystectomy within 72 hours of admission (early group, n = 49) or delayed interval surgery after initial medical treatment (delayed group, n = 50). Thirteen patients (four in the early group and nine in the delayed group) were excluded because of refusal of operation (n = 6), misdiagnosis (n = 5), contraindication for surgery (n = 1), or loss to follow-up (n = 1).
Eight of 41 patients in the delayed group underwent urgent operation at a median of 63 hours (range, 32 to 140 hours) after admission because of spreading peritonitis (n = 3) and persistent fever (n = 5). Although the delayed group required less frequent modifications in operative technique and a shorter operative time, there was a tendency toward a higher conversion rate (23% vs. 11%; p = 0.174) and complication rate (29% vs. 13%; p = 0.07). For 38 patients with symptoms exceeding 72 hours before admission, the conversion rate remained high after delayed surgery (30% vs. 17%; p = 0.454). In addition, delayed laparoscopic cholecystectomy prolonged the total hospital stay (11 days vs. 6 days; p < 0.001) and recuperation period (19 days vs. 12 days; p < 0.001).
Initial conservative treatment followed by delayed interval surgery cannot reduce the morbidity and conversion rate of laparoscopic cholecystectomy for acute cholecystitis. Early operation within 72 hours of admission has both medical and socioeconomic benefits and is the preferred approach for patients managed by surgeons with adequate experience in laparoscopic cholecystectomy.
Laparoscopic cholecystectomy (LC) has displaced open cholecystectomy (OC) in the management of cholelithiasis. However, there are few studies on the role of this technique in patients who run a high risk of surgical complications. We performed a prospective study in 264 patients aged >65 years undergoing surgery for symptomatic cholelithiasis. They were divided into two groups according to the surgical technique performed: OC (131 patients) and LC (133 patients). Conversion from LC to OC was necessary in 11 patients (8.3%). Mean surgery time was 70.9 min for the OC group and 75 min for the LC group. The LC group had a lower rate of postoperative complications (13.53%) than the OC group (23.6%). The incidence of mild complications was similar in both groups; however, the rate of moderate complications was significantly higher in the OC group. Hospital stay was significantly longer in the OC group (9.9 days) than in the LC group (3.71 days). These results suggest that LC should be indicated in elderly patients, as they are better than those obtained with with OC and involve a lower morbidity rate and shorter hospital stay.
Gallstones are found within the main bile duct (MBD) of 7% to 20% of patients undergoing cholecystectomy. MBD stones are the commonest cause of acute cholangitis and acute pancreatitis. Acute cholangitis is the result of infection superimposed on an obstructed biliary system and carries a high mortality rate if left untreated. The mainstay of treatment is a regimen of broad-spectrum intravenous antibiotics followed by prompt decompression of the obstructed biliary tree. Decompression is best accomplished by the endoscopic route, although transhepatic approaches may also be employed. Gallstone pancreatitis may be associated with cholangitis but is also common as a separate entity. Initial treatment is supportive, although new agents designed to suppress the systemic inflammatory response are under development and have proved beneficial in clinical trials. Severe cases should be treated with systemic antibiotics and early removal of the obstructing stones by endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy. Prophylactic cholecystectomy is recommended to prevent further episodes of gallstone pancreatitis.
The introduction of laparoscopic techniques for the management of biliary stone disease has expanded the therapeutic choices for surgeons confronted with choledocholithiasis. As new strategies emerge, the treatment of cholelithiasis and choledocholithiasis remains controversial. This paper discusses the options available for the treatment of common bile duct stones. Diagnostic and therapeutic algorithms are proposed. The treatment of these patients must be individualized, taking into consideration the condition of the patient, associated diseases, secondary complications of the gallstones, and the surgical expertise and resources of the institution.
The long-term outcome after endoscopic papillotomy is poorly defined. The aim of this study was to determine the long-term results of this method in the treatment of common duct calculi and to determine which prognostic factors are associated with the relapse of biliary symptoms.
Between 1985 and 1988, 223 consecutive (149 women, mean age 67.9 years) patients underwent endoscopic papillotomy for duct stones; 127 had already undergone cholecystectomy or underwent this operation during the same hospitalization. Follow-up data were obtained retrospectively from the patients and patients' relatives and general practitioners.
The procedure was successful in 217 of 223 cases (97%), of which 203 were followed-up; 2 patients died in the first month after treatment (0.89%). Mean follow-up for the 201 patients was 6.2 years, during which 31 relapsed (15%). Three significant prognostic factors for late complications were identified in a multivariate analysis. The recurrence rate of biliary symptoms in patients who were left with an in situ gallbladder was 20.2%, and 11% for those whose gallbladder was removed (p = 0.04). Patients with a bile duct 15 mm or greater in diameter were more prone to recurrence of symptoms than those with a bile duct 10 mm or less in diameter (41% vs. 10%, p = 0.025) and were especially at higher risk to develop recurrent stones (19.5% vs. 4.9%, p = 0.019). Stone recurrence, but not biliary symptoms as a whole, was more frequent in patients with a peripapillary diverticulum (p = 0.035).
The long-term results of endoscopic papillotomy are comparable with those of surgical techniques. The prognostic factors associated with relapse of biliary symptoms as a whole are gallbladder left in situ and choledochal diameter. Bile duct size and peripapillary diverticula are associated with recurrent bile duct stones.
Laparoscopic cholecystectomy has become the procedure of choice for laparoscopically skilled surgeons when dealing with both chronic and acute cholecystitis. When choledocholithiasis is encountered in the treatment of these patients the skilled laparoscopist has several treatment options available to treat the patient in one stage and avoid the morbidity of endoscopic sphincterotomy. Although still controversial, laparoscopic common bile duct exploration has been shown to be safe, applicable, and cost-effective in the treatment of choledocholithiasis. This report details several laparoscopic treatment alternatives for choledocholithiasis.
Although laparoscopic cholecystectomy is unusually safe and well tolerated in patients with routine symptomatic cholelithiasis, it can become a formidable procedure when used to manage biliary tract emergencies. Optimally, a reasoned and cautious approach and a low threshold for conversion can avoid major complications. One such emergency, acute cholecystitis, may be particularly hazardous because of the relatively common finding of severe inflammation with dense adhesions to adjacent viscera and gallbladder necrosis. Special modifications of technique may be required. Overall, urgent operation (within 72 hours) results in an acceptably low mortality (0.3%) but a somewhat higher conversion rate (16%) and longer hospital stay (3 days). Unnecessary delays may result in more adhesions and an increased level of operative difficulty. In patients who are at an especially high risk because of co-morbid disease, percutaneous cholecystostomy is an appropriate alternative strategy. Biliary pancreatitis may be associated with high mortality (9%) and has an unpredictable course. Accordingly, a multidisciplinary approach that may include both gastroenterologists and radiologists is generally advisable. Because common bile duct (CBD) stones are present in more than 20% of patients who present with biliary pancreatitis, endoscopic retrograde cholangiopancreatography (ERCP) can be used effectively on a selective basis during the preoperative or postoperative period; the preferred timing continues to be somewhat controversial. As an alternative approach, laparoscopic CBD exploration is gradually gaining wider acceptance. In eight reported series using a variety of techniques for stone extraction, major complications were infrequent (10%), and the conversion rate was low (5%). Acute suppurative cholangitis is a more fulminant problem that is best managed by expeditious ERCP with removal of all intraductal stones. Resuscitation should be continued until complete; laparoscopic cholecystectomy can follow at an appropriate interval.