Laparoscopic cholecystectomy and interventional endoscopy for gallstone complications during pregnancy.

BACKGROUND: Symptomatic or complicated gallstone disease is the most common reason for nongynecological operations during pregnancy. Gallstones are present in 12% of all pregnancies, and more than one-third of patients fail medical treatment and therefore require surgical endoscopy or laparoscopy. Gallstone pancreatitis and jaundice during pregnancy is associated with a high recurrence rate, exposing both fetus and mother to an increased risk of morbidity and mortality. METHODS: During a 4-year period, all pregnant patients (n = 37) with symptomatic or complicated gallstone disease were studied prospectively at the Landeskrankenhaus in Salzburg, Austria. Five patients had an endoscopic retrograde cholangiopancreatogram (ERCP) for biliary pancreatitis or jaundice; two of these underwent subsequent laparoscopic cholecystectomy. Another seven patients required laparoscopic cholecystectomy for severe pain or cholecystitis; all were in their 13th-32nd gestational week. Access was established by Veress needle in all cases. Insufflation pressure was 8-10 mm Hg, and mean operative time was 62 min. RESULTS: All patients delivered full-term, healthy babies. There were no postendoscopic or postoperative complications. All patients enjoyed full relief from their symptoms; there were no recurrences of pancreatitis or jaundice. CONCLUSIONS: The combination of ERCP and laparoscopic cholecystectomy offers a safe and effective option for the definitive treatment of complicated gallstone disease and intractable pain during pregnancy, and there is sufficient access for the combined treatment to be employed.

[Surgical ultrasound--indications for "therapeutic splitting" in complicated gallstones]. / Chirurgischer Ultraschall--Indikation zum "therapeutischen Splitting" beim komplizierten Gallenstein.

The use of selective therapeutic ERCP, indicated by ultrasonographically detected dilation of the common bile duct, is a safe procedure with low morbidity, no mortality and a significant reduction in the need for conversion to open cholecystectomy.

Efficacy and safety of a low-molecular-weight heparin and standard unfractionated heparin for prophylaxis of postoperative venous thromboembolism: European multicenter trial.

A randomized, double-blind multicenter trial was performed to compare the safety and efficacy of a new low-molecular-weight heparin (LMWH) (LU 47311, Clivarine) and standard unfractionated heparin for the prophylaxis of postoperative venous thromboembolism. Altogether 1351 patients scheduled to undergo abdominal surgery were included. Main outcome measures included the incidence of thromboembolic events (deep vein thrombosis, pulmonary embolism, or both) and bleeding complications, including wound hematoma. A total of 655 patients received 1750 anti-Xa IU of LMWH plus a placebo injection daily; 677 patients received 5000 IU of unfractionated heparin (UFH) twice a day. Both drugs were found to be equally effective, as 4.7% of patients in the LMWH group and 4.3% in the UFH group developed postoperative thromboembolic complications. However, the incidence of bleeding complications was significantly reduced in the LMWH group: 55 (8.3%) patients in the LMWH group and 80 (11.8%) in the UFH group developed bleeding complications, a relative risk (RR) of 0.70 (95% CI 0.51-0.97;p = 0.03); wound hematoma occurred in 29 (4.4%) of the LMWH group compared with 55 (7.7%) in those in the UFH group for an RR of 0.57 (95% CI 0.37-0.88;p = 0.01). This study confirmed that a very low dose of 1750 anti-Xa IU daily of this new LMWH is as effective as 10,000 IU of UFH for preventing postoperative deep vein thrombosis. At this dose its administration is associated with a significant reduction in the risk of bleeding including wound hematoma.

[Treatment of postoperative bile fistulas after laparoscopic cholecystectomy by ERCP, EPT and bile duct drainage]. / Die Behandlung postoperativer Gallefisteln nach laparoskopischer Cholezystektomie durch ERCP, EPT und Gallengangsdrainage.

BACKGROUND: Bile leakage as a complication following cholecystectomy can be found more frequently after laparoscopic cholecystectomy (LC) than after open cholecystectomy. The present study planned to find out the importance of ERCP, sphincterotomy and temporary drainage of the bile duct system in the treatment of bile leakage. PATIENTS AND METHODS: From July 1992 to October 1996 15 consecutive patients presenting with bile leakage following LC underwent endoscopic therapy by CBD-drainage with sphincterotomy (n = 11), CBD-drainage without sphincterotomy (n = 1) and sphincterotomy alone (n = 3). RESULTS: Closure of the bile leakage could be achieved in all cases, biliary secretion stopped after 2.1 days (1-7 days). One dislocation of the drainage into the CBD was found and could be treated endoscopically. Endoscopy-related mortality was 0%. CONCLUSIONS: Endoscopic therapy offers a safe, effective and minimal invasive method in the treatment of bile leakage following LC.

[Preoperative therapeutic splitting]. / Präoperatives therapeutisches Splitting.

INTRODUCTION: The best clinical strategy for using ERC combined with LC is still unknown. Based on a wide discussion of literature reports the aim of our study is to critically analyse laparoscopic bile duct exploration and to correlate these data to our prospective study of "therapeutical splitting". PATIENTS AND METHODS: In a prospective study 1645 consecutive patients with sympomatic gall stone disease were examined by ultrasound. 309 patients had open cholecystectomy because of previous gastric surgery or perforation. Patients with a high probability of harbouring stones in the common duct or having other related disorders like biliary pancreatitis had ERC, EPT and stone extraction. 1336 patients had attempted LC. RESULTS: At endoscopy 70% of the 260 patients required therapy like EPT and/or stone extraction, 95% consequently had their gallbladder removed laparoscopically. Including the patients with biliary pancreatitis morbidity amounted to 3% with no mortality. In the non-endoscopic group with 1076 patients conversion was 6.8%, morbidity was 4.3% and mortality 0.09%. Residual stones were found in 0.5% so far. CONCLUSION: If selection criteria for bile duct pathology have a high sensitivity and specificity and endoscopical stone clearance rate is high, at present "therapeutical splitting" still is the method of choice.

[Urgent ERCP and early elective laparoscopic cholecystectomy in biliary pancreatitis]. / Dringliche ERCP und früh-elektive laparoskopische Cholezystektomie bei biliärer Pankreatitis.

BACKGROUND: For many years the best algorithm of treatment for complicated gallstone disease has been intensively discussed. Gallstone pancreatitis with cholangitis still belongs to the most often identified causes of death of necrotizing pancreatitis. The reduction of complication and lethality rates was mainly achieved by urgent ERCP and sequential cholecystectomy. In a prospective study we have combined endoscopic therapy with laparoscopic cholecystectomy (LC) and are discussing the results. PATIENTS AND METHODS: Between May 1991 and December 1996 146 patients with biliary pancreatitis were subjected to ERCP after laboratory tests and ultrasound screening of the biliary system. If there were no contraindications and the gallbladder was still in situ, LC was attempted during the initial admission. RESULTS: Of the 70 patients with attempted LC 26 had common bile duct calculi, 23 had an impacted papillary stone and 10 had signs of a stone passage. 59 patients underwent LC successfully, a conversion to open surgery was necessary in 11 patients. The morbidity rate amounted to 7%, lethality to 0%. DISCUSSION: Since a more liberal indication for ERCP in the management of acute pancreatitis was introduced the number of biliary related cases of acute pancreatitis is increasing. In response to early endoscopic bile duct clearance the rates of morbidity and mortality can be significantly reduced. Early LC is the ideal complementary treatment option to absolutely prevent recurrencies.

[Value of diagnostic laparoscopy and minimal invasive procedures in acute abdomen]. / Der Stellenwert der diagnostischen Laparoskopie und minimal-invasiver Verfahren beim akuten Abdomen.

During the last three years 172 diagnostic laparoscopies (DL) were performed at our department in patients with an acute abdomen of unclear causes. This corresponds to 17% of all patients who underwent operation due to an acute abdomen in the same period. Always the indication for a diagnostic laparoscopy arose then, when the cause or the localization of the acute abdomen could not be found by conventional diagnostic methods. The advantages of DL were either the confirmation (93%) or the exclusion (7%) of the diagnosis "acute abdomen", the exact localization and simultaneously a definitive operative treatment of the cause by minimal invasive interventions (n = 109/65%). In these patients with acute abdomen the main causes were acute inflammations of gallbladder (n = 48) and appendix (n = 29), ulcus perforations (n = 9) and ileus (n = 9). The conversion rate amounted to 2.7%, the postoperative complication rate to 11% and the lethality rate to 1.8% in these patients. A new indication is the so-called "bedside laparoscopy" as means to control the postoperative course of mesenteric embolism (n = 9) and diffuse peritonitis (n = 3) in order to avoid the stress of a second-look operation for these seriously ill patients or to secure the indication for relaparotomy.

The effect of antigen stimulation on splenic transplants.

The present paper deals with the regeneration of splenic tissue after autologous transplantation. Control and transplanted rats (60 days after operation (10(6) cells per injection). The effect of a primary response was studied by a single injection, long-lasting bacteraemia was imitated by 5 injections in weekly intervals. Spleens and transplants were investigated by flow-cytometry and immunohistochemistry. Additionally, the proliferation activity and the specific antibody production against Escherichia coli proteins were tested. Flow-cytometric analysis showed altered behaviour of T-helper cells and B-cells in transplants following a primary response, whereas in the multiple injection group a difference between the splenic and transplant response was restricted to macrophages and MHC II+ cells. The results of the morphometric analysis revealed that the cellular composition of unstimulated transplants was very similar to that of the spleen with some subtle alterations. Only the marginal zone showed more striking differences concerning the homing of several cell classes. Under stimulatory conditions, these subtle alterations became more drastic so that CD5+ cells, B-cells and macrophages responded in an abnormal manner in both groups. The analysis of thymidine kinase disclosed decreased activity in the spleen after weekly antigen stimulation. The stimulation index of all transplant groups was significantly lower than that of the spleen. The specific antibody (IgG) production after a single immunization was highest in the transplant group. All groups responded after the multiple challenge. In conclusion, the results demonstrate that splenic transplants differs in several, but subtle aspects from normal splenic tissue. The main reason for most of these alterations may be a slightly misguided recirculation and/or homing of cells.

[Bedside laparoscopy (BSL) for postoperative follow-up of mesenteric infarct and diffuse peritonitis]. / Bedside-Laparoskopie (BSL) zur postoperativen Verlaufskontrolle beim Mesenterialinfarkt und bei diffuser Peritonitis.

Bedside laparoscopy (BSL) for postoperative follow-up in mesenterial infarction of the intensive care patient undergoing respiration treatment represents an important tool for avoiding second-look operations and/or for precisely securing the indication for a relaparotomy. Up until now, nine patients with mesenterial infarction have undergone a BSL, allowing five of then to avoid a second-look operation in this way. Of these nine patients, three died due to a diffuse peritonitis with anastomotic dehiscence, a pulmonary embolism, and a perforation of the stomach after PEG tube deplacement, respectively. Thus BSL represents a low-complication and simply performed method for postoperative follow-up, especially in mesenterial infarction, but also in cases of diffuse peritonitis.

[Potential for improvement of combined endoscopic-surgical treatment of bleeding gastroduodenal ulcer]. / Verbesserungspotentiale bei der kombiniert endoskopisch-chirurgischen Behandlung des blutenden gastroduodenalen Ulcus.

A total of 119 patients (January 1995-December 1996; 53 women, 66 men) with a medium age of 63.1 years were admitted to hospital with bleeding gastroduodenal ulcer. Emergency gastroduodenoscopy was performed immediately in all cases, sclerotherapy in 94 cases (78.9%). Control endoscopy was done routinely after 12-24 h; the recurrent bleeding rate amounted to 14.3%, mortality was 5%, and surgical intervention was necessary in 8.4% with a mortality of 40% (!).

[Pancreatic duct occlusion with fibrin (glue) to protect the pancreatico-digestive anastomosis after resection of the head of the pancreas in oncologic surgery]. / Die Pankreasgangokklusion mit Fibrin(-kleber) zum Schutz der pankreatiko-digestiven Anastomose nach Pankreaskopfresektion in der onkologischen Chirurgie.

The PDO with FS represents a technically simple, quick and efficient method for the protection of pancreatic-jejunal anastomosis, which is endangered by dehiscences. We could prove--first, in an animal experimental, then in a clinical study of 93 patients--that neither subsequent dehiscence nor a pancreatic fistula occurred. Also, the loss of exo- and endocrine functions is low and can rather be considered as an expression of the extended resection of the pancreatic parenchyma in the scope of the oncological intervention.

Does endoscopic sphincterotomy destroy the function of Oddi's sphincter?

OBJECTIVE: To evaluate the possible destruction of Oddi's sphincter by endoscopic sphincterotomy (ES). DESIGN: Prospective, nonrandomized control trial. The study was done from the beginning of 1986 to the end of 1991. SETTING: The Department of Surgery, Salzburg (Austria) General Hospital. PATIENTS: Ninety-one patients with cholecystolithiasis and concomitant different diseases of the common bile duct. Ninety-five patients exclusively having cholecystolithiasis served as the control group. INTERVENTIONS: Patients with cholecystolithiasis plus concomitant different diseases of the common bile duct underwent preoperative ES and, at a second intervention, conventional cholecystectomy. Patients with cholecystolithiasis only underwent elective conventional cholecystectomy. MAIN OUTCOME MEASURES: During the cholecystectomy, three pressure and flow variables were routinely measured in the common bile duct: the natural resting pressure, the maximum pressure after the standardized injection of physiologic saline solution, and the normalizing time (the time required for the reappearance of the initial resting pressure). RESULTS: The statistical comparison of the two groups showed no significant deviations regarding the resting pressure (P < .4), whereas the maximum pressure was significantly lower (P < .01) in the group that underwent ES. The normalizing time of patients who underwent ES was not statistically different (P < .375) from that of the control group patients. CONCLUSION: The function of Oddi's sphincter is changed but not destroyed following ES.

[Choledocholithiasis--therapeutic splitting]. / Choledocholithiasis--therapeutisches Splitting.

Despite new developments like chemolitholysis and extracorporeal shock wave lithotripsy, conventional cholecystectomy was the "gold standard" in the treatment of gallstones. The range of indications and the operative strategy were well standardized, although the management of common bile duct stones in gallstone disease was still under debate. For high-risk and elder patients endoscopic retrograde cholangio-pancreatography (ERCP), papillotomy and stone extraction was established, in younger patients the best management was questionable. According to better and more accurate preoperative tests like ultrasound and the ample evidence of the function of the papilla after endoscopic papillotomy the trend seemed to be the preoperative endoscopic bile duct clearance in all patients, just when the "bushfire" of laparoscopic cholecystectomy arised and until then praised standards were thrown overboard because of technical difficulties. Routine intraoperative cholangiography (IOC) was replaced by indicated selective IOC due to the lack of talent of many surgeons. Only the therapeutic concept of the removal of the stone-bearing gallbladder survived all new concepts and the debate of whether to perform routine IOC and whether to clear the bile ducts--pre-, intra- or postoperatively or primarily or secondarily convert to open cholecystectomy and bile duct revision. In the eye of a new "gold standard" and according to the literature and our own results we should standardize our management especially in the era of laparoscopic cholecystectomy as "therapeutical splitting" with indicated and selective preoperative ERCP and bile duct clearance offers the best results and facilitates minimally invasive surgery.

[Laparoscopic cholecystectomy in cholecysto-choledocholithiasis. "Therapeutic splitting" or conventional surgical procedure?]. / Laparoskopische Cholecystektomie bei Cholecysto-Choledocholithiasis. "Therapeutisches Splitting" oder konventionelles chirurgisches Vorgehen?

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

An unusual complication in attempted non-surgical treatment of pancreatic bile duct stones.

This report describes a guidewire fracture during an attempt at endoscopic treatment of pancreatic duct calculi in a patient with chronic pancreatitis, multiple pancreatic duct stenoses and pancreatic duct stones. This patient underwent endoscopic sphincterotomy in order to perform pancreatic duct drainage prior to ESWL. After sphincterotomy, a guidewire was introduced into the main pancreatic duct, but was jammed by the calculi. Neither could the guidewire be removed nor a contrast medium catheter be pushed over it, thus making ESWL impossible. A stronger pull resulted in a fracture of the wire, and a 25 mm long part which could not be removed with a Dormia basket remained in the main pancreatic duct. A Whipple's procedure became necessary as definitive treatment for the pancreatico-lithiasis in this patient.

Aggressive extracorporeal shock wave lithotripsy of gall bladder stones within wider treatment criteria: fragmentation rate and early results.

Two hundred and twenty patients with a total of 412 gall bladder stones of between 8 and 38 mm in size were treated with extracorporeal shock wave lithotripsy, using the overhead module Lithostrar Plus. Fifty six per cent of stones were solitary (mean (SD) diameter 23 (5) mm) and 9.5% of the patients had more than three stones. Stones were successfully disintegrated in 218 patients (fragmentation size less than 5 mm in 80%, less than 10 mm in 19%). Some 65% of patients required one treatment and the rest two or three. A mean (SD) of 4100 (1800) shock waves with a pressure of 700 bar were applied. Twenty four to 48 hours after lithotripsy a transient but significant increase in serum transaminase activities (31%) and in bilirubin (29%), urinary amylase (27%), and blood leukocyte (62%) values was observed. In 29% of patients there was a transient microhaematuria, in 2% transient macrohaematuria, and in 25% painless petechiae of the skin. Ultrasound showed temporary gall bladder wall oedema in 13%, temporary distension of the gall bladder in 11%, and transient common bile duct distension in 8% after treatment. After discharge from hospital, 31% of patients complained of recurrent colic that responded to simple analgesics. Four to eight weeks after therapy, four patients developed biliary pancreatitis and 11 biliary obstruction that was managed by endoscopy. To date, 105 patients have been followed for over 12 months. Sixty one of these had a solitary stone, 17 had two, and 27 had three or more stones. A total of 59 patients, including 44 with a primary solitary stone, eight with two stones, and seven with three or more stones are completely stone free.

[Technique of recurrent laryngeal nerve exposure within the scope of interventions of the thyroid gland]. / Zur Technik der Rekurrensdarstellung im Rahmen von Eingriffen an der Schilddrüse.

In anatomical preparations performed during autopsy we developed a well-defined approach for the identification of the recurrent laryngeal nerve during surgery on the thyroid gland. The principle of this concept is to visualize the nerve near the branching of the inferior thyroid artery, where it shows a 30 degree angle to the trachea in a direction running from caudal lateral to cranial medial and lies in front of, behind, or between the branches of the artery. This preparation mode has been prospectively performed in 100 patients undergoing thyroid surgery. In 159 (= 97.6%) sides of the neck out of 163 we identified the nerve at the typical site. The topographical relation of the recurrent nerve to the inferior thyroid artery revealed the following differences for the right and left side of the neck: On the right side the nerve was found to be behind in 48%, in front in 33% and between the branches of the artery in 15% of cases. In contrast, on the left side the nerve was found to be dorsal in 53%, ventral in 23% and between the branches in 23%. Of 163 nerves at risk we observed primary nerve palsy in 2 cases (1.2%), and a definitive palsy rate of 0.6% at the 3-month follow-up. In conclusion, we recommend the described approach for the identification of the recurrent laryngeal nerve during thyroid surgery whenever complete mobilisation of the thyroid lobe (e.g. thyroidectomy, lobectomy, resection of retrotracheal adenomas) is necessary.

[Laparoastoma (open packing) in the treatment concept of infected pancreatic necroses]. / Das Laparoastoma (Open Packing) im Behandlungskonzept infizierter Pankreasnekrosen.

Out of 284 patients with acute pancreatitis 73 (26%) had pancreas necrosis. Of these 73 cases 43 patients with infected pancreas necrosis were treated surgically, whereas conservative treatment proved successful in the remaining 30 cases with so-called sterile necrosis. Our interdisciplinary treatment combined delayed surgery for the better demarcation of the necrotic tissue, with extended intensive care therapy and epigastral laparostomy; through this laparostomy surgical revision with necrosectomy and peritoneal lavage was performed daily for 15 (+/- 6) days, necessitating long-term artificial respiration for an average of 15 (4/168) days. The mortality rate in the 43 patients with infected pancreas necrosis amounted to 16.2% (n = 7); none of the patients with sterile necrosis died. In cases of multiple organ failure the mortality rate was significantly higher (30%) than with failure of only one organ system (4.3%). The mortality rate in all cases with pancreas necrosis (n = 73) amounted therefore to 9.5%. Serious complications of laparostomy occurred in 28% (n = 12) of the 43 patients, whereby 8 of these cases were gastrointestinal fistulae, with a fatal outcome in one patient. The overall mortality rate in the total group of 284 patients with acute pancreatitis was 2.8%.