Endoscopic management of post-cholecystectomy biliary fistula.

OBJECTIVE: Bile duct injury is an uncommon but potentially serious complication in cholecystectomy. A recognized treatment for minor biliary injury is internal biliary decompression by endoscopic retrograde cholangiopancreatography (ERCP) and stent insertion. The aim of this study was to assess the effectiveness of ERCP in the management of minor biliary injuries. METHODS: A retrospective review of medical records at a tertiary referral centre identified 36 patients treated for postoperative minor biliary injuries between 2006 and 2010. Management involved establishing a controlled biliary fistula followed by ERCP to confirm the nature of the injury and decompress the bile duct with stent insertion. RESULTS: Controlled biliary fistulae were established in all 36 patients. Resolution of the bile leak was achieved prior to ERCP in seven patients, and ERCP with stent insertion was successful in 27 of the remaining 29 patients. Resolution of the bile leak was achieved in all patients without further intervention. The median time to resolution after successful ERCP was 4 days. Two patients underwent ERCP complicated by mild pancreatitis. No other complications were seen. CONCLUSIONS: This review confirms that postoperative minor biliary injuries can be managed by sepsis control and semi-urgent endoscopic biliary decompression.

Benign gastro-colic fistula in a woman presenting with weight loss and intermittent vomiting: a case report.

INTRODUCTION: Benign gastro-colic fistula is a rare occurrence in modern surgery due to the progress in medical management of gastric ulcer disease. Here we report the first case of benign gastro-colic fistula occurring whilst on proton-pump inhibitor therapy. This is a case study of benign gastro-colic fistula and review of the available literature in regards to etiology, diagnosis, management and prognosis. CASE PRESENTATION: An 84-year-old woman of Caucasian background presented with 12 months of worsening abdominal pain, nausea, vomiting, diarrhea and weight loss on a background of known gastric ulcer disease. CONCLUSION: The leading cause of gastro-colic fistulae has changed from benign to malignant due to improved medical management of gastric ulcer disease. The rarity and non-specific symptoms of gastro-colic fistula make the diagnosis difficult and it is best made by barium enema; however, computed tomography has not been formally evaluated. Surgical management with en bloc resection of the fistula tract is the preferred treatment. Benign gastro-colic fistulae are becoming exceedingly rare in the context of modern medical management of gastric ulcer disease. Surgical management is the gold standard for both benign and malignant disease.

Percutaneous cystic duct stent placement in the treatment of acute cholecystitis.

Percutaneous cholecystostomy is well established as a temporising treatment option in selected patients presenting with acute cholecystitis. However, some patients who undergo cholecystostomy will have persistent discharge, which precludes catheter removal, or may not be medically suitable for future cholecystectomy. In these circumstances, percutaneous cystic duct stenting isa novel treatment option. It may delay or avoid the need for cholecystectomy, and thereby provide definitive treatment in a subset of patients who have acute cholecystitis and a high anaesthetic risk or limited life expectancy. Current application has been limited largely to patients with pre-existing malignant common bile duct strictures, but there is potential for the application to be broadened to include other subsets of patients. In this paper, we describe the technique used for percutaneous cystic duct stenting in a patient and report on its effectiveness. We also explore the technical considerations and consider the application of the procedure on other groups of patients.

Myotomy for achalasia: to wrap or not to wrap?

One of the potential consequences of carrying out a Heller's myotomy for achalasia is gastro-oesophageal reflux. Whether it is frequent or severe enough to warrant the routine addition of a fundoplication to the operation is debated. In this prospective series of all patients undergoing a myotomy using a minimally invasive method the incidence of gastro-oesophageal reflux disease is examined. It was found that in 124 patients who had been followed for at least 6 months, whereas mild heartburn was common (51 patients; 41%), in only 10 patients (8.2%) was a proton pump inhibitor required and there were no patients whose reflux was not controlled using standard medical treatment. Peptic oesophagitis was an infrequent endoscopic finding with only 3 of 40 patients with no or mild heartburn having mild oesophagitis and no patient on a proton pump inhibitor having active peptic oesophagitis. These findings suggest that the addition of a fundoplication to a Heller's myotomy to prevent gastro-oesophageal reflux disease is not essential.

Endoscopic management of recurrent primary bile duct stones.

BACKGROUND: The management of recurrent choledocholithiasis today remains as challenging as in the pre-endoscopic era. Between 2 and 7% of affected patients have historically required surgical intervention for the treatment of recurrent or retained choledocholithiasis and of these, as many as 24% develop biliary complications. To avoid surgery, repeated endoscopic management of the problem has been suggested. In this study, we evaluate our policy of repeated endoscopic management of recurrent primary bile duct stones. METHODS: This study examined a cohort of nine patients identified from a prospective database with recurrent choledocholithiasis. Demographic, clinical and investigative details were recorded and data were analysed. Complications were determined from a review of the patient's file. RESULTS: There were nine patients and 66 procedures were carried out. Mean age at time of first endoscopy was 70.1 years (36-91 years). Three patients were of male sex (33.3%). The mean number of endoscopies carried out per patient was 7.3 (3-13). Failure to completely clear the duct occurred in 36.4% of all endoscopies. There were no periprocedural complications. CONCLUSION: Repeated endoscopic stone extraction by endoscopic retrograde cholangiopancreatography when required is a safe policy. However, this technique will only provide temporary relief from primary duct stones and repeated endoscopic treatment, again safe, will be required.

Percutaneous cholecystostomy in the management of acute cholecystitis.

BACKGROUND: Percutaneous cholecystostomy (PC) has been used in managing acute cholecystitis in the setting of a patient with severe comorbidities where emergency cholecystectomy would carry significant mortality. The present study aims to assess the role, efficacy and complications of PC in acute cholecystitis. METHODS: Retrospective review of case notes of patients who underwent PC at Box Hill Hospital, Melbourne, Australia between July 1997 and December 2002. RESULTS: Sixteen patients (mean age 75 years; range 50-96) underwent PC. Indications for PC were significant comorbidities (n = 6), failure of conservative treatment (n = 4), bile duct malignancy (n = 2), sepsis of unknown origin (n = 2), patient declined surgery (n = 1) and local perforation (n = 1). Technical success rate was 94%. Clinical response to PC was observed in 15 patients. Overall mortality was 18% (3/16) with one death caused by PC failure. Interval cholecystectomy was performed in seven patients (44%). CONCLUSIONS: Percutaneous cholecystostomy is a useful alternative means of treating non-resolving acute cholecystitis in circumstances where emergency surgery is hazardous. It also offers effective palliation in patients not suitable for subsequent surgery.

Oesophagectomy for early adenocarcinoma and dysplasia arising in Barrett's oesophagus.

BACKGROUND: Oesophagectomy for high-grade dysplasia is controversial. METHODS: A prospective study was carried out on all patients who presented between 1993 and 2001 with dysplasia or early adeno-carcinoma who were considered fit for surgery. Details of endoscopic biopsies, appearance, surveillance, operative pathology and outcome were recorded. RESULTS: Of 18 patients, one had low-grade dysplasia, six had high-grade dysplasia and 11 had early adenocarcinoma. No patient had their biopsy diagnosis down-staged following final pathology, but two patients with high-grade dysplasia on biopsy were upstaged to adenocarcinoma. Our only death from disease occurred in a 39-year-old man who had undergone yearly surveillance for 86 months until adenocarcinoma was confirmed. There was no operative mortality. CONCLUSION: Oesophagectomy for early adenocarcinoma and dysplasia in Barrett's oesophagus can be done with acceptable rates of mortality and morbidity. Surveillance until adenocarcinoma is confirmed does not guarantee curable disease.