'Critical view of safety' as an alternative to routine intraoperative cholangiography during laparoscopic cholecystectomy for acute biliary pathology.

INTRODUCTION: The study aims to evaluate the use of "critical view of safety" (CVS) for the prevention of bile duct injuries during laparoscopic cholecystectomy for acute biliary pathology as an alternative to routine intraoperative cholangiography (IOC). METHODS: A policy of routine CVS to identify biliary anatomy and selective IOC for patients suspected to have common bile duct (CBD) stone was adopted. Receiver operator curves (ROCs) were used to identify cutoff values predicting CBD stones. RESULTS: Four hundred forty-seven consecutive, same admission laparoscopic cholecystectomies performed between August 2004 and July 2007 were reviewed. CVS was achieved in 388 (87%) patients. Where CVS was not possible, the operation was completed open. CBD stones were identified in 22/57 patients who underwent selective IOC. Preoperative liver function and CBD diameter were significantly higher in those with CBD stones (P < .001). ROC curve analysis identified preoperative cutoff values of bilirubin (35 mumol/L), alkaline phosphatase (250 IU/L), alanine aminotransferase (240 IU/L), and a CBD diameter of 10 mm, as predictive of CBD stones. No bile duct injuries occurred in this series. CONCLUSION: In acute biliary pathology, the use of CVS helps clarify the anatomy of Calot's triangle and is a suitable alternative to routine IOC. Selective cholangiography should be employed when preoperative liver function and CBD diameter are above defined thresholds.

Endoscopic therapy for upper gastrointestinal bleeding.

Upper gastrointestinal bleeding (UGIB) is one of the most common medical emergencies and remains a major cause of morbidity and mortality among patients. Although initially employed diagnostically, endoscopy has steadily replaced surgery as a first-line treatment in all but the haemodynamically unstable patient. A vast selection of techniques and devices are now available to the dedicated therapeutic endoscopist, including injection therapy, electrical or thermal coagulation and mechanical banding or clipping. The use of endoscopic ultrasound for targeting treatment is increasing and the development of new technologies, such as capsule endoscopy, is likely to play an important role in future protocols. However, despite numerous randomized controlled trials and meta-analyses comparing the efficacy of different endoscopic interventions, the implementation of obtained results into treatment regimes has so far failed to impact significantly on overall UGIB mortality, which remains stubbornly at 10-14%. Reducing this continues to be one of the main challenges facing the therapeutic endoscopist.