Combined endoscopic treatment for cholelithiasis associated with choledocholithiasis.

BACKGROUND: The advent of endoscopic techniques changed surgery in many ways. For the management of cholelithiasis, laparoscopic cholecystectomy (LC) is the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of option exist, including endoscopic sphinterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic bile duct exploration, open CBD exploration, and postoperative endoscopic retrograde cholangiopancreatography (ERCP). Also, the alternative technique of peroperative ES is emerging. METHODS: We report our experience of routine intraoperative cholangiography followed either by peroperative ERCP in one step or by transcystic drain and postoperative ERCP. In our technique, to facilitate Vater papilla cannulation we inserted a 450-cm transcystic guidewire that was caught by a duodenoscope. Papillotome was then inserted over the guidewire to ensure cannulation of the CBD. RESULTS: Twenty-eight patients were treated successfully in one step and 24 in two steps. The mean operative time was 181 +/- 41 min for patients treated in one step and 131 +/- 30 min for patients treated in two steps. The mean hospital stay was 4.8 +/- 3.3 days for patients treated in one step and 9.6 +/- 4.0 days for patients treated in two steps. Five patients (18%) with positive intraoperative cholangiography for stones for whom peroperative ERCP was not available showed a normal postoperative transcystic cholangiogram and therefore ERCP was canceled. Fourteen of 25 patients treated in one step and none of 17 treated in two steps had raised serum amylase, which resolved spontaneously with no symptoms. No patient developed postoperative pancreatitis. Three (10%) ERCP complications were observed, consisting of mild bleeding of the papilla. All cases were managed by endoscopic adrenaline injection. There was no mortality. CONCLUSION: We believe peroperative ERCP with the technique described should be considered as the treatment of choice for choledocholithiasis associated with cholelithiasis. When single-stage treatment is not possible, a two-step rendezvous technique should be preferred.

Hydrophilic hydromer-coated polyurethane stents versus uncoated stents in malignant biliary obstruction: a randomized trial.

BACKGROUND: Hydromer-coated polyurethane stents (HCPS) have a low coefficient of friction that may reduce sludge formation and potentially increase stent longevity. METHODS: Eighty-three patients (39 men, mean age 69.3 years) with malignant mid or distal bile duct strictures were prospectively randomized to receive either 10F HCPS (n = 40) or standard polyethylene stents (n = 43). RESULTS: Fifteen patients (18.1%) underwent surgery after stent insertion. Six patients were lost to follow-up (7.2%), whereas 34 died of the underlying disease without evidence of stent occlusion (15 HCPS group and 19 polyethylene group). Median survival was 75 days (range 15 to 372 days) and 108 days (range 25 to 325 days) in the HCPS and polyethylene stent groups, respectively (p = not significant). Stent occlusion was observed in 25 patients (42%), 16 with HCPS stents and 9 with polyethylene stents, with a median patency of 103 days (range 40 to 280 days) and 68 days (range 32 to 175 days), respectively (p = not significant). CONCLUSIONS: HCPS do not appear to provide significant clinical advantages in terms of stent longevity over standard plastic prostheses.

[Hemorrhagic necrotic acute pancreatitis: analysis of our case series in the light of the most recent diagnostic and therapeutic criteria]. / La pancreatite acuta necrotico emorragica: analisi della nostra casistica alla luce dei più recenti criteri diagnostici e terapeutici.

During the period between 1-1-1979 and 30-9-1992, 43 cases of hemorrhagic necrotic acute pancreatitis were referred to the authors' attention. Six patients were not operated, 12 underwent emergency surgery and laparotomy was postponed in 25 cases. The introduction of sophisticated diagnostic methods, such as Eco, CT, ERCP, intensive medical therapy and postoperative NPT have allowed a more rational surgical approach in terms of timing and extent to be adopted, operating on patients who are metabolically more stable. NPT is a useful tool in the latter postoperative stage. In the series of patients undergoing emergency laparotomy there was a mortality rate of 66%. The mortality rate fell to 16% in those patients in whom surgery was postponed.

[Ultrasonography and retrograde transpapillary cholangiopancreatography combined with sphincterotomy in the diagnosis of choledochal lithiasis. Our experience with 87 patients]. / L'ecografia e la colangiopancreatografia transpapillare retrograda associata a sfinterotomia nella diagnosi di litiasi coledocica. Nostra esperienza in 87 pazienti.

We retrospectively reviewed the US findings of 87 patients to assess US sensitivity in the detection of choledochal (CBD) stones. Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) was used as the diagnostic standard, except for 1 patient who underwent surgical exploration. First, the distal CBD was studied with transverse and parasagittal US scans through the head and uncinate portions of the pancreas. CBD stones usually appeared as hyperechoic lesions, most of them with acoustic shadowing. In some cases, the stone moves during real-time scanning, which further confirms the diagnosis. Fifty-four of 87 patients had CBD stones and US detected them in 46 cases. The absence of a stone was diagnosed correctly in 28 of 33 patients. In our series, US sensitivity, specificity and accuracy were 85%, positive predictive value 88% and negative predictive value 78%. If the distal duct cannot be demonstrated adequately or if duct size is normal, US sensitivity in detecting stones decreases and other examinations, such as ERCP, should be performed. We conclude that US can be used as the diagnostic method of choice to examine the patients with suspected biliary tract disease. Although ERCP is the gold standard for diagnosis and therapeutic purposes in choledochal stones, it remains an invasive technique and must therefore be held in reserve.

Chronic gastritis and alcohol.

In order to analyse the relationship between the incidence of chronic gastritis and chronic alcohol consumption, the histological pattern of fundic and antral mucosa was studied in 30 asymptomatic non-alcoholic volunteers, 20 heavy drinkers without liver cirrhosis, 39 alcoholics with liver cirrhosis, and 14 non-alcoholic subjects with liver cirrhosis. The data demonstrate an increased incidence of preatrophic gastritis in the fundic as well as in the antral mucosa in abstemious patients with liver cirrhosis, while no significant differences were found between the other three groups. However, the incidence of chronic gastritis, did not show significant differences between the four different groups if subjects of the same age are compared. In conclusion, alcohol does not play an important role in the development of chronic gastritis, particularly in gastritis with major mucosal damage.