Two-stage treatment with preoperative endoscopic retrograde cholangiopancreatography (ERCP) compared with single-stage treatment with intraoperative ERCP for patients with symptomatic cholelithiasis with possible choledocholithiasis.

BACKGROUND AND STUDY AIMS: An ideal treatment for choledocholithiasis in the laparoscopic era has not been established. The objective of this study was to elucidate whether a treatment strategy of performing intraoperative endoscopic retrograde cholangiopancreatography (ERCP) during laparascopic cholecystectomy (when choledocholithiasis is confirmed by intraoperative cholangiography) is better for patients with suspected common bile duct stones than the current strategy (preoperative ERCP followed by laparoscopic cholecystectomy). PATIENTS AND METHODS: This was a prospective randomized study to evaluate which of these two approaches was most benefit- and cost-effective for patients with intermediate risk of choledocholithiasis. Patients underwent either preoperative ERCP followed by a laparoscopic cholecystectomy a few weeks later (the "preoperative ERCP" group) or intraoperative ERCP (the "intraoperative ERCP" group). Intraoperative ERCP was performed using the rendezvous technique. RESULTS: There were 64 patients in the preoperative ERCP group and 59 patients in the intraoperative ERCP group. The demographic and clinical characteristics of the two groups were similar, except that the bilirubin and gamma-glutamyl transferase (GGT) levels and the number of patients treated on an inpatient basis were higher in the preoperative ERCP group. Success rates were similar (96.6 % in the preoperative ERCP group vs. 90.2 % in the intraoperative ERCP group in the per-protocol study). Total morbidity, post-ERCP morbidity, and post-ERCP acute pancreatitis rates were higher in the preoperative ERCP group, but there were no differences between the two groups in the frequency of residual common bile duct stones, the conversion rate to open cholecystectomy, or surgical morbidity. The length of hospital stay and costs were lower in the intraoperative ERCP group despite the longer surgical times in this group. Univariate analysis did not find any relationship between morbidity and total bilirubin or GGT. Logistic regression analysis confirmed that morbidity was related only to the treatment group and the time spent in the operating room: the relative risk (RR) was 4.37 for morbidity and 1.015 for the time spent in the operating room); the RR for papillotomy was 5.49. CONCLUSIONS: Both treatment approaches were equally effective but the intraoperative ERCP group had less morbidity, a shorter hospital stay, and reduced costs. The lower morbidity in the intraoperative ERCP group resulted from the lower rate of papillotomy and lower rates of post-ERCP pancreatitis and cholecystitis. Total morbidity was principally related to the type of treatment approach used.

Treatment of left colon neoplasic obstruction by placement of self-expandable stents.

INTRODUCTION AND OBJECTIVE: Neoplasic stenoses of the left colon are most frequently caused by primary colon carcinoma, infiltration from an external tumour and great adenomatous polyps. These patients often develop obstruction as their first symptom, leading to emergency surgical procedures in adverse circumstances and without an appropriate intestinal preparation that might prevent primary anastomosis. Therapeutic options for this event, such as Hartmann's resection, subtotal colectomy or anterograde colon lavage are not always possible. In these patients a colostomy is performed that requires future reoperation for reconstruction of the intestinal transit. Transtumoral self-expandable stenting followed by elective surgery might be the best option in these cases, as well as an alternative to surgery in non-operable patients. PATIENTS AND METHODS: Twenty four patients treated with this procedure in the past four years were divided in two groups. In group 1 (14 patients), the stent was placed as a permanent and palliative measure for the management of the disease. In group 2 (10 patients), the stent was placed temporarily for the management of the intestinal obstruction and latter the patients underwent elective surgery with fully preoperative and extension study and an appropriate preparation of the colon in order to allow reliable primary anastomosis. RESULTS: There were no hospital mortality nor stent migrations. There was only one complication (perforation caused by the stent) that required emergency surgery, but with any further complications. Failure to place the stent occurred in one patient. CONCLUSIONS: Self-expandable stents relieve neoplasic colon obstructions and allow to complete the study protocol, followed by elective surgery associated to less morbi-mortality. In patients with advanced or irresectable cancer, they provide a palliative and safe alternative to surgery, with satisfactory results.

Tratamiento de la estenosis neoplásica de colon izquierdo mediante colocación de prótesis autoexpandibles / Treatment of left colon neoplasic obstruction by placement of self-expandable stents

Introducción y objetivo: las estenosis neoplásicas en el colon izquierdo como son el carcinoma primitivo de colon, la infiltración neoplásica por vecindad y los grandes pólipos adenomatosos que ocupan la luz, tienen muchas veces como clínica de presentación diagnóstica la obstrucción intestinal. La obstrucción obliga a intervenir al paciente en mal estado y sin preparación adecuada del intestino, lo que impide la realización de una sutura primaria. Las alternativas en esta eventualidad como son la resección de Hartmann, la colectomía subtotal o el lavado anterógrado no siempre pueden hacerse. En estos casos se realiza una colostomía que obliga a reintervenir al paciente candidato a reconstrucción del tránsito intestinal. La utilización de prótesis autoexpandibles intratumorales pueden ser el tratamiento ideal en estos pacientes ya que resuelven la obstrucción permitiendo la realización de una cirugía electiva. Así mismo pueden constituir la alternativa a la cirugía en los casos inoperables. Pacientes y métodos: se incluyen 24 enfermos tratados mediante este procedimiento en los últimos 4 años divididos en dos grupos. Al grupo 1 (14 pacientes) se les colocó la prótesis de un modo definitivo y paliativo como tratamiento de su enfermedad. Al grupo 2 (10 pacientes) se les colocó la prótesis temporalmente para resolver el cuadro de obstrucción intestinal que presentaban, interviniéndoles posteriormente de forma reglada con estudio preoperatorio y de extensión completo, y una adecuada preparación del colon para posibilitar una sutura primaria fiable. Resultados: no hubo mortalidad ni migraciones. Sólo tuvimos una complicación (perforación) que precisó cirugía urgente sin complicaciones posteriores. Se fracasó en el intento de colocación en una ocasión (4 por ciento).Conclusiones: se considera que la colocación de prótesis autoexpandibles resuelve la obstrucción por neoplasias de colon y permite completar el protocolo de estudio, realizando luego un tratamiento quirúrgico programado con menos morbi-mortalidad. En los casos de cáncer avanzado o irresecable, constituyen una alternativa paliativa poco cruenta que evita la cirugía con buenos resultados (AU)

[Polyps of the biliary tract: is their preoperative diagnosis possible?]. / Pólipos de la vía biliar: es posible su diagnóstico preoperatorio?

Bile duct polyps are a very uncommon cause of obstructive jaundice. We present our experience of three patients diagnosed in the last 10 years. Initial presentation usually takes the form of obstructive jaundice associated with abdominal pain, which simulates biliary lithiasis. The diagnosis is usually surgical. Although in some cases radiological studies and endoscopic retrograde cholangiopancreatography (ERCP) may sometimes detect bile duct polyps, exact diagnosis before surgery is very unusual. The radiological signs that suggest the existence of a bile duct polyp in the ERCP seem to be the presence of repletion defects, fixed unilaterally to the biliary conduit, without meniscus and without circumferential stenosis of the affected conduit. The most frequently found polyps are fibroinflammatory, and less frequently adenomatous.

[Acute mixed portal hypertension. Experimental study (author's transl)]. / Hypertension portale aiguë mixte. Une étude expérimentale.

Experimental studies were conducted in dogs to establish a new model for portal hypertension. The model chosen depends on partial obstruction of the portal vein to obtain a portal pressure of 11 +/- 4 ml. and the injection of 600 U. of secretin over a period of 35 min. The validity of the model was demonstrated by hemodynamic studies which resulted in a portal pressure, mesenteric blood flow, and mesenteric vascular resistances similar to those observed in clinical practice (hepatic cirrhosis).