Combined laparoscopic and endoscopic management of cholelithiasis and choledocholithiasis.

With the advent of laparoscopic cholecystectomy, optimal management of common duct stones remains controversial. Seven hundred six patients underwent laparoscopic cholecystectomy in our institution from January 1990 through January 1992. From this group of patients, 50 were identified as having clinical or radiographic evidence of common duct stones. Thirty-one patients demonstrated preoperative risk factors for common duct stones and underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP). The risk factors included jaundice (19%), pancreatitis (23%), elevated liver function tests (52%), and ultrasound evidence of choledocholithiasis (6%). Preoperative ERCP was performed in 94% of patients. There were two failures due to periampullary diverticula. Common duct stones were identified in 18 patients (62%) and successfully removed by endoscopic sphincterotomy in all of these patients. Nineteen patients were found to have unsuspected common duct stones on intraoperative cholangiography. Eighteen patients (95%) underwent successful ERCP and endoscopic sphincterotomy with stone extraction. Overall, major morbidity was 2% and included one patient who experienced endoscopic sphincteroplasty. The three endoscopic failures were managed by open common duct exploration, laparoscopic duct exploration, and combined laparoscopic and open common duct exploration. We conclude that combined laparoscopic and endoscopic therapy is a viable option for the management of cholelithiasis with choledocholithiasis.

Complete blood count indices in colorectal carcinoma.

Since carcinomas of the colon or rectum are associated with blood loss, we wondered if complete blood count data were suggestive of iron deficiency in cases of colorectal carcinoma. The mean corpuscular volume and especially the red blood cell distribution width are thought to be more sensitive to early iron deficiency than the hemoglobin value. These values were recorded from a series of 98 consecutive cases of colorectal carcinoma and compared with an age-matched control group consisting of patients with no history or clinical suspicion of malignant neoplasm. We found that the hemoglobin level, mean corpuscular volume, and red blood cell distribution width in patients with colorectal carcinoma do not generally show evidence of iron deficiency. The addition of the mean corpuscular volume and red blood cell distribution width to the hemoglobin value does not seem to increase the sensitivity of the complete blood count in the detection or clinical suspicion of colorectal carcinoma.

Colorectal cancer: current trends in initial clinical manifestations.

Colorectal carcinoma (CRC) is a common cause of cancer morbidity and mortality in the United States. There continues to be controversy regarding the effectiveness and feasibility of various screening programs for CRC. To determine how cases of CRC are currently detected, we reviewed a series of 246 consecutive patients with well-documented pathologic staging and clinical presentation. Patients with low stage CRC (0 or A) had smaller tumors, were less likely to be anemic at presentation, and were more likely to have tumors located in the left side of the colon than patients with tumors at stage B or higher. Thirty-two of the 246 tumors were detected in asymptomatic patients through screening. These tumors were more likely to be of a lower stage than those in patients with active gastrointestinal symptoms. In our experience active screening programs detect a relatively small number of CRCs. A majority (66%) of CRCs are still detected from symptoms referable to the gastrointestinal tract.

Portal vein thrombosis following combined endoscopic variceal sclerosis and vasopressin therapy for bleeding varices.

We report the occurrence of acute portal vein thrombosis in three patients undergoing endoscopic variceal sclerosis (EVS) for bleeding esophageal varices. All patients received intravenous vasopressin in close proximity to or at the time of EVS. By increasing flow of sclerosant caudally into gastric veins during EVS, vasopressin may predispose to retrograde propagation of thrombus into the portal venous system. Combined use of vasopressin and EVS for treatment of bleeding esophageal varices should be undertaken with caution.

Pancreas imaging by computed tomography after endoscopic retrograde pancreatography.

A method using CT after endoscopic retrograde pancreatography (CT-ERP) is described for pancreatic imaging. When using an ERP technique in the canine model comparable to that used in humans, small amounts of contrast material in peripheral pancreatic radicles resulted in enhancement of the pancreas on CT scans. Nine patients were also studied by CT-ERP. In normal patients (n = 5) there was opacification of the entire pancreas on CT-ERP images. The main pancreatic duct was seen on delayed images. In cases of chronic pancreatitis (n = 2), pancreatic opacification was patchy and heterogeneous. There was no contrast-material enhancement in areas of pancreatic carcinomas (n = 2). CT-ERP showed the true extent of carcinoma better than ERP alone.

The nature of IgG complexes in alcoholic liver disease.

Circulating immune complexes have been described in most liver diseases, including alcoholic liver disease, although their pathogenic significance remains unclear. Currently available immune complex assays do not distinguish immunoglobulin aggregates from antigen-antibody complexes. Immunoglobulin aggregate formation occurs in vitro at 37 degrees C in the presence of hypergammaglobulinemia and/or hypoalbuminemia, conditions common in liver disease. To determine if hypergammaglobulinemia and/or hypoalbuminemia could predispose to immunoglobulin aggregate formation in vivo, 25 patients with alcoholic liver disease were studied. Using sucrose density gradient fractionation followed by quantitation of IgG by radioimmunoassay, high molecular weight IgG complexes (greater than 11S) were frequently present in alcoholic liver disease sera, and correlated with the degree of hypergammaglobulinemia and/or hypoalbuminemia, and with 125I-C1q binding activity. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis of these complexes revealed only IgG and nonspecific trapping of several normal serum proteins. A specific complex-associated antigen could not be identified. While small, undetectable quantities of true antigen-antibody complexes might also be present, our data suggest that IgG complexes in alcoholic liver disease may represent immunoglobulin aggregate formation in vivo.