A prognostic index of unsuccessful laparoscopic cholecystectomy for acute calculous cholecystitis.

The aim of this retrospective study was to investigate the accuracy of using preoperative data for the prediction of conversion from laparoscopic to open cholecystectomy in patients operated on for acute calculous cholecystitis. Laparoscopic cholecystectomy was scheduled in eighty-nine of 184 consecutive patients with acute calculous cholecystitis who underwent urgent or early cholecystectomy without bile duct exploration in our department between 1991 and 1998. The correlation between 11 preoperative clinical, laboratory and ultrasonographic variables, and the rate of conversion to open cholecystectomy was studied. Among the 11 variables tested, age and leukocyte count were independent factors of predictive significance. These two factors were used for constructing an additive prognostic index for conversion to open cholecystectomy. Thus, three groups of patients could be identified having a 10%, 30-70% or over 88% risk of conversion. Logistic regression analysis permits accurate preoperative identification of unsuccessful laparoscopic cholecystectomy in patients with acute calculous cholecystitis.

Influence of bile duct stones on patient features and effect of endoscopic sphincterotomy on early outcome of edematous gallstone pancreatitis.

The objective of this study was to study the influence on patients' features and the effect on early outcome of the presence of bile duct stones and endoscopic sphincterotomy (EST), respectively, in the presence of edematous gallstone pancreatitis (GSP). It was a retrospective review of a patient series from 1981 through 1992 at a university teaching hospital. Altogether 96 patients aged 42 to 93 years (median 74 years) with edematous GSP were investigated by endoscopic retrograde cholangiography (ERC) in our department, 75 of whom underwent ERC at first admission. A total of 49 patients (group 1) had common bile duct (CBD) stones, and in 47 (group 2) no CBD stones were found. All patients in group 1 and 15 in group 2 underwent EST; 57 of the 75 patients had EST at first admission. The main outcome measures were pancreas-related complications and the length of the hospital stay. The early major complication and stone clearance rates of the EST procedure were 3.2% and 96%, respectively. Duration of symptoms prior to ERC was similar in groups 1 and 2 (median 5 and 8 days, respectively). Serum amylase activity was higher in group 2 patients than in group 1 patients [21-258 (median 75) microkat/L vs. 10-328 (median 48) microkat/L (p = 0.01)], but the length of hospital stay was similar: [4-39 (median 11) days vs. 4-19 (median 9) days (p = 0.05)]. Cholangitis at acute admission was more common in group 1 than in group 2 patients (31% vs. 7%; p = 0. 02), whereas a history of pancreatitis was noted more often in group 2 patients (49% vs. 8%; p< 0.001). ERC was done 1 to 18 days (median 2 days) and 1-16 days (median 5 days) (p = 0.02) after admission in groups 1 and 2 respectively, because of the more frequent cholangitis symptoms in group 1. It was concluded that the history and features at admission differed between patients with and without CBD stones at ERC done during an attack of GSP. Early EST had no influence on outcome or hospitalization. This study does not support routine EST in conjunction with mild GSP.

Effect of endoscopic sphincterotomy and interval cholecystectomy on late outcome after gallstone pancreatitis.

BACKGROUND: Endoscopic sphincterotomy alone, or followed by cholecystectomy, are options in patients with gallstone pancreatitis. METHODS: Ninety-six patients of median age 74 (range 30-93) years with gallstone pancreatitis had endoscopic retrograde cholangiography and were followed for a median of 84 (range 33-168) months. Forty-eight of 49 patients with, and nine of 47 without, common bile duct (CBD) stones had urgent endoscopic sphincterotomy. One patient with, and six without, CBD stones had delayed endoscopic sphincterotomy a median of 35 (range 12-111) days after acute pancreatitis. Thus, 64 patients had endoscopic sphincterotomy (group 1) and 32 did not (group 2). Fifteen and 16 patients in each group respectively had interval cholecystectomy after a median of 3 months and 1 month. RESULTS: Patients in groups 1 and 2 had similar rates of interval cholecystectomy (15 of 64 versus 16 of 32 patients respectively) or required cholecystectomy (15 of 49 versus five of 16 patients), recurrent CBD calculi (three of 64 versus three of 32 patients) or total length of hospitalization after interval cholecystectomy (median 15.5 and 15 days) or required (median 22 and 24 days) cholecystectomy. The overall incidence of recurrent pancreatitis was one of 64 patients in group 1 and five of 32 in group 2 (P = 0.02), but after interval cholecystectomy the recurrence rate of biliopancreatic symptoms was similar (one of 15 patients versus three of 16 patients respectively). CONCLUSION: Endoscopic sphincterotomy, but not interval cholecystectomy, reduced the overall incidence of recurrent pancreatitis, but not of late biliary complications. Some 31 per cent of the patients required cholecystectomy, suggesting that routine cholecystectomy should be considered in fit patients following acute pancreatitis.

Cholangiographic appearance of bile-duct cysts.

Bile-duct cysts or congenital bile-duct dilatation are rare but important abnormalities often mimicking calculous biliary tract disease. Bile-duct cysts are most often classified according to Todani. In a retrospective study of percutaneous, peroperative or endoscopic cholangiograms from 25 patients, diagnosed and treated during a 20-year period, images of different types of bile-duct cysts are presented and classified. The disease usually presents with vague symptoms and has a female preponderance. Current opinion on aetiology and complications is discussed. Cholangiography is a necessary prerequisite to surgical therapy.

Factors predictive of early complications of endoscopic treatment of bile duct calculi.

BACKGROUND/AIMS: Factors associated with an increased early complication rate of the endoscopic sphincterotomy procedure have been identified. Precut or needle knife papillotomy has been shown to improve the success rate of endoscopic retrograde cholangiography and endoscopic sphincterotomy, but has often been reported to be hazardous. In order to identify patients with bile duct stones at risk for a complicated course in connection with endoscopic clearance of the calculi, factors predictive of early complications were sought. METHODOLOGY: 417 consecutive patients with bile duct calculi at endoscopic retrograde cholangiography were considered for endoscopic treatment in our department from 1981 to 1992. Endoscopic sphincterotomy was performed in 246 patients with intact gallbladders and in 147 with prior cholecystectomy, 55 of whom had retained calculi. RESULTS: There was a 9.4% overall and 7.1% major early complication rate of the EST procedure and a 30-day mortality of 0.5% (2 patients, non-procedure related). In 22% (6/27) of the patients with major complications, surgery was required or preferred to additional endoscopic measures. Complete stone removal failed in 35/393 patients (8.9%). The immediate and early complication rate of standard sphincterotomy was not found to be increased in patients with prior or present biliopancreatic complications, failed bile duct clearance at first attempt, or juxtapapillary diverticula. It was the same after standard sphincterotomy as after precut papillotomy followed by immediate or delayed sphincterotomy. No increased morbidity was found after failed therapy as compared to failed diagnostic precut papillotomy. There was neither a greater need for, nor an increased complication rate following, precut papillotomy in patients with, as compared to those without, juxtapapillary diverticula. Endoscopic experience did not influence the complication rate. There were no significant differences regarding outcome or risk factors associated morbidity between patients with and without intact gallbladder. CONCLUSIONS: These findings confirm that endoscopic treatment is safe and that precut papillotomy can be performed without increased morbidity. Furthermore, none of the commonly identified factors associated with increased morbidity were found to be risk factors in this study.

Endoscopic drainage in benign pancreatic disease: immediate and medium term outcome.

OBJECTIVE: To elucidate further the role of endoscopy in the treatment of benign pancreatic disease. DESIGN: Retrospective study. SETTING: University hospital, Sweden. SUBJECTS: 136 of 319 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for known or suspected pancreatic disease had abnormal findings at duodenoscopy or ductography, or both. In 28 patients endoscopic treatment was considered because of recurrent acute pancreatitis (n = 6), chronic pancreatitis (n = 5), pancreatic pain syndrome (n = 5), pancreatic fistula with ascites (n = 1), and pseudocyst (n = 1), or appreciable biliary obstruction from chronic pancreatitis (n = 10). INTERVENTIONS: Pancreatic duct drainage was attempted in 18 patients and successful in 13 (72%). Endoscopic sphincterotomy (EST) alone was done in 7/13 patients and an endoprosthesis (stent) was placed in 6/13. Bile duct drainage was attempted and successful in 10 patients by EST together with dilatation with (n = 6) or without (n = 4) simultaneous placement of a stent. MAIN OUTCOME MEASURES: Relief of pain and cholestasis. RESULTS: Immediate (1-30 days after initial treatment) and medium term (median 48 months after initial treatment) outcome after pancreatic duct drainage was excellent (no pain) or good (occasional mild pain) in 62% (8/13) and 67% (8/12) of the patients, respectively. Complications of the endoscopic procedure were encountered in four patients (31%) and comprised infection with abscess formation (n = 1), repeated stent clogging (n = 1) or stent migration (n = 2). Surgery was subsequently required in three patients (23%) because of intraabdominal abscess (n = 1), recurrent pain (n = 1), or no pain relief (n = 1). At medium term follow-up (median 68 months) after biliary drainage 7/10 patients had liver function tests within the reference ranges. Only two patients required subsequent biliodigestive shunts 7 and 13 months after EST, respectively. CONCLUSION: Our findings favour endoscopic drainage as a safe and effective method for temporary and medium term relief of pain and biliary obstruction in selected patients with benign pancreatic disease.

The influence of total porto-systemic shunting on the noradrenaline response and on the contractile effects of various vasoactive agents in small rat portal veins and hepatic arteries.

Contractile responses were studied in isolated tubal segments of branches of the rat portal vein (diameter 300 microns) and hepatic artery (diameter 200 microns) 1, 3 and 6 weeks after total porto-systemic shunt operation (PCS). 5-Hydroxytryptamine contracted hepatic arteries concentration-dependently, whereas it produced only weak and inconsistent contractions in portal veins. Vasopressin effectively contracted hepatic arteries, but had no effect on portal veins. Both vessel types responded to prostaglandin F2 alpha with contractions, although the drug potency was relatively low. The responses to these agents were not changed significantly in hepatic arteries or portal veins of PCS rats compared with controls at any of the postoperative time intervals. In both portal veins and hepatic arteries noradrenaline produced contraction-dependent contractions, portal veins being 3 times more sensitive to noradrenaline than hepatic arteries. PCS did not change the nor-adrenaline sensitivity in hepatic arteries, whereas it increased the noradrenaline sensitivity in portal veins after 1, but not after 3 or 6 weeks. This effect was enhanced by cocaine, suggesting a partial sympathetic denervation of branches of the portal vein as well as a complete reinnervation within 3 weeks. Furthermore, the results of this study indicate no influence in any vessel type on the response to several vasoactive agents after depriving the liver of splanchnic venous blood.

Adenomyoma of the ampulla of Vater: an uncommon cause of bile duct obstruction.

Adenomyomas of the bile ducts are extremely rare. They are most likely often overlooked also when situated in the ampulla of Vater and obstructing bile flow. Of 3,131 endoscopic retrograde cholangiograms, four patients with ampullary adenomyoma and signs of biliary obstruction have been diagnosed. When recognized they can be treated effectively by endoscopic means. However, their radiologic and endoscopic appearances were found difficult to interpret and led to unnecessary endoscopic sessions in one patient and surgery in another. Thus, increased awareness of this entity is important to avoid overlooking or misdiagnosing it.

Routine preoperative infusion cholangiography at elective cholecystectomy: a prospective study in 694 patients.

The role of preoperative infusion cholangiography (PIC) before elective cholecystectomy has yet to be defined. Between 1985 and 1991 PIC was performed routinely in 694 patients with median (range) age of 52 (17-85) years with biliary calculus disease 1 or 4 days before elective cholecystectomy. Satisfactory opacification of the biliary system was achieved in 90.1 per cent and mild to moderate adverse reactions to the infusion of contrast medium occurred in 0.9 per cent of patients. Peroperative cholangiography (POC) in 43 of 499 patients with a normal PIC was normal. The presence of common bile duct stones was confirmed in 34 of 36 patients with prominent stones at bile duct exploration and in 8 of 26 with suspected stones at PIC. Bile duct dilatation (median diameter 10 mm) without concomitant stones was seen at PIC and confirmed at POC in 20 patients. Bile duct anomalies were found or suspected in 35 patients at PIC and were confirmed in six by POC (n = 5), or during the cholecystectomy making the anomaly incidence 0.9 per cent. Information provided by the PIC was not of crucial importance for safe execution of cholecystectomy in any patient, while a single (minor) bile duct lesion (1 of 694; 0.1 per cent) could be ascribed to severe pericholecystitis. The results of this study suggest that routine PIC is not warranted. However, PIC is an alternative to selective preoperative endoscopic retrograde cholangiography or selective POC. PIC needs to be supported by POC in approximately 20 per cent of patients (in case of absent or poor opacification of the bile ducts or suspicion of stones or anomalies at PIC).

Routine preoperative infusion cholangiography versus intraoperative cholangiography at elective cholecystectomy: a prospective study in 995 patients.

BACKGROUND: There has been a resurgence of interest in recent years in preoperative infusion cholangiography (PIC). The role of routine PIC compared to routine intraoperative cholangiography (IOC) has not been clearly defined. STUDY DESIGN: In our department between 1985 and 1991, 1,042 of 1,576 consecutive patients with biliary calculous disease had elective cholecystectomy: 694 patients were prospectively scheduled for PIC, and 348 patients were randomly allocated to IOC. The patients in the PIC and IOC groups were similar with regard to age, history of biliopancreatic complications, and laboratory findings. The cost of PIC in Sweden is nearly five times greater than the cost of IOC. RESULTS: Satisfactory opacification of the biliary system was obtained in 90.1 and 96.8 percent of patients who underwent PIC and IOC, respectively. Preoperative infusion cholangiography required support by IOC in 19.5 percent of patients. There were no statistically significant differences between the PIC and IOC groups with regard to the incidence (7 percent in both groups) of or positive predictive value (68 and 80 percent, respectively) for bile duct stones, rate of retained stones (6 and 20 percent, respectively), intraoperative (5.6 and 6.3 percent, respectively) or postoperative (13.3 and 15.9 percent, respectively) morbidity, or incidence of bile duct anomalies (0.9 and 0.3 percent, respectively). Median operative time was longer in patients with (95 minutes) compared to those without (75 minutes) IOC (p < 0.001). More postoperative complications occurred after bile duct exploration (26 of 75 patients) compared to cholecystectomy alone (114 of 917 patients, p < 0.001). The 30-day mortality was zero. Minor bile duct injuries occurred in two patients (0.2 percent) at cholecystectomy, (one with and one without bile duct exploration). In no patient was the cholangiographic finding of a biliary anomaly crucial for the safe execution of cholecystectomy. CONCLUSIONS: In our study, PIC and IOC were comparable, but routine use of either method did not promote the safety of cholecystectomy and thus their routine use is not warranted. The shorter operative time and preoperative identification of common bile duct (CBD) stones provided by PIC might favor this examination when applied selectively in patients with increased risk of having CBD stones. However, this potential advantage is offset by the need for PIC to be supported by IOC in approximately 20 percent of patients. Also, the cost of PIC is greater than the cost of IOC.

Endoscopic treatment of bile duct calculi in patients with gallbladder in situ: long-term outcome and factors.

BACKGROUND: Whether endoscopic sphincterotomy (EST) in elderly and/or high-risk patients with common bile duct calculi (CBD) and the gallbladder in situ should be followed by routine cholecystectomy is still a subject of controversy. METHODS: To identify factors predictive of subsequent biliary tract symptoms after EST and bile duct clearance, we reviewed 265 patients with intact gallbladder and CBD calculi who were considered for EST in our department from 1981 to 1992. In 15 of 265 patients endoscopic treatment was not carried out, and the records of 4 patients were missing. RESULTS: Complete removal of all bile duct calculi failed in 27 patients (11%). Cholecystectomy was performed in 35 patients (16%) with cleared bile ducts 1-765 days (median, 60 days) after EST, in spite of absence of recurrent symptoms from the biliary tract. The remaining 184 patients have been retrospectively followed up for 14-150 months (median, 69 months). Cholecystectomy was required in 35 because of acute cholecystitis (n = 23) or biliary colic (n = 12). Of the cholecystectomies 86% were performed within 24 months after EST and only one after 4 years of follow-up. Increased frequency of cholecystectomy was found in patients with complete opacification of the gallbladder at endoscopic cholangiography (p = 0.005). This was especially evident in patients younger than 80 years (p = 0.002). Cholecystectomy was also required more often in patients with gallbladder calculi (p = 0.02). The risk of cholangitis in patients without recurrent stones was higher in those with juxtapapillary diverticula (p = 0.02). Fifty-nine patients without and 17 with mild to moderate symptoms from the biliary tract died after a median time of 39 and 46 months, respectively. Seventy-three patients are alive, and 59 are symptom-free. Ten patients have had and four still have complaints of mild to moderate biliary tract symptoms. They have been followed for up to 16-146 months (median, 40 months). CONCLUSIONS: These findings confirm that endoscopic treatment alone in this group of patients is a feasible treatment principle. Recognition of the registered risk factors might be helpful when selecting patients for subsequent cholecystectomy.

Long-term follow-up after endoscopic treatment of bile duct calculi in cholecystectomized patients.

Endoscopic sphincterotomy (EST) is an established method for treatment of retained or recurrent common bile duct (CBD) calculi after cholecystectomy. Present experience shows that few patients have recurrent biliary tract complications, but follow-up periods are most often short. EST was performed in 147 patients with bile duct calculi and remote cholecystectomy in our department from 1981 to 1992. In 8 of 147 patients (5.4%) complete removal of calculi failed. A total of 135 patients with a median age of 71 years (range 24-96 years) were eligible for a follow-up of 23 to 153 months (median 86 months). Thirty-seven patients have died without recurrent symptoms (a recurrent stone was revealed at postmortem examination in one patient), and four patients (two with calculi and two with cholangiocarcinoma) died with recurrent symptoms from the biliary tract. Ninety-four patients are alive; and with the exception of two who have had cholangitis without or with post-EST stenosis, respectively, they are all symptom-free. Jaundice, cholangitis, and biliary pancreatitis prior to EST were the only factors that significantly (p = 0.006, Fisher's exact test) predicted late biliary complications after EST in patients with recurrent calculi. These findings confirm that endoscopic treatment of CBD calculi in cholecystectomized patients has a low long-term rate (5 of 135; 3.7%) of recurrent nonmalignant bile duct disease (three patients with CBD calculi and two with cholangitis).

Endoscopic sphincterotomy for bile duct calculi-factors influencing the success rate.

BACKGROUND/AIMS: Endoscopic sphincterotomy is an established treatment of retained or recurrent common bile duct calculi after cholecystectomy and in the majority of patients with an intact gallbladder. In order to identify patients ultimately requiring additional endoscopic procedures or surgery, factors predictive of decreased endoscopic bile duct clearance were sought. MATERIAL AND METHODS: Between 1981 and 1992 endoscopic sphincterotomy was performed in 393 consecutive patients with either intact gallbladders (n = 246), recurrent (n = 92) or retained (n = 55) calculi. RESULTS: There was a 9.4% overall early complication rate for the procedure and a 30-day mortality rate of 0.5% (two patients, non-procedure related). Complete removal of all bile duct calculi failed in 35/393 patients (8.9%). In patients with intact gallbladder the clearance rate at first attempt was higher (p = 0.002; Chi-square test) in the presence of solitary as compared to multiple stones. The same was found in patients with recurrent stones as well (p < 0.001). In non-cholecystectomized patients with single or multiple stones smaller than 10 mm, the clearance rate was higher at first (p = 0.02) as well as at final (p < 0.002) attempt as compared to patients with larger stones. Single small ( < 10 mm) compared to single large stones in patients with intact gallbladder had a higher clearance rate at final (p = 0.002) but not at first (p = 0.18) attempt. Patients with intact gallbladder and pancreatitis had higher clearance rate at first attempt compared to patients with jaundice (p = 0.001) or patients without concomitant pancreatobiliary disease (p = 0.002). Clearance rate was the same in patients with and without endoscopic sphincterotomy complications, except for patients with basket impaction, in whom the clearance rate was decreased (p = 0.02). CONCLUSIONS: Thus, in patients with intact gallbladder surgery should be considered after failed complete bile duct clearance at first attempt.

Long-term follow-up of a prospective randomized study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ.

Eighty-three patients with bile duct calculi were entered in a prospective randomized study of endoscopic sphincterotomy (ES) and stone removal (group 1) versus surgery alone (group 2), and were followed for more than 5 years. In group 1 endoscopic stone clearance was successful in 35 of 39 patients. Thirteen patients subsequently had cholecystectomy with (n = 7) or without (n = 6) biliary symptoms and one had a cholecystostomy for acute cholecystitis. Two patients have had mild biliary colic or pancreatitis. Two patients died from gallbladder carcinoma after 9 days and 18 months. In group 2 bile duct stones were cleared surgically in 37 of 41 patients. Late complications occurred in two patients (incisional hernia and recurrent stone). One patient with gallbladder carcinoma was cured and another died after 16 months. Early major and minor complications occurred in three and four respectively of 39 patients in group 1, and in three and six respectively of 41 patients in group 2. There were no deaths. During follow-up the total morbidity rate reached 28 percent (11 of 39) and 5 percent (two of 41) (P = 0.005) and the non-biliary related mortality rate was 31 percent (12 of 39) and 10 percent (four of 41) (P = 0.02) in groups 1 and 2 respectively. Nine patients in group 1 and two in group 2 died from heart disease (P = 0.02). Total hospital stay was 2-42 (median 13) days and 6-36 (median 16) days in groups 1 and 2 respectively (P not significant). Endoscopic and surgical treatment of bile duct calculi in middle-aged and elderly patients with gallbladder in situ are equally effective in the long term. However, the significantly increased mortality rate from heart disease in patients treated endoscopically compared with those treated surgically might speak in favour of operation.

Hepatic lipase activity after liver denervation in hypothyroid rats.

Hepatic hilar denervation, hepatic vagotomy or sham operation were performed in hypothyroid rats. Activities of hepatic lipase were measured nine days after surgery. Sham operation in itself was associated with a decrease of hepatic lipase activity by about 40% compared with non-operated animals. Both hilar denervation and hepatic vagotomy were associated with increased hepatic lipase activity (40% and 35%, compared with sham-operated animals). Liver contents of norepinephrine were reduced by about 90% after hilar denervation, whereas hepatic vagotomy did not affect norepinephrine levels. No major changes in lipids and lipoproteins were noted.