Does prophylactic stent insertion to the common bile duct during endoscopic retrograde cholangiopancreatography (ERCP) before cholecystectomy have any impact on the rate of biliary complications?

BACKGROUND: Patients with choledochocystolithiasis generally undergo endoscopic sphincterotomy (ES) followed by elective cholecystectomy. They can experience the development of recurrent biliary events while waiting for their scheduled surgery. AIM: This study investigated whether stent insertion before cholecystectomy influences the rate of complications. METHODS: The study compared retrospective and prospective groups of patients with choledochocystolithiasis who underwent ES with or without prophylactic common bile duct stent insertion before cholecystectomy. The rate of emergency cholecystectomies and biliary complications during the waiting period before the elective procedure was analyzed. RESULTS: For the study, 162 patients with choledochocystolithiasis who underwent endoscopic retrograde cholangiopancreatography (ERCP) with ES were divided to two subgroups. Group A included 52 patients with stent insertion (mean age, 58.3 ± 19.4 years), and group B included 110 patients with no stent insertion (mean age, 61.4 ± 17.7 years) (p = 0.32). Males made up 33.3% of group A and 53.7% of group B (p = 0.018). The median time to elective cholecystectomy (open or laparoscopic) was 41.5 days for the patients without bile duct stent insertion before cholecystectomy and 53.5 days for the patients who had the stent insertion before cholecystectomy (p = 0.63). Repeat emergency ERCP due to acute cholangitis was 5.6% in group A and 1.0% in group B (p = 0.43). Emergency cholecystectomy rates due to acute cholecystitis after ES were 15.4% in group A and 14.5% in group B (p = 1.00). No mortality occurred. CONCLUSIONS: According to the study findings, prophylactic stent insertion during ERCP before cholecystectomy has no impact on biliary complications.

Nosocomial infections after cardiac surgery in infants and children: incidence and risk factors.

This prospective study was undertaken to determine the spectrum, sites and main risk factors for hospital-acquired infections (HAI) in our paediatric cardiothoracic intensive care unit (PCICU), and to determine the main organisms causing bloodstream infection in this setting. All patients admitted between January and December 1999 were prospectively followed for the development of HAI. To define risk factors, patients were grouped by age, complexity score, length of stay in PCICU, and whether the patient's chest was open or closed postoperatively. Three hundred and thirty-five patients underwent cardiac surgery. Fifty-five patients acquired 69 HAIs (HAI patient rate 16.4%). The most common HAI were bloodstream and surgical wound infection in 10 and 8%, respectively. The main causative organisms were Klebsiella spp.,Enterobacter spp. and Pseudomonas spp. in 22, 17 and 16% of episodes, respectively. Staphylococcus spp. accounted for 16% of episodes. The main risk factors for developing HAI were: neonatal age [P < 0.05, odds ratio (OR): 5.89, 95% confidence interval (CI): 2.96-11.58] prolonged PCICU stay (P < 0.05, OR: 6.82, 95% CI: 3.37-14.48), open chest postoperatively (P < 0.05, OR: 3.44, 95% CI: 1.31-8.52) and high complexity score (P < 0.05, OR: 4.03 95% CI: 1.87-8.43). The main causative organisms of bloodstream infections in children hospitalized in the PCICU differ from those in adult and pediatric general intensive care units (ICUs) and include mainly Gram-negative bacilli. High complexity score, neonatal age, prolonged ICU stay, and open chest postoperatively are risk factors of HAI in this patient population.

Septic emboli caused by vascular catheters after surgery for congenital heart disease.

OBJECTIVE: To review the incidence, diagnosis, and management of septic emboli caused by vascular catheters after surgery for congenital heart disease. DESIGN: Retrospective clinical review. All patients were computer registered. Our database includes daily follow-up and every sign of infection registered. SETTING: Pediatric cardiac surgery intensive care unit in a university hospital. PATIENTS: A total of 720 consecutive pediatric cardiac operations performed in 108 neonates and 612 older children from 1995 to 1997 are reviewed. MEASUREMENTS AND MAIN RESULTS: Septic emboli were defined as erythematous non-tender papulonodular hemorrhagic lesions restricted to the limb and distal to the monitoring catheter. Four patients (0.55%) with catheter-related septic emboli after congenital heart surgery were identified, three neonates (0.41%) and one older infant (0.14%). The incidence of catheter-related septic emboli in our patients was significantly higher in the neonatal group compared with older infants (p = .0076; odds ratio=17.45). All infants with catheter-associated septic emboli were severely ill and required prolonged intensive care management postoperatively for periods ranging from 27 to 90 days (mean, 50 days). The catheters involved were in place for periods ranging from 5 to 7 days. All patients were treated by catheter removal and intravenous antibiotics without surgical intervention in the vascular access area. The affected limbs healed well without residual damage. CONCLUSIONS: Septic emboli are a rare complication of infected vascular catheters in neonates and small infants undergoing prolonged postoperative intensive care management (0.55%). They may indicate the source of unexplained sepsis involving mainly Gram-negative bacilli. Generally, treatment consists of removal of the offending catheter and antibiotic administration with no need for surgical intervention.

Upper gastrointestinal endoscopy in the pediatric patient.

During a 4 year period (January 1988 to December 1991), 237 pediatric patients (mean age +/- SD, 9.75 +/- 5.17 years) underwent 289 upper gastrointestinal endoscopies. Premedication was used in only 102 of the endoscopic examinations, mostly in children between 2 and 10 years of age. Patients who were examined without sedation tolerated the procedure well. Abdominal pain was the most frequent indication, accounting for 57.4% of all procedures. Gastritis, esophagitis, duodenitis and duodenal ulcer were the most common endoscopic findings. Seventy-five endoscopies were performed to obtain small bowel biopsies. We found this procedure to be easy and safe and preferable to capsule biopsies. In our experience, upper gastrointestinal endoscopy with or without sedation is a safe and effective diagnostic procedure in the pediatric age group.

Compliance and control: issues in group training for diabetics.

When patients in treatment do not comply with medical directives, the most competent health care may go for naught and patients' well-being may be jeopardized. By focusing on the links between assertiveness and coping skills and compliant behavior, the group program described here increased compliance as well as self-confidence in diabetic group members.