Prospective evaluation of a minimally invasive approach for treatment of bile-duct calculi in the high-risk patient.

BACKGROUND: The best approach to bile duct stones in high-risk patients is controversial. We showed in a randomized trial that open surgery had a morbi-mortality similar to that of endoscopic sphincterotomy alone (ES) and less late biliary complications. The aim of this study was to evaluate a minimally invasive approach to duct stones in high-risk patients compared with open surgery or ES alone. METHODS: Sixty high-risk patients (mean age 80 years) suspected of duct stones were treated by ES + laparoscopic cholecystectomy (LC). High-risk factors were: age > 70 years, Goldman cardiac index > 13, chronic pulmonary disease, liver cirrhosis, neurologic deficit, and severe obesity. RESULTS: ERCP success was 87%. Duct stones were found in 75%. LC succeeded in 92%. Post-LC stay was 4 days. Overall morbidity was 19% and mortality was 3%. Recurrent symptoms (mean follow-up: 9 months) was 3.6%. When compared with open surgery or ES alone, ES + LC had a similar morbi-mortality, but shorter postop stay (p < 0.001). Late symptoms appeared in 20% after ES alone vs 4% after open surgery or ES plus LC (p < 0.04). CONCLUSIONS: Combined ES + LC is an effective alternative to open surgery or ES alone for treatment of duct stones in high-risk patients.

Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bileduct calculi in high-risk patients.

BACKGROUND: Morbidity and mortality after surgical treatment of bileduct stones increase with age and associated diseases. A proposed alternative therapy is endoscopic sphincterotomy (ES) with the gallbladder left in situ, and we elected to compare this option with standard open surgery in high-risk patients. METHODS: 98 patients (mean age 80 years) with symptoms likely to be due to bileduct stones or a recent episode of biliary pancreatitis were randomised to be treated either by open cholecystectomy with operative cholangiography and (if necessary) bileduct exploration (n=48) or by endoscopic sphincterotomy alone (n=50). FINDINGS: The procedure was accomplished successfully in 94% of the surgery group and 88% of the ES group, and there were no significant differences in immediate morbidity (23% vs 16%) or mortality (4% vs 6%). During mean follow-up of 17 months biliary symptoms recurred in three surgical patients, none of whom underwent repeat surgery, and in 10 ES patients, seven of whom had biliary surgery. By multivariate regression analysis endoscopic sphincterotomy was an independent predictor of recurrent biliary symptoms (odds ratio 6.9; 95% Cl 1.46 to 32.54). INTERPRETATION: In elderly or high-risk patients, surgery is preferable to endoscopic sphincterotomy with the gallbladder left in situ as a definitive treatment for bileduct stones or non-severe biliary pancreatitis.

[Subcutaneous venous reservoirs: comparative study of their efficacy in patients with AIDS versus oncology and hematology patients]. / Reservorios venosos subcutáneos: estudio comparativo de su eficacia en pacientes afectados de sida respecto a pacientes oncológicos y hematológicos.

BACKGROUND: Chronic venous access may constitute a serious problem in some patients and the subcutaneous venous reservoirs have demonstrated to be a useful alternative. AIDS patients require intense pharmacologic treatment, thus the use of subcutaneous venous reservoirs may be specially useful. However, the prevalence of septic type complications following placement of the subcutaneous venous reservoirs in these patients is particularly high. AIMS: To know the efficacy of subcutaneous venous reservoirs in the AIDS population and compare the results in a non AIDS population. METHODS: All the subcutaneous venous reservoirs placed between January 1990 and December 1992 were prospectively studied with two groups being established: Group I: patients with positive serology for HIV and who achieved criteria of AIDS requiring placement of a subcutaneous venous reservoirs. Group II: All the remaining patients in whom a subcutaneous venous reservoirs was placed during the same period of time. RESULTS: The incidence of infection was higher in group I (AIDS) with respect to group II (0.1 versus 0.014 infections/100 catheters/day, p < 0.01) and the non septic complications were higher in group II (3.6% versus 12.7%, p < 0.0004). The catheters were most frequently used in group I with respect to group II (12.7 +/- 7.1 versus 3.3 +/- 4.9 punctures/month) but the period was use longer in group II (13.7 +/- 9.2 versus 4.3 +/- 3.1 months, p < 0.0001). CONCLUSIONS: The population of AIDS patients may benefit greatly from the systematic use of subcutaneous venous reservoir due to their clinical and therapeutic characteristics. Nonetheless greater risk of infection may occur in these patients because of the greater need for punctures with respect to the other indications for placement of these catheters.

Juxta-anastomotic sacciform dilation: an unusual complication of colonic stapled suture.

The commonest complications of stapling closure in gastrointestinal surgery are dehiscence, bleeding at the site of anastomosis and stenosis. Juxta-anastomotic sacciform dilation following end-to-side circular stapling anastomosis of the left colon is reported as an unusual complication. The case highlights the need for careful technique in order to obtain all the advantages offered by staplers.

[Enterovesical fistula caused by a prosthesis made of synthetic material]. / Fístula enterovesical producida por una prótesis de material sintético.

Enterovesical fistulas affect mainly male patients, due to the interposition of the uterus in women. They can be caused by neoplastic, inflammatory or traumatic processes. A case of ilovesical fistula due to migration of a silastic plate used to repair an epigastric infissional hernia is presented. This case has two distinctive features: first, the cause is extraurological, causing a fistula between both systems due to an inflammatory process. Secondly, we report the long distance travelled by the synthetic mesh, causing a peculiar clinical picture five years after its implantation.