Predictions and associations of cholecystectomy in patients with cholecystolithiasis treated with extracorporeal shock wave lithotripsy.

Extracorporeal shock wave lithotripsy (ESWL) is effective in the treatment of symptomatic cholecystolithiasis in well-selected patients. We analyzed the predictors of cholecystectomy in a large series of gallstone patients after ESWL. This was a retrospective follow-up cohort-study of consecutive patients undergoing ESWL for symptomatic cholecystolithiasis over a 9-year period. It was possible to analyze a total of 297 patients; there were 211 women and 86 men, with a mean age of 52 years (range, 8-81 years). Patients that had been cholecystectomized after ESWL were compared to patients with their gallbladder still in situ and determinants of cholecystemctomy in terms of clinical, stone, and gallbladder parameters and symptoms analyzed. The mean duration of follow-up was 99 months (range, 27-134 months). During follow-up, 106 (36%) patients underwent a cholecystectomy at a mean of 34 months (range, 0-127 months) after ESWL. Histological data showed a normal gallbladder wall in only 4 cases; 101 examinations revealed some kind of (chronic) inflammation, which was not different from histological gallbladder results in patients without prior lithotripsy. Three gallbladder polyps were found, but no carcinoma. Cholecystectomy after ESWL of gallbladder stones was strongly associated with persitent and/or renewed biliary symtoms. Nevertheless, only three of four patients became asymptomatic after CE. Thus, ESWL proved to be a valuable organ-preserving alternative to cholecystectomy in selected patients.

[Significance of staging laparoscopy in pancreatic carcinoma: a case report]. / Die Bedeutung der Staging-Laparoskopie beim Pankreaskarzinom: eine Falldarstellung.

Accurate staging of pancreatic malignancy is essential to properly plan appropriate therapy. The purpose of preoperative staging of intraabdominal malignancies is to identify patients in whom malignancies are unresectable and therefore would not be candidates for curative surgery. Routine preoperative evaluation of intraabdominal malignancies typically include abdominal helical computed tomographic (CT) scanning and/or ultrafast magnetic resonance (MR) imaging. In fact both investigations are considered mandatory for intraabdominal malignancies. But despite modern techniques a significant number of false negative results occur (more than 20%). This has led to the investigation of additional staging modalities to better identify patients with unresectable disease. In this purpose we present the case of a patient with pancreatic carcinoma. After preoperative imaging (ultrasound, endosonography and MRI) there was no evidence for metastatic disease (uT3uN1). He underwent laparoscopy and a hepatic lesion was detected, histologically consistent with a liver metastasis. In this patient an unnecessary laparotomy could be avoided. In conclusion laparoscopy is an important tool in the staging of intraabdominal malignancy for patients with locally advanced disease without signs of tumor spread in CT or MRT. It is a relatively simple, well-tolerated and safe procedure and decreases the rate of unnecessary laparotomies. It should be considered in all patients with pancreatic malignancy in whom laparotomy is planned, either to establish the diagnosis or before an attempt at curative resection.

Buprenorphine or procaine for pain relief in acute pancreatitis. A prospective randomized study.

BACKGROUND: To assess the analgesic efficacy and side effects of buprenorphine and procaine in patients with acute pancreatitis. METHODS: Forty patients (average age, 50 years; 23 male) with acute pancreatitis or an acute bout of a chronic pancreatitis were prospectively randomized to receive buprenorphine or procaine for pain relief. Both analgesics were administered as constant intravenous (i.v.) infusions and additional analgesics were given on demand. Pain scores were assessed on a visual analogue scale. Close clinical control and laboratory checks were performed during the three-day study period. RESULTS: Patients receiving buprenorphine were significantly less likely to demand additional analgesics (1 versus 14 patients; P < 0.0001). The pain scores for patients in the buprenorphine group were significantly lower over the treatment period in comparison to procaine (P < 0.05). The reduction of pain score was significantly greater during the initial two treatment days using buprenorphine (day 1: 55 versus 25, P < 0.0001; day 2: 62 versus 40, P = 0.005). Side effects were comparable for both groups with the exception of a slightly higher sedation rate under buprenorphine. CONCLUSIONS: Constant i.v. application of buprenorphine is more effective than the recommended procaine for pain relief in acute pancreatitis.

[Percutaneous transhepatic metal stents in therapy of bile duct stenoses]. / Perkutan-transhepatische Metallstents in der Therapie von Gallengangsstenosen.

Treatment of choice for obstructive jaundice of different origin is the percutaneous transhepatic placement of endoprostheses if the endoscopic access fails for technical or anatomical reasons. Expandable metallic stents are generally preferred to plastic endoprostheses because of higher patency rates. Purpose of this study was to retrospectively evaluate the clinical efficiency and the occlusion rates of percutaneous placed metallic stents in 39 patients with malignant and benign biliary obstruction and to compare the results to a review of the literature. Placement of the stents was successful in all cases. Patients were followed-up for a mean of seven months (1-42 months). 54% of the patients had recurrent jaundice after a mean period of seven months (1-38 months). 35% were treated with a second procedure. Since the occlusion rates of percutaneous transhepatic metallic stents increase after six months and follow-up in most studies is short the real occlusion rates must be expected to be higher than reported. Therefore and in view to the high costs indication for the use of metal stents in biliary obstruction should be carefully checked.