Single-stage treatment with intraoperative ERCP: management of patients with possible choledocholithiasis and gallbladder in situ in a non-tertiary Spanish hospital.

BACKGROUND: The best way to reduce endoscopic retrograde cholangiopancreatography (ERCP) complications is not to perform it if it is unnecessary. Both intraoperative and postoperative ERCP rely on use of intraoperative cholangiography as a final diagnostic test for choledocholithiasis (CLD) whenever clinical data are unable to rule out CLD. Intraoperative ERCP could become a therapeutic option when a previous preoperative ERCP fails. We present our experience with intraoperative ERCP. PATIENTS AND METHODS: This is a descriptive and prospective study of a cohort of 82 patients with moderate risk of CLD. They were operated on by laparoscopic cholecystectomy with intraoperative cholangiography (IOC). We performed intraoperative ERCP using the rendezvous technique. RESULTS: Thirty-six out of 82 patients had an abnormal IOC study. Mean age was 58.7 years (standard deviation, SD 16.6, 25-83 years), and 60.6% were females. Ultrasound study showed that 51.4% of patients had a dilated bile duct. Magnetic resonance cholangiography (MRC) was performed on three patients (8.3%). The success rate of intraoperative ERCP was 88.2%. Three out of the 36 patients (8.8%) had ERCP complications [2 mild papillary bleeding (5.8%), 1 acute pancreatitis (2.9%)]. The rate of conversion to open surgery was 5% with a surgical complications rate of 4% [one injured duct and two surgical bleeding which required re-operation (2.5%)]. There were no mortalities. Four patients (11.1%) needed post-surgical ERCP, with a residual CLD rate of 5.6% (two patients) in the postoperative period. Mean surgical time was 181 min (SD 60, 75-345 min). Mean hospital stay was 6.2 days (SD 4.7, 2-24 days). CONCLUSIONS: Intraoperative ERCP is an option to prevent performing ERCP unnecessarily on patients with moderate risk of CLD not confirmed using appropriate radiological studies. It can resolve the biliary disease in a single step with a similar success rate to standard ERCP, but with low morbidity, especially of acute pancreatitis. The residual CLD rate is also very low.

Two-stage treatment with preoperative endoscopic retrograde cholangiopancreatography (ERCP) compared with single-stage treatment with intraoperative ERCP for patients with symptomatic cholelithiasis with possible choledocholithiasis.

BACKGROUND AND STUDY AIMS: An ideal treatment for choledocholithiasis in the laparoscopic era has not been established. The objective of this study was to elucidate whether a treatment strategy of performing intraoperative endoscopic retrograde cholangiopancreatography (ERCP) during laparascopic cholecystectomy (when choledocholithiasis is confirmed by intraoperative cholangiography) is better for patients with suspected common bile duct stones than the current strategy (preoperative ERCP followed by laparoscopic cholecystectomy). PATIENTS AND METHODS: This was a prospective randomized study to evaluate which of these two approaches was most benefit- and cost-effective for patients with intermediate risk of choledocholithiasis. Patients underwent either preoperative ERCP followed by a laparoscopic cholecystectomy a few weeks later (the "preoperative ERCP" group) or intraoperative ERCP (the "intraoperative ERCP" group). Intraoperative ERCP was performed using the rendezvous technique. RESULTS: There were 64 patients in the preoperative ERCP group and 59 patients in the intraoperative ERCP group. The demographic and clinical characteristics of the two groups were similar, except that the bilirubin and gamma-glutamyl transferase (GGT) levels and the number of patients treated on an inpatient basis were higher in the preoperative ERCP group. Success rates were similar (96.6 % in the preoperative ERCP group vs. 90.2 % in the intraoperative ERCP group in the per-protocol study). Total morbidity, post-ERCP morbidity, and post-ERCP acute pancreatitis rates were higher in the preoperative ERCP group, but there were no differences between the two groups in the frequency of residual common bile duct stones, the conversion rate to open cholecystectomy, or surgical morbidity. The length of hospital stay and costs were lower in the intraoperative ERCP group despite the longer surgical times in this group. Univariate analysis did not find any relationship between morbidity and total bilirubin or GGT. Logistic regression analysis confirmed that morbidity was related only to the treatment group and the time spent in the operating room: the relative risk (RR) was 4.37 for morbidity and 1.015 for the time spent in the operating room); the RR for papillotomy was 5.49. CONCLUSIONS: Both treatment approaches were equally effective but the intraoperative ERCP group had less morbidity, a shorter hospital stay, and reduced costs. The lower morbidity in the intraoperative ERCP group resulted from the lower rate of papillotomy and lower rates of post-ERCP pancreatitis and cholecystitis. Total morbidity was principally related to the type of treatment approach used.

Treatment of left colon neoplasic obstruction by placement of self-expandable stents.

INTRODUCTION AND OBJECTIVE: Neoplasic stenoses of the left colon are most frequently caused by primary colon carcinoma, infiltration from an external tumour and great adenomatous polyps. These patients often develop obstruction as their first symptom, leading to emergency surgical procedures in adverse circumstances and without an appropriate intestinal preparation that might prevent primary anastomosis. Therapeutic options for this event, such as Hartmann's resection, subtotal colectomy or anterograde colon lavage are not always possible. In these patients a colostomy is performed that requires future reoperation for reconstruction of the intestinal transit. Transtumoral self-expandable stenting followed by elective surgery might be the best option in these cases, as well as an alternative to surgery in non-operable patients. PATIENTS AND METHODS: Twenty four patients treated with this procedure in the past four years were divided in two groups. In group 1 (14 patients), the stent was placed as a permanent and palliative measure for the management of the disease. In group 2 (10 patients), the stent was placed temporarily for the management of the intestinal obstruction and latter the patients underwent elective surgery with fully preoperative and extension study and an appropriate preparation of the colon in order to allow reliable primary anastomosis. RESULTS: There were no hospital mortality nor stent migrations. There was only one complication (perforation caused by the stent) that required emergency surgery, but with any further complications. Failure to place the stent occurred in one patient. CONCLUSIONS: Self-expandable stents relieve neoplasic colon obstructions and allow to complete the study protocol, followed by elective surgery associated to less morbi-mortality. In patients with advanced or irresectable cancer, they provide a palliative and safe alternative to surgery, with satisfactory results.

[Expandable stents in obstructive unresectable carcinoma of the gastric antrum]. / Prótesis autoexpandible en el cáncer obstructivo de antro gástrico inoperable.

We present a patient with obstructive unresectable carcinoma of the gastric antrum. An expandable stent was placed endoscopically along the tumor to paliate obstruction. Such a procedure allowed unrestricted oral feeding of the patient up to death six months later.

[Absence of effect of atropine on exocrine pancreatic secretion stimulated by cerulein]. / Ausencia de efecto de la atropina en la secreción pancreática exocrina estimulada con ceruleína.

The effect of atropine, 0.9, 1.8, 7 and 29 nmol/kg-1/h-1, on pancreatic exocrine secretion has been measured in seven dogs with gastric and pancreatic fistula in response to IV administration of increasing doses of cerulein (3.7 to 118 pmol/kg-1/h-1). Secretin was perfused continuously, at a rate of 20.5 pmol/kg-1/h-1, starting one hour before perfusion of cerulein. The administration of atropine, 7 and 29 nmol/kg-1/h-1, significantly (p less than 0.05) decreased the protein response to secretin. Only the injection of 29 nmol/kg-1/h-1 of atropine produced a significant decrease in the secretion of bicarbonate in response to secretin. The administration of 3.7 pmol./kg-1/h-1 and larger doses of cerulein significantly increased the secretion of bicarbonate and protein, compared to the levels obtained with the administration of secretin alone. None of the atropine doses showed a significant effect on the pancreatic response to the administration of cerulein. Only the highest dose of atropine, 29 nmol/kg-1/h-1, modified cardiac rate. These findings are consistent with the hypothesis that cholinergic innervation does not modify the effect of cerulein, a CCK analogue, on the pancreatic secretion of protein and bicarbonate in the dog.

Dose-response effects of atropine on pancreatic secretory response to intestinal tryptophan in dogs.

In dogs with gastric and pancreatic fistulas, we studied the effect of intravenous infusion of atropine in doses of 0.9, 1.8, 7, and 29 nmol X kg-1 X h-1 on the pancreatic secretory response to graded loads of intraduodenal infusions of tryptophan, given with a secretin background. Infusions of 1.8, 7, and 29, but not 0.9 nmol X kg-1 X h-1 of atropine sulfate significantly (P less than 0.05) decreased the incremental protein response to all loads of tryptophan. The cumulative incremental protein output was reduced by 44, 37, and 52%, respectively. Infusions of 1.8, 7, and 29 nmol X kg-1 X h-1 of atropine significantly decreased by approximately 50% the incremental bicarbonate response to low (0.12 and 0.37 mmol/h) but not high loads (1.1, 3.3, and 10 mmol/h) of tryptophan. The inhibitory potency of the effective doses of atropine did not differ significantly. Only the highest dose of atropine significantly increased heart rate by 76%. These findings indicate that 1) in the intact animal, the minimal dose of atropine required for inhibition of pancreatic bicarbonate and protein response to intraduodenal tryptophan seems to be 1.8 nmol X kg-1 X h-1, a dose that causes probably few systemic effects, since it does not increase heart rate; and 2) the inhibitory action of atropine on the pancreatic response to tryptophan appears to be an "all-or-none" effect.

Dose-response effects of atropine on pancreatic secretory response to intravenous cerulein in dogs.

In conscious dogs with gastric and pancreatic fistulas, we studied the effect of i.v. atropine in doses ranging from 1.8 to 29 nmol/kg/h on the pancreatic secretory response to i.v. cerulein in doses ranging from 3.7 to 118 pmol/kg/h. Cerulein was given with an i.v. background infusion of secretin (20.5 pmol/kg/h), started 1 h before the lowest dose of cerulein was given. Secretin alone did not stimulate pancreatic protein output above basal. Doses of 7 and 29 nmol/kg/h of atropine significantly (p less than 0.05) decreased the protein output during secretin. A dose of 29 nmol/kg/h, but not lower doses, of atropine significantly inhibited the bicarbonate response to secretin. A dose of 3.7 pmol/kg/h and all higher doses of cerulein significantly stimulated bicarbonate and protein output above the value observed during secretin alone. None of the three doses of atropine given had any significant effect on the incremental bicarbonate and protein responses to cerulein. Secretin and cerulein did not alter basal heart rate; only the highest dose (29 nmol/kg/h) of atropine significantly increased heart rate. These findings are compatible with the hypothesis that cholinergic nerves do not alter the effect of exogenous cerulein, a CCK analogue, on pancreatic bicarbonate and protein secretion in dogs.

Male pseudohermaphroditism by persistent müllerian structures.

We have studied 2 cases of nonfamilial male pseudohermaphroditism by persistent müllerian ducts. The first case, found in a fourteen-year-old male, can be described as the classic form of cryptorchism which resisted hormonal treatment and in which a rudimentary uterus with fallopian tubes and atrophic testicles were found at exploratory laparotomy. The second case was discovered in a thirty-nine-year-old man who had bilateral cryptorchism. He presented with an abdominal mass which was found to be a seminoma in the right intra-abdominal testicle, and a well-defined uterus with fallopian tubes and an atrophic left testicle were seen. Neither case presented phenotype disturbances. Both karyotypes were 46 XY. A total resection of the female sexual organs and testicles was performed in both patients, and the mass was removed in the second case. The tumoral degeneration of the intra-abdominal testicles in this syndrome is found in similar proportion to the simple cryptorchid testicles. Our second case is the tenth one of a testicular tumor in pseudohermaphroditism by persistent müllerian ducts to be reported in the literature.