Percutaneous cholecystostomy in patients with acute cholecystitis: experience of 45 patients at a US referral center.

BACKGROUND: Standard treatment for acute cholecystitis is cholecystectomy, but some patients are at high risk for immediate surgery. Percutaneous cholecystostomy might be the procedure of choice in this group. We reviewed the experience of percutaneous cholecystostomy in a large tertiary center population. STUDY DESIGN: We performed a retrospective analysis of patients who underwent percutaneous cholecystostomy, and recorded indications for cholecystostomy, duration of tube placement, clinical outcome, death within 30 days of procedure, complications, bacteriology of aspirated bile, gallbladder contents, and performance of interval cholecystectomy. RESULTS: Forty-five patients (mean age 63 years) had cholecystostomy tubes placed from July 1999 to March 2002. All had confirmed or presumed acute cholecystitis. Mean duration of tube insertion was 54.3 days. Thirty-six patients improved clinically within 5 days. Nine patients died within 30 days; only one death was directly related to gallbladder sepsis. Nine patients subsequently had laparoscopic cholecystectomy, eight had open cholecystectomy, and two had cholecystoenterostomy. Cholecystectomy was planned in another five patients. Cholecystostomy tubes leaked in two patients, blocked in four, and dislodged in one. One patient developed a hemoperitoneum. Bile aspirated at cholecystostomy was culture positive in 12 patients, negative in 16, and not sent or recorded in 17. Twenty-two patients had gallstones, 10 had sludge, 9 had both, and 4 had neither. CONCLUSIONS: In experienced hands, percutaneous cholecystostomy is easy to perform, with low complication and high success rates. It is the procedure of choice in patients with acute cholecystitis unfit for emergency surgery. Patients often improve clinically, so that cholecystectomy can be done electively.

Outcome of endoscopic minor papillotomy in patients with symptomatic pancreas divisum.

CONTEXT: Pancreas divisum has been associated with recurrent acute pancreatitis, chronic abdominal pain without elevated pancreatic enzymes, and chronic pancreatitis. Prior studies suggest that endoscopic minor papillotomy benefits certain symptomatic pancreas divisum patients. However, the data are quite limited and there is a lack of long-term follow-up. OBJECTIVE: To describe a retrospective study of endoscopic minor papillotomy for pancreas divisum. PATIENTS: Eighty-nine adult patients who underwent endoscopic minor papillotomy at our referral center were included in the study. Median follow-up was 29 months. INTERVENTION: We conducted a telephone survey. Fifty-three patients were available for the telephone survey. RESULTS: Thirty-two patients (60.4%) reported immediate improvement: however, symptoms recurred in 17 (53.1% of the immediate responders). Repeat endoscopic interventions were performed in 8 patients, with long-term improvement in two. Overall long-term improvement was achieved in 17 patients (32.1%). Results of minor papillotomy were more favorable for patients with recurrent, well-defined bouts of pancreatitis (immediate improvement: P=0.036; long-term improvement: P=0.064) compared to those with pancreatitis who reported continuous pain and those without clinical evidence of pancreatitis (immediate improvement: 73.3%, 42.9% and 44.4%, respectively; long-term improvement: 43.3%, 21.4%, and 11.1%, respectively). CONCLUSIONS: The long-term benefit from endoscopic minor papillotomy using strict criteria is poorer than suggested from previous studies. However, pancreas divisum patients with well-defined bouts of pancreatitis are more likely to benefit from endoscopic minor papillotomy than those without symptom-free intervals between "attacks" and those with pain that is not associated with elevated pancreatic enzymes.

Capsule endoscopy: a case study of an 11-year-old girl.

Small-bowel disorders have typically been challenging to diagnose because of difficulty visualizing this organ. The recent development of an innovative M2A trade mark Capsule that provides video visualization of the small bowel may have a unique niche in the diagnosis of small bowel disorders. This article highlights a pediatric patient's experience of capsule endoscopy to help the reader more clearly understand the procedure and appropriate nursing care.

The need for caution with topical anesthesia during endoscopic procedures, as liberal use may result in methemoglobinemia.

During upper gastrointestinal endoscopy, topical oropharyngeal anesthesia with lidocaine and/or benzocaine is used routinely by many endodscopists. Although such a practice is usually safe, there have been a number of reports of methemoglobinemia induced by topical anesthesia. Early treatment is extremely important as the development of methemoglobinemia is potentially fatal. Methemoglobinemia should be considered when oxygen desaturation occurs without another explanation. In this case series, we report 4 cases of methemoglobinemia that followed the liberal application of Cetacaine for ERCP. All patients recovered after appropriate treatment but these cases serve to highlight the potential problem, the importance of early recognition and treatment, and the most appropriate treatment options.