RESUMO
BACKGROUND: The prediction of persistent common bile duct stones (CBDS) in patients during choledocholithiasis crisis is challenging. We developed a model based on the course over time of commonly used biochemical parameters to reduce the rate of unnecessary endoscopic cholangiopancreatography (ERCP) and the risk of perioperative discovery of CBDS. METHODS: Medical charts of patients who presented between 2010 and 2015 for symptomatic gallstone disease with suspected choledocholithiasis were reviewed and compared according to the presence/absence of CBDS on preoperative ERCP or during cholecystectomy. RESULTS: 210 patients were included. Unnecessary ERCP and the discovery rate of CBDS were 9.0 and 22.4%, respectively. Multivariate analysis demonstrated age ≥80 years, neutrophils ≥12000/µL and gamma-glutamyl transpeptidase (GGT) ≥300 units/L at admission, alkaline phosphatase ≥180 units/L at days 3-5 post admission, and a decrease in C-reactive protein ≤10%, aspartate aminotransferase ≤35%, GGT ≤25%, and total bilirubin ≤15% between day 0 and days 3-5 to be predictive of CBDS. The area under the receiver-operator characteristic curve was 0.881. When used to select patients for preoperative ERCP, diagnostic accuracy was 94.8% when three predictors were present. Negative and positive predictive values were 100% in the absence of predictors and when five predictors were present, respectively. Unnecessary ERCP and CBDS discovery rates both decreased to 2.6%. CONCLUSIONS: Commonly used biochemical parameters correctly predict CBDS when they are analysed in a dynamic setting rather than at discrete time points. The proposed model constitutes a reliable tool to decrease unnecessary ERCP and perioperative discovery rates of CBDS.
Assuntos
Biomarcadores/análise , Colecistectomia Laparoscópica/métodos , Coledocolitíase/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Proteína C-Reativa/análise , Colangiopancreatografia Retrógrada Endoscópica/métodos , Coledocolitíase/cirurgia , Ducto Colédoco/patologia , Ducto Colédoco/cirurgia , Feminino , Humanos , Contagem de Leucócitos/métodos , Lipase/sangue , Testes de Função Hepática/métodos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco/métodosAssuntos
Diafragma/diagnóstico por imagem , Diafragma/lesões , Mergulho/lesões , Hérnia Diafragmática Traumática/diagnóstico por imagem , Diafragma/cirurgia , Hérnia Diafragmática Traumática/etiologia , Hérnia Diafragmática Traumática/cirurgia , Humanos , Radiografia , Ruptura/diagnóstico por imagem , Ruptura/etiologia , Ruptura/cirurgiaAssuntos
Colo/cirurgia , Doenças do Íleo/diagnóstico por imagem , Íleo/cirurgia , Perfuração Intestinal/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Anastomose Cirúrgica/métodos , Colo/diagnóstico por imagem , Humanos , Doenças do Íleo/etiologia , Íleo/diagnóstico por imagem , Perfuração Intestinal/etiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Síndrome , Tomografia Computadorizada por Raios XRESUMO
Appendicular abscess occurred in 14.2% of patients presenting acute appendicitis. Management of these patients remains controversial, ranging from an emergency appendectomy to a nonoperative treatment. On board French nuclear submarines, the usual treatment for all cases of appendiceal masses, including both appendicitis and appendiceal abscess, is an appendectomy. In the past 5 years, the introduction of ultrasonography (US) on board has enabled the diagnosis of appendiceal abscess with a high rate of accuracy, and the latest studies show that nonoperative treatment is an alternative approach. This nonsurgical treatment, based on intravenous administration of antibiotics, is successful in about 93% of the patients. Failure of nonsurgical treatment is a reliable indication of percutaneous drainage. The proportion of adult patients who need percutaneous drainage of abscesses is about 27%. A successful primary nonoperative treatment may or may not be followed by interval appendectomy at the conclusion of the patrol. Nonsurgical treatment is associated with a significantly lower morbidity than surgery. Considering that the on-board surgical facility is limited, nonsurgical treatment appears to be the best approach for treating a sailor with an appendiceal abscess during a submarine patrol mission.