Endoscopic management of retained bile stones with an indwelling T-tube.

BACKGROUND: Endoscopic sphincterotomy (ES) is widely used for the treatment of residual bile duct stones in patients who had common bile duct (CBD) exploration and T-tube insertion. METHODS: In a 4-year period 45 patients were referred for endoscopic removal of residual bile duct stones. All patients had been operated 7-15 days earlier for choledocholithiasis and had a T-tube in the common bile duct (CBD). RESULTS: Four patients were excluded. Three patients had a periampullary carcinoma and the fourth patient had no residual stone seen at cholangiography. All patients had a successful ES, conventional in 34, precut-knife in 3, and with the rendezvous technique in 4 patients. In 24 patients, all having stones distal to the T-tube, complete clearance of the CBD was achieved during one session and the T-tube was removed after 48 h. In the remaining 17 patients (15 having stones proximal to the T-tube), the T-tube had to be removed first and following stone extraction, a plastic stent was inserted in the CBD. Complete bile duct clearance and stent removal was achieved in a second session 3-4 weeks later. There were no serious complications or biliary related symptoms after the procedures and after a mean follow-up period of 18 months. CONCLUSION: The endoscopic technique is safe and efficient for the treatment of residual stones after CBD exploration with a T-tube insertion, offering immediate cure compared to the percutaneous techniques. It is also an ideal method for the diagnosis of periampullary carcinomas.

The endoscopic management of persistent bile leakage after laparoscopic cholecystectomy.

BACKGROUND: Bile leakage after laparoscopic biliary surgery is a surgical challenge in which endoscopy can play an important role. METHODS: A total of 26 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) in our department. Patients with evidence of major ductal injury were treated surgically. In all other cases, endoscopic sphincterotomy was performed, any retained bile duct stones were removed, and a biliary endoprosthesis or a nasobiliary catheter was inserted on a selective basis. RESULTS: ERCP was successful in 24 patients. Seven patients were treated surgically after cholangiography revealed major ductal injury. Two more patients were eventually operated on due to bile peritonitis. Of the other 15 patients, 11 had leakage from the cystic duct and four had leakage from the gallbladder bed. Bile duct stones were removed from eight patients, an endoprosthesis were inserted in five patients, and a nasobiliary catheter was inserted in two patients. Bile leakage was treated successfully in all 15 patients with no further complications. CONCLUSION: ERCP is a means of safe diagnosing the cause of a bile leakage and offers a definitive treatment in most cases.

Stapled haemorrhoidectomy compared with Milligan-Morgan excision for the treatment of prolapsing haemorrhoids: a prospective study.

OBJECTIVE: To compare stapled haemorrhoidectomy with Milligan-Morgan haemorrhoidectomy. DESIGN: Prospective open study. SETTING: Teaching hospital, Greece. PATIENTS: 85 patients with prolapsing haemorrhoids were invited to choose between stapled and Milligan-Morgan haemorrhoidectomy. 48 chose the former and 37 the latter. INTERVENTIONS: Operation. Postoperatively, the patients were given analgesics on demand, and were discharged as soon as their condition and particularly their pain had improved. MAIN OUTCOME MEASURES: Patients' symptoms and their opinion about the procedures, which were recorded during their follow-up which lasted for 6 months. RESULTS: Stapling resulted in a significantly shorter operating time, and less postoperative pain and other symptoms, than Milligan-Morgan excision (p < 0.001). Postoperative complications, and mean time in hospital did not differ significantly between the two groups. During the follow-up period there was no significant difference in the incidence of recurrences between the two groups. Six months after the operation, significantly more patients in the stapled group had residual skin tags-external haemorrhoids than in the Milligan-Morgan group, and all these patients had fourth degree haemorrhoids. CONCLUSIONS: Stapled haemorrhoidectomy is a promising method of treatment for prolapsing third degree haemorrhoids. Its effectiveness is questionable for fourth degree ones. Initially, the results are as good as after Milligan-Morgan haemorrhoidectomy, especially for third degree haemorrhoids. However, more patients and longer follow-up periods are required for its long-term efficacy to be confirmed.