Laparoscopic cholecystectomy and perioperative ERCP.

BACKGROUND/AIMS: Study of acceptance of simultaneous laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography for treatment of cholelithiasis with choledocholithiasis. METHODOLOGY: There were 25 patients. Ten patients had acute pancreatitis of biliary etiology, accompanied by transitory icterus. In 15 patients, choledocholithiasis was suspected preoperatively both on ultrasonography and i.v. cholangiography. In all patients laparoscopic cholecystectomy with perioperative endoscopic retrograde cholangiopancreatography and sphincterotomy were performed for the treatment of cholelithiasis and choledocholithiasis. RESULTS: Simultaneous laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography was successfully done in all patients. The patients were discharged home on the 4th day after the surgery. Concerning early complications, there where 3 early complications, e.g., prolonged hemorrhage after papillotomy in a patient with choledocholithiasis with stenotic papillitis. Conservative therapy (fresh frozen plasma, local hemostats) was used in this patient. In 4 patients with choledocholithiasis, transitory hyperamylasemia was observed, with no clinical symptoms of pancreatitis. The symptoms disappeared with conservative therapy 3 days after the beginning of treatment. CONCLUSIONS: Simultaneous laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography for treatment of cholelithiasis and choledocholithiasis is a safe and acceptable treatment.

Use of octreotide-acetate in preventing pancreatitis-like changes following therapeutic endoscopic retrograde cholangiopancreatography.

Acute pancreatitis is a serious complication of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterectomy (EST). In addition, serum pancreatic enzymes increase without clinical symptoms in up to 75% of patients undergoing endoscopic procedures. The aim of this trial was to investigate the effects of octreotide in the prevention of these possible complications in patients undergoing therapeutic ERCP. The study was carried out in 209 subjects who were randomly allocated to two groups (A and B). Group A received 0.5 mg of octreotide-acetate subcutaneously one hour prior to ERCP; group B was given placebo. Serum amylase and lipase values were measured before premedication and 1.5, 2, 6 and 24 hours following endoscopy. Following ERCP, the increase in both amylase and lipase values was significantly greater in the control (placebo) group, but this significance disappeared 24 hours following the procedure. Symptoms of acute pancreatitis developed in 4 (3.85%) patients who were given octreotide-acetate, compared to 10 (9.52%) patients in the control group. The results obtained in our study seem to indicate that octreotide could prevent the increase in serum pancreatic enzymes, but no significant difference was observed in the prevention of post-ERCP pancreatitis.

Whipple's disease: a case study with unexpected prognosis.

Due to the systemic nature of Whipple's disease, its clinical presentation may be highly variable. The diagnosis may, therefore, be unduly delayed. Untreated, Whipple's disease is still potentially lethal. Although it traditionally presents with signs and symptoms of small intestine involvement, such as diarrhea and malabsorption, Whipple's disease can involve many other organs. Typically, the diagnosis is established by biopsy of the small intestine. The authors describe a case of Whipple's disease in order to stress the importance of bearing this polymorphic disease in mind, with special emphasis on its possible lethal outcome in spite of therapy.

Factors predictive of the healing of pancreatic pseudocysts treated by percutaneous evacuation.

BACKGROUND/AIMS: Pseudocyst formation is a well-known complication of pancreatitis which develops over 1 to 4 weeks in approximately 15% of patients. Nearly one-third of pancreatic pseudocysts resolve spontaneously; however, if there is no resolution within six weeks, evacuation must be performed. The aim of this study was to prospectively assess the reliability of the following: etiology; location; amount of pseudocyst liquid; and concentrations of certain biochemical parameters (LDH, glucose, proteins, sodium, potassium, bilirubin, lipase and amylase) in the pseudocyst content and patients' serum, in terms of the efficacy of ultrasound-guided percutaneous evacuation as a therapeutic approach. METHODOLOGY: Pseudocyst fluid was obtained by ultrasound-guided percutaneous evacuation in 67 patients, with a history of pancreatitis and pancreatic pseudocysts larger than five centimeters in diameter, with a matured membraneous wall that persisted for more than six weeks. RESULTS: There is a prognostic value associated with the location of the pseudocyst, the amount of pseudocyst liquid and the concentration of proteins, potassium, lipase and amylase in the evacuated material. CONCLUSION: Analysis of the aforementioned parameters provides an early forecast of the outcome of percutaneous evacuation.

Tuberculous peritonitis--a case report.

Tuberculosis continues to be a major health problem worldwide and, due to its systemic nature, its clinical presentation may be highly variable. The diagnosis may, therefore, be unduly delayed. A 67-year old male refugee was admitted to our Department with a diagnosis of intra-abdominal carcinomatosis. During hospitalization, tuberculous peritonitis was found to be the cause of his symptoms. Antituberculosis therapy was administered and the patient responded adequately, achieving total clinical remission. The importance of considering this polymorphous disease is emphasized.

Giant peptic ulcers in patients undergoing maintenance hemodialysis.

The aim of the study was to investigate the clinical characteristics of hemodialyzed uremic patients with upper gastrointestinal lesions. A total of 20 (7.2%) out of 276 patients on hemodialysis program underwent endoscopy and rentgenography of the upper gastrointestinal tract. The incidence of peptic ulcer disease in the patients with end-stage renal disease was 4.3%. Six (30%) out of 20 uremic hemodialyzed patients with gastrointestinal complications had giant peptic ulcers of duodenum or prepyloric area. In three (50%) out of six subjects, giant peptic ulcers were located in the second portion of the duodenum. Gastrointestinal hemorrhagic complications occurred in 12 (60%) patients. The most frequent sources of bleeding were duodenal ulcers alone (8 patients) or in combination with gastric and/or duodenal flat erosions (6 patients), angiodysplasia of the duodenum (3 patients) and duodenal erosions (one patient). Two patients with bleeding from giant ulcers died from perforation and hemorrhagic shock. The uremic hemodialyzed patients with giant ulcers were older than 65, had higher basal gastrin concentration (305.3 +/- 183.8 pmol/l), and lower basal (1.6 +/- 0.16 mmol/h) and stimulated gastric acid secretion (14.4 +/- 8.63 mmol/h).

Assessment of value of pancreatic pseudocyst amylase concentration in the treatment of pancreatic pseudocysts by percutaneous evacuation.

The aim of our study was to determine the value of the percutaneous pancreatic pseudocyst evacuation. We assessed the relation between the amylase concentration of the pseudocyst contents and the final outcome of the disease treated by the percutaneous evacuation. Forty-three patients with a history of acute pancreatitis and pancreatic pseudocysts larger than 5 cm in diameter that persisted beyond 6 weeks were divided into four groups relative to the amylase concentration in the pseudocystic contents and the number of evacuations. The results show a good correlation between low amylase concentration in the liquid pseudocystic contents (less than or equal to 64 WU) and the healing rate after the percutaneous evacuation (p less than 0.001). The percutaneous evacuation of the pseudocysts failed in patients with increased amylase concentrations in the pseudocyst fluid regardless of the number of evacuations. We conclude that surgical treatment is indicated in patients who have amylase-rich pseudocyst contents.

The value of pancreatic pseudocyst amylase concentration in the detection of pseudocyst communication with the pancreatic duct.

The aims of the study were to compare the results of endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous cystopancreatography (PCP) in the detection of the communication between the pancreatic pseudocyst and the pancreatic duct, and to assess the reliability of the increased amylase concentration in the pseudocyst content as an indicator of the existence of communication between the pancreatic pseudocyst and the pancreatic duct system. Forty-three patients were included in the study. Pseudocystic fluid content was obtained by percutaneous aspiration. Twenty-four patients had pseudocyst amylase concentrations above 64 Wolgemuth units (WU), and 19 patients had less than 64 WU. The communication between pseudocyst and the pancreatic duct was determined in 22 patients by ERCP and in 13 patients by PCP, all in the group with increased pseudocyst amylase concentration. Due to high sensitivity and specificity of pseudocyst amylase concentration for the existence of pseudocyst communication with the pancreatic duct, we conclude that guided percutaneous aspiration of the pancreatic pseudocyst with the determination of amylase concentration in the fluid can replace ERCP as a method of choice for the detection of pseudocyst communication with the pancreatic duct.

[New findings in the etiopathogenesis of ulcers and reevaluation of therapy]. / Bitne novosti u etiopatogenezi ulkusa i reevaluacija terapije.

The etiopathogenesis of ulcer disease is comprehensive and many experimental and clinical data failed to prove the primary cause of the disease. Although much has been learned concerning the pathophysiological mechanism which appear important in the development of ulcer disease, our present knowledge of the etiology of this disease is incomplete. Depression of the gastric acid secretion still remains the main treatment approach, although the cytoprotective drugs are interesting therapeutic challenge. Etiology of the peptic ulcer disease is not solved yet, but the defense mechanisms of the gastric mucosa are much more clear what will lead to better understanding of the defense mechanisms in the gastric cancer. Omeprazole is an interesting new drug healing peptic ulcer in almost 100% of the patients. A philosophic question may be asked: "Do we need to know the etiology of the disease in order to be able to treat it properly?" Omeprazole heals the ulcer and, in fact, we do not know its etiology. In the cost-benefit ratio, the most widely used drugs are still H2-receptor antagonists and sucralfate, and omeprazole is reserved for the patients with resistant ulcer disease, Zollinger-Ellison syndrome and severe reflux esophagitis.