Gallstones in elderly patients: impact of laparoscopic cholecystectomy.

The use of laparoscopic cholecystectomy (LC) in elderly patients may pose problems because of their poor general condition, especially of cardiopulmonary function. Moreover, these patients present with acute cholecystitis and associated common bile duct stones more often than their younger counterparts. From 1990 to 1999, the authors performed 943 LCs; 31 (3.2%) were attempted on elderly patients, 11 (35%) of which were on an emergency basis because of acute cholecystitis, cholangitis or acute biliary pancreatitis. Ten per cent of LCs needed to be converted to an open cholecystectomy, most often because of an increase in the partial pressure of carbon dioxide in the blood produced by excessive operative time. A gasless procedure was used in the last three years of the study on eight cases; the overall rate of conversion from LC to open cholecystectomy in this group was 0%. Associated gallbladder and common bile duct stones were found in five (16%) patients (four preoperative LC endoscopic sphincterotomy and one transcystic approach). The success rate in both of these cases was 100%, overall morbidity was 29% and there was no mortality. These results show that LC is a feasible and safe procedure for use in elderly patients. Gasless LC should be preferred in patients classified as American Society of Anesthesiologists' class III because an excessive duration of operation is the most common reason for converting to an open cholecystectomy.

Extracorporeal shock wave lithotripsy of pancreatic stones in chronic pancreatitis: immediate and medium-term results.

BACKGROUND: Obstruction of the main pancreatic duct with upstream hypertension and dilation is a cause of pain in patients with chronic pancreatitis. Pancreatic ductal drainage can be achieved endoscopically by intraductal stone removal after endoscopic pancreatic sphincterotomy and/or by insertion of a pancreatic stent. Extracorporeal shock wave lithotripsy may be needed whenever stones cannot be removed by endoscopic procedures. We present our results in 35 patients treated with a combined endoscopic-extracorporeal shock wave lithotripsy approach with at least 6 months of follow-up. METHODS: Thirty-five patients with severe chronic pancreatitis were treated by extracorporeal shock wave lithotripsy for endoscopically unretrievable obstructive stones. Extracorporeal shock wave lithotripsy was performed with an electromagnetic lithotriptor in 29 patients and an electrohydraulic lithotriptor in 6. RESULTS: The procedures were well tolerated by the majority of patients. Fragmentation of stones was obtained in all cases while complete clearance and decompression of pancreatic duct were obtained in 26 of 35 (74.3%) and in 30 of 35 (85.7%) cases, respectively. There was no mortality related to the procedure. Morbidity was observed in 8 of 35 patients (22.8%). CONCLUSIONS: Extracorporeal shock wave lithotripsy is a safe and effective treatment for endoscopically unretrievable pancreatic stones in the main pancreatic duct. Extracorporeal shock wave lithotripsy should be considered complementary and not an alternative to endoscopic drainage. Combined with endoscopy, extracorporeal shock wave lithotripsy may increase the success rate of nonsurgical treatment of patients with chronic pancreatitis.

Gall stone pulverisation strategy in patients treated with extracorporeal lithotripsy and follow up results of maintenance treatment with ursodeoxycholic acid.

Between November 1988 and July 1992 70 patients with radiolucent gall stones were treated with extracorporeal lithotripsy (ESL) and ursodeoxycholic acid (UDCA; mean (SD) dose 11.2 (1.9) mg/kg/day). Fifty three patients have been followed for one year. One week after lithotripsy, 30.6% had completely eliminated all stone fragments from the gall bladder and one year later 93.9% were free of stones. Three factors were considered important in achieving these results. 'Pulverisation' of the stone--that is, its fragmentation into echogenic dust (crystalline aggregates, some few hundred mu in size) or particles similar to grains of sand, smaller than 1 mm in diameter, or both, is required. Secondly, dust and particles were rapidly eliminated, strongly suggesting a mechanical elimination process by physiological gall bladder contractions. Thirdly, there must be chemical dissolution with biliary acids. This therapeutic approach gave excellent results without causing any clinically relevant side effects. The first 20 patients who became free of stones after ESL were given oral bile acid maintenance treatment--300 mg/day of UDCA at bedtime, for two years. All were asymptomatic and none had suffered a recurrence after two years. In four patients, crystalline aggregates, detected in gall bladder bile by ultrasound, were subsequently dissolved between one and three months after resuming a full dose regimen of UDCA.

Lower gastrointestinal endoultrasound.

Following a brief history of transrectal ultrasonography, the author explains the fundamentals that led to his research on rectal echographic layers and then describes his theory as applied to the anatomical interpretation of these layers. Personal cases of preoperative staging with transrectal echography provide a basis for the critical evaluation of this method and its proposed role in clinical application.

Hepatic morphotypes. Their statistical individualization using ultrasonography.

The shape, topography, and vascular disposition of the liver depend on a subject's morphotype. The definition and classification of morphotypes was previously based on cadaver observation. In this study, 74 healthy adults (42 women, 32 males) were assessed using ultrasonographic parameters (hepatic diameters, xiphoid angle, orientation of the inferior face of the liver). The results were analyzed by discriminant analysis to differentiate the morphotypes. The three groups known by anatomists as breviligne (endomorphic), longiligne (ectomorphic), and normotype were again demonstrated and individualized in a significant manner. However, with the exception of the normotype group, fundamental differences were observed between our results and those of the anatomists. Ultrasonographic assessment shows that in the breviligne, the liver occupies the right hypochondrium and extends only slightly to the left of the midline; in the longiligne it extends into the left hypochondrium.

Determination of a hepatic volumetric index by ultrasonic scanning.

A prospective study was carried out to calculate, by a fast and simple ultrasonic method, the size of the liver. Seventy-five normal subjects, 38 men and 37 women, average age 51 +/- 17 years (range 19-85) were studied. The three main diameters of the liver, breadth, thickness, and height, were obtained using a compound scan technique; each diameter was measured at its largest dimension. These measurements were multiplied together and the product arbitrarily divided by 27, which is the cube of the three diameters. This yielded the hepatic volumetric index (HVI), which was between 95 and 140 in 95% of normal subjects below 65 years of age and ranged from 80 to 135 in those above 65 years. These last data proved to be in accordance with the well-known involution of liver size in the elderly and with our retrospective study on 207 normal subjects. Then, using the criteria previously proposed by us, the population studied in the prospective study was divided into three groups of morphotypes: endomorphs, ectomorphs, and mesomorphs. The ectomorphs had an HVI slightly lower than that of the endomorphs. This HVI determination, based on standardized measurements and on a statistically controlled method, allows us to separate normal from pathological livers in 10 min and plays an important part in day-to-day clinical practice.

Morphological appearance of low-level echoes in the gallbladder. Interpretation with microscopic biliary analysis and clinical correlation.

A total of 743 patients affected by various gastrointestinal disorders were examined by ultrasound. The presence in the gallbladder bile of low-level echoes (LLE) was observed in 56 (7.5%). Twenty-six of these patients had surgery: 24 underwent cholecystectomy for important biliary-like painful symptomatology, and 2 had cephalopancreatectomy for pancreatic head carcinoma. Both macro- and microscopic controls of the bile were carried out in all 26 patients. In 20 cases, only microscopic cholesterol crystals and calcium bilirubinate granules were observed in the bile. The microscopic evidence of these crystals was associated in four cases with macroscopic evidence of so-called "biliary sludge" and in four cases with macroscopic evidence of highly viscous bile. In the other 6 cases these crystals were associated with the presence of cholesterol stones. The authors consider that the observation of LLE in the gallbladder bile is an important index of the presence of cholesterol crystals and/or calcium bilirubinate granules. These LLE can assume polymorphic aspects, described by the authors, which may simulate other pathologies and lead to incorrect echographic diagnosis. The high incidence of LLE in an alithiasic population (5.1%), together with the elevated frequency, according to the authors, of association of these echoes with a painful biliary-like symptomatology (52.6%), underlines the diagnostic importance of an accurate ultrasound investigation in this type of pathology.

Transrectal ultrasonography: three years' experience.

Since 1983 we have used radial and linear ultrasound probes in the laboratory and clinical examination of the rectum. Normal endosonographic appearances have been characterised by examining polyethylene membranes and resection specimens. Twenty normal subjects and 11 patients with rectal cancer have been examined, and of these 9 were correctly staged.

Transrectal ultrasonography: interpretation of normal intestinal wall structure for the preoperative staging of rectal cancer.

An in vitro ultrasonographic study was carried out to four polyethylene membranes of different thicknesses and on four normal surgical specimens from the rectal wall, to assess its various layers and their anatomical structure. Three different techniques were used, and an electronic equipment measured the thickness of the membranes and of the surgical specimens. Polyethylene membranes less than 1000 microns thick gave linear echoes; the 1000-microns-thick membrane gave a three-layer image--two hyperechogenic layers separated by a hypoechogenic one. The rectal wall was separated into the mucosa-submucosa and the muscularis propria-serosa or muscularis propria (in the extraperitoneal rectum); their thickness ranged from 900 to 1000 microns and from 1500 to 8000 microns, respectively. Even though the mucosa-submucosa, the muscularis propria-serosa, and the muscularis propria each gave a three-layer ultrasonographic image (hyper-hypo-hyper), the resulting image of the entire rectal wall was of five layers (hyper-hypo-hyper-hypo-hyper). Transrectal scan carried out on 20 control patients confirmed the results obtained in vitro, even though at times it was difficult to detect clearly the fifth layer. Interpretation of the five layers was as follows: the second and fourth corresponded to the mucosa-submucosa and muscularis propria, respectively; the first, third, and fifth were considered to reflect interfaces originating from different acoustic impedance structures. The fourth layer was always thicker than the second one. There was no difference between intra- and extra-peritoneal images. A further study carried out on nine patients with rectal cancer by transrectal ultrasonography proved the reliability of this method in assessing the cancer infiltration of the wall and its importance in the preoperative staging of rectal cancer.

[Ultrasonically-guided percutaneous puncture of Wirsung's duct]. / Ponction percutanée échoguidée du canal de Wirsung.

A technique of ultrasonically guided percutaneous puncture of Wirsung's duct for pancreatic juice collection and radiological opacification is described. The equipment used is a linear array real-time transducer with a groove into which a metallic support provided with a guiding needle is attached. Once the depth at which the duct lies has been determined, a Chiba's needle is passed through the guiding needle and pushed up to the corresponding length. Pure pancreatic juice is then withdrawn for lactoferrin assay and a contrast medium is injected for pancreatography.

Determination of a splenic volumetric index by ultrasonic scanning.

In a prospective study carried out to determine spleen size by a rapid and simple ultrasonic method, 45 normal subjects, 20 men and 25 women, average age 54 +/- 17 years (range 17-78) were studied. The three principal dimensions of the spleen, breadth, thickness, and height, were obtained with a compound scan technique; each dimension was measured at its largest point. The values obtained were multiplied by each other and the product arbitrarily divided by 27, which is the cube of the three values. This gave a splenic volumetric index (SVI), which, in 95 per cent of normal subjects, was between 8 and 34. There were no statistically significant differences related to age, sex, or morphotype when endomorphs, ectomorphs, and mesomorphs were examined. This SVI determination, based on standardized measurements, allows the distinction of normal from abnormal spleens in 10 minutes.

[Spontaneous splenorenal and splenocaval shunts studied by echotomography]. / Dérivations spléno-rénales et spléno-caves spontanées explorées par échotomographie.

Spontaneous spleno-renal and spleno-caval shunts may be anatomically and functionally important in portal hypertension syndromes, as demonstrated by the distinct opacification of the inferior vena cava observed after portal venography with iodine contrast media. Part of the course of these porto-caval anastomotic vessels can be visualized by ultrasonography opposite the left adrenal gland and in the space between the spleen and the left kidney. The images obtained are characteristic enough for the diagnosis of spleno-renal shunt to be suspected before it is confirmed by portal venography, as was the case in the four patients with hepatic cirrhosis reported by the authors.

[Ultrasonographic appearances in three cases of pancreas divisum (author's transl)]. / Aspects échographiques observés dans trois cas de pancréas divisum.

Pancreas divisum is an embryological malformation resulting from imperfect fusion of the dorsal and ventral parts of the gland. In this not infrequently observed anomaly, the excretory systems of the two parts remain independent, secretion being through the principal papilla for the ventral, and the accessory papilla for the dorsal pancreas. The pathogenic role of this malformation is now well established. Ultrasonographic findings in the three cases reported, particularly the intrapancreatic pathway of the superior mesenteric vein, were sufficiently atypical for this congenital malformation to be suspected.