Laparoscopic management of common bile duct stones.

BACKGROUND: While laparoscopic cholecystectomy is widely accepted for therapy of cholecystolithiasis, controversy still exists concerning the management of common bile duct stones. Besides preoperative endoscopic papillotomy followed by laparoscopic cholecystectomy and open common bile duct surgery, management of common bile duct stones can be conducted by laparoscopy, if respective experience is available. METHOD: During laparoscopic cholecystectomy a cholangiography via the cystic duct is routinely performed. If bile duct stones are detected they are retrieved via the cystic duct or via incision of the common bile duct by insertion of a Fogarty catheter or Dormia basket. Exclusion criteria against simultaneous laparoscopic management include suspicion of malignancy, severe pancreatitis, or cholangitis. RESULTS: From November 1991 to March 2002, 200 patients primarily underwent laparoscopic therapy of bile duct stones. Retrieval was performed via cystic duct and common bile duct incision in 115 and 85 cases, respectively. Complete removal was achieved in 91%; complication rate and mortality was 7% and 0.5%, respectively. During the same period primary endoscopic papillotomy was necessary in 40 patients because of the above contraindications. CONCLUSIONS: When correct indications and surgical expertise are observed, simultaneous laparoscopic management of common bile duct stones represents a safe and minimally invasive alternative to a two-procedure approach.

[Technique of endoscopic subfascial CO2 insufflation-dissection of perforator veins]. / Technik der Endoskopischen Subfaszialen CO2-Insufflations-Dissektion der Perforansvenen (ESIDP).

Endoscopic subfascial dissection of perforating veins (ESDP) represents a new additional technique for treatment of greater saphenous system varicosities. We present a modification of ESDP, entitled endoscopic subfascial insufflation-dissection of perforating veins (ESIDP). In ESIDP CO2-insufflation induced enlargement of subfascial space (subfascial pneumocave) facilitates identification and dissection of perforating veins. From 1.1.1998 to 1.7.2000, 150 procedures of ESIDP have been conducted in 127 patients (90 females, 37 males). Identification of incompetent perforating and superficial veins and assessment of deep veins were performed preoperatively using duplex sonography. In addition to a description of the surgical technique, we present an overview about indications for ESIDP and possible ESIDP-related postoperative complications.

Implications of histological grade of tumour for the prognosis of radically resected periampullary adenocarcinoma.

OBJECTIVE: To study the influence of histological grade of tumour on the prognosis of radically resected periampullary cancers. DESIGN: Retrospective study. SETTING: Teaching hospital, Austria. SUBJECTS: 156 patients (papilla of Vater, n = 34, head of the pancreas, n = 105, and distal common bile duct, n = 17) who underwent partial pancreaticoduodenectomy for periampullary adenocarcinoma between 1 January, 1967 and 31 December, 1996. OUTCOME MEASURES: The relation between grade of tumour and site, T and N classification, extramural growth, invasion of vessels and resection margins, tumour volume, and survival time. RESULTS: Well differentiated lesions were significantly more common in the papilla of Vater (n = 15, 44%, p = 0.01) than in the pancreatic head or the common bile duct (n = 20, 19%, and n = 5, 29%, respectively). Only in ampullary lesions did the grade of tumour significantly affect the incidence of other histopathological risk factors (T p = 0.003; nodal status p = 0.01; extramural growth p = 0.0001; tumour volume p = 0.02) and survival time (p = 0.02); no significant correlations were found in cancers of the head of the pancreas or common bile duct. CONCLUSIONS: There was a significant difference in the distribution of grade of tumour between the different sites of origin of resected periampullary cancers. Grade of tumour correlated with T and N classification, tumour volume, extramural growth, and survival only in ampullary lesions.