Early Versus Late Cholecystectomy After Clearance of Common Bile Duct Stones by Endoscopic Retrograde Cholangiopancreatography: A Prospective Randomized Study.

INTRODUCTION: The time interval between endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) is a matter of debate. This study was planned to compare early LC versus late LC. PATIENTS AND METHODS: This is a prospective randomized study on patients who are presented with concomitant gallbladder and common bile duct stone. The study population was divided into two groups; group (A) managed by early LC within three days after ERCP; and group (B) managed by late LC one month after ERCP. RESULTS: No significant difference between both groups as regards the conversion rate, the degree of adhesion, cystic duct diameter, and intraoperative common bile duct injury or bleeding. Recurrent biliary symptoms were significantly more in delayed LC group in 7 (12.71%) patient versus 1 patient in early LC (P=0.03). CONCLUSIONS: No significant difference between both groups as regards the conversion rate. Recurrent biliary symptoms were significantly more in delayed LC while waiting LC. Morbidity was significantly more in delayed LC.

Long term outcomes of choledochoduodenostomy for common bile duct stones in the era of laparoscopy and endoscopy.

BACKGROUND/AIMS: Choledochoduodenostomy (CDD) has been reported as an effective treatment of Common bile duct stones (CBDS). This study was designed to analyze short term and long term outcomes of CDD for CBDS. METHODOLOGY: Demographic data, preoperative, intraoperative and postoperative variables were collected. The long term assessment was done in a prospective manner included clinical examination, liver function, abdominal ultrasound, MRCP, upper GIT endoscopy and assessment of quality of life using Gastrointestinal Quality of Life Index (GIQLI). RESULTS: A total of 388 consecutive patients underwent CDD, the mean age was 57.92±13.25 years. The mean CBD diameter was 18.22±4.01 mm. The mean operative time was 81.21±20.23 minutes. Two patients had recurrent stone (0.06%) and managed successfully by endoscope. Gastritis was observed in 16.9% patients. No patient developed sump syndrome, deterioration in liver function or cholangiocarcinoma. Total and subgroup scores on the GIQLI before and after CDD differed significantly at follow-up (P=0.0001). CONCLUSION: CDD is a safe and effective method of drainage of CBD after clearance of CBDS. Long term outcomes are acceptable with good quality of life. Sump syndrome is extremely rare; CDD may be associated with mild to moderate gastritis. CDD doesn't lead to development of cholangiocarcioma.

Delayed gastric emptying after pancreaticoduodenectomy. Risk factors, predictors of severity and outcome. A single center experience of 588 cases.

BACKGROUND: Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PD). This study was designed to evaluate perioperative risk variables for DGE after PD and analyze the factors that predict its severity. PATIENTS AND METHOD: Demographic data, preoperative, intraoperative, and postoperative variables were collected. RESULTS: A total of 588 consecutive patients underwent PD. One hundred and five patients (17.9 %) developed DGE of any type. Forty-three patients (7.3 %) had a type A, 53 patients (9.01 %) had DGE type B, and the remaining nine patients (1.5 %) had DGE type C. BMI > 25, diabetes mellitus (DM), preoperative biliary drainage, retrocolic reconstruction, type of pancreatic reconstruction, presence of complications, postoperative pancreatic fistula (POPF), and bile leaks were significantly associated with a higher incidence of DGE. Thirty-three (31.4 %) patients were diagnosed as primary DGE, while 72 (68.5 %) patients had DGE secondary to concomitant complications. Type B and C DGE were significantly noticed in secondary DGE (P = 0.04). Hospital stay was significantly shorter in primary DGE. CONCLUSION: Retrocolic GJ, DM, presence of complications, type of pancreatic reconstruction, and severity of POPF were independent significant risk factors for development of DGE. Type B and C DGE were significantly more in secondary DGE.

Impact of obesity on surgical outcomes post-pancreaticoduodenectomy: a case-control study.

BACKGROUND: Obesity is a growing worldwide epidemic. There is association between obesity and pancreatic cancer risk. However, the impact of obesity on the outcome of pancreatoduodenectomy (PD) is controversial. The aim of this study was to elucidate effect of obesity on surgical outcomes of PD. STUDY DESIGN: A case-control study. PATIENT AND METHODS: We retrospectively studied all patients who underwent PD in our center between January 2000 and June 2012. Patients were divided into two groups; Group A (patients with BMI <25) and Group B (patients with BMI > 25). Preoperative demographic data, intraoperative data, and postoperative details were collected. RESULTS: Only 112/471 patients (25.9%) had BMI > 25. The median intraoperative blood loss was more in overweight patients (P = 0.06). The median surgical time in group B was significantly longer than that in group A (P = 0.003). The overall incidence of complications was higher in the overweight group (P = 0.001). The severity of complications was also higher in the overweight group (P = 0.0001). Postoperative pancreatic fistula (POPF) (P = 0.0001) and hospital mortality (P = 0.001) were significantly higher in overweight patients. Oral intake was significantly delayed in overweight patients in comparison to normal weight group (P = 0.02). Postoperative stay was significantly longer in overweight patients (P = 0.0001). CONCLUSION: PD is associated with an increased risk of postoperative morbidity in overweight patient. Overweight patients must not be precluded from undergoing PD. However, operative techniques and pharmacological prophylaxis to decrease POPF should be considered in overweight patients.

Impact of cirrhosis on surgical outcome after pancreaticoduodenectomy.

AIM: To elucidate surgical outcomes of pancreaticoduodenectomy (PD) in patients with liver cirrhosis. METHODS: We studied retrospectively all patients who underwent PD in our centre between January 2002 and December 2011. Group A comprised patients with cirrhotic livers, and Group B comprised patients with non-cirrhotic livers. The cirrhotic patients had Child-Pugh classes A and B (patient's score less than 8). Preoperative demographic data, intra-operative data and postoperative details were collected. The primary outcome measure was hospital mortality rate. Secondary outcomes analysed included duration of the operation, postoperative hospital stay, postoperative morbidity and survival rate. RESULTS: Only 67/442 patients (15.2%) had cirrhotic livers. Intraoperative blood loss and blood transfusion were significantly higher in group A (P = 0.0001). The mean surgical time in group A was significantly longer than that in group B (P = 0.0001). Wound complications (P = 0.02), internal haemorrhage (P = 0.05), pancreatic fistula (P = 0.02) and hospital mortality (P = 0.0001) were significantly higher in the cirrhotic patients. Postoperative stay was significantly longer in group A (P = 0.03). The median survival was 19 mo in group A and 24 mo in group B. Portal hypertension (PHT) was present in 16/67 cases of cirrhosis (23.9%). The intraoperative blood loss and blood transfusion were significantly higher in patients with PHT (P = 0.001). Postoperative morbidity (0.07) and hospital mortality (P = 0.007) were higher in cirrhotic patients with PHT. CONCLUSION: Patients with periampullary tumours and well-compensated chronic liver disease should be routinely considered for PD at high volume centres with available expertise to manage liver cirrhosis. PD is associated with an increased risk of postoperative morbidity in patients with liver cirrhosis; therefore, it is only recommended in patients with Child A cirrhosis without portal hypertension.

Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience).

BACKGROUND: Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) remains a challenge even at high-volume centers. METHODS: This study was designed to analyze perioperative risk factors for POPF after PD and evaluate the factors that predict the extent and severity of leak. Demographic data, preoperative, intraoperative, and postoperative variables were collected. RESULTS: A total of 471 consecutive patients underwent PD in our center. Fifty-seven patients (12.1 %) developed a POPF of any type; 21 patients (4.5 %) had a fistula type A, 22 patients (4.7 %) had a fistula type B, and the remaining 14 patients (3 %) had a POPF type C. Cirrhotic liver (P = 0.05), BMI > 25 kg/m(2) (P = 0.0001), soft pancreas (P = 0.04), pancreatic duct diameter <3 mm (0.0001), pancreatic duct located <3 mm from the posterior border (P = 0.02) were significantly associated with POPF. With the multivariate analysis, both BMI and pancreatic duct diameter were demonstrated to be independent factors. The hospital mortality in this series was 11 patients (2.3 %), and the development of POPF type C was associated with a significantly increased mortality (7/14 patients). The following factors were predictors of clinically evident POPF: a postoperative day (POD) 1 and 5 drain amylase level >4,000 IU/L, WBC, pancreatic duct diameter <3 mm, and pancreatic texture. CONCLUSIONS: Cirrhotic liver, BMI, soft pancreas, pancreatic duct diameter <3 mm, pancreatic duct near the posterior border are risk factors for development of POPF. In addition a drain amylase level >4,000 IU/L on POD 1 and 5, WBC, pancreatic duct diameter, pancreatic texture may be predictors of POPF B, C.