A prognostic index of unsuccessful laparoscopic cholecystectomy for acute calculous cholecystitis.

The aim of this retrospective study was to investigate the accuracy of using preoperative data for the prediction of conversion from laparoscopic to open cholecystectomy in patients operated on for acute calculous cholecystitis. Laparoscopic cholecystectomy was scheduled in eighty-nine of 184 consecutive patients with acute calculous cholecystitis who underwent urgent or early cholecystectomy without bile duct exploration in our department between 1991 and 1998. The correlation between 11 preoperative clinical, laboratory and ultrasonographic variables, and the rate of conversion to open cholecystectomy was studied. Among the 11 variables tested, age and leukocyte count were independent factors of predictive significance. These two factors were used for constructing an additive prognostic index for conversion to open cholecystectomy. Thus, three groups of patients could be identified having a 10%, 30-70% or over 88% risk of conversion. Logistic regression analysis permits accurate preoperative identification of unsuccessful laparoscopic cholecystectomy in patients with acute calculous cholecystitis.

Influence of bile duct stones on patient features and effect of endoscopic sphincterotomy on early outcome of edematous gallstone pancreatitis.

The objective of this study was to study the influence on patients' features and the effect on early outcome of the presence of bile duct stones and endoscopic sphincterotomy (EST), respectively, in the presence of edematous gallstone pancreatitis (GSP). It was a retrospective review of a patient series from 1981 through 1992 at a university teaching hospital. Altogether 96 patients aged 42 to 93 years (median 74 years) with edematous GSP were investigated by endoscopic retrograde cholangiography (ERC) in our department, 75 of whom underwent ERC at first admission. A total of 49 patients (group 1) had common bile duct (CBD) stones, and in 47 (group 2) no CBD stones were found. All patients in group 1 and 15 in group 2 underwent EST; 57 of the 75 patients had EST at first admission. The main outcome measures were pancreas-related complications and the length of the hospital stay. The early major complication and stone clearance rates of the EST procedure were 3.2% and 96%, respectively. Duration of symptoms prior to ERC was similar in groups 1 and 2 (median 5 and 8 days, respectively). Serum amylase activity was higher in group 2 patients than in group 1 patients [21-258 (median 75) microkat/L vs. 10-328 (median 48) microkat/L (p = 0.01)], but the length of hospital stay was similar: [4-39 (median 11) days vs. 4-19 (median 9) days (p = 0.05)]. Cholangitis at acute admission was more common in group 1 than in group 2 patients (31% vs. 7%; p = 0. 02), whereas a history of pancreatitis was noted more often in group 2 patients (49% vs. 8%; p< 0.001). ERC was done 1 to 18 days (median 2 days) and 1-16 days (median 5 days) (p = 0.02) after admission in groups 1 and 2 respectively, because of the more frequent cholangitis symptoms in group 1. It was concluded that the history and features at admission differed between patients with and without CBD stones at ERC done during an attack of GSP. Early EST had no influence on outcome or hospitalization. This study does not support routine EST in conjunction with mild GSP.

Effect of endoscopic sphincterotomy and interval cholecystectomy on late outcome after gallstone pancreatitis.

BACKGROUND: Endoscopic sphincterotomy alone, or followed by cholecystectomy, are options in patients with gallstone pancreatitis. METHODS: Ninety-six patients of median age 74 (range 30-93) years with gallstone pancreatitis had endoscopic retrograde cholangiography and were followed for a median of 84 (range 33-168) months. Forty-eight of 49 patients with, and nine of 47 without, common bile duct (CBD) stones had urgent endoscopic sphincterotomy. One patient with, and six without, CBD stones had delayed endoscopic sphincterotomy a median of 35 (range 12-111) days after acute pancreatitis. Thus, 64 patients had endoscopic sphincterotomy (group 1) and 32 did not (group 2). Fifteen and 16 patients in each group respectively had interval cholecystectomy after a median of 3 months and 1 month. RESULTS: Patients in groups 1 and 2 had similar rates of interval cholecystectomy (15 of 64 versus 16 of 32 patients respectively) or required cholecystectomy (15 of 49 versus five of 16 patients), recurrent CBD calculi (three of 64 versus three of 32 patients) or total length of hospitalization after interval cholecystectomy (median 15.5 and 15 days) or required (median 22 and 24 days) cholecystectomy. The overall incidence of recurrent pancreatitis was one of 64 patients in group 1 and five of 32 in group 2 (P = 0.02), but after interval cholecystectomy the recurrence rate of biliopancreatic symptoms was similar (one of 15 patients versus three of 16 patients respectively). CONCLUSION: Endoscopic sphincterotomy, but not interval cholecystectomy, reduced the overall incidence of recurrent pancreatitis, but not of late biliary complications. Some 31 per cent of the patients required cholecystectomy, suggesting that routine cholecystectomy should be considered in fit patients following acute pancreatitis.

Cholangiographic appearance of bile-duct cysts.

Bile-duct cysts or congenital bile-duct dilatation are rare but important abnormalities often mimicking calculous biliary tract disease. Bile-duct cysts are most often classified according to Todani. In a retrospective study of percutaneous, peroperative or endoscopic cholangiograms from 25 patients, diagnosed and treated during a 20-year period, images of different types of bile-duct cysts are presented and classified. The disease usually presents with vague symptoms and has a female preponderance. Current opinion on aetiology and complications is discussed. Cholangiography is a necessary prerequisite to surgical therapy.

Factors predictive of early complications of endoscopic treatment of bile duct calculi.

BACKGROUND/AIMS: Factors associated with an increased early complication rate of the endoscopic sphincterotomy procedure have been identified. Precut or needle knife papillotomy has been shown to improve the success rate of endoscopic retrograde cholangiography and endoscopic sphincterotomy, but has often been reported to be hazardous. In order to identify patients with bile duct stones at risk for a complicated course in connection with endoscopic clearance of the calculi, factors predictive of early complications were sought. METHODOLOGY: 417 consecutive patients with bile duct calculi at endoscopic retrograde cholangiography were considered for endoscopic treatment in our department from 1981 to 1992. Endoscopic sphincterotomy was performed in 246 patients with intact gallbladders and in 147 with prior cholecystectomy, 55 of whom had retained calculi. RESULTS: There was a 9.4% overall and 7.1% major early complication rate of the EST procedure and a 30-day mortality of 0.5% (2 patients, non-procedure related). In 22% (6/27) of the patients with major complications, surgery was required or preferred to additional endoscopic measures. Complete stone removal failed in 35/393 patients (8.9%). The immediate and early complication rate of standard sphincterotomy was not found to be increased in patients with prior or present biliopancreatic complications, failed bile duct clearance at first attempt, or juxtapapillary diverticula. It was the same after standard sphincterotomy as after precut papillotomy followed by immediate or delayed sphincterotomy. No increased morbidity was found after failed therapy as compared to failed diagnostic precut papillotomy. There was neither a greater need for, nor an increased complication rate following, precut papillotomy in patients with, as compared to those without, juxtapapillary diverticula. Endoscopic experience did not influence the complication rate. There were no significant differences regarding outcome or risk factors associated morbidity between patients with and without intact gallbladder. CONCLUSIONS: These findings confirm that endoscopic treatment is safe and that precut papillotomy can be performed without increased morbidity. Furthermore, none of the commonly identified factors associated with increased morbidity were found to be risk factors in this study.

Endoscopic drainage in benign pancreatic disease: immediate and medium term outcome.

OBJECTIVE: To elucidate further the role of endoscopy in the treatment of benign pancreatic disease. DESIGN: Retrospective study. SETTING: University hospital, Sweden. SUBJECTS: 136 of 319 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for known or suspected pancreatic disease had abnormal findings at duodenoscopy or ductography, or both. In 28 patients endoscopic treatment was considered because of recurrent acute pancreatitis (n = 6), chronic pancreatitis (n = 5), pancreatic pain syndrome (n = 5), pancreatic fistula with ascites (n = 1), and pseudocyst (n = 1), or appreciable biliary obstruction from chronic pancreatitis (n = 10). INTERVENTIONS: Pancreatic duct drainage was attempted in 18 patients and successful in 13 (72%). Endoscopic sphincterotomy (EST) alone was done in 7/13 patients and an endoprosthesis (stent) was placed in 6/13. Bile duct drainage was attempted and successful in 10 patients by EST together with dilatation with (n = 6) or without (n = 4) simultaneous placement of a stent. MAIN OUTCOME MEASURES: Relief of pain and cholestasis. RESULTS: Immediate (1-30 days after initial treatment) and medium term (median 48 months after initial treatment) outcome after pancreatic duct drainage was excellent (no pain) or good (occasional mild pain) in 62% (8/13) and 67% (8/12) of the patients, respectively. Complications of the endoscopic procedure were encountered in four patients (31%) and comprised infection with abscess formation (n = 1), repeated stent clogging (n = 1) or stent migration (n = 2). Surgery was subsequently required in three patients (23%) because of intraabdominal abscess (n = 1), recurrent pain (n = 1), or no pain relief (n = 1). At medium term follow-up (median 68 months) after biliary drainage 7/10 patients had liver function tests within the reference ranges. Only two patients required subsequent biliodigestive shunts 7 and 13 months after EST, respectively. CONCLUSION: Our findings favour endoscopic drainage as a safe and effective method for temporary and medium term relief of pain and biliary obstruction in selected patients with benign pancreatic disease.