The Role of Hepatobiliary Scintigraphy as the Initial Investigative Modality for Significant Bile Leak following Laparoscopic Cholecystectomy.

INTRODUCTION: Currently, the rate of bile duct injury and leak following laparoscopic cholecystectomy (LC) is still higher than for open surgery. Diverse investigative algorithms were suggested for bile leak, shifting from hepatobiliary scintigraphy (HBS) toward invasive and more sophisticated means. We aimed to analyze the use of biliary scan as the initial modality to investigate significant bile leak in the drain following LC, attempting to avoid potential unnecessary invasive means when the scan demonstrate fair passage of nuclear substance to the intestine, without leak. METHODS: We have conducted a prospective non-randomized study, mandating hepatobiliary scintigraphy first, for asymptomatic patients harboring drain in the gallbladder fossa, leaking more than 50 mL/day following LC. Analysis was done based on medical data from the surgical, gastroenterology, and the nuclear medicine departments. RESULTS: Among 3,124 patients undergoing LC, significant bile leak in the drain was seen in 67 subjects, of whom we started with HBS in 50 patients, presenting our study group. In 27 of whom, biliary scan was the only investigative modality, showing fair passage of the nuclear isotope to the duodenum and absence of leak in the majority. The leak stopped spontaneously within a mean of 3.6 days, and convalescence as well as outpatient clinic follow-up was uneventful. In 23 patients, biliary scan that was interpreted as abnormal was followed by endoscopic retrograde cholangio-pancreatography (ERCP). However, ERCP did not demonstrate any bile leak in 13 subjects. In 17 patients, ERCP was used initially, without biliary scan, suggesting the possibility of avoiding invasive modalities in 7 patients. CONCLUSIONS: Based on a negative predictive value of 91%, we suggest that in cases of asymptomatic significant bile leak through a drain following LC, a normal HBS as the initial modality can safely decrease the rate of using invasive modalities.

Cognitive Function of Patients with Crohn's Disease is Associated with Intestinal Disease Activity.

BACKGROUND: Systemic inflammation and nutritional deficiencies are characteristics of Crohn's disease (CD) and have been suggested to influence cognitive performance. This study assessed cognitive function in patients with CD. METHODS: Participants were adult patients with CD arriving at routine follow-up. Subjective cognitive complaints, depression, anxiety, fatigue, and sleep were evaluated by validated questionnaires. CD characteristics, blood tests, and Crohn's disease activity index were obtained. Nutritional risk index was derived from serum albumin and change in body weight. Montreal cognitive assessment was used for screening. Patients with either subjective cognitive complaints or Montreal cognitive assessment score ≤ 26 were tested by a computerized cognitive testing battery, with analysis of scores in 7 cognitive domains (CogDs) and an average of the CogD scores-global cognitive score (GCS). Impaired CogD was defined as scoring more than 1 SD below age and education adjusted average. RESULTS: A total of 105 patients were recruited and 61 were tested with computerized cognitive testing battery. Mean age was 39 ± 13 and mean education years were 14 ± 2. The most commonly impaired CogDs were information processing speed (33%) and verbal function (28%). Crohn's disease activity index, nutritional risk index, and hemoglobin were significantly correlated with GCS (r = -0.34, 0.39, 0.33; P = 0.007, 0.003, 0.01). Linear regression revealed significant correlations between Crohn's disease activity index, nutritional risk index, and GCS (ß = -0.3, 0.29; P = 0.03, 0.04), independent of depression. This model explained 24% of the variance in GCS. CONCLUSIONS: Cognitive performance is related to CD activity and nutritional status. The results provide insight into potential influence of nutrition and inflammation on cognitive function. Further studies on cognitive function of patients with CD are warranted.

EUS clarifies the natural history and ideal management of GISTs.

BACKGROUND/AIMS: Gastrointestinal stromal tumors (GISTs) are mesenchymal gastrointestinal tumors expressing C-kit (CD117). Endoscopic ultrasonography (EUS) evaluations of GISTs can help determine optimal therapy and follow-up care. The current study assesses the natural history of 100 GISTs evaluated by EUS, and the impact of EUS on their management. METHODOLOGY: Retrospective review of 2600 EUS files performed over 11 years identified 100 patients with GISTs. Relevant data from all appropriate files and interviews with patients or family of deceased patients were tabulated regarding the GISTs. RESULTS: Every GIST had definitive cytology (n=43) or histology. Seventy of the 100 patients underwent more than one evaluation. Size of the GISTs at initial diagnosis averaged 20.5 mm and at follow-up examination 23.2 mm. Fourteen of 70 GISTs showed significant enlargement (> 1 mm/month). Enlargement during follow-up of GISTs was significantly more common with GISTs over 17 mm at initial diagnosis (p<0.018). Thirty-four were excised (7 endoscopically). Clinically asymptomatic GISTs tended to be smaller. Thirteen percent of GIST patients had second primary malignancy. CONCLUSIONS: EUS elucidates GIST natural history and can help guide management. GISTs larger than 17 mm should be monitored by EUS and considered for more aggressive treatment. Searching for synchronous tumors in patients with GISTs should be considered.

The impact of endoscopic ultrasonography on the management of suspected pancreatic cancer--a comprehensive longitudinal continuous evaluation.

OBJECTIVES: Between 1997 and 2001, a single-center chart review demonstrated significant impact of endoscopic ultrasonography (EUS) in evaluating suspected pancreatic cancer (PCA). Repeating and comparing this review with that from 2001 to 2004 was performed to determine whether increased use of EUS results in more patients being accurately chosen for curative versus palliative procedures, and for surgical versus nonsurgical oncotherapy. METHODS: The complete systematic review was made up of electronic files from the gastroenterology, oncology, and pathology departments of patients presenting with suspected PCA. Results were compared with those obtained in 1997-2001. RESULTS: From 2001 to 2004, 72 patients had PCA. Seven tumor types were identified. Forty-seven percent (34/72) of patients with suspected PCA were preoperatively staged by EUS; 24% (17/72) of all patients underwent surgery. Comparatively, from 1997 to 2001, only 32% (20/62) of patients were evaluated by EUS (P = 0.056) and 45% (28/62) of all patients underwent surgery (P < 0.01). The EUS detected a tumor in 32 of 34 cases. The EUS-guided fine-needle aspiration cytology identified PCA in 14 of 18 cases. F-18-deoxyglucose-positron emission tomography and magnetic resonance imaging were not used. Endoscopic retrograde cholangiopancreatography was performed in 29% (21/72) of patients, with 15 stents inserted. CONCLUSIONS: Increased EUS use for diagnosing and staging PCA resulted in fewer patients undergoing futile surgery. The EUS plays a pivotal role in the management of patients with PCA.

Obstructing gastric heterotopic pancreas: case report and literature review.

Heterotopic pancreas (HP) is generally an asymptomatic lesion and is a rare cause of gastric outlet obstruction. We report such a case in which both upper gastrointestinal series and abdominal computerized tomography (CT) demonstrated an antral mass; surgical and histological results are also reported.