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1.
Gargiulo A Barbaro F Valentini GB Caserta G Gargiulo A Manzi F Mereu A Occhigrossi G Pinto L Schiavone M 《Minerva chirurgica》1998,53(12):965-971
BACKGROUND: Severe acute pancreatitis are still dangerous, as can be seen from the high mortality rate (around 30%). It's commonly known that in the last years diagnostic ability, precise stadiation and control over the disease development were increased. Surgical therapy is directed mainly to achieve the control over septic evolution, and in biliary pancreatitis to resolve hypertension and infection inside the biliary tree (now widely accepted as the real cause of this disease). Recently, some authors demonstrated that the prognosis of a pancreatitis can be greatly improved by stopping the evolution toward a severe phase with necrosis and multiple organ failure without any surgical operation. They believe that's possible to achieve this result performing an early endoscopic sphincterotomy in all biliary pancreatitis (recognised by means of echography and CT scan), before the development of necrosis. METHODS: In our department, following this address, very good results have been obtained: that's why a multicentric trial has been carried out to appraise the results obtained by endoscopic sphincterotomy within 48 hours from the disease onset. Answers from 114 hospitals were received, with a total survey of more than 10,000 pancreatitis. Endoscopic sphincterotomy was performed in 55% of billiary pancreatitis, which were estimated at the onset, on second or third degree of Balthazar classification. RESULTS: In 86% of patients, endoscopic sphincterotomy was performed within 48 hours from symptoms onset. Complications related to this treatment are reported in less than 4% of patients. CONCLUSIONS: The procedure, avoiding the evolution toward necrosis and sepsis, allowed the reduction of surgical operations to 6.7%, and of the mortality amongst all cases gathered to 2.5%. 相似文献
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Endoscopic sphincterotomy for the treatment of gallstone pancreatitis during pregnancy 总被引:1,自引:2,他引:1
Background: Gallstones are the most common cause of acute pancreatitis during pregnancy. Without intervention, gallstone pancreatitis
during pregnancy is associated with an antepartum recurrence rate of 70%, which exposes the mother and fetus to an increased
risk of morbidity and mortality. A safe, effective means to prevent recurrent gallstone pancreatitis during pregnancy is desirable.
Methods: Since 1991, we have managed gallstone pancreatitis in three pregnant patients with endoscopic retrograde cholangiogram (ERC),
followed by spincterotomy, despite the absence of common bile duct stones.
Results: All patients were judged to have mild pancreatitis by modified Ranson criteria and the Multiorgan System Failure criteria.
During cholangiogram, fetal shielding was employed and fluoroscopy times ranged from 36 s to 7.2 min. One patient experienced
postprocedure pancreatitis of 48-h duration. None of the patients experienced further episodes of pancreatitis and none underwent
predelivery cholecystectomy.
Conclusions: In pregnancy-associated gallstone pancreatitis, endoscopic sphincterotomy prevents recurrence of pancreatitis and the need
for cholecystectomy during gestation. We believe endoscopic sphincterotomy represents a promising management alternative for
gallstone pancreatitis during pregnancy. Further investigation is warranted.
Received: 30 December 1996/Accepted: 12 September 1997 相似文献
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S van der Spuy 《Suid-Afrikaanse tydskrif vir geneeskunde》1991,79(1):16-18
An approach to suspected gallstone pancreatitis based on endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) was adopted in 1976 and was followed in 29 patients. ERCP became the routine method of early biliary tract assessment when gallstone pancreatitis was suspected on clinical and biochemical grounds, and further management was based on ERCP findings. If calculi were detected in the common bile duct (13 cases) ES was performed; when calculi were confined to the gallbladder (12 cases) cholecystectomy was advised; and if no calculi were detected on ERCP (4 cases) investigations were continued. ERCP proved to be a reliable guide to management, while ES provided safe and effective symptomatic relief when choledocholithiasis was present, and prevented recurrence of pancreatitis even when the gallbladder remained in situ. 相似文献
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ERCP findings and the role of endoscopic sphincterotomy in acute gallstone pancreatitis 总被引:2,自引:0,他引:2
J P Neoptolemos D L Carr-Locke N London I Bailey D P Fossard 《The British journal of surgery》1988,75(10):954-960
A total of 131 patients with acute pancreatitis (of whom 100 had gallstones) underwent endoscopic retrograde cholangiopancreatography (ERCP) during the same hospital admission. Urgent ERCP (less than 72 h) was performed in 68 cases and early ERCP (3-30 days) in 63 cases; 47 had predicted severe attacks and 84 had predicted mild attacks (modified Glasgow criteria). The highest incidence of common bile duct stones occurred in those with predicted severe attacks and those who had urgent ERCP. Highly significant correlations were found between age and common bile duct and pancreatic duct diameters. Significant correlations were also found between the common bile duct and pancreatic duct (correcting for age) and between these and the admission serum bilirubin. The common bile duct diameter was greatest in those with common bile duct stones and predicted severe attacks. A considerably lower incidence of pancreatic duct filling occurred in those with predicted severe attacks and common bile duct stones; in predicted mild attacks the pancreatic duct diameter was greater in those with common bile duct stones. In gallstone patients complications were highest in those with predicted severe attacks but more significantly in those with common bile duct stones. Endoscopic sphincterotomy was undertaken in 37 patients with common bile duct stones without mortality. The overall complication rate in gallstone patients was 19 per cent and the mortality rate was 2 per cent. These findings suggest that common bile duct stones cause acute common bile duct and pancreatic duct obstruction and are closely associated with complications. Urgent ERCP for detection of common bile duct stones, and endoscopic sphincterotomy for treatment, is strongly recommended for patients with predicted severe attacks due to gallstones and should also be considered for others who fail to show clinical improvement. 相似文献
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T. Ryan Heider M.D. Alphonso Brown M.D. Ian S. Grimm M.D. Kevin E. Behrns M.D. 《Journal of gastrointestinal surgery》2006,10(1):1-5
Patients with moderately severe gallstone pancreatitis with substantial pancreatic and peripancreatic inflammation, but without
organ failure, frequently have an open cholecystectomy to prevent recurrent pancreatitis. In these patients, prophylactic
endoscopic retrograde cholangiography (ERC) with endoscopic sphincterotomy (ES) may prevent recurrent pancreatitis, permit
laparoscopic cholecystectomy, and decrease risks. The medical records of all patients with pancreatitis undergoing cholecystectomy
from 1999–2004 at the University of North Carolina Memorial Hospital were reviewed. Data regarding demographics, clinical
course, etiology of pancreatitis, operative and endoscopic interventions, and outcome were extracted. Moderately severe gallstone-induced
pancreatitis was defined as pancreatitis without organ failure but with extensive local inflammation. Thirty patients with
moderately severe gallstone pancreatitis underwent ERC and ES and were discharged before cholecystectomy. Mean interval between
ES and cholecystectomy was 102 ± 17 days. Cholecystectomy was performed laparoscopically in 27 (90%) patients, open in three
(10%) patients, and converted to open in two (7%) patients, with a morbidity rate of 7% (two patients). No patient required
drainage of a pseudocyst or developed recurrent pancreatitis. Interval complications resulted in hospital readmission in seven
(23%) patients. In conclusion, recurrent biliary pancreatitis in patients with moderately severe gallstone pancreatitis is
nil after ERC and ES. Hospital discharge of these patients permits interval laparoscopic cholecystectomy, but close follow-up
is necessary in these potentially ill patients.
Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18,
2005 (poster presentation). 相似文献
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F C Chen D A Hill T B Hugh B Li A P Meagher 《The Australian and New Zealand journal of surgery》1991,61(2):161-162
The use of minimally invasive techniques of removing gallstones, and the gall-bladder, is an attractive option for patients who may be severely ill with pancreatitis. We describe here a patient with gallstone pancreatitis who was managed completely by endoscopic techniques consisting of endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy. 相似文献
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J P Neoptolemos N London N D Slater D L Carr-Locke D P Fossard A R Moosa 《Archives of surgery (Chicago, Ill. : 1960)》1986,121(6):697-702
From a consecutive series of 112 patients with acute pancreatitis, 70 patients with suspected gallstones were randomized to urgent endoscopic retrograde cholangiopancreatography (ERCP) (less than 72 hours) and endoscopic sphincterotomy (ES) if choledochal stones were present (n = 35), or to conventional treatment (n = 35). Endoscopic retrograde cholangiopancreatography, successful in 89% of cases, indicated choledochal stones in 11 patients, all of whom underwent successful stone retrieval by ES. Later during hospital admission, ERCP was performed in 13 more patients and choledochal calculi were extracted from two patients by ES. No complications were attributable to ERCP or ES. Two patients died of biliary pancreatitis; both had been conventionally treated and may have benefited from urgent ERCP/ES. Our experience, which extends to another 24 patients with ERCP and ten with ES during acute pancreatitis, indicates that these are safe techniques and deserve wider consideration in the management of acute pancreatitis. 相似文献
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BACKGROUND: UK guidelines for gallstone pancreatitis (GSP) advocate definitive treatment during the index admission, or within 2 weeks of discharge. However, this target may not always be achievable. This study reviewed current management of GSP in a university hospital and evaluated the risk associated with interval cholecystectomy. METHODS: All patients that presented with GSP over a 4-year period (2002-2005) were stratified for disease severity (APACHE II). Patient demographics, time to definitive therapy [index cholecystectomy; endoscopic sphincterotomy (ES); Interval cholecystectomy], and readmission rates were analysed retrospectively. RESULTS: 100 patients admitted with GSP. Disease severity was mild in 54 patients and severe in 46 patients. Twenty-two patients unsuitable for surgery underwent ES as definitive treatment with no readmissions. Seventy-eight patients underwent cholecystectomy, of which 40 (58%) had an index cholecystectomy, and 38 (42%) an interval cholecystectomy. Only 10 patients with severe GSP had an index cholecystectomy, whilst 30 were readmitted for Interval cholecystectomy (p = 0.04). The median APACHE score was 4 [standard deviation (SD) 3.8] for index cholecystectomy and 8 (SD 2.6) for Interval cholecystectomy (p < 0.05). Median time (range) to surgery was 7.5 (2-30) days for index cholecystectomy and 63 (13-210) days for Interval cholecystectomy. Fifty percent (19/38) of patients with GSP had ES prior to discharge for interval cholecystectomy. Two (5%) patients were readmitted: with acute cholecystitis (n = 1) and acute pancreatitis (n = 1) , whilst awaiting interval cholecystectomy. No mortality was noted in the Index or Interval group. CONCLUSIONS: This study demonstrates that overall 62% (22 endoscopic sphincterotomy and 40 index cholecystectomy) of patients with GSP have definitive therapy during the Index admission. However, surgery was deferred in the majority (n = 30) of patients with severe GSP, and 19/30 underwent ES prior to discharge. ES and interval cholecystectomy in severe GSP is associated with minimal morbidity and readmission rates, and is considered a reasonable alternative to an index cholecystectomy in patients with severe GSP. 相似文献
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Xin Zhao Da-Zhi Chen Ren Lang Zhong-Kui Jin Hua Fan Tian-Ming Wu Xian-Liang Li Qiang He 《Surgery today》2013,43(6):643-647
Purpose
The aim of this study was to establish enhanced recovery protocols for the management of mild gallstone pancreatitis.Methods
Sixty consecutive patients were divided into enhanced recovery and traditional recovery (TR) groups in a randomized observational study. The basic enhanced recovery elements included early laparoscopic cholecystectomy, restrictive endoscopic intervention, and early oral nutrition. The incidence of complications, readmission, length of stay, and total medical cost were analyzed during the hospital course.Results
The length of hospital stay and medical cost were significantly lower in the enhanced recovery group in comparison to the TR group: 5.9 days vs. 10.6 days (P < 0.01) and ¥10,023 vs. ¥15,035 (P < 0.01). The complications and readmission rates in the two groups were similar.Conclusions
The implementation of enhanced recovery protocols is feasible in the management of mild gallstone pancreatitis. The utilization of these protocols can achieve shorter hospital stays and reduced costs, with no increase in either the re-admission or peri-operative complication rates. 相似文献13.
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Routine early endoscopic cholangiography, sphincterotomy and removal of common duct stones in acute gallstone pancreatitis. 总被引:1,自引:0,他引:1
OBJECTIVE--To study the efficacy, safety and timing of endoscopic retrograde cholangiography (ERC) and sphincterotomy in patients with acute gallstone pancreatitis. DESIGN--Open study in Tampere University Hospital, Finland. SUBJECTS--45 consecutive patients with acute gallstone pancreatitis who underwent ERC, with or without sphincterotomy. MAIN OUTCOME MEASURES--The results of early, compared with late, ERC with or without sphincterotomy. RESULTS--ERC was successful in all 45 patients. Ampullary impacted stone was found in eight. Common duct stones were found in 21 (47%) and sphincterotomy was successful in 19 of these (90%). Nine patients developed complications (20%), five of the nine in whom severe disease had been predicted (56%) and four of the 36 in whom mild disease had been predicted (11%, p < 0.01). Three patients required operations for necrotising pancreatitis, in two of whom sphincterotomy had failed. There was no difference in outcome between the 21 patients who had ERC with or without sphincterotomy within 72 hours (median 48 h) of the onset of symptoms and the 24 in whom it was delayed for a median of 144 hours. CONCLUSION--ERC and sphincterotomy may be done safely as a routine in patients with acute gallstone pancreatitis, and delay for a median of six days (range 3-14) from the onset of symptoms did not seem to affect the outcome in our patients. 相似文献
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S van der Spuy 《Suid-Afrikaanse tydskrif vir geneeskunde》1991,79(1):19-20
Seven patients with gallstone pancreatitis discovered at diagnostic laparotomy did not undergo definitive biliary surgery because it was considered hazardous in the presence of severe acute pancreatitis. The procedures carried out at operation in these cases included cholecystectomy and T-tube drainage (2 patients) cholecystostomy drainage (3 patients), and closure of the abdomen without drainage (2 patients). Direct cholangiography was carried out postoperatively in all cases. The biliary drain was used for this purpose in 5 patients, and endoscopic retrograde cholangiopancreatography was performed in 2. All patients were found to have calculi in the common bile duct and were successfully managed by endoscopic sphincterotomy (ES) without complications or mortality. ES therefore appears to be a safe and effective method of avoiding difficult and hazardous biliary surgery in the presence of severe acute pancreatitis. 相似文献
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Rapid-bolus contrast-enhanced dynamic computed tomography in acute pancreatitis: a prospective study. 总被引:4,自引:0,他引:4
N J London T Leese J M Lavelle K Miles K P West D F Watkin D P Fossard 《The British journal of surgery》1991,78(12):1452-1456
The purpose of this prospective study was to determine the clinicopathological significance of necrotic areas demonstrated by rapid-bolus contrast-enhanced computed tomography (CT) in patients with biochemically predicted severe pancreatitis. Although CT necrosis occurred significantly more frequently in patients with clinically severe (ten of 12) compared with mild (seven of 20) pancreatitis (P less than 0.025), seven of 17 (41 per cent) patients with CT necrosis developed clinically mild pancreatitis and six of ten (60 per cent) patients with clinically severe pancreatitis and CT necrosis recovered with conservative management. The site and extent of CT necrosis did not correlate with disease severity. Fine-needle aspiration cytology, operative and post-mortem findings and endoscopic retrograde cholangiopancreatography examinations all strongly suggested that CT necrosis represents true pancreatic necrosis. We conclude that the finding of CT necrosis is not in itself an indication for operative intervention, but that rapid-bolus contrast-enhanced dynamic CT greatly facilitates the planning and execution of surgical therapy. 相似文献
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Wilson RB Warusavitarne J Crameri DM Alvaro F Davies DJ Merrett N 《ANZ journal of surgery》2005,75(3):152-156
BACKGROUND: The aim of the present study was to evaluate the usefulness of the elastase 1 (E1) enzyme-linked immunosorbent assay (ELISA) in the diagnosis of acute pancreatitis. This is the first Australian evaluation of the E1 ELISA. METHODS: Three groups of patients were prospectively assessed: control patients, patients with acute pancreatitis, and patients with acute non-pancreatitic abdominal pain. Serum was collected on all patients on admission and the sensitivity, specificity and diagnostic accuracy of serum elastase, amylase and lipase was determined. RESULTS: Twenty-nine patients with 30 episodes of pancreatitis, 38 patients with acute non-pancreatitic abdominal pain and 121 control patients were studied. For all patient episodes E1 ELISA at a cut-off of 3.5 ng/mL had a sensitivity of 80%, specificity of 96% and an efficiency of 94% in the diagnosis of acute pancreatitis. For episodes more than 48 h after onset of symptoms, sensitivity was 100%, specificity was 96% and diagnostic efficiency was 96%. This performance was equivalent to amylase but inferior to lipase. CONCLUSION: Of the biochemical markers for pancreatitis currently available, lipase is the most useful. The relatively inferior sensitivity and problematic reference range for the ELISA E1, together with its limitations in measuring total elastase, currently prevent its widespread use. 相似文献
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A consecutive series of 614 operative cholangiograms was studied prospectively to determine the relationship of pancreatic-duct reflux to a previous history of acute gallstone pancreatitis. Of 53 patients who had previously had pancreatitis, 33 had pancreatic-duct reflux on their cholangiogram (62.3%), whereas, of 561 patients with no history of pancreatic disease, pancreatic-duct reflux was seen in only 82 (14.6%). In patients with a history of pancreatitis, reflux occurred into a wider pancreatic duct, at a greater angle between the bile and pancreatic ducts, and was associated with a longer functioning common channel. The wider cystic duct, wider common bile duct, and multiple small stones seen in patients with previous pancreatitis and pancreatic-duct reflux were suggestive of gallstone migration being associated with reflux. There was no correlation between pancreatic-duct reflux and the presence of choledochal calculi. Two patients developed recurrent severe pancreatitis after pancreatic-duct reflux of infected bile. Patients with gallstone pancreatitis appear to have an increased tendency for pancreatic-duct reflux that is mechanically facilitated by differences in the choledocho-pancreatic duct anatomy. 相似文献
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Abdalla Mustafa Irena Begaj Mark Deakin Damien Durkin David J. Corless Richard Wilson John P. Slavin 《Surgical endoscopy》2014,28(1):127-133