Successful double bypass in a patient with severe hemophilia A: a case report

Life expectancy in the hemophilia people is similar to the non–haemophilics and age-related cardiovascular disorders to become more prevalent, but cardiac surgery is considered a very high risk for these patients. In this article we report the successful cardiac double bypass internal mammary artery—coronary artery in a patient with severe hemophilia A. (FVIII<1%; missense mutation: exon 16, c.5508 G>A (domain A3), p.Trp1817Stop). Continuous infusion of rFVIII B-domain deleted was used to control haemostasis during surgery and in post-operative period. There was no bleeding complications and the patient did not need to receive transfusion of red blood cells or platelets.     

Endoscopic sphincterotomy plus large-balloon dilation vs endoscopic sphincterotomy for choledocholithiasis:A meta-analysis

AIM:To perform a meta-analysis of large-balloon dilation(LBD)plus endoscopic sphincterotomy(EST)vs EST alone for removal of bile duct stones.METHODS:Databases including PubMed,EMBASE,the Cochrane Library,the Science Citation Index,and important meeting abstracts were searched and evaluated by two reviewers independently.The main outcome measures included:complete stone removal,stone removal in the first session,use of mechanical lithotripsy,procedure time,and procedure-related complications.A fixed-effects model weighted by the Mantel-Haenszel method was used for pooling the odds ratio(OR)when heterogeneity was not significant among the studies.When a Q test or I2statistic indicated substantial heterogeneity,a random-effects model weighted by the DerSimonian-Laird method was used.RESULTS:Six randomized controlled trials involving835 patients were analyzed.There was no significant heterogeneity for most results;we analyzed these using a fixed-effects model.Meta-analysis showed EST plus LBD caused fewer overall complications than EST alone(OR=0.53,95%CI:0.33-0.85,P=0.008);sub-category analysis indicated a significantly lower risk of perforation in the EST plus LBD group(Peto OR=0.14,95%CI:0.20-0.98,P=0.05).Use of mechanical lithotripsy in the EST plus LBD group decreased significantly(OR=0.26,95%CI:0.08-0.82,P=0.02),especially in patients with a stone size larger than 15 mm(OR=0.15,95%CI:0.03-0.68,P=0.01).There were no significant differences between the two groups regarding complete stone removal,stone removal in the first session,post-endoscopic retrograde cholangiopancreatography pancreatitis,bleeding,infection of biliary tract,and procedure time.CONCLUSION:EST plus LBD is an effective approach for the removal of large bile duct stones,causing fewer complications than EST alone.     

Biliary ascariasis complicating endoscopic sphincterotomy for choledocholithiasis in India

Endoscopic sphincterotomy is the treatment of choice for patients with choledocholithiasis. Biliary ascariasis has been reported from many parts of the world but is common in Kashmir, India. We report five cases of biliary ascariasis of which four were the result of post-endoscopic sphincterotomy for choledocholithiasis. Therefore, biliary ascariasis is not an uncommon complication of endoscopic sphincterotomy.     

Delayed hemorrhage following endoscopic retrograde sphincterotomy for choledocholithiasis

To define the clinical significance of delayed postsphincterotomy hemorrhage, we reviewed 476 consecutive ERCP procedures performed over a three-year period. Of 250 patients who underwent endoscopic sphincterotomy (ES), five (2%) developed postprocedure hemorrhage, two of whom had immediate, self-limited bleeding that resolved after endoscopic injection of epinephrine and did not require transfusion. The other three had delayed hemorrhage characterized by: onset 20–48 hr after the procedure, melena without hematemesis as the index clinical manifestation of bleeding, and atraumatic balloon extraction of common duct stones. Transfusion of 2–6 units of packed erythrocytes was necessary in each and one patient required surgical hemostasis. Delayed hemorrhage following ERS is an important, frequently severe complication to remember when contemplating performing ERS as an outpatient procedure.     

内镜下括约肌切开治疗老年胆总管结石的临床应用

目的 探讨内镜下括约肌切开术(EST)对老年胆总管结石患者的治疗价值,并对其安全性进行评估. 方法 回顾性分析4年来105例≥65岁胆总管结石患者进行EST切开取石的成功率和并发症发生率. 结果 取石获得成功102例,取石成功率97.1%.未成功3例,其中插管造影失败2例,因心肺功能异常终止手术1例.术后并发症:急性胰腺炎4例,活动性出血1例,急性胆管炎1例,心律失常1例. 结论 EST治疗老年胆总管结石是一种创伤小、疗效确切、安全系数高的治疗方法,娴熟的内镜操作技术与规范的治疗可以减少并发症的发生.     

Limited endoscopic sphincterotomy plus large balloon dilation for choledocholithiasis with periampullary diverticula

AIM: To investigate the effectiveness and safety of limited endoscopic sphincterotomy (EST) plus large balloon dilation (LBD) for removing choledocholithiasis in patients with periampullary diverticula (PAD). METHODS: A total of 139 patients with common bile duct (CBD) stones were treated with LBD (10-20 mm balloon diameter) after limited EST. Of this total, 73 patients had PAD and 66 patients did not have PAD (controls). The results of stone removal and complications were retrospectively evaluated. RESULTS...     

Safety advantage of endocut mode over endoscopic sphincterotomy for choledocholithiasis

AIM: To evaluate whether an automatically controlled cut system (endocut mode) could reduce the complication rate of endoscopic sphincterotomy (EST) and serum hyperamylasemia after EST compared to the conventional blended cut mode. METHODS: From January 2001 to October 2003, 134 patients with choledocholithiasis were assigned to either endocut mode group or conventional blended cut mode group at the time of sphincterotomy. The two groups were retrospectively compared for the complications after EST and serum amylase level before and 24 h after the procedure. RESULTS: Of the 134 patients treated, 79 were assigned to conventional blended cut mode group and 55 to endocut mode group. There was no significant difference in age, sex, and serum amylase level before EST between the two groups. Complications were found in 5 patients of the endocut mode group (9%): hyperamylasemia (5 times higher than normal) in 4 and moderate pancreatitis in 1. Complications were found in 13 patients of the conventional blended cut mode group (16%): hyperamylasemia in 12 and moderate pancreatitis in 1. Serum amylase levels were elevated in both groups 24 h after EST (P<0.02). The average serum amylase level 24 h after EST in the conventional blended cut mode group was significantly higher than that in the endocut mode group (P<0.05). CONCLUSION: Endocut mode offers a safety advantage over conventional blended cut mode for pancreatitis after EST by reducing hyperamylasemia.     

Long-term follow-up study of patients after endoscopic sphincterotomy for choledocholithiasis

Late complications have been examined in 96 patients consecutively treated for choledocholithiasis by endoscopic sphincterotomy in the years 1976 to 1980. Forty-four of the patients (46%) had the gallbladder in situ. Patients treated for short-term complications--that is, in the 1st month after sphincterotomy--are not included in this study. The mean length of follow-up study was 4.1 years (range, 2 months to 8 years and 9 months). Late bile duct symptoms occurred in seven patients (7%): three (6.8%) in patients with the gallbladder in situ and four (7.6%) in cholecystectomized patients. Stones were found in the common bile duct in three of these patients, one with and two without the gallbladder. The median duration from sphincterotomy to late complication was 8 months (range, 2 months to 5 years). Six of the patients had cholangitis, and the seventh had jaundice with abdominal pain. Two of the patients died of their complications. In conclusion, our results indicate that the frequency of late complications to endoscopic sphincterotomy is low and apparently independent of possible prior cholecystectomy.     

内镜下逆行胰胆管造影加取石术诊治胆总管结石

[目的]评价内镜下逆行胰胆管造影(ERCP)同时行乳头括约肌切开术(EST)对胆总管结石的诊断与治疗价值.[方法]回顾性分析98例经B超检查诊断为胆总管结石的患者,先行ERCP检查,再行内镜下EST治疗胆总管结石.[结果]98例中ERCP准确诊断胆总管结石96例,怀疑胆总管结石1例,未发现异常1例,其确诊率为97.9%.96例EST后采取网篮取石、球囊取石和机械碎石网篮取石成功,1例失败.[结论]ERcP对胆总管结石诊断价值较高.EST是一种治疗胆总管结石安全、有效、简便的方法.     

Gallbladder motility and lithogenicity of bile in patients with choledocholithiasis after endoscopic sphincterotomy

Background/Aims: Ablation of the sphincter of Oddi has been shown to inhibit gallstone formation in the prairie dog model, probably by allevaiting gallbladder bile stasis. The effect of endoscopic sphincterotomy (ES) on gallbladder emptying and lithogenicity of bile has not been studied adequately in humans. We, therefore, studied the changes in gallbladder emptying and lithogenicity of bile following ES in patients with choledocholithiasis and gallbladder in situ.Methods: Thirteen patients with choledocholithiasis with intact gallbladder underwent ES and common bile duct clearance. Eight patients had concomitant gallstones. Gallbladder emptying was studied by real time ultrasonography after stimulation by ceruletid infusion. Fasting gallbladder bile was collected during endoscopic retrograde cholangiography by placing a 7F or 8F catheter in the common bile duct and after ceruletid stimulation of gallbladder for bile microscopy and cholesterol nucleation time determination. Gallbladder emptying, nucleation time and bile microscopy were performed before ES and again between 4 and 8 weeks after ES after cholangiographic confirmation of clearance of common bile duct stones.Results: Fasting and residual gallbladder volumes decreased and ejection fraction increased significantly following ES, suggesting decreased stasis and improved emptying of gallbladder. Nucleation time was prolonged and cholesterol crystal index in bile decreased after ES, suggesting decreased lithogenicity. The decrease in gallbladder volumes and increase in ejection fraction after ES were observed in both groups of patients, with or without concomitant gallstones.Conclusions: ES decreases the stasis of gallbladder bile, improves gallbladder emptying and decreases the lithogenicity of bile in patients with gallstone disease as reflected by prolongation in nucleation time. ES may find a role as an adjunct to oral bile acid therapy and extracorporeal shock wave lithotripsy in addition to a prophylactic role of preventing gallstone formation in high risk groups.     

Successful multi-vessel percutaneous coronary intervention with bivalirudin in a patient with severe hemophilia A: a case report and review of literature

We describe a 64-year-old male with severe hemophilia A (factor VIII-dependent), acute myocardial infarction (MI) and congestive heart failure (CHF) who underwent successful multi-vessel percutaneous coronary intervention (PCI). The patient was administered factor VIII transfusion to maintain activity levels between 60-80%. Anticoagulation during the PCI procedure was maintained with the direct thrombin inhibitor, bivalirudin. There were no procedural complications and the patient was discharged home the following day. These results suggest that bivalirudin may be used effectively in patients at very high risk of bleeding with enhanced procedural safety.     

Endoscopic papillary balloon dilatation versus endoscopic sphincterotomy in the treatment for choledocholithiasis: a meta-analysis

Background and Aim: Endoscopic papillary balloon dilatation (EPBD) and endoscopic sphincterotomy (EST) are two common nonsurgical treatments endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. The aim of this study was to compare the efficacy and safety of EPBD and EST in the treatment for choledocholithiasis, confining the analysis to work reported in the last decade. Methods: The rate of overall postoperative complications was chosen as the primary outcome, and 10 other outcomes were secondary outcomes. Relative risk (RR) or Peto odds ratio (OR) were computed as the measures of pooled effects. We planned sensitivity analyses a priori for examining the change in robustness of the sensitivity to excluding studies with some inappropriate objects, technique defects or without full‐text acquisition. Results: For complete stone removal, EPBD was similar to EST (95% vs. 96%, P = 0.36) and overall postoperative complications (14.0% vs. 11.7%, P = 0.53). The incidence of post‐ERCP cholangitis (2.5% vs. 1.8%, P = 0.40), basket impaction (0.9% vs. 0%, P = 0.16) and perforation (0.0% vs. 0.4%, P = 0.17) were equivalent between EPBD and EST. On the other hand, EPBD caused more post‐ERCP pancreatitis (PEP) (9.4% vs. 3.3%, P < 0.00001), but less hemorrhage (0.1% vs. 4.2%, P < 0.00001). People undergoing EPBD required more use of endoscopic mechanical lithotripsy (35.0% vs. 26.2%, P = 0.0004). The results of sensitivity analyses showed no substantial change. Conclusion: EPBD is comparable to EST for stone extraction, though it requires more endoscopic mechanical lithotripsy (EML). EPBD may outweigh EST for patients with coagulopathy; however, it may cause more PEP.     

Recurrence of biliary symptoms after endoscopic sphincterotomy for choledocholithiasis in patients with gall bladder stones

BACKGROUND: There are a few reports regarding the long-term results of endoscopic sphincterotomy (EST). However, little data is available on the recurrence of biliary symptoms after EST for choledocholithiasis, in patients with gall bladder stones. METHODS: All patients had gall bladder and common bile duct stones (n = 60; age 32-84 years, median age 55 years), and had received an EST. One group of these patients had a laparoscopic or open cholecystectomy (n = 39; group A), while the other group did not (n = 21; group B). The follow-up- period ranged from 5 to 54 months (average 22 months). RESULTS: Complications included the recurrence of common bile duct stones, recurrent acute cholecystitis, postoperative bile leakage and papillary stenosis. Nine patients (15%) had a recurrence of biliary symptoms. Two significant prognostic factors for the recurrence of biliary symptoms were identified by multivariate analysis; namely an intact gall bladder and a dilated common bile duct. The recurrence rate of biliary symptoms in group B was 20.4%, while in group A it was 10.3% (P< 0.01). Patients with a larger than average common bile duct diameter (mean diameter 14 mm) were more prone to the recurrence of symptoms than those with a smaller common bile duct diameter (mean diameter 10 mm, P< 0.016). The hospital stay period was 8.9 +/- 3.1 days in group A and 2.8 +/- 1.9 days in group B (P< 0.01). CONCLUSIONS: Biliary symptom recurrence occurred in a considerable proportion of patients after EST for the treatment of choledocholithiasis, in patients with gall bladder stones. The prognostic factors associated with the recurrence of biliary symptoms were an intact gall bladder and a dilated common bile duct diameter. Regardless of their short stay in hospital, non-cholecystectomy patients had a higher rate of recurrent biliary symptoms than cholecystectomy patients.     

Recurrent choledocholithiasis following cholecystectomy,sphincterotomy and choledochoduodenostomy: Successful treatment with chenodeoxycholic acid

An elderly woman presented with recurrent choledocholithiasis. She had had three prior surgical procedures on the biliary tract, including a cholecystectomy with common duct exploration, a second common duct exploration with choledocholithotomy and sphincteroplasty, and subsequently a third common duct exploration with choledochoenterostomy. She refused further surgical therapy and chenodeoxycholic acid therapy was instituted. Within six months, there was partial dissolution of the gallstones. One year later, the stones were no longer demonstrable, and the patient was symptom-free. The potential role of chenodeoxycholic acid therapy, endoscopic papillotomy and postoperative extraction of common duct stones via the T-tube tract, using a Dormia basket, as alternates to surgical therapy of recurrent or retained gallstones are discussed.