Optimal irrigation pressures in operative choledochoscopy

A prospective study was conducted on 20 consecutive patients who underwent elective exploration of common bile-ducts for stones to determine the optimal irrigation pressures in choledochoscopy. Ten patients had rigid choledochoscopy and 10 patients had flexible choledochoscopy. Choledochoscopic views were assessed at low irrigation pressure (irrigant delivered at hydrostatic pressure of 1 m of water or 80 mmHg) and high irrigation pressure (irrigant delivered at cuff pressure of 300 mmHg plus hydrostatic pressure of 80 mmHg). Choledochoscopic views were better with high than low irrigation pressures for rigid choledochoscopy. However, there was little difference in the views for flexible choledochoscopy. Common bile-duct pressures were measured with irrigant delivered at pressures 80-380 mmHg at intervals of 50 mmHg. With increasing irrigation pressures, the common duct pressures rose and they were consistently higher in flexible than rigid choledochoscopy. The common duct pressures in rigid choledochoscopy never exceeded the recommended safety limit, even at the high irrigation pressure of 380 mmHg. With flexible choledochoscopy, the common duct pressure was below the recommended safety limit only with low irrigation pressure of 80 mmHg. Therefore, it is recommended that a high irrigation pressure of 380 mmHg for rigid choledochoscopy and a low irrigation pressure of 80 mmHg for flexible choledochoscopy be used.     

Operative choledochoscopy in patients with acute cholangitis: a prospective, randomized study

A prospective, randomized evaluation of operative choledochoscopy was carried out during emergency surgery in patients with acute cholangitis or acute suppurative cholangitis when conservative management had failed. After common bile duct exploration, 79 patients were randomized to have choledochoscopy and 78 patients to the control group. Laboratory and clinical parameters showed that choledochoscopy did not increase the incidence of septicaemia, acute pancreatitis, persistent cholangitis, postoperative wound sepsis, intraperitoneal sepsis and hospital mortality. The incidence of retained common bile duct stones detected by T tube cholangiography performed in the second postoperative week was significantly reduced (P less than 0.01) after choledochoscopy. Choledochoscopy detected stones missed by conventional common bile duct exploration in ten patients. It is concluded that choledochoscopy is a safe and effective technique in patients with acute cholangitis and acute suppurative cholangitis.     

Incidence of complications with operative choledochoscopy

A 5 year retrospective study of the use of cholangioscopy in 153 difficult biliary cases including stones, strictures, tumors, and anomalies has been reported. In the 88 patients (58 percent) who underwent both operative cholangiography and cholangioscopy, the cholangioscope revealed 11 lesions (13 percent) missed by cholangiography. In this series, eight retained stones (5.2 percent) were detected on postoperative T-tube cholangiography; of this group, two patients had previous biliary surgery, two had an associated neoplasm, and four had incomplete cholangioscopy for various reasons. Postoperative complications included transient bile drainage (8 percent), pancreatitis (8 percent), persistent jaundice (7 percent), cholangitis (5 percent), and abscess (5 percent). Comparison of an operative cholangiography-only group with a cholangioscopy-only group revealed no significant difference in the incidence of postoperative complications. Cholangioscopy did not increase postoperative complications in this study. It frequently detected lesions missed by cholangiography and helped define the nature of the lesions. The incidence of retained stones may be reduced by use of the cholangioscope in difficult biliary cases. Its routine use in common bile duct exploration is recommended.     

Operative common bile duct imaging by operative cholangiography and flexible choledochoscopy.

A consecutive series of 108 common bile duct (CBD) explorations was studied to examine the efficacy of routine operative cholangiography and flexible choledochoscopy in the identification of choledocholithiasis. CBD exploration was performed according to the findings of routine operative cholangiography. Nine negative explorations were performed, only one of which would have been avoided had selective cholangiography been employed. Eight patients had unsuspected choledocholithiasis that would have been missed if selective operative cholangiography had been used. Flexible choledochoscopy identified CBD stones on 97 occasions; no additional retained stones were found on subsequent T tube cholangiography. In two cases stones were seen but could not be removed; immediate identification allowed planning for early removal. Flexible choledochoscopy is the most effective method of CBD exploration and should be used in all patients with suspected choledocholithiasis.     

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目的 探讨重症急性胆管炎（ACST）病人的死亡原因及手术时机。方法 回顾性分析48例ACST病人的治疗及预后情况。结果 死亡6例,其中手术治疗死亡3例。早期大剂量应用地塞米松治疗的病人休克得到纠正率（80%,12/15）,明显高于未用地塞米松的病人（50%,4/8）。结论 ACST病人应在出现五联征之前手术,对于已出现休克的病人,应先给予适当的保守治疗,病情稳定后再手术,贻误手术时机、严重并发症、高龄是死亡的主要原因;应早期大剂量应用地塞米松治疗 ACST。     

Kawasaki disease manifesting with acute cholangitis. A case report.

A 3-year-old boy, who developed the signs and symptoms characteristic of Kawasaki disease, is described. The child also had an 8 cm tender hepatomegaly. Hydrops of the gallbladder could not be shown. Liver biopsy showed marked infiltration of inflammatory cells, including neutrophil and eosinophil leucocytes in the portal tracts involving the periphery of the portal arteries and veins, and acute inflammation of the bile ducts with neutrophil and eosinophil infiltration of the walls. Overt cholangitis has been described only once before in Kawasaki disease, when a viral agent was suggested as being important in the pathogenesis. Although the clinical and laboratory findings in cases of Kawasaki disease clearly suggest an acute infection--as they did in this case--no aetiological agent has yet been incriminated. The possibility of a drug-induced auto-allergic or hypersensitivity state is considered. Evidence for such a state includes a history of drug administration, pathological findings similar to peri-arteritis nodosa--a condition often associated with a hypersensitivity state--the presence of eosinophils in the lesions and a response to treatment with aspirin, a drug known to ameliorate hypersensitivity states.     

肝内胆管结石并局部胆管炎症改变42例胆道镜和病理分析

目的探讨肝内胆管结石并局部胆管炎改变的胆道镜和病理改变及临床意义。方法2002年1月-2007年4月间肝内胆管结石经胆道镜检查确诊局部胆管炎改变42例，将同期入院的38例胆总管结石并胆管炎患者作为对照组，分析其临床表现、实验室检查、胆道镜下观察和病理改变。结果肝内胆管结石并局部胆管炎症组与对照组在年龄组成、性别比例和围手术期谷草转氨酶（AsT）、谷丙转氨酶（ALT）两者差别无统计学意义，但其在右上腹痛和黄疸者比例以及术后总胆红素（TB）水平及直接胆红素（DB）水平均低于对照组（P〈0.05）。局部胆管炎改变表现为I-V型病理改变。结论在肝内胆管结石病中，存在局部胆管炎改变，并随炎症浸润加深致肝局部纤维化胆管狭窄，引起肝内胆管结石的发生和复发。控制局部胆管炎症，在其限于黏膜层时，可避免胆管炎进一步发展致引起胆管狭窄，则可能预防肝内胆管结石的发生和复发，从而提高肝内胆管结石的远期治疗效果。     

Clinical evaluation and treatment in elderly patients with acute obstructive suppurative cholangitis

Elderly patients with acute obstructive suppurative cholangitis (AOSC) have a very poor prognosis due both to the gradual development of symptoms and to acute exacerbation, resulting in a condition that is both severe and irreversible. In this study, we evaluated the clinical characteristics and effects of biliary drainage in patients with AOSC treated in our department, with special attention being focused on patients aged 70 years or more. Of 21 patients with AOSC, 7 (33.3%) were more than 70 years of age. All 7 had choledocholithiasis. In all patients with choledocholithiasis, in this study. AOSC was observed in 23.3% of those who were more than 70 years of age (7/30). In elderly patients with AOSC, typical symptoms are often absent, and the severity of the disease is difficult to determine based on the results of examination alone. Since early diagnosis of AOSC and appropriate biliary drainage from the onset of AOSC are extremely important, clinical findings should be examined with the utmost care.     

经胆囊管胆道镜胆道探查技术探讨

目的 探讨胆道镜技术在胆总管探查术中的应用。方法 对46例胆道疾病患者，术中胆囊切除后，行经胆囊管胆道镜胆道探查。结果 成功进行肝内胆管，肝胆管，胆总管和壶腹部全部检查的有41例，5例患者仅施行胆总管和壶腹部的检查。46例中有32例自肝内外胆管中取出1－5枚大小不等的结石，患者术后均恢复良好。结论 胆道镜操作简单，易被外科医生掌握，经胆囊管行胆道检查和治疗，可以减轻患者的痛苦，减少医疗费用，减少患者的住院天数，具有推广价值。     

Factors in management of acute cholangitis

Ninety episodes of acute cholangitis in 66 patients have been analyzed. In 71% of the episodes, an operation was performed. Eight deaths occurred, for a patient mortality rate of 12%. Sixty-seven per cent of the operations were performed after at least 72 hours of antibiotic therapy, whereas only 17% had to be done as life-threatening emergencies within 24 hours of admission to the hospital. Although 86% of the operative deaths occurred in the group operated on more than 72 hours after admission, this was not statistically significant. However, death did correlate with failure to respond to antibiotic therapy (p less than 0.001) irrespective of time of operation. Biliary cancer and congenital lesions were etiologic for 31% of the operative cases in this series, but were responsible for 71% of the postoperative deaths (p less than 0.05). We conclude that acute cholangitis has a wide spectrum of severity and that most cases will respond to antibiotic therapy, affording the surgeon the luxury of operating in an elective fashion. Moreover, acute cholangitis complicated by failure to respond to antibiotic therapy is more likely to occur in biliary cancer and congenital lesions, and subsequently will have a poorer prognosis.     

Surgical treatment of acute suppurative cholangitis. Our experience

The results obtained in 13 cases of acute suppurative cholangitis are reported, stress being laid on the seriousness of the pathology and the need for emergency surgical treatment.     

Risk factors and classification of acute suppurative cholangitis.

A prospective study was performed in 1282 patients with common bile duct stones to determine the clinical and laboratory parameters that could predict cholangitis, and the factors associated with greater severity of cholangitis. Patients were divided into two groups, with or without acute cholangitis, depending on the macroscopic appearance of bile aspirated from the common bile duct during surgery. Acute cholangitis was diagnosed when the aspirated fluid was turbid or clearly pus; the typical Charcot's triad was present in only 22 per cent of patients with acute cholangitis. Several clinical and laboratory parameters were significantly more common in these patients and, depending on their number, the probability of acute cholangitis increased significantly. The operative mortality rate was 1.2 per cent for patients without cholangitis and 11.9 per cent for patients with cholangitis. Depending on the number of factors present, patients with cholangitis were divided into three groups: mild acute cholangitis without mortality; moderate acute cholangitis with a mortality rate of 5.6 per cent; and severe acute cholangitis with a mortality rate of 27.5 per cent. The present classification allows the group of patients needing prompt endoscopic or surgical drainage to be identified.     

Pathophysiology of acute obstructive cholangitis

Because acute obstructive cholangitis is life-threatening, understanding of the pathophysiology of this disease is required to establish a medical treatment. Experimental results indicate that obstruction of the bile duct itself does not induce acute cholangitis, but infection of gut-derived bacteria such asEscherichia coli into the bile triggers fatal septicemia, which leads to liver injury and renal failure. In obstructive cholangitis, functional changes in sinusoidal lining cells are often seen. Mediators produced by Kupffer cells, endothelial cells, and stellate cells may modulate inflammatory reactions especially in the periportal area of bile duct ligated animals. In addition, proliferation of bile duct epithelial cells is induced by bile duct ligation. Recently, nitric oxide has been recognized as an important mediator of multiple organ failure. Actually, when bile duct ligated animals are treated with endotoxin, metabolites of nitric oxide in blood and plasma increase, indicating that nitric oxide may take part in the pathophysiology of acute obstructive cholangitis.     

急性重症胆管炎的治疗

目的　探讨提高急性重症胆管炎 (ACST)外科治疗效果的方法。方法　对我院189例ACST病人的临床资料进行回顾性分析。结果　术前休克得到纠正者 117例 ,死亡 6例 ,死亡率 5 1% ;未得到纠正者 72例 ,死亡 2 0例 ,死亡率 2 7 8% (P <0 .0 1)。术前休克未得到纠正而又及时手术治疗 5 6例 ,死亡 6例 ,死亡率 10 7% ;未及时手术治疗 16例 ,死亡 14例 ,死亡率 87 5 % (P <0 .0 1)。本组病例中单一器官累及者 31例 ,无死亡病例 ;2个器官累及者 5 8例 ,死亡 1例 (1 7% ) ;3个器官累及者 84例 ,死亡 9例 (10 7% ) ;4个或 4个以上器官累及者 16例 ,全部死亡 (10 0 % )。结论　积极进行快速有效的抗休克治疗 ,适时的手术时机选择 ,防治多系统器官功能衰竭 (MOF)是提高ACST治疗效果的关键。     

Non operative management of acute extradural hematomas in children.

The Authors have reported a series of 15 patients with acute epidural hematomas (EDHs) that were not evacuated surgically. These EDHs were diagnosed 6 hours after injury and were followed by serial CT scanning. All patients showed resolution of the hematoma on CT scanning over a period of 2 to 5 weeks. Factors that influence outcome of medical treatment have been discussed.     

Systemic inflammatory response in acute cholangitis and after subsequent treatment.

OBJECTIVE: To measure the concentrations of endotoxin and inflammatory mediators during an attack of acute cholangitis and see what effect endoscopic treatment had on these mediators. DESIGN: Prospective study. SETTING: University teaching hospital The Netherlands. SUBJECTS: Ten patients with acute cholangitis. INTERVENTIONS: Measurements were made during the attack and 1 week after endoscopic treatment. MAIN OUTCOME MEASURE: Changes in clinical variables, and severity of biliary obstruction. Concentrations of endotoxin, cytokines, and endotoxin binding proteins, in plasma. RESULTS: The causes of cholangitis were obstructed endoprosthesis (n = 4) and stones (n = 6). The median bilirubin concentration during the attack was 70.0 micromol/L (range 14-156) and 14.5 micromol/L (range 9-80) after treatment (p < 0.05). Median (range) plasma endotoxin concentrations were 3.6 pg/ml (3.2-107) and 3.6 (2.4-5), respectively. Concentrations of cytokines were high during the acute attack and significantly lower after treatment: median tumour necrosis factor (TNF) fell from 44.6 pg/ml (range 1.2-403) to 7.3 (0-53); soluble TNF receptor p55 from 4.9 ng/ml (2.7-13.8) to 3.6 (1.4-8.2) and TNF receptor p75 from 11.6 ng/ml (7.1-40.6) to 8.1 (2.9-31.3); interleukin 6 (IL-6) fell from 690 pg/ml (34.1-4594) to 8.2 (0-39.3), IL-8 from 226.2 pg/ml (31.6-712.7) to 21.4 (4.2-63.5) and IL-10 from 33.4 pg/ml (2.7-5605) to 4.7 (0-16.7) (p < 0.03). Values for lipopolysaccharide binding protein and soluble CD14 also fell significantly (p < 0.01) from 86.5 (43.4-200) to 21.5 (11.3-37.5) and from 200 (59-200) to 47.8 (0.47-200), respectively. The concentration of bactericidal permeability increasing protein did not change significantly, being 7.1 (2-18.9) during the acute attack and 4.6 (0.8-17.7) a week later. CONCLUSION: There is a considerable systemic inflammatory response during cholangitis, which is dramatically reduced one week after endoscopic treatment.     

Emergency surgery for severe acute cholangitis. The high-risk patients.

Emergency surgery for patients with severe acute cholangitis carries formidable postoperative morbidity and mortality rates. A retrospective study was conducted on 86 consecutive patients who had exploration for the calculous obstructions to identify the high-risk population to guide better management. Septicemic shock was present in 55 patients before surgery. All patients had ductal exploration under general anesthesia. Additional procedures included cholecystectomy (n = 55), cholecystostomy (n = 5), and transhepatic intubation (n = 2). Complications and deaths occurred in 43 (50%) and 17 (20%) patients, respectively. Multivariate analysis on the 25 clinical (n = 14) and biochemical (n = 11) parameters evaluated yield the following five predictive factors (relative risk): the presence of concomitant medical problems (4.5); pH less than 7.4 (3.5); total bilirubin more than 90 mumol/l (3.1); platelet less than 150 x 10(9)/l (2.9), and serum albumin less than 30 g/L (2.9). In the presence of three or more albumin less than 30 g/L (2.9). In the presence of three or more risk factors, postoperative morbidity and mortality rates were 91% and 55%, respectively, which were significantly higher than those with two or less risk factors (34% and 6%, respectively). As thrombocytopenia developed even with transient hypotension, timely ductal decompression would improve outcome of these patients after surgery. For the high-risk population, application of nonoperative biliary drainage might be considered.     

Diagnosis and treatment of acute cholangitis

The results of surgical treatment of 114 patients with acute cholangitis were analysed. With the aim of early diagnosis, the sonography and direct contrasting of the bile ducts were used. The conservative treatment has proved to be effective in 64.9%. Bile ducts decompression before the operation was performed in 29 patients, its effectiveness was 89.6%. Overall lethality in acute cholangitis was 11.4%.