Factors associated with time to laparoscopic cholecystectomy for acute cholecystitis

AIM： To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis. METHODS： A retrospective medical record review of 88 consecutive patients with acute cholecystitis was conducted. Data collected included demographic data, co-morbidities, symptoms and physical findings at presentation, laboratory and radiological investigations, length of stay, complications, and admission service （medical or surgical）. Patients not undergoing cholecystectomy during this hospitalization were excluded from analysis. Hierarchical generalized linear models were constructed to assess the association of pre-operative diagnostic procedures, presenting signs, and admitting service with time to surgery.RESULTS： Seventy cases met inclusion and exclusion criteria, among which 12 were admitted to the medical service and 58 to the surgical service. Mean ± SD time to surgery was 39.3 ± 43 h, with 87% of operations performed within 72 h of hospital arrival. In the adjusted models, longer time to surgery was associated with number of diagnostic studies and endoscopic retrograde cholangio-pancreatography （ERCP, P = 0.01） as well with admission to medical service without adjustment for ERCP （P 〈 0.05）. Patients undergoing both magnetic resonance cholangiopancreatography （MRCP） and computed tomography （CT） scans experienced the longest waits for surgery. Patients admitted to the surgical versus medical service underwent surgery earlier （30.4 ± 34.9 vs 82.7 ± 55.1 h, P 〈 0.01）, had less post-operative complications （12% vs 58%, P 〈 0.01）, and shorter length of stay （4.3 ± 3.4 vs 8.1 ± 5.2 d, P 〈 0.01）.CONCLUSION： Admission to the medical service and performance of numerous diagnostic procedures, ERCP, or MRCP combined with CT scan were associated with longer time to surgery. Expeditious performance of ERCP and MRCP and admission of medically stable patients with suspected cholecystitis to the surgical service to speed     

经内镜诊治肝移植术后胆道远期并发症

目的：探讨经内镜逆行胰胆管造影(ERCP)在诊断和治疗肝移植患者胆道远期并发症中的应用。方法：肝移植术后出现胆道远期并发症患者6例，共行ERCP 12次，根据患者的情况进行扩张、内镜下乳头切开取石、内支架置入等治疗。结果：1例胆总管结石行乳头切开后取石成功，1例胆道狭窄在胆道扩张后胆道梗阻症状解除，4例胆道狭窄合并胆总管结石的狭窄近端结石经乳头切开取出，狭窄远端结石行胆道扩张、内支架置入等治疗后取出。所有患者经治疗后胆红素、碱性磷酸酶等酶学指标均有不同程度的下降，无严重并发症发生。结论：ERCP是诊断和治疗肝移植患者胆道远期并发症安全、有效的手段。     

Early endoscopic retrograde cholangiopancreatography after laparoscopic cholecystectomy can strain the occurrence of trocar site hernia

This study reports a 69-year-old, obese, female patientpresenting with a biliary leakage after laparoscopiccholecystectomy for cholelithiasis. Closure of the um-bilical trocar site had been neglected during the lapa-roscopic cholecystectomy. Early, on postoperative dayfive, endoscopic retrograde cholangiopancreatography(ERCP) requirement after laparoscopic cholecystectomyresolved the biliary leakage problem but resulted with amore complicated clinical picture with an intestinal ob-struction and severe abdominal pain. Computed tomog-raphy revealed a strangulated hernia from the umbilicaltrocar site. Increased abdominal pressure during ERCPhad strained the weak umbilical trocar site. Emergencysurgical intervention through the umbilicus revealed anischemic small bowel segment which was treated withresection and anastomosis. This report demonstratesthat negligence of trocar site closure can result in veryearly herniation, particularly if an endoscopic interven-tion is required in the early postoperative period.     

28例次活体肝移植术后胆道并发症的内镜诊疗体会

目的 回顾性分析活体肝移植术后胆道并发症的临床特点,探讨内镜处置相关问题的有效方式.方法 21例活体肝移植胆道并发症患者接受ERCP诊疗,根据胆道造影所见给予相应治疗,观察内镜治疗的效果.结果 21例患者中43.8%处于术后早期,共接受28次内镜诊疗,其中发现胆管吻合口狭窄19例(90.4%),目.多数存在成角畸形;发现吻合口胆漏9例(42.9%).内镜治疗的操作成功率为85.7%,包括鼻胆管引流5例次、单支架引流10例次、气囊扩张和(或)多支架支撑9例次、胆漏腔引流2例次.随访中3例胆漏患者经治疗漏门已愈合,2例吻合口狭窄已基本消除.结论 活体肝移植术后胆道并发症发生率高且上发生早,吻合口严重狭窄伴成角畸形多见,合并胆漏的发生率较高;采用"先治漏,后治窄"的原则进行内镜治疗可取得满意的疗效.     

Biliary Stricture after Adult Right-Lobe Living-Donor Liver Transplantation with Duct-to-Duct Anastomosis: Long-Term Outcome and Its Related Factors after Endoscopic Treatment

Background/Aims

Biliary stricture is the most common and important complication after right-lobe living-donor liver transplantation (RL-LDLT) with duct-to-duct biliary anastomosis. This study evaluated the efficacy and long-term outcome of endoscopic treatment for biliary stricture after LDLT, with the aim of identifying the factors that influence the outcome.

Methods

Three hundred and thirty-nine adults received RL-LDLTs with duct-to-duct biliary anastomosis between January 2000 and May 2008 at Kangnam St. Mary''s Hospital. Endoscopic retrograde cholangiography (ERC) was performed in 113 patients who had biliary stricture after LDLT. We evaluated the incidence of post-LDLT biliary stricture and the long-term outcome of endoscopic treatment for biliary stricture. The factors related to the outcome were analyzed.

Results

Biliary strictures developed in 121 (35.7%) patients, 95 (78.5%) of them within 1 year of surgery. The mean number of ERCs performed per patient was 3.2 (range, 1 to 11). The serum biochemical markers decreased significantly after ERC (p<0.001). Stent insertion or stricture dilatation during ERC was successful in 90 (79.6%) patients. After a median follow-up period of 33 months from the first successful treatment with ERC, 48 (42.5%) patients achieved treatment success and 12 (10.6%) patients remained under treatment. The factors related to the outcome of endoscopic treatment were nonanastomotic stricture and stenosis of the hepatic artery (p=0.016).

Conclusions

Endoscopic treatment is efficacious and has an acceptable long-term outcome in the management of biliary strictures related to RL-LDLT with duct-to-duct biliary anastomosis. Nonanastomotic stricture and stenosis of the hepatic artery are correlated with a worse outcome of endoscopic treatment.     

Migrated endoclip and stone formation after cholecystectomy： A new danger of acute pancreatitis

Endoclip migration into the common bile duct following laparoscopic cholecystectomy (LC) is an extremely rare complication. Migrated endoclip into the common bile duct can cause obstruction,serve as a nidus for stone formation,and cause cholangitis. We report a case of obstructive jaundice and acute biliary pancreatitis due to choledocholithiasis caused by a migrated endoclip 6 mo after LC. The patient underwent early endoscopic retrog-rade cholangiopancreatography (ERCP) with endoscopic sphincterotomy and stone extraction.     

Advances in endoscopic management of biliary complications after living donor liver transplantation: Comprehensive review of the literature

Apart from noticeable improvements in surgical techniques and immunosuppressive agents, biliary complications remain the major causes of morbidity and mortality after living donor liver transplantation(LDLT). Bile leakage and stricture are the predominant complications. The reported incidence of biliary complications is 15%-40%, and these are known to occur more frequently in living donors than in deceased donors. Despite the absence of a confirmed therapeutic algorithm, many approaches have been used for treatment, including surgical, endoscopic, and percutaneous transhepatic techniques. In recent years, nonsurgical approaches have largely replaced reoperation. Among these, the endoscopic approach is currently the preferred initial treatment for patients who undergo duct-to-duct biliary reconstruction. Previously, endoscopic management was achieved most optimally through balloon dilatation and single or multiple stents placement. Recently, there have been significant developments in endoscopic devices, such as novel biliary stents, as well as advances in endoscopic technologies, including deep enteroscopy, the rendezvous technique, magnetic compression anastomosis, and direct cholangioscopy. These developments have resulted in almost all patients being managed by the endoscopic approach. Multiple recent publications suggest superior long-term results, with overall success rates ranging from 58% to 75%. This article summarizes the advances in endoscopic management of patients with biliary complications after LDLT.     

Plasmapheresis and corticosteroid treatment for persistent jaundice after successful drainage of common bile duct stones by endoscopic retrograde cholangiography

Prolonged cholestasis is a very rare complication of endoscopic retrograde cholangiography （ERC）. Only few cases with this complication are reported in the English literature. We report persisting cholestatic jaundice in a 73-year old man after successful therapeutic ERC for choledocholithiasis. Serologic tests for viral and autoimmune hepatitis were all negative. A second-look ERC was normal also. He denied any medication except for prophylaxis given intravenous 1 g ceftriaxon prior to the ERC procedure. After an unsuccessful trial with ursodeoxycholic acid and cholestyramine for 2 wk, this case was efficiently treated with corticosteroids and plasmapheresis. His cholestatic enzymes became normal and intense pruritis quickly resolved after this treatment which lasted during his followup period. We discussed the possible mechanisms and treatment alternatives of intrahepatic cholestasis associated with the ERC procedure.     

Current management of biliary complications after liver transplantation: Emphasis on endoscopic therapy

Biliary complications occur in 5-25% of patients after liver transplantation and represent a major source of morbidity in this group of individuals. The major risk factor for most of these complications is ischemia of the bile tree usually due to obstruction or vascular insufficiency of the hepatic artery. The most common complications include biliary strictures (anastomostic and nonanastomotic), bile leaks, and biliary filling defects. The initial diagnostic approach starts with a high index of suspicion along with an abdominal ultrasound and Doppler exam. Magnetic resonance imaging is highly sensitive and is usually reserved for confirmation. The vast majority of these complications can be successfully treated with endoscopic retrograde cholangiography, however if this procedure cannot be performed a percutaneous approach or surgery is recommended. Nonanastomotic strictures and living donor recipients present a less favorable response to endoscopic management. This review focuses on the current diagnostic and therapeutic approaches for the management of biliary complications after liver transplantation.     

内镜治疗术后胆漏和继发胆管狭窄

目的 探讨内镜治疗手术后并发胆漏和继发胆管狭窄的方法及效果。方法 胆漏患 者均先行内镜下十二指肠乳头切开,行鼻胆管引流术,继续保留原有胆道、腹腔引流。待胆道、腹腔引 流停止1-2周证实胆漏愈合后拔管,伴有胆道狭窄的患者在拔除鼻胆引流管后置入塑料内支架,持 续扩张2-3个月。结果 22例胆漏患者鼻胆引流3-4周后胆漏处均闭合,13例胆管狭窄置入内支 架者,10例支架取出后狭窄解除,2例合并肝总管狭窄者经重新置入双支架3个月后效果良好,1例 左肝管狭窄伴结石者,再置入单支架,术后仍有胆道感染症状反复出现。结论 内镜治疗可列为手术 后胆漏或继发胆管狭窄治疗的首选方法。     

胆囊切除术后综合征的内镜诊断和治疗

目的 探讨内镜在胆囊切除术后综合征病因诊断和治疗中的应用价值。方法 对326例胆囊切除术后综合征患者ERCP检查明确病因后,对胆管结石行内镜乳头括约肌切开术（EST）和内镜乳头气囊扩张术（EPBD）后取石;对乳头炎必狭窄行EST或EPBD治疗;对乳头旁憩室压迫乳头开口和Oddi括约肌功能紊乱（SOD）行EPBD治疗;对乳头肿瘤和肝门胆管癌行内镜胆管金属内支架治疗（EMBE）;对化脓性胆管炎,继发性胆总管多发结石、结石难以一次取净及术后胆瘘,胆管中段狭窄行内镜鼻胆管引流（ENBD）。结果 315例（96．6％）ERCP成功。未发现异常30例。胆管结石191例,186例经1－3次内镜取石后取净。乳头炎性狭窄39例,经EST或EPBD治疗1次成功。乳头旁憩室压迫乳头开口9例,行EPBD治疗1次成功。胆管中段狭窄16例,11例行ENBD成功。乳头肿瘤6例,肝门胆管癌5例,EMBE治疗后黄疸减退。SOD7例,行EPBD治疗成功。胃十二指肠溃疡6例。胆囊管结石残留4例。胆囊切除术后胆瘘2例,行ENBD治疗成功,避免再次外科手术。总的并发症发生率4．8％,其中急性轻型胰腺炎11例,急性胆管炎3例,上消化道出血1例。结论 ERCP能及早发现胆囊切除术后综合征确切病因并给予相应内镜治疗。熟练掌握ERCP技术可减少并发症的发生。     

腹腔镜胆囊切除术联合内镜下逆行胰胆管造影和十二指肠乳头括约肌切开术治疗胆囊结石合并肝外胆管结石患者疗效研究

目的 探讨采用腹腔镜胆囊切除术(LC)、内镜下逆行胰胆管造影(ERCP)和十二指肠乳头括约肌切开术(EST)联合治疗胆囊结石合并肝外胆管结石患者的疗效.方法 2018年1月～2020年10月我院治疗的胆囊结石合并肝外胆管结石88例,在47例观察组采用LC联合ERCP和EST手术,在41例对照组采用开腹胆囊切除和胆总管探...     

Biliary and pancreatic stenting: Devices and insertion techniques in therapeutic endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography

Stents are tubular devices made of plastic or metal. Endoscopic stenting is the most common treatment for obstruction of the common bile duct or of the main pancreatic duct, but also employed for the treatment of bilio-pancreatic leakages, for preventing post- endoscopic retrograde cholangiopancreatography pancreatitis and to drain the gallbladder and pancreatic fluid collections. Recent progresses in techniques of stent insertion and metal stent design are represented by new, fullycovered lumen apposing metal stents. These stents are specifically designed for transmural drainage, with a saddle-shape design and bilateral flanges, to provide lumen-to-lumen anchoring, reducing the risk of migration and leakage. This review is an update of the technique of stent insertion and metal stent deployment, of the most recent data available on stent types and characteristics and the new applications for biliopancreatic stents.     

ERCP在手术后胆漏中的诊治作用

目的探讨ERCP对肝胆术后胆漏诊断及治疗作用。方法对2003年1月至2008年12月接受ERCP诊治的120例肝胆术后胆漏患者进行回顾性分析。结果120例胆漏患者中,诊断肝外胆漏（Ⅰ型）71例、肝内胆管漏（Ⅱ型）39例、胆囊管漏（Ⅲ型）10例。其中76例行内镜下鼻胆管引流术（ENBD）,35例行胆管内支架引流术（ERBD）,3例行ERBD＋ENBD,2例单纯行经内镜乳头括约肌切开术（EST）,1例放置可回收金属支架行金属支架引流（EMBE）,3例内镜治疗失败。共完整随访98例,占81．7％（98／120）,其中有效治愈胆漏85例,有效治愈率为86．7％（85／98）,平均胆漏愈合时问为（18．2±7．0）d。各型胆漏中,Ⅲ型胆漏有效治愈率最高,为100．0％,且该型胆漏愈合时间最短,为（8．2±3．5）d;在Ⅰ型和Ⅱ型胆漏中,对应非肝移植术后胆漏有效治愈率明显高于肝移植术后（P〈0．01）,且愈合时间明显变短（P〈0．01）。结论ERCP是诊治肝胆术后胆漏的一种安全、有效的手段,具有重要的临床价值,可作为肝胆术后胆漏诊治的首选方法,对于Ⅲ型胆漏治疗效果尤佳。     

Early endoscopic ultrasonography in acute biliary pancreatitis: A prospective pilot study

AIM: To investigate the clinical usefulness of early endoscopic ultrasonography(EUS) in the management of acute biliary pancreatitis(ABP).METHODS: All consecutive patients entering the emergency department between January 2010 and December 2012 due to acute abdominal pain and showing biochemical and/or radiological findings consistent with possible ABP were prospectively enrolled. Patients were classified as having a low,moderate,or high probability of common bile duct(CBD) stones,according to the established risk stratification. Exclusion criteria were: gastrectomy or patient in whom the cause of biliary obstruction was already identified by ultrasonography. All enrolled patients underwent EUS within 48 h of their admission. Endoscopic retrograde cholangiopancreatography was performed immediately after EUS only in those cases with proven CBD stones or sludge. The following parameters were investigated:(1) clinical: age,sex,fever;(2) radiological: dilated CBD; and(3) biochemical: bilirubin,AST,ALT,g GT,ALP,amylase,lipasis,PCR. Association between presence of CBD stone at EUS and the individual predictors wereassessed by univariate logistic regression. Predictors significantly associated with CBD stones(P 0.05) were entered in a multivariate logistic regression model.RESULTS: A total of 181 patients with pancreatitis were admitted to the emergency department between January 2010 and December 2012. After exclusion criteria a total of 71 patients(38 females,53.5%,mean age 58 ± 20.12 years,range 27-89 years; 33 males,46.5%,mean age 65 ± 11.86 years,range 41-91 years) were included in the present study. The probability of CBD stones was considered low in 21 cases(29%),moderate in 26(37%),and high in the remaining 24(34%). The 71 patients included in the study underwent EUS,which allowed for a complete evaluation of the target sites in all the cases. The procedure was completed in a mean time of 14.7 min(range 9-34 min),without any notable complications.The overall CBD stone frequency was 44%(31 of 71),with a significant increase from the group at low pretest probability to that at moderate(OR = 5.79,P = 0.01) and high(OR = 4.25,P = 0.03) pretest probability.CONCLUSION: Early EUS in ABP allows,if appropriate,immediate endoscopic treatment and significant spare of unnecessary operative procedures thus reducing possible related complications.     

Safety and efficacy of endoscopic retrograde cholangiopancreatography in patients with post-liver transplant biliary complications: results of a cohort study with long-term follow-up

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard approach for the management of biliary complications in liver transplant patients; however, its safety and efficacy have not been established in this setting. This study was performed to evaluate the safety and long-term efficacy of ERCP in transplant patients.

Methods

The case reports of 1,500 liver transplant patients were reviewed. Orthotopic liver transplantation (OLT) patients were matched 1:2 with non-OLT patients and followed-up for long-term outcome (median, 7.4 years).

Results

Of the 1,500 liver transplant patients, 94 (6.3%) underwent 150 ERCPs after OLT. Anastomotic strictures were present in 45 patients, biliary stones in 24, biliary leaks in 7, papillary stenosis in 2, and primary sclerosing cholangitis in 1. An ERCP success rate of 90.7% was achieved; biliary stenting led to resolution of the bile leak in 7/7 (100%) patients, and biliary stones were removed in 21/24 (87.5%) patients. In addition, 34 of 45 patients with anastomotic stricture underwent endoscopic dilation. We obtained complete resolution in 22/34 (64.7%) patients. OLT patients did not show a higher probability of complications (odds ratio [OR], 1.04), of pancreatitis (OR, 0.80) or of bleeding (OR, 1.34).

Conclusions

ERCP is safe and effective for the treatment of post-OLT biliary complications, has a low rate of pancreatitis and results in a durable effect.     

Clinical evaluation of 3D-CT cholangiography for preoperative examination in laparoscopic cholecystectomy

Three-dimensional-computed tomography (3D-CT) cholangiography is a 3D shaded surface display image of the biliary tract obtained by using helical CT after intravenous cholangiography or cholangiography per percutaneous transhepatic cholangio-drainage tube. We investigated whether 3D-CT cholangiography could provide a useful image, for preoperative examination in laparoscopic cholecystectomy. Sixty-five patients with biliary diseases were examined by 3D-CT cholangiography. Helical scanning was performed on a Proceed Accell (GE Medical Systems, Waukesha, WI, USA). Three-dimensional images were created using an independent workstation. A clear image of the common bile duct was obtained for all patients (100%) by 3D-CT cholangiography. The gallbladder was well visualized in 54 (93%) and the cystic duct was shown to be opacified in 55 (95%) of the 58 patients with a gallbladder. Thirty-one patients were diagnosed as having gallstones by 3D-CT cholangiography (sensitivity, 72.1%; specificity, 100%; accuracy, 79.3%), while 43 were diagnosed as having cholecystolithiasis by ultrasonography. The advantages of 3D-CT cholangiography were a low level of invasiveness, easily obtained images compared to those obtained with endoscopic retrograde cholangiography (ERC), good opacification, and provision of a three-dimensional understanding of the biliary system, especially of the cystic duct. When combined with ultrasonography and routine liver function tests, 3D-CT cholangiography was considered very useful for obtaining information before laparoscopic cholecystectomy. It allowed the omission of ERC in many patients who were considered to have no common bile duct stone, by employment of 3D-CT cholangiography. (Received Apr. 22, 1998; accepted Aug. 28, 1998)     

Features and management of bile leaks after laparoscopic cholecystectomy

Background/purpose

Leakage of bile is one of the troublesome complications after laparoscopic cholecystectomy.

Methods

The present study reviewed our experience with this complication, in order to analyze its characteristics and proper management.

Results

Postoperative bile leaks occurred in 23 of 1365 patients (1.7%) undergoing laparoscopic cholecystectomy from July 1990 to May 2002, with the policy of routine operative cholangiography and routine drainage of the gallbladder bed. These patients could be divided into four types. In type 1 (17 patients), bile leakage stopped spontaneously within 3 days (subclinical group). In type 2 (3 patients), the leak continued for longer than 3 days but was controlled by an endoscopic nasobiliary drainage (ENBD tube; minor-leakage group). In type 3 (2 patients), bile leakage continued for longer than 3 days and required open repair (major-leakage group). In type 4 (1 patient), bile leakage started several days after surgery (delayed-leakage group).

Conclusions

It is thought that better understanding of these four types of bile leakage should help in the proper management of this complication.     

Single balloon enteroscopy for endoscopic retrograde cholangiography in patients with Roux-en-Y hepaticojejuno anastomosis

AIM:To evaluate single balloon enteroscopy in diagnostic and therapeutic endoscopic retrograde cholangiography(ERC)in patients with Roux-en-Y hepaticojejunoanastomosis(HJA).METHODS:The study took place from January 2009to December 2011 and we retrospectively assessed 15patients with Roux-en-Y HJA who had signs of biliary obstruction.In total,23 ERC procedures were performed in these patients and a single balloon videoen-teroscope(Olympus SIF Q 180)was used in all of the cases.A transparent overtube was drawn over the videoenteroscope and it freely moved on the working part of the enteroscope.Its distal end was equipped with a silicone balloon that was inflated by air from an external pump at a pressure of≤5.4 kPa.The technical limitations or rather the parameters of the single balloon enteroscope(working length-200 cm,diameter of the working channel-2.8 mm,absence of Albarran bridge)showed the need for special endoscopic instrumentation.RESULTS:Cannulation success was reached in diagnostic ERC in 12 of 15 patients.ERC findings were normal in 1 of 12 patients.ERC in the remaining 11 patients showed some pathological changes.One of these(cystic bile duct dilation)was subsequently resolved surgically.Endoscopic treatment was initialized in the remaining 10 patients(5 with HJA stenosis,2 with choledocholithiasis,and 3 with both).This treatment was successful in 9 of 10 patients.The endoscopic therapeutic procedures included:balloon dilatation of HJA stenosis-11 times(7 patients);choledocholitiasis extraction-five times(5 patients);biliary plastic stent placement-six times(4 patients);and removal of biliary stents placed by us-six times(4 patients).The mean time of performing a single ERC was 72 min.The longest procedure took 110 min and the shortest took34 min.This shows that it is necessary to allow for more time in individual procedures.Furthermore,these procedures require the presence of an anesthesiologist.We did not observe any complications in these 15 patients.CONCLUSION:This method is more demanding than s