Early operation for acute biliary tract stone disease

A prospective study to evaluate the accuracy of early diagnosis and the efficacy of early operation for biliary tract stone disease was performed. One hundred fifty-two consecutive patients with signs and symptoms compatible with biliary colic or acute cholecystitis were admitted to the hospital and promptly evaluated with ultrasonography and hepatobiliary (Pipida) scanning. Patients with demonstrable stones or a nonvisualized gallbladder underwent operation within 48 hours of admission. Of 75 patients who underwent operation, 64 had acute and/or severe chronic cholecystitis. Associated biliary pancreatitis was present in 14 of 75 patients. Cholecystectomy with intraoperative cholangiography was performed for 73 of the 75 patients. One patient underwent cholecystectomy only and one patient underwent cholecystostomy. There were 18 common duct explorations. No transfusions were required and there were no deaths. The average duration of hospital stay for all patients who underwent operation was 6.5 days. The results indicate that an accurate diagnosis of acute biliary tract stone disease can be made rapidly with use of sonography and hepatobiliary scanning, that cholecystectomy with intraoperative cholangiography and common duct exploration as necessary can be performed safely (including cases of biliary pancreatitis) in the acute setting, and that with early operation the duration of stay is decreased and morbidity and mortality rates compare favorably with those of elective cholecystectomy. It is concluded that operation performed within at least 48 hours of admission is the treatment of choice for acute biliary tract stone disease.     

Early definitive surgery for acute pancreatitis associated with cholelithiasis

Since the natural history of pancreatitis associated with cholelithiasis is one of recurrence, surgery for the biliary tract disease is mandatory. But appropriate timing of the surgery remains controversial. Seventy-eight patients have been treated with early surgery once a diagnosis of cholelithiasis associated pancreatitis was made. Eighteen patients had previous episodes of nonalcoholic pancreatitis. Utilizing Ranson's prognostic signs, 52 patients had mild pancreatitis and 26 severe. Sixty-eight patients (87%) had surgery within 72 hours after admission and ten patients (13%) within 5 days. All patients had a cholecystectomy and operative cholangiogram performed. Fifty-six (72%) positive operative cholangiograms were obtained and common bile duct exploration revealed choledocholithiasis in 42 patients (75%). No mortality occurred, and four had six complications including mild persistent pancreatitis (two), wound infection (one), urinary tract infection (one), cardiac arrhythmia (one) and heart block requiring permanent pacemaker (one). The average hospital stay was 10.4 days. T-tube cholangiogram done prior to discharge was normal in all patients, and there have been no episodes of recurrent pancreatitis. Early definitive surgery for pancreatitis associated with cholelithiasis is recommended and can be accomplished with minimal morbidity and mortality coupled with judicious utilization of hospital resources.     

急性胆源性胰腺炎41例外科治疗临床体会

目的探讨急性胆源性胰腺炎(acute biliary pancreatitis ABP)外科治疗的时机与方法。方法 41例ABP患者均采用外科手术治疗。结果本组41例患者均获治愈。结论对ABP的治疗应根据其病情与类型而定,对伴有胆总管下端梗阻或胆道感染的重症ABP应急诊或早期(72 h)手术,对不伴胆道完全梗阻、胆管炎的重症ABP患者,早期采取保守治疗,手术尽量延至病情稳定后。对急性水肿性ABP可经保守治疗,病情稳定后2～4周行胆道手术,但保守治疗期间若出现胆管炎、胆囊坏疽或穿孔应急诊手术。     

The role of Chiba-needle cholangiography in the diagnosis of possible acute pancreatitis with cholelithiasis.

In patients with suspected severe acute pancreatitis and known or suspected cholelithiasis, it may be extremely difficult to exclude the diagnosis of gangrenous cholecystitis or obstructive cholangitis by nonoperative means. Since early intra-abdominal surgery has, in our experience, led to markedly increased morbidity in patients with gallstone pancreatitis, non-operative visualization of the biliary tree by percutaneous transhepatic Chiba-needle cholangiography (PTCNC) has been evaluated in 14 patients with suspected acute pancreatitis in whom life-threatening acute biliary disease could not be excluded by other nonoperative means. The final diagnosis was acute pancreatitis in nine patients (Group A) (mean serum amylase 3242 SU%) and acute biliary disease with hyperamylasemia in five patients (Group B) (mean serum amylase 2084 SU%). PTCNC made visualization of the biliary system possible in all patients and excluded the diagnosis of cystic duct or common duct obstruction in each case. Following PTCNC, potentially hazardous early laparotomy was avoided in eight of nine Group A patients. Biliary surgery was undertaken on day 3 to 13 in four Group B patients. When early laparotomy may be needed to evaluate or treat possible life-threatening acute biliary disease but is considered undesirable because of possible acute pancreatitis. PTCNC appears to be a safe and effective nonoperative method of obtaining precise anatomical delineation of the biliary tree.     

Acute biliary pancreatitis. Therapeutic trends

BACKGROUND: Treatment of biliary pancreatitis includes suppression of the biliary cause by cholecystectomy and common bile duct clearance. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy for eradication of biliary stones and laparoscopic cholecystectomy (L.C.) for residual gallbladder stones would be ideal but were once considered to be contraindicated by most surgeons. The timing of definitive biliary tract surgery and the role of ERCP have been the focus of discussion in recent years. METHODS: During a two-year study period 51 patients with acute biliary pancreatitis were studied. Seven patients (14%) underwent emergency laparotomy, necrosectomy, cholecystectomy, exploration of the common bile duct and T-tube insertion, because unstable clinical conditions, with evidence of pancreatic and peripancreatic necrosis on CT-scan. Elective open cholecystectomy and CBD exploration were performed in 7 patients after the resolution of acute pancreatitis during the same hospital admission. RESULTS: Early ERCP and L.C. were associated with favourable outcomes. 33 patients underwent ERCP preoperatively: 17 within 72 hours of admission and 16 after signs of clinical improvement. Laparoscopic cholecystectomy performed 3-25 days after admission was successful in 27 of 29 patients. Postsphincterectomy bleeding occurred in one patient and was treated successfully by endoscopic epinephrine injection. For median hospital stay and recurrence there were statistical differences between early and delayed ERCP. CONCLUSIONS: ERCP and sphincterectomy have a certain role in conjunction with laparoscopic cholecystectomy in the management of patients with acute biliary pancreatitis, particularly in institutions where there is easy access to expert interventional endoscopic techniques. This policy should reduce the risk of cholangitis and recurrent pancreatitis.     

Differential treatment of acute pancreatitis

Results of examination and treatment of 194 patients with acute pancreatitis were analyzed. It is revealed that the diagnosis of an etiopathogenetic form of acute pancreatitis is a key moment in the choice of the treatment. Patients with acute biliary pancreatitis and alimentary pancreonecrosis with pancreatogenic peritonitis require urgent surgical treatment at early stages of the disease. Laparoscopic cholecystectomy and Haulstad's drainage of the common bile duct are the procedures of choice in acute biliary pancreatitis. Alimentary pancreonecrosis with pancreatogenic peritonitis is the indication for videolaparoscopic drainage procedure and peritoneal dialysis as soon as possible after the disease beginning. This approach decreased lethality, number of complication and hospital stay.     

Early versus delayed single-stage laparoscopic eradication for both gallstones and common bile duct stones in mild acute biliary pancreatitis

Several studies addressed that preoperative endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) clearance, followed by interval laparoscopic cholecystectomy (two-stage approach), constitutes the most common practice in cases of uncomplicated mild acute biliary pancreatitis. Between June 1998 and December 2002, 44 patients (35 females and 9 males with a median age of 62 years) suffering from uncomplicated mild acute biliary pancreatitis were treated in our unit. All patients were electively submitted to surgery after subsidence of the acute symptoms, and for definitive treatment we favored the single-stage laparoscopic management, avoiding preoperative ERCP. All patients underwent laparoscopic cholecystectomy plus fluoroscopic intraoperative cholangiogram (IOC). If filling defect(s) were detected in the IOC, a finding suggestive of concomitant choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) was added in the same sitting. Twenty patients were operated upon within 2 weeks since the attack of the acute symptoms and constitute the early group (n=20), whereas 24 patients underwent an operation later on and constitute the delay group (n=24). We retrospectively compare the safety, effectiveness, and outcome after the single-stage laparoscopic management between the two groups of patients. Laparoscopic cholecystectomy alone constituted the definitive treatment in 38 patients, while an additional LCBDE was performed in the remaining 6 patients (14%), and all operations were achieved laparoscopically. There was no statistically significant difference between the groups in terms of operative time, incidence of concomitant choledocholithiasis, morbidity rate, and postoperative hospital stay. During the follow-up, none of the patients experienced recurrent pancreatitis. In uncomplicated mild acute biliary pancreatitis cases, a single-stage definitive laparoscopic management, avoiding preoperative ERCP, can be safely performed during the same admission, after the improvement of symptoms and local inflammation. Postoperative ERCP should be selectively used in patients in whom the single-stage method failed to resolve the problem.     

Timing of surgery for acute gallstone pancreatitis

One hundred four consecutive patients with acute gallstone pancreatitis underwent biliary surgery. The relationships between the timing of surgery, the severity of pancreatitis, and the surgical outcome were examined. Patients were divided into three groups according to the timing of surgery and into four groups according to the gross pancreatic pathologic characteristics observed at operation. Patients who underwent surgery early tended to have a higher incidence of common bile duct stones and more severe forms of pancreatitis; however, neither the timing of surgery nor the severity of pancreatitis had a significant impact on surgical outcome. Other factors, such as the level of serum amylase on admission and presence or absence of choledocholithiasis, did not significantly influence the natural history of the disease or the outcome of surgical therapy, whereas advanced age was associated with higher morbidity. Hemodynamic status and the overall condition of the patients were more important than either the timing of surgery or the gross pathologic characteristics of the pancreas in determining surgical outcome. We conclude that the timing of surgery is not a critical factor in the outcome of surgery for acute gallstone pancreatitis. Provided that the patient is stable and has no medical contraindications, surgery on the biliary tract can be performed safely at any time after initial resuscitation of the patient and confirmation of diagnosis.     

The Timing of Biliary Surgery in Acute Pancreatitis

The timing of biliary surgery remains controversial in patients with acute pancreatitis associated with cholelithiasis. Eighty hospital admissions for acute pancreatitis, occurring in 74 patients with cholelithiasis, have therefore been reviewed. Among 22 patients who underwent abdominal surgery during the first week of treatment, there were five deaths (23%) and four patients (18%) who required more than seven days of intensive care. Fifty-eight episodes of pancreatitis were managed nonoperatively during the first week of treatment, with no deaths, although six (10%) required more than seven days of intensive care. Biliary surgery was undertaken later during the same admission in 37 patients, with no deaths. Twenty-one patients were discharged without biliary operation, but seven (33%) developed further pancreatitis. Previously reported prognostic signs were used to divide pancreatitis into 57 "mild" episodes (1.8% mortality) and 23 "severe" episodes (17% mortality). Early (day 0-7) definitive biliary surgery was undertaken in 11 patients with "mild" pancreatitis, with one death (9%), and in six patients with "severe" pancreatitis, with four deaths (67%). In three recent patients with "severe" pancreatitis, early biliary surgery was limited to cholecystostomy, with no deaths. These findings suggest that although early correction of associated biliary disease may be undertaken safely in many patients with "mild" acute pancreatitis, early definitive surgery is hazardous in "severe" pancreatitis and should, if possible, be deferred until pancreatitis has subsided. In most patients biliary surgery should precede hospital discharge.     

Surgical treatment of biliary tract infections

Despite major advances in surgical and nonsurgical therapy, biliary tract infections remain a significant cause of morbidity and mortality. The two classic biliary tract infections most commonly encountered are acute cholecystitis (either calculous or acalculous) and acute cholangitis. In addition, bile leakage associated with bile duct injuries during laparoscopic cholecystectomy has become a problem not infrequently encountered by surgeons. Acute calculous cholecystitis results from a combination of mechanical, biochemical, and infectious mechanisms, initiated by stone impaction in the cystic duct. After instituting empiric antibiotics, early laparoscopic cholecystectomy should be performed. Although conversion to open cholecystectomy is more common than in chronic cholecystitis, there appears to be no increased morbidity or mortality in that setting. Acute acalculous cholecystitis usually occurs in critically ill patients and may present both a diagnostic and therapeutic dilemma. Aggressive management, however, is warranted, both because of the critical nature of illness in these patients and the high incidence of perforation. Percutaneous cholecystostomy is indicated, particularly in high-risk patients both for diagnosis and treatment. Acute cholangitis results from a combination of bactibilia and biliary obstruction. The majority of patients can be successfully managed with intravenous antibiotics and fluid resuscitation. In those patients in whom initial management is not successful, biliary drainage, which is best accomplished nonoperatively, should be instituted. There is a very limited role for early surgical intervention in acute suppurative cholangitis. Biliary leaks resulting in bile "peritonitis" or bilomas are common sequelae of laparoscopic bile duct injury. Although surgeons may feel it is necessary to operate urgently, delineation of the proximal biliary anatomy via percutaneous transhepatic cholangiography and biliary stent placement is the appropriate first step in management. This procedure will usually control the bile leak and allow delineation of the anatomy and opportune timing of definitive reconstruction.     

急性胆源性胰腺炎行腹腔镜治疗体会

目的　探讨应用腹腔镜技术治疗急性胆源性胰腺炎的可行性及手术时机。方法　回顾性分析 2 0 0 2年～ 2 0 0 3年本科收治急性胆源性胰腺炎 4 3例患者 ,行腹腔镜手术治疗 2 13例 ,急性反应期 (3～ 7天 )手术 5例 ,延迟期手术 18例 ,开腹下手术 2 0例 ,急性反应期 6例 ,延迟期手术 14例。手术包括 :胆囊切除胆总管切开取石 ,“T”管引流 ,腹腔灌洗 ,胰床清创引流术。从手术时间 ,术后腹痛缓解时间 ,术后并发症发生率 ,出院时间进行对照分析。结果　腹腔镜组手术时间与剖腹组无明显差异 (P>0 .0 5 ) ,术后腹痛缓解时间 ,肛门排气时间 ,出院时间腹腔镜组均较剖腹组缩短 ,术后并发病发生率低于剖腹组 (P<0 .0 5 )结论　腹腔镜手术治疗适用于急性胆源性胰腺炎各时机 ,且体现于微创的优越性 ,腹腔镜手术最佳处理时期是同一次住院胆源胰腺炎控制后 ,因手术期处理关键是胰腺炎控制及早期肠内营养     

Pancreatitis and biliary tract disease

Fifty-three cases of chronic and acute pancreatitis on whom biliary tract surgery was performed have been discussed. Biliary tract disease was present in all but six of these. Common duct stone was found in 66 per cent of those with biliary tract disease and chronic pancreatitis and in 78 per cent of those with acute pancreatitis. The surgical treatment, in the vast majority of cases, involved a drainage of the common duct as well as a direct attack on the pancreas. The mortality rate in chronic pancreatitis is that inherent in surgery on the biliary tract, and the mortality rate in acute pancreatitis that found in severe peritonitis. Peritonitis was the predominant cause of death in all cases.     

Gallstone pancreatitis

Gallstone pancreatitis is caused by transient obstruction of the ampulla of Vater by a migrating gallstone. Intraglandular activation of pancreatic enzymes occurs (by an unclear mechanism), and their entry into the circulation causes most of the local and systemic events of pancreatitis. The diagnosis is based on history and physical examination, an elevation of serum amylase above 1000 IU/L, and ultrasound and CT scans. Endoscopic retrograde cholangiopancreatography can be used in less certain cases to confirm the presence of common bile duct stones. Because of the absence of an agent that can abort progression of the disease, therapy should consist of adequate resuscitation, nutritional support, and careful monitoring to detect early complications. In patients with mild pancreatitis, surgery usually can be performed within 48 or 72 hours of admission or as soon as symptoms and amylase levels return to normal. For patients with severe disease, endoscopic sphincterotomy is emerging as the therapeutic modality of choice. Elective treatment of the associated biliary disease should be performed during the same hospitalization after the acute phase of the disease has subsided.     

Therapeutic and diagnostic protocol for mild acute biliary pancreatitis: our experience and review of the literature

Through a critical review of the literature, the authors analyze and re-assess the current diagnostic and therapeutic algorithms used in the treatment of mild acute biliary pancreatitis, reporting their experience with 27 cases observed in the Policlinico Umberto I Emergency Department (Rome) over the period from March 2003 to May 2005. All patients were treated with the same diagnostic and therapeutic protocol: once the diagnosis of acute biliary pancreatitis had been made and the severity evaluated, patients presenting clinical or ultrasonographic signs of main biliary duct stones underwent ERCP within 72 hours of onset of symptoms. All patients then underwent a standard-technique laparoscopic cholecystectomy during the same hospital stay, and whenever ERCP had not been performed preoperatively, an intraoperative cholangiography was performed at the time of surgery. No intra- or postoperative complications were observed, with a mean hospital stay of 10.6 days (range: 5-25 days).     

Acute pancreatitis in elderly patients. Pathogenesis and outcome

Forty patients over 70 years of age with acute pancreatitis were studied. The most common cause of pancreatitis was biliary tract disease (14 patients, 35 percent). Twelve patients (30 percent) were discharged with a diagnosis of idiopathic pancreatitis, but tests such as endoscopic retrograde cholangiopancreatography that might have established the cause of disease were frequently not employed. Eight of the 40 patients died, for a mortality rate of 20 percent. Significant morbidity occurred in an additional seven (17.5 percent). Multisystem failure was the cause of death in all eight patients, and only two patients with multisystem failure survived. The mortality rate was significantly higher in those patients with postoperative pancreatitis. Acute pancreatitis in the elderly carries a grave prognosis. All patients should undergo thorough evaluation, as biliary tract disease is the most common cause. Cholecystectomy should be performed in those with biliary disease to prevent recurrent attacks.     

Pancreatitis after biliary tract surgery

Pancreatitis associated with biliary tract operations continues to be an important clinical problem. The results of biliary tract operations performed on 1256 patients were carefully scrutinized for the presence of postoperative hyperamylasemia and pancreatitis persisting after 48 hours. Patients were evaluated in the context of the presence or absence of preoperative pancreatic dysfunction. Similarly, various operative risk factors were evaluated, including cholangiography, choledocholithiasis, common duct exploration, choledochoscopy, choledochoduodenostomy, and sphincteroplasty. Operative cholangiography did not induce postoperative pancreatitis. The incidence of postoperative pancreatitis following cholecystectomy was 0.6%, which was significantly greater than the incidence following common duct exploration (8.4%). Pancreatitis following biliary tract surgery seemed to be not directly related to the performance of choledochoscopy, sphincteroplasty, or choledochoduodenostomy, as it developed with similar frequency in patients undergoing common duct exploration alone. The timing of operative therapy in patients with biliary tract pancreatitis did not significantly alter the frequency with which pancreatitis persisted in the postoperative period. In 970 patients undergoing cholecystectomy, one patient who had preoperative pancreatitis died of postoperative pancreatitis. Of 286 patients undergoing common duct exploration, seven patients died with pancreatitis. In three of these patients there was no active preoperative pancreatitis, and in one of these patients pancreatitis was the cause of death. Four patients with preoperative pancreatitis eventually died of pancreatitis in the postoperative period. Pancreatitis is an important complication of biliary tract disease and operations, and all efforts should be extended to suppress its occurrence and development.     

Surgical injury of the common bile duct

Review of our experience with twenty-two bile duct injuries and the literature leads us to the following conclusions: (1) Most biliary strictures follow surgery and can be avoided by adequate exposure, accurate dissection, use of hemostatic clips rather than clamps and ties, and the liberal use of operative cholangiography. (2) Injuries diagnosed at the time of surgery should be repaired by end-to-end anastomosis over a T tube if length is adequate or by Roux-en-Y choledochojejunostomy if length is inadequate. (3) The diagnosis of biliary injury should be suspected when jaundice, biliary fistula, or cholangitis occur in the postoperative period. (4) IVC, PTC, ERCP, or fistulography should be used when possible to delineate the site of injury or stricture and assist in planning the operative repair. (5) Surgery should be performed as soon as the diagnosis is made and the patient is in satisfactory condition for operation. (6) Early reoperation may be necessary to establish drainage and prepare for a later definitive procedure. In some cases, definitive repair can be performed this time. (7) Most late strictures should be repaired with a choledochojejunostomy to a defunctionalized limb of jejunum when resection and primary end-to-end repair cannot be accomplished.     

胆源性坏死性胰腺炎外科治疗体会——附36例临床分析

我院从1981年1月至1991年12月共收治胆源性坏死性胰腺炎36例,经早期诊断,早期手术治疗,术中尽量将胰内、外坏死组织彻底清除,将胰腺完全游离,使之漂浮,充分灌洗,充分引流,并去除胆石病因。同时,使用胰酶抑制剂与胰酶合成阻滞剂,抑制胰腺外分泌;早期发现及时恰当处理各种术后并发症,积极进行营养支持治疗,其存活率为58.3％。     

JPN Guidelines for the management of acute pancreatitis: treatment of gallstone-induced acute pancreatitis

Gallstones, along with alcohol, are one of the primary etiological factors of acute pancreatitis, and knowledge of the etiology as well as the diagnosis and management of gallstones, is crucial for managing acute pancreatitis. Because of this, evidence regarding the management of gallstone-induced pancreatitis in Japan was collected, and recommendation levels were established by comparing current clinical practices with optimal clinical practices. The JPN Guidelines for managing gallstone-induced acute pancreatitis recommend two procedures: (1) an urgent endoscopic procedure should be performed in patients in whom biliary duct obstruction is suspected and in patients complicated by cholangitis (Recommendation A); and (2) after the attack of gallstone pancreatitis has subsided, a laparoscopic cholecystectomy should be performed during the same hospital stay (Recommendation B).     

Choledochoduodenostomy in the treatment of benign biliary tract disease

During the 15 year period 1965 through 1979, sixty patients underwent choledochoduodenostomy for benign obstructive lesions of the biliary tract. Patients with traumatic and iatrogenic common duct strictures were excluded. Eighty-two percent of the patients were in the seventh to ninth decades of life. Twenty-seven patients (45 percent) had undergone a total of 40 previous biliary tract surgical interventions. Thirty-three patients (55 percent) in the older age group (average age 75 years) were subjected to choledochoduodenostomy as a primary procedure during the first surgical intervention on the biliary system. Cholangitis recurred in only one patient (in whom the sump syndrome was the culprit), while all other patients have been free of abdominal complaints, cholangitis and pancreatitis during follow-up of 1 to 15 years. There was no operative mortality; morbidity was 26 percent. Hospital stay averaged 15 days. These favorable results mark choledochoduodenostomy as a safe, simple and effective procedure in the treatment of benign biliary tract disease, particularly in aged and high risk patients.