Actigall (ursodiol) capsules/CIBA

Actigall (Urodiol) capsules, a product by CIBA-GEIGY Pharmaceuticals, is an agent intended to dissolve cholesterol (radiolucent, noncalcified) gallstones. It represents a treatment option for nonemergency patients with small-to-medium sized cholesterol gallstones who refuse to undergo surgical removal of the gallbladder or are high-risk surgical candidates.     

Cholecystitis and cholelithiasis

Cholelithiasis and cholecystitis, with their complications, remain major health problems in the United States. At this time, cholecystectomy is the treatment of choice for all patients with symptomatic gallstones and those with acute cholecystitis, except those who are too ill to undergo surgery. Present therapeutic options may be summarized as follows: Asymptomatic patients and those with flatulence and dyspepsia who have gallstones should be observed. Those who have symptoms of biliary pain, gallstone-induced pancreatitis, or common duct stones should have corrective surgery. Those who refuse surgery or who aren't surgical candidates might be treated with dissolution therapy. Dissolution of gallstones with chemical agents and extracorporeal shock-wave lithotripsy show some promise. We need a better understanding of the etiology and formation of gallstones to address the disease from a preventive standpoint and reduce the incidence of cholelithiasis and cholecystitis, and their complications.     

Gallstones. When to observe, when to treat

Although observation is the best form of therapy for patients with asymptomatic gallstones, surgical management offers the least risk and greatest benefit to patients with symptomatic disease. This is particularly true of patients with diabetes and patients over 60 years of age. Dissolution therapy may play a major role in the treatment of symptomatic cholesterol gallstones in the future, but at present the most effective approach remains early cholecystectomy.     

食管癌术后发生胆结石39例临床分析

目的 探讨食管癌术后发生胆结石的机制.方法 回顾性分析我院2007年3月至2010年12月经手术治疗297例食管癌患者的临床资料,包括近期复查随访资料,观察术后胆结石发病情况.结果 本组297例患者术后胆道疾病发病率为17.2％ (51/297),其中胆囊内沉积物形成12例;胆结石39例,发病率为13.1％ (39/297).39例中男24例,女15例;胆囊结石26例,肝内外胆管结石13例;术后1个月内发现1例,1～3个月内3例,4～6个月内8例,6个月～1年内6例,1～2年内9例,2～3年内12例.结论 食管贲门癌根治术后有较高的胆结石发病率,迷走神经的切断在胆结石的发生中起着重要作用,手术中应尽可能保留迷走神经.     

23例妊娠合并急性胆囊炎患者的护理

目的总结23例妊娠合并急性胆囊炎患者的护理要点。方法2007年8月～2012年1月收治23例妊娠合并急性胆囊炎患者,19例给予非手术治疗,3例给予手术治疗,1例流产,治疗过程配合做好护理工作。结果患者均治愈出院,住院时间7～21 d,平均（12.7±4.7）d。结论对妊娠合并急性胆囊炎患者进行保守及手术治疗过程,应重点做好患者病情变化及胎儿情况观察、心理护理、饮食护理,从而保障母婴生命安全。     

Laparoscopic cholecystectomy in cardiac transplant patients - lower threshold for surgery?

Summary

Laparoscopic cholecystectomy is accepted by the surgical community as an advance in the definitive treatment of gallstones. In this paper we describe five patients post-cardiac transplantation, in whom laparoscopic cholecystectomy was undertaken. One patient, who had two previous laparo-tomies, required conversion to an open cholecystectomy. In each case the gallstones were symptomatic and were a major cause of morbidity. The average hospital stay was 4 days in uncomplicated cases, but was prolonged in one patient who required stabilization of cyclosporin levels (7 days) and in one patient due to a sub-hepatic collection (17 days). This was successfully treated by percutaneous ultrasound guided drainage. The technical problems of laparoscopic cholecystectomy are no different in transplant patients but it may have the advantage of being less immunotraumatic and allow earlier mobilization. Laparoscopic cholecystectomy is an advance in the treatment of gallstones and because of the risks of acute cholecystitis in cardiac transplant patients, should lower the threshold to definitive surgery.     

Laparoscopic surgery for gallbladder stones.

The radical treatment of gallstones consists of removal of the calculi and prevention of their recurrence, and cholecystectomy is at present the common solution. Since Langebuch's first operation in 1882, Calot reporting the first French case in 1889, cholecystectomy has reached a high level of technical perfection. With a small access route and complete exploration of the common bile duct, the results are well known: global mortality is less than 0.1%. Frequently, specialised teams report series of patients under 50 years of age with zero mortality. Are there other techniques that permit the removal of calculi and the removal of the gallbladder with results comparable or better than the classic cholecystectomy? We have perfected an operative technique using laparoscopy that destroys the calculi with an ultrasonic lithotriptor followed by drainage or removal of the gallbladder. Our initial results are favourable.     

Problems of retained calculi in the bile duct.

A study of 68 patients subjected to re-surgery for residual or recurrent gallstones provided the following results: Among the 68 patients, the stones were recurrent in only 4, residual in 38, and uncertain but mostly suggesting residual in the other 26 cases. In many of the residual stone cases, the previous operations were cholecystectomy alone, retrospectively suggesting insufficient search for residual stones and other abnormalities in the biliary tract during the operations. Of the 4 recurrent stone cases, 3 of them showed bile duct stricture, papillary stenosis and idiopathic choledochus dilatation, respectively, while the remaining one, though free of any sign of bile stasis, had a gallstone formed around a silk-thread core. The indications for additional sphincteroplasty and biliodigestive anastomosis in re-operations were strictly consistent with those in the first operations. Seven operative fatal cases (10%) were mostly those of long persistent gallstones with serious hepatic failure. The follow-up studies in 53 patients showed as many as 51 cases returning to the preoperative occupation without any significant complaints. These results emphatically suggest that retained gallstone cases should be referred to surgical treatment as early as possible.     

Frontiers of gallstone therapy. How far have we come with nonsurgical methods?

In the next few years, much will be learned about nonsurgical treatment of gallstones, and the role of each method will be more clearly defined. At present, each used alone has limitations (table 1). Oral chemolysis can be used for any number of gallstones, but only about 20% of patients are candidates for this method. Complete dissolution of stones can take months to years. Direct-contact dissolution therapy is rapidly effective, is inexpensive, and can be used for any size and number of gallstones. However, it is invasive, and only about 20% of patients are suitable candidates. Extracorporeal shock wave lithotripsy is noninvasive and avoids the complications and long recovery period of surgery. Up to three stones can be treated, but patients with certain medical conditions are excluded. About 20% to 30% of patients can undergo this treatment. None of these nonsurgical treatments prevents recurrence. Shock wave lithotripsy and dissolution with methyl tert-butyl ether are still in the experimental stage, so results of further study--particularly of combinations of the methods--are eagerly awaited by persons who have had symptomatic gallstones.     

Treatment of cholelithiasis in children with sickle cell disease

Medical and surgical advances have improved the treatment of cholelithiasis (ie, gallstones) in children with sickle cell disease (SCD). Children with SCD have an increased risk of developing pigment gallstones that initially may be asymptomatic but that can lead to acute symptoms of cholelithiasis. An elective laparoscopic cholecystectomy procedure is recommended for pediatric patients with SCD to prevent the risk of requiring an emergency cholecystectomy procedure. The primary benefits of this approach include a shorter hospital stay after surgery, decreased postoperative discomfort, decreased risk of complications, and a quicker return to normal activities. AORN J 77 (June 2003) 1170-1182.     

Cholecystosonography in pregnancy

Ultrasound is currently the modality of choice for examination of the fetus in pregnancy. Pregnancy is felt to be a possible risk factor for the development of gallstones. The purpose of this study was to determine whether obstetric patients sent for ultrasonic evaluation should have a simultaneous ultrasonic examination of the gallbladder to detect asymptomatic gallstones. In this study, 11.3 per cent of 142 patients were found to have gallstones. The authors conclude that cholecystosonography should be performed on pregnant patients sent for ultrasonic examination.     

Cystic duct dilation through endoscopic retrograde cholangiopancreatography for treatment of gallstones and choledocholithiasis: Six case reports and review of literature

BACKGROUNDCholedocholithiasis removal via endoscopic retrograde cholangiopancreatography (ERCP) then followed by laparoscopic cholecystectomy (LC) has gradually become the principal method in the treatment of gallstones and choledocholithiasis. We use ERCP through the cystic duct to treat gallstones combined with choledocholithiasis, with the aim to preserve the normal function of the gallbladder while simultaneously decreasing risk of biliary tract injury.CASE SUMMARYA total of six cases of patients diagnosed with gallstones and choledocholithiasis were treated with ERCP. The efficacy was evaluated via operation success rate, calculus removal rate, postoperative hospital stay and average hospitalization costs; the safety was evaluated through perioperative complication probability, gallbladder function detection and gallstones recrudesce. The calculus removal rate reached 100%, and patients had mild adverse events, including 1 case of postoperative acute cholecystitis and another of increased blood urinary amylase; both were relieved after corresponding treatment, the remaining cases had no complications. The average hospital stay and hospitalization costs were 6.16 ± 1.47 d and 5194 ± 696 dollars. The 3-11 mo follow-up revealed that gallbladder contracted well, without recurrence of gallstones.CONCLUSIONThis is the first batch of case reports for the treatment of gallstones and choledocholithiasis through ERCP approached by natural cavity. The results and effects of six reported cases proved that the new strategy is safe and feasible and is worthy of further exploration and application.     

Management of parotid gland tumors in infants and children.

Seventy-four pediatric patients with parotid gland tumors were seen during a 52-year period. Seventy percent of the lesions were benign and 30% were malignant. When the primary treatment is either subtotal or total parotidectomy, the recurrence rate was 2.3%. The facial nerve should be dissected free of parotid parenchyma and preserved, except if the lesion was malignant--a situation in which the nerve might have to be sacrificed totally or in part to ensure adequate tumor removal. No patient died of a benign or malignant lesion in this series, and the morbidity after surgical removal of primary tumors of the parotid gland in children and infants was low.     

Surgical treatment of pancreatitis: review of a series.

In this review of the surgical experience with pancreatitis, 55 patients had acute relapsing pancreatitis associated with gallstones and 47 had chronic pancreatitis of alcoholic, idiopathic, or familial causation. The severity of pancreatitis associated with gallstones could not be correlated with results of preoperative biochemical tests; only one-third of patients were found to have stones within the biliary ductal system; and postoperative mortality (5%) could not be correlated with the severity of pancreatic inflammation or the timing of surgical intervention. Postoperative observations have revealed that all but four of the patients have remained asymptomatic. With regard to the patients with alcoholic, idiopathic, or familial disease who had significant pancreatic ductal dilatation or obstruction, ductal drainage procedures with or without resection benefited 80%. In the absence of ductal dilatation or obstruction, major resective surgery benefited 50% of patients. Continuing alcohol abuse limited the effectiveness of any operative procedure, and diabetes occurred more often after major resective procedures.     

Chemical analysis of gallstones.

A new promising treatment for patients with symptomatic cholelithiasis is extracorporeal shock wave lithotripsy. In order to learn how to interpret the computed tomographic (CT) densities of gallstones measured in vivo, our radiologists asked the clinical chemistry laboratory to analyse cholesterol, bilirubin and calcium in gallstones. No reference methods for the analysis of gallstones have been described. A literature search for manageable quantitative methods for these analyses was not successful. Among the different X-ray diffraction, infrared and chemical analyses described, we could find no well documented analyses that have been compared with reference methods or proposed reference methods for serum. This finding prompted us to develop chemical methods for cholesterol, bilirubin and total calcium in gallstones starting from (proposed) reference methods for serum and to investigate the accuracy, imprecision and linearity of these methods.     

Chenodeoxycholic acid therapy for gallstones: effectiveness, toxicity and influence on bile acid metabolism.

Chenodeoxycholic acid (1 g daily) was administered to 10 patients with gallstones and three patients with biliary stricture and recurrent cholangitis. Four gallstone patients showed diminution or disappearance of stones including one patient whose stone was in the common bile duct. The patients with recurrent cholangitis showed marked improvement in symptoms during treatment. Serum bile acid levels were significantly elevated in 8 gallstone patients during treatment. Liver biopsy in eight gallstone patients during treatment revealed minor changes in five. Lithocholic acid and bile acid sulphates were found in only small amounts in the bile of patients during treatment. No significant trend in biliary lipid composition during treatment was observed. There was no overall trend in the group of patients whose stones disappeared or diminished. Changes in biliary bile acid composition and in bile acid pool sizes were variable following treatment and could not be correlated with the clinical results of treatment. A further trial of chenodeoxycholic acid is recommended in patients with stones in the biliary tree and recurrent cholangitis who are not amenable to surgical treatment.     

Spontaneous biliary enteric fistulas

Biliary enteric fistulas usually occur as a complication of chronic cholelithiasis, may be difficult to document preoperatively, and often pose problems in surgical management. We reviewed 13 cases of spontaneous biliary enteric fistulas to identify methods of diagnosis, management, and complications. There was no specific set of clinical symptoms or signs that led to the diagnosis of a fistula. In six cases the diagnosis was made preoperatively by x-ray films showing pneumobilia, gallstone in the small bowel, or fistula. Initial surgical treatment included cholecystectomy in six cases, small bowel enterotomy and removal of gallstones in four, and vagotomy and antrectomy in one case. Two patients initially treated without operation were lost to follow-up. Eight complications occurred in six patients, and there were three deaths due to underlying cardiac disease. The morbidity and mortality of biliary enteric fistulas associated with chronic cholecystitis may be avoided by performing elective cholecystectomy when the patient is in optimal condition.     

Postpartum thrombophlebitis of the ovarian vein.

Puerperal pelvic thrombophlebitis is most commonly found in the ovarian veins. It may be diagnosed by laparotomy, but it should be suspected clinically when symptoms develop two to five days after delivery. If medical treatment with antibiotics, anticoagulants, and bed rest is unsuccessful, surgical intervention with ligation or removal of ovarian veins may be necessary.     

The variable appearances of fetal gallstones.

Only four cases of fetal gallstones have been reported previously, which implies that this condition is rare. Gallstones in children have been reported more frequently, and it may be that some of these are present in fetal life. Over a 12 month period in this department, seven cases of gallstones or sludge were seen within the fetal gallbladder. The variable appearances of fetal cholelithiasis are described and the possible causes discussed. Fetal gallstones may not be as rare as indicated by the paucity of cases in the literature.     

Skin cancer of the head and neck. How to recognize and treat it

Skin cancer is the most common malignant tumor encountered in humans, with the head and neck being the most likely sites. The physician should be suspicious of malignant disease when evaluating any skin lesion, and a biopsy is easily performed on those that are questionable. The optimal method of treatment is surgical removal of the cancer in conjunction with histopathologic confirmation of the adequacy of excision. Reconstruction of the surgical defect is best performed by someone familiar with the use of local and regional skin flaps in the head and neck region.