Laparoscopic Management of Common Bile Duct Stones: Transpapillary Stenting or External Biliary Drainage?

Background:

To date, the management of common bile duct stones (CBDs) is still controversial. If laparoscopic exploration is performed and biliary decompression is needed after stone removal, the placement of a laparoscopic transpapillary stent shows promising results in avoiding T-tube–related complications.

Methods:

Between January 2007 and May 2012, a series of 48 patients who underwent biliary decompression after laparoscopic common bile duct exploration (LCBDE) to treat choledocholithiasis was retrospectively analyzed. The results in patients with transpapillary stent placement (TS=35) were compared with those who had an external biliary drainage (EBD=13).

Results:

LCBDE and TS placement was achieved either by a choledochotomy or through the cystic duct. There was no mortality in our series. Patients with an external biliary drainage (EBD) had more surgery-related complications (P<.0001) and a longer hospital stay (P=.03). Postoperative ERCP to remove the TS was successful in all cases.

Conclusion:

Laparoscopic TS is a safe method in the treatment of selected patients with CBD stones that can be achieved without having to perform a choledochotomy. Because of the lower morbidity and the shorter hospital stay compared with EBD, it should be considered as a first approach whenever biliary decompression is needed after LCBDE.     

Severity of Acute Cholecystitis and Risk of Iatrogenic Bile Duct Injury During Cholecystectomy,a Population-Based Case–Control Study

Background

Acute cholecystitis is a common complication to gallstone disease. The relation between the severity of acute cholecystitis and risk of bile duct injury during cholecystectomy has not yet been addressed and is the main focus of this study.

Methods

All cases with iatrogenic bile duct injury during cholecystectomy, within the Lake Mälaren region, Sweden, were identified through ICD procedure codes for biliary reconstruction within the Swedish Inpatient Register and matched to non-injured cholecystectomized controls. Information regarding perioperative variables was collected through medical record review.

Results

After review, 158 cases and 623 controls remained for analyses. Adjusted risk of bile duct injury was doubled among patients with acute cholecystitis (OR 1.97 95 % CI 1.05–3.72), whereas a mild acute cholecystitis (Tokyo grade I) did not affect the risk of bile duct injury (OR 0.96 95 % CI 0.41–2.25), a moderate (Tokyo grade II) more than doubled the risk (OR 2.41 95 % CI 1.21–4.80). Severe cholecystitis (Tokyo grade III) had a close to significant eightfold increase in risk (OR 8.43 95 % CI 0.97–72.9). The intention to use intraoperative cholangiography reduced injury risk by 52 % (OR 0.48, 95 % CI 0.29–0.81).

Conclusions

Patients with on-going acute cholecystitis had twice the risk of sustaining a biliary lesion compared to patients without acute cholecystitis. There was a relation between the Tokyo guidelines severity grading of acute cholecystitis and injury risk and the intention to use intraoperative cholangiography halved the risk of reconstructed bile duct injury during cholecystectomy.

     

Advances in Lasers for the Treatment of Stones—a Systematic Review

Purpose of Review

Laser lithotripsy is increasingly used worldwide and is a continuously evolving field with new and extensive research being published every year.

Recent Findings

Variable pulse length Ho:YAG lithotripters allow new lithotripsy parameters to be manipulated, and there is an effort to integrate new technologies into lithotripters. Pulsed thulium lasers seem to be a viable alternative to holmium lasers. The performance of similar laser fibers varies from manufacturer to manufacturer. Special laser fibers and “cleaving only” fiber tip preparation can be beneficial for the lithotripsy procedure. Different laser settings and the surgical technique employed can have significant impact on the success of laser lithotripsy. When safely done, complications of laser lithotripsy are rare and concern the endoscopic nature of procedure, not the technology itself, making laser lithotripsy one of the safest tools in urology.

Summary

Laser lithotripsy has had several new developments and more insight has been gained in recent years with many more advances expected in the future.

     

Routine Use of Simultaneous Laparoendoscopic Approach in Patients with Confirmed Gallbladder and Bile Duct Stones: Fit for Laparoscopy Fit for “Rendezvous”

Background

The aim of the present work was to determine the feasibility and efficacy, in terms of equipment coordination and timing, of the laparoendoscopic intraoperative rendezvous technique (RVT) for the treatment of gallbladder and common bile duct stones (CBDS).

Methods

The procedure was considered in 269 unselected patients with a suspicion or preoperative imaging demonstration of CBDS who were fit for laparoscopic cholecystectomy (LC). Common bile duct stones were confirmed by intraoperative laparoscopic cholangiography (IOC) in only 113 of these patients (42 %). In 17 (15 %) patients the planned procedure was aborted because of organizational problems, mainly the unavailability of endoscopists in the urgent setting. The remaining 96 patients (84 %) underwent a formal attempt at RVT. Intraoperative endoscopic retrograde cholangiography (ERC) was performed, during LC, by means of a guidewire that reached the duodenum through the cystic duct.

Results

In 18 patients (19 %) the complete procedure failed, either because of difficulty in passing the guidewire through the papilla or because of other technical difficulties that required conversion to laparotomy. An intraoperative ERC was completed in six patients in the classical way (no guidewire) without conversion. No mortality and few complications were recorded (3 % overall: 1 perforation and 2 cholangitis). Retained stones were successively detected in 6 patients (6 %) and successfully retreated by a further ERC. Globally, the one-stage procedure (with and without the guidewire) was possible in 84 of 96 patients (87 %).

Conclusions

The RVT appears to be effective and safe as it was performed at our institution, with an overall percentage of definitive success (passed guide wire and no further ERC) of 81 %. The RVT should be considered as a good option for the treatment of simultaneous gallstones and CBDS.     

Trends in Use of Upper Abdominal Procedures in Sweden 1998–2011: A Population-Based Study

Background

Surgical care is constantly developing as demographic shifts occur and indications change when new techniques are introduced. The purpose of this study was to describe trends of in-hospital upper abdominal procedures in Sweden during 1998–2011.

Methods

Data were collected from the National Patient Register containing annual number of procedures and procedures per 100,000 inhabitants. Comparisons were made between the first 3 years (1998–2000) and last 3 years (2009–2011). High-volume procedures and resectional surgery were studied in particular.

Results

During the study period, a total of 435,394 upper abdominal procedures were performed in 318,991 individuals. The number of procedures increased 44.9 % between the early and late period. Bariatric surgery increased almost sixfold, with a substantial increase in laparoscopic gastric bypass to 58.2/100,000/year. The most common operation was cholecystectomy, 144.9/100,000/year. Liver resections tripled and, in total, major resectional surgery, performed on the esophagus, stomach, liver, and pancreas, increased by 36.3 %. Per 100,000 adult inhabitants and year, resections of the esophagus was performed in 2.3 patients, stomach in 5.9, liver in 9.0, and pancreas in 5.7, in late time period. An increase in all types of endoscopic work was observed.

Conclusions

In total, the number of upper abdominal procedures performed per inhabitant increased. Laparoscopic gastric bypass increased substantially and became the second most common procedure after laparoscopic cholecystectomy. An increase in resectional surgery was observed.     

Epidemiology of hand injuries in a middle‐sized city in southern Sweden: a retrospective comparison of 1989 and 1997

Case notes of patients with hand injuries that required referral to our department in 1989 and 1997, were analysed retrospectively. The incidence of such an injury was at least 7/1000 inhabitants/year (12% of the patients seen in the orthopaedic Accident and Emergency department). Most of the patients were young men with minor injuries, most commonly injured during leisure activities. Only 22% of the patients who worked were injured at work, but such injuries increased the risk of admission to hospital. The amount of sick leave was significantly shorter in 1997, and 77% of the workers were off work for less than two months. There was a reduced risk of injury during July, November, and December, and on Tuesdays. Type and range (type/mechanism/severity) of injuries differed slightly between the years and among the various age groups. Epidemiological data about hand injuries that affect young patients of productive age, are important to optimise resources and organisation of the health care system.     

Immunoglobulin G4–Related Sclerosing Cholangitis Mimicking Hilar Cholangiocarcinoma Diagnosed With Following Bile Duct Resection: Report of a Case

We report a rare case of immunoglobulin G4 (IgG4)–related sclerosing cholangitis without other organ involvement. A 69-year-old-man was referred for the evaluation of jaundice. Computed tomography revealed thickening of the bile duct wall, compressing the right portal vein. Endoscopic retrograde cholangiopancreatography showed a lesion extending from the proximal confluence of the common bile duct to the left and right hepatic ducts. Intraductal ultrasonography showed a bile duct mass invading the portal vein. Hilar bile duct cancer was initially diagnosed and percutaneous transhepatic portal vein embolization was performed, preceding a planned right hepatectomy. Strictures persisted despite steroid therapy. Therefore, partial resection of the common bile duct following choledochojejunostomy was performed. Histologic examination showed diffuse and severe lymphoplasmacytic infiltration, and abundant plasma cells, which stained positive for anti-IgG4 antibody. The final diagnosis was IgG4 sclerosing cholangitis. Types 3 and 4 IgG4 sclerosing cholangitis remains a challenge to differentiate from cholangiocarcinoma. A histopathologic diagnosis obtained with a less invasive approach avoided unnecessary hepatectomy.Key words: Immunoglobulin G4, Cholangitis, Cholangiocarcinoma, Autoimmune pancreatitis, Hepatectomy, DiagnosisSerum immunoglobulin G4–related sclerosing cholangitis (IgG4-SC) is a type of autoimmune pancreatitis associated with elevated serum IgG4 levels.^1,2 Types 3 and 4 IgG4-SC are difficult to differentiate from bile duct cancer, and hepatectomy has been reported sporadically in such situations.^3,4 We describe a rare case of a patient with IgG4-SC but without pancreatic lesions. Accurate diagnosis was made, without the need for performing a partial hepatectomy.     

Suicide Risk in Men with Prostate-Specific Antigen–Detected Early Prostate Cancer: A Nationwide Population-Based Cohort Study from PCBaSe Sweden

Background

The risk of suicide is increased among cancer patients including men with prostate cancer (PCa). However, whether this increased risk applies to men diagnosed subsequent to prostate-specific antigen (PSA) testing is not known.

Objective

To assess the risk of suicide among men diagnosed with PCa subsequent to PSA testing.

Design, setting, and participants

The Prostate Cancer Base Sweden (PCBaSe Sweden) database, the Swedish Cause of Death Register, and the Swedish census database were used. The PCBaSe Sweden is a merged database that includes data from the Swedish National Prostate Cancer Register (NPCR) for cases diagnosed between January 1, 1997, and December 31, 2006. The number of suicides registered for cases in the PCBaSe cohort was compared with the expected number of suicides in an age-matched general male Swedish population.

Measurements

Standardised mortality ratios (SMRs) with 95% confidence intervals (CIs) were calculated for different categories of cases.

Results and limitations

There were 128 suicides among the 77 439 PCa cases in the NPCR compared with an expected number of 85 (SMR: 1.5; 95% CI, 1.3–1.8). The risk of suicide was not increased for the 22 405 men with PSA-detected T1c tumours (SMR: 1.0; 95% CI, 0.6–1.5), whereas the 22 929 men with locally advanced nonmetastatic tumours (SMR: 2.2; 95% CI, 1.6–2.9) and the 8350 men with distant metastases (SMR: 2.1; 95% CI, 1.2–3.6) had statistically significant increased SMRs for suicide. Potential effects of comorbid medical and psychiatric conditions could not be investigated.

Conclusions

No increased risk of committing suicide was observed among men with PCa diagnosed subsequent to PSA testing, whereas the risk was twice as high among men with locally advanced or metastatic disease, compared with an age-matched male population.     

Treatment of a Left Common Iliac Aneurysm with Endovascular Powerlink® Stentgraft in a Patient with an Occlusion of a Left Common Iliac Stent

Isolated iliac aneurysms are uncommon and account for only 2% of all abdominal aneurysms. Typically, patients presenting with this pathology are operated on surgically. In our patient, however, surgery could have been an option but the patient had undergone a laparotomy more than 50 years earlier because of a gun-shot wound, so we preferred an endovascular repair. Furthermore, regular endovascular repair with a straight tube stentgraft was impossible due to the absence of a proximal neck. Consequently, we opted for placing a bifurcated stentgraft to exclude the iliac aneurysm.     

Volume–Outcome Associations after Major Hepatectomy for Hepatocellular Carcinoma: a Nationwide Taiwan Study

Objective

The objective of this study was to explore volume–outcome associations after major hepatectomy for hepatocellular carcinoma (HCC).

Methods

This population-based cohort study retrospectively analyzed 23,107 major hepatectomies for HCC patients from 1998 to 2009. Relationships between hospital/surgeon volume and patient outcome were analyzed by propensity score matching (PSM). Five-year overall survival (OS) was estimated by Kaplan–Meier method, and differences were compared by log-rank test.

Results

The mean length of stay (LOS) after major hepatectomy was 18.1 days, and the mean hospital cost was US$5,088.2. After PSM, the mean OS in high- and low-volume hospitals was 71.1 months (standard deviation (SD) 0.7 months) and 68.6 months (SD 0.6 months), respectively; the mean OS in high- and low-volume surgeons was 78.5 months (SD 0.7 months) and 66.9 months (SD 0.7 months), respectively. The PSM analysis showed that treatment by high-volume hospitals and treatment by high-volume surgeons were both associated with significantly shorter LOS, lower hospital cost, and longer survival compared to their low-volume counterparts (P?<?0.001).

Conclusions

The results of this nationwide study support the regionalization of HCC treatment by hospital volume and by surgeon volume. High surgeon volume revealed both short- and long-term benefits. The applicability of PSM in volume–outcome analysis may also be confirmed.     

ASO Author Reflections: Impact of Bile Duct Tumor Thrombus in Hepatocellular Carcinoma—Does it Influence Staging Systems?

Annals of Surgical Oncology -     

Observational study of risk factors associated with clinical outcome among elderly kidney transplant recipients in Sweden – a decade of follow-up

Kidney transplantation (Ktx) in elderly has become increasingly accepted worldwide despite their higher burden of comorbidities. We investigated important risk factors affecting long-term patient and graft survival. We included all (n = 747) Ktx patients >60 years from 2000 to 2012 in Sweden. Patients were age-stratified, 60–64, 65–69 and >70 years. Follow-up time was up to 10 years (median 7.9 years, 75% percentile >10 years). Primary outcome was 10-year patient survival in age-stratified groups. Secondary outcomes were 5-year patient and graft survival in age-stratified groups and the impact of risk factors including Charlson comorbidity index (CCI) on patient and graft survival. Mortality was higher in patients >70 years, after 10 years (HR 1.94; 95% CI 1.24–3.04; P = 0.004). Males had a higher 10-year risk of death (HR 1.39; CI 95% 1.04–1.86; P = 0.024). Five-year patient survival did not differ between age groups. In multivariate Cox analysis (n = 500), hazard ratio for 10-year mortality was 4.6 in patients with CCI ≥7 vs. <4 (95% CI 2.42–8.62; P = 0.0001). Higher CCI identified ESKD patients with 4.6 times higher risk of death after Ktx. We suggest that this index should be used as a part of the preoperative evaluation in elderly.     

Gabapentin Versus Levodopa for the Treatment of Restless Legs Syndrome in Hemodialysis Patients: An Open‐Label Study

Background. Restless Legs Syndrome (RLS), a common problem increasing morbidity and mortality in hemodialysis (HD) patients, affects 20–30% of uremic patients. Our aim was to find the efficacy of gabapentin in the treatment of RLS in HD patients by comparing a largely used drug, levodopa. Methods. Patients with RLS answered three questionnaires (RLS rating scale proposed by IRLSSG, the Short Form (SF)‐36 and the Pittsburgh Sleep Quality Index) for the evaluation of severity of RLS, effects on quality of life and quality of sleep. Results. Fifteen patients (4.7%) (5 F, 10 M) with a mean age of 45.8 ± 15.3 years got RLS diagnosis. When we compare the two drugs for severity of RLS symptoms relief, the effect of gabapentin was more significant (p < 0.001). Gabapentin significantly improved general health, body pain and social functions (p < 0.001). Moreover, regarding sleep parameters, gabapentin was significantly superior to levodopa for sleep quality, sleep latency (p < 0.001) and sleep disturbance (p < 0.000). Conclusion.. To our knowledge this was the first study comparing gabapentin and levodopa efficacy for the treatment of RLS in HD patients. Our results suggested that gabapentin is an effective drug for the management of RLS in hemodialysis patients.     

Intraductal Papillary-mucinous Tumors Arising in Santorini’s Duct: Clinicopathologic Features and the Treatment of Choice

Almost all reported cases of intraductal papillary-mucinous tumors of the pancreas (IPMTs) originate from Wirsungs duct (WD), the main pancreatic duct, or their branches. IPMTs arising from Santorinis duct (SD) and its branches have rarely been reported. This article presents the clinicopathologic features of IPMTs originating in SD and its branches. Of 36 IPMTs resected in our institution, 5 originated in the region of SD: 3 in SD and 2 from its branches. Both SD and WD were dilated in all cases on radiographic and ultrasonographic studies. The maximum diameter of SD, determined by computed tomography or ultrasonography, was larger than that of WD in all cases. Seven reports of IPMT arising from SD have been published. Four lesions originated from SD and the others from its branches. Overall, 9 of 12 lesions (75%) were considered malignant. In conclusion, the coexistence of an IPMT and a dilated SD suggests an origin in the SD. These tumors have a high malignant potential and should be excised.