Management of common bile-duct stones and associated gallbladder stones: surgical aspects

In most countries, endoscopic sphincterotomy is the first-choice treatment for common bile-duct stones. In patients with residual gallbladder stones, laparoscopic cholecystectomy is the next step. The optimal timing of laparoscopic cholecystectomy after endoscopic sphincterotomy remains to be determined. An alternative approach of combined cholecystocholedocholithiasis consists of laparoscopic cholecystectomy together with laparoscopic stone removal. The advantage of this ‘single-stage’ therapy appears to be limited to patients with stones that can be removed transcystically. This approach is successful in about half of the patients. Laparoscopic common bile-duct exploration is technically more demanding, more time-consuming, and associated with increased postoperative morbidity. If transcystic removal is not possible, a postoperative ERCP with endoscopic sphincterotomy is a good option. Intraoperative ERCP and endoscopic sphincterotomy are also feasible, but require specific organisational efforts.Recurrence of choledocholithiasis after ES is reported in a considerable number of patients (6–21%), resulting from de novo primary stone formation or recurrent secondary migration from the gallbladder. Primary choledocholithiasis is associated with bactobilia and delayed bile-duct clearance, indicated by CBD dilation. Endoscopic reintervention is safe and usually easy to perform. Surgery should be reserved for intractable cases. In selected patients, an underlying lithogenic bile composition (low-phospholipid-associated cholelithiasis) should be identified, and preventive medical treatment with UDCA could be considered.

• in patients with combined cholecystocholedocholithiasis, endoscopic sphincterotomy should be followed by elective laparoscopic cholecystectomy, even in the elderly; however, a ‘wait-and-see’ policy does not lead to higher mortality, and therefore expectant management can be advocated in case of significant contraindications to surgery

• laparoscopic cholecystectomy combined with laparoscopic stone removal offers a one-stage treatment of patients with combined cholecystocholedocholithiasis. Laparoscopic transcystic duct clearance is associated with low morbidity and short hospital stay. In contrast, laparoscopic common bile-duct exploration remains a procedure with increased risk of biliary complications and prolonged hospital stay. In case of stones that cannot be removed transcystically, it may be wise to perform an intraoperative or early postoperative ERCP

• performing an endoscopic sphincterotomy during laparoscopic cholecystectomy using a ‘rendezvous’ procedure may be beneficial in selected patients (especially in case of earlier failed ERCP)

• laparoscopic cholecystectomy after endoscopic sphincterotomy is associated with increased conversion rates to open procedure compared to laparoscopic cholecystectomy for uncomplicated gallstones; laparoscopic cholecystectomy planned early after endoscopic sphincterotomy may reduce this risk

• morphological or functional bile-duct defects, indicated by a dilated CBD, may lead to bactobilia and biliary stasis, thus promoting primary stone formation

• in a subgroup of patients with recurrent bile-duct stones, an MDR3 gene mutation must be considered, resulting in low-phospholipid-associated cholelithiasis. These patients are characterised by early onset of symptoms, recurrence after cholecystectomy, hyperechogenic foci in the liver, and often a history of intrahepatic cholestasis of pregnancy. Ursodeoxycholic acid is beneficial in these patients

• the optimal timing or ERCP in patients scheduled for laparoscopic cholecystectomy (before, during, or after the operation) still needs to be defined.

• further data are needed to determine potentially increased incidence of conversion and postoperative complications for laparoscopic cholecystectomy after endoscopic sphincterotomy compared to laparoscopic cholecystectomy for uncomplicated gallstones

Clericuzio type poikiloderma with neutropenia is distinct from Rothmund-Thomson syndrome

Two siblings from a consanguineous family presented with a poikiloderma of limbs and face, plantar keratoderma, and toenail pachyonychia. Neutropenia and neutrophil dysfunction with impairment of the respiratory burst and bacterial killing resulted in frequent respiratory tract infections. A bronchocentric granulomatous pneumonia was a fatal complication. The clinical presentation is consistent with Clericuzio type poikiloderma with neutropenia. Literature review identified several additional probable patients. Genetic linkage analysis excluded the locus of the RECQL4 gene, mutations in which have been described in some patients with the Rothmund-Thomson poikiloderma syndrome. This report confirms the clinical and genetic identity of the Clericuzio type of poikiloderma with neutropenia syndrome.     

Dysphagia in Head and Neck Cancer Patients Treated with Chemoradiotherapy

Dysphagia is a very common complaint of head and neck cancer patients and can exist before, during, and after chemoradiotherapy. It leads to nutritional deficiency, weight loss, and prolonged unnatural feeding and also has a major potential risk for aspiration. This has a significant negative impact on the patient’s entire quality of life. Because treatment of dysphagia in this setting is rarely effective, prevention is paramount. Several strategies have been developed to reduce dysphagia. These include swallowing exercises, treatment modification techniques such as intensity-modulated radiotherapy, selective delineation of elective nodes, reducing xerostomia by parotid-sparing radiotherapy, and adding of radioprotectors. However, more research is needed to further decrease the incidence of dysphagia and improve quality of life.     

The dialytic management of acute renal failure in the elderly

In this article the different dialysis strategies in the management of acute renal failure (ARF) in the elderly are discussed. Although peritoneal dialysis (PD) offers some theoretical advantages, there are several medical and technical reasons why it is currently less frequently used. The choice between intermittent hemodialysis (HD) and continuous renal replacement therapy (CRRT) is determined by a number of considerations, the most important ones being hemodynamic stability, the need for hyperalimentation and/or ultrafiltration, and the local experience with one or both techniques. Some recent studies with CRRT in elderly ARF patients describe favorable results. Slow extended daily dialysis (SLEDD) modalities may be particularly indicated in elderly, critically ill ARF patients because these techniques combine the advantages of both CRRT and HD. Finally, the importance of the biocompatibility of dialysis membranes is discussed. Although there are a number of theoretical arguments to use biocompatible membranes, this opinion is not always supported by the results of recent comparative studies. It is the opinion of the authors that all dialysis strategies should be mastered and utilized for appropriate indications in elderly ARF patients.     

Detection of flunitrazepam and 7-aminoflunitrazepam in oral fluid after controlled administration of rohypnol

Although administered as a short-acting hypnotic for sleeping disorders, flunitrazepam, often in combination with alcohol or other drugs, was one of the most frequently abused benzodiazepines over the last 10 years. It has been reported in cases of driving under the influence, and its use is associated with marked psychomotor impairment. Studies over the last five years have investigated the use of oral fluid as an alternative matrix to blood and urine, especially when non-intrusive and quick sampling procedures are important (e.g., screening for drugs of abuse at the roadside and screening and confirmatory workplace drug testing). In this study, Rohypnol (flunitrazepam) was administered to four healthy volunteers, and oral fluid samples were collected by spitting into a polypropylene tube at fixed times between 0 and 6 h after the intake of a tablet of 1 mg. A specific and very sensitive method was developed, both for flunitrazepam and for its main metabolite 7-aminoflunitrazepam, based on solid-phase extraction of the oral fluid samples, stored at +4 degrees C, and gas chromatographic-mass spectrometric analyses using negative chemical ionization with methane as the ionization gas. The heptadeuterated parent compound and metabolite were used as internal standards. The respective limits of detection and quantitation were 0.05 microg/L and 0.1 microg/L for flunitrazepam, and 0.1 and 0.15 microg/L for 7-aminoflunitrazepam. The parent drug could only be detected when the analyses were performed within 12-24 h after collection of the oral fluid samples or when 2% of NaF was added to the collection tubes. The stability of flunitrazepam in oral fluid was poor, even at +4 degrees C, when no NaF was added to the sample. In any case, concentrations remained below 1 microg/L. The metabolite was detected in slightly higher concentrations, with or without the presence of NaF, reaching a maximum of 1-3 microg/L within 2-4 h after administration. In all cases the drug was detectable, but at extremely low concentrations, for 6 h after intake of a normal dose of Rohypnol and it will be an analytical challenge to come up with a sufficiently sensitive onsite test for low-dose benzodiazepines in oral fluid.     

Idebenone treatment in Friedreich's ataxia: neurological,cardiac, and biochemical monitoring

The authors report 1-year prospective data on eight patients with Friedreich ataxia. Idebenone did not halt the progression of ataxia. At the end of therapy, cardiac ultrasound demonstrated significant reduction of cardiac hypertrophy in six of eight patients. Cardiac strain and strain rate imaging showed that the reduction of hypertrophy is preceded by an early and linear improvement in cardiac function. Idebenone reduced erythrocyte protoporphyrin IX levels in five of six patients with elevated baseline levels; however, changes did not consistently relate to cardiac improvement.