Surgeons provide definitive care to patients with gallstone pancreatitis

Background

The optimal management of patients with gallstone pancreatitis (GP) remains a matter of debate. There are wide variations in the use of diagnostic testing and same-stay cholecystectomy. We hypothesize that a general surgery service (SURG) will deliver more efficient, definitive care for patients with GP.

Methods

A retrospective cohort study of consecutive GP patients in an urban hospital from 2006 to 2009. Differences between groups were assessed by the two-tailed Student t test for continuous variables and the Fisher exact test for ordinal data.

Results

One hundred twenty-four patients with GP were admitted, 79 to medicine (MED) and 45 to surgery (SURG). In the MED group, 21 patients (27%) underwent same-stay cholecystectomy, and 7 patients (9%) returned with recurrent biliary pancreatitis. In the SURG group, 44 patients had definitive surgery, and none returned with recurrent disease (P < .01 and .09, respectively). The SURG group had fewer laboratory tests, antibiotics, and consultations.

Conclusions

For patients with GP, admission to surgery results in definitive treatment with same-stay cholecystectomy. This is a more efficient approach with fewer readmissions for the same disease process.     

保守治疗胆石性肠梗阻1例报告

1临床资料患者,男性,79岁,因"恶心呕吐、腹痛4d"于2010年7月1日入院。患者无发热,畏寒及皮肤、巩膜黄染;腹部呈阵发性绞痛,肛门停止排便,尚能排气。患者2010年3月曾在本院行腹部CT检查显示:胆囊多发结石,但未行任何治疗。既往无肠道疾病及传染病史。入院查体:皮肤巩膜未见黄染,心肺(-)。全腹平,未见肠型及蠕动波,右上腹轻压痛,无反跳痛及肌紧张,墨菲征阴性,叩诊呈鼓音,肠     

胆宁片对胆汁33.5kDa泡蛋白含量和结构的影响

目的：探讨胆宁片对胆石症患者胆汁中33.5kDa泡蛋白含量及其结构的影响。方法：2008年1月—2010年3月对60例胆囊切除病例和40例胆总管探查病例进行前瞻性临床研究,其中60例胆囊切除病例随机分为3组：胆固醇结石胆宁片组（n=20）、胆固醇结石对照组（n=20）、胆色素性结石组（n=20）,另外设立正常对照组（n=20）。通过酶联免疫吸附法检测每份胆汁中33.5kDa泡蛋白含量,比较各组之间的差异。40例胆总管探查病例分为研究组和对照组（n=20）,通过蔓陀螺凝集素探针（DSA）介导的蛋白印迹法检测胆汁中33.5kDa泡蛋白糖链条带DSA结合率,比较2组糖链结构的变化。结果：胆固醇结石组胆汁中33.5kDa泡蛋白含量显著高于胆色素结石组和正常对照组,胆固醇结石胆宁片治疗组胆汁33.5kDa泡蛋白含量较对照组显著降低（P〈0.01）。胆固醇结石治疗组泡蛋白糖链条带DSA结合率较对照组显著下降（P〈0.05）。结论：胆宁片能降低胆固醇结石患者胆汁中33.5kDa泡蛋白含量,并通过改变糖链结构而使其促成核活性发生变化。     

"三镜"联合一次麻醉序贯治疗肝外胆管结石

目的同顾性评估腹腔镜、胆道镜、十二指肠镜(三镜)联合,一次麻醉序贯治疗肝外胆管结石和胆源性急性胰腺炎(ABP)的可行性.方法总结112例肝外胆管结石(其中23例ABP)治疗经验,对术式选择、操作要点、胆漏防治、注意事项等做分析.结果102例成功,10例中转开腹手术.其中16例内镜胰胆管造影(ERCP)+腹腔镜胆囊切除(LC)、胆总管切开、胆道镜取石、T管引流(LCTD),18例ERCP+LC、胆道镜经胆囊管胆总管取石;22例内镜乳头括约肌切开(EST)取石未完成或禁忌,继续LC、胆总管切开、胆道镜取石、一期缝合;46例鼻胆管引流(ENBD)+LC、胆总管切开、胆道镜取石、一期缝合.内镜治疗时间平均35 min,腹腔镜手术时间平均110 min,术后住院平均6.5 d.无手术死亡,ERCP和EST并发症9例,其中6例急性胰腺炎,2例十二指肠乳头部出血,1例十二指肠穿孔.胆总管一期缝合术后胆漏11例,腹腔引流治愈.拔T管后胆漏2例,再次腹腔镜下置管引流治愈.随访1～3年,B超或MRCP检查无胆管狭窄;胆总管残石和再发结石各3例,EST取石治愈.结论一次麻醉"三镜"序贯治疗肝外胆管结石和ABP,手术环节衔接更为合理,无内镜治疗的恐惧感,能从严掌握EST适应证和减少并发症,提高微创手术成功率等.一旦遇有解剖不清、出血、结石未取净或胆管狭窄等,及时改变术式.     

Duodenal gallstone ileus producing Boerhaave's syndrome

A case of duodenal obstruction by biliary calculus associated with esophageal rupture is described. CT demonstrated air in the gallbladder, an impacted gallstone in the duodenum, pneumomediastinum, and hydropneumothorax. The present report describes the CT findings of these two rare conditions in the same patient.     

Gallstone disease and related risk factors in a large cohort of diabetic patients

BACKGROUND AND AIM: The aim of this study of a large cohort of consecutive patients with diabetes mellitus was to investigate the still controversial questions concerning the prevalence and possible risk factors of gallstone disease in diabetics. PATIENTS AND METHODS: We enrolled 1337 consecutive patients (710 males aged 63 +/- 11 years and 627 females aged 65 +/- 11 years), of whom 1235 (92%) had type 2 and 102 (8%) had type 1 diabetes mellitus. The data were statistically analysed using multiple logistic regression analysis. RESULTS: The prevalence of gallstone disease was significantly higher in diabetics than in the general population with comparable characteristics (MICOL study) (332/1337 (24.8%) versus 4083/29684 (13.8%); z = 11.208, P = 0.0001) and this difference maintained its statistical significance even when only the North Italian centers involved in this nation-wide survey were considered (332/1337 (24.8%) versus 2469/18091 (13.6%); z = 11.225, P = 0.0001). A total of 332 diabetics (25%) had gallstone disease: 261 had stone(s) and 71 had previously undergone cholecystectomy for gallstone disease after a diagnosis of diabetes mellitus. The prevalence of gallstone disease was higher in the females (29% versus 22%, P = 0.003), and increased with age (13, 20 and 30% in patients aged < or = 40, 41-65 and > 65 years, respectively; P = 0.001), body mass index (24% in patients with a body mass index of < or = 30 and 30% in those with a body mass index of > 30 kg/m2; P = 0.001) and a positive family history of gallstone disease (31% versus 23%; P = 0.001). Gallstone disease was not significantly related to the type of diabetes, plasma total and HDL cholesterol and triglyceride levels, alcohol intake, smoking habits, physical activity, weight reduction in the last year, the use of oral contraceptives, parity or menopause. At multivariate analysis, increasing age, a higher body mass index and a positive family history maintained their statistical significance. CONCLUSIONS: In patients with type 1 or type 2 diabetes mellitus, the prevalence of gallstone disease was significantly related to age, body mass index and a family history of gallstone disease.     

In vitro investigation of gallstone shadowing with ultrasound tomography.

A phantom was constructed to simulate the in vivo situation of gallstone detection. Gallstone specimens from 37 patients were scanned. All gallstones cast acoustic shadows, regardles of the specific properties of the stones. Experimental evidence concerning factors that affect the detection of acoustic shadows from gallstones is discussed.     

Der rezidivierende Gallensteinileus

Zusammenfassung Der G.I. ist eine ernste Spätkomplikation des Gallensteinleidens mit einer Sterblichkeit von 29,4% bei 864 Fällen in 78 Arbeiten der Jahre 1955 bis 1968. In etwa 5% ist mit einem Rezidiv durch im Darm zurück gelassene oder aus der G.Bl. nachwandernde Steine zu rechnen. Einschließlich der eigenen 2 fanden wir 70 Rezidive mit einer Mortalität von 21,4%. Das frühe Rezidiv im unmittelbaren postoperativen Verlauf ist mit hoher Sterblichkeit belastet (50%). Bei der Operation muß daher der gesamte Darm ober- und unterhalb der Einklemmung auf weitere Steine und Darmwandschäden abgesucht werden. Das häufigere späte Rezidiv nach Monaten oder sogar Jahren hat eine günstigere Prognose.Hohes Alter und die durch den Ileus hervorgerufenen allgemeinen Schäden erlauben in der Regel nur die Enterolithotomie. Bei weiteren großen Steinen in der G.Bl. kann bei günstigem Allgemeinzustand die Cholecystolithotomie oder die Cholecystektomie unmittelbar angeschlossen werden. Letztere erfordert immer den Nachweis steinfreier und durchgängiger Gallenwege.Nach überstehen des Ileus ist die diagnostische Klärung der Gallenwegserkrankung in jedem Fall durchzuführen; die Operation des Gallenleidens zu wählbarem Zeitpunkt wird operationsfähigen Kranken empfohlen zur Vermeidung des späteren Ileusrezidivs und anderer Komplikationen von seiten der Gallenwege.

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Recurrent gallstone ileus

Summary Two recurrences among our 6 cases of gallstoneileus (g.i.) made us work on recurrent g.i. G.i. is a serious subsequent complication in cholelithiasis with a mortality of 29.4% among 864 cases, which are published in 78 papers from 1955 to 1968. A recurrence may be expected in 5% of the cases, caused by stones remaining in the gut or by stones descended from the gallbladder. We found 70 recurrences including our 2 cases with a mortality of 21.4%. Early recurrence in the immediate postoperative course means high mortality (50%). During the operation the intestinal tract has to be checked for other stones and wall damage above and below the site of obstruction. The more common late recurrence — after months or even years — has a better prognosis.Old age and general damage caused by the intestinal obstruction usually only allow simple enterotomy. In cases with further big stones in the gallbladder connected with a good condition of the patient cholecystolithotomy or cholecystectomy can be done immediately afterwards. Cholecystectomy always demands evidence of free passage and abscence of stones in the biliary tract.After recovery from the ileus diagnostic clarification of the diseased biliary tract ist necessary in any case; operable patients ought to have an operation on their gallbladder disease at an elective time in order to prevent later ileus recurrence and other complications from the biliary tract.

     

The effects of sterile or infected bile and dropped gallstones in abdominal adhesions and abscess formation

Background: The effects of gallstones and sterile or infected bile on postoperative adhesions and abscess formation were investigated in Sprague Dawley rats. Methods: The first three groups were injected intraperitoneally with serum saline, sterile bile, or infected bile, respectively. Laparotomy was adjusted to the next seven groups. Serum saline, sterile bile, and infected bile were injected in the fourth through sixth groups intraperitoneally, respectively. Gallstones were placed intraabdominally to the seventh through ninth groups. The injections of sterile bile in group 7 and of infected bile in group 8 were added to laparotomies. Only laparotomy was carried out in group 10. Results: Abscess formations were seen only in infected-bile-injected groups. Significant adhesion formations were seen in infected-bile groups. Sterile bile and/or gallstones had no significant effect in abscess or adhesion formation. Conclusions: Results suggest that noninfected gallstones and sterile bile, even in combination, do not increase postoperative intraabdominal complications in rats. Received: 29 March 1996/Accepted: 26 August 1996