Combined laparoscopic and endoscopic management of cholelithiasis and choledocholithiasis

With the advent of laparoscopic cholecystectomy, optimal management of common duct stones remains controversial. Seven hundred six patients underwent laparoscopic cholecystectomy in our institution from January 1990 through January 1992. From this group of patients, 50 were identified as having clinical or radiographic evidence of common duct stones. Thirty-one patients demonstrated preoperative risk factors for common duct stones and underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP). The risk factors included jaundice (19%), pancreatitis (23%), elevated liver function tests (52%), and ultrasound evidence of choledocholithiasis (6%). Preoperative ERCP was performed in 94% of patients. There were two failures due to periampullary diverticula. Common duct stones were identified in 18 patients (62%) and successfully removed by endoscopic sphincterotomy in all of these patients. Nineteen patients were found to have unsuspected common duct stones on intraoperative cholangiography. Eighteen patients (95%) underwent successful ERCP and endoscopic sphincterotomy with stone extraction. Overall, major morbidity was 2% and included one patient who experienced endoscopic sphincteroplasty. The three endoscopic failures were managed by open common duct exploration, laparoscopic duct exploration, and combined laparoscopic and open common duct exploration. We conclude that combined laparoscopic and endoscopic therapy is a viable option for the management of cholelithiasis with choledocholithiasis.     

Combined laparoscopic and endoscopic approach in patients with cholelithiasis and choledocholithiasis

BACKGROUND: The Optimal management of common bile duct stones in patients undergoing laparoscopic cholecystectomy remains controversial. METHODS: A prospective study was conducted in 145 of the 481 patients who had a preoperative endoscopic retrograde cholangiogram before their laparoscopic cholecystectomy. RESULTS: Endoscopic retrograde cholangiogram was successful in 138 patients (95%), and common duct calculi were found in 72 (50%) of them. Endoscopic sphincterotomy with ductal clearance was achieved in 62 of 67 patients during a mean of 1.4 sessions (range, 1 to 5). Five (3.4%) patients had complications after endoscopic intervention, all of which resolved uneventfully . Fourteen patients underwent laparoscopic common duct exploration, five had failed endoscopic extraction, five had their common duct stones left intentionally for laparoscopic intervention, and, in addition, four of the seven patients who had a failed endoscopic retrograde cholangiogram had stones identified by intraoperative cholangiogram. Ten of these 14 patients underwent a successful laparoscopic common duct exploration. Laparoscopic cholecystectomy was successfully completed in 134 of the 145 patients, and none had major intraoperative or postoperative complications. The mean postoperative stay was 2.7 days for those patients who underwent a successful laparoscopic procedure. The overall mean number of admissions for completing the treatment was 2.3. CONCLUSIONS: Combined laparoscopic and endoscopic approach is a viable option for patients with gallstones and choledocholithiasis.     

Morbidity after video-laparoscopic cholecystectomy in cholelithiasis associated with liver cirrhosis. A case-control study

At present laparoscopic cholecystectomy represents the treatment of choice for symptomatic cholelithiasis. Authors performed a retrospective case-control study to evaluate whether cirrhosis associated with cholelithiasis increases the risk for morbidity of laparoscopic cholecystectomy. Twenty-one patients with cholelithiasis and cirrhosis (Child-Pugh class A or B) (group A) and 21 controls with cholelithiasis without cirrhosis (group B) entered the study. Controls were paired with cases for age, sex, and indication for cholecystectomy (simple cholelithiasis, acute cholecystitis). The two groups were compared for rate of conversion to open cholecystectomy (19% group A vs 9.5% group B; p = 0.31), morbidity (29.5% group A vs 5.3% group B; p = 0.17), median length of surgery (80 m in the two groups), and median time of postoperative hospitalization (5 days group A vs 3 days group B; p = 0.21). No difference among variables resulted to be statistically significant. Besides, neither common bile duct injuries nor intra or postoperative hemorrhages occurred in patients with cirrhosis. Authors conclude that the laparoscopic cholecystectomy can be considered a safe and effective surgical procedure also for patients with cholelithiasis associated with cirrhosis with a good residual hepatic function.     

Subperiosteal endoscopic forehead facelifting]

We report the first, as far as we know, Mexican case of meningitis caused by Cryptococcus neoformans var. gattii serotype B associated with AIDS in a female patient. The HIV was transmitted to the patient through a blood transfusion. This patient represents, worldwide, the ninth case of C. neoformans var. gattii in patients with AIDS.     

Cholesterol cholelithiasis. A clinical case

The Authors present a case of cholesterinic cholelithiasis, in a patient 13 years of age. The case is interesting because the cholesterol gallstones are uncommon in childhood, with women showing a higher prevalence than men.     

Surgical techniques in complicated chronic pancreatitis]

The experience of surgical treatment of 77 patients with complicated chronic pancreatitis was summarized. Among the operations conducted were: internal drainage, including cystogastrostomy-in 24, cystoduodenostomy-in 9, cystojejunostomy-in 12, fistulojejunostomy-in 2, longitudinal pancreatojejunostomy-in 17, and pancreatic gland resection (proximal-in 2 and distal one-11). After the operation 4 (5.1%) patients died.     

A morphometric study of the femoro-patellar joint from lateral x-ray view

PURPOSE OF THE STUDY: The goal of this study was to specify criteria of femoro-patellar joint normality on lateral view. MATERIAL: This study was based on radiological examination of 102 knees in 51 adults (average age 26.1 years). It concerned 29 women and 22 men that had never suffered from their knee and were supposed healthy. METHODS: The radiological protocol was the following: a lateral view at 45 degrees of flexion, two lateral views in extension, with and without quadriceps contraction. The analysis was focused on patellar surface aspect, its height, its depth and covering measurement. RESULTS: We found 83.7 per cent of so-called "normal" patellar surface, and 12.7 per cent of "abnormal" patellar surface (dysplasia) in the absence of pain. DISCUSSION: We have confirmed figures advanced in others series of the literature concerning patellar height and patellar surface, as well as patellar surface depth and covering. We have underlined the interest of lateral views; in extension with quadriceps contracted and relaxed. Finally, we have defined a trochleo-patellar sign that allows to correlate patellar height to patellar surface height (ITP = 0.35 to 0.84). CONCLUSION: This study insists on the interest of radiological lateral views of the knee and determine criteria for normalities.     

The effect of chenotherapy on the reservoir function of the gallbladder in cholelithiasis patients]

The effect of chenodeoxycholic acid (CDCA) on the reservoir function of the gallbladder was studied in 46 patients with cholesterol cholelithiasis. There was a dependence between a clear increase of filling of the gallbladder in patients treated by this method with subsequent sharp reduction of its size and development of dyspepsia and diarrhea. In 14 patients increase of the gallbladder against the background of chemotherapy was not authentic but no dyspeptic phenomena occurred. Thus, decompensation of the reservoir function of the gallbladder in patients with cholelithiasis against the background of chemotherapy are manifested by a significant increase of the gallbladder size with subsequent emptying of bile into the duodenum and development of collagenous diarrhea.     

Dynamic BSP tests in cholelithiasis patients before and during chenodeoxycholic acid therapy; initial results]

The BSP loading and continuous infusion tests were performed in 7 patients before and after a two-week treatment with chenodeoxycholic acid (10 mg/Kg/die per os). The following parameters were evaluated: 45th minute retention percentage, plasma disappearance rate during the first 16 minutes, compartmental transfer rates, transport maximum and storage. Our results indicated that no cholestatic effects seemed to be induced during the first period of treatment with chenodeoxycholic acid.     

A longitudinal study of green-liver osteomyelitis complex in commercial turkeys

Two flocks of Nicholas tom turkeys from separate farms with histories of above-average condemnations for turkey green-liver osteomyelitis complex (TOC) were studied throughout a 16-week growout. Fifty birds from each farm were necropsied each week for 15 weeks, and birds that had green livers, osteomyelitis in the proximal tibia, or swollen joints were cultured for aerobic bacteria along with an equal number of control birds. At processing, TOC lesions and green livers were obtained for bacterial culture and histopathology. Green-liver-associated TOC was not observed until the turkeys were 9 or 10 weeks of age. The incidence of TOC was higher on one farm, which also had a higher incidence of airsacculitis, higher early and weekly mortality, seroconversion to Newcastle disease virus and Mycoplasma meleagridis, and significantly higher average body weights, relative spleen weights, and relative liver weights. Both farms had a high incidence of intestinal lesions and infestation with Ascaridia dissimilis. Histological evaluation of green livers revealed hyperplasia of bile ducts, dilation of sinusoids, and pigment-containing Kupffer's cells, some of which stained positive for iron. The bacterial isolates most frequently cultured from bones and livers were pleomorphic gram-variable coccobacilli, which grew visible colonies only after a series of subcultures and extended incubation.     

An in situ sem kossel x-ray diffraction study of pseudoelasticity

The coming of age of “smart” materials and structures, i.e. of materials and structures capable of sensing and acting upon changes in the surroundings, has prompted a resurgence of interest in elastic martensites. Here, we have used a miniature ball and ring deformation rig to study the nature of pseudoelastic behavior of a CuAlNi alloy single crystal. By photographing changes in the Kossel X-ray diffraction pattern from a deforming disc of this crystal and, in particular, by recording the pattern when line broadening arising from elastic strain is just sufficient to prevent resolution of the CuK_α1/K_β doublet, we have been able to estimate the level of local strain at which phase transformation occurs. Analysis of the breaking up, prior to this, of a point of triple intersection between sharp diffraction lines has permitted determination of a crystal structure, precursor to that for the low temperature phase.     

Prevalence of cholelithiasis in El Real-Gandia

The aim of this study was to know the prevalence of cholelithiasis (C) in the El Real-Gandia (Spain) as well as the degree of the response of the population. Health examinations were performed in 1,803 adults from El Real (2,000 inhabitants) and Gandia (54,000 inhabitants) using abdominal echography as the screening technique. Cholelithiasis was defined as the presence of biliary lithiasis (BL) or previous cholecystectomy (PC). Of 1,268 (70.3%) participants in the study, C was found in 126 cases (BL in 102 and P in 24) representing a standardized prevalence of around 15% in women and 5% in men. Cholelithiasis was more frequent in females (13.8%) than in males (5.7%) (p < 0.001) increasing linearly with age (p < 0.005). The proportion of PC was significantly higher in women (23.9%) than in men (5.9%) (p < 0.05) and in Gandia (34.4%) than in El Real (13.8%) (p < 0.02). The prevalence of biliary mud and polyps was of 0.3% and 1.1%, respectively. Working obligations (35.4%) and fear of hospitals (22.4%) were the most frequent causes for no response (NR). Males with more than primary a school education originating from outside the Valencian community (VC) were significantly associated with NR in multivariant analysis.     

Surgery for cholelithiasis in cirrhotic patients

Although biliary tract surgery for cholelithiasis is performed frequently, cirrhotic patients require special consideration. The prevalence of postoperative severe complications, such as hepatic failure and biliary peritonitis caused by insufficient fistula formation after removal of the T-tube, is higher than non-cirrhotic patients. We suggest that definitive surgery can be carried out safely, in Child's A and B cirrhotic patients, either electively or as an emergency. However, a more conservative approach is advisable in Child's C patients with acute conditions and definitive surgery is recommended as an elective procedure after liver function has improved. And for the treatment of choledocholithiasis in patients with severe cirrhosis, avoiding surgical intervention through the use of such techniques as endoscopic papillotomy is recommended whenever possible.