Cost-Effectiveness Analysis of Endoscopic Ultrasound versus Magnetic Resonance Cholangiopancreatography in Patients with Suspected Common Bile Duct Stones.

Patients with suspected common bile duct (CBD) stones are often diagnosed using endoscopic retrograde cholangiopancreatography (ERCP), an invasive procedure with risk of significant complications. Using endoscopic ultrasound (EUS) or Magnetic Resonance CholangioPancreatography (MRCP) first to detect CBD stones can reduce the risk of unnecessary procedures, cut complications and may save costs

Optimal treatment of acute biliary pancreatitis

Het onderzoek in dit proefschrift richt zich op twee ernstige complicaties in acute pancreatitis, namelijk orgaanfalen en cholangitis (deel 1), vroege ERCP bij biliaire pancreatitis (deel 2) en het voorkomen van nieuwe galsteen-gerelateerde complicaties na een episode van acute biliaire pancreatitis (deel 3). Het onderzoek is verricht binnen het multidisciplinaire samenwerkingsverband van de Pancreatitis Werkgroep Nederland (PWN). Cholangitis is een indicatie voor een spoed ERCP. In deel 1 hebben we onderzocht of de Tokyo Guideline-criteria (TG18) voor de diagnose van cholangitis gebruikt kunnen worden bij patiënten met acute biliaire pancreatitis, gezien deze criteria niet specifiek voor deze patiëntengroep ontwikkeld zijn, en hoe ze zich verhouden tot criteria voorgesteld door PWN. De TG18-diagnostische criteria overschatten cholangitis in patiënten met acute biliaire pancreatitis, terwijl de PWN-criteria de aanwezigheid van cholangitis juist onderschatten. We beschrijven gedetailleerd de karakteristieken van orgaanfalen en geinfecteerde necrose, en hun impact op sterfte. Op basis van onze resultaten en analyse concluderen we dat vroeg orgaanfalen en de duur van orgaanfalen minder invloed hebben op sterfte dan eerder werd gemeld. Een tweede opvallende bevinding was dat de sterfte hoger was bij patiënten met alleen orgaanfalen dan bij patiënten met orgaanfalen en geïnfecteerde pancreasnecrose. In deel 2 bevestigen we dat er geen rol is voor vroege endoscopische retrograde cholangiopancraticografie (ERCP) bij patienten met een voorspeld milde pancreatitis. In een gerandomiseerde multicenter trial concluderen we dat vroege ERCP met sphincterotomie ook niet de uitkomsten verbetert in patienten met een voorspeld ernstige biliaire pancreatitis. Deze resultaten ondersteunen een conservatieve behandelstrategie, waarbij alleen een ERCP wordt uitgevoerd in geval cholangitis of bij aanhoudende cholestase of choledocholithiasis. Na een episode van milde biliaire pancreatitis, dient vroege cholecystectomie verricht te worden om nieuwe galsteen-gerelateerde complicaties te verminderen. Tot slot zijn voorspellers voor een moeilijke cholecystectomie onderzocht. Een deel van de patienten ervaart nog klachten van galsteenkolieken na cholecystectomie.<br/

JPN Guidelines for the management of acute pancreatitis: treatment of gallstone-induced acute pancreatitis

Gallstones, along with alcohol, are one of the primary etiological factors of acute pancreatitis, and knowledge of the etiology as well as the diagnosis and management of gallstones, is crucial for managing acute pancreatitis. Because of this, evidence regarding the management of gallstone-induced pancreatitis in Japan was collected, and recommendation levels were established by comparing current clinical practices with optimal clinical practices. The JPN Guidelines for managing gallstone-induced acute pancreatitis recommend two procedures: (1) an urgent endoscopic procedure should be performed in patients in whom biliary duct obstruction is suspected and in patients complicated by cholangitis (Recommendation A); and (2) after the attack of gallstone pancreatitis has subsided, a laparoscopic cholecystectomy should be performed during the same hospital stay (Recommendation B)

Laparoscopic Cholecystectomy (LC) and the Risk Factors in the Conversion to Open Cholecystectomy (OC) Surgery: Jordan Statistical Review

This study aimed at exploring the risk factors in the conversion from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) Surgery, and overview the Jordanian statistics for patients over the year 2016 in the Jordanian hospitals. Results show that male gender with symptomatic cholelithiasis was associated with higher conversion rates. And results also showed that the age (&gt;65 years) to be a risk factor for increased perioperative morbidity and conversion rates because of associated acute cholecystitis. Laparoscopic cholecystectomy is a safe procedure in patients, with no increased risk of complications compared with the open procedure. The recovery is faster and the hospital stay, shorter

Impact of Endoscopic Retrograde Cholangiopancreatography on Laparoscopic Cholecystectomy

Background: For Common Bile Duct (CBD) stones an Endoscopic Retrograde Cholangiopancreatography (ERCP) is done prior to cholecystectomy. However, the ideal timing of cholecystectomy following ERCP is still a matter of debate. The aim of the present study was to observe the possible impact of ERCP on subsequent laparoscopic cholecystectomy.Material and Methods: This case control study was carried out in the Department of Surgery Unit 1, Holy Family hospital, Rawalpindi, from January 2018 to March 2019. A total number of 300 patients of symptomatic gallstones presenting to outpatient department were enrolled. Two groups, A (control group) and B (case group) were made on the basis of absence or presence of CBD stones, respectively. Group A underwent laparoscopic cholecystectomy within three working days of admission. In group B, ERCP was performed prior to cholecystectomy. Primary operating surgeon filled structured questionnaires for each patient immediately after surgery to compare operative differences between both groups. The baseline demographic details, clinical characteristics, laboratory investigations and peri-operative findings of both groups were recorded. Means and percentages were calculated with P value &lt;0.05 regarded as statistically significant.Results: Majority of patients in this study were females (81%) of middle age group (42.5+15 years). Biliary colic was most common presenting complaint in both groups (33%). Dissection in triangle of Calot (P=0.00) and removal of gallbladder from liver bed (P=0.00) was significantly more difficult in group B than A. Intra-abdominal lavage was also done more often in post ERCP group (P=0.00). However procedural time did not vary between the two groups (P=0.19).Conclusions: Preoperative ERCP increases difficulty in laparoscopic cholecystectomy but does not prolong procedural time.Key words: Choledocholithiasis, Endoscopic retrograde cholangiopancreatography, Laparoscopic cholecystectom

Interval Laparoscopic Cholecystectomy in the Management of Acute Biliary Pancreatitis

The timing of laparoscopic cholecystectomy following an attack of acute biliary pancreatitis is controversial. The traditional approach of interval cholecystectomy has been challenged recently. The present study was designed to evaluate the benefits of interval laparoscopic cholecystectomy for patients with mild acute pancreatitis (Ranson less than 3). Nineteen patients with mild pancreatitis underwent ultrasonographic evaluation to confirm the biliary etiology. ERCP was performed in all patients on the first available endoscopy list, and endoscopic sphincterotomy was performed in two patients with calculi or dilated common bile duct on ultrasonographic examination. Medical treatment was administered and laparoscopic cholecystectomy was scheduled after 8–12 weeks to allow the inflammatory process to settle. There were no recurrent attacks of pancreatitis during this period. The degree of difficulty of the laparoscopic procedure was assessed by the presence of adhesions to the gallbladder area, difficulty of dissection in the Calot's triangle, intraoperative bleeding and the need for a drain. Six patients (31.5%) had severe adhesions, difficult dissection of the cystic duct and artery, bleeding and prolonged operating time. In two of these patients (10.5%) the procedure was converted to open cholecystectomy. In conclusion, our results suggest that postponing laparoscopic cholecystectomy in acute pancreatitis patients is not advantageous surgically and does not justify the risk of further morbidity caused by the gallbladder disease

A Study on Clinical features, success rate and complications of endotherapy in choledocholithiasis

INTRODUCTION: Choledocholithiasis is defined as the occurrence of stones in the bile ducts. It is a common clinical problem worldwide. It has been estimated that 10–15% of patients undergoing cholecystectomy for symptomatic gallstones harbor concomitant stones in their CBD. Primary ductal stones formed de novo also add a further small percentage to the overall prevalence. OBJECTIVES: 1. To study the various clinical presentations of choledocholithiasis. 2. To study the success rate of endotherapy in choledocholithiasis. 3. To study the complications of endotherapy in choledocholithiasis. 4. To study the epidemiology of choledocholithiasis. 5. To study the associated conditions with choledocholithiasis. MATERIALS AND METHODS: This is a prospective study conducted in DDHD, Government peripheral Hospital, Anna Nagar, Chennai – 102 from April 2008 to December 2009. INCLUSION & EXCLUSION CRITERIA: 1. All patients with CBD stones who underwent ERCP were included in this study. 2. Patients with CBD stones not willing for ERCP were excluded from this study. 3. Patients with CBD stones who were all not fit for ERCP excluded. 4. Patients with obstructive jaundice other than CBD stones were excluded. All patients were explained about the procedure and its complications. We got informed consent from all the patients. ERCP was performed by the Professor and the Associate Professor of our department. All patients received premedications Inj. pentazocine 30mg (1cc), Inj.promethazine 50mg (2cc), Inj. hyoscine butylbromide 20mg (1cc), and Inj.midazolam 2mg I.V. RESULTS: In this study, the patients were divided into three groups; Group 1- Patients with CBD stones with GB stones, Group 2- Patients with CBD stones with no stones in GB, Group 3- Patients with CBD stones in postcholecystectomy state. Total number of patients underwent ERCP in our study were 115. Out of which 51 were males and 64 were females. Overall success rate was 91.3%. Failure rate was 8.69%. The procedure was successful in 95 patients in first attempt, 12 patients in second attempt, and 8 patients in third attempt. Abdominal pain was the presenting symptom in 70 [60.86%] patients, Jaundice in 44 [38.26%], Fever in 42 [36.52%], Charcots triad in 38 [33.04%], Biliary pancreatitis in 6 [5.21%], Asymptomatic in 4 [3.47%] patients. 38 patients developed post procedural abdominal discomfort, 13 patients developed pancreatitis [Mild-9, Moderate -4, and Severe - 0], and 2 patients had retroduodenal perforation. No post sphincterotomy bleeding noted. No procedure related mortality was noted in this study. CONCLUSION 1. Most common presentation of CBD stones in this study was abdominal pain 60.86%, followed by jaundice 38.26%, and fever 36.52%.Charcots triad was seen in 33.04%. 2. In the study, overall success rate was 91.3% and failure rate was 8.69%. 3. Overall complication rate was 13.04%. No post sphincterotomy bleeding was noted. No procedure related mortality was noted. Hence endotherapy are very effective with fewer complications in the treatment of choledocholithiasis. 4. CBD Stones were more common in females (F- 64 pts, M- 51 pts). Mean age of presentation was 49.91 years (range 9 – 76 yrs). 5. Biliary ascariasis was seen in one patient, choledochal cyst type 1 was seen in 2 patients, periampullary diverticulum was seen in 15 patients, distal CBD stricture was seen in 19 patients and intra hepatic stones were seen in 3 patients. 6. There was no statistically significant difference in clinical presentations, associated features, success rate and complications of endotherapy in all the three groups of choledocholithiasis