Early treatment of acute biliary pancreatitis by endoscopic papillotomy

Background. Most patients with acute biliary pancreatitis have stones in the biliary tract or ampulla of Vater. Because these stones may be passed spontaneously soon after a patient is admitted to the hospital, the importance of early operative removal is not known. We tested the hypothesis that endoscopic papillotomy within 24 hours of admission decreased the incidence of complications in patients with acute biliary pancreatitis. Methods. We studied 195 patients with acute pancreatitis who were randomly assigned to one of two groups: 97 patients underwent within 24 hours after admission emergency endoscopic retrograde cholangiopancreatography (ERCP) followed by endoscopic papillotomy for ampullary and common-bile-duct stones, and 98 patients received initial conservative treatment and selective ERCP with or without endoscopic papillotomy only if their condition deteriorated. Results. One hundred twenty-seven patients ultimately proved to have biliary stones. Emergency ERCP with or without endoscopic papillotomy resulted in a reduction in biliary sepsis as compared with conservative treatment (0 of 97 patients vs. 12 of 98 patients, P = 0.001). The decrease in biliary sepsis occurred both in patients predicted to have mild pancreatitis (0 of 56 patients in the group that received emergency ERCP vs. 4 of 58 patients in the conservative-treatment group, P = 0.14) and in patients predicted to have severe pancreatitis (0 of 41 patients vs. 8 of 40 patients, P = 0.008). In all patients who had unrelenting biliary sepsis, persistent ampullary or common-bile-duct stones were identified. There were no major differences in the incidence of local complications (10 patients in the group that received emergency ERCP vs. 12 patients in the conservative-treatment group) or systemic complications (10 patients vs. 14 patients) of acute pancreatitis between the two groups, but the hospital mortality rate was slightly lower in the group undergoing emergency ERCP with or without endoscopic papillotomy (5 patients vs. 9 patients, P = 0.4). Conclusions. Emergency ERCP with or without endoscopic papillotomy is indicated in the treatment of patients with acute pancreatitis.published_or_final_versio

Endoscopic biliary drainage for severe acute cholangitis

Background. Emergency surgery for patients with severe acute cholangitis due to choledocholithiasis is associated with substantial morbidity and mortality. Because recent results suggested that emergency endoscopic drainage could improve the outcome of such patients, we undertook a prospective study to determine the role of this procedure as initial treatment. Methods. During a 43-month period, 82 patients with severe acute cholangitis due to choledocholithiasis were randomly assigned to undergo surgical decompression of the biliary tract (41 patients) or endoscopic biliary drainage (41 patients), followed by definitive treatment. Hospital mortality was analyzed with respect to the use of endoscopic biliary drainage and other clinical and laboratory findings. Prognostic determinants were studied by linear discriminant analysis. Results. Complications related to biliary tract decompression and subsequent definitive treatment developed in 14 patients treated with endoscopic biliary drainage and 27 treated with surgery (34 vs. 66 percent, P>0.05). The time required for normalization of temperature and stabilization of blood pressure was similar in the two groups, but more patients in the surgery group required ventilatory support. The hospital mortality rate was significantly lower for the patients who underwent endoscopy (4 deaths) than for those treated surgically (13 deaths) (10 vs. 32 percent, P<0.03). The presence of concomitant medical problems, a low platelet count, a high serum urea nitrogen concentration, and a low serum albumin concentration before biliary decompression were the other independent determinants of mortality in both groups. Conclusions. Endoscopic biliary drainage is a safe and effective measure for the initial control of severe acute cholangitis due to choledocholithiasis and to reduce the mortality associated with the condition.published_or_final_versio

Acute cholangitis secondary to hepatolithiasis

In a series of 88 patients with acute cholangitis secondary to hepatolithiasis, 26 (30%) required emergency therapeutic intervention because of septicemic shock (n = 15), persistent fever (n = 8), or spreading peritonitis (n = 3). Analysis was made to define factors that predisposed to failure of conservative treatment and characteristics that could predict the need for emergency biliary decompression. The age, incidence of concomitant medical diseases, previous biliary surgery, positive blood culture, bacterial strains resistant to antibiotics used, and multiplicity of bacterial strains in bile cultures in patients who required emergency intervention were similar to these factors in patients who had elective operations after successful conservative management. The incidence of intrahepatic segmental obstruction by stones or strictures was similar, but many more patients who required emergency intervention had concomitant extrahepatic obstruction due to impacted common ductal stones or strictures. Logistic regression analysis of clinical, hematological, and biochemical data showed that maximum pulse rate within 24 hours of presentation (>100 beats per minute, relative risk, 2.8) and platelet count at the time of admission (<150 x 10 9 /L, relative risk, 5.2) were the factors with independent significance in predicting the need for emergency therapeutic procedures. This finding may serve as a guideline for identifying high-risk patients for early intervention.link_to_subscribed_fulltex

Preoperative endoscopic drainage for malignant obstructive jaundice

The role of preoperative endoscopic drainage for patients with malignant obstructive jaundice was evaluated in a randomized controlled trial. A total of 87 patients were assigned to either early elective surgery (44 patients) or endoscopic biliary drainage followed by exploration (43). Thirty-seven patients underwent successful stent insertion and 25 had effective biliary drainage. Complications related to endoscopy occurred in 12 patients. After endoscopic drainage significant reductions of hyperbilirubinaemia, indocyanine green retention and serum albumin concentration were observed. Patients with hilar lesions had a significantly higher incidence of cholangitis and failed endoscopic drainage after stent placement. The overall morbidity rate (18 patients versus 16) and mortality rate (six patients in each group) were similar in the two treatment arms irrespective of the level of biliary obstruction. Despite the improvement of liver function, routine application of endoscopic drainage had no demonstrable benefit. Endoscopic drainage is indicated only when early surgery is not feasible, especially for patients with distal obstruction.link_to_subscribed_fulltex

Hepatic resection for small hepatocellular carcinoma: The Queen Mary Hospital experience

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Doxorubicin for unresectable hepatocellular carcinoma. A prospective study on the addition of verapamil

A prospective study was conducted to assess the safety and efficacy of the addition of oral verapamil to intravenous Adriamycin (doxorubicin) for the management of patients with unresectable hepatocellular carcinoma (HCC). All 28 patients studied had histologically verified disease, and cirrhosis was present in 20 of the 21 patients with adequate tissue sampling. The overall median survival was 57 days. Chemotherapy was terminated in seven patients after one course of treatment. Partial response and complete response were noted in four patients (19%) and one patient (4.8%), respectively, among the 21 patients evaluated. Side effects related to the chemotherapy were present in all patients studied. Death from fulminating sepsis occurred in three of the 13 patients with leukopenia. Symptomatic myocardial dysfunction developed in one patient. The addition of verapamil apparently did not potentiate the tumoricidal effect of systemic Adriamycin on HCC but probably did increase its complications.link_to_subscribed_fulltex

Prediction of the severity of acute pancreatitis

We conducted a prospective study to validate our previous finding that serum urea and plasma glucose levels on admission could predict the outcome of acute pancreatitis. Forty-two (24%) of 176 patients developed complications related to the attack of acute pancreatitis and were classified as having severe disease. By logistic regression analysis of 17 admission parameters, serum urea and plasma glucose levels were again the factors with independent significance in defining the outcome. By adopting the same cutoff levels as in our previous study (serum urea level greater than 7.4 mmol/L and plasma glucose level greater than 11.0 mmol/L), and the presence of either factor above the cutoff level as indicative of severe disease, the sensitivity of prediction was 79%, specificity 67%, and overall accuracy 70%. All the deaths were correctly predicted by this urea/glucose criteria. The overall accuracy was also found to be comparable with those of the APACHE II (cutoff level greater than II) and Ranson's scoring systems. We conclude that the simple prognostic criteria for acute pancreatitis were validated; these criteria have the potential to stratify risk rapidly at the time of admission for patients who might benefit from an aggressive interventional protocol.link_to_subscribed_fulltex

Surgery for malignant obstructive jaundice: Analysis of mortality

Surgery on patients with malignant obstructive jaundice carries formidable morbidity and mortality rates. Clinical records of 120 consecutive patients who had a serum total bilirubin levels of 100 μmol/L or greater before exploration were analyzed retrospectively to provide guidelines for better management. Although most patients underwent bilienteric bypass to either the extrahepatic (n = 45) or intrahepatic ductal system (n = 28), resection was possible in 32 (26.7%). Complications developed in 42 patients (35%), among whom 12 (10%) required reexploration and 32 (26.7%) died within the same hospitalization. Identification of risk factors associated with hospital deaths after surgery was conducted on 84 of the 120 (group A) patients randomly selected from the entire study period. Based on multivariate analysis, age greater than 65 years, a raised serum aspartate transaminase value greater than 90 IU, and serum urea level greater than 7 mmol/L before surgery were the risk factors selected from 39 different clinical (n = 6), laboratory (n = 26), and operative (n = 7) parameters studied. The predictive value was validated in the remaining 36 patients (group B), and a high-risk patient population had been isolated. Because both serum urea and aspartate transaminase values correlated significantly with the necessity of urgent exploration, aggressive nonoperative treatment should be used to control the emergency. Alternative therapeutic options or perioperative management should be considered for the selected high-risk patients before definitive surgical biliary decompression.link_to_subscribed_fulltex

Endoscopic sphincterotomy: 7-Year experience

The present study documents the indications and results of endoscopic sphincterotomy (ES) performed over 7 years in a surgical endoscopy unit. Potential improvement of results over this time period was analyzed. ES was associated with rare but undesirable morbidity and mortality. Specific improvement of results over time has not been reported. ES was attempted in 706 patients (336 men, 370 women) from 1987 to 1994 and was accomplished in 689 patients (97.6%). Complications occurred in 50 patients (7.1%), 13 of whom required emergency operative intervention. The overall 30-day mortality was 4.7% (n = 33), and procedure-related mortality was 0.7% (n = 5). There was a significant decrease in hospital mortality (p < 0.01) and operative intervention for procedure-related complications (P < 0.001) after 1990. Procedure-related mortality has been reduced from 1.3% to 0.3% since 1990 (p = 0.1). ES in emergency situations or for malignant biliary obstruction did not adversely affect the outcome. It was concluded that ES can be performed safely in most patients. With increasing experience, procedure-related morbidity and mortality can possibly be reduced.link_to_subscribed_fulltex

Hepatectomy for large hepatocellular carcinoma: The optimal resection margin

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