[Efficiency of ursotherapy in cholesterol-associated pathology of the gallbladder]

AIM

To assess of lipid disorders nature in holesterin associated pathology of biliary tract and determine the hypercholesterolemia effect on the effectiveness of ursotherapy at biliary sludge of cholesterol genesis, cholesterol cholicyststoliteasis and polypous form of cholesterosis gallbladder.

MATERIAL AND METHODS

We included 450 patients with pathology holesterinassociated pathology of biliary tract: 100 - with biliary sludge (BS), 200 - with cholicyststoliteasis (CL), 150 - with polypous form of cholesterosis gallbladder (CGB). All patients evaluated the levels of common cholesterol (CC), HDL cholesterol and LDL cholesterol in serum. 52 patients with BS, 128 patients with HL and 81 patients with CGB was identified dynamics of these indicators after 3-month course of Ursodeoxycholic acid (UDCA) treatment. To assess the influence of hypercholesterolemia on the effectiveness of litholytic therapy 180 patients with BS, CL, and HZHP were divided into 3 groups of 60 patients in each (30 with normocholesterolemia and 30 - with hypercholesterolemia). UDCA was administered at a dose of 10 mg/kg body weight once at night. Monitoring the clearance of RBCs, dissolution of gallstones and cholesterol polyps performed using ultrasound every 3 months.

RESULTS

Hypercholesterolemia was detected in 57,5% of cases (in 259 out of 450 patients). After 3-month course of UDCA therapy marked positive trend: the reduction of total cholesterol to normal rates depending on the holesterinassociated type of pathology was found in 50.6 - 63.5%. This UDCA had the greatest effect at the level of cholesterol in the blood serum ranging from 5.3 to 6.6 mmol/I, where the decline in total cholesterol was back to normal in the majority of patients. Cholesterol is a factor that reduces the effectiveness of UDCA. Thus, the frequency of complete elimination of BS in normocholesterolemia was 96.7%, while for hypercholesterolemia it was 70% (p <0.05). A similar trend continued in other groups of patients with holesterinassociated pathology of biliary tract.

CONCLUSION

In the absence of risk factors for cardiovascular disease in patients with holesterinassociated pathology of biliary tract, accompanied by expressed hypercholesterolemia, ursotherapy allows lipid corrective effect without the statins use.

[Application of dannang recipe no. 2 in the perioperative stage of laparoscopic cholecystectomy]

OBJECTIVE

To explore the significance of application of Dannang Recipe No. 2 (DNR2), a Chinese herbal preparation, in the perioperative period of laparoscopic cholecystectomy (LC).

METHODS

Three hundred and sixty patients with LC were randomly assigned to two groups, 180 in each group. The treatment group was treated with DNR2 in the perioperative period, one dose of the recipe composed of aucklandia root 10 g, red peony root 15 g, giant knotweed rhizome 10 g, scutellaria root 10 g, honeysuckle flower 15 g, forsythia fruit 10 g, rhubarb 9 g, immature bitter orange 10 g, magnolia bark 10 g, peach kernel 10 g, red sage root 20 g and licorice root 4 g, which was boiled with water and taken one dose per day, starting from the previous night of operation. The control group was treated by antibiotic with Ceftizoxime sodium 2.0 g or Levofloxacin 200 mg via intravenous dripping once 0.5 h before operation preventively and 1-3 days after operation according to patients' condition. The indexes, including recovery time of borborygmus, gas elimination and defecation, post-operation body temperature, days needing fluid transfusion, hospitalization time, incidence of infectious complication, as well as the white blood cell counting (WBC) and serum C-reactive protein (CRP) before and after operation, were analyzed and compared between groups.

RESULTS

The recovery time of borborygmus, gas elimination and defecation were shorter in the treatment group as compared with that in the control group (10.42 +/- 4.38 h vs. 17.11 +/- 6.25 h, 15.60 +/- 5.03 h vs. 32.74 +/- 9.43 h and 38.81 +/- 9.87 h vs. 56.09 +/- 11.00 h, respectively) and all the other indexes were better in the treatment group than those in the control group, showing significant difference (P < 0.01 or P < 0.05), except the incidence of postoperative infectious complication, it was similar in the two groups.

CONCLUSION

Application of DNR2 in perioperative stage of laparoscopic cholecystectomy can effectively promote the recovery of postoperative gastrointestinal motility and suppress the occurrence of acute inflammation.

Does cholecystectomy prior to the diagnosis of pancreatic cancer affect outcome?

Early diagnosis and curative resection are significant predictors of survival in patients with pancreatic cancer. We hypothesize that cholecystectomy within 12 months of pancreatic cancer affects 1-year survival. The Surveillance Epidemiology and End Result (SEER) database linked to Medicare data was used to identify patients diagnosed with pancreatic cancer who underwent cholecystectomy 1 to 12 months prior to cancer diagnosis. The SEER database identified 32,569 patients from 1995 to 2002; 415 (1.3%) underwent cholecystectomy prior to cancer diagnosis. Patients who underwent cholecystectomy had a higher proportion of diabetes (40.2% vs 20.5%; P < 0.01), obesity (8.9% vs 3.1%; P < 0.01), jaundice (17.3% vs 0.7%; P < 0.01), cholelithiasis (70.4% vs 4.2%; P < 0.01), choledocholithiasis (0.7% vs 0.0%; P < 0.01), weight loss (17.3% vs 4.7%; P < 0.01), abdominal pain (79.5% vs 22.5%), steatorrhea (0.7% vs 0.0%; P < 0.01), and cholecystitis (32.3% vs 1.7% ; P < 0.0001). After controlling for tumor stage, patient demographics, and symptoms, survival at 1 year was significantly lower in patients undergoing cholecystectomy (OR, 0.75; 95% CI, 0.58-0.97). Recent cholecystectomy is associated with decreased 1-year survival among patients with pancreatic cancer. For patients older than 65 years of age, further evaluation prior to cholecystectomy may be necessary to exclude pancreatic cancer, especially patients with jaundice, weight loss, and steatorrhea.

Can the MELD score predict perioperative morbidity for patients with liver cirrhosis undergoing laparoscopic cholecystectomy?

The Model for End Stage Liver Disease (MELD) score is a mortality predictor in patients awaiting liver transplantation. We evaluated the MELD score's ability to predict morbidity for patients with cirrhosis undergoing laparoscopic cholecystectomy. From March 1991 to February 2004, data of all patients undergoing laparoscopic cholecystectomy were prospectively collected. Data of patients with liver cirrhosis were reviewed. The MELD and Child scores were correlated with outcome variables. Of 7859 patients undergoing laparoscopic cholecystectomy, 99 patients (1.3%) exhibited liver cirrhosis, 44 women and 55 men. The mean age was 55 years (range, 28 to 92 years). The mortality rate was 6.3 per cent, morbidity rate 18 per cent, and conversion rate 11 per cent. Laboratory values on 55 patients were available to calculate MELD scores. The mean MELD score was 11 (range, 6 to 23). There was no significant variation in MELD scores with gender (P = 0.61) or cirrhosis etiology, alcoholic and nonalcoholic (P = 0.52). MELD and Child's score correlated well (P < 0.001); however, the risk of complication was not related to the MELD (P = 0.94) or Child-Pugh-Turcotte score (P = 0.26). Morbidity for patients with liver cirrhosis undergoing laparoscopic cholecystectomy remains high. The MELD score is useful for transplant risk stratification for but requires further investigation regarding morbidity prediction for laparoscopic cholecystectomy.

Gallbladder torsion-induced emphysematous cholecystitis in a 16-year-old boy

The patient was a 16-year-old boy who had turned to the right rapidly as he fielded a baseball that had come to him quickly. Two days after this event, which occurred in July 2004, he was admitted to hospital with repeated vomiting and increasing right hypochondralgia. Laboratory examination on admission showed elevation of the white blood count and of serum C-reactive protein and total bilirubin. Computed tomography on admission demonstrated an enlarged gallbladder and a thickened wall without gallstones, and magnetic resonance imaging performed 1 day later showed air within the gallbladder wall. His symptoms worsened, with a positive Murphy's sign, and emergency laparotomy was performed, with a diagnosis of emphysematous cholecystitis. Intraoperatively, the gallbladder was dark red, necrotic, distended, and enlarged. The cystic duct was attached only to the mesentery, and the gallbladder was floating freely, with the neck of the gallbladder having rotated 180 degrees counterclockwise, leading to a definitive diagnosis of gallbladder torsion with emphysematous cholecystitis. Cholecystectomy was performed, and analysis of bile showed Escherichia coli to be the causative organism. Histopathologic examination revealed necrotized cholecystitis. The patient is doing well 25 months after surgery, with an uneventful postoperative course.

Laparoscopic cholecystectomy: an early experience at Ayub Teaching Hospital Abbottabad

BACKGROUND

Laparoscopic Cholecystectomy first introduced in 1987, is becoming more and more popular and now it has become gold standard in symptomatic gallstone disease. The current descriptive study is carried out in Department of General Surgery, Ayub Teaching hospital, Abbottabad to evaluate the result of Laparoscopic Cholecystectomy in symptomatic gallstones disease in our set up with special emphasis on complication rate, morbidity and mortality.

METHODS

The data of all patients who underwent Laparoscopic Cholecystectomy form January to December 2007 was entered in standardized proforma and analysed on SPSS 10.

RESULTS

Out of 60 patients, 51 (85%) were female and 9 (15%) were males; the age range from 17 to 65 years mean age being 40.30 years, majority were in age 30-40 years group. Two (3.3%) patients had bile leak, 1 (1.3%) patient developed port site wound infection 1 (1.3%) patient developed collection in pouch of Morrison and in 1 (1.3%) patient stone were recovered from the epigastric port site wound. There was no bile duct or colonic injuries. The conversion rate was 5%. There was no mortality.

CONCLUSION

Laparoscopic cholecystectomy is a safe and effective treatment for gall stone disease and is up to the accepted standard in our set up as compared to national and international data.

Laparoscopic cholecystectomy in the elderly patients. An experience at Liaquat University Hospital Jamshoro

BACKGROUND

Advancing age with its associated co-morbidities increases the likelihood of postoperative complications as well as conversion rate during laparoscopic cholecystectomy. Recent studies have also questioned efficacy of this procedure in geriatric patients. The present study assesses the safety and applicability of laparoscopic cholecystectomy in geriatric patients. The objective of the present study was to asses safety and applicability of laparoscopic cholecystectomy in the elderly patients of 65 years and above.

METHODS

This is a prospective analysis of 173 patients, over 65 years of age, who underwent laparoscopic cholecystectomy from December 2002 to November 2006 at Liaquat University Hospital, Jamshoro. Patients presenting with complicated and uncomplicated gallstone disease were included in the study population and all of them were operated laparoscopically. The data included demographic details, co-morbidities, underlying biliary pathology, indications for surgery, operative and postoperative complications, morbidity and mortality, and hospital stay. The statistical analysis of the data performed on SPSS version 10.

RESULTS

Laparoscopic cholecystectomy undertaken in 173 elderly patients with a mean age of 69.72 years, out of whom 52 (30.05%) were males and 121 (69.94%) were females. Co-morbid conditions were identified in 53.17% (n = 92) patients and included hypertension in 38 patients (21.96%), Diabetes Mellitus in 23 patients (13.29%), COPD in 19 (10.98%) patients, Coronary artery disease in 9 (5.20%) and cardiac arrhythmias in 3 (1.73%) patients. Indications for surgery included simple biliary colic in majority of patients (69.94%) and complicated stone disease in 52 (30.05%) subjects. There were 37 (21.38%) emergency laparoscopic cholecystectomies and 136 (78.61%) patients were operated electively. Mean operative time was 100 minutes with a SD 29.03. Fourteen (8.09%) patients required conversion to OC (Open Cholecystectomy) due to various reasons. Mean hospital stay was 6.28 days. Overall 23 (13.29%) patients developed postoperative complications. One patient died of acute MI on 2nd postoperative day.

CONCLUSION

There is no undue risk in laparoscopic cholecystectomy in the elderly population and the procedure can be regarded as safe as in patients below 65 years of age.

[Ischemic variant of cholecystocardial syndrome in the diseases of gallbladder]

There were analyzed 14 observations of patients suffering ischemic variant of cholecystocardial syndrome on the background of an acute calculous cholecystitis and cholecalculous disease. The rate of the pseudocoronary syndrome revealing was determined. The coding procedure using Minnesota's code was applied for the first time for ECG estimation in the patients.

Gastric heterotopia together with squamous metaplasia in the gallbladder

Heterotopic gastric mucosa in the gallbladder is extremely unusual. In this study, we aimed to report a case of gastric heterotopia together with squamous metaplasia in the gallbladder of a 47-year-old female patient who experienced an intensive abdominal pain. He was admitted to the hospital for clinical treatment without any improvement. Ultrasonography showed a stone located in the gallbladder neck and dilatation of intrahepatic bile ducts, both hepatic ducts and common hepatic duct. Laparoscopic cholecystectomy was performed. In the microscopical examination, the epithelium of the gallbladder revealed an unspecified chronic cholecystitis. Besides, at the level of the gallbladder body, a heterotopic gastric mucosa contain chief, parietal and mucosal cells with cystic glands and squamous metaplasia was found. Actually the patient is in long-time follow-up, asymptomatic. We also review 96 other reports of HGM in the gallbladder in the international medical literature from 1934. As heterotopic tissue may promote carcinogenesis of the gallbladder, close attention should be paid to any occurrence of such lesions in this anatomical region. It appears that laparoscopic cholecystectomy may be unavoidable for patients affected by heterotopic gastric mucosa at the present time and care must be taken when a diagnosis is made based on intraoperative frozen sections.

Gall bladder torsion and rupture in a dog

A 6-year-old desexed female German Shepherd dog was referred to the Murdoch University Veterinary Hospital for assessment and management of acute onset vomiting, diarrhoea, polydipsia and lethargy of 2 days duration. Surgical, microbiological and histological findings were consistent with necrotising cholecystitis secondary to gall bladder torsion, resulting in gall bladder rupture and secondary non-septic bile peritonitis. A chronic peritoneopleural perforation resulting from an abdominal cavity foreign body and congenital peritoneopericardial hernia were also present. The dog made a full recovery following cholecystectomy, foreign body removal, repair of the peritoneopleural perforation and peritoneopericardial herniorrhaphy. This is the first recorded case of gall bladder torsion in the dog.

Occult pancreaticobiliary reflux in gallbladder cancer and benign gallbladder diseases

BACKGROUND AND OBJECTIVES

It was proposed that occult pancreaticobiliary reflux (OPBR) was associated with precancerous mucosal changes in the gallbladder, hence the importance of this disorder. There are no published reports investigating the incidence of OPBR in patients operated on for the entire spectrum of benign gallbladder diseases and gallbladder cancer. Our aim was to determine the incidence of OPBR and measure the levels of active pancreatic enzymes (amylase and lipase) in gallbladder bile of patients undergoing cholecystectomy for benign and malignant gallbladder diseases.

METHODS

One hundred eight patients with normal pancreaticobiliary junction evidenced by operative cholangiography were included in the study.

RESULTS

According to gallbladder bile amylase and lipase levels, 84.2% and 89% patients respectively had OPBR. OPBR was present in all gallbladder cancer patients; in these patients the biliary levels of amylase and lipase were significantly higher than the levels found in patients with benign gallbladder pathology (P < 0.0001).

CONCLUSIONS

OPBR could lead to inflammatory changes of the biliary epithelium and progress towards the development of precancerous mucosal changes and gallbladder cancer. The reason why such high levels of pancreatic enzymes are regurgitated into the biliary tree of patients with gallbladder cancer should be clarified.

Coexistence of Mirizzi syndrome with adenomyomatosis in the gallbladder: report of a case

BACKGROUND

Mirizzi syndrome is a rare complication of cholelithiasis. Adenomyomatosis is a common tumor-like lesion of the gallbladder.

METHODS

A 52-year-old man was admitted to our hospital complaining of right hypochondriac pain and jaundice. Ultrasonography and computed tomography revealed stones in the gallbladder and dilation of the intrahepatic bile ducts. Magnetic resonance cholangiopancreatography revealed narrowing of the common bile duct caused by compression of the gallbladder. Laparotomy revealed type II Mirizzi syndrome.

RESULTS

Partial cholecystectomy with a Roux-en-Y hepaticojejunostomy reconstruction was performed. Histologically, Rokitansky-Aschoff sinus proliferation, hypertrophy of smooth muscles, and fibrosis were seen in the gallbladder. A segmental type of adenomyomatosis of the gallbladder was diagnosed.

CONCLUSIONS

The pathogenic link between the two peculiar entities is unclear. A possible explanation is considered that the pathogenesis of Mirizzi syndrome is resulted from chronic inflammation due to adenomyomatosis.

Effect of early recurrence of hepatitis C on late biliary anastomotic stricture after liver transplantation

The aim of the current study was to clarify whether recurrence of hepatitis C (HCV) infection affects biliary complications after liver transplantation (OLT), with special reference to late biliary anastomotic strictures (LBAS). We reviewed 665 consecutive adult OLT recipients with a choledochocholedochostomy without T-tube placement between 1990 and 2005. Biliary anastomotic stricture was confirmed by ERCP. The LBAS was defined as stricture that occurred 30 days or more after OLT. Recurrence of HCV was diagnosed by histological examination using liver biopsy specimen and confirmed by the presence of HCV-RNA. Early HCV recurrence was defined as recurrence that occurred within 6 months after OLT; LBAS occurred in 54 patients (8% of total). Mean duration from OLT to occurrence of LBAS was 6.9 months (1-44 months). Patients with HCV infection had higher occurrence of LBAS than did non-HCV patients (11% vs 5%, P = .0093). Among HCV patients, those with early HCV recurrence had exclusively high rate of LBAS (16%). In multivariate analyses, early recurrence of HCV (P < .001, relative risk [RR] 6.4), as well as occurrence of HAT (P = .0018, RR 8.0), and prolonged CIT (P = .034, RR 3.3) were independent risk factors affecting LBAS. In conclusion, patients with HCV infection have increased occurrence of LBAS after OLT. Additionally, early recurrence of HCV contributes to a higher rate of LBAS.

[A case of nonocclusive mesenteric ischemia (NOMI) which occurred in a patient with torsion of gallbladder]

We report a case of nonocclusive mesenteric ischemia (NOMI) which occurred in a patient with torsion of gallbladder. A 91-year-old woman was admitted to the hospital and was diagnosed of acute cholecystitis. The next day, she went into shock. Then, we diagnosed her illness as torsion of gallbladder by computed tomography and ultrasonography, and performed an emergency operation. After cholecystectomy, it was recognized that the wide range of the small intestine had become necrotic sporadically. We diagnosed it as NOMI, and performed the wide resection of the small intestine followed by making double stomas. There is no previous report of NOMI associated with torsion of gallbladder. We guess the cause of NOMI in this case would be dehydration because of gallbladder torsion. NOMI has high mortality. Early diagnosis and early treatment are of great importance in NOMI.

Endoscopic transcystic stent placement for an intrahepatic abscess due to gallbladder perforation

Perforation of the gallbladder with cholecystohepatic communication is a rare cause of liver abscess. Because it is a rare entity, the treatment modality has not been fully established. We report for the first time a patient with an intrahepatic abscess due to gallbladder perforation successfully treated by endoscopic stent placement into the gallbladder who had a poor response to continuous percutaneous drainage.

Clinical evaluation of isolated nonvisualized fetal gallbladder

OBJECTIVE

Isolated nonvisualized fetal gallbladder (INVFGB) is relatively rare. In most cases, the gallbladder will eventually be detected. In some cases however, INVFGB may be associated with serious abnormalities, cystic fibrosis (CF), aneuploidy, and agenesis of the gall bladder. We describe a clinical evaluation of prenatally diagnosed INVFGB.

METHODS

Cases of nonvisualized gallbladder were first evaluated by serial scans. Cases with no additional malformations were designated as INVFGB, and were further evaluated by mutation analysis for CF, and amniocentesis for karyotype and microvillar membrane enzymes (MME).

RESULTS

A total of 22 cases of nonvisualized gallbladder were detected. Of these, 2 had additional malformations, and 3 were excluded because of incomplete evaluation. Of the remaining 17 cases, 3 (17.6%) had adverse outcomes: 1 case of CF, 1 case of 47,XXX, and 1 case of multiple congenital anomalies detected only postnatally. Abnormal levels of MMEs were detected in 3 cases, 1 of which was diagnosed with CF. In 2 cases, the gallbladder was not detected even after birth, but development is normal.

CONCLUSION

Evaluation of INVFGB should include genetic counselling, amniocentesis for karyotype and MME analysis, CFTR mutation analysis and repeated ultrasound scans.

[Endovideosurgical methods at the treatment of patients with cholelithiasis]

Experience of 10,046 laparoscopic cholecystectomies is analyzed. The were 8097 female and 1949 male patients aged 13 to 93 years. Complicated cholelithiasis was seen at 4310 (42.9%) patients including 792 patients with acute inflammation of gallbladder, 2375--with chronic empyema, 1143--with gallbladder hydrops. Choledocholithiasis was diagnosed at 502 patients, Mirizzi syndrome--at 8, biliodigestive fistulas--at 12, cancer of gall bladder--at 5 patients. Mini-invasive endoscopic methods were used at all the patients, conversion to open surgery was necessary at 23 cases. Average time of surgery was 20-35 min, hospital stay--1-6 days. Intra- and postoperative complications were diagnosed at 86 patients among the first 3000 procedures. Among successive 7000 operations (after development of prophylactic complex) there were only 3 cases of trocar puncture infection. There were 2 cases of lethal outcome due to pulmonary embolism and pancreonecrosis.

[Chronic pancreatitis: the modern state of the problem. Part 1. Definition, prevalence, and the issues of ethiology and pathogenesis]

The review presents the latest data on the epidemiology of chronic pancreatitis (CP), its etiology and pathogenesis, and the modern classification of the disease. The review supports the great diversity of etiological factors of CP, which determine peculiarities of its pathogenesis and clinical picture.

An open access technique to create pneumoperitoneum in laparoscopic surgery

BACKGROUND

An open access technique might reduce severe vascular and visceral injuries. An open access technique through the umbilical cicatrix tube has been developed as a routine method with the goal to be easy, safe and used by all surgeons in patients without a previous midline incision.

AIM

To evaluate the open technique in a prospective study in 100 consecutive laparoscopic operations regarding time for entrance, surgeons experience and BMI of the patients.

METHODS

A midline incision from the linea alba up into the inverted umbilicus was performed in the cicatrix tube and the peritoneum was penetrated allowing air to flow into the abdominal cavity followed by a blunt trocar insertion.

RESULTS

Time for access was median 93 seconds. Entrance time in patients with BMI >30 (n=18) was 100 sec and with BMI <30 it was 90 sec (p = 0.71). The median time for consultants was 88 sec and for residents 120 sec (p = 0.003). No gas leakage was seen. Prolonged time for access was seen in three patients; two equipment failures and one obese patent.

CONCLUSION

The open access technique is applicable in all patients without a former midline incision. It is fast, easy to learn with very few associated problems.