Endoscopic sphincterotomy and laparoscopic cholecystectomy in a jaundiced infant

Endoscopic sphincterotomy is a useful preoperative management for refractory pancreatitis associated with pancreaticobiliary maljunction

BACKGROUND

Pancreatitis associated with pancreaticobiliary maljunction (PBM) is commonly treated nonoperatively before surgery. It is, however, sometimes uncontrollable, and little has been reported about the management.

METHODS

Focusing on the preoperative management, we reviewed clinical courses of 4 PBM cases (ages 1 to 7 years old). Each had pancreatitis that was totally resistant to medical treatment and was applied endoscopic sphincterotomy (ES).

RESULTS

The first case underwent percutaneous transhepatic catheter drainage (PTCD) primarily. In spite of daily lavage using the drainage tube for a week, plugs located in the common channel were not removed, and clinical findings were not improved. Therefore, ES followed by removal of protein plugs was performed to improve pancreatitis dramatically. Through this experience, 3 subsequent cases with refractory pancreatitis all underwent successful ES primarily soon after the medical treatments turned out to be ineffective. In all 4 cases, protein plugs were impacted in common channels, and ES could successfully remove the plugs that were impossible to remove by using PTCD. Improved preoperative pancreaticobiliary decompression by ES shortens the duration of recalcitrant acute pancreatitis associated with PBM allowing for a subsequent safe operation.

CONCLUSIONS

Endoscopic sphincterotomy is one of the useful preoperative managements for refractory pancreatitis associated with PBM.

Balloon sphincteroplasty in the management of choledocholithiasis in a 10-week-old infant

The management of common bile duct stones in neonates has not been clearly fully standardized, although percutaneous image-guided washing of the bile duct is generally adopted as the first-line treatment. We report the case of a 10-week-old infant with a choledocholithiasis in whom anterograde sphincter balloon dilation was achieved by combining image-guided access and flexible gastroduodenoscopy. This mini-invasive strategy may be an alternative to surgery in cases of impacted choledocholithiasis resistant to bile duct washing.

What is an appropriate indication for endoscopic papillary balloon dilation?

OBJECTIVE

There are a number of views on the indication for endoscopic papillary balloon dilation (EPBD) in the management of bile duct stones. In this study, we have evaluated the efficacy and safety of EPBD compared with endoscopic sphincterotomy (EST).

DESIGN

Prospective randomized trial.

SETTING

One university hospital and one general hospital.

PARTICIPANTS AND MAIN OUTCOME MEASURES

One hundred and forty patients were randomly allocated to EPBD or EST. Outcomes and complications were observed for a median period of 30 months.

RESULTS

Both treatment approaches finally achieved similar success rates and needed similar numbers of treatment sessions for patients with stones less than 10 mm in diameter. However, for patients with stones of 10 mm or more, EPBD required a significantly greater mean number of treatment sessions than EST (2.4 vs 1.6, P < 0.01). Early complications occurred in seven EPBD (four pancreatitis, two cholangitis and one basket impaction) and eight EST (three pancreatitis, two bleeding and three cholangitis) patients. Late complications occurred in four EPBD (three recurrent bile duct stones and one cholecystitis) and six EST (three recurrent stones and three cholecystitis) patients.

CONCLUSIONS

EPBD has little risk of bleeding. The technique removed small bile duct stones just as easily as did EST. These two procedures had approximately the same risk of pancreatitis and incidence of recurrent bile duct stones. Therefore, both procedures appear to be appropriate treatments for small bile duct stones. Whether or not EPBD becomes an established treatment will depend on further long-term studies.

Endoscopic dilatation of the biliary sphincter for removal of bile duct stones: an overview of current indications and limitations

Endoscopic balloon dilatation (EBD) of the biliary sphincter may be an alternative to endoscopic sphincterotomy (EST) for removal of bile duct stones. After EBD of the biliary sphincter to a diameter of 8 mm, stones are removed according to standard guidelines. In the event that stone removal fails after EBD, an additional EST is performed. The overall success rate of stone removal after EBD (90%) is comparable to that of EST. After EBD, an additional EST and mechanical lithotripsy are required in 10% and 30% of patients, respectively. In patients with bile duct stones < 10 mm and a stone number < or = 3, EBD is nearly always successful without the need for additional EST or mechanical lithotripsy. Pancreatitis post-EBD occurs at a rate of 5-7%, which is not significantly different from that after EST. Significant bleeding post-EBD has not been observed in over 400 patients undergoing EBD. EBD is a valuable alternative to EST, especially in patients with smaller bile duct stones and in patients with haemostatic disorders.

Laparoscopic cholecystectomy in children and adolescents

During the period between August 1991 and November 1995, seven patients under age 17 were submitted to videolaparoscopic cholecystectomy (LC). Two were males and five females with ages ranging from 12 to 16 years (mean 13.8 years). The diagnosis of chronic cholecystitis with gallstones was made by the clinical history and physical and ultrasonographic examinations. There was no evidence of an association with hemolytic diseases, familial hyperlipidemia or Glucose-6-phosphate dehydrogenase (G6PD) deficiency. The surgery was performed under general anesthesia and the abdomen approached by four ports: a 10 mm umbilical incision, a 5 mm cystic, a 5 mm one at the xiphoid appendix and a 10 mm one at the left lateral margin of the left rectus abdominal muscle between the umbilical scar and the xiphoid appendix. Operative time averaged 120 minutes (105-150 min). One case required conversion to laparotomic approach because of Mirizzi's Syndrome, which was diagnosed by intraoperative cholangiography performed in all cases. There were no deaths or major postoperative complications. Hospital stays ranged from 1-3 days in the six patients submitted to LC. Thus LC in children can be considered a good method, requiring only more care regarding the use of proper equipment, complete and careful dissection of the biliary hilus, and intraoperative cholangiography. The latter is indispensable, as these children can present a higher rate of anatomic anomalies. The advantages of this techniques include a less painful postoperative period with a faster recovery, and it is especially recommended in children, who are less tolerant to physical restriction and pain than adults.