Preoperative Endoscopic Retrograde Cholangiopancreatography Research Articles

Common bile duct exploration and laparoscopic cholecystectomy: role of intraoperative ultrasonography.

In October 1993, to detect associated common bile duct (CBD) stones, we started an evaluation program of patients with symptomatic cholelithiasis who were candidates for laparoscopic cholecystectomy. We used a standard preoperative algorithm and a laparoscopic ultrasonographic (LUS) examination. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was reserved for high-risk patients for CBD stones. Laparoscopic ultrasonographic examination during cholecystectomy was routinely performed to identify stones unsuspected preoperatively. Two-hundred-sixteen patients with symptomatic cholelithiasis were included in the study; 177 patients (82%) were at low risk for choledocholithiasis and 39 patients (18%) were at high risk and had preoperative ERCP. In 17 patients (43.5%) CBD stones were found, and in 16 patients (41%) they were removed by endoscopic sphincterotomy. In all patients, the main intra- and extrahepatic ducts were well documented by LUS, but in eight cases the distal tract of the CBD was not well-visualized. In eight patients, small stones were found in the CBD. A subsequent peroperative cholangiography or CBD exploration confirmed the diagnosis. In one patient, both LUS and cholangiography suspected a small stone; the CBD exploration did not confirm it (false positive). In two patients a small stone in the CBD was found during the followup period (two false negatives). An endoscopic sphincterotomy solved the problem. Laparoscopic ultrasonographic examination may be a real alternative to cholangiography during laparoscopic cholecystectomy: this may be reserved for selected instances on the basis of LUS findings. On the other hand, considerable ultrasonographic experience is required for LUS to be performed successfully.

The role of endoscopic retrograde cholangiopancreatography in management of patients recovering from acute biliary pancreatitis in the laparoscopic era.

Traditionally an episode of acute biliary pancreatitis (ABP) is an indication for direct imaging of the biliary tree. The optimal approach may vary according to local expertise, and endoscopic retrograde cholangiopancreatography (ERCP) is the most common. The fact that the incidence of choledocholithiasis in patients recovering from ABP varies between 3 and 33% raises a question about the necessity of visualizing the biliary tree in all patients recovering from ABP. In order to evaluate this policy, we reviewed 48 ERCPs performed on patients recovering from ABP who were scheduled for laparoscopic cholecystectomy (LC). We checked the correlations between ERCP findings and the severity of pancreatitis, biochemistry values (which were sampled during the acute phase), and ultrasonographic (US) findings. The ERCP demonstrated common bile duct (CBD) stones in 11 (22.9%) patients. US finding of a dilated CBD and maximal aspartate transaminase (AST) values higher than 90 units/l were significantly correlated with CBD stones (a relative risk [RR] of 2.95 with a 95% confidence interval [CI] for a dilated CBD and RR of 3.89 with a 95% CI of 1.18-12.80 for an AST value higher than 90 units/l). No other parameters were significantly correlated with CBD stones. We, therefore, recommend performing a preoperative ERCP only on patients who present with an ultrasonographic finding of CBD dilatation. The correlation to high AST is still to be proven.

Operative Cholangiography in Laparoscopic Cholecystectomy: Is It Essential?

This study is to evaluate the need for preoperative cholangiography during laparoscopic cholecystectomy when endoscopic retrograde cholangiopancreatography (ERCP) is available. Over a period of four years, 1105 consecutive patients had laparoscopic cholecystectomy. All patients, in addition to their clinical assessment, had routine liver function tests (LFTs) and ultrasound (US) examination of the biliary tract. Preoperative ERCP was performed (diagnostic and/or therapeutic) in 107 (9.6%) of the patients. The indications for ERCP were one or more of the following: 1) abnormal liver function test, 74 patients; 2) jaundice, 37 patients; 3) common bile duct (CBD) stone seen in US, 36 patients, and/or CBD dilatation, 46 patients; and 4) pancreatitis, 20 patients. In 41 out of 107 (38%) patients, CBD stones were present and cleared endoscopically. Postoperative ERCP was necessary in eight patients: to remove retained stones in the CBD (two patients), to stop bile leak (two patients), and to investigate the persistent abnormal LFTs in the remaining patients. The number of patients who had evidence of retained CBD stone following laparoscopic cholecystectomy was only two. In both patients, endoscopic removal was successful. Therefore, it is clear that operative cholangiography in laparoscopic cholecystectomy is not essential if there is a reasonable facility for ERCP.

Do preoperative indicators predict the presence of common bile duct stones during laparoscopic cholecystectomy?

Criteria have been suggested to help decide if an intraoperative cholangiogram (IOC) should be performed during laparoscopic cholecystectomy (LC). They are a clinical history of passing a common bile duct (CBD) stone, elevated serum amylase, elevated liver function tests, or ultrasound findings suggesting a CBD stone. What is the sensitivity and specificity of the above criteria when the presence or absence of CBD stones is already known by IOC? What is the probability that these criteria will predict a CBD stone or be normal if a stone is absent, ie, the positive predictive value (PPV) and negative predictive value (NPV)? We reviewed 420 cases of elective LC done between May 1990 and December 1992. In our teaching hospital, IOC is routine and acted as the reference standard for the presence of CBD stones. All 420 films were reviewed as well as the results of any preoperative endoscopic retrograde cholangiopancreatography (ERCP) (30 were done). The following preoperative indicators of CBD stones were recorded: any clinical history of CBD stones; an elevated amylase, SGOT, alkaline phosphatase, or bilirubin level; and ultrasound findings. The sensitivity, specificity, PPV, and NPV were calculated. CBD stones were found in 12% of these elective LC cases. The sensitivity, specificity, PPV, and NPV, respectively, for each preoperative indicator were: a history suggestive of CBD stones (36%, 94%, 45%, and 91%), serum biochemistries as a group (43%, 86%, 30% and 91%), and ultrasound findings of CBD stones (22%, 92%, 28% and 89%). We compared any elevation versus > 2x from the normal range of the serum indicators and did not improve their accuracy. Combination of the indicators increased sensitivity and NPV but lowered specificity and PPV. The best predictor of CBD stones was the history (45%) and this was in a hospital with a CBD stone prevalence rate of 12%. There are no predictive tests that can sufficiently increase an observer's probability estimate of the presence or absence of CBD stones to allow for "selective" IOC decisions.

One hundred consecutive laparoscopic cholangiograms. Results and conclusions.

In 100 consecutive patients who underwent laparoscopic cholecystectomy, the feasibility, reliability, and cost of routine laparoscopic cholangiography were prospectively studied. Fluoroscopic cholangiograms with multiple exposures were successfully completed in all patients in an average time of 6.9 min. Twenty-one percent were abnormal, and 15 common duct stones and 6 significant anatomic anomalies detected. Thirteen out of 15 patients with common duct stones had preoperative suspicion of common duct stones. Two out of 15 were completely unsuspected. The average cost of cholangiography was $768, and there were no complications related to the procedure. There were no false interpretations. When compared with selective preoperative endoscopic retrograde cholangiopancreatography (ERCP), routine laparoscopic cholangiography is safer, more accurate, and less costly, and may have the added benefit of potentially reducing iatrogenic injuries in patients with anatomic variations. Routine laparoscopic cholangiography should be considered by all surgeons.

Selective use of preoperative endoscopic retrograde cholangiopancreatography in laparoscopic cholecystectomy

Background: The management of possible common bile duct (CBD) stones in patients scheduled for laparoscopic cholecystectomy remains controversial. Methods: Prospective evaluation of 609 patients who underwent laparoscopic cholecystectomy was carried out in relation to the use of selective preoperative ERCP for detection of common duct stones. Preoperative ERCP was performed if there is or has been (1) cholangitis, biliary pancreatitis, or jaundice; (2) abnormal serum liver tests or (3) ultrasonogram showing a dilated CBD or ductal stones. Results: A total of 139 patients underwent preoperative ERCP, and cannulation of CBD was successful in 133 patients (96%). CBD stones were found in 60 patients (45%) and extracted after sphincterotomy. High prevalence of CBD stones was noted in patients with acute cholangitis and CBD stones on ultrasonogram. There were six endoscopic sphincterotomy-related complications (complication rate, 4.5%): bleeding (2), pancreatitis (3), retroduodenal perforation (1). No patient required surgery as the result of a complication. The prediction of the occurrence of ductal stones was further analyzed using stepwise logistic regression. Acute cholangitis and CBD stones on ultrasonogram were shown to be independent significant risk factors with odds ratios of 8.9 and 13.5, respectively. Conclusions: With selective preoperative ERCP, suspected CBD stones can be identified and removed prior to laparoscopic cholecystectomy. (Gastrointest Endosc 1996;43:212-5.)

The Role of Endoscopic Retrograde Cholangiopancreatography and Cholangiography in the Laparoscopic Era

The authors reviewed the results of endoscopic retrograde cholangiopancreatography (ERCP) and intraoperative cholangiography in a series of patients who underwent laparoscopic cholecystectomy. The indications for preoperative and postoperative ERCP and intraoperative cholangiography as adjuncts to laparoscopic cholecystectomy are evolving. The debate regarding the use of selective or routine intraoperative cholangiography has intensified with the advent of laparoscopic cholecystectomy. The authors reviewed the records of 343 consecutive patients who underwent laparoscopic cholecystectomy during a 1-year period. Historical, biochemical, and radiologic findings for the patients who underwent ERCP and intraoperative cholangiography were analyzed. Three hundred forty- three patients underwent laparoscopic cholecystectomy during the period reviewed. Preoperative ERCP was performed in 42 patients. Twenty-seven of these patients (64%) had common bile duct (CBD) stones, which were cleared with a sphincterotomy. Intraoperative cholangiography was performed for 101 patients (29%). Three cholangiograms had false- positive results (3%), leading to two CBD explorations, in which no CBD stones were found, and one normal ERCP. Six patients underwent postoperative ERCP, three for the removal of retained CBD stones (0.9%), all of which were cleared with a sphincterotomy. Fifteen patients had gallstone pancreatitis, six of whom had CBD stones (40%) that were cleared by ERCP. There were 33 complications (10%) and no CBD injuries. The use of routine intraoperative cholangiography is discouraged in view of its low yield and the significant rate of false positive cholangiogram results.

Selection Criteria for Preoperative Endoscopic Retrograde Cholangiopancreatography in the Laparoscopic Era

Indicators for cholangiography were originally designed to select patients at risk for common bile duct (CBD) stones for intraoperative cholangiography. To refine these criteria to apply to the much more invasive procedure of preoperative endoscopic retrograde cholangiopancreatography (ERCP). Retrospective review of selection criteria for ERCP in consecutive patients referred over 18 months following the introduction of laparoscopic cholecystectomy. Two ERCP units in adjacent teaching hospitals. Three hundred seventeen patients with gallstones and in situ gallbladders. Common bile duct imaging at ERCP. Abnormalities justifying ERCP. Abnormalities justifying ERCP were found in 66% of patients. This group differed significantly from those with normal ducts, with more being referred with abnormal results of all liver function tests (P < .001), jaundice (P < = .001), a dilated CBD on ultrasound (P < .001), or CBD stones on ultrasound (P < .001). On the other hand, patients with normal ducts were significantly more likely to have been referred with pancreatitis (P = .003) or elevated results of individual liver function tests (P < .001). A logistic regression model using age, presence of jaundice at ERCP, levels of alkaline phosphatase and albumin, and ultrasonography showing dilated ducts or visible CBD stones was found to have a specificity of 75% and a sensitivity of 89%. Past pancreatitis or elevated results of individual liver function tests were not predictive factors. The use of such a model rather than individual criteria would improve the selection of patients for preoperative ERCP, optimizing its role in the laparoscopic era.

Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy.

Endoscopic retrograde cholangiopancreatography (ERCP) is a useful adjunct to laparoscopic cholecystectomy. Preoperative ERCP is indicated if there is a high degree of suspicion for common duct stones, when severe gallstone-induced pancreatitis is present, or when there is uncertainty regarding the diagnosis. The best indicators of common duct stones preoperatively are an elevated bilirubin, a dilated common bile duct (CBD) on sonography, or stones visualized in the CBD on sonography. Mild gallstone pancreatitis and transient mild elevations in liver enzymes are not predictive of CBD stones and are not indications for ERCP. Postoperative ERCP is highly effective in clearing CBD stones. It has the advantage of being more readily available as compared to laparoscopic CBD exploration, and preserves all the advantages of the laparoscopic approach. Post-operative ERCP is indicated for retained CBD stones, evaluation and therapy of biliary injuries, and persistent biliary symptoms or abnormal liver enzymes and bilirubin. ERCP is the procedure of choice for the evaluation of laparoscopic biliary injuries. Major biliary injuries will generally require surgical therapy. Bile duct strictures are sometimes amenable to endoscopic therapy with dilation and stents. Biliary leaks are readily treatable with endoscopic therapy. Small cystic duct stump leaks and leaks from a duct of Lushka close within a few days with nasobiliary drainage. Larger leaks may require more prolonged drainage with stents and early supplemental percutaneous drainage of an accompanying biloma. Bilious ascites should be treated with nasobiliary drainage using low suction to be prevent contamination of the peritoneal cavity with intestinal flora, and simultaneous percutaneous ascites drainage. Biliary leaks, unless associated with major bile duct injuries, rarely require surgical therapy.

Selective use of preoperative endoscopic retrograde cholangiopancreatography in laparoscopic cholecystectomy

Selective use of preoperative endoscopic retrograde cholangiopancreatography in laparoscopic cholecystectomy

Factors Affecting Conversion of Laparoscopic Cholecystectomy to Open Surgery

To identify the risk factors predictive of conversion of laparoscopic cholecystectomy to open surgery. Demographic, ultrasonographic, and operative data of patients who underwent laparoscopic cholecystectomy were analyzed. Factors affecting conversion to open surgery were identified with statistical analysis. A tertiary referral center. Five hundred patients who underwent laparoscopic cholecystectomies at our institution between March 1991 and July 1994. The patients' data had been prospectively collected. Standard laparoscopic techniques with selective preoperative endoscopic retrograde cholangiopancreatography. Conversion of laparoscopic cholecystectomy to open surgery for management of technical difficulties or intraoperative complications. Increased risk of conversion with statistical significance was found in patients older than 65 years, obese patients, patients who underwent interval elective laparoscopic cholecystectomy for acute cholecystitis, patients with ultrasonographic findings of thickened gallbladder wall, patients seen during the early learning phase of the series, and patients whose surgery was performed by senior surgeons. Increased risk of conversion was not found with patients' sex, previous lower abdominal surgery, history of acute pancreatitis or cholangitis, impaired liver function on presentation, or emergency laparoscopic cholecystectomy for acute cholecystitis. Risk factors, including patient factors, presentation, preoperative ultrasonography, and surgical experience, all contributed to the possibility of conversion. Knowledge of these factors may help in arranging the operating schedule, psychological preparation for the procedure, and planning of the duration of convalescence.

Managing choledocholithiasis in the laparoscopic era

Background: Management options for common bile duct stones have expanded in the era of laparoscopic cholecystectomy (LC), and selecting the most appropriate method for each patient can be problematic due to the difficulty of predicting accurately which patients have choledocholithiasis (CDL). In order to improve selection of appropriate treatment for CDL, treatment options were analyzed for outcome retrospectively during a 25-month period beginning June 1, 1992. Patients and methods: Four hundred four patients underwent LC; 48 (12%) had CDL identified at preoperative endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiogram (IOCG). Forty-seven patients were referred for preoperative ERCP for suspected CDL, 23 (49%) of whom had proven duct stones and underwent endoscopic sphincterotomy and stone retrieval with an 87% success rate. Results: Of 357 patients scheduled for LC without preoperative ERCP, 236 had IOCG, of which 25 (11%) demonstrated CDL. Seven patients had open common bile duct exploration (CBDE). Sixteen patients had postoperative ERCP after positive IOCG, 7 (44%) of which were positive for CDL and whose stones were removed with 100% success. Two patients were observed, anticipating spontaneous passage of a small stone. Conclusions: Preoperative ERCP should be applied selectively. For the large majority of patients without preoperative evidence of CDL, we recommend routine IOCG; if CDL is demonstrated, an intraoperative decision can be made to proceed to postoperative ERCP in the usual case or to open CBDE for very large or multiple stones. Observation in anticipation of spontaneous passage may be appropriate for small, solitary common duct stones. Continuing advances in laparoscopic CBDE are likely to reduce further the need to rely on ERCP in managing CDL.

Sequential endoscopic/laparoscopic management of sickle hemoglobinopathy-associated cholelithiasis and suspected choledocholithiasis.

We reviewed the medical records of 17 patients with sickle hemoglobinopathy-associated cholelithiasis who were candidates for laparoscopic cholecystectomy (LC) between 1991 and 1994. Eight patients with suspected choledocholithiasis (CDL) were identified, all of whom had preoperative endoscopic retrograde cholangiopancreatography (ERCP), which revealed CDL in 3 patients (18%), all of whom had endoscopic ductal clearance. Choledocholithiasis was suspected because of hyperbilirubinemia or serum liver enzyme abnormalities. Incremental hyperbilirubinemia exceeding "baseline" values by > 5 mg/dL was the best predictor of CDL. Subsequent LC was successful with discharge within 2 days of LC in all but one patient, who was converted to open cholecystectomy. This small series suggests that in sickle hemoglobinopathy patients with cholelithiasis (1) CDL is relatively common among patients with an increase above baseline hyperbilirubinemia, (2) bile duct dilatation, alkaline phosphatase, and serum aminotransferase levels are poor predictors of CDL, and (3) sequential endoscopic/laparoscopic management of cholelithiasis and suspected CDL is successful.

The role of endoscopic retrograde cholangiopancreatography in patients with laparoscopic cholecystectomies

Background & Aims: The best clinical strategy for using endoscopic retrograde cholangiopancreatography (ERCP) with laparoscopic cholecystectomy is unknown. The aim of this study is to use decision analysis to assess four different approaches to using ERCP in patients undergoing laparoscopic cholecystectomy. Methods: Decision trees were designed for four clinical strategies: (1) preoperative ERCP, with sphincterotomy for choledocholithiasis; (2) selective preoperative ERCP for patients at high risk for choledocholithiasis, choledocholithiasis found at surgery treated by postoperative ERCP; (3) no preoperative ERCP, choledocholithiasis detected intraoperatively treated by postoperative ERCP; and (4) no preoperative ERCP, choledocholithiasis detected intraoperatively treated with open common bile duct exploration. Using decision analysis with literature-derived data, the impact on outcome parameters was calculated. Results: Postoperative ERCP resulted in the lowest cost, procedure numbers, and hospital and back-to-work days. With high preoperative likelihood of choledocholithiasis, selective preoperative ERCP was probably a clinically equivalent strategy. Sensitivity analysis supported these conclusions when the probabilities and utilities were varied over a wide range. The open operative approach to choledocholithiasis was only favored if ERCP had <75% diagnostic and <50% therapeutic success rates or lengthened hospitalization by >7 days. Conclusions: This study suggests that performing ERCP after laparoscopic cholecystectomy minimizes costs and morbidity; however, when choledocholithiasis is likely, selective preoperative ERCP may be a clinically equivalent strategy.

Selective Operative Cholangiography

To evaluate the results of selective intraoperative cholangiography (IOC) in patients undergoing laparoscopic cholecystectomy. Retrospective study. Mayo Clinic, Rochester, Minn, from 1990 to 1991. Five hundred forty-two patients underwent attempted laparoscopic cholecystectomy. Excluding 28 (5.2%) who underwent conversion to laparotomy and 19 (3.5%) who did not respond to a follow-up questionnaire, there were 495 respondents (mean follow-up, 25 months). Incidence and management of choledocholithiasis, extrahepatic bile duct injuries, and other findings potentially affected by IOC. Twenty patients underwent preoperative endoscopic retrograde cholangiopancreatography for suspected common bile duct abnormalities, and 10 had common bile duct stones removed. Nearly a third (n = 161 [32.5%]) of the patients underwent IOC for laboratory, historical, or operative findings or for training purposes. Common bile duct stones were discovered on IOC in five patients (3.1%), three of whom were treated successfully with postoperative endoscopic therapy; the two others had normal findings on endoscopic retrograde cholangiopancreatography (false-positive results of IOC). In three other patients in whom IOC was unsuccessful or incomplete, symptomatic common bile duct stones developed. Two patients were treated with endoscopic techniques, and one required open common bile duct exploration. Among the 334 patients who did not undergo IOC, symptoms suggestive of retained stones developed in eight (2.4%) (all within 2 months of surgery; mean, 18 days), but stones were found at endoscopy retrograde cholangiopancreatography in only four patients. Two had preoperative criteria for performing IOC. In only three patients (0.6%) from the study population would symptomatic retained common bile duct stones have developed with selective IOC and routinely successful IOC. No common bile duct injuries occurred. Selective IOC during laparoscopic cholecystectomy is a safe practice when the ductal anatomy is clearly defined and there is no laboratory or clinical evidence of common bile duct abnormalities. Symptomatic retained common bile duct stones will be infrequent, and bile duct injuries will be rare when IOC is performed for the appropriate indications. These data do not support the need for routine IOC, although this procedure is an essential tool for the laparoscopic surgeon.

Timing of laparoscopic surgery in gallstone pancreatitis.

To study the effect of the timing of laparoscopic cholecystectomy following acute gallstone pancreatitis. University-based county teaching hospital. Retrospective case series. One hundred forty-two patients with gallstone pancreatitis treated by laparoscopic cholecystectomy between April 1991 and September 1993. There were 16 men and 126 women, with a mean age of 39.5 years. The mean serum amylase level at admission was 1616 U/L. All patients were operated on more than 48 hours after admission, after clinical and biochemical resolution of pancreatitis. Preoperative endoscopic retrograde cholangiopancreatography was performed in 25 patients (more than 48 hours after admission), with common bile duct stones being identified and removed in 10. Twenty patients had three or more Ranson's criteria. Of these, nine had laparoscopic cholecystectomy attempted within the first week of admission. Six (67%) of these patients required conversion to open procedures (two for common bile duct exploration, one for repair of a common hepatic duct injury, and three for anatomic distortion due to inflammation). The mean postoperative stay of the nine patients was 5.4 days. The other 11 patients with three or more Ranson's criteria were operated on after 1 week, and only two required conversion to open cholecystectomy (18%). The mean postoperative stay in these 11 patients was 2.3 days. The difference in conversion rate approached but did not reach statistical significance (P = .08). The postoperative stay, however, was significantly shorter in the group of patients who underwent late operations (P = .03). There were 122 patients with fewer than three Ranson's criteria. In this group, there was no difference in length of postoperative stay between patients operated on earlier and those operated on later (2.4 vs 3.9 days; P = .49; n = 74 and n = 48, respectively). Of these 122 procedures, eight were converted to open procedures (6.6%). There was no significant difference in conversion rates in these patients regardless of whether they were operated on earlier or later. Based on these data, we believe, first, that laparoscopic cholecystectomy is safe in patients recovering from gallstone pancreatitis (mortality rate, 0%; bile duct injury, 0.7%). Furthermore, early operation can safely be recommended in patients with mild pancreatitis. However, in patients with three or more Ranson's criteria, operation during the first week following admission is associated with an increase in operative complications, an increased rate of conversion, and longer postoperative stays.

Laparoscopic cholecystectomy in the elderly: [formula omitted], J. Lavergne, S. Barkin, S.W. Unger, D.K. Reiner. U of Miami, School of Medicine/Mt. Sinai Medical Center, Divisions of GI and Department Surgery

To evaluate the outcomes of laparoscopic cholecystectomy in elderly patients at a single institution.A retrospective chart review was conducted of all patients > or = 65 years of age who underwent laparoscopic cholecystectomy over a 5-year period (January 1995 to December 1999). Four-trocar site laparoscopic cholecystectomy using the open Hasson technique were performed in all patients. The demographic data (age, sex), associated comorbidities, American Society of Anesthesiologist's (ASA) score, postoperative morbidity, mortality, and length of stay were recorded for each patient. Statistical analysis was done using Fisher's exact test and chi-square analysis. Statistical significance was defined as P < or = 0.05.The patient cohort included 46 patients with a median age of 71 years (range, 65 to 87). Seventeen (37%) patients were < or = 70 years of age, and twenty-nine (63%) patients were > or = 70 years of age. Twenty-two (48%) patients had ASA scores of > or = 3. Patients > or = 70 had significantly higher ASA scores. Eighteen patients > or = 70 years had ASA > or = 3 compared with 4 patients < or = 70 with ASA > or = 3 (P<0.05). Twenty-two patients > or = 70 and 8 patients < or = 70 required urgent surgery P<0.05). Fifteen (33%) patients presented with acute cholecystitis, and 31 (67%) patients presented with a greater number of chronic symptoms. Four (9%) patients had pancreatitis on presentation, and 6 patients underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP). Two of these 6 patients also underwent sphincterotomy. Urgent surgery was performed in 30 (65%) patients. The mean operative time was 103 +/- 37 (SD) minutes. One (2%) conversion to open cholecystectomy was required. The mean postoperative stay was 7 days (range, 1 to 46). Fourteen (30%) patients had only a 1-night postoperative stay. Patients > or = 70 had significantly longer postoperative stays. Nine patients > or = 70 and only 1 patient < or = 70 stayed in the hospital for more than 7 days. Postoperative complications were noted in 6 (13%) patients, most of which were chest infections. Five patients > or = 70 and only 1 patient < or = 70 developed postoperative complications. No mortalities occurred.Laparoscopic cholecystectomy is safe and feasible in elderly patients. Patients > or = 70 years seem to have a longer postoperative stay and slightly more postoperative complications. Age alone should not be a contraindication to laparoscopic cholecystectomy in the elderly patient.

Biliary tract dilatation and abnormal choledocho-pancreatic ductal junction in children

Nine children aged between 2 months and 11 years, who had congenital dilatation of extrahepatic biliary tract, with or without intrahepatic dilatation, are presented. The radiological studies performed in eight patients demonstrated abnormal choledochopancreatico ductal junction. Thus, a long common channel is formed out of the duodenal wall, leading to a continuous reflux of pancreatic juice into the biliary system, chronic inflammation of biliary tract wall, fibrosis of muscular layer and finally different types of dilatations. The main clinical findings were upper abdominal pain, vomiting, or obstructive jaundice. In only one child the dilatation was cystic type and the clinical manifestation was palpable abdominal mass. In eight patients the initial diagnosis of biliary tract dilatation was made through abdominal ultrasound and in one case by direct visualization through emergent exploratory laparotomy. The final confirmation of the presence of long common channel was made by preoperative endoscopic retrograde cholangiopancreatography or intraoperative cholangiogram. The radiologic investigation was not performed in only one case due to bad clinical conditions. The surgical treatment indicated to all cases was Roux- en- Y hepatic- jejunostomy. The late follow up demonstrated that all patients are well and assymptomatic.

Gallstone Pancreatitis

To evaluate the efficacy of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy in patients with gallstone pancreatitis and to determine criteria predictive of common bile duct stones (CBDS). Retrospective chart review. Seventy-one consecutive patients with gallstone pancreatitis. Identification and endoscopic management of CBDS, complications, and mortality. Preoperatively, ERCP revealed CBDS in seven of 22 patients and postoperatively, in five of six patients. All stones were successfully removed. Laboratory values and common bile duct dilatation on admission did not predict CBDS. Persistent hyperamylasemia (> 150 U/L) and persistent hyperbilirubinemia (> 29.07 mumol/L [1.7 mg/dL]) were associated with CBDS on ERCP or intraoperative cholangiography. All five patients with cholangitis underwent ERCP, and CBDS were found and removed in four. There were no deaths and there was a 7% complication rate. Gallstone pancreatitis can be effectively managed by selective ERCP, endoscopic sphincterotomy, and laparoscopic cholecystectomy. Preoperative ERCP can be restricted to patients with cholangitis, persistent hyperbilirubinemia, or persistent hyperamylasemia.

A Fifteen-Year Experience with Open Drainage for Infected Pancreatic Necrosis

Advances in the understanding of the pathophysiologic factors of acute pancreatitis, combined with several recent technologic breakthroughs, have led to the establishment of infected pancreatic necrosis as the most common, the most severe and the most lethal of the infectious complications of acute pancreatitis. In this report, a single institutional experience in the surgical management of infected pancreatic necrosis during a 15 year period is chronicled. Using open drainage with scheduled abdominal re-explorations, the overall mortality rate was 15 percent in 71 consecutive patients with infected pancreatic necrosis. In the most recent 25 instances, sequential re-explorations were performed until retroperitoneal granulation occurred, at which time the abdomen was closed over lesser sac lavage catheters. Compared with the original 46 patients permitted to heal entirely by secondary intention, patients undergoing delayed secondary closure and lavage had a significant decrease during the hospitalization period (48.8 versus 30.1 days; p < 0.05), without a significant change in the mortality rate. In the most recent patients, dynamic pancreatography and fine needle aspiration bacteriologic factors were accurate in the preoperative prediction of pancreatic necrosis and microbial infection in 95 and 97 percent of the patients, respectively. Preoperative endoscopic retrograde cholangiopancreatography demonstrated leakage of contrast material from necrotic pancreatic ducts in seven of eight patients, while postoperative pancreatograms revealed abrupt truncation or other abnormalities in 11 of 13 patients. These observations establish that necrotizing pancreatitis involves pancreatic parenchyma as well as peripancreatic adipose tissue. Open drainage with contingent secondary closure and high volume lavage deserves a place in the management of patients with extensive infected pancreatic necrosis.