Prior Cholecystectomy Research Articles

Laparoscopic Omental Harvest for Flap Coverage in Complex Mediastinitis

Mediastinitis is one of the most serious complications of cardiac surgery. The standard of care in mediastinitis includes thorough sequential debridement, flap coverage, and culture-directed antibiotics. The most frequently utilized muscles for flap reconstruction include the rectus abdominus and the pectoralis major. However, in some instances these flaps may be inadequate, unavailable, or fail, thus requiring an alternative choice or adjuvant. Most coronary graft procedures utilize the left internal mammary artery, frequently eliminating the left rectus muscles, while prior open cholecystectomy patients frequently lose availability of their right rectus muscle. In addition, radiation therapy or prior flap failure may exclude other muscle transfer procedures. The omentum offers excellent coverage due to mobility and superb arterial and lymphatic flow. Unfortunately, in the past, this has required a celiotomy in an already critically ill patient. We present a series of 5 patients where the omentum was mobilized laparoscopically and passed through an anterior diaphragmatic incision. This option spares a celiotomy, seals the wound, and hastens recovery in very ill patients. We also present a complete review of literature on the topic and provide an algorithm for complex sternal wound reconstruction.

Troglitazone-induced liver failure: a case study

Background Troglitazone was removed from the U.S. market because its use was associated with an increased risk of liver failure. We evaluated the clinical features of all cases reported to the Food and Drug Administration and estimated the duration and magnitude of the risk of liver failure associated with continued use of the drug. Methods Data from cases of liver failure associated with troglitazone use were abstracted and analyzed. The extent of troglitazone use was determined from national marketing data, and the duration of use was estimated with data from a large, multistate, health care company. Survival analysis was performed to estimate monthly incidence rates and the cumulative risk of liver failure. Results Ninety-four cases of liver failure (89 acute, 5 chronic) were reported. Of the acute cases, 58 (67%) were women and only 11 (13%) recovered without liver transplantation. Progression from normal hepatic functioning to irreversible liver injury occurred within 1 month in 19 patients who were indistinguishable clinically from the 70 patients who had an unknown time course to irreversibility, except for the post hoc observation that prior cholecystectomy was less common in those with rapid onset. The incidence of liver failure was elevated from the first through at least the 26th month of troglitazone use. Accounting for case underreporting, the number needed to harm from troglitazone use was between 600 to 1500 patients at 26 months. Conclusion The progression to irreversible liver injury probably occurred within a 1-month interval in most patients, casting doubt on the value of monthly monitoring of serum aminotransferase levels as a means of preventing troglitazone-induced acute liver failure. The cumulative risk of hepatic failure increased with continued use.

The relationship of bile duct crystals to sphincter of Oddi dysfunction.

Bile duct crystals collected either from the duodenum after gallbladder contraction or directly from bile duct aspiration are surrogates for gallbladder stones and microlithiasis. Whether bile crystals also serve as surrogates for bile duct stones or microlithiasis that forms in the bile duct after cholecystectomy is not known based on current data. Sphincter of Oddi dysfunction (SOD), due either to muscular spasm or sphincter fibrosis, is a cause of bile duct obstruction. Almost all of the literature on SOD involves patients who have had a prior cholecystectomy. Intuitively, obstruction at the SO following cholecystectomy would seem to lead to biliary stasis and predispose patients to bile duct microlithiasis. However, a recent study did not find bile duct crystals in patients with manometrically diagnosed SOD. The reason for this is unknown, although we hypothesize that cholesterol and bilirubinate crystals are not surrogates for brown pigment stones commonly found in patients following cholecystectomy.

Role of intravenous cholangio-cholecystography in the diagnosis of asymptomatic choledocholithiasis

Standard diagnostic procedures (anamnesis, physical examination, laboratory analyses, ultrasound diagnosis), commonly used in diagnosis and preparation for surgical intervention of patients with cholelithiasis, are in most cases a reliable indicator for evaluation of the disease and conditions planned for surgery. In some cases by application of these narrow diagnostic models, some conditions, anatomic variations and biliary tract malformations remain unrecognized. Asymptomatic ("silent") choledocholithiasis (2.02%) represents a special diagnostic and therapeutic problem. Our extended diagnostic protocol includes routine intravenous cholangio-cholecystography as a standard diagnostic procedure for evaluation of cholecysto-choledocholithiasis prior planning cholecystectomy.

Juxtapapillary duodenal diverticula and biliopancreatic disease 1,2

The purpose of this retrospective case-control analysis was to evaluate the association between juxtapapillary duodenal diverticula (JPDD) and disorders of the biliopancreatic system employing univariate and multivariate logistic regression models. The study consisted of 2925 patients who underwent 5497 ERCP procedures between January, 1991 and March, 1996. Each patient in the database received a serial identification number. For each identified case with JPDD, a control patient was selected from the non-JPDD group based on corresponding parameters for age, gender, and indication for ERCP. If more than one control patient matched a case patient, the control patient with the lowest identification number was selected. No patients appear to have been excluded. The study found 350 patients (12%) with JPDD, 86% of whom had a single diverticulum. The median age of patients with JPDD was 71 yr (range = 23–98), versus 62 yr (range = 11–100) ( p < 0.0019) for control subjects. Fourteen variables were analyzed: age; sex; difficult ERCP procedure, defined as impeded access to the papilla and/or 15 min or more needed to cannulate the papilla; significant postsphincterotomy bleeding, defined as requiring injection therapy or blood transfusion; retroperitoneal perforation; prior cholecystectomy; gallbladder stones; bile duct stones; intrahepatic duct stones; recurrent bile duct stones; purulent cholangitis; pancreas divisum; acute pancreatitis; and chronic pancreatitis. Univariate analysis demonstrated that patients with JPDD more frequently underwent difficult ERCP procedures (12.5% vs 5.1%, p < 0.001), experienced significant postsphincterotomy bleeding (8.8% vs 4.8%, p = 0.039), and had more gallbladder stones (29.4% vs 22.6%, p = 0.039), bile duct stones (46.0% vs 33.1%, p < 0.001), and recurrent bile duct stones (6.6% vs 1.4%, p = 0.002). After multivariate analysis, only a difficult ERCP procedure ( p = 0.006), significant postsphincterotomy bleeding ( p = 0.006), and bile duct stones ( p = 0.012) remained significant. On univariate analysis, there was a difference noted in the incidence of purulent cholangitis (5.4% vs 2.6%, p = 0.059), which came close to but did not reach significance. Acute (11.4% vs 8.9%, p = 0.261) or chronic pancreatitis (4.6% vs 6.9%, p = 0.196) and pancreas divisum (4.0% vs 3.4%, p = 0.69) were not encountered significantly more frequently in patients with JPDD. The authors concluded that JPDD is associated with advanced age, a technically more difficult ERCP, a higher bleeding rate after endoscopic sphincterotomy, and a higher frequency of bile duct stones, recurrent common duct stones, and gallbladder stones. JPDD was not noted to significantly increase the risk for developing acute or chronic pancreatitis.

Juxtapapillary duodenal diverticula and biliopancreatic disease.

The purpose of this retrospective case-control analysis was to evaluate the association between juxtapapillary duodenal diverticula (JPDD) and disorders of the biliopancreatic system employing univariate and multivariate logistic regression models. The study consisted of 2925 patients who underwent 5497 ERCP procedures between January, 1991 and March, 1996. Each patient in the database received a serial identification number. For each identified case with JPDD, a control patient was selected from the non-JPDD group based on corresponding parameters for age, gender, and indication for ERCP. If more than one control patient matched a case patient, the control patient with the lowest identification number was selected. No patients appear to have been excluded. The study found 350 patients (12%) with JPDD, 86% of whom had a single diverticulum. The median age of patients with JPDD was 71 yr (range = 23–98), versus 62 yr (range = 11–100) (p < 0.0019) for control subjects. Fourteen variables were analyzed: age; sex; difficult ERCP procedure, defined as impeded access to the papilla and/or 15 min or more needed to cannulate the papilla; significant postsphincterotomy bleeding, defined as requiring injection therapy or blood transfusion; retroperitoneal perforation; prior cholecystectomy; gallbladder stones; bile duct stones; intrahepatic duct stones; recurrent bile duct stones; purulent cholangitis; pancreas divisum; acute pancreatitis; and chronic pancreatitis. Univariate analysis demonstrated that patients with JPDD more frequently underwent difficult ERCP procedures (12.5% vs 5.1%, p < 0.001), experienced significant postsphincterotomy bleeding (8.8% vs 4.8%, p = 0.039), and had more gallbladder stones (29.4% vs 22.6%, p = 0.039), bile duct stones (46.0% vs 33.1%, p < 0.001), and recurrent bile duct stones (6.6% vs 1.4%, p = 0.002). After multivariate analysis, only a difficult ERCP procedure (p = 0.006), significant postsphincterotomy bleeding (p = 0.006), and bile duct stones (p = 0.012) remained significant. On univariate analysis, there was a difference noted in the incidence of purulent cholangitis (5.4% vs 2.6%, p = 0.059), which came close to but did not reach significance. Acute (11.4% vs 8.9%, p = 0.261) or chronic pancreatitis (4.6% vs 6.9%, p = 0.196) and pancreas divisum (4.0% vs 3.4%, p = 0.69) were not encountered significantly more frequently in patients with JPDD. The authors concluded that JPDD is associated with advanced age, a technically more difficult ERCP, a higher bleeding rate after endoscopic sphincterotomy, and a higher frequency of bile duct stones, recurrent common duct stones, and gallbladder stones. JPDD was not noted to significantly increase the risk for developing acute or chronic pancreatitis.

Past, Present, and Future of Endoscopic Retrograde Cholangiopancreatography: Perspectives on the National Institutes of Health Consensus Conference

Past, Present, and Future of Endoscopic Retrograde Cholangiopancreatography: Perspectives on the National Institutes of Health Consensus Conference

Sphincter of Oddi dysfunction in patients addicted to opium: An unrecognized entity

Background: Opiate-induced sphincter of Oddi dysfunction (SOD) as a clinical entity has not been described. Methods: Eight chronic opium addicts (all men, mean age 61.3 years, mean duration of addiction 24.75 years) presenting with pancreatobiliary pain and a dilated bile duct with or without dilated pancreatic duct on abdominal US were studied. All patients underwent ERCP and biliary sphincterotomy. In addition, pancreatic sphincterotomy was performed in 4 patients with a dilated pancreatic duct. Observations: At ERCP, the bile duct was dilated in 8 and pancreatic duct in 4 patients. There was delayed drainage of contrast (>45 minutes) from the bile duct in all 7 patients studied, whereas delayed drainage from the pancreatic duct (>9 minutes) was incidentally observed in 3 patients. In 6 patients followed after sphincterotomy for at least 2 years, there was marked relief of symptoms. Transabdominal US at 2 years follow-up revealed a normal bile duct in 5 and persistent albeit minimal dilatation in 1 patient. Acute pancreatitis developed in 4 patients after ERCP and sphincterotomy, which was fatal in one. No patient had any abnormality in the gallbladder on initial or follow-up transabdominal US. Conclusion: SOD in opium addicts is a distinct clinical entity, mainly seen in men in this population, that is characterized by a long history of opium addiction and the absence of prior cholecystectomy or associated gallstone disease. Most patients are seen with the classic clinical picture of SOD with marked long-term improvement in symptoms after endoscopic sphincterotomy.

ERCP, biliary crystal analysis, and sphincter of Oddi manometry in idiopathic recurrent pancreatitis

Background: This study investigated the role of ERCP, analysis of bile for microcrystals, and sphincter of Oddi manometry in idiopathic recurrent pancreatitis. Methods: One hundred twenty-six patients met criteria for idiopathic recurrent pancreatitis. Patients with a normal ERCP underwent sphincter of Oddi manometry and analysis of bile. Bile was also collected in patients with papillary stenosis (defined as ductal dilation with delayed drainage of contrast, sphincter basal pressures greater than 40 mm Hg, and positive analysis for cholesterol and/or calcium bilirubinate crystals). Results: ERCP alone identified a cause of idiopathic recurrent pancreatitis in 47 (37%) patients: papillary stenosis in 26 (21%), pancreas divisum in 9 (7%), and choledocholithiasis in 6 (5%). Among patients with a gallbladder, microcrystals were found in 27 (50%) and sphincter dysfunction in 17 (31%). Among patients who have undergone cholecystectomy, sphincter dysfunction was identified in 24 (47%). Minor papilla sphincterotomy was performed in 8 patients (89%) with pancreas divisum. Biliary sphincterotomy was performed in 85 patients and included all patients with choledocholithiasis, choledochocele, microcrystals, papillary stenosis, and sphincter dysfunction except 2 patients with microcrystals who underwent cholecystectomy. Additionally, pancreatic sphincterotomy was performed in 32 (78%) patients with pancreatic sphincter hypertension and in 6 (23%) of 26 patients with papillary stenosis with dilated pancreatic ducts. Thus, among the 126 patients, 93 of the 100 patients with a detected abnormality underwent endoscopic sphincterotomy. Response rates varied from 67% to 100% during follow-up (mean 29.6 months, range 18 to 33 months). Conclusion: ERCP techniques including minor papilla cannulation, analysis of bile for microcrystals, and sphincter of Oddi manometry identified a cause of idiopathic recurrent pancreatitis in 79% (endoscopically treatable in 75%) of patients, with or without prior cholecystectomy. (Gastrointest Endosc 2002;55:157-62.)

The rendezvous technique for the treatment of choledocholithiasis

Background: The rendezvous technique combines endoscopy with percutaneous transhepatic cholangiography to facilitate cannulation of the bile duct when previous attempts have failed. Methods: Over a 7-year period, a total of 1753 ERCPs were performed. Twelve of these patients with a diagnosis of choledocholithiasis were poor candidates for surgery. Percutaneous transhepatic cholangiography as well as ERCP with precut papillotomy failed to resolve biliary obstruction. In a further 2 cases the percutaneous approach was used by means of a T-tube positioned at a prior cholecystectomy. Observations: The combined procedure was successful in 13 patients (93%). It was unsuccessful in 1 patient because of a stone lodged distally near the papilla. There was only 1 complication (7%), a retroperitoneal perforation that occurred during papillotomy; no mortality was directly attributable to the technique. Conclusions: The rendezvous technique is recommended for patients who are not eligible for surgery when ERCP is unsuccessful and when it is impossible to resolve biliary obstruction by percutaneous transhepatic cholangiography.

Indications for preoperative ERCP.

The indication for preoperative ERCP is about to be changed after the introduction of MRCP. There are however advantages of ERCP especially if the option of a therapeutic procedure, e.g., extraction of stones or placing of stents is considered. Besides ERCP prior laparoscopic cholecystectomy which is discussed elsewhere in this journal, indications for preoperative ERCP consist in patients after concussion trauma and hyperamylasemia as long as CT or MRI are not able to show pancreatic duct rupture. In this context the possibility of a stent placement is a major advantage of ERCP, since surgery may be avoided by this procedure. Preoperative ERCP may be performed in patients with chronic pancreatitis and refractory pain with the option of endoscopic therapy in cases with limited findings (less than 3 stones located in the pancreatic head). Furthermore, ERCP plays an important role in the preoperative differentiation between cystic neoplasms and pancreatic pseudocysts. Pseudocysts may be cured by endoscopical placement of transpapillary, transgastric or transduodenal stents. But so far no prospective studies have compared surgical with endoscopical drainage of pseudocysts. Finally, ERCP in the primary diagnosis of pancreatic carcinoma plays only a limited role and should be performed only if non-invasive methods are not able to clarify the situation.

4615 Prevention of acute post-ercp pancreatitis with heparin? final results of a prospective study on risk factors for ap.

Explorative analysis obtained a very low incidence of AP in patients who received heparin prior to ERCP with EST. Experimental data showed that heparin has anti-inflammatory effects, improves pancreatic microcirculation during AP and inhibits pancreatic proteases. METHODS: Potential risk factors for AP were prospectively analysed in all consecutive ERCP with EST between 09/94 and 12/98. Pts. were followed up by physical examination and blood samples at 4, 24 and 48 hours af-ter EST. Complications were classified according to commonly accepted criteria (Gastrointest Endosc 1991: 338). Confirmative analysis of RF for AP was performed by uni- and multivariate methods, and the incidence of AP was compared between pts. who received heparin (HEP) and pts. without heparin (CON; control) considering known and suspected confounding variables (RF-analysis for AP). RESULTS: 815 pts. (53.3% m, 46.7% f, 61±17 y); complications 9.9% (81/815; 69 mild-moderate; 11 severe; 4 fatal). The incidence of AP was 6.4% (52/815; 48 mild-moderate; 4 severe; 0 fatal). Heparin was administered in 33.0% (269/815). Multivariate analysis identified 4 independent RF for AP: endoscopist-frequency ≤ 40EST/y (11.8% vs. 4.2%, p=0.002), female sex (9.2% vs. 3.9%, p=0.005), SOD (37.5% vs. 6.1%; p=0.011), pancreas divisum (18.7% vs. 5.9%, p=0.013), and one independent protective factor: heparin administration (3.3% vs. 7.9%; p=0.002). Additionally, prior laparoscopic cholecystectomy (14.3% vs. 6.0%, p=0.044) and pancreatic cannulation (7.8% vs. 4.3%, p=0.057) univariately showed an increased risk for AP. Pt.-age

Cholecystectomy During Abdominal Aortic Aneurysm Repair in Patients with Gallstones

Background: Simultaneous cholecystectomy for asymptomatic cholelithiasis during abdominal aortic aneurysm (AAA) repair is not widely accepted. We reviewed our data to determine morbidity and mortality in patients with cholelithiasis undergoing AAA repair. Methods: Over the past 5 years, 320 infrarenal AAA repairs were done in our institution. Twenty-nine patients were identified as having had a prior cholecystectomy, leaving 291 patients in the study group. Forty-seven patients (16%) were found to have cholelithiasis. Thirty patients underwent a cholecystectomy at the time of the AAA repair (GpA), whereas 17 patients did not have their gallbladder removed (GpB). Patient characteristics, postoperative complications, and mortality were compared. Results: Two patients in GpA died (6.7%), one of renal failure and the other of respiratory failure. In GpB there were three deaths (17.6%) due to postoperative hemorrhage. No deaths in either group were related to the biliary tract. Ten infectious complications occurred in six patients in GpB (35%), compared with only 10% of patients in GpA (p&lt;0.05). Cholecystitis occurred in 24% of patients in GpB, with no cases in GpA (p&lt;0.02). Complications directly related to the biliary tract occurred in 35% of patients in GpB (p&lt;0.02). Conclusions: These data indicate that asymptomatic gallstones resulted in significant morbidity during the postoperative recovery period from AAA repair. We conclude that patients with asymptomatic gallstones should undergo routine cholecystectomy at the time of the AAA repair.

Recurrent pancreatitis in Gardner variant familial polyposis: etiology, diagnostic approach, and interventional results.

Pancreatitis arising from an obstructing ampullary neoplasm in patients with Gardner variant familial polyposis is an infrequently described clinical entity. We reviewed all patients with Gardner variant polyposis presenting with pancreatitis during a 12-year period in our institution, hoping to better define etiology and the appropriate diagnostic and interventional approach. A retrospective record review (1986-1998) defined patient demographics, presenting features, initial and subsequent endoscopic retrograde cholangiopancreatography (ERCP) findings, subsequent treatments, and both immediate and long-term outcomes. Particular consideration was given to initial post-ERCP diagnosis and to endoscopic interventions undertaken at that time. We also looked at those patients who eventually required surgical intervention after long-term failure of medical and endoscopic therapy, the indications for surgery, final pathological characteristics, and follow-up results. Eight patients (6 women and 2 men), with a mean age of 42 years at initial presentation, were found. Each patient was known to have Gardner variant familial polyposis at the time of the initial bout of pancreatitis. All had undergone prior colectomy and 4 of 8 had undergone prior cholecystectomy. None were known to be taking medications or ingesting pancreatoxic substances. Five of 8 patients had obstructing focal or diffuse adenomatous disease involving the ampulla. Two of 8 patients had pancreatitis attributed to other causes (divisum, stones) and a single patient had no clear etiology. Three of 5 patients with ampullary adenomatous disease underwent pancreaticoduodenectomy for recurrent adenomatous encroachment and ampullary stenosis, despite repetitive snare resection and papillotomy. All of these patients had ampullary and other duodenal adenomas, and none had malignant disease. Patients presenting with pancreatitis in the setting of Gardner variant familial polyposis will frequently have an obstructing ampullary neoplasm, although additional etiologies should be sought. Initial endoscopic therapy affords transient relief but may not be definitive. The abnormal scarring and fibrosis (keloid formation, desmoid reaction) that characterize this disease likely play a large role in endoscopic or subsequent surgical failure. A significant number of these patients will go on to require surgical referral and intervention.

Unusual abscess patterns following dropped gallstones during laparoscopic cholecystectomy

Laparoscopic cholecystectomy has become the standard treatment for symptomatic cholelithiasis. Numerous clinical trials have deemed it a safe procedure, regardless of the known increased risk of bile duct injury. However, the consequences and incidence of less well-known complications are still being addressed. Between 1993 and 1995, 1,130 laparoscopic cholecystectomies were performed at two major metropolitan medical centers. Of these patients, we know of 3 (0.3%) who subsequently developed abscesses as a consequence of dropped stones during the laparoscopic cholecystectomy. One additional patient who underwent prior laparoscopic cholecystectomy at another institution developed late infection as well. All 4 patients developed late purulent abscesses that ultimately required open surgical drainage, and 1 patient developed trocar site "tumor" masses that were secondary to inflammatory tissue around gallstone fragments. All patients were successfully treated by surgical drainage, stone removal, and antibiotics. Trocar site inflammatory masses required excision only. Significant costs were involved in the diagnosis, management, and duration of therapy for these problems. This experience closely resembles that of other centers and points out the existence of a late postoperative complication following laparoscopic cholecystectomy that was rarely encountered with open cholecystectomy. Strategies for avoiding this problem are discussed. Whether dropped stones are an indication for conversion to open cholecystectomy remains unclear. Thorough irrigation at time of laparoscopic cholecystectomy with or without placement of a drain in the subhepatic space does not prevent this complication.

Incidence and morbidity of cholelithiasis in patients receiving chronic octreotide for metastatic carcinoid and malignant islet cell tumors.

Octreotide, a long-acting somatostatin analogue, has demonstrated clinical utility in patients with carcinoid syndrome and malignant islet cell tumors of the pancreas. Prior studies have reported a greater than expected incidence of cholelithiasis in patients treated with octreotide for acromegaly. This study attempted to determine the incidence and morbidity of cholelithiasis in a group of patients with metastatic carcinoid or malignant pancreatic islet cell tumors who were receiving chronic therapy with octreotide. Forty-four of 55 patients on investigational protocols with octreotide were eligible for chart review; 10 patients were excluded due to prior cholecystectomy and 1 patient due to asymptomatic cholelithiasis at presentation. Patients fell into three treatment groups. The low dose (LD) group was comprised of 17 patients receiving 150 microg of subcutaneous octreotide 3 times a day. Twenty-one patients received high dose (HD) therapy comprised of 500 microg given 3 times a day. The low dose-high dose (LD-HD) group was comprised of 6 patients who had their dose escalated from 150 microg to 225-500 microg of octreotide 3 times a day. The overall incidence of cholelithiasis and/or gallbladder sludge was found to be 52.3% in all 3 treatment groups. Three of the 44 patients (6.8%) had symptomatic disease requiring emergency cholecystectomy. Five other patients underwent elective or incidental gallbladder surgery. The incidence of cholelithiasis in the LD, LD-HD, and HD groups was 35.3%, 66.6%, and 61.9%, respectively. The incidence of acute cholecystitis in the three groups was 11.8%, 0%, and 4.8%, respectively. Although greater than 50% of patients receiving octreotide developed cholelithiasis, a much smaller percentage of patients had symptomatic gallbladder disease. Patients receiving chronic octreotide treatment require monitoring for the development of gallstones. However, prophylactic cholecystectomy is not indicated, unless it is performed in conjunction with bowel resection or cytoreductive hepatic surgery.

Gallbladder visualization on routine lung perfusion imaging.

Two routine lung SPECT studies showed what appeared to be uptake within the gallbladder. This finding was confirmed on coronal views and three-dimensional reconstruction. There was no contamination or problem with the radiopharmaceutical quality control. The patients had not had any prior nuclear procedures. Gallbladder visualization on routine lung imaging has not been previously observed. The purpose of this study was to ascertain the incidence of gallbladder uptake and to determine a possible mechanism. Fifty-four patients referred for routine lung perfusion imaging were examined. At the end of the lung imaging, an anterior and/or right lateral 3-5 minute view of the abdomen was obtained. Patients too ill for additional imaging or those with prior cholecystectomies were excluded. Nineteen of the 54 patients showed activity within the gallbladder. Activity within the gut, kidneys, and urinary bladder also were observed. Gallbladder activity after Tc-99m macroaggregated albumin injection for lung perfusion studies, is a fairly common finding.

Long-term follow-up after endoscopic sphincterotomy for bile duct stones in patients younger than 60 years of age

Background: Little is known about the long-term effects of endoscopic biliary sphincterotomy. Methods: We retrospectively evaluated the rate of late complications after endoscopic sphincterotomy (EST) for bile duct stones. Patients had to meet the following inclusion criteria: (1) treated between 1976 and 1980, (2) complete stone removal after EST, (3) prior cholecystectomy or elective cholecystectomy within 2 months after EST, and (4) 60 years old or younger at the time of ERCP. A total of 100 patients were identified. Information was obtained from general practitioners and patients by telephone. Patients completed a postal questionnaire and a blood sample was obtained for liver function tests. Results: Information was obtained for 94 patients (in the majority of cases [87%] from multiple sources). There were 26 men and 68 women with a mean age of 51 years at the time of ERCP (range, 23 to 60 years). Early complications (<30 days) occurred in 14 patients (15%). One patient died of a retroperitoneal perforation secondary to EST. During a median period of 15 years (range, 3 to 18 years), 22 patients (24%) developed a total of 36 late complications. There were 21 patients with symptoms of recurrent bile duct stones and one patient with biliary pancreatitis. Other late complications, such as recurrent ascending cholangitis or malignant degeneration, were not observed. An ERCP was performed in 20 of the 22 patients with late complications and demonstrated bile duct stones in 13, combined with stenosis of the EST opening in 9 patients. Late complications were initially managed endoscopically and/or conservatively. One patient underwent surgery after failed endoscopic treatment and one patient died of cholangitis before she could undergo an ERCP. Twelve other patients died of unrelated causes during follow-up. Conclusions: After EST for bile duct stones, late complications occur in a significant proportion of patients. Stone recurrence remains the most important problem, but can in general be managed endoscopically. (Gastrointest Endosc 1996;44:643-9.)

Liver transplantation in the morbidly obese

Study Objective: To test the hypothesis that morbid obesity implies increased difficulty of liver transplantation and increased risk of adverse outcome. Design: Retrospective review of medical records of 40 morbidly obese patients using a control cohort of patients transplanted just before and after the obese patients. Setting: University medical center. Patients: All morbidly obese patients who underwent liver transplantation over a 52-month period were included. Forty adult patients met criterion for morbid obesity with body mass index greater than 30 kg/m 2. Records for 61 time-matched controls were reviewed. Measurements and Main Results: Demographic, intraoperative, and postoperative data were collected including preoperative diagnoses, laboratory and pulmonary function tests, intraoperative transfusion requirements and length of surgery, postoperative complications, and survival. Data were analyzed using Student's t-tests, and Chi-square analyses as appropriate, with significance considered a p-value less than 0.05. Obese patients were more hypoxemic than controls prior to surgery (PaO 2, 82.9 ± 3.5 vs. 93.0 ± 3.0 mmHg), were more likely to be diabetic, and had higher creatinine levels (3.0 ± 0.6 vs. 1.7 ± 0.2 mg/dl). Despite this evidence of multi-organ dysfunction, intraoperative and postoperative pulmonary and cardiac complications did not differ between groups. Though more obese patients had prior cholecystectomy, length of surgery and intraoperative transfusion requirements were not different between groups. Obese patients did not have an increased incidence of reoperation for wound problems, and lengths of intensive care unit and hospital stays did not differ between groups. Graft and patient survival were similar in obese and nonobese liver transplant recipients. Conclusion: Morbid obesity alone does not predispose to increased complications or decreased survival after liver transplantation.

Gallstones in chronic spinal cord injury: Is impaired gallbladder emptying a risk factor?

Objectives: To confirm that spinal cord injured persons are susceptible to gallstones and to evaluate the role of gallbladder stasis as a risk factor. Study Design: Twenty-nine subjects with chronic spinal cord injury underwent fasting ultrasonography to determine the incidence of gallstones and to quantitate gallbladder emptying response to a 20g fat liquid meal. Gallbladder emptying fraction was compared to that of healthy subjects studied concurrently. Results: Gallstones or sludge were found in 6 spinal cord injured men, a minimal prevalence of 21%. Four additional subjects had prior cholecystectomy for stones, giving a potential maximal prevalence of 30%. Four of the 6 subjects had gallstone risk factors of diabetes, obesity, and/or family history. Gallbladder stasis was not apparent in chronic spinal cord injured subjects. Only 5 subjects had poor gallbladder emptying, and 4 of them had diabetes and/or obesity. Conclusions: The study confirms an increased prevalence of gallstones after spinal cord injury. However, gallbladder stasis did not appear to be etiologic, and most gallstones were associated with conventional risk factors. The results do not support a general policy of gallstone screening or prophylactic therapy after spinal cord injury.