Prior Cholecystectomy Research Articles

Prior Cholecystectomy as a Predictor of Preoperative Vitamin D Deficiency in Adults Undergoing Spine Surgery

Prior Cholecystectomy as a Predictor of Preoperative Vitamin D Deficiency in Adults Undergoing Spine Surgery

728 First Time Colonoscopy in the Elderly Yields a High Rate of Curable Colorectal Cancer

included patient demographics, operative details, post-operative weight loss, and time interval between surgery and second imaging. Indications for post-operative imaging included abdominal symptoms. For purposes of this study, all imaging was re-reviewed by a radiologist whereby the common hepatic duct was measured at the level of the porta hepatis to determine interval changes. Results: A total of 551 patients underwent Roux-en Y gastric bypass during the study period. Of these, 82 had biliary imaging both before and after surgery. Thirtythree patients had post-operative imaging at least 3 months following gastric bypass. Mean age was 44 years (21-65) and 79% were female. There were 8 patients who had remote cholecystectomy prior to gastric bypass and 25 patients with gallbladders. In all 33 patients, mean hepatic duct diameter was 5.2 +/2 mm and 7.1 +/2.6 mm pre-operatively and post-operatively respectively (p <0.01). Patients with prior cholecystectomy had hepatic duct diameters of 7.9 +/1.3 mm and 9.5 +/3.5 mm pre-operatively and post-operatively respectively (p=0.3). Patients who had not previously undergone cholecystectomy had hepatic duct diameters of 4.3 +/1.1 mm and 6.4 +/1.8 mm pre-operatively and post-operatively respectively (p<0.01). Overall excess weight loss was 26.8% at a mean follow-up of 8 months (3-14). Conclusions: Hepatic duct diameter increases after Roux-en Y gastric bypass. Patients with prior cholecystectomy have a trend toward increased hepatic duct diameter, though this change was not statistically significant. A better understanding of this phenomenon may limit the need for further work-up in patients with incidentally detected biliary dilation and help to redefine what is considered normal and abnormal in this population.

Reference standard for serum bile acids in pregnancy

Please cite this paper as: Egan N, Bartels Ä, Khashan A, Broadhurst D, Joyce C, O’Mullane J, O’Donoghue K. Reference standard for serum bile acids in pregnancy. BJOG 2012;119:493–498.Objective Obstetric cholestasis (OC) is a liver disorder characterised by pruritus and elevated serum bile acids (SBA) that affects one in 200 pregnant women. It is associated with adverse perinatal outcomes such as premature delivery and stillbirth. Mild OC is defined as SBA levels of 10–39 μmol/l, and severe OC is defined by levels &gt;40 μmol/l. SBA levels in normal pregnancy have not been investigated. We aimed to establish reference values for SBA in healthy pregnant women across different trimesters of pregnancy.Design Cross‐sectional analysis of SBA levels.Setting A large tertiary referral university teaching maternity hospital.Population Healthy pregnant women with a singleton pregnancy and a body mass index (BMI) &lt; 40, excluding women with significant alcohol intake, history of liver disease, prior cholecystectomy and OC.Methods Cross‐sectional analysis of SBA levels at 12, 20, 28 and 36 weeks of gestation, and on days 1–3 postpartum.Main outcome measures SBA levels in μmol/l.Results A total of 219 women attending for antenatal care were recruited, and SBA levels were assayed at 12, 20, 28 and 36 weeks of gestation, and up to 72 hours postpartum (n = 44–49 cases at each stage). The majority were white European women, with a median age of 30 years (range 17–46 years) and median BMI of 25 (range 18–38). Values of SBA ranged from 0.3 to 9.8 μmol/l in 216 women, with only three measurements outside this range. There were no significant changes throughout pregnancy.Conclusions SBA values in uncomplicated pregnancies are consistent, regardless of gestation, and are not elevated in pregnancy. The current reference values for the diagnosis of OC appear to be appropriate.

Influence of Black and Brown Pigment Stone in Cholecystectomized Patients With Acute Biliary Pancreatitis.

BackgroundBiliary tract stones account for the majority of cases with acute pancreatitis, and include black and brown pigment stones. The aim of the study was to compare the presentation and outcome in cholecystectomized patients with acute biliary pancreatits caused by black and brown pigment stones.MethodData from patients with prior cholecystectomy and acute biliary pancreatitis were collected from January 2009 to August 2011. These cases were assigned to black or brown pigment stone groups according to the stone pattern. The general data, laboratory data, image findings and outcomes of the two groups were collected and analyzed.ResultsA total of 98 enrolled patients, with 30 (30.6%) and 68 cases (69.4%) assigned to the black and brown pigment stone groups, respectively. The cases with black pigment stone had higher CT Severity Index scores, bilirubin, ALP, ALT, rates of cholangitis, and positive blood culture. In those with brown pigment stone, there was a higher number of ERCP evaluations performed.ConclusionCholecystectomized cases with biliary pancreatitis due to black pigment stone had a higher prevalence of laboratory cholestasis and a higher rate of cholangitis.

Extent of resection for T2N0 gallbladder carcinoma regarding concurrent extrahepatic bile duct resection.

Backgrounds/AimsGallbladder carcinoma (GBCa) T2 lesions are considered to be advanced tumors showing diverse features in tumor extent. When this T2 lesion does not involve the cystic duct and there is no evidence of lymph node metastasis, we have to consider what is the most reasonable extent of resection - that is, whether to perform concurrent extra-hepatic bile duct resection (EHBD) resection or not. This study intends to evaluate the adequacy of EHBD resection in patients undergoing resection for T2N0 GBCa.MethodsFrom our institutional database of GBCa, 48 cases of T2N0 GBCa who underwent R0 resection during November 1995 and August 2008 were selected. Patients who underwent prior laparoscopic cholecystectomy were excluded. Their medical records were reviewed retrospectively.ResultsTheir mean age was 63.2±83.3 years and females were 25. The mean serum CA19-9 level was 37.3±89.3 ng/ml. The extents of liver resection were wedge resection (n=36) and segment 4a+5 resection (n=12). Concurrent EHBD resection was performed in 16 (33.3%) patients. No fatal surgical complication occurred. The majority of tumor pathology was adenocarcinoma (n=42), with additional unusual types as papillary (n=3), saromatoid (n=1), signet ring cell (n=1) and adenosquamous (n=1) cancers. The overall survival rate was 87.1% at 1 year, 69.5% at 3 years and 61.7% at 5 years. After exclusion of mortalities not related to cancer, the overall patient survival rate was 89.6% at 1 year, 72.9% at 3 years and 64.7% at 5 years, with 3-year survival rates of 72% in the EHBD resection group and 69.2% in the non-resection group (p=0.661).ConclusionsThe results of this study indicate that concurrent EHBD resection did not improve patient survival when R0 resection was achieved in patients with T2N0 GBCa. Therefore, routine EHBD resection may not be indicated for T2N0 GBCa unless the tumor is close to the cystic duct.

Common Clinical Conditions Associated with Small Intestinal Bacteria Overgrowth: A Retrospective Study of 401 Patients

Purpose: Small intestinal bacteria overgrowth (SIBO) is commonly associated with variety of clinical conditions; however, its true etiology is unknown. In this study, we reviewed 401 SIBO patients to determine the prevalence of SIBO as a first step for determining which risk factors are causative and which are merely correlative with SIBO in order to guide future focused therapy for more common etiologies. Methods: We retrospectively reviewed the medical records of 401 SIBO patients diagnosed by a positive 14C D-xylose breath test from 2005 to 2009. All of the GI clinical visit notes including symptoms, medication use, past medical history, past surgical history, and abdominal image studies were reviewed. Results: Of 401 SIBO patients, M:F 35:366 (ratio 1:9.6), median age 60 years (age range 21-88), 262 (65.3%) patients had history of abdominal surgeries, 93 (23.2%) had one surgical procedures, 91 (22.7%) had two procedures, 49 (12.2%) had three procedures, and 29 (7.2%) had more than three procedures. Most commonly performed surgeries were hysterectomy, cholecystectomy, and appendectomy (See table below). Commonly associated medical conditions were hypertension, GERD, hypothyroidism, IBS, and diabetes. Long term medication use was as follows: PPI use in 140 (34.9%), narcotic use in 58 (14.5%), and anticholinergics medication use in 44 (11%). Conditions previously commonly associated with SIBO, including scleroderma, celiac disease, IBD, and cirrhosis accounted for a surprisingly small proportion of SIBO in this cohort. Conclusion: SIBO was found mostly in elderly female patients. Most of the patients had multiple prior abdominal surgeries with prior hysterectomy, cholecystectomy, and appendectomy as the most common procedures associated with SIBO. Chronic PPI and narcotic use was frequently seen in SIBO. The most common medical conditions were hypertension, GERD, IBS, and endocrinologic diseases such as hypothyroidism and diabetes. Contrary to current clinical understanding, celiac disease and IBD were not common etiologies for SIBO. (NIH grant 1UL1RR029890).Table: Table. Common clinical conditions associated with SIBO

Effects of Chronic Transfusions on Abdominal Sonographic Abnormalities in Children with Sickle Cell Anemia

To assess the effects of chronic erythrocyte transfusions on prevalence of sonographic incidence of organ damage in children with sickle cell anemia (SCA). Children (N=148; mean age, 13.0 years) with SCA, receiving chronic transfusions (average, 7 years), underwent abdominal sonography at 25 institutions. After central imaging review, spleen, liver, and kidney measurements were compared with published normal values. Potential relations between ultrasound, clinical, and laboratory data were explored via analysis of variance, Student t test, and Cochran-Mantel-Haenzel tests of non-zero correlation. Average spleen length was similar to normal children, but over one-third had spleen volumes >300 mL, 15 had previous splenectomy for splenomegaly, and 24 had abnormal splenic echotexture. Two-thirds had hepatobiliary disease; 37 had prior cholecystectomy, 46 had gallstones, and 16 had gallbladder sludge. Gallbladder disease correlated with older age (P=.002), longer liver length (P<.001), longer duration of transfusions (P=.034), and higher total bilirubin (P<.001). Liver (P<.001) and renal lengths (P≤.005) were larger than published norms. In children with SCA, long-term transfusion therapy may not prevent development or progression of abdominal organ dysfunction.

Functional evaluation of cystic duct patency with Gd-EOB-DTPA MR imaging: an alternative to hepatobiliary scintigraphy for diagnosis of acute cholecystitis?

To determine if MR cholangiography with Gd-EOB-DTPA can be used to assess cystic duct patency and to establish normal time range for reflux of contrast material into the cystic duct/gallbladder. This retrospective study is HIPAA-compliant and IRB-approved with waiver for informed consent granted. From September 2008 to June 2009, 300 patients who underwent Gd-EOB-DTPA-enhanced MR imaging for various clinical indications, not specifically limited to evaluation for acute cholecystitis, were identified. 112 patients were excluded: prior cholecystectomy (n = 93), severe technical limitations (n = 9), or absence of appropriate clinical follow-up (n = 10). 188 total patients (82 male, 106 female, mean age 51.0 years) were included in the final dataset. Time between contrast administration and contrast reflux into the cystic duct/gallbladder on delayed phase imaging was measured. Reflux of contrast into the gallbladder was identified in 130/188 patients (69.1%) on delayed phase imaging. Average time to gallbladder reflux was 15:24 ± 5:51 minutes (range: 6:01-41:05 min). 58/188 patients (30.9%) demonstrated no reflux of contrast into the gallbladder at time of final delayed phase images. Of 58 patients who demonstrated no reflux into cystic duct/gallbladder, 15 patients demonstrated no extrahepatic biliary excretion, limiting evaluation of cystic duct patency. A total of 173 patients demonstrated biliary excretion of contrast with 76% overall sensitivity of detection of cystic duct patency. MR cholangiography with hepatobiliary MR contrast agents such as Gd-EOB-DTPA can demonstrate cystic duct patency with high sensitivity. MR protocols can be designed within a clinically feasible timeframe to optimize diagnosis of acute cholecystitis.

Laparoscopic total mesorectal excision for low rectal cancer

Laparoscopic total mesorectal excision for rectal cancer is coming out of age with recent publications highlighting its safety, feasibility, sound oncological outcomes, and improved quality of life. Nevertheless, laparoscopic proctectomy remains a challenging procedure. An embedded didactic video demonstrates a step-by-step laparoscopic total mesorectal excision with coloanal anastomosis for a low rectal cancer. A five-trocar technique is shown. The key steps demonstrated are: high division of the inferior mesenteric artery, medial-to-lateral mobilization of the descending colon, high division of the inferior mesenteric vein, take-down of the splenic flexure, total mesorectal excision with division of the rectum at the pelvic floor, and side-to-end coloanal anastomosis. Principles of a good anastomosis and potential pitfalls are described, including protection of the ureter and pelvic autonomic nerves. A series of ten consecutive patients operated for low rectal cancer with total mesorectal excision is reported. Median (range) operative time and estimated blood loss were 274 (135-360) minutes and 25 (10-50) ml. Median tumor height from the anal verge was 7 (4-10) cm. Reconstruction included three coloanal J-pouch and seven side-to-end anastomosis. Nine anastomoses were performed by using a double-stapled technique. One patient with an intersphincteric dissection required a handsewn anastomosis. A diverting ileostomy protected all coloanal anastomosis. Median length of stay was 3 (range, 2-7) days. One of ten patients was readmitted for a small bowel obstruction. The embedded video demonstrates a total mesorectal excision down to the pelvic floor in a patient who had a T2 cancer 6 cm from the anal verge with prior open cholecystectomy and hysterectomy. Laparoscopic total mesorectal excision is a safe and effective procedure. Patient selection and advanced laparoscopic skills are paramount. It is hoped that this didactic video will contribute to a wider and safer practice of laparoscopic total mesorectal excision for low rectal cancer.

The Learning Curve for Single-Port Laparoscopic Cholecystectomy by Experienced Laparoscopic Surgeon

Purpose: Single-port laparoscopic surgery is a rapidly advancing technique in laparoscopic surgery. However, there is currently limited evidence on the learning curve for this procedure. The aim of this study was to estimate the number of single port laparoscopic cholecystectomies required until improvement in the performance of the technique ceases. Methods: This is a descriptive, single-center study using routinely collected clinical data from 70 patients who underwent single port laparoscopic cholecystectomy between May 2009 and June 2010 at Dong-A University Medical Center in Busan, Korea. The review includes the mean operating time, conversion cases, intra-operative GB perforation, post-operative wound infection and mean hospital stay. Results: The mean operating time of the first 30 cases (the learning period) was 91.83 minutes. After 30 operations (the experience period), it plateaued to an average of 75.25 minutes, which remained steady in the next 40 operations - a reduction of more than 16%. Reduction in the operating time was significant (P＜0.001) between the learning period and the experience period. Other factors including additional ports, intraoperative gall bladder perforation, mean hospital stay, post-operative wound infection were not significantly different between the two periods. Conclusion: We suggest that the learning curve for single port laparoscopic cholecystectomy should be around thirty cases for a surgeon with prior conventional laparoscopic cholecystectomy experience and for self-taught single port technique.

Is prior cholecystectomy associated with decreased survival in patients with resectable pancreatic adenocarcinoma following pancreaticoduodenectomy?

Background Patients with pancreatic cancer who present with biliary symptoms may undergo cholecystectomy and thus delay cancer diagnosis. We hypothesized that prior cholecystectomy leads to decreased overall survival in patients with pancreatic adenocarcinoma. Methods Retrospective study of hepatobiliary database. Results Three hundred sixty-five patients with a diagnosis of resectable periampullary pancreatic adenocarcinoma were identified. Eighty-seven patients underwent prior cholecystectomy. Median age ( P = .48), body mass index (BMI) ( P = .8), diabetes status ( P = .06), American Society of Anesthesiologists (ASA) class ( P = .22), stent placement ( P = .13), operative time ( P = .76), estimated blood loss (EBL) ( P = .24), intraoperative transfusion ( P = .91), portal vein resection ( P = .25), LOS ( P = .09) adjuvant therapy ( P = .2), tumor size ( P = .89), differentiation ( P = .67), angiolymphatic invasion ( P = .69), perineural invasion ( P = 54), nodal metastasis ( P = .43), complication rate ( P = .75), and 30-day mortality ( P = .58) were not statistically different between patients with previous cholecystectomy and those without. Median survival was 14 months for patients with a history of cholecystectomy and 16 months for those without ( P = .25). Previous cholecystectomy was not a predictor of survival on Cox regression analysis. Conclusion There was no difference in overall survival in patients with pancreatic cancer with prior cholecystectomy versus those without.

Factors Impacting Quality of Life in Women With Fecal Incontinence

The aim of this study was to characterize differences in health-related quality of life among women presenting for treatment of fecal incontinence. Among 155 women presenting for treatment of fecal incontinence in a specialty clinic, validated questionnaires measured impact on quality of life (Modified Manchester Health Questionnaire) and severity (the Fecal Incontinence Severity Index). Bowel symptoms, including frequency, urgency, and stool consistency, were ascertained. Comorbid diseases were self-reported. Linear regression models were constructed from significant univariate variables to examine differences observed in quality of life scores. The average age was 58.7 +/- 11.5 years, with no differences found in quality of life scores according to race, body mass index, or number of vaginal deliveries (P > .05). Younger age, increased urinary incontinence symptoms, prior cholecystectomy, prior hysterectomy, and severity of bowel symptoms correlated with a negative impact on quality of life in univariate analysis (P < .05). Average severity scores were 30.5 +/- 13.7, with moderate correlation seen with increasing severity and quality of life scores (R2 = 0.60). After controlling for severity, women had increased quality of life scores with more bowel urgency (15 points; 95% CI, 8.1-21.2), harder stool consistency (10 points; 95% CI, 3.8-16.3), and prior hysterectomy (9 points; 95% CI, 2.7-15.4). Bowel symptoms and having undergone a hysterectomy had the greatest negative impact on quality of life in women seeking treatment for fecal incontinence. Targeting individualized treatments to improve bowel symptoms may improve quality of life for women with fecal incontinence.

W1645 Laparo-Endoscopic Single Site (LESS) Cholecystectomy With Epidural Anesthesia: A Safe, Cost Effective, and Appealing Approach

the 66 women choosing this approach and only 48% of the 42 men (P=0.02). Age >50 (P= 0.34), college or graduate level education (P=0.44), history of a prior cholecystectomy (P= 0.85) and an operation in the past 10 years (P=0.19) were not found to be significantly correlated with NOTES preference. The most commonly cited reason for choosing NOTES was less post-op pain (73%), followed closely by less family inconvenience (71%) and less risk of infection (71%). The lack of external scarring ranked fourth out of the six reasons, with 44% of patients selecting this as a factor in their decision. Other less commonly cited reasons were earlier return to work/income (59%) or sports (23%). For patients choosing laparoscopy over NOTES, more available data (86%) and surgical experience (83%) were both commonly selected factors. The oral orifice was most popular, with 64% of all participants preferring this approach. Conclusion: Female gender was significantly associated with a preference for NOTES. Other demographic factors did not correlate significantly with selection of either technique. Decreased pain, family inconvenience and risk of infection were found to be more important than scarring, earlier return to work/income or sports. The oral orifice was preferred by a majority of patients. Patients consider NOTES a reasonable alternative to laparoscopy.

Gallbladder Stent Placement for Prevention of Cholecystitis in Patients Receiving Covered Metal Stent for Malignant Obstructive Jaundice: A Feasibility Study

Covered self-expanding metal stents (CSEMS) have been used for palliation of malignant distal biliary strictures. Occlusion of the cystic duct by CSEMS may be complicated by cholecystitis. This potentially could be prevented by placement of a transpapillary gallbladder stent (GBS). Between 11/2006 and 10/2007, a total of 73 patients (50 male) aged 65 +/- 14 years underwent CSEMS placement for palliation of malignant obstructive jaundice. In cases where CSEMS placement caused occlusion of the cystic duct, a 7 French transpapillary pigtail gallbladder stent (GBS) was inserted to prevent cholecystitis. Of the 73 patients, 18 had a prior cholecystectomy; 34 had the CSEMS placed below the cystic duct insertion. In 19 out of the 21 patients who had a CSEMS covering the cystic duct ostium, GBS placement was attempted, which was successful in 11 individuals (58%). An attempt to access the gallbladder was complicated by wire perforation of the cystic duct in three patients; one patient requiring emergent cholecystostomy tube placement. None of the patients who underwent successful GBS placement developed cholecystitis. One GBS dislodged and was repositioned. Cholecystitis occurred in two (20%) of the ten patients without transpapillary gallbladder decompression who had a CSEMS covering the cystic duct. The ideal placement of a CSEMS is below the cystic duct insertion. Should the cystic duct ostium be occluded, placement of a GBS should be considered to minimize the risk of cholecystitis.

A Previous Cholecystectomy Increases the Risk of Developing Advanced Adenomas of the Colon

There is limited data assessing the relationship between cholecystectomy and colorectal adenomatous polyps (AP). Our aim was to determine if cholecystectomy was associated with an increased prevalence of advanced AP in male veterans. The relationship of whether prior cholecystectomy modified the natural history of AP was investigated in a retrospective study. The patients were divided into two groups: 1) those with AP and a history of cholecystectomy, and 2) those with AP, but without a history of cholecystectomy. Factors in each group associated with advanced AP were examined by univariate analysis (UA) and stepwise logistic regression analysis to determine independent predictors of aggressive clinical characteristics of polyps. Statistical significance was determined at a P < or = 0.05. We identified a total of 1234 patients with AP (cases = 127, controls = 1107). The mean age of patients was 64.1 +/- 1.9 (standard deviation) years. By UA, those with a prior cholecystectomy had a greater mean number of AP (4.2 vs. 3.5; P = 0.04) and more advanced polyps (P = 0.037) than those without a cholecystectomy. By logistic regression, prior cholecystectomy was associated with more advanced AP (OR = 1.5 [1.0-2.2]; P = 0.04). Patients who had a cholecystectomy were 51% more likely to have advanced AP. There appeared to be a trend towards increased time from cholecystectomy being associated with advanced polyps (9.69 years vs. 8.99 years, P = 0.056). A prior cholecystectomy was independently associated with an increased risk of developing advanced AP. Also, there appeared to be a trend toward a greater prevalence of advanced lesions as postcholecystectomy time increased.

Successful Treatment of Pneumomediastinum, Pneumothorax, Pneumoperitoneum, Pneumoretroperitoneum, and Subcutaneous Emphysema Following ERCP without Surgery

Purpose: We present a case of pneumomediastinum, pneumothorax, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema following an ERCP. Methods: A 73-year old female with prior cholecystectomy, gastroduodenostomy and choledocoduodenostomy in childhood presented with jaundice, abdominal pain, elevated LFTs, and dilated bile ducts on abdominal CT. Percutaneous cholangiography (PTC) revealed an anastomostic stricture of the bile duct remnant at its junction with a pseudodiverticulum of the duodenal wall. After temporary percutaneous biliary decompression, a second PTC performed stricture dilation, external-internal biliary stent placement, and biliary brushings, for which pathology was benign. The stricture was thought to be benign and a result of chronic duodenal-biliary reflux. Nonsurgical management was pursued with a combined PTC-ERCP procedure that dilated the stricture and placed dual biliary stents. Two months later, she underwent a second ERCP for further treatment of the stricture. During ERCP, the patient had extraction of the previously placed stents, biliary brushings, balloon dilation, and quadruple stent placement. In the recovery room, she developed chest pain and dyspnea. Physical exam had decreased heart and breath sounds, and extensive crepitus. Chest and abdomen x-rays revealed pneumomediastinum, pneumothorax, retroperitoneal and intraperitoneal air, and subcutaneous emphysema. Supplemental oxygen and IV Zosyn® were administered, and bilateral chest tubes were placed. Esophagogram, chest and abdomen CT, and laryngoscopy were performed to evaluate for a site of perforation, which was not found. The chest tubes were removed after 3 days, diet advanced, and the patient was discharged uneventfully on day 7. She was seen 2 months later, with no residual symptoms, and will have elective stent removal. Conclusion: ERCP-related perforation is uncommon, but mortality rates are high. There are 4 types, in descending severity: I- duodenal wall (endoscope injury); II- periampullary (injury during sphincterotomy); III- ductal (guidewire injury); and IV- retroperitoneal air only (use of compressed air). Diagnosis requires a high clinical suspicion for early detection to allow optimal management of the perforation and a better prognosis. The site of perforation may be visible and localized with extravasation of air or contrast during ERCP, or may not be visible due to microperforation. Management of type I injury and any patient with signs of peritonitis is immediate surgery. Most others can be managed without surgery using IV antibiotics, NPO, and serial abdominal and radiographic exams, with chest tube placement reserved for those with symptomatic pneumothorax as seen in this case.

Does Cholecystectomy Status Influence the Common Bile Duct Diameter? A Matched-Pair Analysis

The common bile duct (CBD) diameter is one factor that clinicians use when deciding on invasive evaluation for intra-ductal pathology, e.g., endoscopic retrograde cholangiopancreatography. Previous studies and gastrointestinal and radiological textbook authors report disparate interpretations. These inconsistent interpretations likely result from methodological limitations in prior studies. The purpose of this work is to primarily compare the CBD diameter among patients with and without prior cholecystectomy and secondarily to compare proximal and distal CBD measurements. Among 40 matched pairs, post-cholecystectomy patients had larger mean CBD diameters at proximal (7.0 vs. 5.4 mm; P < 0.001) and distal (5.9 vs. 4.6 mm; P < 0.001) sites. Post-cholecystectomy patients were also more likely to exceed the 6-mm cut point for proximal (80 vs. 28%; P < 0.001) or distal (58 vs. 20%; P = 0.003) measurements. Incidental radiographic detection of enlarged CBDs among post-cholecystectomy patients is common; therefore, clinicians should use clinical determinants to guide decisions about additional costly or potentially harmful evaluation for intraductal pathology.

Biliary Sphincter of Oddi Dysfunction Type I Versus Occult Biliary Microlithiasis in Post-cholecystectomy Patients: Are They Both Part of the Same Clinical Entity?

We speculate that biliary sphincter of Oddi dysfunction type I and symptomatic migrating biliary microlithiasis may be part of the same disease process. A retrospective analysis of prospectively collected data was carried out using procedure and diagnosis codes during the period of 1997-2006. Seventeen patients (age 51 +/- 17; 94% women) with prior cholecystectomy, right upper quadrant/epigastric abdominal pain, elevated liver enzymes, dilated biliary ducts seen on ultrasound/CT scan were identified. The patients underwent ERCP with biliary endoscopic sphincterotomy. Nine (53%) had biliary microlithiasis and eight (47%) had biliary sphincter of Oddi dysfunction type I. They were followed for 2-108 weeks (median 9 weeks). 6/8 (75%) in biliary sphincter of Oddi dysfunction type I and 6/9 (67%) in biliary microlithiasis group had resolution of abdominal pain (P = 1.00). We conclude that the clinical improvement with biliary sphincterotomy for biliary sphincter of Oddi dysfunction type I versus occult biliary microlithiasis was not significantly different.

Utilidad de la ecoendoscopia en el diagnóstico etiológico de los pacientes con pancreatitis aguda idiopática

The aim of this study was to evaluate the utility of endoscopic ultrasonography in the etiological diagnosis of patients initially diagnosed with acute idiopathic pancreatitis and to determine the clinical and laboratory factors related to the results of this technique. We studied 73 patients initially diagnosed with acute idiopathic pancreatitis and referred to our service for biliopancreatic endoscopic ultrasonography. A positive result was considered to be identification of at least one possible cause of pancreatitis, excluding patients in whom the only echoendoscopic finding was chronic pancreatitis. The clinical characteristics and clinical course of these patients were compared with the results of the technique. Endoscopic ultrasonography diagnosed at least one possible cause of acute pancreatitis in 32 patients (44%). The most frequent diagnoses were cholelithiasis (16%) and biliary sludge (20%). The diagnostic yield of endoscopic ultrasonography was lower in patients with prior cholecystectomy (16% vs. 49%; p=0.037) while a positive result was more likely in patients with elevated glutamyl oxaloacetic transaminase (GOT) or glutamyl pyruvic transaminase (GPT) levels at diagnosis of acute pancreatitis (GOT: 68 vs. 31%; p=0.002; GPT: 63 vs. 26%; p=0.001). No differences were found in diagnostic yield according to whether endoscopic ultrasonography was performed during the first episode of pancreatitis (48%) or in recurrent episodes (37%) (p=0.40). Over a mean follow-up period of 28 months, recurrence of new episodes of pancreatitis was significantly lower in patients with an etiological diagnosis (3 vs. 22%; p=0.02). Endoscopic ultrasonography is a useful technique in the etiological diagnosis of acute pancreatitis of unknown origin, especially in patients with elevated transaminase levels and/or without cholecystectomy. This technique should be used in the first episode of acute idiopathic pancreatitis.

Revision surgery for incidental gallbladder cancer: factors influencing operability and further evidence for T1b tumours

Background and aim. There is a need to increase the available data on revision radical surgery for incidental gallbladder cancer and to determine factors influencing operability. We aimed to assess the impact of stage of disease (pT) and the type of primary surgery (laparoscopy versus open) on resectability rates. Material and methods. The data of 90 consecutive patients referred to the Tata Memorial Hospital between 1 January 2003 and 30 April 2007 for revision radical surgery for incidental gallbladder cancer were reviewed retrospectively. Results. Of the 90 patients who underwent revision surgery, accurate data on T-stage was available in 76, and of these 76 patients, 44 (57.8%) had prior laparoscopic simple cholecystectomy, while 32 (42.2%) had undergone open surgery. The median time interval between the two surgeries was 2 months (range 4 weeks to 11 months). By T-stage, 23 patients had T1b disease, while 33 and 20 patients had T2 and T3 disease, respectively. Successful revision surgery could be undertaken in 71% of patients (54/76) and 29.6% of these had residual disease confirmed by histopathological examination. Conclusions. T-stage is an important factor in determining operability as confirmed by our study. As the T-stage of the disease increased, the chances of finding residual disease increased, while operability decreased. Furthermore, the case for revision surgery is strengthened because the incidence of lymph nodal disease is high even for pT1b cancers. The type of primary surgery does not affect operability in patients undergoing revision radical surgery for incidental gallbladder cancer.