C. Strömberg

Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study.

Objectives To determine whether the routine use of intraoperative cholangiography can improve survival from complications related to bile duct injuries. Design Population based cohort study. Setting Prospectively collected data from the Swedish national registry of gallstone surgery and endoscopic retrograde cholangiopancreatography, GallRiks. Multivariate analysis done by Cox regression. Population All cholecystectomies recorded in GallRiks between 1 May 2005 and 31 December 2010. Main outcome measures Evidence of bile duct injury, rate of intended use of intraoperative cholangiography, and rate of survival after cholecytectomy. Results During the study, 51 041 cholecystectomies were registered in GallRiks and 747 (1.5%) iatrogenic bile duct injuries identified. Patients with bile duct injuries had an impaired survival compared with those without injury (mortality at one year 3.9% v 1.1%). Kaplan-Meier analysis showed that early detection of a bile duct injury, during the primary operation, improved survival. The intention to use intraoperative cholangiography reduced the risk of death after cholecystectomy by 62% (hazard ratio 0.38 (95% confidence interval 0.31 to 0.46)). Conclusions The high incidence of bile duct injury recorded is probably from GallRiks’ ability to detect the entire range of injury severities, from minor ductal lesions to complete transections of major ducts. Patients with bile duct injury during cholecystectomy had impaired survival, and early detection of the injury improved survival. The intention to perform an intraoperative cholangiography reduced the risk of death after cholecystectomy.

Acute Abdominal Pain: Diagnostic Impact of Immediate CT Scanning

BackgroundAcute abdominal pain is a common diagnostic problem. This study aimed to evaluate the routinely use of contrast enhanced computed tomographic (CT) scanning early in the diagnostic process.MethodsA retrospective review of 2,222 patients with acute abdominal pain who underwent contrast enhanced CT scanning within 24 h after admission. The diagnoses obtained were compared with the final diagnoses after 1 month.ResultsAfter CT scanning the following diagnoses were suggested as the primary cause of the abdominal pain: nonspecific abdominal pain 984 (44.3%), appendicitis 354 (15.9%), bowel obstruction 190 (8.6%), diverticulitis 182 (8.2%), gastrointestinal perforation 52 (2.3%), gallstone disease 64 (2.9%), pancreatitis 72 (3.2%), inflammatory bowel disease 13 (0.6%), intra-abdominal malignancy 34 (1.5%), vascular disease (including 1 completely cured patient with paradoxical embolization in the superior mesenteric artery) 33 (1.5%), urological 131 (5.9%), gynecological 54 (2.4%), miscellaneous 31 (1.4%). In 28 cases a conclusive CT examination could not be carried out. The suggested diagnoses were correct in 2,151 cases (96.8%). In 16 cases (0.7%) an incorrect diagnosis was reported, leading to 7 unnecessary laparotomies. False negative reports were obtained in 27 cases (1.2%). After CT examination 500 patients could be discharged immediately.ConclusionsContrast-enhanced CT scanning results in superior diagnostic precision in patients with acute abdominal pain. The present work supports the strategy to include this examination early in the routine diagnostic process.

Endoscopic Sphincterotomy and Risk of Malignancy in the Bile Ducts, Liver, and Pancreas

BACKGROUND & AIMS After endoscopic sphincterotomy (ES), an elevated long-term risk of cholangiocarcinoma has been reported. However, large population-based studies testing this hypothesis are lacking. The aim of this study was to evaluate the risk in a large population-based cohort. METHODS Data concerning all patients having had an inpatient endoscopic retrograde cholangiopancreatography (ERCP) were collected from the Swedish Hospital Discharge Register. Incident cases of malignancy were identified through linkage to the Swedish Cancer Registry. Patients with a diagnosis of malignancy before or within 2 years of the ERCP were excluded. The cohort was followed to a diagnosis of malignancy, censoring as a result of death, emigration, or end of follow-up. The risk of malignancy was calculated as standardized incidence ratio (SIR) compared with the general population, inherently adjusting for age, gender, and year of entry. RESULTS A total of 27,708 patients undergoing ERCP from 1976 through 2003 for benign disease were included in the cohort. ES was performed in 11,617 of these. The risk of malignancy in the bile ducts alone and in the bile ducts, liver, and pancreas together was significantly elevated in the total cohort (SIR, 3.3; 95% confidence interval, 2.3-4.5), irrespective of whether an ES was performed. The risk of malignancy diminished with increasing follow-up time. Patients ever having had a cholecystectomy had a significantly lower risk of the studied malignancies. CONCLUSIONS The risk of malignancy in the bile ducts, liver, or pancreas is elevated after ERCP in benign disease. However, ES does not seem to affect this risk.