Erik A. J. Rauws

Preoperative biliary drainage for cancer of the head of the pancreas

BACKGROUND The benefits of preoperative biliary drainage, which was introduced to improve the postoperative outcome in patients with obstructive jaundice caused by a tumor of the pancreatic head, are unclear. METHODS In this multicenter, randomized trial, we compared preoperative biliary drainage with surgery alone for patients with cancer of the pancreatic head. Patients with obstructive jaundice and a bilirubin level of 40 to 250 micromol per liter (2.3 to 14.6 mg per deciliter) were randomly assigned to undergo either preoperative biliary drainage for 4 to 6 weeks, followed by surgery, or surgery alone within 1 week after diagnosis. Preoperative biliary drainage was attempted primarily with the placement of an endoprosthesis by means of endoscopic retrograde cholangiopancreatography. The primary outcome was the rate of serious complications within 120 days after randomization. RESULTS We enrolled 202 patients; 96 were assigned to undergo early surgery and 106 to undergo preoperative biliary drainage; 6 patients were excluded from the analysis. The rates of serious complications were 39% (37 patients) in the early-surgery group and 74% (75 patients) in the biliary-drainage group (relative risk in the early-surgery group, 0.54; 95% confidence interval [CI], 0.41 to 0.71; P<0.001). Preoperative biliary drainage was successful in 96 patients (94%) after one or more attempts, with complications in 47 patients (46%). Surgery-related complications occurred in 35 patients (37%) in the early-surgery group and in 48 patients (47%) in the biliary-drainage group (relative risk, 0.79; 95% CI, 0.57 to 1.11; P=0.14). Mortality and the length of hospital stay did not differ significantly between the two groups. CONCLUSIONS Routine preoperative biliary drainage in patients undergoing surgery for cancer of the pancreatic head increases the rate of complications. (Current Controlled Trials number, ISRCTN31939699.)

Randomised trial of endoscopic balloon dilation versus endoscopic sphincterotomy for removal of bileduct stones

BACKGROUND Endoscopic sphincterotomy (EST) for the removal of bileduct stones is associated with acute complications and a permanent loss of biliary-sphincter function. Endoscopic balloon dilation (EBD) causes less trauma to the biliary sphincter, but may be less effective in allowing stone removal. METHODS 218 consecutive patients with bileduct stones on endoscopic retrograde cholangiopancreatography (ERCP) were enrolled. 202 who met all eligibility criteria were randomly assigned EST or EBD. The patients were observed in hospital for at least 24 h and followed up at 1 month and 6 months. Complications were classified by an expert panel unaware of treatment allocation and outcome. Analysis was done by intention to treat. FINDINGS After a single ERCP, all stones were removed from 92 (91%) of 101 patients assigned EST and 90 (89%) of 101 assigned EBD (p = 0.81); in nine of the latter, successful removal required additional EST. Mechanical lithotripsy was used to fragment stones in 31 EBD procedures and 13 EST procedures (p < 0.005). Early complications (before 15 days) occurred in 24 EST patients and 17 EBD patients (p = 0.29). One patient died of retroperitoneal perforation after EBD. Four patients had bleeding after EST. Seven patients in each group had pancreatitis. Complications during follow-up occurred in 23 EST patients and 18 EBD patients (p = 0.48). Acute cholecystitis was observed in seven EST patients and one EBD patient (p < 0.05). INTERPRETATION The success rate of EBD was similar to that of EST. We found there is no evidence of the previously suggested higher risk of pancreatitis with EBD and suggest that EBD is preferred in patients at risk of bleeding after EST. Preservation of biliary-sphincter function after EBD may prevent long-term complications and reduce the risk of acute cholecystitis during follow-up. This procedure is a valuable alternative to EST in patients with bileduct stones.

Treatment of Helicobacter pylori Infection: A Review of the World Literature

Background.None of the currently used anti‐Helicobacter pylori drug regimens cures the infection 100%, and cure results still vary considerably. The present article reviews the effectiveness of currently used antimicrobial regimens, aimed to cure H. pylori infection.

The efficacy of endoscopic treatment of pancreatic pseudocysts

BACKGROUND Endoscopic drainage of pancreatic pseudocysts is a new nonsurgical treatment modality. We retrospectively studied the efficacy of endoscopic drainage of pseudocysts in 37 patients with chronic pancreatitis. METHODS Endoscopic retrograde pancreatic drainage was performed in 12 patients, endoscopic cystogastrostomy in 10 patients, and endoscopic cystoduodenostomy in 7 patients. In the remaining 8 patients, combinations of drainage routes were used. RESULTS ECG failed in 3 patients. Procedure-related complications were seen in 6 patients: bleeding in 3, perforation in 2, and apnea in 1 patient. There was no procedure-related mortality. Seven patients had complications in relation to stents or drains: pseudocyst infection due to stent clogging in 2, stent migration in 4, and kinking of the drain in 1 patient. Twenty-four patients had complete resolution of pseudocysts, 7 had partial resolution, and 6 had no resolution. Three patients had pseudocyst recurrences. Mean follow-up was 32 months. Finally, 10 patients underwent surgery. CONCLUSIONS Endoscopic drainage was technically feasible in 92% of the patients. Procedure-related morbidity was 16% and mortality was 0%. Endoscopic drainage was a definitive treatment for two thirds of the patients (65%). Surgery can be reserved for those patients in whom endoscopic therapy fails.

Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomised trial

BACKGROUND Patients who undergo endoscopic sphincterotomy for common bile-duct stones, who have residual gallbladder stones, are referred for laparoscopic cholecystectomy. However, only 10% of patients who do not have this operation are reported to develop recurrent biliary symptoms. We aimed to assess whether a wait-and-see policy is justified. METHODS We did a prospective, randomised, multicentre trial in 120 patients (age 18-80 years) who underwent endoscopic sphincterotomy and stone extraction, with proven gallbladder stones. Patients were randomly allocated to wait and see (n=64) or laparoscopic cholecystectomy (56). Primary outcome was recurrence of at least one biliary event during 2-year follow-up, and secondary outcomes were complications of cholecystectomy and quality of life. Analysis was by intention to treat. FINDINGS 12 patients were lost to follow-up immediately. Of 59 patients allocated to wait and see, 27 (47%) had recurrent biliary symptoms compared with one (2%) of 49 patients after laparoscopic cholecystectomy (relative risk 22.42, 95% CI 3.16-159.14, p<0.0001). 22 (81%) of 27 patients underwent cholecystectomy, mainly for biliary pain (n=13) or acute cholecystitis (7). Conversion rate to open surgery was 55% in patients allocated to wait and see who underwent cholecystectomy compared with 23% in those who were allocated laparoscopic cholecystectomy (p=0.0104). Morbidity was 32% versus 14% (p=0.1048), and median hospital stay was 9 versus 7 days. Quality of life returned to normal within 3 months after either treatment policy. INTERPRETATION A wait-and-see policy after endoscopic sphincterotomy in combined cholecystodocholithiasis cannot be recommended as standard treatment, since 47% of expectantly managed patients developed at least one recurrent biliary event and 37% needed cholecystectomy. No major biliary complications arose, but conversion rate was high.

Population-based epidemiology, malignancy risk, and outcome of primary sclerosing cholangitis.

Extensive population‐based studies are much needed to accurately establish epidemiology and disease course in patients with primary sclerosing cholangitis (PSC). We aimed to obtain population‐based prevalence and incidence figures, insight in disease course with regard to survival, liver transplantation (LT), and occurrence of malignancies, as well as risk factors thereof. Four independent hospital databases were searched in 44 hospitals in a large geographically defined area of the Netherlands, comprising 50% of the population. In addition, all PSC patients in the three Dutch liver transplant centers and all inflammatory bowel disease (IBD) patients in the adherence area of a large district hospital were identified. All medical records were reviewed on‐site, verifying diagnosis. Five hundred and ninety PSC patients were identified, resulting in an incidence of 0.5 and a point prevalence of 6.0 per 100,000. Median follow up was 92 months. Estimated median survival from diagnosis until LT or PSC‐related death in the entire cohort was 21.3 years, as opposed to 13.2 years in the combined transplant centers cohort (n = 422; P < 0.0001). Colorectal carcinoma (CRC) risk was 10‐fold increased, as compared to ulcerative colitis controls, and developed at a much younger age (39 years; range, 26‐64), compared to IBD controls (59 years; range, 34‐73; P = 0.019). Colonoscopic surveillance was associated with significantly better outcome. Conclusion: This study exemplifies that, for relatively rare diseases, it is paramount to collect observational data from large, population‐based cohorts, because incidence and prevalence rates of PSC are markedly lower and survival much longer than previously reported. The selection of a bias‐free, population‐based cohort showed a significantly longer survival, compared to the tertiary referral cohort. CRC can develop at an early age, warranting surveillance from time of PSC diagnosis. (Hepatology 2013; 58:2045–2055)

Delayed gastric emptying after standard pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: an analysis of 200 consecutive patients

BACKGROUND It has been suggested that pylorus-preserving pancreaticoduodenectomy (PPPD) is associated with a high incidence of delayed gastric emptying and consequently with a prolonged hospital stay compared with standard Whipples resection. The aim of this prospective study was to evaluate whether the incidence of delayed postoperative gastric emptying was different after both procedures. STUDY DESIGN From 1989 to 1996, 200 consecutive patients underwent pancreatic head resection (100 standard pancreaticoduodenectomy [PD]; 100 PPPD). The groups were compared with regard to patient characteristics, operative indices, postoperative morbidity, hospital stay, and mortality. Delayed gastric emptying was defined as nasogastric suction for > or = 10 days or delay of regular diet until > 14 days postoperatively. RESULTS Operative time and blood loss were higher for PD: 6 versus 4.8 hours (p < 0.0001) and 1,580 versus 1,247 mL (p < 0.001), respectively. Postoperative morbidity was 48% after PD and 44% after PPPD (not significant [NS]). Hospital mortality was 6% and 1% after PD and PPPD, respectively (NS). Delayed gastric emptying occurred in 34 patients after PD and in 37 after PPPD (NS). Median days of gastric suction was 3 versus 6 days for PD and PPPD (p < 0.0001). A regular diet was tolerated after a median of 10 and 11 days for PD and PPPD, respectively (NS). Postoperative hospital stay was shorter for patients who underwent PPPD: 20 versus 18 days (p < 0.03). Patients with intraabdominal complications (n = 52) showed a higher incidence of delayed gastric emptying (p < 0.0001). CONCLUSIONS Our results show that PPPD is a safe procedure associated with less operative time and blood loss than PD. After PPPD, patients require longer postoperative nasogastric intubation than after PD, suggesting some form of early postoperative gastric stasis. There is, however, no difference in the incidence of delayed gastric emptying or the first postoperative day on which a regular diet is tolerated between these surgical procedures. Intraabdominal complications are major risk factors for delayed gastric emptying.

Long-term results of pancreatic stents in chronic pancreatitis

BACKGROUND Pancreatic stenting is a new nonsurgical treatment for patients with chronic pancreatitis and pain. We studied the long-term safety and efficacy of pancreatic stenting. METHODS Between 1982 and 1993, 51 patients with chronic pancreatitis and persistent pain with dominant strictures in the pancreatic duct were treated with plastic pancreatic stents. RESULTS Stent insertion was successful in 49 of 51 patients. Early complications occurred in 9 of the 51 patients (18%). Patients were followed for a median of 34 months (range 6 to 128). Nine of the 49 patients (82%) had clinical improvement. Sixteen of these 40 patients still had their stents in place. Stents were removed in 22 of the 40 patients with persistent beneficial response in all (median follow-up 28.5 months). The long-term effect of stenting could not be evaluated in the remaining 2 patients because they had a double bypass operation. Stent dysfunction occurred in 27 of the 49 patients (55%) and was successfully treated by exchanging the stent. CONCLUSIONS Pancreatic stenting was associated with minimal early complications, but stent dysfunction remained a frequent late complication. Pancreatic drainage resulted in clinical improvement in 40 of the 49 patients (82%). Twenty-two of these 40 patients maintained the beneficial response after stent removal (28.5 months).

Impaired Quality of Life 5 Years After Bile Duct Injury During Laparoscopic Cholecystectomy: A Prospective Analysis

ObjectiveTo assess the impact of bile duct injury (BDI) sustained during laparoscopic cholecystectomy on physical and mental quality of life (QOL). Summary Background DataThe incidence of BDI during laparoscopic cholecystectomy has decreased but remains as high as 1.4%. Data on the long-term outcome of treatment in these patients are scarce, and QOL after BDI is unknown. MethodsOne hundred six consecutive patients (75 women, median age 44 ± 14 years) were referred between 1990 and 1996 for treatment of BDI sustained during laparoscopic cholecystectomy. Outcome was evaluated according to the type of treatment used (endoscopic or surgical) and the type of injury. Objective outcome (interventions, hospital admissions, laboratory data) was evaluated, a questionnaire was filled out, and a QOL survey was performed (using the SF-36). Risk factors for a worse outcome were calculated. ResultsMedian follow-up time was 70 months (range 37–110). The objective outcome of endoscopic treatment (n = 69) was excellent (94%). The result of surgical treatment (n = 31) depended on the timing of reconstruction (overall success 84%; in case of delayed hepaticojejunostomy 94%). Five patients underwent interventional radiology with a good outcome. Despite this excellent objective outcome, QOL appeared to be both physically and mentally reduced compared with controls (P < .05) and was not dependent on the type of treatment used or the severity of the injury. The duration of the treatment was independently prognostic for a worse mental QOL. ConclusionsDespite the excellent functional outcome after repair, the occurrence of a BDI has a great impact on the patient’s physical and mental QOL, even at long-term follow-up.

Natural history of primary sclerosing cholangitis and prognostic value of cholangiography in a Dutch population

Background: Median survival of patients with primary sclerosing cholangitis (PSC) has been estimated to be 12 years. Cholangiography is the gold standard for diagnosis but is rarely used in estimating prognosis. Aims: To assess the natural history of Dutch PSC patients and to evaluate the prognostic value of a cholangiographic classification system. Patients: A total of 174 patients with established PSC attending a university hospital and three teaching hospitals from 1970 to 1999. Methods: Charts were reviewed for validity and time of diagnosis, concurrent inflammatory bowel disease, interventions, liver transplantation, occurrence of cholangiocarcinoma, and death. Follow up data were obtained from the charts and from the attending clinician or family physician. Median follow up was 76 months (range 1–300). The earliest available cholangiography was scored using a radiological classification system for the severity of sclerosis, developed in our institution. Survival curves were computed by the Kaplan-Meier method. Cholangiographic staging was used to construct a prognostic model, applying Cox proportional hazards analysis. Results: The estimated median survival from time of diagnosis to death from liver disease or liver transplantation was 18 years. Cholangiocarcinoma was found in 18 (10%) patients. Fourteen patients (8%) underwent liver transplantation. Cholangiographic scoring was inversely correlated with survival. A combination of intrahepatic and extrahepatic scoring, together with age at endoscopic retrograde cholangiopancreatography, proved strongly predictive of survival. Conclusions: The observed survival was considerably better than reported in earlier series from Sweden, the UK, and the USA. Classification and staging of cholangiographic abnormalities has prognostic value.