Jukka Karvonen

Bile duct injuries during laparoscopic cholecystectomy: primary and long-term results from a single institution

BackgroundIatrogenic bile duct injury carries high morbidity. After the introduction of laparoscopic cholecystectomy the incidence of these injuries has at least doubled, and even after the learning curve, the incidence has plateaued at the level of 0.5%.MethodsA total of 32 patients sustained biliary tract injuries of the 3736 laparoscopic cholecystectomies performed in and around Turku University Central Hospital between January 1995 and April 2002. The data concerning primary treatment and long-term results were collected and analyzed retrospectively.ResultsThe overall incidence for bile duct injuries, including all the minor injuries (cystic duct leaks and bile duct strictures), was 0.86%; for major injuries alone the incidence was 0.38%. Nineteen percent of the injuries were detected intraoperatively. All the cystic duct leaks were treated endoscopically with a 90% success rate. Of the bile duct strictures 88% were treated successfully with endoscopic techniques. Ninety-three percent of the major injuries, including tangential lesions of common bile duct and total transections, were treated operatively. The operation of choice was either hepaticojejunostomy or cholangiojejunostomy in 69% of the cases; the rest were treated with simple suturing over a T-tube or an endoscopically placed stent. The long-term results, with a median follow-up period of 7.5 years, are good in 79% of the operated patients and in 84% of the whole study population. Mortality rate was 3% and acute or chronic cholangitis was seen in 13% of the patients during follow-up.ConclusionMost of the minor bile duct injuries, including cystic duct leaks and bile duct strictures, are well treatable with endoscopic techniques, whereas most of the major injuries require operative treatment, which at optimal circumstances gives good results.

Is male gender a risk factor for bile duct injury during laparoscopic cholecystectomy

BackgroundSince its introduction in the late 1980s laparoscopic cholecystectomy has become the treatment of choice for gallstone disease. Unfortunately, the rate of iatrogenic biliary duct injuries (BDIs) has at least doubled after the adoption of the laparoscopic method. Population-based studies reporting the distribution of laparoscopic BDI patients according to gender and the severity of the BDI are mostly lacking. The purpose of the present study was to analyze the BDIs sustained during laparoscopic cholecystectomy in and around Turku University Central Hospital, with a special reference to the distribution of patients according to gender and the severity of the BDI.Patients and methodsA total of 3,736 laparoscopic cholecystectomies (2,627 female patients, 1,109 male) was performed in and around Turku University Central Hospital from 1995 to 2002 (by the end of April). The number and severity of BDIs and the gender of BDI patients were recorded, and the risk of BDI during laparoscopic cholecystectomy was calculated for the total patient population and for both genders separately.ResultsThe risk of BDI was 0.86% for the total patient population, 0.95% for female and 0.63% for male. The most conspicuous finding was that the female gender was predominant in the severe types of BDI. However, the risk of mild BDI seemed to be fairly equal in both genders.ConclusionWe conclude that female gender seems to be a risk factor for severe iatrogenic BDI during laparoscopic cholecystectomy.

Stone or stricture as a cause of extrahepatic cholestasis--do liver function tests predict the diagnosis?

Abstract Background: Cholestasis, roughly divided into intrahepatic and extrahepatic forms, is a clinical challenge. Extrahepatic cholestasis, characterized by dilated bile ducts, is caused by either a bile duct stone or stricture, with stricture most often related to a malignancy. The aim of the present study was to analyze the value of common liver function tests in separating patients with malignant bile duct strictures from those with stones. Methods: All consecutive patients admitted for endoscopic retrograde cholangiopancreatography (ERCP) were included in the study population if a bile duct stricture related to a malignancy was found by ERCP (n=103) or if a bile duct stone was successfully extracted during ERCP, thus confirming the diagnosis of a stone (n=109). Plasma alkaline phosphatase, γ-glutamyltransferase, alanine aminotransferase and bilirubin values were determined in the morning before ERCP. Results: Plasma bilirubin (p<0.001), alkaline phosphatase (p<0.001) and alanine aminotransferase (p=0.040) levels were significantly higher in patients with malignant bile duct strictures than in those with bile duct stones. In addition, γ-glutamyltransferase levels seemed to be higher in patients with malignant strictures than in those with stones, although the difference did not reach statistical significance (p=0.053). In receiver operating characteristic analyses, bilirubin proved to be the best laboratory test in differentiating patients (p=0.001 vs. alkaline phosphatase, p<0.001 vs. alanine aminotransferase and p<0.001 vs. γ-glutamyltransferase). With a plasma bilirubin cutoff value of 145μmol/L, four out of five patients were categorized correctly. Conclusions: Plasma bilirubin seems to be the best liver function test in distinguishing patients with malignant bile duct strictures from those with bile duct stones. This routine test should receive more attention in clinical decision-making than has previously been given. Clin Chem Lab Med 2006;44:1453–6.

Reflux laryngitis: a feasible indication for laparoscopic antireflux surgery?

Laparoscopic fundoplication is a routine surgical approach in the treatment of moderate or severe gastro-esophageal reflux disease. However, there are still contradictions regarding supraesophageal symptoms as an indication for surgery. The aim of this study was to determine the subjective symptomatic outcome and objective laryngeal findings after antireflux surgery in patients with pH monitoring proven reflux laryngitis. Between 1998 and 2002, 40 patients with reflux laryngitis underwent laparoscopic Nissen fundoplication. Patients were referred to surgery and followed-up by a specialist in otorhinolaryngology. Subjective symptoms were collected by a structured questionnaire at a median follow-up of 42 months. The objective laryngeal findings improved from the preoperative situation; at 12 months after surgery, the otorhinolaryngeal status was improved in 92.3% (n=24) of the patients. However, only 38.5% (n=10) of these patients evaluated an improvement in their voice quality. Of all, 62.5% (n=25) of the patients reported no or only mild cough or voice hoarseness symptoms postoperatively, 22.5% (n=9) had moderate symptoms, and 15.0% (n=6) suffered from difficult supraesophageal symptoms. Ninety-five percent of the patients regarded the result of their surgery excellent, good, or satisfactory. Of all, 82.5% (n=33) of the patients would still choose surgery, 7.5% (n=3) would abstain from surgery, and 10% (n=4) of the patients were hesitant about their choice. For patients suffering from supraesophageal symptoms of gastro-esophageal reflux disease with objective evidence of pharyngeal acid exposure, laparoscopic Nissen fundoplication provides a good and alternative adding to current treatment.

The diameter of common bile duct does not predict the cause of extrahepatic cholestasis.

Background Extrahepatic cholestasis is usually caused by either a bile duct stone or a stricture. In early phase in primary care, when novel imaging studies such as magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography (ERCP) are seldom available, the differential diagnosis between benign and malignant causes is clinically challenging. The aim of the present study was to analyze the value of the degree of common bile duct dilatation in differential diagnosis of extrahepatic cholestasis. Methods In all, 212 consecutive patients in whom a bile duct stricture (n=103) or a stone (n=109) had been found in ERCP were included in the study population. The maximum diameter of the common bile duct was measured from ERCP images. Plasma bilirubin concentration was measured before ERCP. Results The median (range) values for the common bile duct diameter for the patients with a stricture and those with a stone were 16 (5 to 33 mm) and 15 mm (6 to 29 mm), respectively (P=0.0038). In receiver operating characteristic analysis, the difference was barely significant when compared with random value (P=0.0399). Area under curve for bile duct diameter was 0.615. Conclusions In conclusion, the degree of bile duct dilatation does not aid in differential diagnosis between benign and malignant causes of extrahepatic cholestasis.

Quality of life after iatrogenic bile duct injury – a case control study

Abstract Background: BDIs complicate 0.5 - 0.8% of all LCs even after the learning curve and the limited QoL data on these patients are conflicted. The objective of the current study was to compare the quality of life (QoL) of patients who sustained a bile duct injury (BDI) during laparoscopic cholecystectomy (LC) with a control group who underwent an uneventful LC. Methods: Sixty-one patients were treated for a BDI during 1995 - 2007 at Turku University Hospital. Fifty-one out of 55 available patients (93 %) were reached and QoL was evaluated by 15D questionnaire. QoL outcome was analyzed both according to the type of injury and the type of treatment and compared with a group with similar age and sex distribution who underwent an uneventful LC during the same time period. Results: With a mean follow-up of eight years (range 2–15 years) there were no major differences in QoL between patients with BDI and patients who underwent an uneventful LC. Depression was the only dimension more frequently seen in the control group (P = 0.011), but this difference was not present in the subgroup analysis or in 15D total scores. Conclusions: Even at long-term follow-up BDI does not have a major impact on QoL.

Endoscopic treatment of pseudocystocolonic fistula with fibrin glue

Pseudocysts are common complications of acute pancreatitis, whereas subsequent colonic complications such as necrosis, stenosis, and fistula associated with pseudocysts are rare. 1 External pancreatic fistulas 2 and other GI fistulas 3 have been treated successfully with fibrin glue. A case of endoscopically glued pseudocystocolonic fistula is presented herein.

Female gender may give rise to difficulties in endoscopic and laparoscopic biliary surgery

We read with interest the fine article by Fukatsu and co-authors on unsuccessful cases of biliary cannulation in endoscopic retrograde cholangiopancreatography (ERCP) in which the standard procedure was changed to a needleknife precut papillotomy [1]. ERCP is frequently challenging even for an experienced endoscopist. The most usual problem at ERCP is difficulty in achieving selective cannulation of the common bile duct. In the recent large-scale prospective survey of ERCP practice in the UK overall deep cannulation was achieved in only 2,684 of 3,210 (84%) patients undergoing their first ever ERCP [2]. In the survey by Fukatsu et al. [1] the total success rate of biliary cannulation was as high as 99% (497 out of 501 patients) in a study population in which needleknife precut papillotomy was performed in 16% (n = 80) of cases. Recently, we described our indications, techniques and results of 1,703 consecutive first-time ERCPs [3], in which the overall success rate of bile duct cannulation was 97%. The needle-knife approach was employed in 10% of cases. These figures emphasize that, although every cannulation may be challenging and the results are not satisfactory at the country level, high success rates of bile duct cannulation can be reached in high-volume centres in which needle-knife papillotomy is routine practice in difficult cases. The main purpose of the study of Fukatsu et al. [1] was to scrutinize those patients who had to undergo needleknife precut papillotomy because standard manoeuvres did not lead to successful biliary cannulation. Multivariate analysis indicated that female gender, presence of left lobe hypertrophy after hepatectomy, history of Billroth I reconstruction, and malignant biliary stricture were risk factors associated with difficult biliary cannulation. In our opinion it is not surprising that anatomic factors such as left lobe hypertrophy, Billroth I reconstruction and malignant biliary stricture are associated with difficulties in achieving access into the bile duct. Instead, we find that the association between female gender and cannulation failure reported by Fukatsu et al. is a novel, interesting and important finding. To our knowledge, there are no earlier reports on this association in the literature, which perhaps was the reason why the authors did not discuss this finding in their discussion section. This novel finding of Fukatsu et al. is in accordance with earlier reports that female gender is a risk factor for post-ERCP pancreatitis [4]. We find that difficulties in cannulation in female patients may even play a pivotal role in the development of post-ERCP pancreatitis. Moreover, earlier reports have indicated that female gender is associated with severe iatrogenic bile duct injury during laparoscopic cholecystectomy as well [5]. Traditionally, during the era of open surgery the male anatomy was known to make many abdominal operations such as bile surgery technically more demanding [6]. Nowadays, in the era of endoscopic and laparoscopic surgery, female gender seems to be a risk factor in endoscopic and laparoscopic biliary surgery. But what might be the reason for the findings that female patients seem to be more prone to difficulties in endoscopic and laparoscopic biliary surgery? A definite answer can certainly not be given, but we hypothesize that the elasticity and laxity of female J. M. Grönroos (&) S. Laine P. Salminen J. Karvonen M. Lavonius R. Gullichsen Department of Surgery, University of Turku, PB 52, 20521 Turku, Finland e-mail: juha.gronroos@tyks.fi

Endoscopic treatment of internal gastrointestinal fistulas with fibrin glue.

Objective: Gastrointestinal fistulae are a heterogenous entity originating from various etiologies. When occurring, these fistulae are associated with considerable morbidity and even mortality. One third of the fistulae heal spontaneously and the rest have traditionally required major revisional surgery at a later stage. Even after surgery, the healing rate remains at a level of 75% to 90%. During the last years, gastrointestinal fistulae have been successfully treated endoscopically with fibrin glue. Methods: All (n=8) consecutive patients with diagnosed internal upper or lower gastrointestinal fistula treated endoscopically with fibrin glue. Results: During the minimum follow-up of 11 months, 7 of 8 patients (87.5%) were successfully treated endoscopically, and in only 1 case (12.5%) with a major diagnostic delay, a reoperation was required. Conclusions: Our results support the view that endoscopic treatment with fibrin glue may be considered as a first-line therapy to treat small caliber gastrointestinal fistulas.

Stone or stricture: does the calibre of intrahepatic bile ducts predict the diagnosis?

A 70-year-old male underwent an optical urethrotomy in 2010 for treatment of a dense 3-cm anastomotic urethral stricture. His history is significant for Gleason 9 T2b prostate cancer treated with an uncomplicated prostatectomy in 1998 and external beam radiotherapy in 2003 secondary to local recurrence. His urethral catheter was removed day 3 post-optical urethrotomy. He developed right groin pain radiating to the inner thigh and had difficulty weight bearing on the right leg over the subsequent days. His symptoms intermittently worsened and he presented 5 weeks post-optical urethrotomy to the emergency department with a fever, right groin pain and inability to walk. His C-reactive protein was elevated at 137 mg/L and a urine culture positive for pseudomonas aeruginosa. A contrast-enhanced computed tomography scan of his abdomen and pelvis revealed a hypoechoic lesion in his obturator externus muscle. An initial bone scan showed no area of increased uptake to suggest osteomyelitis. On day 3 of admission, a magnetic resonance imaging showed an extensive collection within the right obturator externus measuring 3.7 ¥ 2.1 cm as well as osteomyelitis of the pubis (Fig. 1). Ultrasound-guided drainage of the collection aspirated 3 mL of purulent material which grew Pseudomonas aeuroginosa. Optical urethrotomy is considered a safe and effective treatment for urethral strictures. The most common complications are fever, bleeding, urinary tract infection, epididymitis, urinary incontinence, urinary extravasation and recurrence of stricture. We postulate that a disruption of the anatomical planes secondary to radiotherapy resulted in the extravasation of urine, from a breach in the corpus spongiosum at time of urethrotomy, into the superficial perineal space which then tracked deep to Colles’ fascia into the medial compartment of the thigh. Pyomyositis is a rare but possible complication of optical urethrotomy, with patients previously treated with local radiotherapy at particular risk.