Lars-Erik Hammarström

Endoscopic Treatment of Bile Duct Calculi in Patients with Gallbladder in Situ Long-Term Outcome and Factors Predictive of Recurrent Symptoms

BACKGROUND Whether endoscopic sphincterotomy (EST) in elderly and/or high-risk patients with common bile duct calculi (CBD) and the gallbladder in situ should be followed by routine cholecystectomy is still a subject of controversy. METHODS To identify factors predictive of subsequent biliary tract symptoms after EST and bile duct clearance, we reviewed 265 patients with intact gallbladder and CBD calculi who were considered for EST in our department from 1981 to 1992. In 15 of 265 patients endoscopic treatment was not carried out, and the records of 4 patients were missing. RESULTS Complete removal of all bile duct calculi failed in 27 patients (11%). Cholecystectomy was performed in 35 patients (16%) with cleared bile ducts 1-765 days (median, 60 days) after EST, in spite of absence of recurrent symptoms from the biliary tract. The remaining 184 patients have been retrospectively followed up for 14-150 months (median, 69 months). Cholecystectomy was required in 35 because of acute cholecystitis (n = 23) or biliary colic (n = 12). Of the cholecystectomies 86% were performed within 24 months after EST and only one after 4 years of follow-up. Increased frequency of cholecystectomy was found in patients with complete opacification of the gallbladder at endoscopic cholangiography (p = 0.005). This was especially evident in patients younger than 80 years (p = 0.002). Cholecystectomy was also required more often in patients with gallbladder calculi (p = 0.02). The risk of cholangitis in patients without recurrent stones was higher in those with juxtapapillary diverticula (p = 0.02). Fifty-nine patients without and 17 with mild to moderate symptoms from the biliary tract died after a median time of 39 and 46 months, respectively. Seventy-three patients are alive, and 59 are symptom-free. Ten patients have had and four still have complaints of mild to moderate biliary tract symptoms. They have been followed for up to 16-146 months (median, 40 months). CONCLUSIONS These findings confirm that endoscopic treatment alone in this group of patients is a feasible treatment principle. Recognition of the registered risk factors might be helpful when selecting patients for subsequent cholecystectomy.

Long-Term Follow-up after Endoscopic Treatment of Bile Duct Calculi in Cholecystectomized Patients

Abstract. Endoscopic sphincterotomy (EST) is an established method for treatment of retained or recurrent common bile duct (CBD) calculi after cholecystectomy. Present experience shows that few patients have recurrent biliary tract complications, but follow-up periods are most often short. EST was performed in 147 patients with bile duct calculi and remote cholecystectomy in our department from 1981 to 1992. In 8 of 147 patients (5.4%) complete removal of calculi failed. A total of 135 patients with a median age of 71 years (range 24–96 years) were eligible for a follow-up of 23 to 153 months (median 86 months). Thirty-seven patients have died without recurrent symptoms (a recurrent stone was revealed at postmortem examination in one patient), and four patients (two with calculi and two with cholangiocarcinoma) died with recurrent symptoms from the biliary tract. Ninety-four patients are alive; and with the exception of two who have had cholangitis without or with post-EST stenosis, respectively, they are all symptom-free. Jaundice, cholangitis, and biliary pancreatitis prior to EST were the only factors that significantly (p = 0.006, Fisher’s exact test) predicted late biliary complications after EST in patients with recurrent calculi. These findings confirm that endoscopic treatment of CBD calculi in cholecystectomized patients has a low long-term rate (5 of 135; 3.7%) of recurrent nonmalignant bile duct disease (three patients with CBD calculi and two with cholangitis).

Factors predictive of bile duct stones in patients with acute calculous cholecystitis.

The objective of the study was to investigate the accuracy of using preoperative data for the prediction of bile duct calculi in patients operated on for acute cholecystitis. 279 consecutive patients underwent cholecystectomy with peroperative cholangiography for acute calculous cholecystitis in the Department of Surgery, Lund University Hospital, between 1985 and 1991. The correlation between 13 preoperative clinical and laboratory variables, and the incidence of bile duct calculi was studied. Among the 13 variables tested, serum bilirubin concentration and serum γ-glutamyltransferase activity were independent factors of predictive significance. These two factors were used for constructing an additive prognostic index for the presence of bile duct stones. Thus, three groups of patients could be identified having a 3, 7–9 or 59% risk of harboring bile duct stones, corresponding to a sensitivity of 61% and a specificity of 93% in predicting the presence of bile duct stones in the ‘high-risk’ group. Logistic regression analysis permits accurate preoperative identification of bile duct stones in patients with acute calculous cholecystitis.

Role of Palliative Endoscopic Drainage in Patients with Malignant Biliary Obstruction

Background: Endoscopic biliary drainage for malignant obstructive jaundice is a viable palliative alternative, but its role and cost-effectiveness compared to percutaneous drainage or surgical bypass are subject to debate. Aim: To review the evidence in the literature with regard to the settings in which endoscopic drainage favorably compares with and affords palliation and quality of life comparable to percutaneous drainage or surgical bypass in malignant obstructive jaundice patients. Method: Using PubMed, Embase, Current Contents, and Medline, a literature search was performed for papers published from 1979 to April 2004. All retrieved papers comparing endoscopic drainage with percutaneous or surgical drainage, with special reference to the level of obstruction, were rated according to the strength of evidence and carefully analyzed. Results and Conclusions: Palliative drainage affords improved quality of life. The outcome of endoscopic and percutaneous drainage was similar, but data were few and inconsistent. Due to fewer late complications, surgical bypass is an alternative to metal stents (Wallstent™) which remain patent longer than plastic stents (large-bore polyethylene), with an overall median of 180 and 109 days, respectively, in patients who survive longer than about 6 months, which cannot be accurately predicted though. Overall early and late morbidity, stent patency, and survival were similar in patients treated for hilar compared to distal obstruction.

Endoscopic management of chronic and non‐biliary recurrent pancreatitis

Endoscopic techniques have emerged as a viable option for treating complications of chronic pancreatitis. They afford immediate, short-term or medium-term symptom relief prior to other measures or progression of the disease alleviating the underlying causes of symptoms. In patients suffering from recurrent (episodic) pancreatitis, endoscopic treatment may eliminate the origin of symptoms and thus offer cure. Endoscopic treatment aims at alleviating ductal obstruction and at accomplishing subsequent relief of ductal and pancreatic tissue pressures. Thus, the presence of a dominant stricture, and/or intraductal calculus with concomitant dilatation of the duct, has been considered a prerequisite for successful symptom relief. Accordingly, endoscopic procedures will drain the main or accessory pancreatic ducts with or without harboured calculi (transpapillary via the major or accessory papilla), peripancreatic fluid collections or pseudocysts (transmurally or transpapillary), the bile ducts (transpapillary via the major papilla) or fistulae draining the pancreatic duct (transpapillary). Symptoms treated in this way include recurrent pancreatitis (pain attacks at monthly or longer intervals, also named pancreatic pain type A) or pain syndrome (pain attacks on a daily or weekly basis or continuous pain, also named pancreatic pain types B and C, respectively), discomfort or pain due to compression of adjacent organs, biliary obstruction with or without cholangitis or collections of pancreatic juice (pancreatic ascites, pleural effusion or cutaneous fistulae). Drainage is obtained by endoprostheses or nasopancreatic catheters with or without endoscopic pancreatic sphincterotomy, and extracorporeal shock wave lithotripsy when appropriate to shatter calculi within or adjacent to the main or accessory pancreatic ducts. In expert hands, endoscopic techniques are associated with high success rates and a few, usually mild, complications. There are few data from clinical randomized controlled trials to support the efficacy of endoscopic techniques and to define their role and cost-effectiveness compared to other treatment modalities in the short or long term. However, although results of endoscopic therapy derived from empirical data are discrepant, they suggest that a great proportion of patients may benefit by significant symptom relief immediately and in the short or medium term. Some complications/ symptoms seem to respond better than others, indicating that appropriate patient selection is an important but not yet clearly defined issue. The aim of this article is to provide guidance when endoscopic therapy is being considered in patients with benign pancreatic disease. To that end, a systematic review of studies rated according to strength of evidence was done in order to compile data for a comprehensive overall assessment of initial success, complications and outcome of endoscopic management.

Stent or Surgery for Malignant Low Bileduct Obstruction

The development of non-surgical techniques for the relief of malignant low bileduct obstruction has cast doubt on the best way of relieving jaundice, particularly in patients fit for surgery whose life expectancy is more than a few weeks. We did a randomised prospective controlled trial comparing endoscopic stent insertion and surgical biliary bypass in patients with malignant low bileduct obstruction. 204 patients were randomised (surgery 103, stent 101); 3 subsequently proved to have benign disease and were excluded, leaving 101 surgical and 100 stented patients for assessment. Technical success was achieved in 94 surgical and 95 stent patients, with functional biliary decompression obtained in 92 patients in both groups. In stented patients, there was a lower procedure-related mortality (3% vs 14%, p=0.01), major complication rate (11% vs 29%, p=0.02), and median total hospital stay (20 vs 26 days, p=0.001). Recurrent jaundice occurred in 36 stented patients and 2 surgical patients. Late gastric outlet obstruction occurred in 17% of stented patients and 7% of the surgical group. Despite the early benefits of stenting there was no significant difference in overall survival between the two groups (median survival: surgical 26 weeks; stented 21 weeks; p=0.065). Endoscopic stenting and surgery are effective palliative treatments with the former having fewer early treatment-related complications and the latter fewer late complications.

THE INFLUENCE OF TOTAL PORTO-SYSTEMIC SHUNTING ON THE NORADRENALINE RESPONSE AND ON THE CONTRACTILE EFFECTS OF VARIOUS VASOACTIVE AGENTS IN SMALL RAT PORTAL VEINS AND HEPATIC ARTERIES

Contractile responses were studied in isolated tubal segments of branches of the rat portal vein (diameter 300 μm) and hepatic artery (diameter 200 μm) 1,3 and 6 weeks after total porto-systemic shunt operation (PCS). 5-Hydroxytryptamine contracted hepatic arteries concentration-dependently, whereas it produced only weak and inconsistent contractions in portal veins. Vasopressin effectively contracted hepatic arteries, but had no effect on portal veins. Both vessel types responded to prostaglandin F2α with contractions, although the drug potency was relatively low. The responses to these agents were not changed significantly in hepatic arteries or portal veins of PCS rats compared with controls at any of the postoperative time intervals. In both portal veins and hepatic arteries noradrenaline produced contraction-dependent contractions, portal veins being 3 times more sensitive to noradrenaline than hepatic arteries. PCS did not change the noradrenaline sensitivity in hepatic arteries, whereas it increased the noradrenaline sensitivity in portal veins after 1, but not after 3 or 6 weeks. This effect was enhanced by cocaine, suggesting a partial sympathetic denervation of branches of the portal vein as well as a complete reinnervation within 3 weeks. Furthermore, the results of this study indicate no influence in any vessel type on the response to several vasoactive agents after depriving the liver of splanchnic venous blood.

Perforated Duodenal Diverticulum; Experience with 8 Patients

Despite the alarming symptoms of perforated duodenal diverticula, they are sometimes diagnosed late or even overlooked, reflecting a 13% mortality rate in recent decades. Between 1980 and 1989 8 patie