Mohammed N. Bani Hani

Safety of endoscopic retrograde cholangiopancreatography during pregnancy

Background:  The risk of choledocholithiasis is expected to be higher during pregnancy. This is attributed to alteration in bile composition as well as biliary stasis that take place during gestation. There is significant concern regarding application of endoscopic procedures especially the more invasive ones for treatment of choledocholithiasis during pregnancy. Our aim was to provide an additional support to the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in the management of biliary diseases during pregnancy.

Usefulness of fatty meal-stimulated cholescintigraphy in the diagnosis and treatment of chronic acalculous cholecystitis

ObjectiveFatty meal cholescintigraphy (fatty meal CS) is a potential physiologic alternative for cholecystokinin (CCK) CS in the diagnosis and treatment of chronic acalculous cholecystitis (CAC). However, there are limited data in the literature to support this assumption. Our objective was to determine the usefulness of fatty meal CS in the diagnosis and treatment of CAC.MethodsWe retrospectively reviewed the medical records of 198 patients who had undergone fatty meal CS for presumed CAC. Data retrieved focused on symptom improvement following management. Gallbladder ejection fraction (GBEF) of 50% or less was considered abnormal. Patients were divided into groups on the basis of test results and management.ResultsIn group 1a, patients with low GBEF and cholecystectomy, 88% (54 of 61) reported symptom improvement, whereas the remaining 12% (7 of 61) retained their symptoms. Group 1b consisted of patients with low GBEF and who were managed medically. Persistence of symptoms was noted in 76% (32 of 42) of patients, whereas the remaining 24% (10 of 42) had symptom improvement. Group 2 consisted of patients with normal GBEF. Follow-up showed that 60% (47 of 78) of patients had symptom improvement either spontaneously or on medical treatment, whereas the remaining 40% (31 of 78) retained their symptoms.ConclusionsFatty meal CS is a very useful technique in the diagnosis of CAC. It predicts a good surgical outcome once GBEF is low in patients with high pre-test probability for CAC. Moreover, fatty meal CS may be a good alternative to CCK CS.

Laparoscopic surgery for symptomatic cholelithiasis during pregnancy.

Introduction We are introducing here additional evidence regarding efficacy and safety of laparoscopic cholecystectomy during pregnancy. This is achieved by analysis of 10 successful cases of symptomatic cholelithiasis operated laparoscopically during pregnancy. Purpose To prove the fact that laparoscopic cholecystectomy is safe and effective during pregnancy, especially in the first trimester. Background Cholecystectomy represents the second most common nonobstetric operation during pregnancy. The laparoscopic management of symptomatic cholelithiasis during pregnancy is becoming the standard of care at our center king Abdullah university hospital (KAUH). Old restrictions on this treatment modality are changing; open surgery is not considered to be the only choice any more. Methods Ten laparoscopic cholecystectomies during pregnancy at variable gestational ages performed between February 2002 and June 2006 are reported here, all at KAUH. Their medical records were reviewed, deliveries were followed up, outcomes were analyzed, and results were compared with literature. Results Five patients were in their first trimester; 3 were in their second trimester and 2 in their third trimester in my series. Open cholecystectomy was not used at all in these patients. Intraoperative cholangiography was not performed. No tocolytic agents were given. No maternal or fetal mortality have been reported. None of fetuses had anomalies. One patient who refused any surgical intervention presented with repeated attacks of biliary colic at gestational age of 26 weeks; this pregnancy ended up with stillbirth at 33 weeks. Conclusions In my series, laparoscopic cholecystectomy was safe through out all stages of pregnancy. When undertaken by skilled laparoscopic surgeon, it carries low mortality and morbidity. We highlight the fact that first trimester symptomatic cholelithiasis can be managed safely by laparoscope. We add to the evidence that laparoscopic cholecystectomy may not interfere with organogenesis. Early uterine contractions were not reported, though, we think that prophylactic tocolytics are not indicated unless uterine contractions are confirmed. Certain positioning styles, and cannulation techniques, are part of major guidelines that we recommend to be followed during this surgery.

A combined laparoscopic and endoscopic approach to acute gastric volvulus associated with traumatic diaphragmatic hernia.

Purpose The purpose of the article was to describe a comprehensive approach to laparoscopic repair of acute intrathoracic gastric volvulus in acquired diaphragmatic hernia. Background Traumatic diaphragmatic hernias are observed in 10% of diaphragmatic injuries, which include blunt trauma, penetrating trauma, and iatrogenic injuries. It is of utmost importance because of its high morbidity and mortality. Minimally invasive approaches are considered to be safe and effective procedures. They also provide rapid recovery from the operation, avoid the morbidity of laparotomy, and allow rapid recovery of gastric function. Method From June 2002 to June 2006, we encountered 4 cases of acquired diaphragmatic hernia with acute gastric volvulus, which were successfully treated with laparoscopic reduction, detorsion, repair of diaphragmatic hernial defect, and percutaneous endoscopic gastropexy. Results There were no operative complications. All 4 patients tolerated the procedure well and the patients were discharged 1 to 3 days after the operation. After 1 to 2 years of follow-up, there were no radiologic recurrences of the volvulus and all patients remained asymptomatic. Conclusions Laparoscopic surgery represents a safe and acceptable approach in the treatment of acute gastric volvulus through the abdominal approach with minimal morbidity and good outcome.

Jejunal disorders: potentially lethal causes of acute abdomen are still overlooked.

Objective To highlight the importance of considering jejunal disorders in the differential diagnosis of acute abdomen. Although these conditions are relatively uncommon, we should keep in mind that jejunum still occurs, and deserves consideration. Method This study was carried out at King Abdullah University Hospital, Jordan. Medical records of 7 patients with uncommon jejunal disorders that were encountered between 2001 and 2007 were retrospectively evaluated. We had 1 patient with jejunal diverticulitis, 1 with jejunal intussusception, 2 with jejuno-ileal tuberculosis complicated by intestinal obstruction, and 3 with acute mesenteric ischemia. All of these patients presented with acute abdominal pain of nonspecific features. Radiologic workup, along with surgical intervention, was necessary to reach a final diagnosis. Results Only 1 patient matched preoperative diagnosis, in which computed tomography scan revealed the presence of intussusception. The remaining patients were diagnosed intraoperatively. Laparoscopy and/or laparotomy with resection were performed. Morbidity was within acceptable range. There was no mortality. Conclusions Jejunal disorders are potentially serious, and are underestimated. They are considered important causes of acute abdomen. Although they should not be at the top of a differential diagnostic list, they should always be ruled out when there is no apparent cause.

Trends of Gallbladder Cancer in Jordan Over 2 Decades: Where Are We?:

Background and Study Aims: The prevalence of gallbladder cancer (GBC) varies between different parts of the world. This study is a review of literature and an update of a previously published study conducted in our university and aims to reassess the incidence of GBC over the past 2 decades. Patients and Methods: We conducted a retrospective study between 2002 and 2016. Data regarding demographics, clinical presentation, risk factors, histopathology, investigations, and treatments were obtained. A diagnosis of GBC established during surgery or primarily detected in the surgical specimen was classified as incidental. Results: Of 11 391 cholecystectomies performed, 31 cases (0.27%) of GBC were found. The mean age of patients with GBC was 68 years (43-103 years), 74% were women. The annual incidence of GBC was 0.2/100 000 (men: 0.1/100 000; women: 0.3/100 000). Biliary colic and acute cholecystitis were the main presentations. Diagnosis of GBC was “incidental” in 67% of cases. About 75% of patients with GBC had gallstones, 13% had polyps, and 3% had porcelain gallbladder. Adenocarcinoma was the dominant (87%) histologic type. Conclusions: The GBC rate in our region, similar to others parts of the world, is still low and has not changed over the past 2 decades. This study consolidates the previously published recommendations regarding the high index of suspicion of GBC in elderly with cholelithiasis.

Passage of Gallstones Into Common Bile Duct During Laparoscopic Cholecystectomy: Is It the Surgeon’s Responsibility?

Purpose: Gallstones patients without preoperative history of jaundice, deranged liver function tests, or dilated bile ducts (BD) are unlikely to have BD stones. However, some of these patients in our series underwent endoscopic stone(s) removal after laparoscopic cholecystectomy (LC). We aim to find the incidence, possible intraoperative risk factors, and if the Surgeon can be blamed for this event. Materials and Methods: We studied LC cases over 12-year period at our university hospital and identified patients who did not have preoperative risk factors for BD stones but developed postoperative jaundice and/or persistent abdominal pain. Results: Only 16 (0.7%) of 2390 LC met the inclusion criteria. In 5/16 patients, cystic duct (CD) stones were felt Intraoperatively and likely passed into BD during surgery. After surgery, 14/16 patients underwent endoscopic stone(s) removal. Conclusions: If CD stone(s) are encountered during LC, we suggest that careful attention should be paid to make sure that patient does not develop complications from possible BD stone(s). Technical precautions during LC (ie, early CD clipping, avoiding excessive manipulation, and crushing the stones) are recommended.