Sara Gobbi

Scoring system to predict asymptomatic choledocholithiasis before laparoscopic cholecystectomy

Background: The purpose of this prospective study was to evaluate if a recently proposed score system based on six preoperative parameters [history of colic pain and/or jaundice, dyspepsia, cholecystitis, ultrasound (US), evidence of common bile duct stones (CBDS), number and size of gallbladder stones at US, level of serum glutamic oxalacetic transaminase and/or alkaline phosphatase is effective in the selection of patients undergoing laparoscopic cholecystectomy (LC) with asymptomatic CBDS and could allow a significant reduction of the total number of preoperative examinations. Methods: In the case group, 408 patients were categorized into low-, medium-, and high-risk classes and underwent, respectively, no further preoperative assessment of the bile duct, intravenous cholangiography (IVC), and endoscopic retrograde cholangiography (ERC). Intraoperative cholangiography (IOC) was performed whenever the surgeon was in doubt as to biliary anatomy or bile duct clearance. These patients were compared with 408 retrospectively matched patients (control group) undergoing routine preoperative IVC and/or ERC. Results: In the case group, significantly lower numbers of IVC (120 vs 392) and IOC (3 vs 16) were performed (p < 0.005), whereas no difference in the total number of ERCs was noted. One patient in the control group had retained CBDS detected during follow-up evaluation, whereas none occurred in the case group. Conclusion: The proposed scoring system allows selective use of IVC, ERC, and/or IOC in patients undergoing elective LC.

Routine intravenous cholangiography, selective ERCP, and endoscopic treatment of bile duct stones before laparoscopic cholecystectomy

BACKGROUND No procedure has yet been identified as the standard for the detection and management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy. METHODS A prospective study involved 1305 patients undergoing elective laparoscopic cholecystectomy. Intravenous cholangiography was performed on all patients except those with jaundice or cholangitis, acute pancreatitis, or allergy to contrast material. Patients underwent endoscopic retrograde cholangiography (ERC) and endoscopic sphincterotomy when there was a strong suspicion of choledocholithiasis, positive or inconclusive findings on intravenous cholangiography or allergy to contrast material with signs of possible choledocholithiasis. Intraoperative cholangiography was performed when patients did not undergo ERC or intravenous cholangiography and whenever the surgeon was in doubt about biliary anatomy or biliary clearance. RESULTS Two hundred thirty-one patients (17.7%) were referred for preoperative ERC; 14 of them were referred for open surgery because of failure of ERC or sphincterotomy. Only 54 patients underwent intraoperative cholangiography. Bile duct stones, detected in 186 cases (14.2%) (68 of which were asymptomatic), were removed before surgery in 162 cases (87.1%) and during surgery in 20 (10.7%). Self-limited pancreatitis occurred in 3.6% of the patients after sphincterotomy. Laparoscopic cholecystectomy was performed in 98.7% of the cases. The conversion rate was 8% if sphincterotomy had been performed previously, and 3% after standard laparoscopic cholecystectomy (p < 0.001). The morbidity rate was 5% and the mortality rate 0.08%. During the follow-up period 4 patients had retained stones that were treated endoscopically. CONCLUSIONS Preoperative ERC followed by laparoscopy is the best approach to treatment of patients with cholecystolithiasis and suspected choledocholithiasis.

Is Tumour Angiogenesis a Prognostic Factor in Patients with Colorectal Cancer and No Involved Nodes

OBJECTIVE To examine a possible association between tumour angiogenesis and conventional prognostic variables and to assess the prognostic value of the variables examined in patients with colorectal cancer, with no involved nodes. DESIGN Retrospective study. SETTING University hospital, Italy. SUBJECTS 119 patients who had had colorectal cancers resected for cure with no involved nodes between 1985-1990. INTERVENTIONS The three microscopic fields with the most microvessels were identified by immunohistochemical techniques. 10 high-power fields in each area were used for the microvessel count and the mean values indicated the microvessel density. MAIN OUTCOME MEASURES Correlation of microvessel density with conventional prognostic factors, recurrence rates, and survival. RESULTS There was a significant correlation between microvessel density and sex, women having a higher density than men (p < 0.05), but no significant correlations between density and recurrence rates or survival. Multivariate analysis did not indicate that microvessel density had a prognostic role. CONCLUSION Microvessel density in colorectal cancer without involved nodes does not correlate with conventional prognostic factors and provides no prognostic information.

Asymptomatic bile duct stones: selection criteria for intravenous cholangiography and/or endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy

Objective Routine use of endoscopic retrograde cholangiography (ERC) and/or intravenous cholangiography (IVC) or magnetic resonance cholangiopancreatography (MRCP) before laparoscopic cholecystectomy (LC) is not cost‐effective. The objective of this study was to determine precise and easily applicable criteria to select patients who should undergo IVC, MRCP and/or ERC before LC. Design and methods Prospectively collected data from 74 consecutive patients who were diagnosed with asymptomatic common bile duct stones (CBDS) before undergoing LC, were compared with data from 74 matched controls without CBDS. Using the X2 test, those variables were identified which were significantly related to the presence of CBDS. These were inserted into a logistic multiple regression model and, by means of conditional regression analysis, each variable was assigned a score from −2 to +4 proportional to the odds ratio. By adding up the scores obtained, a classification was made as to high, medium and low CBDS risk. Results As a result, 51 patients were found to be low‐risk cases, 53 medium‐risk and 44 high‐risk. Assuming no further assessment of the bile duct needed to be carried out in low‐risk patients, an IVC or MRCP in those at medium risk and an ERC in those at high risk, a calculation was made of the positive predictive value and the sensitivity of the system proposed. The positive predictive value and the sensitivity of the procedure were calculated as being greater than 90%. Conclusions This predictive system for the risk of CBDS allows the selective use of ERC, IVC and MRCP to ensure a high yield and improve cost‐effectiveness. A controlled prospective study will verify these results.

Gallstone Ileus: Laparoscopic-Assisted Enterolithotomy

Although longevity in Western countries has probably increased the prevalence of gallstone ileus,1 this disorder remains a rare, often unrecognized, cause of gastrointestinal mechanical obstruction, accountable for no more than 4% of cases.1-3 The advanced age of the patients, the frequent concomitant presence of severe medical diseases, and the delay before surgical treatment contribute to high morbidity and mortality rates, ranging from 11 to 75% and from 8 to 20%, respectively.2,4 Although consensus has not been reached as to the emergency surgical procedure for gallstone ileus, especially regarding the timeliness and timing of biliary surgery,5 a simple enterolithotomy is considered to be the procedure of choice by most authors.1,2,6 To optimize results, the operation should be expeditious and surgical trauma kept to a minimum. We use the videolaparoscopic approach, described here, in the treatment of three cases of gallstone ileus.

Five-year Prospective Audit of Routine Intravenous Cholangiography and Selective Endoscopic Retrograde Cholangiography with or without Intraoperative Cholangiography in Patients Undergoing Laparoscopic Cholecystectomy

Consensus has never been reached regarding the need or the imaging technique for evaluating the common bile duct (CBD) in patients considered for cholecystectomy. With the advent of laparoscopic cholecystectomy there has been a resurgence of interest in the role of preoperative intravenous cholangiography (IVC) as an alternative for evaluating the CBD. The purpose of this audit was to assess whether a diagnostic workup based on IVC, which permits selective use of intraoperative cholangiography (IOC) and endoscopic treatment of CBD stones before surgery, could be useful in patients undergoing laparoscopic cholecystectomy (LC). In patients without jaundice, gallstone pancreatitis, a prior diagnosis of CBD stones, a prior history of contrast allergy, or a risk of contrast-associated acute renal failure, IVC was performed routinely. Patients suspected to have CBD stones based on IVC results or with inconclusive IVC and patients with a strong clinical suspicion of CBD stones were referred for endoscopic retrograde cholangiography (ERC). IOC was carried out in patients who had a history of contrast allergy or risk of contrast-associated acute renal failure and whenever the surgeon was in doubt as to the biliary anatomy or CBD clearance. IVC was carried out in 1155 patients, ERC in 225, and IOC in 54. IVC was conclusive in 1132 patients, with a diagnostic accuracy of 99%. Our workup permitted the sequential endoscopic-laparoscopic treatment of cholecystocholedocholithiasis in 162 cases. During the follow-up period residual CBD stones were detected in four patients. Our diagnostic workup showed that routine IVC exposes the population to a large radiation burden, and the cost is high for the small number of patients who benefit. Moreover, it does not seem helpful in reducing the incidence of CBD injuries during LC.

Preoperative Ultrasonographic Assessment of the Number and Size of Gallbladder Stones Is It a Useful Predictor of Asymptomatic Choledochal Lithiasis

Objective. To evaluate whether preoperative ultrasonographic assessment of the number and size of gallbladder stones can identify patients at increased risk of having asymptomatic common bile duct stones. Methods. Ultrasonographic data for 300 consecutive patients undergoing laparoscopic cholecystectomy were analyzed. Patients were divided into a group in which multiple small (≤5 mm) or multiple variably sized (both ≤5 and >5 mm) gallbladder stones were present (“positive” stones) and a group with multiple large (>5 mm) or single gallbladder stones, considered “negative.” The ultrasonographic description was compared with surgical findings; finally, the prevalence of asymptomatic common bile duct stones in the 2 groups was compared. Results. Ultrasonographic classification of gallbladder stones was confirmed at surgery in 285 cases (95%). Asymptomatic common bile duct stones were diagnosed in 9.5% of patients with an ultrasonographic diagnosis of positive gallbladder stones and in only 2.3% of patients with a diagnosis of negative gallbladder stones (P < .05). Conclusions. Ultrasonography is able to accurately show gallbladder stones; the appearance of multiple small and variably sized gallbladder stones represent a risk factor for synchronous asymptomatic common bile duct stones.

Incidental gallbladder cancer at laparoscopy: a review of two cases.

Early peritoneal seeding and trocar site metastasis from gallbladder cancer have been reported after laparoscopic cholecystectomy. Nevertheless, the role of laparoscopy in gallbladder cancer remains controversial. Two cases of early recurrence of carcinoma of the gallbladder after laparoscopic cholecystectomy are described. In the first case, the use of a gasless technique did not prevent an early, diffuse peritoneal dissemination of the disease. In the second case, despite the use of a retrieval bag to extract the gallbladder, multiple metastases around the gallbladder bed and local peritoneal seeding developed. These cases demonstrate that factors other than bile spillage, CO2 inflation, and the use of a retrieval bag are responsible for early dissemination of gallbladder cancer.

A critical review of classification systems for colorectal cancer

After a chronological overview of the various staging systems for colorectal cancer, presented in an effort to demonstrate the reasons for the current state of confusion, four different systems (Dukes. Astler and Coller, ACPS, TNM) were compared in 791 patients treated at some stage of their disease at Parma University’s Institute of Surgery. Life survival table analysis was used to examine survival according to each staging system. From the analysis of the staging systems commonly utilised, Dukes’system modified by Astler and Coller, emerges as the best reference model now available. The system can be fine-tuned to a certain extent, in order to improve its predictive value, by taking into account the number of lymph nodes affected by the tumour; further improvement is also foreseeable, above all by the use of genetic variables. However, no classification system can be correct, if it is not accompanied by an accurate pre-operative diagnosis and a thorough post-operative histological study.