SURGICAL MANAGEMENTCholecystitis
Acute Cholecystitis
• Acute Calculous Cholecystitis– Infectious mechanism from stone impaction in
cystic duct• Empiric antibiotics• Laparoscopic vs. Open cholecystectomy
• Acute Acalculous Cholecystitis– In critically ill patients• High risk for perforation• Percutanous cholecytostomy
Acute Cholangitis
• Bactibilia + Biliary obstruction– IV antibiotics– Fluid resuscitation– Biliary drainage
• Acute Suppurative Cholangitis– Delineation of proximal bile anatomy– Percutaneous transhepatic cholangiography and
Biliary stent placement
LAPAROSCOPIC CHOLECYSTECTOMY
ERCPEndoscopic retrograde cholangiopancreatography
ERCP
• Endoscopic Retrograde Cholangiopancreatography– For the diagnosis and treatment of benign and
malignant pancreaticobiliary diseases
Indications Benefits• Gallstones trapped in main bile
duct• Blockage of bile duct• Jaundice• Undiagnosed persistent, recurrent
upper abdominal pain• Unexplained loss of appetite and
weight loss• Cancer of the bile ducts or pancreas• Pancreatitis
• Diagnostic and therapeutic technique (e.g. gallstones, blockage)
• Shorter hospital stay
ERCP
• Duodenoscope• Fiber-optic duodenoscope• Videoscope
• Catheter• 6 or 7 Fr Teflon tapering to a 3-5 Fr tip
ERCP
• Prognosis– Success rate 70%-95%
• Complications– Pancreatitis (7.2%)– Hemorrhage (0.8%)– Cholangitis 2° incomplete drainage (0.8%)– Perforation (0.08%)– Others (1.5%)
• e.g. Bile peritonitis or bilomas
Post-ERCP Pancreatitis
• Patient-related characteristics– sphincter of Oddi
dysfunction (21.7%) – previous ERCP-related
pancreatitis (19%), and– recurrent pancreatitis
(16.2%)
• PAIN DURING PROCEDURE (27%)
• Technique-related characteristics– precut access papillotomy
(20%), – multiple cannulation attempts
(14.9%), – sphincterotome use (13.1%), – pancreatic duct manipulation
(13%), – multiple pancreatic injections
(12.3%), – guidewire use (10.2%), and – extent of pancreatic duct
opacification (10%)
Post-ERCP Pancreatitis
• Risk Factors – Multiple cannulation
attempts >1 (P = 0.0001, OR 3.14, 95 % CI 1.74 - 5.67)
– Female sex (P < 0.001, OR 2.22, 95 % CI 1.43 - 3.45)
– Age (P < 0.002, OR 1.09 per 5 year decrease, 95 % CI 1.03 - 1.15)
– Performance in a district hospital vs. university hospital (P = 0.034, OR 2.41, 95 % CI 1.08 - 5.41)
– Pain during procedure– History of recurrent
pancreatitis– Precious ERCP-related
pancreatitis– Pancreatic brush
cytology
STENTS AND DRAINS
Drainage devices
• Stents– Plastic stents
• 3-11.5 Fr, Polyethylene and Teflon materials• Rapid palliation of obstruction• Shorter hospital stay• Less expensive than metal stents ($100)• Indications
– Malignant biliary obstruction– Relieve obstruction of previous metal stents– Benign strictures– Biliary leaks and fistulae
• Indwelling stents tmax = 4-6 weeks
Drainage devices
• Stents– Self-expandable metal stents (SEMS)• Expansion of 8-10mm• Prolonged patency over plastic stents• Do not occlude from bacterial biofilm• Costly (>$1800)
Drainage devices
• Stents– Nasobiliary drainage catheters• 5-7 Fr, 250cm long, 5-9 sideports• For temporary drainage of the biliary tree• Nasal transport tube (reroute tube from mouth to
nose) + Connecting tube (for irrigation and drainage)
• Stents– Bioabsorbable stents• Improved patency• Large diameter• Lower biofilm accumulation• Reduced incidence of bile duct proliferative changes• Lesser procedures• Drug elution and control
– Antimicrobial or antineoplastic agents impregnated on cover – Bioengineered tissue culture
Drainage devices
Drainage devices
• Pros – Palliative bypass without
invasive surgery
• Cons – Device failure– Deployment failure– Malpositioning of stent– Stent occlusion
• Complications– Deposition of bacterial
biofilm and/or plant material (30%)
– Cholecystitis (2.9%-12%)– Stent migration (5%)– Cholangitis– Hemorrhage– Perforation– Pancreatitis– Perforation
References• Chak, A. et. al. Effectiveness of ERCP in Cholangitis: A Community-based Study. Gastrointestinal
Endoscopy (2000) Vol 54, No.4 pp484-489 a• Judah, Joel and Peter Draganov. Endoscopic Therapy of Benign Biliary Strictures. World Journal
of Gastroenterology (July 2007) 13(26): 3531-3539• Lillemoe K.D. Surgical Treatment of Biliary Tract Infections. The American Surgeon (2000) Vol 66
No. 2 pp. 138-144• Vandervoort, J. et. al. Risk Factors for Complications After Performance of ERCP.
Gastrointestinal Endoscopy (2002) Vol 56, Issue 5, pp. 652-656• Williams, EJ. et. al. Risk Factors for complications following ERCP; Results of a Large-scale,
prospective multicenter study. Endoscopy (2007) Vol 39 No. 9 pp. 793-801• “ERCP”. Jackson Siegelbaum. Gastroenterology. (http://gicare.com/Endoscopy-Center/ERCP.aspx
)• “ERCP” MedicineNet, Inc http://www.medicinenet.com/script/main/art.asp?articlekey=358• Baron, TH, Kozarek, R, Carr-Locke, DL. ERCP. Elsevier Inc (2008), China.• Cotton, Peter and Joseph Lesing. Advanced Gastric Endoscopy: ERCP. Blackwell Publishing Ltd
(2006) pp 35-79, USA.• Silverstein, FE and Guido, NJT. Gastrointestinal Endoscopy, 3rd edition, Mosby-Wolfe (1997) pp
237-260, London, UK.