SURGICAL MANAGEMENT Cholecystitis. Acute Cholecystitis Acute Calculous Cholecystitis – Infectious...

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Transcript of SURGICAL MANAGEMENT Cholecystitis. Acute Cholecystitis Acute Calculous Cholecystitis – Infectious...

ERCP

SURGICAL MANAGEMENTCholecystitisAcute CholecystitisAcute Calculous CholecystitisInfectious mechanism from stone impaction in cystic ductEmpiric antibioticsLaparoscopic vs. Open cholecystectomyAcute Acalculous CholecystitisIn critically ill patientsHigh risk for perforationPercutanous cholecytostomy

Lillemoe K.D. Surgical Treatment of Biliary Tract Infections. The American Surgeon (2000) Vol 66 No. 2 pp. 138-1442Acute CholangitisBactibilia + Biliary obstructionIV antibioticsFluid resuscitationBiliary drainageAcute Suppurative CholangitisDelineation of proximal bile anatomyPercutaneous transhepatic cholangiography and Biliary stent placement

Lillemoe K.D. Surgical Treatment of Biliary Tract Infections. The American Surgeon (2000) Vol 66 No. 2 pp. 138-144

Percutaneous transhepatic cholangiography and Biliary stent placement is the appropriate first step in management*Allows delineation of anatomyControl bile leakOpportune timing of definitive reconstruction

3Laparoscopic cholecystectomyERCPEndoscopic retrograde cholangiopancreatographyERCPEndoscopic Retrograde CholangiopancreatographyFor the diagnosis and treatment of benign and malignant pancreaticobiliary diseases

IndicationsBenefits Gallstones trapped in main bile duct Blockage of bile duct Jaundice Undiagnosed persistent, recurrent upper abdominal painUnexplained loss of appetite and weight loss Cancer of the bile ducts or pancreas Pancreatitis Diagnostic and therapeutic technique (e.g. gallstones, blockage) Shorter hospital stayIncludes:the duodenum (the first portion of the small intestine), the papilla of Vater (a small nipple-like structure with openings leading to the bile ducts and the pancreatic duct), the bile ducts, the gallbladder and the pancreatic duct

7ERCP

DuodenoscopeFiber-optic duodenoscopeVideoscopeCatheter6 or 7 Fr Teflon tapering to a 3-5 Fr tipAn ERCP uses x-ray films and is performed in an x-ray room. The throat is anesthetized with a spray or solution, and the patient is usually mildly sedated.The endoscope is then gently inserted into the upper esophagus. The patient breathes easily throughout the exam, with gagging rarely occurring. A thin tube is inserted through the endoscope to the main bile duct entering the duodenum. Dye is then injected into this bile duct and/or the pancreatic duct and x-ray films are taken. The patient lies on his or her left side and then turns onto the stomach to allow complete visualization of the ducts. If a gallstone is found, steps may be taken to remove it. If the duct has become narrowed, an incision can be made using electrocautery (electrical heat) to relieve the blockage. Additionally, it is possible to widen narrowed ducts and to place small tubing, called stents, in these areas to keep them open. The exam takes from 20 to 40 minutes, after which the patient is taken to the recovery areaERCP. Jackson Siegelbaum. Gastroenterology. (http://gicare.com/Endoscopy-Center/ERCP.aspx)

8ERCPPrognosisSuccess rate 70%-95%ComplicationsPancreatitis (7.2%)Hemorrhage (0.8%)Cholangitis 2 incomplete drainage (0.8%)Perforation (0.08%)Others (1.5%)e.g. Bile peritonitis or bilomasProspective study (N=1223; 45.3% diagnostic 54.7% therapeutic)Vandervoort, J. et. al. Risk Factors for Complications After Performance of ERCP. Gastrointestinal Endoscopy (2002) Vol 56, Issue 5, pp. 652-656Frequency of post-ERCP pancreatitis same for both diagnostic and therapeutic 9Post-ERCP PancreatitisPatient-related characteristicssphincter of Oddi dysfunction (21.7%) previous ERCP-related pancreatitis (19%), andrecurrent pancreatitis (16.2%)

PAIN DURING PROCEDURE (27%)

Technique-related characteristicsprecut 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%)

Prospective study (N=1223; 45.3% diagnostic 54.7% therapeutic)Vandervoort, J. et. al. Risk Factors for Complications After Performance of ERCP. Gastrointestinal Endoscopy (2002) Vol 56, Issue 5, pp. 652-656Frequency of post-ERCP pancreatitis same for both diagnostic and therapeutic 10Post-ERCP PancreatitisRisk 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 procedureHistory of recurrent pancreatitisPrecious ERCP-related pancreatitisPancreatic brush cytology

Prospective study (N=1223; 45.3% diagnostic 54.7% therapeutic)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.

11Stents and drainsDrainage devicesStentsPlastic stents3-11.5 Fr, Polyethylene and Teflon materialsRapid palliation of obstructionShorter hospital stayLess expensive than metal stents ($100)IndicationsMalignant biliary obstructionRelieve obstruction of previous metal stentsBenign stricturesBiliary leaks and fistulaeIndwelling stents tmax = 4-6 weeks

StentsPlastic (Polyethylene and Teflon) + pushing and guiding catheters3-11.5 FrRapid palliation of obstructionShorten hospital stayLess expensive than metal stents ($100)IndicationsMalignant biliary obstructionDistal bile duct tumors more palliatively effectedRelieve obstruction of previous metal stentsBenign stricturesPost-sphincterotomy stenosis, chronic pancreatitis, post-surgical injury, ischemia, anastomotic strictures after live transplantBiliary leaks and fistulaeBiliary surgery, cholecystectomy, trauma

Indwelling stents: (Cotton, Peter and Joseph Lesing. Advanced Gastric Endoscopy: ERCP. Blackwell Publishing Ltd (2006) pp 35-79, USA.)

Image: Types of plastic stent. a Straight stent : the stent has two flaps to prevent dislocation or deviation. Should EST be required, a 10-Fr or larger stent can be used. b Pigtail stent: both ends of the stent have a pigtail form to prevent dislocation or deviation. Maximum stent size is 7 Fr (www.springerimages.com)Image: Direct relationship of stent diameter and stent patency (Poiseuilles law) (figure)Straight Amsterdam stents for biliary drainage, straight improves stent patencySingle pig-tail stent frequently in pancreatic duct to prevent inward migrationDouble pig-tail stent anchor stents to prevent upward/downward migration, used to maintain drainage in patients with difficult bile duct stones an hilar structures

13Drainage devicesStentsSelf-expandable metal stents (SEMS)Expansion of 8-10mmProlonged patency over plastic stentsDo not occlude from bacterial biofilmCostly (>$1800)

StentsSelf-expandable metal stents (SEMS)Expansion of 8-10mmProlonged patency over plastic stentsDo not occlude from bacterial biofilmCostly (>$1800)Open Mesh design and covered SEMSWallstent with polymer (Permalune) coating to prevent tumor growth and prolong stent patencyStainless steel or nitinol (nickel-titanium alloy)High degree of flexibility Kink resistance

14Drainage devicesStentsNasobiliary drainage catheters5-7 Fr, 250cm long, 5-9 sideportsFor temporary drainage of the biliary treeNasal transport tube (reroute tube from mouth to nose) + Connecting tube (for irrigation and drainage)

Top to bottom (http://www.medicalblue.com/productosmb.htm)Duodenal PigtailDouble loop

15StentsBioabsorbable stentsImproved patencyLarge diameterLower biofilm accumulationReduced incidence of bile duct proliferative changesLesser proceduresDrug elution and control Antimicrobial or antineoplastic agents impregnated on cover Bioengineered tissue culture

Drainage devices

StentsBioabsorbable stents (INVESTIGATIONAL)Improved patencyLarge diameterLower biofilm accumulationReduced incidence of bile duct proliferative changesLesser proceduresDrug elution and control Antimicrobial or antineoplastic agents impregnated on cover Bioengineered tissue cultureTreatment of strictures

16Drainage devicesPros Palliative bypass without invasive surgeryCons Device failureDeployment failureMalpositioning of stentStent occlusion

ComplicationsDeposition of bacterial biofilm and/or plant material (30%)Cholecystitis (2.9%-12%)Stent migration (5%)CholangitisHemorrhagePerforationPancreatitisPerforationComplicationsHemorrhagePerforationCholangitis Due to stent occlusion, prophylactic antibiotics may be beneficial to prevent/manage Cholecystitis (2.9%-12%)Cystic duct obstructionDeposition of bacterial biofilm and/or plant material (30%) jaundice + cholangitisPancreatitisStent migration (5%) recurrent obstruction and cholangitis, permanent ductal damage, bowel obstruction, perforationPerforation

17ReferencesChak, A. et. al. Effectiveness of ERCP in Cholangitis: A Community-based Study. Gastrointestinal Endoscopy (2000) Vol 54, No.4 pp484-489 aJudah, Joel and Peter Draganov. Endoscopic Therapy of Benign Biliary Strictures. World Journal of Gastroenterology (July 2007) 13(26): 3531-3539Lillemoe K.D. Surgical Treatment of Biliary Tract Infections. The American Surgeon (2000) Vol 66 No. 2 pp. 138-144Vandervoort, J. et. al. Risk Factors for Complications After Performance of ERCP. Gastrointestinal Endoscopy (2002) Vol 56, Issue 5, pp. 652-656Williams, EJ. et. al. Risk Factors for complications following ERCP; Results of a Large-scale, prospective multicenter study. Endoscopy (2007) Vol 39 No. 9 pp. 793-801ERCP. Jackson Siegelbaum. Gastroenterology. (http://gicare.com/Endoscopy-Center/ERCP.aspx)ERCP MedicineNet, Inc http://www.medicinene