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SURGICAL MANAGEMENT

Cholecystitis. SURGICAL MANAGEMENT. 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

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SURGICAL MANAGEMENT

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  1. Cholecystitis SURGICAL MANAGEMENT

  2. Acute Cholecystitis • Acute CalculousCholecystitis • Infectious mechanism from stone impaction in cystic duct • Empiric antibiotics • Laparoscopic vs. Open cholecystectomy • Acute AcalculousCholecystitis • In critically ill patients • High risk for perforation • Percutanouscholecytostomy

  3. Acute Cholangitis • Bactibilia + Biliary obstruction • IV antibiotics • Fluid resuscitation • Biliary drainage • Acute SuppurativeCholangitis • Delineation of proximal bile anatomy • Percutaneoustranshepaticcholangiography and Biliary stent placement

  4. Laparoscopic cholecystectomy

  5. Endoscopic retrograde cholangiopancreatography ERCP

  6. ERCP • Endoscopic Retrograde Cholangiopancreatography • For the diagnosis and treatment of benign and malignant pancreaticobiliary diseases

  7. ERCP • Duodenoscope • Fiber-optic duodenoscope • Videoscope • Catheter • 6 or 7 Fr Teflon tapering to a 3-5 Fr tip

  8. 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

  9. 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%), • sphincterotomeuse (13.1%), • pancreatic duct manipulation (13%), • multiple pancreatic injections (12.3%), • guidewireuse (10.2%), and • extent of pancreatic duct opacification (10%)

  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

  11. Stents and drains

  12. 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

  13. 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)

  14. 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)

  15. Drainage devices • 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

  16. 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

  17. 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 • LillemoeK.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.

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