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.