Endoscopic management of postoperative bile duct injuries: a single center experience

BACKGROUND/AIM

Biliary endoscopic procedures may be less invasive than surgery for management of postoperative bile duct injuries (POBDI). This retrospective work presents the experience of a single referral center during a period of 14 years in endoscopic management of POBDI.

MATERIALS AND METHODS

Between 1994 (March) and 2008 (May), ERCP had been performed on 277 patients suspected to have POBDI. Patients shown to have complete transaction of bile duct were prepared for definitive surgery. For patients with simple biliary leak, sphincterotomy was performed with stenting. Pneumatic dilatation and stenting were done on patients with biliary stricture and preserved ductal continuity. ERCP was repeated every 3 months till the site of narrowing disappeared.

RESULTS

The mean age was 45.3 years, 162 (58.5%) were females. The most common previous surgery was cholecystectomy (open, [N=119] 44%, and laparoscopic, [N=77] 28%). ERCP failed in 17 patients (6.1%). For successfully cannulated cases (N=260, 93.9%), the type of bile duct injury diagnosed at ERCP was completely ligated CBD (N=31/260 , 11.9%). Bile leakage was detected in (N=167/260, 64.2%) all patients with endoscopic sphincterotomy and stent insertion, the leak stopped in all of them. Biliary stricture was diagnosed in 33/260 patients (12.7%) and 17 of them had repeated balloon dilatation with stenting while the remaining had surgical correction. The success rate of endoscopic therapy for biliary strictures was 82%. Cholangiogram was normal in 29 patients (11.2%).

CONCLUSIONS

Endoscopic therapy is safe and effective in the management of postoperative bile duct leak. For postoperative bile ductal strictures, ERCP is a less favorable option.

Surgical management of peri-ampullary tumors: a retrospective study

BACKGROUND/AIMS

Surgical resection still remains the best treatment for patients with periampullary tumors. This study aims to present the results of surgical treatment of this disease at our center.

METHODOLOGY

Between January 1995 and December 2004, 216 periampullary tumors were treated by surgical resection. The mean age was 58 years with male to female ratio 2:1. The most common symptom was jaundice (97.7%). Abdominal pain occurred in 74% of patients. Pancreaticogastrostomy was done in 183 patients and pancreaticojejunostomy in 33 patients.

RESULTS

Operative mortality occurred in 7 patients (3.2%). The median survival was 22.6 months for patients with ampullary tumors and 16.6 months for patients with pancreatic head tumors. Early operative complications occurred in 33% of patients; the most common one was wound infection (11.6%), pancreatic leak (10.6%), abdominal collection (10.6%) and delayed gastric emptying (8.8%). Factors associated with increased risk of developing complications were the type of pancreatico-enteric anastomosis (pancreatic leak was more frequent with pancraticojejunostomy), soft pancreatic texture and intraoperative blood transfusion of more than 4 units. Factors associated with better survival included tumor diameter (less than 3cm), origin (ampullary), differentiation (well differentiated) and margin status (negative resection margins).

CONCLUSIONS

Postoperative complications of pancreaticoduodenectomy, especially with the adoption of pancreaticogastrostomy, occur with reasonable incidence. Survival largely depends on the origin of the tumor.

Low-dose heparin appears safe and can eliminate protamine use for carotid endarterectomy

OBJECTIVE

To determine the morbidity associated with carotid endarterectomy (CEA) when low doses of heparin (30 U/kg) are used for anticoagulation. This technique eliminates the need for protamine and its potentially deleterious effects on some patients.

DESIGN

A retrospective chart review.

SETTING

A large academic medical center.

PARTICIPANTS

The records of 420 consecutive CEAs in 337 patients (83 bilateral procedures).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The amount of heparin used was less than that used in most reported studies. Eighty-two percent of patients received only 2,000 U of heparin for their entire operation (range, 500 to 3,000 U). Complication rates were low. Neurologic complications included a 0.95% incidence of nonfatal stroke and a 2.1% incidence of transient neurologic deficits that resolved in the first day. There was no mortality. The wounds were described in the postoperative period as dry (96%), swollen (3%), or bloody (1%). No patients received protamine.

CONCLUSION

The use of 5 to 10,000 U of heparin will provide anticoagulation for more than an hour. In CEA surgery, anticoagulation for this duration is often unnecessary. A smaller dose of heparin (30 U/kg) can provide adequate anticoagulation for this procedure while eliminating the potentially deleterious effects of protamine use. No additional morbidity was attributed to this technique.