AIM: To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis. METHODS: A retrospective medical record review of 88 consecutive patien...AIM: To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis. METHODS: A retrospective medical record review of 88 consecutive patients with acute cholecystitis was conducted. Data collected included demographic data, co-morbidities, symptoms and physical findings at presentation, laboratory and radiological investigations, length of stay, complications, and admission service (medical or surgical). Patients not undergoing cholecystectomy during this hospitalization were excluded from analysis. Hierarchical generalized linear models were constructed to assess the association of pre-operative diagnostic procedures, presenting signs, and admitting service with time to surgery.RESULTS: Seventy cases met inclusion and exclusion criteria, among which 12 were admitted to the medical service and 58 to the surgical service. Mean ± SD time to surgery was 39.3 ± 43 h, with 87% of operations performed within 72 h of hospital arrival. In the adjusted models, longer time to surgery was associated with number of diagnostic studies and endoscopic retrograde cholangio-pancreatography (ERCP, P = 0.01) as well with admission to medical service without adjustment for ERCP (P < 0.05). Patients undergoing both magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) scans experienced the longest waits for surgery. Patients admitted to the surgical versus medical service underwent surgery earlier (30.4 ± 34.9 vs 82.7 ± 55.1 h, P < 0.01), had less post-operative complications (12% vs 58%, P < 0.01), and shorter length of stay (4.3 ± 3.4 vs 8.1 ± 5.2 d, P < 0.01).CONCLUSION: Admission to the medical service and performance of numerous diagnostic procedures, ERCP, or MRCP combined with CT scan were associated with longer time to surgery. Expeditious performance of ERCP and MRCP and admission of medically stable patients with suspected cholecystitis to the surgical service to speed up time to surgery should be considered.展开更多
AIM: To evaluate double balloon enteroscopy (DBE) in post-surgical patients to perform endoscopic retrograde cholangiopancreatography (ERCP) and interventions. METHODS: In 37 post-surgical patients, a stepwise approac...AIM: To evaluate double balloon enteroscopy (DBE) in post-surgical patients to perform endoscopic retrograde cholangiopancreatography (ERCP) and interventions. METHODS: In 37 post-surgical patients, a stepwise approach was performed to reach normal papilla or enteral anastomoses of the biliary tract/pancreas. When conventional endoscopy failed, DBE-based ERCP was performed and standard parameters for DBE, ERCP and interventions were recorded. RESULTS: Push-enteroscopy (overall, 16 procedures) reached enteral anastomoses only in six out of 37 post-surgical patients (16.2%). DBE achieved a high rate of luminal access to the biliary tract in 23 of the remaining 31 patients (74.1%) and to the pancreatic duct (three patients). Among all DBE-based ERCPs (86 procedures), 21/23 patients (91.3%) were successfully treated. Interventions included ostium incision or papillotomy in 6/23 (26%) and 7/23 patients (30.4%), respectively. Biliary endoprosthesis insertion and regular exchange was achieved in 17/23 (73.9%) and 7/23 patients (30.4%), respectively. Furthermore, bile duct stone extraction as well as ostium and papillary dilation were performed in 5/23 (21.7%) and 3/23 patients (13.0%), respectively. Complications during DBE-based procedures were bleeding (1.1%), perforation (2.3%) and pancreatitis (2.3%), and minor complications occurred in up to 19.1%. CONCLUSION: The appropriate use of DBE yields a high rate of luminal access to papilla or enteral anastomoses in more than two-thirds of post-surgical patients, allowing important successful endoscopic therapeutic interventions.展开更多
To evaluate the respective value of dual- phase helical CT arterial portography (CTAP) and conventional angiography in preoperative predicting resectability of pancreatic ductal adenocarcinoma. Subjects and methods. T...To evaluate the respective value of dual- phase helical CT arterial portography (CTAP) and conventional angiography in preoperative predicting resectability of pancreatic ductal adenocarcinoma. Subjects and methods. Tumor resectability was prospectively evaluated in 54 patients with pathologically proven pancreatic ductal adenocarcinoma who later underwent surgery. Both dual- phase helical CT scanning and selective angiography were obtained in each patient preoperatively. For optimal enhancement of pancreas and major peripancreatic vessels, two catheters connected to an automatic injector via a Y- shaped tube were placed after selective angiography,one in celiac trunk, the other in superior mesenteric artery. Then the patient underwent dual- phase helical CTAP of pancreas and liver. The criteria of irresectability for CTAP include: tumor diameter≥ 5 cm,extrapancreatic invasion, distant metastases and vascular involvement(occlusion, stenosis or semicircular encasement of superior mesenteric artery, hepatic artery, splenic artery, celiac axis; portal vein, superior mesenteric vein or splenic vein). The results of both modalities were correlated with findings from surgery or pathology. Results. Thirty- eight of 54 patients had nonresectable disease. In prediction the irresectability, sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy were 94.7％ ,100％ ,100％ ,88.9％ ,96.3％ respectively for helical CTAP and 63.2％ ,93.8％ ,96.0％ ,51.7％ ,72.2％ respectively for selective angiography. In assessing vascular involvements, dual- phase helical CTAP was also superior to selective angiography. Conclusion. Dual- phase helical CTAP is superior to angiography in assessing resectability of pancreatic ductal adenocarcinoma. The combination of the two modalities may further improve overall accuracy of assessment.展开更多
AIM: To evaluate the feasibility and safety of performing laparoscopic cholecystectomy (LC) in nonteaching rural hospitals of a developing country without intra-operative cholangiography (IOC). To evaluate the possibi...AIM: To evaluate the feasibility and safety of performing laparoscopic cholecystectomy (LC) in nonteaching rural hospitals of a developing country without intra-operative cholangiography (IOC). To evaluate the possibility of reduction of costs and hospital stay for patients undergoing LC.METHODS: A prospective analysis of patients with symptomatic benign diseases of gall bladder undergoing LC in three non-teaching rural hospitals of Kashmir Valley from Jan 2001 to Jan 2007. The cohort represented a sample of patients requiring LC, aged 13 to 78 (mean 47.2) years. Main outcome parameters included mortality, complications, re-operation, conversion to open procedure without resorting to IOC, reduction in costs borne by the hospital, and the duration of hospital stay.RESULTS: Twelve hundred and sixty-seven patients (976 females/291 males) underwent laparoscopic cholecystectomy. Twenty-three cases were converted to open procedures; 12 patients developed port site infection, nobody died because of the procedure. One patient had common bile duct (CBD) injury, 4 patients had biliary leak, and 4 patients had subcutaneous emphysema. One cholecystohepatic duct was detected and managed intraoperatively, 1 patient had retained CBD stones, while 1 patient had retained cystic duct stones. Incidental gallbladder malignancy was detected in 2 cases. No long-term complications were detected up to now.CONCLUSION: LC can be performed safely even in non-teaching rural hospitals of a developing country provided proper equipment is available and the surgeons and other team members are well trained in the procedure. It is stressed that IOC is not essential to prevent biliary tract injuries and missed CBD stones. The costs to the patient and the hospital can be minimized by using reusable instruments, intracorporeal sutures, and condoms instead of titanium clips and endobags.展开更多
AIM： To evaluate survival rate and clinical outcome of cholangiocarcinoma. METHODS： The medical records of 34 patients with cholangiocarcinoma, seen at a single hospital between the years 1999-2006, were retrospecti...AIM： To evaluate survival rate and clinical outcome of cholangiocarcinoma. METHODS： The medical records of 34 patients with cholangiocarcinoma, seen at a single hospital between the years 1999-2006, were retrospectively reviewed. RESULTS： Thirty-four patients with a median age of 75 years were included. Seventeen （50%） had painless jaundice at presentation. Sixteen （47.1%） were perihilar, 15 （44.1%） extrahepatic and three （8.8%） intrahepatic. Endoscopic retrograde cholangiography （ERCP） and/or magnetic resonance cholangiography （MRCP） were used for the diagnosis. Pathologic confirmation was obtained in seven and positive cytological examination in three. Thirteen patients had co-morbidities （38.2%）. Four cases were managed with complete surgical resection. All the rest of the cases （30） were characterized as non-resectable due to advanced stage of the disease. Palliative biliary drainage was performed in 26/30 （86.6%）. The mean follow-up was 32 mo （95% CI, 20-43 too）. Overall median survival was 8.7 mo （95% CI, 2-16 mo）. The probability of 1-year, 2-year and 3-year survival was 46%, 20% and 7%, respectively. The survival was slightly longer in patients who underwent resection compared to those who did not, but this difference failed to reach statistical significance. Patients who underwent biliary drainage had an advantage in survival compared to those who did not （probability of survival 53% vs 0% at 1 year, respectively, P = 0.038）. CONCLUSION： Patients with cholangiocarcinoma were usually elderly with co-morbidities and/oradvanced disease at presentation. Even though a slight amelioration in survival with palliative biliary drainage was observed, patients had dismal outcome without resection of the tumor.展开更多
Objective:The aim of this study was to evaluate the efficacy of three-phase contrast material-enhanced MRI in assessing no-surgical treatment response in peripheral bronchogenic carcinoma preliminarily.Methods:Twenty-...Objective:The aim of this study was to evaluate the efficacy of three-phase contrast material-enhanced MRI in assessing no-surgical treatment response in peripheral bronchogenic carcinoma preliminarily.Methods:Twenty-two patients with bronchogenic carcinoma after no-surgical treatment underwent three-phase contrast material-enhanced MRI.Three scans were obtained at 25 s,120 s and 180 s respectively after nonionic contrast material was administrated via the antecubital vein at a rate of 2 mL/s by using an autoinjector.Precontrast and postcontrast signal intensity on every scan was recorded.Peak Height(PH) and Maximum Enhancement(Emax) were calculated.Enhancement pattern was evaluated on the images obtained at 120 s and 180 s after injection of contrast medium.Results:Precontrast signal intensity,postcontrast signal intensity at 120 s and 180 s were 478 ± 108,926 ± 209 and 1050 ± 252.PH(571 ± 225) and Emax(119 ± 49) of bronchogenic carcinoma after no-surgical treatment were significantly lower than those of bronchogenic carcinoma without any therapy(mean PH 655,mean Emax 150)(t = 2.178,P = 0.005 < 0.05,t = 4.196,P = 0.001 < 0.05).Six cases among 22 appeared homogeneous enhancement at 180 s.At 120 s,there were 4 cases with inhomogeneous enhancement,1 case with homogeneous enhancement,1 case with peripheral enhancement among the 6 cases.Conclusion:Bronchogenic carcinoma after no-surgical treatment shows a gradual increase to the PH after administration of contrast material.Three-phase contrast material-enhanced MRI can reflect the blood supply of bronchogenic carcinoma and might be effective approach for evaluation of no-surgical treatment response in bronchogenic carcinoma.展开更多
文摘AIM: To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis. METHODS: A retrospective medical record review of 88 consecutive patients with acute cholecystitis was conducted. Data collected included demographic data, co-morbidities, symptoms and physical findings at presentation, laboratory and radiological investigations, length of stay, complications, and admission service (medical or surgical). Patients not undergoing cholecystectomy during this hospitalization were excluded from analysis. Hierarchical generalized linear models were constructed to assess the association of pre-operative diagnostic procedures, presenting signs, and admitting service with time to surgery.RESULTS: Seventy cases met inclusion and exclusion criteria, among which 12 were admitted to the medical service and 58 to the surgical service. Mean ± SD time to surgery was 39.3 ± 43 h, with 87% of operations performed within 72 h of hospital arrival. In the adjusted models, longer time to surgery was associated with number of diagnostic studies and endoscopic retrograde cholangio-pancreatography (ERCP, P = 0.01) as well with admission to medical service without adjustment for ERCP (P < 0.05). Patients undergoing both magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) scans experienced the longest waits for surgery. Patients admitted to the surgical versus medical service underwent surgery earlier (30.4 ± 34.9 vs 82.7 ± 55.1 h, P < 0.01), had less post-operative complications (12% vs 58%, P < 0.01), and shorter length of stay (4.3 ± 3.4 vs 8.1 ± 5.2 d, P < 0.01).CONCLUSION: Admission to the medical service and performance of numerous diagnostic procedures, ERCP, or MRCP combined with CT scan were associated with longer time to surgery. Expeditious performance of ERCP and MRCP and admission of medically stable patients with suspected cholecystitis to the surgical service to speed up time to surgery should be considered.
文摘AIM: To evaluate double balloon enteroscopy (DBE) in post-surgical patients to perform endoscopic retrograde cholangiopancreatography (ERCP) and interventions. METHODS: In 37 post-surgical patients, a stepwise approach was performed to reach normal papilla or enteral anastomoses of the biliary tract/pancreas. When conventional endoscopy failed, DBE-based ERCP was performed and standard parameters for DBE, ERCP and interventions were recorded. RESULTS: Push-enteroscopy (overall, 16 procedures) reached enteral anastomoses only in six out of 37 post-surgical patients (16.2%). DBE achieved a high rate of luminal access to the biliary tract in 23 of the remaining 31 patients (74.1%) and to the pancreatic duct (three patients). Among all DBE-based ERCPs (86 procedures), 21/23 patients (91.3%) were successfully treated. Interventions included ostium incision or papillotomy in 6/23 (26%) and 7/23 patients (30.4%), respectively. Biliary endoprosthesis insertion and regular exchange was achieved in 17/23 (73.9%) and 7/23 patients (30.4%), respectively. Furthermore, bile duct stone extraction as well as ostium and papillary dilation were performed in 5/23 (21.7%) and 3/23 patients (13.0%), respectively. Complications during DBE-based procedures were bleeding (1.1%), perforation (2.3%) and pancreatitis (2.3%), and minor complications occurred in up to 19.1%. CONCLUSION: The appropriate use of DBE yields a high rate of luminal access to papilla or enteral anastomoses in more than two-thirds of post-surgical patients, allowing important successful endoscopic therapeutic interventions.
文摘To evaluate the respective value of dual- phase helical CT arterial portography (CTAP) and conventional angiography in preoperative predicting resectability of pancreatic ductal adenocarcinoma. Subjects and methods. Tumor resectability was prospectively evaluated in 54 patients with pathologically proven pancreatic ductal adenocarcinoma who later underwent surgery. Both dual- phase helical CT scanning and selective angiography were obtained in each patient preoperatively. For optimal enhancement of pancreas and major peripancreatic vessels, two catheters connected to an automatic injector via a Y- shaped tube were placed after selective angiography,one in celiac trunk, the other in superior mesenteric artery. Then the patient underwent dual- phase helical CTAP of pancreas and liver. The criteria of irresectability for CTAP include: tumor diameter≥ 5 cm,extrapancreatic invasion, distant metastases and vascular involvement(occlusion, stenosis or semicircular encasement of superior mesenteric artery, hepatic artery, splenic artery, celiac axis; portal vein, superior mesenteric vein or splenic vein). The results of both modalities were correlated with findings from surgery or pathology. Results. Thirty- eight of 54 patients had nonresectable disease. In prediction the irresectability, sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy were 94.7％ ,100％ ,100％ ,88.9％ ,96.3％ respectively for helical CTAP and 63.2％ ,93.8％ ,96.0％ ,51.7％ ,72.2％ respectively for selective angiography. In assessing vascular involvements, dual- phase helical CTAP was also superior to selective angiography. Conclusion. Dual- phase helical CTAP is superior to angiography in assessing resectability of pancreatic ductal adenocarcinoma. The combination of the two modalities may further improve overall accuracy of assessment.
文摘AIM: To evaluate the feasibility and safety of performing laparoscopic cholecystectomy (LC) in nonteaching rural hospitals of a developing country without intra-operative cholangiography (IOC). To evaluate the possibility of reduction of costs and hospital stay for patients undergoing LC.METHODS: A prospective analysis of patients with symptomatic benign diseases of gall bladder undergoing LC in three non-teaching rural hospitals of Kashmir Valley from Jan 2001 to Jan 2007. The cohort represented a sample of patients requiring LC, aged 13 to 78 (mean 47.2) years. Main outcome parameters included mortality, complications, re-operation, conversion to open procedure without resorting to IOC, reduction in costs borne by the hospital, and the duration of hospital stay.RESULTS: Twelve hundred and sixty-seven patients (976 females/291 males) underwent laparoscopic cholecystectomy. Twenty-three cases were converted to open procedures; 12 patients developed port site infection, nobody died because of the procedure. One patient had common bile duct (CBD) injury, 4 patients had biliary leak, and 4 patients had subcutaneous emphysema. One cholecystohepatic duct was detected and managed intraoperatively, 1 patient had retained CBD stones, while 1 patient had retained cystic duct stones. Incidental gallbladder malignancy was detected in 2 cases. No long-term complications were detected up to now.CONCLUSION: LC can be performed safely even in non-teaching rural hospitals of a developing country provided proper equipment is available and the surgeons and other team members are well trained in the procedure. It is stressed that IOC is not essential to prevent biliary tract injuries and missed CBD stones. The costs to the patient and the hospital can be minimized by using reusable instruments, intracorporeal sutures, and condoms instead of titanium clips and endobags.
文摘AIM： To evaluate survival rate and clinical outcome of cholangiocarcinoma. METHODS： The medical records of 34 patients with cholangiocarcinoma, seen at a single hospital between the years 1999-2006, were retrospectively reviewed. RESULTS： Thirty-four patients with a median age of 75 years were included. Seventeen （50%） had painless jaundice at presentation. Sixteen （47.1%） were perihilar, 15 （44.1%） extrahepatic and three （8.8%） intrahepatic. Endoscopic retrograde cholangiography （ERCP） and/or magnetic resonance cholangiography （MRCP） were used for the diagnosis. Pathologic confirmation was obtained in seven and positive cytological examination in three. Thirteen patients had co-morbidities （38.2%）. Four cases were managed with complete surgical resection. All the rest of the cases （30） were characterized as non-resectable due to advanced stage of the disease. Palliative biliary drainage was performed in 26/30 （86.6%）. The mean follow-up was 32 mo （95% CI, 20-43 too）. Overall median survival was 8.7 mo （95% CI, 2-16 mo）. The probability of 1-year, 2-year and 3-year survival was 46%, 20% and 7%, respectively. The survival was slightly longer in patients who underwent resection compared to those who did not, but this difference failed to reach statistical significance. Patients who underwent biliary drainage had an advantage in survival compared to those who did not （probability of survival 53% vs 0% at 1 year, respectively, P = 0.038）. CONCLUSION： Patients with cholangiocarcinoma were usually elderly with co-morbidities and/oradvanced disease at presentation. Even though a slight amelioration in survival with palliative biliary drainage was observed, patients had dismal outcome without resection of the tumor.
文摘Objective:The aim of this study was to evaluate the efficacy of three-phase contrast material-enhanced MRI in assessing no-surgical treatment response in peripheral bronchogenic carcinoma preliminarily.Methods:Twenty-two patients with bronchogenic carcinoma after no-surgical treatment underwent three-phase contrast material-enhanced MRI.Three scans were obtained at 25 s,120 s and 180 s respectively after nonionic contrast material was administrated via the antecubital vein at a rate of 2 mL/s by using an autoinjector.Precontrast and postcontrast signal intensity on every scan was recorded.Peak Height(PH) and Maximum Enhancement(Emax) were calculated.Enhancement pattern was evaluated on the images obtained at 120 s and 180 s after injection of contrast medium.Results:Precontrast signal intensity,postcontrast signal intensity at 120 s and 180 s were 478 ± 108,926 ± 209 and 1050 ± 252.PH(571 ± 225) and Emax(119 ± 49) of bronchogenic carcinoma after no-surgical treatment were significantly lower than those of bronchogenic carcinoma without any therapy(mean PH 655,mean Emax 150)(t = 2.178,P = 0.005 < 0.05,t = 4.196,P = 0.001 < 0.05).Six cases among 22 appeared homogeneous enhancement at 180 s.At 120 s,there were 4 cases with inhomogeneous enhancement,1 case with homogeneous enhancement,1 case with peripheral enhancement among the 6 cases.Conclusion:Bronchogenic carcinoma after no-surgical treatment shows a gradual increase to the PH after administration of contrast material.Three-phase contrast material-enhanced MRI can reflect the blood supply of bronchogenic carcinoma and might be effective approach for evaluation of no-surgical treatment response in bronchogenic carcinoma.
