Biliary stent causing colovaginal fistula: case report.
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OBJECTIVES: Perforation of the bowel during placement of a biliary stent is a known complication of this procedure. We report the endoluminal loss of a biliary stent during routine stent extraction that ultimately led to a chronic colovaginal fistula. This case emphasizes the need for evaluation of fecal passage of stents in patients with a known dislodged prosthesis. CASE REPORT: A 65-year-old white female underwent biliary stent placement for an episode of choledocholithiasis. The stent was lost in the duodenum during routine extraction. The patient was managed expectantly. She denied ever passing this stent via the rectum and began to develop symptoms of colovaginal fistula. Evaluation found a retained biliary stent in the sigmoid colon and a fistula into the vagina. The patient underwent elective low anterior resection and colovaginal fistula repair. DISCUSSION: Reports exist of migration of stents that lead to acute colonic perforation and the need for emergent surgery. For this reason, it has been suggested that dropped or migrated stents be purposefully retrieved. However, if the option of expectant observation is used, it is important to clearly document the fecal passage of these stents and be prepared to retrieve these objects if they have a prolonged bowel transit time. (+info)
A systematic review and economic evaluation of magnetic resonance cholangiopancreatography compared with diagnostic endoscopic retrograde cholangiopancreatography.
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OBJECTIVES: To compare the clinical and cost-effectiveness of magnetic resonance cholangiopancreatography (MRCP) with diagnostic endoscopic retrograde cholangiopancreatography (ERCP) for the investigation of biliary obstruction. DATA SOURCES: Electronic bibliographic databases, the reference lists of relevant articles and various health services research-related resources. REVIEW METHODS: The data sources were searched and selected studies were assessed using quality criteria. In total, 28 prospective diagnostic studies were identified reporting several suspected conditions plus one of patient satisfaction. Analyses were then performed to establish sensitivities, specificities, likelihood ratios and confidence intervals. The relative cost-effectiveness of adopting MRCP scanning in the investigation of the biliary tree was undertaken using a probabilistic economic model. RESULTS: The median sensitivity for choledocholithiasis (13 studies) was 93% and the median specificity 94%. The median likelihood ratio for a positive value was 15.75 and for a negative value 0.08. Reported sensitivities for malignancy were somewhat lower, ranging from 81 to 86%, and specificities ranged from 92 to 100%. There was some evidence that MRCP is an accurate diagnostic test in comparison to ERCP, although the quality of studies was moderate. Claustrophobia prevented at least some patients from having MRCP in ten of the 28 studies. The other 18 studies did not mention claustrophobia. The probability of avoiding unnecessary diagnostic ERCP is estimated at 30%. These patients could avoid the unnecessary risk of complications and death associated with diagnostic ERCP, and substantial cost saving would be gained. The overall expected cost saving associated with MRCP is GBP149; the overall expected gain in quality-adjusted life-year is estimated at 0.011. CONCLUSIONS: There is some evidence that MRCP is an accurate investigation compared with diagnostic ERCP, although the values for malignancy compared with choledocholithiasis were somewhat lower. The quality of studies was moderate. The limited evidence on patient satisfaction showed that patients preferred MRCP to diagnostic ERCP. The estimated clinical and economic impacts of diagnostic MRCP versus diagnostic ERCP are very favourable. The baseline estimate is that MRCP may both reduce cost and result in improved quality of life outcomes compared with diagnostic ERCP. Further research is suggested to compare MRCP and diagnostic ERCP with final diagnosis and also with the full range of target conditions; to examine patient satisfaction and ways of reducing problems with claustrophobia; to look at protocols to help identify who could most benefit from MRCP or ERCP; to assess the relative need and urgency of patient access to magnetic resonance imaging services, and also to determine how demand would affect availability and potential cost savings. (+info)
Abnormal liver function tests in the symptomatic pregnant patient: the local experience in Singapore.
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INTRODUCTION: The causes of abnormal liver function tests in pregnancy are varied and may or may not be pregnancy-related. Often, the diagnosis can be difficult. This study looked at the causes of deranged liver function tests in obstetric patients with significant symptoms and signs. MATERIALS AND METHODS: Data from 50 cases of abnormal liver function tests in pregnant patients, who presented from 1998 to 2001, were analysed. Their presenting symptoms included persistent vomiting (48%), pruritus (14%), jaundice (26%), upper abdominal discomfort (24%) and hypertension (46%). RESULTS: Pregnancy-related causes accounted for 84% of the abnormal liver function tests. Abnormal liver function tests occurred more frequently in the first (34%) and third (58%) trimesters than in the second trimester (8%). Hyperemesis gravidarum (94%) and partial haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome (31%) were the commonest causes in the first and third trimesters respectively. Hepatitis B flare resulted in 2 maternal deaths. Seven patients with pre-eclampsia toxaemia, acute fatty liver of pregnancy or partial/complete HELLP syndrome had their liver function tests measured sequentially before and after delivery. All of them showed rapid improvement postpartum with their alanine aminotransferase (ALT) dropping 50% within 3 days. CONCLUSIONS: The majority of patients with abnormal liver function tests had a cause related to pregnancy, and pregnancy-related causes in the third trimester improved rapidly postpartum. Hepatitis B flare was a significant non-obstetric cause leading to maternal mortality. This diagnosis must therefore be considered in ethnic groups where the incidence of chronic hepatitis B infection is high, especially in chronic hepatitis B carriers with suspected pregnancy-related disease who deteriorate postpartum. (+info)
Three-dimensional virtual cholangioscopy: a reliable tool for the diagnosis of common bile duct stones.
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OBJECTIVE: Our goal was to evaluate the clinical reliability of a new software system employing 3-dimensional (3D) virtual anatomic reconstruction and intraluminal virtual exploration for detection of choledocholithiasis and preoperative visualization of the biliary anatomy. SUMMARY BACKGROUND DATA: Virtual reality systems have been proposed for gastroscopy, bronchoscopy, and colonoscopy, as well as for the 3D reconstruction of liver anatomy and hepatic lesions. The impact of these systems in preoperative diagnostics has not been established due to the lack of large clinical series evaluating their reliability. METHODS: From November 2000 to July 2002, all patients presenting to our Institute with suspected choledocholithiasis were prospectively included in the study. All patients underwent conventional magnetic resonance cholangiopancreatography (MRCP) and either intraoperative cholangiogram (IOC) or endoscopic retrograde cholangiopancreatography (ERCP). The digital data from MRCP were incorporated into an original virtual reality software system to generate a 3D reconstruction. All 3D reconstructions were evaluated by a surgeon and a computer software engineer who were blind to the results of the IOC or ERCP. Sensitivity and specificity were then calculated based on the results of either the IOC or ERCP. RESULTS: Sixty-five patients were enrolled in the study. The average time required to reconstruct the images into navigable virtual reality was 7.5 minutes (range, 4-13.5). The 3D virtual cholangioscopy had sensitivity and specificity rates of 71% and 91%, respectively, compared with 61% and 86% of the standard MRCP. CONCLUSION: : The 3D virtual cholangioscopy provides detailed preoperative reconstruction of biliary anatomy and reliable identification of choledocholithiasis with acceptable sensitivity and specificity in a clinical setting. Newer software developments may further enhance its accuracy, so that virtual cholangioscopy might challenge or replace more invasive diagnostic measures in the near future. (+info)
Biliary drainage after laparoscopic choledochotomy.
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AIM: Transcystic biliary decompression (TCBD) has been proposed as an alternative to T-tube placement after laparoscopic choledochotomy (LCD). This permits safe primary closure of the choledochotomy and eliminates the complications associated with T-tubes. TCBD tube has been secured by Roeder knots and transfixation, and removed later than 3 wk after surgery. We presented a modified TCBD (mTCBD) method after LCD using the ureteral catheter and the Lapro-Clip (David and Geck, Danbury, Connecticut, USA), and compared it with T-tube drainage. METHODS: Between October 2002 and June 2003, patients with choledocholithiasis undergoing LCD with mTCBD (mTCBD Group, n = 30) were retrospectively compared to those undergoing LCD with T-tube drainage (T-tube Group, n = 52) at a single institution. RESULTS: There were no significant differences in operative time and retained stones between the two groups. Patients in mTCBD group had a significantly decreased average output of bile compared with those in T-tube group (306+/-141 vs 409+/-243 mL/24 h, P = 0.000). Removal of drain tubes in mTCBD group was done significantly earlier than that in T-tube group (median, 5 vs 29 d, P = 0.000). No complication related to drain tubes was found in mTCBD group, and morbidity rate with the T-tube was significantly higher (11.5%), and bile leakage following T-tube removal was 5.8%. CONCLUSION: A modified TCBD after LCD is safe, effective and easy to perform. It may reduce postoperative complications, especially bile leakage. (+info)
Fish bone as a nidus for stone formation in the common bile duct: report of two cases.
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We report two cases of common bile duct stone formed around a fish bone which migrated from the intestinal tract, along with their characteristic imaging findings. Two patients who had no history of previous operation were admitted because of cholangitis. Percutaneous transhepatic biliary drainage (PTBD) was performed and the cholangiogram showed filling defects with an unusually elongated shape in the common bile duct. After improvement of the cholangitic symptoms, the stones were removed through the PTBD tract under fluoroscopic guidance. A nidus consisting of a 1.5 cm sized fish bone was found in each stone removed. (+info)
Clip-induced biliary stone.
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Surgical clip migration is a well-known phenomenon ever since their first use in surgery. The mechanism of clip migration is poorly understood, and can occur from days to years after laparoscopic cholecystectomy. Migration of the surgical clips may be a complex process involving necrosis, pressure exerted from intra-abdominal movement, formation of stones over the exposed clip within the bile duct, and eventual migration into the common bile duct. We report two cases, a 58-year-old man and a 54-year-old woman, of clip- induced biliary stones resulting from surgical clip migration a few years after laparoscopic cholecystectomy. (+info)
Results of cholecystectomy without intraoperative cholangiography.
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BACKGROUND: To determine if cholecystectomy can be performed satisfactorily without the use of adjunctive intraoperative cholangiography (IOC), we planned a retrospective analysis at a Canadian university teaching hospital. METHODS: General operative morbidity and mortality (in particular, occurrences and complications of missed choledocholithiasis and reoperations for same, and occurrences of bile duct injuries and bile leaks) were noted and analyzed for a consecutive series of cholecystectomies from a single practice, carried out without IOC. MAIN RESULTS: In general, choledocholithiasis could be identified and treated before the operation; missed cases were infrequent and were treatable without reoperation. No major injuries to the bile duct were encountered. CONCLUSIONS: IOC appears to be optional with cholecystectomy; cholecystectomy can be performed without IOC safely in the defined setting, without related major complications from missed choledocholithiasis or excess occurrence of bile-duct injury. (+info)