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Hepatobiliary papers


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Compared with parenteral nutrition, enteral feeding attenuated the acute phase response and improves disease severity in acute pancreatitis. Windsor A C J, Kanwar S, Li A G K et al. Gut 1998; 42: 431-435.

Early enteral nutrition attenuates the inflammatory response following major surgery and trauma. Total enteral nutrition (TEN) has been shown to reduce the acute phase response and septic complications in burns patients. The aim of this study was to assess whether TEN attenuated the acute phase response and reduced disease severity in acute pancreatitis. Thirty-four patients with acute pancreatitis (amylase >1,000 IU/ml, symptoms <48 hours and no evidence of chronic pancreatitis) were evaluated by the Glasgow score, APACHE II score, CT scan, CRP, anti-endotoxin core antibody and total oxidant capacity. Patients were stratified by disease severity and randomised to receive either TEN or TPN for seven days. No patients were intolerant of the enteral feed. Enteral nutrition reduced the incidence of SIRS, sepsis, multiple organ failure and lessened the ITU stay. It reduced both CRP and APACHE II scores. Anti-endotoxin core antibody levels remained unchanged. In the TPN group there was no reduction in the inflammatory response. Anti-endotoxin core antibody levels were increased. It was concluded that early enteral nutrition is practical and is well tolerated in patients with acute pancreatitis. TEN reduces the acute phase response and improves disease severity and clinical outcome. Enteral nutrition modifies the inflammatory response, limits septic complications and is clinically beneficial in patients with acute pancreatitis.

Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? Lillemoe K D, Cameron J L, Hardacre J M et al. Ann Surg 1999; 230: 322-330. 

Between 25% and 75% of patients with periampullary carcinoma (cancer of the head of pancreas, distal common bile duct, ampulla of Vater and duodenum) who undergo laparotomy with with a view to curative surgery (pancreaticoduodenectomy) are found to have unresectable disease. Most undergo a biliary-enteric bypass to relieve obstructive jaundice. The role of prophylactic gastrojejunostomy to prevent late gastric outflow obstruction is however controversial. Retrospective reviews of both surgical series and patients having their jaundice palliated by endoscopic stenting have shown that late gastric outflow obstruction develops in 10 - 20% of patients with unresectable periampullary tumours. This study was a prospective, randomised, single-institution trial aiming to evaluate the role of prophylactic gastrojejunostomy in patients found to have irresectable periampullary carcinoma. Over a four year period 194 patients with periampullary cancer were found at surgery to have irresectable disease. Of these, 107 were felt to have evidence of impending duodenal obstruction and a gastrojejunostomy was performed in all patients. The remaining 87 patients, thought not to be at risk of obstruction, were randomised to receive or not receive a prophylactic retrocolic gastrojejunostomy. Of these 87 patients, 44 patients received a gastrojejunostomy and 43 did not undergo a bypass procedure. The groups were demographically well matched. There were no post-operative deaths in either group and the post-operative morbidity and hospital stay were comparable. Mean survival was 8.3 months in both groups. 8 of the 43 (19%) patients in the group that did not receive a jejunostomy developed late gastric outflow obstruction requiring therapeutic intervention. No patient in the other group required further surgery. It was concluded that the addition of a prophylactic retrocolic gastrojejunostomy at the time of the initial surgical procedure prevents late gastric outflow obstruction and does not add to the post-operative morbidity or hospital stay.

Emergency cholecystotomy and subsequent cholecystectomy for acute gallstone cholecystitis in the elderly.  Borzellino G, de Manzoni G, Ricci F et alBr J Surg 1999; 86: 1521-1525.

Acute cholecystitis is one of the commonest reasons for surgical admission in western countries. The incidence of cholelithiasis increases with age and with an increasingly elderly population more patients are at risk of developing gallstone-related complications. The morbidity and mortality rates associated with acute cholecystitis are increased. As a result this retrospective cohort review investigated the role of emergency ultrasound-guided percutaneous cholecystotomy followed by elective cholecystectomy after endoscopic treatment of any common bile duct stones in elderly patients with acute cholecystitis. In the 10 years between 1989 and 1998, 84 patients over the age of 70 years with ultrasonographic signs of severe cholecystitis and ASA grades II to IV underwent ultrasound-guided percutaneous cholecystotomy. Transcatheter cholangiography was performed in all patients and ERCP and sphincterotomy was performed in all patients (n=18) with common bile duct stones. After resolution of infection and pre-operative optimisation of the patients condition 70 patients proceeded to cholecystectomy with no deaths and a morbidity rate of 24%. It was concluded that the combination of emergency ultrasound-guided percutaneous cholecystotomy, preoperative endoscopic treatment of of common bile duct stones and subsequent elective cholecystectomy constituted an optimal treatment regimen for acute gallstone cholecystitis in elderly patients.

Comparison of magnetic resonance and endoscopic retrograde cholangiopancreatography in malignant pancreaticobiliary obstruction. Georopoulos S K, Shwartz L H, Jarnagin W R et al. Arch Surg 1999; 134: 1002-1007.

Endoscopic retrograde cholangiopancreatography (ERCP) has revolutionised the diagnosis and management of pancreaticobiliary disease and remains the gold standard for imaging the pancreatic and common bile duct. It is, however, an often difficult and operator dependent technique, occasionally associated with significant complications. It also fails to provide information regarding the extent of pancreatic cancers; information needed to assess operability of tumours. As a result ERCP has to be combined with other imaging modalities, usually CT scanning. Magnetic resonance cholangiopancreatography (MRCP) is a relatively new noninvasive imaging technique for the evaluation of pancreaticobiliary disease. It can provide high resolution images of the biliary and pancreatic ducts as well as providing information on size, character, vascular invasion and metastatic spread of the tumour. Whether MRCP will supplement standard imaging studies in patients with malignant biliary obstruction is unclear. The aim of this study was to assess the comparability of ERCP and MRCP as a diagnostic tool in patients with malignant biliary obstruction. In 1996, 18 patients with suspected pancreaticobiliary malignancy underwent both ERCP and MRCP. Images from both modalities were retrospectively analysed in a blinded fashion and compared with the intraoperative findings. Diagnostic-quality MR images were obtained in all patients. Diagnostic ERCP images were obtained from 16 (89%) of biliary cannulations. MR accurately delineated the level of biliary obstruction in 89% of patients and provided valuable staging information in most patients. Findings from MR correlated well with intraoperative findings (size, location, mesenteric vascular involvement). It was concluded that MRCP is sensitive for detecting the presence and level of biliary obstruction. It is comparable to ERCP but in addition provided additional useful staging information.

Evaluation of magnetic resonance cholangiography in the management of bile duct stones. Demartines N,  Eisner L,  Schnabel K,  Fried R,  Zuber M,  Harder F.  Arch Surg 2000;  135:  148-152.

Common bile duct stones (CBD) can be diagnosed by endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiography (IOC).  The former is popular because it can be both diagnostic and therapeutic.  However, the number of negative investigations is significant and complications can occur.  Magnetic resonance cholangiography (MRC) offers the potential for accurate, non-invasive detection of common bile duct stones prior to cholecystectomy with a reduction in the incidence of negative investigations associated with ERCP.  This study was a prospective cohort study of 70 patients with suspected CBD stones scheduled for cholecystectomy.  Forty patients at high risk of CBD stones (increased bilirubin, increased alkaline phosphatase and a dilated CBD) underwent preoperative ERCP.  Thirty patients at moderate risk of CBD stones (moderately increased bilirubin, normal CBD) underwent IOC.   All  patients underwent MRC the results of which were assessed without knowledge of the ERCP or IOC results.  Results of MRC were positive for CBD stones in 21 (52%) of high risk patients a finding confirmed by ERCP in 19 (90%) of patients.  Results of MRC were positive for CBD stones in 6 (20%) of moderate risk patients all of which were confirmed by IOC.  The overall sensitivity and specificity of MRC for CBD stones were 100% and 96% respectively.  The positive and negative predictive values were 93% and 100% respectively.  It was concluded that MRC is a reliable, non-invasive method for the detection of CBD stones. It has the potential to reduce the number of invasive diagnostic procedures and their associated risks.  

A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites.  Rossle M, Ochs A, Gulberg V et al. N Eng J Med 2000; 342: 1701-1707.

Refractory or recurrent ascites is frequently encountered in patients with ascites.  Effective therapy is difficult but the options available include repeated large-volume paracentesis, peritoneovenous shunting, portosystemic shunting and liver transplantation.  Increased portal venous pressure is believed to be an important aetiological factor and it can be effectively reduced with either the surgical creation of a portosystemic shunt or by the percutaneous  insertion of a transjugular intrahepatic portosystemic shunt (TIPSS).  In patients with cirrhosis and ascites creation of a TIPSS has been shown to reduce ascites and improve renal function.  In this study the role of TIPSS was directly compared with repeated large-volume paracentesis.  In total 60 patients with cirrhosis and refractory ascites (Child-Pugh B n=42, Child-Pugh C n=18) were randomly allocated to either TIPSS (n=29) or repeated paracentesis (n=31).  The median follow up was 44 months. The primary outcome measure was survival without liver transplantation.  Amongst the patients receiving a shunt 15 died and one patient underwent liver transplantation.  In the paracentesis group 23 patients died and 2 underwent liver transplantation.  The overall probability of survival at both one and two years was similar in the two groups.  In a multivariate analysis, treatment with TIPSS was independently associated with survival without the need for transplantation (p=0.02).  At three months, 61% of patients in the shunt group and 18% in the paracentesis group had no ascites (p=0.006).  The frequency of hepatic encephalopathy was similar in the two groups.  It was concluded that in comparison with large-volume paracentesis, the creation of a TIPSS can improve the chance of survival without liver transplantation in patients with refractory or recurrent ascites. 

Acute necrotising pancreatitis:  treatment strategy according to the status of infection.  Buchler M W,  Gloor B,  Muller C A,  Friess H,  Seiler C A,  Uhl W.  Ann Surg 2000;  232:  619-626.

Necrotising pancreatitis represents the most severe form of acute pancreatitis.  Superadded infection occurs in between 40% and 70% of patients and is the most important risk factor predicting for death.  It is generally accepted that infected pancreatic necrosis should be managed surgically. In contrast, the management of of sterile pancreatic necrosis, accompanied by organ failure, remains controversial. Recent evidence has suggested that conservative management of sterile pancreatic necrosis with early antibiotic administration is safe. The aim of this study was to assess prospectively in a single-centre trial the role of the non-surgical management of patients with sterile necrosis and the surgical treatment of patients with infected necrosis.  Between 1994 and 1999, 204 consecutive patients with acute pancreatitis were recruited.  In total 86 (42%) had necrotising disease of whom 57 (66%) had sterile and 29 (34%) had infected necrosis. The presence of pancreatic necrosis was determined by culture of percutaneous fine needle aspiration specimens.  Fine needle aspiration had a sensitivity of 96% for detecting pancreatic infection.  Patients with infected necrosis had more organ failures and a greater extent of necrosis compared with those with sterile necrosis.  When early antibiotic treatment was used in all patients with necrotising pancreatitis the characteristics of pancreatic infection changed to predominantly gram-positive and fungal infection.  An intention-to-treat analysis showed a death rate of 5% with conservative treatment compared with 21% with surgery.  It was concluded that non-surgical management, including early antibiotic treatment, in patients with sterile pancreatic necrosis was safe.  Infected pancreatic necrosis remains a significant complication and in these patients surgical treatment is preferable. 

Procalcitonin strip test in the early detection of severe acute pancreatitis.  Kylanpaa-Back M-L, Takala A, Kemppainen E, Puolakkainen P, Haapiainen R, Repo H.  Br J Surg 2001; 88: 222-227.

Acute pancreatitis involves an inflammatory process that can range in severity from localised pancreatic inflammation to a severe systemic disease affecting several remote organ systems. There is a continuum from the development of the systemic inflammatory response syndrome (SIRS) through to multiple organ dysfunction (MODS) and failure (MOF). The latter occurs in approximately one quarter of patients and carries a high mortality. Most patients with acute pancreatitis recover quickly with simple supportive therapy. There is however a need to detect those patients with severe pancreatitis early in the course of the disease so as to allow supportive therapy in an intensive care unit. Several biochemical parameters, contrast-enhanced CT and clinicobiochemical scores have been developed to assess the severity of acute pancreatitis. An ideal prognostic method should be simple, inexpensive, routinely available and should be accurate with a high negative predictive value. Such a method is not yet available. Procalcitonin is a 116-amino acid propeptide, detectable in both plasma and serum, early in severe infection and inflammation. A rapid semi-quantitative strip test (PCT-Q, Brahms diagnostica, Berlin) for procalcitonin is now available. The aim of this prospective study was to assess the ability of this test to predict outcome in patients with acute pancreatitis and to compare it with C-reactive protein (CRP) and multiple factor scoring systems. On admission and 24 hours thereafter, serum procalcitonin level was measure in 162 consecutive patients with acute pancreatitis. There were 38 severe and 124 mild cases. The accuracy of procalcitonin and CRP in predicting severe acute pancreatitis was compared with the Ransom and APACHE II scores. The PCT-Q test was more accurate in predicting severe acute pancreatitis (sensitivity 92%, specificity 84%) than CRP, Ransom or APACHE II scores. Its negative predictive value was 97% and it detected all patients who developed subsequent organ failure. It was concluded that PCT-Q was a useful screening method for detecting severe acute pancreatitis. It was simple, quick to perform and unlike current multiple factor scoring systems could easily be adopted into routine clinical practice.

The effect of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy.  Sewnath M E,  Birjmohun R S,  Rauws E A J, Huibregtse K,  Obertop H,  Gouma D J.  J Am Coll Surg 2001;  192:  726-734.

Surgery on patients with obstructive jaundice increases the risk of postoperative complications.  Consequently, preoperative biliary drainage has been advocated with the potential of reducing postoperative morbidity and mortality.  Drainage can be achieved externally by inserting a percutaneous drain or internally by placing a stent at ERCP.  Early non-randomised studies reported encouraging results on reduction of mortality in jaundiced patients undergoing pancreaticoduodenectomy for suspected pancreatic carcinoma, but subsequent randomised clinical trials have failed to show a reduction in postoperative complications. The aim of this study was to evaluate whether preoperative biliary drainage improved postoperative outcome in such a group of patients.  A cohort of 311 patients undergoing pancreaticoduodenectomy between 1992 and 1999 was studied.  Overall, 21 patients who underwent external surgical biliary drainage were excluded.  The 232 patients who had preoperative internal drainage were divided into three groups according to the extent of their jaundice.  (<40 m (n=177), 40 to 100 M (n=32) and > 100M (n=32)).  These groups were compared with patients who underwent immediate surgery (n=58) without preoperative drainage. The median number of stent placements was 2(range 1-6) with a median drainage duration of 41 days.  The stent dysfunction rate (blockage or cholangitis) was 33%.  There was no difference in overall morbidity between the drained and non-drained groups.  There was no difference on overall mortality between patients with and without preoperative drainage.  It was concluded that preoperative biliary drainage did not influence the incidence of postoperative complications and although it can be safely performed in jaundiced patients its routine use is not necessary.

Late mortality in patients with severe acute pancreatitis. Gloor B, Muller C A, Worni M, Martignoni M E, Uhl W, Buchler M W. Br J Surg 2001; 88: 975-979.

Over the past decade it has become apparent that acute severe pancreatitis progresses in two phases. The first 14 days are characterized by a systemic inflammatory response syndrome (SIRS) due to the release of various mediators. Two peaks in mortality can be identified. Patients who die early usually do so a result of a massive SIRS without apparent infection. Late death often results from multiorgan dysfunction syndrome (MODS) caused by secondary infection of pancreatic or peripancreatic necrosis. The aim of this study was to analyse the course of the disease in patients suffering from severe acute pancreatitis and to compare survivors with non-survivors. Between 1994 and 2000 details of 263 consecutive patients with acute pancreatitis were entered prospectively into a database. All patients were treated in high dependency or intensive care unit. Overall, 10 (4%) patients died. The mortality was 9% (10/106) in patients with necrotising disease. No deaths occurred in the with oedematous disease. No patient died within the first two weeks of disease onset. The median day of death was 91 (range 15-209). Six patients died from septic MODS. Ransom score, APACHE II score during the first week of disease, pre-existing co-morbidity, body mass index, infection and extent of necrosis were significantly associated with death (p<0.01 for all parameters). However, only infected pancreatic necrosis was an independent risk factor in multivariate analysis. It was concluded that early deaths in patients with severe acute pancreatitis are rare, mainly as a result of modern intensive care treatment. Over 90% of deaths occurred more than 3 weeks after disease onset. Infection of pancreatic necrosis was the main risk factor for death.

Adjuvant chemoradiotherapy and chemotherapy in resectable pancreatic cancer:  a randomised controlled trial.  J Neoptolemos J P,  Dunn J A,  Stocken D D et al.  Lancet 2001;  358:  1576-1585.

Pancreatic ductal adenocarcinoma remains one of the most difficult cancers to treat with an overall 5-year survival of only 0.4%.  Although 10-15% of patients undergo potentially curative surgery with a low postoperative mortality rate, the median survival is only 10-18 months with a 5-year survival of 15-25%.  The best predictors of survival after surgery are stage of disease, tumour grade and resection margin status.  The role of adjuvant therapy in the management of pancreatic cancer remains uncertain.  The aim of this study performed under the auspices of the European Study Group for Pancreatic Cancer (ESPAC) was to assess the role of chemoradiotherapy and chemotherapy in a randomised study.  After resection patients were randomised to adjuvant chemoradiotherapy of chemotherapy.  Clinicians could randomise patients in 2 x 2 factorial design or into one of the main treatment comparisons.  The primary endpoint was death and all analyses were by intention to treat.  Overall, 541 eligible patients with pancreatic ductal adenocarcinoma were randomised.  285 in the 2 x 2 factorial design, a further 68 were randomly assigned chemoradiotherapy or no chemoradiotherapy and 188 chemotherapy or no chemotherapy.  Median follow-up of the 227 (42%) patients still alive was 10 months.  Overall results shoed no benefit for adjuvant chemoradiotherapy (median survival 15.5 vs. 16.1 months) with a HR 1.18 (95% CI; 0.90-1.55).  There was evidence of a survival benefit for adjuvant chemotherapy (median survival 19.7 vs 14.0 months) with a HR 0.66 (95% CI; 0.52-0.83).  It was concluded that there was no survival benefit from adjuvant chemoradiotherapy but the results suggested a potential benefit from adjuvant chemotherapy alone.  It was felt that further randomised controlled trials of adjuvant chemotherapy in the management of pancreatic cancer were justified.

Laparoscopic cholecystectomy versus mini-laparotomy cholecystectomy: a prospective, randomised, single-blind study.  Ros A, Gustafsson L, Krook H et al.  Ann Surg 2001;  234:  741-749.

During the late 1980s and early 1990s, randomised controlled trials showed that recovery from open cholecystectomy (OC) performed through a small subcostal incision was quicker than that performed via a conventional Kocher's approach. Following the introduction of laparoscopic cholecystectomy (LC), it too was shown to be superior to OC. Despite taking longer to perform, it caused less postoperative pain and was associated with a shortened hospital stay and convalescence. Many of these studies comparing LC and OC were performed by surgeons in specialist units. The aim of this study was to compare laparoscopic cholecystectomy (LC) and 'mini' open cholecystectomy (MC) in a routine healthcare system with surgery performed by both consultants and trainees. Between March 1997 and April 1999, a randomised, single-blind, multicentre trial was performed comparing LC and MC. Both elective and acute patients were eligible for inclusion. All surgeons performing cholecystectomies operated on randomised patients. LC was a routine procedure in all hospitals whereas MC was introduced after a short training period. All non-randomised cholecystectomies at participating units during the study period were also recorded to analyse the external validity of the trial results. Of 1705 cholecystectomies performed, 724 entered the trial and 362 patients were randomised to each of the procedures. The groups were well matched for age and sex. There were fewer acute operations in the LC group. In the LC group 264 and in the MC group 150 operations were performed by surgeons who had done less than 25 operations of that type. Median operating time was 100 and 85 minutes for the LC and MC groups respectively (p<0.001). Median hospital stay was 2 days in each group, but was significantly shorter after LC (p=0.04). Return to normal activities was shorter after LC (p<0.001). Intraoperative complications were less frequent in the MC group but there was no difference in postoperative complications between the two groups. There was one serious bile duct injury in each group but no deaths. It was concluded that operating time was longer but postoperative convalescence quicker after LC compared with MC.

Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial.  Llovet J M, Real M I, Montana X et al.  Lancet 2002;  359:  1734-1739.

The incidence of hepatocellular carcinoma is increasing worldwide.  Curative therapies, such as resection, liver transplantation or percutaneous treatments benefit only 25% of patients and are the only chance of improving life expectancy.  Despite the implementation of surveillance programmes for early hepatocellular carcinoma, most tumours are diagnosed at an advanced stage for which no standard treatment has been established.  The aim of this study was to assess the survival benefit of arterial embolisation or chemoembolisation in patients with unresectable hepatocellular carcinoma in comparison with conservative management.  Patients with Child-Pugh class A or B and Okuda stage I and II disease were randomised to repeated arterial embolisation (gelatin sponge), chemoembolisation (gelatin sponge and doxorubicin) or conservative management.  Overall 903 patients were assessed and 112 (12%) were finally included in the study.  The primary endpoint was survival.  Analysis was on an intention to treat basis.  The trial was stopped when the ninth sequential inspection showed that chemoembolisation had a survival benefit compared with conservative treatment (HR of death 0.47.  95% CI 0.25-0.91. p=0.025). Overall 25 of 37 patients assigned embolisation, 21 of 40 patients assigned chemoembolisation and 25 of 35 assigned conservative treatment died. Probability of survival at one and two years were 75% and 50% for embolisation, 82% and 63% for chemoembolisation and 62% and 27% for conservative therapy.  Chemoembolisation induced objective responses sustained for at least 6 months in 35% of cases and was associated with a significantly lower rate of portal invasion than conservative therapy.  Treatment allocation was the only variable independently related to survival (OR 0.45.  95% CI 0.25-0.81. p=0.02).  It was concluded that chemoembolisation improved survival in stringently selected patients with unresectable hepatocellular carcinoma.

Hepatitis B e antigen and the risk of hepatocellular carcinoma.  Yang H-I, Lu S-N, Liaw Y-F et al.  N Eng J Med 2002;  347:  168-174. 

Chronic hepatitis B virus infection is a serious clinical problem because of its world wide distribution and potential for adverse sequelae, including hepatitis, cirrhosis and hepatocellular carcinoma. It is particularly prevalent in the Asian-Pacific region, where patients usually acquire the infection at the time of birth or in early childhood. The presence of the hepatitis B e antigen (HBeAg) in serum indicates active viral replication in hepatocytes. HBeAg is thus a surrogate marker for the presence of hepatitis B virus DNA. The aim of this study was to determine the relationship between positivity for hepatitis B surface antigen (HBsAg) and HBeAg and the development of hepatocellular carcinoma. In 1991 and 1992, 11,893 men in Taiwan, aged 30-65 years and without evdience of hepatocellular carcinoma, were enrolled in the study. Serum samples were obtained and tested for HBsAg and HBeAg by radioimmunoassay. The diagnosis of hepatocellular carcinoma was ascertained through data linkage with the computerised National Cancer Registry in Taiwan and with death certificates. A multiple regression analysis was performed to determine the relative risks of hepatocellular carcinoma among men who were positive for HBsAg alone or HBsAg and HBeAg, as compared with those who were negative for both. Overall, there were 111 cases of newly diagnosed hepatocellular carcinoma during 92,359 person-years of follow-up. The incidence rate of hepatocellular carcinoma was 1169 cases per 100,000 person-years amongst men who were positive for both HBsAg and HBeAg, 324 per 100,000 person-years for those who were positive for HBsAg only and 39 per 100,000 person-years for those who were negative for both. After adjustment for age, sex, the presence or absence of antibodies to hepatitis C virus, cigarette smoking, and use or nonuse of alcohol, the relative risk of hepatocellular carcinoma was 9.6 (95% CI 6.0-15.2) among men who were positive for HBsAg alone and 60.2 (CI 95% 35.5-102.1) amongst those who were positive for both HbsAg and HBeAg, as compared with men who were negative for both. It was concluded that positivity for HBeAg is associated with an increased risk of hepatocellular carcinoma.

Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomised trial.  Boerma D, Rauws E A J, Keulemans C A et al.  Lancet 2002;  360:  761-765. 

Endoscopic sphincterotomy is widely accepted as the treatment of choice for patients with common bile duct stones.  Stones extraction is successful in 97% of patients with a procedure-related morbidity of 6% and a mortality rate of 0.2%.  Whether subsequent laparoscopic cholecystectomy is indicated in patients with concomitant gallbladder stones remains a matter of debate.  In several retrospective and non-randomised prospective studies, it has been shown that only 4-12% of patients not operated on develop biliary complications during the period of follow-up.  The aim of this study was to assess whether a wait-and-see policy after endoscopic sphincterotomy is justified.  A prospective, randomised, multicentre trial was undertaken in 120 patients (18-80 years) who underwent endoscopic sphincterotomy and successful stone extraction and who also had proven gallbladder stones. Patients were randomly allocated to a wait-and-see group (n=64) or laparoscopic cholecystectomy group (n=56).  Primary outcome was recurrence of at least one biliary event during a 2-year follow-up period and secondary outcome measures were complications after cholecystectomy and quality of life.  Analysis was on an intention to treat basis.  Twelve patients were lost to follow-up.  Of the 59 patients allocated to a wait-and-see policy, 27 (47%) had recurrent biliary symptoms compared with one (2%) of the 49 patients allocated to laparoscopic cholecystectomy (RR=22.4, 95% CI 3.16-159.1. p<0.0001).  22 (81%) of these 27 patients underwent cholecystectomy for biliary pain (n=13) or acute cholecystitis (n=7).  Conversion rate to open surgery was 55% in the patients allocated to the wait-and see group compared with 23% in those who were allocated to the laparoscopic cholecystectomy group (p=0.105).  Morbidity and median hospital stay was higher in the wait-and-see group.  It was concluded that a wait-and-see policy after endoscopic sphincterotomy in those with gallbladder stones can not be justified.  No major biliary complications arose but conversion rates were high.

Early prediction of acute pancreatitis:  Prospective study comparing computed tomography scans, Ranson, Glasgow, Acute Physiology and Chronic Health Evaluation II scores and various serum markers.  Roberts J H, Frossard J L, Mermillod B et al.  World J Surg 2002; 26:  612-619.

Acute pancreatitis is a disease of variable severity.  Although approximately 80% of patients experience mild attacks that resolve with little morbidity, the remaining 20% suffer from severe disease, with mortality rates as high as 30%.  Early prediction of the severity of an attack remains the main goal of clinicians treating such patients.  Multifactorial scales including the Ranson, Imrie and Acute Physiology and Chronic Health Evaluation (APACHE II) systems have been used since the 1980s.  However, the complexity of these multifactorial scales accounts for the increasing interest in serum markers of severity.  The aim of this study was to assess the early predictability of a variety of parameters in acute pancreatitis.  Overall, 137 consecutive patients with acute pancreatitis confirmed by CT scan were prospectively included.  The predictive value of each parameter was studied by univariate and multivariate analysis comparing mild and severe pancreatitis.  A total of 111 attacks were graded as mild (81%) and 26 as severe (19%).  Ranson and APACHE II scores appeared insufficiently predictive in univariate analysis.  Pancreatic imaging was insufficiently predictive whereas the presence of extra-pancreatic fluid collections was more indicative of outcome.  In the univariate analysis, the four most reliable serum markers were pancreatic amylase (p<0.001), neutrophil elastase (p<0.05), albumin (p<0.002) and C-reactive protein (p<0.001).  Serum albumin plus the presence of extra-pancreatic fluid collections (negative predictive value 92-96% and positive predictive value 67-100%) comprised the best indicator of severity.  None of the parameters testes achieved sufficient predictability when used alone.  It was concluded that serum albumin plus extra-pancreatic fluid collections comprise the best indicator of severity in acute pancreatitis at the time of admission.

Improvement in perioperative outcome after hepatic resection.  Jarnagin W R,  Gonen M,  Fong Y et al.  Ann Surg 2002;  236:  397- 407.

Over the past decade, many large series have reported improved outcome following hepatic resection performed for a variety of indications, with operative mortality rates typically of less than 5% being reported from high-volume centres.  As a result, hepatic resection has evolved into the treatment of choice for selected patients with benign and malignant hepatobiliary disease.  No single factor has been responsible for the marked improvement in perioperative outcome, but improved anaesthetic and operative techniques and better patient selection have all probably played a role.  This study analyses a consecutive series of unselected patients undergoing hepatic resection over a ten-year period to further define factors associated with morbidity and mortality.  Demographics, extent of resection, concomitant major procedures, operative and transfusion data, complications and hospital stay were analysed for 1,803 consecutive patients undergoing hepatic resection at the Memorial Sloan-Kettering Cancer Centre.  Malignant disease was the commonest diagnosis (n=1,642 patients, 91%) and of these cases, metastatic colorectal cancer accounted for 62% (n=1,021).  387 resections (21%) were performed for primary hepatic or biliary cancer and 161 (9%) for benign disease.  Anatomical resections were performed in 1,568 patients (87%) and included 544 extended hepatectomies, 483 hepatectomies and 526 segmental resections.  The median blood loss was 600 ml and 49% patients were transfused.  Median hospital stay was 8 days, morbidity was 45% and operative mortality was 3%.  Over the study period there was a significant increase in the use of parenchymal-sparing segmental resections and a decrease in the number of hepatic segments resected. In parallel with this was a significant decline in blood loss, the use of blood products and hospital stay.  Despite an increase in the number of concomitant major procedures, operative mortality decreased and with no perioperative deaths occurred in the last 184 cases. On multivariate analysis, the number of hepatic segments resected and operative blood loss were the only independent predictors of both operative morbidity and mortality.  It was concluded that, over the past decade, the use of parenchymal-sparing segmental resections has increased significantly.  The number of hepatic segments resected and operative blood loss were the only predictors of both perioperative morbidity and mortality. 

Selective cholangiography in 600 patients undergoing cholecystectomy with 5-year follow-up for residual bile duct stones.  Charfare H,  Cheslyn-Curtis S.  Ann R Coll Surg Engl 2003;  85:  167-173. 

Laparoscopic cholecystectomy id the treatment of choice for patients with symptomatic gallstones, but the management of bile duct stones in these patients is controversial.  The use of selective cholangiography has been criticised because of the risk of missing bile duct stones that will cause significant complications later in life.  The incidence of symptomatic bile duct stones in patients undergoing cholecystectomy in 3-12%, but it is probable that only stones causing symptoms require treatment and that other stone pass spontaneously or remain silent.  ERCP and sphincterotomy can successfully remove common bile duct stones in over 90% of patients.  In this paper the experience of a single surgeon unit performing selective ERCP in the diagnosis and treatment of common bile duct stones is presented.  The incidence and management of post-operative symptomatic bile ducts stones with a median 5-year follow-up is reported.  Between 1993 and 1999, 600 patients underwent laparoscopic cholecystectomy.  Patients were selected for preoperative or postoperative ERCP based on symptoms, liver function tests and abnormalities on ultrasound examinations.  Of the 600 patients, 107 (18%) with a median age of 57 years were selected to undergo preoperative ERCP.  Of these patients 41 (38%) had bile duct stones.  Postoperative ERCP was performed in 30 patients (5%) and stones were identified in 7 (23%) patients.  Three patients had stones removed within 15 days of their operation.  The overall incidence of bile duct stones was 48 (8%) cases.  Stones were successfully extracted at ERCP in 43 (90%) patients.  It was concluded that a policy of selective pre-operative ERCP is the most effective technique for identifying and removing bile duct stones and that the incidence of symptomatic gallstones following laparoscopic cholecystectomy is very low.

Role of somatostatin in the prevention of pancreatic stump-related morbidity following elective pancreaticoduodenectomy in high-risk patients and elimination of surgeon-related factors.  Shan Y-S,  Sy E D,  Lin P-W.  World J Surg 2003;  27:  709-714.

Pancreaticoduodenectomy remains the 'gold standard' operation in the treatment of periampullary tumours.  As a result of improved surgical technique and perioperative care, mortality in the past 20 years following this operation has declined, but the morbidity rate often remains high.  Most of the local complications are related to the exocrine secretion from the pancreatic remnant.  Somatostatin and its analogues have an inhibitory effect on both exocrine and endocrine pancreatic secretions and may reduce postoperative morbidity after pancreatic resection.  The aim of this study was to evaluate, in a prospective randomised controlled fashion, the efficacy of somatostatin in the prevention of pancreatic stump-related complications in high-risk patients undergoing pancreaticoduodenectomy.  Over a three year period, 54 patients (28 men and 26 women) undergoing pancreaticoduodenectomy were randomly assigned to a somatostatin group (n=27) or placebo group (n=27).  All operations were performed by one high-volume surgeon.  94% patients had pancreatic or periampullary lesions.  All patients underwent either a standard pancreaticoduodenectomy or a pylorus preserving pancreaticoduodenectomy.  A trans-anastomotic tube was inserted into the pancreatic duct and remained in position for three weeks.  The somatostatin group received intravenous somatostatin at a dose of 250 micrograms per hour for seven days postoperatively.  The placebo group received a saline infusion.  There was one perioperative death in each group giving a postoperative mortality rate of 3.7%.  In the somatostatin group the overall morbidity and rate of pancreatic stump-related complications were significantly lower.  This was associated with a 50% decrease in pancreatic juice output and shortened duration of hospital stay.  It was concluded that, after excluding surgeon related factors, prophylactic use of somatostatin reduces the incidence and severity of pancreatic stump-related complications in high-risk patients undergoing pancreaticoduodenectomy.

Implementation of a specialist-led service for the management of acute gallstone disease.  Mercer S J,  Knight J S,  Toh S K C et al.  Br J Surg 2004;  91:  504-508.

Acute cholecystitis and biliary colic commonly require emergency admission to hospital.  Traditionally, treatment was conservative followed by delayed cholecystectomy, usually 6-8 weeks after discharge.  Laparoscopic techniques introduced in the late 1980s were initially thought to be contraindicated for urgent cholecystectomy, but urgent laparoscopic cholecystectomy for acute cholecystitis has been shown to be safe.  Two randomised trials, reported that early laparoscopic cholecystectomy resulted in reduced hospital stay with no increased morbidity.  Few hospitals in the UK routinely perform urgent cholecystectomy for acute gallstone admissions.  The aim of this audit was to assess the implementation of a protocol for urgent cholecystectomy by a specialist upper gastrointestinal surgical team.  A 6 month retrospective audit of emergency admissions with acute cholecystitis or biliary colic led to the development of a specialist-led protocol for the management of acute gallstone disease.  A second audit was carried out over a 6 month period after the implementation.  Overall, 158 patients were admitted with acute cholecystitis or biliary colic in the first audit period and 110 in the second interval.  The rate of cholecystectomy in the index admission increased from 37% to 67%, at median of 3 days following admission.  The conversion rate to open surgery fell from 32% to 12%.  Median hospital stay fell from 9 to 5.5 days and the unplanned readmission rate decreased from 19% to 4%.  It was concluded that urgent cholecystectomy for the management of acute gallstone disease is feasible and achievable in an acute services hospital with a specialist upper gastrointestinal team.  It can lead to a reduced conversion rate, short hospital stay, fewer unplanned readmissions, an acceptable operating time and low complication rates.

Octreotide in the prevention of intra-abdominal complications following elective pancreatic resection.  Suc B,  Msika S,  Piccinini M et al.  Arch Surg 2004;  139:  288-294.

Mortality and morbidity rates after pancreatic resection range from zero to 10% and 20% to 40% respectively.  The most common major complication is pancreatic fistula, usually related to persistent pancreatic secretion which hinders the healing of the pancreatic stump.  Octreotide, a synthetic somatostatin analogue, inhibits exocrine secretion of the pancreas and therefore might lower the rate of postoperative pancreatic fistula formation.  This large prospective multicentre randomised trial was undertaken to determine whether octreotide might decrease the incidence and severity of postoperative intra-abdominal complications in patients undergoing elective pancreatic resection.  Overall, 230 patients undergoing pancreaticoduodenectomy and pancreatic enteric anastomosis for either benign or malignant tumours or chronic pancreatitis were randomised intraoperatively to receive either octreotide (n=122) or control (n=108).  All patients were available for analysis.  All patients were comparable except that significantly more patients in the octreotide groups had biological glue injected into the main pancreatic duct (p<0.001) or reinforcing of the pancreatic enteric anastomosis (p=0.002).  Fewer patients in the octreotide group sustained one or more intra-abdominal complications.  In subgroup analysis, octreotide significantly reduced the intra-abdominal complications when the pancreatic duct was less than 3mm in diameter (p<0.02), when a pancreaticojejunostomy was performed (p<0.02) or both (p<0.02).  Overall, 23 (10%) patients died postoperatively and 16 (70%) had one or more intra-abdominal complications.  The only independent risk factor for these complications was pancreaticoduodenectomy compared distal pancreatectomy.  It was concluded that octreotide is not necessary for all patients undergoing pancreatic resection but that it may be useful when the main pancreatic duct is less than 3mm in diameter and when pancreaticoduodenectomy is completed by a pancreaticojejunostomy. 

A randomised trial of chemoradiotherapy and chemotherapy after resection for pancreatic cancer.  Neoptolemos J P,  Stocken D D,  Friess H et al.  N Engl J Med 2004;  350:  1200-1210.

Pancreatic cancer with an overall five-year survival rate ranging from 0.4 to 4% has a poor prognosis and is one of the top 10 causes of death from cancer in the Western world.  Surgical resection improves the outlook, although only about 10% of patients with pancreatic cancer are eligible for surgery.  Most treatment failures are due to local recurrence, hepatic metastases or both and occur within one or two years of surgery.  Adjuvant therapy may improve long-term survival but is routine use is not universal because the results of randomised trials have been inconclusive.  The European Study Group for Pancreatic Cancer (ESPAC) undertook a multicentre trial to investigate the possible benefit of adjuvant chemoradiotherapy and maintenance chemotherapy in patients with pancreatic cancer.  The study involved a 2x2 factorial design.  Patients were randomly assigned after resection for pancreatic ductal adenocarcinoma to chemoradiotherapy (20Gy over 2 weeks plus flurouracil;  n=73), chemotherapy alone (flurouracil; n=75), both chemoradiotherapy and maintenance chemotherapy (n=72) or observation (n=69).  The analysis was based on 237 deaths among 289 patients (82%) and a median follow-up of 47 months (IQR 33-62).  The estimated five-year rate was 10% amongst patients assigned to receive chemoradiotherapy and 20% among patients who did not receive chemoradiotherapy (p=0.05).  The five-year survival rate was 21% among patients who received chemotherapy and 8% among patients who did not receive chemotherapy (p=0.009).  The benefit of chemotherapy persisted after adjustment for major prognostic factors.  It was concluded that adjuvant chemotherapy has a significant survival benefit in patients with resected pancreatic cancer, whereas adjuvant chemoradiotherapy has a deleterious effect on survival.

Randomized clinical trial of pylorus-preserving duodenopancreatectomy vs. classical Whipple resection - long term results.  Seiler C A,  Wagner M,  Redaelli C A et al.  Br J Surg 2005;  92:  547-556 

Advances in surgical technique have reduced the operative mortality of patients undergoing pancreatic head resection to below 5% in specialist centres.  Because of the relative resistance of these tumours to chemotherapy and radiotherapy, any attempt to achieve a cure must include radical resection.  For many years, the surgical procedure of choice was duodenopancreatectomy (Whipple's procedure).  This was associated with side effects related to the partial gastric resection, notably postoperative weigh loss and dumping syndrome.  A more conservative procedure, the pylorus-preserving pancreaticoduodenectomy (PPPD) has been reported.  It is unknown as to whether PPPD is as effective as the classical Whipple's procedure in the resection of pancreatic and periampullary tumours.  A prospective randomised trial was undertaken to compare the results of the two procedures.  Clinical data, histological findings, short-term results, survival and quality of life of all patients undergoing surgery for suspected pancreatic or periampullary tumours between June 1996 and September 2001 were analysed.  Overall, 214 patients were randomised to undergo either a standard Whipple's procedure or PPPD.  After exclusion of 84 patients on the basis of intraoperative findings, 130 patients (66 standard Whipple's procedure and 64 PPPD) were entered into the trial.  Of these 110 patients with proven adenocarcinoma (57 standard Whipple's procedure and 53 PPPD) were analysed for long-term survival and quality of life.  There were no differences in perioperative morbidity.  Long-term survival, quality of life and weigh gain were identical after median follow-up of 63 (range 4-93) months.  At 6 months, capacity to work was better after PPPD (77% vs. 56%. p=0.019).  It was concluded that both procedures were equally effective for the treatment of pancreatic and periampullary cancer.  PPPD offers some minor advantages in the early postoperative period, but not in the long term.

Surgical intervention in patients with necrotizing pancreatitis.  Besselink M G,  de Bruijn M T,  Rutten J P et al.  Br J Surg 2006;  93:  593-599. 

There is international consensus that surgical intervention is acute pancreatitis is indicated only in the case of suspected or proven infected pancreatic necrosis.  However, there is no agreement as to the optimal surgical strategy.  Several specialist centres have reported the outcome of various surgical approached with mortality rates ranging from 6% to 47%.  The different surgical strategies have never been compared in randomised controlled trials.  The aim of this study was to evaluate the various surgical strategies for the treatment of infected pancreatic necrosis and to determine the referral patterns in the Netherlands for this condition.  This retrospective study included all 106 patients who had surgery for infected pancreatic necrosis in the period 2000-2003.  Surgical approaches included an open abdomen strategy, laparotomy with continuous postoperative lavage, minimally invasive procedures or laparotomy with primary abdominal closure.  The National Hospital Registration System was searched to identify patients with acute pancreatitis who were admitted to the 90 Dutch hospitals that did not participate in the present study.  The overall mortality was 34%, 70% (16 of 23) for the open abdomen strategy, 25% (13 of 53) for continuous peritoneal lavage, 11% (2 of 18) for minimally invasive procedures and 42% (5 of 12) for primary abdominal closure (p<0.001).  During the study interval, 44 (12%) of 362 patients with acute pancreatitis who were likely to require surgical intervention had been referred to university medical centres.  It was concluded that laparotomy with continuous postoperative lavage is the surgical strategy most often used in the Netherlands.  The results of the open abdomen strategy are poor whereas the minimally invasive approach seems encouraging.

Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis.  Mofidi R,  Duff M D,  Wigmore S J et al.  Br J Surg 2006;  93:  738-744. 

Acute pancreatitis has a spectrum of clinical presentation ranging from mild self-limiting disease to severe pancreatitis which results in the development of local and systemic complications with a significant risk of death.  Mortality in patients with acute pancreatitis is associated with the number of ailing organs and the severity and reversibility of organ dysfunction.  The aim of this study was to assess the significance of early systemic inflammatory response syndrome (SIRS) in the development of multiorgan dysfunction syndrome (MODS) and death from acute pancreatitis.  Data for all patients with a diagnosis of acute pancreatitis between 200 and 2004 was reviewed.  Serum C-reactive protein (CRP), Acute and Chronic Health Evaluation (APACHE) II scores and the presence of SIRS were recorded on admission and at 48 hours.  Marshall organ dysfunction scores were calculated during the first week of presentation.  Presence of SIRS and raised serum CRP levels on admission and at 48 hours were correlated with the cumulative organ dysfunction scores in the first week.  Overall, 759 patients with acute pancreatitis were identified of whom 45 (6%) died during the index admission.  SIRS was identified in 162 patients and was persistent in 138 at 48 hours.  The median (range) cumulative Marshall score in patients with persistent SIRS was significantly higher than that in patients in whom SIRS resolved and in those with no SIRS.  Thirty-five patients (25%) with persistent SIRS died from acute pancreatitis, compared to 6 patients (8%) with transient SIRS and 4 patients (1%) without SIRS (p>0.001).  No correlation was observed between CRP level on admission and Marshall score (p=0.81).  There was however a close correlation between CRP level at 48 hours and Marshall score (p<0.001).  It was concluded that persistent SIRS is associated with MODS and death in patients with acute pancreatitis and is an early indicator of the likely severity of acute pancreatitis.

Randomised clinical trial of liver resection with and without hepatic pedicle clamping.  Capussotti L,  Muratore A,  Ferrero A et al.  Br J Surg 2006;  93:  685-689.

Operative blood loss and perioperative transfusions are predictors of morbidity and mortality after hepatic surgery.  Prospective randomised trials comparing liver transection with and without hepatic pedicle clamping (HPC) have shown a significantly lower blood loss in the former group.  Intermittent pedicle clamping has been shown to have benefits in terms of liver tolerance to ischaemic injury when compared with continuous clamping.  Intermittent clamping has become the most commonly used procedure to control bleeding during hepatectomy.  The aim of this study was to compare perioperative outcome of liver resections with and without intermittent hepatic pedicle clamping.  Between 2002 and 2004, 126 consecutive patients with resectable liver tumours were randomised to undergo resection with (n=63) or without (n=63) intermittent hepatic pedicle clamping.  The transection time was significantly higher in the group without hepatic pedicle clamping.  The blood loss per cm2 was similar in the two groups (2.7 ml/cm2  in the groups with versus 3.2 ml/cm2  in the groups without hepatic pedicle clamping (p=0.425).  In the subset with an abnormal liver, there was no difference in blood loss per transection surface.  The rate of blood transfusion was not higher in the non-clamping group.  No differences were observed in the postoperative liver enzyme serum levels, the in-hospital mortality or the number of complications.  It was concluded that liver resection without hepatic pedicle clamping is safe, even in patients with a diseased liver.

Early warning scores predict outcome in acute pancreatitis.  Garcea G,  Jackson B,  Pattenden C J et al.  J Gastrointest Surg 2006;  10:  1008-1015. 

For most patients with acute pancreatitis it is a mild self-limiting condition. However, in 20-30% of cases, severe lift-threatening complications may ensue with the development of associated organ dysfunction.  The reliable identification of these patients would be useful in selecting individuals requiring critical care support.  An ideal prognostic index should be able to identify severe cases of acute pancreatitis within 2-3 days of the onset of symptoms.  To this end, several clinical scoring systems have been adopted including the  Ransom, Imrie and APACHE II systems.  The Early Warning Score (EWS) is a widely used general scoring system to monitor progress in critically unwell patients.  The aim of this study was to evaluate the EWS compared with other established scoring systems in patients with acute pancreatitis.  EWS was compared with APACHE scores, Imrie scores, CT grading scores and Ranson criteria for 110 admissions with acute pancreatitis.  A favourable outcome was considered to be survival without ITU admission or surgery.  Non-survivors, necrosectomy and critical care admission were considered adverse outcomes.  EWS was the best predictor of adverse outcome in the first 24 hours after admission (receiver operating curve, 0.768).  The most accurate predictor of mortality was EWS on day 3 of admission (receiver operating curve, 0.920).  EWS correlated with duration of intensive therapy unit stay and the number of ventilated days (p<0.05) and selected those patients who went on to develop pancreas-specific complications such as pseudocysts or ascites.  EWS of 3 or above was an indicator of adverse outcome in patients with acute pancreatitis.  It was concluded that EWS can accurately predict and reliable select both patients with severe acute pancreatitis and those at risk of local complications.

Preoperative biliary drainage for cancer head of the pancreas.  van der Gaag N A,  Rauws E A J, van Eijck C H J et al.  N Engl J Med 2010;  362:  129-137.

The benefits of preoperative biliary drainage, which was introduced to improve the postoperative outcome in patients with obstructive jaundice caused by a tumour of the pancreatic head, are unclear. In this multicentre, randomized trial, preoperative biliary drainage was compared with surgery alone for patients with cancer of the pancreatic head. Patients with obstructive jaundice and a bilirubin level of 40 to 250 mol per litre (2.3 to 14.6 mg per decilitre) were randomly assigned to undergo either preoperative biliary drainage for 4 to 6 weeks, followed by surgery, or surgery alone within 1 week after diagnosis. Preoperative biliary drainage was attempted primarily with the placement of an endoprosthesis by means of endoscopic retrograde cholangiopancreatography. The primary outcome was the rate of serious complications within 120 days after randomization.  Overall, 202 patients were enrolled; 96 were assigned to undergo early surgery and 106 to undergo preoperative biliary drainage; 6 patients were excluded from the analysis. The rates of serious complications were 39% (37 patients) in the early-surgery group and 74% (75 patients) in the biliary-drainage group (relative risk in the early-surgery group, 0.54; 95% confidence interval [CI], 0.41 to 0.71; P<0.001). Preoperative biliary drainage was successful in 96 patients (94%) after one or more attempts, with complications in 47 patients (46%). Surgery-related complications occurred in 35 patients (37%) in the early-surgery group and in 48 patients (47%) in the biliary-drainage group (relative risk, 0.79; 95% CI, 0.57 to 1.11; P=0.14). Mortality and the length of hospital stay did not differ significantly between the two groups. It was concluded that routine preoperative biliary drainage in patients undergoing surgery for cancer of the pancreatic head increases the rate of complications.

Randomized clinical trial of routine on‐table cholangiography during laparoscopic cholecystectomy.  Khan O A,  Balaji S,  Branagan G et al.  Br J Surg 2011; 98:  362-367. 

A randomized clinical trial was undertaken to assess the utility of routine on‐table cholangiography (OTC) during laparoscopic cholecystectomy for gallstone disease.  Overall, 190 patients with a history of biliary colic or cholecystitis and a low predictive risk for choledocholithiasis were randomized to undergo elective laparoscopic cholecystectomy alone (99 patients) or elective laparoscopic cholecystectomy with OTC (91). Intraoperative findings and postoperative outcomes for the two groups were compared. The primary outcome measure was the incidence of common bile duct (CBD) stones. Of the patients undergoing OTC, ten had abnormal cholangiograms; three had CBD stones and seven had abnormalities without stones. OTC was associated with a significantly longer mean operating time (66(2) versus 54(3) min; p < 0001), but there was no association between performance of OTC and postoperative morbidity. During a one‐year follow‐up, no patient in the OTC group re‐presented to hospital with recurrent biliary symptoms. In contrast, four of the patients allocated to surgery alone re‐presented with symptoms suggestive of CBD obstruction; all settled with conservative treatment and the difference in readmission rate was not significant (p = 0122). It was concluded that routine cholangiography in patients with a low risk for CBD stones does not seem justified.


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