EUS is useful to predict microlithiasis of CBD before laparoscopic cholecystectomy in patients with abnormal liver function tests

1070 Long Cystic Remnant after Cholecystectomy: Surgical Technique and Rationale for Its Removal in Patients with Severe BJiiopancreaticSymptoms. Francesco Cetta, Giulia Montalto, INSTITUTEOF Surg CLINICS, Univ OF SIENA, Siena Italy; Michele Zuckermann, INSTITUTEOF Pathology, Univ OF SIENA, Siena Italy; Paolo Rossi, Andrea Cariati, INSTITUTEOF Surg CLINICS, Univ OF SIENA, Siena Italy; Giancario Guazzi, Andrea Tiribocchi, INSTITUTEOF Radiology, Univ OF SIENA, Siena Italy Backgorund. During cholecystectomythe cystic duct is ligated at a variable distancefrom its confluence with the common duct (CD). Therefore, "long cystic remnants" (LCR), i.e. larger than 1.5cm, can occur either as a result of the surgical technique or of anathomic variability. In fact, in about 1/4 of cases, the cystic duct is long and tortuous and joins the CD on its medial aspect very close to the papilla of Vater, within the pancreas (1). In these cases, concomitant arterial variations usually occur. Methods. During the prospectivestudy of 2200 patients (pts) who underwent surgery for GS, and who had sistamatic stone and bile analysis, 366 had CD stones, 113 pts had postcholecystectomystones (PCS). Nineteen of them had a LCR. Results. GS in the LCR were cholesterol (n=2), mixed (n=4) brown (n=2) and black pigment (n=11). Nine pts had surgery before 1995, 10 pts during the last 5 years, maybe because of recurrent pancreatitis. In the latter group, GS were black (irregular, often spicular, with high calcium carbonatecontent) in 9 pts (5M, 4F) with previous heart surgery, whereas they were mixed cholesterol in a 54-y-old female with a long remnant (LCR plus part of the infundibulum) who had an emergency operation 28 years before. Even if there was considerablevariability in the length of the LCR and the confluence between cystic duct and CD, multiple arterial branches (up to 6) had to be separatelyligated (in 2 cases close to the papilla within the pancreatictissue), in order to remove completely the LCR, analogously to what occurs when dealing whit a choledochalcyst. Conclusion. A complete removal of the LCR is mandatory because,even a small remnant could act as a mini gallbladder, where bile stasis occurs, in these pts who are prone to form GS both for anatomic predisposition (tortuosity and variable diameter of thr LCR) and increased hemolysis, In all pts there was complete remission of symptoms 6 months to 5 years after surgery. Preliminary results are promising, even if specific indications and timing for intervention should be defined in more detail. 1. Cetta F. Hepatology, 1996, 23: 191-2; Cetta F. Gastroenterology1995, 108:h411

1071 Outcome Of Cirrhotic Patients After Cbolecyztectomy: A Case-Control Study. Eduardo B.V. Da Silveira, Enrique G. Molina, Eugene R. Schiff, Univ of Miami, Miami, FL BACKGROUND:Cholelithiasis is a common finding in cirrhotic patients (cp). As in non-cp, cholecystectomy is indicated when gallstones are symptomatic. However, previous studies haveshown that open cholecystectomy(OC) carries a high postoperativerisk of complications and deaths in cp. Laparoscopic cholecystectomy (LC) has significantly decreased hospital stay and post-operative morbidity in non-cp. Recent reports have recommended LC in cp Child's class A and B. AIM: The aim of this study was to evaluatethe outcome of cp after LC and OC in a tertiary center. METHODS:We reviewedthe medical records of 33 consecutive cp who underwent LC and OC between 1/1994 and 6/2000. Cp were randomly matched by age and sex to 66 (2:1) non-cirrhotic controls who underwent cholecystectomy during the same period. Statistical analysis was performed using Chi-square, Student's T test, and Factorial ANOVA. RESULTS:Twenty-two (66%) cp were Child-Pugh class A and 11 (33%) class B. Twenty-four (72%) cp had LC and 9 (27%) OC. A similar percentageof patients in the control group underwent LC (78%) and OC (21%). Cp underwent emergent cholecystectomy more frequently than controls (9/33 vs 7•66, p=O.03). Emergent cholecystectomies were more likely to be OC than elective cholecystectomies (9/16 ve 14183, p=0.00064). However, cp were more likely than controls to have emergent LC(6/9 vs 1/7, p =0.049). The conversion rate from LC to OC was not statistically different between cp (5/33) and controls (8/66). The mean hospital stay for cp and controls was 5.6 and 2.8 days respectively (p = 0.0007). Cp undergoing OC had significantly longer hospitalization (mean 10.1 days) when compared to LC in cp (mean 3.9 days, p=O.OOOl) and OC in controls (mean 4.8 days, p = 0.005). Emergentindicationfor cholecystectomydid not increasethe postoperativehospital stay. Averageduration of surgery was similar in controls and cp (110 vs 121 minutes). The mean estimated blood loss during surgery was 93 ml in controls and 110 ml in cp (p=O.6). Five (15%)cp and 1 (1.5%) non-cp developedpostoperativecomplications (p = 0.025). There were no deaths in either group. CONCLUSION:Laparoscopiccomparedto open cholecystectomy reduces length of hospitalization in cirrhotic patients undergoing elective or emergent surgery. Cholecystectomyin cirrhotics is associatedwith increased morbidity and increased length of hospitalizationwhen compared to non-cirrhotic controls.

was achieved in 86% of group A patients and 95% of group B patients. Group A required emergent procedure,generalanesthesia,multiple sessions, mechanicallithotripsy, and permanent biliary stenting more frequently than group 9. Late complications occurred in 5% of group A patients. In group A patients, the cumulative observed survival was comparableto the expectedvalue for the general population of like age and sex, based on cohort life tables constructed for Japan: 31% and 29%, respectively,at 5 years after ES. Conclusion: ES is a safe and effective treatment for chnledocholithiasis in patients 90 years of age or older. Biliary stenting is a reasonable alternative for difficult stones. Very elderly patients who have undergone ES for bile duct stones are expected to have survival long as that of the general population. 1073

Endoscopic SldllKlerotomy Without Cholecysleefomy For Prevention Of Recurrence Of Acute Blliary PancreatiUs: Loag-Term Follow-Up Of 73 Patients Benito Gonzalez-Conde,JUAN CANALEJOHosp Dept of Gastroenterology,A Corona Spain; Jose Luis Vazquez-lgieslas,JUAN CANALEJOHosp, A Coruna; Leopoldo Lopez-Roses, Xeral-Calde Hosp, Lugo Spain; Pedro Alonso-Aguirre, JUAN CANALEJOHosp, A Coruna; Angel Lancho, XeraI-CaldeHosp, Lugo Spain; Emilio Estevez-Prieto,Francisco SuarezLopaz, Rosa Nunes, JUAN CANALEJGHosp, A Coruna BACKGROUNDAcute gallstone pancreatitis is a potentially life threatening complication of gallstonedisease.Therisk of further pancreatitisis cumulativeand at least35% if the gallbladder is left intact. Removing the gallbladder is a prophylactic measure wich prevents recurret pancreabtis. However, many patients with gallbladder stones have a high anesthesiological risk of cholecystectomy.The aim of this study was to know if endoscopic sphincterotomy could be an alternative to cholecistectomy in high surgical risk patients with a long-term follow-up. METHODSData of patients were collected prospectively in two general hospitals. All patients previously experienced at least one episode of gallstone pancreatitis, denied alcohol abuse or substance abuse and none had evidence of other etiologic factors for pancreutitis. They were selected for endoscopic sphinuterotomy without cholecietectomy if surgery was deemed undesirable because of advanced age or poor medical condition. All patients were followed up by outpatient and telefhone contact and details of symptoms, hospital admissions and cause of death were obtained. RESULTS73 patients ( 40 females, mean age 75 years, range 51-96) were evaluated.Patients were followed for a median of 34 months (range 11-68). No severe complications nor deaths occurred after sphincterotomy. Only seventeenpatients experiencedbiliary complications: Two recurrent pancreatitis ( one related with fibrosis of sphincterutomy, the other was not reevaluated), 7 cholecystitis, 7 billary colic and one acute cholangitis. The mediantime of presentationwere 6 months (range 0.5-51 months). Eight patients havesubsequentlyundergonecholecistectomy,in two patients an endoscopic retrogradecholangiograpbywas successful, and 7 patients were managedby medical therapy. CONCLUSIONSThe results of this series show that endoscopic sphincterotomy is a safeand effectivetherapy in the preventionof new episodesof acute biliay pancreatitis in patientswith litiasic gallbladderand that could potentiallybe used insteadof cholecystectomy as a definitive procedurefor high-risk patients who have recoveredfrom an attack of gallstone pancreatitis. A long-term follow-up of patients revealed that complications of the litiasic gallbladder in situ after endoscopic sphicnterotomy and subsequent cholecystectomies are relatively unfrequent. 1074 EUS Is Useful To Predict Microlithiasis Of CBD Before Laparoscopic Choiecystedom'lf In Patients With Abnormal Liver Function Tests Emanueie Meroni, Dept of Gastroenterology-inst Clinico Humanitas, RozzannItaly; Stefano Bona, Uberto Fumegalti, Mauro Zago, Riccardo Rosati, Dept of Surg -Inst Clinico Humanitas, RozzanoItaly; Alberto Malesci, Dept of Gastroenterology- Inst Clinic(} Humanitas, RozzanoItaly Endoscopicultrasonography(EUS) has been proposed for investigation of common bile duct (CBD) stones before laparoscopic cholecystectomy(LC) in patients with intermediaterisk of choledocholithiasis. However its usefulness has never been investigatedwhen abnormalities in liver function tests (LFTs) are the sole determinant of risk for CBD stones. In the period 7/98-11/00, 64 patients were studied prospectively using EUS before LC. Thirty-six of them (27 F, 9 M; mean age, 64 yrs) met our protocol criteria (symptomatic gallstone disease, abnormal LFTs, neither clinical nor sonographic suspicion of CBD stones). Median values of bilirubin, AST, ALT and ALP were normal; only median GGT (66 U/L) was doubled. In all cases EUS findings were comparedto intraoperativechefangiography(IOC) and/or ERCP. In the first 17 cases, CBD stones were removed endoscopically before LC, whereas in the following 19 patients intraoperativeERCPwas scheduledif laparoscopicapproachfailed. EUS detected small CBD stones (max diameter 3.2 ram) in 8 patients (22.2%). Four of them (with stones smaller than 2 ram) were not confirmed by X-rays. We had one false negative case. Our results were the following : sensitivity 80%, specificity 87.1%, PPV 50%, NPV 96.4%, accuracy 86.1%. CBD microlithiasis can be identified by EUS in patients with only abnormal LFTs. In this clinical setting, EUS before LC is highly reliableto excludecoexisting CBD stones.

1072 Endoscopic Sphincterotomy For Bile Duct Stones In Very Elderly Patients (->90 Years) Masanori Sugiyama, Nobutsugu Abe, Yumi Izumisato, Yasuharu Yamaguchi, Taro Yamato, Hiroyoshi Matsuoka, Makofo Tokuhara, Masanobu Nakashima,Tadahiko Masaki, Tosbiyuki Mori, Yutaka Atomi, Kyorin Univ Sch of Medicine, Tokyo Japan Background: Little information is available on the outcomes of endoscopic sphincterotomy (ES) for choledocholithiasis in very elderly patients (->90 years). To evaluatethe role of ES in managing choledocholithiasis in very elderly patients, we herein retrospectively analyzed the early results of ES in very elderly patients, as compared with those in sfightiy younger patients. Late results of ES in very elderly patients were also evaluated. Methods: ES was performed for choiedocholithlasisin 22 patients aged 90 years or more (group A) and 381 aged 70-89 years (group B). Clinical features and early outcomes of ES were compared between the two groups. In group A, long-term results for a mean follow-up period of 33 months were investigated. Results: Group A patients had a higher incidence of symptoms, acute cholangitis and concomitant diseases,as well as larger and more numerous gallstones, than group B patients. ES was successful in 100% of group A patients and 98% of group B patients, The rate of early complications was low in both groups: 5% in group A and 7% in group B. No deaths relatedto ERCPoccurred in group A patients. Completestone clearance

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Radical Resection For Gallblader Carcinoma Ricardo J. Mondragon-Sanchez,Aria Lilia L. Garduo-Lopez,Inst Nacional de Cancerotogia, Mexico Df Mexico',Aleiandro Mondragon-Sanchez,Hosp 10 de Octubre ISSSTE,Mexico OF Mexico; Rigoberto Bemal-Maldonado,Hosp Ignacio ZaragozaISSSTE,Mexico DF Mexico; Juan Manuel Ruiz-Molina, Manuel GonzalezGeroniz, Ricerdo Almaguer, Inst Nacional de cancerologia, Mexico DF Mexico BACKGROUNDSIn recent years several investigators have showed that radical approach in select cases with GBC has improved survival. AIMS. Evaluatethe short and long term results of radical resection in patients with gall bladder carcinoma (GBC) in an oncological referral center in Mexico. METHODS.A retrospectivereview of patients with radical resection (wedge

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