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Intraoperative laparoscopic-endoscopic treatment for patients with common bile duct stones
AJG – September, Suppl., 2001
both duodenoscopes and pediatric colonoscopes may increase diagnostic and therapeutic success.
286 Suspected sphincter of Oddi dysfunction type II: Measure or . . . just cut! Jeffrey D Linder1, Miguel R Arguedas1 and C Mel Wilcox1*. 1Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL, United States. Purpose: Sphincter of Oddi manometry is considered the “gold standard” for diagnosing sphincter of Oddi dysfunction (SOD). Elevated basal sphincter pressures are frequent in patients with symptoms consistent with type II SOD, and most of these patients will symptomatically improve with endoscopic sphincterotomy. Since manometric sphincter evaluation is not widely available and is associated with potential complications, using decision analysis, we determined the overall costs and outcomes of manometry directed therapy compared to “empiric” sphincterotomy. Methods: A decision analysis model was constructed (DATA 3.5, Williamstown, MA). In a hypothetical cohort of 100 patients with suspected type II SOD, we evaluated the following strategies: a) ERCP with manometry followed by sphincterotomy only if an elevated sphincter of Oddi basal pressure was found, and b) “empiric” sphincterotomy without manometry. The probability of an elevated sphincter of Oddi basal pressure at the time of ERCP in patients with suspected sphincter of Oddi dysfunction type II, proportion of patients improving after sphincterotomy (with and without elevated basal pressures), proportion of patients improving without sphincterotomy, complications and death were obtained from a literature search using Medline®. Procedural and hospitalization costs represented the average Medicare reimbursement at our institution. The expected overall costs and number of patients improving in each strategy were compared. Results: The strategy of ERCP with manometry resulted in total costs of $2,790 per patient whereas a strategy of “empiric” sphincterotomy resulted in total costs of $2,244. In a cohort of 100 patients with suspected SOD, 55% of patients would be expected to improve if manometry is performed compared to 60% of patients improving with “empiric” sphincterotomy. Univariate sensitivity analyses demonstrated that “empiric” sphincterotomy remained a cost-saving strategy compared to ERCP with manometry as long as the probability of spontaneous improvement in patients with a “normal” manometry was less than 41%, the probability of complications associated with manometry was greater than 6% and the probability of complications due to sphincterotomy was less than 19%. Conclusions: For patients with suspected SOD type II, empiric biliary sphincterotomy is cost saving compared to a strategy based on the results of manometry.
287 A case of severe acute pancreatitis associated with type IV hyperlipoproteinemia Sunitha Mannam, MD1, M A Albornoz, MD1 and Hitender Jain, MD1*. 1 Internal Medicine, Mercy Catholic Medical Center, Darby, PA, United States. Methods: A 19 year old male with no significant past medical history presented with one day history of severe epigastric pain of sudden onset, with radiation to back. He complained of nausea and vomiting but denied any diarrhea, hematmesis or malena. There was no history of fever, chills or rigors. Pain increased with meals but he denied any postural variation. He denied any history of alcohol or drug abuse with a negative screening test. Patient had strong family history of hyperlipidemia and early coronary artery disease. He had similar pain of lesser intensity in the past, which was relieved by over the counter medications. Initial laboratory investigation showed a hemoglobin level of 17.00 gm/dl, white blood cell count of 13,000 cu mm/dl, poly-morphonuclear cells of 76%, BUN of 13.0 mg/dl, creatinine of 1.0 mg/dl. His amylase level was 818 mg/dl and lipase was
Abstracts
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603 mg/dl. Lipid profile showed that he had severe triglyceridemia with a triglyceride level of 1652 mg/dl, total cholestrol of 290 mg/dl and a HDL of 18 mg/dl. Liver function tests revealed aspartate transaminase level of 204 U/L, alanine transaminase level of 259 U/L, alkaline phosphatase level of 42 U/L, total bilirubin of 0.7 mg/dl, direct bilirubin of 0.4 mg/dl and serum albumin level of 2.3 gm/dl. Corrected calcium level was 9.1 mg/dl. Ultrasound of the abdomen showed severe pancreatitis with ascites and no evidence of gallstones. CT scan confirmed extensive inflammation of the pancreas (phlegmon) with fluid around pancreas and a left sided pleural effusion. Lipid electrophoresis was consistent with the presence of Type IV hyperlipoproteinemia (HL) with the presence of high pre- lipoprotein level. Patient developed multiple complications during a long hospital stay including acute respiratory distress syndrome requiring ventilator support, shock, and a pancreato-duodenal fistula. Patient was managed conservatively and later on recovered completely and is in a good health as per a recent follow-up. Conclusions: Hypertriglyceridemia is known to cause acute pancreatitis but is usually seen in adults especially in the presence of Type I HL. To the best of our knowledge there are only few case reports in literature of Type IV HL causing acute pancreatitis. This case had multiple life threatening complications associated with severe acute pancreatitis. Mortality rates of up to 38% have been reported in different series of patients with hypertriglyceridemia as the cause of pancreatitis. This case highlights the possible life-threatening complications of Familial HL and the importance of early detection and management because of high recurrence rate of pancreatitis if not managed adequately.
288 Intraoperative laparoscopic-endoscopic treatment for patients with common bile duct stones William D McKnight*, Douglas Friesen, Donna Johnson, Douglas Treptow and Mario Costaldi. Rogers, AR, United States. Purpose: This study evaluated the efficacy of utilizing intraoperative endoscopic retrograde cholangiopancreatography (ERCP) during laparoscopic cholecystectomy for the treatment of cholelithiasis complicated by choledocolithiasis. Methods: The combined approach performing ERCP during laparoscopic surgery for cholelithiasis was applied to 21 patients (11 women, 10 men; mean age 48, age range 16 – 83). The diagnosis of common bile duct (CBD) stones was by laparoscopic cholangiography via the cystic duct. When CBD stones were identified, ERCP was begun. No guide wire had been placed previously. The papillotome was inserted into the CBD endoscopically and sphincterotomy was performed. The stones were removed with balloon catheters. Results: Stone removal was successful in 20/21 cases. Operative time was lengthened by an average of 23 minutes. The hospital stay was not prolonged over that of laparoscopic cholecystectomy alone. Conclusions: This combined laparoscopic-endoscopic approach appears both safe and effective for the treatment of cholecysto-choledocolithiasis.
289 Acute pancreatitis as a possible complication of colonoscopy Mohammad Farivar MD, FACG1, R. Saeid Farivar, MD2, and Alexander S. Farivar, MD3. Caritas Norwood Hospital1, Norwood, MA, Yale New Haven Hospital2, New Haven, CT and U of Washington Hospitals3, Seattle, WA. In our review of the literature, acute pancreatitis secondary to colonoscopy has been reported in at least one patient. We present another patient who developed pancreatitis subsequent to colonoscopy. Case Report: A 56 year-old white male underwent diagnostic colonoscopy for follow up of neoplastic polyp. His past medical history was remarkable for type II diabetes, hypertension and hepatic steatosis. The patient had cholecystectomy complicated by a bile peritonitis five years previous to
both duodenoscopes and pediatric colonoscopes may increase diagnostic and therapeutic success.
286 Suspected sphincter of Oddi dysfunction type II: Measure or . . . just cut! Jeffrey D Linder1, Miguel R Arguedas1 and C Mel Wilcox1*. 1Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL, United States. Purpose: Sphincter of Oddi manometry is considered the “gold standard” for diagnosing sphincter of Oddi dysfunction (SOD). Elevated basal sphincter pressures are frequent in patients with symptoms consistent with type II SOD, and most of these patients will symptomatically improve with endoscopic sphincterotomy. Since manometric sphincter evaluation is not widely available and is associated with potential complications, using decision analysis, we determined the overall costs and outcomes of manometry directed therapy compared to “empiric” sphincterotomy. Methods: A decision analysis model was constructed (DATA 3.5, Williamstown, MA). In a hypothetical cohort of 100 patients with suspected type II SOD, we evaluated the following strategies: a) ERCP with manometry followed by sphincterotomy only if an elevated sphincter of Oddi basal pressure was found, and b) “empiric” sphincterotomy without manometry. The probability of an elevated sphincter of Oddi basal pressure at the time of ERCP in patients with suspected sphincter of Oddi dysfunction type II, proportion of patients improving after sphincterotomy (with and without elevated basal pressures), proportion of patients improving without sphincterotomy, complications and death were obtained from a literature search using Medline®. Procedural and hospitalization costs represented the average Medicare reimbursement at our institution. The expected overall costs and number of patients improving in each strategy were compared. Results: The strategy of ERCP with manometry resulted in total costs of $2,790 per patient whereas a strategy of “empiric” sphincterotomy resulted in total costs of $2,244. In a cohort of 100 patients with suspected SOD, 55% of patients would be expected to improve if manometry is performed compared to 60% of patients improving with “empiric” sphincterotomy. Univariate sensitivity analyses demonstrated that “empiric” sphincterotomy remained a cost-saving strategy compared to ERCP with manometry as long as the probability of spontaneous improvement in patients with a “normal” manometry was less than 41%, the probability of complications associated with manometry was greater than 6% and the probability of complications due to sphincterotomy was less than 19%. Conclusions: For patients with suspected SOD type II, empiric biliary sphincterotomy is cost saving compared to a strategy based on the results of manometry.
287 A case of severe acute pancreatitis associated with type IV hyperlipoproteinemia Sunitha Mannam, MD1, M A Albornoz, MD1 and Hitender Jain, MD1*. 1 Internal Medicine, Mercy Catholic Medical Center, Darby, PA, United States. Methods: A 19 year old male with no significant past medical history presented with one day history of severe epigastric pain of sudden onset, with radiation to back. He complained of nausea and vomiting but denied any diarrhea, hematmesis or malena. There was no history of fever, chills or rigors. Pain increased with meals but he denied any postural variation. He denied any history of alcohol or drug abuse with a negative screening test. Patient had strong family history of hyperlipidemia and early coronary artery disease. He had similar pain of lesser intensity in the past, which was relieved by over the counter medications. Initial laboratory investigation showed a hemoglobin level of 17.00 gm/dl, white blood cell count of 13,000 cu mm/dl, poly-morphonuclear cells of 76%, BUN of 13.0 mg/dl, creatinine of 1.0 mg/dl. His amylase level was 818 mg/dl and lipase was
Abstracts
S91
603 mg/dl. Lipid profile showed that he had severe triglyceridemia with a triglyceride level of 1652 mg/dl, total cholestrol of 290 mg/dl and a HDL of 18 mg/dl. Liver function tests revealed aspartate transaminase level of 204 U/L, alanine transaminase level of 259 U/L, alkaline phosphatase level of 42 U/L, total bilirubin of 0.7 mg/dl, direct bilirubin of 0.4 mg/dl and serum albumin level of 2.3 gm/dl. Corrected calcium level was 9.1 mg/dl. Ultrasound of the abdomen showed severe pancreatitis with ascites and no evidence of gallstones. CT scan confirmed extensive inflammation of the pancreas (phlegmon) with fluid around pancreas and a left sided pleural effusion. Lipid electrophoresis was consistent with the presence of Type IV hyperlipoproteinemia (HL) with the presence of high pre- lipoprotein level. Patient developed multiple complications during a long hospital stay including acute respiratory distress syndrome requiring ventilator support, shock, and a pancreato-duodenal fistula. Patient was managed conservatively and later on recovered completely and is in a good health as per a recent follow-up. Conclusions: Hypertriglyceridemia is known to cause acute pancreatitis but is usually seen in adults especially in the presence of Type I HL. To the best of our knowledge there are only few case reports in literature of Type IV HL causing acute pancreatitis. This case had multiple life threatening complications associated with severe acute pancreatitis. Mortality rates of up to 38% have been reported in different series of patients with hypertriglyceridemia as the cause of pancreatitis. This case highlights the possible life-threatening complications of Familial HL and the importance of early detection and management because of high recurrence rate of pancreatitis if not managed adequately.
288 Intraoperative laparoscopic-endoscopic treatment for patients with common bile duct stones William D McKnight*, Douglas Friesen, Donna Johnson, Douglas Treptow and Mario Costaldi. Rogers, AR, United States. Purpose: This study evaluated the efficacy of utilizing intraoperative endoscopic retrograde cholangiopancreatography (ERCP) during laparoscopic cholecystectomy for the treatment of cholelithiasis complicated by choledocolithiasis. Methods: The combined approach performing ERCP during laparoscopic surgery for cholelithiasis was applied to 21 patients (11 women, 10 men; mean age 48, age range 16 – 83). The diagnosis of common bile duct (CBD) stones was by laparoscopic cholangiography via the cystic duct. When CBD stones were identified, ERCP was begun. No guide wire had been placed previously. The papillotome was inserted into the CBD endoscopically and sphincterotomy was performed. The stones were removed with balloon catheters. Results: Stone removal was successful in 20/21 cases. Operative time was lengthened by an average of 23 minutes. The hospital stay was not prolonged over that of laparoscopic cholecystectomy alone. Conclusions: This combined laparoscopic-endoscopic approach appears both safe and effective for the treatment of cholecysto-choledocolithiasis.
289 Acute pancreatitis as a possible complication of colonoscopy Mohammad Farivar MD, FACG1, R. Saeid Farivar, MD2, and Alexander S. Farivar, MD3. Caritas Norwood Hospital1, Norwood, MA, Yale New Haven Hospital2, New Haven, CT and U of Washington Hospitals3, Seattle, WA. In our review of the literature, acute pancreatitis secondary to colonoscopy has been reported in at least one patient. We present another patient who developed pancreatitis subsequent to colonoscopy. Case Report: A 56 year-old white male underwent diagnostic colonoscopy for follow up of neoplastic polyp. His past medical history was remarkable for type II diabetes, hypertension and hepatic steatosis. The patient had cholecystectomy complicated by a bile peritonitis five years previous to