Common bile duct stones: introduction.
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Gallstones↗
Biomedical subjects
A Csendes
Publications and source records attributed to A Csendes.
Present role of classic open choledochostomy in the surgical treatment of patients with common bile duct stones.
Open choledochostomy still represents an important step of biliary surgery, even during the era of laparoscopic surgery. Although its application has decreased with the widespread use of endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy, still there are some patients in whom it is necessary to perform open choledochostomy and place a T-tube. The morbidity and mortality rates depend mainly on the presence or absence of an acute suppurative cholangitis, rather than the performance of the choledochostomy. In patients with mild cholangitis or those no cholangitis and less than 60 years of age, the mortality rate is lower than that observed after ERCP. This procedure is still an important technique for surgeons dedicated to biliary surgery, and therefore several technical aspects of common bile duct exploration are important to remember.
Cholangiopancreatography, Endoscopic Retrograde↗
Histological findings of gallbladder mucosa in 95 control subjects and 80 patients with asymptomatic gallstones.
The histological appearance of gallbladder mucosa in 95 control subjects and in 80 patients with asymptomatic gallstones separated according to age and sex was determined in a prospective study. The number and size of stones in the latter group were also analyzed. Among controls, 33% showed abnormal histological findings, mainly chronic cholecystitis, which increased with age and was frequently seen among women. All patients with asymptomatic gallstones showed chronic cholecystitis and/or cholesterolosis, and 5% showed acute inflammatory changes. In 55% of them a single stone was found. These findings suggest that chronic inflammatory changes can occur in the gallbladder mucosa prior to the appearance of macroscopic stones at the gallbladder.
Adult↗
'Carditis': an objective histological marker for pathologic gastroesophageal reflux disease.
In a prospective endoscopic and bioptic study, 141 control subjects and 359 patients with symptoms of gastroesophageal reflux (GER) were included to determine the prevalence of cardial epithelium inflammation or 'carditis' and to determine the prevalence of Helicobacter pylori in this area. Two biopsies at the antrum, four distal to the squamous-columnar junction and two proximal in the esophageal mucosa, were taken. Patients with gastroesophageal reflux were divided into four groups, according to the severity of endoscopic findings: patients without esophagitis, patients with erosive esophagitis, patients with short-segment and long-segment Barrett's esophagus (BE). Control subjects had normal histological findings at the cardia in 90% of cases, fundic mucosa being present twice as cardial epithelium. Carditis was present in 8% of cases and intestinal metaplasia (IM) in 2%. On the contrary, patients with GER had carditis in nearly 50% of cases. Intestinal metaplasia was present in 12% of cases with GER without esophagitis or erosive esophagitis, in 35% of cases with short-segment BE and in 65% of the cases with long-segment BE. IM at the antrum was present in only 5% of cases. Helicobacter pylori at the squamous-columnar junction was present in 13% of control subjects and in 30% of the patients with GER. It is concluded that carditis is an easy and objective marker for the presence of chronic gastroesophageal reflux and the presence of Helicobacter pylori at this region must be carefully evaluated in order to determine some pathogenic role for the development of Barrett's esophagus.
Adolescent↗
[Chromosome anomaly and flow cytometry in gallbladder adenocarcinoma].
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Adenocarcinoma↗
Esophagocardioplasty, vagotomy-antrectomy and Roux-en-Y gastrojejunostomy: indication in cases with severe esophageal motor disfunction.
Almost 10% of patients with Crest syndrome associated with severe gastroesophageal reflux and 5-10% of patients with failed cardiomyotomy for achalasia present with cardial or distal esophageal organic stricture. Some of these cases are poor risk patients for surgery and therefore the surgeon must offer a safe procedure with low morbimortality, keeping in mind the pathophysiological motor pattern of these patients. In order to treat the stricture to improve the esophageal transit we treated patients with esophagocardioplasty associated with vagotomy-antrectomy and Roux-en-Y gastrojejunostomy, thereby avoiding the potential acid or biliary reflux in poor risk patients in whom esophagectomy would be a very deleterious procedure. All four patients had a good postoperative evolution and late control demonstrated good esophagogastric transit with no postoperative esophagitis.
Adult↗
Long-term results of classic antireflux surgery in 152 patients with Barrett's esophagus: clinical, radiologic, endoscopic, manometric, and acid reflux test analysis before and late after operation.
BACKGROUND: The classic surgical procedure for patients with Barrett's esophagus (BE) has been either Nissen fundoplication or posterior gastropexy with calibration of the cardia. METHODS: The purpose of our study was to determine late subjective and objective results of these classic surgical techniques in a large number of patients with BE. A total of 152 patients were included in this prospective protocol. RESULTS: There was 1 death (0.7%) after operation. The late follow-up of 100 months demonstrated a high percentage of failures among patients with noncomplicated BE (54%) and an even higher figure in patients with complicated BE (64%). In 15 patients low grade dysplasia appeared at 8 years of follow-up and an adenocarcinoma in 4 patients. Twenty-four-hour pH monitoring demonstrated a decrease in acid reflux into the esophagus, and Bilitec studies also demonstrated a decrease of duodenoesophageal reflux, but in all cases with a higher value than the normal limit. CONCLUSIONS: Classic antireflux surgery in patients with BE results in a high percentage of failures at very late follow-up because it cannot completely avoid acid and duodenal reflux into the esophagus.
Adult↗
[Biopsy and endoscopic prospective study of the prevalence of intestinal metaplasia in the gastroesophageal junction in controls and in patients with gastroesophageal reflux].
BACKGROUND: The classic diagnosis of Barret esophagus is based on the finding of three of more cm of distal esophagus covered by specialized columnar epithelium. However, at the present time, it is based on the presence of intestinal metaplasia in the junction of squamous-columnar mucosae. AIM: To assess the prevalence of Barret esophagus using endoscopic and pathological criteria in healthy subjects and in individuals with gastroesophageal reflux. PATIENTS AND METHODS: One hundred thirty nine controls and 372 patients with symptoms of gastroesophageal reflux subjected to an upper gastrointestinal endoscopy were studied. Patients with Barret esophagus were classified as having a "mini Barret" when the pathological presence of intestinal metaplasia was the only finding. A "short Barret esophagus" was diagnosed when less than 3 cm were covered with fingerings of mucosal substitutions and "extensive Barret esophagus" when more than 3 cm of esophageal mucosa were substituted. RESULTS: Two percent of controls, 12.4% of patients with gastroesophageal reflux without esophagitis and 11.7% of such patients with esophagitis had intestinal metaplasia in the gastroesophageal junction. Patients with Barret esophagus were older than the rest of patients. "Short Barret esophagus" is six times more frequent than "extensive Barret esophagus". Esophageal erosions, peptic ulcers and stenosis were more frequent in patients with extensive Barret esophagus. The prevalence of dysplasia was similar in all types of Barret esophagus. CONCLUSIONS: Intestinal metaplasia was very infrequent in control patients. In subjects with gastroesophageal reflux, classic endoscopic diagnosis may miss up to 80% of patients with Barret esophagus. Thus, gastroesophageal junction biopsies must be obtained in all patients with symptoms of gastroesophageal reflux.
Adolescent↗
[Clinical and laboratory characteristics of patients with pathologic chronic gastroesophageal reflux].
BACKGROUND: Sixty percent of adults has typical symptoms of gastroesophageal reflux in Chile. AIM: To report the clinical and laboratory features of patients with gastroesophageal reflux. PATIENTS AND METHODS: Five hundred thirty-four patients (255 male) with gastroesophageal reflux were included in a prospective protocol that included clinical analysis, manometry and endoscopy in all patients, barium swallow in 427, scintigraphy in 195, acid reflux test in 359, 24 h pH in 175, and differential potential of gastroesophageal mucosa in 73 patients. RESULTS: There was no correlation between the severity of symptoms and the endoscopical severity. Patients with Barret esophagus were 12 years older, were male in a greater proportion and had a higher proportion of manometrically incompetent sphincters than patients with esophageal reflux but without esophagitis or with erosive esophagitis. Severity of acid reflux, measured with 24 h pH monitoring was proportional to the endoscopical damage of the mucosa. There was a close relationship between the mucosal change limit determined with differential potentials and with endoscopy. No short esophagi were found. CONCLUSIONS: Patients with symptoms of gastroesophageal reflux must be assessed using several objective measures to determine the severity of their pathological alterations.
Adult↗
Prevalence of Helicobacter pylori infection in 190 control subjects and in 236 patients with gastroesophageal reflux, erosive esophagitis or Barrett's esophagus.
A prospective study was performed in 190 control subjects and in 236 patients with different degrees of endoscopic esophagitis in order to determine the prevalence of Helicobacter pylori infection at duodenal gastric and esophageal mucosa and its correlation with histological findings. All patients with pathologic gastroesophageal reflux had 24-h pH monitoring studies confirming the presence of acid reflux into the esophagus. Besides the endoscopic findings, biopsies were taken from the duodenal bulb, gastric antrum, gastric fundus and distal esophagus or at the specialized columnar epithelium in patients with Barrett's esophagus. Patients with pathological gastroesophageal reflux were divided into three groups: 55 with absence of endoscopic esophagitis (gastroesophageal reflux), 81 patients with erosive esophagitis and 100 patients with Barrett's esophagus. There was no H. pylori infection present at duodenal or esophageal mucosa or at the specialized columnar epithelium of the distal esophagus in any case. The prevalence of H. pylori infection at gastric antrum was similar in controls and in any group of patients with reflux disease (20-25% of H. pylori infection). No differences in age and sex distribution were seen. H. pylori infection at gastric fundus was very low (less than 5%). The presence of HP infections was correlated with the finding of chronic active superficial or athrophic gastritis while, in the absence of H. pylori infection, gastric mucosa was normal. In the presence of intestinal metaplasia, no H. pylori infection occurred. Based on these findings, it seems that there is no significant evidence for an important pathogenic role for H. pylori infection in the development of pathologic chronic gastroesophageal reflux, erosive esophagitis or Barrett's esophagus, and the presence of antral gastritis in patients with Barrett's esophagus is closely related to the presence of H. pylori infection, and probably not related to an increased duodenogastric reflux.
Adolescent↗
A new physiologic approach for the surgical treatment of patients with Barrett's esophagus: technical considerations and results in 65 patients.
OBJECTIVE: To determine the results of a new surgical procedure for patients with Barrett's esophagus. SUMMARY BACKGROUND DATA: In addition to pathologic acid reflux into the esophagus in patients with severe gastroesophageal reflux and Barrett's esophagus, increased duodenoesophegeal reflux has been implicated. The purpose of this study was to establish the effect of a new bile diversion procedure in these patients. METHODS: Sixty-five patients with Barrett's esophagus were included in this study. A complete clinical, radiologic, endoscopic, and bioptic evaluation was performed before and after surgery. Besides esophageal manometry, 24-hour pH studies and a Bilitec test were performed. After surgery, gastric emptying of solids, gastric acid secretion, and serum gastrin were determined. All patients underwent highly selective vagotomy, antireflux procedure (posterior gastropexy with cardial calibration or fundoplication), and duodenal switch procedure, with a Roux-en-Y anastomosis 60 cm in length. RESULTS: No deaths occurred. Morbidity occurred in 14% of the patients. A significant improvement in symptoms, endoscopic findings, and radiologic evaluation was achieved. Lower esophageal sphincter pressure increased significantly (p < 0.0001), as did abdominal length and total length of the sphincter (p < 0.0001). The presence of an incompetent sphincter decreased from 87.3% to 20.9% (p < 0.0001). Three of seven patients with dysplasia showed disappearance of this dysplasia. Serum gastrin and gastric emptying of solids after surgery remained normal. Basal and peak acid output values were low. Twenty-four hour pH studies showed a mean value of 24.8% before surgery, which decreased to 4.8% after surgery (p < 0.0001). The determination of the percentage time with bilirubin in the esophagus was 23% before surgery; this decreased to 0.7% after surgery (p < 0.0001). Late results showed Visick I and II gradation in 90% of the patients and grade III and IV in 10% of the patients. CONCLUSIONS: This physiologic approach to the surgical treatment of patients with Barrett's esophagus produces a permanent decrease of acid secretion (and avoids anastomotic ulcer), decreases significantly acid reflux into the esophagus, and abolishes duodenoesophageal reflux permanently. Significant clinical improvement occurs, and dysplastic changes at Barrett's epithelium disappear in almost 50% of the patients.
Adult↗
Correlation among ultrasonographic and videoscopic findings of the gallbladder: surgical difficulties and reasons for conversion during laparoscopic surgery.
Laparoscopic cholecystectomy is currently the standard procedure for chronic and acute cholecystitis. The purpose of this prospective study was to evaluate the preoperative ultrasound findings of the gallbladder and correlate those aspects with surgical videoscopic and histopathologic findings and the results concerning intraoperative complications and the conversion index to open surgery. Gallbladder findings were classified into three categories according to the gallbladder wall characteristics and the presence of visible lumen and stones. Simple chronic cholecystitis (type I) and acute cholecystitis, with gallbladder wall thickness <5 mm (type IIa) presented significantly lower intraoperative complications without conversion to open surgery. Scleroatrophic (type III) and acute cholecystitis with gallbladder wall thickness >5 mm (type IIB) presented significantly more surgical difficulties and a higher conversion rate to open surgery (p < 0.01). We postulate that this classification will be useful for surgeons in predicting potential problems in individual patients, at least at the initial laparoscopic cholecystectomy experience, and in advising patients of the potential risks of and conversion to open surgery.
Acute Disease↗
[Gastroesophageal reflux and obesity].
BACKGROUND: There is a possible relationship between gastroesophageal reflux and overweight, that has not been studied extensively. AIM: To study the association between overweight and gastroesophageal reflux in a group of patients and normal controls. SUBJECTS AND METHODS: Body mass index of 85 patients with gastroesophageal reflux and 100 patients with Barrett esophagus, was compared with that of 171 healthy controls. RESULTS: There were no differences in body mass index between healthy subjects and patients with gastroesophageal reflux. However, there was a higher proportion of overweight males and obese females with Barrett esophagus than among healthy controls. CONCLUSIONS: We did not find an association between overweight and gastroesophageal reflux, but patients with Barrett esophagus had a higher body mass index than normal controls.
Adolescent↗
Simultaneous bacteriologic assessment of bile from gallbladder and common bile duct in control subjects and patients with gallstones and common duct stones.
OBJECTIVES: To determine the simultaneous prevalence of bacteria in bile from the gallbladder and common bile duct and to determine the influence of the number of stones present on bacteriologic findings. METHODS: A prospective study was performed in 467 subjects divided into seven groups: 42 control subjects with normal biliary tracts, 221 patients with symptomatic gallstone disease, 12 patients with hydropic gallbladder, 52 patients with acute cholecystitis, 67 patients with common bile duct stones without cholangitis, 49 patients with common bile duct stones and acute cholangitis, and 24 patients with previous cholecystectomy and common bile duct stones. In all except controls, bile samples from the gallbladder and common bile duct were taken simultaneously for aerobic and anaerobic cultures. RESULTS: Control subjects had no bacteria in gallbladder bile. Patients with gallstones, acute cholecystitis, and hydropic gallbladder had similar rates of positive cultures in the gallbladder and common bile duct, ranging from 22% to 46%, but the rate was significantly higher in patients with common bile duct stones without cholangitis (58.2%). Patients with cholangitis or previous cholecystectomy had a high rate of positive cultures of common duct bile (93% to 100%). Age greater than 60 years had a significant influence on the rate of positive bile cultures. There was no relationship between the number of stones in the gallbladder or common bile duct and the percentage of positive cultures. In 98% of the patients, the same bacteria were isolated from gallbladder and common duct bile. CONCLUSIONS: In normal subjects, no bacteria were present in the biliary tract. Among patients with common bile duct stones, there was an increasing percentage of positive cultures according to the severity of the disease. Age had an important influence, but sex and the number of common bile duct stones had no influence on positive cultures.
Acute Disease↗
The presence of Helicobacter pylori in nonoperated duodenal ulcer patients compared to patients late after highly selective vagotomy.
There are many recent studies that clearly suggest that Helicobacter pylori (HP) is an etiological agent for duodenal ulcer disease (1-3). Randomized trials have shown that duodenal ulcers treated by omeprazole or H2 blockers heal faster if HP is eradicated concurrently (4-6). Besides, several studies have demonstrated that eradication of HP significantly reduces duodenal ulcer relapses (7-9). Patients followed up to 7 years after eradication of HP demonstrated that 92% remained HP negative, with only 3% recurrence (10). Highly selective vagotomy has been the treatment of choice for duodenal ulcer patients who are candidates for surgical therapy (11, 12). The late results have shown an approximately 10% recurrence rate 8 to 10 years after surgery (13, 14). We hypothesized that in these asymptomatic cases after HSV, HP probably will exist in a minor proportion of cases, similar to what happens after successful medical antiulcer therapy. Therefore the purpose of the present study was to determine the HP status at the antrum in a group of nonoperated duodenal ulcer patients compared to a group submitted to highly selective vagotomy many years prior to the actual study.
Adult↗
[Subjective and objective evaluation of the results of laparoscopic antireflux surgery in patients with gastroesophageal reflux].
BACKGROUND: Laparoscopic antireflux surgery is a minimally invasive procedure that should have similar results than classical surgical treatment. AIM: To report the results of a prospective study of laparoscopic antireflux surgery in patients with gastroesophageal reflux. PATIENTS AND METHODS: Thirty two patients with gastroesophageal reflux and without Barret's esophagus, were subjected to endoscopy, manometry and measurement of intraesophageal pH before and after laparoscopic surgery. RESULTS: There were no postoperative deaths or complications. Gastroesophageal sphincter pressure and abdominal sphincter length increased from 9.1 +/- 3.9 to 13.0 +/- 3.5 mm Hg and from 8.1 +/- 6.2 to 13.5 +/- 5.4 cm after surgery (p < 0.01). There was a decrease in acid reflux in 82% of patients. CONCLUSIONS: Laparoscopic antireflux surgery reproduces exactly the results of open surgical procedures.
Adult↗
[Long-term follow-up of non-operated patients with symptomatic and asymptomatic cholelithiasis].
BACKGROUND: In Chile, cholelithiasis is a serious public health problem and there are no studies about its natural history. AIM: To assess the long term evolution of patients with symptomatic and asymptomatic cholelithiasis. PATIENTS AND METHODS: Ninety two patients with cholelithiasis (57 female), aged 15 to 80 years old and that were not operated, were followed during a period of 9 to 14 years. RESULTS: Thirteen patients were initially asymptomatic. Of them, seven bad complications or symptoms during follow-up and two were operated. Among the 69 symptomatic patients, 38 (55%) were not operated during follow-up, and seventeen (25%) did not have symptoms again. Ten patients died during follow-up, four due to complications of biliary tract stones. CONCLUSIONS: The present finding suggest that the evolution of cholelithiasis in Chile is more aggressive than abroad, and an early surgical treatment is warranted.
Adolescent↗
[Endoscopic location of squamous columnar mucosal changes in patients with different degrees of pathologic gastroesophageal reflux].
BACKGROUND: There is little information about the precise location of the squamous columnar mucosal junction in the Chilean population. AIM: To study endoscopically, the location of the squamous columnar mucosal junction in patients with esophageal disease. PATIENTS AND METHODS: The location of the squamous columnar mucosal junction was prospectively studied by endoscopy in 347 subjects with normal upper gastrointestinal endoscopy, 117 patients with chronic gastroesophageal reflux without esophagitis, 117 patients with erosive esophagitis, 63 patients with short Barret's esophagus and 28 patients with an extensive Barret's esophagus. RESULTS: No differences in the mucosal junction location were observed between controls and patients with gastroesophageal reflux or erosive esophagitis. In patients with Barret's esophagus, the junction was more proximal. In women, the junction was three cm more proximal than in men, probably due to their shorter stature. CONCLUSIONS: Women have a more proximal squamous columnar mucosal junction than men.
Adolescent↗