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J Vracko

Publications and source records attributed to J Vracko.

9 recordsLinked to original sources
PubMed2006

Conservative treatment versus endoscopic sphincterotomy in the initial management of acute cholecystitis in elderly patients at high surgical risk.

BACKGROUND AND STUDY AIMS: Surgery in elderly patients with acute cholecystitis is quite a high-risk procedure. The recent finding that activated pancreatic enzyme is present in sterile bile from the acutely inflamed gallbladder suggests that obstruction at the level of the common channel is a possible precipitating factor. It was therefore hypothesized that an initial endoscopic sphincterotomy in patients with acute cholecystitis might improve the clinical course. PATIENTS AND METHODS: A prospective unselected series of 105 patients over 65 years of age (52 men, 53 women; mean age 78) suffering from acute cholecystitis were initially treated on a random basis with either conservative methods or endoscopic sphincterotomy. Within the first 72 h after the onset of symptoms, all 52 patients in the endoscopic sphincterotomy group were managed by endoscopic retrograde cholangiopancreatography (ERCP), combined with endoscopic sphincterotomy in 50 cases. The main study parameter was the need for emergency cholecystectomy within the first week after admission. RESULTS: Biliary sepsis requiring emergency surgery occurred in 15 patients in the conservatively treated group, in contrast with none of the 52 patients in the endoscopic sphincterotomy group ( P < 0.001). Iatrogenic complications after endoscopic sphincterotomy occurred in three patients, one of whom required surgery, while two were managed by conservative means. The clinical course improved, avoiding the need for emergency cholecystectomy and other interventions, in 48 patients in the endoscopic sphincterotomy group and in 36 patients in the conservatively treated group ( P < 0.01). CONCLUSIONS: The clinical course after endoscopic sphincterotomy improved in the majority of elderly patients suffering from acute cholecystitis, suggesting that early relief of obstruction at the level of the common channel reduces the risk of developing biliary sepsis. The majority of these patients can undergo surgery electively or can receive further conservative treatment.

Aged↗
PubMed2000

The laparoscopic finding of pericholedochitis at cholecystectomy predicts the presence of unsuspected bile duct stones.

Routine laparoscopic cholangiography and sonography have been recommended for identification of unsuspected bile duct stones in laparoscopic cholecystectomy. The increased prevalence of retained stones seems, however, to confirm that cholangiography has been used rather selectively. The aim of this study was to investigate the kind and extent of a possible correlation between inflammatory changes in the bile duct mucosa and the hepatoduodenal ligament in patients with and without unsuspected bile duct stones. Sixty-eight patients, without symptoms or signs of bile duct stones in their case histories, laboratory findings, and preoperative sonography results, underwent laparoscopic cholecystectomy for symptomatic gallstone disease and diagnostic transcystic cholangiography and cholangioscopy. The initial step at laparoscopy revealed edema of the periductal loose tissue, vascular dilation, and petechiae on the external surface of the distal portion of the extrahepatic bile duct in 47 of 68 patients. Cholangioscopy revealed inflammatory changes in the mucosa of the distal and sphincteric portions of the extrahepatic bile duct in 45 of 47 patients, and unsuspected ductal stones were identified in 41 of these 45 patients. Neither the external surface of the bile duct nor its mucosa exhibited any signs of inflammation in the 21 remaining patients (controls), all of whom showed stone-free bile ducts. Inflammatory changes in the bile duct mucosa, occurring along with unsuspected mobile ductal stones in this study, were reflected on the external surface of the bile duct with a specificity of 87%. The changes in the external surface of the bile duct can be recognized at the initial inspection in laparoscopic cholecystectomy, as in this study, and indicate that more accurate diagnostic procedures to identify unsuspected ductal stones should be used.

Bile Ducts, Extrahepatic↗
PubMed1999

Why is it necessary to retrieve small bile duct stones at cholecystectomy?

Recovery of gallstones from the stool demonstrates that gallstones pass into the duodenum due to antegrade sphincter of Oddi (SO) activity. However, retrograde SO peristalsis occurs in three-fourths of patients with bile duct stones as shown by SO manometry. The aim of this study was to investigate, by comparing patients with and without bile duct stones, whether reversed SO activity would retain even small stones. Thirty-nine patients with gallbladder stones < or = 3 mm in diameter underwent cholecystectomy, 22 of them with concomitant biliary stones. The remaining 17 patients served as controls. The diameters of the cystic duct and the small stones in the gallbladder and bile duct were measured. The case histories of the controls indicated previous passage of gallstones into the duodenum, i.e., a normal antegrade SO activity. Biliary stones < or = 3 mm in diameter were recovered in three-fourths of the patients with ductal stones, a sign of retrograde SO activity. SO dysfunction seems to occur in three-fourths of patients with bile duct stones and should be suspected when stones < or = 3 mm are present, as, under these circumstances, it is necessary to retrieve even such small stones.

Adult↗
PubMed1998

How often might a trans-cystic-duct stone extraction be feasible?

BACKGROUND: Although the sizes of the cystic duct and concomitant bile duct stones are fundamental in evaluating the possibility of a trans-cystic-duct approach as an alternative to cholangiotomy, no conclusive data are supplied in the reports on laparoscopic cholecystectomy. METHOD: The narrowest inner diameter of the cystic duct and the diameter of the largest concomitant bile duct stone are compared in a prospective study of 30 consecutive patients. RESULTS: The bile duct stones were smaller than the cystic duct in 14 patients, 47%, and of equal size in nine, 30%. They were larger than the cystic duct in the remaining seven patients, 23%, with a difference of only 1 mm in five patients and of 2 and 4 mm, respectively, in two. CONCLUSIONS: Physical conditions allowing a trans-cystic-duct stone extraction were present in 23 of 30 patients and an attempt might have been possible after, for example, cystic duct dilatation in a further five.

Adult↗
PubMed1994

Sphincter of Oddi function studied by radioimmunoassay of biliary trypsin in patients with bile duct stones and in controls.

The trypsin level in bile was studied by radioimmunoassay in a prospective series of 63 patients with gallstone disease but without signs or symptoms of cholecystitis or pancreatitis in order to find indirect evidence of a retrograde flow of pancreatic juice. Mobile duct stones were present in 18 patients and impacted stones in 12. The remaining 33 patients had stones only in the gallbladder and served as controls. The average intraoperative trypsin level of the ductal bile was normal, both in the control group and in the group with stones occluding a potential retrograde reflux of pancreatic juice. After removal of the impacted stones, the bile showed a significantly higher trypsin level. The average intraoperative trypsin level for the group with mobile stones was significantly higher than that of the control group, and was further increased 10 days postoperatively. The trypsin level of ductal bile from 23 of the 30 patients (77%) with bile duct stones exceeded that of the 33 patients with stone-free bile ducts, indicating an inflow of pancreatic juice to the bile ducts of patients with bile duct stones. The present results correspond well to those in a previous report on retrograde phasic contractions of the sphincter of Oddi in the majority of patients with bile duct stones. This dysfunction of the sphincter, which persisted for 10 days after surgical stone removal, may be the primary disorder, probably consisting of a retrograde propulsive activity of the sphincter of Oddi.

Adult↗
PubMed1989

[Single-layer closure of a subcostal incision using a monofilament absorbable suture material--comparison of polydioxanone (PDS) and polyglyconate (Maxon)].

In 114 and 108 patients who were operated upon the biliary tract with a subcostal incision and closed in one layer with Polydioyanone (PDS) and Polyglyconate (Maxon), the authors analysed the frequency of the complications in the healing of the operative wound. A superficial infection in the wound appeared in 1% and 0.9% of the patients in the PDS and Maxon group, while a deep infection of the wound appeared in 0.8% and 0% (P less than 0.05). In "contaminated" wound patients, the frequency of the deep infection of the wound was not significantly larger than the "clean" operations (P less than 0.05). The total frequency of the deep infection of the wound in 222 patients was 0.4%. There was no dehiscence of the wound abscesses or ligature fistulas. 4 months following surgery 92% and 90% of the patients from the PDS and Maxon group were checked; an incisional hernia was preceded by an infection of the surgical wound in both the PDS (0.9) and Maxon (1%) group. Risk-factors (older patients, sex, overweight and icterus) did not have any effect on the healing of the wounds. In 66% of the patients of the PDS and 62% of the Maxon group, the gallbladder bed was not drained. The difference in the development of complications in the healing of the surgical wound between the two drained groups was not statistically significant (P less than 0.5). With a one layer closure of the subcostal incision with PDS or Maxon, complications in the healing of the wound were significantly reduced. The purpose of our study was: a clinical evaluation and comparison of the two monofilament absorptive suture materials-Polydioxanone (PDS) and Polyglyconate (Maxon) during a one layer closure of surgical interventions on the biliary tract, and evaluation of certain risk-factors in the healing of the surgical wounds.

Absorption↗
PubMedDate not supplied

Trypsin level in gallbladder bile and ductitis and width of the cystic duct.

BACKGROUND/AIMS: The change from laparotomy to laparoscopy for cholecystectomy has raised the question of how to manage concomitant bile duct stones. The present-day interest--and controversy--has focused on a transcystic approach reported to be feasible in 66-96% of cases, but without explaining the necessary prerequisite: the widening of the cystic duct. The cystic duct, wide mainly in patients with bile duct stones, has been reported to be highly variable: from strictured to very wide. The present study aims at comparing the trypsin level in the gallbladder bile and the cystic duct morphology and width in patients with and without bile duct stones. METHODOLOGY: A prospective series of 63 gallstone patients, 30 with and 33 without bile duct stones (controls), underwent cholecystectomy and bile duct clearance. The study includes the trypsin level in the gallbladder bile, the width and morphology of the cystic duct, and the size of the gallstones. RESULTS: The patients with bile duct stones had, in contrast to the controls, higher trypsin levels in the gallbladder bile (P < 0.001) and wider cystic ducts (P < 0.001) with more pronounced signs of chronic ductitis. CONCLUSIONS: The obtained results strongly suggest that the increased trypsin level, a sign of reflux of pancreatic juice, caused changes in the cystic duct that facilitate gallstone migration, which also ought to render a transcystic stone extraction feasible.

Adult↗
PubMedDate not supplied

Sphincterotomy of Oddi's muscle through posterior distal duodenum: a modified technique with low morbidity and mortality.

BACKGROUND/AIMS: Today, most common bile duct stones are successfully removed with endoscopic and/or laparoscopic techniques; however, in a small number of cases these procedures fail and the stones have to be removed with older techniques. These techniques involve laparotomy and supraduodenal and/or transduodenal common bile duct approaches and are associated with complication rates that may be as high as 12%. We describe in this report a modification of the classic supraduodenal and transduodenal technique that results in substantial decrease of postoperative morbidity and mortality. MATERIALS AND METHODS: Rather than approaching the common bile duct through the anterior wall of the duodenum we reflect the duodenum anteriorly and approach the common bile duct through a 5-10 mm long incision in the posterior wall of the third, horizontal duodenal segment. Prior to the advent of endoscopy and laparoscopy, we used this technique for sphincterotomy and bile duct stone removal in 212 patients. RESULTS: Four to six weeks postoperatively, the common bile ducts were free of stones in 99% of patients, and there were no instances of duodenotomy dehiscence, fistula formation, pancreatitis, infection, hemorrhage, duodenal constriction, ascending cholangitis, or death. CONCLUSIONS: The results shows that sphincterotomy and bile duct stone removal via a duodenotomy in the posterior wall of the horizontal duodenal segment has substantially lower complication rates than if the common bile duct is approached through the anterior duodenal wall. They also suggest that it is the procedure of choice in cases in which endoscopic and/or laparoscopic techniques have failed.

Adolescent↗