Biomedical subjects

P M Heinerman

Publications and source records attributed to P M Heinerman.

10 recordsLinked to original sources

PubMed2001

[Endoscopic treatment of bile leakage after laparoscopic cholecystectomy].

INTRODUCTION: Bile leaks are typical complications following LCHE. By ERC localisation and nature of the leak can be documented and therapy is possible in the same session. The aim is reduction of intraluminal bile pressure. PATIENTS AND METHODS: 1799 LCHE were followed by 34 bile leaks. 2 common duct injuries and a duodenal perforation had surgical revisions. 31 patients had endoscopic therapy only (stent +/- EST). Bile secretion stopped 3.2 days later. Stentextraction/documentation of closure of the fistula 7 weeks later. COMPLICATION/LETHALITY: 1 Stentdislocation. Lethality: 0. CONCLUSION: ERC allows diagnosis and therapy of bile leaks by common duct stenting. Laparoscopic or surgical reintervention is not necessary.

Aged↗

PubMed2000

Laparoscopic cholecystectomy and interventional endoscopy for gallstone complications during pregnancy.

BACKGROUND: Symptomatic or complicated gallstone disease is the most common reason for nongynecological operations during pregnancy. Gallstones are present in 12% of all pregnancies, and more than one-third of patients fail medical treatment and therefore require surgical endoscopy or laparoscopy. Gallstone pancreatitis and jaundice during pregnancy is associated with a high recurrence rate, exposing both fetus and mother to an increased risk of morbidity and mortality. METHODS: During a 4-year period, all pregnant patients (n = 37) with symptomatic or complicated gallstone disease were studied prospectively at the Landeskrankenhaus in Salzburg, Austria. Five patients had an endoscopic retrograde cholangiopancreatogram (ERCP) for biliary pancreatitis or jaundice; two of these underwent subsequent laparoscopic cholecystectomy. Another seven patients required laparoscopic cholecystectomy for severe pain or cholecystitis; all were in their 13th-32nd gestational week. Access was established by Veress needle in all cases. Insufflation pressure was 8-10 mm Hg, and mean operative time was 62 min. RESULTS: All patients delivered full-term, healthy babies. There were no postendoscopic or postoperative complications. All patients enjoyed full relief from their symptoms; there were no recurrences of pancreatitis or jaundice. CONCLUSIONS: The combination of ERCP and laparoscopic cholecystectomy offers a safe and effective option for the definitive treatment of complicated gallstone disease and intractable pain during pregnancy, and there is sufficient access for the combined treatment to be employed.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed1997

[Preoperative therapeutic splitting].

INTRODUCTION: The best clinical strategy for using ERC combined with LC is still unknown. Based on a wide discussion of literature reports the aim of our study is to critically analyse laparoscopic bile duct exploration and to correlate these data to our prospective study of "therapeutical splitting". PATIENTS AND METHODS: In a prospective study 1645 consecutive patients with sympomatic gall stone disease were examined by ultrasound. 309 patients had open cholecystectomy because of previous gastric surgery or perforation. Patients with a high probability of harbouring stones in the common duct or having other related disorders like biliary pancreatitis had ERC, EPT and stone extraction. 1336 patients had attempted LC. RESULTS: At endoscopy 70% of the 260 patients required therapy like EPT and/or stone extraction, 95% consequently had their gallbladder removed laparoscopically. Including the patients with biliary pancreatitis morbidity amounted to 3% with no mortality. In the non-endoscopic group with 1076 patients conversion was 6.8%, morbidity was 4.3% and mortality 0.09%. Residual stones were found in 0.5% so far. CONCLUSION: If selection criteria for bile duct pathology have a high sensitivity and specificity and endoscopical stone clearance rate is high, at present "therapeutical splitting" still is the method of choice.

Adolescent↗

PubMed1997

[Treatment of postoperative bile fistulas after laparoscopic cholecystectomy by ERCP, EPT and bile duct drainage].

BACKGROUND: Bile leakage as a complication following cholecystectomy can be found more frequently after laparoscopic cholecystectomy (LC) than after open cholecystectomy. The present study planned to find out the importance of ERCP, sphincterotomy and temporary drainage of the bile duct system in the treatment of bile leakage. PATIENTS AND METHODS: From July 1992 to October 1996 15 consecutive patients presenting with bile leakage following LC underwent endoscopic therapy by CBD-drainage with sphincterotomy (n = 11), CBD-drainage without sphincterotomy (n = 1) and sphincterotomy alone (n = 3). RESULTS: Closure of the bile leakage could be achieved in all cases, biliary secretion stopped after 2.1 days (1-7 days). One dislocation of the drainage into the CBD was found and could be treated endoscopically. Endoscopy-related mortality was 0%. CONCLUSIONS: Endoscopic therapy offers a safe, effective and minimal invasive method in the treatment of bile leakage following LC.

Adult↗

PubMed1997

[Urgent ERCP and early elective laparoscopic cholecystectomy in biliary pancreatitis].

BACKGROUND: For many years the best algorithm of treatment for complicated gallstone disease has been intensively discussed. Gallstone pancreatitis with cholangitis still belongs to the most often identified causes of death of necrotizing pancreatitis. The reduction of complication and lethality rates was mainly achieved by urgent ERCP and sequential cholecystectomy. In a prospective study we have combined endoscopic therapy with laparoscopic cholecystectomy (LC) and are discussing the results. PATIENTS AND METHODS: Between May 1991 and December 1996 146 patients with biliary pancreatitis were subjected to ERCP after laboratory tests and ultrasound screening of the biliary system. If there were no contraindications and the gallbladder was still in situ, LC was attempted during the initial admission. RESULTS: Of the 70 patients with attempted LC 26 had common bile duct calculi, 23 had an impacted papillary stone and 10 had signs of a stone passage. 59 patients underwent LC successfully, a conversion to open surgery was necessary in 11 patients. The morbidity rate amounted to 7%, lethality to 0%. DISCUSSION: Since a more liberal indication for ERCP in the management of acute pancreatitis was introduced the number of biliary related cases of acute pancreatitis is increasing. In response to early endoscopic bile duct clearance the rates of morbidity and mortality can be significantly reduced. Early LC is the ideal complementary treatment option to absolutely prevent recurrencies.

Adult↗

PubMed1997

[Potential for improvement of combined endoscopic-surgical treatment of bleeding gastroduodenal ulcer].

A total of 119 patients (January 1995-December 1996; 53 women, 66 men) with a medium age of 63.1 years were admitted to hospital with bleeding gastroduodenal ulcer. Emergency gastroduodenoscopy was performed immediately in all cases, sclerotherapy in 94 cases (78.9%). Control endoscopy was done routinely after 12-24 h; the recurrent bleeding rate amounted to 14.3%, mortality was 5%, and surgical intervention was necessary in 8.4% with a mortality of 40% (!).

Adolescent↗

PubMed1994

Does endoscopic sphincterotomy destroy the function of Oddi's sphincter?

OBJECTIVE: To evaluate the possible destruction of Oddi's sphincter by endoscopic sphincterotomy (ES). DESIGN: Prospective, nonrandomized control trial. The study was done from the beginning of 1986 to the end of 1991. SETTING: The Department of Surgery, Salzburg (Austria) General Hospital. PATIENTS: Ninety-one patients with cholecystolithiasis and concomitant different diseases of the common bile duct. Ninety-five patients exclusively having cholecystolithiasis served as the control group. INTERVENTIONS: Patients with cholecystolithiasis plus concomitant different diseases of the common bile duct underwent preoperative ES and, at a second intervention, conventional cholecystectomy. Patients with cholecystolithiasis only underwent elective conventional cholecystectomy. MAIN OUTCOME MEASURES: During the cholecystectomy, three pressure and flow variables were routinely measured in the common bile duct: the natural resting pressure, the maximum pressure after the standardized injection of physiologic saline solution, and the normalizing time (the time required for the reappearance of the initial resting pressure). RESULTS: The statistical comparison of the two groups showed no significant deviations regarding the resting pressure (P < .4), whereas the maximum pressure was significantly lower (P < .01) in the group that underwent ES. The normalizing time of patients who underwent ES was not statistically different (P < .375) from that of the control group patients. CONCLUSION: The function of Oddi's sphincter is changed but not destroyed following ES.

Adolescent↗

PubMed1994

[Choledocholithiasis--therapeutic splitting].

Despite new developments like chemolitholysis and extracorporeal shock wave lithotripsy, conventional cholecystectomy was the "gold standard" in the treatment of gallstones. The range of indications and the operative strategy were well standardized, although the management of common bile duct stones in gallstone disease was still under debate. For high-risk and elder patients endoscopic retrograde cholangio-pancreatography (ERCP), papillotomy and stone extraction was established, in younger patients the best management was questionable. According to better and more accurate preoperative tests like ultrasound and the ample evidence of the function of the papilla after endoscopic papillotomy the trend seemed to be the preoperative endoscopic bile duct clearance in all patients, just when the "bushfire" of laparoscopic cholecystectomy arised and until then praised standards were thrown overboard because of technical difficulties. Routine intraoperative cholangiography (IOC) was replaced by indicated selective IOC due to the lack of talent of many surgeons. Only the therapeutic concept of the removal of the stone-bearing gallbladder survived all new concepts and the debate of whether to perform routine IOC and whether to clear the bile ducts--pre-, intra- or postoperatively or primarily or secondarily convert to open cholecystectomy and bile duct revision. In the eye of a new "gold standard" and according to the literature and our own results we should standardize our management especially in the era of laparoscopic cholecystectomy as "therapeutical splitting" with indicated and selective preoperative ERCP and bile duct clearance offers the best results and facilitates minimally invasive surgery.

Adult↗

PubMed1993

[Laparoscopic cholecystectomy in cholecysto-choledocholithiasis. "Therapeutic splitting" or conventional surgical procedure?].

In a prospective study the impact of preoperative, selective endoscopic cholangiography (ERC/P) and therapy was evaluated in 586 consecutive patients with symptomatic gallstone disease in respect of biliary pathology and laparoscopic cholecystectomy (n = 520). Exclusion criteria for the admission to the study were previous gastric surgery, necrotizing cholecystitis and gallbladder perforation. Because of presumed pathology on ultrasound, suggestive for common bile duct stones or papillary stenosis 59 patients (11.3%) had preoperative ERC/P. In all patients with calculi (n = 40) endoscopic stone removal was successfully performed with/without sphincterotomy (EPT), in three cases of clinically relevant stenosis EPT was indicated. Morbidity was 1.6% after ERC/EPT, in the endoscopic group operative morbidity and mortality was zero. In the non-endoscopic group (n = 461) sixteen complications occurred, although none could have been avoided by preoperative cholangiography. Two patients showed retained calculi (0.3%), missed by preoperative diagnostics. Both cases were successfully treated by ERC. Intraoperative cholangiograms were not done routinely (11%). In conclusion, we think, that selective, preoperative ERC/P, EPT and stone removal--if necessary--facilitate a very low morbidity and mortality in the laparoscopic treatment of complicated gallstone disease. By means of the "therapeutical splitting" the conversion to open bile duct surgery with all its higher morbidity and mortality can be eradicated. Also, only a few of the endoscopically operating hospitals already provide equipment for laparoscopic bile duct revision, not to talk about the gifted and experienced surgeons.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1989

Selective ERCP and preoperative stone removal in bile duct surgery.

This project was undertaken to evaluate in a prospective fashion the effects of selective preoperative endoscopic-retrograde cholangiography and stone extraction (ERCP-ST EXTR) on the results of biliary tract surgery. Over a 6-year period, 728 patients with primary or secondary biliary tract disease were admitted to the First Surgical Department, landeskrankenanstalten, Salzburg, Austria. If, based on preoperative screening, the possibility of common bile duct stones (CBDS) existed, the patients were subjected to ERCP-ST EXTR. Two to 4 days later, these patients underwent a simple cholecystectomy with intraoperative cholangiogram and functional manometry. Evaluation criteria for this study were morbidity, mortality, and retained stone (RST) rates. The overall complication rate for the entire series was 6%. In patients who underwent operative common duct stone removal (n = 78), the complication rate amounted to 21.8%. The rate was reduced to 2.1% by ERCP-ST EXTR. The RST rate was likewise reduced from 2.2% to 0.5% by ERCP-ST EXTR. Mortality in patients with CBDS fell from 3.8% to 1% through the use of this method. In those patients with secondary stones who were treated by ERCP-ST EXTR only, morbidity was 2%, the RST rate was 0%, and mortality was 0%. It is concluded that selective ERCP-ST EXTR, followed by simple cholecystectomy, is a suitable treatment protocol and that this approach may reduce complication and mortality rates.

Adult↗