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Query: UMLS:C0016382 (flushing)
 6,387 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Laparoscopic cholecystectomy has emerged as the treatment of choice for uncomplicated cholelithiasis. Despite early concerns, many surgeons have applied this new technique to more complicated biliary tract disease states, including biliary pancreatitis. To evaluate the safety of laparoscopic cholecystectomy in this setting, we retrospectively reviewed 29 patients with clinical and laboratory evidence of biliary pancreatitis who underwent this procedure between March 1990 and December 1992. The severity of pancreatitis was determined by Ranson's criteria. Two patients had a Ranson's score of 6, one of 5, one of 4, five scored 3, nine scored 2, nine also scored 1, and two patients scored 0. The mean serum amylase level on admission was 1,610 (range 148 to 7680). All patients underwent laparoscopic cholecystectomy during the same hospital admission for biliary pancreatitis, with the mean time of operation being 5.5 days from admission. Operative time averaged 123 minutes (range 60-220 minutes). Intraoperative cholangiography was obtained in 76 per cent of patients. Three patients had choledocholithiasis on intraoperative cholangiography and were treated with choledochoscopy, laparoscopic common bile duct exploration, and saline flushing of the duct. The mean length of hospital stay was 11 days (range 5-32 days). There were seven postoperative complications requiring prolonged hospitalization with all but one treated non-operatively. One patient with a preoperative Ranson score of 6 developed necrotizing pancreatitis and subsequently required operative pancreatic debridement and drainage. There were no deaths in this series and no postoperative wound infections. The average recovery period for return to work was 2 weeks. These statistics compare favorably with literature reports for open cholecystectomy in biliary pancreatitis.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Laparoscopic cholecystectomy in biliary pancreatitis. 750 11

The advent of laparoscopic cholecystectomy (LC) has led to a reassessment of the approach to the management of choledocholithiasis. In a consecutive series of 418 patients undergoing LC, common bile duct (CBD) stones were suspected pre-operatively in 130 patients. Forty-five of the patients (35%) were found to have CBD stones on either pre-operative endoscopic retrograde cholangiopancreatography (ERCP; 20) or on operative cholangiography (OC; 25). Common bile duct stones were detected on OC in a further 12 of 288 patients (4.2%) without pre-operative suspicion of choledocholithiasis. Of the total of 57 patients with CBD stones, the duct was cleared by pre-operative ERCP and endoscopic sphincterotomy (ES) in 15 patients. In 13 patients, two of whom had had a pre-operative ERCP and ES, duct clearance was achieved by relaxing the sphincter pharmacologically and flushing the CBD via the OC catheter. One patient had an on-table ERCP and ES with successful stone extraction during LC. Eleven patients were converted to open operation with bile duct exploration. Sixteen patients had a postoperative ERCP. In five patients the CBD stones had passed spontaneously in the time between LC and ERCP. Ten patients required ES to clear the duct of stones. One patient had a failed ERCP and is still awaiting a repeat. The remaining patient was scheduled, but did not return for follow-up ERCP. In summary, pre-operative ERCP was indicated in less than 10% of patients in this series.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Laparoscopic cholecystectomy and management of choledocholithiasis. 849 12

A 68-yr-old woman who had had a cholecystectomy and endoscopic sphincterotomy developed recurrent common bile duct obstruction. She had another ERCP with extension of the site of endoscopic sphincterotomy, and 3 days later biliary obstruction again developed, this time from a blood clot filling the common bile duct. The clot was removed by Fogarty technique, and the duct was irrigated with heparin; the obstruction resolved. Minor hemobilia (biliary tract hemorrhage without overt GI bleeding) may be confused with choledocholithiasis. When biliary obstruction follows endoscopic sphincterotomy, attempts at flushing the duct should precede empiric maneuvers for stone removal.
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PMID:Bleeding causing biliary obstruction after endoscopic sphincterotomy. 912 34

Different strategies and imaging modalities have been used to detect common bile duct (CBD) stones during laparoscopic cholecystectomy. We prospectively compared fluoroscopic intraoperative cholangiography (FIOC) and laparoscopic intracorporcal ultrasonography (LICU) in patients undergoing laparoscopic cholecystcctomy for this purpose. In a consecutive series of 607 laparoscopic cholecystectomics, FIOC was used in the first 407 patients, whereas LICU was preferentially applied to the subsequent 200 patients. When LICU documented CBD stones, the duct was flushed with saline solution after intravenous administration of glucagon, and stone persistence or absence was confirmed by FIOC and/or repeat LICU. In the FIOC group, 10 patients were converted to open cholecystectomy and 16 patients did not undergo FIOC. Among the remaining 381 patients, FIOC was successful in 370 (97%). In the LICU group, two patients were converted and LICU was not performed in 26 patients. In the remaining 172 patients, the cystic duct (CBD) junction and the CBD were visualized in all cases (P <0.05 vs. FIOC). The mean (+/- SEM) times required to complete FIOC and LICU were 15. 1 +/- 0.4 minutes and 5.3 +/- 0.2 minutes, respectively (P <0.0001). Choledocholithiasis was detected in 25 patients (7%) undergoing FIOC and in 22 patients (13%) undergoing LICU (P <0.05). In the LICU group, the mean sizes of the stones cleared by ampullary dilatation and flushing (17 of 22, 77%) and those requiring more invasive methods (5 of 22, 23%) were 1.6 +/- 0.2 mm and 2.7 +/- 0.3 mm, respectively (P <0.01). Sludge seen in the CBD by LICU in 10 patients (6%), which disappeared with flushing in all cases. LICU is accurate, safe, and permits more rapid evaluation of bile duct stones than FIOC during laparoscopic cholecystectomy. LICU may be overly sensitive in detecting small stones and sludge, which are of questionable significance. Stones 2 mm or less can usually be cleared by flushing, whereas larger ones often require invasive techniques for removal.
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PMID:The utility of intracorporeal ultrasonography for screening of the bile duct during laparoscopic cholecystectomy. 984 68

Our objective was to review our community hospital experience with laparoscopic management of choledocholithiasis from 1991 to 1997. We performed a retrospective review of all case records of patients with choledocholithiasis managed surgically at St. Francis Hospital during the study period. Data regarding the history, presentation, investigations, operative details, and follow-up were recorded. Procedures were performed by multiple attending surgeons supervising surgical residents. All common bile duct explorations (CBDEs) were performed by a transcystic approach and followed routine cholangiography. In most cases, cystic duct dilatation over a guide wire was followed by transcystic CBDE with choledochoscopy. Stone extraction was accomplished through a combination of flushing, basket manipulation, fragmentation, retrieval, or advancement of stones through the ampulla. Data were analyzed using SPSS computer software, and P < 0.05 was considered statistically significant. During the period of study there were 1053 laparoscopic cholecystectomies with and without cholangiography and 100 total CBDE performed. Of these, 54/100 had an attempt at laparoscopic CBDE. There were 39 females and 15 males, with a median age of 52 years (range 14-88). Presentation included acute cholecystitis or biliary colic (63%), gallstone pancreatitis (20%), and jaundice or cholangitis (17%). Successful laparoscopic stone removal was achieved in 36 of 54 (67%) cases. Eighteen of the remainder (33%) were converted to an open procedure. Size, number, position of stones, technical difficulties in accessing the common bile duct, and patient factors contributed to open conversion. The rate of successful laparoscopic CBDE improved for each individual surgeon from an average of 22 per cent in the first half of the study period (1991-1994) to 87 per cent in the second half (1995-1997). There was no operative mortality. Significant morbidity in the laparoscopic group included one retained stone and two cases of postoperative pancreatitis. There were three false negative preoperative endoscopic retrograde cholangiopancreatography examinations. Multivariate analysis showed that experience of the individual surgeon was the only significant factor predicting successful laparoscopic CBDE. Low initial success rate in the early phase of the study period improved dramatically to reach an overall success rate of 87 per cent in the second half. Laparoscopic management of common bile duct stones is possible in a community setting with a high success rate and minimal morbidity. It precludes excessive use of endoscopic retrograde cholangiopancreatography with its own set of complications but is associated with a significant learning curve. It is currently our preferred therapeutic approach for choledocholithiasis discovered pre- or intraoperatively.
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PMID:Laparoscopic transcystic management of choledocholithiasis. 1039 67