Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_785_Библиотеки_им_академика_М_И_Перельмана
.pdf
20.2 Acute Cholangitis 207
What Are the Signs of Complications?
In the elderly patient, or when medical intervention is delayed, the syn-
drome can progress to include two further clinical features:
Confusion (do not assume that any elderly confused patient has senile de-
mentia; ask about the patient’s baseline mental status)
Septic shock
These two, when added to the Charcot’s triad, become the Reynold’s pentad
(B. M. Reynolds, United States), which is associated with a fourfold mortality risk
increase; consequently, clinical decision intervals must be very diligent and hourly.
Special Investigations
Ascending cholangitis is diagnosed on the aforementioned clinical grounds.
With early presentation, the jaundice may only be biochemical and must be substantiated by a liver panel. A typical panel has mildly elevated transaminases,
variably elevated total bilirubin with a direct preponderance, and a dispropor-
tionately elevated alkaline phosphatase and glutamyl transferase; white cells are
usually elevated. Amylase may be mildly elevated (less than fivefold elevation),
representing, perhaps, “chemical pancreatitis.” Note, however, that patients with
gallstone pancreatitis (> Chap. 20.3) may have an associated element of ascending cholangitis. Other laboratory data will be appropriate for the patient’s degree
of hydration and respiratory status, which can deteriorate rapidly if the patient
presents late or the diagnosis is delayed.
The RUQ sonogram is the simplest test to confirm the diagnosis. Most of the
time, gallstones are seen in the gallbladder (unless the patient has had a prior cholecystectomy). Mild intrahepatic ductal dilatation may be demonstrated, and the common hepatic duct/CBD axis will be variably dilated above a normal level of 7 mm.
Ultrasound is notorious for missing around half of bile duct stones, so do not be
fooled if you do not see any. If gallstones are not seen in the gallbladder, then the diagnosis of malignant periampullary biliary obstruction must be suspected to justify
the performance of a computed tomographic (CT) scan, MRCP, or both or even an
endoscopic ultrasound (EUS), depending on the facilities available in your center.
Trea tm ent
Initial Management
Antibiotics. Initial management comprises appropriate empiric antibiotics
with bowel rest and rehydration. Although it has always been felt that antibiotic
208 Gary Gecelter
selection should be based on the drug’s ability to concentrate in the biliary system,
recent re-evaluation of this concept has concluded that no antibiotics are able to
reach obstructed bile, and that the spectrum of suspected pathogens is a better target for antimicrobial selection. Coverage must be directed against gram-negative,
gut-derived organisms (typically Escherichia coli and Klebsiella). Up to a fifth of
bile cultures will grow anaerobic organisms such as Bacteroides or Clostridia sp.,
so it is a good idea to include a drug like metronidazole.
ERCP. It is important to recognize that most patients will defervesce within
24 hrs on the above treatment, allowing interventional therapies to be scheduled
electively and selectively. A minority of patients will have persistent fever and
pain, and their bilirubin may rise, implying a persistent complete obstruction. It
is at this time that urgent ERCP is indicated with sphincterotomy and stone extraction. It is the gastroenterologist’s task to ensure biliary decompression at the first
attempt. This does not mean complete duct clearance as stones may be difficult to
extract at one session, but it may mean that the placement of a plastic biliary stent
or nasobiliary tube is necessary. The latter’s advantage is that it can be removed
without re-endoscopy after cholecystectomy. If ERCP fails in the critically ill cholangitis patient, there is another nonoperative alternative: ultrasound-guided percutaneous drainage of the obstructed ductal system by the radiologist.
Surgical Strategies
If the patient is one of the majority who settle with initial conservative measures, then one can elect to perform one of the following semielective procedures, based on local expertise:
Preoperative ERCP with common duct clearance, followed by laparoscopic
cholecystectomy.
ERCP with common duct clearance alone, leaving the gallbladder in situ.
This is indicated in the very high-risk patient; on follow-up, most patients
so treated never require a cholecystectomy.
Laparoscopic cholecystectomy with laparoscopic CBD exploration (with or
without a choledochoduodenostomy).
Open cholecystectomy with CBD exploration.
In most hospitals, preoperative ERCP is selected if it is available. It is diagnostic
if periampullary carcinoma is suspected. If it is unsuccessful and the papilla cannot be cannulated, then the surgeon knows preoperatively that clearance of the
biliary tree at operation must be ensured (or the duct bypassed). In most large
centers, biliary and pancreatic anatomical imaging is mostly noninvasive these
days. The role for diagnostic ERCP is shrinking, and fast.
20.2 Acute Cholangitis 209
Primary Emergency Surgical Treatment
We have encountered another subset of patients who present with rapid
clinical deterioration and may even develop diffuse signs suggesting gallbladder
perforation. It is this group who probably benefits from expeditious surgery following resuscitation. The case is made more compelling if they have had a prior
gastrectomy that prevents rapid cannulation for ERCP.
Another option is percutaneous decompression of the biliary system.
Percutaneous US or CT-guided cholecystostomy may do the job if the gallbladder
is in situ, dilated, and communicating with the CBD through a patent cystic duct.
[Percutaneous transhepatic drainage is another option, which may be safer, in
our opinion, than emergency definitive surgery in these severely sick patients—
The Editors.]
Conclusions
Acute cholangitis is best managed by a concordant multidisciplinary team
that understands when appropriate interventions are needed. Since the introduction of endoscopic management of bile duct stones, surgery is seldom required as an emergency. Removal of the gallbladder and clearance of the bile
duct of all stones are the two goals of treatment. In the absence of stones, suspect
periampullary carcinoma. When the patient is toxic and ERCP fails or is not immediately available, do not procrastinate, waiting for “re-ERCP tomorrow”;
rather, operate and drain the obstructed biliary system.
In ascending cholangitis consider the CBD an abscess.
Management of CBD Stones
in Acute Biliary Pancreatitis
B. Ramana
You can read about acute pancreatitis in general in > Chap. 19. Here, the
focus is on the approach to patients with gallstone pancreatitis.
You should suspect gallstone pancreatitis in patients who present with
acute pancreatitis (> Chap. 19) and are found (on ultrasound) to harbor stones
in the gallbladder. Suspect it also in nonalcoholic patients even if stones are not
visualized as occasionally “idiopathic acute pancreatitis” is caused by tiny gallbladder stones or sludge (microlithiasis).
Commonly, in addition to the elevated pancreatic enzymes, there is some
degree of chemical liver dysfunction (similar to that described for patients with
ascending cholangitis). It is believed that biliary pancreatitis is caused by small
stones dropping into the common bile duct (CBD) from the gallbladder and
migrating distally through the papilla. More than 30 years ago, Dr. John Acosta
established his name in the hall of fame of surgery by sifting through the feces of
patients with suspected gallstone pancreatitis, finding small stones in their feces
within 10 days of their admission. In those patients who underwent a laparotomy
within 48 hrs, impacted stones in the papilla were found in more than two-thirds
of individuals (and the morbidity and mortality [M & M] was high); in those who
underwent a delayed operation, no impacted stones were found, and the M & M
was minimal. From Acosta (and the other stool strainers who duplicated his
findings and added more information), we learned:
The vast majority of the CBD stones responsible for pancreatitis pass spon-
ta neously.
Most of the so-called impacted stones will pass into the duodenum if you
wait long enough.
In most such patients, preoperative ERCP is negative for bile duct stones.
In most such patients, the (intraoperative) cholangiogram during laparo-
scopic cholecystectomy (LC) is normal.
Sifting through patients’ feces may change your life and make you famous.
20.3
B. Ramana
Wockhardt Hospitals, 6 C & D, Amaravati, 63 Purna Das Road, Kolkata, 700029, West Bengal, India
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_20.3, © Springer-Verlag Berlin Heidelberg 2010
211
212 B. Ramana
This has taught us how to manage these patients:
Start conservative treatment as described in > Chap. 19. In most patients,
resolution of the clinical features of pancreatitis occurs within a few days and is
marked by normalization of white cell count and pancreatic and liver enzymes. It
is then—within a week or so—that you want to go ahead with cholecystectomy—
preventing recurrent biliary pancreatitis by removing the source of the problem.
There is no need to wait longer; once signs of pancreatic inflammation have subsided and chemical cholestasis is improving, you can safely go ahead with surgery. The aim should be to perform cholecystectomy during the same hospital
admission as the episode of acute pancreatitis.
What about “suspected” CBD stones? How can you be sure that they have
indeed migrated into the duodenum?
If the CBD is not dilated on ultrasound (US) and liver enzymes are back
to normal, there is no need for any preoperative imaging of the CBD. Add-
ing routine intraoperative cholangiogram in this situation is controversial.
Cholangiography may indeed demonstrate small stones, but stones that
would pass spontaneously in most instances.
If the CBD is dilated and liver function is deteriorating, you have to sus-
pect impacted CBD stones (often associated with cholangitis). An urgent
therapeutic ERCP may be needed and if successful followed a day or so
later by LC. Whether an early endoscopic sphincterotomy to remove an
impacted stone is beneficial in aborting the episode of acute pancreatitis
is controversial. Some claim it is—if performed early enough (within a few
hours…)—but try to find a center where patients undergo ERCP within a
few hours after their pains have started.
Nowadays magnetic resonance cholangiopancreatography (MRCP) is a
good option to select which patients need to undergo invasive ERCP before
cholecystectomy. If normal, you can proceed with LC.
Wha t do you do wit h p ati ents w it h co mpl ica ted acu te p anc reat itis ? You surely
do not want to operate on them. Treat conservatively as described in > Chap. 19.
Delay the cholecystectomy until pancreatitis and its complications are resolved.
What d o you do w ith p ati ents w ho a re no t fit for L C? Clearly, you do not have
to rush with LC in medically unfit patients. Let them recuperate from the acute
disease and try to improve their general condition before proceeding with cholecystectomy. Do note, however, that some patients may suffer recurrent acute pancreatitis during the waiting period. Another option (as in high-risk patients with
cholangitis) is ERCP with endoscopic sphincterotomy, leaving the gallbladder in
situ. Now, the stones can enter the CBD and rapidly fall into the duodenum
without producing pancreatitis. This is a viable option on the very old, frail, and
medically unfit, and it has been shown to reduce the risk of recurrent AP.
20.3 Management of CBD Stones in Acute Biliary Pancreatitis 213
In conclusion, in most patients let the pancreatic inflammation subside,
wait for the CBD stones to pass spontaneously, and then remove the gallbladder.
Some patients need bile duct imaging and possibly ERCP and sphincterotomy. In
a few patients, you will have to wait longer for the acute pancreatitis to resolve.
Common Bile Duct Injury Diagnosed During
Laparoscopic Cholecystectomy
It is well said that a bile duct injury is usually the result of a three-part
combo (like a Mac, Coke, and fries): an easy case, abnormal anatomy, and an
overconfident surgeon—often showing off his or her speed or in a hurry. Do
remember this all your life and spare everyone the rigors of a bile duct injury. In
case you are unfortunate enough to have actually done it, and you have realized
it, what then?
Take a deep breath, relax, and accept it. You have done the deed, so do your best
to redeem yourself. The best thing is to avoid denial, something that leads to a
missed diagnosis and kills many. You may find the theater staff or the anesthe-
tist looking at you like it is all your fault. Whatever happens, never panic: it is
bad for your heart—and for the patient’s hepatic duct or whatever is left of it.
Call for help if you do not have experience in managing such injuries. We
hope of course that you do not have too much experience.
Discuss and decide with your buddies about the next step: leave a drain,
close, and ship a patient to the ivory tower institution or convert to laparo-
tomy and address the damage.
Assess whether you have a partial or total injury. This would mean the dif-
ference between doing a hepaticojejunostomy versus a simple suture repair
of the bile duct, often over a T-tube. Also assess if you have injured anything
else, including the hepatic artery, right duct, and so on.
A full-blown excision-transection injury needs a hepaticojejunostomy, an
operation that is not very forgiving. Restenosis and biliary cirrhosis are not
uncommon when repair is done by untrained or unskilled hands. More-
over, there is the issue of ischemia of a duct that has been ruthlessly up-
rooted from its bed. Therefore, if you cannot, do not even try.
We repeat: if you are going to ship the patient out, you should drain the
right subhepatic space. You can ligate the duct off or intubate it (to prevent
biliary peritonitis before the resurgery), but there is a risk of reducing bile
duct length, which may adversely affect prognosis, converting a not-so-
high “Bismuth 2” injury into a higher “Bismuth 3” one. (Henri Bismuth is a
contemporary French surgeon.)
214 B. Ramana
It has been assumed that you would have opened up the patient by now:
it would be very thrilling and dangerous indeed if someone tries to do a
hepaticojejunostomy laparoscopically, and there are people who have done
just about everything laparoscopically. Do not be tempted.
Counsel the patient and the relatives extensively, showing sympathy and
concern. Do not appear to have lost your confidence but never be cocky, saying things like, “Oh, you will be cured of your problems in no time.”
If you have shipped the patient to an ivory tower institution, keep in touch
with the treating surgical team. You never look good when running away
from your own complications.
Keep the number of your lawyer in your mobile speed dial list; you may
need it sooner rather than later.
Small Bowel Obstruction
Moshe Schein
It is less dangerous to leap from the Clifton Suspension Bridge than to suffer from
acute intestinal obstruction and decline operation. (Fredrick Treves, 1853–1923)
By far, the most common causes of small bowel obstruction (SBO) are
postoperative adhesions and hernias. Other less-common mechanical etiologies
are bolus obstruction (e.g., bezoar), malignant or inflammatory (e.g., Crohn’s
disease) causes, or intussusception. Hernias causing SBO are discussed in
>
Chap. 22; early postoperative small bowel obstruction (EPSBO) and paralytic
ileus are discussed in > Chap. 48. SBO developing in the aftermath of bariatric
abdominal surgery is discussed in >Chap. 31. Mention is made here of SBO in the
virgin abdomen, intussusception, the cancer patient, radiation enteritis, and
gallstone ileus. Peritoneal tuberculosis as a cause of SBO is mentioned in >Chap.
37.1. The bulk of this chapter is, however, devoted to adhesive SBO.
Sir William Osler (1849–1919) used to say that “intestinal adhesions are the
refuge of the diagnostically destitute,” but the truth of the matter is that iatrogenic—surgeon-made—adhesions are responsible for more than two-thirds of
episodes of obstruction, whatever the exact mechanisms are. Please note that in
this era of laparoscopic surgery some patients may not volunteer a history of
previous surgery, and the abdominal scar is often almost invisible when the previous operation has been, say, something as banal as laparoscopic tubal ligation.
Banal—yes, but it could have left a single “band” adhesion causing complete
SBO. Remember also that upper abdominal, supracolic, procedures are much
less likely to be associated with small bowel adhesions than the infracolic ones.
Finally, as you are not an internist, we scarcely need remind you that adhesions
almost never (never say never in surgery) cause colonic obstruction.
21
The Dilemma
The majority of patients with adhesive SBO (at least half of them, if not
more) respond to conservative (nonoperative) treatment. But, persevering with
conservative management in SBO may delay the recognition of compromised
Moshe Schein
Marshfield Clinic Ladysmith Center, 906 College Avenue, Ladysmith, WI 54848, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_21, © Springer-Verlag Berlin Heidelberg 2010
215
216 Moshe Schein
(strangulated) bowel, leading to a poor outcome. Clearly, your challenge is to
resolve the following issues:
Which patients need an urgent laparotomy for impending or established
bowel strangulation? And when is initial, conservative treatment appropriate and safe?
Once instituted, how long should conservative treatment be continued be-
fore an operation is deemed necessary? In other words, how do you avoid an
operation without risking intestinal compromise?
All surgeons acknowledge that symptoms and signs suggesting that the
bowel may be compromised call for an immediate operation. However, surgeons
across the world tend to offer a wide range of opinions regarding the duration of
nonoperative therapy before declaring that it failed. Some still preach the outdated dictum “Never let the sun set or rise over intestinal obstruction,” while
others persist in avoiding an operation seemingly forever.
We aim to provide you with guidelines to answer these questions and help
you develop a commonsense approach. First, we need to clarify some terminology.
Definitions
“Simple” obstruction: the bowel is blocked, compressed, or kinked, but its
vascular supply is not threatened.
Strangulation-obstruction: the vascular supply to the segment of ob-
structed bowel is compromised.
Closed-loop obstruction: a segment of bowel is obstructed at a proximal
and distal point. Commonly, the involved bowel is strangulated.
Understanding the terms partial versus complete obstruction is crucial to
the planning of treatment. Some surgeons offer definitions based on symptoms,
which are notoriously inaccurate. To us, the best way to distinguish between
partial and complete SBO is radiology, starting with the humble plain abdominal
X-ray (see > Chap. 5)
Partial obstruction: there is gas seen in the colon in addition to the small
bowel distension with fluid levels.
Complete obstruction: no gas is seen in the colon.
Most episodes of partial SBO will resolve without an operation, while the
majority of patients presenting with a complete obstruction will require one.
Соседние файлы в папке Библиотека им академика М.И. Перельмана