EDITOR,-I C McManus and colleagues rightly emphasise the importance of teaching communication skills, but they do not mention written communication. Sometimes at the end of a consultation the patient is so exhausted and confused that, however good the doctor's communication skills, he or she has difficulty in comprehending the opinion given and the advice proffered. In a randomised trial in the Milton Keynes department of psychiatry, in association with the applied psychology unit of Cranfield College of Aeronautics, colleagues and I found that this problem could be overcome by writing to the patient after an outpatient consultation and summarising both the patient's and the doctor's contributions to the consultation.Patients who received letters were significantly more pleased with the consultation than patients whose general practitioners received letters in the traditional way.2 Patients reported that the receipt of a letter increased their self esteem and made them feel valued by the service.' They pointed out that to be written to (rather than about) was to be treated as a sane and responsible person; this was especially important to those attending the psychiatric outpatient clinic, in many cases for the first time in their lives. The letters were read many times; they were frequently shown to other family members and so formed the basis of family discussion about the illness and its treatment. The referring general practitioner was sent a copy of the letter and so knew what the patient had been told by the psychiatrist. The patients were asked to bring the letters to follow up consultations and to request correction and clarification when necessary.Several patients spontaneously remarked, "Why can't all doctors do this?" In fact, letters and other forms of written summary have been found useful in other specialties2 4; why not general practice too?We found that the prospect of writing to the patient rather than to the general practitioner made our consultations more patient centred. They were harder work but more fun. Why not make some experience of writing to the patient a regular part of the medical student curriculum or general professional training?
ERCP in 0,48% of patients with gallstone disease, the median age was 55.5 (46-69.5) without gender difference. 50% of our cases were diagnosed before surgery. Endoscopic therapeutic procedures included biliary decompression techniques using nasal bile drainage or plastic stents, balloon sweeping after selective catheterization of cystic duct and large balloon papillary dilation with double cannulation. The success rate of endoscopic management was 66,6%. Surgical treatment was performed at the same time as laparoscopic cholecystectomy in patients with lithiasic gall bladder. CONCLUSIONS: Mirizzi syndrome remains a fascinating and rare condition complicating gallstone disease with no uniform guidelines to date. Our study emphasizes the role of ERCP as a diagnostic and therapeutic procedure in the management of type I Mirizzi syndrome.
Background: Klatskin's tumour is a cholangiocarcinoma that develops from the right or left bile ducts and the upper part of the main bile duct. They are usually diagnosed at an advanced, inoperable stage, and have an extremely poor prognosis. Biliary drainage is proposed in palliative situation and carries a high risk of infectious complications. The aim of our work is to report the results of endoscopic biliary drainage as well as the factors associated with its success or failure. Methods: This is a retrospective and analytical study of 75 patients, conducted between July 2009 and August 2021, including all patients admitted with Klatskin's tumour and for whom endoscopic drainage was indicated. Factors associated with the success or failure of endoscopic treatment were studied by logistic regression analysis. Results: The average age of our patients was 62.67 years with a male predominance of 68%. Cholangiocarcinoma was classified as bismuth IV in 50.6% of patients, bismuth IIIa in 30% of patients, bismuth IIIb in 13% of patients and bismuth II in 6% of patients. Sixteen percent of patients had liver metastases. Endoscopic drainage was successfully performed in 81.3% of patients by plastic prosthesis in 32% of cases, by a metal prosthesis in 45.2% and by nasobiliary drain in 4.1% . Forty-seven percent of patients had dilatation of the stenosis prior to prosthesis placement. Causes of stenting failure were primarily related to failure of papilla catheterisation, failure to pass the guidewire through the stenosis, or duodenal invasion by the tumour. In multivariate analysis and by adjusting the studied parameters, namely the age, gender, bismuth tumour type, presence of metastases and endoscopic dilatation of the stenosis, only the presence of metastases, endoscopic dilatation of the stenosis and the bismuth tumour classification affect the success rate. Indeed, endoscopic dilatation of the stenosis prior to stenting increases the success rate fourfold. Prosthesis increases the success rate by a factor of 4 [OR=4; p=0.01], whereas the presence of metastases decreases this rate by 65% [OR=0.35; p<0.001]. However, tumours classified as bismuth IV [OR=8; p<0.001] or bismuth IIIa [OR=5; p=0.004] were associated with a risk of endoscopic treatment failure. Conclusion: Our study suggests that the presence of metastatic hilar cholangiocarcinoma classified as bismuth IV or bismuth IIIa appear to be associated with failure of endoscopic biliary drainage, whereas endoscopic dilatation prior to prosthesis placement appears to be associated with success.
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