OPBR could lead to inflammatory changes of the biliary epithelium and progress towards the development of precancerous mucosal changes and gallbladder cancer. The reason why such high levels of pancreatic enzymes are regurgitated into the biliary tree of patients with gallbladder cancer should be clarified.

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.

Clinical and surgical observations confirm that acute cholecystitis (ACh) and acute biliary pancreatitis can coexist and that differentiation may be difficult even at surgery. Synchronous appearance of ACh and acute biliary pancreatitis suggests a similar etiology. Endoscopic sphincterotomy, with relief of the common channel outlet obstruction, has become the established therapeutical modality that improves the outcome in acute biliary pancreatitis. Patients suffering from ACh could be treated in a similar manner to prevent reflux of pancreatic juice into the common bile duct and the gallbladder with the intention to improve the clinical course. The present study investigated the presence and amount of pancreatic trypsin in the gallbladder bile in 73 patients operated on for gallstone disease with ACh and in controls. The average gallbladder bile trypsin level in the "edematous cholecystitis" group ranged between 0.525 and 4500 ng/mL, significantly exceeding that of controls, 0.5-53 ng/mL (P < 0.0001). The average gallbladder bile trypsin level in the "gangrenous cholecystitis" group, 0.1-71.5 ng/mL, was within the range of controls (n.s.), most likely to be explained as a consequence of consumption of trypsin due to the fulminant development of the disease. Further controlled studies are mandatory before it would be acceptable to recommend endoscopic sphincterotomy as a valuable choice in the initial/early management of patients suffering from ACh. Such a study is underway to assess the possible role of obstruction at, or other disorders of, the sphincter of Oddi with consequent pancreatic juice reflux into the gallbladder as a possible initial cause of ACh.

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.

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.

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.

No abstract

No abstract