1. SURGICAL MANAGEMENT Cholecystitis

2. Acute Cholecystitis Acute Calculous Cholecystitis – Infectious mechanism from stone impaction in cystic duct Empiric antibiotics Laparoscopic vs. Open cholecystectomy Acute Acalculous Cholecystitis – In critically ill patients High risk for perforation Percutanous cholecytostomy

3. Acute Cholangitis Bactibilia + Biliary obstruction – IV antibiotics – Fluid resuscitation – Biliary drainage Acute Suppurative Cholangitis – Delineation of proximal bile anatomy – Percutaneous transhepatic cholangiography and Biliary stent placement

4. LAPAROSCOPIC CHOLECYSTECTOMY

6. ERCP Endoscopic retrograde cholangiopancreatography

7. ERCP Endoscopic Retrograde Cholangiopancreatography – For the diagnosis and treatment of benign and malignant pancreaticobiliary diseases IndicationsBenefits Gallstones trapped in main bile duct Blockage of bile duct Jaundice Undiagnosed persistent, recurrent upper abdominal pain Unexplained loss of appetite and weight loss Cancer of the bile ducts or pancreas Pancreatitis Diagnostic and therapeutic technique (e.g. gallstones, blockage) Shorter hospital stay

8. ERCP Duodenoscope Fiber-optic duodenoscope Videoscope Catheter 6 or 7 Fr Teflon tapering to a 3-5 Fr tip

9. ERCP Prognosis – Success rate 70%-95% Complications – Pancreatitis (7.2%) – Hemorrhage (0.8%) – Cholangitis 2° incomplete drainage (0.8%) – Perforation (0.08%) – Others (1.5%) e.g. Bile peritonitis or bilomas

10. Post-ERCP Pancreatitis Patient-related characteristics – sphincter of Oddi dysfunction (21.7%) – previous ERCP-related pancreatitis (19%), and – recurrent pancreatitis (16.2%) PAIN DURING PROCEDURE (27%) Technique-related characteristics – precut access papillotomy (20%), – multiple cannulation attempts (14.9%), – sphincterotome use (13.1%), – pancreatic duct manipulation (13%), – multiple pancreatic injections (12.3%), – guidewire use (10.2%), and – extent of pancreatic duct opacification (10%)

11. Post-ERCP Pancreatitis Risk Factors – Multiple cannulation attempts >1 (P = 0.0001, OR 3.14, 95 % CI 1.74 - 5.67) – Female sex (P < 0.001, OR 2.22, 95 % CI 1.43 - 3.45) – Age (P < 0.002, OR 1.09 per 5 year decrease, 95 % CI 1.03 - 1.15) – Performance in a district hospital vs. university hospital (P = 0.034, OR 2.41, 95 % CI 1.08 - 5.41) – Pain during procedure – History of recurrent pancreatitis – Precious ERCP-related pancreatitis – Pancreatic brush cytology

12. STENTS AND DRAINS

13. Drainage devices Stents – Plastic stents 3-11.5 Fr, Polyethylene and Teflon materials Rapid palliation of obstruction Shorter hospital stay Less expensive than metal stents ($100) Indications – Malignant biliary obstruction – Relieve obstruction of previous metal stents – Benign strictures – Biliary leaks and fistulae Indwelling stents t max = 4-6 weeks

14. Drainage devices Stents – Self-expandable metal stents (SEMS) Expansion of 8-10mm Prolonged patency over plastic stents Do not occlude from bacterial biofilm Costly (>$1800)

15. Drainage devices Stents – Nasobiliary drainage catheters 5-7 Fr, 250cm long, 5-9 sideports For temporary drainage of the biliary tree Nasal transport tube (reroute tube from mouth to nose) + Connecting tube (for irrigation and drainage)

16. Stents – Bioabsorbable stents Improved patency Large diameter Lower biofilm accumulation Reduced incidence of bile duct proliferative changes Lesser procedures Drug elution and control – Antimicrobial or antineoplastic agents impregnated on cover – Bioengineered tissue culture Drainage devices

17. Pros – Palliative bypass without invasive surgery Cons – Device failure – Deployment failure – Malpositioning of stent – Stent occlusion Complications – Deposition of bacterial biofilm and/or plant material (30%) – Cholecystitis (2.9%-12%) – Stent migration (5%) – Cholangitis – Hemorrhage – Perforation – Pancreatitis – Perforation

18. References Chak, A. et. al. Effectiveness of ERCP in Cholangitis: A Community-based Study. Gastrointestinal Endoscopy (2000) Vol 54, No.4 pp484-489 a Judah, Joel and Peter Draganov. Endoscopic Therapy of Benign Biliary Strictures. World Journal of Gastroenterology (July 2007) 13(26): 3531-3539 Lillemoe K.D. Surgical Treatment of Biliary Tract Infections. The American Surgeon (2000) Vol 66 No. 2 pp. 138-144 Vandervoort, J. et. al. Risk Factors for Complications After Performance of ERCP. Gastrointestinal Endoscopy (2002) Vol 56, Issue 5, pp. 652-656 Williams, EJ. et. al. Risk Factors for complications following ERCP; Results of a Large-scale, prospective multicenter study. Endoscopy (2007) Vol 39 No. 9 pp. 793-801 “ERCP”. Jackson Siegelbaum. Gastroenterology. (http://gicare.com/Endoscopy-Center/ERCP.aspx)http://gicare.com/Endoscopy-Center/ERCP.aspx “ERCP” MedicineNet, Inc http://www.medicinenet.com/script/main/art.asp?articlekey=358http://www.medicinenet.com/script/main/art.asp?articlekey=358 Baron, TH, Kozarek, R, Carr-Locke, DL. ERCP. Elsevier Inc (2008), China. Cotton, Peter and Joseph Lesing. Advanced Gastric Endoscopy: ERCP. Blackwell Publishing Ltd (2006) pp 35-79, USA. Silverstein, FE and Guido, NJT. Gastrointestinal Endoscopy, 3 rd edition, Mosby-Wolfe (1997) pp 237- 260, London, UK.