Ann Chir. 1986;40:184-195. 4. Schein M, Saadia R, Decker GAG. The open management of the septic abdomen. Surg Gynecol Obstet. 1986;163:587-592. 5. Schein M, Saadia R, Freinkel Z, Decker GAG. Aggressive treatment of severe diffuse peritonitis: a prospective study. Br J Surg. 1988;75:173-176. 6. Schein M, Decker GAG. Gastro-intestinal fistulas associated with large abdominal wall defects: experience with 43 cases. Br J Surg. 1990;77:97\x=req-\ 100.
cases.
Reply.\p=m-\Dr Schein disagrees with supposition that the occurrence of nontraumatic small-bowel perforations during open treatment for intra-abdominal sepsis has not been described so far In
our
and states that it is a well-known and documented entity. Intestinal perforations and fistulizations are indeed common complications in patients treated for intra-abdominal sepsis, but there are obvious causes for fistulization in all cases reported in the literature, such as abdominal reentry damage, anastomotic breakdown, or abdominal-wall dehiscence. Dr Schein cites several references to support his argument but, again, all these cases had obvious causes. The article by Sitges-Serra et al deals with 87 fistulas, all secondary to either anastomotic breakdown, direct trauma to the small bowel, or small-bowel inflammation. In the article by Levy et al, causes for fistulization were anastomotic dehiscence (52%), small-bowel trauma (41%), abdominal-wall necrosis (1.7%), and a combination of these factors (5.3%). Schein's own group1 described a patient with a small-bowel fistula that, as they stated, was due to the polypropylene mesh. Bradley and Fulenwider^ re¬ ported a similar experience. The perforations described by us de¬ veloped in the granulating layers of leftopen abdomens, not in abdominal-wall dehiscences. They occurred in intact segments of the small bowel, not in pre¬ existing suture lines, and they were not the result of reentry damage, because then they would have been treated ei-
ther by suturing (and sutures would have been present at the site of perfora¬
tion) or by creating a stoma. Therefore,
they were not the result of well-known causes but indeed formed an entity that has not been described previously. When not treated, the perforations became large defects in granulating lay¬ ers, mimicking loop enterostomies, that could not be dealt with adequately. An expectant approach, as in small enterocutaneous fistulas
(which Dr Schein
probably thinks we are dealing with), was not possible. There were no recur¬ rences after resection and primary anastomosis, but the
recurrence rate 18% after closing in layers. Finally, the mortality in this series (64%) was not related to the occurrence of perfora¬ tions but to the underlying disease. Therefore, we stick to our therapeutic was
recommendations. HAN C. KUIJPERS, MD, PHD WALTER MASTBOOM, MD THEO WOBBES, MD, PHD FRANS SCHOOTS, MD Nijmegen, the Netherlands 1. Schein
M, Saadia R, Freinkel Z, Decker GAG.
Aggressive treatment of severe diffuse peritonitis: a prospective study. Br J Surg. 1988;75:173-176. 2. Bradley E, Fulenwider JT. Open treatment of pancreatic abscess. Surg Gynecol Obstet. 1984; 159:509-513.
Elective Cholecystectomy After Biliary Lithotripsy: An Indication for Routine Intraoperative
lithotripsy. There were no indications of intraoperative cholangiography except the presumption that stone fragments were likely to have traveled down the common bile duct. ary
Report of a Case. \p=m-\A50-year-old Hispanic presented with recurrent postprandial right upper quadrant pain and nausea 6 months after undergoing biliary lithotripsy for symptomatic cholelithiasis. These symptoms began 10 years before admission. Prior to lithotripsy, a single 2-cm gallstone was documented sonographically. Her symptoms persisted and she requested surgical treatment. She denied a history of dark urine, acholic stools, jaundice, fever, or chills. Physical examination was significant for a well-appearing anicteric woman without abdominal tenderness or palpable masses. Complete blood cell counts and results of liver function chemistry analyses were nor¬ mal. A repeated sonogram demonstrated multiple gallstones and normal gallbladder woman
wall thickness. The common bile and intrahe¬ patic ducts were not dilated and there were no stones seen within the common bile duct. At operation, the gallbladder was found to be noninflamed and multiple gallstones were palpable. The common bile duct was of nor¬ mal caliber. A routine cholecystectomy was performed, and an intraoperative cystic duct cholangiogram revealed three small filling defects in the distal common bile duct. A common bile duct exploration was performed in the usual fashion with the retrieval of three small angulated cholesterol stones, each measuring less than 1 cm. A follow-up T-tube cholangiogram revealed no residual filling defects and prompt flow of contrast material into the duodenum.
Cholangiography? To the Editor.\p=m-\Given the increasing popularity of extracorporeal shock wave biliary lithotripsy and the fact that small stone fragments leave the gall-
Comment.—With the above consid¬ erations in mind, we feel that the list of indications for routine cystic duct cholangiography should be expanded to include those patients who undergo elective cholecystectomy following at¬
becoming more apparent. We report a case of a patient who underwent elective cholecystectomy after failing bili-
I. MICHAEL LEITMAN, MD KIMBERLY VAN ZEE, MD ANTHONY C. ANTONACCI, MD New York, NY
bladder via the common bile duct, the complications of this therapy are now
tempted biliary lithotripsy.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/07/2015
cases.
Reply.\p=m-\Dr Schein disagrees with supposition that the occurrence of nontraumatic small-bowel perforations during open treatment for intra-abdominal sepsis has not been described so far In
our
and states that it is a well-known and documented entity. Intestinal perforations and fistulizations are indeed common complications in patients treated for intra-abdominal sepsis, but there are obvious causes for fistulization in all cases reported in the literature, such as abdominal reentry damage, anastomotic breakdown, or abdominal-wall dehiscence. Dr Schein cites several references to support his argument but, again, all these cases had obvious causes. The article by Sitges-Serra et al deals with 87 fistulas, all secondary to either anastomotic breakdown, direct trauma to the small bowel, or small-bowel inflammation. In the article by Levy et al, causes for fistulization were anastomotic dehiscence (52%), small-bowel trauma (41%), abdominal-wall necrosis (1.7%), and a combination of these factors (5.3%). Schein's own group1 described a patient with a small-bowel fistula that, as they stated, was due to the polypropylene mesh. Bradley and Fulenwider^ re¬ ported a similar experience. The perforations described by us de¬ veloped in the granulating layers of leftopen abdomens, not in abdominal-wall dehiscences. They occurred in intact segments of the small bowel, not in pre¬ existing suture lines, and they were not the result of reentry damage, because then they would have been treated ei-
ther by suturing (and sutures would have been present at the site of perfora¬
tion) or by creating a stoma. Therefore,
they were not the result of well-known causes but indeed formed an entity that has not been described previously. When not treated, the perforations became large defects in granulating lay¬ ers, mimicking loop enterostomies, that could not be dealt with adequately. An expectant approach, as in small enterocutaneous fistulas
(which Dr Schein
probably thinks we are dealing with), was not possible. There were no recur¬ rences after resection and primary anastomosis, but the
recurrence rate 18% after closing in layers. Finally, the mortality in this series (64%) was not related to the occurrence of perfora¬ tions but to the underlying disease. Therefore, we stick to our therapeutic was
recommendations. HAN C. KUIJPERS, MD, PHD WALTER MASTBOOM, MD THEO WOBBES, MD, PHD FRANS SCHOOTS, MD Nijmegen, the Netherlands 1. Schein
M, Saadia R, Freinkel Z, Decker GAG.
Aggressive treatment of severe diffuse peritonitis: a prospective study. Br J Surg. 1988;75:173-176. 2. Bradley E, Fulenwider JT. Open treatment of pancreatic abscess. Surg Gynecol Obstet. 1984; 159:509-513.
Elective Cholecystectomy After Biliary Lithotripsy: An Indication for Routine Intraoperative
lithotripsy. There were no indications of intraoperative cholangiography except the presumption that stone fragments were likely to have traveled down the common bile duct. ary
Report of a Case. \p=m-\A50-year-old Hispanic presented with recurrent postprandial right upper quadrant pain and nausea 6 months after undergoing biliary lithotripsy for symptomatic cholelithiasis. These symptoms began 10 years before admission. Prior to lithotripsy, a single 2-cm gallstone was documented sonographically. Her symptoms persisted and she requested surgical treatment. She denied a history of dark urine, acholic stools, jaundice, fever, or chills. Physical examination was significant for a well-appearing anicteric woman without abdominal tenderness or palpable masses. Complete blood cell counts and results of liver function chemistry analyses were nor¬ mal. A repeated sonogram demonstrated multiple gallstones and normal gallbladder woman
wall thickness. The common bile and intrahe¬ patic ducts were not dilated and there were no stones seen within the common bile duct. At operation, the gallbladder was found to be noninflamed and multiple gallstones were palpable. The common bile duct was of nor¬ mal caliber. A routine cholecystectomy was performed, and an intraoperative cystic duct cholangiogram revealed three small filling defects in the distal common bile duct. A common bile duct exploration was performed in the usual fashion with the retrieval of three small angulated cholesterol stones, each measuring less than 1 cm. A follow-up T-tube cholangiogram revealed no residual filling defects and prompt flow of contrast material into the duodenum.
Cholangiography? To the Editor.\p=m-\Given the increasing popularity of extracorporeal shock wave biliary lithotripsy and the fact that small stone fragments leave the gall-
Comment.—With the above consid¬ erations in mind, we feel that the list of indications for routine cystic duct cholangiography should be expanded to include those patients who undergo elective cholecystectomy following at¬
becoming more apparent. We report a case of a patient who underwent elective cholecystectomy after failing bili-
I. MICHAEL LEITMAN, MD KIMBERLY VAN ZEE, MD ANTHONY C. ANTONACCI, MD New York, NY
bladder via the common bile duct, the complications of this therapy are now
tempted biliary lithotripsy.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/07/2015
