Results of Dwijen
C. Misra, Jr,
Surgical Therapy for Biliary Dyskinesia MD; Geoffrey B. Blossom, MD; Darlene Fink-Bennett, MD; John L. Glover,
hundred eighty-seven patients who presented with symptoms consistent with biliary colic but had no ultrasonic evidence of cholelithiasis were observed in an effort to identify those with a functional gallbladder disorder that might benefit from surgical intervention. All patients underwent quantitative evaluation of gallbladder emptying using cholecystokinin biliary scanning, and ejection fractions less than 35% were considered abnormal. One hundred twenty-nine patients (69%) had abnormal ejection fractions, and 88 (68%) of these subsequently underwent cholecystectomy. Sixty of the surgical specimens revealed pathologic changes. Eighty-four percent of patients successfully contacted for follow-up experienced complete relief, and another 13% had partial relief of preoperative symptoms. Only two patients reported no change in symptom complex. Twenty\x=req-\ nine patients with abnormal ejection fractions elected not to undergo surgery. Fifty-nine percent of these patients continued to experience symptoms of biliary colic at a mean follow-up of 22 months. Of the 44 patients with normal ejection fractions, 35 (80%) reported resolution of symptoms during follow-up of medical treatment. Cholecystokinin biliary scanning can help identify patients with acalculous, functional gallbladder disease who may benefit from chole\s=b\ One
cystectomy. (Arch Surg. 1991;126:957-960)
the perplexing problems facing surgeon what advice give patient referred for One ofdeciding disease without of a
more
is
to biliary tract
a
gall¬ good chance that the gallbladder is diseased and that cholecystectomy will relieve the symp¬ toms, some patients will have normal gallbladders and still recurrent symptoms stones. While there is
have there
persistent are
or
a
recurrent
symptoms.
In such cases,
other, nonmedicai potential risks, such as mal¬
suits (usually for lack of informed consent) and sanctions by peer review organizations. Consequently, it would be useful to have a test that would reliably indicate which patients will have sustained
practice
Accepted for publication June 30,
1991. From the Departments of Surgery (Drs Misra, Blossom, and Glover) and Nuclear Medicine (Dr Fink-Bennett), William Beaumont Hospital, Royal Oak, Mich. Read before the 98th Annual Meeting of the Western Surgical Association, Scottsdale, Ariz, November 13, 1990. Reprint requests to the Department of Surgery, William Beaumont Hospital, 3601 W Thirteen Mile Rd, Royal Oak, Ml 48073 (Dr
Clover).
MD
improvement if surgical treatment is selected. In this re¬ gard, cholecystokinin (CCK) has been used, either alone to reproduce symptoms or in conjunction with cholecystography. We report its use in conjunction with quanti¬
tative cholescintigraphy—calculation ofthe percent of iso¬ tope emptied from the gallbladder after injection of CCK—in 187 patients with symptoms of biliary tract dis¬ ease
whose progress
was
followed up
prospectively.
PATIENTS, MATERIALS, AND METHODS We observed all 187 patients who had undergone CCK biliary scanning between July 1986 and February 1989. These patients had symptoms of recurrent episodes of colicky right-upperquadrant pain thought to be biliary colic. They had been referred for scanning by internists, surgeons, and gastroenterologists af¬ ter various other diagnostic tests had failed to demonstrate sig¬ nificant abnormalities. The test was performed in a fashion sim¬ ilar to that first described by Krishnamurthy et al1 and was adopted in our hospital due to the efforts of Fink-Bennett and DeRidder, who described the technique and reported some re¬ sults. Cholecystokinin hepatobiliary scans were performed follow¬ ing the intravenous administration of 185 000 Bq of technetium Tc 99m disofenin (Hepatolite). All patients had nothing by mouth for 4 to 6 hours before the test. Using a large-field-of-view gamma camera with a low-energy medium resolution, an all-purpose collimator, and a 20% window centered at 140 keV, anterior 500 000count hepatobiliary images were obtained every 10 minutes for 1 hour or until the gallbladder maximally filled (little or no activity within the major hepatic radicles, mainly within the gallbladder itself). Sincalide (Kinevac; 0.02 µg/kg) was then infused over a 3-minute period. Following the CCK infusion, anterior post-CCK analog hepatobiliary images were obtained every 5 minutes for 20 minutes. The post-CCK analog images were obtained for equal time intervals, not counts, and the time per image was deter¬ mined from the number of seconds required to obtain the preCCK anterior 500 000-count biliary scintiscan. Gallbladder ejection fractions were determined from simulta¬ neously acquired 1-minute images stored on a 64 x 64 computer matrix in word mode. Acquisition was begun 1 minute before intravenous administration of CCK and continued for 20 minutes afterward. Ejection fractions were determined by manually as¬ signing regions of interest around the gallbladder and around an adjacent background area on the pre-CCK, 5-minute, 10-minute, 15-minute, and 20-minute post-CCK images. Background activ¬ ity was subtracted from both pre- and post-CCK images. Total counts and the number of pixels within each region of interest were determined and the gallbladder ejection fraction (GBEF) was calculated according to the following formula: GBEF(i)= NetPre-CCK GB Count-Net Post-CCK (at timin)/NetPre-CCK GB Counts
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pennsylvania User on 06/19/2015
GB Counts
Relief of Symptoms at
chronic
No. (%) of Patients
Group 69)
1 (n
=
2 (n
=
29)
=
44)
3 (n
Complete 58 (84) 0
35 (80)
Partial
None
9 (13)
2 (3)
12 (41)
17 (59)
0
9 (20)
in which i indicates the time after CCK administration. For each observation, net GB (gallbladder) counts equal total GB counts minus BK, in which BK equals the number of background counts per pixel multiplied by the number of pixels in the GB region of interest. A normal gallbladder ejection fraction response to CCK was defined as one in which the gallbladder ejected at least 35% of its contents, a value determined by Krishnamurthy et al1 and Mesgarzedeh et al.2 Ejection fractions of less than 35% were deemed indicative of abnormal gallbladder motor function from chronic acalculous cholecystitis, the cystic duct syndrome, and/or gallbladder dyskinesia; these findings were reported by FinkBennett et al3,4 and Swayne et al.5 In the appropriate clinical set¬ ting, these patients were advised to undergo cholecystectomy. The medical records of all 187 patients were reviewed, and the following information was recorded: age, symptom complex, du¬ ration of symptoms, results of CCK-biliary scan and other di¬ agnostic tests, any surgical intervention, and the results of all tissue examinations. Three categories of patients participated in the study: (1) those with abnormal CCK-biliary scan results (max¬ imal gallbladder ejection fraction response to CCK 35%) who had not
undergone cholecystectomy. Some patients with abnormal scan results refused cholecys¬ tectomy initially but changed their minds when symptoms per¬ sisted; they were included in group 1. Cholecystectomies were performed by several members of the surgical staff. After the medical records were reviewed, we attempted to con¬ tact all patients by telephone. A standardized form was used and patients were questioned regarding persistence or resolution of symptoms, further diagnostic evaluations performed, and sat¬ isfaction with surgical procedures performed. Patients who were satisfied with the results of surgery but who had persistence of some of their preoperative symptoms were classified as showing partial improvement. RESULTS
Ofthe 187 patients, 142 (76%) were contacted. The mean age of all patients was 48 years, and the mean duration of symptoms was 17 months. There were 39 men (21%) and 148 women (79%). The mean follow-up was 22 months. Separation of patients into groups 1, 2, and 3 and their status at follow-up is shown in the Table. There were 88 patients in group 1 (abnormal CCK-bil¬ iary scan results and cholecystectomy), including 15 men (17%) and 73 women (83%); their mean age was 44 years, and the mean duration of symptoms was 18 months. Sixtynine patients were interviewed. All patients contacted had preoperative complaints of right-upper-quadrant abdom¬ inal pain, 46 (67%) had fatty food intolerance and 41 (59%) had complained of nausea. Fifty-eight patients (84%) re¬ ported complete resolution of symptoms and no recur¬ rence following cholecystectomy. Nine patients (13%) had improvement of symptoms following surgery but not complete relief. Only two patients (3%) believed they had no
postoperative improvement in symptoms.
the 88 surgical specimens showed six of which (7%) had small gall¬ stones not detected before surgery. The criteria for chronic cholecystitis included the presence of Rokitansky-Aschoff sinuses and lymphocytic and plasmacytic infiltrates in the muscularis. Twelve (14%) of 88 patients had cholesterolosis. Specimens from 28 patients (32%) showed no his¬ tologie abnormality; seven of these patients had partial or no relief of symptoms. In contrast, 39 (95%) of the 41 pa¬ tients with pathologic changes in their gallbladders had resolution of their symptoms (P .011). There were 41 patients in group 2 (abnormal CCK-biliary scan results and no cholecystectomy), including 10 men (24%) and 31 women (76%). The mean age of patients was 54 years, and the mean duration of symptoms was 24 months. Twenty-nine patients were interviewed. Twentyeight (97%) had right-upper-quadrant abdominal pain, 18 (62%) had fatty food intolerance, and 15 (52%) had nausea. Twelve patients (41%) reported some improvement of their symptoms (P
C. Misra, Jr,
Surgical Therapy for Biliary Dyskinesia MD; Geoffrey B. Blossom, MD; Darlene Fink-Bennett, MD; John L. Glover,
hundred eighty-seven patients who presented with symptoms consistent with biliary colic but had no ultrasonic evidence of cholelithiasis were observed in an effort to identify those with a functional gallbladder disorder that might benefit from surgical intervention. All patients underwent quantitative evaluation of gallbladder emptying using cholecystokinin biliary scanning, and ejection fractions less than 35% were considered abnormal. One hundred twenty-nine patients (69%) had abnormal ejection fractions, and 88 (68%) of these subsequently underwent cholecystectomy. Sixty of the surgical specimens revealed pathologic changes. Eighty-four percent of patients successfully contacted for follow-up experienced complete relief, and another 13% had partial relief of preoperative symptoms. Only two patients reported no change in symptom complex. Twenty\x=req-\ nine patients with abnormal ejection fractions elected not to undergo surgery. Fifty-nine percent of these patients continued to experience symptoms of biliary colic at a mean follow-up of 22 months. Of the 44 patients with normal ejection fractions, 35 (80%) reported resolution of symptoms during follow-up of medical treatment. Cholecystokinin biliary scanning can help identify patients with acalculous, functional gallbladder disease who may benefit from chole\s=b\ One
cystectomy. (Arch Surg. 1991;126:957-960)
the perplexing problems facing surgeon what advice give patient referred for One ofdeciding disease without of a
more
is
to biliary tract
a
gall¬ good chance that the gallbladder is diseased and that cholecystectomy will relieve the symp¬ toms, some patients will have normal gallbladders and still recurrent symptoms stones. While there is
have there
persistent are
or
a
recurrent
symptoms.
In such cases,
other, nonmedicai potential risks, such as mal¬
suits (usually for lack of informed consent) and sanctions by peer review organizations. Consequently, it would be useful to have a test that would reliably indicate which patients will have sustained
practice
Accepted for publication June 30,
1991. From the Departments of Surgery (Drs Misra, Blossom, and Glover) and Nuclear Medicine (Dr Fink-Bennett), William Beaumont Hospital, Royal Oak, Mich. Read before the 98th Annual Meeting of the Western Surgical Association, Scottsdale, Ariz, November 13, 1990. Reprint requests to the Department of Surgery, William Beaumont Hospital, 3601 W Thirteen Mile Rd, Royal Oak, Ml 48073 (Dr
Clover).
MD
improvement if surgical treatment is selected. In this re¬ gard, cholecystokinin (CCK) has been used, either alone to reproduce symptoms or in conjunction with cholecystography. We report its use in conjunction with quanti¬
tative cholescintigraphy—calculation ofthe percent of iso¬ tope emptied from the gallbladder after injection of CCK—in 187 patients with symptoms of biliary tract dis¬ ease
whose progress
was
followed up
prospectively.
PATIENTS, MATERIALS, AND METHODS We observed all 187 patients who had undergone CCK biliary scanning between July 1986 and February 1989. These patients had symptoms of recurrent episodes of colicky right-upperquadrant pain thought to be biliary colic. They had been referred for scanning by internists, surgeons, and gastroenterologists af¬ ter various other diagnostic tests had failed to demonstrate sig¬ nificant abnormalities. The test was performed in a fashion sim¬ ilar to that first described by Krishnamurthy et al1 and was adopted in our hospital due to the efforts of Fink-Bennett and DeRidder, who described the technique and reported some re¬ sults. Cholecystokinin hepatobiliary scans were performed follow¬ ing the intravenous administration of 185 000 Bq of technetium Tc 99m disofenin (Hepatolite). All patients had nothing by mouth for 4 to 6 hours before the test. Using a large-field-of-view gamma camera with a low-energy medium resolution, an all-purpose collimator, and a 20% window centered at 140 keV, anterior 500 000count hepatobiliary images were obtained every 10 minutes for 1 hour or until the gallbladder maximally filled (little or no activity within the major hepatic radicles, mainly within the gallbladder itself). Sincalide (Kinevac; 0.02 µg/kg) was then infused over a 3-minute period. Following the CCK infusion, anterior post-CCK analog hepatobiliary images were obtained every 5 minutes for 20 minutes. The post-CCK analog images were obtained for equal time intervals, not counts, and the time per image was deter¬ mined from the number of seconds required to obtain the preCCK anterior 500 000-count biliary scintiscan. Gallbladder ejection fractions were determined from simulta¬ neously acquired 1-minute images stored on a 64 x 64 computer matrix in word mode. Acquisition was begun 1 minute before intravenous administration of CCK and continued for 20 minutes afterward. Ejection fractions were determined by manually as¬ signing regions of interest around the gallbladder and around an adjacent background area on the pre-CCK, 5-minute, 10-minute, 15-minute, and 20-minute post-CCK images. Background activ¬ ity was subtracted from both pre- and post-CCK images. Total counts and the number of pixels within each region of interest were determined and the gallbladder ejection fraction (GBEF) was calculated according to the following formula: GBEF(i)= NetPre-CCK GB Count-Net Post-CCK (at timin)/NetPre-CCK GB Counts
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pennsylvania User on 06/19/2015
GB Counts
Relief of Symptoms at
chronic
No. (%) of Patients
Group 69)
1 (n
=
2 (n
=
29)
=
44)
3 (n
Complete 58 (84) 0
35 (80)
Partial
None
9 (13)
2 (3)
12 (41)
17 (59)
0
9 (20)
in which i indicates the time after CCK administration. For each observation, net GB (gallbladder) counts equal total GB counts minus BK, in which BK equals the number of background counts per pixel multiplied by the number of pixels in the GB region of interest. A normal gallbladder ejection fraction response to CCK was defined as one in which the gallbladder ejected at least 35% of its contents, a value determined by Krishnamurthy et al1 and Mesgarzedeh et al.2 Ejection fractions of less than 35% were deemed indicative of abnormal gallbladder motor function from chronic acalculous cholecystitis, the cystic duct syndrome, and/or gallbladder dyskinesia; these findings were reported by FinkBennett et al3,4 and Swayne et al.5 In the appropriate clinical set¬ ting, these patients were advised to undergo cholecystectomy. The medical records of all 187 patients were reviewed, and the following information was recorded: age, symptom complex, du¬ ration of symptoms, results of CCK-biliary scan and other di¬ agnostic tests, any surgical intervention, and the results of all tissue examinations. Three categories of patients participated in the study: (1) those with abnormal CCK-biliary scan results (max¬ imal gallbladder ejection fraction response to CCK 35%) who had not
undergone cholecystectomy. Some patients with abnormal scan results refused cholecys¬ tectomy initially but changed their minds when symptoms per¬ sisted; they were included in group 1. Cholecystectomies were performed by several members of the surgical staff. After the medical records were reviewed, we attempted to con¬ tact all patients by telephone. A standardized form was used and patients were questioned regarding persistence or resolution of symptoms, further diagnostic evaluations performed, and sat¬ isfaction with surgical procedures performed. Patients who were satisfied with the results of surgery but who had persistence of some of their preoperative symptoms were classified as showing partial improvement. RESULTS
Ofthe 187 patients, 142 (76%) were contacted. The mean age of all patients was 48 years, and the mean duration of symptoms was 17 months. There were 39 men (21%) and 148 women (79%). The mean follow-up was 22 months. Separation of patients into groups 1, 2, and 3 and their status at follow-up is shown in the Table. There were 88 patients in group 1 (abnormal CCK-bil¬ iary scan results and cholecystectomy), including 15 men (17%) and 73 women (83%); their mean age was 44 years, and the mean duration of symptoms was 18 months. Sixtynine patients were interviewed. All patients contacted had preoperative complaints of right-upper-quadrant abdom¬ inal pain, 46 (67%) had fatty food intolerance and 41 (59%) had complained of nausea. Fifty-eight patients (84%) re¬ ported complete resolution of symptoms and no recur¬ rence following cholecystectomy. Nine patients (13%) had improvement of symptoms following surgery but not complete relief. Only two patients (3%) believed they had no
postoperative improvement in symptoms.
the 88 surgical specimens showed six of which (7%) had small gall¬ stones not detected before surgery. The criteria for chronic cholecystitis included the presence of Rokitansky-Aschoff sinuses and lymphocytic and plasmacytic infiltrates in the muscularis. Twelve (14%) of 88 patients had cholesterolosis. Specimens from 28 patients (32%) showed no his¬ tologie abnormality; seven of these patients had partial or no relief of symptoms. In contrast, 39 (95%) of the 41 pa¬ tients with pathologic changes in their gallbladders had resolution of their symptoms (P .011). There were 41 patients in group 2 (abnormal CCK-biliary scan results and no cholecystectomy), including 10 men (24%) and 31 women (76%). The mean age of patients was 54 years, and the mean duration of symptoms was 24 months. Twenty-nine patients were interviewed. Twentyeight (97%) had right-upper-quadrant abdominal pain, 18 (62%) had fatty food intolerance, and 15 (52%) had nausea. Twelve patients (41%) reported some improvement of their symptoms (P
