11th Global Gastroenterologists Meeting: Recent advances in common bile duct stones management - Errawan R Wiradisuria - Indonesian Society of Endo-Laparoscopic Surgeons, Indonesia

Since laparoscopic cholecystectomy was done for the first time by Philippe Mouret (France, 1987), the development of minimally invasive surgery in hepatobiliary system have been progressing, followed by Berci, Phillips (USA, 1991) who has done laparoscopic common bile duct exploration (LCBDE) successfully later on. Abnormal intra operative cholangiogram, unsuccessful attempts at endoscopic stone extraction for large/occluding stones, and intra hepatic stones are the indications for a LCBDE. While contraindications for the procedure, such as inability of the surgeons to perform the necessary maneuvers, absent of indication, instability of the patient, local condition in the porta hepatic made exploration hazardous, diameter of cystic duct less than 4 mm (transcystic procedure) or diameter common bile duct (CBD) less than 6 mm (transcholedochal). Three major options in management of cholelithiasis with CBD stone were open cholecystectomy with CBD exploration, endoscopic sphincterotomy and stone extraction followed by laparoscopic cholecystectomy (two stages) or laparoscopic cholecystectomy and laparoscopic CBD exploration done in one stage. Choice of the treatment was based on patient safety consideration, time efficiency, and cost effectiveness. Surgeons’ competency becomes an important role to determine a successful LCBDE. Availability and preparedness of instruments/equipment included Endoscopic Retrograde Cholangiopancreatography (ERCP) facilities are also the crucial supporting factors. LCBDE in Jakarta was done from August 2004 to July 2016 with 44 cases. Mean age of the patients were 52 years. Mean operation time was approximately 3.5 hours, with mean hospital stay about 5.5 days. Conversion of the operation was caused by impacted stones, massive adhesion (anatomical reason) or instrument failures. Several complication or morbidity after the surgery included retained stone, subphrenic abscess, T-tube insertion leakage, respiratory tract infection, urinary tract infection and superficial wound infection. Recently, the LCBDE become an important alternative choice in treatment of CBD stone, especially in the failure of ERCP/endoscopic stone extraction. LCBDE as a minimal invasive procedure has the advantages with high success rate, low morbidity and mortality rate and faster post-operative period recovery. However, we still need more training and learning curve.

COVID-19 patients can experience GI symptoms and probably fecal-oral transmission. In patients with COVID-19, the disease caused by the novel coronavirus, there are multiple expressed gastrointestinal symptoms and a potential fecal-oral transmission. According to evidence from previous SARS research, SARS coronavirus (SARS-CoV) gastrointestinal tract (intestine) tropism has been confirmed by viral identification in biopsy specimens and stools, also in discharged patients, which can partially provide explanations for gastrointestinal symptoms, possible recurrence and SARS transmission from persistently shedding humans as well. Patients with these symptoms had longer periods from diagnosis to admission, and their prognosis was worse than patients with no symptoms. Digestive symptoms, such as diarrhea, may be a characteristic of COVID-19, and the alarm level will need to be elevated early in patients with digestive symptoms at risk, rather than waiting for respiratory symptoms to appear. Patients with COVID-19 may complain of weak appetite, nausea, vomiting, diarrhea, elevated liver enzymes or exacerbation of symptoms or disease activity for pre-existing digestive diseases such as inflammatory bowel disease (IBD). Odor loss following a viral infection is the second most common cause of odor loss, possibly accounting for around 12 percent of all cases; ENT surgeons around the globe have reported reports that they have seen patients suffering anosmia indicating the role of anosmia and hyposmia as a possible COVID-19 associated symptom. After the infection, around 40 per cent of cases of anosmia occur. Because SARS-CoV-2 can be extracted in feces by cultivation and rRT-PCR attention should be paid to feces contaminated environment that can lead to touch or aerosol transmission and medical staff treating suspected COVID patients with GI problems should be shielded from fecal contamination.

According to Market research the Global Gastrointestinal Drugs Market Revenue by Region in 2016, North America was the highest by getting the revenue of 17,288 US Dollar Million, while the Middle East and Africa Continent was having least generation of revenue. The global gastrointestinal endoscopic devices market accounted for approximately USD 5.6 Billion in 2015 and is expected to reach approximately USD 8.5 Billion by 2021, growing at a CAGR of around 7.0% between 2016 and 2021. Celiac disease utilized to be considered a uncommon disease restricted nearly exclusively to the region of Europe and the age group of children. However, the first comprehensive tests, propelled in the 1980s, have uncovered a exceptionally different reality. Celiac disease is one of the most frequent of all long lasting diseases, influences children and adults in rise to measure and is more common in ladies ­(ratio men/women = 1:1.5-2). In Italy and for the most part in Europe where a incredible deal of research on celiac disease has been conducted there are varieties in the rate of predominance in the distinctive nations. This can too be seen in the Americas, where the rate is as it was 0.2 to 0.6 % in Brazil but 1.5-3.5 % in Mexico. New Technological advancements will continue to precede the gastrointestinal endoscope market. Recent generations of endoscopes will continue to progressively promote on visualization and detection technologies. It is projected to exceed $1.7 billion by 2020. In the United States, 20 per cent to 30 per cent of individuals living with HIV are co infected with HCV. Hepatitis C is common among individuals living with HIV. This implies that approximately 225,000 to 330,000 individuals in the United States are living with both viruses. The larger part of individuals living with hepatitis C does not know they have it. The most common course of transmission in the UK is utilizing non-sterile needles and other equipment for infusing drugs. 90 per cent of individuals who got HIV from infusing drugs are moreover infected with HCV. This is since both infections can be spread effectively through blood and blood products. The demand for ambulatory surgery center is high in Europe and Asia Pacific owing to the government initiatives to overcome the shortage of medical facilities in remote areas of developing countries such as India and China. The North America ambulatory surgery center market is expected to witness significant growth rate in future due to the enough outpatient surgery centers and government regulations governing the preference for outpatient surgery centers in order to expand the reach of medical facilities.


Errawan R Wiradisuria

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