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Biomedical subjects

M B Farnell

Publications and source records attributed to M B Farnell.

At least 19 recordsLinked to original sources
PubMed2005

Purified beta-glucan as an abiotic feed additive up-regulates the innate immune response in immature chickens against Salmonella enterica serovar Enteritidis.

Functionally, the innate immune system of immature chickens is inefficient during the first week posthatch. This immunological inefficiency enables pathogens such as Salmonella enterica serovar Enteritidis (SE) to invade and colonize the visceral organs of immature chickens. The objective of this study was to evaluate the effect of purified beta-glucan as an immunomodulator of the innate immune response. beta-glucan, as a feed additive, significantly provided protection against SE organ invasion in young chickens (P<0.05). The functional efficiency of heterophils isolated from neonatal chickens fed a beta-glucan ration was significantly (P<0.05) up-regulated when compared to heterophils isolated from chickens fed a control ration as determined with an array of functional assays. Phagocytosis, bactericidal killing, and oxidative burst were significantly increased in heterophils isolated from chickens fed the purified beta-glucan ration (P<0.05). To our knowledge, this is the first report of a purified beta-glucan feed additive significantly decreasing the incidence of SE organ invasion in immature chickens and up-regulating the functional abilities of heterophils isolated from immature chickens against an invading pathogen, SE.

Administration, Oral↗
PubMed2005

Effect of prebiotic on gut development and ascites incidence of broilers reared in a hypoxic environment.

Modern broilers have been genetically selected for an increased growth rate and improved feed conversion, but they are also more susceptible to ascites. Ascites occurs when there is an imbalance between available oxygen and the oxygen demand of the broiler. We hypothesized that promoting neonatal gut development with a prebiotic, such as Aspergillus meal (Prebiotic-AM), would enhance gut efficiency, decrease the oxygen demand of the gut, and reduce ascites incidence. In this study, we compared the effect of Prebiotic-AM on ascites incidence and gut development in commercial broilers reared at a local altitude (390 m above sea level) and a simulated high altitude (2,900 m above sea level). Half of the birds received a National Research Council recommended corn-soybean ration, and the other half received the same ration supplemented with 0.2% Prebiotic-AM. These 2 groups were further divided into a local altitude group and a simulated high altitude group for a total of 4 treatment combinations. Tissues were collected on d 1, 3, 7, 14, and 21 from the duodenum and lower ileum and placed in 10% buffered formalin for morphometric analysis. At a simulated high altitude, ascites incidence was 68% for birds fed the Prebiotic-AM supplement compared with 92% ascites incidence in birds given the control feed. The simulated high altitude decreased (P < 0.05) gut development, but prebiotic-treated birds reared in hypoxic conditions had similar gut development to control birds reared at local altitude. These data suggest that a feed ration supplemented with Prebiotic-AM may reduce the effect of hypoxia on broiler gut development and ascites incidence.

Altitude↗
PubMed2005

Hypobaric hypoxia in ascites resistant and susceptible broiler genetic lines influences gut morphology.

Genetic selection based on rapid growth rates, improved feed conversion, and increased body weights has led to a predisposition to ascites in broiler populations. Sire-family selection was applied to a commercial elite line to produce divergent lines of ascites-resistant (RES) and ascites-susceptible (SUS) broilers by the 8th generation. One objective of this research was to determine the effects of hypobaric hypoxia on gut morphology in these genetic lines. In two separate trials, pedigree broiler chickens were randomly assigned to cages in a hypobaric chamber (simulated 2,900 m above sea level) or a matching local altitude chamber (390 m above sea level). Ascites incidence was characterized by heart enlargement and fluid accumulation in the abdominal cavity. At the end of the study on d 42, all surviving birds were killed and evaluated for the presence of ascites and 2-cm sections from the duodenum and lower ileum were collected from 5 chickens per line, per altitude for each trial for morphometric analysis. At a high altitude, ascites incidence was lower in the RES line (20.9 and 3.7%) than in the SUS line (86.4 and 66.9%, Trials 1 and 2, respectively). No ascites was observed at a local altitude. Under hypoxic conditions, duodenum villus surface area was higher (P < 0.05) in the RES line (181.3 +/- 16.8 and 219 +/- 10.9 microm) compared with the SUS line (130.1 +/- 10.5 and 134.3 +/- 9.3 microm; Trials 1 and 2, respectively). No differences in ileum villus morphology were observed for any of the parameters measured. The reduced surface area in the duodenum of birds selected for ascites susceptibility suggests reduced enteric function and may provide clues as to why these birds have increased incidence of ascites.

Altitude↗
PubMed2005

Campylobacter susceptibility to ciprofloxacin and corresponding fluoroquinolone concentrations within the gastrointestinal tracts of chickens.

AIMS: This study evaluated the relationship between Campylobacter susceptibility and enteric fluoroquinolone concentrations in chickens treated with different doses of enrofloxacin. METHODS AND RESULTS: All chickens were challenged with seven fluoroquinolone sensitive Campylobacter jejuni (6.6 x 10(6) CFU per bird) at 2 weeks posthatch. At 26 days of age chickens were treated with 0 (n = 29 birds), 25 mg ml(-1) enrofloxacin (Baytril, Bayer Corp., Shawnee Mission, KS, USA) for 3 days (n = 45 birds) or 50 mg ml(-1) enrofloxacin for 7 days (n = 65 birds) in the drinking water. The crop, upper ileum, lower ileum, ceca and colon contents were collected from both enrofloxacin treatment groups (n = 5 birds per day per treatment group) and nonmedicated controls. The minimum inhibitory concentration (MIC) of ciprofloxacin for Campylobacter increased for isolates from both treatment groups within the first day of dosing and the daily average ranged from 1.4 to 6.5 microg ml(-1) throughout the study. Although enteric fluoroquinolone concentrations were higher (P < 0.05) in birds dosed with 50 mg ml(-1)vs 25 mg ml(-1) enrofloxacin, there were no differences between the isolates collected from these groups for MIC values. CONCLUSION: These data indicate, for the doses used, differences in gut fluoroquinolone concentrations do not produce isolates of Campylobacter with differing susceptibility to ciprofloxacin. SIGNIFICANCE AND IMPACT OF THE STUDY: Using the manufacturers lowest, shortest duration dose vs the highest, longest duration dose of enrofloxacin did not change Campylobacter susceptibility to ciprofloxacin. However, ciprofloxacin MIC values for Campylobacter determined in this study were lower than previously reported.

Animals↗
PubMed2001

Postobstructive chronic pancreatitis: results with distal resection.

HYPOTHESIS: For most patients with chronic obstructive pancreatitis, distal pancreatectomy confers pain relief. DESIGN: Retrospective case series. Follow-up was complete in 80% of study subjects (mean follow-up, 6.7 years). SETTING: Tertiary care center. PATIENTS: Among 484 patients with chronic pancreatitis undergoing operation from 1976 to 1997, 40 with postobstructive chronic pancreatitis were identified. Criteria for selection included an isolated, dominant major pancreatic duct stricture or cutoff, changes of chronic pancreatitis in the distal pancreas, and ostensibly normal parenchyma without calcification in the proximal gland. The patients were reviewed with regard to operative procedure, postoperative course, and outcome. MAIN OUTCOME MEASURES: Outcome measures included degree of pain relief, morbidity and mortality of operation, survival, rates of endocrine and exocrine insufficiency, and ability to return to work and/or normal activities. RESULTS: All but 1 of the 40 patients had abdominal pain, and 20 (50%) had recurrent episodes of acute pancreatitis. Suspicion of malignancy was a concern in 16 patients (40%). Thirty-eight patients underwent distal pancreatectomy; 1 had a central resection and another a Roux-en-Y cystojejunostomy. There was no operative mortality, but significant morbidity occurred in 15%. Among 31 patients with preoperative pain in whom long-term follow-up was available, complete or significant pain relief was achieved in 25 (81%); 74% returned to normal social function, but about half had some element of pancreatic insufficiency. CONCLUSIONS: Distal pancreatectomy is a safe procedure and achieves pain relief and good quality of life in a large percentage of patients (80%) with presumed postobstructive chronic pancreatitis. However, some of these patients with chronic pancreatitis involving the entire gland have disease masquerading as postobstructive chronic pancreatitis secondary to an ostensibly isolated dominant pancreatic ductal stricture.

Abdominal Pain↗
PubMed2001

Surgical management of chronic pancreatitis at the Mayo Clinic.

The authors' approach to the overall surgical management of chronic pancreatitis is to treat complications, that is, pain and, less commonly, obstruction and bleeding. The authors' practice is to exhaust nearly all forms of nonsurgical intervention before suggesting a surgical approach. Nonresponders are then evaluated for severity of pain, interference of quality of life, and presence of chemical dependency. Appropriate candidates undergo imaging examinations to determine the primary site of disease, presence of pancreatic ductal dilatation, and associated peripancreatic complications. The surgical treatment approach involves classic lines of proximal resection (pylorus-preserving pancreaticoduodenectomy) for small duct disease and lateral pancreaticojejunal drainage for a dilated pancreatic duct. The authors have not yet routinely adopted the duodenum-preserving head resections of Beger and Frey, or thoracoscopic transthoracic splanchnicectomy, but they remain open-minded and avidly await good confirmatory, independent trials of these promising surgical interventions.

Chronic Disease↗
PubMed2001

Cystic neoplasms of the pancreas: benign to malignant epithelial neoplasms.

Clinical presentation and state-of-the-art imaging permit the differentiation of most cystic pancreatic neoplasms not only from other cystic pancreatic disorders but also from one another. The differentiation of serous cystic lesions from the mucinous neoplasms (cystadenoma or carcinoma and IPMT) is crucial because of the radically different biological characteristics of these two neoplasms. Although mucinous cystic neoplasms should be resected because of their premalignant or overtly malignant tendency, most patients with serous neoplasms require no operative intervention unless they are symptomatic. IPMT is best treated by a total pancreatectomy, although lesser subtotal resections should be strongly considered depending on patient age, medical comorbidity, and psychosocial situations.

Adenocarcinoma, Mucinous↗
PubMed2001

Periampullary cancers: are there differences?

Our review supports the clinical impression that periampullary cancers vary in outcome after resection. Overall survival after pancreaticoduodenectomy is greatest for patients with ampullary and duodenal cancers, intermediate for patients with bile duct cancer, and least for patients with pancreatic cancer. Moreover, survival for each tumor stage is greater for nonpancreatic periampullary cancers than for pancreatic cancers. Invasion of the pancreas by nonpancreatic periampullary cancers is a major factor adversely affecting survival. Recent data suggest that inherent differences in tumor biology rather than embryologic, anatomic, or histologic factors probably account for these differences in survival. Finally, although pancreaticoduodenectomy remains the procedure of choice for resectable periampullary cancers, further increases in survival will likely evolve through more effective neoadjuvant or adjuvant therapies rather than modifications in the surgical approach.

Ampulla of Vater↗
PubMed2001

The Mayo clinic approach to the surgical treatment of adenocarcinoma of the pancreas.

Ductal carcinoma of the pancreas remains a challenging problem for gastrointestinal surgeons. Significant progress has been made in diagnosis, preoperative staging, and safety of surgery; however, long-term survival after resection is unusual, and cure is rare. That said, the authors maintain their aggressive posture regarding this disease, recognizing that resection offers the only potential for cure. The authors' approach such patients in the most efficient and least invasive manner possible, relying primarily on triple phase helical abdominal CT for clinical diagnosis and staging, reserving ERCP and EUS for diagnostic dilemmas. In fit candidates with potentially resectable lesions, the authors eschew pre- or intraoperative biopsy, angiography, or endoscopic stenting and use preliminary limited staging laparoscopy selectively. Surgical palliation is chosen for fit patients who, at exploration for potentially curative resection, are found to have occult distant metastases or locally unresectable disease. Radical pancreatoduodenectomy can be performed with a mortality rate of 3% or less, and although morbidity remains significant, most can be managed with conservative measures. Quality of life after pancreatoduodenectomy is good and, if not, is generally a manifestation of recurrence rather than physiologic alterations inherent to the procedure. Adjuvant chemoradiation is standard therapy after resection, recommended for those with locally unresectable disease but used selectively for those with distant metastasis. Survival after potentially curative resection has remained disappointing. Whether extended lymphadenectomy or neoadjuvant chemoradiation improves survival has not been determined. Clearly, methods for earlier diagnosis of pancreatic cancer and more effective adjuvant therapies are sorely needed.

Adenocarcinoma↗
PubMed2000

Pancreatoduodenectomy for chronic pancreatitis: long-term results in 105 patients.

HYPOTHESIS: For patients with head-dominant, small-duct chronic pancreatitis who require operative intervention, pancreatoduodenectomy can be performed safely and affords satisfactory pain relief in most. DESIGN: Retrospective case series. Follow-up was complete in 86% of study subjects (average, 6.6 years). SETTING: Tertiary care center. PATIENTS: Among 484 consecutive cases of chronic pancreatitis treated surgically from January 1976 through April 1997, 105 (22%) in which pancreatoduodenectomy was performed were reviewed with regard to criteria for selection, operative procedure, postoperative course. and long-term outcome. MAIN OUTCOME MEASURES: The main outcome measure was degree of pain relief. Additionally, late mortality, cause of death, the presence of endocrine and exocrine insufficiency, and quality of life were recorded. RESULTS: There were 72 men (69%) and 33 women (31%) with a mean age of 51 years (range, 24-77 years). The cause of chronic pancreatitis was alcohol related in 58 patients (55%) and idiopathic in 41 (39%). Clinical manifestations included abdominal pain in 86 patients (82%), obstructive jaundice in 27 (26%), and vomiting in 11 (11%). Suspicion of malignant neoplasm was a concern in 67 patients (64%). Operative morbidity was 32%, and mortality, 3%. Mean hospital stay was 16 days (range, 12-82 days). Survival was significantly lower than that of age-matched controls. Among 66 patients with preoperative pain, pain relief was achieved in 59 (89%); it was complete in 44 patients (67%) and partial in 15 (23%). Operation resulted in a significant increase in patients with normal functional status (73 patients [81%] vs 51 [49%]; P<.001). Forty patients (48%) had diabetes. Steatorrhea was observed in 39 patients (43%), while weight maintenance or gain occurred in 59 (66%). CONCLUSIONS: Pancreatoduodenectomy achieves pain relief and good quality of life in a large percentage of selected patients with small-duct, head-dominant disease and is especially useful when a malignant neoplasm must be excluded. Morbidity and mortality are acceptable in experienced hands. Onset of diabetes and steatorrhea, while reflecting the natural course of the disease, is likely accelerated by pancreatoduodenectomy.

Adult↗
PubMed2000

What prognostic factors are important in duodenal adenocarcinoma?

HYPOTHESIS: Survival of patients with adenocarcinoma of the duodenum depends on the ability to perform a complete resection and the tumor stage DESIGN: Retrospective case series. SETTING: Tertiary care referral center. PATIENTS: A cohort of 101 consecutive patients (mean age, 62 years), undergoing surgery for duodenal adenocarcinoma from January 1, 1976, through December 31, 1996. Patients with ampullary carcinoma were specifically excluded. Mean duration of follow-up was 4 years. INTERVENTIONS: Surgery was curative in 68 patients (67%) and palliative in 33 patients (33%). Of the curative group, 50 patients (74%) underwent radical surgery, ie, 30 (60%), pancreaticoduodenectomy; 15 (30%), pylorus-preserving pancreaticoduodenectomy; and 5 (10%), total pancreatectomy. A more limited resection procedure was used in 18 patients (26%) involving a segmental duodenal resection in 15 (83%) and a transduodenal excision in 3 (17%). patient survival, and correlation with patient and tumor variables using univariate and multivariate analysis. RESULTS: Actuarial 5-year survival for the curative group was 54%. Only 1 patient in the unresected group survived beyond 3 years. Nodal metastasis (P = .002), advanced tumor stage (P<.001), positive resection margin (P = .02), and weight loss (P<.001) had a significant negative impact on survival in multivariate analysis. Tumor grade, size, and location within the duodenum had no impact on survival. Patient age and tumor depth of invasion influenced survival in univariate analysis, but lost their prognostic significance in multivariate analysis. CONCLUSIONS: Metastasis to lymph nodes, advanced tumor stage, and positive resection margins are associated with decreased survival in patients with duodenal adenocarcinoma. An aggressive surgical approach that achieves complete tumor resection with negative margins should be pursued. Pancreaticoduodenectomy is usually required for cancers of the first and second portion of the duodenum. Segmental resection may be appropriate for selected patients, especially for tumors of the distal duodenum.

Adenocarcinoma↗
PubMed2000

Intraoperative topical tetracycline sclerotherapy following mastectomy: a prospective, randomized trial.

BACKGROUND AND OBJECTIVES: Postoperative wound seromas are a frequent and troublesome occurrence after mastectomy. Recent reports have suggested the efficacy of topical sclerosants at reducing their formation. METHODS: A prospective, randomized, double-blinded trial was performed to examine the effect of intraoperatively administered topical tetracycline on the occurrence of postoperative mastectomy seromas. Thirty-two women were randomized to the control arm (normal saline) and 30 women to the tetracycline arm. In the treatment group, 100 ml (2 g) of tetracycline solution was administered topically to the chest wall and skin flaps prior to skin closure. The control group received an equal volume of normal saline. Patients were monitored for the development of postoperative wound seroma. RESULTS: There were no significant differences between groups regarding total volume of closed suction drainage, numbers of patients leaving hospital with drains in place, or duration of catheter drainage. Seroma formation 2 weeks postoperatively was greater in the tetracycline group than the control group (53% vs. 22%, P = 0.01). There were no differences between groups regarding the degree of postoperative pain, wound infection, or seroma formation 1 month postoperatively. CONCLUSIONS: Topical tetracycline is not effective at preventing post-mastectomy wound seromas.

Administration, Topical↗
PubMed2000

Hemosuccus pancreaticus complicating chronic pancreatitis: an obscure cause of upper gastrointestinal bleeding.

BACKGROUND: Hemosuccus pancreaticus, a rare form of upper gastrointestinal bleeding, may complicate chronic pancreatitis and pose a significant diagnostic and therapeutic dilemma. AIM: To present our experience with this potentially life-threatening complication of chronic pancreatitis. METHODS: We reviewed our experience with management (both operative as well as angiographic embolization) of patients with hemosuccus pancreaticus complicating histologically documented chronic pancreatitis between 1976 and 1997. Diagnosis of hemosuccus pancreaticus was based on clinical presentation, preoperative endoscopic and radiographic imaging, operative findings, and pathologic evaluation. RESULTS: During the period, we managed eight patients with hemosuccus pancreaticus (1.5% of all patients with chronic pancreatitis treated surgically). Gastrointestinal bleeding presented as hematemesis in three and hematochezia in three, but all had recent melena and were anemic; three of these patients were hemodynamically unstable. Abdominal pain was present in six. When performed, angiography (n=6) was diagnostic of a pseudoaneurysm; computed tomography (n=7) showed a pseudoaneurysm in two and a pseudocyst in five. Endoscopy (n=8) revealed blood issuing from the ampullary papilla in two patients. Operative management (n=6) involved distal pancreatectomy, pancreatoduodenectomy, or total pancreatectomy in two patients each. Angiographic embolization was successful in one patient, but the other died from uncontrollable hemorrhage. CONCLUSIONS: Hemosuccus pancreaticus is rare, but should be considered in patients with chronic pancreatitis and gastrointestinal bleeding. In the absence of pancreatitis-related indications for surgery, angiographic embolization can be definitive treatment. If there are pancreatitis-related indications for operation, angiographic embolization may allow an elective operative procedure based on structural changes of the pancreas. If embolization fails, pancreatic resection is usually required, often on an emergent basis.

Adult↗
PubMed2000

The significance of sinistral portal hypertension complicating chronic pancreatitis.

BACKGROUND: Sinistral portal hypertension, a localized (left-sided) form of portal hypertension may complicate chronic pancreatitis as a result of splenic vein thrombosis/obstruction. AIM: To determine appropriate surgical strategy for patients with splenic vein thrombosis/obstruction secondary to chronic pancreatitis. METHODS: We reviewed our experience with operative management of 484 consecutive patients with histologically documented chronic pancreatitis treated between 1976 and 1997. The diagnosis of sinistral portal hypertension was based on clinical presentation, preoperative endoscopic and radiographic imaging, and operative findings. "Symptomatic," herein defined, denotes those patients with sinistral hypertension and either gastrointestinal bleeding or hypersplenism. "Asymptomatic" patients were those with sinistral hypertension alone. RESULTS: Sinistral portal hypertension was present in 34 of the 484 patients (7%). Gastric or gastroesophageal varices were confirmed in 12 patients (35%), of whom 6 had variceal bleeding and 4 had hypersplenism (25%). All symptomatic patients were treated by splenectomy alone or in conjunction with distal pancreatectomy. Splenectomy at the time of pancreatectomy for primary pancreatic symptoms was also performed in 15 patients with (asymptomatic) sinistral portal hypertension. None of the 23 patients who had splenectomy rebled in mean follow-up of 4.8 years. In contrast, 1 of the 11 patients with asymptomatic sinistral portal hypertension who underwent pancreatic surgery without splenectomy died of later variceal bleeding 3 years after lateral pancreatojejunostomy. CONCLUSIONS: Symptomatic sinistral portal hypertension is best treated by splenectomy. Concomitant splenectomy should be strongly considered in patients undergoing operative treatment of symptomatic chronic pancreatitis if sinistral portal hypertension and gastroesophageal varices are also present.

Adult↗
PubMed2000

Management of biliary tract disease in heart and lung transplant patients.

BACKGROUND: Preexisting gallstones and pharmacologic alterations in both bile lithogenicity and immune function may predispose organ transplant recipients to the complications of biliary calculi. METHODS: Records of all 178 patients undergoing heart, lung, or heart-lung transplantation at our institution between 1980 and 1998 were reviewed. Patients with biliary tract disease were grouped as follows: group I, pretransplantation diagnosis and treatment; group II, pretransplantation diagnosis and posttransplantation treatment; group III, normal pretransplantation biliary tree with posttransplantation diagnosis and treatment; group IV, unknown pretransplantation biliary status with posttransplantation diagnosis and treatment. Comparison among groups was made with regard to ultrasound findings, presentation, indication for operation, procedure, and outcome. RESULTS: Of the 141 patients undergoing pretransplantation and/or posttransplantation ultrasound surveillance, the prevalence of abnormal ultrasonography was 36%. All patients in group I (n = 11) underwent elective intervention without complication. Of the 14 patients (groups II through IV) undergoing posttransplantation operation, intervention was mandated by acute complications of biliary tract disease in 7. The mortality rate in these 7 patients was 29%. CONCLUSIONS: Cholecystectomy in the posttransplantation period is often required emergently and has a high mortality. Posttransplantation surveillance of the biliary tree is crucial because of the high rate of de novo stone formation. All biliary calculi should be eradicated electively in stable patients before transplantation and on diagnosis after transplantation.

Adolescent↗
PubMed2000

Long-term results after surgery for chronic pancreatitis.

AIM: To determine the early and late morbidity and mortality after surgical treatment of chronic pancreatitis. METHODS: We determined long-term outcome and early and late morbidity and mortality, respectively, in 484 consecutive patients undergoing surgery for chronic pancreatitis from 1976 through 1997. Sixty-five percent of the patients had small duct disease (main pancreatic duct <7 mm), whereas 35% had large duct disease. Indications for operation were pain (95%), suspicion of malignancy (28%), and complications involving adjacent organs (35%). Pseudocysts were present in 27% of patients. Hospital morbidity (8 vs 23%, p = 0.0002) and mortality (0 vs 1.9%, p = 0.12) were less after drainage procedures (n = 162) than after pancreatic resections (n = 286). Among resectional procedures, total pancreatectomy had the highest 30-d operative mortality (5%) and morbidity rates (47%), followed by pancreatoduodenectomy (3 and 32%, respectively). The best results with pain relief occurred after proximal pancreatic resection (89% after mean follow-up of 6.5 yr). The number of patients able to function normally after surgical treatment increased from 39 to 79% (p < 0.001). Long-term survival of our patients was lower than expected rates based on Minnesota life tables analysis (p < 0.0001) especially in alcoholics. Patients undergoing a ductal drainage procedure had the longest survival, whereas those after total pancreatectomy had the shortest survival (p = 0.06). Pancreatic insufficiency, peptic ulcer, and/or anastomotic ulcers caused significant morbidity after total pancreatectomy and pancreatoduodenectomy. A small percentage (3%) developed pancreatic cancer. CONCLUSIONS: Operative treatment of chronic pancreatitis, when indicated, can be performed safely with good results in terms of pain relief and quality of life. Resectional procedures (especially total pancreatectomy) are associated with higher early and late morbidity, greater perioperative mortality, and lower survival rates compared with drainage procedures. Abstinence from alcohol is associated with longer survival rates, which, however, still remain lower than expected rates.

Adolescent↗
PubMed1999

Long-term results of biliary reconstruction after laparoscopic bile duct injuries.

HYPOTHESIS: The Hepp-Couinaud approach to biliary enteric reconstruction for laparoscopic bile duct injuries provides a durable, long-term result in most patients. DESIGN: Retrospective study of patients who underwent operative repair of laparoscopic bile duct injuries from January 1990 through December 1997. SETTING: Academic tertiary referral center. MAIN OUTCOME MEASURES: Outcome was assessed using a grading system based on clinical symptoms, liver function tests, and need for reintervention for anastomotic stricture. The Kaplan-Meier method was employed to estimate stricture-free survival. RESULTS: Fifty-nine consecutive patients underwent operative repair of the following laparoscopic bile duct injuries (Strasberg classification): B: n = 2 (3%), C: n = 1 (1%), D: n= 2 (3%), E1: n= 5 (8%), E2: n= 16 (27%), E3: n= 25 (42%), E4: n = 5 (8%), and E5: n = 3 (5%). Forty-seven patients (80%) had 1 or more interventions prior to the index repair. The extrahepatic left bile duct (Hepp-Couinaud approach) was used in 46 of 53 patients who underwent a Roux-en-Y hepaticojejunostomy. Follow-up (mean+/-SEM, 3.7+/-0.3 years) was complete in 54 of the 57 patients still alive. Five patients developed subsequent anastomotic strictures and were treated with percutaneous transhepatic dilation (n = 3), endoscopic dilation (n = 1), and operative revision (n= 1). Excellent to good long-term results were achieved in the remaining 49 patients (91%). Life-table analysis yielded 95% and 88% chances of stricture-free survival at 2 and 5 years, respectively. CONCLUSIONS: Complex iatrogenic proximal bile duct injuries and strictures are amenable to operative repair using the extrahepatic left bile duct. The Hepp-Couinaud approach offers a durable result in more than 90% of patients, even after previous interventions have failed.

Bile Ducts↗