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PubMedDate not supplied

A case of complex hepatolithiasis successfully treated with a systematic approach.

A systematic approach is required to treat complex hepatolithiasis. A 45 year-old female patient with hepatolithiasis had bilateral intrahepatic stones, biliary strictures at the right hepatic duct and segment IV duct, cholangitic abscess, and shrinkage of the right hepatic lobe. Six sessions of lithotomy were carried out under the guidance of percutaneous transhepatic choledochoscopy using a dye-laser lithotriptor through the segment III duct. Although stones were eradicated from the common bile duct and segment III duct, stones remained in other segments where cholangioscopic access was not feasible. Biliary bilirubin concentration increased and the liver abscess was resolved. Thereafter, the patient underwent right hepatectomy and choledochojejunostomy. After surgery, percutaneous transhepatic cholangio-drainage and balloon dilatation of the segment IV duct was performed. The patient underwent 11 more sessions of cholangioscopic lithotomy through 2 transhepatic routes and the bilioenteric bypass. Thereafter, the patient became almost stone-free. After discharge, biliary tracts were irrigated with saline through a subcutaneously placed reservoir. The patient is alive and well and had been without stone recurrence for 3 years. This report shows the efficacy of the vigorous combination therapy, including repeated cholangioscopic lithotomy through multiple routes using laser lithotripsy, surgery, and long-term biliary irrigation.

Bile Duct Diseases↗
PubMedDate not supplied

[Accidents in laparoscopic surgery: Mirizzi's syndrome].

It's still much discussed if Mirizzi syndrome must be operated in laparoscopy. Many authors stress the importance to make laparoscopy but others refuse absolutely such possibility and they only work in the classic manner. Nobody has still described the injury of right hepatic duct for Mirizzi syndrome Csendes type I during laparoscopic cholecystectomy. The authors report such a case that has been converted in the classic manner due to the importance of the injury for unknown Mirizzi syndrome.

Adult↗
PubMed1999

Primary intrahepatic lithiasis: report of a case treated by laparoscopic bilioenteric anastomosis.

Recent advances in videolaparoscopic surgery have made this method the treatment of choice for many biliary diseases. However, it has not been used in certain cases, such as primary intrahepatic lithiasis. The authors report a case of a 62-year-old woman with a history of several episodes of cholangitis. Investigation revealed dilated intra- and extrahepatic bile ducts with intrahepatic stones. The patient underwent laparoscopy, and intraoperative cholangiography disclosed an enlarged common duct with absence of stones and the presence of multiple calculi in the intrahepatic biliary tree. A choledochotomy followed by choledochoscopy was performed, which revealed several intrahepatic pigmented stones that were completely retrieved, followed by a laterolateral choledochoduodenostomy to decompress the biliary tree and to allow the migration of residual or recurrent stones. The patient had an uneventful recovery and was discharged on the fourth postoperative day. After 15 months of follow-up the patient is asymptomatic with normal results of liver function tests. Late postoperative upper digestive endoscopy showed a patent choledochoduodenostomy.

Bile Ducts, Intrahepatic↗
PubMed2000

Primary bile reflux gastritis: which treatment is better, Roux-en-Y or biliary diversion?

Primary bile reflux gastritis is an unusual and elusive problem. Postgastrectomy bile reflux has been long recognized and treated variously with Roux-en-Y gastrojejunostomy, Braun enteroenterostomy, and Henley jejunal interposition. All of these procedures have been fraught with postoperative side effects, the worst of which is stasis. A new procedure utilizing biliary diversion has been proposed to divert bile from the gastric lumen without vagotomy or gastric resection. This procedure was used for 16 patients with diagnosed bile reflux, and results were compared with those of a previous group of 21 patients who had been treated with Roux-en-Y gastrojejunostomy. The patient groups were similar in age, sex, weight, symptoms, and results of investigative studies. The earlier group all had vagotomy, antrectomy, and gastrojejunal anastomosis to a 45-cm Roux limb. The later group all had an end-to-side choledochojejunostomy to a 45-cm Roux limb, taken 45 cm from the ligament of Treitz. The patients in the bile diversion group had fewer complications and shorter hospital stays. In addition, they had few postoperative complaints, no further operations for either bile reflux or upper gastrointestinal stasis, and no long-term deaths due to gastrointestinal problems or malnutrition. Their eventual postoperative gastric emptying improved significantly when compared with the Roux-en-Y patients, suggesting that the dysmotility observed preoperatively may well have been a result of the bile injury to the stomach, rather than an underlying gastric dysmotility.

Anastomosis, Roux-en-Y↗
PubMed2000

[Application of different kinds of internal biliary duct drainage in emergency surgery].

The immediate and late results of treatment of 139 patients, operated on with formation of biliodigestive anastomosis, were analyzed. Six (4.32%) patients died. Of 39 patients, to whom choledochoduodenostomy was performed, in 18--good late follow-up result was noted and the fair one--in 21. Of 23 patients, in whom choledochojejunostomy in Roux-en-Y fashion was performed, good result was noted in 4, fair--in 18 and poor--in 1.

Aged↗
PubMed2000

Chemoprevention of biliary carcinogenesis in syrian hamsters by the novel carboxamide derivative IS-741 after initiation with N-nitrosobis(2-oxopropyl)amine (BOP).

To elucidate the possible inhibitory effect of a novel carboxamide derivative (IS-741) on biliary carcinogenesis, Syrian hamsters were subjected to cholecystoduodenostomy and ligation of the distal end of the common duct, and then given a regular diet (group I) or a diet containing 200 p.p.m. of IS-741 (group II). All hamsters were subcutaneously injected with N-nitrosobis(2-oxopropyl)amine until 10 weeks after surgery, and continued to feed on their respective dietary regimen until termination of the experiment at 16 weeks after surgery. Biliary adenocarcinomas were evaluated histologically. Non-cancerous and cancerous hepatobiliary tract tissues were analyzed for phospholipase A(2) (PLA(2)) activity, myeloperoxidase (MPO) activity, and the concentrations of prostaglandin (PG), i.e., prostaglandin E(2), 6-ketoprostaglandin F(1)alpha and thromboxane B(2). IS-741 significantly inhibited the development and multiplicity of hepatobiliary adenocarcinomas and reduced the proliferating cell nuclear antigen labeling indices in non-cancerous hepatobiliary tissues, compared with group I. The anti-cancerous effect of IS-741 was associated with a significant inhibition of PLA(2) and MPO levels in non-cancerous tissues of the extrahepatic biliary tract and the liver, and in cancerous tissue of the liver. Furthermore, IS-741 reduced the production of PGs in non-cancerous hepatobiliary tissues, compared with group I. Although the precise mechanism of action of IS-741 in preventing biliary tumorigenesis remains to be elucidated, it is likely to be related to modulation of arachidonic acid metabolism and/or suppression of neutrophil accumulation.

6-Ketoprostaglandin F1 alpha↗
PubMed2000

[Treatment of common bile duct stones].

Open single-stage treatment of gallstones and common bile duct stones (CBDS) has previously been standard procedure. Endoscopic stone extraction after a sphincterotomy has become a well-established therapeutic modality during the last twenty years and is now the standard procedure. The available options for management of patients with CBDS are reviewed. Although there is no evidence concerning the best treatment of CBDS, it is concluded, that a two-stage procedure with endoscopic CBDS extraction followed by cholecystectomy has no advantages over a single stage open or laparoscopic procedure. In the future the treatment of CBDS will be differentiated depending on size of the stone, the occurrence of complications to CBDS and the general health of the patient.

Choledochostomy↗
PubMed2000

[Minimally invasive surgery in cholelithiasis].

The results of minimally invasive surgical interventions (percutaneous transhepatic cholecystostomy, retrograde cholangiopancreatography with endoscopic papillosphincterotomy, percutaneous transhepatic cholangiostomy with endobiliary intervention, extracorporeal shock wave lithotripsy, laparoscopic cholecystectomy) in 1590 patients were analyzed, 2 methods and more were used in 74 of them. In 155 patients minimally invasive interventions were combined with open surgery. Rational combination of minimally invasive methods in cholelithiasis permits to cure majority of the patients, to avoid open operation and associated complications.

Adult↗
PubMedDate not supplied

Hepatobiliary scintigraphy after biliary reconstruction--a comparative study on Roux-Y and ESCD.

BACKGROUND/AIMS: Reconstruction of extrahepatic biliary tract with benign lesion still has some unsettled problems, such as postoperative cholangitis. This study was conducted to compare bile through the remnant alimentary tract in patients undergoing end-to-side choledochoduodenostomy, and those undergoing Roux-Y choledochojejunostomy, using hepatobiliary scintigraphy. METHODOLOGY: Five normal human volunteers and 13 patients underwent end-to-side choledochoduodenostomy (n = 5), Roux-Y choledochojejunostomy (n = 8), using hepatobiliary scintigraphy. RESULTS: Postoperative acute cholangitis developed in 1 patient (12%) with Roux-Y choledochojejunostomy and none with end-to-side choledochoduodenostomy. Hepatobiliary scintigraphy showed prominent stasis of 99mTc in the proximal jejunum loop of the patients who underwent the Roux-Y choledochojejunostomy procedure, which was not found in the upper jejunum of the patients with end-to-side choledochoduodenostomy. The time taken before visualization of 99mTC at the upper jejunum in the patient who underwent Roux-Y choledochojejunostomy (66.5 +/- 5 min) was significantly longer than that in the healthy controls (40 +/- 5 min). On the other hand, the time taken before visualization of 99mTc at the upper jejunum in end-to-side choledochoduodenostomy (35 +/- 5 min) was similar to that of healthy controls. CONCLUSIONS: This data suggested that end-to-side choledochoduodenostomy procedure for reconstructing the extrahepatic biliary tract was more physiological with less postoperative complication than Roux-Y choledochojejunostomy procedure.

Anastomosis, Roux-en-Y↗
PubMedDate not supplied

Mucosal dysplasia in the bile duct after choledochoduodenostomy: a case report.

A 60-year-old woman who had undergone cholecystectomy, choledocholithotomy and choledochoduodenostomy 21 years previously for cholecystolithiasis and choledocholithiasis, presented with nausea and vomiting. With a preoperative diagnosis of recurrent common bile duct stones, the extrahepatic bile duct was excised and choledochojejunostomy was performed. Histologic examination of the resected specimen disclosed chronic cholangitis, papillary epithelial hyperplasia, and mild dysplasia. Choledochoduodenostomy predisposes to reflux of duodenal contents, resulting in chronic mechanical and chemical irritation likely to induce histopathologic alterations in the bile duct mucosa. Since bile duct dysplasia induced by chronic inflammation may be a precursor of cancer, indication for choledochoduodenostomy should be specific and limited, and careful long-term follow-up is mandatory.

Bile Ducts↗
PubMed2000

Obstructive jaundice in adult Ethiopians in a referral hospital.

Forty-nine adult Ethiopians with obstructive jaundice were studied. Right upper quadrant pain was the main presenting complaint (89%). Most (94%) of the jaundiced patients had right upper quadrant tenderness. In 87% the obstruction was corroborated by ultrasonographic examination, but causal factors were identified in only 39%. Operative findings showed that choledocholithiasis (41%) and malignant conditions (22%) were the two important causes of obstructive jaundice among the adult patients seen at a referral hospital in Addis Ababa. The causes and the outcome of the different types of surgical procedures used in the management are discussed.

Abdominal Neoplasms↗
PubMedDate not supplied

Percutaneous T-tube placement for bilateral internal drainage in malignant hilar obstruction.

BACKGROUND/AIMS: The aim of this retrospective study was to determine the efficacy and safety of percutaneous T-tube placement for malignant hilar obstruction. Results were compared with self-expanding metal stents. METHODOLOGY: Between June 1989 and April 1999, 24 consecutive patients with type II, III, IV hilar obstructions underwent T-tube (n = 12) and metal stent placement (n = 12). A 9-F T-tube was placed percutaneously into the right and left hepatic ducts. Metal stents (diameter: 6-10 mm) were placed in both ducts. RESULTS: Stent placement was successful in all patients. Early complications occurred in 2 patients in the metal stent group (arterio-biliary fistula and cholangitis). In the T-tube group, the 30-day mortality rate were 25%. These were not procedure related. The median patency period in the metal stent group (365.0 +/- 113.3 days) was longer than in the T-tube group (167.0 +/- 71.1 days). There were no significant differences in the median survival rates (224.0 +/- 39.0 days vs. 197.0 +/- 104.8 days). CONCLUSIONS: Internal T-tube placement for drainage of malignant hilar obstruction is safe and associated with few complications. The advantage of this procedure is removability of the T-tube stents.

Aged↗
PubMed2000

[Carcinoma of the pancreatic head].

Focusing mainly on invasive ductal carcinoma of the pancreas, the history of radical surgery for this type of cancer is reviewed, including pancreatoduodenectomy, total pancreatectomy, extended radical surgery with main vascular resection and extended lymphadenectomy/retroperitoneal soft-tissue clearance, pylorus-preserving pancreaticoduodenectomy. In addition, duodenum-preserving pancreatic head resection, which has recently attracted attention in this field, as an operative technique for less-malignant, noninvasive intraductal papillary adenocarcinoma is also reviewed.

Anastomosis, Surgical↗
PubMed2000

Linkage of persistent cholangitis after bilioenterostomy with biliary carcinogenesis in hamsters.

Biliary carcinoma occurring after bilioenterostomy has been reported as a late complication of this surgical procedure. The present study was designed to determine if bilioenterostomy promotes biliary carcinogenesis, and also to clarify the relationship between biliary inflammation and biliary carcinogenesis in hamsters. Syrian hamsters underwent a simple laparotomy (SL), choledochoduodenostomy (CD) or choledochojejunostomy (CJ). All hamsters received subcutaneous injections of the chemical carcinogen, N-nitrosobis (2-oxopropyl) amine (BOP), and were sacrificed 20 weeks after surgery. Neoplastic lesions in the biliary tree were histologically examined, and the presence and degree of cholangitis was also evaluated with special reference to biliary carcinogenesis. The incidence of bile duct carcinoma was not significantly different among the three groups. Numerous bile duct carcinomas, however, were recognized in the bilioenterostomized animals, especially in the CJ group. Moreover, significant correlations between biliary carcinogenesis and the presence of cholangitis were noted in both the CD and CJ groups, but not in the SL control group. Severe cholangitis was evident in the CJ group, and the number of biliary carcinomas was well correlated with the degree of cholangitis. In conclusion, the risk of carcinoma in the biliary tract may increase when persistent cholangitis is present after biliary reconstruction.

Animals↗
PubMed2001

[Can common bile duct lithiasis be removed laparoscopically without external biliary drainage?].

AIM OF THE STUDY: To evaluate the indications, feasibility and results of laparoscopic treatment of common bile duct stones without biliary drainage. PATIENTS AND METHODS: Between 1992 and 1999, laparoscopic procedures were performed in 70 consecutive patients, mean age 60 +/- 15 years (range: 18-82). Stone removal was attempted via the cystic duct (n=25) or choledocotomy (n=45). The emptiness of the common bile duct was checked by intraoperative cholangiography or endoscopy. After choledocotomy, closure was performed by interrupted or non-interrupted suture with slowly resorbable thread. Transcystic drainage was used whenever necessary. RESULTS: Nine conversions to laparotomy were necessary (12.8%). Among the 61 patients who had an exclusively laparoscopic procedure, 21 were treated via the transcystic route and 40 through choledocotomy. Biliary endoscopy was possible in only 10 of the 21 patients (47.6%) treated via the transcystic route and in all with choledocotomy. No biliary drainage was used in 16 of the 21 patients treated via the transcystic route and in 39 of the 40 treated through choledocotomy. The 30-day mortality was 1/61 (1.6%). Morbidity was 9.8% and 2 patients underwent a second laparoscopic procedure (one fistula on a choledocotomy suture, one hemoperitoneum of unknown origin). An endoscopic sphincterotomy for residual stone was necessary in 4 patients (4/61, 6.5%), 2 after choledocotomy for an unrecognized stone without biliary drainage. CONCLUSIONS: These results confirm the feasibility of laparoscopic treatment of common bile duct stones and suggest it can be performed without biliary drainage in most cases.

Adolescent↗
PubMed2000

Diagnostic and therapeutic choledochoscopy.

Laparoscopic cholecystectomy and common bile duct exploration are common surgical procedures for the general surgeon. To successfully remove common bile duct stones, choledochoscopy is an important technique for efficient and effective management. The choledochoscope can be introduced intraoperatively through the cystic duct or directly into the common bile duct and it also can be inserted transhepatically through a T-tube tract and per orally using a therapeutic duodenoscope. All of these methods allow for many options for the surgeon to consider, and one must be familiar with each of these techniques to maximize care. Successful stone extraction with the choledochoscope can be achieved in 75% to 95% of the cases with a morbidity less than 5%. Using this technique, the surgeon can improve the cost benefit of bile duct exploration.

Choledochostomy↗
PubMedDate not supplied

Management of choledocholithiasis found during laparoscopic cholecystectomy: a strategy based on the use of postoperative endoscopic retrograde cholangiography and sphincterotomy.

BACKGROUND: Several strategies have been proposed for the diagnosis and management of common bile duct stones in candidates for laparoscopic cholecystectomy. METHODS: Clinical characteristics, treatment, and outcome of five patients in whom CBDS were demonstrated by intraoperative cholangiography during a laparoscopic cholecystectomy were analyzed. All patients were treated by endoscopic sphincterotomy. Post-treatment outcome was emphasized. RESULTS: Mean age of the patients was 55 years. Four were female and one male. Preoperative liver function tests were within normal range in all patients. Duct stones of a mean size of 0.8 cm were found in the lower third of the biliary tree. Four were retrieved by endoscopic sphincteroplasty using a Dormia basket and in one patient after an unsuccessful endoscopic attempt, an open choledochoduodenostomy was performed. There were no post-treatment complications. At a mean follow-up of 2 years no evidence of recurrent common bile duct obstruction has been found in any patient. CONCLUSIONS: This small series supports the use of postoperative endoscopic retrograde cholangiography and sphincteroplasty in patients with unsuspected common bile duct stones found during laparoscopic cholecystectomy. Retrieval of the stones immediately after surgery at the operative room is recommended.

Adult↗