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PubMedDate not supplied

Complete resection of choledochal cyst with Roux-en-Y derivation vs. cyst-enterostomy as standard treatment of cystic disease of the biliary tract in the adult patient.

BACKGROUND/AIMS: Cystic disease of the biliary tract (CDBT) is characterized by varying degrees of dilatation of the biliary system with high morbidity and mortality in which the surgical management is the corner stone of treatment. The cyst-enterostomies (CE) temporarily solve the obstruction to the biliary flow but have a high long-term morbidity. Complete resection of affected bile ducts with Roux-en-Y derivation (CRR-en-Y) is a good procedure with low mortality and complications. The purpose of the study was to analyze the outcome of CRR-en-Y versus CE in the treatment of CDBS in adult patients from 1970 to 2002. METHODOLOGY: Patients who underwent surgical treatment were divided for their analysis into two groups: Group I: CRR-en-Y and Group II: CE. Following features were compared: demography, clinical picture, postoperative morbimortality, outcome and survival. RESULTS: Thirty-four adult patients were analyzed. There were 82% (28) females and 18% (6) males. The age average was 33.58 years (13-84). Seventy percent (30) were "choledochal cyst". Eighty percent (27) were surgically handled: 52% (14) with CRR-en-Y (Group I) versus 58% (13) with CE (Group II). Both groups were comparable. Without operative mortality and low postoperative morbidity in both, CE had more long-term complications: In this group 70% (9) were readmitted: and 7 underwent reoperation. Mean follow-up was 35 months (6-132) versus 152 months (12-408) respectively. CONCLUSIONS: CRR-en-Y is the standard treatment of CDBS in the adult patient.

Adolescent↗
PubMedDate not supplied

Hepatobiliary scintigraphy after biliary reconstruction-Roux Y and RY-DJ.

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 Roux-Y-duodenojejunal anastomosis (RY-DJ) which was designed for decompressing the jejunal limb of R-Y and for allowing an inflow of bile into the duodenum, and those undergoing Roux-Y choledochojejunostomy (R-Y), using hepatobiliary scintigraphy. METHODOLOGY: Five normal human volunteers and 20 patients underwent R-Y (n=14), RY-DJ (n=6), using hepatobiliary scintigraphy. RESULTS: Postoperative cholangitis developed in 2 patients (14%) with R-Y and none with RY-DJ. Hepatobiliary scintigraphy showed prominent stasis of 99mTc in the proximal jejunum loop of the patients who underwent R-Y, which was not found in the upper jejunum of the patients with RY-DJ. The time taken before visualization of 99mTc at the upper jejunum in the patient who underwent R-Y (65 +/- 5 min) was significantly longer than that in the healthy control (40 +/- 5 min). On the other hand, the time taken before visualization of 99mTc at the upper jejunum in RY-DJ (45 +/- 5 min) was similar to that of healthy controls. CONCLUSIONS: These data suggested that this new method (RY-DJ) for reconstructing the extrahepatic biliary tract was more physiological with less postoperative complications than R-Y.

Anastomosis, Roux-en-Y↗
PubMedDate not supplied

Ischemic stricture of Roux-en-Y intestinal loop and recurrent cholangitis.

The commonest complication of hepaticojejunostomy for the management of biliary strictures is recurrent cholangitis. We report a 54-year-old man who underwent choledochojejunostomy after choledochal cyst excision, and later developed ischemic stricture of the Roux-en-Y loop intestinal loop and recurrent cholangitis. The stricturous intestinal loop was excised with re-anastomosis with new Roux-en-Y loop, with uneventful recovery.

Bile Ducts↗
PubMed2005

Management of the mucin filled bile duct. A complication of intraductal papillary mucinous tumor of the pancreas.

CONTEXT: Biliary obstruction secondary to intrabiliary mucin is a relatively rare presentation of malignant intraductal pancreatic mucinous tumor. We report a case of unresectable intraductal pancreatic mucinous tumor associated with obstructive jaundice secondary to intrabiliary mucin. This case and a review of the literature, highlight the difficulty in obtaining sustained palliation from jaundice using endoscopically placed biliary stents or percutaneously placed biliary catheters due to rapid occlusion with thick mucin secreted by the tumor. Furthermore, this case differs from that commonly seen in the setting of pancreatic adenocarcinoma, where endoscopic or percutaneous biliary drainage is usually successful at long-term palliation from jaundice. CASE REPORT: Case report We report a case of obstructive jaundice secondary to invasive intraductal pancreatic mucinous tumor associated with dilated bile ducts containing copious amounts of mucin. The diagnosis of intraductal pancreatic mucinous tumor was established based on diagnostic findings on computed tomography scan and endoscopic retrograde cholangiopancreatography. The tumor was unresectable due to vascular invasion. Attempts at endoscopic biliary drainage proved unhelpful with the patient experiencing rapid occlusion of the biliary stents with thick mucinous material leading to recurrent cholangitis. The patient eventually underwent a choledochojejunostomy leading to complete and sustained resolution of the cholestasis. CONCLUSION: If intraductal pancreatic mucinous tumor in association with intrabiliary mucinous obstruction is deemed unresectable, surgical biliary bypass seems to be superior to endoscopic biliary drainage and should be performed on initial presentation. This is due to rapid occlusion of biliary stents with thick mucin leading to frequent stent changes and recurrent cholestasis.

Adenocarcinoma, Mucinous↗
PubMed2005

[Effect of basic fibroblast growth factor on wound healing of bilioenteric anastomosis].

OBJECTIVE: To observe the effects of basic fibroblast growth factor (bFGF) on wound healing of bilioenteric anastomosis as to prevent postoperative biliary strictures. METHODS: A model of choledochoduodenostomy in 31 dogs were constructed at first, then bFGF was administered on the local anastomosis (bFGF group) for 1 week after the operation as compared with sodium chloride solution (control group). Both groups were observed with light microscope (HE, Masson staining) and electron microscope 3 days, 1 and 3 weeks and 3 and 6 months after the operation (n=3). Hydroxyproline was measured at the same time. RESULTS: bFGF group healed more quickly compared with control group. Good function of cells were detected by electron microscope. Better mucosa epithelia, fibroblast, and capillary vessel proliferation were detected by histological observation in bFGF group. In bFGF group, collagen fibers were arranged orderly. Three weeks after operation, collagen fibers in control group were orderless and in whirlpool. Hydroxyproline of bFGF group was lower than that of control group (P<0.05). CONCLUSION: bFGF administered in local anastomosis is an effective method to prevent postoperative anastomotic stenosis.

Animals↗
PubMedDate not supplied

Experiences with single-layer biliodigestive anastomosis.

BACKGROUND/AIMS: The right technique for biliodigestive anastomosis is still being researched. The present study investigated the single-layer method. METHODOLOGY: The authors performed single-layer biliodigestive anastomosis in 153 patients between 1995 January and 2000 August. Among the operative procedures there were pancreatoduodenectomy, pancreatic head resection, pancreatic drainage operation, GEA and in a small percentage of the cases other procedures. 88.2% of the anastomoses were done with a continuous suture technique, mainly with 4/0 PDS. RESULTS: In 96 cases the diagnosis was tumor, while the others were benign diseases. Hepatico- or choledochojejunostomy was twice as much as cholecystojejunostomy. There were complications in 29.4% of the cases, from which the rate of biliary fistula was 3.9%. All fistulas healed for conservative therapy. Reoperation was in 7.1%, the operative mortality was 9.8%. Preoperatively 77.1% of the patients had cholestasis, which improved in all cases postoperatively. CONCLUSIONS: In summary the authors offer the single-layer technique for biliodigestive anastomosis.

Anastomosis, Surgical↗
PubMedDate not supplied

The use of stents for duct-to-duct anastomoses of biliary reconstruction in orthotopic liver transplantation.

BACKGROUND/AIMS: Biliary anastomotic complications remain a major cause of morbidity in liver transplant recipients. The objective of this retrospective study is to reassess the use of anastomotic stents for biliary reconstruction while focusing on an end-to-end choledochocholedochostomy (EECC) in orthotopic liver transplantation (OLT). METHODOLOGY: EECC for the biliary reconstruction in OLT was performed in 115 patients. Sixty-three had their bile duct reconstructed over a T-tube stent (S group) while the remaining 52 patients underwent the same procedure without the stent (non-S group). The two groups were compared in terms of biliary complications and the conversion rate to a hepaticojejunostomy (HJS). RESULTS: Twenty-three biliary complications were observed in the OLT patients. In the S group, the incidence of a biliary leak was 12.7%, 8 of 63 patients in which 5 patients showed a bile leak when T tubes were removed. The rate of biliary stricture in the S group was 25.4%, or 16 patients. This stricture rate was not significantly different from the 13.5% rate observed in the non-S group (p=0.086). In the non-S group, 7 patients showed a biliary stricture. Four of 7 patients also developed a bile leak identified to be an anastomotic leak, which consequently resulted in HJS. A total of 6 patients, 5.2% of all OLT patients, underwent a subsequent revision of their primary anastomoses. The incidence of conversion from EECC to HJS in the non-S group, 57.1% was significantly higher than that in the S group, 12.5% (p=0.046). CONCLUSIONS: EECC (i.e. with or without a T-tube stent) is both a safe and effective technique for biliary reconstruction in OLT. However, the conversion rate from EECC to HJS in the non-S group was significantly higher than that in the S group. An indwelling T-tube stent is therefore considered to be useful for both achieving the lowest possible rate of severe anastomotic stricture and to prevent any subsequent intervention.

Anastomosis, Surgical↗
PubMed1992

[Primary intrahepatic lithiasis].

Isolated intrahepatic lithiasis is a very rare condition in western countries; the reported case has to be added to the 29 cases described to date in the literature. The pathogenesis of this disease is unknown; physical and chemical bile alterations favouring lithogenesis is the most reliable hypothesis. In this case the Roux-en-Y hepaticojejunostomy with cutaneous stoma allowed us to perform periodic cleaning of intrahepatic bile ducts until complete elimination of all stones.

Bile Ducts, Intrahepatic↗
PubMed1992

[Our experience of surgery for common bile duct lithiasis. Apropos of 370 cases].

We report a series of 370 common bile duct stones in which the diagnosis was made preoperatively in 56% of cases. We performed: choledochotomy with Kehr drainage in 70% of cases, biblio-intestinal anastomosis in 20%, transcystic extraction with drainage via the same route in 7%, surgical sphincterotomy in 2%. The global mortality was 2.7% related to preexisting deficiency states. The residual stone rate was 5.6%.

Adolescent↗
PubMed2005

Combined surgical therapy for hepatolithiasis.

OBJECTIVE: To evaluate the combined surgical therapy for calculi of intrahepatic duct. METHODS: One hundred and eight cases of hepatolithiasis treated in our hospital from January 1986 to September 2003 were summarized and analyzed retrospectively. The primary surgery included 57 cases of biliary tract exploration and cholangiolithotomy, 26 cases of cholangiojejunostomy, and 25 cases of partial hepatectomy. Of these cases, 156 operations were performed totally. There were 36 patients undergoing two or more operations for cholangiolithiasis problem. Fiberoptic choledochoscopy was employed to examine and remove the residual stones during and after operation in all cases. RESULTS: The residual stone rates were 57.89% (33/57), 26.92% (7/26), and 24.0% (6/25) for biliary tract exploration and cholangiolithotomy, cholangiojejunostomy, and partial hepatectomy, respectively. Fiberoptic choledochoscopy was utilized pre- and post-operatively for each patient, which was performed 2 to 9 times on each case. Following the combined treatment, the rate of residual stone after operation decreased to 12.96% (14/108). CONCLUSIONS: The combined surgical therapy is valuable for resolving the problem of hepatolithiasis in most of the patients. Regarding the clinical outcomes of different surgical procedures, partial hepatectomy is superior to cholangiojejunostomy or biliary tract exploration and cholangiolithotomy. Fiberoptic choledochoscopy is also important to reduce the occurrence of residual stones and the rate of reoperation.

Adult↗
PubMed2005

[Biliary complications following early hepatic arterial insufficiency in liver transplantation].

OBJECTIVE: To explore the clinical feature and treatment efficiency of patients with early hepatic arterial insufficiency (HAI) and biliary complications (BC) following liver transplantation (LT). METHODS: The clinical data of 240 patients receiving LT from February 1999 to February 2004 were analyzed retrospectively. End-to-end choledococholocostomy was applied to 236 patients as the major biliary reconstructive method. Hemodynamic monitoring of the hepatic artery was performed to discover HAT, including hepatic arterial thrombosis (HAT) or hepatic arterial stenosis (HAS) in the first 3 months after transplantation. RESULTS: In HAI Group, 7 cases of stricture of biliary tract and 4 cases of biliary leakage occurred; and 6 cases underwent endoscopic and/or intervention treatment, 4 cases underwent repair of anastomotic stoma and biliary drainage, 1 case underwent medication. Eight patients died and 3 were cured. A total of 32 patients (13.3%) developed biliary complications (BCs), Eleven of the 32 patients with BCs, biliary stricture in 8 cases and biliary leakage in 3 cases, had early HAI (HAI Group) with an incidence of 4.6% for BC with background of HAI (11/236). Another 21 patients with BCs (21/236, 8.7%) did not showed background of HAI (non-HAI Group). Preoperative serum total bilirubin levels were 373.3 +/- 93.9 micromol/L in HAI Group and 110.8 +/- 45.0 micromol/L in non-HAI Group (P = 0.008). Three cases with HAT underwent emergency thrombectomy then the hepatic arterial flow turned to normal. Two cases with HAS received short-term anticoagulant therapy. Recipients with BC underwent radiological and/or endoscopic interventional treatment (n = 6), surgical repair of leak site and biliary drainage (n = 4), and ordinary medication (n = 1). The 1 and 3-year survival rates of HAI Group were 54.6% and 16.4% respectively; both significantly lower than those of non-HAI Group (66.3% and 61.2%, both P = 0.042). CONCLUSION: The recipients with BC following early HAI are associated with poor outcome. The monitoring protocol of hepatic hemodynamics by color dopplar ultrasonography should be enhanced, which contributes to urgent revascularization or recovery of hepatic hemodynamics. Interventional therapies should be immediately applied and transferred to surgical treatment or even retransplantation when necessary for patients with BC following early HAI.

Arterial Occlusive Diseases↗
PubMed2005

Oral (99m)Tc-DTPA simultaneous determination of duodenobiliary reflux and intestinal permeability in patients after choledocholithotomy plus T-tube drainage.

BACKGROUND: The high choledocholithiasis recurrence rate after choledocholithotomy plus T-tube drainage is related to biliary bacterial infection. These bacteria are from the intestine, either via the major duodenal papilla, or the penetrating intestinal mucosa. It is therefore possible that duodenobiliary reflux and increased intestinal permeability exist in patients who have undergone choledocholithotomy. This study was undertaken to find the evidence of duodenobiliary reflux and to assess intestinal permeability in these patients. METHODS: Twenty-one patients who underwent choledocholithotomy plus T-tube drainage 2 months ago, and 11 healthy volunteers (controls) took orally 185MBq of (99m)Tc-DTPA. The patients' bile was collected in the next 2 hours via a T-tube and the (99m)Tc-DTPA radioactivity in the bile was counted. Intestinal permeability was evaluated by measuring the 24-hour urinary excretion rate of ingested (99m)Tc-DTPA in both patients and controls. RESULTS: In 6 of the 21 patients, radioactivity in the bile was detected. The intestinal permeability was significantly higher in patients (11.45%+/-6.16%) than that in controls (3.61%+/-1.63%, t=3.28, P<0.05). CONCLUSIONS: Duodenobiliary reflux exists in patients who have undergone choledocholithotomy plus T-tube drainage. The intestinal permeability is higher in these patients than in healthy subjects. Duodenobiliary reflux and increased intestinal permeability may be factors of cholelithiasis recurrence.

Administration, Oral↗
PubMed2005

Middle and long-term clinical outcomes of patients with regional hepatolithiasis after subcutaneous tunnel and hepatocholangioplasty with utilization of the gallbladder.

BACKGROUND: Roux-en-Y choledochojejunostomy is routinely performed in patients with regional hepatolithiasis. However, some of these patients, who have a normal gallbladder and normal Oddi's sphincter, are unnecessarily undergoing bilio-intestinal drainage. Alternatively, reconstruction can be achieved by subcutaneous tunnel and hepatocholangioplasty with the utilization of the gallbladder (STHG). This method is effective to potential endoscopic tunnel and intervention during follow-up, and prevention of reflux cholangitis as well as the disorders of the GI tract. METHODS: The middle and long-term complications of 46 patients who underwent STHG were analyzed. With B-ultrasonography and biochemical assay, the contraction and concentration function of the gallbladder were also studied. RESULTS: Follow-up showed that all patients survived with a relatively normal life. One patient experienced right epigastric pain, chills and fever because of a stone which impacted in the left hepatic bile duct. Another patient had cholangitis because of biliary ascariasis. The two patients were treated by endoscopic therapy within the subcutaneous gallbladder under local anesthesia. CONCLUSIONS: This operation not only keeps the normal physical functional of the gallbladder, Oddi's sphincter and gastrointestinal tract, but also prevents reflux cholangitis and the disorder of the digestive tract. Hence STHG is a novel operation dealing with regional hepatolithiasis.

Adult↗
PubMedDate not supplied

Choledochoduodenostomy: a study of 28 consecutive cases.

OBJECTIVES: Choledocholithiasis is a common problem in South Asia. Proper drainage of the CBD is essential to reduce the chance of residual stones and recurrent stones. The paper highlights the surgical management of choledocholithiasis by side to side choledochoduodenostomy and the post surgical complications. METHOD: 28 cases of choledocholithiasis treated by choledochoduodenostomy between March 1995 and June 2003 were studied. After pre operative diagnosis and per operative confirmation, side to side choledochoduodenostomy was done. It is a triangulated anastomosis between the bile duct and post bulbar duodenum using single layer interrupted suture. The cases were meticulously followed up for detecting complications RESULTS: 79% of the patients who underwent choledochoduodenostomy were female and majority (43%) belonged to the 51 to 60 age group. All the patients selected for CDD had a dilated common duct of at least 1.5 cm diameter and 71% of them had multiple stones. 79% were asymptomatic during the follow up, two patients developed wound infection. 18% developed alkaline reflux gastritis and only one patient suffered from recurrent cholangitis because of inadequate stoma size. No case of sump syndrome was observed in this series. CONCLUSION: Side to side CDD is an easy, effective and definitive method of decompression, especially when there are multiple stones in a dilated CBD.

Adult↗