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PubMed1990

Post-choledochoenterostomy 'sump syndrome'.

The 'sump syndrome' is an uncommon, late complication of a side-to-side choledochoenterostomy. Five patients with this syndrome were encountered over a 5-year period. Pain or cholangitis was the clinical presentation in four patients, whereas one patient presented with secondary septic arthritis and a hepatic abscess. Liver function tests were mildly abnormal in each patient. All patients had a stomal size of less than 1 cm as assessed by forward- or side-viewing endoscopy. Endoscopic retrograde cholangiography revealed either stones or debris in the distal common bile ducts of all patients. Four patients had a surgical clearance of their duct with concurrent closure of the choledochoduodenostomy in three patients and the creation of a Rouxen-Y end-to-side choledochojejunostomy in the fourth patient. The other patient had an endoscopic sphincterotomy performed. After 1-4 years of follow-up, four patients have had a total resolution of symptoms. The other patient with follow-up for 4 years has had one episode of cholangitis which resolved rapidly with antibiotic treatment. The pathogenesis and clinical spectrum of the sump syndrome are reviewed and current management strategies are discussed.

Abdominal Pain↗
PubMed1990

[Diagnosis and treatment of mechanical jaundice].

Various instrumental methods of examination were applied in 364 cases with obstructive jaundice. Drainage of the biliary tract in 190 patients was conducted by laparoscopic cholecystostomy, percutaneous, transhepatic cholangiostomy, endoscopic papillosphincterotomy. The results of 167 operations performed at the peak of obstructive jaundice were compared with those of 81 operations undertaken after successful preoperative drainage of the biliary tract. The incidence of complications reduced from 40.5% to 22%, the death rate from 22% to 9.8%.

Adult↗
PubMed1990

Surgical treatment of congenital choledochal cyst.

20 cases of congenital choledochal cyst were operated by modified Lilly's method from 1980 to November 1985 in our Hospital. There were 4 males and 16 females. Their ages ranged from 50 days to 15 years with a mean of 5.1 years. All patients had preoperative ultrasonographic examination, barium meal radiography of the gastrointestinal tract or percutaneous transhepatic cholangiography. All had choledochal cystectomy with retention of the outer layer of the posterior wall of the cyst. We modified Lilly's method by injecting normal saline between the outer and inner layer of the choledochal cyst so that the outer layer could be isolated. Reconstruction of the biliary tract was then performed. 2 patients had choledochoduodenostomy and 18 patients had hepaticojejunostomy (1 end to end and 17 end to side). 19 patients had also had cholecystectomy. The post-operative course of the operation was found to be smooth and safe. Patients were followed up for a period from 6 months to 7 years. 3 patients had cirrhosis of liver, 2 of whom died within 8 months. The mortality rate in our series was 10%. The operative treatment and the problems of biliary reconstruction are discussed.

Adolescent↗
PubMed1990

[Surgical tactics in mechanical jaundice].

On the basis of complex examination and treatment of 167 patients with obstructive jaundice of various etiology, the authors suggest a differentiated approach to the choice of the volume, method, and duration of detoxification therapy as well as the time and volume of an operative intervention. The necessity of preoperative correction of cholestasis by nonoperative measures and instrumental methods of decompression of the biliary tract is substantiated. It is shown that intraarterial regional infusion therapy must be applied in patients whose condition is most serious.

Choledochostomy↗
PubMed1990

[Comparative evaluation of the results of traditional and laser papillosphincterotomy].

The techniques of papillosphincterotomy were improved on the basis of CO2 laser and special laser tools. The results of 212 routine and 114 laser papillosphincterotomies were appraised. With the laser techniques, the incidence of postoperative complications reduced to 14% as compared to 23.6% with the routine method. The incidence of postoperative pancreatitis decreased from 7.5% to 4.3%, the destructive pancreatitis mortality, from 4.7% to 0.9%. The long-term results provide evidence for laser papillosphincterotomy.

Ampulla of Vater↗
PubMed1990

[Hepaticojejunostomy with a subcutaneous blind jejunum segment. An alternative in the treatment of stenosing bile duct diseases].

The choledochojejunostomy and hepaticojejunostomy with a blind subcutaneous segment of the jejunum offer a safe, simple and nearly linear access for repeated retrograde balloon dilatations of the biliary tract. 81 patients, both with malignant as well as benign stenoses of the biliary system have been treated with this method during the last 8 years. Operative technique and preliminary results of this new procedure, which we believe to be the method of choice in recurrent or multiple iatrogenic or posttraumatic biliary strictures, are presented in this paper.

Aged↗
PubMed1990

A comparison of cholecysto- and choledochoenterostomy for obstructing pancreatic cancer.

This report compares the efficacy of cholecystoenterostomy and choledochoenterostomy for relief of biliary obstruction due to pancreatic cancer. From 1976 to 1988, 109 biliary enteric bypass procedures were performed on patients with pancreatic carcinoma considered unresectable at exploration. Sixty-four of these patients underwent cholecystoenteric anastomosis (CCEA) and 45 choledochoenteric anastomosis (CDEA). Thirty-day operative mortality was 6.3 per cent for CCEA and 8.8 per cent for CDEA; the mean length of survival after operation was 7.8 months for CCEA and 8.9 months for CDEA. Of the 64 patients who underwent CCEA, all but two experienced short-term (greater than 60 days) relief of jaundice and pruritus. These patients were found to have an obstructed cystic duct and a cholecystectomy and choledochojejunostomy were performed. Five other patients in the CCEA group had recurrence of jaundice for an overall failure rate of 10.9 per cent. Operative morbidity in this group was 14 per cent. One of the patients in the CDEA group had an early recurrence of jaundice and three others experienced late recurrence, for an overall failure rate of 8.8 per cent. Operative morbidity in this group was 16 per cent. We conclude that these procedures have comparable morbidity and mortality. Although a few patients with cholecystoenteric anastomosis will develop recurrent jaundice, the simplicity of the procedure, the shorter operative time, and the equivalent relief of symptoms make it a useful procedure and one we believe preferable in high-risk patients.

Aged↗
PubMed1990

[Diagnosis, etiology and treatment of cholangitis following bilio-digestive surgery].

Cholangitis occurring after biliary-enteric anastomosis is a well-recognized but insufficiently analyzed surgical complication. Guidelines for assessment have not been established and management remains controversial. We examined a two-year experience with recurrent cholangitis following bilio-enteric anastomosis; cholangitis in the absence of anastomotic obstruction was surprisingly frequently encountered. Although selected cases without anastomotic stenosis may be amenable to nonoperative treatment, a low threshold for surgical reintervention should be maintained because radiologic assessment of anastomotic patency is often equivocal and the clinical problem is often best managed surgically.

Cholangitis↗
PubMed1990

[Postoperative complications following biliodigestive anastomoses].

Between 1980 and 1988 a total of 91 bilidigestive anastomoses were performed in 91 patients at the University Hospital of Zurich. Fifty-seven percent of the patients with an average age of 55 years were male. The main reasons for surgery were cancer of the pancreas, gallbladder or bile-duct in 38%, and chronic pancreatitis in 33%. In 57% the bilidigestive anastomosis was performed as hepaticojejunostomy, in 38% as choledochojejunostomy. The hospital mortality was 7.6%, the morbidity 40%. Thirteen percent had a leakage of the anastomosis: 11% of the hepaticojejunostomy and 17% of the choledochojejunostomy. Ten percent of the patients with a one-layer single knotted suture presented a leakage of the anastomosis, 11% of those with a two-layer single knotted suture, and 25% of those with a continuous suture. Only a quarter of the leakages had to be reoperated. All the others could be managed conservatively. Renal failure appeared in 13%. Two of those patients needed dialysis. No cases of gastrointestinal bleeding were found in this series. Concluding from these results we perform the bilidigestive anastomosis as hepaticojejunostomy with a one- or two-layer single knotted suture.

Adult↗
PubMed1990

[Enlarged choledocho-duodenostomy].

Twenty patients underwent enlarged choledocho-duodenostomy in the treatment of bile duct residual stones, stones lodged in hepatobiliary ducts, muddy calculi or distal stenosis of the common bile duct. Postoperative courses were all uneventful. Twenty one up to fourty one months follow-up found all patients well nourished and back to their original work. Postoperative duodenoscopy done in 17 cases found perianastomatic inflammation in 5, upper GI barium study revealed regurgitation in 4. B-model ultrasonography showed the extraction of residual stones. It is the author's belief that this procedure has the advantage of avoiding the "cul-de-sac" and bile stasis, hence preventing reflux and retrograde infection as well as its safety and easy performing.

Adolescent↗
PubMed1990

[Surgical treatment of lithiasis of the common bile duct: our experience].

On the basis of their personal experience of biliary pathology, the authors present their opinion of surgical treatment of benign diseases of the common bile duct. From 1980 to 1988 a total of 930 patients were assessed, 140 of whom were affected by choledocholithiasis. Data confirmed that, with the exception of choledochotomy as a direct approach for removing stones, good results were achieved using papillosphincterotomy, since this technique best restores the physiology of the biliary tract. In cases where common duct dilation exceeded 20 mm or where the patient was in poor clinical condition, bile was drained into the gut forming a side-to-side choledochoduodenostomy.

Adult↗
PubMed1990

Liver abscesses: successful treatment with choledochoduodenostomy.

I have described two cases of hepatic abscess due to E coli after choledochoduodenostomy for choledocholithiasis, and have discussed the relationship between abscess formation and size of the anastomosis. I conclude that a small anastomosis may in some cases predispose to this problem. Treatment by percutaneous drainage of the abscess was successful in both cases.

Aged↗
PubMed1990

Choledochocholedochostomy without a T tube or internal stent in transplantation of the liver.

Different techniques have been used for biliary reconstruction in transplantation of the liver. Early techniques of cholecystodoudenostomy and cholecystojejunostomy had high rates of biliary complications often with associated mortality. Today, most centers use a choledochocholedochostomy with a T tube (CC-T) or Roux-en-Y choledochojejunostomy (RYCJ) for biliary reconstruction in hepatic transplantation with a low mortality rate but still significant morbidity. In our early experience at the University of Chicago, we used CC-T as the procedure of choice and RYCJ in the remaining instances. However, it was noted that a large number of biliary complications in the CC-T group were related to the use of T tubes, which prompted us to consider the use of primary anatomosis without tube drainage or stenting (CC). We reviewed 136 transplants with a graft survival rate of greater than two weeks. The over-all complication rates for each group were 38 CC, 18 per cent; 26 CC-T, 35 per cent, and 72 RYCJ, 21 per cent. One patient died as a direct result of a biliary complication. The main difference between CC and CC-T was early biliary complications (5 versus 31 per cent, p less than 0.02 most were T-tube related. We advocate the use of CC (without a T tube) when-possible. We recommend RYCJ whenever reoperation and biliary revision are required. We have found that both CC and RYCJ can be used safely for biliary reconstruction in hepatic transplantation.

Adult↗
PubMed1989

Transhepatic endoprosthesis and surgical anastomosis in the palliative treatment of bile duct obstructions.

Ninety-six patients with non-resectable malignant tumours occluding the bile duct were treated either with a transhepatic endoprosthesis (n = 60) or a surgical biliointestinal anastomosis (n = 36). The mean survival time for patients treated with a transhepatic endoprosthesis was 5.8 months, as compared with 8,1 months for patients treated surgically. The mortality rates in the first 30 days were 18% and 17% for patients treated anastomosis, respectively. We consider that this militates in favour of an endoprosthesis rather than surgery.

Aged↗
PubMed1989

Iatrogenic bile duct injuries: avoidance, recognition, and treatment.

Common bile duct injury has potential catastrophic implications if unrecognized or inadequately managed at the time of initial surgical intervention. Every precaution necessary to avoid operative injury to the common duct should be taken, and with experience and meticulous attention to detail, this complication should rarely be encountered in the career of a well-trained general surgeon. If ever this unexpected occurrence happens, adherence to certain principles of recognition and management may preclude significant morbidity and mortality. Two patients with injured common bile ducts are discussed. One patient presented with an iatrogenic stricture due to previous operative trauma. A second patient suffered a complete transection of the common duct while undergoing a routine cholecystectomy; the transection was recognized and repaired primarily. The fundamental principles of bile duct reconstruction and biliary-enteric anastomoses are discussed. The prevention of stricture formation is explained, with specific guidelines presented to minimize this potentially lethal complication.

Choledochostomy↗