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Obstructive jaundice may be, still today, a surgical emergency. After the analysis of the serious syndrome following a persistent cholestasis, the authors discuss new technological diagnostic procedures and indications, pros and cons of the use of P.T.D. (Percutaneous Transhepatic Drainage). Finally, they underline emergency cases and proper surgical management, on the basis of their personal experience, as well.
Since the early 50s, the routine use of operative cholangiography in biliary surgery has decreased the rate of negative choledochotomy and retained stones. In the last twenty years no further progress has occurred and negative choledochotomy rate remains at 30% and for retained stones at 1.3%. Modern endoscopic technology has improved the diagnosis and treatment of biliary diseases so we think that the routine use of endoscopic retrograde cholangiopancreatography (ERCP) as a preoperative study for patients to be surgically treated of biliary disease can reduce the incidence of negative choledochotomies, retained stones and duodenostomies that are the most important sources of biliary surgery complications. The results of ERCP as routine preoperative study in patients with diagnosis of symptomatic gallstones selected for surgical treatment are discussed. From June 1988 to June 1989 56 patients who filled the requirements were included. Ultrasound scan, laboratory test. EKG and complete digestive studies were performed at admission. ERCP was done immediately before surgery. Abnormalities on biliary tract were seen in 10 cases (17.9%). Six (10.7%) had stones in the common duct, in 4 of these patients (7.1%) the lithiasis was unsuspected, Four cases (7.1%) had dilated ducts, three of them with narrowing of the distal end of the choledochus. In 5 cases with duct stones and 3 with dilated ducts an endoscopic sphincterotomy was performed at the same time of the study, stones were withdrawn and biliary system cleared before laparotomy. Only one choledochotomy was done in a patient with a carcinoma of the gallbladder and a big stone impacted in cystic duct that produced compression of the common bile duct (Mirizzi Syndrome).(ABSTRACT TRUNCATED AT 250 WORDS)
We present a prospective unrandomized series of 40 patients with symptomatic choledocholithiasis and symptomatic cholelithiasis. The patients were divided in two groups of 20 patients each one. The patients fallen in the first group had endoscopic sphincterotomy and elective cholecystectomy on a later date in the same hospital course as the recommended treatment. The second group underwent elective cholecystectomy and common bile duct exploration. There was no difference in the percentage of morbidity and mortality between the groups. In the first group the figures on morbidity and mortality were not different from that seen when each process was performed alone. Endoscopic Sphincterotomy plus elective cholecystectomy is a therapeutic alternative in choledocholithiasis when there is gallbladder with stones.
Infundibullotomy or the method of endoscopic choledochoduodenostomy is an alternative to surgical bilio-digestive anastomosis for common bile duct obstructions due to impacted stone in the ampulla de Vater when occasionally standard endoscopic sphincterotomy was unsuccessful. In addition the endoscopic choledochoduodenostomy is a method described as final palliative treatment in elderly patients and/or those as high operative risk with malignant obstructions in the distal part of the common bile duct.
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An investigation of long-term results of treatment of 226 patients has shown that endoscopic papillosphincterotomy is a highly effective method of treatment of patients with cholelithiasis and stenosis of the major duodenal papilla. The complex use of the surgical and endoscopic methods of treatment gave most favorable results.
A subcutaneously placed afferent jejunl loop pexis, which is often performed during a hepaticojejunostomy, opens a route to the biliary tract, through which appropriate instruments can be passed should postoperative complications arise, requiring a choledochoscopy, the removal of calculi, and for the dilatation of the anastomotic site. From our clinical experience with such a pexis, however, postoperative cholangitis showing a transient fever with abdominal pain and liver dysfunction frequently develops. Further, in cases in which a subsequent dissection of this jejunal pexis was performed, there was a reduction in the incidence of cholangitis, which suggests a possible correlationship between such a pexis and cholangitis. In this investigation, bile stasis in jejunal loop has been studied, using hepatobiliary scintiscanning in examining 31 patients given a hepaticojejunostomy. Fourteen of these patients were also given a jejunal loop pexis, and 17 patients were without such a pexis. Bile stasis was found to be more frequent in the group given a jejunal loop pexis (p less than 0.001). Further, bile stasis was found in 90% of patients showing postoperative cholangitis whereas postoperative cholangitis was observed in 60% of patients with bile stasis (p less than 0.01). Thus, based on the data obtained, as well as our clinical experience, it would seem that a subcutaneously placed jejunal loop pexis should be avoided while performing a hepaticojejunostomy, unless the possibility of anastomotic stenosis and/or the retention of stones are strongly expected.
A rare case of common bile duct cyst was observed in a girl aged 22 months. The clinical course of the disease and laboratory investigations necessary for diagnosis are describe in detail. Successful operation confirmed the diagnosis.
The peripheral lymph of the leg and venous blood from donor volunteers were compared. The lymph was found to issue at a higher rate in the active period of the day (from 9 a. m. to 9 p. m.) than at night (from 9 p. m. to 9 a. m.) and is equal to 0.45 and 0.22 X 10(-3) litre/hour, respectively. Its cell composition was lower than that of the peripheral blood (lymph, 2.04 X 10(7) cell/litre; blood, 509 X 10(7) cell/litre) with erythrocytes and platelets not taken into account. Lymphocytes (over 90 per cent) and monocytes (9 per cent) prevailed; the cell number varied with the time of the day; at daytime it was 5-6 times greater than at night. The immunological parameters of the lymph were characterized by a lower content of B cells, greater proportion of 0 cells, and a close T-cell proportion, the active lymphocytes being prevalent. This T-cell proportion correlated with higher spontaneous and lower PHA-induced proliferative activities. The lymph immunoglobulin level was 10-27 per cent of the serum immunoglobulin level; a relationship was observed between the plasma and lymph levels in different age groups.
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The results of 56 consecutive orthotopic liver transplants in the pig were reviewed to determine the incidence of primary biliary tract complications. There were 8 biliary tract complications in 56 grafts (14.2%) directly responsible for death. End-to-end choledochocholedochostomy (ee-CC) was the most frequently used technique (40 cases) with 4 technical failures (10.0%). Choledochojejunostomy with a Roux-en-Y jejunal loop (RYCJ) was used in 9 cases with 2 technical failures (22.2%). Side-to-side choledochocholedochostomy (ss-CC) was used in 7 cases with 2 technical failures (28.5%). Biliary leak and stenosis were the most common complications. End-to-end choledochocholedocostomy appears to be the most suitable and easy biliary reconstruction in the pig but possible gross disparity in the sizes of the donor and recipient ducts may represent and adverse factor.
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The cumulative experience in liver transplantation since the introduction of cyclosporine A has confirmed its efficacy in the treatment of diverse liver diseases in children and adults. In the present study we review the surgical aspects of 45 transplants performed in 39 patients (17 children and 22 adults). Immunosuppressive treatment consisted of cyclosporine A, steroids and monoclonal antibodies (OKT3) in rejection unresponsive to steroids. The actuarial survival rate one year after transplantation was 74%. In the course of development of the program, the elective use of veno-venous bypass during the anhepatic phase in adults was confirmed as useful. Among pediatric transplantations there were numerous arterial malformations (31.5%) in donor organs, which, with the malformations associated in receptors, made allograft reconstruction difficult. Our results confirm those reported by other groups, as well as the importance of specialized training for this type of intervention.
"Declive" latero-terminal and latero-lateral hepaticocholedocho-jejunoanastomosis with a loop of the small intestine isolated by the Roux method was carried out in 6 patients (5 females and 1 male) according to absolute indications. In this type of anastomosis, the longitudinal incision in the hepaticocholedochus is made not on the midline but latero-dorsally on its right supraduodenal circumference. The anastomosis is formed by means of a modified suture or a suture commonly used for bilio-digestive anastomoses; the needle is inserted through the wall of the bile duct 2-2.5 mm from the border of its opening and the sutures are placed at a similar distance from one another, the seromusculo-submucous sutures are applied 6-7 mm from the edge of the opening and at a distance of 3-3.5 mm from one another. Comparison with patients in whom heapticocholedochojejunoanastomosis was established by the routine method showed the results to be better in the modified method.
Experience in the treatment of 238 patients for nontumorous lesions of the biliary tract by choledochotomy is generalized. Choledochotomy was performed in obstructive jaundice during the operation, in cholangiolithiasis, suppurative cholangitis, strictures of the terminal part of the choledochus, and indurative pancreatitis which were attended by biliary hypertension. Diagnostic choledochotomy was undertaken only in 5.8% of patients. Twenty-two (9.2%) patients died after choledochotomy. The method of completing choledochotomy was chosen individually according to the character of the pathological changes in the bile ducts and the acuteness of the inflammatory process. Choledochotomy was completed by external drainage of the common bile duct in 116 patients, by complete suturing of the choledochus in 19, by creation of bile-draining anastomoses in 89, and by papillosphincterotomy in 14 patients. Terminal and lateral choledochoduodenoanastomosis was formed in 25 patients, with good immediate results. Mortality was highest after papillosphincterotomy and external drainage of the choledochus.