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PubMed1994

[Intrahepatic lithiasis].

From 1982 to 1993 9 patients with primary intrahepatic lithiasis and 49 with secondary intrahepatic lithiasis were treated. Out of the first group of patients, 2 underwent right hepatectomy, 2 left hepatectomy and 1 lithotomy + hepatico-jejunostomy. No death occurred within thirty days from operation: morbidity occurred as a consequence of wound infection in one case and bronchopulmonary complications in two cases. At follow-up (6 months-11 years) 1 cholangitis and 1 relapse were found. Secondary intrahepatic lithiasis was treated as follows: in 15 cases we performed lithotomy + cholangio-jejunostomy + 9 postoperative percutaneous transhepatic cholangio-jejunostomy + 9 postoperative percutaneous transhepatic cholangioscopies (PTCS) + 2 cutaneous jejunostomies; in 5 cases lithotomy + papillosphincteroplasty (PSP) + Kehr + 1 trans-Kehr fiber cholangioscopy (PTKCS); in 1 case lithotomy + choledochoduodenostomy (CDS); in 3 cases right hepatectomy and in 4 cases left hepatectomy; in 14 cases lithotomy + hepatico-jejunostomy; in 5 cases PTKCS alone and in 2 cases PTCS alone. Overall mortality summed up to one case only. Overall morbidity occurred in the shape of two biliary fistulas, 3 subhepatic abscesses, 8 bronchopulmonary complications, 4 wound infections, 1 ileal perforation. Follow-up (6 months-11 years) revealed 2 stenosis of the biliodigestive anastomosis, 3 cholangitis relapses and 2 relapsing lithiasis. Since 18 cases were successfully treated through postoperative fiber cholangioscopy, the authors come to the conclusion that in all cases not requiring hepatectomy due to monolateral lithiasis, it is always advisable to leave open an access to the biliary tract, which might allow further improving maneuvers after surgery.

Bile Ducts, Intrahepatic↗
PubMedDate not supplied

[Therapeutic development in common bile duct lithiasis. Apropos of a 25-year experience].

Authors' experience in the treatment of common bile duct stones (LVBP), including 592, operated patients, is presented. During the years 1969-1983, the most used technique was transduodenal sphincterotomy, while after 1983 choledocotomy, mostly with associated external temporary biliary drainage, was the preferred one. Since 1985 endoscopic sphincterotomy (SE) has been used, firstly for high-risk patients, and then with increasing indications; at present the first choice in treatment of LVBP consists in sequential SE and laparoscopic cholecystectomy. Postoperative results of these techniques showed a specific mortality rate of 1.1% for ST, of 0% for CT and SE, and a specific morbidity rate of 4.6% for ST, of 6.9% for CT and of 5.6% for SE. At follow-up patients in I and II Visick group were 87% for ST, 91% for CT and 100% for SE. Even if a statistical analysis of such results is not proposable, the only existence of a specific mortality for ST made us to change our choice. At present the treatment of choice for LVBP is in our opinion the sequential SE and laparoscopic cholecystectomy, waiting for a complete evaluation of all laparoscopic procedure. Traditional surgery is now indicated for failures of sequential approach and, as a first choice, for treatment of "empierrement" of common bile duct, for intrahepatic lithiasis and for atonic megacholedocus.

Choledochostomy↗
PubMedDate not supplied

[Arterial and biliary complications of hepatic transplantation].

Despite progress in standardization of reconstruction procedures, arterial and biliary complications remain an important problem in liver transplantation. These complications directly affect graft survival and patient mortality. We review a series of 165 consecutive orthoptic liver transplantations performed in 146 patients including 3 children. Biliary reconstruction included bilio-biliary termino-terminal anastomosis in 88% of the cases and bilio-digestive choledoco-jejunal anastomosis in 12%. Biliary complications occurred in 15% (25/165) with more obstruction (64%, 16/25) than leakages (64%, 7/25); 28% (7/25) of these complications were related to biliary drainage (3 obstructions and 4 leakages). There were no arterial complications in the 7 patients with non-anastomotic biliary stenosis. The rate of arterial complications was 11%; with 8 stenoses, 5 thrombosis and 5 pseudoaneurysms. Among the 18 transplantations with an arterial complication, 7 (39%) also had a biliary complication. Among the 10 patients with a complete interruption of arterial blood flow (thrombosis or surgical ligature or a ruptured pseudo-aneurysm), 5 (50%) also had a biliary complication, 1 underwent early retransplantation and 2 died early. In conclusion, the biliary tree of the graft are particularly susceptible to interrupted arterial flow. Ischaemic biliary lesions predominate in the intra-hepatic biliary ducts. Biliary drainage is important.

Adolescent↗
PubMed1995

[Management of cholelithiasis associated with acute edematous pancreatitis].

The authors operated on fifty-four patients for gallstone disease associated with acute edematous pancreatitis in the years 1988-1993. The patients were operated on in the first admission, after the symptoms of pancreatitis had run their course and after normalization of amylase-concentration. Preoperative EST was successful in 7%. Depending on the results of routine intraoperative cholangiomanometry choledochotomy was carried out in 11% of the cases. There were no surgical technical difficulties in operations performed in the same admission. At the onset of pancreatitis the authors consider it right to apply one of the objective prognostic scoring systems suitable to predict the severity and prognosis of pancreatitis. Then, depending on its result and the risks of the planned intervention, ERCP-EST is proposed, leaving the gallbladder "in situ" and, either traditional, or laparoscopic cholecystectomy is also permissible.

Acute Disease↗
PubMed1994

Role of ERCP in the management of bile duct lesions post bile duct surgery.

INTRODUCTION: Therapeutic Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is an established mode of treatment for bile duct lesions. AIM: This paper reviews the role of ERCP in the management of bile duct lesions developing after biliary surgery. PATIENTS AND METHODS: Of the 894 ERCPs performed in our department between January 1990 and May 1992, 23 (13 female, 10 male) were for patients with post-operative bile duct lesions. The mean age of these 23 patients was 59 years (range 38-91 years). The previous biliary surgical procedures were conventional cholecystectomy (n = 19), laparoscopic cholecystectomy (n = 3) and a cholecystectomy with choledochojejunostomy. Associated medical conditions of ischaemic heart disease, unstable angina, hypertensive heart disease, chronic obstructive airway disease and hepatitis B cirrhosis were present in 7 of these patients. RESULTS: Ten patients had benign biliary strictures. Endoscopic stenting (with one or 2 stents) was successful in 9. The strictures reopened in 2 patients after a total stenting duration of 12 and 18 months respectively. Four patients had biliary leakages that were successfully treated with stenting. Two patients had spontaneous sealing of biliary leak at 3 and 6 months respectively. Nine patients had retained stones (7 with solitary stone, 2 with multiple stones) that were successfully removed with Dormia basket after sphincterotomy. Complications were few and manageable. CONCLUSIONS: Therapeutic ERCP is safe and effective. It is a useful adjunct in the management of patients with post-operative biliary lesions.

Adult↗
PubMed1994

[Biliary tract cancer following bilioenteric anastomosis].

Two cases of carcinoma of bile ducts after bilioenteric anastomosis are presented. The first one arose in the gallbladder eleven years after cholecystojejunostomy; the second, in the common bile duct three years after cholecystectomy and choledocoduodenostomy. The reflux into the bile duct and recurrent infections can be risk factors in tumor development. Although palliative resection was feasible in one case, the early tumor spread and the invasion of the enteric structure, resulted in a poor outcome in the second case.

Adenocarcinoma↗
PubMed1994

[Choledochoduodenostomy using suturing device SPP-20].

The article discusses the results of choledochoduodenostomy formed with the C[symbol; see text]-20 suturing instrument in 51 patients by a method developed by the authors. The late-term results were studied in 46 patients in follow-up periods of 3 months to 2 years. In the group of 46 patients who were examined 45 had no complaints, they returned to their previous occupation, and stopped adhering to the diet 3-6 months after the operation. One patient noted significant improvement of his condition but nonetheless complained of aching pain experienced from time to time in the epigastrium, a bitter taste in the mouth, and sometimes nausea, which was associated with chronic pancreatitis. Immediate and late-term complications directly connected with formation of the anastomosis with a mechanical suture (C[symbol; see text]-20 instrument) as well as fatal outcomes were not encountered.

Choledochostomy↗
PubMed1995

[Common bile duct lithiasis. Analysis of surgical treatment of 130 consecutive cases].

OBJECTIVES: Common bile duct lithiasis can be treated either surgically or endoscopically. Generally, morbidity and mortality is thought to be greater for surgery. The aim of this work was to evaluate the results of surgical cure in 130 consecutive patients treated from 1983 to 1993. METHODS: Transcytic extraction was performed in 16 cases, ideal choledocotomy in 25, choledocotomy with external biliary drainage in 45, choledocojuodenal anastomosis in 14 and transduodenal sphincterotomy in 32. RESULTS: There were 3 deaths. Morbidity was 11.5%. The postoperative hospitalization time was 9.86 +/- 8.9 days for patients without drainage and 15.13 +/- 3.09 days with drainage. Stone extraction was unsuccessful in 2 cases. CONCLUSIONS: Morbidity and mortality for surgical cure of common duct lithiasis are comparable or lower than for endoscopic sphincterotomy. It is much more adapted for stone desobstruction via the choledoscopy. Supra-duodenal choledocotomy without external drainage was performed in most cases with a small incision and without touching the Oddi sphincter thus allowing a hospital stay equivalent to that for endoscopic sphincterotomy. Associating surgery with laparoscopic cholecystectomy would allow simple benign treatment in most cases of common bile duct lithiasis.

Adult↗
PubMedDate not supplied

Pylorus preserving pancreaticoduodenectomy.

We have performed 9 pylorus preserving pancreaticoduodenectomies (PPPD) for periampullary malignancies. In these 9 patients, six had been diagnosed as having carcinoma of the ampulla of Vater, two pancreatic carcinoma and one duodenal carcinoma. We have no operative mortality and a 44 per cent rate of morbidity. Complications include wound infections (3), pleural effusion (1), intraabdominal abscess (1), delayed gastric emptying (1). There was neither biliary nor pancreatic leakage in these patients. None of the patients had gastrointestinal haemorrhage and marginal ulceration. We have complete follow-up for all cases. Eight of 9 patients are alive, one patient who had been operated for carcinoma of ampulla of Vater died the 14th month postoperatively. During the follow-up, in 7 patients we have observed neither recurrence nor metastasis but in one patient, who is still alive, operated for carcinoma of the pancreas, recurrence in the pancreatic remnant was detected 27 months after the operation. In four months, all patients regained 90 per cent of the weight lost prior to operation. During the follow-up period no patients had gastrointestinal dumping, diarrhoea, or delayed gastric emptying. We concluded that PPPD, technically easier and faster, can therefore be performed with a much lower morbidity and mortality than the standard Whipple procedure. Preservation of the pylorus reduces the incidence of marginal ulceration, and patients undergoing PPPD are more likely to regain their preoperative weight. The antrum and pylorus were structurally preserved in the first successful radical pancreaticoduodenectomy performed by Kausch in 1912 (13) and Whipple in 1935 (28).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMedDate not supplied

Evaluation of choledochojejunostomy with subcutaneous jejunostomy for treatment of intrahepatic stones.

Twenty-nine patients, 16 males and 13 females, with intrahepatic stones were treated by choledochojejunostomy with subcutaneous jejunostomy after choledocholithotomy in cases where the common bile duct was dilated more than 2 cm in diameter. This surgical technique consists of putting a segment of jejunum in the subcutaneous area with a jejunostomy after finishing the choledochojejunostomy. If the stone recurs years later, this loop of jejunum will offer a route for inserting the scope while producing the fistulotomy under local anesthesia. These patients became symptomless soon after removal of the residual stone by postoperative choledochoscope. After more than five years of follow-up study, seven cases (24.1%) had reflux cholangitis and among them, four patients had recurrent stones. Reopening of the fistulotomy was carried out under local anesthesia, and the choledochoscope was inserted into the bile duct through the jejunum for removal of those recurrent stones. We believe that this surgical technique is very effective for the treatment of patients with recurrent intrahepatic stones without the necessity of major laparotomy.

Adult↗
PubMed1994

[Method of constrictive anastomosis].

A combined cuff suture was elaborated in the clinic for the formation of a functioning constrictor and prevention of suture incompetence in various anastomoses. The method of its application is discussed and the results of its testing in gastroduodeno- and gastrojejunostomy in animal experiments are shown. The cuff suture was used in the clinic in 129 patients, in operative management of obstruction of the hepaticocholedochus and biliodigestive anastomoses in 77, in formation of constrictor digestive anastomoses after resection of the stomach and gastrectomy in 42 patients, and in cystogastrostomy in one patient with favorable functional outcomes. The functional condition of the stomach which was operated on and biliopancreatic system was studied by modern informative methods. The technique was also used in treatment of a duodenal stump after operations on the stomach in 27 patients and in closure of defects and injuries of hollow organs of the digestive tract and in ileotransversostomy under conditions of peritonitis in 9 patients. Fatal outcomes in 5 patients who underwent operation and postoperative complications in 13 cases were not connected with the operative method.

Adult↗
PubMed1994

Late surgical complications of choledochal cystoenterostomy.

Choledochal cyst is a rare congenital abnormality of the biliary tract characterized by dilatation and stasis. Cyst excision is now preferred to internal drainage because of the predilection for development of cancer in the unresected cyst wall. We report on four patients who required reoperations for complications of prior cystoenteric drainage from 14 to 21 years after the original operations. Gastrointestinal bleeding from cyst ulceration as occurred in one patient is heretofore unreported. This reoperative experience emphasizes the importance of cyst excision as primary therapy and underscores these principles: 1) The spectrum of complications, including infection, pancreatitis, cancer, and bleeding may occur with or without intracyst and ductal stones; 2) Radical operative procedures may be required for treatment of the complications; 3) Despite these, cholangiocarcinoma has a dismal prognosis; 4) Patients whose cysts remain unexcised require meticulous lifelong scrutiny and strong consideration for planned reoperation at the time of the first complication.

Adult↗