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PubMed1993

Long-term effects in bilio-digestive shunts.

Duodenogastric reflux (DGR) and its effects were studied in patients with bile stones, operated by various bilio-digestive by-pass techniques, and followed up for 13-73 months. Ten patients underwent cholecystectomy and choledochoduodenostomy (CD), eight cholecystectomy and transduodenal sphincteroplasty (TDS) and ten cholecystectomy and endoscopic papillotomy (EP). The control group consisted of eight patients who had undergone minor surgery. DGR was studied by 99mTc-DISIDA scanning, and primary and secondary bile acids were assayed in reflux fluid. The effects were studied by gastroduodenoscopy and biopsies from the body of the stomach and antrum. Only patients operated by TDS (7/8) presented significant increases in DGR and bile acids (p < 0.008). Half the patients in this same group (4/8) had chronic atrophic gastritis and major clinical disorders. Some physiopathological mechanisms possibly involved in DGR and its effects are suggested.

Adult↗
PubMed1993

[Calculosis of the cystic duct].

The authors report on three cases of cystic duct syndrome, a fairly uncommon complication of cholelithiasis, consisting in migration of a large gallstone from the gallbladder to the common bile duct, resulting in the formation of a common cavity between cystic, hepatic and common bile ducts. They review the pathogenesis of this entity, as well as the diagnostic modalities best suited to a precise diagnosis. They stress that surgical therapy must be chosen on a case by case basis, trying to restore a functional extrahepatic biliary tree.

Aged↗
PubMed1993

[Surgical treatment of patients with cholestatic hepatitis].

The experience with treatment of 86 patients with cholestatic form of hepatitis has been summarized. The operative intervention included drainage of the extrahepatic bile ducts, denervation of the hepatoduodenal ligament, marginal hepatic resection. In ineffective conservative therapy, the patients should be operated on at the early period. When establishing the indications for the operation, the functional state of hepatocytes should be considered.

Adolescent↗
PubMed1993

[A case of spontaneous biloma accompanied with incarcerated choledocholithiasis].

A 55-year-old man was admitted with abdominal pain and nausea. CT-scan and US showed no abnormal findings. On the 5th hospital day, a large mass was palpable on the upper abdomen, and CT-scan (7th hospital day) demonstrated a large, cystic mass below the left lobe. A thoracentesis under ultrasound guidance obtained bile-stained fluid. PTCD revealed choledocholithiasis and severe dilatation of the common bile duct and the left branch. After conservative treatment, cholecystectomy and choledocholithotomy were performed. Biloma occurred mainly traumatically or iatrogenically. This case had a spontaneous biloma, and only 11 cases have been previously reported as spontaneous biloma in Japan.

Bile↗
PubMed1993

Long term results of choledochoduodenostomy versus choledochojejunostomy for choledocholithiasis. The French Association for Surgical Research.

The current randomized study was done to compare the results of choledochoduodenostomy (CD) and choledochojejunostomy (CJ) for choledocholithiasis, with special reference to long term results and the risk of ascendant cholangitis. From January 1978 to January 1990, 130 patients were included in the study--64 with CD (side to side, in all patients) and 66 with CJ (side to side in 25 patients and end to side in 41). No significant difference was observed between the CD and CJ groups for postoperative mortality (3.8 percent) and morbidity rates. One hundred and twenty patients (58 CD and 62 CJ) were available for long term follow-up evaluation (mean follow-up period of 29 +/- 11 months). One hundred and seven patients had no symptoms attributable to biliary disease or operation. Five patients in this group died of unrelated causes. Thirteen patients experienced biliary symptoms suggestive of cholangitis, or at least related to the bilioenteric anastomosis--six patients in the CD group and seven in the CJ group. Cholangitis was observed in the first postoperative year in eight of these 13 patients and during the second year for the five others. In the CD group, cholangitis was the result of sump syndrome (n = 3), anastomotic stricture (n = 1) and unknown causes (n = 2). In the CJ group, cholangitis was the result of anastomotic stricture (n = 3), residual intrahepatic stones (n = 1) and unknown causes (n = 3). The results of the current study confirm the good long term results of both procedures. However, it suggests that CD is preferable for choledocholithiasis for two reasons--it is technically easier and faster to perform than CJ and, unlike CJ, CD permits easy access to further endoscopic exploration or treatment if necessary.

Aged↗
PubMed1993

[A 41-year-old woman with recurrent cholangitis after bile duct operation 17 years earlier. A case report].

The case of an 41 year old female is reported, who underwent surgical correction of a congenital cyst of the common bile duct 17 years ago. Because of repeated pain attacks in the right upper quadrant in connection with fever and serochemical signs of cholestasis the patient was admitted to our unit. The exploration with ERCP and CT now showed a common channel in combination with a congenital cyst of the common bile duct. The risk of the anomalous pancreaticobiliary junction upon either the biliary tract or the pancreatic duct will be discussed, also the fact of an higher incidence of malignant tumors of the biliary system. The therapeutic procedures will be discussed.

Adult↗
PubMed1993

[The differential diagnosis and therapeutic procedure in nontumorous mechanical jaundice and cholangitis].

The results of operative treatment of 2,875 patients with obstructive jaundice and cholangitis of nonneoplastic genesis are generalized. On the basis of rich clinical experience, the authors substantiate the principles of differential and topical diagnosis in obstructive jaundice and purulent cholangitis as well as the optimal therapeutic tactics in obstruction of the bile ducts of various levels and types. Problems are elaborated with respect of complex antibacterial therapy with the use of various routes of administration, including administration in the pre- and intraoperative period for preventive purposes.

Cholangitis↗
PubMedDate not supplied

Definitive surgical treatment of cholelithiasis in selective patients with liver cirrhosis.

A review of 132 cirrhotic patients with cholelithiasis was carried out. Of the 87 patients who underwent definitive surgical procedures for gallstones, patients of Child's A grade had less operative blood loss, blood transfusion and shorter hospital stay than those of B and C grades. No mortality in cirrhotic patients with Child's A and B grade was found in both emergency and elective surgery. Emergency operation in patients with Child's C grade resulted in more operative blood loss and requirement than elective surgery. Patients in this grade had also a higher morbidity rate and four deaths ensued. Of the 83 survivals after definitive procedures, 78 patients (93.9%) were still alive in the following 62.8 months without any biliary tract symptoms. Of patients who survived after cholecystolithotomy, 6 patients (33.3%) had recurrent stones in the same follow-up period. Therefore, we recommend that definitive biliary surgery be selectively carried out in cirrhotic patients in Child's A and B grade. However, a conservative approach is more suitable in Child's C patients in emergency conditions and definitive procedures should be considered when their liver function improves.

Adult↗
PubMed1993

Multifocal mucus secreting papillary adenocarcinoma of the bile duct causing obstructive jaundice.

We present a 64-year-old Malay lady who had undergone a choledochoduodenostomy (CDD) two years ago for obstructive jaundice. She was admitted with jaundice and underwent ultrasonography, percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangio pancreatography (ERCP) and computed tomographic (CT) scanning of the liver and biliary tree. All the investigations confirmed a type IVa choledochal cyst. At operation, the grossly dilated biliary system was packed with a thick mucoid material and the mucosa of the bile ducts was visibly abnormal with scattered nodules. This mucoid material had caused occlusion of the entire biliary tree resulting in obstructive jaundice. To the best of our knowledge, this is probably the first report of obstructive jaundice caused by thick mucus. The peculiar management problems of this case and the risk of malignant change in choledochal cysts are discussed.

Adenocarcinoma, Papillary↗
PubMed1993

[Congenital cysts of the choledochus].

We describe six cases of congenital choledochal cyst of the Toddani type I. All were female, with a mean age of 33.5 years (16-52). The onset of symptoms ranged 8-192 months (mean 92.8), with an unexpected finding. Ultrasound scan was performed in five patients, with two accurate diagnoses, one suspicious and two wrong results. In two cases a C.T. was performed and the diagnosis was confirmed in both. A cholelithiasis was associated in four cases. Four patients (66.4%) were treated by cyst excision, Roux-en-Y hepaticojejunostomy and cholecystectomy, three of them as a primary procedure, and one more after failure of some derivative operations. All evolved well but one, requiring sphincterotomy and Wirsungtomy. Two patients (33.6%) were treated by cholecystectomy only, with a favourable evolution. Nevertheless, we emphasize the good results achieved with cyst excision and we recommend it as the procedure of choice.

Adolescent↗
PubMed1993

Dextrocholedocholithiasis: calculous obstruction complicating double ductus choledochus in an adult.

Double ductus choledochus is a rare anomaly of the extrahepatic biliary tree in which the common bile duct is represented by two independent hepatic ducts. Patients with this abnormality may have unimpeded biliary drainage and remain symptom free, yet various forms of double ductus choledochus are occasionally encountered in patients undergoing operation for symptomatic cholelithiasis. We describe a patient in whom doubled biliary ducts were identified on exploration for cholecystectomy along with calculous obstruction of the right-sided duct (ductus choledochus dextri). This case illustrates the potential for significant injury to the biliary tree when double ductus choledochus is present. In addition to a means by which to manage this problem at the time of operation, a review of the literature, as well as a description of this rare embryologic abnormality, is presented.

Adult↗
PubMed1993

[Trans-Kehr postoperative cholangiography in upright and horizontal positions: the morphofunctional aspects of the biliary tract].

To change from the lying position to the upright position, in patients without their gallbladder, causes: a) a rapid and partial emptying of the biliary ducts towards the duodenum by the amplification of the opening phasic waves activity of the sphincter of Oddi (S. O.); b) an important reduction caliber of the main biliary duct (M. B. D) and c) stability of the intraductal pressure with slight raising in upright position. These physiological concepts allow a better cholangiographic exploration by means of a drip of 60 to 70 drops per minute of diluted tri-iodic in: 1) Upright position, which gives a good image regarding the terminal choledochus; of the biliary duodenal flow, and of the reduction of the caliber of the MBD. 2) In lying down position which allows: the filling up of the complete biliary-tree with possible scarcity of information about the distal choledochus-duct; the appreciation of the degree of the expansion of the MBD, and the measuring of the delay of the emptying out of the X-ray-opaque substance in relation to what was found in the upright position. The elasticity of the walls of the biliary ducts acts efficiently in the compliance of the container and contained. In normal choledochal ducts, the top level images in the upright position do not go beyond the hepatic duct. When there are problems with the flow through the S. O., there is a filling up of the intrahepatic biliary ducts with the contrast substance introduced in the upright position.

Biliary Tract↗
PubMed1993

Results of bilio-digestive derivative surgical procedures for benign lesions.

Short and long term results of 52 derivative-surgical procedures (43 choledocho-duodenal and 9 hepatico-jejunal with 45 latero-lateral and 7 termino-lateral approaches) were examined. The procedures were performed on patients with benign bilio-digestive conditions: 46 cases of lithiasis, 2 of which were sump syndromes after latero-lateral derivations, and 6 cases of chronic pancreatitis. Several patients were in poor pre-operative condition, which may have influenced postoperative mortality rates (6%). Morbidity was 15 per cent. Four patients (8%) without anastomotic stenosis had infections of the hepatobiliary system within four years of choledochoduodenostomy. In some cases of benign bilio-digestive lesions, derivative surgery is the procedure of choice, being preferable to endoscopic sphincterotomy. In derivative surgery, a termino-lateral approach has better results than a latero-lateral approach. Furthermore, due to the risk of stasis following a choledochoduodenostomy, a hepaticojejunostomy may be preferable.

Aged↗
PubMedDate not supplied

Recurrent common bile duct stones associated with periampullary duodenal diverticula and calcium bilirubinate stones.

We reviewed operative procedures, type of stones, and coexistence of periampullary duodenal diverticula in 115 patients with common bile duct stones who underwent first surgery at our department between 1982 and 1991. Among these patients, 109 underwent choledochotomy with T-tube drainage, 4 underwent side-to-side choledocho-jejunostomy, and 2 had end-to-side choledochojejunostomy. Five patients developed recurrent common bile duct stones (RCS) after surgery. All these patients were older women who had calcium bilirubinate stones in the common duct and coexisting periampullary duodenal diverticula. No patients who underwent end-to-side choledochojejunostomy developed RCS after the initial surgery or reoperation. The results of the present study suggest that both calcium bilirubinate stones and periampullary duodenal diverticula are contributing factors in the development of RCS in patients with common bile duct stones, and that end-to-side choledocho-jejunostomy should be considered for patients with these two factors after the initial common duct exploration.

Adult↗
PubMed1995

[Acute stomach volvulus complicating hiatal hernia revealed by common bile duct calculi].

The authors report about one observation of acute gastric volvulus on paraoesophageal hiatus hernia caused by a choledocholithiasis, requiring gastrectomy and choledochotomy in emergency. On the basis of this case they sum up the main characteristics of this complication of hiatus hernia and insist on a earlier diagnosis before stage of irreversible lesions.

Acute Disease↗
PubMed1995

Bile ascites.

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Ascites↗