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PubMed1996

Laparoscopic choledochoduodenostomy.

Choledochoduodenostomy is less often performed since the advent of ERCP and endoscopic sphincterotomy (ES). It may, however, still prove necessary in patients where ERCP and ES fail to provide long-term biliary drainage or when CBD stones recur after ES. We have performed laparoscopic choledochoduodenostomy in two patients (aged 66 and 71 years). Surgery was performed in one patient for recurrent CBD stones 25 years after cholecystectomy where three attempts at ERCP failed to cannulate the CBD. In the second patient it was performed for recurrent CBD stones 16 years after cholecystectomy and after two previous endoscopic sphincterotomies. Surgery was completed in just over 3 h in both cases and postoperative stay was 4 days. Laparoscopic choledochoduodenostomy is a viable technique which may prove valuable in the management of patients in whom ERCP and ES has failed to provide long-term biliary drainage.

Aged↗
PubMed1996

Choledochoduodenostomy: influence of risk factors in post-operative morbidity.

BACKGROUND: Choledochoduodenostomy is performed for a variety of lower common bile duct lesions. AIMS: To analyse the influence of risk factors on the post-operative morbidity following choledochoduodenostomy. METHODS: Relation of risk factors including age more than 60 years, medical Illness, hemoglobin less than 10 g/dL, albumin less than 3 g/dL, bilirubin more than 10m/dL, presence of cholangitis at admission (treated pre-operatively), use of pre-operative endoscopic sphincterotomy and common bile duct diameter at surgery were related to the occurrence of post-operative morbidity was studied using univariate analysis. RESULTS: Fifty patients underwent choledochoduodenostomy. One patient (2%) died; major post-operative morbidity occurred in 12 patients (24%). Presence of cholangitis at admission was the only factor related (p = 0.00012) to the occurrence of post-operative morbidity. No long-term complications were encountered in 35 patients (70%) mean with followup period of 28 (range 8-60) months. CONCLUSIONS: Choledochoduodenostomy is a safe permanent drainage procedure for benign lower biliary obstruction.

Age Factors↗
PubMed1996

[Percutaneous choledochoscopic electrohydraulic lithotripsy].

Treatment of biliary stones impacted in the distal, common bile duct is a technical challenge. We report 2 consecutive patients, a woman aged 80 years and a man aged 64, in whom all operative attempts failed. In both, the stone was removed by percutaneous, choledochoscopic, electrohydraulic lithotripsy in a single session. To the best of our knowledge these are the first such cases reported in Israel.

Aged↗
PubMed1995

Biliary lithiasis: retrospective analysis of a case series.

The paper analyses a series of biliary lithiasis cases encountered in 1983-92 in which cholelithiasis accounted for 79.3%, cholecystocholedochic calculosis for 16.6%, chronic stenotic papillitis for 2.1%, residual/recurring calculosis of the main biliary way after cholecystectomy for 1.7% and intrahepatic calculosis for 0.3%. Among the cases involving the main biliary way, the highest percentage (35/50 cases or 70%) of transduodenal papillosphincterostomies was performed in the first five years, while endoscopic papillosphincterotomy prevailed (28/42 or 66.7%) in the second five years. The endoscopic technique was initially considered elective for residual/recurring biliary calculosis after cholecystectomy and for cholecystocholedochic calculosis in patients who were elderly and/or at risk. Thereafter its use was gradually extended as technological developments allowed its use as a complementary technique in cases of giant stones. The advent of minimally invasive surgery has given a further boost to the use of endoscopic clean-up procedures in cases of biliary calculosis prior to laparoscopic cholecystectomy. The laparoscopic treatment of gallstones is a more recent development.

Adolescent↗
PubMed1996

An experimental teaching model for laparoscopic choledochojejunostomy.

For advanced laparoscopic procedures, team collaboration and good suturing skills are only two of many requirements to achieve success. Teaching opportunities are mandatory to allow general surgeons to become acquainted with advanced procedures and to gain confidence in new laparoscopic procedures. In this teaching model presented herein, the technical difficulties and operative steps of a laparoscopic choledochojejunostomy and drainage via Roux-en-Y-loop are outlined as performed on eight pigs weighing about 35 kg each (range, 31.2-41.2) with nondistended common bile ducts (5.6 mm; range, 4.2-6.3). Functionality of the bypass was assessed by a weekly monitoring of bilirubin levels and a contrast material injection into the gallbladder after a 4-month follow-up with measurements of the common bile duct (9.8 mm; range, 7.2-15.2) and the diameter of the choledochojejunostomy (5.0 mm; range, 3.6-6.2) at necropsy. This model provides outstanding conditions for teaching laparoscopic suture techniques to be applied in advanced laparoscopy and demonstrates the feasibility of laparoscopic choledochojejunostomy within a reasonable operation time (122 min; range, 105-155).

Animals↗
PubMed1996

Management of common bile duct stones.

Management of common bile duct stones has changed rapidly as new developments in surgical and endoscopic equipment have become available. Prior to advanced laparoscopic surgical techniques and endoscopic sphincterotomy, common bile duct stones required open surgery, choledochotomy, and manual removal. New alternatives in the management of choledocholithiasis must be understood to allow for comprehensive management of common bile duct stones. Endoscopic and surgical techniques can also be combined for excellent results utilizing minimally invasive techniques. The appropriate choice of therapy will depend on the experience and the resources available.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMed1996

[Evaluation of palliative surgical procedures in tumors of the pancreatic head].

Authors studied 87 patients with obstructive jaundice secondary to unresectable cancer of the head of the pancreas undergoing palliative biliary bypass procedure. They compared the four different types of biliodigestive anastomoses regarding to the postoperative morbidity, the mortality, the late complications and the survival. Their data suggest that Roux-en-Y choledochojejunostomy with prophylactic GEA is the optimal palliation. They studied the incidence of a second operation for duodenal obstruction. Comparing the operative mortality of each group they suggest that prophylactic gastroenterostomy adds no risk to patients, but they advise it's routine use only with choledochoenteric bypass and in lack of distant metastasis. Survival was significantly higher (p = 0.015) in the group of patients above 70 years. This data support the slower progression of the pancreatic tumor in old-age. They analyse three different factors affecting operative mortality. It was not related to the depth of jaundice and the age of the patients, but it was in a very close correlation with the preoperative blood urea nitrogen level. Authors suppose this parameter a simply and useful criteria in the selection for non-operative palliative procedures.

Aged↗
PubMed1996

[The "sump syndrome": a case treated by surgical endoscopy. A discussion about biliodigestive diversions and endoscopic sphincterotomies].

A case of "sump syndrome", occurred in our department, suggested the discussion about the opportunity of endoscopic operative procedures in choledocholithiasis and in biliary tract surgery complications. Improvement of endoscopic operative procedures allow extensive indication of ERCP sphincterotomy instead of traditional choledochoduodenostomy or transduodenal papillosphincterotomy. Additionally, operative endoscopic procedures are good alternative to reoperation for traditional biliary tract surgery complications.

Biliary Tract Surgical Procedures↗
PubMed1996

[Biliary and gastrointestinal bypass: laparoscopic possibilities].

OBJECTIVE: Although surgical biliary bypass for non-resectable peri-ampullary tumors is superior to endoscopic stent placement, the latter has become popular because of its "minimally invasive" approach. Laparoscopic biliary bypass would appear to offer the advantages of both. However, this technique remains technically difficult using existing instrumentation. In this paper the efficacy of a new endoscopic device designed for rapidly completing a small diameter intestinal anastomosis under laparoscopic guidance is summarized. METHODS: In 57 female pigs different techniques for laparoscopic choledocho-jejunostomy have been evaluated. 36 animals underwent a new instrumental anastomosis (TESA = temporary endoluminally-stented Anastomosis) using different size absorbable stents. The results have been compared with 21 animals undergoing laparoscopically handsewn anastomosis. Follow-up and results were identical with minimal differences in final diameter of bile ducts and anastomoses but the operating time was significantly less in the animals operated by TESA-technique.(105 versus 165 min, p < 0.01). CONCLUSIONS: Applying TESA or handsewn anastomosis, laparoscopic choledochojejunostomy can be performed rapidly and safely revealing good bypass function over a period of three and six months respectively. With regard to treatment for non-resectable peri-ampullary tumors TESA may offer a new therapeutic approach combining the benefits of minimally invasive endoscopic stent placement with the functional results and lower readmission of conventional Roux-en-Y choledochojejunostomy.

Anastomosis, Surgical↗
PubMed1996

[Open surgery of choledochus in Denmark].

For each of the years 1991-1994 400, 209, 170 and 133 open common bile duct stone extraction were performed in Denmark, corresponding to 35%, 17%, 12% and 5% respectively of patients diagnosed with common bile duct stone. There was only little variation between the 16 hospital counties. The expected decrease in open common bile duct surgery corresponds to the introduction of several non-invasive methods for the treatment of common bile duct stones. To achieve further reduction in open surgery, centralization of the treatment of common bile duct stones is necessary.

Centralized Hospital Services↗
PubMed1996

[Biliary-enteric anastomosis: role of cholangiography with magnetic resonance].

Our study was aimed at investigating the role of MR-cholangiography (MRC) in the examination of patients treated with biliary-enteric anastomosis. MRC was performed in 15 patients (8 men and 7 women, mean age: 64.7 years) operated on for biliary-enteric anastomoses (13 hepaticojejunostomies and 2 choledochoduodenostomies) whose symptoms were as follows: persistent jaundice in 4 patients; cholangitis and abnormal liver function tests in 2 patients; associated transient jaundice, epigastric pain, abnormal liver function tests in 2 patients. The remaining 7 patients were asymptomatic and examined during their follow-up. MRC was performed with a non-breath-hold, fat-suppressed 3D turbo spin echo sequence (TR = 3000 msec, TE = 700 msec, ETL = 128) with an acquisition time ranging 4 min 24 sec to 5 min 48 sec. Six patients were subsequently submitted to Percutaneous Transhepatic Cholangiography (PTC) to confirm the diagnosis and to perform a therapeutical procedure. Two patients, submitted to choledochoduodenostomy were examined with ERCP. The remaining seven patients, examined during their surgical follow-up and who presented no major symptoms or dilation of the bile ducts, were not submitted to any invasive procedure. Image quality was graded as good to fair in 12/15 cases (80%) and poor in 3/15 cases (20%). The degree of bile ducts dilation was correctly assessed with complete inter observer agreement in 8/8 patients. MRCP correctly showed: bile ducts irregularities in 2 of 4 patients with cholangitis (k = 0.59), anastomosis stenosis in 8 of 8 patients (k = 0.86), and 5-15 mm stones in 5 of 5 patients (k = 0.95). In conclusion, MRCP is a safe, noninvasive technique in the study of biliary-enteric anastomoses with high accuracy in assessing the cause of jaundice. MRCP images can be used as a guide for subsequent interventional procedures. Its main disadvantages are the lack of functional information and the high cost which limits its its use to the screening of symptomatic patients.

Aged↗
PubMedDate not supplied

Long-term results of choledochoduodenostomy and T-tube drainage.

BACKGROUND/AIMS: In this study, gastric mucosal changes and the other clinical results of patients with choledochoduodenostomy (CDD) and T-tube drainage (TTD) were compared in a follow up period of at least 5 years. MATERIALS AND METHODS: The previous files of these patients were evaluated, physical examination and abdominal ultrasonography (US) and gastroscopic examination were made. Esophagus, stomach and the first two parts of the duodenum and size of the anastomosis in patients with choledochoduodenostomy were examined during gastroscopy. Two biopsies from antrum and corpus of the stomach were taken and sections stained with Hematoxylin and eosin for histopathological examination under light microscope. RESULTS: In total 45 patients, 21 of them with TTD and 24 of them with CDD, were accepted for the study. No difference was present between the mean age, female/male ratio, and interval between the operation date and endoscopic control of both groups (p > 0.05). Common bile duct was evidently wide in the CDD group at the first operation (p < 0.05). In the late postoperative clinical classification of the patients, moderate group was predominant, while incidence of alkaline reflux gastritis was obviously high in the CDD group (p < 0.05). No other difference in the results was present between the two groups (p > 0.05). CONCLUSION: According to our study long-term results of T-tube drainage is superior over choledo-choduodenostomy.

Adult↗
PubMed1996

[Value of percutaneous catheter cholangiography in postoperative biliodigestive and bilio-biliary anastomoses].

AIM OF STUDY: To examine the relative importance of percutaneous catheter cholangiography in postoperative diagnostics after biliary reconstruction. METHODS: 55 patients (33 males, 22 females) were subjected to 101 catheter cholangiographies. 30-50 ml of a water-soluble, iodic contrast medium were administered via an infusion system. Initial examinations were performed between the 3rd and 7th day following operation, while follow-up examinations were executed between the 8th and 145th day after surgery. The position of the catheter, the function of the anastomosis, the filling of the biliary ducts and the discharge of the contrast medium were assessed. RESULTS: 45 examinations were inconspicuous. Drainage obstruction of the contrast medium was observed in 24 cases. Filling defects were observed in 8 examinations. A dislocation of the catheter was encountered in 5 cholangiographies while 19 examinations displayed a bile leak. CONCLUSION: Percutaneous catheter cholangiographies can be used to detect postoperative complications following biliary reconstruction in an easy, reliable, and cost-effective manner that also does not put too much strain on the patient. Indications for the implementation of catheter cholangiographies are the occurrence of abdominal complaints, the clinical appearance of a peritonitis, or an increase of the serum bilirubin value. Routine examinations are recommended in conditions following liver transplantations. In addition to this, a cholangiography should be carried out prior to the removal of the catheter.

Adult↗
PubMed1996

The role of nuclear scintigraphy of suspected bile duct injury following laparoscopic cholecystectomy.

Nuclear scintigraphy is a rapid and non-invasive tool for the diagnosis of suspected bile duct injury following laparoscopic cholecystectomy. We describe our experience with this technique in 19 out of more than 1,000 cases of laparoscopic cholecystectomy in our department. Of the five patients in whom nuclear scintigraphy revealed abnormalities, three showed bile leak to the peritoneum and underwent immediate laparotomy. Only one of these required choledochojejunostomy; in the others the leak would have closed spontaneously without surgery. In the remaining two patients there was apparently no passage to the duodenum on nuclear scintigraphy. Endoscopic retrograde cholangiopancreatography (ERCP) performed in one showed a normal bile duct. In the other patient, repeated scintigraphy done 12 h later, prior to ERCP, showed normal passage to the duodenum. Our experience indicates that laparotomy could have been avoided had ERCP been performed first. Therefore, we suggest that if nuclear scintigraphy fails to demonstrate passage to the bowel or shows a bile leak, ERCP is indicated.

Aged↗
PubMedDate not supplied

[Cancer of the head of the pancreas with a unique evolution].

Case report of a 67-years-old man with cephalopancreatic carcinoma and a peculiar evolution, undergoing several operations. The diagnostic was established 3 years ago through a peroperative pancreatic bioptic puncture, followed by choledochoduodenostomy considering the tumor as inextirpable. After 2 1/2 years symptoms of high occlusion and upper digestive bleeding caused by duodenal invasion and a Wölfler precolic gastrojejunostomy was performed. After 4 month the upper digestive bleeding relapsed severely imposing the second reintervention (cephalic duodenopancreatectomy with a special montage). The evolution was favourable, the clinical, biological and imagistic control at 6 month showing the absence of recidive.

Adenocarcinoma↗