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PubMedDate not supplied

Long-term results of management of type I choledochal cysts in adults.

Choledochal cysts in adults is a rare condition. The present study describes our experience with this abnormality of the biliary tree. During a 16-year period (1978-1993) eight adults with type I choledochal cyst were treated surgically in our departments. They were 4 men and 4 women with a mean age of 38.9 years (range 20-84). Symptoms, clinical findings and abnormalities in laboratory investigations included pain in all patients, history of cholangitis (n = 3), cholangitis (n = 2), acute pancreatitis (n = 1), palpable mass (n = 2), abdominal tenderness (n = 4), leucocytocis (n = 2), and increased levels of serum total bilirubin (n = 4), SGOT (n = 2), and serum alkaline phosphatase (n = 4). Diagnosis was established by intravenous cholangiography in one case, by CT-scanning in one, by ultrasonography in 5 and by intraoperative cholangiography in one. All the patients were treated surgically. Three of them underwent a Roux-en-Y choledochocystojejunostomy and one a choledochocystoduodenostomy. The other 4 patients were treated with cyst excision and Roux-en-Y hepaticojejunostomy. There were no deaths among our patients. The mean follow-up period was 6.7 years (range 1-17). So far, five episodes of mild ascending cholangitis have occurred in the patient treated with choledochocystoduodenostomy. One patient in whom a Roux-en-Y choledochocystojejunostomy was performed had 2 episodes of right upper quadrant colic pain and one episode of cholangitis. Both these patients were treated conservatively. The other 6 patients had no episodes of pain cholangitis or jaundice. In conclusion, the primary treatment of choledochal cyst type I is the excision of the cyst with Roux-en-Y hepaticojejunostomy. The Roux-en-Y choledochocystojejunostomy is indicated in cases where, for various reasons, the cyst can not be safely removed.

Adult↗
PubMed1997

Surgical biliary bypass for benign and malignant extrahepatic biliary tract disease.

BACKGROUND: The optimal management of patients with benign and malignant disease affecting the extrahepatic biliary tract remains unresolved. A retrospective study was undertaken of all surgical biliary bypass procedures performed in one hepatobiliary unit. METHODS: A total of 121 patients treated in a 9-year period and comprising 60 patients with benign disease and 61 with malignant disease were reviewed. RESULTS: There was no significant difference in 30-day mortality rate between patients with benign and malignant disease (2 versus 8 per cent respectively, P = 0.22). There was no significant difference between surgery for benign and malignant disease in early morbidity rate (13 versus 21 per cent respectively, P = 0.36) or late morbidity rate (20 versus 25 per cent, P = 0.70). The median postoperative stay in both groups of patients was 10 days. The median survival of all patients with malignant disease was 7 months, being significantly more favourable for those with cholangio-carcinoma (18 months) than for those with pancreatic carcinoma (6.5 months) (P < 0.01). CONCLUSION: Biliary bypass procedures can be undertaken with acceptable rates of morbidity and mortality, and therefore should be considered in all patients with malignant disease of the extrahepatic biliary tract. If there is evidence of advanced malignancy, or if the patient is unfit for surgical intervention, non-operative procedures are a suitable alternative.

Adolescent↗
PubMed1996

[The choice of the operation and management in cholangitis].

Irrespective of the high rate of bacterial flora (intestinal, respectively) penetration into the biliary apparatus, clinically manifested cholangitis cases are relatively seldom met with. The predisposing factors involved are: penetration of virulent flora (anaerobic inclusive) into the bile ducts, presence of conditions promoting delay or discontinuation of the bile passage (biliary hypertension), and longstanding of the disease. Cholangitis associated with cholangiohepatitis development is one of the severest conditions of cholelithiasis (ChL), being observed as an independent nosological entity also. Over the period 1974 through 1993, in the clinic of abdominal surgery a total of 144 patients presenting cholangitis undergo treatment, of which in 74 (8.7 per cent) it is associated with ChL, in 58 it is discovered during reoperation on the biliary apparatus, and in twelve it is diagnosed as an independent disease, unrelated to calculosis. Acute cholangitis runs a foudroyant course with a poor prognosis, whereas the chronic form is characterized by larvate (masked) development with exacerbation periods. The clinical picture is dominated by Charcot's triad. The disease runs a rather severe course in the contingent liable to reoperation. As a rule, it occurs as the result of stricture of the bile ducts or obliteration of bilidigestive anastomosis. 58 per cent of the patients are older than 50 years. Operative intervention in acute cholangitis should be done on an emergency basis. External drainage insertion is a palliative measure, practicable in heavily damaged patients. The operation in acute and chronic cases is aimed at maximum possible healing of the biliary tract and elimination of the underlying causes of obstructed passage. Lethality is higher than the medium rate, and the prognosis remains serious.

Acute Disease↗
PubMedDate not supplied

Current problems with intrahepatic bile duct stones in Japan--congenital biliary malformations as a cause.

BACKGROUND/AIMS: In patients with primary intrahepatic bile duct stones, strictures of the biliary duct are often present, but the relationship between these strictures and the formation of the stones remains controversial. Intrahepatic bile duct carcinoma in association with intrahepatic bile duct stones has recently been reported. The present study attempted to ascertain whether bile stasis induced by congenital biliary strictures is the basis for the formation of stones and occurrence of carcinoma. MATERIALS AND METHODS: We analyzed the location of strictures in 58 patients with strictures in the upper portion of the biliary tract including 38 patients with intrahepatic bile duct stones and 9 with intrahepatic bile duct carcinoma. The cell cycle of epithelial cells from the intrahepatic bile duct were analyzed with using proliferating cell nuclear antigen, which is a immunohistochemical staining method. RESULTS: Fifty six of 58 patients had congenital cystic dilatation of the common bile duct (two infant type and 54 adult type). Thirty eight patients had intrahepatic bile duct stones proximal to the strictures at the hepatic hilum. The location of the strictures were classified into four types. Nine patients had intrahepatic bile duct carcinoma and eight of the 9 carcinomas coexisted with intrahepatic bile duct stones. In the nine patients with intrahepatic bile duct carcinoma, the expression of proliferating cellular nuclear antigen (PCNA) in the carcinoma and the normal bile duct epithelium adjacent to the carcinoma was higher than that of patients with hepatocellular carcinoma without anomaly of the biliary duct. CONCLUSION: Considering the location of the strictures and clinical features, the strictures may have been formed congenitally. Furthermore, adult type cysts of the common bile duct with strictures in the upper portion of the biliary tract are thought to be the basis for the formation of primary intrahepatic bile duct stones. The most appropriate treatment for intrahepatic bile duct stones is thus suggested to be removal of the affected hepatic segment including the region of strictures, combined eventually with hepaticoenterostomy.

Adult↗
PubMedDate not supplied

[A minimally invasive approach in choledocholithiasis].

In the last years several less aggressive procedures diminished the role of open choledochotomy (CT) in the treatment of common bile duct (CBD) lithiasis. Between them are endoscopic sphincterotomy (EST) and laparoscopic choledochotomy. In a lap of 18 month were followed up, in a prospective way, all the cases of CBD lithiasis admitted in our department. Twenty-seven patients were treated by EST and 28 by CT. The endoscopy was as efficient as open CT in clearing the CBD (85% vs. 83%). Even if the endoscopic group was at a higher risk the morbidity was lower than in the classic approach and the mortality was the same (3.5%). The most common complication after EST was acute pancreatitis (7.5%). The mean hospital stay was lower after EST. Near by are discussed 3 cases of associated gallbladder and CBD lithiasis treated exclusively by laparoscopic approach.

Adult↗
PubMed1995

Long-term management of biliary tract complications.

Biliary tract complications represent an important problem after transplantation. They are not only important in the immediate posttransplantation period, but perhaps of even greater importance in the long-term management of transplant recipients. One of the major changes that has occurred over the past several years is an increasing use of nonoperative therapy, either via endoscopic or percutaneous routes. In many cases of biliary leak, stones, and T-tube malposition, nonoperative management may be curative. The exact role they play in the management of strictures, particularly diffuse stricturing and isolated hepatic duct strictures, remains to be determined. At the least, it provides temporary drainage before initiating surgical therapy. In addition to being efficacious, nonsurgical management is quite safe. In 64 cases of biliary complications managed nonoperatively, complications occurred at UCSF in only four patients. One patient developed bleeding along the percutaneous catheter tract and required replacement with a larger diameter catheter to tamponade the bleeding. Two patients developed hemobilia secondary to intrahepatic pseudoaneurysms caused by the percutaneous drainage catheter. One patient developed an osteomyelitis of a rib related to an indwelling percutaneous biliary catheter that responded to antibiotics and rib resection. Finally, understanding several of the biliary complications that occur after transplantation (ie, sphincter of Oddi dysfunction) will require additional research and hopefully will determine the pathophysiology of these complications. This should lead to more rational therapy.

Biliary Tract Diseases↗
PubMed1996

[Research of clinic and laboratory of face acupuncture effect and the exploration of their afferent pathways].

This paper shows that face acupuncture point (Liver point through gallbladder point) has significant effect of promoting bile secretion on the patients of cholecystectomy and choledochotomy and drainage. Special different point is that face acupuncture stimulation has very obvious posteffect comparing with other three body acupuncture groups and this posteffect lasts more than fifty minuts. The results also show that the successful rate of face acupuncture anesthesia is better than body acupuncture anesthesia during the ligation of oviduct and subtotal gastrectomy. The above results are all analysed statistically and there is a very significant difference among them. During the research on domestic dog anesthesiaed by face acupuncture, the successful rate is 86.5%, moreover the analgesic effect of face acupuncture can be blocked by blocking bilateral postganglionic fibre of trigeminal ganglion with 2% procaine. The results imply that trigeminal ganglion is the main afferent way of stimulation information of face acupuncture.

Acupuncture Analgesia↗
PubMed1997

The removal of cystic duct and gallbladder remnant by microlaparotomy.

The so called "Postcholecystectomy Syndrome" may be due to various pathological biliary causes. While a very small number of patients may have symptoms attributable to problems related to cholecystectomy. Twenty five patients underwent a second operation on the bile ducts after cholecystectomy, cholecystostomy and choledocho-duodenostomy by micro and minilaparotomy between December 1990 and December 1996. The second most common causes for reexploration were cystic duct and gallbladder remnants (16%). After incomplete cholecystectomy they usually find that the cystic duct stump and the alot triangle embedded in inflamed scar tissue. For this reason the surgical risk is to high with laparoscopic surgery to reoperate for these pathological changes.

Bile Ducts↗
PubMed1997

[Endoscopic treatment of the "cul de sac" syndrome: our experience].

The "Sump Syndrome" represents a known late complication not easily recognizable within the interventions of CDS and L-L CDS. Its incidence ranges from 0% to 9.6% according to the literature. Up to ten years ago the "Sump Syndrome" treatment was mostly surgical. Currently endoscopic treatment reduces considerably the operative risk and the number, frequency and severity of complications. The technique consists of an endoscopic papillosphincterotomy with removal of calculus, gall mud, alimentary fragments and restoration of a satisfactory flow towards the duodenum. From January 1985 to October 1993, 492 ERCP were performed in Popoli's Hospital Digestive Department with an overall success rate of 92% and a selective incannulation success rate of 87%. Endoscopic treatment was used in 56% of the cases (319 patients) with 90% of success; 271 patients (35%) with lithiasic pathology were examined and 35 (12.9%) of them presented the "Sump Syndrome". Six patients underwent operation, 2 had no treatment and 27 underwent endoscopic treatment. In 21 cases an endoscopic papillotomy was performed and in 6 cases a bile-duct washing or calculi fragmentation was assured; 21 patients recovered completely while 6 patients still refer a painful-dyspeptic symptomatology with occasional colics which could be related to phenomena of chronic pancreatitis. The clinical experience allowed us to positively evaluate the endoscopic treatment of the "Sump Syndrome" since it carries a low mortality and morbidity rate and, furthermore, it is easily repeatable.

Aged↗
PubMed1997

[Personal experience in the treatment of carcinoma of the head of the pancreas].

The Authors report 195 cases of carcinoma of the head of the pancreas observed in the period 1983-1995. Only 94 (48%) of these patients were operated: in 32 cases an exploratory laparotomy was performed, while in 36 a bilio-digestive bypass, associated in 2 patients with a gastro-jejunal bypass was assured. In 26 patients a resection was performed: in 12 a Whipple procedure, in 6 a total duodenopancreatectomy, in 8 a pylorus preserving procedure (Traverso-Longmire). The mean survival was 2 months after laparotomy, 6 months after bilio-digestive bypass, 20 months after Whipple procedure, 20 months after total duodenopancreatectomy, 23 months after a pylorus preserving procedure (Traverso-Longmire). The Authors believe that the Whipple procedure is the treatment of choice for the carcinoma of the head of the pancreas. Only in cases of suspected multifocality or when there is a severe nodal involvement it is advisable to perform a total duodenopancreatectomy.

Biliopancreatic Diversion↗
PubMed1997

[Choledochotomy and its results].

Of 21 patient to whom after choledochotomy the external drainage of common bile duct was conducted, the suture insufficiency have occurred in 3, 2 patients died. After choledochoduodenostomy conduction the suture insufficiency was observed in 3 of 17 patients, 2 patients died. After papilloshincteroplasty conduction the complications were revealed in 5 of 23 patients, 3 patients died. Of 4 patients, in whom the twin internal drainage was conducted, 3 died.

Choledochostomy↗
PubMed1998

[Value and technique of laparoscopic choledochus revision in choledocholithiasis].

Despite a large scale indication to ERCP, 5% of unsuspected stones are shown by principally intraoperative cholangiography in our patients. Praeoperative diagnostic makes it possible to select the individual optimal therapy for each patient, the possibility of saving the Papilla vateri gives the large scale indication to laparoscopic common bile duct exploration. Also suspected stones gets a one-time cure therapy by complete laparoscopic operation. After balloon-dilatation of cysticus duct to 6 mm, the laparoscopic choledochoscopy is possible through the cysticus duct. Little stones are flushed into the duodenum or extracted by Segura-basket through the cysticus duct. Big stones needs a Laser- or electrohydraulic lithotripsy, the stonefragments can be flushed into the duodenum or aspirated through the cysticus duct. Multiple big or proximal incarcerated stones gives the indication for laparoscopic choledochotomy. Effective extraction is possible by big Segura-basket, residual stones are taken out under choledochoscopic control by little Segura-basket. Incarcerated stones needs the lithotripsy. Microdrainage of the common bile duct and only in special indication the T-tube saves the gall-flow to restitution of papilla function, the common bile duct is closed by running suture in Lahodny-technique. After the regular postoperative cholangiography on third day after operation, the microdrainage can be taken out. In 96% of all laparoscopic cholecystectomies the intraoperative cholangiography was successful. Only 3 of 103 patients needs a postoperative EPT because of residual fragments after trans cystic duct exploration. 8 laparoscopic choledochotomies shows the successness of endoscopic techniques, the postoperative complications can be the same then in conventional operation.

Cholecystectomy, Laparoscopic↗
PubMed1998

[Early and late outcome of biliodigestive anastomosis and transduodenal papillotomy in benign diseases of the bile ducts].

The results of a prospective study of 188 choledochoduodenostomies, 51 choledocho-jejunostomies, and 114 transduodenal papillotomies in patients with benign diseases are presented. The operations were performed between 1974 and 1997. The status of the patients was checked every one to two years. During the same time period a total of 5128 patients with benign disorders of the gall bladder or biliary tract was operated upon. In consequence to the important progress of endoscopic diagnostic and therapeutic options indications and methods of biliary surgery have changed significantly. Open procedures at the choledochal duct, biliodigestive anastomoses, and transduodenal papillotomies are recently performed only in rare instances.

Adolescent↗
PubMed1997

A clinical study of elderly patients with acute cholecystitis.

UNLABELLED: In recent years, an increase in average life expectancy has led to a rapid rise in the number of elderly patients undergoing surgery for acute cholecystitis. We studied the clinical characteristics of elderly patients (aged 75 years of more) undergoing surgery for acute cholecystitis, as compared with those of non-elderly patients (aged less than 75 years) undergoing similar procedures. Twenty-four of the patients were elderly, and 44 were non-elderly. RESULTS: Echography and abdominal computed tomography (CT) revealed no characteristic findings specific to elderly patients, but a smaller proportion of elderly patients showed a three-layered structure of the gallbladder wall. The leukocyte count on admission was significantly lower in elderly patients than in non-elderly patients. As for therapy, a significantly higher proportion of elderly patients underwent percutaneous transhepatic gallbladder drainage (PTGBD) + cholecystectomy + choledochotomy/choledocholithotomy, as compared with non-elderly patients. In contrast, cholecystectomy alone was performed more frequently in non-elderly patients than in elderly patients. The main postoperative complications were psychic symptoms and respiratory tract infections. The postoperative hospital stay was significantly longer for elderly patients, in part because they requested to remain in the hospital until they were able to perform activities of daily living.

Acute Disease↗