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The experience of external drainage application of biliary ducts via lig. teres hepatis was summarized. The lowering of complications rate by 7.8%, lethality--by 4.1% was promoted by the above mentioned method application.
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Between January 1995 and December 1997 42 liver transplantations were performed in Centre for cardiovascular surgery and transplantation's in Brno. The patients were divided into two groups. The first group consist of 27 transplantations, where the biliary reconstruction was performed by means of choledochocholedochostomy or choledochojejunostomy over a drain. The drain was used on the first 20 patients for initial irrigation and for the decompression of the biliary tree later on. It was used only for the decompression in the last 7 patients of this group. The second group consist of 14 patients, where the choledochocholedochostomy was performed without any drain. The rate of the biliary complications was significantly higher in the first group. Nine biliary obstructions, 6 leaks a and 6 cholangitis occurred. Four patients died in consequence of the biliary complications. There was no biliary complication in the second group. Choledochocholedochostomy without a drain is considered as a method of choice for biliary tract reconstruction in liver transplantation.
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Retrospective evaluation of experience in treatment of 378 patients (1972-1997 years) with cicatricial stricture of hepatic ducts is presented. For the period for 1972 to 1986 years the basic principle consisted in obligatory use of a drainage--frame for prolonged (not less than 2 years) drainage of the biliary anastomosis aimed at a decrease of the recurrence risk. Changeable transhepatic drainage (CTD) was used. 199 patients were operated on, 18 died. In postoperative period a number of specific complications caused by CTD were observed: leak into infradiaphragmatic space (hemobilia, bile biliduodenal fistula, etc.). At follow-up period after restorative operations (34) relapse of cicatricial stricture was observed in 8 patients, which was a consequence of complications due to CTD. After reconstructive operations CTD was removed in 109 patients, relapse being detected in 5 (4.5%). Atraumatic needles with inert monifilament sutures as well as resolving suture threads enabled creation of high bilio-intestinal anastomoses without drainage-frame. Since 1987 to 1997 years 130 patients were operated on. Dissection of the hepatic ducts was made proximally to the cicatricial tissues, longitudinal cut of the left hepatic duct was performed. Atraumatic needles with threads of small size were used, the bilio-intestinal anastomosis was established by one layer nodular suture with nodules exteriorly faced and without seizure of intestinal mucous membrane. Complications in postoperative period were observed in 24 patients, no lethal outcomes occurred. In late postoperative period unsatisfactory results were documented in 7 patients. At present time we give preference to operations without drainage-frame. CTD is indicated in the presence of severe pyogenic and inflammatory infiltration at hepatic porta with involvement of the bile ducts' walls, cyrrhosis of the liver and portal hypertension hindering hepatic ducts' dissection; cicatricial stricture of the right hepatic duct followed by sclerosing process in sectoral ducts.
Many years' experience in treatment of 617 patients with choledocholithiasis (ChDL) served the basis for analysis of the causes of residual (72.4%) and recurrent (21.4%) lithiasis of bile ducts in patients with postcholecystectomy syndrome. In 6.2% of cases identification of the type of ChDL was not a success. Recommendations in prophylaxis of recurrent as well as residual lithiasis are given. In 78.5% of patients with residual stones after primary operation choledochotomy with removal of the stones was made with cholecystectomy but as was evidenced later not all the stones were removed. Data on diagnostic value of clinical symptoms and US examinations for revealing ChDL are presented. ChDL without jaundice was detected in 47.4% of patients. Current diagnostic facilities in primary choledocholithiasis before the operation and intraoperative are discussed. After choledochotomy, if there are no contraindications, it is recommended to finish the operation by external drainage of bile ducts with the use of T-shaped drainage tube. If residual ChDL is detected, it would be reliably eliminated without surgery.
The secondary anastomotic stenosis is often occured from the repair and reconstructive operation of the injured bile duct. It is difficult to treat and the outcome is serious. In order to prevent this complication, the fibrin glue instead of traditional suturing technique combined with inner support was used. Fifty-four hybrid dogs were divided into 3 groups. Group A received Roux-en-y choledochojejunostomy with fibrin glue; group B received Roux-en-y choledochojejunostomy, with a fibrin glue combined support left permanently in the bile duct and group C received Roux-en-y choledocholejejunostomy with fibrin glue combined a support left temporarily in the bile duct. The amount of collagen in the scar was measured at 3/4, 3, 6, 9, 12 months respectively after operation. The results showed: 1. the mature period of scar was shortened from 12 months to 9 months when fibrin glue instead of suture was used in choledochojejunostomy; 2. the mature period of scar was further shortened from 9 months to 6 months when fibrin glue combined with inner support instead of fibrin glue was used in choledochojejunostomy. The conclusions were as follows: 1. fibrin glue could facilitate the healing of wound by inhibiting the formation of scar and accelerrate the maturation of scar; 2. when the inner support was used with fibrin glue in the operation, the mature period of scar could be further shortened; 3. the mechanism of action of the fibrin glue included minimizing the injury, avoiding foreign-body reaction, modifying organization of hematoma, preventing formation of biliary fistular and enhancing intergration and cross-linkage of collagen.
Residual calculi were removed by different methods in 704 patients aged 22-86 years having residual choledocholithiasis. The author considers non-operative eradication of it to be a preferable method for patients with the external drain of bile ducts, for patients without the drain endoscopic papillosphincterotomy (EPST) should be chosen. The removal of residual concrements with the Dormia basket through the external bile fistula gave positive results in 94.5% of cases. The effectiveness of EPST in removing the calculi without the external drain was 86%. Reoperations were performed in 9.5% of the patients. Long-term results were followed up in all the patients during 5 years: good long-term results after non-operable removal of the residual calculi through the external duct were from 92% during the first 3 years to 98% in the following 7-10 years.
Data concerning operative treatment of 227 patients with lithiasis of the extrahepatic biliary ducts, covering an eleven-year period (1985 to 1995 inclusive), are presented. In all cases diagnosis and operation are done in the Second Surgical Clinic at the Medical University--State University Hospital "Alexandrovska"--Sofia. By type the surgical interventions are distributed as follows: external drainage of hepaticocholedochus--122 cases (53.74 per cent), choledochoduodenostomy 69 (30.39 per cent) and transduodenal papillosphincterotomy 36 (15.85 per cent). Fifteen patients develop postoperative complications (6.60 per cent), and in five patients the outcome is fatal with postoperative lethality amounting to 2.20 per cent. The basic indications for the various types of surgical interventions are established.
Choledochoduodenostomy (CDS), suggested by T. Roth, and performed for the first time by O. Sprengel (1891), became a definitely affirmed operation after the publications of F. Sasse (1913). From purely anatomical standpoint, CDS contributes to bypass all problems relating to obstruction in the retroduodenal, transpancreatic and intramural segments of the hepatocholedochus with a wide orifice for spontaneous passage of eventual newly formed or residual concrements being secured. The basic indications for performing CDS include: multiple concrements in the extrahepatic biliary ducts, ampullar stenosis, cholangitis, chronic pancreatitis, cyst induced enlargement of choledochus and the like. It is worth noting that in most patients more than a single indication are present. The major shortcomings of the procedure with a reference to the long-term results are attributed to potentialities of cholangitis and cholangiohepatitis development, and "blind sac" formation between the anastomosis and p. Vateri. It is established that all patients with poor post-CDS results have stenosis of the anastomosis, or else, the restoration of papillary patency fails (endoscopically confirmed), i.e. they are most frequently a sequel of technical errors. CDS is a safe, readily performed and effective surgical procedure with few (sporadic) postoperative complications, including patients undergoing long-term follow-up study.