Management of choledocholithiasis in the laparoscopic era.
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Cholangiopancreatography, Endoscopic Retrograde↗
Biomedical subjects
S M Strasberg
Publications and source records attributed to S M Strasberg.
Imaging of the common bile duct during laparoscopic cholecystectomy: sonography versus videofluoroscopic cholangiography.
OBJECTIVE: The purpose of this prospective study was to compare the accuracies of laparoscopic sonography and laparoscopic videofluoroscopic cholangiography in detecting common bile duct stones and in identifying ductal anomalies during laparoscopic cholecystectomy. SUBJECTS AND METHODS: Ninety-five patients who underwent laparoscopic videofluoroscopic cholecystectomy were prospectively studied with laparoscopic sonography and laparoscopic videofluoroscopic cholangiography. The number of successful studies, the time required to complete the study, and complications resulting from the study were recorded. The biliary system was evaluated for complete visualization of the common bile duct, visualization of the cystic duct, ductal anomalies, maximum diameter of the common bile duct, and common bile duct stones and/or debris. Also determined was whether laparoscopic sonographic findings altered operative management. RESULTS: Laparoscopic sonography was successfully performed in 93 of 95 patients, and laparoscopic videofluoroscopic cholangiography was successfully performed in 90 of 95 patients. The time required to complete laparoscopic sonography ranged from 3 to 18 min (mean +/- SD, 8 +/- 3 min), and that required to complete laparoscopic cholangiography ranged from 5 to 28 min (mean +/- SD, 14 +/- 6 min). Laparoscopic sonography visualized the complete common bile duct in 84 of 93 patients, and laparoscopic cholangiography did so in 86 of 90 patients. Laparoscopic sonography showed the cystic duct in 87 of 93 patients, and laparoscopic cholangiography did so in 80 of 90 patients. Laparoscopic sonography showed no ductal anomalies in any of the 93 patients. Laparoscopic cholangiography showed ductal variants in 13 of 90 patients; however, 11 of the variants were proximal to the sonographic scan plane. Laparoscopic sonography showed common bile duct stones in 12 of 93 patients, and laparoscopic cholangiography did so in five of 90 patients. Laparoscopic sonography altered operative management in two of 93 patients. CONCLUSION: Our results show that laparoscopic sonography is as accurate as laparoscopic videofluoroscopic cholangiography in visualizing the common bile duct and cystic duct and in detecting common bile duct stones. However, the data are too limited to determine whether laparoscopic sonography is as accurate as laparoscopic cholangiography in detecting ductal anomalies.
Adult↗
Evidence of preservation injury to bile ducts by bile salts in the pig and its prevention by infusions of hydrophilic bile salts.
Preservation injury to bile ducts is a serious problem in liver transplantation, especially when preservation exceeds 12 hours. The authors hypothesized that the injury was caused by contact of bile ducts with bile salts during cold preservation and might be preventable by infusion of more hydrophilic bile salts. Swine livers were harvested after intraportal infusions of saline (control), of the hydrophobic bile salt taurodeoxycholate, or of the hydrophilic bile salts tauroursodeoxycholate or dehydrocholate. The effect of infusing a combination of hydrophilic and hydrophobic bile acids was also studied. Bile samples were taken before and during the infusions. Then livers were perfused with UW solution, ducts were flushed retrograde with UW, and livers were stored at 0 to 1 degree C for 20 hours. Bile ducts were harvested after preservation, and coded microscopic slides of the specimens were examined by light microscopy. There was large variability in baseline bile salt concentration. Injury after preservation consisted of sloughing and pyknosis of surface and glandular epithelium. The histologic injury score determined after preservation was directly related to bile salt concentration in bile ducts at the time of flushing. During bile salt infusions, the infused bile salt replaced most or all of the other bile salts present in bile. Severe postpreservation injury of intrahepatic ducts occurred after taurodeoxycholate infusions, but injury was minimal when either of the two hydrophilic bile salts was infused. The mixture of bile acids produced intermediate results. Retrograde flushing with UW does not prevent injury to intrahepatic ducts. The authors conclude that the injury is caused by contact with bile salts, is dependent on bile salt concentration and composition, and is preventable.
Adenosine↗
Effect of deoxycholate on immunoglobulin G concentration in bile: studies in humans and pigs.
Because an increase in biliary deoxycholate levels seems to be a risk factor for cholesterol gallstone formation, we determined the relationship between deoxycholate levels and levels of the pronucleating protein, immunoglobulin G (Ig) in human gallbladder bile. Patients with cholesterol gallstones had a higher concentration of biliary IgG compared with a pigmented stone group and control patients. This was associated with the simultaneous presence of two conditions in the cholesterol stone group, supersaturated bile and a high deoxycholate/cholate ratio. The other patient groups met only one of the two conditions. Next, animal studies were performed to determine if model biles mimicking the two conditions could affect IgG secretion by the gallbladder. Gallbladders were exposed in vivo and then in an Ussing chamber to model biles. The voltage clamp technique was used to monitor functional integrity of the preparation. Three different model biles were tested: (1) taurodeoxycholate (TDC), 80%; taurocholate (TC), 20%; and cholesterol saturation index (CSI), 1.2; (2) TDC, 20%; TC, 80%; and CSI, 1.2; and (3) TDC, 80%; TC, 20%; and CSI, 0.6. IgG concentrations became significantly higher in group 1 than in the other two groups. The concentration of mucous glycoprotein was also significantly greater in group 1 when compared with group 2. Plasma cells were increased in number in mucosal and submucosal layers in group 1. We conclude that cholesterol supersaturated model bile with high content of TDC induces gallbladder epithelial alterations, which increase the luminal concentration of IgG and mucous glycoprotein.
Animals↗
An analysis of the problem of biliary injury during laparoscopic cholecystectomy.
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Bile Ducts↗
Selecting the donor liver: risk factors for poor function after orthotopic liver transplantation.
Initial poor function and primary nonfunction are important problems in clinical transplantation. The incidence of primary nonfunction is about 6% and that of initial poor function is about 15%. Grafts with initial poor function have a higher graft failure rate in the first 3 mo after transplantation. Severe steatosis and cold preservation in University of Wisconsin solution for over 30 hr will alone cause primary nonfunction. However, primary nonfunction is probably most often caused by the presence of multiple relative risk factors. The major donor-relative risk factors are moderate steatosis, cold preservation over 12 hr and donor age over 50 yr, whereas retransplantation, high (United Network of Organ Sharing class 4) medical status and kidney failure are recipient relative risk factors. The most important perioperative risk factor is warm ischemia time. Rates of primary nonfunction and initial poor function might be reduced by avoidance of combinations of risk factors. Several tests have been developed to predict primary nonfunction and initial poor function, but none is yet clinically efficient.
Adult↗
The effects of hepatic preservation at 0 degrees C compared to 5 degrees C: influence of antiproteases and periodic flushing.
The optimal preservation temperature for liver allografts is unknown. We evaluated the effect of small differences in preservation temperature, 5 degrees C vs 0 degrees C, on outcome of prolonged preservation. Livers of Wistar rats were preserved at these temperatures in UW solution for 40 h. Function was studied during reperfusion on the isolated perfused rat liver system at 37 degrees C. To compare the effects of a small reduction in temperature with known beneficial strategies, the effects of including antiproteases and periodic flushing of the graft with UW solution during cold preservation at 5 degrees C were also studied. Aspartate transaminase (AST) and alanine transaminase release after 4 h of reperfusion were much higher in the livers stored at 5 than at 0 degrees C (P < 0.0005). Addition of antiproteases to the preservation solution or periodic flushing reduced AST release but neither treatment at 5 degrees C was as good as simple storage at 0 degrees C. Cumulative bile production after 4 h of reperfusion was significantly greater in the 0 degrees C preserved group than in liver at 5 degrees C or 5 degrees C with periodic flushing. The addition of antiproteases resulted in slightly increased bile production (not significant). Platelets and WBCs in the perfusate decreased during reperfusion. This effect was more pronounced in the 5 degrees C preserved livers than in those stored at 0 degrees C. Antiproteases in the preservation solution appeared to inhibit platelet and WBC loss. Perfusate flow was significantly higher in the 0 degrees C group. We conclude that small differences in preservation temperature even at these low temperatures are important in postreperfusion liver function.
Adenosine↗
Diffusion of substances into human cholesterol gallstones.
BACKGROUND/AIMS: The possibility that substances penetrate gallstones and accumulate after stones have formed has not been examined. The specific aims of this study were to determine whether cholesterol gallstones are permeable and, if so, the effect of molecular weight on permeability. METHODS: Cholesterol gallstones from patients with multiple stones were collected during surgery and incubated in fluorescein solution or in solutions of fluoresceinated albumin or immunoglobulin (Ig) G. To determine egress from the stones, some stones were removed from the fluoresceinated solution after incubation and placed in bicarbonate buffer. The total area of the stone and the area of dye that had diffused into the calculi were calculated. To determine mass of penetrating IgG, stones were powdered after incubation, and IgG was measured by an enzyme-linked immunosorbent assay. RESULTS: All substances penetrated stones. Although all compounds tested diffused back out of the stones when they were replaced in buffer, proteins did so more slowly than fluorescein. CONCLUSIONS: Substances of different molecular weights can diffuse into and out of cholesterol gallstones. These findings must be taken into account when considering the role of substances contained in stones on stone formation and growth.
Cholelithiasis↗
Risk factors in elective laparoscopic cholecystectomy for conversion to open cholecystectomy.
BACKGROUND: Most cholecystectomies can be performed using a laparoscopic approach. However, 3 to 10 percent of laparoscopic cholecystectomies (LC) must be converted to open cholecystectomies (OC) and preoperative factors that predict risk for conversion are still not defined. STUDY DESIGN: Preoperative and intraoperative data were collected and analyzed from 628 patients who were scheduled for elective LC by two surgeons in an academic institution. Logistic regression was performed on data from two groups of patients: LC completed, 596 patients (95 percent) and LC converted, 32 patients (5 percent). RESULTS: Elective LC was accomplished with no common bile duct injuries, low morbidity rate (7.3 percent), and zero mortality rate. Both patient and surgeon factors predicted conversion from LC to OC. Older patients (65 years of age or older, (p < 0.01), males (p < 0.01), and patients with multiple attacks (ten or more) of biliary colic (p < 0.01), or a documented history of acute cholecystitis (p < 0.01) had a greater risk for conversion. Both surgeons had higher rates of conversion (p < 0.05) during the learning phase (fewer than 50 LC) of their experience. CONCLUSIONS: Risk factors for conversion may be predicted and awareness of these factors should help in the selection of the appropriate procedure for patients and in selection of cases for resident training.
Adult↗
Issues in cholecystectomy and management of duct stones.
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Bile Duct Diseases↗
Prediction of the outcome of transplantation in man by platelet adherence in donor liver allografts. Evidence of the importance of prepreservation injury.
We examined platelet adhesion in thirty human donor livers to determine if the degree of platelet adhesion could predict outcome of transplantation. Wedge liver biopsies were taken at the start of the donor operation (biopsy 1) and 1 hr after reperfusion in the recipient (biopsy 2). Biopsies were stained with a monoclonal antibody against platelet glycoprotein Ib and graded for platelet adhesion. Hematoxylin and eosin-stained sections were examined for polymorphonuclear leukocyte adhesion and necrosis. Platelet adhesion was much more frequent and extensive than expected in biopsy 1. Nine of 30 biopsies showed moderate or high-grade platelet adhesion. Thus in this study endothelial cell damage was present in about one-third of donors before the donor operation. The injury was not detectable by routine microscopic or clinical examination or biochemical tests. The degree of platelet adhesion in biopsy 1 predicted development of PMN adhesion and necrosis in biopsy 2 and postoperative transaminase concentrations and prothrombin times in recipients. During preservation and implantation some livers converted from low to either moderate or high grades of platelet adhesion. The grade of platelet adhesion in biopsy 2 predicted postoperative outcome as measured by transaminase and PT levels. Patients whose platelet grade converted to a higher level during preservation and implantation did not do as well as patients who remained at a low adhesion grade. These findings strongly suggest that the degree of platelet adhesion is an important determinant in assessing outcome and may provide a means of measuring the status of liver allografts prior to transplantation.
Age Factors↗
Laparoscopic versus open cholecystectomy: a matched study.
To determine the efficacy of laparoscopic cholecystectomy (LC) in the treatment of gallstone disease, all patients who underwent elective surgery for cholelithiasis during three consecutive periods (1989, 1990 and 1991) were studied. There were 121 patients in each period. All patients in the first period underwent open cholecystectomy (OC), whereas 70 (58%) patients underwent laparoscopic procedures in the second period (OC-LC). LC was the treatment of choice in the third period. Multiple factors, including sex, age, clinical and biochemical presentation of the disease and modified Apache II score were comparable among the three groups. The authors found significant differences in length of hospitalization (6.4 +/- 4.2 days in the OC group, 3.6 +/- 2.4 days in the OC-LC group and 2.4 +/- 1.7 days in the LC group, p < 0.01 when compared with the OC group) and return to work after surgery (5.8 +/- 2.8 weeks, 2.8 +/- 1.2 weeks and 1.3 +/- 1.8 weeks respectively, p < 0.01 when compared with the OC group). There was no significant difference in postoperative complications among the groups, but complications in the OC patients were more severe. Although operative time increased significantly after the introduction of LC, it returned to the range of OC after 36 procedures. Nine patients (5%) with LC required conversion to OC. Benefits of LC include a shorter hospital stay and a shorter recovery period. There were no deaths, very low morbidity, a substantial decrease in overall cost and a high degree of patient satisfaction with LC.
Adult↗
Changes in bilirubin pigments secreted in bile after liver transplantation.
The species of bile pigments secreted in T-tube fistula bile after liver transplantation were ascertained by high-performance liquid chromatography in 15 patients for 10 days after liver transplant. Nine glycosidic conjugates and unconjugated bilirubin were resolved by the analytical procedure. The principal pigments in bile and their proportions in normal patients were the following: bilirubin diglucuronide = 83.0% +/- 3.1% (S.D.); bilirubin monoglucuronide = 9.7% +/- 1.4% (S.D.); bilirubin monoglucuronide monoglucoside = 4.0% +/- 2.8% (S.D.); and bilirubin monoglucuronide monoxyloside = 1.5% +/- 1.8% (S.D.). All of the other possible glucuronide, glucose and xylose monoconjugates and diconjugates and unconjugated bilirubin were also found, but each was normally less than 1% of the total. In 13 of the 15 transplant patients, a significant depression in proportions of bilirubin diglucuronide and elevation in proportions of bilirubin monoglucuronide were found after the transplant, with an accompanying but generally small increase in the proportions of the minor conjugates. In two patients with rejection of the transplant, the changes were of larger magnitude, with improvement occurring only with recovery from the rejection. In one of these patients, kidney failure was present, and in addition to the diglucuronide and monoglucuronide conjugates, diglucoside and monoglucoside monoxyloside conjugates were found in plasma. The underlying metabolic abnormalities are not clear but likely reflect underlying abnormal intracellular cofactor levels for conjugation. Glycogen depletion with reduction of UDP-glucuronate levels or reduced UDP-glucuronate formation from UDP-glucose, secondary to elevation of UDP-xylose, could potentially account for the changes in pigment excretion.
Adult↗
Cholecystolithiasis: lithotherapy for the 1990s.
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Algorithms↗
Effect of intraportal glucose infusion on hepatic glycogen content and degradation, and outcome of liver transplantation.
Recent animal studies suggest that nutritional repletion may improve function of liver allografts, and the authors have found that intraportal glucose infusion in pigs produces rapid and substantial hepatic glycogenation. A controlled prospective randomized study in 32 patients was done to determine glycogen content and degradation in human livers during transplantation, and the effect of intraportal glucose-insulin infusions during the donor operation on these variables and on outcome of transplantation. Peripheral blood glucose concentrations were "clamped" at 14 mmol/L during the glucose-insulin infusion. Liver biopsies were taken at various stages of the procedure. Liver glycogen decreased 2.0 +/- 1.2 g/100 g dry weight liver (mean +/- standard error of the mean) in controls, but increased 6.8 +/- 1.8 g/100 g dry weight in glucose-infused donors. In both groups there was glycogen degradation during periods of cold preservation, anoxic rewarming, and after reperfusion with portal blood. Degradation rates were greater in the glucose-infused group than in controls in all three periods (p less than 0.05). Despite wide variation in postoperative aspartate aminotransferase (AST) levels among recipients in both groups, the difference in peak postoperative AST levels approached significance (p = 0.06). In addition, peak AST levels were closely correlated to anoxic rewarming time in both groups, but the slope of the relationship was much lower (3834 versus 734, p less than 0.01) in the glucose-infused group. Thus at anoxic rewarming times over 90 minutes, glycogenation was protective of liver function. Peak postoperative AST was significantly correlated to glycogen degradation in the cold preservation and rewarming periods in the glucose-infused group only. Intraoperative glucose infusions in humans can reglycogenate the liver, increase glycogen degradation, and improve certain outcome measures in liver transplantation.
Adult↗
Recent results of elective open cholecystectomy in a North American and a European center. Comparison of complications and risk factors.
Results of elective open cholecystectomy in 1252 patients treated in a North American and a European center were examined using a recent standardized classification of complications. Although there were significant differences between centers in population age, rate of concomitant disorders, and numbers of operators, the frequency and severity of complications were comparable. There were no deaths, but 12% and 14% of the patients developed complications in the two centers. About 6% of the patients developed grade I complications. Grade II complications were noted in 6% and 8%, and grade III in 0% and 0.3%. Using univariate and multivariate analysis, individual risk factors for developing complications were found to be different in the two centers. Two preoperative scoring systems, ASA and a simplified APACHE II, were predictive for complications in both centers, but did not account for all risk in these patients. Data from the two centers could not be combined because of significant interaction between risk factors and center. Elective open cholecystectomy is a safe procedure, particularly in terms of highly morbid complications and death. Generalization of risk factors identified in a particular center may be misleading because local conditions may significantly affect risk factors for complications. The data also demonstrate the advantages of a uniform way of reporting surgical complications, which may permit meaningful comparisons among centers.
Adolescent↗
Preservation and reperfusion injuries in liver allografts. An overview and synthesis of current studies.
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Humans↗
A method for sequential excision biopsies of rat liver in an isolated perfused system.
We describe a simple method of performing sequential excision biopsies during liver reperfusion in the isolated perfused rat liver. After hepatectomy, four ligatures (5.0 silk) tied with a slip knot are placed around the pedicles of: (1) the inferior and (2) the superior parts of the caudate lobe, as well as (3) the inferior and (4) the superior parts of the right lateral lobe. At the time of biopsy, the prepared 5.0 silk ties are tightened with sufficient force to occlude the vascular pedicle, preventing leakage of circulating perfusate. The procedure provides four biopsies of more than 350 mg each without alteration of perfusate transaminases and tissue ATP contents. The total tissue removed by this method comprises 20-25% of the whole liver weight.
Animals↗