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PubMed1995

New anastomosis technique for (laparoscopic) instrumental small-diameter anastomosis.

This study presents a new technique for visceral anastomosis. The principle consists of connecting the two parts to be anastomosed around a reabsorbable stent which is transluminally introduced into small-diameter viscus, where it is fixed. Advancing a larger tube along the axis of the machine, the larger, perforated viscus is inverted and pulled over the stent, and finally a rubber band pops off the machine endoluminally in order to fix the intestinal walls in seroserosal contact onto the stent. To evaluate this "micro" anastomosis, a biliary bypass (choledochojejunostomy and roux-en-y-loop) was performed in ten pigs. Nine of ten animals showed biliary bypass with good runoff in contrast radiography and completely reabsorbed stent after a 3-month follow-up. Weight gain, bilirubin, and alkaline phosphatase were normal. This technology demonstrates a safe and quick way to perform instrumental "micro" anastomosis without remnant foreign material.

Anastomosis, Roux-en-Y↗
PubMed1995

Sutured or fibrin-glued laparoscopic choledochojejunostomy.

Minimally invasive techniques for choledochojejunostomy offer theoretical advantages for palliating unresectable periampullary neoplasms. Fibrin glue, a biologic adhesive containing concentrated fibrinogen, may obviate suturing and promote healing without stricture formation. We examined the technical ability to perform laparoscopic choledochojejunostomy (LCJ) and the applicability of thrombin-activated fibrin glue in an animal model of biliary obstruction. Domestic pigs underwent laparoscopic cholecystectomy and ligation of the distal bile duct. Three days later, a side-to-side LCJ was performed by intracorporeal sutured anastomosis (n = 7) or using four stay sutures and homologous fibrin glue (n = 7). Control animals underwent a similar bypass via open laparotomy (n = 7). The postoperative interval to ambulation and oral intake was recorded, and serial serum liver enzymes were measured. The animals were sacrificed at 6 weeks, and tensile strength of the anastomoses was assessed by tensometry. Liver function tests returned to normal values within 7 days following all methods of choledochojejunostomy. In the fibrin glue group, three anastomotic leaks (43%) occurred in the 1st postoperative week. At 6 weeks, all other anastomoses were intact and patent by cholangiogram, but there was moderate stenosis of two open and one fibrin-glue anastomosis. The sutured LCJ, while taking approximately 1 h longer to perform (P < 0.05), resulted in similar efficacy and more rapid recovery (P < 0.05) than open biliary-enteric bypass. Fibrin-glued LCJ was performed rapidly, but had less tensile strength (P < 0.05) and often leaked in the early post-operative interval. We conclude that while there may be a role for laser-activated solders for primary anastomosis, thrombin-activated fibrinogen cannot be advocated as the primary means of creating biliary anastomoses. Using intracorporeal suturing techniques, laparoscopic choledochojejunostomy may be performed safely.

Alanine Transaminase↗
PubMed1993

The successful surgical management of perforation after endoscopic sphincterotomy: report of two cases.

Retroperitoneal perforation following endoscopic sphincterotomy (EST) is an infrequent but serious complication with a high mortality rate in patients who do not receive prompt treatment. We report herein two cases of perforation, diagnosed 3 and 7 days after EST, one of whom was treated by choledochojejunostomy (Roux-en-Y) and suturing of the perforation site with jejunal patching, and the other by pancreatoduodenectomy. Both operations were successful as emergency treatments and therefore we consider that radical surgery should be attempted for cases of perforation after endoscopic sphincterotomy with a delayed diagnosis.

Aged↗
PubMed1993

Surgery for cholelithiasis in cirrhotic patients.

Although biliary tract surgery for cholelithiasis is performed frequently in Japan, cirrhotic patients require special consideration. Postoperative complications after biliary tract surgery were studied in 23 patients with liver cirrhosis and associated cholelithiasis, 9 of whom had no complications, 8 had minor complications, and 6 had severe complications. Concerning the relation between Child's classification and postoperative complications, no complications were seen in four Child's type A patients, but seven of ten (70%) Child's type B patients and seven of nine (78%) Child's type C patients developed complications. Two (20%) of the Child's type B patients and four (44%) of the Child's type C were severe, and three of the latter group died. Regarding the preoperative laboratory findings, significant differences were seen between the patients without complications and those with severe complications in serum bilirubin, albumin, and ICG R15 values. Of the six patients with severe complications, five had choledocholithiasis, three of whom died of liver failure, while two developed biliary peritonitis caused by insufficient fistula formation after removal of the T-tube. Thus, for the treatment of choledocholithiasis in patients with severe cirrhosis, avoiding surgical invasion through the use of such techniques as endoscopic papillotomy is recommended whenever possible.

Biliary Tract Surgical Procedures↗
PubMed1997

Duodenogastric reflux after choledochoduodenostomy.

Duodenogastric reflux (DGR) has been implicated in several disease processes. The present study was carried out to document the incidence and evaluate the clinical significance of DGR after choledochoduodenostomy (CDD). A total of 13 patients who had undergone cholecystectomy with a standard side-to-side CDD for choledocholithiasis or chronic pancreatitis were studied by symptom evaluation, scintigraphy, endoscopy, and gastric mucosal histology at least 6 months after surgery. The scintigraphic findings were then compared with those of 10 patients who had undergone cholecystectomy alone. Only two patients (15%) had mild dyspeptic symptoms. The incidence of DGR after CDD was 69% compared to 20% in the cholecystectomy alone group (P < 0.05). In the majority of patients the DGR was only mild to moderate and the severity correlated well with the degree of endoscopic gastritis, but not with the clinical symptoms or histological findings. These results indicate that while CDD is associated with a high incidence of DGR, its occurrence does not produce significant clinical symptoms.

Adult↗
PubMed1991

[Animal experiment studies of development of anastomosis ulcers after reflux-inducing and reflux preventing stomach resection].

In an animal experiment the role of bile reflux in development of anastomotic ulcer after partial gastrectomy was investigated. On 45 pigs 2/3 partial gastrectomies and on 5 animals only laparotomies were carried out. The ulcer risk after reconstruction procedures with possible bile reflux was compared with reflux-free techniques. Anastomotic ulcer developed after maximal exposure of the gastric remnant to bile as well as after reflux-free reconstructions: B-II-Roux, 40 cm jejunum loop (n = 5/10); B-II-Roux, 20 cm jejunum loop (n = 3/5); B-II-Roux, 40 cm jejunum loop and truncal vagotomy (n = 1/5); B-I and choledochojejunostomy (n = 2/10); B-II-Roux, 40 cm jejunum loop and cholecystogastrotomy (n = 4/5). After B-I resection with medium duodeno-gastric reflux (n = 0/10) and in the control group (n = 0/5, laparotomy only) no ulcer occurred. Because basal acid output after B-I and B-II-Roux resection was reduced to O mval/h, stimulated gastric acid seems to be important in development of anastomotic ulcer. The experimental results prove the protective role of postresectional duodenogastric reflux. After partial gastrectomy for primary ulcer surgery reconstruction procedures guaranteeing duodenogastric reflux should be preferred to Roux-en-Y gastrojejunostomy.

Anastomosis, Roux-en-Y↗
PubMed1993

Human sphincter of Oddi motility and cholecystokinin response following liver transplantation.

The reported incidence of sphincter of Oddi dysfunction following orthotopic liver transplantation has ranged from 3% to 7%. If sphincteric dysfunction is unrecognized, therapy may be inappropriate; when recognized, extensive surgery may be required. To prospectively identify patients with sphincteric dysfunction, we performed sphincter of Oddi motility studies through the t-tube tract three months after transplantation. Baseline sphincter motility and response to intravenous cholecystokinin were evaluated. The results of 10 subjects are reported; nine had normal basal sphincter pressure (16 +/- 5.8 mm Hg), and all had normal frequency (3.6 +/- 1/min), amplitude (86 +/- 31 mm Hg), and duration (4.5 +/- 1 sec) of phasic contractions. One subject had an elevated basal pressure (47 mm Hg). All, including the subject with elevated basal pressure, demonstrated a normal response to intravenous cholecystokinin with significant inhibition of phasic contraction frequency and amplitude. We demonstrate that simultaneous studies of the sphincter and duodenum can be obtained via the t-tube tract, providing the opportunity for prospective evaluation of sphincteric function. We conclude that sphincter of Oddi function usually remains normal following liver transplantation with choledochocholedochostomy.

Cholecystokinin↗
PubMed1997

Ductoplasty for an aberrant hepatic duct in a choledochal cyst.

The confluence of the right and left hepatic ducts at the hepatic hilum frequently shows normal anatomic variations. Choledochal cysts (CC) are also accompanied by similar variations, and devices for free drainage of bile are occasionally required in biliary reconstruction. We present a CC that had an aberrant posterior branch of the right hepatic duct draining into the distal common hepatic duct. A capacious hepaticoduodenostomy at the hilum was performed after joining the hilar and aberrant ducts.

Child, Preschool↗
PubMedDate not supplied

Exogenous growth hormone: effects on the catabolic response to surgically produced acute stress and on postoperative immune function.

The first purpose of the present prospective randomized study was to determine if the protein catabolic response after operation could be restrained by administration of hypocaloric parenteral nutrition (HPN) plus human growth hormone (hGH). Our second aim was to determine if the administration of hGH could improve the systemic host defenses, thereby reducing the risk of infection. We performed a placebo-controlled randomized double-blind trial in 180 patients after elective cholecystectomy with or without choledochoduodenostomy (placebo = control group, n = 93; hGH-treated group, n = 87). The results obtained in this study show that positive nitrogen balance can be achieved during the postoperative period from the first 24 hours onward, with a combination of HPN support (1.0-1.5 g protein/kg/day and 900 kcal/day) together with the administration of small doses (8 IU) of hGH. The potassium balance tended to follow the same positive balance as the nitrogen balance. Our study shows that in the control group, treated only with HPN, a significant decrease in serum levels of some acute-phase proteins (retinol-binding protein, transferrin, prealbumin), albumin, total proteins, and immunoglobulins occurs by the 5th postoperative day. In the GH group the values of all the above-mentioned proteins do not change or tend to rise if compared to preoperative levels. In the GH-treated group liver function appeared to improve at the start of the study. GH and somatomedin C levels were similar in the two groups and had not changed significantly in the control group by the 5th postoperative day.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Proteins↗
PubMed1994

Recurrence of intrahepatic stones after an end-to-side choledochojejunostomy.

The risk factors for the recurrence of intrahepatic stones after an end-to-side choledochojejunostomy were investigated, along with the outcome following the treatment of such stones. Thirty-two patients with intrahepatic stones underwent an end-to-side choledochojejunostomy, and a complete lithotomy was achieved in 26 of them. The follow-up which ranged from 5-19 years after surgery revealed that eight patients developed a recurrence of intrahepatic stones, and their clinical and cholangiographic findings were thus reviewed. Recurrent stones were associated with onset of symptoms at a younger age and were predominantly located in the intrahepatic bile ducts. Recurrence was also associated with severe intrahepatic bile duct dilatation. Six of the eight patients developed recurrent stones more than 5 years after a complete lithotomy. One of these patients died of liver cirrhosis while two died of acute obstructive suppurative cholangitis. Five patients underwent cholangioscopic lithotomy through the jejunostomy for their recurrent stones, and a complete lithotomy was accomplished in three of them. These findings indicate the necessity of performing a hepatectomy in such patients whenever possible, and also emphasize the need for a long-term follow-up after a complete lithotomy with an end-to-side choledochojejunostomy. In addition, any recurrent stones should be treated promptly by a cholangioscopic lithotomy through a jejunostomy.

Adult↗
PubMed1991

CT appearance of the Roux limb following choledochojejunostomy in liver transplantation.

Choledochojejunostomy in Roux-en-Y is a frequent form of biliary reconstruction in liver transplants. On computed tomography (CT), fluid in the Roux limb may simulate a fluid collection. We studied the CT appearance of the Roux jejunal limb in 25 normal and complicated liver transplant patients. The Roux limb was identified in 21 (84%) of 25 cases. Most frequently useful features were characteristic location, continuous tubular appearance, biliary stent, "bull's eye" appearance, and gas in the loop. Two of 18 normal Roux loops were initially suspected of being abscesses and one gas-containing abscess was initially mistaken for the Roux limb. In five of seven patients with complications (four abscesses, two bile leaks, one anastomotic hemorrhage), identification of the Roux limb was possible and was useful in interpreting CT scans. Knowledge of the appearance of the normal and abnormal Roux limb is essential for proper interpretation of CT scans in liver transplant patients.

Abscess↗
PubMed1994

Long-term observations on morphological changes of choledochal epithelium after choledochoenterostomy in rats.

Morphological changes of the common bile duct were observed macroscopically and microscopically 20 months after choledochojejunostomy and choledochocolonostomy in rats. The common bile ducts were remarkably dilated in all rats of both experimental models. Choledochal stones consisting of fatty acid calcium and calcium bilirubinate were seen in two of six rats with choledochojejunostomy and two of five rats with choledochocolonostomy. The main pathological change observed in both the groups was remarkable hyperplasia of the choledochal epithelium. Only one rat with choledochojejunostomy revealed normal epithelium with choledochal stone formation. Intestinal metaplasia was seen in two rats with choledochojejunostomy and all with choledochocolonostomy. Squamous pseudostratification of the epithelium indicating atypism was observed in two rats with choledochojejunostomy. Sialomucin producing cells and sulfomucin producing cells were seen in the hyperplastic portion of the epithelium. No malignant alteration of the epithelium was detected. These findings indicate that long-lasting exposure to digestive enzymes and bacteria causes epithelial hyperplasia and further exposure to digestive enzymes plays a major role in appearance of the epithelial atypism. Carcinogenesis of the choledochal epithelium under such an environment will need much more time to be established.

Animals↗
PubMed1995

Ultrastructural study on hyperplastic epithelium of rat common bile duct after choledochoenterostomy.

Hyperplasia of the choledochal epithelium occurs in rats after choledochoenterostomy. It is tubular or papillary and not like small intestinal mucosa in rats with choledochojejunostomy. It is, however, like large intestinal mucosa in rats with choledochocolonostomy. We investigated the ultrastructure of the hyperplastic epithelium in the two experimental groups of rats in this study. The main constituent cells of the hyperplasia of both the groups were like the principal cells of the control, but differed in that they had long microvilli and contained an aggregation of mucus droplets and an increased number of lysosomes. These findings were not seen in the control. The microvilli were sparse in the choledochojejunostomy group, but were dense in the choledochocolonostomy group. These findings suggest that the main function of the epithelium may be cytoprotection in the choledochojejunostomy group and both resorption and cytoprotection in the choledochocolonostomy group.

Animals↗
PubMedDate not supplied

Dissolution of multiple biliary duct stones using methyl tert-butyl ether (MTBE): experience in two cases.

Methyl tert-butyl-ether (MTBE) was successfully used for stone dissolution in 2 patients with multiple bile duct cholesterol stones. The presence of a biliary-enteric anastomosis precluded the endoscopic approach. Because of leakage of MTBE into the bowel, dissolution time ranged from 7.5 to 36 h. No significant complications other than mild nausea were encountered. No recurrence of stone formation has been found at a follow-up varying from 9 to 12 months.

Adult↗