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PubMed1989

Biliary tract complications in orthotopic adult liver transplantation.

In a series of orthotopic liver transplantations performed between April and August 1987 at the University of Pittsburgh, the monofilament absorbable suture polyglyconate was compared with a braided absorbable suture, polyglactin 910, for its biliary complication rate over a 6-month postoperative period. Complications that were suture-related (obstruction or leak from the anastomotic site) occurred in 1 of 21 transplantations in the polyglyconate group compared with 8 of 26 in the polyglactin 910 group (p = 0.02). Even though the patient sample was relatively small, it appears that the type of suture used for the biliary anastomosis directly correlates with the outcome. A larger patient trial could confirm these initial results.

Anastomosis, Surgical↗
PubMed1991

Variation in management based on type of choledochal cyst.

The management of 23 patients treated for choledochal cysts at the Oregon Health Sciences University between 1969 and 1990 is reviewed. The median age was 27 years, with a range from 1 month to 90 years. Seventy-eight percent of patients presented with abdominal pain, and 35% were jaundiced. Three patients presented with cholangitis, two with cyst rupture, and one with recurrent pancreatitis. Nine patients had had previous biliary surgery. The diagnosis was made in all patients with ultrasound and/or cholangiography. Fifteen patients (65%) had type I cysts, 2 had a type II cyst, 5 (22%) had type III cysts, and 1 had a type IV cyst. Stones were present in four (17%) cysts, and all excised cysts were benign. Seventeen patients with type I and II choledochal cysts had complete cyst excision and choledochoenterostomy. Four of five patients with type III cysts had endoscopic cyst incision and drainage, while the fifth patient had transduodenal cyst excision and sphincteroplasty. The patient with a type IV cyst had extrahepatic cyst excision and choledochojejunostomy. There were no operative deaths. Two postoperative complications occurred: cholangitis and a prolonged ileus. All patients had resolution of their pain and jaundice. Two patients had late cholangitis. Cyst excision and choledochojejunostomy are the treatment of choice for types I and II choledochal cysts. Extrahepatic cyst excision and choledochojejunostomy may be adequate treatment for type IV cysts. Endoscopic incision and drainage is appropriate for selected patients with type III cysts.

Adolescent↗
PubMed1992

Choice of palliation for malignant hilar biliary obstruction.

Clinical data from 50 consecutive patients with unresectable hilar tumors situated at or proximal to the common hepatic duct were retrospectively analyzed to aid in the selection of appropriate palliative measures. Thirty-four patients had cholangioenteric bypass (CEB) to either left (28 patients), right (3 patients), or both (3 patients) intrahepatic ductal systems. Sixteen patients had nonoperative drainage (NOD) established either endoscopically (4 patients), percutaneously (9 patients), or using a combined endoscopic-percutaneous approach (3 patients). When compared with patients with CEB, patients with NOD had more frequent medical problems (p less than 0.03) and lower serum albumin levels on admission (p less than 0.03). While comparable postprocedural complications (13 CEB patients versus 4 NOD patients) were observed, patients with NOD had a significantly higher hospital mortality (9 CEB patients versus 9 NOD patients, p less than 0.05). Excluding the 12 patients (6 CEB patients versus 6 NOD patients) who died within 30 days after drainage, the quality of survival of the remaining 38 patients was analyzed with reference to 6 objective parameters. Although patients with NOD had significantly more frequent admissions relating to their catheters (p less than 0.02), there was no qualitative difference in the survival rate between the two groups of patients. For selected high-risk patients with limited life expectancy, NOD should be offered. However, additional prospective studies are required to decide the best choice of palliation for patients who are not at such high risk.

Aged↗
PubMed1992

Management of biliary complications after liver transplantation.

Biliary tract complications after liver transplantation are common, and the evaluation of newer treatment options compared with standard surgical treatment is important. In 62 liver transplants performed in 55 adult patients, the biliary tract was reconstructed with choledochocholedochostomy (CC) in 52 (84%) and Roux-en-Y choledochojejunostomy (RYCJ) in 10 (16%). Seventeen biliary tract complications occurred in 16 patients (29%). The incidence of complications was the same after CC and RYCJ. Eight complications (47%) occurred within the first month and nine (53%) thereafter. Only 6 of 17 (35%) biliary tract complications required operation. One patient died of a biliary tract complication. No other allografts were lost due to biliary tract complications. Four patients transplanted at other centers were also treated, for a total of 21 biliary tract complications. Overall, there were nine bile leaks, eight bile duct strictures, two Roux loop hemorrhages, one choledocholithiasis, and one ampullary dyskinesia. Temporary or permanent stents were used successfully in seven of eight strictures. Five bile leaks were managed without operation. Nonsurgical management is appropriate for a selected majority of patients with late bile leaks, biliary tract strictures, or choledocholithiasis after liver transplantation.

Biliary Tract Diseases↗
PubMed1992

Importance of hepatic metabolism in the antiaggregating activity of the thienopyridine clopidogrel.

The thienopyridine clopidogrel is not active in vitro and must be administered i.v. or orally, suggesting that metabolism is necessary for activity. To verify whether the effect after i.v. administration was consecutive to recycling by hepatic bile secretion of clopidogrel or its metabolite(s) in the digestive tract, a catheter was implanted in the choledocus of rats, preventing bile and pancreatic secretions from being excreted into the digestive tractus. Two hours after clopidogrel administration (10 mg/kg, i.v.), blood was withdrawn and platelet-rich plasma aggregation was measured after the addition of 5 microM ADP. Clopidogrel treatment was equally efficient for sham-operated and catheterized animals (% inhibition of platelet aggregation: 76% and 59%, respectively) suggesting that the i.v. effect of clopidogrel was independent of re-absorption of biliary-excreted products and consequently that enteric metabolism is not necessary for activity. The antiaggregating activity of clopidogrel in rats before and after functional hepatectomy by a porto-jugular shunt was then studied. A great difference between treated animals was observed 30 min after i.v. administration of 25 mg/kg of clopidogrel. Per cent inhibition of platelet aggregation was 76% and 6% (P less than 0.001) for sham-operated and hepatectomized animals, respectively. Similar results were obtained after intraduodenal administration of clopidogrel, showing that the treatment was completely ineffective in hepatectomized animals. In isolated, blood-perfused rat livers, clopidogrel inhibited ADP-induced platelet aggregation, thereby supporting the theory that the activity of clopidogrel is highly dependent on hepatic metabolism.

Adenosine Diphosphate↗
PubMed1988

Combined surgical and radiologic approach to recurrent cholangitis and intrahepatic pigment stones.

A 37-yr-old white woman from Australia presented with ascending cholangitis and jaundice and was found to have multiple brown, "earthy" pigment stones in the biliary tree, including the segmental ducts. Removal of these stones was accomplished via a subcutaneously placed afferent jejunal limb of a choledochojejunostomy using balloon dilators. The jejunal conduit also served as an access for periodic removal of newly formed stones. This combined surgical and radiologic approach is an effective way of removing recurring pigment stones. The afferent jejunal limb can also be used to perfuse dissolution agents, if necessary, via catheters placed in the biliary tree.

Adult↗
PubMed1992

Reversibility of secondary biliary fibrosis by biliodigestive anastomosis in the rat.

Biliary cirrhosis with portal hypertension and hepatocellular failure is a well-known complication of extrahepatic obstruction. It is unclear to what extent these changes are reversible by biliodigestive anastomosis. Therefore a rat model of relief of biliary obstruction was developed by performing Roux-en-Y choledochojejunostomy in rats after bile duct obstruction. Patency of the biliodigestive anastomosis was documented by biliary scintigraphy. Microsomal function was assessed in vivo by the aminopyrine breath test and portal hypertension by spleen pulp pressure. Microsomal function was markedly impaired in obstructed animals but recovered after biliodigestive anastomosis. Microsomal cytochrome P450 content paralleled these changes. Similarly, portal hypertension was reversed after successful relief of obstruction. Stereologic analysis showed that biliodigestive anastomosis partially reversed bile ductular proliferation and fibrosis. Studying the time course of recovery showed that restoration of microsomal function was achieved after 2 weeks whereas recovery from portal hypertension required 4 weeks of biliary drainage. Recovery of microsomal function was paralleled by normalization of microsomal lipid composition while resolution of portal hypertension occurred parallel to resolution of the histologic abnormalities.

Anastomosis, Roux-en-Y↗
PubMed1991

Biliary obstruction from hepatic regeneration following extended right hepatectomy for tumor.

Two patients, aged 2 and 6 months, underwent extended right hepatectomy for hepatoblastoma. Tumor resection was complete in both and postoperative chemotherapy was begun. One patient became markedly jaundiced 4 months postoperatively. Imaging evaluation showed marked nodular liver enlargement and intrahepatic ductal dilatation. At laparotomy an obstructed distal common duct was draped over a huge regenerating liver nodule. A high Roux-En-Y choledochojejunostomy was followed by a decrease in bilirubin to normal within 4 days. Chemotherapy was restarted and the patient remains anicteric and healthy. No evidence of tumor recurrence was found. A second patient became jaundiced 2 weeks after resection. Imaging evaluation suggested tumor recurrence. At laparotomy biopsy failed to confirm recurrent tumor but the area of the porta was not explored. Jaundice persisted and the patient died of liver failure thought secondary to tumor recurrence 4 months postoperation. Postmortem examination showed a completely obstructed common duct draped over a liver nodule and no evidence of tumor. These two patients illustrate the heretofore unrecorded entity of biliary obstruction from regenerating liver following resection for tumor. The sudden appearance of jaundice following a successful liver resection for tumor should raise the suspicion of benign repairable biliary obstruction rather than unresectable tumor recurrence. The definitive evaluation is reexploration rather than various imaging modalities, which may not only be misleading, but may delay life-saving intervention.

Carcinoma, Hepatocellular↗
PubMed1991

Growth failure and decreased levels of insulin-like growth factor I in obstructive jaundice are reversed by bile diversion.

Insulin-like growth factor I (IGF-I) is one of the principal stimuli of linear growth. Growth failure in children with chronic cholestatic jaundice may be related to decreased hepatic synthesis of IGF-I. It was hypothesized that (1) biliary obstruction would lead to growth retardation and decreased circulating IGF-I levels; and (2) surgical drainage of the obstructed biliary system would reverse these effects. To test this hypothesis, the following study of male Sprague-Dawley rats (135 g; 10 animals per group) was performed. Group I underwent common bile duct ligation (CDL); group II underwent choledochoduodenostomy 2 weeks following CDL; group III were sham-operated and fed with CDL rats; and group IV were sham-operated and fed ad libitum. Daily food intake and weekly body weight were recorded. Statistical analysis was by repeated-measures analysis of variance and individual comparisons were evaluated by Student's t test. Biliary obstruction results in decreased food intake, rate of weight gain, and IGF-I levels. A significant reduction in IGF-I levels was also noted in the pair-fed sham-operated rats (group III). Relief of obstructive jaundice by surgical drainage results in a reversal of these changes. It is concluded that the growth failure and decreased IGF-I levels associated with obstructive jaundice can be reversed by surgical drainage of the obstructed biliary system and, in part, are due to inadequate nutrition.

Analysis of Variance↗
PubMed1991

Impaired hepatic bacterial clearance is reversed by surgical relief of obstructive jaundice.

Sepsis is a major cause of morbidity and mortality in infants with cholestatic jaundice. Previous studies have shown that biliary obstruction in rats causes a significant decrease in hepatic phagocytosis of viable Escherichia coli. This study tests this hypothesis and further evaluates whether the impaired function of the reticuloendothelial system of the liver (Kupffer cells) can be reversed by the relief of the biliary obstruction. Male Sprague-Dawley rats (weighing 140 to 150 g) were placed in three groups. Group I (n = 10) consisted of sham-operated controls. In Group II (n = 30), ligation and division of distal common bile duct (CDL) was performed. Group III (n = 30) underwent choledochoduodenostomy 2 weeks following ligation and division of common bile duct. At 1, 2, and 3 weeks following the operation, 10(9) 35S-radiolabeled viable E coli were injected intravenously via the tail vein. At 10 minutes, bacterial distribution in the liver, spleen, kidneys, and lungs was determined. Tissue samples (50 to 100 mg) from each organ were processed for liquid scintillation counting. The final distribution of bacteria was calculated from the input specific activity (dpm/bacteria) and expressed as the mean percentage of injected viable E coli per gram of tissue and per total organ weight. There was a significant decrease in the trapping of bacteria by the liver's Kupffer cells in rats in group II, at 2 and 3 weeks following CDL (45.0% +/- 14.0% and 15.1% +/- 4.9%, respectively, v controls 75.9% +/- 13.7%; P less than .005).(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1993

Biliary tract complications in pediatric orthotopic liver transplantation.

Biliary tract complications are reported in 15% to 30% of orthotopic liver transplantations (OLTs). Since 1986, 53 OLTs were done in 48 children with a mean age and weight of 5.3 years and 18.9 kg, respectively. Twenty-seven transplantations (51%) were reduced liver grafts (RLG) and 26 (49%) were whole liver grafts (WLG). Since 1988, 70% of transplantations have been RLG. Choledochocholedochostomy (mean weight, 25 kg) with a T-tube (CC) or choledochojejunostomy (CJ) (mean weight, 14.5 kg) were done in 24 (45%) and 29 (55%) cases, respectively. The overall mortality was 19% but none of the deaths were related to biliary problems. There were 13 biliary tract complications (24.5%) in 11 patients including 7 leaks, 5 obstructions, and 1 intrahepatic biloma. Leaks leading to bile peritonitis were managed with simple suture and drainage and were related to the T-tube (4), to the Roux-en-Y loop (2), and to the transection margin of a RLG (1). Obstruction was documented in 5 cases with none associated with hepatic artery thrombosis (HAT). Stenosis after CC reconstruction (2) required conversion to CJ. Two patients had revision of CJ because of kinking of the common bile duct after a left lateral segment graft and an anastomotic stricture 46 months after OLT. The last patient developed a vanishing bile duct syndrome 4 months posttransplant and is awaiting retransplantation. One patient had multiple episodes of cholangitis after HAT and was retransplanted. Neither the type of grafts (RLG 25.9% v WLG 23.1%) nor the type of biliary reconstruction (CC 25% v CJ 24%) influenced the rate of biliary complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Amino Acid Metabolism, Inborn Errors↗
PubMed1995

The role of endoscopic retrograde cholangiopancreatography in the management of choledochal cysts in children.

Endoscopic retrograde cholangiopancreatography (ERCP) was performed in eight consecutively treated patients with choledochal cyst to assess its technical feasibility and complications. Satisfactory visualization of the complete anatomy of the biliary tract was possible in seven patients. Four patients had a type IV choledochal cyst and three had type I. In one patient, the procedure showed a congenital web in the lower end of the common bile duct; in another, there was complete membranous block of the lower end of the common bile duct. The findings of ERCP and intraoperative cholangiography were concordant for six patients. Only one patient had exacerbation of preexisting cholangitis. The authors conclude that ERCP is an essential investigative method in the management of choledochal cysts in children.

Anastomosis, Roux-en-Y↗
PubMed2003

Small bowel transit and gastric emptying after biliodigestive anastomosis using the uncut jejunal loop.

BACKGROUND: The Roux-en-Y loop is an effective procedure for biliodigestive drainage. However, up to 15% of patients suffer from postoperative cholangitis or blind loop syndrome. A new technique to prevent motility abnormalities has been developed. METHODS: Male Lewis rats were used to compare gastric emptying and transit in the small bowel after either a standard Roux-en-Y anastomosis or a new biliodigestive anastomosis technique which involves creating an "uncut" jejunal loop with luminal occlusion. Unoperated rats served as controls. (99)Technetium HIDA and (111)Indium-tagged amberlite were respectively used to investigate small bowel transit and gastric emptying. RESULTS: Histopathology showed distinctive abnormalities only in the liver of conventional Roux-en-Y animals. No recanalization of the obliterated gut lumen occurred in uncut Roux animals. Distribution of (99)Tc-HIDA and (111)In showed were similar in both groups. Gastric emptying is slowed in both groups. CONCLUSIONS: The uncut proximal jejunum loop is a good alternative to the conventional Roux-en-Y loop and showed preserved small bowel motility and adequate jejunal transit. Gastric emptying is slowed in both groups.

Anastomosis, Roux-en-Y↗
PubMed2004

Laparoscopic biliary reconstruction.

BACKGROUND: Biliary reconstruction represents a relatively untested frontier in laparoscopy. METHODS: Retrospective review of all patients who underwent laparoscopic biliary operations at Legacy Health System from 1998 to 2003. RESULTS: Seven patients underwent laparoscopic biliary reconstruction. Indications included benign calculous disease in 4 patients, benign stricture on 1 patient, choledochal cyst in 1 patient, and malignant biliary obstruction in 1 patient. Operations performed included choledochoduodenostomy, hepaticojejunostomy, stricturoplasty, choledochal cyst excision with hepaticojejunostomy, and cholecystojejunostomy. Median operative time was 300 minutes. Median hospital stay was 4 days. One perioperative complication of a bowel obstruction required reoperation. Median follow-up was 15 months. One patient died of metastatic cancer 8 months after surgery. All other patients are symptom free with no signs of stricture or recurrent biliary obstruction. CONCLUSIONS: Laparoscopic biliary reconstruction represents a viable treatment option in carefully selected patients.

Adult↗
PubMed2005

[Biliary-enteric anastomosis malfunction: retrospective study of 20 surgical cases. Review of literature].

INTRODUCTION: This retrospective study of 20 procedures for malfunction of a biliary-enteric anastomosis include 7 choledochoduodenal anastomosis (CD) and 13 choledocho- or hepaticojejunal anastomosis (HJ). METHODS AND RESULTS: The malfunctions were revealed by angiocholitis (N=16) jaundice (N=4) acute abdominal syndrome (N=1). Among the 7 CD, the median waiting period before reoperation has been 14 years, the procedures were justified by a biliary disorder in 5 cases (1stricture, 4 stones or food obstruction) or by a duodenal stricture (2 cases). The CD have been converted into HJ. The operative mortality was null, the morbidity rate was of 14%. A recurrence of angiocholite occurred in the long-term followed-up. About HJ, the waiting time before reoperations was 6 years and 9 months, the procedures were justified by anastomotic anastomosis stricture (7) calculi without stricture (4) Roux-en-Y limb anomalies (2). Two Roux-en-Y limbs have been lengthened. The anastomoses have been redone when necessary. The side-to-side HJ were converted in end-to-side HJ. The operative mortality was null, the morbidity rate of 8%. In the long term followed-up, 2 stenosis recurrence and 1 lithiase recurrence occurred. CONCLUSIONS: Malfunctions of biliodigestives anastomosis are revealed by angiocholitis that can lead to secondary biliary cirrhosis. The complications treatment of CD is easy and effective. The complications evolution of HJ depends of initial pathology.

Abdomen, Acute↗
PubMed2005

[Spontaneous rupture of a choledochal cyst in a 11-month-old girl].

Choledochal cysts are rare congenital malformations of the biliary tract. Though most cysts are diagnosed incidentally, some present directly with complications. We report on the case of an 11-month-old girl admitted for abdominal pain, fever and vomiting. Ultrasonography revealed intraabdominal fluid and the absence of a choledochal cyst diagnosed 2 months earlier. Laparotomy for suspected rupture of a choledochal cyst was planned and a choledochojejunostomy with Roux-en-Y was performed. Spontaneous rupture of a choledochal cyst is rare and occurs most frequently in children under the age of 4. The exact cause is yet unknown and several factors have been implicated. The most probable cause is the combination of pancreatic reflux and epithelial irritation of a weakened cyst wall. Choledochal cysts should preferably be treated as soon as the child is 6 months old. Complete excision of the cyst is mandatory because of the risk of malignant transformation.

Anastomosis, Roux-en-Y↗
PubMed2006

Influence of bactibilia after preoperative biliary stenting on postoperative infectious complications.

The aim of this study was to correlate the bactibilia found after preoperative biliary stenting with that of the bacteriology of postoperative infectious complications in patients with obstructive jaundice. One hundred thirty-eight patients (83% malignant and 17% benign etiologies) with obstructive jaundice had both their bile and all postoperative infectious complications cultured. Eighty-six (62%) had preoperative biliary stents (stent group) and 52 (38%) did not (no-stent group). There were no differences for age, sex, incidence of malignancy, type of operation, estimated blood loss, transfusion requirements, hospital length of stay, morbidity, or mortality rates between the two groups. Of 31 infectious complications, 23 were in the stent group and eight were in the no-stent group (P > 0.05), but only 13 (42%) infectious complications had bacteria that were also cultured from the bile. Only wound infection (P = 0.03) and bacteremia (P = 0.04) were more likely to occur in stented patients. Taken together, these data show that preoperative biliary stenting increases the incidence of bactibilia, bacteremia, and wound infection rates but does not increase morbidity, mortality, or hospital length of stay. Jaundiced patients can undergo preoperative biliary stenting while maintaining an acceptable postoperative morbidity rate.

Anastomosis, Roux-en-Y↗