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PubMedDate not supplied

Laser lithotripsy of difficult biliary stones.

From June 1991 to September 1992, 16 patients (mean age, 72 +/- 5 years) were treated with intra-corporeal laser lithotripsy (ICL). Thirteen patients had choledocholithiasis with at least one stone larger than 20 mm; 3 patients had intra-hepatic lithiasis. All other methods, including mechanical lithotripsy, extra-corporeal lithotripsy (1 case), and intra-corporeal electrohydraulic lithotripsy (1 case), had failed to clear the bile ducts. Approaches for ICL were choledochoscopy with a "baby" endoscope via an existing sphincterotomy (8 cases), retrograde cholangioscopy with a gastroscope through a choledochoduodenal anastomosis or a sphincterotomy in patients with a gastrojejunal anastomosis (5 cases), and trans-hepatic cholangioscopy with a fibercholangioscope (3 cases, in 1 of which retrograde and trans-hepatic approaches were combined). Free bile ducts were obtained in 14/16 (87.5%) patients after a mean of 1.66 ICL sessions per patient. Mortality and laser-related morbidity did not occur; endoscopy-related morbidity was 12.5% for minor complications (1 transitory fever, 1 mild and transitory hemobilia) and 6.25% for major complications (1 post-sphincterotomy hemorrhage). Mean length of hospital stay was 11.5 +/- 2.5 days. We conclude that although it is rarely indicated and is expensive, ICL does offer a limited treatment option in selected patients. It allows the complete relief of complex biliary lithiasis. Morbidity is related to maneuvers preceding ICL, not to ICL itself.

Adult↗
PubMed1995

Results of a change to routine fluorocholangiography during laparoscopic cholecystectomy.

BACKGROUND: Early in our experience with laparoscopic cholecystectomy (LC), intraoperative cholangiography (IOC) was performed selectively with static imaging techniques. We subsequently changed to routine digital fluorocholangiography (FIOC) and evaluated the results of this strategy. METHODS: In a consecutive series of 356 LCs, 11 patients (3%) were converted to open cholecystectomy. In the remaining 345 patients FIOC was attempted in 336 patients (97%) and was successfully completed in 328 patients (95%). Results of IOC and outcomes were compared prospectively in patients without indications for IOC (group I, n = 185) with those with criteria for selective IOC (group 2, n = 160) and retrospectively with patients without indications for IOC undergoing static IOC (group 3, n = 56). RESULTS: Time to perform FIOC was less than for static IOC (14 +/- 1 versus 24 +/- 1 minutes, p < 0.001). Aberrant ductal anatomy was appreciated by using FIOC in 11% but affected operative management in only 3% of patients. Choledocholithiasis was detected in 23 patients (7%) undergoing FIOC; only two of these patients with stones were in Group 1. Duct stones discovered by IOC were cleared laparoscopically in 89% of those attempted (73% of all patients). Neither morbidity nor duct injury caused by FIOC was noted. CONCLUSIONS: FIOC is much more rapid to perform than static IOC. Digital fluoroscopy is accurate and safe and permits rapid evaluation and management of bile duct stones. Selective use of FIOC efficiently assesses the common duct in the era of LC.

Cholangiography↗
PubMed1997

Late development of bile duct cancer after sphincteroplasty: a ten- to twenty-two-year follow-up study.

BACKGROUND: Transduodenal sphincteroplasty is designed to destroy the sphincteric muscle fibers, producing a terminal choledochoduodenostomy. In the absence of Oddi's sphincter, intestinal contents with both activated pancreatic juice and bacterial flora are refluxed into the bile duct and remain there for a prolonged time. The long-term effect of producing the reflux has not been evaluated to date. METHODS: One hundred nineteen consecutive patients undergoing transduodenal sphincteroplasty between February 1973 and July 1984 were included in this study. Postoperative clinical courses of 108 patients could be evaluated by means of a retrospective review of the hospital records. Median follow-up was 18 years. RESULTS: Eight cases (7.4%) of primary bile duct cancer were found among the 108 cases at intervals of 1 to 20 years after sphincteroplasty. Two patients had concurrent hepatolithiasis. The patency of sphincteroplasty was confirmed in all cases, and the bile was infected in seven cases. Pathologic specimens obtained demonstrated cholangiocarcinomas and various degrees of atypical hyperplastic lesions under the background of chronic cholangitis. CONCLUSIONS: Chronic cholangitis can be an important causative factor in late development of bile duct cancer after sphincteroplasty. Any patients treated with choledochoduodenostomy should be closely monitored for late cholangiocarcinoma.

Adult↗
PubMed1989

Surgical palliation for pancreatic cancer.

The effectiveness of surgical palliation for pancreatic cancer has been reviewed. Jaundice should be relieved early as this eliminates distressing pruritus, improves the quality of life, and avoids the sequelae of prolonged extrahepatic obstruction. The procedure may prolong survival, but this has not been proved. Biliary obstruction is managed best by a simple loop cholecystojejunostomy. If the gallbladder is unavailable, a choledochojejunostomy is equally effective. Nonsurgical techniques such as percutaneous or endoscopically placed biliary stents may be appropriate in patients who are not candidates for surgery. A gastrojejunostomy should be done in all patients who have gastroduodenal obstruction by tumor. Most patients who undergo surgical biliary bypass also should have a gastrojejunostomy, even if gastroduodenal obstruction has not yet developed. Otherwise, more than 20 per cent of patients may need a second operation if gastroduodenal obstruction develops later. Pain, a problem in more than half of patients, is best relieved by an intraoperative celiac ganglion block with 50 per cent ethanol. Laparotomy is desirable in most of these patients with pancreatic cancer, because it provides tissue for diagnosis, allows a definite assessment of resectability, and produces effective palliation.

Anastomosis, Roux-en-Y↗
PubMed1993

Reversibility of cholestatic changes following experimental common bile duct obstruction: fact or fantasy?

In 36 male Wistar rats extrahepatic cholestasis was induced by ligation and transsection of the common bile duct. After 1, 2 and 3 weeks of cholestasis the bile flow was restored by means of a Roux-en-Y choledochojejunostomy. Plasma levels of bilirubin, alkaline phosphatase, GOT and clotting factor X were measured weekly. Liver biopsies were taken at the time of restored bile flow as well as 3 and 8 weeks thereafter. Histochemical reaction for lactate dehydrogenase activity and Sirius Red F3BA staining were used as measure for functional liver parenchyma and collagen, respectively. Acid phosphatase, alkaline phosphatase and 5'-nucleotidase activities as well as the glycogen content were demonstrated in cryostat sections of the same biopsies. After 1, 2 and 3 weeks of common bile duct obstruction, levels of bilirubin, alkaline phosphatase and GOT significantly increased, whereas levels of clotting factor X decreased. RBF resulted in normalization of all these levels to control range. The volume density of functional parenchyma was found to be reduced to 90%, 73% and 64% of the control values following 1, 2 and 3 weeks of common bile duct obstruction respectively, returning to 96%, 94% and 88% at 8 weeks, respectively, after restored bile flow. The collagen content increased significantly during cholestasis up to 5-fold after 3 weeks of common bile duct obstruction. After restored bile flow, a slight decrease of collagen was measured in some animals but in none of the three groups a return to normal values appeared. Cholestasis induced an alteration in localization and/or activity of the three enzymes analyzed as well as a depletion of glycogen stores. All changes in activity and distribution pattern of the three enzymes, as well as the glycogen depletion during common bile duct obstruction normalised after restored bile flow was performed. However, the longer common bile duct obstruction had existed, the longer period was needed for full recovery. In conclusion, even after 3 weeks of common bile duct obstruction the parenchyma/stroma relationship grossly normalized after restored bile flow with an almost complete restoration of the parenchyma and a concomitant recovery of liver function. However, collagen once formed, did not disappear but remained as more condensed septa, which apparently did not interfere with normal function.

5'-Nucleotidase↗