[THE DIVULSION OF THE PAPILLA IN SURGERY OF THE HEPATIC DUCT AND COMMON BILE DUCT].
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Ampulla of Vater↗
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Medical management of common bile duct stones.
Common bile duct stones are a common cause of morbidity and mortality in adults. An increasing number of surgical and medical therapies are available to manage them, with different success rates reported. The various medical treatment strategies were developed during the last decade, but these medical modalities should not be contemplated as a first-line alternative of treatment. A consensus from experts is that there is no primary indication to use solvents on common bile duct stones because they have a relatively high rate of adverse effects and their success is limited compared with lithotripsy. However, there is a subgroup of patients in whom invasive or surgical treatment is risky or may fail. In these patients stone dissolution by solvent may constitute a plausible therapeutic alternative or may help reduce the size of the stones sufficiently to facilitate subsequent endoscopic extraction. Solvents may also be indicated in settings where endoscopic techniques or lithotripsy are not available and the patient has a T-tube in the common bile duct. Even in this condition, however, it is probably quicker and more effective to refer the patient to a center with expertise and technologic support to practice stone removal.
Caprylates↗
Functional gradients in muscle cells isolated from gallbladder, cystic duct, and common bile duct.
The existence of a gradient inherent to muscle cells of the biliary tract was examined in muscle cells isolated separately from the fundus of the gallbladder, cystic duct, and common bile duct of the dog. Muscle cells, measured in suspension or as single perfused cells, exhibited a proximal-to-distal gradient expressed by the magnitude of response and the sensitivity to hormonal cholecystokinin octapeptide and neural (acetylcholine and methionine-enkephalin) contractile agonists. Measurements in suspensions showed that cells from the fundus 1) were 7-40 times more sensitive to contractile agonists than cells from the cystic duct and 13-200 times more sensitive than cells from the common bile duct and 2) generated greater maximal contraction. The latter was expressed by the ratio of maximal responses (fundus: cystic duct cells, 1.90 +/- 0.12, P less than 0.001; fundus: common bile duct cells, 1.50 +/- 0.07 P less than 0.001), which was independent of sensitivity to agonists. Similar results were obtained in measurements on single cells with respect to relative sensitivity and to ratio of maximal responses (fundus: cystic duct cells, 1.80 +/- 0.08, P less than 0.001; fundus: common bile duct cells, 1.49 +/- 0.06, P less than 0.001). The ratio of responses to low concentrations of agonists was even higher (three- to fourfold), reflecting both the greater sensitivity and the greater contraction of muscle cells of the fundus. We conclude that a proximal-to-distal biliary gradient exists that is an inherent property of muscle cells from various regions of the biliary tract; the gradient would act to facilitate gallbladder emptying in response to hormonal and neural stimulation.
Acetylcholine↗
Pseudocalculus of the common bile duct.
Common-bile-duct growths are rarely identified unless they cause chronic biliary obstruction. This case report describes a 71-year-old woman who had jaundice and epigastric pain. A cholecysto-colonic fistula was demonstrated by endoscopic retrograde cholangiopancreatography. The patient also had multiple filling defects in the common bile duct. The fistula was closed and stones were removed. A postoperative cholangiogram showed two calculi. One was removed with a basket through the T-tube tract, but the second, which did not appear completely free of the common-duct wall, could not be removed by the basket method. Subsequently at laparotomy this was found to be a benign pedunculated polyp, composed of collagenous and vascular tissue and with no surface epithelium. Surgeons should bear in mind the possibility of a common-bile-duct growth in cases of extrahepatic biliary obstruction.
Aged↗
Operative cholangiography by direct puncture of the common bile duct.
Direct common bile duct puncture offers an alternative to cystic duct cannulation in performance of operative cholangiography. Materials are readily available; no unusual cannulas or clamps are needed. The technique is easily mastered and consistently successful. Multiple roentgenograms, including one obtained after aspiration of dye from the duct, are of great advantage in detecting small stones. Careful application of puncture of the common bile duct does not add to morbidity nor does it prolong the recovery period.
Aged↗
[Minimally-invasive management of common bile duct stones].
Common bile duct stones may present a health hazard for our patients. Nevertheless, since the implementation of laparoscopic cholecystectomy optimal diagnostic and therapeutic algorithm are not yet defined. Symptomatic calculi can be assumed on the basis of pathological laboratory values or diagnosed by means of ultrasound, Intraoperative Cholangiography (IOC) or Magnetic-Resonance-Cholangio-Tomography (MRCT). For therapy of common bile duct stones endoscopic and laparoscopic minimally-invasive strategies are available. As any type of management may show some benefit, it is not yet evident which policy we should prefer. Specialists do not agree on the necessity of therapy in asymptomatic patients with common bile duct calculi at all. This article shows a current state of the opinion and art and tends to highlight trends and future perspectives.
Cholangiography↗
Investigations on common bile duct stones.
Common bile duct stones from 59 consecutive patients who underwent cholecystectomy more than 1 year before radiological detection of choledocholithiasis (group I) and from 31 consecutive patients with choledocholithiasis and gallbladder in situ (group II) were subjected to chemical analysis and compared with the composition of gallbladder stones from the same population (two consecutive biopsy and autopsy series, n = 343). In contrast to cholecystolithiasis, inorganic calcium salts were infrequent in choledocholithiasis while calcium bilirubinate and fatty acid calcium salts played an important role in the composition of common bile duct stones. This is of particular importance in terms of litholysis. With respect to stone pathogenesis, clinical and radiological data were analyzed, as was hepatic bile lipid composition. There was no significant difference in the lithogenic index (percent cholesterol saturation) in cholecystectomized and in non-cholecystectomized patients with choledocholithiasis. The most important cause of stone recurrence in the common duct after surgery was incrustation of unabsorbed suture material, which was the case in 30.5% of group-I patients.
Calcium↗
Percutaneous retrieval of a proximally migrated common bile duct endoprosthesis from the right anterior duct.
Common bile duct (CBD) endoprostheses that are inserted at endoscopy are in routine clinical use to decompress the obstructed biliary tract. This case describes the proximal migration of a CBD endoprosthesis into the right anterior duct. An attempt at endoscopic retrieval failed. The endoprosthesis was retrieved by a percutaneous transhepatic approach using an Amplatz goose-neck snare. To the best of our knowledge, use of the Amplatz goose-neck snare has not been reported for this application.
Common Bile Duct↗
[A common bile duct web in association with common bile duct stone].
Webs are diagnosed by their characteristic appearance on imaging studies, typically appearing as thin, radiolucent rings with or without dilatation of the organ proximal to it. Like in other organs, the etiology of webs in the common bile duct is controversial. Some webs are thought to be congenital, whereas others occur in the presence of chronic inflammation, suggesting a pathogenic relationship. We report a case of a common bile duct septum in association with numerous large black pigment stones in a 62-year-old woman. The patient was treated by cholecystectomy with T-tube insertion.
Cholangiopancreatography, Endoscopic Retrograde↗
CT diagnosis of common bile duct stone.
Common bile duct stones were demonstrated as high-density objects on CT in 22 of 45 cases. About 96% of the remaining cases (22 of 23) exhibited other abnormal CT findings which included common bile duct dilatation, concomitant gallbladder stones, and/or presence of intraductal air. CT is a useful diagnostic modality in the elevation of patients with suspected choledocholithiasis.
Adult↗
Self-retaining small-looped catheter for narrow bile ducts in high common bile duct obstruction.
A new self-retaining catheter was devised for percutaneous drainage of small bile ducts. The device allows safe external drainage without the risk of catheter dislocation even in high bile duct obstruction. The catheter is also suitable for percutaneous nephrostomy in non-dilated pyelocaliceal system.
Catheterization↗
Brown pigment stones in the common bile duct: reduced bilirubinate diconjugate in bile.
BACKGROUND: Bilirubin is the main component of most common bile duct stones. Normally, almost all bilirubin in bile is conjugated to glucuronic acid or some other sugar moiety. These conjugates are unstable and liable to deconjugation. Unconjugated bilirubin is insoluble and may precipitate as the calcium salt found in brown pigment stones. The pattern of bilirubin conjugates in common duct bile of patients with choledocholithiasis has been unknown. METHODS: In a clinical series of 55 patients with choledocholithiasis common-duct bile was aspirated, and the bilirubin conjugates analyzed with high-performance liquid chromatography. One stone from each patient was analyzed for cholesterol and bilirubin content to determine stone type. RESULTS: Sixteen patients had cholesterol stones, 38 patients had brown pigment stones, and 1 patient had a black stone. Patients with pigment stones had a lower percentage of bilirubin diglucuronide (median, 60.3%; interquartile range, 49.7%-67.3%) than patients with cholesterol stones (64.0%; 60.2%-73.3%) (Mann-Whitney, P=0.015). No significant difference was found for the other bilirubin conjugates, total bilirubin, or biliary pH when pigment and cholesterol stone patients were compared. The time of bile sampling in relation to papillotomy and treatment of cholestasis was not associated with the low percentage of bilirubin diglucuronide. The observation of reduced values for bilirubin diglucuronide could not be ascribed to duodenal diverticula or Billroth-II gastric resection. CONCLUSION: The percentage of the main bilirubinate conjugate, bilirubin diglucuronide, is decreased in the common duct bile of patients with pigmented compared with cholesterol stones.
Aged↗
Laparoscopic treatment of common bile duct stones.
Common bile duct stones were present in sixteen of our first two hundred cases of laparoscopic cholecystectomy. Treatment included flushing into the duodenum, catheter drainage of the duct for cholangiographic and percutaneous access, open choledochotomy with stone removal and E.R.C.P., or combinations thereof. A technique for open choledocholithotomy with suture closure of the duct is presented.
Aged↗
Pathogenesis and presentation of common bile duct stones.
Common bile duct stones are generally classified as primary or secondary stones based on the locations of origin. The vast majority of the stones found in the biliary tree are secondary stones. The current review discusses the pathogenesis and presentations of primary and secondary biliary stones. Based on discussion of disease pathogenesis and presentation, recommendations for the evaluation and management of common and uncommon disease processes associated with choledocholithiasis are proposed.
Common Bile Duct↗
Choledochoscopy and common bile duct exploration.
Common bile duct (CBD) exploration is often indicated when cholecystectomy is performed for gallstone disease. Choledochoscopy may help to decrease the incidence of retained common duct stones. The present study reviews 97 consecutive CBD exploration cases performed between 1980 and 1988, in order to evaluate the authors' experience with flexible choledochoscopy and CBD exploration. Fifty-nine patients had CBD exploration plus flexible choledochoscopy and 38 underwent CBD exploration alone. Retained stones were found postoperatively in ten per cent of the patients who had only CBD exploration versus four per cent in the choledochoscopy group. The retained stones in five patients were later removed by percutaneous basket retrieval (3), flush irrigation (1), and choledochoscopy (1). Flexible choledochoscopy detected additional stones after routine CBD exploration in 12 patients, clarified T-tube cholangiograms in four patients, and aided stone extraction in two patients. For these reasons, and because choledochoscopy was associated with a lower incidence of retained stones, the authors believe this procedure is a worthwhile addition in most cases of CBD exploration.
Cholecystectomy↗
Biochemical changes in liver, kidney and blood associated with common bile duct ligation.
Common bile duct ligation (CBDL) in rats was used to induce liver disease and secondary kidney damage. The biochemical changes in the liver, kidney and plasma were studied at 3, 6, 10 and 21 days post CBDL. The observed alterations climaxed at the 6th day following ligation. Renal, activities of aldolase (ALD), lactic dehydrogenase (LDH), isocitric dehydrogenase (ICDH), sorbitol dehydrogenase (SDH), and alkaline phosphatase (ALP), were lowered in CBDL rats. Further, microsomal Na,K-ATPase and Mg-ATPase and mitochondrial oxidative-phosphorylation were inhibited. In the liver from CBDL rats the activities of aspartate aminotransferase (AST), Mg-ATPase and ALP were elevated, while SDH, ALD, malic dehydrogenase (MDH), LDH, malic enzyme (ME) and Na,K-ATPase were lowered. Plasma enzymes, AST, ALP, MDH, LDH, ALD, acid phosphatase (ACP) and ICDH and the metabolites bile acids, bilirubin, creatinine and urea were elevated. Addition of bile acids or bilirubin at concentrations comparable to those found in the plasma of CBDL rats, to the reaction mixture of the various enzymes strongly inhibited most, particularly mitochondrial oxidative phosphorylation. High concentrations of these substances in the blood may explain the development of renal failure during liver disease and its reversibility when liver function returns to normal.
Animals↗
[Analysis of the occurrence of bile duct calculi in relation to the width of the cystic duct and common bile duct].
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Cholelithiasis↗
[Cicatricial strictures of anastomosis of the hepatic duct and common bile duct].
The authors have observed 34 cases of scarry strictures of bilio-digestive anastomoses requiring repeated surgical correction. The causes of such complications, methods of clinical and special diagnostic are discussed. The technique of reoperations for such complications is described along with their results and recommendations for prevention of scarry strictures of anastomoses of the common hepatic duct.
Adolescent↗