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PubMed1999

Why is it necessary to retrieve small bile duct stones at cholecystectomy?

Recovery of gallstones from the stool demonstrates that gallstones pass into the duodenum due to antegrade sphincter of Oddi (SO) activity. However, retrograde SO peristalsis occurs in three-fourths of patients with bile duct stones as shown by SO manometry. The aim of this study was to investigate, by comparing patients with and without bile duct stones, whether reversed SO activity would retain even small stones. Thirty-nine patients with gallbladder stones < or = 3 mm in diameter underwent cholecystectomy, 22 of them with concomitant biliary stones. The remaining 17 patients served as controls. The diameters of the cystic duct and the small stones in the gallbladder and bile duct were measured. The case histories of the controls indicated previous passage of gallstones into the duodenum, i.e., a normal antegrade SO activity. Biliary stones < or = 3 mm in diameter were recovered in three-fourths of the patients with ductal stones, a sign of retrograde SO activity. SO dysfunction seems to occur in three-fourths of patients with bile duct stones and should be suspected when stones < or = 3 mm are present, as, under these circumstances, it is necessary to retrieve even such small stones.

Adult↗

PubMedDate not supplied

Percutaneous transhepatic cholangioscopic lithotripsy and change of biliary manometry patterns.

BACKGROUND/AIMS: Percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) is used to remove bile duct stones. This work aims to evaluate the clinical usefulness of PTCSL and the reversibility of the terminal bile duct dysfunctions after PTCSL. METHODOLOGY: Thirty patients who underwent PTCSL using mechanical and/or electrohydraulic lithotripsy over the past 10 years (20 patients with common bile duct stones and 10 with intrahepatic bile duct stones) were evaluated. Terminal bile ductal pressure was measured using the percutaneous transhepatic biliary drainage (PTBD) tube prior to and after lithotripsy by means of variable-load cholangiomanometry. RESULTS: Complete stone extraction was possible in 26 patients (86.7%). The other 4 patients had intrahepatic stones. Complications included 2 cases of hemobilia, one of pneumonia, and 3 of localized peritonitis. Of 26 patients without residual stones, only 4 patients had a linear pressure flow (P-F) pattern which indicates normal biliary tract function prior to lithotripsy. In 17 of 22 patients with other type P-F patterns, however, these types also changed to a linear pattern after complete removal of stones. The P-F pattern of the other 5 patients remained unchanged. CONCLUSIONS: PTCSL is a safe and efficient method treating biliary tract lesions while preserving the function of the sphincter of Oddi. The terminal biliary tract function normalized after stone removal. Thus, PTCSL was useful for patients with complicated bile duct stones not accessible to endoscopic retrograde management.

Bile Ducts↗

PubMed2000

[The C tube in biliary surgery--its development and clinical application].

BACKGROUND: The T tube procedure for bile drainage after biliary surgery has been used all over the world for more than 90 years. However, this method has serious drawbacks: a high complication ratio and a need for long-term hospitalization. Therefore other bile drainage methods including PTGBD, PTBD and ENBD have been developed, but none has so far been able to replace T tube. We have developed a new technique for bile drainage using the C tube (cystic duct tube), which is a slender tube (6Fr. polyvinyl) inserted via the cystic duct into the common bile duct (CBD). We have used C tube in more than 400 cases over the last 20 years: for open surgery during the first 10 years, and for laparoscopic surgery in the last 10 years. Here we describe the history of improvements in the C tube method and the techniques of C tube application in biliary surgery. Elastic surgical suture has been used to fix the C tube to the cystic duct, which successfully prevented bile leakage from the ductal stump after withdrawal of the tube. C tube is not only used for postoperative bile drainage but also for the management of remnant stones. The purpose of this study is to assess the safety and benefits of the C tube procedure. METHODS: I: From 1980 to 1998, 335 cholecystectomized cases which had undergone the C tube procedure were examined for complications resulting from C tube placement. II: We analyzed 134 patients with choledocholithiasis: 34 patients had been treated using C tube drainage, and 100 patients had been treated with the T tube procedure after undergoing CBD exploration. The main outcome criteria were: the frequency of post-operative complications, quantity of bile drainage, drainage period, and length of post-operative hospital stay. III: Between 1990 and 1999, 131 patients (15.2%) of a total of 860 laparoscopically cholecystectomized patients with gallstones underwent C tube treatment. We assessed the usefulness of the C tube procedure for the detection and management of remnant stones. RESULTS: I: There were no major complications (bile-leakage, CBD stenosis, etc.) in 335 cases which underwent the C tube procedure. Minor complications related to C tube were: spontaneous withdrawal of the tube in 5 cases, movement of the tube tip in 17 cases, and difficulties during tube removal in 32 cases which included slight resistance. Two cases had liver dysfunction (GOT 705 IU/l and 488 IU/l), although this was easily normalized after withdrawal of the tube tip from the duodenal papillae into the CBD. II: The frequency of complications in patients who underwent the C tube procedure was zero, whilst in the T tube group the major complication rate was 3% and the minor complication rate was 21%. The quantity of bile drainage was 283.6 +/- 22.9 ml/day in the C tube group compared with 302.7 +/- 10.3 ml/day in the T tube group, showing no significant difference. The drainage period (5.9 +/- 0.6 days) in the C tube group was significantly shorter than in the T tube group (27.7 +/- 0.9 days). Hospital stays (11.6 +/- 0.6 days) in the C tube group were significantly shorter than in the T tube group (45.0 +/- 1.5 days). III: Remnant CBD stones were detected by postoperative cholangiography via the C tube in 28 (21.4%) of the C tube replacement cases and in 3.3% of all the laparoscopically cholecystectomized patients. Seventeen patients with remnant stones were managed using glyceryl trinitrate CBD perfusion-induced relaxation of the sphincter of Oddi. The remaining patients were managed with endoscopic papillary balloon dilatation (EPBD) and/or endoscopic sphincterotomy (EST) without reoperation. We also have described other applications of the C tube procedure for the evaluation of sphincter of Oddi motility as an indication for EST, for bile drainage in liver resection, in the treatment of liver injuries, and for duodenal decompression after duodenal surgery. Finally we have mentioned the possibility of C tube application in the management of obstructive jaundice and bile drainage in liver transplantation surgery. CONCLUSION: The C tube method in biliary surgery is safe and useful in comparison with the T tube method. We are strongly convinced that the T tube will be completely replaced by the C tube.

Aged↗

PubMed2001

Autonomic dysfunction and cholelithiasis in patients with cirrhosis.

Gallstones are seen in 33-46% of patients with cirrhosis, and their prevalence is known to increase with the duration and severity of liver disease. We hypothesized that autonomic neuropathy may contribute to the formation of gallstones or gallbladder disease, as in diabetics with autonomic neuropathy, due to impaired gallbladder emptying. The objective of our study was to determine the prevalence of gallstones or gallbladder disease in cirrhotic patients with and without autonomic neuropathy. We determined autonomic function tests, gallstones, and other gallbladder disease in 123 (male 71) with varying severity of liver disease (Child classes: A, 40; B, 45; C, 35). In all, 54 patients had gallstones and an additional 22 patients had other gallbladder disease (cholecystitis, common bile duct stones, or debris). Autonomic neuropathy was seen in 97 patients (one abnormal test in 48 and two or more in 49). The prevalence of gallstones was similar in Child A (57%), Child B (64%), and Child C (63%) cirrhosis. The gallstones or gallbladder disease was not increased in women, blacks, diabetics, or alcoholic cirrhotics. The prevalence of gallbladder disease was increased in patients with autonomic neuropathy (51% vs 35%, P = 0.08); in patients with Child C cirrhosis, gallstones (P = 0.018) and gallbladder disease (P = 0.03) were seen more commonly in patients with autonomic neuropathy. Our findings suggest that autonomic neuropathy may contribute to the formation of gallstones in patients with advanced cirrhosis, perhaps by impairing gallbladder and sphincter of Oddi dysmotility.

Adult↗

PubMed1990

Morphine-augmented hepatobiliary scintigraphy in the severely ill: caution is in order.

Morphine augmentation in hepatobiliary scintigraphy has been reported as a useful tool to shorten imaging time. The technique has not been extensively evaluated in patients who are severely ill and receiving total parenteral nutrition, although the study of these patients with non-morphine-augmented hepatobiliary scintigraphy is problematic. The authors retrospectively analyzed 51 morphine-augmented hepatobiliary studies performed in a tertiary referral center on a population with a high proportion of severe intercurrent illness (18 patients, 14 of whom were receiving total parenteral nutrition) and hepatocellular dysfunction (eight patients). The overall sensitivity was 94%, specificity was 69%, and the false-positive rate was 40% for the diagnosis of acute cholecystitis. The majority of the false-positive cases occurred in the severely ill subgroup (false-positive rate, 60%). Morphine-augmented hepatobiliary studies may be advantageous because of shortened imaging time. However, patients who have severe intercurrent illness, whether or not they are receiving total parenteral nutrition, have a higher frequency of false-positive morphine-augmented hepatobiliary studies, and positive findings at scintigraphy in this patient group should be interpreted with caution.

Acute Disease↗

PubMed1981

Duodenoscopic sphincterotomy in the treatment of the "sump syndrome".

The "sump syndrome" is recognized as a complication of a choledochoenterostomy (choledochoduodenostomy or choledochojejunostomy) performed for recurrent stone disease. A sump (a pit or well) develops in the distal, nonfunctioning limb of the common bile duct where lithogenic bile, gastrointestinal contents, and debris accumulate. This results in obstruction of the enterostomy stoma producing either cholangitis, pancreatitis pain, and/or cholestasis. It is thought that dysfunction of the sphincter mechanism contributes to the development of this syndrome. Filling defects in the bile duct are appreciated on gastrointestinal series when barium reflexes into the biliary tree through the patent stoma. Treatment has largely been surgical, but, more recently, the availability of ERCP has enabled the endoscopist to make a major contribution to the management of this syndrome. A nonsurgical alternative to treatment is duodenoscopic sphincterotomy which has been performed in 11 patients presenting with the sump syndrome. There have been no recurrences of stones in 10 patients while stones were found in one patient with an open sphincterotomy. In follow-ups of 3-30 months, there was satisfactory relief of symptoms in all patients. Because of these results, duodenoscopic sphincterotomy is recommended as a primary treatment modality in the sump syndrome.

Adult↗

PubMed1983

Transduodenal sphincteroplasty and transampullary septectomy for postcholecystectomy pain.

Ninety-two patients underwent a transduodenal sphincteroplasty and transampullary septectomy (extended papilloplasty) for chronic, incapacitating upper abdominal pain over an 11-year period. Seventy-nine had a prior cholecystectomy; 42 of 56 patients with reported pathology had documented gallstone disease. Serious morbidity included two moderately severe cases of postoperative pancreatitis and a pulmonary embolus. There were no deaths. Operative findings revealed stenosing papillitis (n = 45), transampullary septitis (n = 40), and papillary dysfunction (n = 7). Histologic examination of septal biopsy specimens revealed inflammation in 34 cases and fibrosis in 19 cases. There were no microscopic abnormalities in 39 biopsy specimens. The results at 1 to 10 years in 83 patients is as follows: good in 36 patients (no pain--43%), fair in 27 patients (occasional pain--33%), and poor in 20 patients (unrelieved by the procedure--24%). Patients with prior sphincteroplasty (12 of 15 with a fair to good result) benefitted the most from the procedure. Those who underwent concomitant cholecystectomy responded poorly. Risk factors for failure include alcoholism, drug addiction, mental illness, and duodenal ulcer disease. The finding of papillary cholesterolosis at operation also was accompanied by a less than optimal result. Transduodenal sphincteroplasty with transampullary septectomy provides long-term benefit to carefully selected patients with chronic abdominal pain after cholecystectomy.

Abdomen↗

PubMed1981

Surgical applications of sphincteroplasty and choledochoduodenostomy.

The papilla of Vater is subject to a variety of abnormalities that include congenital anomalies, inflammation, neoplasms, fibrosis, and motor dysfunction. Some of these lesions are clinically obvious (such as cancer or an impacted gallstone) and require aggressive therapy in order to provide relief from pain or biliary-pancreatic ductal obstruction. Other lesions, such as stenosing papillitis, are more subtle and provide few clues to their existence except recurrent episodes of abdominal pain. I have focused my discussion on the relative indications for sphincteroplasty and choledochoduodenostomy in the management of benign lesions of the papilla, especially those related to gallstone disease. I prefer a choledochoduodenostomy for the management of recurrent common duct stones when the bile duct is enlarged (greater than 2 cm) and thick-walled. The opening should be at least 2 cm in length when the anastomosis is completed. I employ a long anterior sphincteroplasty (greater than 2 cm) with a transampullary septectomy when treating inflammatory or fibrosing lesions of the papilla of Vater which are associated with recurrent episodes of severe, chronic (more than 1 year) abdominal pain. There is currently no standardized way to diagnose these latter conditions, therefore, the approach is empirical, and should be used sparingly and with a high degree of caution.

Ampulla of Vater↗