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PubMed1993

Mirizzi's syndrome: identification and management strategy.

Fourteen cases of Mirizzi's syndrome are presented here. Clinical presentation was pain (14), jaundice (14), fever (10) and peritonitis (1). A clinical diagnosis of choledocholithiasis was considered in all the patients. Pre-operative diagnosis of Mirizzi's syndrome was made in five patients on the basis of cholangiogram and the remaining cases were diagnosed at surgery. The stage (type) of Mirizzi's syndrome was based on the extent of erosion of the common bile duct. Four patients had type I, seven type II and three type III lesions. Associated choledocholithiasis was present in five and acute free perforation of the gall-bladder in one. The operative procedures performed were partial cholecystectomy for type I, partial cholecystectomy, choledochoplasty and T-tube choledochostomy for type II and bilioenteric anastomosis for type III lesions. Two patients had retained common bile duct stones. Mean follow up was 14 months (range 1-27 months). One patient with secondary biliary cirrhosis continues to have persistently elevated serum alkaline phosphatase levels without any demonstrable biliary obstruction. Diagnostic and operative strategies are discussed and a follow up protocol for such patients is suggested.

Adult↗

PubMedDate not supplied

Prevention of bile leak after major hepatectomy.

BACKGROUND/AIMS: Bile leak remains a serious complication after major hepatectomy. The usefulness of external biliary drainage to prevent intraperitoneal bile leak was studied. METHODOLOGY: Thirty-nine patients who underwent major hepatectomy from April 1997 through June 2000 were studied. The bile leak test was performed to identify and close leaks following the resection. Patients who still had leakage underwent retrograde transhepatic biliary drainage (RTBD) via a tube inserted through a choledochostomy. Patient's backgrounds, incidence of bile leak, and time until resolution of bile leak were compared between patients who did and did not have an RTBD tube placed. RESULTS: Nineteen patients had an RTBD tube (48.7%). Bile leak developed in 4 patients with the tube (21.1%), and in 4 patients without the tube (20.0%) (not significant). However, the time until resolution of bile leak was 13.3 days for patients with the tube and 51.3 days for patients without the tube (p<0.05). Two patients developed local peritonitis when the tube was removed. CONCLUSIONS: Though some patients had bile leakage even with the RTBD tube, use of the RTBD tube decreased the length of time leakage that occurred. RTBD tube drainage should be done routinely with major hepatectomy.

Aged↗

PubMed2005

Endoscopic biliary stenting facilitates safe and early removal of T-tube in liver transplant patients.

AIM: Duct to duct anastomosis in orthotopic liver transplant (OLT) patients have been traditionally performed with a t-tube in place for 3 to 6 months. Following removal of the t-tube a high incidence of biliary leakage has been reported. METHODS: Prospective study to evaluate the role of endoscopic biliary stenting to facilitate early and uncomplicated t-tube removal. All patients with duct to duct biliary anastomosis who had a t-tube in situ, from January 1998 to December 2002 were included in this study. RESULTS: There were 29 patients eligible for the study. Eight patients were not included due to early death. A protocol t-tube cholangiogram was performed in all patients, (median 12 days; range 4-47 days) followed by an endoscopic stent insertion (median 37 days; range 20-55 days). The stent was removed later (median 84 days; range 45-133 days). All complications related to the procedure were noted. Stent insertion was successful in all cases. In 2 patients a second endoscopic retrograde cholangiopancreatography (ERCP) was necessary, either because of failure to cannulate the papilla or to reposition the stent. There was a patient who presented a biliary leak due to stent displacement requiring a laparotomy. There were two further biliary leaks, one of them in an asymptomatic patient, which were managed conservatively. In addition 1 patient developed a mild case of postERCP pancreatitis. CONCLUSIONS: In liver transplants patients with an end-to-end choledochostomy with a t-tube, endoscopic biliary stenting allows an early removal of the T tube, with few complications.

Adult↗

PubMed1989

[Biliary secretion. Significance of hypercholeresis from the surgical point of view].

In patients carrying a Kehr tube choledochostomy, the surgeon may observe, but rarely, important hypercholeresis, non-bile-acid dependent, in people with severe advanced chronic hepatic diseases or persistent cholestasis. The amount of bile flowing to the outside can reach two liters and more daily. We have seen this in two patients with compensated hepatic disorders and in another suffering from light cholestasis produced by choledocholithiasis. We have also found the same in three other people with liver and the main biliary extrahepatic tract completely normal. This hypercholeresis is continuous and subject to rapid increases relative to the ingestion of food. Such increases are related to gastrointestinal hormones, specially secretin, which is produced when portions of gastric chyme enters the duodenum.

Aged↗

PubMed1993

Complete transection of common bile duct due to blunt abdominal trauma: a case report and literature review.

A case of complete transection of the common bile duct due to abdominal blunt injury in a 49-year-old man is presented. The rarity of this injury and its initial presentation as a pancreatic pseudocyst warrant its description. This patient was diagnosed as having bile duct injury following ascites aspiration. Common bile duct transection was documented and a choledochostomy was done. However, bile leaked into the peritoneal cavity one week after the operation. A Roux-en-Y choledochojejunostomy was done successfully in a second operation. Delayed diagnosis is common in these kinds of injuries, but it should be considered when a patient has bile ascites, abdominal distention and jaundice after a blunt abdominal injury. A review of the literature, methods of diagnosis and the technique of surgical repair are described.

Cholangiography↗

PubMed1993

Second peak of plasma diazepam concentration and enterogastric circulation.

Intragastric food administration caused a pronounced second peak of plasma diazepam concentration in rabbits after iv diazepam 5 mg.kg-1. The second peak disappeared after gastrostomy and choledochostomy. A large amount of diazepam was found in the gastric juice while its content in bile remained at a much lower level during the whole experiment. These results suggested that diazepam may undergo an enterogastric circulation in addition to its enterohepatic circulation, with the former mainly contributing to the appearance of the second peak.

Animals↗

PubMed1997

Bacteremia following liver biopsy in transplant recipients with Roux-en-Y choledochojejunostomy.

Between 1990 and 1995, 666 percutaneous liver biopsies were performed in 196 patients at Gregorio Marañón General Hospital (mean 3.4 biopsies/patient); 533 biopsies (80.03%) were carried out in patients with choledochostomy biliary anastomosis and 133 (19.97%) in patients with choledochojejunostomy. Infectious complications, in the form of sepsis, occurred in two patients, who recovered favorably with antibiotic therapy. These two patients had undergone Roux-en-Y choledochojejunostomy (1.5%, not significant). Our findings suggest that the incidence of infectious complications after liver biopsy in transplant recipients is very low. Antibiotic prophylaxis at the time of liver biopsy in patients with Roux-en-Y choledochojejunostomy may decrease the frequency of infectious complications.

Adult↗

PubMed1997

[Surgery of biliary tract from minimal approach].

The results of surgical treatment of 209 patients with diseases of bile ducts with use of minimum approach and special instrument are presented. Cholecystectomy was carried out in 186 patients, cholecystectomy together with other interventions-in 15, operations on hepaticocholedochus in 7, cholecystectomy and choledochostomy-in 1. Intraoperation surgical complications were observed in 0.95% of cases, postoperative ones--in 2.34%; postoperative mortality rate made up 0.95%. After cholecystectomy the patients were discharged in 3-9 days. The authors consider the operations on biliary tract from minimum approach as an alternative to conventional laparotomy as well as laparoscopic cholecystectomy.

Adolescent↗

PubMed1976

Management of 1,590 consecutive cases of liver trauma.

Between 1939 and 1974, more than 1,500 patients have been treated for penetrating or blunt liver trauma at our institution. Gunshot wounds and major blunt trauma have increased, stab wounds decreased, as percent of total. In most cases techniques other than partial hepatic resection were used, although this was performed in 49 instances. Choledochostomy was infrequently employed. Intracaval shunts were useful in 15 selected patients with massive hepatic, concomitant suprarenal vena caval, or hepatic vein injuries. The overall mortality of this group was 13.1%. The improvement in mortality from liver injuries is attributable to (1) early exploration for suspected intra-abdominal traumatic injury, (2) a conservative approach to the liver injury, and (3) the limitation of lobar resection, vascular cannulae, and afferent vascular compression to highly selected cases.

Adolescent↗

PubMed1985

Biliary-bronchial fistula after right hepatic lobectomy.

Biliary-bronchial fistula is an extremely unusual complication of thoracoabdominal trauma or suppurative hepatobiliary disease. We treated a patient with a biliary-bronchial fistula that developed after right hepatectomy for an infected traumatic intrahepatic hematoma. The diagnosis of biliary-bronchial fistula was confirmed by percutaneous transhepatic cholangiography. Surgical therapy included a primary transabdominal choledochostomy, with the insertion of a T-tube, sphincteroplasty, and open marsupialization of the chronic subphrenic abscess.

Adult↗

PubMed1989

Mirizzi syndrome and cholecystobiliary fistula: a unifying classification.

A new classification of patients with Mirizzi syndrome and cholecystobiliary fistula is presented. Type I lesions are those with external compression of the common bile duct. In type II lesions a cholecystobiliary fistula is present with erosion of less than one-third of the circumference of the bile duct. In type III lesions the fistula involves up to two-thirds of the duct circumference and in type IV lesions there is complete destruction of the bile duct. A total of 219 patients were identified with these lesions from 17,395 patients with benign biliary tract diseases undergoing surgery. The incidence of type I lesions was 11 per cent, type II 41 per cent, type III 44 per cent and type IV 4 per cent. The majority had obstructive jaundice. In type I lesions, cholecystectomy plus choledochostomy is effective. In type II lesions, suture of the fistula with absorbable material or choledochoplasty with the remnant of gallbladder can be performed. In type III lesions suture is not indicated and choledochoplasty is recommended. In type IV lesions, bilioenteric anastomosis is preferred. Operative mortality rate increases according to the severity of the lesion, as does postoperative morbidity. During cholecystectomy, partial resection is recommended in order to extract the stones, visualize the common bile duct and define the type and location of the fistula. T tubes should be placed distal to the fistula.

Adult↗

PubMed1993

Bile duct injury and bile leakage in laparoscopic cholecystectomy.

Between January 1991 and July 1992, 350 laparoscopic cholecystectomies were performed. There were six biliary complications (1.7 per cent): common bile duct (CBD) injury (one patient), delayed CBD necrosis (one), immediate postoperative bile leakage (one) and delayed bile leakage (three). All six patients required laparotomy. Primary repair with long-arm T tube splinting for 3 months was performed for the CBD injury. Religation of the cystic duct was carried out after immediate postoperative bile leakage. Laparotomy with T tube choledochostomy only was performed in the three patients with delayed bile leakage, and hepatojejunostomy Roux-en-Y was undertaken for CBD necrosis. The patient with primary repair of the CBD injury required choledochojejunostomy Roux-en-Y 18 months later for stenosis. Episodes of intermittent cholangitis occurred in the patient with CBD necrosis. The outcome for the four patients with bile leakage was good. There were no deaths.

Adult↗

PubMed1987

[Problems in the reconstruction of bile flow in orthotopic liver transplantation].

In hepatic transplantation complications of the biliary drainage were frequently observed. Ischemia of the extrahepatic bile duct which occurs for anatomical reasons can cause necrosis of the bile duct. The reconstruction of biliary drainage by biliodigestive anastomosis results in ascending infections of the graft. Biliary sludge could obstruct the intra- or extrahepatic bile duct. Recently, operation methods are mainly applied in which the function of Oddi's sphincter is preserved, i.e. choledocho-choledochostomy or gallbladder conduit method. If it is not possible to perform these methods the Roux-y-jejunum loop is used. Finally, an immediate operative revision of the biliary drainage is indicated if its complication is diagnosed.

Bile Ducts↗

PubMed1983

Effect of phenobarbital on serum and biliary parameters in a patient with Crigler-Najjar syndrome, type II and acquired cholestasis.

The effect of phenobarbital treatment on bilirubin metabolism and bile secretion was studied in a patient with Crigler-Najjar syndrome, type II and acquired cholestasis. Following cholecystectomy and choledochostomy, a balloon inflatable T tube was inserted to facilitate bile collection. Hepatic UDP-glucuronyltransferase in surgically obtained liver tissue was 25% of normal activity and bilirubin monoconjugates accounted for greater than 80% of the pigments in bile. Phenobarbital therapy decreased the concentration of fasting serum bile acids by 33% and partially reestablished their enterohepatic cycling postprandially. The total fasting serum bilirubin concentration (greater than 90% unconjugated) increased 21% during phenobarbital treatment and was unaffected by caloric intake. Bile flow was increased 2.7 times after phenobarbital treatment. The biliary concentration of total bilirubin was increased 2.4 times, primarily due to monoconjugated bilirubin, which accounted for 91% of the biliary pigments. Bile acid, phospholipid, cholesterol, and calcium concentrations in bile were significantly increased after phenobarbital. The data indicate that even in the presence of cholestasis an underlying deficiency in bilirubin conjugation may be confirmed by biliary pigment analysis.

Adult↗

PubMed1985

Hemostatic defects in experimental obstructive jaundice.

To elucidate the etiology of hemostatic abnormalities in cases of obstructive jaundice, we occluded the bile duct of rats for one week and found that the moderately jaundiced rats exhibited a marked reduction in the value of Hepaplastin test and Thrombotest with minimum histological changes in liver. All other coagulation and fibrinolysis profiles were within normal limits. These findings exclude the occurrence of a hypercoagulable state or hypofibrinolytic state in the jaundiced rats due to bile duct occlusion. Similar results were obtained in rats with tube choledochostomy. The abnormalities were almost completely prevented by the daily parenteral administration of vitamin K. These observations suggest that malabsorption of vitamin K may be the sole etiologic factor producing hemostatic defects in case of uncomplicated obstructive jaundice.

Animals↗

PubMed2001

Myelodysplastic syndrome progresses rapidly into erythroleukemia associated with synchronous double cancers of the stomach and the papilla of Vater.

Patients with myelodysplastic syndrome (MDS) show a relatively high incidence of developing cancers. However, it is extremely rare that synchronous double cancers develop in an MDS patient. We report a case of MDS that progressed rapidly into erythroleukemia (M6 by French-American-British classification) complicated by gastric cancer and carcinoma of the papilla of Vater. A 66-year-old man was admitted because of pancytopenia with peripheral blasts. A diagnosis of MDS (with refractory anemia with excess of blasts in transformation [RAEB-T]) was made by bone marrow examination. Chromosome analysis revealed 46,XY. An early gastric cancer was also diagnosed by endoscopic examination. The peripheral blasts gradually proliferated and the disease progressed to M6. A chromosome abnormality 46,XY,del(1)(q42) was detected at the leukemic transformation. A CAG (low-dose cytarabine and aclarubicin in combination with granulocyte colony-stimulating factor) regimen was started as a remission-induction therapy. However, obstructive jaundice developed and a marked dilatation of bile ducts was observed by abdominal computed tomography (CT). A carcinoma of the papilla of Vater was detected by endoscopy. As remission was achieved and the pancytopenia improved, the patient subsequently underwent a surgical jejuno-choledochostomy to manage the jaundice. However, the leukemia relapsed thereafter and additional chromosome abnormalities including der(5)t(5;10)(p15:q11) were observed.

Aclarubicin↗

PubMed1983

Oriental infestational cholangitis.

One hundred forty-one patients with non-neoplastic cholangitis in Southwest Korea were analyzed for etiologic factors, pathologic changes, and clinical management in an effort to understand the clinicopathologic course of this disease. Our study supports the concept of infestational cholangitis. A staging system for this disease process has been proposed. The limited value of choledocholithotomy and choledochostomy in the more advanced stages of the disease process has been documented, suggesting the need for more effective internal biliary drainage when irreversible changes have occurred.

Adolescent↗

PubMed1987

Emergency management of choledochal cysts in adult patients.

Congenital cystic dilation of the biliary tree is rarely considered as cause of cholangitis in the adult patient. Emergency operation in seven adults with unsuspected choledochal cysts resulted in reoperation in all seven. Each patient presented with right upper quadrant pain, a mass, and cholangitis or jaundice. Abdominal ultrasonography incorrectly identified the cyst as a dilated gallbladder in three of the patients. All initial emergency drainage procedures required subsequent modification to cyst excision and Roux-Y reconstruction. From review of the experience presented and the literature to date, we recommend that otherwise stable patients be managed nonsurgically and undergo endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography to plan primary single-stage excisional operation. Patients requiring emergency decompression should have cholecystostomy or choledochostomy for good control without compromising subsequent operation. At the time of excision, a technical consideration not previously reported is the presence of small daughter cysts in Calot's triangle which must be distinguished from the hepatic bile ducts. The surgical literature has frequently addressed the problems of elective surgery for choledochal cysts; however, emergency complications requiring urgent operative intervention are seldom addressed. We believe emergency intervention should correct the urgent complication without compromising the definitive surgical treatment.

Adult↗