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PubMed1983

Avulsion of common bile duct after blunt abdominal injury: a review of the literature.

Injury to the common bile duct following blunt injury of the abdomen has been reported in 82 previous cases in the literature that we have reviewed. An additional rare case of complete avulsion of the common bile duct at its junction with the pancreas is presented here. Diagnosis has usually been late, peritonitis has commonly been present and 33 per cent of the cases ended fatally. Although diagnosis is often late, there have been many attempts at primary repair; we describe a new technique of delayed repair, which involved intermittent closure of the common duct and was successful in increasing its diameter by the time of the second operation. The initial injury was treated by a cutaneous choledochostomy and 2 jejunostomy tubes, one for decompression and drainage and the other for feeding and replacement of bile. The final repair consisted of a choledochojejunostomy, jejunojejunostomy and T-tube drainage of the common juct. The patient is completely well after two years.

Abdominal Injuries↗

PubMedDate not supplied

Transcystic cholangiogram access via rubber band with early withdrawal after liver transplantation: a safe technique.

OBJECTIVE: Since different techniques have been described for cholangiogram access after liver transplantation, we compared two different methods for patients with duct-to-duct biliary anastomoses. METHODS: Adult liver transplant patients from program inception in 1993 to May 2003 in whom a duct-to-duct biliary anastomosis with a T-tube choledochostomy were compared with those having a transcystic duct catheter using a rubber band. We excluded 10 patients in which a different technique was used or graft or patient survived less than 21 days. Group A (n = 28,) had a number 10 T-tube exteriorized through the recipient main bile duct; and group B (n = 33) a number 5 Bard ureteral stent tied to the cystic stump with reabsorbable suture and secured with a hemorrhoidal rubber ligature. RESULTS: The biliary complication rate was lower among the transcystic catheter group (9.1%, 3/33) compared to the T-tube group (35.7%, 10/28). Postcatheter withdrawal peritonitis was present in two patients in the T-tube group, one of whom required emergency laparotomy. A satisfactory postoperative cholangiogram was obtained in both groups. The transcystic catheter was withdrawn on average at 29 days, compared to 136 days in the T-tube group. CONCLUSIONS: Both techniques are equally effective in obtaining a satisfactory postoperative cholangiogram. However, the transcystic catheter technique allows a significantly earlier withdrawal with fewer complications compared to the T-tube technique.

Adult↗

PubMed2006

Biliodigestive anastomosis in liver transplantation: review of 13 years.

Hepaticojejunostomy is a good alternative technique for biliary reconstruction in liver transplantation. Among 517 liver transplants performed between March 1992 and July 2005, 33 involved hepaticojejunostomy, namely, 18 men and 12 women of average age: 44.8 years. The main cause for this technique was retransplant (n = 10), secondary biliary cirrhosis (n = 5), alcoholic cirrhosis (n = 5), HCV cirrhosis (n = 2), primary biliary cirrhosis (n = 1), cryptogenic cirrhosis (n = 1), sclerosing cholangitis (n = 3), fulminant liver failure (n = 1), autoimmune cirrhosis (n = 1), and insulinoma metastasis (n = 1). Choledochojejunostomy was performed for all Roux-en-Y loops, with an average cold ischemia time of 361.16 minutes (180-780). The biliary complications were biliary fistula in four cases (13.3%), including two who required surgery; stenosis of the anastomosis in two cases (6.6%) including one diagnosed by HIDA that resolved with medical treatment and the other, diagnosed by cholangio-MRI, requiring a new hepaticojejunostomy; and biliary peritonitis in three cases (10%), all of whom required surgery. The vascular complications were thrombosis of the hepatic artery (n = 1), which required retransplantation, and pseudoaneurysm of hepatic artery (n = 1). No biliary complications occurred. The 6-month patient survival was 80% and the 6-month graft survival was 77%; no patient died due to biliary complications. Hepaticojejunostomy is a technique with higher morbidity than choledocho-choledochostomy, but it is the best alternative when the latter is not possible.

Adolescent↗

PubMed1990

Biliary complications following orthotopic liver transplantation.

The gall-bladder conduit anastomosis (choledocho-cholecysto-choledochostomy) has been the most frequently used technique for the biliary tract anastomosis in the Cambridge/King's College Hospital joint liver transplantation programme since 1976. Cholangiograms and interventional biliary procedures performed over a 3 year period were reviewed retrospectively. Seventy-six of 148 patients managed post-operatively at King's College Hospital were studied (79 transplants). Cholangiograms were abnormal in 63 (80%) transplants with biliary strictures; inspissated bile formation, bile leak and T-tube malposition occurring in 50, 23, 14 and three transplants respectively. Anastomotic strictures occurred most frequently, predominantly at the proximal anastomosis, and the presence of inspissated bile and the T-tube in relation to these contributed towards subsequent biliary obstruction. Non-anastomotic strictures in the donor biliary tract were associated with a high position of the T-tube tip at or above the liver hilum. Saline irrigation of the bile ducts for inspissated bile or its removal via the endoscope were effective measures in the management of biliary obstruction but percutaneous balloon dilatation and endoscopic stent insertion for biliary strictures were found to have a limited role.

Adolescent↗

PubMed1978

A preliminary investigation of the renal and hepatic excretion of gallamine triethiodide in man.

The fate of gallamine triethiodide has been investigated in patients undergoing cholecystectomy with choledochostomy (group I), pelvic operations (group II) and orthopaedic operations (group III). Following a single i.v. injection of gallamine 2.5 mg kg(-1) the disappearance of the drug from the serum occurred in three phases with half-lives of less than 5, 30, 138 min, less than 5, 39, 141 and less than 5, 48, 144 min in the respective groups. Twenty-four hours after injection the renal excretion of the unchanged drug was 53% (15-100%) of the administered dose in group I, 67% (40-90%) in group II and 95% (89-100%) in group III. The biliary excretion of gallamine appeared to be negligible in man. The relationship between renal excretion and duration of action of gallamine, and the influence of some intraoperative factors on drug disposition, are discussed.

Adult↗

PubMedDate not supplied

Atypia of hepatic histiocytes induced by Renografin-60.

Recurrent bouts of abdominal pain in a 12-year-old patient were diagnosed as due to intermittent obstruction of the choledochus. The condition was corrected by choledochostomy. Incidental liver biopsy showed atypia of intrahepatic histiocytes. However, electron microscopy identified associated foreign bodies suspected of being an iodinated compound. Six months later a repeat liver biopsy and extensive search showed no carcinoma present. The hepatic atypia was thought to have been induced by diatrizoate meglumine/diatrizoate sodium (Renografin-60), an iodinated compound (E. R. Squibb, Princeton, NJ, U.S.A.) used during percutaneous transhepatic cholangiography.

Child↗

PubMed1974

Occurrence of cholesterol crystals in human bile.

The occurrence of cholesterol crystals was studied in 20 consecutive gallstone patients with functioning gallbladders. The frequency with which crystals were found rose sharply with the number of stones. Gallbladder bile was found more often to contain cholesterol crystals than hepatic bile of the same individual. Such crystals were absent in T tube drain bile from 10 consecutive choledochostomy patients, studied after the reestablishment of the enterohepatic circulation for at least five days. In gallstone patients in whom the gallbladder was visualized at cholecystography the hepatic bile contained cholesterol crystals more often than in patients with gallbladders not so visualized. In the latter patients the crystals tended to disappear after prolonged fasting. Bile analysis showed hepatic bile of patients with non-functioning gallbladders to be less lithogenic than bile in cases with functioning gallbladders. In the former group bile contained relatively more chenodeoxycholic acid than in the latter. The composition of bile with cholesterol crystals did not differ significantly from that of bile without crystals. In the final analysis it is important to identify possible factors responsible for the precipitation of cholesterol from supersaturated bile.

Bile↗

PubMed1999

The bile duct anastomosis in liver transplantation.

In spite of the dramatic improvement of survival after orthotopic liver transplantation over the last decades, biliary tract complications are still the 'achilles heal' of liver transplantation with a potential risk of significant morbidity and mortality. Biliary leaks or strictures, the major types of biliary complications, may occur after direct choledocho-choledochostomy (CC) or Roux-Y choledocho-jejunostomy (CRY). The majority of these biliary complications, however, are often a consequence of surgical technique and therefore potentially amenable to improved surgical technique.

Anastomosis, Surgical↗

PubMedDate not supplied

Effect of a taurine-supplemented diet on conjugated bile acids in biliary surgical patients.

The effect of a taurine-supplemented diet on the level of conjugated bile acids in postoperative patients was investigated during two consecutive 5-day period. Eighteen hepatobiliary patients with choledochostomies and a specific T-tube insertion were collected and divided randomly into two groups. In group 1, an ordinary postoperative soft diet was prescribed for the first 5 postoperative days and then followed with a taurine-supplemented soft diet (40 mumol/kg per day) for 5 consecutive days. In group 2, the taurine-supplemented diet was prescribed in reverse. At the end of the two periods, on days 5 and 10, bile was collected via a T-tube with an inflatable balloon and low-pressure motor suction. Analysis of conjugated bile acids was done by high-performance liquid chromatography. The results showed that a taurine-supplemented diet increased the concentration of taurocholic acid, glycocholic acid, taurochenodeoxycholic acid, glycochenodeoxycholic acid, and total bile acid from 0.5, 1.9, 0.3, 1.4, and 4.7 mg/mL (on day 5) to 1.1, 3.5, 1.0, 2.6, and 8.9 mg/mL, respectively, on day 10 in group 1. Similar findings were noted in group 2. These results indicate that a taurine-supplemented diet may enhance the conjugation and secretion of bile acid in hepatobiliary patients.

Adult↗

PubMedDate not supplied

An improved model for rat liver transplantation including arterial reconstruction and simplified microvascular suture techniques.

For experimental liver transplantation in the rat, the models that have been used most frequently do not include reconstruction of the arterial blood supply to the liver. In these procedures, specially developed cuff anastomoses rather than the conventional microvascular suture technique are used almost exclusively in the recipient operation, so that the anhepatic time is minimized. In this study the technical details of an improved rat model for orthotopic liver transplantation are described. During the donor operation in this experimental method, the liver is prepared with an arterial pedicle that includes the abdominal segment of the aorta, permitting perfusion in situ of the portal vein as well as the hepatic artery. The transplantation of the excised donor organ into the recipient site is carried out with simplified microvascular suture techniques and includes reconstruction of the arterial supply to the liver. Anastomosis of the bile duct is accomplished by choledocho-choledochostomy with a splint technique and supplemental suturing. For the entire procedure, magnifying glasses with 2- to 2.5-fold magnification are sufficient. When this technique has been mastered, the average duration of the anhepatic phase is about 20 min, well below the critical 30-min limit for survival of the experimental animals. As proficiency increased, the perioperative mortality was reduced to 9.2% (n = 130). With the combination of portal and arterial in situ flushing during the donor operation and the rearterialization of the transplant during the recipient operation, the clinical conditions can be approximated more closely than is possible when the transplanted rat liver is supplied only by the portal vein. Use of microvascular suture techniques, without cuff anastomoses, reduces the need for ex situ handling of the donor organ.

Anastomosis, Surgical↗

PubMed1975

Flow through the bile duct after cholecystectomy.

The human bile duct has no intrinsic motility, but following cholecystectomy, flow through the bile duct is governed by the intraductal pressure generated by the liver, by the resistance to flow through the duct and sphincter at the terminal end of bile duct and by intraduodenal pressure. Pressure-flow experiments were performed upon 50 patients with biliary T-tube drainage following cholecystectomy and choledochostomy; nine patients had also undergone transduodenal sphincterotomy. Saline solution was introduced into the bile duct at controlled pressures, ranging from zero to 30 centimeters of water, while recordings were made of the flow rate of saline solution, intraduodenal pressure and respiratory movements. Although the flow rate of saline solution increased as its perfusion pressure was increased, three types of variation in flow were also recorded: rhythmic arrests of flow, occurring four to eight times per minute, believed to be due sphincteric contractions; nonrhythmic arrests of flow, lasting up to one minute, believed to be due to sphincteric contraction, and variations in flow associated with changes in intraduodenal pressure. The resistance to the flow of saline solution and the variations in flow rate were also similar in the patients who had undergone sphincterotomy. This study supports the view that sphincteric activity is present followingcholecystectomy, that the choledochal sphincter has rhythmic activity which differs from that of duodenal motility and that sphincter probably opens and closes continuously in a rhythmic manner during fasting periods in patients who have undergone cholecystectomy.

Bile Ducts↗

PubMed2006

[Prophylaxis and treatment of operation-correlated complications in orthotopic liver transplantation].

OBJECTIVE: To investigate the common reasons, prophylaxis and treatment of operation-correlated complications in orthotopic liver transplantation (OLT). METHODS: Six hundred and forty-seven patients who underwent OLT from Apr 1993 to Dec 2004 were enrolled and analyzed retrospectively. RESULTS: There were totally 39 cases (6.0%, 39/647) of vascular complications including 23 cases (3.6%) of hepatic artery complications, 6 cases (0.9%) of portal vein complications and 10 cases (1.5%) of vena cava complications. All vena cava complications were occurred in the patients of non-cavaplasty. The success rate of stent placement in treatment of hepatic artery stenosis was 2/2; for patients with hepatic artery thrombosis, the success rate of retransplantation was 4/6, that of revasculation and balloon dilation were 3/7 and 2/7 respectively. Stent placement can treat both anastomotic strictures and venae cavae stricture with the cure rate of 3/3 and 10/10 respectively. There were 34 cases of biliary complications, in which 27 cases were in patients with T tube, and 7 cases in without T tube. The incidence of biliary leak and biliary infection was significantly different between these two groups. CONCLUSIONS: The modified piggyback (cavaplasty) technique could prevent the incidence of venae cavae complications effectively. Stent placement is an effective way to treat vascular stenosis. And retransplantation should be performed in early hepatic artery thrombosis. It is important to protect the blood supply of biliary system, and choledochostomy without T tube is the first choice for biliary reconstruction.

Adolescent↗

PubMedDate not supplied

[Transtumoral drilling--an efficient solution and in many cases the only one available in the surgical treatment of Klatskin tumors].

PURPOSE: Reviewing the cases and evaluate the efficacity of the trans-tumoral drilling in the Klatskin tumours which were operated in Colentina Surgical Department. MATERIAL AND METHOD: This is a clinical retrospective study on 109 cases of Klatskin tumours operated between 1998-2004. in 80 cases of them we could practice a biliary drainage using a trans-tumoral drilling. SURGICAL INDICATION: Malignant tumours of the main biliary duct developed at the level and above the junction of the two hepatic ducts , extended to the liver in many cases. SURGICAL TECHNIQUE: Through the choledochostomy, we performed with a special instrument the trans-tumoral drilling with the setting of a biliary axial drainage (40 cases), external biliary drainage through a semirigid trans-choledochal tube (25 cases), Kehr tube (9 cases), U tube (3 cases), internal drainage with intra-choledochal stent (2 cases), lost tube (1 case). RESULTS: In all cases we observed the early decrease of the jaundice. In the cases in which we used internal drainage, we had to perform a replacement of the closed tubes in 1-2 months after the first operation. Instead, the external biliary drainage, less expensive and periodically washed to preserve his permeability, proved his high efficiency. The average survival time was 8,9 months (between 5-20 months). CONCLUSIONS: The external biliary drainage through trans-tumoral drilling remains in many cases the only one available therapeutical solution for the Klatskin tumours.

Aged↗

PubMed1991

[A review of 139 cases of acute necrotic pancreatitis].

One hundred and thirty-nine cases of acute necrotic pancreatitis were treated in our hospital from Oct. 1975 through Feb. 1990. The mode of treatment went through three stages: (1) From Oct. 1975 to Dec. 1980, application of early operation including necrosectomy, gastrostomy, jejunostomy, choledochostomy and postoperative local peritoneal irrigation, with a survival rate of 50%; (2) From Jan. 1981 through Dec. 1987, early operation with regular pancreatectomy as the operation of choice, and peripancreatic exploration, planned postoperative debridement performed at weekly intervals, with a survival rate of 65.45%; (3) From Jan. 1988 through Feb. 1990 the adoptation of the strategy of "Individualization" consisting of early operation for those with apparent signs of inflammation and complications, and late exploration for those without signs of infection and/or complication, with a survival rate rose to 72.41%.

Adolescent↗

PubMed1990

[Early and late results of orthotopic liver transplantation].

Between 4/1986 to 1/1989, 74 orthotopic liver transplantation were performed in 62 patients (62 first liver transplants, 10 as second graft and two as a third graft); 57 in adults and 17 in children. The main indication for the operation was liver cirrhosis (61.4%) (the most frequent etiology was alcoholic cirrhosis, 28.5%). Six cirrhotic patients had a hepatocarcinoma (9.6%). Two received a liver and kidney transplant due to terminal renal insufficiency and hemodialysis. The most frequent indication in children was biliary atresia (33.3%). Six patients had a fulminal liver failure (9.6%). AB0 blood group compatibility was identical in 87.5%, compatible in six and incompatible in three patients. Total orthotopic liver transplantation was performed in 67 patients, and size-reduced liver was indicated in 7 patients. Extracorporeal veno-venous bypass was used in adults but never in children. In 93.1% of the transplants a single hepatic artery was anastomosed to the recipient and in 6.9% a double anastomosis was performed. In 62.5% of the patients a end-to-end choledocho-choledochostomy was performed and in 34.8% hepatico-jejunostomy was indicated. Three months postoperative mortality rate was 12.9%. Arterial stenosis and thrombosis were the most frequent complication.

Adolescent↗

PubMed1989

[Surgical intraoperative complications in simple cholecystectomy].

In a retrospective analysis of all simple cholecystectomies performed between 1970 and 1987, we were particularly interested in the incidence of intraoperative surgical complications and their long-term follow-up. We analyzed 2441 consecutive simple cholecystectomies and found 60 major intraoperative complications with 55 patients (2.25%): there were 31 vascular lesions (1.27%) and 26 lesions of the biliary tract (1.06%). Amongst the patients with biliary tract lesion but one had to be reoperated one year later due to a stricture which occurred as a consequence of an end-to-end-hepatico-choledochostomy over a T-tube. Intraoperative technical complications may happen. Their early recognition and treatment are of utmost importance.

Cholecystectomy↗

PubMed1989

Indications and results of sphincteroplasty in benign biliary diseases.

A retrospective analysis of 143 patients submitted to sphincteroplasty at the Department of Surgery, University of Chile Clinical Hospital was performed. A significant percentage of these patients (90%) were admitted due to acute biliary tract disease with or without cholangitis. The standard operative procedure was anterior transduodenal sphincteroplasty with supraduodenal choledochal exploration leaving a choledochostomy. A high number of our cases presented with intrahepatic lithiasis (23.8%). The morbidity was 15.4% and the 30 days post operative mortality rate was 4.9%, similar to other reports. Residual stones were observed in 10 patients (7%), and were successfully removed by other procedures. Three patients showed recurrent stenosis of the papilla and were operated on again with good results.

Adolescent↗

PubMed1984

Choledochocholedochostomy is successful in orthotopic liver transplantation.

The viability of the extrahepatic bile ducts of liver grafts depends on their arterial blood supply, and consequently, on the patency of the arterial anastomosis. Thrombosis of the hepatic artery leads almost inevitably to necrosis of the extrahepatic bile ducts of the liver graft. An impeccable technique of arterial anastomosis is essential to avoid biliary complications resulting from ischemia. The low incidence of biliary complications (17%) in our 31 patients indicates that choledocho-choledochostomy is a relatively safe biliary procedure in clinical liver transplantation, especially when compared with other commonly used biliary anastomoses.

Adult↗