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PubMed1994

Surgical implications of preduodenal portal vein in the adult. Case report and review of the literature.

Occasionally, a preduodenal portal vein (PDPV) is found in pediatric patients with intestinal obstruction due to duodenal compression. In adults, it is often symptom-less and is an exceptionally rare condition. It is of surgical importance, however, because the vein lies in the most superficial position ventral to the common bile duct and is easily damaged during operations involving the biliary tract and duodenum. We recently treated a patient with PDPV, which stimulated a review of the disease process, including diagnosis, association with other anomalies, and surgical treatment.

Aged↗
PubMed1995

Biliary tract complications after liver transplantation.

OBJECTIVE: To assess the incidence, type, and treatment of biliary complications after orthotopic liver transplantation. DESIGN: Case series. SETTING: Tertiary referral center. PATIENTS: One hundred ninety consecutive adults who underwent 220 orthotopic liver transplantations with biliary reconstruction between January 1, 1989, and December 31, 1993, with follow-up of all survivors to May 1994. MAIN OUTCOME MEASURES: Incidence, type, and treatment of biliary complications. RESULTS: Biliary complications were identified in 65 of the 190 patients who underwent biliary reconstruction (49 of 147 with choledochocholedochostomy and 16 of 43 with Roux-en-Y choledochojejunostomy). The group with complications who had choledochocholedochostomy had 32 biliary leaks (22 T-tube related), 11 strictures or obstructions, and six cases of choledocholithiasis. Twelve percent of choledochocholedochostomies were converted to choledochojejunostomies, while 26 of 49 biliary complications in patients who had choledochocholedochostomies were treated nonoperatively. Elective removal of T tubes resulted in biliary leak in 15 of 89 patients, treated nonoperatively in 12. Leaks (unrelated to scheduled removal of the tube) occurred earlier than strictures (choledochocholedochostomy, mean +/- SEM 25.6 +/- 5.8 vs 184.7 +/- 61.0 days; choledochojejunostomy, 13.4 +/- 4.4 vs 521.0 +/- 142.0 days) and were more often treated operatively (choledochocholedochostomy, 14 of 17 vs three of seven; choledochojejunostomy, four of five vs three of eight). Three deaths were associated with early biliary leaks, all in patients with preexisting multiorgan dysfunction. There was no significant difference in the incidence of biliary complications by type of reconstruction, year of transplantation, age, UNOS (United Network for Organ Sharing) status, preservation time, or indication for transplantation. CONCLUSIONS: Biliary complications are common after orthotopic liver transplantation but are rarely an isolated cause of death. Stenting of the choledochocholedochostomy or choledochojejunostomy anastomosis does not prevent strictures, and T tubes are associated with a high incidence of biliary leakage on removal. Nonoperative interventions have an increasing role in the treatment of biliary complications.

Adult↗
PubMed1996

Biliary-enteric anastomosis by means of a single layer of serosubmucosal sutures without T-tube drainage.

BACKGROUND: To lessen anastomotic stricture after biliary-enteric anastomosis, we developed a new biliary-enteric anastomosis that uses a single layer of interrupted serosubmucosal sutures without T-tube drainage. OBJECTIVE: To evaluate the safety and reliability of this new technique in a canine model of choledochoduodenostomy. METHODS: In 10 beagles, the common bile duct (2 to 3 mm in diameter) was ligated close to the duodenum with 3-0 polyglactin. On the fifth day after operation, the serum bilirubin level was elevated (137 to 205 mumol/L [8 to 12 mg/dL]) and the bile duct was dilated. The anastomosis between serosubmucosal layers of the dilated bile duct (8 to 10 mm in diameter) and duodenum was accomplished with interrupted sutures of 6-0 polyglactin with two needles. Stitches were inserted in the submucosal plane at the cut edge of the duct and duodenum to appose the mucosa accurately and to avoid accidental perforation of the entire thickness of the duct and duodenum. A T tube was not placed. RESULTS: There was no anastomotic leakage and the bilirubin level was normalized (14 to 17 mumol/L [0.8 to 1.0 mg/dL]) 7 days after operation for anastomosis. Histologic examination of specimens removed 6 or 12 months after operation showed good connective-tissue union and good mucosal continuity between the bile duct and the duodenum. There was no mucosal scarring and contracture or stricture formation. CONCLUSION: This new technique is simple and reliable and is recommended as an alternative method for restoring the continuity between the bile duct and intestinal tract after operation for obstructive jaundice caused by benign and malignant stricture of the bile duct.

Animals↗
PubMed2000

Factors influencing survival after resection for ductal adenocarcinoma of the head of the pancreas.

BACKGROUND AND OBJECTIVES: Recent reports have demonstrated improvement in the 5-year actuarial survival for patients with resected ductal adenocarcinoma. The purpose of this study is to determine the factors favoring long-term survival after pancreaticoduodenectomy. METHODS: Between 1974 and 1995, 75 patients with pancreatic head carcinoma underwent pancreaticoduodenectomy in our department. RESULTS: Overall postoperative mortality rate was 5. 3% and morbidity was 24%. Median survival following resection was 17 months. Estimated 1-, 2-, and 5-year survival rates were 68%, 46.7%, and 18.7%, respectively. Five-year survival was greater for node-negative than for node-positive patients (41.7% vs. 7.8%, P < 0. 001) and for smaller (<3 cm) than for larger tumors (33.3% vs. 8.8%, P < 0.006). The 5-year survival in patients with negative margins (n = 60) was 23.3%, whereas no patient with positive margins (n = 15) survived at 13 months (P < 0.001). Multivariate analysis, performed by the Cox proportional hazards model, indicated that margin status, lymph node metastasis, tumor size, and poor histological differentiation were independent predictors of poor survival. CONCLUSIONS: Five-year survival for patients undergoing pancreaticoduodenectomy for ductal adenocarcinoma of the pancreas was 18.7%. Survival was greater in the group of patients with negative lymph nodes, tumor size <3 cm, and negative margin status.

Actuarial Analysis↗
PubMed1999

Laparoscopic biliary and enteric bypass.

Very few patients with a periampullary neoplasm present with resectable disease. Consequently, various operative and non-operative techniques have been developed to palliate patients with unresectable periampullary disease. Laparoscopic biliary (cholecystojejunostomy) and enteric bypass (gastrojejunostomy) are reasonable options as compared to their open counterparts for operative palliation. However, only a limited number of carefully selected patients meet selection criteria for laparoscopic palliation.

Bile Duct Neoplasms↗
PubMed1989

Long-term follow-up after choledochojejunostomy for bile duct stones with complex clearance of the bile duct.

In this retrospective study, the long-term follow-up of patients undergoing choledochojejunostomy (Roux-en-Y) for bile duct stones with complex clearance of the bile duct is evaluated. Bile duct exploration and subsequent choledochojejunostomy (Roux-en-Y) was performed in 43 patients (median age 67 years) in the period 1976-82. There was no mortality and only one patient had a major complication. Twenty patients died during follow-up (median follow-up period 5 years); the median follow-up period for the remaining 23 patients was 8 years. Good long-term results were found in 98 per cent of cases. No signs or symptoms could be related to bile duct obstruction or to cholangitis. Nearly all liver function tests and serum bilirubin levels were normal in the 21 patients who were tested. We conclude that patients with bile duct stones with complex clearance of the bile duct can be safely treated by means of a choledochoenterostomy (in this study a choledochojejunostomy Roux-en-Y).

Adult↗
PubMed1989

Endoscopic endoprosthesis insertion following failure of cholecystojejunostomy in pancreatic carcinoma.

Sixteen patients in whom malignant biliary obstruction recurred after failure of cholecystojejunostomy had attempted relief of obstruction by endoscopic insertion of an endoprosthesis. This treatment was successful in 13 patients, although one required percutaneous insertion because of duodenal distortion and one required a combined percutaneous-endoscopic approach. Median survival after stenting was 3.5 months (range from 2 weeks to 16 months). Of the three treatment failures, two patients had external drainage only and one succumbed before further treatment could be attempted. There were two complications associated with the procedure (one small bile leak and one episode of cholangitis) but the 30-day mortality rate of 12.5 per cent was related to disease progression rather than the procedure. Endoscopic stent insertion may achieve further worthwhile palliation of jaundice after the failure of surgery to relieve malignant biliary obstruction.

Adenocarcinoma↗
PubMed1990

Management of the Mirizzi syndrome and the surgical implications of cholecystcholedochal fistula.

Several methods of handling the residual choledochal defects encountered during operation for type II Mirizzi syndrome have been described. Early experience with eight patients treated by a variety of procedures including direct suture and flap techniques led to disappointingly high morbidity and mortality rates. Since 1986 a standardized surgical approach has been used in four patients without complications or mortality. Essential to management are preoperative diagnosis by ultrasonography and endoscopic retrograde cholangiopancreatography and classification of the Mirizzi syndrome into two types as proposed by McSherry. Mirizzi type I consists of an extrinsic compression of the hepatic duct by a calculus impacted in the cystic duct or in Hartmann's pouch. This is treated by cholecystectomy with or without common bile duct exploration. In the more difficult Mirizzi type II, the stone has eroded into the hepatic duct causing a cholecystcholedochal fistula. This is treated by partial cholecystectomy and a cholecystcholedochoduodenostomy. This management strategy prevents inadvertent bile duct injury and has yielded satisfactory results.

Aged↗
PubMed1990

Operative choledochoscopy: common bile duct exploration is incomplete without it.

This paper reviews the reported experience of operative choledochoscopy. Development of choledochoscopes to the currently available rigid and flexible instruments is described. The collected results of both rigid and flexible choledochoscopy are reported. Retained stones occurred in 97 of 2712 stone-positive explorations with the rigid choledochoscope (3.6 per cent) and in 35 of 1726 stone-positive explorations with the flexible choledochoscope (2.0 per cent). Choledochoscopy should now be a mandatory part of common bile duct exploration.

Choledochostomy↗
PubMed1990

Assessment of the biliary tract after liver transplantation: T tube cholangiography or IODIDA scanning.

Biliary tract obstruction or anastomotic leakage are common problems following liver transplantation. In a sequential study, 31 patients with a liver transplant were investigated by 99mTc-IODIDA (IODIDA) scanning and T tube cholangiography (TTC) and the results were compared with clinical outcome. Seven patients had an extrahepatic biliary obstruction and one patient had a biliary leak. In the detection of biliary complications TTC and IODIDA scanning were similar in terms of sensitivity (63 per cent for both) but TTC had a better specificity (79 per cent versus 60 per cent) and accuracy (74 per cent versus 60 per cent) than IODIDA scanning. When liver function was taken into account, the diagnostic efficacy of both tests in patients with bilirubin levels of less than 200 mumol/l was similar. With levels greater than 200 mumol/l there was a greater number of false positive results with IODIDA scanning (12 per cent versus 54 per cent). The only significant biliary leak was clearly detected by TTC but not IODIDA scanning. TTC remains the more effective way of evaluating the biliary tract after transplantation. IODIDA scanning has limited value when bilirubin levels are elevated, but may provide additional information about blood supply, hepatocyte function and intrahepatic cholestasis.

Adolescent↗
PubMed1991

Long-term results of choledochoduodenostomy in the treatment of choledocholithiasis: assessment of 225 cases.

During a 10-year period 2610 patients were operated on for biliary lithiasis; in 225 (8.6 per cent) cases the operation concluded with a choledochoduodenostomy. The commonest preoperative diagnosis (62.2 per cent) in these 225 patients was choledocholithiasis; 30 patients had previously had a cholecystectomy. After choledochoduodenostomy, 4.0 per cent of patients had an intra-abdominal complication; six patients developed an intra-abdominal abscess and three developed an external biliary fistula. Four patients (1.8 per cent) died, three from pulmonary complications and one from a biliary fistula. After a mean follow-up period of 4.6 years, 71.5 per cent of patients were asymptomatic. The remainder suffered from dyspepsia (15.1 per cent), colicky pain (8.7 per cent) or episodes of cholangitis (4.7 per cent). Endoscopy in the symptomatic patients allowed the following conclusions: (a) no patient with dyspepsia had a problem at the anastomosis; (b) 27 per cent of those with colic had anastomotic stenosis or the sump syndrome; and (c) all patients with cholangitis had anastomotic stenosis and residual calculi.

Aged↗
PubMed1991

Combined surgical and interventional radiological approach for complex benign biliary tract obstruction.

In patients with complicated high benign biliary strictures surgical technique alone cannot exclude the possibility of recurrent problems, and hepatic atrophy/hypertrophy, portal hypertension and intrahepatic stones may all complicate surgical management. A multidisciplinary approach to these complex cases, which minimizes the need for repeated surgical interventions, has been pursued. Roux-en-Y hepaticojejunostomy was performed and an extended limb of the jejunum brought to the abdominal wall to allow access for later radiological intervention. Over a 30-month period 58 biliary-enteric anastomoses for benign disease were performed. Seventeen of these 58 patients were managed using the combined approach. Ten of these 17 patients had complex postcholecystectomy strictures and seven had strictures resulting from inflammatory disease, hepatic resection or congenital problems. A new classification of results of management of bile duct strictures is proposed. Seven patients were classified as 'excellent', six 'good', two 'fair' and two 'poor'. Results were obtained at a mean follow-up of 16 months and it seems likely that in some patients major surgical reinterventions were avoided.

Adult↗
PubMed1991

Primary sclerosing cholangitis: surgical options, prognostic variables and outcome.

The natural history of primary sclerosing cholangitis (PSC) is poorly defined and its management remains controversial. Forty-eight symptomatic patients (median age 39 years, range 8-67 years; 30 male) with PSC were reviewed retrospectively. Thirty patients had inflammatory bowel disease. Four patients (8 per cent) developed or had an associated malignancy. Twenty-one (44 per cent) died; overall 5 year actuarial survival was 30 per cent. Twenty-three patients had 27 non-transplant related biliary operations (16 patients specifically for PSC) of whom 12 died. Serum bilirubin was the only parameter to improve after biliary surgery. Seventeen patients (35 per cent) underwent orthotopic liver transplantation (OLT) of whom nine are currently alive (1 year projected survival of 55 per cent). Previous biliary surgery correlated with a poor outcome (P less than 0.0001) after OLT. Being male, presence of cirrhosis, duration of symptomatic disease (greater than 3 years) and a serum bilirubin level greater than 100 mumol/l at presentation, were independently associated with a poor outcome (P less than 0.05). These data provide evidence that PSC is a progressive disease and conventional surgical options have little influence on the outcome. Previous biliary surgery adversely affects outcome following OLT. For progressive liver disease, liver transplantation should be considered the treatment of choice.

Adolescent↗
PubMed1991

Effect of biliary infection on common bile duct healing in the rat.

It has been postulated that biliary infection plays a role in bile duct stricture formation. The aim of this study was to verify this hypothesis and to evaluate the effect of biliary infection on common bile duct healing. A 3-mm longitudinal choledochotomy was performed in 120 rats and closed with a continuous 11/0 Ethilon suture. Common bile duct division with end-to-end anastomosis using interrupted 11/0 Ethilon sutures was performed in another 30 rats. Biliary infection was achieved in half of the animals with retrograde injection of living 046:K1:H31 strain Escherichia coli recovered from the rat colonic content. All rats with choledochotomy, including those with biliary infection, showed no bile leakage at the suture line, and the bursting pressure at the site of choledochotomy exceeded 40 mmHg as early as 24 h. Rats with common bile duct anastomosis alone showed no stricture formation for up to 6 months after operation. All rats with biliary sepsis developed complete occlusion at the anastomosis. On scanning electron microscopy, the biliary epithelium was well preserved in all rats. The study suggests that in rats with biliary sepsis the risk of bile leakage after primary closure of the common bile duct is negligible, but biliary infection may play a critical role in common bile duct stricture formation.

Anastomosis, Surgical↗