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PubMed1992

Effect of biliary decompression on reticuloendothelial function in jaundiced rats.

The recovery of reticuloendothelial system (RES) function following decompression of obstructive jaundice was studied using a rat model with bile duct ligation and side-to-side choledochoduodenostomy. Histopathological changes in the liver were still present 5 weeks after relief of jaundice, while results of liver function tests had returned to normal. RES function evaluated by the blood clearance and organ uptake of radiolabelled Escherichia coli using a corrected phagocytic index gradually returned to normal following biliary decompression. The severely impaired RES activity noted 1 week after operation may explain the increased incidence of sepsis and renal insufficiency in the early period after biliary surgery in jaundiced patients.

Animals↗
PubMed1992

Operative common bile duct imaging by operative cholangiography and flexible choledochoscopy.

A consecutive series of 108 common bile duct (CBD) explorations was studied to examine the efficacy of routine operative cholangiography and flexible choledochoscopy in the identification of choledocholithiasis. CBD exploration was performed according to the findings of routine operative cholangiography. Nine negative explorations were performed, only one of which would have been avoided had selective cholangiography been employed. Eight patients had unsuspected choledocholithiasis that would have been missed if selective operative cholangiography had been used. Flexible choledochoscopy identified CBD stones on 97 occasions; no additional retained stones were found on subsequent T tube cholangiography. In two cases stones were seen but could not be removed; immediate identification allowed planning for early removal. Flexible choledochoscopy is the most effective method of CBD exploration and should be used in all patients with suspected choledocholithiasis.

Adult↗
PubMed1993

Reoperation for biliary tract complications following orthotopic liver transplantation.

Biliary tract complications were analysed after 54 orthotopic liver transplantations performed in 49 patients over a 2-year period. Reconstruction of the bile duct consisted of end-to-end choledochocholedochostomy over a T tube in 47 cases and Roux-en-Y choledochojejunostomy in seven (two for sclerosing cholangitis, one for secondary biliary cirrhosis, four retransplants). The T tube was withdrawn 12-16 weeks after operation in all but two patients (2-3 weeks). There was no intraoperative mortality. Eight patients (16 per cent) died during the first month and the 1-year actuarial survival rate was 75 per cent. Early biliary complications (up to 3 months after operation) consisted of five bilomas, for which ultrasonographically guided drainage was effective in three and surgical drainage necessary in two. Late biliary complications (3 months onwards) consisted of biliary peritonitis following T tube removal (four patients; reoperation was required in all four) and necrosis of the bile duct secondary to a late arterial thrombosis (one). The incidence of reoperation as a result of early biliary complications was low (two patients), but higher for biliary peritonitis following T tube removal.

Adolescent↗
PubMed1994

Choledochoduodenostomy and sphincterotomy in the treatment of choledocholithiasis.

Over a 10-year period, 2610 patients underwent operation for biliary lithiasis. Exploratory choledochotomy was indicated in 591 patients (22.6 per cent). This was followed by simple choledochorrhaphy over a T tube in 240 patients (40.6 per cent), transduodenal sphincterotomy and choledochorrhaphy over a T tube in 126 (21.3 per cent), supraduodenal choledochoduodenostomy in 216 (36.5 per cent), and choledochoduodenostomy and transduodenal sphincterotomy in nine (1.5 per cent). Choledochoduodenostomy was performed if the bile duct was more than 12 mm in diameter. The indication for transduodenal sphincterotomy was the presence of a stone impacted in the papilla and/or papillary stenosis. Six patients developed abdominal abscess and three an external biliary fistula following choledochoduodenostomy. There were four abscesses and two episodes of acute pancreatitis in patients undergoing sphincterotomy. There was no difference in mortality rate between the two groups. After a mean follow-up of 5.6 years, 71.5 per cent of patients who underwent choledochoduodenostomy and 75.2 per cent of those who received transduodenal sphincterotomy were asymptomatic. The remainder suffered from dyspepsia, colicky pain or episodes of cholangitis. Nine patients underwent reoperation for residual calculi (six choledochoduodenostomies, three sphincterotomies).

Adult↗
PubMed1994

Laparoscopic surgery in patients with human immunodeficiency virus.

Fifteen patients with acquired immune deficiency syndrome (AIDS), and one who tested positive for human immunodeficiency virus but had no AIDS-defining diagnosis, underwent a range of laparoscopic procedures between March 1991 and March 1993. Seven cholecystectomies and one cholecystojejunostomy were performed. Three patients underwent diagnostic laparoscopy after presenting with abdominal emergencies. Two further patients had laparoscopic adhesiolysis and one appendicectomy. A further patient underwent laparoscopically assisted end colostomy and another an inguinal hernia repair, both performed electively. Two patients died in the postoperative period. There was little postoperative morbidity. Six patients died 3-18 months after surgery from progressive AIDS. This early experience suggests that laparoscopic surgery is well tolerated in these patients.

Acquired Immunodeficiency Syndrome↗
PubMed1995

Healing process of sutureless choledochojejunostomy in an experimental model.

The healing characteristics and morphological features of sutureless choledochojejunostomy were investigated in a rat experimental model. The common bile duct of 34 conditioned Wistar rats was exposed, divided transversely and a choledochojejunostomy constructed with only a vinyl chloride tube positioned between the common duct and jejunum. The animals were killed 4, 12 and 52 weeks after surgery. Cholangiographic evaluation of the anastomosis in all three groups showed wide openings with dilatation of the extrahepatic bile duct. Microscopic examination of the anastomosis showed hyperplastic changes of the bile duct epithelium. The epithelial defect was completely covered with proliferative epithelium 12 weeks after operation. At long-term follow-up of 52 weeks there were no biliary strictures after the sutureless technique. This surgical approach may be useful for patients in whom sutured anastomosis of the bile duct might lead to stricture, such as those with a normal thin-walled bile duct.

Alanine Transaminase↗
PubMed2004

Advantages of laparoscopic stented choledochorrhaphy over T-tube placement.

BACKGROUND: Postoperative complications after laparoscopic choledochotomy are mainly related to the T tube. Both laparoscopic endobiliary stent placement with primary closure of the common bile duct (CBD) and primary closure of the CBD without drainage have been proposed as safe and effective alternatives to T tube placement. METHODS: This was a retrospective analysis of data collected prospectively on 53 consecutive patients suffering from proven choledocholithiasis who underwent laparoscopic CBD exploration through a choledochotomy between January 1999 and January 2003. In the early period a T tube was placed at the end of the procedure (n = 32). Biliary stent placement and primary CBD closure was performed from June 2001 (n = 21). RESULTS: There were no significant differences in epidemiological characteristics, preoperative factors or intraoperative findings between the groups. Seven patients developed complications, six in the T tube group and one in the stent group. Univariate analysis revealed a significantly lower morbidity rate and shorter postoperative hospital stay in the stent group. CONCLUSION: Placement of a biliary endoprosthesis after laparoscopic choledochotomy achieves biliary decompression, and avoids the complications of a T tube, leading to a shorter postoperative hospital stay. The method is a safe and effective alternative method of CBD drainage after laparoscopic choledochotomy.

Aged↗
PubMed1997

Infection complicating percutaneous liver biopsy in liver transplant recipients.

There is controversy about the frequency of and risk factors for infectious complications of percutaneous liver biopsy in liver transplant recipients. The aim of this study was to identify the incidence and nature of complications associated with liver biopsy after orthotopic liver transplantation (OLT), with particular emphasis on infection. The medical records of all patients undergoing OLT between January 1990 and August 1994 were reviewed retrospectively to identify complications requiring hospitalization within one week of percutaneous liver biopsy. The nature and severity of complications were recorded and possible risk factors for infectious complications were examined. One hundred ninety-eight patients underwent 1,136 percutaneous liver biopsies. There were eleven complications (0.96%), including as follows: 7 infections, 3 bleeding episodes, and 1 vasovagal reaction. Infections after percutaneous liver biopsy included fever and bacteremia (n = 6), and fever without bacteremia (n = 1). All infections developed only in patients with underlying biliary tract abnormalities; the frequency of infection was higher (9.8%) in patients with choledochojejunostomy when compared with those with choledochocholedochostomy (1.4%). Bacteremia was more likely caused by skin flora in patients with choledochocholedochostomy (CDC) and by enteric bacteria in patients with choledochojejunostomy (CDJ). All infections were treated successfully with parenteral antibiotics. We conclude that biliary tract abnormalities are the primary risk factors for infection after percutaneous liver biopsy, although the risk is higher in patients with CDJ than with CDC. These data support the use of antibiotic prophylaxis before percutaneous liver biopsy in OLT recipients with biliary tract abnormalities.

Anastomosis, Roux-en-Y↗
PubMed2005

A case of successful enteroscopic balloon dilation for late anastomotic stricture of choledochojejunostomy after living donor liver transplantation.

Biliary complications remain a major concern after living donor liver transplantation. We describe a pediatric case who underwent a successful endoscopic balloon dilatation of biliary-enteric stricture following living donor liver transplantation using a newly developed method of enteroscopy. The 7-year-old boy with late biliary stricture of choledochojejunostomy was admitted 6 years after transplantation. Since percutaneous transhepatic cholangiography was technically difficult in this case, endoscopic retrograde cholangiography was performed using a double-balloon enteroscope under general anesthesia. The enteroscope was advanced retrograde through the duodenum, jejunum, and the leg of Roux-Y by the double-balloon method, and anastomotic stricture of choledochojejunostomy was clearly confirmed by endoscopic retrograde cholangiography and endoscopic direct vision. Balloon dilatation was performed and the anastomosis was expanded. Restenosis was not noted as of 2 years after the treatment. In conclusion, endoscopic balloon dilation of biliary-enteric anastomotic stricture using a new enteroscopic method can be regarded as an alternative choice to percutaneous transhepatic management and surgical re-anatomists.

Bile Ducts, Intrahepatic↗
PubMed1998

Intraoperative donor cholangiography.

Biliary drainage has long been called the Achilles' heel of liver transplantation, and biliary complications compromise the success of liver transplantation by increasing graft loss and the rates of a required second operation, morbidity, and mortality. One cause of complications is unrecognized anomalous biliary anatomy. We examined 73 intraoperative donor duct cholangiograms (IODDCs) to assess our ability to identify biliary anomalies intraoperatively. Normal anatomy was seen in 42% (31/73); some part of the right-sided biliary system drained into the left bile duct in 22% (16/73); trifurcated systems with a single branch point for the right posterior, right anterior, and left ducts appeared in 16% (12/73); low insertion of a right segmental duct to the hepatic duct was seen in 11% (8/73); and drainage of a right segmental duct into the cystic duct or into the hepatic duct at the cystic duct origin was noted in 8% (6/73). It was believed that the last group represented a condition that dictated extra caution in biliary reconstruction. The incidence of radiographic recognition of these anomalies was more than twice the clinical recognition in our patient population, implying that many such "problem" ducts usually go unrecognized. IODDCs facilitate training of transplant fellows. Costs are low, and morbidity is nil.

Cholangiography↗
PubMed2000

Results of choledochojejunostomy in the treatment of biliary complications after liver transplantation in the era of nonsurgical therapies.

Advances in radiological and endoscopic techniques have allowed many biliary complications after orthotopic liver transplantation (OLT) to be managed without surgery. The influence of nonsurgical management on the outcome of patients requiring surgical revision has not been addressed. We reviewed our 10-year experience (October 1988 to January 1998) of Roux-en-Y choledochojejunostomy (CDJ) to treat biliary complications after OLT. Forty-six patients underwent CDJ for biliary complications (32 men, 14 women; age, 22 to 65 years; median, 60 years). Biliary reconstruction at the time of OLT was duct to duct in 41 patients, primary CDJ in 3 patients, and gall bladder conduit in 2 patients. T-tubes were used only in patients with gallbladder conduit. The indication for CDJ was biliary leak (23 patients), stricture (20 patients), biliary stones (2 patients), and biliary sludge (1 patient). Two patients (4.3%) had associated hepatic artery thrombosis. The bile leaks were diagnosed at a median of 29 days post-OLT (range, 2 to 65 days) and strictures at a median of 2 years (range, 33 days to 6.5 years) post-OLT. Before surgery, 25 patients (54%) underwent an attempt at radiological or endoscopic therapeutic intervention that failed. Median follow-up was 5 years (range, 9 months to 10 years). Early complications occurred in 12 patients (26%); the most common was chest infection (4 patients). There were 3 perioperative deaths (6%); 1 death was directly related to surgery. Late complications, mainly anastomotic strictures, occurred in 10 patients (22%), half of which were successfully treated by biliary balloon dilatation. The complication rate post-CDJ was less in those who underwent a failed nonsurgical approach than those proceeding straight to surgery (9 of 25 patients; 36% v 13 of 21 patients; 62%; P =.21, not significant). The procedure-related mortality for surgical revision of biliary complications after OLT is low, but early and late complications are common. A failed attempt at nonsurgical management does not increase the complications of reconstructive surgery. Strictures after CDJ should be considered for biliary balloon dilatation.

Adult↗
PubMed2001

An improved rat model of obstructive jaundice and its reversal by internal and external drainage.

BACKGROUND: A simple and reproducible rat model that allows studies of the reversal of obstructive jaundice (OJ) by internal (ID) and external (ED) drainage is not available at present. METHODS: OJ was induced in rats by double ligation and division of the common bile duct. To minimize tissue handling and dissection the duodenum was extracted with a ophthalmic muscle hook and the common bile duct isolated using very fine forceps. One week after bile duct ligation, ID was accomplished by implanting a length of infant feeding tube between the dilated bile duct and the duodenum. ED was achieved by placing a PVC tube into the dilated bile duct and exteriorizing the other end at the nape of the neck. RESULTS: Minimal adhesions were found around the dilated common bile duct, which made relaparotomy for drainage easy. Alanine transaminase, total bilirubin, alkaline phosphatase, and gamma-glutamyltransferase were significantly raised after bile duct ligation. All parameters returned to control levels after ID for 7 days. In the ED group plasma albumin was significantly decreased and alkaline phosphatase remained marginally elevated. CONCLUSIONS: We have developed a simple and reproducible rat model that allows for the study of reversal of OJ by ID or ED. We also demonstrated that ID is superior to ED in reversing impaired liver function in OJ.

Animals↗
PubMed1992

Choledochoenterostomy with an anti-reflux mechanism.

A new technique of choledochoenterostomy was devised to solve some of the problems of enterobiliary anastomosis with a normal calibre. The distal extremity of the common bile duct is completely surrounded by the bowel mucosa to a length of 3 cm after seromyectomy of a bowel wall rectangle of 4 x 1 cm. Experimental studies in rats and dogs demonstrated that this procedure prevents the risks of anastomotic disruption and functions like a mechanical unidirectional valve, which has great efficacy in stopping enterobiliary reflux. Studies in ten patients with obstructive jaundice with an extrahepatic biliary dilation less than 1.2 cm diameter submitted to this procedure confirmed the experimental results. All patients were asymptomatic, without jaundice and with normalization of the liver enzymes after 2 months. The permeability of the valvular anastomosis studied by cholangiography, the HIDA 99mTc test and manometry was quite similar to other classical biliary-enteric anastomosis. In contrast, anti-reflux efficacy was only demonstrated in patients with a valvular anastomosis.

Animals↗
PubMed1996

MR cholangiopancreatography (MRCP) at 0.5 T: technique optimisation and preliminary results.

The aim of our study was to evaluate the feasibility of MR cholangiopancreatography (MRCP) at 0.5 T. To our knowledge no previous studies of MRCP have been performed at mid-field strength. Thirty-one patients with dilated biliary systems were examined with three-dimensional MRCP. All patients were studied with a 0.5 T superconducting magnet. A three-dimensional turbo spin-echo (TSE) sequence was acquired (TR = 5000 ms, TE = 244 ms, echo train length = 45; acquisition time = 14 min 10 s). Coronal images were post-processed with the MIP algorithm. Recently, the parameters have been optimised (TR = 3000 ms, TE = 700 ms, echo train length = 128), reducing the acquisition time to 3 min. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 26 cases; 5 patients underwent percutaneous transhepatic cholangiography PTC. MRCP and ERCP images were evaluated by an experienced radiologist and an endoscopist. MRCP of diagnostic quality was acquired in all patients. Choledocholithiasis was correctly evaluated by MRCP in 12 of 12 patients, compared with 11 correct diagnoses by ERCP. The presence and the level of the stricture were accurately shown in 16 of 16 patients with MRCP and in 13 of 16 patients with ERCP. The peripheral biliary tree above the obstruction and pancreatic duct were better evaluated by MRCP in all cases. In 3 of 3 patients who had undergone bilio-enteric surgery, a correct evaluation of the site of the anastomosis was possible with MRCP. It is concluded that MRCP performed at mid-field strength allows good visualisation of the dilated biliary system. Excellent results have been obtained on comparison with ERCP. MRCP performed at mid-field strength could have the same clinical value as high field strength MRCP.

Adult↗
PubMed1990

[Increased bile acid retention in biliodigestive Roux-Y anastomosis in animal experiment].

In an experimental study on 65 rats the influence of different Roux-Y biliary anastomoses on the enterohepatic bile acid circulation was investigated. Long (10 cm) and short (3 cm) isoperistaltic and long (10 cm) anisoperistaltic Roux-Y loops were studied and compared to sham-operated controls. 75-SeHCAT a y-labeled synthetic bile acid was used for assessment of enterohepatic circulation. Hepatic excretion and enteric bile flow was investigated by 99m-Tc-HIDA. Intestinal transit time was evaluated by 51-Cr-EDTA an inert marker of intestinal contents. Animals with biliary anastomoses showed an increased retention of the synthetic bile acid 75-SeHCAT compared to the controls. Highest retention values were found in animals with anisoperistaltic loops (t1/2 = 98.6 h). Isoperistaltic loops showed uniform values independently of the length of the Roux-limb (t1/2 = 59.8 h resp. 59.3 h). Differences to the controls (t1/2 = 42.6 h) were highly significant (p less than 0.001). In the 99m-Tc-HIDA hepatic excretion into the connected small bowel was normal in all groups. But in rats with biliary anastomoses a marked stasis of the 99m-Tc-HIDA in the Roux-Y loop was apparent. Bowel transit time tested by 51-Cr-EDTA showed comparable results in all groups without significant differences. The results demonstrate an increased bile acid retention in Roux-Y biliary anastomoses. An alteration of the enterohepatic circulation due to stasis in the Roux-Y limb seems to be the underlying mechanism.

Anastomosis, Roux-en-Y↗