Acute cholecystitis occurring as a complication of percutaneous transhepatic drainage

Sepsis is a common occurrence during long term transhepatic biliary drainage. Most of these episodes are attributed to cholangitis, are relatively minor and can be managed nonoperatively. During a 42 month period, nine patients who had sepsis develop after biliary drainage were found to have acute cholecystitis, a complication not previously noted after this procedure. Seven of the nine patients had an underlying malignant lesion, and three of these patients had undergone percutaneous biliary drainage for palliation of unresectable or metastatic tumor. Eight of the nine patients underwent cholecystectomy whereas percutaneous cholecystostomy was used in one patient with an unresectable cholangiocarcinoma. Operative and pathologic evidence of acute cholecystitis was present in all, but only two patients had gallstones. Seven patients survived the surgical procedure and were discharged at an average of 11.7 days postoperatively. Based on this series, we propose that acute cholecystitis should be considered as a source of sepsis in patients undergoing biliary drainage who do not respond to antibiotics and catheter manipulations. Moreover, cholecystectomy should be performed at the time of laparotomy, if prolonged transhepatic drainage is planned for unresectable malignant conditions.     

A new endoprosthesis for nonoperative intubation of the biliary tract in malignant obstructive jaundice.

A method for palliative treatment of obstructive jaundice due to malignant growths consists of an indwelling tube, endoprosthesis, inserted percutaneously transhepatically under local anesthesia. A permanent bile drainage was established in 12 patients with inoperable obstructions of the bile duct, and in seven, a temporary drainage was used.     

One stage hepaticocholecystojejunostomy as an easy and long term effective bilioenteric bypass for unresectable carcinoma of the pancreas

A new anastomotic technique was used as an initial operation for jaundice due to an unresectable carcinoma of the pancreas. This bypass operation consisted of interposition of the gallbladder between the common hepatic duct and the jejunum by which bile drainage was excellently facilitated.     

Surgical treatment for ductal adenocarcinoma of the pancreas

A ten year community hospital experience of 124 patients with ductal adenocarcinoma of the pancreas proved at biopsy is reported. All patients underwent a celiotomy, and 94 per cent were observed until death. All of the patients were stratified by stage (I, 9 per cent; II, 30 per cent; III, 18 per cent, and IV, 43 per cent). Nine of the patients with Stage I disease underwent resection with a high postoperative mortality rate of 44 per cent and only one five year survivor. Fifty-nine patients with Stages II and III disease underwent biliary bypass with a low postoperative mortality rate of 2 per cent. Bypass of the common bile duct (N = 24) provided more permanent palliation against recurrent jaundice or cholangitis (p less than 0.05), but did not improve the survival time when compared with bypass of the gallbladder (N = 20). This was not true for those with Stage IV disease in whom recurrent jaundice did not develop in those with either bypass of the gallbladder or common duct. Adding prophylactic gastroenterostomy (GE) to biliary bypass (N = 25) conferred no survival benefit, but did protect against subsequent duodenal obstruction (p less than 0.05). Thirty-seven per cent of the 38 patients in whom a GE was not performed had duodenal obstruction develop. Adjuvant radiation and chemotherapy in 22 patients with unresectable Stages II and III disease resulted in a significant prolongation of survival time compared with 15 untreated patients in the control group (p less than 0.05). Fifty-one patients with Stage IV disease underwent biliary bypass or biopsy of the tumor resulting in a 14 per cent postoperative mortality rate and a median survival time of four months. Nine per cent of the 44 survivors with Stage IV disease lived at least one year. The implications of these findings to clinical practice are discussed.     

Avoidance of transhepatic drainage prior to hepaticojejunostomy for obstruction of the biliary tract

We retrospectively reviewed the course of 14 consecutive patients with symptomatic hepatic duct bifurcation obstruction of the biliary tract because of unresectable non-Klatskin malignant disease to clarify issues of diagnostic and therapeutic strategy. All patients were symptomatic with pruritis and were expected to survive three months or more. Ten patients underwent percutaneous transhepatic cholangiography preoperatively. In no instance did the study influence operative decision making, and complications included septic shock in two patients. Decompression of the biliary tract in one patient made the duct technically inadequate for internal drainage. The remaining 13 patients underwent surgical drainage of the biliary tree. Ten had peripheral hepaticojejunostomies, which offers the best palliation of symptomatic obstruction of the biliary tract due to unresectable malignant disease at the hepatic duct bifurcation. Percutaneous transhepatic cholangiographic drainage should not be used for diagnostic studies prior to hepaticojejunostomy for malignant obstruction as it interferes with surgical drainage.     

Endoscopic sphincterotomy and endoscopic fulguration in the management of adenoma of the papilla of Vater

Adenoma of the papilla of Vater is a rare premalignant lesion usually treated by local surgical resection. Five patients with adenomas of the papilla, presenting with obstructive jaundice, underwent endoscopic sphincterotomy with reversal of hepatic biochemistry to normal. Thereafter, four patients underwent local surgical excision. The adenoma recurred in all four patients within six to 18 months after the operation. The recurrent adenomas were eradicated by diathermic fulguration through the endoscope and were not found during a 12 to 24 month follow-up period. Snare polypectomy was performed upon one patient (who refused surgical treatment) who had a flat, broad-based adenoma, with an incomplete resection of the adenoma. This patient had adenocarcinoma of the head of the pancreas develop 40 months later. We conclude that endoscopic sphincterotomy is effective for biliary decompression of adenoma of the papilla of Vater presenting with acute obstructive jaundice. Endoscopic snare polypectomy of the adenoma combined with fulguration may be used as an alternative to surgical treatment in high risk patients.     

Hepatic abscess after biliary tract procedures

Seven patients with hepatic abscess that developed after prior operation upon the biliary tract were treated during a two year period. In contrast with the fulminant clinical presentation of hepatic abscess usually associated with acute obstructive suppurative cholangitis, the presentation of hepatic abscess after prior biliary tract procedures was surprisingly indolent; several patients had been treated with oral antibiotics for several weeks or months with the presumptive diagnosis of nonsuppurative cholangitis. Thorough investigation of the entire biliary tree was necessary to identify associated biliary disease, which included biliary-enteric anastomotic stricture, intrahepatic stricture, excluded sectoral bile duct from iatrogenic injury and reflux of abnormally contaminated intestinal contents. Extensive reconstructions of the biliary tract were performed upon three patients. Recurrence of the abscess occurred once after percutaneous and once after surgical drainage and was managed by drainage of the associated excluded sectoral bile duct or fistulojejunostomy. Operative drainage of hepatic abscess after prior biliary operation may be preferable to percutaneous techniques to provide definitive surgical management of associated pathologic findings of the biliary tract.     

Carcinoma of the head of the pancreas.

Optimal treatment for unresectable carcinoma of the pancreas remains controversial. This study was done to examine the relationship between perioperative jaundice and postoperative morbidity, and type of palliative biliary bypass and postoperative morbidity and jaundice clearance. Seventy-six patients with obstructive jaundice secondary to carcinoma of the head of the pancreas were studied. Forty-nine patients underwent one of four different types of palliative bypass: 1, cholecystojejunostomy (n = 22); 2, choledochojejunostomy (n = 11); 3, choledochoduodenostomy (n = 9), and 4, cholecystoduodenostomy (n = 7). Age, sex and preoperative health status were similar for all operative groups, as well as for those with and without postoperative morbidity. The postoperative complication rate was 33 per cent and there was one postoperative death. Length of preoperative jaundice and peak preoperative bilirubin levels were independent of morbidity. Postoperative morbidity was similar for each type of bypass used and no significant difference was found when cholecystoenteric (1 and 4) and choledochoenteric (2 and 3) bypass were compared. The results of this study support the view that postoperative morbidity is not directly related to the presence of jaundice preoperatively. Furthermore, the rate of jaundice clearance and the occurrence of postoperative complications are not dependent on the type of bypass used.     

Diagnostic and therapeutic approaches to pyogenic abscess of the liver

A review was conducted of 33 patients with pyogenic hepatic abscesses seen during the past seven years to evaluate the effect of roentgenologic refinements on diagnosis and therapy. Cause, bacterial infection and clinical manifestations were determined. An ultrasonogram was positive in 27 of 29 patients; computed tomographic scan was diagnostic in 20 of 23 patients, and radionuclide studies were positive in eight of 13 patients. Abscesses were confined to the right lobe in 19 patients, to the left lobe in six and were diffuse in eight. In the group of patients with abscesses developing from a biliary route, one patient was successfully managed by roentgenologically controlled drainage while three others required subsequent surgical drainage. Five of seven patients in the biliary route category who were treated with primary surgical drainage were permanently cured. Twelve patients had an abscess emanating from the portal route. In five of these, drainage under roentgenologic control was successful. Two patients upon whom the procedure failed subsequently underwent drainage at operation. Five had primary surgical drainage, and two of these died. All nine patients with post-traumatic, cryptogenic abscesses or an abscess evolving from an arterial route were successfully drained surgically. Three patients with multiple or diffuse abscesses were successfully treated by primary hepatic resection. Refined roentgenologic techniques established the diagnosis of pyogenic abscess in almost all instances. Roentgenologically controlled drainage may be therapeutic in some patients, but surgical drainage remains the standard. Resection has been used as primary treatment in selected patients.     

Palliative surgical treatment of sixty-eight patients with carcinoma of the head of the pancreas

A retrospective study is presented of 68 patients who underwent biliary enteric bypass procedures for carcinoma of the head of the pancreas between the years of 1960 through 1975. Forty patients underwent some form of biliary enteric bypass only. Twenty-six patients were treated with concomitant gastrojejunostomy, and only two patients in this group underwent vagotomy. Two patients underwent gastrojejunostomy for obstruction at the gastric outlet without jaundice. Five operative deaths occurred among the 40 patients who underwent solely some form of biliary enteric bypass procedure, and three deaths occurred among the 26 patients who underwent concomitant gastrojejunostomy. The over-all operative mortality for biliary enteric bypass procedures was eight deaths among 68 patients. Obstruction of the duodenum developed in seven patients after undergoing a biliary enteric bypass operation. The mean postoperative interval for the development of complications was 5.57 months. All but one patient underwent a second operation, with no operative deaths. Among the 26 patients treated with concomitant gastrojejunostomy, obstruction developed in two patients because of anastomotic failure; there was massive upper gastrointestinal tract bleeding from a marginal ulcer in four patients, and one patient had a perforated marginal ulcer. The mean survival time after biliary enteric bypass was 6.69 months and after combined biliary enteric bypass and gastrojejunostomy, 9.90 months. The over-all mean survival time was 8.00 months.     

Percutaneous biliary drainage as an initial therapy in sepsis of the biliary tract

Percutaneous biliary drainage offers a rapid, low-risk, effective method of decompressing the biliary tract in the patient with cholangitis and sepsis. A definite surgical procedure can be delayed until the patient is stabilized. The procedure provides anatomic detail that can be used to plan surgical treatment. In some patients who do not have surgically correctable lesions, operation can be avoided altogether.     

Different response to preliminary biliary drainage in proximal versus distal malignant biliary obstruction

This study assessed prospectively the results of endoscopic biliary drainage preoperatively in 40 patients with extrahepatic malignant biliary obstruction. The patients were divided into two groups depending upon the location of the obstruction. Those in group 1, n = 20, were patients with proximal malignant obstruction and those in group 2, n = 20, had distal malignant biliary obstruction. Preliminary endoscopic biliary drainage succeeded in lowering the biliary pressure and the incidence of bacteremia in patients in group 2. In contrast, for those in group 1, it failed to reduce the intrabiliary pressure and, thus, in the presence of bile infection led to an increased incidence of bacteremia. From the results of the present study, preliminary endoscopic biliary drainage is recommended for patients with distal malignant biliary obstruction. For those with proximal malignant biliary obstruction, surgical drainage appears to be the method of choice.     

Progress in reconstruction after resection of the head of the pancreas

Fistulas of the pancreas due to dehiscence of pancreaticojejunostomy after partial pancreaticoduodenectomy caused severe postoperative complications. Whereas various methods with and without anastomosis of the pancreas are recommended to deal with the pancreatic stump, mortality rates of 20 to 75 per cent have been reported. These different results prompted us to start a prospective, nonrandomized study in which three methods of reconstructing the remnant of the pancreas involving anastomosis were compared with pancreaticocutaneous drainage without anastomosis. One hundred and thirty-one patients with partial pancreaticoduodenectomy entered this trial, 54 female and 77 male patients with an average age of 55.9 years. The indications included: 42 instances of chronic pancreatitis, 44 instances of carcinoma of the pancreas and 45, periampullary carcinoma. We performed 33 end to side pancreaticojejunostomy procedures (four fistulas of the pancreas, a mortality rate of 15.0 per cent), 31 end to end anastomoses (three fistulas of the pancreas, a mortality rate of 6.5 per cent) and 48 double loops with anastomoses of the pancreatic and hepatic duct to separate jejunal loops (nine fistulas of the pancreas, a mortality rate of 2 per cent). Nineteen patients were operated upon using external drainage of the pancreatic stump by means of Penrose drains (five fistulas of the pancreas, a mortality rate of zero per cent). To reduce the fatal risks caused by combined fistulas of the pancreas and biliary tract, the use of separate intestinal loops for anastomoses of the pancreas and biliary tract offers the best solution, since no fatal complications of the pancreaticojejunostomy were observed. In contrast, pancreaticocutaneous drainage was performed upon patients with endangered pancreatic anastomoses due to local morphologic conditions, such as tender pancreatic parenchyma or thin pancreatic ducts. The total loss of exocrine function and the high morbidity rate of 37 per cent is justified in spite of the mortality rate of zero per cent. Total pancreaticoduodenectomy, for technical reasons, represents no acceptable alternative in view of higher mortality rates.     

Stricture of the common bile duct from chronic pancreatitis

Early diagnosis and treatment of stricture of the common bile duct from chronic pancreatitis are essential as the life-threatening complications of biliary cirrhosis and acute cholangitis can occur even in the absence of clinical jaundice. In a series of 40 patients with longstanding chronic pancreatitis and stricture of the common bile duct, findings included chronic pain in 26 patients, jaundice in 17 patients, secondary biliary cirrhosis in six patients and acute cholangitis in six patients. Persistent elevation of the alkaline phosphatase level was the most sensitive laboratory indicator of occult obstruction of the biliary tract. The diagnostic long tapered stenosis of the distal common bile duct was delineated by percutaneous transhepatic cholangiography in 21 of 22 patients and endoscopic retrograde cholangiopancreatography in eight of 11 patients. Operative decompression of the biliary tract included 32 biliary-enteric bypasses, three sphincteroplasty procedures and three emergency tube drainages. There was one postoperative death and seven other patients had postoperative complications. Sphincteroplasty failed to relieve the obstruction in two patients and two patients with biliary-enteric bypass had late anastomotic strictures develop which required reoperation. Only seven patients were free of pain at follow-up study which ranged from 0.5 to 15.0 years. Clinical suspicion based upon persistent hyperaklalinphosphatemia, diagnosis by cholangiography and decompression of the biliary tract by choledochoenterostomy can reliably avert the lethal complications of stricture of the common bile duct caused by chronic pancreatitis.     

Cystic neoplasms of the pancreas

Eight patients with cystic neoplasms of the pancreas were seen at four Northern California hospitals between the years 1978 and 1986. Three of the tumors were benign and five were malignant. Three females, whose average age was 61 years, had cystadenomas. Three females and two males, whose average age was 48 years, had mucinous cystadenocarcinomas. Clinical presentations were similar among all patients. Abdominal pain was a prominent feature. Anorexia, weight loss, nausea and vomiting with a palpable abdominal mass were seen in five of eight patients. Obstructive jaundice was seen in two of eight patients. Among patients with benign lesions, one lesion was in the head and two lesions were in the tail of the pancreas. The malignant lesions were in the head of the pancreas in three patients and in the tail or body in two. A presumptive diagnosis was made preoperatively on the basis of the clinical, laboratory and roentgenographic findings in seven of eight patients. Of the patients with benign tumors, two are alive and well at seven years and four months and one patient was lost to follow-up study at four years. Among the patients with a malignant condition who underwent operation, resection for cure was performed upon four patients. One patient died postoperatively and the other three patients are alive and well without evidence of a recurrence at three and one-half, four and four years after resection. Pancreaticoduodenectomy was performed upon two patients and distal pancreatectomy in another. Palliation was attempted in one critically ill patient with an unresectable tumor by longitudinal pancreaticojejunostomy. This procedure was not effective in providing pain relief because of obstruction of the pancreatic duct by the viscous mucoid secretion of the tumor. The preoperative diagnosis of these very rare tumors is usually possible roentgenographically, especially with the use of the computed tomography scan. The presence of a thick mucoid secretion of high viscosity is diagnostic of mucinous cystadenocarcinoma. Cystic neoplasms of the pancreas should always be resected, if possible, with the expectation of long term survival.     

A two year experience with 99mTC HIDA cholescintigraphy in teaching hospital practice

One hundred and thirty-four sequential patients who underwent 99mTC HIDA cholescintigraphy have been studied. Patients were investigated for suspected acute cholecystitis, chronic cholelithiasis, enterogastric reflux or jaundice, and in the assessment of biliary tract drainage after transplantation of the liver and other operations of the biliary tract. The technique is most valuable in the diagnosis of acute cholecystitis when its accuracy rate is 96 per cent; it is also useful in the assessment of postoperative biliary drainage. It is least helpful in the investigation of jaundice and suspected chronic cholelithiasis.     

Current management of hilar cholangiocarcinoma.

The goal in the treatment of hilar cholangiocarcinoma is the relief of biliary obstruction with the quality survival. The choice of therapy for an individual patient requires complete preoperative staging to determine the resectability. This is best accomplished in a multidisciplinary setting with radiologists, gastroenterologists and surgeons participating in the diagnostic and therapeutic strategies. Operative removal of the tumor can be performed with low mortality and, when possible, provides the longest palliation and offers potential for cure. For tumors found at operation to be unresectable, biliary enteric bypass provides a durable method of palliation. The relative merits of the newer methods of radiologic stenting are encouraging, but further study will require prospective trials in comparison to operative biliary enteric bypass.     

The management of fistulas of the biliary tract after injury to the bile duct during cholecystectomy

Twelve of 123 patients who were treated for benign stricture of the bile duct after cholecystectomy presented with an external fistula of the biliary tract. Nine of these patients had undergone multiple operations prior to referral, six having undergone earlier attempts at repair of the bile duct. Two patients initially required urgent laparotomy for drainage of infected abdominal collections. Distal obstruction of the bile duct below the origin of the fistula was present in five patients. Repair of the bile duct was undertaken after careful investigation and correction of nutritional, fluid and electrolyte status in five patients who had little prospect of spontaneous closure of the fistula. The other seven patients were initially treated conservatively; in three, the fistula closed at five to nine weeks without complication, and no further surgical treatment has been required (a range of six to 36 months). The remaining four patients required delayed operation after the development of cholangitis or jaundice. The overall median survival time between development of fistula and operative repair was 3.5 months, and all nine of these patients remained asymptomatic with normal results from liver function tests (a median follow-up period of 17 months). The need for careful initial assessment prior to repair of the bile duct and the possibility of conservative treatment for patients with a postcholecystectomy fistula of the biliary tract are emphasized.     

A comparison of cefotaxime versus cefamandole in prophylaxis for surgical treatment of the biliary tract

Fiscal considerations prompted comparison of cefotaxime (a third generation cephalosporin) with cefamandole (a second generation cephalosporin) for prophylaxis in the surgical treatment of the biliary tract. One hundred and eight patients who underwent an operation upon the biliary tract received three 1 gram doses of cefotaxime (54 patients) or cefamandole (54 patients) at induction of anesthesia and then one and three hours later. The study was prospective, blinded and randomized. The groups (cefotaxime versus cefamandole) were statistically comparable for age, sex, diagnosis, type and duration of operation and positive cultures. The most prevalent bacteria isolated from qualitative aerobic and anaerobic cultures of bile and the wall of the gallbladder were Escherichia coli, Streptococcus and Klebsiella. The incidence of bactibilia in patients with one of these conditions was: 75 per cent for cancer; 69 per cent for patients more than 60 years old; 33 per cent for jaundice; 58 per cent for pancreatitis; 60 per cent for exploration of the common bile duct, and 22 per cent for acute cholecystitis. Microbiologic agar diffusion assays of tissue from the wall of the gallbladder, subcutaneous fat and rectus muscle and samples of bile and serum obtained 30 minutes after the second dose of antibiotic showed a statistically significant greater concentration of cefamandole in the wall of the gallbladder. Otherwise there was no difference between the concentration of cefamandole and cefotaxime. The groups showed no statistical difference for temperature of more than or equal to 38 degrees C. on two consecutive measurements, postoperative wound and urinary infections, postoperative hospital stay and days in the intensive care unit and incidence of readmission within a month. Prophylactic use of cefotaxime in a three dose regimen provided no advantage in prophylaxis compared with cefamandole.     

The surgical treatment of choledochal cyst.

Eleven consecutive infants and children with choledochal cyst were evaluated for operative resection of the cyst as the primary surgical therapy. Total excision and biliary reconstruction by choledochojejunostomy was successfully performed in nine patients. Simple intestinal drainage of the cyst was used in two instances because of severe liver disease. Four patients had coexisting biliary malformations. In all five infants, biopsy of the liver was consistent with biliary atresia. In addition, the extrahepatic bile ducts proximal to the cyst were obliterated in two infants. The findings suggest that pathogenesis of choledochal cyst may be different in infants than in older children. The indications for excision of the cyst in four patients were due to complications from earlier internal drainage procedures. In most patients, including all those having had a cystoenterostomy earlier, resection was done from the inside of the cyst, thus minimizing the danger of injury to the neighboring vascular structures. There were no operative deaths, and morbidity was minor. The traditional operation for a choledochal cyst has been internal drainage of the cyst into the intestine. Because of the high incidence of late complications and the frequent association of major co-existing biliary malformations, the procedure should be reserved for highly specific indications. Total surgical excision is the procedure of choice for a choledochal cyst.