Lithotomy of intrahepatic and choledochal stones with Yag laser

Eight patients with intrahepatic bile duct stones and three with choledochal stones were treated by Yag laser using a choledochofiberscope. A choledochoscope was inserted through a T-tube fistula in five patients or a percutaneous transhepatic cholangiodrainage fistula in six patients. In one patient, right partial lobectomy of the liver was performed after most of the stones were withdrawn, since some stones in the extremely narrow bile duct had not been removed. Most of the intrahepatic bile duct stones and choledochal stones will be withdrawn using the Yag laser and a choledochofiberscope, when they were bilirubin stones.     

Use of the pulsed dye laser and ultrasonic lithotriptor for removal of multiple intrahepatic gallstones

Two established urologic modalities used for removal of kidney stones were applied in a complementary manner for percutaneous transhepatic removal of multiple intrahepatic gallstones. A pulsed dye laser was used through a flexible nephroscope to fragment a large impacted stone. A stone basket was used to remove stone fragments and a few small entrapped stones. Subsequently, an ultrasonic lithotriptor carried by a rigid nephroscope was tried and found to be a much more efficient means of removing the remaining small stones.     

A reevaluation of 202 patients after surgical removal of intrahepatic stones: with special emphasis on intrahepatic biliary stricture

Intrahepatic stones are one of the most distressing problems of biliary diseases in the Orient. Surgical treatment, though greatly advanced over the last ten years, still poses a relatively high incidence of residual and recurrent stones. There were 258 patients treated by surgery for intrahepatic stones over a seven-year period at Yuan General Hospital in Taiwan. Among them, 202 patients (78.3%) were adequately followed up. The patients included 82 men and 120 women with a mean age of 40.5 years. There were 111 cases (55.0%) involving only the left side, 37 cases (18.3%) involving only the right side and 54 cases (26.7%) involving both hepatic biliary trees. Hepatic resection, either segmentectomy or lobectomy (37 cases, 18.3%) and extended choledocholithotomy with or without drainage procedures (165 cases, 81.7%) were the surgical procedures carried out in these patients. Treatment failure was defined by the existence of stones, residual or recurrent in the bile ducts. The failure rate of extended choledocholithotomy (32/165, 23.6%) was higher than that of hepatic resection (3/37, 8.1%) although the difference was not statistically significant (p = 0.06). The addition of various drainage procedures did not appear to affect the outcome of extended choledocholithotomy (p = 0.23). A significant number of patients had intrahepatic strictures in the biliary tracts. (62 cases, 30.7%). The overall treatment failure rate in patients with intrahepatic biliary stricture was significantly higher (28/62, 45.2%, p = 0.001) than those without stricture (14/100, 14%). However, hepatic resection was associated with a significantly lower failure rate than other treatment modalities (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Hepatic hemodynamics after chronic obstruction of the biliary tract in the dog

Hepatic blood flow was measured in 12 dogs before and two weeks after obstruction of the bile duct (BD) or sham operation, using the electromagnetic flowmeter technique. Eight dogs with obstructed BD revealed an 41 per cent decrease in total hepatic blood flow caused by an approximately equal percentage decrease in both hepatic arterial (HA) and portal venous (PV) flow, a decrease in arterial blood pressure, an increase in PV vascular resistance and little change in hepatic oxygen consumption. Four sham operated dogs showed minimal hemodynamic response. A dual mechanism for the hepatic hemodynamic consequences of chronic biliary obstruction is suggested: Decreased HA blood flow associated with diminished blood pressure and reduced PV blood flow resulting from raised intrahepatic PV vascular resistance.     

Obstructive mullerian anomalies and modern laparoscopic management

STUDY OBJECTIVE: Congenital uterine anomalies are common, although the majority are asymptomatic. When an obstructed system exists, women may present with abdominal pain, or dysmenorrhea. Removal of the obstructed horn may be required in the symptomatic patient. In the past, surgical treatment necessitated a laparotomy. DESIGN: After preoperative diagnosis and planning using magnetic resonance imaging, laparoscopic removal of the obstructed uterine horn and tube was performed. Morcellation of tissue was used to permit removal through a 15mm port. SETTING: A central London tertiary referral teaching hospital. PARTICIPANTS: 15 women aged between 13 and 41. INTERVENTIONS: Between 1999 and 2005, all women underwent laparoscopic removal of the obstructed uterine horn and tube. MAIN OUTCOME MEASURES: Recovery, hospital stay, length of operation. RESULTS: All women recovered well, with an operation time of 80 to 300 minutes and an average hospital stay of 5 days. CONCLUSIONS: A laparoscopic approach is a safe and appropriate technique for the removal of an obstructed uterine horn.     

Biliary tract disease in Thailand

One hundred and eighty-nine patients were documented as having biliary tract disease. Two hundred and nine lesions were found. The prevalence of malignant disease of the biliary tract was represented by 30.1 per cent, and cholangiocarcinoma was a leading cause. The carcinogenesis of cholangiocarcinoma has been speculated. Acute cholecystitis represented 55 per cent of biliary tract disease in Thailand, which consisted of acute calculous cholecystitis and acute noncalculous cholecystitis, 94.8 and 5.2 per cent, respectively. Among acute calculous cholecystitis, the prevalence of cholelithiasis, choledocholithiasis and intrahepatic stones were 58.5, 68.8 and 15.6 per cent, respectively. The high prevalence of choledocholithiasis and intrahepatic stones requires elucidation. In the remaining surgical disease of the biliary tract, opisthorchiatic cyst was the most common cause. The diagnosis of opisthorchiatic cyst was made roentgenologically in association with the identification of Opisthorchis ova in the aspirated bile. Opisthorchiatic cyst appears to be a unique clinical entity, differing from other types of intrahepatic cysts. Another form of presentation of biliary tract opisthorchiasis is through obstruction of the common bile duct by an aggregated mass of dead worms. This condition is cured by surgical removal of the worms. It is worth while to mention that, among 189 patients with biliary tract disease, there were three documented instances of choledochal cysts. This probably indicates a high prevalence of choledochal cysts when compared with that for the United States. In the present study, a 36 year old female with a diagnosis of Caroli's disease, ascariasis of the common bile duct and choledocholithiasis is presented.     

Hepaticocholecystojejunostomy as a simple technique for decompression of the biliary tract

A technique for decompressing the biliary tree obstructed by tumors in the upper part of the bile duct is described. It involves draining intrahepatic bile ducts through the gallbladder to a loop of the jejunum. The problem of bleeding is obviated by compression of the crushed liver by the balloon of a Foley catheter which also forms a temporary drain. Only two simple anastomoses are involved and complications are avoided if due attention is paid to the anatomy of the bed of the gallbladder.     

Laparoscopic cholecystectomy: the first 50 patients]

Laparoscopic cholecystectomy (LC) has rapidly gained wide acceptance in the United States. The applicability, safety and efficacy of this new procedure for the treatment of cholelithiasis in Taiwan, however, needs evaluation. We performed LC in 50 out of 98 cases of cholelithiasis at Cathay General Hospital from 28 December 1990 to 28 April 1991. We found that the applicability rate was 51%. The reasons for not selecting LC in the 48 open cases were: acute and gangrenous cholecystitis (13), common bile duct stones (11), concomitant intra-abdominal malignancy (5), intrahepatic stones (5), multiple upper abdominal incisions (4), pancreatitis or pancreatic abscesses (3) and other causes (7). In the LC group, there were 44 patients with symptomatic chronic calculus cholecystitis, 3 patients with acute calculus cholecystitis and 3 patients with gall bladder polyps. The age of the patients ranged from 27 to 79. There were 14 males and 36 females. All of the patients had a detailed preoperative workup including complete liver function test and sonographic examination of the hepatobiliary system. Additional pre-operative endoscopic retrograde cholangiopancreatographies were done in 3 and operative cholangiograms were done in another 3 to confirm the absence of common bile duct stones or to delineate anatomy. Although we encountered a few problems during the operations, such as severe adhesion, bleeding, difficult dissection, CO2 leakage, difficult insufflation, or large stones, all of the 50 patients completed the LC successfully without conversion to open cholecystectomy. The average operation time was 60 minutes, ranging from 30 to 135 minutes. Drain tubes were used in 7 cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Urolithiasis following formation of a continent urostomy: case report and review of the literature

BACKGROUND: Formation of urinary stones in a continent urostomy (Indiana pouch) has been described as a late complication. Management of a patient with symptomatic multiple large stones and review of the literature are outlined. CASE REPORT: A 32-year-old woman presented with recurrent urinary tract infections and pyelonephritis 6 years after a total pelvic exenteration and creation of a continent urostomy for central recurrent carcinoma of the cervix after radical pelvic radiation. Multiple large stones were found to be the underlying etiology. Laparotomy, enterocystotomy, and removal of stones were performed without apparent complication. CONCLUSION: It is recommended that for single calculi or multiple small stones, electroshock wave lithotripsy or the percutaneous endoscopic approach be considered. For larger stones the use of laparotomy and enterocystostomy may be appropriate.     

Unusual case of OHVIRA syndrome with a single uterus,unrecognized before labor and followed by an intrapartal rupture of obstructed hemivagina

Purpose

The acronym for obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) was created to describe patients with an obstructed hemivagina and ipsilateral renal anomaly and enables inclusion of other uterine anomalies except uterus didelphys. The main goal of this article is to present a rare case of OHVIRA syndrome with intrapartal rupture of obstructed hemivagina.

Methods

We present an unusual case of OHVIRA syndrome with single uterus, uterine septum (previously resected by hysteroscopy) and renal agenesis, unrecognized before labor and followed by an intrapartal rupture of obstructed hemivagina.

Results and conclusion

Various symptoms, included in OHVIRA acronym, are a result of different morphologic variants included in this syndrome. Most likely, in our case, the absence of communication between the cervical canal/patent vagina and the obstructed hemivagina prevented formation of mucocolpos or hematocolpos. This rare clinical variant made our MRI diagnosis of obstructed hemivagina, as well of the entire OHVIRA syndrome, ineffective. We did not find OHVIRA cases in the literature with a single septate uterus and single cervix, associated with obstructed hemivagina diagnosed during and after labor and presented with intrapartal rupture of hemivagina. Because of lack of guidelines, the final decision about management of the labor in such rare cases of OHVIRA syndrome is difficult.     

Preoperative bilirubin, alkaline phosphatase and amylase levels as predictors of common duct stones

The predictive value of the preoperative level of bilirubin, alkaline phosphatase and amylase as indicators of choledocholithiasis was determined by prospectively evaluating 304 consecutive patients undergoing cholecystectomy. Elevated levels of bilirubin and alkaline phosphatase are associated with an increased incidence of common duct stones, and the percentage incidence of stones increases with rising bilirubin and alkaline phosphatase levels. Alkaline phosphatase levels as great as 200 are associated with common duct stones in a low percentage of instances, being equivalent to that for unsuspected stones. Levels of 200 or greater are associated with a marked increase in the incidence of common duct stones. An elevated serum or urine amylase level, or both, is of little, if any, value as a predictor of common duct stones. Alkaline phosphatase appears to be a better indicator of common duct stones than does bilirubin, but neither bilirubin nor alkaline phosphatase in themselves are statistically significant indicators. Bilirubin and alkaline phosphatase in combination is a statistically significant predictor of common duct stones at all levels. The combination of a bilirubin level of greater than 3.0 and an alkaline phosphatase level of greater than 250 has a 76.2 per cent probability of an associated common duct stone. The quite important role of operative cholangiography in demonstrating unsuspected stones and in preventing unnecessary common duct explorations is reinforced.     

Clinical experience with endoscopic stents for treatment of common bile duct stones.

Endoscopic removal of common bile duct (CBD) stones after endoscopic sphincterotomy (EST) is now a widely accepted procedure. Surgery is usually recommended when extraction of stones after EST fails. For patients with major medical problems or who are at high surgical risk, however, endoscopic stent placement may help to prevent stone impaction and cholangitis. In this report, we describe the long-term effects and complications of biliary stent use in elderly patients with CBD stones. From August 1995 to June 1998, 19 patients with CBD stones underwent stent placement by duodenoscopy. Three of these patients underwent this procedure for temporary treatment while awaiting surgery or EST. In the remaining 16 patients (6 men and 10 women, mean age 76 +/- 10 years), invasive management carried a high risk of complications. We used a 7F straight stent for the first patient, while the remaining 15 received 7F pigtail stents. During a mean follow-up period of 34 months, two patients were lost to follow-up and two patients had migration of the stents. Three patients had acute cholangitis with stents in situ. Of these, one underwent stent exchange 8 months later, while the CBD stones were cleared either by endoscopy or surgery in the other two patients. Five patients died of nonbiliary diseases during the follow-up period. Our results show that long-term biliary stent placement is an advisable alternative therapeutic modality for high-risk and debilitated patients with CBD stones.     

Persistence of Endometriosis after Correction of an Obstructed Reproductive Tract Anomaly

BackgroundEndometriosis is commonly found in adolescents with an obstructed reproductive tract and has been reported to always regress after correction. This study highlights 5 patients who had persistent pain and a diagnosis of endometriosis following correction of their anomaly.CasesThe cases include patients with agenesis of the lower vagina or an obstructed hemivagina. All had recurrence of pain 6 months to 5 years after their corrective surgery. Laparoscopy revealed Stage I, II, and IV endometriosis.Summary and ConclusionsThis case series reveals that endometriosis does not always resolve following repair of an obstructive anomaly. This may result from prior/ongoing peritoneal seeding or other factors. Given possible disease progression and potential adverse effect on fertility, it important to consider laparoscopy and medical therapy if these patients have persistent pain.     

Long term results of Roux-en-Y hepaticojejunostomy

One hundred and twenty-three patients with benign diseases involving the bile ducts, curable by biliary bypass, underwent a Roux-en-Y hepaticojejunostomy, and the long term results of this operation were evaluated to ascertain if hepaticojejunostomy is a safe and durable procedure. There were no operative deaths. A peptic ulcer developed postoperatively in two patients. Only one instance of anastomotic stenosis was observed at follow-up study, averaging 5.5 years. Six of the 11 patients with postoperative biliary symptoms had intrahepatic lithiasis, a possible indication that the symptoms were due to temporary obstruction of the anastomosis by residual stones. A refined operative technique has improved the results which over-all are highly satisfactory.     

Les cholestases néonatales

Neonatal jaundice lasting more than two weeks needs urgent investigations, starting with examination of stool colour and blood tests with total and conjugated serum bilirubin. If neonatal cholestasis (NC) is confirmed, vitamin K should be immediately injected, and the child should be referred to a specialised centre for investigations and treatment. Biliary atresia (BA) is the first cause of NC. Its diagnosis is urgent, since the chance of success of the conservative surgical treatment (Kasai operation or variants) decreases rapidly as the age at surgery increases. Normal ultrasound scans cannot rule out BA. The diagnosis can often be suspected before surgery, and is confirmed by operative findings with or without cholangiogram. In case of failure to restore the biliary drainage, biliary cirrhosis progresses and leads to liver transplantation, generally in the first years of life. The other causes of neonatal obstructive jaundice are stones in the main bile duct, choledocal cyst and spontaneous perforation of bile ducts. Correction of biliary obstruction (by surgery or interventional radiology) is also urgent to prevent progression of liver fibrosis, which is very rapid in the first months of life. The most common medical aetiologies of NC are: Alagille syndrome, 1-antitrypsin deficiency, progressive familial intrahepatic cholestasis and cystic fibrosis. Other medical causes of NC are numerous, including infectious, hormonal, nutritional, metabolic or storage diseases. Some of the conditions may require a specific therapy.     

Cholestasis of pregnancy, pruritus and 5-hydroxytryptamine 3 receptor antagonists

Pruritus, an early symptom of intrahepatic cholestasis of pregnancy, may be severe. Conventional treatment includes ursodeoxycholic acid and cholestyramine. Ondansetron, a 5-hydroxytryptamine 3 receptor antagonist antiemetic, has been shown to reduce pruritus of different etiologies including cholestasis. We now report the successful preoperative use of ondansetron in a patient with pruritus from intrahepatic cholestasis of pregnancy. While the mechanism for our patient's response is poorly understood, 5-hydroxytryptamine 3 receptor antagonists should be further evaluated and possibly considered as a treatment option for intrahepatic cholestasis of pregnancy-related pruritus.     

Intraoperative sonography during cholecystectomy for gallstones.

The current study reports on the ease and results of intraoperative sonography in 131 patients operated upon for gallstones. Sonography was performed through a standard incision or a small incision, without duodenal mobilization and prior to systematic cholangiography. Sonography or cholangiography, or both, detected biliary duct stones in eight patients. The entire biliary tract was visualized by ultrasound in 123 patients. Sonography identified seven patients with stones in the major biliary ducts and overlooked only a single stone of the cystic duct. In contrast, intraoperative cholangiography failed to reveal stones in a right hepatic duct and led, in another instance, to unnecessary choledochotomy. During cholecystectomy for gallstones, sonography is a simple efficient technique providing good detection of biliary stones. It is the study of choice and cholangiography is required in only selected instances in which sonographic visualization is incomplete. There may be future value in sonographic applications for laparoscopic cholecystectomy.     

Patient rotation and resolution of unilateral cornual obstruction during hysterosalpingography

OBJECTIVE: Unilateral obstruction of the proximal fallopian tube is identified in 10-24% of patients undergoing hysterosalpingography for evaluation of infertility. Upon further testing, this obstruction spontaneously resolves 16-80% of the time. We hypothesized that patient rotation during hysterosalpingography might resolve proximal tubal obstruction in some cases by altering either the location of intrauterine air bubbles or the spatial relationship of the tube to the uterine fundus. METHODS: In patients in whom unilateral proximal tubal obstruction was detected during hysterosalpingography performed for standard clinical indications, the patient was rotated on her hip approximately 45 degrees such that the obstructed tube was first superior (ventral) to the patent tube, and dye was reinjected. If obstruction did not resolve, the patient was rotated in the opposite direction so that the obstructed tube was inferior (dorsal) to the patent tube and dye reinjected. RESULTS: Unilateral tubal obstruction was found in 15% of cases (24 of 156). Rotating the patient with obstructed tube superior to the patent tube never resulted in tubal patency, whereas rotating the patient with the obstructed tube inferior resulted in resolution of tubal patency in 63% of cases (15 of 24) CONCLUSION: .Unilateral cornual obstruction during hysterosalpingography is often resolved by rotating the patient such that the obstructed tube is more inferior. Although this observation may be the result of dislodging smaller air bubbles, from a fluid dynamics perspective a more likely explanation is unkinking of the more inferior tube.     

Selective contraindications based on multivariate analysis for operative cholangiography in biliary lithiasis

This study was done to select patients with a low risk of common bile duct (CBD) stones in whom operative cholangiography could be avoided. Operative cholangiography was performed upon 511 patients. Two different groups of patients were identified--patients with CBD stones visualized by CBD exploration (n = 90) and patients with no CBD stones at the time of operative cholangiography (n = 421). Multivariate analysis (stepwise logistic regression) showed that five variables were correlated with the presence of CBD stones--size of CBD equal to or greater than 12 millimeters, gallstones equal to or less than 10 millimeters, advanced age, chronic or acute cholecystitis and past history of biliary colic. Using a scoring system, a group of patients with a low risk (less than 2 percent) of CBD stones could be easily determined. In this group of patients, operative cholangiography may be avoided.     

Plasma lipid profiles of women with intrahepatic cholestasis of pregnancy

OBJECTIVE: Intrahepatic cholestasis of pregnancy is associated with dyslipidemia, but the gestational lipid profile in relation to clinical diagnosis of the disease is unknown. The aim of this study was to undertake a detailed analysis of plasma lipids in women presenting with intrahepatic cholestasis of pregnancy and pruritus gravidarum. METHODS: Plasma lipid concentrations were assessed in nonfasting blood samples from 63 women with intrahepatic cholestasis of pregnancy (n = 54, recruited at the time of diagnosis, and n = 9, who later developed the disease), 43 women with pruritus gravidarum, and 26 healthy pregnant controls during pregnancy and at 4-6 weeks postpartum. RESULTS: Intrahepatic cholestasis of pregnancy was associated with an abnormal lipid profile. Low-density lipoprotein (LDL) cholesterol, apolipoprotein B-100, and total cholesterol concentrations were significantly raised during pregnancy in women with intrahepatic cholestasis of pregnancy compared with pruritus gravidarum and controls, and LDL-cholesterol was raised before clinical diagnosis. High-density lipoprotein cholesterol was lower in women with intrahepatic cholestasis of pregnancy compared with the pruritus gravidarum group. Ursodeoxycholic acid did not alter plasma lipid concentrations. CONCLUSION: Intrahepatic cholestasis is associated with dyslipidemia, which may contribute to the pathogenesis of the disease. The elevation of LDL cholesterol and reduction of high-density lipoprotein cholesterol before clinical diagnosis may prove to be a useful biomarker for the early identification of intrahepatic cholestasis of pregnancy and differentiation from pruritus gravidarum. LEVEL OF EVIDENCE: II-2.