Early bile duct carcinoma.

The clinocopathologic features of seven patients with early bile duct carcinoma are reported. Early bile duct carcinoma has been defined as bile duct carcinoma limited to the bile duct wall. The seven patients included six men and one woman ranging in age from 44 to 77 years. Six patients complained of jaundice and the other presented with right hypochondralgia. Ultrasonography showed a dilated proximal bile duct in the seven with a polypoid mass in three. Computerized tomography showed a dilated biliary tree in the seven together with a polypoid mass in two. Direct visualization of the bile duct with endoscopic retrograde cholangiography and/or percutaneous transhepatic cholangiography showed a polypoid tumour of the bile duct and a dilated proximal biliary tree in all seven. Each of the seven polypoid tumours were well differentiated papillary or tubular adenocarcinoma restricted to the bile duct wall with minimal stromal invasion. There was neither any lymph node metastasis nor perineural invasion. Five of the seven patients were doing well at 24-112 months after a complete resection. One patient died from multiple liver metastases 21 months after intervention. The other patient died from other diseases 138 months after operation. These seven cases can be classified as early bile duct carcinoma due to both the limited invasion and favourable prognosis. The clinical features of the seven patients were quite similar to those of usual bile duct carcinoma. However there are still no proper diagnostic clues for early bile duct carcinoma and these patients represent fortunate cases that clinicians happened to discover by chance.     

Percutaneous transhepatic bile drainage.

Percutaneous transhepatic bile drainage was performed in 13 patients with obstructive jaundice, using a combination of the PTC technique and a Seldinger angiography catheter. In 11 cases, the outflow of bile through the catheter was satisfactory and complications were few. Since the risk of the procedure is low and it can be done without laparotomy, it is an ideal technic for biliary decompression before attempting to do a resection. Also, repeated cholangiography through a catheter which is left in place is helpful as a diagnostic aid before and after surgery.     

Cholecystectomy without operative cholangiography. Implications for common bile duct injury and retained common bile duct stones.

OBJECTIVE: This study evaluated the selective use of endoscopic retrograde cholangiopancreatography (ERCP) in the context of laparoscopic cholecystectomy (LC) while minimizing the use of operative cholangiography. SUMMARY BACKGROUND DATA: There has been a long-standing debate between routine and selective operative cholangiography that has resurfaced with LC. METHODS: Prospective data were collected on the first 1300 patients undergoing LC at McGill University. Preoperative indications for ERCP were recorded, radiologic findings were standardized, and technical points for a safe LC were emphasized. RESULTS: A total of 106 patients underwent 127 preoperative ERCPs. Fifty patients were found to have choledocholithiasis (3.8%), and clearance of the common bile duct (CBD) with endoscopic sphincterotomy was achieved in 45 patients. The other five patients underwent open cholecystectomy with common duct exploration. Intraoperative cholangiography (IOC) was attempted in only 54 patients (4.2%), 6 of whom demonstrated choledocholithiasis. Forty-nine postoperative ERCPs were performed in 33 patients and stones were detected in 17 (1.3%), with a median follow-up time of 22 months. Endoscopic duct clearance was successful in all of these. The incidence of CBD injury was 0.38%, and a policy of routine operative cholangiography might only have led to earlier recognition of duct injury in one case. The rate of complication for all ERCPs was 9% and the associated median duration of the hospital stay was 4 days. The median duration of the hospital stay after open CBD exploration was 13 days. CONCLUSIONS: LC can be performed safely without routine IOC. The selective use of preoperative and postoperative ERCP will clear the CBD of stones in 92.5% of patients.     

External radiotherapy and extrahepatic bile duct cancer.

The hospital records of patients with extrahepatic bile duct cancer who where treated surgically between 1968 and 1983 were reviewed. Of 55 patients, 16 (29%) received radiotherapy after surgery. The total dose given ranged from 40 to 60 Gy. Median follow-up time for analysis was 4.0 months and lasted until January 1988. The overall median survival was 4 months (range 0-36), that of the irradiated patients was 16 months (range 2-36), and that of the 39 patients who were not irradiated was 3 months (range 0-32). When the 13 post operative deaths were excluded the median survival was 4 months. Radiotherapy did not cause any severe complications. No firm conclusion about the role of radiotherapy can be drawn from these data because the patients were not randomly chosen to receive radiotherapy and selection was therefore biased. We conclude that most patients with extrahepatic bile duct cancer still die of locoregional disease. Effective adjuvant treatments are needed and should be evaluated in prospective randomized trials.     

Some observations on gallstones and bile composition.

A series of 31 consecutive patients undergoing surgery for gallstone disease has been studied and the composition of the gallstones and bile from the gallbladder and common duct determined. As a result of the stone analysis by the X-ray powder diffraction method, the patients were classified according to whether their stones consisted of cholesterol, calcium salts or a mixture of the two. The mean composition of the common duct bile for the groups with cholesterol and mixed stones was just outside the micellar region of cholesterol solubility. The gallbladder bile from the cholesterol group of stone-formers was also supersaturated, but the gallblader bile from the group of mixed stone-formers was undersaturated with respect to cholesterol. None of the patients forming gallstones of calcium salts showed any abnormality in the cholesterol content of their bile.     

Reoxygenation injury following anoxic perfusion preferentially impairs bile acid-independent bile flow.

We perfused isolated rat livers with Krebs-Ringer buffer, with no recirculation. Bile flow virtually stopped during 30 min of anoxia and resumed following reoxygenation to reach a plateau of 44% of the control level. When taurodehydrocholic acid (TDHC, 50 nmol/min/g liver) was administered during reoxygenation, bile flow increased three-fold (16.1 +/- 1.3 to 45.3 +/- 6.3 microliters/g liver). The increase in bile output with TDHC was 27.8 microliters/g liver, which was 89% of the control output. Bile acid output during this period was 1.4 mumol/g liver, which was 93% of the control level. Addition of allopurinol (50 nmol/min/g liver) without TDHC increased bile flow significantly (16.1 +/- 1.3 to 21.3 +/- 1.2 microliters/g liver), but the change was not significant when allopurinol and TDHC were given. The addition of allopurinol also reduced the cumulative release of lactate dehydrogenase from the liver during the reoxygenation period, but had no effect on hepatic adenosine triphosphate levels. Our data suggest that the bile acid-independent bile flow is sensitive to reoxygenation injury following anoxia whereas bile acid output and bile acid-dependent bile flow are resistant.     

Spontaneous and postoperative bile peritonitis. Surgical technique

BACKGROUND: Bile peritonitis has a diversified aetiology that can present in clinical pictures of variable gravity depending on whether the bile is uncontaminated or activated by other secretions (intestinal, pancreatic) or actually infected. The consequent treatment is therefore eclectic. In our opinion, however, the therapeutic strategy proves effective if modulated on the basis of certain priority elements that should be carefully considered. The type of treatment adopted in relation to immediate and long-term results has been evaluated. METHODS: The investigation was carried out retrospectively on the series of bile peritonitis treated at the Surgical Clinic of the University of Modena from 1980 to 1998. 45 cases of bile peritonitis are reported of which: 32 postoperative, 2 post-traumatic, 2 following transparietohepatic injection, 7 during acute necrotic cholecystitis, 2 following spontaneous perforation of the biliary tree. As regards the type of treatment, in 13 cases (well-drained postoperative forms) a conservative solution was adopted; in another 13 cases (9 septic and 4 with mixed bile supply) surgery was resorted to again, in the remainder transparietohepatic drainage was carried out in association almost always with the application of a transpapillary endoprosthesis. RESULTS: Morbility was 26.6% (12 cases); 4 patients (8.8%) were reoperated for late complications with mortality of 50%. Total mortality was 20% (9 patients). CONCLUSIONS: Treatment of bile peritonitis may be eclectic but the complex forms benefit from early surgical or parasurgical treatment for a definitive resolution of this feared complication.     

Diagnosis and management of bile duct strictures.

In the majority of patients, strictures of the common bile duct result from an injury to the duct. The earlier the injury is repaired or the more quickly the diagnosis of stricture is made and repaired, with antibiotics to prevent infection, the better are the results of the repair. Five types of repair have been utilized: (1) choledochoduodenostomy, (2) duct-to-duct repair, (3) choledochojejunostomy, (4) plastic revision of the stricture, or (5) dilatation of a previous stricture when multiple, previous operative procedures or the difficulty of operative exposure proves too great for adequate repair. Our overall results after repair of biliary stricture are good or excellent in 84 per cent of patients. We have had the best results in patients in whom choledochoduodenostomy was performed.     

Retained common bile duct calculi.

A method of elimination of gallstones remaining in the common bile duct after exploration of the duct is described. The retained stone is flushed through the common duct sphincter into the duodenum using rapid infusion of normal saline via a T tube. The method is quick and simple and is recommended as the first step to take in the management of this discomforting group of patients. The method is not without potential morbidity and should only be carried out under carefully controlled conditions.     

Laparoscopic common bile duct exploration.

Operative common bile duct exploration, performed in conjunction with cholecystectomy, has been considered the treatment of choice for choledocholithiasis in the presence of an intact gallbladder. With the advent of laparoscopic cholecystectomy, the management of common bile duct stones has been affected. More emphasis is being placed on endoscopic sphincterotomy and options other than operative common duct exploration. Because of this increasing demand, we have developed a new technique for laparoscopic common bile duct exploration performed in the same operative setting as laparoscopic cholecystectomy. A series of five patients who successfully underwent common bile duct exploration, flexible choledochoscopy with stone extraction, and T-tube drainage, all using laparoscopic technique, is reported. Mean postoperative length of hospital stay was 4.6 days. Outpatient T-tube cholangiography was performed in all cases and revealed normal ductal anatomy with no retained stones. Follow-up ranged from 6 weeks to 4 months, and all patients were asymptomatic and had normal liver function tests.     

The effect of bile duct ligation and bile diversion on FK506 pharmacokinetics in dogs.

Mongrel or beagle dogs were submitted to bile duct ligation, or to extraenteric biliary diversion by means of choledochoureterostomy. The kinetics of intravenously administered FK506 was not changed from control status two weeks after bile duct ligation, but the bioavailability of orally administered FK506 was nearly quadrupled. Following oral administration, the absorption of FK506 was highly variable. The results indicate that in dogs FK506 is absorbed from the intestine just as efficiently in the absence of enteric bile and in presence of exogenous bile salt supplement when compared with its absorption in presence of normal bile drainage. These findings with FK506 are different from those with cyclosporine after biliary obstruction or diversion and will have important practical as well as experimental ramifications.     

Operative ultrasonic bile duct scanning.

The concept of operative echography is introduced. A technique of operative ultrasonic bile duct visualization is presented as an alternative to contrast cholangiography during surgery. The technique is rapid, sensitive, provides immediate results, and does not involve the use of ionizing radiation.     

The effect of bile acid synthesis on cholesterol secretion into the bile.

Cholesterol secretion into the bile has been shown to be related to the bile acid secretion rate. It has been suggested that the availability of bile acid micelles controls the entry of cholesterol into the bile. However, previous data could have been interpreted to indicate that bile acid synthesis controls cholesterol secretion into the bile. To discover whether bile acid synthesis has a significant influence on cholesterol secretion, Rhesus monkeys were studied during the period of increasing bile acid secretion and bile acid synthesis, which begins 6-10 hours following interruption of the enterohepatic circulation of bile acids. This is the only condition in which bile acid synthesis and bile acid secretion increase simultaneously. The cholesterol secretion rate fell signficantly during this period, and this effect was enhanced by phenobarbital administration. An increasing cholesterol secretion rate would have been expected if micellar attraction controlled cholesterol secretion under these conditions. Bile acid synthesis appears to have an important influence upon cholesterol secretion into the bile.     

Secretin-induced bile secretion, bile acid output and blood supply to the liver in the dog.

Bile secretion and blood flow in the portal vein and the hepatic artery were determined in cholecystectomized anesthetized dogs before and during continuous infusion of varying doses of secretin. Secretin increases bile volume without alteration of bile acid output. Hepatic arterial flow was not altered by any dose. However, high doses of secretin increased portal venous blood flow significantly. It is concluded that secretin action on liver blood flow mirrors mainly superior mesenteric arterial vasodilation and seems to be a rather pharmacologic than a physiologic response. Bile secretion is not influenced by changes of hepatic blood flow in the physiologic range.