Carcinoma of the distal choledochus: its differential diagnosis and surgical treatment. Our experience

Carcinomas of the biliary tree present very difficult problems in diagnosis and treatment. Low common bile duct tumors, excluding papillary tumors, are rare but not easily detectable preoperatively and correctly treated. Authors report their clinical experience on the argument.     

Our experience with the treatment of cavitary and external biliary fistulas following surgical operations for hepatic echinococcosis]

Successful treatment of five personal cases of external cavitary and biliary fistulae following radical liver hydatid surgery is reported. Stress is laid on the fact that complications may still occur, even when the latest techniques are employed. These can be avoided if the pathological anatomy and biliary physiopathology associated with the disease are fully understood, so that techniques can be adjusted to the different situations revealed by pre- and intraoperative exploration. Medical or surgical management must be preceded by precise knowledge of the reasons for persistence of the fistula.     

Our experience with recurrent biliary calculosis after cholecystectomy

Recurrent calculi of the main bile way may be recurrent or residual. Recurrent stones are yellow-brown, crumbly and earthy and contain high quantities of calcium palmitate; residual stones, on the other hand, are firmer, round or berry-like, usually faceted and contain cholesterol, bilirubinate and carbonate of calcium (aragonite, vaterite, etc.) but never palmitate. Residual stones at times also present a peripheral "shell" presenting palmitate and this shows that a new component determined by bile changes is added to the cholesterol stone, which represents the central core, because of stasis and biliary infection. The distinction of calculi into residual and recurrent is also made on the basis of the classic morphologic and clinical criteria described in the literature, also and above all on the basis of specific, objective scientific criteria deriving from in-depth clinical study of the patient, the chemical study of the bile, morphological, mineralogical and structural study of the stone. The following are considered in particular: instrumental examinations made during hospitalisation and operation; pH, enzymatic activity (phospholipase, trypsin and amylase) and examination of bile cultures; morphological, microscopic examination (electronic scan microscopy) and mineralogical examination (X-ray diffractometry and infrared spectroscopy) of the calculus. A personal series of recurrent calculosis of the main biliary way is considered, special attention being paid to a case that was particularly interesting in relation to the fact lithiasic recurrence occurred just 10 months after the previous operation and the fact that biliary stasis was not determined by stenosis of the papilla which proved fully patent.     

Fifteen years' experience with an antirefluxing biliary drainage valve

PURPOSE: The aim of this study was to examine the efficacy of the antirefluxing, mucosal-flap valve (AMFV) for biliary drainage relative to technical feasibility, surgical complications, and incidence of ascending cholangitis (AC). METHODS: Twenty-seven infants requiring biliary tract reconstruction underwent valve construction. Twenty biliary atresia (BA) patients received the Kasai procedure, and 7 choledochal cyst (CC) infants had cystectomy and hepatoenterostomy. A retrospective review of all patients was performed including radiographic evaluation of the current valve function in 10 patients. RESULTS: Construction was successful in all cases, and no morbidity was incurred by incorporation of the valve. Of 7 CC patients, there have been no known episodes of AC with mean follow-up of 4.4+/-4.2 years. Of 20 BA patients, there have been 5 deaths (25%), 7 liver transplants (35%), 2 (10%) lost to follow-up, and 6 (30%) survivors. Nine BA patients (45%) have had AC, with patients in all 4 outcome categories represented. Ten patients (5 CC and 5 BA) have been evaluated with barium small bowel radiographs, with no reflux to the liver hilum in all cases. CONCLUSIONS: The AMFV has caused no morbidity and continues to prevent reflux to the liver hilum. Despite functioning as designed, it does not appear to influence the occurrence of AC. Because CC patients had no AC, we feel that infection is related to the underlying atresia rather than to reflux.     

Progressive biliary pathology associated with common pancreato-biliary channel

A female infant who presented with transient obstructive jaundice and who was shown to have mild fusiform dilatation of the common bile duct at the age of 18 months was followed up with hepatobiliary ultrasound scans over a period of 17 years. Enlarging gallbladder polyps were identified during the last 2 years of follow-up, and endoscopic retrograde cholangio-pancreatography (ERCP) showed a common pancreato-biliary channel with minimal bile duct dilatation. A high concentration of pancreatic amylase was detected in the bile. Hepaticojejunostomy and cholecystectomy were performed. Histologically, the resected common bile duct showed fibrous thickening of the wall and loss of surface epithelium. Muscular hypertrophy and polypoid lesions, which were foci of cholesterosis, were identified in the gallbladder. There was a minimal lymphocytic infiltrate in the subepithelial connective tissue. This report documents a progressive change in the ultrasound appearances of the gallbladder and histological changes in the extrahepatic ducts secondary to a common pancreato-biliary channel and pancreato-biliary reflux.     

Endoscopic sphincterotomy in the treatment of biliary lithiasis. Our experience

Endoscopic Sphincterotomy (E.S.) is a simple and efficacious method for the management of bile duct stones and papillary stenosis. In this series, the E.S. was attempted in 25 patients and performed in 23 (92%). Nine patients had common bile duct stones. Eleven patients (48%) had common bile duct and gallbladder stones. Two patients (8.7%) had intrahepatic lithiasis and one patient (4.3%) had papillary stenosis without gallstones. After E.S. all patients underwent instrument removal of bile duct stones, using "Dormia" basket and "Fogarty" balloon catheter. Transnasal bile duct drainage was performed in 20 patients (86.9%). Early complications were observed in three patients (13%); one sphincterotomy side bleeding and two acute pancreatitis, which were treated successfully conservatively. Mean follow-up was 10.7 months (range 3-27 months). Late complications did not occur for the method and/or for gallbladder stones. Four patients over 80 years of age, died for unrelated causes during follow-up.     

Our experience with the appropriate use of esophagogastroduodenoscopy

Many studies emphasize the right indications about the execution of an EGDS showing that a lot of requests are inappropriate. We have wanted to report our experience too, that showed more comfortable results than that checked, by other Authors moreover we have emphasized that the inappropriate requestsare justly divided between generical and specialized physicians.     

Decrease in regeneration capacity of rat liver after external biliary drainage.

In order to discover the effect of external biliary drainage on liver regeneration, we have produced a model system carrying cannula in the common bile duct of rat liver and examined the regeneration capacity of liver after partial hepatectomy under various conditions. Previously we have shown that hepatic cells proliferate by obstructive jaundice alone without partial hepatectomy [Terasaki et al; Jpn J Cancer Res 1991;82:170-175]. In the present study, we showed that DNA polymerase-alpha was induced by partial hepatectomy of rats suffering from obstructive jaundice and the induced level was similar to that of the normal regenerating liver. The level of DNA polymerase-alpha activity corresponded well to the liver regeneration capacity estimated by mitotic index. Contrary to our expectation, external biliary drainage for obstructive jaundice markedly suppressed the regeneration capacity of the remaining liver which was estimated by DNA polymerase-alpha activity, mitotic index and [3H]thymidine incorporation. The suppression may be due to the external biliary drainage itself because the liver regeneration of normal rats without jaundice was also suppressed by the biliary drainage. These results suggest that the external biliary drainage seriously suppresses the regeneration capacity of liver at least at the early stage of obstructive jaundice.     

Innovative modification of the hepatic portoenterostomy. Our experience of treating biliary atresia

We modified conventional hepatic portoenterostomy by pulling the remnant fibrous mass caudally and placing 5 or 6 numbered and individually clamped absorbable 5-0 double-needle sutures horizontally in the liver surface of the posterior side of the remnant fibrous mass before excision and apposing the posterior and anterior margins of the hepatic portoenterostomy to resemble a flattened isosceles triangle. Our technique was used to treat 14 cases of biliary atresia. Good postoperative biliary excretion (serum total bilirubin, <2 mg/dL) was achieved in 13 (92.9%) of 14 patients.