Is choledochoduodenostomy in the treatment of stones in the common bile duct an obsolete technique?

The complex pathogenesis of bile duct stones, the anatomical properties of the biliary tree, the patient's age, associated diseases, as well as the technical devices available, may explain the great variety of procedures and preferences of different groups in the treatment of choledocholithiasis. Since no technique is infallible or free of complications, it seems unfair to argue that procedures whose efficacy has been proven by many authors are obsolete. This is the case of choledochoduodenostomy (CDS) in the treatment of common bile duct (CBD) stones. The complications associated with CDS, (ascending cholangitis, and sump syndrome) have been overemphasized and have led CDS to be rejected by many surgeons. Our experience with this technique is good and concurs with that of Madden and others.Data on 125 patients with CBD stones treated with CDS between 1968 and 1982 are analyzed. Sixty-eight of them were female and the mean age was 61.4 years; 73.6% were more than 50 years old. There were frequent accompanying diseases, especially cardiovascular ones. More than half of the patients had a previous operation on the biliary tree. The duct diameter was always greater than 20 mm and it was frequently associated with stenosis of the distal choledochus. Floercken's technique of CDS was the most frequently used, after Kocher's maneuver had been performed. There was no intraoperative mortality. Postoperative mortality was 3.2% and is analyzed in detail. The incidence of postoperative complications was 42.4%. Most were septic complications or those ascribed to accompanying diseases. Late operative cholangitis was present in 1.6% of patients, comparable with reports of other authors. We encourage the use of CDS in the treatment of CBD stones provided that: (a) careful attention is paid to its clinical indications, considering that the patient may benefit from alternative techniques, for example, duodenoscopic papillotomy; and (b) choledochal dilatation is greater than 20 mm in diameter and the choledochal and duodenal walls are normal. We specifically recommend CDS as the primary operation for patients with choledochal funnel syndrome. The operation is simple, restores normal digestive function, and almost always resolves the problems of CBD stones in high-risk patients.

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Resumen La compleja patogenia de los cálculos del colédoco, las propiedades anatómicas del árbol biliar, la edad del paciente, las patologías asociadas y otros factores, junto con la disponibilidad de diversos elementos técnicos, explican la gran variedad de procedimientos y de preferencias por parte de los cirujanos en el tratamiento y de preferencias por parte de los cirujanos en el tratamiento de la litiasis biliar. Puesto que ninguna técnica operatoria es infalible ni totalmente libre de complicaciones, parece injusto argumentar que procedimientos cuya eficacia ha sido comprobada por muchos autores sean calificados como obsoletos. Tal es el caso de la coledocoduodenostomía (CDS) en el tratamiento de los cálculos del colédoco. Las complicaciones asociadas con la CDS (colangitis ascendente y el sindrome del segmento distal ciego) han sido exageradas, lo cual ha llevado a muchos cirujanos a rechazar la CDS. Nuestra experiencia con esta técnica es buena y está de acuerdo con la de Madden y de otros. Se analizaron los datos en 125 pacientes con cálculos del colédoco tratados con CDS entre 1968 y 1982. Sesenta y ocho eran mujeres y la edad promedio fué de 61.4 años; 73.6% eran mayores de cincuenta años. Otras enfermedades asociadas fueron halladas con frecuencia, especialmente las cardiovasculares. Más de la mitad de los pacientes tenían historia de una operación previa sobre el árbol biliar. El diámetro del colédoco fué superior a 20 mm en todos los casos y con frecuencia se encontró estenosis árbol de la porción distal. La técnica de Floercken fué la más frecuentemente utilizada, una vez realizada la maniobra de Kocher. No hubo mortalidad intraoperatoria. La mortalidad postoperatoria fué de 3.2% y se analiza en detalle. La tasa de complicaciones postoperatorias fué de 42.4%, incluyendo las sistematicas y las locales, leves y severas, habiéndose observado predominancia de las complicaciones sépticas y de aquellas relativas a patologiás asociadas. La colangitis operatoria tardía ocurrió en el 1.6% de los pacientes, tasa comparable a la informada por otros autores. Nosotros preconizamos el uso de la CDS en el tratamiento de los cálculos del colédoco siempre que: (a) se preste atención cuidadosa a sus indicaciones clínicas, considerando que el paciente puede beneficiarse con otras alternativas, por ejemplo la papilotomía duodenoscópica; y (b) la dilatación del colédoco sea de un diámetro superior a 20 mm y que las paredes tanto del colédoco como del duodeno sean normales. Específicamente recomendamos la CDS como la operación primaria para pacientes con el síndrome del embudo coledociano (estenosis distal con dilatación proximal). La operación es sencilla, restaura la función digestiva normal y en forma casi uniforme resuelve los problemas que producen los cálculos del colédoco en pacientes de alto riesgo.

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Résumé La pathogénie complexe de la lithiase biliaire, les caractères anatomiques des voies biliaires ainsi que l'âge des malades, les affections associées et la grande variété des méthodes techniques expliquent la grande diversité des procédés de traitement de la lithiase choledocienne employés par les différentes équipes chirurgicales. Aucune technique n'étant infaillible ou exempte de complications, il paraît inconsidéré d'abandonner toute méthode qui a fait ses preuves. Il en est ainsi de la choledocoduodénostomie. Les complications attribuées à ce type d'intervention comme l'angiocholite ascendante, et le syndrome du moignon sous-anastomotique ont été exagérées conduisant de nombreux chirurgiens à l'écarter de leur pratique. Notre expérience de la choledocoduodénostomie est bonne et coincide avec celle de Madden et d'autres auteurs. Les données recueillies chez 125 malades qui présentaient des calculs de la V.B.P. et qui furent traités par la choledocoduodénostomile de 1968 à 1982 ont été étudiées. Soixante-huit étaient des femmes. La moyenne d'âge était de 61.4 ans, 73.6% étaient âgés de plus de 50 ans. Les affections associées étaient fréquentes en particulier les affections cardiovasculaires. Plus de la moitié de nos opérés avaient déjà subi une intervention sur la voie biliaire. Le diamètre de la voie biliaire a toujours été supérieur à 20 mm et la dilatation se trouvait souvent au dessus d'un rétrécissement du bas cholédoque. La technique de Floercken fut le plus souvent employée après le décollement du bloc duodénopancréatique. Il n'y eu aucun décès peropératoire. La mortalité postopératoire s'est élevée à 3.2% et a été étudiée avec précision. Le taux des complications postopératoires a atteint 42.4%, dont les infections et les désordres secondaires aux affections associées occupent la première place. Le taux de l'angiocholite postopératoire tardive s'est élevé à 1.6%, identique à celui rapporté par d'autres auteurs. Notre expérience nous permet de recommander la choledocoduodénostomie à condition (a) d'apporter une attention particulière aux indications après avoir pris en considération la possibilité de traiter la lithiase par une autre méthode, la sphinctérotomie endoscopique par exemple; et (b) de la réserver aux cas où le diamètre de la V.B.P. est supérieur à 20 et ou les parois de la voie biliaire et du duodénum sont normales. Nous considérons qu'elle est particulièrement indiquée en présence du syndrome du cholédoque en entonnoir. L'intervention est simple, restaure la fonction digestive normale et résoud le problème des calculs de la V.B.P. chez les malades de haut risque.

     

Neural projections of the preoptic-suprachiasmatic region to the median eminence in the rat: A quantitative autoradiographic study

The possibility of a preferential distribution of projections from the preoptic-suprachiasmatic region (POA-Sch) to the median eminence in the male rat was studied using autoradiographic and computer procedures. A cocktail of [3H]leucine-[3H]proline was injected into the POA-Sch. Animals were killed after either 1, 4, or 24 h of incorporation time (IT). The number of silver grains per 25-micron square was counted throughout the median eminence. Squares with silver grain densities at or above the 75 percentile of the population for any given IT group were labeled as "concentrating areas." The distribution of these concentrating areas in median eminence tissue was analyzed utilizing univariate procedures. Visual inspection of the distribution of silver grain densities in a rostrocaudal fashion indicated the likelihood of uneven distribution; however, these differences were not statistically significant. In the dorsoventral plane, results indicated that the highest silver grain density was at 50 to 75 micron from the floor of the 3rd ventricle. Such distribution was apparent both ipsi- and contralateral to the injection site, but was greater on the ipsilateral side.     

Effect of photobiomodulation therapy on the proliferation phase and wound healing in rats fed with an experimental hypoproteic diet

Lasers in Medical Science - Photobiomodulation therapy (PBMT) has been indicated for enforcement on healing skin wounds. This study evaluated the effects of PBMT on the healing of skin wounds...     

Towards the development of a conceptual distance metric for the UMLS

The objective of this work is to investigate the feasibility of conceptual similarity metrics in the framework of the Unified Medical Language System (UMLS). We have investigated an approach based on the minimum number of parent links between concepts, and evaluated its performance relative to human expert estimates on three sets of concepts for three terminologies within the UMLS (i.e., MeSH, ICD9CM, and SNOMED). The resulting quantitative metric enables computer-based applications that use decision thresholds and approximate matching criteria. The proposed conceptual matching supports problem solving and inferencing (using high-level, generic concepts) based on readily available data (typically represented as low-level, specific concepts). Through the identification of semantically similar concepts, conceptual matching also enables reasoning in the absence of exact, or even approximate, lexical matching. Finally, conceptual matching is relevant for terminology development and maintenance, machine learning research, decision support system development, and data mining research in biomedical informatics and other fields.     

Isolation of putative dengue virus receptor molecules by affinity chromatography using a recombinant E protein ligand

Nucleotide sequences coding for the full-length envelope (E) glycoprotein gene of dengue virus type 4 was amplified using an RT-PCR method from infected C6/36 cells and cloned into pPROEx-Hta expression vector. The expression of the recombinant E protein in Escherichia coli was confirmed by Western blot using a polyclonal anti-dengue polyclonal antibody. The His-tagged fusion protein was obtained from the bacterial cellular extracts in almost pure form by immobilized metal affinity chromatography and the recombinant protein retained its ability to bind to 40 and 45 kDa proteins, previously described as putative receptors for dengue virus in C6/36 cells. To purify the 40 and 45 kDa molecules, a total protein extract from C6/36 cells was passed through an affinity chromatography column using immobilized recombinant E protein. After washing with isotonic buffer, elution was accomplished using a high salt buffer. The two proteins obtained, with molecular weights of 40 and 45 kDa, were recognized by dengue 4 virus, in virus overlay protein binding assay. This procedure allows further characterization of molecules that could be involved in dengue binding and entry.