Bile duct injury repair: when? what? who?

Laparoscopic cholecystectomy is associated with a two-to-four times higher risk of bile duct injury (BDI) than open cholecystectomy. BDI can lead to significant morbidity and even mortality. The first priority in BDI is to control peritoneal and biliary sepsis and to convert an acute BDI to a controlled external biliary fistula (EBF) — this can be achieved by endoscopic and/ or radiological intervention in most cases. This should be followed by assessment of the extent of injury — both biliary and vascular. Immediate management of BDI recognized during cholecystectomy depends on the type of injury, the condition of the patient, and the experience of the surgeon. For BDI recognized after cholecystectomy, early repair is not recommended, as the results are poor. The EBF may evolve into a benign biliary stricture (BBS), which should be electively repaired by a Roux-en-Y hepatico-jejunostomy. The use of an endoscopic stent as definitive management of BDI is not recommended. Long-term follow-up is essential after the repair of a BBS, as recurrence can occur several years after repair. Recurrent BBS is best treated with endoscopic balloon dilatation. Excellent early and long-term results can be obtained in specialized units at tertiary care referral centers.     

胸导管阻断在食管癌手术中的应用

目的探索使用安全、有效的胸导管阻断方法，以减少或避免食管癌手术后乳糜胸的发生．方法在熟悉胸导管解剖结构基础上，低位明视结扎之，近期使用染色技术使胸导管更易辨认，确定其形态并确定无遗漏后结扎．术后观察效果．结果文献报告食管癌术后乳糜胸的发生率为０．４～２．６％，本组２８０例术后无１例发生乳糜胸．结论食管癌手术中胸导管阻断应低位、明视、准确结扎，使用染色技术更易辨认．凡主动脉弓以上食管胃吻合者，均应便用胸导管阻断技术以进免术后乳糜胸的发生。     

老年肝外胆管梗阻85例治疗分析

目的：探讨老年性肝外胆管梗阻的治疗。方法：85例老年胆管梗阻中良性疾病引起的梗阻为59例，主要是由于胆管结石嵌顿MIRRIZI‘S综合征；恶性肿瘤引起的梗阻为26例，主要为壶腹部周围癌，肝门区肿瘤等。手术分别采取胆囊切除术、胆总管切开取石＋T管引流术、胰十二指肠切除术、腹部探查＋内外引流术以及ERCP下行置管内支撑术后引流和ENBD等。结果：良性疾病引起的梗阻中仅1例术后死于ARDS，恶性肿瘤 引起的梗阻者中有11例术后死于肝肾综合征、ARDS和DIC等。结论；手术仍是老年肝外胆管梗阻的首选方法。老年患者合并其它脏器病变，病情较重者如先行胆管引流，能有效降低病死率及延长生命。     

A technique for vascular reconstruction of pancreaticoduodenal allograft. A literature review and case report

In most cases, whole pancreaticoduodenal allograft vessels can be reconstructed using a segment of donor common iliac artery bifurcation. An alternative way to bridge the splenic artery and the superior mesenteric artery (SMA) is to use a short segment of distal SMA as an interposition graft, as described herein.     

B超对肝外恶性梗阻性黄疸的诊断及其评价

本文报告了手术治疗肝外恶性梗阻性黄疸212例。根据B超(BUS)检查结果与术中所见进行对照研究,认为BUS对肝外恶性梗阻性黄疸与内科黄疸的鉴别诊断(正确率99%)、梗阻部位的定位(准确率95.3%),提供了可靠的依据;对恶性梗阻性黄疸的病因诊断仍不理想(阳性率59.4%)。因此BUS检查应列为常规或首选方法,对于确诊或定性有困难者,再选用ERCP或PTC。     

Solid and Cystic Tumor of the Pancreas in an Adult Male

A solid and cystic tumor (SCT) was located at the head of the pancreas in a 43-year-old Japanese male, and pancreatoduodenectomy was performed on the suspicion of papillary carcinoma or cystadenocarcinoma of the pancreas. The lesion, which measured 4.5 X 4.5 X 4.0 cm, was clearly demarcated by connective tissue. The cut surface showed solid grayish-white areas with central cystic degenerative changes. The solid areas consisted of small round cells proliferating in a small solid or a pseudopapillary pattern. The tumor cells partially invaded the surrounding normal pancreatic parenchyma. Immunohistochemical studies revealed positive staining for alpha-1-antitrypsin and neuron-specific enolase, but no staining for known pancreatic hormones. Moreover, ultrastructural studies showed the absence of zymogen granules and the presence of anullate lamellae and neurosecretory granules. On the basis of these findings, a diagnosis of SCT of the pancreas was established. In order to clarify the histogenesis and biological behavior of the tumor, it is necessary to accumulate and analyze similar cases, an endeavor which in turn will contribute to the successful management of this disease. Acta Pathol Jpn 41: 763-770, 1991.     

Sodium bicarbonate secretion indicated by ultrastructural cytochemical localization of HCO3 −, Cl−, and Na+ ions on rat bile duct brush cells

Brush cells are widely distributed in the digestive and respiratory apparatus, but their function is still unknown. Because brush cells (BC) are found in organs secreting NaHCO₃, it was hypothesized that these cells may secrete NaHCO₃. To test this possibility, rat common bile duct epithelia were examined by ultrastructural cytochemical methods for localizing HCO₃⁻, Cl⁻, and Na⁺ ions. All three ion precipitates were few in or on BCs of rats without stimulation. Lead carbonate precipitates, which localized HCO₃⁻ ions by the lead nitrate-osmium method, increased markedly on the surface of the microvilli (MV) of BCs after secretin or meal stimulation, but similar precipitates were few on the luminal surface of principal cells (PCs). Silver chloride precipitates, which indicate the presence of Cl⁻ ions by the silver-osmium method, increased in the apical cytoplasm and in MV of BCs after secretin or meal stimulation, but they were few in PCs. Sodium pyroantimonate precipitates, which localize Na⁺ ions by the potassium pyroantimonate-osmium method, increased on the surface of the MV, along the basolateral membrane, and in the apical cytoplasm of BCs after secretin or meal stimulation, but they were few in PCs. These results strongly suggest that BCs may be a significant source of NaHCO₃ secretion.     

FGF signaling segregates biliary cell-lineage from chick hepatoblasts cooperatively with BMP4 and ECM components in vitro.

Intrahepatic bile ducts (IHBDs) are indispensable for transporting bile secreted from hepatocytes to the hepatic duct. The biliary epithelial cells (BECs) of the IHBD arise from bipotent hepatoblasts around the portal vein, suggesting the portal mesenchyme is essential for their development. However, except for Notch or Activin/TGF-beta signaling molecules, it is not known which molecules regulate IHBD development. Here, we found that FGF receptors and BMP4 are specifically expressed in the developing IHBD and the hepatic mesenchyme, respectively. Using a mesenchyme-free culture of liver bud, we showed that bFGF and FGF7 induce the hepatoblasts to differentiate into BECs, and that BMP4 enhances bFGF-induced BEC differentiation. The extracellular matrix (ECM) components in the hepatic mesenchyme induced BEC differentiation. Forced expression of a constitutively active form of the FGF receptor partially induced BEC differentiation markers in vivo. These data strongly suggest that bFGF and FGF7 promote BEC differentiation cooperatively with BMP4 and ECMs in vivo.     

Ultrastructural changes of bile duct epithelium in primary biliary cirrhosis in relation to progression of bile duct loss

Summary Using wedge liver biopsies from patients with primary biliary cirrhosis (PBC), ultrastructural features of the intrahepatic bile ducts in livers with slight or no bile duct loss were compared with those in livers with advanced bile duct loss and in extrahepatic cholestasis (EHC).Most changes in the biliary epithelium in PBC were similar to those in EHC. Microvillous loss and bleb formation, mitochondrial damage and increase in endoplasmic reticulum and ribosomes were found in PBC irrespective of the degree of bile duct loss, and also in EHC. These changes were present almost equally at any level of the biliary tree, and are presumed to represent a variety of non-specific lesions of biliary epithelial cells. As the loss of bile ducts in PBC progressed, cytoskeletal filaments and cytophagosomes increased in number and basement membranes were more thickened and reduplicated. These changes were more or less conspicuous in smaller branches of the biliary tree, and were also prominent in EHC. They might be causally related to the bile flow disturbance in the liver. Lateral intercellular spaces were irregularly dilated and contained osmiophilic membranous and/or granular material, similar to that found in duct lumena, within and without the basement membrane, and in the cytoplasm of periductal macrophages. Furthermore, pinocytotic vesicles were increased in the biliary cytoplasm facing periphery. These findings suggest possible alteration of the permeability of biliary epithelial cells, probably in the direction from the lumena to the periductal tissue. Such changes were found in PBC livers with virtual absence of bile duct loss, and the significance of this phenomenon is discussed.