Surgical treatment of extrahepatic bile duct carcinoma

OBJECTIVE: To evaluate the experience in the diagnosis and surgical treatment of the extrahepatic bile duct carcinomas. METHODS: 242 patients with extrahepatic bile duct carcinoma over the past 20 years was retrospectively studied. RESULTS: The origin points were carcinomas of the upper bile duct in 168, of the middle bile duct in 18, and of the lower bile duct in 56 patients. The preoperative diagnostic rates for the location and the nature of the lesion were respectively raised to 97.2% and 94.5% by combination of ultrasonography and CT. The curative resection rates for the tumors in the upper, middle, and lower bile duct over the recent five years reached to 50.0%, 50.0% and 71.4%. respectively. Follow-up of patients with curative resection showed a one year recurrent rate of 73.9% and a three year recurrent rate of 100.0% with a mean recurrent time of 9.6 months in patients with local metastasis, in contrast to 13.3%, 71.4% and 17.5 months in those without metastasis. Metastasis was mainly responsible for the recurrence. Liver or multiple organ failure, intra-abdominal infection and gastrointestinal hemorrhage were the common and serious complications. CONCLUSION: The case number of the bile duct carcinoma presented a remarkable increment tendency. Ultrasonography and CT were satisfactory enough for diagnosis. To reduce the recurrent rate, resection of the tumor together with the lymph, nervous, fatty and connective tissues in the hepatic hilus, even the right celiac ganglia, should be considered the necessary procedure. Monitoring and protecting the main organs to prevent the multiple organ failure, controlling the gastrointestinal hemorrhage and the intra-abdominal infection are important to decreasing the mortality.     

Hyaline cartilage at porta hepatis in extrahepatic biliary atresia

Hyaline cartilage was found on microscopy of sections of the extrahepatic biliary tree in two infants with extrahepatic biliary atresia (EHBA). Respiratory epithelium was not present, and the cartilage did not seem to block the bile duct lumen. Hyperbilirubinemia was manifest in one infant on the second postnatal day, but clinical courses were otherwise unremarkable. In neither infant was the ductal plate malformation found on light microscopy of liver biopsy specimens, and in neither infant was visceral topography abnormal. Hyaline cartilage at the porta hepatis appears to be a novel finding in EHBA. Its significance remains to be defined.     

Disposition of nafcillin in patients with cirrhosis and extrahepatic biliary obstruction

Nafcillin, a semisynthetic penicillin effective against penicillinase-producing staphylococci, is eliminated largely in man via the liver. This study assessed the effect of cirrhosis and extrahepatic biliary obstruction in man on the pharmacokinetics of nafcillin. The plasma clearance of nafcillin controls was 583 +/- 144.2 ml per min (mean +/- SD) and fell strikingly to 291 +/- 147.6 and 163 +/- 56.3 ml per min in patients with cirrhosis and extrahepatic obstruction, respectively (P less than 0.001). In the latter two groups nafcillin excreted in urine increased from about 30 to 50% of administered dose (P less than 0.02), suggesting that renal disease superimposed on hepatic disease would further decrease over-all nafcillin clearance. The depression of nafcillin clearance with hepatobiliary disease did not correlate with any conventional liver laboratory test. The initial volume of distribution of nafcillin (V1) was unaltered but at steady state (Vd()) there was a significant reduction in the distribution volume in the patients with liver disease. Accordingly, the impairment in drug elimination, as assessed by its clearance from plasma, was underestimated by the prolongation of the nafcillin elimination half-life (t1/2(beta)) which was 1.02 +/- 0.20 hr in controls, and 1.23 +/- 0.31 (P greater than 0.05) and 1.73 +/- 0.44 hr (P less than 0.03), respectively, in patients with cirrhosis and extrahepatic obstruction.     

Surgical treatment of acute biliary pancreatitis

The analysis of surgical treatment of 126 patients with acute biliary pancreatitis is made. The authors follow an active surgical policy in patients with justified risk of surgery. The operation is carried out in two stages: 1st-radical elimination of pathologic changes of extrahepatic bile ducts, restoration of the passage through the large duodenal papilla (LDP), and 2nd stage is the operation on the pancreas. The indications and contraindications for transduodenal intervention in acute biliary pancreatitis have been determined. The authors think it necessary in destructive forms of acute pancreatitis accompanied by extensive fermentative damage of parapancreatic and retroperitoneal cellular tissue to remove it thoroughly and to drain it widely. The reoperation should be performed not earlier that 12-21 days after the initial operation. Postoperative lethality was 8.7%.     

Surgical treatment of cicatricial biliary strictures

BACKGROUND/AIMS: Cicatricial biliary strictures are usually associated with high morbidity and mortality rates, frequently related to technical difficulties of their surgical repair, mainly in hilar lesions. Interference with bile duct blood supply during surgical attempts for correction is a major factor for unsuccessful results. The aim of this study is to evaluate, after an extended follow-up period, the results obtained with a modified technique for surgical correction of cicatricial biliary strictures. METHODOLOGY: The medical records of 57 patients surgically treated for cicatricial biliary strictures between January 1984 and July 1995 were reviewed and the immediate and long term results retrospectively analyzed. Patients consisted of 46 females and 11 males. The average age was 43 years. The etiology of the biliary lesion was: cholecystectomy alone (23); cholecystectomy with duct exploration (8); T tube CBD drainage (6); Biliary-enteric anastomosis stricture (16); choledochoplasty (2) and trauma (2). In 28 cases (49.1%) the stricture was located in the upper third of the bile duct, in 28 (49.1%) in the middle third and in one case (1.7%) it was low. All patients were submitted to longitudinal Roux-en-Y hepaticojejunostomy with mucosa apposition after dissection of the anterior aspect of the biliary tract. No transanastomotic stents were used. RESULTS: Ten patients (17.5%) presented 11 postoperative complications: biliary fistula (4), duodenal fistula (1), wound infection (5), and acute pancreatitis (1). Average hospital stay was 11 days and there were no postoperative mortalities. The follow-up study was possible in 54 patients and ranged from one to ten years, with an average of 2.9 years. Four patients of 28 (14%) with hilar lesions developed stricture recurrence and cholangitis episodes, whereas no patients bearing lesions below the biliary junction had such complications. CONCLUSION: Roux-en-Y hepaticojejunostomy with mucosa apposition without transanastomotic stent performed after minimal dissection of the biliary duct, thus avoiding major interference with the bile duct blood supply, is a safe and efficient method for the surgical repair of cicatricial biliary strictures. Using this technique excellent results can be obtained in the lesions below the biliary junction and acceptable results may be achieved in patients with hilar lesions.     

Arterial radio-anatomy of the extrahepatic biliary system (author's transl)

The uni-arterial vascularisation of the lateral bilary duct makes it impossible to systematise the arteries which supply the common bile duct. Only the cystic artery is seen at coelio-mesenteric catheterization. The techniques essential for visualisation of the cystic artery are discussed, on the basis of one hundred coelio-mesenteric arteriograms: frequency of demonstration, origin, course, termination, calibre and length. The frequent finding of opacification of the wall of the gall bladder under normal conditions is stressed.     

Treatment of extrahepatic biliary atresia with interferon-alpha in a murine infectious model

The etiology of extrahepatic biliary atresia (EHBA) in newborns remains unknown, although a first infectious animal model with complete obstruction of the common bile duct could be established. Intraperitoneal inoculation of newborn Balb/c mice with rhesus rotavirus induced cholestasis, leading, in most cases, to biliary atresia with lethal outcome, similar to EHBA in human newborns. The influence of interferon-alpha (IFN-alpha) on the hepatotropism of rotavirus infection was investigated in this animal model. Single-dose therapy with 10000 IU of IFN-alpha protected all rhesus rotavirus-infected pups from cholestatic disease. The same dose, injected 5 d after infection, had no protective effect. Starting with onset of cholestatic symptoms, the treatment with 10000 IU of IFN-alpha daily showed good results in 29 mice. Seventy-six percent of the mice recovered after 1 wk of therapy. Histologic investigation revealed normal findings in the hepatobiliary tract of clinically normal mice. Twenty-one percent of the descendants of infected and prophylactic IFN-alpha-treated mice showed cholestatic symptoms after infection with rhesus rotavirus (79% in an untreated control group) and a milder form of the illness. In conclusion, we found that prophylactic treatment with IFN-alpha prevented the hepatobiliary system of newborn Balb/c mice from severe damage by rhesus rotavirus in this artificially designed infectious model for EHBA. Infected and icteric mice, treated for 1 wk with IFN-alpha, had good prospects for recovery and prevention of complete and irreversible occlusion of the extrahepatic bile ducts. Infected and prophylactic IFN-alpha-treated dams gave good protection to their descendants. This means that EHBA in this model could probably be averted by maternal antibodies against rotavirus.     

Epidermal growth factor receptor immunoreactivity in gallbladder and extrahepatic biliary tract tumours

BACKGROUND: Brain dysfunction is common in patients with advanced liver disease; it is often manifested as hepatic encephalopathy, but its cause is not clearly understood. METHODOLOGY: Intracranial blood flow velocity parameters, including peak systolic velocity, end diastolic velocity and mean velocity of both middle cerebral arteries were measured by transcranial Doppler ultrasonography in 37 patients with cirrhosis without encephalopathy (16 Child's A, 10 Child's B and 11 Child's C) and 12 normal controls. The cause was alcohol-related in 24 and non-alcohol-related in 13. RESULTS: No significant differences in any of the Doppler parameters were detected in Child's group A when compared with controls. However, a statistically significant decrease in middle cerebral artery blood flow velocity was evident when Child's B and C patients without clinically apparent encephalopathy were compared with controls irrespective of the cause. Our results demonstrate that intracranial blood flow is abnormal in patients with advanced liver disease without clinically apparent encephalopathy.     

Histologic study of biliary fibrous remnants in 48 cases of extrahepatic biliary atresia: correlation with postoperative bile flow restoration

The authors studied the transformation of infraslow oscillations of brain potentials in 15 patients with neuroses during 50 sessions of hypnosis. The results of such studies permitted to distinguish some important traits in the changes of infraslow oscillations of brain potentials in different stages of hypnosis. It is concluded that a study of these changes during hypnosis may establish some correlations between the physiological state of the brain and the unconscious mental processes.     

Surgical treatment of intraoperative injuries and cicatricial strictures of extrahepatic bile ducts

The analysis of 70 cases of surgical treatment for intraoperative injuries and cicatricial strictures of extrahepatic bile ducts was carried out. In 25 patients surgical procedure was restorative and in 45--reconstructiver. Most common causes of corrective operations were: iatrogenic injuries of extrahepatic bile ducts (14) and cicatricial strictures of hepaticocholedochal duct due to intraoperative trauma (31). The problems of operative technique in performing biliobilio-, hepato-hepatico and hepatico-jejuno-anastomoses are considered. There were three deaths in the early postoperative period: 2 patients died of hepatic failure, pyogenic cholangiogenic intoxication caused by cholangioectasies and intrahepatic abscesses, and 1-due to generalyzed peritonitis caused by acute gastric ulcer perforation. Special attention is paid to the choice of the method of prolonged drainage used in reconstructive as well as in restorative operations.     

Retrograde injections of formaldehyde into the biliary tree induce alterations of biliary epithelial function in rats

Formaldehyde may induce severe lesions of intrahepatic and extrahepatic bile ducts. The purpose of this study was to examine in vivo the functional consequences of an alteration of the biliary epithelium induced by a retrograde intrabiliary injection of formaldehyde in rats. After basal bile collection, a 10% formaldehyde solution was injected into the biliary tree of anesthetized rats, and the cannula was occluded for 30 minutes. Choleresis was then reestablished, and bile flow, bile acid, and bicarbonate secretion were measured both spontaneously and during ursodeoxycholate infusions. Formaldehyde injections induced a significant increase in bile flow and a marked inhibition of ursodeoxycholate-induced increase in biliary bicarbonate concentration and secretion. Biliary glucose secretion, which is normally very low, was increased about 20-fold in animals injected with formaldehyde. Histological and ultrastructural examination of the liver showed alterations of biliary epithelial cells, whereas hepatocytes, bile canaliculi, and canalicular tight junctions remained normal. Hepatocytic excretory function, as assessed by biliary secretion of bile acids, was not affected. It was concluded that short-term formaldehyde intrabiliary injections cause an inhibition of ursodeoxycholate-induced hypersecretion of bicarbonate, an increase in biliary glucose secretion, and selective structural alterations of biliary epithelial cells. These results suggest that formaldehyde retrograde biliary injection may be a useful model to study alterations of biliary epithelial function in vivo.     

Surgical treatment of biliary atresia in the liver transplantation era

Biliary atresia (BA) still remains one of the most intractable gastrointestinal diseases in infancy despite the concerted efforts of pediatric surgeons all over the world. The introduction of liver transplantation has revolutionized the protocols for the treatment of this condition. In this editorial, the role of hepatic portoenterostomy (the Kasai procedure) in the surgical treatment of BA in the "transplantation era" will be discussed.