A simple method for bile duct anastomosis and interval bile collection in the liver-transplanted rat

A mini T-tube is introduced for the bile duct anastomosis of rat liver transplantation as well as interval bile collection. The validity of the T-tube was evaluated in 14 liver-transplanted rats and compared to 14 rats using traditional stent for bile duct anastomosis. Changes of biliary tree after the T-tube anastomosis were examined by T-tube cholangiography on sample rats at 4 days and at 4 months after liver grafting. Additionally, bile volumes and rates of bile salt secretion were compared in the continuously flowing cannula and the chronic T-tube fistula in normal rats. The results show that the mini T-tube facilitates bile duct anastomosis and study of bile secretion after liver transplantation in rats without increase in surgical difficulty or interference of biliary enterohepatic circulation.     

Compliance with supportive periodontal therapy

CONCLUSIONS: Bronchobiliary fistula is an in frequent manifestation of common bile duct obstruction. The slowly progressive narrowing of the common duct by the fibrosis of chronic pancreatitis is an even more rare mechanism of such fistula formation with only two cases having been reported previously. A third case of bronchobiliary fistula caused by chronic pancreatitis is presented and its successful management is discussed. BACKGROUND: A 54-yr-old male with known chronic pancreatitis presented with a cough productive of copious amounts of bile and with pulmonary infiltrates. METHODS: Diagnosis of bronchobiliary fistula was made based on HIDA scan and confirmed by operative cholangiogram. RESULTS: Successful correction of this fistula was accomplished by operative closure of the fistulous tract and diversion of the narrowed bile duct by hepaticojejunal bypass.     

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.     

Liver metastases from colon cancer with intra-bile duct tumor growth: radiologic features

PURPOSE: Our goal was to characterize the radiologic features of liver metastases from colon cancer with intrahepatic bile duct (IHBD) dilatation. METHOD: Radiologic findings of liver metastases from colon cancer with IHBD dilatation of four patients were compared with pathologic findings. RESULTS: The cause of bile duct dilatation in all cases was due to papillary tumor growth in the bile duct. In two patients, intra-bile duct tumor growth (IBDTG) was observed on imaging. In the other two patients, IBDTG was not observed, but a nontapered abrupt obstruction of a dilated bile duct was seen, corresponding to the microscopically proven papillary tumor growth in the ductal lumen. In three patients who underwent an extensive hepatic resection, there has been no recurrence. In one patient who had a nonanatomic limited resection, a recurrence was seen 1 year after surgery. CONCLUSION: When liver tumor with IBDTG is suspected on imaging, liver metastases should be considered in the differential diagnosis besides hepatocellular carcinoma or cholangiocellular carcinoma. Careful preoperative assessment for IBDTG by imaging is essential to determine the extent of surgical resection.     

Efficacy of endoscopic diagnosis and treatment for postoperative biliary leak

BACKGROUND/AIMS: The purpose of this study was to evaluate the efficacy of endoscopic approaches for the diagnosis and treatment of postoperative biliary leak. METHODOLOGY: Endoscopic retrograde cholangiopancreatography (ERCP) was performed in eight patients with postoperative biliary leak. Of 8 cases, 6 had biliary leak alone (4 cases with a cystic duct leak and 2 cases with a bile duct leak) and 2 cases with a bile duct leak were associated with a bile duct stricture. Endoscopic sphincterotomy (ES) and endoscopic biliary stenting (EBS) were employed in 5 patients and nasobiliary tube drainage (NBD) without ES was performed in 3 patients. RESULTS: In all the patients, ERCP was successfully performed and could demonstrate exact nature and site of postoperative bile duct injuries. In 2 patients with a concomitant bile duct stricture, repetitive endoprosthesis placements were required. The remaining six patients with biliary leak alone were successfully treated by temporary stenting, i.e., ES and EBS (n = 3), and NBD (n = 3). CONCLUSIONS: The patients with postoperative biliary leaks can be successfully diagnosed by ERCP and treated by temporary endoscopic methods. Among various endoscopic treatments, NBD alone appears to be preferable in treating patients with small bile leaks. However, cases with a concomitant bile duct stricture were intractable and required longer period of stenting.     

Preoperative diagnosis of laparoscopic cholecystectomy. Is there an indication for routine intravenous cholangiography?

In a retrospective study including 163 patients we investigated the necessity of i.v. cholangiography in preoperative routine diagnostic workup prior to laparoscopic cholecystectomy. We evaluated the evidence of i.v. cholangiography concerning the anatomy of the biliary system, the evidence of common bile duct or cystic duct stones and the influence on the further therapeutic procedure. While the common bile duct could be demonstrated in 96.3%, the cystic duct could be visualized in only 54.6%. One out of two patients with a short cystic duct was identified. Stones in the gallbladder were recognized in 72.4% of cases, while only two out of three patients with common bile duct stones were diagnosed. In nine cases a deep junction of the cystic duct was found, but there was no influence on further operative procedure. Thus we found no improvement after routine use of i.v. cholangiography concerning the evidence of common bile duct stones or avoidance of intraoperative lesions of the common bile duct. The routine use of i.v. cholangiography prior to laparoscopic cholecystectomy is therefore not justified.     

Reversibility of hepatic mitochondrial damage in rats with long-term cholestasis

BACKGROUND/AIMS: Long-term bile duct ligation in rats is associated with secondary biliary cirrhosis and metabolic alterations, e.g. mitochondrial dysfunction. We performed the current studies to characterize the reversibility of hepatic mitochondrial dysfunction after reversing biliary obstruction by Roux-en-Y anastomosis. METHODS: Rats were studied after 4 weeks of bile duct ligation, and after 5 or 14 days of reanastomosis. Control rats were pair-fed to treated rats and all rats were studied after starvation for 24 h. Mitochondria were isolated by differential centrifugation and enzyme activities determined by spectrophotometric methods. RESULTS: In comparison to controls, plasma beta-hydroxybutyrate concentrations were decreased in bile duct ligated rats (200+/-70 vs. 790+/-200 micromol/l) and remained decreased after relief of biliary obstruction. In contrast, plasma free fatty acids were not different between controls and treated rats. Oxidative metabolism of L-glutamate, succinate and duroquinol was decreased in liver mitochondria from bile duct ligated rats. After relief of biliary obstruction, the metabolism of L-glutamate and duroquinol normalized quickly, whereas succinate metabolism remained impaired. Similar results were obtained for the mitochondrial oxidases in disrupted mitochondria. The activities of complex I, II, III and V of the respiratory chain were reduced in bile duct ligated rats. After relief of biliary obstruction, complex I and III normalized quickly, whereas complex II and V remained impaired. Oxidative metabolism of long-chain fatty acids by isolated liver mitochondria was decreased in bile duct ligated rats and did not recover after relief of biliary obstruction. CONCLUSIONS: Long-term cholestasis in the rat is associated with a decrease in specific functions of liver mitochondria which recover only partially after Roux-en-Y anastomosis. The persistence of decreased mitochondrial fatty acid metabolism cannot be explained by impaired activity of the respiratory chain, but is more likely due to alterations in mitochondrial beta-oxidation.     

Cancer of the gallbladder associated with anomalous junction of the pancreatobiliary duct system without bile duct dilatation

The aim of this study was to delineate clinical features and prognosis of cancer of the gallbladder associated with anomalous junction of the pancreatobiliary duct system without bile duct dilatation, and to determine methods for managing the disease. A retrospective study of seven patients is presented. A further 27 cases from the Japanese literature were reviewed retrospectively with regard to method of treatment and prognosis. In 11 of 18 patients in whom staging was known the tumour was stage V, representing advanced disease. In seven of 34 cases curative operation was performed; only two patients survived for > 3 years. This poor outcome was due largely to delayed diagnosis of cancer of the gallbladder. Prophylactic cholecystectomy is recommended in patients with this anomalous junction without bile duct dilatation or a malignant lesion in the gallbladder, because of the high incidence of cancer of the biliary tract.     

Surgical treatment for iatrogenic damage at the confluence of hepatic duct

Since 1989, 4 patients with iatrogenic bile duct injuries at the level of bifurcation were treated. Among them, the bifurcation together with both right and left hepatic duct had had wrongly been resected in 2 cases. The bifurcation was partially resected in the other 2 cases. The establishment of a permanent hepaticoentertostomy is essential. Abnormal bile flow would impede surgical effect, hence in the author's opinion, peripheral hepaticoenterostomy such as Longmire's procedure is unsuitable for iatrogenic bile duct injuries. The author's special technique for adequate exposure and accurate dissection of intrahepatic bile ducts is described. Four cases have been followed up for 7 months to 5 years with good result.     

Value of intraoperative cholangiography in laparoscopic cholecystectomy

By introduction of laparoscopic cholecystectomy, an increase of accidental common bile duct injuries up to 1.2% has been reported. In the present study of 325 cholecystectomies we evaluated whether mandatory intraoperative cholangiography (IOC) can reduce the rate of accidental bile duct injuries or, at least, identify them early in order to make an adequate repair possible. In addition 163 patients underwent preoperative intravenous cholangiography (IVC). Both imaging techniques were compared with regard to their sensitivity in the detection of anatomic variations and stones of the extrahepatic bile duct system. Our results demonstrated a great advantage of the IOC. The IOC was feasible in 98.1% of the cases and presented a complete depiction of the extrahepatic bile duct system in 99.3%. IVCs showed the biliary system in 91.4% of the cases but without visualization of the cystic duct in 51.5% and the hepatic confluence in 16%. Anatomic variations of the bile duct system which consecutively influenced the operative management were found in additional 27.6% exclusively by IOC. 71.4% of bile duct stones were not detected by IVC. The intraoperative time consumption of IOC was unimportant. The x-ray-load was clearly lower by a factor of 3.5. There was no complication after IOC. In comparison, 6.1% of patients demonstrated an anaphylactic reaction by IVC. One common duct injury (0.3%) was detected intraoperatively by IOC and at the same operation treated without postoperative complications. In conclusion, we recommend an IOC in addition to a thorough preoperative ultrasound-examination. By this technique intraoperatively identified stones of the common bile duct can be sufficiently treated by postoperative endoscopic extraction and anatomic variations of the bile duct system will be visualized and therefore accidental injuries will be avoided.     

Laparoscopic cholecystectomy and lithiasis of the common bile duct: prospective study on the importance of preoperative endoscopic ultrasonography and endoscopic retrograde cholangiography

OBJECTIVES: Laparoscopic cholecystectomy is the standard treatment of symptomatic gallstones. At present, no consensus has been reached on the diagnostic and therapeutic methods of concomitant common bile duct stones. Systematic preoperative endoscopic ultrasonography followed, if necessary, by endoscopic retrograde cholangiography and sphincterotomy during the same anesthetic procedure could be a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct. METHODS: One hundred and twenty-five patients underwent a prospective endoscopic ultrasonographic evaluation prior to laparoscopic cholecystectomy for symptomatic gallstones. Fourty-four patients (35%) had at least one predictive factor for common bile duct stones. Endoscopic ultrasonography and cholecystectomy were performed on the same day. Endoscopic ultrasonography was followed by endoscopic retrograde cholangiography and sphincterotomy by the same endoscopist in case of common bile duct stones on endoscopic ultrasonography. Patients were routinely followed up between 3 and 6 months and one year after cholecystectomy. RESULTS: Endoscopic ultrasonography suggested common bile duct stones in 21 patients (17%). Endoscopic ultrasonography identified a stone in 17 of 44 patients (38.6%) with predictor of common bile duct stones and only in 4 of 81 patients (4.9%) without predictor of common bile duct stone. Among these 21 patients, one patient was not investigated with endoscopic retrograde cholangiography because of the high risk of sphincterotomy, 19 patients had a stone removed after sphincterotomy, one patient had no visible stone neither on endoscopic retrograde cholangiography, nor on exploration of the common bile duct after sphincterotomy. Endoscopic ultrasonography was normal in 104 patients (83%). However, two patients in this group were investigated with endoscopic retrograde cholangiography because endoscopic ultrasonography was incomplete in one case and because endoscopic ultrasonography was normal in the second case but a stone in the left hepatic duct was detected by ultrasonography. A stone was removed after endoscopic sphincterotomy in these two patients. In the group of 102 patients without stone, 91 out of 92, continued to be asymptomatic during a median follow-up of 8.5 months. One patient with symptoms one month after cholecystectomy underwent endoscopic sphincterotomy but no stone was found. CONCLUSIONS: Systematic preoperative endoscopic ultrasonography followed, if necessary with endoscopic retrograde cholangiography and sphincterotomy is a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecystectomy without intraoperative investigation of the common bile duct for all patients. This alternative is only justifiable in patients with predictor of common bile duct stones.     

Ventral pancreatic resection for adenoma and low-grade malignancies of the head of the pancreas

The head of the pancreas can be anatomically divided into two sections, one drained by the duct of the Santorini system, and the other drained by the ventral pancreatic duct. This study was undertaken to determine whether independent resection of the ventral pancreas drained by the ventral pancreatic duct could be performed safely and effectively, by employing the following method in four patients. First, the duodenum and pancreas were sufficiently separated preserving the mesoduodenum and the posterior pancreaticoduodenal artery. Next, the main pancreatic duct was divided at the papillary portion, and sectioned at its junction with the duct of Santorini, ensuring preservation of the intrapancreatic bile duct. After the ventral pancreas had been detached from the glistening intrapancreatic bile duct, the ventral pancreas was connected with the dorsal pancreas by only the pancreatic parenchyma. The ventral pancreatic resection was completed following the incision of this border. A pancreatic fistula developed in one patient postoperatively, but this healed within 30 days. The hospital stay after surgery ranged from 35 to 58 days, and a good quality of life was maintained in all four patients. Thus, we conclude that ventral pancreatic resection can be safely performed and is especially valuable for treating the increasingly frequent adenomas and borderline malignancies in the main pancreatic duct system of the head of the pancreas.     

Selective and organotypic culture of intrahepatic bile duct cells from adult pig liver

Secondary culture of nontransformed bile duct epithelium has been difficult to achieve. STO feeder cell-dependent secondary cultures of adult pig bile duct cells were established from primary cultures of adult pig liver cells. Adult pig hepatocytes exhibited limited or no replication and were lost from the secondary culture at Passage 3 or 4. In contrast, adult pig bile duct cells replicated and were carried for 4-8 passages in secondary culture. A simple method to produce nearly pure pig intrahepatic bile duct cultures was first to freeze a relatively crude liver cell preparation. Upon subsequent thawing, all hepatocytes and most macrophages were lysed. Bile duct cells composed 95% of the surviving cells after the freeze/thaw, and they grew out rapidly. The bile duct cells grew on top of the STO feeder cells as closely knit epithelial, colonial outgrowths. Histocytochemical and biochemical analyses demonstrated high levels of gamma-glutamyltranspeptidase activity and low levels of P450 activity in the bile duct cultures. The bile duct cells spontaneously adopted a multicellular ductal morphology after 7-10 d in static culture which was similar to that found in in vivo pig liver. Transmission electron microscopic examination revealed complex junctions and desmosomes typical of epithelium, and lumenally projecting cilia typical of in vivo intrahepatic bile ductules. This simple method for the coculture of pig intrahepatic bile duct cells which adopt in vivo-like structure may facilitate biological studies of this important, but difficult to culture, cell type.     

Obstructive jaundice in rats results in exaggerated hepatic production of tumor necrosis factor-alpha and systemic and tissue tumor necrosis factor-alpha levels after endotoxin

BACKGROUND: Obstructive jaundice (OJ) predisposes patients to postoperative sepsis. We determined whether OJ led to an increased endotoxin stimulated tumor necrosis factor-alpha (TNF-alpha) production by macrophage-rich organs and whether a lack of intraluminal gut bile contributed to this increased sensitivity. METHODS: Rats underwent laparotomy and common bile duct ligation and division (CBDL) or sham operation after they were given low-dose endotoxin or saline solution (NS). TNF-alpha levels in plasma, perfusate from the isolated perfused rat liver, and tissue from lung, spleen, and liver were measured 90 minutes later. An additional group underwent creation of a choledochal-vesical fistula and endotoxin administration. RESULTS: The plasma TNF-alpha, liver perfusate TNF-alpha, and the tissue TNF-alpha levels in liver, lung, and spleen were significantly elevated in the CBDL + endotoxin (CBDL + ETX) group compared with the SHAM + ETX and CBDL + NS groups (p < 0.05). The choledochal-vesical fistula group after endotoxin had plasma TNF-alpha levels only 27% that of the CBDL + ETX group (p < 0.05). CONCLUSIONS: OJ sensitizes macrophage-rich organs to produce larger amounts of TNF-alpha in response to endotoxin. This sensitization is not solely due to decreased intraluminal gut bile.     

Extracorporeal shockwave lithotripsy in the treatment of common bile duct calculi

Fifteen patients with stones in the common bile duct, in whom treatment with endoscopic papillotomy and stone-extraction had been unsuccessful were treated with extracorporeal shockwave lithotripsy. Nine patients were stone-free after one or two sessions, and two patients after further endoscopic treatment. One patient achieved partial clearance and palliation. One patient had a choledochoduodenostomy performed due to ineffectiveness of the shockwave lithotripsy. Two patients, who were thought to have a stone, turned out to have neoplasma in the common bile duct. Complications were frequent but temporary and needed no treatment. We conclude that extracorporeal shockwave lithotripsy is a valuable and safe alternative in those cases where conventional endoscopic treatment has failed, and should be considered before operation, especially to old for high-risk patients.     

Intraductal ultrasonography for the diagnosis of proximal invasion in extrahepatic bile duct cancer

Intraductal ultrasonography (IDUS) was performed on 22 patients with extrahepatic bile duct cancer, using the percutaneous transhepatic approach. Intraductal ultrasonography images of the proximal invasion of the bile duct cancer were defined. In addition, three patients were examined through the peroral approach, to try to diagnose whether or not the cancer invaded to the bifurcation of the hepatic duct. Intraductal ultrasonography images obtained through the percutaneous approach could be classified into three patterns, types 1, 2 and 3, according to the features of the interior surface of the bile duct and the thickness of the bile duct wall. Type 1 images, which did not show protrusions into the bile duct lumen and had a bile duct wall of even thickness, were not likely to show bile duct cancer. Type 2 images showed protrusions of the tumour into the bile duct lumen and the surfaces of the protrusions were irregular. Type 3 images showed single or multiple low echoic papillary masses in the bile duct. Using the peroral technique, we considered all three cases to be type 1 and could diagnose that cancer had not invaded to the bifurcation of the hepatic ducts. From the results of this study, we suggest that proximal invasion of extrahepatic bile duct cancer can be diagnosed using IDUS.     

Extrahepatic peribiliary glands express alpha-amylase isozymes, trypsin and pancreatic lipase: an immunohistochemical analysis

We examined expression of alpha-amylase isozymes (pancreatic and salivary), trypsin and pancreatic lipase on the epithelium of extrahepatic peribiliary glands immunohistochemically using 53 autopsied normal extrahepatic bile ducts. Three parts of the extrahepatic bile duct (common bile duct, intrapancreatic bile duct and bile duct at the ampulla of Vater) were examined in each case. Histologically, the extrahepatic bile duct harbored branched tubular glands (extrahepatic peribiliary glands). Extrahepatic peribiliary glands were few in the common bile duct and intrapancreatic bile duct and numerous in the bile duct at the ampulla of Vater. Immunohistochemically, pancreatic alpha-amylase was expressed in the epithelium of extrahepatic peribiliary glands in 42 cases (79%). Salivary alpha-amylase was expressed in the epithelium of the glands in 38 cases (72%). Trypsin was expressed in the epithelium of the glands in 32 cases (60%). Pancreatic lipase was expressed in the epithelium of the glands in 45 cases (85%). The immunoreactivity of these enzymes was granular and located in the supranuclear cytoplasm (corresponding to the Golgi apparatus) of the epithelium of the glands. We confirmed the specificity of the immunoreactivity of these enzymes with various methods. These results suggest that extrahepatic peribiliary glands produce alpha-amylase isozymes, trypsin and pancreatic lipase and secrete these enzymes into lumens of the extrahepatic bile duct. The secreted enzymes may play an important role in the physiology of the extrahepatic bile duct and bile.     

Densities of cerebrospinal fluid and spinal anaesthetic solutions in surgical patients at body temperature

OBJECTIVE: To study the effects of monopolar diathermy on the bile ducts in pigs. DESIGN: Experimental study. SETTING: University hospital, Norway. MATERIAL: 18 pigs. INTERVENTIONS: Laparotomy, application of diathermy at standard sites along the cystic duct, the bile ducts, and a cystic duct containing a metal clip, 3 to 12 times of 5 seconds' duration at each site. Temperature was subsequently recorded at standard measurement points on the bile ducts. Twelve pigs were killed after three weeks for assessment of the bile ducts at necropsy. MAIN OUTCOME MEASUREMENTS: Increase in temperature in the bile duct walls and late changes in the bile ducts. RESULTS: Temperature increased by 4-6 degrees C during 6 of 330 diathermy applications along the cystic duct, by 4-18 degrees C in 8 of 126 applications along the common bile duct, and by 4-11 degrees C at the clip in 9 of 54 applications. There were no macroscopic or microscopic changes in the bile ducts. CONCLUSION: Monopolar diathermy induced unexpected distant increases in the temperature of the bile duct walls and at a clip on the cystic duct probably because diathermy current energy was distributed along channels of high current conductivity.     

Expression of the liver Na+-independent organic anion transporting polypeptide (oatp-1) in rats with bile duct ligation

BACKGROUND/AIMS: In rats with cholestasis due to bile duct ligation, the expression of the Na+-dependent taurocholate co-transporting polypeptide, the major uptake system for conjugated bile acids in hepatocytes, is down-regulated. Our purpose was to examine the expression of the organic anion transporting polypeptide, a Na+-independent uptake system for bile acids and organic anions, in rats with bile duct ligation, and to compare the expression of organic anion transporting polypeptide to that of Na+-dependent taurocholate co-transporting polypeptide. METHODS: Rats with bile duct ligation were studied after 1, 3 or 7 days. The expression of organic anion transporting polypeptide and Na+-dependent taurocholate co-transporting polypeptide proteins was examined by Western blot analysis and steady-state mRNA levels were determined by Northern blot analysis using cDNAs encoding organic anion transporting polypeptide and Na+-dependent taurocholate co-transporting polypeptide. Sham-operated animals were used as controls. RESULTS: The expression of organic anion transporting polypeptide protein was slightly, but not significantly, decreased 1 day after ligation (10.3%); it was markedly decreased after 3 days (56.9%; p<0.03) and 7 days (46.8%; p<0.05) compared to sham-operated animals. Steady-state mRNA levels of organic anion transporting polypeptide were decreased by 79.7% (p<0.04), 48.8% (p<0.02) and 57.4% (p<0.02) after 1, 3 and 7 days respectively. For comparison, Na+-dependent taurocholate co-transporting polypeptide protein and mRNA levels were decreased by 73.8% (p<0.03) and 70.0% (p<0.05) at 1 day and remained low after 3 and 7 days. CONCLUSIONS: In rats with bile duct ligation, the expression of organic anion transporting polypeptide protein and mRNA is down-regulated. Down-regulation of organic anion transporting polypeptide seems less pronounced than that of Na+-dependent taurocholate co-transporting polypeptide. Nevertheless, it could contribute to a decreased uptake of potentially toxic bile acids or organic anions in this situation.     

Laparoscopic treatment of gallbladder and common bile duct stones: a prospective study

The aim of this study was to investigate prospectively the feasibility, success rate, safety, and short-term results of single-stage laparoscopic treatment of gallstones and ductal stones in 100 consecutive, unselected patients. Common bile duct (CBD) stones were diagnoses at routine intraoperative cholangiography and choledochoscopy in 100 of 950 patients with gallstones undergoing laparoscopic cholecystectomy (LC). Unsuspected CBD stones were present in 39 patients (4.1% of 950; 39% of 100); 26 patients were referred for surgery after failed endoscopic sphinctertomy (ES) performed elsewhere. Transcystic duct CBD exploration (TC-CBDE) was the procedure of choice. When it was not feasible, choledochotomy and direct CBD exploration (D-CBDE) was performed. Use of biliary drainage was liberal. A completion cholangiogram was obtained for all patients. Laparoscopic treatment of CBD stones was successful in 96 patients: after TC-CBDE in 63 and after D-CBDE in 33. Four operations were converted to open surgery (4%). Retained stones, observed in five patients, were treated by ES in two cases and by percutaneous endoscopic/fluoroscopic lithotripsy in three. Minor morbidity included biloma (n = 2), port site infection (n = 2), and subumbilical hematoma (n = 1). Major morbidity was bile leakage from the cystic duct stump in two cases due to clips or transcystic duct drainage displacement, respectively. One elderly, high risk patient died after being referred for several failed attempts of endoscopic clearance; she died from cardiogenic shock 3 days after successful laparoscopic treatment. Laparoscopic CBD exploration is feasible and safe in most patients, with short-term results that compare favorably with the results of sequential ES/LC reported in the literature.