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.     

Vibration bouginage in the cicatricial strictures of esophagus

In 66 patients for the dilation of the cicatricial stricture of the esophagus vibration method was used. In 48 patients the vibrator was attached to proximal end of the bouge, in 18 patients the vibration device was introduced directly in the area of the stricture. The suggested method provided an easy and fast dilation of the stricture in 63 patients. In 3 cases surgical treatment was carried out because multiple strictures in separate areas resulted in complete obliteration of the esophagus. There were no complications due to the vibrobouginage. For the treatment of inflammatory disorders of the esophagus and for prophylaxis of the scar formation in the area of stricture in 29 patients the therapeutic laser irradiation was used. This treatment has ensured promising results.     

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%.     

Benign biliary strictures associated with recurrent pyogenic cholangitis: treatment with expandable metallic stents

OBJECTIVE: The purpose of this study was to determine the long-term effectiveness of expandable metallic stents in benign biliary strictures associated with recurrent pyogenic cholangitis and the differences in primary patency of the various types of stents deployed. SUBJECTS AND METHODS: During a 20-month period, 26 metallic stents (19 Gianturco-Rosch Z stents and seven Strecker stents) were used to treat benign biliary strictures associated with recurrent pyogenic cholangitis in 23 patients (11 men and 12 women; mean age, 42 years; range, 30-78 years). Insertion routes were percutaneous transhepatic biliary drainage tracts for 16 stents, T-tube tracts for seven stents, and retrograde endoscopic routes for three stents. The deployed locations were common hepatic or common bile ducts for 11 stents, right or left hepatic ducts for 10 stents, and segmental ducts for five stents. RESULTS: The initial technical success rate was 100%. Two stents in one patient migrated spontaneously. Primary stent patency for the remaining 24 stents was 34 months (range, 3-58 months). Primary stent patency of the Gianturco-Rosch Z and Strecker stents was 50 and 10 months, respectively (p < .05). Primary stent patency for the intrahepatic and extrahepatic ducts was 50 and 18 months, respectively (p = .05). Primary patency rates for all stents at 6, 12, 24, and 36 months were 92%, 75%, 67%, and 46%, respectively. The causes of stent obstruction were recurrent stone or sludge in eight stents and epithelial hyperplasia in five stents. CONCLUSION: We believe that metallic stent placement is not an effective long-term treatment technique for benign biliary stricture associated with recurrent pyogenic cholangitis.     

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.     

Shape-memory nitinol alloy endoprosthesis for malignant biliary strictures

A new design of endoprosthesis, made of shape-memory nitinol alloy, was used to replace the currently used one, which was soon clogged with bile mud. After nitinol wire coil stent was slenderized in ice water, it was inserted into the strictured bile duct by endoscopy or operation. When nitinol wire coil was positioned in a narrowed biliary segment, normal saline heated to 39 degrees C was rapidly hand-injected into the lumen of the inner transport catheter to make the alloy coil to resume its original shape with a length of 3 to 10cm, and a diameter of 5 to 10mm. Since June 1991, 13 patients with malignant biliary strictures were treated with nitinol endoprosthesis. The follow-up period ranged from 1 to 16 months (average 6 months). Biliary sludge was not found in the endoprosthesis during the period. The results suggested that shape-memory nitinol alloy endoprosthesis could maintain long term patency without severe infection or obstruction due to biliary sludge.     

Endoscopic management of biliary tract strictures in primary sclerosing cholangitis

BACKGROUND AND STUDY AIMS: In a subgroup of patients, primary sclerosing cholangitis (PSC) is complicated by high-grade focal strictures of the bile ducts, and this can have an unfavorable influence on the natural course of the disease. The aim of this study was to evaluate the efficacy and safety of endoscopic treatment in this selected patient group. PATIENTS AND METHODS: Twelve symptomatic patients with primary sclerosing cholangitis and major ductal strictures were included in a prospective study of endoscopic treatment. All patients were managed by repeated angioplasty-type balloon dilation and nasobiliary catheter perfusion. A minimum of two treatment sessions was used, and therapy was continued until satisfactory reopening of the strictures was obtained. Routine endoscopic follow-up was performed after three, six, 12, 18, and 24 months, and then at yearly intervals. The efficacy of therapy was assessed by evaluating clinical symptoms, laboratory data, and cholangiograms. RESULTS: The long-term follow-up averaged 23 months (range: 12-50 months). Two to nine (mean: three) treatment sessions were required to obtain satisfactory reopening of major biliary strictures. Eight patients showed considerable and sustained improvement. The mean serum bilirubin, alkaline phosphatase, gamma-glutamyl-transpeptidase, and alanine aminotransferase levels felt significantly by 73% (P = 0.0164), 46% (P = 0.0022), 55% (P = 0.0022), and 58% (P = 0.0022), respectively. The average radiographic stricture score before treatment was 3.2 +/- 0.8 (P = 0.0033). Three patients required liver transplantation seven, 12, and 40 months after the initiation of endoscopic treatment, due to a deterioration in hepatic function or an inability to exclude complex biliary malignancy. No major procedure-related side effects were observed. CONCLUSIONS: Our results suggest that the endoscopic treatment of PSC patients with dominant bile duct strictures is effective, safe, and well-tolerated. However, it is important not to overlook the potential development of cholangiocarcinoma.     

Surgical significance of extrahepatic biliary tree anomalies

A patient with an anomalous insertion of the right hepatic duct into the cystic duct was noted during cholecystectomy and confirmed by operative cholangiography. This case and related anomalies of the bile ducts are of sufficient importance that, because of the technical difficulties and dangers incidental to their presence, no surgeon who operates on the gallbladder and bile ducts can afford to be unaware of their existence. Adequate exposure, careful dissection, and accurate knowledge of the regional anatomy plus a realization of the frequency and multiplicity of abnormalities of the extrahepatic biliary tree are requisites for safe biliary tract surgery. In addition, carefully performed operative cholangiography can be an indispensable aid in the clarification of anatomic variations. In case of recognized operative injury to the extrahepatic biliary tree, primary repair or biliary-intestinal anastomosis can usually be carried out with good results.     

Surgical widening of strictures in the small intestine in Crohn disease

Twenty-two stricture plasties were performed in five patients with multiple stenosis of the small intestine due to Crohn's disease. Immediate post-operative results were satisfactory but progressive degradation followed. These findings are similar to those reported in the literature on this technique which does not give better results than other methods since none have an effect on the clinical course of the disease. The only advantage is to decrease the amount of intestinal mutilation.     

Endoscopic retrograde wire-guided cytology of malignant biliary strictures using a novel scraping brush

A cigarette which heats rather than burns tobacco (Premier) was introduced in 1988, but was unacceptable due to unpleasant taste and low nicotine intake. We examined availability of nicotine from a new version (Eclipse), in the same four subjects as our earlier Premier study. Average blood nicotine boosts of 23.7 and 17.8 ng/ml were obtained from smoking a first and second Eclipse. This substantially exceeds intake from Premier (boost 13 ng/ml) and that obtained by heavy smokers from conventional brands (boost 12-15 ng/ml). Eclipse (or similar product) may be the best option for averting Peto's dire warnings of rising millions of annual smoking deaths in the 2020s, and its potential for large-scale, long-term switching warrants further study.     

Operative treatment of the endobronchial tuberculosis with cicatricial bronchiarctia

OBJECTIVE: The experience of surgical treatment in 32 patients with cicatricial brochiarctia by endobronchial tuberculosis was reported. METHOD: The modes of surgical treatment in the series include: sleeve resection was done in 19 cases, lobectomy in 4 cases, pneumonectomy in 7, and left principal bronchial reconstruction in 2 cases. RESULTS: The results were excellent and without operative death. Serious postoperative complication was bronchopleural fistula in one case. The patient was treated by surgical repair of the bronchial stump and buttressed with vascularized pedicle flaps of omentum in the second operation. 2 cases of 32 patients were affected with mild stenosis of bronchial anestomosis after a follow-up of 12 to 18 months. CONCLUSIONS: It was suggested that when the patient developed the endobronchial tuberculosis with cicatricial bronchiarctia, corrective operation should be performed as early as possible, and the sleeve resection should be the first choice.     

Usefulness of K-ras gene mutation at codon 12 in bile for diagnosing biliary strictures

Point mutations of the K-ras gene at codon 12 are often detected in the pancreatic juice of patients with pancreatic cancer. Detection of these mutations may, thus, have diagnostic implications. K-ras mutations may also have diagnostic potential for other biliary tumors. We sought to detect K-ras mutations in DNA obtained from bile in patients with biliary tract cancers, pancreatic cancer and benign biliary disease but who had obstructive jaundice. In 35 patients, bile was collected during percutaneous transhepatic choledocal drainage (PTCD) catheters. K-ras gene mutations at codon 12 in the samples were examined using mutant-allele-specific-amplification (MASA). We compared these results with cytological analyses of bile. K-ras mutations at codon 12 in bile were detected in 11 of 14 (79%) of the patients with biliary duct cancer, 3 of 9 (33%) with pancreatic cancer but not in patients with gallbladder cancer (n=3), papilla of Vater's cancer (n=3) or benign biliary diseases (n=6). In the patients, where cytological evaluation did not reveal malignant cells, K-ras mutations in bile were detected in 5 of 7 (71%) patients with biliary duct cancer and 2 of 5 (40%) with pancreatic cancer. This approach, when used in conjunction with bile cytology, may improve the yield in diagnosing suspected malignant tumors of the pancreatic-biliary system.     

Subconjunctival mitomycin C for the treatment of ocular cicatricial pemphigoid

PURPOSE: The authors performed a prospective evaluation of the efficacy of treating ocular cicatricial pemphigoid (OCP) with subconjunctival mitomycin C. DESIGN: Unmasked, prospective, internally controlled case series. METHODS: Patients were eligible for treatment with subconjunctival mitomycin C under three criteria: (1) significant complications of systemic immunosuppressant therapy; (2) markedly asymmetric conjunctival disease; and (3) end-stage OCP. All patients received monocular subconjunctival injections of 0.25 ml of 0.2 mg/ml mitomycin C to both the superior and inferior bulbar conjunctivae in the eye with the more severe disease. RESULTS: Nine eyes of nine patients (mean age, 74 years) were treated with subconjunctival mitomycin C to the more-involved eye and were followed for a mean of 23.5 months (range, 12-40 months). Eight of nine patients showed quiescence of their OCP in the treated eye based on serial evaluation of conjunctival cicatrization and grading of conjunctival erythema. Five of the nine untreated eyes showed progression of the conjunctival disease. One patient required concomitant systemic immunosuppressive therapy after subconjunctival mitomycin C. Two patients underwent successful visual rehabilitative surgery in the mitomycin C-treated eye. CONCLUSION: The use of subconjunctival mitomycin C may be effective in preventing progression of conjunctival cicatrization and erythema in patients with OCP. No complications of mitomycin C treatment were noted. Long-term follow-up and further investigation into the efficacy of subconjunctival mitomycin C in the management of OCP is warranted.     

Benign nonpeptic esophageal strictures. Diagnosis and treatment

This article studies the causes and treatment of benign nonpeptic esophageal strictures. The authors also discuss various therapeutic techniques for esophageal strictures, including esophageal dilatation with various dilators and balloons. Although the goals of stricture therapy are to relieve dysphagia and prevent stricture reoccurrence, only the first of these goals (effective dilatation with bougienage or balloon dilatation) has been achieved. The prevention of stricture reoccurrence remains to be achieved.     

Liver transplantation: does prolonged storage promote non-anastomatic biliary strictures [correction of structures] ?

Many osteopathic medical students and physicians have an inherent fear of injuring patients when they perform osteopathic manipulative treatment (OMT). Based on the estimated several hundred million treatments performed each year in the United States as well as a review of the literature over the past six decades, only 185 reports of injury were found. However, besides good training in these techniques, the key to the safety of OMT is the taking of a thorough patient history and performing a thorough physical examination before the application of any manipulative procedure.     

Cholangiographic features of biliary strictures after liver transplantation for primary sclerosing cholangitis: evidence of recurrent disease

Cervico-vaginal smears were quite difficult to accept when they were first introduced in France, during the fifties, probably due to a fear that cytology might replace surgical pathology, whereas both methods may develop close together. At last, bridging the gap was accomplished by the pathologists and, nowadays, a number of cytopathologists have been trained and have become quite clever. Obviously, clinicians cannot do without the method described by George N. Papanicolaou (the so-called Pap test). Although cervical carcinoma is the very one cancer that should have been eradicated, as complete recovery is the rule when the diagnosis is made in time, at the preinvasive stage of the tumor, in France it is still responsible for 2000 annual deaths. Systematical target population screening should be organized, as well as in other countries and should become one of the main priorities of health care control.