Post-operative bile duct strictures: Management of eight patients

Management of eight patients with benign bile duct stricture following cholecystectomy is discussed. Seven patients had been operated for gall stones while one had undergone cholecystectomy and repair of hepatic duct confluence after blunt abdominal trauma. Five patients had undergone multiple operations before referral to this hospital on admission, all the patients had abnormal liver function tests. Three patients had low serum albumin, 4 had a history of previous major infection and one patient had associated cirrhosis and portal hypertension. Five patients had an external biliary fistula. All the patients were operated upon: 4 by mucosal graft operation [Bismuth type-IV], 3 by hepatico-jejunostomy by direct suture [Bismuth type-III and II] and one by choledocho-duodenostomy [Bismuth type-I]. There were no post-operative deaths in patients treated by hepaticojejunostomy. One of the 4 patients treated by mucosal apposition died in the immediate postoperative period; he had associated cirrhosis and portal hypertension. Six patients [75%] have a good result with a mean follow up of 3.5 years [range 2-8 years]. One patient has occasional attacks of jaundice and fever and persistently raised serum alkaline phosphatase. Factors influencing outcome were prolonged jaundice, site of stricture, number of previous attempts at stricture repair, associated cirrhosis and portal hypertension

Omental grafting in fore arm

A 45 years old female patient was admitted with extensive fore arm injury after a road side accident. There was loss of skin and muscles of the flexor compartment. Most of the flexor muscles were lost leaving the bones necked. Only a few muscles were left in the extensor compartment but the skin was totally lost. The skin on the dorsum of the hand was also lost. The remaining tendons were left necked. The finger tips were pale and cold. After 48 hours the finger rips became black. The greater omentum was mobilised through a mini lap to cover the extensive raw area to provide coverage to the bones and tendons and to bring nutrition to the ischaemic hand

Smith's mucosal graft operation in a case of external biliary fistula

A patient with external biliary fistula after cholecystectomy was admitted in Surgical Unit-1, Nishtar Hospital, Multan. The patient had fever and jaundice which was obstructive in nature. On exploratory laparotomy, bile was seen coming out of a track lined by fibrous tissue. After a tediouss dissection of the track, we ended up with the finding of the openings of right and left hepatic ducts in the porta hepatis. The common hepatic duct and the common bile duct could not be traced. A short distal stump of common bile duct was found after duodenotomy and probing of the ampulla of Vater. An end to end anastomosis of the duct was not possible. A mucosal graft operation was performed. The problems of management of this complication, are discussed

Smith's mucosal graft operation in a case of external biliary fistula

A patient with external biliary fistula after cholecystectomy was admitted in Surgical Unit-1, Nishtar Hospital, Multan. The patient had fever and jaundice which was obstructive in nature. On exploratory laparotomy, bile was seen coming out of a track lined by fibrous tissue. After a difficult dissection of the track, we ended up with the finding of the openings of right and left hepatic ducts in the porta hepatis. The common hepatic duct and the common bile duct could not be traced. A short distal stump of common bile duct was found after duodenotomy and probing of the ampulla of Vater. An end to end anastomosis of the duct was not possible. A mucosal graft operation was performed. The problems of management of this complication are discussed