Role of intraoperative enteroscopy in the management of gastrointestinal bleeding of small bowel origin

Through the period between June 1985 to January 1990, 28 patients were operated because of gastrointestinal bleeding of small bowel origin. The procedure of intraoperative enteroscopy was selected for 13 cases of this group of patients. Eight of whom were men. The indications for intraoperative enteroscopy were: To detect otherwise occult lesions not evident by gross examination [seven cases], to confirm bleeding from known lesions [three cases], and to aid in determining the extend of necessary resection [three cases]. Enteroscopy was successfully performed in all cases either through per os route [five cases] or through small bowel enterotomy [eight cases]. Inspection of the small bowel through a small bowel enterotomy has a several advantages over per os and transanal routes. Bleeding was totally controlled in eleven patients during a mean follow up period of 12 months. Two patients died six months and one year after operation because of advanced neoplasia. No serious complications related directly to enteroscopy were encountered. Intraoperative enteroscopy is reliable, accurate and safe procedure. It is now an essential adjunct to laparotomy for gastrointestinal bleeding of small bowel origin

Urgent endoscopic drainage for acute suppurative cholangitis due to choledocholithiasis

Sixty-four patients with acute suppurative cholangitis due to choledocholithiasis, who did not respond to conservative management, underwent urgent endoscopic drainage of the biliary system at a mean of 1.5 days after admission. Treatment was successful in 54 patients [85%]. They were classified into four groups. Group 1 included 33 patients for whom adequate sphincterotomy and nasobiliary drainage were done. Group 2 included 12 patients with coexisting coagulopathies for whom small papillotomy [<0.5 cm] and nasobiliary catheter drainage were performed. Group 3 included 7 patients, properly selected, for whom adequate sphincterotomy and stone extraction were done in the same session. Group 4 included 2 patients underwent drainage and stone extraction via a previous choledochoduodenostomy. Post-sphincterotomy bleeding was seen in 4 cases [7.5%]. The bleeding was controlled either by local adrenaline injection 1/10.000 [in 3 cases] or by heat probe thermocoagulation [in one case]. Seven patients died, 5 of them were among those underwent endoscopic drainage [9.2%]. Three cases were in group 2 and 2 cases were in group 1. The cause of death was uncontrollable sepsis despite adequate drainage. In conclusion, urgent endoscopic drainage could be used successfully to control biliary sepsis and should be offered to all patients with acute suppurative cholangitis

Management of benign high bile duct strictures following cholecystectomy

Biliary sepsis was controlled by proper antibiotics. Patients with subdiaphragmatic bilomas underwent ultrasonic guided drainage. PTC was the most valuable method of diagnosis in the majority of cases. It should be scheduled immediately prior to repair. Stricture repair using side to side hepaticojejunostomy was performed in 19 patients [16 type 3 and 3 type 4]. Bilateral jejunal mucosal graft was performed in 5 cases [all type 4], where exposure of the left duct system was difficult. There were no operative deaths. Follow up was done for a mean period of 4 years [range 3-6 years]. Among those managed by jejunal mucosal graft, two developed re-stenosis. This was 6 months and one year after repair. Both underwent percutaneous transhepatic balloon dilatation. One patient expired after an attack of hemobilia, while the second was successfully dilated with no evidence of re-stenosis for a follow-up period of 12 months. None of the patients underwent side to side hepaticojejunostomy developed re- stenosis. The overall success rate of side to side hepaticojejunostomy in dealing with high bile duct stricture was about 80%. In conclusion, the majority of high bile duct strictures can be managed with a high rate of success by side to side hepaticojejunostomy. In absence of liver disease and previous attempts of repair the long term results in these cases are excellent. Jejunal mucosal graft should be considered for patients in whom the biliary mucosa is inaccessible despite a deep and adequate dissection. Patients with re-stenosis after jejunal mucosal graft can be managed by percutaneous transhepatic balloon dilatation