Evaluation of bilioenteric anastomosis using quantitative hepatobiliary scintigraphy.

BACKGROUND/AIMS: The patterns of quantitative hepatobiliary scintigraphy for bilioenteric anastomoses have not been objectively defined. This study was undertaken to establish the patterns of quantitative hepatobiliary scintigraphy in the patients with bilioenteric anastomoses performed for repair of postcholecystectomy benign biliary strictures. METHODOLOGY: 37 patients with bilioenteric anastomosis (Study group) and 10 postcholecystectomy healthy subjects (Controls) underwent quantitative hepatobiliary scintigraphy. Study group patients were further categorized into: Group A (n=27) - normal clinical and biochemical parameters, and Group B (n=10) - abnormal clinical and/or biochemical parameters. On scintigraphy, time of maximal activity and time of clearance of half of the activity was calculated at the liver parenchyma and hepatic hilum. Time of appearance of activity in the intestine was also recorded. RESULTS: There was no significant difference in the scintigraphic parameters between Group A and Controls except for earlier appearance of activity in the intestines (p=0.036) in Group A. In Group B there was significant increase in the time of clearance of half of the activity at the liver parenchyma and hepatic hilum compared to Controls (p=0.003 and 0.036 respectively), and at the liver parenchyma compared to Group A (p=0.002). CONCLUSIONS: Quantitative hepatobiliary scintigraphic patterns in patients with bilioenteric anastomosis were similar to those of postcholecystectomy controls. Patients with abnormal biochemical parameters had significant delay in clearance of activity. Significance of these scintigraphic patterns in this subset of patients can be determined only on long-term follow-up.

Abdominal tuberculosis: diagnosis by laparoscopy and colonoscopy.

BACKGROUND: Histopathological confirmation in abdominal tuberculosis is difficult due to suboptimal noninvasive access to the involved area. Peritoneoscopy and colonoscopy provide semi-invasive access to the peritoneum, large intestine and ileocecal area. Information on the diagnostic yield of these two investigation in abdominal tuberculosis is scarce. OBJECTIVE: To evaluate the role of laparoscopy and colonoscopy in the diagnosis of abdominal tuberculosis. PATIENTS AND METHODS: Between January 1998 and July 2001, 34 patients were diagnosed to have abdominal tuberculosis on the basis of laparoscopy or colonoscopy. The case records of these patients were retrospectively reviewed to assess the usefulness of laparoscopy and colonoscopy in the diagnosis of abdominal tuberculosis. RESULTS: Laparoscopy was performed in 23 patients. Peritoneal tuberculosis was diagnosed in 19 of them, characterized by presence of ascites, multiple whitish tubercles, fibrous bands and adhesions, hyperaemic edematous bowel loops or dense adhesions without ascites. Multiple jejunoileal hyperemic short segments with serosal neovascularization was noticed in three patients. One patient had cecal mass with pericecal inflammatory adhesions. In three patients, laparoscopy was converted to open laparotomy due to bowel injury, extensive adhesions, and difficulty in assessing lymph nodal mass in one patient each. Peritoneal biopsy confirmed the diagnosis in 10 of the 15 (67%) patients. In one patient pericecal tissue biopsy confirmed the diagnosis. The remaining patients received therapeutic trial with anti tuberculosis treatment. All patients showed good response. Thus laparoscopy provided positive diagnosis of tuberculosis in 20/23 (87%) and positive histology in 10 of the 15 (67%) patients with peritoneal lesions. Thirteen patients underwent colonoscopy. Mucosal lesions involving terminal ileum, cecum and colon was noted in 11 patients. Colonoscopic biopsy confirmed the diagnosis in six of the 11 patients (54%). Non of these patients had any complication related to colonoscopy. CONCLUSION: Laparoscopy was safe and helped in the diagnosis of peritoneal as well as intestinal tuberculosis in 87% of patients. Colonoscopy is useful for colonic and terminal ileal lesion with a positive diagnostic yield of 54%.

Laparoscopic bile duct injuries: spectrum at a tertiary-care center.

BACKGROUND AND PURPOSE: Laparoscopic cholecystectomy (LC) is associated with a higher incidence of bile duct injury than is open cholecystectomy. We reviewed our experiences with the management of laparoscopic bile duct injuries. PATIENTS AND METHODS: From October 1992 through August 1998, 34 patients with bile duct injuries (BDI) following LC were seen. The presentation, type of injury (Strasberg classification), management, and outcome were analyzed in these patients. RESULTS: Of the 16 patients who sustained injury at our center (type A [N = 9], D [N = 5], and E1 [N = 2]), in 14, the injury was detected during LC, and two patients manifested with postoperative bile leak. All patients had an excellent outcome at a median follow-up of 5.5 (range 1.9-8.0) years. Of the 18 patients who sustained injury elsewhere (type C [N = 1], D [N = 2], E [N = 14; 6 with external biliary fistula (EBF) and 8 with benign biliary stricture (BBS)], and not known [1]), 9 had EBF, 1 had biliary peritonitis, and 8 had BBS at the time of presentation. Of these 18 patients, 4 underwent early repair of the BDI before referral (repair over a T-tube [N = 2] and Roux-Y hepaticojejunostomy [N = 2]). Three of them developed restricture. One patient was referred to us within 12 hours of injury and had a successful repair over a T-tube. Two patients with early repair for lateral injury had an excellent outcome. Eleven patients with BBS underwent repair with an excellent (N = 10) or fair (N = 1) outcome at a median follow-up of 5.0 (2.0-6.2) years. Three patients were lost to follow-up. CONCLUSION: The spectrum of injuries sustained at LC at a tertiary-care center is different from that in the community hospitals. Missed injuries and attempts at repair in inexperienced hands result in serious sequelae of stricture formation and long-term morbidity.