Cystic duct leaks in laparoscopic cholecystectomy.

BACKGROUND: Cystic duct leak (CDL) appears to complicate laparoscopic cholecystectomy (LC) more often than open cholecystectomy (OC). No mention of CDL was found in a literature review that covered 48,822 OCs and their complications. PATIENTS AND METHODS: Fifty-four patients who developed biliary tract injuries following LC were reviewed for: the time from LC to presentation, presenting symptoms, method of diagnosis, treatment, outcome, and follow-up. RESULTS: Seventeen of 54 biliary tract complications (31%) were CDLs. The CDLs presented at a median of 4 days after LC with pain (76%) and nausea and/or vomiting (35%). Endoscopic retrograde cholangiopancreatography (ERCP) defined the diagnosis and the anatomy of the leak in 11 patients (65%). Biliary endoprosthesis placement was employed in 8 patients, with concomitant sphincterotomy in 5 (63%), and resolved CDL in every case. Seven (88%) of these patients were asymptomatic at a median interval of 10 months after stent retrieval. Six patients (35%) underwent reoperation. Five had laparotomy with ligation of the cystic duct stump and 1 underwent laparoscopic examination with reclipping of the cystic duct stump. Five (83%) were asymptomatic at a median follow-up of 26 months. CDLs may result from inaccurate clip placement, perforations proximal to the clips, and stump necrosis, as documented at reoperation. CONCLUSIONS: CDLs occur more frequently in LC than in the OCs reported in the literature. Most leaks require intervention. ERCP with stent placement is the diagnostic and therapeutic procedure of choice and has a high success rate of resolving leaks. To forestall CDLs, it is important to place clips accurately and avoid electrocautery in the vicinity of the cystic duct.

Complicated access for regional infusion chemotherapy. A consequence of variant hepatic artery anatomy.

Arterial access for regional infusion chemotherapy of primary or metastatic liver cancers may be complicated because of inadequate vessel size or variant hepatic artery anatomy. Recently, an unusual case required that we devise an extemporaneous method of single-catheter access. This approach may, in selected cases, be an acceptable and safe alternative to a more traditional access technique.

Interaction of hindlimb blood flow, A-V shunting and A-V oxygen difference.

The interactions of blood flow, A-V O2 difference (AVDO2), and A-V shunting were measured in normal hindlimbs of nine anesthetized dogs. An aorto-iliac nonpulsatile perfusion pump was used to change femoral artery blood flow from zero (collateral flow only) to twice its baseline level. Femoral AVDO2 was measured by in-line spectrophotometric O2 analysis. A-V shunting was measured with radio-labeled microspheres. Systemic hemodynamic parameters and temperature remained constant during the experiments. Despite changes in femoral mean arterial pressure (160 to 54 mm Hg) and AVDO2 (1.8 to 8.2 ml O/2/dl) that occurred with femoral blood flow reduction, peripheral A-V shunting remained constant at 4.1-5.5%. Alpha-adrenergic ablation (sympathectomy) was used to increase A-V shunting (up to 20%) during part of this experiment. When hindlimb blood flow was normal or increased, autoregulation of O2 extraction maintained constant hindlimb O2 consumption, despite sympathectomy-induced changes in A-V shunting. Subnormal femoral artery blood flow reduced hindlimb O2 consumption, and in this setting the increased A-V shunting further decreased femoral AVDO2 and O2 consumption. Since AVDO2 is dependent upon both blood flow and the variable efficiency of cellular O2 extraction, it cannot be used as an accurate indicator of A-V shunting. Direct microsphere techniques should be applied to A-V shunt measurements in clinical settings where A-V shunting is suspected.