Bile duct injury during laparoscopic cholecystectomy.

OBJECTIVE: To determine the nature of bile duct injuries during laparoscopic cholecystectomy, the treatment of these injuries and patient outcome. DESIGN: Case series review. SETTING: Two tertiary care hospitals. PATIENTS: Twenty-one patients (average age 37 years) who sustained bile duct injuries during laparoscopic cholecystectomy over a 2-year period. Two groups were analysed: patients whose injury was recognized intraoperatively (9 patients) and patients in whom it was diagnosed postoperatively (12 patients). INTERVENTIONS: Laparoscopic cholecystectomy, duct-to-duct repair over a T tube, Roux-en-Y hepaticojejunostomy, endoscopic cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC). RESULTS: Misidentification of the common duct during laparoscopic cholecystectomy, resulting in accidental division or resection of a portion of the duct, and obstruction of the duct by hemoclips were the most common types of injury. Pain, jaundice and bile collections were the typical presenting features of injuries that became evident after laparoscopic cholecystectomy. ERCP and PTC accurately defined the injuries. Immediate duct-to-duct repair over a T tube was associated with a high failure rate. Twenty of the 21 patients required Roux-en-Y hepaticojejunostomy for definitive treatment. There were no deaths. CONCLUSIONS: Proper identification of the pertinent anatomy will prevent the majority of these injuries. Prompt radiographic visualization of the biliary tract is indicated in patients who have pain, jaundice and bile collections postoperatively. A hepaticojejunostomy is the procedure of choice for repair of these bile duct injuries.

Endoscopic retrograde cholangiopancreatography in the management of choledocholithiasis with laparoscopic cholecystectomy.

With the advent of laparoscopic cholecystectomy, endoscopic retrograde cholangiopancreatography (ERCP) has an increasing role in perioperative management. To assess this role, the authors studied, retrospectively, 12 patients who underwent ERCP out of a series of 475 who had laparoscopic cholecystectomy. ERCP was indicated preoperatively for biliary colic in four patients, gallstone pancreatitis in two and common bile duct stone on ultrasonography in one. ERCP was performed postoperatively for jaundice in three patients, for cholangitis in one and for a positive intraoperative laparoscopic cholangiogram in one. Choledocholithiasis was diagnosed in six patients preoperatively and in three postoperatively. Only one patient had an unsuspected residual bile duct stone postoperatively. Of nine patients with stones, endoscopic sphincterotomy was performed in eight and stones were cleared in all with no complications; a stone passed spontaneously in the other patient. ERCP is indicated before laparoscopic cholecystectomy in cases of jaundice, gallstone pancreatitis, cholangitis, abnormal liver biochemistry suggesting cholestasis and ultrasonographic demonstration of either a common bile duct stone or a common bile duct greater than 8 mm in diameter. Operative laparoscopic cholangiography is indicated when the anatomy is unclear or the bile duct appears dilated. If choledocholithiasis is founded, the options include open or laparoscopic common bile duct exploration and intra- or postoperative endoscopic sphincterotomy.

Adenocarcinoma of the pancreatic ducts: comparative evaluation with CT and MR imaging at 1.5 T.

A prospective comparison of computed tomography (CT) and magnetic resonance (MR) imaging at 1.5 T was performed in 50 patients with the suspected diagnosis of pancreatic carcinoma. CT scans were obtained before and after administration of contrast material in 41 of 50 patients (82%); 34 of 41 postcontrast scans (83%) were obtained with dynamic CT. MR images were interpreted without knowledge of the results of CT, ultrasound, cholangiography, or endoscopic retrograde cholangiopancreatography in 48 patients (96%). Surgical correlation of findings at CT and MR imaging was performed in 24 patients (48%) at laparotomy and in two patients (4%) at autopsy. On T1-weighted MR images, relatively diminished signal intensity of tumor compared with that of the adjacent pancreas was a consistent finding. MR imaging proved superior to CT in identification of pancreatic carcinoma (particularly in smaller intrapancreatic tumors), peripancreatic extension, vascular and portal vein invasion, and duodenal invasion. These results suggest that MR imaging of the pancreas is superior in many instances to CT in preoperative evaluation of pancreatic carcinoma.

Fate of the gallbladder with cholelithiasis after endoscopic sphincterotomy for choledocholithiasis.

Endoscopic sphincterotomy is the treatment of choice for choledocholithiasis after cholecystectomy. Its role has been expanded to treat choledocholithiasis in patients with gallbladders still in place. The authors report their experience with endoscopic sphincterotomy, with emphasis on the safety of the procedure, in high-operative-risk patients with choledocholithiasis and gallbladder in situ. Stones were successfully removed in 72 of 75 patients (96%); 1 required an emergency operation and 2 an elective one. Complications included bleeding, pancreatitis and cholangitis; there were no associated deaths. Follow-up of 54 of the patients, who had associated cholelithiasis at the time of endoscopic sphincterotomy, showed that 14 died of causes unrelated to the biliary tract. Of the others, 14 underwent cholecystectomy for failure of endoscopic sphincterotomy (2), acute cholecystitis (4) or persistent biliary tract symptoms (8). The other 26 patients were well after a mean follow-up of 30.4 months; 1 had mild biliary tract symptoms. Ultrasonography in 16 of the 26 patients showed persistent cholelithiasis in 12. Life-table analysis revealed a 15% probability of acute cholecystitis within 5 years of endoscopic sphincterotomy.

Radiologic findings of retroperitoneal perforation after sphincterotomy.

The radiographs of all patients with perforation into the retroperitoneum following endoscopic sphincterotomy, performed between 1981 to 1984 at University Hospital, London, Ontario were reviewed retrospectively. The incidence of perforation was very low. There were only three patients with perforation (1.1%), although 264 sphincterotomies had been performed. The initial and most important radiological findings are air and contrast medium in the retroperitoneum outlining the right kidney; a mottled air and soft tissue density in the right anterior pararenal space due to leak of duodenal contents, bile and air; or both of these findings together. With ultrasonography, a right paranephric fluid collection or an inflammatory mass adjacent to the right kidney or both may be better visualized. Computed tomography, the definitive study, delineates the true extent of the fluid or mass in the anterior pararenal space. Early detection by the radiologist is mandatory to minimize morbidity. To make this diagnosis early requires a high index of suspicion when reviewing the abdominal radiographs of those patients with pain during, or a few hours after, sphincterotomy.

Histologic sequelae of endoscopic sphincterotomy: a canine experiment.

Concern for the late formation of strictures at the site of an endoscopic sphincterotomy has delayed the acceptance of this procedure as treatment for choledocholithiasis in otherwise healthy patients. The authors addressed this issue by comparing the biochemical and histologic sequelae of sphincterotomy in 23 dogs with those in 10 sham-operated controls. Twenty-four hours after sphincterotomy, hemorrhagic, edematous mucosa surrounded the incision. Microscopically, there was an acute inflammatory exudate bridging the mucosal surfaces. Mucosal regeneration was sufficient after 1 week to cover the defect caused by the cautery, although some inflammatory changes were still evident. A widely patent sphincterotomy orifice was seen in 15 dogs followed up for 10 weeks. In three dogs, the fibres of the papilla had reunited below the incision, resulting in a choledochoduodenal fistula. Histologically, complete healing of the mucosal surface had occurred with no evidence of scar formation or chronic inflammation. Serum bilirubin and liver enzyme measurements did not show evidence of biliary obstruction due to the sphincterotomy. From the results of our study, there is no evidence to suggest that an endoscopic sphincterotomy is predisposed to late stenosis.

Hemobilia after percutaneous liver biopsy: role of endoscopic retrograde cholangiopancreatography and sphincterotomy.

Hemobilia is a rare complication of percutaneous liver biopsy. We present such a case that demonstrates the usefulness of endoscopic retrograde cholangiopancreatography in establishing the diagnosis, the importance of localization of the bleeding site by angiography, and the therapeutic usefulness of arterial embolization for the control of persistent bleeding. Also, we propose a possible indication for endoscopic sphincterotomy in the rare case where retained intrabiliary blood clot causes progressive obstructive jaundice complicated by severe pain and sepsis.

Diagnosing papillary stenosis by technetium-99m HIDA scanning.

The diagnosis of papillary stenosis, occasionally seen after cholecystectomy, is confirmed by endoscopic retrograde cholangiopancreatography (ERCP), which demonstrates delayed emptying of contrast material into the duodenum for more than 45 minutes. The authors assessed 2,6-dimethyl phenyl carbamoyl methyl iminodiacetic acid labelled with technetium-99m (99mTc HIDA) as a less invasive procedure in these circumstances by comparing it with the findings from ERCP. Twenty-six patients who had pain after cholecystectomy were studied by continuous 1-hour scintigraphy after injection of 99mTc HIDA. Biliary flow was estimated by measuring uptake and clearance of the entire liver and common bile duct. Volunteers who had no pain after cholecystectomy served as controls. Of the 26 study patients, all 99mTc HIDA scan findings were within the control range in 11. Of these, 10 had normal biliary drainage confirmed by ERCP. The one patient with delayed drainage did not improve after endoscopic sphincterotomy. Two patients demonstrated pooling of 99mTc HIDA in cystic dilatations of the biliary tree, while the other 13 patients had obstruction of the distal common bile duct and impaired flow demonstrated on the 99mTc HIDA scan. All 13 of these patients had papillary stenosis proven by ERCP. The authors conclude that 99mTc HIDA scanning is a valuable, minimally invasive method of diagnosing papillary stenosis.

Endoscopic papillotomy.

Endoscopic papillotomy is a major therapeutic advance in the management of common bile duct obstruction. During 1981, the procedure was performed in 48 of 51 patients between 17 and 93 years of age. There were 13 men and 35 women. Common duct stones were removed in 26 of 31 patients (84%), six of whom had their gallbladders in place and two of whom had cholangitis. Failure in five patients occurred because of stone adherence to the common duct wall, stone size, ductal stenosis, or caught Dormia basket. Papillotomy was done in 10 of 11 patients for stenosis, two for recurrent pancreatitis, two with the sump syndrome, one for hemobilia, and one for bile duct tumor biopsy. The "precut" technique was required in 11 patients. Mild pancreatitis developed in three patients and severe hemorrhagic pancreatitis in one. Three of the four had the precut technique. One patient had minor bleeding, and two developed acute cholangitis requiring laparotomy, one of whom died (2.1%) 40 days after initial endoscopic papillotomy. A Dormia basket became caught in one patient. The duration of hospitalization was 24 to 36 hours after endoscopic papillotomy. Endoscopic papillotomy is considered the method of choice in the management of postcholecystectomy choledocholithiasis.

Involvement of small intestine in familial polyposis coli.

Extracolonic intestinal manifestations of familial polyposis coli have been described in recent years, but the exact frequency is still unknown. To date the more common sites of extracolonic polyposis appear to be stomach and duodenum with true adenomas being somewhat rare in jejunum and ileum. The authors report a further two cases of ileal polyposis in siblings from a family with familial polyposis coli and conclude that this condition cannot be considered as a disease exclusively of the large bowel. They emphasize that examination of the upper gastrointestinal tract and small bowel must be included in the investigation and follow-up of patients with familial polyposis coli.

Effects of plasma cholesterol lowering agents on hepatobiliary lipid metabolism and cholesterol turnover in the rhesus monkey.

The effects of clofibrate, cholestyramine, and neomycin on hepatobiliary lipid metabolism were studied in adult rhesus monkeys in metabolic steady state with intact but exteriorized enterohepatic circulations. Clofibrate (30 mg/kg, id) had no effect on lipid secretion while cholestyramine (150 mg/kg, id) decreased biliary cholesterol secretion rate from 0.19 +/- 0.03 to 0.13 +/- 0.02 mmol/24 h, p less than 0.05. Neomycin (30 mg/kg, id) decreased bile flow from 216 +/- 10 to 191 +/- 7mL/24 h, p less than 0.05, and tended only to decrease bile salt and phospholipid secretion rates. Cholestyramine decreased cholesterol composition from 1.81 +/- 0.22 to 1.30 +/- 0.22 mol %, p less than 0.05, while clofibrate and neomycin had insignificant effects. Cholestyramine and neomycin decreased bile salt pool size from 1 +/- 0.1 to 0.77 +/- 0.15 and from 1.45 +/- 0.16 to 1.13 +/- 0.21 mmol, p less than 0.05, respectively, while clofibrate had no effect. Bile salt synthetic rate was increased only by cholestyramine, i.e., from 0.63 +/- 0.04 to 1.48 +/- 0.26 mmol/24 h, p less than 0.01. Concomitant cholesterol turnover studies revealed that cholestyramine increased the production rate and excretion of cholesterol in the rapidly miscible cholesterol pool and increased the transfer of cholesterol from slow to rapidly miscible pools. Neomycin, on the other hand, decreased the size of the rapidly miscible pool by decreasing production rate without affecting the size of the slowly miscible pool, while clofibrate had insignificant effects.

Rectal wall bleeding--an overlooked source of massive lower gastrointestinal hemorrhage.

Two cases of acute massive bleeding from the rectum are described. In both cases, the diagnosis was made angiographically. Some points of angiographic technique are discussed. In both cases, there had been previous negative sigmoidoscopy. Care must be taken to include the entire rectum on the films obtained during injection of the inferior mesenteric artery regardless of findings on sigmoidoscopy.