Operative choledochoscopy in common bile duct surgery.

Surgical exploration of the common bile duct for gallstones is a common operation but carries a high residual stone rate. Conventional techniques for exploring the bile ducts are blind procedures. The surgeon cannot see what he is doing. Also there has been no reliable method for a postexploratory check of the bile ducts before closure, usually around a T-tube. Operative choledochoscopy allows the surgeon to see stones in the duct, may aid the removal of stones and provides visual postexploratory checks that the common bile duct and the hepatic ducts are clear, that papilla is patent and that no stone is left behind before closure. A personal series of 150 patients had operative choledochoscopy using a flexible fibreoptic choledochoscope. If there was a clear indication on preoperative investigations that the ducts should be explored, an operative cholangiogram was omitted and the choledochoscope used as the exploring instrument. In 127 patients with a diagnosis of gallstone disease, choledochoscopy was used at the primary operation. In 12 patients choledochoscopy was used at a secondary operation for recurrent gallstone disease, and 11 patients had malignant obstruction of the biliary tract. In 70 of the 127 patients, gallstones were found and extracted using the choledochoscope. In 53 patients the ducts were clear, and in 4, other lesions were found: 3 papillomas and one polycystic disease. One hundred and six of the patients had the common bile duct closed primarily with no T-tube drainage. There was no increase in complications and no deaths associated with choledochoscopy or primary closure of the common bile duct. There was one case of recurrent stone in the common bile duct presenting six years later. This is a failure rate of 1.4 omicron (O amongst the 70 patients in whom stones were found. Choledochoscopy reduces the incidence of residual common bile duct stone.

Effects of x-radiation on fibreoptic endoscopes.

Fibreoptic endoscopes exposed to x-radiation showed increased optical density of the fibre bundles with a reduction in light transmission. The length irradiated was important as well as the total dose, and there was a linear relationship between the dose/length product (Rm) and the loss of light transmission. The minimum light transmission acceptable for performing ERCP was found to be 57% of that through an unused fibre bundle, and this degree of damage occurred after a total dose of 33.9 Rm. The radiation dose to the duodenoscope during ERCP examinations was measured. The endoscope sheath was shown to have screening properties, with a transmission factor of about 30% for the Olympus JFB-1 and about 11% for the JFB-2 and JFB-3 instruments. The actual dose received by the fibre bundle of an Olympus JFB-2 duodenoscope was 0.084 R per ERCP and the mean dose-length product to the fibre bundle was calculated as 0.028 Rm per ERCP. Some degree of recovery of light transmission occurred while a duodenoscope was 'resting'. The expected life of a duodenoscope was estimated to be about 1200 examinations, but might be much less than this in units where greater radiation doses and longer exposures were used, and the endoscope was in constant use. Ways of minimising the radiation exposure during ERCP and prolonging the useful life of the duodenoscope are outlined.

Fibreoptic choledochoscopy in common bile duct surgery.

Fibreoptic choledochoscopy permits visual examination of the interior of the bile ducts during operations for gallstones. But it does not replace operative cholangiography, and the common bile duct should not be opened simply to perform choledochoscopy. Operative choledochoscopy following conventional exploration and removal of stones ensures that the ducts are clear before insertion of a T tube and closure, avoiding the problem of the retained stone. Exploratory choledochoscopy with stone retrieval under direct vision is less traumatic to the ducts than conventional blind methods, and visual confirmation that the lower end of the duct is clear and the papilla patent may allow the common bile duct to be closed without a T tube, shortening the patient's convalescent period.

Liver transplantation in man--3, Studies of liver function, histology, and immunosuppressive therapy.

The experience gained from 13 hepatic transplant operations is described, with particular reference to the findings in nine patients who survived the immediate operative period. A major problem was found to be infection. Fulminant pneumonia caused death in two adults, at a time when liver function was virtually normal. Infection related to bile fistula and sepsis may be overcome by an improved method of biliary drainage by cholecyst-dochostomy, which was carried out in the last two patients. Jaundice in the second week due to rejection was observed in several patients. The striking histological change was centrilobular cholestasis. The jaundice, which was not prevented by administration of antilymphocyte globulin, was rapidly controlled by temporarily increasing die dose of prednisone. One patient who survived for four and a half months and who had a poor tissue match subsequently developed chronic rejection with progressive cholestatic jaundice. Five of the patients were able to go home and at time of publication two are alive and well 14 and 20 weeks after treatment.