Management of bile duct injury during and after laparoscopic cholecystectomy.

BACKGROUND: Bile duct injury (BDI) is perhaps the most feared complication of laparoscopic cholecystectomy (LC). Proper management of iatrogenic BDI is mandatory to avoid immediate or later life-threatening sequelae. The results of surgery depend mainly on the type of injury, prompt detection of the injury, and timing of the surgery. METHODS: Twelve patients with BDI after LC were treated. Eight of them were referred to our institution for further treatment. The follow-up evaluation was focused on clinical outcome and biochemical analysis. RESULTS: Five of the patients had minor BDI with leakage. In all of them, the BDI was recognized postoperatively. Two of these patients were managed by endoscopic retrograde cholongio pancreatographic sphincterotomy and stent placement. The other three patients underwent open laparotomy and bile duct ligation. Seven of the patients had major BDI. In two patients, biliary injuries were identified at the time of LC, and the procedure was converted to laparotomy. At the time of conversion, primary suture repair with T-tube drainage of the injured bile duct was performed. Strictures developed in these patients after 2 and 6 months, respectively, and they were treated with a Roux-en-Y hepaticojejunostomy. In five additional patients, BDI was recognized postoperatively. One of these patients died because of delayed detection of biliary peritonitis. At this writing, during a median follow-up period of 52 months, neither clinical nor biochemical evidence of biliary disease has been found in the remaining patients. CONCLUSIONS: Laparoscopic BDI has a high morbidity and mortality rate. Late recognition of the BDI remains a problem.

Pedicle grafts of peritoneum and transversalis muscle for the repair of large defects in the duodenal wall.

OBJECTIVE: To find out if pedicle grafts of peritoneum and transversalis muscle could be used to repair large defects in the wall of the duodenum. DESIGN: Experimental study. MATERIAL: 18 healthy mongrel dogs. INTERVENTIONS: Defects were created in the second part of duodenum and repaired with pedicle grafts of peritoneum and transversalis muscle from the anterior wall of the right side of the abdomen. MAIN OUTCOME MEASURES: Postoperative complications, appearances on upper gastrointestinal radiography two and four months after operation, and histological examination of necropsy specimens. RESULTS: There were no postoperative deaths or complications. Radiographs of the duodenum showed no abnormalities and in particular no signs of obstruction. Animals were killed at intervals from one week to eight months after operation, and the only abnormality was 20-30% stenosis found in five dogs killed within two months of operation, which did not affect gastric emptying. Histological examination showed that by four months after operation the patch was completely covered by neomucosa that was similar to normal duodenal mucosa. By six months the site of the defect was well healed and the histological appearance was the same as at four months. CONCLUSION: Pedicle grafts of peritoneum and transversalis muscle may be useful in the treatment of patients with large defects in the wall of the duodenum.

Changes in gastric secretion after intracerebroventricular infusion of bombesin in dogs.

Synthetic bombesin (BBS) was infused intracerebroventricularly in 14 mongrel dogs, to study the effects of the peptide on gastric secretion and on gastrin and neurotensin levels. The infusion was performed with a specific apparatus, and gastric fluid was collected with a Pavlov pouch. BBS was given in two series of experiments: as a bolus intracerebroventricular injection of 308.6 pmol/kg and as a continuous intracerebroventricular infusion at a rate of 617.3 pmol/kg/h for 30 min. The bolus injection caused a very significant decrease of gastric fluid volume, a significant decrease of HCl output, and a significant increase of its pH, while serum immunoreactive gastrin increased significantly. The continuous infusion of BBS caused similar changes in gastric secretion. The plasma neurotensin levels did not change. In conclusion, the intracerebroventricular administration of BBS increases the serum gastrin levels, decreases the volume and HCl content of gastric fluid, and increases its pH.