Cholangiographic appearance of bile-duct cysts.

Bile-duct cysts or congenital bile-duct dilatation are rare but important abnormalities often mimicking calculous biliary tract disease. Bile-duct cysts are most often classified according to Todani. In a retrospective study of percutaneous, peroperative or endoscopic cholangiograms from 25 patients, diagnosed and treated during a 20-year period, images of different types of bile-duct cysts are presented and classified. The disease usually presents with vague symptoms and has a female preponderance. Current opinion on aetiology and complications is discussed. Cholangiography is a necessary prerequisite to surgical therapy.

The influence of total porto-systemic shunting on the noradrenaline response and on the contractile effects of various vasoactive agents in small rat portal veins and hepatic arteries.

Contractile responses were studied in isolated tubal segments of branches of the rat portal vein (diameter 300 microns) and hepatic artery (diameter 200 microns) 1, 3 and 6 weeks after total porto-systemic shunt operation (PCS). 5-Hydroxytryptamine contracted hepatic arteries concentration-dependently, whereas it produced only weak and inconsistent contractions in portal veins. Vasopressin effectively contracted hepatic arteries, but had no effect on portal veins. Both vessel types responded to prostaglandin F2 alpha with contractions, although the drug potency was relatively low. The responses to these agents were not changed significantly in hepatic arteries or portal veins of PCS rats compared with controls at any of the postoperative time intervals. In both portal veins and hepatic arteries noradrenaline produced contraction-dependent contractions, portal veins being 3 times more sensitive to noradrenaline than hepatic arteries. PCS did not change the nor-adrenaline sensitivity in hepatic arteries, whereas it increased the noradrenaline sensitivity in portal veins after 1, but not after 3 or 6 weeks. This effect was enhanced by cocaine, suggesting a partial sympathetic denervation of branches of the portal vein as well as a complete reinnervation within 3 weeks. Furthermore, the results of this study indicate no influence in any vessel type on the response to several vasoactive agents after depriving the liver of splanchnic venous blood.

Adenomyoma of the ampulla of Vater: an uncommon cause of bile duct obstruction.

Adenomyomas of the bile ducts are extremely rare. They are most likely often overlooked also when situated in the ampulla of Vater and obstructing bile flow. Of 3,131 endoscopic retrograde cholangiograms, four patients with ampullary adenomyoma and signs of biliary obstruction have been diagnosed. When recognized they can be treated effectively by endoscopic means. However, their radiologic and endoscopic appearances were found difficult to interpret and led to unnecessary endoscopic sessions in one patient and surgery in another. Thus, increased awareness of this entity is important to avoid overlooking or misdiagnosing it.

Postoperative recovery after cholecystectomy by minilaparotomy: a randomized double-blind comparison between alpha-trinositol and placebo.

An opioid-sparing effect of alpha-trinositol (D-myo-inositol 1,2,6-trisphosphate) following cholecystectomy in otherwise healthy patients was suggested by a pilot study. In order to verify this result, pain, pain relief and nausea were studied in patients undergoing elective cholecystectomy by minilaparotomy. The patients were randomized using double-blind design to receive an intravenous infusion of either alpha-trinositol or sodium chloride (placebo) for eight hr after the operation. Pain, pain relief and nausea were evaluated up to 72 hr after surgery using visual analogue scales (VAS). Rescue analgesic medication was registered. As a further measure of pain and/or restrictions caused by pain, peak expiratory flow, walking distance and pressure pain thresholds were assessed. There was no difference between the groups in ratings of pain, pain relief, nausea or amount of analgesic medication given. The mean ratings of pain were significantly higher in the sitting position compared to lying down. Neither pressure pain thresholds, nor the walking distance differed between the patients given alpha-trinositol and placebo, respectively. There were significant reductions of peak expiratory flow and of pressure pain thresholds under both costal margins up to 72 hr after surgery compared to presurgery values. As a conclusion, no analgesic effect of alpha-trinositol at the dosage used was observed in the postoperative patients studied.

Routine preoperative infusion cholangiography at elective cholecystectomy: a prospective study in 694 patients.

The role of preoperative infusion cholangiography (PIC) before elective cholecystectomy has yet to be defined. Between 1985 and 1991 PIC was performed routinely in 694 patients with median (range) age of 52 (17-85) years with biliary calculus disease 1 or 4 days before elective cholecystectomy. Satisfactory opacification of the biliary system was achieved in 90.1 per cent and mild to moderate adverse reactions to the infusion of contrast medium occurred in 0.9 per cent of patients. Peroperative cholangiography (POC) in 43 of 499 patients with a normal PIC was normal. The presence of common bile duct stones was confirmed in 34 of 36 patients with prominent stones at bile duct exploration and in 8 of 26 with suspected stones at PIC. Bile duct dilatation (median diameter 10 mm) without concomitant stones was seen at PIC and confirmed at POC in 20 patients. Bile duct anomalies were found or suspected in 35 patients at PIC and were confirmed in six by POC (n = 5), or during the cholecystectomy making the anomaly incidence 0.9 per cent. Information provided by the PIC was not of crucial importance for safe execution of cholecystectomy in any patient, while a single (minor) bile duct lesion (1 of 694; 0.1 per cent) could be ascribed to severe pericholecystitis. The results of this study suggest that routine PIC is not warranted. However, PIC is an alternative to selective preoperative endoscopic retrograde cholangiography or selective POC. PIC needs to be supported by POC in approximately 20 per cent of patients (in case of absent or poor opacification of the bile ducts or suspicion of stones or anomalies at PIC).

Routine preoperative infusion cholangiography versus intraoperative cholangiography at elective cholecystectomy: a prospective study in 995 patients.

BACKGROUND: There has been a resurgence of interest in recent years in preoperative infusion cholangiography (PIC). The role of routine PIC compared to routine intraoperative cholangiography (IOC) has not been clearly defined. STUDY DESIGN: In our department between 1985 and 1991, 1,042 of 1,576 consecutive patients with biliary calculous disease had elective cholecystectomy: 694 patients were prospectively scheduled for PIC, and 348 patients were randomly allocated to IOC. The patients in the PIC and IOC groups were similar with regard to age, history of biliopancreatic complications, and laboratory findings. The cost of PIC in Sweden is nearly five times greater than the cost of IOC. RESULTS: Satisfactory opacification of the biliary system was obtained in 90.1 and 96.8 percent of patients who underwent PIC and IOC, respectively. Preoperative infusion cholangiography required support by IOC in 19.5 percent of patients. There were no statistically significant differences between the PIC and IOC groups with regard to the incidence (7 percent in both groups) of or positive predictive value (68 and 80 percent, respectively) for bile duct stones, rate of retained stones (6 and 20 percent, respectively), intraoperative (5.6 and 6.3 percent, respectively) or postoperative (13.3 and 15.9 percent, respectively) morbidity, or incidence of bile duct anomalies (0.9 and 0.3 percent, respectively). Median operative time was longer in patients with (95 minutes) compared to those without (75 minutes) IOC (p < 0.001). More postoperative complications occurred after bile duct exploration (26 of 75 patients) compared to cholecystectomy alone (114 of 917 patients, p < 0.001). The 30-day mortality was zero. Minor bile duct injuries occurred in two patients (0.2 percent) at cholecystectomy, (one with and one without bile duct exploration). In no patient was the cholangiographic finding of a biliary anomaly crucial for the safe execution of cholecystectomy. CONCLUSIONS: In our study, PIC and IOC were comparable, but routine use of either method did not promote the safety of cholecystectomy and thus their routine use is not warranted. The shorter operative time and preoperative identification of common bile duct (CBD) stones provided by PIC might favor this examination when applied selectively in patients with increased risk of having CBD stones. However, this potential advantage is offset by the need for PIC to be supported by IOC in approximately 20 percent of patients. Also, the cost of PIC is greater than the cost of IOC.

Endoscopic treatment of bile duct calculi in patients with gallbladder in situ: long-term outcome and factors.

BACKGROUND: Whether endoscopic sphincterotomy (EST) in elderly and/or high-risk patients with common bile duct calculi (CBD) and the gallbladder in situ should be followed by routine cholecystectomy is still a subject of controversy. METHODS: To identify factors predictive of subsequent biliary tract symptoms after EST and bile duct clearance, we reviewed 265 patients with intact gallbladder and CBD calculi who were considered for EST in our department from 1981 to 1992. In 15 of 265 patients endoscopic treatment was not carried out, and the records of 4 patients were missing. RESULTS: Complete removal of all bile duct calculi failed in 27 patients (11%). Cholecystectomy was performed in 35 patients (16%) with cleared bile ducts 1-765 days (median, 60 days) after EST, in spite of absence of recurrent symptoms from the biliary tract. The remaining 184 patients have been retrospectively followed up for 14-150 months (median, 69 months). Cholecystectomy was required in 35 because of acute cholecystitis (n = 23) or biliary colic (n = 12). Of the cholecystectomies 86% were performed within 24 months after EST and only one after 4 years of follow-up. Increased frequency of cholecystectomy was found in patients with complete opacification of the gallbladder at endoscopic cholangiography (p = 0.005). This was especially evident in patients younger than 80 years (p = 0.002). Cholecystectomy was also required more often in patients with gallbladder calculi (p = 0.02). The risk of cholangitis in patients without recurrent stones was higher in those with juxtapapillary diverticula (p = 0.02). Fifty-nine patients without and 17 with mild to moderate symptoms from the biliary tract died after a median time of 39 and 46 months, respectively. Seventy-three patients are alive, and 59 are symptom-free. Ten patients have had and four still have complaints of mild to moderate biliary tract symptoms. They have been followed for up to 16-146 months (median, 40 months). CONCLUSIONS: These findings confirm that endoscopic treatment alone in this group of patients is a feasible treatment principle. Recognition of the registered risk factors might be helpful when selecting patients for subsequent cholecystectomy.

Surgicel reinforced resection lines in left-sided hepatectomy with linear stapling device. An experimental study on pigs.

Fourteen pigs underwent left-sided hepatectomy. The resection was performed with a linear stapling device and the pigs were randomised to either Surgicel reinforced resection lines or not. The median time required for resection was 25 min (range 17-30) in the Surgicel reinforced group compared to 30 min (range 21-41) in the stapled group. This difference was, however, not statistically significant (p = 0.053). The postoperative haemoglobin value was lower in the stapled group compared to the Surgicel reinforced group 69 g/l (range 42-85) versus 82 g/l (range 78-90) (p = 0.018). The estimated blood losses by weighing the compresses were 287 ml (range 166-379) for the stapled group and 204 ml (range 152-264) for the Surgicel reinforced group (p = 0.053). The median number of additional haemostatic sutures in the Surgicel reinforced group was 7 (range 3-11) and in the stapled group 10 (range 5-15) (p = 0.038). The haemoglobin value was similar in the two groups 1 week postoperatively; 100 g/l (range 87-104) and 102 g/l (range 95-114), p = 0.27, in the stapled group and the Surgicel reinforced group, respectively. In the stapled group reinforced with the Surgicel there was one postoperative death. In the solely stapled group there was no postoperative death (p = 0.5). Four out of six pigs in the Surgicel group had massive adhesions to the resection lines. One of these six pigs was sacrificed postoperatively as it was ill and had small bowel obstruction secondary to Surgicel induced adhesions. On the other hand, no adhesions were seen in the solely stapled pigs (p = 0.09). At this point, we can not recommend the use of Surgicel to reinforce resection lines at stapled liver resection in the clinical situation, because of the high frequency of adhesions this material creates.

Long-term follow-up of a prospective randomized study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ.

Eighty-three patients with bile duct calculi were entered in a prospective randomized study of endoscopic sphincterotomy (ES) and stone removal (group 1) versus surgery alone (group 2), and were followed for more than 5 years. In group 1 endoscopic stone clearance was successful in 35 of 39 patients. Thirteen patients subsequently had cholecystectomy with (n = 7) or without (n = 6) biliary symptoms and one had a cholecystostomy for acute cholecystitis. Two patients have had mild biliary colic or pancreatitis. Two patients died from gallbladder carcinoma after 9 days and 18 months. In group 2 bile duct stones were cleared surgically in 37 of 41 patients. Late complications occurred in two patients (incisional hernia and recurrent stone). One patient with gallbladder carcinoma was cured and another died after 16 months. Early major and minor complications occurred in three and four respectively of 39 patients in group 1, and in three and six respectively of 41 patients in group 2. There were no deaths. During follow-up the total morbidity rate reached 28 percent (11 of 39) and 5 percent (two of 41) (P = 0.005) and the non-biliary related mortality rate was 31 percent (12 of 39) and 10 percent (four of 41) (P = 0.02) in groups 1 and 2 respectively. Nine patients in group 1 and two in group 2 died from heart disease (P = 0.02). Total hospital stay was 2-42 (median 13) days and 6-36 (median 16) days in groups 1 and 2 respectively (P not significant). Endoscopic and surgical treatment of bile duct calculi in middle-aged and elderly patients with gallbladder in situ are equally effective in the long term. However, the significantly increased mortality rate from heart disease in patients treated endoscopically compared with those treated surgically might speak in favour of operation.

Glucose homeostasis after peri-arterial hepatic denervation in partially hepatectomized rats.

Peri-arterial hepatic denervation did not change the low basal plasma glucose levels on the 1st post-operative day in partially hepatectomized animals. On the 2nd post-operative day, the denervated animals had significantly higher basal plasma glucose levels than innervated animals. Basal plasma insulin levels were similar in both resected groups, suggesting a relative hyperinsulinemia in the innervated group. Basal plasma glucagon levels were similar in all groups on the 1st post-operative day, but were significantly raised on the 2nd post-operative day in the two resected groups. After i.v. glucose (0.5 g/kg b.w.) on the 1st post-operative day, or glucagon (10 micrograms/kg b.w.) on the 2nd post-operative day, the absolute increments and eliminations of glucose and insulin were similar in all groups. We conclude that the hypoglycemia observed after partial hepatectomy is not only due to the evident loss of glycogen stores, but is also mediated by mechanisms dependent on the peri-arterial hepatic nerves, possibly through an effect on basal plasma insulin levels.

Focal periportal liver steatosis.

Focal steatosis of the liver may have various appearances on ultrasonography (US) and computed tomography (CT). An unusual case with a macroscopically periportal location is presented and the etiology and differential diagnosis of the condition is discussed.

Trisomy 7 in nonneoplastic focal steatosis of the liver.

Cytogenetic analysis of short-term cultures of a nonneoplastic focal steatosis of the liver showed trisomy 7 as the sole chromosomal change. This finding, especially when viewed in light of previous reports describing +7 in nonneoplastic tissues, strongly suggests that trisomy 7 cannot be considered a tumor-specific abnormality when it occurs as the only change. The cell type in which +7 is present is not yet known.

Left-sided hepatectomy with a linear stapling device: an experimental study on pigs.

Thirteen pigs underwent resection of the left liver lobe. By random selection, the animals were resected either with the aid of an RLG 90R linear stapling device or by the conventional finger-fracture technique. There was one postoperative death due to anaesthetic complications. The median operative time using the stapler was 27 min (range 19-40 min) which was significantly shorter (p = 0.0065) than that required for resection by the finger-fracture technique (42.5 min; range 37-55 min). The median blood loss, estimated by counting the number of gauze swabs used, was 425 ml and 275 ml for the finger-fracture resected and stapler resected groups, respectively (ranges 275-550 ml versus 175-300 ml; p = 0.015). The animals were sacrificed and examined one week after the operative procedure. Except for a small bile pseudo-cyst in one pig operated upon with conventional resection, no sign of bleeding or biliary leakage was revealed. This study demonstrates the feasibility of stapling the liver to facilitate resection.

Effects of nitrous oxide on cerebral haemodynamics and metabolism during isoflurane anaesthesia in man.

Seven normoventilated and five hyperventilated healthy adults undergoing cholecystectomy and anaesthetized with methohexitone, fentanyl and pancuronium were studied with measurement of cerebral blood flow (CBF), cerebral metabolic rate of oxygen (CMRO2), and quantified electroencephalography (EEG) under two sets of conditions: 1) 1.7% end-tidal concentration of isoflurane in air/oxygen; 2) 0.85% end-tidal concentration of isoflurane in nitrous oxide (N2O)/oxygen. The object was to study the effects of N2O during isoflurane anaesthesia on cerebral circulation, metabolism and neuroelectric activity. N2O in the anaesthetic gas mixture caused a 43% (P less than 0.05) increase in CBF during normocarbic conditions but no significant change during hypocapnia. CMRO2 was not significantly altered by N2O. EEG demonstrated an activated pattern with decreased low frequency activity and increased high frequency activity. The results confirm that N2O is a potent cerebral vasodilator in man, although the mechanisms underlying the effects on CBF are still unclear.

Peritoneal ovarian metastases simulating liver parenchymal metastases.

Ovarian carcinoma frequently metastasizes to the peritoneum, both locally in the pelvis and elsewhere. Computed tomography (CT) has a limited ability to identify peritoneal implants with a diameter of 2 cm or less. Three cases of subphrenic, diaphragmatic peritoneal implants, preoperatively at CT thought to represent liver parenchymal metastases, are presented. The difficulty in the differentiation of diaphragmatic peritoneal implants from metastases to the capsule and parenchyma of the liver is discussed. To achieve a radical liver resection in patients with ovarian carcinoma, metastatic peritoneal implants must be excluded during operation.

Hepatic lipase activity after liver denervation in hypothyroid rats.

Hepatic hilar denervation, hepatic vagotomy or sham operation were performed in hypothyroid rats. Activities of hepatic lipase were measured nine days after surgery. Sham operation in itself was associated with a decrease of hepatic lipase activity by about 40% compared with non-operated animals. Both hilar denervation and hepatic vagotomy were associated with increased hepatic lipase activity (40% and 35%, compared with sham-operated animals). Liver contents of norepinephrine were reduced by about 90% after hilar denervation, whereas hepatic vagotomy did not affect norepinephrine levels. No major changes in lipids and lipoproteins were noted.

Segmental liver resection with linear stapling device. An experimental study on pigs.

Segmental liver resection was performed in 14 pigs. The pigs were randomized either to resection with conventional finger fracture technique or resection with linear stapling device (TA-90R, US Surgical Corporation). The median time for resection was shorter in the stapled group, although the difference was not statistically significant. The median weight of the specimen was the same in both groups. The median postoperative Haemoglobin value was somewhat lower in the finger fracture resected group as compared to the stapler resected group, 82.5 g/l versus 87.5 g/l, but there was no statistically significant difference between the groups. Blood loss, estimated by counting the number of compresses, amounted to 188 ml for the finger fracture resected group and 181 ml for the stapler resected group. At the post-mortem examination there were no signs of bile leakage or postoperative blood loss in any of the operated animals. This study demonstrates that hepatic resection in the pig can be performed quickly and safely by using linear stapling device. Stapler resection was easier and somewhat quicker to perform than conventional hepatic resection.

Impaired hemostasis following denervation of the rat spleen.

The possibility that the noradrenergic system might play a role in modulating platelet activation within the spleen was examined. A new microsurgical model for achieving selective denervation of the rat spleen was created. The denervation procedure resulted in a 96% reduction of the norepinephrine content in splenic tissue. One week after splenic denervation, animals were subjected to standardized splenic resection or standardized transection of mesenteric microvessels. The denervation of the spleen was accompanied by a highly significant increase in bleeding time and blood loss at both locations of trauma. Furthermore, platelet function, measured as adenosine diphosphate (ADP)-induced aggregation, decreased significantly after denervation, indicating that platelet aggregation might be modulated by noradrenergic fibres within the spleen.