Surgical treatment of cicatricial biliary strictures.

BACKGROUND/AIMS: Cicatricial biliary strictures are usually associated with high morbidity and mortality rates, frequently related to technical difficulties of their surgical repair, mainly in hilar lesions. Interference with bile duct blood supply during surgical attempts for correction is a major factor for unsuccessful results. The aim of this study is to evaluate, after an extended follow-up period, the results obtained with a modified technique for surgical correction of cicatricial biliary strictures. METHODOLOGY: The medical records of 57 patients surgically treated for cicatricial biliary strictures between January 1984 and July 1995 were reviewed and the immediate and long term results retrospectively analyzed. Patients consisted of 46 females and 11 males. The average age was 43 years. The etiology of the biliary lesion was: cholecystectomy alone (23); cholecystectomy with duct exploration (8); T tube CBD drainage (6); Biliary-enteric anastomosis stricture (16); choledochoplasty (2) and trauma (2). In 28 cases (49.1%) the stricture was located in the upper third of the bile duct, in 28 (49.1%) in the middle third and in one case (1.7%) it was low. All patients were submitted to longitudinal Roux-en-Y hepaticojejunostomy with mucosa apposition after dissection of the anterior aspect of the biliary tract. No transanastomotic stents were used. RESULTS: Ten patients (17.5%) presented 11 postoperative complications: biliary fistula (4), duodenal fistula (1), wound infection (5), and acute pancreatitis (1). Average hospital stay was 11 days and there were no postoperative mortalities. The follow-up study was possible in 54 patients and ranged from one to ten years, with an average of 2.9 years. Four patients of 28 (14%) with hilar lesions developed stricture recurrence and cholangitis episodes, whereas no patients bearing lesions below the biliary junction had such complications. CONCLUSION: Roux-en-Y hepaticojejunostomy with mucosa apposition without transanastomotic stent performed after minimal dissection of the biliary duct, thus avoiding major interference with the bile duct blood supply, is a safe and efficient method for the surgical repair of cicatricial biliary strictures. Using this technique excellent results can be obtained in the lesions below the biliary junction and acceptable results may be achieved in patients with hilar lesions.

[Prognostic value of the sites of pancreatic necrosis determined by computed tomography of the abdomen]. / Valor prognóstico das localizações das necroses pancreéaticas pela tomografia computadorizada de abdome.

Correlations between tomographic findings and the outcome of the disease was made in 49 patients with necrotizing pancreatitis submitted to surgical treatment. Mortality rate was 20.40% resulting mostly from sepsis and multiple organ failures. There was no correlation between APACHE II index and number of necrotic areas diagnosed by abdominal computed tomography although they were closely related with mortality. These findings suggest that different necrotic areas have different prognostic values. The root of the superior mesenteric artery and retropancreatic area were related to worst prognosis with 100% mortality rate. Incomplete necrotic tissue removal is the possible explanation for the high mortality rate.

[Surgical treatment of ascites and pleural effusion in patients with chronic pancreatitis]. / Tratamento cirúrgico da ascite e do derrame pleural em pacientes com pancreatite crônica.

Pleural effusion and ascites are now recognized as possible complications of chronic pancreatitis. Diagnosis of these conditions can be made by the finding of high amylase levels in the pleural or ascite fluid. Out of 31 of our patients with this complications 19 had ascites, 10 pleural effusions and two both pleural effusion and ascites. In 19 patients, presenting poor clinical conditions, the treatment was external drainage. Remaining patients were treated by internal drainage or resection. Eight out of the 19 patients treated by external drainage and one of the 13 patients with internal drainage had to be reoperated. There was no mortality. Though external drainage is followed by high incidence of reoperations this technique should be used in patients with poor conditions.

[Etiology of chronic pancreatitis in São Paulo: a study of 407 cases]. / Etiologia das pancreatites crônicas em São Paulo: estudo de 407 casos.

The etiology of chronic pancreatitis was investigated in 407 patients: 381 (93.6%) had a history of heavy alcoholic ingestion (average = 295.3 +/- 171.3 g of ethanol) during a time of 19.2 +/- 8.0 years: five patients (1.0%) had familial background of pancreatitis, two (0.5%) had the obstructive form, and two (0.5%) presented history of malnutrition. In 18 patients (4.4%) it was not possible to determine the etiology. Patients with the alcoholic form started the alcohol abuse at the age of 19.4 +/- 6.0 years. A careful dietetic inquiry showed that patients with chronic pancreatitis lived on a diet which was significantly richer in protein than that of patients of the control group (p less than 0.01). Attention is called to the high incidence of chronic alcohol abuse in patients with chronic pancreatitis.

Acute pancreatic necrosis in chronic alcoholic pancreatitis.

Necrotic lesions are rarely observed in chronic pancreatitis, but its presence in a few patients has been misinterpreted in the diagnosis of acute pancreatitis. In this series, 12 patients (11.2%) of 107 operated for chronic alcoholic pancreatitis, presented with acute pancreatic necrosis associated with pancreatic fibrosis characteristic of chronic pancreatitis. Ten patients were treated by pancreatic debridement and drainage and two by distal pancreatic resections. Postoperative complications included five pancreatic fistulas and two pancreatic abscesses. Despite the severity of the pancreatic lesions which led to several complications, all the patients survived. The occurrence of pancreatic necrosis in patients with chronic pancreatitis is demonstrated.

New technique of pancreaticojejunal anastomosis after partial pancreaticoduodenectomy.

The authors propose a new technique of pancreaticojejunal anastomosis after pancreatoduodenectomy with the aim of reducing the incidence of anastomotic disruption and late stenosis of the duct. Basically the technique consists of end-to-end pancreaticojejunal anastomosis with invagination of the pancreas into the intestinal loop and mucosal juxtaposition of the pancreatic duct and jejunum.