Laparoscopic highly selective vagotomy: technical considerations and preliminary results in 119 patients with duodenal ulcer or gastroesophageal reflux disease.

The technical considerations and preliminary results of 119 patients submitted to laparoscopic highly selective vagotomy are presented. There were 33 with duodenal ulcers, 31 with duodenal ulcers plus gastroesophageal reflux, and 55 with gastroesophageal reflux. Operating time varied from 120 to 160 minutes. Six complications occurred: four perforations of the gastric fundus and two bleeding episodes. Conversion to open surgery was done in four cases and reoperation in one case. No deaths occurred, and the mean hospital stay was 3 days. The mean follow-up was 16 months, being 94% of the cases with Visick I or II and 6% with Visick III or IV. This technique is completely feasible by laparoscopic procedure and reproduces exactly what has been done with the laparotomy approach.

Gallstone ileus.

A retrospective analysis of 74 patients with gallstone ileus detected during the period between 1975 and 1987 was performed at the Surgical Department. The group comprised 55 females and 19 males, with a mean age of 64.8 years. Previous biliary symptoms had been observed in 76% of the cases and in 58% there had been concomitant disease. The main duration of symptoms previous to admission was 3.4 days. In 85% of the cases complementary diagnostic procedures were performed. The triad of air in the biliary tract, air-fluid levels and ectopic stone was found in only 9.5% of the cases. The preoperative diagnosis of gallstone ileus was made in 31% of the patients. The preoperative period was 2.2 days. The main surgical procedure was enterolithotomy in 92% of the cases, the site of impaction being the terminal ileum in 65%. Only in 1 case was simultaneous biliary tract surgery and enterolithotomy performed. Overall, the 30-day postoperative mortality rate was 13.5%, with intra-abdominal sepsis as the main cause of death. Sixteen patients were submitted to biliary surgery 2 to 6 months later, and no deaths occurred.

Indications and results of hepaticojejunostomy in benign strictures of the biliary tract.

The postoperative and late results of 99 patients with benign strictures of the biliary tract are presented. Patients were classified according to Bismuth into 24 cases with lesion type I, 36 cases with type II, 35 cases with type III and 4 patients with type IV. All were submitted to hepaticojejunostomy with a long Roux-en-Y loop. The etiology of the strictures varied according to the type of stricture. In patients of type I, inflammatory and iatrogenic causes were observed. Among type II and III patients, previous cholecytocholedochal fistulas were the main cause, together with accidental section or ligature of the common bile duct. Operative mortality was absent in strictures of types I and II, while it was around 25% in cases of types III and IV. At late control, the best results were seen among patients with strictures of types I and II. We believe that the main factor determining the early and late outcome of these cases with benign strictures is the location of the stricture and the quality of the proximal duct.

[Percutaneous drainage of abdominal abscesses]. / Drenaje percutaneo de abscesos abdominales.

Percutaneous drainage has been widely accepted as the preferred treatment for abdominal abscess. Indications have been clarified recently and the absence of a secure route is the only absolute contraindication. We performed this procedure in 65 patients with abdominal abscess at different locations: liver 27, subphrenic 33, lesser cavity 3 and perirenal 3. Overall success rate was 85%, with 89% for liver and 88% for the subphrenic location. Six patients died of multisystemic failure even though the abscess was properly drained. Four patients were operated on for persistent abscess. A pancreatic fistula was shown in 1 and a peritoneal hydatid cyst was the original lesion in the other. Pneumothorax occurred in 5 patients requiring drainage in 2. Two other patients developed hydro-pneumothorax and empyema, that was drained. The overall complication rate was 14%. Thus, percutaneous drainage is a simple and highly successful treatment for abdominal abscess. Results are influenced by the accuracy of diagnosis and a proper selection of patients.

[Early complications of caustic injuries of the digestive tract]. / Complicaciones precoces de las lesiones por caustico del tubo digestivo.

We retrospectively analyzed the gastrointestinal complications observed in 119 patients who had ingested corrosive agents. Hydrochloric acid and sodium hydroxide were the agents involved in 62% of patients. Women predominated over men (p less than 0.001); mean age was 36 for males and 29 for women (p less than 0.05). Endoscopy was performed in 55% of patients and revealed acute lesions in 69%. Complications were observed in 18% of patients requiring surgery in 12 (10%). Main complications included sepsis of abdominal or mediastinal origin and gastrointestinal bleeding. Mortality among these patients was 73%.

Resultados del tratamiento del abceso hepatico piogeno en un periodo de 10 aÑos / Results of the treatment of pyogenic hepatic abscess in a period of 10 years

Se presenta la experiência del Hospital Clínico de la Universidad de Chile en el tratamiento del absceso hepático piógeno en distintos períodos de la última década. Se hace revisión retrospectiva de 56 casos tratados con tres alternativas terapéuticas, la mortalidad global del período es de 27%, bajando a 19% al considerar los últimos tres años. No se aprecian cambios significativos al comparar distintos períodos en los resultados quirúrgicos. Fueron tratados 14 pacientes con drenaje percutáneo, con éxito terapéutico en 85% y un fallecido. Cinco casos fueron tratados sólo con antibióticos, con buen resultado en cuatro de ellos. Se analizan las diferentes cifras de letalidad, estableciéndose que se trata de universos no comparables dada la inevitable selección de enfermos, reservándose la cirugía para los casos de mayor gravedad. El drenaje percutáneo constituye la primera opción terapéutica en pacientes con absceso único sin foco primario intraabdominal susceptible de corrección quirúrgica

Resultados del tratamiento del abceso hepatico piogeno en un periodo de 10 aÑos / Results of the treatment of pyogenic hepatic abscess in a period of 10 years

Se presenta la experiÛncia del Hospital Clínico de la Universidad de Chile en el tratamiento del absceso hepático piógeno en distintos períodos de la última década. Se hace revisión retrospectiva de 56 casos tratados con tres alternativas terapéuticas, la mortalidad global del período es de 27%, bajando a 19% al considerar los últimos tres años. No se aprecian cambios significativos al comparar distintos períodos en los resultados quirúrgicos. Fueron tratados 14 pacientes con drenaje percutáneo, con éxito terapéutico en 85% y un fallecido. Cinco casos fueron tratados sólo con antibióticos, con buen resultado en cuatro de ellos. Se analizan las diferentes cifras de letalidad, estableciéndose que se trata de universos no comparables dada la inevitable selección de enfermos, reservándose la cirugía para los casos de mayor gravedad. El drenaje percutáneo constituye la primera opción terapéutica en pacientes con absceso único sin foco primario intraabdominal susceptible de corrección quirúrgica (AU)

Treatment of residual common bile duct stones after cholecystectomy.

This study was conducted to determine the occurrence of "open" residual common bile duct stones after cholecystectomy to establish predisposing factors and possible alternative treatments. Correct diagnosis of choledocholithiasis before or during surgery, adequate exploration of the common bile duct, and suitable selection of technical procedures are the most important points in preventing retained CBD stones. If these occur, an adequate alternative treatment may prove helpful. Classical "clysis" of the bile duct is least recommended because of its high failure rate. The best method of chemical dissolution seems to be the use of mono-octanoin with 60% good results and a no-response rate of 30-40%. Instrumental extraction has been reported to be very successful (80-98%). Endoscopic sphincterotomy is currently the most frequently employed procedure for retained CBD stones, especially in poor risk patients. The reported success rate is 82-93% according to literature, with an extremely low mortality (0.2%). Reoperation should be resorted to only if all the other methods fail. Sphincteroplasty or choledochoduodenostomy, whenever indicated, are good alternative operations, with a mortality rate of approx. 3.5%.

Results of surgical treatment in patients with "western" intrahepatic lithiasis.

The results of the surgical treatment in 251 patients with intrahepatic stones are discussed. The mean age of the group was 48 years, with a predominance of females. Gallstones were observed in 72% of the cases, because 28% had had previous cholecystectomy. Associated common bile duct stones were present in 222 (88%) cases, while primary intrahepatic stones were seen in 29 patients. The intrahepatic stones were usually bilateral. Three main operations were employed. Choledochostomy with or without cholecystectomy was performed in 166 (66%) cases with 6 deaths (3.6%). Bilioenteric anastomosis such as sphincteroplasty or choledochoduodenostomy were used in the rest with similar results. However, residual stones were documented in 32% after choledochostomy, while only 4% were seen after choledochoduodenostomy. In our groups, intrahepatic stones originated from migrated stones from the gallbladder, and surgical treatment should be orientated towards complete extraction of the stones and prevention of their further appearance.

Indications and results of sphincteroplasty in benign biliary diseases.

A retrospective analysis of 143 patients submitted to sphincteroplasty at the Department of Surgery, University of Chile Clinical Hospital was performed. A significant percentage of these patients (90%) were admitted due to acute biliary tract disease with or without cholangitis. The standard operative procedure was anterior transduodenal sphincteroplasty with supraduodenal choledochal exploration leaving a choledochostomy. A high number of our cases presented with intrahepatic lithiasis (23.8%). The morbidity was 15.4% and the 30 days post operative mortality rate was 4.9%, similar to other reports. Residual stones were observed in 10 patients (7%), and were successfully removed by other procedures. Three patients showed recurrent stenosis of the papilla and were operated on again with good results.

[Results of the treatment of pyogenic hepatic abscess over a 10-year period]. / Resultados del tratamiento del abceso hepático piógeno en un periodo de 10 años.

The experience of the Hospital Clínico de la Universidad de Chile in the treatment of pyogenic liver abscess, during various periods of the last decade is presented. Fifty six cases treated by means of three therapeutic options are reviewed retrospectively. The overall mortality during period was of 27% and it decreased to 19% if only the last three years were taken into account. There were no significant changes comparing surgical treatment in different periods. Fourteen patients were managed with percutaneous drainage, with therapeutic success in 85% of cases and one death. Five cases were treated only with antibiotics; results were good in four of them. The different mortality figures were analyzed concluding that they belonged to man comparable universes because of the unavoidable patient selection. Surgery was reserved for the more severe cases. Percutaneous drainage is the first choice treatment in patient with solitary abscess without a surgically treatable abdominal primary location.

Resultados del tratamiento del abceso hepático piógeno en un periodo de 10 años. / [Results of the treatment of pyogenic hepatic abscess over a 10-year period]

The experience of the Hospital Clínico de la Universidad de Chile in the treatment of pyogenic liver abscess, during various periods of the last decade is presented. Fifty six cases treated by means of three therapeutic options are reviewed retrospectively. The overall mortality during period was of 27

and it decreased to 19

if only the last three years were taken into account. There were no significant changes comparing surgical treatment in different periods. Fourteen patients were managed with percutaneous drainage, with therapeutic success in 85

of cases and one death. Five cases were treated only with antibiotics; results were good in four of them. The different mortality figures were analyzed concluding that they belonged to man comparable universes because of the unavoidable patient selection. Surgery was reserved for the more severe cases. Percutaneous drainage is the first choice treatment in patient with solitary abscess without a surgically treatable abdominal primary location.