Common bile duct pressure in patients with common bile duct stones with or without acute suppurative cholangitis.

Resting common bile duct pressure was measured in three groups of patients: group 1, 53 patients with gallstones but without common duct stones; group 2, 35 patients with common bile duct stones unaccompanied by cholangitis; and group 3, 36 patients with common duct stones and acute suppurative cholangitis. A significantly higher pressure in the common bile duct was documented in patients with cholangitis when compared with the other two groups. Twenty-four patients with cholangitis had common duct pressure values above 20 cm H2O, the maximal values of normal. Additionally, patients with cholangitis with pressure values over 30 cm H2O (nine patients) showed absence of green bile in the extrahepatic biliary tract, suggesting cessation of bile excretion into biliary duct. In all these cases, an impacted stone at the distal end of the common bile duct was documented.

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 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.

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.

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%.

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.

Indications and results of choledochoduodenostomy in benign biliary tract diseases.

During a 12-year period ending December 1987, 17,200 operations for biliary tract disease were performed at the Dept. of Surgery of the University of Chile. Choledochoduodenostomy was performed in 140 of these patients operated upon for benign biliary tract and/or gallbladder diseases. The indications for this procedure were choledocholithiasis, stenosis of the sphincter of Oddi, compression of the extrahepatic biliary duct, stenosis of the distal biliary duct and duodenal diverticula. The postoperative course was uncomplicated in 126 patients (90%). The mortality rate was 4.2%. Although the mortality was somewhat greater in patients with acute cholangitis, the difference was not significant, and no significant relation could be established with other factors that might affect mortality. Choledocholithiasis is the main cause of benign obstruction of the biliary tract in Chile. This is also the most frequent indication for external choledochoduodenostomy and is a promising method even in the presence of an infection of the biliary duct.

[Laparoscopic cholecystectomy. 1203 cases with ultraselective cholangiography]. / Colecistectomía laparoscópica. 1203 casos con colangiografía ultraselectiva.

We present our experience at the University of Chile Hospital with 1203 cases of laparoscopic cholecistectomy between April 1991 and July 1993. In only 36 patients ultraselective cholangiography was performed. In 88 cases an endoscopic cholangiography was performed prior to surgery because of suspicion of choledocolithiasis. In 31 of them choledocolithiasis was demonstrated, and was successfully treated by papilotomy in 30 of them. In 5.8% of cases coversion to open surgery was necessary: 1.4% in chronic cholecystitis, 13% in acute cholecystitis and 39% in cases with fibrosis and esclerosis of gallbladder with or without biliary digestive fistula. The intraoperative cholangiography has been advocated as a manner to prevent the common duct injury. In spite of the small number of cases operated on with cholangiography, we haven't seen serious injuries of biliary tract; a carefully disection, as far away as possible of the common duct, is the best way to prevent iatrogenic lesions. Postoperative morbidity was present in 15 cases, 8 of them required a new operation. Two patients died.

[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.

Treatment of common bile duct injuries during laparoscopic cholecystectomy: endoscopic and surgical management.

The increase of laparoscopic cholecystectomy has resulted in an increase of bile duct injuries. The purpose of this article is to define the types of injury, their occurrence and frequency, and their management by endoscopic and surgical techniques. Three investigations were included in the present study. 1. A 3-year retrospective study among 29 hospitals with 25,007 laparoscopic cholecystectomies. 2. An 8-year prospective study at our institution of 6488 patients. 3. A prospective endoscopic study of 94 patients with injuries and strictures of the common bile duct (CBD) after laparoscopic cholecystectomy. A special classification for bile duct injuries was developed. Among 25,007 patients from 29 hospitals, a total of 74 lesions were detected with an incidence of 0.29%. At our institution, 20 cases were seen (0.29%) with type I, II, and III injuries. The 94 cases managed by endoscopic procedure were submitted to endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy, with placement of several stents 5 to 10 F during 8 months. The results of this procedure have been excellent to good in 76% of the cases up to 3 years of follow-up. According to our previous and present experience, bile duct injuries after laparoscopic procedure are two times higher than after open procedure. The best treatment is the prevention of these injuries by careful surgical technique. If they occur, the best moment to repair them is during surgery. If they are noticed after the operation, endoscopic or surgical procedures can be employed.

[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%.

Endoscopic bile duct stone removal prior to laparoscopic cholecystectomy.

Of 1049 patients referred for laparoscopic cholecystectomy (LC) for symptomatic gallstone disease, 67 (6%) had clinical, biochemical, or echographic findings suggesting common bile duct stones. Patients in this group were studied preoperatively with endoscopic retrograde cholangiopancreatography (ERCP). In 26 patients (39%), the diagnosis was confirmed. In 12 other cases (18%), the macroscopic finding of a stripped or bleeding papilla without common bile duct stones suggested stone migration. ERCP in the remaining 29 patients (43%) was normal. Thirty-four endoscopic sphincterotomies (ES) were performed, 26 for common bile duct stones and 8 for cystic lithiasis or gallbladder microlithiasis. In the entire group of patients with choledocholithiasis, stone removal was possible. All 67 patients underwent laparoscopic cholecystectomy on an average of 2.8 days following the endoscopic procedure. Twenty-one patients (31%) had acute cholecystitis, and 5 had chronic scleroatrophic cholecystitis. Five (7.5%) of the 67 patients were converted to an open procedure. In 10 cases (16%), the cystic diameter was larger than an 8-mm M-L clip, which made necessary the use of endoligature or extra clips. No complications or deaths resulted from ERCP or ES. Two of the 62 patients (3.2%) who underwent LC had to be reoperated on, 1 because of a right subphrenic collection, and the other because of bilious ascites. No common bile duct lesions or deaths resulted in the analyzed group. The average hospitalization time, with the exception of those patients converted or reoperated on, was 8 days.

[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.

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.

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