Ultrasonic guided percutaneous transhepatic bile drainage for cholangitis due to intrahepatic stones.

Acute cholangitis due to intrahepatic stones is frequently associated with biliary sepsis. Emergency surgery for these high-risk patients is usually associated with a high mortality. Therefore, we recommend nonoperative methods for the management of this acute disease. Percutaneous transhepatic cholangiography and drainage (PTCD) combined with antibiotic and fluid treatment was used successfully in the management of 41 patients with acute pyogenic cholangitis due to intrahepatic stones. The general condition of these patients improved after treatment with PTCD. Repeated cholangiography should be performed so that the entire biliary tree and lesions can be viewed. Elective surgery (21 patients) or removal of the stone through the sinus tract via PTCD (14 patients) was performed when the patients' general condition improved following emergency PTCD. Therefore, we recommend PTCD over emergency surgery in the treatment of acute septic intrahepatic stones.

Ultrasound survey of hepatobiliary lesions in Kaohsiung, Taiwan.

An ultrasound survey of the liver and biliary system was made in the city of Kaohsiung and a neighbouring village in the southwest of Taiwan. 1,166 persons (538 males and 628 females between 5 and 83 years) from 388 families were examined. Abnormalities were found in 104 cases (8.9%). Hepatolithiasis was suspected in 22 cases (1.9%). This gives an incidence of hepatolithiasis of 42.3% in a total of 52 cases of cholelithiasis. Hepatoma was suspected in 4 (0.3%) of cases.

The role of insulin and glucagon in experimental obstructive jaundice.

BACKGROUND/AIMS: The oxidative phosphorylation of liver mitochondria is regulated by the amount of portal insulin available to the hepatocytes. Thus, hepatic energy is mediated by the values of blood sugar and insulin. Insulin and glucagon are the main fuel homeostats in the liver. This study was performed to investigate the concept of energy mediated by glucose, during the process of obstructive jaundice and its recovery. METHODOLOGY: Experimental Wistar rats were studied, with bile duct tied for 4, 7 and 14 days respectively. The serum concentration and relative tissue concentration of insulin and glucagon were measured. And the common bile duct was tied for 4, 7 and 14 days, then relieved by time sequences for 4, 7 and 14 days. Serum concentration and relative tissue concentration of insulin and glucagon were also measured. RESULTS: When the common bile duct was tied for 4, 7, and 14 days respectively, the serum concentration and relative tissue concentration of insulin declined (p < 0.05) and glucagon concentration was elevated (p < 0.05). When the common bile duct was tied for 4, 7 and 14 days, then relieved by time sequences for 4, 7 and 14 days, the concentrations of insulin in both groups appeared to decline at first (p < 0.05) and then progressively increase (p < 0.05). The concentrations of glucagon exhibit the reverse behavior. Both serum and tissue concentration are elevated at first (p < 0.05), then progressively decline (p < 0.05). CONCLUSIONS: These studies indicated that, during obstructive jaundice, more fuel is demanded to make up for the energy deficiency. In spite of surgical or non-surgical relief of obstructive jaundice, the energy reserve is still not sufficiently recovered. The recovery of the hepatic energy reserve takes longer than we expected.

Extracorporeal shockwave lithotripsy for treatment of intrahepatic stones: in vitro and in vivo studies.

In vitro, bile duct stones, mostly comprising calcium bilirubinate, are readily fragmented by extracorporeal shockwave lithotripsy (ESWL). In the case of intrahepatic stones, ESWL is effective if the stones float freely in the bile, but if the stones completely fill, or are impacted within, the hepatic duct or bile duct, attempts at fragmentation will end in failure. Three patients with intrahepatic stones were treated with ESWL, and effectively fragmented. The stone fragments passed out spontaneously through T-tube sinus tract, PTDC sinus tract and the sphincter of Oddi as shown in the second cholangiogram. No specific complication was noted in our experimental and clinical experience. We believe that ESWL for fragmentation of biliary stones is technically reliable. The problem of the passage of these fragmented stones is considered; if necessary, it can be overcome by endoscopic means.

Morphology of intrahepatic duct in surgical treatment of hepatolithiasis.

BACKGROUND/AIMS: Surgery is the usual treatment for hepatolithiasis. However, the method of choice is based on intrahepatic duct morphology. MATERIAL AND METHODS: Six hundred sixty-two patients with hepatolithiasis were operated on in the period between 1980-1994. Hepatolithiasis was clinically classified into primary (75.8%) and secondary (24.2%) types. RESULTS: Patients treated between 1990-1994 (35.9%), liver resection was performed in 71 patients (69 of left and 2 of the right liver). However, liver resection was chosen only in 6.7% (11/163) during the 1970s. Candidacy for liver resection increased recently due to the increase in primary type. According to the morphology of intrahepatic ducts, the location of stricture was classified into: Central type (n = 59, 30%), Segmental type (n = 101, 51%), and Subsegmental type (n = 21, 10.6%), and unclassified (n = 17, 8.4%). Liver resection was recommended for patients of segmental or subsegmental type. Choledocho-lithotomy with T-tube drainage was indicated in two third of the patients with hepatolithiasis. However, the incidence of post-operative retained stones was very high, and post-operative choledochoscopic lithotripsy was used to treat these post-operative problems easily. The mortality of this disease was 1% (2/198) in the 1990s compared with that of 4.1% (19/464) in 1980s and 10.1% (15/148) in 1970s. CONCLUSION: We strongly recommend that liver resection for patients with adequate indications will have good results. In addition, one should pay attention to the abnormal pattern of intrahepatic ducts that are commonly found in patients with hepatolithiasis during liver resection. Liver resection is an ideal surgical method for the eradication of diseased lesions and to prevent malignant changes from bile duct with stones. Concise information concerning the anatomic structure was found to be important in determining post-operative results in the management of hepatolithiasis.

Role of angiogenesis in hepatitis and hepatocellular carcinoma.

BACKGROUND/AIMS: Hepatocellular carcinoma (HCC) is usually a hypervascular tumor. Factor VIII-related antigens, including von Willebrand factor, are known to be expressed in HCC, which cause capillarization of the sinusoids of HCC. Capillarization of hepatic sinusoids may play a role in hepatocarcinogenesis and its metastasis. The aim of this study is to clarify the expression of Factor VIII in patients with hepatitis B or C (n = 18) and HCC (n = 16). METHODOLOGY: All specimens were sufficient for immunohistochemical study of the neo-angiogenesis with regard to clinical results. Microvessel count per square millimeter (MVC) and hot spot of microvessel per square millimeter (HSV) were measured from the histochemical study. RESULTS: In the patients with hepatitis group, the positive staining on the vessels of the portal triad was 11.1% (2/18) but in the non-neoplastic tissue of HCC patients the positive rate was 68.7% (11/16) showing a significant difference from the hepatitis group. The amount of vasculatures was easily found in the surrounding capsule of resected HCC. The MVC of the capsule was 10.17 +/- 2.78 and 13.66 +/- 5.42 for the HCC with non-direct invasion and direct invasion during operation, respectively. The HSV of capsules were 7.51 +/- 2.09 and 9.14 +/- 4.02 for the non-invasion and invasion, respectively. Therefore, in our study, it is clear that the high MVC or HSV scores were found in patients of direct invasion. However, there was no relation between hepatitis B or hepatitis C to the tumor invasiveness. The median survival times were 21.5 months for the non-invasive group and 14.5 months for the invasive group (p < 0.05). The positive rate of Factor VIII in the vessels of the portal triad were 60% and 83.3% for the non-invasive and invasive groups, respectively. However, the lower values of MVC and HSV showed a trend toward a longer recurrence time. CONCLUSIONS: It is pertinent to prove that the high score of neo-angiogenesis has a high risk of recurrence. In addition, it is wise to pay more attention to the interval of the follow-up study to detect the recurrent lesion earlier, where possible, in the patient with a high score of microvascularity.

Laparoscopic subsegmentectomy for hepatocellular carcinoma with cirrhosis.

BACKGROUND/AIMS: Laparoscopic liver resection is feasible for both benign and malignant disease with today's laparoscopic techniques and technology. Location of the tumor at the edge of segment 3, 4, 5, or 6 of our patients makes them an ideal candidate for laparoscopic resection. METHODOLOGY: There were 9 patients who underwent laparoscopic subsegmentectomy for hepatocellular carcinoma with cirrhosis. They were classified as Child A in 6 and B in 3 patients. Hepatitis B was found in 5 and Hepatitis C in 4 cases. Preoperative diagnosis of hepatocellular carcinoma was completed in 7 and definitive histologic diagnosis from frozen section in 2 cases. All 9 patients underwent subsegmentectomy and removal of the tumor with non-tumor cirrhotic liver with a distance of 10 mm at the least margin. Laparoscopic ultrasound allows exact localization of lesions and achievement of adequate resection margin. RESULTS: Those patients resumed a full diet on the 2nd-3rd day after the operation and were discharged home on day 4-7 with no complications but one had prolonging discharge due to ascitis from a drainage tube. Finally, the ascitis was controlled by medications for 1 week. All patients had high postoperative satisfaction. CONCLUSIONS: Laparoscopic liver resection is a procedure of significant risk and technically demanding. Therefore, it should be performed only by experienced liver surgeons with a high level of laparoscopic skill and in the carefully selected patient.

Clinical significance of cell differentiation in hepatocellular carcinoma.

BACKGROUND/AIMS: Hepatocellular carcinoma is commonly found in Asian countries and prognosis still remains unsatisfactory due to recurrence after surgical tumor resection. METHODOLOGY: We try to demonstrate the recurrence and survival time in 99 surgical patients grading by tumor cellular differentiation from surgical specimen. RESULTS: The rates of well, moderate, and poor differentiation were encountered in 21 cases (21.2%), 61 cases (61.6%) and 17 cases (17.7%), respectively. Small tumor (< 3 cm) was found in only one (5.9%) in the poor differentiation group and 38.1% and 37.7% in the well and moderate differentiation groups. Capsular invasion was found in 13 (61.9%), 39 (63.9%) and 7 (41.1%) in the well, moderate and poor differentiation group, respectively. We found 41.9% (18/43) and 22.4% (13/58) to be tumor free in capsule invasion (-) and (+) after a period of 18.1 and 29.9 months, respectively. However, the recurrent time was 10.6 and 11.3 months, respectively with no significant difference (p > 0.05). Vascular invasion was more frequent in the poor differentiation group (76.5%) than the well (23.8%) and moderate (60.7%) differentiation groups (P < 0.05). We found 23.5% (4/17) and 35% (21/60) to be tumor free but the recurrence time was 6.5 and 14.1 months for the vascular invasion (-) and (+), respectively. The residual median survival times were 6.5 and 14 months after recurrence, respectively. The tumor recurrence rates were 52.7% (11/21), 52.4% (32/61), and 35.5% (6/17) and recurrence times were 11.7, 11.9, and 4.5 months for the well, moderate and poor differentiation group respectively totally. The recurrence time of young age group (< 39 years old) was shorter than the others and there was no patient of well differentiation less than 40 years old. The recurrence time was shorter in the poor differentiation group but there was no significant difference according to age group. The median survival times were 22.2, 22.9, and 9.5 months for each group, respectively. CONCLUSIONS: Differentiation of hepatocellular carcinoma cell had a clinical significance and was found to be positively correlated with the invasive proclivity. The median survival time was longer in both the well and moderate differentiation group, but not in the poor differentiation group. The clinical data revealed that the extended operations performed upon the patients with poor differentiation effected the recurrence time but not the survival time.

A comparative study of cefotaxime sodium versus a combination of cefapirin and gentamicin in the prophylactic treatment of patients undergoing cholecystectomy.

This was a randomized open evaluation of claforan vs. combination treatment of cefapirin + gentamicin. Patients taking part in the study were randomized in 3 parallel groups: 3 x 1 g claforan given during a period of 24 h (regimen I) was compared to 1 x 1 g claforan given at the time of incision (regimen II) and to a combination of cefapirin + gentamicin given in divided doses for 5 days (regimen III). Sixty-five patients (31 males and 34 females) aged between 23 and 76 years, who underwent cholecystectomy, were included in the study. There were no significant differences between the study groups in terms of sex, age, height, weight, diagnosis, aggravating factors and clinical condition of patients. Sixty of sixty-five patients noted "cholelithiasis" as diagnosis. The majority of patients documented an acute exacerbation of chronic condition. Twenty-three patients documented concomitant diseases/conditions or aggravating factors. The most frequent were: Diabetes mellitus, jaundice and clonorchiasis. During the study no additional administration of antibiotics or other concurrent treatment was recorded. Tolerance of the test substances was noted as "good" by 63 patients and satisfactory in 2 patients. In 3 patients (one patient in each treatment group) a postoperative wound infection was documented. One patient from regimen II with wound infection, therefore, received more than 1 g claforan. Postoperative hemoglobin decreased in all 3 groups (p less than 0.05). BUN decreased in the regimen group I (p less than 0.05) and increased together with creatinine in the group of regimen III (p less than 0.05). No side effects were documented in any treatment groups. The use of a single or three doses of claforan was more convenient and simple than the combination regimen. Less laboratory adverse effects (renal function) were also noted in claforan treated patients than the combination of cefapirin + gentamicin group.

[The management of obstructive jaundice caused by pancreatic head carcinoma and periampullary carcinoma].

We had treated 115 patients with malignant obstructive jaundice, including 69 pancreatic head carcinoma and 46 periampullary carcinoma during the period between 1982 and 1991. In the 115 jaundiced patients 33 had undergone pancreaticoduodenectomy, 50 had bypass operation and the remaining 32 patients undergone percutaneous transhepatic biliary drainage (PTBD) only. No operative mortality happened for the 33 pancreaticoduodenectomies. Postoperative complications occurred in 12 patients. Leakage from the choledochojejunostomy was the most often occurred complications, it was found in 7 patients (21.2%). Intraabdominal abscesses happened in six patients (18.2%) which recovered by treating with ultrasound-guided catheteral drainage. Leakage from pancreaticojejunostomy was also found in five patients (15.2%), the complication recovered uneventfully after administration of total parenteral nutrition and good abdominal drainage. Twenty-two out 33 patients with pancreaticoduodenectomy received preoperative biliary drainage. However, despite preoperative biliary drainage, 10 of 22 patients (45.5%) still suffered postoperative complications. It implied that hyperbilirubinemia would trend to carry a high postoperative morbility. The prognosis for our patients with pancreatic head carcinoma was extremely poor. The mean survival period for all of them was not exceeding 12 months. Those who had PTBD as the sole treatment had the shortest survival period, which was 3.4 +/- 3.1 months only. On the other hand, the mean survival period for those who had periampullary cancer and had pancreaticoduodenectomy was 35.5 +/- 27.2 months, while it was 13.3 +/- 10.1 and 11.8 +/- 10.0 months for those having bypass operation and PTBD respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Subcutaneous implantation of KMC tube for removal of recurrent intrahepatic stones without laparotomy.

About half of 361 patients with intrahepatic stones had recurrent stone(s) requiring additional surgery in the past 10 years. In order to cope with this problem, a new tube referred to as the KMC (Kaohsiung Medical College) tube was developed to allow the removal of stones without additional surgery. This tube was implanted subcutaneously between the common bile duct and the abdominal wall after successful extrication of intra- or extra-hepatic stones. Thirty-nine patients with intrahepatic stones were accepted for this new trial. The surgical procedure consisted of first removing the biliary drainage tube followed by insertion of the KMC tube. The KMC tube was introduced through a small skin incision under local anesthesia and the KMC tube fixed with abdominal fascia. The benefit of this procedure is that the contrast medium could be percutaneously injected into the tube for follow-up cholangiographic study when necessary. The procedure for removal of recurrent stones included removing the KMC tube under local anesthesia, then inserting the choledochofiberscope through the original sinus tract to engage the stone(s) without laparotomy. This procedure had been performed on 4 patients with successful removal of their recurrent stones after 6 to 24 months without the necessity for abdominal surgery.

Conservative hepatic resection for hepatocellular carcinoma of cirrhotic patients.

We evaluated in retrospect the applicability of conservative hepatic resection for hepatocellular carcinoma (HCC) of cirrhotic patients. Eighty (14.6%) of 548 patients with HCC underwent liver resection over a period of 10 years in this hospital. They were divided into two groups according to surgical procedures. In group I, 22 patients underwent major hepatic resection, and in group II, 58 patients underwent conservative liver resection. The operative mortality for patients in group I was 13.6% while it was 3.5% for those in group II. The difference was significant (p<0.05). The five-year survival rate was 22% for patients in group I, while it was 21% for group II patients. The rate of HCC recurrence was 47.4% for group I patients while it was 57.1% for group II patients. The difference was not significant. The tumor-free survival rates at 6-, 12-, 24- and 36-months were 80%, 75%, 55% and 55% respectively for patients in group I, while they were 50%, 42.5%, 42.5% and 42.5% for patients in group II. It suggested that conservative liver resection was associated with early recurrence of HCC. But the difference of mean tumor-free survival time is not significant (35.82+/-5.47 vs 38.63+/-8.05 months, p>0.05). Using Cox's regression analysis, the presence of Child's B was identified as an independent adverse prognostic factor (p=0.000) for long-term survival. The factors associated with poor tumor-free survival rate were Child's classification (p=0.008), metastasis (p=0.021), liver cirrhosis (p=0.039) and tumor size (p=0.054). By evaluating the operative mortality, long-term survival rate, prognostic factors for cumulative survival time and tumor-free survival time, it suggests that conservative liver resection can be selectively used to treat HCC associated with liver cirrhosis.

Evaluation of choledochojejunostomy with subcutaneous jejunostomy for treatment of intrahepatic stones.

Twenty-nine patients, 16 males and 13 females, with intrahepatic stones were treated by choledochojejunostomy with subcutaneous jejunostomy after choledocholithotomy in cases where the common bile duct was dilated more than 2 cm in diameter. This surgical technique consists of putting a segment of jejunum in the subcutaneous area with a jejunostomy after finishing the choledochojejunostomy. If the stone recurs years later, this loop of jejunum will offer a route for inserting the scope while producing the fistulotomy under local anesthesia. These patients became symptomless soon after removal of the residual stone by postoperative choledochoscope. After more than five years of follow-up study, seven cases (24.1%) had reflux cholangitis and among them, four patients had recurrent stones. Reopening of the fistulotomy was carried out under local anesthesia, and the choledochoscope was inserted into the bile duct through the jejunum for removal of those recurrent stones. We believe that this surgical technique is very effective for the treatment of patients with recurrent intrahepatic stones without the necessity of major laparotomy.

Changes of insulin and somatostatin and their relationship to liver regeneration in experimental obstructive jaundice.

The liver is a parenchymal organ that has a substantial capacity to regenerate after damage. Obstructive jaundice is a common surgical disease and potentially risky. A successful outcome of operations depends upon the hepatic regeneration reserve. Insulin is one of factors responsible for hepatotrophic regeneration and somatostatin has a reversal suppressive action. Experimental obstructive jaundice was introduced and relieved. In addition, serum insulin and somatostatin concentrations were measured. We used immuno-histochemical study of pancreatic tissue by immunogold to express the tissue relative insulin and somatostatin concentrations. Nucleolar organizer regions (NORs) were used to predict the nucleolar activity of liver cells. In our studies, we observed the serum concentrations of insulin and somatostatin were similar to the relative tissue concentration in pancreatic tissues. The relative tissue gold-particle score of insulin in group A (rats with common bile duct tied), was CONT: T4: T7: T14 = 100%: 90.5%: 68.3%: 46.2%; of somatostatin was 100%: 120%: 118.2%: 115.5% respectively. In group B (common bile duct tied for 4 days then relieved), the gold-particle score of insulin was T4: T4R4: T4R7: T4R14 = 90.5%: 62.8%: 72.2%: 95.4%; of somatostatin was 120.2%: 114.3%: 108.1%: 106.2% respectively. In group C (common bile duct tied for 7 days then relieved), the gold-particle score of insulin was T7: T7R4: T7R7: T7R14 = 68.3%: 53.3%: 73.5%; of somatostain was 118.2%: 109.4%: 104.6%: 102.1% respectively. The mean numbers of AgNORs in group A revealed CONT: T4: T7: T14 = 2.24 +/- 0.24: 3.02 +/- 0.96: 3.26 +/- 1.02:3.08 +/- 0.84, group B was T4: T4R4: T4R7: T4R14 = 3.02 +/- 0.96: 3.03 +/- 0.73: 3.36 +/- 1.12: 3.72 +/- 1.46, and group C showed T7: T7R4:T7R7: T7R14 = 3.26 +/- 1.02: 3.26 +/- 0.84: 3.31 +/- 1.24: 3.54 +/- 1.24. In conclusion, our studies suggested: (1) liver regeneration appeared promptly after obstructive jaundice developed, but prolonged cholestasis inhibited this process. (2) Insulin levels gradually fell during the process of obstructive jaundice. Those levels elevated when cholestasis was improved. Nevertheless, both insulin and hepatic regeneration power could not reflect the initial improvement of cholestasis simultaneously. It took a longer time for the improvement of cholestasis and the recovery of the liver function. (3) Patho-physiologically, somatostatin had a weak influence on hepatic regeneration during obstructive jaundice. (4) Our studies provided clues that early biliary drainage might improve hepatic regeneration capacity. Supplement of insulin during the obstructive jaundice might be helpful for the improvement of hepatic regeneration power.

Laparoscopic fenestration for giant liver cyst.

Laparoscopic fenestration for treatment of the non-parasitic cyst of the liver has been rarely reported, but sporadic cases appeared elsewhere in the literature. Here we report four cases with symptomatic giant nonparasitic liver cysts which were treated by a laparoscopic fenestration procedure that allowed the successful removal of the cyst dome. Before starting to excise the wall of the cyst, laparoscopic-quided needle aspiration of the cyst fluid was done first in order to clean the visual field for laparoscopic intervention where possible. The cyst wall was usually slightly transparent and somewhat smooth in the external and internal surface of the cysts. It was necessary to lysis the omental adhesion sometime before starting to remove the dome of the cyst. The cyst wall of the exposed part could be removed first with heat-probe instrument through laparoscopy. Those patients were discharged and revealed an uneventful post-operative course in three cases but in one case we had to convert to the traditional laparostomy to perform resection of the multiple cystic lesions. Post-operative echographic study showed that the giant cyst had collapsed. Therefore, we believe laparoscopic fenestration for the liver cyst is simple and effective, if the patient is a candidate who requires operation to remove the dome of the giant cyst.

Laparoscopic subsegmentectomy for hepatocellular carcinoma with cirrhosis: a case report.

Laparoscopic liver resection is feasible for both benign and malignant disease with present laparoscopic techniques and technology. Laparoscopic liver tumor resection is indicated instead of the conventional hepatectomy if the tumor is located in the peripheral part of the liver. Here, we reported a case of a 73-year-old woman who accepted laparoscopic subsegmentectomy for hepatocellular carcinoma of segment 6. After traditional laparoscopic trocar was settled down under the low pneumoperitoneal pressure of 8 mm Hg, laparoscopic ultrasound allowed exact localization of lesions first and then transection line was marked. Then, dissection the liver parenchyma was carried out with laparoscopic microwave coagulator and ultrasonic aspirator gradually. After operation, she resumed full diet on the second day and was discharged on the 5th post-operative day with no complications and high patient satisfaction. She had follow-up study regularly in our clinic and was disease free at nine months. With the improvement of laparoscopic techniques and the development of new and dedicated technologies, laparoscopic hepatectomy has become feasible.

Pancreatic pseudocyst involving the spleen.

The pseudocyst of the pancreas is a frequent complication of acute pancreatitis. The splenic involvement from the pancreatic pseudocyst is an uncommon entity. A 40-year-old man, who had a five-year history of alcohol consumption, was referred to our hospital for treatment of throbbing pain over left upper quadrant (LUQ) of the abdomen. Except for LUQ tenderness, physical examination was essentially normal. MRI showed two cystic lesions in splenic hilum and pancreatic tail, and prominent vessels in left infrasplenic area and gastrosplenic ligament. Angiography revealed splenic vein thrombosis. Because of persistent LUQ pain, he underwent laparotomy. During the operation, we found the cysts in pancreatic tail and splenic hilum. The cystic content was aspirated to check amylase, which showed the level of amylase being as high as 20,000 IU/L. The diagnosis of a pancreatic pseudocyst involving the spleen was established. Splenectomy and distal pancreatectomy were performed to remove both cysts. The pathologic examination of the resected spleen showed splenic infarction with cyst formation and pancreatic pseudocyst. The patient recovered uneventfully after operation.

Ultrasound-guided percutaneous transhepatic drainage of gallbladder followed by cholecystectomy for acute cholecystitis--10 years' experience.

Acute cholecystitis is a common disease which may carry the risk of complications, including empyema, perforation, abscess, peritonitis and sepsis. Percutaneous transhepatic drainage of the gallbladder (PTGBD) with antibiotics can provide prompt decompression of gallbladder in acute cholecystitis and interrupt the natural history of the disease effectively. From July 1986 to June 1996, 154 patients with acute cholecystitis were reviewed retrospectively in Kaohsiung Medical College Hospital. The chief symptoms and signs were pain (98.1%), fever (57.1%) and jaundice (37.7%). WBC count more than 10,000 was noted in 116 (75.3%) patients. Associated diseases included empyema: 42 (27.3%), septic shock: 14 (9.1%), diabetes mellitus: 13 (8.4%), pancreatitis: 10 (6.5%), perforation: 7 (4.5%), liver cirrhosis: 6 (3.9%) and respiratory failure: 1 (0.6%). All of them underwent ultrasound-guided PTGBD immediately after the diagnosis was established. The symptoms and signs disappeared soon after this procedure. Bacterial culture was found positive in 104 (67.5%) of 154 patients in which Escherichia coli (51.9%) was the most common organism, followed by Klebsiella pneumonia (20.2%). After acute stage, 138 patients obtained the cholangiography via PTGBD tube. Gallbladder stones were only noted in 56 (40.6%) patients, gallbladder stone concomitant with common bile duct stone in 26 (18.8%), cystic duct obstruction in 25 (18.1%), acalculous cholecystitis in 21 (15.2%), gallbladder perforation in 1 (0.7%), choledochocyst in 1 (0.7%), and cholecystocolonic fistula in 1 (0.7%). There were 135 patients to undergo surgery after the clinical condition was stable. The operative findings included gallbladder stones only in 88 (65.2%), gallbladder stone concomitant with common bile duct stone in 34 (25.2%), acalculous cholecystitis in 13 (9.6%), choledochocyst in 1 (0.7%), and cholecysto-colonic fistula in 1 (0.7%). The postoperative complications included wound infection 8 (5.9%), UGI bleeding 3 (2.2%), acute renal failure 1 (0.7%) and acute respiratory failure 1 (0.7%). The postoperative mortality rate was 0.7% (1/135), which was much lower than those of previous reports, which not undergoing PTGBD initially. It led us to conclude that PTGBD, as an initial preoperative modality to treat acute cholecystitis, is effective in decreasing postoperative morbidity and mortality.

Liver Surgery for Hepatocellular Carcinoma: Laparoscopic versus Open Approach.

In this study, we try to compare the benefit of laparoscopic versus open operative procedures. Patients and Methods. One hundred and sixteen patients underwent laparoscopic liver resection (LR) and another 208 patients went for open liver resection (OR) for hepatocellular carcinoma (HCC). Patients' selection for open or laparoscopic approach was not randomized. Results. The CLIP score for LR and OR was 0.59 ± 0.75 and 0.86 ± 1.04, respectively, (P = .016). The operation time was 156.3 ± 308.2 and 190.9 ± 79.2 min for LR and OR groups, respectively. The necessity for blood transfusion was found in 8 patients (6.9%) and 106 patients (50.9%) for LR and OR groups. Patients resumed full diet on the 2nd and 3rd postoperative day, and the average length of hospital stay was 6 days and 12 days for LR and OR groups. The complication rate and mortality rate were 0% and 6.0%, 2.9% and 30.2% for LR and OR groups, respectively. The 1-yr, 3-yr, and 5-yr survival rate was 87.0%, 70.4%, 62.2% and 83.2%, 76.0%, 71.8% for LR and OR group, respectively, of non-significant difference. From these results, HCC patients accepted laparoscopic or open approach were of no significant differences between their survival rates.

Silver-binding nucleolar organizer regions in hepatolithiasis and bile duct cancer.

Hepatolithiasis and bile duct cancer have usually been linked together especially in Asian countries. Epithelium cells of bile duct or ductal glands had proliferative changes in patients with hepatolithiasis usually. The numbers and shape of the nucleoli were studied with special staining of AgNOR (Nucleolar Organizer Regions) on bile ducts without calculi (n = 11), with calculi (n = 21), and hepatolithiasis with bile duct carcinoma (n = 14). The patterns of AgNOR were classified into a dotted type and a cluster type under light microscopic examination. AgNORs scores were found to be 2.7 +/- 1.2 (M +/- SD) and 3.6 +/- 1.2 for intramural glandular cells and extramural glandular cells in hepatolithiasis (p < 0.05). In the cases of bile duct carcinoma, the percentage of the cluster form of AgNOR was 28.1 +/- 4.4%, and the scores were 4.7 +/- 2.4 for bile duct cancer, which was significantly different from intramural glands, but not different from the extramural glands in hepatolithiasis. High scores of the dotted type and high percentage of cluster type have high potentiality of malignant changes. From this study, unknown substances for malignant transformation might be secreted from the inner epithelium and or intramural glandular epithelium both of which are usually in contact with the infected bile and have chronic irritation from the stones. Extramural glands of the bile duct had higher potential for proliferation or malignant transformation in our study. Hence, long-term follow-up study of those patients with hepatolithiasis should be done very carefully especially due to the possibility of a combination of neoplastic changes in hepatolithiasis.