Combined laparoendoscopic approach for biliary lithiasis treatment.

BACKGROUND/AIMS: The treatment of common bile duct stones diagnosed during videolaparoscopic cholecystectomy is still under debate. In cases of suspected common bile duct stones, a double approach with endoscopic retrograde cholangiopancreatography either prior to, or following videolaparoscopic cholecystectomy is the current routine in many centers. An intraoperative endoscopic retrograde cholangiopancreatography with endoscopic papillosphincterotomy and stone extraction has recently been proposed. METHODOLOGY: We compared the approaches for suspected common bile duct stones in 21 cases of combined intervention endoscopic retrograde cholangiopancreatography during videolaparoscopic cholecystectomy to 17 cases of sequential intervention (endoscopic retrograde cholangiopancreatography prior to videolaparoscopic cholecystectomy). Complications and postoperative monitoring are discussed and reported on the basis of hospital stay. RESULTS: Although the efficacy and the complications are similar, patients treated with the sequential approach stayed in the hospital longer because of the double monitoring period during both after endoscopic retrograde cholangiopancreatography and after videolaparoscopic cholecystectomy. CONCLUSIONS: A combined approach to suspected common bile duct stones during videolaparoscopic cholecystectomy could be an effective and a financially worthwhile treatment.

Surgery for hilar cholangiocarcinoma: an Italian experience.

From January 1980 to June 1997 we treated 159 patients with carcinoma of the hepatic duct confluence. Seventy-five patients underwent surgical resection (overall resectability rate: 47.2%), and radical resection was attempted in 46 patients (radical resectability rate: 28.9%) classified in the first three stages of our staging system. Perioperative mortality was 10% (16 patients). The 5-year survival rate for 46 patients with curative resection was 17.5% with a median survival of 19 months. The 5-year survival rate for those patients who underwent combined caudate lobectomy (n = 17) was 25%, whereas the survival rate for those who did not was zero. The difference between these two groups' results was statistically significant. The importance of careful preoperative staging is stressed. Preoperative tests should be limited to investigations (ultrasound with Doppler scan, spiral computed tomography, percutaneous transhepatic cholangiography) supplying most information about intra- and extrabiliary diffusion of the tumoral mass. We conclude by highlighting the importance of resection as the only treatment potentially improving long-term survival. On the basis of these results, caudate lobectomy is always recommended in association with resectional treatment of the neoplasm.

Repeated hepatic resections for recurrent metastasis of colorectal cancer.

BACKGROUND/AIM: Few cases of repeated hepatic resection for recurrent metastasis have been in literature. This paper focuses on metastatic recurrences and their surgical treatment, comparing the outcome of resective therapy with the natural history of metastases. Results of alternative methods (alcoholization and trans-arterial chemo-embolization), are evaluated through the analysis of indications, complications and real benefit. MATERIALS AND METHODS: Between January 1980 and Jan 1995, 163 patients with hepatic metastases were operated on in our Department. In 132 cases, metastases originated from colorectal cancer: 105 were submitted to hepatic resection, 3 were treated by selective ischemia, 5 by chemotherapy through an infusaid catheter, 5 by alcoholization under ultrasonographic control, 14 by a new phase II trial of schedule oriented biochemical modulation of FUra bolus by MTX and B interferon and FUra continuous infusion by leucovorin. RESULTS: Out of 76 metachronous metastases operated on, 10 were metastatic hepatic recurrences surgically treated by second resection. The average time-interval intercurring between the two hepatic resections was 15 months. The average follow-up and survival period after repeated resection was 27 months (range 2-129). CONCLUSIONS: Through the analysis of these ten cases, we sorted out the segmentary localization of hepatic metastases, the type of operation performed, the disease free interval, serum CEA patterns, morbidity and survival.

[Intrahepatic lithiasis]. / La litiasi intraepatica.

From 1982 to 1993 9 patients with primary intrahepatic lithiasis and 49 with secondary intrahepatic lithiasis were treated. Out of the first group of patients, 2 underwent right hepatectomy, 2 left hepatectomy and 1 lithotomy + hepatico-jejunostomy. No death occurred within thirty days from operation: morbidity occurred as a consequence of wound infection in one case and bronchopulmonary complications in two cases. At follow-up (6 months-11 years) 1 cholangitis and 1 relapse were found. Secondary intrahepatic lithiasis was treated as follows: in 15 cases we performed lithotomy + cholangio-jejunostomy + 9 postoperative percutaneous transhepatic cholangio-jejunostomy + 9 postoperative percutaneous transhepatic cholangioscopies (PTCS) + 2 cutaneous jejunostomies; in 5 cases lithotomy + papillosphincteroplasty (PSP) + Kehr + 1 trans-Kehr fiber cholangioscopy (PTKCS); in 1 case lithotomy + choledochoduodenostomy (CDS); in 3 cases right hepatectomy and in 4 cases left hepatectomy; in 14 cases lithotomy + hepatico-jejunostomy; in 5 cases PTKCS alone and in 2 cases PTCS alone. Overall mortality summed up to one case only. Overall morbidity occurred in the shape of two biliary fistulas, 3 subhepatic abscesses, 8 bronchopulmonary complications, 4 wound infections, 1 ileal perforation. Follow-up (6 months-11 years) revealed 2 stenosis of the biliodigestive anastomosis, 3 cholangitis relapses and 2 relapsing lithiasis. Since 18 cases were successfully treated through postoperative fiber cholangioscopy, the authors come to the conclusion that in all cases not requiring hepatectomy due to monolateral lithiasis, it is always advisable to leave open an access to the biliary tract, which might allow further improving maneuvers after surgery.

Comparison in human and rat hepatocytes of the DNA-damaging activity of five chemicals probably carcinogenic to humans.

Five chemicals-acrylonitrile, adriamycin, bischloroethyl nitrosourea, phenacetin and procarbazine-classified by the International Agency for Research on Cancer as probably carcinogenic to humans were assayed for DNA-damaging activity in primary cultures of human and rat hepatocytes in order to assess possible interspecies differences that might cast doubt on the extrapolation to humans of results obtained in rodents. DNA damage was measured by the alkaline elution technique. In the range of subtoxic concentrations indicated, dose-related increases in the frequencies of DNA single-strand breaks were induced in cells of both species by acrylonitrile (1.0-5.6 mm) and procarbazine (5.6-18 mm), whereas phenacetin was inactive up to the maximal soluble dose (3.2 mm). Adriamycin (1.8-5.6 mum) and bischloroethyl nitrosourea (18-56 mum) produced in cells of both species dose-dependent increases in the frequencies of both DNA breaks and cross-links. The responses of human hepatocytes were qualitatively similar to those of rat hepatocytes, but modest statistically significant differences between the two species in the average frequencies of DNA lesions were observed with the four active agents: the amount of DNA damage was greater in rat than in human hepatocytes with acrylonitrile (1.7-fold), adriamycin (1.4-fold), and BCNU (1.3-fold), whereas procarbazine was more genotoxic (1.4-fold) for human hepatocytes. However, as the interindividual variability of the response was greater than that occurring between the two species, the results should be interpreted as indicating that rat hepatocytes are good predictors of metabolic activation/detoxification and DNA-damaging activity in humans for the five chemicals studied.

Intrahepatic lithiasis above a bilio-digestive anastomosis.

The authors review their experience of twenty-five cases of intrahepatic lithiasis proximal to a bilio-digestive anastomotic stricture. Patients were operated on between 1970 and 1990, with a later follow-up in 1993. The pathogenesis of stone formation, in these cases, was relatable to multiple factors: biliary infection, presence of lithogenic nuclei (e.g. foreign bodies such as suture stitches), biliary stasis due to the stenosis. Management of this peculiar disease must take into account both surgical options and percutaneous as well as endoscopic methods. Our approach is the reconstruction of the stenotic anastomosis at its highest point, associated with intraoperative lithotomy followed by post-operative lithotomy and lithotripsy (if necessary) using PTCS (percutaneous transhepatic cholangioscopy). The best results are achieved with cooperation between surgeon, radiologist and endoscopist, aimed at preventing post-operative complications and severe consequences for the patient.

Neoplasm of the hepatic hilum: the role of resection.

A series of one hundred cases of primitive tumors of the biliary confluence (Klatskin tumor) observed between 1970 and 1990 are reviewed with respect to the variations occurring in the diagnostic backup and treatment policy. The need for peroperative staging is noted: On the basis of their clinical experience, the authors restricted the preoperative study to those investigations providing more information about endo- and exobiliary diffusion of tumoral mass (ultrasound, direct cholangiography). The review demonstrates the possibilities of a surgical approach to a palliative or resectional treatment in all patients in whom no local or general contraindications are present. Other cases are treated with percutaneous or endoscopic biliary stenting. The authors conclude that tumor resection with bilio-digestive anastomosis is the treatment of choice in selected patients, and results in a better quality of life with an improved "comfort index".

Primitive hepatic hilum neoplasm.

One hundred ten cases of primitive hepatic hilum neoplasms (Klatskin tumor) observed from January 1970 to June 1992 are reviewed and the variations occurring in the diagnostic back-up and treatment policy are considered. The importance of careful preoperative staging is stressed. Preoperative tests should be limited to investigations supplying most informations about endo- and esobiliary diffusion of the tumoral mass (ultrasound, direct cholangiography, portography). This paper demonstrates that a surgical approach with both palliative or resective aims is suitable for all patients with no local or general contraindications. Other cases are treated with percutaneous or endoscopic biliary stenting. The authors conclude by pointing out that tumoral resection with biliodigestive anastomosis is in any case the treatment of choice in these patients as it gives a better quality of life (improved "comfort index").

Percutaneous transhepatic biliary drainage--twelve years' experience.

Our experience with percutaneous transhepatic biliary drainage in a total of 362 patients carried out between January 1977 and December 1988 is described. Three hundred and fifty drains were correctly placed, and results were good in 285 (81.5%), fair in 53 (15.1%) and poor in 12 (3.4%). In 12 of the total number of cases (3.4%) it was not possible to position the drain effectively. The mortality rate of the method was 0.8% (3 cases). Complications were as follows: obstruction 7 (1.9%), dislodgement 15 (4.1%), hemobilia 15 (4.1%), hemoperitoneum 1 (0.2%), cholangitis 6 (1.6%), and choleperitoneum 10 (2.7%). In view of the good results and low incidence of complications the conclusion is that in skilled hands, percutaneous transhepatic biliary drainage is a very useful method that should be available in any center specializing in hepatobiliary surgery.

Percutaneous transhepatic biliary drainage twelve years' experience.

Experience with a total of 362 percutaneous transhepatic biliary drainage (PTBD) carried out between January 1977 and December 1988, is described. Of these, 350 drains were correctly placed and 285 (81.5%) showed a good result, 53 (15.1%) a fair result and 12 (3.4%) a poor outcome. In 12 of the total number of cases (3.4%) it was not possible to position the drain effectively. The mortality rate of the method was 0.8% (3 cases). Complications were as follows: obstruction 7 (1.9%), dislodgement 15 (4.1%), hemobilia 15 (4.1%), hemoperitoneum 1 (0.2%), cholangitis 6 (1.6%), choleperitoneum 10 (2.7%). In view of the good results and low incidence of complications it is concluded that in skilled hands PTBD is a very useful method that should be available at any center specializing in hepatobiliary surgery.

Percutaneous fibercholangioscopies.

This is a report on our experience in 309 percutaneous fiberendoscopies of the biliary tract done in 106 patients of the 115 scheduled for the procedure. We describe the relevant approaches, techniques, complications and results. In particular, percutaneous transhepatic cholangioscopies (PTCS) were accomplished on transhepatic percutaneous drainages located radiologically in 35 patients: in 13 for differential diagnosis to distinguish between malignant and benign stenoses (diagnostic accuracy in 92% of the biopsies), in 22 cases with therapeutic intent, including 14 lithotomies for extrahepatic biliary tract calculosis, combined in 4 cases with a simple dilatation of the papilla and a percutaneous "descending" papillotomy; in 7 patients a dilatation of the biliary tract (BT) or of the stenosis of a biliodigestive anastomosis was accomplished (malignant in 4 patients, benign in 3 patients). In 38 patients postoperative percutaneous transhepatic cholangioscopies were performed along surgically located transparietohepatic drains, both to assess the biliodigestive anastomosis healing process carried out by two different techniques (30 patients), and to complete the biliary tract drainage as part of the primary and secondary endoscopic surgical treatment of massive intrahepatic lithiasis. In two further patients affected by such pathology, PTCS was done in combination with fibercholangioscopy performed via a transjejunal approach using a Völker drain on a Y-shaped loop. Nine of these patients were treated successfully and one patient later underwent a left hepatectomy, since attempts to drain that area had remained unsuccessful. The transjejunal approach was carried out in 3 patients as a diagnostic measure: in two cases to check the lithotomy, and in one case to check a cholangiojejunal anastomosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Chemico-experimental data on the principal bile constituents in patients with obstructive jaundice]. / Rilievi chimico-sperimentali sui principali costituenti biliari in pazienti con ittero ostruttivo.

Bile samples from patients suffering from cholestasis were tested. Cholesterol, phospholipids, and bile acids (cholic, lithocholic, deoxycholic, chenodeoxycholic) were measured and the methods for the gas-chromatographic determination of cholesterol and major bile acids as well as for the colorimetric determination of phosphorus in phospholipids of human bile are described in extenso. Bile samplings were first carried out on the day the drainage tube was positioned and were repeated every 5 days for four times. Between the first and the last sampling, 1250 mg of phosphatidylcholine was intravenously administered to each patient daily. The aim of the experiment was to evaluate the possible variations in the bile constituents occurring over the specified time.

Technique and endoscopic monitoring of the healing process in bilioenteric anastomoses.

Thirty-three patients were given cholangiojejunoanastomoses: 13 for benign postoperative stenoses of the biliary tract (BT) with or without lithiasis; five for massive intra and extra-hepatic lithiasis; 15 for malignant stenoses on the upper third of the biliary ways. The 15 patients in Group A were given a muco-mucosal anastomosis and the 18 in Group B extramucosal anastomosis after excision of the excess mucosa on the jejunotomy. In both groups an interrupted suture using fine, slow-absorption thread was employed. Three patients (two from Group A and one from Group B) were excluded from the study due to postoperative filtration of the anastomosis. Transhepatic cholangioscopic monitoring of the healing process on the 15th, 20th, 30th and 40th day showed that while both types of anastomosis were equally secure, the extramucosal suture after excision of excess mucosa produced wider anastomoses and is therefore advisable in all cases of bilioenteric anastomosis (BEA) but especially when the biliary ways are narrow or tendentially thin-walled.