The relationship between bile reflux and common bile duct diameter after cholecystectomy: a clinical case-control study.

OBJECTIVE: The present study aims to investigate the relationship between bile reflux (BR) and diameter of the common bile duct (CBD) in patients after cholecystectomy. MATERIALS AND METHODS: In our case series analysis, according to the endoscopy results, the patients who underwent cholecystectomy were divided into two groups as those with BR and those non-BR. Age, sex, CBD diameter measured on ultrasonography, computed tomography, magnetic resonance cholangiopancreatography, and endoscopic biopsy results of the patients were statistically analyzed. RESULTS: In a total of 188 patients included in the study, BR was detected in 93 patients, it was not observed in 95 patients. The CBD diameter of the patients was observed to be 7 mm or less in 70.9% (n = 66) in the BR group, and 23% (n = 22) in the non-BR group. The statistical analysis revealed that while there was a significant difference between the two groups in terms of CBD diameter and intestinal metaplasia, the results were similar in both groups in terms of inflammation, activity, atrophy, and Helicobacter pylori. CONCLUSION: We believe that CBD diameter may be a predictive factor in the detection of BR after cholecystectomy.

OBJETIVO: Investigar la relación entre el reflujo biliar y el diámetro del colédoco después de la colecistectomía. MÉTODO: Estudio retrospectivo en el que, de acuerdo con los resultados de la endoscopia, los pacientes que se sometieron a colecistectomía se dividieron en dos grupos: con reflujo biliar y sin reflujo biliar. Se analizaron estadísticamente la edad, el sexo, el diámetro del conducto biliar común medido por ultrasonografía, tomografía computarizada y colangiopancreatografía por resonancia magnética, y los resultados de la biopsia endoscópica. RESULTADOS: En un total de 188 pacientes incluidos en el estudio, se detectó reflujo biliar en 93 pacientes y no se observó en 95 pacientes. Se vio que el diámetro del conducto biliar común de los pacientes era de 7 mm o menos en el 70.9% (n = 66) del grupo con reflujo biliar y en el 23% (n = 22) del grupo sin reflujo biliar. El análisis estadístico reveló que, si bien hubo una diferencia significativa entre los dos grupos en términos de diámetro del conducto biliar común y metaplasia intestinal, los resultados fueron similares en ambos grupos en términos de inflamación, actividad, atrofia y presencia de Helicobacter pylori. CONCLUSIONES: Creemos que el diámetro del colédoco puede ser un factor predictivo en la detección de reflujo biliar después de la colecistectomía.

Evaluation of hepatobiliary excretion and enterobiliary reflux in rats with biliary obstruction submitted to bilioduodenal or biliojejunal anastomosis.

Bilioduodenal and biliojejunal anastomoses are effective for the treatment of biliary obstruction. The objective of this study was to compare the effects of these anastomoses on hepatobiliary excretion and enterobiliary reflux. Enterobiliary reflux and biliary excretion were evaluated respectively after oral administration of technetium ((99m)Tc) in combination with sodium phytate and intravenous infusion of (99m)Tc with diisopropyl-iminodiacetic acid. Enterobiliary reflux occurred to an equal degree in the bilioduodenal and biliojejunal groups. Maximum hepatic activity time (T(max)) and radiotracer clearance half-time (T(1/2)) were similar in both groups. However, when compared with that found for the sham-operated group, T(max), and T(1/2) were higher in the biliojejunal group (P = 0.02 and P = 0.01, respectively). Histopathological analysis showed marked reduction in ductal proliferation in both groups. These data undermine the theoretical advantages attributed to biliojejunal anastomosis and further the understanding of the pathophysiology of cholangitis that occurs even with patent anastomosis.

Occult pancreaticobiliary reflux in gallbladder cancer and benign gallbladder diseases.

BACKGROUND AND OBJECTIVES: It was proposed that occult pancreaticobiliary reflux (OPBR) was associated with precancerous mucosal changes in the gallbladder, hence the importance of this disorder. There are no published reports investigating the incidence of OPBR in patients operated on for the entire spectrum of benign gallbladder diseases and gallbladder cancer. Our aim was to determine the incidence of OPBR and measure the levels of active pancreatic enzymes (amylase and lipase) in gallbladder bile of patients undergoing cholecystectomy for benign and malignant gallbladder diseases. METHODS: One hundred eight patients with normal pancreaticobiliary junction evidenced by operative cholangiography were included in the study. RESULTS: According to gallbladder bile amylase and lipase levels, 84.2% and 89% patients respectively had OPBR. OPBR was present in all gallbladder cancer patients; in these patients the biliary levels of amylase and lipase were significantly higher than the levels found in patients with benign gallbladder pathology (P < 0.0001). CONCLUSIONS: OPBR could lead to inflammatory changes of the biliary epithelium and progress towards the development of precancerous mucosal changes and gallbladder cancer. The reason why such high levels of pancreatic enzymes are regurgitated into the biliary tree of patients with gallbladder cancer should be clarified.

[Changes in the gastric mucosa after iso- and anisoperistaltic gastrojejunostomy in rats]. / Alterações da mucosa gástrica na gastrojejunostomia isoperistáltica e anisoperistáltica em rato.

Gastrojejunostomies are frequently associated to postoperative manifestations, provoked by biliopancreatic reflux to the stomach. Not only the symptoms can be severe, but also regenerative and reactional transformations of the gastric epithelium, dysplastic alterations and perianastomotic ulcers may be formed. Changes of gastric mucosa and their relation to surgical iso and anisoperistaltic gastrojejunal anastomosis were carried out. Gastrojejunostomies non associated with gastrectomy were performed in two groups (n = 7) of Holtzman rats. In the 30th postoperative day, the stomach and the jejunum close to the anastomosis were removed for pathohistological study. The group with anisoperistaltic anastomosis had a greater extension of histological alterations compatible with the histological picture of reflux gastropathy than the isoperistaltic group (P < 0.05). Three anastomotic ulcers were identified in the anisoperistaltic group and only one in the isoperistaltic, but these results were not statistically significant. Among the gastric surgeries, the gastrojejunostomies are the ones which cause greater biliopancreatic reflux. This reflux may induce changes in the gastric mucosa close to the anastomosis and even lead to cancer. According to other papers, the amount of reflux to the stomach can be directly related to the histological alterations on its mucosa. In conclusion, the anisoperistaltic gastrojejunostomy causes more changes in the gastric mucosa than the isoperistaltic, in this experimental model.

Alteraçöes da mucosa gástrica na gastrojejunostomia isoperistáltica e anisoperistáltica em rato / Alterations in the gastric mucosa after iso and anisoperistaltic gastrojejunostomy in rat

As gastrojejunostomias associam-se freqüentemente a manifestações pós-operatórias, em grande parte relacionadas ao refluxo de líquido biliopancreático para o estômago. Além dos sintomas, que podem ser intensos, encontram-se alterações degenerativas e reacionais do epitélio gástrico, displasias e formação de úlceras próximas à anastomose. Com o objetivo de se estudar as alterações da mucosa gástrica e a relação destas com o procedimento cirúrgico, procedeu-se à avaliação histológica da mucosa do estômago após a realização de anastomoses gastrojejunais isoperistálticas e anisoperistálticas. Foram confeccionadas gastrojejunostomias e fechamento duodenal não-associados à gastrectomia em dois grupos (n = 7) de ratos Holtzman. No trigésimo dia pós-operatório, retirou-se a peça cirúrgica composta pelo estômago e jejuno próximo à anastomose. No grupo com anastomose anisoperistáltica, houve maior área de alterações histológicas das glândulas gástricas da região da anastomose que no grupo isoperistáltico (P < 0,05). Foram encontradas três úlceras anastomáticas no grupo anisoperistáltico e somente uma no grupo isoperistáltico. Concluindo, a gastrojejunostomia anisoperistáltica não-associada à gastrectomia provoca mais alterações da mucosa gástrica e anastomáticas que a isoperistáltica, no modelo experimental utilizado.

Comparison between Henley jejunal interposition and Roux-en-Y anastomosis as concerns enterogastric biliary reflux levels.

The amount of enterogastric biliary reflux was assessed in patients who previously underwent Henley operation (n = 8) or Roux-en-Y biliary diversion (n = 7) using the radiopharmaceutical 99mTechnetium-DISIDA. Two other groups were investigated: a control group consisting of patients with unoperated duodenal ulcer (n = 10) and a group of patients who underwent Billroth II gastrectomy (n = 7). The length of the interposed segment of jejunum ranged from 20 to 30 cm (median of 22.5 cm) in the Henley patients, and from 30 to 60 cm (median of 40 cm) in the Roux-en-Y group. In Henley patients, the percentage of administered 99mTechnetium-DISIDA that was recovered from the stomach (median of 0.92%) was lower (p less than 0.01) than that obtained for Billroth II patients (median of 32.28%) and did not differ (p greater than 0.10) from that of the Roux-en-Y (median of 0.36%) and duodenal ulcer groups (median of 2.53%). These results indicate that Henley operation is as effective as Roux-en-Y diversion in promoting the reduction of the amount of enterogastric biliary reflux that follows Billroth II distal gastrectomy.

Gastritis alcalina: reoperaciones gástricas / Alkaline gastritis: gastric reoperations

Los autores presentan 23 casos (1,6%) de pacientes portadores de un síndrome de gastritis alcalina reoperados en el Hospital Nacional de Gastroenterología "Dr Bonorino Udaondo", en el período comprendido entre enero de 1960 y diciembre de 1985, sobre un total de 1.400 intervenciones quirúrgicas practicadas para tratar la enfermedad ulcerosa gastroduodenal; 19 de los 23 casos presentaban un síndrome de gastritis alcalina bien definido, mientras que el resto (4 casos) un síndrome mixto por el agregado o participación de otros síndromes. La operación primaria consistió en una resección gástrica tipo Bilroth II en 22 casos y el restante era portador de una vagotomía con gastroenteroanastomosis. En todos ellos se estudiaron los aspectos clínicos, radiológicos, de laboratorio, endoscópicos e histopatológicos, test de Kay y Hollander. Las intervenciones quirúrgicas correctoras fueron: Soupault-Bucaille con asa isoperistáltica (7 casos); con asa anisoperistáltica tipo Poth (1 caso); reoperaciones con la técnica de Y de Roux (14 casos); desgastroenterostomía, cierre de la brecha gástrica y yeyunal y piloroplastia (1 caso). Se completó con vagotomía. Un 50% de los casos tienen 5-8 años de operados; otros fueron reexaminados a los 10 y 15 años, hallándose asintomáticos

Gastritis alcalina: reoperaciones gástricas / Alkaline gastritis: gastric reoperations

Los autores presentan 23 casos (1,6%) de pacientes portadores de un síndrome de gastritis alcalina reoperados en el Hospital Nacional de Gastroenterología "Dr Bonorino Udaondo", en el período comprendido entre enero de 1960 y diciembre de 1985, sobre un total de 1.400 intervenciones quirúrgicas practicadas para tratar la enfermedad ulcerosa gastroduodenal; 19 de los 23 casos presentaban un síndrome de gastritis alcalina bien definido, mientras que el resto (4 casos) un síndrome mixto por el agregado o participación de otros síndromes. La operación primaria consistió en una resección gástrica tipo Bilroth II en 22 casos y el restante era portador de una vagotomía con gastroenteroanastomosis. En todos ellos se estudiaron los aspectos clínicos, radiológicos, de laboratorio, endoscópicos e histopatológicos, test de Kay y Hollander. Las intervenciones quirúrgicas correctoras fueron: Soupault-Bucaille con asa isoperistáltica (7 casos); con asa anisoperistáltica tipo Poth (1 caso); reoperaciones con la técnica de Y de Roux (14 casos); desgastroenterostomía, cierre de la brecha gástrica y yeyunal y piloroplastia (1 caso). Se completó con vagotomía. Un 50% de los casos tienen 5-8 años de operados; otros fueron reexaminados a los 10 y 15 años, hallándose asintomáticos (AU)