Management of bile duct injury during and after laparoscopic cholecystectomy.

BACKGROUND: Bile duct injury (BDI) is perhaps the most feared complication of laparoscopic cholecystectomy (LC). Proper management of iatrogenic BDI is mandatory to avoid immediate or later life-threatening sequelae. The results of surgery depend mainly on the type of injury, prompt detection of the injury, and timing of the surgery. METHODS: Twelve patients with BDI after LC were treated. Eight of them were referred to our institution for further treatment. The follow-up evaluation was focused on clinical outcome and biochemical analysis. RESULTS: Five of the patients had minor BDI with leakage. In all of them, the BDI was recognized postoperatively. Two of these patients were managed by endoscopic retrograde cholongio pancreatographic sphincterotomy and stent placement. The other three patients underwent open laparotomy and bile duct ligation. Seven of the patients had major BDI. In two patients, biliary injuries were identified at the time of LC, and the procedure was converted to laparotomy. At the time of conversion, primary suture repair with T-tube drainage of the injured bile duct was performed. Strictures developed in these patients after 2 and 6 months, respectively, and they were treated with a Roux-en-Y hepaticojejunostomy. In five additional patients, BDI was recognized postoperatively. One of these patients died because of delayed detection of biliary peritonitis. At this writing, during a median follow-up period of 52 months, neither clinical nor biochemical evidence of biliary disease has been found in the remaining patients. CONCLUSIONS: Laparoscopic BDI has a high morbidity and mortality rate. Late recognition of the BDI remains a problem.

Laparoscopic cholecystectomy in two patients with symptomatic cholelithiasis and situs inversus totalis.

BACKGROUND: Situs inversus viscerum is a rare condition with a genetic predisposition. We report 2 patients with situs inversus totalis and symptomatic cholelithiasis successfully treated via laparoscopic cholecystectomy. PATIENTS AND METHODS: The first patient was a 61-year-old female presenting with pain in the left upper quadrant associated with fever, chills, nausea and vomiting. The abdomen was tender with guarding and rebounding pain in the same region. Abdominal ultrasound and CT scan confirmed the diagnosis of gallstones as well as situs inversus with the liver and gallbladder on the left side and the spleen on the right. The second patient was a 37-year-old male with known situs inversus who presented with biliary colic due to cholelithiasis. In both patients cholecystectomy was performed laparoscopically in a reverse fashion. RESULTS: Laparoscopic cholecystectomy was carried out successfully despite the reversed anatomic relationships and both patients made a smooth recovery. CONCLUSION: Cholelithiasis occurring with situs inversus totalis is rare and may present a diagnostic problem. Laparoscopic cholecystectomy can be safely and effectively applied in the setting of situs inversus, although attention must be paid to the details of left-right reversal.

Management of large rectal wall defects with open pedicle grafts of small intestine. An experimental study.

The aim of this study was to evaluate the possible repair of large rectal wall defects using an open pedicle ileal graft as a mucosal patch. This experiment was carried out in 14 adult mongrel dogs. By excision of a portion of the antimesenteric wall comprising 50-70% of the circumference and measuring 5-6 cm in length, a suitable full thickness defect was created in the lower part of the rectum. A segment of the distal ileum was then isolated on a mesenteric pedicle and opened from its antimesenteric border. This was sutured over the defect in two layers. The animals were observed for a period of 15 days to 12 months. All the animals survived the operation apart from 1 dog that died of fecal peritonitis. Function of the rectum generally remained normal. Barium X-ray did not show any obstruction, shrinkage of the patch, lumen dilatation or extravasation. At the time of autopsy pedicles of ileal grafts appeared intact and pulsating. On gross examination there was no evidence of focal hemorrhage, ulceration or any cicatricial thickening of the grafts. Healing was good and the ileal mucosa retained its villi and general characteristics without any major inflammatory reactions. There was an increase in the number of goblet cells which returned to normal in 6 months.

External biliary fistula.

We report 210 cases of external biliary fistula treated in our clinics between 1970-1992. In 7 cases, fistulas were formed after iatrogenic bile duct injury, in 4 cases after exploration of common bile duct, in 4 cases due to disruption of biliary-intestinal anastomosis, and in 2 cases due to liver trauma. In 85 cases bile leak was observed after cholecystomy, in 103 cases after hydatid disease surgery, and in 4 cases after the passage of P.T.C. catheter. In one patient the appearance of the fistula was due to spontaneous discharge of a gallbladder empyema. 173 cases were managed conservatively, and 37 cases surgically.

Splanchnic ischemia during laparoscopic cholecystectomy.

BACKGROUND: Experimental studies have shown that elevation of intraabdominal pressure by means of gas insufflation produces hemodynamic disturbances in the peritoneal viscera, leading to splanchnic ischemia. The purpose of this clinical investigation is to reproduce the experimental data in humans undergoing laparoscopic cholecystectomy. METHODS: Sixteen females participated in this study. Eight of them (the control group) were subjected to open laparotomy for biliary surgery, while on the remaining eight laparoscopic cholecystectomy was performed. In all patients hepatic microcirculation was registered during the time of operation using the laser-Doppler technique. A single-fiber laser-Doppler microprobe was introduced transcutaneously within the hepatic parenchyma, through a Chiba needle, under direct or laparoscopic vision. Additionally, gastric intramucosal/intramural pH, a low level of which indicates tissue ischemia, was assessed by means of a tonometric nasogastric catheter. Hepatic microcirculation and gastric intramucosal/intramural pH were assessed between controls and pneumoperitoneum-subjected patients, and within the laparoscopic surgery group, i.e., during pneumoperitoneum and after abdominal deflation. RESULTS: Hepatic microcirculation was found to be significantly decreased in laparoscopic surgery patients in relation to controls (22.21 +/- 5.48 vs 57.52 +/- 18.06 perfusion units of flow, P = 0.0001) as was gastric intramural pH (7.15 +/- 0.16 vs 7.37 +/- 0.02, P = 0.003). Similarly, immediately after abdominal deflation, hepatic microcirculation exhibited a sudden elevation (22.21 +/- 5.48 vs 67.49 +/- 7.93 perfusion units of flow, P = 0.0001), while gastric intramural pH return to its normal values (7.15 +/- 0.16 vs 7.43 +/- 0.07, P = 0.0001). CONCLUSIONS: It is concluded that during laparoscopic cholecystectomy abdominal organs are hypoperfused, leading to a splanchnic ischemia environment. The clinical significance of these events remains to be clarified.

Pedicle grafts of peritoneum and transversalis muscle for the repair of large defects in the duodenal wall.

OBJECTIVE: To find out if pedicle grafts of peritoneum and transversalis muscle could be used to repair large defects in the wall of the duodenum. DESIGN: Experimental study. MATERIAL: 18 healthy mongrel dogs. INTERVENTIONS: Defects were created in the second part of duodenum and repaired with pedicle grafts of peritoneum and transversalis muscle from the anterior wall of the right side of the abdomen. MAIN OUTCOME MEASURES: Postoperative complications, appearances on upper gastrointestinal radiography two and four months after operation, and histological examination of necropsy specimens. RESULTS: There were no postoperative deaths or complications. Radiographs of the duodenum showed no abnormalities and in particular no signs of obstruction. Animals were killed at intervals from one week to eight months after operation, and the only abnormality was 20-30% stenosis found in five dogs killed within two months of operation, which did not affect gastric emptying. Histological examination showed that by four months after operation the patch was completely covered by neomucosa that was similar to normal duodenal mucosa. By six months the site of the defect was well healed and the histological appearance was the same as at four months. CONCLUSION: Pedicle grafts of peritoneum and transversalis muscle may be useful in the treatment of patients with large defects in the wall of the duodenum.

Changes in gastric secretion after intracerebroventricular infusion of bombesin in dogs.

Synthetic bombesin (BBS) was infused intracerebroventricularly in 14 mongrel dogs, to study the effects of the peptide on gastric secretion and on gastrin and neurotensin levels. The infusion was performed with a specific apparatus, and gastric fluid was collected with a Pavlov pouch. BBS was given in two series of experiments: as a bolus intracerebroventricular injection of 308.6 pmol/kg and as a continuous intracerebroventricular infusion at a rate of 617.3 pmol/kg/h for 30 min. The bolus injection caused a very significant decrease of gastric fluid volume, a significant decrease of HCl output, and a significant increase of its pH, while serum immunoreactive gastrin increased significantly. The continuous infusion of BBS caused similar changes in gastric secretion. The plasma neurotensin levels did not change. In conclusion, the intracerebroventricular administration of BBS increases the serum gastrin levels, decreases the volume and HCl content of gastric fluid, and increases its pH.

Formalin-induced experimental sclerosing cholangitis in the rat.

The few reported cases of sclerosing cholangitis following removal of an echinococcus cyst are thought to be a consequence of the chemical action of formalin used for sterilization of the residual cavity. The aim of this study was to assess this hypothesis. We injected 0.15ml of 2% buffered formalin solution into the central hepatic lobe of five rats, after a midline laparotomy. At 6, 12, 18 and 24 weeks after formalin injection all rats were reoperated upon and a sample of hepatic parenchyma from both the central and the left hepatic lobe was obtained for microscopic evaluation. Our findings, dilatation of portal tracts and bile canaliculi, thickening of the pericanalicular cytoplasm, portal and periportal inflammatory cell infiltration and fibrosis and enlargement of the perisinusoidal space of Disse, suggest that 2% formalin solution leads to the development of essential phenomena of cholestasis and sclerosing cholangitis in the rat, so thus it should be avoided in liver hydatid disease surgery.

Long-term results after esophagoplasty with colon. An endoscopic study.

Eight patients from a series of 13 having esophageal resection and colon interposition for benign disease have been evaluated by endoscopic testing, with special emphasis on the mucosal long-term changes of the colon segment and their histologic documentation. The average follow-up period was 7.2 years. All patients were in a satisfactory nutritional state but described problems associated with eating, such as regurgitation of undigested foods and substernal postprandial heartburn. No stricture was present but endoscopy confirmed the existence of food in the haustra. There was no gross evidence of colitis but the histological evaluation revealed inflammatory cell infiltration or fibrosis in all patients but one. It is believed that the main cause of mucosal damage is the prolonged cascading of food and delayed emptying, leading to digestion in the haustra.