A review of the management of iatrogenic bile duct injuries.

Injuries to the extrahepatic biliary tree occurring during cholecystectomy or other upper gastrointestinal surgical procedures are not uncommon. The consequences are often catastrophic. We report the results of a personal series of bile duct repairs from a tertiary referral centre over a twenty-one year period. A total of 33 patients were referred. Percutaneous transhepatic cholangiography was the radiological investigation of choice to outline the biliary system. Percutaneous transhepatic dilatation was performed in six patients and 22 patients had either primary surgical repair, or reconstruction of their biliary tree performed by hepaticojejunostomy with an 80 cm Roux-en-Y limb. Of these only two have required revision surgery. We recommend early referral of patients with recognised iatrogenic injuries to specialist hepatobiliary units with no attempt at repair prior to referral.

A prospective trial of endoscopic sclerotherapy v oesophageal transection and gastric devascularisation in the long term management of bleeding oesophageal varices.

In a prospective three centre study oesophageal transection and gastric devascularisation have been compared with endoscopic sclerotherapy in the long term management of bleeding oesophageal varices. Cirrhotic patients (Child's A or B grade) with documented bleeding oesophageal varices were treated initially with emergency sclerotherapy, and after five days stability, were allocated to one of the two treatment regimes. The endoscopic sclerotherapy group underwent regular sclerotherapy until variceal obliteration while those undergoing surgery were not endoscoped unless bleeding recurred, when they were treated by sclerotherapy if appropriate. Ninety two patients were eligible for analysis (68% alcoholic cirrhosis; mean age 50.1 years) and follow up was achieved for a mean of 52.5 months (range 17-83). Mortality in the first three months was greater in the oesophageal transection and gastric devascularisation group (20% v 1%) but by two years the survival curves were the same and thereafter there was no difference in mortality. Rebleeding occurred in 13/41 (31%) patients, undergoing oesophageal transection and gastric devascularisation. The costs incurred during the first year of oesophageal transection and gastric devascularisation treatment were significantly greater than with endoscopic sclerotherapy (4369 pounds v 1067 pounds, p < 0.0001) and the high rate of rebleeding in the surgical group meant that no cost savings occurred in subsequent years. It is concluded that oesophageal transection and gastric devascularisation confers no benefit over endoscopic sclerotherapy in terms of long term survival and that it is not cost effective as judged by the current health care costs in the United Kingdom.

Proximal gastric vagotomy: follow-up at 10-20 years.

From August 1969 to December 1989, 600 patients had elective proximal gastric vagotomy for duodenal ulceration with an operative mortality of 0.2 per cent. Of these, 372 patients had surgery over 10 years ago. Three hundred and forty-two patients survived for more than 10 years and, in a prospective study, 305 were reviewed, forming the basis of this 10-20-year follow-up report. Forty-six (15 per cent) have had recurrent ulceration; 80 per cent of these developed symptoms within 5 years and no patient has had recurrence after 13 years. Although 29 patients required reoperation for recurrent ulceration, the current patient satisfaction rate for Visick grades I and II is 92 per cent. Only two patients required reoperation because of gastric stasis. It is concluded that proximal gastric vagotomy is a safe and satisfactory first choice operation for duodenal ulceration.

Are child's class C patients with acute variceal bleeding worth treating?

In the ten year period January 1980 to December 1989, 102 patients with Child's Class C liver disease (Pugh's Modification) were admitted with acute variceal bleeding to one surgical unit with a policy of early sclerotherapy. There were 56 males and 46 females; the average age was 55 years (range 28-77). Fifty-three suffered from alcoholic cirrhosis. Four died before definitive treatment could be carried out, three from liver failure and one from uncontrolled bleeding. Of the remaining 98 patients, eight had urgent oesophageal transection with three deaths from hepatorenal failure; 90 had sclerotherapy with 19 hospital deaths, nine from recurrent bleeding, eight from liver failure often coupled with renal failure and two from respiratory complications. Of the 76 who survived to leave hospital, 52 received chronic injection sclerotherapy, 10 had elective oesophageal transection and 14 did not have further elective intervention for various reasons. Surviving patients have been followed up at a special Liver Clinic with minimum follow up of one year. Although no patient has yet survived ten years, the one, five and eight year survivals of 50%, 21% and 13% suggest that salvage of these patients is worthwhile.

Predictive value of perioperative gastric acid tests.

Preoperative acid studies and early postoperative insulin tests in 275 patients undergoing various forms of vagotomy have been related to recurrent ulceration. Follow-up time has been from two to nine years, mean 4-3 years. Recurrence is directly related to basal acidity in both tests but is not related to stimulated acid levels preoperatively. In the insulin tests higher levels of acidity after insulin are associated with a higher incidence of recurrence. When positive, Hollander's and multiple criteria are both associated with a higher recurrence rate.