Prognostic implications of preserved bile duct confluence after iatrogenic injury.

BACKGROUND/AIMS: Biliary reconstruction is performed according to the level of the injury. A comparative study between patients in whom the biliary junction was preserved and another group where the biliary junction was not preserved was done. METHODOLOGY: A retrospective review of the biliary reconstructions performed at our institution after iatrogenic lesions between 1990-2002 was done. Postoperative outcome, functional status of the anastomosis, recurrent cholangitis, need for radiological instrumentation and/or reoperation were analyzed. RESULTS: We reviewed 204 cases, 130 cases had a preserved biliary junction while in 74 the injury included the junction. All patients were treated with a Roux-en-Y hepatojejunostomy. In the first group, 4% required reoperation, 4% underwent radiological percutaneous instrumentation, 8% had anastomotic dysfunction and 4% cholangitis. In the second group, 24% needed reoperation and 80% radiological instrumentation. Anastomotic dysfunction was observed in 64% and cholangitis in 55%. It is important to note that 52 of the 74 cases in the second group had a history of more than two reconstruction attempts. CONCLUSIONS: When the biliary junction is preserved after a iatrogenic injury we found a significantly better outcome. The results of biliary reconstruction in this type of patient are better long-term compared to those where the junction was not preserved, evidenced by a lower reoperation and radiological instrumentation rate.

Current role of surgery for the treatment of portal hypertension.

Portal hypertension surgery has evolved widely in the last decades. Since the first surgical shunt was done in 1945 for the treatment of recurrent hemorrhage, many surgical options have been developed including selective shunts, low diameter shunts and extensive devascularization procedures. Many of them have been studied and compared showing their advantages and disadvantages, evolving also their role in the therapeutic armamentarium. Surgery is nowadays a second line treatment option (after b blockers and endoscopic therapy), and it's main indication is for patients whose main and only problem is history of bleeding, with good liver function (Child-Pugh A). For emergency situations it has a very limited role and for primary prophylaxis virtually has also no role. Patients with good liver function, electively operated with portal blood flow preserving procedures are the patients that benefit from surgical treatment. Patients with a bad liver function are better candidates for a liver transplant.

Surgical treatment of non-cirrhotic presinusoidal portal hypertension.

BACKGROUND/AIMS: Non-cirrhotic portal hypertension has a better prognosis than other forms of portal hypertension because of a well-preserved liver function in most cases. These patients are good candidates to receive surgical treatment, which is the therapeutic choice available with the lowest rebleeding rate. Because of abnormalities in the splanchnic vessels due to the nature of the diseases, many of them cannot be shunted. An extensive esophagogastric devascularization, the complete portoazygos disconnection, was evaluated. METHODOLOGY: A retrospective review of files of 31 patients, among 491 operations between 1991 an 2001 was carried out in a tertiary care Academic University Hospital. Patients comprised those with non-cirrhotic bleeding portal hypertension treated by means of complete portoazygos disconnection. Extensive two-stage (thoracic and abdominal) esophagogastric devascularization with modified transection of the esophagus was performed. MAIN OUTCOME MEASURES: recurrence of hemorrhage, encephalopathy and survival. RESULTS: Thirty-one patients were treated. In 17 cases (54%) a hypercoagulable state was demonstrated. No operative mortality was observed (0-30 days) with a total of 62 operations (two stages per patient). No case of encephalopathy was observed and in 3 cases (9%) rebleeding was recorded. The survival curve showed a 5-year survival of 97% and a 10-year survival of 93%. CONCLUSIONS: Complete portoazygos disconnection is an excellent surgical alternative for patients with non-cirrhotic portal hypertension, with a low morbidity and mortality as well as a low rebleeding rate and good long-term survival.

[Iatrogenic injury of the bile duct. Experience with repair in 180 patients]. / Lesión iatrogénica de la vía biliar. Experiencia en la reconstrucción en 180 pacientes.

OBJECTIVE: Biliary duct lesions have a prevalence of 0.3-0.6% This prevalence is independent of the learning curve: The present paper evaluated survival and quality of life of patients following operative repair. METHODS: In a 12-year period, 180 patients underwent bile duct reconstruction. Of these patients (61 males and 129 females, mean age 39 years), 52% sustained injury during open operation and 42% during laparoscopic procedure. Quality of life was evaluated in the postoperative period. RESULTS: All 180 patients were treated surgically by means of Roux en Y hepaticojejunostomy. Transhepatic stents were used in 142 patients. Eight patients had independent left and right duct anastomosis and in 51 cases, partial resection of segment IV of liver to improve exposure of hilus was carried out. Mortality was 1.7%, due to multiorganic failure. After removal of stent, radiologic manipulation was required in 16% of cases to remove debris and stones or to dilate anastomosis. A total of 83% of patients were completely rehabilitated both clinically and biochemically. CONCLUSIONS: Bile duct injury has a good prognosis in specialized tertiary-care centers. Roux en Y hepatoyeyunostomy is procedure of choice with trans-hepatic stent when needed. Full rehabilitation can be achieved in 80% of patients.