Laparoscopic Cholecystectomy in Cirrhotic Patient

Cholecystectomy is associated with increased risk in patients with liver cirrhosis. Moreover, cirrhosis and portal hypertension have been considered relative or absolute contraindication to laparoscopic cholecystectomy. As experience with laparoscopic cholecystectomy increased, we decided to treat cirrhotic patients via this approach. Between January 1994 and April 1995, nine patients with a Child-Pugh's stage A cirrhosis underwent elective laparoscopic cholecystectomy with intraoperative cholangiography. There was no significant per- or post-operative bleeding and no blood transfusion was necessary. There was no mortality and very low morbidity. Median hospital stay was 3 days. This series suggests that wellcompensated cirrhosis can not be considered a contraindication to laparoscopic cholecystectomy

Short Intussusception Valves Prevent Reflux After Jejunal Interposition Bilioduodenal Anastomosis

Short whole circumference and semi-circumference intussusception valves were created in interposition cholecysto-jejunal-duodenal conduits in pigs to determine which method best prevented gastrointestinal reflux into the biliary tract. Following intravenous injection of 99 mTc-HIDA the time interval for its excretion from the liver and appearance in the duodenum was not different in either whole or semi-circumference valve animals or in controls without valves. After intragastric administration of 99 mTc-DTPA the relative radioactivity of gallbladder contents (reflux) in the cohort without valves was significantly higher than in both cohorts with valves. Animals with semi-circumferential valves in turn had significantly higher levels of nuclide than those with whole circumference valves. Reflux was observed grossly in 100% of animals without valves, in 20% of those with semi-circumference valves, and in no animals with whole circumference valves. This study indicates that both Whole and semi-circumference intussusception valves placed in jejunal biliary conduits allow unimpeded flow of bile into the gastrointestinal tract. Whole circumference valves are more effective for prevention of reflux than semi-circumferential valves

Improved Results for Resection of Periampullary Adenocarcinoma

Background: This study evaluates the indications for and effects of pancreaticoduodenectomy (102 patients) or total pancreatectomy (15 patients) with extensive lymph node dissection performed upon 117 patients for treatment of periampullary adenocarcinoma

Iatrogenic Biliary Strictures: Surgical Experience with 39 Patients

The authors report their experience with surgical treatment of 39 patients with biliary strictures of iatrogenic origin. Patients were grouped according to the level of obstruction as described by Bismuth, and the type of repair was based on this classification. A total of 45 operations were performed, including those for recurrent strictures: 22 hepaticojejunostomies, 10 Hepp and Couinad's operations, 6 choledochojejunostomies, 3 separate right and left hepaticojejunostomies, 1 hepaticojejunostomy with mucosal graft (Smith's technique), 1 intrahepatic cholangiojejunostomy (Longmire's technique), 1 choledochoduodenostomy and 1 choledochoplasty. Results were considered good if the patient was free of symptoms, jaundice or episodes of cholangitis, with serum alkaline phosphatase less than two-times the normal value. Minimum follow-up period of two years (obtained in 35 patients) was required to evaluate the results. Good results were obtained in 26 of those 30 patients (87%) who underwent only one biliary reconstruction, and in 3 of those 5 (60%) with more than one repair. Overall, 29 patients (83% of those 35) presented good results. The complexity of the surgical treatment of biliary strictures imposes the adoption of measures to prevent lesions to the bile duct. Factors related to the prognosis that must be emphasized are surgeonsa' individual experience and skills, location of the stricture and diameter of the anastomosis

Structural and Functional Alterations in The Zona Fasciculata of The Rat Adrenal Cortex in Obstructive Jaundice

This study investigated the effect of experimentally-induced cholestasis in the rat on the structure and function of the zona fasciculata, the glucocorticoid secretory region of the adrenal cortex. Wistar-Furth rats (200-250g) were assigned to three groups: bile duct ligated (BDL), Sham operated (Sham) and unmodified normal control (NC). On day 14, serum bilirubin and liver histology were performed to confirm cholestasis in BDL animals together with basal 24 hour 17-hydroxycorti-costeroid excretion, adrenal histology and zona fasciculata ultrastructure in all experimental groups. Following this laparotomy, structural and functional studies were repeated on day 15 to evaluate the response of the gland to surgically induced stress. Basal 24 hr. 17-hydroxycorticoid steroid excretion was elevated in BDL animals (26.9 ±3.2 μ g/24 hr) with respect to Sham (10.4 ± 2.3) and NC groups (13.5 ± 3.2) (p <0.05). Adrenal histology and ultrastructural studies demonstrated excessive accumulation of vesicles laden with glucocorticoid biogenic precursors. Following surgical stress 24 hr 17 OH corticosteroid excretion increased in all groups: BDL (31.0 ± 3.0 μg/24 hr) vs Sham (15.6 ± 1.8) and NC (14.5 ± 2.4) Moderate alterations in zona fasciculata architecture were seen following surgery in all groups. Cholestasis induces overactivity of the zona fasciculata of the adrenal cortex, and may modify the normal metabolic responses to surgical and other stresses

Immune Dysfunctlon in Patients With Obstructive Jaundice, Mediators and Implications for Treatments

Patients with obstructive jaundice have an increased perioperative complication rate. Sepsis, bleeding, wound problems, renal and liver malfunction are all seen in these patients. Assessment of immune function has been an active research area in these patients. This review will examine various aspects of immune functions in obstructive jaundice, discuss the recent research results and controversies and then go on to discuss the relevant mediators of immune function and some possible implications for treatment