Management of bile duct stones in the era of laparoscopic cholecystectomy: appraisal of routine operative cholangiography and endoscopic treatment

OBJECTIVE

To assess the value of preoperative or postoperative endoscopic treatment of bile duct stones and routine use of operative cholangiography (OC) for detection of unsuspected common bile duct (CBD) stones in conjunction with laparoscopic cholecystectomy.

DESIGN

Prospective study.

SETTING

University hospital, Sweden.

MAIN OUTCOME MEASURES

Diagnostic and therapeutic yield of stones at endoscopic retrograde cholangiography (ERC) before or after laparoscopic cholecystectomy and routine operative cholangiography.

RESULTS

Of 630 patients who underwent laparoscopic cholecystectomy, 84 had preoperative ERC. Of these 84, 47 (56%) had bile duct stones. Endoscopic sphincterotomy was done for all 47, of whom 3 (6%) had retained stones at OC. OC was done for 590 (94%) of the 630 patients, and 45 (7.6%) were found to have choledocholithiasis. At postoperative ERC, however, 10 of these patients were free of stones and there were two cases of false negative OC, which resulted in sensitivity and specificity of OC of 95% and 98%, respectively. Thus, 35 patients (6%) had bile duct stones discovered at OC, of whom 33 had "unsuspected" stones. Of these 35 patients, 29 were cleared endoscopically after cholecystectomy. The remaining 6 patients were cleared of stones either by open choledocholithotomy (n = 2) or by laparoscopic transcystic manipulation (n = 4). There was no mortality after diagnostic or therapeutic ERC, and morbidity was confined to two cases each of pancreatitis and cholangitis, which resulted in a complication rate of 3% (4/118). No complications resulted from IOC.

CONCLUSIONS

Preoperative ERC should be done for patients with symptoms or findings indicating ductal calculi. In most patients undergoing laparoscopic cholecystectomy, OC is feasible and its routine use is strongly advocated. Bile duct stones diagnosed at OC can safely and successfully be treated endoscopically after laparoscopic cholecystectomy. Until laparoscopic bile duct exploration becomes routine and generally applicable, endoscopic management of bile duct stones both before and after cholecystectomy will be an important therapeutic option.

VIP-antiserum and indomethacin inhibit calcium and bicarbonate secretion by the inflamed feline gallbladder mucosa

Ionized calcium (Ca2+) and bicarbonate (HCO(3)-) are important ions for gallstone formation. In the present study the effect of indomethacin and vasoactive intestinal peptide-antiserum (VIP-antiserum) on the Ca2+, HCO(3)- and fluid secretion in the inflamed gallbladder were tested in a validated experimental model in cats. The animals were studied in acute experiments 6 weeks after cystic duct ligation and gallstone implantation. During basal conditions there was a continuous secretion of Ca2+, HCO(3)- and fluid into the lumen of the inflamed gallbladder. Indomethacin and VIP-antiserum inhibited the Ca2+, HCO(3)- and fluid secretion across the inflamed gallbladder mucosa. Intraluminal amiloride inhibited the absorption of Ca2+, HCO(3)- and fluid after indomethacin infusion. An impaired absorption of Ca2+, HCO(3)- and fluid in the inflamed gallbladder is probably important for the solubility of calcium salts in the early stages of inflammation in the gallbladder mucosa.

Sympathetic and VIP-ergic control of calcium and bicarbonate transport in the feline gall bladder mucosa in vivo

The regulation of calcium ion absorption by the gall bladder mucosa may be important for gall stone formation but this process is poorly understood. In this study performed in anaesthetized cats, the gail bladder lumen was perfused by a buffer equilibrated with 4% CO2 in air. During basal conditions, the pH and the [Ca2+] x [CO3(2-)] ion product decreased in the buffer when passing through the gall bladder lumen. The net absorption of calcium ions and fluid was significantly enhanced by stimulation of the splanchnic nerves. Intravenous infusion of vasoactive intestinal peptide (VIP) increased pH and the [Ca2+] x [CO3(2-)] ion product significantly in the buffer during the passage through the gall bladder lumen. Moreover, the basal fluid absorption was reversed to a net fluid secretion. In view of the presence of noradrenergic and VIP-immunoreactive nerve fibres in the gall bladder wall, and VIP-receptors on the gall bladder epithelial cells, the study suggests the existence of neural control mechanisms influencing the transport of Ca2+ by the gall bladder mucosa. These may be important to reduce potential calcium lithogenicity in the gall bladder lumen.

Extracorporeal shock-wave lithotripsy of gallbladder stones: an alternative for the selected few

OBJECTIVE

To define selection criteria for optimal outcome of ESWL with oral litholysis (ursodeoxycholic acid) for gallbladder stones.

DESIGN

Prospective study.

SETTING

University hospital, Sweden.

SUBJECTS

145 patients with symptomatic gallbladder stones occupying a maximum of half the fasting gallbladder volume and gallbladder opacification at oral cholecystography.

MAIN OUTCOME MEASURES

Three-year stone clearance rates in relation to initial stone burden, occurrence of calcified stones, and degree of gallbladder opacification at cholecystography.

RESULTS

At all times clearance rates according to life table analysis were significantly higher for patients whose stone volume was < or = 4.2 ml (corresponding to one stone with a diameter of < or = 2.0 cm) (83% at 3 years) than for patients whose stone volume was > 4.2 ml (67% at 3 years), and patients with one stone had significantly higher clearance rates (88% at 3 years) than patients with multiple stones (58% at 3 years). Of all patients treated for gallbladder stones during one year, 25/194 (13%) had a stone volume of < or = 4.2 ml and 16/194 (8%) a solitary stone with volume < or = 4.2 ml. Neither the degree of gallbladder opacification nor the occurrence of calcified stones influenced clearance rates.

CONCLUSION

ESWL may be an alternative to surgery in the few patients whose stone volume is roughly 4 ml or less and preferably have only one stone. Gallbladder function and patency of the cystic duct are poorly evaluated by oral cholecystography.

A simple way to indicate pulmonary nodules at thoracoscopic wedge resections

PURPOSE

Small pulmonary subpleural nodules are sometimes difficult to localise at thoracotomy. With the advent of minimal invasive surgery, thoracoscopic resection avoiding anterolateral thoracotomy is an attractive procedure. Since this technique does not allow manual palpation, preoperative indication of lesions is mandatory. A simple and cost-effective system for preoperative CT-guided localisation of small subpleural nodules before thoracoscopic resection is described.

MATERIAL AND METHODS

The system consists of a 0.2 mm steel wire 30-40 cm in length and a 0.9-mm biopsy needle. The tip of the wire is bent to a hook, and, guided by CT, it is placed in the vicinity of the lesion. The technique was tested in 8 cases.

RESULTS

The procedure was possible to perform in 7 patients. In all instances the wire remained in place when the lung was collapsed during the thoracoscopic procedure. The staple resected part of the lung also contained the lesion when examined extracorporeally.

CONCLUSION

This simple and inexpensive system was found to be useful for indication of pulmonary lesions at thoracoscopic wedge resections.

Role of nitric oxide in induction of inflammatory fluid secretion by the mucosa of the feline gallbladder

BACKGROUND & AIMS

Nitric oxide is synthesized from L-arginine and is metabolized to nitrate and nitrite. This study evaluates the effects of a pharmacological blockade of NO synthesis on fluid transport by the inflamed gallbladder mucosa.

METHODS

Experiments were performed in cats with cholecystitis and in control animals. NO synthase activity was measured in gallbladder tissue; the enzyme was characterized by immunoblotting techniques and localized by immunofluorescence. Fluid transport and release of nitrate and nitrite by the gallbladder mucosa and bile and bile salt secretion from the liver were registered simultaneously in vivo.

RESULTS

Fluid secretion in inflamed gallbladders was reversed to a net absorption in response to the NO synthase blockers N omega-nitro-L-arginine and aminoguanidine, and formation of nitrate was reduced. The effects were reversed by L-arginine. Increased levels of inducible NO synthase in inflamed gallbladders were shown by immunoblotting, by immunofluorescence (mainly in macrophages), and by Ca(2+)-independent [3H]citrulline formation from [3H]arginine. The NO synthase blockers had no effect on gallbladder fluid transport in normal gallbladders.

CONCLUSIONS

Increased levels of inducible NO synthase activity are shown in inflamed gallbladders, and a pharmacological blockade of this enzyme blocks fluid secretion and decreases nitrate release from the mucosa.

Value of routine intraoperative cholangiography in detecting aberrant bile ducts and bile duct injuries during laparoscopic cholecystectomy

A prospective study was performed to determine the frequency and type of bile duct abnormalities, and to determine whether routine use of intraoperative cholangiography during laparoscopic cholecystectomy might aid in the prevention of bile duct injuries. Overall, anatomical aberrations of the bile ducts were found in 98 (19 per cent) of 513 cholangiograms. The most common anomalies were at the hepatic confluence and constituted different types of right hepatic subsegmental ducts draining separately into the biliary tree (n = 43, 8.4 per cent), either close to the cystic duct or directly into the cystic duct. Three bile duct injuries (0.5 per cent) occurred during the study period. These results show that routine intraoperative cholangiography is feasible and provides valuable information about the anatomy of the biliary tract, thereby improving the safety of laparoscopic cholecystectomy. If an injury to the biliary tract occurs early during operation, the cholangiogram allows the surgeon to detect the injury, to make a prompt repair and thereby reduce the morbidity associated with a delayed diagnosis. Routine use of intraoperative cholangiography is strongly recommended.

Inflammation reduces mucosal secretion of hydrogen ions and impairs concentrating function and luminal acidification in feline gallbladder

BACKGROUND

The gallbladder mucosa normally absorbs fluid and secretes H+ ions. The fluid secretion in inflamed gallbladders is induced by prostaglandins and mediated by intramural vasoactive intestinal peptide (VIP)-ergic nerves.

METHODS

The influence of inflammation on gallblader contents due to secretion of H+ into the lumen. In animals with inflamed gallbladder this acid secretion was reduced; there was secretion of HCO3- and no evident acidification of the gallbladder contents. Injection of VIP antiserum or indomethacin restored H+ secretion and inhibited HCO3- and fluid secretion by the inflamed gallbladder mucosa. An impaired acidification of the gallbladder contents due to mucosal inflammation may reduce the solubility of calcium salts in gallbladder bile and increase the risk of their precipitation in the lumen.

CONCLUSION

Mucosal inflammation reduces H+ secretion and impairs acidification of the gallbladder contents.

Role of nitric oxide in motility and secretion of the feline hepatobiliary tract

BACKGROUND

Nitric oxide (NO) mediates inhibition of gastrointestinal smooth-muscle cells via nonadrenergic, non-cholinergic (NANC) nervous pathways. The effect of NO on the absorption and secretion by the mucosa of the gastrointestinal and hepatobiliary tracts is less well known. The aim of this study was to evaluate the effects of a pharmacologic blockade of NO synthase on sphincter of Oddi activity, gallbladder function, and bile secretion and to demonstrate the presence of NO synthase-positive neurons in this region.

METHODS

Experiments were conducted on anesthetized cats after blockage of noradrenergic and cholinergic neurotransmission. Flow resistance in the sphincter of Oddi, gallbladder fluid absorption and motility, bile outflow from the liver, and bile salt secretion were registered.

RESULTS

Flow resistance exerted by the sphincter of Oddi increased dose-dependently in response to the NO synthase blocker NG-nitro-L-arginine. The increase in flow resistance was reversed stereospecifically by L-arginine, the substrate for NO synthesis. No significant effects on bile secretion, gallbladder fluid transport, or gallbladder motility were observed. NO synthase-positive neurons were identified close to the sphincter of Oddi and in the gallbladder mucosa.

CONCLUSIONS

This tonically active inhibitory NANC innervation of the sphincter of Oddi may be important in the physiologic regulation of the bile duct pressure.

A comparative retrospective study of thoracoscopy versus thoracotomy for the treatment of spontaneous pneumothorax

Thoracoscopic surgery has been claimed to reduce patient disability, recovery time, and hospital costs compared with open surgery. We analyzed 25 patients who had undergone thoracoscopic surgery and compared the outcome to 24 patients who had undergone conventional surgery for spontaneous pneumothorax. The thoracoscopic group was able to return to work and daily activities earlier and had less impairment of shoulder movement. There was a loss of sensation corresponding to the dermatomes where the thoracoscopic ports were placed, which could have resulted from compression of the intercostal nerves by the instruments. However, a similar loss of sensation was found in the thoracotomy group. We conclude that thoracoscopy may be the method of choice for the treatment of spontaneous pneumothorax, although further methodological development should be done.

Medication with ursodeoxycholic acid enhances the biliary clearance of polyethylene glycol 900, but not mannitol

Ursodeoxycholic acid (UDCA) is a nontoxic bile acid currently used in the treatment of different cholestatic diseases. This bile acid is also considered to be a 'hypercholeretic bile acid'. The effects of daily administration of UDCA on bile flow and the bile acid secretion rate in man are not fully known. The aim of this study was to explore the effects by UDCA on bile flow and its different functions. The biliary clearances of polyethylene glycol 900 (PEG 900) and mannitol were measured simultaneously in patients with an indwelling T tube after cholecystectomy. One group (n = 6) were given UDCA (10 mg/kg/day) for at least 14 days before the investigation and a control group (n = 8) received no bile acid treatment. The bile secretion was studied in acute experiments where bile was drained for 6 h. The bile plasma ratio for PEG 900 was 31 and that for mannitol was 0.7 which corresponds well with the results obtained in different animal species. The relationship between bile flow and the bile salt secretion rate, as expressed by linear regression analysis, showed no difference between the 2 groups (control y = 0.22 + 0.012x, r = 0.61, p < 0.001; UDCA y = 0.20 + 0.016x, r = 0.88, p < 0.001). The relationship between the biliary clearance of PEG 900 and the bile salt secretion rate, as expressed with linear regression analysis, showed a significantly steeper slope for the UDCA-treated patients (control y = 8.1 + 0.34x, r = 0.41, p < 0.05; UDCA y = 5 + 1.58x, r = 0.78, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Raised pressure in the bile ducts after orthotopic liver transplantation

Biliary complications are common after orthotopic liver transplantation. Bile leakage in the immediate postoperative period and on removal of the T-tube could possibly be caused by a raised bile duct pressure. In order to test this hypothesis, bile duct pressure was studied in seven consecutive liver transplant patients. During the operation, the common bile duct was anastomosed end-to-end over a T-tube. The initial bile duct pressure measurement was performed a median of 12 days (range 10-17 days) after the transplantation and on one or two more occasions during the following 3 months. Seven cholecystectomized gallstone patients with indwelling T-tubes were used as controls. The bile duct pressure at the level of the xiphoid process in the transplanted group was 7.7 +/- 1.4 cm H2O and in the control group 0.5 +/- 0.8 cm H2O (P < 0.001). The initially increased bile duct pressure after liver transplantation decreased with time (P < 0.05) towards normal during the following 3 months. The raised pressure may increase the risk of bile leakage in the postoperative period.

VIP-antiserum inhibits fluid secretion by the inflamed gallbladder mucosa

The inflammatory fluid secretion by the gallbladder mucosa in experimental cholecystitis is induced by an increased prostaglandin formation and is mediated by intramural nerves. In the present study the effect of VIP-antiserum on the inflammatory fluid secretion in the gallbladder was tested in a validated experimental model in cats. The animals were studied in acute experiments 6 weeks after a procedure when the cystic duct was tied and gallstones were implanted in the gallbladder. During basal conditions there was a continuous secretion of fluid into the lumen of the inflamed gallbladder averaging 0.43 +/- 0.18 ml/h. Injection of VIP antiserum, obtained from immunized rabbits and diluted with saline 1:10 in a bolus of 4 ml into the coeliac artery reversed this secretion into an absorption of 1.72 +/- 0.44 ml h-1 (P < 0.001). VIP-antiserum did not affect the fluid adsorption in control animals with an intact gallbladder and injection of control serum from rabbits not immunized to VIP did not affect fluid secretion in the inflamed gallbladders. The results support the idea that the inflammatory fluid secretion in the gallbladder mucosa is mediated by VIP-ergic nerve fibres.

A possible role of ursodeoxycholic acid in liver transplantation

There are many different causes of graft dysfunction and cholestasis after liver transplantation. These include non-primary function, preservation and reperfusion injury, acute rejection, artery thrombosis, drug toxicity, bile leakage, and bile duct stenosis. Medication with ursodeoxycholic acid (UDCA) has beneficial effects in different cholestatic conditions. The initial rationale for its use after liver transplantation was to alter the bile acid pool to a more atoxic composition, as liver transplantation can be associated with cholestasis and can stimulate the initial bile production. We have consecutively treated 41 patients with primary graft function with UDCA. During the first postoperative month, 17% of the UDCA treated patients had an episode of acute rejection compared with 75% of a historical control group of 8 patients. The results suggest that adjuvant treatment with UDCA reduces acute liver graft rejection. This has to be confirmed by controlled prospective trials; one is presently being carried out in the Nordic countries. Several studies have indicated an immunomodulating capacity of this bile acid and we have recently reported our results from a heart transplant model in the rat, where treatment with UDCA prolonged graft survival. Improvement in surgical technique and postoperative care as well as immunosuppressive treatment has improved the results of liver transplantation. Acute rejection is nowadays a dominating problem after liver transplantation and the inclusion of UDCA may reduce morbidity.

Contraction and evacuation of the gallbladder studied simultaneously by ultrasonography and 99mTc-labeled diethyl-iminodiacetic acid scintigraphy

Emptying of the gallbladder was studied by the simultaneous use of 99mTc-labeled diethyl-iminodiacetic acid [HIDA] scanning and real-time ultrasonography. In response to a liquid test meal the gallbladder volume was reduced for 80 min and then increased again, but the radionuclide evacuation continued and was more complete than could be explained by the reduction of gallbladder volume. In response to intravenous infusion of cholecystokinin, a maximal contraction of the gallbladder to 35% of the basal volume was obtained at 40 min, and 36% of the HIDA then remained in the gallbladder. In a separate series repeated intravenous injections of 99mTc-HIDA were given after the test meal, and the isotope was found to enter the gallbladder even when the gallbladder contracted. The results support the view that the gallbladder acts like a 'bellows' when contracting and that postprandial fluid secretion by the gallbladder mucosa may help to evacuate its contents.

In vivo regulation of mucosal transport of H+ and HCO3- in the feline gall bladder

In the gall bladder of a fasting subject, a decline in the pH of the contents occurs due to secretion of H+ from the mucosa. In this study in anaesthetized cats, the gall bladder lumen was perfused with a bicarbonate buffer bubbled with 4% CO2 in air. During basal conditions, the PCO2 always rose while the pH and [HCO3-] fell in the buffer when passing through the gall bladder lumen, indicating a continuous secretion of H+ by the mucosa. This H+ secretion was enhanced by stimulation of the respective sympathetic nerves and was blocked by intraluminal amiloride. Intravenous infusion of vasoactive intestinal peptide (VIP) raised the pH and [HCO3-] in the buffer during the passage through the gall bladder lumen, indicating a secretion of bicarbonate from the mucosa. In view of the presence of sympathetic and VIP immunoreactive nerve fibres in the gall bladder wall and VIP receptors on the luminal epithelial cells, the study demonstrates that there are functional grounds for physiological variations in the secretion of H+ and HCO3- by the gall bladder mucosa. These variations may be important for the solubility of calcium salts in the gall bladder contents.