Relaparotomy for postoperative intra-abdominal sepsis in jaundiced patients

During the period 1979-84, 30 abdominal re-explorations were performed for postoperative intra-abdominal sepsis and single or multiple organ failure in jaundiced patients. Postoperative sepsis was caused by intra-abdominal abscess in 16 cases (53 per cent), by suture line leakage in 9 cases (30 per cent) and by technical error in 5 cases (17 per cent). Abscesses occurred most commonly in the subphrenic space (6 cases), in the subhepatic space (6 cases) and in the lesser sac (5 cases). Sepsis was associated with single organ failure in 20 cases and with multiple organ failure in 10 cases. The overall mortality rate was 50 per cent (15/30). Factors that were statistically associated with fatal outcome were: serum bilirubin greater than 100 mumol/l (P less than 0.008), positive blood culture (P less than 0.013), malignant disease (P less than 0.02), multiple organ failure (P less than 0.02) and age greater than 60 years (P less than 0.031). Mortality rose with the number of failed organs. Autopsy revealed continuing sepsis in 12 of the 15 fatal cases. Because mortality was high in spite of adequate operative drainage at relaparotomy, it is concluded that earlier definitive diagnostics are needed to lower the mortality rate.

Intra-abdominal surgery in patients with advanced cirrhosis

Between 1971 and 1984, intra-abdominal surgical procedures were required in 51 patients with cirrhosis who had advanced liver dysfunction and/or ascites. These included the following types of surgery: gastric, 17 patients; small bowel, two patients; colon, five patients; hepatic, nine patients; and pancreas, nine patients. Twelve patients also underwent exploratory celiotomy for an acute condition of the abdomen (six patients) and jaundice (six patients). Patients fell into two groups: (1) those with prothrombin time (PT) greater than 2.5 s over control (24 patients), and (2) those with PT within 2.5 s of control (27 patients). The 30-day mortality rate was 34 (67%) of 51 patients. Nineteen (83%) of 23 patients who had ascites died. Twenty-two (91%) of 24 patients with elevated PT greater than 2.5 s of control died. Twenty-five (86%) of 29 patients who underwent surgery under emergency conditions died. Intraabdominal surgery in decompensated patients with cirrhosis must be undertaken with great caution.

Kron's biliary prosthetic bypass in the treatment of neoplastic jaundice

After experimental study in the dog, which showed the material to be highly reliable, an original method of biliary bypass using a silicone prosthesis in the treatment of neoplastic jaundice is introduced. This prosthesis allows the bile duct to be bypassed regardless of the location of the obstacle. This method was used in 150 patients; recession was sufficiently good in 84 of them to confirm good tolerance and the excellence of the results. In fact, good results were recorded in 95% of cases of cancer of the hilum, which is all the more remarkable in consideration of the difficulties involved in these operations. The main postoperative complications are bile fistulas which resolve spontaneously if the precaution of extensively draining the zones of intubation is taken; postoperative comfort is excellent; no constraint is necessary and the operative risk is moderate, this is particularly desirable in patients in a poor general condition. A short prosthesis makes transtumoral intubation possible, and a long prosthesis allows implantation in the digestive tract: stomach, duodenum or first intestinal loop. Postoperative persistence of jaundice is rare if a prosthesis of sufficient diameter is used and if no major bile duct or part of the liver is excluded. Cholangitis is exceptional and indicative of an excluded biliary area.

Cholecystectomy in the elderly: a prospective study

The mortality and morbidity of 151 elderly patients (greater than 64 years of age) undergoing biliary surgery for benign disease were prospectively studied. The overall mortality was 3.3 per cent. This comprised a 0.77 per cent mortality in the elective group and a 19 per cent mortality in the emergency group. In spite of 77 per cent of the emergency group having a gangrenous gallbladder, a complication difficult to predict preoperatively, the majority of deaths were from cardiovascular disease. The overall incidence of common bile duct exploration was 36 per cent, which was similar in the elective and emergency groups. A comparison between the old (65-74 years) and the aged (over 74 years of age) revealed twice the number of emergency cases in the aged. Considering elective biliary surgery, there was no difference between the mortality, morbidity, or common bile duct exploration rate comparing the old with the aged. This suggests that elective biliary surgery is safe even in the aged.

Hepatic resection in 125 patients

Hepatic resection was performed in 125 patients. Ninety-three of the 125 patients had malignant neoplasms; primary liver carcinoma in 61, metastatic liver carcinoma in 15, carcinoma of the bifurcation of the hepatic ducts in 16, and carcinoma of the gallbladder in one. Performance of hepatic resection was complicated by the presence of liver cirrhosis and jaundice in 42 and 19 patients, respectively. Nine of the 125 patients died within 30 days of the operations, with an operative mortality of 7.2%. Eight of the nine deaths were due to liver failure in the cirrhotic patients who underwent resection of more than two segments of the liver. None of the jaundiced patients died postoperatively. The three-year actuarial survival rates of the patients with hepatocellular carcinoma, metastatic liver carcinoma, and carcinoma of the bifurcation of the hepatic ducts were 31%, 56%, and 21% respectively.

Common bile duct pressure changes after fentanyl, morphine, meperidine, butorphanol, and naloxone

Five groups of 10 patients received thiamylal, enflurane, nitrous oxide-oxygen anesthesia for elective cholecystectomy. The common bile duct was intubated via the cystic duct with a 16-g plastic catheter, and the control intraductal pressure was measured. Patients then were given equi-analgesic doses of fentanyl, morphine, meperidine, butorphanol, or placebo intravenously, and the common bile duct pressure was recorded for 20 min. Fentanyl, morphine, and meperidine significantly increased pressure in the common duct (P less than 0.001). Butorphanol produced only insignificant changes. Naloxone given 20 min later significantly (P less than 0.001) decreased pressure in patients given fentanyl, morphine, and meperidine. Naloxone given without narcotics caused an increase in pressure that, although statistically significant (P less than 0.03), was clinically insignificant. In five additional patients anesthetized with thiamylal, nitrous oxide-oxygen and intermittent doses of fentanyl, common bile duct pressures were normal.

Effect of percutaneous transhepatic drainage upon liver function and postoperative mortality

The results of the use of percutaneous transhepatic drainage in 109 patients between 1968 and 1980 were analyzed. The serum concentration of bilirubin decreased during the three week drainage period but not to normal values and more slowly than would be expected from normal hepatic bilirubin elimination, in site of adequate drained bile volumes. This decrease was most pronounced during the first week of drainage and in patients with high predrainage bilirubin levels. During refeeding of bile into the intestine, hepatic bilirubin excretion seemed to increase, possibly as a result of higher bile acid excretion. Of the 109 percutaneous transhepatic drainage patients, 58 underwent surgical treatment. Their postoperative mortality was compared with that of a control group of 65 patients, who were operated upon immediately after simple diagnostic percutaneous transhepatic cholangiography. It was not possible to demonstrate any significant difference in the postoperative mortality between these two groups. When the complications and, in addition, even mortality of the percutaneous transhepatic drainage procedure are taken into account, it seems doubtful that percutaneous transhepatic external drainage will benefit patients undergoing operation. This procedure may still be of great value in patients in whom only palliation is demanded.

Non-invasive techniques in the diagnosis of jaundice--ultrasound and computer

This study describes the use of ultrasound in 84 consecutive patients to distinguish between medical (intrahepatic) and surgical (extrahepatic) types of jaundice. Accuracy rates in the 84 patients investigated were compared with those found in 169 patients using the computer-aided diagnostic model for jaundice. In 50 patients in whom both techniques were carried out direct comparison was possible. Ultrasound failed to give adequate visualisation for technical reasons in two patients, but 75 of the remaining 82 (91.5%) were correctly separated into medical and surgical categories. A similar percentage (90%, 152 of 169 patients) were correctly classified by the computer-assisted model, and in the 50 patients assessed by both techniques correct diagnostic separation was achieved in 43 (86%) by ultrasound and in 42 (84%) by computer. However, in this latter group two of the errors with computer diagnosis were falsely positive for a surgical jaundice (extrahepatic obstruction), and a surgical exploration performed on the basis of this test could have been unnecessary. This was not found with ultrasound in these same patients, all the errors being false negative. A high degree of confidence can therefore be attached to the demonstration by ultrasound of a dilated biliary tree.

[Benign surgical icterus (author's transl)]

Among 3192 operations on the gall bladder and biliary ducts clinically and chemically a benign icterus was found in 318 patients (9.9%) (maximal serum bilirubin values 21 mumol/l). 140 patients (44%) had a typical biliary history over many years, 173 patients (54%) had only cholelithiasis, 98 patients (30.9%) had concrements in the gall bladder and biliary ducts and 9 patients (2.8%) had concrements in the biliary ducts only. In 141 patients (44.3%) additional complications were found. The post-operative mortality was 5% among which were 9 patients dying of the final stages of their basic disease or its complications; 7 patients died of cardiopulmonary complications. An improvement of the prognosis can only be reached by early operation of patients with gallstones.

Cholecystectomy and a simple technique of operative cholangiography

A simple, easily reproducible technique of operative cholangiography is described. The technique has three advantages: (a) there is no need to divide or ligate the cystic duct; (b) it demonstrates the cystic duct anatomy clearly and is particularly useful in demonstrating stones in that duct thus eliminating the hazard of the retained stone in the cystic duct stump; (c) it is possible to eliminate the problem of false positives due to air bubbles. A consecutive series of 442 cholecystectomy patients is reviewed. The overall operative mortality was 1.6 per cent; no death could be attributed to operative cholangiography. Thirty-five of 324 patients (10.8 per cent) with gallstones and no history of jaundice were shown to have unexpected abnormalities in the common bile duct.

[The economical use of methods employed in the diagnosis of jaundice: decisional attitude as opposed to diagnostic attitude (author's transl)]

For the diagnosis of jaundice, a comparison is established between a classical diagnostic attitude and a decisional attitude which consists in guiding and restricting the investigations according to the therapeutic possibilities. It appears from the comparative study of the two groups of patients that the decisional attitude is better, resulting in a treatment which occurs earlier, is less expensive and probably of a better quality.

Jaundice associated with polycystic liver disease

Jaundice is rarely encountered in polycystic disease of the liver. In the present case, pressure from tense cysts at the hilus of the liver caused a marked narrowing of the common hepatic duct and slowing of bile flow with the formation of stasis stones. Decompression of the cysts and removal of debris in the intrahepatic ducts resulted in a rapid decrease of the serum bilirubin level.

[Causes and treatment of jaundice associated with inflammatory pancreatic disease (author's transl)]

Jaundice or biliary stasis occurred in 32 of 82 patients with acute and 58 of 152 patients with chronic pancreatitis. A biliary cause was present in only 12 patients with acute and 19 with chronic pancreatitis. In the case of mild acute pancreatitis the cause of the jaundice lay in oedema of the head of the pancreas, while in the severe forms there was necrosis of the head. In chronic pancreatitis the jaundice is caused by tube-like, long stenosis of the choledochal duct or its compression by a cyst within the head of the pancreas. In acute pancreatitis treatment depends on the severity of the inflammation; in the biliary form the biliary tracts are attended to. In chronic pancreatitis resection of the head of the pancreas is preferred, biliodigestive anastomosis being practised if there is likely to be poor cooperation by the patient.

Adaptive increase of respiratory enzymes in jaundiced patients

A biochemical analysis of mitochondrial metabolism was made on biopsy specimens of fifteen jaundiced patients. In all but three jaundiced patients the phosphorylative activity based on mitochondrial protein was within normal limits or higher. In nine jaundiced patients the concentrations of cytochrome a(+a3), as representative of respiratory enzymes, increased to more than 1.0 x 10(-10) moles/mg protein, as compared with 0.81 of normal mitochondria, and the relative concentrations of cytochromes, flavoproteins and pyridine nucleotides in relation to cytochrome a(+a3) level remained unchanged. In such patients the phosphorylative activity per unit of cytochrome a(+a3) decreased to approximately 50 per cent of controls, whereas it was within normal limits or greater in jaundiced patients with cytochrome a(+a3) less than 1.0 x 10(-10) moles/mg protein. It is suggested that respiratory enzyme concentrations increase to compensate for the inhibited phosphorylative activity of respiratory assemblies and to maintain the energy balance in the liver in jaundiced patients.

Demonstration of dilated biliary ducts by total-body opacification. Differentiation of surgical from nonsurgical jaundice

Differentiation of surgical from medical jaundice remains a difficult clinical problem. Dilated biliary ducts can be demonstrated by total-body opacification (TBO) and their typical appearance is presented. This suggests that TBO may represent a noninvasive adjunct in distinguishing surgical from medical jaundice.