The early use of fine-needle percutaneous transhepatic cholangiography in an approach to the diagnosis of jaundice in a surgical unit

Percutaneous transhepatic cholangiography: Ibadan experience

Our experience using the teflon method in carrying out transhepatic cholangiography is described. A teflon needle (20 gauge) was used instead of the conventional Chiba needle. The number of successful examinations and their complication rate are comparable with examination carried out with Chiba needle. The ease of the procedure with the teflon needle and its relative cheapness make this technique preferable, although not without risks, especially in the developing countries where inadequate funds are available for health care.

Should surgeons operate on the evidence of ultrasound alone in jaundiced patients?

The biliary ultrasound scans of 132 patients having a laparotomy for jaundice have been reviewed to assess the role of ultrasound in the selection of patients for surgery. When scans were technically satisfactory the finding of a dilated extrahepatic duct (EHD) indicated obstructive jaundice in all cases, but the obstructing lesion in 5 per cent of such cases was too proximal for jaundice to be relieved by direct surgical decompression. Scans were further classified on the basis of abnormalities detected in the gallbladder. When EHD dilation was associated with gall bladder findings 'typical' of distal common bile duct (CBD) obstruction due to gall stones (small gallbladder with multiple gallstones) or tumour (dilated gallbladder without gallstones), surgically remediable obstruction was always present. Although ultrasound identified the obstructing lesion itself in a minority of cases, the cause of obstruction could be correctly inferred in 95 per cent of 'typical' scans. These results suggest that it is safe to proceed directly to surgery only when an experienced ultrasonographer demonstrates findings 'typical' of distal CBD obstruction due to gallstones or tumour.

Spontaneous closure of choledochoduodenostomy: diagnosis by endoscopy and ERCP

Choledochoduodenostomy has been recommended for the management of benign lower common bile duct obstruction, but opinion on this is still divided. Two cases are presented of recurrent cholangitis following choledochoduodenostomy, in which endoscopy and ERCP demonstrated closure of the choledochoduodenal anastomosis, continuing lower biliary obstruction and retained stones or debris. Persistent of recurrent symptoms following this operation may be due to stoma closure without adequate biliary drainage, and in these circumstances endoscopy with ERCP is proving most useful and in difficult cases may be the investigation of choice.

Hepatic resection for trauma, tumour and biliary obstruction

Hepatic resection was performed in 37 patients. Fifteen emergency procedures were undertaken for blunt trauma and 16 patients had elective resection for hepatic tumour. A further 6 resections were performed for benign biliary tract obstruction. The importance of preoperative assessment and the indications for resection are discussed particularly in relation to resection for biliary obstruction. Operative procedures are outlined and the technique of extended left lobectomy is described in detail.