Presidential address: Eponyms in biliary tract surgery

A selected group of men whose eponyms are currently used in biliary tract surgery are described. The eponyms chosen comprise two areas: gross anatomy (Glisson, Wirsung, Santorini, Winslow, Heister, and Vater) and operative anatomy (Kocher, Courvoisier, Morison, Hartmann, Calot, Roux, and Oddi). A brief review of biliary tract disease from antiquity until the 17th century places these men in proper historical sequence. A condensed biographical sketch of each man's life and work is provided and a few closing comments are made about eponyms.

Antibiotic prophylaxis in gastric, biliary and colonic surgery

Antibiotic prophylaxis for surgery has appeared indicated whenever likelihood of infection is great or consequences of such are catastrophic. For better clarification, a prospective, randomized, double-blind study was run on 400 patients undergoing elective gastric, biliary, and colonic operations. There were four treatment categories, with antibiotic being instituted 12 hours preoperatively, just prior to operation, after operation, or not at all. During operation, samples of blood, viscera, muscle, and fat were taken for determination of antibiotic concentration. Both aerobic and anareobic cultures were also taken of any viscus entered, peritoneal cavity, and incision. Similar cultures were run on all postoperative infections. Results demonstrated that the incidence of wound infection could be reduced significantly by the preoperative administration of antibiotic in operations on the stomach (22% to 4%), on the biliary tract (11% to 2%), and large bowel (16% to 6%). Less impressive results were obtained for peritoneal sepsis. Initiation of antibiotic postoperatively gave an almost identical infection rate as if antibiotic had not been given (15% and 16%, respectively).

Preoperative external biliary drainage in obstructive jaundice. A prospective controlled clinical trial

57 patients with obstructive jaundice were randomly allocated to surgery with preoperative external biliary drainage (29 patients) and without preoperative external biliary drainage (28 patients). 22 patients ultimately underwent laparotomy after a mean of 11.7 days of drainage and 25 had surgery without preoperative drainage. The postoperative complication rate was low and similar in both groups but complications associated with the drainage procedure were substantial. Perioperative mortality was 4/28 (14%) in the drainage group and 4/27 (15%) in the non-drainage group. There seems to be no advantage associated with routine preoperative external biliary drainage before surgery for obstructive jaundice.

Randomized clinical trial of adjuvant gemcitabine chemotherapy versus observation in resected bile duct cancer

BACKGROUND

Although some retrospective studies have suggested the value of adjuvant therapy, no recommended standard exists in bile duct cancer. The aim of this study was to test the hypothesis that adjuvant gemcitabine chemotherapy would improve survival probability in resected bile duct cancer.

METHODS

This was a randomized phase III trial. Patients with resected bile duct cancer were assigned randomly to gemcitabine and observation groups, which were balanced with respect to lymph node status, residual tumour status and tumour location. Gemcitabine was given intravenously at a dose of 1000 mg/m2 , administered on days 1, 8 and 15 every 4 weeks for six cycles. The primary endpoint was overall survival, and secondary endpoints were relapse-free survival, subgroup analysis and toxicity.

RESULTS

Some 225 patients were included (117 gemcitabine, 108 observation). Baseline characteristics were well balanced between the gemcitabine and observation groups. There were no significant differences in overall survival (median 62·3 versus 63·8 months respectively; hazard ratio 1·01, 95 per cent c.i. 0·70 to 1·45; P = 0·964) and relapse-free survival (median 36·0 versus 39·9 months; hazard ratio 0·93, 0·66 to 1·32; P = 0·693). There were no survival differences between the two groups in subsets stratified by lymph node status and margin status. Although haematological toxicity occurred frequently in the gemcitabine group, most toxicities were transient, and grade 3/4 non-haematological toxicity was rare.

CONCLUSION

The survival probability in patients with resected bile duct cancer was not significantly different between the gemcitabine adjuvant chemotherapy group and the observation group. Registration number: UMIN 000000820 (http://www.umin.ac.jp/).

Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends the use of endoscopic ultrasound-guided biliary drainage (EUS-BD) over percutaneous transhepatic biliary drainage (PTBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction when local expertise is available.Strong recommendation, moderate quality evidence. 2: ESGE suggests EUS-BD with hepaticogastrostomy only for malignant inoperable hilar biliary obstruction with a dilated left hepatic duct when inadequately drained by ERCP and/or PTBD in high volume expert centers.Weak recommendation, moderate quality evidence. 3: ESGE recommends that EUS-guided pancreatic duct (PD) drainage should only be considered in symptomatic patients with an obstructed PD when retrograde endoscopic intervention fails or is not possible.Strong recommendation, low quality evidence. 4: ESGE recommends rendezvous EUS techniques over transmural PD drainage in patients with favorable anatomy owing to its lower rate of adverse events.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients at high surgical risk, EUS-guided gallbladder drainage (GBD) should be favored over percutaneous gallbladder drainage where both techniques are available, owing to the lower rates of adverse events and need for re-interventions in EUS-GBD.Strong recommendation, high quality of evidence. 6: ESGE recommends EUS-guided gastroenterostomy (EUS-GE), in an expert setting, for malignant gastric outlet obstruction, as an alternative to enteral stenting or surgery.Strong recommendation, low quality evidence. 7: ESGE recommends that EUS-GE may be considered in the management of afferent loop syndrome, especially in the setting of malignancy or in poor surgical candidates. Strong recommendation, low quality evidence. 8: ESGE suggests that endoscopic ultrasound-directed transgastric ERCP (EDGE) can be offered, in expert centers, to patients with a Roux-en-Y gastric bypass following multidisciplinary decision-making, with the aim of overcoming the invasiveness of laparoscopy-assisted ERCP and the limitations of enteroscopy-assisted ERCP.Weak recommendation, low quality evidence.

Intrahepatic cholangiocarcinoma: Epidemiology, risk factors, diagnosis and surgical management

Intrahepatic cholangiocarcinoma (ICC), the least common form of cholangiocarcinomas, is a rare hepatobiliary malignancy that arises from the epithelial cells of the intrahepatic bile ducts. The incidence of ICC has been rising in the global scale over the last twenty years, which may reflect both a true increase and the trend of earlier detection of the disease. Other than some well recognized causative risk factors, the association between viral and metabolic factors and ICC pathogenesis has been increasingly identified recently. Surgical resection is currently the only feasible modality with a curative ability, but the resectability and curability remain low. The high invasiveness of ICC predisposes the tumors to multifocality, node metastasis and vascular invasions, leading to poor long-term survival after resection. The role of liver transplantation is controversial, while locoregional treatments and systematic therapies may provide survival benefits, especially in patients with unresectable and advanced tumors. The present review discussed the epidemiology, risk factors, surgical and multimodal management of ICCs, which mainly focused on the outcomes and factors associated with surgical treatment.

Partial external diversion of bile for the treatment of intractable pruritus associated with intrahepatic cholestasis

Partial diversion of bile flow to an external stoma was performed in 6 patients with chronic intrahepatic cholestasis with severe pruritus that had been refractory to medical measures. Four patients with progressive intrahepatic cholestasis and 2 with arteriohepatic dysplasia were treated. Follow-up has been 3-8 yr. Patients with progressive intrahepatic cholestasis have been free of itching since surgery. Serum bile salt concentrations fell from 218-275 microM (normal less than 10) before to less than 10 microM after surgery. Biochemical tests of liver function and histology returned to normal or near normal. Patients with arteriohepatic dysplasia had persistent mild pruritus after surgery. Serum bile salt concentrations fell from 153-317 to 25-37 microM. There was little or no improvement in biochemical tests or histology. Bile volume and bile salt diverted were higher in patients with progressive intrahepatic cholestasis (7.3-13.0 ml/kg.day and 83-137 mumol/kg.day, respectively) than those with arteriohepatic dysplasia (3.2-4.5 ml/kg.day and 21-36 mumol/kg.day). The quality of life since surgery has been excellent in patients with progressive intrahepatic cholestasis, but not as optimal in those with arteriohepatic dysplasia. These findings suggest that partial external biliary diversion can provide effective relief from pruritus and perhaps reversal of liver disease in patients with progressive intrahepatic cholestasis. It should be used in patients with arteriohepatic dysplasia only in those with disabling pruritus.

Biliary reconstruction in right lobe living-donor liver transplantation: Comparison of different techniques in 321 recipients

OBJECTIVE

To assess the incidence of biliary complications after right lobe living-donor liver transplantation (LDLT) in patients undergoing duct-to-duct choledochocholedochostomy or Roux-en-Y choledochojejunostomy reconstruction.

SUMMARY BACKGROUND DATA

Biliary tract complications remain one of the most serious morbidities following liver transplantation. No large series has yet been carried out to compare the 2 techniques in LDLT. This study undertook a retrospective assessment of the relation between the method of biliary reconstruction used and the complications reported.

METHODS

Between February 1998 and June 2004, 321 patients received right lobe LDLT. Biliary reconstruction was achieved with Roux-en-Y choledochojejunostomy in 121 patients, duct-to-duct choledochocholedochostomy in 192 patients, and combined Roux-en-Y and duct-to-duct choledochocholedochostomy in 8 patients. The number of graft bile duct and anastomosis, mode of anastomosis, use of stent tube, and management of biliary complications were analyzed.

RESULTS

The overall incidence of biliary complications was 24.0%. Univariate analysis revealed that hepatic artery complications, cytomegalovirus infections, and blood type incompatibility were significant risk factors for biliary complications. The respective incidence of biliary leakage and stricture were 12.4% and 8.3% for Roux-en-Y, and 4.7% and 26.6% for duct-to-duct reconstruction. Duct-to-duct choledochocholedochostomy showed a significantly lower incidence of leakage and a higher incidence of stricture; however, 74.5% of the stricture was managed with endoscopic treatment.

CONCLUSIONS

The authors found an increase in the biliary stricture rate in the duct-to-duct choledochocholedochostomy group. Because of greater physiologic bilioenteric continuity, less incidence of leakage, and easy endoscopic access, duct-to-duct reconstruction represents a feasible technique in right lobe LDLT.

An aggressive surgical approach leads to improved survival in patients with gallbladder cancer: a 12-year study at a North American Center

OBJECTIVE

To determine if an aggressive surgical approach, with an increase in R0 resections, has resulted in improved survival for patients with gallbladder cancer.

SUMMARY BACKGROUND DATA

Many physicians express a relatively nihilistic approach to the treatment of gallbladder cancer; consensus among surgeons regarding the indications for a radical surgical approach has not been reached.

METHODS

A retrospective review of all patients with gallbladder cancer admitted during the past 12 years was conducted. Ninety-nine patients were identified. Cases treated during the 12-year period 1990 to 2002 were divided into 2 time-period (TP) cohorts, those treated in the first 6 years (TP1, N = 35) and those treated in the last 6 years (TP2, N = 64).

RESULTS

Disease stratification by stage and other demographic features were similar in the 2 time periods. An operation with curative intent was performed on 38 patients. Nine (26%) R0 resections were performed in TP1 and 24 (38%) in TP2. The number of liver resections, as well as the frequency of extrahepatic biliary resections, was greater in TP2 (P < 0.04). In both time periods, an R0 resection was associated with improved survival (P < 0.02 TP1, P < 0.0001 TP2). Overall survival of all patients in TP2 was significantly greater than in TP1 (P < 0.03), with a median survival of 9 months in TP1 and 17 months in TP2. The median 5-year survival in TP1 was 7%, and 35% in TP2. The surgical mortality rate for the entire cohort was 2%, with a 49% morbidity rate.

CONCLUSIONS

A margin-negative, R0 resection leads to improved survival in patients with gallbladder cancer.

Preoperative endoscopic drainage for malignant obstructive jaundice

The role of preoperative endoscopic drainage for patients with malignant obstructive jaundice was evaluated in a randomized controlled trial. A total of 87 patients were assigned to either early elective surgery (44 patients) or endoscopic biliary drainage followed by exploration (43). Thirty-seven patients underwent successful stent insertion and 25 had effective biliary drainage. Complications related to endoscopy occurred in 12 patients. After endoscopic drainage significant reductions of hyperbilirubinaemia, indocyanine green retention and serum albumin concentration were observed. Patients with hilar lesions had a significantly higher incidence of cholangitis and failed endoscopic drainage after stent placement. The overall morbidity rate (18 patients versus 16) and mortality rate (six patients in each group) were similar in the two treatment arms irrespective of the level of biliary obstruction. Despite the improvement of liver function, routine application of endoscopic drainage had no demonstrable benefit. Endoscopic drainage is indicated only when early surgery is not feasible, especially for patients with distal obstruction.

Surgical treatment of obesity

More than half of the European population are overweight (body mass index (BMI) > 25 and < 30 kg/m2) and up to 30% are obese (BMI > or = 30 kg/m2). Being overweight and obesity are becoming endemic, particularly because of increasing nourishment and a decrease in physical exercise. Insulin resistance, type 2 diabetes, dyslipidemia, hypertension, cholelithiasis, certain forms of cancer, steatosis hepatis, gastroesophageal reflux, obstructive sleep apnea, degenerative joint disease, gout, lower back pain, and polycystic ovary syndrome are all associated with overweight and obesity. The endemic extent of overweight and obesity with its associated comorbidities has led to the development of therapies aimed at weight loss. The long-term effects of diet, exercise, and medical therapy on weight are relatively poor. With respect to durable weight reduction, bariatric surgery is the most effective long-term treatment for obesity with the greatest chances for amelioration and even resolution of obesity-associated complications. Recent evidence shows that bariatric surgery for severe obesity is associated with decreased overall mortality. However, serious complications can occur and therefore a careful selection of patients is of utmost importance. Bariatric surgery should at least be considered for all patients with a BMI of more than 40 kg/m2 and for those with a BMI of more than 35 kg/m2 with concomitant obesity-related conditions after failure of conventional treatment. The importance of weight loss and results of conventional treatment will be discussed first. Currently used operative treatments for obesity and their effectiveness and complications are described. Proposed criteria for bariatric surgery are given. Also, some attention is devoted to more basic insights that bariatric surgery has provided. Finally we deal with unsolved questions and future directions for research.

Effects of controlled interruption of the enterohepatic circulation of bile salts by biliary diversion and by ileal resection on bile salt secretion, synthesis, and pool size in the rhesus monkey

The effects of controlled interruption of the enterohepatic circulation (EHC) of bile salts by biliary diversion on bile volume, bile salt secretion and synthesis rates, bile salt pool size, and the relationship to fecal fat excretion were studied in 16 rhesus monkeys. Bile from a chronic bile fistula was returned to the intestine through an electronic stream-splitter which, by diverting different percentages of bile to a collecting system, provided graded and controlled interruption of the EHC. The increase in hepatic bile salt synthesis in response to interruption of the EHC was limited and reached a maximum rate at 20% interruption of the EHC. Up to this level of biliary diversion, the increased hepatic synthesis compensated for bile salt loss so that bile salt secretion and pool size were maintained at normal levels. With diversion of 33% or more, there was no further increase in hepatic bile salt synthesis to compensate for external loss, and as a result there was diminished bile salt secretion, a reduction in bile salt pool size, and steatorrhea was observed. The effects of interruption of the EHC by the streamsplitter were compared with those produced by resection of the distal one-third or two-thirds of small bowel. While ileal resection appreciably reduced bile salt secretion, the EHC was by no means abolished. Bile salt reabsorption from the residual intestine was greater after one-third than after two-thirds small bowel resection. These observations suggest that jejunal reabsorption of bile salts occurs and may well contribute to the normal EHC.

Biliary strictures: classification based on the principles of surgical treatment

The classification of biliary strictures used at Hopital Paul Brousse is based on the lowest level at which healthy biliary mucosa is available for anastomosis. The classification is intended to help the surgeon choose the appropriate technique for the repair. Type I strictures, with a common duct stump longer than 2 cm, can be repaired without opening the left duct and without lowering the hilar plate. Type II strictures, with a stump shorter than 2 cm, require opening the left duct for a satisfactory anastomosis. Lowering the hilar plate is not always necessary but may improve the exposure. Type III lesions, in which only the ceiling of the biliary confluence is intact, require lowering the hilar plate and anastomosis on the left ductal system. There is no need to open the right duct if the communication between the ducts is wide. With type IV lesions the biliary confluence is interrupted and requires either reconstruction or two or more anastomoses. Type V lesions are strictures of the hepatic duct associated with a stricture on a separate right branch, and the branch must be included in the repair. Although this classification is intended for established strictures, it is commonly used to describe acute bile duct injuries. The surgeon must be aware, however, that the established stricture is generally one level higher than the level of the injury at the original operation.

Biliary strictures in 130 consecutive right lobe living donor liver transplant recipients: results of a Western center

Biliary strictures remain the most challenging aspect of adult right lobe living donor liver transplantation (RLDLT). Between 04/2000 and 10/2005, 130 consecutive RLDLTs were performed in our center and followed prospectively. Median follow-up was 23 months (range 3-67) and 1-year graft and patient survival was 85% and 87%, respectively. Overall incidence of biliary leaks (n = 19) or strictures (n = 22) was 32% (41/128) in 33 patients (26%). A duct-to-duct (D-D) or Roux-en-Y (R-Y) anastomosis were performed equally (n = 64 each) with no difference in stricture rate (p = 0.31). The use of ductoplasty increased the number of grafts with a single duct for anastomosis and reduced the biliary complication rate compared to grafts >/=2 ducts (17% vs. 46%; p = 0.02). Independent risk factors for strictures included older donor age and previous history of a bile leak. All strictures were managed nonsurgically initially but four patients ultimately required conversion from D-D to R-Y. Ninety-six percent (123/128) of patients are currently free of any biliary complications. D-D anastomosis is safe after RLDLT and provides access for future endoscopic therapy in cases of leak or stricture. When presented with multiple bile ducts, ductoplasty should be considered to reduce the potential chance of stricture.

Digital, single-operator cholangiopancreatoscopy in the diagnosis and management of pancreatobiliary disorders: a multicenter clinical experience (with video)

BACKGROUND AND AIMS

Digital cholangioscopes provide higher-resolution imaging of the pancreatobiliary tract compared with fiberoptic instruments. The role of a new, digital, single-operator cholangiopancreatoscopy (SOC) system for diagnosis and treatment of pancreatobiliary disorders in clinical practice is not known.

METHODS

We performed a multicenter, observational study of 105 consecutive patients with suspected pancreatobiliary disorders. The main outcome measures were (1) sensitivity and specificity of SOC visual appearance and biopsies in the diagnosis of indeterminate biliary strictures and (2) achieving complete duct clearance in patients with biliary or pancreatic duct stones.

RESULTS

A total of 98 cholangioscopy and 7 pancreatoscopy procedures were performed in 105 patients. Superior views of the ductal lumen and mucosa were obtained in all 44 patients with indeterminate biliary strictures. Among the 44 patients who underwent SOC-guided biopsies, the specimen was adequate for histologic evaluation in 43 patients (97.7%). The sensitivity and specificity of SOC visual impression for diagnosis of malignancy was 90% (95% confidence interval [CI], 69.9%-97.2%) and 95.8% (95% CI, 79.8%-99.3%), respectively. The sensitivity and specificity of SOC-guided biopsies for diagnosis of malignancy was 85% (95% CI, 64.0%-94.8%) and 100% (95% CI, 86.2%-100%). In patients with biliary or pancreatic duct stones (N = 36), complete duct clearance with stone removal in 1 session was accomplished in 86.1% of patients (31/36). Three patients (2.9%) experienced SOC-related adverse events that included cholangitis in 2 patients and postprocedure pancreatitis in 1 patient.

CONCLUSIONS

SOC has become an integral part of the ERCP armamentarium and has high accuracy in the evaluation of indeterminate biliary strictures. Complete stone clearance was achieved in all but 1 patient with challenging biliary or pancreatic duct stones. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT01815619.).

Classification of biliary tract cancers established by the Japanese Society of Hepato-Biliary-Pancreatic Surgery: 3(rd) English edition

The 3(rd) English edition of the Japanese classification of biliary tract cancers was released approximately 10 years after the 5(th) Japanese edition and the 2(nd) English edition. Since the first Japanese edition was published in 1981, the Japanese classification has been in extensive use, particularly among Japanese surgeons and pathologists, because the cancer status and clinical outcomes in surgically resected cases have been the main objects of interest. However, recent advances in the diagnosis, management and research of the disease prompted the revision of the classification that can be used by not only surgeons and pathologists but also by all clinicians and researchers, for the evaluation of current disease status, the determination of current appropriate treatment, and the future development of medical practice for biliary tract cancers. Furthermore, during the past 10 years, globalization has advanced rapidly, and therefore, internationalization of the classification was an important issue to revise the Japanese original staging system, which would facilitate to compare the disease information among institutions worldwide. In order to achieve these objectives, the new Japanese classification of the biliary tract cancers principally adopted the 7(th) edition of staging system developed by the International Union Against Cancer (UICC) and the American Joint Committee on Cancer (AJCC). However, because there are some points pending in these systems, several distinctive points were also included for the purpose of collection of information for the future optimization of the staging system. Free mobile application of the new Japanese classification of the biliary tract cancers is available via http://www.jshbps.jp/en/classification/cbt15.html.

Biliary surgery in the same admission for gallstone-associated acute pancreatitis

The clinical course of 47 patients with gallstone-associated acute pancreatitis who had surgery during the same admission has been reviewed. In 37 patients, when the signs and symptoms of pancreatitis settled on conservative management, biliary tract surgery was safely performed during that admission without mortality. The 10 patients whose clinical condition failed to settle prior to surgery had a complicated hospital stay and a 50 per cent mortality. A revised prognostic factor grading system has been outlined in which the age factor is removed and serum transaminase levels are considered of prognostic significance only if greater than 200 u/l within 48 h of admission. This revised system gives a more accurate assessment of the severity of individual attacks of gallstone-associated acute pancreatitis.

Improved Outcome of Resection of Hilar Cholangiocarcinoma (Klatskin Tumor)

BACKGROUND

Treatment of hilar cholangiocarcinoma (Klatskin tumors) has changed in many aspects. A more extensive surgical approach, as proposed by Japanese surgeons, has been applied in our center over the last 5 years; it combines hilar resection with partial hepatectomy for most tumors. The aim of this study was to assess the outcome of a 15-year evolution in the surgical treatment of Klatskin tumors.

METHODS

A total of 99 consecutive patients underwent resection for hilar cholangiocarcinoma in three 5-year time periods: periods 1 (1988-1993; n=45), 2 (1993-1998; n=25), and 3 (1998-2003; n=29). Outcome was evaluated by assessment of completeness of resection, postoperative morbidity and mortality, and survival.

RESULTS

The proportion of margin negative resections increased significantly from 13% in period 1 to 59% in period 3 (P<.05). Two-year survival increased significantly from 33%+/-7% and 39%+/-10% in periods 1 and 2 to 60%+/-11% in period 3 (P<.05). Postoperative morbidity and mortality were considerable but did not increase with this changed surgical strategy (68% and 10%, respectively, in period 3). Lymph node metastasis was, next to period of resection, also associated with survival in univariate analysis.

CONCLUSIONS

Mainly in the last 5-year period (1998-2003), when the Japanese surgical approach was followed, more hilar resections were combined with partial liver resections that included segments 1 and 4, thus leading to more R0 resections. This, together with a decrease in lymph node metastases, resulted in improved survival without significantly affecting postoperative morbidity or mortality.

The role of bile salts in controlling the rate of intestinal cholesterogenesis

According to current concepts, the liver and gastrointestinal tract are considered to be the major, if not the sole, sources of circulating serum cholesterol. While several mechanisms have been described which control the rate of hepatic cholesterogenesis, only biliary diversion is known to alter the rate of sterol synthesis in the intestine. The present study was designed to identify the inhibitory constituent of bile and to define its anatomic and biochemical sites of action. After either biliary diversion or cholestyramine feeding, there is a marked enhancement of cholesterogenesis at every level of the small intestine; this effect is specific for sterol synthesis since acetate incorporation into fatty acids and CO(2) is unaffected by these experimental manipulations. In the present investigation bile salt has been shown to be the constituent of whole bile responsible for the inhibited rate of sterol synthesis found in the intact animal, and in addition, an inverse relationship has been shown to exist between the steady-state intraluminal bile salt concentration and the rate of cholesterogenesis in the adjacent bowel wall. The inhibitory effect of bile salt is directed at the cells of the intestinal crypt, the major anatomic site for sterol synthesis in the small bowel. This feedback inhibition has been localized in the biosynthetic sequence to a step between acetyl CoA and mevalonic acid and, presumably, is at the enzymatic step mediated by hydroxymethylglutaryl reductase. These studies emphasize the close interrelationship which exists between the mechanisms of control of cholesterogenesis in the liver and small intestine. Sterol synthesis in the liver is regulated by exogenous cholesterol intake, whereas the rate of intestinal sterol synthesis is controlled by bile salt, the major end product of the hepatic catabolism of cholesterol.

Antimicrobial prophylaxis: a critique of recent trials

Most evaluations of antimicrobial prophylaxis have serious defects in design or fail to assess the clinical importance of observed differences. Reports that were published in the last decade and that meet stringent criteria indicate that antimicrobial prophylaxis is justified in few circumstances and nearly always only in very short courses, often just a single dose. These situations include vaginal hysterectomies (cephalosporin or penicillin), total abdominal hysterectomies (cephalosporin), high-risk cesarean sections (cephalosporin), elective colorectal surgery (oral erythromycin-neomycin, kanamycin-metronidazole, or doxycycline), vascular grafts of the abdominal aorta or lower extremity vasculature (cephalosporin), total hip replacement (cephalosporin or penicillinase-resistant penicillin), head and neck cancer surgery (cephalosporin), travelers' diarrhea (doxycycline), prevention of pneumonia due to Pneumocystis carinii in susceptible cancer patients (trimethoprim-sulfamethoxazole), and recurrent urinary tract infections in females (trimethoprim-sulfamethoxazole). Elective high-risk gastric and biliary tract surgery and prosthetic cardiac valve replacement may also merit prophylaxis, but the information is less conclusive.

Postoperative enteral vs parenteral nutrition. A randomized controlled trial

Twenty patients undergoing major upper-gastrointestinal-tract or pancreaticobiliary surgery were randomized to receive postoperative nutritional support by total parenteral nutrition (TPN) or elemental diet administered by needle-catheter jejunostomy (NCJ). Both routes of administration provided adequate nutritional support. No unexpected complications were encountered. The NCJ group compared favorably with the TPN group at the end of the seven-day trial. The NCJ group provided significant cost efficiency while maintaining adequate nutritional support.

Preoperative percutaneous transhepatic biliary decompression lowers operative morbidity in patients with obstructive jaundice

Percutaneous transhepatic biliary decompression is a safe and potentially helpful procedure. If done correctly, it will accomplish adequate decompression of the biliary tree and permit hepatic function to return to a more normal state preoperatively. The time gained while waiting for the bilirubin level to decrease can be used for adequate preoperative preparation of the patient. Use of this technique may make it possible for operative treatment of obstructive jaundice to return to a two-stage procedure, the first stage being percutaneous transhepatic biliary decompression.

Experimental and clinical studies on the effect of biliary drainage in obstructive jaundice

Mitochondrial respiratory function, ketogenesis and collagen metabolism of the liver in biliary obstruction and after its relief were investigated in dogs and patients with obstructive jaundice. In dogs, it was found that hepatic mitochondrial respiratory function decreased significantly with prolongation of biliary obstruction, but recovered to varying degrees depending on both the duration of obstruction and of the period after the relief of obstruction. Ketogenesis was also impaired by biliary obstruction and its recovery was found in a slight degree only in cases with short-term obstruction. Hepatic collagen content and the synthetic ability significantly increased in biliary obstruction, and returned to normal levels with a relatively short period after the relief. Analogous results were obtained in clinical cases, but the decrease in serum bilirubin was somewhat delayed and increased hepatic collagen content continued after relief of the obstruction. When major surgery is required in patients with obstructive jaundice, biliary drainage should be carried out first 4 to 6 weeks before the performance of major operations. In cases with biliary obstruction for 12 weeks or more, it is desirable to wait for more than 6 weeks after biliary drainage since recovery of hepatic function, especially mitochondrial function, will be extremely slow.

Diagnostic and Therapeutic Endoscopic Retrograde Cholangiography Using a Short-Type Double-Balloon Endoscope in Patients With Altered Gastrointestinal Anatomy: A Multicenter Prospective Study in Japan

OBJECTIVES

To evaluate the utility and safety of a short-type double-balloon endoscope (DBE) in the treatment of biliary disease in patients with surgically altered gastrointestinal (GI) anatomy.

METHODS

This study was conducted as a multicenter, single-arm, prospective trial at five tertiary academic care centers and three community-based hospitals in Japan. Consecutive patients with biliary disease with altered GI anatomy were prospectively included in this study.

RESULTS

A total of 311 patients underwent double-balloon endoscopic retrograde cholangiography (ERC). The success rate of reaching the target site, the primary end point, was 97.7% (95% confidence interval (CI): 95.4-99.1). The success rate of biliary cannulation and contrast injection of the targeted duct, the secondary end point, was 96.4% (95% CI: 93.6-98.2), and the therapeutic success rate was 97.9% (95% CI: 95.4-99.2). Adverse events occurred in 33 patients (10.6%, 95% CI: 7.1-14.0) and were managed conservatively in all patients with the exception of 1 in whom a perforation developed, requiring emergency surgery.

CONCLUSIONS

ERC using a short-type DBE resulted in an excellent therapeutic success rate and a low rate of adverse events. This treatment can be a first-line treatment for biliary disease in patients with surgically altered GI anatomy.

Right hepatic artery injury associated with laparoscopic bile duct injury: incidence, mechanism, and consequences

Because most bile duct injuries involve the common hepatic duct, the right hepatic artery, which is nearby, can also be injured. Reports on the frequency and significance of right hepatic artery injury (RHAI) associated with bile duct injury are sparse but suggest that RHAI increases mortality and decreases the success of the biliary repair. We studied the incidence, mechanism, and consequences of RHAI accompanying major bile duct injury. A total of 261 laparoscopic bile duct injuries were analyzed. Distribution was as follows: class I, 6%; class II, 22%; class III, 61%; and class IV, 11%. RHAI was present in 84 cases (32%): class I, 6%; class II, 17%; class III, 35% (P < 0.04 vs. class I/II); and class IV, 64% (P < 0.007 vs. class I/II/III). RHAI was more commonly associated with abscess, bleeding, hemobilia, right hepatic lobe ischemia, and subsequent hepatectomy (54% with RHAI vs. 11% without RHAI; P < 0.0001). RHAI had no influence on the success of the bile duct injury repair or on the mortality rate. Complications occurred more often with RHAI among cases repaired by the primary surgeon (41% RHAI vs. 2% no RHAI; P < 0.0001) but not among repairs by a biliary surgeon (3% RHAI vs. 2% no RHAI, P=NS; P < 0.0001 primary vs. biliary surgeon). RHAI increased morbidity, and occurred more often with class III and IV injuries reflecting the mechanisms of these injuries. RHAI did not increase the mortality rate or alter the success of biliary repair. Among biliary injuries repaired by the primary surgeon, RHAI was associated with a higher incidence of postoperative abscess, bleeding, hemobilia, hepatic ischemia, and the need for hepatic resection. A similar increase in the complication rate was not seen in patients treated by a biliary specialist.