Current assessment of choledochoduodenostomy: 130 consecutive series

Introduction Cholelithiasis usually can be managed successfully by endoscopic sphincterotomy. Choledochoduodenostomy (CDD) is one of the surgical treatment options but its acceptance remains debated because of the risk of reflux cholangitis and sump syndrome. The aim of this study was to assess the current features and outcomes of patient undergoing CDD. Patients and methods We retrospectively analysed the surgical results of consecutive 130 patients treated by CDD between 1991 and 2013 and excluded five cases with a malignant disorder. Indications for surgery included endoscopic management where stones were difficult or failed to pass and primary common bile duct stones with choledochal dilatation. Incidences of reflux cholangitis, stone recurrence, pancreatitis or sump syndrome were investigated and the data between end-to-side and side-to-side CDD were compared. Results Reflux cholangitis and stone recurrence was 1.6% (2/125) and 0% (0/125) of cases by CDD. There is no therapeutic-related pancreatitis in CDD. Sump syndrome was not also observed in side-to-side CDD. Conclusions This study is a first comparative study between end-to-side and side-to-side CDD. The surgical outcomes for CDD treatment of choledocholithiasis were acceptable. The incidence of reflux cholangitis, stone recurrence, pancreatitis and sump syndrome was very low.

Comparision of modified and conventional delta-shaped gastroduodenostomy in totally laparoscopic surgery

AIM: To evaluate the safety and feasibility of a modified delta-shaped gastroduodenostomy (DSG) in totally laparoscopic distal gastrectomy (TLDG).

METHODS: We performed a case-control study enrolling 63 patients with distal gastric cancer (GC) undergoing TLDG with a DSG from January 2013 to June 2013. Twenty-two patients underwent a conventional DSG (Con-Group), whereas the other 41 patients underwent a modified version of the DSG (Mod-Group). The modified procedure required only the instruments of the surgeon and assistant to complete the involution of the common stab incision and to completely resect the duodenal cutting edge, resulting in an anastomosis with an inverted T-shaped appearance. The clinicopathological characteristics, surgical outcomes, anastomosis time and complications of the two groups were retrospectively analyzed using a prospectively maintained comprehensive database.

RESULTS: DSG procedures were successfully completed in all of the patients with histologically complete (R0) resections, and none of these patients required conversion to open surgery. The clinicopathological characteristics of the two groups were similar. There were no significant differences between the groups in the operative time, intraoperative blood loss, extension of the lymph node (LN) dissection and number of dissected LNs (150.8 ± 21.6 min vs 143.4 ± 23.4 min, P = 0.225 for the operative time; 26.8 ± 11.3 min vs 30.6 ± 14.8 mL, P = 0.157 for the intraoperative blood loss; 4/18 vs 3/38, P = 0.375 for the extension of the LN dissection; and 43.9 ± 13.4 vs 39.5 ± 11.5 per case, P = 0.151 for the number of dissected LNs). The anastomosis time, however, was significantly shorter in the Mod-Group than in the Con-Group (13.9 ± 2.8 min vs 23.9 ± 5.6 min, P = 0.000). The postoperative outcomes, including the times to out-of-bed activities, first flatus, resumption of soft diet and postoperative hospital stay, as well as the anastomosis size, did not differ significantly (1.9 ± 0.6 d vs 2.3 ± 1.5 d, P = 0.228 for the time to out-of-bed activities; 3.2 ± 0.9 d vs 3.5 ± 1.3 d, P = 0.295 for the first flatus time; 7.5 ± 0.8 d vs 8.1 ± 4.3 d, P = 0.489 for the resumption of a soft diet time; 14.3 ± 10.6 d vs 11.5 ± 4.9 d, P = 0.148 for the postoperative hospital stay; and 30.5 ± 3.6 mm vs 30.1 ± 4.0 mm, P = 0.730 for the anastomosis size). One patient with minor anastomotic leakage in the Con-Group was managed conservatively; no other patients experienced any complications around the anastomosis. The operative complication rates were similar in the Con- and Mod-Groups (9.1% vs 7.3%, P = 1.000).

CONCLUSION: The modified DSG, an alternative reconstruction in TLDG for GC, is technically safe and feasible, with a simpler process that reduces the anastomosis time.

Stapled gastro/duodenojejunostomy shortens reconstruction time during pylorus-preserving pancreaticoduodenectomy

AIM: To investigate whether a stapled technique is superior to the conventional hand-sewn technique for gastro/duodenojejunostomy during pylorus-preserving pancreaticoduodenectomy (PpPD).

METHODS: In October 2010, we introduced a mechanical anastomotic technique of gastro- or duodenojejunostomy using staplers during PpPD. We compared clinical outcomes between 19 patients who underwent PpPD with a stapled gastro/duodenojejunostomy (stapled anastomosis group) and 19 patients who underwent PpPD with a conventional hand-sewn duodenojejunostomy (hand-sewn anastomosis group).

RESULTS: The time required for reconstruction was significantly shorter in the stapled anastomosis group than in the hand-sewn anastomosis group (186.0 ± 29.4 min vs 219.7 ± 50.0 min, P = 0.02). In addition, intraoperative blood loss was significantly less (391.0 ± 212.0 mL vs 647.1 ± 482.1 mL, P = 0.03) and the time to oral intake was significantly shorter (5.4 ± 1.7 d vs 11.3 ± 7.9 d, P = 0.002) in the stapled anastomosis group than in the hand-sewn anastomosis group. There were no differences in the incidences of delayed gastric emptying and other postoperative complications between the groups.

CONCLUSION: These results suggest that stapled gastro/duodenojejunostomy shortens reconstruction time during PpPD without affecting the incidence of delayed gastric emptying.

Safety of modified double-stapling end-to-end gastroduodenostomy in distal subtotal gastrectomy

BACKGROUND AND OBJECTIVES

Double-stapling end-to-end gastroduodenostomy (DS-BI) has several potential advantages over other anastomotic techniques in that it is a simple procedure, with no additional gastrotomy on the remnant stomach, and less tension on the anastomosis site. We evaluated the safety of DS-BI by comparing it with the hand-sewn Billroth II gastrojejunostomy (B-II).

METHODS

Medical records of 933 consecutive patients (DS-BI 428, B-II 505) who underwent distal subtotal gastrectomy were retrospectively reviewed. Several clinicopathological features and treatment results were compared between the two groups.

RESULTS

The overall complication rates were 9.3% in the DS-BI group and 15.2% in the B-II group (P = 0.007). Anastomosis-related complications, such as anastomosis-site leakage, stenosis, and intraluminal bleeding, did not differ between the two groups (1.2% in the DS-BI group and 1.8% in the B-II group, P = 0.59). All the anastomosis-related complications were managed conservatively. Postoperative mortality rates were 0% in the DS-BI group and 0.4% (2/505) in the B-II group.

CONCLUSIONS

Modified DS-BI is a safe procedure, with short-term results similar to those of hand-sewn Billroth II anastomosis.

Choledochoduodenostomy for common bile duct stones

Among the techniques for dealing with common bile stones, choledochoduodenostomy (CDS) represents a useful alternative. This operation is indicated mainly in patients with recurrent stones, giant stones, or concomitant common bile stricture and duct stones. At the present time most of the patients undergoing CDS have been already undergone endoscopic retrograde cholangiography or ultrasonography to study the common bile duct and the cause of symptoms. The common bile duct diameter is of paramount importance when determining the feasibility of performing a CDS, the critical size being 1.2 cm. The most common operation is a side-to-side anastomosis employing absorbable sutures. Stomal patency is the most important factor for preventing classic complications such as cholangitis and sump syndrome. These complications are rare, being observed in only 5% of the patients. Long-term results of the operation show that it is a safe procedure that should be considered a good option in selected patients with choledocholithiasis.

Duodenocolostomy: a surgical complication of duodenal atresia repair

A variety of complications after repair of congenital duodenal obstruction have been reported. The authors describe a case in which the duodenum was mistakenly anastomosed to the transverse colon, which resulted in intractable diarrhea.

Transpapillary and transmural drainage of pancreatic pseudocysts

BACKGROUND

Endoscopic drainage of pseudocysts using the transpapillary and transmural approaches has been reported. We evaluated endoscopic drainage in 53 patients with symptomatic pancreatic pseudocysts in whom conservative management had failed.

METHODS

After preliminary endoscopic retrograde pancreatography, transpapillary drainage was attempted in 33 patients with pseudocysts that communicated with the main pancreatic duct. Transmural drainage of pseudocysts in contact with the stomach or duodenal wall was attempted in the remaining 20 patients and in 4 patients selected for combined transpapillary and transmural drainage. The cause of pseudocysts was chronic pancreatitis in 92%. The median pseudocyst size was 7.0 cm (range, 2 to 16).

RESULTS

Endoscopic drainage was technically successful in 50 patients (94%), of whom 47 had complete pseudocyst resolution. Complications occurred in 11% and included gallbladder puncture (n = 1) and bleeding (n = 2) after transmural drainage, and pancreatitis (n = 1) after transpapillary drainage; stent clogging resulted in abscess formation in 2 patients. Mean follow-up was 22 months (range, 1 to 70); pseudocysts recurred in 11 patients (23%), of whom 7 were successfully re-treated endoscopically.

CONCLUSION

Both transpapillary and transmural pseudocyst drainage are highly effective in patients with pseudocysts demonstrating suitable anatomy for these endoscopic techniques.

Choledochal cyst in the adult

OBJECTIVE

The authors examined the natural history of choledochal cysts in adults treated surgically.

BACKGROUND

An initial diagnosis of choledochal cyst is uncommon in adults. The recommended treatment is excision, rather than bypass, to achieve effective biliary drainage and because of the risk of cancer.

METHODS

A retrospective study of 27 adult patients was completed to determine the frequency of anastomotic complications and the incidence of cancer.

RESULTS

Fifteen patients were treated by cyst excision, and one developed an anastomotic stricture, treated by percutaneous dilation. Eight of 11 patients treated by cyst enterostomy required additional surgery for anastomotic revision. A final patient was treated by T-tube drainage. Five of the seven patients with cancer have died at a mean of 21.6 months.

CONCLUSION

This experience documents the high incidence of cancer (26%), and high rate of stricture after cyst enterostomy (73%). The dismal prognosis once cancer has developed warrants cyst excision, even in asymptomatic patients, including those with prior cyst enterostomies.

Serum drug concentrations after oral administration of paracetamol to patients with surgical resection of the gastrointestinal tract

Serum concentrations of paracetamol were measured at 30, 60, 120 and 180 min after oral administration of a solution of 1500 mg paracetamol in normal subjects (n = 32) (Group A) and in patients with total gastrectomy (Roux-en-Y reconstruction) (n = 5) (Group B), distal partial gastrectomy (Billroth I reconstruction) (n = 7) (Group C), pylorus preserving pancreatoduodenectomy (Billroth I type reconstruction) (n = 12) (Group D), and short bowel syndrome (n = 5) (Group E). In Group B, the dose was delivery directly into the jejunum 20 cm distal to the duodenojejunal flexure. The highest serum drug concentrations were observed in the 30 min sample in Groups B and C and in the 120 min sample in Groups A, D, and E. Mean (+/- s.d.) concentrations at these times were 18.90 +/- 1.55 micrograms ml-1 (Group B), 12.89 +/- 2.12 micrograms ml-1 (Group C), 11.12 +/- 3.16 micrograms ml-1 (Group A), 9.78 +/- 2.85 micrograms ml-1 (Group D), and 4.89 +/- 1.96 micrograms ml-1 (Group E), respectively. We conclude that in patients with normal intact gastrointestinal tract, most of a dose of oral paracetamol is absorbed from the jejunum distal to the duodenojejunal flexure.

Ten-year follow-up of a prospective, randomized trial of selective proximal vagotomy with ulcer excision and partial gastrectomy with gastroduodenostomy for treating corporeal gastric ulcer

Between 1975 and 1980, 30 patients with type I corporeal gastric ulcer were randomly allocated to undergo selective proximal vagotomy with ulcer excision or partial gastrectomy with gastroduodenostomy. Sixteen patients underwent selective proximal vagotomy (1 was excluded from the follow-up since microscopic examination of the excised ulcer revealed an early gastric cancer) and 14 underwent partial gastrectomy. No significant differences in the clinical results were found 3 years after surgery. During a median follow-up of 10 years, ulcer recurred in 3 patients after selective proximal vagotomy and in 2 after partial gastrectomy. One patient in each group had recurrent ulcer without symptoms and received no treatment. Two selective proximal vagotomy patients and three partial gastrectomy patients had epigastric pain with or without ulcer. One patient with selective proximal vagotomy underwent a second operation because of epigastric pain and recurrent ulcer. Bowel habits remained unchanged in all but one patient in each group, and mild or moderate dumping was recorded for two patients in each group. Very good or good results (modified Visick scale) were recorded for 11 of 15 patients after selective proximal vagotomy and for 10 of 14 patients after partial gastrectomy. Except for one patient in each group who had moderate dumping, patients classified as Visick III or IV had no symptoms during treatment with antacids or H2-blockers, or had asymptomatic ulcers and needed no treatment. Selective proximal vagotomy reduced the median acid response to insulin hypoglycemia and to pentagastrin by 100% and 80%, respectively, for at least 3 to 5 years, and partial gastrectomy reduced the median acid response to pentagastrin by 97%. In our opinion, selective proximal vagotomy with ulcer excision is an alternative to partial gastrectomy for surgically treating type I gastric ulcer.

Urinary trypsin levels observed in pancreas transplant patients with duodenocystostomies promote in vitro fibrinolysis and in vivo bacterial adherence to urothelial surfaces

This study evaluated the role of activated urinary trypsin in mediating the increased incidence of infectious and hemorrhagic lower urinary tract complications in pancreas transplant patients with pancreatico-duodenocystostomies (PDC). The effect of trypsin concentrations corresponding to those observed in the urine of PDC patients were studied using an in vitro assay of clot lysis and an in vivo assay of bacterial-urinary tract adherence. Results were compared with those of parallel assays performed using urine from a pancreas transplant patient with a duodenocystostomy and control human urine. All trypsin concentrations studied demonstrated fibrinolytic activity. Fibrinolysis increased as a direct function of both trypsin concentration and duration of substrate exposure (P < 0.0001). Fibrin lysis resulting from the urine of the transplant patient was 4.6 times greater than that predicted based upon assays of total trypsin content in the sample. Fibrinolytic activity in control urine specimens was 0.16% of that observed in transplant urine specimens. Exposure of the rat urinary bladder to 200 micrograms/ml trypsin concentrations, or transplant urine, resulted in a significant increase in bacterial adherence over that seen in control urine from treated animals (P < 0.05). These findings demonstrate a significant effect of urinary trypsin on physiologic processes involved in hemostasis and the prevention of urinary tract infection. Active urinary trypsin may play an etiologic role in hemorrhagic and infectious lower urinary tract complications observed in patients with a PDC.

Superior results with combined kidney-pancreas transplants

From February of 1987 to February of 1991 the authors performed 23 pancreas transplants for Type I diabetes mellitus. Eight of the pancreas transplants were in patients who had a previous kidney transplant, 14 were simultaneous kidney and pancreas transplants, and 1 was in a pre-uremic diabetic. Two patients have been retransplanted after losing first grafts. All pancreata were retrieved from heart-beating cadaver donors. Pancreata were transplanted into the iliac fossa of the recipient using the iliac artery and vein as arterial inflow and venous outflow, respectively. Drainage of the pancreatic ductal system was accomplished by anastomosing either a patch or segment of duodenum surrounding the ampulla of Vater to the urinary bladder. All pancreata functioned initially with no patient requiring insulin 6 hours after surgery. Two grafts were lost early due to thrombosis of the venous drainage of the transplant; 4 grafts were lost to acute rejection; 3 were lost to chronic rejection; and 1 patient died with a functioning pancreas. One-year graft survival for all pancreatic grafts is 62 per cent. One-year patient survival is 96 per cent. One-year pancreatic graft and patient survival for the 14 combined kidney-pancreas transplants is 88 per cent and 100 per cent, respectively. Two kidneys transplanted with pancreata also were lost to acute rejection. Pancreas transplantation has proven to be a viable treatment alternative for selected patients with Type I diabetes mellitus. Long-term results are best when pancreas transplantation is done in combination with renal transplantation.

Studies of the release of gastrin from the human duodenum induced by gastrin-releasing peptide

In the present study the influence of duodenal exclusion and vagotomy on basal release of gastrin from extra-antral stores has been investigated in addition to the consequences of these procedures on the gastrin response to gastrin-releasing peptide (GRP) infusion. Basal gastrin concentrations and the response to GRP were measured in seven patients after a Whipple operation, in seven patients after antrectomy combined with selective gastric vagotomy and B I reconstruction, in seven patients operated on with antrectomy, selective gastric vagotomy, and Roux-en-Y reconstruction, and finally in seven patients after antrectomy, truncal vagotomy, and Roux-en-Y reconstruction. Gastrin was measured by a highly specific radioimmunoassay. Very low concentrations were obtained after a Whipple operation, and no increase followed GRP infusion. The basal gastrin concentrations were slightly higher in antrectomized patients, irrespective of whether a selective gastric vagotomy had been added. However, in these patients a significant gastrin response followed GRP infusion. Duodenal exclusion seemed not to influence the response to GRP. On the other hand, extragastric vagotomy was followed by low gastrin concentrations in the basal state and only a marginal response to GRP administration. These results strongly suggest that GRP releases gastrin from the human duodenal mucosa and that duodenal exclusion does not alter the response of the duodenal gastrin cells to GRP stimulation. Vagal denervation of the duodenal mucosa seems to suppress the gastrin response to GRP, indicating an excitatory influence of the vagus nerve.

Follow up studies on various reconstruction methods of the biliary tract including our new method (Roux Y-duodenojejunal anastomosis)

Thirty six patients with benign diseases of the biliary tract (14 patients with congenital choledochal dilatation, 15 patients with postoperative stricture and 7 patients with others) were divided into three groups: 21 patients who underwent a Roux Y (RY), 7 patients who underwent a jejunal interposition (IP) and 8 patients who underwent a side to side anastomosis between the jejunal limb of the Roux Y and the duodenum (RY-DJ). The RY-DJ was designed to decompress the Roux Y jejunal limb and to allow an inflow of bile into the duodenum. Significant complications, including cholangitis, infection, or abdominal pain, developed in 10 of the patients with RY (48 per cent), 7 of the patients with IP (100 per cent) and 1 of the patients with RY-DJ (13 per cent). None had a postoperative peptic ulcer. Simultaneous scintigraphy showed the time required for the two agents, 99mTc-IDA and 111In-DTPA, to mix at the upper jejunum, which revealed that the time taken by the patients with RY-DJ was similar to that of the patients with IP and to that of healthy controls. The time was markedly longer in the patients with RY, presumably due to a prominent stasis of the bile tracer in the Roux Y jejunal limb. Our new method (RY-DJ) for reconstruction of the extrahepatic biliary tract is more physiological and has less postoperative complications than other conventional methods.

Liver injury with perivenular fibrosis and alcoholic hyalin after pancreatoduodenectomy for pancreatic carcinoma

We describe a patient who developed progressive hepatic failure one year after pancreatoduodenectomy for pancreatic carcinoma and died of gastrointestinal bleeding. He suffered from progressive weight loss after surgery, even though obstruction or stenosis of the gastrointestinal tract was excluded. At autopsy, the liver showed extensive perivenular fibrosis associated with variable loss of hepatocytes, perisinusoidal fibrosis, alcoholic hyalin and a lack of parenchymal regenerative activity, all of which closely resembled severe alcoholic liver disease. Stricture of both the main pancreatic duct and the pancreaticojejunostomy with almost complete loss of exocrine acini was also found, and the recurrent tumor was seen to have caused portal venous obstruction and hepatic arterial stenosis. A combination of these nutritionally unfavorable circumstances and prolonged ischemia appeared to have been responsible for the liver injury in this non-alcoholic patient.