Scintigraphic diagnosis of bile leakage after laparoscopic cholecystectomy. A prospective study

To assess the role of Tc-99m IDA cholescintigraphy in diagnosing bile leakage and bile obstruction after laparoscopic cholecystectomy, 51 studies were performed in 51 patients on the first postoperative day. Two different radioactive bile acid analogs were used, Tc-99m HIDA and Tc-99m trimethylbromo IDA. Scintigraphic findings were correlated with the clinical conditions. Results of seven out of 51 cholescintigrams were abnormal, showing accumulations of activity in the right paracolic gutter. Of these seven patients, only three had clinical symptoms consisting of more than normal postoperative abdominal pain and peritoneal irritation. The other four patients had minimal abnormal accumulation in the right paracolic gutter and showed no clinical signs postoperatively. Complete common bile duct obstruction or other bile duct-related complications, except for bile leakage, were not observed. Cholescintigraphy is feasible for the early detection of bile leakage and bile flow obstruction after laparoscopic cholecystectomy in patients with increased postoperative abdominal discomfort.

Hepatic resections for colorectal metastases in The Netherlands. A multiinstitutional 10-year study

BACKGROUND AND METHODS

The records of 118 patients who had hepatic resections for colorectal liver metastases were analyzed retrospectively.

RESULTS

The patient group, from 15 institutions in The Netherlands, was found to have a 5-year actuarial survival rate of 21% and a 5-year actuarial disease-free survival rate of 19%. The postoperative mortality rate was 7.6%. In the remaining group, the morbidity rate was 34.7%. A number of factors were examined that were reported to be of prospective significance in other studies. In the multivariate proportional hazard model of Cox, the number of metastases (P = 0.001) and the amount of perioperative blood loss (P = 0.002) were related significantly to disease-free survival. A factor that may be considered a contraindication to resection is the presence of extrahepatic disease (whether nodal or visceral), even if resectable.

CONCLUSIONS

Although the actual benefit of resection is limited, and it is associated with considerable morbidity, surgical therapy offers some patients a chance for cure. It is a valid expectation that improvement in techniques and a proper understanding of hepatic anatomy will improve the safety and efficacy of hepatic resections in the future. Future research should focus on defining better selection criteria and on study of the value of adjuvant treatment modalities.

Cytokines tumor necrosis factor and interleukin-6 in experimental biliary obstruction in mice

The putative role of the cytokines interleukin-6 and tumor necrosis factor in the pathophysiology of the complications and mortality after surgery in jaundiced patients was studied in a murine model. Cytokine serum levels were determined in mice with experimental biliary obstruction. As an indicator of the activation status of macrophages, cytokine release by mononuclear phagocytes obtained from such mice was assessed. Following surgery, interleukin-6 levels increased to 2 to 3 ng/ml after 3 to 4 hr, but declined rapidly afterward to levels of 60 pg/ml after 10 days. After 12 days, substantial interleukin-6 levels were observed in jaundiced mice (100 pg/ml), whereas levels in sham mice further decreased (p less than 0.001). The cytokine tumor necrosis factor was frequently present in the serum of jaundiced mice. After 22 days, when killed, all jaundiced mice showed significant tumor necrosis factor levels (p less than 0.001). This was in contrast to sham mice in which tumor necrosis factor was never detected. The presence of an activated state of macrophages in jaundiced mice was concluded from the observed high spontaneous cytokine release and significantly higher release after stimulation (p less than 0.05). The presence of circulating cytokines was discussed in the context of the postoperative complications observed in jaundiced patients.

[Laparoscopic cholecystectomy in The Netherlands: early national results]

The results of laparoscopic cholecystectomy in 58 of the 66 hospitals in which surgeons introduced this method after attending a practical course are evaluated. Data of 546 patients were collected. The indication for laparoscopic surgery was symptomatic gallstone disease without evidence of common bile duct stones, cholecystitis or previous upper abdominal surgery. In 70% of the 58 hospitals fewer than 10 laparoscopic cholecystectomies were performed nine months after the first practical course because of shortage of equipment. The mean age was 50 years (range 20-80) with a male:female ratio of 1:4. The average operation time was 95 minutes. In 8.2% of the patients the laparoscopic procedure was converted to laparotomy. Adhesions, cholecystitis or difficulty in recognition of the anatomy was responsible for the conversion in 31 of the 45 patients. In the remaining 14 patients bleeding or bile leakage during the procedure compelled the surgeon to perform a laparotomy. One patient died because of bleeding from the cystic artery. Eleven patients underwent laparotomy postoperatively because of bleeding (3), bile leakage (6) and lesion of the ductus choledochus (2). Minor complications occurred in 30 patients. Laparoscopic cholecystectomy is expanding rapidly in the Netherlands. The early results are encouraging, although the experience is limited. Further registration is necessary to be able to compare the results of laparoscopic cholecystectomy more critically with those of conventional cholecystectomy.

[Prognostic factors for the survival time in gallbladder carcinoma]

Survival of 74 patients with proven gallbladder carcinoma was studied retrospectively. Initial treatment consisted of cholecystectomy, cholecystectomy and common bile duct exploration, bypass procedure (hepatojejunostomy) or laparotomy and biopsy or percutaneous biliary drainage. Staging (according to the American Joint Committee on Cancer) was the most important determinant for survival (chi 2 = 29.34; df 3; p less than 0.001). Most individual complaints such as pain (chi 2 = 1.66;), nausea/vomiting (chi 2 = 0.35), and palpable mass (chi 2 = 2.62) were not related significantly with survival. However cachexia (chi 2 = 17.12; df I; p less than 0.001) was correlated with decreased survival. Establishing the diagnosis preoperatively was associated with significantly shorter survival (chi 2 = 22.67; df I; p less than 0.001) than establishment at the moment of hospitalisation. In a hospital where a radical surgical treatment is not performed, less invasive non surgical therapy (insertion of an endoprosthesis) could probably be considered for this group of patients. Selected patients should be referred to a centre for a radical surgical approach.

Complications in obstructive jaundice: role of endotoxins

Surgical treatment of patients with obstructive jaundice is associated with a high postoperative morbidity and mortality. A correlation was suggested between endotoxins and the observed complications. The mechanism by which endotoxins affect the negative outcome in operated jaundiced patients was, however, not clear, nor was the mechanism of clinically used preventive treatments. Several experiments were therefore performed in rats with biliary obstruction, to investigate whether and how endotoxins are active. The role of endotoxins was studied in a model in which endotoxins were absent. In germfree rats (free of bacteria and thus of endotoxin) the effect of biliary obstruction was studied and compared with biliary obstruction in conventional rats. To substantiate further the role of endotoxin, anti-endotoxin treatments (oral lactulose or internal drainage) were tested in rats with obstructive jaundice undergoing a severe surgical trauma. It is shown that endotoxins are responsible for complications (suppression of cellular immunity, kidney function, mortality) and that these complications can be prevented with an anti-endotoxin treatment. These results may have implications for preoperative treatment of jaundiced patients.

Acute calculous cholecystitis. What is new in diagnosis and therapy?

The management of patients with acute calculous cholecystitis has changed during recent years. The etiology of acute cholecystitis is still not fully understood. Infection of bile is relatively unimportant since bile and gallbladder wall cultures are sterile in many patients with acute cholecystitis. Ultrasonography is first choice for diagnosis of acute cholecystitis and cholescintigraphy is second best. Percutaneous puncture of the gallbladder that can be used for therapeutic drainage has also diagnostic qualities. Early cholecystectomy under antibiotic prophylaxis is the treatment of choice, and has been shown to be superior to delayed surgery in several prospective trials. Mortality can be as low as 0.5% in patients younger than 70-80 years of age, but a high mortality has been reported in octogenerians. Selective intraoperative cholangiography is now generally accepted and no advantage of routine cholangiography was shown in clinical trials. Percutaneous cholecystostomy can be successfully performed under ultrasound guidance and has a place in the treatment of severely ill patients with acute cholecystitis. Laparoscopic cholecystectomy can be done safely in patients with acute cholecystitis, but extensive experience with this technique is necessary. Endoscopic retrograde drainage of the gallbladder by introduction of a catheter in the cystic duct is feasible but data are still scarce.

Prospective randomized double-blind trial of branched chain amino acid enriched versus standard parenteral nutrition solutions in traumatized and septic patients

The addition of branched chain amino acids (BCAA) to total parenteral nutrition (TPN) solutions of balanced aminoacid composition has been reported to result in improved nitrogen balance, preservation of plasma protein levels, and improved immune function; however, only a few large clinical studies have been performed, yielding conflicting results. We, therefore, studied in a prospective, randomized double blind trial, the effects of BCAA enrichment of an otherwise isonitrogenous and isocaloric TPN solution on plasma protein levels in 101 traumatized and septic patients. TPN-derived nitrogen intake was similar in both study groups. Nitrogen balances in the BCAA group (n = 49) were not different from those in the standard group (n = 52). Plasma total protein levels increased significantly in the standard group resulting in a significant difference between study groups on day 7. Pre-albumin levels increased significantly in the BCAA group and in the standard group. The number of neutrophils (rods) was significantly lower in the standard group compared to the BCAA group on day 7. Lymphocytes increased significantly in the standard group as did the number of platelets, resulting in a significant difference between study groups on day 7. We conclude that BCAA enrichment of standard TPN solutions does not result in more efficient nitrogen metabolism in septic or traumatized patients.

[Early cholecystectomy for acute cholecystitis; effect of length of symptoms on morbidity and mortality]

In this retrospective study the results of "early' cholecystectomy for acute cholecystitis were analysed, especially the influence of duration of symptoms on morbidity and mortality. During a 4-year period 122 patients underwent early cholecystectomy for acute cholecystitis. The mean age was 64 years (range 20-101). Cholecystectomy was performed in 93 patients, 25 underwent cholecystectomy and common bile duct exploration and the remaining 4 patients cholecystostomy. The mortality was 1.6% (2 patients 88 and 89 years of age). Biliary surgery related complications and wound infection occurred in 14 and 11 patients respectively. There was no significant difference in morbidity and mortality according to duration of symptoms (2 days versus 2-7 days). The duration of symptoms is not a major contraindication to early cholecystectomy. Early cholecystectomy appears to be a safe procedure for acute cholecystitis for patients within 7 days after onset of symptoms.

Effects of infusion of branched chain amino-acids enriched TPN solutions on plasma amino-acid profiles in sepsis and trauma patients

Total parenteral nutrition with branched chain amino-acids enriched solutions has been advocated in patients with sepsis and stress because of favourable effects on nitrogen balance, protein synthesis and immune competence. The rationale for the use of BCAA-enriched solutions is based on their potential to correct the plasma amino-acid imbalances seen in these patients. In a 7-day prospective randomised study we investigated the effects on plasma amino-acid concentrations of a standard amino-acid solution (15.6% BCAA) and a branched chain amino-acid enriched solution (50.2% BCAA) in 101 parenterally fed patients with carefully assessed sepsis and/or stress scores. The infusion of the BCAA-enriched solution led to an imbalance of the essential plasma amino-acids. The branched chain amino-acids valine, leucine and isoleucine increased significantly while the non-BCAA essential amino-acids decreased significantly. In the standard solution the non-BCAA-essential amino-acids increased significantly with a slow and insignificant rise in the levels of the branched chain amino-acids. We conclude that infusion of a BCAA enriched TPN formulation induced amino-acid profile derangements that can be considered ill-suited to the achievement of anti-catabolic effects.

Effect of branched chain amino acid enrichment of total parenteral nutrition on nitrogen sparing and clinical outcome of sepsis and trauma: a prospective randomized double blind trial

Administration of extra branched chain amino acids (BCAA) has been associated with a nitrogen sparing effect in septic and traumatized patients. Whether nitrogen sparing is associated with decreased morbidity and mortality rates is unknown. We therefore undertook a prospective, randomized, double blind trial investigating the effects of BCAA enrichment of a total parenteral nutrition (TPN) regimen on nitrogen balance, 3-methylhistidine excretion, morbidity as evidenced by disturbances in organ function, severity of sepsis and mortality. One hundred and one patients entered the study; 52 received a standard TPN solution and 49 a BCAA-enriched solution. Both groups received 30 kcal kg-1 body-weight, 15 per cent fat calories and 0.17 g nitrogen kg-1 body-weight. In the BCAA-enriched group, patients received 0.56 g BCAA kg-1 body-weight (50.2 per cent BCAA). Standard group patients received 0.18 g BCAA kg-1 body-weight (15.6 per cent BCAA). Nitrogen balances and 3-methylhistidine excretion were not significantly different between groups. Although morbidity scores tended to decrease during the study no difference was observed between groups. Mortality (early or late), sepsis or stress-related, did not differ significantly between groups. We were not able to confirm the reported beneficial effects of BCAA-enriched TPN solutions for use in septic and traumatized patients.

Prevention of postoperative complications in jaundiced rats. Internal biliary drainage versus oral lactulose

In an experiment mimicking a severe surgical trauma by deliberate renal ischemia, the postoperative outcome in jaundiced rats was studied. Intervention studies were performed with preoperative oral lactulose (to reduce endotoxin toxicity) or preoperative internal biliary drainage. Compared to control, obstructive jaundice in rats significantly reduced survival time (p less than 0.001) and enhanced renal impairment (p less than 0.001) after renal ischemia. Preoperative supportive therapy of jaundiced rats with oral lactulose increased survival time (p less than 0.01) but did not reduce deterioration of renal function. Preoperative internal biliary drainage proved to be superior, with a significant reduction of renal impairment (p less than 0.001) and an improved survival time (p less than 0.001). Our experiments provide further evidence that obstructive jaundice increases the complication rate following major surgical procedures. Based on our results in rats, we suggest that in obstructive jaundice preoperative internal biliary drainage is the supportive therapy of choice. However, if adequate drainage is not possible, oral treatment with lactulose may help reduce postoperative complications.

Effect of preoperative risk factors on the outcome after surgery for complicated diverticular disease

The influence of age and severity of peritonitis was studied in 111 (16%) out of a total of 694 patients treated for diverticular disease. These 111 patients had complications of the disease and were operated upon by four different approaches. The outcome after surgery was expressed as 30 days mortality, number of operations and postoperative complications per patient, overall hospital stay and number of permanent colostomies in surviving patients. The overall hospital stay lasted significantly longer for patients older than 70 years compared to the younger patients (64 versus 41 days). The complications per patient increased significantly from 1.0 to 1.9 and from 1.1 to 2.7 respectively for an age above 70 years and for peritonitis. Preoperative risk factors as age and peritonitis adequately predict the outcome after surgery for complicated diverticular disease. The type of surgery employed seems more dependent on the perioperative findings than on the superiority of one of the procedures.

Primary conservative management of external small-bowel fistulas. Changing composition of fistula series?

A primary conservative approach was used in treatment of 42 patients with 45 external small-bowel fistulas. Closure of fistula was achieved in 29 patients but failed in 13 (10 died and 3 discharged with open fistula). There was no time-related improvement in closure rate or mortality, probably because of a general shift towards more serious cases. To evaluate this concept more specifically, groups of simple (19) or complicated (23) fistula were distinguished. The 23 patients with complicated fistula were more severely ill, had more sepsis, e.g. intra-abdominal abscess, and were more often treated in the intensive care unit (p less than 0.01) than the 19 with simple fistula. The respective mortality rates were 7/23 and 3/19. All six patients who died of sepsis had complicated fistula. Mortality in the simple fistula group was related to the primary disease. Especially in cases of complicated fistula, further improvements in management of septic complications should be aimed for, to permit success in delayed definitive surgery.

Lactulose inhibits endotoxin induced tumour necrosis factor production by monocytes. An in vitro study

Preoperative oral treatment with lactulose is used to prevent complications after surgery in patients with obstructive jaundice. The effect is perhaps the result of an inactivation of gut derived endotoxins but the exact mechanism of action is, however, unknown. Tumour necrosis factor is an important mediator of endotoxin toxicity. The cytokine tumour necrosis factor is mainly produced by mononuclear phagocytes. In this study, the effect of lactulose on the endotoxin induced tumour necrosis factor release by monocytes was investigated. The direct effect of lactulose on endotoxin was tested in a chromogenic limulus amoebocyte lysate assay. Polymyxin B a known inactivator of endotoxin was used as control in both experiments. Lactulose has a limited capacity to inactivate endotoxin as measured in the endotoxin assay. In contrast lactulose significantly reduced endotoxin induced tumour necrosis factor production by monocytes. In conclusion lactulose inhibits tumour necrosis factor production by a direct inhibitory effect on monocytes, rather than by inactivation of endotoxin. Because tumour necrosis factor is an important mediator of endotoxin toxicity, this inhibitory effect could explain the beneficial effect of lactulose in obstructive jaundice.

Suppression of cellular immunity in obstructive jaundice is caused by endotoxins: a study with germ-free rats

The increased susceptibility to infections after surgery in jaundiced patients is considered to be caused by an impairment of cellular immunity and/or nutritional status. Endotoxins are suggested to play a role in the pathogenesis. However, the mechanism of action is unknown. Germ-free rats were used to study the effect of biliary obstruction in a model with negligible amounts of endotoxin. Cellular immunity, production of tumor necrosis factor (as a mediator of endotoxin toxicity) by peritoneal macrophages, and the nutritional status were assessed. Significant suppression of cellular immunity was found in conventional rats with obstructive jaundice. In contrast, cellular immunity was not suppressed in jaundiced germ-free rats. Large amounts of tumor necrosis factor were spontaneously secreted by peritoneal macrophages of jaundiced conventional rats, whereas macrophages from jaundiced germ-free rats did not. Moreover macrophage activation (expressed in tumor necrosis factor production) was significantly related to suppression of cellular immunity. Weight changes and depression of albumin levels were not different in germ-free and conventional rats after bile duct ligation. The data presented indicate that suppression of cellular immunity in obstructive jaundice is caused by endotoxins, whereas the impaired nutritional status seems to not be affected by the presence of endotoxins.

['Minor' surgical interventions and treatment of minor lesions in family practice]

A prospective study was performed of 'minor' surgical interventions and treatment of minor injuries in a catchment area of six GPs with approx. 14,250 patients. This group of GPs was studied with regard to: the pattern of items of service and referrals, adherence to working arrangements made and the results of the treatment. Prior to this investigation, after a pilot study general guidelines for the treatment were drawn up. During a 6-month period 574 patients were treated, of whom 45 (7.9%) went directly to the emergency department of Maastricht University Hospital. Fifty five patients (9.6%) were referred by the GP in the first or second instance. Working arrangements on pathological examination of skin tumours were kept relatively well, those on tetanus prophylaxis only fairly well. The treatment of minor injuries and the performance of minor operations, mostly excision of skin tumours, gave good results in approx. 90% of the cases. The results of treatment of panaritium was poor. Since GPs, especially those in rural areas, have to perform minor operations and treat small injuries frequently, adequate attention should continue to be paid to practical training of GPs in minor surgery.

Bile acids inhibit endotoxin-induced release of tumor necrosis factor by monocytes: an in vitro study

Endotoxins play an important role in the pathogenesis of complications of surgery in obstructive jaundice. Preoperative treatment with orally administered deoxycholic acid prevented endotoxin-related complications, such as renal malfunction. Other bile acids, however, were less effective, and the mechanism of action is not known. Endotoxin toxicity is considered to be largely mediated by tumor necrosis factor/cachectin, a cytokine release by mononucler phagocytes. Therefore, we studied the influence of different bile acids on endotoxin-induced tumor necrosis factor production by monocytes in vitro. Bile acids inhibit tumor necrosis factor production through a direct inhibitory effect on the monocytes. Deoxycholic acid was the most effective, chenodeoxycholic acid was less effective and ursodeoxycholic acid was ineffective in the concentrations used. Bile acids did not inactivate endotoxin as measured in a chromogenic Limulus amebocyte lysate assay. The therapeutic effect of bile acids in obstructive jaundice can be explained by an inhibition of endotoxin-induced tumor necrosis factor release by mononuclear phagocytes.

Long-term follow-up after choledochojejunostomy for bile duct stones with complex clearance of the bile duct

In this retrospective study, the long-term follow-up of patients undergoing choledochojejunostomy (Roux-en-Y) for bile duct stones with complex clearance of the bile duct is evaluated. Bile duct exploration and subsequent choledochojejunostomy (Roux-en-Y) was performed in 43 patients (median age 67 years) in the period 1976-82. There was no mortality and only one patient had a major complication. Twenty patients died during follow-up (median follow-up period 5 years); the median follow-up period for the remaining 23 patients was 8 years. Good long-term results were found in 98 per cent of cases. No signs or symptoms could be related to bile duct obstruction or to cholangitis. Nearly all liver function tests and serum bilirubin levels were normal in the 21 patients who were tested. We conclude that patients with bile duct stones with complex clearance of the bile duct can be safely treated by means of a choledochoenterostomy (in this study a choledochojejunostomy Roux-en-Y).

Plasma-amino acid profiles in sepsis and stress

Sepsis has been associated with specific plasma amino acid patterns. Sixty-five patients were prospectively investigated as to whether these patterns are indeed sepsis specific, or specific for metabolic stress without concomitant sepsis, or associated with the presence of organ failure. Virtually all aminoacid levels were decreased by 10-30% (p less than 0.05), whereas cystine and phenylalanine were significantly elevated. These changes were more pronounced in severe sepsis. Organ failure was not associated with significantly altered amino acid profiles. No differences were found between sepsis and stress without signs of sepsis. In addition, imminent death was not associated with aberrant amino acid profiles. We conclude that sepsis and metabolic stress are associated with changes in plasma amino acid profiles, but that such changes are aspecific and therefore poor indicators of disease severity.

Reinfusion of secretions from high-output proximal stomas or fistulas

Patients with proximal stomas or high fistulas and defunctionalized intestine who are receiving total parenteral nutrition (TPN) often develop hepatic enzyme abnormalities and hyperbilirubinemia. A technique was developed to collect intestinal secretions from proximal stoma and to reinfuse these secretions into the distal part of the intestine. This technique was applied in eight patients with a disrupted intestinal tract. A significant decrease (p less than 0.05) in elevated serum bilirubin, alkaline phosphatase and gamma-glutamyl transpeptidase levels was observed. Alanine aminotransferase and aspartate aminotransferase levels did not change significantly. The plasma sodium levels, slightly subnormal before reinfusion (131.0 +/- 4.6 millimolar per liter), despite enormous supplementation, normalized during reinfusion (137.0 +/- 4.0 millimolar per liter). TPN was continued during this infusion. This suggests that TPN by itself does not cause intrahepatic cholestasis. Neither could it be explained by an effect of secondary bile acids because these were most likely not produced as bile did not reach the distal defunctionalized intestine. Three possible mechanisms are suggested. Restoration of passage in the distal intestine may diminish bacterial overgrowth, endotoxin production and absorption. Enlargement of the bile acid pool may diminish the susceptibility of the liver to the deleterious effects of endotoxins. We advocate this reinfusion technique to overcome the metabolic disturbances occurring in those patients with high-output stomas or fistulas arising from the proximal parts of the small intestine.

Preoperative total parenteral nutrition (TPN) in severe Crohn's disease

This study was performed to evaluate the effect of preoperative total parenteral nutrition (TPN) on the results after surgical treatment of patients with severe Crohn's disease. Of 67 patients admitted with complications of Crohn's disease, 51 had severe active disease and abdominal masses, fistulas and/or obstruction (mean Crohn's disease activity index score, 301). Forty-four patients received preoperative TPN for a mean period of 33 days. Complications of TPN were limited. Spontaneous closure of fistulas was achieved in 75% of the cases. Serum albumin levels improved significantly, from 29.1 +/- 1.1 gm/L to 35.4 +/- 0.7 gm/L (p less than 0.001). Mean body weights improved from 81% to 89% ideal body weights or 52.6 kg to 57.2 kg, respectively (p less than 0.05). Surgical procedures were facilitated by remission of the active inflammatory process and associated with a major complications rate of only 6%. No deaths occurred. the mean hospital stay for the TPN-treated group of patients was 63 days. TPN is an effective preoperative treatment for patients with severe complicated Crohn's disease. The prolonged hospital stay and high costs, however, are disadvantages of this approach. Preoperative TPN treatment should therefore be limited to patients with severe active disease.

The effect of preoperative internal and external biliary drainage on mortality of jaundiced rats

Mortality following abdominal infection induced by cecal ligation and puncture was studied in rats with obstructive jaundice and after relief of the obstruction by preoperative internal or external biliary drainage. Four groups of adult Sprague-Dawley rats were used: common bile duct ligation (BDL), BDL followed by internal drainage after two weeks, BDL followed by external drainage after two weeks, and sham operation. The serum bilirubin concentration was significantly increased in the BDL group and returned to normal following internal and external drainage. Mortality in the sham group was 16.5% and increased to 83.3% following BDL, but it decreased significantly (25%) to near-normal values after preoperative internal drainage. However, after external drainage no significant reduction in mortality (63%) was found. These findings confirm the poor results of preoperative external drainage in previous studies and establish the efficacy of internal biliary drainage in a well-controlled experimental model that has to be evaluated in the clinical situation.

Progression of a benign epithelial ampullary tumor to adenocarcinoma

Benign tumors of the extrahepatic biliary ducts are rare. The high recurrence rate following local resection of these benign tumors is well known, but the development of one into a malignant tumor has received little attention. The recurrence 4 years after local excision of a benign periampullary tumor that developed into a well-differentiated papillar adenocarcinoma is described in this case report. Radical resection was performed by means of a pancreatoduodenectomy. The literature concerning the progression of benign extrahepatic tumors to adenocarcinomas is reviewed.

Calcium-induced contraction and contractile protein of gallbladder smooth muscle after high-cholesterol feeding of prairie dogs

Feeding a high-cholesterol diet to prairie dogs causes a reduction in contractile responses of gallbladder smooth muscle from these animals. In this study, the influence of cholesterol feeding on the contractile response to calcium and on the concentration of the contractile proteins actin and myosin was determined. Strips of gallbladder smooth muscle, at their optimal length for tension development, were stimulated maximally with carbachol. Then the muscle cell membranes were made permeable and strips were exposed to a maximally effective concentration of calcium. Strips from cholesterol fed animals developed less stress than those from control animals under all conditions. The concentration of actin and myosin was determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. There were no differences in the concentrations of either protein between the cholesterol-fed and control animals. Our results indicate that the decreased contractile response seen in muscle from cholesterol-fed animals is not due to alterations in membrane excitation, excitation-contraction coupling, or in total contractile proteins.

Changes in nutritional status associated with obstructive jaundice and biliary drainage in rats

Effect of bile duct ligation (BDL) and internal biliary drainage on food intake and nutritional status was studied in rats and compared with sham and pair-fed animals. During week 1, food intake of BDL animals was reduced (p less than 0.05), resulting in weight loss (p less than 0.05). In weeks 2 and 3, food intake, nitrogen balance, and weight gain were similar in all groups. Internal biliary drainage or sham operation after 3 wk produced transient changes in food intake and N2 balance. Serum albumin fell in all groups, returned to normal in sham (3.2 +/- 0.1 g/dl) and pair-fed (3.1 +/- 0.1 g/dl), but persisted in BDL rats (2.4 +/- 0.2 g/dl, p less than 0.001). Jaundice was associated with anemia. Although BDL produces transient changes in food intake, weight gain, and N2 balance, anorexia and malnutrition are not features of this animal model. Nutritional risk factors associated with hyperbilirubinemia are probably due to changes in intermediary metabolism.

Influence of autonomic drugs on the motility of the sphincter of Oddi in the opossum

We have evaluated the effect of various autonomic drugs on the electromyographic activity of the sphincter of Oddi and the small intestine of seven opossums. Hexamethonium bromide and atropine sulfate abolished and bethanechol increased the frequency of spike bursts in the sphincter of Oddi and duodenum. Phenylephrine and epinephrine increased the number of spike bursts in the sphincter of Oddi after a short period of stimulation. No spike potentials were seen in the duodenum after infusion of norepinephrine. Clonidine and dobutamine decreased spike burst activity in the sphincter of Oddi and duodenum. Terbutaline also decreased the frequency of spike bursts in the sphincter of Oddi but did not change the number in the duodenum. Prior infusion of antagonists blocked partially or totally the effect of all respective agonists except for yohimbine, which did not inhibit the effect of clonidine. These findings suggest that the sphincter of Oddi may have cholinergic, alpha 1, alpha 1, beta 1 and beta 2-adrenergic receptors. Cholinergic agonists stimulate and alpha 2, beta 1 and beta 2-adrenergic agonists inhibit the motility of the sphincter of Oddi and the small intestine. Alpha-adrenergic agonists stimulate the motility of the sphincter of Oddi and inhibit the motility of the small intestine.

Gastrointestinal motility following small bowel obstruction in the opossum

The motility of the gastrointestinal tract of six opossums with total and four with partial small bowel obstruction was evaluated. Following the establishment of small bowel obstruction, the migrating myoelectric complex was substituted by a new pattern which was characterized by periods of intense spike activity interspersed with quiescent periods. In the experiments with total intestinal obstruction, the frequency and duration of the periods of intense spike activity were related to the recording site and the time after establishment of intestinal obstruction. The frequency of spike bursts in the ileum proximal and distal to the obstruction was the greatest in the first 2 days after the establishment of the obstruction, while in the antrum and proximal small bowel, the frequency of bursts of spike potentials increased gradually from the first to the fourth postobstruction day (P less than 0.01). However, there was no change in the frequency, duration, and localization of periods of intense spike activity during the 5 days following the establishment of partial intestinal obstruction. We concluded that following intestinal obstruction, the migrating myoelectric complex is substituted by a myoelectric pattern that is characterized by periods of intense spike activity interspersed with quiescent periods. In the animals with total intestinal obstruction, the periods of increased motility are initially more frequent in the bowel proximal and distal to the obstruction and afterwards in the stomach and upper small bowel.

Impaired specific cell-mediated immunity in experimental biliary obstruction and its reversibility by internal biliary drainage

Little is known of the effect of cholestasis on host immunity. This study evaluates lymphocytic responsiveness to PHA and LPS mitogen and to allogeneic F344 antigen in Sprague-Dawley rats 21 days following bile duct ligation and 31 days following relief of jaundice by internal biliary drainage. Serum bilirubin level was significantly elevated in the bile duct ligated animals at Day 21 (P less than 0.001) and thereafter returned to preoperative levels following internal biliary drainage. Results demonstrate depressed responsiveness to PHA (P less than 0.001) and allogeneic F344 antigen in vivo (P less than 0.04) and in vitro (P less than 0.02) in bile duct ligated animals as compared to sham, sham pair-fed, and normal control rats. The observed deficiency in responsiveness to T-cell-dependent mitogen and antigen cannot be explained on the basis of complicating nutritional, renal, or infective factors. Subsequent internal biliary drainage results in some improvement in T-cell responsiveness in the bile duct ligated group although recovery is not complete. B-Lymphocytic response to LPS mitogen is not affected by bile duct ligation. We conclude that cholestasis subsequent to extrahepatic biliary obstruction per se results in impairment of cell-mediated immunity in vivo. This impairment is partly reversible by internal biliary drainage. In vitro B-cell function does not appear to be affected in this model. Further study of impaired cell-mediated immunity in extrahepatic biliary obstruction will improve our understanding of the immunological status of patients with obstructive jaundice and cholestatic liver diseases.

Effect of 16,16-dimethyl prostaglandin E2 on the myoelectric activity of the gastrointestinal tract of the opossum

Myoelectric recordings of the opossum gastrointestinal tract were performed during continuous infusion of 16,16-dimethyl prostaglandin E2 at 0.1, 1, 2 and 5 micrograms/kg X h. Continuous administration of prostaglandin caused a dose-dependent reduction of the duration of the migrating myoelectric complex cycle and an increase in the velocity of phase III migration from the duodenum to the terminal ileum. The reduction of the migrating myoelectric complex cycle was due to a shortening of the duration of both phase I and II. Bolus administration of 16,16-dimethyl prostaglandin E2 caused intense spike activity for 2-4 min in all recording sites simultaneously. Administration of indomethacin did not change the myoelectric activity of the gastrointestinal tract. Infusion of prostaglandin E2 caused diarrhoea in eight of forty experiments. These changes in gastrointestinal motility may be important contributory factors in the pathogenesis of prostaglandin-induced diarrhoea.

Serotonin increases the velocity of propagation and frequency of the migrating myoelectric complexes

The effect of serotonin on the myoelectric activity of the gastrointestinal tract was evaluated in seven opossums. Continuous intravenous administration of serotonin reduced the cycle duration of the migrating myoelectric complex and increased the velocity of propagation of the phase III. These changes were dose-dependent and were observed only with high doses of serotonin of 0.1 mg kg-1 h-1 or more. Infusion of 0.01 mg kd-1 h-1 had no effect on the motility of the gastrointestinal tract. The motility changes occurred in all segments of the gastrointestinal tract studied and were characterized by a continuous and organized increase in the velocity of propagation of the activity front (phase III) of the migrating myoelectric complex from the antrum to the terminal ileum. The cycle duration of the two migrating myoelectric complexes following administration of methysergide at 1.0 mg kg-1 was similar to the control migrating myoelectric complexes. We concluded that continuous infusion of serotonin in the opossum increases the velocity of propagation of the phase III of the migrating myoelectric complex from the antrum to the terminal ileum.

Estimation of hepatic blood flow by hydrogen gas clearance

The hydrogen gas clearance technique was evaluated to estimate regional hepatic blood flow. Initially, the H2 gas method was compared to the indocyanine green clearance in mini pigs. The blood flow measured by the H2 gas method (0.49 +/- 0.03 ml/min/gm) was only 39% of the calculated blood flow by the indocyanine green method (1.26 +/- 0.14 ml/min/gm). The blood flow determined by H2 gas decreased to 0.06 +/- 0.04 ml/min/gm after ligation of the hepatic artery. No difference in blood flow was found by simultaneous measurements on the left (0.89 +/- 0.1 ml/min/gm) and right (0.96 +/- 0.13 ml/min/gm) liver lobes in rats. After ligation of the left hepatic artery in the rats, a delayed response to H2 application was present and the determined blood flow (0.14 +/- 0.02 ml/min/gm) was significantly reduced (p less than 0.001) compared with the right liver lobe H2 determined blood flow as a control. No current was generated after ligation of the left hepatic artery and the portal vein indicating that there was no blood flow measured by the gas H2 method. The results indicate that the H2 gas clearance technique may be a method that assesses hepatic arterial liver perfusion rather than estimates total hepatic blood flow. The safety and simplicity of the H2 gas clearance technique may make it suitable for clinical application in serial measurement of hepatic arterial blood flow in man.

Endotoxemia after relief of biliary obstruction by internal and external drainage in rats

Systemic and portal endotoxemia were studied in rats with biliary obstruction and after relief of the obstruction by internal and external drainage. Endotoxemia was increased after bile duct ligation (p less than 0.001) compared with control values. The incidence of systemic and portal endotoxemia was significantly reduced after internal drainage (p less than 0.001). A significantly higher incidence of portal (86 percent) and systemic (57 percent) endotoxemia, however, was found after external drainage. The persistence of endotoxemia after external drainage, when serum bilirubin levels returned to normal units, indicates that bile flow is important in controlling endotoxemia during preoperative biliary drainage. These results suggest that the systemic endotoxemia observed after relief of obstruction by external drainage may contribute to the increased mortality, as found in previous rat studies. This observation may contribute to an understanding of why patients with preoperative external drainage of biliary obstruction have a higher incidence of septic complications.

Effect of feeding on myoelectric activity of the sphincter of Oddi and the gastrointestinal tract in the opossum

The effect of different foods on the myoelectric activity of the sphincter of Oddi and gastrointestinal tract was evaluated in the opossum. Gallbladder pressure was also recorded. Feeding fat and mixed food resulted in the greatest incidence of spike activity in the duodenum and jejunum, followed by protein. The lowest incidence of slow waves with spikes in the duodenum and jejunum followed feeding of carbohydrates (P less than 0.01). Likewise, the lowest spike activity in the sphincter of Oddi was observed after carbohydrate feeding (P less than 0.05). There was no significant difference in the incidence of spike potentials in the sphincter of Oddi when fat, protein, or mixed food was fed. No significant change in gallbladder pressure during fasting and following feeding of different aliments was observed. We concluded that there is a correlation between the frequency of spike potentials in the sphincter of Oddi and in the small bowel following feeding. The duration of the fed pattern for each type of food correlated with the number of spikes in the sphincter of Oddi and gastrointestinal tract.

[Effect of physiological stimuli on Oddi's sphincter motility]

The myoelectric activity of the sphincter of Oddi was studied both in the fasted and fed states and following administration of gastrointestinal hormones. Electromyographic recordings were obtained from 21 opossums in the fasted state and following administration of 20 Cal/kg of fat, protein, carbohydrate or isocaloric mixture of these three aliments. The proximal segment of the sphincter of Oddi generated spontaneous spike potentials that migrated to the distal segment of the sphincter. The frequency of spike potentials correlated with the migrating myoelectric complex in the duodenum. Following feeding, the migrating myoelectric complex was abolished and substituted by a fed pattern. The duration of the fed pattern and the frequency of spike potentials depended on the kind of aliment. Cholecystokinin and pentagastrin increased and glucagon and secretion decreased the frequency of spike potentials in the sphincter of Oddi. It is concluded from these studies that the sphincter of Oddi may play an important role in controlling the time and rate of biliary drainage into the duodenum.

A palliative percutaneous drainage procedure for proximal bile duct carcinoma

Proximal bile duct carcinoma is surgically irresectable in most patients and some form of palliative drainage is necessary. Percutaneous transhepatic drainage for this condition has been performed in eight patients through internal and external drainage. Five patients had an adequate drainage with a mean palliative drainage period of 11 months, the longest period being 21 months. The other three patients, with a mean age of 88 years, died within four weeks due to terminal disease. The direct transhepatic approach seems an attractive alternative to surgical bypass procedures as a palliative treatment. In particular, if the tumor involves both hepatic ducts, combined left and right hepatic duct drainage offers a new possibility in palliative treatment.

Intrahepatic biliary papillomatosis

Intrahepatic bile duct papillomatosis associated with changes of nuclear atypia is described in a young man. Radical excision was performed by left hepatic lobectomy and removal of the common bile duct and left hepatic ducts. Fourteen previous cases of intrahepatic or diffuse intrahepatic and extrahepatic biliary papillomatosis are reviewed. While local recurrence and progression to death from obstructive jaundice and cholangitis is the rule, only two definite cases of malignant change have been reported. Radical surgery may be curative for this rare condition.

Percutaneous transhepatic drainage and insertion of an endoprosthesis for obstructive jaundice

As a consequence of the good results with percutaneous transhepatic cholangiography using the Chiba needle, a similar technique was employed for percutaneous transhepatic drainage and insertion of a percutaneous transhepatic endoprostheses. Herein we have described the technique and results of percutaneous transhepatic cholangiography with the Chiba needle in 45 patients and of combined percutaneous transhepatic drainage and insertion of an endoprosthesis in a consecutive group of 69 patients with obstructive jaundice. In the latter group, 50 patients had a malignant lesion. Of these, 38 were subject to continuous drainage, 14 externally and 24 with an endoprosthesis. The percutaneous transhepatic drainage and insertion of an endoprosthesis procedure brings a new dimension to preoperative decompression of the bile ducts and palliative treatment of obstructive jaundice in high-risk patients.