Underutilization of Surgery in Periampullary Cancer Treatment

BACKGROUND

Site-specific outcomes of resection for periampullary cancer have not been analyzed on a large, registry-based scale.

METHODS

We assessed data on periampullary cancers from the SEER database. Site- and stage-specific outcomes were analyzed. Resection was compared to no resection.

RESULTS

Resection was the main therapy in stages 1 and 2 (resection vs. no resection, 8644 vs. 7208 patients), was less frequent in stage 3 (1248 vs. 2783 patients) and was rarely-but still-used in stage 4 disease (541 vs. 11,212 patients). Pancreatic head (75.7%), 11.4% distal bile duct, 7.7% ampullary, and 5.3% duodenal cancers. Cancer subtype-independent median survival was 22.0 (resection) vs. 7.0 months (no resection) in stages 1 and 2, 21.0 vs. 8.0 months in stage 3, and 10.0 vs. 3.0 months in stage 4. Subtype-dependent median survival (resection vs. no resection) was 18.0 vs. 5.0 months in pancreatic head, 19.0 vs 4.0 months in distal bile duct, 41.0 vs 7.0 months in ampullary, and 38.0 vs 4.0 months in duodenal adenocarcinoma. On multivariable analysis, patient comorbidities, marital and insurance status, and income all influenced the decision to undergo resection.

CONCLUSIONS

Surgery is still underutilized in the treatment of periampullary cancers. Patients with cancers originating from the duodenum or the ampulla of Vater benefit most from resectional surgery.

The top 100: A review of the most cited articles in Surgery

INTRODUCTION

We performed a study of the top 100 most cited articles in the five general surgery journals with the highest impact according to Journal Citation Report.

METHODS

We selected the five journals with the highest impact in 2015: Annals of Surgery, British Journal of Surgery, JAMA Surgery, Surgery, and Journal of the American College of Surgeons. In January 2017, using the Web of Science application, we performed a search of all articles published by these journals and identified the 100 most cited articles (top 100). We evaluated the number of citations, year of publication, type of article, country and hospital of the article, area of interest and number of authors.

RESULTS

The median number of citations per top 100 paper was 490. Twenty percent of the top 100 papers have been published since 2000. Overall, 70% are original papers, 8% randomized control trials, 11% reviews, 1% meta-analyses and 11% other subtypes. There are 13% proceedings papers. Sixty-one percent are from the US. The most frequently discussed topic is hepato-pancreato-biliary surgery (33%).

CONCLUSIONS

The top 100 most cited articles tend to be original articles describing studies carried out in the US, reporting significant surgical breakthroughs. Hepato-pancreato-biliary surgery is the most common subject area. Annals of Surgery had twice as many citations as the other journals studied. The archetypal article of the Top15 most cited is an original paper published in the twentieth century, with an average of 2000 citations.

Modified transprepancreatic septotomy reduces postoperative complications after intractable biliary access

This study aimed to assess the clinical value of transprepancreatic septotomy indwelling guide wire or pancreatic duct stent in intractable endoscopic retrograde cholangiopancreatography (ERCP) for bile duct cannulation.Of the 2107 patients treated by ERCP, a total of 81 cases with difficult bile duct cannulation underwent transprebiliopancreatic septotomy (referred to as the septotomy group, 37 cases) and transprepancreatic septotomy with pancreatic duct stent (modified septotomy group, 44 cases). Success rates of cannulation and postoperative complications for both methods were compared.Among them, 77 cases were successfully administered bile duct cannulation. The success rates of the septotomy and modified septotomy groups were 91.89% and 97.73%, respectively, with no significant difference (P = .489). Of the 77 patients, 12 cases had complications. The septotomy group included 7 acute pancreatitis, 1 bleeding, and 1 biliary tract infection cases; while in the modified septotomy group, there were 1 acute pancreatitis, 1 bleeding, and 1 biliary tract infection cases. The occurrence rate of acute pancreatitis in the modified septotomy group was lower than that of the septotomy group (2.33% vs 20.59%) with a significant difference (P = .026).These findings indicate that transprepancreatic septotomy with pancreatic duct stent seems to be a safe and feasible operation with reducing complication rates.

Increased rate of abdominal surgery both before and after diagnosis of celiac disease

BACKGROUND

The detection of celiac disease (CD) is suboptimal.

AIMS

We hypothesized that misdiagnosis is leading to diagnostic delays, and examine this assertion by determining if patients have increased risk of abdominal surgery before CD diagnosis.

METHODS

Through biopsy reports from Sweden's 28 pathology departments we identified all individuals with CD (Marsh stage 3; n=29,096). Using hospital-based data on inpatient and outpatient surgery recorded in the Swedish Patient Register, we compared abdominal surgery (appendectomy, laparotomy, biliary tract surgery, and uterine surgery) with that in 144,522 controls matched for age, sex, county and calendar year. Conditional logistic regression estimated odds ratios (ORs).

RESULTS

4064 (14.0%) individuals with CD and 15,760 (10.9%) controls had a record of earlier abdominal surgery (OR=1.36, 95% CI=1.31-1.42). Risk estimates were highest in the first year after surgery (OR=2.00; 95% CI=1.79-2.22). Appendectomy, laparotomy, biliary tract surgery, and uterine surgery were all associated with having a later CD diagnosis. Of note, abdominal surgery was also more common after CD diagnosis (hazard ratio=1.34; 95% CI=1.29-1.39).

CONCLUSIONS

There is an increased risk of abdominal surgery both before and after CD diagnosis. Surgical complications associated with CD may best explain these outcomes. Medical nihilism and lack of CD awareness may be contributing to outcomes.

Internal transfistulary drainage for intrabiliary rupture of hydatid cyst of the liver: Analysis of the indications and the results. Report of 50 cases

BACKGROUND

The rupture of hydatid cyst of the liver into the biliary tracts through a large fistula is one of the most difficult complications to treat. The techniques are various and each has its own morbidity. Internal transfistulary drainage is a surgical method of treatment of hydatid cysts of the liver opening in the biliary tract.

AIMS

The aim of this study was to identify the risk factors of specific postoperative complications of this surgical technique Methods: During the period's study, 823 patients with liver hydatid cyst were operated. 86 (11 %) of them were opened in the bile ducts through a large fistula. 50 patients (58 %) had internal transfistulary drainage.

RESULTS

The sex ratio was 1.6. The population was young with an average age of 40.8 years. The most frequent clinical feature of the opening in the biliary tract was acute cholangitis (42 %). The most common location of hydatid cyst was at the hepatic dome. The pericyst was flexible in only 62 % of cases. Thick pericysts were made flexible in 20% of cases and partly resection of protruding dome was made in 36 % of cases. Specific morbidity rate was 16% with no mortality. The uni and multivariate analysis had identified as risk factors for specific complications: the thick pericyst (P = 0.04), a size of the residual cavity ≥ 9cm; non visualization of the residual cavity on the post operative cholangiography was of borderline statistical significance (P = 0.049).

CONCLUSION

The internal transfistulary drainage is an easy and reliable surgical technique, its morbidity is low. It's indicated in the cases of large fistula with a thin pericyst and a diameter of the residual cavity less than 09 cm. Making thick pericyst flexible is a false security for the indication of internal transfistulary drainage and the non visualization of the residual cavity on the post operative cholangiography impose more frequent control for these patients since they are at risk of complications.

Management of choledochal cysts and their complications

Choledochal cysts are increasingly reported in adults. The presence of cyst-related complications alters its presentation and complicates the management. We reviewed our experience to find the clinical presentation, complications, and the management of choledochal cysts. The records of 132 patients with choledochal cysts presented to us between 2003 and 2010 maintained as a prospective database were analyzed for demography, clinical presentation, radiological investigation, management, and outcome. There were 12 children and 120 adults. Based on preoperative cholangiogram, 93 (71%) patients had Type I and 39 (29%) Type IVA cysts. The overall incidence of complicated choledochal cyst was 4 of 12 (33%) in children and 85 of 120 (71%) in adults. The most common complication was cystolithiasis (49%) followed by cholangitis (32%), acute pancreatitis (10%), hepatolithiasis (7%), malignancy (3%), portal hypertension (2%), and chronic pancreatitis (2%). Acute pancreatitis and cholangitis were managed conservatively. Endoscopic stenting was performed in patients with cholangitis and those requiring staged treatment as a result of portal hypertension. Overall 114 patients underwent cyst excision with Roux-en-y hepaticojejunostomy. The overall morbidity was 17.5 per cent (wound infection 13% and bilioenteric anastomotic leak 7%). There was one postoperative death resulting from cardiac failure. Three patients developed anastomotic stricture and underwent redo hepaticojejunostomy. Choledochal cysts in adults are often associated with complications. Complications are more common in adults compared with children. Acute pancreatitis, cholangitis and portal hypertension are managed conservatively and then followed up by definitive surgery. Cyst excision with Roux-en-Y hepaticojejunostomy is necessary to prevent the recurrence of complications.

Positive serum hepatitis B e antigen is associated with higher risk of early recurrence and poorer survival in patients after curative resection of hepatitis B-related hepatocellular carcinoma

BACKGROUND/AIMS

To study the impact of hepatitis B e antigen on tumor recurrence and patients' survival after curative resection of hepatocellular carcinoma.

METHODS

Two hundred and three patients with small hepatocellular carcinomas (3cm) who had undergone curative resection were divided into HBeAg-positive group and HBeAg-negative group. Clinicopathological factors and postoperative outcomes were compared between groups, and risk factors for survival and recurrence were studied.

RESULTS

The median follow-up time was 32.9months. Patients with negative HBeAg had higher 5-year overall survival rates (76% vs 53.9%, hazards ratio (HR): 2.363, 95% CI: 1.335-4.181, p=0.002) and 5-year disease-free survival rates (52.9% vs 37.4%, HR: 1.603, 95% CI: 1.00-2.561, p=0.046). There was no significant difference in operative morbidity and tumor factors between the two groups, but younger age, higher serum alanine aminotransferase levels, and more macronodular cirrhosis were found in the HBeAg-positive group. Multivariate analysis revealed that age >50years, HBeAg positivity and macronodular cirrhosis were independent factors for overall survival, and HBeAg positivity and multiple tumor nodules were independent factors for disease-free survival. Positive serum HBeAg was associated with a higher risk of early recurrence (within 1year).

CONCLUSIONS

HBeAg is associated with a higher risk of early recurrence and poorer survival in patients after curative resection of small HCC.

Resection of hepatocellular adenoma in patients with glycogen storage disease type Ia

BACKGROUND/AIMS

Because dietary modifications have prolonged the life expectancy of patients with glycogen storage disease type Ia (GSD Ia), the incidence of hepatocellular adenoma (HCA) to carcinoma (HCC) transformation is increasing. The objective of this retrospective study is to assess the safety and effectiveness of HCA resection in GSD Ia patients.

METHODS

Clinicopathologic, peri-operative, and long-term data were reviewed from patients who underwent HCA resection. Comparisons were made with Fisher's exact, Mann-Whitney U, and log-rank tests; survival was estimated with Kaplan-Meier analysis.

RESULTS

From 1998 to 2006, 38 patients underwent HCA resection. Seven (22%) had GSD Ia. Post-operative mortality occurred in one GSD Ia patient. GSD Ia patients had greater morbidity (86% vs. 20%) and shorter time to adenoma progression (median 23 months vs. not yet reached) after partial hepatectomy compared to the general population (p<0.05). Six GSD Ia patients had no evidence of HCC and recovered after resection without long-term morbidity. Three GSD Ia patients underwent liver transplantation 77, 32, and 23 months after adenoma resection.

CONCLUSIONS

Despite substantial morbidity, partial hepatectomy is feasible in GSD Ia patients and is an effective intermediate step in the prevention of HCC until definitive treatment with liver transplantation.

[Access to the biliary tract through trans-pancreatic sphincterotomy]

OBJECTIVE

Several pre-cut procedures have been used in patients with inaccessible bile ducts. Trans-pancreatic sphincterotomy (TS) has been demonstrated to be a valid, but little used technique. We describe our experience with TS with a prospective analysis of its results.

PATIENTS AND METHODS

Twenty patients who underwent TS due to the impossibility of cannulating the biliary tract using routine methods between November 2004 and October 2005 were included. CT-25 sphincteromes (Cook) were used, introducing the tip into the common bile duct or pancreatic duct, performing the cut toward the bile duct, and sectioning the roof of the common bile duct.

RESULTS

We performed 298 ERCP, 176 sphincterotomies and 20 TS (11.3% of sphincterotomies). Cannulation was achieved in 90% of the patients overall and immediate cannulation was achieved in 85%. The percentage of complications was 15% and none were severe. There were no cases of post-ERCP pancreatitis or mortality due to complications.

CONCLUSIONS

TS is an effective technique in gaining immediate access to the biliary tract in a high percentage of patients when access cannot be obtained using routine methods. The risk of complications in not higher than that of other pre-cut techniques.

Technical complications are rising as common duct exploration is becoming rare

BACKGROUND

Both hospital and surgeon volume influence outcomes. With introduction of new technologies, some procedures are now performed less frequently. ERCP has replaced the need for common duct exploration (CDE) in most cases of choledocholithiasis. We explored the secular trends and outcomes of CDE and how they have changed relative to introduction of ERCP.

STUDY DESIGN

The National Hospital Discharge Survey database was analyzed for the years 1979 to 2001. Procedural frequency of ERCP and CDE was determined. Charlson and Elixhauser comorbidity indices were used to characterize patients' disease burden for the years 1993 to 2001. Length of stay, mortality, and complication rates for each procedure were determined.

RESULTS

At the beginning of the study period, an estimated 47,000 CDEs were performed annually. These declined to 7,700 per year as ERCP increased to 42,500 procedures per year at the end of the study period. CDE complication rates increased from 3.4% to 17.4% over the same period. Comorbidity analysis for the years 1993 to 2001 revealed that ERCP and CDE patients had equivalent disease burdens. Technical complication rates rose in parallel to the increased overall CDE complication rate.

CONCLUSIONS

ERCP has replaced the need for most but not all CDE. With diminished CDE experience at a national level, the complication rate has markedly increased, at least in part from technical complications. Both choledocholithiasis treatment algorithms and clinical training paradigms need to account for the rarity of CDE and high complication rates associated with it, by incorporation of training modules in surgical residencies and advocating referral to centers having expertise in biliary tract operations from surgeons with little CDE experience.

Bile duct injury during cholecystectomy and survival in medicare beneficiaries

CONTEXT

Common bile duct (CBD) injury during cholecystectomy is a significant source of patient morbidity, but its impact on survival is unclear.

OBJECTIVE

To demonstrate the relation between CBD injury and survival and to identify the factors associated with improved survival among Medicare beneficiaries.

DESIGN, SETTING, AND PATIENTS

Retrospective study using Medicare National Claims History Part B data (January 1, 1992, through December 31, 1999) linked to death records and to the American Medical Association's (AMA's) Physician Masterfile. Records with a procedure code for cholecystectomy were reviewed and those with an additional procedure code for repair of the CBD within 365 days were defined as having a CBD injury.

MAIN OUTCOME MEASURE

Survival after cholecystectomy, controlling for patient (sex, age, comorbidity index, disease severity) and surgeon (procedure year, case order, surgeon specialty) characteristics.

RESULTS

Of the 1 570 361 patients identified as having had a cholecystectomy (62.9% women), 7911 patients (0.5%) had CBD injuries. The entire population had a mean (SD) age of 71.4 (10.2) years. Thirty-three percent of all patients died within the 9.2-year follow-up period (median survival, 5.6 years; interquartile range, 3.2-7.4 years), with 55.2% of patients without and 19.5% with a CBD injury remained alive. The adjusted hazard ratio (HR) for death during the follow-up period was significantly higher (2.79; 95% confidence interval [CI]; 2.71-2.88) for patients with a CBD injury than those without CBD injury. The hazard significantly increased with advancing age and comorbidities and decreased with the experience of the repairing surgeon. The adjusted hazard of death during the follow-up period was 11% greater (HR, 1.11; 95% CI, 1.02-1.20) if the repairing surgeon was the same as the injuring surgeon.

CONCLUSIONS

The association between CBD injury during cholecystectomy and survival among Medicare beneficiaries is stronger than suggested by previous reports. Referring patients with CBD injuries to surgeons or institutions with greater experience in CBD repair may represent a system-level opportunity to improve outcome.

Noncardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study follow-up (HERS II)

CONTEXT

The Heart and Estrogen/progestin Replacement Study (HERS) was a randomized trial of estrogen plus progestin therapy after menopause.

OBJECTIVE

To examine the effect of long-term postmenopausal hormone therapy on common noncardiovascular disease outcomes.

DESIGN AND SETTING

Randomized, blinded, placebo-controlled trial of 4.1 years' duration (HERS) and subsequent open-label observational follow-up for 2.7 years (HERS II), carried out between 1993 and 2000 in outpatient and community settings at 20 US clinical centers.

PARTICIPANTS

A total of 2763 postmenopausal women with coronary disease and average age of 67 years at enrollment in HERS; 2321 women (93% of those surviving) consented to follow-up in HERS II.

INTERVENTION

Participants were randomly assigned to receive 0.625 mg/d of conjugated estrogens plus 2.5 mg of medroxyprogesterone acetate (n = 1380) or placebo (n = 1383) during HERS; open-label hormone therapy was prescribed at personal physicians' discretion during HERS II. The proportions with at least 80% adherence to hormones declined from 81% (year 1) to 45% (year 6) in the hormone group and increased from 0% (year 1) to 8% (year 6) in the placebo group.

MAIN OUTCOME MEASURES

Thromboembolic events, biliary tract surgery, cancer, fracture, and total mortality.

RESULTS

Comparing women assigned to hormone therapy with those assigned to placebo, the unadjusted intention-to-treat relative hazard (RH) for venous thromboembolism declined from 2.66 (95% confidence interval [CI], 1.41-5.04) during HERS to 1.40 (95% CI, 0.64-3.05) during HERS II (P for time trend =.08); it was 2.08 overall for the 6.8 years (95% CI, 1.28-3.40), and 3 of the 73 women with thromboembolism died within 30 days due to pulmonary embolism. The overall RH for biliary tract surgery was 1.48 (95% CI, 1.12-1.95); for any cancer, 1.19 (95% CI, 0.95-1.50); and for any fracture, 1.04 (95% CI, 0.87-1.25). There were 261 deaths among those assigned to hormone therapy and 239 among those assigned to placebo (RH, 1.10; 95% CI, 0.92-1.31). Adjusted and as-treated analyses did not alter our conclusions.

CONCLUSIONS

Treatment for 6.8 years with estrogen plus progestin in older women with coronary disease increased the rates of venous thromboembolism and biliary tract surgery. Trends in other disease outcomes were not favorable and should be assessed in larger trials and in broader populations.

Operations for extrahepatic bile duct cancers: are the results really improving?

OBJECTIVE

To find out if our results for the treatment of extrahepatic bile duct cancer have improved we reviewed our latest patients as a comparison to a previously reported series from this department.

DESIGN

Retrospective study.

SETTING

Tertiary referral centre, Sweden.

SUBJECTS

102 patients who presented with extrahepatic bile duct cancer 1979-1995.

MAIN OUTCOME MEASURES

Morbidity, mortality, and short and long term survival.

RESULTS

16 patients had various types of resection, which were radical in 14 according to the surgeon and in 10 according to the pathologist. One patient (6%) died in hospital, and 1 (44%) developed complications. 13 patients had other operations that did not involve resection, 23 had laparotomy alone, 61 had biliary drainage either by percutaneous transhepatic cholangiography (PTC) or endoscopy, and 10 had no active treatment. One patient of the 16 (6%) who had resections has survived for more than five years and another one is still alive after 40 months.

CONCLUSION

Long term survival has not improved for patients with extrahepatic bile duct cancer in our hospital during the last decades.

Major HPB procedures must be undertaken in high volume quaternary centres?

BACKGROUND

Reports of better results at national referral centers than at low-volume community hospitals have prompted calls for regionalizing pancreaticoduodenectomy (the Whipple procedure). We examined the relationship between hospital volume and mortality with this procedure across all US hospitals.

METHODS

Using information from the Medicare claims database, we performed a national cohort study of 7,229 Medicare patients more than 65 years old undergoing pancreaticoduodenectomy between 1992 and 1995. We divided the study population into approximate quartiles according to the hospital's average annual volume of pancreaticoduodenectomies in Medicare patients: very low (<1/y), low (1-2/y), medium (2-5/y), and high (5+/y). Using multivariate logistic regression to account for potentially confounding patient characteristics, we examined the association between institutional volume and in-hospital mortality, our primary outcome measure.

RESULTS

More than 50% of Medicare patients undergoing pancreaticoduodenectomy received care at hospitals performing fewer than 2 such procedures per year. In-hospital mortality rates at these low- and very-low-volume hospitals were 3- to 4-fold higher than at high-volume hospitals (12% and 16%, respectively, vs. 4%, P<.001). Within the high-volume quartile, the 10 hospitals with the nation's highest volumes had lower mortality rates than the remaining high-volume centers (2.1% vs. 6.2%, P<.01). The strong association between institutional volume and mortality could not be attributed to patient case-mix differences or referral bias.

CONCLUSIONS

Although volume-outcome relationships have been reported for many complex surgical procedures, hospital experience is particularly important with pancreaticoduodenectomy. Patients considering this procedure should be given the option of care at a high-volume referral center.

Prospective study of gastric outlet obstruction in unresectable periampullary adenocarcinoma

Controversy persists regarding the role of prophylactic gastrojejunostomy in patients with unresectable periampullary adenocarcinoma. In review of the retrospective series, presence of gastric outlet obstruction (GOO) has been claimed to be a bad prognostic sign. This prospective study aimed to clarify the necessity of routine prophylactic gastrojejunostomy in patients with unresectable periampullary adenocarcinoma. The incidence and prognostic significance of GOO were also evaluated. Sixty-six patients with unresectable periampullary adenocarcinoma were enrolled. They were divided into 2 groups to receive either a single biliary bypass or a double bypass (concomitant gastric and biliary bypasses) if they had GOO. The single bypass group was followed up to assess the incidence of GOO and subsequent need of a gastric bypass. Prognostic factors were evaluated by univariate and multivariate analyses. Forty-four (67%) of the overall 66 patients presented with GOO at the time of diagnosis. There was no statistical difference regarding the morbidity and mortality between the 2 groups, except longer (7 days) hospital stay in the double bypass group. Seven (31.8%) of the 22 patients in the single bypass group subsequently developed GOO an average of 6.2 +/- 1.0 months after their initial biliary bypass. By univariate analysis, significant prognostic factors for unresectable periampullary adenocarcinoma were: GOO (p = 0.0379), pancreatic head origin (p = 0. 0146 by univariate analysis), and distant metastasis (p < 0.0001). After multivariate analysis, only pancreatic head origin and distant metastasis remained significant independent factors of poor prognosis. In conclusion, gastrojejunostomy should be performed prophylactically in addition to a biliary bypass in patients with unresectable periampullary adenocarcinoma. The presence of GOO is not an independent factor of poor prognosis, but a reflection of the aggressive biologic behavior of pancreatic head adenocarcinoma.

[Reoperations on the biliary system]

Reoperations of the biliary apparatus is a branch of biliary surgery still not well enough clarified and difficult to cope with. A total of 169 patients are subjected to operation and investigation in the clinic of abdominal surgery. In 71 of them reoperation is undertaken over the period 1952-1973, and in 97--in the period 1974 through 1993, representing 8.7 per cent of all biliary operations done for benign diseases of the biliary apparatus. In 95 per cent of cases the primary operation is related to cholelithiasis (ChL). One-hundred fifty-five cases (92.6 per cent) are reoperated once, nine (5.3 per cent)--twice, and four (0.7 per cent)--three, four and five times. What is more, 56 of the patients are operated in the clinic of abdominal surgery, and 112--elsewhere in surgical units and departments throughout the country. The severer clinical picture, prolonged postoperative period, increased operative risk and worsened prognosis in the latter group are underscored. The underlying causes necessitating secondary corrective intervention are analyzed--76 per cent are conditioned by ChL, and 24 per cent--by the primary operation. The indications for reoperation are classified in three groups: a) failure to remove or partially removed gallbladder, b) in case of preexisting primary, or secondary postoperative development of various forms of cholelithiasis, c) in surgery induced morbid conditions. A table is presented illustrating the character of secondary operations, performed in the series of 168 patients under study, namely: in 20 per cent the gallbladder is operated on, and in 80 per cent--the extrahepatic bile ducts. Postoperative morbidity is higher as compared to the one in primary operations and not infrequently it is conditioned by preexisting complications. Postoperative mortality rate amounts to 10 per cent.

[The quality of life of the geriatric patient after a surgical intervention. VI. Interventions on the biliary tract]

After reviewing the literature on this subject, the authors examine the quality of life of geriatric patients after biliary tract surgery secondary to biliary tract carcinoma or non-neoplastic pathologies. From an analysis of the results the authors conclude that surgery is useful not only in non-neoplastic forms, but also in the event of carcinoma given that it is possible to improve the quality of life of these patients.

Conventional treatment of biliary atresia: long-term results

From 1968 to 1983, 271 patients were treated for biliary atresia by a group of surgeons from the same pediatric surgical unit, in Paris, using procedures adapted to the local anatomy and all derived from the Kasai technique. Eighty children have survived more than 10 years since the surgery, without the need for liver transplantation during the 10-year period. However, three children died subsequently from complications of the liver disease. Thirteen others later underwent liver transplantation, which accounted for three additional deaths. Thus, of the 64 patients left for study, 38 had a good result with respect to serum bilirubin level, but 18 of them still have symptoms of portal hypertension. Among another group of 14 patients with serum bilirubin levels between 18 and 36 mumol/L, 11 are leading a near-normal life. The mean follow-up period for this study is 14 years; the oldest patient is aged 24 years. One patient, already the mother of a normal son, is awaiting her second baby; she was treated by portocholecystostomy at 2 months of age. As a rule, liver transplantation should not be considered an alternative to the Kasai operation as initial treatment of biliary atresia. It may be the only form of treatment for survivors without jaundice, if survival becomes compromised by complications owing to portal hypertension or pulmonary shunts.

[The surgical and alternative treatment potentials in biliary tract cancer. I. Surgical treatment]

Biliary apparatus cancer is a rare condition characterized by low operability percentage. This is a comparative study of two series of patients, operated during the periods 1952-1979 and 1980-1994. In the first observation period (28 years) 119 patients are operated, and in the second 13-year period a total of 206 patients are subjected to operative and endoscopic treatment. One-hundred five patients present gallbladder carcinoma. The age, gender and clinical patterns characterizing the contingent being examined do not show noteworthy changes with time. Over the past few years, a variety of palliative operations are used, with the proportion of cases subjected to radical operation showing no increase. Carcinoma of bile ducts is diagnosed in 98 patients. During the second observation period, the number of women and patients in advanced and senile age augment. The diagnosis is delayed; thanks to puncture biopsy with cytological study, histological verification shows a three-fold increase. The number of radical operations is slightly increased while the percentage of explorative laparotomies is noticeably diminished. Carcinoma of papilla Vateri has optimal outlooks for surgical treatment. In the latter case too the number of women and patients above 60 years of age shows an increase. Radical intervention is resorted to in fourteen out of 33 patients.

Biliary anastomosis after liver transplantation does not benefit from T tube splintage

T tubes are commonly used to splint biliary anastomoses after liver transplantation. Although several advantages are claimed for this approach, there is undoubtedly some iatrogenic morbidity associated with the use of T tubes in this situation. We have evaluated 120 consecutive biliary reconstructions after liver transplant, the majority of which were unsplinted end to end bile duct anastomoses. We have shown that biliary leakage and stricture rates are not significantly affected by T tubes. We have also shown that endoscopic retrograde cholangiopancreatography and percutaneous cholangiography are reliable posttransplant methods for cholangiography and stricture dilatation. Routine T tube splintage of post-liver transplant biliary anastomoses is unjustified.

[Extrahepatic biliary lesions in abdominal traumatism]

The extrahepatic biliary tree traumatisms are rare and hard to diagnose; 15 of 864 patients with surgery treatment for abdominal trauma for over 19 years (1974-1992) were studied retrospectively. Twelve blunt abdominal traumas (9 traffic accident and 3 falls down) and 3 open traumas (stabbing in two and gunshot wounds in one case). Eleven had gallbladder injury, two gallbladder and biliary duct and two exclusively biliary duct. Only one case was an isolated lesion, in the rest of cases, intra or extra abdominal lesions, occasionally both, were seen. The diagnostic method, associated lesions, morbi-mortality are reviewed. Surgical treatment was cholecystectomy for gallbladder injury and direct suture with T-tube (Kehr) for biliary duct injury.

[Biliary surgery and cholescintigraphy with iminodiacetic acid (IDA) analogs. An evaluation of the results and the complications]

Hepatobiliary scintigraphy with analogs of iminodiacetic acid (IDA) has become one of the primary tools in the diagnosis of biliary tract diseases, especially in the evaluation of surgical results and detection of complications that may arise from biliary operative procedures. We have performed cholescintigraphy in 19 patients. Of them, 9 underwent choledochojejunostomy with Roux-en-Y reconstruction for recurrent choledocholithiasis, 1 underwent right hepatic resection for metastasis extirpation, 8 were post cholecystectomy patients effected with upper abdominal pain located either in the epigastric region or right upper quadrant referable to post cholecystectomy syndrome and the last exhibited chronic pancreatitis ans suspicious sphincter of Oddi stenosis. The scintigraphy data were compared with the information yielded by sonography, intravenous cholangiogram (IVC) and, when possible, by endoscopic retrograde cholangiopancreatography (ERCP). Scans were considered pathologic when one or more of the following criteria were present: a) delayed biliary to bowel transit (greater than 1 hr), b) abnormal time-activity dynamic, c) no intestinal activity (obstruction), d) apparent ductal dilatation. In the group of biliary-enteric anastomosed patients, cholescintigraphic findings have shown 3 normal cases, 3 cases of biliary-intestinal obstruction confirmed by surgery, and 3 with abnormal activity retention in the jejunum loop due, in 2 patients, to hypokinesia since the quick emptying following the administration of 10 mg i.v. of metoclopramide, while in the other one, the surgery reexploration exhibited the presence of adhesions producing intestinal stricture. in the last patient of this group, the cholescintigraphy was performed to detect possible biliary leaks. In the post cholecystectomy patients, the cholescintigraphy exhibited in 3 cases dilated common duct with functional patency since the normal biliary-bowel transit time (less than 1 hr); this was confirmed by sonogram and IVC.(ABSTRACT TRUNCATED AT 250 WORDS)

[Relaparotomy: the indications, procedure and results]

Based on an analysis of 284 observations amounting to 1.8% of the total number of operations on organs of the abdominal cavity the authors give more exact indications to early relaparotomy and to more optimal methods to eliminate complications appearing after primary operations. They recommend wider use of additional methods of diagnosis of postoperative complications which will result in less lethality after relaparotomies.

[Biliodigestive anastomoses on echography. The normal and pathological aspects]

The normal and pathological US features of different types of bilioenterostomy (hepaticojejunostomy, choledochoduodenostomy, polyductal bilioenteric anastomosis) are described, as observed in a prospective study of 27 patients, for a total number of 35 (18 normal and 17 abnormal) examinations. For 20 patients with hepaticojejunostomy, the bilioenteric anastomosis was identified on 13/13 normal examinations and 10/12 pathological examinations. For 2 patients with choledochoduodenostomy, the bilioenteric anastomosis was identified on 2/2 examinations. For 5 patients with polyductal bilioenteric anastomosis (each patient having 2 or 3 anastomoses), all surgical anastomoses were separately identified on 6/8 examinations; as for the remaining 2 patients, 2/3 and 1/3 anastomoses were seen. An abnormal condition was correctly recognized in all the 11 patients with local disease (lithiasis and benign biliary stricture, 2 patients; benign biliary stricture, 5 patients; primary cholangiocarcinoma, 1 patient; recurrent malignancy, 3 patients); in 1 patient, parenchymal and biliary abnormalities due to vascular obstruction were misinterpreted as a result of benign stricture. US can demonstrate the surgical anastomoses between the resected common bile duct or second order intrahepatic ducts and the jejunal loop, with typical features according to the type of surgery performed. Knowledge of such normal appearances after bilioenteric surgery is mandatory in order to detect and correctly evaluate such possible abnormalities at this site as lithiasis and benign or malignant strictures.

[Biliary tract surgery in patients of 70 and older: an assessment of our experience with 100 consecutive cases]

A series of 100 consecutive patients aged 70 years and older having biliary tract lithiasis observed over a 19-year period (1970-1989) at the 1st Surgical Department of the University of Rome was analyzed in an effort to define morbidity and mortality. Eighty-eight patients underwent surgical treatment. Three patients died postoperatively (3.4%); 12 patients had local and 13 general complications. The highest incidence of complications occurred in patients with associated diseases and bacteriobilia. A long-lasting symptomatology involved a more frequent exploration of the common bile duct. Morbidity and mortality were not significantly related to the type of surgical procedure performed. Elective biliary tract surgery is a safe procedure even in aged patients.

[Biliary surgery on those over 70: an analysis of 109 cases]

109 patients older than seventy years of age and operated of gallstone disease in our service during a period of 4.5 years are presented. The average age of the series was 78.8 years, with a male/female (M/F) ratio of 1/1.6. 77% of the patients were admitted on an emergency basis due to a complication derived from the gallstone disease they were suffering. Only 39.8% of the patients were previously diagnosed of gallstone disease at the time of admission and 10% presented an associated surgical condition which was treated simultaneously. Overall morbidity of the series was 36%, with a mortality of 2 cases (1.9%).