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Clinicopathological characteristics and surgical procedures for carcinoma of the papilla of vater
April 1 9 9 5
• CLINICOPATHOLOGICAL CHARACTERISTICS AND SURGICAL PROCEDURES FOR CARCINOMA OF THE PAPILLA OF VATER. W. Kimura, Y. Wada, N. Futakawa, T. Muto. First Department of Surgery, the University of Tokyo, Japan [Aim] To study clinicopathological characteristics of carcinoma of the papilla of Vater and suitable surgical procedures. [Materials and Methods] Sixty cases of resected carcinoma of the papilla of Vater were studied clinicopathologically. After pancreatoduodenectomy or local resection of the tumor, the specimens were fixed in 10% formalin and the gross appearance of the tumor was studied. The tumor was also embedded in paraffin, cut into 4 urn-thick sections, stained with hematoxylin and eosin, and studied histologically. [Results] Among the 40 male and 20 female patients, a polypoid type without ulceration and an ulcer-formation type, with regard to the gross appearance, were found in 37 cases and 23 cases, respectively. Submucosal invasion, invasion to the sphincter Oddi, pancreatic parenchymal invasion and lymph node involvement were found more frequenUy in the ulcer-formation type than in the polypoid type without ulceration. Postoperative survival curves revealed that the prognosis was poor when either lymph node involvement, invasion to pancreatic parenchyma or ulcer formation was found. Local resection was performed in seven cases, in all of whom carcinoma was found histologically in the cut surface of the tumor. This is easily explained by the fact that mucosal spread or interstitial infiltration was frequently found even in cases with carcinoma at a relatively early stage. However, there were no differences between the postoperative survival curves of patients who underwent pancreatoduodenectomy or local resection. [Conclusion] Local resection for carcinoma of the papilla of Vater is inadequate as a curative resection of the carcinoma, and pylorus-preserving pancreatoduodenectomy should be the treatment of choice for carcinoma of the papilla of Vater. However, local resection may still be suitable for patients with other major diseases or a poor condition.
EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY FOR RETAINED BILE DUCT STONES. J, Knuchel, U. Meierhofer, J. Altorfer, H. Buehler, R. Muench, F. Lammer, M. Fried, Ch. Meyenberger. Dept. of Medicine, Division of Gastroenterology, University Hospital, CH-8091 Ziirich, Switzerland. About 5 to 10% of bile duct stones are not amenable to routine endoscopic measures. The aim of the present study was to evaluate the efficacy of extracorporenl shock wave lithotripsy (ESWL) in patients in whom endoscopic treatment had failed. Patients and methods: 54 consecutive patients (32f, 22m, age 74y, range 33 - 92) with retained bile duct stones were treated by ESWL and retrospectively analysed. Endoscopic measures had failed because of stone size (n=24), bile duct stenosis (n=15), stone incarceration (n=10), intrahepatic location of stones (n=3) and anatomical reasons (n=2). 30 patients had solitary and 24 patients had multiple stones, the mean stone size was 23_+13mm.53/54 patients had an endoscopic (n=51) or a surgical transduedenal sphincterotomy (n=2), 52/54 patients received a biliary drainage (nasobiliary tube n=35, postsurgical drain n=l 1, pereutanenusly placed transhepatic catheter n--4, biliary endoprosthesis n=2). ESWL was performed either under fluoroscopic (Domier HM3; patients n=49, treatments n=56) or ultrasonographie (Domier MPL 9000; patients n=5, treatments n=8) control in peridural anesthesia (n=46), general anesthesia (n=ll) or i.v. sedoanalgesia (n=7). ESWL was considered suecessfull if repeated cholangiography revealed complete stone clearance from the biliary tree. Results: Stone disintegration was achieved in 50 patients (92.5%). Complete stone clearance from the bile ducts was obtained in 40 patients (74.1%) aider one and in 45 patients (83.3%) after one ore more shock wave treatments either by spontaneous passage (n=8), endoscopic extraction (n=36) or insertion of a wallstent into a hepaticojejunostomy stenosis (n=l). ESWL failed in 9 patients (16.7%). Severe complications occurred in 5 patients (9%; eholangiosepsis n=3, aspiration pneumonia n=l, pulmonary embolism n=l), 1 patient died of cholangiosepsis with multiple liver abscesses (mortality rate=l.9%). The mean stone size where the ESWL failed was 27.8+8mm versus 20_+9ram in patients with complete stone clearance after the first session (p<0.05). Intrahepatic location of stones was significantly associated with treatment failure (p<0.005). The number or incarceration of stones or the presence of bile duct stenosis had no significant influence on the success rate. Conclusions: ESWL is a safe and efficient treatment of bile duet stones not amenable to routine endoscopic measures. Stone size and intrahapatie location of stones had a significant influence on the success rate, whereas the number or incarceration of stones or the presence of bile duct stennsis did not influence the outcome.
Biliary Disorders
A421
REPEATED VERSUS SINGLE ELECTROHYDRAULIC SHOCK WAVE THERAPY FOR PATIENTS WITH MULTIPLE GALLBLADDER STONES: A RANDOMIZED TRIAL. U,G. F:lueODelberg, P. Schmitt, M. Sackmann, J. Holl, C. v. Ritter, J. Pauletzki, G. Sauter, T. Sauerbruch, G. Paumgartner. Dept. Medicine II, University Hospital Grosshadern, Munich, Germany.
Extracorporeal shock wave lithotripsy (ESWL) with adjuvant bile acid dissolution is a well-established noninvasive therapy for selected patients with radiolucent gallbladder stones. Results have been disappointing in patients with multiple stones. Repeated lithotripsy may improve stone disintegration thereby enhancing clearance of fragments. Thus, we conducted a randomized study to evaluate the efficacy of repeated versus single lithotripsy in patients with multiple (2-10) stones. Methods: Patients (n=48) with 2-10 stones occupying -<30% of fasting gallbladder volume and gallbladder contraction _>30% in response to a standard meal were randomly assigned to either a single session of ESWL (electrohydraulic lithotripter, Dornier MPL 9000; group A, n=24:>_1600 discharges, >_21 kV) or up to five sessions (group B, n=24: first session as in group A, sessions 2 to 5 in weekly intervals _<20kV, _<1200 pulses). All patients received adjuvant ursedeoxycholic acid (UDCA 10-12mg/kg body weight per day). The primary endpoint was the stone free rate at six months after the first ESWL. Results: Maximum stone diameter (11 mm/14 mm respectively) and number (4/3)), age, gender, and follow-up time were well matched. Number (1600/1600), energy (24/24 kV) of shock waves applied in the first session, and size of the largest fragment (3.5/3.5 ram) after the first ESWL was similar in both groups (median, group A and B, respectively). In group B a mean of additional 2144 shock waves were applied. The stone free rate at six months was higher after repeated (43%) than after single ESWL (9%) (p=0.007). Complications included transient cholestasis (1 patient in group A), and acute cholecystitis requiring cholecystectomy (1 patient in group B). The frequency of post-treatment biliary pain (29%/21%)was comparable in both groups. Conclusions: In patients with multiple gallbladder stones, the efficacy of ESWL combined with UDCA can be increased by repeated lithotfipsy sessions. Thus, patients with multiple stones may be regarded suitable for this non-invasive regimen, provided that multiple sessions are applied,
• CHANGES IN DNA SYNTHESIS, ADENINE NUCLEOTIDES AND L I P O P E R O X I D E IN THE LIVER DURING THE OBSTRUCTIVE JAUNDICE IN RATS M.Komura, N.Kameoka, K.Chijiiwa, Department of Surgery I, Kyushu University Faculty of Medicine, Fukuoka, Japan Postoperative morbidity and mortality are still high in patients with obstructive jaundice in spite of the advances of surgical technique and perioperative care. Therefore, it is indispensable to clarify the limits of hepatic compensatory capacity under the condition of obstructive jaundice. In this study, we investigated the influences of obstructive jaundice on fiver metabolism and regeneration. [Methods] The common bile ducts were ligated and divided, and the changes of DNA synthesis, malonediatdehyde (MDA), total adenine nucieotides, energy charge (EC), DNA and protein concentrations in the liver and arterial ketone bodies were determined before and on days I. 2, 4, 7 and 14 after surgery in the jaundiced and shamoperated rats. DNA synthesis was measured by the incorporation of intraperitoneally injected [3H]thymidine into DNA, and adenine nueleotides was measured by high performance liquid chromatography. MDA was measured as lipoperoxide by toe thiobarbituric acid reaction assay method. EC was calculated according to the following formula : EC=(ATP+I/2ADP)/ (ATP+ADP+AMP). [Results] In accordance with the prolongation of jaundice, the level of hepatic MDA concentration gradually increased and on day 14, it was significantly higher in the jaundiced group than the shamoperated group. The levels of ATP and EC in the jaundiced liver began to decrease after surgery and on day 2, it was reduced significantly compared with that in the sham-operated group. The rate of incorporation of [3H]thymidine into hepatic cellular DNA in the jaundiced group was significantly higher compared with that in the sham-operated group up to 7 days after surgery. Even on I day in the jaundiced group, the rate of DNA synthesis significantly increased to more than 3 times of that in the shamoperated group. On day 2, DNA synthesis reached its maximal level and was more than 9 times higher compared with that in the sham-operated group. However, on day 14, the rate in the jaundiced group decreased to the control level. [Conclusions] Prolonged obstructive jaundice results in liver dysfunction by the evidences of decreased EC and increased MDA. Hepatic DNA synthesis is activated at an early phase of obstructive jaundice.
• CLINICOPATHOLOGICAL CHARACTERISTICS AND SURGICAL PROCEDURES FOR CARCINOMA OF THE PAPILLA OF VATER. W. Kimura, Y. Wada, N. Futakawa, T. Muto. First Department of Surgery, the University of Tokyo, Japan [Aim] To study clinicopathological characteristics of carcinoma of the papilla of Vater and suitable surgical procedures. [Materials and Methods] Sixty cases of resected carcinoma of the papilla of Vater were studied clinicopathologically. After pancreatoduodenectomy or local resection of the tumor, the specimens were fixed in 10% formalin and the gross appearance of the tumor was studied. The tumor was also embedded in paraffin, cut into 4 urn-thick sections, stained with hematoxylin and eosin, and studied histologically. [Results] Among the 40 male and 20 female patients, a polypoid type without ulceration and an ulcer-formation type, with regard to the gross appearance, were found in 37 cases and 23 cases, respectively. Submucosal invasion, invasion to the sphincter Oddi, pancreatic parenchymal invasion and lymph node involvement were found more frequenUy in the ulcer-formation type than in the polypoid type without ulceration. Postoperative survival curves revealed that the prognosis was poor when either lymph node involvement, invasion to pancreatic parenchyma or ulcer formation was found. Local resection was performed in seven cases, in all of whom carcinoma was found histologically in the cut surface of the tumor. This is easily explained by the fact that mucosal spread or interstitial infiltration was frequently found even in cases with carcinoma at a relatively early stage. However, there were no differences between the postoperative survival curves of patients who underwent pancreatoduodenectomy or local resection. [Conclusion] Local resection for carcinoma of the papilla of Vater is inadequate as a curative resection of the carcinoma, and pylorus-preserving pancreatoduodenectomy should be the treatment of choice for carcinoma of the papilla of Vater. However, local resection may still be suitable for patients with other major diseases or a poor condition.
EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY FOR RETAINED BILE DUCT STONES. J, Knuchel, U. Meierhofer, J. Altorfer, H. Buehler, R. Muench, F. Lammer, M. Fried, Ch. Meyenberger. Dept. of Medicine, Division of Gastroenterology, University Hospital, CH-8091 Ziirich, Switzerland. About 5 to 10% of bile duct stones are not amenable to routine endoscopic measures. The aim of the present study was to evaluate the efficacy of extracorporenl shock wave lithotripsy (ESWL) in patients in whom endoscopic treatment had failed. Patients and methods: 54 consecutive patients (32f, 22m, age 74y, range 33 - 92) with retained bile duct stones were treated by ESWL and retrospectively analysed. Endoscopic measures had failed because of stone size (n=24), bile duct stenosis (n=15), stone incarceration (n=10), intrahepatic location of stones (n=3) and anatomical reasons (n=2). 30 patients had solitary and 24 patients had multiple stones, the mean stone size was 23_+13mm.53/54 patients had an endoscopic (n=51) or a surgical transduedenal sphincterotomy (n=2), 52/54 patients received a biliary drainage (nasobiliary tube n=35, postsurgical drain n=l 1, pereutanenusly placed transhepatic catheter n--4, biliary endoprosthesis n=2). ESWL was performed either under fluoroscopic (Domier HM3; patients n=49, treatments n=56) or ultrasonographie (Domier MPL 9000; patients n=5, treatments n=8) control in peridural anesthesia (n=46), general anesthesia (n=ll) or i.v. sedoanalgesia (n=7). ESWL was considered suecessfull if repeated cholangiography revealed complete stone clearance from the biliary tree. Results: Stone disintegration was achieved in 50 patients (92.5%). Complete stone clearance from the bile ducts was obtained in 40 patients (74.1%) aider one and in 45 patients (83.3%) after one ore more shock wave treatments either by spontaneous passage (n=8), endoscopic extraction (n=36) or insertion of a wallstent into a hepaticojejunostomy stenosis (n=l). ESWL failed in 9 patients (16.7%). Severe complications occurred in 5 patients (9%; eholangiosepsis n=3, aspiration pneumonia n=l, pulmonary embolism n=l), 1 patient died of cholangiosepsis with multiple liver abscesses (mortality rate=l.9%). The mean stone size where the ESWL failed was 27.8+8mm versus 20_+9ram in patients with complete stone clearance after the first session (p<0.05). Intrahepatic location of stones was significantly associated with treatment failure (p<0.005). The number or incarceration of stones or the presence of bile duct stenosis had no significant influence on the success rate. Conclusions: ESWL is a safe and efficient treatment of bile duet stones not amenable to routine endoscopic measures. Stone size and intrahapatie location of stones had a significant influence on the success rate, whereas the number or incarceration of stones or the presence of bile duct stennsis did not influence the outcome.
Biliary Disorders
A421
REPEATED VERSUS SINGLE ELECTROHYDRAULIC SHOCK WAVE THERAPY FOR PATIENTS WITH MULTIPLE GALLBLADDER STONES: A RANDOMIZED TRIAL. U,G. F:lueODelberg, P. Schmitt, M. Sackmann, J. Holl, C. v. Ritter, J. Pauletzki, G. Sauter, T. Sauerbruch, G. Paumgartner. Dept. Medicine II, University Hospital Grosshadern, Munich, Germany.
Extracorporeal shock wave lithotripsy (ESWL) with adjuvant bile acid dissolution is a well-established noninvasive therapy for selected patients with radiolucent gallbladder stones. Results have been disappointing in patients with multiple stones. Repeated lithotripsy may improve stone disintegration thereby enhancing clearance of fragments. Thus, we conducted a randomized study to evaluate the efficacy of repeated versus single lithotripsy in patients with multiple (2-10) stones. Methods: Patients (n=48) with 2-10 stones occupying -<30% of fasting gallbladder volume and gallbladder contraction _>30% in response to a standard meal were randomly assigned to either a single session of ESWL (electrohydraulic lithotripter, Dornier MPL 9000; group A, n=24:>_1600 discharges, >_21 kV) or up to five sessions (group B, n=24: first session as in group A, sessions 2 to 5 in weekly intervals _<20kV, _<1200 pulses). All patients received adjuvant ursedeoxycholic acid (UDCA 10-12mg/kg body weight per day). The primary endpoint was the stone free rate at six months after the first ESWL. Results: Maximum stone diameter (11 mm/14 mm respectively) and number (4/3)), age, gender, and follow-up time were well matched. Number (1600/1600), energy (24/24 kV) of shock waves applied in the first session, and size of the largest fragment (3.5/3.5 ram) after the first ESWL was similar in both groups (median, group A and B, respectively). In group B a mean of additional 2144 shock waves were applied. The stone free rate at six months was higher after repeated (43%) than after single ESWL (9%) (p=0.007). Complications included transient cholestasis (1 patient in group A), and acute cholecystitis requiring cholecystectomy (1 patient in group B). The frequency of post-treatment biliary pain (29%/21%)was comparable in both groups. Conclusions: In patients with multiple gallbladder stones, the efficacy of ESWL combined with UDCA can be increased by repeated lithotfipsy sessions. Thus, patients with multiple stones may be regarded suitable for this non-invasive regimen, provided that multiple sessions are applied,
• CHANGES IN DNA SYNTHESIS, ADENINE NUCLEOTIDES AND L I P O P E R O X I D E IN THE LIVER DURING THE OBSTRUCTIVE JAUNDICE IN RATS M.Komura, N.Kameoka, K.Chijiiwa, Department of Surgery I, Kyushu University Faculty of Medicine, Fukuoka, Japan Postoperative morbidity and mortality are still high in patients with obstructive jaundice in spite of the advances of surgical technique and perioperative care. Therefore, it is indispensable to clarify the limits of hepatic compensatory capacity under the condition of obstructive jaundice. In this study, we investigated the influences of obstructive jaundice on fiver metabolism and regeneration. [Methods] The common bile ducts were ligated and divided, and the changes of DNA synthesis, malonediatdehyde (MDA), total adenine nucieotides, energy charge (EC), DNA and protein concentrations in the liver and arterial ketone bodies were determined before and on days I. 2, 4, 7 and 14 after surgery in the jaundiced and shamoperated rats. DNA synthesis was measured by the incorporation of intraperitoneally injected [3H]thymidine into DNA, and adenine nueleotides was measured by high performance liquid chromatography. MDA was measured as lipoperoxide by toe thiobarbituric acid reaction assay method. EC was calculated according to the following formula : EC=(ATP+I/2ADP)/ (ATP+ADP+AMP). [Results] In accordance with the prolongation of jaundice, the level of hepatic MDA concentration gradually increased and on day 14, it was significantly higher in the jaundiced group than the shamoperated group. The levels of ATP and EC in the jaundiced liver began to decrease after surgery and on day 2, it was reduced significantly compared with that in the sham-operated group. The rate of incorporation of [3H]thymidine into hepatic cellular DNA in the jaundiced group was significantly higher compared with that in the sham-operated group up to 7 days after surgery. Even on I day in the jaundiced group, the rate of DNA synthesis significantly increased to more than 3 times of that in the shamoperated group. On day 2, DNA synthesis reached its maximal level and was more than 9 times higher compared with that in the sham-operated group. However, on day 14, the rate in the jaundiced group decreased to the control level. [Conclusions] Prolonged obstructive jaundice results in liver dysfunction by the evidences of decreased EC and increased MDA. Hepatic DNA synthesis is activated at an early phase of obstructive jaundice.