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Congenital choledochal dilatation with emphasis on pathophysiology of the biliary tract
INTERNATIONAL
1479
ABSTRACTS
mucosally denuded colonic muscle were grafted with multiple free small bowel mucosal grafts of 4 to 10 mm diameter. Colonic mucosa can be removed along the submucosal plane without any colonic mucosal rests. None of the mucosally denuded colonic muscle surfaces regrew any colonic mucosa, and healing occurred essentially by contracture. The authors conclude that reported techniques for growing new small bowel mucosa, while interesting and stimulating in concept, are inadequate in their present form for clinical application.-Prem hlti
The type of choledochal dilatation correlates with the choledochopancreaticoductal junctional anatomy. The junctional anatomy, in association with a lack of normal junctional sphincteric pressures, may allow reflux of pancreatic juice into the biliary system and lead to changes causing choledochal cystic dilatationEdward G. Ford
Isolated Extrahepatic Bile Duct Injury: Diagnosis and Surgical Management. A. Krishna, D.B. Kaul, M.V. Murali, et al. Pediatr
Surg Int 7:143-145, (March), 1992. ABDOMEN Laparoscopic Cholecystectomy in Young Patients With Sickle Hemoglobinopathies. R.E. Ware, T.R. Kinney, J.R. Casey, et al. J
Pediatr 120:58-61, (January), 1992. Elective surgical management of cholelithiasis in patients with sickle hemoglobinopathies has been recommended to avoid the potential complications of cholecystitis and choledocholithiasis. Nine young patients with sickle hemoglobinopathies successfully underwent laparoscopic cholecystectomy. No complications resulted from the procedure. The mean postoperative hospital stay was 1.6 days. The technique appears to be safe and efficacious in these children-George Holcomb, Jr
The Technique of Laparoscopic Cholecystectomy in Children. A.M. Davidofi G.D. Branum, E.A. Murray, et al. Ann Surg 215:186-
191, (February), 1992. Twelve children, aged 8 to 19 years, underwent laparoscopic cholecystectomy for symptomatic cholelithiasis (hemolytic disorders 11, glycogen storage disease 1). The procedure is similar to that for adults with some exceptions. For small children with scaphoid abdomens a Hassan trocar was used under direct vision for increased safety. Maximal inflation pressures were 15 mm Hg. The small size of the abdominal cavity makes retraction of the gallbladder over the liver difficult. Therefore, the gallbladder is grasped closer to Calot’s triangle and retracted caudally. The authors report rapid recovery with discharge within 2 days. There were no complications and no conversions to open operation. The paper has several diagrams of trocar placement and intraoperative anatomy.-Edward G. Ford Congenital Choledochal Dilatation With Emphasis on Pathophysiology of the Biliary Tract. N. Iwai, J. Yanagihara, K. Tokiwa, et al. Ann Surg 215:27-30, (January), 1992.
Thirty-seven children, aged 8 days to 12 years, with choledochal cysts were evaluated by endoscopic retrograde cholanglopancreatography (ERCP) and underwent cystectomy with Roux-en-y hepaticojejunostomy. The common bile duct-pancreatic duct junction could clearly be identified in 26 patients (ERCP 16, operative cholangiogram 3. both 7). Findings were classified into three types; (1) C-P type, the pancreatic duct is the main duct and is joined by the common duct; (2) P-C type, the common duct is the main duct and joined by the pancreatic duct; (3) miscellaneous type, not clearly C-P or P-C. Biliary manometry was performed in 11 patients. An abnormal common duct-pancreatic duct junction was identified in 96% of patients. Ten of 12 with cystic dilatation had C-P type, 9 of 13 with fusiform dilatation had P-C type, and 1 patient had multicystic dilatation and miscellaneous type. All patients had markedly elevated amylase levels in the choledochal cyst. Choledochopancreaticoductal junction pressures were not different between the cyst types, but were lower than sphincter of Oddi pressures.
A 3-year-old boy, who presented with biliary ascites due to rupture at the confluence of right and left hepatic ducts, is reported. There was a history of trauma 29 days prior to admission. A technetium 99m-DISIDA isotope scan showed good hepatic uptake, pooling of radiotracer at the superolateral aspect of the right lobe of the liver, and nonvisualisation of extrahepatic biliary system. At operation, free and encysted bile was drained. The left and right hepatic ducts were mobilised and the distal biliary tree and gallbladder excised. An oblique-to-side anastomosis of the left and right hepatic ducts separately to a Roux-en-Y limb of jejunum was performed. At 1 year follow-up the results were good.-George Ninan
Embolization of Traumatic Hemobilia in a Child. P. de Lagausie, D. Pariente, F. Gauthier, et al. Pediatr Surg Int 7:61-63, (January),
1992. Posttraumatic hemobilia is an uncommon complication of liver trauma, especially in children. The authors report a 9-year-old boy with multiple injuries who had two intrahepatic false aneurysms and an arterioportal fistula in the right lobe of the liver, diagnosed by means of duplex ultrasonography. Subsequently, selective hepatic angiography and embolization with gelfoam was done. The postembolization course was complicated by a clot in the common bile duct. Spasmolytic therapy resulted in expulsion of the clot.George Ninan A Long Term Experience With Biliary Atresia. D.U. Tagge, E.P. Tagge, R.A. Drongowski, et al. Ann Surg, 214:590-598, (November),
1991. Results of surgical management of 34 patients with biliary atresia from a single institution are presented. Operative techniques include cholangiogram, sharp portal dissection above the portal vein bifurcation, and end- jujunal 20- to 25-cm retrocolic Rouxen-Y portoenterostomy as described by Kasai (11 patients) or Sawaguchi (23 patients). Operations occured at ages 2.9 to 24.6 weeks (mean, 9.9 weeks), with an overall survival of 47% (70% at 1 year, 37% at 5 years). Mean follow-up was 45 months. Ninety-four percent of survivors are jaundice free. Patients operated on after 8 weeks of age had better survival than those operated on at less than 8 weeks of age. Liver biopsy showed cirrhosis in 33%. marked fibrosis in 47%. and minimal fibrosis in 20%. Fifty-eight percent of patients with cirrhosis or marked fibrosis are deceased, and 83% of those with minimal fibrosis are jaundice free. Ascending cholangitis occured in 56% of patients (Kasai 82%. Sawaguchi 45%). with 42% having three or more episodes. There was no correlation between liver histology and age at operation, bile duct size and postoperative bile flow, nor the type of operation (Kasai vs Sawaguchi) and survival. The authors recommend use of the Kasai operation because there is no increase in mortality: the repair requires only one operation; stoma1 complications, such as fluid and electrolyte disorders or variceal bleeding, are less; and the increasing use of liver transplantation requires a simplified portoenterostomy.-Edward G. Ford
1479
ABSTRACTS
mucosally denuded colonic muscle were grafted with multiple free small bowel mucosal grafts of 4 to 10 mm diameter. Colonic mucosa can be removed along the submucosal plane without any colonic mucosal rests. None of the mucosally denuded colonic muscle surfaces regrew any colonic mucosa, and healing occurred essentially by contracture. The authors conclude that reported techniques for growing new small bowel mucosa, while interesting and stimulating in concept, are inadequate in their present form for clinical application.-Prem hlti
The type of choledochal dilatation correlates with the choledochopancreaticoductal junctional anatomy. The junctional anatomy, in association with a lack of normal junctional sphincteric pressures, may allow reflux of pancreatic juice into the biliary system and lead to changes causing choledochal cystic dilatationEdward G. Ford
Isolated Extrahepatic Bile Duct Injury: Diagnosis and Surgical Management. A. Krishna, D.B. Kaul, M.V. Murali, et al. Pediatr
Surg Int 7:143-145, (March), 1992. ABDOMEN Laparoscopic Cholecystectomy in Young Patients With Sickle Hemoglobinopathies. R.E. Ware, T.R. Kinney, J.R. Casey, et al. J
Pediatr 120:58-61, (January), 1992. Elective surgical management of cholelithiasis in patients with sickle hemoglobinopathies has been recommended to avoid the potential complications of cholecystitis and choledocholithiasis. Nine young patients with sickle hemoglobinopathies successfully underwent laparoscopic cholecystectomy. No complications resulted from the procedure. The mean postoperative hospital stay was 1.6 days. The technique appears to be safe and efficacious in these children-George Holcomb, Jr
The Technique of Laparoscopic Cholecystectomy in Children. A.M. Davidofi G.D. Branum, E.A. Murray, et al. Ann Surg 215:186-
191, (February), 1992. Twelve children, aged 8 to 19 years, underwent laparoscopic cholecystectomy for symptomatic cholelithiasis (hemolytic disorders 11, glycogen storage disease 1). The procedure is similar to that for adults with some exceptions. For small children with scaphoid abdomens a Hassan trocar was used under direct vision for increased safety. Maximal inflation pressures were 15 mm Hg. The small size of the abdominal cavity makes retraction of the gallbladder over the liver difficult. Therefore, the gallbladder is grasped closer to Calot’s triangle and retracted caudally. The authors report rapid recovery with discharge within 2 days. There were no complications and no conversions to open operation. The paper has several diagrams of trocar placement and intraoperative anatomy.-Edward G. Ford Congenital Choledochal Dilatation With Emphasis on Pathophysiology of the Biliary Tract. N. Iwai, J. Yanagihara, K. Tokiwa, et al. Ann Surg 215:27-30, (January), 1992.
Thirty-seven children, aged 8 days to 12 years, with choledochal cysts were evaluated by endoscopic retrograde cholanglopancreatography (ERCP) and underwent cystectomy with Roux-en-y hepaticojejunostomy. The common bile duct-pancreatic duct junction could clearly be identified in 26 patients (ERCP 16, operative cholangiogram 3. both 7). Findings were classified into three types; (1) C-P type, the pancreatic duct is the main duct and is joined by the common duct; (2) P-C type, the common duct is the main duct and joined by the pancreatic duct; (3) miscellaneous type, not clearly C-P or P-C. Biliary manometry was performed in 11 patients. An abnormal common duct-pancreatic duct junction was identified in 96% of patients. Ten of 12 with cystic dilatation had C-P type, 9 of 13 with fusiform dilatation had P-C type, and 1 patient had multicystic dilatation and miscellaneous type. All patients had markedly elevated amylase levels in the choledochal cyst. Choledochopancreaticoductal junction pressures were not different between the cyst types, but were lower than sphincter of Oddi pressures.
A 3-year-old boy, who presented with biliary ascites due to rupture at the confluence of right and left hepatic ducts, is reported. There was a history of trauma 29 days prior to admission. A technetium 99m-DISIDA isotope scan showed good hepatic uptake, pooling of radiotracer at the superolateral aspect of the right lobe of the liver, and nonvisualisation of extrahepatic biliary system. At operation, free and encysted bile was drained. The left and right hepatic ducts were mobilised and the distal biliary tree and gallbladder excised. An oblique-to-side anastomosis of the left and right hepatic ducts separately to a Roux-en-Y limb of jejunum was performed. At 1 year follow-up the results were good.-George Ninan
Embolization of Traumatic Hemobilia in a Child. P. de Lagausie, D. Pariente, F. Gauthier, et al. Pediatr Surg Int 7:61-63, (January),
1992. Posttraumatic hemobilia is an uncommon complication of liver trauma, especially in children. The authors report a 9-year-old boy with multiple injuries who had two intrahepatic false aneurysms and an arterioportal fistula in the right lobe of the liver, diagnosed by means of duplex ultrasonography. Subsequently, selective hepatic angiography and embolization with gelfoam was done. The postembolization course was complicated by a clot in the common bile duct. Spasmolytic therapy resulted in expulsion of the clot.George Ninan A Long Term Experience With Biliary Atresia. D.U. Tagge, E.P. Tagge, R.A. Drongowski, et al. Ann Surg, 214:590-598, (November),
1991. Results of surgical management of 34 patients with biliary atresia from a single institution are presented. Operative techniques include cholangiogram, sharp portal dissection above the portal vein bifurcation, and end- jujunal 20- to 25-cm retrocolic Rouxen-Y portoenterostomy as described by Kasai (11 patients) or Sawaguchi (23 patients). Operations occured at ages 2.9 to 24.6 weeks (mean, 9.9 weeks), with an overall survival of 47% (70% at 1 year, 37% at 5 years). Mean follow-up was 45 months. Ninety-four percent of survivors are jaundice free. Patients operated on after 8 weeks of age had better survival than those operated on at less than 8 weeks of age. Liver biopsy showed cirrhosis in 33%. marked fibrosis in 47%. and minimal fibrosis in 20%. Fifty-eight percent of patients with cirrhosis or marked fibrosis are deceased, and 83% of those with minimal fibrosis are jaundice free. Ascending cholangitis occured in 56% of patients (Kasai 82%. Sawaguchi 45%). with 42% having three or more episodes. There was no correlation between liver histology and age at operation, bile duct size and postoperative bile flow, nor the type of operation (Kasai vs Sawaguchi) and survival. The authors recommend use of the Kasai operation because there is no increase in mortality: the repair requires only one operation; stoma1 complications, such as fluid and electrolyte disorders or variceal bleeding, are less; and the increasing use of liver transplantation requires a simplified portoenterostomy.-Edward G. Ford