1/16. Iatrogenic injury in videolaparoscopic cholecystectomy: difficult surgical correction biliary tract. Two cases of biliary tract serious lesions during videolaparoscopic cholecystectomy are reported. In the first case of lithiasic cholecystitis there had been a complete damage of the common biliary duct; in the second case there had been a double main biliary duct binding with removal of a biliary tract segment. In both cases a biliary confluence-jejunal anastomosis with Roux-en-Y loop was made up. In the first one the operation was difficult because of the main bile duct's fragility and modest expansion. In the second one the presence of a secondary biliary duct in gallbladder fossa not recognized, but drained outside with a common drainage placed during the operation prevented appearance of jaundice with dilatation of biliary ducts. It was heavily conditioned performing confluence-jejunal anastomosis with Roux-en-Y loop. The post-operative course was characterized by appearance of an external biliary fistula which has spontaneously disappeared. One year later, neither of the two patients had any stenosis or cholangitis problems. ( info) |
| BACKGROUND: Among a myriad of physiological adverse affects of pneumoperitoneum-associated intra-abdominal hypertension, compromise of the mesenteric circulation is well documented. methods: After experiencing a case of fatal small bowel ischemia in the aftermath of laparoscopic cholecystectomy, the literature was reviewed. RESULTS: A medline and Index Medicus search revealed at least 6 cases of small bowel ischemia following laparoscopic cholecystectomy. CONCLUSIONS: Mesenteric ischemia should be considered in the differential diagnosis of patients developing nonspecific abdominal symptoms after laparoscopic procedures. ( info) |
3/16. Richter's hernia: an unusual presentation. Richter's hernia is an unusual form of herniation. The incarceration accompanying the hernia invariably leads to bowel ischemia. Chronic incarceration of the antimesenteric border of the intestine, presenting with a long-standing history of signs and symptoms with no dire consequences is unusual. We present a case with a typical acute presentation, and the only case we are aware of with a chronic incarceration leading to a true diverticulum of the hepatic flexure. ( info) |
4/16. Hepatic abscess as a complication of the sump syndrome. We report a case of hepatic abscess associated with the sump syndrome. The patient was a 66-year-old woman who had undergone cholecystectomy and side-to-side choledochoduodenostomy for a common bile duct (CBD) stone in 1983, and who presented with fever and right lower chest pain. A hepatic abscess was diagnosed; after it was drained, percutaneous transhepatic biliary drainage was performed. Bacteriological studies revealed the presence of bacteroides fragilis and streptococcus intermedius in the pus in the hepatic abscess cavity, and klebsiella pneumoniae and pseudomonas aeruginosa in the bile. The hepatic abscess and cholangitis rapidly resolved in response to two drainage procedures. At surgery, simple closure of the anastomosis was performed, because free drainage was observed from the distal CBD into the duodenum, despite the existence of a periampullary diverticulum. ( info) |
5/16. Bronchobiliary fistula: principles of management. Bronchobiliary fistula is an uncommon entity. Recently, we encountered 2 patients with this problem. Both were treated successfully with resection of the involved pulmonary tissue and interposition of viable tissue between the lung and the fistulous tract. This approach, although invasive, provided a rapid resolution of the patients' problem. ( info) |
6/16. Obstructive jaundice due to internal herniation: a case report and review of the literature. A 45-year-old man was suffering from abdominal pain and vomiting. He was admitted to our hospital with a diagnosis of ileus and obstructive jaundice. He had undergone Roux-en-Y anastomosis for choledocholithiasis 14 years earlier. A computed tomography scan revealed a dilated afferent loop and dilated intrahepatic bile duct. Upper gastrointestinal examination with contrast medium and percutaneous transhepatic cholangiography showed a high intestinal obstruction around the jejunojejunal anastomosis. The patient underwent laparotomy based on a diagnosis of obstructive jaundice due to ileus. During the operation, he was found to have internal herniation of the small bowel through a rent in the mesentery around the Roux-en-Y anastomosis for choledochojejunostomy. The hernia was reduced, and bowel resection was performed due to stenosis of the afferent loop. Jejunojejunal anastomosis was re-performed and the defect in the mesocolon was closed. Internal herniation after Roux-en-Y anastomosis is a rare sequela, but it should be recognized that this complication can occur after Roux-en-Y anastomosis. For prevention of internal herniation around the Roux-en-Y limb, secure closing of the mesenteric defects is important. ( info) |
| We describe two patients who formed inflammatory polyps at the side holes of T-tubes. It seems advisable to remove T-tubes as soon as it is appropriate. New designs and materials may also help avert these lesions. ( info) |
| BACKGROUND: Although the efficacy of extracorporeal shockwave lithotripsy for treatment of bile duct calculi is established, there are few studies of the value of extracorporeal shockwave lithotripsy for cystic duct remnant stones and for mirizzi syndrome. methods: patients who required extracorporeal shockwave lithotripsy for cystic duct stones were identified in a cohort of 239 patients with bile duct stones treated by extracorporeal shockwave lithotripsy between January 1989 and December 2001 at a single institution. The medical records of these patients were reviewed. Follow-up information was obtained by telephone contact. OBSERVATIONS: Six women (age range 19-85 years) underwent extracorporeal shockwave lithotripsy for cystic duct stones after failure of endoscopic treatment measures. Three of the patients presented with retained cystic duct remnant calculi (one also had mirizzi syndrome type I), and 3 presented with mirizzi syndrome type I. The stones were fragmented successfully by extracorporeal shockwave lithotripsy in all patients; the fragments were extracted endoscopically in 5 patients. endoscopy plus extracorporeal shockwave lithotripsy was definitive treatment for all patients except one who subsequently underwent cholecystectomy. CONCLUSIONS: gallstones in a cystic duct remnant and in mirizzi syndrome can be successfully treated by extracorporeal shockwave lithotripsy in conjunction with endoscopic measures. Extracorporeal shockwave lithotripsy is especially useful when surgery is contraindicated. ( info) |
9/16. Analysis of the motor function of the human sphincter of oddi by endoscopic retrograde cinecholangiography gated by manometry--a report of a case. Although the motor function of the sphincter of oddi (SO) has been clearly identified by endoscopic SO manometry (ESOM), the physiologic role of the phasic contractions of the SO remains unsettled in humans. The aim of this study was to correlate SO motor activity measured by ESOM with bile flow characteristics determined by simultaneously recorded endoscopic retrograde cinecholangiography. We investigated a 55-year-old female patient by means of ESOM. During the station pull-through recording, the ESOM catheter was withdrawn into the SO zone and retained there for 15 min. The pressures transmitted by the external transducers and the enlarged video picture of the choledochoduodenal junction from the X-ray fluoroscopic monitor (25 digital pictures/sec) were recorded simultaneously on the computer system with a time-correlated basis. During the analysis without taking note of the cinefluoroscopic events, we selected different manometric periods manually, such as the pressure wave of the SO phasic contraction, no SO phasic activity and the first second of the beginning of the next phasic contraction. Cumulative cinecholangiographic pictures were then constructed by the computer for each period, at a frequency of one frame/sec to create representative sum-of-pictures for each manometric period. By means of the application of manometrically gated cinecholangiography, we succeeded in demonstrating an exact time correlation between the SO systolic and diastolic movements on cinecholangiography and the pressure recording detected by ESOM in humans. ( info) |
10/16. Pneumobilia: benign or life-threatening. Pneumobilia, or air within the biliary tree of the liver, suggests an abnormal communication between the biliary tract and the intestines, or infection by gas-forming bacteria. Pneumobilia usually can be distinguished from air in the portal venous system by its appearance on computed tomography (CT) scan. The most common conditions associated with pneumobilia include: 1) a biliary-enteric surgical anastamosis, 2) an incompetent sphincter of oddi, or 3) a spontaneous biliary-enteric fistula. Three cases of pneumobilia associated with its most common causes are presented and further differential diagnostic possibilities as well as the implications of this finding on patient management are discussed. ( info) |