Cases reported "Biliary Tract Diseases"

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1/55. Pseudocholelithiasis in an elderly man with calcified hydatid cysts.

    A 69 year old man with intrabiliary rupture of a calcified echinococcal cyst mimicking acute cholelithiasis is discussed. This case is of interest because the correct diagnosis was not recognized preoperatively despite the fact that certain aspects of the illness were classic features of this complication of hydatid disease. Although this is a common complication of hydatid disease, which is well recognized in other countries, only seven cases have been reported in the American literature. Treatment of our patient included successful use of a Roux-en-Y drainage procedure which, to the best of our knowledge, has not previously been employed in treating this disease.
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2/55. Pethidine reverses morphine-induced delirium.

    A young patient had unexpected and prolonged postoperative delirium apparently associated with morphine-induced biliary colic. naloxone had no therapeutic effect, but a small dose of pethidine produced a dramatic return to lucidity. Unrecognized biliary spasm should be considered as a cause of agitation in the recovery room in postoperative patients who have received morphine.
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keywords = operative
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3/55. Biliary cysts.

    This review brings the total number of biliary cysts reported in the world literature to 955. Eighty-one per cent of patients are females and 61% were discovered before age ten. The classical triad of right upper quadrant pain, right upper quandrant mass, and juandice is present in 38% of cases. The duration of symptoms prior to diagnosis ranged from less than one week to more than 40 years. The etiology is multifaceted and evidence of the existence of both acquired and congenital cysts is presented. The most useful diagnostic tool is fiberoptic endoscopy with retrograde contrast injection of the common bile duct and pancreatic duct. The incidence of biliary carcinoma in patients with biliary cysts is found to be 2.5%; 24 cases have been reported. Considerable controversy has existed concerning the best operative procedure for biliary cysts; no treatment or medical treatment yielding a 97% mortality rate. In an analysis of 235 patients presented since 1968 with an average followup of 5.2 years, the best procedure appears to be excision with either choledochocholedocostomy or Roux-en-Y hepaticojejunostomy. The operative mortality for all procedures is now 3 to 4%.
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4/55. Bilo-pancreatic ascaris lumbricoides infestation. Endoscopic discovery and removal.

    ascaris lumbricoides infestation is relatively rare in industrialized countries, and it occurs mainly in conditions in which hygiene is lacking. We describe here a case of a 39-year-old female from ex-Jugoslavia affected by recurrent hepatic colic. At entry ultrasonography revealed microlithiasis in the gallbladder and widening of the pancreatic head. The subsequent ERCP showed slight filling defects in the choledochus and an inflammation-like stricture of the papilla of Vater, and after endoscopic sphincterotomy we saw an outflow of dense bile and microlitholits. Thus, a standard surgical cholecystectomy was carried out and the patient was dismissed on the 3rd postoperative day without any symptoms. However, the patient was admitted again after four days for a new coliky pain attack. An upper endoscopy showed a 23 cm long mobile parasite in the duodenum: it was caught with the polypectomy loap, extracted and identified as A. Lumbricoides. The patient's symptoms disappeared after the endoscopic removal of the worm and she was dismissed the day after the worm's removal. No recurrence of symptoms was noted during a 1-year follow-up. This case showed that A. Lumbricoides infestation of the biliary tree should be considered when biliary and/or pancreatic symptoms recur, especially in patients coming from undeveloped countries. At the same time we showed that endoscopic removal is a safe and effective treatment for this infestation.
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keywords = operative
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5/55. Therapeutic approaches to anergy in surgical patients. Surgery and levamisole.

    skin tests (ST) in 1332 patients are associated with increased morbidity from sepsis. patients with normal skin tests had a 7% major sepsis rate and 2% mortality rate. Thirty-six per cent of anergic (A) patients and 21% of relatively anergic (RA) patients died; 52% of A patients and 34% of RA patients had sepsis. These data include all patients studied and represent their worst skin test. Two studies were done. The first was a retrospective evaluation of effect of surgery upon 49 anergic patients with biliary tract disease, colon cancer, bowel obstruction, hypovolemia and visceral abscesses. The patients did not receive total parenteral nutrition (TPN). The data show that surgery without TPN can reverse the anergic state and did so in 84% of patients reported. The second study was a prospective, double-blind, randomized trial of the effect of levamisole on skin tests, neutrophil chemotaxis (CTX), sepsis and mortality iin 39 preoperative anergic patients. Major sepsis was significantly increased in placebo group (p less than 0.05). mortality, minor sepsis, restoration of skin tests and chemotaxis were somewhat better in levamisole patients but not statistically so. These studies show that in addition to TPN, surgery and immunorestorative drugs are viable approaches to the management of selected anergic patients.
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6/55. Advanced gallbladder carcinoma with biliobiliary fistula, resected by hepatopancreatoduodenectomy, in an aged patient.

    We report a 78-year-old man with a gallbladder carcinoma and biliobiliary fistula, diagnosed by percutaneous transhepatic cholangioscopic biopsy through the fistula. The impacted stones in the common hepatic duct were crushed, and then selective cholangiography under percutaneous transhepatic cholangioscopy (PTCS) revealed a biliobiliary fistula. Cholangioscopic biopsy tissues taken from the gallbladder revealed adenocarcinoma, but biopsies taken from the fistula revealed no evidence of malignancy. Further investigations indicated that the gallbladder carcinoma involved the duodenum and the distal common bile duct. A hepatopancreatoduodenectomy, including both an extended right hepatic lobectomy with resection of the caudate lobe and a pancreatoduodenectomy, was performed. Despite the patient's advanced age, he made an unremarkable postoperative recovery and was able to enjoy an active social life for 8 months after the surgery. We discuss biliobiliary fistula associated with gallbladder carcinomas and the use of hepatopancreatoduodenectomy for advanced biliary cancer in aged patients.
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keywords = operative
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7/55. Bilary tract exploration via T-tube tract: improved technique.

    A total of 40 cases referred for postoperative reexploration of the biliary tract via the T-tube trace was reviewed. In selected cases, a modified technique of dilatation of the T-tube tract or bile ducts and endoscopy via the T-tube tract was used. dilatation of the T-tube tract is a relatively simple procedure that was necessary in over one-half of our cases, since the retained stone was larger than the T-tube inserted during surgery. A new T-tube with a larger external limb was developed in order to reduce the necessity for dilatation of the biliary-cutaneous fistulous tract. Fiberoptic endoscopy of the biliary system via the T-tube tract offers another means for removing large or impacted stones and for investigating mucosal defects. This modified technique has reduced the number of patients requiring surgical reexploration.
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keywords = operative
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8/55. Intrabiliary rupture of hydatid cyst: diagnosis with MRI and hepatobiliary isotope study.

    Intrabiliary rupture is the most common complication of hepatic hydatid cyst yet it is unusual, occurring in only 3-17% of cases. The diagnosis is rarely difficult on ultrasound and CT when typical radiological features are present. In rare cases of complete evacuation, when characteristic findings of hydatid cyst are absent or when there is no evidence of the previous existence of liver hydatid cyst, the diagnosis may be difficult. In difficult cases, MRI, MRCP, ERCP and (99)Tc(m)-mebrofenin hepatobiliary scintigraphy are employed. We present a rare case of surgical obstructive jaundice due to rupture of a liver hydatid cyst into the biliary tract and gall bladder, with complete evacuation of its contents leading to misdiagnosis on CT and ultrasound. MRCP and (99)Tc(m)-mebrofenin hepatobiliary scintigraphy were able to establish a firm pre-operative diagnosis.
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keywords = operative
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9/55. Cystic echinococcosis with perforation into the biliary tract in an eight-year-old girl.

    Cystic echinococcosis (CE) is a zoonotic infection caused by echinococcus granulosus and is still frequent in endemic areas. CE is predominantly localised in the liver. The therapy of choice is the surgical sanitation of the lesions, increasingly through interventional procedures such as percutaneous punctation of the cysts, aspiration of the cystic fluid, instillation of a protoscolicidal solution and reaspiration of this solution (PAIR). However, in some cases, such as perforation into the biliary tract, PAIR is not feasible. We report on an eight-year-old girl who suffered from CE with perforation of one cyst into the biliary tract. The diagnosis was confirmed by ERCP and cholangioscopy and a right hemihepatectomy was performed. The girl received adjuvant chemotherapy with albendazol perioperatively and is still asymptomatic with no indications of disease 10 months after the operation.
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keywords = operative
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10/55. Choledochal cysts: roentgenographic techniques.

    Twenty-four cases of choledochal cysts were reviewed. Only 7 cases were definitely diagnosed preoperatively: 3 by 131I rose bengal scanning, 2 by intravenous cholangiography, 1 by oral cholecystography, and 1 by 99mTc sulfur colloid scanning followed by angiography. The highest percentage of definitive positive examinations was found in the 131I rose bengal scan (3 of 4), but the study most helpful in suggesting the diagnosis in a general way was the upper gastrointestinal series. The more frequent use of 131I rose bengal scanning and ultrasound should increase diagnostic accuracy.
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keywords = operative
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