L. H. Blumgart

High coincidence of Mirizzi syndrome and gallbladder carcinoma

BACKGROUND Mirizzi syndrome is a rare complication of long-standing cholelithiasis. It is defined as obstructive jaundice caused by external compression of the common hepatic duct by an impacted stone in the gallbladder neck. Gallstone disease and cholelithiasis-associated chronic biliary inflammation may play a causative role in the pathogenesis of gallbladder carcinoma. The purpose of this study was to investigate the coincidence of gallbladder carcinoma associated with Mirizzi syndrome. Furthermore, the diagnostic value of elevated CA 19-9 levels as indicator for a coincidental gallbladder carcinoma in this syndrome was studied. METHODS Patient demographics, clinical findings, laboratory data, results of diagnostic studies, pathologic reports, and intraoperative findings of 1579 patients undergoing cholecystectomy were obtained from patient records and were retrospectively studied. Only patients with proven Mirizzi syndrome (i.e., extrinsic mechanical compression of the common hepatic duct by impacted gallstones, associated chronic cholecystitis, and a history of jaundice) were included in this study. RESULTS Eighteen cases of Mirizzi syndrome (1.0%) out of 1759 cholecystectomies performed between January 1986 and March 1995 were identified. The seven male patients and 11 female patients had an average age of 74.8 years (range, 32 to 87 years). In five of these patients (27.8%) coincidental cases of gallbladder carcinoma were detected. The incidence of unsuspected malignancies in long-standing gallstone disease was 36 (2%) of 1759 and was statistically significantly different (p < 0.001) from the incidence in patients with Mirizzi syndrome (27.8%, 5 of 18). No significant difference was noted in age, gender, duration of jaundice, and type of lesions between these two groups. Tumor-associated antigen CA 19-9 level was elevated in 12 patients with Mirizzi syndrome, but it was significantly higher (p < 0.0001) in all five patients with coincidental gallbladder neoplasm and peaked at 1000 units/ml. All patients diagnosed with gallbladder carcinoma died within 18 months after operation. CONCLUSIONS There is high association of gallbladder cancer in Mirizzi syndrome. Elevated CA 19-9 levels in this syndrome are indicative of a coincidental gallbladder malignancy. Because of this high coincidence of Mirizzi syndrome and gallbladder cancer we recommend an intraoperative frozen section of the gallbladder in all patients presenting with Mirizzi syndrome.

Hepatic Resection Using a Water Jet Dissector

The mortality and morbidity in major hepatic resection is often related to hemorrhage. A high pressure, high velocity water jet has been developed and has been utilized to assist in hepatic parenchymal transection. Sixty-seven major hepatic resections were performed for solid hepatic tumors. The tissue fracture technique was used in 51 patients (76%), and the water jet dissector was used predominantly in 16 patients (24%). The extent of hepatic resection using each technique was similar. The results showed no difference in operative duration (p = .499). The mean estimated blood loss using the water jet was 1386 ml, and tissue fracture technique 2450 ml (p = .217). Transfusion requirements were less in the water jet group (mean 2.0 units) compared to the tissue fracture group (mean 5.2 units); (p = .023). Results obtained with the new water dissector are encouraging. The preliminary results suggest that blood loss may be diminished.

The Effect of Communication Between the Right and Left Liver on the Outcome of Surgical Drainage for Jaundice due to Malignant Obstruction at the Hilus of the Liver

Debate continues regarding the optimal management of irresectable malignant proximal biliary obstruction. Controversy exists concerning the ability of unilateral drainage to provide adequate biliary decompression with tumors that have occluded the communication between the right and left hepatic ductal systems. Between October 1986 and October 1989, 18 patients with malignant proximal biliary obstruction were treated by an intrahepatic biliary enteric bypass. Patients were divided into two groups based on the presence or absence of a communication between the right and left biliary systems. In Group I (n = 9), there was free communication; and in Group II (n = 9) there was no communication. There were two perioperative deaths (11%) one due to persistent cholangitis and the other to myocardial insufficiency both with one death in each group. The median survival (excluding perioperative deaths) was 5.6 months. Comparison of pre- and postoperative serum levels of bilirubin and alkaline phosphatase showed a significant decrease in each group, but no difference between the groups in the size of the reduction. Sixteen patients survived at least three months and the palliation was judged as excellent in eight, fair in five, and unchanged in three. These results demonstrate the effectiveness of biliary enteric bypass regardless of communication between the left and right biliary ductal systems.

Hepatic Surgery Facilitated by a New Jet Dissector

Increasing experience with major hepatic resections has stimulated the development of improved resectional techniques and tools. A new high velocity water jet dissector is reported which offers significant advances over previously developed ultrasonic and low pressure water jet machines. It has been successfully used in 8 major hepatic resections with minimal blood loss, excellent visibility and without complications. The dissector is also of value in the exposure of intrahepatic bile ducts for biliaryenteric anastomosis.

Fatal ascaris pancreatitis: an uncommon problem in the west.

Gastrointestinal parasites, although an uncommon cause of biliary and pancreatic problems in western medicine, can produce fatal complications. A Swiss patient presented with acute pancreatitis, with no evidence of gall stones or history of alcohol abuse. He died after a short fulminant illness. At necropsy, an Ascaris lumbracoides was found impacted within the ampulla of Vater and serves as a reminder that non-indigenous causes of biliary tract obstruction should not be overlooked.

Post-Operative Hepatic Necrosis due to Reduction in Hepatic Arterial Blood Flow during Surgery for Chronic Biliary Obstruction

Three patients with malignant biliary obstruction, who developed postoperative hepatic necrosis due to compromise of the hepatic arterial blood flow, are reported. Two patients had major hepatic necro

Evaluation of adaptive changes by non-invasive imaging in hepatic vein outflow obstruction.

Hepatic vein outflow obstruction induces remarkable changes of intra–hepatic blood circulation; the significance of these changes remains uncertain. Six patients with obstruction of the hepatic veins were evaluated by duplex Doppler ultrasound and computed tomography. The adaptive changes secondary to obstruction were analyzed and their significance was correlated with the clinical findings. Four patients presenting unilateral hepatic vein occlusion had unilateral reversed portal flow. Two of them, with lobar liver atrophy and contralateral compensatory hypertrophy required operation; the other two, with normal appearance of the liver, benefitted from conservative treatment. Two patients with bilateral hepatic vein occlusion, intra-hepatic bypasses, bilateral lobar atrophy and caudate lobe hypertrophy, received operations. Intrahepatic unilateral portal flow reversal compensates for unilateral hepatic outflow obstruction. The combination of complete or subtotal hepatic vein obstruction and atrophy–hypertrophy complex predicates advanced disease despite flow reversal or spontaneous shunt.

Pylorus-Preserving Pancreatoduodenectomy. Experience in 20 Patients

Twenty patients underwent a pylorus-preserving pancreatoduodenectomy for benign or malignant periampullary and pancreatic disease. Eighteen patients had a partial and two patients a total pancreatectomy. There were 19 elective and 1 emergency operations. Post-operative mortality was 4% (1/20 patients) and the median follow up was 31 months (range, 15– 75 months), during which period 8 patients with a malignant disease died. Pylorus-preserving pancreatoduodenectomy did not compromise survival in ampullary cancer. One patient developed a marginal ulcer during the study period and one of twelve patients, examined by technetium scintigraphy (done more than 3 months after the procedure), had delayed gastric emptying. Two patients presented with a gastric retention as the first sign of recurrent pancreatic cancer. The result of the operation was judged as excellent in 7 patients, good in 8 and as bad in only 2 of the 17 patients who survived more than 6 months . Body weight was studied in 15 patients surviving more than one year after operation; five patients had gained weight, two had lost weight and in 8 there was no difference. Pylorus-preserving pancreatoduodenectomy seems to be a valuable alternative in the treatment of patients with benign and selected malignant pancreaticobiliary disease.

Technik der Papilloduodenektomie

SummaryLocal excision of preiampullary tumours first described in 1898 has been relegated in the background after introduction of pancreaticoduodenectomy in 1935. Recent reports suggest that ampullary excision may give good results. In order to define the place of this operation which may be a simple excision of the duodenal mucosa (ampullectomy) or a wide excision of the papilla encompassing the posterior duodenal wall and the distal bile and pancreatic ducts (papilloduodenectomy) it is important to make a clear distinction between these two techniques. We describe the technique of papilloduodenectomy and define the place of this operation, which may be useful in selected cases.ZusammenfassungDie Lokalexzision von periampulldren Tumoren, erstmals 1898 beschrieben, ist nach Einführung der Pankreatikoduodenektomie 1935 in den Hintergrund gedrdngt worden. Neuere Berichte lassen vermuten, daß die ampullary Exzision gute Resultate erreicht. Um den Platz dieser Operation zu bestimmen, welche eine einfache Mukosaexzision (Ampullektomie) oder eine weite Exzision der Papille zusammen mit der Duodenalhinterwand und den distalen Anteilen von Gallen- und Pankreasgang sein kann (Papilloduodenektomie), ist es wichtig, these Technik genau zu definieren. Wir beschreiben deshalb die Papilloduodenektomie und bestimmen den Platz dieser Operation, die in ausgewählten Fällen nützlich sein kann.

Outcome of Diffuse Faecal and Purulent Peritonitis following Colonic Perforation

The mortality from faecal or purulent peritonitis following colonic perforation has been reported to be between 15 and 40%. These reports extend over many years and cannot take into account the influe