M. N. Van Der Heyde

Benign biliary strictures. Surgery or endoscopy

OBJECTIVE This study compared the results of surgery and endoscopy for benign biliary strictures in one institution, over the same period of time and with the same outcome definitions. SUMMARY BACKGROUND DATA Surgery is considered the treatment of choice, offering more than 80% long-term success. Endoscopic stenting has been reported to yield similar results and might be a useful alternative. METHODS In this nonrandomized retrospective study, 101 patients with benign biliary strictures were included. Thirty-five patients were treated surgically and 66 by endoscopic stenting. Patient characteristics, initial trauma, previous repairs, and level of obstruction were comparable in both groups. Surgical therapy consisted of constructing a biliary-digestive anastomosis in normal ductal tissue. Endoscopic therapy consisted of placement of endoprostheses, with trimonthly elective exchange for a 1-year period. RESULTS Mean length of follow-up was 50 +/- 3.8 and 42 +/- 4.2 months for surgery and endoscopy, respectively. Early complications occurred more frequently in the surgically treated group (p < 0.03). Late complications during therapy, occurred only in the endoscopically treated group. In 46 patients, the endoprostheses were eventually removed. Recurrent stricturing occurred in 17% in both surgical and endoscopic patients. CONCLUSIONS Surgery and endoscopy for benign biliary strictures have similar long-term success rates. Indications for surgery are complete transections, failed previous repairs, and failures of endoscopic therapy. All other patients are candidates for endoscopic stenting as the initial treatment.

Liver Regeneration and Restoration of Liver Function after Partial Hepatectomy in Patients with Liver Tumors

Liver regeneration and restoration of liver function were studied in six patients who underwent partial hepatectomy with removal of 30-70% of the liver. Liver volume and liver regeneration were studied by single-photon computed tomography (SPECT), using 99mTc-colloid as tracer. The method was assessed in 11 patients by comparing the pre- and post-operative volume measurements with the volume of the resected liver mass. The correlation coefficient between these methods was 0.899 (P less than 0.01). Liver function was determined by measuring the galactose elimination capacity and the caffeine clearance. After a postoperative follow-up period of 50 days the liver had regenerated maximally to a volume of 75 +/- 2% of the preoperative liver mass. Maximal restoration of liver function was achieved 120 days after operation and amounted to 75 +/- 10% for the caffeine clearance and to 100 +/- 25% for the galactose elimination capacity. This study shows that SPECT is a useful method for assessing liver regeneration in patients after partial hepatectomy. Our study furthermore shows that caffeine clearance correlates well with total liver volume, whereas the galactose elimination capacity overestimates total liver volume after partial hepatectomy.

An in vitro method for comparing the efficacy of two preservation solutions in one canine liver using the 5′-nucleotidase assay

Abstract. The activity and localization of the plasma membrane‐bound enzyme 5‘‐nucleotidase (5’‐NT) in liver tissue are sensitive parameters of ischemic damage. The value of 5‘‐NT as a marker of liver graft viability was studied in relation to liver preservation. In six mongrel dogs, the main right and left branches of the portal vein were cannulated and flushed separately in situ with cold University of Wisconsin (UW) solution and Euro‐Collins (EC) solution, respectively. After hepatectomy, the right and left liver lobes were split and stored at 5oC in either of the two solutions. 5’‐NT activity was demonstrated in cryostat sections of liver tissue using the lead salt method. After 48 h of storage in EC solution, the 5‘‐NT score had decreased to 31 ± 16 % (n = 6), whereas in UW solution the 5’‐NT score was 76%± 10% (n=6). Significantly (P < 0·05) higher 5‘‐NT scores were also found after 24‐h and 72‐h preservation times in UW versus EC solutions. This result is in keeping with the higher preservation tolerance of liver grafts preserved in UW solution. The 5’‐NT assay was studied in relation to graft function in orthotopic liver transplantation experiments in dogs. All dogs with liver grafts preserved in UW solution for 24 h (n= 4) and 48 h (n= 3) survived (> 5 days). Pretransplant 5‘‐NT scores ranged from 61% to 100%. The 72‐h‐preserved livers (n= 5) did not show life‐supporting function. Pretransplant 5’‐NT scores (33%± 12%, n = 5) were significantly (P < 0·05) decreased. The 5‘‐NT score pretransplantation was a more reliable indicator of graft function than peak SGOT values post‐transplantation. In conclusion, the 5’‐NT assay, in conjunction with the double flush method through the portal vein, provides a simple and rapid “in vitro” method to test solutions for liver preservation.

Split pancreaticojejunostomy in the surgical treatment of chronic pancreatitis.

“Split” pancreaticojejunostomy is a procedure consisting of vertical transection of the pancreas and anastomosis of both sides of the cut pancreatic duct with an interposed, Roux-en-Y jejunal loop. In this paper we report the long term results of this procedure in the treatment of eight patients with chronic pancreatitis (CP).

Primary cholangiocarcinoma of the hepatic hilus. How to approach and how to choose the type of surgical management

Summary45 consecutive patients with proximal malignant biliary obstruction underwent surgery between September 1983 and May 1987. 27 patients (group A) had complete or partial resection and 18 (group B) underwent complete tumor resection with concomitant major liver resection with or without resection of the regional vascular structures of the porta hepatis. Reconstruction of the intrahepatic biliary tree in all patients was carried out by mucosa-to-mucosa intrahepatic cholangiojejunostomies between segmental hepatic ducts and a Roux-Y jejunal loop with only temporary use of anastomotic tubes.5 patients died, 2 group-A patients (2/27) and 3 of the 18 group-B patients. Resection was radical in 2 patients of group A and in 6 of group B. At the time of writing (May 1987) 29 patients were alive, 16 from group A (16/27) and 13 from group B (13/18). Survivors have a satisfactory quality of postoperative life.Based on the results, simple resection of tumor is considered as the method of choice for the management of proximal malignant biliary obstruction in the majority of patients. Combined tumor and liver resection with or without regional vascular resection is reserved for a group of patients in whom after careful perioperative assessment of the clinical and operative characteristics, the increased risk of such procedures should be contemplated in favor of a prospective longer long-term survival.Zusammenfassung45 Patienten mit einem Cholangiokarzinom der Hepatikusgabel wurden operiert. Bei 27 Patienten (Gruppe A) wurde der Tumor komplett order partiell ohne zusätzliche operative Maßnahmen reseziert, während bei 18 Patienten (Gruppe B) eine Eingriffserweiterung vorgenommen wurde: 11mal Leberresektion, 6mal Leberresektion plus Resektion und Rekonstruktion von regionalen Gefäßen, 1mal Resektion und Rekonstruktion von regionalen Gefäßen, ohne Leberresektion. Die Wiederherstellung der Gallendrainage erfolgte durch intrahepatische Cholangio-Jejunostomien. 5 patienten verstarben postoperativ. Die überlebenden Patienten verloren ihren Ikterus und konnten ein zufriedenstellendes Leben ohne Restcholangitis führen. Im Mai 1987 waren 29 Patienten noch am Leben. Die vorliegende Erfahrung zeigt, daß die einfache Resektion des Gallengangskarzinoms mit einer niedrigen Mortalität und einer hohen langfristigen Überlebensrate verknüpft ist und daß die Qualität des postoperativen Lebens auch bei Patienten mit palliativer Tumorresektion zufriedenstellend ist. Die Eingriffserweiterung durch Leberresektion mit oder ohne zusätzliche Resektion und Rekonstruktion von regionalen Gefäßen erbrachte keinen wesentlichen Unterschied in der Überlebensrate zur einfachen Tumorresektion. Die postoperative Lebensqualität der Patienten mit erweiterten Resektionen ist ebenfalls zufriedenstellend. Operationsindikation und Operationstaktik bringen bei Patienten mit Cholangiokarzinom der Leberpforte schwierige Entscheidungen mit sich und sollten in jedem Fall individuell abgestimmt werden.

A New Alternative for Chronic Pancreatitis

Chronic pancreatitis is a challenging clinical problem, and the results after surgical management are controversial [1–6]. It is distressing and disappointing for both the surgeon and the patient to learn soon after a time-consuming operation that the complaints and symptoms are coming back, and that a new operation or a new modality of management is warranted. How can we possibly avoid such a situation? On the basis of our experience in the Hepato-biliary-pancreatic unit of the Academic Medical Centre, we developed a new surgical technique that is applicable in a number of patients suffering of chronic pancreatitis.