Torsten Holmin

Endoscopic Treatment of Bile Duct Calculi in Patients with Gallbladder in Situ Long-Term Outcome and Factors Predictive of Recurrent Symptoms

BACKGROUND Whether endoscopic sphincterotomy (EST) in elderly and/or high-risk patients with common bile duct calculi (CBD) and the gallbladder in situ should be followed by routine cholecystectomy is still a subject of controversy. METHODS To identify factors predictive of subsequent biliary tract symptoms after EST and bile duct clearance, we reviewed 265 patients with intact gallbladder and CBD calculi who were considered for EST in our department from 1981 to 1992. In 15 of 265 patients endoscopic treatment was not carried out, and the records of 4 patients were missing. RESULTS Complete removal of all bile duct calculi failed in 27 patients (11%). Cholecystectomy was performed in 35 patients (16%) with cleared bile ducts 1-765 days (median, 60 days) after EST, in spite of absence of recurrent symptoms from the biliary tract. The remaining 184 patients have been retrospectively followed up for 14-150 months (median, 69 months). Cholecystectomy was required in 35 because of acute cholecystitis (n = 23) or biliary colic (n = 12). Of the cholecystectomies 86% were performed within 24 months after EST and only one after 4 years of follow-up. Increased frequency of cholecystectomy was found in patients with complete opacification of the gallbladder at endoscopic cholangiography (p = 0.005). This was especially evident in patients younger than 80 years (p = 0.002). Cholecystectomy was also required more often in patients with gallbladder calculi (p = 0.02). The risk of cholangitis in patients without recurrent stones was higher in those with juxtapapillary diverticula (p = 0.02). Fifty-nine patients without and 17 with mild to moderate symptoms from the biliary tract died after a median time of 39 and 46 months, respectively. Seventy-three patients are alive, and 59 are symptom-free. Ten patients have had and four still have complaints of mild to moderate biliary tract symptoms. They have been followed for up to 16-146 months (median, 40 months). CONCLUSIONS These findings confirm that endoscopic treatment alone in this group of patients is a feasible treatment principle. Recognition of the registered risk factors might be helpful when selecting patients for subsequent cholecystectomy.

A Microsurgical Method for Denervation of the Liver in the Rat

The role of the nerves in the hepato-duodenal ligament should be of special surgical interest, since these nerves are often injured in hepatic and biliary tract surgery. We have developed a microsurgical procedure for liver denervation. All visible nerves were resected after staining. Norepinephrine values in central liver tissue of denervated rats were only 18% of the corresponding values in innervated liver tissue, indicating an appreciable degree of sympathetic denervation. No detectable immunoreactivity of gastrin, cholecystokinin, vasoactive intestinal polypeptide, substance P, somatostatin or enkephalin were found within resected hepatic nerves. The described denervation procedure is simple and reproducible. It can be used to obtain additional information about the nervous regulation of various liver functions.

Hepatic sympathetic denervation potentiates glucagon-stimulated glycogenolysis and hyperinsulinaemia in the rat.

The influence of hepatic nerves on glucagon-stimulated hyperglycaemia and hyperinsulinaemia was studied in rats. Using microsurgical techniques, hepatic sympathectomy (resulting in approximately 80% reduction of liver noradrenaline content) or hepatic vagotomy was performed. Glucagon (10 micrograms/kg b.wt.) was injected i.v. one week after the operative procedure. Plasma levels of glucose and insulin rose more rapidly and to a higher level in rats subjected to hepatic sympathectomy than in sham-operated or non-operated control animals. In contrast, hepatic vagotomy did not influence the plasma glucose or insulin response to glucagon. In conclusion, our findings suggest a role for the hepatic sympathetic nerves in glucagon-stimulated glycogenolysis and insulin secretion in the rat.

Trisomy 7 in nonneoplastic focal steatosis of the liver

Cytogenetic analysis of short-term cultures of a nonneoplastic focal steatosis of the liver showed trisomy 7 as the sole chromosomal change. This finding, especially when viewed in light of previous reports describing +7 in nonneoplastic tissues, strongly suggests that trisomy 7 cannot be considered a tumor-specific abnormality when it occurs as the only change. The cell type in which +7 is present is not yet known.

A Microsurgical Method for Total Hepatectomy in the Rat

A microsurgical three-stage-procedure for total hepatectomy in the rat is described. In the first stage, suprarenal ligature and division of the inferior vena cava is performed. A modified portacaval shunt is constructed in the second stage and total hepatectomy is performed in the third stage. Microsurgical technique is of great benefit in both the second and third stages, especially in choosing the proper location for the shunt and minimizing blood loss. All the rats survived to the 6-hour study and 65% of the rats survived to the 18-hour study, despite the fact that body temperature was upheld to a level of 35-37 degrees C. Based on our experience in 165 hepatectomies, we recommend our method for metabolic studies in anhepatic rats.

Splenic and gastro-duodenal vein occlusion—influence on the pancreatic gland and on the outcome of experimental pancreatitis

SummaryThe observation that splenic vein thrombosis results in pancreatic changes similar to haemorrhagic pancreatitis initiated the present investigation. The influence of splenic and/or gastroduodenal vein occlusion on the pancreatic gland was evaluated and compared to that obtained after induction of experimental pancreatitis (EP). The influence of splenic vein occlusion on EP was also investigated. An approximately 4-fold increase in serum amylase activity was obtained after simultaneous ligation of the splenic and gastroduodenal veins. This increase was comparable to that obtained after EP. On the other hand, amylase activity in ascites was considerably lower after vein occlusion than after EP. Splenic vein occlusion in rats with EP more moderately increased the amylase activity but did not influence mortality rate 24 h postoperatively. Venous thromboses were observed in all groups with occluded veins but not in rats with EP. Vein occlusion alone did not result in fat necroses. Although occlusion of the splenic and gastroduodenal veins results in macromorphologic and biochemical changes resembling those in EP, the microscopic findings of the two conditions differ. Thus, the results do not support the hypothesis that pancreatic vein thromboses are of etiologic significance for the development of acute haemorrhagic pancreatitis.

Systemic reactive amyloidosis caused by hepatocellular adenoma: A case report

Systemic reactive amyloidosis caused by non-malignant tumors seems to be extremely rare. In the present paper a 39-year-old female with systemic reactive amyloidosis caused by a hepatocellular adenoma is described. The patient had a history of using contraceptive drugs. She had a pronounced nephrotic syndrome, a renal biopsy showing reactive (AA) amyloidosis, and a bone scintigraphy (99mTc methylene diphosphonate, TcMDP) showing an increased uptake in soft tissues. Removal of the adenoma was followed by a gradual resolution of the nephrotic syndrome and a normalization of the bone scintigraphy. The tumor was histologically a mixture of focal nodular hyperplasia and liver cell adenoma.

Hepatic lipase activity increases after liver denervation in the rat

We have investigated the effects of hilar denervation of rat liver upon the activity of hepatic lipase determined in tissue extracts. Denervated animals had an enzyme activity of 7.89 +/- 0.37 mU/mg protein, compared to 6.45 +/- 0.43 in sham-operated controls (mean +/- S.E.; P less than 0.05). We conclude that hepatic innervation may contribute to the regulation of hepatic lipase activity.

Hepatic reticuloendothelial function in rats with various portasystemic shunts and total liver arterialization

Hepatic reticuloendothelial function was measured in 6 experimental groups of rats with various portasystemic shunts or total liver arterialization by computer calculation of the hepatic uptake rate of intravenously injected 99mTc-sulphur colloid. Marked reduction of the hepatic reticuloendothelial system (RES) function was found both 1 and 3 weeks after the construction of a mesentericocaval or conventional end-to-side portacaval shunt. Hepatic RES function was also lowered both 1 and 3 weeks after a modified portacaval shunt, but the reduction was much less pronounced. Total liver arterialization produced a similar mild reduction of hepatic RES function after 1 week; however, there was no longer any significant reduction after 3 weeks. This study concludes that total liver arterialization ameliorates the negative effect that portasystemic shunting has on hepatic RES function.

Microsurgical denervation of rat adipose tissue: Lack of effect on lipoprotein lipase

Abstract The effects of unilateral microsurgical denervation on the activity of lipoprotein lipase in rat epididymal adipose tissue have been investigated. This technique provides successful denervation in 30–70% of the operations. Lipoprotein lipase activities were not different from those on the non-operated side, although the concentrations of norepinephrine were at least ten times lower. It is concluded that lipoprotein lipase of rat adipose tissue is unlikely to be regulated by an adrenergic nervous mechanism.