Non-operative removal of bile duct stones by duodenoscopic sphincterotomy in the elderly.

Between January 1975 and December 1979, 71 patients over the age of 70 underwent attempted duodenoscopic sphincterotomy for stones in the common bile duct. Fifteen patients still had gall bladders in situ. Sphincterotomy was possible in 69 of the patients and in 65 of these duct clearance was achieved, giving an overall success rate of 92%. Failure to achieve sphincterotomy in two cases was due to substantial peripapillary diverticula. Duct clearance failed in four patients, mostly due to the size of the retained stones. The largest stone extracted was 24 mm diameter. There were no deaths but complications occurred in nine patients (13%); these were haemorrhage in four (requiring surgery in one), cholangitis in four (two of whom required surgical extraction of stones), and pancreatitis in one. The average duration of hospital stay in successful cases was 11 days (range three to 30). Clinical follow-up of 55 patients one to five years after sphincterotomy showed no evidence of stones or of stenosis of the sphincter. Duodenoscopic sphincterotomy is a major advance in the management of elderly patients with stones in the common bile duct.     

Electrohydraulic lithotripsy with peroral choledochoscopy.

OBJECTIVE--To determine the efficacy of peroral electrohydraulic lithotripsy performed with an extra large duodenoscope (outside diameter 14.8 mm) and a choledochoscope with a diameter of 4.1 mm (Olympus "mother and baby" endoscope system) in the removal of very large stones from the common bile duct. DESIGN--Prospective study of patients with giant stones in the common bile duct that were resistant to extraction by conventional means. SETTING--Endoscopy unit at a university hospital. PATIENTS--Four women and one man aged 48-82 (mean 66.4 years) with a total of nine stones in their common bile ducts ranging from 2.2 to 3.6 cm in diameter. INTERVENTIONS--Peroral electrohydraulic lithotripsy was performed after intravenous sedation and under antibiotic cover. Two endoscopists took part in each procedure, coordination being achieved by means of a video monitor. The procedures were performed with a Lithotron EL-23 lithotripter and a 3 French lithotripsy probe inserted through the choledochoscope under direct vision. MAIN OUTCOME MEASURE--Complete clearance of the common bile duct confirmed by occlusion cholangiography. RESULTS--All nine stones (mean minimal diameter 2.6 cm; mean maximal diameter 3.1 cm) were successfully fragmented by electrohydraulic lithotripsy, allowing subsequent extraction with the aid of endoscopy and clearance of the common bile duct. A median of three (range two to five) sessions of endoscopic retrograde cholangiopancreatography were required to achieve complete clearance of the ducts. Patients stayed a median of eight days in hospital after lithotripsy (range eight to 14). There were no complications. CONCLUSION--Peroral electrohydraulic lithotripsy offers a safe and effective alternative for the management of patients with large stones in the common bile duct.     

Intermittent Secretion of Abnormal Bile in Patients with Cholesterol Gall Stones

Gall bladder and hepatic bile was sampled from 66 patients undergoing elective operations on the biliary tract. Fifty-one patients had cholesterol gall stones but only 59% of these were found to have bile which was supersaturated with cholesterol. Repeated sampling of hepatic bile from patients with T-tubes showed that the secretion of supersaturated bile was intermittent.These results indicate that it is impossible to separate patients with cholesterol stones from controls simply by examination of the lipid composition of their bile, since an appreciable number of bile samples from patients with cholesterol stones were unsaturated.The fact that cholesterol gall stones form when the bile is supersaturated with cholesterol only intermittently suggests that the gall bladder may also have a part in their formation.     

CHOLEDOCHOLITHIASIS-Correlation of Preoperative with Operative and Postoperative Data to Enhance Diagnostic Insight

One hundred cases of common bile duct explorations were reviewed in an attempt to obtain information that might give insight into the diagnosis and definitive treatment of choledocholithiasis. Fifty of the hundred patients had common duct stones. Correlations were made between the incidence of choledocholithiasis as proved at operation, and the following factors: Kind and number of choledochal exploratory criteria used, the clinical diagnosis of common duct stones, and the pathologic features of gallbladders removed. The incidence of stones was statistically related to aging. The most frequent choledochal exploratory criteria were common duct dilatation or thickening (63 cases) and history of jaundice (50 cases). The most reliable single criterion in "diagnosing" common duct stones was palpable common or hepatic duct stones, the diagnosis having been correct in 15 of 17 such cases. The most reliable combination of criteria was a history of jaundice, plus palpable stones, with correct diagnosis in all such cases. The clinical diagnosis of choledocholithiasis was correct in only 17 per cent of cases. The correlation of the incidence of common duct stones with the degree of gallbladder disease-that is, acute or chronic-did not provide information that might be helpful in diagnosing choledocholithiasis. The incidence of proven retained common duct stones was 3 per cent, the non-fatal postoperative complication rate was 21 per cent and operative mortality was 1 per cent.     

CHOLEDOCHOLITHIASIS—Correlation of Preoperative with Operative and Postoperative Data to Enhance Diagnostic Insight

One hundred cases of common bile duct explorations were reviewed in an attempt to obtain information that might give insight into the diagnosis and definitive treatment of choledocholithiasis. Fifty of the hundred patients had common duct stones. Correlations were made between the incidence of choledocholithiasis as proved at operation, and the following factors: Kind and number of choledochal exploratory criteria used, the clinical diagnosis of common duct stones, and the pathologic features of gallbladders removed.The incidence of stones was statistically related to aging.The most frequent choledochal exploratory criteria were common duct dilatation or thickening (63 cases) and history of jaundice (50 cases).The most reliable single criterion in “diagnosing” common duct stones was palpable common or hepatic duct stones, the diagnosis having been correct in 15 of 17 such cases.The most reliable combination of criteria was a history of jaundice, plus palpable stones, with correct diagnosis in all such cases.The clinical diagnosis of choledocholithiasis was correct in only 17 per cent of cases.The correlation of the incidence of common duct stones with the degree of gallbladder disease—that is, acute or chronic—did not provide information that might be helpful in diagnosing choledocholithiasis.The incidence of proven retained common duct stones was 3 per cent, the non-fatal postoperative complication rate was 21 per cent and operative mortality was 1 per cent.     

Pilot study of combination treatment for gall stones with medium dose chenodeoxycholic acid and a terpene preparation.

Thirty patients with radiolucent stones in a radiologically functioning gall bladder were treated for up to two years with a combination of Rowachol (one capsule twice daily), a mixture of cyclic monoterpenes, and chenodeoxycholic acid (7.0-10.5 mg/kg/day). The patients were not selected for body weight or size of stones. All complete dissolutions diagnosed by oral cholecystography were confirmed or refuted by ultrasound examination. Control of symptoms was excellent, only one patient withdrawing from the study because of persistent biliary pain. No evidence of hepatotoxicity was detected biochemically, and diarrhoea due to chenodeoxycholic acid was minimal at this dose. Stones disappeared completely in 11 patients (37%) within one year and in 15 (50%) within two years. These results compared favourably with those obtained with similar doses of chenodeoxycholic acid alone, in particular those of the National Co-operative Gallstone Study (complete dissolution in 13.5% of patients at two years). Treatment with a combination of medium dose chenodeoxycholic acid with Rowachol for radiolucent gall stones is economical, effective, and likely to minimise persistent symptoms and adverse effects of treatment.     

复发性胆源性胰腺炎的临床特征及危险因素分析

目的:研究复发性胆源性胰腺炎(RGP)的临床特征及危险因素。方法:选择从2012年1月至2017年1月在本院接受治疗的80例RGP患者作为观察组,另选同期在本院接受治疗的胆源性胰腺炎(GP)患者86例作为对照组,分析观察组患者的临床特征及两组患者的致病因素,采用Logistic回归分析RGP的危险因素。结果:在RGP患者的临床特征中,复发次数均较多,平均达到(3.21±0.23)次。发病诱因则主要是胆囊结石、胆总管结石及高脂血症;临床症状主要是黄疸、呕吐、恶心、腹痛、腹胀;并发症主要包括胆管炎、胰腺脓肿以及腹水;临床体征主要有出血征象、腹肌紧张、腹部压痛等。观察组的男性、重度胰腺炎、合并胆总管结石、胆胰管开口狭窄、有高脂血症、手术治疗的患者致病率分别高于对照组,并且观察组急性生理与慢性健康评分(APACHE-Ⅱ)明显高于对照组,差异均有统计学意义(P0.05)。由多因素Logistic回归分析可知,导致RGP的危险因素有男性、高APACHE-Ⅱ评分、重度胰腺炎、合并胆总管结石、胆胰管开口狭窄、有高脂血症以及手术治疗。结论:RGP患者的临床特征具有一定的规律性,其中男性、高APACHE-Ⅱ评分、重度胰腺炎、合并胆总管结石、胆胰管开口狭窄、有高脂血症以及手术治疗是导致RGP发生的危险因素。     

Cephalexin Levels in Human Bile in Presence of Biliary Tract Disease

Cephalexin was given to 24 patients before and after operation on the bile ducts and gall bladder. Two patients had obstructive jaundice. Samples of the bile were taken either directly from the gall bladder at operation or via the T-tube. Cephalexin was excreted in the bile, peak levels being obtained after two to three hours. These levels could be raised if probenecid was given concurrently. Higher levels were found in patients with functioning gall-bladders. A trial of cephalexin seems justified for the treatment of typhoid carriers.     

One-dimensional models of the human biliary system

This paper studies two one-dimensional models to estimate the pressure drop in the normal human biliary system for Reynolds number up to 20. Excessive pressure drop during bile emptying and refilling may result in incomplete bile emptying, leading to stasis and subsequent formation of gallbladder stones. The models were developed following the group's previous work on the cystic duct using numerical simulations. Using these models, the effects of the biliary system geometry, elastic property of the cystic duct, and bile viscosity on the pressure drop can be studied more efficiently than with full numerical approaches. It was found that the maximum pressure drop occurs during bile emptying immediately after a meal, and is greatly influenced by the viscosity of the bile and the geometric configuration of the cystic duct, i.e., patients with more viscous bile or with a cystic duct containing more baffles or a longer length, have the greatest pressure drop. It is found that the most significant parameter is the diameter of the cystic duct; a 1% decrease in the diameter increases the pressure drop by up to 4.3%. The effects of the baffle height ratio and number of baffles on the pressure drop are reflected in the fact that these effectively change the equivalent diameter and length of the cystic duct. The effect of the Young's modulus on the pressure drop is important only if it is lower than 400 Pa; above this value, a rigid-walled model gives a good estimate of the pressure drop in the system for the parameters studied.     

Ampicillin Levels in Human Bile in the Presence of Biliary Tract Disease

Ampicillin levels were measured in the serum and in the bile from both the gall bladder and the common bile duct in patients undergoing surgery for biliary tract diseases. In patients with radiologically non-functioning gall bladders ampicillin was either not present or its concentration was lower than normal. Therapeutic levels were present in the common bile duct of all patients except those with obstruction of the common bile duct. Hence ampicillin fails appreciably to penetrate the obstructed viscus in obstructive biliary tract disease, and it is unlikely to be effective in treating infection associated with this.     

Studies on the microvascularization of the digestive tract by scanning electron microscopy of vascular corrosion casts. 2. Bile duct in guinea pigs.

The microvascularization of the bile duct was studied in 20 adult guinea pigs (Cavia porcellus) using microvascular corrosion casts in the scanning electron microscope. The main supplying and draining vessels are located in the adventitial layer; from there they form the subepithelial capillary network. The microangioarchitecture of the common bile duct is reminiscent of that of the cystic and hepatic ducts. The diameter of these ducts is 1,000 microns on average. The microvascular arrangement in the bile duct suggests a probable involvement of the capillaries in the absorption of bile hormones.     

Epidemiology of typhoid carriers among blood donors and patients with biliary, gastrointestinal and other related diseases

Enteric fever due to Salmonella Typhi is a major public health problem. Typhoid carriers have high titres of Vi agglutinins in their sera. We worked out the baseline data for Vi agglutinins from 705 healthy blood donors (controls) by ELISA and compared it with 446 patients with biliary, gastrointestinal and other related diseases (cases). The samples were divided into five groups based on the disease condition of the patients from whom they were collected. Group A (n=196) consisted of patients with stones in the gall bladder/common bile duct and Group B (n=27) with gall bladder carcinoma. Group C (n=33) comprised patients with carcinoma of the pancreas/ampulla, obstructive jaundice and/or cholangiocarcinoma. Group D (n=112) had patients with acute/chronic pancreatitis, abdominal pain, intestinal obstruction, peritonitis, carcinoma oesophagus, chronic diarrhoea, gastrointestinal bleeding and dyspepsia. Group E (n=78) included patients with miscellaneous diseases. The mean absorbance value obtained for healthy subjects +3 standard deviations was taken as the cut-off value for a positive typhoid carrier. In Group A, 10.2% samples were positive; in Group B, 7.4%; in Group C, 12.0%; in Group D, 9.8% and in Group E, 9.0%. There was a highly significant (P <0.001) increase in the presence of Vi agglutinins in the cases compared to the controls. High prevalence of typhoid carriers occurs in patients with biliary, gastrointestinal and other related diseases. Vi serology employing highly purified Vi antigen offers a practical and cost-effective way of screening for S. Typhi carriers.     

The homeobox gene Hhex is essential for proper hepatoblast differentiation and bile duct morphogenesis

Hhex is required for early development of the liver. A null mutation of Hhex results in a failure to form the liver bud and embryonic lethality. Therefore, Hhex null mice are not informative as to whether this gene is required during later stages of hepatobiliary morphogenesis. To address this question, we derived Hhex conditional null mice using the Cre-loxP system and two different Cre transgenics (Foxa3-Cre and Alfp-Cre). Deletion of Hhex in the hepatic diverticulum (Foxa3-Cre;Hhex(d2,3/-)) led to embryonic lethality and resulted in a small and cystic liver with loss of Hnf4alpha and Hnf6 expression in early hepatoblasts. In addition, the gall bladder was absent and the extrahepatic bile duct could not be identified. Loss of Hhex in the embryonic liver (Alfp-Cre;Hhex(d2,3/-)) caused irregular development of intrahepatic bile ducts and an absence of Hnf1beta in many (cystic) biliary epithelial cells, which resulted in a slow, progressive form of polycystic liver disease in adult mice. Thus, we have shown that Hhex is required during multiple stages of hepatobiliary development. The altered expression of Hnf4alpha, Hnf6 and Hnf1beta in Hhex conditional null mice suggests that Hhex is an essential component of the genetic networks regulating hepatoblast differentiation and intrahepatic bile duct morphogenesis.     

ERCP术治疗胆总管结石的有效性及安全性分析

目的:分析经内镜逆行胰胆管造影术(ERCP)术治疗胆总管结石的有效性及安全性。方法:选择2017年1月～2018年8月在我院接受择期ERCP治疗的164例胆总管结石患者为研究对象,分析患者的手术情况、取石效果、手术前后胃肠疾病生活质量指数(GIQLI)量表评分和并发症的发生情况。结果:胆总管结石患者手术时间为(37.90±4.21)min、术中出血量(10.86±1.29)mL、术后通气时间(4.38±0.65)d、切口疼痛时间(1.02±0.12)d、住院时间(8.62±0.96)d、手术成功率为97.56%(160/164)、一次取净结石率为95.73%(157/164)、二次取净结石率为1.82%(3/164)。术后,胆总管结石患者GIQLI评分均显著高于术前(P0.05)。胆总管结石患者术后发生胰腺炎5例、胆管炎1例、出血6例、高淀粉酶血症4例。结论:ERCP术是胆总管结石患者的有效治疗手段,但需积极预防并处理相关并发症。     

Morphology of the digestive system of Antarctic nototheniid fishes Received: 24 November 1995/Accepted: 27 January 1996

 Although Antarctic nototheniid fishes are ecologically diverse, this survey of aspects of the anatomy and histology of the digestive system of 25 species showed little interspecific variation in the structure of this system. The gastrointestinal tract is illustrated and all but two species shared a similar pattern of intestinal coiling. The average number of pyloric ceca in most nototheniids was 6–7, with means ranging from 3.0 to 7.6. Reduction in the number of ceca was evident in both phyletically basal and derived species. Intraspecific variation in cecal number was nonexistent in some species, but in others ranged between 2 and 4 ceca. Numerous hepatic ducts, contained within the liver parenchyma, converged on the neck of the gall bladder. The bile duct penetrated the gut wall near the origins of the most dorsally located ceca. The terminal portion of the pancreatic duct paralleled, but did not join, the bile duct. The exocrine pancreas was diffuse and present in intercecal and splenic mesenteries, in the wall of the gall bladder and in tissue near the walls of the bile and pancreatic ducts. Unlike many other teleosts, the liver of nototheniids usually lacked pancreatic exocrine tissue. Nototheniids had a principal pancreatic islet (Brockmann body) and 2–3 accessory islets. Peritoneal melanism was a convergent feature of species living in the water column and probably served to screen the bioluminescence from gut contents.     

Oblique Bile Duct Predisposes to the Recurrence of Bile Duct Stones

Background and Study Aims

Bile stones represent a highly prevalent condition and abnormalities of the biliary tree predispose to stone recurrence due to development of biliary stasis. In our study, we assessed the importance of an altered bile duct course for stone formation.

Patients and Methods

1,307 patients with choledocholithiasis in the absence of any associated hepatobiliary disease who underwent endoscopic retrograde cholangiopancreatography (ERCP) between 2002 and 2009 were analysed. The angle enclosed between the horizontal portion of the common bile duct (CBD) and the horizontal plane was measured (angle α). Oblique common bile duct (OCBD) was defined as a CBD with angle α<45°.

Results

103 patients (7.9%) were found to harbour OCBD and these were compared to 104 randomly selected control subjects. Compared to controls, OCBD patients were (i) significantly older (72±13 vs. 67±13, p<0.00001); (ii) more frequently underwent a cholecystectomy (p = 0.02) and biliary surgery (p = 0.003) prior to the diagnosis and (iii) more often developed chronic pancreatitis (p = 0.04) as well as biliary fistulae (p = 0.03). Prior to and after ERCP, OCBD subjects displayed significantly elevated cholestatic parameters and angle α negatively correlated with common bile duct diameter (r = -0.29, p = 0.003). OCBD subjects more often required multiple back-to-back ERCP sessions to remove bile stones (p = 0.005) as well as more ERCPs later on due to recurrent stone formation (p<0.05).

Conclusion

OCBD defines a novel variant of the biliary tree, which is associated with chronic cholestasis, hampers an efficient stone removal and predisposes to recurrence of bile duct stones.     

An acetylcholinesterase method for in toto staining of peripheral nerves.

Stomach, small intestine, uterus, urinary bladder, vagina, mesentery, mesometrium and joint capsule of rats, gall bladder, cystic duct and bile duct of dogs and uteri of young children are stained in toto. Procedure: Tissue is perfused with saline containing hyaluronidase, then pinned on a flat layer of Paraplast and fixed for 24 hr in cold sucrose formol solution. Stomach, urinary bladder and gall bladder are also fixed in toto. Rinse for 2 days in cold 0.22 M sucrose in a sodium cacodylate buffer pH 7.2. Incubate in medium consisting of 60 mM acetate-buffer pH 5.0 or pH 5.6 (for human material only), 2 mM acetylthiocholine iodide, 15 mM Na citrate, 3 mM Cu sulphate, 0.5 mM K3Fe(CN)6, 5 times 10-4 M iso-OMPA, 1% Triton X 100 at 37C. Rinse in doubly distilled water. Dehydrate in glycerine/water mixtures of increasing glycerine content. Store in glycerine or delaminate under dissecting microscope. Delaminated specimens are mounted on gelatinized object glasses, cleared in xylene and coverslipped with Malinol. Specimens stored in glycerine can be studied microscopically. Stained specimens can also be embedded in Paraplast and sections can be studied after counterstaining.     

CHOLANGIOGRAPHY FOLLOWING COMMON DUCT DRAINAGE

In a series of 197 patients with extrahepatic biliary disease, 65 who had symptoms that met certain established criteria were operated upon to explore the common bile duct for stones. Stones or debris were found in 34 cases.Certain phases of the procedure used are being reevaluated.Because of unsatisfactory results with immediate cholangiograms, they were made only in selected cases in which the anticipated advantages outweighed the known disadvantages. Delayed cholangiography (10 or 12 days postoperatively) is considered a “must,” however, for determination of the presence of remaining stones. If residual stones are shown, they are removed as soon as possible.     

中国近十年胰管结石流行病学特征及诊治经验的Meta分析

目的:探讨中国近10年胰管结石的流行病学特征和诊疗经验的Meta分析.方法:联合检索中国知网和维普数据库有关胰管结石的文章,提取文章内有关数据输入特定excel表格,然后分类计算人数、性另q比例、百分比,分析胰管结石的流行病学特征和诊治经验.结果:中国从2000.1.1至2010.7.1共报道1841例胰管结石,男女比例为2.16:1,有准确年龄及平均年龄报道1585例,平均年龄45.68岁,平均年龄在35～55岁之间占总病例数81.86%.12.66%病例分布在浙江,为各省最多,96.91%的病人有腹痛表现.胰管切开取石,胰管空肠Roux-en-Y吻合术是最主要的治疗手段.结论:胰管结石男性好发,以中青年为主.浙江省病例最多,胰管切开取石,胰管空肠Roux-en-Y吻合术为主要治疗手段.     

Prevalence of gall stones in Dundee: a necropsy study.

Necropsy records from two large general hospitals in Dundee showed short-term fluctuations in the prevalence of gall stones that had not previously been described. There was no evidence of a rise in the standardised prevalence rate between 1902-9 and 1953-73. A spurious increase was apparent from the crude prevalence rates for these periods, which resulted simply from the increased age of the patients in the later period. Since there was no real increase in prevalence no conclusions can be drawn about dietary or other changes. Patients with stones in the common bile duct were likely to die from an associated cause. This related mainly to a high mortality rate in women. In patients with established epilepsy the prevalence of gall stones was greater than expected, which suggests that phenobarbitone does not diminish the likelihood of gall stones.