Jeffrey B. Matthews

Surgery or Endoprosthesis for Malignant Obstructive Jaundice

Layton F. Rikkers

Liver Transplantation in the Treatment of Bleeding Oesophageal Varices

William C. Dooley

John L. Cameron

Early Versus Delayed Surgery in Gallstone Pancreatitis

Traumatic injury to the extrahepatic biliary system is rare and usually diagnosed at laparotomy when it isassociated with other visceral injuries. Isolated gallbladder rupture due to blunt abdominal trauma is evenrarer. The clinical presentation of gallbladder injury is variable, resulting in a delay in diagnosis andtreatment. Awareness to the possibilty of trauma to the extrahepatic biliary system enables early surgicalintervention and eliminates the high morbidity associated with delated diagnosis.A 5 year old child with isolated gallbladder rupture caused by blunt abdominal trauma is presented.

P.  Schachter

A.  Czerniak

E.  Shemesh

I.  Avigad

G.  Lotan

I.  Wolfstein

Isolated Gallbladder Rupture Due to Blunt Abdominal Trauma

In a case operated on for calculous jaundice the right and left hepatic ducts drained directly into thegallbladder and the cystic duct was the only route by which hepatic bile reached the duodenum.Exploration of the inside of the gallbladder was a crucial step for the discovery of the anomaly. Continuityof bile drainage was secured by the preservation of a portion of the gallbladder which contained hepaticand cystic ducts.

A.  Elhamel

A Rare Extrahepatic Biliary Anomaly

Papillotubular adenoma of the ampullary region in a rare tumor which has the potential for malignanttransformation. Although reported more frequently nowadays, ampullary tumors are difficult to diagnosebefore operation unless they cause obstructive jaundice. Occasionally they are detected byultrasonography, computed tomography or ERCP in patients who complain of nonspecific upperabdominal discomfort.We report a case of a periampullary papilotubular adenoma causing generalized pruritus and weightloss but no jaundice. The tumor was extirpated by pancreaticoduodenectomy, and the patient hasremained healthy for over five years.

Minoru  Numata

Toru  Noguchi

Papillotubular Adenoma of The Ampullary Region

M. J. Hollands

R. Jaworski

K. P. Wong

J. M. Little

A Leiomyoma of The Liver

Twenty-four pyogenic liver abscesses have been treated during a six-year period percutaneously.
Percutaneous management included percutaneous drainage and fine needle aspiration under ultrasound
or CT scan guidance. Percutaneous management was successful in 92&#x25; of cases, and no further treatment
was required in 91&#x25; of these.One patient died, giving a mortality rate of 4.1&#x25;. There were no complications related to this method.
The authors conclude that percutaneous management of pyogenic liver abscesses should be attempted in
all cases, since results compare favourably with surgical procedures.

O. Helenon

M. Krachte

D. Mathieu

N. Vasile

N. Rotman

P. &#x2013;L. Fagniez

Percutaneous Management of Pyogenic Liver Abscesses

The pharmacokinetics of ciprofloxacin excretion have been studied in 54 patients undergoing biliary and
pancreatic operations with and without obstruction of the common bile duct. High concentrations were
achieved in common duct bile within 20 minutes of intravenous injection and persisted for over 3 hours
after 100 mg and for over 8 hours after 200 mg. The concentration of ciprofloxacin in the bile of functioning
gall bladders was much greater than that in the common duct bile. Remarkably, it was identified in
therapeutic concentrations in the bile of obstructed ducts. This and the rapid fall from initially high venous
concentrations probably reflect diffusion from the circulation as a result of the exceptional tissue
penetration. A unique feature of this study was the finding of clinically significant concentrations in the
bile of obstructed ducts.Two patients developed wound infection and no side effects were observed. The broad spectrum
antibiotic ciprofloxacin has potential as a useful agent for prophylaxis in biliary surgery maintaining biliary
and venous concentrations in excess of the MIC90 for most biliary pathogens for more than 8 hours.

C. S. Ball

J. Mck. Manson

Fiona Reid

D. E. F. Tweedle

The Pharmacokinetics of The Biliary Excretion of Ciprofloxacin

Differential diagnosis between pancreatic cancer and chronic pancreatitis is still difficult to establish. In
63 patients with suspected pancreatic neoplasm we performed: serum CA 19-9 assessment, abdominal
ultrasound, CT scan and CT-guided pancreatic percutaneous fine-needle biopsy. The conclusive diagnosis
was pancreatic cancer in 40 patients and chronic pancreatitis in 23 patients. With regard to the differential
diagnosis, sensitivity and specificity were respectively 80&#x25; and 78&#x25;  for serum CA 19-9, 75&#x25;  and 65&#x25;  for
abdominal US, 85&#x25; and 70&#x25;  for CT scan, 00&#x25; and 87&#x25;  for percutaneous fine-needle biopsy. We
conclude that CT-guided percutaneous fine-needle biopsy is the most reliable method for differential
diagnosis between pancreatic cancer and chronic pancreatitis.

Michele Carlucci

Alessandro Zerbi

Danilo Parolini

Sandro Sironi

Angelo Vanzulli

Carlo Staudacher

Agostino Faravelli

Paola Garancini

Alessandro del Maschio

Valerio di Carlo

CT-Guided Pancreatic Percutaneous Fine-Needle Biopsy in Differential Diagnosis between Pancreatic Cancer and Chronic Pancreatitis

Multiple surgical and nonsurgical approaches have been advocated for the treatment of proximal bile ductcancer. However, survival appears longest when a resection can be performed. Fifteen patients treated at auniversity center were managed with an aggressive surgical approach. Resection of the tumor wasperformed in 13 of 15 patients (87&#37;). Of the patients undergoing resection, major hepatic resection wasperformed in 8 (62&#37;), while excision of vessels with reconstruction was performed in 5 (38&#37;). Eleven ofthe 13 resected patients (85&#37;) were discharged from the hospital. Clinical symptoms of recurrent diseaseoccurred between 3 and 36 months after surgery in 7 patients, 6 of whom have died. Three other patientsare alive at 5, 21, and 36 months without clinical evidence of recurrence. There was no correlation betweenthe completeness of resection and the duration of disease-free survival.These results demonstrate that radical resection of high bile duct tumors can be accomplished with anacceptable early mortality rate, thereby extending the benefits of resection to a higher proportion ofpatients. While resection is clearly effective at controlling local disease and providing palliation of jaundice,surgical cure remains exceptional. Further improvement in the therapy of bile duct cancer must awaitdevelopment of more effective multi-modality approaches.

Jean C. Emond

James T. Mayes

Dale A. Rouch

J. Richard Thistlethwaite

Christoph E. Broelsch

Experience With Radical Resection in The Management of ProximalBile Duct Cancer

It is not known whether microcalculi possess structural differences compared with larger stones or
whether they represent simply an earlier stage in stone disease.We carried out a controlled study on 10 patients affected by gallbladder cholesterol microlithiasis (CM).
In all patients, samples from all parts of the stones were studied by X-ray diffraction and by infrared
spectrophotometry. Bile analysis was carried out to determine cholesterol, phospholipid and total bile
acid content. The cholesterol saturation indices (C.S.I.) were calculated. In all samples, bacterial bile
culture was carried out. The results were compared with those of 10 patients who had undergone
cholecystectomy for large cholesterol stones, and for 10 patients who had undergone abdominal surgery
but without biliary pathology. Patients in these latter groups were matched with the first according to sex
and age.Microcalculi proved to be layered (nucleus and external layer) in only 2 cases and larger stones in 9;
cholesterol was seen to be the principal crystalline component in all cases. Traces of bilirubin were found
in 7 CM and in the nuclei of 5 larger stones.These results show that the structural composition of microcalculi is similar to that of the nucleus of
larger stones. No substantial differences exist, however, between the two groups of patients regarding the
other parameters taken into consideration.

Leopoldo Sarli

Matteo Gafa&#x27;

Ernesto Longinotti

Fabio Carreras

Nicola Pietra

Anacleto Peracchia

Claudio Dotti

Simonetta Cavalier

Cholesterol Microlithiasis: Bacteriology, Gallbladder Bile and Stone Composition

This study investigated the effect of experimentally-induced cholestasis in the rat on the structure and
function of the zona fasciculata, the glucocorticoid secretory region of the adrenal cortex. Wistar-Furth
rats (200-250g) were assigned to three groups: bile duct ligated (BDL), Sham operated (Sham) and
unmodified normal control (NC). On day 14, serum bilirubin and liver histology were performed to
confirm cholestasis in BDL animals together with basal 24 hour 17-hydroxycorti-costeroid excretion,
adrenal histology and zona fasciculata ultrastructure in all experimental groups. Following this
laparotomy, structural and functional studies were repeated on day 15 to evaluate the response of the gland
to surgically induced stress. Basal 24 hr. 17-hydroxycorticoid steroid excretion was elevated in BDL animals
(26.9 ±3.2 μ g/24 hr) with respect to Sham (10.4 ± 2.3) and NC groups (13.5 ± 3.2) (p &lt;0.05). Adrenal
histology and ultrastructural studies demonstrated excessive accumulation of vesicles laden with
glucocorticoid biogenic precursors. Following surgical stress 24 hr 17 OH corticosteroid excretion increased
in all groups: BDL (31.0 ± 3.0 μg/24 hr) vs Sham (15.6 ± 1.8) and NC (14.5 ± 2.4) Moderate alterations
in zona fasciculata architecture were seen following surgery in all groups. Cholestasis induces overactivity
of the zona fasciculata of the adrenal cortex, and may modify the normal metabolic responses to surgical
and other stresses.

P. T. Roughneen

K. M. Tallon

Diane Haley Russell

B. J. Rowlands

Structural and Functional Alterations in The Zona Fasciculata of
The Rat Adrenal Cortex in Obstructive Jaundice

Significant obstructive jaundice in chronic pancreatitis is generally considered to be rare. Eleven of 57
consecutive patients with proven chronic pancreatitis have developed significant obstructive jaundice of
more than transient duration. Eight presented as jaundice complicating known pancreatitis and three as
jaundice of unknown cause.Life table analysis showed a steady rise in the risk of developing jaundice up to the end of 10 years from
the onset of chronic pancreatitis. Jaundice was found to occur in the presence of more “destructive”
disease, and jaundiced patients had a higher incidence of pancreatic calcification, diabetes and
malabsorption at the time of presentation with jaundice.Obstructive jaundice caused by chronic pancreatitis was found to carry a good prognosis for jaundice,
for pain and for life. Only one of the 11 patients died in hospital.It is important to distinguish chronic pancreatitis from cancer in these patients. Pre-operative and intraoperative
cytology have been helpful. Stent insertion is not an appropriate method of treatment for these
patients because of the benign nature of the disease and the possibility of exacerbating the pancreatitis. It is
important to be aware of another form of “malignant masquerade” causing obstructive jaundice.

Obstructive Jaundice in Chronic Pancreatitis

J. R. Goldring

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