The pattern of fall of serum bilirubin after operative relief of obstructive jaundice. A preliminary report

This is the beginning of a prospective study on patients who have obstructive jaundice to see how the serum bilirubin falls after operative relief of the obstruction. Seven of such patients have been studied; four had carcinoma of the head of the pancreas while the other three had choledocholithiasis. The patients with carcinoma had relief of the jaundice through a biliary-enteric anastomosis and those with common bile duct stones had choledochotomy with stone extraction which was completed with insertion of a T-tube. Serial bilirubin estimations were then performed post-operatively to chart the pattern and rate of descent of this in each patient. Our observations suggest that the pattern of fall of serum bilirubin after successful decompression of the extra-hepatic biliary tree exhibit a distinct pattern regardless of the surgical procedure performed for the relief of the obstruction.

Obstructive jaundice secondary to neuroendocrine tumour in a patient with von Recklinghausen's disease

Neurofibromatosis type 1 (NF1) is an autosomal dominant genetic disorder, with variable clinical manifestations and unpredictable course, associated with an increased incidence of various tumours. Plexiform neurofibromas are hallmark lesions of NF1; they are slow-growing tumours, which account for substantial morbidity, including disfigurement and functional impairment, and may even be life-threatening. Neuroendocrine tumours (NETs), a rare diverse group of neoplasms, are occasionally associated with neurofibromatosis. Pancreatic NETs are tumours with an incidence of less than 1/100 000 population/year and complex patterns of behaviour, which often need complicated strategies for optimal management. We present the case of a young adult with NF1, having a unique concurrence of plexiform neurofibroma involving the liver with an ampullary NET, and we discuss step by step the management in a specialist centre.

Biliary tract schwannoma: A rare cause of obstructive jaundice in a young patient

Schwannoma is a tumor derived from Schwann cells which usually arises in the upper extremities, trunk, head and neck, retroperitoneum, mediastinum, pelvis, and peritoneum. However, it can arise in the gastrointestinal tract, including biliary tract. We present a 24-year-old male patient with obstructive jaundice, whose investigation with computed tomography abdomen showed focal wall thickening in the common hepatic duct, difficult to differentiate with hilar adenocarcinoma. He was diagnosed intraoperatively schwannoma of common bile duct and treated with local resection. The patient recovered well without signs of recurrence of the lesion after 12 mo. We also reviewed the common bile duct schwannoma related in the literature and evaluated the difficulty in pre and intraoperative differential diagnosis with adenocarcinoma hilar. Resection is the treatment of choice for such cases and the tumor did not recur in any of the resected cases. (C) 2012 Baishideng. All rights reserved.

核素131I胆道腔内辐照支架的制作和动物实验及临床应用研究

恶性梗阻性黄疸(malignant obstructive jaundice,MOJ)发现时多为晚期,如不治疗生存期仅3个月。由于肿瘤位置特殊、患者一般情况较差,仅5%～20%的患者可行外科切除和分流手术,并且手术死亡率相当高,分流术病死率高达10%～43%。1974年Molnar和Stocknm首先采用PTCD术（经皮肝胆管内外引流术，Percutaneous Transhepatic Cholangic Drainage,PTCD）,使MOJ患者的临床症状得到缓解, 获得进一步治疗的机会。1989年金属支架开始应用于胆道系统,恢复了胆汁的生理性引流,并使大多数患者拔除引流管,提高了生活质量,成为非手术治疗MOJ的首选方法。但肿瘤生长是造成支架堵塞、黄疸复发的主要原因。文献报道MOJ患者放置金属支架后,支架堵塞的概率达20%～86%,其中大多数由肿瘤生长通过支架网眼或超过支架边缘引起。因此,在支架置放的同时如何积极控制肿瘤生长成为提高疗效的关键问题。MOJ的局部治疗方法有多种,但都存在不足之处。国内学者采用动脉化疗栓塞结合PTCD或支架置放的方法治疗MOJ,使患者的生存期得到延长。但引起MOJ的胆管癌、淋巴结转移癌、胰腺癌、壶腹癌多为少血供肿瘤,而且由于血供特殊,大部分病例碘油沉积欠佳,因此动脉化疗栓塞对这类肿瘤的作用是有限的。外辐照治疗对胆管癌、淋巴结转移癌、胰腺癌、壶腹癌等引起MOJ的肿瘤有一定疗效,并与胆道引流术结合应用于上述肿瘤引起的MOJ。由于瘤体周围有肝脏、胰腺、胃肠道、肾脏等对射线敏感的器官, 限制了外辐照剂量,影响了疗效的提高。近几年,一种斩新的治疗手段正在应用于临床，就是通过PTCD手术时建立的通道再行腔内辐照治疗(核素内辐照治疗),可以较好的控制肿瘤继续生长，抑制支架再狭窄的发生,可使MOJ的治疗取得更好的效果。本研究的目的就是探索胆道内辐照支架制作的可行性，并设计特别的施源器，其具体方法可以简述为：以球囊扩张器扩张重度狭窄胆管+置入特制的二腔单囊管+腔内低剂量率放疗+腔内热频热疗+胆管引流等联合方法治疗。同时，就该二腔单囊管内辐照支架的安全性进行动物实验，从分子生物学、核医学的角度阐述了实验研究的机理和病理改变，同时进行了临床的应用研究，探讨胆道支架发生再阻塞的相关因素及对策，进一步提高（MOJ）患者的生存期。本工作结果总结如下： 1 对放射源和施源器均进行了改进，放射源为液态放射性核素131I，施源器为可调节的长柱形球囊，是专门设计的硅橡胶二腔单囊管，其功能为：中腔通接胆管腔（蓝色），具有引流胆汁作用；另一腔管连接球囊（绿色），是长柱状形可调节长短的球囊，囊内装填放射性液态核素131I；囊内还设置射频加热电极，能加热升温。另外，还可以根据肿瘤的大小和长度，来调节施源器的长度（长柱形球囊），一般照射长度超出支架两端1-2cm。二腔单囊管内辐照支架的特点：剂量分布合理，低剂量率效应，射线能量适中，放疗、热疗同步实施，引流、扩张和局部用药作用。与其他治疗方法比较，这一核医学治疗技术的最大优点是：大直径柱状液态源，近似面源，液囊适形病变胆管腔，均匀贴紧病灶壁，剂量分布合理，γ射线能量适中，低剂量率持续照射，同时联合射频温热治疗及胆道引流、局部用药对症处理等。 2 动物实验研究结果指出，囊装液态131I支架对胆管壁的放射性损伤随131I放射性活度的增加而逐渐加重,呈现明显的放射性活度效应关系。而普通支架组胆管壁无放射性损伤,但是胆管壁粘膜层和肌层增生较131I支架组重,胆管出现再狭窄倾向。本研究为临床合理应用131I支架治疗胆管癌及胆管良性狭窄选择合适的131I放射性活度,提供了必要的剂量学和基础研究依据。 3 动物实验研究结果表明,131I支架组犬胆管组织Fas表达较普通支架组明显,且其表达水平的变化与犬胆管壁平滑肌细胞凋亡的检测结果相同。131I支架组胆管腔面积比普通支架组明显增加,胆管狭窄程度比普通支架组轻。这主要是由于131I辐射促进Fas 基因表达,诱导增殖性平滑肌细胞凋亡,从而减轻胆管损伤后愈合过程中的管腔狭窄。 4． 胆道恶性梗阻胆道腔内囊装液态131I辐照治疗施源的直径为8mm时是胆管充分扩张的最低限度,根据近距离放疗的剂量学特点,它能保证胆管癌腔内辐照治疗时将施源管因素导致的放疗反应和局部肿瘤复发减至最低。并具有创伤小,操作简单,疗效明显,易被患者接受的特点。 5．囊装液态131I治疗恶性梗阻性黄疸（肝门部胆管癌18例），临床疗效满意，随访7～21个月,3个月生存率83.33 %(15/ 18)；6个月生存率72.22%(13/18)；9个月生存率56.25%(12/16)；12个月生存率46.15%(6/13),15个月生存率36.33%(4/11)；18个月生存率22.22%(2/9),21个月生存率28.57%(2/7)。4例发生并发症,其中2例为放射性胆管炎胆道出血,1例为胆汁性腹膜炎,另1例是胰瘘胰腺炎

Experiencia en nefrectomía: serie de casos de cuatro años

Introducción: Las indicaciones por las cuales un paciente requiere una nefrectomía son múltiples: las neoplasias, la hidronefrosis y la exclusión funcional son las principales. En manos expertas la nefrectomía es un procedimiento seguro, especialmente porque en la actualidad el abordaje por excelencia es realizar una técnica mínimamente invasiva con conservación de nefronas. Se presenta el análisis de la experiencia en Mederi, Hospital Universitario Mayor en esta intervención. Metodología: Se realizó una serie de casos de pacientes llevados a nefrectomía entre mayo de 2008 y mayo de 2012. Se incluyeron la totalidad de los casos. Resultados: Se analizaron 72 registros, 49 mujeres y 25 hombres; 13 de ellas fueron laparoscópicas. La edad promedio fue de 58,6 años. El tiempo medio operatorio fue 169,23 minutos (118-220 minutos). El sangrado operatorio promedio fue de 680,63 ml (IC95%: 2,83-1358 ml). El tiempo de hospitalización promedio fue de 4,88 días IC95%. La mayoría de los pacientes se distribuyeron en estadios medios de la enfermedad tumoral, con poco compromiso ganglionar y metástasis; el diagnóstico histológico y estadio dominante fueron el carcinoma de células renales grado 3 de Fuhrman respectivamente. Se reportan 13 casos de compromiso de la capsula de Gerota y 11 con compromiso del hilio. Discusión: La experiencia en nefrectomía de la institución es muy positiva por el bajo número de mortalidad y complicaciones. En cuanto a la técnica, es importante promover la técnica laparoscópica

Biliary intervention augments chemotactic reaction and aggravates cholestatic liver injury in rats

Background
Intervention of the biliary system is frequently done in patients with obstructive jaundice and is associated with significant morbidity and mortality. The pathogenesis is unknown.
Materials and methods
A rat model of bile duct ligation (BDL) for 2 weeks was established in which biliary intervention was feasible by injection of normal saline through an indwelling catheter in the bile ducts. Plasma levels of C-C chemokine MCP-1 and C-X-C chemokine MIP-2 were measured by using ELISA. Blood monocytes, Kupffer cells, and neutrophils in the liver were characterized with antibodies to ED1, ED2, and myeloperoxidase (MPO). Lipid peroxidation was measured by malondialdehyde contents and apoptosis by TUNEL stain of the liver.
Results
Biliary intervention resulted in an increase of plasma MCP-1 and MIP-2 proteins by 1 h, which declined to normal level by 3 h in both sham and BDL rats. The levels in BDL rats were significantly higher than in sham at most points. There was a transient increase of ED1- and ED2-positive cells and MPO-staining cells in sham rat liver by 1 h after intervention. ED2-positive cells increased significantly by 1 h, while ED1- and MPO-positive cells decreased, yet insignificantly after intervention in BDL rats. The cell counts in BDL were constantly higher than in sham. Malondialdehyde increased precipitously in BDL by 3 h and was significantly higher than in sham throughout the study period. Parenchymal liver injury, manifested by elevated ALT, as well as apoptosis and necrosis of liver cells, was significantly increased in BDL rats, but not in sham rats.
Conclusion
Biliary intervention augments chemokine expression, precipitates lipid peroxidation, and aggravates liver injury in cholestatic rats.

Inflammatory pseudotumour of the liver : the residuum of a biliary cystadenoma?

Inflammatory pseudotumour is a rare form of a liver mass. We report the case of a 28-year-old man presenting with obstructive jaundice, in whom an inflammatory pseudotumour arose with the resolution of a mucus secreting cystic liver lesion. The initial features suggested an intrahepatic cystadenoma or cystadenocarcinoma, which on its involution left a solid mass. Histopathology showed an inflammatory pseudotumour with no evidence of malignancy. A similar case has been reported recently, with the development of an inflammatory pseudotumour following collapse of a liver cyst seen on imaging. These two cases may shed some light on the origins of these rare liver lesions.

Translocação bacteriana para o pulmão na icterícia obstrutiva experimental em ratos

RESUMO: Objetivo: Tem sido demonstrado que a icterícia obstrutiva provoca depressão do sistema imunológico, mudança no padrão de colonização bacteriana dos intestinos e passagem de bactérias da luz intestinal para a circulação porta e sistêmica. Estudo experimental em ratos procurou observar a possibilidade de translocação bacteriana para os pulmões após a ligadura do colédoco. Método: Foram utilizados 20 ratos Wistar pesando de 178 a 215g, separados aleatoriamente em dois grupos iguais. Nos ratos do grupo I foi feita a ligadura do colédoco e nos do grupo II apenas a manipulação do colédoco com pinça atraumática (sham operation). No sétimo dia de observação os animais foram mortos com superdose de anestésico, sangue foi colhido para dosagem de bilirrubinas e os pulmões ressecados sob condições assépticas. Metade de cada pulmão foi homogeneizada e semeada em meios de cultura ágar McConkey e ágar sangue. A outra metade serviu para exame histopatológico –coloração hematoxilina e eosina. Os dados foram analisados pelo teste t, com significância 0,05. Resultados: revelaram bilirrubina total em média 18,7±3,6 no grupo I e 0,7±0,2 no grupo II. No grupo I foram isoladas colônias de Klebsiela sp nos pulmões de 30% dos animais e E. coli em 20%, e os escores histopatológicos atingiram a média 6,2±2,08. No grupo II não foram detectadas bactérias nos pulmões e os escores do exame histopatológico atingiram 1,8±1,16. A diferença dos dados analisados mostrou-se significativa (p<0,05). Conclusões: Concluiu-se que a icterícia obstrutiva por ligadura do colédoco em ratos provocou translocação de germes Gram-negativos para os pulmões e resultou em alterações histopatológicas significativas.

Biliary tract reconstruction using jejunal tube: an experimental study in dogs

BACKGROUND: To physiologically reconstruct the biliary tract, Crema et al suggested the application of the Monti principle to the biliary tract, already used in humans for the urinary tract. With this technique, a jejunal segment is transversely retubularized. This study aimed to evaluate the efficacy of jejunal tube interposition between the common bile duct and duodenum in dogs.METHODS: Thirteen dogs underwent a laparoscopic common bile duct ligature, followed by a biliodigestive connection by jejunal tube interposition after one week. The levels of glutamic-pyruvic and glutamic-oxalacetic transaminases, total bilirubins, alkaline phosphatase and gamma-glutamyltransferase were assessed before surgery and thereafter weekly until euthanasia, which was performed 6 weeks after biliodigestive connection.RESULTS: Data on 9 dogs were analyzed statistically. The dogs presented with obstructive jaundice after common bile duct ligature, as confirmed by biochemical examination. They showed a statistically significant reduction in cholestasis after biliodigestive connection by jejunal tube interposition and were healthy until the end of the experiment.CONCLUSION: A statistically significant reduction was seen in total bilirubin and canalicular enzymes (alkaline phosphatase and gamma-glutamyltransferase) in the 9 dogs 6 weeks after biliodigestive conviction by jejunal tube interposition.

Proposal of a new technique for bile duct reconstruction after iatrogenic injury. Study in dogs and review of the literature

Purpose: Interposition of a jejunal tube between the common bile duct and duodenum. Methods: Five adult mongrel dogs of both sexes, weighing on average 22.3 kg (18 to 26.5 kg), were used. Obstructive jaundice was induced by ligation of the distal common bile duct. After one week, a 2.5-cm long jejunal tube was fabricated from a segment of the loop removed 15 cm from the Treitz angle and interposed between the common bile duct and duodenum. Results: The animals presented good clinical evolution and no complications were observed. After 6 weeks, complete integration was noted between the bile duct mucosa, tube and duodenum and a significant reduction in total bilirubin and alkaline phosphatase was observed when compared to the values obtained one week after ligation of the common bile duct. Conclusion: The jejunal tube interposed between the dilated bile duct and duodenum showed good anatomic integration and reduced total bilirubin and alkaline phosphatase levels in the animals studied.

Pancreatic adenocarcinoma in a patient with situs inversus: a case report of this rare coincidence.

BACKGROUND: Situs inversus (SI) is a relatively rare occurrence in patients with pancreatic adenocarcinoma. Pancreatic resection in these patients has rarely been described. CT scan imaging is a principle modality for detecting pancreatic cancer and its use in SI patients is seldom reported. CASE PRESENTATION: We report a 48 year old woman with SI who, despite normal CT scan 8 months earlier, presented with obstructive jaundice and a pancreatic head mass requiring a pancreaticoduodenectomy. The surgical pathology report demonstrated pancreatic adenocarcinoma. CONCLUSION: SI is a rare condition with concurrent pancreatic cancer being even rarer. Despite the rarity, pancreaticoduodenectomy in these patients for resectable lesions is safe as long as special consideration to the anatomy is taken. Additionally, radiographic imaging has significantly improved detection of early pancreatic cancer; however, there continues to be a need for improved detection of small neoplasms.

Hidatidose hepática complicada : revisão da literatura : a propósito de um caso clínico

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014