In patients with portal hypertension, particularly with extrahepatic portal vein obstruction, portal biliopathy producing biliary ductal and gallbladder wall abnormalities are common. Portal cavernoma formation, choledochal varices and ischemic injury of the bile duct have been implicated as causes of these morphological alterations. While a majority of the patients are asymptomatic, some present with a raised alkaline phosphatase level, abdominal pain, fever and cholangitis. Choledocholithiasis may develop as a complication and manifest as obstructive jaundice with or without cholangitis. Endoscopic sphincterotomy and stone extraction can effectively treat cholangitis when jaundice is associated with common bile duct stone(s). Definitive decompressive shunt surgery is sometimes required when biliary obstruction is recurrent and progressive.

Symptomatic biliary obstruction in patients with extrahepatic portal hypertension may be relieved by a portasystemic shunt. Rarely biliary bypass may be required and is rendered safer by previous portasystemic shunting to decompress the pericholedochal varices. A direct approach to the biliary tract without a preliminary shunt may be hazardous and is frequently unnecessary.

LNR is a strong predictor of outcome after curative resection for GBC. The retrieval and examination of at least 6 nodes can influence staging quality and DFS in node-negative patients.

Background: Surgical repair for a postcholecystectomy bile duct injury can be complicated by the development of an anastomotic stricture which necessitates re-intervention. The authors reviewed their experience with patients requiring re-operation after unsuccessful surgical repair of the bile duct injury, to analyze the possible causes of the failure of the operative procedure and the long-term outcome following revisional surgery. Methods: Retrospective analysis of the records of 41 patients referred to a tertiary care center for the management of recurrent stricture following surgical repair performed for a postcholecystectomy bile duct injury. Results: Before referral, 69 operative procedures had been performed on these 41 patients. Factors likely to be associated with increased chances of failure of the biliary reconstructive procedures included presentation with cholangitis after the biliary injury, no cholangiographic study before the surgical repair and surgical intervention within 3 weeks of the injury. Thirty-seven (90%) patients were found to have strictures at or above the level of confluence of right and left hepatic ducts, while at the time of the index repair only 12 (29%) patients had an injury at that level. Revisional surgery in all the patients was a Roux-en-Y hepaticojejunostomy. One patient died, 2 patients with multiple previous operations developed recurrence and needed intervention again. Over a mean follow-up period of 4.2 years, 90% patients had a satisfactory outcome. Conclusion: Development of recurrent stricture following surgical repair of a postcholecystectomy biliary injury can be related to the technique and timing of the surgical procedure, the complication may therefore be avoidable in some patients. In experienced hands the results of revisional surgery are good but are adversely affected as the number of previous repairs increases.

No abstract

Isolated Roux loop pancreaticojejunostomy is not superior to conventional PJ; instead, it increases the duration of surgery.

Gastric cicatrization is a well recognized late sequela of corrosive gastric injury, but the optimum timing and type of surgery for this complication are still unclear. Over a 7-year period (1988-1994) 34 patients underwent elective surgery for gastric lesions secondary to corrosive ingestion. A total of 18 (53%) patients had an associated esophageal stricture and presented with dysphagia, 15 (44%) patients had features of gastric outlet obstruction, 6 (18%) had diffuse gastric injury, and 28 (82%) had a segmental lesion. A tube jejunostomy was done in 23 (68%) patients to improve nutrition and resulted in a significant increase in weight and in the serum protein level after 8 weeks of tube feeding. Elective surgery was performed 3 to 24 months (average 7 months) after ingestion of the corrosive substance. Gastric resection was done in 20 (59%) patients and gastrojejunostomy (without vagotomy) in 11 (32%); at follow-up the latter group did not exhibit development of a stomal ulcer. In patients with an associated esophageal stricture, endoscopic dilatation was successful in 89% patients and simplified the surgical approach. In conclusion, the success of surgery for corrosive-induced gastric injury depends on selecting the right procedure and intervening at the appropriate time.

Choledochal cysts in children and adults may behave differently. To identify these differences the records of 49 patients (22 children and 27 adults) who underwent surgery for choledochal cysts over a period of 7 years were analysed retrospectively. In two adult patients who had undergone a previous cholecystectomy an acquired malformation could not be excluded. Cholangitis was more common in adults. Choledochal cysts in children were predominantly Type I cystic lesions, whereas Type IV cysts were more common in adult patients. Anomalies of the pancreatic duct and associated hepatobiliary problems were seen exclusively in adults and the latter can make excision of the cyst more difficult and complicated. To prevent the development of complications choledochal cysts should be excised as soon as they are detected.