An unusual biliary obstructive syndrome

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<ul><li><p>An Unusual Biliary Obstructive i </p><p>Jomq P. TRO.XLX~AI.D, ,XLD., Portland, Oregon </p><p>Syndrome </p><p>T IlE symptoms and signs of acute ehole- cystitis are usually clear-cut. In diagnosing chronic cholecystitis there is always time for a thorough case study. When calculi are present the problem is most often not a difficult one. It is non-calculous disease of the extrahepatic biliary tract which throughout the history of medicine has been a source of controversy from the viewpoint of diagnosis and therapy. Oral cholangiography has been helpful, and more recently intravenous cholangiography has con- tributed additional information in certain cases. However, a good historyis still by far the most essential diagnostic factor. This must not be ignored when symptoms persist or recur in spite of normal x-ray and laboratory findings. </p><p>The purpose of this paper is to review the significant features of three cases with history and physical findings typical of extrahepatic biliary obstruction, all having normal oral cholecystograms. Unfortunately intravenous cholangiography was not available when these cases were studied. </p><p>All the patients had similar pain, in the right upper quadrant or mid-epigastrium, frequently radiating through to the right subscapular region. This pain was intermittent, often severe and lasted from a few minutes to several hours, usually appearing after a meal. The total durations were one, two and four years, and in all the pain was disabling to the point that a state of near invalidism had been reached. Nausea and vomiting occurred, but not as frequently as the pain which came every day or two, sometimes as a heavy dull ache in the mid-epigastrium, sometimes as an excruciating, squeezing biliary colic. Loss of weight was another common feature, so much so that in the two older patients pancreatic malignancy was seriously considered. It was not a true anorexia, but rather fear of pain that kept these patients from taking adequate nourishment. </p><p>Examination showed tenderness over the </p><p>307 </p><p>area of the gallbladder or mld-epigastrium, or both. No masses were palpated. No clinical jaundice was present nor was the icterus index elevated. Liver function tests were carried out in one patient and gave normal results. </p><p>Oral choleeystograms and upper gastro- intestinal x-ray studies were normal in all three patients. Pyelograms taken of two of the patients were negative. Unfortunately, no special effort was made to visualize the common duct. In the future we plan to take advantage of intravenous cholangiography in cases of this </p><p> type now that it is available. Surgery was recommended only after a fair </p><p>trial of medical treatment, consisting mainly of antispasmodics and dietary management. No reasonable relief was thus obtained, and all of these patients pressed for an operation because of the severity and chronicity of their pain and its concomitant disability. The possibility of psychoneurosis had been considered in two of these patients, and certainly such patients can and do appear psychoneurotic and the evalua- tion of their pain is sometimes quite difficult. </p><p>At operation the common duct in all three patients was definitely dilated to 8 or 9 mm. Several enlarged lymph nodes along the com- mon duct were found in two patients. In all three the gallbladder was slightly more opaque than normal due to a minimal thickening, but was freely compressible and without stones. The liver and pancreas were normal in appear- ance and to palpation, and there was no evi- dence of gastric or duodenal ulcer. </p><p>Because of inability to pass a 3 ram. Bakes dilator through the sphincter, duodenotomy was carried out. In one patient a pinpoint, markedly fibrotic papilla was encountered; in the other two only moderate narrowing and fibrosis were noted. In all three the fibrotic ring was transected, allowing dilatation up to I cm. Routine exploration revealed no common duct stones. The gallbladder was then removed </p><p>American Journal o.[ Surgery', Volume 92, August, z956 </p></li><li><p>Trommald </p><p>Fro. I. Bakes dilator pressing stenosed papilla forward against anterior duodenal wall. This marks center of small transverse incision to be made in anterior wail. Duodenum should be modillzed laterally when necessary. </p><p>after insertion of a loose fitting, long-limbed T-tube and closure of the duodenotomy in- cision. The gallbladders were reported by the pathologist as showing "chronic cholecystitis." It is well to remember that in any large series of postmortem examinations at least 60 to 75 per cent of gallbladders examined are the site of some pathologic change? Judd quite aptly stated that no one actually knew what constituted "chronic cholecystitis" either from tile standpoint of clinical symptoms or from that of pathologic findings? A biopsy specimen taken from the pinpoint sphincter showed marked fibrosis. </p><p>To date, two of tile patients, a sixty-five year old housewife and a forty-three year old logger, have had complete relief from their pain and each has gained back the zo pounds lost prior to surgery. It is well over two years since their operations. The third patient, a twenty-three year old housewife, has been entirely symp- tom-free except for two attacks of pain; the first lasted twenty hours and the ntore recent, three hours. All three patients believe that the surgery has been well worth while. </p><p>TECHNIC OF TRANSDUODENAL SPttlNCTEROTOYM </p><p>AND REVIEW OF OPERATIVE EXPERIENCES </p><p>Figures i, a and 3 demonstrate points to be kept in mind during transduodena[ sphincter- </p><p>Fro. 2. Note presenting tip of Bakes dilator. Insert shows most important step of operation, the grasping of posterior duodenal wall with an Allis foreep on each side of papilla. </p><p>otomy. The most important step in our experi- ence is to secure firm hold of the posterior duodenal wall with an Allis clamp on each side of tlle papilla before the dilator is forced through. In this way tile papilla is under con- trol at all times and the whole procedure can be performed with ease through a small trans- verse incision in the anterior dnodenal wall without undue trauma to tile delicate edges of tile duodenotomy incision. </p><p>In tile past ten years I have performed twenty-one sphincterotomies in twenty pa- tients, the average age being fifty-four 5"ears. Eighteen had definite fibrosis, and fourteen of these had calculous disease. The common duct has been dilated in all these patients except one where it was considerably thickened. Common duct stones were noted in three patients, two of whom had jaundice. The only other patient with jaundice, our first and most severe ease of fibrosis, was operated on ten years ago. There were no stones in the gall- bladder which was markedly shrunken and thickened, nor were there ans; stones in the common duct. There was complete ampullary obstruction and deep jaundice, and the liver showed gross evidence of damage. His health since sphincterotomy has remained excellent to date. </p><p>Fibrosis has been suspected when a 3 ram. </p><p>308 </p></li><li><p>An Unusual Biliary </p><p>Bakes dilator could not be passed through the sphincter of Oddi from above. We lmve more recently come to believe that fibrosis should be considered when a 4 mm. dilator meets per- sistent unyielding resistance at the sphincter. Duodenotomy is carricd out in all such cases, the papilla visualized and sphincterotomy per- formed when fibrosis exists. </p><p>Eleven short-limbed and ten long-limbed T-tubes have been used with equally good results, most of them having been removed at the end of the second or third week. There has been no suturing in the ampullary region except in one patient in whom a false passage was made while trying to force a 3 ram. sound under direct vision. Here it was necessary to repair the laceratcd ampullary and common duct wails. In such circumstances we believe the use of a long-limbed tube is advisable, and leave it in for two or three months. Whenever such a tube has been used we have been careful to see that its diameter is 3 or 4 ham. less than that of the common duct and ampulla, giving a loose fit so that the opening of the pancreatic duct would not be obstructed. Mahorner rec- ommends fenestrating the portion of the tube running through the common duct. Cattetl ~- believes that a snug-fitting tube is all right, and in his extensive experience has not thought that the pancreatic duct opening was ever thus obstructed. There' has been no flare up of pancreatitis in any of our patients. </p><p>Three duodenal fistulas occurred, all appear- ing the sixth or seventh day. They healed spon- taneously, two of them in a week with only slight drainage, the third being quite serious and persisting for two months with copious drainage. In the third patient, a serious case, a short-Iimbed T-tube had been used. Should a duodenal fistula occur we cannot help but believe that one is better off when a Iong- limbed T-tube has been used, and healing should be quicker. \\re have been equally satis- fied with short- and long-limbed T-tubes in most cases, but would favor the use of the long-limbed T-tube when there has been undue trauma in the ampullary region necessitating sutures, or when duodenal closure has been unsatisfactory or difficult due to injury of the duodenal walk </p><p>One postoperative hemorrhage into the bowel occurred on tbe first postoperative day. This must have been from the sphincterotomy site or the duodenotomy incision. It subsided </p><p>Obstructive Syndrome </p><p>1 . . . . . . . . . . . . . . </p><p>FIG. 3- Bakes dilator is forced through fibrotlc sphincter and (insert) is followed back with straight hemostat. Its jaws are then spread and fibrotic sphincter incised its full length while held on stretch, making certain to cut through all the fibrotic area in superior lip of papilla. </p><p>spontaneously after a loss of approximately 1,5oo cc of blood. </p><p>There have been no deaths, and good results have been obtained in all of the cases we have been able to follow (eighteen of the twenty) except one. In this patient sphlncterotomy was repeated because of recurring symptoms, and he has been well since the second operation four years ago. Either the fibrotic area had been incompletely incised or fibrosis had recurred. </p><p>The gallbladder should always be removed after sphincterotomy, regardless of its condi- tion, inasmuch as it ceases to function. 3 \Ve know of two cases in which this was not done and cholecystectomy was later necessary to relieve troublesome symptoms. Animal experi- ments 3 and clinical experience ~ have proved that a properly incised sphincter remains incompetent and retracted with or without a long-limbed T-tube. Postoperative choledo- chograms have been taken two weeks following surgery in patients in whom the short-limbcd tubes have been used and have shown normal- sized ducts with rapid emptying. It is our plan to carry out cholegrafin studies in the patients who have had sphincterotomy over two years ago. </p><p>309 </p></li><li><p>Trommald </p><p>Anyone wishing to review the subject of sphincterotomy should refer to the papers of Strode, 5 Cattell and Coleock, 6 Doubilet and hluIhoIIand, 3a Mahorner and Browne, s.9 and Partington.~ </p><p>A COMMENTS </p><p>Ogilvie n recently wrote an artlcle advising any yoting surgeon who would keep the respect of his students, the trust of his colleagues and the integrity of his conscience to deny the existence of non-calculous gallbIadder disease and chronic appendicitis, or at least to refuse a fee for operating on them. "Only in middle life when he has set his r~putatlon in an unas- sailable position by years of honest dealing may he admit to himself that such lesions do exist, and recommend to patients that they be treated by operation." </p><p>This was also the teaching during our medical school and postgraduate years and certainly the burden of the proof is on the surgeon who removes numerous functioning non-calculous gallbladders and fails to obtain symptomatic relief for the patient. </p><p>In our total surgical experience we have removed six non-calculous gallbladders, two of them in secondary operations foIIowing cholecystostomy for empyema without calculi, the three reported here, and one in which per- sistent spasm of the sphincter was thought to be present. Sphincterotomy was considered necessary in the four non-acute cases. AIl have been relieved of their symptoms for two years or more. </p><p>It is our intent to continue a conservative policy towards non-calculous gallbladder dis- ease. Nevertheless, there are patients much like the three reported herein who drift from one physician to another without relief because too little attention is paid to their complaints and too much to their negative x-ray and laboratory findings. Partington ~ reported three very similar cases in I952 , bug was able to give excellent preoperative radiographic evidence of a dilated common duct and fibrotic terminal common duct in each instance. </p><p>Cattell and Colcock 8 reported only seventeen patients as having appreciable common duct dilatation of forty-nine in whom fibrosis of the sphincter of Oddi was demonstrated. There- fore, this condition must be considered even when a normaIly sized common duet can be radiographical[y demonstrated, so Iong as there </p><p>is a good history and a careful differential diagnosis has been accomplished. In our own series a dilated common duet has been present in seventeen of eighteen cases of proved fibrosis. </p><p>In I933 Strauss ~2 reported an interesting series of eases with chronic biliary ~tasis. He suggested that the fibrosis encountered in </p><p>I cases similar to ours had as its pathologic basis an infection which begins as a duodenitis and ascends the common duct and also the pan- creatic duct in the 9o per cent having a "com- mon channel." "These cases all have as the pathological basis of their symptoms an in- filtrative inflammatory process of the Iower portion of the common duet, with thickening and narrowing of the ampulla of Vater." We are inclined to agree with this except that spasm and inflammation without actual infec- tion may well be the trigger mechanism which sets off the ampullary involvement. Just when spasm or so-called hypertonie dyssynergia n enters the picture is difficult to ascertain, but certainly it must play a definite part. The end result of this type of ampullary obstruction can result in liver and pancreatic damage if unreIieved. </p><p>SUMMARY AND CONCLUSION </p><p>Three cases have been reported with symp- toms typical of cxtrahepatic biliary obstruction and having normal oral choIccystograms. At operation all had dilated common ducts and either a marked or incipient fibrosis of the sphincter of Oddi without calculi. All have been relieved for two years or more by transduo- dcnaI sphinctcrotomy and cholecystectomy. A discussion of our experience with transduodenaI sphincterotomy has bccn given. There may be a small number of cases encountered in any series brought to surgery for biliary disease in which the history, regardless of negative x-ray and laboratory findings, has made operation mandatory. The...</p></li></ul>

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