Bile Duct Patency Research Articles

Minimally Invasive Cholecystostomy in the Dog: Evaluation of Placement Techniques and Use in Extrahepatic Biliary Obstruction

To evaluate 4 methods of cholecystostomy catheter placement and to report on laparoscopic (Lap) cholecystostomy for the management of extrahepatic biliary obstruction (EHBO) in 3 dogs. Experimental study and clinical report. Cadaveric dogs (n=20); 2 canine and 1 feline patient. Pigtail cholecystostomy catheters were inserted in 20 canine cadavers using ultrasound (US) or Lap guidance. Insertion routes were either transperitoneal or transhepatic. Methods studied included Lap-transperitoneal, US-transperitoneal, US-transhepatic, and US-Seldinger (n=5 dogs/group). Insertion success, pleural penetration, and insertion site leakage (Lap-transperitoneal group) were evaluated. Three clinical EHBO cases were treated by Lap-transperitoneal technique. Insertion success was 100% by Lap-transperitoneal but 0% with US-transperitoneal and US-Seldinger methods. US-transhepatic yielded 3 of 5 successful placements. The pleura was penetrated in all US-transhepatic and US-Seldinger insertions. Leakage pressure for Lap-transperitoneal catheters averaged 75 cm H2O (+/-20 cm H2O). Lap-transperitoneal cholecystostomy resulted in marked improvement in 2 dogs, but the catheter became obstructed in the cat. One dog spontaneously regained common bile duct patency and the remaining 2 animals had successful cholecystoenterostomy. In cadaver testing, the Lap-transperitoneal cholecystostomy method was superior based on high insertion success with no pleural penetration. In 2 clinical cases, Lap-transperitoneal placement successfully provided biliary drainage for patient stabilization. The role for temporary cholecystostomy has yet to be established, but may aid patient stabilization and mortality reduction in EHBO.

Endoscopic treatment of anastomotic biliary strictures after deceased donor liver transplantation: outcomes after maximal stent therapy

The optimal endoscopic treatment for anastomotic biliary strictures after deceased donor liver transplantation is undefined. Endoscopic therapy with conventional methods of biliary dilation and stent placement has been successful but often requires prolonged therapy. To determine the outcomes of an aggressive endoscopic approach that uses endoscopic dilation followed by maximal stent placement. Tertiary-care academic medical center. Of 176 patients who underwent deceased donor liver transplantation between June 1999 and July 2004, 25 were diagnosed with anastomotic biliary strictures. Patients were treated endoscopically with a combined technique of balloon dilation and maximal stent placement. Treatment outcomes, including bile-duct patency, a need for surgical intervention, morbidity, and mortality, were evaluated retrospectively. Endoscopic dilation followed by maximal stent placement was performed until resolution of strictures in 22 of 25 patients (88% immediate success on intent-to-treat analysis). Persistent resolution of strictures was achieved in 18 of these 22 patients. Re-treatment was successful in 2 of 4 patients with recurrent strictures. Overall, 20 of 22 patients who completed endoscopic therapy (91%) avoided surgical intervention. Median duration of endoscopic treatment was 4.6 months. Patients with early onset strictures required a significantly shorter duration of endoscopic therapy (3 vs 9 months; P<.01). Multiple stent placement was not technically difficult, and no major complications were encountered. Aggressive endoscopic therapy with combined biliary dilation and maximal stent placement allows resolution of anastomotic biliary strictures after deceased donor liver transplantation in a relatively short period, with sustained success and minimal complications.

Correlation between hepatobiliary scintigraphy and surgery or postmortem examination findings in dogs and cats with extrahepatic biliary obstruction, partial obstruction, or patency of the biliary system: 18 cases (1995–2004)

To evaluate the usefulness of serum biochemical variables and scintigraphic study results for differentiating between dogs and cats with complete extrahepatic biliary obstruction (EHO) and those with partial EHO or patent bile ducts. Retrospective case series. 17 dogs and 1 cat. Animals that underwent hepatobiliary scintigraphy and had either surgical or postmortem confirmation of the degree of bile duct patency were included. Scintigraphic images were evaluated and biliary tracts were classified as patent, partially obstructed but patent, or obstructed. Surgery or postmortem examination was considered the gold standard for diagnosis, and compared with those findings, sensitivity and specificity of scintigraphy were calculated. With absence of radioactivity in the intestinal tract as the diagnostic criterion for EHO, the sensitivity and specificity of scintigraphic diagnosis were both 83% when final images were acquired at 19 to 24 hours, compared with 100% and 33%, respectively, when 180 minutes was used as the cutoff time. Animals with partial biliary obstruction had less intestinal radioactivity that arrived later than that observed in animals with patent biliary tracts. Animals in which intestinal radioactivity has not been observed after the standard 3 to 4 hours should undergo additional scintigraphic imaging. Findings in animals with partial biliary obstruction include delayed arrival of radioactivity and less radioactivity in the intestine. Distinguishing between complete and partial biliary tract obstruction is important because animals with partial obstruction may respond favorably to medical management and should not be given an erroneous diagnosis of complete obstruction.

Bilioenteric Reconstruction for Small Bile Ducts Without Mucosa-to-Mucosa Alignment

Biliary reconstruction of the small bile duct is difficult, and bilioenteric reconstruction without mucosa-to-mucosa alignment would be a simple and useful maneuver in this situation; however, the long-term results of this surgical technique remain to be evaluated. To evaluate the usefulness of bilioenteric reconstruction without mucosa-to-mucosa alignment from the standpoint of the long-term results. Retrospective review. University hospital. Bilioenteric reconstruction without mucosa-to-mucosa alignment was performed in 17 patients at our institution. Six patients had malignancy, and 11 were liver transplant recipients from a living donor. Clinical records, blood chemistry data, and findings from dynamic computed tomography. Among the 17 patients, 4 died of recurrent malignant disease, and 3 died of thrombosis, brain hemorrhage, and pneumonia, respectively. During the follow-up (median, 41.2 months) of the remaining 10 patients, cholangitis occurred in 2 (1 episode in each), and anastomotic leakage from the hepaticojejunostomy performed by the standard method for other thicker ducts developed in 1. There were no other anastomosis-related complications. Dynamic computed tomography performed 2.4 to 62.7 months (median, 34.4 months) after the operation showed no bile duct dilatation in any of the 10 cases. Long-term patency of the small bile ducts after bilioenteric reconstruction without mucosa-to-mucosa alignment was demonstrated. Thus, this technique is useful for the reconstruction of small bile ducts, especially in patients with poor liver function in whom even minimal additional reduction in the volume of functioning liver due to occlusion of a small bile duct would be acceptable.

Long-Term Outcomes for Patients with Post–Liver Transplant Anastomotic Biliary Strictures Treated by Endoscopic Stent Placement

Background: Biliary stricture is one of the most common complications of liver transplantation. A number of treatment options are available, but a standard approach has not been established. Methods: A total of 25 patients with post-liver transplantation anastomotic strictures were treated endoscopically by stent placement. Long-term outcomes (bile duct patency, morbidity, and mortality) were reviewed retrospectively. Results: Placement of a stent was attempted in 25 patients with anastomotic stricture. Successful stent placement with stricture resolution at the time of stent removal was noted in 22 patients (technical success 88%). In those 22 patients, long-term success (mean follow-up after all stents removed, 54 months) was observed in 20 patients (90%) and partial success in two (10%). Long term, failure did not occur in any patient. There was no procedure- or disease-related mortally. Three mild episodes of cholangitis occurred during the period while the stents were in place, in relation to 79 endoscopic interventions for a procedure-related complication rate of 3.7%. Conclusions: The long-term outcome for patients with post-liver transplantation biliary anastomotic strictures treated with endoscopic stent placement is excellent, with no therapy- or disease-associated mortality and minimal morbidity.

Long-term outcome in patients with benign biliary strictures treated endoscopically with multiple stents

Background: The long-term efficacy of sequential insertion of multiple plastic stents for benign biliary strictures is poorly defined. The aims of this study were to evaluate the long-term outcome (bile duct patency, complications) of this therapy and to identify predictors of a good outcome. Methods: Retrospective review of 29 cases of benign biliary strictures treated with sequential plastic stent insertion in progressively increasing numbers and/or of increasing diameter. Results: Stricture etiology was as follows: postoperative 19 (66%), chronic pancreatitis 9 (31%), and idiopathic 1 (3%). Therapy succeeded in 18 patients (62%) (mean follow-up 48.0 [11.56] months after stent removal). Therapy failed in 11 patients (38%) (mean interval to failure 11.59 [9.79] months after stent removal). The 2 groups of patients in which therapy failed had either a hilar stricture (n = 4, 25% success) or distal common bile duct stricture caused by chronic pancreatitis (n = 9, 44% success). In the remaining cases, therapy succeeded in 13 of 16 (81% success). The observed differences in success rate among subgroups were not statistically significant. There were no ERCP-related deaths. One episode of mild pancreatitis and 2 episodes of cholangitis developed during 126 ERCPs over a period of stent insertion of 36 patient years. Conclusions: In selected patients with benign biliary strictures, sequential endoscopic insertion of multiple biliary stents may lead to long-term success that could be equal to or superior to surgery with minimal morbidity. Hilar strictures and those caused by chronic pancreatitis appear to respond poorly to this therapy. (Gastrointest Endosc 2002;55:680-6.)

Polyurethane-covered wallstents to recanalize wallstents obstructed by tumor ingrowth from malignant common bile duct obstruction

Four patients with malignant obstruction of the common bile duct had been treated with uncovered Wallstents and suffered from a reobstruction after 2-13 months (mean 5.3 months). Repeat cholangiography revealed severe stenosis of the stent lumen caused by tumor ingrowth through the mesh. A Wallstent with a self-made polyurethane-cover was inserted through the uncovered stent in these patients. The four patients were followed for 3-13 months (mean 6.3 months) until death. There was good drainage with no evidence of recurrent obstruction in all patients. We conclude that a covered Wallstent may extend patency of stented bile ducts, preventing tumor ingrowth in patients with neoplastic obstruction. Further observations are needed.

A comparison of Ultraflex Diamond stents and Wallstents for palliation of distal malignant biliary strictures.

The objective of this study was to compare the effectiveness of the Ultraflex Diamond stent and the Wallstent for the drainage of distal malignant biliary strictures. The results obtained in 23 consecutive patients in whom the insertion of a Ultraflex Diamond stent had been attempted were compared with those obtained in 23 patients matched for age, gender, serum bilirubin, and diagnosis who had been treated with Wallstents. Biliary drainage was obtained in 100% of cases. More than one stent was required in 4% and 12% of patients treated with Ultraflex Diamond stents and Wallstents, respectively (p > 0.05). The first stent inserted did not provide adequate biliary drainage in four patients, because of the impaction of the proximal end of Wallstents into the bile duct wall (n = 2) and obstruction of the stent lumen by tumor tissue (one in each group). Procedure-related morbidity and mortality were 4%. Patients were followed-up for a mean of 228 days (range, 1 to 1262 days). During follow-up, bile duct obstruction relapsed in 5/22 and 6/21 patients treated with Ultraflex Diamond stents and Wallstents, respectively. Life table analysis of bile duct patency was similar with both stent models. Ultraflex Diamond stents are easy to insert and provide a high success rate of biliary drainage with minimal complication. Although long-term patency rates obtained with this stent were similar to those observed with Wallstents, no firm conclusion can be drawn in this regard due to the relatively small number of patients studied.

A comparison of Ultraflex diamond stents and Wallstents for palliation of distal malignant biliary strictures

OBJECTIVE: The objective of this study was to compare the effectiveness of the Ultraflex Diamond stent and the Wallstent for the drainage of distal malignant biliary strictures. METHODS: The results obtained in 23 consecutive patients in whom the insertion of a Ultraflex Diamond stent had been attempted were compared with those obtained in 23 patients matched for age, gender, serum bilirubin, and diagnosis who had been treated with Wallstents. RESULTS: Biliary drainage was obtained in 100% of cases. More than one stent was required in 4% and 12% of patients treated with Ultraflex Diamond stents and Wallstents, respectively ( p > 0.05). The first stent inserted did not provide adequate biliary drainage in four patients, because of the impaction of the proximal end of Wallstents into the bile duct wall (n = 2) and obstruction of the stent lumen by tumor tissue (one in each group). Procedure-related morbidity and mortality were 4%. Patients were followed-up for a mean of 228 days (range, 1 to 1262 days). During follow-up, bile duct obstruction relapsed in 5/22 and 6/21 patients treated with Ultraflex Diamond stents and Wallstents, respectively. Life table analysis of bile duct patency was similar with both stent models. CONCLUSIONS: Ultraflex Diamond stents are easy to insert and provide a high success rate of biliary drainage with minimal complication. Although long-term patency rates obtained with this stent were similar to those observed with Wallstents, no firm conclusion can be drawn in this regard due to the relatively small number of patients studied.

Magnetic resonance cholangiography--feasibility and application in the paediatric population.

To assess the feasibility of magnetic resonance cholangiography (MRC) in paediatrics. MRC was attempted in 41 children from 1 week to 14-years. There were three groups: (1) children studied with MRI for non-biliary problems as controls; (2) infants with jaundice; and (3) older children suspected of biliary disease. The examination was successfully performed in 35 children, which included 12 children studied for non-biliary problems, 12 infants with jaundice, and 11 older children with suspected biliary disease. In group 1, the entire common duct was visualised in all 12 children. In group 2, successful demonstration of the common duct was achieved in two of the ten infants with subsequent confirmation of normal bile duct patency. In the last group of patients with suspected biliary disease, MRC gave good anatomical display of six choledochal cysts but failed to demonstrate the anomalous choledochopancreatic channel. It helped to confirm the diagnosis of two cases of pancreatic head cysts, and one case of Caroli's disease. MRC can be applied to the paediatric population, but its value depends on the type of problem to be evaluated. With current spatial resolution, its value in the diagnosis of biliary atresia is probably limited because it cannot reliably demonstrate the bile ducts in young infants with non-obstructive jaundice. In older children, it could provide a non-invasive anatomical display of the biliary tree and its disease. It has a potential role in addressing problematic cases encountered during ultrasonography.

Ultrasonographic "triangular cord": the most definitive finding for noninvasive diagnosis of extrahepatic biliary atresia.

Early diagnosis of extrahepatic biliary atresia (EHBA) is very important for a successful bile drainage procedure. An urgent and extensive investigation is warranted to make a differential diagnosis of EHBA from other cholestatic disease, especially neonatal hepatitis (NH). The diagnosis may be made by laparotomy with cholangiogram and liver biopsy but these procedure are invasive. Because a cone-shaped fibrous tissue was always found at the porta hepatis during Kasai's procedure and that type of fibrous tissue has never been seen in other types of cholestatic jaundice, the authors have used ultrasonography (US) to detect fibrous remnants at the porta hepatis in infants clinically suspected of having EHBA and identified a triangular- or tubular-shaped echogenic density in the bifurcation of the portal vein at the porta hepatis in EHBA and called it an ultrasonographic "triangular cord (TC)". The authors determined that the presence of TC denoted the EHBA. On the other hand, nonvisualization of TC was interpreted as consistent with NH. In the present study, the authors reviewed ultrasonographic examination and hepatobiliary scintigraphy in a series of 41 infants suspected of having EHBA or NH. The TC was identified in thirteen infants. In twelve of thirteen infants with TC found by US, the diagnosis of EHBA was confirmed at the time of Kasai's Roux-en-Y hepatoportojejunostomy operation. The remaining one died at 15 months of age without having treatment. TC was not visualized in 28 infants. Twenty-seven of 28 infants with absent TC improved clinically through medical treatment for NH. The other, diagnosed to have NH by needle and wedge liver biopsies, eventually showed a TC on follow-up US examination performed 40 days after the initial examinations. Moreover, follow-up percutaneous liver biopsy specimen showed typical findings of biliary atresia with bile duct proliferation and portal fibrosis. The patient underwent a Kasai hepatoportoenterostomy. On review of the hepatobiliary scintigraphy, all 13 infants with TC had no intestinal excretion of isotope. Thirteen of 28 infants (46%) without TC also had no intestinal excretion of isotope in the 24hour follow-up but all of them were confirmed to have NH by percutaneous liver biopsy and their subsequent clinical course confirmed NH with the detection of bile in their stool except one. On the basis of these results, the authors conclude that ultrasonographic TC is a very specific finding representing the fibrous cone at the porta hepatis and is a quick, simple, and definitive tool in the noninvasive diagnosis of EHBA. If TC is visualized, no further studies are necessary and exploratory-laparotomy can be done. If TC is not visualized, hepatobiliary scintigraphy is recommended to demonstrate bile duct patency. Percutaneous liver biopsy is only required if neither TC nor intestinal excretion of isotope is seen. However, early exploration or close US follow-up study is recommended in any patient suspected of having EHBA clinically, even if liver biopsy confirms the presence of NH.

Duodenal duplication with bile duct obstruction and keratinaceous casts

We report an unusual case of duodenal duplication presenting in a newborn with duodenal and bile duct obstruction. The duplication and biliary tract were filled with keratinaceous casts. To our knowledge, such an association has not been previously reported; this case demonstrates the importance of confirming bile duct patency during operations to remove duodenal duplications.

Discordant Uptake of Three Different Agents for Liver Scintigraphy in a Patient With Focal Nodular Hyperplasia

Focal nodular hyperplasia of the liver is composed of hepatocytes, variable amounts of Kupffer cells, and bile ducts. The amount of Kupffer cells per unit volume of tissue determines the uptake of Tc-99m phytate. However, the uptake of Tc-99m DTPA galactosyl human serum albumin (Tc-99m GSA) depends on the presence of normally functioning hepatocytes, and the uptake and excretion of Tc-99m pyridoxyledene-5-methyl tryptophan (Tc-99m PMT) depends on the presence of normally functioning hepatocytes as well as the patency of bile ducts. in this proven case of focal nodular hyperplasia, there was no uptake of Tc-99m phytate, but mildly decreased uptake of Tc-99m GSA and increased uptake of Tc-99m PMT were observed, compared to normal liver tissue. These are exceptional findings for focal nodular hyperplasia and mimicked those of a hepatic adenoma.

Obstructive jaundice caused by neuroblastoma managed with temporary cholecystostomy tube

Neuroblastoma presenting as obstructive jaundice is very rare. The authors present two cases of neuroblastoma, one primary and one recurrent, manifesting as a malignant obstruction of the extrahepatic biliary system. Various methods of biliary decompression were considered in these children including transhepatic or retrograde biliary stenting and internal cholecystoenteric bypass. An attempt at percutaneous transhepatic stent placement failed in one case. In each patient, a simple insertion of a cholecystostomy tube proved effective. Immediately postoperatively, both patients had rapid resolution of symptoms and a decrease in bilirubin levels. Transient mild cholangitis in both children was successfully treated with antibiotics. Chemotherapy reduced the tumor size in each case, and the cholecystostomy tubes were removed within 3 weeks, after cholangiography showed patency of the distal common bile ducts. Temporary cholecystostomy tube drainage and systemic chemotherapy proved to be a safe, simple, and effective method for managing obstructive jaundice caused by neuroblastoma in these two cases.

The Role of Endoscopic Retrograde Cholangiopancreatography in Cholestatic Infants

Conjugated hyperbilirubinemia in infants is a serious problem, and one that requires further investigation. Early differentiation between extrahepatic and intrahepatic causes of cholestasis is essential for the proper management of cholestasis in infancy. A successful outcome in patients with extrahepatic biliary atresia is significantly influenced by the age at which the Kasai procedure (hepatoportoenterostomy) is performed. However, extensive diagnostic workup may fail to distinguish definitively between intrahepatic and extrahepatic disease, and exploratory laparotomy and intraoperative cholangiography are sometimes necessary to exclude extrahepatic disease. In the last four years, 20 cholestatic infants were referred to our center in whom no definite diagnosis was possible, despite thorough diagnostic evaluation. In an attempt to increase the accuracy of our diagnostic work-up, we performed ERCP during the anesthetic period planned for liver biopsy. We succeeded in performing ERCP in 18 children (90%); in five of them (28%), patent bile ducts were demonstrated, and unnecessary laparotomy could be avoided. In four patients (22.2%), a stricture of the common bile duct was seen, in three combined with a choledochal cyst. In two patients (11.1%), only the common bile duct and gallbladder were opacified. Five of seven patients in whom only the pancreatic duct was visualized had complete occlusion of the extrahepatic biliary ducts at surgery. The other two patients did not undergo surgery because initially no signs of extrahepatic obstruction were found in their biopsy. One of these patients deteriorated and needed a liver transplant one year later. This patient proved to have extrahepatic biliary atresia. No severe complications of ERCP were observed; only sporadically, a slight elevation of pancreatic enzymes was noted. We advocate this procedure in the workup of infants with unexplained conjugated hyperbilirubinemia. Anomalies in the biliary tree can be demonstrated, and when patent bile ducts are found, laparotomy can be avoided.

Reduction in biliary IgA after burn injury. Role of diminished delivery via the thoracic duct and of enhanced loss from the systemic circulation.

The concentration of biliary IgA is greatly reduced after scald burn injury in the rat, thereby contributing to a deficiency in upper intestinal immune defense. This reduction in biliary IgA might have several explanations, including failure of the transhepatic transport of polymeric IgA (pIgA) from the circulation, decreased delivery of pIgA to the hepatocyte, or decreased local synthesis of IgA in the liver. The authors examined whether burn injury reduces circulating pIgA available for delivery to the hepatocyte. In initial studies, they demonstrated that burn injury induces a decrease in circulating pIgA in bile-duct-ligated rats. They then sought to determine whether this decrease in pIgA was due to increased loss from the circulation or to a decreased supply of pIgA to the circulation through the thoracic duct. After injection of purified 125I-pIgA into bile duct-ligated rats, radioactivity was removed more rapidly from the circulation of burn-injured compared with control rats. The radioactivity localized in the skin and muscle at the site of burn injury. In another group of rats with patent bile ducts, the thoracic duct was cannulated and lymph collected for 12 hours. The total amount of IgA protein in lymph was found to be reduced in burn-injured compared with control animals. Thus, burn injury is accompanied by reduced circulating pIgA, which may be attributed to its enhanced loss from the circulation and to decreased delivery of pIgA from the intestinal mucosa to the systemic circulation via the thoracic duct.

Endoscopic retrograde cholangiopancreatography in infantile cholestasis.

The difficulty of distinguishing surgically correctable causes of conjugated hyperbilirubinaemia in infants from other causes means that some infants may undergo laparotomy and intraoperative cholangiography unnecessarily, and others may be referred for surgery too late. In an attempt to improve the diagnostic accuracy in infants with conjugated hyperbilirubinaemia when standard methods produced equivocal results, we have been using prototype paediatric duodenoscopes (PJF 7.5 and XPJF 8.0; Olympus) to perform endoscopic retrograde cholangiopancreatography (ERCP). From 159 infants with conjugated hyperbilirubinaemia, 11 were referred for ERCP, which was performed in nine. In four in whom bile ducts were definitely visualised laparotomy was avoided. Operative cholangiography confirmed patent bile ducts in one in whom visualisation had been uncertain. Three of four in whom bile ducts were not seen had extrahepatic biliary atresia. Visible bile drainage in the fourth excluded atresia. No major complications ensued but there was radiological evidence of gall bladder perforation in one (common hepatic duct block) and overinflation with air was a problem until finer cannulae (Wilson-Cook) were introduced. In appropriately selected patients with conjugated hyperbilirubinaemia, ERCP with paediatric duodenoscopes in experienced hands may provide useful diagnostic information.

Anomalous biliary ducts associated with duodenal atresia

Duodenal atresia is rarely associated with anomalous biliary ducts that permit communication between the proximal and distal duodenal segments. Two such cases are presented herein and the literature is reviewed. Although the typical radiographic pattern of duodenal atresia is the “double bubble” sign with absence of distal bowel gas, air may be present in the distal bowel when anomalous bile ducts provide a conduit around the atretic segment. Contrast studies are generally not performed in the typical clinical and radiographic evaluation of duodenal atresia; however, an upper gastrointestinal series may be useful in defining the more complex anomaly. Clinical presentation may occur relatively late if the biliary communication is large enough to permit passage of some milk or formula. Care should be taken at surgery to avoid obstruction or injury to the anomalous bile ducts, and operative cholangiography may be useful to document continued bile duct patency following repair of the atresia. Theories of the etiology of this anomaly relate to interference with recanalization of the duodenum by the process of hepaticopancreatic duct formation and persistence of the primitive “dual duct” stage.

Long‐term Efficacy of Percutaneous Transhepatic Choledochoscopic Y AG Laser Therapy for Malignant Biliary Obstruction

Abstract: The long‐term effect of percutaneous transhepatic choledochoscopic YAG laser therapy for malignant biliary tract obstruction was evaluated. Ten consecutive patients underwent laser therapy to alleviate the obstruction. All patients were followed up for 8 months or more (range: 8–33 month, average: 15). Cholangiography was performed when re‐elevation of the alkaline phosphatase level was observed during the regular checkup. Choledochoscopy was performed when any sign of recurrence was observed on cholangiography. Sufficient re‐opening of the bile duct was obtained in every case, without complications. Indwelling of the internal drainage tube was perfomed in 5 patients, the remaining 5 having “tube free” internal drainage. Five patients showed no rise in alkaline phosphatase levels during their 8‐ to‐13 month follow‐up period. Re‐elevation of the alkaline phosphatase level was observed 9 times in 5 patients, mostly from internal drainage tube occlusion. The cholangiogram performed on each occasion revealed a patent bile duct without any sign of recurrence (6/9), slight narrowing (2/9) or tumorous obstruction (1/9). Cholangitis was complicated 6 times in 3 patients, mostly from internal drainage tube occlusion. Choledochoscopy was performed in the 3 patients suspected of tumor recurrence on cholangiogram. In 2 of them, no signs of recurrence were noted endoscopically or histologically, but the tumor was revealed to have recurred only at the part previously treated, in the remaining. Thus, choledochoscopic I'AG laser therapy can locally control the malignant biliary tract obstruction for a long period of time. “tube free” internal drainage may serve as a means to prevent cholangitis, which is one of the complications frequently occurring with conventional stent therapy.

Bile duct patterns in the hilar region of the liver in two cases of biliary atresia

Bile duct patterns in the hilar region of the liver were demonstrated in two autopsy cases of biliary atresia by three-dimensional graphic reconstructions. In one case, jaundice had completely disappeared after successful hepatic portojejunostomy. However, at the age of 4 months, this patient died of cardiac failure caused by endocardial cushion defect. The histological reconstruction of this case showed that there were large patent bile ducts, 150 microns to 400 microns in diameter, and plenty of bile ductules surrounding the large ducts to form networks. The other patient died of hepatic failure at the age of 9 months. In this case, only a few large ducts ended in bile lakes that did not connect with the portojejunostomy, and only a few ductules were found around the large ducts. These results indicate that the existence of networks of bile ductules and the patency of large bile ducts at the porta hepatis contribute to good postoperative bile excretion.