Malignant obstructive jaundice is always encountered in advanced stage. Malignancies include Distal Bile duct Carcinoma, Ampulla of Vater Carcinoma, and Pancreas Carcinoma are sometimes impossible to cure and resect. Therefore, palliative treatments are the only way to relieve the disease for the patients to have a better quality of life in their remaining life- span. Available palliative treatments include stenting and surgical bypass. In our analysis, metallic stenting and double bypass composing hepaticojejunostomy and gastrojejunostomy are studied as they can be considered as the two most efficient palliative methods so far that are widely used in Hong Kong in the management of malignant biliary obstruction. The treatment options depends on both the physicians and the patient. However, patients are often on the horns of a dilemma when they are allowed to choose these palliative treatments. This study hence aim to compare the cost-effectiveness of metallic stenting and surgical double bypass palliative treatment among five factors: 1) Number of hospital stay, 2) Re-admission rate, 3) Overall complication, 4) Change of bilirubin level and 5) Survival rate. A total of 40 patients data are being retrieved from the Queen Mary Hospital as 20 data are form the metallic stenting group, while the other 20 data are from surgical bypass. After collecting the data and finishing the study, it was found that apart from a longer hospital stay, the surgical bypass patient group would generally have a lower re-admission and complication rate. While the parameters include bilirubin change before and after the treatment and the survival rate are not significantly different, which indicated these two parameters may not be the determining factors when deciding the treatment choice. Based on the research outcome, surgical bypass may be a better choice of palliative treatment in the management of Malignant Biliary Obstruction that allows patients to obtain a better quality of life. / published_or_final_version / Medicine / Master / Master of Medical Sciences

Thesis (doctoral)--Ludwig Maximilians-Universität zu München, 1979.

A research report submitted to the degree of Master of Medicine in the Department of Surgery for the University of the Witwatersrand Health Sciences, 2013 / Biliary atresia (BA) is characterised by a progressive obliterative cholangiopathy. If surgical treatment by a Kasai Portoenterostomy (KP) is undertaken early on in life there is the potential for successful bile drainage. The natural disease progression without intervention results in fibrosis and cirrhosis, necessitating liver transplantation before two years of life. Despite the advances in the management of biliary atresia over the recent decades we still do not have a good indicator of which patients will do well after surgery and which will require further intervention for their liver dysfunction. There are many clinical and serological indicators that suggest liver failure, but liver histology remains the gold standard indicating the extent of liver damage. This is, however, being slowly replaced by various new less-invasive biological markers, including the Aminotransferase Aspartate to Platelet Ratio Index (APRi). This study looks at this biological marker for patients with biliary atresia with reference to their level of disease at the time of surgery and whether it is a prognostic tool for long-term outcomes in this group of patients.

Graduation date: 1991

Thesis (Ph.D.) -- Flinders University, Dept. of General and Digestive Surgery, School of Medicine. / Typescript (bound). Includes bibliographical references (leaves 254 - 270). Also available online.

Orientadores: Luiz Sergio Leonardi, Michel Cremer, Luis Alberto Magna / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-10T11:06:50Z (GMT). No. of bitstreams: 1 Trentini_ElianeAnrain_M.pdf: 2064169 bytes, checksum: 0b3a3597ddde6867786067aded166323 (MD5) Previous issue date: 2006 / Resumo: Não há, ainda, um modelo ideal de reconstrução das lesões extensas da via biliar. A reconstrução em Y de Roux é clássica, com vantagens como baixa incidência de refluxo de conteúdo intestinal para as vias biliares. Porém, como não é anatômica, ela dificulta enormemente ou impede o acesso endoscópico à via biliar. Uma técnica fisiológica para a substituição do colédoco é a interposição de segmento pediculado de jejuno entre a via biliar e o duodeno, descrita desde 1950 e realizada com êxito em número expressivo de pacientes. Contudo, esta técnica não se tornou amplamente utilizada. Com o intuito de reconstruir a via biliar de maneira fisiológica foi proposta a aplicação do princípio de Monti às vias biliares, que já está estabelecido em humanos para vias urinárias. Nesta técnica, faz-se a detubularização e retubularização transversa de um segmento de jejuno, promovendo uma modificação no sentido das pregas mucosas, tornando-as longitudinais o que facilita o fluxo de líquidos no seu interior. Ao aplicá-la na reconstrução das vias biliares possibilita-se, sobretudo, o acesso endoscópico, diagnóstico e terapêutico, às vias biliares. No presente estudo, foram operados 13 cães: inicialmente foi realizada ligadura laparoscópica do colédoco dos cães para provocar dilatação da via biliar e icterícia obstrutiva. Após uma semana, foi realizada derivação biliodigestiva por laparotomia com a interposição do tubo jejunal acima descrito entre a via biliar dilatada e o duodeno. Os cães foram submetidos a dosagens bioquímicas de transaminases glutâmico-pirúvica e glutâmico-oxalacética, bilirrubinas totais, fosfatase alcalina e gamaglutamiltransferase no pré-operatório das cirurgias e semanalmente, até a eutanásia, realizada seis semanas após a derivação biliodigestiva, quando foi realizada nova laparotomia e ressecção da peça via biliar-tubo jejunal-duodeno em monobloco para análise macroscópica. Foi coletada bile dos cães por ocasião da derivação biliodigestiva e no sacrifício. Dos 13 submetidos a ligadura laparoscópica de colédoco, um foi excluído porque não alcançou significativa dilatação da via biliar. Após a derivação biliodigestiva três cães morreram; destes três, apenas um apresentou peritonite à necropsia. Portanto, nove cães tiveram seus dados submetidos à análise estatística. Eles apresentaram icterícia obstrutiva após sete dias de ligadura do colédoco, comprovada por exames bioquímicos. Todos os nove animais apresentaram redução gradativa, estatisticamente significativa, de sua colestase após derivação biliodigestiva com a interposição do tubo jejunal pediculado e mantiveram-se saudáveis até o término do experimento. Os valores médios de bilirrubina total, fosfatase alcalina e gamaglutamiltransferase uma semana após ligadura da via biliar foram: 4,39; 3251,7 ; 66,1. Os valores dessas variáveis seis semanas após a derivação biliodigestiva foram 0,11 ; 323,1 ; 10,7, respectivamente. Concluiu-se que o tubo de segmento jejunal interposto entre o colédoco previamente ligado e o duodeno foi eficaz na descompressão da via biliar. A análise macroscópica das peças coletadas mostrou boa integração via biliar-tubo e tubo-duodeno. Com a abertura longitudinal das peças observou-se ótima cicatrização das estruturas anastomosadas e perviedade do tubo jejunal / Abstract: An ideal model for reconstruction of extensive lesions of the biliary tract has not been found so far. The Roux-en-Y reconstruction is a classic reconstruction and presents advantages as the low incidence of intestine contents reflux to the biliary tract. However, since this is not anatomical, it impedes or impairs the endoscopic access to the biliary tract. A physiological technique to replace the common bile duct is the interposition of a pediculated segment of jejunum between the biliary tract and the duodenum, described since 1950 and successfully performed in several patients. However, this technique has not been widely adopted. The present experimental study was proposed for reconstruction of the biliary tract in a physiological manner, by application of the Monti principle to the biliary tract, which is well established in humans for the urinary tract. This technique comprises detubulization and transverse retubulization of a segment of jejunum, changing the mucosal folds in longitudinal direction, thus enhancing the flow of liquids inside it. Its application for reconstruction of the biliary tract would allow endoscopic access to the biliary tract, for both diagnostic and therapeutic purposes. Thirteen dogs were operated in the present study; initially, laparoscopic ligation of the common bile duct of dogs was performed to induce extrahepatic cholestasis. After one week, biliodigestive derivation was performed by laparotomy with interposition of the aforementioned jejunal tube between the dilated biliary tract and the duodenum. The dogs were submitted to biochemical dosage of alanine and aspartate transaminases, total bilirrubin, alkaline phosphatase and gamma-glutamyltransferase preoperatively and weekly for six weeks postoperatively. Another laparotomy was then performed with resection of a monoblock specimen from the biliary tract-jejunal tube-duodenum for macroscopic analysis and the animals were killed. Bile was collected from the dogs upon biliodigestive derivation and upon killing. From the 13 animals submitted to laparoscopic ligation of the common bile duct, one was excluded because significant dilation of the biliary tract was not achieved. Three dogs died after biliodigestive derivation; among these, only one exhibited peritonitis upon autopsy. Thus, data on nine dogs were submitted to statistical analysis. These dogs exhibited obstructive jaundice at seven days after ligation of the common bile duct, as demonstrated by biochemical examinations. All nine animals presented statistically significant gradual reduction of cholestasis after biliodigestive derivation by interposition of a pediculated jejunal tube and were healthy until study completion. The mean values of total bilirubin, alkaline phosphatase and gamma glutamyltransferase at one week after ligation of the biliary tract were: 4.39; 3251.7; and 66.1. The values of these variables at six weeks after biliodigestive derivation were 0.11 ; 323.1 and 10.7, respectively. It was concluded that interposition of a jejunal segment tube between the previously ligated common bile duct and the duodenum was effective for decompression of the biliary tract. Macroscopic analysis of the collected specimens revealed good integration between the biliary tract and the tube and between the tube and the duodenum. Longitudinal sectioning of the specimens revealed optimal healing of the anastomosed structures and patency of the jejunal tube / Mestrado / Cirurgia / Mestre em Cirurgia

No description available.

Thesis--Odense. / Summary in Danish. Includes bibliographical references (p. 136-[147]) and index.

Thesis--Odense. / Summary in Danish. Includes index. Bibliography: p. 136-[147]

Introdução / Objetivos: O prognóstico do adenocarcinoma ampular pode ser influenciado por fatores como estadiamento e variáveis histopatológicas, como o padrão intestinal ou pancreatobiliar. O diagnóstico do padrão histopatológico pode ser auxiliado pela expressão de citoqueratinas, CK, 7 e 20 e do gene homeobox CDX2. O objetivo do estudo foi analisar associações entre características histopatológicas e sobrevida, e entre padrão histopatológico e expressão de CK7, CK20 e CDX2. Método: Estudo de coorte retrospectivo desenvolvido no Hospital de Clínicas de Porto Alegre entre 2000 e 2011. Foram avaliados dados histopatológicos, estadiamento pTNM, padrão histopatológico e expressão imunoistoquímica e sobrevida. Resultados: A amostra constou de 65 carcinomas ampulares (n = 65). Foi observado padrão intestinal em 46, pancreatobiliar em 16 e outros em três. Sobrevida em cinco anos após duodenopancreatectomia (n = 47) foi de 27%. Associaram-se à menor sobrevida na análise univariada: dois ou mais linfonodos metastáticos, razão de linfonodos, RL, maior ou igual a 20%; estágio IIB em relação a inferiores; tumor de alto grau; invasão linfovascular. Na análise multivariada, metástase linfonodal e RL ≥ 20% influenciaram sobrevida. Conclusões: O pior prognóstico foi associado à metástase linfonodal. Não foi observada associação entre padrão histopatológico e expressão imunoistoquímica. / Background / Objectives: The prognosis of patients with ampullary adenocarcinomas can be influenced by such factors as pTNM stage and histopathological variables, such as intestinal or pancreatobiliary patterns. The characterization of these patterns can be facilitated by the expression of cytokeratins 7 (CK7) and 20 (CK20) and caudal-related homeobox gene 2 (CDX2). The aim of the present study was to analyze the association between the histopathological characteristics and the survival of patients with ampullary adenocarcinomas, as well as the association between the histopathological patterns and CK7, CK20 and CDX2 expression. Methods: This retrospective cohort study was performed at the Clinics Hospital of Porto Alegre between 2000 and 2011 and examined the histopathological data, pTNM stage, histopathological patterns, immunohistochemical expression patterns and survival of patients with ampullary adenocarcinomas. Results: The sample patient population consisted of 65 ampullary carcinomas. Of these carcinoma samples, an intestinal pattern was observed for 46, a pancreatobiliary pattern was observed for 16 and other patterns were observed 3 of the samples. The 5-year survival rate for patients following pancreaticoduodenectomy (n = 47) was 27%. From the univariate analysis, the following variables were associated with shorter survival times: the presence of 2 or more metastatic lymph nodes; positive lymph node ratio (LR) ≥ 20%; stage IIB or greater; high-grade tumors; and lymphovascular invasion. From the multivariate analysis, lymph node metastases and a LR ≥ 20% were shown to influence survival significantly. Conclusions: Lymph node metastases were associated with poor patient prognoses, although no association was found between the histopathological pattern and immunohistochemical expression.