Common Bile Duct Obstruction Associated With a Dacron H-graft Portacaval Shunt Richard A.
Prinz, MD, Jack Pickleman,
MD
unusual patient had ascending cholangitis secondary to bile duct obstruction by stones and a Dacron graft previously utilized in the performance of an H-graft portacaval shunt. Erosion of this foreign body into the common bile duct appeared to be secondary to bacterial contamination of the graft and direct contact of the foreign material with the biliary tree. \s=b\ An
common
(Arch Surg 113:333-335, 1978) Charcot1 first described acute ascending cholan¬ and characterized it by the diagnostic triad of fever and chills, jaundice, and right upper quadrant pain. One hundred years later, this process of infection occurring in an obstructed biliary tract remains a challenging problem for the surgeon. The present report describes an unusual patient in whom a Dacron prosthesis used to perform an -graft portacaval shunt eroded into the common bile duct, served as a nidus for stone formation, and resulted in ascending cholangitis.
1877, In gitis
REPORT OF A CASE woman was first seen at Loyola 45-year-old, University Medical Center, Maywood, 111, in May 1975, when she was transferred from a neighboring community hospital because of bleeding esophageal varices. While living in Mexico in 1972, she underwent a Dacron -graft portacaval shunt for bleeding varices. In February 1975, she had a recurrent upper gastrointes¬
This
Mexican-born
tinal tract hemorrhage and was treated with a subtotal gastrec¬ tomy and Billroth II reconstruction. Three months later, she again had hematemesis and was treated with balloon tamponade. On May 25, 1975, she was transferred to Loyola University Hospital, with a Sengstaken tube in place. After 24 hours there was no
Accepted
for publication Oct 18, 1977. From the Department of Surgery, Loyola University Medical Center, Maywood, Ill. Reprint requests to Department of Surgery, Loyola University Medical Center, 2160 S First Ave, Maywood, IL 60153 (Dr Pickleman).
evidence of bleeding, and the tube was removed. Endoscopy disclosed large esophageal varices and was otherwise normal. On May 29, 1975, she rebled massively; this was not controllable by balloon tamponade. Emergency celiac angiography disclosed prominent splenic and coronary veins with esophageal varices. The portacaval shunt was nonfunctioning (Fig 1). Intra-arterially administered vasopressin (Pitressin) only partially controlled the hemorrhage, and an emergency splenorenal shunt and splenec¬ tomy were performed. In order to complete the anastomosis, the tail of the pancreas was resected. Her postoperative course was complicated by a left subphrenic abscess, which was found to extend across the midline when it was drained on June 21, 1975. Cultures from the abscess grew Escherichia coli and y-Streptococcus group D. The abscess resolved with drainage and parenteral cephalothin sodium therapy, and she was discharged on July 5, 1975. The patient remained well until Aug 15,1976, when she entered the hospital with fever, chills, and right upper quadrant pain associated with nausea and vomiting. She had experienced no previous similar symptoms or other symptoms of biliary tract disease. Her temperature was 38.7 C; pulse, 120 beats per minute; and blood pressure, 120/80 mm Hg. She was icteric and had right upper quadrant guarding and rebound tenderness with a palpable gallbladder. Hemoglobin level was 12.4 gm/100 ml; the WBC count was 16,000/cu mm, with 52% neutrophils and 45% band cells. Bilirubin level was 5.4 mg/100 ml, with a direct fraction of 4.9 mg/100 ml. A diagnosis of ascending cholangitis was made and an emergency laparotomy was performed. Her gallbladder was enlarged, tense, and thickened. Cholecystectomy and operative cholangiography were performed. The common bile duct was markedly dilated, and there was no passage of dye into the duodenum (Fig 2). Common duct exploration demonstrated thick, inspissated bile with soft, friable stone formation. Multiple stones were extracted with biliary stone forceps. A 2-cm length of 18-mm Dacron graft that was lying free in the distal common duct was also removed by the stone forceps. It appeared that this was the entire length of the Dacron graft; there was no evidence of
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 05/11/2015
Fig 1.—Venous phase of celiac angiogram, demonstrating occluded portal vein and significant collateralization. Sengstaken tube is in place, with gastric balloon inflated. Fig 2.—Operative cholangiogram, demonstrating common by Dacron graft and biliary sludge.
bile
duct obstruction
bleeding into the bile ducts after removal of this prosthesis. The exploration was completed, and a tube was inserted into the common duct. A T-tube cholangiogram demonstrated free flow into the duodenum. Cultures from both the Dacron foreign body and bile grew E coli, y-Steptococcus group D, and Proteus mira¬ bilis. Microscopic examination of the gallbladder showed fibrous thickening with an acute and chronic inflammatory cell infiltrate and focal areas of microabscess formation. The gallbladder contained
no
stones.
Postoperatively, there
was
minimal
drainage from
the Penrose
drain; this was removed on the fourth postoperative day. However,
the T-tube cholangiogram showed a filling defect in the distal common duct compatible with a retained stone. The patient was treated with continuous irrigation of the tube with 75,000 units of heparin daily for seven days. A subsequent T-tube cholangio¬ gram showed no evidence of retained stones, and there was free flow of bile into the duodenum. The tube was removed. Three months afterwards, the WBC count, albumin, bilirubin, and alkaline phosphatase values had all returned to normal. In April 1977, the patient underwent a total thyroidectomy for a mixed papillary-follicular carcinoma of the thyroid with nodal metastases. At that time, she had no clinical or laboratory evidence of biliary tract disease.
COMMENT
Ascending cholangitis occurs as a complication of biliary
tract disease and often requires emergency operation. Since the biliary tract is obstructed, high pressures may develop, and organisms may gain access into the circula¬ tion and hepatic parenchyma. When a suppurative process is present under pressure, surgical drainage of the bile duct is the cornerstone of successful therapy. A recent review showed a 100% mortality in patients with acute suppura¬ tive cholangitis treated medically, and a 25% mortality in
those treated with operation.2 Common bile duct calculi are the most frequent cause of biliary obstruction resulting in cholangitis and were present in 79 of the 92 cases reviewed by Longmire.3 Biliary strictures, tumors, ampullary fibro¬ sis, congenital anomalies, pancreatitis, parasites, and
foreign bodies have all been reported as less frequent causes of ascending cholangitis.2·4·5 Numerous foreign bodies have been found in the biliary tract, including seeds, bullets, pins and needles, and the ova of parasites.'17 Following operative procedures on the biliary tree, nonab¬
sorbable suture material, cotton gauze, and rubber drains have been found within the biliary tract."*s These foreign bodies may mechanically obstruct the biliary tract them¬ selves, but more commonly they contribute to biliary stasis and serve as a nidus for stone formation. These stones then secondarily cause biliary tract obstruction. We have not encountered a case of biliary tract obstruction or fistula formation from a vascular prosthesis in our review of the literature. A fistula between the biliary ducts and blood vessels is not rare following trauma, where hemobilia normally results because the pressure in the portal system is usually higher than in the bile ducts.9 A fistula between the hepatic duct and portal vein has been reported in a patient with choledocholithiasis. Since the pressure in the common bile duct exceeded portal venous pressure, massive bilemia occurred, resulting in shock and death.1" This situation was possibly averted in our patient, because the portal vein was thrombosed. The first portasystemic H grafts were reported in 1951 by Reynolds and Southwick." Although the initial efforts utilized autogenous vein for interposition grafting, Dacron vascular prosthetic materials have been shown to be quite effective.'-·" The use of H grafting in the performance of portal decompression has increased because of the tech¬ nical advantages it offers. The amount of dissection of the portal vein and the vena cava is decreased, and the need for caudate lobectomy is eliminated. The distortion and kinking of the portal vein and the vena cava that result when an anastomosis is performed under tension is also eliminated.14*1" We have been unable to find any reports of H grafts for
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 05/11/2015
portal hypertension that became infected, nor have we encountered any reports of fistulae arising from prosthetic
materials used for this purpose. Several reports of
synthetic graft infections in arterial reconstruction have been published and we believe that the same principles of prevention and treatment employed in dealing with infected synthetic arterial grafts are also applicable to synthetic grafts used for venous decompression. Prosthetic enteric fistula is a rare but devastating complication of vascular surgery. The most common type is the aortoduodenal fistula, but aortogastric, aortojejunal,
and aortoileal fistulae have all been described.17 Factors responsible for fistula formation include direct contact of a viscus with a graft, contamination and infection of the prosthesis, and the use of silk suture material. A prosthesis in direct contact with a viscus may initiate a foreign body reaction that will gradually cause an erosion of the wall of that viscus. Infection will usually ensue, producing an abscess that will then dissect along the prosthesis.1" The capacity of a synthetic graft to become a nidus of continuing infection is well recognized, and control of that infection requires removal of all related synthetic materi¬ al.2" Since silk suture material was reportedly not used to perform the -graft anastomosis in our patient, direct contact of the graft with the common bile duct and infection are probably responsible for the erosion in this case. Although an anteriorly placed portal vein in front of the common bile duct has been reported, this is an anoma¬ ly.21 A technical error in making the H graft too long may have pushed the portal vein anteriorly, causing the graft to come in contact with the common bile duct. Infection is probably the most important factor leading to the graft erosion and subsequent biliary stone and '*
sludge formation in this patient. Although infection of the Dacron prosthesis following the portacaval anastomosis
cannot be ruled
out, we believe a technical error rather than infection caused thrombosis of this shunt, because the portal vein was nonfunctioning prior to the splenorenal shunt. The subphrenic abscess following the splenorenal shunt seems a more likely cause of the Dacron prosthetic infection. This nidus then eroded into the common bile duct, and the stasis and infection resulted in stone forma¬ tion in the common bile duct and in acute cholangitis. Supporting this chain of events is the growth of E coli and y-Streptococcus group D from the subphrenic abscess and also from the bile and Dacron graft one year later. These organisms had exactly the same antibiotic sensitivities on both occasions. That the biliary mud and stones in the common duct were secondary to stasis produced by the infected prosthesis is supported by the lack of stones in the
gallbladder.
Prevention of this potential complication is clearly important. Aseptic technique must be strictly followed, not only when the synthetic graft is inserted but at all subsequent operations, in order to avoid contamination. If possible, synthetic grafts must be isolated and separated from all other intra-abdominal organs by the interposition of viable tissue.22 Retroperitoneal fat, omentum, or mesen¬
tery may be utilized for this purpose. However, once a graft is infected, it must be completely removed or it will continue to act
as a source
Nonproprietary
of infection.
Name and Trademark of
Drug
Cephalothin sodium—Keflin.
References 1. Charcot JM: Lecons sur les maladies du foie des voies filiares et des reins, thesis, Paris, 1877. 2. Welch JP, Donaldson GA: The urgency of diagnosis and surgical treatment of acute suppurative cholangitis. Am J Surg 131:527-532, 1976. 3. Longmire WP Jr: Suppurative cholangitis, in Hardy JD (ed): Critical Surgical Illness. Philadelphia, WB Saunders Co, 1971, p 397. 4. Glenn F: Obstruction of the common bile duct. Surg Gynecol Obstet 132:25-35, 1971. 5. Hinshaw DB: Acute obstructive suppurative cholangitis. Surg Clin North Am 53:1089-1094, 1973. 6. Morse LJ, Millin J: Gallstone formation secondary to a foreign body. N Engl J Med 284:590-591, 1971. 7. Toland CG: Foreign bodies in the biliary tract. Ann Surg 98:904-908,
1933. 8. Newman CE, Hamer JD: Non-absorbable cystic duct ligatures and bile duct calculi. Br Med J 4:504, 1975. 9. Hendren WH, Warshaw AL, Fleischli DJ, et al: Traumatic hemobilia: Non-operative management with healing documented by serial angiography. Ann Surg 147:991, 1971. 10. Antebi E, Adar R, Zweig A, et al: Bilemia: An unusual complication of bile duct stones. Ann Surg 177:274-275, 1973. 11. Reynolds JT, Southwick HW: Portal hypertension: Use of venous grafts when side to side anastomosis is impossible. Arch Surg 62:789-800, 1951. 12. Drapanas T: Interposition mesocaval shunt for the treatment of common
portal hypertension.
Ann Surg 176:435, 1972. JW, Rossi G, Daliana M, et al: Portasystemic shunts in the management of massive hemorrhage from esophageal varices due to cirrhosis of the liver. Am J Surg 121:241, 1971. 14. Graziano JL, Sullivan HJ: Portal decompression: Clinical experience with the "H" graft. Ann Surg 178:209-214, 1973. 15. Smith RB, Perdue GD: Early and late morbidity of portasystemic shunts including experience with seven H-grafts. Am J Gastroenterol 58:396-410, 1972. 16. Thompson BW, Read RC, Casali RE: Interposition grafting for portal hypertension. Am J Surg 130:733-738, 1975. 17. Elliot JP, Smith RF, Szilagyi DE: Aortoenteric and paraprostheticenteric fistulas. Arch Surg 108:479-490, 1974. 18. Tobias JA, Daicoff GR: Aortogastric and aortoileal fistulas repaired by direct suture. Arch Surg 107:909-911, 1973. 19. DeWeese MS, Fry WJ: Small bowel erosion following aortic resection. JAMA 179:882-886, 1962. 20. Ehrenfeld WK, Lord RS, Stoney RJ, et al: Subcutaneous arterial bypass grafts in the management of fistulae between the bowel and plastic arterial prostheses. Ann Surg 168:29-35, 1968. 21. Brook W, Gardner M: Anteroposition of the portal vein and spontaneous passage of gallstones. Br J Surg 59:737-739, 1972. 22. Youmans CR, Derrick JR: Gastrointestinal erosion after prosthetic arterial reconstructive surgery. Am J Surg 114:711-715, 1967. 13. Lord
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 05/11/2015
Prinz, MD, Jack Pickleman,
MD
unusual patient had ascending cholangitis secondary to bile duct obstruction by stones and a Dacron graft previously utilized in the performance of an H-graft portacaval shunt. Erosion of this foreign body into the common bile duct appeared to be secondary to bacterial contamination of the graft and direct contact of the foreign material with the biliary tree. \s=b\ An
common
(Arch Surg 113:333-335, 1978) Charcot1 first described acute ascending cholan¬ and characterized it by the diagnostic triad of fever and chills, jaundice, and right upper quadrant pain. One hundred years later, this process of infection occurring in an obstructed biliary tract remains a challenging problem for the surgeon. The present report describes an unusual patient in whom a Dacron prosthesis used to perform an -graft portacaval shunt eroded into the common bile duct, served as a nidus for stone formation, and resulted in ascending cholangitis.
1877, In gitis
REPORT OF A CASE woman was first seen at Loyola 45-year-old, University Medical Center, Maywood, 111, in May 1975, when she was transferred from a neighboring community hospital because of bleeding esophageal varices. While living in Mexico in 1972, she underwent a Dacron -graft portacaval shunt for bleeding varices. In February 1975, she had a recurrent upper gastrointes¬
This
Mexican-born
tinal tract hemorrhage and was treated with a subtotal gastrec¬ tomy and Billroth II reconstruction. Three months later, she again had hematemesis and was treated with balloon tamponade. On May 25, 1975, she was transferred to Loyola University Hospital, with a Sengstaken tube in place. After 24 hours there was no
Accepted
for publication Oct 18, 1977. From the Department of Surgery, Loyola University Medical Center, Maywood, Ill. Reprint requests to Department of Surgery, Loyola University Medical Center, 2160 S First Ave, Maywood, IL 60153 (Dr Pickleman).
evidence of bleeding, and the tube was removed. Endoscopy disclosed large esophageal varices and was otherwise normal. On May 29, 1975, she rebled massively; this was not controllable by balloon tamponade. Emergency celiac angiography disclosed prominent splenic and coronary veins with esophageal varices. The portacaval shunt was nonfunctioning (Fig 1). Intra-arterially administered vasopressin (Pitressin) only partially controlled the hemorrhage, and an emergency splenorenal shunt and splenec¬ tomy were performed. In order to complete the anastomosis, the tail of the pancreas was resected. Her postoperative course was complicated by a left subphrenic abscess, which was found to extend across the midline when it was drained on June 21, 1975. Cultures from the abscess grew Escherichia coli and y-Streptococcus group D. The abscess resolved with drainage and parenteral cephalothin sodium therapy, and she was discharged on July 5, 1975. The patient remained well until Aug 15,1976, when she entered the hospital with fever, chills, and right upper quadrant pain associated with nausea and vomiting. She had experienced no previous similar symptoms or other symptoms of biliary tract disease. Her temperature was 38.7 C; pulse, 120 beats per minute; and blood pressure, 120/80 mm Hg. She was icteric and had right upper quadrant guarding and rebound tenderness with a palpable gallbladder. Hemoglobin level was 12.4 gm/100 ml; the WBC count was 16,000/cu mm, with 52% neutrophils and 45% band cells. Bilirubin level was 5.4 mg/100 ml, with a direct fraction of 4.9 mg/100 ml. A diagnosis of ascending cholangitis was made and an emergency laparotomy was performed. Her gallbladder was enlarged, tense, and thickened. Cholecystectomy and operative cholangiography were performed. The common bile duct was markedly dilated, and there was no passage of dye into the duodenum (Fig 2). Common duct exploration demonstrated thick, inspissated bile with soft, friable stone formation. Multiple stones were extracted with biliary stone forceps. A 2-cm length of 18-mm Dacron graft that was lying free in the distal common duct was also removed by the stone forceps. It appeared that this was the entire length of the Dacron graft; there was no evidence of
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 05/11/2015
Fig 1.—Venous phase of celiac angiogram, demonstrating occluded portal vein and significant collateralization. Sengstaken tube is in place, with gastric balloon inflated. Fig 2.—Operative cholangiogram, demonstrating common by Dacron graft and biliary sludge.
bile
duct obstruction
bleeding into the bile ducts after removal of this prosthesis. The exploration was completed, and a tube was inserted into the common duct. A T-tube cholangiogram demonstrated free flow into the duodenum. Cultures from both the Dacron foreign body and bile grew E coli, y-Steptococcus group D, and Proteus mira¬ bilis. Microscopic examination of the gallbladder showed fibrous thickening with an acute and chronic inflammatory cell infiltrate and focal areas of microabscess formation. The gallbladder contained
no
stones.
Postoperatively, there
was
minimal
drainage from
the Penrose
drain; this was removed on the fourth postoperative day. However,
the T-tube cholangiogram showed a filling defect in the distal common duct compatible with a retained stone. The patient was treated with continuous irrigation of the tube with 75,000 units of heparin daily for seven days. A subsequent T-tube cholangio¬ gram showed no evidence of retained stones, and there was free flow of bile into the duodenum. The tube was removed. Three months afterwards, the WBC count, albumin, bilirubin, and alkaline phosphatase values had all returned to normal. In April 1977, the patient underwent a total thyroidectomy for a mixed papillary-follicular carcinoma of the thyroid with nodal metastases. At that time, she had no clinical or laboratory evidence of biliary tract disease.
COMMENT
Ascending cholangitis occurs as a complication of biliary
tract disease and often requires emergency operation. Since the biliary tract is obstructed, high pressures may develop, and organisms may gain access into the circula¬ tion and hepatic parenchyma. When a suppurative process is present under pressure, surgical drainage of the bile duct is the cornerstone of successful therapy. A recent review showed a 100% mortality in patients with acute suppura¬ tive cholangitis treated medically, and a 25% mortality in
those treated with operation.2 Common bile duct calculi are the most frequent cause of biliary obstruction resulting in cholangitis and were present in 79 of the 92 cases reviewed by Longmire.3 Biliary strictures, tumors, ampullary fibro¬ sis, congenital anomalies, pancreatitis, parasites, and
foreign bodies have all been reported as less frequent causes of ascending cholangitis.2·4·5 Numerous foreign bodies have been found in the biliary tract, including seeds, bullets, pins and needles, and the ova of parasites.'17 Following operative procedures on the biliary tree, nonab¬
sorbable suture material, cotton gauze, and rubber drains have been found within the biliary tract."*s These foreign bodies may mechanically obstruct the biliary tract them¬ selves, but more commonly they contribute to biliary stasis and serve as a nidus for stone formation. These stones then secondarily cause biliary tract obstruction. We have not encountered a case of biliary tract obstruction or fistula formation from a vascular prosthesis in our review of the literature. A fistula between the biliary ducts and blood vessels is not rare following trauma, where hemobilia normally results because the pressure in the portal system is usually higher than in the bile ducts.9 A fistula between the hepatic duct and portal vein has been reported in a patient with choledocholithiasis. Since the pressure in the common bile duct exceeded portal venous pressure, massive bilemia occurred, resulting in shock and death.1" This situation was possibly averted in our patient, because the portal vein was thrombosed. The first portasystemic H grafts were reported in 1951 by Reynolds and Southwick." Although the initial efforts utilized autogenous vein for interposition grafting, Dacron vascular prosthetic materials have been shown to be quite effective.'-·" The use of H grafting in the performance of portal decompression has increased because of the tech¬ nical advantages it offers. The amount of dissection of the portal vein and the vena cava is decreased, and the need for caudate lobectomy is eliminated. The distortion and kinking of the portal vein and the vena cava that result when an anastomosis is performed under tension is also eliminated.14*1" We have been unable to find any reports of H grafts for
Downloaded From: http://archsurg.jamanetwork.com/ by a New York University User on 05/11/2015
portal hypertension that became infected, nor have we encountered any reports of fistulae arising from prosthetic
materials used for this purpose. Several reports of
synthetic graft infections in arterial reconstruction have been published and we believe that the same principles of prevention and treatment employed in dealing with infected synthetic arterial grafts are also applicable to synthetic grafts used for venous decompression. Prosthetic enteric fistula is a rare but devastating complication of vascular surgery. The most common type is the aortoduodenal fistula, but aortogastric, aortojejunal,
and aortoileal fistulae have all been described.17 Factors responsible for fistula formation include direct contact of a viscus with a graft, contamination and infection of the prosthesis, and the use of silk suture material. A prosthesis in direct contact with a viscus may initiate a foreign body reaction that will gradually cause an erosion of the wall of that viscus. Infection will usually ensue, producing an abscess that will then dissect along the prosthesis.1" The capacity of a synthetic graft to become a nidus of continuing infection is well recognized, and control of that infection requires removal of all related synthetic materi¬ al.2" Since silk suture material was reportedly not used to perform the -graft anastomosis in our patient, direct contact of the graft with the common bile duct and infection are probably responsible for the erosion in this case. Although an anteriorly placed portal vein in front of the common bile duct has been reported, this is an anoma¬ ly.21 A technical error in making the H graft too long may have pushed the portal vein anteriorly, causing the graft to come in contact with the common bile duct. Infection is probably the most important factor leading to the graft erosion and subsequent biliary stone and '*
sludge formation in this patient. Although infection of the Dacron prosthesis following the portacaval anastomosis
cannot be ruled
out, we believe a technical error rather than infection caused thrombosis of this shunt, because the portal vein was nonfunctioning prior to the splenorenal shunt. The subphrenic abscess following the splenorenal shunt seems a more likely cause of the Dacron prosthetic infection. This nidus then eroded into the common bile duct, and the stasis and infection resulted in stone forma¬ tion in the common bile duct and in acute cholangitis. Supporting this chain of events is the growth of E coli and y-Streptococcus group D from the subphrenic abscess and also from the bile and Dacron graft one year later. These organisms had exactly the same antibiotic sensitivities on both occasions. That the biliary mud and stones in the common duct were secondary to stasis produced by the infected prosthesis is supported by the lack of stones in the
gallbladder.
Prevention of this potential complication is clearly important. Aseptic technique must be strictly followed, not only when the synthetic graft is inserted but at all subsequent operations, in order to avoid contamination. If possible, synthetic grafts must be isolated and separated from all other intra-abdominal organs by the interposition of viable tissue.22 Retroperitoneal fat, omentum, or mesen¬
tery may be utilized for this purpose. However, once a graft is infected, it must be completely removed or it will continue to act
as a source
Nonproprietary
of infection.
Name and Trademark of
Drug
Cephalothin sodium—Keflin.
References 1. Charcot JM: Lecons sur les maladies du foie des voies filiares et des reins, thesis, Paris, 1877. 2. Welch JP, Donaldson GA: The urgency of diagnosis and surgical treatment of acute suppurative cholangitis. Am J Surg 131:527-532, 1976. 3. Longmire WP Jr: Suppurative cholangitis, in Hardy JD (ed): Critical Surgical Illness. Philadelphia, WB Saunders Co, 1971, p 397. 4. Glenn F: Obstruction of the common bile duct. Surg Gynecol Obstet 132:25-35, 1971. 5. Hinshaw DB: Acute obstructive suppurative cholangitis. Surg Clin North Am 53:1089-1094, 1973. 6. Morse LJ, Millin J: Gallstone formation secondary to a foreign body. N Engl J Med 284:590-591, 1971. 7. Toland CG: Foreign bodies in the biliary tract. Ann Surg 98:904-908,
1933. 8. Newman CE, Hamer JD: Non-absorbable cystic duct ligatures and bile duct calculi. Br Med J 4:504, 1975. 9. Hendren WH, Warshaw AL, Fleischli DJ, et al: Traumatic hemobilia: Non-operative management with healing documented by serial angiography. Ann Surg 147:991, 1971. 10. Antebi E, Adar R, Zweig A, et al: Bilemia: An unusual complication of bile duct stones. Ann Surg 177:274-275, 1973. 11. Reynolds JT, Southwick HW: Portal hypertension: Use of venous grafts when side to side anastomosis is impossible. Arch Surg 62:789-800, 1951. 12. Drapanas T: Interposition mesocaval shunt for the treatment of common
portal hypertension.
Ann Surg 176:435, 1972. JW, Rossi G, Daliana M, et al: Portasystemic shunts in the management of massive hemorrhage from esophageal varices due to cirrhosis of the liver. Am J Surg 121:241, 1971. 14. Graziano JL, Sullivan HJ: Portal decompression: Clinical experience with the "H" graft. Ann Surg 178:209-214, 1973. 15. Smith RB, Perdue GD: Early and late morbidity of portasystemic shunts including experience with seven H-grafts. Am J Gastroenterol 58:396-410, 1972. 16. Thompson BW, Read RC, Casali RE: Interposition grafting for portal hypertension. Am J Surg 130:733-738, 1975. 17. Elliot JP, Smith RF, Szilagyi DE: Aortoenteric and paraprostheticenteric fistulas. Arch Surg 108:479-490, 1974. 18. Tobias JA, Daicoff GR: Aortogastric and aortoileal fistulas repaired by direct suture. Arch Surg 107:909-911, 1973. 19. DeWeese MS, Fry WJ: Small bowel erosion following aortic resection. JAMA 179:882-886, 1962. 20. Ehrenfeld WK, Lord RS, Stoney RJ, et al: Subcutaneous arterial bypass grafts in the management of fistulae between the bowel and plastic arterial prostheses. Ann Surg 168:29-35, 1968. 21. Brook W, Gardner M: Anteroposition of the portal vein and spontaneous passage of gallstones. Br J Surg 59:737-739, 1972. 22. Youmans CR, Derrick JR: Gastrointestinal erosion after prosthetic arterial reconstructive surgery. Am J Surg 114:711-715, 1967. 13. Lord
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