World J. Surg., 2, 639-644, 1978
Histological, Laboratory, and X-ray Findings after Repair of the Common Bile Duct with a Teflon | Graft Hans Hartung, M.D., Rainer Kirchner, M.D., Nobuo Baba, M.D., Dieter Waldmann, M.D., and Ernst-Peter Strecker, M.D. Department of Surgery,Universityof Freiburg, Freiburgim Breisgau,WestGermany
The c o m m o n duct was ligated in 25 dogs, 5 of which served as controls. Serum bilirubin, GOT, GPT, and alkaline phosphatase were measured pre- and postoperatively. Eight days later, in 10 dogs, a longitudinal incision was made across the stenosed segment of the c o m m o n bile duct, which was then widened with a Teflon | patch. In 10 other dogs, the stenosis was resected and the defect was bridged with a Teflon | prosthesis. A few days later, laboratory parameters returned to normal. Histological examination after 4 weeks showed that the Teflon | patch and Teflon | prosthesis were lined with bile duct epithelium. X-ray studies 6, 12 and 24 months after repair showed no evidence of stenosis. We conclude that it is possible to use a Teflon | graft in reconstructive c o m m o n bile duct surgery.
nign strictures of the common bile duct. When bile duct injuries are recognized immediately, suture over a T tube usually results in a satisfactory outcome. However, reconstruction of the injured bile duct that is not discovered at the time of injury is very difficult. Usually, end-to-end repair without tension is not possible [3]. In these cases, choledochoduodenostomy or choledochojejunostomy are required [4]. Frequently, these methods of choledochointestinal repair are disappointing, because they do not preserve the function of the sphincter of Oddi [5], and ascending cholangitis, recurrent strictures, and biliary cirrhosis are common sequelae. This report describes the results of experiments that were aimed at finding a method of reestablishing the flow of bile into the duodenum, preserving the sphincter of Oddi.
Injuries of the extrahepatic bile ducts are serious complications that can occur after operations on the stomach and more often after cholecystectomy [ 1, 2]. Especially during cholecystectomy, there are 3 conditions that favor damaging the common bile duct, namely, overhanging recesses (Hartmann's pouch) at the neck of the gallbladder, a shrunken calcific, chronically inflamed gallbladder, and low union of the cystic and hepatic ducts [2]. Accidental operative trauma is the most common cause of be-
Methods
The experiments involved 25 dogs, weighing 20-30 kg. Laparotomy was performed under intravenous pentobarbital anesthesia through an upper midline incision. The distal common bile duct was isolated and ligated. Serum bilirubin glutamic-oxaloacetic transaminase (GOT), glutamic-pyruvic transaminase (GPT), and alkaline phosphatase were measured pre- and postoperatively. Eight days later a longitudinal incision varying from 2 to 4 cm in length was made across the stenosed segment of the
Presented at the XXVIIth Congress of the Soci6t6 Internationale de Chirurgie, Kyoto, Japan, September 3-8, 1977. Reprint requests: Hans Hartung, M.D., Klinikum der Albert-Ludwigs-Universitat, Hugstetter Strasse 55, 78 Freiburg im Breisgau, West Germany.
0364-2313/78/0002-0639 $01.20 9 1978 Soci6t6 Internationale de Chirurgie 639
640
World J. Surg. Vol. 2, No. 5, September, 1978
Fig. 1. Photograph at operation of Teflon* patch inserted in the common bile duct. common bile duct in 10 dogs. The stenosed segment was then widened by application of a Teflon* patch (Fig. 1), according to Vossschulte's technique for repair of aortic coarctation [6]. In 10 other dogs, the stenotic segment was resected and the resulting 4 cm long defect was bridged with a 5 mm in diameter Teflon* prosthesis. The anastomoses were performed with interrupted suture of 6-0 Dexon*. The operative area was not drained. In the immediate postoperative period, Binotal | (Bayer Leverkusen, GFR) was administered daily. Serum bilirubin, GOT, GPT, and alkaline phosphatase were measured on the first, third, and fifth postoperative days, and then monthly. Dogs were sacrificed at intervals of 4 weeks. Bacterial cultures of bile and histological examinations of the liver and common bile duct were performed. Endoscopic retrograde cholangiography was performed 6, 12 and 24 months after replacement of the common bile duct. Five control dogs received no repair of the bile duct stenosis and were subjected to the same studies as the test dogs.
of stenosis. Bacteriological examination of bile after repair of the common bile duct with a Teflon| graft showed no bacterial growth. Two dogs are still alive and well 2 years after insertion of a Teflon* graft. They have gained from 3 to 5 kg in weight and have normal serum levels of bilirubin, GOT, GPT, and alkaline phosphatase. G r o s s examinations of tissues obtained at sacrifice showed the common bile duct, including the grafted area, to be covered by firm smooth connective tissue totally encircling the Teflon* patch or prosthesis. The suture lines were smooth and there was no evidence of foreign body granulomas. The grafted segments did not show any shortening (Fig. 2). Microscopically, the channel surrounding the graft was composed of connective tissue with collegen fibers. Four weeks after replacement, the Teflon* patch and prosthesis were lined with bile duct epithelium (Fig. 3). The liver parenchyma was normal.
Discussion Results
Elevated serum levels of bilirubin, GOT, GPT, and alkaline phosphatase returned to normal within a few days after both widening of the common bile duct with a Teflon* patch and replacement of the bile duct with a Teflon* prosthesis, in contrast to the persistent abnormalities observed in the control dogs subjected to bile duct ligation without repair. Intravenous cholangiography and endoscopic retrograde cholangiography did not show any evidence
Our experience and that of other authors [%9] have shown that repair of common bile duct stenosis with autografts of artery, vein, or ureter is not satisfactory. Gross and microscopic studies of bile duct grafts of fresh and preserved homologous and autogenous veins, arteries, and ureter have uniformly shown failure, with frequent necrosis and perforation of the graft [10]. The most common complications were fibrosis and stenosis with cholangitis. Insufficient blood supply of the free tissue grafts and perhaps a necrotizing effect of bile on cells near
H. Hartung et al.: Teflon | Graft for C o m m o n Bile Duct Repair
641
Fig. 2. Common bile duct removed 4 weeks after repair of stenosis with a Teflon* patch. The needle points to the grafted area. thing except molten alkali metal. It has been used as a tube within anastomoses connecting the hepatic duct with the d u o d e n u m or jejunum [11], and as a tube around which end-to-end anastomoses o f the c o m m o n bile duct were made [12]. H o w e v e r , previous experiments with Teflon* patches and prostheses have not shown any epithelization within the graft [13-15]. T o d a y , knitted Teflon* with a pore size o f 30/x is available for prostheses. Fibroblasts can penetrate the prosthesis and produce firm adhesiveness with the bile duct epithelium that migrates from both sides of the prosthesis. In our experiments, the Teflon* graft was covered with bile duct epithelium within 4 weeks after placement, without any shrinking or occlusion by bile salts. We conclude, therefore, that it is possible to use a Teflon* graft in the treatment of benign stenosis of the c o m m o n bile duct. Since 1974, we have treated 4 patients with stenosis of the bile duct in the manner used in our experimental studies, All of the patients have remained free of biliary obstruction.
R6sum6 Fig. 3. Photomicrograph of the common bile duct obtained 4 weeks after insertion of a Teflon* patch.
the suture lines prevented successful reconstruction. Teflon*, polytetrafluorethylene, has good mechanical properties. For example, it does not absorb water and does not react chemically with any-
Le chol6doque a 6t6 li6 chez 25 chiens, dont 5 ont servi de t6moins. L a bilirubine, SGOT et S G P T et la phosphatase alcaline ont 6t6 dos6es avant et apr6s l'op6ration. Dix jours plus tard, chez 10 chiens, la st6nose chol6docienne a 6t6 incis6e longitudinalement et 61argie par un patch en Teflon| Chez l0 autres chiens, la zone de st6nose a 6t6 r6s6qu6e, la continuit6 r6tablie par une proth6se en Teflon| Quelques jours plus tard, les donn6es biologiques sont redevenues normales. A 4 semaines,
642
l'examen histologique montre que le patch et la proth6se en Teflon| sont tapiss6s d'6pith61ium biliaire. Les contr61es radiographiques ~t 6, 12 et 24 mois ne r6v~lent pas de st6nose. Une proth6se en Teflon| peut donc fitre utilis6e pour reconstruire la voie biliaire.
World J. Surg. Vol. 2, No. 5, September, 1978
8.
9.
References
10. 1. Gfitgemann, A., Schriefers, K.H., Philipp, R., Wfilfing, D.: Zur rekonstruktiven Chirurgie des Verletzten und strikturierten gro/3en Gallengangs. Bruns Beitr. Klin. Chir. 210:129, 1965 2. Zenker, R., Hamelmann, H.: Wiederherstellungsoperationen an den Galleng~ingen. Chirurg29:385, 1958 3. Longmire, W.P., Jr.: Early management of injury to the extrahepatic biliary tract. J.A.M.A. 195:623, 1966 4. Warren, K.W., Poulantzas, J.K., Kune, G.A.: Use of a Y-tube splint in the repair of biliary strictures. Surg. Gynecol. Obstet. 122:785, 1966 5. Dogliotti, A.M., Fogliati, E.: Operations for fibrous stenosis of the common bile duct. Surgery 36:69, 1954 6. Vossschulte, K.: Isthmusplastik zur Behandlung der Aortenisthmusstenose. Thoraxchirurgie 4:443, 1956 7. Pearce, A.E., Ulin, A.W., Entine, J.H., Froio, G.F.: Experimental reconstruction of the extrahepatic sys-
11. 12. 13. 14. 15.
tern using free venous grafts. Ann. Surg. 134:808, 1951 Santos, M., Smith, M.L., Hughes, C.W., Riley, P.A., Jr.: Reconstruction of the bile ducts. An experimental study using free arterial grafts and nylon mesh tubes. Surgery 42:462, 1957 Sedgwick, D.E.: Reconstruction of the bile duct with a free ureteral graft. An experimental study. Surg. Gynecol. Obstet. 92:571, 1951 Ulin, A.W., Van Ess, L., Entine, J., Pearce, A.E., Martin, W.L.: Further experiences with the experimental reconstruction of the common bile duct: use of autogenous and homologous, fresh and preserved grafts of blood vessels, ureter and common duct. Am. Surg. 19:867, 1953 Myrin, S.O.: The use of Teflon in reconstructive choledochal surgery. Acta Chir. Scand. 119:118, 1960 Hallberg, O., Jonson, G.: Teflon choledochoplasty in dogs. Acta Chit. Scand. 119:120, 1960 Bandura, W.P., Arbulu, A.: Experimental replacement of the common bile duct with Teflon graft. Am. Surg. 27:518, 1961 Thomas, J.P., Metropol, H.J., Myers, R.T.: Teflon patch graft for reconstruction of the extrahepatic bile duct. Am. Surg. 160:967, 1964 Ingalls, W.J.: Teflon grafts and homografts in the common bile duct. A preliminary evaluation. Ohio Med. J. 57:265, 1961
Invited Commentary John W. Braasch, M.D. Lahey Clinic, Boston, Massachusetts, U.S.A. The technique of bile duct stricture repair continues to attract worldwide attention because of the element of tragedy in its occurrence following cholec y s t e c t o m y and because appreciable numbers of failures follow repair. The use of a Teflon| patch or tube as reported in this study in dogs adds another prosthesis to the list of those previously tried. There is great hazard in comparing results of various techniques in the repair of benign biliary stricture since the result is often determined mainly by the details and types of cases reported. It has been our experience [1] that preservation of the sphincter of Oddi by end-to-end repair o f a stricture did not yield results significantly better than hepaticojejunostomy in our 1950-1960 series. This conclusion regarding the importance of the sphincter of Oddi is further emphasized by the rarity of stricture after bile duct reconstruction following the Whipple procedure or after anastomoses for stone disease in which the sphincter has been bypassed. Thus, it is not certain that one of the important advantages of the repair described in this paper exists.
Secondly, another advantage for the use of a prosthesis can be questioned because length of duct is not a problem. Bowel can be brought to the porta hepatis or indeed to the secondary or tertiary ducts within the liver for anastomoses without tension. Lastly, the use of a tube prosthesis in duct repair requires the construction o f 2 anastomoses. Thus, the risk of contraction of the reconstruction is double that of just a single anastomosis. In spite of these considerations it is interesting to note that biliary epithelium lines the inside of the prosthesis within a relatively short time and that contracture of the lumen was not noted in this study. It is conceivable that large-pore size Teflon| has some salutory affect on biliary anastomoses, an idea worth consideration. Reference
1. Cattell, R.B., Braasch, J.W.: End-to-end repair of bile duct strictures. Current Surgical Management I1. Philadelphia, W.B. Saunders Co., 1960, pp. 140-143
Histological, Laboratory, and X-ray Findings after Repair of the Common Bile Duct with a Teflon | Graft Hans Hartung, M.D., Rainer Kirchner, M.D., Nobuo Baba, M.D., Dieter Waldmann, M.D., and Ernst-Peter Strecker, M.D. Department of Surgery,Universityof Freiburg, Freiburgim Breisgau,WestGermany
The c o m m o n duct was ligated in 25 dogs, 5 of which served as controls. Serum bilirubin, GOT, GPT, and alkaline phosphatase were measured pre- and postoperatively. Eight days later, in 10 dogs, a longitudinal incision was made across the stenosed segment of the c o m m o n bile duct, which was then widened with a Teflon | patch. In 10 other dogs, the stenosis was resected and the defect was bridged with a Teflon | prosthesis. A few days later, laboratory parameters returned to normal. Histological examination after 4 weeks showed that the Teflon | patch and Teflon | prosthesis were lined with bile duct epithelium. X-ray studies 6, 12 and 24 months after repair showed no evidence of stenosis. We conclude that it is possible to use a Teflon | graft in reconstructive c o m m o n bile duct surgery.
nign strictures of the common bile duct. When bile duct injuries are recognized immediately, suture over a T tube usually results in a satisfactory outcome. However, reconstruction of the injured bile duct that is not discovered at the time of injury is very difficult. Usually, end-to-end repair without tension is not possible [3]. In these cases, choledochoduodenostomy or choledochojejunostomy are required [4]. Frequently, these methods of choledochointestinal repair are disappointing, because they do not preserve the function of the sphincter of Oddi [5], and ascending cholangitis, recurrent strictures, and biliary cirrhosis are common sequelae. This report describes the results of experiments that were aimed at finding a method of reestablishing the flow of bile into the duodenum, preserving the sphincter of Oddi.
Injuries of the extrahepatic bile ducts are serious complications that can occur after operations on the stomach and more often after cholecystectomy [ 1, 2]. Especially during cholecystectomy, there are 3 conditions that favor damaging the common bile duct, namely, overhanging recesses (Hartmann's pouch) at the neck of the gallbladder, a shrunken calcific, chronically inflamed gallbladder, and low union of the cystic and hepatic ducts [2]. Accidental operative trauma is the most common cause of be-
Methods
The experiments involved 25 dogs, weighing 20-30 kg. Laparotomy was performed under intravenous pentobarbital anesthesia through an upper midline incision. The distal common bile duct was isolated and ligated. Serum bilirubin glutamic-oxaloacetic transaminase (GOT), glutamic-pyruvic transaminase (GPT), and alkaline phosphatase were measured pre- and postoperatively. Eight days later a longitudinal incision varying from 2 to 4 cm in length was made across the stenosed segment of the
Presented at the XXVIIth Congress of the Soci6t6 Internationale de Chirurgie, Kyoto, Japan, September 3-8, 1977. Reprint requests: Hans Hartung, M.D., Klinikum der Albert-Ludwigs-Universitat, Hugstetter Strasse 55, 78 Freiburg im Breisgau, West Germany.
0364-2313/78/0002-0639 $01.20 9 1978 Soci6t6 Internationale de Chirurgie 639
640
World J. Surg. Vol. 2, No. 5, September, 1978
Fig. 1. Photograph at operation of Teflon* patch inserted in the common bile duct. common bile duct in 10 dogs. The stenosed segment was then widened by application of a Teflon* patch (Fig. 1), according to Vossschulte's technique for repair of aortic coarctation [6]. In 10 other dogs, the stenotic segment was resected and the resulting 4 cm long defect was bridged with a 5 mm in diameter Teflon* prosthesis. The anastomoses were performed with interrupted suture of 6-0 Dexon*. The operative area was not drained. In the immediate postoperative period, Binotal | (Bayer Leverkusen, GFR) was administered daily. Serum bilirubin, GOT, GPT, and alkaline phosphatase were measured on the first, third, and fifth postoperative days, and then monthly. Dogs were sacrificed at intervals of 4 weeks. Bacterial cultures of bile and histological examinations of the liver and common bile duct were performed. Endoscopic retrograde cholangiography was performed 6, 12 and 24 months after replacement of the common bile duct. Five control dogs received no repair of the bile duct stenosis and were subjected to the same studies as the test dogs.
of stenosis. Bacteriological examination of bile after repair of the common bile duct with a Teflon| graft showed no bacterial growth. Two dogs are still alive and well 2 years after insertion of a Teflon* graft. They have gained from 3 to 5 kg in weight and have normal serum levels of bilirubin, GOT, GPT, and alkaline phosphatase. G r o s s examinations of tissues obtained at sacrifice showed the common bile duct, including the grafted area, to be covered by firm smooth connective tissue totally encircling the Teflon* patch or prosthesis. The suture lines were smooth and there was no evidence of foreign body granulomas. The grafted segments did not show any shortening (Fig. 2). Microscopically, the channel surrounding the graft was composed of connective tissue with collegen fibers. Four weeks after replacement, the Teflon* patch and prosthesis were lined with bile duct epithelium (Fig. 3). The liver parenchyma was normal.
Discussion Results
Elevated serum levels of bilirubin, GOT, GPT, and alkaline phosphatase returned to normal within a few days after both widening of the common bile duct with a Teflon* patch and replacement of the bile duct with a Teflon* prosthesis, in contrast to the persistent abnormalities observed in the control dogs subjected to bile duct ligation without repair. Intravenous cholangiography and endoscopic retrograde cholangiography did not show any evidence
Our experience and that of other authors [%9] have shown that repair of common bile duct stenosis with autografts of artery, vein, or ureter is not satisfactory. Gross and microscopic studies of bile duct grafts of fresh and preserved homologous and autogenous veins, arteries, and ureter have uniformly shown failure, with frequent necrosis and perforation of the graft [10]. The most common complications were fibrosis and stenosis with cholangitis. Insufficient blood supply of the free tissue grafts and perhaps a necrotizing effect of bile on cells near
H. Hartung et al.: Teflon | Graft for C o m m o n Bile Duct Repair
641
Fig. 2. Common bile duct removed 4 weeks after repair of stenosis with a Teflon* patch. The needle points to the grafted area. thing except molten alkali metal. It has been used as a tube within anastomoses connecting the hepatic duct with the d u o d e n u m or jejunum [11], and as a tube around which end-to-end anastomoses o f the c o m m o n bile duct were made [12]. H o w e v e r , previous experiments with Teflon* patches and prostheses have not shown any epithelization within the graft [13-15]. T o d a y , knitted Teflon* with a pore size o f 30/x is available for prostheses. Fibroblasts can penetrate the prosthesis and produce firm adhesiveness with the bile duct epithelium that migrates from both sides of the prosthesis. In our experiments, the Teflon* graft was covered with bile duct epithelium within 4 weeks after placement, without any shrinking or occlusion by bile salts. We conclude, therefore, that it is possible to use a Teflon* graft in the treatment of benign stenosis of the c o m m o n bile duct. Since 1974, we have treated 4 patients with stenosis of the bile duct in the manner used in our experimental studies, All of the patients have remained free of biliary obstruction.
R6sum6 Fig. 3. Photomicrograph of the common bile duct obtained 4 weeks after insertion of a Teflon* patch.
the suture lines prevented successful reconstruction. Teflon*, polytetrafluorethylene, has good mechanical properties. For example, it does not absorb water and does not react chemically with any-
Le chol6doque a 6t6 li6 chez 25 chiens, dont 5 ont servi de t6moins. L a bilirubine, SGOT et S G P T et la phosphatase alcaline ont 6t6 dos6es avant et apr6s l'op6ration. Dix jours plus tard, chez 10 chiens, la st6nose chol6docienne a 6t6 incis6e longitudinalement et 61argie par un patch en Teflon| Chez l0 autres chiens, la zone de st6nose a 6t6 r6s6qu6e, la continuit6 r6tablie par une proth6se en Teflon| Quelques jours plus tard, les donn6es biologiques sont redevenues normales. A 4 semaines,
642
l'examen histologique montre que le patch et la proth6se en Teflon| sont tapiss6s d'6pith61ium biliaire. Les contr61es radiographiques ~t 6, 12 et 24 mois ne r6v~lent pas de st6nose. Une proth6se en Teflon| peut donc fitre utilis6e pour reconstruire la voie biliaire.
World J. Surg. Vol. 2, No. 5, September, 1978
8.
9.
References
10. 1. Gfitgemann, A., Schriefers, K.H., Philipp, R., Wfilfing, D.: Zur rekonstruktiven Chirurgie des Verletzten und strikturierten gro/3en Gallengangs. Bruns Beitr. Klin. Chir. 210:129, 1965 2. Zenker, R., Hamelmann, H.: Wiederherstellungsoperationen an den Galleng~ingen. Chirurg29:385, 1958 3. Longmire, W.P., Jr.: Early management of injury to the extrahepatic biliary tract. J.A.M.A. 195:623, 1966 4. Warren, K.W., Poulantzas, J.K., Kune, G.A.: Use of a Y-tube splint in the repair of biliary strictures. Surg. Gynecol. Obstet. 122:785, 1966 5. Dogliotti, A.M., Fogliati, E.: Operations for fibrous stenosis of the common bile duct. Surgery 36:69, 1954 6. Vossschulte, K.: Isthmusplastik zur Behandlung der Aortenisthmusstenose. Thoraxchirurgie 4:443, 1956 7. Pearce, A.E., Ulin, A.W., Entine, J.H., Froio, G.F.: Experimental reconstruction of the extrahepatic sys-
11. 12. 13. 14. 15.
tern using free venous grafts. Ann. Surg. 134:808, 1951 Santos, M., Smith, M.L., Hughes, C.W., Riley, P.A., Jr.: Reconstruction of the bile ducts. An experimental study using free arterial grafts and nylon mesh tubes. Surgery 42:462, 1957 Sedgwick, D.E.: Reconstruction of the bile duct with a free ureteral graft. An experimental study. Surg. Gynecol. Obstet. 92:571, 1951 Ulin, A.W., Van Ess, L., Entine, J., Pearce, A.E., Martin, W.L.: Further experiences with the experimental reconstruction of the common bile duct: use of autogenous and homologous, fresh and preserved grafts of blood vessels, ureter and common duct. Am. Surg. 19:867, 1953 Myrin, S.O.: The use of Teflon in reconstructive choledochal surgery. Acta Chir. Scand. 119:118, 1960 Hallberg, O., Jonson, G.: Teflon choledochoplasty in dogs. Acta Chit. Scand. 119:120, 1960 Bandura, W.P., Arbulu, A.: Experimental replacement of the common bile duct with Teflon graft. Am. Surg. 27:518, 1961 Thomas, J.P., Metropol, H.J., Myers, R.T.: Teflon patch graft for reconstruction of the extrahepatic bile duct. Am. Surg. 160:967, 1964 Ingalls, W.J.: Teflon grafts and homografts in the common bile duct. A preliminary evaluation. Ohio Med. J. 57:265, 1961
Invited Commentary John W. Braasch, M.D. Lahey Clinic, Boston, Massachusetts, U.S.A. The technique of bile duct stricture repair continues to attract worldwide attention because of the element of tragedy in its occurrence following cholec y s t e c t o m y and because appreciable numbers of failures follow repair. The use of a Teflon| patch or tube as reported in this study in dogs adds another prosthesis to the list of those previously tried. There is great hazard in comparing results of various techniques in the repair of benign biliary stricture since the result is often determined mainly by the details and types of cases reported. It has been our experience [1] that preservation of the sphincter of Oddi by end-to-end repair o f a stricture did not yield results significantly better than hepaticojejunostomy in our 1950-1960 series. This conclusion regarding the importance of the sphincter of Oddi is further emphasized by the rarity of stricture after bile duct reconstruction following the Whipple procedure or after anastomoses for stone disease in which the sphincter has been bypassed. Thus, it is not certain that one of the important advantages of the repair described in this paper exists.
Secondly, another advantage for the use of a prosthesis can be questioned because length of duct is not a problem. Bowel can be brought to the porta hepatis or indeed to the secondary or tertiary ducts within the liver for anastomoses without tension. Lastly, the use of a tube prosthesis in duct repair requires the construction o f 2 anastomoses. Thus, the risk of contraction of the reconstruction is double that of just a single anastomosis. In spite of these considerations it is interesting to note that biliary epithelium lines the inside of the prosthesis within a relatively short time and that contracture of the lumen was not noted in this study. It is conceivable that large-pore size Teflon| has some salutory affect on biliary anastomoses, an idea worth consideration. Reference
1. Cattell, R.B., Braasch, J.W.: End-to-end repair of bile duct strictures. Current Surgical Management I1. Philadelphia, W.B. Saunders Co., 1960, pp. 140-143
