Direct Gallbladder Indocyanine Green Injection Fluorescence Cholangiography During Laparoscopic Cholecystectomy.

PubMed

Graves, Claire; Ely, Sora; Idowu, Olajire; Newton, Christopher; Kim, Sunghoon

2017-10-01

Intravenous injection of indocyanine green (ICG) is used to illuminate extrahepatic biliary anatomy. Fluorescence of biliary structures may lower surgical complications that can arise due to inadvertent injury to the common bile duct. We describe a method of injecting ICG directly into the gallbladder to define the cystic duct and common bile duct anatomy. A standard laparoscopic cholecystectomy was performed using a laparoscope with near-infrared imaging capability. Before dissection, the gallbladder was punctured with a cholangiogram catheter or a pigtail catheter to aspirate the bile within the gallbladder. The aspirated bile is mixed with ICG solution, which is reinjected into the gallbladder to fluoresce the gallbladder, cystic duct, and common bile duct structures. Eleven patients underwent direct gallbladder ICG injection for fluorescence cholangiography during cholecystectomy. Direct gallbladder ICG injection clearly defined the extrahepatic biliary anatomy, including the cystic duct-common bile duct junction, by fluorescence. In addition, the dissection plane between the gallbladder and the liver is highlighted with the gallbladder ICG fluorescence. Direct gallbladder ICG injection provides immediate visualization of extrahepatic biliary structures and clarifies the dissection plane between the gallbladder and the liver bed.

Comparison of Different Magnetic Resonance Cholangiography Techniques in Living Liver Donors Including Gd-EOB-DTPA Enhanced T1-Weighted Sequences

PubMed Central

Kinner, Sonja; Steinweg, Verena; Maderwald, Stefan; Radtke, Arnold; Sotiropoulos, Georgios; Forsting, Michael; Schroeder, Tobias

2014-01-01

Objectives Preoperative evaluation of potential living liver donors (PLLDs) includes the assessment of the biliary anatomy to avoid postoperative complications. Aim of this study was to compare T2-weighted (T2w) and Gd-EOB-DTPA enhanced T1-weighted (T1w) magnetic resonance cholangiography (MRC) techniques in the evaluation of PLLDs. Materials and Methods 30 PLLDs underwent MRC on a 1.5 T Magnetom Avanto (Siemens, Erlangen, Germany) using (A) 2D T2w HASTE (Half Fourier Acquisition Single Shot Turbo Spin Echo) fat saturated (fs) in axial plane, (B) 2D T2w HASTE fs thick slices in coronal plane, (C) free breathing 3D T2w TSE (turbo spin echo) RESTORE (high-resolution navigator corrected) plus (D) maximum intensity projections (MIPs), (E) T2w SPACE (sampling perfection with application optimized contrasts using different flip angle evolutions) plus (F) MIPs and (G) T2w TSE BLADE as well as Gd-EOB-DTPA T1w images without (G) and with (H) inversion recovery. Contrast enhanced CT cholangiography served as reference imaging modality. Two independent reviewers evaluated the biliary tract anatomy on a 5-point scale subjectively and objectively. Data sets were compared using a Mann-Whitney-U-test. Kappa values were also calculated. Results Source images and maximum intensity projections of 3D T2w TSE sequences (RESTORE and SPACE) proved to be best for subjective and objective evaluation directly followed by 2D HASTE sequences. Interobserver variabilities were good to excellent (k = 0.622–0.804). Conclusions 3D T2w sequences are essential for preoperative biliary tract evaluation in potential living liver donors. Furthermore, our results underline the value of different MRCP sequence types for the evaluation of the biliary anatomy in PLLDs including Gd-EOB-DTPA enhanced T1w MRC. PMID:25426932

Percutaneous transhepatic cholangiography for choledocholithiasis after laparoscopic gastric bypass surgery

PubMed Central

Milella, Marialessia; Alfa-Wali, Maryam; Leuratti, Luca; McCall, James; Bonanomi, Gianluca

2014-01-01

INTRODUCTION Gallstones are a common condition in bariatric patients after a laparoscopic Roux-en-Y gastric bypass (LRYGB). The management of ductal stones is challenging due to the altered gastrointestinal anatomy. Various techniques have been reported to manage bile duct stones. PRESENTATION OF CASE We present the successful percutaneous trans hepatic management of common bile duct stones after LRYGB. One year after a LRYGB for morbid obesity, a 59-year-old female presented with acute cholecystitis. One month after laparoscopic cholecystectomy a 1 cm calculus was found within the distal CBD and patient underwent a percutaneous trans hepatic cholangiography under local anesthetic. This involved a right sided anterior segmental duct puncture. With the sphincter dilated to 10 mm, a balloon catheter was used to push the stone into the duodenum leaving an internal- external drain. Patient recovered completely at follow up. DISCUSSION Patients with morbid obesity have a higher incidence of gallstones. After LRYGB, the altered anatomy does not allow the conventional endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. Various techniques have been reported as means of managing bile duct stones in LRYGB patients. These include a double balloon enteroscope-assisted ERCP, laparoscopic transgastric ERCP, laparoscopic or open biliary surgery and interventional radiology. We report a non-surgical approach using percutaneous transhepatic technique under local anesthetic that resulted effective and could be applied more extensively. CONCLUSION Due to the increase of global obesity, bariatric centers need to strategically plan resources such as interventional radiology in order to manage post LRYGB choledocholithiasis safely, efficiently and in a cost effective manner. PMID:24705194

A prototype percutaneous transhepatic cholangiography training simulator with real-time breathing motion.

PubMed

Villard, P F; Vidal, F P; Hunt, C; Bello, F; John, N W; Johnson, S; Gould, D A

2009-11-01

We present here a simulator for interventional radiology focusing on percutaneous transhepatic cholangiography (PTC). This procedure consists of inserting a needle into the biliary tree using fluoroscopy for guidance. The requirements of the simulator have been driven by a task analysis. The three main components have been identified: the respiration, the real-time X-ray display (fluoroscopy) and the haptic rendering (sense of touch). The framework for modelling the respiratory motion is based on kinematics laws and on the Chainmail algorithm. The fluoroscopic simulation is performed on the graphic card and makes use of the Beer-Lambert law to compute the X-ray attenuation. Finally, the haptic rendering is integrated to the virtual environment and takes into account the soft-tissue reaction force feedback and maintenance of the initial direction of the needle during the insertion. Five training scenarios have been created using patient-specific data. Each of these provides the user with variable breathing behaviour, fluoroscopic display tuneable to any device parameters and needle force feedback. A detailed task analysis has been used to design and build the PTC simulator described in this paper. The simulator includes real-time respiratory motion with two independent parameters (rib kinematics and diaphragm action), on-line fluoroscopy implemented on the Graphics Processing Unit and haptic feedback to feel the soft-tissue behaviour of the organs during the needle insertion.

Percutaneous transhepatic cholangiography for choledocholithiasis after laparoscopic gastric bypass surgery.

PubMed

Milella, Marialessia; Alfa-Wali, Maryam; Leuratti, Luca; McCall, James; Bonanomi, Gianluca

2014-01-01

Gallstones are a common condition in bariatric patients after a laparoscopic Roux-en-Y gastric bypass (LRYGB). The management of ductal stones is challenging due to the altered gastrointestinal anatomy. Various techniques have been reported to manage bile duct stones. We present the successful percutaneous trans hepatic management of common bile duct stones after LRYGB. One year after a LRYGB for morbid obesity, a 59-year-old female presented with acute cholecystitis. One month after laparoscopic cholecystectomy a 1cm calculus was found within the distal CBD and patient underwent a percutaneous trans hepatic cholangiography under local anesthetic. This involved a right sided anterior segmental duct puncture. With the sphincter dilated to 10mm, a balloon catheter was used to push the stone into the duodenum leaving an internal- external drain. Patient recovered completely at follow up. Patients with morbid obesity have a higher incidence of gallstones. After LRYGB, the altered anatomy does not allow the conventional endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. Various techniques have been reported as means of managing bile duct stones in LRYGB patients. These include a double balloon enteroscope-assisted ERCP, laparoscopic transgastric ERCP, laparoscopic or open biliary surgery and interventional radiology. We report a non-surgical approach using percutaneous transhepatic technique under local anesthetic that resulted effective and could be applied more extensively. Due to the increase of global obesity, bariatric centers need to strategically plan resources such as interventional radiology in order to manage post LRYGB choledocholithiasis safely, efficiently and in a cost effective manner. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.

Routine intraoperative cholangiography is unnecessary in patients with mild gallstone pancreatitis and normalizing bilirubin levels.

PubMed

Pham, Xuan-Binh D; de Virgilio, Christian; Al-Khouja, Lutfi; Bermudez, Michael C; Schwed, Alexander C; Kaji, Amy H; Plurad, David S; Lee, Steven L; Bennion, Robert S; Saltzman, Darin J; Kim, Dennis Y

2016-12-01

The benefit of intraoperative cholangiography (IOC) is controversial in patients with gallstone pancreatitis whose bilirubin levels are normalizing. IOC with subsequent endoscopic retrograde cholangiopancreatography may lengthen duration of surgery and length of stay, whereas failure to clear the common bile duct may result in recurrent pancreatitis. We performed a 6-year retrospective cohort analysis of consecutive adult patients with mild gallstone pancreatitis undergoing same-admission cholecystectomy at 2 university-affiliated medical centers. Institution A routinely performed IOC, whereas institution B did not. The primary outcome was readmission within 30 days for recurrent pancreatitis. Of 520 patients evaluated, 246 (47%) were managed at institution A (routine IOC) and 274 (53%) were managed at institution B (restricted IOC). Patients at institution B had a shorter duration of surgery (1.0 vs 1.6 hours, P < .001), shorter length of stay (4 vs 5 days, P < .001), and fewer postoperative endoscopic retrograde cholangiopancreatographies performed (1.8% vs 21%, P < .001), without a difference in readmissions (1.5% vs 0%, P = .12). Routine IOC is not necessary in the setting of mild gallstone pancreatitis with normalizing bilirubin values. Copyright © 2016 Elsevier Inc. All rights reserved.

A comparison of operation, endoscopic retrograde cholangiopancreatography, and percutaneous transhepatic cholangiography in biliary complications after hepatic transplantation.

PubMed

Kuo, P C; Lewis, W D; Stokes, K; Pleskow, D; Simpson, M A; Jenkins, R L

1994-08-01

Biliary complications (BC) remain a significant cause of morbidity and mortality after orthotopic liver transplantation (OLT). In an effort to determine the incidence of BC after OLT and the success of management options, 157 hepatic transplants performed from January 1987 to July 1991 were reviewed. The incidence of BC was 25 percent, with a one year mortality rate of 43.5 percent compared with 23.4 percent for patients in a control group (p < 0.05). Most BC occurring before postoperative day 30 presented as leaks, with a one year mortality rate of 50 percent (p < 0.03 versus control group). Biliary complications presenting after postoperative day 30 presented as strictures, with a one year mortality rate of 36.8 percent (p = NS versus control group). Endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTHC), and operative treatment were analyzed to determine relative patency rates after intervention for BC. The analysis showed that ERCP and PTHC were equivalent, with a one year patency rate of 45 percent. Operative treatment had a patency rate of 89 percent (p < 0.05 compared to ERCP and PTHC). The results from ERCP and PTHC may be useful for delineation of rejection versus BC after OLT. However, operative treatment is significantly more effective for definitive treatment of BC after OLT.

Double-balloon endoscopy for retrograde cholangiography in patients with choledochojejunostomy and Roux-en-Y reconstruction.

PubMed

Pohl, J; May, A; Aschmoneit, I; Ell, C

2009-02-01

Choledochojejunal anastomoses with Roux-en-Y reconstruction excludes the biliary tract from conventional endoscopic retrograde cholangiography (ERC) with standard endoscopes due to the length of the interposed small bowel segment. Double-balloon enteroscopy (DBE) facilitates deep insertion into the small bowel and may be used to perform ERC in these patients. In the present case series we report our experience with diagnostic and therapeutic double-balloon ERC in patients with choledochojejunostomy to a long Roux-en-Y loop previously unavailable for standard length endoscopes. Between December 2004 and May 2008 15 patients (mean age: 60.2 years) with choledochojejunal anastomosis underwent a total of 25 DBE-ERC procedures. Cannulation of the bile ducts was achieved in 22 / 25 procedures (84 %). Twenty-one therapeutic interventions, including stone removal, biliary duct dilation, stent placement and removal of previously placed stents were performed during 16 procedures in 8 patients. The mean total duration time of the procedures was 74.6 +/- 25.0 minutes. Postinterventional self-limiting fever occurred after 4 procedures in 3 patients with cholangitis. After therapeutic interventions all patients had a significant drop of bilirubin levels and all except one patient were free of complaints (follow-up 10.4 +/- 8.6 months). The DBE system permits diagnostic and therapeutic ERC in surgically modified anatomy, previously unavailable for endoluminal access. In our experience this procedure is safe and has a high success rate with a favourable patient outcome.

Accuracy of percutaneous transhepatic cholangiography in predicting the location and nature of major bile duct injuries.

PubMed

Fidelman, Nicholas; Kerlan, Robert K; Laberge, Jeanne M; Gordon, Roy L

2011-06-01

To determine the ability of percutaneous transhepatic cholangiography (PTC) to predict accurately the anatomic location and nature of major bile duct injuries, to examine the contribution of endoscopic retrograde cholangiopancreatography (ERCP) and PTC to the diagnosis of injuries to the low-inserting right posterior segmental ducts, and to compare the ability of radiologists and gastroenterologists to detect injuries to the low-inserting right posterior segmental duct. PTC images and operative reports of 78 consecutive patients who underwent surgical repair of major bile duct injuries at the authors' institution were retrospectively reviewed. The location of injury was assessed according to the Bismuth classification. Images were also evaluated for the presence of a biliary stricture, biliary leak, or both. Imaging observations were compared with findings obtained during surgical biliary reconstruction. PTC correctly predicted the anatomic location of injuries in 85% of patients. Incorrect Bismuth type was assigned in 12 patients. Seven of the errors (58%) originated from the inability to distinguish injuries at the confluence of the lobar ducts from injuries involving the cephalad 2 cm of the common hepatic duct. Injuries to the right posterior segmental duct were detected more often on ERCP images by gastroenterologists than by diagnostic radiologists. In four patients (5%), biliary strictures were masked on PTC by the presence of a concomitant leak. PTC accurately depicts the location and nature of major bile duct injuries in most patients. Copyright © 2011 SIR. Published by Elsevier Inc. All rights reserved.

[External biliary fistulas selectively managed by endoscopic retrograde cholangiography with sphincterotomy and/or stent placement].

PubMed

Săftoiu, A; Gheonea, D I; Surlin, V; Ciurea, M E; Georgescu, A; Andrei, E; Blendea, A; Georgescu, C C; Georgescu, I; Ciurea, T

2006-01-01

External bile duct fistulas are inherent postoperative complications that usually appear after biliary tract surgery, traumatic bile duct injuries and liver surgery for hepatic hydatid disease or liver transplant. The management is highly individualized, while the success and long-term results of endoscopic and surgical techniques are conflicting. The study included 32 cases with external bile duct fistulas managed by endoscopic retrograde cholangiography (ERC) with sphincterotomy and/or stent placement, including "rendez-vous" procedures in 2 cases. The causes of the external fistula were represented by cholecystectomy with/without retained common bile duct stones or strictures (22 cases), cholecystectomy and drainage of a subphrenic abscess caused by severe acute pancreatitis (1 case) and surgical interventions for hepatic hydatid disease (9 cases). Due to the prospective protocol of the study we were able to apply an individualized endoscopic treatment: sphincterotomy with proper relief of the bile duct obstruction (stone extraction) or sphincterotomy with large-size (10 Fr) stent placement for large-sized bile duct defects. The results consisted in closure of the fistula in 3.5 +/- 1.7 days for the subgroup of patients with sphincterotomy alone. Among the patients with stent insertion, fistulas healed slower in 14 +/- 3.5 days. There were no complications after endoscopic treatment; however the stent could not be passed in one patient that required subsequent surgery. In conclusion, endoscopic intervention is the treatment of choice for small external biliary fistulas complicating biliary tract surgery or liver surgery for hepatic hydatid disease. When the fistula is large, the placement of a 10 Fr endoprosthesis becomes necessary, while failure of endoscopic treatment leads to surgery with hepatico-jejunal anastomosis.

Mucin gene expression in bile of patients with and without gallstone disease, collected by endoscopic retrograde cholangiography

PubMed Central

Vilkin, Alexander; Geller, Alex; Levi, Zohar; Niv, Yaron

2009-01-01

AIM: To investigate the pattern of mucin expression and concentration in bile obtained during endoscopic retrograde cholangiography (ERC) in relation to gallstone disease. METHODS: Bile samples obtained at ERC from 29 consecutive patients, 17 with and 12 without gallstone disease were evaluated for mucin content by gel filtration on a Sepharose CL-4B column. Dot blot analysis for bile mucin apoproteins was performed with antibodies to Mucin 1 (MUC1), MUC2, MUC3, MUC5AC, MUC5B and MUC6. Staining intensity score (0-3) was used as a measure of antigen expression. RESULTS: MUC1, MUC2, MUC3, MUC5AC, MUC5B and MUC6 were demonstrated in 34.4%, 34.4%, 51.7%, 51.7%, 55.1% and 27.5% of bile samples, respectively. The staining intensity scores were 0.62 ± 0.94, 0.58 ± 0.90, 0.79 ± 0.97, 1.06 ± 1.22, 1.20 ± 1.26 and 0.41 ± 0.73, respectively. Mean mucin concentration measured in bile by the Sepharose CL-4B method was 22.8 ± 24.0 mg/mL (range 3.4-89.0 mg/mL). Mean protein concentration was 8.1 ± 4.8 mg/mL (range 1.7-23.2 mg/mL). CONCLUSION: High levels of MUC3, MUC5AC and MUC5B are expressed in bile aspirated during ERC examination. A specific pattern of mucin gene expression or change in mucin concentration was not found in gallstone disease. PMID:19452580

Comparison of intraductal ultrasonography-directed and cholangiography-directed endoscopic retrograde biliary drainage in patients with a biliary obstruction.

PubMed

Rew, Soo-Jung; Lee, Du-Hyeon; Park, Chang-Hwan; Jeon, Jin; Kim, Hyun-Soo; Choi, Sung-Kyu; Rew, Jong-Sun

2016-09-01

Endoscopic retrograde biliary drainage (ERBD) has become a standard procedure in patients with a biliary obstruction. Intraductal ultrasonography (IDUS) has emerged as a new tool for managing extrahepatic biliary diseases. IDUS-directed ERBD can be performed without conventional cholangiography (CC). The goal of this study was to assess the effectiveness and safety of IDUS-directed ERBD compared to CC-directed ERBD in patients with an extrahepatic biliary obstruction. A total of 210 patients who had undergone IDUS-directed ERBD (IDUS-ERBD, n = 105) and CC-directed ERBD (CC-ERBD, n = 105) between October 2013 and April 2014 were analyzed retrospectively. The primary outcome measure was the procedural success rate. Secondary outcome measures included clinical outcomes, total procedure time, radiation exposure time, and overall complication rates. The total technical success rate of ERBD was 100% (105/105) in the IDUS-ERBD and CC-ERBD groups. Mean procedure time was slightly prolonged in the IDUS-ERBD group than that in the CC-ERBD group (32.1 ± 9.9 minutes vs. 28.4 ± 11.6 minutes, p = 0.023). Mean radiation exposure time was one-third less in the IDUS-ERBD group than that in the CC-ERBD group (28.0 ± 49.3 seconds vs. 94.2 ± 57.3 seconds, p < 0.001). No significant differences in complication rates were detected between the groups. IDUS-ERBD was equally effective and safe as CC-ERBD in patients with an extrahepatic biliary obstruction. Although IDUS-ERBD increased total procedure time, it significantly decreased radiation exposure.

Comparison between intraoperative cholangiography and choledochoscopy for ductal clearance in laparoscopic CBD exploration: a prospective randomized study.

PubMed

Vindal, Anubhav; Chander, Jagdish; Lal, Pawanindra; Mahendra, Balu

2015-05-01

Laparoscopic CBD exploration (LCBDE) is an accepted treatment modality for single stage management of CBD stones in fit patients. A transcholedochal approach is preferred in patients with a dilated CBD and large impacted stones in whom ductal clearance remains problematic. There are very few studies comparing intraoperative cholangiography (IOC) with choledochoscopy to determine ductal clearance in patients undergoing transcholedochal LCBDE. This series represents the first of those comparing the two from Asia. Between April 2009 and October 2012, 150 consecutive patients with CBD stones were enrolled in a prospective randomized study to undergo transcholedochal LCBDE on an intent-to-treat basis. Patients with CBD diameter of less than 9 mm on preoperative imaging were excluded from the study. Out of the 132 eligible patients, 65 patients underwent IOC (Group A), and 67 patients underwent intraoperative choledochoscopy (Group B) to determine CBD clearance. There were no differences between the two groups in the demographic profile and the preoperative biochemical findings. There was no conversion to open procedures, and complete stone clearance was achieved in all the 132 cases. The mean CBD diameter and the mean number of CBD stones removed were comparable between the two groups. Mean operating time was 170 min in Group A and 140 min in Group B (p < 0.001). There was no difference in complications between the two groups. Nine patients in Group A (13.8%) showed non-passage of contrast into the duodenum on IOC which resolved after administration of i.v. glucagon, suggesting a transient spasm of sphincter of Oddi. Two patients (3%) showed a false-positive result on IOC which had to be resolved with choledochoscopy. The present study showed that intraoperative choledochoscopy is better than IOC for determining ductal clearance after transcholedochal LCBDE and is less cumbersome and less time-consuming.

Ultrahigh-field imaging of the biliary tract at 7 T: initial results of gadoxetic acid-enhanced magnetic resonance cholangiography.

PubMed

Fischer, Anja; Kraff, Oliver; Orzada, Stephan; Nensa, Felix; Schäfer, Lena C; Ladd, Mark E; Umutlu, Lale; Lauenstein, Thomas C

2014-05-01

The objectives of this study were to assess the feasibility of magnetic resonance cholangiography (MRC) using biliary-secreted gadoxetic acid at 7 T and to compare it with T2-weighted (w) MRC at 3 T. Ten healthy volunteers were examined on a 7-T whole-body magnetic resonance system. T2-weighted turbo-spin-echo sequence, T1-w volume-interpolated breath-hold examination (VIBE), and fast low-angle shot (FLASH) with inversion recovery (IR) were acquired in coronal orientation. For dynamic imaging, gadoxetic acid was administrated and data were collected for a period of 5 to 40 minutes after injection. The volunteers underwent subsequent T2-w respiratory-gated MRC at 3 T. For qualitative analysis, a 5-point scale was used. Contrast ratios (CRs) were calculated for quantitative assessment. Contrast-enhanced T1-w MRC at 7 T showed a homogeneous depiction of the intrahepatic and extrahepatic biliary tract with a maximum enhancement of 20 minutes after contrast. Volume-interpolated breath-hold examination and FLASH IR provided a good image quality for the intrahepatic (VIBE, 3.60; FLASH IR, 3.67) and extrahepatic bile ducts (VIBE, 3.50; FLASH IR, 3.72). The quantitative analysis revealed high CR values for FLASH IR (intrahepatic CR, 0.41; extrahepatic CR, 0.45) because of an effective suppression of hepatic tissue and vessels. The T2-w TSE at 7 T showed only a poor image quality without diagnostic potential (intrahepatic, 2.22; extrahepatic, 1.93). Seven-tesla VIBE and FLASH revealed superiority in the depiction of the intrahepatic bile ducts, whereas 3-T MRC was superior in the delineation of the extrahepatic biliary tract. Our results demonstrate the feasibility of contrast-enhanced imaging of the biliary ducts at 7 T.

Near-infrared fluorescence cholangiography with indocyanine green for biliary atresia. Real-time imaging during the Kasai procedure: a pilot study.

PubMed

Hirayama, Yutaka; Iinuma, Yasushi; Yokoyama, Naoyuki; Otani, Tetsuya; Masui, Daisuke; Komatsuzaki, Naoko; Higashidate, Naruki; Tsuruhisa, Shiori; Iida, Hisataka; Nakaya, Kengo; Naito, Shinichi; Nitta, Koju; Yagi, Minoru

2015-12-01

Hepatoportoenterostomy (HPE) with the Kasai procedure is the treatment of choice for biliary atresia (BA) as the initial surgery. However, the appropriate level of dissection level of the fibrous cone (FC) of the porta hepatis (PH) is frequently unclear, and the procedure sometimes results in unsuccessful outcomes. Recently, indocyanine green near-infrared fluorescence imaging (ICG-FCG) has been developed as a form of real-time cholangiography. We applied this technique in five patients with BA to visualize the biliary flow at the PH intraoperatively. ICG was injected intravenously the day before surgery as the liver function test, and the liver was observed with a near-infrared camera system during the operation while the patient's feces was also observed. In all patients, the whole liver fluoresced diffusely with ICG-containing stagnant bile, whereas no extrahepatic structures fluoresced. The findings of the ICG fluorescence pattern of the PH after dissection of the FC were classified into three types: spotty fluorescence, one patient; diffuse weak fluorescence, three patients; and diffuse strong fluorescence, one patient. In all five patients, the feces evacuated after HPE showed distinct fluorescent spots, although that obtained before surgery showed no fluorescence. One patient with diffuse strong fluorescence who did not achieve JF underwent living related liver transplantation six months after the initial HPE procedure. Four patients, including three cases involving diffuse weak fluorescence and one case involving spotty fluorescence showed weak fluorescence compared to that of the surrounding liver surface. We were able to detect the presence of bile excretion at the time of HPE intraoperatively and successfully evaluated the extent of bile excretion using this new technique. Furthermore, the ICG-FCG findings may provide information leading to a new classification and potentially function as an indicator predicting the clinical outcomes after HPE.

Diagnostic value of Gd-EOB-DTPA-enhanced MR cholangiography in non-invasive detection of postoperative bile leakage.

PubMed

Kul, Melahat; Erden, Ayşe; Düşünceli Atman, Ebru

2017-04-01

To assess the diagnostic value of dynamic T 1 weighted (T1w) gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid (Gd-EOB-DTPA)-enhanced MR cholangiography (MRC) for the detection of active bile leaks. A total of 28 patients with suspected biliary leakage who underwent routine T 2 weighted (T2w) MRC and T1w GD-EOB-DTPA-enhanced MRC at our institution from February 2013 to June 2016 were included in this study. The image sets were retrospectively analyzed in consensus by three radiologists. T1w Gd-EOB-DTPA-enhanced MRC findings were correlated with clinical data, follow-up examinations and findings of invasive/surgical procedures. Patients with positive bile leak findings in Gd-EOB-DTPA-enhanced MRC were divided into hepatobiliary phase (HBP) (20-30 min) and delayed phase (DP) (60-390 min) group according to elapsed time between Gd-EOB-DTPA injection and initial bile leak findings in MRC images. These groups were compared in terms of laboratory test results (total bilirubin, liver enzymes) and the presence of bile duct dilatation in T2w MRC images. In each patient, visualization of bile ducts was sufficient in the HBP. The accuracy, sensitivity and specificity of dynamic Gd-EOB-DTPA-enhanced T1w MRC in the detection of biliary leaks were 92.9%, 90.5% and 100%, respectively (p < 0.001). 19 of 28 patients had bile leak findings in T1w Gd-EOB-DTPA-enhanced MRC [HBP group: N = 7 (36.8%), DP group: N = 12 (63.2%)]. There was no statistically significant difference in terms of laboratory test results and the presence of bile duct dilatation between HBP and DP group (p > 0.05). Three patients, each of them in DP group, showed normal laboratory test results and bile duct diameters. Dynamic T1w Gd-EOB-DTPA-enhanced MRC is a useful non-invasive diagnostic tool to detect bile leak. Advances in knowledge: Prolonged DP imaging may be required for bile leak detection even if visualization of biliary tree is sufficient in HBP and liver function tests

Microbiological Assessment of Bile and Corresponding Antibiotic Treatment: A Strobe-Compliant Observational Study of 1401 Endoscopic Retrograde Cholangiographies.

PubMed

Rupp, Christian; Bode, Konrad; Weiss, Karl Heinz; Rudolph, Gerda; Bergemann, Janine; Kloeters-Plachky, Petra; Chahoud, Fadi; Stremmel, Wolfgang; Gotthardt, Daniel Nils; Sauer, Peter

2016-03-01

The aim of this study was to determine the antibiotic susceptibility profiles of bacteria in bile samples and to analyze the clinical relevance of the findings as only limited information about risk factors for elevated frequence of bacterial and fungal strains in routinely collected bile samples has been described so far.A prospective cohort study at a tertiary care center was conducted. Seven hundred forty-four patients underwent 1401 endoscopic retrograde cholangiographies (ERCs) as indicated by liver transplantation (427/1401), primary sclerosing cholangitis (222/1401), choledocholithiasis only (153/1401), obstruction due to malignancy (366/1401), or other conditions (233/1401). Bile samples for microbiological analysis were obtained in all patients.The 71.6% (823/1150) samples had a positive microbiological finding, and 57% (840/1491) of the bacterial isolates were gram-positive. The main species were Enterococcus spp (33%; 494/1491) and Escherichia coli (12%; 179/1491). Of the samples, 53.8% had enteric bacteria and 24.7% had Candida spp; both were associated with clinical and laboratory signs of cholangitis (C-reactive proteins 35.0 ± 50.1 vs 44.8 ± 57.6; 34.5 ± 51.2 vs 52.9 ± 59.7; P < 0.001), age, previous endoscopic intervention, and immunosuppression. Multi-resistant (MR) strains were found in 11.3% of all samples and were associated with clinical and laboratory signs of cholangitis, previous intervention, and immunocompromised status. In subgroup analysis, strain-specific antibiotic therapy based on bile sampling was achieved in 56.3% (89/158) of the patients. In cases with a positive bile culture and available blood culture, blood cultures were positive in 29% of cases (36/124), and 94% (34/36) of blood cultures had microbial species identical to the bile cultures.Bactobilia and fungobilia can usually be detected by routine microbiological sampling, allowing optimized, strain-specific antibiotic treatment. Previous endoscopic

Benign Biliary Strictures: Diagnostic Evaluation and Approaches to Percutaneous Treatment.

PubMed

Fidelman, Nicholas

2015-12-01

Interventional radiologists are often consulted to help identify and treat biliary strictures that can result from a variety of benign etiologies. Mainstays of noninvasive imaging for benign biliary strictures include ultrasound, contrast-enhanced computed tomography and magnetic resonance imaging, magnetic resonance cholangiopancreatography, and computed tomography cholangiography. Endoscopic retrograde cholangiography is the invasive diagnostic procedure of choice, allowing both localization of a stricture and treatment. Percutaneous biliary interventions are reserved for patients who are not candidates for endoscopic retrograde cholangiography (eg, history of distal gastrectomy and biliary-enteric anastomosis to a jejunal roux limb). This review discusses the roles of percutaneous transhepatic cholangiography and biliary drainage in the diagnosis of benign biliary strictures. The methodology for crossing benign biliary strictures, approaches to balloon dilation, management of recalcitrant strictures (ie, large-bore biliary catheters and retrievable covered stents), and the expected outcomes and complications of percutaneous treatment of benign biliary strictures are also addressed. Copyright © 2015 Elsevier Inc. All rights reserved.

Radiography of the bile ducts: a symposium of the use of new modalities for diagnosis and treatment

DOE Office of Scientific and Technical Information (OSTI.GOV)

Berk, R.N.; Cooperberg, P.L.; Gold, R.P.

1982-10-01

New diagnostic and therapeutic techniques have enabled the radiologist to assume a significant role in the management of jaundice, whereas before he was powerless to make any contribution at all. In this symposium, sonography, percutaneous transhepatic cholangiography, endoscopic retrograde cholangiography, and interventional procedures are analyzed and placed in perspective.

Pre-operative endoscopic ultrasonography can optimise the management of patients undergoing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocholithiasis: a prospective study.

PubMed

Meroni, E; Bisagni, P; Bona, S; Fumagalli, U; Zago, M; Rosati, R; Malesci, A

2004-01-01

Pre-operative endosonography has been proposed as a cost-effective procedure in the management of patients who undergo laparoscopic cholecystectomy having an intermediate risk of common bile duct stones. We prospectively evaluated the impact of pre-operative endosonography on the management of patients facing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocolithiasis. Among 587 consecutive patients scheduled for laparoscopic cholecystectomy, 47 (8%) patients having one or more abnormal liver function tests but a normal appearance of common bile duct at abdominal ultrasound, underwent pre-operative endosonography. In patients with endosonography-detected common bile duct stones, a pre-operative endoscopic retrograde cholangiography was performed, or an intra-operative endoscopic retrograde cholangiography was scheduled. In all endosonography-negative patients, an intra-operative trans-cystic cholangiography was performed. Endosonography detected common bile duct stones in nine patients (19%) but only in five of them stones were radiologically confirmed (PPV 0.55). Endosonography-detected stones were confirmed in four of four (100%) patients in whom cholangiography was performed within 1 week, but only in one of five (20%) patients in whom radiology was further delayed (P < 0.05). In three of four cases (75%), stones detected at endosonography but not confirmed at X-rays, were smaller than 2.0 mm. Among 38 patients with negative endosonography, common bile duct stones were found in two patients (NPV 0.95), whereas unplanned endoscopic stone extraction was needed only in one patient (NPV 0.97). Pre-operative endosonography can spare unnecessary pre-operative endoscopic retrograde cholangiography as well as inappropriate scheduling of intra-operative endoscopic retrograde cholangiography in patients undergoing laparoscopic cholecystectomy with abnormal liver function tests. To maximise the impact of endosonography on

3D T2-weighted and Gd-EOB-DTPA-enhanced 3D T1-weighted MR cholangiography for evaluation of biliary anatomy in living liver donors.

PubMed

Cai, Larry; Yeh, Benjamin M; Westphalen, Antonio C; Roberts, John; Wang, Zhen J

2017-03-01

To investigate whether the addition of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced 3D T1-weighted MR cholangiography (T1w-MRC) to 3D T2-weighted MRC (T2w-MRC) improves the confidence and diagnostic accuracy of biliary anatomy in living liver donors. Two abdominal radiologists retrospectively and independently reviewed pre-operative MR studies in 58 consecutive living liver donors. The second-order bile duct visualization on T1w- and T2w-MRC images was rated on a 4-point scale. The readers also independently recorded the biliary anatomy and their diagnostic confidence using (1) combined T1w- and T2w-MRC, and (2) T2w-MRC. In the 23 right lobe donors, the biliary anatomy at imaging and the imaging-predicted number of duct orifices at surgery were compared to intra-operative findings. T1w-MRC had a higher proportion of excellent visualization than T2w-MRC, 66% vs. 45% for reader 1 and 60% vs. 31% for reader 2. The median confidence score for biliary anatomy diagnosis was significantly higher with combined T1w- and T2w-MRC than T2w-MRC alone for both readers (Reader 1: 3 vs. 2, p < 0.001; Reader 2: 3 vs. 1, p < 0.001). Compared to intra-operative findings, the accuracy of imaging-predicted number of duct orifices using combined T1w-and T2w-MRC was significantly higher than that using T2w-MRC alone (p = 0.034 for reader 1, p = 0.0082 for reader 2). The addition of Gd-EOB-DTPA-enhanced 3D T1w-MRC to 3D T2w-MRC improves second-order bile duct visualization and increases the confidence in biliary anatomy diagnosis and the accuracy in the imaging-predicted number of duct orifices acquired during right lobe harvesting.

[The ultrasonic diagnosis of jaundice. 199 cases (author's transl)].

PubMed

Weill, F; Marmier, A; Paronneau, P; Zeltner, F; Charton, M N

1978-11-25

Thank to a thorough ultrasonographic analysis of biliary tree ("shotgun sign"), liver and pancreas, a positive diagnosis of obstruction was carried out in 92% of cases. The success rate in diagnosis of level of obstruction was also 92%. Aetiologic diagnosis was successful in 61% of cases only (almost 100% in jaundices of pancreatic origine). No false positive diagnosis of obstruction was made in non-obstructive jaundice. This enabled to carry out instrumental cholangiography (i.e. "skinny" needle percutaneous cholangiography, and ERC) only in case of clinical, biological and sonographic discrepancies, or in hilar obstructions.

The era of ultrasonography during laparoscopic cholecystectomy.

PubMed

Onders, Raymond P; Hallowell, Peter T

2005-03-01

The use of ultrasound cholangiography during cholecystectomy has been well described. This study was undertaken to assess the use of the umbilical port exclusively for ultrasound and to assess its employment on the use of fluoroscopy resources. In addition, we also looked at the increased use of ultrasound from 2000 to 2004. The use of imaging techniques during all cholecystectomies was analyzed from January 2000 to July 2001 for one surgeon and compared with that surgeon's present use from January 2004 to June 2004. Patient demographics, intraoperative finding, and postoperative results were reviewed. During the first study period, ultrasound was used in 29% of 189 laparoscopic cholecystectomies. During 2004, ultrasound was used in 77% of 66 laparoscopic cholecystectomies. Throughout both periods, fluoroscopy was only used during 6 laparoscopic common bile duct explorations (2.4% of all cases). There were no false-positive or -negative ultrasounds, and there were no bile duct injuries. As experience with ultrasound cholangiography increases, there is little indication for fluoroscopic cholangiography except for rare questions concerning anatomy and during therapeutic maneuvers for common bile duct stones.

Traumatic thoracobiliary (pleurobiliary and bronchobiliary) fistula.

PubMed

Andrade-Alegre, Rafael; Ruiz-Valdes, Maylin

2013-02-01

Traumatic thoracobiliary fistula is a rare but serious complication. A series of thoracobiliary fistulas secondary to penetrating trauma and analysis of trends in management are presented. We retrospectively reviewed all patients with traumatic thoracobiliary fistula, treated from April 2008 to February 2010. There were 5 patients: 4 suffered gunshot wounds and 1 was stabbed. The mean injury severity score was 22. Initial treatment was insertion of a chest tube in all cases. One patient underwent damage-control surgery and hepatic packing, and 3 were managed with laparotomy, a perihepatic closed drain, and suture of the diaphragm. Two patients developed bronchobiliary fistulas and 3 had pleurobiliary fistulas. Diagnostic procedures involved determination of bilirubin in pleural effusion, computed tomography, magnetic resonance cholangiography, hepatobiliary iminodiacetic scans, and endoscopic retrograde cholangiography. Definitive treatment included sphincterotomy and stenting in 4 cases, pulmonary decortication in 5, fistulectomy in 2, hepatic suture in 2, perihepatic closed drain placement in 4, and suture of the diaphragm in 4. Traumatic thoracobiliary fistulas are complex lesions. A multidisciplinary approach is required for a timely and successful outcome. Endoscopic retrograde cholangiography is very useful as the initial procedure to confirm the diagnosis and also for treatment.

The value of percutaneous cholangiography

PubMed Central

Evison, Gordon; McNulty, Myles; Thomson, Colin

1973-01-01

Percutaneous cholangiograms performed on fifty patients in a district general hospital have been reviewed, and the advantages and limitations of the examination are described. The investigation is considered to have sufficient diagnostic value to warrant its inclusion in the diagnostic armamentarium of every general radiological department. ImagesFig. 1Fig. 2Fig. 3Fig. 4 PMID:4788917

A case of Mirizzi syndrome that was successfully treated by laparoscopic choledochoplasty using a gallbladder patch.

PubMed

Hiraki, Masatsugu; Ueda, Junji; Kono, Hiroshi; Egawa, Noriyuki; Saeki, Kiyoshi; Tsuru, Yasuhiro; Ide, Takao; Noshiro, Hirokazu

2017-11-01

The use of laparoscopic surgery in the treatment of Mirizzi syndrome is considered controversial due to the degree of technical difficulty. We herein describe the case of a 36-year-old woman who was admitted to our hospital due to appetite loss, nausea and back pain. Endoscopic retrograde cholangiography revealed a round-shaped filling defect at the confluence of the bile duct. The patient was diagnosed with Mirizzi syndrome Type II according to the Csendes classification. Before surgery, an endoscopic nasobiliary drainage tube was placed for intraoperative cholangiography. Based on the intraoperative findings, the anterior wall of Hartmann's pouch was excised to remove the impacted gallstone. The neck portion of the gallbladder wall was then used to make a gallbladder patch, which was sutured to cover the anterior wall of the common hepatic bile duct. Laparoscopic choledochoplasty using a gallbladder patch was a technically feasible treatment for Mirizzi syndrome Type II.

[Development of Biliary Contrast Agents Remote Pushing Device].

PubMed

Zhu, Haoyang; Dong, Dinghui; Luo, Yu; Ren, Fenggang; Zhang, Jing; Tan, Wenjun; Shi, Aihua; Hu, Liangshuo; Wu, Rongqian; Lyu, Yi

2018-01-30

A biliary contrast agents pushing device, including a syringe pushing system and a remote controller is introduced. The syringe pushing system comprises an injector card slot, a support platform and an injection bolus fader. A 20 mL syringe can be fitted on the syringe pushing system and kept with the ground about 30 degree. This system can perform air bubble pumping back and contrast agents bolus injection as well as speed adjustment. Remote controller is an infrared remote control which can start and stop the syringe pushing system. With this device, the remote controlled cholangiography technology can be achieved, which can not only protect doctors from X-ray radiation but also improve the traditional T-tube cholangiography and the contrast effect, reduce postoperative complications in patients as well. The application of this device will improve the current diagnosis and treatment system, the device will benefit the majority of doctors and patients.

Laparoscopy-guided intracorporeal ultrasound accurately delineates hepatobiliary anatomy.

PubMed

Yamamoto, M; Stiegmann, G V; Durham, J; Berguer, R; Oba, Y; Fujiyama, Y; McIntyre, R C

1993-01-01

The purpose of this study was to develop a technique and assess the ability of a laparoscopic ultrasound probe to delineate biliary antomy and to determine the presence or absence of duct stones. Five pigs had ultrasonography of biliary structures and liver at laparoscopy followed by cholangiograms and anatomical dissection. Five patients had ultrasonography of the biliary tract at laparoscopic cholecystectomy. All animals had adequate visualization of important hepatobiliary structure, and an optimal method of accessing these structures at laparoscopy was established. Patients had ultrasonography which used methods developed in the animal trial. All had adequate visualization of the entire common bile duct confirmed by cholangiography. Limitations in demonstrating the relationship of the cystic duct to the common duct were technical and can be corrected. Laparoscopic ultrasonography has significant potential for delineation of biliary anatomy and determination of presence or absence of duct calculi. Clinical implementation could minimize the risk of iatrogenic duct injury and the need for operative cholangiography.

A case of Mirizzi syndrome that was successfully treated by laparoscopic choledochoplasty using a gallbladder patch

PubMed Central

Hiraki, Masatsugu; Ueda, Junji; Kono, Hiroshi; Egawa, Noriyuki; Saeki, Kiyoshi; Tsuru, Yasuhiro; Ide, Takao

2017-01-01

Abstract The use of laparoscopic surgery in the treatment of Mirizzi syndrome is considered controversial due to the degree of technical difficulty. We herein describe the case of a 36-year-old woman who was admitted to our hospital due to appetite loss, nausea and back pain. Endoscopic retrograde cholangiography revealed a round-shaped filling defect at the confluence of the bile duct. The patient was diagnosed with Mirizzi syndrome Type II according to the Csendes classification. Before surgery, an endoscopic nasobiliary drainage tube was placed for intraoperative cholangiography. Based on the intraoperative findings, the anterior wall of Hartmann’s pouch was excised to remove the impacted gallstone. The neck portion of the gallbladder wall was then used to make a gallbladder patch, which was sutured to cover the anterior wall of the common hepatic bile duct. Laparoscopic choledochoplasty using a gallbladder patch was a technically feasible treatment for Mirizzi syndrome Type II. PMID:29230280

Traumatic Gallbladder Rupture Treated by Laparoscopic Cholecystectomy

PubMed Central

Egawa, Noriyuki; Ueda, Junji; Hiraki, Masatsugu; Ide, Takao; Inoue, Satoshi; Sakamoto, Yuichiro; Noshiro, Hirokazu

2016-01-01

Abstract Gallbladder rupture due to blunt abdominal injury is rare. There are few reports of traumatic gallbladder injury, and it is commonly associated with other concomitant visceral injuries. Therefore, it is difficult to diagnose traumatic gallbladder rupture preoperatively when it is caused by blunt abdominal injury. We report a patient who underwent laparoscopic cholecystectomy after an exact preoperative diagnosis of traumatic gallbladder rupture. A 43-year-old man was admitted to our hospital due to blunt abdominal trauma. The day after admission, abdominal pain and ascites increased and a muscular defense sign appeared. Percutaneous drainage of the ascites was performed, and the aspirated fluid was bloody and almost pure bile. He was diagnosed with gallbladder rupture by the cholangiography using the endoscopic retrograde cholangiopancreatography technique. Laparoscopic cholecystectomy was performed safely, and he promptly recovered. If accumulated fluids contain bile, endoscopic cholangiography is useful not only to diagnose gallbladder injury but also to determine the therapeutic strategy. PMID:27462188

DOE Office of Scientific and Technical Information (OSTI.GOV)

Miraglia, Roberto, E-mail: rmiraglia@ismett.edu; Maruzzelli, Luigi; Tuzzolino, Fabio

Purpose: The aim of this study was to estimate radiation exposure in pediatric liver transplants recipients who underwent biliary interventional procedures and to compare radiation exposure levels between biliary interventional procedures performed using an image intensifier-based angiographic system (IIDS) and a flat panel detector-based interventional system (FPDS). Materials and Methods: We enrolled 34 consecutive pediatric liver transplant recipients with biliary strictures between January 2008 and March 2013 with a total of 170 image-guided procedures. The dose-area product (DAP) and fluoroscopy time was recorded for each procedure. The mean age was 61 months (range 4-192), and mean weight was 17 kgmore » (range 4-41). The procedures were classified into three categories: percutaneous transhepatic cholangiography and biliary catheter placement (n = 40); cholangiography and balloon dilatation (n = 55); and cholangiography and biliary catheter change or removal (n = 75). Ninety-two procedures were performed using an IIDS. Seventy-eight procedures performed after July 2010 were performed using an FPDS. The difference in DAP between the two angiographic systems was compared using Wilcoxon rank-sum test and a multiple linear regression model. Results: Mean DAP in the three categories was significantly greater in the group of procedures performed using the IIDS compared with those performed using the FPDS. Statistical analysis showed a p value = 0.001 for the PTBD group, p = 0.0002 for the cholangiogram and balloon dilatation group, and p = 0.00001 for the group with cholangiogram and biliary catheter change or removal. Conclusion: In our selected cohort of patients, the use of an FPDS decreases radiation exposure.« less

Pure 3D laparoscopic living donor right hemihepatectomy in a donor with separate right posterior and right anterior hepatic ducts and portal veins.

PubMed

Hong, Suk Kyun; Suh, Kyung-Suk; Kim, Hyo-Sin; Yoon, Kyung Chul; Ahn, Sung-Woo; Oh, Dongkyu; Kim, Hyeyoung; Yi, Nam-Joon; Lee, Kwang-Woong

2017-11-01

Despite increases in the performance of pure laparoscopic living donor hepatectomy, variations in the bile duct or portal vein have been regarded as relative contraindications to this technique [1-3]. This report describes a donor with separate right posterior and right anterior hepatic ducts and portal veins who underwent pure laparoscopic living donor right hemihepatectomy, integrated with 3D laparoscopy and indocyanine green (ICG) near-infrared fluorescence cholangiography [1, 4, 5]. A 50-year-old man offered to donate part of his liver to his older brother, who required a transplant for hepatitis B-associated liver cirrhosis and hepatocellular carcinoma. Donor height was 178.0 cm, body weight was 82.7 kg, and body mass index was 26.1 kg/m 2 . Preoperative computed tomography and magnetic resonance cholangiopancreatography showed that the donor had separate right posterior and right anterior hepatic ducts and portal veins. The entire procedure was performed under 3D laparoscopic view. Following intravenous injections of 0.05 mg/kg ICG, ICG near-infrared fluorescence camera was used to demarcate the exact transection line and determine the optimal bile duct division point. The total operation time was 443 min; the donor required no transfusions and experienced no intraoperative complications. The graft weighed 1146 g with a graft-to-recipient weight ratio of 1.88%. The optimal bile duct division point was identified using ICG fluorescence cholangiography, and the bile duct was divided with good patency without any stricture. The right anterior and posterior portal veins were transected with endostaplers without any torsion. The patient was discharged on postoperative day 8, with no complications. Using a 3D view and ICG fluorescence cholangiography, pure 3D laparoscopic living donor right hemihepatectomy is feasible in a donor with separate right posterior and right anterior hepatic ducts and portal veins.

Gallbladder Agenesis in 17 Dogs: 2006-2016.

PubMed

Sato, K; Sakai, M; Hayakawa, S; Sakamoto, Y; Kagawa, Y; Kutara, K; Teshima, K; Asano, K; Watari, T

2018-01-01

Gallbladder agenesis (GBA) is extremely rare in dogs. To describe the history, clinical signs, diagnosis, treatment, and outcomes of dogs with GBA. Seventeen client-owned dogs with GBA. Medical records from 2006 through 2016 were retrospectively reviewed. Dogs were included when GBA was suspected on abdominal ultrasonography and confirmed by gross evaluation. Signalment, clinical signs, clinicopathological data, diagnostic imaging, histopathology, treatment, and outcome were recorded. Dogs were of 6 different breeds, and Chihuahuas (10 of 17) were most common. Median age at presentation was 1.9 (range, 0.7-7.4) years. Clinical signs included vomiting (5 of 17), anorexia (2 of 17), ascites (2 of 17), diarrhea (1 of 17), lethargy (1 of 17), and seizures (1 of 17). All dogs had increased serum activity of at least 1 liver enzyme, most commonly alanine aminotransferase (15 of 17). Fifteen dogs underwent computed tomography (CT) cholangiography; common bile duct (CBD) dilatation was confirmed in 12, without evidence of bile duct obstruction. Gross evaluation confirmed malformation of the liver lobes in 14 of 17 dogs and acquired portosystemic collaterals in 5 of 17. Ductal plate malformation was confirmed histologically in 16 of 17 dogs. During follow-up (range, 4-3,379 days), 16 of 17 dogs remained alive. Dogs with GBA exhibit clinicopathological signs of hepatobiliary injury and hepatic histopathological changes consistent with a ductal plate abnormality. Computed tomography cholangiography was superior to ultrasound examination in identifying accompanying nonobstructive CBD distention. Computed tomography cholangiography combined with laparoscopic liver biopsy is the preferable approach to characterize the full disease spectrum accompanying GBA in dogs. Copyright © 2018 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.

[Preoperatory sonography efficiency in paediatric patients with cholelithiasis undergoing laparoscopic cholecystectomy].

PubMed

Riñón, C; de Mingo, L; Cortés, M J; Ollero, J C; Alvarez, M; Espinosa, R; Rollán, V

2009-01-01

Biliary lithiasis is not much frequent in paediatric patients. The manegement of cholelithiasis in patients undergoing laparoscopic cholecystectomy is still controversial. We propose the preoperatory echographic study of the biliary tree 24-48 h before surgery, as the first choice, instead of the intraoperatory cholangiography. We made a retrospective study of 42 patients undergoing laparoscopic cholecystectomy due to symptomatic biliary lithiasis during the last 15 years, with ages between 18 months and 17-years-old (mean age 9,6-years-old) and weight between 11 and 70 kg (mean weight 42 kg) at the moment of surgery. Six of them had haematological illnesses, 17 came to the hospital because of acute abdominal pain, 10 had been studied because of recurrent abdominal pain and 9 had casual diagnoses. Abdominal sonography was performed in all patients 24-48 hours before surgery. Four children were diagnosed of biliary duct lithiasis: two choledocolithiasis and two stones in the cystic duct. One of the cystic stones was extracted in the operating room and the rest resolved spontaneously. One patient presented dilatation of choledocal duct after surgery, without any stones' evidence. Also this patient resolved spontaneously. We had no complications. Biliary lithiasis is not frequent in children, even if it seems to be increasing. A few of these patients will suffer of choledocolithiasis. The intraoperatory exploration of the biliary tree during laparoscopic surgery is technically difficult due the small size of paediatric patients. Cholangiography is not always successful and can produce some important complications as pancreatitis. Preoperative sonography 24-48 hours before surgery is a safe and efficient method for the diagnosis and follow-up of paediatric patients with biliary lithiasis undergoing laparoscopic cholecystectomy. It is safe enough to be performed without intraoperatory cholangiography.

[MR cholangiopancreatography in choledochal cysts].

PubMed

Frampas, E; Moussaly, F; Léauté, F; Heloury, Y; Le Neel, J C; Dupas, B

1999-12-01

To assess the value of MR cholangiopancreatography (MRCP) in the diagnosis and preoperative evaluation of choledochal cysts. Five patients (aged between 6 days and 28 years) were investigated by MRCP, referred for ultrasonographic detection of a bile duct dilatation or a cystic structure, of antenatal diagnosis (1 case), for jaundice or abdominal pain (3 cases) or in late follow-up of a choledochal cyst surgery. Two endoscopic-ultrasonographic studies were performed. The five patients underwent surgery without preoperative biliary cholangiography. MRCP was performed using a HASTE sequence in frontal, oblique, axial planes (1,5 Tesla MR unit). MRCP allowed to confirm choledochal cyst, helps to specify the anatomical type (2 type I, 3 type II), detects choledocholithiasis (3 cases). Anatomic correlation was perfect. MRCP allowed to exclude gastrointestinal duplication. Anomalous junction of the pancreaticobiliary duct was found in one case. MRCP diagnoses choledochal cysts, specifies type, helps surgery and can avoid endoscopic retrograde cholangiography or endoscopic sonographic examinations especially for children. It may find an anomalous junction of the pancreaticobiliary duct.

Laparoscopic Common Bile Duct Exploration Four-Task Training Model: Construct Validity

PubMed Central

Otaño, Natalia; Rodríguez, Omaira; Sánchez, Renata; Benítez, Gustavo; Schweitzer, Michael

2012-01-01

Background: Training models in laparoscopic surgery allow the surgical team to practice procedures in a safe environment. We have proposed the use of a 4-task, low-cost inert model to practice critical steps of laparoscopic common bile duct exploration. Methods: The performance of 3 groups with different levels of expertise in laparoscopic surgery, novices (A), intermediates (B), and experts (C), was evaluated using a low-cost inert model in the following tasks: (1) intraoperative cholangiography catheter insertion, (2) transcystic exploration, (3) T-tube placement, and (4) choledochoscope management. Kruskal-Wallis and Mann-Whitney tests were used to identify differences among the groups. Results: A total of 14 individuals were evaluated: 5 novices (A), 5 intermediates (B), and 4 experts (C). The results involving intraoperative cholangiography catheter insertion were similar among the 3 groups. As for the other tasks, the expert had better results than the other 2, in which no significant differences occurred. The proposed model is able to discriminate among individuals with different levels of expertise, indicating that the abilities that the model evaluates are relevant in the surgeon's performance in CBD exploration. Conclusions: Construct validity for tasks 2 and 3 was demonstrated. However, task 1 was no capable of distinguishing between groups, and task 4 was not statistically validated. PMID:22906323

Detection of biliary and vascular anatomy in living liver donors: value of gadobenate dimeglumine enhanced MR and MDCT angiography.

PubMed

Artioli, Diana; Tagliabue, Marianna; Aseni, Paolo; Sironi, Sandro; Vanzulli, Angelo

2010-11-01

To evaluate the performance of magnetic resonance (MR) and multidetector computed tomography (MDCT) in the assessment of living donor's vascular and biliary anatomy, having surgical findings as reference standard. Thirty-two living liver donors underwent MR cholangiography (1.5-T; standard cholangiography pulse sequences and delayed acquisitions after administration of biliary contrast agent) for biliary anatomy evaluation. MDCT (16-row multidetector scanner, multiphase protocol, 3mm slice thickness) was also performed in all cases for the assessment of vascular anatomy before transplantation. Hepatic veins (<4mm in diameter) were not considered. MR and MDCT images interpretation was performed by two reviewers by consensus, based on source axial images, multiplanar reformats, and three-dimensional (3D) postprocessing images. Surgical intraoperative findings were used as standard of reference. At surgery, 17 biliary anomalies, 3 portal anomalies, 32 venous and 8 arterial variants were found in the 32 patients. MR correctly identified 15/17 biliary anomalies, with a sensitivity of 88% and a specificity of 93%. MDCT correctly identified 8/8 arterial, 3/3 portal and 29/32 venous variants, with a sensitivity of 100% and 91%, respectively, and a specificity of 100%. MR and MDCT proved to be efficient in evaluating living liver donor's biliary and vascular anatomy. Copyright © 2009 Elsevier Ireland Ltd. All rights reserved.

Magnetic resonance cholangiopancreatography: value of using the half-Fourier acquisition single-shot turbo spin-echo (HASTE) sequence.

PubMed

Ho, J T; Yap, C K

1999-05-01

The purpose of this study was to evaluate the accuracy of magnetic resonance cholangiopancreatography (MRCP) for visualisation and diagnosis of pancreatico-biliary diseases. Our results of 35 case studies, correlating with results from endoscopic, percutaneous cholangiopancreatography or laparotomy, showed that MRCP performed using the half-Fourier acquisition single-shot turbo spin echo (HASTE) sequences was fast and accurate for depiction of the biliary and pancreatic system, with a diagnostic value comparable to that of direct cholangiography. The presence of biliary obstruction was accurately diagnosed in all but one patient. In hilar strictures, MR cholangiogram was able to depict the intrahepatic biliary tree proximal to the level of obstruction which was not readily displayed by endoscopic retrograde cholangiopancreatography (ERCP) (Figs. 1 & 2). This overview of the entire biliary system was found to be advantageous for preprocedural planning. However, the accuracy for stone detection was limited by the presence of aerobilia from previous sphincterotomy or biliary-enteric anastomosis. Ductal stones less than 3 mm in size within a non-dilated system may be missed due to inadequate spatial resolution. This occurred in a patient with pancreatic duct stones. It is hoped that the accuracy of HASTE magnetic resonance cholangiopancreatography in evaluation of pancreatico-biliary disease would obviate the need for diagnostic invasive cholangiography in selected patients.

[Gallbladder agenesis. Case report].

PubMed

Cavazos-García, Ricardo; Díaz-Elizondo, José Antonio; Flores-Villalba, Eduardo; Rodríguez-García, Héctor Alejandro

2015-01-01

Gallbladder agenesis is a very rare congenital abnormality of the biliary tract. The diagnosis is made during surgery, because all preoperative studies have failed to identify this malformation. The purpose of this article is to present a case of gallbladder agenesis diagnosed during surgery, its management, and a review of the literature. The case involves a sixty-two year- old female, referring to repeated biliary colic symptoms. The abdominal ultrasound diagnosed cholelithiasis. It was impossible to identify the gallbladder during surgery. Diagnosis was confirmed by intra-operative cholangiography. Preoperative diagnostic workup has failed to recognise patients with gallbladder agenesis. It is currently recommended to abandon the surgery once this diagnosis is suspected and confirm it by a cholangio-magnetic resonance scan in order to avoid a bile duct injury. Agenesis of the gallbladder is a rare congenital abnormality of the biliary tree. Every surgeon must keep this rare entity in mind when a "difficult dissection" or an anatomic variant is identified during surgery, and make use of an intra-operative cholangiography, mainly to prevent a bile duct injury. Copyright © 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. All rights reserved.

Palliative percutaneous transhepatic drainage for inoperable obstructive jaundice.

PubMed Central

Baxter-Smith, D. C.; Temple, J. G.; Howarth, F.

1982-01-01

A technique of percutaneous transhepatic drainage under local anaesthesia is described for the relief of intractable pruritus in patients with obstructive jaundice due to inoperable carcinoma. After standard percutaneous transhepatic cholangiography a polyethylene catheter is introduced into one of the large dilated bile ducts and left in situ, thereby establishing external retrograde biliary drainage. The technique has been used successfully in 6 cases with reduction in serum bilirubin levels and relief of pruritus. PMID:6182832

/sup 99m/Tc-IDA imaging in the differential diagnosis of acute cholecystitis and acute pancreatitis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Fonseca, C.; Greenberg, D.; Rosenthall, L.

1979-02-01

Technetium-/sup 99m/-labelled dimethly-acetanilide-iminodiacetic acid (/sup 99m/Tc-IDA) hepato-biliary imaging was evaluated for its efficacy in distinguishing acute cholecystitis from acute pancreatitis. In a retrospective review, gallbladders were demonstrated by /sup 99m/Tc-IDA in 13 of 15 patients (87%) with acute pancreatitis. This is significantly higher than reports on the frequency of gallbladder filling with oral and intravenous cholangiography in the presence of acute cholecystitis.

Bronchobiliary fistula and cholangiocarcinoma: a case report and principles of management.

PubMed

Delande, S; Goffette, P; Verbaandert, C; Rahier, J; Graux, C; Mazzeo, F; Humblet, Y; Machiels, J P

2007-01-01

A 64-year-old woman was admitted with fever and cough. At admission, she had jaundice, hepatomegaly, and green-stained sputum. Computed tomography (CT) showed an intrahepatic abscess located near the dome, multiple hepatic metastases, biliary tract dilatation, and a right pleural effusion. Percutaneous transhepatic cholangiography demonstrated a communication between the intrahepatic biliary ducts and the bronchial tree. The patient was treated with antibiotic therapy, pleural and biliary drainages and a percutaneous drainage of the hepatic abscess.

In vivo evaluation of a new bioabsorbable self-expanding biliary stent.

PubMed

Ginsberg, Gregory; Cope, Constantin; Shah, Janak; Martin, Tanisha; Carty, Anthony; Habecker, Perry; Kaufmann, Carol; Clerc, Claude; Nuutinen, Juha-Pekka; Törmälä, Pertti

2003-11-01

Bioabsorbable stents may offer advantages for the treatment of benign and malignant biliary strictures, including large stent diameter, decreased biofilm accumulation and proliferative changes, elimination of the need for stent removal and imaging artifacts, and prospects for drug impregnation. However, suboptimal expansion has hampered prior iterations. A new bioabsorbable biliary stent (BioStent) was evaluated in a porcine model. BioStents were placed in 8 animals for long-term follow-up. The following were evaluated: accuracy and ease of delivery and deployment, radial expansion, and radiologic visualization. Stent function and biotolerance were assessed by cholangiography, serum bilirubin, and necropsy for histopathology performed in pairs at 2, 4, 6, and 12 months. Stents were delivered without sphincterotomy and were deployed easily, accurately, and with good immediate stent expansion and radiographic visualization. On follow-up, all stents were fully expanded and serum bilirubin levels remained within the normal range. Although there was no clinical evidence of biliary obstruction, filling defects were common at cholangiography. On histopathologic evaluation, there was neither bile duct integration or proliferative change. The BioStent bioabsorbable biliary stent, modified with axial runners, can be effectively deployed endoscopically, is self-expanding, is visualized radiographically, and remains patent up to 6 months. There was no bile duct integration or proliferative change, which are potential advantages. Stent occlusion and migration remain concerns.

Applications of nuclear magnetic resonance in paediatric surgery: magnetic resonance cholangiopancreatography and new sequences.

PubMed

Ragazzi, S; Vanzulli, A; Del Maschio, A; Tomaselli, V; Dell' Agnola, C A

2007-12-01

The aim of the study was to evaluate fast magnetic resonance cholangio-pancreatography (MRCP) sequences as an alternative and safe investigation method for neonatal and children's pancreaticobiliary diseases. Between January 2000 and December 2000, five children (age: 1 month 14 years; mean: 7 years) affected by pancreaticobiliary diseases or already operated for biliary pathologies were studied. Patients were evaluated by 1.5 T magnet single shot T2-weighted sequences (1 image per s, TR = infinite, TE = 150-180 ms). T1-weighted conventional sequences were obtained to study parenchymal tissue. No patient needed general anaesthetic. Only in one case was sedation necessary. Fast MRCP sequences provided very precise information on biliary tract anatomy. They revealed the intra and extrahepatic bile ducts, the gallbladder, the common bile duct and the bilio-pancreatic junction in all cases investigated. MRCP allowed us to evaluate Roux-en-Y type bilio-enteric anastomosis as accurately as percutaneous transhepatic cholangiography (PTC). In addition MRCP was the only reliable study in evaluating Roux-en-Y type anastomosis where ultrasonography (US) and endoscopic retrograde cholangiography (ERCP) could not be used. In conclusion MRCP is an accurate and non-invasive method with which to investigate the anatomy of the pancreaticobiliary tract in children. It could become the investigation of choice after US in the case of biliary and pancreatic diseases.

Delayed rearterialization unlikely leads to nonanastomotic stricture but causes temporary injury on bile duct after liver transplantation.

PubMed

Liu, Yang; Wang, Jiazhong; Yang, Peng; Lu, Hongwei; Lu, Le; Wang, Jinlong; Li, Hua; Duan, Yanxia; Wang, Jun; Li, Yiming

2015-03-01

Nonanastomotic strictures (NAS) are common biliary complications after liver transplantation (LT). Delayed rearterialization induces biliary injury in several hours. However, whether this injury can be prolonged remains unknown. The correlation of this injury with NAS occurrence remains obscure. Different delayed rearterialization times were compared using a porcine LT model. Morphological and functional changes in bile canaliculus were evaluated by transmission electron microscopy and real-time PCR. Immunohistochemistry and TUNEL were performed to validate intrahepatic bile duct injury. Three months after LT was performed, biliary duct stricture was determined by cholangiography; the tissue of common bile duct was detected by real-time PCR. Bile canaliculi were impaired in early postoperative stage and then exacerbated as delayed rearterialization time was prolonged. Nevertheless, damaged bile canaliculi could fully recover in subsequent months. TNF-α and TGF-β expressions and apoptosis cell ratio increased in the intrahepatic bile duct only during early postoperative period in a time-dependent manner. No abnormality was observed by cholangiography and common bile duct examination after 3 months. Delayed rearterialization caused temporary injury to bile canaliculi and intrahepatic bile duct in a time-dependent manner. Injury could be fully treated in succeeding months. Solo delayed rearterialization cannot induce NAS after LT. © 2014 The Authors. Transplant International published by John Wiley & Sons Ltd on behalf of Steunstichting ESOT.

[Mirizzi syndrome: experience at Spanish Hospital of Veracruz].

PubMed

Roesch-Dietlen, Federico; Pérez-Morales, Alfonso Gerardo; Martínez-Fernández, Silvia; Remes-Troche, José María; Jiménez-García, Victoria Alejandra; Romero-Sierra, Graciela

2013-01-01

Mirizzi syndrome is a complication of gallbladder stones impacted in Hartmann's pouch or cystic duct with compression of the bile duct. The diagnosis is made by imaging studies, although most of them are found through intraoperative surgical findings. Treatment is cholecystectomy and bile duct restoration when needed. to analyze a series of cases of Mirizzi syndrome and compare the results with those published in the literature. We report 4 cases with Mirizzi syndrome in a cohort of 1,034 cases studied in the Hospital Español of Veracruz over 21 years. In our series the frequency of Mirizzi syndrome was 0.38%, the average age was 32.1 ± 58.4 years, 50% were male gender and 25% had jaundice with a demonstrable liver profile. In 1 case, ultrasound suggested Mirizzi syndrome and percutaneous cholangiography and computed tomography confirmed the diagnosis. All patients underwent laparoscopic cholecystectomy, and 2 transcystic cholangiographies were performed. One case was classified as Type I-A and three as type I-B. (Beltran and Csendes). The postoperative evolution was satisfactory in all and no mortality was presented. Mirizzi syndrome should be suspected in patients with gallstones who develop obstructive jaundice and it must be confirmed with imaging studies. The surgeon must take extreme precautions to avoid accidental injury to the bile ducts.

[Choledocholithiasis and pregnancy. Hybrid laparo-endoscopic treatment in one step].

PubMed

Valadez-Caballero, David; González-Santamaría, Roberto; Soto-Mendoza, Héctor; Alberto Blanco-Figueroa, Jorge; Flores-Pantoja, Juan Manuel

2014-01-01

Complications associated with choledocholithiasis are uncommon during pregnancy. However, when it occurs, the morbidity and mortality related for the product and the mother increases, so a proper treatment is imperative in these patients. A 25-year-old pregnant woman on her second trimester. The current condition was started four days prior to the hospital admission with abdominal pain in the right upper quadrant with nausea and vomit.Twenty-four hours later jaundice and dark urine is observed. Physical examination shows scleral jaundice, right upper quadrant abdominal pain without peritoneal irritation. Uterus at umbilicus level without uterine activity. Uterus at umbilicus level without uterine activity. Laboratory tests showed elevated bilirubin and transaminases without leukocytosis; ultrasound reported live intrauterine unique product, with a heart rate of 128 beats per minute, gallbladder with multiple images inside that cast acoustic shadowing, and a 10 mm common bile duct dilated bile duct with dilatation of intrahepatic bile ducts. It was perform laparoscopic cholecystectomy with intraoperative cholangiography and placement of a transcystic jaguar guide for selective cannulation of the common bile duct. Intraoperative endoscopic retrograde cholangiopancreatography was performed with endoscopic stone extraction. The outcome was satisfactory with a hospital discharge at 48 hours. Current evidence has shown that the combined use of laparoscopy and therapeutic endoscopic cholangiography in one step is effective for the treatment of choledocholithiasis, decreasing the risk of complications associated with cannulation of the bile duct.

Indocyanine green fluorescence imaging in hepatobiliary surgery.

PubMed

Majlesara, Ali; Golriz, Mohammad; Hafezi, Mohammadreza; Saffari, Arash; Stenau, Esther; Maier-Hein, Lena; Müller-Stich, Beat P; Mehrabi, Arianeb

2017-03-01

Indocyanine green (ICG) is a fluorescent dye that has been widely used for fluorescence imaging during hepatobiliary surgery. ICG is injected intravenously, selectively taken up by the liver, and then secreted into the bile. The catabolism and fluorescence properties of ICG permit a wide range of visualization methods in hepatobiliary surgery. We have characterized the applications of ICG during hepatobiliary surgery into: 1) liver mapping, 2) cholangiography, 3) tumor visualization, and 4) partial liver graft evaluation. In this literature review, we summarize the current understanding of ICG use during hepatobiliary surgery. Intra-operative ICG fluorescence imaging is a safe, simple, and feasible method that improves the visualization of hepatobiliary anatomy and liver tumors. Intravenous administration of ICG is not toxic and avoids the drawbacks of conventional imaging. In addition, it reduces post-operative complications without any known side effects. ICG fluorescence imaging provides a safe and reliable contrast for extra-hepatic cholangiography when detecting intra-hepatic bile leakage following liver resection. In addition, liver tumors can be visualized and well-differentiated hepatocellular carcinoma tumors can be accurately identified. Moreover, vascular reconstruction and outflow can be evaluated following partial liver transplantation. However, since tissue penetration is limited to 5-10mm, deeper tissue cannot be visualized using this method. Many instances of false positive or negative results have been reported, therefore further characterization is required. Copyright © 2016 Elsevier B.V. All rights reserved.

Analysis of biliary anatomy according to different classification systems.

PubMed

Deka, Pranjal; Islam, Mahibul; Jindal, Deepti; Kumar, Niteen; Arora, Ankur; Negi, Sanjay Singh

2014-01-01

Variations in biliary anatomy are common, and different classifications have been described. These classification systems have not been compared to each other in a single cohort. We report such variations in biliary anatomy on magnetic resonance cholangiopancreatography (MRCP) using six different classification systems. In 299 patients undergoing MRCP for various indications, biliary anatomy was classified as described by Couinaud (1957), Huang (1996), Karakas (2008), Choi (2003), Champetier (1994), and Ohkubo (2004). Correlation with direct cholangiography and vascular anatomy was done. Bile duct dimensions were measured. Cystic duct junction and pancreaticobiliary ductal junction (PBDJ) were classified. Normal biliary anatomy was noted in 57.8 %. The most common variants were Couinaud type D2, Choi type 3A, Huang type A1, Champetier type a, Ohkubo types D and J, and Karakas type 2a. The Ohkubo classification was the most appropriate; 3.1 % of right ducts and 6.3 % of left ducts with variant anatomy could not be classified using the Ohkubo classification. There was a good agreement between MRCP and direct cholangiography (ĸ = 0.9). Anomalous PBDJ was noted in 8.7 %. Variant biliary anatomy was not associated with gender (p = 0.194) or variant vascular anatomy (p = 0.24). Although each classification system has its merits and demerits, some anatomical variations cannot be classified using any of the previously described classifications. The Ohkubo classification system is the most applicable as it considers most clinically relevant variations pertinent to hepatobiliary surgery.

Direct peroral cholangioscopy using an ultraslim upper endoscope for management of residual stones after mechanical lithotripsy for retained common bile duct stones.

PubMed

Lee, Y N; Moon, J H; Choi, H J; Min, S K; Kim, H I; Lee, T H; Cho, Y D; Park, S-H; Kim, S-J

2012-09-01

The incidence of residual stones after mechanical lithotripsy for retained common bile duct (CBD) stones is relatively high. Peroral cholangioscopy using a mother-baby system may be useful for confirming complete extraction of stones, but has several limitations regarding routine use. We evaluated the role of direct peroral cholangioscopy (DPOC) using an ultraslim upper endoscope for the evaluation and removal of residual CBD stones after mechanical lithotripsy. From August 2006 to November 2010, 48 patients who had undergone mechanical lithotripsy for retained CBD stones with no evidence of filling defects in balloon cholangiography were recruited. The bile duct was inspected by DPOC after balloon cholangiography. Detected residual CBD stones were directly retrieved with a basket or balloon catheter under DPOC. The incidence of residual stones detected by DPOC, and the success rate of residual stone retrieval under DPOC were investigated. DPOC was successfully performed in 46 of the 48 patients (95.8%). Of these, 13 patients (28.3%) had residual CBD stones (mean number 1.4, range 1-3; mean diameter 4.5 mm, range 2.3-9.6). The residual stones were removed directly under DPOC in 11 of these patients (84.6%). There were no complications associated with DPOC or stone removal. DPOC using an ultraslim upper endoscope is a useful endoscopic procedure for the evaluation and extraction of residual stones after mechanical lithotripsy for retained CBD stones. © Georg Thieme Verlag KG Stuttgart · New York.

[Extrinsic compression of the hepatocholedocus caused by cavernomatosis of the portal vein. Report of a case].

PubMed

Carpani, M; Guma, C I; Casal, M A

1982-01-01

The extrinsic compression of the hepatocholedochus by a cavernomatosis of the portal vein, is an unusual pathology. The present case begun clinically as an obstructive jaundice, assuming that the vascular origin of the compression increased the litiasic biliary disease. The percutaneous transhepatic cholangiography was the diagnostic method that suggested a double illness of the biliary system. The surgery and the pathology certificated the diagnosis. The correct treatment once confirmed the obstructive trial, must be: the extraction of the biliary gallstones and the bile-digestive derivation (preferently the hepatic-jejunum anastomosis in Y of Roux).

[Imaging of the intrahepatic biliary tree with thick slice MR cholangiography].

PubMed

Leclerc, J C; Cannard, L; Lefèvre, F; Debelle, L; Béot, S; Boccaccini, H; Bazin, C; Régent, D

2001-02-01

To assess the value of single shot fast spin echo MR sequence (SS-FSE) in the evaluation of the normal and pathologic intrahepatic biliary tree. 418 consecutive patients (457 examinations) referred for clinical and/or biological suspicion of biliary obstruction underwent MR cholangiopancreatography (MRCP). All patients were imaged with a Signa 1.5 T GE MR unit, with High Gradient Field Strength and Torso Phased Array Coil. Biliary ducts were imaged with SS-FSE sequence, coronal and oblique coronal 20 mm thick slices on a 256 x 256 matrix. Total acquisition time was 1 second. Source images were reviewed by two radiologists blinded to clinical information. In case of disagreement, a third radiologist's opinion was requested. In all cases, MRCP results were compared with direct biliary tract evaluation, other imaging studies and clinical and biological follow-up. In all cases, MRCP produced high quality images. Numerous branch of division were observed although the peripheral intrahepatic ducts were well seen in more than 90% in an area 2 cm below the capsule. The number of division was statistically higher when mechanical obstruction was present. Intrahepatic calculi or peripheral cholangiocarcinoma were well detect by MRCP. For the detection of cholangitis, MRCP sensitivity was 87.5% but the positive predictive value was only 57.7% because of a high number of false positive. The diagnosis of primary sclerosing cholangitis must be made only on strict criteria and slightly dilated peripheral bile ducts unconnected to the central ducts in several hepatic segments were a characteristic MR sign of primary sclerosing cholangitis. MRCP can be proposed as a first intention imaging technique for the evaluation of intrahepatic ducts.

Pancreaticobiliary maljunction and biliary cancer.

PubMed

Kamisawa, Terumi; Kuruma, Sawako; Tabata, Taku; Chiba, Kazuro; Iwasaki, Susumu; Koizumi, Satomi; Kurata, Masanao; Honda, Goro; Itoi, Takao

2015-03-01

Pancreaticobiliary maljunction (PBM) is a congenital malformation in which the pancreatic and bile ducts join anatomically outside the duodenal wall. Japanese clinical practice guidelines on how to deal with PBM were made in 2012, representing a world first. According to the 2013 revision to the diagnostic criteria for PBM, in addition to direct cholangiography, diagnosis can be made by magnetic resonance cholangiopancreatography (MRCP), 3-dimensional drip infusion cholangiography computed tomography, endoscopic ultrasonography (US), or multiplanar reconstruction images by multidetector row computed tomography. In PBM, the common channel is so long that sphincter action does not affect the pancreaticobiliary junction, and pancreatic juice frequently refluxes into the biliary tract. Persistence of refluxed pancreatic juice injures epithelium of the biliary tract and promotes cancer development, resulting in higher rates of carcinogenesis in the biliary tract. In a nationwide survey, biliary cancer was detected in 21.6% of adult patients with congenital biliary dilatation (bile duct cancer, 32.1% vs. gallbladder cancer, 62.3%) and in 42.4% of PBM patients without biliary dilatation (bile duct cancer, 7.3% vs. gallbladder cancer, 88.1%). Pathophysiological conditions due to pancreatobiliary reflux occur in patients with high confluence of pancreaticobiliary ducts, a common channel ≥6 mm long, and occlusion of communication during contraction of the sphincter. Once the diagnosis of PBM is established, immediate prophylactic surgery is recommended. However, the surgical strategy for PBM without biliary dilatation remains controversial. To detect PBM without biliary dilatation early, MRCP is recommended for patients showing gallbladder wall thickening on screening US under suspicion of PBM.

Outcome of gallbladder preservation in surgical management of primary bile duct stones.

PubMed

Tian, Ming-Guo; Shi, Wei-Jin; Wen, Xin-Yuan; Yu, Hai-Wen; Huo, Jing-Shan; Zhou, Dong-Feng

2003-08-01

To evaluate the methods and outcome of gallbladder preservation in surgical treatment of primary bile duct stones. Thirty-five patients with primary bile duct stones and intact gallbladders received stone extraction by two operative approaches, 23 done through the intrahepatic duct stump (RBD-IDS, the RBD-IDS group) after partial hepatectomy and 12 through the hepatic parenchyma by retrograde puncture (RBD-RP, the RBD-RP group). The gallbladders were preserved and the common bile duct (CBD) incisions were primarily closed. The patients were examined postoperatively by direct cholangiography and followed up by ultrasonography once every six months. In the RBD-IDS group, residual bile duct stones were found in three patients, which were cleared by a combination of fibrocholedochoscopic extraction and lithotripsy through the drainage tracts. The tubes were removed on postoperative day 22 (range: 16-42 days). In the RBD-RP group, one patient developed hemobilia and was cured by conservative therapy. The tubes were removed on postoperative day 8 (range: 7-11 days). Postoperative cholangiography showed that all the gallbladders were well opacified, contractile and smooth. During 54 (range: 6-120 months) months of follow-up, six patients had mildly thickened cholecystic walls without related symptoms and further changes, two underwent laparotomies because of adhesive intestinal obstruction and gastric cancer respectively, three died of cardiopulmonary diseases. No stones were found in all the preserved gallbladders. The intact gallbladders preserved after surgical extraction of primary bile duct stones will not develop gallstones. Retrograde biliary drainage is an optimal approach for gallbladder preservation.

Percutaneous intraductal radiofrequency ablation for treatment of biliary stent occlusion: A preliminary result.

PubMed

Xia, Ning; Gong, Ju; Lu, Jian; Chen, Zhi-Jin; Zhang, Li-Yun; Wang, Zhong-Min

2017-03-14

To assess the feasibility and effectiveness of a novel application of percutaneous intraductal radiofrequency (RF) for the treatment of biliary stent obstruction. We specifically report a retrospective study presenting the results of percutaneous intraductal RF in patients with biliary stent occlusion. A total of 43 cases involving biliary stent obstruction were treated by placing an EndoHPB catheter and percutaneous intraductal RF was performed to clean stents. The stent patency was evaluated by cholangiography and follow-up by contrast enhanced computed tomography or ultrasound after the removal of the drainage catheter. Following the procedures, of the 43 patients, 40 survived and 3 died with a median survival of 80.5 (range: 30-243) d. One patient was lost to follow-up. One patient had the stent patent at the time of last follow-up. Two patients with stent blockage at 35 d and 44 d after procedure underwent percutaneous transhepatic drain insertion only. The levels of bilirubin before and after the procedure were 128 ± 65 μmol/L and 63 ± 29 μmol/L, respectively. There were no related complications (haemorrhage, bile duct perforation, bile leak or pancreatitis) and all patients' stent patency was confirmed by cholangiography after the procedure, with a median patency time of 107 (range: 12-180) d. This preliminary clinical study demonstrated that percutaneous intraductal RF is safe and effective for the treatment of biliary stent obstruction, increasing the duration of stent patency, although randomized controlled trials are needed to confirm the effectiveness of this approach.

Biliary tract obstruction secondary to cancer: management guidelines and selected literature review.

PubMed

Lokich, J J; Kane, R A; Harrison, D A; McDermott, W V

1987-06-01

Malignant biliary tract obstruction (MBTO) due to either primary biliary tract cancer or metastasis to the porta hepatis is a common clinical problem. The most common metastatic tumors causing MBTO in order of frequency are gastric, colon, breast, and lung cancers. Radiographic diagnostic procedures should proceed in a cost-effective sequence from ultrasonography, computerized tomography (CT), percutaneous transhepatic cholangiography (PTHC), and endoscopic retrograde pancreatography with the goal of establishing the site of the biliary tract obstruction. The identification of the site of obstruction could be established by ultrasound 70% to 80%, CT scan 80% to 90%, PTHC 100%, and endoscopic retrograde cholangiography (ERCP) 85%. Therapeutic intervention by radiographic decompression (PTHC or endoscopic prosthesis), surgical bypass, or radiation therapy with or without chemotherapy may be selectively used based on (1) the site of obstruction; (2) the type of primary tumor; and (3) the presence of specific symptoms related to the obstruction. ("Prophylactic" biliary tract decompression to prevent ascending cholangitis is not supported by the literature in that the frequency of sepsis in the face of malignant obstruction is small (in contrast to sepsis associated with stone disease). Furthermore, PTHC with drainage as a long-term procedure is associated with a substantial frequency of sepsis and is unnecessary and possibly problematic as a preoperative procedure simply to reduce the bilirubin level. The use of radiation therapy in conjunction with chemotherapy for patients not deemed suitable for a surgical bypass because of the presence of proximal obstruction is an important alternative to PTHC.

[Extrahepatic biliary atresia: diagnostic methods].

PubMed

Cauduro, Sydney M

2003-01-01

To emphasize the importance of precocious diagnosis of extrahepatic biliary atresia and its direct relationship with the surgical re-establishment of the biliary flow before the second month of life. To discuss several complementary methods with the aim of selecting the ones that present better evidence, and avoiding delays in diagnosis and worse prognostic. Bibliographical researching regarding the period of 1985-2001, in Medline and MdConsult, using the following key words: neo-natal cholestasis; extrahepatic biliary atresia; neo-natal hepatitis. National and foreign articles were also elected based on the bibliography of consulted publications, and when necessary, for better understanding of the theme, opinions emitted in theses and textbooks were referred. The revision of the consulted bibliography led to the assumption that early diagnosis of EHBA and surgical treatment to reestablish the biliary flow up to 60 days of life are fundamental in order to achieve good results. Among several complementary methods of diagnosis, cholangiography by MR, US and the hepatic biopsy are the ones that provide the largest success indexes. The referring of patients bearers of EHBA to centers of references in Brazil, is still made tardily, probably due to lack of enlightenment of the doctors of primary attention, allied to bureaucratic and technological difficulties. The experience in England in relation to the "Yellow Alert" program, allowed that the number of children referred to surgical treatment before the 60 days of life increased significantly. Among the complementary methods, the MR cholangiography, ultrasonography and hepatic biopsy should be used, depending on the technological resources of the diagnosis units.

Percutaneous intraductal radiofrequency ablation for treatment of biliary stent occlusion: A preliminary result

PubMed Central

Xia, Ning; Gong, Ju; Lu, Jian; Chen, Zhi-Jin; Zhang, Li-Yun; Wang, Zhong-Min

2017-01-01

AIM To assess the feasibility and effectiveness of a novel application of percutaneous intraductal radiofrequency (RF) for the treatment of biliary stent obstruction. METHODS We specifically report a retrospective study presenting the results of percutaneous intraductal RF in patients with biliary stent occlusion. A total of 43 cases involving biliary stent obstruction were treated by placing an EndoHPB catheter and percutaneous intraductal RF was performed to clean stents. The stent patency was evaluated by cholangiography and follow-up by contrast enhanced computed tomography or ultrasound after the removal of the drainage catheter. RESULTS Following the procedures, of the 43 patients, 40 survived and 3 died with a median survival of 80.5 (range: 30-243) d. One patient was lost to follow-up. One patient had the stent patent at the time of last follow-up. Two patients with stent blockage at 35 d and 44 d after procedure underwent percutaneous transhepatic drain insertion only. The levels of bilirubin before and after the procedure were 128 ± 65 μmol/L and 63 ± 29 μmol/L, respectively. There were no related complications (haemorrhage, bile duct perforation, bile leak or pancreatitis) and all patients’ stent patency was confirmed by cholangiography after the procedure, with a median patency time of 107 (range: 12-180) d. CONCLUSION This preliminary clinical study demonstrated that percutaneous intraductal RF is safe and effective for the treatment of biliary stent obstruction, increasing the duration of stent patency, although randomized controlled trials are needed to confirm the effectiveness of this approach. PMID:28348491

Percutaneous transhepatic bile drainage.

PubMed Central

Mori, K; Misumi, A; Sugiyama, M; Okabe, M; Matsuoka, T

1977-01-01

Percutaneous transhepatic bile drainage was performed in 13 patients with obstructive jaundice, using a combination of the PTC technique and a Seldinger angiography catheter. In 11 cases, the outflow of bile through the catheter was satisfactory and complications were few. Since the risk of the procedure is low and it can be done without laparotomy, it is an ideal technic for biliary decompression before attempting to do a resection. Also, repeated cholangiography through a catheter which is left in place is helpful as a diagnostic aid before and after surgery. Images Fig. 3. Fig. 4. Fig. 5. Fig. 6. PMID:831630

Autoimmune hepatitis/sclerosing cholangitis overlap syndrome in childhood: a 16-year prospective study.

PubMed

Gregorio, G V; Portmann, B; Karani, J; Harrison, P; Donaldson, P T; Vergani, D; Mieli-Vergani, G

2001-03-01

To investigate whether sclerosing cholangitis with an autoimmune serology characteristic of autoimmune hepatitis (AIH) and AIH are distinct entities, we studied 55 consecutive children with clinical and/or biochemical evidence of liver disease and circulating antinuclear (ANA), anti-smooth muscle (SMA), and/or liver-kidney-microsomal type 1 (LKM1) autoantibodies. They underwent liver biopsy, direct cholangiography, sigmoidoscopy, and rectal biopsy at presentation. Twenty-eight were diagnosed as AIH in the absence and 27 autoimmune sclerosing cholangitis (ASC) in the presence of radiological features of cholangiopathy. Twenty-six ASC and 20 AIH had ANA and/or SMA; 1 ASC and 8 AIH LKM1 autoantibody. Similarities between the 2 conditions included most clinical and biochemical parameters and a lower frequency of HLA DR4. Inflammatory bowel disease and histological biliary changes were more common in ASC; coagulopathy, hypoalbuminemia, lymphocytic periportal hepatitis, and HLA DR3 were more common in AIH. Histological biliary changes were observed in 65% of ASC and 31% of AIH patients. Eighty-nine percent responded to immunosuppression. Follow-up liver biopsies from 17 ASC and 18 AIH patients had similarly reduced inflammatory activity and no progression to cirrhosis. Sixteen follow-up cholangiograms from AIH patients and 9 from ASC patients were unchanged, while 8 ASC patients showed a progressive cholangiopathy. One child with AIH and ulcerative colitis developed sclerosing cholangitis 8 years after presentation. At 2 to 16 years (median, 7 years) from presentation, all patients are alive, including 4 ASC patients who underwent liver transplantation. In conclusion, ASC and AIH are similarly prevalent in childhood; cholangiography is often needed to distinguish between these 2 entities, which are likely to lie within the same disease process.

Elizabethkingia Meningoseptica in a Case of Biliary Tract Infection Following Liver Transplantation

PubMed Central

Musalem, Hebah M.; Honjol, Yazan N.; Tuleimat, Lin M.; Al Abbad, Saleh I.; Alsohaibani, Fahad I.

2017-01-01

Patient: Female, 55 Final Diagnosis: Percutaneous transhepatic cholangiography biliary drain infection with Elizabethkingia meningoseptica Symptoms: Right upper quadrant abdominal pain Medication: IV Ciprofloxacin 400 mg/12 hrs Clinical Procedure: None Specialty: Surgery and Internal Medicine Objective: Rare disease Background: Elizabethkingia meningoseptica (E. meningoseptica) is an aerobic Gram-negative bacillus known to thrive in moist environments, and is now recognized as a hospital-acquired infection, being found to contaminate hospital equipment, respiratory apparatus, hospital solutions, water, and drainage systems. Nosocomial infection with E. meningoseptica occurs in immunocompromised patients, requires specialized identification methods, and is resistant to conventional antibiotics. We report a case of E. meningoseptica infection arising from a percutaneous transhepatic biliary drainage (PTBD) tube. Case Report: A 55-year-old Saudi woman underwent liver transplantation. The post-operative period immediately following transplantation was complicated by anastomotic biliary stricture and bile leak, which was managed with percutaneous transhepatic cholangiography (PTC) with PTBD. She developed right upper quadrant abdominal pain, and her ultrasound (US) showed a sub-diaphragmatic collection. Microbial culture from the PTBD tube was positive for E. meningoseptica, which was treated with intravenous ciprofloxacin and metronidazole. This case is the second identified infection with E. meningoseptica at our specialist center, fifteen years after isolating the first case in a hemodialysis patient. We believe that this is the first case of E. meningoseptica infection to be reported in a liver transplant patient. Conclusions: The emerging nosocomial infectious organism, E. meningoseptica is being seen more often on hospital equipment and medical devices and in water. This case report highlights the need for awareness of this infection in hospitalized

Assessment of Chronological Effects of Irreversible Electroporation on Hilar Bile Ducts in a Porcine Model

DOE Office of Scientific and Technical Information (OSTI.GOV)

Choi, Jae Woong, E-mail: cooljay@korea.ac.kr; Lu, David S. K., E-mail: dlu@mednet.ucla.edu; Osuagwu, Ferdnand, E-mail: fosuagwu@mednet.ucla.edu

2013-11-07

PurposeTo evaluate the chronological effects of irreversible electroporation (IRE) on large hilar bile ducts in an in vivo porcine model correlated with computed tomography (CT) cholangiography and histopathology.Materials and MethodsTwelve IRE zones were made along hilar bile ducts intraoperatively under ultrasound (US)-guidance in 11 pigs. Paired electrodes were placed either on opposing sides of the bile duct (straddle [STR]) or both on one side of the bile duct (one-sided [OSD]). The shortest electrode-to-duct distance was classified as periductal (≤2 mm) or nonperiductal (>2 mm). CT cholangiography and laboratory tests were performed before IRE and again at 2 days, 4 weeks, and 8 weeks after IRE.more » Degree of bile duct injury were graded as follows: grade 0 = no narrowing; grade 1 = ≤50 % duct narrowing; grade 2 = >50 % narrowing without proximal duct dilatation; grade 3 = grade 2 with proximal duct dilatation; and grade 4 = grade 3 with enzyme elevation. Pigs were selected for killing and histopathology at 2 days, 4, and 8 weeks.ResultsNonperiductal electrode placement produced no long-term strictures in 5 of 5 ducts. Periductal electrode placement produced mild narrowing in 6 of 7 ducts: 5 grade 1 and 1 grade 2. None showed increased enzymes. There was no significant difference between STR versus OSD electrode placement. Histopathology showed minor but relatively greater ductal mural changes in narrowed ducts.ConclusionIn the larger hilar ducts, long-term patency and mural integrity appear resistant to IRE damage with the energy deposition used, especially if the electrode is not immediately periductal in position.« less

[Portal thrombosis, common bile duct varices and cholestasis].

PubMed

Agüera Arroyo, B; Pérez Durán, M A; Montero Alvarez, J L; Navarro Jarabo, J M; Calero Ayala, B; Miño Fugarolas, G

1996-03-01

A case of cholestasis in a young patient with portal cavernomatosis is reported. This clinical picture is very infrequent and appears as a consequence of extrinsic compression on the common bile duct due to which the derivative venous collaterals. There does not appear to be any relationship between the intensity of the morphologic alteration of the biliary tract and the level of portal hypertension and the degree of extrahepatic obstruction. Diagnosis was fundamentally achieved by arteriography and retrograde cholangiography with differential diagnosis with the previously mentioned diseases being required. Chronic cholestasis advises derivative surgery in which difficulties may be found due to the presence of thick collaterals in the hepatic pedicle as occurred in this patient.

A refractory duodenal ulcer with a biliary-duodenal fistula following the administration of bevacizumab.

PubMed

Horibe, Yohei; Adachi, Seiji; Okuno, Mitsuru; Ohno, Tomohiko; Goto, Naoe; Iwama, Midori; Yamauchi, Osamu; Saito, Koshiro; Yasuda, Ichiro; Shimizu, Masahito

2016-07-01

A 65-year-old woman with recurrent breast cancer was repeatedly treated with bevacizumab, an anti-VEGF antibody. In addition, she was also frequently prescribed a nonsteroidal anti-inflammatory drug for abdominal pain. Melena was revealed 2 months after the final treatment with bevacizumab, and an endoscopic study revealed a duodenal ulcer (DU) that was resistant to anti-ulcer therapy. A cholangiography identified a biliary-duodenal fistula with bile juice leaking from the ulcer base. Therefore, a biliary stent was placed into the common bile duct for 3 months until the DU healed. This is the first case of a refractory DU with a biliary-duodenal fistula in a patient treated with bevacizumab.

Mirizzi syndrome--a report of 3 cases with a review of the present classifications.

PubMed

Khan, T F; Muniandy, S; Hayat, F Z; Sherazi, Z A; Nawaz, M H

1999-03-01

We report three cases of Mirizzi syndrome, two with external compression of the common hepatic duct and another with cystobiliary fistula. All patients presented with jaundice. The diagnosis was suggested by ultrasonography and confirmed by endoscopic retrograde cholangiography (ERC). All three had the stones removed surgically, one through a choledochotomy, another through an opening in the gall bladder and the third at the time of subtotal cholecystectomy. We would like to propose a simple classification of Mirizzi syndrome, based on surgical procedures necessary for the correction of the pathological anatomy. If it involves the removal of calculi with some form of cholecystectomy, we consider it as Type I, whereas Type II involves the construction of a hepaticojejunostomy apart from the removal of calculi.

Double Gallbladder Originating from Left Hepatic Duct: A Case Report and Review of Literature

PubMed Central

Gorecki, Piotr J.; Andrei, Valeriu E; Musacchio, Tito

1998-01-01

Background: Double gallbladder is a rare anomaly of the biliary tract. Double gallbladder arising from the left hepatic duct was previously reported only once in the literature. Case Report: A case of symptomatic cholelithiasis in a double gallbladder, diagnosed on preoperative ultrasound, computed tomography (CT) and endoscopic retrograde cholangiopancreatogram (ERCP) is reported. At laparoscopic cholangiography via the accessory gallbladder no accessory cystic duct was visualized. After conversion to open cholecystectomy, the duplicated gallbladder was found to arise directly from the left hepatic duct; it was resected and the duct repaired. Conclusions: We emphasize that a careful intraoperative cholangiographic evaluation of the accessory gallbladder is mandatory in order to prevent inadvertent injury to bile ducts, since a large variety of ductal abnormality may exist. PMID:10036124

Bronchobiliary Fistula Treated by Self-expanding ePTFE-Covered Nitinol Stent-Graft

DOE Office of Scientific and Technical Information (OSTI.GOV)

Gandini, Roberto; Konda, Daniel; Tisone, Giuseppe

A 71-year-old man, who had undergone right hepatectomy extended to the caudate lobe with terminolateral Roux-en-Y left hepatojejunostomy for a Klatskin tumor, developed bilioptysis 3 weeks postoperatively due to bronchobiliary fistula. Percutaneous transhepatic cholangiography revealed a non-dilated biliary system with contrast medium extravasation to the right subphrenic space through a resected anomalous right posterior segmental duct. After initial unsuccessful internal-external biliary drainage, the fistula was sealed with a VIATORR covered self-expanding nitinol stent-graft placed with its distal uncovered region in the hepatojejunal anastomosis and the proximal ePTFE-lined region in the left hepatic duct. A 10-month follow-up revealed no recurrence ofmore » bilioptysis and confirmed the complete exclusion of the bronchobiliary fistula.« less

[The thoracic surgeon and the management of the bronchial biliary fistula of hydatid origin].

PubMed

Rabiou, S; Belliraj, L; Ammor, F Z; Issoufou, I; Sylla, B; Lakranbi, M; Ouadnouni, Y; Benajah, D; Smahi, M

2018-02-01

The bronchial biliary fistula surgery is a major one, always going with a higher rate of complication especially in case of bile duct obstruction. The aim of this study is to find out the contribution of endoscopic sphincterotomy while reporting the results of surgical treatment of bronchial biliary fistulae by exclusive thoracotomy. This was a retrospective study, which took place in the Department of Thoracic Surgery, University Hospital Hassan II, from January 2009 to March 2016. The parameters studied in connection with the bronchial biliary fistula of hydatid origin were: age, sex, origin, history of surgery especially for hepatic hydatid cyst, term of bilyptysie, imaging results, preoperative cholangiography indications, surgical treatment modalities and patients trends. A sample of 12 patients was included (6 men and 6 women) with an average age of 44 years old, with a gap spanning between 17 and 81 years. Seven patients had at least a history of hepatic hydatid surgery. The biliptysie was the main symptom in 8 patients. A biological cholestasis syndrome was found in 6 patients. The thoracoabdominal CT scan performed on all patients comes out with results in 100% of cases. Four patients received endoscopic retrograde cholangiography that allowed them to release the bile duct completely by sphincterotomy with extraction of hydatid membrane in one patient and with development of a biliary stent in another patient. The incision was a low posterolateral thoracotomy in 10 patients that went under surgery. It has allowed to deal in one-time liver and lung injuries combined with diaphragmatic breach repair. Inside the group of patients that went under surgery, the postoperative results were simple in 8 cases. We have noted an overall mortality rate of 18.2%. Bronchial biliary fistula surgery complications remains considerable despite the progress of diagnostic imaging. Preoperative endoscopic sphincterotomy is a milestone in the handling of this surgery. It may

Management of complicated gallstones: results of an alternative approach to difficult cholecystectomies.

PubMed

Lirici, Marco Maria; Califano, Andrea

2010-10-01

Laparoscopic cholecystectomy (LC) is the gold standard treatment of gallstones. Nevertheless, the incidence of conversion and injuries to the biliary tract is still high in difficult cholecystectomies. In this study we sought to determine how using operative risk predictive scores (PSs) and the Nassar scale to grade the difficulty of LC would optimize the perioperative management of complicated gallstone patients. We also evaluated whether the "fundus-first" approach to LC combined with ultrasonic dissection minimizes the risk of conversion and biliary injury in difficult cholecystectomies, and avoids routine intraoperative cholangiography. A prospective non-randomized study was carried out from 2005 to 2007 including 237 patients referred for gallbladder diseases. All patients were evaluated using an operative risk PS. The LC grade of difficulty was assessed according to Nassar. Diagnostic accuracy, sensitivity, and specificity of PS were calculated. LC in difficult cases was accomplished with a fundus-first approach. Outcome measures included: Conversion rate, bile duct (BD) injury rate, and postoperative complications according to Clavien. In 178 out of 237 patients, a higher risk of conversion and complication was predicted. In 146 out of these 178 cases, intra-operative grading confirmed the difficulty of the procedure. The PS diagnostic accuracy was 0.865, sensitivity was 100%, and specificity 65%. Positive predictive value and negative predictive value were 0.82 and 1, respectively. Conversion rate was 2.7%. Mean operating time and postoperative length of hospital stay were 75 minutes and 3.5 days. Intra-operative cholangiography was necessary in five cases, and one intraoperative biliary complication occurred with an uneventful postoperative course. Overall, postoperative complications were 2.7% with a mortality rate of 0.68% (1 myocardial infarction). Fundus-first LC by ultrasonic dissection is safe and minimizes the risk of conversion and biliary injuries

A retrospective comparison of robotic cholecystectomy versus laparoscopic cholecystectomy: operative outcomes and cost analysis.

PubMed

Strosberg, David S; Nguyen, Michelle C; Muscarella, Peter; Narula, Vimal K

2017-03-01

Robotic-assisted surgery is gaining popularity in general surgery. Our objective was to evaluate and compare operative outcomes and total costs for robotic cholecystectomy (RC) and laparoscopic cholecystectomy (LC). A retrospective review was performed for all patients who underwent single-procedure RC and LC from January 2011 to July 2015 by a single surgeon at a large academic medical center. Demographics, diagnosis, perioperative variables, postoperative complications, 30-day readmissions, and operative and hospital costs were collected and analyzed between those patient groups. A total of 237 patients underwent RC or LC, and comprised the study population. Ninety-seven patients (40.9 %) underwent LC, and 140 patients (50.1 %) underwent RC. Patients who underwent RC had a higher body mass index (p = 0.03), lower rates of coronary artery disease (p < 0.01), and higher rates of chronic cholecystitis (p < 0.01). There were lower rates of intraoperative cholangiography (p < 0.01) and conversion to an open procedure (p < 0.01), however longer operative times (p < 0.01) for patients in the RC group. There were no bile duct injuries in either group, no difference in bile leak rates (p = 0.65), or need for reoperation (p = 1.000). Cost analysis of outpatient-only procedures, excluding cases with conversion to open or use of intraoperative cholangiography, demonstrated higher total charges (p < 0.01) and cost (p < 0.01) and lower revenue (p < 0.01) for RC compared to LC, with no difference in total payments (p = 0.34). Robotic cholecystectomy appears to be safe although costlier in comparison with laparoscopic cholecystectomy. Further studies are needed to understand the long-term implications of robotic technology, the cost to the health care system, and its role in minimally invasive surgery.

Endoscopic Management of Post-Liver Transplantation Biliary Strictures With the Use of Fully Covered Metallic Stents.

PubMed

Jiménez-Pérez, M; Melgar Simón, J M; Durán Campos, A; González Grande, R; Rodrigo López, J M; Manteca González, R

2016-09-01

The aim of this work was to evaluate the safety and efficacy of a fully covered self-expandable metal stent (FCSEMS) in the treatment of post-liver transplantation biliary strictures. From October 2009 to October 2014, 44 patients with post-liver transplantation biliary stenosis were treated with the use of endoscopic retrograde cholangiography and placement of FCSEMS after informed consent. The FCSEMS was scheduled to remain in situ for 3-6 months. Patients were followed at regular intervals to evaluate for symptoms and liver function tests. Technical success, complications, and patient outcome were analyzed. All of the strictures were anastomotic, 52% having occurred within the 1st year following the transplantation. Placement of the FCSEMS was possible on the 1st attempt in 54% of patients. Stricture resolution at the time of stent removal was seen in 100% of the cases. During an average follow-up of 27.83 ± 18.3 months after stent removal, stenosis recurred in 9 out of 41 patients (21.9%). The average time of recurrence was 11.78 ± 13.3 months. In all of these cases, the recurrence was resolved by means of placement of another FCSEMS. In 4 cases, the recurrence was associated with a migration of the prosthesis, partial in 2 cases and total in 2 cases. Stent migration occurred in a total of 17 of the 41 patients (41.4%), in 13 of the 32 (40.6%) who had no recurrence of stenosis and in 4 of the 9 (44.4%) of those who experienced recurrence. The average numbers of endoscopic retrograde cholangiography studies required per patient were 2.8 in those with no recurrence and 3.3 in those with recurrence. No death was associated with the process. FCSEMS is a safe effective alternative to plastic stents in the treatment of post-transplantation biliary strictures, resulting in a lower risk of complications and better patient acceptance. Copyright © 2016 Elsevier Inc. All rights reserved.

[A photo-optical observation of gallbladder motility in dogs (author's transl)].

PubMed

Kudo, N

1976-03-01

A photo-optical observation on gallbladder motility was made with the 16 mm cine-cholangiography. The subjects studied were thirty two mongrel dogs. The gallbladder was exposed by a short upper midline abdominal incision under pentothal anesthesia. Gallbladder bile was aspirated and contrast medium was given into the bladder, through a transhepatic route. The cine-cholangiography was done by an image intensifier at a speed of one frame every 2 to 4 seconds. The cinefilms taken were observed repeatedly by the screen projection at various speeds. The drawings were made by tracing the outline of the image of the gallbladder on each frame and were overlapped. Moreover, a contraction curve was made by the cholecystometry using of film motion analyzer in every case. At the same time bile flow into the duodenum was recorded to study a relationship between the gallbladder contraction and motility of the terminal common bile duct. The results obtained are as follows: 1. In a resting state any contraction of the gallbladder was not seen during 30 minutes, and a peristalsis-like movements of the neck portion was observed. However, there was not a relationship between the contraction curve of the gallbladder and the bile flow into the duodenum. 2. Immediately after giving Caerulein, the contrast medium injected into the gallbladder was rapidly discharged into the common bile duct by a peristalsis-like movement of the neck. The size of the gallbladder was markedly decreased into three fifths of the initial state three minutes after administration. At the same time contrast medium was continuously discharged into the duodenum. 3. After giving pilocarpine a marked contraction with forceful movement of the neck and body was observed, and the size of the gallbladder was decreased into three quarters ot the initial state. Bile discharge into the duodenum was markedly increased with an active open- and closing movement of the terminal common bile duct.

Autoimmune hepatitis in children.

PubMed

Mieli-Vergani, Giorgina; Vergani, Diego

2002-08-01

AIH, ASC, and de novo AIH after liver transplantation are childhood liver diseases of an autoimmune nature. The mode of presentation of AIH in childhood is variable, and the disease should be suspected and excluded in all children presenting with symptoms and signs of prolonged or severe acute liver disease. Although corticosteroids are effective in all types of childhood AIH, patients with LKM1 have a higher frequency of acute hepatic failure and relapse after corticosteroid withdrawal than do patients with ANA/SMA. ASC occurs commonly in the absence of inflammatory bowel disease, requires cholangiography for diagnosis, and improves during corticosteroid therapy. The development of AIH de novo in children who undergo liver transplantation for nonautoimmune liver disease may reflect interference with the maturation of T cells by immunosuppressive drugs.

Endoscopic and Photodynamic Therapy of Cholangiocarcinoma.

PubMed

Meier, Benjamin; Caca, Karel

2016-12-01

Most patients with cholangiocarcinoma (CCA) have unresectable disease. Endoscopic bile duct drainage is one of the major objectives of palliation of obstructive jaundice. Stent implantation using endoscopic retrograde cholangiography is considered to be the standard technique. Unilateral versus bilateral stenting is associated with different advantages and disadvantages; however, a standard approach is still not defined. As there are various kinds of stents, there is an ongoing discussion on which stent to use in which situation. Palliation of obstructive jaundice can be augmented through the use of photodynamic therapy (PDT). Studies have shown a prolonged survival for the combinations of PDT and different stent applications as well as combinations of PDT and additional systemic chemotherapy. More well-designed studies are needed to better evaluate and standardize endoscopic treatment of unresectable CCA.

IgG4-negative autoimmune pancreatitis with sclerosing cholangitis and colitis: possible association with primary sclerosing cholangitis?

PubMed

Saeki, Keita; Hozawa, Shigenari; Miyata, Naoteru; Nishizawa, Toshihiro; Soma, Hiromitsu; Iwao, Yasushi; Kameyama, Kaori; Hibi, Toshifumi

2008-01-01

We report a case of autoimmune pancreatitis (AIP) with cholangiography and histopathology showing features characteristic of primary sclerosing cholangitis (PSC) and colitis. A 55-year-old previously-healthy man was diagnosed with anti-nuclear antibody (ANA)-positive AIP according to the finding of serum biochemistry, abdominal US (ultrasonography), CT (computed tomography) and ERCP (endoscopic retrograde cholangiopancreatography). However, bead-like strictures of intrahepatic bile ducts were also found and liver tissue showed onion skin-like periductal fibrosis but no anti-IgG4-positive cells. In addition, colon fiberscopy showed a pancolitis similar to ulcerative colitis indicating that, in this case, there may be an association with PSC. Here, we report a rare case of IgG4-negative AIP with sclerosing cholangitis and colitis with many clinical features that support an association with PSC.

[A case of hemorrhagic cholecystitis associated with Churg-Strauss syndrome].

PubMed

Koizumi, Satomi; Kamisawa, Terumi; Kuruma, Sawako; Chiba, Kazuro; Tabata, Taku; Koizumi, Koichi; Kurata, Masanao; Horiguchi, Shinichiro; Hishima, Tsunekazu

2016-01-01

A woman in her 70s with Churg-Strauss syndrome presented with epigastric pain. She was being treated with steroids at the time of admission. Computed tomography showed swelling of the gallbladder, and percutaneous transhepatic cholangiography revealed bloody secretion. On duodenoscopy, bleeding was observed from the orifice of the major duodenal papilla. Emergency cholecystectomy was performed under a diagnosis of hemorrhagic cholecystitis;intraoperatively, extensive hematoma was detected in the thickened wall of the gallbladder. Subsequent histopathological examination revealed mucosal ulceration with infiltration of inflammatory cells, torn small vessels, and extensive transmural bleeding and abscess formation in the thickened wall of the gallbladder. We considered that the hemorrhagic cholecystitis was induced by either vasculitis or corticosteroid therapy. To the best of our knowledge, this is the first report of hemorrhagic cholecystitis associated with Churg-Strauss syndrome.

Sclerosing Cholangitis: Clinicopathologic Features, Imaging Spectrum, and Systemic Approach to Differential Diagnosis.

PubMed

Seo, Nieun; Kim, So Yeon; Lee, Seung Soo; Byun, Jae Ho; Kim, Jin Hee; Kim, Hyoung Jung; Lee, Moon-Gyu

2016-01-01

Sclerosing cholangitis is a spectrum of chronic progressive cholestatic liver disease characterized by inflammation, fibrosis, and stricture of the bile ducts, which can be classified as primary and secondary sclerosing cholangitis. Primary sclerosing cholangitis is a chronic progressive liver disease of unknown cause. On the other hand, secondary sclerosing cholangitis has identifiable causes that include immunoglobulin G4-related sclerosing disease, recurrent pyogenic cholangitis, ischemic cholangitis, acquired immunodeficiency syndrome-related cholangitis, and eosinophilic cholangitis. In this review, we suggest a systemic approach to the differential diagnosis of sclerosing cholangitis based on the clinical and laboratory findings, as well as the typical imaging features on computed tomography and magnetic resonance (MR) imaging with MR cholangiography. Familiarity with various etiologies of sclerosing cholangitis and awareness of their typical clinical and imaging findings are essential for an accurate diagnosis and appropriate management.

Endoscopic and Photodynamic Therapy of Cholangiocarcinoma

PubMed Central

Meier, Benjamin; Caca, Karel

2016-01-01

Background Most patients with cholangiocarcinoma (CCA) have unresectable disease. Endoscopic bile duct drainage is one of the major objectives of palliation of obstructive jaundice. Methods/Results Stent implantation using endoscopic retrograde cholangiography is considered to be the standard technique. Unilateral versus bilateral stenting is associated with different advantages and disadvantages; however, a standard approach is still not defined. As there are various kinds of stents, there is an ongoing discussion on which stent to use in which situation. Palliation of obstructive jaundice can be augmented through the use of photodynamic therapy (PDT). Studies have shown a prolonged survival for the combinations of PDT and different stent applications as well as combinations of PDT and additional systemic chemotherapy. Conclusion More well-designed studies are needed to better evaluate and standardize endoscopic treatment of unresectable CCA. PMID:28229075

Bile duct hamartomas (von Mayenburg complexes) mimicking liver metastases from bile duct cancer: MRC findings

PubMed Central

Nagano, Yasuhiko; Matsuo, Kenichi; Gorai, Katsuya; Sugimori, Kazuya; Kunisaki, Chikara; Ike, Hideyuki; Tanaka, Katsuaki; Imada, Toshio; Shimada, Hiroshi

2006-01-01

We present a case of a 72-year-old man with a common bile duct cancer, who was initially believed to have multiple liver metastases based on computed tomography findings, and in whom magnetic resonance cholangiography (MRC) revealed a diagnosis of bile duct hamartomas. At exploration for pancreaticoduodenectomy, liver palpation revealed disseminated nodules at the surface of the liver. These nodules showed gray-white nodular lesions of about 0.5 cm in diameter scattered on the surface of both liver lobes, which were looked like multiple liver metastases from bile duct cancer. Frozen section of the liver biopsy disclosed multiple bile ducts with slightly dilated lumens embedded in the collagenous stroma characteristics of multiple bile duct hamartomas (BDHs). Only two reports have described the MRC features of bile duct hamartomas. Of all imaging procedures, MRC provides the most relevant features for the imaging diagnosis of bile duct hamartomas. PMID:16534895

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nasser, Felipe; Rocha, Rafael Dahmer, E-mail: rafaeldrocha@gmail.com; Falsarella, Priscila Mina

PurposeTo report a novel modified occlusion balloon technique to treat biliary leaks.MethodsA 22-year-old female patient underwent liver transplantation with biliary-enteric anastomosis. She developed thrombosis of the common hepatic artery and extensive ischemia in the left hepatic lobe. Resection of segments II and III was performed and a biliary-cutaneous leak originating at the resection plane was identified in the early postoperative period. Initial treatment with percutaneous transhepatic drainage was unsuccessful. Therefore, an angioplasty balloon was coaxially inserted within the biliary drain and positioned close to the leak.ResultsThe fistula output abruptly decreased after the procedure and stopped on the 7th day. Atmore » the 3-week follow-up, cholangiography revealed complete resolution of the leakage.ConclusionThis novel modified occlusion balloon technique was effective and safe. However, greater experience and more cases are necessary to validate the technique.« less

Technical tips for peroral transluminal cholangioscopy using novel single-operator cholangioscope (with videos).

PubMed

Ogura, Takeshi; Takagi, Wataru; Kurisu, Yoshitaka; Higuchi, Kazuhide

2016-10-01

Endoscopic retrograde cholangiopancreatography (ERCP) is the gold-standard modality for diagnosis and therapy of bilio-pancreatic disease. In particular, peroral cholangiography (POCS) is a useful modality not only for diagnosing biliary disease, but also for therapeutic procedures such as electrohydraulic lithotripsy. The SPY-DS single-operator cholangioscope has recently become available, and offers favorable visualization, a wide view, suction function and a larger accessory working channel. However, if the duodenoscope cannot be advanced into the ampulla of Vater for reasons such as surgical anatomy, POCS cannot be performed. On the other hand, percutaneous transhepatic cholangiodrainage (PTCD) has been developed as an alternative endoscopic ultrasound-guided approach to the biliary tract. Peroral transluminal cholangioscopy (PTLC) using SPY-DS is a novel approach. Because transluminal interventional procedures under endoscopic ultrasound guidance have recently been developed, our technique may have clinical impact for selected cases. © 2016 Japanese Society of Hepato-Biliary-Pancreatic Surgery.

[Liability of surgeons with respect to injuries to the bile duct during laparoscopic cholecystectomy : Analyses of malpractice litigations in the years 1996-2009].

PubMed

Fellmer, P T; Fellmer, J; Jonas, S

2011-01-01

Injuries to the bile duct during laparoscopic cholecystectomy are often a cause of malpractice litigations. A total of 13 legal verdicts as a result of bile duct injury from 1996 to 2009 were reviewed. Comments on the verdicts and the opinions of expert witnesses were analyzed. Out of 13 claims, 7 were upheld and 6 were rejected. Most expert witnesses from 1996 to 2002 stated that not carrying out a cholangiography and insufficient preparation of the cystic duct constituted a performance below the standard of care expected. Expert witness testimonies from 2004 to 2009, however, regarded injury to the bile duct as predominantly inherent to treatment. With the expansion and acceptance of laparoscopic interventions, changes in the results of malpractice litigation have become evident. In contrast to the phase during establishment of the technology, an injury to the bile duct is nowadays judged predominantly as inherent to treatment.

Cholestasis caused by Fasciola gigantica.

PubMed

Beştaş, Remzi; Yalçin, Kendal; Çiçek, Muttalip

2014-01-01

Fascioliasis is an infectious disease caused by the hepatic trematodes Fasciola hepatica and Fasciola gigantica. Here, we report the case of Fasciola gigantica presenting with biliary obstruction and abdominal pain that was diagnosed and treated by endoscopic retrograde cholangiography (ERCP). A 46-year-old woman presented with right upper quadrant abdominal pain and jaundice. Physical examination revealed icterus and hepatomegaly. Laboratory findings revealed an increase in liver transaminases and bilirubin. Abdominal ultrasonography showed extrahepatic and intrahepatic bile duct dilatation. The patient underwent ERCP. One live Fasciola gigantica was removed from the common bile duct by ERCP. In conclusion, fascioliasis should be considered in the differential diagnosis of obstructive jaundice, especially in endemic regions, and it should be kept in mind that ERCP plays an important role in the diagnosis and treatment of these patients. To our knowledge, this is the second case report of Fasciola gigantica treated by ERCP in Turkey.

A case of recurrent cholangitis after bile duct injury during laparoscopic cholecystectomy: value of scintigraphy with Tc-99m GSA and hepatobiliary scintigraphy for indication of lobectomy.

PubMed

Nishiguchi, S; Shiomi, S; Sasaki, N; Iwata, Y; Tanaka, H; Kubo, S; Hirohashi, K; Ochi, H

2000-10-01

A 39-year-old woman with acute cholecystitis and gallstones underwent laparoscopic cholecystectomy. She suffered from recurrent episodes of cholangitis due to injury of the major bile ducts during laparoscopic cholecystectomy. Hepatobiliary scintigraphy with Tc-99m Sn-N-pyridoxyl-5-methyltryptophan was performed. Although normal bile excretion was found from the left hepatic duct to the percutaneous transhepatic biliary drainage (PTBD) tube, excretion from the right hepatic lobe was prolonged. Scintigraphy with Tc-99m diethylenetriaminepentaacetic acid-galactosyl human serum albumin demonstrated atrophy of the right hepatic lobe and enlargement of the left hepatic lobe. Cholangiography via the PTBD tube revealed complete obstruction of the left hepatico-jejunal anastomosis and could not enhance the right intrahepatic bile duct. A right hepatic lobectomy was performed because of the atrophy, glissonitis and the absence of an appropriate bile duct for reconstruction. Postoperatively she was active and exhibited no evidence of recurrent cholangitis.

True left-sided gallbladder with variations of bile duct and cholecystic vein.

PubMed

Ishii, Hiromichi; Noguchi, Akinori; Onishi, Mie; Takao, Koji; Maruyama, Takahiro; Taiyoh, Hiroaki; Araki, Yasunobu; Shimizu, Takeshi; Izumi, Hiroyuki; Tani, Naoki; Yamaguchi, Masahide; Yamane, Tetsuro

2015-06-07

A left-sided gallbladder without a right-sided round ligament, which is called a true left-sided gallbladder, is extremely rare. A 71-year-old woman was referred to our hospital due to a gallbladder polyp. Computed tomography (CT) revealed not only a gallbladder polyp but also the gallbladder located to the left of the round ligament connected to the left umbilical portion. CT portography revealed that the main portal vein diverged into the right posterior portal vein and the common trunk of the left portal vein and right anterior portal vein. CT cholangiography revealed that the infraportal bile duct of segment 2 joined the common bile duct. Laparoscopic cholecystectomy was performed for a gallbladder polyp, and the intraoperative finding showed that the cholecystic veins joined the round ligament. A true left-sided gallbladder is closely associated with several anomalies; therefore, surgeons encountering a true left-sided gallbladder should be aware of the potential for these anomalies.

True left-sided gallbladder with variations of bile duct and cholecystic vein

PubMed Central

Ishii, Hiromichi; Noguchi, Akinori; Onishi, Mie; Takao, Koji; Maruyama, Takahiro; Taiyoh, Hiroaki; Araki, Yasunobu; Shimizu, Takeshi; Izumi, Hiroyuki; Tani, Naoki; Yamaguchi, Masahide; Yamane, Tetsuro

2015-01-01

A left-sided gallbladder without a right-sided round ligament, which is called a true left-sided gallbladder, is extremely rare. A 71-year-old woman was referred to our hospital due to a gallbladder polyp. Computed tomography (CT) revealed not only a gallbladder polyp but also the gallbladder located to the left of the round ligament connected to the left umbilical portion. CT portography revealed that the main portal vein diverged into the right posterior portal vein and the common trunk of the left portal vein and right anterior portal vein. CT cholangiography revealed that the infraportal bile duct of segment 2 joined the common bile duct. Laparoscopic cholecystectomy was performed for a gallbladder polyp, and the intraoperative finding showed that the cholecystic veins joined the round ligament. A true left-sided gallbladder is closely associated with several anomalies; therefore, surgeons encountering a true left-sided gallbladder should be aware of the potential for these anomalies. PMID:26074714

[Cholangiocarcinoma in the middle third of the bile duct treated with radical surgery in Guillermo Almenara Hospital, Lima, Peru].

PubMed

Núñez Ju, Juan José; Anchante Castillo, Eduardo; Torres Cueva, Victor; Yeren Paredes, Cecilia; Carrasco Mascaro, Felix; Becerra, Oscar; Cordero Palomino, Ernesto; Sumire, Julia

2015-01-01

We report the case of a patient who had the initial diagnosis of tumor in the bile duct in the middle third. Patient presented with lost weight of 10 kilograms in two months and moderate epigastric pain, no jaundice. The patient underwent radical surgery of the bile duct with multiple freeze biopsy surgical margins, intraoperative choledochoscopy, intraoperative cholangiography and reconstruction bilioenteric anastomosis Y Roux transmesocolic, he had a great recovery and early discharge. The pathological results showed moderately differentiated tubular adenocarcinoma on the basis of an adenoma. Negatives retroperitoneal, retropancreatic, pericholedochal, lesser curvature and negative hepatic artery nodes, and extension of surgical margins free of neoplasia proximal and distal edges. R0 surgery. pT1N0Mx. Stage 1. After the optimal surgical outcomes, is managed by liver and biliary tract surgery service and medical oncology service for regular monitoring and controls. We present here the sequence of events and a review of the literature.

Development of a Training Model for Laparoscopic Common Bile Duct Exploration

PubMed Central

Rodríguez, Omaira; Benítez, Gustavo; Sánchez, Renata; De la Fuente, Liliana

2010-01-01

Background: Training and experience of the surgical team are fundamental for the safety and success of complex surgical procedures, such as laparoscopic common bile duct exploration. Methods: We describe an inert, simple, very low-cost, and readily available training model. Created using a “black box” and basic medical and surgical material, it allows training in the fundamental steps necessary for laparoscopic biliary tract surgery, namely, (1) intraoperative cholangiography, (2) transcystic exploration, and (3) laparoscopic choledochotomy, and t-tube insertion. Results: The proposed model has allowed for the development of the skills necessary for partaking in said procedures, contributing to its development and diminishing surgery time as the trainee advances down the learning curve. Further studies are directed towards objectively determining the impact of the model on skill acquisition. Conclusion: The described model is simple and readily available allowing for accurate reproduction of the main steps and maneuvers that take place during laparoscopic common bile duct exploration, with the purpose of reducing failure and complications. PMID:20529526

Agenesis of the gallbladder with hypoplastic cystic duct diagnosed at laparoscopy.

PubMed

Kwon, A-Hon; Yanagimoto, Hiroaki; Matsui, Yoichi; Imamura, Atsushi

2006-08-01

An 86-year-old man was admitted to our department with complaints of intermittent upper abdominal pain. Ultrasonography of the abdomen showed dilated extrahepatic bile ducts containing stones; however, the gallbladder was not clearly identified. Magnetic resonance cholangiopancreatography showed dilated extrahepatic ducts and choledocholithiasis without gallbladder visualization. The stone extraction was performed with endoscopic sphincterotomy. Three-dimensional images using spiral-computed tomography after intravenous-infusion cholangiography clearly demonstrated an obstruction of the cystic duct. The patient was scheduled for laparoscopic cholecystectomy. At laparoscopy, the gallbladder fossa was not identified on the undersurface of the liver. Despite a thorough examination of the intrahepatic (left-sided within the lesser omentum), retroperitoneal, retrohepatic (within the falciform ligament), retroduodenal, and retropancreatic areas using laparoscopic ultrasonography, the gallbladder was not found. After careful dissection of the hepatoduodenal ligament, the dilated extrahepatic bile duct and a 1-cm length of hypoplastic cystic duct were found. Gallbladder agenesis is usually accompanied by the lack of the cystic duct. The present case is the third report of gallbladder agenesis with a patent or hypoplastic cystic duct.

Post-operative imaging in liver transplantation: State-of-the-art and future perspectives

PubMed Central

Girometti, Rossano; Como, Giuseppe; Bazzocchi, Massimo; Zuiani, Chiara

2014-01-01

Orthotopic liver transplantation (OLT) represents a major treatment for end-stage chronic liver disease, as well as selected cases of hepatocellular carcinoma and acute liver failure. The ever-increasing development of imaging modalities significantly contributed, over the last decades, to the management of recipients both in the pre-operative and post-operative period, thus impacting on graft and patients survival. When properly used, imaging modalities such as ultrasound, multidetector computed tomography, magnetic resonance imaging (MRI) and procedures of direct cholangiography are capable to provide rapid and reliable recognition and treatment of vascular and biliary complications occurring after OLT. Less defined is the role for imaging in assessing primary graft dysfunction (including rejection) or chronic allograft disease after OLT, e.g., hepatitis C virus (HCV) recurrence. This paper: (1) describes specific characteristic of the above imaging modalities and the rationale for their use in clinical practice; (2) illustrates main imaging findings related to post-OLT complications in adult patients; and (3) reviews future perspectives emerging in the surveillance of recipients with HCV recurrence, with special emphasis on MRI. PMID:24876739

[Postbular duodenal ulcer. Problems of diagnosis and treatment. Role of vagotomy in surgical treatment].

PubMed

Juvara, I; Rădulescu, D; Păcescu, E; Dragomirescu, C; Gavrilescu, S

1977-01-01

A number of 43 cases is presented, of post-bulbar duodenal ulcers in which surgery has been performed between 1965 and 1974, of which 30 were located in the first portion of the duodenum, in the postbulbar area, and 15 in the second portion, above the ampula of Vater. Problems of terminology and pathological anatomy are discussed, especially in connection with the symptomatology, complications, methodology of investigations and treatment of post-bulbar ulcers. The particular frequency is stressed, of complicated clinical forms, with stenosis and hemorrhagies, and a detailed description is made of atypical forms, with misleading, predominantly biliary or pancreatic symptomatology. Conditions are stressed, of the radiologic gastroduodenal exploration, of major importance in the diagnosis preceding surgery, as well as of pre- and intra-surgery cholangiography. The risk must be carefully evaluated, in the choice of the surgical method, and exeresis of the ulcer must be balanced with the risk of its continued presence. Priority should be given to th risks entailed by surgery. The choice solution in many cases is vagotomy associated to exclusion resection or to gastric derivation.

Successful treatment of limy bile syndrome extending to the common bile duct by laparoscopic cholecystectomy and common bile duct exploration: A case report and literature review.

PubMed

Masuda, Yuka; Mizuguchi, Yoshiaki; Kanda, Tomohiro; Furuki, Hiroyasu; Mamada, Yasuhiro; Taniai, Nobuhiko; Nakamura, Yoshiharu; Yoshioka, Masato; Matsushita, Akira; Kawano, Yoichi; Shimizu, Tetsuya; Uchida, Eiji

2017-02-01

Limy bile syndrome extending to the common bile duct (CBD) is a rare condition that lacks a standardized treatment. Laparoscopic cholecystectomy with laparoscopic choledocholithotomy by CBD exploration is preferred because it preserves the function of the sphincter of the Vater's papilla and allows treatment of both lesions. A 37-year-old man who was receiving entecavir for chronic hepatitis B developed right upper quadrant pain. Abdominal ultrasonography revealed a calcified shadow in the gallbladder and CBD. Abdominal imaging revealed a liquid-like material identified by a calcified shadow in two phases separated by a fluid-fluid level. Abdominal and 3-D drip infusion cholangiography CT showed stones in the gallbladder and CBD with limy bile. The patient underwent laparoscopic cholecystectomy and choledocholithotomy. Intraoperatively, white-yellow-colored bile and stones were drained from the CBD. A C-tube was placed. Postoperatively, remnant stones and radiopaque materials were absent. The stones comprised of >95% calcium carbonate. © 2016 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.

Intraductal ultrasonographic anatomy of biliary varices in patients with portal hypertension.

PubMed

Takagi, Tadayuki; Irisawa, Atsushi; Shibukawa, Goro; Hikichi, Takuto; Obara, Katsutoshi; Ohira, Hiromasa

2015-01-01

The term, portal biliopathy, denotes various biliary abnormalities, such as stenosis and/or dilatation of the bile duct, in patients with portal hypertension. These vascular abnormalities sometimes bring on an obstructive jaundice, but they are not clear which vessels participated in obstructive jaundice. The aim of present study was clear the bile ductal changes in patients with portal hypertension in hopes of establishing a therapeutic strategy for obstructive jaundice caused by biliary varices. Three hundred and thirty-seven patients who underwent intraductal ultrasound (IDUS) during endoscopic retrograde cholangiography for biliary abnormalities were enrolled. Portal biliopathy was analyzed using IDUS. Biliary varices were identified in 11 (2.7%) patients. IDUS revealed biliary varices as multiple, hypoechoic features surrounding the bile duct wall. These varices could be categorized into one of two groups according to their location in the sectional image of bile duct: epicholedochal and paracholedochal. Epicholedochal varices were identified in all patients, but paracholedochal varices were observed only in patients with extrahepatic portal obstruction. IDUS was useful to characterize the anatomy of portal biliopathy in detail.

Combined Endoscopic and Laparoscopic Management of Postcholecystectomy Mirizzi Syndrome from a Remnant Cystic Duct Stone: Case Report and Review of the Literature

PubMed Central

Amin, Arpit; Zhurov, Yuriy; Ibrahim, George; Maffei, Anthony; Giannone, Jonathan; Cerabona, Thomas; Kaul, Ashutosh

2016-01-01

Mirizzi syndrome has been defined in the literature as common bile duct obstruction resulting from calculi within Hartmann's pouch or cystic duct. We present a case of a 78-year-old female, who developed postcholecystectomy Mirizzi syndrome from a remnant cystic duct stone. Diagnosis of postcholecystectomy Mirizzi syndrome was made on endoscopic retrograde cholangiography (ERCP) performed postoperatively. The patient was treated with a novel strategy by combining advanced endoscopic and laparoscopic techniques in three stages as follows: Stage 1 (initial presentation): endoscopic sphincterotomy with common bile duct stent placement; Stage 2 (6 weeks after Stage 1): laparoscopic ultrasonography to locate the remnant cystic duct calculi followed by laparoscopic retrieval of the calculi and intracorporeal closure of cystic duct stump; Stage 3 (6 weeks after Stage 2): endoscopic removal of common bile duct stent along with performance of completion endoscopic retrograde cholangiogram. In addition, we have performed an extensive review of the various endoscopic and laparoscopic management techniques described in the literature for the treatment of postcholecystectomy syndrome occurring from retained cystic duct stones. PMID:27047698

Side-by-side placement of bilateral endoscopic metal stents for the treatment of postoperative biliary stricture.

PubMed

Kaino, Seiji; Sen-Yo, Manabu; Shinoda, Shuhei; Kawano, Michitaka; Harima, Hirofumi; Suenaga, Shigeyuki; Sakaida, Isao

2017-02-01

Postoperative biliary strictures are usually complications of cholecystectomy. Endoscopic plastic stent prosthesis is generally undertaken for treating benign biliary strictures. Recently, fully covered metal stents have been shown to be effective for treating benign distal biliary strictures. We present the case of a 53-year-old woman with liver injury in which imaging studies showed a common hepatic duct stricture. Endoscopic retrograde cholangiopancreatography also confirmed the presence of a common hepatic duct stricture. Temporally fully covered metal stents with dilated diameters of 6 mm were placed in a side-by-side fashion in the left and right hepatic ducts, respectively. We removed the stents 2 months after their placement. Subsequent cholangiography revealed an improvement in the biliary strictures. Although we were apprehensive about the fully covered metal stents obstructing the biliary side branches, we noted that careful placement of the bilateral metal stents did not cause any complications. Side-by-side deployment of bilateral endoscopic fully covered metal stents can be one of the safe and effective therapies for postoperative biliary stricture.

Cholangiocarcinoma in a middle-aged patient working at a printing plant.

PubMed

Tanaka, Shogo; Fukumoto, Nobusuke; Ohno, Kohichi; Tanaka, Sayaka; Ohsawa, Masahiko; Yamamoto, Takatsugu; Nakanuma, Yasuni; Kuboo, Shoji

2014-06-01

A 39-year-old male with elevated serum transferases consulted our hospital in September 2010. Since 1999, he had worked at a printing company using organic solvents. Cholangiography revealed stenosis of the left hepatic duct with peripheral dilation, stricture of the right hepatic duct, and irregularity of the extrahepatic bile duct. As a preoperative diagnosis of sclerosing cholangitis and cholangiocarcinoma was made, extended left hepatectomy with resection of the extrahepatic bile duct and anastomosis of the anterior and posterior branches of the bile duct and the jejunum (Roux-en Y reconstruction) were performed. A histological examination showed papillary carcinoma of the medial hepatic bile duct with intraductal growth, and biliary intraepithelial neoplasia-2/3 lesions from the medial hepatic bile duct to the right hepatic and the common bile ducts. Chronic cholangitis was shown around the tumors. Postoperatively, the patient was treated with adjuvant chemo-radiation, and he is doing well 30 months after the operation, without recurrence. Unknown causes, including exposure to organic solvents, might have induced chronic bile duct injury and contributed to the development of cholangiocarcinoma.

The emerging role for robotics in cholecystectomy: the dawn of a new era?

PubMed Central

Zaman, Jessica A.

2018-01-01

Though laparoscopic cholecystectomy (LC) was highly criticized in its early stages, it quickly grew to become a new standard of care and has revolutionized the field of general surgery. Now emerging robotic technology is making its way into the minimally invasive arena. Robotic cholecystectomy (RC) is often disparaged as a costly technology that can lead to increased operative times with outcomes that are quite similar to LC. However, this perspective is skewed as many existing studies were performed in the early phase of learning for this procedure. RC can be performed in a cost-effective manner as the volume of robotic procedures increases. In addition, improved visualization and capability to perform fluorescence cholangiography can improve the safety profile of cholecystectomy to a level that has not yet been achieved with conventional laparoscopy. Advanced simulation technology for robotic surgery, and newer single-site robotic platforms have the potential to further revolutionize this technology and lead to improved patient satisfaction. In this review, we will present current data, trends, and controversies in robotic-assisted cholecystectomy. PMID:29531940

Combined Endoscopic and Laparoscopic Management of Postcholecystectomy Mirizzi Syndrome from a Remnant Cystic Duct Stone: Case Report and Review of the Literature.

PubMed

Amin, Arpit; Zhurov, Yuriy; Ibrahim, George; Maffei, Anthony; Giannone, Jonathan; Cerabona, Thomas; Kaul, Ashutosh

2016-01-01

Mirizzi syndrome has been defined in the literature as common bile duct obstruction resulting from calculi within Hartmann's pouch or cystic duct. We present a case of a 78-year-old female, who developed postcholecystectomy Mirizzi syndrome from a remnant cystic duct stone. Diagnosis of postcholecystectomy Mirizzi syndrome was made on endoscopic retrograde cholangiography (ERCP) performed postoperatively. The patient was treated with a novel strategy by combining advanced endoscopic and laparoscopic techniques in three stages as follows: Stage 1 (initial presentation): endoscopic sphincterotomy with common bile duct stent placement; Stage 2 (6 weeks after Stage 1): laparoscopic ultrasonography to locate the remnant cystic duct calculi followed by laparoscopic retrieval of the calculi and intracorporeal closure of cystic duct stump; Stage 3 (6 weeks after Stage 2): endoscopic removal of common bile duct stent along with performance of completion endoscopic retrograde cholangiogram. In addition, we have performed an extensive review of the various endoscopic and laparoscopic management techniques described in the literature for the treatment of postcholecystectomy syndrome occurring from retained cystic duct stones.

Laparoscopic transcystic management of choledocholithiasis.

PubMed

Hyser, M J; Chaudhry, V; Byrne, M P

1999-07-01

Our objective was to review our community hospital experience with laparoscopic management of choledocholithiasis from 1991 to 1997. We performed a retrospective review of all case records of patients with choledocholithiasis managed surgically at St. Francis Hospital during the study period. Data regarding the history, presentation, investigations, operative details, and follow-up were recorded. Procedures were performed by multiple attending surgeons supervising surgical residents. All common bile duct explorations (CBDEs) were performed by a transcystic approach and followed routine cholangiography. In most cases, cystic duct dilatation over a guide wire was followed by transcystic CBDE with choledochoscopy. Stone extraction was accomplished through a combination of flushing, basket manipulation, fragmentation, retrieval, or advancement of stones through the ampulla. Data were analyzed using SPSS computer software, and P < 0.05 was considered statistically significant. During the period of study there were 1053 laparoscopic cholecystectomies with and without cholangiography and 100 total CBDE performed. Of these, 54/100 had an attempt at laparoscopic CBDE. There were 39 females and 15 males, with a median age of 52 years (range 14-88). Presentation included acute cholecystitis or biliary colic (63%), gallstone pancreatitis (20%), and jaundice or cholangitis (17%). Successful laparoscopic stone removal was achieved in 36 of 54 (67%) cases. Eighteen of the remainder (33%) were converted to an open procedure. Size, number, position of stones, technical difficulties in accessing the common bile duct, and patient factors contributed to open conversion. The rate of successful laparoscopic CBDE improved for each individual surgeon from an average of 22 per cent in the first half of the study period (1991-1994) to 87 per cent in the second half (1995-1997). There was no operative mortality. Significant morbidity in the laparoscopic group included one retained stone and

[National project for the clinical management of healthcare processes. The surgical treatment of cholelithiasis. Development of a clinical pathway].

PubMed

Villeta Plaza, R; Landa García, J I; Rodríguez Cuéllar, Elías; Alcalde Escribano, J; Ruiz López, Pedro

2006-11-01

Because surgical treatment of gallstones is highly prevalent, this topic is particularly suitable for a national study aimed at determining the most important indicators and developing a clinical pathway. To analyze the results obtained during the hospital phase of the process. To define the key indicators of the process. To design a clinical pathway for laparoscopic cholecystectomy. A multicenter, prospective, cross-sectional, descriptive study was performed of patients who consecutively underwent surgery for gallstones in 2002. The sample size calculated with data provided by the National Institute of Statistics was 304 patients, which was increased by 45% to compensate for possible losses. Inclusion criteria consisted of elective cholecystectomy for gallstones, without preoperative findings suggestive of common duct stones. A database was designed (Microsoft Access 2000) with 76 variables analyzed in each patient. Completed questionnaires were obtained from 37 hospitals with 426 patients. The mean age was 55.69 years, with a predominance of women (68.3%). The most frequent symptom was biliary colic (23%). A total of 20.3% of the patient had prior episodes of cholecystitis and 18% had a history of mild pancreatitis. Diagnosis was given by ultrasonography in 93.2% of the patients. Informed consent was provided by 93.2%. The intervention was performed on an inpatient basis in 96.1% and in the ambulatory setting in the remainder. Antibiotic and antithrombotic prophylaxis was administered in 78.9% and 75.1% of the patients respectively. The laparoscopic approach was used in 84.6%, with a conversion rate of 4.9%. Intraoperative cholangiography was performed in 17.8% of the patients and common duct stones were found in 7 patients. The most frequent complication was surgical wound infection (1.1%). Possible accidental lesion of the biliary tract occurred in 0.7% of the patients and was described as biliary fistula. There were four reinterventions: biliary fistula (1

[Contribution to the diagnosis of Dubin-Johnson syndrome].

PubMed

Lanosa, R A; Mazzini, O; Pietrángelo, C; Celia, E J; Monserrat, J M

1980-01-01

Eight patients with Dubin-Johnson's syndrome have been reported. It appoints the greatest casuistry about the theme in our country. The coincidence covers all the aspects of the disease except by the fact that we emphasize, as a matter of interest, that we were able to visualize the gallblader and the biliary tract through oral cholecystography visualize the gallblader and the biliary tract through oral cholecystography or through intravenous cholangiography, in all the patients who have been studied. It doesn't agree with the class descriptions in which these exams have negative results. So we point out the possibility of this disease's existence in spite of the radiographic visulaization of biliary tract, particularly in those patients with moderated hepatic pigment-deposit. Refering to pathologic anathomy we remark the importance in the search of the pigment charactiristic of the Dublin-Johnson's syndrome in all the liver histopathologic exams. Besides, we consider it valuable to make the Fontana-Masson coloration in those patients who present negative pigment reaction to iron. The systematic examinations of the cytoplasmatic pigments will allow us to diagnose the disease even in the cases with minimum and latent characteristics.

Ballooning of the papilla during contrast injection: the semaphore of a choledochocele.

PubMed

Kim, M H; Myung, S J; Lee, S K; Yoo, B M; Seo, D W; Lee, M H; Jung, S A; Kim, Y S; Min, Y I

1998-09-01

Choledochocele is a rare abnormality involving the intramural segment of the common bile duct. ERCP is essential to demonstrate a choledochocele. The aim of this study was to investigate the duodenoscopic and cholangiographic findings during ERCP. Over a 4-year period, 17 symptomatic patients (8 men, 9 women; age range 45 to 83 years) were identified as having choledochoceles. The diagnosis of choledochocele was made by both duodenoscopic and cholangiographic findings. As a characteristic duodenoscopic finding, the enlarged bulging papilla was noted in 8 patients (47%), whereas a normal-appearing papilla was noted in 9 patients (53%) before the injection of contrast media. However, in all 17 patients progressive enlargement or ballooning of the papilla was noted during contrast injection. The maximum diameter of the choledochocele, determined by cholangiography, was significantly larger (19 +/-4 mm) in patients with initially bulging papilla than in those with normal-appearing papilla (9+/-3 mm) (p < 0.05). Ballooning of the papilla during contrast injection may be a specific duodenoscopic finding for choledochocele. To avoid missing the diagnosis of a choledochocele, especially when it is small, it is important to watch the papilla carefully during contrast injection.

A case of an infant with congenital combined pituitary hormone deficiency and normalized liver histology of infantile cholestasis after hormone replacement therapy.

PubMed

Wada, Keisuke; Kobayashi, Hironori; Moriyama, Aisa; Haneda, Yasuhiro; Mushimoto, Yuichi; Hasegawa, Yuki; Onigata, Kazumichi; Kumori, Koji; Ishikawa, Noriyoshi; Maruyama, Riruke; Sogo, Tsuyoshi; Murphy, Lynne; Taketani, Takeshi

2017-01-01

Congenital combined pituitary hormone deficiency (CPHD) may present with cholestasis in the neonate or during early infancy. However, its precise mechanism is unknown. A 3-mo-old boy presented with cryptorchidism and hypoplastic scrotum after birth. Neonatal jaundice was noted but temporarily improved with phototherapy. Jaundice recurred at 2 mo of age. Elevated direct bilirubin (D-Bil) and liver dysfunction were found but cholangiography showed no signs of biliary atresia (BA). Liver biopsy findings showed giant cell formation of hepatocytes with hypoplastic bile ducts. Subsequent magnetic resonance imaging (MRI) of the head revealed a hypoplastic pituitary gland with an ectopic posterior lobe, and the patient was diagnosed with congenital CPHD based on decreased secretion of cortisol and GH by the pituitary anterior lobe load test. D-Bil levels promptly improved after hydrocortisone (HDC) replacement. We subsequently began replacement with levothyroxine (L-T 4 ) and GH, and liver histology showed normal interlobular bile ducts at 8 mo old. This is the first case report of proven histological improvement after hormone replacement therapy. This suggested that pituitary-mediated hormones, especially cortisol, might be involved in the development of the bile ducts.

A case of an infant with congenital combined pituitary hormone deficiency and normalized liver histology of infantile cholestasis after hormone replacement therapy

PubMed Central

Wada, Keisuke; Kobayashi, Hironori; Moriyama, Aisa; Haneda, Yasuhiro; Mushimoto, Yuichi; Hasegawa, Yuki; Onigata, Kazumichi; Kumori, Koji; Ishikawa, Noriyoshi; Maruyama, Riruke; Sogo, Tsuyoshi; Murphy, Lynne; Taketani, Takeshi

2017-01-01

Abstract. Congenital combined pituitary hormone deficiency (CPHD) may present with cholestasis in the neonate or during early infancy. However, its precise mechanism is unknown. A 3-mo-old boy presented with cryptorchidism and hypoplastic scrotum after birth. Neonatal jaundice was noted but temporarily improved with phototherapy. Jaundice recurred at 2 mo of age. Elevated direct bilirubin (D-Bil) and liver dysfunction were found but cholangiography showed no signs of biliary atresia (BA). Liver biopsy findings showed giant cell formation of hepatocytes with hypoplastic bile ducts. Subsequent magnetic resonance imaging (MRI) of the head revealed a hypoplastic pituitary gland with an ectopic posterior lobe, and the patient was diagnosed with congenital CPHD based on decreased secretion of cortisol and GH by the pituitary anterior lobe load test. D-Bil levels promptly improved after hydrocortisone (HDC) replacement. We subsequently began replacement with levothyroxine (L-T4) and GH, and liver histology showed normal interlobular bile ducts at 8 mo old. This is the first case report of proven histological improvement after hormone replacement therapy. This suggested that pituitary-mediated hormones, especially cortisol, might be involved in the development of the bile ducts. PMID:29026274

Clonorchis sinensis ova in bile juice cytology from a patient with severe hyperbilirubinemia and portal vein thrombosis.

PubMed

Fujiya, Keiichi; Ganno, Hideaki; Ando, Masayuki; Chong, Ja-Mun

2016-03-01

Infection with the trematode Clonorchis sinensis is the most common human fluke infection in East Asian populations. Although this infection is associated with obstructive jaundice or choledocholithiasis, portal vein thrombosis has not been reported. Here, we report the first case of a 60-year-old man who had both C. sinensis infection and portal vein thrombosis with severe hyperbilirubinemia (75.4 mg/dl). He initially presented with abdominal pain and jaundice. Computed tomography revealed gallstones, common bile duct calculus, and thrombus in the left main branch of the portal vein. A nasobiliary tube was inserted under endoscopic retrograde cholangiography. Cytology of the bile juice revealed many C. sinensis eggs. The abdominal pain and jaundice improved following choledocholithotomy and combination treatment with a chemotherapeutic agent and anti-coagulant. This case suggests that inflammation around the portal vein as a result of C. sinensis infection has the potential to evoke portal vein thrombosis. Such cases should be treated with both a chemotherapeutic agent and anti-coagulant therapy. In conclusion, the possibility of infection with C. sinensis should be considered in patients presenting with hyperbilirubinemia and portal vein thrombosis, particularly in East Asian populations. © 2015 Wiley Periodicals, Inc.

Efficacy of preoperative biliary tract decompression in patients with obstructive jaundice.

PubMed

Gundry, S R; Strodel, W E; Knol, J A; Eckhauser, F E; Thompson, N W

1984-06-01

Fifty consecutive matched patients with benign or malignant biliary tract obstruction were compared to determine the efficacy of preoperative percutaneous biliary drainage (PBD). Twenty-five patients underwent PBD for an average of nine days before operation; 25 patients underwent percutaneous transhepatic cholangiography ( PTHC ) followed immediately by operation. Serum bilirubin levels before PTHC were 16.5 +/- 7.6 mg/dL and 14.9 +/- 7.6 mg/dL in PBD and non-PBD groups, respectively. Serum bilirubin levels decreased to 6.5 +/- 6.2 mg/dL preoperatively in patients having PBD. One week after operation, bilirubin levels were 4.2 +/- 4.3 mg/dL and 9.0 +/- 5.2 mg/dL in the PBD and non-PBD groups, respectively. Major morbidity (sepsis, abscess, renal failure, or bleeding) occurred in two patients (8%) having PBD and in 13 patients (52%) without PBD. One patient (4%) with PBD, and five patients (20%) without PBD, died. The mean hospital stay was shorter for the PBD group. Preoperative PBD reduces operative mortality and morbidity and results in a more rapid resolution of hyperbilirubinemia during the postoperative period.

Pseudotumor of the distal common bile duct at endoscopic retrograde cholangiopancreatography

PubMed Central

Tan, Justin H.; Coakley, Fergus V; Wang, Zhen J.; Poder, Liina; Webb, Emily; Yeh, Benjamin M.

2010-01-01

Background Prior studies have described a pseudocalculus appearance in the distal common bile duct as a normal variant at cholangiography. The objective of this study is to describe the occurrence of pseudotumor in the distal common bile duct at endoscopic retrograde cholangiopancreatography (ERCP). Methods Nine patients who underwent ERCP between May 2004 and July 2008 were identified as having a transient eccentric mural-based filling defect in the distal common bile duct. A single reader systematically reviewed all studies and recorded the imaging findings. Results The mean diameter of the filling defect was 9 mm (range, 5 to 11). Eight patients had resolution of the filling defect during the same ERCP or on a subsequent ERCP, and in 2 of these patients the inferior border of the filling defect was not well visualized. The other patient underwent surgical resection of a presumed tumor with no evidence of malignancy on surgical pathology. Conclusion An eccentric mural-based filling defect in the distal common bile duct can be artifactual in nature and may reflect transient contraction of the sphincter of Oddi. Recognition of this pseudotumor may help avoid unnecessary surgery. PMID:21724120

Comparison of double-balloon and single-balloon enteroscope for therapeutic endoscopic retrograde cholangiography after Roux-en-Y small bowel surgery.

PubMed

De Koning, Michael; Moreels, Tom G

2016-08-22

Roux-en-Y reconstructive surgery excludes the biliopancreatic system from conventional endoscopic access. Balloon-assisted enteroscopy allows therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in these patients, avoiding rescue surgery. The objective of the current study is to compare success and complication rate of double-balloon (DBE) and single-balloon enteroscope (SBE) to perform ERCP in Roux-en-Y patients. Seventy three Roux-en-Y patients with suspected biliary tract pathology underwent balloon-assisted enteroscopy in a tertiary-care center. Retrospective analysis of 95 consecutive therapeutic ERCP procedures was performed to define and compare success and complication rate of DBE and SBE. Male-female ratio was 28/45 with a mean age of 58 ± 2 years. 30 (32 %) procedures were performed with DBE and 65 (68 %) with SBE. Overall ERCP success rate was 73 % for DBE and 75 % for SBE (P = 0.831). Failure was due to inability to reach or cannulate the intact papilla or bilioenteric anastomosis. Success rate was significantly higher when performed at the bilioenteric anastomosis (80 % success in 56 procedures) or at the intact papilla in short-limb Roux-en-Y (80 % in 15 procedures) as compared to the intact papilla in long-limb (58 % in 24 procedures; P = 0.040). Adverse event rates were 10 % (DBE) and 8 % (SBE) (P = 0.707) and mostly dealt with conservatively. ERCP after Roux-en-Y altered small bowel anatomy is feasible and safe using both DBE and SBE. Both techniques are equally competent with high success rates and acceptable adverse events rates. ERCP at the level of the intact papilla in long limb Roux-en-Y is less successful as compared to short-limb or bilioenteric anastomosis.

Clinical models are inaccurate in predicting bile duct stones in situ for patients with gallbladder.

PubMed

Topal, B; Fieuws, S; Tomczyk, K; Aerts, R; Van Steenbergen, W; Verslype, C; Penninckx, F

2009-01-01

The probability that a patient has common bile duct stones (CBDS) is a key factor in determining diagnostic and treatment strategies. This prospective cohort study evaluated the accuracy of clinical models in predicting CBDS for patients who will undergo cholecystectomy for lithiasis. From October 2005 until September 2006, 335 consecutive patients with symptoms of gallstone disease underwent cholecystectomy. Statistical analysis was performed on prospective patient data obtained at the time of first presentation to the hospital. Demonstrable CBDS at the time of endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiography (IOC) was considered the gold standard for the presence of CBDS. Common bile duct stones were demonstrated in 53 patients. For 35 patients, ERCP was performed, with successful stone clearance in 24 of 30 patients who had proven CBDS. In 29 patients, IOC showed CBDS, which were managed successfully via laparoscopic common bile duct exploration, with stone extraction at the time of cholecystectomy. Prospective validation of the existing model for CBDS resulted in a predictive accuracy rate of 73%. The new model showed a predictive accuracy rate of 79%. Clinical models are inaccurate in predicting CBDS in patients with cholelithiasis. Management strategies should be based on the local availability of therapeutic expertise.

Agenesis of the gallbladder: A dangerously misdiagnosed malformation

PubMed Central

Peloponissios, Nicolas; Gillet, Michel; Cavin, René; Halkic, Nermin

2005-01-01

Isolated agenesis of the gallbladder is a rare anomaly, often asymptomatic. However, one patient out of four presented with right upper abdominal pain, nausea, and fatty food intolerance. The condition is frequently mistaken with an excluded or sclero-atrophic gallbladder, regardless of the imaging modality used. Consequently, AG often leads to unnecessary and potentially dangerous laparoscopic surgery as described in a few case reports over the last 10 years. The aim of this study is to clarify the diagnostic and therapeutic approach of this unusual pathology. Two cases seen in our institutions were retrospectively reviewed, together with a review of the American and European literature. During laparoscopy, the absence of normal anatomical structures and the impossibility of pulling on the gallbladder to expose and dissect the triangle of Callot increases the risk of iatrogenic injury to biliary or portal structures. Depending on the experiment of the surgeon in laparoscopic procedure, this has to be taken into account to decide a conversion to laparotomy. A high index of suspicion is necessary when interpreting the radiological images. In case of doubt, a MRI-cholangiography is mandatory. Because of possible inherited transmission, relatives with a history of biliary symptoms should be investigated. PMID:16273658

Microbiological analysis of bile and its impact in critically ill patients with secondary sclerosing cholangitis.

PubMed

Voigtländer, Torsten; Leuchs, Ensieh; Vonberg, Ralf-Peter; Solbach, Philipp; Manns, Michael P; Suerbaum, Sebastian; Lankisch, Tim O

2015-05-01

Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is an emerging disease entity with unfavourable outcome. Our aim was to analyze the microbial spectrum in bile of patients with SSC-CIP and to evaluate the potential impact on the empiric antibiotic treatment in these patients. 169 patients (72 patients with SSC-CIP and 97 patients with primary sclerosing cholangitis (PSC)) were included in a prospective observational study between 2010 and 2013. Bile was obtained during endoscopic retrograde cholangiography (ERC) and microbiologically analyzed. Patients with SSC displayed a significantly different microbiological profile in bile. Enterococcus faecium, Pseudomonas aeruginosa and non-albicans species of Candida were more frequent in SSC compared to patients with PSC (p < 0.05). Patients with SSC showed a higher incidence of drug or multi-drug resistant organisms in bile (p = 0.001). The antimicrobial therapy was adjusted in 64% of patients due to resistance or presence of microorganisms not covered by the initial therapy regimen. Patients with SSC-CIP have a distinct microbial profile in bile. Difficult to treat organisms are frequent and an ERC with bile fluid collection for microbiological analysis should be considered in case of insufficient antimicrobial treatment. Copyright © 2015 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

White gauze test: a novel technique in preventing post-hepatectomy bile leak.

PubMed

Yugasaravanan, K; Affirul, C A; Zamri, Z; Azlanudin, A; Bong, J J

Post-hepatectomy bile leak may lead to undesired morbidity. Multiple methods have been employed to identify this leak but can be inconclusive and taxing. This novel white gauze test is a simple and reliable method. This is a prospective study performed from January 2010 until March 2011. All open hepatic resection were included. Dry white gauze is compressed onto the transected surface and observed for bile staining. The leaking duct is repaired immediately upon detection. The process is repeated until negative. Drain was removed on postoperative day-5. Post-operative bile leak is defined as: 1. Bilirubin concentration of the drain fluid is 3 times or higher than serum; 2. Presence of intra-abdominal bile collection on imaging and upon drainage; 3. Bile leak demonstrated on postoperative cholangiography. 42 patients were recruited. Seven (16.7%) patients were cirrhotic with Child-Pugh A. White gauze test were positive for intra-operative bile leaks in 29 patients (70%), which were primarily repaired. As a result, there was no postoperative bile leak in this series. One mortality was detected in this series due to postoperative pancreatic fistula and multi organ failure. The White Gauze Test is a useful method for the prevention of bile leakage after hepatic resection. It is safe, quick and cheap.

Post-cholecystectomy syndrome: spectrum of biliary findings at magnetic resonance cholangiopancreatography

PubMed Central

Girometti, R; Brondani, G; Cereser, L; Como, G; Del Pin, M; Bazzocchi, M; Zuiani, C

2010-01-01

Post-cholecystectomy syndrome (PCS) is defined as a complex of heterogeneous symptoms, consisting of upper abdominal pain and dyspepsia, which recur and/or persist after cholecystectomy. Nevertheless, this term is inaccurate, as it encompasses biliary and non-biliary disorders, possibly unrelated to cholecystectomy. Biliary manifestations of PCS may occur early in the post-operative period, usually because of incomplete surgery (retained calculi in the cystic duct remnant or in the common bile duct) or operative complications, such as bile duct injury and/or bile leakage. A later onset is commonly caused by inflammatory scarring strictures involving the sphincter of Oddi or the common bile duct, recurrent calculi or biliary dyskinesia. The traditional imaging approach for PCS has involved ultrasound and/or CT followed by direct cholangiography, whereas manometry of the sphincter of Oddi and biliary scintigraphy have been reserved for cases of biliary dyskinesia. Because of its capability to provide non-invasive high-quality visualisation of the biliary tract, magnetic resonance cholangiopancreatography (MRCP) has been advocated as a reliable imaging tool for assessing patients with suspected PCS and for guiding management decisions. This paper illustrates the rationale for using MRCP, together with the main MRCP biliary findings and diagnostic pitfalls. PMID:20335441

[A case of gastric metastasis and carcinomatous peritonitis of breast cancer with improved QOL by stent implantation and gemcitabine].

PubMed

Mukaibashi, Tomoe; Kojima, Izumi; Yamanaka, Ayumi; Nishiyama, Sachiko; Yamanaka, Takashi; Nakayama, Hirotaka; Matsuura, Hitoshi; Matsuzu, Kenichi; Inaba, Masaaki; Yoshida, Akira; Shimizu, Satoru

2013-08-01

A 73-year-old woman had undergone mastectomy for left breast cancer. One year later, bone metastasis was detected. After 7 years, the patient experienced epigastric discomfort, and gastrointestinal endoscopy showed stenosis of the pylorus and enlarged gastric folds. Stomach cancer was suspected at first, but gastric metastasis of breast cancer was diagnosed on the basis of endoscopic reexamination and computed tomography(CT)images. The patient could not drink water, and therefore, gastrointestinal stenting was performed, which facilitated ingestion to some extent. However, at the same time, an elevated serum carcinoembryonic antigen(CEA)level and jaundice were observed. Therefore, biliary tract stenosis due to carcinomatous peritonitis was diagnosed. We attempted to treat the jaundice with endoscopic retrograde cholangiopancreatography( ERCP)or percutaneous transhepatic cholangiography(PTCD), but the treatment was not successful, and an increase in ascites was noted. Accordingly, gemcitabine was administered as systemic therapy. As a result, ascites decreased and jaundice improved. Patients with gastric metastasis of breast cancer have poor quality of life(QOL)because of difficulties in ingestion or vomiting, and poor prognoses, because of frequent concurrent carcinomatous peritonitis. We experienced a case of gastric metastasis and carcinomatous peritonitis, and were able to improve the patient's QOL by gastrointestinal stenting and gemcitabine administration.

Novel Biliary Reconstruction Techniques During Liver Transplantation

PubMed Central

Carmody, Ian C.; Romano, John; Bohorquez, Humberto; Bugeaud, Emily; Bruce, David S.; Cohen, Ari J.; Seal, John; Reichman, Trevor W.; Loss, George E.

2017-01-01

Background: Biliary complications remain a significant problem following liver transplantation. Several surgical options can be used to deal with a significant size mismatch between the donor and recipient bile ducts during the biliary anastomosis. We compared biliary transposition to recipient biliary ductoplasty in cadaveric liver transplant. Methods: A total of 33 reconstructions were performed from January 1, 2005 to December 31, 2013. In the biliary transposition group (n=23), 5 reconstructions were performed using an internal stent (5 or 8 French pediatric feeding tube), and 18 were performed without. Of the 10 biliary ductoplasties, 2 were performed with a stent. All patients were managed with standard immunosuppression and ursodiol. Follow-up ranged from 2 months to 5 years. Results: No patients in the biliary transposition group required reoperation; 1 patient had an internal stent removed for recurrent unexplained leukocytosis, and 2 patients required endoscopic retrograde cholangiography and stent placement for evidence of stricture. Three anastomotic leaks occurred in the biliary ductoplasty group, and 2 patients in the biliary ductoplasty group required reoperation for biliary complications. Conclusion: Our results indicate that biliary reconstruction can be performed with either biliary transposition or biliary ductoplasty. These techniques are particularly useful when a significant mismatch in diameter exists between the donor and recipient bile ducts. PMID:28331447

A novel method of forceps biopsy improves the diagnosis of proximal biliary malignancies.

PubMed

Kulaksiz, Hasan; Strnad, Pavel; Römpp, Achim; von Figura, Guido; Barth, Thomas; Esposito, Irene; Schirmacher, Peter; Henne-Bruns, Doris; Adler, Guido; Stiehl, Adolf

2011-02-01

Tissue specimen collection represents a cornerstone in diagnosis of proximal biliary tract malignancies offering great specificity, but only limited sensitivity. To improve the tumor detection rate, we developed a new method of forceps biopsy and compared it prospectively with endoscopic transpapillary brush cytology. 43 patients with proximal biliary stenoses, which were suspect for malignancy, undergoing endoscopic retrograde cholangiography were prospectively recruited and subjected to both biopsy [using a double-balloon enteroscopy (DBE) forceps under a guidance of a pusher and guiding catheter with guidewire] and transpapillary brush cytology. The cytological/histological findings were compared with the final clinical diagnosis. 35 out of 43 patients had a malignant disease (33 cholangiocarcinomas, 1 hepatocellular carcinoma, 1 gallbladder carcinoma). The sensitivity of cytology and biopsy in these patients was 49 and 69%, respectively. The method with DBE forceps allowed a pinpoint biopsy of the biliary stenoses. Both methods had 100% specificity, and, when combined, 80% of malignant processes were detected. All patients with non-malignant conditions were correctly assigned by both methods. No clinically relevant complications were observed. The combination of forceps biopsy and transpapillary brush cytology is safe and offers superior detection rates compared to both methods alone, and therefore represents a promising approach in evaluation of proximal biliary tract processes.

Pancreatic acinar cell carcinoma extending into the common bile and main pancreatic ducts.

PubMed

Yamaguchi, Rin; Okabe, Yoshinobu; Jimi, Atsuo; Shiota, Koji; Kodama, Takahito; Naito, Yoshiki; Yasunaga, Masafumi; Kinoshita, Hisafumi; Kojiro, Masamichi

2006-10-01

Acinar cell carcinoma (ACC) of the pancreas is relatively rare, accounting for only approximately 1% of all exocrine pancreatic tumors. A 69-year-old man was found to have a mass lesion measuring approximately 4 cm in diameter in the pancreatic head on ultrasound, abdominal dynamic CT, and percutaneous transhepatic cholangiography. Magnetic resonance cholangiopancreatography showed defect of the lower common bile duct (CBD) due to obstruction by the tumor cast. Histopathologically, the pancreatic head tumor invaded the main pancreatic duct (MPD) and CBD with extension into the CBD in a form of tumor cast. The tumor cells consisted of a solid proliferation with abundant eosinophilic cytoplasm and round nuclei in an acinar and trabecular fashion. A 55-year-old man with upper abdominal pain and nausea, had a cystic lesion approximately 3 cm in size in the pancreatic tail on CT. Histopathologically, the tumor was encapsulated by fibrous capsule and had extensive central necrosis with solid areas in the tumor periphery, and invaded with extension into the MPD in a form of tumor cast. The tumor cells resembled acinar cells in solid growths. Two resected cases of ACC with unusual tumor extension into the CBD and the MPD, respectively, are reported.

Emerging Technologies for the Diagnosis of Perihilar Cholangiocarcinoma.

PubMed

Rizvi, Sumera; Eaton, John; Yang, Ju Dong; Chandrasekhara, Vinay; Gores, Gregory J

2018-05-01

The diagnosis of malignant biliary strictures remains problematic, especially in the perihilar region and in primary sclerosing cholangitis (PSC). Conventional cytology obtained during endoscopic retrograde cholangiography (ERC)-guided brushings of biliary strictures is suboptimal due to limited sensitivity, albeit it remains the gold standard with a high specificity. Emerging technologies are being developed and validated to address this pressing unmet patient need. Such technologies include enhanced visualization of the biliary tree by cholangioscopy, intraductal ultrasound, and confocal laser endomicroscopy. Conventional cytology can be aided by employing complementary and advanced cytologic techniques such as fluorescent in situ hybridization (FISH), and this technique should be widely adapted. Interrogation of bile and serum by examining extracellular vesicle number and cargo, and exploiting next-generation sequencing and proteomic technologies, is also being explored. Examination of circulating cell-free deoxyribonucleic acid (cfDNA) for differentially methylated regions is a promising test which is being rigorously validated. The special expertise required for these analyses has to date hampered their validation and adaptation. Herein, we will review these emerging technologies to inform the reader of the progress made and encourage further studies, as well as adaptation of validated approaches. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Reality named endoscopic ultrasound biliary drainage

PubMed Central

Guedes, Hugo Gonçalo; Lopes, Roberto Iglesias; de Oliveira, Joel Fernandez; Artifon, Everson Luiz de Almeida

2015-01-01

Endoscopic ultrasound (EUS) is used for diagnosis and evaluation of many diseases of the gastrointestinal (GI) tract. In the past, it was used to guide a cholangiography, but nowadays it emerges as a powerful therapeutic tool in biliary drainage. The aims of this review are: outline the rationale for endoscopic ultrasound-guided biliary drainage (EGBD); detail the procedural technique; evaluate the clinical outcomes and limitations of the method; and provide recommendations for the practicing clinician. In cases of failed endoscopic retrograde cholangiopancreatography (ERCP), patients are usually referred for either percutaneous transhepatic biliary drainage (PTBD) or surgical bypass. Both these procedures have high rates of undesirable complications. EGBD is an attractive alternative to PTBD or surgery when ERCP fails. EGBD can be performed at two locations: transhepatic or extrahepatic, and the stent can be inserted in an antegrade or retrograde fashion. The drainage route can be transluminal, duodenal or transpapillary, which, again, can be antegrade or retrograde [rendezvous (EUS-RV)]. Complications of all techniques combined include pneumoperitoneum, bleeding, bile leak/peritonitis and cholangitis. We recommend EGBD when bile duct access is not possible because of failed cannulation, altered upper GI tract anatomy, gastric outlet obstruction, a distorted ampulla or a periampullary diverticulum, as a minimally invasive alternative to surgery or radiology. PMID:26504507

Development and validation of real-time simulation of X-ray imaging with respiratory motion.

PubMed

Vidal, Franck P; Villard, Pierre-Frédéric

2016-04-01

We present a framework that combines evolutionary optimisation, soft tissue modelling and ray tracing on GPU to simultaneously compute the respiratory motion and X-ray imaging in real-time. Our aim is to provide validated building blocks with high fidelity to closely match both the human physiology and the physics of X-rays. A CPU-based set of algorithms is presented to model organ behaviours during respiration. Soft tissue deformation is computed with an extension of the Chain Mail method. Rigid elements move according to kinematic laws. A GPU-based surface rendering method is proposed to compute the X-ray image using the Beer-Lambert law. It is provided as an open-source library. A quantitative validation study is provided to objectively assess the accuracy of both components: (i) the respiration against anatomical data, and (ii) the X-ray against the Beer-Lambert law and the results of Monte Carlo simulations. Our implementation can be used in various applications, such as interactive medical virtual environment to train percutaneous transhepatic cholangiography in interventional radiology, 2D/3D registration, computation of digitally reconstructed radiograph, simulation of 4D sinograms to test tomography reconstruction tools. Copyright © 2015 Elsevier Ltd. All rights reserved.

Common Bile Duct Stricture After Laparoscopic Cholecystectomy: Case Report

PubMed

Zoričić, Ivan; Soldo, Ivo; Simović, Ivan; Sever, Marko; Bakula, Branko; Grbavac, Martin; Marušić, Marinko; Soldo, Anamaria

2017-03-01

Despite progress in laparoscopic surgery and increasing surgical experience, the incidence of bile duct injury during laparoscopic cholecystectomy fails to fall below 0.3%-0.6% and it is still higher than those recorded in the era of open cholecystectomy. Bile duct injuries belong to the most serious complications of abdominal surgery in general and often end up with liver transplantation as the only hope for cure. We present a case of a 78-year-old jaundiced male patient who sustained common hepatic duct injury during laparoscopic cholecystectomy eight months earlier. Exploratory laparotomy, ERCP and MRCP revealed a metal clip placed just below hepatic duct confluence and causing stricture of bile duct with dilatation of bile ducts proximal to the level of stenosis (Strasberg classification type E3 injury). Repair of the injury was performed by creating termino-lateral hepaticojejunostomy between the right and left hepatic ducts and retrocolic Roux en-Y jejunal limb. By presenting this case, we wish to emphasize the importance of timely conversion and execution of intraoperative cholangiography in all cases when identification of the structures of Calot’s triangle is not clear enough. Successful treatment of bile duct injury is only possible with joint approach of radiologist, gastroenterologist and experienced hepatobiliary surgeon.

Analysis of different ways of drainage for obstructive jaundice caused by hilar cholangiocarcinoma.

PubMed

Xu, Chuan; Lv, Peng-Hua; Huang, Xin-En; Wang, Shu-Xiang; Sun, Ling; Wang, Fu-An

2014-01-01

To evaluate the prognosis of different ways of drainage for patients with obstructive jaundice caused by hilar cholangiocarcinoma. During the period of January 2006- March 2012, percutaneous transhepatic catheter drainage (PTCD)/ percutaneous transhepatic biliary stenting (PTBS) were performed for 89 patients. According to percutaneous transhepatic cholangiography (PTC), external drainage was selected if the region of obstruction could not be passed by guide wire or a metallic stent was inserted if it could. External drainage was the first choice if infection was diagnosed before the procedure, and a metallic stent was inserted in one week after the infection was under control. Selection by new infections, the degree of bilirubin decrease, the change of ALT, the time of recurrence of obstruction, and the survival time of patients as the parameters was conducted to evaluate the methods of different interventional treatments regarding prognosis of patients with hilar obstruction caused by hilar cholangiocarcinoma. PTCD was conducted in 6 patients and PTBS in 7 (p<0.05). Reduction of bilirubin levels and ALT levels was obvious after the procedures (p<0.05). The average survival time with PTCD was 161 days and with PTBS was 243 days (p<0.05). With both drainage procedures for obstructive jaundice caused by hilar cholangiocarcinoma improvement in liver function was obvious. PTBS was found to be better than PTCD for prolonging the patient survival.

The "right" way is not always popular: comparison of surgeons' perceptions during laparoscopic cholecystectomy for acute cholecystitis among experts from Japan, Korea and Taiwan.

PubMed

Hibi, Taizo; Iwashita, Yukio; Ohyama, Tetsuji; Honda, Goro; Yoshida, Masahiro; Takada, Tadahiro; Han, Ho-Seong; Hwang, Tsann-Long; Shinya, Satoshi; Suzuki, Kenji; Umezawa, Akiko; Yoon, Yoo-Seok; Choi, In-Seok; Huang, Wayne Shih-Wei; Chen, Kuo-Hsin; Miura, Fumihiko; Watanabe, Manabu; Abe, Yuta; Misawa, Takeyuki; Nagakawa, Yuichi; Yoon, Dong-Sup; Jang, Jin-Young; Yu, Hee Chul; Ahn, Keun Soo; Kim, Song Cheol; Song, In Sang; Kim, Ji Hoon; Yun, Sung Su; Choi, Seong Ho; Jan, Yi-Yin; Sheen-Chen, Shyr-Ming; Shan, Yan-Shen; Ker, Chen-Guo; Chan, De-Chuan; Wu, Cheng-Chung; Toyota, Naoyuki; Higuchi, Ryota; Nakamura, Yoshiharu; Mizuguchi, Yoshiaki; Takeda, Yutaka; Ito, Masahiro; Norimizu, Shinji; Yamada, Shigetoshi; Matsumura, Naoki; Shindoh, Junichi; Sunagawa, Hiroki; Gocho, Takeshi; Hasegawa, Hiroshi; Rikiyama, Toshiki; Sata, Naohiro; Kano, Nobuyasu; Kitano, Seigo; Tokumura, Hiromi; Yamashita, Yuichi; Watanabe, Goro; Nakagawa, Kunitoshi; Kimura, Taizo; Yamakawa, Tatsuo; Wakabayashi, Go; Endo, Itaru; Miyazaki, Masaru; Yamamoto, Masakazu

2017-01-01

Generally, surgeons' perceptions of surgical safety are based on experience and institutional policy. Our recent pilot survey demonstrated that the acceptable duration of surgery and criteria for open conversion during laparoscopic cholecystectomy (LC) vary among workplaces. A web-based survey was distributed to 554 expert LC surgeons in Japan, Korea, and Taiwan. The questionnaire covered LC experience, safety measures and recognition of landmarks, decision-making regarding conversion to open/partial cholecystectomy and the implications of this decision. Overall responses were compared among nations, and then stratified by LC experience level (lifetime cases 200-499, 500-999, and ≥1,000). The response rate was 92.6% (513/554); 67 surgeons with ≤199 LCs were excluded, and responses from 446 surgeons were analyzed. We observed significant differences among nations on almost all questions. Differences that remained after stratification by LC experience were on questions related to acceptable duration of surgery, adoption rates of intraoperative cholangiography, the "critical view of safety" technique, identification of Rouvière's sulcus, recognition of the SS-Inner layer theory, and intraoperative judgment to abandon conventional LC. Even among experts, surgeons' perceptions during LC are workplace-dependent. A novel grading system of surgical difficulty and standardized LC procedures are paramount to generate high-level evidence. © 2016 Japanese Society of Hepato-Biliary-Pancreatic Surgery.

Prior minimal endoscopic sphincterotomy to prevent pancreatitis related to endoscopic balloon sphincteroplasty

PubMed Central

Kanazawa, Ryo; Sai, Jin Kan; Ito, Tomoyasu; Miura, Hiroko; Ishii, Shigeto; Saito, Hiroaki; Tomishima, Ko; Shimizu, Ryo; Sato, Koki; Hayashi, Manabu; Watanabe, Sumio; Shiina, Shuichiro

2016-01-01

AIM To investigate the efficacy of prior minimal endoscopic sphincterotomy (EST) to prevent pancreatitis related to endoscopic balloon sphincteroplasty (EBS). METHODS After bile duct access was gained and cholangiogram confirmed the presence of stones < 8 mm in the common bile duct at endoscopic retrograde cholangiography, patients were subjected to minimal EST (up to one-third of the size the papilla) plus 8 mm EBS (EST-EBS group). The incidence of pancreatitis and the difference in serum amylase level after the procedure were examined and compared with those associated with 8-mm EBS alone in 32 patients of historical control (control group). RESULTS One hundred and five patients were included in the EST-EBS group, and complete stone removal was accomplished in all of them. The difference in serum amylase level after the procedure was - 25.0 (217.9) IU/L in the EST-EBS group and this value was significantly lower than the 365.5 (576.3) IU/L observed in the control group (P < 0.001). The incidence of post-procedure pancreatitis was 0% (0/105) in the EST-EBS group and 15.6% (5/32) in the control group (P < 0.001). CONCLUSION Prior minimal EST might be useful to prevent the elevation of serum amylase level and the occurrence of pancreatitis related to EBS. PMID:27803773

Percutaneous transhepatic vs. endoscopic retrograde biliary drainage for suspected malignant hilar obstruction: study protocol for a randomized controlled trial.

PubMed

Al-Kawas, Firas; Aslanian, Harry; Baillie, John; Banovac, Filip; Buscaglia, Jonathan M; Buxbaum, James; Chak, Amitabh; Chong, Bradford; Coté, Gregory A; Draganov, Peter V; Dua, Kulwinder; Durkalski, Valerie; Elmunzer, B Joseph; Foster, Lydia D; Gardner, Timothy B; Geller, Brian S; Jamidar, Priya; Jamil, Laith H; Keswani, Rajesh N; Khashab, Mouen A; Lang, Gabriel D; Law, Ryan; Lichtenstein, David; Lo, Simon K; McCarthy, Sean; Melo, Silvio; Mullady, Daniel; Nieto, Jose; Bayne Selby, J; Singh, Vikesh K; Spitzer, Rebecca L; Strife, Brian; Tarnaksy, Paul; Taylor, Jason R; Tokar, Jeffrey; Wang, Andrew Y; Williams, April; Willingham, Field; Yachimski, Patrick

2018-02-14

The optimal approach to the drainage of malignant obstruction at the liver hilum remains uncertain. We aim to compare percutaneous transhepatic biliary drainage (PTBD) to endoscopic retrograde cholangiography (ERC) as the first intervention in patients with cholestasis due to suspected malignant hilar obstruction (MHO). The INTERCPT trial is a multi-center, comparative effectiveness, randomized, superiority trial of PTBD vs. ERC for decompression of suspected MHO. One hundred and eighty-four eligible patients across medical centers in the United States, who provide informed consent, will be randomly assigned in 1:1 fashion via a web-based electronic randomization system to either ERC or PTBD as the initial drainage and, if indicated, diagnostic procedure. All subsequent clinical interventions, including crossover to the alternative procedure, will be dictated by treating physicians per usual clinical care. Enrolled subjects will be assessed for successful biliary drainage (primary outcome measure), adequate tissue diagnosis, adverse events, the need for additional procedures, hospitalizations, and oncological outcomes over a 6-month follow-up period. Subjects, treating clinicians and outcome assessors will not be blinded. The INTERCPT trial is designed to determine whether PTBD or ERC is the better initial approach when managing a patient with suspected MHO, a common clinical dilemma that has never been investigated in a randomized trial. ClinicalTrials.gov, Identifier: NCT03172832 . Registered on 1 June 2017.

Outcomes of endo-radiological approach to management of bile leakage after right lobe living donor liver transplantation.

PubMed

Chok, Kenneth S H; Chan, Albert C Y; Sharr, William W; Cheung, Tan To; Fung, James Y Y; Chan, See Ching; Lo, Chung Mau

2016-01-01

Bile leakage is a major complication after right lobe living donor liver transplantation (RLDLT). It can result in significant morbidities and, occasionally, mortalities. Endo-radiology is a non-surgical means that has been used to manage this complication. This study reviews the outcomes of the endo-radiological approach to the management of bile leakage after RLDLT with duct-to-duct anastomosis (DDA) at a high-volume center. A retrospective study was conducted on all adult patients who received RLDLT at our center between January 2001 and December 2013. There were 496 RLDLTs performed during the study period. Only patients who had DDA as the only bile duct reconstruction method were included in the study. Twelve (3.7%) out of the 328 study subjects developed bile leakage after RLDLT. Six out of these 12 patients were successfully treated with the endo-radiological approach without the need for laparotomy. They had endoscopic retrograde cholangiography with stenting followed by percutaneous drainage of biloma. One of the 12 patients died from recurrence of hepatocellular carcinoma 37 months after transplantation. The remaining 11 patients are all alive. The endo-radiological approach should be the first-line management for bile leakage for selected patients with DDA as the bile duct reconstruction method. © 2015 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.

Imaging and radiological interventions in extra-hepatic portal vein obstruction

PubMed Central

Pargewar, Sudheer S; Desai, Saloni N; Rajesh, S; Singh, Vaibhav P; Arora, Ankur; Mukund, Amar

2016-01-01

Extrahepatic portal vein obstruction (EHPVO) is a primary vascular condition characterized by chronic long standing blockage and cavernous transformation of portal vein with or without additional involvement of intrahepatic branches, splenic or superior mesenteric vein. Patients generally present in childhood with multiple episodes of variceal bleed and EHPVO is the predominant cause of paediatric portal hypertension (PHT) in developing countries. It is a pre-hepatic type of PHT in which liver functions and morphology are preserved till late. Characteristic imaging findings include multiple parabiliary venous collaterals which form to bypass the obstructed portal vein with resultant changes in biliary tree termed portal biliopathy or portal cavernoma cholangiopathy. Ultrasound with Doppler, computed tomography, magnetic resonance cholangiography and magnetic resonance portovenography are non-invasive techniques which can provide a comprehensive analysis of degree and extent of EHPVO, collaterals and bile duct abnormalities. These can also be used to assess in surgical planning as well screening for shunt patency in post-operative patients. The multitude of changes and complications seen in EHPVO can be addressed by various radiological interventional procedures. The myriad of symptoms arising secondary to vascular, biliary, visceral and neurocognitive changes in EHPVO can be managed by various radiological interventions like transjugular intra-hepatic portosystemic shunt, percutaneous transhepatic biliary drainage, partial splenic embolization, balloon occluded retrograde obliteration of portosystemic shunt (PSS) and revision of PSS. PMID:27358683

[Laparoscopic therapy of choledocholithiasis].

PubMed

Beller, S; Bodner, W; Szinicz, G

1995-01-01

In the period November 1991 to October 1993 altogether 418 patients underwent laparoscopic cholecystectomy in our unit. Routine intraoperative cholangiography, a prerequisite for diagnosing choledocholithiasis, was successful in 99.3% of cases. 38 patients were found to have common bile duct calculi and their management and follow up are reported in this study. In 36 cases stones were successfully eliminated by means of the laparoscopic procedure, via the cystic duct in 22 cases and by choledochotomy in 14 cases. One patient required postoperative endoscopic papillotomy, and in the remaining case surgical management was changed to classical laparotomy and open choledochotomy. Postoperative complications occurred in five cases. One patient suffering from bacterial peritonitis underwent laparotomy on the 9th postoperative day, another with postoperative bleeding from the cystic artery was relaparoscopied on the same day as the minimal invasive procedure. One patient developed a liver abscess three weeks after operation, requiring drainage with the aid of ultrasound. A superficial wound infection in one patient and biliary leakage after removal of the T-tube in another patient both healed spontaneously. Our results are similar to those obtained with other therapeutic concepts. Because the papilla of Vater remains intract in minimal invasive surgery, which causes relatively little stress to the patient, as well as considering the economic advantages of a single-step procedure, this management strategy can be recommended as a valuable alternative procedure.

Extrahepatic duct injury in blunt trauma: two case reports and a literature review.

PubMed

Zago, Thiago Messias; Pereira, Bruno Monteiro Tavares; Calderan, Thiago Rodrigues Araujo; Hirano, Elcio Shiyoiti; Fraga, Gustavo Pereira

2014-08-01

Traumatic injuries of the extrahepatic biliary tract are rare. Associated injuries are usually responsible for immediate indication for surgical treatment, the time when an injury to the extrahepatic biliary ducts may be diagnosed. However, missed injuries are often common. The primary aim of this paper is to describe the clinical features, diagnosis, treatment, and outcome of two patients with left hepatic duct injury after blunt abdominal trauma. As a secondary objective, a literature review is presented. The two cases presented in this study are as follows: (1) A young male, involved in a motor vehicle crash, was admitted with blunt hepatic trauma in a general hospital. Endoscopic retrograde cholangiography was conducted 3 weeks later and revealed a large leakage at the left hepatic duct. Exploratory laparotomy was performed 26 days after the initial traumatic event and identified a complete section of the left hepatic duct, treated with anastomosis. (2) A male fell from a height. On exploratory laparotomy, a 30 % partial injury of the left hepatic duct was found in addition to hemoperitoneum, liver injury, gallbladder detachment together with cystic duct rupture, retroperitoneal hematoma to the right, and cecum hematoma. A high level of suspicion is necessary to identify injuries to the hepatic ducts. Early diagnosis that occurs during laparotomy due to associated injuries is important to reduce complications.

Primary cancers of extrahepatic biliary passages

DOE Office of Scientific and Technical Information (OSTI.GOV)

Mittal, B.; Deutsch, M.; Iwatsuki, S.

The records of 22 patients with cancers of extrahepatic biliary passages (EHBP) were analyzed to understand their natural histories and patterns of failure and to evaluate the effectiveness of various treatments. None of the preoperative investigations consistently defined the entire extent of tumor. Percutaneous transhepatic cholangiography (PTHC) was the most helpful (100%) in accurately defining the site of ductal obstruction. Computed tomography was helpful in diagnosing liver metastases in 53% and primary tumor mass in 23% of patients. The most common sites of tumor failure or persistence were: liver (67%), tumor bed (56%), peritoneum (22%), porta hepatis and lymph nodesmore » (17%). The median survival for the entire group was 6.8 months. Surgery plays an important role in managing these tumors and in defining tumor extent for subsequent adjuvant irradiation. Patients receiving radiation doses greater than or equal to 70 TDF had a longer median survival (11 months) than patients receiving less than 70 TDF (4.4 months). All three patients, who were alive and free of disease greater than 1 year, received radiation doses greater than or equal to 70 TDF. From the data, it is difficult to comment on the effectiveness of chemotherapy. The authors have made suggestions regarding radiation volume and doses to various structures. The need for entering these patients into multi-institutional clinical trials is stressed.« less

Primary cancers of extrahepatic biliary passages.

PubMed

Mittal, B; Deutsch, M; Iwatsuki, S

1985-04-01

We analyzed the records of 22 patients with cancers of extrahepatic biliary passages (EHBP) to understand their natural histories and patterns of failure and to evaluate the effectiveness of various treatments. None of the preoperative investigations consistently defined the entire extent of tumor. Percutaneous transhepatic cholangiography (PTHC) was the most helpful (100%) in accurately defining the site of ductal obstruction. Computed tomography was helpful in diagnosing liver metastases in 53% and primary tumor mass in 23% of patients. The most common sites of tumor failure or persistence were: liver (67%), tumor bed (56%), peritoneum (22%), porta hepatis and lymph nodes (17%). The median survival for the entire group was 6.8 months. Surgery plays an important role in managing these tumors and in defining tumor extent for subsequent adjuvant irradiation. Patients receiving radiation doses greater than or equal to 70 TDF had a longer median survival (11 months) than patients receiving less than 70 TDF (4.4 months). All three patients, who were alive and free of disease greater than 1 year, received radiation doses greater than or equal to 70 TDF. From our data, it is difficult to comment on the effectiveness of chemotherapy. We have made suggestions regarding radiation volume and doses to various structures. The need for entering these patients into multi-institutional clinical trials is stressed.

Biliary complications after orthotopic liver transplantation from donors after cardiac death: broad spectrum of disease.

PubMed

Abou Abbass, A; Abouljoud, M; Yoshida, A; Kim, D Y; Slater, R; Hundley, J; Kazimi, M; Moonka, D

2010-11-01

Donation-after-death liver transplantation (DCD-LT) carries higher complication rates compared with donation-after-brain death liver transplantation (DBD-LT). In this report we describe our experience with biliary complications in DCD-LT with emphasis on anatomical patterns and outcomes. We performed retrospective review of patients' medical records from August 2004 to December 2008, during which time total of 26 DCD-LTs were performed. Mean follow-up was 29 months (range 3 to 51 months). Biliary complications occurred in 12 patients (46%), of whom 9 were related to DCD (35%). Four patients had more than 1 biliary complication, and 4 had concomitant arterial problems (stricture/thrombosis). Treatment of complications included: ERCP (n = 5, 3 resolved), conversion to roux (n = 5, 2 resolved), revision of roux (n = 1), percutaneous transhepatic cholangiography (n = 1), artery revision (n = 3). Three patients with casts had operative extraction of casts depicting a mummified biliary tree; histology showed casts and fibrosis and anastomotic suture material. Six patients underwent retransplantation (23%). Among retransplanted patients, 2 deaths occurred (7.7%). Our experience with DCD-LT reveals a high prevalence of biliary complications with a new and wide spectrum of clinicopathologic findings. Better strategies for prevention of these unique biliary complications are needed to better justify the added risks and costs for performance of DCD-LT. Copyright © 2010 Elsevier Inc. All rights reserved.

Liver Function Assessment by Magnetic Resonance Imaging.

PubMed

Ünal, Emre; Akata, Deniz; Karcaaltincaba, Musturay

2016-12-01

Liver function assessment by hepatocyte-specific contrast-enhanced magnetic resonance imaging is becoming a new biomarker. Liver function can be assessed by T1 mapping (reduction rate) and signal intensity measurement (relative enhancement ratio) before and after GD-EOB-DTPA (gadoxetic acid) administration, as alternative to Tc-99m galactosyl serum albumin scintigraphy, 99m Tc-labeled mebrofenin scintigraphy, and indocyanine green clearance test. Magnetic resonance imaging assessment of liver function can enable diagnosis of cirrhosis, nonalcoholic fatty liver disease associated fibrosis and steatohepatitis, primary sclerosing cholangitis, toxic hepatitis, and chemotherapy and radiotherapy-related changes, which may be only visible on hepatobiliary phase images. Simple visual assessment of signal intensity at hepatobiliary phase images is important for the diagnosis of different patterns of liver dysfunction including diffuse, lobar, segmental, and subsegmental forms. Furthermore, preoperative assessment of liver function is feasible before oncologic hepatic surgery, which may be important to prevent posthepatectomy liver failure and to estimate future remnant volume. Functional magnetic resonance cholangiography obtained by T1-weighted images at hepatobiliary phase can allow diagnosis of acalculous cholecystitis, biliary leakage, bile reflux to the stomach, sphincter of oddi dysfunction, and lesions with communication to biliary tree. Functional information can be easily obtained when Gd-EOB-DTPA is used for liver magnetic resonance imaging. Copyright © 2016 Elsevier Inc. All rights reserved.

Value of MRI in three patients with major vascular injuries after laparoscopic cholecystectomy.

PubMed

Ragozzino, Alfonso; Lassandro, Francesco; De Ritis, Rosaria; Imbriaco, Massimo

2007-11-01

The aim of this study was to describe three cases of major vascular injuries after laparoscopic cholecystectomy depicted on magnetic resonance (MR) examination. Three female patients (mean age, 32 years; range, 22-39 years) were studied with clinical suspicion of bilio-vascular injuries after laparoscopic cholecystectomy. All MR examinations were performed within 24 h after the laparoscopic procedure. MR imaging was evaluated for major vascular injuries involving the arterial and portal venous system, for bile duct discontinuity, presence or absence of biliary dilation, stricture, excision injury, free fluid and collections. In the first patient, a type-IV Bismuth injury with associated intrahepatic bile ducts dilation was observed. Contrast-enhanced MR revealed lack of enhancement in the right hepatic lobe due to occlusion of the right hepatic artery and the right portal branch. This patient underwent right hepatectomy with hepatico-jejunostomy. In the other two cases, no visualization of the right hepatic artery and the right portal branch was observed on MR angiography. In the first case, the patient underwent right hepatectomy; in the second case, because of stable liver condition, the patient was managed conservatively. MR imaging combined with MR angiography and MR cholangiography can be performed emergently in patients with suspicion of bilio-vascular injury after laparoscopic cholecystectomy allowing the simultaneous evaluation of the biliary tree and the hepatic vascular supply that is essential for adequate treatment planning.

Repair of a mal-repaired biliary injury: a case report.

PubMed

Aldumour, Awad; Aseni, Paolo; Alkofahi, Mohmmad; Lamperti, Luca; Aldumour, Elias; Girotti, Paolo; De Carlis, Luciano-Gregorio

2009-05-14

Iatrogenic bile-duct injury post-laparoscopic cholecystectomy remains a major serious complication with unpredictable long-term results. We present a patient who underwent laparoscopic cholecystectomy for gallstones, in which the biliary injury was recognized intraoperatively. The surgical procedure was converted to an open one. The first surgeon repaired the injury over a T-tube without recognizing the anatomy and type of the biliary lesion, which led to an unusual biliary mal-repair. Immediately postoperatively, the abdominal drain brought a large amount of bile. A T-tube cholangiogram was performed. Despite the contrast medium leaking through the abdominal drain, the mal-repair was unrecognized. The patient was referred to our hospital for biliary leak. Ultrasound and cholangiography was repeated, which showed an unanatomical repair (right to left hepatic duct anastomosis over the T-tube), with evidence of contrast medium coming out through the abdominal drain. Eventually the patient was subjected to a definitive surgical treatment. The biliary continuity was re-established by a Roux-en-Y hepatico-jejunostomy, over transanastomotic external biliary stents. The patient is now doing well 4 years after the second surgical procedure. In reviewing the literature, we found a similar type of injury but we did not find a similar surgical mal-repair. We propose an algorithm for the treatment of early and late biliary injuries.

Repair of a mal-repaired biliary injury: A case report

PubMed Central

Aldumour, Awad; Aseni, Paolo; Alkofahi, Mohmmad; Lamperti, Luca; Aldumour, Elias; Girotti, Paolo; Carlis, Luciano Gregorio De

2009-01-01

Iatrogenic bile-duct injury post-laparoscopic cholecystectomy remains a major serious complication with unpredictable long-term results. We present a patient who underwent laparoscopic cholecystectomy for gallstones, in which the biliary injury was recognized intraoperatively. The surgical procedure was converted to an open one. The first surgeon repaired the injury over a T-tube without recognizing the anatomy and type of the biliary lesion, which led to an unusual biliary mal-repair. Immediately postoperatively, the abdominal drain brought a large amount of bile. A T-tube cholangiogram was performed. Despite the contrast medium leaking through the abdominal drain, the mal-repair was unrecognized. The patient was referred to our hospital for biliary leak. Ultrasound and cholangiography was repeated, which showed an unanatomical repair (right to left hepatic duct anastomosis over the T-tube), with evidence of contrast medium coming out through the abdominal drain. Eventually the patient was subjected to a definitive surgical treatment. The biliary continuity was re-established by a Roux-en-Y hepatico-jejunostomy, over transanastomotic external biliary stents. The patient is now doing well 4 years after the second surgical procedure. In reviewing the literature, we found a similar type of injury but we did not find a similar surgical mal-repair. We propose an algorithm for the treatment of early and late biliary injuries. PMID:19437572

Does an isolated benign choledochal stricture hide a PSC?

PubMed

De Angelis, Paola; Tambucci, Renato; Romeo, Erminia; Rea, Francesca; Caloisi, Claudia; Caldaro, Tamara; di Abriola, Giovanni Federici; Foschia, Francesca; Torroni, Filippo; Monti, L; Dall'Oglio, Luigi

2013-05-01

Strictures of the extra-hepatic biliary tree are rare in children and have a benign non-traumatic inflammatory origin or are related to idiopathic fibrosing pancreatitis. Primary sclerosing cholangitis (PSC) can manifest as multiple biliary strictures or as a single dominant stricture. We describe the presentation, treatment, and outcome of six cases of isolated benign choledochal stricture (IBCS). All patients underwent magnetic resonance cholangiography (MRC). Five patients underwent diagnostic and therapeutic ERCP, and 4 patients underwent intra-choledochal mini-probe EUS and biopsy. Colonoscopy was performed in suspected ulcerative colitis (UC). We report 6 patients (mean age at diagnosis: four males, 12.1 years; two females, 14.2 years) with IBCS. Clinical onset included 3 cases of acute biliary pancreatitis and obstructive jaundice, one obstructive jaundice, one cholestasis, and one pancreatitis. At diagnosis, MRC confirmed IBCS in all patients. Biliary sphincterotomy, stricture dilation, and stenting were performed in 4 patients. One child underwent hepaticojejunostomy for a type I choledocal cyst. During follow-up (mean: 21 months; range: 1-3 years), all patients were asymptomatic. Four patients developed UC (three pancolitis, one descending colitis). One child developed PSC. IBCS can be successfully treated by therapeutic ERCP. The occurrence of UC could suggest that IBCS is a form of PSC. Copyright © 2013 Elsevier Inc. All rights reserved.

Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi: a randomized trial.

PubMed

Nathanson, Leslie K; O'Rourke, Nicholas A; Martin, Ian J; Fielding, George A; Cowen, Alistair E; Roberts, Roderick K; Kendall, Bradley J; Kerlin, Paul; Devereux, Benedict M

2005-08-01

Prospectively evaluate whether for patients having laparoscopic cholecystectomy with failed trans-cystic duct clearance of bile duct (BD) stones they should have laparoscopic choledochotomy or postoperative endoscopic retrograde cholangiography (ERCP). Clinical management of BD stones found at laparoscopic cholecystectomy in the last decade has focused on pre-cholecystectomy detection with ERCP clearance in those with suspected stones. This clinical algorithm successfully clears the stones in most patients, but no stones are found in 20% to 60% of patients and rare unpredictably severe ERCP morbidity can result in this group. Our initial experience of 300 consecutive patients with fluoroscopic cholangiography and intraoperative clearance demonstrated that, for the pattern of stone disease we see, 66% of patients' BD stones can be cleared via the cystic duct with dramatic reduction in morbidity compared to the 33% requiring choledochotomy or ERCP. Given the limitations of the preoperative approach to BD stone clearance, this trial was designed to explore the limitations, for patients failing laparoscopic trans-cystic clearance, of laparoscopic choledochotomy or postoperative ERCP. Across 7 metropolitan hospitals after failed trans-cystic duct clearance, patients were intraoperatively randomized to have either laparoscopic choledochotomy or postoperative ERCP. Exclusion criteria were: ERCP prior to referral for cholecystectomy, severe cholangitis or pancreatitis requiring immediate ERCP drainage, common BD diameter of less than 7 mm diameter, or if bilio-enteric drainage was required in addition to stone clearance. Drain decompression of the cleared BD was used in the presence of cholangitis, an edematous ampulla due to instrumentation or stone impaction and technical difficulties from local inflammation and fibrosis. The ERCP occurred prior to discharge from hospital. Mechanical and extracorporeal shockwave lithotripsy was available. Sphincter balloon dilation as an

[Separate entrance of the main pancreatic duct and of the common bile duct: is it synonymous with easy retrograde cholangiography using endoscopic approach?

PubMed

Benatta, Mohammed Amine

2018-01-01

This study focused on endoscopic examination of a prominent papilla which showed two separate orifices revealing separate entrance of the main pancreatic duct and of the common bile duct (A). This was the most rare anatomoendoscopic variation, accounting for only 10% of retrograde cholangiopancreatographies using endoscopic approach (ERCP). However, it facilitated selective biliary catheterization (SBC) in our patient, as one might have expected. Papilla had a pseudo polypoid appearance and a biliary orifice (BO) at the right angle toward the duodenal wall; hence this was a more difficult approach than that via the pancreatic orifice (PO) which, on the other hand, required undesired pancreatic catheterization (B). As SBC was the approach we decided to adopt, the special techniques to consider in this particular case were: transpancreatic sphincterotomy (TPS) alone or TPS after implantation of a pancreatic stent (PS). We opted for the second technique (STP + PS) and we noticed that the implantation of a PS resulted in better BO visualization (C). We could perform SBC without recourse to TPS. In this specific case, as in other cases of difficult SBC in our practice, PS has proven effectiveness.

Comparison of infection between internal-external and external percutaneous transhepatic biliary drainage in treating patients with malignant obstructive jaundice.

PubMed

Xu, Chuan; Huang, Xin-En; Wang, Shu-Xiang; Lv, Peng-Hua; Sun, Ling; Wang, Fu-An

2015-01-01

Percutaneous transhepatic biliary drainage (PTBD) is a form of palliative care for patients with malignant obstructive jaundice. We here compared the infection incidence between internal-external and external drainage for patients with malignant obstructive jaundice. Patients with malignant obstructive jaundice without infection before surgery receiving internal-external or external drainage from January 2008 to July 2014 were recruited. According to percutaneous transhepatic cholangiography (PTC), if the guide wire could pass through the occlusion and enter the duodenum, we recommended internal-external drainage, and external drainage biliary drainage was set up if the occlusion was not crossed. All patients with infection after procedure received a cultivation of blood and a bile bacteriological test. Among 110 patients with malignant obstructive jaundice, 22 (52.4%) were diagnosed with infection after the procedure in the internal-external drainage group, whereas 19 (27.9%) patients were so affected in the external drainage group, the difference being significant (p<0.05). In 8 patients (36.3%) in the internal-external group infection was controlled, as compared to 12 (63.1%) in the external group (p<0.05). The mortality rate for patients with infection not controlled in internal-external group in one month was 42.8%, while this rate in external group was 28.6% (p<0.05). External drainage is a good choice, which could significantly reduce the chance of biliary infection caused by bacteria, and decrease the mortality rate at one month and improve the long-term prognosis.

Anatomic Variation in Intrahepatic Bile Ducts: an Analysis of Intraoperative Cholangiograms in 300 Consecutive Donors for Living Donor Liver Transplantation

PubMed Central

Choi, Jin Woo; Kim, Kyoung Won; Kim, Ah Young; Kim, Pyo Nyun; Ha, Hyun Kwon; Lee, Moon-Gyu

2003-01-01

Objective To describe the anatomical variation occurring in intrahepatic bile ducts (IHDs) in terms of their branching patterns, and to determine the frequency of each variation. Materials and Methods The study group consisted of 300 consecutive donors for liver transplantation who underwent intraoperative cholangiography. Anatomical variation in IHDs was classified according to the branching pattern of the right anterior and right posterior segmental duct (RASD and RPSD, respectively), and the presence or absence of the first-order branch of the left hepatic duct (LHD), and of an accessory hepatic duct. Results The anatomy of the intrahepatic bile ducts was typical in 63% of cases (n=188), showed triple confluence in 10% (n=29), anomalous drainage of the RPSD into the LHD in 11% (n=34), anomalous drainage of the RPSD into the common hepatic duct (CHD) in 6% (n=19), anomalous drainage of the RPSD into the cystic duct in 2% (n=6), drainage of the right hepatic duct (RHD) into the cystic duct (n=1), the presence of an accessory duct leading to the CHD or RHD in 5% (n=16), individual drainage of the LHD into the RHD or CHD in 1% (n=4), and unclassified or complex variation in 1% (n=3). Conclusion The branching pattern of IHDs was atypical in 37% of cases. The two most common variations were drainage of the RPSD into the LHD (11%) and triple confluence of the RASD, RPSD and LHD (10%). PMID:12845303

Elevated interleukin-8 in bile of patients with primary sclerosing cholangitis.

PubMed

Zweers, Serge J; Shiryaev, Alexey; Komuta, Mina; Vesterhus, Mette; Hov, Johannes R; Perugorria, María J; de Waart, D Rudi; Chang, Jung-Chin; Tol, Shanna; Te Velde, Anje A; de Jonge, Wouter J; Banales, Jesus M; Roskams, Tania; Beuers, Ulrich; Karlsen, Tom H; Jansen, Peter L; Schaap, Frank G

2016-09-01

To better understand the pathogenesis of primary sclerosing cholangitis, anti- and pro-inflammatory factors were studied in bile. Ductal bile of PSC patients (n = 36) and controls (n = 20) was collected by endoscopic retrograde cholangiography. Gallbladder bile was collected at liver transplantation. Bile samples were analysed for cytokines, FGF19 and biliary lipids. Hepatobiliary tissues of PSC and non-PSC patients (n = 8-11 per patient group) were collected at transplantation and were analysed for IL8 and FGF19 mRNA expression and IL8 localization. The effect of IL8 on proliferation of primary human cholangiocytes and expression of pro-fibrotic genes was studied. In PSC patients, median IL8 in ductal bile was 6.6 ng/ml vs. 0.24 ng/ml in controls. Median IL8 in gallbladder bile was 7.6 ng/ml in PSC vs. 2.2 and 0.3 ng/ml in two control groups. IL8 mRNA in PSC gallbladder was increased and bile ducts stained positive for IL8. In vitro, IL8 induced proliferation of primary human cholangiocytes and increased the expression of pro-fibrotic genes. Elevation of IL8 in bile of PSC patients, collected at different stages of disease, indicates an ongoing inflammatory stimulus that drives IL8 production. This challenges the idea that advanced PSC is a burned-out disease, and calls for reconsideration of anti-inflammatory therapy in PSC. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

[From Langenbuch to Strasberg: the spectrum of bile duct injuries].

PubMed

Mercado, Miguel Angel

2004-01-01

Bile duct injuries are the main serious complication of laparoscopy cholecystectomy. The frequency of this type of injuries rangers, between 1 to 3 in 1,000 cases and although this rate remains stables, their frequency has increased because of the increasing expansion of the indication of cholecystectomy. Each lesion is the individual in it's features as well as the scenario in which the surgeon faces it. Several classifications have been developed, but that developed by Strasberg most used nowadays. Intraoperative cholangiography has shown evidence in meta analytic studies that diminishes the frequency of lesions but does not abolish them. Conversion from laparoscope's to the open approach with ample and convincent dissection is probably the best maneuver to reduce the frequency of lesions, when any anatomical or technical doubt appears. No patient should be operated in critical condition. In this situation, biliary reconstruction has a secondary role and only drainage of the ducts (percutaneous or surgical) is indicated. Roux en Y hepatoyeyunostomy is the procedure of choice for almost all cases, leaving other types of procedures for selected cases. Transhepatic transanastomotical stents should be used according to the individual status of the patient when small, scared or inflamed ducts are found. High quality anastomosis is obtained when proper ducts are found. Sometimes high dissection of the ducts is needed in order to obtain adequate ducts. Nine of each ten cases are completely rehabilitated, obtaining a good quality of life.

Diagnosis and management of biliary complications in pediatric living donor liver transplant recipients.

PubMed

Feier, Flávia H; Chapchap, Paulo; Pugliese, Renata; da Fonseca, Eduardo A; Carnevale, Francisco C; Moreira, Airton M; Zurstrassen, Charles; Santos, Aline C; Miura, Irene K; Baggio, Vera; Porta, Adriana; Guimarães, Teresa; Cândido, Helry; Benavides, Marcel; Godoy, Andre; Leite, Katia M R; Porta, Gilda; Kondo, Mario; Seda-Neto, João

2014-08-01

The incidence of biliary complications (BCs) after living donor liver transplantation (LDLT) can reach 40%. Published data on the pediatric population are limited, and treatment protocols vary. Our aim was to describe the clinical scenario for BCs and treatment approaches after LDLT. Between October 1995 and December 2012, 489 pediatric LDLT procedures were performed. BCs developed in 71 patients (14.5%). Biliary strictures (BSs) developed in 45 (9.2%) patients, and bile leaks (BLs) developed in 33 patients (6.7%). The BL diagnosis was clinical in all cases, and 69.7% of the patients underwent surgery. Nearly half of the BS cases had clinical features or suggestive ultrasound findings. Liver biopsy findings suggested BSs in 51.7%. Percutaneous transhepatic cholangiography was performed in 95.6% of the BS patients. The success rate was 77% [mean number of percutaneous biliary interventions (PBIs) = 3.9 ± 1.98, median drainage time = 8 months]. In conclusion, BL patients can be managed with conservative therapy, even though most of these patients will ultimately be treated with surgery. Diagnosing a BS requires a high degree of clinical suspicion because the available resources for its identification can fail in up to 50% of cases. A higher number of PBIs and the use of a drainage catheter for a longer time may be required to achieve better results with this technique. © 2014 American Association for the Study of Liver Diseases.

[Laparoscopic therapy of choledocholithiasis].

PubMed

Rechner, J; Beller, S; Zerz, A; Szinicz, G

1996-01-01

The introduction of laparoscopic cholecystectomy has led to controversial discussions about the proceeding in case of coincident common bile duct stones. In our unit choledocholithiasis has been treated laparoscopically since November 1991. Basic requirement has been a routine intraoperative cholangiography. 67 patients with common bile duct stones were treated until January 1995. All patients underwent a follow up and the results were compared to other concepts. In 40 cases common bile duct stones were eliminated via cystic duct and in 27 cases by choledochotomy. The choledochus was drained routinely for postoperative x-ray control. In 9 cases we found residual concrements: 7 patients required postoperative endoscopic papillotomy and in 2 cases the calculi where eliminated with a dormia basket introduced via drainage tube. In one case surgical management was changed to laparotomy. Postoperative complications occurred in 8 cases. One patient suffering from bacterial peritonitis underwent laparotomy on the 9th postoperative day; one with bleeding from the cystic artery was treated by relaparoscopy. One patient developed a liver abscess and two patients a bilioma requiring ultrasound guided drainage. A superficial wound infection in one patient and a biliary leakage after removal of the drainage in two patients healed spontaneously. Due to an intact papilla with less stress to the patient, as well as a complication rate comparable with other published therapeutic concepts, this strategy can be recommended as a valuable alternative procedure.

Expanding endourology for biliary stone disease: the efficacy of intracorporeal lithotripsy on refractory biliary calculi.

PubMed

Sninsky, Brian C; Sehgal, Priyanka D; Hinshaw, J Louis; McDermott, John C; Nakada, Stephen Y

2014-07-01

We evaluated the efficacy of ureteroscopic therapy (electrohydraulic lithotripsy [EHL] and intraductal laser lithotripsy [ILL]) in patients with challenging biliary stones secondary to anatomic variations resulting from a previous surgical procedure, including liver transplantation. A retrospective chart review was performed for all patients with previous surgical alteration of the gastrointestinal (GI) tract who underwent EHL or ILL via peroral or percutaneous access for choledocholithiasis by a single surgeon at our institution from 2000 to 2012. A database containing clinical and surgical variables was created, and long-term follow-up was conducted (3-138 months; median, 99 months). Thirteen patients (51.7±20.0 years; M:F, 10:3) in whom endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTHC), or both failed were identified. Failure of ERCP/PTHC was because of inaccessibility of the calculi in all cases. Stone clearance was achieved in 12/13 (93%) patients; 8/12 (62%) after one procedure, and 4/12 (31%) after two procedures. One patient with biliary cast syndrome needed four interventions over 9 years. Major complications were low, with only one patient with hypotension and cholangitis that resolved with 24 hours of administration of intravenous fluids and antibiotics. Both endoscopic and percutaneous lithotripsies are effective treatments for refractory biliary calculi resulting from the post-surgical GI tract. Although a staged second procedure may be necessary in patients with significant stone burden, this is significantly better than extensive open surgery.

Risk factors and clinical indicators for the development of biliary strictures post liver transplant: Significance of bilirubin

PubMed Central

Forrest, Elizabeth Ann; Reiling, Janske; Lipka, Geraldine; Fawcett, Jonathan

2017-01-01

AIM To identify risk factors associated with the formation of biliary strictures post liver transplantation over a period of 10-year in Queensland. METHODS Data on liver donors and recipients in Queensland between 2005 and 2014 was obtained from an electronic patient data system. In addition, intra-operative and post-operative characteristics were collected and a logistical regression analysis was performed to evaluate their association with the development of biliary strictures. RESULTS Of 296 liver transplants performed, 285 (96.3%) were from brain dead donors. Biliary strictures developed in 45 (15.2%) recipients. Anastomotic stricture formation (n = 25, 48.1%) was the commonest complication, with 14 (58.3%) of these occurred within 6-mo of transplant. A percutaneous approach or endoscopic retrograde cholangiography was used to treat 17 (37.8%) patients with biliary strictures. Biliary reconstruction was initially or ultimately required in 22 (48.9%) patients. In recipients developing biliary strictures, bilirubin was significantly increased within the first post-operative week (Day 7 total bilirubin 74 μmol/L vs 49 μmol/L, P = 0.012). In both univariate and multivariate regression analysis, Day 7 total bilirubin > 55 μmol/L was associated with the development of biliary stricture formation. In addition, hepatic artery thrombosis and primary sclerosing cholangitis were identified as independent risk factors. CONCLUSION In addition to known risk factors, bilirubin levels in the early post-operative period could be used as a clinical indicator for biliary stricture formation. PMID:29312864

Reconstruction of Bile Duct Injury and Defect with the Round Ligament.

PubMed

Dokmak, Safi; Aussilhou, Béatrice; Ragot, Emilia; Tantardini, Camille; Cauchy, François; Ponsot, Philippe; Belghiti, Jacques; Sauvanet, Alain; Soubrane, Olivier

2017-09-01

Lateral injury of the bile duct can occur after cholecystectomy, bile duct dissection, or exploration. If direct repair is not possible, conversion to bilioenteric anastomosis can be needed with the risk of long-term bile duct infections and associated complications. We developed a new surgical technique which consist of reconstructing the bile duct with the round ligament. The vascularized round ligament is completely mobilized until its origin and used for lateral reconstruction of the bile duct to cover the defect. T tube was inserted and removed after few months. Patency of the bile duct was assessed by cholangiography, the liver function test and magnetic resonance imaging (MRI). Two patients aged 33 and 59 years old underwent lateral reconstruction of the bile duct for defects secondary to choledocotomy for stone extraction or during dissection for Mirizzi syndrome. The defects measured 2 and 3 cm and occupied half of the bile duct circumference. The postoperative course was marked by low output biliary fistula resolved spontaneously. In one patient, the T tube was removed at 3 months after surgery and MRI at 9 months showed strictly normal aspect of the bile duct with normal liver function test. The second patient is going very well 2 months after surgery and the T tube is closed. Lateral reconstruction of the bile duct can be safely achieved with the vascularized round ligament. We will extend our indications to tubular reconstruction.

Clinical application of indocyanine green-fluorescence imaging during hepatectomy

PubMed Central

Ishizawa, Takeaki; Saiura, Akio

2016-01-01

In hepatobiliary surgery, the fluorescence and bile excretion of indocyanine green (ICG) can be used for real-time visualization of biological structure. Fluorescence cholangiography is used to obtain fluorescence images of the bile ducts following intrabiliary injection of 0.025−0.5 mg/mL ICG or intravenous injection of 2.5 mg ICG. Recently, the latter technique has been used in laparoscopic/robotic cholecystectomy. Intraoperative fluorescence imaging can be used to identify subcapsular hepatic tumors. Primary and secondary hepatic malignancy can be identified by intraoperative fluorescence imaging using preoperative intravenous injection of ICG through biliary excretion disorders that exist in cancerous tissues of hepatocellular carcinoma (HCC) and in non-cancerous hepatic parenchyma around adenocarcinoma foci. Intraoperative fluorescence imaging may help detect tumors to be removed, especially during laparoscopic hepatectomy, in which visual inspection and palpation are limited, compared with open surgery. Fluorescence imaging can also be used to identify hepatic segments. Boundaries of hepatic segments can be visualized following injection of 0.25−2.5 mg/mL ICG into the portal veins or by intravenous injection of 2.5 mg ICG following closure of the proximal portal pedicle toward hepatic regions to be removed. These techniques enable identification of hepatic segments before hepatectomy and during parenchymal transection for anatomic resection. Advances in imaging systems will increase the use of fluorescence imaging as an intraoperative navigation tool that can enhance the safety and accuracy of open and laparoscopic/robotic hepatobiliary surgery. PMID:27500144

Molecular identification of protozoa causing AIDS-associated cholangiopathy in Buenos Aires, Argentina.

PubMed

Nétor Velásquez, Jorge; Marta, Edgardo; Alicia di Risio, Cecilia; Etchart, Cristina; Gancedo, Elisa; Victor Chertcoff, Agustín; Bruno Malandrini, Jorge; Germán Astudillo, Osvaldo; Carnevale, Silvana

2012-12-01

Several species of microsporidia and coccidia are protozoa parasites responsible for cholan-giopathy disease in patients infected with human immunodeficiency virus (HIV). The goals of this work were to identift opportunistic protozoa by molecular methods and describe the clinical manifestations at the gastrointestinal tract and the biliary system in patients with AIDS-associated cholangiopathy from Buenos Aires, Argentina. This study included 11 adult HIV-infected individuals with diagnosis ofAIDS- associated cholangiopathy. An upper gastrointestinal endoscopy with biopsy specimen collection and a stool analysis for parasites were performed on each patient. The ultrasound analysis revealed bile ducts compromise. An endoscopic retrograde cholangiopancreatography and a magnetic resonance cholangiography were carried out. The identification to the species level was performed on biopsy specimens by molecular methods. Microorganisms were identified in 10 cases. The diagnosis in patients with sclerosing cholangitis was cryptosporidiosis in 3 cases, cystoisosporosis in 1 and microsporidiosis in 1. In patients with sclerosing cholangitis and papillary stenosis the diagnosis was microsporidiosis in 2 cases, cryptosporidiosis in 2 and cryptosporidiosis associated with microsporidiosis in 1. In 3 cases with cryptosporidiosis the species was Cryptosporidium hominis, 1 of them was associated with Enterocytozoon bieneusi, and the other 2 were coinfected with Cryptosporidium parvum. In the 4 cases with microsporidiosis the species was Enterocytozoon bieneusi. These results suggest that molecular methods may be useful tools to identify emerging protozoa in patients with AIDS-associated cholangiopathy.

Saw palmetto-induced pancreatitis.

PubMed

Jibrin, Ismaila; Erinle, Ayodele; Saidi, Abdulfattah; Aliyu, Zakari Y

2006-06-01

Saw palmetto is a frequently used botanical agent in benign prostatic enlargement (BPH). Although it has been reported to cause cholestatic hepatitis and many medical conditions, Saw palmetto has not been implicated in acute pancreatitis. We report a case of a probable Saw palmetto induced acute hepatitis and pancreatitis. A 55-year-old reformed alcoholic, sober for greater than 15 years, presented with severe non-radiating epigastric pain associated with nausea and vomiting. His only significant comorbidity is BPH for which he intermittently took Saw palmetto for about four years. Physical examination revealed normal vital signs, tender epigastrium without guarding or rebound tenderness. Cullen and Gray Turner signs were negative. Complete blood count and basic metabolic profile were normal. Additional laboratory values include a serum amylase: 2,152 mmol/L, lipase: 39,346 mmol/L, serum triglyceride: 38 mmol/L, AST: 1265, ALT: 1232 and alkaline phosphatase was 185. Abdominal ultrasound and magnetic resonance cholangiography revealed sludge without stones. A hepatic indole diacetic acid scan was negative. Patient responded clinically and biochemically to withdrawal of Saw palmetto. Two similar episodes of improvements followed by recurrence were noted with discontinuations and reinstitution of Saw Palmetto. Simultaneous and sustained response of hepatitis and pancreatitis to Saw palmetto abstinence with reoccurrence on reinstitution strongly favors drug effect. "Natural" medicinal preparations are therefore not necessarily safe and the importance of detailed medication history (including "supplements") cannot be over emphasized.

Diurnal variation in the biliary excretion of flomoxef in patients with percutaneous transhepatic biliary drainage

PubMed Central

Hishikawa, Shuji; Kobayashi, Eiji; Sugimoto, Koh-ichi; Miyata, Michio; Fujimura, Akio

2001-01-01

Aims To examine diurnal variation in biliary excretion of flomoxef. Methods Flomoxef (1 g) was injected intravenously in eight patients with percutaneous transhepatic cholangiography with drainage at 09.00 h and 21.00 h by a cross-over design with a 36 h washout period. Drained biliary fluid was collected for 6 h after each dosing. These patients still had mild to moderate hepatic dysfunction. Results Bile flow and bile acid excretion for 6 h after dosing did not differ significantly between the 09.00 h and 21.00 h treatments. The maximum concentration of biliary flomoxef was significantly greater and its total excretion for 6 h tended to be greater after the 21.00 h dose [maximum concentration (µg ml−1): 34.2 ± 29.9 (09.00 h dose) vs 43.5 ± 28.3 (21.00 h dose) (95% confidence interval for difference: 2.6∼15.9, P = 0.013); total excretion (mg 6 h−1): 1.4 ± 1.3 (09.00 h dose) vs 1.6 ± 1.2 (21.00 h dose) (95% confidence interval for difference: −26.8, 313.7, P = 0.087)]. The period that biliary flomoxef remained above the minimal inhibitory concentration did not differ significantly between the two treatment times. Conclusions These results suggest that biliary excretion of flomoxef shows diurnal variation. However, as the difference was relatively small, flomoxef could be given at any time of day without any dosage adjustments. PMID:11453891

Diurnal variation in the biliary excretion of flomoxef in patients with percutaneous transhepatic biliary drainage.

PubMed

Hishikawa, S; Kobayashi, E; Sugimoto , K; Miyata, M; Fujimura, A

2001-07-01

To examine diurnal variation in biliary excretion of flomoxef. Flomoxef (1 g) was injected intravenously in eight patients with percutaneous transhepatic cholangiography with drainage at 09.00 h and 21.00 h by a cross-over design with a 36 h washout period. Drained biliary fluid was collected for 6 h after each dosing. These patients still had mild to moderate hepatic dysfunction. Bile flow and bile acid excretion for 6 h after dosing did not differ significantly between the 09.00 h and 21.00 h treatments. The maximum concentration of biliary flomoxef was significantly greater and its total excretion for 6 h tended to be greater after the 21.00 h dose [maximum concentration (microg ml(-1)): 34.2 +/- 29.9 (09.00 h dose) vs 43.5 +/- 28.3 (21.00 h dose) (95% confidence interval for difference: 2.6 approximately 15.9, P = 0.013); total excretion (mg 6 h(-1)): 1.4 +/- 1.3 (09.00 h dose) vs 1.6 +/- 1.2 (21.00 h dose) (95% confidence interval for difference: -26.8, 313.7, P = 0.087)]. The period that biliary flomoxef remained above the minimal inhibitory concentration did not differ significantly between the two treatment times. These results suggest that biliary excretion of flomoxef shows diurnal variation. However, as the difference was relatively small, flomoxef could be given at any time of day without any dosage adjustments.

Temporary placement of fully covered self-expandable metal stents in benign biliary strictures.

PubMed

Ryu, Choong Heon; Kim, Myung Hwan; Lee, Sang Soo; Park, Do Hyun; Seo, Dong Wan; Lee, Sung Koo

2013-07-01

Benign biliary strictures (BBSs) have been endoscopically managed with plastic stent placement. However, data regarding fully covered self-expandable metal stents (FCSEMSs) in BBS patients remain scarce in Korea. Forty-one patients (21 men, 65.9%) with BBSs underwent FCSEMS placement between February 2007 and July 2010 in Asan Medical Center. Efficacy and safety were evaluated retrospectively. Patients were considered to have resolution if they showed evidence of stricture resolution on cholangiography and if an inflated retrieval balloon easily passed through the strictures at FCSEMS removal. The mean FCSEMS placement time was 3.2 (1.9-6.2) months. Patients were followed for a mean of 10.2 (1.0-32.0) months after FCSEMS removal. The BBS resolution rate was confirmed in 38 of 41 (92.7%) patients who underwent FCSEMS removal. After FCSEMS removal, 6 of 38 (15.8%) patients experienced symptomatic recurrent stricture and repeat stenting was performed. When a breakdown by etiology of stricture was performed, 14 of 15 (93.3%) patients with chronic pancreatitis, 17 of 19 (89.5%) with gall stone-related disease, 4 of 4 (100%) with surgical procedures, and 2 of 2 (100%) with BBSs of other etiology had resolution at FCSEMS removal. Complications related to stent therapy occurred in 12 (29%) patients, including post-ERCP pancreatitis (n=4), proximal migration (n=3), distal migration (n=3), and occlusion (n=2). Temporary FCSEMS placement in BBS patients offers a potential alternative to plastic stenting. However, because of the significant complications and modest resolution rates, the potential benefits and risks should be evaluated in further investigations.

Correlation Between Bile Reflux Gastritis and Biliary Excreted Contrast Media in the Stomach.

PubMed

Hyun, Jong Jin; Yeom, Suk Keu; Shim, Euddeum; Cha, Jaehyung; Choi, Inyoung; Lee, Seung Hwa; Chung, Hwan Hoon; Cha, Sang Hoon; Lee, Chang Hee

This study aimed to evaluate the relationship between biliary excreted contrast media in the stomach and the presence of bile reflux gastritis. Consecutive 111 patients who underwent both gadoxetic acid-enhanced magnetic resonance cholangiography (gadoxetic MRC) and gastric endoscopy were included in this study. We performed a review of the gadoxetic-MRC image sets acquired 60 minutes after intravenous injection of contrast media and endoscopic images. We recorded amount of contrast media in the stomach. The sensitivity, specificity, and accuracy of duodenogastric bile reflux diagnosis were evaluated for the gadoxetic MRC. Statistical analysis was performed using the Fisher exact test and the linear-by-linear association test. Among the 111 patients, 39 had 60-minute delayed images showing the presence of contrast media in the stomach. Of these 39 patients, 13 had bile reflux gastritis and 5 showed bile in the stomach without evidence of erythematous gastritis. Of the 72 patients who did not show contrast media in the stomach, none had bile reflux gastritis and 2 patients showed bile staining in the stomach without evidence of erythematous gastritis. Bile reflux gastritis was significantly more frequent in patients with contrast media in the stomach on gadoxetic MRC than in those without. Patients with high-grade extension of contrast media in the stomach had significantly frequent bile reflux gastritis than did those with low-grade extension. Biliary excreted contrast media in the stomach on 60-minute delayed gadoxetic MRC has a correlation with the presence of bile reflux gastritis on endoscopic examination.

Usefulness of transpapillary bile duct brushing cytology and forceps biopsy for improved diagnosis in patients with biliary strictures.

PubMed

Kitajima, Yasuhiro; Ohara, Hirotaka; Nakazawa, Takahiro; Ando, Tomoaki; Hayashi, Kazuki; Takada, Hiroki; Tanaka, Hajime; Ogawa, Kanto; Sano, Hitoshi; Togawa, Shozo; Naito, Itaru; Hirai, Masaaki; Ueno, Koichiro; Ban, Tessin; Miyabe, Katuyuki; Yamashita, Hiroaki; Yoshimura, Norihiro; Akita, Shinji; Gotoh, Kazuo; Joh, Takashi

2007-10-01

Transpapillary bile duct brushing cytology and/or forceps biopsy was performed in the presence of an indwelling guidewire in patients with biliary stricture, and the treatment time, overall diagnosis rate, diagnosis rate of each disease, complications, and influences on subsequent biliary drainage were investigated. After endoscopic retrograde cholangiography, brushing cytology was performed, followed by forceps biopsy. In patients with obstructive jaundice, endoscopic biliary drainage (EBD) was subsequently performed. To investigate the influences of bile duct brushing cytology and forceps biopsy on EBD, patients who underwent subsequent EBD by plastic stent were compared with patients who underwent EBD alone. The samples for cytology were collected successfully in all cases, and the sensitivity for malignancy/benignity, specificity, and accuracy were 71.6%, 100%, and 75.0%, respectively. The biopsy sampling was successful in 51 patients, and samples applicable to the evaluation were collected in all 51 patients. The sensitivity for malignancy/benignity, specificity, and accuracy were 65.2%, 100%, and 68.6%, respectively. Combination of the two procedures increased the sensitivity and accuracy to 73.5% and 76.6%, respectively. The time required for cytology and biopsy was 11.7 min, which is relatively short. Cytology and biopsy did not affect drainage. Regarding accidents, bile duct perforation occurred during biopsy in one patient (1.9%), but was rapidly improved by endoscopic biliary drainage. Transpapillary brushing cytology and forceps biopsy could be performed in a short time. The diagnosis rate was high, and the incidence of complication was low, having no influence on subsequent biliary drainage.

[Intraoperative ultrasonography during laparoscopic surgery].

PubMed

Alecu, L; Lungu, C; Pascu, A; Costan, I; Corodeanu, G; Deacu, A; Marin, A

2000-01-01

Of this study is the introduction and the results evaluation of laparoscopic ultrasonography performed. We realize a prospective study about laparoscopic ultrasonography performed in 37 cases with laparoscopic surgical treatment. The Aloka SSD 2000 mobile scanner is used. This system make possible the use of an linear-array transducer, with mechanical flexibility and availability of Doppler analysis. Most frequently we used intraoperative ultrasonography in laparoscopic cholecystectomy as an alternative for cholangiography to exclude CBD pathology. Because of various surgical pathology with laparoscopic approach, the laparoscopic ultrasonography utilization range was vastly. In all the cases we could performed the laparoscopic ultrasonography. In 6 of 27 cases with laparoscopic cholecystectomy we found pathological disorders of bile ducts. CBD with diameter found between 5-12 mm. We properly saw the distal segment of CBD in 23 cases (89.2%), and common hepatic duct in 26 cases (97.3%). The quality of visualization was very good in 21 cases (83.8%) and moderate in 6 cases (16.2%). We easy identify CBD stones and we successfully used Doppler color mode in differentiating vascular from non-vascular from non-vascular structures. Laparoscopic ultrasonography performed in a case with left colon cancer excluded liver metastasis and lymph nodes metastasis. 1. Laparoscopic ultrasonography combines the advantages of diagnostic laparoscopy and intraoperative contact ultrasonography; 2. Laparoscopic ultrasonography is a simple and very efficient intraoperative examination procedure; 3. Laparoscopic ultrasonography is the technique to choose in CBD intraoperative exploration; 4. Laparoscopic ultrasonography improve abdominal malignancy exploration, thus modifying therapeutic decisions; 5. Color Doppler mode guides the surgeon's steps in difficult directions.

Methylene blue-aided cholangioscopy in patients with biliary strictures: feasibility and outcome analysis.

PubMed

Hoffman, A; Kiesslich, R; Bittinger, F; Galle, P R; Neurath, M F

2008-07-01

Chromoendoscopy using methylene blue is employed in the gastrointestinal tract to delineate neoplastic lesions. We tested the value of chromoendoscopy during choledochoscopy for characterization of local inflammation, neoplasias, and other alterations in patients with biliary strictures. Patients with suspected biliary lesions were scheduled for endoscopic retrograde cholangiography with subsequent cholangioscopy. After initial inspection of the bile duct, 15 ml methylene blue (0.1 %) was administered via the working channel of the cholangioscope. Newly appearing circumscribed or unstained lesions were judged according to their macroscopic type and staining features. Methylene-blue-aided diagnosis was compared with either clinical follow-up of the patients or, in some cases, with the results of targeted biopsies. A total of 55 patients [biliary stenosis/cholestasis of unknown origin (n = 24), stenosis after orthotopic liver transplantation (n = 11), primary sclerosing cholangitis (n = 20)] were included. Methylene blue unmasked subtle mucosal changes and permitted macroscopic characterization of circumscribed lesions. Characteristic surface staining patterns were seen in chronic inflammation, dysplasia, and ischemic-type biliary lesions. Nondysplastic mucosa appeared homogeneously stained, whereas scarred strictures showed a weak uptake of methylene blue. In this prospective feasibility study, methylene-blue-aided cholangioscopy was used for the first time to define different staining patterns of the bile duct. The differences in staining patterns identified normal, dysplastic, and inflamed mucosa of the bile duct, as was proved by follow-up or, in some cases, histology. Whereas homogeneous staining predicted the presence of normal mucosa, absence of staining of circumscribed lesions, or diffused staining of such lesions, represented neoplastic changes or inflammation.

Hospital readmission after ambulatory laparoscopic cholecystectomy: incidence and predictors.

PubMed

Rosero, Eric B; Joshi, Girish P

2017-11-01

The aim of the study was to assess the rate of 30-d hospital readmissions after ambulatory laparoscopic cholecystectomy. The 2009 to 2011 State Ambulatory Surgery and Services and State Inpatient Databases from California, Florida, and New York were analyzed to evaluate the incidence of 30-d readmissions after laparoscopic cholecystectomy performed in outpatient settings. Hospital transfers and the principal diagnoses of hospital readmission were analyzed as secondary outcomes. Multilevel generalized mixed linear regression analyses with fixed and random effects were used to evaluate variables associated with increased likelihood of readmissions. A total of 230,745 encounters for ambulatory laparoscopic cholecystectomies performed in 890 ambulatory facilities between 2009 and 2011 in the three states were analyzed. The rate of 30-d readmission was 20.2 per 1000 discharges. The rate of direct transfers from the ambulatory surgery center to an acute care hospital was 0.6 per 1000 discharges. The most common diagnoses of readmission were surgical complications, postoperative pain, infection, and nausea or vomiting. After adjusting for comorbidities, increasing age, male sex, non-Hispanic white race/ethnicity, any nonprivate insurance type, diagnosis of acute cholecystitis, use of intraoperative cholangiography, and having the procedure performed on a weekend were significantly associated with increased odds of 30-d readmissions. This large-state data analysis reveals that the unplanned admission and readmission rates after laparoscopic cholecystectomy are very low. Some causes of readmission (e.g., pain, nausea, and vomiting) are modifiable by the intervention of surgeons and anesthesia providers. Copyright © 2017 Elsevier Inc. All rights reserved.

Percutaneous Transhepatic Removal of Bile Duct Stones: Results of 261 Patients

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ozcan, Nevzat, E-mail: nevzatcan@yahoo.com; Kahriman, Guven, E-mail: guvenkahriman@hotmail.com; Mavili, Ertugrul, E-mail: ertmavili@yahoo.com

2012-08-15

Purpose: To determine the effectiveness of percutaneous transhepatic removal of bile duct stones when the procedure of endoscopic therapy fails for reasons of anatomical anomalies or is rejected by the patient. Methods: Between April 2001 and May 2010, 261 patients (138 male patients and 123 female patients; age range, 14-92 years; mean age, 64.6 years) with bile duct stones (common bile duct [CBD] stones = 248 patients and hepatolithiasis = 13 patients) were included in the study. Percutaneous transhepatic cholangiography was performed, and stones were identified. Percutaneous transhepatic balloon dilation of the papilla of Vater was performed. Then stones weremore » pushed out into the duodenum with a Fogarty balloon catheter. If the stone diameter was larger than 15 mm, then basket lithotripsy was performed before balloon dilation. Results: Overall success rate was 95.7%. The procedure was successful in 97.5% of patients with CBD stones and in 61.5% of patients with hepatolithiasis. A total of 18 major complications (6.8%), including cholangitis (n = 7), subcapsular biloma (n = 4), subcapsular hematoma (n = 1), subcapsular abscess (n = 1), bile peritonitis (n = 1), duodenal perforation (n = 1), CBD perforation (n = 1), gastroduodenal artery pseudoaneurysm (n = 1), and right hepatic artery transection (n = 1), were observed after the procedure. There was no mortality. Conclusion: Our experience suggests that percutaneous transhepatic stone expulsion into the duodenum through the papilla is an effective and safe approach in the nonoperative management of the bile duct stones. It is a feasible alternative to surgery when endoscopic extraction fails or is rejected by the patient.« less

Radiologic Characterization of Ischemic Cholangiopathy in Donation-After-Cardiac-Death Liver Transplants and Correlation With Clinical Outcomes.

PubMed

Giesbrandt, Kirk J; Bulatao, Ilynn G; Keaveny, Andrew P; Nguyen, Justin H; Paz-Fumagalli, Ricardo; Taner, C Burcin

2015-11-01

The purpose of this study was to define the cholangiographic patterns of ischemic cholangiopathy and clinically silent nonanastomotic biliary strictures in donation-after-cardiac-death (DCD) liver grafts in a large single-institution series. We also examined the correlation of the radiologic findings with laboratory data and clinical outcomes. Data were collected for all DCD liver transplants at one institution from December 1998 to December 2011. Posttransplant cholangiograms were obtained during postoperative weeks 1 and 3 and when clinically indicated. Intrahepatic biliary strictures were classified by anatomic distribution and chronologic development. Radiologic findings were correlated with laboratory data and with 1-, 3-, and 5-year graft and patient survival rates. A total of 231 patients received DCD grafts. Cholangiograms were available for 184 of these patients. Postoperative cholangiographic findings were correlated with clinical data and divided into the following three groups: A, normal cholangiographic findings with normal laboratory values; B, radiologic abnormalities and cholangiopathy according to laboratory values; and C, radiologic abnormalities without laboratory abnormalities. Group B had four distinct abnormal cholangiographic patterns that were predictive of graft survival. Group C had mild nonprogressive multifocal stenoses and decreased graft and patient survival rates, although cholangiopathy was not detected in these patients according to laboratory data. Patterns and severity of nonanastomotic biliary abnormalities in DCD liver transplants can be defined radiologically and correlate with clinical outcomes. Postoperative cholangiography can depict the mild biliary abnormalities that occur in a subclinical manner yet cause a marked decrease in graft and patient survival rates in DCD liver transplants.

Surgery or EUS-guided choledochoduodenostomy for malignant distal biliary obstruction after ERCP failure

PubMed Central

Artifon, Everson L.A.; Loureiro, Jarbas F.; Baron, Todd H.; Fernandes, Kaie; Kahaleh, Michel; Marson, Fernando P.

2015-01-01

Background and Objectives: Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice for drainage in patients with distal malignant biliary obstruction, but it fails in up to 10% of cases. Percutaneous transhepatic cholangiography (PTC) and surgical bypass are the traditional drainage alternatives. This study aimed to compare technical and clinical success, quality of life, and survival of surgical biliary bypass or hepaticojejunostomy (HJT) and endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDT) in patients with distal malignant bile duct obstruction and failed ERCP. Patients and Methods: A prospective, randomized trial was conducted. From March 2011 to September 2013, 32 patients with malignant distal biliary obstruction and failed ERCP were studied. The HJT group consisted of 15 patients and the CDT group consisted of 14 patients. Technical and clinical success, quality of life, and survival were assessed prospectively. Results: Technical success was 94% (15/16) in the HJT group and 88% (14/16) in the CDT group (P = 0.598). Clinical success occurred in 14 (93%) patients in the HJT group and in 10 (71%) patients in the CDT group (P = 0.169). During follow-up, a statistically significant difference was seen in mean functional capacity scores, physical health, pain, social functioning, and emotional and mental health aspects in both techniques (P < 0.05). The median survival time in both groups was the same (82 days). Conclusion: Data relating to technical and clinical success, quality of life, and survival were similar in patients who underwent HJT and CDT drainage after failed ERCP for malignant distal biliary obstruction. PMID:26374583

Klatskin tumour: meticulous preoperative work-up and resection rate.

PubMed

Otto, G; Hoppe-Lotichius, M; Bittinger, F; Schuchmann, M; Düber, C

2011-04-01

Surgery represents the only potentially curative treatment of hilar cholangiocarcinoma (hilCC). It may be suggested that meticulous preoperative work-up in Asian countries leads to higher resection rates. One hundred and eighty-two patients treated in our department between 1998 and 2008 were included in an analysis based on our prospectively recorded database. Among them, 75 % had a percutaneous transhepatic cholangiography as part of their diagnostic work-up. A total of 160 patients underwent explorative surgery and 123 patients were resected (77 % of patients undergoing exploration, 68 % of all patients). Ninety-one percent of the patients were diagnosed to have Bismuth III and IV tumours. En-bloc resection of the tumour and the adjacent liver including segment 1 was the standard procedure in 109 of these patients, while hilar resection was performed in 14 patients. Upon tumour resection, hospital mortality was 5.7 %. Five-year survival in patients without surgery or with mere exploration was 0 %, after resection it reached 26 %. Patients with R 1 resection experienced longer survival than patients without resection (p < 0.001). Right and left hemihepatectomies were performed with identical frequency resulting in identical survival. Lymph node involvement proved to be the only significant predictor of prognosis (p = 0.006). Resection should be performed whenever possible since even after palliative resection survival is substantially increased compared to patients without resection. Meticulous preoperative work-up may contribute to a high resection rate in patients with hilCC by providing additional information allowing the surgeon to perform more aggressive approaches. © Georg Thieme Verlag KG Stuttgart · New York.

Experimental Study of Poly-l-Lactic Acid Biodegradable Stents in Normal Canine Bile Ducts

DOE Office of Scientific and Technical Information (OSTI.GOV)

Yamamoto, Kiyosei, E-mail: yamakiyo@zg7.so-net.ne.jp; Yoshioka, Tetsuya; Furuichi, Kinya

Purpose: This study was designed to clarify the advantages of biodegradable stents in terms of mucosal reaction and biodegradation after placement. We designed a biodegradable stent and assessed stent degradation and changes in the normal bile ducts of dogs. Methods: The biodegradable stent is a balloon-expandable Z stent consisting of poly-l-lactic acid (PLLA) with a diameter of 6 mm and a length of 15 mm. We assessed four groups of three beagle dogs each at 1, 3, 6, and 9 months of follow-up. After evaluating stent migration by radiography and stent and bile duct patency by cholangiography, the dogs weremore » sacrificed to remove the bile duct together with the stent. The bile duct lumen was examined macroscopically and histologically, and the stent degradation was examined macroscopically and by scanning electron microscopy (SEM). Results: Bile duct obstruction was absent and none of the stents migrated. Macroscopic evaluation showed moderate endothelial proliferation in the bile ducts at the implant sites at 3 and 6 months and a slight change at 9 months. Slight mononuclear cell infiltration was histologically identified at all time points and epithelial hyperplasia that was moderate at 3 months was reduced to slight at 6 and 9 months. Stent degradation was macroscopically evident in all animals at 9 months and was proven by SEM in two dogs at 6 months and in all of them at 9 months. Conclusions: Our results suggest that PLLA bioabsorbable stents seems to be useful for implantation in the biliary system with further investigation.« less

Surgical management of complicated hydatid cysts of the liver

PubMed Central

Malik, Ajaz A; Bari, Shams UL; Amin, Ruquia; Jan, Masooda

2010-01-01

AIM: To review the clinical presentation and surgical management of complicated hydatid cysts of the liver and to assess whether conservative surgery is adequate in the management of complicated hydatid cysts of liver. METHODS: The study was carried out at Sher-i-Kashmir Institute of Medical Science, Srinagar, Kashmir, India. Sixty nine patients with hydatid disease of the liver were surgically managed from April 2004 to October 2005 with a follow up period of three years. It included 27 men and 42 women with a median age of 35 years. An abdominal ultrasound, computed tomography and serology established diagnosis. Patients with jaundice and high suspicion of intrabiliary rupture were subjected to preoperative endoscopic retrograde cholangiography. Cysts with infection, rupture into the biliary tract and peritoneal cavity were categorized as complicated cysts. Eighteen patients (26%) had complicated cysts and formed the basis for this study. RESULTS: Common complications were infection (14%), intrabiliary rupture (9%) and intraperitoneal rupture (3%). All the patients with infected cysts presented with pain and fever. All the patients with intrabiliary rupture had jaundice, while only four with intrabiliary rupture had pain and only two had fever. Surgical procedures performed in complicated cysts were: infection-omentoplasty in three and external drainage in seven; intrabiliary rupture-omentoplasty in two and internal drainage in four patients. Two patients with intraperitoneal rupture underwent external drainage. There was no mortality. The postoperative morbidity was 50% in complicated cysts and 16% in uncomplicated cysts. CONCLUSION: Complicated hydatid cyst of the liver can be successfully managed surgically with good long term results. PMID:21160854

Outcomes and risk factors for cancer patients undergoing endoscopic intervention of malignant biliary obstruction.

PubMed

Haag, Georg-Martin; Herrmann, Thomas; Jaeger, Dirk; Stremmel, Wolfgang; Schemmer, Peter; Sauer, Peter; Gotthardt, Daniel Nils

2015-12-04

Malignant bile duct obstruction is a common problem among cancer patients with hepatic or lymphatic metastases. Endoscopic retrograde cholangiography (ERC) with the placement of a stent is the method of choice to improve biliary flow. Only little data exist concerning the outcome of patients with malignant biliary obstruction in relationship to microbial isolates from bile. Bile samples were taken during the ERC procedure in tumor patients with biliary obstruction. Clinical data including laboratory values, tumor-specific treatment and outcome data were prospectively collected. 206 ERC interventions in 163 patients were recorded. In 43 % of the patients, systemic treatment was (re-) initiated after successful biliary drainage. A variety of bacteria and fungi was detected in the bile samples. One-year survival was significantly worse in patients from whom multiresistant pathogens were isolated than in patients, in whom other species were detected. Increased levels of inflammatory markers were associated with a poor one-year survival. The negative impact of these two factors was confirmed in multivariate analysis. In patients with pancreatic cancer, univariate analysis showed a negative impact on one-year survival in case of detection of Candida species in the bile. Multivariate analysis confirmed the negative prognostic impact of Candida in the bile in pancreatic cancer patients. Outcome in tumor patients with malignant bile obstruction is associated with the type of microbial biliary colonization. The proof of multiresistant pathogens or Candida, as well as the level of inflammation markers, have an impact on the prognosis of the underlying tumor disease.

Early biliary decompression versus conservative treatment in acute biliary pancreatitis (APEC trial): study protocol for a randomized controlled trial.

PubMed

Schepers, Nicolien J; Bakker, Olaf J; Besselink, Marc G H; Bollen, Thomas L; Dijkgraaf, Marcel G W; van Eijck, Casper H J; Fockens, Paul; van Geenen, Erwin J M; van Grinsven, Janneke; Hallensleben, Nora D L; Hansen, Bettina E; van Santvoort, Hjalmar C; Timmer, Robin; Anten, Marie-Paule G F; Bolwerk, Clemens J M; van Delft, Foke; van Dullemen, Hendrik M; Erkelens, G Willemien; van Hooft, Jeanin E; Laheij, Robert; van der Hulst, René W M; Jansen, Jeroen M; Kubben, Frank J G M; Kuiken, Sjoerd D; Perk, Lars E; de Ridder, Rogier J J; Rijk, Marno C M; Römkens, Tessa E H; Schoon, Erik J; Schwartz, Matthijs P; Spanier, B W Marcel; Tan, Adriaan C I T L; Thijs, Willem J; Venneman, Niels G; Vleggaar, Frank P; van de Vrie, Wim; Witteman, Ben J; Gooszen, Hein G; Bruno, Marco J

2016-01-05

Acute pancreatitis is mostly caused by gallstones or sludge. Early decompression of the biliary tree by endoscopic retrograde cholangiography (ERC) with sphincterotomy may improve outcome in these patients. Whereas current guidelines recommend early ERC in patients with concomitant cholangitis, early ERC is not recommended in patients with mild biliary pancreatitis. Evidence on the role of routine early ERC with endoscopic sphincterotomy in patients without cholangitis but with biliary pancreatitis at high risk for complications is lacking. We hypothesize that early ERC with sphincterotomy improves outcome in these patients. The APEC trial is a randomized controlled, parallel group, superiority multicenter trial. Within 24 hours after presentation to the emergency department, patients with biliary pancreatitis without cholangitis and at high risk for complications, based on an Acute Physiology and Chronic Health Evaluation (APACHE-II) score of 8 or greater, Modified Glasgow score of 3 or greater, or serum C-reactive protein above 150 mg/L, will be randomized. In 27 hospitals of the Dutch Pancreatitis Study Group, 232 patients will be allocated to early ERC with sphincterotomy or to conservative treatment. The primary endpoint is a composite of major complications (that is, organ failure, pancreatic necrosis, pneumonia, bacteremia, cholangitis, pancreatic endocrine, or exocrine insufficiency) or death within 180 days after randomization. Secondary endpoints include ERC-related complications, infected necrotizing pancreatitis, length of hospital stay and an economical evaluation. The APEC trial investigates whether an early ERC with sphincterotomy reduces the composite endpoint of major complications or death compared with conservative treatment in patients with biliary pancreatitis at high risk of complications. Current Controlled Trials ISRCTN97372133 (date registration: 17-12-2012).

Autoimmune liver disease in children.

PubMed

Mieli-Vergani, G; Vergani, D

2003-03-01

Autoimmune liver disorders are characterised by an inflammatory liver histology, circulating non-organ specific autoantibodies and increased levels of immunoglobulin G (IgG) in the absence of a known aetiology. They respond to immunosuppressive treatment, which should be instituted as soon as diagnosis is made. Liver disorders with a likely autoimmune pathogenesis include autoimmune hepatitis (AIH) and autoimmune sclerosing cholangitis (ASC). Two types of AIH are recognised according to seropositivity for smooth muscle and/or antinuclear antibody (SMA/ANA, type 1) or liver kidney microsomal antibody (LKM1, type 2). There is a female predominance in both. LKM1-positive patients tend to present more acutely, at a younger age, and commonly have immunoglobulin A (IgA) deficiency, while duration of symptoms before diagnosis, clinical signs, family history of autoimmunity, presence of associated autoimmune disorders, response to treatment and long-term prognosis are similar in both groups. The most common type of paediatric sclerosing cholangitis is ASC. The clinical, biochemical, immunological and histological presentation of ASC is often indistinguishable from that of AIH. In both, there are high IgG, non-organ specific autoantibodies and interface hepatitis. Diagnosis is made by cholangiography. Children with ASC respond to immunosuppression satisfactorily and similarly to AIH in respect to remission and relapse rates, times to normalisation of biochemical parameters and decreased inflammatory activity on follow-up liver biopsies. However, the cholangiopathy can progress and there may be an evolution from AIH to ASC over the years, despite treatment. Whether the juvenile autoimmune form of sclerosing cholangitis and AIH are 2 distinct entities, or different aspects of the same condition, remains to be elucidated.

Inpatient Choledocholithiasis Requiring ERCP and Cholecystectomy: Outcomes of a Combined Single Inpatient Procedure Versus Separate-Session Procedures.

PubMed

Passi, Monica; Inamdar, Sumant; Hersch, David; Dowling, Oonagh; Sejpal, Divyesh V; Trindade, Arvind J

2018-03-01

Separate-session endoscopic retrograde cholangiography (ERCP) and laparoscopic cholecystectomy (LC) is the usual method for management of inpatient choledocholithiasis. Our goal was to compare single operative-session LC and ERCP to a multi-session approach for both the same hospitalization and within 30 days after; there is limited data comparing the three groups. A retrospective review on inpatients with choledocholithiasis that underwent ERCP and LC was performed. Single operative-session ERCP + LC (SOS group) and separate hospitalization ERCP + LC (DH group) were compared against the control cohort: separate-session ERCP + LC performed during the same hospitalization (SH group). Among the 214 cases, 37 (17%) had LC + ERCP performed under a single operative session (SOS), 130 (60.7%) cases had LC + ERCP performed in separate operative sessions during the same hospitalization (SH), and 47 (22%) cases had LC + ERCP performed in different hospitalizations, within 30 days (DH). There was no statistically significant difference in efficacy or adverse events. The SOS group had a statistically significant mean shorter length of hospital stay as compared to the SH and DH groups (5.46 vs 7.15 vs 9.38; p = 0.05 and 0.02). There was a statistically significant reduction in the total cost of care in the SOS group versus the SH group ($59,221 vs $75, 808; p = 0.007). The SOS approach is safe, efficacious, and cost-efficient when compared to separate operative sessions. This approach can be considered in situations where it is preferable for the patient to undergo a single session of anesthesia, without compromising technical success and safety.

Differentiating immunoglobulin g4-related sclerosing cholangitis from hilar cholangiocarcinoma.

PubMed

Tabata, Taku; Kamisawa, Terumi; Hara, Seiichi; Kuruma, Sawako; Chiba, Kazuro; Kuwata, Go; Fujiwara, Takashi; Egashira, Hideto; Koizumi, Koichi; Fujiwara, Junko; Arakawa, Takeo; Momma, Kumiko; Kurata, Masanao; Honda, Goro; Tsuruta, Koji; Itoi, Takao

2013-03-01

Few studies have differentiated immunoglobulin G (IgG) 4-related sclerosing cholangitis (IgG4-SC) from hilar cholangiocarcinoma (CC). Thus, we sought to investigate useful features for differentiating IgG4-SC from hilar CC. We retrospectively compared clinical, serological, imaging, and histological features of six patients with IgG4-SC and 42 patients with hilar CC. In patients with hilar CC, obstructive jaundice was more frequent (p<0.01), serum total bilirubin levels were significantly higher (p<0.05), serum CA19-9 levels were significantly higher (p<0.01), and serum duke pancreatic monoclonal antigen type 2 levels were frequently elevated (p<0.05). However, in patients with IgG4-SC, the serum IgG (p<0.05) and IgG4 (p<0.01) levels were significantly higher and frequently elevated. The pancreas was enlarged in all IgG4-SC patients but only in 17% of hilar CC patients (p<0.01). Salivary and/or lacrimal gland swelling was detected in only 50% of IgG4-SC patients (p<0.01). Endoscopic retrograde cholangiography revealed that the hilar or hepatic duct was completely obstructed in 83% of hilar CC patients (p<0.01). Lower bile duct stenosis, apart from hilar bile duct stenosis, was more frequent in IgG4-SC patients (p<0.01). Bile duct wall thickening in areas without stenosis was more frequent in IgG4-SC patients (p<0.01). An integrated diagnostic approach based on clinical, serological, imaging, and histological findings is necessary to differentiate IgG4-SC from hilar CC.

Differentiating Immunoglobulin G4-Related Sclerosing Cholangitis from Hilar Cholangiocarcinoma

PubMed Central

Tabata, Taku; Hara, Seiichi; Kuruma, Sawako; Chiba, Kazuro; Kuwata, Go; Fujiwara, Takashi; Egashira, Hideto; Koizumi, Koichi; Fujiwara, Junko; Arakawa, Takeo; Momma, Kumiko; Kurata, Masanao; Honda, Goro; Tsuruta, Koji; Itoi, Takao

2013-01-01

Background/Aims Few studies have differentiated immunoglobulin G (IgG) 4-related sclerosing cholangitis (IgG4-SC) from hilar cholangiocarcinoma (CC). Thus, we sought to investigate useful features for differentiating IgG4-SC from hilar CC. Methods We retrospectively compared clinical, serological, imaging, and histological features of six patients with IgG4-SC and 42 patients with hilar CC. Results In patients with hilar CC, obstructive jaundice was more frequent (p<0.01), serum total bilirubin levels were significantly higher (p<0.05), serum CA19-9 levels were significantly higher (p<0.01), and serum duke pancreatic monoclonal antigen type 2 levels were frequently elevated (p<0.05). However, in patients with IgG4-SC, the serum IgG (p<0.05) and IgG4 (p<0.01) levels were significantly higher and frequently elevated. The pancreas was enlarged in all IgG4-SC patients but only in 17% of hilar CC patients (p<0.01). Salivary and/or lacrimal gland swelling was detected in only 50% of IgG4-SC patients (p<0.01). Endoscopic retrograde cholangiography revealed that the hilar or hepatic duct was completely obstructed in 83% of hilar CC patients (p<0.01). Lower bile duct stenosis, apart from hilar bile duct stenosis, was more frequent in IgG4-SC patients (p<0.01). Bile duct wall thickening in areas without stenosis was more frequent in IgG4-SC patients (p<0.01). Conclusions An integrated diagnostic approach based on clinical, serological, imaging, and histological findings is necessary to differentiate IgG4-SC from hilar CC. PMID:23560161

Current diagnosis and treatment of benign biliary strictures after living donor liver transplantation

PubMed Central

Chang, Jae Hyuck; Lee, Inseok; Choi, Myung-Gyu; Han, Sok Won

2016-01-01

Despite advances in surgical techniques, benign biliary strictures after living donor liver transplantation (LDLT) remain a significant biliary complication and play an important role in graft and patient survival. Benign biliary strictures after transplantation are classified into anastomotic or non-anastomotic strictures. These two types differ in presentation, outcome, and response to therapy. The leading causes of biliary strictures include impaired blood supply, technical errors during surgery, and biliary anomalies. Because patients usually have non-specific symptoms, a high index of suspicion should be maintained. Magnetic resonance cholangiography has gained widespread acceptance as a reliable noninvasive tool for detecting biliary complications. Endoscopy has played an increasingly prominent role in the diagnosis and treatment of biliary strictures after LDLT. Endoscopic management in LDLT recipients may be more challenging than in deceased donor liver transplantation patients because of the complex nature of the duct-to-duct reconstruction. Repeated aggressive endoscopic treatment with dilation and the placement of multiple plastic stents is considered the first-line treatment for biliary strictures. Percutaneous and surgical treatments are now reserved for patients for whom endoscopic management fails and for those with multiple, inaccessible intrahepatic strictures or Roux-en-Y anastomoses. Recent advances in enteroscopy enable treatment, even in these latter cases. Direct cholangioscopy, another advanced form of endoscopy, allows direct visualization of the inner wall of the biliary tree and is expected to facilitate stenting or stone extraction. Rendezvous techniques can be a good option when the endoscopic approach to the biliary stricture is unfeasible. These developments have resulted in almost all patients being managed by the endoscopic approach. PMID:26819525

Percutaneous Transhepatic Removal of Bile Duct Stones: Results of 261 Patients

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ozcan, Nevzat, E-mail: nevzatcan@yahoo.com; Kahriman, Guven, E-mail: guvenkahriman@hotmail.com; Mavili, Ertugrul, E-mail: ertmavili@yahoo.com

2012-06-15

Purpose: To determine the effectiveness of percutaneous transhepatic removal of bile duct stones when the procedure of endoscopic therapy fails for reasons of anatomical anomalies or is rejected by the patient. Methods: Between April 2001 and May 2010, 261 patients (138 male patients and 123 female patients; age range, 14-92 years; mean age, 64.6 years) with bile duct stones (common bile duct [CBD] stones = 248 patients and hepatolithiasis = 13 patients) were included in the study. First, percutaneous transhepatic cholangiography was performed and stones were identified. Percutaneous transhepatic balloon dilation of the papilla of Vater was performed. Then stonesmore » were pushed out into the duodenum with a Fogarty balloon catheter. If the stone diameter was larger than 15 mm, then basket lithotripsy was performed before balloon dilation. Results: Overall success rate was 95.7%. The procedure was successful in 97.5% of patients with CBD stones and in 61.5% of patients with hepatolithiasis. A total of 18 (6.8%) major complications, including cholangitis (n = 7), subcapsular biloma (n = 4), subcapsular hematoma (n = 1), subcapsular abscess (n = 1), bile peritonitis (n = 1), duodenal perforation (n = 1), CBD perforation (n = 1), gastroduodenal artery pseudoaneurysm (n = 1), and right hepatic artery transection (n = 1), were seen after the procedure. There was no mortality. Conclusion: Our experience suggests that percutaneous transhepatic stone expulsion into the duodenum through the papilla is an effective and safe approach in the nonoperative management of the bile duct stones. It is a feasible alternative to surgery when endoscopic extraction fails or is rejected by the patient.« less

Biliary tract visualization using near-infrared imaging with indocyanine green during laparoscopic cholecystectomy: results of a systematic review.

PubMed

Vlek, S L; van Dam, D A; Rubinstein, S M; de Lange-de Klerk, E S M; Schoonmade, L J; Tuynman, J B; Meijerink, W J H J; Ankersmit, M

2017-07-01

Near-infrared imaging with indocyanine green (ICG) has been extensively investigated during laparoscopic cholecystectomy (LC). However, methods vary between studies, especially regarding patient selection, dosage and timing. The aim of this systematic review was to evaluate the potential of the near-infrared imaging technique with ICG to identify biliary structures during LC. A comprehensive systematic literature search was performed. Prospective trials examining the use of ICG during LC were included. Primary outcome was biliary tract visualization. Risk of bias was assessed using ROBINS-I. Secondly, a meta-analysis was performed comparing ICG to intraoperative cholangiography (IOC) for identification of biliary structures. GRADE was used to assess the quality of the evidence. Nineteen studies were included. Based upon the pooled data from 13 studies, cystic duct (Lusch et al. in J Endourol 28:261-266, 2014) visualization was 86.5% (95% CI 71.2-96.6%) prior to dissection of Calot's triangle with a 2.5-mg dosage of ICG and 96.5% (95% CI 93.9-98.4%) after dissection. The results were not appreciably different when the dosage was based upon bodyweight. There is moderate quality evidence that the CD is more frequently visualized using ICG than IOC (RR 1.16; 95% CI 1.00-1.35); however, this difference was not statistically significant. This systematic review provides equal results for biliary tract visualization with near-infrared imaging with ICG during LC compared to IOC. Near-infrared imaging with ICG has the potential to replace IOC for biliary mapping. However, methods of near-infrared imaging with ICG vary. Future research is necessary for optimization and standardization of the near-infrared ICG technique.

Correlation of CBD/CHD angulation with recurrent cholangitis in patients treated with ERCP.

PubMed

Chong, Charing Cn; Chiu, Philip Wy; Tan, Teresa; Teoh, Anthony Yb; Lee, Kit Fai; Ng, Enders Kwok Wai; Lai, Paul Bs; Lau, James Yw

2016-01-01

Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) for bile duct stone extraction has a major role in the treatment of cholangitis. It is well known that certain risk factors predispose to recurrence of such stones. The aims of this study were to evaluate the correlation between angulation of the common bile duct (CBD), right hepatic duct (RHD), and left hepatic duct (LHD) with recurrent cholangitic attacks and to elucidate other risk factors that may be associated with these attacks. This is retrospective study included 62 patients who had undergone therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones. Their medical records were followed until May 1, 2009. The RHD, LHD, and CBD angulation and CBD diameter were measured on cholangiography prior to any endoscopic procedures. Among these 62 patients, 6 (9.7 %) had recurrence of cholangitis. Both angles of the RHD and the CBD were significantly smaller in the group with recurrence (P = 0.001, P = 0.004). A CBD angle ≤ 130(o) and RHD angle ≤ 125(o) were found to be significantly associated with an increased risk of recurrence (RR = 10.526, P = 0.033; RR = 24.97, P = 0.008) in multivariate analysis. Cholecystectomy was not a protective factor against recurrence of cholangitis (P = 0.615). Angulation of the CBD (≤ 130°) and RHD (≤ 125°) on ERCP are independent risk factors for recurrent cholangitis. Further prospective studies using these data may be warranted for a more accurate estimation and verification of the risk factors predisposing to recurrent cholangitis.

Hilar cholangiocarcinoma: diagnosis, treatment options, and management

PubMed Central

Soares, Kevin C.; Kamel, Ihab; Cosgrove, David P.; Herman, Joseph M.

2014-01-01

Hilar cholangiocarcinoma (HC) is a rare disease with a poor prognosis which typically presents in the 6th decade of life. Of the 3,000 cases seen annually in the United States, less than one half of these tumors are resectable. A variety of risk factors have been associated with HC, most notably primary sclerosing cholangitis (PSC), biliary stone disease and parasitic liver disease. Patients typically present with abdominal pain, pruritis, weight loss, and jaundice. Computed topography (CT), magnetic resonance imaging (MRI), and ultrasound (US) are used to characterize biliary lesions. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) assess local ductal extent of the tumor while allowing for therapeutic biliary drainage. MRCP has demonstrated similar efficacies to PTC and ERCP in identifying anatomic extension of tumors with less complications. Treatment consists of surgery, radiation, chemotherapy and photodynamic therapy. Biliary drainage of the future liver remnant should be performed to decrease bilirubin levels thereby facilitating future liver hypertrophy. Standard therapy consists of surgical margin-negative (R0) resection with extrahepatic bile duct resection, hepatectomy and en bloc lymphadenectomy. Local resection should not be undertaken. Lymph node invasion, tumor grade and negative margins are important prognostic indicators. In instances where curative resection is not possible, liver transplantation has demonstrated acceptable outcomes in highly selected patients. Despite the limited data, chemotherapy is indicated for patients with unresectable tumors and adequate functional status. Five-year survival after surgical resection of HC ranges from 10% to 40% however, recurrence can be as high as 50-70% even after R0 resection. Due to the complexity of this disease, a multi-disciplinary approach with multimodal treatment is recommended for this complex disease. PMID:24696835

[Image fusion, virtual reality, robotics and navigation. Effects on surgical practice].

PubMed

Maresceaux, J; Soler, L; Ceulemans, R; Garcia, A; Henri, M; Dutson, E

2002-05-01

In the new minimally invasive surgical era, virtual reality, robotics, and image merging have become topics on their own, offering the potential to revolutionize current surgical treatment and assessment. Improved patient care in the digital age seems to be the primary impetus for continued efforts in the field of telesurgery. The progress in endoscopic surgery with regard to telesurgery is manifested by digitization of the pre-, intra-, and postoperative interaction with the patients' surgical disease via computer system integration: so-called Computer Assisted Surgery (CAS). The preoperative assessment can be improved by 3D organ reconstruction, as in virtual colonoscopy or cholangiography, and by planning and practicing surgery using virtual or simulated organs. When integrating all of the data recorded during this preoperative stage, an enhanced reality can be made possible to improve intra-operative patient interactions. CAS allows for increased three-dimensional accuracy, improved precision and the reproducibility of procedures. The ability to store the actions of the surgeon as digitized information also allows for universal, rapid distribution: i.e., the surgeon's activity can be transmitted to the other side of the operating room or to a remote site via high-speed communications links, as was recently demonstrated by our own team during the Lindbergh operation. Furthermore, the surgeon will be able to share his expertise and skill through teleconsultation and telemanipulation, bringing the patient closer to the expert surgical team through electronic means and opening the way to advanced and continuous surgical learning. Finally, for postoperative interaction, virtual reality and simulation can provide us with 4 dimensional images, time being the fourth dimension. This should allow physicians to have a better idea of the disease process in evolution, and treatment modifications based on this view can be anticipated. We are presently determining the

Wing-shaped plastic stents vs. self-expandable metal stents for palliative drainage of malignant distal biliary obstruction: a randomized multicenter study.

PubMed

Schmidt, Arthur; Riecken, Bettina; Rische, Susanne; Klinger, Christoph; Jakobs, Ralf; Bechtler, Matthias; Kähler, Georg; Dormann, Arno; Caca, Karel

2015-05-01

Previous studies have shown superior patency rates for self-expandable metal stents (SEMS) compared with plastic stents in patients with malignant biliary obstruction. The aim of this study was to compare stent patency, patient survival, and complication rates between a newly designed, wing-shaped, plastic stent and SEMSs in patients with unresectable, malignant, distal, biliary obstruction. A randomized, multicenter trial was conducted at four tertiary care centers in Germany. A total of 37 patients underwent randomization between March 2010 and January 2013. Patients underwent endoscopic retrograde cholangiography with insertion of either a wing-shaped, plastic stent without lumen or an SEMS.  Stent failure occurred in 10/16 patients (62.5 %) in the winged-stent group vs. 4/18 patients (22.2 %) in the SEMS group (P = 0.034). The median time to stent failure was 51 days (range 2 - 92 days) for the winged stent and 80 days (range 28 - 266 days) for the SEMS (P = 0.002). Early stent failure (< 8 weeks after placement) occurred in 8 patients (50 %) vs. 2 patients (11.1 %), respectively (P = 0.022). After obtaining the results from this interim analysis, the study was discontinued because of safety concerns. The frequency of stent failure was significantly higher in the winged-stent group compared with the SEMS group. A high incidence of early stent failure within 8 weeks was observed in the winged-stent group. Thus, the winged, plastic stent without central lumen may not be appropriate for mid or long term drainage of malignant biliary obstruction. Study registration ClinicalTrials.gov (NCT01063634). © Georg Thieme Verlag KG Stuttgart · New York.

Spontaneous remission of obstructive jaundice in rats: Selection of experimental models

PubMed Central

Lv, Yunfu; Yue, Jie; Gong, Xiaoguang; Han, Xiaoyu; Wu, Hongfei; Deng, Jie; Li, Yejuan

2018-01-01

The aim of the present study was to evaluate the prevalence and causes of spontaneous remission of obstructive jaundice in rats. Healthy male and female Wistar rats (180–220 g) were randomly assigned to receive common bile duct ligation (CBDL) and transection (group A), CBDL only (group B), or CBD dissection without ligation or transection (control group C; n=36 in each group). There was a difference in eye and skin jaundice prevalence between groups A and B from 14 days after surgery. The level of total bilirubin (TB) did not continue to increase in group A and began to decrease in the majority of rats in group B (P<0.05 vs. group B). At day 21 after surgery, the TB level returned to normal in group B and no significant difference was observed compared with group C. At day 21 after surgery, significant dilatation of bile ducts above the ligature was observed in group A following cholangiography with 38% meglumine diatrizoate and this contrast agent did not spread to other sites. Slight dilatation of the proximal bile ducts was observed in group B and the contrast agent entered the intestinal lumen through the omental ducts adhering to the porta hepatis. After 14 days of surgery, there were 36 rats in group A and B, and 17 rats exhibited spontaneous regression of jaundice. Overall, 47.2% (17/36) of rats experienced spontaneous remission of obstructive jaundice, 82.4% (14/17) of which underwent ligation only. The spontaneous remission of jaundice may have been caused by shunting through very small bile ducts or omental ducts adhering to the porta hepatis. If a model of biliary obstruction is to be established in future research, a model of CBDL and transection is preferable. In this case, jaundice reduction surgery should be performed 14 days after establishment of the model. PMID:29904412

SUPRAPUBIC LAPAROSCOPIC CHOLECYSTECTOMY: TECHNIQUE AND PRELIMINARY RESULTS

PubMed Central

SALES, Leonardo Adolpho S.; PINTO, João Odilo G.; QUEIROZ, Carlos Eduardo F.; CASTRO, Marcelo; DOURADO, Paulo Henrique F.; PINHEIRO, Fernando Antonio S.

2014-01-01

Background The minimally invasive abdominal surgery has evolved to reduce portals, culminating with a single incision and natural orifice operation. However, these methods are still expensive, difficult to implement and with questionable aesthetic results. Aim To present the standardization and preliminary results of a technique for performing laparoscopic suprapubic access by the principle which was called the Supra Pubic Endoscopic Surgery for cholecystectomy. Method The average body mass index of patients, the mean operative time, clinical data of the postoperative complications and quality of life were prospectively studied. The operation incisions consisted of: A) umbilical for instrumental dissection and clipping; B) in the right groin for handling and gallbladder gripping; C) suprapubic for the camera. With the patient in reverse Trendelenburg and left lateral decubitus, the operation flew by the camera trocar in C, proceeding with dissection and isolation of the biliary pedicle, identification of cystic duct and artery, with usual instrumentation. Transcystic intraoperative cholangiography was performed in all cases in which there were indications. The procedure was completed with clipping and sectioning of the cystic duct and artery, retrograde resection of the gallbladder and extracting it by the umbilical trocar incision under direct vision. Results Thirty patients undergone this surgical procedure between March and June 2012 and were evaluated. The mean age was 40.7 years and the indications were typical biliary colic in 18 cases (60 %), cholecystitis in five cases (16.6 %), biliary pancreatitis in one case (3.3%); polyp in three cases (10%) and obstructive jaundice at three cases (10%). The average body mass index was 27.8 (23.1-35.1) and surgical time ranged between 24 and 70 minutes. Conclusion The technique proved to be feasible and safe , with no significant complications, and satisfactory cosmetic results. PMID:24676293

Post-ERCP acute pancreatitis and its risk factors.

PubMed

Iorgulescu, A; Sandu, I; Turcu, F; Iordache, N

2013-03-15

Endoscopic retrograde cholangiopancreatography (ERCP) is a complex endoscopic technique that evolved from a diagnostic to a mainly therapeutic procedure. This was due to the identification of post-procedural complications that can follow both simple ERCP and that associated with the instrumentation of the biliary and pancreatic ductals. The identification of post ERCP complications in a proportion of 5 to 10% of cases, with a mortality rate of 0.33%, imposed their analysis and study of risk factors involved in their occurrence. The significance of post ERCP complications reveals the necessity of their avoidance by adopting additional measures if risk factors are identified. We have retrospectively analyzed 900 cases that underwent ERCP in the Surgery Department of "Sf. Ioan" Clinical Hospital in a period of 17 years. The complications of the procedure were studied. Among them, a special attention was given to post-ERCP acute pancreatitis (pERCP-AP), the most common complication that occurred in the study group. We also tried to find out and highlight the risk factors for this complication. ERCP is a relatively safe invasive procedure, yet it has complications (8% of cases), some of them potentially fatal (mortality 0.43%). The most common complications after ERCP are acute pancreatitis (3.7%), papillary bleeding (1.04%), retroperitoneal duodenal perforation (0.69%) and biliary septic complications like acute cholecystitis and cholangitis (1.21%). Acute pancreatitis is by far the most common complication. Risk factors for its occurrence are difficult sphincterotomy with precut use, failure of CBD desobstruction, pancreatic sphincterotomy, repeated injection of contrast in the pancreatic ductal system, dysfunction of the sphincter of Oddi and the absence of changes of chronic pancreatitis. When risk factors are identified, the patients' selection must be very strict and diagnostic ERCP should be avoided in favor of non-invasive diagnostic methods (MRI-cholangiography

Prophylaxis of post-ERC infectious complications in patients with biliary obstruction by adding antimicrobial agents into ERC contrast media- a single center retrospective study.

PubMed

Wobser, Hella; Gunesch, Agnetha; Klebl, Frank

2017-01-13

Patients with biliary obstruction are at high risk to develop septic complications after endoscopic retrograde cholangiography (ERC). We evaluated the benefits of local application of antimicrobial agents into ERC contrast media in preventing post-ERC infectious complications in a high-risk study population. Patients undergoing ERC at our tertiary referral center were retrospectively included. Addition of vancomycin, gentamicin and fluconazol into ERC contrast media was evaluated in a case-control design. Outcomes comprised infectious complications within 3 days after ERC. In total, 84 ERC cases were analyzed. Primarily indications for ERC were sclerosing cholangitis (75%) and malignant stenosis (9.5%). Microbial testing of collected bile fluid in the treatment group was positive in 91.4%. Detected organisms were sensitive to the administered antimicrobials in 93%. The use of antimicrobials in contrast media was associated with a significant decrease in post-ERC infectious complications compared to non-use (14.3% vs. 33.3%; odds ratio [OR]: 0.33, 95% confidence interval [CI]: 0.114-0.978). After adjusting for the variables acute cholangitis prior to ERC and incomplete biliary drainage, the beneficial effect of intraductal antibiotic prophylaxis was even more evident (OR = 0.153; 95% CI: 0.039-0.598, p = 0.007). Patients profiting most obviously from intraductal antimicrobials were those with secondary sclerosing cholangitis. Local application of a combination of antibiotic and antimycotic agents to ERC contrast media efficiently reduced post-ERC infectious events in patients with biliary obstruction. This is the first study that evaluates ERC-related infectious complications in patients with secondary sclerosing cholangitis. Our first clinical results should now be prospectively evaluated in a larger patient cohort to improve the safety of ERC, especially in patients with secondary sclerosing cholangitis.

Endoscopic Treatment of Biliary Stenosis in Patients with Alveolar Echinococcosis--Report of 7 Consecutive Patients with Serial ERC Approach.

PubMed

Stojkovic, Marija; Junghanss, Thomas; Veeser, Mira; Weber, Tim F; Sauer, Peter

2016-02-01

Biliary vessel pathology due to alveolar echicococcosis (AE) results in variable combinations of stenosis, necrosis and inflammation. Modern management strategies for patients with cholestasis are desperately needed. The aim is proof of principle of serial ERC (endoscopic retrograde cholangiography) balloon dilation for AE biliary pathology. Retrospective case series of seven consecutive patients with AE-associated biliary pathology and ERC treatment in an interdisciplinary endoscopy unit at a University Hospital which hosts a national echinococcosis treatment center. The AE patient cohort consists of 106 patients with AE of the liver of which 13 presented with cholestasis. 6/13 received bilio-digestive anastomosis and 7/13 patients were treated by ERC and are reported here. Biliary stricture balloon dilation was performed with 18-Fr balloons at the initial and with 24-Fr balloons at subsequent interventions. If indicated 10 Fr plastic stents were placed. Six patients were treated by repeated balloon dilation and stenting, one by stenting only. After an acute phase of 6 months with repeated balloon dilation, three patients showed "sustained clinical success" and four patients "assisted therapeutic success," of which one has not yet reached the six month endpoint. In one patient, sustained success could not be achieved despite repeated insertion of plastic stents and balloon dilation, but with temporary insertion of a fully covered self-expanding metal stent (FCSEMS). There was no loss to follow up. No major complications were observed. Serial endoscopic dilation is a standard tool in the treatment of benign biliary strictures. Serial endoscopic intervention with balloon dilation combined with benzimidazole treatment can re-establish and maintain biliary duct patency in AE associated pathology and probably contributes to avoid or postpone bilio-digestive anastomosis. This approach is in accordance with current ERC guidelines and is minimally disruptive for patients.

Endoscopic Treatment of Biliary Stenosis in Patients with Alveolar Echinococcosis – Report of 7 Consecutive Patients with Serial ERC Approach

PubMed Central

Stojkovic, Marija; Junghanss, Thomas; Veeser, Mira; Weber, Tim F.; Sauer, Peter

2016-01-01

Background and Aims Biliary vessel pathology due to alveolar echicococcosis (AE) results in variable combinations of stenosis, necrosis and inflammation. Modern management strategies for patients with cholestasis are desperately needed. The aim is proof of principle of serial ERC (endoscopic retrograde cholangiography) balloon dilation for AE biliary pathology. Methods Retrospective case series of seven consecutive patients with AE-associated biliary pathology and ERC treatment in an interdisciplinary endoscopy unit at a University Hospital which hosts a national echinococcosis treatment center. The AE patient cohort consists of 106 patients with AE of the liver of which 13 presented with cholestasis. 6/13 received bilio-digestive anastomosis and 7/13 patients were treated by ERC and are reported here. Biliary stricture balloon dilation was performed with 18-Fr balloons at the initial and with 24-Fr balloons at subsequent interventions. If indicated 10 Fr plastic stents were placed. Results Six patients were treated by repeated balloon dilation and stenting, one by stenting only. After an acute phase of 6 months with repeated balloon dilation, three patients showed “sustained clinical success” and four patients “assisted therapeutic success,” of which one has not yet reached the six month endpoint. In one patient, sustained success could not be achieved despite repeated insertion of plastic stents and balloon dilation, but with temporary insertion of a fully covered self-expanding metal stent (FCSEMS). There was no loss to follow up. No major complications were observed. Conclusions Serial endoscopic dilation is a standard tool in the treatment of benign biliary strictures. Serial endoscopic intervention with balloon dilation combined with benzimidazole treatment can re-establish and maintain biliary duct patency in AE associated pathology and probably contributes to avoid or postpone bilio-digestive anastomosis. This approach is in accordance with current

Diagnosis of Alagille syndrome-25 years of experience at King's College Hospital.

PubMed

Subramaniam, P; Knisely, A; Portmann, B; Qureshi, S A; Aclimandos, W A; Karani, J B; Baker, A J

2011-01-01

The aim of the study was to study the clinical and histological features of Alagille syndrome (AGS) at presentation comparing the value of the various modalities before the implementation of genetic diagnosis. We performed a retrospective analysis of the records of 117 children diagnosed as having AGS after referral to King's College Hospital between 1980 and 2005. Cholestasis was seen in 104 of 117 (89%), characteristic facies in 91 of 117 (77%), posterior embryotoxon in 72 of 117 (61%), butterfly vertebrae in 44 of 117 (39%), heart disease (most often peripheral pulmonary stenosis) in 107 of 117 (91%), and renal disease in 27 of 117 (23%). Serum cholesterol levels of >5 mmol/L were seen in 52 of 86 (60.4%). Liver biopsy showed characteristic features of paucity of interlobular bile ducts in 59 of 77 (76.6%) children younger than 16 weeks of age, in 10 of 14 (71.4%) between 16 weeks and 1 year of age, and in 8 of 12 (66.66%) older than 1 year of age. Other biopsy findings were those of nonspecific hepatitis and biliary features. Iminodiacetic acid scans showed no excretion of isotope into the bowel after 24 hours in 21 of 35 (60%), and small/no gallbladder on ultrasound was seen in 29 of 104 (27.8%). Eleven of 117 (9.4%) had a diagnostic laparotomy and operative cholangiography, 2 proceeding to Kasai portoenterostomy before referral to our unit. Clinical features of AGS are not as consistently informative as suggested in the literature. Hypercholesterolaemia is nonspecific but may be a helpful pointer. Histology is not characteristic in 25%; hepatobiliary iminodiacetic acid scan and ultrasound may suggest a false diagnosis of biliary atresia in 60% and 28%, respectively, supporting the concept that infants with liver disease warrant early referral to a specialist centre. The advent of genetic diagnosis will redefine the syndrome with likely effects on the prognosis of the defined group.

Risk factors and outcome in patients with primary sclerosing cholangitis with persistent biliary candidiasis.

PubMed

Rupp, Christian; Bode, Konrad Alexander; Chahoud, Fadi; Wannhoff, Andreas; Friedrich, Kilian; Weiss, Karl-Heinz; Sauer, Peter; Stremmel, Wolfgang; Gotthardt, Daniel Nils

2014-10-23

Candidiasis is commonly observed in patients with primary sclerosing cholangitis (PSC), but the clinical risk factors associated with its presence have not been fully investigated. In this study, we aimed to analyse the incidence, risk factors, and transplantation-free survival in primary sclerosing cholangitis (PSC) patients with persistent biliary candidiasis. We retrospectively analysed patients diagnosed with PSC who were admitted to our department during 2002 to 2012. One-hundred fifty patients whose bile cultures were tested for fungal species were selected, and their clinical and laboratory parameters were investigated. The results of endoscopic retrograde cholangiography (ERC) and bile cultures were analysed using chart reviews. The cases of biliary candidiasis were sub-classified as transient or persistent. Thirty out of 150 (20.0%) patients had biliary candidiasis. Although all patients demonstrated comparable baseline characteristics, those with biliary candidiasis showed significantly reduced transplantation-free survival (p < 0.0001) along with a markedly elevated frequency of cholangiocarcinoma (CCA) (p = 0.04). The patients were further sub-classified according to the transient (15/30) or persistent (15/30) nature of their biliary candidiasis. A subgroup analysis showed reduced survival with a greater necessity for orthotopic liver transplantation (OLT) only in patients with persistence of Candida (p = 0.007). The survival in the patients with transient biliary candidiasis was comparable to that in candidiasis-free patients. In a multivariate regression analysis that included Mayo risk score (MRS), sex, age, dominant stenosis, inflammatory bowel disease, autoimmune hepatitis overlap syndrome, and number of times ERC was performed, biliary candidiasis was an independent risk factor for reduced survival (p = 0.008). Risk factors associated with acquisition of biliary candidiasis were age at PSC diagnosis and number of ERCs. The persistence of biliary

Autoimmune paediatric liver disease

PubMed Central

Mieli-Vergani, Giorgina; Vergani, Diego

2008-01-01

Liver disorders with a likely autoimmune pathogenesis in childhood include autoimmune hepatitis (AIH), autoimmune sclerosing cholangitis (ASC), and de novo AIH after liver transplantation. AIH is divided into two subtypes according to seropositivity for smooth muscle and/or antinuclear antibody (SMA/ANA, type 1) or liver kidney microsomal antibody (LKM1, type 2). There is a female predominance in both. LKM1 positive patients tend to present more acutely, at a younger age, and commonly have partial IgA deficiency, while duration of symptoms before diagnosis, clinical signs, family history of autoimmunity, presence of associated autoimmune disorders, response to treatment, and long-term prognosis are similar in both groups. The most common type of paediatric sclerosing cholangitis is ASC. The clinical, biochemical, immunological, and histological presentation of ASC is often indistinguishable from that of AIH type 1. In both, there are high IgG, non-organ specific autoantibodies, and interface hepatitis. Diagnosis is made by cholangiography. Children with ASC respond to immunosuppression satisfactorily and similarly to AIH in respect to remission and relapse rates, times to normalization of biochemical parameters, and decreased inflammatory activity on follow up liver biopsies. However, the cholangiopathy can progress. There may be evolution from AIH to ASC over the years, despite treatment. De novo AIH after liver transplantation affects patients not transplanted for autoimmune disorders and is strikingly reminiscent of classical AIH, including elevated titres of serum antibodies, hypergammaglobulinaemia, and histological findings of interface hepatitis, bridging fibrosis, and collapse. Like classical AIH, it responds to treatment with prednisolone and azathioprine. De novo AIH post liver transplantation may derive from interference by calcineurin inhibitors with the intrathymic physiological mechanisms of T-cell maturation and selection. Whether this condition is a

Autoimmune paediatric liver disease.

PubMed

Mieli-Vergani, Giorgina; Vergani, Diego

2008-06-07

Liver disorders with a likely autoimmune pathogenesis in childhood include autoimmune hepatitis (AIH), autoimmune sclerosing cholangitis (ASC), and de novo AIH after liver transplantation. AIH is divided into two subtypes according to seropositivity for smooth muscle and/or antinuclear antibody (SMA/ANA, type 1) or liver kidney microsomal antibody (LKM1, type 2). There is a female predominance in both. LKM1 positive patients tend to present more acutely, at a younger age, and commonly have partial IgA deficiency, while duration of symptoms before diagnosis, clinical signs, family history of autoimmunity, presence of associated autoimmune disorders, response to treatment, and long-term prognosis are similar in both groups. The most common type of paediatric sclerosing cholangitis is ASC. The clinical, biochemical, immunological, and histological presentation of ASC is often indistinguishable from that of AIH type 1. In both, there are high IgG, non-organ specific autoantibodies, and interface hepatitis. Diagnosis is made by cholangiography. Children with ASC respond to immunosuppression satisfactorily and similarly to AIH in respect to remission and relapse rates, times to normalization of biochemical parameters, and decreased inflammatory activity on follow up liver biopsies. However, the cholangiopathy can progress. There may be evolution from AIH to ASC over the years, despite treatment. De novo AIH after liver transplantation affects patients not transplanted for autoimmune disorders and is strikingly reminiscent of classical AIH, including elevated titres of serum antibodies, hypergammaglobulinaemia, and histological findings of interface hepatitis, bridging fibrosis, and collapse. Like classical AIH, it responds to treatment with prednisolone and azathioprine. De novo AIH post liver transplantation may derive from interference by calcineurin inhibitors with the intrathymic physiological mechanisms of T-cell maturation and selection. Whether this condition is a

Biliary strictures complicating living donor liver transplantation: Problems, novel insights and solutions.

PubMed

Rao, Harshavardhan B; Prakash, Arjun; Sudhindran, Surendran; Venu, Rama P

2018-05-21

Biliary stricture complicating living donor liver transplantation (LDLT) is a relatively common complication, occurring in most transplant centres across the world. Cases of biliary strictures are more common in LDLT than in deceased donor liver transplantation. Endoscopic management is the mainstay for biliary strictures complicating LDLT and includes endoscopic retrograde cholangiography, sphincterotomy and stent placement (with or without balloon dilatation). The efficacy and safety profiles as well as outcomes of endoscopic management of biliary strictures complicating LDLT is an area that needs to be viewed in isolation, owing to its unique set of problems and attending complications; as such, it merits a tailored approach, which is yet to be well established. The diagnostic criteria applied to these strictures are not uniform and are over-reliant on imaging studies showing an anastomotic narrowing. It has to be kept in mind that in the setting of LDLT, a subjective anastomotic narrowing is present in most cases due to a mismatch in ductal diameters. However, whether this narrowing results in a functionally significant narrowing is a question that needs further study. In addition, wide variation in the endotherapy protocols practised in most centres makes it difficult to interpret the results and hampers our understanding of this topic. The outcome definition for endotherapy is also heterogenous and needs to be standardised to allow for comparison of data in this regard and establish a clinical practice guideline. There have been multiple studies in this area in the last 2 years, with novel findings that have provided solutions to some of these issues. This review endeavours to incorporate these new findings into the wider understanding of endotherapy for biliary strictures complicating LDLT, with specific emphasis on diagnosis of strictures in the LDLT setting, endotherapy protocols and outcome definitions. An attempt is made to present the best management

Technical report: gadoxetate-disodium-enhanced 2D R2* mapping: a novel approach for assessing bile ducts in living donors.

PubMed

Fazeli Dehkordy, Soudabeh; Fowler, Kathryn J; Wolfson, Tanya; Igarashi, Saya; Lamas Constantino, Carolina P; Hooker, Jonathan C; Hong, Cheng W; Mamidipalli, Adrija; Gamst, Anthony C; Hemming, Alan; Sirlin, Claude B

2017-10-31

Gadoxetate-disodium (Gd-EOB-DTPA)-enhanced 3D T1- weighted (T1w) MR cholangiography (MRC) is an efficient method to evaluate biliary anatomy due to T1 shortening of excreted contrast in the bile. A method that exploits both T1 shortening and T2* effects may produce even greater bile duct conspicuity. The aim of our study is to determine feasibility and compare the diagnostic performance of two-dimensional (2D) T1w multi-echo (ME) spoiled gradient-recalled-echo (SPGR) derived R2* maps against T1w MRC for bile duct visualization in living liver donor candidates. Ten potential living liver donor candidates underwent pretransplant 3T MRI and were included in our study. Following injection of Gd-EOBDTPA and a 20-min delay, 3D T1w MRC and 2D T1w ME SPGR images were acquired. 2D R2* maps were generated inline by the scanner assuming exponential decay. The 3D T1w MRC and 2D R2* maps were retrospectively and independently reviewed in two separate sessions by three radiologists. Visualization of eight bile duct segments was scored using a 4-point ordinal scale. The scores were compared using mixed effects regression model. Imaging was tolerated by all donors and R2* maps were successfully generated in all cases. Visualization scores of 2D R2* maps were significantly higher than 3D T1w MRC for right anterior (p = 0.003) and posterior (p = 0.0001), segment 2 (p < 0.0001), segment 3 (p = 0.0001), and segment 4 (p < 0.0001) ducts. Gd-EOB-DTPA-enhanced 2D R2* mapping is a feasible method for evaluating the bile ducts in living donors and may be a valuable addition to the living liver donor MR protocol for delineating intrahepatic biliary anatomy.

Diagnostic value of T1-weighted gradient-echo in-phase images added to MRCP in differentiation of hepatolithiasis and intrahepatic pneumobilia.

PubMed

Erden, Ayşe; Haliloğlu, Nuray; Genç, Yasemin; Erden, Ilhan

2014-01-01

The purpose of this article is to determine the added diagnostic value of T1-weighted gradient-echo in-phase images obtained during MRCP in the detection and differentiation of hepatolithiasis and intrahepatic pneumobilia. Intrahepatic bile ducts in 47 patients were scored in terms of their possibility of containing biliary stone and air. MRI was performed with a 1-T system for 32 patients and with a 3-T system for 15 patients. Two radiologists independently reviewed two sets of MRI scans: set 1 included T2-weighted MRCP images, and set 2 included T2-weighted MRCP images plus T1-weighted gradient-echo in-phase images. The diagnostic performances of set 1 and set 2 in the evaluation of the bile ducts containing air or stone and bile ducts containing neither of them were analyzed using the area under the receiver operating characteristic curve (AUC) for clustered data. The sensitivities and specificities of both image sets to detect intrahepatic stone or air were also calculated and compared. For the diagnosis of hepatolithiasis, the AUC obtained from set 2 (0.983) was significantly higher than that obtained from set 1 (0.879; p = 0.037). For the diagnosis of pneumobilia, the AUC obtained from set 2 (0.965) was also significantly higher than that of set 1 (0.765; p = 0.002). With use of percutaneous transhepatic cholangiography, ERCP, and CT as the reference standards, the sensitivity of set 2 (97.1%; 95% CI, 91.1-100%) was significantly higher than that of set 1 (74.3%; 95% CI, 56.7-91.9%) in detecting intrahepatic stones (p = 0.011). For the detection of pneumobilia, the sensitivity of set 2 (98.5%; 95% CI, 95.4-100%) was also significantly higher than that of set 1 (70.8%; 95% CI, 57.7-83.3%; p = 0.000). The addition of T1-weighted gradient-echo in-phase images to standard MRCP sequences improves the detection and differentiation of hepatolithiasis and intrahepatic pneumobilia.

Modulation of gut barrier function in patients with obstructive jaundice using probiotic LP299v.

PubMed

Jones, Claire; Badger, Stephen A; Regan, Mark; Clements, Barry W; Diamond, Tom; Parks, Rowan W; Taylor, Mark A

2013-12-01

This study aimed to determine the effect of LP229v on intestinal permeability and tumour necrosis factor (TNF) p55 receptor concentrations in patients with obstructive jaundice undergoing biliary drainage. Patients undergoing biliary drainage were recruited and randomized into three groups to receive Lactobacillus plantarum 299v (LP299v), inactivated LP299v (placebo) or water. These were administered daily at noon until 7 days after biliary drainage. Intestinal permeability was measured using the lactulose/mannitol (L/M) dual sugar absorption test on admission, the day before biliary drainage and on days 1 and 7 after biliary drainage. Blood and urine were collected to determine the L/M ratio and the TNF p55 receptor levels at each time point. A total of 25 patients were recruited; 12 had choledocholithiasis and nine had a periampullary tumour. Open surgical biliary drainage was performed in nine patients, endoscopic retrograde cholangiopancreatography in 12 and percutaneous transhepatic cholangiography in two. Five patients received LP299v, five received placebo and seven, water. The median L/M ratio was 0.035 (0.018-0.065) at baseline. No difference existed between the groups on admission, before drainage and on day 7 after drainage (P=0.59, 0.175 and 0.61, respectively). The L/M ratio was lower in the LP299v group on day 1 after drainage [0.01 (0.01) vs. 0.18 (0.03-0.3) and 0.11 (0.07-0.14); P=0.37]. Although the TNF p55 receptor levels were lower on day 1 after drainage in the LP299v group (15.3 vs. 30.9 vs. 82.7 ng/ml; P=0.43), the concentration at the four time points was similar (P=0.24, 0.96, 0.43 and 0.68). Pretreatment with probiotic LP299v improves intestinal permeability after biliary drainage and attenuates the inflammatory response. However, a larger multicentre trial is required to determine the effect on clinical outcome.

Management of cystic echinococcosis complications and dissemination: where is the evidence?

PubMed

Dziri, Chadli; Haouet, Karim; Fingerhut, Abe; Zaouche, Abdeljelil

2009-06-01

This systematic review was designed to provide "evidence-based" answers to identify the best treatment for a complicated hydatid cyst of the liver and the appropriate management of disseminated cystic echinococcosis. An extensive electronic search of the relevant literature was performed using Medline and the Cochrane Library. This systematic review enabled us make to determine the best treatment options for the following conditions. Liver hydatid cysts ruptured into the biliary tract: Common bile duct exploration should be conducted using intraoperative cholangiography and choledoscopy. When the biliary tract is cleared of all cystic content, T-tube drainage should be sufficient. The principal difficulty concerned the management of the large biliocystic fistula: suture or internal transfistulary drainage or fistulization. Medical treatment is indicated in association with surgery for 3 months postoperatively. During the preoperative period, endoscopic retrograde cholangiopancreatography (ERCP) combined with preoperative endoscopic sphincterotomy (ES) may decrease the incidence of postoperative external fistula. Liver hydatid cysts involving the thorax: An abdominal approach is mandatory when common bile duct drainage is required, and it may be sufficient to treat a direct rupture into bronchi. An acute abdomen, owing to Liver hydatid cysts ruptured into peritoneum, requires an emergent operation. Medical treatment should be associated. Cystic echinococcosis of the lung: Surgery is still the main therapeutic option to remove the cyst, suture bronchial fistula if necessary, followed by capitonnage. Osseous cystic echinococcosis: Wide surgical excision is recommended. Cystic echinococcosis of the heart: Cystopericystectomy is the "gold standard" procedure but is sometimes unsuitable for particular sites. Cystic echinococcosis of the kidney: Cystectomy with pericystectomy is feasible in 75% of cases; nephrectomy must be reserved for destroyed kidney. Multiple

Successful treatment of recurrent cholangitis by constructing a hepaticojejunostomy with long Roux-en-Y limb in a long-term surviving patient after a Whipple procedure for pancreatic adenocarcinoma.

PubMed

Tsalis, Konstantinos; Antoniou, Nikolaos; Koukouritaki, Zambia; Patridas, Dimitrios; Sakkas, Leonidas; Kyziridis, Dimitrios; Lazaridis, Charalampos

2014-08-20

Female, 74. Recurrent cholangitis. -. -. -. Gastroenterology and Hepatology. Unusual clinical course. Cholangitis may result from biliary obstruction (e.g., biliary or anastomotic stenosis, or foreign bodies) or occur in the presence of normal biliary drainage. Although reflux of intestinal contents into the biliary tree after hepaticojejunostomy appears to be a rare complication, it is important to emphasize that there are few available surgical therapeutic techniques. A 74-year-old woman presented to our hospital after 17 years of episodes of cholangitis. The patient had undergone a pancreatoduodenectomy (Whipple procedure) 18 years earlier due to pancreatic adenocarcinoma. The reconstruction was achieved through the sequential placement of pancreatic, biliary, and retrocolic gastric anastomosis into the same jejunal loop. The postoperative course was uneventful and the patient received adjuvant chemotherapy. Approximately 6 months after the initial operation, the patient started having episodes of cholangitis. Over the next 17 years she experienced several febrile episodes presumed to be secondary to cholangitis. A computing tomography (CT) scan of the abdomen revealed intrahepatic bile ducts partially filled with orally administered contrast material (Gastrografin). Magnetic resonance cholangiopancreatography (MRCP) showed dilatation of the left intrahepatic bile ducts. A percutaneous transhepatic cholangiography showed that the bilioenteric anastomosis was normal, without stenosis. Based on these findings, a diagnosis of a short loop between the hepaticojejunostomy and the gastrojejunostomy permitting the reflux of intestinal juice into the biliary tree was made. During the re-operation, a new hepaticojejunal anastomosis in a 100-cm long Roux-en-Y loop was performed to prevent the reflux of the intestinal fluid into the biliary tree. The patient was discharged on postoperative day 10. One year after the second procedure, the patient enjoys good health and has

[Prevention, diagnosis and surgical treatment of injuries of the biliary tract during laparoscopic cholecystectomy. Treatment of papilla injuries caused by invasive endoscopy. Part 2. Surgical treatment of biliary tract injuries].

PubMed

Sváb, J; Pesková, M; Krska, Z; Gürlich, R; Kasalický, M

2005-04-01

Introduction of endoscopic invasive procedures in the 70th and 80th years leaded to decrease reoperations on biliary tree. latrogenic injury of the biliary tract have increased in incidence in the first decade with the introduction of laparoscopic cholecystectomy. Athough a number of factors have been identified with a high risk of injury (and number of technical steps have been emphasized to avoid these injury, the incidence of the bile duct injury has reached at least double the rate observed with open cholecystectomy. Most patients that sustained a bile duct injury are recognized in the weeks following laparoscopic cholecystectomy. Careful preoperative preparation should include control of sepsis by draining any bile collections or fistulas and complete cholangiography. Long-term results are best achieved in specialized hepatobiliary centers performing biliary reconstruction with a Roux-Y hepaticojejunostomy. Success rates over 90% have been reported from several centres to date with intermediate follow-up. Introduction of an invasive endoscopy. Very dangerous is injury after endoscopic papilotomy. In an article of a review of experiences of the Ist Department of Surgery of General hospital in Prague since 1971 in 1 017 reoperations on biliary tree has been carried out. There were in 311 patients 164 hepato-hepatostomies and 147 hepaticojejunostomies used (Tab. 1). By laparoscopic injuries in the last decade were hilary injuries (Bismuth IV) and hepaticojejunostomy was done in all cases. Died 6%, long-term results are acceptable by injured patients with hepatico-hepaticostomies in 70%, by hepaticojejunostomies in 90%. Reoperated were 10% patients. Remnant patients were dilated endoscopically. Postoperatively morbidity was high, above 26%. In years 1995-2003 were 8 patients with papila injury and inflammation in retroperitoneum operated as a injured duodenum (Tab. 2). Better experiences with treatment of injured biliary tree and papila are in centres interested

Microbiological Assessment of Bile and Corresponding Antibiotic Treatment

PubMed Central

Rupp, Christian; Bode, Konrad; Weiss, Karl Heinz; Rudolph, Gerda; Bergemann, Janine; Kloeters-Plachky, Petra; Chahoud, Fadi; Stremmel, Wolfgang; Gotthardt, Daniel Nils; Sauer, Peter

2016-01-01

Abstract The aim of this study was to determine the antibiotic susceptibility profiles of bacteria in bile samples and to analyze the clinical relevance of the findings as only limited information about risk factors for elevated frequence of bacterial and fungal strains in routinely collected bile samples has been described so far. A prospective cohort study at a tertiary care center was conducted. Seven hundred forty-four patients underwent 1401 endoscopic retrograde cholangiographies (ERCs) as indicated by liver transplantation (427/1401), primary sclerosing cholangitis (222/1401), choledocholithiasis only (153/1401), obstruction due to malignancy (366/1401), or other conditions (233/1401). Bile samples for microbiological analysis were obtained in all patients. The 71.6% (823/1150) samples had a positive microbiological finding, and 57% (840/1491) of the bacterial isolates were gram-positive. The main species were Enterococcus spp (33%; 494/1491) and Escherichia coli (12%; 179/1491). Of the samples, 53.8% had enteric bacteria and 24.7% had Candida spp; both were associated with clinical and laboratory signs of cholangitis (C-reactive proteins 35.0 ± 50.1 vs 44.8 ± 57.6; 34.5 ± 51.2 vs 52.9 ± 59.7; P < 0.001), age, previous endoscopic intervention, and immunosuppression. Multi-resistant (MR) strains were found in 11.3% of all samples and were associated with clinical and laboratory signs of cholangitis, previous intervention, and immunocompromised status. In subgroup analysis, strain-specific antibiotic therapy based on bile sampling was achieved in 56.3% (89/158) of the patients. In cases with a positive bile culture and available blood culture, blood cultures were positive in 29% of cases (36/124), and 94% (34/36) of blood cultures had microbial species identical to the bile cultures. Bactobilia and fungobilia can usually be detected by routine microbiological sampling, allowing optimized, strain-specific antibiotic treatment. Previous

Endoscopic sphincterotomy: follow-up evaluation of effects on the sphincter of Oddi.

PubMed

Geenen, J E; Toouli, J; Hogan, W J; Dodds, W J; Stewart, E T; Mavrelis, P; Riedel, D; Venu, R

1984-10-01

Endoscopic sphincterotomy (ES) alters the structure and motor function of the sphincter of Oddi (SO). The magnitude and duration of these changes, however, have not been critically examined. Before ES, 22 patients with common bile duct stones were evaluated by endoscopic retrograde cholangiography. The pressure gradient between the common bile duct and the duodenum, the SO basal pressure, and the SO peak phasic pressures were obtained. After ES, the electrosurgical incision length was determined using the extended papillotome and an inflated Fogarty balloon as reference. A high correlation existed between the endoscopist's estimate of ES incision size using this technique and the actual length of simulated incisions fashioned in cardboard mounts. These studies were repeated in all 22 patients at 1-yr follow-up and in 8 of these patients at 2-yr follow-up. At 12 mo and 24 mo after ES, the common bile duct (CBD) to duodenal pressure gradient and the sphincter of Oddi basal pressure were virtually eliminated. The amplitude of SO phasic contractions was significantly diminished 12 mo after ES (124 +/- 16 mmHg to 37 +/- 10 mmHg; p less than 0.001), but 24 mo after ES, SO phasic contraction amplitude was not significantly different from the values before ES. Incision length at 1-yr follow-up was reduced in the group of 22 patients from 11.6 +/- 0.8 mm to 8.3 +/- 0.5 mm (p less than 0.001), and in the group of 8 patients from 11.0 +/- 1.5 mm to 7.5 +/- 0.7 mm (p less than 0.025). After an additional 12 mo, however, i.e., 24 mo after ES, the incision length was 6.5 +/- 0.7 mm. There was no significant difference in incision length between the 12-mo and 24-mo examinations. We conclude that after ES, incision length decreases during the first year. There appears to be no further significant reduction in incision length at 2 yr. In addition, the reduction of the CBD to duodenal pressure gradient and the SO basal pressure remain unchanged for at least 2 yr. These manometric

Dual-energy CT revisited with multidetector CT: review of principles and clinical applications.

PubMed

Karçaaltıncaba, Muşturay; Aktaş, Aykut

2011-09-01

Although dual-energy CT (DECT) was first conceived in the 1970s, it was not widely used for CT indications. Recently, the simultaneous acquisition of volumetric dual-energy data has been introduced using multidetector CT (MDCT) with two X-ray tubes and rapid kVp switching (gemstone spectral imaging). Two major advantages of DECT are material decomposition by acquiring two image series with different kVp and the elimination of misregistration artifacts. Hounsfield unit measurements by DECT are not absolute and can change depending on the kVp used for an acquisition. Typically, a combination of 80/140 kVp is used for DECT, but for some applications, 100/140 kVp is preferred. In this study, we summarized the clinical applications of DECT and included images that were acquired using the dual-source CT and rapid kVp switching. In general, unenhanced images can be avoided by using DECT for body and neurological applications; iodine can be removed from the image, and a virtual, non-contrast (water) image can be obtained. Neuroradiological applications allow for the removal of bone and calcium from the carotid and brain CT angiography. Thorax applications include perfusion imaging in patients with pulmonary thromboemboli and other chest diseases, xenon ventilation-perfusion imaging and solitary nodule characterization. Cardiac applications include dual-energy cardiac perfusion, viability and cardiac iron detection. The removal of calcific plaques from arteries, bone removal and aortic stent graft evaluation may be achieved in the vascular system. Abdominal applications include the detection and characterization of liver and pancreas masses, the diagnosis of steatosis and iron overload, DECT colonoscopy and CT cholangiography. Urinary system applications are urinary calculi characterization (uric acid vs. non-uric acid), renal cyst characterization and mass characterization. Musculoskeletal applications permit the differentiation of gout from pseudogout and a reduction of

One-step laparoscopic and endoscopic treatment of gallbladder and common bile duct stones: our experience of the last 9 years in a retrospective study.

PubMed

Liverani, Andrea; Muroni, Mirko; Santi, Francesco; Neri, Tiziano; Anastasio, Gerardo; Moretti, Marco; Favi, Francesco; Solinas, Luigi

2013-12-01

The optimal timing and best method for removal of common bile duct stones (CBDS) associated with gallbladder stones (GBS) is still controversial. The aim of this study is to investigate the outcomes of a single-step procedure combining laparoscopic cholecystectomy (LC), intraoperative cholangiography (IOC), and endoscopic retrograde cholangiopancreatography (ERCP). Between January 2003 and January 2012, 1972 patients underwent cholecystectomy at our hospital. Of those, 162 patients (8.2%; male/female 72/90) presented with GBS and suspected CBDS. We treated 54 cases (Group 1) with ERCP and LC within 48 to 72 hours. In 108 patients (Group 2) we performed LC with IOC and, if positive, was associated with IO-ERCP and sphincterotomy. In Group 1, a preoperative ERCP and LC were completed in 50 patients (30%). In four cases (2%), an ERCP and endobiliary stents were performed without cholecystectomy and then patients were discharged because of the severity of clinical conditions and advanced American Society of Anesthesiologists score (III to IV). Two months later a preoperative ERCP and removal of biliary stents were performed followed by LC 48 to 72 hours later. In Group 2, the IOC was performed in all cases and CBDS were extracted in 94 patients (87%). In two cases, the laparoscopic choledochotomy was necessary to remove large stones. In another two cases, an open choledochotomy was performed to remove safely the stones with T-tube drainage. In three cases, conversion was necessary to safely complete the procedure. The mean operative time was 95 minutes (range, 45 to 150 minutes) in Group 1 and 130 minutes (range, 50 to 300 minutes) in Group 2. The mean hospital stay was 6.5 days (range, 4 to 21 days) in Group 1 and 4.7 days (range, 3 to 14 days) in Group 2. Five cases (two in Group 2 and three in Group 1) presented with CBDS at 12 to 18 months after surgery. They were treated successfully with a second ERCP. There was no perioperative mortality. Our experience suggests

Agents for gallstone dissolution.

PubMed

Pitt, H A; McFadden, D W; Gadacz, T R

1987-02-01

Numerous methods are presently available for gallstone dissolution, including oral bile salts; cholesterol solvents such as mono-octanoin and methyl tert-butyl ether; calcium or pigment solvents such as EDTA and polysorbate; mechanical extraction techniques through a T-tube tract or after endoscopic sphincterotomy; or fragmentation methods such as ultrasonography or electrohydraulic lithotripsy, lasers, and extracorporeal shock waves. Which, if any, of these methods will be appropriate for an individual patient depends on the type of stones, whether they are in the gallbladder or bile ducts, whether access to the biliary tree is available, the patient's age and general medical condition, and the availability of expert radiologists, endoscopists, and newer equipment. In the United States, the only available oral bile salt for cholesterol gallstone dissolution is chenodeoxycholate. Ursodeoxycholate, which is more rapid and less toxic, has not been approved by the Federal Drug Administration. These agents are most effective in thin women with small, floating, radiolucent cholesterol gallstones in a functioning gallbladder. Only about half of this small subset of patients, however, will experience partial or complete dissolution of stones in 6 to 12 months. Moreover, recurrence is very likely, and the potential toxicity of long-term therapy is unknown. Thus, for most patients, cholecystectomy remains the most cost-effective and, perhaps, safest option. Intragallbladder instillation of methyl tert-butyl ether and extracorporeal shock wave therapy are also likely to be applicable to only small subsets of patients and to be associated with high recurrence rates. In patients with retained ductal cholesterol stones and access to the biliary tree, mono-octanoin therapy is advantageous in that it can be begun as soon as cholangiography demonstrates no extravasation. In properly selected patients, a 90 percent success rate with mono-octanoin infusion can be expected within a

Severe and fatal complications after diagnostic and therapeutic ERCP: a prospective series of claims to insurance covering public hospitals.

PubMed

Trap, R; Adamsen, S; Hart-Hansen, O; Henriksen, M

1999-02-01

one patient who had pancreatitis prior to ERCP. ERCP, even for diagnostic purposes, may be associated with very serious and even fatal complications. The use of the precut procedure for access should still be considered dangerous. Other means of investigating the bile ducts should be developed. If endoscopic ultrasonography and magnetic resonance cholangiography prove to have the same diagnostic value as ERCP, which must be considered the gold standard for visualizing the ducts today, they might replace ERCP as the primary investigation in patients with an intermediate or low risk of bile duct stones; this would reduce the numbers of patients exposed to the risks of ERCP.

Magnetic resonance cholangiogram patterns and clinical profiles of ketamine-related cholangiopathy in drug users.

PubMed

Seto, Wai-Kay; Mak, Siu-King; Chiu, Keith; Vardhanabhuti, Varut; Wong, Ho-Fai; Leong, Heng-Tat; Lee, Paul S F; Ho, Y C; Lee, Chi-Kei; Cheung, Ka-Shing; Yuen, Man-Fung; Leung, Wai K

2018-07-01

Recreational ketamine use has emerged as an important health and social issue worldwide. Although ketamine is associated with biliary tract damage, the clinical and radiological profiles of ketamine-related cholangiopathy have not been well described. Chinese individuals who had used ketamine recreationally at least twice per month for six months in the previous two years via a territory-wide community network of charitable organizations tackling substance abuse were recruited. Magnetic resonance cholangiography (MRC) was performed, and the findings were interpreted independently by two radiologists, with the findings analysed in association with clinical characteristics. Among the 343 ketamine users referred, 257 (74.9%) were recruited. The mean age and ketamine exposure duration were 28.7 (±5.8) and 10.5 (±3.7) years, respectively. A total of 159 (61.9%) had biliary tract anomalies on MRC, categorized as diffuse extrahepatic dilatation (n = 73), fusiform extrahepatic dilatation (n = 64), and intrahepatic ductal changes (n = 22) with no extrahepatic involvement. Serum alkaline phosphatase (ALP) level (odds ratio [OR] 1.007; 95% CI 1.002-1.102), lack of concomitant recreational drug use (OR 1.99; 95% CI 1.11-3.58), and prior emergency attendance for urinary symptoms (OR 1.95; 95% CI 1.03-3.70) had high predictive values for biliary anomalies on MRC. Among sole ketamine users, ALP level had an AUC of 0.800 in predicting biliary anomalies, with an optimal level of ≥113 U/L having a positive predictive value of 85.4%. Cholangiographic anomalies were reversible after ketamine abstinence, whereas decompensated cirrhosis and death were possible after prolonged exposure. We have identified distinctive MRC patterns in a large cohort of ketamine users. ALP level and lack of concomitant drug use predicted biliary anomalies, which were reversible after abstinence. The study findings may aid public health efforts in combating the growing epidemic of ketamine

Endotherapy for bile leaks from isolated ducts after hepatic resection: A long awaited challenge.

PubMed

Mutignani, Massimiliano; Forti, Edoardo; Dokas, Stefanos; Pugliese, Francesco; Fontana, Paola; Tringali, Alberto; Dioscoridi, Lorenzo

2017-08-01

Bile leakage is a common complication after hepatic resection [1-4] (Donadon et al., 2016; Dechene et al., 2014; Zimmitti et al., 2013; Yabe et al., 2016). Endotherapy is the treatment of choice for this complication except for bile leaks originating from isolated ducts; a condition resembling the post laparoscopic cholecystectomy Strasberg type C lesions [5-9] (Lillemo et al., 2000; Gupta and Chandra, 2011; Park et al., 2005; Colovic, 2009; Mutignani et al., 2002). In such cases, surgical repair is complex, often of uncertain result and with a high morbidity and mortality [1] (Donadon et al., 2016). On the other hand, percutaneous interventions (i.e. plugging the isolated duct with glue) are technically difficult and risky [7,8] (Park et al., 2005; Colovic, 2009). Endoscopy, thus far, was not considered amongst treatment options. That is because the isolated duct cannot be opacified during cholangiography and is not accessible with the usual endoscopic methods [5,6] (Lillemo et al., 2000; Gupta and Chandra, 2011). Considering the pathophysiology of this type of bile leaks, it is possible to change the pressure gradient endoscopically in order to direct bile flow from the isolated duct towards the duodenal lumen, thus creating an internal biliary fistula to restore bile flow. In order to achieve this goal, we have to perforate the biliary tree into the abdomen. The key element of endoscopic treatment is to create a direct connection between the abdominal cavity and the duodenal lumen by-passing the residual biliary tree with a new technique fully explained in the paper. Our case series (from 2011 to 2016) consists of 13 patients (eight male, five female, mean age 58 years) with fistulas from isolated ducts after various types of hepatic resection. We performed sphincterotomy and placed a biliary stent with the proximal edge inside the intra-abdominal bile collection in 11 patients (eight biliary fully-covered self-expandable metal stents; three plastic stents). In

A prospective group sequential study evaluating a new type of fully covered self-expandable metal stent for the treatment of benign biliary strictures (with video).

PubMed

Poley, Jan-Werner; Cahen, Djuna L; Metselaar, Herold J; van Buuren, Henk R; Kazemier, Geert; van Eijck, Casper H J; Haringsma, Jelle; Kuipers, Ernst J; Bruno, Marco J

2012-04-01

Fully-covered self expandable metal stents (fcSEMSs) are an alternative to progressive plastic stenting for the treatment of benign biliary strictures (BBS) with the prospect of a higher treatment efficacy and the need for fewer ERCPs, thereby reducing the burden for patients and possibly costs. Key to this novel treatment is safe stent removal. To investigate the feasibility and safety of stent removal of a fcSEMS with a proximal retrieval lasso: a long wire thread integrated in the proximal ends of the wire mesh that hangs freely in the stent lumen. Pulling it enables gradual removal of the stent inside-out. A secondary aim was success of stricture resolution. Non-randomized, prospective follow-up study with 3 sequential cohorts of 8 patients with BBS. Academic tertiary referral center. Eligible patients had strictures either postsurgical (post-cholecystectomy (LCx) or liver transplantation (OLT)), due to chronic pancreatitis (CP), or papillary stenosis (PF). Strictures had to be located at least 2 cm below the liver hilum. All patients had one plastic stent in situ across the stricture and had not undergone previous treatment with either multiple plastic stents or fcSEMS. The first cohort of patients underwent stent placement for 2 months, followed by 3 months if the stricture had not resolved. The second and third cohort started with 3 months and 4 months, respectively, both followed by another 4 months if indicated. Treatment success was defined by stricture resolution at cholangiography, the ability to pass an inflated extraction balloon and clinical follow-up (at least 6 months). safety of stent removal. Secondary outcomes were complications and successful stricture resolution. A total of 23 patients (11 female; 20-67 yrs) were eligible for final analysis. One patient developed a malignant neuroendocrine tumor in the setting of CP. Strictures were caused by CP (13), OLT (6), LCx (3) and PF (1). In total 39 fcSEMS were placed and removed. Removals were easy

[Laparoscopic and general surgery guided by open interventional magnetic resonance].

PubMed

Lauro, A; Gould, S W T; Cirocchi, R; Giustozzi, G; Darzi, A

2004-10-01

room, the tubing and light head being passed through penetration panels. Intraoperative MR-cholangiography was performed using fast spin echo (SSFSE) techniques with minimal intensity projection 3-dimensional reconstruction. About skin sarcomas, 2 of them were skin recurrences of previously surgically treated sarcomas (all of them received preoperative biopsy) and the extent of the lesion was then determined using short tau inversion recovery (STIR) sequence. The skin was closed in each case without need for any plastic reconstruction. The breast lesions were visualized with both Signa and real-time imaging and all enhanced with contrast: 2 (20%) were visualized only after contrast enhancement; intraoperative real time imaging clearly demonstrated a resection margin in all cases. Maximum dimensions of breast specimens (range 8-50 mm, median 24.5 mm) were not significantly different from those measured by Signa (p>0.17, Student's paired t-test) or real time images (p>0.4): also there was no significant difference in lesion size between Signa and real time images (p>0.25). All postprocedure scans clearly demonstrated complete excision. The extent of the tumor at MR imaging was greater in each case than suggested by clinical examination. Adequate resection margins were planned using STIR sequences. Histological examination confirmed clear surgical margins of at least 1 cm in each case. During right hemicolectomy, both intraoperative SSFSE and FSPGR contrast imaging revealed the lesion and details of the colonic surface; imaging of the lymph node draining right colon was only partially successful, due to movement artifact. Concerning laparoscopic procedures, both FSE and SSFSE techniques produced reasonable images of the gallbladder and intrahepatic ducts, but the FSE imaging was of poor quality due to respiration artifact; however, SSFSE allowed visualization of the gallbladder and part of the common bile duct. About skin sarcomas, the extent of the tumor at MR imaging

Biochemical characteristics of neonatal cholestasis induced by citrin deficiency

PubMed Central

Wang, Jian-She; Wang, Xiao-Hong; Zheng, Ying-Jie; Fu, Hai-Yan; Chen, Rui; Lu, Yi; Fang, Ling-Juan; Saheki, Takeyori; Kobayashi, Keiko

2012-01-01

AIM: To explore differences in biochemical indices between neonatal intrahepatic cholestasis caused by citrin deficiency (NICCD) and that with other etiologies. METHODS: Patients under 6 mo of age who were referred for investigation of conjugated hyperbilirubinaemia from June 2003 to December 2010 were eligible for this study. After excluding diseases affecting the extrahepatic biliary system, all patients were screened for the two most common SLC25A13 mutations; the coding exons of the entire SLC25A13 gene was sequenced and Western blotting of citrin protein performed in selected cases. Patients in whom homozygous or compound heterozygous SLC25A13 mutation and/or absence of normal citrin protein was detected were defined as having NICCD. Cases in which no specific etiological factor could be ascertained after a comprehensive conjugated hyperbilirubinaemia work-up were defined as idiopathic neonatal cholestasis (INC). Thirty-two NICCD patients, 250 INC patients, and 39 infants with cholangiography-confirmed biliary atresia (BA) were enrolled. Laboratory values at their first visit were abstracted from medical files and compared. RESULTS: Compared with BA and INC patients, the NICCD patients had significantly higher levels of total bile acid (TBA) [all measures are expressed as median (inter-quartile range): 178.0 (111.2-236.4) μmol/L in NICCD vs 112.0 (84.9-153.9) μmol/L in BA and 103.0 (70.9-135.3) μmol/L in INC, P = 0.0001]. The NICCD patients had significantly lower direct bilirubin [D-Bil 59.6 (43.1-90.9) μmol/L in NICCD vs 134.0 (115.9-151.2) μmol/L in BA and 87.3 (63.0-123.6) μmol/L in INC, P = 0.0001]; alanine aminotransferase [ALT 34.0 (23.0-55.0) U/L in NICCD vs 108.0 (62.0-199.0) U/L in BA and 84.5 (46.0-166.0) U/L in INC, P = 0.0001]; aspartate aminotransferase [AST 74.0 (53.5-150.0) U/L in NICCD vs 153.0 (115.0-239.0) U/L in BA and 130.5 (81.0-223.0) U/L in INC, P = 0.0006]; albumin [34.9 (30.7-38.2) g/L in NICCD vs 38.4 (36.3-42.2) g/L in BA and