Bile Duct Pressure Research Articles

EP72 - Spontaneous Hepatic subcapsular Biloma Secondary to Choledocholithiasis with concurrent calculous cholecystitis

Abstract Introduction The term "Biloma," introduced in 1979 by Gould and Patel, denotes an encapsulated extrahepatic bile collection primarily caused by iatrogenic or traumatic injuries1. Spontaneous Biloma, a rare non-traumatic occurrence, involves the spontaneous perforation of extrahepatic or intrahepatic bile ducts. In our case report, the spontaneous Biloma developed because of an abrupt increase in bile duct pressure secondary to biliary obstruction because of choledocholithiasis 2. Case Report We present an 85-year-old male with calculous cholecystitis and concurrent choledocholithiasis, leading to acute severe cholangitis. There was no history of surgery, instrumentation, or trauma. He exhibited hemodynamic instability and acute renal failure. Diagnostic tests revealed raised inflammatory markers and deranged liver and kidney functions. CT scans unveiled a large subcapsular liver collection compressing the parenchyma (Figure a &b), alongside dilated intrahepatic biliary radicles, common bile duct, and choledocholithiasis. Treatment Nowadays, treatment for spontaneous Biloma is nonsurgical. Urgent endoscopic drainage and percutaneous transhepatic cholangiogram (PTC) – (Figure c) were performed, followed by ERCP, sphincterotomy, and stone removal (Figure d) once the patient stabilized3. Subsequent CT scans indicated resolution of the subcapsular collection (Figure e). During recovery, the patient experienced a small pulmonary embolism, managed conservatively. Conclusion This case underscores the rare occurrence of spontaneous hepatic subcapsular Biloma associated with choledocholithiasis in an elderly patient. Timely intervention with endoscopic and radiological procedures proved effective, leading to resolution of the Biloma and successful management of causative pathology.

Sphincter of Oddi Dysfunction Induces Gallstone by Inhibiting the Expression of ABCB11 via PKC-α.

The abnormal increase of Oddi sphincter pressure and total bile duct pressure may play an important role in the formation of cholesterol stones, but the specific molecular mechanism is still unclear. This study aims to investigate it through in vitro and in vivo experiments. A mouse model of Oddi sphincter dysfunction was constructed by stone-inducing diet. We compared the two groups with PKC-α inhibitor GÖ6976 and PKC-α agonist thymeleatoxin. Oddi sphincter pressure and total bile duct pressure were measured. Biochemical analysis of total cholesterol, bile acid and bilirubin was then conducted. The histopathologic changes of bile duct were observed by HE staining and the ultrastructure of liver cells and surrounding tissues was observed by transmission electron microscopy. Through the above experiments, we found that the change of PKC-α expression may affect the formation process of gallstones. The relationship between PKC-α and ABCB11 was further verified by in vitro and in vivo experiments. Our results suggest that ABCB11 and PKC-α are co-expressed in the tubule membrane of hepatocytes and interact with each other in hepatocytes. The high cholesterol diet further enhances the activation of PKC-α and thus reduces the expression of ABCB11. The formation of cholesterol stones is associated with the down-regulation of ABCB11 expression in the tubule membrane of hepatocytes due to kinase signaling. This is the first study to demonstrate that sphincter of Oddi dysfunction induces gallstones through PKC-α inhibition of ABCB11 expression.

Bacteriobilia frequency in patients afflicted by biliary obstruction at a tertiary care center

Background: Bile typically remains sterile within individuals possessing a normal biliary tract, but bacterial colonization arises with biliary obstruction. Infections often stem from ascending duodenal infection or bacterial translocation from the portal vein. Elevated common bile duct pressure due to obstruction, combined with infected bile, can lead to bacterial backflow into lymphatics, fostering cholangitis. In this study, 30 sequential bile samples were examined, scrutinizing the occurrence of bacteriobilia and comparing its incidence between benign and malignant etiologies. Aims and Objectives: Bacteriobilia typically manifests without symptoms. This study aimed to assess the prevalence of bacteriobilia in patients with obstructive jaundice undergoing endoscopic retrograde cholangiopancreatography (ERCP) at our institution, investigating associated risk factors. Furthermore, the study aimed to elucidate the microbiological profile of bile in obstructed biliary systems, make a comparative analysis of bacteriobilia frequency between benign and malignant obstructions, and delve into the drug sensitivity patterns of bacteria cultured from bile at our center. Materials and Methods: In a prospective, observational, and diagnostic study conducted at the Department of Digestive Health and Diseases, Government Peripheral Hospital, Anna Nagar, Chennai, from September 2011 to February 2012, with ethical committee approval and informed consent from all participants, we investigated 30 consecutive patients who underwent ERCP for biliary obstruction. The study cohort comprised 13 males and 17 females. Following successful biliary cannulation, bile samples were collected and subjected to microbiological analysis. Results revealed positive bile cultures in 16 patients, with 10 exhibiting benign etiology and 6 malignant. Gram-negative organisms, predominantly Klebsiella, were identified, displaying favorable susceptibility to cephalosporins while demonstrating resistance to ciprofloxacin. Results: Bile cultures yielded positive results in 16 patients, with 10 cases attributed to benign etiology and 6 to malignant etiology. The cultured organisms were predominantly Gram-negative, with Klebsiella exhibiting significant growth. Notably, these organisms exhibited favorable susceptibility to cephalosporins while displaying resistance to ciprofloxacin. Conclusion: Bile culture serves as a valuable tool for prompt diagnosis and pre-emptive management of complications. Gram-negative bacilli infections prevail within obstructed biliary systems. This study underscores the pivotal role of routine bile sampling during ERCP in obstructed biliary systems, offering predictive insights to avert complications like cholangitis.

Common bile duct pressure after open intraoperative instrumentation in patients with uncomplicated choledocholithiasis.

Common bile duct pressure (CBDP) after surgical exploration has not been fully detailed. The objective was to describe the changes of CBDP after open surgical exploration in patients with choledocholithiasis, considering clinical scenarios in remote locations. A before-after study was designed. Patients with choledocholithiasis who required an open cholecystectomy with exploration of bile ducts were included in the study. Open cholecystectomy was performed and perioperative T-tube CBDP was registered immediately after the procedure and weekly thereafter, with a 6 week follow-up. Control T-tube cholangiogram was performed at week 6 to exclude residual stones. Data were analyzed with T test for paired samples. Thirteen patients were included (age range, 17-69 years; 38.69 ± 17.97). Mean CBDP (cm H2O) registered were as follows: Initial = 19.5, week 1 = 16.2, week 2 = 14.3, week 3 = 13.0, week 4 = 12.1, week 5 = 11.1, and week 6 = 9.7. There were significant differences shown when comparing week 2 (p = 0.05), week 3 (p = 0.036), week 4 (p = 0.023), week 5 (p = 0.010), and week 6 (p = 0.004) with the initial value. CBDP decreases between 2nd and 3rd post-operative weeks. The use of choledochomanometry is useful in clinical scenarios with no access to imaging or interventionism facilities as in remote populations or rural locations.

Analysis of the Relationship Between Periampullary Diverticulum and Recurrent Bile Duct Stones After Endoscopy on Magnetic Resonance Imaging of Magnetic Nanoparticles

The objective of this work was to investigate the effect of magnetic resonance cholangiopancreatography (MRCP) based on super-paramagnetic iron oxide nanoparticles (SPIONs) on the recurrence diagnosis of periampullary diverticulum (PAD) and bile duct stone (BDS), so as to provide a scientific research basis for the recidivation factors of bile duct stones in clinic. Patients with PAD diagnosed in hospital from July 2019 to March 2021 (who had undergone endoscopic gallstone surgery) were selected for study in this work. They were rolled into two groups, the parapapillary group (123 cases) and the cholangiopancreatic duct directly opening in the diverticulum group (97 cases), according to the clinical classification. Then, 100 patients without PAD who had undergone bile duct node therapy were selected as the control group. The recidivation of BDS, serological index, and biliary pressure index before and after treatment were compared. The relationship between PAD and recidivation of bile duct stones was analyzed. The results showed that the average particle size, hydration kinetic particle size, effective time, and duration of polyethylene glycol (PEG)/polyethyleneimine (PEI)/poly aspartic acid-super-paramagnetic iron oxide nanoparticles(PASP-SPIONs) were better than PEG/PEI-SPIONs and SPIONs. The recidivation rate of BDS in Groups R and X was remarkably higher than the rate in control group (P < 0.05). Before treatment, common bile duct pressure in the control group was lower obviously than that in Groups R and X (P < 0.05). After treatment, the indexes including total bilirubin, direct bilirubin, and alkaline phosphatase in control group were lower than those in Groups R and X (P < 0.05). The incidence of complications in Groups R and X was much higher than in contrast to the control group (P < 0.05). Therefore, PEG/PEI/PASP-SPIONs had good contrast effect and could be used as magnetic resonance imaging contrast agent. Complications such as common bile duct pressure and infection were increased by PAD, which may be the main factor for the recidivation of BDS.

Estrogenic Activity of Mycoestrogen (3β,5α,22E)-Ergost-22-en-3-ol via Estrogen Receptor α-Dependent Signaling Pathways in MCF-7 Cells.

Armillariella tabescens (Scop.) Sing., a mushroom of the family Tricholomataceae, has been used in traditional oriental medicine to treat cholecystitis, improve bile secretion, and regulate bile-duct pressure. The present study evaluated the estrogen-like effects of A. tabescens using a cell-proliferation assay in an estrogen-receptor-positive breast cancer cell line (MCF-7). We found that the methanol extract of A. tabescens fruiting bodies promoted cell proliferation in MCF-7 cells. Using bioassay-guided fractionation of the methanol extract and chemical investigation, we isolated and identified four steroids and four fatty acids from the active fraction. All eight compounds were evaluated by E-screen assay for their estrogen-like effects in MCF-7 cells. Among the tested isolates, only (3β,5α,22E)-ergost-22-en-3-ol promoted cell proliferation in MCF-7 cells; this effect was mitigated by the ER antagonist, ICI 182,780. The mechanism underlying the estrogen-like effect of (3β,5α,22E)-ergost-22-en-3-ol was evaluated using Western blot analysis to detect the expression of extracellular signal-regulated kinase (ERK), phosphatidylinositol 3-kinase (PI3K), Akt, and estrogen receptor α (ERα). We found that (3β,5α,22E)-ergost-22-en-3-ol induced an increase in phosphorylation of ERK, PI3K, Akt, and ERα. Together, these experimental results suggest that (3β,5α,22E)-ergost-22-en-3-ol is responsible for the estrogen-like effects of A. tabescens and may potentially aid control of estrogenic activity in menopause.

Common bile duct pressure in patients with and without cholelithiasis: A case-control study.

The reflux of pancreatic enzymes into the bile duct and the gallbladder is an abnormal phenomenon that plays a role in lithogenesis and carcinogenesis. Because the pressure of the common bile duct depends on the pressures of the sphincter of Oddi, its dysfunction would be reflected in an increase in the pressure of the common bile duct in patients with cholelithiasis. The objective of this study was to measure the pressures of the common bile duct in patients with and without cholelithiasis and to relate them to the presence of pancreatobiliary reflux. A prospective case-control study was designed. The study universe was constituted by all patients undergoing total gastrectomy for gastric cancer stages I and II over 30months. The primary outcome measure was to establish differences between common bile duct pressures in patients with and without cholelithiasis. Common bile duct pressures in patients with gallstones showed a significant elevation (16.9mmHg) compared to patients without gallstones (3.3mm Hg) (p<0.0001). These pressures correlated with the levels of amylase and lipase in gallbladder bile; higher levels were found in patients with gallstones compared to patients without gallstones (P<0.0001). Common bile duct pressure in patients with cholelithiasis was significantly higher compared to patients without cholelithiasis leading to pancreatobiliary reflux.

Endoscopic endoclip papilloplasty preserves sphincter of oddi function.

Endoscopic sphincterotomy (EST) can destroy sphincter of Oddi (SO) structure and function. The purpose of this study was to assess the feasibility of endoscopic endoclip papilloplasty (EEPP) in restoring SO function after EST. Seven 26-week-old domestic pigs were divided into control and EEPP groups. Necropsy and haematoxylin-eosin staining plus anti-α-smooth muscle actin (α-SMA) staining of papilla and sphincter of Oddi manometry (SOM) were conducted in animals at three independent time points. EST and EEPP were safely performed in all 7 pigs without serious adverse events. For primary outcome, compared to the controls, EEPP generated smaller dilation and less inflammation. Fibrous repair of the papilla was observed at 24weeks after EEPP. For secondary outcome, in the control group, SO basal pressure (17.25±18.14 to 5.50±0.71mmHg), SO contraction amplitude (46.00±19.20 to 34.50±48.79mmHg), peak (4.50±4.04 to 1.50±2.12) and frequency (3.05±3.29 to 1.41±2.19/min) were reduced after EST. Further reductions to almost 0 of these SOM parameters were observed 3weeks later, including common bile duct pressure and SO contraction period. In contrast, in the EEPP group, these manometric data were recovered to pre-EST levels, including CBD pressure (11.5±7.31 vs 11±2.16mmHg), SO pressure (17.50±17.75 vs 18.20±21.39mmHg) and SO contraction amplitude (53.67±21.54 vs 60.00±36.08mmHg). However, no significant differences were observed between control and EEPP groups by Student t test. In this porcine study, EEPP accelerated and improved papillary healing after EST, further preserved SO function.

Mechanism of pancreatic juice reflux in pancreaticobiliary maljunction: A fluid dynamics model experiment.

Pancreatic juice reflux to the common bile duct and gallbladder is observed in the pancreaticobiliary maljunction (PBM), and various pathological conditions occur in the biliary tract. However, the mechanism of pancreatic juice reflux has not been discussed yet. This study aimed to investigate the mechanism of this phenomenon from the perspective of the fluid dynamics theory. A fluid dynamics model of PBM without biliary dilatation having gallbladder function and of the pressure of sphincter of Oddi was developed. Water (as bile juice and pancreatic juice) was flowed to these models with a flow rate similar to that in humans. Pancreatic and bile juice flow and bile duct pressure were observed in three phases of gallbladder function. Moreover, the same experiment was performed in the PBM without biliary dilatation model without gallbladder. Pancreatic juice reflux could be observed when the gallbladder was passively expanded with the pressure in the bile duct lower than that in the sphincter of Oddi. However, pancreatic juice reflux was not observed in the model without gallbladder. Gallbladder function may be strongly involved in pancreatic juice reflux in PBM without biliary dilatation. Cholecystectomy may be able to stop the reflux of pancreatic juice.

Common Bile Duct Pressures in Patients With and Without Cholelithiasis

Common Bile Duct Pressures in Patients With and Without Cholelithiasis

Clinical application of wire-guided percutaneous transhepatic biliary drainage

Objective To evaluate the feasibility and safety of guidewire guidance method in percutaneous transhepatic biliary drainage (PTBD). Methods A total of 174 consecutive patients with biliary diseases who underwent PTBD in Heilongjiang Provincial Hospital from January 2011 to December 2017 were enrolled in this retrospective study. There were 85 patients undergoing conventional PTBD (the conventional group), and 89 wire-guided PTBD (the wire-guided group). In the wire-guided group, the contrast media was not injected immediately after puncture, on the contrary, the needle coat was inserted deeply along the bile duct thereafter, then the bile was extracted to reduce the pressure of bile duct, at last the contrast media was infused. The drainage success rate and incidence of cholangitis related with PTBD were compared between the two groups. Results The incidence of PTBD-related cholangitis of the wire-guided group was significantly lower compared with the conventional group [10.1% (9/89) VS 21.2% (18/85), χ2=5.270, P=0.022], although the drainage success rate was not significantly different between the two groups [94.4% (84/89) VS 97.6% (83/85), χ2=1.200, P=0.273]. Conclusion Wire-guided PTBD may yield a similar success rate, but can reduce the incidence of cholangitis compared with conventional PTBD. Key words: Biliary tract diseases; Cholangitis; Percutaneous transhepatic biliary drainage; Guide wire guidance

The relationship between bile duct pressure, bile duct dilatation, and jaundice after acute common bile duct obstruction and its clinical significance

The relationship between bile duct pressure, bile duct dilatation, and jaundice after acute common bile duct obstruction and its clinical significance

Spontaneous biliary peritonitis with common bile duct stones: report of a case.

Spontaneous biliary peritonitis is rare in adults. We herein report a case of spontaneous biliary peritonitis. An 84-year-old man was admitted to our hospital for abdominal pain for 5 days. He developed fever, jaundice, and abdominal rigidity. Computed tomography (CT) revealed massive ascites in the omental bursa and around the liver. The ascites obtained by diagnostic paracentesis was dark yellow-green in color, which implied bile leakage. With a diagnosis of bile peritonitis, the patient underwent emergency exploratory laparotomy. There was massive biliary ascites in the abdominal cavity, especially in the omental bursa. Because exploration failed to demonstrate the perforation site in the gallbladder and biliary duct, we performed abdominal lavage alone. Postoperative endoscopic retrograde cholangiopancreatography showed stones in the common bile duct, and there was no evidence of biliary leakage. Endoscopic retrograde biliary drainage was performed using a plastic stent to reduce the pressure of the common bile duct. After the operation, the patient showed satisfactory recovery and started oral intake on postoperative day 8. However, the patient developed heart failure due to renal dysfunction with nephrotic syndrome at 1 month after the operation. With a diagnosis of rapidly progressive glomerulonephritis due to immune complex, the patient received steroid treatment for nephritis, diuretics, and carperitide for heart failure. Although heart failure and renal dysfunction improved by these treatment, the patients developed toxic epidermal necrolysis which was refractory to intensive treatments including steroid pulse and immunoglobulin, and the patient died 76 days after the operation.

Resultados del tratamiento endoscópico en fugas biliares. Experiencia del Centro Médico Nacional Siglo XXI IMSS

Injuries or bile leaks, among other causes, occur after open or laparoscopic cholecystectomy with an incidence of 0.1-1%. These bile leaks (Strasberg A-C) are treated by endoscopic retrograde cholangiopancreatography (ERCP). Sphincterotomy and placement of biliary stent decreases bile duct pressure to the duodenum, and promotes transpapillary bile flow, with a 70-90% response. ObjetivesTo describe the characteristics of benign bile leaks treated by ERCP and their associated complications, as well as to evaluate the results of endoscopic treatment. Material and methodsA descriptive, retrospective study was conducted by performing an analysis on ERCP reports from2011-2013, with a diagnosis of benign bile leakage. ResultsA total of 560 reports were reviewed, of which 82 (14.64%) underwent ERCP. The most common history was laparoscopic cholecystectomy in 62 (75.6%). A low biliary leakage (30.5%) and a high output (30.5%) was observed in 53 (64.6%) patients. The most common leakage site was cystic in 29.3%, and hepatobiliary stump in 20.7%. A sphincterotomy was performed on all of them, and a biliary stent was inserted in those with high output, with the leak being resolved in 95.1% of patients at 1 month, and in 100% at 6 months. Other complications related to biliary leakage were choledocholithiasis and benign biliary stenosis in 18 (22%) patients. ConclusionsThe endoscopic treatment using the sphincterotomy technique, or combined with biliary stent placement is effective in most patients with bile leaks.

Diagnosis and treatment of patients with bile duct injury after laparoscopic cholecystectomy

Objective To study the role of endoscopic retrograde cholangiopancreatography (ERCP) in diagnosing and treating iatrogenic bile duct injury after laparoscopic cholecystectomy (LC). Methods A retrospective study was conducted on 45 patients with iatrogenic bile duct injury after LC who were investigated and treated by ERCP from December 2002 to August 2015. Results Using the Strasberg-Bismuth classification, there were 14 patients with type A and 4 with type C who were managed successfully using endoscopic nasobiliary drainage (ENBD) and interventional ultrasound abdominal localized puncture and drainage; 7 patients with type D were managed successfully using endoscopic sphincterotomy (EST) and endoscopic retrograde biliary drainage (ERBD). For the 5 patients with type EⅠand 3 patients with type EⅡ who were treated by EST and ERBD, one patient who had common bile duct transection required cholangioenteric Roux-en-Y anastomosis. For the 6 patients with type EⅢ and 6 patients with type EⅣ who were treated by EST and ERBD, a patient required a cholangioenteric Roux-en-Y anastomosis to achieve good results. Conclusions When iatrogenic bile duct injury is suspected after LC, correct assessment with ERCP should be taken immediately. ERCP when combined with ENBD and (or) ERBD could reduce bile duct pressure and dilate stenotic bile ducts to avoid further operation. Key words: Laparoscopic cholecystectomy; Bile duct injury; Endoscopic retrograde cholangio-pancreatography; Stasberg-Bismuth classification

Effects of sphincter of Oddi motility on the formation of cholesterol gallstones.

To investigate the mechanisms and effects of sphincter of Oddi (SO) motility on cholesterol gallbladder stone formation in guinea pigs. Thirty-four adult male Hartley guinea pigs were divided randomly into two groups, the control group (n = 10) and the cholesterol gallstone group (n = 24), which was sequentially divided into four subgroups with six guinea pigs each according to time of sacrifice. The guinea pigs in the cholesterol gallstone group were fed a cholesterol lithogenic diet and sacrificed after 3, 6, 9, and 12 wk. SO manometry and recording of myoelectric activity were obtained by a multifunctional physiograph at each stage. Cholecystokinin-A receptor (CCKAR) expression levels in SO smooth muscle were detected by quantitative real-time PCR (qRT-PCR) and serum vasoactive intestinal peptide (VIP), gastrin, and cholecystokinin octapeptide (CCK-8) were detected by enzyme-linked immunosorbent assay at each stage in the process of cholesterol gallstone formation. The gallstone formation rate was 0%, 0%, 16.7%, and 83.3% in the 3, 6, 9, and 12 wk groups, respectively. The frequency of myoelectric activity in the 9 wk group, the amplitude of myoelectric activity in the 9 and 12 wk groups, and the amplitude and the frequency of SO in the 9 wk group were all significantly decreased compared to the control group. The SO basal pressure and common bile duct pressure increased markedly in the 12 wk group, and the CCKAR expression levels increased in the 6 and 12 wk groups compared to the control group. Serum VIP was elevated significantly in the 9 and 12 wk groups and gastrin decreased significantly in the 3 and 9 wk groups. There was no difference in serum CCK-8 between the groups. A cholesterol gallstone-causing diet can induce SO dysfunction. The increasing tension of the SO along with its decreasing activity may play an important role in cholesterol gallstone formation. Expression changes of CCKAR in SO smooth muscle and serum VIP and CCK-8 may be important causes of SO dysfunction.

Establishment of a novel rat model of severe acute cholangitis.

This study aimed to establish a novel non-binding, reversible rat model of acute cholangitis of the severe type (ACST). Twenty-six rats were randomly divided into the sham-operated group (n=13) and the ACST group (n=13). All rats were intubated with a modified catheter through the external jugular vein. The ACST model was established by ligation of the distal bile duct, placing one end of a modified catheter in the common bile duct, and then injecting lipopolysaccharides from the other end of the catheter and sealing it. The common bile duct pressure was measured before and at 0, 24, 48, and 72 hr after the model was established; similarly, the levels of serum total bilirubin (TBIL), alanine aminotransferase (ALT), and tumor necrosis factor (TNF)-α were measured at 0, 12, 24, and 48 hr after the model was established. Pathological examination of liver tissues was carried out at 24 and 72 hr. The common bile duct pressure increased gradually after the operation. Serum levels of TBIL, ALT, and TNF-α in the ACST group progressively increased and were significantly higher than those in the sham-operated group, at each time point (P<0.05). Obvious pathological changes were observed in the liver tissue of rats in the ACST group. This model appears to reflect the early course of human ACST and thus, can be used in postoperative experimental studies of ACST.

Biliary manometry in patients with common bile duct stones and juxtapapilary duodenal diverticulum

Objective To explore the impact of juxtapapilary duodenal diverticulum on the formation of choledocholithiasis and biliary manometry after surgery. Methods The clinical data of 97 patients with common bile duct stones who successfully underwent ERCP and biliary manometry treatment from May 2011 to March 2014 were retrospectively analyzed. Ninty-seven common bile duct stone patients were divided to two groups, that is, 52 cases of juxta-papilary duodenal diverticulum (experimental group) and 45 cases without juxta-papilary duodenal diverticulum (control group). The biliary manometric results before and after EST of both groups were compared. Results The basal pressure of sphincter Oddi of the experimental group before EST[(84.8±26.1)mmHg]was higher than that of the control group before EST[(75.5±14.6)mmHg](P 0.05). The biliary manometry was performed in 81 patients after one month and it was found that the basal pressure of sphincter Oddi of experimental group was still higher than that of the control group[(34.8±17.1) mmHg VS (29.6±15.3)mmHg, P<0.05]. The biliary pressure of common bile of the experimental group was higher than that of the control group[(19.9±11.2)mmHg VS (17.1±13.1)mmHg, P<0.05]. Conclusion The existence of juxtapapilary duodenal diverticulum increases the pressure of common bile duct and Oddi sphincter and leads to CBD stones. Key words: Biliary manometry; Juxta-papilary duodenal diverticulum; Cholangiopancreatography, endoscopic retrograde; Choledocholithiasis; Sphincter of Oddi pressure; Common bile duct pressure

Possible Recovery of Manifestation of Prolactin Receptor and Some of Its Target Proteins in the Liver and Kidney Cells of Female Rats after Relief of Cholestasis Complicated and Not Complicated by Hyperprolactinemia.

Immunohistochemistry with semi-quantitative analysis of computer images showed that prolactin receptor and cystic fi brosis transmembrane regulator (CFTR) in cholangiocytes of female rats elevated in cholestasis quickly respond to its relief. The effect of hyperprolactinemia on the extent of return of these proteins to baseline was different. Decompression of the bile duct abolishes the negative effect of hyperprolactinemia on CFTR expression and its positive effect on mrp3 expression in the proximal renal tubules. In renal medulla, mrp2 expression decreased when cholestasis was induced against the background of hyperprolactinemia and increases after its removal. Prolactin receptors and CFTR in cholangiocytes are most susceptible to the decrease in bile duct pressure. Changes in the expression of the studied proteins after cholestasis relief are apparently associated with attenuated toxicity of the products removed by the kidneys, which abolishes the effects of prolactin.

Is LigaSure a safe cystic duct sealer? An ex vivo study

To compare the efficacy and safety of both mechanical methods (clips) and electrosurgical instruments, harmonic scalpel (HS) and LigaSure (LS), for securing the cystic duct during laparoscopic cholecystectomy (LC). During the study period from October 2010 to October 2012, 458 patients with gallbladder stones underwent LC. A total of 38 patients were excluded from the study for different reasons. The gallbladder was excised laparoscopically through the traditional method. The gallbladder specimens of the patients were divided into three equal groups randomly, and the distal part of the cystic duct was sealed exvivo using ligaclips (Group A), HS (Group B), and LS (Group C). The gallbladders were then connected to a pneumatic tourniquet device and we very gradually increased the pressure with air. The bursting pressure of the cystic duct (CDBP) was measured and differences between the three groups were calculated. The mean CDBP was 329.7±38.8mmHg in the ligaclip group, 358.0±33.1mmHg in the HS group, and 219.7±41.2mmHg in the LS group. A comparison of the mean CDBP between the groups indicated the superiority of HS over ligaclip and LS. CDBP was significantly higher in the ligaclips group compared with the LS group (p<0.001). HS and ligaclips were found to be safe sealers as their mean CDBP was found to be higher (>195mmHg) than the maximum common bile duct pressure, whereas for LS the CDBP range was 150-297mmHg, indicating that it is not safe for sealing. HS is a safe alternative to clips. In fact, it was even safer than clips. By contrast, LS is not safe for cystic duct sealing.