Bile Tree Research Articles

Development of pancreatic islet cells in the extrahepatic bile ducts of rats with experimentally-induced metabolic syndrome

Context There is data about the existence of some endocrine cells in the epithelial layer of the bile duct in humans and rats. Objective We evaluated Ghrelin-, Insulin-, Glucagon- and Somatostatin-positive cells in peribiliary glands, mast cells, and nerve fibres. Materials and methods Wistar rats were used for dietary manipulation with a 15% fructose solution for 12 weeks. Tissue samples were elaborated with immunohistochemistry for Insulin, Glucagon, Ghrelin, and Somatostatin. Glucose and lipid parameters were studied. Results In treated animals, Ghrelin+ and Insulin+ cells in perybiliary glands (PBGs) were significantly increased. In the male fructose group there was a significant increase of the homeostasis model assessment insulin resistance (HOMA-IR). Conclusions Stem/progenitor cells in extrahepatic bile tree (EHBT) could be a source of Insulin-producing cells in metabolic syndrome. Fructose treatment induces the increase of Ghrelin+ and Insulin+ cells in PBGs and the elevation of Insulin and Ghrelin plasma concentration.

Iatrogenic Injury of Biliary Tree-Single-Centre Experience.

Cholecystolithiasis is among the most prevalent gastrointestinal disorders requiring surgical intervention, and iatrogenic damage to the bile tree is a severe complication. We aimed to present the frequency of bile duct injuries and how our facility handles these complications. We retrospectively analyzed bile duct injuries in patients undergoing surgery. We concentrated on factors such as sex, age, indications for surgery, type of surgery, primary procedure, bile tree injury, repair, and timing as well as early and late complications. There were 22 cases of bile duct injury in the studied material, primarily affecting women-15 individuals (68.2%). Eleven cases (45.7%) of acute cholecystitis were the primary reason for surgery, and an injury to the common bile duct that extended up to 2 cm from the common hepatic duct was the most common complication (European Association for Endoscopic Surgery grade 2). Roux-en-Y hepaticojejunostomy was the most common repair procedure in 14 cases (63.6%). Eleven patients (50%) experienced early complications following reconstruction surgery, whereas five patients (22.7%) experienced late complications. An annual mortality rate of 22.7% (five patients) was observed. Iatrogenic bile duct injury is a severe complication of surgical treatment for cholecystolithiasis. Reconstruction procedures are characterized by high complication rates and high mortality.

Actuarial Patency Rates of Hepatico-Jejunal Anastomosis after Repair of Bile Duct Injury at a Reference Center.

Background: Bile duct injury complicates patients’ lives, despite the subsequent repair. Repairing the injury must restore continuity of the bile tree and bring the patient into a state of cure referred to as “patency”. Actuarial primary or actuarial secondary patency rates, depending on whether the patient underwent primary or secondary repair of injury, are proposed to be a proper metric in evaluating outcomes. This study was undertaken to assess outcomes of 669 patients with bile duct injuries Strasberg D and E type referred to the department from public surgical wards between 1990 and 2020. In 442 patients, no attempt was made to repair prior to a referral, and in 227 an attempt to repair was made which failed. Methods: Observations were summarized on December 31st, 2020. The retrospective analysis included: primary patency attained (Grade A result), secondary patency attained (Grade C result), patency loss, and actuarial patency rates of the bile tree at 2, 5, and 10 years. Results: Twenty-five (3.7%) patients died after repair surgery. Actuarial patency rates at 2, 5, and 10 years of follow-up were 93%, 88%, and 74% or 86%, 75%, and 55% in patients attaining Grade A and Grade C outcomes, respectively (p < 0.001). Conclusion: Bile duct injury stands out as a surgical challenge, requiring specialized management at a referral center. Improper proceeding after an injury is the factor leading to faster loss of anastomotic patency.

WAYS TO IMPROVE THE RESULTS OF TREATMENT OF PATIENTS WITH CHOLELITHIASIS AND MECHANICAL JAUNDICE.

Purpose. To create a personalized tactic of surgical treatment of patients with BSD and MJ considering the stage of the pathological process and thereby improve the results of treatment. Materials and methods. The experience of diagnosis and treatment of 537 patients with complications of cholelithiasis, manifested by mechanical jaundice, was analyzed. The first stage was 537 minimally invasive decompressions of the biliary tract, the second-500 different types of endosurgical interventions. Results. Depending on the tactical principles, all the subjects were divided into two groups. In one (control) group (n = 249), patients were admitted from 2010 to 2014. Their treatment was empirical: decompression of the bile tree was performed at different times, and surgery was performed without taking into account the stages of the pathological process and the severity of the patients. In the other analyzed group (n = 251), patients were admitted to the hospital from 2015 to 2019. Their treatment tactics were personalized: taking into account the stages of mechanical jaundice. individual terms of decompression of the bile ducts and the choice of surgical intervention were determined. When comparing the results obtained, the advantage of the personalized approach was established: a decrease in the percentage of postoperative complications and mortality was revealed. Conclusion. In patients with cholelithiasis and jaundice, the severity of the condition is due to hyperbilirubinemia. Stage 2 of mechanical jaundice-determined by the severity of cytolysis in hepatic insufficiency, manifested by hypertransaminasemia. The severity of cholangitis is determined by purulent-inflammatory, as well as septic signs of the disease, characterized by leukocytosis, circulating immune complexes and medium-weight molecules. In the cholestatic stage of jaundice development, treatment is planned, in the cytolytic stage — urgent, and in cholangitis-emergency. The use of personalized tactics for the treatment of patients with breast cancer has reduced the number of complications and mortality.

Quiste de colédoco

Introducción: Los quistes de colédoco son dilataciones congénitas raras en cualquier segmento del árbol biliar, con una incidencia de aproximadamente 1:100.000 a 1:150.000 nacidos vivos, siendo más frecuente en países asiáticos, con mayor frecuencia en el sexo femenino (4:1), el 80% de los casos se diagnostican en la infancia y el 20% en adultos en los cuales suele estar asociado a otra patología biliar; el primer caso documentado fue reportado por Douglas en 1852.&#x0D; Objetivo: Describir un caso clínico de quiste del colédoco&#x0D; Material y métodos: Estudio descriptivo retrospectivo presentación de caso clínico.&#x0D; Resultados: Se presenta al caso de una paciente de 23 años que acude por presentar dolor abdominal intenso tipo cólico que se acompaña de diarreas, vómitos e ictericia generalizada. &#x0D; Conclusiones: A pesar de que el quiste de colédoco sea una entidad rara el galeno debe tenerlo en cuenta en pacientes jóvenes que presenten sintomatología que se correlacione con la patología, de la misma manera el uso de ecografía abdominal ante la sospecha ya que el acceso universal disminuye el tiempo de diagnóstico y una intervención oportuna

A278 TB OR NOT TB OF THE PANCREAS

Abstract Background Pancreatic TB is a rare clinical presentation which has proved difficult to diagnose. Its symptomatology and imaging characteristics mimic neoplastic findings. Aims We present the case of a previously healthy 58-year-old man, from an endemic area who presented with epigastric pain caused by pancreatic TB. Methods Case report and review of literature Results A previously well 58-year-old male presented to the emergency room with severe epigastric pain, without fevers or significant weight loss. He had immigrated to Canada from the Philippines in 2001. He denied a personal history of TB, however, he did report that his father had received treatment for active TB. An abdominal CT revealed intrahepatic and extrahepatic bile tree dilation with an abrupt transition in the pancreatic head, possible stricture, as well as mucosal thickening of the duodenum at the level of the abrupt narrowing of the dilated common bile duct, concerning for malignancy. Initial laboratory investigations revealed WBC 6.1 x10E9 cells/L, amylase 114 U/L and lipase 59 U/L. Malignancy work up revealed a normal Ca 19-9 at 29.6 kU/L. HIV testing was negative. CT chest revealed bilateral apical fibrotic lesions and smaller lesions throughout the upper and mid-zones bilaterally, suggestive of progressive massive fibrosis. This was in keeping with the patient’s former occupation as a miner. There was no evidence of granulomatous disease. EUS was undertaken and this revealed a mass in the head of the pancreas measuring 29 x 29 mm. The mass was invading into the common bile duct. The pancreatic head mass appeared to be invading into the duodenum, as a necrotic ulcerating lesion was also identified in the second part of the duodenum and this was biopsied. The surgical pathology returned as necrotizing granuloma, however, the tissue could not be tested for TB. The patient underwent a repeat endoscopy which again revealed a fungating and friable mass in the second part of the duodenum with biopsies taken. Pathology revealed mild chronic inflammation. Staining for Acid Fast Bacilli was negative, however, Mycobacterium Tuberculosis Complex was isolated on tissue culture. The patient was diagnosed with pancreatic TB and initiated on pyrazinamide, ethambutol, isoniazid and rifampin. Conclusions Pancreatic involvement by TB is very rare but it has been increasingly reported in both immunocompromised and immunocompetent populations. Symptomatically, pancreatic TB can present with a multitude of non-specific symptoms, including epigastric pain, fever, anorexia, weight loss, or jaundice. In addition, imaging findings of pancreatic TB may mimic malignancy. Our patient, from an endemic area, presented with epigastric pain consistent with the existing literature on pancreatic TB. Isolated pancreatic TB is a rare clinical entity but should be in the list of differential diagnoses in a patient with pancreatic mass especially in the setting of risk factors of TB. Funding Agencies None

Initial experience with irreversible electroporation of liver tumours

Abstract Introduction Thermal ablation of liver tumours is an established technique used in selected patients with relatively small tumours that can be ablated with margin. Thermal ablation methods are not advisable near larger bile ducts that are sensitive to thermal injury causing strictures and severe morbidity. Irreversible electroporation (IRE) has the possibility to treat these tumours without harming the bile tree. The method is relatively new and has been proven to be feasible and safe with promising oncological results. Methods 50 treatments were performed on 42 patients that were not resectable or treatable by thermal ablation (12 women and 30 men) with 59 tumours in total. 51% were colorectal cancer liver metastases (CRCLM) and 34% were hepatocellular carcinomas (HCC). 70% of the treatments were performed using stereotactic CT-guidance for needle placement. Results 81% of the treatments were performed with initial success. All patients with missed ablations were re-treated. Local recurrence rate at 3 months was 3% and 37% at one year. The complication rate was low with 2 patients having major complications (Clavien-Dindo grade 3b-5) and without 30-day mortality. Conclusion IRE is safe for treating tumours not suitable for thermal ablation with 63% of patients being without local recurrence after one year in a group of patients with tumours deemed unresectable. IRE has a role in the treatment of unresectable liver tumours close to heat-sensitive structures not suitable for thermal ablation. Level of Evidence: Level 4, Case Series.

Initial experience with irreversible electroporation of liver tumours

IntroductionThermal ablation of liver tumours is an established technique used in selected patients with relatively small tumours that can be ablated with margin. Thermal ablation methods are not advisable near larger bile ducts that are sensitive to thermal injury causing strictures and severe morbidity. Irreversible electroporation (IRE) has the possibility to treat these tumours without harming the bile tree. The method is relatively new and has been proven to be feasible and safe with promising oncological results. Methods50 treatments were performed on 42 patients that were not resectable or treatable by thermal ablation (12 women and 30 men) with 59 tumours in total. 51% were colorectal cancer liver metastases (CRCLM) and 34% were hepatocellular carcinomas (HCC). 70% of the treatments were performed using stereotactic CT-guidance for needle placement. Results81% of the treatments were performed with initial success. All patients with missed ablations were re-treated. Local recurrence rate at 3 months was 3% and 37% at one year. The complication rate was low with 2 patients having major complications (Clavien-Dindo grade 3b-5) and without 30-day mortality. ConclusionIRE is safe for treating tumours not suitable for thermal ablation with 63% of patients being without local recurrence after one year in a group of patients with tumours deemed unresectable. IRE has a role in the treatment of unresectable liver tumours close to heat-sensitive structures not suitable for thermal ablation.Level of Evidence: Level 4, Case Series.

Su1398 - Predictors of Bile Tree Pathology in Patients Presenting with Gallbladder Disease

Su1398 - Predictors of Bile Tree Pathology in Patients Presenting with Gallbladder Disease

Emergencies in Neonatal Management: Jaundice and Biliary Atresia

Biliary atresia is a severe and progressive inflammatory process of unknown cause, which initially involves the extrahepatic bile ducts but which quickly proceeds towards the intrahepatic bile tree leading rapidly to biliary cirrhosis. Biliary atresia is the major reason for liver transplantation during childhood. The extrahepatic bile ducts in biliary atresia become connective fibrotic cords which is irreversibly damaged.

Enfermedades fibropoliquísticas hepáticas

IntroductionFibropolycistic diseases of the liver comprise a heterogeneous group of different disorders in which fibrosis is associated with segmental dilatations of the bile ducts. Although classified into specific conditions, there is much overlap between them and close association with fibrocystic anomalies in the kidneys is usually seen. ClassificationIn polycystic liver disease associated with renal cysts the impairment in renal function may overshadow the liver disease. In congenital hepatic fibrosis the principal symptoms arise from portal hypertension, as the liver synthetic function is preserved. Simple hepatic cysts and von Meyendeburg complex are the minimal expression of all these fibrocystic diseases. Carolís syndrome and Carolís disease both have large intrahepatic bile duct dilatations; however liver fibrosis and portal hypertension signs occur only in Carolís syndrome. Dilatation of the extrahepatic bile ducts, name commonly as choledocal cysts cause cholangitis. PathogenyThe origin of all these conditions is the malformation of the ductal plate during the embryonic period. On the one hand, the abnormal proliferation of the bile epithelium leads to an excess synthesis of extracellular matrix (fibrosis). On the other hand large cysts arise in the liver and also in the bile tree.

Staged Surgery for Bronchobiliary Fistula and Incidental Finding of Mitral Valve Disease

Bronchobiliary fistula (BBF) is defined as abnormal passage between bronchial system and the bile tree which often manifests as presence of bile in the sputum (biloptysis). BBF is a serious complication which requires early diagnosis and well-planned management strategy to avoid the high morbidity and mortality rate. The hydatid cystic disease is still the leading cause of the BBF. In this paper we present a case of 32-year-old man with BBF who was incidentally found to have a mitral valve disease for which he underwent mitral valve replacement during his management course.

Rapid progression of primary sclerosing cholangitis complicated with ulcerative colitis.

Primary sclerosing cholangitis is a cholestatic condition with unknown etiology and long-standing, progressive course, leading to cirrhosis and requiring orthotropic liver transplant. In approximately 80%, primary sclerosing cholangitis is accompanied by inflammatory bowel disease, and in most cases the recognition of bowel disease precedes the diagnosis of primary sclerosing cholangitis. We describe a case of 22-year-old male diagnosed simultaneously with primary sclerosing cholangitis and ulcerative colitis, with a medical history suggesting uncommon prior development of the liver disease. Five months after the initial diagnosis, we observed advanced lesions of bile tree due to progression of primary sclerosing cholangitis, which led to the unusually fast necessity for the orthotopic liver transplant.

Towards a bioengineered liver

A critical shortage of donor organs for treating end-stage organ failure highlights the urgent need for generating organs from human induced pluripotent stem cells (iPSCs). Despite many reports describing functional cell differentiation, no studies have succeeded in generating a three-dimensional vascularized organ such as liver. Here we show the generation of vascularized and functional human liver from human iPSCs by transplantation of liver buds created in vitro (iPSC-LBs). Specified hepatic cells (immature endodermal cells destined to track the hepatic cell fate) self-organized into three-dimensional iPSC-LBs by recapitulating organogenetic interac- tions between endothelial and mesenchymal cells. Immunostaining and gene-expression analyses revealed a resemblance between in vitro grown iPSC-LBs and in vivo liver buds. Human vasculatures in iPSC-LB transplants became functional by connecting to the host vessels within 48 hours. The formation of functional vasculatures stimulated the maturation of iPSC-LBs into tissue resembling the adult liver. Highly metabolic iPSC-derived tissue performed liver- specific functions such as protein production and human-specific drug metabolism without recipient liver replacement. Furthermore, mesenteric transplantation of iPSC-LBs rescued the drug-induced lethal liver failure model. To our knowledge, this is the first report demonstrating the generation of a functional human organ from pluripotent stem cells. Although efforts must ensue to translate these techniques to treatments for patients, this proof-of-concept demon- stration of organ-bud transplantation provides a promising new approach to study regenerative medicine. 2013 European Association for the Study of the Liver. Published

Intrahepatic Transposition of Bile Ducts

Objective. To describe the intrahepatic bile duct transposition (anatomical variation occurring in intrahepatic ducts) and to determine the frequency of this variation. Material and Methods. The researches were performed randomly on 100 livers of adults, both sexes. Main research methods were anatomical macrodissection. As a criterion for determination of variations in some parts of bile tree, we used the classification of Segmentatio hepatis according to Couinaud (1957) according to Terminologia Anatomica, Thieme Stuugart: Federative Committee on Anatomical Terminology, 1988. Results. Intrahepatic transposition of bile ducts was found in two cases (2%), out of total examined cases (100): right-left transposition (right segmental bile duct, originating from the segment VIII, joins the left liver duct-ductus hepaticus sinister) and left-right intrahepatic transposition (left segmental bile duct originating from the segment IV ends in right liver duct-ductus hepaticus dexter). Conclusion. Safety and success in liver transplantation to great extent depends on knowledge of anatomy and some common embryological anomalies in bile tree. Variations in bile tree were found in 24–43% of cases, out of which 1–22% are the variations of intrahepatic bile ducts. Therefore, good knowledge on ductal anatomy enables good planning, safe performance of therapeutic and operative procedures, and decreases the risk of intraoperative and postoperative complications.

Current management of biliary complications after liver transplantation: Emphasis on endoscopic therapy

Biliary complications occur in 5–25% of patients after liver transplantation and represent a major source of morbidity in this group of individuals. The major risk factor for most of these complications is ischemia of the bile tree usually due to obstruction or vascular insufficiency of the hepatic artery. The most common complications include biliary strictures (anastomostic and nonanastomotic), bile leaks, and biliary filling defects. The initial diagnostic approach starts with a high index of suspicion along with an abdominal ultrasound and Doppler exam. Magnetic resonance imaging is highly sensitive and is usually reserved for confirmation. The vast majority of these complications can be successfully treated with endoscopic retrograde cholangiography, however if this procedure cannot be performed a percutaneous approach or surgery is recommended. Nonanastomotic strictures and living donor recipients present a less favorable response to endoscopic management. This review focuses on the current diagnostic and therapeutic approaches for the management of biliary complications after liver transplantation.

Contrast-enhanced MR cholangiography with gadoxetic-acid-disodium (Gd-EOB-DTPA) for the evaluation of post-gunshot traumatic bile duct injury: A case report

Bile duct injury is a common complication after hepatobiliary surgery, but may also occur in post-traumatic patients. Early diagnosis and treatment are crucial to prevent long-term morbidity. We present a case with a liver laceration and biliary leakage following a gunshot incident, which was demonstrated on MR cholangiography using gadoxetic-acid-disodium (Primovist). This liver-specific contrast agent provides excellent demonstration of bile leakage as well as the intrahepatic bile tree, being a safe, non-invasive and accurate technique for contrast-enhanced cholangiography without use of ionizing radiation.

A Case of Mirizzi’s Syndrome Mimicking Carcinoma: The Role of CBD-Stenting for Easy Surgical Management

Mirizzi's syndrome accounts for an important risk for bile tree injury during surgery, since preoperative diagnosis is missed in half of the cases and is often difficult to differentiate from carcinoma. A 79-year-old male, with a known history of cholelithiasis, was admitted with a progressive obstructive jaundice over 20 days, without pain, fever, or other symptoms. Magnetic resonance cholangiopancreatography described possible microlithiasis of the distal bile duct, but on endoscopic retrograde cholangiopancreatography (ERCP), an irregular stenosis was detected under the junction of hepatic ducts, which was described as possibly neoplastic. A temporary stent was placed and the patient was referred for surgery. On first view the gallbladder appeared hard, embedded in adhesions, giving the impression of an unresectable tumor and the bile duct was not approachable. After a fundus-down incision of the gallbladder multiple stones were extracted. Frozen biopsies from the gallbladder wall were negative. The incision was extended towards the gallbladder neck and a large communication with the common bile duct (CBD) was revealed. A difficult partial cholecystectomy was performed, followed by cholecystojejunostomy with a Roux-en-Y jejunal loop. The patient had a totally uneventful postoperative course. Stent removal was succeeded endoscopically 1 month later. The importance of preoperative ERCP and CBD stenting is highlighted in this article. ERCP may have failed to distinguish Mirizzi's syndrome from carcinoma, however the stent placement saved the cardiologically compromised patient from further surgical manipulations. Therefore, in ambiguous cases, whatever the final diagnosis turns to be, either carcinoma or Mirizzi's syndrome, CBD stenting can be useful for the final management of the patient.

Is Preoperative Evaluation of the Biliary Tree Necessary in Uncomplicated Gallstone Disease?

To analyse if preoperative radiology is of value in patients with uncomplicated gallstone disease. 312 patients intended for laparoscopic cholecystectomy were randomly allocated to undergo preoperative radiology (intravenous cholangiography or magnetic resonance cholangiography) or to a control group. Intraoperative cholangiography was not used routinely in either group. There was no bile duct injury and no difference in complication frequency between the two groups. The incidence of common bile duct stones was 3.8% within the first postoperative year with no statistical difference between the two groups. Routine preoperative evaluation of the bile tree seems unnecessary before laparoscopic cholecystectomy in patients with uncomplicated gallstone disease.

Hepatic artery thrombosis and graft ischemia in the presence of preserved arterial inflow: Not a contradiction but a real possibility

A 25-year-old Caucasian male underwent orthotopic liver transplantation in June 2000 because of Caroli's disease. He was retransplanted in May 2001 due to intractable chronic rejection. Retransplantation was performed with a conventional technique using veno-venous bypass, anastomosis between the hepatic artery of the graft and the common hepatic artery of the recipient, and a Roux-en-Y choledochojejunostomy. An episode of acute rejection was diagnosed in the second postoperative week that responded to high-dose steroids, and the patient was discharged 34 days after retransplantation. No significant abnormality in the graft function was detected until June 2003, when the patient developed fever and leukocytosis associated with biochemical signs of cholestasis followed by jaundice; transaminases remained normal or showed minimal increase. Hepatic ultrasonogram revealed moderate dilatation of the intrahepatic bile ducts with 2 small bilomas, while Doppler US showed normal intraparenchymal arterial resistive index and systolic acceleration time. HAT, hepatic artery thrombosis. Abdominal computed tomography scan confirmed diffuse dilatation of the bile ducts with hypodense areas consistent with biloma (Fig. 1). Selective celiac arteriography showed a complete obstruction of hepatic artery (Fig. 2), while the arteriogram of the superior mesenteric artery demonstrated the presence of compensatory collateral vessels recruited from the jejunal vascular arcade of the Roux limb (Fig. 3). Despite antibiotic treatment, the patient developed recurrent episodes of cholangitis with persistent jaundice and is now listed for retransplantation. Hepatic computed tomography showing diffuse dilatation of the intrahepatic bile ducts with hypodense areas in the left liver and triangular areas in the right consistent with biloma and parenchyma ischemia respectively. Celiac axis angiogram shows complete occlusion of the hepatic artery (white arrow). Superior mesenteric artery angiogram shows arterial collaterals (white arrows) arising from the jejunal vascular arcade of the Roux limb perfusing the liver. Hepatic artery thrombosis (HAT) after orthotopic liver transplantation still represents one of the main causes of failure of liver transplantation, with an incidence ranging from 3 to 9% in adult recipients.1 When it occurs in the early postoperative period, unless promptly recognized and treated, HAT is normally associated with graft loss.2, 3 Late HAT typically has been associated with less severe complications and may even be asymptomatic.4 This fact is normally attributed to the development of arterial collaterals, possibly due to the gradual progression of arterial stenosis prior to HAT.5 Development of arterial collaterals has been reported in pediatric liver transplant recipients6-8 probably due to the more common presence of Roux-en-Y choledochojejunostomy, but has been rarely described in adults.9, 10 However, in these patients, even in those rare cases where arterial flow is still detectable, Doppler ultrasonogram always shows gross abnormalities with low resistive index and very high systolic acceleration time (almost always above 100 milliseconds).10, 11 In the present case, probably due to the considerable size of the vessels that revascularized the liver after hepatic artery occlusion, doppler signal was normal. As previously reported the rearterialization spared the graft function while permanent damage to intrahepatic bile tree was observed.5 In our patient the suspicion of liver ischemia was induced by the features of the intrahepatic bile tree. Hepatic angiogram is recommended in the presence of unexplained cholestasis, even when the normal arterial signal is detected at Doppler ultrasonogram.