Biliary Pressure Research Articles

Research progress of application and nursing of nasobiliary duct

Endoscopic nasobiliary drainage (ENBD) , a minimal invasive treatment technique that can relieve biliary obstruction quickly, reduce biliary pressure and clear biliary tract, is widely used in clinic. The study reviewed the application scope, features, methods of intubation and fixation, indwelling time, common complications and relevant nursing interventions of nasobiliary duct. The purpose of the study was to provide references for clinical nursing of nasobiliary duct, which was helpful to offer the high quality nursing service. Key words: Review; Nasobiliary drainage; Canal nursing; Research progress

Endoscopic management of acute cholangitis as a result of common bile duct stones.

Acute cholangitis is infectious disease of the biliary system and potentially can cause significant morbidity and mortality. With advances in intensive care, antibiotic therapy advances and endoscopic and other modalities of biliary drainage, mortality rates have significantly come down of late. Although most cases respond to antibiotics alone, definitive therapy is required later in most of the patients. Increased biliary pressure leads to biliovenous reflux of bacteria and purulent bile into the circulation leading to systemic inflammation and sepsis with subsequent organ dysfunction. Biliary decompression increases antibiotic penetration in bile. Therefore, patients with high-risk factors and organ dysfunction require early and urgent biliary drainage, respectively, as they are unlikely to respond with antibiotics alone. Biliary decompression is best achieved by endoscopic retrograde cholangiopancreatography (ERCP) compared to percutaneous and surgical decompression. ERCP can be technically difficult and sometimes unsuccessful especially in patients with altered anatomy and upper gastrointestinal obstruction. Earlier percutaneous transhepatic biliary drainage (PTBD) and surgery were the only viable options in those patients. PTBD requires a dilated biliary system, is more invasive and cannot achieve ductal clearance in cholangitis as a result of choledocholithiasis, whereas surgery is associated with high morbidity and mortality. Advances in therapeutic endoscopy such as balloon enteroscopy-guided biliary drainage or endoscopic ultrasound guided-biliary drainage have added new dimensions to endoscopic management of acute cholangitis as a result of choledocholithiasis obviating the need for more invasive procedures.

Actomyosin contractility drives bile regurgitation as an early response during obstructive cholestasis

A wide range of liver diseases manifest as biliary obstruction, or cholestasis. However, the sequence of molecular events triggered as part of the early hepatocellular homeostatic response in obstructive cholestasis is poorly elucidated. Pericanalicular actin is known to accumulate during obstructive cholestasis. Therefore, we hypothesized that the pericanalicular actin cortex undergoes significant remodeling as a regulatory response to obstructive cholestasis. In vivo investigations were performed in a bile duct-ligated mouse model. Actomyosin contractility was assessed using sandwich-cultured rat hepatocytes transfected with various fluorescently labeled proteins and pharmacological inhibitors of actomyosin contractility. Actomyosin contractility induces transient deformations along the canalicular membrane, a process we have termed inward blebbing. We show that these membrane intrusions are initiated by local ruptures in the pericanalicular actin cortex; and they typically retract following repair by actin polymerization and actomyosin contraction. However, above a certain osmotic pressure threshold, these inward blebs pinch away from the canalicular membrane into the hepatocyte cytoplasm as large vesicles (2-8μm). Importantly, we show that these vesicles aid in the regurgitation of bile from the bile canaliculi. Actomyosin contractility induces the formation of bile-regurgitative vesicles, thus serving as an early homeostatic mechanism against increased biliary pressure during cholestasis. Bile canaliculi expand and contract in response to the amount of secreted bile, and resistance from the surrounding actin bundles. Further expansion due to bile duct blockade leads to the formation of inward blebs, which carry away excess bile to prevent bile build up in the canaliculi.

Bronchobiliary Fistula: A Rare Complication After Pancreaticoduodenectomy

Introduction: Bronchobiliary fistulas (BBF) are rare complications leading to communication between the thorax and biliary system. We present a case of a BBF that developed nearly a decade after pancreaticoduodenectomy (PD) for a neuroendocrine tumor.Figure 2Case: A 70-year-old man with an ampullary neuroendocrine tumor s/p PD complicated by biliary stricture and hepaticojejunostomy (HJ) anastomosis revision, presented with progressive dyspnea, fatigue and iron deficiency anemia attributed to iron malabsorption from prior bowel resections. He was transfused three units of pRBCs and discharged home. However, two days post discharge, he returned with worsened dyspnea, productive cough with bilious sputum. Initial impression was concerning for pneumonia. However, he had significant sputum output and hyperbilirubunemia. Work-up revealed cirrhosis, perihepatic ascites and right pleural effusion on right upper quadrant ultrasound. CT scan demonstrated a diaphragmatic fistula (Figure 1). Cholangiogram demonstrated a stricture at the afferent limb of HJ and biliary duct dilation (Figure 2). He was started on antibiotics and a percutaneous biliary drain was placed. He improved and was discharged. His fistula is now maintained with a biliary drain and he has had no further episodes of bilioptysis. He also receives iron sucrose infusions for chronic iron deficiency anemia.Figure 2Discussion: BBF represents a fistulous tract connecting the biliary system to the thoracic cavity, through the pleural space, lung parenchyma and bronchial tree. Risk factors for development of a BBF include conditions involving the hepatobiliary system including infection, blunt trauma or malignancy. In iatrogenic BBF, prior biliary tract intervention predates presenting symptoms by approximately 6 months. The development of BBF here likely resulted from the biliary-afferent limb anastomotic stricture after PD causing elevated biliary pressure. With the negative pressure in the thoracic cavity, the fistulous tract developed to relieve high pressure in the portal system. As bile is a strong irritant, erosions through the bronchial wall occurred leading to his presentation with bilioptysis. The patient recovered remarkably with conservative management with percutaneous biliary drain. This case highlights one mechanism for development of BBF and demonstrates that conservative management is a viable option in patients deemed to be poor surgical candidates with the potential for favorable outcomes.

T-drain reduces the incidence of biliary leakage after liver resection.

Biliary leakage is a serious complication after liver resection and represents the major cause of post-operative morbidity. In spite of already identified risk factors, little is known about the role of intra-biliary pressure following liver surgery in the development of biliary leakage. Biliary decompression may have a positive impact and reduce the incidence of biliary leakage at the parenchymal resection site. 397 patients undergoing liver resection without bilioenteric anastomosis were included in the retrospective analysis of the risk factors for the development of biliary leakage focusing on the intra-operative reduction of the biliary pressure by T-tube and liver histology. Among 397 analyzed patients after parenchymal resection, biliary leakage occurred in 39 cases (9.8%). The extent of parenchymal resection was not associated with the total occurrence of biliary leak (p=0.626). Lower incidence of biliary leakage from the resection surface was significantly associated with the use of T-tube (4.9 vs. 13.2%; p=0.006). In the subgroup analysis, insertion of a T-tube was not associated with a reduction of biliary leakage after anatomical hemihepatectomies (p=0.103) and extraanatomical liver resection (p=0.676). However, a high statistical significance could be detected in patients with extended hemihepatectomies (58.3 vs. 3.8%; p<0.001). Once biliary leak occurred without T-tube, median hospitalization duration significantly increased compared to patients with biliary decompression and without biliary leak (p<0.001). The results of our retrospective data analysis suggest a significant beneficial impact of the T-tube on the development of biliary leakage in patients undergoing extended liver surgery.

Metabolic preconditioning protects BSEP/ABCB11−/− mice against cholestatic liver injury

Cholestasis is characterized by intrahepatic accumulation of potentially cytotoxic bile acids (BAs) subsequently leading to liver injury with disruption of hepatocellular integrity, inflammation, fibrosis and ultimately liver cirrhosis. Bile salt export pump (BSEP/ABCB11) is the main canalicular BA transporter and therefore the rate limiting step for hepatobiliary BA excretion. In this study we aimed to investigate the role of BSEP/ABCB11 in the development of acquired cholestatic liver and bile duct injury. Wild-type (WT) and BSEP knockout (BSEP-/-) mice were subjected to common bile duct ligation (CBDL) or 3.5-diethoxycarbonyl-1.4-dihydrocollidine (DDC) feeding as models for cholestasis with biliary obstruction and bile duct injury. mRNA expression profile, serum biochemistry, liver histology, immunohistochemistry, hepatic hydroxyproline levels and BA composition as well as biliary pressure were assessed. BSEP-/- mice were protected against acquired cholestatic liver injury induced by 7days of CBDL or 4weeks of DDC feeding, as reflected by unchanged serum levels of liver transaminases, alkaline phosphatase and BAs. Notably, BSEP-/- mice were also protected from cholestasis-induced hepatic inflammation and biliary fibrosis. In line with induced BA detoxification/hydroxylation pathways in BSEP-/- mice, polyhydroxylated BAs were increased 4-fold after CBDL and 6-fold after DDC feeding in comparison with cholestatic WT mice. Finally, following CBDL, biliary pressure in WT mice increased up to 47mmH2O but remained below 11mmH2O in BSEP-/- mice. Metabolic preconditioning with subsequent changes in BA metabolism favors detoxification of potentially toxic BAs and thereby protects BSEP-/- mice from cholestatic liver and bile duct injury. Reduced hepatobiliary bile acid transport due to loss of BSEP function leads to increased hydroxylation of bile acids in the liver. Metabolic preconditioning with a hydrophilic bile pool protects the BSEP-/- mice from acquired cholestatic liver disease.

Role of farnesoid X receptor in cholestasis.

The nuclear receptor farnesoid X receptor (FXR) plays an important role in physiological bile acid synthesis, secretion and transport. Defects of FXR regulation in these processes can cause cholestasis and subsequent pathological changes. FXR regulates the synthesis and uptake of bile acid via enzymes. It also increases bile acid solubility and elimination by promoting conjugation reactions and exports pump expression in cholestasis. The changes in bile acid transporters are involved in cholestasis, which can result from the mutations of transporter genes or acquired dysfunction of transport systems, such as inflammation-induced intrahepatic cholestasis. The modulation function of FXR in extrahepatic cholestasis is not identical to that in intrahepatic cholestasis, but the discrepancy may be reduced over time. In extrahepatic cholestasis, increasing biliary pressure can induce bile duct proliferation and bile infarcts, but the absence of FXR may ameliorate them. This review provides an update on the function of FXR in the regulation of bile acid metabolism, its role in the pathophysiological process of cholestasis and the therapeutic use of FXR agonists.

Effects of carbon dioxide insufflation during direct cholangioscopy on biliary pressures and vital parameters: apilot study in porcine models.

Direct per-oral cholangioscopy allows endoscopic visualization of the biliary tract. Insufflation with carbon dioxide (CO2) is an alternative to saline solution irrigation during direct cholangioscopy. There are no data on maximal CO2 insufflation in direct cholangioscopy without causing biliary barotrauma or fatal gas embolism. We aimed to evaluate the safety of increasing CO2 insufflation in direct cholangioscopy without causing biliary barotrauma or fatal gas embolism. This was an invivo animal study. Four domestic pigs, under general endotracheal anesthesia, were used. The first animal was used to validate the feasibility of direct cholangioscopy and biliary pressure measurements, after which all animals underwent laparotomy, insertion of a pressure transducer in the cystic duct, and direct transpapillary placement of the cholangioscope. The common bile duct (CBD) and cystic duct were ligated to contain the instilled gas and exclusively expose the biliary tree. Insufflation of CO2 started at 200 mL/min and was continuously increased until there was evidence of bile duct rupture (as measured by a drop in intraductal pressures) or instability of vital signs (hypotension, bradycardia, bradypnea, O2 desaturation). Necropsy was performed on all animals to assess the liver and biliary system for evidence of barotrauma. CO2 was insufflated up to 8 L/min without causing bile duct rupture or instability in vital signs despite increasing CBD pressure with insufflation. There was significant correlation between CO2 flow with partial pressure of CO2 in arterial blood (PaCO2) (coefficient, 0.96-1.00; P< .01) and end tidal expired CO2 (EtCO2) (coefficient, 0.94-1.00; P< .01). However, the pulse rate, respiratory rate, arterial blood pressure, and O2 did not correlate with the amount of CO2 flow. There was no evidence of hepatic or biliary barotrauma on necropsy. This pilot experience in porcine models suggests that CO2 insufflation is safe for direct cholangioscopy and does not result in biliary barotrauma or vital signs instability.

Chronic fibrous-degenerative pancreatitis with involvement of adjacent organs and their dysfunction: contemporary approaches to surgical treatment.

Presently, there is no single opinion concerning the method preferable for surgical treatment of chronic pancreatitis (CP) with dysfunction of adjacent organs. Surgical treatment was applied to 144 patients with CP. In 54 (37.5%) patients, CP was complicated by dysfunction of adjacent organs. Particularly these were biliary hypertension (BH) in 36 (25%) patients and chronic duodenal obstruction (CDO) in 8 (5.5%) patients. In 5 (3.5%) patients, BH was combined with CDO, and another 5 (3.5%) patients had a combination of BH, CDO and venous hypertension (VH) of the portomesenteric area. In 24 patients with BH, we applied intraoperative monitoring of biliary pressure (IOM BP) in the process of performing duodenum-preserving pancreas resections. Frey's procedure was applied in 26 (48.1%) cases, where CP was complicated by the development of CDO, BH or CDO + BH. To correct BH, Frey's procedure was supplemented by application of hepatico-entero anastomosis (HEA) in 10 patients, pancreas lingual was excised; internal biliopancreatic anastomosis was applied in two patients. Beger's procedure was used in 2 (3.7%) patients, in which CP was complicated by BH + CDO + VH. Pancreaticoduodenal resection (PDR) according to Whipple was used in 5 (9.2%) cases. Longitudinal pancreatic-enteric anastomosis (LPEA) supplemented by HEA due to BH was applied to 8 (14.8%) patients. The results of chronic treatment were traced in 23 (42.5%) patients throughout the period of 6 to 36 months. Life quality indicators appeared to be the best among the patients who underwent resection surgeries on the pancreas. The method selected to treat surgically the patients with CP that involves adjacent organs and causes their dysfunction is duodenum-preserving resection surgeries on pancreas head, which in some cases should be supplemented by application of biliodigestive anastomosis or biliopancreatic diversion in the area of pancreas resection to eliminate the BH.

OC-079 Evaluation of Tertiary Centre Management of Type 2 Sphincter of Oddi Dysfunction Supports Manometry Defined Endoscopic Intervention

Introduction There is still doubt about the role of manometry and endoscopic intervention in Type 2 sphincter of Oddi dysfunction (T2SOD). We aimed to examine the efficacy of a manometry guided approach in the evolving management of T2SOD in our tertiary clinical practice at Hammersmith Hospital, London, UK. Methods We retrospectively evaluated all T2SOD patients referred between 2010 and 2014. Baseline characteristics and procedural outcomes were extracted including manometry readings, type of endoscopic intervention (sphincterotomy or Botulinum toxin injection), complications and pain improvement at 3 and 12 months. Results 74 T2SOD patients were identified, 17 of whom were excluded due to prior sphincterotomy or follow up elsewhere. Botulinum toxin injection was performed in 11 patients with normal manometry; 27% of whom reported short term but unsustained benefit. 46 patients were managed with dual sphincterotomy. Sustained benefit at 12 months was seen significant more often in those with abnormal (72%) than normal (21%) sphincter pressure (p = 0.046, OR = 4.6, CI: 1.2–17.5). Complications occurred in 19.2% (11/57) of patient’s post-sphincterotomy, but interestingly were confined only to those with abnormal manometry. Initial pain relief after cholecystectomy (p = 0.037, OR = 11.7, CI = 1.227–110.953) predicted better outcome while those with prior hysterectomy (p = 0.039, OR = 0.039, CI = 0.006-0.849) had worse outcome. Daily opiate users were more likely to suffer complications (p = 0.072, OR = 6.333, CI = 1.114–35.997). Finally, biliary and pancreatic sphincter pressures correlated highly (R = 0.586, p Conclusion We found abnormal manometry predicted both sustained pain improvement post-sphincterotomy and complications. The increased complication risk seems attributable to the underlying disease highlighting the safety of manometry itself. The correlation between biliary and pancreatic sphincter pressure suggests measurement of both may not be necessary before dual sphincterotomy after confirmation of sphincter hypertension. Our study of all-comers advocates a strategy of manometry-defined endoscopic intervention in T2SOD. Disclosure of Interest None Declared

RESECTION OPERATIONS IN SURGICAL TREATMENT OF PATIENTS WITH CHRONIC PANCREATITIS COMPLICATED BY BILIARY HYPERTENSION

Surgical treatment was applied in 145 patients with complicated forms of chronic pancreatitis (CP) at the department of surgery of the Ivano-Frankivsk Regional Clinical Hospital in 2009–2016. Fourty-nine (33.7 %) patients had symptoms of biliary hypertension (BH); in five (3.4 %) of them BH was combined with chronic duodenal obstruction (CDO), the other 5 (3.4 %) patients had a combination of BH+CDP and local venous hypertension of pancreaticobiliary area vessels. Resection-type surgeries were applied in 28 (57.1 %) patients with CP complicated by BH. Intraoperative monitoring of biliary pressure was used in 17 patients in the process of duodenum-preserving resections of the pancreas. Frey’s procedure was applied to 20 (71.4 %) patients, in whom BH persisted after the resection stage of the surgery; Frey’s procedure was supplemented by interventions on bile ducts: hepaticoenteroanastomosis was applied in 12 patients, excision of pancreas lingula was applied in one patient, internal biliopancreatic anastomosis was applied in one patient. Berne modification was used in 2 (7.2 %) patients, and pancreaticoduodenal resection (PDR) according to Whipple – in 6 (21.4 %) patients. Remote results were studied in 19 (67.8 %) patients. Patients after duodenum-preserving resections had the best quality of life indicators, for BH signs were absent.

Congenital choledochal malformation: search for a marker of epithelial instability

PurposeThere is a predisposition to the development of malignancy in congenital choledochal malformation (CCM) although the degree of risk is unknown. We investigated the role of CA19-9 in bile and the MIB-1 (Ki-67) epithelial proliferation index as markers of an at risk choledochal epithelium at the time of definitive surgery. MethodsBile collected at surgery was analyzed for levels of amylase (as a surrogate of pancreatic reflux) and CA19-9. Immunohistochemical staining for CA19-9 and MIB-1 index (expressed as %) was performed on resected specimens. Data are quoted as median (IQR) and differences assessed using non-parametric statistics. A P value of 0.05 was regarded as significant. ResultsOur study group consisted of 78 children with CCM (Type 1 fusiform, n=34; Type 1 cystic, n=30 and Type 4, n=14). Median bile CA19-9 was 159,400 (6–1×106) kU/L. There was no correlation with bile amylase (P=0.49) or biliary pressure (P=0.17) but modest correlation with bilirubin (rs=0.24; P=0.02). In contrast, bile amylase was correlated with plasma γ-glutamyl transpeptidase (P=0.02), alkaline phosphatase (P=0.05) and aspartate aminotransferase (P=0.02); and inversely correlated with biliary pressure (rs=−0.38; P<0.0008).Epithelial expression of CA19-9 and MIB-1 was assessed in 43 specimens. CA19-9 was diffusely expressed on all choledochal epithelium. MIB-1 expression was divided into: high expression (>40%)n=3; moderate (20–40%) n=5, low (6–20%) n=7 and very low (≤5%) n=28. There was no correlation with choledochal pressure (P=0.87), CA19-9 (P=0.51) or bile amylase (P=0.55). ConclusionBiliary CA19-9 levels were grossly (and unexpectedly) raised in choledochal malformation and appear to arise from biliary rather than pancreatic epithelium. MIB-1 confirms that a small proportion (19%) has marked epithelial proliferation but no clinical correlates could be identified.

A Rare Cause of Acute Pancreatitis: Unexpected Travel of the Biliary Catheter.

To the Editor, Biliary leakage is an important complication that occurs after cholecystectomy (1). Unless uncomplicated, it generally closes spontaneously if there is no distal obstruction (2). The therapeutic endoscopic retrograde cholangiopancreatography (ERCP) procedure is helpful in the clearance of biliary flow and lowering the biliary pressure (3). In case of insufficiency of the ERCP procedure, percutaneous biliary drainage maneuvers can help to control biliary fistulas or save time for surgery (4,5). We present a case of bile leakage which occurred after laparoscopic cholecystectomy, where we encountered an interesting cause of acute pancreatitis. A 32 year-old woman who underwent a laparoscopic cholecystectomy two weeks previously was referred to us with a drain placed in the operation wound, suggesting bile leakage. Physical examination revealed disseminated tenderness of the abdomen. Transaminase, amylase and lipase levels were normal. Computed tomography scan showed a 10 cm fluid collection in the sub-hepatic area. We followed her up for two weeks with the drainage of 200 mL of bile daily. A magnetic resonance cholangiopancreatography imaging was obtained showing some sludge and stone of 22 mm in the distal common hepatic duct (CHD). An ERCP was applied, where the pancreatic duct was found to be widened, but CHD could not be cannulated. An 8 F pigtail-locked percutaneous internal-external biliary drainage catheter (Flexima® Drainage Catheters, Boston Scientific; Natick, MA, USA) was placed and a prominent leakage from the cystic duct stump was demonstrated in cholangiography (Figure 1a). Fluid collection diminished by the 24th day. During the second catheter cholangiography, some small stones were pushed into the duodenum by a balloon catheter. One big stone, which remained in place, was extracted on the following day, by a successful ERCP procedure performed with the guidance of a biliary catheter (Figure 1b). Oral feeding was never paused. The intra-abdominal drainage catheter was removed and the patient was discharged on the 33rd day with the biliary catheter. On the 15th day of discharge, she presented with abdominal pain. Laboratory assessment demonstrated a marked elevation in serum amylase and lipase levels. She was re-hospitalized for acute pancreatitis. A control catheter cholangiogram showed an unexpected migration of the catheter into the duct of Virsung, which clarified the etiology of acute pancreatitis (Figure 1c). The catheter was repositioned (Figure 1d) and she was discharged on the following day. A spontaneous closure of the leakage was observed on a consequent catheter cholangiogram obtained a week later. The biliary catheter was removed and the patient visited the outpatient clinic without any complaint after three weeks. FIG. 1. a, b. Cholangiography film obtained after the internal-external biliary drainage catheter is placed. Biliary leakage at the level of cystic duct stump (white arrow). Image of stone or sludge at the level of distal common bile duct (CBD) (white arrow head). ... Biliary drainage catheters are loyal assistants of surgeons. Unless hemobilia or bilhemia occurs, they serve as lifeguards in biliary problems, whereas catheters are foreign bodies and can sometimes make matters worse. When a patient being followed-up with a percutaneous biliary catheter exhibits a state of sudden acute pancreatitis, besides other common reasons, catheter migration through the duct of Virsung must be kept in mind. This case seems to be the first in the literature demonstrating a biliary catheter responsible for acute pancreatitis by migrating into the duct of Virsung.

Exercise-induced cholangitis and pancreatitis.

Cholangitis requires bactibilia and increased biliary pressure. Pancreatitis may be initiated by elevated intraductal pressure. The sphincter of Oddi regulates pancreatobiliary pressures and prevents reflux of duodenal contents. However, following biliary bypass or pancreatoduodenectomy, increased intra-abdominal pressure may be transmitted into the bile ducts and/or pancreas. The aim of this analysis is to document that cholangitis or pancreatitis may be exercise-induced. The records of patients with one or more episodes of cholangitis or pancreatitis precipitated by exercise and documented to have patent hepatico- or pancreatojejunostomies were reviewed. Cholangitis was defined as fever with or without abdominal pain and transiently abnormal liver tests. Pancreatitis was defined as abdominal pain, with transient elevation of serum amylase and documented by peripancreatic inflammation on computerized tomography. Twelve episodes of cholangitis occurred in six patients who had undergone hepaticojejunostomy for biliary stricture (N=3), Type I choledochal cyst (N=2), or pancreatoduodenectomy for renal cell carcinoma metastatic to the pancreas (N=1). Four episodes of pancreatitis occurred in two patients who had undergone pancreatoduodenectomy for ampullary carcinoma or chronic pancreatitis. Workup and subsequent follow-up for a median of 21 months have not documented anastomotic stricture. Each episode of cholangitis and pancreatitis was brought on by heavy exercise and avoidance of this level of exercise has prevented future episodes. Following biliary bypass or pancreatoduodenectomy, significant exercise may increase intra-abdominal pressure and cause cholangitis or pancreatitis. Awareness of this entity and behavior modification will avoid unnecessary procedures in these patients.

BIOMECHANICAL MODELING OF CHOLEDOCH BILE FLOW IN CHOLEDOCHOLITHIASIS IN THE PROJECT “VIRTUAL PHYSIOLOGICAL HUMAN”

Aim. To ground the role of biomechanics in development of the model of biliary system within the norm and pathology in the frame of the project “Virtual Physiological Human”. The model will be based on the methods of computational biomechanics using anatomical, experimental, physiological data of hepatopancreatoduodenal (HPD) organs obtained by means of radial diagnostic methods determining the unique anatomy of a patient. Mathematical solution of the task of bile flow in the common bile duct in case of chloledocholithiasis is presented as an initial stage in realization of dynamic modeling of bile flow in the anhepatic bile-excreting tracts. Materials and methods. The problem was posed and the mathematical model of bile flow in the choledoch with concretion in its acute blockade was developed. The model is based on solution of the Navier-Stokes equation recorded for non-newton fluid (Casson fluid) in special conditions. Results. Flow rate profiles, dependence of duct lumen bile flow on time and concretion size as well as dependence of biliary pressure on choledoch and concretion diameter are presented in the paper. Conclusions. The worked out mathematical model permits to estimate dynamics of the postoperative period and to predict the development of specific complications based on changes in the values of choledoch biliary pressure from the side of HPD organs. Moreover, estimation of biliary pressure in the duct is objective for determination of biliary decompression efficiency during endoscopic transpapillary interventions on the large duodenal papilla when the pressure is high and the bile excretion volume is less than 35 % of the proposed standard.

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

Mo1403 Gastrojejunal Tube Feeding: a Potential New Treatment for Sphincter of Oddi Dysfunction Type III (SODPPP) Patients With Severe Post-Prandial Pain

Mo1403 Gastrojejunal Tube Feeding: a Potential New Treatment for Sphincter of Oddi Dysfunction Type III (SODPPP) Patients With Severe Post-Prandial Pain Tae Joo Jeon*, Byung Kyu Park, Laith H. Jamil, Simon K. Lo Cedars-Sinai Medical Center, Los Angeles, CA; Division of Gastroenterology, Inje University Sanggye Paik Hospital, Seoul, Korea (the Republic of); Division of Gastroenterology, National Health Insurance Service Ilsan Hospital, Goyang-si, Korea (the Republic of) Background: ERCP and Sphincterotomy had been widely used to evaluate and treat the Sphincter of Oddi dysfunction (SOD) type III condition until their benefit was disputed by the recent EPISOD study. Unfortunately, there is no proposed alternative to manometry-directed sphincterotomy at the present moment. Aim: To determine if gastrojejunal tube (PEGJ) feeding may have therapeutic benefits for SODPPP patients. Method: All SODPPP patients without sustained improvement after bi-ductal sphincterotomies were offered percutaneous endoscopic gastrostomy-jejunostomy tube (PEGJ) feeding. SOD III was defined by pancreatic or biliary type pain without a dilated duct or abnormal pancreatic or liver tests. PEGJ was placed in the usual fashion and inserted into the proximal antrum. PEGJ’s tip location in the proximal jejunum was confirmed with fluoroscopy. Strict NPO was kept within the first 4-6 weeks. PEGJ feeding was maintained as long as these patients needed feeding to provide nutrition or pain relief. Results: Nine highly symptomatic SODPPP patients underwent PEGJ tube insertion for feeding. All were female. Median age was 41 years old (25-53). Median duration of SOD symptoms was 27 months (22-96). All but one patient had elevated pancreatic or biliary sphincter pressure. Only one patient did not have a prior cholecystectomy. Eight patients had sphincterotomy and experienced pain improvement for a short duration (median; 8 weeks) before recurrence of symptoms. The mean duration of tube feeding was 5.08 months (S.E 1.83). Seven patients reported dramatic pain improvement. Six had less number of hospitalizations or ER visits after PEGJ feeding. Five patients were satisfied with the procedure and could return to normal daily activities while on tube feeding. Only 1 patient was not satisfied because of the lack of effectiveness. The demand of analgesics was decreased in 5 patients. Complications included prolonged tube insertion site pain-2, pinkish drainage-1, and nausea-1. Persistent insertion site pain was the reason for tube removal on day 7 in on patient. There were 4 tube malfunctions (J-tube dislodgement-2, tube coiling-1, broken tube-1). PEGJ had since been removed in 5 patients (no benefit-1, dramatic clinical improvement-1, husband’s disagreement-1, unsightly catheter-1, insertion site pain1). Interestingly, those 2 patients who had tube removal due to personal issues eventually requested PEGJ re-insertion. Conclusion: PEGJ feeding may have therapeutic benefits for the subset of highly symptomatic SOD III patients with postprandial pain exacerbations. It may represent a breakthrough in the management of these patients and should be confirmed by a larger, prospective clinical study.

Su1626 Bile Aspiration During ERCP Is Associated With Lower Risk of Post-ERCP Cholangitis: a Single Center Prospective Study

Endoscopic retrograde cholangiopancreatography (ERCP) is associated with adverse events. Pancreatitis and cholangitis are the most common adverse events. Bile aspiration is performed to obtain bio-markers and theoretically should reduce biliary pressure and may decrease post-ERCP adverse events in particular cholangitis.

Correlations of portal pressure in post-cholecystectomy benign biliary stricture.

Presence of portal hypertension (PH) adversely affects perioperative and long-term outcome in patients with post-cholecystectomy benign biliary stricture (PCBBS). Identification of factors related to the development of PH will help to prevent this complication. From September 2010 to December 2012, 30 patients with PCBBS were studied prospectively for correlation of portal pressure (PP) with injury repair interval (IRI), biliary pressure (BP), severity of hepatic fibrosis (FS), severity of hepatic inflammation (IS) and obstructive biliary pathology score (OBPS). Appropriate statistical methods employed and P ≤ 0.05 (two-sided) was considered statistically significant. Mean PP, mean BP and median IRI were 19.4 ± 4.74 mmHg, 20.1 ± 3.99 mmHg and 145 days, respectively. Spearman's rank correlation coefficients (P-value) of PP with IRI, FS, IS and OBPS were 0.564 (0.001), 0.502 (0.004), 0.752 (0.0001) and 0.242 (0.19), respectively. Pearson correlation of PP with BP was r = 0.383 (r(2) = 0.146, P = 0.03). Spearman's rank correlation coefficients (P-value) of FS with IS and OBPS were 0.561 (0.003) and 0.371 (0.04), respectively. Spearman's rank correlation coefficient of serum bilirubin with OBPS was 0.550 (P = 0.001). Incidence of PH was 33.3% and mean fall of PP following biliary repair was 6.2 ± 1.98 mmHg (P < 0.0001). PP in patients with PCBBS has a good correlation with IS, and a fair correlation with both FS and IRI whereas PP was not directly related to BP and OBPS; further prospective trials are mandatory to confirm this correlation, and to evaluate mechanism of fall in PP following biliary decompression.

Biliary tract pressure before and after endoscopic papillary balloon dilation treatment for common bile duct stones

Biliary tract pressure before and after endoscopic papillary balloon dilation treatment for common bile duct stones