Biliary Problems Research Articles

Choledochoduodenostomy versus T-tube drainage in patients have stones in common bile duct with risk factors of post-operative missed stones

Background: Residual or missed stones of common bile duct (CBD) and ascending cholangitis after CBD exploration are major biliary surgery problems. Repeated biliary tract interventions for correction of complications are catastrophic on both patients and surgeons.Methods: This is a prospective study of 83 patients which compares two methods for surgical management of CBD stones between June 2016 to May 2018. Group I included 43 patients who were managed by CBD exploration followed by insertion of T tube, the risk factors of the incidence of missed retained stone in CBD were multiple stones in CBD and hugely dilated CBD (>15 mm).The second method was choledochoduodenal anastomosis for patients having the same previous risk factors (Group II) which included 40 patients. Postoperative follow up was for 12 to 18 months.Results: In group I, 6 patients developed residual stones in CBD, reoperation was required for 3 of them and endoscopic retrograde cholangiopancreatography with sphincterotomy for another 3 patients, while in the other group (group II) 2 patients suffered from ascending cholangitis and are managed conservatively. No missed or residual CBD stones were developed and no patients need reoperation.Conclusions: With choledochoduodenostomy in patients with multiple CBD stones or markedly dilated CBD the incidence of missed or retained stones in CBD was reduced.

Status of Geriatric Patients with Abdominal Pain Presented To Emergency Department

Background: As the development of better health facilities with advanced tools for diagnosis and management our country is not away from global trend. Nepal’s life expectancy at birth is increasing at its pace, it has in­creased in about 30 years in last 4 decades. Among the various problem presenting to ED abdominal pain is one of the common complain elderly patients are greater risk of missing life-threatening causes during evalua­tion and investigation. The aim of the study wasEdit to identify the frequency, cause and outcome of patient presenting in Emergency department with abdominal pain.
 Methods: It is a retrospective study conducted in tertiary care center at Chitwan, Nepal during the period from 01/09/2017 to 30/08/2018. Elec­tronic data entered by medical officer were retrieved and analyzed. Statis­tical analysis of the record was done using SPSS 16 software.
 Results: Elderly population who presented with chief complaints of ab­dominal pain was 1160 (21.79%). Among the patient presented with ab­dominal pain 605(52.2%) were male and 555(47.8%) were female. Mean age of patients was 71.72±8.50 years. Most common system involved was gastrointestinal and biliary problem 730(62.93%). Most common diagno­sis was Urinary tract infection 269 (23.2%) among them, 487(41.98%) re­quired hospital admission.
 Conclusions: Abdominal pain is one of the common presentations of el­derly to emergency department. Disorders of Gastrointestinal and biliary system were among leading causes of emergency visit. Emergency phy­sician should be tactful to identify life threatening conditions and emer­gency management.

Is percutaneous cholecystostomy acceptable as a bridge treatment for acute cholecystitis in high risk patients who has a biliary problem?

Introduction: This study aimed to investigate the safety and effectiveness on laparoscopic cholecystectomy (LC) following percutaneous cholecystostomy (PC), especially in patients with biliary tract disease (BD). Method: Of the 4182 LC cases for acute cholecystitis (AC) from January 2012 to December 2016, 70 patients with high risk for general anesthesia underwent PC followed by LC. 14 patients of these patients were diagnosed AC with BD and 56 patients were diagnosed without biliary tract disease (non-BD). We compared the peri-LC and peri-PC outcomes between two groups, retrospectively. Result: There were no significant differences about severe complications regarding PC and LC on both groups. In BD group, hospitalization was longer than non–BD group (20.9 vs 12.4 days, p <0.001) and the readmission rate were significantly higher (71.42% vs 25.00%, p=0.034). Conclusion: PC is a safe treatment of bridging for AC in high-risk patients. When AC accompanied by BD, PC should be followed by LC as soon as possible.

A novel self-expanding biflanged metal stent vs tubular metal stent for EUS-guided transmural drainage of pancreatic pseudocyst: A retrospective, cohort study.

Although endoscopic ultrasound (EUS)-guided transmural drainage of pancreatic fluid collections with metal stents is generally preferred over plastic stents, its superiority among different types of metal stents has not yet been well studied. We conducted this study to compare clinical outcomes and complications of a novel self-expanding biflanged metal stent (BFMS) and a traditional-shaped tubular metal stent (TMS) in treating pancreatic pseudocyst (PPC).This was a retrospective analysis on consecutive patients with PPC underwent EUS-guided transmural drainage with either TMS or BFMS in a single tertiary center with expertise in management of complex biliary and pancreatic problems. The technical and functional success rate, reintervention, complications, and recurrence rate were evaluated.From September 2013 to January 2018, 125 patients (66.4% male, median age 47 years) underwent EUS-guided transmural drainage for PPC. Among them, 49 used TMS and 76 used BFMS. All patients met the inclusion criteria that cyst diameter was >6 cm or the distance between cyst and stomach wall was shorter than 1 cm. There was no difference in technical success (98% vs 97.4%, P = 1.0) or functional success rate (87.8% vs 92.1%, P = .54) using 2 types of metal stents. However, more procedure related complications occurred in TMS than in BFMS group. TMS group had a much higher migration rate than BFMS group (14.6% vs 0, P = .001), even though there was no significant difference in bleeding, infection, or death rate between 2 groups. With similar clinical outcomes, TMS group required more additional plastic stent placement than BFMS group for better drainage.TMS and BFMS placement can both be considered as methods of endoscopic transmural PPC drainage with equal efficacy, whereas BFMS could be preferred for fewer complications or less need of additional plastic stent placement.

Aggressive prevention and preemptive management of vascular complications after pediatric liver transplantation: A major impact on graft survival and long‐term outcome

Vascular complications are a major cause of patient and graft loss after LTs. The aim of this study was to evaluate the effect of a multimodal perioperative strategy aimed at reducing the incidence of vascular complications. A total of 126 first isolated LTs-performed between November 2008 and December 2015-were retrospectively analyzed. A minimum follow-up period of 24months was analyzable for 124/126 patients (98.4%). The aggressive preemptive strategy consisted of identifying and immediately managing any problem and any abnormality in the vascular flow, in any of the hepatic vessels, and at any time after the liver graft revascularization. As a result, with a median follow-up of 57months (3-112months), not a single graft has been lost from vascular or biliary problems. The actuarial 8-year graft survival is 96.5%. These results have shown that a combination of technical attention, medical prevention, an early diagnosis, and rapid interventions reduced the negative impact of vascular problems on the outcome of both grafts and patients.

Severe Unresolved Cholestasis Due to Unknown Etiology Leading to Early Allograft Failure Within the First 3 Months of Liver Transplantation.

Causes of severe cholestasis after liver transplantation (LT) are multi-factorial. Although the etiology is predictable in some, others culminate in graft/patient loss without a definitive cause identified. Severe cholestasis is usually associated with overlapped histological findings of rejection and biliary features, and diagnostic interpretation may pose a challenge. This is 10-year retrospective analysis of patients with unexplained severe cholestasis resulting in death/graft loss within 90 days of LT. Of 1 583 LT during the study period, 90-day graft failure occurred in 129 (8%) cases; a total of 45 (3%) patients had unresolving severe cholestasis (bilirubin, >100 μmol/L; alkaline phosphatase, >400 UI/L after 15 days from LT), excluding those due to primary nonfunction/sepsis/vascular causes (n = 84). Demographics, allograft biopsies, radiological investigations, and clinical outcome were analyzed. All patients had persistent abnormal liver biochemistry. Doppler ultrasound scan was normal in all cases. Thirty-five (78%) recipients had at least 1 allograft biopsy (2 [1-9]). On the first biopsy, 22 (63%) patients had acute rejection, 4 (18%) early-chronic rejection, 12 (34%) antibody-mediated rejection. In subsequent biopsies chronic rejection was evident in 5 (14%) cases. Donor-specific antibodies were detected in all patients tested. Biliary anatomy was studied in detail in 9 (20%) patients, all presenting biliary strictures. The majority (n = 39; 87%) died within 32 (10-91) days, only survivors were from retransplantation (n = 3;6.5%) and biliary intervention (n = 3;6.5%). Unresolving severe cholestasis after LT is a key parameter predicting patient/allograft outcome. Histologically, rejection seems to overlap with biliary strictures; hence, allograft biopsy with signs of rejection should not be a reason to overlook biliary problems, in particular when biliary features are present. Only extensive radiological investigation/intervention or retransplantation prevents patient/allograft loss.

Post Liver Transplant Biliary Complications and Management in Local University Hospital

Introduction Biliary complications have still remained as major problem after liver transplant (LT) and accepted as Achilles’ heel. Herein, we introduce our experience of biliary complications after LT in small volume center. Methods From November 2002 to July 2017, 100 patients underwent LT at Dongsan Medical center, Daegu, Korea. Among these patients, 60 patients underwent deceased donor liver transplant (DDLT) and 40 patients underwent living donor liver transplant (LDLT). Medical records of these patients were reviewed retrospectively Results Among these patients, biliary complications (bile leakage in 10 patients and bile duct stricture in 26 patients) were developed in 28 patients (28%). For the management of biliary complications, reoperation was performed in 2 patients for bile leakage, percutaneous transhepatic biliary drainage (PTBD) in 11 patients and endoscopic retrograde biliary drainage (ERBD) in 22 patients for bile leakage and biliary stricture. All patients were improved after treatment and followed up without biliary problem until now. Conclusion The rate of biliary complications in our center was comparable with that of other centers reported previously and the outcome of treatment was acceptable. Co-operation with interventionist and gastroenterologist is important to overcome biliary complications after liver transplant.

Life-threatening or nearly life-threatening complications in living liver donors.

To determine the relationship between a transplant center's experience and life-threatening or nearly life-threatening complications during living donor hepatectomy (LDH). The medical records of 1140 patients who underwent LDH were analyzed. To determine the relationship between life-threatening complications and a transplant center's experience, the following comparisons between LDH cases were performed: first 100 vs subsequent 100; first 100 vs subsequent 1040; first 200 vs subsequent 940; right hepatectomy vs left hepatectomy; and first 5years of experience vs subsequent 5years. A total of 36 life-threatening or nearly life-threatening complications developed in 34 of 1140 (2.98%) healthy individuals undergoing LDH. Of these, 5 occurred intraoperatively, 26 within 1month, and 5 beyond 1month. The most common complications were biliary problems and postoperative bleeding. None of the donors died at follow-up. One donor underwent deceased donor liver transplantation (DDLT) for severe hepatic failure. Only 2 comparisons were significantly different with regard to life-threatening complications: the first 100 vs the subsequent 1040 (P=.03) and the first 200 vs the subsequent 940 (P=.01). This study indicates that the incidence of life-threatening or nearly life-threatening complications are reduced by increased center experience (>200 LDHs).

Propofol–midazolam versus propofol–dexmedetomidine as a deep sedation for endoscopic retrograde cholangio-pancreaticoduodenoscopy

Background Endoscopic retrograde cholangio-pancreaticoduodenoscopy (ERCP) is a day procedure for diagnostic or therapeutic biliary problems. Many kinds of sedation are used to provide patients comfort and facilitate work. Propofol and midazolam is the preferred cocktail. Dexmedetomidine with sedo-analgesic properties makes it another suitable regimen. The aim of this study was to compare the efficacy of adding either midazolam or dexmedetomidine to propofol for procedural sedation during ERCP. Patients and methods This study was conducted in Mansoura University Hospitals, Gastroenterology Center. A total of 84 patients (40–80 years), American Society of Anesthesiologist II, III, and IV scheduled for ERCP were randomly allocated into two groups: the PM group received propofol–midazolam and the group PD received propofol–dexmedetomidine. Heart rate, mean arterial blood pressure, and SpO2 were recorded at basal, intraoperative, postanesthesia care unit (PACU), till discharge. O2 desaturation, total dose of propofol, intraoperative complications, patients, and surgeon satisfaction were recorded. Results Heart rate and mean arterial blood pressure showed a significant reduction in group D compared with group M. Onset of deep sedation shows a significant reduction in group D versus group M. Recovery time and onset of discharge from the postanesthesia care unit shows statistically significant prolongation in group D versus group M. The total dose of propofol, intraoperative complications and also surgeon and patient satisfaction were comparable. Conclusion Administration of 1-μg/kg loading dose of dexmedetomidine or midazolam 1 mg intravenous, followed by intravenous propofol (1 mg/kg) and then 10 mg increments can produce an effective and smooth sedation without causing hemodynamic or respiratory side effects. So, dexmedetomidine could be an important alternative to midazolam for sedation in ERCP and other short procedures.

ДІАГНОСТИКА І ЛІКУВАЛЬНІ ТРАНСПАПІЛЯРНІ ВТРУЧАННЯ У ХВОРИХ З ПРИВОДУ ПОРТАЛЬНОЇ БІЛІОПАТІЇ

Проаналізовані результати мініінвазивних ендоскопічних втручань у 31 хворого з приводу портальної біліопатії (ПБ). У 7 (23%) хворих ПБ виникла на тлі тромбозу ворітної вени (ВВ), у 19 (61%) - виявлені клінічні ознаки, пов’язані з ураженням жовчних проток: холедохолітіазу (у 16%), стриктури (у 35%), папілостенозу, що супроводжувалося гіпербілірубінемією, жовтяницею, холангітом. Діагностичний комплекс включав ультразвукове дослідження (УЗД) з допплерографією, контрастно-підсилену комп’ютерну томографію (КТ), магніторезонансну холангіопанкреатикографію (МРХПГ), діагностичну та лікувальну ендоскопічну ретроградну холангіографію (ЕРХГ) з папілосфінктеротомією (ЕПСТ), літоекстракцією, ендобіліарним стентуванням. Ендоскопічні транспапілярні втручання, не усуваючи основну патогенетичну причину ПБ - портальну гіпертензію (ПГ), дозволяють у більшості хворих вирішити проблеми біліарної гіпертензії.

THE CASE FILES

THE CASE FILES

Diagnostic Value of Amylase and Lipase in Diagnosis of Acute Pancreatitis

Introduction In acute pancreatitis, blood amylase increased. Sometimes up to 6-4 times the highest normal level rises (1). Amylase levels also in other diseases, such as pancreatic duct obstruction, pancreatic cancer and biliary problems specifically rise. Several types are called amylase isoenzy

Access loop Roux-en-Y hepaticojejunostomy: revisited a study of twenty two cases over 15 years (2001-2015)

Background: Access-loop Roux-en-Y hepaticojejunostomy (HJ), an interesting and an unique surgical technique described in the past seems to have resurfaced amidst commendation and condemnation.Methods: The technique involves the incorporation of a cutaneous access stoma in the Roux-en-Y loop of jejunum used for the anastomosis. This stoma provides permanent access to the bilio-enteric anastomosis and thus to the hepatobiliary tree for non-operative management of chronic and recurrent biliary tract problems. Here we are presenting our experience in 22 cases managed by us with “access-loop Roux-en-Y hepaticojejunostomy (HJ)” over a period of 15 years (2001 to 2016).Results: 22 cases were managed successfully. The maximum follow-up was for 05 years with no recurrence or stricture only 01 patient had a small Incisional hernia.Conclusions: The objective of this work is to, describe an optional technique (although less known and practiced) during the accomplishment of a "roux-en-Y" hepaticojejunostomy that, allows future endoscopic and interventional radiology access to the bilio-enteric anastomosis.

Pneumococcal biliary tract infections - How rare are they?

Pneumococcal biliary tract infections (PBTIs) were reported as rare due to the bacterium's bile solubility. The purpose of this study was to determine the occurrence and clinical characteristics of PBTIs. A retrospective case series review was conducted from January 2006 to August 2014 at a tertiary referral university hospital in Japan. Patients with a blood or bile culture positive for Streptococcus pneumoniae diagnosed with definite cholangitis or cholecystitis according to Tokyo Guideline 2013 were enrolled in this study. Data on clinical information, treatments, and outcomes were collected. During 104 months, 48 cases of positive blood cultures and 13 cases of positive bile cultures were recorded, and after excluding 43 and 5 of these, respectively, a total of 10 patients were diagnosed with PBTI. Most patients (9/10) had biliary tract problems and biliary devices in place. PBTIs were not rare; conversely, they were a relatively common cause of pneumococcal bacteremia in this center treating a high volume of biliary tract illnesses.

Liver Transplantation in Polish Children With α1-Antitrypsin Deficiency: A Single-Center Experience

Backgroundα1-Antitrypsin deficiency (ATD) is the most common genetic cause of liver injury in young children. Asymptomatic hepatitis is observed in most patients. However, the course of liver disease due to ATD is unpredictable, and some children develop liver cirrhosis. Liver transplantation (Ltx) dramatically improves their outcome and in some cases is required in the first years of life. The aim of the study was to evaluate the course of the disease in children with ATD treated with Ltx in a single center. MethodsWe retrospectively reviewed the clinical features (ascites, esophageal varices, esophageal bleeding) and laboratory parameters of liver function in children with ATD who were treated with Ltx. ResultsTwenty-two Ltxs were performed in 20 children (13 boys, 7 girls). Median age at transplantation was 12 years (range 0.5 to 17.1). Four children were transplanted in the first 2 years of life and 16 patients were over 7 years old. The indications for Ltx in younger children were progressive cholestasis with coagulopathy and ascites. In older patients, the indications were as follows: liver failure presenting with variceal bleeding in 7 patients, ascites in 5 patients, hypersplenism in all but 1 patient. In the group of children transplanted over 7 years old, the frequency of cholestasis decreased intermittently in the second year of life: 4 patients (25%) compared to 15 patients (94%) and 10 patients (63%) in the neonatal and pretransplant period, respectively. In the group of children transplanted earlier, cholestasis and hepatitis were maintained until Ltx. Of transplanted patients, 50% were malnourished at the transplantation, and 50% were followed for more than 10 years. Five-year post-transplant survival was 100% (n = 14), and 10-year survival was 90%. Two patients died as adults with biliary post-transplant complications and problems with compliance. ConclusionsOur experience suggests that transient normalization of liver parameters in some patients with ATD do not exclude the liver disease progression to cirrhosis and unfavorable outcome of liver disease in childhood. In our group of patients, median age at transplantation was high compared to other centers. The long-term prognosis in children after transplantation is very good, but early post-transplant complications and probable problems with compliance in young adults may lead to graft failure.

An Unusual Complication of Gallstones: Mirizzi Syndrome - A Case Report and Literature Review

1 Department of Medicine, Capital Development Authority (CDA) Hospital, Islamabad, Pakistan 2 Department of Medicine, Capital Development Authority (CDA) Hospital, Islamabad, Pakistan 3 Department of Medicine, Capital Development Authority (CDA) Hospital, Islamabad, Pakistan Corresponding Author Adnan Bashir Bhatti, MD Email: dr.adnanbashir@gmail.com Abstract Mirizzi syndrome is a rare complication of gallstone disease, causing major biliary problems, if the diagnosis is not made early. This condition was also reported to occur in the setting of acute acalculous cholecystitis. It was first described in 1948 by Pablo Mirizzi and presented itself in the form of unusually lodged gallstone in either the cystic duct or most frequently in Hartmann pouch of the gallbladder. We report a 50-year-old female with exquisite pain in right hypochondrium and epigastrium with nausea and vomiting for the last 20 days. She also had yellowish discoloration of urine, clay-colored stools, and tender right hypochondrium. Laboratory investigations revealed raised liver enzymes and ultrasonography (USG) was inconclusive in describing an impacted stone in the gallbladder neck. Computerized tomography (CT) scan and magnetic resonance cholangiopancreatography (MRCP) revealed it as suspected case of a mirizzi syndrome which was later confirmed by surgery. The patient was recovered after surgery without complications.

Intraoperative ERCP for management of cholecystocholedocholithiasis.

The introduction of minimally invasive techniques in management of biliary problems added new procedures for treating patients with cholecystocholedocholithiasis (CCL). This study presents the results of intraoperative ERCP (IOERCP) during LC as a single-session minimally invasive procedure for management of patients who have preoperatively diagnosed CBD stones. The database of patients presented to our center by CCL between October 2007 and December 2015 who were treated by LC and IOERCP was collected and analyzed. CBD stones were diagnosed using clinical data, laboratory tests and abdominal sonogram. MRCP was requested for doubtful cases. In the first cases ERCP was done using rendezvous technique, but in late cases standard ERCP immediately after completion of LC under the same anesthesia was used. Preoperative, intraoperative and postoperative data were recorded, analyzed and reported. Data reported include success/failure rate, complications, conversion to open surgery, operative details and incidence of residual CBD stones. The study was conducted on 346 patients who had CCL. The mean age was 34.7years, and 298 of them were females. The most common presentation was abdominal pain (98.5%) and jaundice (64.9%). Fifteen patients were excluded, and IOERCP was not done due to negative IOC results in 10 patients and conversion to open surgery in 5 patients. IOERCP was tried in the remaining 331 patients. The mean operative time was 55min, and the mean hospital stay was 2.4days. Major complications had been reported in 13/323 patients (4.0%). Failure of CBD clearance was reported in 8 patients (2.4%) with a success rate of 97.6%. Thirty-day follow-up was possible in 142 patients, and there was a residual CBD stone in one patient and wound infection in another one. IOERCP during LC is a safe and effective option for management of CCL.

Management of biliary tract problems

Biliary disorders are relatively rare in childhood but early recognition is important and investigations need to be organized efficiently to facilitate a timely diagnosis and specific treatment. The classical clinical presentation of biliary disorders is with jaundice, particularly in the newborn period, abdominal pain and fever but incidental antenatal diagnosis is becoming an increasingly important presentation. Abdominal ultrasound remains the imaging modality of choice but magnetic resonance cholangiopancreotography and endoscopic ultrasound have an increasing role. The role of endoscopic retrograde cholangiopancreotography has evolved from a diagnostic to a therapeutic tool. Surgical treatment is necessary for many biliary disorders and while laparoscopic cholecystectomy is now the standard of care, open surgery remains the preferred method for Kasai Portoenterostomy. This review article focuses on the clinical features of biliary disorders in childhood and the diagnostic tools available. The epidemiology, clinical features and treatment of the most important biliary tract problems are then discussed.

Multiple bile ducts: do the duct distance and the number of biliary anastomosis have an impact on the recipient's biliary problems?

Introduction: The variation of multiple bile ducts in a living donor graft can be encountered frequently but whether or not this leads to biliary complications has not been known yet. Especially a duct distance between the bile duct and the number of biliary anastomosis has not been known to the risk of the recipient's complication. Method: From 316 patients who underwent living donor liver transplantation from 2011 to 2013, a total of 55 patients had more than 2 bile duct openings. Result: Forty-seven patients had 2 openings while 3 patients had 3 openings. Duct to duct anastomosis was done in 46 patients and 25 had tailored telescope reconstruction (TTR) while 29 patients had 1 or 2 internal stents placed. The average distance between the ducts was 5.8 mm. 25 patients were performed one biliary anastomosis using TTR method. Duct complication was not increased when the distance between ducts was longer. And the number of biliary anastomosis does not impact on complication. Conclusion: 8 patients from a total of 50 patients developed biliary complications showing a complication rate of 16%, which is not significantly high compared with complication rates with 1 duct opening in other articles. In the 2 bile duct group, duct distances is not significant that the longer distance between the ducts does not cause the worse outcomes as most would tend to expect. And TTR method could make one biliary anastomosis and it seems beneficial effect in small distance between the ducts.

Mix and match, appliance of ERCP to decrease the biliary problem during DPPHR

Mix and match, appliance of ERCP to decrease the biliary problem during DPPHR