Biliary Problems Research Articles

Diagnosis and treatment for biliary complications of hepatic cystic echinococcosis

Objective To evaluate the diagnosis and treatment of hepatic cystic echinococcosis with biliary complications. Methods 284 patients with hepatic cystic echinococcosis (CE) with biliary complications were surgically treated from January 2002 to January 2009 in our hospital. A summary of the surgical procedures was categorized and compared in the current study. Results (1) Intrabiliary rupture of CE with obstructive jaundice and (or) inflammation of bile duct (51 patients). The diagnosis of biliary complications of hepatic hydatid cyst was difficult on ultrasound and CT, with sensitivity rates of 78.4% and 85.7%, respectively. MRCP was an effective, noninvasive and useful diagnostic tool in difficult cases; ERCP was used as the gold standard in confirmation. Biliary fistulae were seen in 3 patients (10.7%) treated by suturing the rupture site. In the non-sutured group, 17 patients (74%) developed biliary fistulae after surgery (P＜0.01). In three patients the fistula was a high-output type (the fistula output was greater than 250 ml/d). (2) CE communicated with the bile duct and (or) infection (210 patients): The cavity-related problems and draining time in group C (no bile duct exploration and decompression) were significantly higher than group A (biliary system explored and decompressed through the cystic duct) and group B (biliary system explored and decompressed through the common bile duct), while cavity-related problems and draining time between the A and B groups showed no significant difference. Biliary tract-related problems in group A was significantly lower than group B (P＜0. 05). Conclusions (1) MRCP was an effective, noninvasive and useful diagnostic tool; ERCP was used only as the gold standard in confirming intrabiliary rupture of liver cystic hydatid disease, and also as an effective technique for treating extended postoperative external biliary fistula. (2) This study indicated that suturing the communication at the rupture site and biliary decompression were effective with low morbidity and mortality rates. (3) Cholangiography and common bile duct exploration through the cystic duct could solve the cavity-related problems while avoiding the T-tube related problems. Key words: Liver; Cystic echinococcosis; Biliary complications; Diagnosis; Treatment

Intensive therapy after solid organ transplantation

ZusammenfassungTransplantationsmedizin ist eine interdisziplinäre Aufgabe. Oberstes Ziel ist die schnelle Wiederherstellung der individuellen Eigenständigkeit des Patienten. Nach einer Nierentransplantation sind die Überwachung der Organperfusion, ein adäquater Volumenstatus und die Vermeidung einer nephrotoxischen Medikation entscheidend. Die Betreuung von Patienten mit einer weit fortgeschrittenden Leberinsuffizienz ist nach Einführung des „Model-of-end-stage-liver-disease“- (MELD-)Systems häufiger geworden; dies geht mit dem Anstieg des Anteils komplikationsträchtiger Verläufe einher. Die Überwachung der Transplantatfunktion, die Diagnose früher Perfusions- oder Gallengangskomplikationen, eine spezifische Gerinnungssubstitution und die hämodynamische Optimierung im Sinne der Vermeidung einer Leberstauung sind die Eckpunkte der intensivmedizinischen Betreuung. Viele Patienten zur Herztransplantation sind bereits präoperativ aufgrund der stark eingeschränkten Herzfunktion in intensivmedizinischer Behandlung. Eine differenzierte Unterstützung der Transplantatfunktion mithilfe pulmonalarterieller Dilatatoren und Inotropika ist postoperativ regelhaft notwendig. Die Lungentransplantation zielt besonders auf eine Verbesserung der Lebensqualität der Patienten. Postoperativ ist auf die Limitierung des pulmonalarteriellen Drucks, die Vermeidung einer Flüssigkeitsüberladung und die zügige Entwöhnung vom Respirator zu achten.

The application of SpyScope® technology in evaluation of pre and post liver transplant biliary problems

Peroral cholangioscopy with its limitations led to further research regarding development of SpyScope® technology. The aim of this retrospective study was to investigate the efficacy of a new device and the application of this device in our Liver Transplant Center. Charts of patients who had undergone evaluation with SpyScope® were retrospectively reviewed. Indications included pre-transplant as well as post-transplant evaluation of biliary strictures. If strictures or filling defects were noted by cholangiogram, SpyScope® was performed. Biopsy was obtained under direct visualization if necessary with SpyBite® biopsy forceps. Demographic features, indications for SpyScope® evaluation, results, and histopathological diagnoses were recorded. Ten patients (6 male, 4 female; median age: 55) had undergone SpyScope® procedure between August 2007 and January 2008. Six out of 10 cases were in the pre-transplant work-up period, referred to as Group I, while the remaining four were post-transplant patients, referred to as Group II. In Group I, 4 of 6 cases had undergone the procedure for work-up of primary sclerosing cholangitis prior to orthotopic liver transplantation. In Group II, indications were either strictures noted during the previous endoscopic retrograde cholangiopancreatography (n=2) or common bile duct stones with elevated total bilirubin levels and stones with long segment biliary stricture (n=2). In the patient with anastomotic stricture, the biliary lithiasis was eventually exposed just above the anastomotic stricture, after abundant lavage was applied at that level. All SpyBite® biopsy specimens were reported to be adequate samples for histopathological examination. No malignancy was detected among 4 patients with primary sclerosing cholangitis and patients with elevated CA 19-9. SpyScope® allows direct visualization of biliary strictures and SpyScope®/SpyBite® were found to be technically superior to conventional cholangiogram with better sampling than brushing obtained by endoscopic retrograde cholangiopancreatography. Prospective, multicenter, large volume studies are warranted to identify its sensitivity and specificity.

Ectopic opening of the common bile duct and duodenal stenosis: an overlooked association

BackgroundEctopic opening of the common bile duct into the duodenal bulb (EO-CBD-DB) is a rare disease that may be complicated by duodenal ulcer, deformity, stenosis and biliary stones. The aim of this study is to report clinical presentations, endoscopic diagnosis and treatment of this entity as well as to investigate its association with duodenal stenosis.MethodsGastroduodenoscopic findings and radiological imaging were evaluated for ectopic papilla and duodenal stenosis. Diagnostic methods, endoscopic procedures and long-term outcomes of the endoscopic treatment were presented.ResultsEO-CBD-DB was found in 74 (77.1%) of the 96 patients with duodenal deformity/stenosis (79 male, 17 female, mean age: 58.5, range: 30-87 years). The papilla with normal appearance was retracted to the bulb in 11 while it was at its usual location in the remaining 11. The history of biliodigestive surgery was more common in patients with EO-CBD-DB who were frequently presented with the common bile duct stone-related symptoms than the other patients. Thirteen (17.6%) of the patients with EO-CBD-DB were referred to surgery. Endoscopic treatment was completed in 60 (81.1%) patients after an average of 1.7 (range: 1-6) procedures. These patients were on follow-up for 24.8 (range: 2-46) months. Endoscopic intervention was required in 12 (20%) of them because of recurrent biliary problems. Treatment of the patient who had stricture due to biliary injury during laparoscopic cholecystectomy is still continued.ConclusionsThe presence of EO-CBD-DB should be considered particularly in middle-aged male patients who have duodenal deformity/stenosis. Endoscopic treatment is feasible in these patients. The long-term outcomes of endoscopic therapy need to be compared with surgical treatment.

Predictors of endoscopic treatment outcomes in the management of biliary problems after liver transplantation at a high-volume academic center

Biliary tract problems are the most common complications after liver transplantation. ERCP is increasingly being used to address posttransplantation biliary problems. To identify predictors of endoscopic treatment outcomes in the management of post-liver transplantation complications. All adult patients who underwent liver transplantation at the University of California, San Francisco between January 1999 and December 2008 were reviewed. A multivariate regression analysis. Identification of donor and recipient factors as well as technical considerations that predicted success or failure in the endoscopic management of posttransplantation biliary complications. In 1062 patients who underwent liver transplantation, there were 224 biliary complications. ERCP was the primary treatment modality and was successful in the majority of patients treated. Patients with biliary complications who had take-back surgery for a nonbiliary indication during the first month after liver transplantation (odds ratio [OR], 0.32; P = .03), particularly for bleeding (OR, 0.18; P = .02), were less likely to respond to endoscopic therapy. Those who received a graft from a donor after cardiac death (OR, 0.15; P = .02) or a living donor (OR, 0.11; P < .01) were also less likely to respond to endoscopic therapy. Take-back surgery for a nonbiliary indication in the first month after liver transplantation was also identified as a novel risk factor for the development of biliary complications (OR, 1.80; P = .02). Retrospective design. ERCP can be used to treat the majority of posttransplantation biliary problems. However, endoscopic therapy is less efficacious in the treatment of complications associated with ischemia.

Surgical management of biliary complications following living donor liver transplantation

Biliary complications (BC) account for much of the morbidities seen after living donor liver transplantation (LDLT). Surgical reconstruction might be necessary after the failure of endoscopic or percutaneous procedures. Between November 2002 and December 2009, a total of 76 LDLTs were performed. Six patients were excluded from statistical analysis because of early graft or patient loss. Of 70, 26 (37.1%) developed BC; 12 (46.2%) were successfully managed by non-surgical procedures, three (11.5%) died from BC-related sepsis, one (3.8%) died from BC-unrelated causes, and 10 (38.5%) underwent surgical reconstruction. Of those 10, four patients had single duct reconstruction, five patients had double ducts reconstruction, and reconstruction was abandoned in one patient because of hepatic artery thrombosis. After a median follow-up period of 4.5 yr (0.1-6), seven (70%) remained well with no recurrent biliary problems, and three (30%) had recurrent BCs that were managed either conservatively or by retransplantation. Patients who underwent surgical reconstruction had significantly fewer hospital admissions, less need for invasive procedures, and shorter cumulative hospital stay (p < 0.05). In our experience, BCs after LDLT were frequently resistant to non-surgical procedures. Surgical reconstruction is associated with fewer hospital admissions and less need for invasive procedures leading to reduced resources utilization.

ERCP experience in patients with choledochoduodenostomy: diagnostic findings and therapeutic management

Endoscopic retrograde cholangiopancreatography (ERCP), besides reducing the need for surgery in a wide spectrum of biliary disease, is increasingly be used for the treatment of biliary complications of surgery. In this paper, we review our experience with postoperative ERCPs required after biliary surgery with a special focus on side-to-side choledochoduodenostomy (CD). The records of 70 patients with a history of CD who underwent ERCP from May 2000 to February 2006 were analyzed. There were 70 patients, 32 (45.7%) women and 38 (35.6%) men, with a mean age of 56 (range, 21-80) years. Indications for ERCP were cholangitis in 46 (65.7%), abnormal liver function tests with abdominal pain and abnormal USG in 22 (31.4%), and abnormal liver function tests and abnormal USG in 2 (2.9%). Overall 133 ERCP were performed. Anastomotic stenosis was found in 14 (20%), benign biliary stricture above the anastomosis in 13 (18.6%), sump syndrome in 11 (15.7%), common bile duct stone in 8 (11.4%), malignancy in 4 (5.7%), hepatolithiasis in 1 (1.4%), and secondary sclerosing cholangitis in 1 (1.4%). ERCP was normal in 18 (25.8%). Patients were managed by stone extraction in 8 (11%), stent insertion in 22 (36%), balloon dilatation in 15 (21%), nasobiliary drainage in 11 (16%), and bougie dilatation in 2 (3%) patients. We have reported one of the largest groups of patients with CD in the literature and showed that ERCP is a very important diagnostic and therapeutic tool for the management of biliary problems after CD.

Use of fully covered self-expanding metal stents for the management of benign biliary conditions

biliary self-expanding metal stents (SEMS) have the advantage of being inserted undeployed with very small sizes and provide, when fully opened, large diameters for biliary drainage. However, their use in benign conditions has been very limited, mainly because of difficulty in their extraction. We present our initial experience with a fully covered SEMS (Wallflex) for the management of benign problems of the bile duct. in a prospective study, stents of 8 mm in diameter and 4, 6 or 8 cm long were inserted by means of ERCP. These SEMS were chosen when according to medical judgement it was thought that diameters greater than 10 French (3.3 mm) were needed for proper biliary drainage. Stents were extracted also endoscopically, several months later when deemed clinically appropriate. twenty biliary SEMS were inserted. Reasons for insertion were: large intrahepatic biliary fistula after hydatid cyst surgery (1), perforation of the papillary area following endoscopic sphincterotomy (2), coaxial insertion to achieve patency in obstructed uncovered stents inserted in benign conditions (3), benign strictures (7), multiple and large common bile duct stones that could not be extracted because of tapering and stricturing of the distal common bile duct (7). In all cases, successful biliary drainage was achieved and there were no complications from insertion. Stents were easily extracted after a mean time of 132 days (36-270) in place. Complete resolution of biliary problems was obtained in 14 patients (70%). in our initial experience, the fully covered Wallflex biliary stent was removed without any complication after being in place in the common bile duct for a mean time of over four months. Therefore, it could be used in the management of benign biliary conditions.

A 5-year analysis of readmissions following elective laparoscopic cholecystectomy – cohort study

Aims This study aimed to determine readmission rates, causes for readmission and outcomes for patients undergoing elective Laparoscopic Cholecystectomy (LC) without intraoperative cholangiogram (IOC). Methods Timing related to readmissions was grouped as <6 weeks, 6 weeks–1 year, 1–2 years and >2 years. Outcomes and variables related to readmission were evaluated. Results 101 readmissions (6.6) were noted amongst 1523 consecutive LC. The median follow up was 4 years (range 1.6–6.4 years). There was no difference in the median age (48 vs. 53 years, P = 0.2) and sex of the patients between the readmitted and no readmission groups. The incidence of readmissions ( n = 101) within the first 6 weeks, 6 weeks–1 year, 1–2 years and >2 years were 2.8%, 1.5%, 1.4% and 0.7% respectively. The most common reasons for readmissions were non-specific abdominal pain (NSAP) (36%), obstructive jaundice (14%), peptic ulcer disease (10%), intra-abdominal collection (4%) and bile leak (3%), pancreatitis (3%), and other reasons (30%). Overall, 24 (22%) of readmissions were related to biliary problems, the majority of these occurred (15/24, 63%) within 6 weeks of LC. The incidence of retained stones within the first 6 weeks, 6 weeks–1 year, 1–2 years and >2 years were 0.4%, 0.3%, 0.1% and 0% respectively. Overall 14 (14%) patients were readmitted with retained stones and all were managed by ERCP & ductal clearance. Conclusions Readmission rate following elective LC is low with the majority occurring within the first 6 weeks and only a quarter of these related are directly to biliary pathology. In the absence of routine IOC, around 1% of patients present with retained stones within 2 years of LC. A small fraction of patients continue to suffer from NSAP and should be warned prior to the surgery.

Intraoperative portal vein blood flow predicts allograft and patient survival following liver transplantation

BackgroundWe hypothesized that operative variables might predict survival following liver transplantation. MethodsWe examined perioperative variables from 469 liver transplants carried out at the University of Washington during 2003–2006. Logistic regression determined the variables' contributions to survival at 30, 90 and 365 days. ResultsPortal vein blood flow (>1l/min) was significant to patient survival at 30, 90 and 365 days. Complete reperfusion was only a significant predictor of survival at 30 days. This provided model receiver operating characteristic (ROC) area under the curve (AUC) statistics of 0.93 and 0.87 for 30 and 90 days, respectively. At 365 days, hepatic artery blood flow (>250ml/min) combined with portal vein blood flow was significantly predictive of survival, with an AUC of 0.74. A subset analysis of 110 transplants demonstrated improved 1-year survival with more aggressive vascular revisions. DiscussionPortal vein blood flow is a significant predictor of survival after liver transplantation. Initially, the liver's survival is based on portal vein blood flow; however, subsequent biliary problems and patient demise result from both poor portal vein and inadequate hepatic artery blood flow.

Mirizzi syndrome-rare cause of major biliary complications. /Case Report/

Mirizzi syndrome is a rarely observed complication of gallstone disease, causing major biliary problems, if not diagnosed previously. It was described in 1948 by P. L. Mirizzi and presents unusual lodged gallstone in either the cystic duct or most frequently in Hartmann pouch of the gallbladder. Impaction, acute obstruction and wall ischemia are causative for inflammation and abscess formation. External common hepatic bile duct compression and obstruction result in clinical presentation of intermittent or constant jaundice. We report 57-year-old male with extensive mechanical icter, fever, nausea and vomiting, and upper abdominal pain in epigastria from five days. Abdominal US evaluation showed 17mm stone localized in infundibulum and shrunk of gallbladder. MRCT revealed impacted stone, chronic tissue inflammation, involved common hepatic duct with stricture. Mirizzi syndrome was diagnosed. Intraoperatively was found an impacted gallstone in the Hartmann pouch, extensive fibrosis of hepatoduodenal ligament and abscess cavity formation in the Callot’s triangle with engagement of common hepatic bile duct wall. Antegrade cholecystectomy was made and T drain was placed. Second operation and Roux-Y limb anastomosis was performed after unsuccessful tentative for recanalization of distal CBD with clamping of T drain.

Simultaneous/Incidental Cholecystectomy During Gastric/Esophageal Resection: Systematic Analysis of Risks and Benefits

After esophageal/gastric resection with resulting truncal vagotomy, the incidence of gallstone formation seems to increase. The clinical relevance of gallstones and the role of simultaneous/incidental cholecystectomy in this setting are controversially discussed. Systematic analysis has been performed for retrospective/prospective studies on the incidence/symptoms of gallstone formation after esophageal/gastric resection. Pooled estimates of the incidence of cholecystectomies were calculated by random effect models. Risk analyses of simultaneous, acute postoperative cholecystectomy and long-term cholecystectomy were performed. Sixteen studies on gallstone formation after upper gastrointestinal (GI) surgery (3,735 patients) reported increased incidences of 5-60% with a pooled estimate of 17.5% (95% confidence interval (CI), 14.1-21.2%; inconsistency statistic (I (2)) = 86%) compared with 4-12% in the control population. In 113 of 3,011 patients (12 studies), late cholecystectomies were performed for symptomatic cholecystolithiasis, corresponding to an estimated overall proportion of 4.7% (95% CI, 2.1-8.2%; I (2) = 92%). In 1.2% (95% CI, >0-3.7%; I (2) = 93%) of patients undergoing upper GI surgery, a cholecystectomy was performed because of acute postoperative biliary problems (4 studies, 8,748 patients). Simultaneous cholecystectomy had a higher morbidity of 0.95% (95% CI, 0.54-1.49%; I (2) = 28%) compared with the calculated additional morbidity of early and late cholecystectomy of 0.45%. Approximately 6% of patients undergoing upper GI surgery are expected to require cholecystectomy during follow-up. Because late cholecystectomies can be performed safely and because the additional calculated morbidity for these operations is lower than the morbidity for simultaneous cholecystectomy, it cannot generally be recommended to remove a normal acalculous gallbladder during upper GI surgery.

Comparison of biliary complications in adult living‐donor liver transplants performed at two busy transplant centers

Adult living-donor liver transplantation (ALDLT) has a high rate of biliary complications. We identified risk factors that correlate with biliary leaks and strictures by combining data from two centers. Records of ALDLT right lobe recipients (n = 156) at two centers between December 1998 and February 2005 were reviewed. Leak rate was analyzed in 144 recipients after we excluded those with hepatic artery thrombosis or death within 30 d of transplant. Stricture rate was also analyzed in 132 recipients after we excluded those with graft survival or follow-up <180 d. Biliary reconstructions were performed using either duct-to-duct (DD) or Roux-en-Y hepaticojejunostomy and were subclassified by anatomic type, number of anastomoses performed, and stent use. Prevalence of a leak and/or a stricture was 39%; 11% of recipients developed both. Single DD anastomoses between the graft right hepatic duct to the recipient common duct had significantly lower incidence of leaks compared to all other anastomotic types. Early leak was predictive of late stricture development (p = 0.006), but recipient demographics, diagnosis, warm ischemia time, anastomosis type, duct number, year of transplant, stent use, and transplant center were not. The results suggest donors with a single right hepatic duct reconstructed to the recipient common bile duct are the most likely to avoid biliary problems after ALDLT.

Long-term outcomes of emergency liver transplantation for acute liver failure

Acute liver failure continues to be associated with a high mortality rate, and emergency liver transplantation is often the only life-saving treatment. The short-term outcomes are decidedly worse in comparison with those for nonurgent cases, whereas the long-term results have not been reported as extensively. We report our center's experience with urgent liver transplantation, long-term survival, and major complications. From 1994 to 2007, 60 patients had emergency liver transplantation for acute liver failure. The waiting list mortality rate was 6%. The mean waiting time was 2.7 days. Post-transplantation, the perioperative mortality rate was 15%, and complications included neurological problems (13%), biliary problems (10%), and hepatic artery thrombosis (5%). The 5- and 10-year patient survival rates were 76% and 69%, respectively, and the graft survival rates were 65% and 59%. Recipients of blood group-incompatible grafts had an 83% retransplantation rate. Univariate analysis by Cox regression analysis found that cerebral edema and extended criteria donor grafts were associated with worse long-term survival. Severe cerebral edema on a computed tomography scan pre-transplant was associated with either early mortality or permanent neurological deficits. The keys to long-term success and continued progress in urgent liver transplantation are the use of good-quality whole grafts and a short waiting list time, both of which depend on access to a sufficient pool of organ donors. Severe preoperative cerebral edema should be a relative contraindication to transplantation.

Steatosis of the hepatic graft as a risk factor for post‐transplant biliary complications

Despite recent advances in organ preservation, immunosuppression, and surgical techniques, the biliary tree is still considered the Achilles' heel of liver transplantation. The aim of this study is to retrospectively analyze the incidence of biliary complications and identify risk factors that might predispose to the development of biliary problems. From January 2004 to December 2007, 117 consecutive liver transplantations were retrospectively analyzed for the development of biliary complications by the review of medical records. Patients were divided into group 1 with biliary complications (n = 43) and group 2 without biliary complications (n = 74). The overall biliary complication rate was 36.8% (leakage 6% and stricture 30.8%). Univariate analysis indicated that significant predictors of biliary complications were the time interval between portal and arterial reperfusion (p = 0.037) and macrovacuolar steatosis of the graft > 25% (p = 0.004). Stepwise logistic regression model demonstrated that a macrosteatosis of the graft > 25% (OR = 5.21 CI 95% [1.79-15.15], p = 0.002) was the only independent risk factor predicting biliary complications after liver transplantation. No differences in patient's and graft's survival were noted between the two groups. According to our experience, transplanting a liver with > 25% of steatosis is a risk factor for the development of biliary complication.

Endoscopic Retrograde Cholangiopancreatography Using the Single Balloon Enteroscope Technique in Patients with Roux-en-Y Anastomosis

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging or impossible in patients with complex postsurgical anatomy. The aim of this cohort study was to assess the technical success of ERCP with the single balloon enteroscope (SBE) in patients with Roux-en-Y anastomosis. Patients: Patients with Roux-en-Y anastomosis presenting with cholestasis undergoing ERCP with the SBE technique in a tertiary university hospital. Diagnostic success was defined as successful duct cannulation or securing the diagnosis and therapeutic success was defined as the ability to successfully accomplish endoscopic therapy. Results: ERCP using the SBE was performed on 17 occasions in 13 patients (5 F, 8 M, mean age 66.5 years, range 25–77) with Roux-en-Y anastomosis. Indications for ERCP were biliary obstruction with common bile duct stones and/or cholangitis in all patients. The diagnostic success was 61.5% and the therapeutic success was 53.8%. Therapeutic interventions included dilation of common bile duct stenosis with a balloon (n = 4), biliary stent insertion (n = 2), removal of bile duct stones (n = 2), stent retrieval (n = 2), papillectomy (n = 1), and sphincterotomy (n = 1). No major complications occurred. Conclusions: ERCP using the SBE is feasible in patients with altered postsurgical anatomy presenting with biliary problems permitting diagnostic and therapeutic interventions.

Comparison of complication and success rates of endoscopic retrograde cholangiopancreatography between 2001 and 2007： a retrospective report from Changhai hospital

Objective To investigate the changes of indications, degree of difficulty in procedure, complication and its severity in endoscopic retrograde cholangiopancreatography （ERCP） in Changhai hospital from 2001 to 2007. Methods The clinical data, including demographic data, indications, degree of difficulty in procedure, success rate, complication rate and severity of complication, of 2374 patients who underwent ERCP in 2001 and 2007 （966 in 2001 and 1408 in 2007 ） , were retrospectively reviewed. Results Indications of ERCP changed at an interval of 5 years. Operations due to bile duct stone decreased （59.0% vs. 49.3 %, P = 0. 000）, while operations due to pancreas disease, especially chronic pancreatitis （6. 6% vs. 18.5% , P =0. 000） and recurrent pancreatitis （0. 2% vs. 1.6% , P =0. 001 ）, increased. Pa- tients with biliary duct problems after liver transplantation appeared in 2007. The procedures of ERCP performed in 2007 were more difficult （ P = 0. 000 ）, with an increased percentage of Degree 5 procedure （7.3% vs. 33.3% , P =0. 000）. The number of diagnostic ERCP significantly decreased （ Degree 1 ＋ Degree 3, 30. 5% ＋2. 8% vs. 5.9% ＋3.1% , P =0. 000）. There was no significant difference in the success rate between the two years （ P = 0. 084）. The complication rate of ERCP in 2007 was significantly higherthan that in 2001 （3.73% vs. 7. 88% , P =0. 000）, but the severity of complication showed no significant difference （P = 0. 820）. Conclusion Cases of diagnostic ERCP decreased in 2007. Indications of ERCP have changed, with a decrease in bile duct diseases and an increase in pancreatic diseases. The procedures are more complicated, but it does not lead to lower success rate. The increase in complication rate is possibly due to increase of therapeutic ERCP. Key words: Cholangiopancreatography, endoscopic retrograde ; Postoperative complications ; Retrospective studies

Liver Transplantation Complications in the Intensive Care Unit and at 6 Months

Objective This study sought to determine the factors that influence the 6-month outcomes of liver transplants. Patients and Methods One hundred ninety-six variables (donor, recipient, operation, intensive care unit [ICU], evolution at 3 and 6 months) were collected from the first 74 consecutive liver transplantation performed from 2002 to 2004. The primary endpoint was patient survival at 6 months. The statistical analysis included a screening univariate analysis followed by a stepwise logistic regression with forward inclusion to test independent associations and finally generation of receiver-operator characteristic (ROC) curves to evaluate predictive factors. Results Patient survival at 6 months was 86%, namely 10 deaths, including 4 intraoperatively and 6 postoperatively due to sepsis. Complications in the ICU were classified as reoperations due to biliary problems, vascular complications, and peritonitis. Late complications included 51% rejection episodes, 24% infections, 11% pleural effusions, and 16% diabetes mellitus. Logistic regression analysis showed independent negative predictors of survival were the number of packed red cells during transplantation, the number of fresh frozen plasma units administered in the ICU, blood urea nitrogen (BUN) concentration in the ICU, and graft complications. The odds ratios of these variables were 10.2, 5.2, 42.1, and 36.9, respectively. The area under the curve (AUC) of the ROC was 0.99; the sensitivity was 94%; and the specificity was 100%. The independent predictors of surgical complications were the length of the operation, the need for pressor support, and the number of fresh frozen plasma units administered in the operating room, with odds ratios of 1.0, 7.7, and 1.1, respectively. Conclusion This study revealed specific operative and ICU variables that correlated with the evolution of our patients.

Infectious complications in pediatric liver transplantation candidates

We analyzed infections that occurred within one month prior to LT, identified factors associated with their occurrence and effect of infections on post-transplant mortality. The study group included 40 consecutive children who underwent LT. Sites and types of infection and culture results were recorded prospectively. IID was assessed. Risk factors for the infectious events were analyzed. Forty infection episodes were found in 24 patients (60%); 90% were bacterial, 7.5% fungal, and 2.5% viral. Overall, IID was 38.2 per 1000 patient days. Sites of bacterial infection were urinary tract in 13 events (36.1%) and blood stream in 11 events (30.5%). Bacteremia (culture positive infection episodes) was identified in 19 events (52.7%). Gram-negative isolates were twice as frequent as Gram-positive infections (63.1% vs. 36.9%). Risk factors for the infectious complications were young age, low body weight, prior abdominal surgery, chronic liver disease related to biliary problems, presence of ascites, portal hypertension and cirrhosis, and high PELD score (p < 0.05 for all). Infectious complications in pediatric LT candidates are common. Preventive measures are important not only to reduce the infectious complications but also to prevent the post-operative mortality.

Symptomatic portal biliopathy: a single centre experience from the UK

Biliary obstruction as a consequence of portal biliopathy, because of extrahepatic portal vein occlusion is an uncommon cause of biliary disease in the western world. We reviewed all patients presenting to the Regional Liver Transplant Unit in Birmingham, UK with symptomatic portal biliopathy between 1992 and 2005 and report the presentation, investigation, management and outcome of these complex patients. Thirteen patients with symptomatic portal biliopathy were followed up for a median of 2 years (range 1-18 years). Jaundice was the presenting feature in all cases and was associated with bile duct stones or debris in 77% (10 of 13) of cases. Successful treatment of biliary problems was achieved by biliary decompression in six cases (metallic stent=three, plastic stent=one, combined procedure=one and sphincterectomy=one) and portal decompression in three cases (transjugular intrahepatic portosystemic shunt=two, meso-caval shunt=one). Successful biliary drainage could not be achieved endoscopically or by portal decompression in one case that was accepted for combined liver and small bowel transplantation. Three patients had spontaneous resolution without recurrence over the follow-up period. Ten patients (77%) experienced gastrointestinal bleeding. Two deaths over the follow-up period occurred; both were associated with portal hypertensive bleeding. Endoscopic management (sphincterectomy and stone extraction or stent insertion) is effective initial therapy for patients with symptomatic portal biliopathy. In the case of persistent biliary obstruction porto-systemic shunting (transjugular intrahepatic portosystemic shunt or surgical) should be considered, however, the extent of vascular thrombosis precludes this in most cases.