Biliodigestive Anastomosis Research Articles

Cholangitis in the postoperative course after biliodigestive anastomosis.

Hepatobiliary surgery with biliodigestive anastomosis (BDA) results in a loss of the sphincter of Oddi with consecutive ascension of bacteria into the bile system which may cause cholangitis in the postoperative course. Patients who received reconstruction with a BDA after hepatobiliary surgery were analyzed retrospectively for their postoperative course of disease depending on intraoperatively obtained bile cultures and antibiotic prophylaxis. Two hundred forty-three patients were included in the analysis, 49.4% of whom had received endoscopic stenting before the operation. Stenting was significantly associated with the presence of drug-resistant bacteria in the intraoperatively obtained bile sample (p < 0.001, OR = 4.09). Of all patients, 14.4% developed postoperative cholangitis. This was significantly associated with the postoperative length of stay in the intensive care unit (p = 0.002, OR = 1.035). The highest incidence of postoperative cholangitis was found in patients with cholangiocellular carcinoma (n = 12, p = 0.046, OR = 2.178). Patients were more likely to harbor strains with resistance against the antibiotic that was given intraoperatively. The risk for the presence of drug-resistant bacteria is increased by preoperative stenting of the common bile duct. Bile culture by intraoperative swabs can be altered by the perioperative antibiotic prophylaxis as it induces microbiological selection in the common bile duct.

Dilation of biliodigestive anastomosis by transjejunal access

Dilation of biliodigestive anastomosis by transjejunal access

Role of Liver Transplantation in Bilio-Vascular Liver Injury After Cholecystectomy

BackgroundThe aim of this study was to report 2 cases of liver transplantation (LT) for iatrogenic bile-vascular injury (BVI) sustained during cholecystectomy and to review the literature for LT after cholecystectomy. MethodsBetween March 2001 and July 2013, within our institution, 12 patients were treated after cholecystectomy, 3 of 12 received LT, 1 for acute de-compensation in a cirrhotic patient and 2 after iatrogenic lesions. ResultsThe majority of iatrogenic injury occurred during video-laparocholecystectomy (63,6%; 7/11). Three patients of 12 (25%) received LT: the first patient developed acute de-compensation in chronic and after liver failure. The second patient developed recurrent cholangitis and secondary biliary cirrhosis. The third patient had undergone emergency hepatectomy because of bleeding and subsequent total hepatectomy with porto-caval shunt. Five of 12 (42%) patients were treated with bilio-digestive anastomosis: 1 patient with direct repair on T-tube; 2 patients (17%) with arterial vascular lesion requiring surgical treatment; and 1 patient treated with medical therapy. No deaths occurred. The post-operative morbidity included 1 re-intervention, 3 recurrent cholangitis, 1 anastomotic biliary stricture, 1 anastomotic bile leak, and cholestasis in 3 patients. The overall hospital stays were higher after LT. Median follow-up was 8.25 years (range, 2–14). ConclusionsThe management of iatrogenic injury during cholecystectomy depends on the time of recognition, extent of injury, experience of the surgeon, and the patient's general condition. If safe repair is possible, BVI should be treated promptly, otherwise all patients should be treated in an experienced center.

Endoscopic Treatment of Biliary Stenosis in Patients with Alveolar Echinococcosis--Report of 7 Consecutive Patients with Serial ERC Approach.

Background and AimsBiliary vessel pathology due to alveolar echicococcosis (AE) results in variable combinations of stenosis, necrosis and inflammation. Modern management strategies for patients with cholestasis are desperately needed. The aim is proof of principle of serial ERC (endoscopic retrograde cholangiography) balloon dilation for AE biliary pathology.MethodsRetrospective case series of seven consecutive patients with AE-associated biliary pathology and ERC treatment in an interdisciplinary endoscopy unit at a University Hospital which hosts a national echinococcosis treatment center. The AE patient cohort consists of 106 patients with AE of the liver of which 13 presented with cholestasis. 6/13 received bilio-digestive anastomosis and 7/13 patients were treated by ERC and are reported here. Biliary stricture balloon dilation was performed with 18-Fr balloons at the initial and with 24-Fr balloons at subsequent interventions. If indicated 10 Fr plastic stents were placed.ResultsSix patients were treated by repeated balloon dilation and stenting, one by stenting only. After an acute phase of 6 months with repeated balloon dilation, three patients showed “sustained clinical success” and four patients “assisted therapeutic success,” of which one has not yet reached the six month endpoint. In one patient, sustained success could not be achieved despite repeated insertion of plastic stents and balloon dilation, but with temporary insertion of a fully covered self-expanding metal stent (FCSEMS). There was no loss to follow up. No major complications were observed.ConclusionsSerial endoscopic dilation is a standard tool in the treatment of benign biliary strictures. Serial endoscopic intervention with balloon dilation combined with benzimidazole treatment can re-establish and maintain biliary duct patency in AE associated pathology and probably contributes to avoid or postpone bilio-digestive anastomosis. This approach is in accordance with current ERC guidelines and is minimally disruptive for patients.

Minilaparotomy cholecystectomy in elderly and senile patients

Aim. To evaluate the efficacy of minilaparotomy access and programmed treatment of cholecystectomy complications in elderly and senile patients.Methods. 160 patients (113 women and 47 men), who underwent surgery in the period from 2010 to 2012 in the departments of surgery at the Municipal clinical hospital №1 (Bishkek), were followed-up. Patients mean age was 68.4±3.5 years. Cholecystectomy and biliodigestive anastomoses were performed using mini-access in all patients. In addition to clinical and laboratory diagnostic methods, ultrasound examination with gallbladder projection detection on the anterior abdominal wall to select surgical approach was used.Results. The surgery results of 160 elderly and senile patients with acute cholecystitis who underwent minilaparotomy cholecystectomy are presented. In 12 (7.5%) patients after cholecystectomy, choledochotomy (or choledochoduodenostomy) was performed to remove stones from the common bile duct; external drainage of the common bile duct by Ker or A.V. Vishnevskiy was performed on 10 of them, and in 2 cases choledochoduodenoanastomosis by Yurash-Vinogradov was imposed. Complications were registered in 9 (5.6%) patients. 1 patient died as a result of pulmonary embolism developed on the 5th day after the surgery. Conversion rate was 5% (8 patients). Treatment of complications was performed by developed and implemented in the clinic algorithm (regional lymphostimulation, breathing exercises, infrared laser irradiation). The average hospital stay of patients without complications was 7.8±0.87 bed-days, and patients with complications - 9.4±0.14 bed-days.Conclusion. Our observations showed the possibility to perform surgery for acute cholecystitis in elderly and senile patients by the minilaparotomy access in case of taking into account patients general condition, following the surgical technique and the active management of the postoperative period.

METHOD OF EXTRAHEPATIC BILE DUCTS RECONSTRUCTION WITH FORMATION OF AN ACCESS FOR MINIMALLY INVASIVE INTERVENTIONS

Background: Methods of repair for iatrogenic extrahepatic bile ducts injuries are still under discussion. Aim: To improve surgical outcomes in patients with diseases and iatrogenic injuries of extrahepatic bile ducts. Materials and methods: The new surgical method for treatment of the diseases and traumatic injuries of extrahepatic bile ducts improves immediate and long-term outcomes in patients with iatrogenic injuries and diseases of bile ducts. The method provides a direct endoscopic access allowing for minimally invasive biliodigestive anastomosis interventions (balloon dilation, endoprothesis positioning and change, etc.) under direct vision. Results: The new method is associated with less surgical trauma, reduced intra-/postoperative complications, better quality of life and no impact on patients’ life-style. Conclusion: In our study, endoscopic repair of biliodigestive anastomoses through persistent gastroenteroanastomosis was a simple, available and safe method. The procedure may be performed by surgeon-endoscopist under local anesthesia. If needed, multiple procedures are possible.

Bile duct injuries after laparoscopic cholecystectomy: 11-year experience in a tertiary center

Incidence of bile duct injuries (BDI) is low but remains a dramatic complication after laparoscopic cholecystectomy (LC). This study aimed to assess BDI incidence and management strategies. All patients treated in our institution for BDI after LC between 2000 and 2011 were retrospectively analyzed. Patients referred from others centers were excluded. Strasberg classification was used to determine the type of lesion. Thirteen patients presented iatrogenic BDI among 2,840 consecutive cholecystectomies performed (0.46%). Four cases were classified Strasberg type A, 4 type D, and 5 type E. Injury was recognized intraoperatively in 6 cases (46%). Three of these 6 required conversions to open surgery and all but one were primary sutured on a drain; the remaining patient required immediate biliodigestive anastomosis. In 7 patients, the injury was discovered postoperatively (54%). Among them, one was treated by direct closure of a cystic leak through immediate re-laparoscopy. Six underwent initially main bile duct stenting, but 4 required delayed secondary surgery (mean time 115 days), 2 to improve bile duct drainage and 2 for biliodigestive derivation. BDI incidence remains low but management depends on the time of diagnosis. BDI are complex and require tailored treatment usually in a tertiary center for a multidisciplinary approach.

Interventional radiology in treatment of biliodigestive anastomoses strictures

To analyze efficacy of interventional methods via antegrade transhepatic approach in treatment of patients with strictures of biliodigestive anastomoses. 24 patients aged 47.2 years were treated for the period 2002-2015. Average time from extrahepatic biliary reconstruction using transhepatic stented tubes to strictures appearance varied from 9 months to 12 years. One- and double-sided percutaneous transhepatic cholangiostomy was performed to abort biliary hypertension. Stricture recanalization was achieved using «catheter-wire» system. Antegrade dilatation of stricture was made using balloon catheter 8 mm and pressure up to 6 atm and stage exposition up to 10 minutes. Balloon repair of anastomosis was supplemented by stented outer-inner drainage of the area of stricture. Restoration of patency of stricture area using antegrade interventional methods was effective in 22 patients. Recurrent stricture occurred in 2 cases within 1.5 years that required repeated biliary reconstruction including antegrade extraction of blocked uncovered stent in 1 patient. There were no major postoperative complications and deaths. Maximal recurrence-free follow-up after stent installation was 11 years.

Antegrade endobiliary interventions in undilated bile ducts

To show advisability of antegrade transhepatic approach to bile ducts for benign and malignant biliary diseases if endoscopic technique is impossible or ineffective. 38 patients underwent external biliary drainage followed by endobiliary interventions for the period 2009-2016. In all patients treatment was effective and included following manipulations: antegrade balloon dilatation of stricture of biliodigestive anastomosis, papillodilatation, antegrade dislocation of calculuses from common bile duct to duodenum. There were 2 cases of complications after antegrade interventions. 1 woman died from severe pancreatic necrosis. Percutaneous transhepatic cholangiostomy on undilated bile ducts is effective for temporary biliary drainage in closure of external duodenal or biliary fistula, treatment of intra-abdominal bilema. The method is indicated in elective endobiliary interventions for choledocholithiasis management, elimination of stricture of biliodigestive anastomosis of major duodenal papilla if endoscopic or conventional approaches are impossible or ineffective.

Advisability of biliary drainage in liver fragments reconstruction

to estimate the effect of decompressive stented drainage of biliary anastomosis on incidence of biliary complications. 294 patients aged from 5 months to 61 years (mean 13.8±0.81) were enrolled. They underwent liver fragments transplantation in the Department of Liver Transplantation of Petrovsky Russian Research Center of Surgery for the period from March 1997 to January 2016. Decompressive stented drainage tubes were used in 28 (9.5%) patients. Reconstruction without drainage was applied in 266 (90.5%) cases. In the group of biliobiliary reconstruction drainage was used in 18 out of 89 cases (20.2%), in the group of biliodigestive reconstruction - in 10 out of 202 cases (4.9%). Incidence of specific biliary complications was assessed. There was significant direct correlation of stented drainage of biliodigestive anastomosis with various biliary complications including bile leakage (r= -0,1253; p=0.06), obturation of anastomosis (r=0.045; p=0.501), stricture of anastomosis (r= -0.0665; p=0.320), other strictures of intrahepatic bile ducts (r= -0.0291; p=0.664), hepatolithiasis (r=0.0857; p=0.199). However significant direct correation was observed between stented drainage and incidence of intrahepatic bile ducts strictures (r=0.2117; p=0.046) and anastomosis obturation (r=0.2330; p=0.028) in case of biliobiliary reconstruction. Significant correation with other biliary complications was absent (p>0.05). Unconstrained stented drainage during primary biliary reconstruction is associated with increased incidence of biliary complications and should not be indicated routinely. Clear need for drainage should be determined in further investigations.

CT-guided high-dose-rate brachytherapy in the interdisciplinary treatment of patients with liver metastases of pancreatic cancer

CT-guided high-dose-rate brachytherapy (CT-HDRBT) is an interventional radiologic technique for local ablation of primary and secondary malignomas applying a radiation source through a brachycatheter percutaneously into the targeted lesion. The aim of this study was to assess local tumor control, safety and efficacy of CT-HDRBT in the treatment of liver metastases of pancreatic cancer. Twenty consecutive patients with 49 unresectable liver metastases of pancreatic cancer were included in this retrospective trial and treated with CT-HDRBT, applied as a single fraction high-dose irradiation (15-20 Gy) using a 192Ir-source. Primary endpoint was local tumor control and secondary endpoints were complications, progression-free survival and overall survival. The mean tumor diameter was 29 mm (range 10-73). The mean irradiation time was 20 minutes (range 7-42). The mean coverage of the clinical target volume was 98% (range 88%-100%). The mean D100 was 18.1 Gy and the median D100 was 19.78 Gy. Three major complications occurred with post-interventional abscesses, three of which were seen in 15 patients with biliodigestive anastomosis (20%) and overall 15%. The mean follow-up time was 13.7 months (range 1.4-55.0). The median progression-free survival was 4.9 months (range 1.4-42.9, mean 9.4). Local recurrence occurred in 5 (10%) of 49 metastases treated. The median overall survival after CT-HDRBT was 8.6 months (range 1.5-55.3). Eleven patients received chemotherapy after ablation with a median progression-free survival of 4.9 months (mean 12.9). Nine patients did not receive chemotherapy after intervention with a median progression-free survival of 3.2 months (mean 5.0). The rate of local tumor control was 91% in both groups after 12 months. CT-HDRBT was safe and effective for the treatment of liver metastases of pancreatic cancer.

P-156 Biliary drainage in patients with extrahepatic bile ducts cancer and obstructive jaundice

Introduction: The malignant stenosis of extrahepatic bile ducts mostly affect confluence of the right and left hepatic duct (Klatskin tumors), followed by adenocarcinomas with distal location (periampullary tumors) and tumors of middle part. Biliary drainage is an important part of the treatment of extrahepatic bile ducts tumors. There are some contradictions on different types and methods of resolving the obstructive jaundice. To present and analyze the results of the application of different types of biliary drainage in patient with malignant stenosis of extrahepatic bile ducts, admitted in the Department of General and Hepato-pancreatic Surgery, University Hospital “Alexandrovska”, Sofia, Bulgaria for a period of 6 years. Methods: Between 2009-2014 year in the Department of General and Hepato-pancreatic Surgery were treated 64 patients with extrahepatic bile duct cancer, complicated with obstructive jaundice. The distribution of men to women is 1.37:1. The average age is 64 years. According to the classification of Longmire with perihilar tumors were 31 patients, middle part of the biliary tract was affected in 2 patients and 31 patients was with distal part lesions (10 with adenocarcinoma of common bile duct and 21 with adenocarcinoma of papilla Vateri). According to the classification of Bismuth-Corlette, with type I was two patients, with type II – 3, with type IIIa – 3, with type IIIb – 2, with type IV - 21. The methods used for biliary drainage in radical surgery (18 patients or 11.52%) were: tumor resection with bilio-digestive anastomosis with or without protective biliary drainage. In palliative surgery (25 patients or 16%) were administered: transtumoral internal/external biliary drainage (15 patients), internal biliary drainage (8 patients), external biliary drainage (2 patients). In 15 patients were administered percutaneous transhepatic external / internal-external biliary drainage and 1 - endoscopic prosthesis. In 5 patients obstructive jaundice was treated conservatively. Results: In 55 patients (85.9%) obstructive jaundice is resolved. During hospitalization, death occurred in 9 patients (29.03%). Complications were detected in 11.5%: insufficiency of the anastomosis, drainage obstruction, bleeding of the drainages, pancreatitis, cholangitis, wound infection. There is disagreement in opinions about preoperative biliary drainage in radical surgery. In advanced disease and contraindications for radical surgery, palliative biliary drainage is justified in order to improve the quality of life and reduce the pruritus. Conclusion: Management of obstructive jaundice in patient with malignant stenosis of extrahepatic bile ducts is an essential part of the complex treatment. More research is needed to assess the place and role of different types of biliary drainage.

Major liver resection as definitive treatment in post-cholecystectomy common bile duct injuries.

Common bile duct injuries (CBDI) are serious complications of cholecystectomies which are often associated with vascular involvement, meaning that their management represents a major challenge to the physician. We present our experience in major hepatectomy due to CBDI, highlighting indications, postoperative complications, and long-term outcomes. From August 1993 to September 2013, 287 patients with CBDI were treated in our centre. In 15 patients of this group (5 %), a major hepatectomy was performed. Eleven patients presented E4 and four presented E5 injuries of Strasberg classification. Seven patients presented vascular involvement. In 12 patients, prior treatment attempts, either biliodigestive anastomosis, endoscopic or percutaneous drainage, was performed without success. The median time delay between lesional surgery and hepatectomy was 24 months. Right hepatectomy was performed in 10 patients and left hepatectomy in 5. Postoperative morbidity was 60 %. The incidence of serious complications (≥ grade IIIa of DC classification) was 40 %. There was no mortality in our study. The mean follow-up was 43.5 months and the overall survival was 100 %. Three patients had a single episode of ascendant cholangitis who were successfully treated with medical treatment. All other patients were asymptomatic during follow-up. No patients required further surgical procedures. In our series, major hepatectomy due to CBDI was a successful treatment with high rates of postoperative morbidity and excellent long-term outcomes which require a multidisciplinary approach in referral centres of HPB surgery.

Stage II Pancreatic Cancer: Radical, Palliative Surgery or Stenting?

Background: Pancreatic ductal adenocarcinoma is the fourth most common reason of death among oncological diseases with ever increasing mortality. At the time of diagnosis, patients are usually suitable for three ways of treatment: radical, palliative surgery or stenting. Deciding the best option depends on clinical situation, but is still a matter of debate. Methods: We performed a retrospective research of patients with stage II pancreatic head cancer treated in our clinic between years 2002-2014. Four groups were formed according to the used treatment method: group A: radical surgery with R0 (microscopic tumour clearance) margin; group B: radical surgery with R1 (presence of tumour cells within 1 mm of the resection margin) margin; group C: biliary tract stenting; group D: biliodigestive anastomosis. Clinical data and most importantly the survival of these patients were compared. Results: 200 patients were involved in the final analysis, 82 (41%) of them were IIA and 118 (59%) were IIB. Group A consisted of 113 patients; group B consisted of 28 patients; group C consisted of 33 patients; group D consisted of 26 patients. In patients with IIA stage, group A had the highest survival rate compared with other groups, mean survival was 3.242 versus 1.600; 0.454; 0.652 years. Patients with IIB stage of cancer similarly had longer survival in group A versus other groups, 1.720 versus 0.931; 0.713; 0.957 years. Conclusions: Patients with IIA and IIB stage of pancreatic cancer benefit the most from radical surgery with R0 margin. However, for patients with lymph node involvement (stage IIB) and when achieving R0 margin is hardly possible, neoadjuvant treatment seems promising, but we need further randomized controlled trials to fully confirm its effectiveness.

Ультразвуковая визуализация билиодигестивных анастомозов

The authors conducted a retrospective analysis of medical records of 71 patients operated on biliary obstruction with biliodigestive anastomoses. In the early postoperative period of 71 patients with various types of complications were observed in 14 (19,7%) patients of еarly postoperative mortality was 5,6% (4 patients) and 56 patients were observed from 1 year to 7 years after surgery. All patients in the postoperative period were performed trans-abdominal ultrasound imaging, tomography, magnetic resonance tomography, fistulography. The technique of improving ultrasonic visualization of the distal bile duct and area BDA and ultrasound semiotics state of biliodigestive anastomoses in the early and late postoperative period were developed. Ultra-sound criteria of insolvency biliodigestive anastomoses in the early postoperative period, and signs of scarring biliodigestive anastomoses and development of reflux cholangitis in the late postoperative period were carried out and systematized. High precision of data of ultrasonic imaging with a clinical diagnosis was noted. The sen-sitivity of ultrasound in detecting reflux cholangitis amounted to 100%; specificity – 83,7%; accuracy was 87,5%. The sensitivity of ultrasound in detecting scar stricture biliodigestive anastomoses amounted to 87,5%; the specificity was 93,8% of the respondents; the accuracy of 92,9%.

Subadventitial cystectomy in the management of biliary fistula with liver hydatid disease

Biliary fistulas are the most common morbidity (8.2–26%) following hydatid liver surgery. The aim of this study was to evaluate the results of subadventitial cystectomy in the treatment of liver hydatid cyst associated with a biliocystic fistula. The medical records of 153 patients who underwent subadventitial cystectomy for a liver hydatid cyst between January 2006 and December 2010 were retrospectively reviewed. Cysts were located in the right lobe anterior segment 37 (24.2%) patients, right lobe posterior segment 59 (38.6%) patients, the left lobe in 26 (17.0%) patients, and both lobes in 6 (3.9%) patients. The surgical procedures performed were closed (non-incised) subadventitial total cystectomy in 74 patients (48.4%), open (incised) subadventitial total cystectomy in 30 patients (19.6%), and subadventitial subtotal cystectomy in 49 patients (32.0%). Biliocystic communication was found in 52 patients (34.0%), and 21 patients (13.7%) were treated with T-tube drainage. Two patients had performed biliodigestive anastomosis. Biliary fistula was detected in 9 patients after subtotal subadventitial cystectomy. Biliary fistulas closed spontaneously within 10 days and 61 days respectively and the amount of drainage varying between 50 and 400ml after the procedure. Postoperative complication and recurrence rates were 19.0% and 0.7%, respectively. The mortality rate was 0%. Subadventitial cystectomy should be the surgical treatment of choice for this disease because of its feasibility and low rates of recurrence, complications of the residual cavity, and incidence of associated biliary fistula.

Totally Percutaneous Rendezvous Techniques for the Treatment of Bile Strictures and Leakages

Some challenging pathologic conditions of the biliary tract cannot be treated with endoscopy alone, and a combined approach with rendezvous techniques is frequently needed. Three different totally percutaneous rendezvous techniques were successfully applied in three cases. The rendezvous techniques were performed either with bilateral catheterization of bile ducts to treat a challenging type IV biliary stenosis and iatrogenic biliary damage or with biliary catheterization and percutaneous puncture of the anastomotic loop to treat a biliodigestive anastomosis failure with bile leakage.

Fatal Cerebral Air Embolism Due to a Patent Foramen Ovale during Endoscopic Retrograde Cholangiopancreatography.

Fatal air embolism to the cerebrum during an endoscopic retrograde cholangiopancreatography (ERCP) has not been reported in a patient with a biliodigestive anastomosis and multiresistant extended-spectrum β-lactamase Escherichia coli (ESBL) bacteremia. A 59-year-old woman with a history of laparoscopic cholecystectomy and iatrogenic injury of the right choledochal duct, choledochojejunostomy (biliodigestive anastomosis), recurrent cholangitis, revision of the biliodigestive anastomosis, recurrent liver abscesses, and recurrent stenting of stenotic bile ducts, was admitted because of fever and tenderness of the right upper quadrant. On ERCP, a previously deployed covered Wallstent was replaced. Blood cultures grew ESBL. After stent removal 8 days later, the patient did not wake up and developed arterial hypotension and respiratory insufficiency, requiring mechanical ventilation. Computed tomography scans showed extensive air embolism to the liver, heart, and cerebrum. She died 1 day later. Although the exact pathogenesis of the fatal cerebral air embolism remains speculative, the nonphysiological anatomy and chronic infection with ESBL may have been contributory factors.

Candida albicans arteritis transmitted by preservation fluid after liver transplantation

Fungal infections remain among the main causes of mortality in the chronically immunosuppressed liver transplant (LT) patient. Bacterial and fungal contamination of preservation fluid (PF), in which grafts are stored, represents a potential source of infection for recipients. A 54-year-old patient underwent LT for chronic alcoholic cirrhosis. Mycological culture of the liver PF was positive for Candida albicans. The patient received antimycotic prophylaxis for 4 weeks in absence of clinical and serological signs of infection. He was urgently readmitted 4 months later with hemobilia caused by an arterial pseudoaneurysm that was fistulized in the biliary anastomosis. After an unsuccessful embolization, arterial resection and reconstruction and a biliodigestive anastomosis were performed, with an uneventful postoperative course. Pathology found a mycotic arteritis of the graft artery. Mycotic culture of the arterial segment confirmed the presence of the same Candida albicans genotype previously isolated in the PF. Mycotic arteritis is one of the possible complications of yeast contamination of PF. Surgeons and physicians involved in the care of LT patients should be aware of this potentially lethal complication and adopt all the available means for early detection.

Chronic Bile Duct Stenosis after Hepaticojejunostomy Requiring Re-Operation Leading to Liver Transplantation–A Case Report

Background: Stenosis of a biliodigestive anastomosis is a rare complication of mid- and long-term survival after hepatobiliary surgery. First line therapy is endoscopic intervention. Only if this option is not successful or not possible a surgical approach is indicated. Case Report: A 40 year old male patient presented with recurrent episodes of cholangitis after hepaticojejunostomy due to neuroendocrine tumor in the common bile duct more than 17 years ago. Advanced endoscopic techniques and percutaneous drainage failed to overcome this disorder resulting in subsequent surgical therapy. During the first operation the bile duct could not be found in order to create sufficient bile drainage. However, during preparation of the liver hilum the portal vein was inadvertently hurt. Following vessel reconstruction the patient suffered from recurrent thrombosis of the vein in the course and since the bile duct could not be identified and arrosion bleeding caused acute liver failure the patient was listed for liver transplantation. The latter was successfully performed allowing complete recovery of the patient. Conclusion: In case of stenosis of a billiodigestive anastomosis and unsuccessful reconstruction of sufficient bile drainage despite extended surgical efforts or following complications during revision liver transplantation might be a good option for the treatment of patients in exceptional cases.