Duct Orifice Research Articles

A New Technique of Endoscopic Transpapillary Gallbladder Drainage Combined with Intraductal Ultrasonography for the Treatment of Acute Cholecystitis.

Background/Aims:Endoscopic transpapillary gallbladder drainage (ETGBD) is useful for the treatment of acute cholecystitis; however, the technique is difficult to perform. When intraductal ultrasonography (IDUS) is combined with ETGBD, the orifice of the cystic duct in the common bile duct may be more easily detected in the cannulation procedure. The aim of this study was to evaluate the efficacy of ETGBD with IDUS compared with that of ETGBD alone. Methods:A total of 100 consecutive patients with acute cholecystitis requiring ETGBD were retrospectively recruited. The first 50 consecutive patients were treated using ETGBD without IDUS, and the next 50 patients were treated using ETGBD with IDUS. Through propensity score matching analysis, we compared the clinical outcomes between the groups. The primary outcome was the technical success rate. Results:The technical success rate of ETGBD with IDUS was significantly higher than that of ETGBD without IDUS (92.0% vs. 76.0%, p=0.044). There was no significant difference in procedure length between the two groups (74.0 min vs. 66.7 min, p=0.310). The complication rate of ETGBD with IDUS was significantly higher than that of ETGBD without IDUS (6.0% vs. 0%, p<0.001); however, only one case showed an IDUS technique-related complication (pancreatitis). Conclusions:The assistance of IDUS may be useful in ETGBD.

1426 Type 1 Choledochal Cyst With Anomalous Pancreaticobiliary Malunion Diagnosed on Cholangioscopy

INTRODUCTION: Choledochal cysts are cystic dilatations found within the intra and/or extrahepatic bile ducts. Untreated choledochal cysts can lead to increased risk for strictures, pancreatitis, cholangitis, gallbladder cancer, cholangiocarcinoma and pancreatic cancer. Early and accurate identification of choledochal cysts is crucial to determine appropriate medical and surgical planning. We present a case of a patient with a type 1 choledochal cyst with anomalous pancreaticobiliary malunion. CASE DESCRIPTION/METHODS: A 42-year-old female with a PMH of a cholecystectomy and known biliary cyst presented with acute onset abdominal pain. MRCP demonstrated a 5.5 cm fusiform dilatation of the common bile duct (CBD). EUS confirmed a CBD dilatation (Figure 1). ERCP with spyglass cholangioscopy showed an abnormal pancreaticobiliary junction with a common channel about 1 cm long leading to two separate openings, one to the CBD/choledochal cyst and another to the pancreatic duct orifice (Figure 2). Fluoroscopy showed contrast filling a dilated cystic structure in the proximal CBD consistent with a choledochal cyst (Figure 3). A 7 French × 7 cm flex stent was deployed into the CBD. Findings were consistent with a type 1 choledochal cyst and an anomalous pancreaticobiliary malunion. Patient underwent ex-lap with resection of the choledochal cyst with roux-en-y hepaticojejunostomy creation, which she tolerated well. DISCUSSION: The Todani classification is based on cyst location and bile duct dilatation. There are 5 types with type 1 as the most common which comprises of 80-90% of all choledochal cysts. Type 1 choledochal cysts involve fusiform dilatation of the entire CBD without any intrahepatic dilatation. Cancer is more common in patients who are older and with type I and IV cysts. These are typically treated with complete cyst resection and Roux-en-Y hepaticojejunostomy. Additionally, 50-80% of patients with choledochal cysts have an anomalous pancreaticobiliary malunion. The KOMI classification is used to classify anomalous pancreaticobiliary malunions into 3 types, which is based on the CBD/pancreatic duct angle and presence of CBD dilation. This case was a KOMI type IIB anomalous pancreaticobiliary malunion given the common hepatic and pancreatic ducts join each other at an acute angle creating a single common channel.

3023 Necrotizing Pancreatitis Following Ampullary Biopsy Without Biliary Cannulation

INTRODUCTION: Patients with familial adenomatous polyposis (FAP) have an almost 100% lifetime risk of developing colorectal cancer (CRC). In addition, they are at increased risk for developing cancers in the duodenum and ampulla. While pancreatitis is a known complication of ampullary manipulation, it typically presents within hours and is relatively mild. We present a unique case of a patient with FAP who underwent an excision biopsy for a diminutive ampullary adenoma and presented with necrotizing pancreatitis 12 days following the procedure. CASE DESCRIPTION/METHODS: A 70-year-old male with a history of FAP and CRC who is status post-total abdominal colectomy was found to have a 2-cm sessile polyp on the lateral wall of the duodenum and a diminutive ampullary polyp (Figure 1) on surveillance esophagogastroduodenoscopy (EGD). The lateral polyp was removed via piecemeal endoscopic mucosal resection. The ampullary polyp was cautiously removed via biopsy excision with an attempt to biopsy along the left lateral margin deliberately away from the tentative pancreatic duct orifice. Both lesions were tubular adenomas. The patient did well for 12 days post-procedure until he presented to the emergency department for epigastric pain, nausea and vomiting. On presentation, serum lipase was 2000 U/L. A CT scan of the abdomen showed necrotizing pancreatitis with an 11-cm peripancreatic fluid collection. The patient denied alcohol use, and imaging did not reveal any cholelithiasis. Serum triglycerides and IgG-4 levels were within normal limits. The patient was admitted, managed with intravenous hydration and early nutrition, and was discharged on hospital day 10. CT abdomen pelvis performed 3 months later showed an 8-cm pancreatic fluid collection consistent with walled-off necrosis (WON). The patient is completely asymptomatic and is being followed clinically with plan for repeat imaging in 3 months. DISCUSSION: Acute pancreatitis is a common complication following endoscopic retrograde cholangiopancreatography (ERCP), but is exceedingly rare without attempts at biliary/pancreatic duct cannulation. In our case, the patient developed necrotizing pancreatitis following an excision biopsy of a diminutive ampullary adenoma without any attempts at cannulation of the ampulla. Patients need to be adequately counseled about the risks of severe pancreatitis, and a high level of suspicion should be maintained for up to two to three weeks after a procedure.

Left liver anatomical resection via the left vertical groove and intraoperative antegrade cholangioscopy in patients with left-sided hepatolithiasis and previous biliary tract surgery.

ObjectiveThis study aimed to assess the safety and efficacy of left liver anatomical resection via the left vertical groove following intraoperative antegrade cholangioscopy (biliary exploration through the left hepatic duct orifice) in patients with left-sided hepatolithiasis (LSH) and previous biliary tract surgery.MethodsBetween January 2012 and January 2016, eligible patients with LSH (n = 28) who underwent left liver anatomical resection via the left vertical groove followed by intraoperative antegrade cholangioscopy, were referred to our hospital. Clinical results, such as the overall operative time, length of hospital stay, intraoperative complications, residual stones and postoperative bile leaks, were recorded and analyzed.ResultsNo residual stones and bile leakage occurred in the patients. No patients experienced intraoperative complications or T-tube placement. The mean operative time was 135.1 ± 18.9 minutes. The mean postoperative duration of hospitalization was 7.8 ± 1.8 days.ConclusionsLeft liver anatomical resection via the left vertical groove combined with intraoperative antegrade cholangioscopy is a safe and useful method for patients with LSH and previous biliary tract surgery. This technique simplifies the operative procedure by avoiding dissection of the porta hepatis and subsequent choledochotomy.

Dual stent placement to treat a persistent bile leak in a patient with aberrant biliary anatomy

A 68-year-old man underwent ERCP for suspected cystic duct leak after cholecystectomy. Cholangiography confirmed a high-grade cystic duct leak. Sphincterotomy was performed, and a 10F × 5 cm plastic biliary stent was placed. Persistent daily drain output prompted repeated ERCP 6 weeks later. A cholangiogram revealed a persistent cystic duct leak, and a 10 mm × 60 mm covered self-expanding metal stent (CSEMS) was placed to occlude the cystic duct orifice.

Risk Factors for Pancreatitis and Cholecystitis after Endoscopic Biliary Stenting in Patients with Malignant Extrahepatic Bile Duct Obstruction.

Background/Aims:For the treatment of malignant biliary obstruction, endoscopic retrograde biliary drainage (ERBD) has been widely accepted as a standard procedure. However, post-ERBD complications can affect the lives of patients. The purpose of this study was to identify the predictive factors for these complications, including the patient’s status, cancer status, and stent type. Methods:This was a retrospective analysis conducted in a single tertiary hospital from January 2007 to July 2017. The following variables were evaluated: sex, age, body mass index, cancer type, history of pancreatitis, gallbladder stone, previous biliary stenting, precut papillotomy, stent type, contrast injection into the pancreatic duct or gallbladder, cystic duct invasion by the tumor, and occlusion of the cystic duct orifice by a metal stent. Results:Multivariate analysis showed that contrast injection into the pancreatic duct was a risk factor for pancreatitis. Patients with a history of bile drainage showed a lower risk of pancreatitis. For cholecystitis, the analysis revealed contrast injection into the gallbladder and cystic duct invasion by the tumor as important predictive factors. Metal stents showed a greater risk of post-procedure pancreatitis than plastic stents, but did not affect the incidence of cholecystitis. Conclusions:Considering that contrast injection is the most important factor for both complications, a careful approach by the physician is essential in preventing the occurrence of any complications. Further, choosing the type of stent is an important factor for patients at a risk of post-procedure pancreatitis.

Lesions of the Parotid Gland and Buccal Artery After Buccal Fat Pad Reduction.

The significant increase in esthetic surgery, especially buccal fat pad reduction, has led to a corresponding increase in lesions and postoperatory after-effects from this surgical procedure. The aim of this study is to discuss the immediate and mediate risks of removing the Bichat ball, as well as describing a clinical study in which this surgical procedure resulted in lesions of the parotid gland and buccal artery, which was confirmed via nuclear magnetic resonance. The facial lesions were remedied via exploratory surgery by opening a new orifice of the glandular duct in the buccal cavity followed by drainage and compressive surgical bandages.

The LEST technique: Treatment of prostatic obstruction preserving antegrade ejaculation in patients with benign prostatic hyperplasia.

The objective of this study was to search for an alternative technique to relieve prostatic obstruction due to benign prostatic hyperplasia without affecting the ejaculatory function. The technical requirements are a laser with a wavelength well absorbed by water (good vaporizing effect) and at the same time by hemoglobin (good hemostatic effect) and laser fibers very resistant at high emission power allowing perfect vaporization in a contact mode. The aim of the technique is to avoid damage of the structures that allow the peripheral region of the prostate and the seminal vesicles to discharge their secretions into the posterior urethra. The orifices of the ejaculatory ducts must therefore be identified and preserved, damage of the ejaculatory ducts along their path inside the prostate must be avoided and the so called "genital sphincter" must be saved. The steps of the Leonardi Ejaculation Sparing Technique (LEST) procedure are as follow: Step 1 - ejaculatory duct orifices must be identified and the limits of the vaporization section must be marked. Step 2 - bladder neck is cleaned of the prostate hypertrophic tissue saving, as much as possible, the smooth muscle fibers of the bladder neck. Step 3 - vapo-resection of the lateral lobe (or enucleation of the adenoma) is performed. Step 4 - cautious and meticulous preparation of the prostatic apexes is obtained with saving of the orifices of the ejaculatory ducts. An antegrade ejaculation is maintained in about 80% of cases in patients without a middle lobe, although in the presence of a middle lobe this rate drops to about 50%.

A New Approach to Accomplish Intraoperative Cholangiography in Left Lateral Segmentectomy of Living Liver Donation.

BackgroundThere are 2 main methods of bile duct division in harvesting left lateral segment of a living donor: 1) by intraoperative cholangiography through cystic duct with cholecystectomy, or 2) by direct vision with preoperative magnetic resonance cholangiopancreatography. Here, we present a new approach to cholangiography by using the bile duct stump of the fourth liver segment (B4 stump) to achieve left lateral segmentectomy in pediatric living donor liver transplantation.Material/MethodsThis was a prospective study of 221 living donors who had undergone intraoperative cholangiography via the B4 stump in the course of left lateral segmentectomy. We collected and analyzed the clinical data, including the success rate of cholangiography by catheterizing the B4 stump; the associated time cost; the classification of the donor liver’s biliary anatomy; the number of bile duct orifices on the graft side; and postoperative complications involving the biliary tract.ResultsWe were successful in catheterizing B4 stumps in all 221 patients. The mean time cost of these procedures was 7.21±3.62 minutes. Variations in the confluence of the right and left lobes were found in 58 patients (26.24%). Overall, sludge was detected in 18 cases (8.14%), gallstones were found in 3 patients (1.36%), and a polypoid gallbladder lesion was found in 1 patient (0.45%). There were 11 cases (4.98%) of bile leakage; no biliary strictures were found in the donors.ConclusionsIntraoperative cholangiography via the B4 stump is an alternative procedure for living donors who undergoes left lateral segmentectomy.

Nipple Discharge After Nipple-Sparing Mastectomy With and Without Associated Pregnancy

BackgroundNipple-sparing mastectomies (NSMs) preserve the intact nipple, including nipple duct orifices. Retained orifices might remain patent and communicate with the underlying reconstruction. We report the incidence and outcomes of nipple discharge after NSM in pregnant and nonpregnant women. Patients and MethodsRetrospective review of all NSMs at our institution from June 2007 to June 2018 was performed. Subsequent pregnancies and nipple discharge were documented. Patient demographic, operative, histopathology, and cancer treatment data were collected. Descriptive analysis was performed for patients who developed nipple discharge. ResultsFrom June 2007 to June 2018, 2778 NSM procedures were performed in 1620 patients, with a mean age of 48 (range, 20-80) years. Fifteen hundred sixty-eight NSMs were therapeutic and 1210 were for risk reduction. Thirty-three subsequent pregnancies were observed in 27 patients, with a mean age of 33 (range, 26-42) years at NSM. Bilateral or unilateral discharge occurred in 6 of 27 (22%) postpartum patients and resolved spontaneously. At 54 months mean follow-up after NSM (range, 16-98 months) and 23 (range, 1-61) months after delivery, no local-regional recurrences were observed. In 1593 patients without subsequent pregnancy, there were 4 patients (0.25%) treated with bilateral NSM with subsequent unilateral watery nipple discharge. There was no evidence of associated malignancy on physical exam, imaging, or cytology, and with 55 to 110 months follow-up, no new or recurrent cancers have been observed. ConclusionDespite extensive removal of nipple and subareolar duct tissue during NSM, milky nipple discharge is possible postpartum. Watery, acellular discharge occurs rarely in nonpregnant patients. To date, no patient with discharge has developed a local recurrence or new breast cancer.

Power Doppler ultrasound-guided sialography using the phenomenon of increased blood flow: A technical report.

PurposeThis report presents a procedure for performing power Doppler ultrasound-guided sialography using the phenomenon of increased blood flow and illustrates its application to practical patient cases.Materials and MethodsThe salivary gland was scanned using ultrasound equipment (GE LOGIQ5 Expert® device; GE Medical Systems, Milwaukee, WI, USA) to identify pathological findings related to the patient's chief complaint. To identify the orifice of the main duct, it should be cannulated using a lacrimal dilator. After inserting the catheter into the cannulated main duct, the position of the catheter within the duct was confirmed by ultrasound. A contrast agent was injected until the patient felt fullness, and ultrasound (B-mode) was used to confirm whether the contrast agent filled the main canal and secondary and tertiary ducts. Then, power Doppler ultrasound was performed to determine whether the salivary gland had increased blood flow.ResultsIn 2 cases in this report, a power Doppler ultrasound scan showed a significant increase in blood flow after contrast medium injection, which was not observed on a preoperative scan.ConclusionPower Doppler ultrasound was found to be a simple, safe, and effective tool for real-time sialography monitoring.

An Innovative Technique of Transurethral Seminal Vesiculoscopy with Ultrasonic Lithotripter for Severe Persistent Hematospermia

Abstract Introduction: To introduce an innovative technique of transurethral seminal vesiculoscopy (TSV) with ultrasonic lithotripter for severe persistent hematospermia. Materials and Methods: From May 2012 to December 2015, totally 14 patients with severe persistent hematospermia underwent TSV with an ultrasonic lithotripter. For the patient with a positive urine solution microorganism culture, the sensitive antimicrobial therapy is administrated and the negative culture outcome is confirmed before the TSV procedure.1,2 Under general anesthesia, the patient is positioned in the standard lithotomy position. The 8F rigid ureteroscopy used as the seminal vesiculoscopy is inserted retrogradely, under the guidance of a 0.032-inch Zebra guidewire, through the utricular orifice at the verumontanum.3 After entering the lumen, the Zebra guidewire is further introduced through the ejaculatory duct orifice to guide the ureteroscopy entering seminal vesicle. If the orifice is masked behind a thin transparent membra...

Diagnostic and Therapeutic Benefits of Direct Visualization of the Biliary Tree

Endoscopic retrograde cholangiopancreatography (ERCP) uses radiographs to image the biliary tree, but a challenge with ERCP is the inability to directly visualize the biliary tree. The emergence of direct peroral cholangioscope technology (DPCT) allows direct visualization of the bile duct using a small scope. This report describes the successful treatment of a cystic duct stone using DCPT that was otherwise not amenable to ERCP. A 54-year-old female presented with a 3-week history of low-grade fevers, RUQ pain, and melena. Labs showed elevated alkaline phosphatase of 1227 IU/L. CT showed a 10 cm x 8 cm liver mass in the right lobe concerning for abscess vs. necrotic cancer. Magnetic resonance cholangiopancreatography (MRCP) revealed debris, common bile duct of 12 mm, and cholelithiasis. ERCP revealed hemobilia, and a plastic stent was placed. Biopsy of the liver mass showed necrotic material. After admission to our facility, she developed cholangitis due to stent migration. ERCP showed blood clots filling the bile duct and a metal stent was placed to facilitate drainage. The patient's condition stabilized, and she was discharged on antibiotics. She was lost to follow-up, and later presented with acute cholecystitis requiring cholecystectomy. Interestingly, her liver abscess had completely resolved. Four weeks later, an elective ERCP was performed and the previously placed metal stent was removed. Initial cholangiogram revealed no pathology and a balloon sweep revealed minimal amount of sludge. Due to unclear etiology of her illness, DPCT was utilized and a large stone was discovered at the orifice of the cystic duct which was inconspicuous on MRCP and ERCP cholangiograms. Guided via DCPT, a long wire was passed into the cystic duct. (Fig. 1) After minor manipulation, stone was dislodged and removed. (Fig. 2A & B) At 6-month follow-up, patient was asymptomatic. This was a challenging case, as the etiology of the patient's liver abscess and hemobilia proved difficult, especially due to the inability to exclude neoplasm. Standard visualizing techniques were non-diagnostic, but DPCT was integral in both diagnosis and therapy. Undetected stones by ERCP may be higher than expected, and DPCT is successful in treating difficult stones due to its ease of use, safety profile, and high utility. Gastroenterologists should consider implementation of DPCT for diagnosis and therapy, especially in the setting of challenging cases.1391_A.tif Figure 1: DPCT used to guide long wire into the cystic duct1391_B.tif Figure 2:A. DPCT used to reveal large-impact stone at the orifice of the cystic duct1391_C.tif Figure 3: Extracted stone in the duodenum

Bouncing Off the Balloon: A New Trick for Selective Cystic Duct Cannulation

Introduction: Management of acute cholecystitis in non-surgical or high-risk candidates includes endoscopic (transpapillary or transmural stenting) or percutaneous drainage of the gallbladder (GB). Endoscopic cannulation of the cystic duct (CD) for transpapillary GB drainage in such cases can be technically challenging and difficult, given narrowing of cystic duct orifice from edema, stones and valves in the cystic duct, and angulation of the cystic duct takeoff. Here we describe a novel technique, using no special equipment that can be utilized in cases of angulated CD takeoff. Case Description: A 47-year-old woman was admitted with acute cholecystitis and choledocholithiasis. Her vitals were stable with no signs of sepsis. Her WBC was 7.7 X 103/dl, AST 78 unit/L, ALT 267 unit/L, ALP 207 unit/L, total bilirubin was 1.2 mg/dl. Given her morbid obesity (BMI 53) and multiple comorbidities (history of recent uterine infection with perforation, multiple intra-abdominal abscesses, and a diversion colostomy) she was deemed not a surgical candidate for cholecystectomy. Subsequently, she underwent an endoscopic retrograde cholangiography (ERC) with successful mechanical lithotripsy and balloon extraction of multiple common bile duct (CBD) stones. Selective CD cannulation was then attempted; however, was unsuccessful despite multiple attempts using different guidewires and catheters given the downward angulation (Image 1) of the CD takeoff that made it technically challenging. A 15 mm extraction balloon was inflated in the distal common hepatic duct (1 cm proximal to the CD orifice) and a 0.035-inch guidewire was inserted into the CBD alongside the extraction balloon catheter. The guidewire was further advanced into the bile duct allowing the guidewire to recoil (bounce) off the balloon, and was carefully manipulated into the angulated CD takeoff (Image 2). Contrast injection showed filling defect in the neck of the gallbladder. Pus was seen draining from the major ampulla after CD cannulation. A transpapillary 7 Fr x 22 cm double-pigtail plastic stent was successfully placed across the CD with the internal pigtail in the gallbladder lumen (Image 3).1323_A.tif Figure 1: No Caption available.1323_B.tif Figure 2: No Caption available.1323_C.tif Figure 3: No Caption available.Discussion: There is a paucity of techniques describing CD cannulation. These include using intraductal ultrasound or cholangioscopy for guidance, however, such devices may not be readily available. We believe our novel and simple method can be utilized for selective CD cannulation in such difficult cases.

AB071. Transurethral seminal vesiculoscopy for recurrent hemospermia: experience from 419 cases

BackgroundWe summarize our experience in transurethral seminal vesiculoscopy (TSV) for recurrent hemospermia by introducing surgical techniques, intra-operative findings and treatment outcomes.MethodsTSV was performed in 419 patients with an initial diagnosis of persistent hemospermia at Shanghai Changhai Hospital (Shanghai, China) from May 2007 to November 2015. TSV was successfully performed in 381 cases (90.9%). Hemospermia was alleviated or disappeared in 324 (85.0%) patients by 3 months after surgery. Common intra-operative manifestations were bleeding, obstruction or stenosis, mucosal lesions and calculus.ResultsEndoscopic presentation of the ejaculatory duct orifice and the verumontanum was categorized into 4 types, including 8 (1.9%), 32 (7.6%), 341 (81.4%) and 38 (9.1%) cases in types A, B, C and D, respectively. TSV is an effective and safe procedure in the management of seminal tract disorders.ConclusionsThis study may help other surgeons to become familiar with and improve this procedure. However, further multicenter clinical trials are warranted to validate these findings.

STUDY OF THE PECULIARITIES OF THE STRUCTURE OF THE NASOLACRIMAL DUCT ORIFICE ACCORDING TO THE DATA OF MULTISLICE COMPUTED TOMOGRAPHY

Objective. To develop a method for investigating the perculiarities of the structure of the nasolacrimal duct orifice according to the data of multislice computed tomography (MSCT). Material and methods . The structure of the nasolacrimal duct orifice was investigated in 96 cases in 65 people, including healthy volunteers (n=29), patients with dacryostenosis (n=45), and those with unilateral dacryocystitis (n=22). The type of the nasolacrimal duct orifice was identified using the developed procedure on the basis of the data of contrast-enhanced MSCT of the lacrimal passages. For verification, the investigators used retrograde probing of the nasolacrimal duct in all cases. Results . There were four possible types of the structure of the nasolacrimal duct orifice. Five cases showed discordance between the type of nasolacrimal duct office and the MSCT type identified by retrograde probing. The accuracy of the developed procedure to identify the type of the nasolacrimal duct orifice was 94.8%. Conclusion. The developed methodology based on CT is noninvasive, can reliably identify the type of the structure of the nasolacrimal duct orifice, and may be included in the algorithm for examination of patients with lacrimation disorders.

Outcome of donor biliary complications following living donor liver transplantation.

Background/AimsBiliary complications are the most common donor complication following living donor liver transplantation (LDLT). The aim of this study is to investigate the long-term outcomes of biliary complications in right lobe adult-to-adult LDLT donors, and to evaluate the efficacy of endoscopic treatment of these donors.MethodsThe medical charts of right lobe donors who developed biliary complications between June 2000 and January 2008 were retrospectively reviewed.ResultsOf 337 right lobe donors, 49 developed biliary complications, including 36 diagnosed with biliary leakage and 13 with biliary stricture. Multivariate analysis showed that biliary leakage was associated with the number of right lobe bile duct orifices. Sixteen donors, five with leakage and 11 with strictures, underwent endoscopic retrograde cholangiography (ERC). ERC was clinically successful in treating eight of the 11 strictures, one by balloon dilatation and seven by endobiliary stenting. Of the remained three, two were treated by rescue percutaneous biliary drainage and one by conservative care. Of the five patients with leakage, four were successfully treated using endobiliary stents and one with conservative care. In overall, total 35 improved with conservative treatment. All inserted stents were successfully retrieved after a median 264 days (range, 142 to 502) and there were no recurrences of stricture or leakages during a median follow-up of 10.6 years (range, 8 to 15.2).ConclusionsAll donors with biliary complications were successfully treated non-surgically, with most improving after endoscopic placement of endobiliary stents and none showing recurrence on long term follow-up.

MANAGEMENT OF ACUTE BACTERIAL SIALADENITIS (Case Report)

Background : Sialadenitis is the inflammation of the salivary gland. Predisposing factors for acute sialadenitis include diabetes mellitus, hypothyroidism, renal failure, and Sjogren syndrome. The most common bacterial cause of acute bacterial sialadenitis is Staphylococcus aureus. Purpose : to report the management of Acute bacterial sialadenitis, especially the recommendation antibiotic for treatment of Acute bacterial sialadenitis. Case : Woman, 34 years old, suffered the pain of left buccal especially when she was eating. There was a lowgrade fever. She has been suffering since 3 days ago, but she did not give any drugs. The intra oral examination showed the stenoni of parotid gland was swollen and painful, and erythematous. The purulent discharge often was observed from the duct orifice when the gland was checked by palpation. The patient was diagnosed as Acute Bacterial sialadenitis. Case management : Amoxycillin caplet 500 mg three times a day, Ibuprofen caplet 400 mg three times a day, and oral rinse contains aloevera gargle three times a day for seven days, then the instruction to patient took a lot of rehydration. After seven days, Cefadroxil capsul 500 mg two times a day replaced amoxycillin caplet 500 mg three times a day. Conclusion : It can be concluded that Cephalosporins display superior pharmacokinetics in saliva and cover the spectrum of all bacteria implicated in sialadenitis.

Transurethral seminal vesiculoscopy for recurrent hemospermia: experience from 419 cases.

We summarized our experience in transurethral seminal vesiculoscopy (TSV) for recurrent hemospermia by introducing surgical techniques, intraoperative findings, and treatment outcomes. TSV was performed in 419 patients with an initial diagnosis of persistent hemospermia at Shanghai Changhai Hospital (Shanghai, China) from May 2007 to November 2015. TSV was successfully performed in 381 cases (90.9%). Hemospermia was alleviated or disappeared in 324 (85.0%) patients by 3 months after surgery. Common intraoperative manifestations were bleeding, obstruction or stenosis, mucosal lesions, and calculus. Endoscopic presentation of the ejaculatory duct orifice and the verumontanum was categorized into four types, including 8 (1.9%), 32 (7.6%), 341 (81.4%), and 38 (9.1%) cases in Types A, B, C, and D, respectively. TSV is an effective and safe procedure in the management of seminal tract disorders. This study may help other surgeons to become familiar with and improve this procedure. However, further multicentric clinical trials are warranted to validate these findings.

Tumor invasion to the arteries feeding the gallbladder as a novel risk factor for cholecystitis after metallic stent placement in distal malignant biliary obstruction.

Cholecystitis is a major complication after self-expandable metallic stent (SEMS) placement for malignant biliary obstruction. Ischemia is one of the risk factors for cholecystitis, but little is known about the influence of tumor invasion to the feeding artery of the gallbladder on the onset of cholecystitis after SEMS placement. The aim of the present study was to identify risk factors for cholecystitis after SEMS placement. Incidence and nine predictive factors of cholecystitis were retrospectively evaluated in 107 patients who underwent SEMS placement for unresectable distal malignant biliary obstruction at Kyoto University Hospital and Otsu Red Cross Hospital between January 2012 and June 2016. Cholecystitis occurred in 13 of 107 patients (12.1%) after SEMS placement during the median follow-up period of 262 days. Univariate analyses showed that tumor invasion to the feeding artery of the gallbladder and tumor involvement to the orifice of the cystic duct were significant predictors of cholecystitis (P = 0.001 and P < 0.001). Multivariate analysis confirmed that these two factors were significant and independent risks for cholecystitis with odds ratios of 22.13 (95% CI, 3.57-137.18; P = 0.001) and 25.26 (95% CI, 4.12-154.98; P < 0.001), respectively. This study showed for the first time that tumor invasion to the feeding artery of the gallbladder as well as tumor involvement to the orifice of the cystic duct are independent risk factors for cholecystitis after SEMS placement.