Hepatic Bile Duct Research Articles

Efficacy of near-infrared fluorescence cholangiography using indocyanine green in laparoscopic cholecystectomy: A retrospective study.

While laparoscopy has been the standard procedure for gallstone treatment, recent advances including the use of indocyanine green (ICG) in laparoscopic cholecystectomy have made it easier to understand the biliary tree and reduce the risk of bile duct injury. In this retrospective study, we aim to determine the efficacy of ICG in near-infrared fluorescence cholangiography (NIRFC) for visualising biliary anatomy. A total of 90 patients with the symptoms of cholelithiasis were enrolled for this retrospective study. All the patients underwent cholecystectomy approximately 53.8 min (40-90 min) after the intravenous administration of mean volume 1.6 ml (1-2 ml) ICG. The surgeons used NIRFC along with ICG for real-time visualisation of biliary anatomy. The mean operative time for the surgery was 65.7 min (25-120 min) with no post-surgical complications observed in the patients. The average length of stay was 2 days (1-3 days). ICG usage with NIRFC enabled identification of cystic duct, common hepatic and common bile duct, the junction between common hepatic and bile duct, right and left hepatic duct in 87.7%, 94.4%, 80% and 14.4% of cases, respectively. ICG fluorescence allowed successful visualisation of at least 1 biliary structure in 100% of cases.

Assessment of Hepatic Lesions After non-Thermal Tumor Ablation by Irreversible Electroporation in a Pig Model.

Irreversible electroporation (IRE) is a non-thermal and minimal invasive modality to ablate pathologic lesions such as hepatic tumors. Histological analysis of the initial lesions after IRE can help predict ablation efficacy. We aimed to investigate the histological characteristics of early hepatic lesions after IRE application using animal models. IRE (1500 V/cm, a pulse length of 100 μs, 60 or 90 pulses) was applied to the liver of miniature pigs. H&E and TUNEL staining were performed and analyzed. Ablated zones of pig liver were discolored and separated from the normal zone after IRE. Histologic characteristics of ablation zones included preserved hepatic lobular architecture with a unique hexagonal-like structure. Apoptotic cells were detected, and sinusoidal dilatation and blood congestion were observed, but hepatic arteries and bile ducts were intact around the ablation zones. The early lesions obtained by delivering monophasic square wave pulses through needle electrodes reflected typical histological changes induced by IRE. Therefore, it was found that the histological assessment of the early hepatic lesion after IRE can be utilized to predict the IRE ablation effect.

Evaluation of Morphological Changes in Hepatic Parenchyma, Bile Ducts, and Hepatic Vasculature in Patients with Oriental Cholangiohepatitis using Ultrasonography

Objective: The objective of this study is to study the morphological changes in hepatic parenchyma, to characterize the intra and extrahepatic ductal changes and to study the morphological changes in vasculature of the liver in patients with oriental cholangiohepatitits (OCH). Materials and Methods: All documented or newly diagnosed cases of OCH, referred to the department of radiodiagnosis and imaging from Departments of Surgical Gastroenterology and Medical Gastroenterology were evaluated by ultrasonography (USG) and color Doppler study. The dilatation of the intrahepatic as well as extra-hepatic ducts was noted. The morphological changes in the liver parenchyma as well as hepatic vasculature were studied. Results: USG showed calculi in 53 (98.1%) cases, ductal dilatation in 52 (96.3%), and worms within biliary ducts in 10 cases (18.5%). Among parenchymal changes, atrophy was seen in 9 cases (16.6%), space-occupying lesion was seen in seven cases (12.9%), and peri-portal echogenicity in 10 cases (18.5%). Significant association was found between atrophic segments and reduced/absent blood flow in the affected segmental portal venous branches. Conclusion: USG is the preferred primary examination. Further imaging depends on the USG findings, the patient's symptomatology, the clinical problems, and the intended mode of treatment. Advances in Knowledge: USG plays a pivotal role in the evaluation of oriental cholangiohepatitis in the low resource settings where higher modalities like MRI are not available, especially in the remote areas of developing countries, as it has high degree of accuracy in the diagnosis of OCH.

Lateral dorsal infundibular approach: an alternative option for the safe completion of difficult laparoscopic cholecystectomy

BackgroundDifficult laparoscopic cholecystectomy (LC) due to acute cholecystitis (AC) increases the risk of bile duct injuries and postoperative complications. Here, we added the lateral dorsal infundibular approach as an initial surgical maneuver during LC to improve outcomes.MethodsWe describe the detailed technical procedure of the lateral dorsal infundibular approach in patients with AC resulting in difficult LC. This technique was developed after nearly 10 years of experience in laparoscopic surgery, and has been routinely used in the past 5 years. We also retrospectively analyzed the perioperative data for 469 patients with difficult LC.ResultsA total of 469 patients with AC received difficult LC between July 2016 and June 2021, of which 438 (93.4%) performed a lateral dorsal infundibular approach. Sixty-four patients (13.6%) had variations of the hepatic bile duct and cystic duct according to preoperative magnetic resonance cholangiopancreatography, 438 patients (93.4%) received elective surgery, 31 (6.6%) received emergency surgery, and 10 (2.1%) underwent conversion. There was no postoperative bile leaks and no bile duct injuries in the described technique.ConclusionDuring difficult LC, the critical view of safety can be gradually achieved by changing the surgical approach to achieve cholecystectomy.

Treatment and follow-up of late onset intra hepatic bile duct stones in congenital biliary dilatation.

The postoperative course after surgery for congenital biliary dilatation (CBD) has some complications. Intrahepatic bile duct (IHBD) stones were known as a late complication. We report on the treatment and long-term follow-up of postoperative IHBD stones in our department. Patients who underwent CBD surgery at age 15years or younger in our department were identified. Those followed up for 5years or more were enrolled. Annual blood chemistry tests and abdominal ultrasonography were performed. Each patient's surgical procedure, IHBD stone diagnosis, treatments, and outcomes were retrospectively assessed. Fifty-one patients were analyzed. The median age at the last visit was 24years (range 7-45years), and the median age at CBD surgery was 3years. Eight patients (16%) developed late-onset IHBD stones. The median age at onset was 25years, and the median duration after surgery was 20years. The initial treatment was double-balloon enteroscopy (DBE) in 4 cases, which resulted in stone removal in 3 of the 4 patients (75%). Since CBD may cause late-onset IHBD stones, continuous follow-up is required even in adulthood. In this study, DBE was effective and minimally invasive, and it is recommended as the initial treatment.

Danlu tongdu tablets: Preclinical safety evaluation and mechanism of hepatotoxicity.

Danlu tongdu tablets (DLTD) is a listed Chinese patent medicine collected in the Pharmacopoeia of the People's Republic of China (version 2020). This prescription has been applied in clinics in China for lumbar spinal stenosis and lumbosacral disc herniations. The wide application of Danlu tongdu in therapy has raised some clinical adverse reactions, such as significant elevation of alanine transaminase (ALT) and aspartate transaminase (AST) in individual patients after use. The present study aimed to investigate the safety of Danlu tongdu and analyze its adverse effects on the liver. The maximum feasible dose (MFD) was used to carry out the acute toxicity tests. Mortality, adverse effects, body weight and food consumption were recorded for up to 14days post treatment. In the 6-month chronic toxicity test, sprague-dawley rats were randomly divided into four groups according body weight, the experimental groups were administrated to rats at the concentrations of 1.67, 3.34 and 6.67g/kg/day, whereas the control group was received the ultrapure water (vehicle) only, 10ml/kg, once a day. The animal's body weight, food consumption was monitored weekly. In addition, their hematological and biochemical parameters, body and organ weights and histopathology, were all measured at specific observation time points. Additionally, we further explored the adverse effects mechanism of Danlu tongdu on the liver through transcriptome analysis. No deaths or substance-relative toxicity were observed in the acute toxicity study or the 6-month chronic toxicity study with doses of 1.67g/kg and 3.34g/kg, respectively. We found that mild hypertrophy and hyperplasia of hepatic interlobular bile ducts were detected in some rats with doses of 6.67g/kg after repeated oral administration of Danlu tongdu for 13 and 26weeks, but the above changes in liver were reversible. The results of transcriptome sequencing showed that Danlu tongdu had a significant effect on cytochrome P450 enzymes in rat liver, especially cytochrome P450 1 (CYP1) subtype. Therefore, the toxic target organ of Danlu tongdu is the liver and the mechanism of mild liver injury is closely related to the up-regulation of cytochrome P450 1A1 (CYP1A1) and cytochrome P450 1A2 (CYP1A2) expression.

BILIPTYSIS: BRONCHOBILIARY FISTULA (BBF) RESULTING FROM RIGHT LOWER LUNG ABSCESS

BILIPTYSIS: BRONCHOBILIARY FISTULA (BBF) RESULTING FROM RIGHT LOWER LUNG ABSCESS

S3669 Spotting the Deceiver: Metastatic Urothelial Carcinoma to the Liver Masquerading as a Well-Differentiated Neuroendocrine Tumor Histologically

Introduction: Metastatic urothelial carcinoma of the bladder is generally considered an aggressive disease. It has the potential to metastasize to lymph nodes, bones, lungs, liver, and peritoneum. The accurate diagnosis of metastatic urothelial carcinoma is challenging especially in the setting of histological mimickers. Without pathological expertise and additional immunohistochemistry, metastatic tumors could remain incorrectly diagnosed and delay therapeutic intervention. Case Description/Methods: Herein, we describe a 62-year-old man who presented with jaundice, elevated LFTs, diffuse abdominal pain, and early satiety. MRI of the abdomen revealed a hilar hyperintense mass involving the common bile duct, bilateral hepatic ducts causing narrowing, a 1.1 cm mass in segment 6, and hydroureteronephrosis with thickening of the renal pelvis. Discussion: Clinical differential diagnosis included cholangiocarcinoma and other tumors including a metastatic neuroendocrine tumor (NET). Microscopic evaluation of liver mass biopsy revealed insular growth pattern with monotonous epithelioid cells arranged in nests morphologically suggestive of well-differentiated neuroendocrine tumor (WDNET). However, neuroendocrine immunohistochemical stains, including synaptophysin, chromogranin, and CD56, were all negative, and the Ki-67 staining was 37%, higher than expected for a WDNET, (see Figure 1) prompting broadening of the differential. Following further workup, a diagnosis of metastatic urothelial carcinoma was confirmed by immunopositivity for immunohistochemical markers P40, and GATA3 (see Figure 1). Familiarity with tumors that are histologically identical is critical. Considering an appropriate differential diagnosis, and following a stepwise immunohistochemical approach will be crucial in spotting the mimickers and rendering appropriate management promptly.Figure 1.: Metastatic urothelial carcinoma, hematoxylin & eosin (A and B), and immunohistochemical markers (C-F).

Biliary Tract Exploration After Laparoscopic Left-sided Hepatectomy: A Comparative Study of Left Hepatic Duct Orifice Versus Common Bile Duct Approach.

Laparoscopic left-sided hepatectomy (LLH) and additional biliary tract exploration are effective methods to treat left-sided hepatolithiasis (LSH) combined with extrahepatic bile duct stones. Although biliary tract exploration through common bile duct (CBD) incision has been widely accepted, the safety and effectiveness of the left hepatic duct (LHD) orifice approach after LLH is still in debate. One hundred and forty-four patients with LSH who underwent LLH and biliary tract exploration in our institution from April 2014 to September 2021 were enrolled in the retrospectively study. They were divided into 3 groups: LHD group (n=67), CBD/T-tube group (n=58), and CBD/PC group (n=19). Patients' demographic characteristics, intraoperative, and postoperative outcomes were retrospectively analyzed. LHD group exhibited a shorter operative time (202.8±42.2 vs. 232.7±47.5min, P =0.000), time to first bowel movement (2.3±0.5 vs. 2.9±0.7d, P =0.000) and postoperative hospital stay (7.5±2.1 vs. 9.8±5.2d, P =0.001) compared with the CBD/T-tube group. The lithotomy time in the LHD group was significantly longer than that in the CBD/T-tube group (33.6±7.3 vs. 29.0±6.3min, P =0.000) and CBD/PC group (33.6±7.3 vs. 28.7±3.7, P =0.006). Intraoperative blood loss, blood transfusion rate, initial stone clearance rate, and stone recurrence rate all had no significant differences between the 3 groups (all P >0.05). LHD group showed less rate of electrolyte imbalance than that of the CBD/T-tube group (3.0% vs. 19.0%, P =0.004) but it was equivalent to the CBD/PC group ( P >0.05). The type of biliary tract exploration (odds ratio: 5.43, 95% confidence interval: 0.04-0.95, P =0.032) as independent predictors of electrolyte imbalance. No reoperation and mortality occurred in the 3 groups. The conversion rate was comparable among 3 groups (1.5% vs. 1.7% vs. 0, all P >0.05). No significant difference in stone recurrence rate was seen (1.5% vs. 3.4% vs. 0, all P >0.05). Biliary tract exploration through LHD orifice after LLH is a safe and effective treatment for selected patients with LSH, with an advantage over the T-tube drainage in the field of operative time, the incidence of electrolyte imbalance, recovery of gastrointestinal function, and postoperative hospital stay.

S2870 Successful Use of EUS-Guided Choledochoduodenostomy With LAMS in a Post-Liver Transplant Patient With Recurrent Choledocholithiasis and Cholangitis

Introduction: Biliary complications, like anastomotic stricture and cholangitis, are seen in 10-15% of orthotopic liver transplants (OLT). OLTs often require multiple endoscopic retrograde cholangiopancreatoscopy (ERCP) for recurrent disease. Endoscopic ultrasound guided choledochoduodenostomy (EUS-CD) has been effective in treatment of malignant distal biliary obstruction after failed ERCP; however, there are limited reports regarding EUS-CD in OLTs. We present a case of successful EUS-CD with lumen apposing metal stents (LAMS) in an OLT with recurrent cholangitis secondary to benign anastomotic stricture refractory to management with ERCP. Case Description/Methods: A 61-year old female with 3 OLTs (1996 and twice in 2008) for autoimmune hepatitis presented with recurrent cholangitis secondary to anastomotic biliary stricture in the setting of duct mismatch with a dilated common hepatic bile duct to 3 cm. She had recurrent choledocholithiasis measuring 3 cm despite prior mechanical and electrohydraulic lithotripsy with cholangioscopy confirmed clearance. As a result, she had undergone a total of 26 prior ERCP treatments (2012-2021). She underwent an EUS-CD with LAMS for definitive treatment. 2-weeks later, an upper endoscope was traversed through the LAMS to perform lithotripsy of remaining choledocholithiasis. At this time, the patient remains free of cholangitis for the past 8 months. (Figure) Discussion: Biliary complications, like anastomotic stricture and recurrent cholangitis, are a common occurrence in OLTs. With use of various ERCP techniques, obstructions can be removed or ameliorated. Timely treatment of cholangitis is imperative as the mortality rate is high (10-30%). With each cholangitis episode and subsequent ERCP, the cumulative procedural risk and mortality increases. EUS-CD has been demonstrated to be effective in treatment for malignant distal biliary obstruction after failed ERCP. Our patient had previously undergone 26 ERCPs and additionally was on Warfarin for pulmonary embolism putting her at very high risk for complications with additional future endoscopic procedures. This represents a case of successful use of EUS-CD with LAMS in a patient post-OLT with a significant distal common bile duct stricture which had been refractory to traditional management via ERCP. Long term studies are indicated to see if this can provide durable benefit.Figure 1.: 1A. MRI imaging demonstrating a large 3 cm choledocholithiasis within the dilated CBD, which formed as a result of bile stasis. 1B. CT coronal view demonstrating successful deployment of LAMS to complete EUS-CD. 1C. Fluoroscopic view of the standard upper scope traversing through the LAMS for definitive lithotripsy and dredging of remaining choledocholithiasis. 1D. Endoscopic view of the final LAMS placement with double pigtail plastic stents.

S2901 Afferent Limb Syndrome Treated With Non-Cautery-Enhanced Lumen Apposing Metal Stent: An Alternate Approach

Introduction: Afferent limb syndrome (ALS) is a known complication after gastrojejunostomies from mechanical obstruction of the afferent limb (AL). Recently endoscopic ultrasound (EUS) guided gastroenterostomy placement has provided an alternate to surgical correction. However this approach is not always technically possible. We describe a case successfully treated with endoluminal non-cautery enhanced lumen apposing metal stent (LAMS) placement. Case Description/Methods: A 63 year old woman with a history of ileocolonic Crohns disease (diagnosed at age 25), status post multiple surgeries including ileocolic resections and Billroth II gastrectomy, was referred with persistent abdominal pain. She was recently diagnosed with acute pancreatitis with CT concerning for dilated afferent jejunal limb, a luminal stricture near the biliary anastomosis and dilated intra and extra hepatic bile ducts (Figure a). She underwent two deep enteroscopies revealing a stricture in the AL from intra-abdominal adhesion. This was dilated with minimal improvement in symptoms and imaging. After multi-disciplinary discussion it was decided to attempt EUS guided drainage of the AL to promote drainage of pancreatico- biliary secretions. During the procedure a significant amount of food residue was identified in the gastric remnant. The dilated afferent limb was visualized endosonographically adjacent to the posterior stomach at an acute angle. Considering large amount of food in the stomach, difficult angulation to deploy the AXIOS stent and concern for food entering the already obstructed limb after stent deployment it was decided to reconsider this approach. The AL was then explored with a therapeutic upper endoscope with stenosis at 10 cm from the anastomosis. A wire was passed through the stenosis under fluoroscopy. It was decided to place a stent using the 15 x 10 mm LAMS stent system considering short (< 1 cm) stricture. Using non cautery technique both flanges were deployed successfully across the stricture under fluoroscopic and endoscopic guidance with decompression of the AL (Figure b,c). 1 month follow up imaging demonstrated continued decompression of the AL. Discussion: EUS guided gastrojejunostomy has been increasingly used for ALS. However it can be challenging in situations where a good window cannot be identified. In such settings using a traditional luminal route to reach the stenosis and placing a non-cautery enhanced LAMS can provide a viable alternative.Figure 1.: (a) Dilated afferent limb with stricture (arrows), (b) post non-cautery enhanced LAMS deployment, (c) Fluoroscopy image post LAMS deployment

Plasma amyloid-beta levels correlated with impaired hepatic functions: An adjuvant biomarker for the diagnosis of biliary atresia.

BackgroundBiliary atresia (BA) is an infantile fibro-obstructive cholestatic disease with poor prognosis. An early diagnosis and timely Kasai portoenterostomy (KPE) improve clinical outcomes. Aggregation of amyloid-beta (Aβ) around hepatic bile ducts has been discovered as a factor for BA pathogenesis, yet whether plasma Aβ levels correlate with hepatic dysfunctions and could be a biomarker for BA remains unknown.MethodPlasma samples of 11 BA and 24 controls were collected for liver function test, Aβ40 and Aβ42 measurement by enzyme-linked immunosorbent assay (ELISA). Pearson's chi-squared test or Mann–Whitney U test was performed to assess differences between groups. Correlation between Aβ42/Aβ40 and liver function parameters was performed using Pearson analysis. The area under the receiver-operative characteristic (ROC) curve (area under curve; AUC) was measured to evaluate the diagnostic power of Aβ42/Aβ40 for BA. Diagnostic enhancement was further evaluated by binary regression ROC analysis of Aβ42/Aβ40 combined with other hepatic function parameters.ResultsPlasma Aβ42/Aβ40 was elevated in BA patients. Aβ42 displayed a weak positive correlation with γ-glutamyl transpeptidase (GGT) (Pearson’s correlation = 0.349), while there was no correlation for Aβ40 with hepatic functions. Aβ42/Aβ40 was moderately correlated with GGT, total bile acid (TBA), direct bilirubin (DBIL) (Pearson’s correlation = 0.533, 0.475, 0.480), and weakly correlated with total bilirubin (TBIL) (Pearson’s correlation = 0.337). Aβ42/Aβ40 showed an acceptable predictive power for cholestasis [AUC = 0.746 (95% CI: 0.552–0.941), p < 0.05]. Diagnostic powers of Aβ42/Aβ40 together with hepatic function parameters for cholestasis were markedly improved compared to any indicator alone. Neither Aβ42/Aβ40 nor hepatic function parameters displayed sufficient power in discriminating BA from choledochal cysts (CC); however, combinations of Aβ42/Aβ40 + GGT along with any other hepatic function parameters could differentiate BA from CC-cholestasis (AUC = 1.000, p < 0.05) with a cut-off value as 0.02371, −0.28387, −0.34583, 0.06224, 0.01040, 0.06808, and 0.05898, respectively.ConclusionAβ42/Aβ40 is a good indicator for cholestasis, but alone is insufficient for a distinction of BA from non-BA. However, Aβ42/Aβ40 combined with GGT and one other hepatic function parameter displayed a high predictive power as a screening test for jaundiced neonates who are more likely to be BA, enabling them to early intraoperative cholangiography for BA confirmation and KPE to improve surgical outcomes. However, a multi-centers validation is needed before introduction into daily clinical practice.

Intraoperative ultrasound-guided percutaneous hepatocholangiostomy applied in the cholangioscopic lithotripsy for hepatolithiasis and choledocholithiasis.

Percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) is a minimally invasive treatment for hepatolithiasis. But it may make a long cycle of treatment so that it was further improved to complete the percutaneous hepatic choledochotomy and choledochoscopic lithotripsy in phase I surgery. The aim of this study was to evaluate the efficacy of the modified technique comparing with laparoscopic choledochotomy. Retrospective analysis of the clinical data of patients with hepatolithiasis or choledocholithiasis consulted at our hospital from February 2018 to December 2021. The cases were divided into two groups according to surgical modality, intraoperative ultrasound-guided percutaneous transhepatic cholangioscopic lithotripsy (IUG-PTCSL) and laparoscopic choledochotomy lithotripsy (LC-L). Contrast analysis determined the advantages of the two approaches. IUG-PTCSL was performed in 44 patients, aged 58.14 ± 14.01years, including 9 male and 35 female. There were 15 patients underwent LC-L, aged 62.13 ± 15.03years, including 1 male and 14 female. There was not statistically significant difference in the composition of patients' age and sex between the two groups (p = 0.356, 0.219). The success rate of intraoperative ultrasound-guided percutaneous hepatic bile duct puncture was 100% followed with the success rate of hepatocholangiostomy was 100%. Although 1 (1/44) patient showed significant bleeding during choledochoscopic lithotripsy and was converted to open choledochotomy for stone extraction, 43 patients completed IUG-PTCSL with the rate of phase I surgical stones removal was 81.40% (35/43), whereas the stones removal rate of LC-L was 66.67% (10/15). There was not statistically significant difference between them (p = 0.067). Both the groups showed no significant complications with the postoperative hospital stay of 8 (6, 10) days and 10 (8, 11) days, respectively, and the difference was statistically significant (p = 0.028). Intraoperative ultrasound-guided percutaneous transhepatic cholangioscopy might be a safe and reliable ideal method for bile duct stones with the advantages of rapid recovery for patients. Intraoperative ultrasound-guided percutaneous hepatocholangiostomy may be the key technique for the successful completion of the surgery.

Extrahepatic Biliary Tract Variations is an Effect for Acute Calculous Cholecystitis.

To evaluate the anatomy of the extrahepatic bile duct and to reveal its importance in the formation of acute calculous cholecystitis (ACC). Case-control study. Department of General Surgery and Radiology, Kanuni Sultan Suleyman Training and Research Hospital of the University of Health Sciences, Turkey, between January 2016 and December 2021. The data of the patients treated with ACC were analysed on MRCP by an experienced radiologist. The patients were divided into two groups; asymptomatic gallstones (AsGS, control group) and ACC. The cystic duct, common hepatic duct, and common bile duct lengths and variations in cystic duct opening were measured. Receiver operating characteristics (ROC) analysis was conducted to define a cut-off value and compared categorical results of the two groups by Mann-Whitney U test. One-hundred and seventy-three patients were analysed, one-hundred and seven were females, and 66 were males. The median age was 46 years in the AsGS group and 53 years in the ACC group. It was statistically significant that ACC had a higher median age value than AsGS (p=0.014). In the analysis of extrahepatic variations, cystic duct, common hepatic duct, and common bile duct length, were statistically longer in the calculous cholecystitis group (p<0.001, p=0.022, and p=0.019 respectively). ROC analysis was performed for cystic, common hepatic, and common bile duct length, respectively. Cut-off values ​​were 30.5 mm, 36.5 mm, and 42.5 mm. Extrahepatic bile duct variations are of critical importance in ACC surgery. In the data, as the cystic duct and common bile duct lengthens, the possibility of ACC increases. There is need for studies with larger samples. Acute calculous cholecystitis, Extrahepatic biliary tract, Anatomical variations, Cholelithiasis.

Hepatic and Extrahepatic Fascioliasis Mimicking Colon Cancer with Hepatic Metastasis

&lt;i&gt;Fascioliasis hepatica&lt;/i&gt; is a rare parasitic infection affecting the hepatobiliary system. On the imaging examination, it presents as multiple hepatic abscesses and bile duct dilatation. Extrahepatic fascioliasis of the gastrointestinal tract is a rare condition, resulting from the duodenal migration of fasciola flukes. The current case showed both hepatic and colonic masses, mimicking colon cancer with hepatic metastasis. However, diagnostic clues from multimodality approaches, especially in combination with magnetic resonance imaging, led to an accurate diagnosis of hepatic and extrahepatic fascioliasis.

Increasing Living Liver Donor Pools: Liver Paired Exchange Versus ABO-incompatible Living Donor Liver Transplantation.

Increasing Living Liver Donor Pools: Liver Paired Exchange Versus ABO-incompatible Living Donor Liver Transplantation.

Laparoscopic donor and recipient hepatectomy followed by robot-assisted liver graft implantation in living donor liver transplantation

Minimally invasive surgery has been introduced for liver transplantations. Although laparoscopic or robot-assisted living donor hepatectomy is being used, minimally invasive surgery is rarely performed in recipients during liver transplantation. A 63-year-old patient (body mass index: 21.9kg/m2 ) with primary biliary cirrhosis underwent total laparoscopic explant hepatectomy, followed by robot-assisted liver engraftment using advanced technological innovations. The total operation time for the recipient was 12h 20min, including laparoscopic explant hepatectomy (140min) and robot-assisted engraftment (220min). Achieving hepatic and portal vein anastomoses consumed 35 and 28min, respectively. The hepatic artery anastomosis and bile duct reconstruction took 83 and 66min, respectively. The estimated blood loss was 3600ml. The warm and cold ischemic times were 87 and 220min, respectively. The patient received 10 units each of red blood cells and fresh frozen plasma during the surgery and recovered from early allograft dysfunction after liver transplantation. This case study suggests that laparoscopic explant hepatectomy followed by robot-assisted engraftment is feasible in selected recipients only. We obtained informed consent for this innovative procedure from the patient and from her living donor.

The Effect of Microcirculation Disturbance of Peribiliary Vascular Plexus on Hepatic Bile Duct Epithelial Cells in Rats Undergoing Liver Transplantation and Postoperative Rejection Reduction by Nanocarrier Mediation.

This study was to investigate the effect of microcirculation disturbance of PVP on HBD epithelial cells in rats undergoing liver transplantation and to explore the postoperative rejection reduction by nanocarriers mediation. For this aim, adult male rats weighing 210-250 g, were fed cleanly and were subjected to liver transplantation. 3 days after the surgery, the rats were randomly divided into three groups based on different intervention factors: group A (HAL), group B (HAMI combined with HAL), and group C (control). The three groups of rats were divided into three subgroups according to the duration of the University of Wisconsin (UW) solution (UW time) used to preserve the donor organs for transplantation, which were 2h, 8h, and 16h, respectively. In addition, the RNA sequence of rat class-II transactivator (CIITA) the rat was searched, and the target interference sequence was designed concerning the RNA. Results showed that the carrier nanoparticles were spherical without obvious oxygen vacancies, the distribution was relatively tight and concentrated, and the main particle size was 50-140 nm. As the mass ratio of HGPAE to DNA increased, the mobility speed of the nanocarrier/shRNA plasmid complex decreased due to the decrease in surface charge. When the mass ratio reached 90:1, the mobility of the complex was completely blocked, suggesting that the DNA was completely compounded. The counts of PCNA, CK-19, F-VIII-Ag, VEGFA, VEGFB, and VEGFC in the 3 groups all showed a downward trend with the increase of UW time; the count in group B was lower than that of groups A and C. In the PCNA count statistics, there was no obvious difference between group A and group B at UW8h, but there were differences in contrast to group C (p<0.05). It was concluded that the blood supply of the microcirculation of the PVP was extremely important for the transplanted liver tissue. When the blood vessels around the HBD of the rat were completely ischemic, the HBD epithelial cells became the most important target of damage, and the proliferation and changes of the HBD epithelial cells can be directly observed. In addition, the nanocarrier-mediated genes were applied to discuss postoperative rejection. The expression of class-II MHC-II gene in nanocarrier CIITA-shRNA was inhibited, which interfered with the recipient's immune recognition of the graft, thereby reducing the intensity of the rejection reaction and relieving the rejection reaction.

Sphincter of Oddi dysfunction.

Sphincter of Oddi dysfunction (SOD) is a benign non-tumoral disorder of the major papilla. It occurs mainly after cholecystectomy but can also occur before surgery. Biliary pain and biliary colic are the most frequent symptoms although recurrent pancreatic pain or pancreatitis can also be presenting symptoms. In about half of the cases, there is a fibrotic stricture of the sphincter of Oddi, probably secondary to the passage of biliary stones, while in the remaining half, the syndrome is due to ampullary motility disorders. The diagnosis of SOD first requires exclusion of choledocholithiasis or ampullary tumor, by means of ERCP, endoscopic ultrasound or magnetic resonance imaging. Findings on biliary manometry will establish the diagnosis, but this technique is performed less and less often because its high risk of inducing pancreatitis discourages its use as a diagnostic procedure. Biliary scintigraphy offers a risk-free alternative albeit with lower sensitivity. Medical treatment relies on the administration of trimebutine and nitroglycerine when pain occurs. Their efficacy is moderate. Sometimes patients are referred for endoscopic sphincterotomy. Endoscopic treatment should be performed only for patients with biliary pain associated with hepatic function disorders and/or bile duct dilatation. Practicians and patients should be aware that endoscopic sphincterotomy in this clinical setting is associated with a high risk of pancreatitis and its efficacy is limited in patients with pain but without laboratory anomalies or dilatation of the biliary duct (type III Milwaukee classification). Patients with Milwaukee classification type III disorders have mostly functional complaints or psychosocial disabilities and require only medical management.

Postoperative Adjuvant Transarterial Chemoembolization Plus Tyrosine Kinase Inhibitor for Hepatocellular Carcinoma: a Multicentre Retrospective Study.

PurposeThis study aimed to assess the efficacy and safety of adjuvant transarterial chemoembolization (TACE) plus tyrosine kinase inhibitor (TKI) treatment in patients with hepatocellular carcinoma (HCC) with a high risk of early recurrence after curative resection.Patients and MethodsPatients from multiple centres were divided into postoperative adjuvant TACE with (n=57) or without (n=142) TKI administration groups. The disease-free survival (DFS) curve was depicted by the Kaplan–Meier method, and the difference between the two groups was tested using the log rank test. Univariate and multivariate Cox analyses were performed to identify independent risk factors for DFS. Additionally, three propensity score analyses were performed to minimise the potential confounding factors to facilitate a more reliable conclusion. Adverse events (AEs) were assessed according to the Common Terminology Criteria for Adverse Events, version 4.0.ResultsThe 1-and 2-year DFS rates of the TACE plus TKI treatment group were 45.5% and 34.9%, respectively, which were significantly better than those of the TACE alone group (26.8% and 18.3%, respectively). Multivariate analysis identified adjuvant TACE plus TKI treatment as an independent prognostic factor for DFS (hazard ratio: 0.611, 95% confidence interval: 0.408–0.915, P=0.017). Further analysis based on the various propensity score methods yielded similar results. Subgroup analysis showed that patients with tumour diameter ≥5 cm, tumour number <3, absence of hepatic vein tumour thrombus and bile duct tumour thrombus, ruptured tumours, and stage IIIB could benefit more from TACE plus TKI treatment (all P<0.05). Some patients (33.33%) experienced grade ≥3 AEs in the TACE plus TKI group.ConclusionTACE plus TKI treatment can reduce the incidence of early recurrence with tolerable adverse events in HCC patients at high risk of recurrence after hepatectomy and may be an appropriate option in postoperative anti-recurrence treatment.