Incidence Of Cholangitis Research Articles

Modified method of hepatic portal choledochoplasty to treat benign strictures of hilar biliary ducts

Roux-en-Y hepaticojejunostomy (RYHJ) is usually used to treat benign strictures of hilar bile ducts. However, RYHJ might also induce ascending cholangitis and recurrent hepatolithiasis. The present study aims to introduce a modified hepatic portal choledochoplasty with a pedicled graft of gallbladder (HPC) to treat this disease. One hundred and forty-nine patients, who had undergone HPC or RYHJ from January 1997 to January 2006 in our institutions, were included in this study, and the clinical data were retrospectively collected and analyzed. The incidences of perioperative bile leakage and inflammatory ileus in patients treated with HPC were slightly lower than RYHJ without significant difference (1.89% vs 2.08% and 3.77% vs 5.21%, both P > 0.05). However, in a long-term follow up, patients treated with HPC had significantly lower incidences of cholangitis and recurrent hepatolithiasis (5.66% and 3.77%, respectively) than those treated with RYHJ (cholangitis, 21.88%; hepatolithiasis, 16.67%; both P < 0.05). Compared to RYHJ, HPC is a safer and more efficient method to treat benign strictures of hilar biliary ducts. It preserves the sphincter of Oddi and normal biliary duct pressure, thus avoiding bile reflux into the bile duct.

Intraductal Stent (“Inside Stent”) Placement for Post Liver Transplant Duct-to-Duct Anastomotic Biliary Strictures: A Feasibility Study

Introduction: Placement of a biliary stent entirely within the bile duct above the intact biliary sphincter (“inside stent”) has been shown to decrease the incidence of stent occlusion in animal studies. Biliary sphincter preservation may reduce biliary bacterial colonization and resultant stent occlusion, and also decrease sphincterotomy related complications. Aim: To assess the feasibility of inside stent placement for anastomotic biliary strictures after liver transplantation with duct-to-duct anastomosis. Methods: Patients found to have an anastomotic biliary stricture during ERCP underwent inside stent placement. Biliary endoprostheses (8.5 Fr-10 Fr 5 cm) with one internal flap and with the distal flap removed to allow passage of the stent above the papilla were placed endoscopically during ERCP. The entire stent was intraductal, straddling the stricture, with its distal end above the biliary sphincter. A 7 cm long 2.0 prolene suture was affixed to the distal side-hole of the stent to facilitate removal of the stent. After stent deployment the suture traversed the papilla with its distal end in the duodenum. Results: An inside stent was placed in 10 patients with anastomotic biliary strictures and abnormal liver tests after liver transplantation. Median duration of stenting was 69.5 days (4-113 days) before patients underwent a scheduled follow-up ERCP for stent removal. At subsequent ERCP, normalization of, or >50% improvement in AST, ALT, alkaline phosphatase and total bilirubin was seen in 6/10 (60%), 6/10 (60%), 8/10 (80%) and 9/10 (90%) patients respectively. Stent occlusion based on the 10 cm water cup test was seen in one asymptomatic patient after 83 days. There was no incidence of cholangitis, pancreatitis, bleeding or perforation after inside stent placement or removal. Stents were removed by grasping the suture with a rat-tooth forceps to remove the stent from the duct and then subsequently snared. The suture was pulled off the stent in 1 case and the stent was then removed from the duct with a rat-tooth forceps. At follow-up ERCP, 9 of 10 stents were noted to be in good position (1 stent migrated upstream above the stricture). Of the 9 patients with improvement in bilirubin after inside stenting, 3 patients required further endoscopic therapy (2 with sphincterotomy and transpapillary stenting and 1 with biliary sphincterotomy alone). Conclusions: Biliary inside stent placement is a safe, feasible, sphincter-preserving option for therapy of anastomotic biliary strictures after liver transplantation. Further studies comparing inside stents with standard transpapillary stents in the post-transplant setting are required.

Surgical Complications and Long-Term Outcome of Different Biliary Reconstructions in Liver Transplantation for Primary Sclerosing Cholangitis—Choledochoduodenostomy versus Choledochojejunostomy

Choledochojejunostomy (CJS) is commonly used for biliary reconstruction in liver transplantation for primary sclerosing cholangitis (PSC). We alternatively performed choledochoduodenostomy (CDS) and side-to-side choledochodocholedochstomy in a large cohort of patients. Fifty-one patients with PSC, transplanted between 1988 and 2000, were analyzed retrospectively. Biliary reconstruction was CDS in 25 (49%), CJS in 20 (39%) and CC in 6 transplantations (12%). Biliary leaks occurred in the early follow-up (< or =41 days) only in CDS patients (20%). However, in the late follow-up (>4 months), stricturing of anastomosis was found once in CDS (4%) and CJS (5%). Later (>9 months), intrahepatic bile duct strictures were diagnosed in four CDS (16%), one CJS (5%) and one CC (17%) patient(s). In 48% of CDS (12/25), 60% of CJS (12/20) and 17% of CC (1/6) at least one incidence of cholangitis was observed. Overall, biliary complication rates were significantly higher in CDS (40%) than CJS (10%) and CC (17%); of those none in CC and 12% in CDS were anastomosis-related. Graft/patient survival showed no significant differences among groups. Based on our results we consider CJS the standard method for biliary reconstruction in PSC; however, in selected cases where CJS is difficult to accomplish because of previous surgery or for retransplantation, CDS may present an alternative technique.

Effect of corticosteroid therapy on outcomes in biliary atresia after Kasai portoenterostomy

Purpose This study tests the hypothesis that steroid administration improves the outcome of biliary atresia (BA) by evaluating the efficacy of postoperative steroid use on surgical outcomes in infants with BA. Methods Steroid use and outcomes in patients with BA were retrospectively analyzed at a tertiary pediatric hospital. Institutional review board approval was obtained. Results Kasai portoenterostomy (PE) was performed in 43 patients with BA treated from 1992 to 2004 (16 boys and 27 girls). Twenty-one PE patients received steroids and 22 did not. Portoenterostomy was successful in 24 patients (55.8%) with consistent serum bilirubin less than 2 mg/dL. Sixteen (66%) received postoperative steroids. A normal postoperative bilirubin was achieved at 6 months in 16 (76%) of 21 patients with steroids compared with 8 (37%) of 22 in untreated controls (Fisher's Exact test, P = .01). Of the 43 patients, 19 (44%) required liver transplantation, including 7 (37%) of 19 with steroids vs 12 (63%) of 19 without ( P = .2). Twenty-eight infants developed cholangitis (fever with and without changes in hepatic function): 25 after PE and 3 after transplant. Of the 25, 12 (48%) received steroids. Seven died (16%) (range, 7 months to 4 years): 2 while awaiting transplantation (received steroids) and 5 after transplantation (1 received steroids and 4 were untreated). Survival was 86% (18/21) in patients with steroids and 82% (18/22) in those without. Transplant survival (74%) was comparable to previously reported historical controls (82%). Conclusions The Kasai PE continues to be the procedure of choice in infants with BA younger than 3 months. A significantly improved clearance of postoperative jaundice and lower serum bilirubin levels were observed in patients receiving steroids. However, steroids had no effect on the incidence of cholangitis, need for liver transplantation, and overall survival. A prospective study with standardized dose and length of steroid administration and longer period of follow-up is necessary to more accurately assess the effectiveness of steroids after PE.

Therapeutic aspects of radio-isotopes in hepatobiliary malignancy

Liver tumours frequently present at a late stage and only a minority of patients are likely to benefit from resection or transplantation. Inoperable tumours carry a grave prognosis. External beam irradiation of the liver is dose-limited by the radiosensitivity of hepatocytes, particularly in the presence of cirrhosis, but internal radiation using radio-isotope sources can achieve more selective irradiation of the chosen field. Sealed sources are dose-limited by their effects on surrounding tissues, whereas with unsealed sources the dose of radio-isotope administered is limited by bone marrow suppression. Iridium-192 wires are most frequently employed as a sealed intracavitary source. They may be inserted surgically, transhepatically or endoscopically. Doses of up to 60 Gy can be delivered to a malignant biliary stricture without damage to the surrounding parenchyma. The incidence of cholangitis is low if treatment is administered after insertion of an endoprosthesis. Unsealed radio-isotope sources may be injected directly into the tumour, administered embolically via the hepatic artery in the form of microspheres or lipid droplets, or given via parenteral infusion attached to tumour-specific antibodies. Of these vehicles, the lipid agent Lipiodol appears to be the most effective and can deliver a potentially lethal dose of radiation to small tumours. Host reaction to the injected antibody remains a major drawback to the use of monoclonal antibodies as targeting agents. Iodine-131 is a beta- and gamma-emitter, producing a local tumoricidal effect and allowing accurate dosimetry by means of external scintigraphy. Yttrium-90 is a pure beta-emitter with a greater maximum beta energy and cytotoxic range; however, it is retained in bony tissues, resulting in a dose-related risk of marrow suppression. Bone absorption cannot be measured by external imaging owing to the absence of gamma emission. This lack of accurate dosimetry, coupled with the toxic side-effects of yttrium treatment, make iodine-131 the current isotope of choice.

Palliation of irresectable hilar cholangiocarcinoma with biliary drainage and radiotherapy.

Twelve patients with irresectable or recurrent hilar cholangiocarcinoma were treated with internal biliary drainage followed by intraluminal (iridium-192) and external-beam radiotherapy. Biliary drainage was accomplished by means of a combined surgical and interventional radiological approach. Initial biliary decompression was performed surgically by tumour resection, intrahepatic biliary enteric bypass or distal biliary-enteric anastomosis with a temporary stent. Maintenance of internal biliary drainage and application of intraluminal radiotherapy were accomplished radiologically with the use of percutaneous dilatation and metallic expandable biliary endoprostheses. Median survival was 14.5 months; all 12 patients survived for at least 6 months. Early complications during radiotherapy were minor and included two patients with cholangitis and one with transient haemobilia. Jaundice was relieved in ten of 12 patients, while episodes of cholangitis were seen during long-term follow-up in 11 (median 1.5 episodes per patient). Internal biliary drainage, in conjunction with radiotherapy, appears to be safe and effective palliation of irresectable or recurrent hilar cholangiocarcinoma. Patients can maintain a reasonable quality of life with an acceptable incidence of cholangitis, without the hindrance of external drainage devices.

The Role of Ciprofloxacin in Prolonging Polyethylene Biliary Stent Patency: A MultiCenter, Double-Blinded Effectiveness Study

Plastic stents are the mainstay of the palliation of malignant jaundice but are complicated by recurrent obstruction. Previous trials have failed to demonstrate any improvement in patency with the use of antibiotics. Patients with malignant jaundice were randomized in a double-blind fashion, after polyethylene stent insertion, to receive ciprofloxacin or placebo. After successful stent decompression, there were 50 patients in the treatment arm and 44 in the placebo. There were 14 (33%) episodes of stent occlusion in the ciprofloxacin group versus 23 (49%) in placebo (chi(2) test, P=0.115). There was no significant difference in patency (log-rank test, P=0.17). There were significantly fewer episodes of cholangitis with ciprofloxacin: 10 (23%) versus 21 (42%) in the placebo (P=0.047). The ciprofloxacin group also demonstrated a significant improvement in the Social Function domain of the SF-36 Quality of Life Survey at 1 month (paired T test, P=0.03). The other domains of the SF-36 were not different, nor was survival (log rank, P=0.80). There is insufficient evidence to show that prophylactic ciprofloxacin can prolong plastic biliary stent patency. The observed trends suggest that ciprofloxacin significantly decreases the incidence of cholangitis and results in improvements in certain aspects of quality of life.

Periportal edema and necrosis as diagnostic histological features of early humoral rejection in ABO-incompatible liver transplantation.

Humoral rejection caused by antidonor blood group A/B antibodies is one of the most important obstacles for successful ABO-incompatible liver transplantation. However, no specific morphologic features of liver biopsies to distinguish humoral rejection from other conditions such as ischemia or sepsis have been satisfactorily documented. To histologically clarify the early changes in humoral rejection, we studied 41 cases of living donor ABO-incompatible liver transplantation whose allograft biopsies during the first episode of suspected acute rejection were available within the first postoperative month. Postoperative isohemagglutinin IgM titers were x64 or more in 21 patients (51%; high-titer group) and less than x64 in 20 cases (49%; low-titer group). In the high-titer group, elevation of postoperative titers x64 or more occurred within postoperative days 5.7 +/- 4.1 (range: 1-17). An increase in the incidence of cholangitis was observed in the high-titer group (90% vs. 30%, P <.0001), as well as poorer overall graft survival than in the low-titer group (38% vs. 70%, P <.05). Seven biopsies obtained from the high-titer group within 3 days after the onset of elevation of the antibody titers and one biopsy obtained at the peak of the antibody titers demonstrated periportal edema and necrosis, neither of which was found in the low-titer group. All grafts of these patients caused massive hepatocyte necrosis or severe biliary complications. In conclusion, a high morbidity rate of ABO-incompatible liver transplantation is associated with high postoperative levels of antibody titers. Periportal edema and necrosis observed during elevation of antibody titers can be regarded as histological indications of early changes in severe humoral rejection.

Five- and 10-year survival rates after surgery for biliary atresia: a report from the Japanese biliary atresia registry

Purpose The aim of this study was to elucidate the epidemiology and short- and long-term results of biliary atresia in Japan analyzing the data of the Japanese Biliary Atresia Registry (JBAR). Methods In 1989, the Japanese Biliary Atresia Society started a nationwide registry, JBAR, to investigate all aspects of biliary atresia. A total of 1,381 patients, 863 girls, 507 boys, and 11 unknown, were registered between 1989 and 1999. JBAR includes an initial and follow-up questionnaires. Using these patients’ data, the incidence, sex distribution, associated anomalies, the type of obstruction, the type of operation, and the surgical results were evaluated. The 5- and the 10-year results of 735 patients who were registered initially in or before 1994 also were analyzed. Results The incidence of biliary atresia was 1 in 9,640 live births. One hundred sixty-four patients (11.9%) had type I atresia of the common bile duct, 34 (2.5%) had type II atresia of the hepatic ducts, and 1,162 (84.1%) had type III atresia at the porta hepatis. Congenital associated anomalies were found in 19.6% of the patients including 33 cases associated with polysplenia. Impact of the age at operation on bile flow was not clear until 90 days of age, and after 90 days the bile flow rate worsened. The original Roux-en-Y procedure had been used in more than 50% of the patients since 1995. In 1999, 96% of the patients underwent the original Roux-en-Y procedure or the Roux-en-Y with an intestinal valve, and only 3 patients (3.5%) underwent other modifications. There were no significant differences in either the rate of disappearance of jaundice or the incidence of cholangitis among these 3 procedures. Of the 735 patients registered in or before 1994, 19 patients (2.6%) were lost to follow-up. The 5-year survival rates of patients registered in 1989, 1990, 1991, 1992, 1993, and 1994 were 62%, 64.5%, 61.3%, 59.0%, 58.7%, and 52.7% without liver transplantation (LTx), and 69.4%, 74.2%, 75.2%, 79.5%, 78%, and 78.3% with LTx, respectively. Although the overall 5-year survival rate changed from 69.4% to 78.3%, the difference was not statistically significant. According to the 10-year follow-up results of the 108 patients initially registered in 1989, 72 (66.7%) and 57 (52.8%) survived with and without the aid of LTx, respectively. Conclusions The overall 5- and 10-year survival rates were 75.3% (553 of 734) and 66.7% (72 of 108), respectively. In spite of the increasing number of survivors after LTx, there was no significant improvement in the 5-year survival rate. It was shown that the JBAR system was functioning well with only 19 patients lost to follow-up among the 743 patients registered from 1989 to 1994.

Nitinol stents for palliative treatment of malignant obstructive jaundice: should we stent the sphincter of Oddi in every case?

To evaluate the necessity of metallic stenting of the sphincter of Oddi in malignant obstructive jaundice when the tumor is more than 2 cm from the papilla of Vater. Sixty-seven self-expandable biliary stents were used in 60 patients with extrahepatic lesions of the common hepatic or common bile duct and with the distal margin of the tumor located more than 2 cm from the papilla of Vater. Stents were placed above the papilla in 30 cases (group A) and in another 30 with their distal part protruding into the duodenum (group B). The 30-day mortality was 15%, due to the underlying disease. The stent occlusion rate was 17% after a mean period of 4.3 months. No major complications were noted. Average survival was 132 days for group A and 140 days for group B. In group A, 19 patients survived < or = 90 days and in eight of these, cholangitis occurred at least once. Of 11 patients in group A with survival > 90 days, only two developed cholangitis. In group B, 13 patients who survived < or = 90 days had no episodes of cholangitis and in 17 with survival > 90 days, cholangitis occurred in three. There is a statistically significant difference (p < 0.05) regarding the incidence of cholangitis in favor of group A. In patients with extrahepatic lesions more than 2 cm from the papilla and with a relative poor prognosis (< or = 3 months), due to more advanced disease or to a worse general condition, the sphincter of Oddi should also be stented in order to reduce the postprocedural morbidity.

Analysis of survival and morbidity after pediatric liver transplantation with full-size and technical-variant grafts.

To alleviate the shortage of size-matched whole-donor organs, too-large-for-size cadaveric donor grafts are modified by liver resection techniques. These modifications result in technical-variant liver transplantation (TVLTx). Patient and graft survival rates after TVLTx are considered comparable to those after full-size liver transplantation (FSLTx). However, morbidity after TVLTx is often underexposed. The aim of this study was to analyze the results of FSLTx and TVLTx in terms of patient and graft survival rates and morbidity. A consecutive series of 97 primary and elective pediatric liver transplantations performed in a single center was retrospectively analyzed. Forty-seven children had a FSLTx and 50 a TVLTx (38 reduced-size liver grafts and 12 split-liver grafts). The overall median follow-up period was 3.5 years. There were no differences in patient and graft survival rates between FSLTx and TVLTx. However, after TVLTx there was a significantly higher complication rate (1.42 vs. 0.81 after FSLTx). TVLTx is more hampered by biliary complications (30% vs. 17%), expressed by a higher incidence of cholangitis and leakage of bile. These complications led to a significantly higher incidence of sepsis (44% vs. 19%) and a significantly higher intervention rate (0.40 vs. 1.28) after TVLTx. There was no difference in the incidence of retransplantations between FSLTx and TVLTx. Both FSLTx and TVLTx offer the same prognosis in terms of patient and graft survival rates for children after a primary and elective liver transplantation. However, TVLTx has a higher morbidity.

Ruolo Dell'Endoscopia Nella Palliazione Del Carcinoma Pancreatico

The incidence of pancreatic cancer continues to increase and, although improving of diagnostic techniques, the prognosis is very poor with 5-year survival less than 5% and high mortality cancer rate. Neural and lymphatic micrometastases appear in early stages and curative resection is possible in few selected cases; in these patients there is a high local recurrence rate and a low median survival. Most patients with pancreatic cancer need palliative care of the obstructive jaundice (90%), duodenal stenosis and abdominal pain; endoscopic procedures have an important role in the treatment of these patients. Endoscopic placement of plastic biliary stents is a safe and efficient technique to perfom a biliary drainage with a short hospital stay. The use of metal stent, instead of plastic prosthesis, improve median patency of the prosthesis with a low incidence of cholangitis, but they should be used only in patients with a life expectancy of more than six months, because of their high costs. Laparoscopic gastro-entero-anastomosis is a valide alternative to laparotomic procedure in the treatment of the duodenal stenosis, with a shorter hospital stay and a lower morbidity rate. The endoscopic treatment of abdominal pain with pancreatic endoprosthesis placement or with endosonography-guided celiac plexus neurolysis is an alternative approach to radiotherapy and analgesic drugs.

Induction and Persistence of Immune-Mediated Cholangiohepatitis in Neonatally Thymectomized Mice

The availability of recombinant autoantigens allows the experimental study of the relationships between primary biliary cirrhosis (PBC) and mitochondrial antigens. We took advantage of these recombinant autoantigens and attempted to induce autoimmune cholangitis by immunizing neonatally thymectomized (NTx) lipopolysaccharide (LPS)-treated A/J mice, known to be prone to organ-specific autoimmune diseases. We employed a recombinant protein containing a dual-headed molecule that coexpresses the immunodominant epitope of the E2 subunits of the pyruvate dehydrogenase complex and the branched-chain keto-acid dehydrogenase complex. We report herein that an immune-mediated cholangiohepatitis was induced by such immunization and the concurrent injection of LPS into NTx mice. The incidence of cholangitis was 79% in the NTx, immunized, LPS group compared to 14% in the NTx, nonimmunized, LPS group. The histopathology ranged from mild to severe and included bile duct damage, focal hepatic necrosis, and endotheliitis, but no granulomas. Moreover, almost all such lesions persisted for 12 weeks after the discontinuation of immunization and LPS injections in the NTx mice. Interestingly, we were successful (89%) in transferring the cholangiohepatitis by injection of liver infiltrating mononuclear cells from the NTx, immunized, LPS mice into congenic nonimmunized NTx mice; such lesions could not be transferred with spleen cells. Although the pathology is not typical of PBC, this model offers a unique venue for the study of immune-mediated hepatobiliary injury.

The role of therapeutic endoscopy associated with extracorporeal shock-wave lithotripsy and bile acid treatment in the management of Caroli's disease.

Caroli's disease causes relapsing episodes of cholangitis due to the presence of intrahepatic lithiasis. Strategies for cholangitis prevention are still widely debated. Ursodeoxycholic acid, hepaticojejunostomy, partial hepatectomy, or transplantation, have all been proposed as therapeutic options. The aim of this study was to evaluate the role of therapeutic endoscopy, and especially endoscopic sphincterotomy (ES), in the management of Caroli's disease. Between 1983 and 1995, six patients with Caroli's disease (mean age 52, range 17-75) underwent endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis. Sphincterotomy was performed if common bile duct stones were present. Extracorporeal shock-wave lithotripsy, (ESWL) or intraductal electrohydraulic lithotripsy (IEL) were performed if necessary. The mean number of endoscopic sessions per patient was four (range three to seven). Sphincterotomy was performed in five patients and cholangioscopy in three. ESWL was performed twice in each of four patients. A Strecker expandable metal stent was placed in one patient to maintain sphincterotomy patency. In one patient, two sessions of IEL and pulsed laser were carried out. Complete clearance of intrahepatic stones was achieved in four of the six subjects (66.6%) and partial clearance in two patients. No morbidity or mortality was observed. During the follow-up (mean 6.2 years; range: 2.1-16.3), only two patients had acute cholangitis at nine months and three years, respectively, after the endoscopic treatment. Both had residual intrahepatic stones left after the initial endoscopic attempt at clearance. ERCP is a necessary diagnostic procedure which should always be carried out in patients with Caroli's disease. Our experience shows that ES does not result in an increased incidence of cholangitis and that therapeutic endoscopy allows complete clearance of intrahepatic stones in the majority of patients with unresectable symptomatic Caroli's disease. Nevertheless, the oncological risk in these patients remains unchanged, and they still have an increased risk of cholangiocarcinoma.

Gallstone pancreatitis: a prospective study on the incidence of cholangitis and clinical predictors of retained common bile duct stones.

The aim of this study was to define the incidence of cholangitis in gallstone pancreatitis, in the absence of cholangitis, to identify the clinical predictors of persistent common bile duct (CBD) stones at endoscopic retrograde cholangiography (ERCP) or at intraoperative cholangiography (IOC). A total of 122 consecutive patients with acute gallstone pancreatitis were prospectively evaluated for the presence of CBD stones as determined by elective ERCP or IOC. Urgent ERCP was restricted to patients with concomitant cholangitis. APACHE II scores and serial laboratory data were obtained. Four (3%) patients had cholangitis and all underwent urgent ERCP successfully. Eighteen (15%) patients without cholangiogram were excluded. The remaining 100 patients underwent elective ERCP or IOC on a mean of hospital day 6.8. Twenty-one (21%) patients had persistent CBD stones. Univariate analysis detected significant differences in serum total bilirubin, ALT, and alkaline phosphatase levels between patients with and without persistent CBD stones. On multivariate analysis, serum total bilirubin on hospital day 2 was the best predictor of CBD stones. A serum total bilirubin level > 1.35 mg/dl had a sensitivity of 90.5% and specificity of 63%. Age, gender, mean APACHE II score, amylase, and presence of CBD dilation on ultrasound were not predictive of CBD stones. In patients with gallstone pancreatitis, 1) cholangitis is uncommon, and 2) the best clinical predictor of persistent CBD stones is serum total bilirubin on hospital day 2.

Gallstone Pancreatitis: A Prospective Study on the Incidence of Cholangitis and Clinical Predictors of Retained Common Bile Duct Stones

Objective: The aim of this study was to define the incidence of cholangitis in gallstone pancreatitis, in the absence of cholangitis, to identify the clinical predictors of persistent common bile duct (CBD) stones at endoscopic retrograde cholangiography (ERCP) or at intraoperative cholangiography (IOC). Methods: A total of 122 consecutive patients with acute gallstone pancreatitis were prospectively evaluated for the presence of CBD stones as determined by elective ERCP or IOC. Urgent ERCP was restricted to patients with concomitant cholangitis. APACHE II scores and serial laboratory data were obtained. Results: Four (3%) patients had cholangitis and all underwent urgent ERCP successfully. Eighteen (15%) patients without cholangiogram were excluded. The remaining 100 patients underwent elective ERCP or IOC on a mean of hospital day 6.8. Twenty-one (21%) patients had persistent CBD stones. Univariate analysis detected significant differences in serum total bilirubin, ALT, and alkaline phosphatase levels between patients with and without persistent CBD stones. On multivariate analysis, serum total bilirubin on hospital day 2 was the best predictor of CBD stones. A serum total bilirubin level > 1.35 mg/dl had a sensitivity of 90.5% and specificity of 63%. Age, gender, mean APACHE II score, amylase, and presence of CBD dilation on ultrasound were not predictive of CBD stones. Conclusion: In patients with gallstone pancreatitis, 1) cholangitis is uncommon, and 2) the best clinical predictor of persistent CBD stones is serum total bilirubin on hospital day 2.

Further experience with the antireflux valve to prevent ascending cholangitis in biliary atresia

Background/Purpose: The intussusception-type antireflux valve is a mechanism introduced by Nakajo, who reported the results of his initial 17 cases in 1990. This report summarizes our further experience with new patients, together with follow-up results of the cases previously reported by Nakajo. Methods: In total, 46 new patients who had biliary atresia underwent portoenterostomy at the authors' two units. The authors hoped to construct the intussuscepted antireflux valve in the Roux-en-Y loop, whenever possible, at the time of hepatic portoenterostomy. Results: Among the 46 patients, one case each was found to be too young or too old to have the valve constructed during the surgery. In another case, the Roux-en-Y loop became too short after repeated revisions of the portoenterostomy. In another patient, the valve was first constructed but later removed because of jejunal perforation near the valve. In the last patient, the valve was not constructed for unspecified reasons. The authors constructed the antireflux valve in 42 patients, but it was maintained in 41. In one case, the valve truly prevented reflux of the intestinal juice during an episode of intestinal obstruction. The valve was found to be incompetent in one patient 5 years after the initial surgery. Conclusion: The incidence of cholangitis was high in patients with postoperative cystic dilatation of the intrahepatic bile ducts, and low in those without it.

Endoscopic sphincterotomy for common bile duct stones: Impact of recent technical advances

Technical improvements, such as mechanical lithotripsy, stenting or nasobiliary drainage, and wire-guided cannulation, have reduced the risk of complications in endoscopic sphincterotomy. To determine the extent of this reduction in risk, we assessed the medical records of 1352 patients with common bile duct stones in whom the procedure was conducted. Complications examined were: acute cholangitis and pancreatitis. Stone clearance was achieved in 1256 patients (92.8%), with an overall morbidity rate of 7.7% and a mortality rate of 0.15%. One hundred and forty-two patients had stones with a diameter greater than 20mm; 97 of these patients did not undergo lithotripsy. Cholangitis occurred in 10 of these 97 patients (10.3%), whereas, in the 45 patients who underwent lithotripsy, there were no cases of cholangitis (P=0.02). Stone removal was not immediately accomplished or attempted in 396 patients. In 82 of these patients in whom a stent or a nasobiliary drain was placed in the common bile duct, the incidence of cholangitis was 1.2%, significantly less (P=0.045) than the incidence of 6.4% in the other 314 patients given no stenting or nasobiliary drain. To overcome difficult cannulation, precut sphincterotomy was conducted in 134 patients and wireguided sphincterotomy, a recently introduced procedure, was conducted in 55 patients. When the precutting technique was used, the incidence of acute pancreatitis was significantly higher (8/134; 6.0%) than that in the patients in whom the standard procedure was conducted, i.e., neither the precut technique nor wire-guided ES was used (23/1218; 1.9%) (P=0.008). There were no cases of pancreatitis in the 55 patients in whom wire-guided sphincterotomy was performed, although the difference was not statistically significant because of the small number of patients (P=0.06). Based on these findings, we conclude that improved technologies have led to a significant reduction of complications in endoscopic sphincterotomy.

The intussusception antireflux valve is ineffective in preventing cholangitis in biliary atresia

Cholangitis is the most common complication after portoenterostomy for biliary atresia. The construction of an intussusception valve in the Roux-en-Y limb of the portoenterostomy has been advocated as a means to ameliorate this complication. The authors reviewed the records of children who underwent portoenterostomy to assess the incidence and severity of cholangitis, as well as outcome. The children were divided into two groups according to whether they did not have (group I) or did have (group II) an antireflux valve in the Roux limb of the bilioenteric conduit. There were 19 children in each group. There were no significant differences between the groups with respect to age at time of portoenterostomy or length of follow-up (Table 1). Nine group I patients are alive and well; five died and five have had or are awaiting transplantation. In group II, 10 patients are alive and well, eight have had transplantation, and one is awaiting transplantation. Outcome with respect to death or the need for liver transplantation because of progressive hepatic failure is not different between the groups ( P = 1.0, Fisher's 2 × 2). The incidence of cholangitis was evaluated by comparing the average number of episodes of cholangitis during the follow-up period, the number of episodes per year, and the number of episodes in the first postoperative year (when this complication is most prevalent). Analysis of the data showed no difference in incidence between those with valved and nonvalved biliary conduits. The severity of cholangitis, judged by total length of antibiotic treatment, did not differ between the groups. It appears that the presence of an intussusception valve in the Roux-en-Y biliary conduit does not affect the incidence of cholangitis or the outcome after portoenterostomy, over short-term follow-up.

Outcomes of ileocolic conduit for biliary drainage in infants with biliary atresia; Comparison with Roux-en-Y type reconstruction

This study was undertaken to define the role of an ileocolic conduit that was devised as anti-reflux procedure in comparative study with Roux-en-Y type reconstruction in infants with biliary atresia treated at a single institution. The ileocolic conduit (IC) consisted of 30 cm of distal ileum anastomosed to the portahepatis and a 10-cm segment of ascending colon vented through the abdominal wall, which was later anastomosed to the second portion of the duodenum. In the Roux-en-Y type reconstruction (RY), 40 to 60 cm of jejunum was used for the hepatic limb. Twenty-three infants in group IC and 16 infants in group RY were entered in this study. Mean ages at definitive surgery were 65.3 ± 23.1 days for group IC and 65.0 ± 19.5 days for group RY. The two groups were compared for the postoperative outcomes in terms of bile excretion, incidence of cholangitis, esophageal varices, survival rate, and the effects on physical development. The follow-up ranged from 4 to 15 years. Bile excretion was obtained in all infants in both groups. Twenty infants (87.0%) in group IC and 10 infants (62.5%) in group RY became anicteric. Cholangitis occurred in 60.9% of group IC, compared with 83.3% for group RY, in which 6 infants required revision to complete diversion of Roux-en-Y limb (Suruga II). There was the same occurrence rate of esophageal varices for both groups. However, the varices tended to develop later in group IC (53.0 ± 18.4 months) than in group RY (12.7 ± 6.0 months) ( P < .02). The 4-year survival for group IC was 73.9%, compared with 43.8% for group RY ( P<.01). Among the survivors 77.3% of patients had a BAPI score of <50. A BAPI of <25, indicating good quality of life with near normal liver function, was seen in 53.3% of the patients in group IC, compared with only 28.6% in group RY. The patients in group IC had lower mean Z scores for height and weight (−1.9 ± 1.7, −0.8 ± 1.0) compared with the patients in group RY (−0.5 ± 1.5, +0.1 ± 1.1) at the time of last follow-up. The ileocolic conduit played a role in decreasing the morbidity of ascending cholangitis and improving the patient survival and quality of life, although some metabolic and physiological drawbacks were present.