Intrahepatic Tract Research Articles

Robotic Surgery for a Choledochal Cyst

Purpose: Choledochal cyst are a rare congenital disease, traditionally treated with a complete excision and biliary tract reconstruction. Out purpose is to show our first robotic excision of a Type I choledochal cyst with a Roux-en-y-hepaticojejunostomy reconstruction. Method: A 19 years old patient was sent to our consultation after the diagnosis of choledochal cyst during a laparoscopic procedure. The preoperative MRI showed a large cyst of 31 × 20 × 21 mm (T × AP × CC) with prominence of the main hepatic duct and intrahepatic tract, without solid components and conserved distal choledochus. Gallbladder polyps were also described, with a maximum diameter of 10 mm. Results: The surgery was performed by Davinci Xi Robot. Classic Colecystectomy associated with choledochal cyst disection was performed as usual. Distal section of Choledochus was closed with running suture. Hepaticojejunostomy was created using 4/0 monofilament, double running suture. Mechanical jejunojejunostomy was completed with endoGIA 45mm. Postoperative period without incidences, with a hospital stay of 5 days. Conclusion: Robotic assisted surgery for choledochal cyst are feasible, offers a high precision and allows a minimal invasive reconstruction.

Миниинвазивные вмешательства на внутрипеченочных путях под ультразвуковым контролем у пациентов с опухолями билиопанкреатодуоденальной зоны

Миниинвазивные вмешательства на внутрипеченочных путях под ультразвуковым контролем у пациентов с опухолями билиопанкреатодуоденальной зоны

Radiofrequency Ablation for Hepatic Malignancies: Is Needle Tract Cauterization Necessary for Preventing Iatrogenic Bleeding?

Objective: To evaluate whether iatrogenic hemorrhage can be prevented by intrahepatic tract ablation following radiofrequency ablation (RFA) therapy for hepatic malignancies. Methods: A retrospective cohort study analyzing a prospective database in a single institution was conducted. The incidence of postprocedural complications was compared in two groups: one with cauterization of the needle tracts after RFA and the other without. Results: The complication rates of intraperitoneal hemorrhage were 1.05% (4/380) and 0.92% (6/652) in the nonablation group and the ablation group, respectively (p = 0.90). All of these 10 patients with iatrogenic bleeding were classified as Child-Pugh grade A. Among the 15 hemodialysis patients in this study, hemorrhage was seen in 2 (13.3%), compared with 8 (0.79%) of the nonhemodialysis patients (p = 0.0002). There were no statistically significant differences in the incidence of other complications including pleural effusion, serous ascites, pneumothorax, hemothorax, hepatic infarction, bile duct injury and pericardial effusion between the two groups. Gastrointestinal perforation, peritonitis or tumor seeding were not observed. Conclusion: Our study found a high incidence of bleeding after RFA among hemodialysis patients. Irrespective of tract ablation being after RFA, iatrogenic hemorrhage appeared to be equivalent in this population.

Hepatic Hematoma After Islet Cell Transplantation

Hepatic Hematoma After Islet Cell Transplantation

Educational Exhibit Abstract No. 354 - Primary placement of a constrained transjugular intrahepatic portosystemic shunt: how we do it

Learning Objectives Three methods for placement of a primary constrained transjugular intrahepatic portosystemic shunt (TIPS) will be reviewed. Background TIPS creation is often complicated by hepatic encephalopathy. Medical management fails in approximately 5-10% of cases. In those patients, TIPS revision may be required by creating a flow-limiting stent using a variety of methods. To avoid the complication of hepatic encephalopathy, however, we occasionally place primary constrained stents during the initial TIPS creation, particularly if the indication for TIPS is refractory ascites. Clinical Findings/Procedure Details We take one of three approaches to creating a primary constrained TIPS. In one approach, a self-expanding 10 mm Gore-Viatorr stent graft is deployed and a 5-0 Prolene suture is tied around the midpoint. The modified graft is then crimped into a peel-away sheath and re-sterilized. After formation of the intrahepatic tract, the graft is deployed and balloon dilated. The suture creates a flow-limiting constriction which may be dilated and/or broken as needed to improve flow. Prolene is favored due to its high elasticity, which allows for balloon expansion. Another approach involves deploying the stent graft through a balloon-expandable bare metal stent. After accessing the portal vein, we place a short 6-8 mm bare metal stent within the intrahepatic tract. Once this stent is in place, the Viatorr stent graft is deployed within it and the entire assembly is dilated to the diameter needed. The outer stent maintains a constriction in the inner stent graft due to its higher radial force, and can be dilated at a later time. In the third technique, a balloon-mounted Atrium iCast stent graft is placed on a 10-French sheath and a 4-0 absorbable suture is tied around its midpoint. This stent is then crimped onto a balloon and deployed, with the suture serving as the constriction point. Dilation can be done at a future time if needed. Conclusion and/or Teaching Points Creation of a primary constrained TIPS can be readily performed, enabling a degree of control over reduction of the portosystemic gradient both at initial TIPS creation and at follow up. Whether these techniques result in a reduction of hepatic encephalopathy requires further investigation.

Improving survival in patients with decompensated cirrhosis

In theeducation program, we believe that initial success is important forlong-standing success. However, unexpected intraoperative bleed-ing can cause failure and frustration.Therefore, EUS performed byan expert before the beginner will be helpful to ensure successfulESD.ESD as a curative method for gastric neoplasms should beperformed all over the world and is rapidly being introduced.Preventing bleeding is an important factor for successful ESD, andthe risk is correlated with the status of submucosal vascularity. Inaddition to the role of EUS for diagnosing T and N staging ofgastric cancer, Kikuchi

Ultrasonography-guided percutaneous transhepatic portacaval shunt creation

We successfully created a percutaneous transhepatic portacaval shunt under ultrasonography (US) guidance in a 46-year-old man with refractory ascites. The shunt was created to salvage an attempt to create a transjugular intrahepatic portosystemic shunt (TIPS) that failed because of the elevated level of portal vein bifurcation due to alcoholic liver cirrhosis. Under US guidance, we simultaneously punctured the right branch of the portal vein and the inferior vena cava (IVC) using a two-step biliary drainage set. An Amplatz gooseneck snare was introduced transjugularly to retrieve the percutaneously inserted guidewire. The intrahepatic tract between the portal vein and the IVC was dilated using a balloon catheter, and a stent was placed in the tract. The patient showed complete resolution of ascites at discharge. We assume that our method is an alternative method for TIPS creation in patients with inadequate anatomical relations between the portal vein branches and the hepatic veins. This approach is thought to be feasible for patients with occluded or small hepatic veins.

Therapeutic effects of left-external lobe laparosopic resection on calculus of intrahepatic tract

肝内胆管结石临床常见.对于复杂性的左侧肝内胆管结石,病变肝段切除是最有效的治疗手段.温州医学院附属第一医院于2003年11月开始采用完全腹腔镜下左肝外叶切除治疗肝内胆管结石,至2008年10月已经成功进行了24例手术。

Management Strategy for Congenital Choledochal Cyst with Co-existing Intrahepatic Dilation and Aberrant Bile Duct As Well As Other Complicated Biliary Anomalies

The purpose of this study was to investigate and discuss imaging methods and management strategies for congenital choledochal cyst with co-existing intrahepatic dilation and aberrant bile duct as well as other complicated biliary anomalies. In this study we reviewed and analyzed 72 patients with congenital choledochal cyst, ranging in age from 15 days to 12 years old and who were seen at our hospital during the past 12 years, from January 1993 to October 2005. The image manifestation and clinical significance of patients with coxisting intrahepatic biliary dilation and aberrant bile duct were carefully examined during operation via MRCP, cholangiography and choledochoscope. Twenty-two cases (30.1%) presented with intrahepatic bile duct dilation and 12 of these were of the cystic type. That is, the orifice of the dilated intrahepatic tract that converged into the common hepatic duct showed membrane or septum-like stenosis. In 10 cases the dilation tapered off from the porta hepatis to the initiating terminals of the intra-hepatic bile ducts and was not accompanied by stenosis. An aberrant bile duct was observed in 2 of the cases. In 3 cases, the right and left hepatic ducts converged at the choledochal cyst. In conclusion, the imaging methods for intrahepatic bile duct dilation possess important clinical significance. Further, for hepatojejunostomy with radical excision of a choledochal cyst, additional operative procedures for intrahepatic stenosis, possible bile duct malformation and pancreaticobiliary common duct calculi can potentially reduce postoperative complications.

Doppler ultrasound for TIPS: does it work?

The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of complications of portal hypertension such as variceal hemorrhage and ascites is well established. However, TIPS has a limited patency due to dysfunction consisting in occlusion or stenosis of the intrahepatic tract or stenosis of the outflow hepatic vein. Timing of dysfunction cannot be predicted, so routine surveillance and percutaneous intervention are continuously required to maintain TIPS patency. Trans-shunt venography is the gold standard technique in TIPS evaluation, but it is expensive and invasive. Doppler ultrasound (DU) has been the most commonly used noninvasive tool in TIPS patency. Despite many reported series, its role remains controversial. After more than 10 years of experience with TIPS, we followed our patients with DU and trans-shunt venography to establish Doppler criteria of dysfunction and its accuracy in assessing shunt dysfunction.

TIPS: a new alternative for the variceal bleeder

Standard medical therapies for variceal bleeding secondary to portal hypertension (vasopressin, esophagogastric balloon tamponade and sclerotherapy) are associated with high rates of recurrent bleeding. Surgical shunting has a mortality rate of 15% to 50%. The transjugular intrahepatic portosystemic shunt offers a novel, minimally invasive procedure for nonsurgical portal decompression. Following catheterization of the hepatic vein from a jugular vein approach, a needle is directed fluoroscopically from the hepatic vein into a branch of the portal vein along an intrahepatic tract. The intrahepatic tract is then dilated and held open with a stainless steel stent delivered on a balloon catheter. This creates a portosystemic shunt entirely within the liver. The collective experience of more than 300 cases from several centers has been reported. The technical success rate for the transjugular intrahepatic portosystemic shunt is 92% to 96%. Thirty-day mortality rates range from 0% to 14%, with less than 3% attributed to procedural complications. Primary shunt patency is about 90%, with a secondary patency rate of 100%. Rates of encephalopathy and rebleeding are 9% to 14%. Ascites resolves in 80% to 90% of patients. The transjugular intrahepatic portosystemic shunt appears to be a safe and effective procedure for management of variceal bleeding and holds promise for becoming the treatment of choice for portal hypertension.

Nonsurgical production of intrahepatic portosystemic venous shunts in portal hypertension with the double lumen balloon catheter

A nonsurgical production of intrahepatic shungs between the left portal and left hepatic vein was evaluated in twelve dogs with acute portal hypertension. Dilatation of the intrahepatic tract was achieved by means of a double lumen balloon catheter introduced into the portal system with the transjugular approach. The shunts proved to be effective in immediate reduction of increased portal pressure and no significant complications were encountered.

Production of Nonsurgical Portosystemic Venous Shunts in Dogs by Transjugular Approach

Intrahepatic shunts between the left portal and hepatic veins were performed in 50 dogs (20 acute, 30 chronic experiments) using the transjugular approach with Dotter's coaxial catheter system. All shunts were occluded within two days; significant complications arose only after a shunt stayed in the animal a prolonged period. The intrahepatic tract wall was completely organized and fibrosed after three weeks.