Recurrence Of Jaundice Research Articles

Endoscopic stenting of bile ducts for preventing mechanical jaundice recurrence in gallstone migration

Aim. To study the reasons for stone migration from the gallbladder into the main bile ducts after endoscopic lithoextraction and to develop methods for preventing recurrent mechanical jaundice before performing the cholecystectomy.Material and methods. Delayed cholecystectomy was recommended for 328 patients with calculous cholecystitis and mechanical jaundice after endoscopic papillosphincterotomy, lithoextraction and restoration of adequate bile outflow. 23 patients were readmitted to hospital with recurrent mechanical jaundice caused by recurrent choledocholithiasis. All patients underwent duodenoscopy, endoscopic retrograde cholangiography and lithoextraction within 12 hours after admission. The size of the gallstones, the diameter of the cystic duct, the level of its insertion into the common hepatic duct, and the length of the previously performed papillotomy were considered as possible causes of recurrent choledocholithiasis.Results. Multiple gallstones of 2–4 mm and low cystic duct insertion into the common hepatic duct were detected in all 23 patients. An increase in the diameter of the cystic duct >5 mm was revealed in 18 patients. In 10 patients, the initial papillotomy was <8 mm.Conclusion. The factors predisposing to recurrent mechanical jaundice due to migration of gallstones into the bile duct and indications for its stenting after lithoextraction before cholecystectomy are ultrasound signs of multiple small gallstones, low insertion the dilated cystic duct into the bile duct, and partial, non-extended papillotomy.

Management of massive bilothorax post-percutaneous trans-hepatic biliary drainage

BackgroundIatrogenic bilothorax is an infrequent major complication of percutaneous trans-hepatic biliary drainage (PTBD) and optimal treatment remains under-reported. The authors herein describe a case of PTBD complicated by a massive bilous effusion.Case presentationAn 80-year-old male underwent PTBD due to malignant obstructive jaundice (total bilirubin 20.0 mg/dL). Following discharge, the patient was readmitted with severe dyspnea and recurrence of jaundice (total bilirubin 15.0 mg/dL). CT depicted the drainage catheter traversing the right costophrenic sulcus, complete obliteration of the right pleural space, no aerated right lung parenchyma and left mediastinal shift. The pleural effusion was successfully drained, and the biliary drainage catheter tract was sealed with Gelfoam pledgets and coils, to prevent bilopleural fistula formation and recurrence of the effusion.ConclusionsIn this case, a successful totally percutaneous management of iatrogenic bilothorax following PTBD is described. Due to the potential of rapid clinical deterioration and empyema formation, immediate evaluation and treatment are warranted. Prompt pleural drainage with antibiotic therapy and bile flow diversion from the pleural cavity are required.

Endoscopic ultrasonography-guided biliary drainage for malignant jaundice by using electrocautery-enhanced lumen-apposing metal stents (Hot-SPAXUS stent).

Biliary drainage with endoscopic retrograde cholangiopancreatography (ERCP) for tumoral jaundice fails in a certain percentage of patients. In these patients, endoscopic ultrasonography-guided lumen-apposing metal stents (LAMS) with electrocautery-enhanced (ECE) technology allows a single-step, radiation-free palliative treatment. We reviewed the data of patients who underwent choledochoduodenostomy with placement of ECE-LAMS (Hot-SPAXUS stent) after ERCP failure in a single tertiary center. Technical and clinical success rates were calculated and adverse events recorded. Data of 15 patients (8 male, median age 72 years) were collected. The procedure was technically successful in all patients, whilst clinical success was achieved in 14 (93.3%) patients. One (6.7%) patient presented delayed bleeding treated endoscopically. At follow up, stent occlusion with recurrence of jaundice occurred in 2 (13.3%) patients, due to food impaction (n=1), or neoplastic ingrowth (n=1). Our results suggest that the Hot-SPAXUS procedure is effective and safe for palliative treatment in patients with distal biliary malignant obstruction after failure of ERCP.

EUS-guided biliary drainage with LAMS for distal malignant biliary obstruction when ERCP fails: single-center retrospective study and maldeployment management.

EUS-guided biliary drainage (EUS-BD) with Lumen Apposing Metal Stent (LAMS) is a mini-invasive approach for jaundice palliation in distal malignant biliary obstruction (D-MBO) not amenable to ERCP, with good efficacy and not exiguous adverse events. From January 2015 to December 2019, we retrospectively enrolled all the EUS-BD with electrocautery-enhanced LAMS for biliary decompression in unresectable D-MBO and failed ERCP. Primary study aims were to evaluate technical/clinical success and AEs rate. In case of maldeployment, we estimated the efficacy of an intra-operative rescue therapy. Secondary aims were to assess the jaundice recurrence and gastric outlet obstruction symptoms. Thirty-six EUS-BD were enrolled over a cohort of 738 patients (ERCP cannulation failure rate was 2.6%): 31 choledocho-duodenostomy and 5 cholecystogastrostomy. A pre-loaded guidewire through the LAMS was systematically used in case of common bile duct ≤ 15mm or scope instability for a safe/preventive biliary entryway in case of intra-procedural complications. Technical success was 80.6% (29/36 patients). Seven cases of LAMS maldeployment during EUS-guided choledocho-duodenostomy were successfully treated with RT by an over-the-wire fully-covered Self-Expandable Metal Stent (FC-SEMS). The FC-SEMS was released through the novel fistula tract in endoscopic fashion in 5/7 cases and transpapillary in percutaneous-transhepatic-endoscopic rendezvous (1/7) and laparoscopic-endoscopic rendezvous (1/7) in the two remaining cases. The total efficacy of rescue therapy was 100%. Same-session duodenal SEMS was placed in 17 patients with optimal gastric outlet obstruction management. Final clinical success was 100% and no other late adverse events or FC-SEMS migration were observed. EUS-BD with LAMS is effective for jaundice palliation after ERCP failure but with considerable adverse events. Maldeployment remains a serious complication with fatal evolution if not correctly recognized/managed. Rescue therapy must be promptly applied especially in tertiary-care centers with highly skilled endoscopists, interventional radiologist and dedicated surgeon.

Deep-Learning-Based Smartphone Application for Self-Diagnosis of Scleral Jaundice in Patients with Hepatobiliary and Pancreatic Diseases.

Outpatient detection of total bilirubin levels should be performed regularly to monitor the recurrence of jaundice in hepatobiliary and pancreatic disease patients. However, frequent hospital visits for blood testing are burdensome for patients with poor medical conditions. This study validates a novel deep-learning-based smartphone application for the self-diagnosis of scleral jaundice in such patients. The system predicts total serum bilirubin levels using the deep-learning-based regression analysis of scleral photos taken by the smartphone’s built-in camera. Enrolled patients were randomly assigned to either the training cohort (n = 90, 1034 photos) or the validation cohort (n = 40, 426 photos). The intraclass correlation coefficient value for predicted serum total bilirubin (PSB) derived from the images repeatedly taken at the same time for the same patient showed good reliability (0.86). A strong correlation between measured serum total bilirubin (MSB) and PSB was observed in the subgroup with MSB levels ≥1.5 mg/dL (Spearman rho = 0.70, p < 0.001). The receiver operating characteristic curve for PSB showed that the area under the curve was 0.93, demonstrating good test performance as a predictor of hyperbilirubinemia (p < 0.001). Using a cut-off PSB ≥1.5, the prediction sensitivity of hyperbilirubinemia was 80.0%, with a specificity of 92.6%. Hence, the tool is effective for patient monitoring.

A preliminary single-center investigation of percutaneous biliary stenting in malignant hilar biliary obstruction: what impacts the clinical success and the long-term outcomes?

The purpose of this study is to investigate the influencing factors that may impact the clinical success, jaundice-free time, and overall survival in patients of malignant hilar biliary obstruction (MHBO) treated with a self-expanding metallic stent (SEMS). Patients diagnosed with MHBO and treated with SEMS through percutaneous access from 1 Jul. 2013 to 1 Jul. 2018 were enrolled in this monocentric study. Demographic information, disease baseline measurements, and interventional strategies were collected and examined. Bilirubin was measured 1-3days before and 3-7days after stenting using the unit of "μmol/L." The bilirubin reduction ratio was compared between different study groups, which were separated by specific characteristics. Univariate and multivariate analyses were performed to evaluate each characteristic's impact on jaundice-free time (JF) and overall survival time (OS). Statistical analyses were conducted using SPSS 14.0, p < 0.05 indicated significance. Eighty patients were enrolled. Direct bilirubin (DB) and indirect bilirubin (IB) both significantly decreased after stenting (U = 1575.0, p < 0.001; U = 1541.0, p < 0.001). The DB reduction ratio of the "nearby lymph metastases" group was significantly higher (U = 566.0, p = 0.037). The IB reduction ratio in the "single stent" group was significantly higher (U = 554.0, p = 0.018). Sixty-six cases reached jaundice recurrence, the median JF was 6months, and the 95% confidence interval was 4.411 ~ 7.589months. Fifty-eight cases ended in death, the median OS was 7months, and the 95% confidence interval was 5.759 ~ 8.241months. "Nearby lymph metastases" and "distant metastases" independently impacted OS (OR = 2.344, p = 0.013; OR = 3.239, p = 0.042). "IB reduction ratio" independently impacted both JF and OS (OR = 0.422, p = 0.021; OR = 0.315, p = 0.001). The goal of treatment in patients with MHBO is to recover liver function. However, the overall survival is greatly impacted by the presence of metastases. Managing to obtain adequate liver function recovery may improve the long-term outcomes in affected patients.

Endoscopic ultrasound-guided biliary drainage of malignant stenosis, not treatable with endoscopic retrograde cholangiopancreatography: a single-center, prospective observational study.

Background and study aims The therapeutic role of endoscopic ultrasound (EUS) evolved in recent decade,s opening a new chapter in the field of endoscopic biliary drainage (BD). EUS-BD has emerged as a new mini-invasive technique for neoplastic jaundice not amenable to endoscopic retrograde cholangiopancreatography (ERCP). The primary study aims were to assess the clinical efficacy of EUS-BD using an electrocautery-enhanced lumen apposing metal stent (ECE-LAMS) in patients with malignant biliary obstruction with failed\\unfeasible ERCP and the adverse event (AE) rate. The secondary aims were to evaluate the technical success and incidence of jaundice recurrence. Patients and methods Data from All patients referred to our tertiary-care Institute with obstructive jaundice due to unresectable malignant distal biliary stricture and unfeasible\\failed ERCP, were prospectively recorded from January 2015 to February 2018. The procedures were performed by a single-step ECE-LAMS (AXIOS-EC, Boston Scientific) placement, from the upper gut lumen to the biliary tree, for definitive biliary decompression. Results Twenty-one patients were consecutively enrolled. Mean pre-procedure common bile duct diameter was 16 mm and the bilirubin level was 13.9 mg/dL (range 3.8–29.5). LAMS was positioned from the duodenal bulb (n = 19) to gastric antrum (n = 2). We registered a 100 % of technical and clinical success. No AEs occurred. We observed a single case of delayed AE consisting of a buried LAMS, which was successfully resolved endoscopically. Conclusions Despite the limits of being non-comparative, our study shows outcomes in a homogeneous population in terms of indications and technique. EUS-BD with dedicated ECE-LAMS is associated with extremely good clinical efficacy and safety and can be considered as an alternative in cases of failed/unfeasible ERCP.

Effectiveness of Saccharomyces boulardii combined with phototherapy in the treatment of hyperbilirubinemia in neonates: a prospective randomized controlled trial

OBJECTIVE To study the effectiveness of Saccharomyces boulardii combined with phototherapy in the treatment of hyperbilirubinemia in neonates. METHODS The neonates with hyperbilirubinemia who were hospitalized from January to December 2018 were enrolled and randomly divided into an observation group (n=61) and a control group (n=63). The neonates in the observation group were treated with phototherapy combined with Saccharomyces boulardii, and those in the control group were treated with phototherapy combined with placebo. Treatment outcomes were compared between the two groups. Fecal samples were collected 72 hours after treatment and 16s rRNA high-throughput sequencing was used to compare the features of gut microbiota between the two groups. RESULTS There was no significant difference in the total serum bilirubin level between the two groups before treatment (P>0.05). At 24, 48, and 72 hours after treatment, the observation group had a significantly lower level of total serum bilirubin than the control group (P<0.05). Compared with the control group, the observation group had a significantly lower proportion of neonates requiring phototherapy again [20% (12/61) vs 75% (47/63), P<0.05]. Compared with the control group, the observation group had a significantly higher abundance of Bacteroides (P<0.05) and a significantly lower abundance of Escherichia coli and Staphylococcus in the intestine at 72 hours after treatment (P<0.05). CONCLUSIONS In neonates with hyperbilirubinemia, phototherapy combined with Saccharomyces boulardii can effectively reduce bilirubin level and prevent the recurrence of jaundice. Saccharomyces boulardii can favour the treatment outcome by regulating the gut microbiota of neonates.

Interrupted Versus Continuous Suture Technique in End-to-End Stentless Biliary Reconstruction

Abstract Background: A wide variety of techniques to restore biliary-enteric continuity after biliary injuries, the biliary tree is most commonly anastomosed to the jejunum; either as (Roux-en-Y or a simple loop anastomosis) or less commonly to the duodenum. The anastomosis may be performed to the bile duct, common hepatic duct, 1st or 2nd order hepatic duct branches, or to the gallbladder. Anastomoses may be performed in an end-to-side or side-to-side fashion, using continuous or interrupted sutures. Stents may be deployed across the anas-tomosis. Aim of Study: Biliary strictures and injuries; present a surgical technical challenge for Hepato-biliary surgeons. High biliary strictures are difficult to treat and re-stenosis rates reported of 10 - 30% following corrective repair, Complication rates; mostly due to inflammation, ischemia and tension at the anastomosis site. A combined prospective and retrospective study to evaluate the outcome of bile duct reconstruction using a continuous and interrupted suture technique for anastomosis. A combined prospective and retrospective study to evaluate the outcome of bile duct reconstruction using a continuous and interrupted suture technique for anastomosis.. Patients and Methods: A total number of 30 patients presented with biliary injuries, biliary strictures or stenosis permitted for surgical interventions in a General Surgical Department of Al-Azhar University Hospitals from February 2015 to May 2019, 15 patients were performed by continuous suture as (Group A), and 15 patents performed by interrupted suture technique as (Group B). Data and Statistical Analysis: Data on our series of bile duct anastomosis with either distal biliary duct or small bowel performed including: Surgical procedure, diagnosis, co-morbidities, peri-operative morbidity, and clinical symptoms after repair, liver function tests and the need for surgical or radiological interventions following surgery were evaluated as a prospectively collected on an institutionally approved electronic database. Non-parametric data were described as median and range and parametric data as average and standard deviation. The outcome measures were assessed: peri-operative morbidity, clinical symptoms after repair, liver function tests and the need for surgical or radiological interventions following surgery.Results: End-to-ends Biliary reconstruction, Hepatico-, Choledocho jejnostomy anastomoses were performed. In (Group A) 15 patients underwent biliary reconstruction using the continuous suture technique. The median operative time was 140 minutes (range 60-300 minutes). Post-operative morbidity was present in three patients (12.5%), shows post-operative biliary leak, wound sepsis, post-operative fever in sequence. In 14 (98.25%) of the 15 patients, there has been no recurrence of jaundice, cholangitis or biliary dilatation on abdominal ultrasonography and liver function tests improved and have returned to normal without further surgical or radiological intervention. Out of anastomoses, there were two patients in (group A) who developed leakage, and 3 patients who developed a stricture for an incidence of 1.75% and 3.25% respectively. Our overall biliary complication rate was 4%, which is lower than previously reported. Conclusions: A continuous suture technique of biliary anastomoses results in an extremely low incidence of common significant complications.

GALLSTONE DISEASE WITH UNCONJUGATED HYPERBILIRUBINEMIA: CLINICAL APPROACH TO GILBERT’S SYNDROME

Gallstones are the commonest ailment affecting the hepato-biliary system. Associated jaundice is usually direct, commonly due to biliary obstructive lesions. Unconjugated hyperbilirubinemia with cholelithiasis is commonly seen with hemolytic disease. In the absence of hemolysis or systemic causes, congenital causes prevail, commonest of which is Gilbert’ Syndrome. This study aims to ascertain a clinical approach to the patient of gallstones with Gilbert’s syndrome. This is retrospective study of 58 patients with gallstone associated unconjugated hyperbilirubinemia, who underwent surgery over a two-year period. Patients underwent repeat blood investigations and ultrasound to confirm the diagnosis. Obstructive biliary pathology was ruled out by MRCP images; EUS added if indicated. The remaining patients underwent genetic test for Gilbert’s syndrome – namely UGT1A1 gene assessment by PCR. All patients underwent laparoscopic cholecystectomy as routine; with addition of intra-operative liver biopsy. Sixteen of the 58 patients were short-listed to be high risk factors for harboring Gilbert’s syndrome after ruling out other systemic causes. On gene study, 14 patients tested positive for UGT1A1 gene, hence Gilbert’s syndrome. The other two were kept on follow up for jaundice recurrence in future. The management algorithm is depicted as flowchart. Gilbert’s syndrome can be identified in select “high-risk” individuals presenting with gallstone disease. Genetic testing is gold standard, and helps in effective management and better patient counselling.

Applycation of laparoscopy in the diagnosis and treatment of obstructive infantile cholestasis

Objective To study the use of laparoscopy in the diagnosis and treatment of obstructive infantile cholestasis. Methods The clinical data of 106 patients with obstructive infantile cholestasis from January 2012 to June 2017 were studied retrospectively. After two weeks of conservative treatments which failed to decrease the bilirubin levels significantly, these patients were subjected to laparoscopic diagnosis and treatment. Results A correct diagnosis was established in all these 106 patients by laparoscopic biliary tract exploration and cholangiography. Eighty-eight patients were diagnosed to have biliary atresia (83.0%), 16 patients inspissated bile syndrome (15.1%) and 2 patients biliary hypoplasia (1.9%). Thirty-eight of the 88 biliary atresia patients gave up operative treatment after laparoscopic biliary tract exploration and cholangiography. The remaining 50 biliary atresia patients were treated with open Kasai portoenterostomy. The prognosis of the biliary atresia patients were different from the non-biliary atresia patients. On follow-up for 4 months to 5 years, all the 18 non-biliary atresia patients were in good condition and there was no recurrence of jaundice after laparoscopic cholecystostomy and biliary tract irrigation. Conclusions The laparoscopic minimally invasive technique helped to establish diagnosis and treatment in patients with obstructive infantile cholestasis. For patients with biliary atresia, this procedure gave a definitive diagnosis and offered an opportunity for surgery. For patients with inspissated bile syndrome and biliary hypoplasia patients, laparoscopic cholecystostomy and biliary tract irrigation established the correct diagnosis and reduced liver damage resulted by cholestasis. Key words: Laparoscopy; Biliary tract surgical procedure; Biliary tract diseases; Biliary atresia; Infant, newborn, disease

EUS-guided Biliary Drainage for Malignant Perihilar Biliary Strictures after Further Transpapillary Intervention Has Been Judged to Be Impossible or Ineffective.

Objective Patients with perihilar malignancy often develop recurrence of infectious cholangitis, which makes further transpapillary intervention extremely difficult. As endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) of an intrahepatic bile duct is a possible option for additional intervention, the aim of this study was to estimate the feasibility of such intervention. Methods and Patients Patients who had undergone EUS-BD after further transpapillary intervention was deemed impossible or ineffective were investigated in this study. Those who had not received previous interventions via the papilla were excluded. Procedure-related adverse events, clinical efficacy, and time to recurrence of jaundice or infectious cholangitis transthyretin (TTR) were evaluated. Results Seven patients were eligible for the study between 2007 and 2016 (7 men; mean age, 77 years; 4 with perihilar cholangiocarcinoma and 3 with intrahepatic cholangiocarcinoma). No procedure-related adverse events were observed. EUS-BD was clinically effective and enabled hospital discharge in 4 patients (57%). The TTR in these 4 clinically effective patients was 43, 105, 118, and 147 days after the procedure (median, 112 days). Conclusion EUS-BD was found to be safe and often effective in patients in whom additional transpapillary intervention had become difficult, although its efficacy was limited to a short period.

Long-term follow-up for anicteric survival with native liver after redo Kasai: a first report

PurposeWe present a first report of the long-term follow-up of biliary atresia (BA) patients who became anicteric with the native liver (ANL; total bilirubin <1.5mg/dL) after redo-Kasai. MethodsForty-six redo-Kasai cases (1984–2015) were the subjects for this study. ANL ratios were determined using the Kaplan–Meier estimate. ResultsBA type was I (n=3), II (n=1), and III (n=42). Mean ages (initial/redo) at Kasai were 60.3/231.9days, respectively. Jaundice persisted after the initial Kasai in 24/46 cases while 22 had recurrence of jaundice after initially becoming anicteric. After redo, 5/24 of the persistent jaundice cases and 14/22 of the initially anicteric cases became anicteric (p<.05). Of these 19, 7 (one type I, six type III) are currently ANL while the remaining 12 had LTx or died. Morbidity/Complications documented in the 7 post-redo ANL cases after a mean follow-up of 16.7years (range: 10.0–31.1) included 4 episodes of cholangitis, 3 episodes of portal hypertension, 4 episodes of esophageal varices, 3 episodes of splenomegaly, one splenectomy, and 4 episodes of thrombocytopenia. ConclusionsOurs is the first long-term follow-up study of redo-Kasai cases. We found that the ANL ratio after redo-Kasai was low at 7/46 (15.2%) and that ANL were prone to multiple morbidity. Level of evidenceRetrospective comparative study, level III.

Percutaneous Transhepatic Cholangiography and Intraductal Radiofrequency Ablation Combined with Biliary Stent Placement for Malignant Biliary Obstruction

PurposeTo determine the safety and feasibility of percutaneous transhepatic cholangiography (PTC) and intraductal radiofrequency (RF) ablation combined with biliary stent placement for malignant biliary obstruction. Materials and MethodsData from patients with unresectable malignant biliary obstruction who underwent PTC, intraductal RF ablation, and biliary stent placement (n = 12) or PTC and biliary stent placement only (control group; n = 14) were reviewed. Postoperative complications, jaundice remission, and stent patency were assessed. ResultsAll procedures were successful. No severe complications (eg, biliary bleeding, perforation) occurred. Two experimental group patients developed cholangitis, which resolved with conservative treatment. The 1-week jaundice remission and 3-month stent patency rates were similar in both groups, but the 6-month stent patency rate was higher in the experimental group (P < .05). In the experimental group, one death occurred as a result of gastrointestinal hemorrhage (unrelated to stent placement) by 3 months, and there were two cases of recurrent jaundice by 6 months. The latter two patients underwent repeat PTC, ablation, and stent placement. In the control group, one death occurred as a result of hepatic failure caused by progressive jaundice at 3 months, and another death resulted from disseminated intravascular coagulation caused by jaundice recurrence at 138 days after stent placement. In addition, seven patients developed jaundice recurrence (50–151 d after stent placement). PTC and repeat stent placement were performed in these patients. ConclusionsPercutaneous transhepatic cholangiography and intraductal RF ablation combined with biliary stent placement for malignant biliary obstruction is safe and feasible and effectively prolongs stent patency time.

Damage to Pig Bile Duct Caused by Intraluminal Brachytherapy Using a 125i Ribbon

Stent occlusion by tumor ingrowth or overgrowth is the main cause of jaundice recurrence after metal stent insertion in patients with malignant obstructive jaundice (MOJ). The application of intraluminal brachytherapy (ILBT) in patients with MOJ results in local control of malignant tumors, which prolong stent patency. To evaluate the safety of ILBT in pig bile ducts using ribbons of iodine-125 ((125)I) seeds. Sixteen healthy pigs were randomly assigned to four groups of four pigs each. A (125)I seed ribbon was implanted into the common bile duct of each animal through an incision in the duct wall, and was fixed by suturing. The four groups of animals were sacrificed at 15, 30, 60, and 120 days after ribbon implantation, respectively. Serum bilirubin concentrations, alanine aminotransferase concentrations, and white blood cell counts before and after implantation were compared within each group. Pathological changes to the bile duct wall were observed using a light microscope. Morphological changes in biliary epithelial cells and organelles were observed with electron microscopy. (125)I ribbons were successfully implanted in all animals without surgery-related death. We found no significant difference in pre- and post-implant serum bilirubin, alanine aminotransferase, or white blood cell counts. Light and electron microscopy showed that the most severe bile duct damage occurred in the 15-day group, which exhibited necrosis and detachment of numerous epithelial cells, and infiltration of inflammatory cells. Repair and proliferation of the bile duct epithelium began 30 days after implantation and was nearly complete at 60 days. This study demonstrated the safety of ILBT using a (125)I ribbon in the pig bile duct. (125)I seed ribbons may be used in the treatment of MOJ in humans.

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With availability of specific and sensitive HLA antibody assays, the importance of donor specific antibodies (DSA) in liver transplant has grown. Patients undergoing 2nd liver transplant are at high risk of DSA. We present contrasting outcomes in 2 patients. We retrospectively reviewed the DSA in 2 liver recipients and compared them to the clinical outcomes. Pt #1: A 28 year old woman with PBC underwent a living donor liver transplant in 2006. In the next 4 years she received her 2nd, 3rd and 4th liver transplants due to graft failures. Plasmapheresis and IVIG were used at the 3rd & 4th transplants due to high PRA. A positive B cell flow crossmatch was noted at the last transplant. DSA monitoring was initiated after the 4th transplant. Elevated levels of class II antibodies to DR4, DR53 and DQ8 persisted. Patient had recurrence of jaundice after 6 months and showed short lived response to thymoglobulin, plasmapheresis, IVIG and Rituximab with rebound of DSA within a month of antibody therapy. Coincidentally, donors 2, 3 and 4 all had DR4, DR53 and DQ8. The patient underwent Bortezomib therapy as liver biopsy continued to show mixed portal infiltrate & bile duct injury. Pt #2: A 25 yr old woman with autoimmune hepatitis underwent liver transplant in 2006. Graft function deteriorated following steroid non-responsive rejection treated with Thymoglobulin & OK T3. Retransplant was done in early 2011. B cell crossmatch was positive and patient received thymoglobulin, plasmapheresis and IVIG. DSA assay showed the presence of anti-A2, -A11, -DR53, and -DQ8. During a follow up of 11 months, graft function was excellent despite the persistence of high titers of Class II antibodies. In contrast, level of class I antibodies remain under cutoff. Sensitization status needs serious consideration in retransplantation of liver. Avoidance of donors with unacceptable antigens may be crucial in some liver retransplant recipients. A positive B cell crossmatch may portend a poor outcome.

Reestablishing Biliary Drainage after Through-Wall Migration of a Fully Coated Biliary Self-Expanding Biliary Metal Stent (SEMS)

Purpose: Coated SEMS have been marketed in the hopes of superior patency and potential removability compared to uncoated SEMS. Several studies have reported incidents of coated stent out and in-migration. We report a new form of migration. Case Report: A 64 y.o. male presented with obstructive jaundice with an obvious unresectable pancreatic head mass. ERCP brush proved adenocarcinoma, and a fully coated SEMS was placed with success, resulting in resolution of jaundice. Recurrence of jaundice was noted after one month. CT revealed internal through-wall migration and he was referred. At ERCP, the proximal 2 cm of the stent was obviously outside the confines of the common bile duct and the lower end was partially in-migrated. Removal was not attempted due to fear of involvement of deeper structures, especially the portal vein or hepatic artery. Drainage was re-established using the following sequence of techniques: First, a high-pressure balloon occlusion cholangiogram ruptured the coated stent membrane, resulting in filling of the CBD (see image). A partially tensed papillotome was then positioned at a right angle to the rupture and a guidewire was passed through the sidewall of stent wires into the common bile duct. The puncture site was then opened with an 8.5Fr Soehendra screw extractor, and a 7Fr argon plasma circumferential coagulation probe was advanced up the duct and through the sidewall opening. Upon gently pulling the probe back, the tip would “catch” on the stent wires. Brief bursts of 90W were then applied, cutting the wires one by one. An optical fiber (SpyGlass, BostonSci) was placed through a 035 sphincterotome and used as a tiny 6Fr baby endoscope to confirm adequacy of the opening for additional stent placement. At the close, an uncoated SEMS was placed over the guidewire positioned across the fenestration into the true lumen. No complication occurred. The jaundice rapidly cleared. Summary: This case documents both through-wall migration through the upper common bile duct wall as well as in-migration into the lower duct. The re-establishment of drainage endoscopically required several unusual techniques. Fenestration of the metal wires with intraductal APC may be a unique use of this technology.Figure: Balloon occlusion cholangiogram with rupture of the membrane and filling of the common bile duct.

Mycoplasma pneumoniae associated with severe autoimmune hemolytic anemia: case report and literature review

We report a case of severe hemolytic anemia following Mycoplasma pneumoniae infection in a 29-year-old male patient who was treated with azithromycin. Direct Coombs' test was strongly positive and the cold agglutinin titer was high, with anti-I specificity. Antimycoplasma antibody titer by complement fixation was high 1:10,240. The patient was discharged after 12 days of hospitalization in good health. He remains clinically well with no recurrence of jaundice.

Trimming of a Migrated Biliary Nitinol Stent Using Argon Plasma

Metallic stent migration is a well-known complication which cannot always be managed by removal or repositioning, especially in case of uncovered stent. We report a patient who developed obstructive jaundice due to migration of an expandable metallic stent (EMS) inserted in the lower bile duct. Trimming of the EMS using argon plasma was performed, with the power setting of 60 W and 2.0 l/min of argon flow. The distal part of the EMS was removed and mechanical cleaning using balloon catheter was performed for remnant EMS. Without additional stent insertion, jaundice was relieved in a few days. No complication was recognized during the procedure and no recurrence of jaundice in the rest of his life.

BILIARY MANOMETRIC PERFUSION TEST IN THE EVALUATION OF BENIGN BILIARY STRICTURE TREATMENT - A CASE REPORT

Benign biliary strictures treated radiologically by percutaneous dilatation treatment are usually evaluated by 'clinical test'. For objective evaluation of treatment success, measurement of the pressure inside the biliary tree has been proposed. The aim of this article is to report our experience with the measurement of the pressure in the biliary tree after treatment, to present the biliary manometric perfusion test (BMPT) as an alternative method of treatment evaluation and to demonstrate why the perfusion test is a better method of evaluation. A 65 year old lady with post operative biliary stricture and symptoms of jaundice was treated in our Department with percutaneous dilatation treatment and long-term drainage. The perfusion test (BMPT) was adopted for evaluating treatment success after the treatment for 9 months. An intrabiliary pressure less than 20 cms of water during perfusion test was considered success threshold. The test was carried out without any complications and the pressure inside the biliary tree was less than 20 cms of water during the test. Eventually the drain was removed. On follow-up at 6 months the patient developed no recurrence of jaundice and the quality of life improved clinically. Periodic liver function tests during follow-up were normal. The perfusion test (BMPT) is promising efficacious alternative method for the evaluation of radiological treatment of benign biliary strictures. It helps us to decide the end points in treatment and also helps in identifying patients who might later develop strictures.