Endoscopic management of biliary complications after orthotopic liver transplantation

BACKGROUND: Biliary complications are a serious problem in patients after liver transplantation and often require reoperation. This study was conducted to summarize the endoscopic diagnosis and management of biliary complications after orthotopic liver transplantation (OLT). METHODS: From December 2000 to November 2003, twelve endoscopic retrograde cholangiopancreatographies(ERCPs) were performed in 7 patients after OLT at Digestive Endoscopic Center of Changhai Hospital in Shanghai, China. The therapeutic maneuvers included endoscopic sphincterotomy (EST), biliary stent placement, balloon and basket extraction, irrigation, and nasobiliary tube placement. A retrospective study was made to determine the types of biliary tract complications after OLT. The success of ERCP and therapeutic maneuvers was also evaluated. RESULTS: Biliary tract complications including biliary stricture, biliary leak, biliary sludge, and stump leak of the cyst duct were treated respectively by endoscopic sphincterotomy with sludge extraction, stricture dilation or endoscopic retrograde biliary drainage. Two of the 3 patients with proximal common bile duct stricture were successfully treated with ERCP and stent placement. Four patients with anastomotic stricture and/without bile leak were treated successfully by dilation and stent placement or endoscopic nosobiliary drainage. No severe ERCP-related complications occurred. CONCLUSIONS: ERCP is an effective and accurate approach for the diagnosis of biliary tract complications after OLT, and placement of a stent is a safe initial treatment for biliary complications after liver transplantation.     

肝移植术后胆栓形成过程中内镜的诊治价值

Objective To evaluate endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and management of biliary cast syndrome after orthotropic liver transplantation. Methods A total of 71 consecutive patients with abnormal liver function and MRCP findings after liver transplantation underwent ERCP for diagnosis and management. Their data were retrospectively reviewed. Results A total of 188 sessions of ERCP were carried out on the 71 patients, most of whom were found to have stenosis of anastomotic stoma and/or bile duct. Bile sludge was found and removed in all patients diagnosed within 3 months after liver transplantation, while pigmentoid stones were found and removed in patients diagnosed within 3-6 months and biliary casts in patients diagnosed at more than 6 months. Each patient underwent 2.6 sessions averagely. Biliary casts were formed at an average time of 22. 7 ± 15.6 months after transplantation. PostERCP complications included 2 cases of pancreatitis and 3 cholangitis, with an occurrence rate of 2. 6%(5/188), which were all controlled with conservative treatment. The follow-up data was available in 56 patients showing improvement in liver function after ERCP, among who 42 met the endoscopic criteria of cure,1 0 received second liver transplantation because of progressive sclerosing cholangitis and 4 died from diseases other than liver transplantation. Conclusion Therapeutic ERCP for the biliary cast syndrome after liver transplantation is feasible, safe and effective, and can be performed repeatedly with good short-term effect.     

肝移植术后胆栓形成过程中内镜的诊治价值

Objective To evaluate endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and management of biliary cast syndrome after orthotropic liver transplantation. Methods A total of 71 consecutive patients with abnormal liver function and MRCP findings after liver transplantation underwent ERCP for diagnosis and management. Their data were retrospectively reviewed. Results A total of 188 sessions of ERCP were carried out on the 71 patients, most of whom were found to have stenosis of anastomotic stoma and/or bile duct. Bile sludge was found and removed in all patients diagnosed within 3 months after liver transplantation, while pigmentoid stones were found and removed in patients diagnosed within 3-6 months and biliary casts in patients diagnosed at more than 6 months. Each patient underwent 2.6 sessions averagely. Biliary casts were formed at an average time of 22. 7 ± 15.6 months after transplantation. PostERCP complications included 2 cases of pancreatitis and 3 cholangitis, with an occurrence rate of 2. 6%(5/188), which were all controlled with conservative treatment. The follow-up data was available in 56 patients showing improvement in liver function after ERCP, among who 42 met the endoscopic criteria of cure,1 0 received second liver transplantation because of progressive sclerosing cholangitis and 4 died from diseases other than liver transplantation. Conclusion Therapeutic ERCP for the biliary cast syndrome after liver transplantation is feasible, safe and effective, and can be performed repeatedly with good short-term effect.     

Endoscopic management of postoperative bile leaks

BACKGROUND: Significant bile leak as an uncommon complication after biliary tract surgery may constitute a serious and difficult management problem. Surgical management of biliary fistulae is associated with high morbidity and mortality. Biliary endoscopic procedures have become the treatment of choice for management of biliary Gstulae. METHODS: Ninety patients presented with bile leaks after cholecystectomy ( open cholecystectomy in 45 patients, cholecystectomy with common bile duct exploration in 20 and laparoscopic cholecystectomy in 25). The presence of bile leaks was confirmed by ERCP and the appearance of bile in percutaneous drainage of abdominal collections. Of the 90 patients with postoperative bile leaks, 18 patients had complete transaction of the common bile duct by ERCP and were subjected to bilioenteric anastomosis. In the remaining patients after cholangiography and localization of the site of bile leaks. therapeutic procedures like sphinctero-tomy, biliary stenting and nasobiliary drainage ( NBD ) were performed. If residual stones were seen in the common bile duct, sphincterotomy was followed by stone extraction using dormia basket. Nasobiliary drain or stents of 7F size were placed according to the standard techniques. The NBD was removed when bile leak stopped and closure of the fistula confirmed cholangiographically. The stents were removed after an interval of 6-8 weeks. RESULTS: Bile leaks in 72 patients occurred in the cystic duct (38 patients), the common bile duct (30 ), and the right hepatic duct (4). Of the 72 patients with post-operative bile leak, 24 had associated retained common bile duct stones and 1 had ascaris in common bile duct. All the 72 patients were subjected to therapeutic procedures including sphincterotomy with stone extraction followed by biliary stenting (24 patients), removal of ascaris and biliary stenting (1), sphincterotomy with biliary stenting (18), sphincterotomy with NBD (12), biliary stenting alone (12), and NBD alone (5). Bile leaks stopped in all patients at a median interval of 3 days (range 3-16 days) after endoscopic in- terventions. No difference was observed in efficacy and in time for the treatment of bile leak by sphincterotomy with endoprosthesis or endoprosthesis alone in patients with bile leak after surgery. CONCLUSIONS: Post-cholecystectomy bile leaks occur most commonly in the cystic duct and associated common bile duct stones are found in one-third of cases. Endoscopic therapy is safe and effective in the management of bile leaks and fistulae after surgery. Sphincterotomy with endoprosthesis or endoprosthesis alone is equally effective in the management of postoperative bile leak.     

Endoscopic retrograde cholangiopancreatography during pregnancy without radiation

AIM： To present our experience with pregnant patients who underwent endoscopic retrograde cholangiopancreatography （ERCP） without using radiation, and to evaluate the acceptability of this alternative therapeutic pathway for ERCP during pregnancy. METHODS： Between 2000 and 2008, six pregnant women underwent seven ERCP procedures. ERCP was performed under mild sedoanalgesia induced with pethidine HCI and midazolam. The bile duct was cannulated with a guidewire through the papilla. A catheter was slid over the guidewire and bile aspiration and/or visualization of the bile oozing around the guidewire was used to confirm correct cannulation. Following sphincterotomy, the bile duct was cleared by balloon sweeping. When indicated, stents were placed. Confirmation of successful biliary cannulation and stone extraction was made by laboratory, radiological and clinical improvement. Neither fluoroscopy nor spot radiography was used during the procedure. RESULTS： The mean age of the patients was 28 years （range, 21-33 years）. The mean gestational age for the fetus was 23 wk （range, 14-34 wk）. Five patients underwent ERCP because of choledocholithiasis and/or choledocholithiasis-induced acute cholangitis. In one case, a stone was extracted after precut papillotomy with a needle-knife, since the stone was impacted. One patient had ERCP because of persistent biliary fistula after hepatic hydatid disease surgery. Following sphincterotomy, scoleces were removed from the common bile duct. Two weeks later, because of the absence of fistula closure, repeat ERCP was performed and a stent was placed. The fistula was closed after stent placement. Neither post-ERCP complications nor premature birth or abortion was seen. CONCLUSION： Non-radiation ERCP in experienced hands can be performed during pregnancy. Stent placement should be considered in cases for which complete common bile duct clearance is dubious because of a lack of visualization of the biliary tree.     

Complications and management of forgotten long-term biliary stents

AIM To evaluate complications and management outcomes of retained long-term plastic biliary stents.METHODS Endoscopic plastic biliary stent placement was performed in 802 patients at Yeungnam University Hospital between January 2000 and December 2014. Follow-up loss with a subsequently forgotten stent for more than 12 mo occurred in 38 patients. We retrospectively examined the cause of biliary stent insertion, status of stents, complications associated with biliary stents and management outcomes of longterm plastic biliary stents. Continuous variables were analyzed using the t test. Observed frequencies in subsets of the study population were compared using Fisher's exact test and χ~2 tests. Statistical significance was defined as P 0.05(two-tailed).RESULTS Mean age of patients was 73.7 ± 12 years and maleto-female ratio was 2.2:1. Indications of plastic biliary stent insertion were bile duct stones(63.2%, 24/38) and benign bile duct stricture(52.6%, 20/38). Mean duration of retained plastic stent was 22.6 ± 12.2 mo, and in 10 cases(26.3%), stents were retained for more than 24 mo. Common bile duct(CBD) stones or sludgewere found in most cases(92.1%, 35/38). The most common complication was acute cholangitis(94.7%, 36/38). Stent removal by endoscopic approach was successfully performed in 92.1%(35/38) of the cases. In 3 cases, an additional plastic stent was inserted alongside the previous stent due to failure of the stent removal. Endoscopic removal of bile duct stones was successful in 73.7%(28/38) of the cases. When patients were divided into two groups by duration of stent placement(12 to 24 mo vs over 24 mo), there were no differences in the development of cholangitis, presence of biliary stones, and success rate of endoscopic removal of stones and biliary stents. CONCLUSION The most common complication of retained long-term plastic biliary stents was acute cholangitis associated with CBD stones. Endoscopic management was successfully performed in most cases.     

Fully covered self-expandable metal stents for treatment of malignant and benign biliary strictures

AIM:To present a series of covered self-expandable metal stents(CSEMS) placed for different indications and to evaluate the effectiveness,complications and extractability of these devices.METHODS:We therefore retrospectively reviewed the courses of patients who received CSEMS due to malignant as well as benign biliary strictures and postsphincterotomy bleeding in our endoscopic unit between January 2010 and October 2011.RESULTS:Twenty-six patients received 28 stents due to different indications(20 stents due to malignant biliary strictures,six stents due to benign biliary strictures and two stents due to post-sphincterotomy bleeding).Biliary obstruction was relieved in all cases,regardless of the underlying cause.Hemostasis could be achieved in the two patients who received the stents for this purpose.Complications occurred in five patients(18%).Two patients(7%) developed cholecystitis,stents dislocated/migrated in other two patients(7%),and in one patient(3.6%) stent occlusion was documented during the study period.Seven stents were extracted endoscopically.Removal of stents was easily possible in all cases in which it was desired using standard forceps.Twelve patients underwent surgery with pylorus preserving duodenopancreatectomy.In all patients stents could be removed during the operation without difficulties.CONCLUSION:Despite the higher costs of these devices,fully covered self-expanding metal stents may be suitable to relief biliary obstruction due to bile duct stenosis,regardless of the underlying cause.CSEMS may also represent an effective treatment strategy of severe post-sphincterotomy bleeding,not controlled by other measures.     

Endoscopic management of occluded metal biliary stents: metal versus 10F plastic stents

AIM:To compare the efficacy of self-expandable metal stents(SEMSs) with 10F plastic stents(PSs) in the endoscopic management of occluded SEMSs.METHODS:We retrospectively reviewed the medical records of 56 patients who underwent SEMS insertion for palliation of unresectable malignant biliary obstruction between 2000 and 2007 and subsequent endoscopic retrograde biliary drainage(ERBD) with SEMS or PS for initial SEMS occlusion between 2000 and 2008.RESULTS:Subsequent ERBD with SEMS was performed in 29 patient...     

Efficacy of multiple biliary stenting for refractory benign biliary strictures due to chronic calcifying pancreatitis

AIM To investigate endoscopic therapy efficacy for refractory benign biliary strictures(BBS) with multiple biliary stenting and clarify predictors.METHODS Ten consecutive patients with stones in the pancreatic head and BBS due to chronic pancreatitis who underwent endoscopic therapy were evaluated. Endoscopic insertion of a single stent failed in all patients. We used plastic stents(7F, 8.5F, and 10F) and increased stents at intervals of 2 or 3 mo. Stents were removed approximately 1 year after initial stenting. BBS and common bile duct(CBD) diameter were evaluated using cholangiography. Patients were followed for ≥ 6 mo after therapy, interviewed for cholestasis symptoms, and underwent liver function testing every visit. Patients with complete and incomplete stricture dilations were compared.RESULTS Endoscopic therapy was completed in 8(80%) patients, whereas 2(20%) patients could not continue therapy because of severe acute cholangitis and abdominal abscess, respectively. The mean number of stents was 4.1 ± 1.2. In two(20%) patients, BBS did not improve; thus, a biliary stent was inserted. BBS improved in six(60%) patients. CBD diameter improved more significantly in the complete group than in the incomplete group(6.1 ± 1.8 mm vs 13.7 ± 2.2 mm, respectively, P = 0.010). Stricture length was significantly associated with complete stricture dilation(complete group; 20.5 ± 3.0 mm, incomplete group; 29.0 ± 5.1 mm, P = 0.011). Acute cholangitis did not recur during the mean follow-up period of 20.6 ± 7.3 mo.CONCLUSION Sequential endoscopic insertion of multiple stents is effective for refractory BBS caused by chronic calcifying pancreatitis. BBS length calculation can improve patient selection procedure for therapy.     

Management of biliary complications after orthotopic liver transplantation： The role of endoscopy

Biliary complications are significant causes of morbidity and mortality after orthotopic liver transplantation （OLT）. The estimated incidence of biliary complications after OLT ranges between 10%-25%, however, these numbers continue to decline due to improvement in surgical techniques. The most common biliary complications are strictures （both anastomotic and non-anastomotic） and bile leaks. Most of these problems can be appropriately managed with endoscopic retrograde colangiography （ERC）. Other complications such as bile duct stones, bile casts, sphincter of Oddi dysfunction, and hemobilia, are less frequent and also can be managed with ERC. This article will review the risk factors, diagnosis, and endoscopic management of the most common biliary complications after OLT.     

Rotational assisted endoscopic retrograde cholangiopancreatography in patients with reconstructive gastrointestinal surgical anatomy

AIM: To evaluate the success rates of performing therapy utilizing a rotational assisted enteroscopy device in endoscopic retrograde cholangiopancreatography(ERCP) in surgically altered anatomy patients. METHODS: Between June 1, 2009 and November 8, 2012, we performed 42 ERCPs with the use of rotational enteroscopy for patients with altered anatomy(39 with gastric bypass Roux-en-Y, 2 with Billroth Ⅱ gastrectomy, and 1 with hepaticojejunostomy associated with liver transplant). The indications for ERCP were: choledocholithiasis: 13 of 42(30.9%), biliary obstruction suggested on imaging: 20 of 42(47.6%), suspected sphincter of Oddi dysfunction: 4 of 42(9.5%), abnormal liver enzymes: 1 of 42(2.4%), ascending cholangitis: 2 of 42(4.8%), and bile leak: 2 of 42(4.8%). All procedures were completed with the Olympus SIF-Q180 enteroscope and the Endo-Ease Discovery SB overtube produced by Spirus Medical. RESULTS: Successful visualization of the major ampulla was accomplished in 32 of 42 procedures(76.2%). Cannulation of the bile duct was successful in 26 of 32 procedures reaching the major ampulla(81.3%). Successful therapeutic intervention was completed in 24 of 26 procedures in which the bileduct was cannulated(92.3%). The overall intention to treat success rate was 64.3%. In terms of cannulation success, the intention to treat success rate was 61.5%. Ten out of forty two patients(23.8%) required admission to the hospital after procedure for abdominal pain and nausea, and 3 of those 10 patients(7.1%) had a diagnosis of post-ERCP pancreatitis. The average hospital stay was 3 d.CONCLUSION: It is reasonable to consider an attempt at rotational assisted ERCP prior to a surgical intervention to alleviate biliary complications in patients with altered surgical anatomy.     

Role of interventional therapy in hepatic artery stenosis and non-anastomosis bile duct stricture after orthotopic liver transplantation

AIM: To analyze the clinical manifestations and the effectiveness of therapy in patients with orthotopic liver transplantation (OLT)-associated hepatic artery stenosis (HAS) and non-anastomosis bile duct stricture. METHODS: Nine cases were diagnosed as HAS and non-anastomosis bile duct stricture. Percutaneous transluminal angioplasty (PTA) was performed in four HAS cases, and expectant treatment in other fi ve HAS cases; percutaneous transhepatic bile drainage, balloon dilation, stent placement were performed in all nine cases. RESULTS: Diffuse intra-and extra-bile duct stricture was observed in nine cases, which was associated with bile mud siltation and biliary infection. Obstruction of the bile duct was improved obviously or removed. Life span/ follow-up period was 13-30 mo after PTA of four HAS cases, 6-23 mo without PTA of other fi ve cases. CONCLUSION: Progressive, non-anastomosis, and diffuse bile duct stricture are the characteristic manifestations of HAS and non-anastomosis bile duct stricture after OLT. These are often associated with bile mud siltation, biliary infection, and ultimate liver failure. Interventional therapy is signifi cantly benefi cial.     

Diagnosis and management of primary sclerosing cholangitis-perspectives from a therapeutic endoscopist

Primary sclerosing cholangitis(PSC) is a chronic,cholestatic liver condition characterized by inflammation,fibrosis,and destruction of the intra-and extrahepatic bile ducts.The therapeutic endoscopist plays a key role in the diagnosis and management of PSC.In patients presenting with a cholestatic profile,endoscopic retrograde cholangiopancreatography(ERCP) is warranted for a definite diagnosis of PSC.Dominant strictures of the bile duct occur in 36%-57% of PSC patients.Endoscopic balloon dilatation with or without stenting have been employed in the management of dominant strictures.In addition,PSC patients are at increased risk of developing cholangiocarcinoma with a 20% lifetime risk.Brush cytology obtained during ERCP and use of fluorescence in situ hybridization forms the initial diagnostic step in the investigation of patients with dominant biliary strictures.Our review aims to summarize the current evidence supporting the role of a therapeutic endoscopist in the management of PSC patients.     

Placement of removable metal biliary stent in post-orthotopic liver transplantation anastomotic stricture

Postoperative biliary strictures are the most common cause of benign biliary stricture in Western countries, secondary to either operative injury or bile duct anastomotic stricture following orthotopic liver transplantation(OLT).Surgery or endoscopic interventions are the mainstay of treatment for benign biliary strictures.We aim to report the outcome of 2 patients with refractory anastomotic biliary stricture post-OLT,who had successful temporary placement of a prototype removable covered self-expandable m...     

Recurrence of choledocholithiasis following endoscopic bile duct clearance: Long term results and factors associated with recurrent bile duct stones

AIM To evaluate the rate of recurrence of symptomatic chol-edocholithiasis and identify factors associated with the recurrence of bile duct stones in patients who underwent endoscopic retrograde cholangiopancreatography(ERCP) and endoscopic sphincterotomy(EST) for bile duct stone disease.METHODS All patients who underwent ERCP and EST for bile duct stone disease and had their bile duct cleared from 1/1/2005 until 31/12/2008 was enrolled. All symptomatic recurrences during the study period(until 31/12/2015) were recorded. Clinical and laboratory data potentially associated with common bile duct(CBD) stone recurrence were retrospectively retrieved from patients' files.RESULTS A total of 495 patients were included. Sixty seven(67) out of 495 patients(13.5%) presented with recurrent symptomatic choledocholithiasis after 35.28 ± 16.9 mo while twenty two(22) of these patients(32.8%) experienced a second recurrence after 35.19 ± 23.2 mo. Factors associated with recurrence were size(diameter) of the largest CBD stone found at first presentation(10.2 ± 6.9 mm vs 7.2 ± 4.1 mm, P = 0.024), diameter of the CBD at the first examination(15.5 ± 6.3 mm vs 12.0 ± 4.6 mm, P = 0.005), use of mechanical lithotripsy(ML)(P = 0.04) and presence of difficult lithiasis(P = 0.04). Periampullary diverticula showed a trend towards significance(P = 0.066). On the contrary, number of stones, angulation of the CBD, number of ERCP sessions required to clear the CBD at first presentation, more than one ERCP session needed to clear the bile duct initially and a gallbladder in situ did not influence recurrence. CONCLUSION Bile duct stone recurrence is a possible late complication following endoscopic stone extraction and CBD clearance. It appears to be associated with anatomical parameters(CBD diameter) and stone characteristics(stone size, use of ML, difficult lithiasis) at first presentation.     

Non-surgical treatment of post-surgical bile duct injury: Clinical implications and outcomes

AIM:To investigate the prognostic factors determining the success rate of non-surgical treatment in the management of post-operative bile duct injuries(BDIs).METHODS:The study patients were enrolled from the pancreatobiliary units of a tertiary teaching hospital for the treatment of BDIs after hepatobiliary tract surgeries,excluding operations for liver transplantation andmalignancies,from January 1999 to August 2010.A total of 5167 patients underwent operations,and 77patients had BDIs following surgery.The primary end point was the treatment success rate according to different types of BDIs sustained using endoscopic or percutaneous hepatic approaches.The type of BDI was defined using one of the following diagnostic tools:endoscopic retrograde cholangiography,percutaneous transhepatic cholangiography,computed tomography scan,and magnetic resonance cholangiography.Patients with a final diagnosis of BDI underwent endoscopic and/or percutaneous interventions for the treatment of bile leak and/or stricture if clinically indicated.Patient consent was obtained,and study approval was granted by the Institutional Review Board in accordance with the legal regulations of the Human Clinical Research Center at the Seoul National University Hospital in Seoul,South Korea.RESULTS:A total of 77 patients were enrolled in the study.They were divided into three groups according to type of BDI.Among them,55 patients(71%)underwent cholecystectomy.Thirty-six patients(47%)had bile leak only(type 1),31 patients had biliary stricture only(type 2),and 10 patients had both bile leak and biliary stricture(type 3).Their initial treatment modalities were non-surgical.The success rate of non-surgical treatment in each group was as follows:BDI type 1:94%;type 2:71%;and type 3:30%.Clinical parameters such as demographic factors,primary disease,operation method,type of operation,non-surgical treatment modalities,endoscopic procedure steps,type of BDI,time to diagnosis and treatment duration were evaluated to evaluate the prognostic factors affecting the success rate.The type of BDI was a statistically significant prognostic factor in determining the success rate of non-surgical treatment.In addition,a shorter time to diagnosis of BDI after the operation correlated significantly with higher success rates in the treatment of type 1 BDIs.CONCLUSION:Endoscopic or percutaneous hepatic approaches can be used as an initial treatment in type1 and 2 BDIs.However,surgical intervention is a treatment of choice in type 3 BDI.     

Role of CD56-expressing immature biliary epithelial cells in biliary atresia

AIM: To analyze the clinical and pathological parameters and expression of the neural cell adhesion molecule(CD56) in patients with biliary atresia(BA).METHODS: Established clinical laboratory markers of hepatic function, including enzyme activity, protein synthesis, and bilirubin metabolism, were evaluated in patients with BA and compared with those in patients with choledochal cysts and neonatal hepatitis. Pathological changes in tissue morphology and fibrosis were examined by histological and tissue collagen staining. Immunohistochemical staining for the biliary epithelial cell markers CD56 and CK19 together with the Notch signaling related molecules Notch1 and Notch2 was performed in the context of alterations in the structure of intrahepatic biliary ducts.RESULTS: Differences in some clinical laboratoryparameters among the three diseases examined were observed, but they did not correlate with the pathological classification of fibrosis in BA. Immunohistochemical staining showed the presence of CD56-positive immature bile ducts in most patients(74.5%) with BA but not in patients with choledochal cysts or neonatal hepatitis. The number of CD56-expressing cells correlated with disease severity, with more positive cells present in the later stages of liver damage(81.8% vs 18.2%). Furthermore, bile plugs were mainly found in CD56-positive immature biliary ducts. Notch signaling was a key regulatory pathway in biliary duct formation and played a role in tissue fibrosis. Notch1 was co-expressed in CD56-positive cells, whereas Notch2 was found exclusively in blood vessels in the portal area of patients with BA. CONCLUSION: The maturation of biliary epithelial cells and the expression of Notch may play a role in the pathogenesis of BA.     

内镜下胆总管取石术患者不同时期生存质量比较分析

Objective To investigate the influence of endoscopic retrograde cholangiopancreatography (ERCP) on life quality of patients with common bile duct stones. Methods The life quality of 35 patients, who underwent ERCP because of common bile duct stones, were assessed by GIQLI questionnaires before, 2 and 6 weeks after the procedure. Results The mean GIQLI score of patients before ERCP was 99. 9, which was significantly increased to 112. 2 and 121.9 at 2 and 6 weeks after ERCP (P ＜0. 01 ). At 6weeks after ERCP, the GIQLI score was similar to that of normal population. Conclusion ERCP can improve the life quality of patients with common bile duct stones.     

Liver resection for the treatment of post-cholecystectomy biliary stricture with vascular injury

AIM:To report experience with liver resection in a select group of patients with postoperative biliary stricture associated with vascular injury.METHODS:From a prospective database of patients treated for benign biliary strictures at our hospital,cases that underwent liver resections were reviewed.All cases were referred after one or more attempts to repair bile duct injuries following cholecystectomy(open or laparoscopic).Liver resection was indicated in patients with Strasberg E3/E4(hilar stricture)bile duct lesions associated with vascular damage(arterial and/or portal),ipsilateral liver atrophy/abscess,recurrent attacks of cholangitis,and failure of previous hepaticojejunostomy.RESULTS:Of 148 patients treated for benign biliary strictures,nine(6.1%)underwent liver resection;eight women and one man with a mean age of 38.6 years.Six patients had previously been submitted to open cholecystectomy and three to laparoscopic surgery.The mean number of surgical procedures before definitive treatment was 2.4.All patients had Strasberg E3/E4injuries,and vascular injury was present in all cases.Eight patients underwent right hepatectomy and one underwent left lateral sectionectomy without mortality.Mean time of follow up was 69.1 mo and after longterm follow up,eight patients are asymptomatic.CONCLUSION:Liver resection is a good therapeutic option for patients with complex postoperative biliary stricture and vascular injury presenting with liver atrophy/abscess in which previous hepaticojejunostomy has failed.