Risk factors for acute suppurative cholangitis caused by bile duct stones

OBJECTIVE: Acute suppurative cholangitis is fatal unless adequate biliary drainage is obtained in a timely manner. The major cause of acute suppurative cholangitis is bile duct stones, but it is not known which patients with bile duct stones are likely to develop acute suppurative cholangitis. METHODS: Between May 1994 and December 2005, 343 consecutive patients with bile duct stones were referred to our department. Of these, 38 patients presented with acute suppurative cholangitis. A nasobiliary catheter or biliary stent was emergently inserted endoscopically to control acute suppurative cholangitis in those patients. Risk factors for the development of acute suppurative cholangitis in the 343 patients were investigated using univariate and multivariate analyses. RESULTS: A nasobiliary catheter or stent was inserted endoscopically in all 38 patients with acute suppurative cholangitis. Although biliary drainage was considered to be effective in all patients, two patients (5.3%) died of deteriorating comorbid diseases despite subsiding cholangitis. In the univariate analysis, age >or=70 years, neurological disease, and peripapillary diverticulum were identified as risk factors for the development of acute suppurative cholangitis. In the multivariate analysis, these three factors remained significant. CONCLUSIONS: Advanced age, comorbid neurological disease, and peripapillary diverticulum were identified as independent risk factors for the development of acute suppurative cholangitis in patients with bile duct stones.     

Endoscopic Biliary Drainage for Acute Obstructive Cholangitis: Analysis of 100 Consecutive Patients

Abstract: Acute obstructive suppurative cholangitis is a life-threatening condition and prompt biliary decompression is essential if the patient is to survive. One hundred patients with acute obstructive (suppurative) cholangitis were treated by simple endoscopic cannulation for biliary drainage. Forty-eight patients had common duct stones alone, 33 patients had additional stones in the gallbladder, and 18 patients had stones in the intrahepatic ducts. Another patient had a confluence stone. Twenty-six patients had undergone endoscopic sphincterotomy. Bile duct dilatation was present in only 25 of 47 patients (53%) studied by ultrasound tomography. Biliary decompression was achieved in 98 patients. One tortuous distal bile duct and one oversized stone were the causes of failure in two patients. Forty-seven patients proved to have suppurative cholangitis. Most patients felt instant and dramatic relief of their syniptoms. Bleeding at sphinctetomy was the only complication associated with the decompression ocurring in 2 patients. Bending (2 patients) and withdrawal (2 patients) of a nasobiliary catheter, and nasal bleeding (1 patient) were the complications related to nasobiliary drainage. Two patients with suppurative cholangitis died despite successful decompression performed 3 and 5 days after the onset of cholangitis. This delay seemed responsible for their deaths. Thus the mortality rate was 2.0% for all the patients arid 4.3% for those with suppurative cholangitis. These results suggest that endoscopic cannulation, which is feasible even in the absence of bile duct dilatation, is a prompt, safe, and effective procedure for emergency biliary decompression for the treatment of acute obstructive (suppurative) cholangitis.     

Does the addition of endoscopic sphincterotomy to stent insertion improve drainage of the bile duct in acute suppurative cholangitis?

BACKGROUND: The treatment of patients with bile duct stones and acute suppurative cholangitis is emergent biliary decompression either by endoscopic sphincterotomy, nasobiliary drainage, or stent insertion. The aim of this retrospective study was to determine whether endoscopic sphincterotomy, in addition to an internal endoprosthesis, improves outcome for patients with acute suppurative cholangitis. METHODS: A total of 74 patients with acute suppurative cholangitis and bile duct stones were included in the study; 37 had endoscopic sphincterotomy before insertion of plastic stent (Group 1), and 37 had a plastic stent inserted through an intact papilla (Group 2). RESULTS: The success rates for stent insertion in Groups 1 and 2 were, respectively, 89.2% and 86.5% (p = 1.000). The complication rates in Group 1 and Group 2 were, respectively, 10.8% and 2.7% (p = 0.358). The median (interquartile range 25th-75th percentile) durations of hospital stay for patients in Group 1 and Group 2 were, respectively, 6.5 (4-11) days and 7 (5-12) days (p = 0.614). The median (interquartile range) lengths of time for resolution of jaundice in Group 1 and Group 2 were, respectively, 3 (2-6) days versus 4 (2-5) days (p = 0.981). CONCLUSIONS: Endoscopic sphincterotomy, in addition to biliary stent insertion, is not required for successful biliary decompression in patients with severe acute cholangitis.     

Endoscopic biliary drainage for acute obstructive cholangitis: Effects of bilionasal drainage and stent placement

Acute obstructive suppurative cholangitis is a life-threatening condition which requires prompt biliary decompression. A retrospective review of 92 patients with acute obstructive suppurative or nonsuppurative cholangitis (46 men and 46 women with a mean age of 65.1 years) was conducted. All patients had undergone endoscopic biliary decompression by retrograde cannulation with (79 patients) or without (13 patients) sphincterotomy. Nineteen patients had received sphincterotomy previously. In addition to biliary decompression, 48 of the 92 patients had a bilionasal catheter or a stent placed in the common bile duct (group A), while the other 44 patients did not (group B). The effect of drainage was successful in 83 of the 92 patients (90%), but 1 patient in group A died of liver failure due to advanced cirrhosis of the liver despite successful drainage; thus, the overall mortality rate was 1.1%. Although the mortality and overall morbidity rates (2.1% and 42% in group A, and 0% and 34% in group B, respectively) did not differ between the two groups, the frequency of recurrent cholangitis was significantly higher in group B (60%) than in group A (4.2%) (P<0.001). We conclude that endoscopic biliary decompression is a prompt, safe, and effective method for the treatment of acute obstructive cholangitis. We stress that a stent or a bilionasal drainage catheter should always be placed if recurrent cholangitis is to be prevented until complete clearance of the stones is achieved.     

ENDOSCOPIC NASOBILIARY DRAINAGE: CURRENT INDICATIONS AND EVALUATION OF THE PRODUCTS

Endoscopic nasobiliary drainage (ENBD) is a well established mode of biliary decompression. Although ENBD is certainly an uncomfortable procedure with the potential risk of spontaneous dislocation or removal of the drainage catheter by disoriented patients, it has several advantages over endoscopic biliary drainage (EBD) using an indwelling stent. The current indications for ENBD are: (i) temporary drainage to treat obstructive jaundice and cholangitis caused by malignant or benign biliary stricture; (ii) urgent drainage to treat suppurative cholangitis primarily caused by common bile duct stones; (iii) temporary drainage after stone removal in patients with suspected incomplete clearance and/or with cholangitis; and (iv) biliary leaks that occur primarily after surgery, as well as other indications. Different types of nasobiliary catheters are currently available that have been designed with various diameters, shapes, and materials. However, the current catheters are not considered by most endoscopists to be sufficient. Further improvements are needed to achieve better drainage and better maneuverability.     

Endoscopic biliary drainage for severe acute cholangitis in biliary obstruction as a result of malignant and benign diseases

BACKGROUND AND AIMS: Endoscopic biliary drainage is an established mode of biliary decompression in patients with acute cholangitis as a result of biliary obstruction secondary to stones and benign strictures. However, there are no reports on endoscopic management of severe acute cholangitis caused by malignant conditions. We prospectively compared the efficacy of the endoscopic drainage for severe acute cholangitis in biliary obstruction as a result of malignant and benign diseases. METHODS: Forty-three patients with severe acute cholangitis requiring urgent biliary drainage were included. Sixteen patients (mean age 58.2 +/- 9.3 years; seven men, nine women) had biliary obstruction as a result of malignant diseases and 27 had benign biliary diseases (mean age 41.6 +/- 14.3 years; nine men, 18 women). Indications for urgent drainage included any one of the following: temperature >38 degrees C (n = 21), septic shock with systolic blood pressure <100 mmHg (n = 9), localized peritonism (n = 21), impaired consciousness (n = 6) and failure to improve within 72 h of conservative management (n = 13). After successful bile duct cannul degrees ation, patients received either a nasobiliary catheter (n = 38) or an in-dwelling stent (n = 5) with or without sphincterotomy for biliary drainage. Outcome measures included complications and clinical response. RESULTS: Endoscopic drainage was established successfully in all the patients in both the groups. Clinical improvement after biliary drainage occurred in 94% patients (15/16) in the malignant group compared with 96% patients (26/27) in the benign group (P = not significant [NS]). Fever subsided at a median of 2.2 days in the malignant group and at 1 day in the benign group (P = NS). Normalization of leukocyte count was seen at a median of 6 days (range 1-17) and 2 days (range 1-5) days in the malignant group and the the benign group, respectively (P = NS). There were no endoscopic retrograde cholangiopancreatography-related complications. The mortality rate as a result of cholangitis was 4.6%, that is two of 43 patients (6.2% of the malignant group vs 3.7% of the benign group; P = NS). CONCLUSIONS: Endoscopic biliary drainage is equally effective in patients with severe acute cholangitis caused by either malignant or benign biliary diseases.     

Acute suppurative obstructive cholangitis due to stones: treatment by urgent endoscopic sphincterotomy

Endoscopic sphincterotomy is an accepted treatment for retained common bile duct stones, but there is little specific information available regarding its application in acute suppurative obstructive cholangitis with sepsis due to choledocholithiasis. Thirteen patients with this condition were referred to the authors for consideration of urgent endoscopic common bile duct decompression. All had been judged to be poor surgical candidates. Pus was released from the common bile duct by sphincterotomy within 24 hours of admission in all 13. Stones were removed endoscopically in 10 patients (77%) without complications. After endoscopic stone removal, symptoms, signs, and abnormal laboratory values returned to normal rapidly; follow-up endoscopic retrograde cholangiography did not show retained stones. Three patients whose large stones precluded endoscopic removal underwent operative choledocholithotomy. Urgent endoscopic sphincterotomy offers an important alternative in the treatment of acute suppurative obstructive cholangitis secondary to choledocholithiasis.     

Emergency endoscopic nasobiliary drainage for acute calculous suppurative cholangitis and its potential use in chemical dissolution

Abstract Acute suppurative cholangitis is one of the common causes of acute abdomen in Taiwan. Emergency decompression is a life-saving procedure if patients fail to respond to antibiotic treatment. From July 1988 to June 1991, 224 patients were encountered with concomitant bile duct stones and cholangitis; 40 were brought to the emergency service with shock or mental confusion or responded poorly to antibiotic treatment. The patients consisted of 20 males and 20 females aged 21–81 years (mean age 64 years); 55% had intrahepatic duct stones, 50% had positive blood culture, 38% had undergone previous biliary surgery, 25% had concomitant medical illnesses and 20% presented with mental confusion. Emergent endoscopic nasobiliary drainage (ENBD) was performed within 48 h of each patient's arrival in the emergency room. In 3 days all the patients exhibited significant improvement as defined by body temperature, vital signs, white blood cell count, serum bilirubin and alkaline phosphates levels. When their condition had stabilized, 21 patients underwent elective surgery. Six patients received ethylenediaminetetraacetic acid infusion through an ENBD tube. Two of the patients' stones dissolved completely. Six patients received papillotomy with stone removal. The remaining patients refused further treatment. There was no hospital mortality. It is therefore concluded that ENBD offers an effective treatment for acute calculus suppurative cholangitis and it is a potential route of administration for the chemical dissolution of bile duct stones.     

Acute cholangitis after endoscopic sphincterotomy: Complications of expectant treatment

Two elderly patients who had endoscopic sphincterotomy (EST) for their common duct stones developed acute cholangitis and, one of them also developed acute pancreatitis after the procedure. Despite the presence of an adequate sphincterotomy which allows subsequent spontaneous stone elimination, transient ductal obstruction during stone migration through the sectioned papilla is probably accountable for their complications. From the present reported experience, it is clear that expectant treatment of common duct stone after EST can be associated with definite hazards. Immediate biliary decompression with either active instrumental extraction or, when not feasible, insertion of nasobiliary catheter, should be performed to prevent these complications in selected patients.     

The benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis

Objective: Endoscopic nasobiliary drainage for acute cholangitis is performed with or without endoscopic sphincterotomy. However, sphincterotomy carries a small but important risk of complications. We evaluated the benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis.
Methods: A total of 166 patients underwent endoscopic nasobiliary drainage with sphincterotomy (73 patients, sphincterotomy group) or without (93 patients, nonsphincterotomy group). The indications were acute cholangitis due to choledocholithiasis (120 patients) or benign (10 patients) or malignant (36 patients) biliary stricture. Patient backgrounds were similar in the two groups. The outcomes of nasobiliary drainage were compared between the groups.
Results: Nasobiliary drainage was successful in 69 patients (95%) in the sphincterotomy group and in 89 (96%) in the nonsphincterotomy group. Efficient drainage was achieved in 67 patients (92%) in the sphincterotomy group and in 87 (94%) in the nonsphincterotomy group. Procedure-related complications developed in eight sphincterotomy-group patients (hemorrhage in three, acute cholecystitis in three, acute pancreatitis in one, catheter withdrawal in one) and in two nonsphincterotomy patients (pancreatitis in one, catheter withdrawal in one) (11% vs 2%;   p < 0.05  ). There were no deaths.
Conclusions: Endoscopic nasobiliary drainage without endoscopic sphincterotomy is a simple, safe, and effective treatment for acute cholangitis. This procedure is especially useful for critically ill patients and those with coagulopathy.     

Retained common bile duct stones after endoscopic sphincterotomy: temporary and longterm treatment with biliary stenting.

Basket extraction after endoscopic sphincterotomy failed to clear the bile ducts immediately in 85 (30%) of 283 consecutive patients with common bile duct stones. Temporary biliary drainage was established by the insertion of a single 7 Fr double pigtail stent before further planned endoscopic attempts at stone removal. In 84 patients (21 male: 63 female, mean age 77 years) this measure relieved biliary obstruction, mean serum bilirubin falling from 101 to 18 umol/l by the time of the second endoscopic retrograde cholangiopancreatography. Six patients died from non-biliary causes with temporary stents in situ. Common bile duct stone extraction was achieved endoscopically in 50 of the remaining 79 patients after a mean of 4.3 months (range 1-12), 34 (68%) requiring only one further procedure. Three patients were referred for biliary surgery. Single stents were also effective for longterm biliary drainage in the remaining 26 elderly patients with unextractable stones. The main biliary complication of stenting was 13 episodes of cholangitis but all except one responded to medical treatment and early stent exchange. If common bile duct stones remain after endoscopic sphincterotomy, a single 7 Fr double pigtail stent is effective and safe for temporary biliary drainage before further endoscopic attempts at duct clearance and for longterm biliary drainage especially in the old and frail.     

Multicenter study of endoscopic preoperative biliary drainage for malignant distal biliary obstruction

AIM: To determine the optimal method of endoscopic preoperative biliary drainage for malignant distal biliary obstruction.METHODS: Multicenter retrospective study was conducted in patients who underwent plastic stent(PS) or nasobiliary catheter(NBC) placement for resectable malignant distal biliary obstruction followed by surgery between January 2010 and March 2012. Procedurerelated adverse events, stent/catheter dysfunction(occlusion or migration of PS/NBC, developmentof cholangitis, or other conditions that required repeat endoscopic biliary intervention), and jaundice resolution(bilirubin level 3.0 mg/d L) were evaluated. Cumulative incidence of jaundice resolution and dysfunction of PS/NBC were estimated using competing risk analysis. Patient characteristics and preoperative biliary drainage were also evaluated for association with the time to jaundice resolution and PS/NBC dysfunction using competing risk regression analysis.RESULTS: In total, 419 patients were included in the study(PS, 253 and NBC, 166). Primary cancers included pancreatic cancer in 194 patients(46%), bile duct cancer in 172(41%), gallbladder cancer in three(1%), and ampullary cancer in 50(12%). The median serum total bilirubin was 7.8 mg/d L and 324 patients(77%) had ≥ 3.0 mg/d L. During the median time to surgery of 29 d [interquartile range(IQR), 30-39 d]. PS/NBC dysfunction rate was 35% for PS and 18% for NBC [Subdistribution hazard ratio(SHR) = 4.76; 95%CI: 2.44-10.0, P 0.001]; the pig-tailed tip was a risk factor for PS dysfunction. Jaundice resolution was achieved in 85% of patients and did not depend on the drainage method(PS or NBC).CONCLUSION: PS has insufficient patency for preoperative biliary drainage. Given the drawbacks of external drainage via NBC, an alternative method of internal drainage should be explored.     

Removal of a large stone growing around and encasing a plastic biliary stent: Respect the ductal axis

Plastic biliary stents are commonly used during Endoscopic Retrograde Cholangio-Pancreatography (ERCP). The main indication for biliary stenting is benign or malignant obstruction. Plastic stents, among others, can be used as an escape route in patients with large common bile duct stones, or in cases of acute cholangitis with or without sphincterotomy to provide drainage until definitive treatment. Stent occlusion is the main disadvantage, limiting their patency to around 3 months, after which replacement is recommended. We present a case of a large, close to 2 cm, stone developing around and encasing the proximal end of a plastic biliary stent. The stent/stone complex was successfully removed en bloc. The stent was placed in the common bile duct without sphincterotomy, and remained in situ for 2 years. The presented case highlights the importance of definitive treatment for common bile duct stones, the need to respect the ductal axis especially when dealing with large stones and the significance of biliary sphincterotomy during endoscopic interventions in the bile duct.     

A randomised controlled trial of endoscopic sphincterotomy in acute cholangitis without common bile duct stones

BACKGROUND: Biliary decompression with endoscopic sphincterotomy (EPT) is beneficial in patients with biliary obstruction due to common bile duct (CBD) stones. However, it is not known whether EPT with decompression of the bile duct is beneficial in patients with acute cholangitis and gall bladder stones but without evidence of CBD stones. AIM: A randomised controlled study to assess the effect of EPT on the outcome of patients suffering from acute cholangitis with gall bladder stones but with no CBD stones on initial endoscopic retrograde cholangiopancreatography. PATIENTS: A total of 111 patients were recruited into the study. METHODS AND RESULTS: Fifty patients were randomised to receive EPT while 61 patients received no endoscopic intervention. There was a significant difference in the duration of fever in the EPT and non-EPT groups (mean (SD): 3.2 (2.2) days v 4.3 (2.1) days; p<0.001). Duration of hospital stay was also shorter in the EPT group than in the non-EPT group (mean (SD): 8.1 (3.0) v 9.1 (3.2) days; p=0.04). Patients were followed up for a mean (SD) of 42.4 (11.1) months. Twenty three patients (20.3%) developed recurrent acute cholangitis (RAC): 14 patients (12.6%) in the EPT group and nine patients (8.1%) in the non-EPT group (p=0.09). CONCLUSION: EPT in patients with acute cholangitis without CBD stones decreased the duration of acute cholangitis and reduced hospital stay but it did not decrease the incidence of RAC.     

Endoscopic management of postoperative bile leak

Significant bile leak is an uncommon but serious complication of biliary tract surgery. Of twenty-five patients presenting with postoperative bile leak, 11 had complete tie-off of common bile duct and required surgery, while the remaining 14 had injury without complete obstruction and could be managed by endoscopic methods. Of these 14 cases, bile leak occurred from the cystic duct in 11 patients and from the common hepatic duct, right hepatic duct and left hepatic duct in one patient each. Endoscopic procedures performed included sphincterotomy alone (four patients), sphincterotomy and stent placement (seven patients) and sphincterotomy followed by nasobiliary catheter drainage (three patients). There was no technical failure and bile leak was stopped in all patients. One patient died of haemobilia 5 days after stent placement. When technically feasible, postoperative bile leak can be managed safely and effectively by endoscopic methods, obviating the need for surgical reexploration.     

Endoscopic management of acute calculous cholangitis

Acute cholangitis is associated with significant morbidity and mortality. Endoscopic drainage procedures have been shown to be a safe and effective mode of treatment in acute cholangitis. As there is paucity of large series on endoscopic management of acute cholangitis, a study was performed to evaluate safety and efficiency of endoscopic biliary decompression in acute cholangitis. The study included 89 consecutive patients (mean age 55 ± 15 years; range 35–70 years; 50 males) with acute cholangitis requiring biliary drainage. Main presenting features were upper abdominal pain (84%), fever with chills (90%) and jaundice (74%). Altered sensorium, hypotension, features of peritonitis and acute renal failure were present in 15, 11, 18 and 5%, respectively. Endoscopic procedures performed were endoscopic sphincterotomy (ES) with stone extraction (n= 40); ES with endoscopic nasobiliary drainage (ENBD; n= 30); ENBD without ES (n= 8); and ES with stent placement (n= 11). Of the 89 patients, 85 (95%) responded within 48–72 h. Endoscopic common duct clearance could be achieved in 58 of 78 (74%) patients, whereas in 11 patients undergoing stent placement, stone extraction was not attempted. Complications included post-sphincterotomy bleed (n= 2), retroduodenal perforation (n= 1) and acute pancreatitis (n= 1) with an overall complication rate of 4.4%. All the complications were seen in patients undergoing ES with stone extraction. Mortality was 3.3%. In conclusion, endoscopic biliary drainage is a safe and effective mode of treatment for acute cholangitis. Endoscopic nasobiliary drainage or stent placement is safer than ES in acute cholangitis as an initial step.     

Additional endoscopic procedures instead of urgent surgery for retained common bile duct stones.

One hundred and twenty seven patients were treated by nasobiliary drainage, or stenting, to prevent biliary obstruction after endoscopic failure to clear stones from the common bile duct. At presentation, 91 (72%) patients were jaundiced and 39 (31%) had cholangitis. Placement of either a nasobiliary drain or stent was successful in 124 (98%) patients. One hundred and twenty one (95%) patients were followed up. Clearance was ultimately achieved endoscopically in 52 and surgically in 25 patients after (mean) 2.4 months. Thirty day mortality was 3%. There were no complications of nasobiliary drainage, but two of 39 patients treated by temporary stents developed cholangitis, both successfully managed by endoscopic duct clearance. Forty two patients unfit for surgery or further endoscopic attempts at duct clearance were followed with stents in situ for a mean 15.9 months (range 2.5-37.5). Cholangitis developed in four patients and was successfully managed by stent change. These results indicate that longterm stenting can be useful for poor risk surgical patients and that nasobiliary drainage or temporary stenting permits further elective rather than urgent endoscopic or surgical treatment.     

Endoscopic management of biliary leaks. The answer for the future

Bile duct diseases and biliary leaks are not uncommon complications and their management is challenging. Majority of bile leaks occur secondary to trauma, major liver, gallbladder and biliary tract surgeries. Early recognition of bile leaks by imaging combined with a high clinical suspicion is required. Bile leaks can be managed either conservatively, or through percutaneous drainage, or endoscopically or by surgical intervention. The innovations in endoscopic techniques have expanded the horizons for managing patients with bile leaks irrespective of their etiology. Endoscopic interventions through biliary sphincterotomy alone, biliary stenting with or without sphincterotomy, and nasobiliary drainage with or without sphincterotomy, use of self expanding covered metal stents and the recent use of biodegradable stents have been very effective in the management of all kinds of biliary leaks. All endoscopic techniques are based on the principle that eliminating the rise in pressure inside the bile duct by promoting decompression in the form of stent placement/sphincterotomy promotes healing of bile leaks. Further future developments in endoscopic techniques are expected to improve their effectiveness in managing patients with bile leaks.     

Aeromonas infection in acute suppurative cholangitis: review of 30 cases

OBJECTIVES: Aeromonads, though not common pathogens in biliary sepsis, caused substantial mortality in patients with impaired hepatobiliary function. Our aim was to study the pathogenic role of Aeromonas in acute suppurative cholangitis. METHODS: Between 1996 and 1998, the medical records of patients with a diagnosis of biliary sepsis were reviewed. Those who fulfilled the diagnostic criteria for acute suppurative cholangitis and had positive bile or blood cultures for Aeromonas species were studied. RESULTS: One thousand and forty-five patients were confirmed to have acute suppurative cholangitis. Of these, 30 patients (2.9%) had Aeromonas species isolated from bile; four were complicated by aeromonas septicaemia with simultaneous recovery of the bacteria from blood. All except two isolates were A. hydrophila. Twenty-four patients (80%) had bile duct stones, four (13%) had cholangiocarcinoma and two (7%) pancreatic cancer. Twenty-five cases (83%) had previous exploration of the biliary tract. There was substantial resistance to piperacillin (58%), ceftazidime (30%) and imipenem (15%). Most patients improved after biliary decompression. Only three patients (10%) died, two had terminal malignancy and one had end-stage liver failure. No excess mortality was attributable to Aeromonas infection in biliary sepsis. CONCLUSIONS: Previous instrumentation facilitated ascending Aeromonas infection of the biliary tract from the gastrointestinal tract. Unlike early reports, our results showed that aeromonads did not adversely affect the clinical outcome of acute suppurative cholangitis with successful drainage of biliary obstruction.     

Endoscopic diagnosis and treatment of biliary leak in patients following liver transplantation:a prospective clinical study

Introduction As a choice of therapy, orthotopic liver trans- plantation (LT) is widely applied to end- stage liver disease. However, 13%-35% of procedures are complicated by problems of the biliary tract, the most common being stricture and leakage.[1-5] In an analysis of 259 LT recipients, Hwang et al[6] found 12 episodes of anastomotic bile leak and 42 episodes of anastomotic stenosis in 50 recipients. For choledochocholedochostomy cases, the common types of biliary leak are T-tube and an…