Removable intraductal stenting in duct-to-duct biliary reconstruction in liver transplantation

Biliary reconstruction during liver transplantation (LT) is most oftenly performed by duct-to-duct biliary anastomosis. We hypothesized that the internal stenting might diminish the incidence and severity of biliary complications in patients receiving small duct size donor grafts. The purpose of this study was to report a technique of biliary reconstruction, including intraductal stent tube (IST) placement followed by postoperative endoscopic removal. A custom-made segment of a T-tube was placed into the bile in 20 patients in whom the diameter of the graft bile duct was smaller than 5 mm. The tube was removed endoscopically 4-8 months after LT, or in case of IST-related adverse events. After a median follow-up of 15.2 (range 2.5-27.5) months, endoscopic removal of the IST was performed in 17 patients. No technical failure and no procedure-related complications were recorded during drain removal. Biliary complications occurred in four patients, including one cholangitis, one hemobilia, one asymptomatic biliary leakage, and one anastomotic stricture. No biliary complication occurred in the group of patients who underwent deceased donor whole graft LT. IST is technically feasible and safe, and may help to prevent severe biliary complication when duct-to-duct biliary anastomosis is performed on small size bile ducts.     

Plasma secretin levels in total pancreatectomy and pancreaticoduodenectomy

The secretory response of plasma secretin to intrajejunal acid was measured in 11 patients who underwent total pancreatectomy and eight with pancreaticoduodenectomy. In cases of pancreaticoduodenectomy, the secretory response of plasma secretin was well maintained, but in those with total pancreatectomy there was a significantly impaired secretory response of plasma secretin. Among patients with total pancreatectomy, those with Billroth II type anastomosis showed a significantly impaired response compared with those with Billroth I type anastomosis. Thus biliary secretion is more impaired in patients with total pancreatectomy than in those with pancreaticoduodenectomy. To improve the impaired biliary secretion after total pancreatectomy, Billroth I type anastomosis for reconstruction procedure of the alimentary tract appears to be more feasible. In the case of the major pancreatectomy, much attention should be given biliary secretion and such may decrease the possibility of occurrence of ulcer at the anastomosis and improve the digestion-absorption of fat.     

Synthetic bioabsorbable stent material for duct-to-duct biliary reconstruction

Biliary stricture remains a significant cause of morbidity after liver transplantation. We performed duct-to-duct biliary anastomosis by using an absorbable stent tube with a diameter equal to that of pig common bile duct as an internal stent. The stent tube was constructed using a synthetic biodegradable material-a lactic glycolic acid and epsilon-caprolactone copolymer. Three pigs were alive without cholestasis for 180 d; however, 1 pig died on the 65th postoperative d, and autopsy revealed no cholestasis or biliary sledge in the biliary stent tube. The 3 pigs were euthanized for histological examinations 180 d after surgery; the biliary stent tube was completely absorbed by this time. These experimental results showed the good patency of the absorbable biliary stent tube. In the future, the absorbable biliary stent tube is expected to be clinically developed as a biliary stent for biliary anastomosis, which may protect the biliary anastomotic stricture.     

Technique of bile duct reconstruction and management of biliary complications in right lobe living donor liver transplantation

From December 1999 to January 2002, 50 right lobe living donor liver transplantations were performed. The donor operations included an intraoperative cholangiography to elicit variations in bile duct anatomy. The biliary reconstruction was done whenever possible as an end-to-end microanastomosis of the donor right hepatic duct with the recipient's bile duct. As a result of the early segmental branching of the donor biliary tree, two segment bile ducts had to be anastomosed in 20 patients and three segment bile ducts in three patients. In 12 patients, a Roux-en-Y hepaticojejunostomy was performed. All anastomoses were drained externally. We observed two leakages at the resection surface which could be treated successfully by an external drainage. Six leaks occurred at the site of end-to-end biliary anastomoses. Twice the problem could be conservatively solved placing a stent percutaneously. In two patients a hepaticojejunostomy was performed after a bile duct necrosis. In two patients with an anastomotic leak, occurring 3 d, respectively, 3 month after the original transplantation, the bile duct could be directly reconstructed over a T-tube. Two anastomotic stenoses were observed, one in combination with a leak treated by percutaneous stent implantation and the second, 3 month after transplantation which was treated surgically. Biliary reconstruction after living donor liver transplantation requires microsurgical techniques and can be performed as a direct end-to-end anastomosis in most cases. Biliary complications were treated by percutaneous drainage or surgical revision in all cases.     

经皮经肝胆道引流术联合胆道球囊扩张术治疗良性胆肠吻合口狭窄

目的评估经皮经肝胆道引流术联合胆道球囊扩张术治疗良性胆肠吻合口狭窄的有效性及安全性。方法回顾性分析经皮经肝胆道引流术联合胆道球囊扩张术治疗的良性胆肠吻合口狭窄患者14例,记录手术成功率、引流管拔除率、手术相关并发症,并随访胆肠吻合口长期开通情况。结果对所有患者均一次性成功实施经皮经肝胆道引流术,手术成功率100%(14/14),行胆道球囊扩张术1~6次,平均(3.0±1.8)次,胆道球囊直径8~10mm,单次球囊扩张时间1~3min。引流管拔除率85.71%(12/14),可夹闭引流管、但需间断开放引流管者占14.29%(2/14)。14例患者术后总胆红素、直接胆红素、丙氨酸氨基转移酶、天冬氨酸氨基转移酶、碱性磷酸酶、γ-谷胺酰转肽酶较术前均明显下降(P均0.05)。所有患者术中、术后生命体征平稳,1例患者因术中疼痛需静脉麻醉处理。随访6~54个月,中位随访时间17.5个月,吻合口开放良好。结论经皮经肝胆道引流术联合胆道球囊扩张术处理良性胆肠吻合口狭窄临床效果好,患者耐受性良好,手术并发症少。     

Metastatic seeding of bile duct carcinoma in the transhepatic catheter tract: Report of a case

We describe herein the case of a 51-year-old woman in whom metastatic tumor seeding of the percutaneous transhepatic biliary drainage tract occurred following a pancreatoduodenectomy for carcinoma of the distal common bile, duct. An abdominal computed tomography scan done 6 months after the initial operation detected a hepatic lesion located at the site of the previous percutaneous transhepatic biliary drainage tract. Implantation of bile duct carcinoma in the drainage tract was diagnosed, and the recurrent tumor was successfully resected by performing a subsegmentectomy of segment 3 and removal of the adjacent abdominal wall. At present, 5 years and 4 months after the second resection, the patient is in good health without any signs of recurrence. This case report demonstrates that an aggressive surgical approach should be performed for tumor seeding of a transhepatic biliary catheter tract.     

肝移植术后早期非肝动脉栓塞性胆道缺血性损伤并发症的预防

目的：探讨肝移植术后早期非肝动脉栓塞性胆道缺血性损伤并发症的预防。方法：对60例同种原位背驮式肝移植病人术中、术后采用改善供肝血液循环的策略。结果：术后6个月内出现胆道并发症3例，发生率为5％（5／60），1例因拔T管时发生胆漏；1例经T管胆道造影导致胆道感染，胆泥形成；1例胆道吻合口渗漏。结论：肝移植术中、术后扩张血管、改善胆管微循环是预防术后早期非肝动脉栓塞性胆道缺血性损伤并发症的重要措施。     

Staged repair of type A interrupted aortic arch using the Blalock-Park method in infancy: development of the reconstructed aortic arch

Three infants with type A interrupted aortic arch, VSD and PDA underwent staged operation. Aortic arch reconstruction with Blalock-Park's method, PDA division, and PA banding were performed as the first operation. Subsequently all patients were underwent the second operation, consisting of VSD closure and PA debanding, and are doing well now. Pressure gradient at the anastomosis site, the diameters of the anastomosis site and the left subclavian artery, and the diameter ratios of the anastomosis site and the left subclavian artery to the ascending aorta were evaluated after the first and second operation. Two patients with good size of the left subclavian artery at the first operation showed excellent growth of the reconstructed aortic arch and trivial pressure gradient at the anastomosis site. The other patient, whose preoperative left subclavian artery was small (2.5 mm in diameter) resulted in residual stenosis at the anastomosis site. The development of the left subclavian artery was satisfactory in all patients. These data suggest that the aortic arch reconstructed with Blalock-Park's method can grow if the diameter of the anastomosis site has adequate size at the first operation.     

Nonsurgical policy for treatment of bilioenteric anastomotic stricture after living donor liver transplantation.

Biliary complications remain a significant cause of morbidity following living donor liver transplantation. The purpose of this retrospective study was to assess the outcome of nonsurgical management for hepatojejunostomy stricture in our institution. We reviewed 22 patients with hepatojejunostomy stricture among the 231 patients who underwent living donor liver transplantation between June 1990 and December 2005. Hepatojejunostomy stricture was confirmed by percutaneous transhepatic or endoscopic retrograde cholangiography. Anastomotic strictures were treated by balloon dilatation. Percutaneous transhepatic cholangiography was performed on 15 of the 22 patients. Two of 15 patients, with complete obstruction of the anastomosis, were treated successfully by Yamanouchi magnet compression anastomosis. Although another two patients died of infectious disease that was unlikely to have been related to biliary complications, anastomotic patency was maintained in the other 13 patients. Endoscopic retrograde cholangiography was performed on seven of the 22 patients. None of the 22 patients required re-operation or died of biliary complications. The 5-year graft survival rate of 85.6% in the 22 patients with stricture was equivalent to that of the patients without stricture (82.9%, P = 0.98). Advances in intervention techniques have enabled wider application of nonsurgical approaches for this complication, and fair results have been obtained.     

Pathophysiologic mechanisms in patients with cholangitis or obstructive jaundice: Results of a cholangiographic study

Bacterial reflux from the biliary tract to the systemic circulation is considered to be the primary etiologic factor in bacteremia and the development of sepsis. However, as the pathophysiologic features of the biliary tract that may promote such a reflux of biliary bacteria remain unclear, we investigated, using direct cholangiography, the pathophysiologic relationship between the intrahepatic bile ducts and biliary reflux into the systemic circulation after the percutaneous infusion of a contrast material containing indocyanine green (ICG) into the circulating blood. The subjects were 19 patients who underwent percutaneous transhepatic cholangiography with drainage to treat either a biliary infection or obstructive jaundice, an 8 post-T-tube control patients with normal biliary drainage. The relationship between the biliary tract pressure and ICG reflux during cholangiography was also analyzed. An ICG reflux was observed in all 19 patients who had undergone percutaneous transhepatic cholangiography with drainage and in 2 of the 8 control patients. In all patients who showed positive ICG reflux, this occurred when the biliary pressure increased to 25cm H₂O. An ICG reflux was seen in the 16 patients with a positive bile culture, and in 7 of 13 patients with a negative bile culture. When we analyzed ICG reflux in relation to the morphology of the intrahepatic bile duct, we found that all 4 patients who had cholangitic hepatic abscesses also exhibited higher ICG reflux concentrations and the clinical symptoms of cholangitis. Radiologically, all 7 patients with cholangitis demonstrated many small intrahepatic branches, and they exhibited moderate ICG refluxes, whereas the 6 patients who had obstructive jaundice but no cholangitis had fewer ICG refluxes and no clinical symptoms. This study demonstrated two possible pathophysiological routes for biliary reflux: (1) via cholangitic hepatic abscesses, with entry of the bacteria directly into the circulating blood, or (2) via the small intrahepatic biliary branches, in which entry of bacteria into the systemic circulation occurs through the cholangioles.     

Stoma-related variceal bleeding: an under-recognized complication of biliary atresia

The medical records of 52 children with biliary atresia treated by portoenterostomy and evaluated for liver transplantation were reviewed to determine the frequency of stoma variceal bleeding and the optimal strategies for prevention and treatment. Eighteen patients had had prior stoma closure, four by preperitoneal closure without takedown from the abdominal wall. Three of the four developed occult variceal bleeding from the stoma closure site. Twenty-two patients had a stoma present at evaluation. All 22 patients with stomas (100%) had at least one bleeding episode requiring transfusion. Treatment included transfusion and local pressure (9), suture ligation of the bleeding site (5), and stoma closure and/or takedown (11). Local treatment led to recurrences in eight of 14 (57%) of the cases. To reduce the high mortality in patients with biliary atresia awaiting liver transplantation, multiple variceal bleeding episodes should be prevented. To eliminate one source, stoma variceal bleeding, the stoma, whether functioning or nonfunctioning should be taken down and closed. Preperitoneal closure alone does not prevent stoma bleeding.     

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目的探讨原位肝移植术后非吻合口胆管狭窄(NABS)的预防和治疗措施。方法对2004年1月至2006年12月中山大学附属第一医院收治的516例同种原位肝移植病人的临床资料进行回顾性分析。总结肝移植术后发生NABS的情况。结果共发生NABS18例(3.5%),其中肝门部胆管狭窄9例,肝内胆管多发狭窄6例,肝内外胆管多发狭窄3例。18例病人采用给予反复的介入、内镜治疗、外科重建胆道及再次肝移植治疗。该组近期临床治愈率为55.6%(10/18),与NABS相关的再次肝移植率为38.9%(7/18),与NABS相关病死率为22.2%(4/18)。结论肝移植术后发生NABS临床处理棘手,应注重预防。NABS的治疗主要包括介入治疗和手术治疗,其中胆管介入治疗在NABS的临床处理中仍占重要地位,对于介入治疗、外科手术重建胆道等措施均无法控制其进行性发展的重度NABS病人,应把握好时机行再次肝移植。     

ERCP治疗医源性胆道损伤应用价值（附27例分析）

目的 探讨ERCP对医源性胆道损伤的诊断与治疗。方法 回顾2009年1月至2011年1月收治的医源性胆道损伤27例,先行ERCP检查,明确损伤的部位、性质及程度,继而行内镜下乳头括约肌切开（EST）,胆道球囊扩张及鼻胆管引流（ENBD）或胆道内支架植入术（ERBD）。结果 27例胆道损伤病人,除1例恶性肿瘤病人死于肿瘤转移,其余26例病人临床症状完全缓解;10例胆瘘者内镜引流术,腹腔平均胆汁引流量由术前300mL/d减至50mL/d以下,两者比较有显著性减少（P<0.01）,窦道多在1~2周内自行愈合。发生黄疸者19例,治疗后第1天平均总胆红素由术前（65.2±11.6）μmol/L下降到（31.6±9.1）μmol/L,治疗前后相比有显著性降低（P<0.01）。3例患者术后出现一过性血淀粉酶增高,4～6d后恢复正常,1例出现胆道感染,无出血、穿孔和急性胰腺炎发生。结论 ERCP可作为处理胆道手术并发症如大流量胆瘘和或胆道狭窄的首选治疗。内镜下乳头括约肌切开鼻胆管引流能降低胆道内的压力,减少瘘口流量,促进瘘口闭合;大口径内支架植入能有效扩张狭窄胆管,有利于胆汁排泄通畅。     

Early variceal rebleeding after successful distal splenorenal shunt

Of 77 patients with repeated variceal hemorrhage who underwent distal splenorenal shunt, five (6.5%) developed rebleeding despite a patent splenorenal anastomosis. Three of the five patients died. Early variceal rebleeding usually indicates shunt thrombosis but may occur with a patent anastomosis. Anatomic or functional left renal vein and/or splenic vein hypertension producing incomplete variceal decompression is generally the cause. Ineffective separation of the main portal vein from the gastrosplenic venous plexus may coexist and further intensify variceal congestion. Urgent angiographic studies and direct shunt catheterization with measurement of splenic vein, left renal vein, and inferior vena cava pressures should be performed to plan appropriate therapy. A significant gradient between the splenic and renal veins is evidence of an unsatisfactory anastomosis and should be managed by balloon angioplasty or reoperation. High splenic and left renal vein pressures with a gradient of more than 10 mm Hg between the renal vein and the inferior vena cava indicate renal vein hypertension. Initial therapy should include serial injection sclerotherapy, as renal vein hypertension will usually resolve over time as additional collaterals develop. However, persistent or recurrent variceal hemorrhage may require total portal decompression to bypass the restrictive left renal vein segment.     

胆道自脱落支架在老年胆总管结石患者胆管一期缝合中的应用体会

目的总结老年患者胆总管切开取石胆道自脱落支架置入的临床体会。方法分析27例胆结石老年患者行胆总管切开取石术的术式及病例资料特点。结果 13例在腹腔镜下全部完成胆总管切开取石胆道自脱落支架置入术,14例开腹胆总管切开取石胆道自脱落支架置入术,并发症少,无死亡病例。结论胆总管切开探查取石、胆道自脱落支架置入术具有安全可靠、患者损伤小、康复快、住院时间短等优点,是治疗老年胆总管结石的有效术式。     

Unusual Bleeding From Hepaticojejunostomy Controlled by Adult Variable Stiffness Colonoscopy: Report of a Case and Literature Review

We herein present a case of a 59-year-old man who had undergone pylorus preserving pancreaticoduodenectomy with regional lymph node dissection prior to episodes of melena. Series of conventional endoscopic investigations failed to identify the bleeding source. Enhanced computed tomography scan revealed complete obstruction of the main portal vein with numerous collateral veins running towards the hepatic hilus. Comprehensively, hemorrhage from the jejunal varices caused by postoperative portal hypertension was highly suspected. As the jejunal loop was out of reach, adult variable-stiffness colonoscope (AVSC) was utilized to solve the Roux-en-Y anatomy. Numerous telangiectasis and small varices at hepaticojejunostomy were observed and in the mean time, bleeding was noticed and endoclips were placed without any delay. Ectopic variceal bleeding in jejunal loop after pancreaticoduodenectomy is difficult to manage. We believe that AVSC is an alternative device when specialized jejunal endoscopy is not available.Key words: Hepaticojejunostomy, Adult variable stiffness colonoscopy, Endoclip, Jejunal varicose vein, Portal hypertensionBleeding ectopic varices in the jejunal loop after biliary reconstruction is a rare entity.¹ Management of such bleeding is difficult and is not well defined. Here, we report a case of a pancreatic cancer patient who had pylorus-preserving pancreaticoduodenectomy (PD) 2.5 years prior to variceal bleeding at hepaticojejunostomy (HJ) anastomosis (Roux-en-Y fashion). We successfully treated this out-of-reach afferent jejunal loop bleeding by using adult variable stiffness colonoscopy (AVSC).     

胆道出血的原因诊断与治疗

目的探讨胆道出血的原因、诊断及处理方法。方法对我院收治的32例胆道出血患者的出血原因、诊断与治疗进行回顾性分析。结果 32例患者中术前出血患者21例,其中胆道结石伴感染15例,肝肿瘤2例、肝门部胆管癌2例,胆囊癌1例,肝脓肿1例;术中出血患者4例,均为胆道取石术中出血,3例为胆管壁损伤出血,1例为结石卡压致左肝内胆管左门静脉瘘出血;术后出血患者7例,其中胆总管切开取石术后4例,胆肠吻合术后1例,经皮肝穿术后2例。10例保守治疗,9例痊愈,1例死亡。5例行肝动脉血管造影与介入栓塞治疗,4例止血成功,1例失败后手术治愈。13例行手术治疗,均痊愈。4例术中出血,3例采用胆道镜直视下电凝法治疗,1例行左半肝切除治愈。结论胆道结石伴感染是胆道出血的主要原因,近年来医源性操作及创伤性胆道出血逐年增多,及时分析胆道出血的原因,做出正确的诊断,根据不同的病因,选择合适的治疗方法,可提高胆道出血的治疗效果原因。     

Metastatic Biliary Polypoid Thrombus from Renal Cell Carcinoma: Report of a Case

We report an extremely rare case of metastatic biliary polypoid thrombus with hepatic metastases from renal cell carcinoma. A 74-year-old man was admitted with a low-grade fever and obstruction of the left hepatic duct. He had undergone left nephrectomy 17 years previously due to a diagnosis of renal cell carcinoma. A preoperative diagnosis of left hepatic duct carcinoma was made, and a left lobectomy and left caudate lobectomy with right biliary anastomosis of jejunal loop were performed. The resected specimen showed a polypoid mass in the left hepatic duct with metastases in the caudate lobe, and a histological examination revealed both tumors to be clear cell-type renal cell carcinoma. The mechanism of biliary metastatic thrombus formation was speculated to be as follows: caudate lobe metastases invade the adjacent bile ducts, and a tumor fragment in the bile duct then becomes implanted in the intraluminal left hepatic duct, thus leading to the growth of the biliary polypoid thrombus. Received: April 16, 2001 / Accepted: November 20, 2001     

Acute Abdomen Secondary to a Spontaneous Perforation of the Biliary Tract,a Rare Complication of Choledocholithiasis

IntroductionThe spontaneous perforation of the biliary tract (SPBT) is an extremely rare cause of peritonitis, which was first described by Freeland in 1982, to date only around 70 cases have been reported. Here we present a case of spontaneous perforation of the biliary tract, in a patient with choledocholithiasis, which was treated with ultrasound-guided drainage and ERCP.Case reportA 51-year-old male was admitted to the emergency room for 15-day evolution jaundice, localized pain in the right flank and hypochondrium of 3 days. He had a history of cholecystectomy 15 years ago and 4 episodes of cholangitis, the last one in 2015. A magnetic resonance imaging (MRI) was performed, that showed evidence of choledocholithiasis, in addition to a possible biliary leakage. The patient was treated with ultrasound-guided drainage and ERCP successfully.DiscussionSpontaneous perforation of the biliary tract is a disease entity in which wall of the extrahepatic or intrahepatic duct is perforated without any traumatic or iatrogenic injury. The clinical presentation varies from nonspecific abdominal pain to biliary peritonitis, in most of the cases forming bilomas. Universal management involves decompression of the biliary tree and repair of the leak site.ConclusionThe spontaneous perforation of the biliary tract is a disease that represents a diagnostic challenge. The treatment in the patients with SPBT is not well established and has to be individualized for each case, depending on the history of the patient, the site of perforation, the time of evolution, the suspicion of infection, and the patient status.     

Endoscopic treatment of biliary complications after right-lobe living-donor liver transplantation with duct-to-duct biliary anastomosis

BACKGROUND/PURPOSE: The aims of this study were to characterize the features of the biliary complications that occur after right-lobe living-donor liver transplantation (RL-LDLT) with duct-to-duct biliary anastomosis, and to evaluate the efficacy of treating biliary complications endoscopically. METHODS: The records of 273 consecutive patients who underwent RL-LDLT with duct-to-duct biliary anastomosis from July 1999 through July 2005 at Kyoto University Hospital were reviewed to determine the overall incidence of postoperative biliary complications and the outcome of endoscopic repair of those complications. RESULTS: Biliary complications occurred in 93 (34.1%) of the patients. These complications were: 80 biliary strictures (75 anastomotic and 5 nonanastomotic) and 16 biliary leakages (5 patients with biliary leakage also had a biliary stricture); most (72%) of the anastomotic strictures were complex (i.e., fork-shaped or trident-shaped). The strictures and leakages were repaired by the endoscopic placement of multiple inside stents above the sphincter of Oddi, and by nasobiliary drainage, respectively. The procedure was successful in repairing 51 (68.0%) of the anastomotic strictures and 8 (50.0%) of the biliary leakages. CONCLUSIONS: Endoscopic stenting of the bile ducts is efficacious in treating biliary complications related to RL-LDLT with duct-to-duct biliary anastomosis and the stenting should be attempted before surgical revision of strictures and leakages.