Randomized cross-over trial comparing albumin and frusemide infusions in nephrotic syndrome

The contribution of hypoalbuminemia to impaired diuretic responsiveness can be overcome by administering larger doses of loop diuretics. However, the clinical efficacy of the combination of loop-acting diuretics with human albumin remains controversial. In the study reported here, 16 children with nephrotic syndrome and refractory edema were randomized in a cross-over trial to receive either the combination of 20% human albumin and frusemide infusion (HA+FU infusion group) or frusemide infusion alone (FU infusion group). At the end of study, median urine volume was 3.27 [95% confidence interval (CI) 2.04–4.50] ml/kg per hour in the HA+FU infusion group and 1.33 (95% CI 0.79–1.88) ml/kg per hour in the FU infusion group (P = 0.01); the median daily sodium excretion was 58 (95% CI 30–366) mEq and 30 (95% CI 10–122) mEq (P = 0.08), respectively The changes in other variables included weight loss [HA+FU 5.2% (95% CI 3.1–8.8); FU 0.8% (95% CI −1.9 to 4.1); P = 0.006]; urine osmolality [HA+FU 315 (95% CI 220–426) mOsm/kg; FU 368 (95% CI 318–446) mOsm/kg; P = 0.13]; osmolal clearance [HA+FU 1600 (95% CI 916–4140) ml/day; FU 880 (95% CI 510–2105) ml/day; P = 0.01; free water clearance [HA+FU −190 (95% CI −960 to 280) ml/day; FU −162 (95% CI −446 to −70) ml/day; P = 0.18]. The findings from this study suggest that the co-administration of albumin and frusemide infusions is more effective than the administration of frusemide infusion alone in inducing diuresis and natriuresis in patients with nephrotic syndrome.     

Laparoscopic common bile duct exploration in patients with previous abdominal biliary tract operations

A history of abdominal biliary tract surgery has been identified as a relative contraindication for laparoscopic common bile duct exploration (LCBDE), and there are very few reports about laparoscopic procedures in patients with a history of abdominal biliary tract surgery. We retrospectively reviewed the clinical outcomes of 227 consecutive patients with previous abdominal biliary tract operations at our institution between December 2013 and June 2019. A total of 110 consecutive patients underwent LCBDE, and 117 consecutive patients underwent open common bile duct exploration (OCBDE). Patient demographics and perioperative variables were compared between the two groups. The LCBDE group performed significantly better than the OCBDE group with respect to estimated blood loss [30 (5–700) vs. 50 (10–1800) ml; p = 0.041], remnant common bile duct (CBD) stones (17 vs. 28%; p = 0.050), postoperative hospital stay [7 (3–78) vs. 8.5 (4.5–74) days; p = 0.041], and time to oral intake [2.5 (1–7) vs. 3 (2–24) days; p = 0.015]. There were no significant differences in the operation time [170 (60–480) vs. 180 (41–330) minutes; p = 0.067]. A total of 19 patients (17%) in the LCBDE group were converted to open surgery. According to Clavien’s classification of complications, the LCBDE group had significantly fewer postoperative complications than the OCBDE group (40 vs. 57; p = 0.045). There was no mortality in either group. Multiple previous operations (≥ 2 times), a history of open surgery, and previous biliary tract surgery (including bile duct or gallbladder + bile duct other than cholecystectomy alone) were risk factors for postoperative adhesion (p = 0.000, p = 0.000, and p = 0.000, respectively). LCBDE is ultimately the least invasive, safest, and the most effective treatment option for patients with previous abdominal biliary tract operations and is especially suitable for those with a history of cholecystectomy, few previous operations (< 2 times), or a history of laparoscopic surgery.     

Laparoscopic Deployment of Biliary Self-Expandable Metal Stent (SEMS) for One-Step Palliation in 23 Patients with Advanced Pancreatico-Biliary Tumors—a Pilot Trial

Background Exploratory laparoscopy is commonly undertaken in patients with highly suspicious biliary and pancreatic lesions to facilitate diagnosis and staging cancer is present. If an unresectable tumor is identified, a second endoscopic procedure may be required do deploy a self-expandable metal stent (SEMS) for palliation. As endoscopic retrograde cholangio pancreatography (ERCP) may be unsuccessful in up to 20% of patients, we evaluated the feasibility and safety of deployment of self-expandable metal stents at the same time as the initial laparoscopy. Patients and Methods A total of 23 eligible patients (8 male and 15 female) with malignant obstruction of the common bile duct underwent deployment of SEMS at laparoscopy. Primary outcome measure was the successful laparoscopic deployment of stent and secondary outcome measure was complications rates. Results Indications for stent deployment were unresectable pancreatic cancer in 18, cholangiocarcinoma in two, neuroendocrine tumor in one and ampullary adenocarcinoma in two patients. The median age was 73 years (range 49–93). Twenty-two of 23 stents were deployed successfully: 17 stents were deployed transcystically and five via a choledochotomy. Median times for laparoscopic exploration and SEMS deployment were 165 min (range 105–230) and 20 min (range 10–50), respectively. Pre- and post-procedures median total bilirubin were 9.4 mg/dl (range 5.4–17.5) and 4.0 (range 2.6–7.1). The median size of the pancreatic mass was 3 cm (range 2–5 cm) and that of the common bile duct (CBD) from 9.2 mm (range 7.2–17.4). The mean duration of laparoscopy was 170 min (range 120–230 min) and that for stent deployment 23 min (range 10–50 min). Complications included bleeding, obstruction, and wound infection. Bleeding occurred on day 7 in two patients and on day 30 in one patient; bleeding occurred at the gastrojejunal anastomosis site and was successfully treated with endoscopic hemostasis. A total of three stent obstructions were identified: one each at 60, 90, and 120 days follow-up. All complications were successfully managed endoscopically. There were a total of seven deaths, six as a result of progressive cancer and one of surgical wound infection and ensuing complications. Conclusion This study demonstrates that laparoscopic deployment of self-expandable metal bile duct stents is feasible and safe. This option appears to be a reasonable option in patients with inoperable malignant obstruction of the distal common bile duct.     

Comparing the efficacy of initial percutaneous transhepatic biliary drainage and endoscopic retrograde cholangiopancreatography with stenting for relief of biliary obstruction in unresectable cholangiocarcinoma

In patients with cholangiocarcinoma (CC), management of biliary obstruction commonly involves either up-front percutaneous transhepatic biliary drainage (PTBD) or initial endoscopic retrograde cholangiopancreatography (ERCP) with stent placement. The objective of the study was to compare the efficacy and of initial ERCP with stent placement with efficacy of initial PTBD in management of biliary obstruction in CC. A single-center database of patients with unresectable CC treated between 2006 and 2017 was queried for patients with biliary obstruction who underwent either PTBD or ERCP. Groups were compared with respect to patient, tumor, procedure, and outcome variables. Of 87 patients with unresectable CC and biliary obstruction, 69 (79%) underwent initial ERCP while 18 (21%) underwent initial PTBD. Groups did not differ significantly with respect to age, gender, or tumor location. Initial procedure success did not differ between the groups (94% ERCP vs 89% PTBD, p = 0.339). Total number of procedures did not differ significantly between the two groups (ERCP median = 2 vs. PTC median = 2.5, p = 0.83). 21% of patients required ERCP after PTBD compared to 25% of patients requiring PTBD after ERCP (p = 1.00). Procedure success rate (97% ERCP vs. 93% PTBD, p = 0.27) and rates of cholangitis (22% ERCP vs. 17% PTBD, p = 0.58) were similar between the groups. Number of hospitalizations since initial intervention did not differ significantly between the two groups (ERCP median = 1 vs. PTC median = 3.5, p = 0.052). In patients with CC and biliary obstruction, initial ERCP with stent placement and initial PTBD both represent safe and effective methods of biliary decompression. Initial ERCP and stenting should be considered for relief of biliary obstruction in such patients in centers with advanced endoscopic capabilities.     

Surgical management of spontaneous intrabiliary rupture of hydatid liver cysts

Abstract. Purpose: The most common complication of hydatid liver cysts is spontaneous rupture into the biliary tract. This study was conducted to evaluate the surgical management of spontaneous intrabiliary rupture of a hydatid liver cyst in 41 patients. Methods: The preoperative diagnosis was confirmed by ultrasound in all 41 patients, 37 of whom were jaundiced. Results: According to Gharbi's classification, 39% of the cysts were type III and they ranged from 3 to 18 cm in diameter, with a mean diameter of 9 cm. The mean total bilirubin and alkaline phosphatase values were 6.3 mg/dl and 450 IU, respectively. Partial cystectomy, cholecystectomy, and common bile duct exploration were performed in all patients. In seven patients, the visible biliary duct within the cyst cavity was sutured with 2/0 silk. Intraoperative cholangiography was performed in all patients, and choledochoscopy was performed in 11 patients. A T-tube was inserted after the biliary tract content was thought to have been totally cleaned out in 38 patients (93%), and a choledochoduodenostomy was performed in 3 patients (7%). An external biliary fistula developed in five patients, persisting for 11–25 days. The fistulae healed within a mean period of 5 days after endoscopic sphincterotomy (EST). For patients without a fistula the mean hospitalization time was 8 days and there was no mortality. Conclusion: These results suggest that when a hydatid liver cyst ruptures into the biliary tract, common bile duct exploration should be conducted using intraoperative cholangiography and choledochoscopy. If the biliary tract is cleaned of all cystic content, T-tube drainage should be sufficient, but EST is an effective technique for treating persistent extended external biliary fistulae. Received: September 26, 2001 / Accepted: January 8, 2002     

Duodeno-Gastric-Esophageal Reflux—What is Pathologic? Comparison of Patients with Barrett’s Esophagus and Age-Matched Volunteers

Introduction The aim of the study was to analyse pH- and bile-monitoring data in patients with Barrett’s esophagus and in age- and gender-matched controls. Subjects and Methods Twenty-four consecutive Barrett’s patients (8 females, 16 males, mean age 57 years), 21 patients with esophagitis (10 females, 11 males, mean age 58 years), and 19 healthy controls (8 females, 11 males, mean age 51 years), were included. Only patients underwent endoscopy with biopsy. All groups were investigated with manometry, gastric and esophageal 24-h pH, and simultaneous bile monitoring according to a standardized protocol. A bilirubin absorption >0.25 was determined as noxious bile reflux. The receiver operator characteristic (ROC) method was applied to determine the optimal cutoff value of pathologic bilirubin levels. Results Of Barrett’s patients, 79% had pathologic acidic gastric reflux (pH<4 >5% of total measuring time). However, 32% of healthy controls also had acid reflux (p < 0.05) without any symptoms. The median of esophageal bile reflux was 7.8% (lower quartile (LQ)–upper quartile (UQ) = 1.6–17.8%) in Barrett’s patients, in patients with esophagitis, 3.5% (LQ–UQ = 0.1–13.5), and in contrast to 0% (LQ–UQ = 0–1.0%) in controls, p = 0.001. ROC analysis showed the optimal dividing value for patients at more than 1% bile reflux over 24 h (75% sensitivity, 84% specificity). Conclusion An optimal threshold to differentiate between normal and pathological bile reflux into the esophagus is 1% (24-h bile monitoring with an absorbance >0.25).     

经内镜胆管内支架置入术对良恶性胆管梗阻的临床应用

目的探讨经内镜胆管内支架置入术对各种良恶性胆管梗阻的治疗效果。方法95例良恶性胆管梗阻病人先行内镜逆行胰胆管造影（ERCP）检查,确定胆管梗阻病变部位和性质后,再决定使用内镜下塑料胆道支架引流（ERBD）和内镜下金属胆道支架引流（EMBE）。结果95例患者中92例插管成功,成功率96.84%（92/95）。针对良性胆管梗阻行ERBD 28例,主要见于胆总管结石;针对恶性胆管梗阻行ERBD 44例,行EMBE 20例,主要见于胰头癌、胆管癌、壶腹癌、原发性肝癌及肝门、肝内转移压迫胆管,所有病例均在引流后总胆红素及直接胆红素明显下降。结论：经内镜下胆管内支架引流术的应用愈来愈广泛,其操作安全而有效,特别是对各种良恶性病变引起的胆管梗阻起了关键性的治疗作用。     

Palliative Stenting for Late Malignant Gastric Outlet Obstruction

Malignant gastric outlet obstruction (MGO) is a late complication of pancreatobiliary and gastric cancers. Although surgical gastrojejunostomy provides good palliation, many of these patients may be nonoperative candidates or underwent previous extensive resection such as a Whipple procedure. Recently, endoscopically placed self-expanding metallic stents (SEMS) have been used to palliate MGO. The aim of this study was to evaluate the efficacy of SEMS for palliation of late MGO. Medical records of patients with endoscopic placement of SEMS for palliation of MGO were reviewed. Results showed that 30 patients with MGO had SEMS placed for late gastroduodenal (n = 20) or jejunal (n = 10) obstruction. Twenty-one patients (70%) had previous surgery. Return to oral feeding was observed in 90% of patients who presented with recurrent obstruction after prior bypass surgery and in 88% of nonoperative patients in whom SEMS were placed as the primary therapy for obstruction. No major complications were observed, and median survival after SEMS was 4.1 months (0.1 to 10.5 months). SEMS also did not interfere with biliary drainage. In conclusion, endoscopically placed SEMS are safe and provide good palliation for late malignant gastroduodenal and jejunal strictures and are an excellent complement to recurrent obstruction after surgical gastrojejunostomy. This paper was presented at the 45th Annual Meeting of the Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 14–20, 2004 (poster presentation).     

Evaluation of needle-knife precut papillotomy after unsuccessful biliary cannulation, especially with regard to postoperative anatomic factors

Background Biliary cannulation is the first step in therapeutic endoscopic retrograde cholangiopancreatography. This study aimed to evaluate unsuccessful cases of biliary cannulation in which the standard procedure was changed to a needle-knife precut papillotomy (NKPP), with particular attention given to postoperative anatomic factors. Methods Between October 2002 and February 2006, a total of 501 consecutive patients with an intact duodenal papilla were retrospectively investigated. After biliary cannulation using standard maneuvers was unsuccessful within 20 min, NKPP was performed in 80 cases (16%). The clinical backgrounds for difficult biliary cannulation were compared between patients who had standard maneuvers (n = 421, 84%) and those who underwent NKPP. Results For 76 difficult cannulation cases (95%), successful cannulation after NKPP was accomplished, and the total success rate reached 99% (497/501). Multivariate analysis indicated that female gender (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.34–3.79), left lobe hypertrophy after hepatectomy (OR, 6.25; 95% CI, 2.52–15.54), history of Billroth I reconstruction after gastrectomy (OR, 7.49; 95% CI, 2.55–22.02), and malignant biliary stricture (OR, 2.31; 95% CI, 1.21– 4.41) were significant risk factors associated with unsuccessful standard procedures used for biliary cannulation. Complications after NKPP were observed in nine cases (11%), all of which were pancreatitis. Conclusions Difficult biliary cannulation was strongly associated with postoperative anatomic factors. In these situations, early introduction of NKPP should be recommended if the conventional biliary cannulation promises to be difficult.     

Clinical outcome of simultaneous self-expandable metal stents for palliation of malignant biliary and duodenal obstruction

Background: Previous studies have shown that self-expanding metal stents are an effective method for palliation of malignant biliary or duodenal obstruction. We present our experience with the use of simultaneous self-expandable metal stents for palliation of malignant biliary and duodenal obstruction. Methods: We performed a retrospective review of all patients undergoing simultaneous biliary and duodenal self-expandable metal stent placement between November 98 and May 2001. All the patients had documented evidence of biliary obstruction and symptomatic duodenal obstruction. The patients received endoscopic biliary stenting with biliary Ultraflex or Wallstents, and endoscopic duodenal stenting using enteral Wallstents. They were followed until their death. Results: We identified 18 patients (11 men and 7 women) whose mean age was 65 years, (range, 46–85 years). Malignancies included pancreatic 14 (78%), biliary 2 (11%), lymphoma 1 (5%), and metastatic 1 (5%) disorders. Ten patients previously had plastic biliary stents placed for past malignant biliary obstruction (4 patients had recurrent biliary obstruction). All the patients had evidence of duodenal obstruction. Combined metal stenting was successful in 17 patients. One procedure failed due to a tortuous duodenal stricture. All the patients had effective palliation of biliary obstruction, as evidenced by a decrease in the level of total bilirubin and alkaline phosphatase. Of the 17 patients with successful duodenal stenting, 16 had a good clinical outcome, with relief of obstructive symptoms. No immediate stent-related complications were noted. During the follow-up period, 12 patients died of progression of the underlying malignancy. None of the deaths were stent related. Median survival time was 78 days. Two patients had recurrent biliary obstruction from tumor ingrowth at 45 and 68 days, respectively. Both underwent restenting: one by endoscopic retrograde cholangiopancreatography (ERCP) and the other by percutaneous transhepatic cholangiography (PTC). Two other patients had recurrent duodenal obstruction, respectively, 36 and 45 days after the initial stenting. One obstruction was secondary to tumor ingrowth, and the other was caused by distal stent migration. Both patients had successful duodenal restenting. Conclusion: Combined self-expandable metal stenting for simultaneous palliation of malignant biliary and duodenal obstruction may provide a safe and less invasive alternative to surgical palliation with an acceptable clinical outcome. Simultaneous self-expandable metal stents should be considered as a treatment option for patients who are poor candidates for surgery.     

EUS-guided versus endoscopic transpapillary gallbladder drainage in high-risk surgical patients with acute cholecystitis: a systematic review and meta-analysis

In patients with acute cholecystitis who are deemed high risk for cholecystectomy, percutaneous cholecystostomy (PC) was historically performed for gallbladder drainage (GBD). There are several limitations associated with PC. Endoscopic GBD [Endoscopic transpapillary GBD (ET-GBD) and EUS-guided GBD (EUS-GBD)] is an alternative to PC. We performed a systematic review and meta-analysis to compare the effectiveness and safety of EUS-GBD versus ET-GBD. We performed a systematic search of multiple databases through May 2019 to identify studies that compared outcomes of EUS-GBD versus ET-GBD in the management of acute cholecystitis in high-risk surgical patients. Pooled odds ratios (OR) of technical success, clinical success and adverse events between EUS-GBD and ET-GBD groups were calculated. Five studies with a total of 857 patients (EUS-GBD vs ET-GBD: 259 vs 598 patients) were included in the analysis. EUS-GBD was associated with higher technical [pooled OR 5.22 (95% CI 2.03–13.44; p = 0.0006; I2 = 20%)] and clinical success [pooled OR 4.16 (95% CI 2.00–8.66; p = 0.0001; I2 = 19%)] compared to ET-GBD. There was no statistically significant difference in the rate of overall adverse events [pooled OR 1.30 (95% CI 0.77–2.22; p = 0.33, I2 = 0%)]. EUS-GBD was associated with lower rate of recurrent cholecystitis [pooled OR 0.33 (95% CI 0.14–0.79; p = 0.01; I2 = 0%)]. There was low heterogeneity in the analyses. EUS-GBD has higher rate of technical and clinical success compared to ET-GBD. While the rates of overall adverse events are statistically similar, EUS-GBD has lower rate of recurrent cholecystitis. Hence, EUS-GBD is preferable to ET-GBD for endoscopic management of acute cholecystitis in select high-risk surgical patients.     

CXCR4���������Ե��������ٴ���ֵ�о�

??CXCR4 to clinically distinguish malignant biliary obstruction from benign biliary obstruction LIN Ke-yu??SU Hua-wei. Department of General Surgery??the Second Affiliated Hospital of Harbin Medical University??Harbin 150086??China
Correspongding??SU Hua-wei??E-mail??Shw@medmail.com.cn
Abstract Objective Aim of the study was to investigate the value of bile and serum chemokine receptor-4??CXCR4) for distinguishing malignant biliary obstruction from benign biliary obstruction. Methods Selected 44 cases of obstructive jaundice patients treat in the second affiliated hospital of Harbin medical university in February 2013 to June??including 21 cases of malignant biliary obstruction??23 cases of benign biliary obstruction. Their sera and bile were collected to detect the CXCR4 concentration by using enzyme-linked immunosorbent method, and conventional testing other biochemical indexes: hemoglobin(Hb)??total bilirubin??direct bilirubin??alkaline phosphatase(ALP)??alanine aminotransferase(ALT)??aspartate aminotransferase(AST)??γ-glutamine transferase ammonia(GGT). Do a statistical analysis of the index difference of benign and malignant biliary obstruction patients. Results We can found that age??sex??hemoglobin??ALT??AST??ALP had no significant value between the benign and malignant biliary obstruction (P>0.05). However??r-GT??total bilirubin??serum CXCR4??bile CXCR4 had statistical significance (P<0.05). The result of multiple regression analysis show that the 5 indicators which enriched in the regression analysis??only the bile CXCR4 had relationship with benign and malignant biliary obstruction (OR=1.05??95%CI 1.04~1.06??P<0.05). Conclusion Measurement of biliary CXCR4 may differentiate malignant biliary from benign biliary strictures??and for the clinical differential diagnosis has a reference value.     

Long-term Anastomotic Complications After Pancreaticoduodenectomy for Benign Diseases

Background The study of long-term complications after pancreaticoduodenectomy (PD) for malignant disease has been problematic given the paucity of patients with long-term survival after diagnosis and surgical resection. We therefore studied patients who were surgically treated with a PD for a benign diagnosis to evaluate long-term anastomotic durability. Methods A retrospective analysis of 122 patients who had PD performed in the interval 1993–2003 inclusive for benign pancreatic diseases was undertaken. Long-term morbidity and mortality (specifically biliary, pancreaticojejunostomy [PJ], and gastrojejunostomy [GJ] strictures) were evaluated. Results Gender was equally represented with 53% female and 47% male. The median age at surgery was 55 years (range 15–81 years). The three most frequent diagnoses were chronic pancreatitis (40%), intraductal papillary mucinous neoplasm (16%), and cystic neoplasms (9%). Median follow-up in the 95 patients alive at last follow-up was 4.1 years (10 days–12.6 years). The 5- and 10-year survival rates were 83% (76, 91%) and 62% (49%, 78%), respectively. The observed survival was significantly lower than the expected survival in an age- and gender-matched U.S. white population, p < 0.001 (one-sample log-rank test). The 5- and 10-year cumulative probability of biliary stricture was 8% (2%, 14%) and 13% (4%, 22%), respectively. For pancreatic strictures the 5- and 10-year rates were 5% (0%, 9%) and 5% (0%, 9%), respectively. No GJ strictures were noted. The management of biliary strictures was primarily with dilatation and stent (78%) and less commonly operative intervention (22%). Pancreatic strictures required surgery alone (25%), surgery followed by endoscopic intervention (25%), or endoscopic therapy alone (50%). Conclusion Intervention for anastomotic strictures after pancreaticoduodenectomy is uncommon. Biliary strictures can usually be treated nonoperatively with dilation and stent. Our study likely underestimates the incidence of stricture formation. Prospective imaging studies may be warranted for a more accurate assessment of the rate of long-term anastomotic complications.     

经内镜胆道支架置入术姑息性治疗恶性梗阻性黄疸的临床应用

目的 探讨经十二指肠镜放置胆道支架(EMBE、ERBD)和鼻胆管引流姑息治疗恶性梗阻性黄疸的有效性及临床应用价值.方法 回顾性分析2002年6月至2009年3月51例有绝对或相对手术禁忌证的恶性梗阻性黄疸病人成功行经内镜胆道支架置入术的有效率、并发症发生率、支架通畅时间及生存时间.结果 51例病人中,置入金属支架31例,置人塑料支架15例,2例单纯置入鼻胆管引流.其中黄疸指数下降48例,总胆红素从(279.6±143.7)μmol/L一周后下降到(125.7±78.3)μmol/L(P＜0.01).出现急性胰腺炎并发腹痛者3例,高淀粉酶血症9例,发生胆绞痛者1例,贲门撕裂伴大出血1例,并发症发生率27.4%;支架通畅时间119 d;置入支架组随访39例,3个月、6个月生存率达到91%和74%.结论 通过十二指肠镜进行胆道支架置入和有效引流是姑息治疗恶性梗阻性黄疸的有效方法.     

Safety of Conservative Management of Bile Leakage after Hepatectomy with Biliary Reconstruction

Background  The risks associated with the conservative management of bile leakage after hepatectomy and associated cholangiojejunostomy are not well defined. Aim  The aim of this study was to evaluate incidence and severity of complications associated with bile leakages after liver resection with biliary reconstruction. Patients and methods  Clinical data from 1,034 consecutive patients who underwent liver resection were prospectively collected and reviewed. Bile leakage occurred in 25 out of 119 patients (21.0%) who underwent hepatectomy with biliary reconstruction (group 1) and in 42 out of 915 patients (4.6%) without biliary anastomosis (group 2; p < 0.001). Serum albumin and bilirubin levels were the only preoperative factors significantly different between the two groups. Lymphadenectomy was more frequently performed in patients of group 1 (88% vs 16.7, p < 0.001). Results  Mortality rates were similar in the two groups (8% in group 1 vs 2.3% in group 2, p = 0.28). One or more postoperative complications occurred in 68% in group 1 and in 40.4% in group 2 (p = 0.02). The incidence of sepsis (32% vs 7.1%, p = 0.01), intra-abdominal abscess (12% vs 0, p = 0.04), and abdominal bleeding (28% vs 0, p = 0.006) was significantly higher in group 1. Bile leaks spontaneously healed in 52% of patients in group 1 vs 76.2% in group 2 (p = 0.04). In order to identify independent predictive factors for abdominal bleeding, we compared clinical data of patients with abdominal bleeding (seven patients) and without abdominal bleeding (18 patients) after hepatectomy and biliary reconstruction. Stepwise logistic regression analysis identified the number of reconstructed bile ducts as an independent predictive factor of abdominal bleeding (p = 0.038). Conclusions  Conservative management of bile leakage after liver resection with biliary reconstruction is associated with higher rates of morbidity. The most severe complication is abdominal bleeding, which is related to the number of bile ducts requiring reconstruction.     

Effectiveness of the HoloLens mixed-reality headset in minimally invasive surgery: a simulation-based feasibility study

The advent of Virtual Reality technologies presents new opportunities for enhancing current surgical practice. Studies suggest that current techniques in endoscopic surgery are prone to disturbance of a surgeon’s visual-motor axis, influencing performance, ergonomics and iatrogenic injury rates. The Microsoft® HoloLens is a novel head-mounted display that has not been explored within surgical innovation research. This study aims to evaluate the HoloLens as a potential alternative to conventional monitors in endoscopic surgery. This prospective, observational and comparative study recruited 72 participants consisting of novices (n = 28), intermediate-level (n = 24) and experts (n = 20). Participants performed ureteroscopy, within an inflatable operating environment, using a validated training model and the HoloLens mixed-reality device as a monitor. Novices also completed the assigned task using conventional monitors; whilst the experienced groups did not, due to their extensive familiarity. Outcome measures were procedural completion time and performance evaluation (OSATS) score. A final evaluation survey was distributed amongst all participants. The HoloLens facilitated improved outcomes for procedural times (absolute difference, − 73 s; 95% CI − 115 to − 30; P = 0.0011) and OSAT scores (absolute difference, 4.1 points; 95% CI 2.9–5.3; P < 0.0001) compared to conventional monitors. Feedback evaluation demonstrated 97% of participants agreed or strongly agreed that the HoloLens will have a role in surgical education (mean rating, 4.6 of 5; 95% CI 4.5–4.8). Furthermore, 95% of participants agreed or strongly agreed that the HoloLens is feasible to introduce clinically and will have a role within surgery (mean rating, 4.4 of 5; 95% CI 4.2–4.5). This study demonstrates that the device facilitated improved outcomes of performance in novices and was widely accepted as a surgical visual aid by all groups. The HoloLens represents a feasible alternative to the conventional setup, possibly by aligning the surgeon’s visual-motor axis.     

Laparoscopic common bile duct exploration for elderly patients with choledocholithiasis: a systematic review and meta-analysis

Laparoscopic common bile duct exploration (LCBDE) has been becoming more and more popular in patients with symptomatic choledocholithiasis. However, the safety and effectiveness of LCBDE in elderly patients with choledocholithiasis is still uncertain. This meta-analysis is aimed to appraise the safety and feasibility of LCBDE for elderly patients with choledocholithiasis. Studies comparing elderly patients and younger patients who underwent LCBDE for common bile duct stone were reviewed and collected from the PubMed, Medline, EMBASE, and Cochrane Library. Primary outcomes were stone clearance rate, overall complication rate, and mortality rate. Secondary outcomes were operative time, conversion rate, pulmonary complication, bile leakage, reoperation, residual stone rate, and recurrent stone rate. Nine studies, including two prospective studies and seven retrospective studies, met the inclusion criteria. There were 2004 patients in this meta-analysis, including 693 elderly patients and 1311 younger patients. There was no statistically significant difference between elderly patients and younger patients regarding stone clearance rate (OR 0.73; 95% CI 0.42–1.26; p = 0.25), overall complication rate (OR 1.31; 95% CI 0.94–1.82; p = 0.12), and mortality rate (OR 2.80; 95% CI 0.82–9.53; p = 0.10). Similarly, the operative time, conversion rate, bile leakage, reoperation, residual stone rate, and recurrent stone rate showed no significant difference between two groups (p > 0.05). While elderly patients showed high risk for pulmonary complication (OR 4.41; 95% CI 1.78–10.93; p = 0.001) compared with younger patients. Although there is associated with higher pulmonary complication, LCBDE is still considered as a safe and effective treatment for elderly patients with choledocholithiasis.     

Clinicopathologic Characteristics of Hepatocellular Carcinoma with Bile Duct Invasion

To clarify the characteristics of hepatocellular carcinoma (HCC) with bile duct invasion, we retrospectively analyzed clinical features and surgical outcome of HCC with bile duct invasion (b⁺ group, n = 15) compared to those without bile duct invasion (b⁻ group, n = 256). In the b⁺ group, four patients (27%) showed obstructive jaundice, and a diagnosis of bile duct invasion was obtained preoperatively in seven patients (47%). The levels of serum bilirubin and carbohydrate antigen 19–9 were significantly higher in the b⁺ group. Macroscopically, confluent multinodular type and infiltrative type were predominant in the b⁺ group (P = 0.002). Microscopically, capsule infiltration (P = 0.040) and intrahepatic metastasis (P = 0.013) were predominant in the b⁺ group. Portal vein invasion was associated significantly with the b⁺ group (P = 0.004); however, the frequency of hepatic vein invasion was similar (P = 0.096). The median survival after resection was significantly shorter in the b⁺ group than in the b⁻ group (11.4 vs. 56.1 months, P = 0.002), and eight of 11 intrahepatic recurrences in the b⁺ group occurred within 3 months after surgery. HCC with bile duct invasion has an infiltrative nature and a high risk of intrahepatic recurrence, resulting in poor prognosis.     

Outcomes of cholecystectomy after endoscopic sphincterotomy for choledocholithiasis

Laparoscopic cholecystectomy (LC) for treatment of symptomatic common bile duct stones (CBDS) after endoscopic sphincterotomy (ES) is associated with increased conversion and complications compared with other indications. We examined factors associated with conversion and complications of LC after ES. A retrospective study of 32 patients undergoing ES for CBDS followed by cholecystectomy was undertaken. Surgical outcomes for this group were compared with a control population of 499 LCs for all other indications. Factors associated with open cholecystectomy and complications in the ES group were analyzed. Patients undergoing LC preceded by ES had a significantly higher complication (odds ratio [OR] = 7.97; 95% CI, 2.84–22.5) and conversion rate (OR = 3.45; 95% CI, 1.56–7.66) compared with LC for all other indications. Pre-ES serum bilirubin greater than 5 mg/dL was predictive of conversion (positive predictive value = 63%, P < 0.005). Patients with symptomatic CBDS that undergo LC after ES have higher complication and conversion rates than patients undergoing LC without ES. Pre-ES serum bilirubin is useful in identifying patients who may not have a successful laparoscopic approach at cholecystectomy. Presented at the Society of American Gastrointestinal Endoscopic Surgeons 2004 Annual Scientific Session and Postgraduate Course, Denver, Colorado, March 31, 2004 to April 3, 2004.     

An angulated common bile duct predisposes to recurrent symptomatic bile duct stones after endoscopic stone extraction

Background Endoscopic sphincterotomy and stone extraction are standard procedures for the removal of bile duct stones. Stone recurrence can, however, occur in up to 25% of cases. Risk factors have been poorly defined, but are believed to be related to bile stasis. This study investigated whether an angulated common bile duct (CBD) that may predispose to bile stasis influences symptomatic stone recurrence after successful endoscopic therapy. Methods This study included 232 consecutive patients (mean age, 64.1 years; 86 men) who had undergone therapeutic endoscopic retrograde cholangiopancreatography for bile duct stones. Data from the follow-up period (36 ± 17 months) were obtained from medical records and patient questioning. Common bile duct angulation and diameter were measured from the cholangiogram after stone removal. Results Symptomatic bile duct stones recurred in 16% of the patients (36/232). Three independent risk factors were identified by multivariate analysis: an angulated CBD (angle, ≤145°; relative risk [RR], 5.2; 95% confidence interval [CI], 2.2–12.5; p = 0.0002), a dilated CBD (diameter, ≥13 mm; RR, 2.6; 95% CI, 1.2–5.7; p = 0.017), and a previous open cholecystectomy (RR, 2.7; 95% CI, 1.3–5.9; p = 0.0117). Gender, age, urgency of procedure, or a periampullary diverticulum did not influence the recurrence rate. Conclusions Angulation of the CBD (≤145°) on endoscopic cholangiography, a dilated CBD, and a previous open cholecystectomy are independent risk factors for symptomatic recurrence of bile duct stones. The findings support the role of bile stasis in stone recurrence. Further studies using these data prospectively to identify high-risk patients are warranted. Part of this work was presented at the Digestive Disease Week in New Orleans, 16–20 May 2004, and published in abstract form in Gastrointestinal Endoscopy 2004;59: AB197