Ascaris-induced acute pancreatitis.

The incidence, clinical disease and outcome of acute pancreatitis caused by ascariasis in an endemic area of Kashmir, India, was studied prospectively. Ascariasis was an aetiological factor in 59 of 256 patients (23.0 per cent) with acute pancreatitis. Worms had invaded the bile duct in 51 patients, the pancreatic duct in four and both ducts in four. Pancreatitis was mild in 46 patients and severe in 13. Associated pyogenic cholangitis was present in eight. Acute complications occurred in 11 patients. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in all cases within 72 h of admission and delineated ascarides in the duodenum invading the ampullary orifice (44 patients), in the bile duct (55) and in the pancreatic duct (eight). At ERCP, worms were extracted from the ampullary orifice and removed via the mouth of 33 patients with intractable epigastric pain, leading to rapid relief of symptoms. The eight patients with pyogenic cholangitis underwent endoscopic nasobiliary drainage to decompress the bile ducts; worms were extracted from the bile duct of three of these patients using a Dormia basket. A total of 56 patients recovered from acute illness with a combination of conservative and endoscopic treatment; the other three required emergency surgery. At a mean(s.d.) follow-up of 19(7) months, ten patients showed symptomatic worm reinvasion of the biliary tree. The overall mortality rate was 3 per cent.     

Biliary ascariasis as a cause of post-cholecystectomy syndrome in an endemic area

BACKGROUND: Post-cholecystectomy syndrome encompasses numerous biliary, pancreatic and other entities. Biliary ascariasis is a common cause of adult biliary disease in an endemic area. Post-cholecystectomy biliary ascariasis, a cause of post- cholecystectomy syndrome although not yet defined is frequently seen in this part of the world. METHOD: Between Jan. 1990 and Jan. 2001, 104 cases of post-cholecystectomy biliary ascariasis were seen. Ultrasonography was found to be an excellent tool for diagnosing and monitoring of the worms inside the biliary tract. Endoscopic retrograde cholangiopancreatography had both diagnostic and therapeutic value. RESULTS: The majority (68.2%) of patients responded to conservative treatment. Surgical treatment was advocated in 18.2%, which included 2 patients with liver abscesses. Endoscopic extraction of worms was successful in 48.2%. CONCLUSION: Post-cholecystectomy biliary ascariasis as a cause of post-cholecystectomy syndrome needs to be included in the list of causes for post-cholecystectomy syndrome. Although the majority of patients respond to conservative treatment but endoscopic extraction or surgical intervention may be needed. Routine deworming of patients undergoing cholecystectomy both preoperatively and postoperatively should be done in all patients in endemic areas of ascariasis. Although this entity is rare in Europe and United States, due to population migration and increased travel, it is necessary for surgeons in these countries to be aware of this condition.     

Endoscopic Management of Early Postoperative Biliary Ascariasis in Patients with Biliary Tract Surgery

Bile leak and residual stones are well known complications of biliary tract surgery. In endemic areas of ascariasis, invasion of the biliary tract by roundworms during the early postoperative period is an infrequent but serious complication. The present study describes the endoscopic management of postoperative biliary ascariasis in 19 consecutive patients. There were 5 men and 14 women with a mean age of 33.3 ± 6.3 years. All patients had undergone cholecystectomy, with choledocholithotomy and placement of a T-tube in 13 (68.4%) patients. Eight (42.1%) patients including two with T-tubes were acutely sick at referral. Altogether, 16 (84.2%) patients had widened papillae due to previous endoscopic sphincterotomy (3 patients) or recent dilatation of the sphincter of Oddi by Bakes dilators (13 patients). All patients with a T-tube in situ had undergone unsuccessful attempts to remove the worms by flushing saline through the T-tube. Endoscopic retrograde cholangiopancreatography was performed 4 to 16 days after biliary tract surgery and revealed roundworms in the common bile duct in 10 patients, in the hepatic ducts in 2, or in both ducts in 7. Three patients had coexisting biliary leakage: from the cystic duct stump in two and from a T-tube track in one. Endoscopic treatment consisted of extracting the worms from the biliary tree and placing stents in those with coexisting leakage. Endoscopic success was defined as complete worm extraction and resolution of biliary leakage and was achieved in all patients. Complications occurred in one (5.3%) patient. We concluded that endoscopic management is an effective, safe approach for extracting ascarids from the biliary tree during the early postoperative period. It reduces the hospital stay, avoids T-tube-related complications, and permits a postoperative complication to be treated using a nonsurgical method.     

Biliary ascariasis in fifteen patients.

Ascarids in the biliary tract may cause cholecystitis, pancreatitis and obstruction of the common bile ducts. We retrospectively evaluated clinical features, radiographic findings and surgical treatment of 15 patients. Obstructive jaundice in eight patients (53.3%), acute cholecystitis in five patients (33.3%), and chronic calculous cholecystitis in two patients (13.3%) had been shown in our series. In four of the patients with obstructive jaundice signs of acute cholangitis were observed. Of 15 patients, two had hepatic abscess besides biliary ascariasis and one had hydatid cyst. In our series, all of the patients were operated on. Choledochotomy and primary closure were performed on six patients (40%), choledochoduodenostomy on six patients (40%), T-tube drainage on two patients (13.3%) and only cholecystectomy on one patient (6.6%). No mortality was determined in our patients.     

Duct-to-duct biliary anastomosis with a "corner-saving suture" technique in living-related liver transplantation

OBJECTIVES: Biliary complications after living-related liver transplantation (LRLT) remain a major source of morbidity for recipients. We describe our technique and early results with 32 recipients who underwent LRLT with duct-to-duct anastomoses during the last 2 years. METHODS: Between January 2003 and December 2004, 50 patients underwent liver transplantation in our center with overall patient and graft survival rate of 86.4% and 86.4%. Of 50 patients, 41 (82.0%; 17 adult and 24 pediatric) underwent LRLT, 32 (78.0%) of whom had duct-to-duct biliary anastomoses with a "corner-saving suture" technique. RESULTS: Of 32 patients in whom duct-to-duct biliary anastomoses were performed, 4 (12.5%) had an anastomotic leak with 2 eventually developing bile duct strictures within 3 months. One patient required reoperation for a bile leak. All other anastomotic leaks and strictures were treated with percutaneous drainage and balloon dilatation with excellent outcomes. There was no long-term morbidity and no graft loss owing to biliary complications. Seven patients died during follow-up (0.5 to 25 months); 43 are doing well with optimal liver function in the early posttransplantation period. CONCLUSION: According to our early results, we recommend duct-to-duct anastomosis in LRLT when calibration of the ducts show suitable results and when there is no tension on the anastomosis site. Otherwise, Roux-en-Y hepaticojejunostomy should be performed to decrease risk of biliary complications.     

The surgery of "correctable" biliary atresia

Seven of 114 (6%) patients treated in Denver for biliary atresia had a variant of the disease in which only microscopic bile ducts or ductules were identified at the porta hepatis, hepatic lesions were present, even in the neonatal example, and intrahepatic biliary hypoplasia was uniformly present. The excised bile duct cysts consisted of fibrosis or scar tissue and with little or no epithelial lining. Six patients had corrective surgery. The first patient was treated by choledochoenterostomy and became totally obstructed. Definitive operation in this patient and all subsequent patients consisted of excision of all extrahepatic duct structures and Roux-en-Y portoenterostomy. Two patients died, the one who did not have surgical correction and a second who had correction at age 35 weeks. The other five patients have been followed for 18 to 158 months and are anicteric but have some degree of residual liver damage. We conclude that so-called correctable biliary atresia occurs in less than 10% of cases, that because of coincident biliary hypoplasia, "cure" is not a possible outcome, and that the treatment of choice is complete surgical excision of the extrahepatic bile ducts and Roux-en-Y portoenterostomy.     

Management of Biliary Ascariasis in Pregnancy

Ascariasis is a helminthic infection of humans caused by the nematode Ascaris lumbricoides. Biliary ascariasis is one of the most common and well described entities caused by ascaris. In endemic areas pregnant women are prone to develop biliary ascariasis. Its management poses a great challenge to both the attending surgeon and the endoscopist. Between January 1993 and March 2003, 15 cases of biliary ascariasis were seen in pregnant patients in our institution. Ultrasonography was used as the main investigative tool. Treatment involved management by conservative, endoscopic, and surgical methods, taking due care of both the mother and the fetus. Ten patients (66.6%) were in the third trimester of pregnancy, and 10 (66.6%) patients were in their third pregnancy. Ultrasonography proved to be the best tool for diagnosing and monitoring worms inside the biliary ductal system. Nine (60%) patients responded to the conservative treatment; endoscopic extraction was successful in 4 (66.6%) patients. Surgical treatment was required in 2 (13.3%) patients. One (6.6%) patient had had spontaneous abortion at 12 weeks gestation, and one (6.6%) patient had a premature labor. The remaining patients had normal pregnancies. Management of biliary ascariasis in pregnancy is a challenge for both the attending surgeon and the endoscopist. Safe and effective management requires special attention to the gestational age and accurate recognition of the specific pathology in the patient. The majority of patients respond to conservative treatment, but endoscopic extraction may be needed in nonresponsive cases. Lead shielding of the fetus and limitation of the total fluorscopic exposure during therapeutic endoscopy can minimize the teratogenic risk of ionizing radiation. Failures of endoscopic extraction may lead to surgical intervention, which carries risks of fetal wastage and premature labor. Routine worming of women in the child-bearing years is recommended in endemic areas of ascariasis. Though ascariasis is a problem in developing countries, because of increased travel and population migration, clinicians elsewhere should be aware of the problems associated with ascariasis.     

The portoenterostomy procedure for biliary atresia: a five year experience.

The portoenterostomy (Kasai) procedure in infants with biliary atresia has dramatically altered the outlook for this heretofore fatal disease. When performed on infants under three months of age, bile drainage can be achieved in a majority of the patients. Since 1972, 37 infants have been treated with this operation at our institution. Diagnostic operative cholangiography and liver biopsy are recommended if the cause of conjugated hyperbilirubinemia is presumed to be obstructive. When biliary atresia is encountered, identification of the atretic ducts with transection high in the porta hepatis is carried out. Thirty-two infants have had the portojejunostomy, while five, in whom the proximal hepatic ducts were atretic but the gall bladder and distal ducts were patent, underwent portocholecystostomy. Examination of the resected fibrous duct tissue revealed a statistically significant correlation between ductal histology and postoperative outcome. Extended bile drainage has been achieved in 26 of 37 patients. Seventeen exhibit near normal growth and development four months to five years postoperatively. Seven have died with progressive liver disease despite bile drainage. Two additional patients died, jaundice free, from unrelated causes. Despite bile drainage, progressive hepatic fibrosis has been confirmed by serial biopsies in 14 patients. This finding indicates that biliary obstruction is not the sole component in the development of biliary cirrhosis. These data suggest that extrahepatic biliary atresia is a dynamic obliterative process, which can be favorably modified in approximately 50% of the infants by early surgical treatment.     

婴儿梗阻性黄疸99mTc-EHIDA肝胆显像诊断价值和治疗探讨

目的 探讨SPECT(99mTc-EHIDA)肝胆肠道动态显像检查对婴儿梗阻性黄疸诊断及鉴别诊断的价值,并对婴儿梗阻性黄疸临床治疗方法 进行研究.方法 应用SPECT核素对24例已诊断为梗阻性黄疸的患儿进行肝胆肠道延时动态显像检查,明确临床诊断,鉴别梗阻部位和性质,并经手术及临床治疗证实,同时采取相应不同的治疗.结果 8例肝胆、肠道延时核素显像为胆汁淤滞型黄疸,其中5例因黄疸加重行经套管针胆囊内置管加压冲洗治愈,3例药物治愈.16例为先天性胆道闭锁(肝外型10例、肝内型6例)延时核素检查有肝脏显像,胆囊、肠道不显像.16例先天性胆道闭锁患儿中14例(肝外型10例、肝内型4例)行Kasai手术,术后均有胆汁排出,3例肝外型因胆瘘再次手术均病死,4例肝内型术后病死,手术后存活7例(50%).另外2例肝内型未及手术死于肝衰竭.本组患儿全部行SPECT核素检查,灵敏度为100%、特异度为66.7%、准确性为100%.结论 SPECT(99mTc-EHIDA)肝胆肠道动态显像可鉴别梗阻性黄疸的性质和部位,是安全有效的检查方法 ,有很高的诊断价值.先天性胆道闭锁患儿在适当药物治疗基础上尽早手术,术后亦应相应药物治疗.年龄小于60 d的胆汁淤滞性黄疸患儿先应以相应药物治疗2周,如胆红素升高则手术治疗.     

Gallbladder ascariasis: presentation and management

BACKGROUND: As many as 1.5 billion people around the world harbour Ascaris lumbricoides in the digestive tract. Gallbladder ascariasis, although less common than bile duct ascariasis, is quite often seen in endemic areas. METHODS: Some 1300 patients with hepatobiliary ascariasis, admitted between October 1992 and June 1998, were analysed prospectively. The clinical features and outcome of 56 cases of gallbladder ascariasis are presented. RESULTS: Forty-seven patients were diagnosed by ultrasonography and nine were diagnosed at laparotomy. Only ten patients diagnosed by ultrasonography expelled the worms spontaneously, with resolution of symptoms and signs. The remaining 37 patients underwent cholecystectomy. CONCLUSION: Gallbladder ascariasis is a significant entity in endemic areas which usually requires cholecystectomy.     

Etiology and Outcome of Acute Pancreatitis in Children in Kashmir (India). An Endemic Area of Hepatobiliary Ascariasis

Background

The purpose of the present study was to determine the etiology, management, and outcome of acute pancreatitis (AP) in children in an endemic area of hepatobiliary ascariasis (HBA).

Methods

This was a prospective, hospital-based study over a 9-year period that included 156 children younger than 12 years of age who had a diagnosis of AP.

Results

Of the 156 patients, 71 were boys and 85 were girls with a mean age of 8.4 ± 1.5 years (range 3–12 years). The various factors contributing to AP were biliary ascariasis in 93 cases (60 %), gallstones 16 (10 %), trauma 5 (3 %), choledochal cyst 4 (3 %), impacted bile duct stone 3 (2 %), and gallbladder sludge 2 (1 %). Idiopathic group 33 cases (21 %). Diagnosis was based on clinical picture, abdominal ultrasonography, and elevated serum amylase level. Pancreatitis was mild in 113 (72 %) patients and severe in 43 (28 %). With conservative therapy, 123 patients (79 %) improved, whereas the remaining 33, who had intractable abdominal pain, cholangitis, or worsening cholecystitis, underwent emergency endoscopic retrograde cholangiopancreatography for removal of worms (26 patients) and stones in the bile duct (7 patients). Bile duct stones were extracted in all 7 patients with that condition, and worms were extracted from 23 of the 26 patients with ascariasis. Emergency surgery was performed in five patients. Three patients died. Pancreatitis recurred in 16 patients due to HBA.

Conclusions

Pancreatitis is not uncommon in children. Ascariasis is a leading cause of AP in endemic areas. Patients usually respond to conservative management, but endoscopic treatment is effective. Surgery is rarely required.     

The role of nontransplant procedures for sclerosing cholangitis

Twenty-five of 38 patients with sclerosing cholangitis underwent operative therapy at our institution. Seven patients with primarily extrahepatic obstruction had biliary bypass procedures and maintained normal liver function for 1 to 96 months. Biliary procedures were performed in 11 patients with combined intrahepatic and extrahepatic disease. Seven patients underwent subsequent liver transplantation because of deteriorating hepatic function, and two patients died before transplantation could be performed. Although there were no significant differences in outcome of liver transplantation whether or not a biliary procedure had been performed previously, previous biliary tract procedures influenced the type of biliary reconstruction performed, and two complications occurred as direct results of prior operations. Nontransplant procedures should be restricted to those patients with primarily extrahepatic obstruction, whereas liver transplantation should be considered the initial procedure of choice for patients with diffuse sclerosing cholangitis.     

Pyogenic liver abscess: Changing patterns in approach

AIM: To define optimum management of the pyogenic liver abscess and assess new trends in treatment.METHODS: One hundred and sixty nine patients with pyogenic liver abscess managed at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir (India) from July 2001 to August 2006 were studied to evaluate and define the optimum treatment.RESULTS: Mortality in the surgically treated group of patients was 9.4% (12/119), while those treated non-surgically had a fatality rate of 16.66% (7/42). Multiple liver abscesses treated surgically had a surprisingly low mortality of 30%. The biliary tract (64.97%) was the most common cause of liver abscess. Multiple abscesses, mixed organisms and abscess complications are all associated with a significantly increased mortality. However, the lethality of the primary disease process was the most important factor in determining survival.CONCLUSION: Transperitoneal surgical drainage and antibiotics are the mainstay of treatment. Percutaneous drainage is recommended for high risk patients only.     

Pyogenic liver abscess after hepatobiliary and pancreatic surgery

From 1984 to 1998, a total of 2158 patients underwent hepatobiliary and pancreatic surgery, and 12 patients developed liver abscess after hepatobiliary and pancreatic surgery; thus, the incidence of liver abscess was 0.6%. The main reasons for liver abscess were anastomotic stricture in 5 patients, obstruction of percutaneous transhepatic biliary drainage (PTBD) tube in 3 patients, and portal vein and hepatic artery obstruction due to intraoperative radiation in 1 patient, transportal chemotherapy in 1 patient, chemo-lipiodolization in 1 patient, and unknown in 1 patient. Ten of the 12 patients initially underwent percutaneous transhepatic abscess drainage of whom 2 patients subsequently received surgical drainage. The other 2 patients were treated with antibiotics only. Eight of the 12 patients were cured, but 4 patients died. The reasons for death were sepsis in 3 patients and liver failure due to portal vein and hepatic artery obstruction in 1 patient. Our results indicate that liver abscess should be taken into consideration for patients with risk factors.     

原位肝移植术后胆道并发症的预防与诊治

目的　探讨肝移植术后胆道并发症的预防、诊断和治疗。　方法　对 1993年 4月～2 0 0 1年 11月我科实施的 12 3例肝移植患者临床资料进行回顾性分析。　结果　 12 3例肝移植患者中11例通过胆道造影确诊为肝移植术后胆道并发症 ,9例治愈 ,1例好转 ,死亡 1例。胆道并发症发生率为 8 9% ( 11/ 12 3) ,与胆道并发症相关的死亡率为 0 8% ( 1/ 12 3) ,与T管相关的胆道并发症发生率为4 2 % ( 5 / 119) ,与肝动脉供血相关的胆道并发症发生率为 1 6 % ( 2 / 12 3)。热缺血时间 >3min、冷缺血时间 >8h组胆道并发症发生率明显升高 (P <0 0 5 )。　结论　保存性损伤和缺血性损伤是肝移植术后胆道并发症的重要原因。修肝时应维护肝外胆管的血供和警惕变异胆管的存在。改进T管置管方法可显著降低与T管相关的胆道并发症发生率。术后早期胆道造影有助于及时诊断胆道并发症。介入技术是胆道并发症的主要治疗手段。     

Combined diagnostic techniques and contemporary methods of treatment of external biliary fistula

Analysis of surgical treatment results of 103 patients with the extrahepatic biliary ducts external fistula was presented. The external biliary fistula had formatted due to iatrogenic damage of biliary ducts during performance of cholecystectomy, gastric resection and echinococcectomy. Preoperatively correction of water-electrolytic balance disorders was done in all patients, as well as treatment and prophylaxis of hepatorenal insufficiency, anaerobic anti-infection measures. In all patients the reconstructive intervention was performed. Postoperative complications had occurred in 14 (13.6%) patients, mortality was 3.6%. The main cause of mortality is the sutures of anastomosis insufficiency, intoxication, hepatorenal insufficiency due to occurrence of purulent cholangitis and cholangiogenic abscess of liver.     

Management of liver abscess

Thirteen patients with amebic liver abscess and 26 with pyogenic abscess were identified during a 10 year period. All but one patient with an amebic abscess had emigrated or traveled to areas where amebiasis was endemic. Half of the patients in whom pyogenic abscesses developed had debilitating disease and anemia. Factors predisposing to multiple rather than solitary hepatic abscess were biliary tract disease before surgery, cancer, chemotherapy, steroid administration and alcoholism. Elevated levels of alkaline phosphatase and hypoalbuminemia were present in most patients. Three patients with amebic abscess died, two of whom has massive gastrointestinal hemorrhage from associated amebic colitis. No patient with a solitary pyogenic liver abscess died. Fifteen of 16 patients with multiple liver abscesses died. Failure to consider the diagnosis of liver abscess, confusion over interpretation of the scan, failure to operate or provide a timely operation and failure to adequately explore the abdomen or identify all abscesses were factors responsible for eight unnecessary deaths.     

内镜逆行胰胆管造影术治疗肝移植术后并发胆管结石受者临床分析

目的探讨肝移植术后并发胆管结石受者行内镜逆行胰胆管造影术(ERCP)治疗的安全性和有效性。 方法回顾性分析南京军区福州总医院肝胆外科2005年1月至2015年12月肝移植术后并发胆管结石受者的临床资料。24例受者胆管结石确诊主要依据T管造影、MRCP或ERCP。确诊胆管结石受者均采用ERCP下行球囊扩张联合胆道塑料支架置入治疗,术中采用地西泮镇静,同时密切监测生命体征。观察肝移植术后并发胆管结石受者结石类型、狭窄情况、ERCP治疗情况及其治疗前后肝功能指标变化。采用Wilcoxon符号秩和检验比较ERCP治疗前后受者血清总胆红素(TBil)、碱性磷酸酶(ALP)、谷氨酰转肽酶(GGT)、ALT和AST水平变化。P<0.05为差异有统计学意义。 结果24例受者中胆总管结石20例(包括单纯胆总管结石11例、胆总管结石合并胆管狭窄9例),肝内、外胆管结石4例。肝移植至并发胆管结石平均间隔时间(604±215)d。19例发生在术后12～66个月,余5例发生在术后3个月内。11例胆总管结石受者采用柱状球囊扩张＋取石篮取石＋胆总管置入内支架引流治疗,治疗有效。9例胆总管结石合并胆管狭窄受者采用柱状球囊扩张＋取石篮取石＋胆总管置入内支架＋鼻胆管引流治疗,其中8例治疗有效;1例因重度胆管狭窄,反复内镜取石不能取尽,继发感染再次行肝移植。4例肝内、外胆管结石受者均采用柱状球囊扩张＋取石篮取石＋左、右肝管置入内支架＋鼻胆管引流治疗,治疗有效。受者内镜治疗后血清TBil、ALP和GGT分别为31、179和247 mmol/L,均低于内镜治疗前水平(43、273和385 mmol/L),差异均有统计学意义(z＝0.042、0.001、0.004,P均<0.05)。截至2017年12月,24例受者随访时间为1～2年,4例因原发性肝癌复发分别于肝移植术后9、5、34、25个月死亡,1例因上消化道出血于肝移植术后34个月死亡,1例因重度胆管狭窄行二次肝移植并于2014年4月因肝脓肿继发感染性休克死亡,1例因感染性休克于肝移植术后33个月死亡,其余17例随访期间未见结石再发。 结论内镜下行球囊扩张联合塑料支架置入治疗原位肝移植术后并发胆管结石安全、有效,可作为目前原位肝移植术后并发胆管结石的首选治疗方案。     

Intraperitoneal ascariasis

Seven children with intraperitoneal ascariasis are reported. One of them had two episodes. There were four instances of free worms in the peritoneal cavity, whereas others had peritoneal abscesses containing round worms. It is suggested that peritoneal ascariasis should be suspected whenever a child presents with peritonitis and/or an inflammatory abdominal mass having evidence of ascarial infestation.     

胰十二指肠切除术后肝梗死、肝脓肿发病原因及诊治研究

目的 探讨胰十二指肠切除术（PD）后肝梗死、肝脓肿病因及治疗方法。方法 回顾性分析中国医学科学院北京协和医院2012年1月至2018年12月期间PD术后诊断为肝梗死、肝脓肿的病例，分析其病因及治疗。结果 共11例病人术后明确诊断肝梗死、肝脓肿，其中3例在围手术期死亡，6例出现胆漏。7例明确合并肝固有动脉、副右肝动脉的截断或狭窄，1例术前存在腹腔干根部狭窄，3例存在门静脉狭窄。肠球菌、克雷伯菌是比较常见的致病菌，真菌作为致病菌较为常见。抗感染及介入治疗是主要的治疗手段。结论 PD后肝动脉、门静脉的缺血是发生肝梗死、肝脓肿的主要原因，常合并胆漏及多重致病菌的感染，病死率较高。