[Implementation of the «safe cholecystectomy¼ program in the Leningrad Region]. / Realizatsiya programmy «bezopasnaya kholetsistektomiya¼ v Leningradskoi oblasti.

OBJECTIVE: To present a treatment program for patients with cholelithiasis in the region in accordance with modern requirements for the quality of medical care in the realities of a three-level system of surgical care. MATERIAL AND METHODS: The results of treatment of patients with cholelithiasis at various levels of medical care were analyzed with an assessment of the indicators of operational activity of performing cholecystectomy by laparoscopic and open methods, the development of complications of surgery and inpatient mortality. RESULTS: A programmatic approach has been developed to assist patients with cholelithiasis in the conditions of regional healthcare at different levels of surgical care. CONCLUSION: The implementation of this program minimizes the number of postoperative complications and mortality at the second and third levels of surgical care. It is determined that a rational approach to reduce the number of bile duct injuries is their prevention by impeccable compliance with the technique of surgical intervention on the organs of the upper floor of the abdominal cavity, and to reduce the number of negative consequences - compliance with the proposed algorithm of diagnosis and treatment.

Hepatic subcapsular or capsular flow in biliary atresia: is it useful imaging feature after the Kasai operation?

OBJECTIVES: To evaluate the implications of hepatic subcapsular and capsular flows using ultrasonography (US) in children after Kasai operation. METHODS: Children who underwent liver US including color Doppler US and microvascular imaging (MVI) from May 2017 to October 2017 were retrospectively included. Children who underwent the Kasai operation for biliary atresia were included in the Kasai group and children with normal liver were included in the control group. Using US results, the number of intrahepatic biliary cysts and the maximum diameter of the spleen were evaluated in the Kasai group. Liver stiffness values were included when patients in the Kasai group had transient elastography (TE) or shear wave elastography (SWE) results. Hepatic subcapsular and capsular flows on color Doppler US and MVI were compared between the two groups using the following scores: 0, no flow reaching the hepatic capsule; 1, any flow reaching the hepatic capsule; and 2, contiguous hepatic capsular flow. The logistic regression test was used to identify associations between age, intrahepatic biliary cysts, spleen size, SWV, TE results, and flow scores measured on Doppler US and MVI in the Kasai group using the odds ratio (OR) and 95% confidence interval (CI). RESULT: A total of 65 children (mean 7.6 ± 5.3 years), 44 in the Kasai group and 21 in the control group, were included. In the control group, one child had score 1 on MVI and others had score 0 on both Doppler US and MVI. Among the Kasai group, 28 children (63.6%) had score 1, while others had score 0 using Doppler US. Using MVI, 24 children (54.5%) had score 2, 18 children had score 1, and one child had score 0. In the Kasai group, increased liver stiffness on TE was the only factor significantly associated with the presence of subcapsular flow on color Doppler US (OR 1.225, 95% CI 1.020-1.470) and increased spleen size was the only factor significantly associated with increased flow scores on MVI (OR 1.397, 95% CI 1.002-2.724). CONCLUSION: Detection of hepatic subcapsular, capsular flows on US would be meaningful for children after receiving the Kasai operation. KEY POINTS: • Hepatic subcapsular or capsular flows can be useful not only for the diagnosis but also for the postoperative follow-up in patients with biliary atresia. • Increased liver stiffness and splenomegaly after the Kasai operation were associated with presence of subcapsular or capsular flow on ultrasonography. • Evaluation of hepatic subcapsular and capsular flows could be needed to assess disease progression after receiving the Kasai operation.

[Hybrid minimally invasive interventions in the treatment of solitary cholangiogenic liver abscesses]. / Gibridnye miniinvazivnye vmeshatel'stva pri lechenii solitarnykh kholangiogennykh abstsessov pecheni.

Treatment of solitary cholangiogenic liver abscesses is considered in the article. Successful treatment of cholangiogenic liver abscess with hybrid technologies is reported. The authors conclude that restoration of bile outflow is essential for fast elimination of the abscess.

Mirizzi syndrome: when the gallbladder meets bile ducts.

A 64-year-old female presented to the Emergency Department with jaundice, choluria, fever and abdominal pain over the last few days. The abdomen was tender with epigastric pain on palpation.

An international, multicenter, comparative trial of EUS-guided gastrogastrostomy-assisted ERCP versus enteroscopy-assisted ERCP in patients with Roux-en-Y gastric bypass anatomy.

BACKGROUND AND AIMS: ERCP is challenging in patients with Roux-en-Y gastric bypass (RYGB) anatomy. EUS-guided gastrogastrostomy (GG) creation is a promising novel technique to access the excluded stomach to facilitate conventional ERCP. We aimed to compare procedural outcomes and adverse events (AEs) between EUS-guided GG-assisted ERCP (EUS-GG-ERCP) and enteroscopy-assisted ERCP (e-ERCP) in patients with RYGB. METHODS: Patients with RYGB anatomy who underwent EUS-GG-ERCP or e-ERCP between 2014 and 2016 at 5 tertiary centers were included. The primary outcome was technical success of ERCP, defined as successful cannulation of the selected duct with successful intervention as intended. Secondary outcomes included total procedural time (in the EUS-GG group, total procedural time included EUS-GG creation plus ERCP procedure time), length of hospital stay, and rate/severity of AEs graded according to the American Society for Gastrointestinal Endoscopy lexicon. RESULTS: A total of 60 patients (mean age, 57.2 ± 13.2; 75% women) were included, of whom 30 (50%) underwent EUS-GG-ERCP and 30 (50%) underwent e-ERCP (double-balloon enteroscope ERCP, 19; single-balloon enteroscope ERCP, 11). The technical success rate was significantly higher in the EUS-GG-ERCP versus the e-ERCP group (100% vs 60.0%, P < .001). Total procedure time was significantly shorter in patients who underwent EUS-GG-ERCP (49.8 minutes vs 90.7 minutes, P < .001). Postprocedure median length of hospitalization was shorter in the EUS-GG group (1 vs 10.5 days, P = .02). Rate of AEs was similar in both groups (10% vs 6.7%, P = 1). CONCLUSIONS: EUS-GG-ERCP may be superior to e-ERCP in patients with RYGB anatomy in terms of a higher technical success and shorter procedural times and offers a similar safety profile.

Hepatocellular carcinoma in a free-living marmoset (Callithrix sp.) with concomitant biliary trematodiasis.

Hepatocellular carcinoma (HCC) is rare in New World primates. We report the gross, microscopical, and immunocytochemical features of a spontaneous HCC in a free-living marmoset (Callithrix sp.). Hepatitis B and C virus and aflatoxin immunohistochemistry were negative; however, concomitant intra- and extrahepatic biliary trematodiasis could have played a role.

Obstructive jaundice due to a blood clot after ERCP: a case report and review of the literature.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently performed procedures for the treatment of biliary-pancreatic diseases. The most frequent complications of ERCP include pancreatitis, haemorrhage, perforation and cholangitis. While post-ERCP biliary bleeding leading to biliary obstruction is rare. CASE PRESENTATION: We herein report a case of exceptional post-ERCP cholangitis due to a blood clot in the common bile duct (CBD). This case involves a 75-year-old woman with a history of recurring upper abdominal pain. Abdominal computerized tomography (CT) revealed dilatation of the extrahepatic bile duct with stones at the lower CBD. After ERCP, clearance of stones was obtained. The post-ERCP course was symptomatic with upper abdominal pain and a significant increase in cholestatic parameters. A second CT scan demonstrated a markedly dilated biliary tree with a longitudinal high-density image at the middle CBD. The patient was successfully treated with a repeated ERCP, and a blood clot was extracted. We also present a review of the literature published between 1985 and 2016 in PubMed. Four similar cases were reported during this period from France, Turkey, the USA and the UK, separately. Our case is the first reported in China. CONCLUSIONS: Post-ERCP biliary bleeding leading to biliary obstruction is rare. We describe a rare case of post-ERCP cholangitis due to a blood clot in the common bile duct (CBD), which is consistent with most clinical presentations of similar cases already described. An analysis of the possible pathophysiological mechanisms and a review of the current literature are provided. We attempt to attract clinicians' attention to the differential diagnosis of post-ERCP obstruction. The complications might be severe or even fatal. The diagnosis of blood clot is based on clinical and laboratory data, particularly imaging. Repeated ERCP is often necessary and effective.

Clinical features and risk factors of bile duct perforation associated with pediatric congenital biliary dilatation.

PURPOSE: This study aimed to investigate the clinical features and risk factors of bile duct perforation in pediatric congenital biliary dilatation (CBD) patients. METHODS: CBD patients, whose initial symptom was abdominal pain, were enrolled in this study and were divided into perforated and non-perforated groups. The clinical features of the perforated group were investigated. Moreover, the age at operation, sex, and morphologic features of the extrahepatic bile duct were compared between the groups. RESULTS: Fifteen cases of bile duct perforation (10.4%) were identified among the 144 CBD patients who had abdominal pain. Majority of bile duct perforation occurred in patients aged < 4 years. The median duration from onset of abdominal pain to bile duct perforation was 6 (4-14) days. Age at onset [< 4 years old; P = 0.02, OR 13.9, (1.663, 115.3)], shape of extrahepatic bile duct [non-cystic type; P = 0.009, OR 8.36, (1.683, 41.5)], and dilatation of the common channel [P = 0.02, OR 13.6, (1.651, 111.5)] were risk factors of bile duct perforation. CONCLUSIONS: Emergent bile duct drainage might be planned to prevent bile duct perforation if CBD patients have the abovementioned risk factors and experience persistent abdominal pain lasting for a few days from onset.

Type V biliary cyst with cystolithiasis.

We present the case of a 40-year-old female who presented to the General Surgery clinic due to a single episode of abdominal pain which required a visit to the Emergency Department. The patient had undergone surgery during childhood due to the suspicion of a hepatic hydatid cyst. However, an intraoperative cholangiography identified a small, non-complicated biliary cyst. Therefore, a hepatic resection was not performed. The patient did not undergo follow-up of the lesion.

Vitamin A deficiency in chronic cholestatic liver disease: Is vitamin A therapy beneficial?

Chronic cholestatic diseases are progressive diseases of the biliary tract that cause hepatic fibrosis and ultimately lead to liver failure. Liver transplantation is the sole curative option currently available, and because of high morbidity and mortality rates of these diseases, new therapeutic approaches are needed. Vitamin A is a nutrient essential for health as it regulates many processes, including epithelial growth and immunological processes. Vitamin A is primarily stored in hepatic stellate cells, and during liver injury, through an unknown mechanism, these cells lose vitamin A and convert into collagen-producing myofibroblasts, which contributes to hepatic fibrosis. Vitamin A deficiencies in chronic cholestatic diseases have been frequently reported, and therefore, retinoid metabolism has attracted a lot of attention. Retinoids have been shown to attenuate or even prevent hepatic fibrosis, and to regulate hepatic immunological response to cholestatic injury in different rodent models of chronic cholestasis. Recently, their potential as therapeutic drugs in primary sclerosing cholangitis patients was analyzed. The aim of this review is to summarize the existing knowledge and hypotheses about vitamin A role and the disease progression in cholestatic liver disease.

Biliary diseases as main causes of pyogenic liver abscess caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae.

BACKGROUND & AIMS: Little is known about aetiology and morbidity and clinical characteristics of pyogenic liver abscess caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae. METHODS: An analysis between pyogenic liver abscess patients caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae isolates and those caused by non-extended-spectrum beta-lactamase-producing Enterobacteriaceae was performed. RESULTS: Among 817 pyogenic liver abscess patients, there were 176 patients (21.5%) with pyogenic liver abscess of biliary origin, and 67 pyogenic liver abscess patients (8.2%) caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae isolates (mainly Escherichia coli and Klebsiella pneumoniae). Of 176 pyogenic liver abscess patients related to biliary disorders, there were 48 pyogenic liver abscess patients (27.3%) caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae. Within 67 pyogenic liver abscess patients caused by Enterobacteriaceae expressing extended-spectrum beta-lactamases, the occurrences of 48 pyogenic liver abscess patients (71.6%) were associated with biliary disorders. When compared with pyogenic liver abscess patients caused by non-extended-spectrum beta-lactamase-producing Enterobacteriaceae, there were significantly greater incidences of polymicrobial infections, bacteremia, pulmonary infection, recurrence and death in pyogenic liver abscess patients caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae. Carbapenems remain mainstay drugs against extended-spectrum beta-lactamase-producing E. coli and K. pneumoniae. Independent risk factors for occurrence of pyogenic liver abscess caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae were biliary disorders including extra- and intrahepatic cholangiolithiasis and an abnormal bilioenteric communication between bile and gut, a treatment history of malignancy such as operation and chemotherapy, pulmonary infection, and diabetes mellitus. CONCLUSIONS: Pyogenic liver abscess caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae isolates mainly occurs in patients with biliary disorders or with a treatment history of malignancy. The mainstay of treatment remains carbapenems in combination with adequate aspiration or drainage.

The porta hepatis microcyst: an additional sonographic sign for the diagnosis of biliary atresia.

OBJECTIVES: To describe and evaluate an additional sonographic sign in the diagnosis of biliary atresia (BA), the microcyst of the porta hepatis, in comparison with previously described signs. METHODS: Ultrasound performed in 321 infants (mean age 55 days) with cholestasis were retrospectively analyzed. BA was surgically confirmed in 193 patients and excluded in 128. US evaluated gallbladder type (1: normal; 2: consistent with BA; 3: suspicious), triangular cord sign (TCS), microcyst and macrocyst, polysplenia syndrome, portal hypertension, and bile duct dilatation. T test and Pearson χ2 test were used to compare US signs between the two groups, followed by univariate regression analysis. RESULTS: The highest specificity and sensitivity for BA (p < 0.001) were respectively obtained with non-visible gallbladder (100 %-13 %), macrocyst (99 %-10 %), polysplenia (99 %-11 %), microcyst (98 %-20 %), type 2 gallbladder (98 %-34 %), and TCS (97 %-30 %). Combination of signs (macro or microcyst; cyst and no bile duct dilatation; microcyst and/or TCS; type 2 gallbladder and/or cyst) provided better sensitivities (25-49 %) with similar specificities (95-98 %) (p < 0.001). On univariate analysis, the single US signs most strongly associated with BA were polysplenia (odds ratio, OR 16.3), macrocyst (OR 14.7), TCS (OR 13.4) and microcyst (OR 8). CONCLUSIONS: Porta hepatis microcyst is a reliable US sign for BA diagnosis. KEY POINTS: • The porta hepatis microcyst is a specific sign of biliary atresia. • It was found in 31 (16.1 %) of 193 patients with biliary atresia. • Its specificity was 98 % (p < 0.001). • High frequency transducer and color Doppler can show the porta hepatis microcyst.

A Case of Biliary Ascariasis in Korea.

Biliary ascariasis is still the leading cause of surgical complication of ascariasis, though its incidence has been dramatically reduced. Herein, we report a case of biliary ascariasis for the purpose of enhancing awareness of parasitic infections as a possible cause. A 72-year-old male visited the emergency room of Dankook University Hospital on 12 July 2015, complaining of right-upper-quadrant pain. By endoscopic retrograde cholangiopancreatography (ERCP), a tubular filling defect in the right hepatic duct was detected. The defect was endoscopically removed and diagnosed as an adult female of Ascaris lumbricoides worm, of 30 cm length. Upon removal of the worm, the pain subsided, and the patient was discharged without any complication. When treating cases of biliary colic, physicians should not neglect biliary ascariasis as the possible cause.

Distal Common Bile Duct Tuberculosis with Obstructive Jaundice: A Case Report.

Tuberculosis (TB) isolated in Common Bile Duct (CBD) is very rare and its treatment is somewhat controversial. We report a case of distal CBD tuberculosis diagnosed as cholangiocarcinoma. A 40 year old man presented with obstructive jaundice without abdominal pain, fever or weight loss. Ultrasonography and Magnetic Resonance Cholangio-Pancreatography (MRCP) indicated a mass lesion in the Distal CBD, which caused structure of the distal common bile duct. As Cholangiocarcinoma was suspected, he underwent Whipple procedure (pancreaticoduodenectomy). Histological examination of resected specimen revealed typical features of tuberculosis in the distal CBD, pancreatic head and lymph nodes. The rest of the abdominal cavity was unremarkable. Anti-microbial therapy for tuberculosis is started for 12 month course and he is well.

[Spontaneous perforation of the bile duct in a neonate: An unexpected finding. Case report]. / Perforación espontánea de la vía biliar en un neonato: un hallazgo inesperado. Caso clínico.

Spontaneous extrahepatic bile duct perforation is rare in newborns. It is a surgical cause of jaundice in this period and the acute presentation is unusual. OBJECTIVE: To report a case of spontaneous bile duct perforation in a newborn due to its serious complications if an early and timely diagnosis is not performed. CLINICAL CASE: A 10-day-old newborn who developed food rejection, fever and abdominal distension without jaundice, acolia, or coluria two days prior of admission. The laboratory tests showed leukopenia, thrombocytosis, increased C-reactive protein, and normal hepatic function. The abdominal x-ray showed pneumoperitoneum, and the diagnosis of necrotizing enterocolitis was made. Laparotomy was performed; extrahepatic bile duct perforation and biliary peritonitis were noted. Intraoperative cholangiography demonstrated rescatable proximal bile duct and dilated cystic duct. Hepatic-jejunostomy was performed with Roux-en-Y and cholecystectomy. In the postoperative study portal thrombosis was found, so he received anticoagulant treatment. At 8 months of age, the patient had enteral feeding tolerance and adequate weight gain. CONCLUSIONS: Biliary perforation is a rare entity and more in the neonatal period, a condition that makes it a diagnostic and therapeutic challenge. The prognosis will depend on early intervention and intraoperative findings.

[Treatment of non-cirrhotic, non-tumoural portal vein thrombosis]. / Actuación ante la trombosis portal no cirrótica no tumoral.

Thrombosis of the splenoportal axis not associated with liver cirrhosis or neoplasms is a rare disease whose prevalence ranges from 0.7 to 3.7 per 100,000 inhabitants. However, this entity is the second most common cause of portal hypertension. Prothrombotic factors are present as an underlying cause in up to 70% of patients and local factors in 10-50%. The coexistence of several etiological factors is frequent. Clinical presentation may be acute or chronic (portal cavernomatosis). The acute phase can present as abdominal pain, nausea, vomiting, fever, rectorrhagia, intestinal congestion, and ischemia. In this phase, early initiation of anticoagulation is essential to achieve portal vein recanalization and thus improve patient prognosis. In the chronic phase, symptoms are due to portal hypertension syndrome. In this phase, the aim of treatment is to treat or prevent the complications of portal hypertension. Anticoagulation is reserved to patients with a proven underlying thrombophilic factor.

[Renal hemodynamic in hydronephrosis concurrent with hepatobiliary system disorders, its dynamics in the course of treatment].

This article examines measurements of renal vascular ultrasound in 85 patients with hydronephrosis concurrent with disorders of the gallbladder and biliary tract, depending on severity and dynamics during treatment. The estimation of blood flow changes depending on applied renoprotective and hepatoprotective therapy is provided.

Should prophylactic cholecystectomy be performed in patients with concomitant gallstones after endoscopic sphincterotomy for bile duct stones?

BACKGROUND: Endoscopic sphincterotomy (EST) is the standard treatment for biliary duct stones. However, performing additional cholecystectomy after EST is controversial. In this study, we aimed to evaluate the effects of cholecystectomy after EST. METHODS: Between December 2008 and July 2011, we performed a prospective, randomized, single-center trial in 90 patients with proven gallstones who underwent EST and stone extraction. After the procedure, patients were randomly allocated to undergo cholecystectomy (n = 45) or to the group of GB left in situ (n = 45). The primary outcome was biliary complications at follow-up. RESULTS: Cholecystectomy was performed in 26 patients (60.5 %) in cholecystectomy group and in 13 patients (28.9 %) in intended conservative group. The median follow-up was 41 months. An intention-to-treat analysis showed that 8 patients (18.6 %) in the cholecystectomy group and 9 (20.0 %) in those who had their GB left in situ had recurrent biliary events (Kaplan-Meier curve, Breslow test, p = 0.555). In an as-treated analysis, 4 patients (10.3 %) who underwent cholecystectomy and 13 patients (26.5 %) who did not undergo cholecystectomy had additional biliary events during the follow-up period (Log-rank, p = 0.037). However, additional biliary events of cholangitis were similar in the two groups, except for a case of cholecystitis (Log-rank, p = 0.998). CONCLUSIONS: Cholecystectomy after EST for biliary duct stones fails to reduce additional recurrent cholangitis but reduces additional cholecystitis.