Severe hyponatraemia due to high output external biliary drainage corrected with bile refeeding: A case report.

Hyponatraemia is an uncommon complication of external biliary drainage. We report on a 62-year-old male with hilar cholangiocarcinoma who developed refractory severe hyponatraemia despite sodium replacement during preoperative external biliary drainage. Nasojejunal bile refeeding restored sodium levels to normal.

Re-thinking of T-tube use in whole liver transplantation: an analysis on the risk of delayed graft function.

The liver-gut axis has been identified as crucial mediator of liver regeneration. Thus, the use of a T-tube in liver transplantation (LT), which interrupts the enterohepatic bile circulation, may potentially have a detrimental effect on the early allograft functional recovery. We retrospectively analyzed a cohort of 261 patients transplanted with a whole liver graft, with a duct-to-duct biliary anastomosis, who did not develop any surgical complication within postoperative day 14. Early allograft dysfunction (EAD) was defined according to the criteria of Olthoff et al. (EAD-O), and graded according to the Model for Early Allograft Function (MEAF) score. EAD-O developed in 24.7% of recipients and the median MEAF score was 4.0 [interquartile range 2.9-5.5]. Both MEAF and EAD predicted 90-day post-LT mortality. A T-tube was used in 49.4% of cases (n = 129). After a propensity score matching for donor age, cold and warm ischemia time, donor risk index, balance of risk score, Child-Pugh class C, and MELD score, the T-tube group showed a significantly higher prevalence of EAD-O and value of MEAF than the no-T-tube group (EAD-O: 29 [34.1%] vs 16 [19.0%], p = 0.027; MEAF 4.5 [3.5-5.7] vs 3.7 [2.9-5.0], p = 0.014). In conclusion, T-tube use in LT may be a risk factor for EAD and higher MEAF, irrespective of graft quality and severity of pre-LT liver disease.

Survey on the current status of the indication and implementation protocols for bile replacement in patients with external biliary drainage with special reference to infection control.

PURPOSE: This survey of bile replacement (BR) was conducted on patients with external biliary drainage to assess the current status of indication and implementation protocol of BR with special reference to infection control. METHODS: A 12-item questionnaire regarding the performance of perioperative BR was sent to 124 institutions in Japan. RESULTS: BR was performed in 29 institutions, and the indication protocol was introduced in 19. BR was performed preoperatively in 11 institutions, pre- and postoperatively in 12, and postoperatively in 6. The methods used for BR administration included oral intake (n = 10), nasogastric tube (n = 1), enteral nutrition tube (n = 3), oral intake and enteral nutrition tube (n = 6), oral intake or nasogastric tube (n = 2), nasogastric tube and enteral nutrition tube (n = 2), and oral intake or nasogastric tube and enteral nutrition tube (n = 5). In 10 of 29 institutions, isolation of multidrug-resistant organisms and a high bacterial load were considered contraindications for the use of BR. Seven institutions experienced environmental contamination. CONCLUSIONS: Given the different implementation of BR among institutions, the appropriate indication and protocols for BR should be established for infection control.

Safety and Efficacy of Low-Dose Single-Agent Capecitabine in Inoperable Gallbladder Cancer with Jaundice Post-Single-System Single-Catheter External Biliary Drainage: a Pilot Study from a Highly Endemic Area.

Gallbladder cancer (CaGB) in the subcontinent belongs to low socioeconomic status, and at the time of diagnosis, a large number is unresectable or inoperable so the palliative treatment remains the only option. In the present study, attempt was made to see the effect and safety profile of single-agent oral capecitabine in inoperable CaGB in presence of low levels of jaundice post-single-catheter transhepatic external biliary drainage. In N = 35 of inoperable jaundiced CaGB, post-biliary drainage capecitabine in low dose was started when their total bilirubin levels fell to 10 mg% or below. Post-external drainage decreased bilirubin level to < 10 mg/dl within 1-4 weeks, mean 2.37 ± 0.80 weeks. Survival was 1-6 months, mean 3.26 ± 1.46 months. Catheter patency time was 1.92 ± 0.64 months (range 0-3 months). Young age, male sex, level of jaundice at presentation, and duration of decrease in jaundice after drainage were significantly associated with progressive disease course. Poor survival was significantly associated with progressive disease course, young age, and level of jaundice at admission. To the best of our knowledge, this is the first study to establish that single-agent capecitabine can be safely given in CaGB in presence of jaundice.

Internal biliary drainage superior to external biliary drainage in improving gut mucosa barrier because of goblet cells and mucin-2 up-regulation.

Backgroud: Obstructive jaundice increases intestinal permeability, but the pathological mechanisms remain obscure, which results in debates about the necessity of performing preoperative biliary drainage in patients with obstructive jaundice. Mucin-2 (MUC2) and goblet cells regulated by bile acids play an important role in maintaining the function of intestinal mucosal barrier. The present study was to investigate the role of goblet cells and MUC2 in obstructive jaundice and evaluate the effect of biliary drainage on intestinal permeability. STUDY DESIGN: We enrolled patients with malignant biliary obstruction and controls. We also did animal studies with four groups of rats: sham operation, obstructive jaundice, internal biliary drainage, and external biliary drainage. Histopathological analysis, biochemical measurement, and electron microscopy examination were done on pertinent samples. RESULTS: Compared with the control group, the small intestinal mucosa was significantly damaged; goblet cells and MUC2 were significantly decreased and serum endotoxin level was significantly increased in patients and rats with obstructive jaundice. Biliary drainage, especially internal biliary drainage, significantly increased goblet cells and MUC2 and attenuated the damage of small intestinal mucosa. CONCLUSIONS: In obstructive jaundice condition, goblet cells and MUC2 were reduced which were involved in the damage of intestinal mucosa barrier; biliary drainage increased goblet cells and MUC2, repaired mucosa layer and restored the intestinal mucosa barrier function.

Outcomes following partial external biliary diversion in patients with progressive familial intrahepatic cholestasis.

BACKGROUND/PURPOSE: PFIC is a family of bile acid (BA) transport disorders that may result in serious liver disease requiring transplantation. We reviewed our experience with PEBD as a method to improve liver function and avoid transplantation. METHODS: All patients with PFIC were reviewed. Outcomes included changes in serum BA, conversion to ileal bypass (IB), and survival without transplantation. Statistics were obtained using paired t-test and Wilcoxon test. RESULTS: Thirty-five patients with PFIC were identified. Data were available in 24. Twenty-four children (12 males) underwent PEBD: 10 PFIC-1, 13 PFIC-2, and one PFIC-3. BA levels decreased in PFIC-1 patients (1724±3215 to 11±6µmol/L, P=0.03) and in the single PFIC-3 patient (821 to 11.2µmol/L), but not significantly in PFIC-2 patients (193±99 to 141±118µmol/L, P=0.15). Seven patients were converted to IB. There were no significant changes in BA levels following conversion. Five-year transplant-free survival was 100% in PFIC-1 and PFIC-3, but only 38% (5/13) in PFIC-2 (P=0.004). CONCLUSION: PEBD is an effective procedure to reduce total BA levels and improve symptoms in PFIC patients. However, it appears to be less efficacious in the PFIC-2 group. The higher BA levels could contribute to ongoing liver damage, and thus a higher transplant rate in PFIC-2 patients. LEVEL OF EVIDENCE: Level IV.

Effect of External Biliary Drainage via Cystic Duct in Laparoscopic Choledochotomy with Primary Closure / 中国微创外科杂志

Objective To investigate the effectiveness and safety of the slender external biliary drainage tube (F5 ureter catheter) inserted into the common bile duct via the cystic duct in laparoscopic choledochotomy with primary closure.Methods Clinical data of 59 patients with cholecystolithiasis and choledocholithiasis treated in our hospital between Feburary 2013 and March 2016 were retrospectively analyzed.The patients were treated with laparoscopic common bile duct exploration followed by primary duct closure,and bile duct drainage with a slender catheter through cystic duct after closure of the choledochotomy.Results All the cases underwent surgery successfully.The postoperative output of bile drainage was 30-570 ml/d.There were no complications such as biliary leakage,cholangitis or biliary pancreatitis.The catheter was withdrawn in 6-8 d in 57 patients after the operation,and was withdrawn in 10-11 d in 2 patients after the operation.There was no discomfort after removing the catheter.Postoperative hospitalization time was (9.1 ± 2.0) d.All patients were followed up for 5 months to 3 years,with an average of 16 months.The B ultrasound examinations showed no residual bile duct stones and liver functions were normal.Conclusions External biliary drainage using a slender ureter catheter via the cystic duct is safe,effective and easy to perform.It may reduce postoperative potential complications,especially bile leakage.

Primary closure after laparoscopic choledochotomy with transcystic cholangiography and biliary drainage / 中华肝胆外科杂志

Objective To assess the clinical outcomes in patients who underwent laparoscopic primary closure of common bile duct (CBD) with or without transcystic cholangiography and transcystic biliary drainage.Methods From June 2013 to March 2016,we operated on 46 patients who underwent primary closure of common bile duct after laparoscopic choledochotomy (group A).The results were compared with 51 patients who underwent primary closure of common bile duct after laparoscopic choledochotomy together with transcystic biliary drainage (group B) during the same study period.Results There was a significant difference in the incidence of postoperative bile leakage between the two groups.The risk in group A was sig nificantly higher than group B (8.7％ vs 0％,P ＜0.05).The duration of operation in group A was significantly shorter than in group B [(125.3 ± 28.3) min vs (131.3 ± 20.5) min].There were no significant differences in the duration of hospital stay between the two groups [(7.3 ± 2.4) days vs (7.8 ± 1.9) days,P ＞ 0.05].All patients were followed up (range 3 months to 29 months,average 8.4 months).B-ultrasound examination showed no residual bile duct stones and the liver functions were normal.Conclusions Laparoscopic primary closure of common bile duct was possible after choledochotomy.Transcystic cholangiography and transcystic biliary drainage after primary closure of common bile duct were safer and more reli able.

Progressive familial intrahepatic cholestasis.

Progressive familial intrahepatic cholestasis (PFIC) is a group of rare disorders which are caused by defect in bile secretion and present with intrahepatic cholestasis, usually in infancy and childhood. These are autosomal recessive in inheritance. The estimated incidence is about 1 per 50,000 to 1 per 100,000 births, although exact prevalence is not known. These diseases affect both the genders equally and have been reported from all geographical areas. Based on clinical presentation, laboratory findings, liver histology and genetic defect, these are broadly divided into three types-PFIC type 1, PFIC type 2 and PFIC type 3. The defect is in ATP8B1 gene encoding the FIC1 protein, ABCB 11 gene encoding BSEP protein and ABCB4 gene encoding MDR3 protein in PFIC1, 2 and 3 respectively. The basic defect is impaired bile salt secretion in PFIC1/2 whereas in PFIC3, it is reduced biliary phospholipid secretion. The main clinical presentation is in the form of cholestatic jaundice and pruritus. Serum gamma glutamyl transpeptidase (GGT) is normal in patients with PFIC1/2 while it is raised in patients with PFIC3. Treatment includes nutritional support (adequate calories, supplementation of fat soluble vitamins and medium chain triglycerides) and use of medications to relieve pruritus as initial therapy followed by biliary diversion procedures in selected patients. Ultimately liver transplantation is needed in most patients as they develop progressive liver fibrosis, cirrhosis and end stage liver disease. Due to the high risk of developing liver tumors in PFIC2 patients, monitoring is recommended from infancy. Mutation targeted pharmacotherapy, gene therapy and hepatocyte transplantation are being explored as future therapeutic options.

Clinical application of overriding external drainage in high malignant obstructive jaundice / 实用放射学杂志

Objective To explore the bile drainage method in patients with high malignant obstructive jaundice.Methods 13 pa-tients with high obstructive jaundice were confirmed by type-B ultrasonography,CT and MR cholangiopancreatography (MRCP). Under C arm X-ray machine,we performed percutaneous puncture of the right hepatic duct and external drainage of the left and right hepatic ducts by the internal and external bile drainage tube (COOK Company).Results All of 13 patients,1 was carcinoma of head of pancreas,1 was metastatic tumor in hepatic hilar region,and 1 1 cases were cholangiocarcinomas.They were successfully per-formed external biliary drainage riding across the left and right hepatic ducts.The patients were followed up at 1-1 5 months.2 pa-tients died with cachexia after 1 and 4 months.For the other patients,jaundice was relieved and appetite was improved.Conclusion The overriding external biliary drainage is an effective drainage method for completely high obstructive jaundice.

Improvement of liver function of rats with obstructive jaundice by selective external biliary drainage / 中华消化外科杂志

Objective To explore the effects of selective external biliary drainage (SEBD) on the liver function of rats with obstructive jaundice. Methods The rates of right hepatic lobe weight against body weight of SD rats in SEBD group and total external biliary drainage (TEBD) group were calculated at day 0, 1, 4, 7, 10 after external biliary drainage. The mRNA and protein expressions of multidrug resistance-associated protein 2 (MRP2) and bile salt export pump (BSEP) were detected by RT-PCR and Western blot. Results Compared with TEBD group, the rate of right hepatic lobe weight against body weight and mRNA and protein expression of MRP2 and BSEP were significantly higher in SEBD group (t=15.569, P <0.05 ; t =4.485, 7.143, 9.169, 5.178, P <0.05). Conclusions SEBD improves the liver function of rats with obstructive jaundice, which may be related to the compensatory increase of remnant liver volume and elevation of expression per volume of membrane transport proteins.

Influence of Preoperative Portal Vein Branch Ligation in Regeneration of Remaining Rat Liver with or without Jaundice

Purpose: The goal of this study is to define whether or not preoperative portal vein embolization has any additional role in the total amounts of liver regeneration and functional improvement after major hepatectomy in rat model. In addition, this study is to define obstructive jaundice has any positive or negative effect on it. METHODS: There were a total of 650 rats, divided into three experimental groups. Experiment A was done under the normal liver status, experiment B was done under the obstructive jaundice status, experiment C was done under the external biliary drainaged status. Each experimental group was divided into three groups that had been made by different surgery. One was 70% partial hepatectomy, another was 70% portal vein branch ligation, and the other was 70% portal vein ligation followed by 70% hepatectomy. Each operational group required over 60 rats for serial data collection which was taken at the operation and 6, 12, 24, 48, 72 hours after operation. RESULTS: We finally observed that there was no additional regeneration of remaining liver by doing preoperative portal vein embolization. It was same in obstructive jaundice group and external biliary drainaged group. And also, there was no significant fucntional improvement or deterioration by existence of obstructive jaundice. Conclusion: We conclude it is no worth doing preoperative portal vein embolization for getting additional liver regeneration and obstructive jaundice does not has significant positive or negative effect on liver regeneration and hepatic function in itself.