Interobserver Agreement for Classifying Post-liver Transplant Biliary Strictures in Donation After Circulatory Death Donors.

INTRODUCTION: Biliary strictures are a common complication of donation after circulatory death (DCD) liver transplantation (LT) and require multiple endoscopic retrograde cholangiopancreatography (ERCP) procedures. Three classification systems, based on cholangiograms, have been proposed for categorizing post-LT biliary strictures. We examined the interobserver agreement for each of the three classifications. METHODS: DCD LT recipients from 2012 through March 2017 undergoing ERCP for biliary strictures were included in the study. Initial cholangiograms delineating the entire biliary tree prior to endoscopic intervention were selected. One representative cholangiogram was selected from each ERCP. Five interventional endoscopists independently viewed each anonymized cholangiogram and classified the post-LT stricture according to each of the three classification systems. The Ling classification proposes four types of post-LT strictures based on their location. The Lee classification proposes four classes based on location and number of intrahepatic strictures. The binary system classifies strictures into anastomotic or non-anastomotic types. The Krippendorff's alpha reliability estimate was used to grade the strength of agreement as "poor," "fair," "moderate," "good," or "excellent" for values between 0-0.20, 0.21-0.4, 0.41-0.6, 0.61-0.08, and 0.81-1, respectively. RESULTS: One hundred DCD LT recipients (age 57.07 ± 8.8 years; 71 males) were initially evaluated. Of these, 49 patients who underwent 206 ERCP procedures for biliary strictures were included in the analysis. One hundred thirty-nine cholangiograms were selected and subsequently classified by five endoscopists. Interobserver agreement for post-LT biliary strictures was 0.354 for Ling classification (fair agreement), 0.405 for Lee classification (fair agreement), and 0.421 for the binary classification (moderate agreement). The binary classification provided the least amount of detail regarding the location and number of biliary strictures. DISCUSSION: The currently available classification systems for assessing post-LT biliary strictures have sub-optimal interobserver agreement. A better-designed classification system is needed for categorizing post-LT biliary strictures.

Preoperative assessment for feasibility of laparoscopic cholecystectomy using magnetic resonance cholangiography.

BACKGROUND/AIMS: We present the results of classification of magnetic resonance cholangiography (MRC) focusing upon visualization of cystic duct for preoperative laparoscopic cholecystectomy (LC), along with assessments of a possible correlation between MRC classification and feasibility of LC. METHODOLOGY: The study included a total of 663 patients who were diagnosed as cholelithiasis. MRC were classified into four types: Type A; entire biliary tract was visualized (+), Type B; cystic duct (+) but gallbladder was not(-), Type C; gallbladder (+), cystic duct (-), and Type D; gallbladder (-), cystic duct (-). The feasibility of LC was assessed using the following two variables: 1) percentages of cases in which LC was changed to open cholecystectomy (OC) and 2) operating time. The results were compared in respect of the relationship with the MRC classification. RESULTS: MRC were classified as follows: Type A (58.4%), Type B (15.2%), Type C (19.3%) and Type D (7.1%). A total of 124 patients (18.7%) had chronic cholecystitis, and a strong correlation with MRC type was noted (p<0.0001). In 46 patients (7.5%), the surgical procedure was changed from LC to OC. The percentages of cases in which LC was changed to OC was significantly higher for Type C and Type D (p<0.0001), so these two groups demonstrated prolonged operating time. CONCLUSIONS: Our MRC classification based on the visualization of cystic duct can reflect the feasibility of LC, and LC may be less feasible tin Type C, and in particular Type D patients.

¿Es necesario el tubo en "T" después de una cirugía directa sobre el esfínter de Oddi con apertura del colédoco? / Is T-tube necessary after choledochotomy and surgical manipulation of oddi's sphincter?

Objetivo. Evaluar y analizar la utilidad de la coledocorrafia primaria en el tratamiento de la litiasis biliar. Determinar en la coledocorrafia primaria la existencia o no de diferencias entre la papilotomía quirúrgica transduodenal o la dilatación instrumental de la papila. Pacientes y método. Se analizan las características clínicas y la evolución quirúrgica de una serie de 25 pacientes sometidos a coledocorrafia primaria desde el 1 de enero de 1990 hasta el 31 de diciembre de 1995, que cumplían los criterios de selección previamente establecidos. Se practicaron de forma sistemática, y en todos los casos por el mismo cirujano, las siguientes intervenciones: colecistectomía, colangiografía intraoperatoria, coledocotomía con esfinterotomía (sin plastia) o dilatación instrumental, drenaje ambiente y cierre coledocal. Resultados. Las características del ingreso de los pacientes tratados con coledocorrafia primaria fueron: 6 días de estancia media y ningún reingreso. En cuanto a las complicaciones precoces, hubo 2 casos de bilirragia, y como complicaciones tardías se halló un caso de esclero-odditis a los 3 años y un caso de colangitis, a los 6 años, por coledocolitiasis. Conclusión. La coledocorrafia primaria es una técnica útil y segura en el tratamiento de la vía biliar litiásica, que contribuye a reducir la estancia media hospitalaria, así como el riesgo de reingreso y de morbilidad debida al uso sistemático del tubo de Kehr (AU)

El tratamiento quirúrgico del tumor de Klatskin. Una asignatura pendiente de la cirugía / Surgical treatment of Klatskin' s tumor. An unresolved surgical issue

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Colangio-TC en el diagnóstico de coledocolitiasis / Computed tomographic cholangiography in the diagnosis of choledocholithiasis

Introducción, material y métodos: Con la sospecha clínica o radiológica de coledocolitiasis, realizamos en el período de un año, 32 tomografías computarizadas (TC) convencionales tras la administración de contraste intravenoso de eliminación biliar (Bilisergol). Los resultados obtenidos fueron contrastados mediante la realización de CPRE y/o cirugía. Resultados: La sensibilidad y especificidad de la colangiografía intravenosa con TC convencional fue del 95 por ciento. Conclusiones: Demostramos que la realización de un estudio protocolizado con cortes finos en fases de apnea, se demuestra como una técnica muy útil, al alcance de cualquier servicio de radiología y con una altísima sensibilidad y especificidad en el diagnóstico de las coledocolitiasis (AU)