[Percutaneous treatment of intrahepatic lithiasis]

AIM

To present our experience with percutaneous intracorporeal electrohydrolic lithotripsy in the treatment of intrahepatic lithiasis.

SUBJECTS AND METHODS

From January 1989 to November 1998, 53 patients with intrahepatic lithiasis were treated with percutaneous intracorporeal electrohydrolic lithotripsy. Twenty-six patients had primary intrahepatic lithiasis. Intrahepatic stones were associated with intrahepatic duct abnormalities in 11 patients, 9 had strictures and 2 had cystic dilatations. Twenty-seven patients had secondary intrahepatic lithiasis formed a biliodigestive bypass in 20 patients. Intracorporeal electrohydrolic lithotripsy was performed under cholangioscopic guidance in all patients. The endoscope was introduced into the biliary ducts through a cutaneobiliary tract in 51 patients, through a cutaneocholecystic tract in one and through a cutaneojejunal tract in one. These tracts were created and gradually dilated in two sessions three days apart. In twenty-two patients stenosis or sharp angulation prevented adequate positioning of the scope which was only successful after balloon dilation or insertion of a stiff wire.

RESULTS

Complete clearance of stones was achieved in 49 patients (92%). Biliary or hepaticojejunostomy strictures were successfully dilated with an angioplasty balloon in all patients. Ten patients (19%) had early complications: four had bilomas treated by percutaneous drainage, three had resolutive onset of cholangitis, two had transient arterial hemobilia, and one had a pneumothorax. The mean duration of follow-up was five years. During this period, 5 patients (9%) had recurrent symptoms of biliary obstruction. Among these patients, three (5.7%) had recurrent symptomatic intrahepatic lithiasis, one had a recurrent biliary stricture and one had secondary sclerosing cholangitis. Treatment of recurrent stones was repeated intracorporeal electrohydrolic lithotripsy in two and left hepatectomy in one; recurrent biliary stricture was treated by hepaticojejunostomy and secondary sclerosing cholangitis by antibiotics.

CONCLUSION

Intracorporeal electrohydrolic lithotripsy is effective and safe and should be proposed as the first line treatment of primary or secondary intrahepatic lithiasis.

Intrahepatic biliary lesions after orthotopic liver transplantation

Intrahepatic biliary lesions (IBL) are rare (2-9%) after orthotopic liver transplantation (OLT). The aim was to evaluate the incidence, etiology and outcome. In nine years, a total 532 OLTs were performed in 481 patients. Twenty-four patients developed IBL. Eight were due to HAT, seven to ABOI, three to CDR and six to PI. The time until diagnosis of HAT is longest in patients (14+/-6) with IBL. ABOI is another cause of IBL. CDR is a rare cause of IBL, however when it takes place, patients must undergo Rtx. Finally, PI is a relevant cause of IBL. In order to suppress the incidence of IBL we should consider 1) the systematic use of Doppler-Ultrasound; 2) emergency reoperation of patients with HAT, 3) avoid ABOI in OLT; 4) Rtx in cases of CDR, and 5) OLT should still be performed as an emergency procedure.

Various Presentations of Postcholecystectomy Bile Leak Diagnosed By Scintigraphy

Hepatobiliary scintigraphy is an established method for the diagnosis of a bile leak from the biliary system. A bile leak should be considered in any patient after cholecystectomy who has unexplained abdominal pain after operation. Three patients with bile leak diagnosed by scintigraphy are described, one of whom had an unusual pattern of hepatic subcapsular collection of the bile. The second patient had a bile leak through the postsurgical drainage tube, whereas the third patient had a more typical pattern of leakage into the peritoneal cavity.

Biliary complications in 100 adult liver transplantations: a retrospective clinical study

Biliary complications were reviewed in 100 consecutive adult liver transplantations. Included in the study were 92 patients surviving for more than 1 month. In 86 transplantations biliobiliary anastomosis was performed with (n = 25) or without (n = 61) a T-tube. In six cases biliodigestive anastomosis (Roux-en-Y) was performed. Biliary stricture caused by hepatic arterial thrombosis was not included. Biliary complications were seen in 17 cases: seven anastomotic strictures, four T-tube-related leakages, four anastomotic leakages, one leakage of unknown origin and one late cholangitis. Nine were surgically treated (six strictures and three leakages). Patients with primary sclerosing cholangitis had the highest biliary complication rate (36%). Early anastomotic strictures were associated with a higher rate of major bacterial infections (P = 0.03) and CMV disease (P = 0.08) than those without biliary complications. Biliobiliary anastomosis with a T-tube was associated with more complications (28%) than anastomoses without a T-tube (13%). To date, total patient survival including all 100 transplantations was 71% (median follow-up 3.3 years). We conclude that biliary complications are rather common but they do not affect survival and can be treated. Biliary T-tubes can be omitted.

Randomized trial of choledochocholedochostomy with or without a T tube in orthotopic liver transplantation

OBJECTIVE

To compare the incidence of biliary complications after liver transplantation in patients undergoing choledochocholedochostomy reconstruction with or without T tube in a multicenter, prospective, randomized trial.

SUMMARY BACKGROUND DATA

Several reports have suggested that biliary anastomosis without a T tube is a safe method of biliary reconstruction that could avoid complications related to the use of T tubes. No large prospective randomized trial has so far been published to compare the two techniques.

METHODS

One hundred eighty recipients of orthotopic liver transplantation were randomly assigned to choledochocholedochostomy with (n = 90) or without (n = 90) a T tube in six French liver transplantation centers. All types of biliary complications were taken into account.

RESULTS

The overall biliary complication rate was increased in the T-tube group, even though these complications did not lead to an increase in surgical or radiologic therapeutic procedures. The major significant complication was cholangitis in the T-tube group; this did not occur in the other group. The incidence of biliary fistula was 10% in the T-tube group and 2.2% in the group without a T tube. Other biliary complications were similar. The complication rate of cholangiography performed with the T tube was greater than with other types of biliary exploration. The graft and patient survival rates were similar in the two groups.

CONCLUSION

This study is the first large prospective, randomized trial of biliary complications with or without a T tube. The authors found an increase in the biliary complication rate in the T-tube group, which was linked to minor complications. The T tube did not provide a safer access to the biliary tree compared with the others types of biliary explorations. The authors recommend the performance of choledochocholedochostomy without a T tube in liver transplantation.

[Usefulness of magnetic cholangioresonance in the study of hepatobiliary disease in patients adults with cystic fibrosis]

INTRODUCTION

Because alterations in the bile ducts found in cystic fibrosis mimic those found in primary sclerosing cholangitis, magnetic resonance cholangiography (MRC) could be a useful diagnosis technique, especially because it is non-invasive.

MATERIAL AND METHODS

We prospectively studied 26 adult patients with cystic fibrosis. Of these, 11 had liver disease previously diagnosed on the basis of symptomatology, physical examination, liver function tests and abdominal ultrasound (group A) and 15 had no apparent liver disease (group B). In all patients liver function tests, abdominal ultrasound and MRC using 1.5 Teslas General Electric and Siemens systems were carried out. The images were interpreted blind by two radiologists with experience in the interpretation of biliary alterations in cystic fibrosis.

RESULT

In 6 of the 11 patients in group A, MRC showed signs of liver cirrhosis (nodularity, irregular surface, splenomegaly, varicosity); 4 patients showed rose-colored images in the choledoch and intrahepatic ducts; of the 5 patients with previous non-cirrhotic liver disease, 2 showed rose-colored intrahepatic ducts, 2 showed dilatation of the intrahepatic ducts and 1 showed hepatosplenomegaly with hepatic steatosis. Of the 15 patients in group B, bile duct anomalies were found in 5. Of these, 3 showed rose-colored images of the hepatic ducts and/or choledoch, 1 showed stenosis of the common hepatic duct with rigidity of the intrahepatic ducts and 1 showed irregularities in the caliber of the intrahepatic ducts without dilatation, which were suspicious for intrahepatic lithiasis.

CONCLUSIONS

MRC is a useful technique in the study of hepatobiliary disease in cystic fibrosis because it detected anomalies in all our patients previously diagnosed with liver disease and revealed ductal lesions not revealed by other non-invasive techniques.

Percutaneous recanalization of the bile duct along an endoscopic naso-biliary catheter

Percutaneous recanalization of the bile duct is essential for placing biliary stents and carrying out other interventions. This prospective study was performed to establish safe approaches for percutaneous recanalization of the bile duct when it had previously resulted in failure. Between July 1995 and July 1999, percutaneous recanalization of the bile duct was attempted in 58 patients with a malignant biliary stenosis. When recanalization failed, an endoscopic naso-biliary drainage (ENBD) catheter was placed across the stenosis. The procedure was again attempted along the ENBD catheter. In the period of the study, four patients underwent successful recanalization after ENBD, although attempts prior to ENBD had been unsuccessful. As a result, the success rate of recanalization in the period was 100% (58/58). When recanalization fails, the use of an ENBD catheter may provide access to the biliary tree, and the biliary stenosis can be recanalized safely.

Value of MR cholangiography in the evaluation of postoperative biliary complications following orthotopic liver transplantation

The aim of this study was to describe the spectrum of abnormal biliary findings as seen with magnetic resonance cholangiography (MRC) in symptomatic patients after orthotopic liver transplantation (OLT). In our study we included 12 consecutive patients post-OLT who presented with clinical and/or biochemical suspicion of biliary complications. In all patients MRC was performed on a 1.0-T whole-body magnet and breathhold half-Fourier acquired single-shot turbo spin echo and rapid acquisition with relaxation enhancement sequences were used. Diagnostic confirmation was obtained with percutaneous transhepatic cholangiography (PTC; n = 3 patients), endoscopic retrograde cholangiography (ERC; n = 3 patients), or clinical follow-up. A vast array of biliary abnormalities were detected in 11 of 12 patients: high-grade, obstructive, anastomotic stricture was the most common unique abnormality. Findings consistent with bile duct necrosis, the second most common abnormality, were accompanied by arterial abnormalities in 2 of 5 patients on subsequent MR- and digital subtraction angiography. Compared with the findings obtained with direct cholangiography (n = 5 patients), MRC was highly accurate for the detection and characterization of postoperative biliary complications. Compared with the final diagnosis, which was based on PTC-ERC findings and/or all available clinical data, MRC imaging alone was able to provide a specific diagnosis in 9 of 12 patients. Magnetic resonance cholangiography is an accurate, time-saving, and non-invasive imaging modality in the evaluation of post-OLT patients in whom suspicion of biliary complications exists. Although the precise value of MRA in this patient group requires larger dedicated studies, single session "all-in-one" MR evaluation of both biliary and arterial system in our series proved to be a substantial benefit in obtaining an accurate and complete diagnosis.

[Biliary complications during videolaparoscopic cholecystectomy. Remarks on methodology and indications in the training period]

In our study we have considered the activity of a surgeon working in our Surgery Department during his laparoscopic training period. We focus our attention on a date related to the same complications checked in 27 cases of cholelithiasis operated by the same surgeon. We have observed three cases of biliary cholelithiasis fistulas, all of them during the three last operations. The examination of the above mentioned cases considers the clinical post-surgery situation and the therapeutic standards we adopted to work out the complications. Now we can precisely state, according to our experience, the particular directions for the videolaparoscopic training period. In addition we can propose one simple mathematical formula to value the IRL (Laparoscopic Risk Index) concerning three variables: the experience of the surgeon; the instruments condition; the clinical situation of the patient. The relation of these three factors turned in numbers suggests the chance of success of a videolaparoscopic operation. We conclude our study mentioning the gasless videolaparoscopic technique that seems to have a large indication, according to the same Surgery School. This technique is particulary indicated on those classes of patients in which the CO2 insufflation into abdominal cavity and the increase of endocavity pressure can represent a contraindication to the videolaparoscopic approach: in this case the surgeon will follow the surgical indication to solve the clinical situation, as happens in war surgery.

[Diagnostic and therapeutic endoscopic cholangiopancreatography in biliary leak after liver transplantation. Report of 2 cases]

BACKGROUND

The most common biliary tract complications after orthotopic liver transplantation are anastomotic strictures and bile leaks. These remain important causes of morbidity, frequently prompting surgical approach and/or biliary drainage.

OBJECTIVE

To report our experience using endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and management of biliary tract complications in patients with hepatic transplantation.

PATIENTS/METHODS AND RESULTS

We present two patients with hepatic transplantation who developed bile peritonitis secondary to biliary leaks diagnosed by ERCP, both treated with sphincterotomy and biliary endoprostheses. Bile leaks rapidly resolved after endoscopic sphincterotomy and stent placement.

CONCLUSIONS

ERCP is a useful diagnostic and therapeutic intervention for post-transplantation biliary tract complications.

Drug and toxin-induced bile duct disorders

Various drugs of toxins have been implicated in the development of a particular form of liver damage predominantly involving the bile ducts. Such liver toxicity is often associated with a clinical picture of prolonged cholestasis and may even evolve in rare instances, into the full picture of the vanishing bile duct syndrome, eventually complicated with biliary cirrhosis. Drug and toxins potentially responsible for bile duct injury are reviewed as well as the characteristics of its clinical presentation. The pathophysiologic aspects of the syndrome are also reviewed including recent data, which are strongly in favor of the role of a genetic predisposition.

Clinicopathologic evaluation of hepatocellular carcinoma with bile duct thrombi

BACKGROUND

The aim of this study was to evaluate the clinicopathologic characteristics of patients with hepatocellular carcinoma (HCC) and bile duct thrombi (BDT).

PATIENTS

Seventeen patients with HCC and BDT among 671 patients with HCC who underwent hepatic resection were enrolled in this study.

RESULTS

There were no significant differences in the survival rates between patients with and those without BDT, although the rate of stage IV or portal vein invasion was significantly higher in patients with HCC and BDT than in those with HCC but without BDT. In 9 of 17 patients with BDT, preoperative jaundice was observed. Five of the 17 patients underwent a bile duct resection combined with hepatic resection, and 12 patients underwent hepatic resection with removal of the BDT without bile duct resection. None of the patients had histopathologic evidence of direct tumor invasion into the bile duct wall or of any tumor recurrence related to the BDT. There were no significant differences in the survival rates between patients who underwent bile duct resection and those who did not.

CONCLUSION

Hepatic resection and the removal of BDT without bile duct resection were sufficient surgical interventions to treat patients with HCC and BDT.

[Nonobstructive residual mucocele of the cystic duct. Reassessment of complications in our 13 years' experience with liver transplantation]

PURPOSE

We reassessed the incidence of mucocele of the residual cystic duct in our series of orthotopic liver transplantation (OLT) patients.

MATERIAL AND METHODS

We examined a series of 283 liver transplants with end-to-end choledocho-choledocal anastomosis (263 patients, 163 men and 80 women, 24-65 years old), performed at the II Surgical Department of the University of Bologna from May 1986 to April 1999 and subsequently followed-up in our Institute. All patients were examined with gray-scale and color Doppler US and some also underwent CT and CT cholangiography.

RESULTS

An anechoic ovoidal structure just before the portal vein and in proximity of the main bile duct was found in 13 patients. US and CT findings, the latter when available, led us to make a diagnosis of nonobstructive mucocele of the cystic duct. The radiological diagnosis was eventually confirmed by clinical and surgical findings.

DISCUSSION AND CONCLUSIONS

In our series the incidence of this complication was 4.5%, a slightly higher value than those reported in the literature. Cystic duct mucocele cannot be considered an uncommon complication and should thus be more carefully searched for by operators. In our experience this complication never required reoperation for cholestasis.

Foreign body reaction to a metal clip causing a benign bile duct stricture 16 years after open cholecystectomy: report of a case

We present herein a case where a benign bile duct stricture developed 16 years after an open cholecystectomy and without any prior symptoms. The patient was thought to have a Klatskin tumor both pre- and intraoperatively and was treated with a resection of the mass and bile duct confluence, while hepaticojejunostomies were also performed to both ducts separately. A pathologic examination of the specimen revealed extensive fibrosis, chronic inflammation, and a nonnecrotizing granulomata. Any hilar mass presenting after upper abdominal surgery should therefore be considered to be potentially a benign bile duct stricture, even with a long symptom-free interval.

[Determination of index of the transcutaneous electrostimulation effect on the liver and bile ducts based on micellar structure and lithogenicity of bile in patients with the exterior drainage of the common duct]

Kept under clinical observation were 78 patients under common bile duct drainage for mechanical jaundice of the nontumor genesis. In all patients, micellarity and lithogenicity of the hepatic bile (fraction "C") were studied postoperatively, with an individual selection having been carried out of the index of transcutaneous electrostimulation effect on the hepatobilliary system. An effective modality has been elaborated for treatment and prophylaxis of hepatic insufficiency, correction of micellarity and lithogenicity of bile in the early postoperative period in patients with mechanical jaundice of the nontumor genesis, that can be recommended for use in the health care practice.

Endoscopic management of biliary leaks after T-tube removal in liver transplant recipients: nasobiliary drainage versus biliary stenting

This study presents the long-term sequelae of endoscopic retrograde cholangiopancreatography (ERCP)-managed biliary leakage in patients who underwent orthotopic liver transplantation (OLT) and compares the relative efficacy, safety, and charges of nasobiliary drainage (NBD) versus biliary stenting (BS). We identified all orthotopic liver transplant recipients from January 1, 1993, to December 31, 1997, who had undergone ERCP for biliary leakage. Clinical outcome and charges were calculated on an intention-to-treat basis according to initial endoscopic therapy. Of the 1,166 adult OLTs performed during the study period, 442 patients underwent elective T-tube removal. ERCP was attempted in 69 patients (16%) who developed biliary leakage after T-tube removal. Three patients (5%) in whom initial ERCP was unsuccessful underwent surgery. NBD and BS were used as primary therapy in 45 (68%) and 21 patients (32%), respectively. Three patients initially treated with NBD required reendoscopy or surgery compared with 6 patients initially treated with BS (P <.05). Although not statistically significant, there was a trend toward greater expense in the BS group compared with the NBD group. ERCP is a safe and effective method of managing biliary leakage after T-tube removal in orthotopic liver transplant recipients. However, our results suggest NBD is the preferred method because recurrent leaks were more common in patients treated initially with BS. With prompt use of ERCP, surgery is rarely needed for this complication of OLT.

Surgical complications and long-term outcome in pediatric liver transplantation

BACKGROUND/AIMS

Liver transplantation has been widely accepted for the treatment of children with end-stage liver disease over the last 10 years particularly with the advent of reduced-size liver transplant technique. This study reviewed the perioperative and long-term results in the pediatric program of the Queensland Liver Transplant Service, Brisbane, Australia.

METHODOLOGY

Retrospective analysis was performed in 153 children who received 176 liver grafts between 1985 and 1995, including 109 (62%) reduced-size and 67 (38%) whole liver grafts. Median follow-up period was 5.3 years.

RESULTS

One-, 5-, and 10-year patient and graft survival rates were 82% and 74%, 75% and 63%, and 70% and 60%, respectively. Normal physical and intellectual development was observed in 98% of survivors. There were no significant differences in patient or graft survival rates between transplants using reduced-size and whole liver grafts. Portal vein thrombosis was the most common vascular complication, occurring in 8%. Hepatic artery thrombosis occurred in 7%, including 11% of children less than 1 year old and 8% of those under 10 kg. Biliary complication was found in 16% and posttransplant gastrointestinal perforation in 19%.

CONCLUSIONS

Liver transplantation has the potential to cure and allow development in children with end-stage liver disease.

Factors predictive of bile duct stones in patients with acute calculous cholecystitis

The objective of the study was to investigate the accuracy of using preoperative data for the prediction of bile duct calculi in patients operated on for acute cholecystitis. 279 consecutive patients underwent cholecystectomy with peroperative cholangiography for acute calculous cholecystitis in the Department of Surgery, Lund University Hospital, between 1985 and 1991. The correlation between 13 preoperative clinical and laboratory variables, and the incidence of bile duct calculi was studied. Among the 13 variables tested, serum bilirubin concentration and serum gamma-glutamyltransferase activity were independent factors of predictive significance. These two factors were used for constructing an additive prognostic index for the presence of bile duct stones. Thus, three groups of patients could be identified having a 3, 7-9 or 59% risk of harboring bile duct stones, corresponding to a sensitivity of 61% and a specificity of 93% in predicting the presence of bile duct stones in the 'high-risk' group. Logistic regression analysis permits accurate preoperative identification of bile duct stones in patients with acute calculous cholecystitis.