Preliminary exploration of SpyGlass direct visualization system in diagnosis and treatment of biliary stricture after liver transplantation / 器官移植

Objective To preliminarily evaluate the application value of SpyGlass direct visualization system in the diagnosis and treatment of biliary stricture after liver transplantation. Methods Clinical data of 4 patients presenting with biliary stricture after liver transplantation who underwent SpyGlass direct visualization system examination were collected. The examination, treatment and prognosis of biliary stricture were analyzed. Results The examination results of color Doppler ultrasound, magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) in 4 patients suggested biliary anastomotic stricture with intrahepatic biliary dilatation, and 2 of them were complicated with intrahepatic biliary calculi. Repeated placement of biliary stent under ERCP yielded poor effect in 3 cases. SpyGlass direct visualization system examination hinted biliary anastomotic stricture in 4 patients, 3 cases of intrahepatic biliary dilatation, 3 cases of intrahepatic biliary calculi, 2 cases of purulent bile and 3 cases of floccules within the biliary tract, 1 case of congestion and edema of biliary tract wall and 2 cases of local epithelial necrosis and stiffness changes of intrahepatic biliary tract wall. The wire could not be inserted in 1 patient due to severe biliary anastomotic stricture. Four patients were treated with biliary stricture resection + biliary stone removal + biliary end-to-end anastomosis, biliary stricture resection + biliary-intestinal anastomosis, ERCP lithotomy + biliary metal stent implantation, and biliary metal stent implantation + percutaneous transhepatic bile duct lithotomy, respectively. Relevant symptoms were relieved without evident complications. All patients survived during the follow-up until the submission date. Conclusions Compared with traditional imaging examination, SpyGlass direct visualization system may more directly display the morphological characteristics of biliary tract wall and structural changes within biliary tract cavity, which is an effective examination tool for biliary stricture after liver transplantation. In addition, individualized treatment methods may be adopted for different biliary tract diseases, which is expected to improve clinical prognosis of patients.

Reoperation for biliary-enteric strictures after hepaticojejunostomy in children with congenital biliary dilatation / 中华普通外科杂志

Objective:To evaluate clinical characteristics and treatment of postoperative anastomotic stricture in pediatric congenital biliary dilatation patients.Methods:The clinical data of 24 children with postoperative anastomotic stricture from Apr 2012 to Oct 2019 in Beijing Children's Hospital was retrospectively analyzed.Results:There were 6 males and 18 females. Patients were divided into bile- leak group (BL, n=6) and non bile-leak group (NBL, n=18) based on whether there was anastomotic leakage after primary surgery. The main symptoms in BL group was persistent obstructive jaundice, and recurrent cholangitis in NBL group. Postoperative symptoms were first shown in an average of 7.0 months in BL group, compared to 59.0 months in NBL group, P<0.05. In BL group, 4 underwent redoing hepaticojejunostomy, 2 underwent anastomosis plasty. In NBL group, 3 underwent redoing hepaticojejunostomy, 15 did anastomosis plasty with multiple biliary stones found necessitating extraction. After reoperation, one patient had bile leakage, 2 patients had recurrent cholangitis within one-month, 21 patients had uneventful recovery. Five were found to have biliary stones in long-term follow-up. Conclusions:Biliary-enteric anastomotic leakage can cause stricture in postoperative patients of congenital biliary dilatation ,reoperation is necessary in symptomatic patients.

Choledochal cysts in children: How to Diagnose and Operate on

OBJECTIVE: To identify the best mode for diagnosing and treating the patients with choledochal cysts. METHODS: A retrospective study was performed with medical records of patients diagnosed with choledochal cysts from January 1994 to December 2017. In all cases, the diagnosis was based on ultrasound examination. All the patients underwent cyst resection and were divided in two groups: bile enteric anastomosis in the high portion of the common hepatic duct or in the dilated lower portion. RESULTS: Eighty-one cases were studied. The age of presentation was 4 y 2 mo ± 4 y 1 mo, and the age for the surgical treatment was 5 y 5 mo ± 4 y 6 mo. In 61 cases, US was the only image examination performed. There were 67 cases of Todani type I (82.7%), 13 cases of type IV (16.0%) and one case of type III (1.2%). Nine patients (29.0%) in the first period and 2 patients (4.0%) in the second period presented with postoperative complications (p=0.016). CONCLUSION: In patients with choledochal cysts, US is the only necessary diagnostic imaging. Performing the bile enteric anastomosis in the lower portion of the common hepatic duct is safer and has a lower risk of complications.

Prenatal ultrasound diagnosis and clinical outcomes of fetal hepatohilar cystic occupying lesions / 中华超声影像学杂志

Objective To explore the prenatal ultrasound diagnosis and postnatal clinical outcomes of fetuses with hepatohilar cystic occupying lesions . Methods T his was a retrospective study that included all fetuses found to have hepatohilar cystic occupying lesions diagnosed by ultrasound in the First Affiliated Hospital of Sun Yat‐sen University between January 2008 and December 2017 . According to the morphology of the cyst and max diameter ,the cases were divided into four groups . Cases with polygonal cysts and max diameter over 30 mm were assigned to group 1 ,non‐polygonal cysts and max diameter over 30 mm to group 2 ,polygonal cysts and max diameter under 30 mm to group 3 ,non‐polygonal cysts and max diameter under 30 mm to group 4 . T he birth status ,ultrasound review image ,surgical treatment and pathological findings were tracked to analyze the prognosis of these fetuses . Results Among 47 cases of fetal hepatohilar cystic occupying lesions ,38 fetuses were born and 9 were terminated with only 1 case taking pathological examination . T here were 39 cases with pregnancy outcomes . T wenty‐seven cases ( 69 .2% ,27/39) were diagnosed as congenital biliary dilatation ( CBD) ,5 cases ( 12 .8% ,5/39) were found cysts resolved in postnatal ultrasound examinations . Biliary atresia was diagnosed in 3 cases ( 7 .8% ,3/39 ) by operation ; M esenteric cysts ( 5 .1% ,2/39) were diagnosed in 2 cases by ultrasound . One ( 2 .6% ,1/39) was diagnosed as double‐gallbladder by ultrasound . 1 ( 2 .6% , 1/39 ) was diagnosed as teratoma by operation . M ost cases were in the group 3 ,but there was no significant difference compared with other groups ( all P ＞ 0 .05) . Conclusions More than half of hepatohilar cystic occupying lesions diagnosed in prenatal ultrasound are proved to be CBD with good prognosis . T he cysts in few cases can be resolved after born . 7 .8% of cases are biliary atresia with poor prognosis ,w hich give messages to prenatal clinical consultation .

New concept of surgical treatment for biliary dilatation / 中华消化外科杂志

At present,it is not uncommon for patients with biliary dilatation who have failed to undergo multiple operations in clinic.Dong's classification has a definite guiding significance for choosing appropriate surgical methods.Active hepatectomy with "tailor-made" treatment can cure refractory biliary dilatation involving intrahepatic bile ducts.At present,there are still some controversies about the range of hepatectomy and the management of type D lesions in children.At the same time,we should pay close attention to the long-term complications after dilated bile duct resection.

Laparoscopic classification and treatment of extrahepatic biliary dilatations / 中华肝胆外科杂志

Objective To establish a laparoscopic classification of extrahepatic biliary dilatations (EHBD) that can guide minimally invasive treatment.Methods According to inclusion criteria,124 patients with EHBD who were admitted and treated from July 2001 to July 2017 in the First Hospital Affiliated to Army Military Medical University were included in this study.A new laparoscopic classification of EHBD was proposed based on the preoperative imaging data and laparoscopic findings of the position and extent of EHBD.The minimally invasive diagnosis and treatment strategies were made based on the new classification.Results According to the preoperative imaging data and intraoperative laparoscopic findings,124 patients with EHBD were divided into the following groups:type A (upper segment,34 cases),type B (middle segment,27 cases),type C (lower segment,20 cases),and type D (entire bile duct,43 cases).The clinical symptoms (abdominal pain,jaundice and mass) and reoperation rates were not significantly different among the 4 groups(both P＞0.05).The incidences of comorbidities (calculus or inflammation) were significantly different (P＜0.05).The operative time(type A:237.6±66.7 min,type B:259.2±60.0 min,type C:286.1 ± 74.7 min,type D:347.5±94.4 min) and blood loss (type A:192.6±102.2 ml,type B:201.5±120.2 ml,type C:297.5±162.1 ml,type D:305.8±237.3 ml) were significantly different among the groups (P＜ 0.05).The short-term complication rates after surgery (5.9％ ～ 20.0％) were significantly different (P＜ 0.05),while the long-term complication rates after surgery (7.4％ ～ 10.0％) were not significantly different.The conversion rates to open surgery were significantly higher in patients with type C and D lesions than in those with type A and B lesions (P＜0.05).Conclusion This laparoscopic classification predicted the difficulty of laparoscopic surgery for EHBD and had a guiding significance in the minimally invasive treatment for this disease entity.

Efficacy of laparoscopic surgery on the treatment of Dong Type C adult biliary dilatation / 国际外科学杂志

Objective To investigate the technical and therapeutic effects of laparoscopic surgery for adult patients with Dong Type C bile duct dilatation.Methods A retrospective cohort study approach was used.The clinical data of 47 patients with Dong Type C adult biliary dilatation who underwent surgery in Fujian Provincial Hospital from January 2014 to December 2017 were collected.There were 12 males and 35 females.The age ranged from 16 to 68 years,with a median age of 30 years.According to different surgical methods,the patients were divided into the laparoscopic group (treated with laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy,n =21) and the open group (treated with traditional open operation,n =26).The intraoperative blood loss,complication rate,operation time,postoperative intestinal function recovery time and postoperative hospital stay were observed.Measurement data with normal distribution were expressed as mean ± standard deviation (Mean ±SD) and analyzed by t test.Comparison of count data was done by the chi-square test.Results There was no perioperative deaths in either group.There was no significant difference in intraoperative blood loss and complication rate between the two groups (P ＞ 0.05).The operation time of the laparoscopic group was significantly longer than that of the open group[(333.7 ±61.1) min vs (235.9 ±64.3) min],with statistically significant difference between graps (P =0.000).The recovery time for the intestinal function of the laparoscopic group was significantly shorter than that of the open group [(2.2 ± 0.5) d vs (2.9 ± 0.6) d],with statistically significant difference between groups (P =0.000).The postoperative hospital stay in the laparoscopic group was significantly shorter than the open group [(7.1 ± 1.8) d vs (12.0 ± 5.9) d],with statistically significant difference between groups (P =0.001).Conclusion For adult biliary dilatation patiens with Dong Type C,laparoscopic surgery is safe and feasible with the advantages of mini-invasive and quick recovery.

Application of perihilar surgical technique in the treatment of central cholangiectasis / 中国实用外科杂志

Central biliary dilatation (BD) is a primary biliary disease characterized by intrahepatic central biliary dilatation with or without extrahepatic biliary dilatation, including B1, B2, D1 and D2 in Dong clinical classification. Because of its great anatomical variability, impaired liver function, difficulty in preoperative evaluation and complicated operation, central BD has a high incidence of complications and poor prognosis.In view of the difficulties in diagnosis and treatment of central BD, comprehensive application of perihilar surgical technique,through preoperative systemic perihepatic portal imaging evaluation and liver function maintenance, individualized surgical treatment and comprehensive postoperative management will help to improve the surgical efficacy of central BD.

Application value of perihilar surgery technique in the reoperation of biliary dilatation of central large intra-and extra-hepatic bile ducts above the hilar convergence / 中华消化外科杂志

Objective To explore the application value of perihilar surgery technique in the reoperation of biliary dilatation of central large intra-and extra-hepatic bile ducts above the hilar convergence.Methods The retrospective cross-sectional study was conducted.The clinical data of 3 patients with biliary dilatation of central large intra-and extra-hepatic bile ducts above the hilar convergence who underwent the reoperation in the Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine from August 2017 to January 2018 were collected.All three patients had been collected a detailed previous surgical history.After preoperative lab and imaging examinations,evaluation of liver function,residual liver volume and general condition were done,then 3 patients underwent left hemihepatectomy + dilated right hepatic duct and extrahepatic bile duct resection,right anterior and posterior hepatic duct reconstructive surgery and Roux-en-Y anastomosis of the jejunum.The surgical procedures followed as:intra-abdominal adhesions separation,extrahepatic antergrade dissection of porta hepatis,transverse cutting the dilated extrahepatic bile duct,split the cantlie line,exposure of the hilar plate,left hemihepatectomy,dilated right hepatic bile duct resection,right anterior and posterior hepatic duct remodeling and biliary-enteric anastomosis.Observation indicators included:(1) surgical and postoperative recovery;(2) follow-up.Follow-up using outpatient examination and telephone interview was performed to detect general condition,complications,liver function and residual choledochal cysts up to May 2018.Results (1) Surgical and postoperative recovery:All the 3 patients underwent choledochal cysts resection + left hemihepatectomy + dilated right hepatic duct + right anterior and posterior hepatic duct reconstructive surgery and Roux-en-Y anastomosis of the jejunum using the perihilar surgery technique and extrahepatic anterograde combined by intrahepatic retrograde dissection method exposing portal hepatis.There was no perioperative death.The operation time and volume of intraoperative blood loss in 3 patients were 435 minutes,490 minutes,395 minutes and 250 mL,300 mL,200 mL,respectively.There was no intraoperative blood transfusion.Three patients had no bleeding and abdominal liver function.One patient with bile leakage and delayed gastric emptying at 1 week postoperatively received puncture drainage,gastrointestinal decompression,gastric lavage with hypertonic saline,acupuncture and total parenteral nutrition,then bile leakage was cured after 3-week therapy,gastric motility was improved after 5-week therapy,and then gastric tube was removed.The abdominal drainage tube was removed at 3 weeks postoperatively in 1 patient and at 1 week postoperatively in 2 patients.The postoperative gross specimen examinations showed intra-and extra-hepatic bile duct dilatation in 3 patients,including 2 combined with choledocholithiasis and 1 with left intrahepatic bile duct cancer.The postoperative pathological findings showed that 3 patients had intrahepatic bile duct cystic dilatation with chronic inflammation,peripheral small bile duct hyperplasia with inflammatory cell infiltration,1 of which had intrahepatic intraductal papilloma with high grade intraepithelial neoplasia.One and 2 patients were discharged from hospital at 7 weeks postoperatively and 2 weeks postoperatively,respectively.(2) Follow-up:All 3 patients were followed up for 4-8 months.During the follow-up,patients had good general condition and no symptoms of cholecystitis such as abdominal pain,chills and fever,liver function was normal,and no residual bile duct cyst was found by enhanced scan of CT.Conclusion The perihilar surgery technique and extrahepatic anterograde combined by intrahepatic retrograde dissection method exposing portal hepatis for the treatment of biliary dilatation of central large intra-and extrahepatic bile ducts above the hilar convergence can increase the radical resection rate and surgical efficacy.

Difficulties and countermeasures of diagnosis and treatment of biliary dilatation / 中华消化外科杂志

The pathogenesis of biliary dilatation is unclear and the preoperative evaluation of pancreaticobiliary junction type is still difficult.The indication of minimally invasive surgery is limited.Diagnosis and treatment of gestational biliary dilatation and reoperation of biliary dilatation are two tricky problems.There are two dilemmas in the treatment of biliary dilatation,including the balance between radical resection of pathological bile ducts and organ reservation,as well as balance between radical resection of pathological bile ducts and surgical safety.The most difficult regions of diagnosis and treatment lie in the hilar dilated bile duct and dilated bile duct in the pancreatic segment.Dong's classification simplifies the classification of extrahepatic bile duct dilatation and subdivides the classification of intrahepatic bile duct dilatation on the basis of Todani classification.It highlights the difficulties of treatment and provides more accurate basis for choosing appropriate method according to the classification.The therapeutic goals of biliary dilatation are the radical excision of pathological bile duct,removal of the secondary lesions and reconstruction of excellent cholangiojejunostomy.The principle of surgical procedure choice is choosing appropriate method according to the classification.Perihilar surgery technique and pancreatic door plate descending technique can be used to deal with the dilated bile ducts at hilar and pancreatic segment on the basis of accurate evaluation in order to improve the thoroughness and security of pathological bile duct resection.Not only short-term complications such as postoperative bile leakage and pancreatic leakage require management,but radical resection of lesion and long-term life quality of patients should be paid more attention.

Clinical classification and surgical treatment of biliary dilatation: application and consideration / 中华消化外科杂志

Optimization of surgical treatment of biliary dilatation (BD) depends on reasonable clinical classification and standardized classification-based treatment strategy.Due to increasing limits and defects of classic Todani classification,a new classification named Dong-classification has been proposed,which was based on a large series analysis from a single referral center.Some important parameters including anatomical location and range of BD,pathogenic factors,and different surgical managements were main considerations in the new classification.After practical application and evaluation,Dong-classification has been improved step by step.It is believed that Dong-classification may contribute to improving surgical treatment decision and selecting reasonable operative plan.

Expression of interleukin-13 in peripheral blood and liver of infants with biliatry atresia or congenital biliary dilatation / 第二军医大学学报

Objective To study the expression pattern of interleukin-13 (IL-13) in the sera and liver tissue of biliary atresia. Methods 13 infants with biliatry atresia (BA) were studied. 10 children with congenital biliary dilatation (CBD) were studied as a control. Both the BA and CBD were confirmed at operation and histological examination on the liver tissue of biopsy. The sera level of IL-13 was measured by enzyme-linked immunosorbent assay. The expression of IL-13 mRNA in liver tissue was detected with Real-time quantitative reverse transcriptase-polymerase chain reaction. The expression of IL-13 protein in liver tissue was examined by western blotting. Results The IL-13 level in sera of BA was significantly lower than that of CBD group (154.5±18.23 pg/ml vs. 268.2±19.30 pg/ml,p<0.01). Compared with CBD group, the expression of IL-13 mRNA in liver tissue was significantly lower in BA (0.0150±0.0021 vs. 0.0320±0.0050, p=0.0220), and the expression of IL-13 protein was decreased (0.3446±0.0150 vs. 0.5765±0.0215, p=0.0122). Conclusions The expression of IL-13 in the sera and liver tissue of BA is significantly elevated. It may play a key role in the pathogenesis of BA and is worthy of further investigation.

Treatment of Traumatic Pancreatitis after Hepaticoenterostomy in Congenital Biliary Dilatation / 天津医药

Objective To investigate the cause of postoperative pancreatitis in Congenital Biliary Dilatation(CBD), and to explore the preventive measures to decrease its occurrence. Methods Patients with CBD (n=22) were summarized during July 2010-March 2014 in Guiyang children's hospital, which include 8 cases of male, 14 cases of female;Cases that developed postoperative traumatic pancreatitis were taken as experimental group. Cases that did not developed it was used as control group. Ages are from 6 months old to 6 years and 9 months old. All patients were received cyst excision and hepatic duct-jejunum Roux- en- Y anastomosis. All postoperative patients are followed up regularly in clinic and by telephone. All followed up were from 3 months to 3 years with a comprehensive physical examination, routine blood test and urine amy?lase analysis. B-ultrasonic examination was used to understand pancreas recovery as well as the expansion of bile duct in the liver. Results Among the 22 cases, the postoperative 1st and 4th day blood amylase as well as 1st,4th and 7th day urine amylase in the experimental group are all higher than those in the control group with statistical difference ( P < 0.05). Patients in experiment group show low thermal and high leucocyte represent postoperative traumatic pancreatitis. All pa?tients were given trypsin inhibitor and anti-inflammatory treatment who were completely recovered after 4-9 days. All chil?dren growth developed normally, with only 2 cases of raised transaminase which were finally settled. Children showed no pan?creatitis and their ascending cholangitis, upper gastrointestinal angiography revealed no reflux gastritis. Conclusion The patients with CBD should receive surgery-cyst excision, hepatic duct-jejunum Roux-en-Y anastomosis early. During opera?tion, cysts decompression should be applied early. Besides these two procedures, interrupting pancreatic confluence and treat?ing pancreatic enzyme inhibitors postoperative can both help to decrease the occurrence of postoperative traumatic pancreatitis.

A Case Report of Recrudescent Cholangitis Successfully Treated with Kampo Medicine / 日本東洋医学雑誌

We report a case of recrudescent cholangitis successfully treated with Kampo medicine. The patient was a 31-year-old female. She was diagnosed with congenital biliary dilatation, and underwent an operation for partial resection of the liver, and a choledocho-jejunostomy. However, the cholangitis returned two years ago, when she was 29 years old. She had repeated abdominal pain and fever, and at that time received treatment with antibiotics. She desired pregnancy, and was hoping that Kampo treatment would enable her to decrease the amount of antibiotic she was taking. We prescribed inchinkoto as a base treatment and added to daisaikoto or shosaikoto. We changed the prescription according to her symptoms. As a result, her antibiotic quantity was reduced markedly, she safely conceived, and kept taking Kampo medicine while she was pregnant. She remained in good condition throughout her pregnancy. Thus, we consider that Kampo medicine may be useful for treating recrudescent cholangitis after an operation for reconstruction of the biliary tract.

A Case of Ampullary Adenomyoma Associated with Dilatations of Pancreatic and Biliary Ducts / 대한소화기내시경학회지

Adenomyoma is a nonneoplastic lesion that can be found anywhere in the gastrointestinal tract, but it's rarely found in the ampulla of Vater. To the best of our knowledge, it is a benign lesion, but most cases are misdiagnosed as carcinoma or adenoma by a preoperative endoscopic or radiologic procedure, and this leads to unnecessarily extensive surgical resection. We report here on a case of ampulla of Vater adenomyoma that resulted in biliary and pancreatic duct dilatation. The tumor was diagnosed by endoscopic papillectomy.

Preoperative localization value of MRI and MRCP in patients with congenital biliary dilatation:a report of 30 cases / 中国基层医药

Objective To evaluate the preoperative localization value of MRI and MRCP for congenital biliary dilatation.Methods 30 cases of congenital biliary dilatition diagnosed by either surgery or pathology were studied.MRI and MRCP findings of all these cases were analyzed.Results MRI and MRCP preoperative examination manifested the place of choledochal cyst and the relation between choledochal cyst and the biliary ductal system around in all 30 patients.Through surgery findings as follow,using Todani's classification,the accuracy of MRI and MRCP in evaluating the site and classification of congenital biliary dilatation was 100%,the accurate visualization rate of pancreatic duct was 73.3% and the junction of pancreaticobiliary duct was 33.3%.Conclusion MRI and MRCP manifestations are very reliable in preoperative localization of congenital biliary dilatation.