Clinical efficacy of precise hepatectomy for the treatment of recurrent unilateral hepato-lithiasis and prognostic factors analysis / 中华消化外科杂志

Objective:To investigate the clinical efficacy of precise hepatectomy for the treatment of recurrent unilateral hepatolithiasis and prognostic factors.Methods:The retrospec-tive case-control study was conducted. The clinicopathological data of 166 patients with recurrent unilateral hepatolithiasis who were treated by precise hepatectomy in the First Affiliated Hospital of Anhui Medical University from January 2015 to January 2021 were collected. There were 51 males and 115 females, aged (58±12)years. Observation indicators: (1)diagnosis and classification; (2) surgical and intraoperative situations; (3) postoperative situations; (4) follow-up; (5) analysis of prognostic factors. Follow-up was conducted using the outpatient examination and telephone inter-view to detect final stone clearance or recurrence and survival of patients up to August 2021. Patients with T-tube were performed T-tube cholangiography or choledochoscopy to evaluate the final stone clearance rate at postoperative week 8. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers or percentages. Univariate and multi-variate analyses were conducted using the Logistic regression model. Results:(1) Diagnosis and classifica-tion: 166 patients were diagnosed as hepatolithiasis by preoperative imaging examination and intraoperative evaluation, including 134 cases with common bile duct stones. Of the 166 patients, 115 cases had stones located in the left lobe of liver and 51 cases had stones located in the right lobe of liver. There were 111 cases with bile pigment stones, 31 cases with cholesterol stones, 24 cases with mixed type of stones. There were 9 cases classified as Tsunoda type Ⅰ, 89 cases as Tsunoda type Ⅱ, 65 cases as Tsunoda type Ⅲ, 3 cases as Tsunoda type Ⅳ. There were 12 cases classified as type Ⅰ, 99 cases as type Ⅱ, 47 cases as type Ⅲ, 8 cases as type Ⅳ according to Japanese classification in 2001. All the 166 patients were classified as type Ⅰ based on Chinese classification. According to the classification of author team, 166 patients were classified as type Ⅱ. (2) Surgical and intra-operative situations: 119 of 166 patients had liver lobe or segment atrophy. All the 166 patients underwent precise hepatectomy combined with different methods of drainage, of which 28 cases underwent left hemihepatectomy, 11 cases underwent right hemihepatectomy, 1 case underwent liver resection of segment Ⅰ, 5 cases underwent liver resection of segment Ⅱ, 5 cases underwent liver resection of segment Ⅲ, 8 cases underwent liver resection of segment Ⅳ (left medial lobe), 3 cases underwent liver resection of segment Ⅴ, 2 cases underwent liver resection of segment Ⅵ, 2 cases underwent liver resection of segment Ⅷ, 68 cases underwent liver resection of segment Ⅱ and Ⅲ (left lateral lobe), 3 cases underwent liver resection of segment Ⅴ and Ⅵ, 6 cases underwent liver resection of segment Ⅴ and Ⅷ (right anterior lobe), 21 cases underwent liver resection of segment Ⅵ and Ⅶ (right posterior lobe), 1 case underwent liver resection of segment Ⅱ, Ⅲ and Ⅳa, 1 case underwent liver resection of segment Ⅴ, Ⅵ and Ⅶ, 1 case underwent liver resection of segment Ⅰ, Ⅱ, Ⅲ and Ⅳ. For biliary drainage methods of 166 patients, 120 patients received T-tube external drainage, 23 cases received choledochojejunostomy, 23 cases received choledochojejunostomy combined with T-tube external drainage. The original cholangiojejunal anastomotic stenosis was found and reconstructed in 10 patients. The operation time was (258±87)minutes and intraopera-tive blood transfusion rate was 16.87%(28/166) of 166 patients. All the 166 patients underwent fiber choledochoscopy, showing 77 cases with normal function of Oddi sphincter, 38 cases with disorder, 40 cases with dysfunction. There were 11 patients undergoing choledochojejunostomy who were not evaluate the function of Oddi sphincter. There were 21.69%(36/166)of patients with intra-hepatic biliary stricture. One hundred and forty-nine of 166 patients were conducted bile culture, showing the positive rate as 75.17%(112/149). There were 22 cases cultured multiple kinds of bacteria. The most common bacterium was Escherichia coli (43 cases), followed by Pseudomonas aeruginosa (12 cases), Klebsiella pneumoniae (9 cases), Klebsiella oxytoca (7 cases), Enterococcus faecium (7 cases). (3) Postoperative situations. The postoperative complication rate of 166 patients was 16.87%(28/166). In the 8 patients with serious complications of Clavien-Dindo grade Ⅲ, 6 cases were performed thoracocentesis or abdominocentesis for effusion, 1 case was stopped bleeding under gastroscopy for stress ulcerbleeding, 1 case was performed surgery for adhesive intestinal obstruction. Two patients with septic shock of Clavien-Dindo grade Ⅳ were converted to intensive care unit for treatment and discharged after recovery. There were 13 patients with biliary leakage, 10 patients with pulmonary infection, 6 cases with incision infection, which were improved after conservative treatments. There was no perioperative death. The instant stone clearance rate of 166 patients was 81.93%(136/166). The duration of postoperative hospital stay of 166 patients was (11±6)days. (4) Follow-up: 166 patients were followed up for (37±17)months. The final stone clearance rate and stone recurrence rate of 166 patients were 94.58%(157/166) and 16.87%(28/166), respectively. According to Terblanche classification of prognosis, there were 91, 36, 25, 14 cases of grade Ⅰ, Ⅱ, Ⅲ, Ⅳ in 166 patients, respectively. Five of the 166 patients underwent intrahepatic secondary malignancy in which 4 cases died. (5) Analysis of prognostic factors: results of univariate analysis showed that biliary culture, the number of previous surgeries, immediate stone clearance, final stone clearance were related factors affecting the prognosis of precise hepatectomy in patients with recurrent unilateral hepatolithiasis ( odds ratio=2.29, 7.48, 2.69, 4.52, 95% confidence interval as 1.09?4.85, 2.80?19.93, 1.16?6.25, 1.15?17.77, P<0.05). Results of multivariate analysis showed that the number of previous surgeries ≥3 was an independent risk factor affecting the prognosis of precise hepatectomy in patients with recurrent unilateral hepato-lithiasis ( odds ratio=6.05, 95% confidence interval as 2.20?16.62, P<0.05). Conclusions:Precise hepatectomy is safe and effective for the treatment of patients with recurrent unilateral hepato-lithiasis. The number of previous surgeries ≥3 is an independent risk factor affecting the prognosis of precise hepatectomy in patients with recurren t unilateral hepatolithiasis.

Spontaneus Perforation of the Common Bile Duct in a 3 Years Old Boy

@#Peritonitis caused by biliary tract perforation is unsual. After other causes, such as trauma, biliary tract stone, cyst of choledocal duct, can be rule out, we should reconsider leakage or rupture of biliary tract. We report a 3 years old boy was administered to emergency room with abdominal distended, vomiting and diarrhea, low-grade fever, and diffuse abdominal pain. There’s no history of jaundice and abdominal pain before, neither trauma. Sign of peritonitis were found. The patient underwent laparotomy, perforation at common bile duct was found without any other disease. Intra abdominal drain was placed near the leak and primary repair was done with tube drain inside the duct. The pastient discharged after 8 days hospitalized uneventful.

The Role of Peroral Cholangioscopy in Evaluating Indeterminate Biliary Strictures

Biliary strictures are considered indeterminate when the initial radiologic evaluation and endoscopic retrograde cholangiopancreatography with brush cytology and/or forceps biopsy do not reveal diagnostic findings. Evaluation of these strictures is challenging and often requires a multidisciplinary approach and multiple procedures. Peroral cholangioscopy allows direct visualization of these lesions and targeted tissue acquisition using miniature biopsy forceps. In the past decade, there have been significant improvements in the field of cholangioscopy. These advances have allowed higher-quality image acquisition, easy setup, operation by a single operator, easy maneuverability, and excellent targeted tissue sampling performance. However, the interpretation of cholangioscopic visual findings remains challenging. In this review, we discuss the role of peroral cholangioscopy in the evaluation of indeterminate biliary strictures.

Clinical application of transparent cap gastroscope in the Billroth Ⅱprocedure after subtotal gastrectomy with bile duct disease in patients with ERCP / 中国基层医药

Objective To explore the clinical application value of transparent cap gastroscope in the Billroth Ⅱ procedure after subtotal gastrectomy in patients with bile duct diseases by endoscopic retrograde cholangiopancreatography(ERCP).Methods 20 patients underwent ERCP with Billroth Ⅱ gastrectomy postoperation with biliary diseases were selected as the research subjects,selected the transparent cap gastroscope ERCP,successful intubation received endoscopic sphincterotomy(EST) and(or) endoscopic nasobiliary drainage(ENBD),endoscopic papillary balloon dilatation(EPBD),endoscopic biliary metal stent drainage(EMBE),endoscopic biliary drainage(ERBD) treatment.Results 20 patients with Billroth Ⅱ gastrectomy after angiography were successful,the successful rate was 100.00%,14 cases of EST patients,4 patients underwent EPBD surgery,common bile duct stones all took the net,took the net rate of 100.00%;1 case of bile duct cancer underwent EMRE resection,1 case of bile duct stenosis after biliary tract surgery ERBD operation,hyperamylasemia occurred in 1 case,no serious complications such as bleeding and perforation of digestive tract.Conclusion Billroth Ⅱ gastrectomy postoperative patients with bile duct disease receiving ERCP,endoscopic transparent cap can provide good operative field for jejunal loop inside the mirror,improve the success rate of bile duct intubation,conducive to the removal of stones,improve the success rate of surgery,reduce complications security,safety of operation,and can be used in clinical application.

Intraoperative gastrobiliary duct drainage for iatrogenic distal common bile duct injury / 中华普通外科杂志

Objective To evaluate gastrobiliary duct drainage in the treatment for iatrogenic distal common bile duct injury found during the operation.Methods We analyzed clinical data of 17 cases with application of gastrobiliary duct drainage in immediate treatment for the injury of distal common bile duct found during the operation from June 2010 to June 2016.Postoperative bile drainage,postoperative gastrointestinal function recovery,time for removal of the gastrobiliary duct and hospitalization time were recorded.Postoperative bile leakage,intestinal fistula and pancreatic leakage were observed.Patients were followed up until June 2016.Results The mean volume of bile drainage on the third postoperative day were (310 ± 112)ml,the mean time of postoperative gastrointestinal function recovery were (3.0 ± 1.5) days,time for removal of the gastrobiliary stent were (7.5 ± 1.0) days and hospitalization time were (9.5 ± 1.5) days.There was no postoperative bile leakage,intestinal fistula and pancreatic leakage.All patients were followed up for a median time of 12 months (range,1-45 months).Meanwhile,we found no significant biliary strictures and cholangitis patients.Conclusion Gastrobiliary duct drainage is a simple,rational and effective treatment for iatrogenic injury of distal common bile duct during common bile duct exploration.

A clinical study of virtual endoscopy ultrasound Fly-Thru in the diagnosis of obstructive degree and nature for obstructive bile duct diseases / 中华超声影像学杂志

Objective To investigate the utility of virtual endoscopy ultrasound Fly-Thru in the diagnosis of obstructive bile duct diseases.Methods One-hundred patients with obstructed bile duct diseases underwent Fly-Thru examination.All Fly-Thru images were reviewed by two radiologists with different experience.The capabilities of Fly-Thru for bile duct obstructive degree evaluation and distinguishing malignant lesion from benign one were assessed respectively.Results The accuracy and sensitivity of Fly-Thru image in obstruction degree evaluation were 70.59％ and 89.2％ (95％CI 74.6％-96.9％).The diagnosis accuracy of 2DUS for lesion characteristics increased from 80％ to 84％,accompany with Fly-Thru images,especially for lesions in common bile duct from 77.2％ to 86.0％ (x2 =14.399,P =0.001).Conclusions The virtual endoscopy ultrasound Fly-Thru is only partly capable to display the obstructed degree of some bile ducts,but it can improve the diagnostic accuracy of common bile duct diseases.

Mirizzi's syndrome: lessons learnt from 169 patients at a single center

BACKGROUNDS/AIMS: Mirizzi's syndrome (MS) poses great diagnostic and management challenge to the treating physician. We presented our experience of MS cases with respect to clinical presentation, diagnostic difficulties, surgical procedures and outcome. METHODS: Prospectively maintained data of all surgically treated MS patients were analyzed. RESULTS: A total of 169 MS patients were surgically managed between 1989 and 2011. Presenting symptoms were jaundice (84%), pain (75%) and cholangitis (56%). Median symptom duration s was 8 months (range, <1 to 240 months). Preoperative diagnosis was possible only in 32% (54/169) of patients based on imaging study. Csendes Type II was the most common diagnosis (57%). Fistulization to the surrounding organs (bilio-enteric fistulization) were found in 14% of patients (24/169) during surgery. Gall bladder histopathology revealed xanthogranulomatous cholecystitis in 33% of patients (55/169). No significant difference in perioperative morbidity was found between choledochoplasty (use of gallbladder patch) (15/89, 17%) and bilio-enteric anastomosis (4/28, 14%) (p=0.748). Bile leak was more common with choledochoplasty (5/89, 5.6%) than bilio-enteric anastomosis (1/28, 3.5%), without statistical significance (p=0.669). CONCLUSIONS: Preoperative diagnosis of MS was possible in only one-third of patients in our series. Significant number of patients had associated fistulae to the surrounding organs, making the surgical procedure more complicated. Awareness of this entity is important for intraoperative diagnosis and consequently, for optimal surgical strategy and good outcome.

Histological Changes in the Bile Duct after Long-Term Placement of a Fully Covered Self-Expandable Metal Stent within a Common Bile Duct: A Canine Study

BACKGROUND/AIMS: To date, it has been difficult to determine the optimal stenting duration of a fully covered self-expandable metal stent (FCSEMS) in a benign biliary stricture. The purpose of this study was to identify the histopathological changes in a bile duct resulting from long-term placement of a FCSEMS. METHODS: An FCSEMS was inserted into the common bile duct of 12 canines, and the animals were divided into four groups. Posteuthanasia, necropsy was performed to examine the histopathological changes in the bile ducts after 1, 3, 6, and 9 months. RESULTS: The results of necropsy showed that the covered membranes of the FCSEMSs were intact and easily removed from the bile ducts in 11 of the canines. Severe epithelial hyperplasia of the stented bile duct and epithelial ingrowth into the stent occurred in one animal (from the 3-month group). On histopathological examination, mild inflammatory changes were observed in the stented bile ducts, and there was no significant difference between the four groups. Among the 12 animals, five had de novo stricture. CONCLUSIONS: An FCSEMS can be inserted into the bile duct without severe histopathological changes up until 9 months. However, a de novo stricture and severe epithelial hyperplasia relating to the stent insertion might occur.

Cystic Disease of the Liver / 대한내과학회지

Cystic lesions of the liver in the adult can be classified as developmental, neoplastic, inflammatory, or miscellaneous. They occur in symptomatic or asymptomatic patients with or without preexisting liver disease. Many of the lesions represent a diagnostic dilemma for the clinician and usually a single imaging study is not diagnostic. The physician must understand the clinical, radiologic, and pathologic characteristics of these cystic lesions including benign lesion such as simple (bile duct) cyst, autosomal dominant polycystic liver disease, biliary hamartoma, Caroli disease, congenital hepatic fibrosis, and premalignant lesion such as biliary cystadenoma and cystadenocarcinoma. In this review, we review the clinical, radiological, and histologic features of the most common benign cystic liver disease and also present current management options. An understanding of these facts will allow more definitive diagnosis and shorten the diagnostic workup for focal cystic liver lesions.

Temporary Placement of Fully Covered Self-expandable Metal Stents in Benign Biliary Strictures / 대한소화기학회지

BACKGROUND/AIMS: Benign biliary strictures (BBSs) have been endoscopically managed with plastic stent placement. However, data regarding fully covered self-expandable metal stents (FCSEMSs) in BBS patients remain scarce in Korea. METHODS: Forty-one patients (21 men, 65.9%) with BBSs underwent FCSEMS placement between February 2007 and July 2010 in Asan Medical Center. Efficacy and safety were evaluated retrospectively. Patients were considered to have resolution if they showed evidence of stricture resolution on cholangiography and if an inflated retrieval balloon easily passed through the strictures at FCSEMS removal. RESULTS: The mean FCSEMS placement time was 3.2 (1.9-6.2) months. Patients were followed for a mean of 10.2 (1.0-32.0) months after FCSEMS removal. The BBS resolution rate was confirmed in 38 of 41 (92.7%) patients who underwent FCSEMS removal. After FCSEMS removal, 6 of 38 (15.8%) patients experienced symptomatic recurrent stricture and repeat stenting was performed. When a breakdown by etiology of stricture was performed, 14 of 15 (93.3%) patients with chronic pancreatitis, 17 of 19 (89.5%) with gall stone-related disease, 4 of 4 (100%) with surgical procedures, and 2 of 2 (100%) with BBSs of other etiology had resolution at FCSEMS removal. Complications related to stent therapy occurred in 12 (29%) patients, including post-ERCP pancreatitis (n=4), proximal migration (n=3), distal migration (n=3), and occlusion (n=2). CONCLUSIONS: Temporary FCSEMS placement in BBS patients offers a potential alternative to plastic stenting. However, because of the significant complications and modest resolution rates, the potential benefits and risks should be evaluated in further investigations.

Laparoscopic techniques in the diagnosis and treatment of bile duct diseases in newborns and infants / 中国微创外科杂志

Objective To investigate the value of lapa ro scopic surgery in the diagnosis and treatment of bile duct diseases in newborns and infants. Methods Clinical records of 9 newborns or infants with bile duct diseases diagnosed and treated under laparoscope from January 20 03 to August 2004 in this hospital were reviewed retrospectively. Resul ts Laparoscopic exploration in the 9 cases found 2 cases of congenital choledochal cyst, 5 cases of biliary atresia, 1 case of cholestasis, and 1 case of congenital bile duct hypoplasia. Cholangiography was successfully performed i n 8 cases. Two patients with choledochal cyst received an excision of the cyst a nd Roux-en-Y hepatico-jejunostomy. Among the 5 patients with biliary atresia, he patic porto-enterostomy was performed via open approach in 3 patients and via la paroscopic approach in 1, and surgery was refused in 1 patient. Open hepatic por to-enterostomy was also used in the patient with bile duct hypoplasia. The patie nt with cholestasis underwent a biliary tract irrigation. Conclusions Laparoscopy is simple and reliable in the diagnosis of bile duct disease s in newborns and infants. For the treatment of bile duct diseases, laparoscopic techniques have advantages of minimal invasion, good cosmetic results, less blo od loss, quick recovery, and reliable clinical effects.

A case of simple type Caroli's disease confined to one segment of the liver / 대한내과학회지

Caroli's disease is a rare congenital anomaly of the intrahepatic biliary tree characterized by multiple, saccular and cystic dilatation of the bile ducts that are connected with the biliary drainage system. It is frequently associated with congenital hepatic fibrosis, resulting in portal hypertension. The complications are stone formation, recurrent cholangitis and occasionally cancer. Less than 20% of all cases reported describe monolobar or segmental invovement. In the pure form or simple type, the patient presents without hepatic fibrosis or portal hypertension. We report a case of simple type Caroli's disease confined to the one hepatic segment in a 22 year-old woman. She was admitted because of cystic mass, associated with right upper abdominal pain. Radiologic findings including abdominal ultrasonography, computerized tomography, magnetic resonance imaging demonstrated that the cystic lesions involving segment VIII of the liver. The lesion was treated with hepatic segmentectomy.

Expressions and Significance of p21 Protein and K-ras Protein in Congenital Biliary Dilatation / 实用儿科临床杂志

Objective To investigate the expressions and significance of p21 protein and K-ras protein in congenital biliary dilatation(CBD),and their relationship.Methods Surgical specimens of CBD were obtained during operation on 36 children from Jan.2000 to Sep.2007.Nine normal bile ducts specimens from miscarried fetus and children's corpse.The specimens were fixed in 40 g?L-1 formalin and embeded by paraffin,slice-fixed.SP immunohistochemical method was used to detect the expressions of p21 protein and K-ras protein.Results The positive rate of K-ras protein was 13.8% in CBD,which was significantly higher than that in normal bile duct tissues.The positive rate of p21 protein was 55.6% in CBD,and 100% in normal bile duct tissues.p21 protein positive expression rate in CBD was significantly lower than that in normal bile duct tissues(P

A Case of Mirizzi Syndrome Misdiagnosed as a Cholangiocarcinoma / 한국간담췌외과학회지

The Mirizzi syndrome is a rare benign cause of obstructive jaundice. It is particularly interesting to surgeons because the surgery has to be carefully planned to avoid unnecessary damage to the common bile duct. Furthermore, it gives a differential diagnosis dilemma for surgeons as well as radiologist because there are no diagnostic procedures or clinical features that have a perfect access. As a result, the Mirizzi syndrome often has been mistaken for gallbladder cancer and cholangiocarcinoma. We experienced of a 76-year-old male patient, whose clinical symptoms were jaundice, epigastric pain and fever with chill and misdiagnosed as a cholangiocarcinoma with liver metastasis.

The Diagnostic Value of MR Cholangiopancreatography in Gallstones / 天津医药

Objective: To evaluate the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) in gallstones.Methods: Seventy-three patients with gallstones were examined with MRCP. Results: MRCP showed the lesions directly in69 patients,of which 58 patients were proved by surgery. The characteristic imaging appearance included a round,oval ormultifaceted area of filling defect and crateriform depression within the lumen of the bile ducts. MRCP could show false-positive result caused by air within the bile ducts. In the other 4 patients with tiny intra-hepatic stones ( ＜4 mm) ,MRCP couldnot show the lesions except for the proximal bile duct dilation. Conclusion:MRCP is a safe,non-invasive and reliable examination and may act as substitute method for patients unsuitable for endoscopic retrograde cholangiopancreatography (ER-CP).

Change of calcimn metabolism in liver mitochondria and its effect on mitochondrial respiratory function fol- lowing biliary obstruction / 中华肝胆外科杂志

Objective To explore the change of liver mitochondrial calcium metabolism and its effect on mitochondrial respiratory function.Methods The model of dog biliary obstruction was made by bile duct ligation. Mitochondria were obtained by differential centfifugation.Mitochondrial calcium content,calcium uptake rate and respiratory function were observed and compared.Results Liver mitochondrial calcium content was increased sig- nificantly,calcium uptake rate and respiratory function were obviously reduced after biliary obstruction.Mitochon- drial calcium content was highly negatively correlated with mitochondrial respiratory function (P

Treatment of cholepathia under laparoscopy and endoscopy / 中华消化内镜杂志

Objective To report the method and effect of treating cholepathia under laparoscopy and endoscopy. Methods Laparoscopy, duodenoscopy and choledochoscopy in combination were used in treating 1 990 cases of cholepathy and the results were analyzed. Results Laparoscopy and duodenoscopy in combination were used in 1 350 cases of cholecystolilhiasis and choledocholith with cure rate ( 93. 6% ) ; laparoscopy and choledochoscopy in combination were used in 332 cases of choledocholith with cure rate (100% ) ; laparoscopy, duodenoscopy and choledochoscopy in combination were used in 258 cases of choledocholith (29 cases with pancreatitis) and 24 cases of Mirizzi syndrome with cure rate( 100% ). There was no serious complications happened. Followed up 1 051 patients from 3 months to 12 years (average 7.8 years) , 10 cases have recurrence of stones. There was no long-term complication such as stenosis of bile duct, etc occurred. Conclusion The procedure had minor trauma, mild suffering, and less operative complications compared with the traditional laparotomy.