Íleo biliar complicado con infección con SARS-CoV-2. Reporte de caso

Introducción: El Íleo biliar (IB) es una obstrucción intestinal mecánica muy poco frecuente, del 1 al 4 % de todas las obstrucciones intestinales, y es más común en pacientes de edad avanzada. Se produce a través de una fístula bilioentérica en el intestino delgado, sobre todo en el íleon distal. Luego de tener un enfoque diagnóstico mediante imagenología, en su gran mayoría, se opta por el tratamiento quirúrgico para eliminar el o los cálculos impactados. El éxito de esta intervención depende en gran medida del tamaño del cálculo biliar, de la ubicación de la obstrucción intestinal y comorbilidades preexistentes. Caso clínico: Mujer de 78 años con cuadro clínico de obstrucción intestinal, emesis de contenido fecaloide y sintomática respiratoria; se evidenció una masa concéntrica a nivel de íleon distal y proceso neumónico concomitante por tomografía toracoabdominal. Se realizó laparotomía exploratoria con enterolitotomía, extracción de cálculo y anastomosis íleo-ileal y fue trasladada a la UCI en donde presentó falla ventilatoria y requerimiento de ventilación mecánica; se confirmó infección viral por SARS-CoV-2 mediante RT - PCR. Discusión: El IB es una obstrucción intestinal que ocurre con mayor frecuencia en pacientes de edad avanzada. Se habla de la fisiopatología y mecanismo de producción de la fístula entérica y se presentan opciones diagnósticas, terapéuticas y quirúrgicas para dirigir el manejo clínico más apropiado. Conclusión: El IB es difícil de diagnosticar. Debido a su baja incidencia, no existe un consenso que paute el manejo a seguir en los pacientes con diagnóstico de IB. Aunque el tratamiento estándar es la intervención quirúrgica, hay diversas opiniones en cuanto al tipo de cirugía a realizar.

Introduction: Biliary ileus (BI) is a very rare mechanical intestinal obstruction, responsible for 1-4% of all intestinal obstructions and more frequent in elderly patients. It occurs through a bilioenteric fistula in the small bowel, mainly in the distal ileum. After a diagnostic imaging approach, the vast majority opt for surgical treatment to remove the impacted stone or stones. The success of this intervention depends largely on the size of the stone, the location of the bowel obstruction and pre-existing comorbidities. Case report: 78-year-old woman with clinical symptoms of intestinal obstruction, fecaloid emesis, respiratory symptoms, concentric mass at the level of the distal ileum and concomitant pneumonic process in the thoraco-abdominal CT scan. Exploratory laparotomy was performed, with total lithotomy, extraction of the calculus and ileo-ileal anastomosis, and she was transferred to the ICU, where she presented ventilatory failure and required mechanical ventilation. SARS-CoV-2 infection was confirmed with RT-PCR. Discussion: IB is an intestinal obstruction that occurs more frequently in elderly patients. The pathophysiology and the mechanism of production of enteric fistula are discussed and diagnostic, therapeutic and surgical options are presented to guide the most appropriate clinical management. Conclusion: Enteric fistula is difficult to diagnose. Due to its low incidence, there is no consensus on the management of patients diagnosed with IB. Although the standard treatment is surgical intervention, there are divergent opinions as to the type of surgery to be performed.

Function of peribiliary glands as well as its relationship with ischemic-type biliary lesions / 中华消化外科杂志

Peribiliary glands (PBG) is a kind of microscopic structure around the intra-hepatic bile ducts and extrahepatic bile ducts. PBG not only participates in maintaining the normal physiological function of biliary epithelial tissue, but also plays an important role in its damage and repair process. Biliary tree stem/progenitor cells in PBG are important cell sources of biliary epithelial regeneration and repair. PBG and the surrounding peribiliary vascular plexus are key influencing factors for the occurrence of ischemic-type biliary lesions (ITBL) after liver transplantation. Based on relevant literatures and clinical practice, the authors summarize the function of PBG as well as its relationship with ITBL.

Risk factors of acute biliopancreatic complications in patients of pregnancy combined with gallbladder stone and construction of prediction model / 中华消化外科杂志

Objective:To investigate the risk factors of acute biliopancreatic complica-tions in patients of pregnancy combined with gallbladder stone and construction of prediction model.Methods:The retrospective case-control study was constructed. The clinical data of 98 patients of pregnancy combined with gallbladder stone who were admitted to the First Hospital of Lanzhou University from September 2011 to October 2022 and 53 patients of pregnancy combined with gallbladder stone who were admitted to Gansu Provincial Hospital May 2014 to October 2021 were collected. The age of 151 patients was 29(25,32)years. Observation indicators: (1) situations of patients of pregnancy combined with gallbladder stone; (2) risk factors of acute biliopancreatic com-plications in patients of pregnancy combined with gallbladder stone; (3) construction of prediction model for acute biliopancreatic complications in patients of pregnancy combined with gallbladder stone. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the independent t test. Measurement data with skewed distribution were represented as M( Q1, Q3), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test. Comparison of ordinal data was conducted using the rank sum test. Univariate and multi-variate analyses were conducted using the Logistic regression model. Nomogram prediction model was conducted, and the receiver operating characteristic (ROC) curve was used to evaluate discri-mination of the nomogram predic-tion model. The calibration curve and clinical decision curve were used to evaluate calibration and net clinical benefit of the nomogram prediction model. Internal validation of the prediction model was performed by applying 10-fold cross-validation. Results:(1) Situations of patients of pregnancy combined with gallbladder stone. The total cholesterol, triglyceride, high density lipoprotein cholesterol, low density lipoprotein cholesterol, prepregnancy body mass index (<18.5 kg/m 2, 18.5?24.0 kg/m 2, >24.0 kg/m 2), gesta-tional period (early, mid, late), primipara (positive, negative), stone type (solitary, non solitary), diameter of stone (≤10 mm, >10 mm), gallbladder wall thickness (≥4 mm, <4 mm) were (4.9±1.4)mmol/L, 1.88(1.22,2.93)mmol/L, 1.48(1.22,1.83)mmol/L, (2.8±0.9)mmol/L, 13, 75, 58, 37, 45, 69, 86, 65, 37, 114, 89, 62, 38, 113 in the 151 patients of pregnancy combined with gallbladder stone. Of the 151 patients, the age, prepregnancy body mass index (<18.5 kg/m 2, 18.5?24.0 kg/m 2, >24.0 kg/m 2), primipara (positive, negative), stone type (solitary, non solitary), diameter of stone (≤10 mm, >10 mm), gallbladder wall thickness (≥4 mm, <4 mm) were 31(28,37)years, 3, 30, 36, 29, 40, 32, 37, 26, 43, 4, 65 in 69 cases without symptom, versus 27(24,31)years, 10, 45, 22, 57, 25, 5, 77, 63, 19, 34, 48 in 82 cases combined with acute biliopancreatic complications, showing significant differences in the above indicators between them ( Z=?3.636, ?2.385, χ2=11.544, 32.862, 23.729, 25.310, P<0.05). Five of the 82 patients of pregnancy combined with gallbladder stone missed data of prepregnancy body mass index. Of the 82 patients, there were 42 patients of simple acute cholecystitis, 40 patients of common bile duct stone and/or acute biliary pancreatitis including 18 cases of common bile duct stone, 13 cases of acute biliary pancreatitis and 9 cases of common bile duct stone combined with acute biliary pancreatitis. (2) Risk factors of acute biliopancreatic complications in patients of pregnancy combined with gallbladder stone. Results of multivariate analysis showed that primipara, non solitary stone, diameter of stone ≤10 mm, gallbladder wall thickness ≥4 mm were independent risk factors of acute biliopancreatic complications in patients of pregnancy combined with gallbladder stone ( odds ratio=3.102, 6.305, 3.674, 6.686, 95% confidence interval as 1.280?7.519, 1.886?21.080, 1.457?9.265, 1.984?22.528, P<0.05). Results of multivariate analysis in further analysis showed that primipara, non solitary stone, gallbladder wall thickness ≥4 mm were independent risk factors of simple acute cholecystitis in patients of pregnancy combined with gallbladder stone ( odds ratio=3.671, 8.905, 7.137, 95% confidence interval as 1.386?9.723, 2.332?34.006, 1.902?26.773, P<0.05), and age, non solitary stone, diameter of stone ≤10 mm, gallbladder wall thickness ≥4 mm were independent risk factors of common bile duct stone and/or acute biliary pancreatitis in patients of pregnancy combined with gallbladder stone ( odds ratio=0.883, 5.361, 5.472, 8.895, 95% confidence interval as 0.789?0.988, 1.062?27.071, 1.590?18.827, 2.064?38.325, P<0.05). (3) Construction of prediction model for acute biliopancreatic complications in patients of pregnancy combined with gallbladder stone. The nomogram prediction model for acute biliopancreatic complications in patients of pregnancy combined with gallbladder stone was constructed based on the clinical factors of age, primipara, stone type, diameter of stone and gallbladder wall thickness. The area under the curve (AUC) of ROC curve of prediction model was 0.869 (95% confidence interval as 0.813?0.923), indicating that the prediction model with good predictive ability. Results of Hosmer-Lemeshow test showed a good fit ( χ2=5.680, P>0.05), indicating that the prediction model with good calibration. Results of decision curve analysis showed the prediction model with high net clinical benefit. Results of internal validation of the prediction model based on 10-fold cross-validation showed the AUC of ROC curve for the cross-validation sample was 0.833, indicating that the prediction model with good stability. Conclusions:Primigravida, non solitary stone, diameter of stone ≤10 mm, gallbladder wall thickness ≥4 mm are independent risk factors of acute biliopancreatic complications in patients of pregnancy combined with gallbladder stone. The prediction model for acute biliopancreatic complications has good predictive ability.

Influence of lymphadenectomy on efficacy of patients with intrahepatic cholangiocarcinoma at different locations / 中华消化外科杂志

Objective:To investigate the influence of lymphadenectomy on efficacy of patients with intrahepatic cholangiocarcinoma (ICC) at different locations.Methods:The retro-spective cohort study was conducted. The clinicopathological data of 123 patients with ICC who were admitted to the Affiliated Hospital of North Sichuan Medical College from January 2015 to January 2022 were collected. There were 78 males and 45 females, aged 55(rage, 50?60)years. All patients underwent radical resection. Observation indicators: (1) clinical characteristics of patients with ICC; (2) follow-up; (3) surgical situations in ICC patients with different number of lymph nodes dissected. Measurement data with normal distribution were represented as Mean± SD, and compari-son between groups was conducted using the independent sample t test. Measurement data with skewed distribution were represented as M(range), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test. Kaplan-Meier method was used to draw survival curve and Log-Rank test was used for survival analysis. Results:(1) Clinical characteristics of patients with ICC. Of the 123 patients, 81 cases had peripheral ICC and 42 cases had central ICC. The albumin-bilirubin grade (grade 1, grade 2?3), preoperative lymph node metastasis risk assessment (low risk, high risk), the number of lymph nodes dissected (<6, ≥6), lymph node metastasis (positive, negative) were 57, 24, 51, 30, 49, 32, 15, 66 in patients with peripheral ICC, versus 19, 23, 17, 25, 14, 28, 16, 26 in patients with central ICC, showing significant differences in the above indicators between them ( χ2=7.40, 5.66, 8.17, 5.62, P<0.05). (2) Follow-up. All the 123 patients were followed up for 28(range, 21?38)months. The 3-year overall survival rate was 57.8% in the 81 patients with peripheral ICC, versus 32.3% in the 42 patients with central ICC, showing a significant difference between them ( χ2=5.98, P<0.05). Of the 42 patients with central ICC, there were 25 cases with high risk of lymph node metastasis before surgery and 17 cases with low risk of lymph node metastasis before surgery. Of the 25 central ICC patients with high risk of lymph node metastasis before surgery, the 3-year overall survival rate was 28.9% in the 18 cases with the number of lymph nodes dissected ≥6, versus 14.3% in the 7 cases with the number of lymph nodes dissected <6, showing a significant difference between them ( χ2=8.90, P<0.05). (3) Surgical situa-tions in patients with the different number of lymph nodes dissected. Of the 123 patients, cases with the number of lymph nodes dissected <6 and ≥6 were 63 and 60, and there was no significant difference in the operation time, intraoperative blood transfusion, postoperative complications, bile leakage, liver insufficiency, pulmonary infection, pleural effusion, abdominal effusion, or lymphatic leakage between them ( P>0.05). One patient might have multiple complications. Conclusions:The prognosis of patients with peripheral ICC is better than that of patients with central ICC. For patients with central ICC who are at high risk of lymph node metastasis before surgery, adequate lymph node dissection may result in a better prognosis.

Strategy of laparoscopic treatment of right posterior bile duct hepatolithiasis / 中华消化外科杂志

Hepatolithiasis is a common biliary disease in China. Surgical treatment principles of hepatolithiasis include "removing lesions, cleaning stones, correcting strictures, recovering the drainage and preventing the recurrence". Laparoscopic techniques have been increasingly applied in surgical treatment of hepatolithiasis recently. Right posterior bile duct is a predilection site of hepatolithiasis. Due to its unique anatomy, right posterior lobectomy, right posterior bile duct lithotomy and plasty remain challenging under laparoscopy. Based on relevant literatures and clinical experiences, the authors explore the strategy of laparoscopic treatment right posterior bile duct hepatolithiasis, aiming to provide reference for surgical colleagues.

Clinical features of portal biliopathy / 临床肝胆病杂志

ObjectiveThis article aims to investigate the clinical features of portal biliopathy （PB） patients， in order to improve the understanding of PB. MethodsClinical data were collected from 22 patients who were diagnosed with PB in recent years in The First Hospital of Jilin University， and an analysis was performed for their clinical manifestations， liver function， abdominal color Doppler ultrasound， abdominal CT， and hepatobiliary magnetic resonance imaging. The imaging manifestations of biliary tract abnormalities were described， as well as the type of collateral circulation and the location of thrombosis. ResultsAs for the initial symptom in these 22 patients， three were 11 patients with gastrointestinal bleeding， 5 with abdominal distension， 3 with abdominal pain， 1 with fever， 1 with abdominal discomfort， and 1 with gingival bleeding. There were 3 patients with an increase in aspartate aminotransferase， 4 with an increase in alanine aminotransferase， 4 with an increase in gamma-glutamyl transpeptidase， 7 with an increase in alkaline phosphatase， 8 with a reduction in cholinesterase， 9 with a reduction in albumin， 2 with an increase in globulin， and 5 with an increase in total bilirubin. Among the 22 patients， 20 had cavernous transformation of the portal vein， and 2 had portal vein thrombosis without cavernous transformation. All 22 patients had bile duct abnormalities， among whom 2 had extrahepatic bile duct abnormalities alone， 12 had intrahepatic bile duct dilatation alone， and 8 had dilatation of both intrahepatic and extrahepatic bile ducts. Varices at different sites were observed in 20 patients， among whom 19 had esophageal and gastric varices and 1 had peri-gallbladder varices， and no varices was observed in the superior mesenteric vein or the splenic vein. ConclusionThere are no typical clinical symptoms and changes in liver function parameters in patients with PB， but radiological examination may show dilatation， stenosis， or malformation of the bile ducts at different parts. Therefore， it is necessary to expand the sample size to further explore the diagnosis and treatment of PB.

Current research status of biliary stents / 临床肝胆病杂志

Biliary tract diseases are a common type of hepatobiliary diseases in China and have a relatively high incidence rate， and related complications are important influencing factors for the health of Chinese patients. Biliary stents are mainly used to alleviate and relieve benign or malignant biliary stricture and obstruction， with the features of little trauma， high safety， and in line with the physiological and anatomical structure of biliary tract， and it has become the preferred palliative treatment method for biliary obstruction caused by unresectable pancreaticobiliary tumors. However， there is still a lack of satisfactory treatment outcomes since commonly used biliary stents have the shortcomings such as bacterial adhesion， cholestasis， stent obstruction， and stent migration. In recent years， scholars have conducted extensive and in－depth studies on the causes of biliary stent obstruction， the improvement of stent design， and the extension of drainage duration and have made certain progress. This article reviews the types， advantages and disadvantages， and development history of biliary stents and proposes the future research directions and application value of biliary stents.

Exploration of critical values of monitoring indexes for perioperative major adverse cardiac events in elderly patients with biliary diseases / 中华老年医学杂志

Objective:The purpose of this study was to explore the critical values of monitored indexes of perioperative major adverse cardiac events(MACE), so as to take effective prevention and treatment measures in time to maintain the stability of perioperative cardiac function to further improve the perioperative safety of elderly patients with biliary diseases.Methods:The clinical data of 246 elderly patients with biliary diseases in our hospital from May 2016 to February 2022 were collected.According to whether MACE occurred during the perioperative period, they were divided into the MACE group and the non-MACE group.The differences of clinical data, the monitoring indexes of postoperative cardiac function, and the coagulation function between the two groups were compared and analyzed.Logistic regression was used to analyze the independent risk factors of perioperative MACE, the cut-off value of the receiver operating characteristic(ROC)curve was calculated, and the Logistic multivariate prediction model was established.Results:In the MACE compared with the non-MACE group, age, postoperative complications and mortality, postoperative hospital stay, and the levels of postoperative high sensitivity troponin-I(Hs-TnI), creatine kinase isoenzyme(CK-MB), myoglobin(MYO), B-type natriuretic peptide(BNP), and D-dimer(D-D)were significantly increased(all P<0.05). Multivariate Logistic regression showed that postoperative BNP and D-D were two independent risk factors for perioperative MACE, and their cut-off values in the ROC curve were 382.65 pg/mL and 0.975mg/L respectively.The Logistic multivariate prediction model established by the Logistic regression equation was P= ex/(1+ ex), X=-5.710+ 0.003X 1+ 0.811X 2, where X 1 was the postoperative BNP level and X 2 was the postoperative D-D level.The accuracy, specificity and sensitivity of this prediction model for predicting perioperative MACE were 96.3%(237/246), 100.0%(235/235), and 18.2%(2/11). Conclusions:The Logistic multivariate prediction model established in this study can effectively predict the occurrence of perioperative MACE in elderly patients.Postoperative BNP and D-D were two independent risk factors for perioperative MACE.The cut-off values of BNP and D-D in the ROC curve could be used as critical values for monitoring perioperative MACE.Therefore, it is of great clinical significance to take effective prevention and treatment measures in time to maintain the stability of perioperative cardiac function, and further improve the perioperative safety of elderly patients with biliary diseases.

Application status and prospect of biodegradable polymer stents in pancreatobiliary disease / 中华肝胆外科杂志

Endoscopic stent implantation is one of the main methods for the treatment of biliary and pancreatic diseases. At present, the commonly used biliary and pancreatic stents are mainly plastic and metal stents which are still have some deficiencies in clinical applications, and the emergence of the new type of biodegradable polymer materials is expected to achieve the purpose of treatment to overcome these shortcomings. It is a potential hope to break through the bottleneck of endoscopic treatment of choleopancreatic diseases. Previous animal experiments and human clinical studies have preliminarily shown its safety and effectiveness, which can effectively solve some problems of bile and pancreatic duct stenosis and so on. Biodegradable polymer stents have been widely studied, but their clinical application progress is slow and not yet popular, and it has gradually become a research hotspot in recent years . This article discusses the research status and development direction of biodegradable polymer stents in biliary and pancreatic diseases.

Distribution and drug resistance of pathogenic bacteria of biliary tract infection in patients subjected to hepatobiliary surgery / 中国基层医药

Objective:To study the distribution and drug resistance of pathogenic bacteria of biliary tract infection in patients with hepatobiliary surgery.Methods:A total of 103 patients with biliary tract infection who received treatment in the Department of Hepatobiliary Surgery, Lanxi People's Hospital from May 2020 to October 2022 were included in this study. Their bile was cultured to analyze the distribution and drug resistance of pathogenic bacteria. The data were processed using the WHONET5.5 software system.Results:Fifty-eight pathogenic bacteria-positive samples were cultured from the bile of 103 patients with biliary tract infection, with a pathogenic bacteria-positive rate of 56.31%. Among 58 strains of pathogenic bacteria, 38 strains (65.52%) were gram-negative bacteria, mainly Escherichia coli and Klebsiella pneumonia, and 5 strains (8.62%) were fungal strains. Escherichia coli and Klebsiella pneumoniae were highly resistant to sulfamethoxazole-trimethoprim, ciprofloxacin, and other antibacterial drugs, and were completely sensitive to imipenem and meropenem. Enterococcus faecalis was mainly resistant to ampicillin and penicillin G,and it was completely sensitive to vancomycin and teicoplanin. Staphylococcus aureus was resistant to vancomycin, ciprofloxacin, cefotaxime, and other drugs. A total of 13 strains of ultrabroad-spectrum beta-lactamase bacteria were isolated from 25 strains of Escherichia coli and 7 strains of Klebsiella pneumonia, with the positive detection rate of 40.63%. Conclusion:The main pathogenic bacteria of biliary tract infection are Gram-negative bacteria, which are widely distributed and have serious drug resistance. In clinical practice, antimicrobial drugs should be reasonably selected according to the results of bile drug sensitivity tests.

Experiencia en colangioscopia digital peroral con SpyGlass DS en diferentes centros de referencia en gastroenterología y endoscopia digestiva en Colombia: Serie de casos

SpyGlass DS es un sistema de colangioscopia peroral, asociado a mejor calidad de imagen y conFiguración. Actualmente, existe diversidad en su uso y escasa información sobre su implementación, incluyendo resultados clínicos y eventos adversos. Describir la experiencia de uso del SpyGlass DS en varios centros de referencia en gastroenterología en Colombia, mencionando eficacia y posibles eventos adversos. Este es un estudio observacional (serie de casos). La principal indicación fue coledocolitiasis (n:204), seguida de estenosis biliar (n:40) y pancreatolitiasis (n:16). 49,2% fueron hombres, edad media de 58,6 años, clínicamente con predominio de dolor abdominal (80,5%) e ictericia (86,1%). Todos los casos presentaron diagnóstico por imagen previo (tomografía computarizada, resonancia magnética o ecografía), 98,07% colangiopancreatografía retrógrada endoscópica previa (n:255) y 75% stent plástico biliar. Se utilizó láser en 78/220 pacientes y litotricia electrohidráulica en 142/220 pacientes, con tasas de resolución en una sola sesión 96,15% y 95,07%, respectivamente. Siete casos requirieron segunda sesión de litotricia y 3 pacientes requirieron manejo quirúrgico, uno por pancreatolitiasis con páncreas divisum de base y 2 por hepatolitiasis. 40/260 pacientes presentaron estenosis biliar, 32/40 con hallazgos malignos (colangiocarcinoma) y 8/40 con patología benigna (colangitis esclerosante primaria, cambios inflamatorios inespecíficos) tras estudios histopatológicos. Como complicaciones, se registraron 6 casos de bacteriemia (2,5%), siendo más frecuentes en casos de estenosis. La estancia media postoperatoria fue 2,04 días. Concluimos que el uso del SpyGlass DS es factible en nuestro medio, siendo eficaz para diagnóstico y tratamiento de lesiones biliares, y con bajo riesgo de eventos adversos.

SpyGlass DS is a peroral cholangioscopy system, associated with improved image quality and conFiguration. Currently, there is diversity in its use and little information on its implementation, including clinical outcomes and adverse events. To describe the experience of using SpyGlass DS in several gastroenterology reference centres in Colombia, mentioning efficacy and possible adverse events. This is an observational study (case series). The main indication was choledocholithiasis (n:204), followed by biliary stricture (n:40) and pancreatolithiasis (n:16). 49.2% were male, mean age 58.6 years, clinically with predominance of abdominal pain (80.5%) and jaundice (86.1%). All cases had previous imaging (CT scan, MRI or ultrasound), 98.07% previous endoscopic retrograde cholangiopancreatography (n:255) and 75% biliary plastic stent. Laser was used in 78/220 patients and electrohydraulic lithotripsy in 142/220 patients, with single-session resolution rates of 96.15% and 95.07%, respectively. Seven cases required a second lithotripsy session and 3 patients required surgical management, one for pancreatolithiasis with basal pancreas divisum and 2 for hepatolithiasis. 40/260 patients presented with biliary stricture, 32/40 with malignant findings (cholangiocarcinoma) and 8/40 with benign pathology (primary sclerosing cholangitis, non-specific inflammatory changes) after histopathological studies. As complications, 6 cases of bacteraemia (2.5%) were recorded, being more frequent in cases of stenosis. The mean postoperative stay was 2.04 days. We concluded that the use of SpyGlass DS is feasible in our setting, being effective for diagnosis and treatment of biliary lesions, and with low risk of adverse events.

Influencing factors of endoscopic radiofrequency ablation complications for malignant biliary obstruction / 中华肝胆外科杂志

Objective:To study the influencing factors of postoperative complications in patients with malignant biliary obstruction treated by endoscopic radiofrequency ablation(RFA).Methods:Data of patients with malignant biliary obstruction who underwent endoscopic RFA at the Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine from January 2010 to June 2021 were retrospectively analyzed. There were 62 males and 48 females, with age (74.1±11.1) years. Based on occurrence of postoperative complications, these patients were divided into the complication group ( n=18) and the control group ( n=92). Univariate and multivariate logistic regression analysis were used to analysis the influencing factors of complications. Results:RFA was successfully performed in 110 patients with malignant biliary obstruction, and the technical success rate was 100.0% (110/110). Postoperative complications occurred in 18 patients (16.4%), including 12 patients with of biliary tract infection (8 patients with acute cholangitis, 4 patients with acute cholecystitis) and 6 patients with acute pancreatitis. All these patients responded well to treatment. The proportion of patients who developed complications having associated diabetes, bile duct stenosis length >2.5 cm, fractional RFA for bile duct stenosis, and single stent drainage were significantly higher than those in the control group (all P<0.05). Multivariate logistic regression analysis showed that the risk of complications after endoscopic RFA was significantly increased in patients with diabetes ( OR=6.967, 95% CI: 1.256-38.658) and fractional RFA of bile duct stenosis ( OR=8.297, 95% CI: 1.526-45.122), while the risk of complications after multiple stents drainage ( OR=0.037, 95% CI: 0.008-0.169) was significantly decreased (all P<0.05). Conclusion:Diabetes and fractional RFA of bile duct stenosis were risk factors for complications after endoscopic RFA of malignant biliary obstruction. Multiple stents drainage was a protective factor. Better clinical attention should be paid to the patients with high risk factors.

Clinical characteristics and surgical effects of acute calculous cholecystitis in high altitude area of Tibet / 中华消化外科杂志

Objective:To investigate the clinical characteristics and surgical effects of acute calculous cholecystitis (ACC) in high altitude area of Tibet.Methods:The retrospective cohort study was conducted. The clinicopathological data of 182 ACC patients who underwent surgery in the 954th Hospital of Army from January 2016 to December 2020 were collected. There were 56 males and 126 females, aged (41±13)years. Of the 182 patients, 61 cases undergoing open cholecystec-tomy were divided into the open group, and 121 cases undergoing laparoscopic cholecystectomy (LC) were divided into the laparoscopic group. Observation indicators: (1) clinical characteristics of ACC in high altitude area; (2) surgical situations; (3) postoperative complications; (4) follow-up. Follow-up was conducted using outpatient examination and telephone interview to detect postopera-tive complications of patients up to October 2021. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measure-ment data with skewed distribution were represented as M( Q1, Q3) or M(range), and comparison between groups was conducted using the Mann-Whitney U test. Count data were expressed as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test. Results:(1) Clinical characteristics of ACC in high altitude area. Of the 182 patients, cases with symptom duration as <3 days, 3 days to 1 month, >1 month and ≤12 months, >12 months were 37, 43, 57, 45, respectively. Seventy-seven of the 182 patients were combined with other diseases before surgery. (2) Surgical situations. Two cases in the open group were found common bile duct stones during the operation, and underwent choledochotomy and T-tube drainage. Nine cases in the laparoscopic group were converted to laparotomy, including 3 cases with severe abdominal adhesion and ineffective hemostasis, 6 cases with anatomical variation of Calot triangle. The conversion to laparotomy rate was 7.438%(9/121). The other patients in the open group and the laparoscopic group completed surgery successfully. The operation time, volume of intraoperative blood loss, time to postoperative first out-of-bed activities, time to postoperative first flatus, cases with indwelling drainage tube, cases with acute simple cholecystitis, acute suppurative cholecystitis, acute gangrene cholecystitis, gallbladder perforation of disease pathological type, postoperative white cell count, postoperative neutrophil percentage, duration of postoperative hospital stay were (109±42)minutes, 50(45,100)mL, (16.1±1.5)hours, (31.4±11.9)hours, 33, 25, 27, 6, 3, (6.8±1.9)×10 9/L, 72.7%±7.4%, (7.3±1.7)days for the open group. The above indicators were (98±43)minutes, 20(20,50)mL, (12.9±1.4)hours, (26.7±12.1)hours, 51, 56, 51, 9, 5, (7.1±2.4)×10 9/L, 70.5%±8.7%, (6.4±1.7)days for the laparoscopic group. There were significant differences in the volume of intraopera-tive blood loss, time to postoperative first out-of-bed activities, time to postoperative first flatus, duration of postoperative hospital stay between the two groups ( Z=?6.75, t=14.41, 2.46, 3.45, P<0.05). There was no significant difference in the operation time, cases with indwelling drainage tube, diseases pathological type, postoperative white cell count, postoperative neutrophil percentage between the two groups ( t=1.66, χ2=2.33, 0.84, t=?0.71, 1.66, P>0.05). (3) Postoperative complica-tions. Postoperative complications occurred in 7 of the 61 patients in the open group and 5 of the 121 patients in the laparoscopic group. There was no significant difference in the postoperative complications between the two groups ( χ2=2.46, P>0.05). (4) Follow-up. Of the 182 patients, 115 cases including 35 cases in the open group and 80 cases in the laparoscopic group were followed up for 12(range, 3?24)months. During the follow-up, 1 case of the 35 patients in the open group had abdominal pain and jaundice, which was diagnosed as choledocholithiasis. The patient was improved after stone removal with endoscopic retrograde cholangiopancreatography. Two cases of the 35 patients in the open group had upper abdominal pain with fever and were improved after anti-infection treatment. Of the 80 patients in the laparoscopic group, 1 case had upper abdominal pain and 1 case had dyspepsia and anorexia, respectively. The two cases were improved after symptomatic treatment. Conclusions:Patients with ACC in the high altitude area of Tibet have high ratio of preoperative complications, long diseases history and high incidence rates of pyogenic perforation of the gallbladder. Patients with ACC in the high altitude area undergoing LC is safe and effective. Compared with open cholecystectomy, LC have less volume of intraoperative blood loss, faster postoperative recovery and shorter duration of postoperative hospital stay.

Analysis of influencing factors for the development of gallstone in population of Beijing / 中华消化外科杂志

Objective:To investigate the influencing factors for the development of gall-stone in population of Beijing.Methods:The retrospective cross-sectional survey was conducted. From November 2016 to September 2020, patients living in Beijing (registered residence in Beijing ≥12 months) who visited the biliary outpatient of Department of General Surgery of Peking Union Medical College Hospital, Chinese Academy of Medical Sciences for the first time were recruited to participate as respondents. The survey was conducted by the questionnaire survey on correlation between dietary habits and incidence of gallstones, in which the information of gender, age, body mass index (BMI), gallstone status, metabolic indicators (hypercholesterolemia, history of diabetes mellitus, reproductive times for female, menopause status of female, duration of menopause for female, history of weight loss), dietary indicators (dietary mix of meat and vegetable dishes, times of coffee intake per month, times of alcohol consumption per month, times of greasy diet intake per month, times of breakfast skipping per week, average overnight fasting time of breakfast skipping, times of supper skipping per week, average overnight fasting time of supper skipping), family history of gallstones, lifestyle indicators (times of staying up late per month, average overnight fasting time when staying up late, daily sedentary time, weekly physical activity score). Observation indicators: (1) results of questionnaire survey; (2) analysis of influencing factors for the occurrence of gallstone. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M( Q1, Q3). Count data were expressed as absolute numbers or percentages. Univariate and multivariate analyses were performed using the Logistic regression model. Results:(1) Results of questionnaire survey. A total of 1 036 questionnaires were distributed, and 1 004 complete questionnaires were recovered. Of the 1 004 patients who completed the questionnaire survey, there were 329 males and 675 females, aged (44±12)years. The BMI of 1 004 patients was (24±3)kg/m 2. Of the 1 004 patients, there were 659 cases with a history of cholecystolithiasis and 345 cases without. (2) Analysis of influencing factors for the occurrence of gallstone. Results of univariate analysis showed that age, history of diabetes mellitus, history of weight loss, times of coffee intake per month, times of greasy diet intake per month, family history of gallstone and daily sedentary time were related factors for the development of gallstone in 1 004 patients ( odds ratio=1.03, 2.26, 1.74, 1.01, 1.01, 2.22, 1.06, 95% confidence intervals as 1.02?1.05, 1.09?5.18, 1.22?2.53, 1.00?1.03, 1.00?1.01, 1.60?3.11, 1.01?1.11, P<0.05). Results of multivariate analysis showed that age, history of diabetes mellitus, history of weight loss, times of greasy diet intake per month, family history of gallstone and daily sedentary time were independent influencing factors for the development of gallstone in 1 004 patients ( odds ratio=1.03, 2.26, 1.82, 1.01, 2.22, 1.06, 95% confidence intervals as 1.02?1.05, 1.11?5.13, 1.28?2.62, 1.00?1.02,1.60?3.09, 1.01?1.12, P<0.05). Conclusion:Age, history of diabetes mellitus, history of weight loss, times of greasy diet intake per month, family history of gallstone and daily sedentary time are independent influencing factors for the development of gallstone in population of Beijing.

Current status and progress of endoscopic drainage for acute cholecystitis / 中华消化外科杂志

The fundamental treatment for acute cholecystitis is surgical cholecystectomy, especially laparoscopic cholecystectomy. Some high-risk surgical patients need gallbladder drainage. The traditional drainage method is percutaneous transhepatic gallbladder drainage. However, in recent years, two endoscopic approaches, including endoscopic transpapillary gallbladder drainage and endoscopic ultrasound-guided gallbladder drainage, have developed rapidly and have advantages in long-term outcomes. In this article, the authors discuss the historical development, technical characteristics, comparison between methods , adverse events and long-term outcomes of the two endoscopic drainage methods through literature review.

Progress in endoscopic diagnosis and treatment of benign biliary strictures in the sights of precision surgery / 中华消化外科杂志

Benign biliary strictures (BBSs) is a kind of difficult clinical problem in biliary surgery. Surgery and endoscopic treatment are common diagnostic and therapeutic methods. The rapid development of endoscopic technology challenges the traditional surgery. How to integrate surgery and endoscopic technology in an orderly manner and develop strengths and circumvent weaknesses requires a breakthrough in guiding ideas. The precision surgery, with the characteristics of certainty, predictability, controllability, standardization, individualization and systematization, has become an ideal choice for integrating surgery and endoscopic technology. Based on clinical practice, the authors discuss the endoscopic diagnosis and treatment strategy of BBSs from the perspective of precision surgery by implementing the core elements of precision surgery.

Supervivencia postrasplante hepático en receptores con complicaciones biliares / Survival after liver transplantation in recipients with biliary complications

RESUMEN Introducción: Las complicaciones relacionadas con la anastomosis biliar son reconocidas como la primera causa de morbilidad postrasplante hepático y pueden repercutir de manera negativa en la supervivencia de los pacientes. Objetivo: Evaluar el comportamiento de la supervivencia a largo plazo en los pacientes con complicaciones biliares postrasplante. Métodos: Se realizó un estudio observacional, longitudinal y retrospectivo en 152 pacientes con trasplante hepático entre 1999 y 2019. Se excluyeron: pacientes con supervivencia menor de 72 horas, retrasplantes y pacientes con trombosis de la arteria hepática. Las variables estudiadas fueron edad y sexo de los receptores, causa pretrasplante, escala Model for End Stage Liver Desease, usada a nivel mundial para determinar el estado de la enfermedad hepática y asignar órganos a los candidatos a trasplante, técnica de anastomosis biliar, tipo de complicación biliar, tiempo de aparición y terapéutica empleada. Las variables categóricas se relacionaron mediante la prueba estadística chi cuadrado y prueba exacta de Fisher, con diferencias significativas cuando p< 0,05; en el estudio de las variables cuantitativas se aplicó la prueba t - Student y para el análisis de la supervivencia se utilizaron curvas de Kaplan-Meier. Resultados: Se relacionaron de forma significativa con la presencia de complicación biliar, una puntuación mayor de la escala de valores de Model for End Stage Liver Desease (p=0,008) y la técnica de anastomosis término-terminal (p=0,039). Predominaron las complicaciones biliares precoces y la estenosis anastomótica. El tratamiento por colangiopancreatografía retrógrada endoscópica fue el más empleado. Los pacientes con complicación biliar tuvieron una media de supervivencia de 10,9 años (IC del 95 % 8,75-13,19), mientras que los pacientes sin ésta, tuvieron una media de nueve años (IC del 95 % 7,03-10,98); no existió diferencia significativa (p=0,24). Conclusiones: Las complicaciones biliares constituyeron una causa importante de morbilidad postrasplante, pero sin afectar la supervivencia de los pacientes.

ABSTRACT Introduction: Complications related to biliary anastomosis are recognized as the first cause of post-liver transplantation morbidity and can negatively affect patient survival. Objective: To evaluate the behavior of long-term survival in patients with post-transplant biliary complications. Methods: An observational, longitudinal, and retrospective study was carried out in 152 patients with liver transplantation between 1999-2019, the following were excluded: patients with survival less than 72 hours, retransplants and patients with hepatic artery thrombosis. The variables studied were age and sex of the recipients, pre-transplant etiology, MELD index (Model for End Stage Liver Desease), biliary anastomosis technique, type of biliary complication, time of onset and treatment used. The categorical variables were related using the Chi square statistical test and Fisher's exact test, with significant differences when p <0.05; In the study of quantitative variables, the T-Student test was applied and Kaplan - Meier curves were used for survival analysis. Results: They were significantly related to the presence of biliary complication, a higher MELD index score (p = 0.008) and the end-to-end anastomosis technique (p = 0.039). Early biliary complications (66.7%) and anastomotic stenosis (58.7%) predominated. Treatment by endoscopic retrograde cholangiopancreatography (ERCP) was the most used (68.2%). Patients with biliary complications had a mean survival of 10.9 years (95% CI 8.75-13.19), while patients without it had a mean of 9 years (95% CI 7.03 -10.98); there was no significant difference (p = 0.24). Conclusions: Biliary complications were an important cause of post-transplant morbidity, but without affecting patient survival.

Endoscopic technology boosts the development of precision biliary and pancreatic surgery / 中华消化外科杂志

The diagnosis and treatment of complex biliary and pancreatic diseases is still one of the major problems and challenges faced by modern medicine. The concept of "precision surgery" proposed by academician Jiahong Dong provides a new way to solve this problem. With the rapid development of biliary and pancreatic endoscopy, it has become an important vehicle for the diagnosis and treatment of complex biliary and pancreatic diseases. In recent years, the authors have combined accurate endoscopy with precision surgery in the treatment of clinical complex biliary and pancreatic diseases, achieving good effects.

Research advances in the bile acid membrane receptor TGR5 in biliary tract diseases / 临床肝胆病杂志

TGR5 is a bile acid-activated G protein-coupled receptor and plays an important role in the physiological and pathological processes of the biliary system. This article describes the normal expression of TGR5 in the liver and bile duct under normal physiological conditions and its functions including the regulation of bile acid secretion and metabolism and cytoprotection. This article also summarizes the changes in the expression and function of TGR5 under pathophysiological conditions and the mechanism of TGR5 in affecting the development and progression of biliary tract diseases through inflammatory response and cell proliferation and apoptosis. TGR5 may be a potential target for the treatment of biliary tract diseases in the future.

Absceso hepático por colecistitis xantogranulomatosa y adenomiomatosis vesicular: reporte de un caso

La colecistitis xantogranulomatosa (CXG) y la adenomiomatosis (AV) son infrecuentes, con escasos reportes en nuestro medio. La diferenciación preoperatoria e intraoperatoria es difícil, porque presenta características radiológicas y macroscópicas similares al cáncer. Frecuentemente se presenta como una colecistitis aguda. Y el diagnóstico se establece por la presencia de fibrosis, histiocitos espumosos, y de los senos de Rokitansky-Aschoff, respectivamente. Presentamos el caso de una mujer que acudió por dolor abdominal, náuseas y vómitos. La tomografía reveló una colección hepática subcapsular. Se interviene quirúrgicamente y se evidencia absceso hepático bloqueado por epiplón, con múltiples adherencias; y vesícula de paredes engrosadas perforada en bacinete. La paciente recibe antibioticoterapia, cursa con buena evolución, y la histopatología concluye una CXG y AV. La CXG y la AV son enfermedades raras, asociadas a colelitiasis. En nuestro caso, su asociación y su complicación con absceso hepático hacen que sea particularmente excepcional. Requiriendo ambas, cirugía e histopatología para confirmarlas.

Xanthogranulomatous cholecystitis (CXG) and Adenomyomatosis (VA) are rare, with few reports in our setting. The preoperative and intraoperative differentiation is difficult because it presents radiological and macroscopic characteristics, similar to cancer. It often presents as acute cholecystitis. And the diagnosis is established by the presence of fibrosis, foamy histiocytes, and Rokitansky-Aschoff sinuses, respectively. We present the case of a woman who came in for abdominal pain, nausea and vomiting. The tomography revealed a subcapsular liver collection. Surgery was performed and a hepatic abscess blocked by the omentum was evidenced, with multiple adhesions; and thickened-walled vesicle perforated in bacinete. Patient receives antibiotic therapy, progresses well, and histopathology concludes CXG and VA. CXG and VA are rare diseases associated with cholelithiasis. In our case, its association, and its complication with liver abscess, make it particularly exceptional. Requiring both surgery and histopathology to confirm them.