Biliary complications after liver transplantation / Complicações biliares pós-transplante hepático

ABSTRACT Background: Biliary reconstitution has been considered the Achilles's heel of liver transplantations due to its high rate of postoperative complications. Aim: To evaluate the risk factors for occurrence of biliary strictures and leakages, and the most efficient methods for their treatment. Method: Of 310 patients who underwent liver transplantation between 2001 and 2015, 182 medical records were retrospectively analyzed. Evaluated factors included demographic profile, type of transplantation and biliary reconstitution, presence of vascular and biliary complications, their treatment and results. Results: 153 (84.07%) deceased donor and 29 (15.93%) living donor transplantations were performed. Biliary complications occurred in 49 patients (26.92%): 28 strictures (15.38%), 14 leakages (7.7%) and seven leakages followed by strictures (3.85%). Hepatic artery thrombosis was present in 10 patients with biliary complications (20.4%; p=0,003). Percutaneous and endoscopic interventional procedures (including balloon dilation and stent insertion) were the treatment of choice for biliary complications. In case of radiological or endoscopic treatment failure, surgical intervention was performed (biliodigestive derivation or retransplantation (32.65%). Complications occurred in 25% of patients treated with endoscopic or percutaneous procedures and in 42.86% of patients reoperated. Success was achieved in 45% of patients who underwent endoscopic or percutaneous procedures and in 61.9% of those who underwent surgery. Conclusion: Biliary complications are frequent events after liver transplantation. They often require new interventions: endoscopic and percutaneous procedures at first and surgical treatment when needed. Hepatic artery thrombosis increases the number of biliary complications.

RESUMO Racional: A reconstituição biliar é considerada o calcanhar-de-Aquiles do transplante hepático devido à sua elevada taxa de complicações pós-operatórias. Objetivo: Analisar os fatores de risco para ocorrência de estenoses e fístulas biliares e os métodos terapêuticos mais eficientes para seu tratamento. Método: De 310 pacientes transplantados entre 2001 e 2015, 182 prontuários foram analisados retrospectivamente. Foram avaliados o perfil demográfico dos pacientes, tipo de transplante e reconstituição biliar, presença de complicações biliares e vasculares, tratamento utilizado e seus resultados. Resultados: Foram realizados 153 (84,07%) transplantes hepáticos cadavéricos e 29 intervivos (15,93%). Complicações biliares ocorreram em 49 pacientes (26,92%): 28 estenoses (15,38%), 14 fístulas (7,7%) e sete fístulas seguidas de estenose (3,85%). Trombose de artéria hepática esteve presente em 10 pacientes com complicações biliares (20,4%, p=0,003). Os tratamentos de escolha foram os procedimentos endoscópicos ou percutâneos (incluindo dilatação por balão e colocação de próteses (40,82%). No insucesso deles, foi realizado tratamento cirúrgico (derivação biliodigestiva ou retransplante (32,65%). Complicações ocorreram em 25% dos pacientes que fizeram procedimentos endoscópicos ou percutâneos e em 42,86% dos submetidos ao tratamento cirúrgico. A resolução das complicações biliares foi de 45% com os procedimentos endoscópicos ou percutâneos e de 61,9% com o cirúrgico. Conclusão: Complicações biliares são frequentes após transplante hepático. Comumente requerem novas intervenções. Os procedimentos endoscópicos e percutâneos são a primeira escolha e os cirúrgicos, empregados na falha destes. Trombose de artéria hepática aumenta a incidência de complicações biliares.

Tratamiento quirúrgico de las lesiones iatrogénicas de la vía biliar poscolecistectomía / Surgical treatment of iatrogenic bile duct injury post cholecystectomy

Introducción: Las lesiones de la vía biliar (LVB) iatrogénicas durante una colecistectomía constituyen una complicación grave, con una significativa morbimortalidad. El objetivo del estudio es analizar los resultados de la reparación de las LVB poscolecistectomía realizadas entre los años 2000 y 2015. Métodos: Estudio de serie de casos. Se consignaron en una base de datos: variables demográficas, el centro donde se realizó la colecistectomía, la vía de reparación, el tipo de LVB, el tipo de reparación efectuada, las complicaciones postoperatorias, la mortalidad operatoria y la sobrevida. Para el análisis estadístico se utilizó el software SPSS 22 (SPSS Inc., Chicago, IL, EE. UU.). Resultados: Se estudiaron 36 pacientes, de los cuales 33 (92%) fueron mujeres; la edad promedio fue de 48,5 ± 14 años. La colecistectomía que originó la iatrogenia fue laparoscópica en 24 (67%) casos. La LVB fue identificada en el intraoperatorio en 9 pacientes (25%). La LVB más frecuente se localizó a menos de 2cm de la confluencia (Bismuth-Strasberg tipo E2) en 14 (39%) pacientes. La derivación biliodigestiva con asa en Y de Roux fue la técnica más utilizada en la reparación de las LVB en 26 (72%) casos. A largo plazo, se observó una estenosis en 7 (19%) pacientes, con necesidad de una nueva reparación. Hubo mortalidad operatoria de un paciente (3%). Conclusiones: Las LVB poscolecistectomía fueron satisfactoriamente reparadas preferentemente con una derivación biliodigestiva con Y de Roux en nuestro centro.

Abstract Introduction: Iatrogenic bile duct injuries (BDI) during a cholecystectomy are a serious complication with significant morbidity and mortality. The aim of this study is to analyze the results BDI's repair post cholecystectomy which was performed between the years 2000-2015. Methods: Case series study. Demographic variables, the center where the cholecystectomy was performed, repair pathway, the type of bile duct injury, the type of reparation performed, postoperative complications, operative mortality and survival were entered in a database. For statistical analysis, software SPSS 22 was used. Results: Thirty-six patients were studied; 33 (92%) were women; mean age 48.5 ± 14 years. The Cholecystectomy that originated the iatrogenia was laparoscopic in 24 (67%) cases. BDI was identified intraoperatively in 9 patients (25%). The most common BDI was located less than 2 cm to confluence (Bismuth-Strasberg type E2) in 14 (39%) patients. The biliodigestive Roux-Y bypass was the most used technique in the repair of the BDI in 26 (72%) cases. In the long term, stenosis was observed in 7 (19%) patients with the need of a new repair. Operative mortality of 1 patient (3%). Conclusions: BDI post cholecystectomy were successfully repaired preferably with a biliodigestive Roux-Y bypass in our center.

Role of Gastroenterologists in Management of Obesity / 대한소화기학회지

Obesity is a serious disorder that increases morbidity and mortality. Primary intervention with life style modification and medication is not always effective for obese patients. Endoscopic management of obesity may be a less invasive, more cost-effective, and relatively safer option than bariatric surgery. Moreover, therapeutic endoscopy is considered to be the primary modality for managing complications that occur after bariatric surgery. In the near future, role of gastroenterologists will be more important in the management of obesity and its related problems.

Endoscopic Management of Bile Leakage after Liver Transplantation

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) can be an effective treatment for bile leakage after liver transplantation. We evaluated the efficacy of endoscopic treatment in liver transplantation in patients who developed bile leaks. METHODS: Forty-two patients who developed bile leaks after liver transplantation were included in the study. If a bile leak was observed on ERCP, a sphincterotomy was performed, and a nasobiliary catheter was then inserted. If a bile leak was accompanied by a bile duct stricture, either the stricture was dilated with balloons, followed by nasobiliary catheter insertion across the bile duct stricture, or endoscopic retrograde biliary drainage was performed. RESULTS: In the bile leakage alone group (22 patients), endoscopic treatment was technically successful in 19 (86.4%) and clinically successful in 17 (77.3%) cases. Among the 20 patients with bile leaks with bile duct strictures, endoscopic treatment was technically successful in 13 (65.0%) and clinically successful in 10 (50.0%) cases. Among the 42 patients who underwent ERCP, technical success was achieved in 32 (76.2%) cases and clinical success was achieved in 27 (64.3%) cases. CONCLUSIONS: ERCP is an effective and safe therapeutic modality for bile leaks after liver transplantation. ERCP should be considered as an initial therapeutic modality in post-liver transplantation patients.

Endoscopic Management of Bile Leakage after Liver Transplantation

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) can be an effective treatment for bile leakage after liver transplantation. We evaluated the efficacy of endoscopic treatment in liver transplantation in patients who developed bile leaks. METHODS: Forty-two patients who developed bile leaks after liver transplantation were included in the study. If a bile leak was observed on ERCP, a sphincterotomy was performed, and a nasobiliary catheter was then inserted. If a bile leak was accompanied by a bile duct stricture, either the stricture was dilated with balloons, followed by nasobiliary catheter insertion across the bile duct stricture, or endoscopic retrograde biliary drainage was performed. RESULTS: In the bile leakage alone group (22 patients), endoscopic treatment was technically successful in 19 (86.4%) and clinically successful in 17 (77.3%) cases. Among the 20 patients with bile leaks with bile duct strictures, endoscopic treatment was technically successful in 13 (65.0%) and clinically successful in 10 (50.0%) cases. Among the 42 patients who underwent ERCP, technical success was achieved in 32 (76.2%) cases and clinical success was achieved in 27 (64.3%) cases. CONCLUSIONS: ERCP is an effective and safe therapeutic modality for bile leaks after liver transplantation. ERCP should be considered as an initial therapeutic modality in post-liver transplantation patients.

ENDOSCOPIC TREATMENT OF POST-LIVER TRANSPLANTATION ANASTOMOTIC BILIARY STRICTURE: systematic review andmeta-analysis / Tratamento endoscópico na estenose da anastomose biliar no pós-transplante hepático: revisão sistemática e meta-análise

Context Biliary strictures after liver transplantation are recognized as its Achilles’ heel. The strictures are classified in anastomotic and ischemic or non-anastomotic biliary strictures, and they figure among the most common complications after liver transplantation. There are some treatment options including balloon dilation, the placement of multiple plastic stents and the placement of self-expandable metal stents and all of them seem to have good results. Objectives The aim of this study was to systematically review the literature concerning the results of the endoscopic treatment of anastomotic biliary strictures after liver transplantation. Methods A systematic review of the literature was performed on the management of anastomotic biliary strictures post- orthotopic liver transplantation. The Medline-PubMed, EMBASE, Scielo-LILACS, and Cochrane Databases were electronically searched from January 1966 to April 2013. Results No well-designed randomized controlled trial was found. Most studies were retrospective or prospective comparisons in design. One study (86 patients) compared the endoscopic and the percutaneous accesses. The sustained clinical success rates were similar but the treatment duration was longer in the percutaneous group access. Two studies (56 patients) compared balloon dilation with balloon dilation and multiple plastic stents. There were no differences concerning sustained clinical success and complication rates. Conclusions Balloon dilation is as effective as balloon dilation plus multiple plastic stenting for the resolution of the anastomotic biliary strictures. Well-designed randomized trials are still needed to compare balloon dilation versus multiple plastic stenting versus metallic stenting. .

Contexto A estenose biliar figura como uma das complicações mais frequentes pós-transplante hepático. São classificadas em anastomóticas e não anastomóticas, sendo estas últimas geralmente isquêmicas. Dentre as várias opções de tratamento, destacam-se a dilatação balonada, a colocação de próteses plásticas e a colocação de próteses metálicas autoexpansíveis, que podem ser realizadas tanto por via endoscópica, como por via percutânea. Não há consenso quanto ao melhor tratamento para a estenose da anastomose biliar. Objetivos O objetivo deste estudo foi realizar revisão sistemática da literatura sobre o resultado do tratamento endoscópico da estenose da anastomose biliar após transplante hepático. Métodos Revisão sistemática da literatura foi realizada sobre o tratamento da estenose da anastomose biliar pós transplante hepático, através do acesso aos bancos de dados pesquisados eletronicamente: Medline - PubMed, EMBASE, Scielo- Lilacs, Cochrane de janeiro de 1966 a abril de 2013. Resultados Não foi encontrado estudo clinico controlado e randomizado. A maioria dos estudos são comparativos retrospectivos ou prospectivos. Um estudo (86 pacientes) avaliou o acesso endoscópico e percutâneo. As taxas de sucesso clínico sustentados foram semelhantes, mas a duração do tratamento foi maior no grupo de acesso percutâneo. Dois estudos (56 pacientes) compararam a dilatação por balão com dilatação por balão e múltiplas próteses plásticas. Não houve diferenças em relação as taxas de sucesso e de complicações clínicas sustentadas. Conclusões A dilatação com balão é tão eficaz quanto a dilatação ...

A terapêutica endoscópica nas complicações biliares pós-transplante hepático / Endoscopic management of biliary complications after liver transplantation

RACIONAL: O transplante hepático é o único tratamento efetivo para as hepatopatias crônicas terminais e a taxa de sobrevida tem aumentado nas últimas décadas. No entanto, as complicações biliares têm alta incidência e permanecem como o "calcanhar de Aquiles" do transplante de fígado. OBJETIVO: Avaliar retrospectivamente os resultados do tratamento endoscópico das complicações biliares em pacientes submetidos à transplante hepático. MÉTODOS: Foram avaliados pacientes transplantados hepáticos para realização de colangiopancreatografia retrógrada endoscópica por suspeita de complicação biliar. RESULTADOS: Quinze pacientes (11 homens, média de idade de 49,57 anos) foram estudados. Nesse período foram realizadas 36 colangiopancreatografias retrógradas endoscópicas (2,4/paciente). Neste grupo, 100% receberam órgão de doador falecido. Estenose da anastomose coledococoledocociana foi diagnosticada em 13 pacientes e o sucesso da terapêutica endoscópica foi de 53,84% (38,46% ainda em tratamento). Fístula biliar foi diagnosticada em um paciente, sendo resolvida pelo tratamento endoscópico. Disfunção da âmpola hepatopancreaticobiliar com coledocolitíase foi diagnosticada em um paciente, também resolvida pela terapêutica endoscópica. CONCLUSÕES: As complicações biliares pós-transplante hepático são relativamente comuns, com predominância de estenoses. O tratamento endoscópico foi eficaz na maioria dos pacientes desta série.

BACKGROUND: Liver transplantation is the only effective treatment for chronic liver diseases and terminal survival rate has increased in recent decades. However, biliary complications have high incidence and remain as the "Achilles heel" for liver transplantation. AIM: To evaluate retrospectively endoscopic treatment outcomes of biliary complications in post-liver transplantations. METHODS: The sample consisted of post-liver transplantation patients for endoscopic retrograde cholangiopancreatography due to suspected biliary complications. RESULTS: Fifteen patients were included (10 male, mean age of 49.57 years) and 36 endoscopic retrograde cholangiopancreatographies were undertaken (2.4/patient). Biliary stricture was diagnosed in 13 patients and endoscopic treatment was successful in 56% (38,46% still in treatment). Biliary leaks were found in one patient and dysfunction of the hepatobilliary ampulla with choledocholithiasis was diagnosed in one patient, both cured by endoscopic treatment. CONCLUSIONS: Post-liver transplantation biliary complications are relatively common and endoscopic treatment may result in satisfactory outcome. Stenosis was the more frequent complication in this series.

Reconstrução cirúrgica da estenose cicatricial de vias biliares pós-colecistectomia / Surgical reconstruction of post-cholecistectomy cicatricial biliary stenosis

OBJETIVO: Avaliar uma série de casos de estenose cicatricial de vias biliares pós-colecistectomia submetidos à reconstrução cirúrgica. MÉTODOS: Foi realizado estudo retrospectivo de 27 pacientes submetidos à reconstrução cirúrgica da via biliar por estenose cicatricial. O tipo de colecistectomia que resultou na lesão, idade e sexo, sinais e sintomas, o momento do diagnóstico, se precoce ou tardio, presença de cirurgias prévias na tentativa de reconstruir a árvore biliar, classificação das estenoses, e tipo de operação empregada para o tratamento da injúria foram analisados. RESULTADOS: Vinte e seis lesões ocorreram durante laparotomia e uma durante vídeolaparoscopia. Dezesseis pacientes (59%) tiveram as lesões diagnosticadas no transoperatório ou nos primeiros dias de pós-operatório, sete (26%) dos quais já submetidos à reoperação no hospital de origem, evoluindo mal; nove pacientes desse grupo (33%) não tinham reoperação. Onze pacientes (41%) apresentaram a forma clássica de estenose cicatricial, sem acidentes transoperatórios aparentes, com desenvolvimento de obstrução biliar tardia. Todos os pacientes foram submetidos à anastomose hepático-jejunal em "Y" de Roux, sendo que em dois casos os ductos hepáticos direito e esquerdo foram implantados separadamente na alça exclusa de jejuno. Vinte e seis pacientes (96,3%) evoluíram bem inicialmente, um paciente teve fístula biliar e foi a óbito. Uma paciente com bom resultado inicial apresentou recidiva da anastomose, cirrose secundária e está aguardando transplante hepático. CONCLUSÃO: A maioria das lesões foi diagnosticada durante a colecistectomia ou nos primeiros dias de pós-operatório, sete pacientes já tinham sido operados na tentativa de reconstruir o trato biliar. A hepaticojejunostomia em "Y" de Roux empregada mostrou-se segura e efetiva em recanalizar a via biliar a curto e longo prazos.

OBJECTIVE: To evaluate a series of cases of cicatricial stenosis of the biliary tract after cholecystectomy undergoing surgical reconstruction. METHODS: We conducted a retrospective study with 27 patients who underwent surgical reconstruction of the biliary tree for cicatricial stenosis. We analyzed the type of cholecystectomy that resulted in injury, age, gender, signs and symptoms, time of diagnosis, early or late, presence of previous surgery in an attempt to reconstruct the biliary tree, classification of stenosis and type of operation used for treatment of the injury. RESULTS: Twenty-six injuries occurred during a laparotomy and one during laparoscopy. Sixteen (59%) lesions were diagnosed intraoperatively or within the first postoperative day, seven (26%) havinh been submitted to reoperation at the local hospital, with poor results; nine patients in this group (33%) had no reoperation. Eleven patients (41%) had the classic form of cicatricial stenosis, without apparent intraoperative accidents and late development of biliary obstruction. All patients underwent Roux-en-Y hepatic-jejunal anastomosis; in two cases the right and left hepatic ducts were implanted separately in the excluded jejunal loop. Twenty-six patients (96.3%) had no early complications; one patient had biliary fistula and died. One patient presented with stenosis recurrence, secondary cirrhosis and is awaiting liver transplantation. CONCLUSION: Most injuries were diagnosed during cholecystectomy within the first postoperative days; seven patients had been reoperated in an attempt to reconstruct the biliary tract. Roux-en-Y hepaticojejunostomy proved safe and effective in draining the bile duct in the short and long term.

Infección por VIH, hígado y tracto biliar: evaluación de las complicaciones en los pacientes infectados / HIV infection, liver and biliary tract. Evaluation of complications in infected patients

Liver and biliary tract disease in patients with HIV infection is common and is related to immunosuppression, therapy and coinfection with hepatitis B and/or C virus. In this way, we can observe the development of opportunistic infections or malignancies related or not to HIV, viral hepatitis, drug toxicity, multifactorial hepatic steatosis and cirrhosis. We review each one of these complications and major clinical elements for diagnosis. Finally, an algorithm for the study of the complications of the liver and biliary tract in these patients is proposed.

La enfermedad hepática y de la vía biliar en pacientes con infección por VIH es común y se relaciona con la inmunosupresión, el tratamiento y la coinfección por virus B y/o C. De esta forma, podemos observar el desarrollo de infecciones oportunistas, neoplasias relacionadas o no a VIH, hepatitis virales, toxicidad por drogas, esteatosis hepática multifactorial y cirrosis. Revisamos cada una de estas complicaciones y los elementos clínicos más importantes para su diagnóstico. Finalmente, se propone un algoritmo de estudio de las complicaciones hepáticas y de la vía biliar en estos pacientes.

Colangiopatía asociada a SIDA: cuando la sola imagen no basta / AIDS cholangiopathy: when images in isolation are not enough

In HIV-infected patients, liver and biliary tract may be affected by different entities, such as AIDS-cholangiopathy, which is usually associated with CD4+T lymphocytes count below 100 cells/mm³ along with non-specific symptoms. Although imaging studies play a major diagnostic role they should always be evaluated according to patients clinical context. While ultrasound and CT scans provide relevant diagnostic information, specialized studies such as MRI and MRCP have become increasingly valuable due to their ability to demonstrate parietal as well as stenotic biliary changes. Despite ERCP remains the gold-standard for diagnosis of AIDS-related cholangiopathy, currently it is usually reserved to clearly exclude the presence of malignancy, or as a specific invasive therapeutic procedure, when indicated.

En pacientes infectados con VIH, el hígado y las vías biliares pueden presentar compromiso de distinta índole. Dentro de éstos, la colangiopatía asociada al SIDA se presenta con una sintomatología más bien inespecífica y habitualmente con recuentos de linfocitos T CD4 <100/mm³. En este escenario, si bien los estudios de imagen juegan un rol muy relevante, éstos siempre deben ser evaluados en relación al contexto clínico del paciente. Si bien la ecografía y la TC aportan valiosa información en el diagnóstico, en la actualidad la resonancia magnética de abdomen combinada con colangioresonancia tienen gran utilidad, por ser capaces de demostrar tanto las alteraciones parietales, como los cambios morfológicos estenóticos biliares de esta patología. Si bien la ERCP aún conserva su valor de gold standard para el diagnóstico, actualmente la tendencia se dirige a reservarla para el descarte de neoplasias, en casos dudosos o como procedimiento terapéutico invasivo específico, cuando sea indicado.

Incidencia, factores de riesgo y tratamiento de las complicaciones biliares del trasplante hepático / Biliary tract complications after liver transplantation

Biliary tract complications (BC) are cause of mortality after liver transplantation (LT). There are different treatment alternatives for this complication. Aim: to determ¨ªnate incidence, risk factors and treatment of biliary complications after LT. Materials and Methods: A retrospective descriptive cohort of patients undergoing LT between March 1994 and March 2009. Risk factors and incidence for BC were ex-plored. Also the BC impact on overall survival on LT patients was assessed. We used SPSS 15.0 for statistical analysis and considered a significant p value less than 0.05. Results: 107 LT were performed in 102 patients. In 30 (28 percent) there was some biliary complication. Ten (33.3 percent) were early complications (< 3 months) and 20 (66.7 percent) were late ( > 3 month). Anastomotic stricture was the more frequent BC. The gender male recipient, the cold ischemic time and biliary reconstruction technique without tutor were associated with an increased risk for BC. Endoscopic treatment of biliary stricture was successful in 91 percent of cases at one year follow up. Three (10 percent) patients died due to BC or their long-term treatment. Conclusions: Biliary Complications after Liver Transplantation are frequent and are cause of mortality. Decrease cold ischemic time and improve te-chniques for biliary reconstruction could reduce the high incidence of this complication.

Introducción: Las complicaciones biliares (CB) en el trasplante hepático (TH) son causa de mortalidad post-trasplante. Existen diferentes alternativas terapéuticas para su tratamiento. Objetivo: Determinar la incidencia, factores de riesgo y evaluar los resultados del tratamiento de las CB posterior al TH. Materiales y Método: Estudio retrospectivo, descriptivo de una cohorte de pacientes sometidos a un TH entre marzo-1994 y marzo-2009. Se analizó los factores de riesgo para CB, su incidencia en el tiempo, su tratamiento y se determinó su impacto en la sobrevida global de los pacientes. Se utilizó el programa SPSS 15.0 para cálculos estadísticos y se consideró significativo un p < 0,05. Resultados: Se realizaron 107 TH en 102 pacientes. En 30 (28 por ciento), se consignó una o más CB. En 10 (33,3 por ciento), la CB fue precoz y en 20 (66,7 por ciento) tardía. La estenosis de la anastomosis fue la CB más frecuente. El sexo masculino del receptor, el tiempo de isquemia fría y la técnica de reconstrucción biliar sin tutor, se asociaron significativamente a un mayor riesgo de CB. El tratamiento endoscópico de la estenosis biliar fue exitoso en el 91 por ciento de los casos a un año de seguimiento. Tres (10 por ciento) pacientes fallecieron por una CB o su tratamiento a largo plazo. Conclusiones: Las CB del TH son frecuentes y son causa de mortalidad. Disminuir el tiempo de isquemia fría y mejorar las técnicas de reconstrucción biliar podrían disminuir su incidencia.

¿Es la comunicación quisto-biliar, un factor de riesgo para el desarrollo de morbilidad postoperatoria en pacientes con hidatidosis hepática? / Intrabiliary rupture of hydatid cysts as a risk factor for postoperative complications

Background: Intrabiliary rupture is a complication of hepatic hydatid cysts. Aim: To determine if intrabiliary rupture is a risk factor for postoperative complications of hydatid cysts. Material and Methods: Prospective follow up of patients operated for hepatic hydatid cysts between 1996 and 2006. Patients were evaluated every six months during the first years and every 12 months thereafter. The presence of intrabiliary rupture was evaluated as a risk factor to develop complications during the follow up. Results: Ninety six patients with and 156 patients without intrabiliary rupture, 56 percent females, aged 42 years, were followed for a mean of 86.5 months. The overall incidence of complications was 17 percent. The incidence in patients with and without intrabiliary rupture was 9,4 and 21,8 percent respectively (p = 0.01). The bivariate analysis showed differences between patients with and without complications in leukocyte count, serum bilirubin, alkaline phosphatases, transaminases, cyst diameter, hospital stay and cyst complications. The relative risk for complications of intrabiliary rupture was 3,4 (95 percent confidence intervals 2,6-4,2). Conclusions: The presence of intrabiliary rupture of a hepatic hydatid cyst is an independent risk factor for the development of complications in the postoperative period.

Introducción: Una de las complicaciones evolutivas de la hidatidosis hepática (HH) es la comunicación quisto-biliar (CQB). El objetivo de este estudio es determinar si la CQB es un factor de riesgo para el desarrollo de morbilidad postoperatoria en pacientes con HH. Material y Método: Estudio de cohorte prospectiva. Pacientes intervenidos quirúrgicamente por HH entre 1996 y 2006 en el Hospital Regional de Temuco, Chile, con seguimiento mínimo de 12 meses y controles clínicos en los meses 1,6, 12, 24, 36, 48 y 60. La variable resultado fue "desarrollo de morbilidad postoperatoria", considerada de forma dicotómica. La variable de exposición fue presencia de CQB; analizada en forma dicotómica (CQB presente o ausente); y según el número de CQB (sin CQB, con una CQB y con dos o más CQB). El tamaño de la muestra fue estimado en base a intervalo de confianza de 95 por ciento, un poder de 80 por ciento, relación pacientes con CQB: sin CQB de 1:1; proporción de morbilidad postoperatoria en pacientes con CQB de 30 por ciento, y de 14 por ciento en pacientes sin CQB. Se utilizó estadística descriptiva, análisis bivariados y multivariados, con modelos de regresión logística ordinal; de este modo se calcularon riesgos relativos (RR) y sus respectivos intervalos de confianza del 95 por ciento (IC). Resultados: Las cohortes están compuestas por 96 pacientes sin CQB (38,1 por ciento) y 156 pacientes con CQB (61,9 por ciento). Se caracterizan por una mediana de edad de 42 años; 56,4 por ciento de género femenino, una mediana de diámetro quístico y de seguimiento de 15 cm y 86,5 meses respectivamente. Se verificó un 17,1 por ciento de morbilidad. La morbilidad del grupo sin CQB fue de 9,4 por ciento y del grupo con CQB de 21,8 por ciento (p = 0,011). Del análisis bivariado destacan diferencias entre grupos en las variables recuento de leucocitos, bilirrubina, fosfatasa alcalina, transaminasas, diámetro del quiste, estancia hospitalaria y existencia de complicación del quiste (p < 0,01). Se verificó un RR de 3,4 (IC de 2,64, 4,18) para la comparación de subgrupos sin CQB o con dos o más CQB (p < 0,001). Conclusión: La presencia de dos o más CQB constituye un factor de riesgo para el desarrollo de morbilidad postoperatoria en pacientes con HH.

Manejo mínimamente invasivo de lesión de vía biliar / Minimaly invasive management of bile duct injuries

La colecistectomía laparoscópica presenta una mayor incidencia de lesión de vía biliar que la técnica abierta. Esta complicación tiene una baja incidencia, por lo que su manejo no ha podido estandarizarse. Se presenta un caso clínico con el objetivo de dar a conocer la conducta quirúrgica tomada frente a una paciente que cursó con lesión de vía biliar tipo D de Strasberg secundaria a una colecistectomía laparoscópica, siendo reparada por esta misma vía. Además se realizara una revisión de dicha complicación, poniendo énfasis en su clasificación, prevención, factores asociados y tratamiento, con el fin de proponer una pauta de manejo.

Gastrointestinal problems at high altitude.

Gastrointestinal (GI) problems at high altitude are commonplace. The manifestations differ considerably in short-term visitors, long-term residents and native highlanders. Ethnic food habits and social norms also play a role in causing GI dysfuntion. Symptoms like nausea and vomiting are common manifestations of acute mountain sickness and are seen in 81.4% short-term visitors like mountaineers. Anorexia is almost universal and has a mutifactorial causation including effect of hormones like leptin and cholecystokinin and also due to hypoxia itself. Dyspepsia and flatulence are other common symptoms. Diarrhoea, often related to poor hygiene and sanitation is also frequently seen especially among the short-term visitors. Peptic ulceration and upper gastro-intestinal haemorrhage are reported to be common in native highlanders in the' Peruvian Andes (9.6/10000 population per year) and also from Ladakh in India. A hig h incidence o f gastriccarcinoma is also reported, especially from Bolivia (138.2 cases per 10000 population per year). Megacolon and sigmoid volvulus are common lower GI disorders at high altitude. The latter accounted for 79% of all intestinal obstructions at a Bolivian hospital. Thrombosis of the portosystemic vascultature and splenic hematomas has been reported from India. Malnutrition is multifactorial and mainly due to hypoxia. Fat malabsorption is probably significant only at altitudes > 5000m. Neonatal hyperbilirubinemia was found to be four times more common in babies born at high altitude in Colorado than at sea level. Gall stones disease is common in Peruvian highlands. A high seroprevalence of antibodies to H pylori (95%) has been found in Ladakh but its correlation to the prevalence of upper gastro-intestinal disease has not been proven.

Anatomia das vias biliares em doadores e receptores de transplante hepático inter vivos / Study of biliary anatomy in living related liver transplantation / Study of biliary anatomy in living related liver transplantation

RACIONAL: Variações anatômicas das vias biliares são freqüentes e aumentam as complicações dos transplantes hepáticos. OBJETIVO: Avaliar a anatomia das vias biliares nos doadores e receptores do transplante hepático inter vivos realizados no Hospital de Clínicas da Universidade Federal do Paraná e do Hospital Nossa Senhora das Graças de Curitiba, Curitiba, PR. CASUíSTICA E MÉTODOS: A avaliação foi retrospectiva de março de 1998 até setembro de 2002 (23 transplantes), quando os dados passaram a ser captados de forma prospectiva (17 transplantes), até agosto de 2003. Foram obtidos dados de 80 pacientes consecutivos (40 doadores e 40 receptores), submetidos a transplante hepático inter vivos, sendo 32 transplantes com receptor adulto e 8 transplantes pediátricos (receptor com idade inferior a 15 anos). Entre os 80 pacientes incluídos no estudo, 51 eram do sexo masculino (27 receptores e 24 doadores) e 29 do feminino (13 receptores e 16 doadores). A idade média dos doadores foi de 32,6 anos e a dos receptores de 36,3 anos. RESULTADOS: Nas cirurgias de captação do lobo hepático direito, a via biliar direita foi única em 25 entre 29 casos (86,2 por cento), dupla em dois (6,9 por cento) e tripla em dois (6,9 por cento). Nos oito casos em que o setor lateral esquerdo ou o lobo hepático esquerdo foram captados, a via biliar foi única. Entre os 33 pacientes submetidos a colangiografia por ressonância magnética, variações foram verificadas em três pacientes (9,1 por cento), sendo a mais comum o ducto biliar posterior direito tributário do ducto hepático esquerdo (6,06 por cento; n = 2). CONCLUSÃO: A prevalência de anomalias biliares nos transplantes inter vivos de fígado é elevada e algumas não são diagnosticadas com os exames de imagem pré-operatórios.

BACKGROUND: Anatomic variations of the biliary tree are frequent and increase complications after liver transplantation. AIM: To describe the anatomy of the bile ducts of donors and recipients of living related liver transplantation. METHODS: From March 1998 to September 2002, the study was retrospective (23 transplantations). From October 2002 to August 2003, the study was prospective (17 transplantations). We studied the hepatic anatomy of 80 consecutive patients (40 donors and 40 recipients) of the living-related liver transplantation program of the "Hospital de Clínicas da Universidade Federal do Paraná" and the "Hospital Nossa Senhora das Graças", Curitiba, PR, Brazil; 51 were male (27 recipients 24 donors) and 29 female (13 recipients and 16 donors). The median age among the donors was 32.6 years and among the recipients was 36.3 years. Thirty-two recipients were adults and 8 recipients were under 15 years old. The bile duct anatomy was studied by magnetic resonance cholangiography in 33 patients, and anomalies were seen in 3 of them (9.1 percent). RESULTS: The most prevalent variation of bile ducts was the fusion of the right posterior duct with the left duct (6.06 percent; n=2). In the 40 harvesting operations, the right bile duct was single in 25 patients (87.5 percent), among the 32 right-lobe donors, double in 2 (6.25 percent) and triple in 2 (6.25 percent). All of the eight left livers procured had single bile ducts. Among the 40 recipients, the common bile duct was bifurcated in 2 of them (5 percent). CONCLUSION: The prevalence of biliary anomalies is high in patients subjected to living liver transplantation and some anomalies are not diagnosed with preoperative imaging exams.

Endoscopic management of post-cholecystectomy bile leak

Endoscopic management of post cholecystectomy biliary leak is described in a 56-year-old patient who developed a cystic duct leak following open cholecystectomy

Biliary mishaps in laparoscopic cholecystectomy.

AIM: To determine the incidence and types of biliary complications following laparoscopic cholecystectomy in our patients. METHODS: The clinical records of one hundred and fifty-five patients undergoing laparoscopic cholecystectomy were reviewed. RESULTS: Five patients developed biliary mishaps. The overall incidence of biliary complications was 3.2% (5/155). The incidence of major complications was 1.9% (3/155) and the incidence of minor biliary complications was 1.2% (2/155). In 3 out of 5 patients the mishap was attributed to developmental anomalies. Dense pericholecystic adhesions and cystic duct blow out were responsible for biliary complications in one patient each. Bilioenteric anastomosis was performed in two patients and restoration of continuity of the common hepatic duct over a T-tube was done in one patient. Side hole in an accessory duct was repaired over a T-tube and cystic duct blow out was managed with endoscopic biliary drainage alone. CONCLUSIONS: A high index of suspicion of developmental anomalies, cautions approach in difficult cases and readiness to consider conversion to open cholecystectomy are recommended to reduce the incidence of biliary complications in laparoscopic cholecystectomy.

Hepatobiliary abnormalities and parenteral nutrition.

Hepatobiliary dysfunctions (TPN-HBD) occur during parenteral nutrition. In older children these are usually reversible whereas in newborns and infants these hepatobiliary abnormalities play a significant role in the morbidity. Cholestasis is a commonly occurring TPN-HBD. It correlates directly with the decreasing gestational age, low birth weight and increasing duration of TPN therapy. The pathogenesis of cholestasis of TPN is multifactorial and predisposed by necrotising enterocolitis, sepsis, cardiac failure, shock, and hypotension. Diagnosis is made with exclusion of other causes of direct hyperbilirubinemia. Most TPN-HBD appear within 4 weeks of starting of TPN but severe complications manifest usually after the 16th week. Histologically there is intralobular cholestasis. In few cases there may be severe portal fibrosis followed by development of micronodular biliary cirrhosis. Enteral starvation, defective bile acid carriers, hypercaloric TPN are the major factors responsible for TPN-HBD, including cholestasis. Biliary complications of TPN-HBD are acalculous, cholecystitis, and cholelithiasis. Bile stasis is a major pathological factor for these. If the calories are provided only by glucose or glucose-containing electrolyte solutions it may lead to cholestasis and other TPN-HBD. Even small oral alimentation (continuous or bolus) during TPN, prevent TPN-HBD. Choleretic agents have been useful in the prevention and management of cholestasis and other parenteral nutrition induced hepatobiliary abnormalities.