The outcome of endoscopic management of bile leakage after hepatobiliary surgery

BACKGROUND/AIMS: Despite improvements in surgical techniques and postoperative patient care, bile leakage can occur after hepatobiliary surgery and may lead to serious complications. The aim of this retrospective study was to evaluate the efficacy of endoscopic treatment of bile leakage after hepatobiliary surgery. METHODS: The medical records of 20 patients who underwent endoscopic retrograde cholangiopancreatography because of bile leakage after hepatobiliary surgery from August 2009 to September 2014 were reviewed retrospectively. Endoscopic treatment included insertion of an endoscopic retrograde biliary drainage stent after endoscopic sphincterotomy. RESULTS: Most cases of bile leakage presented as percutaneous bile drainage through a Jackson-Pratt bag (75%), followed by abdominal pain (20%). The sites of bile leaks were the cystic duct stump in 10 patients, intrahepatic ducts in five, liver beds in three, common hepatic duct in one, and common bile duct in one. Of the three cases of bile leakage combined with bile duct stricture, one patient had severe bile duct obstruction, and the others had mild strictures. Five cases of bile leakage also exhibited common bile duct stones. Concerning endoscopic modalities, endoscopic therapy for bile leakage was successful in 19 patients (95%). One patient experienced endoscopic failure because of an operation-induced bile duct deformity. One patient developed guidewire-induced microperforation during cannulation, which recovered with conservative treatment. One patient developed recurrent bile leakage, which required additional biliary stenting with sphincterotomy. CONCLUSIONS: The endoscopic approach should be considered a first-line modality for the diagnosis and treatment of bile leakage after hepatobiliary surgery.

Multiple Metastatic Infection Related to Arteriovenous Graft Infection in an ESRD Patient on Hemodialysis / 대한신장학회지

Arteriovenous vascular access infection associated with S. aureus bacteremia may cause metastatic complications, which relate to a poor outcome especially if proper diagnosis and treatment are delayed. We report a case of a 61-year-old male patient on maintenance hemodialysis who developed multiple metastatic infections associated with arteriovenous graft infection caused by methicillin-resistant Staphylococcus aureus (MRSA). At 7th hospital day, multiple metastatic infections, including osteomyelitis of clavicle, vertebral osteomyelitis, and tendinitis of the 5th finger proximal interphalangeal joint, were diagnosed by CT of chest, ultrasonography of hands, and whole body bone scan. Infected arteriovenous graft was removed and antibiotics was administrated for 18 weeks. Thereafter, MRSA bacteremia and clinical symptoms and signs related to metastatic infections were improved.

Delayed Recovery of Sedation by Continuous Midazolam Infusion in an ESRD Patient on Peritoneal Dialysis: A Case Report / 대한신장학회지

Midazolam, a benzodiazepine derivatives, is widely used in intensive care unit for sedation of patients who require mechanical ventilation. Although midazolam has a short acting time, it might cause a prolonged sedation, especially in patients with renal failure. We report the case of a 76-year-old man who received peritoneal dialysis and showed prolonged sedation after stopping continuous infusion of midazolam. The patient who has received maintenance hemodialysis for five months admitted in intensive care unit to manage pneumonia and severe congestive heart failure. In ICU, hemodialysis was transferred to peritoneal dialysis due to severe cardiac dysfunction. He was treated with mechanical ventilation under sedation with midazolam. However, even though stopping midazolam, deep sedation by midazolam was not restored. The patient completely recovered from sedation after 280 hours.

Comparison of Once-Biweekly Administration of Epoetin-alpha with Darbepoetin-alpha in Chronic Kidney Disease Patients Not Receiving Dialysis / 대한신장학회지

PURPOSE: It is very important to correct renal anemia by erythropoiesis stimulating agents (ESA) because anemia is associated with poor outcomes in chronic kidney disease (CKD) patients. We investigated whether once-biweekly (Q2W) treatment with epoetin-alpha (EPO-alpha) is as effective as Q2W darbepoetin-alpha (DA-alpha) in CKD patients who are not on dialysis. METHODS: Fifteen CKD patients not receiving dialysis with renal anemia (M:F 6:9, age 60.1+/-7.2 years, eGFR-MDRD 15.7+/-6.4 mL/min/1.73m2, DM 46.7%) were enrolled. All patients received Q2W subcutaneous DA-alpha (40 microgram) for 10 weeks. After 6 weeks of wash-out period, patients were switched to Q2W subcutaneous EPO-alpha (10,000 IU) for 10 weeks. RESULTS: There were no significant differences in baseline parameters, such as hemoglobin (Hb), serum ferritin, and transferrin saturation, between before DA-alpha therapy and before EPO-alpha therapy. Hb levels significantly increased after completion of ESA therapy (DA-alpha, 9.8+/-0.4 vs. 10.4+/-0.6 g/dL, p=0.001; EPO-alpha, 9.6+/-0.7 vs. 10.2+/-0.4 g/dL, p=0.003). After completion of ESA therapy, Hb levels did not reveal significant differences between two groups (p=0.123). Erythropoietin resistance index (8.2+/-1.6 vs. 8.4+/- 1.5 IU/kg weight/g hemoglobin/week, p=0.136) and % increase of Hb (106.7+/-5.5 vs. 106.8+/-6.4%, p=0.776) were not significantly different between DA-alpha therapy and EPO-alpha therapy. There were no significant adverse effects observed during study periods. CONCLUSION: These findings indicate that Q2W high dose (10,000 IU) of EPO-alpha therapy in CKD patients who are not on dialysis may be effective in maintaining Hb levels as Q2W DA-alpha therapy.