Can occult cystobiliary fistulas in hepatic hydatid disease be predicted before surgery?

BACKGROUND: Biliary fistulas because of the cystobiliary communication is the most frequent and undesirable postoperative complication of hepatic hydatid surgery. We aimed to identify the predicting factors of the occult cystobiliary communication in this study. METHODS: The patients who underwent surgical treatment for hepatic hydatid disease between 2003 and 2008 were reviewed retrospectively. The patients who had jaundice history, preoperative high total bilirubin and direct bilirubin levels, dilated bile duct in preoperative radiologic imagings were not included the study. Patients were divided into two groups: group A; without postoperative biliary fistula, group B; with biliary fistula. The two groups were compared according to preoperative descriptive findings, cystic specialties, and laboratory findings. RESULTS: There were 53 patients and 15 patients in groupA and groupB, respectively. The 20 (37.7%) of 53 patients were male in group A and the 10 (66.7%) patients were male in group B (p<0.05). The age, number of cysts, Garbi scores of cysts, the rate of recurrent cysts, the level of preoperative bilirubin, alkalene phosphatase, and transaminases were similar in both groups (p>0.05). GGT was significantly different between two groups (p<0.05). The cystotomy + drainage, cystotomy + omentopexy, and intracystic biliary suture rates were similar in both groups. Postoperative non biliary complications were determined in 4 (7.5%) patients in group A and 7 patients (46.7%) in group B (p<0.05). Hospital stay was longer in group B significantly (p<0.05). CONCLUSIONS: In conclusion, GGT as a laboratory [corrected] test for predicting occult CBC preoperatively have been shown to be useful in the clinical practice. However, larger prospective studies are needed on this subject. Occult cysto-biliary fistulas can only be exposed during surgery when suspected by a surgeon. If occult CBC is found, the opening in the biliary system should be sutured with absorbable material, with or without cystic duct drainage. If no biliary opening is found, cystic duct drainage may be performed if preoperative factors predict the presence of CBC. As the development of external biliary fistulas increases the morbidity and the hospitalization period, novel surgical methods to prevent the development of bile fistulas are required in such patients.

Bilhemia: a fatal complication following percutaneous placement of a transhepatic inferior vena cava catheter in a child.

A transhepatic central venous catheter was implanted in a 2-year-old child with a history of multiple venous access procedures and superior and inferior vena cava thrombosis. After 2 weeks, inadvertent dislodgement of the catheter was complicated by a biloma. The biloma was percutaneously drained, but a biliary-venous fistula led to a rapidly progressive and fatal bilhemia. We report this case as an infrequent complication of transhepatic catheterization.

Low serum albumin is not a contraindication for early iatrogenic bile duct injury repair.

UNLABELLED: Most iatrogenic bile duct injuries are recognized in the early postoperative period (first 48 hours). These patients usually have additional complications such as a suboptimal hydroelectrolitic status, subhepatic collections, external biliary fistula and malnutrition. In these circumstances, besides the elevation of bilirubin and transaminases associated with the injury, hypoalbuminemia is frequently encountered. The timing for repair is decided according to the condition of each patient. We report the impact of preoperative abnormal low serum albumin levels on the results of biliary tract reconstruction after a iatrogenic biliary lesion. METHOD: Patients who underwent biliary reconstruction in our center from 1998 to 2002 were analyzed. Only patients with complex injuries (Strasberg E, Bismuth III-IV, Stewart-Way III) were included. Major postoperative complications were recorded and correlated with preoperative liver function tests. RESULTS: Seventy seven patients were analyzed. In 41 cases, the injury was a consequence of a laparoscopic operation. All patients were treated by a Roux-en-Y hepatojejunostomy. No operative mortality was recorded. The most frequent postoperative complications were postoperative biliary fistula (8/77-9%, p < 0.017) and subhepatic collections (9/77-9%, p < 0.39). All fistulae closed spontaneously and the subhepatic collections were drained. Overall, complications were more common in the group with hypoalbuminemia (p < 0.002). CONCLUSION: Early repair is indicated if there is no systemic contraindication (sepsis, multiple organic failure, electrolytic imbalance). Abnormalities in the liver function tests, particularly a low serum albumin, should not delay the operation. Although significantly more postoperative complications are observed in an early repair, long-term results are comparable to those of an elective repair.

[Endoscopic diagnosis and treatment of non-traumatic bilhemia. A case report]. / Diagnóstico endoscópico y tratamiento de bilhemia de origen no traumática. Reporte de un caso.

Biliovascular fistulas are abnormal communications with two types of clinical manifestations depending on type of flow in fistulous tract: 1) hemorrhage into biliary tract known as hemobilia, or 2) bile into bloodstream, known as bilhemia. Historically, this complication has been treated with surgery; however, technological progress at present allows treatment with intervention techniques without surgery being mandatory. In 1975, Clemens and Wittrin introduced the term bilhemia, a rare complication of hepatic damage producing excessively high levels of serum bilirubin and moderate rise of hepatic enzymes secondary to post-traumatic intrahepatic biliovenous fistula. Although this pathology is rare, it is considered dangerous; of 50 patients reported in the literature, 25 died due to this problem. The main purpose of treatment is to release tract obstruction by endoscopic sphincterotomy of Vater's papilla or, if the process is localized in proximal areas of biliary tract, through percutaneous biliary drainage or preferably nasobiliary drainage with continuous suction. This procedure can at least produce temporary relief and occasionally fistula closure. A longer effect can be achieved with biliary stent placement. We describe what is, to our knowledge, the first case of diagnosis and successful treatment of non-traumatic bilhemia with endoscopic sphincterotomy and nasobiliary catheter placement.

Cholesterol kinetics in subjects with bile fistula. Positive relationship between size of the bile acid precursor pool and bile acid synthetic rate.

Our aim was to identify and quantitate cholesterol pools and transport pathways in blood and liver. By studying bile fistula subjects, using several types of isotopic preparations, simultaneous labeling of separate cholesterol pools and sampling all components of blood and bile at frequent intervals, we developed a comprehensive multicompartmental model for cholesterol within the rapidly miscible pool. Data in six components (bile acids, esterified cholesterol in whole plasma, and free cholesterol in blood cells, bile, alpha lipoproteins, and beta lipoproteins) were modeled simultaneously with the SAAM program. The analysis revealed extensive exchange of free cholesterol between HDL and liver, blood cells, and other tissues. There was net free cholesterol transport from HDL to the liver in most subjects. The major organ that removed esterified cholesterol from blood was the liver. A large portion (4,211 mumol) of total hepatic cholesterol comprised a pool that turned over rapidly (t1/2 of 72 min) by exchanging mainly with plasma HDL and was the major source of bile acids and biliary cholesterol. Only 6% of hepatic newly synthesized cholesterol was used directly for bile acid synthesis: the analysis showed that 94% of newly synthesized cholesterol was partitioned into the large hepatic pool (putative plasma membrane free cholesterol) which exchanged rapidly with plasma lipoproteins. Bile acid synthetic rate correlated directly with the size of the large hepatic pool. In conclusion, hepatic and blood cholesterol pools and transports have been quantitated. HDL plays a central role in free cholesterol exchange/transport between all tissues and plasma. In humans, the metabolically active pool comprises a large portion of total hepatic cholesterol that, in part, regulates bile acid synthesis.

Impaired response to alloantigens in murine biliary obstruction.

Male Lewis strain rats underwent bile duct ligation and division (BDL), selective hepatic duct ligation (SHL), simple ligation and recanalization (RCN), or sham celiotomy (SC). Unoperated rats served as normal controls (NC). At intervals of 1, 2, and 3 weeks postoperatively, the popliteal lymph node assay was used to study host versus graft (HVG) response. LBN-F1 splenocytes (5 x 10(6)) were injected into the hind foot pads, and the contralateral foot pad was injected with medium as a control. The popliteal lymph nodes were removed and weighed 7 days later. In the BDL group, HVG response was significantly impaired at 1 (BDL, 12.9 +/- 5.1 mg; SC, 21.6 +/- 2.6; NC, 22.4 +/- 9.4; P < 0.005, BDL vs SC or NC), 2 (BDL, 12.6 +/- 5.6; SC, 19.1 +/- 3.0; NC, 15.8 +/- 5.8; P < 0.001, BDL vs SC), and 3 weeks (BDL, 8.9 +/- 3.9; SC, 21.7 +/- 6.3; NC, 16.7 +/- 3.8; P < 0.001, BDL vs SC or NC). SHL did not cause hyperbilirubinemia or impair the HVG response at 2 weeks (SHL, 17.2 +/- 4.5; NC, 16.7 +/- 7.4). The serum bilirubin was normal 2 and 3 weeks after RCN, and the HVG response was normal in both groups; however, the HVG response was somewhat lower at 2 weeks (RCN, 12.1 +/- 2.1) than at 3 weeks (RCN, 18.2 +/- 4.4; P < 0.01, RCN 2 weeks vs RCN 3 weeks). BDL causes significant impairment in the murine response to alloantigens as measured by the popliteal lymph node assay.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of cyclosporine and steroids on canine bile flow.

Cyclosporine and hydrocortisone are the main immunosuppressants used in transplant surgery. The purpose of this study was to determine the effect of intravenous administration of cyclosporine and hydrocortisone on bile flow in dogs. Cyclosporine in doses of 0.5, 1.0 and 1.5 mg.kg-1.hr-1 were administered along with 18 mumol/min intravenous sodium taurocholate to dogs with chronic biliary and gastric fistulas. Bile volume and bile chloride concentration and output were increased by cyclosporine in a dose-related manner, whereas bile salt concentration decreased and bile salt output was unchanged. Hydrocortisone produced small but significant increases in bile flow only at the highest dose of hydrocortisone administered. Subsequently, experiments were performed when sodium taurocholate was administered in progressively increasing doses (9, 18 and 36 mumol/min), with the dose changed every hour. Bile volume, [14C]erythritol clearance in bile and bile salt concentrations were measured with and without cyclosporine and hydrocortisone administration. Cyclosporine increased the bile salt-independent fraction of canalicular bile flow and ductular bile flow. Experiments evaluating the role of the cyclosporine carrier polyoxyethylated castor oil (Cremophor EL) demonstrated that this substance had no independent choleretic activity, whereas cyclosporine dissolved in ethanol and administered without Cremophor EL significantly increased bile flow. The results of this study indicate that cyclosporine stimulates chloride-rich choleresis independent of bile salt secretion.

Morphologic and biochemical changes in dogs after portacaval shunt plus bile fistula or ileal bypass: failure of bile fistula or ileal bypass to prevent hepatocyte atrophy.

External biliary fistula (BF) or ileal bypass (IB) was performed in dogs at the time of or 2 weeks after portacaval shunt (PCS). The pathologic changes in the dog livers 2 to 4 weeks later were compared to those caused by PCS alone. Histopathologic differences between PCS alone vs. PCS plus BF or IB could not be found. Thus, the experiments did not confirm recent observations by others in rats that BF prevents or reverses the hepatic injury of PCS. As estimated by plasma mevalonic acid determinations, the increase in hepatic cholesterol synthesis that is characteristic after BF or IB was suppressed in animals with PCS. BF and IB reduced but did not eliminate the postprandial elevation in serum bile acid that occurs after PCS. The findings have possible relevance in planning the treatment of patients with familial hypercholesterolemia with the combined use of PCS and IB.

Multicompartmental analysis of cholesterol metabolism in man. Quantitative kinetic evaluation of precursor sources and turnover of high density lipoprotein cholesterol esters.

The purpose of this study is to delineate the immediate sources and fractional turnover of high density lipoprotein (HDL) esterified cholesterol in man. Various labeled preparations were administered in 11 experiments to six subjects who had either a complete bile fistula (maximally stimulated cholesterol metabolism) or an intact enterohepatic circulation. The administered tracers included [(3)H]mevalonic acid; [(14)C]cholesterol bound to albumin; low density lipoprotein (LDL) free [(3)H] or [(14)C]cholesterol; HDL free [(3)H] or [(14)C]cholesterol; HDL esterified [(3)H]cholesterol; and LDL esterified [(3)H]cholesterol. Blood samples were obtained at frequent intervals for up to 5 d after the administration of tracers. The mass and radioactivity in individual plasma lipoprotein (very low density lipoprotein [VLDL], HDL, and LDL) free and esterified cholesterol were determined. The data were subjected to multicompartmental analysis using the SAAM-27 computer program. The analysis revealed that plasma free cholesterol was not the only immediate source of either a single- or two-compartment HDL ester system. When LDL esters and plasma (HDL) free cholesterol were tested together as sources of one HDL ester compartment, data from all the experiments were readily fit. The fluxes arrived at with the final model indicated that only approximately 20% of the esterified cholesterol in HDL was newly synthesized from plasma (HDL) free cholesterol (2.36 mumol/min); the remaining 80% was from LDL ester (8.92 mumol/min). The presence of a bile fistula had no obvious effect on HDL esterified cholesterol metabolism. The rate of HDL cholesterol ester turnover was 3-12 times/d, indicating that the ester component of the HDL particle is in a very dynamic state.