Severe complications of chronic cholelithiasis treatment.

BACKGROUND: Gallstone disease is a burden affecting about 15% percent of the population around the world. The complications of gallstone disease are numerous and many require emergency care. Severe complications are not uncommon and require special attention, as lethal outcome is possible. CASE PRESENTATION: We present a retrospective analysis of eight cases describing severe complications of gallstones in patients undergoing endoscopic treatment of chronic gallstones conditions. All patients were admitted to our emergency care department following symptoms onset. The diagnostic difficulties, treatment strategies and outcomes are presented. The associated risk factors and preventative measures are discussed. Two patients developed profuse bleeding, two developed acute pancreatitis, two patients had perforation related complications. One rare case of bilioma and one case of iatrogenic injury are presented. All patients had severe condition, in two cases lethal outcome was a result of co-morbidity and difficulties in management. CONCLUSION: Special care should be taken in patients with risk factors of severe complications in order to improve outcome and prevent the development of life-threatening conditions.

Hepato-bronchial fistula secondary to perforated sigmoid diverticulitis: a case report.

BACKGROUND: Patients with diverticulitis are predisposed to hepatic abscesses via seeding through the portal circulation. Hepatic abscesses are well-documented sequelae of diverticulitis, however instances of progression to hepato-bronchial fistulization are rare. We present a case of diverticulitis associated with hepatic abscess leading to hepato-bronchial fistulization, which represents a novel disease course not yet reported in the literature. CASE PRESENTATION: A 61-year-old Caucasian man presented with a history of unintentional weight loss and dyspnea both at rest and with exertion. He had a significant tobacco and alcohol misuse history. A massive right-sided pleural effusion was found on chest X-ray, which responded partially to chest tube insertion. A computed tomography scan of his thorax confirmed the presence of innumerable lung abscesses as well as a complex pleural effusion. An indeterminate tiny air pocket at the dome of the liver was also noted. A follow-up computed tomography scan of his abdomen revealed a decompressed hepatic abscess extending into the right pleural space and the right lower lobe. A sigmoid-rectal fistula was also revealed with focal colonic thickening, presumed to be the sequelae of remote or chronic diverticulitis. An interventional radiologist inserted a percutaneous drain into the decompressed hepatic abscess and the instillation of contrast revealed immediate filling of the right pleural space, lung parenchyma, and bronchial tree, confirming a hepato-bronchial fistula. After two concurrent chest tube insertions failed to drain the remaining pleural effusion completely, surgical lung decortication was conducted. Markedly thickened pleura were seen and a significant amount of gelatinous inflammatory material was debrided from the lower thoracic cavity. He recovered well and was discharged 10 days post-thoracotomy on oral antibiotics. The percutaneous liver abscess tube was removed 3 weeks post-discharge from hospital after the drain check revealed that the fistula and abscess had entirely resolved. CONCLUSIONS: Refractory right-sided pleural effusion combined with constitutional symptoms should alert clinicians to search for possible hepatic abscess, especially in the context of diverticulitis. The rupture of an untreated hepatic abscess could lead to death from profound sepsis or rarely, as in this case, a hepato-bronchial fistula. Timely investigation and a multidisciplinary treatment approach can lead to improved patient outcomes.

[Vacuum-therapy for complicated anterior abdominal wall wounds and intestinal fistulas in children].

AIM: To present results of VAC application in children with complicated wounds of anterior abdominal wall combined with intestinal and/or biliary fistulas. MATERIAL AND METHODS: For the last 7 years 8 patients aged from 1.5 months to 15 years with infected postoperative wounds of anterior abdominal wall complicated by intestinal fistulas (6), biliary and intestinal fistulas (1) and biliary fistula (1) have been treated at the surgical department №2 of Russian Children's Clinical Hospital. All patients received complex medical therapy and local VAC-therapy. RESULTS: Granulation and wound's size reduction were observed within first 7 days of VAC-therapy application in 5 (62.5%) children. In 4 (50%) patients at least 1 intestinal fistula has been closed in 15 days after VAC-therapy initiation on the average (range 7--24). Closure of all fistulas and wounds healing were observed in all patients in 28 days (range 16--42) after VAC-therapy initiation on the average. CONCLUSION: VAC-therapy is safe and effective treatment of complicated wounds of anterior abdominal wall combined with intestinal and/or biliary fistulas in children.

Early precut fistulotomy for biliary access: time to change the paradigm of "the later, the better"?

BACKGROUND: The precut timing during the biliary cannulation algorithm is a subject of controversy. Some studies suggest that early institution of precut is a safe and effective strategy even though the extent to which this approach may affect the duration of the ERCP is seldom addressed. OBJECTIVE: To assess the success, safety, and procedure duration of an early precut fistulotomy (group A) versus a classic precut strategy after a difficult biliary cannulation (group B). DESIGN: Single-center, prospective cohort study. SETTING: University-affiliated hospital. PATIENTS: A total of 350 patients with a naïve papilla. INTERVENTIONS: Standard biliary cannulation followed by needle-knife fistulotomy (NKF). MAIN OUTCOME MEASUREMENTS: Biliary cannulation rate, NKF success, adverse events, and ERCP duration. RESULTS: The overall cannulation rate was similar, at 96% and 94% for groups A and B, respectively. The adverse event rate was 6.2% and 6.4%, respectively, with pancreatitis as the most frequent adverse event (group A, 3.9%; group B, 5.2%). The mean ERCP duration was, however, significantly shorter in group A, both when biliary cannulation was achieved without precutting (14 minutes vs 25 minutes, P < .001) as well as when biliary cannulation was attempted after NKF (18 minutes vs 31 minutes, P < .0001). LIMITATIONS: Single-center study design, referral center. CONCLUSIONS: If the endoscopist is experienced in ERCP and precut techniques, an early precut strategy should be the preferred cannulation strategy because this approach is as safe and effective as the late fistulotomy approach and substantially reduces ERCP duration.

Cysto-biliary communication in liver hydatidosis.

BACKGROUND: Liver hydatidosis is a severe health problem in endemic areas. Due to migration from these countries to other zones, now it is a worldwide problem. Liver hydatidosis can provoke many complications (abscess, fistula to adjacent organs, migration, etc.), but the most frequent and one of the most severe complication is the communication between the cyst and the biliary tree. AIM: The aim of this study is to perform a review on the epidemiology, clinical features, diagnostic methods, and therapeutic options to treat the communication between the cyst and the biliary tree. RESULTS: Due to the lack of randomized clinical trial or meta-analysis on this topic, we performed a classical review and included our personal algorithm. CONCLUSIONS: The communication between the cyst and the biliary tree varies from a small communication to a frank intrabiliary rupture. The percentage of patients with the communication between the cyst and the biliary tree is not well known because there is no accepted definition. The therapeutic options are multiple and related to the size of the communication, the location of the cyst, and the experience of the hepatobiliary surgeon. ERCP is now an important tool for the treatment of the communication between the cyst and the biliary tree.

Utilización de prótesis metálicas autoexpandibles totalmente recubiertas en procesos biliares benignos / No disponible

Introducción y objetivo: las prótesis metálicas autoexpandibles biliares (PMAB) tienen la ventaja de introducirse plegadas con calibres muy pequeños y proporcionar, al abrirse completamente, diámetros grandes para el drenaje biliar. Su utilización en procesos benignos ha estado muy limitada, fundamentalmente por la dificultad en su extracción. Presentamos nuestra experiencia inicial con una PMAB totalmente recubierta (Wallflex) para tratar patología benigna de la vía biliar. Pacientes y métodos: en un estudio descriptivo prospectivo se insertaron por CPRE prótesis de 8 mm de diámetro y 4, 6 u 8 cm de longitud, cuando se consideró que para el drenaje biliar eran precisos diámetros superiores a 10 french (3,3 mm). Las prótesis se retiraron también por endoscopia varios meses después según se consideró oportuno clínicamente. Resultados: se insertaron 20 PMAB. Los motivos fueron: gran fístula biliar intrahepática tras cirugía de quiste hidatídico (1), perforación del área papilar por esfinterotomía endoscópica (2), recanalización de prótesis no recubiertas insertadas en procesos benignos (3), estenosis benignas (7), coledocolitiasis múltiples y de gran tamaño con afilamiento-estenosis del colédoco distal que no pudieron extraerse (7). En todos los casos se logró un drenaje biliar satisfactorio y no se produjeron complicaciones por la inserción. Las prótesis se extrajeron con facilidad a los 132 días de media (36-270). La resolución completa de los procesos se obtuvo en 14 pacientes (70%). Conclusiones: en nuestra experiencia inicial, la prótesis Wallflex biliar totalmente recubierta pudo extraerse sin complicaciones tras permanecer en el colédoco hasta una media de más de cuatro meses, por lo que podría utilizarse en el tratamiento de procesos biliares benignos(AU)

Background and aim: biliary self-expanding metal stents (SEMS) have the advantage of being inserted undeployed with very small sizes and provide, when fully opened, large diameters for biliary drainage. However, their use in benign conditions has been very limited, mainly because of difficulty in their extraction. We present our initial experience with a fully covered SEMS (Wallflex) for the management of benign problems of the bile duct. Patients and methods: in a prospective study, stents of 8 mm in diameter and 4, 6 or 8 cm long were inserted by means of ERCP. These SEMS were chosen when according to medical judgement it was thought that diameters greater than 10 French (3.3 mm) were needed for proper biliary drainage. Stents were extracted also endoscopically, several months later when deemed clinically appropriate. Results: twenty biliary SEMS were inserted. Reasons for insertion were: large intrahepatic biliary fistula after hydatid cyst surgery (1), perforation of the papillary area following endoscopic sphincterotomy (2), coaxial insertion to achieve patency in obstructed uncovered stents inserted in benign conditions (3), benign strictures (7), multiple and large common bile duct stones that could not be extracted because of tapering and stricturing of the distal common bile duct (7). In all cases, successful biliary drainage was achieved and there were no complications from insertion. Stents were easily extracted after a mean time of 132 days (36- 270) in place. Complete resolution of biliary problems was obtained in 14 patients (70%). Conclusions: in our initial experience, the fully covered Wallflex biliary stent was removed without any complication after being in place in the common bile duct for a mean time of over four months. Therefore, it could be used in the management of benign biliary conditions(AU)

Bronchobiliary fistula: an anesthetic challenge!

A case of bronchobiliary fistula is reported in an adult following liver laceration repair. Since patients with bronchobiliary fistula usually have poor lung condition preoperatively, perioperative respiratory management and intraoperative double-lumen tube insertion assists in the management of these patients.

Detection of a suspected bronchobiliary fistula by hepatobiliary scintigraphy.

Bronchobiliary fistula (BBF) represents a rare but severe complication in patients affected by liver metastases. Although a clinical suspicion can arise when specific clinical signs, in particular biliptysis, are present, conventional imaging modalities often fail to confirm the diagnosis. We present a case of a patient affected by colon cancer with liver metastases previously treated with partial right-sided hepatectomy and multiple thermo-ablative treatments combined with chemotherapy, who manifested a septic fever associated with productive cough and biliptysis. Diagnosis of BBF was confirmed only by hepatobiliary scintigraphy with (99m)Tc-heptoiminodiacetic acid.

Fístula biliar externa espontánea en el anciano / Spontaneous cholecystocutaneous fistula in the ederly

No disponible

Íleo biliar: relato de caso e revisão da literatura / Gallstone illeus: case related and literature revision

O íleo biliar é uma afecção rara, decorrente de complicação da litíase biliar. Apresenta maior prevalência em pacientes do sexo feminino (> 70 por cento) com idade entre 60 e 75 anos. O desenvolvimento do íleo biliar deve-se basicamente à formação de uma comunicação anormal entre a via biliar e o tubo digestivo, tendo como uma das causas mais comuns a presença de fístulas biliodigestivas. O quadro clínico cursa com sintomas de obstrução intestinal completa ou incompleta. O diagnóstico é obtido através da anamnese, exame físico e exames complementarres (hemograma, ionograma, radiografia de abdome, etc.). Na grande maioria dos casos o diagnóstico se faz durante intervenção cirúrgica. O tratamento é eminentemente cirúrgico, devendo ser instituído precocemente, devido à elevada morbidez associada à demora terapêutica. A propedêutica por imagem tem determinado o diagnóstico precoce das afecções da via biliar, com redução na incidência de íleo biliar

Biliobiliary fistulas manifested by worsening liver function--a case report.

We report a case of cholecystolithiasis with biliobiliary fistulas from gallbladder to hepatic ducts, which were manifested by worsening liver dysfunction. Although it was not diagnosed preoperatively, it was successfully treated by cholecystectomy with closure of fistulas by the gallbladder wall. This case suggests that an internal biliary fistula may be possible, when the gallbladder wall is thickened and shrunken in the case of cholecystolithiasis, accompanied with liver dysfunction despite no dilatation of the common bile duct.