Effect of sphincter of Oddi dysfunction on the abundance of biliary microbiota (biliary microecology) in patients with common bile duct stones.

Objective: Biliary calculi, a common benign disease of the gastrointestinal tract, are affected by multiple factors, including diet, lifestyle, living environment, and personal and genetic background. Its occurrence is believed to be related to a change in biliary microbiota. Approximately 10%-20% of symptomatic patients with cholecystolithiasis have choledocholithiasis, resulting in infection, abdominal pain, jaundice, and biliary pancreatitis. This study aimed to determine whether a dysfunction in the sphincter of Oddi, which controls the outflow of bile and separates the bile duct from the intestine, leads to a change in biliary microbiota and the occurrence of biliary calculi. Methods: Forty patients with cholecystolithiasis and choledocholithiasis were prospectively recruited. Bile specimens were obtained, and biliary pressure was measured during and after surgery. The collected specimens were analyzed with 16S rRNA gene to characterize the biliary microbiota. The risk factors of common bile duct calculi were analyzed numerically combined with the pressure in the sphincter of Oddi. Results: Different biliary microbiota were found in all cases. Patients with sphincter of Oddi dysfunction had significantly increased biliary microbiota as well as significantly higher level of systemic inflammation than patients with normal sphincter of Oddi. Conclusions: The systemic inflammatory response of patients with sphincter of Oddi dysfunction is more severe, and their microbial community significantly differs from that of patients with normal sphincter of Oddi, which makes biliary tract infection more likely; furthermore, the biliary tract of patients with sphincter of Oddi dysfunction has more gallstone-related bacterial communities.

Etiological Diagnosis of Linear-Array Endoscopic Ultrasonography in Distal Common Bile Duct Dilatation.

ABSTRACT: The etiology of distal common bile duct (CBD) dilatation is complex. Linear-array endoscopic ultrasonography (EUS) can not only visualize the distal and surrounding structures of the bile duct closely but also obtain pathological specimens by fine-needle aspiration, which provides an important basis for the diagnosis and differential diagnosis. The purpose of this study was to evaluate the diagnostic value of linear-array EUS in the etiology of distal CBD dilatation. Patients with distal CBD dilatation underwent linear-array EUS in the endoscopic center of The Second Affiliated Hospital of Soochow University and Traditional Chinese Medicine Hospital of Kunshan were collected from January 2015 to June 2019. The pathology results after surgery, endoscopic pathology, computed tomography (CT), and magnetic resonance imaging (MRI) results were retrospectively analyzed. The diagnostic accuracy of linear-array EUS and CT or MRI was compared. For the diagnosis of choledocholithiasis, the diagnostic accuracy of linear-array EUS was 97.5%, which was significantly higher than that of MRI (86.36%) and CT (89.74) (P < 0.001 and 0.006, respectively). The diagnostic accuracy of linear-array EUS for periampullary tumors was 93.75%, which was higher than MRI and CT with an accuracy of 82.73% and 80.34% (P = 0.004 and 0.001, respectively). Linear EUS was effective for the etiological diagnosis of distal CBD dilatation.

Bile duct wall calcification: A rare entity in portal cavernoma cholangiopathy.

Cavernomatous transformation of the portal vein, seen in extrahepatic portal venous obstruction (EHPVO), can cause impingement or ischemic insult on bile ducts manifesting as "portal cavernoma cholangiopathy" (PCC). Bile duct wall calcification in portal biliopathy is a rare occurrence and has not been reported in the literature to the best of our knowledge. We report a 59-year-old male, a known case of EHPVO, who had undergone laparoscopic cholecystectomy, splenectomy, and splenorenal shunt in the past. The patient had now presented to us in view of recurrent episodes of cholangitis for which a bilioenteric bypass was planned. Intraoperatively, dilated and densely thickened bile ducts with multiple pericholedochal collaterals were noted. Incision of common hepatic duct and left hepatic duct showed completely calcified ductal wall with no visible healthy mucosa. Calcifications were removed partially from the bile duct walls near choledochotomy site. With the anticipation of futile benefit from bilioenteric bypass, Roux-en-Y HJ was abandoned. Hepaticoduodenostomy was done to prevent bile leak from choledochotomy site.

Case Report: Surgical Intervention for Fasciolopsis buski Infection: A Literature Review.

Fasciolopsis buski, also called the giant intestinal fluke, is the largest intestinal fluke of the zoonotic trematode parasites and found mainly in Southeast Asian countries, including China. Fasciolopsis buski infection was formerly a common health problem in many countries, but it is now rare. Typically, it can be cured by oral drugs, but some infected patients need surgical intervention because of the severity of their condition or because of an unclear diagnosis or even misdiagnosis. Here, we report a case of a 15-year-old girl from Guizhou Province, China, presenting with recurrent upper-middle abdominal pain that was misdiagnosed as a choledochal cyst. Through laparotomy combined with postoperative histopathological examination, the source of the pain was proven to be mechanical biliary obstruction caused by F. buski infection. In the past, mechanical obstruction, especially biliary obstruction, caused by F. buski infection leading to surgery was not uncommon, but it is very rare in modern society. Moreover, delayed treatment and misdiagnosis of parasitic infection can lead to severe consequences. Therefore, we reviewed the previous literature on F. buski infection treated by surgical operation and summarized the characteristics and therapeutic strategies of these cases to raise clinicians' awareness of this rare infection.

Choledochoduodenal Fistula Secondary to Peptic Ulcer Disease: A Case Report.

BACKGROUND Choledochoduodenal fistula is an uncommon complication secondary to peptic ulcer disease. Determining this diagnosis is challenging especially when confronted with unspecific physical and radiological findings. CASE REPORT Here we report a case of a 29-year-old Ethiopian female who presented to Geitaoui University Hospital in Beirut, Lebanon with epigastric pain and was diagnosed to have of choledochoduodenal fistula. CONCLUSIONS Choledochoduodenal fistula is a rare complication of duodenal ulcer and this case report may help clinicians to identify suspected cases of this entity with similar presentations.

Ectopic papilla of Vater in duodenum bulb: A hospital-based study.

The major papilla of Vater can be ectopically present in the stomach, pyloric canal, duodenal bulb, and third or fourth portion of the duodenum. In this study, we determined the clinical significance of ectopic papilla of Vater by endoscopic retrograde cholangiopancreatogram (ERCP).A retrospective study was conducted by reviewing the medical records of 6133 patients receiving ERCP from 1988 to 2011. The diagnosis was confirmed if both the common bile duct (CBD) and the main pancreatic duct (PD) drained into the same opening, either by ERCP or magnetic resonance cholangiopancreatography.Eight patients with major papilla of Vater in the duodenal bulb were identified among 6133 patients receiving ERCP from 1988 to 2011, with an incidence rate of 0.13%. The mean age was 67 years and patients were predominantly male. Duodenal bulb deformity was noted in all patients and three of them had shallow gastric and/or duodenal ulcers. Hook-shaped CBD configuration was seen only in half of our cases. Three patients with CBD stones were treated successfully after endoscopic sphincterotomy or papillary balloon dilation.Ectopic orifice of papilla is a rare finding of ERCP. Opacification of both the CBD and main PD from the same opening is an essential criterion for diagnosing an ectopic papilla of Vater in the duodenal bulb.

Risk Factors and Nomogram for Common Bile Duct Stricture in Chronic Pancreatitis: A Cohort of 2153 Patients.

GOALS: To identify the risk factors and develop nomograms for common bile duct (CBD) stricture in chronic pancreatitis (CP) patients. BACKGROUND: CBD stricture is a common complication in CP and has a variable clinical presentation ranging from asymptomatic to overt jaundice and cholangitis. STUDY: Patients with CP admitted to Changhai Hospital (Shanghai, China) from January 2000 to December 2013 were enrolled. Cumulative rates of CBD stricture after onset and diagnosis of CP were calculated. Patients were randomly assigned, in a 2:1 ratio, to the training and validation cohort. On the basis of the training cohort, risk factors for CBD stricture and symptomatic CBD stricture were identified through Cox proportional hazards regression model, and nomograms was developed, respectively. Internal and external validations were performed based on the training and validation cohort, respectively. RESULTS: With a total of 2153 patients, the median duration of follow-up was 7.0 years. CBD strictures were detected in 340 (15.8%) patients, whereas 159 of them were symptomatic. Male gender, age at onset of CP, smoking, body mass index, and morphology of main pancreatic duct were identified risk factors for CBD stricture development. Age at onset of CP, body mass index, and type of pain were identified risk factors for symptomatic CBD stricture development. Both nomograms achieved good concordance indexes with well-fitted calibration curves. CONCLUSIONS: The nomogram achieved an individualized prediction of symptomatic CBD stricture development in CP patients. It may help the early diagnosis and intervention of symptomatic CBD stricture and reduce the rates of severe adverse events.

Common bile duct dilation after bariatric surgery.

BACKGROUND: Biliary dilation suggests obstruction and prompts further work up. Our experience with endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in the symptomatic post-bariatric surgery population revealed many patients with radiographically dilated bile ducts, but endoscopically normal studies. It is unclear if this finding is phenomenological or an effect of surgery. Additionally, it is unknown whether the type of bariatric surgery alters biliary pathophysiology. Thus, we studied whether a change occurs in biliary diameter following Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). METHODS: A single-center retrospective study assessing biliary diameter before and after RYGB or SG based on radiographic imaging. All adult patients undergoing RYGB or SG from January 2010 to December 2013 who had imaging studies before and > 3 months after surgery were included. Those with known obstructive etiologies and those without post-operative imaging were excluded. Common bile duct (CBD) diameter was re-read by a radiologist at the same location in the CBD for pre- and post-operative imaging. Baseline clinical factors and cholecystectomy status were collected. RESULTS: 269 patients met inclusion criteria (193 RYGB;76 SG). Between the groups, there were no significant differences in pre-operative characteristics. Average time from surgery to repeat imaging was 24.1 months. After adjusting for pre-operative factors, subjects who underwent an RYGB had an increase in CBD diameter of 1.4 mm (95% CI 0.096, 0.18), which was greater than the change following SG 0.5 mm(95% CI - 0.007, 0.11). The magnitude of this change did not depend on prior cholecystectomy in the RYGB cohort. Within the SG group, for patients without a prior cholecystectomy, there was a significant increase in post-operative CBD diameter of 0.8 mm(95% CI 0.02, 0.14). CONCLUSION: Bariatric surgery results in CBD dilation, with changes more pronounced after RYGB. Biliary dilation occurs irrespective of cholecystectomy status. Further work is necessary to determine the cause and clinical implications of this phenomenon.

Hypothermic oxygenated machine perfusion reduces bile duct reperfusion injury after transplantation of donation after circulatory death livers.

Dual hypothermic oxygenated machine perfusion (DHOPE) of the liver has been advocated as a method to reduce ischemia/reperfusion injury (IRI). This study aimed to determine whether DHOPE reduces IRI of the bile ducts in donation after circulatory death (DCD) liver transplantation. In a recently performed phase 1 trial, 10 DCD livers were preserved with DHOPE after static cold storage (SCS; www.trialregister.nl NTR4493). Bile duct biopsies were obtained at the end of SCS (before DHOPE; baseline) and after graft reperfusion in the recipient. Histological severity of biliary injury was graded according to an established semiquantitative grading system. Twenty liver transplantations using DCD livers not preserved with DHOPE served as controls. Baseline characteristics and the degree of bile duct injury at baseline (end of SCS) were similar between both groups. In controls, the degree of stroma necrosis (P = 0.002) and injury of the deep peribiliary glands (PBG; P = 0.02) increased after reperfusion compared with baseline. In contrast, in DHOPE-preserved livers, the degree of bile duct injury did not increase after reperfusion. Moreover, there was less injury of deep PBG (P = 0.04) after reperfusion in the DHOPE group compared with controls. In conclusion, this study suggests that DHOPE reduces IRI of bile ducts after DCD liver transplantation. Liver Transplantation 24 655-664 2018 AASLD.

Massive Biliary Dilation after Roux-en-Y Gastric Bypass: Is it Ampullary Achalasia?

BACKGROUND: This series of patients with a history of Roux-en-Y gastric bypass (RYGB) and cholecystectomy presented with symptoms consistent with obstructive biliary disease and massive biliary dilation of ≥15 mm, suggesting a structural cause. Findings from laparoscopic-assisted transgastric (TG) ERCP were a normal-appearing ampulla without structural lesions or stones, suggesting a functional cause instead. STUDY DESIGN: Patients who underwent TGERCP from January 2008 to October 2016 and had a surgical history of RYGB and cholecystectomy were identified from an institutional database. Inclusion criteria was biliary dilation ≥15 mm, age 18 years or older, and no explanatory obstructive pathology. RESULTS: Nine female patients met the inclusion criteria. At time of TGERCP, their mean age was 53.9 years, mean BMI was 32.5 kg/m2, mean bile duct diameter was 18.1 mm, and all patients experienced abdominal pain. Six patients (66.7%) presented with abnormal liver enzymes, 5 (55.6%) with nausea and/or vomiting, and 4 (44.4%) with earlier episode(s) of acute pancreatitis. Each patient had a normal-appearing papilla of Vater without stones or strictures at the time of TGERCP, with 8 (88.9%) patients experiencing cessation of abdominal pain after biliary sphincterotomy. CONCLUSIONS: This cohort of patients with a history of RYGB and cholecystectomy presented with massively dilated biliary trees lacking an obstructive disease process and experienced immediate symptom improvement after sphincterotomy. Their surgical history predisposed them to vagal nerve injury, leading to denervation of the sphincter of Oddi, and resulting in tonic contraction of the ampulla, that is, ampullary achalasia.

Iatrogenic common bile duct injuries: Increasing complexity in the laparoscopic era: A prospective cohort study.

PURPOSE: Iatrogenic bile duct injury (BDI) is the most significant associated complication to laparoscopic cholecystectomy (LC). Little is known about the evolution of the pattern of BDI in the era of laparoscopy. The aim of the study is to assess the pattern of post-LC BDIs managed in a tertiary referral centre. METHODS: Post-LC BDI referred over two decades were studied. Demographic data, type of BDI (classified using the Strasberg System), clinical symptoms, diagnostic investigations, timing of referral, post-referral management and morbidity were analysed. The pattern of injury, associated vascular injuries rate and their management were compared over two time periods (1992-2004,2005-2014). RESULTS: 78 BDIs were referred. During the second time period Strasberg A injuries decreased from 14% to 0 and Strasberg E1increased from 4% to 23%, the rate of associated vascular injury was six time higher (3.6% versus 22.7%), more patients had an attempted repair at the index hospital (16% versus 35%) sand fewer patients could be managed without surgical intervention at the referral hospital (28% versus 4%). CONCLUSION: Complexity of referred BDIs and rate of associated vascular injuries have increased over time. These findings led to more patients managed requiring surgical intervention at the referral hospital.