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At least 307 records · Page 17Linked to original sources
PubMed1996

Liver biopsy in liver transplantation: no additional risk of infections in patients with choledochojejunostomy.

BACKGROUND/AIMS: This study aimed to determine whether there is an increased infectious risk following liver biopsy in liver transplant patients with choledochojejunostomy. METHODS: We evaluated the incidence of liver-biopsy-related sepsis in a consecutive series of 27 patients who underwent choledochojejunostomy, either during the transplant procedure (17 patients) or later following biliary complications (10 patients). We evaluated another 138 patients as a control group who had orthotopic liver transplantation during the same period and underwent duct-to-duct anastomosis. All liver biopsies had routine, prior ultrasound evaluation to detect dilated biliary ducts. RESULTS: In the 27 patients who underwent choledochojejunostomy, 96 liver biopsies were performed: the sepsis rate was 3.12% per biopsy (n = 96) or 7.4% per patient (n = 27). However, despite a normal ultrasound, subsequent ERCP demonstrated biliary obstruction in one patient. Thus the rate of sepsis was 2.1% per biopsy or 3.7 per patient. In the control group 338 liver biopsies were performed: the sepsis rate was 1.5% per biopsy (n = 338) or 2.9% per patient (n = 138). The difference was not significant. All septic episodes had positive blood cultures for a single enteric microorganism, and all responded to antibiotics CONCLUSIONS: Our data do not suggest that liver-transplanted patients with choledochojejunostomy are more at risk of sepsis following liver biopsy, providing there is no "occult" biliary obstruction; therefore, they do not require prophylactic antibiotics as has been suggested by other authors.

Adolescent↗
PubMed1996

Decreased constitutive hepatic nitric oxide synthase expression in secondary biliary fibrosis and its changes after Roux-en-Y choledocho-jejunostomy in the rat.

BACKGROUND/AIMS: Inducible nitric oxide synthase (iNOS) in the liver has been shown to increase after stimulation by different compounds. Its exact role in cirrhosis is unclear, but it is thought to be an important factor in the development of the hyperdynamic state. In contrast, little is known about the constitutive form of nitric oxide synthase (cNOS) in the liver, and in particular in liver disease. We therefore investigated immunohistochemical expression of endothelial NOS (cNOS) and, in addition, of macrophage NOS (iNOS), a constitutive and inducible form of NOS, in secondary biliary fibrosis and after reversing these changes by biliodigestive anastomosis. METHODS: Sprague-Dawley rats were allocated to one of seven groups: sham-operated controls (CTR), bile duct ligation for 3 weeks (BDL) and BDL followed by Roux-en-Y choledochojejunostomy (RY); the latter group was studied after 1, 2, 3, 7 and 45 days (RY1, RY2, RY3, RY7, and RY45). cNOS-positive hepatocytes were stained with a monoclonal antibody specifically recognizing this isoenzyme, and quantitated stereologically. RESULTS: Virtually all hepatocytes were positive for cNOS in CTR (99.9 +/- 0.2%); this was markedly reduced in BDL (73.7 +/- 9.8%; p < 0.05). After RY, cNOS positive hepatocytes increased to reach normal levels (99.7 +/- 0.5%) in RY45. In contrast to cNOS, there was no iNOS positive staining with a monoclonal macrophage NOS antibody for this isoenzyme, which was confirmed by determining total iNOS protein concentration by Western blot. Serum nitrite/nitrate concentrations mirrored these findings and decreased from 7.9 +/- 3.7 mol/l in CTR to 2.1 +/- 0.4 mol/l in BDL. After RY, nitrite/nitrate concentration increased to 22.7 +/- 30.1, 32.4 +/- 21.4 and 44.6 +/- 32.7 mol/l in RY1, RY2 and RY3, respectively; in RY45, serum nitrite/nitrate concentration was normal averaging 6.1 +/- 1.2 mol/l. CONCLUSIONS: The present investigation shows that, in secondary biliary fibrosis, endothelial nitric oxide synthase is decreased in hepatocytes, macrophage nitric oxide synthase is not increased, and that-in contrast to current thinking-nitrate/nitrate production is diminished.

Anastomosis, Roux-en-Y↗
PubMed1996

Bilioenteric anastomosis reverses hyperkinetic circulation in bile duct-ligated cirrhotic rats.

BACKGROUND/AIMS: The chronic bile duct-ligated rat is used to study hemodynamic changes in cirrhosis but suffers from total biliary obstruction and deep jaundice. The extent of reversibility of hemodynamics and histology following bile flow reconnection is controversial. We aimed to characterize the hemodynamics and histology of bile duct-ligated cirrhotic rats in which bile flow was reconnected by a Roux-en-y choledochojejunostomy. METHODS: Operations created four groups: double sham (control), bile duct ligated, and two reconnected groups. Cardiac index and regional blood flows were measured by radioactive microspheres 4 weeks following the last operation in the first three groups and 8 weeks afterwards in the second reconnected group. Liver histology was assessed by a computer-aided scoring program. RESULTS: Cardiac index, mean arterial pressure, and systemic vascular resistance in the reconnected groups were different from bile duct-ligated rats and returned to control values. Portal pressures in the reconnected groups (4-weeks, 10.0 +/- 0.5 and 8-week, 9.7 +/- 0.6 mmHg) were significantly lower than in bile-duct-ligated rats (13.7 +/- 0.6) but remained elevated compared to controls (7.0 +/- 0.3). Portal pressure in the reconnected rats was correlated with cardiac index and mesenteric blood flow, r = 0.66 and r = 0.45, respectively. Liver histology was improved in the reconnected rats, with decreased bile duct proliferation, fibrosis and apoptosis. CONCLUSIONS: We conclude that many of the histological features of secondary biliary cirrhosis are reversible after bilioenteric anastomosis. Furthermore, the hyperdynamic circulation is also largely reversible and is related to the degree of portal hypertension.

Alanine Transaminase↗
PubMed1997

Hepatic stellate cells (Ito cells) but not collagen IV may partly be responsible for lower portal pressure after reversing secondary biliary cirrhosis in the rat.

BACKGROUND/AIMS: Chronic bile duct obstruction in the rat leads to biliary cirrhosis and portal hypertension. Biliary decompression with Rouxen-Y choledocho-jejunostomy (RY) reverses most but not all of these changes. The aim of the present study was to determine whether hepatic stellate cells, as a main source of extracellular matrix proteins, participate in this process. METHODS: Sprague-Dawley rats were allocated to one of three groups: Bile duct ligation (BDL) for 3 weeks, BDL followed by RY and sham-operated animals as controls (SHAM). At the end of the experimental period, portal pressure was measured, livers subjected to random sampling and hepatocytes, bile ducts/ductules, hepatic stellate cells and collagen IV determined stereologically. Hepatic stellate cells and collagen IV were characterized immunohistochemically with an antibody against desmin and collagen IV, respectively. RESULTS: Volume fraction of hepatocytes decreased from 65.6 +/- 5.3 in sham-operated animals to 27.9 +/- 8.8% in bile duct ligated animals (p < 0.05). In contrast, volume fraction of bile ducts/ductules increased from 0.4 +/- 0.2 in sham-operated animals to 25.3 +/- 8.6% in bile duct ligated ones; similarly, hepatic stellate cells increased from 0.4 +/- 0.2 in sham-operated animals to 2.6 +/- 0.9% in bile duct ligated ones (p < 0.01) and collagen IV from 10.0 +/- 2.3 in sham-operated animals to 24.5 +/- 8.0% (p < 0.01) in bile duct ligated animals. These changes were partially reversed by Roux-en-Y choledocho-jejunostomy; hepatocytes, bile ducts/ductules, hepatic stellate cells and collagen IV averaging 54.8 +/- 13.1, 6.1 +/- 6.8, 1.6 +/- 0.6 and 14.5 +/- 3.6%, respectively (p < 0.05 RY vs. BDL). Portal pressure in sham-operated animals, bile duct ligated animals and those with a Roux-en-Y choledocho-jejunostomy averaged 13.4 +/- 0.7, 20.1 +/- 2.7 and 16.9 +/- 1.6 cm H2O, respectively, and correlated significantly with the volume fraction of hepatic stellate cells (rS = 0.96; p < 0.001) and less with collagen IV (rS = 0.61; p < 0.007). However, by stepwise regression, collagen IV did not significantly add to the ability of the equation to predict portal pressure. CONCLUSIONS: These results lend further support to the notion that hepatic stellate cells are prominently involved in fibrogenesis and in the reversibility of these changes, but hepatic stellate cells do not completely revert to normal even 4 weeks after successful decompression. Furthermore, our data suggest that hepatic stellate cells may be related to maintenance of portal hypertension.

Anastomosis, Roux-en-Y↗
PubMed1990

Local management of pancreatic carcinoma: iodine-125 implantation.

A retrospective review of patients with pancreatic carcinoma treated from 1983 to 1986 was performed. Group 1 comprise 11 patients judged surgically unresectable who were implanted with iodine-125 followed by external beam therapy post-operatively (Implant + XRT). Eight patients received external beam therapy alone (XRT) Group 2, and 23 patients underwent radical surgical resection (group 3). Median survival was 8 months in the implant + XRT group; 5 months in the XRT alone group and 7.5 months in the surgical group. Locoregional control was achieved in 8/11 (73%), 2/8 (25%), and 11/23 (48%) of these groups respectively. Pain was the most common presenting symptom, 38/42 (90%). Complete, lasting palliation was achieved in 8/10 (80%) of group one, 2/8 (25%) of group two, and 13/20 (65%) of group three patients. Despite surgical unresectability implant + XRT appears to offer similar results to radical surgery. The data are presented with respect to the implant technique, disappearance of the tumour on CT scan and patterns of failure.

Adenocarcinoma↗
PubMed2001

Ultrasound guidance in accessing the afferent limb of a modified Roux-en-Y choledochojejunostomy for percutaneous dilation of biliary strictures.

Percutaneous retrograde biliary dilation via the afferent limb of a modified Roux-en-Y choledochojejunostomy is used in the management of chronic biliary strictures. Access to the afferent loop may be challenging in the absence of surgically placed radiopaque markers. Ultrasound (US) guidance was used to access the loop in 10 patients with subcutaneous afferent loops and three patients with subfascial afferent loops. Successful puncture was made in all 10 patients with subcutaneous loops and in one patient with a subfascial loop. Initial fluoroscopically guided attempts failed in five loops, which were then successfully accessed with use of US guidance. US is useful in accessing subcutaneous afferent loops.

Adult↗
PubMedDate not supplied

Two-stage trauma pancreaticoduodenectomy: delay facilitates anastomotic reconstruction.

A case of a gunshot wound to the head of the pancreas and superior mesenteric vein requiring pancreaticoduodenectomy is discussed. Managing such an injury is challenging, first because of the ongoing hemorrhage and second because of the technical difficulty in working with a normal pancreas and bile duct. In the case presented herein, enteric reconstruction was performed 72 hours after the initial surgery. A delay in reconstruction resulted in tissue changes that facilitated enteric reconstruction A two-stage pancreaticoduodenectomy may be considered if the surgeon is faced with an unstable patient.

Adult↗
PubMed1999

Management of biliary tract complications following liver transplantation.

BACKGROUND: A review of biliary tract complications was performed in 32 patients who underwent liver transplantation by the Western Australian Liver Transplantation Service during a 2-year period. METHODS: A review was made of patient data collected prospectively, and confirmed by retrospective casenote review. RESULTS: A total of 30 patients (31 grafts) survived more than 2 days after transplantation, and of these 28 had an end-to-end biliary anastomosis. Analysis of these 28 patients found that eight of 17 patients with T-tubes had complications: three leaks at T-tube removal; two strictures and leaks; and three strictures. Six of 11 patients without a T-tube had complications: one leak; three strictures and leaks; and two strictures. Predisposing factors were present in eight of the 14 patients with biliary tract complications: hepatic artery stenosis in three; and one each with hepatic artery thrombosis; biliary calculi; donor-recipient bile duct mismatch; severe cellular rejection: and prolonged postoperative hypotension. Acute rejection, steroid-resistant rejection and cytomegalovirus infection were all significantly more common in those patients with biliary tract complications compared with those without. There was no difference in cold ischaemic time or donor age. Twelve of the 14 patients with biliary complications required endoscopic stenting with or without balloon dilation, and eight patients required radiological percutaneous drainage of bile collections. Only one patient required biliary reconstruction and two patients required re-transplantation. One patient died of uncontrolled infection. Of three patients who underwent choledochojejunostomy, biliary leak developed in two patients, both of whom required operative biliary and hepatic repair. One of the three patients died from disseminated Aspergillus infection. The median total hospital stay of patients with biliary complications was 61 days (range: 30-180 days) compared with 33.5 days (range: 22-70 days) for patients without. Of patients with end-to-end biliary anastomosis, 50% had biliary tract complications and more than half of these had predisposing factors. The majority of biliary complications were managed without the need for surgery. CONCLUSION: A total of 50% of patients with end-to-end biliary anastomosis had biliary tract complications. Biliary strictures presented later than leaks, and the majority of these complications were managed without the need for surgery.

Adolescent↗
PubMed2000

Alternative uses for the haemostatic vascular sheath.

The haemostatic vascular sheath has several non-vascular applications in interventional radiology. It is used to preserve access to an organ (i.e. contrast can be introduced without removing catheters and guidewires). There are also advantages regarding patient comfort and safety. Three such applications are described.

Blood Vessel Prosthesis↗
PubMed2002

Complications of biliary T-tubes after choledochotomy.

BACKGROUND: Traditional management of choledocholithiasis has been supraduodenal choledochotomy, duct exploration and insertion of a T-tube. This study reviews the complications associated with T-tube use and assesses whether laparoscopic procedures are associated with an increase in complications relating to T-tube use. METHODS: Case records from two large public hospitals in New South Wales (Australia) were analysed retrospectively for a 10-year period using a standardized data collection form. Morbidity, mortality and potential factors influencing the complication rate after choledochotomy and T-tube insertion were recorded. All complications were reviewed by an experienced biliary surgeon. RESULTS: T-tubes were inserted in 274 patients, with 42 patients (15.3%) experiencing a total of 60 complications relating to T-tube use. Morbidity occurring while the tube was in situ included fluid and electrolyte disturbance (five patients), sepsis (10 patients), premature dislodgement (three patients) and bile leakage (six patients). Complications resulting after planned tube removal included localized pain (13 patients), biliary peritonitis (seven patients), a prolonged biliary fistula (seven patients) and a late bile duct stricture (one patient). T-tube complications resulted in a prolonged hospital stay (19 days vs 13 days, P = 0.005), 10 additional abdominal operations and two deaths. Complications related to T-tubes were constant over the study period and were similar between laparoscopic and open cases (13.8% vs 15.5%, P = 0.81). CONCLUSIONS: Although this retrospective review is likely to have underestimated the incidence of T-tube complications, it has demonstrated significant morbidity associated with T-tube use. The incidence of these complications has been constant and is unrelated to a laparoscopic approach.

Cholangiography↗
PubMed2003

Duodenogastric reflux after biliary surgery: scintigraphic quantification and improvement with erythromycin.

BACKGROUND: Persistence of dyspeptic symptoms after cholecystectomy or choledochoduodenostomy is common. There is -evidence that at least some of these symptoms may be attributed to duodenogastric reflux (DGR). The aim of the study was to quantify DGR before and after cholecystectomy, with or without choledochoduodenostomy, and endoscopic sphincterotomy for common bile duct stones, and to assess the effect of erythromycin on the increased DGR. METHODS: Forty-seven patients before and after cholecystectomy, 26 after cholecystectomy and choledochoduodenostomy and nine after sphincterotomy had postprandial (300 mL of fresh milk, 4% fat) duodenogastric reflux measured by 99mTc-hepatic imino diacetic acid scintigraphy. Patients with a DGR index (DGRi) >20% were considered as having pathological DGR that justifies symptoms, and their DGRi was reassessed after administration of 200 mg of erythromycin intravenously. RESULTS: Twenty-seven patients before cholecystectomy (57%) showed a normal DGRi <7%. In five cases DGRi was greater than 20%. After cholecystectomy, duodenogastric refluxes increased, so that only 16 patients (32%) showed a normal DGRi, while a DGRi >20% was observed in 10 cases. Only eight patients after cholecystectomy and choledochoduodenostomy (23%) presented with a DGRi within the normal range. The remaining 18 had a DGRi >7%. Five of them exhibited a DGRi >20%. Of the nine patients with sphincterotomy, three showed a DGRi >20%. Erythromycin almost completely normalized DGRi in all 18 patients with pathological DGR (P < 0.0001). CONCLUSIONS: Duodenogastric reflux is common after biliary surgery, including endoscopic sphincterotomy. Erythromycin appears to decrease duodenogastric reflux to normal levels.

Adult↗
PubMed2000

Biliary anastomosis in living related liver transplantation using the right liver lobe: techniques and complications.

Since the introduction of adult-to-adult living donor liver transplantation using the right lobe of the liver, biliary problems have led the list of complications resulting in postoperative morbidity. We report our experience with the first 30 living donor liver transplantations performed in our institution from August 1998 to January 2000. Patients were 21 men and 9 women, with a mean age 45 +/- 16 years. Mean recipient weight was 65.1 +/- 17.9 kg, mean graft weight was 877 +/- 146 g, and the mean graft-recipient weight ratio was 1.5 +/- 0.6. Patient and graft survival rates were 83.3% and 80%, respectively. Biliary anastomosis was either an end-to-end hepaticocholedochostomy with a T-drain or hepaticojejunostomy. Mean follow-up was 217.4 +/- 149.8 days. The overall complication rate was 26.6% (8 of 30 procedures) and was directly correlated to the type of anastomosis and number of bile ducts. Surgical revision was necessary in all cases. Biliary complications were not the primary cause of graft loss. Adult living donor liver transplantation using the right lobe is a successful procedure, with graft and patient survival similar to those in cadaver full-organ transplantation. Postoperative morbidity, mainly caused by biliary leak, was directly related to the number of ducts and type of anastomosis. With increasing experience, we have better defined our plane of transection on the hilar plate, with the goal of obtaining only 1 biliary duct for the anastomosis. We also improved our parenchymal transection technique, which resulted in a decreased incidence of leak at the cut-surface area.

Adult↗
PubMed2001

Ascending cholangitis provokes IL-8 and MCP-1 expression and promotes inflammatory cell infiltration in the cholestatic rat liver.

BACKGROUND/PURPOSE: Postoperative cholangitis is one of the most common complications after bile duct reconstruction. The pathogenesis and early consequences of ascending cholangitis still are unidentified. METHODS: Male Sprague-Dawley rats were divided into 5 treatment groups: control (n = 4), blood sampling and liver biopsy only; group I, [BDL/Eschericha coli; n = 6], ligation of common bile duct (BDL) for a week, followed by Roux-en-Y choledochojejunostomy (RYCJ) and injection of E coli (ATCC 25922) into Roux limb after 24 hours; group II, [BDL/NS; n = 5], same procedures as in group I, with injection of normal saline (NS) into Roux limb; group III, [SBDL/E coli; n = 6], primary RYCJ was constructed 1 week after sham ligation of common bile duct (SBDL) followed by the same treatment as group I; Group IV, [SBDL/N.S; n = 6], same procedures as in group III, but injecting NS into Roux limb. All animals were killed after 24 hours of treatment. Blood was sampled for culture and serum cytokine levels. The liver was harvested for quantitative bacterial culture, as well as for MCP-1, interleukin (IL)-8 (CINC in the rat) and transforming growth factor beta1 mRNA expression by reverse transcriptase polymerase chain reaction (RT-PCR) and for immunohistochemistry. The choledochojejunostomy was resected for culture. Serum cytokine levels were detected by ELISA kits. RESULTS: A significant increase of E coli ATCC 25922, occurred in the livers of group I rats, compared with group IV (P =.037). MCP-1 expression increased in all groups, compared with control (P =.000). The IL-8 mRNA expression was significantly higher in group I than in control (P =.021). The expression of TGF-beta1 mRNA was similar among the groups (P =.361), consistent with the immunohistochemistry results. The serum MCP-1 and IL-8 levels were higher in the 4 groups than in the control (P =.000) and were significantly higher in group I than in group IV (P =.001). CONCLUSIONS: This study found that a significant colonization of E coli of the same strain was present in the cholestatic rat liver injected into the Roux limb, which was associated with a higher expression of liver MCP-1 and IL-8 mRNA, a significant increase of serum MCP-1 and IL-8, and a more evident inflammatory cell infiltration into the porta hepatis.

Anastomosis, Roux-en-Y↗
PubMed2003

Surgical complications of pancreatectomy for persistent hyperinsulinaemic hypoglycaemia of infancy.

PURPOSE: The aim of this study was to review the surgical complications of pancreatectomy for persistent hyperinsulinaemic hypoglycaemia of infancy (PHHI). METHODS: A retrospective review was conducted of patients undergoing pancreatectomy for PHHI in one institution over the past 13 years. RESULTS: The records of 48 patients were reviewed; the age at operation ranged from 10 days to 30 months (median, 8 weeks). Weight at operation ranged from 1.97 to 11.4 kg (median, 5.2 kg). There were no deaths. Intraoperative complications comprised bleeding in 7, (major in 2), splenic injury in one, bile duct injury in 2 (1 oversewn, 1 choledochoduodenostomy), and 1 small bowel injury. Postoperatively, 5 children underwent choledochoduodenostomy: 2 for biliary leak and 3 for delayed bile duct stricture. Other postoperative complications included wound infection (n = 3), prolonged ileus (n = 1) and adhesion obstruction (n = 1), and wound leakage (n = 1). Renal failure developed in one child owing to acute tubular necrosis. Nine patients required further pancreatic resection because of continued hypoglycaemia. Three patients continued to require medication for hyperinsulinism despite surgery, 20 required insulin, and 13 required pancreatic enzyme replacement at the time of the last review. CONCLUSIONS: Pancreatectomy resulted in resolution of hyperinsulinism in 45 of 48 patients. Sixteen patients required no further surgery or medication. Pancreatectomy for PHHI may be associated with major intra and postoperative morbidity.

Bile Ducts↗