Biliary Tract Diseases ; Humans ; Liver Diseases ; Liver Transplantation/adverse effects* ; Postoperative Complications/etiology* ; Retrospective Studies

Biliary Tract Diseases ; etiology ; surgery ; therapy ; Blood Loss, Surgical ; prevention & control ; Graft Rejection ; etiology ; therapy ; Humans ; Liver Transplantation ; adverse effects

Biliary Tract Diseases ; etiology ; prevention & control ; therapy ; Cholestasis ; etiology ; prevention & control ; therapy ; Humans ; Liver Transplantation ; adverse effects

Biliary Tract Diseases ; complications ; surgery ; Humans ; Hypertension, Portal ; complications ; etiology ; surgery ; Liver Cirrhosis ; complications ; surgery ; Perioperative Care

Obesity is a serious disorder that increases morbidity and mortality. Primary intervention with life style modification and medication is not always effective for obese patients. Endoscopic management of obesity may be a less invasive, more cost-effective, and relatively safer option than bariatric surgery. Moreover, therapeutic endoscopy is considered to be the primary modality for managing complications that occur after bariatric surgery. In the near future, role of gastroenterologists will be more important in the management of obesity and its related problems.
Bariatric Surgery/adverse effects ; Biliary Tract Diseases/etiology ; Endoscopy, Gastrointestinal ; Gastric Balloon ; Gastric Bypass ; Humans ; Obesity/*therapy ; *Physician's Role

OBJECTIVETo prevent and manage biliary complications after orthotopic liver transplantation (OLT).

METHODSNinety-five patients of OLT performed at our institute from February, 1999 to December 2002 were retrospectively analysed. Recipient operation was performed using standard method combined with veno-venous bypass in 12 patients and piggyback method in 78 patients and living-related liver transplantation in 5 patients. Biliary reconstruction was performed by end-to-end choledochocholedochostomy (C-C) over a T-tube in 55 patients and without a T-tube in 36 patients while the remaining 4 patients underwent Roux-en-Y choledochojejunostomy (CRY). C-C and CRY were performed by the interrupted or continuous suture with 5 - 0 or 6 - 0 Vicryl or PDS. Routine examination of liver function, Doppler ultrasonography and cholangiography were performed during the follow-up period.

RESULTSBiliary complications occurred in 7 patients (7.3%). Two patients with bile leakage at the anastomotic site developed biliary peritonitis on the seventh and tenth postoperative day and needed reoperation. One patient developed anastomotic biliary stricture one month after the operation and was cured by endoscopic stenting. Two patients developed bile leakage after T-tube removal. One of the two patients was treated conservatively and the other underwent a exploratory laparotomy to ligate the T-tube tract and drain the peritoneal cavity. One patient died of biliary vast syndrome five months after OLT and one patient died of biliary tract necrosis secondary to hepatic artery thrombosis on the tenth postoperative day. One - 42-month (mean 11.4 months) follow-up revealed no biliary stricture in 74 patients. No biliary stone and biliary sludge were detected by Doppler ultrasound and/or cholangiography. Serological examinations proved that liver grafts functioned well in these patients.

CONCLUSIONSTo prevent biliary complications, it is crucial to protect biliary mucosa and arterial blood supply of the common bile duct while harvesting the graft and to obtain perfect mucosa-to-mucosa apposition of no-tension end-to-end anastomosis of the bile duct. Endoscopic dilation and stenting are effective for post-OLT extrahepatic biliary stricture.

Adult ; Aged ; Biliary Tract Diseases ; etiology ; prevention & control ; therapy ; Biliary Tract Surgical Procedures ; adverse effects ; methods ; Female ; Follow-Up Studies ; Humans ; Liver Transplantation ; adverse effects ; methods ; Male ; Middle Aged ; Postoperative Complications ; etiology ; prevention & control ; therapy ; Retrospective Studies ; Young Adult

OBJECTIVETo summarize the Patho-typing and the clinical manifestation of biliary cast syndrome (BCS) in patients after orthotopic liver transplantation.

METHODSThe clinical manifestation, findings,therapeutic means and efficacy of 103 patients with biliary cast syndrome after orthotopic liver transplantation were retrospectively analyzed. According to the injury level of biliary duct epithelium, patients were divided into different groups. All cases were followed up for twelve months. The place, degree and time after operation would be recorded when non-anastomotic biliary stricture was found.

RESULTSThere were 59 BCS cases in the general hospital of armed police force of China. The incidence rate of BCS was 9.1%. Many BCS patients showed symptoms such as jaundice, deep urine color, gray stools, itch of skin and fever. Some were asymptomatic. In laboratory test, the liver functional enzyme in serum were increased, the total white cell count in peripheral blood was increased either. Cholangiography via T tube of biliary tract might show filling defect. According to the change degree of the biliary tract tree, there were four types filling defect concluded from all the presentation in BCS patients. Solid obturation of biliary tract were found by the check with optical fiber choledochoscope in all BCS patients, necrosis of biliary tract epithelium were observed in partial BCS patients. According to the injury level of biliary duct epithelium (gradually aggravated), BCS patients were divided into six groups (type I, type II, type III, type IV, type V and type VI). Fourteen cases were found in type I and 18 in type II. No clinical symptom was found in these two groups, a few indicators in serum (alanine aminotransferase ALT, total bilirubin TBIL, direct bilirubin DBIL) were in normal range, and others (gamma-glutamyl transferase GGT, alkaline phosphatase ALP) were heightened in 5 patients. There was no biliary cast (BC) found anymore in the period of follow-up in two groups. No stricture was found in both group. Twenty-seven cases in type III and 23 cases in type IV, it was found there were about 33.4% patients accompanied with fever and 25.9% accompanied with jaundice in type III. Paralleled,there were about 30.4% and 34.8% patients in type IV. The liver functional enzyme in serum were found increased in both type. After supporting treatment for 3-6 months,there were 5 and 3 patients present as mild non-anastomotic biliary stricture in type III and type IV group. In the group type V, there were 13 patients. The detected liver functional indicators in serum were increased. After supporting treatment for 6-12 months,there were 4 patients present as moderate non-anastomotic biliary stricture in this group. There were 18 patients in type VI group, all indicators of the liver functional enzyme in serum before the treatment were elevated conspicuously. All patients in this group were found serious stricture up to three places that have not been sustained in the period of follow-up. Nine died of MOSF, 1 died of AOSC, 8 had undergone retransplantation. In the retransplantation patients, 4 died of post operation MOSF, 3 recovered to normal, 1 patient was found BCS once more 15 d after the retransplantation and the third-transplantation was performed 7 months after the second transplantation, no BCS was found again. The deaths total rate was 13.6%, death rate of retransplantation was 44.0%, total cure rate was 54.0%, total improvement rate was 71.0% and total stenosis rate was 29.0%.

CONCLUSIONS(1) According to the check with optical fiber choledochoscope, there are 6 types of patho-typing in BCS patients. The clinical manifestation includes jaundice and fever. The filling defect of the biliary tract tree might showed 4 appearances. (2)The patho-typing contributes to the clinical manifestation and the filling defect of the biliary tract tree.

Adult ; Aged ; Biliary Tract Diseases ; etiology ; pathology ; therapy ; Female ; Follow-Up Studies ; Humans ; Liver Transplantation ; Male ; Middle Aged ; Postoperative Complications ; etiology ; pathology ; therapy ; Prognosis ; Retrospective Studies

OBJECTIVETo investigate best diagnosing methods and therapy for patients with biliary tract complications after liver transplantation and analyze related factors.

METHODSA review was made of data collected from 96 patients, and confirmed by retrospective case notes examination.

RESULTSA total of 94 patients (97 grafts) survived more than 2 days after transplantation; of whom, 92 had an end-to-end biliary anastomosis with a T tube. The average follow-up was 5.8 months (range: 0.3 - 10.2 months). Among the 94 patients, eight (8.5%, 8/94) had complications: leakage during T-tube removal (2 patients), leakage at an earlier stage (2), simultaneous stricture and leak (2) and just stricture (2). Six patients with biliary tract complications had predisposing factors including hepatic artery stenosis (2 patients, including one hepatic artery stenosis combined with severe rejection, hepatic artery thrombosis (3), and donor-recipient bile duct mismatch (1). There was no difference in cold ischemic time. With hepatic artery thrombosis and/or stenosis > 50%, five patients were re-transplanted; without hepatic artery thrombosis and/or stenosis < 50%, three patients required endoscopic stenting and radiological percutaneous drainage of bile collection with or without balloon dilation. All patients survived.

CONCLUSIONSBiliary strictures occur later than leaks after surgery. Without hepatic artery thrombosis and/or stricture, there is no need for surgery; with hepatic artery thrombosis and/or stricture > 50%, re-transplantation is needed as early as possible.

Adult ; Biliary Tract Diseases ; etiology ; therapy ; Female ; Humans ; Liver Transplantation ; adverse effects ; Male ; Middle Aged ; Postoperative Complications ; etiology ; therapy ; Reoperation ; Retrospective Studies

An 84-year-old man was admitted to our hospital with fever, jaundice, and itching. He had been diagnosed previously with chronic renal failure and diabetes, and had been taking allopurinol medication for 2 months. A physical examination revealed that he had a fever (38.8degrees C), jaundice, and a generalized maculopapular rash. Azotemia, eosinophilia, atypical lymphocytosis, elevation of liver enzymes, and hyperbilirubinemia were detected by blood analysis. Magnetic resonance cholangiography revealed multiple cysts similar to choledochal cysts in the liver along the biliary tree. Obstructive jaundice was suspected clinically, and so an endoscopic ultrasound examination was performed, which ruled out a diagnosis of obstructive jaundice. The patient was diagnosed with DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) syndrome due to allopurinol. Allopurinol treatment was stopped and steroid treatment was started. The patient died from cardiac arrest on day 15 following admission.
Aged, 80 and over ; Allopurinol/adverse effects ; Biliary Tract/pathology ; Biliary Tract Diseases/diagnosis ; Bilirubin/blood ; Creatine/blood ; Drug Hypersensitivity Syndrome/*diagnosis/etiology ; Endosonography ; Eosinophils/cytology ; Humans ; Magnetic Resonance Angiography ; Male ; Tomography, X-Ray Computed

Endoscopic therapy by balloon dilation and placement of multiple large-bore plastic stents is the treatment of choice for benign biliary stricture. This approach is effective but it typically requires multiple endoscopic sessions given the short duration of stent patency. The endoscopic approach for treatment of bile leak involves the placement of a stent with or without biliary sphincterotomy. The self-expandable metal stent (SEMS) has traditionally been used for palliation of malignant biliary strictures given the long duration of stent patency owing to their larger stent diameter. Recently, SEMS has been used in a variety of benign biliary strictures and leaks, especially with the design of the covered self-expandable metal stent (CSEMS), which permits endoscopic-mediated stent removal. The use of CSEMS in benign biliary stricture could potentially result in a decrease in endoscopic sessions and it is technically easier when compared to placement of multiple plastic stents. However, complications such as cholecystitis due to blockage of cystic duct, stent migration, infection and pancreatitis have been reported. The potential subsegmental occlusion of contralateral intrahepatic ducts also limits the use of CSEMS in hilar stricture. Certain techniques and improvement of stent design may overcome these challenges in the future. Thus, CSEMS may be appropriate in only highly selected conditions, such as refractory benign biliary stricture, despite multiple plastic stent placement or difficult to treat bile duct stricture from chronic pancreatitis, and should not be used routinely. This review focuses on the use of fully covered self-expandable metal stent for benign biliary strictures and bile leaks.
*Bile ; Biliary Tract Diseases/diagnosis/etiology/*surgery ; Coated Materials, Biocompatible ; Constriction, Pathologic ; Diagnostic Imaging ; Equipment Design ; Foreign-Body Migration ; Humans ; Metals ; Plastics ; Postoperative Complications ; Sphincterotomy, Endoscopic ; *Stents