OBJECTIVE: To find the pathogenies and risk factors related to surgical intensive care unit (SICU) readmission for patients who underwent hepatobiliary-pancreatic surgery, and to develop a predictive model for determining patients who are likely to be readmitted to SICU. METHODS: The patients who admitted to SICU of the Affiliated Hospital of Qingdao University from January 2013 to August 2018; who first stayed in SICU after hepatobiliary-pancreatic surgery; who were assessed and discharged from SICU by surgeons and SICU physicians after treatment, and then transferred to SICU again because of the change of their condition were enrolled. The unintended return to SICU within 3 days and 7 days were recorded. Patients who returned to SICU within 7 days were studied for the pathogenies, risk factors and predictive model of returning to SICU, and non-returning patients were enrolled according to 1:1 as the controls. A total of 43 indicators were divided into five categories, including general clinical data, medical history, surgical indicators before first admission of SICU, length of first SICU stay, and other indicators on the day of first discharge from the SICU. Logistic regression was used to screen the risk factors associated with SICU readmission, then the Nomogram diagram was drawn by using the R 3.4.1 software for predicting SICU readmission, and the classification performance of Nomogram was evaluated by self-help sampling test. RESULTS: Of the 763 patients discharged from the SICU, 2.10% (16/763) of them were readmitted within 3 days and 3.28% (25/763) were readmitted within 7 days to the SICU unexpectedly. The pathogenies of SICU readmission within 7 days included infection [56.00% (14/25)], heart failure [16.00% (4/25)], infarction [12.00% (3/25)], bleeding [12.00% (3/25)], and sutures splitting [4.00% (1/25)]. The pathogenies of SICU readmission within 3 days included infection [56.25% (9/16)], heart failure [18.75% (3/16)], infarction [12.50% (2/16)], and bleeding [12.50% (2/16)]. Nomogram analysis showed that the risk factors associated with unplanned SICU readmission were length of first SICU stay, history of hypertension, and activity of daily living (ADL) score, white blood cell count (WBC), arterial partial pressure of oxygen (PaO₂), prothrombin time (PT), fibrinogen (FIB) on the day of first SICU discharge. Self-help sampling test was carried out on the Nomogram map, and the results showed that the coherence index (C-index) was 0.962 [95% confidence interval (95%CI) = 0.869-1.057]. The classification performance of the model was good. CONCLUSIONS The common pathogenies of SICU readmission for patients who underwent hepatobiliary-pancreatic surgery were infection, heart failure, infarction and bleeding. Risk factors of readmission after SICU discharge included the length of first SICU stay, history of hypertension, and ADL score, WBC, PaO₂, PT, FIB on the day of first SICU discharge. The model consisted of above risk factors showed a good performance in predicting the probability of readmission after SICU discharge for patients who underwent hepatobiliary-pancreatic surgery.
Biliary Tract Diseases/surgery* ; Digestive System Surgical Procedures/adverse effects* ; Humans ; Intensive Care Units ; Liver Diseases/surgery* ; Models, Statistical ; Pancreatic Diseases/surgery* ; Patient Readmission/statistics & numerical data* ; Postoperative Complications/therapy* ; Risk Factors

BACKGROUND/AIMS: Endoscopic therapy with endoscopic retrograde cholangiopancreatography (ERCP) has been suggested as an effective diagnostic and therapeutic tool for biliary and pancreatic disorders during pregnancy. In this report, we describe our experiences with pancreatobiliary endoscopic procedures during pregnancy. METHODS: We reviewed ERCP and endoscopic ultrasonography (EUS) procedures that were performed at a single tertiary care referral center between January 2002 and October 2013. Medical records were reviewed for the procedure indication, the duration of fluoroscopy, postprocedure complications, etc. Pregnancy outcomes and fetal complications were identified by chart review and phone calls to patients. RESULTS: A total of 10 ER-CPs and five EUSs were performed in 13 pregnant patients: four of whom underwent the procedure in the first trimester, eight in the second trimester, and one in the third trimester. Indications for endoscopic therapy included gallstone pancreatitis, obstructive jaundice with common bile duct (CBD) stone, asymptomatic CBD stone, pancreatic cyst, choledochal cyst, and acute cholecystitis. Only one patient had a complication, which was postprocedural hyperamylasemia. Two patients underwent an artificial abortion, one according to her own decision and the other due to an adverse drug reaction. CONCLUSIONS: ERCP seems to be effective and safe for pregnant women. Additionally, EUS can be an alternative to ERCP during pregnancy.
Adult ; Biliary Tract Diseases/*surgery ; Cholangiopancreatography, Endoscopic Retrograde/*adverse effects/methods ; Endosonography/*adverse effects/methods ; Female ; Fetus ; Humans ; Obstetric Surgical Procedures/*adverse effects/methods ; Pancreatic Diseases/*surgery ; Pregnancy ; Pregnancy Complications/*surgery ; Pregnancy Outcome ; Retrospective Studies ; Young Adult

No abstract available.
Biliary Tract Diseases/*surgery ; Cholangiopancreatography, Endoscopic Retrograde/*adverse effects ; Endosonography/*adverse effects ; Female ; Humans ; Obstetric Surgical Procedures/*adverse effects ; Pancreatic Diseases/*surgery ; Pregnancy ; Pregnancy Complications/*surgery

BACKGROUNDCurrently, the recommendation when treating acute biliary or pancreatic disease during pregnancy is to perform endoscopic retrograde cholangiopancreatography (ERCP) without radiation exposure, either empirically (with no radiographic guidance) or with ultrasound guidance. However, few published studies compared these two ways. This study aimed to compare ultrasound-guided ERCP with the procedure without radiographic guidance in the treatment of acute pancreaticobiliary disease in pregnant patients.

METHODSThe clinical data of 68 pregnant patients with acute pancreaticobiliary disease admitted to our hospital between January 2004 and May 2010 were reviewed retrospectively. ERCP was performed without radiographic guidance in 36 cases (group A) and with ultrasound guidance in 32 cases (group B). Data on the following variables were compared between the two groups: surgical success rate, rate of complete stone removal, time to resolution of clinical manifestations and laboratory indicators, length of hospital stay, complications, outcome and differences in efficacy of ERCP during different stages of pregnancy.

RESULTSIn group A, the rates of surgical success and complete removal of stones were 69% and 60%, respectively; the corresponding values were 91% and 89% in group B (P < 0.05). Postoperatively, clinical manifestations improved rapidly in all patients; there was no statistically significant difference between the groups (P > 0.05). Leukocyte counts and liver function had improved significantly after one week in all patients; they recovered more quickly in group B ((8.64 ± 1.83) days vs. (14.57 ± 3.74) days, (14.29 ± 4.64) days vs. (20.00 ± 5.40) days, P < 0.01). The hospital stay was shorter in group B ((16.28 ± 7.25) days vs. (28.00 ± 6.83) days, P < 0.001). The complication rate was 14% in group A and 3% in group B (P < 0.05). There were no significant differences between the two groups in the procedure's efficacy during different stages of pregnancy.

CONCLUSIONSIn the treatment of acute pancreaticobiliary disease during pregnancy, ultrasound-guided ERCP is safer and more effective than performing the procedure empirically without radiographic guidance when performed by experienced practitioners. Its more widespread use is recommended.

Acute Disease ; Adult ; Biliary Tract Diseases ; surgery ; Cholangiopancreatography, Endoscopic Retrograde ; methods ; Female ; Humans ; Pancreatic Diseases ; surgery ; Pregnancy ; Pregnancy Complications ; surgery ; Retrospective Studies ; Ultrasonography, Interventional

OBJECTIVE: The objective of this study was to evaluate the technical aspects and clinical efficacy of selective embolization for post-endoscopic sphincterotomy bleeding. MATERIALS AND METHODS: We reviewed the records of 10 patients (3%; M:F = 6:4; mean age, 63.3 years) that underwent selective embolization for post-endoscopic sphincterotomy bleeding among 344 patients who received arteriography for nonvariceal upper gastrointestinal bleeding from 2000 to 2009. We analyzed the endoscopic procedure, onset of bleeding, underlying clinical condition, angiographic findings, interventional procedure, and outcomes in these patients. RESULTS: Among the 12 bleeding branches, primary success of hemostasis was achieved in 10 bleeding branches (83%). Secondary success occurred in two additional bleeding branches (100%) after repeated embolization. In 10 patients, post-endoscopic sphincterotomy bleedings were detected during the endoscopic procedure (n = 2, 20%) or later (n = 8, 80%), and the delay was from one to eight days (mean, 2.9 days; +/- 2.3). Coagulopathy was observed in three patients. Eight patients had a single bleeding branch, whereas two patients had two branches. On the selective arteriography, bleeding branches originated from the posterior pancreaticoduodenal artery (n = 8, 67%) and anterior pancreaticoduodenal artery (n = 4, 33%), respectively. Superselection was achieved in four branches and the embolization was performed with n-butyl cyanoacrylate. The eight branches were embolized by combined use of coil, n-butyl cyanoacrylate, or Gelfoam. After the last embolization, there was no rebleeding or complication related to embolization. CONCLUSION: Selective embolization is technically feasible and an effective procedure for post-endoscopic sphincterotomy bleeding. In addition, the posterior pancreaticoduodenal artery is the main origin of the causative vessels of post-endoscopic sphincterotomy bleeding.
Aged ; Aged, 80 and over ; Angiography, Digital Subtraction ; Biliary Tract Diseases/radiography/*surgery ; Cholangiopancreatography, Endoscopic Retrograde ; Embolization, Therapeutic/*methods ; Female ; Gastrointestinal Hemorrhage/*etiology/radiography/*therapy ; Humans ; Male ; Middle Aged ; Postoperative Complications/*etiology/radiography/*therapy ; Retrospective Studies ; *Sphincterotomy, Endoscopic ; Treatment Outcome

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

Recent progress in chemotherapy has prolonged the survival of patients with malignant biliary strictures, leading to increased rates of stent occlusion. Even we employed metallic stents which contributed to higher rates and longer durations of patency, and occlusion of covered metallic stents now occurs in about half of all patients during their survival. We investigated the complication and patency rate for the removal of covered metallic stents, and found that the durations were similar for initial stent placement and re-intervention. In order to preserve patient quality of life, we currently recommend the use of covered metallic stents for patients with malignant biliary obstruction because of their removability and longest patency duration, even though uncovered metallic stents have similar patency durations.
Biliary Tract Diseases/*surgery ; Coated Materials, Biocompatible ; Device Removal ; Drainage/methods ; Endoscopy ; Foreign-Body Migration/surgery ; Humans ; Metals ; Postoperative Complications/surgery ; *Stents/adverse effects

Endoscopic retrograde biliary drainage (ERBD) is useful for the palliative decompression of biliary obstruction. However, the complications of ERBD include cholangitis, hemorrhage, acute pancreatitis, obstruction of the stent, and duodenal perforation. Pressure necrosis on the duodenal mucosa by the stent may contribute to perforation. Although duodenal perforation following ERBD is very rare compared to other complications, it can result in a fatal outcome. Recent reports describe nonsurgical treatment for small gastrointestinal perforation with localized peritonitis and suggest that endoclipping may be appropriate in the management of a well selected group of patients with iatrogenic perforation. We describe a case of duodenal perforation secondary to ERBD that was successfully treated with approximating using endoclip and detachable snare.
Bile Ducts, Extrahepatic ; Biliary Tract Diseases/complications/surgery ; Cholangiopancreatography, Endoscopic Retrograde ; Drainage ; Duodenal Diseases/*diagnosis/etiology/therapy ; Female ; Gallbladder Neoplasms/diagnosis ; Humans ; Intestinal Perforation/*diagnosis/etiology/therapy ; Middle Aged ; Plastics ; Stents/*adverse effects ; Tomography, X-Ray Computed

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

OBJECTIVETo evaluate the therapeutic effect of subcutaneous tunnel hepaticoplasty on the treatment of hepatolithiasis.

METHODSThe early complications and clinical effects of 99 hepatolithiasis cases who underwent subcutaneous tunnel hepaticoplasty from January 1993 to August 2006 were analyzed retrospectively. The stones of 28 (28.3%) patients were in the left lobe, 24.2% (24/99) in the right, and 47.5% (47/99) in bilateral lobe. Sixty-six patients (66.7%) had both stones and biliary strictures. During the procedure, a portion of the liver habouring stone was resected if necessary. The hepatic duct and strictures were opened, the stones were removed, and the porta hepatis was repaired by one end of a segment of jejunum. The other end of the jejunum was set subcutaneously. The gall bladders of 27 patients (27.3%) were used as subcutaneous tunnel instead.

RESULTSNinety-five out of ninety-nine cases were followed up with an average of 4.2 years (1 month to 13.5 years). The rates of residual stone, recurrent stone and cholangitis were 23.2% (23/99), 20.0% (19/95) and 14.7% (14/95) respectively. Postoperatively, 34 cases who had residual or recurrent stones were underwent lithotomy by choledochoscope through the subcutaneous blind loop and the achievement ratio was 91.2% (31/34).

CONCLUSIONSSubcutaneous tunnel hepatocholangioplasty decreases the relapsing cholangitis effectively, and makes an easy way to take out residual or recurrent stones.

Adolescent ; Adult ; Aged ; Aged, 80 and over ; Bile Ducts, Intrahepatic ; pathology ; surgery ; Biliary Tract Surgical Procedures ; methods ; Cholelithiasis ; pathology ; surgery ; Female ; Follow-Up Studies ; Hepatectomy ; methods ; Humans ; Liver Diseases ; pathology ; surgery ; Male ; Middle Aged ; Postoperative Complications ; etiology ; prevention & control ; Recurrence ; Retrospective Studies ; Treatment Outcome