BACKGROUND:To physiologically reconstruct the biliary tract,Crema et al suggested the application of the Monti principle to the biliary tract,already used in humans for the urinary tract.With this technique,a jejunal ...BACKGROUND:To physiologically reconstruct the biliary tract,Crema et al suggested the application of the Monti principle to the biliary tract,already used in humans for the urinary tract.With this technique,a jejunal segment is transversely retubularized.This study aimed to evaluate the efficacy of jejunal tube interposition between the common bile duct and duodenum in dogs.METHODS:Thirteen dogs underwent a laparoscopic common bile duct ligature,followed by a biliodigestive connection by jejunal tube interposition after one week.The levels of glutamic-pyruvic and glutamic-oxalacetic transaminases,total bilirubins,alkaline phosphatase and gamma-glutamyltransferase were assessed before surgery and thereafter weekly until euthanasia,which was performed 6 weeks after biliodigestive connection.RESULTS:Data on 9 dogs were analyzed statistically.The dogs presented with obstructive jaundice after common bile duct ligature,as confirmed by biochemical examination.They showed a statistically significant reduction in cholestasis after biliodigestive connection by jejunal tube interposition and were healthy until the end of the experiment.CONCLUSION:A statistically significant reduction was seen in total bilirubin and canalicular enzymes(alkaline phosphatase and gamma-glutamyltransferase)in the 9 dogs 6 weeks after biliodigestive connetion by jejunal tube interposition.展开更多
BACKGROUND:Endoscopic therapy has been successful in the management of biliary complications after both deceased donor liver transplantation(DDLT) and living donor liver transplantation(LDLT).LDLT is thought to be ass...BACKGROUND:Endoscopic therapy has been successful in the management of biliary complications after both deceased donor liver transplantation(DDLT) and living donor liver transplantation(LDLT).LDLT is thought to be associated with higher rates of biliary complications,but there are few studies comparing the success of endoscopic management of anastomotic strictures between the two groups.This study aims to compare our experience in the endoscopic management of anastomotic strictures in DDLT versus LDLT.METHODS:This is a retrospective database review of all liver transplant patients undergoing endoscopic retrograde cholangiopancreatography(ERCP) after liver transplantation.The frequency of anastomotic stricture and the time to develop and to resolve anastomotic stricture were compared between DDLT and LDLT.The response of anastomotic stricture to endoscopic therapy was also analyzed.RESULTS:A total of 362 patients underwent liver transplantation between 2003 and 2011,with 125 requiring ERCP to manage biliary complications.Thirty-three(9.9%) cases of DDLT and 8(27.6%) of LDLT(P=0.01) were found to have anastomotic stricture.When comparing DDLT and LDLT,there was no difference in the mean time to the development of anastomotic strictures(98±17 vs 172±65 days,P=0.11),likelihood of response to ERCP [22(66.7%) vs 6(75.0%),P=0.69],mean time to the resolution of anastomotic strictures(268±77 vs 125±37 days,P=0.34),and the number of ERCPs required to achieve resolution(3.9±0.4 vs 4.7±0.9,P=0.38).CONCLUSIONS:Endoscopic therapy is effective in the majority of biliary complications relating to liver transplantation.Anastomotic strictures occur more frequently in LDLT compared with DDLT,with equivalent endoscopic treatment response and outcomes for both groups.展开更多
Iatrogenic bile-duct injury post-laparoscopic cholecystectomy remains a major serious complication with unpredictable long-term results.We present a patient who underwent laparoscopic cholecystectomy for gallstones,in...Iatrogenic bile-duct injury post-laparoscopic cholecystectomy remains a major serious complication with unpredictable long-term results.We present a patient who underwent laparoscopic cholecystectomy for gallstones,in which the biliary injury was recognized intraoperatively.The surgical procedure was converted to an open one.The first surgeon repaired the injury over a T-tube without recognizing the anatomy and type of the biliary lesion,which led to an unusual biliary malrepair.Immediately postoperatively,the abdominal drain brought a large amount of bile.A T-tube cholangiogram was performed.Despite the contrast medium leaking through the abdominal drain,the malrepair was unrecognized.The patient was referred to our hospital for biliary leak.Ultrasound and cholangiography was repeated,which showed an unanatomical repair(right to left hepatic duct anastomosis over the T-tube),with evidence of contrast medium coming out through the abdominal drain.Eventually the patient was subjected to a definitive surgical treatment.The biliary continuity was reestablished by a Roux-en-Y hepatico-jejunostomy,over transanastomotic external biliary stents.The patient is now doing well 4 years after the second surgical procedure.In reviewing the literature,we found a similar type of injury but we did not find a similar surgical malrepair.We propose an algorithm for the treatment of early and late biliary injuries.展开更多
BACKGROUND Lynch syndrome(LS)is a hereditary cancer predisposition syndrome associated with increased risk of multiple cancers.While colorectal cancer surveillance decreases mortality in LS and is recommended by guide...BACKGROUND Lynch syndrome(LS)is a hereditary cancer predisposition syndrome associated with increased risk of multiple cancers.While colorectal cancer surveillance decreases mortality in LS and is recommended by guidelines,there is lack of evidence for the efficacy of surveillance for extra-colonic cancers associated with LS,including small intestinal cancer(SIC)and urinary tract cancer(UTC).Given the limited evidence,guidelines do not consistently recommend surveillance for SIC and UTC,and it remains unclear how often individuals will choose to undergo and follow through with extra-colonic surveillance recommendations.AIM To study factors associated with SIC and UTC surveillance uptake and outcomes in LS.METHODS This is an IRB-approved retrospective analysis of individuals with LS seen at a tertiary care referral center.Included individuals had a pathogenic or likely pathogenic variant in MLH1,MSH2,MSH6,PMS2,or EPCAM,or were a confirmed obligate carrier,and had at least one documented visit to our center.Information regarding SIC and UTC surveillance was captured for each individual,and detailed personal and family history was obtained for individuals who had an initial LS management visit in our center’s dedicated high-risk LS clinic between January 1,2017 and October 29,2020.During these initial management visits,all patients had in-depth discussions of SIC and UTC surveillance with 1 of 3 providers experienced in LS management to promote informed decision-making about whether to pursue SIC and/or UTC surveillance.Statistical analysis using Pearson’s chi-squared test and Wilcoxon rank-sum test was completed to understand the factors associated with pursuit and completion of SIC and UTC surveillance,and a P value below 0.05 was deemed statistically significant.RESULTS Of 317 individuals with LS,86(27%)underwent a total of 105 SIC surveillance examinations,with 5 leading to additional work-up and no SICs diagnosed.Additionally,99(31%)patients underwent a total of 303 UTC surveillance examinations,with 19 requiring further evaluation and 1 UTC identified.Of 155 individuals who had an initial LS management visit between January 1,2017 and October 29,2020,63(41%)chose to undergo SIC surveillance and 58(37%)chose to undergo UTC surveillance.However,only 26(41%)and 32(55%)of those who initially chose to undergo SIC or UTC surveillance,respectively,successfully completed their surveillance examinations.Individuals with a pathogenic variant in MSH2 or EPCAM were more likely to initially choose to undergo SIC surveillance(P=0.034),and older individuals were more likely to complete SIC surveillance(P=0.007).Choosing to pursue UTC surveillance was more frequent among older individuals(P=0.018),and females more frequently completed UTC surveillance(P=0.002).Personal history of cancer and family history of SIC or UTC were not significantly associated with electing nor completing surveillance.Lastly,the provider discussing SIC/UTC surveillance was significantly associated with subsequent surveillance choices.CONCLUSION Pursuing and completing SIC/UTC surveillance in LS is influenced by several factors,however broad incorporation in LS management is likely unhelpful due to low yield and frequent false positive results.展开更多
文摘BACKGROUND:To physiologically reconstruct the biliary tract,Crema et al suggested the application of the Monti principle to the biliary tract,already used in humans for the urinary tract.With this technique,a jejunal segment is transversely retubularized.This study aimed to evaluate the efficacy of jejunal tube interposition between the common bile duct and duodenum in dogs.METHODS:Thirteen dogs underwent a laparoscopic common bile duct ligature,followed by a biliodigestive connection by jejunal tube interposition after one week.The levels of glutamic-pyruvic and glutamic-oxalacetic transaminases,total bilirubins,alkaline phosphatase and gamma-glutamyltransferase were assessed before surgery and thereafter weekly until euthanasia,which was performed 6 weeks after biliodigestive connection.RESULTS:Data on 9 dogs were analyzed statistically.The dogs presented with obstructive jaundice after common bile duct ligature,as confirmed by biochemical examination.They showed a statistically significant reduction in cholestasis after biliodigestive connection by jejunal tube interposition and were healthy until the end of the experiment.CONCLUSION:A statistically significant reduction was seen in total bilirubin and canalicular enzymes(alkaline phosphatase and gamma-glutamyltransferase)in the 9 dogs 6 weeks after biliodigestive connetion by jejunal tube interposition.
文摘BACKGROUND:Endoscopic therapy has been successful in the management of biliary complications after both deceased donor liver transplantation(DDLT) and living donor liver transplantation(LDLT).LDLT is thought to be associated with higher rates of biliary complications,but there are few studies comparing the success of endoscopic management of anastomotic strictures between the two groups.This study aims to compare our experience in the endoscopic management of anastomotic strictures in DDLT versus LDLT.METHODS:This is a retrospective database review of all liver transplant patients undergoing endoscopic retrograde cholangiopancreatography(ERCP) after liver transplantation.The frequency of anastomotic stricture and the time to develop and to resolve anastomotic stricture were compared between DDLT and LDLT.The response of anastomotic stricture to endoscopic therapy was also analyzed.RESULTS:A total of 362 patients underwent liver transplantation between 2003 and 2011,with 125 requiring ERCP to manage biliary complications.Thirty-three(9.9%) cases of DDLT and 8(27.6%) of LDLT(P=0.01) were found to have anastomotic stricture.When comparing DDLT and LDLT,there was no difference in the mean time to the development of anastomotic strictures(98±17 vs 172±65 days,P=0.11),likelihood of response to ERCP [22(66.7%) vs 6(75.0%),P=0.69],mean time to the resolution of anastomotic strictures(268±77 vs 125±37 days,P=0.34),and the number of ERCPs required to achieve resolution(3.9±0.4 vs 4.7±0.9,P=0.38).CONCLUSIONS:Endoscopic therapy is effective in the majority of biliary complications relating to liver transplantation.Anastomotic strictures occur more frequently in LDLT compared with DDLT,with equivalent endoscopic treatment response and outcomes for both groups.
文摘Iatrogenic bile-duct injury post-laparoscopic cholecystectomy remains a major serious complication with unpredictable long-term results.We present a patient who underwent laparoscopic cholecystectomy for gallstones,in which the biliary injury was recognized intraoperatively.The surgical procedure was converted to an open one.The first surgeon repaired the injury over a T-tube without recognizing the anatomy and type of the biliary lesion,which led to an unusual biliary malrepair.Immediately postoperatively,the abdominal drain brought a large amount of bile.A T-tube cholangiogram was performed.Despite the contrast medium leaking through the abdominal drain,the malrepair was unrecognized.The patient was referred to our hospital for biliary leak.Ultrasound and cholangiography was repeated,which showed an unanatomical repair(right to left hepatic duct anastomosis over the T-tube),with evidence of contrast medium coming out through the abdominal drain.Eventually the patient was subjected to a definitive surgical treatment.The biliary continuity was reestablished by a Roux-en-Y hepatico-jejunostomy,over transanastomotic external biliary stents.The patient is now doing well 4 years after the second surgical procedure.In reviewing the literature,we found a similar type of injury but we did not find a similar surgical malrepair.We propose an algorithm for the treatment of early and late biliary injuries.
文摘BACKGROUND Lynch syndrome(LS)is a hereditary cancer predisposition syndrome associated with increased risk of multiple cancers.While colorectal cancer surveillance decreases mortality in LS and is recommended by guidelines,there is lack of evidence for the efficacy of surveillance for extra-colonic cancers associated with LS,including small intestinal cancer(SIC)and urinary tract cancer(UTC).Given the limited evidence,guidelines do not consistently recommend surveillance for SIC and UTC,and it remains unclear how often individuals will choose to undergo and follow through with extra-colonic surveillance recommendations.AIM To study factors associated with SIC and UTC surveillance uptake and outcomes in LS.METHODS This is an IRB-approved retrospective analysis of individuals with LS seen at a tertiary care referral center.Included individuals had a pathogenic or likely pathogenic variant in MLH1,MSH2,MSH6,PMS2,or EPCAM,or were a confirmed obligate carrier,and had at least one documented visit to our center.Information regarding SIC and UTC surveillance was captured for each individual,and detailed personal and family history was obtained for individuals who had an initial LS management visit in our center’s dedicated high-risk LS clinic between January 1,2017 and October 29,2020.During these initial management visits,all patients had in-depth discussions of SIC and UTC surveillance with 1 of 3 providers experienced in LS management to promote informed decision-making about whether to pursue SIC and/or UTC surveillance.Statistical analysis using Pearson’s chi-squared test and Wilcoxon rank-sum test was completed to understand the factors associated with pursuit and completion of SIC and UTC surveillance,and a P value below 0.05 was deemed statistically significant.RESULTS Of 317 individuals with LS,86(27%)underwent a total of 105 SIC surveillance examinations,with 5 leading to additional work-up and no SICs diagnosed.Additionally,99(31%)patients underwent a total of 303 UTC surveillance examinations,with 19 requiring further evaluation and 1 UTC identified.Of 155 individuals who had an initial LS management visit between January 1,2017 and October 29,2020,63(41%)chose to undergo SIC surveillance and 58(37%)chose to undergo UTC surveillance.However,only 26(41%)and 32(55%)of those who initially chose to undergo SIC or UTC surveillance,respectively,successfully completed their surveillance examinations.Individuals with a pathogenic variant in MSH2 or EPCAM were more likely to initially choose to undergo SIC surveillance(P=0.034),and older individuals were more likely to complete SIC surveillance(P=0.007).Choosing to pursue UTC surveillance was more frequent among older individuals(P=0.018),and females more frequently completed UTC surveillance(P=0.002).Personal history of cancer and family history of SIC or UTC were not significantly associated with electing nor completing surveillance.Lastly,the provider discussing SIC/UTC surveillance was significantly associated with subsequent surveillance choices.CONCLUSION Pursuing and completing SIC/UTC surveillance in LS is influenced by several factors,however broad incorporation in LS management is likely unhelpful due to low yield and frequent false positive results.
