Endoscopic retrograde cholangiopancreatography in pancreatic and biliary tract disease in Korean children

AIM:To assess the indications,findings,therapeutic procedures,safety,and complications of endoscopic retrograde cholangiopancreatography(ERCP) performed in Korean children.METHODS:The demographic characteristics,indications for ERCP,findings,therapeutic procedures,and complications of 122 pediatric patients who underwent 245 ERCPs in the Asan Medical Center between June 1994 and March 2008 were investigated.RESULTS:The mean age of the 122 patients was 8.0 ± 4.2 years.Indications were biliary pathology in 78(64.0%),pancreatic pathology in 43(35.2%),and chronic abdominal pain in one.Biliary indications included choledochal cysts in 40,choledocholithiasis in 24,suspected sclerosing cholangitis in 8,trauma in 2,and other conditions in 4.Pancreatic indications includedacute pancreatitis in 7,acute recurrent pancreatitis in 11,chronic pancreatitis in 20,trauma in 3,and pancreatic mass in 2.Of the 245 ERCPs,success rate was 98.4% and 190(77.6%) were for therapeutic purposes,including endoscopic nasal drainage(51.8%),biliary sphincterotomy(38.0%),pancreatic sphincterotomy(23.3%),stent insertion(15.1%),stone extraction(18.8%),and balloon dilatation(11.0%).Complications were postERCP pancreatitis in 16(6.5%),ileus in 23(9.4%),hemorrhage in 2(0.8%),perforation in 2(0.8%),sepsis in 1(0.4%),and impacted basket in 1(0.4%).There were no procedure-related deaths,and most complications improved under supportive care.CONCLUSION:This study showed that there is a high incidence of choledochal cyst and diagnostic and therapeutic ERCP for the management of various biliary and pancreatic diseases was safe and effective in Korean children.

Reoperation for benign biliary tract diseases in 149 cases: causes and prevention

BACKGROUND: Failure to diagnose and treat benign bi- liary tract disease relatively common surgical disease may cause serious consequences. Since the introduction of B- mode ultrasonography, CT, or MRI early and accurate diagnosis of the disease has been possible. In clinical prac- tice, however, these methods have not been adequately used. Inappropriate surgical procedures can also lead to bile duct injury or stenosis after injury, residual cholecystitis, stenosis after cholangiojejunostomy, or stenosis of the Od- di' s sphincter. But improvement of the diagnosis and treat- ment of benign biliary tract disease remains a great chal- lenge to clinicians. METHODS: A total of 149 patients with benign biliary tract disease who had received reoperation from June 1988 to June 2001 were analyzed retrospectively. Among them 95 patients (63.76%) received operation twice and 38 (25.5%) underwent 3 operations. Sixteen patients (10.74%) needed 4 or more operations. The procedures for the first opera- tion included cholecystectomy (71 patients, 47.65%), cho- lecystectomy with exploration of the common bile duct (42, 28.19%), cholangiojejunostomy (21, 14.1%), and la- paroscopic cholecystectomy (15, 10.06%). RESULTS: The causes for reoperation included residual and recurrent bile duct stones in 53 patients (35.57%), bile duct injury or stenosis after injury in 41 (27.52%), residual cho- lecystitis with or without stones in 28 (18.8%), stenosis af- ter cholangiojejunostomy in 17 (11.41%), stenosis of the Oddi's sphincter in 5 (5.35%), and others in 5 (5.35%). Four patients (2.68%) died after operation. CONCLUSIONS: To prevent reoperation for benign biliary tract diseases, the following measures should be taken to in- crease preoperative diagnostic rate, to understand condi- tions of the biliary tract by using imaging techniques and cholangiography, to examine comprehensively and careful- ly with choledochoscopy, cholangiography and B-mode ul-trasonography intraoperatively, to choose appropriate ope- rative procedures to decrease the rate of residual stones, and to decide the time for the first repair according to inju- ry type of the bile duct. Roux-en-Y hepaticojejunostomy with cholangioplasty is the best operation for the recon- struction of the biliary tract.

CA19-9 antigen levels can distinguish between benign and malignant pancreaticobiliary disease

BACKGROUND:CA19-9 is a carbohydrate tumor-associated antigen which is frequently upregulated in pancreatobiliary neoplasia.However,it may also be elevated in patients with jaundice in the absence of a tumor due to biliary obstruction,and in other non-hepato-pancreatico-biliary conditions.This study aimed to evaluate whether CA19-9 levels could accurately differentiate between benign and malignant pancreatobiliary disease.METHODS:All patients referred to a single surgeon for investigation of pancreaticobiliary disease in 2003 in whom a firm diagnosis had been established were included.For malignant disease,a histological diagnosis was required but for benign disease a firm radiological diagnosis was deemed adequate.The patients were divided into 4 categories:pancreatic adenocarcinoma(PCa);cholangiocarcinoma(CCa);chronic pancreatitis(CP)and biliary calculous disease(Calc).Bilirubin and alkaline phosphatase levels corresponding to the point of assessment of CA19-9 were also noted.RESULTS:Final diagnoses were made of pancreatic adenocarcinoma(PCa,n=73),cholangiocarcinoma(CCa,n=19),ampullary carcinoma(Amp,n=7),neuroendocrine carcinoma(Neu,n=4),duodenal carcinoma(Duo,n=3),chronic pancreatitis(CP,n=115),and biliary calculous disease(Calc,n=27).Median CA19-9 levels(U/ml)were:PCa,653;CCa,408;Duo,403;Calc,27;CP,19;Neu,10.5;Amp,8(reference range:0-37).The CA19-9 levels were significantly greater for malignant than for benign disease,could differentiate PCa from CCa/Duo,and were significantly higher in unresectable than in resectable PCa.The sensitivity,specificity,positive predictive value(PPV)and negative predictive value(NPV)for CA19-9 were 84.9%,69.7%,67.7%and 86.1%,respectively.A ROC analysis provided an area under the curve for CA19-9 of 0.871(0.820-0.922),giving an optimal CA19-9 of 70.5 U/ml for differentiating benign from malignant pathology.Using this cut-off,the sensitivity was 82.1%,while specificity,PPV and NPV improved to 85.9%,81.3%and 86.5%,respectively.When standard radiology was included(US/ CT/MRCP)in the decision process,the results improved to 97.2%,88.7%,86.6%,and 97.7%.For benign disease,the CA19-9 correlated directly with the serum bilirubin,but for malignant disease,CA19-9 levels were elevated independent of the bilirubin level.CONCLUSIONS:CA19-9 is useful in the differentiation of pancreatobiliary disease and when using an optimized cut-off and combining with routine radiology,the diagnostic yield is improved significantly,thus stressing the importance of a multi-disciplinary approach to pancreatobiliary disease.

Management of occluded self-expanding biliary metal stents in malignant biliary disease

Background: Occlusion of self-expanding metal stents(SEMS) in malignant biliary obstruction occurs in up to 40% of patients. This study aimed to compare the different techniques to resolve stent occlusion in our collective of patients.Methods: Patients with malignant biliary obstruction and occlusion of biliary metal stent at a tertiary referral endoscopic center were retrospectively identified between April 1, 1994 and May 31, 2014. The clinical records were further analyzed regarding the characteristics of patients, malignant strictures, SEMS,management strategies, stent patency, subsequent interventions, survival time and case charges.Results: A total of 108 patients with biliary metal stent occlusion were identified. Seventy-nine of these patients were eligible for further analysis. Favored management was plastic stent insertion in 73.4% patients. Second SEMS were inserted in 12.7% patients. Percutaneous transhepatic biliary drainage and mechanical cleansing were conducted in a minority of patients. Further analysis showed no statistically significant difference in median overall secondary stent patency(88 vs. 143 days, P = 0.069), median survival time(95 vs. 192 days, P = 0.116), median subsequent intervention rate(53.4% vs. 40.0%, P = 0.501)and median case charge(€5145 vs. €3473, P = 0.803) for the treatment with a second metal stent insertion compared to plastic stent insertion. In patients with survival time of more than three months,significantly more patients treated with plastic stents needed re-interventions than patients treated with second SEMS(93.3% vs. 57.1%, P = 0.037).Conclusions: In malignant biliary strictures, both plastic and metal stent insertions are feasible strategies for the treatment of occluded SEMS. Our data suggest that in palliative biliary stenting, patients especially those with longer expected survival might benefit from second SEMS insertion. Careful patient selection is important to ensure a proper decision for either management strategy.

Empirical antibiotic treatment with piperacillin-tazobactam in Patients with microbiologically-documented biliary tract infections

AIM: To report our experience with empiric antimicrobial monotherapy (piperacillin/tazobactam, of which no data are available in such specific circumstances) in microbiologically-documented infections in patients with benign and malignant conditions of the biliary tract.METHODS: Twenty-three patients, 10 with benign and 13 with malignant conditions affecting the biliary tree and microbiologically-documented infections were recruited and the efficacy of empirical antibiotic therapy was assessed.RESULTS: The two groups featured similar demographic and clinical data. Overall, the infective episodes were most due to Gram negative agents, more than 60% of such episodes (mostly in malignant conditions) were preceded by invasive instrumental maneuvers. Empirical antibiotic therapy with a single agent (piperacillin/tazobactam) was effective in more than 80% of cases. No deaths were reported following infections. CONCLUSION: An empiric therapeutic approach with piperacillin/tazobactam is highly effective in biliary tract infections due to benign or malignant conditions.

Managing malignant biliary obstruction in pancreas cancer: Choosing the appropriate strategy

Most patients with pancreatic cancer develop malignant biliary obstruction.Treatment of obstruction is generally indicated to relieve symptoms and improve morbidity and mortality.First-line therapy consists of endoscopic biliary stent placement.Recent data comparing plastic stents to self-expanding metallic stents(SEMS)has shown improved patency with SEMS.The decision of whether to treat obstruction and the means for doing so depends on the clinical scenario.For patients with resectable disease,preoperative biliary decompression is only indicated when surgery will be delayed or complications of jaundice exist.For patients with locally advanced disease,self-expanding metal stents are superior to plastic stents for long-term patency.For patients with advanced disease,the choice of metallic or plastic stent depends on life expectancy.When endoscopic stent placement fails,percutaneous or surgical treatments are appropriate.Endoscopic therapy or surgical approach can be used to treat concomitant duodenal and biliary obstruction.

Pancreaticobiliary reflux in patients with a normal pancreaticobiliary junction:Pathologic implications

Knowledge on pancreaticobiliary reflux in normal pancreaticobiliary junction and its pathologic implications has experienced tremendous progress during the last few years.This editorial reviews the current knowledge on this condition and its pathological implications on gallbladder diseases.The following aspects were def ined appropriate for discussion:(1) Evidence of carcinogenesis associated with pancreaticobiliary reflux;(2) Evidence of pancreaticobiliary reflux in normal pancreaticobiliary junction;and(3) Evidence of sphincter of Oddi(SO) dysfunction as a cause of pancreaticobiliary reflux in normal pancreaticobiliary junction.The articles reviewed were selected and classif ied according to f ive levels of evidence:Level-this condition.Although an important body of research has been published regarding pancreaticobiliary reflux in normal pancreaticobiliary junction and its clinical significance,the current evidence does not fully support what has been suggested.Studies with evidence level Ι have not been undertaken.This is a fascinating subject of study,and if finally supported by evidence level Ι,the importance of this condition will constitute a major breakthrough in biliary pathology.

Biliary-colonic fistula caused by cholecystectomy bile duct injury

Biliary-colonic fistula is a rare complication after laparoscopic cholecystectomy. We present a case of post-cholecystectomy iatrogenic biliary injury that resulted in a fistula between the common hepatic duct and large bowel. Magnetic resonance cholangiopancreatography provided good visualization of injury even with concurrent normal level of alkaline phosphatase. Radiologic findings and surgical management of this condition are discussed in detail.

Biochemical and radiological predictors of malignant biliary strictures

AIM: Differentiation of benign biliary strictures (BBS) from malignant biliary strictures (MBS) remains difficult despite improvement in imaging and endoscopic techniques. The aim of this study was to identify the clinical, biochemical and or radiological predictors of malignant biliary strictures.METHODS: We retrospectively reviewed all charts of patients who had biliary strictures (BS) on endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous cholangiography (PTC) in case of unsuccessful ERCP from March 1998 to August 2002. Patient characteristics, clinical features, biochemical, radiological and biopsy results were all recorded. Stricture etiology was determined based on cytology,biopsy or clinical follow-up. A receiver operator characteristic (ROC) curve was constructed to determine the optimal laboratory diagnostic criterion threshold in predicting MBS.RESULTS: One hundred twenty six patients with biliary strictures were enrolled, of which 72 were malignant. The mean age for BBS was 53 years compared to 62.4 years for MBS (P=0.0006). Distal bile duct stricture was mainly due to a malignant process 48.6% vs 9% (P=0.001). Alkaline phosphates and AST levels were more significantly elevated in MBS (P=0.0002). ROC curve showed that a bilirubin level of 84 μmol/L or more was the most predictive of MBS with a sensitivity of 98.6%, specificity of 59.3% and a positive likelihood ratio of 2.42 (95% CI=0.649-0.810). Proximal biliary dilatation was more frequently encountered in MBS compared to BBS, 73.8% vs39.5% (P=0.0001). Majority of BBS (87%) and MBS (78%) were managed endoscopically.CONCLUSION: A serum bilirubin level of 84 μmol/L or greater is the best predictor of MBS. Older age, proximal biliary dilatation, higher levels of bilirubin, alkaline phosphatase, ALT and AST are all associated with MBS. ERCP is necessary to diagnose and treat benign and malignant biliary strictures.

Disease spectrum and use of cholecystolithotomy in gallstone ileus

BACKGROUND: Gallstone ileus is a heterogeneous and highly morbid condition that suffers from a lack of consensus regarding the timing and approach to management of the biliary tree and associated fistula. METHODS: We report three cases that demonstrate the spectrum of gallstone ileus with classical examples of both Barnard’s and Bouveret’s syndromes. Clinical presentation diagnostic imaging, surgical technique and outcome are discussed. RESULTS: One patient with Barnard’s syndrome presented with recurrent gallstone ileus. To minimize the risks of complex, definitive biliary surgery and avoid further recurrent episodes, a cholecystolithotomy was performed with effect Two cases of Bouveret’s syndrome were successfully managed with enterolithotomy/cholecystectomy and multivisceral resection respectively, thus highlighting the diverse nature of this disease and management options. CONCLUSIONS: Following enterolithotomy, potentially morbid definitive one-stage surgery in typically compromised, elderly patients needs to be weighed against the risk of recurrence and ongoing biliary pathology. We suggest the use of open cholecystolithotomy for the removal of residual gallstones when the patient is not suitable for definitive biliary surgery.

Liver involvement in patients with COVID-19 infection:A comprehensive overview of diagnostic imaging features

During the first wave of the pandemic,coronavirus disease 2019(COVID-19)infection has been considered mainly as a pulmonary infection.However,different clinical and radiological manifestations were observed over time,including involvement of abdominal organs.Nowadays,the liver is considered one of the main affected abdominal organs.Hepatic involvement may be caused by either a direct damage by the virus or an indirect damage related to COVID-19 induced thrombosis or to the use of different drugs.After clinical assessment,radiology plays a key role in the evaluation of liver involvement.Ultrasonography(US),computed tomography(CT)and magnetic resonance imaging(MRI)may be used to evaluate liver involvement.US is widely available and it is considered the first-line technique to assess liver involvement in COVID-19 infection,in particular liver steatosis and portal-vein thrombosis.CT and MRI are used as second-and third-line techniques,respectively,considering their higher sensitivity and specificity compared to US for assessment of both parenchyma and vascularization.This review aims to the spectrum of COVID-19 liver involvement and the most common imaging features of COVID-19 liver damage.

Experiences relating to management of biliary tract complications following liver transplantation in 96 cases

OBJECTIVE: To investigate best diagnosing methods and therapy for patients with biliary tract complications after liver transplantation and analyze related factors. METHODS: A review was made of data collected from 96 patients, and confirmed by retrospective case notes examination. RESULTS: A 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%, re-transplantation is needed as early as possible.

Pyogenic liver abscess: Differences in etiology and treatment in Southeast Asia and Central Europe

Knowledge of etiology and timely treatment of underlying causes,when possible,play an important role in the successful therapy of patients with pyogenic liver abscess (PLA).Recent publications from Central Europe and Southeast Asia hint at considerable differences in etiology.In this article,we aim to elaborate these differences and their therapeutic implications.Apart from some special types of PLA that are comparable in Southeast Asia and Central Europe (such as posttraumatic or postprocedural PLA),there are clear differences in the microbiological spectrum,which implies different risk factors and disease courses.Klebsiella pneumoniae (K.pneumoniae) PLA is predominantly seen in Southeast Asia,whereas,in Central Europe,PLA is typically caused by Escherichia coli,Streptococcus or Staphylococcus,and these patients are more likely to be older and to have a biliary abnormality or malignancy.K.pneumoniae patients are more likely to have diabetes mellitus.Control of septic spread is crucial in K.pneumoniae patients,whereas treatment of the underlying diseases is decisive in many Central European PLA patients.

Generalized megaviscera of lupus:Refractory intestinal pseudo-obstruction,ureterohydronephrosis and megacholedochus

Dilated dysfunction involving multiple visceral organs has been reported in patients with systemic lupus erythematosus （SLE）. Chronic intestinal pseudoobstruction （CIPO） resulting from intestinal smooth muscle damage has presented in conjunction with ureterohydronephrosis and, more rarely, biliary dilatation （megacholedochus）. While the molecular pathogenesis is largely unknown, observed histopathologic features include widespread myositis, myocyte necrosis in the intestinal muscularis propria with subsequent atrophy and fibrosis, preserved myenteric innervations and little vasculitis. High dose immunosuppression usually results in resolution of symptoms with recovery of smooth muscle function, indicative of an autoimmune etiology. We report a patient with SLE who presented with intestinal pseudo-obstruction, ureterohydronephrosis and megacholedochus, and present images that illustrate megaviscera simultaneously involving all 3 visceral organs. Since the co-manifestation of all 3 is unusual and has been reported only once previously, we have termed this rare clinical syndrome generalized megaviscera of lupus （GML）. Although the SLE disease-activity parameters responded to aggressive immunomodulative therapy in our patient, clinical evidence of peristaltic dysfunction persisted in all involved viscera. This is a variation from the favorable outcomes reported previously in SLE patients with GML and we attribute this poor clinical outcome to disease severity and, most importantly, delayed clinical presentation. Since inflammation followed by atrophy and fibrosis are key aspects in the pathogenesis and natural history of GML, the poor response in our patient who presented late in the clinical course may be the result of ＇burnt out＇ inflammation with irreversible end-stage fibrosis. Thus, early recognition and timely initiation of treatment may be the key to recover visceral peristaltic function in patients with GML.

Clinical analysis of patients with iatrogenic bile duct injury

BACKGROUND: The main cause of iatrogenic bile duct injury is misidentification of the common bile duct as the cystic duct. In this article, we summarize the experience in the treatment of 112 patients with iatrogenic bile duct injury. METHOD: Clinical data of these patients treated at 10 hospitals of Songhua river area, Heilongjiang province, China from January 1978 to January 2005 were analyzed retrospectively. RESULTS: In 55.4% patients (62/112), iatrogenic bile duct injury was due to misidentification of the anatomy of Calot's triangle before cholecystectomy. Their diagnosis was based on clinical features, celiac puncture and imaging examination in which ultrasonography was most sensitive, giving a diagnostic rate of 97. 5%. Six types of injury were identified according to their locations, and type Ⅲ damage was commonly seen ( 92/112 ). The curative rate in this group was 95.5% (107/112). Eighty-seven patients (77.7%) underwent Roux-en-Y choledochojejunostomy with a cure rate of 94.3% (82/87). CONCLUSION: The prevention of iatrogenic bile duct injury lies in identifying the topography of extrahepatic bile ducts. Roux-en-Y choledochojejunostomy is usually the treatment of choice.

Carbohydrate antigen 19-9 — tumor marker: Past, present, andfuture

Carbohydrate antigen 19-9 (CA 19-9) is a cell surface glycoprotein complex mostcommonly associated with pancreatic ductal adenocarcinoma (PDAC). Koprowskifirst described it in 1979 using a mouse monoclonal antibody in a colorectalcarcinoma cell line. Historically, it is one of the most commonly used tumormarkers for diagnosing, managing, and prognosticating PDAC. Additionally,elevated CA 19-9 levels are used as an indication for surgery in suspected benignpancreatic conditions. Another common application of CA 19-9 in the biliary tractincludes its use as an adjunct in diagnosing cholangiocarcinoma. However, itsclinical value is not limited to the hepatopancreatobiliary system. The reality isthat the advancing literature has broadened the clinical value of CA 19-9. Thepotential value of CA 19-9 in patients' workup extends its reach to gastrointestinalcancers – such as colorectal and oesophageal cancer – and further beyond thegastrointestinal tract - including urological, gynecological, pulmonary, andthyroid pathologies. Apart from its role in investigations, CA 19-9 presents apotential therapeutic target in PDAC and acute pancreatitis. In a bid toconsolidate its broad utility, we appraised and reviewed the biomarker’s currentutility and limitations in investigations and management, while discussing thepotential applications for CA 19-9 in the works for the future.

Diagnostic role of secretin-enhanced MRCP in patients with unsuccessful ERCP

AIM:To evaluate the value of MR cholangiopancreatography (MRCP)in patients in whom endoscopic retrograde cholangiopancreatography(ERCP)was unsuccessfully performed by experts in a tertiary center. METHODS:From January 2000 to June 2003,22 patients fulfilled the inclusion criteria.The indications for ERCP were obstructive jaundice(n=9),abnormal liver enzymes(n=8), suspected chronic pancreatitis(n=2),recurrent acute pancreatitis(n=2),or suspected pancreatic cancer(n=1). The reasons for the ERCP failure were the postsurgical anatomy(n=7),duodenal stenosis(n=3),duodenal diverticulum(n=2),and technical failure(n=10).MRCP images were evaluated before and 5 and 10 rain after i.v. administration of 0.5 IU/kg secretin. RESULTS:The MRCP images were diagnosed in all 21 patients.Five patients gave normal MR findings and required no further intervention.MRCP revealed abnormalities(primary sclerosing cholangitis,chronic pancreatitis,cholangitis,cholecystolithiasis or common bile duct dilation)in 20 patients,who were followed up clinically.Four patients subsequently underwent laparotomy(hepaticojejunostomy in consequence of common bile duct stenosis caused by unresectable pancreatic cancer;hepaticotomy+Kehr drainage because of insufficient biliary-enteric anastomosis;choledochoj- ejunostomy,gastrojejunostomy and cysto-Wirsungo gastrostomy because of chronic pancreatitis,or choledochojejunostomy because of common bile duct stenosis caused by chronic pancreatitis).Three patients participated in therapeutic percutaneous transhepatic drainage.The indications were choledocholithiasis with choledochojejunostomy,insufficient biliary-enteric anastomosis,or cholangiocarcinoma. CONCLUSION:MRCP can assist the diagnosis and management of patients in whom ERCP is not possible.

Risk factors of choledocholithiasis formation after liver transplantation

Systematic study of risk factors for biliary stone post-liver transplantation is rarely performed. To investigate the risk factor of choledocholithiasis formation after liver transplantation, we c onducted a case-control study. Fourteen patients were selected into a study group. The stones of the bile duct of the patients were confirmed and treated successfully by endoscopic retrograde cholangiopancreatography. For univariate analysis, we selected carefully some potential risk factors such as cold ischemia time, warm ischemia time, and biliary stricture. The results revealed that cold ischemia time and biliary stenosis were significant predictors. But multivariate analysis revealed that only biliary stenosis was a significant risk factor. In conclusion, biliary stenosis is a risk factor of bile duct stones formation after liver transplantation. Endoscopic retrograde cholangiopancreatography is effective and safe in the diagnosis or treatment of bile duct stones after liver transplantation.

Instrumental detection of cystic duct stones during laparoscopic cholecystectomy

Residual cystic duct stones (CDSs) after cholecystectomy have been recognized as a cause of post cholecystectomy pain. This study was undertaken to determine the incidence of CDSs during laparoscopic cholecystectomy(LC). A cohort of 330 consecutive patients (80 males and 250females) undergoing LC between November 2006 and May2010 was studied. Their age ranged between 16 and 88 years(median 50, IQR: 36.62). The data were prospectively collected of preoperative liver function tests, imaging, the presence of intraoperative CDSs, and common bile duct stones at on-table cholangiogram. CDSs were detected intraoperatively in 64 of the 330 patients (19%). Ultrasound failed to detect CDSs in any of these cases. Deranged liver function tests were noted in 73% of the patients with CDSs and in 57% without CDSs Common bile duct stones were detected in 9% (29) of the 330patients. CDSs occur commonly at routine cholecystectomy, and preoperative investigations are not helpful in their diagnosis As CDSs may lead to postoperative morbidity, they should be actively sought out during surgery if present.

Clinical features and treatment of sump syndrome following hepaticojejunostomy

BACKGROUND:Cholangitis after Roux-en-Y hepaticojejunostomy is usually caused by anastomotic stricture.A small number of cases present without evidence of obstruction and are ascribed to reflux of gastro-intestinal content into the biliary tree above the anastomosis (sump syndrome).Despite prophylactic rotating antibiotic therapy,the cholangitic episode may be severe and life-threatening.METHODS:From 2001 to 2006,six patients who had undergone an end-to-side hepaticojejunostomy presented to our institution with recurrent episodes of biliary sepsis.Anastomotic stricture was excluded by liver MRI/MRCP and percutaneous transhepatic cholangiogram (PTC).Barium meal showed reflux of contrast into the biliary tree in all patients.Three patients had a short jejunal Roux limb (less than 50 cm) on pre-operative imaging.RESULTS:Five patients underwent surgery and two of them had two operations.One patient had a Tsuchida antireflux valve and subsequently underwent lengthening of the Roux loop.Three patients had lengthening of the Roux loop;one underwent re-do hepaticojejunostomy and one had concomitant revision of the hepaticojejunostomy and lengthening of the Roux loop.The latter underwent further lengthening of the Roux loop.Three patients are cholangitis-free 6,36 and 60 months after surgery;two still experience mild episodes of cholangitis.CONCLUSIONS:An adequate length of the Roux loop is important to prevent reflux.However,Roux loop lengthening to 70 cm or more does not always resolve the problem and cholangitis,although generally less frequent and severe,may recur despite appropriate reconstructive or antireflux surgery.In these cases,life-long rotating antibiotics is the only available measure.