Hilar cholangiocarcinoma (hCCA) is a primary liver tumor associated with a dimprognosis. The role of preoperative and palliative biliary drainage has long beendebated. The most common techniques are endoscopic retrogr...Hilar cholangiocarcinoma (hCCA) is a primary liver tumor associated with a dimprognosis. The role of preoperative and palliative biliary drainage has long beendebated. The most common techniques are endoscopic retrograde cholangiopancreatography(ERCP) and percutaneous transhepatic biliary drainage (PTBD);however, recently developed endoscopic ultrasound-assisted methods are gainingmore atention. Selecting the best available method in any specific scenario iscrucial, yet sometimes challenging. Thus, this review aimed to discuss theavailable techniques, indications, perks, pitfalls, and timing-related issues in themanagement of hCCA. In a preoperative setting, PTBD appears to have someadvantages: low risk of postprocedural complications (namely cholangitis) andbetter priming for surgery. For palliative purposes, we propose ERCP/PTBDdepending on the experience of the operators, but also on other factors: the levelof bilirubin (if very high, rather PTBD), length of the stenosis and the presence ofcholangitis (PTBD), ERCP failure, or altered biliary anatomy.展开更多
Hemostasis is a complex physiological process based on the balance between procoagulant and anticoagulant systems to avoid pathological bleeding or thrombosis.The changes in standard coagulation tests in liver disease...Hemostasis is a complex physiological process based on the balance between procoagulant and anticoagulant systems to avoid pathological bleeding or thrombosis.The changes in standard coagulation tests in liver disease were assumed to reflect an acquired bleeding disorder,and cirrhotic patients were considered naturally anticoagulated.In the light of the new evidence,the theory of rebalanced hemostasis replaced the old concept.According to this model,the hemostatic alteration leads to a unique balance between pro-coagulant,anticoagulant,and fibrinolytic systems.But the balance is fragile and may prone to bleeding or thrombosis depending on various risk factors.The standard coagulation tests[INR(international normalized ratio),platelet count and fibrinogen]only explore parts of the hemostasis,not offering an entire image of the process.Rotational thromboelastometry(ROTEM)and thromboelastography(TEG)are both point of care viscoelastic tests(VET)that provide real-time and dynamic information about the entire hemostasis process,including clot initiation(thrombin generation),clot kinetics,clot strength,and clot stability(lysis).Despite prolonged PT/INR(international normalized ratio of prothrombin time)and low platelet counts,VET is within the normal range in many patients with both acute and chronic liver disease.However,bleeding remains the dominant clinical issue in patients with liver diseases,especially when invasive interventions are required.VET has been shown to asses more appropriately the risk of bleeding than conventional laboratory tests,leading to decrial use of blood products transfusion.Inappropriate clotting is common but often subtle and may be challenging to predict even with the help of VET.Although VET has shown its benefit,more studies are needed to establish cut-off values for TEG and ROTEM in these populations and standardization of transfusion guidelines before invasive interventions in cirrhotic patients/orthotopic liver transplantation.展开更多
Background and Study Aims:We present ten patients who developed secondary sclerosing cholangitis following long-term treatment in an intensive care unit(ICU) between 1999 and 2004.Patients and Methods:Ten consecutive ...Background and Study Aims:We present ten patients who developed secondary sclerosing cholangitis following long-term treatment in an intensive care unit(ICU) between 1999 and 2004.Patients and Methods:Ten consecutive patients who had no evidence suggestive of pre-existing hepatobiliary disease were admitted to an ICU because of trauma(n = 5) ,intracerebral hemorrhage(n = 3) ,or nonabdominal postsurgical complications(n = 2) .All the patients had required treatment with long-term ventilation,catecholamines,total parenteral nutrition,and several antimicrobial agents.Results:Cholestasis was first noted within 11 days after the initial insult.Endoscopic retrograde cholangiopancreatography(ERCP) ,performed after a median follow-up of 69 days,revealed multifocal stricturing and beading of the intrahepatic bile ducts,and attenuation of the peripheral branches.In all the patients,the bile ducts were partially filled by black-pigmented thrombotic material.All the patients underwent endotherapy,which comprised sphincterotomy and removal of the occluding material,in an attempt to improve biliary drainage;the treatment had to be repeated in seven of the ten patients.After a median follow-up period of 21 months,despite transient clinical improvement following endotherapy,complete recovery has not been achieved in any of the patients and so far one patient has had to undergo orthotopic liver transplantation as a result of end-stage liver disease.Conclusions:The development of secondary sclerosing cholangit is in patients who have received long-term treatment in an ICU is a rare event of unknown pathophysiology,but patients demonstrate characteristic findings on ERCP.It is not known whether endotherapy can delay the progress of the condition in the long term.展开更多
文摘Hilar cholangiocarcinoma (hCCA) is a primary liver tumor associated with a dimprognosis. The role of preoperative and palliative biliary drainage has long beendebated. The most common techniques are endoscopic retrograde cholangiopancreatography(ERCP) and percutaneous transhepatic biliary drainage (PTBD);however, recently developed endoscopic ultrasound-assisted methods are gainingmore atention. Selecting the best available method in any specific scenario iscrucial, yet sometimes challenging. Thus, this review aimed to discuss theavailable techniques, indications, perks, pitfalls, and timing-related issues in themanagement of hCCA. In a preoperative setting, PTBD appears to have someadvantages: low risk of postprocedural complications (namely cholangitis) andbetter priming for surgery. For palliative purposes, we propose ERCP/PTBDdepending on the experience of the operators, but also on other factors: the levelof bilirubin (if very high, rather PTBD), length of the stenosis and the presence ofcholangitis (PTBD), ERCP failure, or altered biliary anatomy.
文摘Hemostasis is a complex physiological process based on the balance between procoagulant and anticoagulant systems to avoid pathological bleeding or thrombosis.The changes in standard coagulation tests in liver disease were assumed to reflect an acquired bleeding disorder,and cirrhotic patients were considered naturally anticoagulated.In the light of the new evidence,the theory of rebalanced hemostasis replaced the old concept.According to this model,the hemostatic alteration leads to a unique balance between pro-coagulant,anticoagulant,and fibrinolytic systems.But the balance is fragile and may prone to bleeding or thrombosis depending on various risk factors.The standard coagulation tests[INR(international normalized ratio),platelet count and fibrinogen]only explore parts of the hemostasis,not offering an entire image of the process.Rotational thromboelastometry(ROTEM)and thromboelastography(TEG)are both point of care viscoelastic tests(VET)that provide real-time and dynamic information about the entire hemostasis process,including clot initiation(thrombin generation),clot kinetics,clot strength,and clot stability(lysis).Despite prolonged PT/INR(international normalized ratio of prothrombin time)and low platelet counts,VET is within the normal range in many patients with both acute and chronic liver disease.However,bleeding remains the dominant clinical issue in patients with liver diseases,especially when invasive interventions are required.VET has been shown to asses more appropriately the risk of bleeding than conventional laboratory tests,leading to decrial use of blood products transfusion.Inappropriate clotting is common but often subtle and may be challenging to predict even with the help of VET.Although VET has shown its benefit,more studies are needed to establish cut-off values for TEG and ROTEM in these populations and standardization of transfusion guidelines before invasive interventions in cirrhotic patients/orthotopic liver transplantation.
文摘Background and Study Aims:We present ten patients who developed secondary sclerosing cholangitis following long-term treatment in an intensive care unit(ICU) between 1999 and 2004.Patients and Methods:Ten consecutive patients who had no evidence suggestive of pre-existing hepatobiliary disease were admitted to an ICU because of trauma(n = 5) ,intracerebral hemorrhage(n = 3) ,or nonabdominal postsurgical complications(n = 2) .All the patients had required treatment with long-term ventilation,catecholamines,total parenteral nutrition,and several antimicrobial agents.Results:Cholestasis was first noted within 11 days after the initial insult.Endoscopic retrograde cholangiopancreatography(ERCP) ,performed after a median follow-up of 69 days,revealed multifocal stricturing and beading of the intrahepatic bile ducts,and attenuation of the peripheral branches.In all the patients,the bile ducts were partially filled by black-pigmented thrombotic material.All the patients underwent endotherapy,which comprised sphincterotomy and removal of the occluding material,in an attempt to improve biliary drainage;the treatment had to be repeated in seven of the ten patients.After a median follow-up period of 21 months,despite transient clinical improvement following endotherapy,complete recovery has not been achieved in any of the patients and so far one patient has had to undergo orthotopic liver transplantation as a result of end-stage liver disease.Conclusions:The development of secondary sclerosing cholangit is in patients who have received long-term treatment in an ICU is a rare event of unknown pathophysiology,but patients demonstrate characteristic findings on ERCP.It is not known whether endotherapy can delay the progress of the condition in the long term.
