- 作者列表："Schreuder AM","Busch OR","Besselink MG","Ignatavicius P","Gulbinas A","Barauskas G","Gouma DJ","van Gulik TM
BACKGROUND:Bile duct injury (BDI) is a devastating complication following cholecystectomy. After initial management of BDI, patients stay at risk for late complications including anastomotic strictures, recurrent cholangitis, and secondary biliary cirrhosis. METHODS:We provide a comprehensive overview of current literature on the long-term outcome of BDI. Considering the availability of only limited data regarding treatment of anastomotic strictures in literature, we also retrospectively analyzed patients with anastomotic strictures following a hepaticojejunostomy (HJ) from a prospectively maintained database of 836 BDI patients. RESULTS:Although clinical outcomes of endoscopic, radiologic, and surgical treatment of BDI are good with success rates of around 90%, quality of life (QoL) may be impaired even after "clinically successful" treatment. Following surgical treatment, the incidence of anastomotic strictures varies from 5 to 69%, with most studies reporting incidences around 10-20%. The median time to stricture formation varies between 11 and 30 months. Long-term BDI-related mortality varies between 1.8 and 4.6%. Of 91 patients treated in our center for anastomotic strictures after HJ, 81 (89%) were treated by percutaneous balloon dilatation, with a long-term success rate of 77%. Twenty-four patients primarily or secondarily underwent surgical revision, with recurrent strictures occurring in 21%. CONCLUSIONS:The long-term impact of BDI is considerable, both in terms of clinical outcomes and QoL. Treatment should be performed in tertiary expert centers to optimize outcomes. Patients require a long-term follow-up to detect anastomotic strictures. Strictures should initially be managed by percutaneous dilatation, with surgical revision as a next step in treatment.
背景: 胆管损伤 (BDI) 是胆囊切除术后的严重并发症。在BDI初始治疗后，患者仍处于晚期并发症的风险中，包括吻合口狭窄、复发性胆管炎和继发性胆汁性肝硬化。 方法: 我们提供了关于BDI的长期结果的当前文献的全面概述。考虑到文献中关于吻合口狭窄治疗的数据有限，我们还回顾性分析了836例BDI患者的前瞻性维护数据库中肝管空肠吻合术 (HJ) 后吻合口狭窄患者。 结果: 尽管内镜、放射学和外科治疗BDI的临床结果良好，成功率约为90%，但即使在 “临床成功” 治疗后，生活质量 (QoL) 也可能受损。手术治疗后，吻合口狭窄的发生率为5-69%，大多数研究报告发生率约为10-20%。狭窄形成的中位时间在11和30个月之间变化。长期BDI相关死亡率在1.8和4.6% 之间变化。在我中心治疗的91例HJ术后吻合口狭窄患者中，经皮球囊扩张治疗81例 (89%)，远期成功率为77%。24例患者主要或次要接受了手术翻修，21% 发生了复发性狭窄。 结论: 无论在临床结果还是QoL方面，BDI的长期影响都是相当大的。治疗应在三级专家中心进行，以优化结果。患者需要长期随访以发现吻合口狭窄。狭窄应首先通过经皮扩张进行治疗，并将手术翻修作为下一步治疗。
METHODS:AIM:To investigate the value of contrast enhanced ultrasound with high resolution linear transducers (HF-CEUS) for differential diagnosis of focal fundal gallbladder (GB) wall thickening. METHODS:A total of 32 patients with incidentally detected focal fundal GB wall thickening were included. After conventional B mode ultrasound (BMUS) examinations, HF-CEUS were performed with a 7.5-12 MHz 9L4 linear transducer (S2000 HELX OXANA unit, Siemens). Two radiologists independently reviewed the HF-CEUS enhancement patterns to determine the differential features between malignancy and benignity with a five-point confidence scale. The diagnostic accuracy of BMUS and HF-CEUS for GB wall thickening was compared. The final gold standard was surgery with histological examination. RESULTS:Final diagnoses included GB adenocarcinoma (n = 16), adenomyomatosis (n = 12), Xanthogranulomatous (n = 2) and cholecystitis (n = 2). HF-CEUS features associated with GB adenocarcinoma including arterial phase inhomogeneous hyperenhancement, venous phase hypoenhancement and disruption of GB wall layer structure (P < 0.05). Two small (5 mm) liver metastasis were confirmed by HF-CEUS during the late phase liver sweep as hypoenhanced lesions. Nonenhanced Rokitansky-Aschoff sinuses were clearly observed in 83.3% focal adenomyomatosis. Overall sensitivity, specificity and accuracy for differentiation between malignant and benign focal fundal GB wall thickening of HF-CEUS and BMUS were 84.3% vs 53.1%, 90.6% vs 59.3% and 87.5% vs 56.2% (P < 0.005). CONCLUSIONS:CEUS performed with high frequency linear transducers could be a useful alternative in the differential diagnosis of focal fundal GB wall thickening on conventional ultrasound.
METHODS::Small-for-size graft (SFSG) syndrome after living donor liver transplantation (LDLT) is the dysfunction of a small graft, characterized by coagulopathy, cholestasis, ascites, and encephalopathy. It is a serious complication of LDLT and usually triggered by excessive portal flow transmitted to the allograft in the postperfusion setting, resulting in sinusoidal congestion and hemorrhage. Portal overflow injures the liver directly through nutrient excess, endothelial activation, and sinusoidal shear stress, and indirectly through arterial vasoconstriction. These conditions may be attenuated with portal flow modulation. Attempts have been made to control excessive portal flow to the SFSG, including simultaneous splenectomy, splenic artery ligation, hemi-portocaval shunt, and pharmacological manipulation, with positive outcomes. Currently, a donor liver is considered a SFSG when the graft-to-recipient weight ratio is less than 0.8 or the ratio of the graft volume to the standard liver volume is less than 40%. A strategy for transplanting SFSG safely into recipients and avoiding extensive surgery in the living donor could effectively address the donor shortage. We review the literature and assess our current knowledge of and strategies for portal flow modulation in LDLT.
METHODS:BACKGROUND:Seasonal variation in the occurrence of medical illnesses reflects the effect of the environment, provides insight into pathogenesis, and can assist health care administrators in allocating resources accordingly. Seasonal variation has been reported in various infectious and surgical diseases, but has been rarely studied in acute cholecystitis. Our objective was to study seasonal variation in acute cholecystitis at our institution. METHODS:We performed a retrospective analysis of patients who underwent cholecystectomy for acute cholecystitis from January 1988 to December 2018. Chi-square goodness-of-fit test was used to analyze seasonality of acute cholecystitis adjusting for variation in number of days between seasons. The number of days for seasons were taken as 92, 92, 91, and 90.25 for spring, summer, fall, and winter, respectively. RESULTS:Overall, 3924 patients underwent cholecystectomy for acute cholecystitis during the study period. The frequency of cholecystectomies performed varied between months (minimum February n = 259, maximum July n = 372, P < 0.001) and seasons (minimum winter n = 789, maximum summer n = 1101 P < 0.001). Age and gender distribution across months and seasons was similar (P > 0.05). CONCLUSIONS:Our findings confirm seasonal variation in occurrence of acute cholecystitis with summer season witnessing the most and the winter season encountering the least patients with acute cholecystitis. Validation of our findings through prospectively collected data at national level is the way forward.