Biliary Atresia
Gianfranco Alpini, Domenico Alvaro, Marco Marzioni, Gene LeSage, Nicholas LaRusso in The Pathophysiology of Biliary Epithelia, 2020
Rare patients with “correctable” BA, atresia of the distal common bile duct, can be treated by choledochojejunostomy. Most other cases do not have patent extrahepatic ducts and are treated by Kasai hepatoportoenterostomy. Once the diagnosis of BA has been confirmed by intraoperative cholangiogram and liver biopsy, the gallbladder and fibrous common bile duct are used as traction as the dissection is continued up towards the liver. The cone of fibrous extrahepatic duct is amputated flush with the surface of the liver. The fibrous cone is sent for frozen section to determine if microscopic bile ducts are present. A limb of jejunum is sewn up to the cut surface and a Roux-en-Y anastomosis created. There are many variations of this surgical procedure, most designed to decompress the jejunal conduit and/or add an intussusception valve to reduce the risk of ascending cholangitis.
Infections in Solid Organ Transplant Recipients Admitted to the Critical Care Unit
Cheston B. Cunha, Burke A. Cunha in Infectious Diseases and Antimicrobial Stewardship in Critical Care Medicine, 2020
In OLT recipients, intra-abdominal infections may be responsible for 50% of bacterial complications along with significant morbidity [48], including intra-abdominal abscess, biliary tree infection, and peritonitis [49,50]. Risk factors are prolonged duration of surgery, transfusion of large volumes of blood products, choledochojejunostomy (Roux-en-Y) instead of a choledochostomy (duct-to-duct) for biliary anastomosis, repeat abdominal surgery, biliary-tract dehiscence or obstruction, intra-abdominal hematoma, vascular problems in the allograft (e.g., thrombosis of the hepatic artery or ischemia of the biliary tract may condition cholangitis episodes and liver abscesses), previous antibiotic therapy, and CMV infection [51]. Occasionally, complications will appear after a procedure such as a liver biopsy or a cholangiography. These infections may be bacteremic, and OLT recipients show the highest rate of secondary bloodstream infections (BSI) [52]. Most common microorganisms include Enterobacteriaceae, enterococci, anaerobes and Candida spp.
The Pancreas and the Periampullary Area
E. George Elias in CRC Handbook of Surgical Oncology, 2020
Palliative management of pancreatic cancer should be aimed at relieving the obstructive jaundice, the anticipated duodenal obstruction, and the pain. The type of the by-pass procedure continues to be controversial. While some investigators recommend cholecystojejunostomy and claim that it gives the same results as other complicated procedures, it has its limitations. This operation has a slightly higher morbidity. It also cannot be performed if the patient had a previous cholecystectomy or if the cystic duct joins the common duct near the tumor. Roux-en-y choledochojejunostomy is the main acceptable procedure, yet I strongly believe that a choledo-choduodenostomy is very acceptable in those patients who have a short survival.11 Tumors of the periampullary area and the pancreas that extend and invade the duodenum rarely ever cause complete duodenal obstruction preventing the bile flow.
Quality of life after total pancreatectomy with islet autotransplantation for chronic pancreatitis in Japan
Published in Islets, 2023
Tadashi Takaki, Daisuke Chujo, Toshiaki Kurokawa, Akitsu Kawabe, Nobuyuki Takahashi, Kyoji Ito, Koji Maruyama, Fuyuki Inagaki, Koya Shinohara, Kumiko Ajima, Yzumi Yamashita, Hiroshi Kajio, Mikio Yanase, Chihaya Hinohara, Makoto Tokuhara, Yukari Uemura, Yoshihiro Edamoto, Nobuyuki Takemura, Norihiro Kokudo, Shinichi Matsumoto, Masayuki Shimoda
All patients underwent TP, which was performed using the standard technique. The pancreas was often atrophic, fibrotic, hard, and adherent to the surrounding tissue. The splenic artery and/or gastroduodenal artery were preserved until just before pancreatic resection to minimize the warm ischemia time. The spleen was resected in all cases. The pancreas was transported by the two-layer method28 after intraductal organ preservation29 and delivered to the cell processing facility for islet isolation. The gastrointestinal tract was reconstructed by simultaneous gastrojejunostomy and choledochojejunostomy. If necessary, a jejunal tube was placed for postoperative nutritional support. The patient then remained in the operating room with an open abdomen until islet transplantation.
Therapeutic targets for liver regeneration after acute severe injury: a preclinical overview
Published in Expert Opinion on Therapeutic Targets, 2020
Hidenobu Kojima, Kojiro Nakamura, Jerzy W. Kupiec-Weglinski
The impact of cholangitis on liver regeneration and postoperative outcomes was evaluated in 450 patients who underwent preoperative PVE and major hepatectomies [81]. The daily increase rate of nonembolized lobe was significantly lower in patients with cholangitis. There were also significant differences in post-hepatectomy liver failure, prothrombin time, total bilirubin levels, and infectious complications. This study suggested cholangitis might delay and aggravate liver regeneration. In the early phase after 70% PHx, the mRNA levels coding for HGF and EGF were significantly lower while those for IL-6, TNF-α, and toll-like receptor (TLR) 4 were all higher in rats with choledochojejunostomy, resulting in delayed restoration of the liver weight [82]. Cholangitis, common complication with choledochojejunostomy due to intestinal content reflux, might impair liver regeneration. A recent study showed that cholangiocyte senescence impaired the regenerative response of the liver parenchyma with the induction of hepatocyte senescence [83]. This might account for the loss of hepatocyte function in human PBC/PSC patients. Thus, biliary tree pathologies, such as cholangitis, PBC, and PSC might impair parenchymal regeneration.
Benefits and risks of the treatment with fibrates––a comprehensive summary
Published in Expert Review of Clinical Pharmacology, 2018
Bogusław Okopień, Łukasz Bułdak, Aleksandra Bołdys
Gallstones are relatively mild disease leading to occasional pain and discomfort in the right upper quadrant of the abdomen. But potential complications may be fatal and include bile duct obstruction, cholangitis, liver abscesses and acute pancreatitis. The reason for mentioning this is the propensity of fibrates to induce gallstones formation. The etiology of this process is connected with increased excretion of cholesterol via bile during administration of fibrates [45]. This can lead, in susceptible patients, to oversaturation of bile and formation of stones. According to the recently performed metaanalysis, the risk of acute pancreatitis (probably due to changes in bile constituent and cholelithiasis) was not increased in patients taking fibrates (relative risk––RR = 1.39 [95% CI (1.00–1.95)] [100]. Additionally in those trials fibrates were introduced to the therapy in mild hypertriglyceridemia (mean baseline TG levels varied between 145–184 mg/dL), which probably precluded their beneficial, preventive role in acute pancreatitis resulting from severe hypertriglyceridemia. However in a large-scale, multicenter FIELD study, fenofibrate use was associated with increased risk of acute pancreatitis––(0.8 vs. 0.5%; p = 0.031) [90]. It is problematic to draw conclusion from gathered data. The most reasonable approach is to prescribe fibrate for patients who may benefit the most, follow contraindications for fibrate and avoid fibrates in patients with gallstones or cholelithiasis.
Related Knowledge Centers
- Common Hepatic Duct
- Gastrointestinal Tract
- Pancreas
- Digestion
- Common Bile Duct
- Liver
- Bile
- Gallbladder
- Cystic Duct
- Ampulla of Vater