• Journal of radiological science and technology
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• v.20 no.1
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• pp.43-49
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• 1997

Purpose of this paper is to extend help for clinical application in balloon cholangiography on patients who have undergone endoscopic sphincterotomy, impacted stones of intrahepatic duct, and missed bile duct because of other diseases in operating endoscopic retrograde cholangiopancreatography. This study was done for the patients who had clinical signs of biliary diseases from January to December In 1996. We studied 45 patients who had endoscopic sphincterotomy, re-examination after interventional treatment of the endoscopic retrograde cholangiopancreatography, and uncertain diagnosis due to common bile duct and intrahepatic duct those are not filled with contrast media. Balloon cholangiography was performed in case of uncertain diagnosis while operating endoscopic retrograde cholangiopancreatography. First of all, we insert balloon catheter Into the working channel of treatment jejunofiberscope and remove treatment Jejunofiberscope after ballooning, and lastly take biliary tract X-ray after Injection and changing position of patient. The results of this study were as follows. (1) In classification of diseases, stones of gall bladder, those of common bile duct, and those of intrahepatic duct were 30 cases, fistula was 1 case. (2) In total cases of 45, only diagnosis were 25 cases, interventional treatment were 20 cases. (3) In case of interventional treatment, endoscopic sphincterotomy and endoscopic nasobiliary drainage, and stone removal were about the same, 7, 7, 6 respectively. Balloon cholangiography will be useful to prevent patients from having repeated and unnecessary studies for the cases above explained. It is considered that this study will be useful for clinical application in terms of reducing medical expenses, pain while examination, and consultation hours.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.27 no.3
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• pp.287-291
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• 2023

Backgrounds/Aims: Pancreaticoduodenectomy (PD) is commonly performed pancreatic procedure for tumors of periampullary region. Delayed gastric emptying (DGE) and pancreatic fistula are the most common specific complications following PD. DGE can lead to significant morbidity, resulting in prolonged hospital stay and increased cost. Various factors might influence the occurrence of DGE. We hypothesized that kinking of jejunal limb could be a cause of DGE post PD. Methods: Antecolic (AC) and retrocolic (RC) side-to-side gastrojejunostomy (GJ) groups in classical PD were compared for the occurrence of DGE in a prospective study. All patients who underwent PD between April 2019 and September 2020 in a tertiary care center in south India were included in this study. Results: After classic PD, RC GJ was found to be superior to AC in terms of DGE rate (26.7% vs. 71.9%) and hospital stay (9 days vs. 11 days). Conclusions: Route of reconstruction of GJ can influence the occurrence of DGE as RC anastomosis in classical PD provides the most straight route for gastric emptying.

• Tuberculosis and Respiratory Diseases
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• v.70 no.3
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• pp.261-265
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• 2011

Cholethorax is a bilious pleural effusion caused by a pleurobiliary fistula or leakage of bile into the pleural space. Most cases of cholethorax arise from a complication of abdominal trauma, hepatobiliary infection, or invasive procedures or surgery of hepatobiliary system. However, we experienced a case of a patient with cholethorax of unknown origin. There was no evidence of pleurobiliary fistula or leakage of bile from the hepatobiliary system although we examined the patient with various diagnostic tools including chest and abdominal computed tomography, endoscopic retrograde cholangiopancreatography, tubography, bronchofiberscopy, hepatobiliary scintigraphy and video-assisted thoracoscopic surgery. Herein we report a case of cholethorax for which the specific cause was not identified. The patient was improved by percutaneous drainage of pleural bile.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.26 no.1
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• pp.84-90
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• 2022

Backgrounds/Aims: Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) remains a dreadful complication. Duct-to-mucosa pancreaticojejunostomy (DTMPJ) is a commonly performed anastomosis after PD. This study aims to evaluate whether there is a size limit of pancreatic duct below which POPF rate increases significantly after DTMPJ. Methods: A retrospective study was performed from a database with prospectively collected data on consecutive patients undergoing DTMPJ. Results: Between the years 2003 and 2019, a total of 288 patients with DTMPJ were recruited. POPF occurred in 56.3% of the patients, of which 43.8% were biochemical leak, 8.7% were grade B, and 1.4% were grade C. Overall operative morbidity was 51.4%, of which 19.1% were major complications. Five patients (1.7%) died within 90 days of operation. Patients with grade B/C POPF had significantly soft pancreas (p < 0.001), smaller duct size (p = 0.031), and a diagnosis of carcinoma of the pancreas (p = 0.027). When a clinically significant POPF rate was analysed based on the pancreatic duct diameter, pancreatic duct size ≤ 1 mm had the highest POPF rate (35.7%). There was a significant difference in POPF rate between adjacent ductal diameter ≤ 1 mm and > 1 mm to 2 mm (35.7% vs 13.3%; p = 0.040). Multivariable analysis showed that for the soft pancreas, pancreatic duct diameter ≤ 1 mm was the only significant predictive factor for POPF (p = 0.027). Conclusions: DTMPJ can be safely performed for pancreatic duct > 1 mm without significantly increased POPF risk.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.27 no.1
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• pp.76-86
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• 2023

Backgrounds/Aims: The aim of this study was to describe short- and long-term outcomes of patients who underwent pancreatoduodenectomy (PD) at a typical United Kingdom hepatopancreatobiliary unit. Methods: A retrospective analysis of all PD patients with histologically-confirmed pancreatic ductal adenocarcinoma (PDAC), ampullary adenocarcinoma (AA), or distal cholangiocarcinoma (CC) from September 1st, 2006 to May 31st, 2015 was carried out. The following information was obtained: demographics, comorbidities, preoperative investigations, neoadjuvant treatment, operative details, postoperative management, complications, adjuvant treatment, five-year recurrence, and five-year survival. Effects of selected preoperative variables on short- and long-term outcomes were investigated. Results: Of 271 included patients, 57.9% had PDAC, 25.8% had AA, and 16.2% had CC. In total, 67.9% experienced morbidity and 17.3% developed a Clavien-Dindo grade ≥ III complication. The 90-day mortality was 3.3%. Clinically-relevant postoperative pancreatic fistula, bile leak, gastrojejunal leak, postpancreatectomy haemorrhage and delayed gastric emptying affected 8.1%, 4.1%, 0.0%, 9.2%, and 19.9% of patients, respectively. American Society of Anesthesiologists grade III-VI correlated with overall morbidity (p = 0.002) and major morbidity (p = 0.009), but not 90-day mortality or five-year survival. The same pattern was observed in patients with a preoperative serum bilirubin > 29 µmol/L and/or a neutrophil/lymphocyte ratio > 3.1. Five-year cancer recurrence and five-year survival were 68.3% and 22.5%, respectively. PDAC patients had higher five-year recurrence but lower five-year survival rates (both p = 0.001). Conclusions: In our series, the majority of patients experienced a complication. However, few patients experienced major morbidity. Surgical risk factors did not affect five-year survival.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.27 no.1
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• pp.87-94
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• 2023

Backgrounds/Aims: Central pancreatectomy (CP) is associated with a higher rate of postoperative pancreatic fistula (POPF), and it is less preferred over distal pancreatectomy (DP). We compared the short- and long-term outcomes between CP and DP for low-grade pancreatic neck and body tumors. Methods: This was a propensity score-matched case-control study of patients who underwent either CP or DP for low-grade pancreatic neck and body tumors from 2003 to 2020 in a tertiary care unit in southern India. Patients with a tumor >10 cm or a distal residual stump length of <4 cm were excluded. Demographics, clinical profile, intraoperative and postoperative parameters, and the long-term postoperative outcomes for exocrine and endocrine insufficiency, weight gain, and the 36-Item Short Form Survey (SF-36) quality of life questionnaire were compared. Results: Eighty-eight patients (CP: n=37 [cases], DP: n=51 [control]) were included in the unmatched group after excluding 21 patients (meeting exclusion criteria). After matching, both groups had 37 patients. The clinical and demographic profiles were comparable between the two groups. Blood loss and POPF rates were significantly higher in the CP group. However, Clavien-Dindo grades of complications were similar between the two groups (p = 0.27). At a median follow-up of 38 months (range = 187 months), exocrine sufficiency was similar between the two groups. Endocrine sufficiency, weight gain, SF-36 pain control score, and general health score were significantly better in the CP group. Conclusions: Despite equivalent clinically significant morbidities, long-term outcomes are better after CP compared to DP in low-grade pancreatic body tumors.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.28 no.1
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• pp.80-91
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• 2024

Backgrounds/Aims: Optimal intravenous fluid management during the perioperative period for patients undergoing pancreaticoduodenectomy (PD) within the framework of enhanced recovery after surgery (ERAS) is unclear. Studies have indicated that excessive total body salt and water can contribute to the development of oedema, leading to increased morbidity and extended hospital stays. This study aimed to assess the effects of an intravenous therapy regimen during postoperative day (POD) 0 to 2 in PD patients within ERAS. Methods: A retrospective interventional cohort study was conducted, and it involved all PD patients before and after implementation of ERAS (2009-2017). In the ERAS group, a targeted maintenance fluid regimen of 20 mL/kg/day with a sodium requirement of 0.5 mmoL/kg/day was administered. Outcome measures included the mmol of sodium and chloride administered, length of stay, and morbidity (postoperative pancreatic fistula, POPF; acute kidney injury, AKI; ileus). Results: The study included 169 patients, with a mean age of 64 ± 11.3 years. Following implementation of the intravenous fluid therapy protocol, there was a significant reduction in chloride and sodium loading. However, in the multivariable analysis, chloride administered (mmoL/kg) did not independently influence the length of stay; or rates of POPF, ileus, or AKI (p > 0.05). Conclusions: The findings suggested that a postoperative intravenous fluid therapy regimen did not significantly impact morbidity. Notably, there was a trend towards reduced length of stay within an increasingly comorbid patient cohort. This targeted fluid regimen appears to be safe for PD patients within the ERAS program. Further prospective research is needed to explore this area.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.26 no.2
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• pp.178-183
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• 2022

Backgrounds/Aims: Proximal splenorenal shunt (PSRS) is considered a one-time treatment for noncirrhotic portal hypertension (NCPH) to prevent recurrent upper gastrointestinal (UGI) hemorrhage and long-term complications. Long-term shunt patency is necessary to achieve these. The lie of the shunt is a contributing factor to early shunt thrombosis. We investigated the role of resection of the distal tail of pancreas (caudal pancreatectomy [CP]) in improving the lie of shunt and decreasing shunt thrombosis. Methods: This was a retrospective cohort study of patients with NCPH who underwent PSRS between 2014-2020 in JIPMER, Puducherry, India. CP was performed in patients with a long tail of pancreas, with the tip of pancreatic tail extending up to splenic hilum on preoperative CT. Perioperative parameters and shunt patency rate of patients who underwent PSRS with CP (Group A) were compared with patients undergoing conventional PSRS (Group B). Statistical analysis was performed using the Mann-Whitney U test and χ² test. Results: Eighty four patients with NCPH underwent PSRS (extrahepatic portal vein obstruction = 39; noncirrhotic portal fibrosis = 45). Blood loss was lower (p = 0.002) and post-shunt fall in portal pressure higher (p = 0.002) in Group A. Shunt thrombosis rate was lower (p = 0.04) while rate of complete variceal regression (p = 0.03) and biochemical pancreatic leak (p = 0.01) were higher in Group A.There was no clinically relevant pancreatic fistula in either group. Conclusions: CP is a safe and useful technique for reducing shunt thrombosis after PSRS in patients with NCPH by improving the lie of shunt.

• Tuberculosis and Respiratory Diseases
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• v.65 no.2
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• pp.131-136
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• 2008

Cholethorax (bilious pleural effusion) is an extravasation of bile into the thoracic cavity via a pleurobiliary fistula (and also a bronchobiliary fistula). It is an extremely rare complication of thoraco-abdominal injuries. It can be caused by congenital anomaly and also by hepatobiliary trauma, severe infection or iatrogenic procedures. The definitive diagnosis is made with aspiration of bilious fluid from the pleural space during thoracentesis, by finding a fistulous tract during endoscopic retrograde cholangiopancreatography (ERCP) or cholagioscopy, or with finding an abnormal pleural accumulation of radioisotope during hepatobiliary nuclear imaging. Its symptoms include coughing, fever, dyspnea and pleuritc chest pain. Herein we report on a case of cholethorax following performance of percutaneous transhepatic cholangioscopy (PTCS) to remove incidentally discovered common bile duct (CBD) stones.

• Journal of Yeungnam Medical Science
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• v.23 no.2
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• pp.152-161
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• 2006

Carcinoma of the gallbladder is an uncommon but highly malignant tumor with a poor five year survival rate. Early detection is very important for successful treatment because this tumor is very hard to cure in cases where it has advanced beyond the reach of surgical treatment. The purpose of this review was to evaluate risk factors for carcinoma of the gallbladder and determine the best management approach.. Solitary polys, more than one cm are considered to be predisposing factors for gallbladder carcinoma when they are found to be echopenic, sessile, and with a high cell density. Anomalous union of the pacreato-biliary duct(AUPBD) without a choledochal cyst is also considered to increase risk for gallbladder carcinoma. A polyps size of more than one cm and an AUPBD are indications for prophylactic cholecystectomy. The presence of gallstones is a well-established risk factor for the development of gallbladder carcinoma; risk appears to correlate with the stone size and the duration of chronic cholecystitis. Metaplastic changes of the gallbladder epithelium present with chronic cholecystitis and may indicate a premalignant lesion. Abnormal forms of cholecystitis such as xanthogranulomatous or a porcelain gallbladder also have malignant potential; cholecystoenteric fistula as well as bacterial infection of the gallbladder(typhoid, helicobacter species) also has malignant potential. In this review, the risk factors associated with carcinoma of the gallbladder are summarized with special attention to gallstones, polyps, AUPBD, and chronic inflammation.