• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.27 no.4
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• pp.224-235
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• 2024

Purpose: Biliary atresia (BA) is the leading cause of neonatal cholestasis (25-45%). The primary treatment is hepatic portoenterostomy (Kasai procedure), but only 20-40% provide long-term benefits. This study aimed to develop a predictive model for surgical efficacy by comparing preoperative and early postoperative indicators in infants with different outcomes. Methods: We enrolled 166 infants with BA (93 girls, 73 boys) who underwent the Kasai procedure between September 2002 and December 2021, dividing them into favorable or adverse outcome groups. Over 40 parameters were measured, and the diagnostic significance of the prognostic model was evaluated. Results: Kasai surgery was efficacious in 69 patients (42%) and non-efficacious in 97 (58%). Our model assesses efficacy by day 14 after surgery, improving on the <34 µmol/L direct bilirubin threshold established for 3-6 months after the procedure. Including the Desmet fibrosis score refined the model. Conclusion: Blood cholesterol below 5.41 mmol/L, direct bilirubin below 56.3 µmol/L on postoperative days 14±3, and a low Desmet score indicate a high probability of efficacious Kasai surgery in infants with BA.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.27 no.3
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• pp.264-270
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• 2023

Backgrounds/Aims: Proximal splenorenal shunt (PSRS) is a commonly performed procedure to decompress portal hypertension, in patients with refractory variceal bleed, especially in non-cirrhotic portal hypertension (NCPH). If conventional methods are hindered by any technical or pathological factors, alternative surgical techniques may be required. This study analyzes the effectiveness of various unconventional shunt surgeries performed for NCPH. Methods: A retrospective analysis of NCPH patients who underwent unconventional shunt surgeries during the period July 2011 to June 2022 was conducted. All patients were followed up for a minimum of 12 months with doppler study of the shunt to assess shunt patency, and upper gastrointestinal endoscopy to evaluate the regression of varices. Results: During the study period, 130 patients underwent shunt surgery; among these, 31 underwent unconventional shunts (splenoadrenal shunt [SAS], 12; interposition mesocaval shunt [iMCS], 8; interposition PSRS [iPSRS], 6; jejunal vein-cava shunt [JCS], 3; left gastroepiploic-renal shunt [LGERS], 2). The main indications for unconventional shunts were left renal vein aberration (SAS, 8/12), splenic vein narrowing (iMCS, 5/8), portalhypertensive vascular changes (iPSRS, 6/6), and portomesenteric thrombosis (JCS, 3/3). The median fall in portal pressure was more in SAS (12.1 mm Hg), and operative time more in JCS, 8.4 hours (range, 5-9 hours). During a median follow-up of 36 months (6-54 months), shunt thrombosis had been reported in all cases of LGERS, and less in SAS (3/12). Variceal regression rate was high in SAS, and least in LGERS. Hypersplenism had reversed in all patients, and 6/31 patients had a recurrent bleed. Conclusions: Unconventional shunt surgery is effective in patients unsuited for other shunts, especially PSRS, and it achieves the desired effects in a significant proportion of patients.

• 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.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.19 no.4
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• pp.281-285
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• 2016

Laparoscopic cholecystectomy, though an uncommon surgical procedure in paediatric age group is still associated with a higher risk of post-operative bile duct injuries when compared with the open procedure. Small leaks from extra hepatic biliary apparatus usually lead to the formation of a localized sub-hepatic bile collection, also known as biloma. Such leaks are rare complication after laparoscopic cholecystectomy, especially in paediatric age group. Minor bile leaks can usually be managed non-surgically by percutaneous drainage combined with endoscopic retrograde cholangio-pancreatography (ERCP). However, surgical exploration is required in cases not responding to non-operative management. If not managed on time, such injuries can lead to severe hepatic damage. We describe a case of an eight-year-old girl who presented with biloma formation after laparoscopic cholecystectomy who was managed by ERCP.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.27 no.4
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• pp.350-365
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• 2023

Backgrounds/Aims: Extra hepatic portal venous obstruction (EHPVO) is the most common cause of portal hypertension in Indian children. While endoscopy is the primary modality of management, a subset of patients require surgery. This study aims to report the short- and long-term outcomes of EHPVO patients managed surgically. Methods: All the patients with EHPVO who underwent surgery between August 2007 and December 2021 were retrospectively reviewed. Postoperative complications were classified after Clavien-Dindo. Binary logistic regression in Wald methodology was used to determine the predictive factors responsible for unfavourable outcome. Results: Total of 202 patients with EHPVO were operated. Mean age of patients was 20.30 ± 9.96 years, and duration of illness, 90.05 ± 75.13 months. Most common indication for surgery was portal biliopathy (n = 59, 29.2%), followed by bleeding (n = 50, 24.8%). Total of 166 patients (82.2%) had shunt procedure. Splenectomy with esophagogastric devascularization was the second most common surgery (n = 20, 9.9%). Nine major postoperative complications (Clavien-Dindo > 3) were observed in 8 patients (4.0%), including 1 (0.5%) operative death. After a median follow-up of 56 months (15-156 months), 166 patients (82.2%) had favourable outcome. In multivariate analysis, associated splenic artery aneurysm (p = 0.007), isolated gastric varices (p = 0.004), preoperative endoscopic retrograde cholangiography and stenting (p = 0.015), and shunt occlusion (p < 0.001) were independent predictors of unfavourable long-term outcome. Conclusions: Surgery in EHPVO is safe, affords excellent short- and long-term outcome in patients with symptomatic EHPVO, and may be considered for secondary prophylaxis.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.27 no.3
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• pp.307-312
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• 2023

Hepatic arterioportal fistulae are abnormal communications between the hepatic artery and portal vein. They are reported to be congenital or acquired secondary to trauma, iatrogenic procedures, hepatic cirrhosis, and hepatocellular carcinoma, but less likely to occur spontaneously. Extrahepatic portal venous obstruction (EHPVO) can lead to pre-hepatic portal hypertension. A spontaneous superimposed hepatic arterioportal fistula can lead to pre-sinusoidal portal hypertension, further exacerbating its physiology. This report describes a young woman with long-standing EHPVO presenting with repeated upper gastrointestinal variceal bleeding and symptomatic hypersplenism. Computed tomography scan demonstrated a cavernous transformation of the portal vein and a macroscopic hepatic arterioportal fistula between the left hepatic artery and portal vein collateral in the central liver. The hepatic arterioportal fistula was associated with a flow-related left hepatic artery aneurysm and a portal venous collateral aneurysm proximal and distal to the fistula, respectively. Endovascular coiling was performed for the hepatic arterioportal fistula, followed by proximal splenorenal shunt procedure. This case illustrates an uncommon association of a spontaneous hepatic arterioportal fistula with EHPVO and the utility of a combined endovascular and surgical approach for managing multifactorial non-cirrhotic portal hypertension in such patients.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.27 no.4
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• pp.372-379
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• 2023

Backgrounds/Aims: While single-incision laparoscopic cholecystectomy (SILC) has advantages in cosmesis and postoperative pain, its utilization has been limited. This study raises the possibility of expanding its indication to acute cholecystitis with the novel method of solo surgery under retrospective analysis. Methods: We compared the outcomes of SILC (n = 58) to those of three-incision laparoscopic cholecystectomy (TILC; n = 117) for acute cholecystitis, being performed from March 2014 to December 2015. Results: Intraoperative results, including the operation time, did not differ significantly, except for drain catheter insertion (p = 0.004). Each group had 1 case of open conversion due to common bile duct injury. There was no significant difference in the length of hospital stay. Either group by itself was not a risk factor for complications, but in preoperative drainage for intraoperative perforation, 3 factors of intraoperative perforation, biliary complication, and history of upper abdominal operation for additional port, only American Society of Anesthesiology (ASA) scores for postoperative complication of Clavien-Dindo grades III and IV were significant risk factors. Conclusions: Our study findings showed comparative outcomes between both groups, providing evidence for the safety and feasibility of SILC for acute cholecystitis.

• Pediatric Gastroenterology, Hepatology & Nutrition
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• v.24 no.6
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• pp.528-534
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• 2021

Purpose: Living-donor liver transplant emerged as an alternative treatment for end stage liver disease due to the lack of cadaveric organs availability that met the demand. In Portugal, pediatric living-donor liver transplant (P-LDLT) was initiated in 2001 in Portugal in order to compensate for the scarcity of cadaveric organs for such cases. The aim of this study was to retrospectively analyze the morbi-mortality of the 28 donors included in P-LDLT program performed at Coimbra's Pediatric Hospital (CHUC), a Portuguese reference center. Methods: We retrospectively collected pertinent donor data and stratified complications according to Clavien's scoring system. Results: In total, 28.6% (n=8) of the donors had surgical complications. According to Clavien-Dindo's classification, two donors had major complications (Clavien grade ≥3), four donors had grade 2 complications, and two donors had grade 1 complications. There were no P-LDLT-related mortalities in the present case series. The most common verified complications were biliary tract injuries and superficial incisional infections, which are consistent with the complications reported in worldwide series. Conclusion: These patients from CHUC shows that donor hepatectomy in P-LDLT is a safe procedure, with low morbidity and without mortality.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.26 no.2
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• pp.138-143
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• 2022

Backgrounds/Aims: Pancreaticoduodenectomy (PD) is a standard surgical procedure for patients with periampullary cancer. During the follow-up period after PD, recurrence can be observed in various places with different prognosis. The aim of this study was to clarify the pattern of recurrence and factors affecting the survival of patients with periampullary cancer. Methods: Overall, 88 patients who received PD for distal common bile duct cancer or ampulla of Vater cancer were finally included and their clinical characteristics were analyzed. Patients were divided into three groups: recurrence-free (RF) group, an isolated locoregional recurrence (LR) group, and a distant metastasis (DM) group. Prognostic factors affecting recurrence in each group were analyzed and a survival analysis was performed. Results: Perineural invasion (PNI), T stage, and lymphovascular invasion (LVI) were significant risk factors for LR and PNI, lymph node metastasis, LVI, and T stage were associated with DM group compared to RF group in univariate analysis, respectively. N stage and PNI were significant risk factors (p = 0.046, p = 0.041) in overall survival of the LR and the DM groups. There was no significant difference in 5-year overall survival between the LR and DM groups. Conclusions: T stage was a significant risk factor of LR, while PNI was a significant risk factor of DM. There was no significant difference in overall survival depending on the site of recurrence.

• Journal of radiological science and technology
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• v.44 no.5
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• pp.451-457
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• 2021

Recently, the number of interventional procedures has increased dramatically as an alternative of invasive surgical procedure and patient radiation exposure is also increasing accordingly. In this study, we evaluated the patient dose of major interventional procedures nationwide and we established our Korean database. With these results, we tried to suggest the reference dose level for major interventional procedures. We evaluated patent dose data in the field of interventional radiology from foreign countries. Measurement of radiation dose exposure for 11 major interventional procedures was conducted using embedded DAP meters in 10,006 patients from 47 hospitals, and reference level of each interventional procedure was suggested. The DRLs of each intervenional procedure are as follows: TACE 206(Gy·cm²), AVF 12(Gy·cm²), LE intervention 43(Gy·cm²), TFCA 122(Gy·cm²), Cerebral aneurysm coil embolization 214(Gy·cm²), PTBD 22(Gy·cm²), Biliary stent 60(Gy·cm²), PCN 7(Gy·cm²), Hickman catheter 2.1(Gy·cm²), Chemoport 1.4(Gy·cm²), BAE 104(Gy·cm²). Compared with the previously established DRL in 2012, the radiation dose decreased in all 10 interventional procedures. In the future, continuous publicity and education on the radiation dose reduction will be needed.