RESUMEN
The self-expandable metallic stent (SEMS) has become a common device for palliative treatment of malignant biliary obstructions or benign strictures. Despite the ease of placement of SEMSs, their removal has been reported to be very difficult. Here, we report a case with primary sclerosing cholangitis who developed massive hemorrhage after intraoperative removal of a SEMS. Possible living donor liver transplantation (LT) was considered for a 49-year-old female with primary sclerosing cholangitis. However, her general condition did not meet the criteria for LT; therefore, she was referred back to her primary physician. Two years later, she developed jaundice, and her primary physician placed multiple SEMSs, 1 of which was placed across the papilla of Vater. She was evaluated rapidly, and underwent living donor LT. During the operation, the common bile duct was examined and an incision was made. A stent was found firmly embedded in the bile duct. Each wire of the SEMS was pinched and then successfully pulled out 1 by 1. Finally, all parts of the SEMS were removed. Before creating the Roux-en-Y limb, hemorrhage from the remnant bile duct was confirmed by examination of the duodenum and bile duct stump. The bile duct was sewn internally with monofilament stitches and compressed for 10 minutes. Finally, hemostasis was brought about and transplantation was completed successfully. Despite some reports regarding successful endoscopic removal of SEMSs, its removal in patients with portal hypertension coagulopathy is risky. SEMSs should not be placed in patients who are candidates for LT.
Asunto(s)
Sistema Biliar/patología , Colangitis Esclerosante/patología , Colangitis Esclerosante/terapia , Hemorragia/etiología , Trasplante de Hígado/instrumentación , Trasplante de Hígado/métodos , Stents/efectos adversos , Conductos Biliares/patología , Femenino , Hemostasis , Humanos , Ictericia/etiología , Donadores Vivos , Persona de Mediana Edad , PronósticoRESUMEN
We developed a plasma recycling dialysis (PRD) system based on plasma exchange (PE). In this system, rapid reduction of toxic substances and restitution of deficient essential substances are performed by PE and subsequent blood purification is performed by dialysis between separated plasma recycled over a purification device and the patient's blood across the membrane of a plasma separator. To demonstrate the safety and efficacy of this system, we used a pig model of fulminant hepatic failure (FHF) and anion exchange resin, activated charcoal and hemodialysis for the purification device. FHF was induced by intraportal administration of alpha-amanitine (0.1 mg/kg) and lipopolysaccharides (1 microg/kg) in pigs. Three groups of animals were studied: group 1, diseased controls (N = 4); group 2, PE group (N = 4), 16 h after drug infusion the pigs underwent PE of approximately 1.2 L for 2 h; and group 3, PE + PRD group (N = 4), the pigs underwent PE followed by PRD for 6 h. The hemodynamic status of all animals was stable during the procedure. In group 3, the values of ammonia, total bile acid and total bilirubin continuously decreased and were significantly lower than those of the animals in group 2 24 h after the induction of FHF. The Fischer ratio was significantly higher than in group 2 after 24 h. Group 3 pigs maintained a higher level of consciousness and survived longer than group 2 pigs. Safety of this PE-based PRD system was demonstrated and the removal of toxic substances was significant. This study confirmed the clinical utility of this system as an artificial liver support.
Asunto(s)
Diálisis/métodos , Fallo Hepático Agudo/terapia , Hígado Artificial , Intercambio Plasmático/métodos , Amoníaco/sangre , Animales , Resinas de Intercambio Aniónico/uso terapéutico , Ácidos y Sales Biliares/sangre , Bilirrubina/sangre , Carbón Orgánico/uso terapéutico , Modelos Animales de Enfermedad , Femenino , Hemodinámica , Tasa de Supervivencia , PorcinosRESUMEN
AIM: To analyze the efficacy of routine intraoperative ultrasound (IOUS) as a guide for understanding biliary tract anatomy, to avoid bile duct injury (BDI) after laparoscopic cholecystectomy (LC), as well as any burden during the learning period. METHODS: A retrospective analysis was performed using 644 consecutive patients who underwent LC from 1991 to 2006. An educational program with the use of IOUS as an operative guide has been used in 276 cases since 1998. RESULTS: IOUS was highly feasible even in patients with high-grade cholecystitis. No BDI was observed after the introduction of the educational program, despite 72% of operations being performed by inexperienced surgeons. Incidences of other morbidity, mortality, and late complications were comparable before and after the introduction of routine IOUS. However, the operation time was significantly extended after the educational program began (P < 0.001), and the grade of laparoscopic cholecystitis (P = 0.002), use of IOUS (P = 0.01), and the experience of the surgeons (P = 0.05) were significant factors for extending the length of operation. CONCLUSION: IOUS during LC was found to be a highly feasible modality, which provided accurate, real-time information about the biliary structures. The educational program using IOUS is expected to minimize the incidence of BDI following LC, especially when performed by less-skilled surgeons.
Asunto(s)
Conductos Biliares/diagnóstico por imagen , Conductos Biliares/lesiones , Enfermedades de las Vías Biliares/diagnóstico por imagen , Enfermedades de las Vías Biliares/cirugía , Colecistectomía Laparoscópica/educación , Complicaciones Intraoperatorias/prevención & control , Ultrasonografía Intervencional , Adulto , Anciano , Colecistectomía Laparoscópica/efectos adversos , Competencia Clínica , Estudios de Factibilidad , Femenino , Humanos , Complicaciones Intraoperatorias/etiología , Masculino , Persona de Mediana Edad , Evaluación de Programas y Proyectos de Salud , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoRESUMEN
Pseudoaneurysm is a life-threatening complication after pancreaticoduodenectomy. An endovascular covered stent was employed for treatment of pseudoaneurysm of the common hepatic artery after pancreaticoduodenectomy. A 77-year-old female underwent pylorus-preserving pancreaticoduodenectomy for lower bile duct cancer. She complained of hematochezia but upper gastrointestinal endoscopy did not find a bleeding source. Angiography was performed and pseudoaneurysm of the common hepatic artery was discovered. Since no collateral perfusion to the liver was detected, embolization of the common hepatic artery was considered to expose the patient to the danger of severe hepatic dysfunction. Successful exclusion of the pseudoaneurysm was completed with an endovascular covered stent. Inflow of the hepatic artery was secured and no hepatic dysfunction developed. Patency of the stent was confirmed at 5 months follow-up. An endovascular covered stent can be a feasible modality for selected cases of the hepatic arterial pseudoaneurysm.
Asunto(s)
Aneurisma Falso/terapia , Arteria Hepática , Pancreaticoduodenectomía/efectos adversos , Stents , Anciano , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/etiología , Neoplasias de los Conductos Biliares/cirugía , Femenino , Humanos , Radiografía AbdominalRESUMEN
Endo-beta-xylosidase from the mid-gut gland of the molluscus Patinopecten is an endo-type glycosidase that hydrolyzes the xylosyl serine linkage between a core protein and a glycosaminoglycan (GAG) chain, releasing the intact GAG chain from proteoglycan. In this study, we investigated GAG chain transfer activity of this enzyme, in order to develop a method for attaching GAG chains to peptide. Peptidochondroitin sulfate (molecular mass of sugar chain, 30 kDa) from bovine tracheal cartilage as a donor and butyloxycarbonyl-leucyl-seryl-threonyl-arginine-(4-methylcoumaryl-7-amide) as an acceptor were incubated with endo-beta-xylosidase. As a result, a reaction product with the same fluorescence as the acceptor peptide was observed. High pressure liquid chromatography analysis, cellulose acetate membrane electrophoresis, and enzymatic digestion showed that this reaction product had the chondroitin sulfate (ChS) from the donor. Furthermore, the acceptor peptide was released from this reaction product after hydrolysis by endo-beta-xylosidase. Therefore, it was confirmed that the ChS chain released from the donor was transferred to the acceptor peptide by the GAG chain transfer reaction of endo-beta-xylosidase. The optimal pH for hydrolysis by this enzyme was found to be about 4.0, whereas that for this reaction was about 3.0. Not only the ChS but also the dermatan sulfate and the heparan sulfate were transferred to the acceptor peptide by this reaction. By using this reaction, the GAG chain could be attached to the peptide in one step. The GAG chain transfer reaction of endo-beta-xylosidase should be a significant glycotechnological tool for the artificial synthesis of proteoglycan.