ročník 6,1998 č.2-3

Editorial

  1. Management of bile duct injuries caused by laparoscopic cholecystectomy*

Abstrakta

  1. Biliární komplikace po transplantaci jater
  2. Renální komplikace a transplantace jater
  3. Hematologické komplikace transplantace jater
  4. Ligace v léčbě krvácejících jícnových varixů
  5. Mikrobiologické nálezy a antimikrobní profylaxe u nemocných po PTC
  6. Mikrobiologická problematika v časném pooperačním období po transplantaci jater

Editorial

Management of bile duct injuries caused by laparoscopic cholecystectomy*

Gouma, D.J., Keulemans, Y.C.A., van Gulik, T.M., Obertop, H.
Department of Surgery
Academic Medical Center, Amsterdam
* Presented during VI. Spring meeting of the Czech chapter of IHPBA, Loket, 1997 by T.M. van Gulik

During the past years laparoscopic cholecystectomy has been generally accepted as the treatment of choice for symptomatic gallstone disease and has replaced the conventional "open" cholecystectomy. Several studies have shown the efficacy and safety of the procedure as well as the advantages as reduced hospital stay, earlier recovery, less intra-abdominal adhesions and a better cosmetic outcome ( 1, 2, 3, 4 ). Unfortunately it appeared that this minimal invasive technique is associated with a higher incidence of bile duct injury ( BDI ) ( 5 ). It has been reported that the incidence of BDI is strongly related with experience and therefore an increase of experience will lead to a decrease of BDI today.
Comparatively few papers have focused on an early diagnosis and classification of the severity of BDI and by that a more adequate selection of patients for the different treatment modalities and in particular selection for the endoscopic or surgical approach.
During the past years more than one hundred patients were treated at least partially at the Academic Medical Centre (AMC) with a bile duct injury after laparoscopic cholecystectomy.The management of all these patients was discussed in a team consisting of radiologists, gastroenterologists and surgeons. This paper is a summary of the AMC experience and a reflection of the findings from the literature concerning the incidence, symptoms, classification, diagnosis and treatment of bile duct injury after laparoscopic cholecystectomy.

Incidence and risk factors

The incidence of bile duct injury varies widely and is reported between 0 and more than 1% in several studies ( 5 - 9 ). The difference is partly due to the various definitions of bile duct injury which have been used in the literature. In some series a cystic duct leakage is also included as an injury whereas in other studies only the more severe common bile duct injuries or even only transection of the bile ducts are included and reported. The incidence in the different studies is also influenced by the selection of patients. In a recent review, McMahon reported an incidence of 0,2 % after an open procedure compared to 0,3 % after laparoscopic cholecystectomy in a single centre study and 0,5 % after laparoscopic cholecystectomy in audit studies ( 5 ).
In a survey from the Netherlands between 1990 and 1992, shortly after the introduction of laparoscopic chlecystectomy, the incidence was 0,86 % ( 6 ). From this study comprising 6076 patients who underwent laparoscopic cholecystectomy the bile duct injuries ( n = 49 ) were evaluated by reviewing the medical records of all patients with BDI in the different hospitals by an independent investigator in order to identify possible risk factors. Limited experience correlated significantly with an increasing probability of a bile duct injury.
Acute cholecystitis was also a risk factor for more severe types of injuries. It has been suggested that we are beyond the learning curve in 1997 and recently a few studies with a lower incidence have been reported.
In a recent audit from the west of Scotland of nearly six thousand patients the incidence of BDI had decreased from 0,8 % in 1990 - 1993 to 0,4 % during 1995 ( 10 ). Nair reported recently in a survey from England during 1994 an incidence of 0,07 % ( 12 ) after laparoscopic cholecystectomy in 4000 patients. An underestimation of the real incidence of BDI in this study is probable because the incidence is lower than in any other non-selected "nation-wide" series.
Between 1990 and 1996 106 patients with BDI from 45 hospitals were diagnosed and treated by the departments of gastroenterology and surgery of the AMC. Table I shows that the number of patients referred to the AMC did not decrease during that period. The higher number of patients with bile duct injuries may be related to the increasing number of laparoscopic cholecystectomies performed yearly in the Netherlands. But more likely it could be due to a change in referral pattern, since BDI are nowadays preferentially referred to a hepatobiliary center. The change of the referral pattern does not allow conclusion about the incidence of BDI in The Netherlands.

Table I: The number of patients with a bile duct injury (BDI) after laparoscopic cholecystectomy diagnosed and treated at the AMC Amsterdam between 1991 and 1996.
Year Number of patients with BDI
1991 9
1992 20
1993 21
1994 16
1995 12
1996 28
Total 106

Classification

The generally accepted classification of Bismuth for bile duct lesions used in many previous reports of strictures after open surgery is a classification according to the level of injury but unfortunately not to the nature of the lesion and can therefore not be used for all lesions (vbile leaksv) after laparoscopic surgery. Several new classifications for a bile duct injury have been reported during the past years. McMahon suggested in a review a more simplified definition by dividing BDI only into major and minor bile duct injury ( 5 ).
In 1993 we introduced a new classification for bile duct injuries as recently reported ( 12 ). In this new classification a bile duct injury was defined as any clinically evident damage to the biliary system including the cystic duct and intrahepatic duct radials ( so called duct of Luschka ).
Four types of bile duct injury can be identified:

A. Cystic duct leaks or leakage from aberrant or peripheral hepatic radicles.
B. Major bile duct leaks with or without concomitant biliary strictures.
C. Bile duct strictures without bile leakage.
D. Complete transection of the bile duct with or without excision of a part of the bile duct. The classification of the patients ( n = 106 ) referred to the AMC with a bile duct injury between 1990 and 1996 is summarized in table II. It was found that treatment and prognosis of a bile duct injury are mainly dependent on the nature of the lesion.

Diagnosis

Clinical presentation
The time interval between laparoscopic cholecystectomy and the detection of the lesion varies widely and three different groups of patients with a bile duct injury can be identified. Firstly the injury can be detected during the laparoscopic procedure. In a previous study from the Netherlands about 1/3 of the lesions were detected during the initial surgical procedure which is in accordance with the literature ( 8 ). Detection of an injury during the procedure was not dependent on the general use of routine cholangiography. It has been suggested that nowadays most lesions should be detected during the procedure because of the wide attention and many articles about this subject. Convincing data confirming by this suggestion, however, are not yet available.
Table II: Patients (n=106) with a bile duct injury sustained during laparoscopic cholecystectomy rferred to the AMC and classified in type A to D according to the modified classification from Gut 1996; 38: 141-146.
Type of bile duct injury Number Percentage
Type A 36 34%
Type 24 23%
Type C 15 14%
Type D 31 29%
Total 106  

In our series only 16 % of the injuries were detected during the procedure but this is may be due to the selection of patients referred for treatment ( 13 ). Unfortunately there was no change in early detection rate of 14 % in the first 4 years ( 1990 - 1994 ) after introduction of laparoscopic cholecystectomy compared with a rate of 18 % the second period, the last two years ( 1995 -1996 ). A second group of patients are those with a delayed identification ( > 24 hours after surgery ) of a bile duct injury. These patients presented postoperatively with a median interval after surgery of 7 days. In our series symptoms in the early postoperative phase were aspecific as general malaise, nausea, vomiting, anorexia, abdominal pain and low grade fever and these aspecific symptoms were probably responsible for the delay in diagnosis. These patients were frequently discharged from hospital the second postoperative day and are re - admitted after a few days because of persistent complaints. Other symptoms may become manifest later and consist of sepsis and jaundice and in most patients these symptoms will eventually lead to the (delayed) detection of the injury.
In patients analyzed from the first period 1990 - 1994, symptoms occurred 3 - 5 days after the procedure and a bile duct injury was detected after a mean period of 9 days after occurrence of the first symptoms ( latency time ). In the second period ( 1995 - 1996 ) the latency time between symptoms and diagnosis decreased significantly from 9 days to 3,5 days ( p < 0.05 ) ( 13 ). So bile duct injuries after laparoscopic cholecystectomy appear to be recognized earlier than in previous years.
A third group consists of patients have a relatively long symptom free interval ( even up to more than one year ) and present with obstructive jaundice frequently without cholangitis due to a stricture. It has been suggested that these late bile duct strictures originate mainly from ischaemic lesions caused by extensive dissection, or partial occlusion of the common duct with a clip during the initial procedure. In a recent study by our group the difference of clinical symptoms, laboratory findings and latency - time between the second group of patients comprising Type A, B and D lesions and the third group of patients, exclusively Type C lesions was reported in detail and is summarized in table III ( 12 ).
Table III: Symptomps and signs in 47 patients with BDI after laparoscopic cholecystectomy that were noted postoperatively.
  Overall (%) (n=47) Bile leakage (%)(Type A,B and D, n=38) Biliary structures (%)(Type C, n=9)
Symptoms
Jaundice
40 29 78 p<O,O5+
Cholestatic LFTs 68 58 100 p<O,O5+
Dilatation biliary tract on ultrasound 29 13 89 p<O,O01+
General malaise 72 84 33 p<O,O5+
Fever 49 63 0 p<O,O1+
Right upper abdominal pain 78 84 56 p=O,17+
Fluid collections on ultrasound/cumputed tomography 63 79 0 p<O,O01+
Sepsis 10 13 0 p=O,56+
Ileus 18 23 0 p<O,O17+
Symptom-latency time
(median, range)
8
(1-651)
3
(1-24)
57 p<O,O01+
(3-651)
Diagnosis-latency time
(median, range)
8
(0-81)
8
(0-81)
7 p<O,O68+
(1-78)

Diagnostic procedures

An early diagnosis is important and can easily be established by ultrasound, and is extremely helpful in the detection of a fluid collection or bile duct dilatation. Subsequent percutaneous aspiration of bile will establish the diagnosis. Unfortunately a fluid collection ( suggesting a bile duct lesion ) was still an indication for exploratory laparotomy for many surgeons. Laparotomy should however be avoided in this stage without a classification of the injury and a clean therapeutic strategy.
In our series about 30 % of the patients have been referred after one or more "diagnostic" explorative laparotomies without preoperative diagnosis and classification of the severity of the bile duct injury and therefore without a treatment strategy. The next step is an ERCP not only to establish the diagnosis but in particular to identify the nature and level of the lesion ( fig. 1 ).

Fig. 1 - A cystic stump leakage ( type A ) after laparoscopic cholecystectomy demonstrated by ERCP ( left side ) and treated by endoscopic sphincterotomy and stent for 6 weeks. The control ERCP after removal of the stent 6 weeks later

ERCP established the diagnosis in all type A, B and C lesions ( fig. 2 ).

Fig. 2 - An ERCP in a patient with a stricture of the CBD caused by a clip. A wire guide and catheter could pass the stricture and the patient was treated with long term endoscopic stenting

In patients with a type D lesion ERCP generally shows a total stop or leakage of the distal common duct. The proximal biliary tract is not visualized at the ERCP and visualisation can be established by a cholangiography through the percutaneous drainage catheter ( drainography ) in the fluid collection ( fig. 3 ).

Fig. 3 - A patient with persistent biliary leakage after cholecystectomy. ERCP did not show any leakage ( left panel ) and was considered to be normal. A subsequent drainagography ( middle panel ) showed leakage of the segment 6 / 7 right hepatic duct. This part was overlooked at the initial ERCP. The patient was treated with a hepaticojejunostomy ( right panel )

If the intrahepatic bile ducts are dilated, a percutaneous transhepatic cholangiography should be performed ( fig. 4 ).

Fig. 4 - ERCP and PTC in a patienl with severe biliary leakage due to total transection and removal of a part of the bile duct. Elective repair by a hepatojejunostomy was performed after 8 weeks of biliary drainage.


Recently MRCP was introduced and this might replace diagnostic ERCP's in the future ( fig. 5 ).

Fig. 5 - A patient with obstructive jaundice 6 months after laparoscopic cholecystectomy. A clip was removed two days after the initial procedure without further complications, but cholangitis occurred after 6 months. MRCP showed a hilar stricture extending into the segmental intrahepatic ducts

The quality improved dramatically during the past years and most lesions can be identified by this new modality.
Previously Hida scintigraphy was also used as a diagnostic procedure. This is a highly sensitive test to detect biliary leakage but does not identify the location of the injury and has therefore limited value ( 14 ). The different diagnostic modalities are summarized in table IV.

Treatment

The multidisciplinary approach is not only advocated for the diagnostic work-up ( classification ) but is also important to select patients for different treatment modalities. Furthermore one should realize that not all forms of treatment are available in every hospital. Therefore treatment principles as outlined in the next paragraph are only usefull and applicable in centers with sufficient experience in interventional radiology, therapeutic endoscopy and reconstructive surgery. Unfortunately bile duct injuries will occur in every hospital and can not totally be prevented. Inadequate diagnostic work up and subsequent suboptimal treatment of these injuries is however not acceptable nowadays after many experienced centers showed excellent results of repair procedures.
Treatment policy is totally different for acute injuries detected during surgery compared with delayed detected injuries. If an injury is detected during the laparoscopic procedure one should first call for help and consult a surgeon with sufficient experience. Next, further laparoscopic or open exploration should be performed to identify the structures in the hepatoduodenal ligament and identify the severity of the injury. If local anatomy is still unclear one should stop further exploration and only perform adequate drainage. If the bile duct lesion is adequately identified and not associated with extension damage of part of the bile duct and therefore suitable for a primary repair an end - to - end anastomosis should be performed with drainage by a T - tube. It has been reported that this procedure is associated with a high incidence of development of late bile duct strictures but one should realize that this procedure provides an optimal biliary drainage with a reasonable chance for cure and otherwise creates the optimal circumstances for reconstructive surgery by means of an elective hepaticojejunostomy at a later stage ( 15 - 18 ).
If part of the bile duct is accidentally resected but the proximal border is well below the bifurcation of the hepatic duet and optimal local circumstances ( experience ) are available an acute reconstruction by a hepalojejunostomy can be performed. For higher lesions at the bifurcation or intrahepatically located lesions without a dilated ductal system adequate drainage seems to be indicated and patients should be referred for elective reconstruction later.
If local experience is limited during detection of the injury in this acute phase one should limit exploration and only perform a drainage procedure and refer the patient to an experienced center.
Patients with a liver duct injury that has been detected in a later phase, should never undergo exploration before classification of the injury except patients suffering from severe biliary peritonitis which cannot be managed by percutaneous biliary drainage. Drainage should preferably be performed by ERCP and stent insertion or PTC combined with adequate percutaneous drainage of a fluid collection. An important factor for the final outcome of the surgical treatment is the timing of surgery. It has been suggested that a surgical reconstruction by a hepaticojejunostomy in the "late" acute postoperative phase ( often in a patient with bile leakage and subsequent peritonitis, ileus and the presence of local inflammatory changes in the hepatoduodenal ligament ) is associated with a higher risk for postoperative complications such as bile leakage and eventually stenosis of the anastomosis. Therefore patients are sent home with a drainage catheter and occasionally some of these patients will have a nasogastric tube to replace bile into the duodenum. Reconstruction is performed electively after 6 to 8 weeks. Patients with an acute reconstruction in non optimal circumstances have a high incidence ( 50 % ) of stenosis of the anastomosis instead of 90 % success rate after elective reconstruction. Summarizing the results from our recent series most patients ( 94 % ) with a Type A lesion could be treated with an endoprothesis. Patients with Type B lesions were successfully treated endoscopically in 70 % and with a Type C lesions 50 %. All patients with Type D lesions underwent surgical reconstruction by one or more intrahepatic hepatojejunostomies. Patients who develop a stenosis after a surgical reconstruction are preferably treated by percutaneous transhepatic pneumodilatation.

In conclusion

Laparoscopic cholecystectomy has shown its overall safety and most centers are now well beyond the learning curve. The incidence of bile duct injury seems to be marginally increased compared with open surgery and a decrease of the incidence of injuries has been reported recently. Management in terms of early diagnosis and classification of injuries before explorative laparotomies is still suboptimal and in our series no difference could be found between 1990 - 1994 and 1995 - 1996. Still 30 % of the patients with a bile duct injury underwent a diagnostic laparotomy. Most Type A and B injuries ( 90 % ) can be treated endoscopically and all Type D lesions have to be treated by surgical reconstruction. A delayed elective reconstruction was associated with less complications compared to acute repair under suboptimal circumstances.

References

1. Gouma, D.J., Obertop, H.: Gallstone treatment in "the laparoscopic cholecystectomy era". Neth. J. Med., 45, 1994: 1 - 7
2. Go, P.M.N.Y.H., Schol, F.P.G., Gouma, D.J.: Laparoscopic cholecystectomy in the Netherlands. Br. J. Surg., 80, 1993: 1180 - 1183
3. Deriel, D.J., Millikan, K.W., Exonomou, S.G. et al.: Complications of laparoscopic cholecystectomy: a national survey of 4.292 hospitals and an analysis of 77.604 cases. Am. J. Surg., 165, 1993: 9 - 14
4. Lee, V.S., Chari, R.S., Cucchiaro, G. et al.: Complications of laparoscopic cholecystectomy. Am. J. Surg., 165, 1993: 527 - 532
5. McMahon, A.J., Fullarton, G., Baxler, J.N. et al.: Bile duct injury and bile leakage in laparoscopic cholecvsteetomy. Br. J. Surg., 82, 1995: 307 - 313
6. Schol, F.P.G., Go, P.M.N.Y.H., Gouma, D.J.: Risk factors for bile duct injury in laparoscopic cholecystectomy: analysis of 49 cases. Br. J. Surg., 81, 1994: 1786 - 1788
7. Rossi, R.L., Schirmer, W.J., Braasch, J.W. et al.: Laparoscopic bile duct injuries. Risk factors, recognition, and repair. Arch. Surg., 127, 1992: 596 - 602
8. Gouma, D.J., Go, P.M.N.Y.H.: Bile duct injury during laparoscopic and conventional cholecystectomy. J. Am. Coll. Surg., 178, 1994: 229 - 233
9. Peters, J.H., Gibbons, G.D., Innes, J.T. et al.: Complications of laparoscopic cholecystectomy. Surgery 110, 1991: 769 - 778
10. Richardson, M.C., Bell, G.: Fullarton GM and the West of Scotland laparoscopic cholecystectomy audit group. Incidence and nature of bile duct injuries following laparoscopic cholecystectomy an audit of 5913 cases. Br. J. Surg., 83, 1996: 1356 - 1360
11. Nair, R.G., Dunn, D.C., Fowler, S. et al.: Progress with cholecystectomy: improving results in England and Wales. Br. J. Surg., 84, 1997: 1396 - 1398
12. Bergman, J.J.G.H.M., Brink van den G.R., Rauws, E.A.J. et al.: Treatment of bile duct lesions after laparoscopic cholecystectomy. Gut 38, 1996: 141 - 147
13. Keulemans, Y.C.A., Bergman, J.J.G.H.M., Wit de L.T. et al.: Improvement in the management of bile duct injuries ? In press: J. Am. Coll. Surg., 1998
14. Schipper, I.B., Rauws, E.A.J., Gouma, D.J. et al.: Diagnosis of right hepatic duct injury after cholecystectomy: the use of cholangiography through percutaneous drainage catheters. Castrointest. Endosc., 44, 1996: 35l - 354
15. Lillemoe, K.D., Martin, S.A., Cameron, J.L. et al.: Major bile duct injuries during laparoscopic cholecystectomy. Follow-up after combined surgical and radiologic management. Ann. Surg., 225, 1997: 459 - 471
16. Mirza, D.F., Narsimhan, K.L., Ferraz Neto B.H. et al.: Bile duct injury following laparoscopic cholecystectomy: referral pattern and management. Br. J. Surg., 84, 1997: 786 - 790
17. Moossa, A.R., Easter, D.W., Van Sonnenberg E. et al.: Laparoscopic injuries to the bile duct. Ann. Surg., 215, 1992: 203 - 208
18. Branum, G., Schmitt, C., Baillie, J. et al.: Management of major biliary complications after laparoscopic cholecystectomy. Ann. Surg., 5, 1993: 532 - 541.

Correspondence to:
Prof. Dr. D.J. Gouma
Academic Medical Center
Dept. of Surgery / G4-116
Meibergdreef 9
1105 AZ Amsterdam
The Netherlands


Abstrakta

Biliární komplikace po transplantaci jater

Špičák, J., Ryska, M., Bělina, F., Drastich, P., Dutka, J., Filip, K., Filipová, H., Peregrin, J., Skála, I., Šperl, J., Taimr, P., Trunečka, P., Wohl, P., Vítko, Š.
Klinika hepatogastroenterologie
přednosta: Doc. MUDr. J. Špičák, CSc.
Klinika transplantační chirurgie
přednosta: Doc. MUDr. M. Ryska, CSc.
Klinika radiodiagnostiky a intervenční radiologie
přednosta: MUDr. J. Peregrin, CSc.
Institut klinické a experimentální medicíny (IKEM) v Praze
ředitel: MUDr. K. Filip, CSc.

Souhrn

Cílem našeho sdělení je podat rozbor biliárních komplikací u všech 86 nemocných transplantovaných v IKEM od počátku programu v roce 1995 až do současné doby.
Různé druhy biliárních komplikací se objevily u 30 ( 26,1 % ) nemocných. U 3 s hepatikojejunoanastomózou se manifestovala protrahovaná cholangoitída zvýšením jaterních enzymů, které se znormalizovaly po několikatýdenní antibiotické léčbě. Biliární peritonitída, která u 3 dalších nemocných vznikla v odstupu několika dnů od transplantace, byla řešena chirurgicky změnou rekonstrukce žlučových cest na hepatikojejunoamastomózu. U 2 se s delším odstupem od transplantace objevila choledocholitiáza. U 3 se objevily komplikace v souvislosti se žlučovým drenem ( leak po jeho odstranění, odlomení drenu ve žlučových cestách, nemožnost jeho odstranění ). Jednou jsme zaznamenali dysfunkci Vaterské papily. U 16 nemocných jsme zjistili stenózy žlučového stromu. Jednou se jednalo o intrahepatální zaškrcení podvazem segmentárního žlučovodu během odběru jaterního štěpu a dvakrát vznikla stenóza v oblasti junkce hepatiků v důsledku útlaku potransplantační lymfoproliferací. U 15 nemocných se objevila stenóza v místě anastomózy 7 - 60 dnů od operace. Chirurgická rekonstrukce pro biliární komplikaci byla provedena u 3 nemocných. U ostatních nemocných bylo možné řešit komplikaci endoskopicky ( celkem 68 výkonů ). Endoprotézu jsme zaváděli celkem u 18 nemocných, z toho u 3 s pomocí transhepatálního přístupu. U 10 nemocných bylo možné s odstupem 6 - 12 měsíců přistoupit k extrakci endoprotézy.
Biliární komplikace po transplantaci jater jsou závažné svým významem a zajímavé šíří spektra a klinickými souvislostmi. V našem souboru byly v počáteční fázi programu transplantace jater časté. Podařilo se je správně diagnostikovat a vyřešit, aniž by došlo k podstatnému ovlivnění celkově příznivých výsledků. Po změně operační techniky a přechodu na end-to-end CHDCHDA bez T - drénu se staly biliární komplikace méně časté.
Klíčová slova: transplantace jater - biliární komplikace - diagnostika a terapie

Summary

Biliary complications after liver transplantation
Špičák, J., Ryska, M., Bělina, F. et al.
Biliary complications of liver transplant program in IKEM in all 86 patients is analysed by authors.
Some kind of biliary complication was appeared in 30 patients ( 26,1 % ). In 3 patients with HJA we noted moderate cholangoitis with the elevation of liver enzymes which normalized after antibiotic therapy in few weeks. Biliary peritonitis in 4 cases in postoperative period was indication to surgery with the conversion to HJA. Choledocholithiasis after liver transplantation we observed in 2 patients. In 3 cases was the cause of biliary complication T - tube: biliary leak after removing of it, the rupture of T - tube in biliary tract, T - tube impacting in choledochus. Dysfunction of papila of Vater was observed in 1 patients. Biliary stenosis was the cause of biliary problem in 18 patients. From this group we observed one patients with the ligation of posterior right bile duct during procurement with the need of posttransplant reconstruction and twisly stenosis in ductal bifurcation because of extrahepatic compression of posttransplant lymphoproliferation. Stenosis of biliary anastomosis was observed in 15 patients within period of 7 - 60 POD. Surgical recosntruction was provided in 3 patients. In others patients was able to use endoscopic approach ( totally 68 procedures ). Endoprothesis was inserted in 18 patients, in 3 cases transhepatic transcutaneouslly including. Endoprothesis was removed in 10 patients within 6 - 12 month.
Biliary complications after liver transplantation are significantly important and interesting by the wide of clinical consequences. In our group of patients were very often in the beginning of program. By early diagnosis and treatment biliary complications were not significantly influenced promising results of program.
After conversion to end-to-end anastomosis without T - tube biliary complications observed very sporadically.
Key words: liver transplantation - biliary complications - diagnosis and treatment

Renální komplikace a transplantace jater

Hrnčárková, H., Malý, J., 1Ryska, M., Špičák, J., Trunečka, P., 2Schück, O.
Klinika hepatogastroenteriologie
přednosta: Doc. MUDr. Julius Špičák, CSc.
1Klinika transplantační chirurgie
přednosta: Doc. MUDr. Miroslav Ryska, CSc.
2Klinika nefrologie
přednosta: Doc. MUDr. Vladimír Teplan, CSc.
Institut klinické a experimentální medicíny, Praha
ředitel: MUDr. Karel Filip, CSc.

Souhrn

Autoři retrospektivně hodnotí výskyt renálních komplikací u 60 nemocných po ortotopické transplantaci jater (OTJ). V období 4/95 - 9/97 bylo v IKEM provedeno 61 OTJ u 60 nemocných. Snížení renálních funkcí před OTJ autoři zaznamenali u 4 ( 7 % ) pacientů.
Po OTJ, zejména v časném období, byl zaznamenán pokles renálních funkcí u 41 ( 68,3 % ) pacienta. Ve 4 ( 7 % ) případech bylo nutno přechodně přistoupit k hemodialýze.
Běžně prováděné nefrologické vyšetření kandidátů transplantace jater nedává dostatečnou informaci o funkci ledvin pacienta. Komplexní nefrologické vyšetření a pečlivé sledování nemocných před a po OTJ jater je nezbytné pro ovlivnění rozvoje a progrese renální insuficience po OTJ.
Klíčová slova: ortotopická transplantace jater - renální komplikace - hemodialýza

Summary

Renal complications and liver transplantation
Hrnčárková, H., Malý, J., Ryska, M. et al.
Retrospective analysis of renal complication in 60 patients after 61 ortotopic liver transplantation ( OLTx) provided in Institute for clinical and experimental medicine, Prague is presented ( 4/95 - 9/97 ). The decreasing of renal function was noted by authors in 4 patients before OLTx ( 7 % ).
After OLTx especially in early postoperative period, was diagnosed the decreasing of renal functions in 41 patients ( 68,3 % ). In 4 cases ( 7 % ) temporary hemodialysis was indicated. Routinally examination of nephrologist is not available to give the exact information about renal function. The special nefrologist approach to care the patient before and after OLTx is necessary for the influence to development and progress of renal insufficiency after OLTx.
Key words: orthotopic liver transplantation - renal complications - haemodialysis

Hematologické komplikace transplantace jater

Charvát J., +Ryska M., +Bělina F., ++Trunečka P.
Pracoviště specializovaných laboratoří
+Klinika transplantační chirurgie
++Klinika hepatogastroenterologie,
Institut klinické a experimentální medicíny, Praha

Souhrn

Východisko: Hemokoagulační změny patří k hlavním problémům transplantace jater. Cílem naší práce bylo zhodnotit náš léčebný postup, zda minimalizuje krevní ztráty a nebezpečí trombotických komplikací.
Metody, výsledky: U 49 transplantací jsme sledovali po 3 měsíce vybrané koagulační parametry. Krevní ztráty odpovídaly výsledkům zavedených transplantačních center - při operaci bylo zapotřebí 7,0 Ż 4,7 (1 až 22) transfúzních jednotek (dále TU) erytrocytových koncentrátů. Jejich spotřeba nezávisela na hloubce koagulační poruchy před operací.
Závěr: Vhodná substituční léčba pacienta před, v průběhu a po transplantaci jater podle individuálních výsledků koagulační vyšetření minimalizuje krevní ztráty a nebezpečí trombotických komplikací.
Klíčová slova: transplantace jater - krevní ztráty - fibrinolýza - trombocytopenie - hemostáza

Ligace v léčbě krvácejících jícnových varixů

Drastich, P., Špičák, J.
Klinika diabetologie a hepatogastroenterologie
Institut klinické a experimentální medicíny, Praha
přednosta: Doc. MUDr. J. Špičák, CSc.

Souhrn

Endoskopická ligace je v současnosti metodou volby v léčbě krvácejících jícnových varixů. V naší práci předkládáme výsledky ligace u 18 nemocných, u kterých jsme provedli celkem 73 výkonů. Akutní krvácení bylo zastaveno sklerotizací nebo podáváním terlipressinu a balónkovou tamponádou. Dosáhli jsme vysokého stupně eradikace varixů ( 83 % ) při průměrném počtu 4,1 Ż 1,5 endoskopických výkonů. Opakované krvácení se vyskytlo pouze u 2 nemocných ( 11 % ) ve 3 a 8 měsících od zahájení ligace. K rekurenci varixů došlo u 3 nemocných ( 17 % ) v intervalu 3 - 7 měsíců od dosažení eradikace. V době sledování od akutního krvácení ( 3 - 11 měsíců ) jsme nezaznamenali žádné úmrtí. K ošetření varixů jsme použili v 53 případech ligační instrumentárium s overtubem umožňující nasadit při jednom zavedení endoskopu jen jednu ligaturu a ve 20 případech multiplikátor poskytující najednou 5 - 6 ligatur. U všech nemocných jsme pozorovali povrchní vředy jako důsledek ligace. Tyto vředy byly asymptomatické a rychle se hojily.
Endoskopickou ligaci hodnotíme jako vysoce úspěšnou metodu léčby jícnových varixů. Její výhodou je ve srovnání se sklerotizací zejména malá interindividuální variabilita techniky výkonu, rychlá eradikace a malý výskyt komplikací. Výkon s použitím multiplikátorů je technicky jednodušší, kratší a bezpečnější.
Klíčová slova: jícnové varixy - ligace - sklerotizace

Summary

Ligation in the treatment of bleeding oesophageal varices
Drastich, P., Špičák, J.
Endoscopic ligation is currently the method of choice in the treatment of bleeding oesophageal varices. We present the results of ligation in 18 patients undergoing a total of 73 procedures. Acute bleeding was arrested by sclerotization or terlipressin administration with ballon tamponade. We achieved a high level of varix eradication ( 83 % ) with a mean number of 4,1 Ż 1,5 endoscopic procedures. Bleeding episodes recurred in 2 patients only ( 11 % ) at month 3 and 8 from the start of ligation. Varix recurrence was observed in 3 patients ( 17 % ) at an interval of 3 - 7 months from eradication. There was no death during follow - up from acute bleeding ( 3 - 11 months). In 53 cases, varix management was affected using ligation instrumentarium with overtube allowing to establish one ligature only per endoscope insertion while, in 20 cases, a multiple ligation device was used providing 5 - 6 ligatures at time. Superficial ulcers were seen in all patients as the consequence of ligation. The ulcers were asymptomatic and healed rapidly.
We believe endoscopic ligation is highly successful method for the treatment of oesophageal varices. Compared with sclerotization, its advantages include especially a low inter - individual variability of the technique of procedure, rapid eradication, and low complication rate. The procedure using a multiple ligation device is technically simpler, shorter, and safer.
Key words: Oesophageal varices - ligation - sclerotization

Mikrobiologické nálezy a antimikrobní profylaxe u nemocných po PTC

Drábek, J., Keil, R., Lochmann, O., Janík, V., Pádr, R.
Interní klinika FN Motol, Praha
přednosta: Prof. MUDr. F. Kolbel, DrSc.
Mikrobiologický ústav FN Motol, Praha
přednosta: Prof. MUDr. A. Součková, CSc.
Klinika zobrazovacích metod FN Motol, Praha
přednosta: Prof. MUDr. S. Tůma, DrSc.

Souhrn

Práce se zabývá problematikou cholangoitídy a mikrobiologických nálezů ze žluče u nemocných, kterým byl proveden transhepatální zákrok na žlučových cestách. Je hodnocen soubor 50 nemocných, kterým bylo provedeno PTC a byli hospitalisováni na Interní klinice FN Motol v letech l994 - 96. Cílem práce je snaha o stanovení racionální antimikrobní profylaxe u pacientů s transhepatálními výkony a správná taktika léčby cholangoitídy u těchto nemocných.
Klíčová slova: obstrukce žlučových cest - cholangoitída - antimikrobní profylaxe - PTC

Summary

Microbiolical patterns and antimicrobial prophylaxis in patients after PTC
Drábek, J., Keil, R., Lochmann, O. et al.
Cholangoitis and microbial patterns from bile in patients after transhepatic biliary procedures are discussed. 50 patiets after PTC who admitted in internal department Faculty of medicine, Motol are analysed.
This presentation would like to state reasanable antimicrobial prophylaxis in patients after transhepatic procedures and the strategy of the treatment of cholangoitis of these patients.
Key words: biliary tract obstruction - cholangoitis
- antimicrobial prophylaxis - PTC

Mikrobiologická problematika v časném pooperačním období po transplantaci jater

Hatala, M., Petkov, V., Pechancová, J.
Mikrobiologická Laboratoř
Institut klinické a experimentální medicíny, Praha
přednosta: MUDr. Hatala, M., CSc.

Souhrn

V době leden 95 - listopad 97 bylo v mikrobiologické laboratoři IKEM Praha vyšetřeno celkem 3226 vzorků od 68 pacientů v časném období po transplantaci jater před jejich prvním propuštěním do domácí péče. U 38 transplantovaných v době 1/95 - 11/96 byla jako antimikrobní profylaxe aplikována kombinace Tobramycin ( TOB ) - Cefotaxim ( CTX ) - Metronidazol ( MTZ ), u 30 pacientů v období 11/96 - 11/97 kombinace Amikacin ( AMI ) - Piperacilin ( PIP ). Výměnou cefalosporinu 3 generace za ureidopenicilin došlo k výraznému snížení záchytu enterokoků a koaguláza negativních stafylokoků, které v prvním období byly nejčastěji izolovaným agens. Počet izolovaných fermentativních a nefermentativních gramnegativních tyček a kvasinek se výrazně nezměnil. U obou skupin bylo srovnatelné i procento pozitivních kultivací.
Klíčová slova: antimikrobiální profylaxe - transplantace jater - grampozitivní a gramnegativní baktérie

Summary

In the period of 1/1995 - 11/1997 were in microbiological laboratory of the Institute for clinical and experimental medicine, Prague examinated 3226 samples of 68 patients in early postoperative period after liver transplantation before their the first discharge to home care. 38 patients in the period of 1/95 - 11/96
Key words: Antimicrobial prophylaxis - liver transplantation - grampozitive and gramnegative microbs