EFFECTIVENESS OF ENDOSCOPIC TREATMENT OF BILIARY FISTULAS

Despite the great experience in biliary surgery, the total frequency of iatrogenic bile duct lesions, accompanied by the formation of biliary fistulas, reaches 2%. The aim of the study is to analyze the results of endoscopic treatment of patients with biliary fistulas after cholecystectomy. Materials and methods of research. The results of endoscopic treatment of 19 patients with biliary fistulas that occurred after cholecystectomy were studied. Women were 11 (57.9%), men – 8 (42.1%). Research results. The reason of the formation of bile fistula was biliary hypertension in case of choledocholithiasis in 14 (73.6%) patients. Endoscopic papillosphincterectomy was performed to restore the free passage of bile into the duodenum. Lithoextraction with balloon was carried out in 11 (57.9%) patients, and in 3 (15.8%) patients was used litoextraction with basket. Endobiliary drainage was performed in 5 (26.3%) patients. Conducting decompression of bile ducts in all cases of type A fistulas resulted in the cessation of bile fistula the day after surgery. Conclusions. ERCP is a highly effective method for treating biliary fistulas, which identifies the location of leakage of bile, and restoring of bile flowing to the duodenum helps to heal the fistula.

The result of diagnosis and treatment of intra abdominal compartment syndrome in management of live injury

Tóm tắt Đặt vấn đề: Chấn thương (CT) gan là chấn thương bụng kín thường gặp. Cho tới nay, hơn 80% CT gan được điều trị bảo tồn. Tuy nhiên có nhiều biến chứng xảy ra trong quá trình theo dõi và điều trị bảo tồn. Tăng áp lực ổ bụng (TALOB) là một trong những biến chứng nặng đe dọa đến tính mạng người bệnh lại chưa được nghiên cứu nhiều. Phương pháp nghiên cứu: Nghiên cứu mô tả hồi cứu trên các bệnh nhân được chẩn đoán chấn thương gan có tăng áp lực ổ bụng được điều trị và hoặc phẫu thuật tại khoa Phẫu thuật cấp cứu bụng, bệnh viện Hữu nghị Việt Đức từ 2016 – 2018. Kết quả: Có 10 bệnh nhân đủ tiêu chuẩn nghiên cứu, trong đó có 07 bệnh nhân (BN) nam (70%), 03 BN nữ (30%). Tuổi trung bình của nhóm nghiên cứu là 40,7 (tuổi lớn nhất là 69, tuổi nhỏ nhất là 20). Tai nạn giao thông (TNGT) chiếm 20%, tai nạn lao động (TNLĐ) chiếm 60%, tai nạn sinh hoạt (TNSH) chiếm 20%. Thời gian xảy ra TALOB sau chấn thương gan từ 3 đến 10 ngày chiếm 80%, sau tai nạn từ 1 đến 3 ngày có 2 BN chiếm 20%. 100% các trường hợp có dấu hiệu bụng chướng căng, thở nhanh nông, suy hô hấp, bão hòa oxy (SpO2) dao động từ 60 - 90% là 9 NB (90%), có 1 NB SpO2 < 60%, 4 NB sốt 38,5 độ, 4 NB có HA < 90 mmHg, 4 trường hợp hồng cầu < 2,5 triệu, 5 NB hematocrit < 25%, men gan tăng cao 100% các trường hợp. Chụp cắt lớp vi tính (CLVT) ổ bụng: CT gan phải: 60%, CT gan phải và gan trái: 40%, có 80% CT gan độ IV, 20% CT gan độ III, 70% có đường vỡ > 10cm (7 NB). Có 6 trường hợp TALOB (60%), 2 trường hợp TALOB và rò mật, 2 trường hợp TALOB và viêm phúc mạc mật. Trong đó có 8 BN được chọ hút dịch ổ bụng dưới siêu âm, 01 BN được thực hiện phẫu thuật nội soi hút rửa dẫn lưu ổ bụng, 01 BN được mổ mở làm sạch, lau rửa, dẫn lưu ổ bụng. Kết luận: Tăng áp lực ổ bụng là biến chứng nặng sau điều trị bảo tồn chấn thương gan thường xảy ra với tỷ lệ cao: sau 3 ngày đến 10 ngày sau tai nạn (80%). 100% các trường hợp đều có suy hô hấp nặng (khó thở, bão hòa oxy giảm thấp) và thở máy trước khi can thiệp hoặc phẫu thuật. Các biện pháp can thiệp giảm ALOB như dẫn lưu dưới siêu âm, phẫu thuật nội soi hoặc mổ mở làm giảm biến chứng và tử vong. Abstract Introduction: The proportion of conservation treatment of live injury is more than 80,0% and the late complications post hepatic injury (intra abdominal compartment syndrome, persistent bleeding, bile fistula, choleperitonitis, hepatic necrosis) occurred with high proportion. However the intra abdominal compartment syndrome (IACS) could be lethal but not reported enough. We therefore conduct a study to evaluate the results of diagnosis as well as management of IACS regarding the treatment of hepatic injury such as the conservative treatment, conventional surgery and laparoscopic surgery Material and Methods: Retrospective descriptive study. All the patients diagnosed hepatic injury complicated IACS have been treated or operated on in the department of abdominal emergencies at Viet Duc University Hospital during 2016 -2018 were enrolled. Results: 10 patients met with the criteria selection, 7 men (70,0%), 3 women (30,0%), the mean age was 40,7 (range 20 - 69). Road traffic accident were 20%, occupational accident 60%, and leisure accident 20%. Time from onset to complication happened: from 3 days to ten days post injury was 80,0%, before 3 days was 20,0% (two patients). Serious abdominal distention and rapid breathing or respiratory distress accounting for 100%, SpO2 were between 60-90% in 9 patients (90%), one had SpO2 < 60%, four patients had fever as high as 38,5 celsius degree, four patients had hypotension < 90 mmHg, four patients had anemia with red blood cell < 2,5, five patients had hematocrit < 25%, and hypertransaminesia accounting for 100%. Findings from CT scanner are: The right hepatic injury was 60,0%, combined right-left hepatic injury was 40,0%, the grade IV was 80,0% and grade III 20%, rupture size were above 10cm in 7 patients. There were 6 cases with IACS (60%), other two had IACS complicated bile fistula, two had IACS complicated choleperitonitis. Treatment: 8 patients who were underwent a drainage under ultrasound, 01 patient: laparoscopic surgery due to choleperitonitis and 01 patient: laparotomy and drainage due to bile fistula. Conclusion: The intraabdominal compartment syndrome is a serious complication after the conservative treatment of hepatic injury, happened from 3 day to ten day post injury by 80,0%.m100% developed respiratory distress with low SpO2, were mechanical ventilation before the operation or intervention. Some procedures of treatment such as drainage under ultrasound, laparoscopic and drainage, laparotomy and drainage can reduce rate of complication and mortality. Keywords: Live trauma, intra abdominal compartment synch one (IACS), post hepatic trauma intra abdominal compartemt

Ileus Biliaire : A Propos D’un Cas Clinique

Introduction: Gallstone ileus is a rare mechanical occlusion. It is caused by the enclosure of biliary macro lithiasis in a portion of the digestive tract resulting from a digestive bile fistula. We report a clinical case to discuss therapeutic modalities through a review of the literature. Medical observation: We report the case of a 77-year-old patient who was hospitalized in the Nephrology department of the university hospital in Montpellier for functional kidney failure and dehydration from vomiting and diarrhea. The none-injected abdominal-pelvic CT scan showed a gallstone ileus with 5 enclaved duodenum, jejunum and ileum lithiasis resulting into a small bowel obstruction. There are no signs of acute cholecystitis. The management was simple by enterolithotomy surgery alone after fixing of hydro electrolyte imbalance. The after surgery sequence was simple. Conclusion: Gallstone ileus is a rare surgical condition. The high mortality rate in the management of this condition makes enterolithotomy the least invasive and recommended method.

Apolipoprotein A-V is present in bile and its secretion increases with lipid absorption in Sprague-Dawley rats

Apolipoprotein (apo) A-V is a protein synthesized only in the liver that dramatically modulates plasma triglyceride levels. Recent studies suggest a novel role for hepatic apoA-V in regulating the absorption of dietary triglycerides, but its mode of action on the gut remains unknown. The aim of this study was to test for apoA-V in bile and to determine whether its secretion is regulated by dietary lipids. After an overnight recovery, adult male Sprague-Dawley bile fistula rats indeed secreted apoA-V into bile at a constant rate under fasting conditions. An intraduodenal bolus of intralipid ( n = 12) increased the biliary secretion of apoA-V but not of other apolipoproteins, such as A-I, A-IV, B, and E. The lipid-induced increase of biliary apoA-V was abolished under conditions of poor lymphatic lipid transport, suggesting that the stimulation is regulated by the magnitude of lipids associated with chylomicrons transported into lymph. We also studied the secretion of apoA-V into bile immediately following bile duct cannulation. Biliary apoA-V increased over time (∼6-fold increase at hour 16, n = 8) but the secretions of other apolipoproteins remained constant. Replenishing luminal phosphatidylcholine and taurocholate ( n = 9) only enhanced apoA-V secretion in bile, suggesting that the increase was not due to depletion of phospholipids or bile salts. This is the first study to demonstrate that apoA-V is secreted into bile, introducing a potential route of delivery of hepatic apoA-V to the gut lumen. Our study also reveals the uniqueness of apoA-V secretion into bile that is regulated by mechanisms different from other apolipoproteins.

Phloracetophenone-induced choleresis in rats is mediated through Mrp2

Phloracetophenone (2,4,6-trihydroxyacetophenone, THA) is a potent choleretic in the bile fistula rat, although the mechanism is unknown. In the present study, we examined how THA enhances bile secretion. Stepwise infusions of THA (1–4 μmol/min) in the isolated perfused rat liver resulted in an immediate and dose-dependent increase in bile flow (BF), which reached saturation. The increase in BF was not associated with a change in the excretion of bile acids, suggesting that THA stimulated bile acid-independent bile flow. To further define the mechanism, the effect of THA on the excretion of sulfobromophthalein (BSP) and disulfobromophthalein (DBSP), typical multidrug resistance protein-2 (Mrp2) substrates was examined. THA inhibited the biliary excretion of both substrates. Because DBSP is excreted without conjugation to glutathione, in contrast to BSP, the findings suggest that THA might compete with DBSP and BSP metabolites at a common canalicular transport site, presumably Mrp2. THA infusions had no effect on the subcellular localization and distribution of either Mrp2 or the bile salt export pump (Bsep), nor the integrity of the tight junction. In contrast, the choleretic activity of THA was completely absent in the TR−rat, an animal model that lacks Mrp2, directly implicating this canalicular export pump as the mechanisms by which THA is excreted in bile. THA also partially reversed the cholestatic effects of estradiol-17β-d-glucuronide, a process also dependent on Mrp2. In conclusion, the choleretic activity of THA and its possible metabolites is dependent on Mrp2. THA appears to stimulate BF by its osmotic effects and may attenuate the cholestatic effects of hepatotoxins undergoing biotransformation and excretion via similar pathways.