Percutaneous Transhepatic Cholangiography and Drainage is an Effective Rescue Therapy for Biliary Complications in Liver Transplant Recipients Who Fail Endoscopic Retrograde Cholangiopancreatography

BackgroundWe attempted to evaluate both the factors that predispose a patient to biliary complications after liver transplantation and the results of percutaneous transhepatic cholangiography and drainage (PTCD) for the management of those complications.MethodsThis study retrospectively reviewed the cases of 81 patients who received liver transplants at Taipei Veterans General Hospital between February 2003 and June 2008. Biliary complications were diagnosed on the basis of clinical findings, laboratory data, and the results of imaging studies.ResultsA total of 18 patients (22.2%) developed biliary complications, and living donor liver transplantation (LDLT) was a significant risk factor (p = 0.035), compared to cadaveric liver transplantation. Eight patients with biliary complications received PTCD as the first treatment modality and 6 had successful results. An additional 10 patients received endoscopic retrograde cholangiopancreatography (ERCP) initially, but only 2 patients were effectively managed. One patient received conservative treatment after ERCP failure. One patient died from sepsis after ERCP. The remaining 6 patients with failed ERCP were successfully managed with PTCD. The overall mortality rate in these patients with biliary complications was 16.7%. No significant prognostic predictors were identified, including age, sex, biochemical data, and model for end-stage liver disease scores.ConclusionBiochemical markers cannot predict biliary complications preoperatively. LDLT increases the risk of biliary complications. PTCD is an effective rescue therapy when ERCP fails

Percutaneous transhepatic techniques for retrieving fractured and intrahepatically dislodged percutaneous transhepatic biliary drainage catheters

Dislodged intrabiliary drainage devices, including catheters, endoprostheses, and stents, may further impair drainage and cause various local reactions, vascular and gastrointestinal tract complications. Endoscopic approaches for management of plastic biliary endoprostheses have been extensively discussed. However, in rare cases of fracture of percutaneous transhepatic biliary drainage (PTBD) catheters, only a percutaneous transhepatic technique for retrieving should be applied to avoid further damage by its rigid fragment. We present the adjusted techniques using either a goose neck snare, over-the-wire balloon catheter, or biopsy forceps with image demonstration and reviews. We encountered two patients with PTBD tube fracture and intrahepatic dislodgment. In both patients, percutaneous approaches were used for successfully retrieving and removing the fractured catheter through transhepatic tract: one with the use of a biopsy forceps, another with an inflatable balloon catheter

Multidisciplinary Taiwan consensus for the use of conventional TACE in hepatocellular carcinoma treatment

Developed in early 1980s, transarterial chemoembolization (TACE) with Lipiodol was adopted globally after large-scale randomized control trials and meta-analyses proving its effectiveness were completed. Also known as “conventional TACE” (cTACE), TACE is currently the first-line treatment for patients with unresectable intermediate stage hepatocellular carcinoma (HCC) and delivers both ischemic and cytotoxic effects to targeted tumors. Although new technology and clinical studies have contributed to a more comprehensive understanding of when and how to apply this widely-adopted therapeutic modality, some of these new findings and techniques have yet to be incorporated into a guideline appropriate for Taiwan. In addition, differences in the underlying liver pathologies and treatment practices for transcatheter embolization between Taiwan and other Asian or Western populations have not been adequately addressed, with significant variations in the cTACE protocols adopted in different parts of the world. These mainly revolve around the amount and type of chemotherapeutic agents used, the type of embolic materials, reliance on Lipiodol, and the degree of selectiveness in catheter positioning. Subsequently, interpreting and comparing results obtained from different centers in a systematic fashion remain difficult, even for experienced practitioners. To address these concerns, we convened a panel of experts specializing in different aspects of HCC treatment to devise modernized recommendations that reflect recent clinical experiences, as well as cTACE protocols which are tailored for use in Taiwan. The conclusions of this expert panel are described herein

Management of hemodynamically unstable, ruptured multiple hepatic artery pseudoaneurysms by open surgery combined with endovascular embolization

Hepatic artery pseudoaneurysm is a type of visceral artery aneurysm, which may cause life-threatening situation if the diagnosis and treatment are delayed after rupture. Increased clinical awareness and aggressive, definitive management are necessary in obtaining optimal outcomes. In general, surgery is the preferred treatment for extrahepatic lesions, whereas embolization is appropriate for intrahepatic aneurysms. However, exploratory laparotomy for vascular ligation or anastomosis is the only way in emergency if the hemodynamic status is unstable. Since the cases of ruptured pseudoaneurysm in both intra- and extra-hepatic artery is rare, we present a case of ruptured hepatic artery pseudoaneurysms with hemorrhagic shock rescued by surgery to stabilize the patient, followed by angioembolization to manage the multiple hepatic aneurysms and provide a review of the current literature on this topic, focusing on appropriate decision-making under multidisciplinary management

Magnetic Resonance Angiography and Doppler Scanning for Detecting Atherosclerotic Renal Artery Stenosis

Atherosclerotic renal artery stenosis (ARAS) is a progressive but potentially reversible chronic kidney disease. Although the high sensitivity and specificity of renal Doppler scanning (RDS) for ARAS has been reported in western countries, ARAS has not been detected by RDS. This study used magnetic resonance angiography (MRA) to evaluate the sensitivity and specificity of RDS for detecting ARAS among outpatients at a nephrology clinic, and to calculate the degree of underestimation of ARAS by RDS. Methods: A total of 257 outpatients, aged > 50 years were examined for ARAS by RDS and MRA. Results: Thirty-seven (14.4%) and 139 (54.1%) of 257 patients had stenosis detected by RDS and MRA, respectively. Among the 220 patients whose RDS results were negative, MRA detected stenosis in 111 (50.45%). Multivariate logistic regression analysis showed that age > 65 years, duration of smoking, coronary artery disease, and serum creatinine levels > 354 mmol/L (4 mg/dL) were significant and independent factors that influenced ARAS in patients with negative results by RDS. Conclusion: RDS might still be the diagnostic procedure of choice for screening outpatients for ARAS because it is inexpensive, convenient, able to detect severity, and avoids the use of contrast media. When RDS is negative in aged people who have smoked longer than 20 years, with coronary artery disease or serum creatinine > 4 mg/dL, MRA is recommended for further evaluation of ARAS

Right Hepatic Artery Pseudoaneurysm Ruptured Into the Gallbladder Demonstrated by Magnetic Resonance Angiography

Rupture of a right hepatic artery pseudoaneurysm into the gallbladder is very rare. We demonstrated a 20-mm dumbbell-shaped pseudoaneurysm in the gallbladder lumen by using contrast-enhanced magnetic resonance angiography in a 73-year-old man with acute right upper abdominal pain. Inflammation of the gallbladder caused by calculous cholecystitis, which leads to biliary leakage and erodes the right hepatic artery, could have been the cause

Application of stent placement or nasojejunal feeding tube placement in patients with malignant gastric outlet obstruction: A retrospective series of 38 cases

Background: Malignant gastric outlet obstruction (MGOO), a late complication of advanced carcinoma of the stomach, duodenum, periampulla or pancreas, causes significant malnutrition and morbidity. The current treatment for MGOO is palliative in nature, with the goal of maintaining the best quality of life possible during the terminal phase of the illness. Methods: A total of 38 patients with MGOO were enrolled in our institute from January 2007 to December 2011; 18 patients received nasojejunal (NJ) feeding tube placement, and 20 patients received duodenal stent placement. Food intake, measured by the gastric outlet obstruction scoring system (GOOSS), survival, complications, recurrent obstructive symptoms, and reintervention were evaluated in both groups. Results: No significant differences were noted with regard to patient characteristics, survival rate (NJ group: 140 days vs. stent group: 186 days, p = 0.617), and complication rate. Recurrent obstructions developed more frequently in patients treated with NJ feeding tube placement than in those treated with duodenal stent placement [12 (66.7%) vs. 5 (25%), p = 0.014]. The duration for patency was shorter in the NJ group than in the stent group (median: 40 days vs. 130 days, p = 0.009). The GOOSS score was significantly better in the stent group than in the NJ group. Conclusion: NJ tube placement and duodenal stent placement are both effective and safe treatments for patients with MGOO. Both groups had similar complication rates and survival rates. While NJ tube placement is associated with lower costs, stent placement has a longer duration of patency, superior oral intake, and a lower reintervention rate. We suggest that stent placement should be considered first in patients who are able to afford the related costs

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Background: Atherosclerotic renal artery stenosis (ARAS) is a progressive but potentially reversible chronic kidney disease. Although the high sensitivity and specificity of renal Doppler scanning (RDS) for ARAS has been reported in western countries, ARAS has not been detected by RDS. This study used magnetic resonance angiography (MRA) to evaluate the sensitivity and specificity of RDS for detecting ARAS among outpatients at a nephrology clinic, and to calculate the degree of underestimation of ARAS by RDS. Methods: A total of 257 outpatients, aged > 50 years were examined for ARAS by RDS and MRA. Results: Thirty-seven (14.4%) and 139 (54.1%) of 257 patients had stenosis detected by RDS and MRA, respectively. Among the 220 patients whose RDS results were negative, MRA detected stenosis in 111 (50.45%). Multivariate logistic regression analysis showed that age > 65 years, duration of smoking, coronary artery disease, and serum creatinine levels > 354 μmol/L (4 mg/dL) were significant and independent factors that influenced ARAS in patients with negative results by RDS. Conclusion: RDS might still be the diagnostic procedure of choice for screening outpatients for ARAS because it is inexpensive, convenient, able to detect severity, and avoids the use of contrast media. When RDS is negative in aged people who have smoked longer than 20 years, with coronary artery disease or serum creatinine > 4 mg/dL, MRA is recommended for further evaluation of ARAS. [J Chin Med Assoc 2010;73(6):300-307