Hepatolithiasis in a 52-year-old native liver survivor with postoperative biliary atresia

Hepatolithiasis is well known to be a late complication after biliary reconstruction. However, there were few reports regarding hepatolithiasis in late complications of long-term, native liver survivors in postoperative patients of biliary atresia. Here, we present a 52-year-old woman who underwent Kasai portoenterostomy for biliary atresia type Ⅲ at the age of 110 days. She was asymptomatic for over 30 years, and birthed three normal babies. Then she suffered from repeated cholangitis due to multiple hepatolithiasis since age 50. A lithotripsy via Roux-en-Y limb was performed but failed due to hepatic hilum strictures. Finally, she underwent living donor liver transplantation. Endoscopic lithotripsy and hepatectomy for hepatolithiasis often fail in biliary atresia patients due to unresolvable intrahepatic or hilar bile duct stenosis and liver dysfunction. Therefore, we consider that liver transplantation is curative and strongly recommended for symptomatic hepatolithiasis as a late complication after biliary atresia surgery

National trends in the outcomes of subarachnoid haemorrhage and the prognostic influence of stroke centre capability in Japan: retrospective cohort study

Objectives To examine the national, 6-year trends in in-hospital clinical outcomes of patients with subarachnoid haemorrhage (SAH) who underwent clipping or coiling and the prognostic influence of temporal trends in the Comprehensive Stroke Center (CSC) capabilities on patient outcomes in Japan.Design Retrospective study.Setting Six hundred and thirty-one primary care institutions in Japan.Participants Forty-five thousand and eleven patients with SAH who were urgently hospitalised, identified using the J-ASPECT Diagnosis Procedure Combination database.Primary and secondary outcome measures Annual number of patients with SAH who remained untreated, or who received clipping or coiling, in-hospital mortality and poor functional outcomes (modified Rankin Scale: 3–6) at discharge. Each CSC was assessed using a validated scoring system (CSC score: 1–25 points).Results In the overall cohort, in-hospital mortality decreased (year for trend, OR (95% CI): 0.97 (0.96 to 0.99)), while the proportion of poor functional outcomes remained unchanged (1.00 (0.98 to 1.02)). The proportion of patients who underwent clipping gradually decreased from 46.6% to 38.5%, while that of those who received coiling and those left untreated gradually increased from 16.9% to 22.6% and 35.4% to 38%, respectively. In-hospital mortality of coiled (0.94 (0.89 to 0.98)) and untreated (0.93 (0.90 to 0.96)) patients decreased, whereas that of clipped patients remained stable. CSC score improvement was associated with increased use of coiling (per 1-point increase, 1.14 (1.08 to 1.20)) but not with short-term patient outcomes regardless of treatment modality.Conclusions The 6-year trends indicated lower in-hospital mortality for patients with SAH (attributable to better outcomes), increased use of coiling and multidisciplinary care for untreated patients. Further increasing CSC capabilities may improve overall outcomes, mainly by increasing the use of coiling. Additional studies are necessary to determine the effect of confounders such as aneurysm complexity on outcomes of clipped patients in the modern endovascular era