Non-Operative Management of a Common Bile Duct Injury Sustained During Cholecystectomy in a Morbidly Obese Patient. (Non-Operative Repair of CBD Injury)

A 29 year old morbidly obese patient suffered injury to his common bile duct during cholecystectomy. Subsequent access to the biliary tree was obtained by using a long heavy gauge needle after first opacifying the system with contrast injection through a nasobiliary tube. It is now twenty six months after initial percutaneous biliary drainage placement and eighteen months after removal of all biliary access. The patient is asymptomatic and has normal liver function tests. This technique can be useful in morbidly obese patients who are at increased risk from surgical repair of biliary duct injuries

Leveraging Aberrant Vasculature in Celiac Artery Stenosis: The Arc of Buhler in Pancreaticoduodenectomy

Background: Celiac artery stenosis and occlusion have been described rarely in patients undergoing pancreaticoduodenectomy (PD), although it occurs relatively frequently in this group. An arterial connection between the celiac and superior mesenteric arteries, known as the Arc of Buhler, provides alternative flow to the celiac distribution once the gastroduodenal artery (GDA) is ligated in PD. Case Presentation: A 69-year-old man, in whom pre- and intraoperative efforts to stent an occluded celiac artery failed, had sufficient retrograde flow from an unrecognized Arc of Buhler to maintain adequate hepatic arterial perfusion after ligation of the GDA during a PD. Conclusions: Although there are several case reports and case series regarding the management of celiac stenosis in PD, the impact of an Arc of Buhler variant in this setting has been rarely reported. This case report demonstrates the ability of an intact Arc of Buhler to maintain adequate hepatic perfusion after ligation of the GDA and avoid the potential morbidity of a hepatic artery bypass procedure

Minimal Risk of Biliary Tract Complications, Including Hepatic Abscess, After Transarterial Embolization for Hepatocellular Carcinoma Using Concentrated Antibiotics Mixed with Particles.

PURPOSE: To assess the incidence of biliary complications, cholecystitis, and abscess formation in HCC patients following transarterial embolization (TAE) using particles mixed with concentrated antibiotics. MATERIALS AND METHODS: Retrospective review of HCC patients treated with embolization over a 10-year period revealed 499 procedures in 257 patients. TAE was performed with particles mixed with concentrated antibiotics in addition to IV antibiotics. All follow-up imaging after treatment was retrospectively reviewed for the development of bilomas, biliary strictures, acute cholecystitis, and hepatic abscess. Clinical notes and laboratory tests were also reviewed. RESULTS: Mean follow-up duration was 18.2 months. In total, there was one biliary complication consisting of biloma formation. This patient had subsegmental hepatic infarction identified on imaging 8 days post-embolization in the setting of subsegmental portal vein thrombus, with subsequent biloma development. There were no cases of new biliary strictures in the embolized portion of the liver at any point after treatment. One patient developed acute gangrenous cholecystitis 10 days post-procedure. No patients developed a hepatic abscess, although 10 patients had bilioenteric anastomoses or incompetent sphincters of Oddi. CONCLUSIONS: Biliary complications and cholecystitis occurred extremely rarely after TAE, at a markedly lower rate than historical data on TACE. Despite significant risk factors for abscess formation in 10 patients, TAE with particles mixed with concentrated antibiotics resulted in zero abscesses, in contrast to a very high rate after TACE in the literature

Probing gut‐brain links in Alzheimer's disease with rifaximin

Abstract Gut‐microbiome‐inflammation interactions have been linked to neurodegeneration in Alzheimer's disease (AD) and other disorders. We hypothesized that treatment with rifaximin, a minimally absorbed gut‐specific antibiotic, may modify the neurodegenerative process by changing gut flora and reducing neurotoxic microbial drivers of inflammation. In a pilot, open‐label trial, we treated 10 subjects with mild to moderate probable AD dementia (Mini‐Mental Status Examination (MMSE) = 17 ± 3) with rifaximin for 3 months. Treatment was associated with a significant reduction in serum neurofilament‐light levels (P < .004) and a significant increase in fecal phylum Firmicutes microbiota. Serum phosphorylated tau (pTau)181 and glial fibrillary acidic protein (GFAP) levels were reduced (effect sizes of −0.41 and −0.48, respectively) but did not reach statistical significance. In addition, there was a nonsignificant downward trend in serum cytokine interleukin (IL)‐6 and IL‐13 levels. Cognition was unchanged. Increases in stool Erysipelatoclostridium were correlated significantly with reductions in serum pTau181 and serum GFAP. Insights from this pilot trial are being used to design a larger placebo‐controlled clinical trial to determine if specific microbial flora/products underlie neurodegeneration, and whether rifaximin is clinically efficacious as a therapeutic

Effectiveness of Transarterial Embolization of Hepatocellular Carcinoma as a Bridge to Transplantation.

PURPOSE: To assess the effectiveness of bland transarterial embolization of hepatocellular carcinoma (HCC) as a bridge to transplantation. MATERIALS AND METHODS: In this retrospective study, 117 patients with HCC that met Milan criteria underwent bland embolization as their initial and sole therapy for treatment of HCC (88 men and 29 women; mean age, 60.4 y; range, 35-88 y). Subsequent postembolization contrast-enhanced computed tomography or magnetic resonance imaging studies were reviewed to determine whether Milan criteria were met in an intent-to-transplant analysis. Freedom from progression beyond Milan criteria and survival were calculated by Kaplan-Meier technique. Predictors of progression and survival were also assessed. RESULTS: After embolization, 87% and 78% of patients\u27 disease still met Milan criteria at 6 and 12 months, respectively. The median time until disease progression beyond Milan criteria was 22.6 months (95% confidence interval, 16.2-29 mo). α-Fetoprotein levels, number of lesions, United Network for Organ Sharing stage, Model for End-stage Liver Disease score, and cirrhosis etiology did not correlate significantly with stability within Milan criteria. A total of 34 patients (29%) underwent eventual liver transplantation at a median of 3.3 months (range, 0.5-20.9 mo). Liver transplantation was a significant independent predictor of longer survival (6.9 y vs 2.6 y; P \u3c .001). The major complication rate within 30 days of embolization was 2.6%, including one mortality. CONCLUSIONS: Bland transarterial embolization as a bridging strategy to maintain HCC within Milan criteria was successful in 78% of patients at 1 year, which compares favorably with other locoregional embolotherapies