Migrated biliary stent into the portal vein: a case report

Biliary stent insertion is a well-established treatment of bile duct obstruction. Stent migration is a late-onset complication and can be life-threatening. We present a case of proximal biliary stent migration to the portal vein. An upper endoscopy was performed, and the biliary stent was retracted. Bleeding was seen from the papilla of Vater. The hepatoduodenal ligament was explored, and the common bile duct was found fully adherent to the portal vein, with a fistula between the common bile duct and the portal vein. The patient underwent surgery with extrahepatic bile duct resection and hepaticoduodenostomy. The patient survived and was discharged without surgical postoperative complications on postoperative Day 8.

Clinical implications of multidisciplinary team pancreatic cyst evaluation

INTRODUCTION

The detection of incidental pancreatic cysts (PCs) is increasing due to frequent use of imaging. The aim of the present study was to evaluate the clinical consequences of regular multidisciplinary team (MDT) conferences for patients with PCs.

METHODS

All patient data were obtained by review of patient medical records. PCs were assessed at the weekly MDT in accordance with the revised Fukuoka guidelines.

RESULTS

A total of 455 patients were evaluated within 12 months. A large proportion of the cysts could not be characterised and was handled as branch duct (BD)-intraductal papillary mucinous neoplasia (IPMN). A total of 245 patients were included in a follow-up programme, whereas 175 patients were excluded. Further diagnostic work-up was recommended for 31 patients. A total of 66 patients were reviewed on MDT a second time during the study period, eight of whom received a diagnosis different from that given at the first MDT. A total of 35 patients with mucinous PC or cysts treated as BD-IPMN had either worrisome features (WF) or high-risk stigmata (HRS), four of these patients had a PC ≤ 10 mm. Indication for surgery was WF or HRS and, in the course of 12 months, six patients were recommended surgery taking their PS into account. Two patients had a malignant and two had a premalignant lesion.

CONCLUSION

In all, 455 patients were evaluated to find 35 patients with suspected premalignant PCs. This means that almost 8% of the referred patients had suspicious lesions, which indicates a need for a regular MDT conference.

FUNDING

None.

TRIAL REGISTRATION

Not relevant.

Long-term outcome after early repair of iatrogenic bile duct injury. A national Danish multicentre study

BACKGROUND

The aim of this retrospective study was to evaluate the peri-operative and long-term outcome after early repair with a hepaticojejunostomy (HJ).

METHODS

Between 1995 and 2010, a nationwide, retrospective multi-centre study was conducted. All iatrogenic bile duct injury (BDI) sustained during a cholecystectomy and repaired with HJ in the five Hepato-Pancreatico-Biliary centres in Denmark were included.

RESULTS

In total, 139 patients had an HJ repair. The median time from the BDI to reconstruction was 5 days. A concomitant vascular injury was identified in 26 cases (19%). Post-operative morbidity was 36% and mortality was 4%. Forty-two patients (30%) had a stricture of the HJ. The median follow-up time without stricture was 102 months. Nineteen out of the 42 patients with post-reconstruction biliary strictures had a re-HJ. Twenty-three patients were managed with percutaneous transhepatic cholangiography and dilation. The overall success rate of re-establishing the biliodigestive flow approached 93%. No association was found between timing of repair, concomitant vascular injury, level of injury and stricture formation.

CONCLUSION

In this national, unselected and consecutive cohort of patients with BDI repaired by early HJ we found a considerable risk of long-term complications (e.g. 30% stricture rate) and mortality in both the short- and the long-term perspective.

Dispersion and monochromatization of x-rays using a beryllium prism

We demonstrate experimentally and numerically that an x-ray prism made of beryllium can be used to disperse and monochromatize x-rays. A polished beryllium cuboid was employed as refractive and dispersive optics. The results of a proof-of-principle experiment and methods of performance optimization are presented. The spatial separation of undulator harmonics and their subsequent selection using a slit are described. A numerical study, assuming realistic beam and beamline parameters, suggests that undulator harmonics can be spatially separated in the range from 3 keV to beyond 20 keV, while maintaining throughput above 50%. Refractive optics is particularly suitable for low-repetition-rate sources such as free-electron lasers and other LINAC-based short-pulse sources.

Perceptions of participating in high-intensity functional exercise among older people dependent in activities of daily living (ADL)

The purpose of the study was to evaluate how older people, dependent in ADL perceive their participation in a high-intensity, functional exercise program compared to the perceptions of those participating in a control activity. Forty-eight older people living in residential care facilities answered a questionnaire about their perceptions of participating in an activity for three months. They were aged 65-98, had a mean score of 24 on Mini Mental State Examination (MMSE) and 14 on Barthel ADL Index. The participants had been randomized to exercise (n=20) or control activity (n=28). Differences in responses between exercise and control activity were evaluated using logistic and ordinal regression analyses. The results show that a majority of the exercise group perceived positive changes in lower limb strength, balance, and in the ability to move more safely and securely compared to a minority of the control group (p<0.001). Significantly more respondents in the exercise activity answered that they felt less tired due to the activity (p=0.027) and that they prioritized this activity above other activities (p=0.010). More exercise participants reported that meeting for three months was too short, and fewer that it was too long compared to the control group (p=0.038). This study shows that older people living in residential care facilities, dependent in ADL, and with mild or no cognitive impairment had positive perceptions about participating in high-intensity functional exercise. The findings support the use of a high-intensity exercise program in this population of older people.

Inhibition of human cytomegalovirus UL80 protease by specific intramolecular disulfide bond formation

A symmetrically substituted disulfide compound, CL13933, was identified as a potent inhibitor of human cytomegalovirus UL80 protease. Two types of inhibited protease were observed, depending on inhibitor concentration. At high concentrations, CL13933 formed a covalent adduct with the protease on Cys residues. At lower concentrations, this compound induced specific intramolecular disulfide formation between Cys84 and Cys87, and between Cys138 and Cys161. In contrast, Cys202 did not form disulfide bonds. Inhibition was reversed upon reduction of the protease. Each of the five cysteines of the UL80 protease was individually mutated to Ala. Each of the mutant proteases retained enzymatic activity, but mutants C138A and C161A were resistant to inhibition by CL13933, suggesting that disulfide bond formation between Cys138 and Cys161 is responsible for inhibition. This disulfide is apparently not induced by air oxidation. Examination of the CL13933 loading patterns of wild type and the five mutant proteases by mass spectrometry revealed that residues Cys87, Cys138, and Cys161 react with CL13933, and that the disulfide pair partner of each (Cys84, Cys161, and Cys138, respectively) is able to displace the compound via thiol-disulfide exchange. The possible significance of these reactive thiols in the protease is discussed.