Primary Sclerosing Cholangitis Limited to Intrahepatic Bile Ducts Has Distinctly Better Prognosis

BACKGROUND

There are two sub-phenotypes of large-duct primary sclerosing cholangitis (PSC): isolated intrahepatic PSC (IIPSC) and extrahepatic disease with or without intrahepatic (extra/intrahepatic).

AIMS

This study examined the differences in outcomes in patients with IIPSC compared to extra/intrahepatic and small-duct PSC.

METHODS

Patients with PSC treated at our institution from 1998 to 2019 were investigated. Biochemistries, clinical events, and survival were assessed by chart review and National Death Index. Cox-proportional hazards were used to determine the risk of clinical outcomes based on biliary tract involvement.

RESULTS

Our cohort comprised 442 patients with large-duct PSC (57 had IIPSC, 385 had extra/intrahepatic PSC) and 23 with small-duct PSC. Median follow-up in the IIPSC group was not significantly different from the extra/intrahepatic group [7 vs. 6 years, P = 0.06]. Except for lower age (mean 37.9 vs. 43.0 years, P = 0.045), the IIPSC group was not different from the extra/intrahepatic. The IIPSC group had longer transplant-free survival (log-rank P = 0.001) with a significantly lower risk for liver transplantation (12% vs. 34%, P < 0.001). The IIPSC group had a lower risk of death or transplantation than the extra/intrahepatic PSC group [HR: 0.34, 95% CI: 0.17-0.67, P < 0.001]. No bile duct or gallbladder cancers developed in patients with IIPSC, compared to 24 in the extra/intrahepatic group. The clinical characteristics and outcomes of IIPSC were similar to 23 individuals with small-duct PSC.

CONCLUSIONS

Patients with IIPSC have a favorable prognosis similar to small-duct PSC. These data are important for counseling patients and designing therapeutic trials for PSC.

Management of erythropoietic protoporphyria with cholestatic liver disease: A case report

Erythropoietic protoporphyria (EPP) is a rare metabolic disease of the heme biosynthetic pathway where an enzymatic dysfunction results in protoporphyrin IX (PPIX) accumulation in erythroid cells. The porphyrins are photo-reactive and are responsible for severe photosensitivity in patients, thus drastically decreasing their quality of life. The liver eliminates PPIX and as such, the main and rare complication of EPP is progressive cholestatic liver disease, which can lead to liver failure. The management of this complication is challenging, as it often requires a combination of approaches to promote PPIX elimination and suppress the patient's erythropoiesis. Here we described a 3-year follow-up of an EPP patient, with three episodes of liver involvement, aggravated by the coexistence of a factor VII deficiency. It covers all the different types of intervention available for the management of liver disease, right through to successful allogeneic hematopoietic stem cell transplantation.

Challenges in Diagnosing and Reporting Cholangiocarcinoma

Intrahepatic cholangiocarcinoma is a challenge to the practicing surgical pathologist for several reasons. It is rare in many parts of the world, and thus practical exposure may be limited. Related to the fact of its rarity is the fact that more common tumors which frequently metastasize to the liver can be morphologically indistinguishable (eg, pancreatic ductal adenocarcinoma). Immunohistochemical testing is generally non-contributory in this context. Other difficulties arise from the protean morphologic manifestations of cholangiocarcinoma (ie, small duct vs. large duct) and the existence of combined cholangiocarcinoma and hepatocellular carcinoma. These, and other issues of concern to the practicing diagnostic pathologist are discussed herein.

Solid-Tubulocystic carcinoma: A new variant of intrahepatic cholangiocarcinoma

A new variant of intrahepatic cholangiocarcinoma (iCCA) has been recognized in recent years presenting predominantly as a large hepatic mass in young woman with the characteristic expression of inhibin by immunohistochemistry. This variant iCCA was originally termed as cholangioblastic variant of iCCA, and subsequently proposed to be renamed as inhibin-positive hepatic carcinoma or solid-tubulocystic variant of iCCA to better reflect its immunohistochemical profile or morphologic spectrum. The tumor histologically is composed of small to medium sized cells with scant to moderate amount of eosinophilic cytoplasm heterogeneously organized in solid, tubular, and cystic growth patterns. The tumor cells are positive for biliary markers, inhibin and albumin, and have a novel recurrent gene fusion, NIPBL::NACC1. Awareness of this new iCCA variant and its clinicopathologic features will aid in the diagnostic work-up and avoid confusion with other primary and metastatic hepatic neoplasms.

Intragastric fish bones migrate into the liver: A case report

BACKGROUND

A foreign body in the digestive tract is a common disease in the clinic. However, it is rare for a foreign body to migrate into the liver. Most patients are diagnosed before or after perforation of the digestive tract. Laparoscopic removal of intrahepatic foreign bodies is an effective treatment method.

CASE SUMMARY

A 55-year-old male patient was admitted to the hospital due to fever for 3 d, in addition to pain and discomfort in the right side of his waist. After admission, abdominal computed tomography showed a foreign body in the liver, and gastroscopy did not indicate obvious erosion or ulcers. The patient then underwent laparoscopic surgery. During the operation, an abscess was seen near the gastric antrum and between the caudate lobes of the liver. It was approximately 30 mm × 31 mm × 23 mm in size. The abscess was cut open, and a fish bone was found inside. The fish bone had penetrated the liver and was successfully removed. It was confirmed that the fish bone migrated from the stomach to the liver.

CONCLUSION

Although intrahepatic foreign bodies are rare, they should be diagnosed and treated as early as possible to avoid serious complications such as intrahepatic abscess, which may lead to liver resection and even life-threatening events.

Clinicopathologic characteristics and long-term prognosis of intraductal papillary neoplasm of the bile duct: a retrospective study

BACKGROUND

Intraductal papillary neoplasm of the bile duct (IPNB) is a premalignant neoplasm that can involve both the intrahepatic and extrahepatic bile ducts. Owing to the low incidence and confusing nomenclature, its clinicopathological features remain controversial. Additionally, only a few studies have reported on the long-term prognosis of IPNB to date. Therefore, the present study aimed to clarify the clinicopathological characteristics and prognosis of IPNB.

METHODS

Medical records of patients with IPNB treated at our hospital between August 2000 and October 2021 were retrospectively reviewed. A database of demographic characteristics, test results, surgical details, pathological findings, and follow-up information was constructed for analysis. Patients were divided into intrahepatic and extrahepatic groups, and dysplasia and invasive carcinoma groups for comparison. Differences between study groups were analyzed using the χ² test, Fisher's exact test, t-test, or Mann-Whitney U test, as appropriate. Cumulative survival rates were estimated using the Kaplan-Meier method.

RESULTS

In total, 43 patients (21 men and 22 women) with IPNB were included in the study. The median age at diagnosis was 62 (54-69) years. Thirty-eight patients underwent surgery. The mean operation time was (269.5 ± 94.9) min. Five patients underwent endoscopic retrograde cholangiopancreatography for biopsy. Twenty-one and 22 patients had intrahepatic and extrahepatic lesions, respectively. The extrahepatic group had more patients with intraluminal masses (p = 0.021) and abnormal bilirubin levels (p = 0.001), but fewer patients with hepatolithiasis (p = 0.021). The operation time was longer in patients with extrahepatic lesions (p = 0.002). Twenty patients had dysplasia and 23 had invasive carcinoma. The invasive carcinoma group had a longer operation time than the dysplasia group (p = 0.004). As of March 2022, 39 patients were followed up, with a mean follow-up time of (56.2 ± 38.2) months. Fifteen patients survived without tumors, two survived with tumors, and 22 patients died. The 1-, 3-, 5-, and 10-year cumulative overall survival rates were 86.9%, 65.8%, 49.8%, and 32.0%, respectively.

CONCLUSIONS

IPNB is a rare bile duct disease that occurs mainly in patients with advanced age. Surgery is the primary treatment strategy. Intrahepatic and extrahepatic lesions, as well as dysplasia and invasive carcinoma have their own unique characteristics. The long-term prognosis of IPNB is generally poor.

Stereotactic radiotherapy for intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (iCCA) is an aggressive malignancy with an increasing incidence worldwide and poor prognosis, despite several advances and continuous efforts to develop effective treatments. Complete surgical resection is the mainstay of treatment and offers a potentially curative option, but is only possible in less than a third of patients, owing to advanced disease. Chemotherapy is a well-established treatment in the adjuvant and palliative setting, however, confers limited benefit. Conventional radiotherapy is challenging due to local toxicity. With recent advances in stereotactic ablative radiotherapy (SABR), it is now possible to focus ablative beams of radiotherapy precisely aimed at tumours to minimise damage to surrounding viscera. This review details the history, technical background and application of SABR to iCCA, with directions for future research suggested.

Update on the association of hepatitis B with intrahepatic cholangiocarcinoma: Is there new evidence?

Intrahepatic cholangiocarcinoma (iCCA) is a subgroup of cholangiocarcinoma that accounts for about 10%-20% of the total cases. Infection with hepatitis B virus (HBV) is one of the most important predisposing factors leading to the formation of iCCA. It has been recently estimated based on abundant epidemiological data that the association between HBV infection and iCCA is strong with an odds ratio of about 4.5. The HBV-associated mechanisms that lead to iCCA are under intense investigation. The diagnosis of iCCA in the context of chronic liver disease is challenging and often requires histological confirmation to distinguish from hepatocellular carcinoma. It is currently unclear whether antiviral treatment for HBV can decrease the incidence of iCCA. In terms of management, surgical resection remains the mainstay of treatment. There is a need for effective treatment modalities beyond resection in both first- and second-line treatment. In this review, we summarize the epidemiological evidence that links the two entities, discuss the pathogenesis of HBV-associated iCCA, and present the available data on the diagnosis and management of this cancer.

Relationship between PD-L1 expression, CD8+ T-cell infiltration and prognosis in intrahepatic cholangiocarcinoma patients

BACKGROUND

Programmed death- ligand 1 (PD-L1) seems to be associated with the immune escape of tumors, and immunotherapy may be a favorable treatment for PD-L1-positive patients. We evaluated intrahepatic cholangiocarcinoma (ICC) specimens for their expression of PD-L1, infiltration of CD8+ T cells, and the relationship between these factors and patient survival.

METHODS

In total, 69 resections of ICC were stained by immunohistochemistry for PD-L1, programmed death factor-1 (PD-1), and CD8+ T cells. CD8+ T-cell densities were analyzed both within tumors and at the tumor-stromal interface. Patient survival was predicted based on the PD-L1 status and CD8+ T-cell density.

RESULTS

The expression rate of PD-L1 was 12% in cancer cells and 51% in interstitial cells. The expression rate of PD-1 was 30%, and the number of CD8+ T-cells increased with the increase of PD-L1 expression (p < 0.05). The expression of PD-L1 in the tumor was correlated with poor overall survival(OS) (p = 0.004), and the number of tumor and interstitial CD8+ T-cells was correlated with poor OS and disease-free survival (DFS) (All p < 0.001).

CONCLUSIONS

The expression of PD-L1 in the tumor is related to poor OS, and the number of tumor or interstitial CD8+ T-cells is related to poor OS and DFS. For patients who lose their chance of surgery, PD-L1 immunosuppressive therapy may be the focus of future research as a potential treatment.

Characterization and natural history of congenital intrahepatic portosystemic shunts

Congenital intrahepatic portosystemic shunts are rare vascular malformations in which abnormal communications are created between the portal veins and the hepatic veins or the inferior vena cava system. Diagnosis is made by prenatal or postpartum ultrasound. Published data regarding presentation, symptoms, and prognosis is scarce. This study aimed to better understand the natural history and the course of the intrahepatic portosystemic shunts. Data were collected from children in two medical centers who were diagnosed with congenital intrahepatic portosystemic shunts on either prenatal or postnatal sonographic screening. The subjects' medical information was collected including demographics, medical background, and sonographic and clinical outcome. Blood test results including ammonia levels and liver function tests were documented, as well as the sonographic dimensions of the shunt vessels and the spleen size. The data were analyzed using various statistical methods. Twenty-three children with portosystemic shunts were found and reviewed. Eight children were excluded from the study since records and follow-up were insufficient. Fifteen patients were included in the study (six females). All had intrahepatic shunt diagnosed either by prenatal screening or postnatal abdominal ultrasound and had more than one ultrasound and repeated blood tests. Shunt closure was observed in all children within a mean of 114.31 ± 115.05 days (median 84). There was no correlation between liver enzymes, ammonia, and ultrasound vascular and splenic diameters to time to closure. None of the children had any hepatic or other sequelae.Conclusions: Our study suggests that congenital intrahepatic portosystemic shunt is a benign, self-limiting condition in which no correlation between the size of the shunt and the blood ammonia level to the outcome of the shunt was found. This is the first study that correlated radiological measures to the outcome. These results suggest that the treating physician should reassure families and conduct minimal follow-up and interventions in children with such conditions. Further, larger and prospective studies should be done to corroborate these conclusions. What is Known: • Characteristics and natural history of intrahepatic portosystemic shunts are less defined. • The natural course of the intrahepatic malformations varies, but spontaneous, self-resolution of small shunts, usually occures within 1 to 2 years. What is New: • In this study, congenital intrahepatic portosystemic shunt was shown to be benign, self-limiting condition in which all shunts closed within 3 months. • No correlation between the size of the shunt and the blood ammonia level to the outcome of the shunt was found.

Durable response after discontinuation of pembrolizumab therapy for intrahepatic cholangiocarcinoma: a case report

Although it has recently been reported that immune checkpoint inhibitors (ICIs) constitute effective treatment for solid tumors, the success rate in patients with intrahepatic cholangiocarcinoma is limited. We administered pembrolizumab to a patient as treatment for liver and lymph node metastases of intrahepatic cholangiocarcinoma. The patient had abundant infiltration of programmed death ligand 1-positive macrophages, cytotoxic T cells (CD8-positive lymphocytes), and programmed death 1-positive lymphocytes as well as a high combined positive score of 33.1, high-frequency microsatellite instability, and mismatch repair deficiency. These characteristics are predictive biomarkers of the efficacy of ICIs. After pembrolizumab was administered four times (triweekly administration), the carbohydrate antigen 19-9 serum level fell within the normal range, and computed tomography revealed that the size of the metastatic liver tumors and enlarged hilar lymph node had markedly decreased. However, the patient developed pruritus and exanthema on the trunk and limbs after 14 administrations and was diagnosed with bullous pemphigoid. We discontinued pembrolizumab therapy and started treatment for bullous pemphigoid. Nine months after discontinuation of pembrolizumab therapy, the patient remains alive without tumor relapse. This patient had durable response even after discontinuation of pembrolizumab therapy for multiple metastases of intrahepatic cholangiocarcinoma.

Oral ibuprofen promoted cholestatic liver disease in very low birth weight infants with patent ductus arteriosus

OBJECTIVES

Hemodynamically significant patent ductus arteriosus (hsPDA) in very low birth weight (VLBW) infants is routinely treated in many countries with oral ibuprofen. This study retrospectively assessed whether the risk of cholestatic liver disease (CLD) increased due to oral ibuprofen administration in VLBW infants.

METHODS

A total of 122 VLBW preterm infants (26∼32 weeks, birth weight<1500g) diagnosed with patent ductus arteriosus (PDA) admitted to our neonatal intensive care unit (NICU) between September 2016 to August 2018 were included. Sixty-four infants were diagnosed with hs-PDA and received ibuprofen treatment. VLBW infants with PDA untreated with ibuprofen served as controls. Soybean oil and fat emulsions were routinely added to parenteral nutrition (PN). Once CLD was diagnosed, the fat emulsions were immediately replaced with multi-oil fat emulsion injections. To assess the independent association of treatment and duration of ibuprofen with CLD and duration of fasting and PN, binary logistic regression or multivariate linear regression analyses were conducted, adjusting for major confounders (birth weight, gestational age, Clinical Risk Index for Babies, and cholestasis-associated risk factors).

RESULTS

The duration of PN increased due to ibuprofen treatment for 6.559 days (95% CI: 1.769, 11.349; P=0.008), and the risk of prolonged fasting (cutoff>5 days) might have increased due to ibuprofen treatment (OR: 3.043, 95% CI: 0.965, 9.594; P=0.057). Furthermore, CLD was influenced by ibuprofen treatment (OR: 6.730; 95% CI: 1.279, 35.41; P=0.024), early thrombocytopenia 7 days postnatal (OR: 6.996; 95% CI: 1.769, 27.658; P=0.004), and late onset sepsis (OR: 6.976; 95% CI: 1.561, 31.169; P=0.011). Further analysis adjusting for cholestasis-associated risk factors revealed that CLD was influenced by the duration of ibuprofen treatment (OR: 2.864; 95% CI: 1.104, 7.422; P=0.030), Platlets counts 7 days postnatal (OR: 0.971; 95% CI: 0.950, 0.994; P=0.013), and duration of antibiotics (OR: 1.134; 95% CI: 1.002, 1.282; P=0.046).

CONCLUSIONS

This retrospective study indicated oral ibuprofen duration-dependently increased the risk of CLD in VLBW infants with PDA, and early thrombocytopenia served as the critical risk factor.

Sorted B cell transcriptomes point towards actively regulated B cell responses during ongoing chronic hepatitis B infections

The natural course of chronic hepatitis B virus (HBV) infections follows distinct clinical disease phases, characterized by fluctuating levels of serum HBV DNA and ALT. The immune cells and their features that govern these clinical disease transitions remain unknown. In the current study, we performed RNA sequencing on purified B cells from blood (n = 42) and liver (n = 10) of healthy controls and chronic HBV patients. We found distinct gene expression profiles between healthy controls and chronic HBV patients, as evidenced by 190 differentially expressed genes (DEG), but also between the clinical phenotypes of a chronic HBV infection (17-110 DEG between each phase). Numerous immune pathways, including the B cell receptor pathway were upregulated in liver B cells when compared to peripheral B cells. Further investigation of the detected DEG suggested an activation of B cells during HBeAg seroconversion and an active regulation of B cell signalling in the liver.

Intraductal papillary neoplasm of the left hepatic duct treated with endoscopic retrograde cholangiopancreatography guided radiofrequency ablation

Intraductal papillary neoplasm of the biliary tree (IPNB) is a rare non-invasive neoplasm that carries a high potential for progression to malignancy. Typically, these tumors are managed via surgery with total resection being the fundamental goal. Recently, radiofrequency ablation (RFA) has gained momentum as a treatment option for biliary cancers. Prior studies examining the effect of RFA on biliary tumors usually group all tumor types together, leaving few reports looking at sole outcomes in IPNB. We present an elderly woman with advanced dementia who was admitted with obstructive jaundice secondary to intrahepatic IPNB, and underwent Endoscopic Retrograde Cholangiopancreatography (ERCP) with RFA and stenting resulting in objective improvement in both the size of the lesion and laboratory markers. In the right subset of patients, endobiliary RFA can be used as a safe and effective modality of treatment with minimal complications.

Intrahepatic cholangiocarcinoma: pathogenesis, current staging, and radiological findings

To this date, it is a major oncological challenge to optimally diagnose, stage, and manage intrahepatic cholangiocarcinoma (ICC). Imaging can not only diagnose and stage ICC, but it can also guide management. Hence, imaging is indispensable in the management of ICC. In this article, we review the pathology, epidemiology, genetics, clinical presentation, staging, pathology, radiology, and treatment of ICC.

Intrahepatic pseudoaneurysm following penetrating abdominal injury: Surgical and endovascular management of 2 complicated cases

INTRODUCTION

Post-traumatic pseudoaneurysm of the hepatic artery is a rare complication of abdominal injury. Prompt intervention is essential to avoid a life-threatening hemorrhage. We report two complicated cases of intrahepatic pseudoaneurysm (IHPA).

PRESENTATION OF CASES

Case 1: A victim of a bomb blast with thoracoabdominal injury presented in hypovolemic shock. Emergency laparotomy revealed actively bleeding liver lacerations, which had been successfully controlled with perihepatic packing. After 72 h, computed tomography (CT) of the abdomen showed a 3 cm × 1.8 cm IHPA of the left hepatic artery, which was treated with endovascular microcoils embolization. Postoperatively, the patient developed bile leakage and biliopleural fistula, which were managed conservatively. Case 2: A patient suffered a shotgun injury to the abdomen. In laparotomy, a grade III liver laceration was noted. The bleeding was controlled with perihepatic packing. The packs were removed 48 h later. Ten days postoperatively, the patient developed severe abdominal pain with shock, CT of the abdomen showed; 24 cm × 13 cm × 8 cm subcapsular liver hematoma. Superselective hepatic angiography showed a 1-cm IHPA of the right hepatic artery. The entry and exit points of the aneurysm were successfully embolized with two microcoils. No complications related to angioembolizaion were encountered.

DISCUSSION

IHPA following bomb blast and shotgun injury is rarely reported. Timely diagnosis is crucial.

CONCLUSION

We advise to keep in mind the possibility of IHPA, when dealing with high-grade liver injury. CT is recommended before removal of perihepatic packs, as it may pick up a life-threatening pseudoaneurysm.

Common and Alternative Routes of Euthanasia Solution Administration

There are many acceptable routes of euthanasia solution administration in companion animals. The most common ones are those with consistent use and success, and that align with what is best for the patient, client, and veterinary team. Common injection sites include the venous, hepatic, and renal systems. The barbiturate drugs are in consistent use today, but other drugs may be better given the setting and circumstances at the time. Alternative techniques are available, but only reached for when other more suitable routes of administration are not ideal.

The role of down staging treatment in the management of locally advanced intrahepatic cholangiocarcinoma: Review of literature and pooled analysis

Backgrounds/Aims

Approximately 60–80% of patients with intrahepatic cholangiocarcinoma (iCCA) are not suitable for surgical resection due to advanced disease at presentation. This review assesses the role of surgical resection followed by down staging treatment in the management of patients with locally advanced iCCA.

Methods

A systematic review and pooled analysis were performed of the relevant published studies published between January 2000-December 2018. The primary outcome measure was overall survival. Secondary outcome measures were rates of clinical benefit, margin-negative (R0) resections, overall and surgery-specific complications, and post-operative mortality.

Results

Eighteen cohort studies with 1880 patients were included in the review. The median overall survival in all patients was 14 months (range, 7–18 months). Patients undergoing resection following down staging had significantly longer survival than those who did not (median: 29 vs. 12 months, p<0.001). The Clinical Benefit Rate with this strategy (complete response+partial response+stable disease) was 64% (244/383), ranging from 33-90%. Thirty-eight percent of the patients underwent resections with a 60% R0 resection rate and 6% postoperative mortality.

Conclusions

Although the evidence to support the benefits of NAT for iCCA is limited, the review supports the use of down staging treatment and also surgical resection in the cohort with response to NAT in order to improve long-term survival in patients with locally advanced iCCA.

Intrahepatic cholangiocarcinoma: Limitations for resectability, current surgical concepts and future perspectives

Intrahepatic cholangiocarcinoma (iCCA) is the second most common hepatic malignancy and its incidence has been shown to increase significantly during the past decades. Complete surgical resection is currently acknowledged as the only curative treatment option able to provide adequate long-term outcomes. We herein review technical, functional and oncologic limitations for resectability, discuss current surgical aspects as well as highlight the fields in which future research and practice should focus on in order to ameliorate long-term outcomes in patients with iCCA.

Rare spontaneous intrahepatic portosystemic shunt in hepatitis B-induced cirrhosis: A case report

BACKGROUND

The portosystemic shunt is the pathway between the portal vein (PV) and systemic circulation. A spontaneous intrahepatic portosystemic shunt (SPISS) is a rare portosystemic shunt type. Here we report an extremely rare type of SPISS, a spontaneous intrahepatic PV-inferior vena cava shunt (SPIVCS).

CASE SUMMARY

A 66-year-old woman was admitted to our hospital with the complaint of abdominal distention and a decreased appetite for 1 mo. The patient had a 20-year history of hepatitis B surface antigen positivity and a 5-year history of cirrhosis. She had been treated with Chinese herbal medicine for a long time. Liver function tests showed: alanine aminotransferase, 35 U/L; aspartate aminotransferase, 42 U/L; serum albumin (ALB) 32.2 g/L; and serum ascites ALB gradient, 25.2 g/L. Abdominal ultrasonography and enhanced computed tomography showed that the left branch of the PV was thin and occluded; the right branch of the PV was thick and showed a vermicular dilatation vein cluster in the upper pole of the right kidney that branched out and converged into the inferior vena cava from the bare area of the lower right posterior lobe of the liver. We diagnosed her with an extremely rare SPIVCS caused by portal hypertension and provided symptomatic treatment after admission. One week later, her symptoms disappeared and she was discharged.

CONCLUSION

SPIVCS is a rare portosystemic shunt with a clear history of cirrhosis and portal hypertension. Clarifying the type PV shunt has important clinical significance.

Embryology, Anatomy, and Imaging of the Biliary Tree

"The anatomy of the biliary tree is notoriously variable. This variation is the bane of the hepatobiliary surgeon, to whom an understanding of biliary anatomic variation is key to the planning and safe conduct of liver surgery, from oncological resections to split-liver transplantation. The hepatic diverticulum, also termed "the liver bud," is the first semblance of the biliary system in the human embryo. A variety of techniques used in the mid twentieth century for imaging the biliary tree have since been abandoned in favor of more practical, safer, less invasive, and more sensitive and specific contemporary methods."

Preoperative Biliary Drainage Is Associated with Increased Complications After Liver Resection for Proximal Cholangiocarcinoma

BACKGROUND

Preoperative biliary drainage (PBD) prior to liver resection for hilar and intrahepatic cholangiocarcinoma (CCA) is common. While PBD for those with distal obstructions has been studied extensively and is associated with increased infectious complications, the impact of PBD among patients undergoing hepatectomy for non-disseminated proximal CCA has yet to be clearly elucidated.

METHODS

Patients undergoing liver resection between 2014 and 2016 for non-disseminated hilar and intrahepatic CCA were analyzed using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Associations between PBD (percutaneous or endoscopic) and 30-day outcomes were evaluated.

RESULTS

There were 905 liver resections performed, with 186 (20.6%) for hilar CCA and 719 (79.4%) for intrahepatic CCA. Of those, 251/897 (28.0%) patients underwent PBD. Independent preoperative predictors of PBD were hilar CCA, major hepatectomy, open surgery, lower BMI, and higher preoperative bilirubin. Adjusting for preoperative variables, extent of resection, and bilirubin, PBD was independently associated with increased wound infection (OR 2.93), organ space infection (OR 3.63), sepsis (OR 3.17), renal insufficiency (OR 4.25), transfusion (OR 2.40), bile leak (OR 3.23), invasive intervention (OR 2.72), liver failure (OR 3.20), readmission (OR 3.01), reoperation (OR 2.32), and mortality (OR 4.24, all p < 0.05).

CONCLUSIONS

Among patients undergoing hepatectomy for proximal CCA, PBD is associated with increased postoperative complications. These data suggest that avoidance of routine preoperative biliary drainage may decrease short-term complications.

Cholangiocarcinoma

This article focuses on cholangiocarcinoma, both intrahepatic and extrahepatic. The various classification schemes based on anatomic location, macroscopic growth pattern, microscopic features, and cell of origin are outlined. The clinicopathologic, immunohistochemical and molecular differences between intrahepatic cholangiocarcinoma and extrahepatic cholangiocarcinoma, as well as differences in the 2 subtypes of intrahepatic cholangiocarcinoma, are discussed. Finally, precursor lesions, prognosis, treatment, and promising new potential targeted therapies are reviewed.

Update on Treatment Options for Advanced Bile Duct Tumours: Radioembolisation for Advanced Cholangiocarcinoma

Cholangiocarcinoma is a rare form of gastrointestinal cancer with a poor prognosis. Patients often present with biliary obstruction or non-specific abdominal pain, and a high proportion of patients have advanced disease at initial diagnosis. The goal of this review is to discuss treatment options for patients with advanced bile duct tumours focusing on radioembolisation (RE) and its impact on overall survival. RE provides a therapeutic option for patients with unresectable cholangiocarcinoma. However, although systemic chemotherapy has demonstrated a survival benefit in randomised controlled trials, there is limited supporting evidence for the use of RE in this setting. Studies are mostly limited to single-centre, small cohorts with variable outcome measures. Additionally, patients included in these studies received a variety of previous therapies including chemotherapy, surgery or alternative intra-arterial therapy; therefore, a true assessment of overall survival benefit is difficult.

Spontaneous external biliary fistula arising from an intrahepatic duct

A spontaneous external biliary fistula is most commonly a cholecystocutaneous fistula secondary to acute cholecystitis. A fistula arising from an intrahepatic duct is extremely rare. An 87-year-old man presented with swelling of the epigastric region and right upper quadrant abdomen. He had a history of cholecystectomy and endoscopic sphincterotomy. After antibiotic treatment and surgical opening of both lesions, abdominal computed tomography demonstrated a soft tissue mass cephalad to the umbilicus. We excised the mass, and found it to be associated with a fistula through the linea alba. Fistulography showed an abscess cavity communicating with the intrahepatic duct in segment III. Histopathological examination of the mass showed an abscess without malignancy. The fistula closed spontaneously without laparotomy. In this case, the underlying pathology was considered to be associated with a subcapsular hepatic cyst in segment III.

Defining Long-Term Survivors Following Resection of Intrahepatic Cholangiocarcinoma

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is an aggressive primary tumor of the liver. While surgery remains the cornerstone of therapy, long-term survival following curative-intent resection is generally poor. The aim of the current study was to define the incidence of actual long-term survivors, as well as identify clinicopathological factors associated with long-term survival.

METHODS

Patients who underwent a curative-intent liver resection for ICC between 1990 and 2015 were identified using a multi-institutional database. Overall, 679 patients were alive with ≥ 5 years of follow-up or had died during follow-up. Prognostic factors among patients who were long-term survivors (LT) (overall survival (OS) ≥ 5) were compared with patients who were not non-long-term survivors (non-LT) (OS < 5).

RESULTS

Among the 1154 patients who underwent liver resection for ICC, 5- and 10-year OS were 39.6 and 20.3% while the actual LT survival rate was 13.3%. After excluding 475 patients who survived < 5 years, as well as patients were alive yet had < 5 years of follow-up, 153 patients (22.5%) who survived ≥ 5 years were included in the LT group, while 526 patients (77.5%) who died < 5 years from the date of surgery were included in the non-LT group. Factors associated with not surviving to 5 years included perineural invasion (OR 4.78, 95% CI, 1.92-11.8; p = 0.001), intrahepatic metastasis (OR 3.75, 95% CI, 0.85-16.6, p = 0.082), satellite lesions (OR 2.12, 95% CI, 1.15-3.90, p = 0.016), N1 status (OR 4.64, 95% CI, 1.77-12.2; p = 0.002), ICC > 5 cm (OR 2.40, 95% CI, 1.54-3.74, p < 0.001), and direct invasion of an adjacent organ (OR 3.98, 95% CI, 1.18-13.4, p = 0.026). However, a subset of patients (< 10%) who had these pathological characteristics were LT.

CONCLUSION

While ICC is generally associated with a poor prognosis, some patients will be LT. In fact, even a subset of patients with traditional adverse prognostic factors survived long term.

Mild asymptomatic intrahepatic biliary dilation after cholecystectomy, a common incidental variant

OBJECTIVE

The purpose of this study is to evaluate the prevalence of intra- and extrahepatic ductal dilatation in asymptomatic individuals after cholecystectomy.

METHODS AND MATERIALS

This IRB-approved retrospective cohort study evaluated the prevalence of intra- and extrahepatic biliary dilation in 77 consecutive post cholecystectomy patients who had CT obtained in the portal venous phase. These were then compared to age and sex matched control patients. Two radiologists in consensus blinded to surgical history evaluated the intrahepatic ducts qualitatively for dilatation. A single radiologist using the best of three orthogonal planes measured the extrahepatic ducts. Extrahepatic ducts were considered dilated if >7 mm plus 1 mm/decade after 60 years. T tests and chi-squared tests were performed.

RESULTS

Cholecystectomy patient duct patterns: normal ducts 26% (20/77); intra- and extrahepatic dilation 31.2% (24/77); intrahepatic dilation only 18.2% (14/77); extrahepatic dilation only 24.7% (19/77). Control patient duct patterns: normal ducts 88.3% (68/77); intra- and extrahepatic dilation 2.6% (2/77); intrahepatic dilation only 2.6% (2/77); extrahepatic dilation only 6.5% (5/77). All intrahepatic ductal dilatation was mild. Total intrahepatic dilation: 49.4% (cholecystectomy); 5.2% (control patients). The relative risk of intrahepatic ductal dilation in cholecystectomy patients was 9.5:1. Increased prevalence of intra- and extrahepatic dilation in cholecystectomy patients was statistically significant (p < 0.0001). Average extrahepatic duct was 7.8 mm (cholecystectomy) and 5.3 mm (control patients) (p < 0.001).

CONCLUSION

Mild intrahepatic biliary dilation in the setting of cholecystectomy is very common, and if not associated with clinical or biochemical evidence of obstruction is likely of no clinical significance.

The effect of adjuvant chemotherapy in patients with intrahepatic cholangiocarcinoma: a matched pair analysis

PURPOSE

The purpose of this study was to identify prognostic factors of patients with intrahepatic cholangiocarcinoma (ICC) treated with resection and to investigate the effect of adjuvant chemotherapy (CT).

METHODS

Patients with ICC diagnosed between 2000 and 2015 treated at Hannover Medical School were included. Clinicopathologic characteristics were analyzed in univariate and multivariate analysis. In a matched pair survival analysis, patients with or without adjuvant CT were matched by these prognostic factors.

RESULTS

Two hundred and ten patients were included. Median survival was 28.7 months, 1-, 3-, and 5-year survival rates were 72.8%, 29.6%, and 14.1%, respectively. In multivariate analysis, lymph node involvement (p = 0.006, HR 1.84), larger tumor size (p = 0.013, HR 1.79), vascular invasion (p = 0.038, HR 1.70), and prolongation of prothrombin time (p < 0.001, HR 4.20) were significantly related to poor survival. Thirty-nine patients received adjuvant CT of which 60% had lymph node involvement. Each 25 patients with and without adjuvant CT were matched to the identified prognostic factors. The median survival of patients with adjuvant CT was 33.5 months, compared to 18 months in the control group (p = 0.002). The 1-, 3-, and 5-year survival rates were 96, 36, and 12%, compared to 60, 4, and 0% in non-treated patients.

CONCLUSIONS

We identified several prognostic factors for patients with ICC treated with resection. Our data support the use of adjuvant CT in patients with ICC. The results of prospective randomized controlled studies will clarify the role of adjuvant CT in the future.

Intrahepatic pancreatic pseudocyst: A review of the world literature

AIM

To investigate and summarize the literature regarding the diagnosis and management of intrahepatic pancreatic pseudocysts (IHPP).

METHODS

A literature search was performed using PubMed (MEDLINE) and Google Scholar databases, followed by a manual review of reference lists to ensure that no articles were missed. All articles, case reports, systematic reviews, letters to editors, and abstracts were analyzed and tabulated. Bivariate analyses were performed, with significance accepted at P < 0.05. Articles included were primarily in the English language, and articles in other languages were reviewed with native speakers or, if none available, were translated with electronic software when possible.

RESULTS

We found 41 published articles describing 54 cases since the 1970s, with a fairly steady rate of publication. Patients were predominantly male, with a mean age of 49 years. In 42% of published cases, the IHPP was the only reported pseudocyst, but 58% also had concurrent pseudocysts in other extrapancreatic locations. Average IHPP size was 9.5 cm and they occurred most commonly (48%) in the left hemiliver. Nearly every reported case was managed with an intervention, most with a single intervention, but some required up to three interventions. Percutaneous treatment with either simple aspiration or with an indwelling drain were the most common interventions, frequently performed along with stenting of the pancreatic duct. The size of the IHPP correlated significantly with both the duration of treatment (P = 0.006) and with the number of interventions required (P = 0.031). The duration of therapy also correlated with the initial white blood cell (WBC) count (P = 0.048).

CONCLUSION

Diagnosis of IHPP is difficult and often missed. Initial size and WBC are predictive of the treatment required. With appropriate intervention, most patients achieve resolution.

Clinical intraocular islet transplantation is not a number issue

It is now well established that beta cell replacement through pancreatic islet transplantation results in significant improvement in the quality-of-life of type 1 diabetes (T1D) patients. This is achieved through improved control and prevention of severe drops in blood sugar levels. Islet transplant therapy is on the verge of becoming standard-of-care in the USA. Yet, as with other established transplantation therapies, there remain hurdles to overcome to bring islet transplantation to full fruition as a long-lasting therapy of T1D. One of these hurdles is establishing reliable new sites, other than the liver, where durable efficacy and survival of transplanted islets can be achieved. In this article, we discuss the anterior chamber of the eye as a new site for clinical islet transplantation in the treatment of T1D. We specifically focus on the common conceptions, and preconceptions, on the requirements of islet mass, and whether or not the anterior chamber can accommodate sufficient islets to achieve meaningful efficacy and significant impact on hyperglycemia in clinical application.

Hepatolithiasis and intrahepatic cholangiocarcinoma: A review

Although the incidence of hepatolithiasis is decreasing as the pattern of gallstone disease changes in Asia, the prevalence of hepatolithiasis is persistently high, especially in Far Eastern countries. Hepatolithiasis is an established risk factor for cholangiocarcinoma (CCA), and chronic proliferative inflammation may be involved in biliary carcinogenesis and in inducing the upregulation of cell-proliferating factors. With the use of advanced imaging modalities, there has been much improvement in the management of hepatolithiasis and the diagnosis of hepatolithiasis-associated CCA (HL-CCA). However, there are many problems in managing the strictures in hepatolithiasis and differentiating them from infiltrating types of CCA. Surgical resection is recommended in cases of single lobe hepatolithiasis with atrophy, uncontrolled stricture, symptom duration of more than 10 years, and long history of biliary-enteric anastomosis. Even after resection, patients should be followed with caution for development of HL-CCA, because HL-CCA is an independent prognostic factor for survival. It is not yet clear whether hepatic resection can reduce the occurrence of subsequent HL-CCA. Furthermore, there are no consistent findings regarding prediction of subsequent HL-CCA in patients with hepatolithiasis. In the management of hepatolithiasis, important factors are the reduction of recurrence of cholangitis and suspicion of unrecognized HL-CCA.

Hypoxia impairs anti-viral activity of natural killer (NK) cells but has little effect on anti-fibrotic NK cell functions in hepatitis C virus infection

BACKGROUND & AIMS

Natural killer (NK) cells have been shown to exert anti-viral as well as anti-fibrotic functions in hepatitis C virus (HCV) infection. Previous studies, however, analyzed NK cell functions exclusively under atmospheric oxygen conditions despite the fact that the liver microenvironment is hypoxic. Here, we analyzed the effects of low oxygen tension on anti-viral and anti-fibrotic NK cell activity.

METHODS

Peripheral (n=34) and intrahepatic (n=15) NK cells from HCV(+) patients as well as circulating NK cells from healthy donors (n=20) were studied with respect to anti-viral and anti-fibrotic activity via co-culture experiments with HuH7 replicon cells and hepatic stellate cells, respectively.

RESULTS

Anti-viral activity of resting NK cells from healthy controls was not affected by hypoxia. However, hypoxia significantly reduced the response of healthy NK cells to cytokine stimulation. In contrast to healthy controls, we observed resting and cytokine activated peripheral NK cells from HCV patients to display a significantly decreased anti-viral activity when cultured at 5% or 1% oxygen, suggesting HCV NK cells to be very sensitive to hypoxia. These findings could be confirmed when intrahepatic NK cells were tested. Finally, we show that anti-fibrotic NK cell activity was not affected by low oxygen tension.

CONCLUSIONS

Our results show that anti-viral function of NK cells from HCV(+) patients is critically affected by a hypoxic microenvironment and, therefore, indicate that in order to obtain an accurate understanding of intrahepatic NK cell anti-HCV activity, the laboratory modelling should take into account the liver specific levels of oxygen.

A novel method for murine intrahepatic islet transplantation via cecal vein

Islet transplantation is one of the most beneficial treatment modality to treat type 1 diabetic patients with frequent hypoglycemic unawareness. In clinical setting, human islets are infused via portal vein and are settled in the end-portal venules in the liver. However, mouse islets are transplanted into kidney subcapsule or liver through direct portal vein. These conventional transplantation methods have several drawbacks such as different physiological environments around the transplanted islets in kidney subcapsule from the liver and high mortality rate in direct portal vein approach. In this study, we introduced murine intrahepatic islet transplantation method via cecal vein to have the same surgical operation route in humans as well as guaranteeing low mortality rate after islet transplantation. With this protocol, consistent normoglycemia can be obtained in diabetic mice, while keeping operation-related mortality extremely low. This approach with easier accessibility and low mortality will make murine intrahepatic islet transplantation a useful model for studying immunological mechanisms such as strong innate and adaptive immune responses that occur in human islet transplantation.

Huge hepatocellular carcinoma with multiple intrahepatic metastases: An aggressive multimodal treatment

INTRODUCTION

Huge hepatocellular carcinoma (HCC) possesses a potential risk for spontaneous rupture, which leads to a life-threatening complication with a high mortality rate. In addition, a large HCC is frequently accompanied by intrahepatic metastases.

PRESENTATION OF CASE

We describe, the case of a 74-year-old woman with a huge extrahepatically expanding HCC with multiple intrahepatic metastases who was treated by liver resection with repeated transcatheter arterial chemoembolization (TACE). To prevent tumor rupture or bleeding, we performed right hepatectomy. After the operation, TACE was applied for multiple intrahepatic metastases in the remnant liver. Furthermore, the elevated protein induced vitamin K absence (PIVKA II) level had decreased to limits within the normal range. Three months after the first TACE, computed tomography revealed several recurrences in the liver. TACE was applied for the second and third time and the tumors were well controlled.

DISCUSSION

Although, liver resection is occasionally performed for patients with huge HCC to avoid spontaneous tumor rupture, only surgical approach might not be sufficient for such advanced HCC. To achieve long-term survival, it is necessary to control the residual intrahepatic tumors. We could control multiple intrahepatic metastases with repeated TACEs after hepatectomy.

CONCLUSION

Multimodal treatment involving hepatectomy and TACE might be a good treatment strategy for patients with huge HCC with multiple intrahepatic metastases if the tumors are localized in the liver without distant or peritoneal metastasis.

Review of a challenging clinical issue: Intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is a reversible pregnancy-specific cholestatic condition characterized by pruritus, elevated liver enzymes, and increased serum bile acids. It commences usually in the late second or third trimester, and quickly resolves after delivery. The incidence is higher in South American and Scandinavian countries (9.2%-15.6% and 1.5%, respectively) than in Europe (0.1%-0.2%). The etiology is multifactorial where genetic, endocrine, and environmental factors interact. Maternal outcome is usually benign, whereas fetal complications such as preterm labor, meconium staining, fetal distress, and sudden intrauterine fetal demise not infrequently lead to considerable perinatal morbidity and mortality. Ursodeoxycholic acid is shown to be the most efficient therapeutic agent with proven safety and efficacy. Management of ICP consists of careful monitoring of maternal hepatic function tests and serum bile acid levels in addition to the assessment of fetal well-being and timely delivery after completion of fetal pulmonary maturity. This review focuses on the current concepts about ICP based on recent literature data and presents an update regarding the diagnosis and management of this challenging issue.

Primary intrahepatic malignant epithelioid mesothelioma

INTRODUCTION

Primary malignant hepatic mesotheliomas are extremely rare. We report the case of a patient with primary intrahepatic malignant mesothelioma who was treated in our department.

PRESENTATION OF CASE

A 66-year old male patient was admitted to our department for the evaluation of anemia. An abdominal computed tomography scan revealed a large space occupying lesion in the right liver lobe.

DISCUSSION

The tumor was subsequently resected and a diagnosis of primary intrahepatic malignant mesothelioma was made after pathologic examination. The patient did not receive adjuvant therapy and is currently alive and free of disease, 36 months after the resection.

CONCLUSION

To our knowledge this is the eighth adult case of primary intrahepatic malignant mesothelioma reported in the literature. These tumors are rarely diagnosed preoperatively. Absence of previous asbestos exposure does not exclude malignant mesothelioma from the differential diagnosis. Proper surgical treatment may offer prolonged survival to the patient, without adjuvant therapy.

Diagnosis and treatment of intrahepatic biliary cystadenoma

AIM: To explore the clinical features of intrahepatic biliary cystadenoma, so as to raise awareness of the disease and reduce the misdiagnosis rate.

METHODS: Clinical data for 11 intrahepatic biliary cystadenoma patients treated from January 2009 to August 2013 at the Second Affiliated Hospital of Nanchang University were analyzed retrospectively. The clinical manifestations, imaging features, surgical and pathological characteristics were summarized.

RESULTS: There were one male (age, 49 years) and 10 females (mean age, 54.5 years±2.0 years). Main clinical manifestations were abdominal pain and discomfort, and two cases had jaundice. Imaging data showed intrahepatic bile duct dilatation and cystic or solid mass lesions; one patient had gallstones, two had intrahepatic bile duct stones, and two had gallbladder polyps. Pathological examinations showed five cases of intrahepatic biliary cystadenoma, two cases of mucinous cystadenoma, two cases of papillary cystadenoma, and two cases of borderline cystadenoma. All patients underwent complete surgical resection, and no recurrence was observed during follow-up.

CONCLUSION: Intrahepatic biliary cystadenoma often occurs in middle-aged women, and its clinical manifestations are not specific. Ultrasound, computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography can help improve the diagnosis and preoperative assessment of the disease. Complete resection is recommended for the treatment of this disease.

IMP3 expression is associated with poor outcome and epigenetic deregulation in intrahepatic cholangiocarcinoma. Hum Pathol. 2014;45:1184-1191. [PMID: 24745619 DOI: 10.1016/j.humpath.2014.01.016]

IMP3 is a fetal protein not expressed in normal adult tissues. IMP3 is an oncoprotein and a useful biomarker for a variety of malignancies and is associated with reduced overall survival of a number of them. IMP3 expression and its prognostic value for patients with intrahepatic cholangiocarcinoma (ICC) have not been well investigated. The molecular mechanism underlying IMP3 expression in human cancer cells remains to be elucidated. Here we investigated IMP3 expression in ICC and adjacent nonneoplastic liver in 72 unifocal primary ICCs from a single institute by immunohistochemistry, immunoblotting, and real-time polymerase chain reaction. IMP3 was specifically expressed in cancer cells but not in the surrounding normal tissue, and 59 (82%) of 72 ICCs were IMP3 positive by immunohistochemistry. Among 35 cases with lymphovascular invasion, 26 (74%) showed IMP3 positivity in lymph node metastases. IMP3 expression was significantly correlated with tumor size, pathological grade, metastasis, and clinical stage. Kaplan-Meier analysis demonstrated an inverse correlation between IMP3 expression and overall survival rate. Multivariate analysis revealed that IMP3 was the only risk factor associated with survival. To further explore the mechanism of IMP3 expression in cancers, we identified 2 CpG islands at IMP3 proximal promoter. Interestingly, the IMP3 promoter was almost completely demethylated in ICCs in contrast to densely methylated promoter in normal liver tissues. IMP3 expression is a useful biomarker for ICCs and can provide an independent prognostic value for patients with ICC. To our knoweldge, this is the first direct evidence of epigenetic deregulation of IMP3 in human cancer.

Ezetimibe markedly attenuates hepatic cholesterol accumulation and improves liver function in the lysosomal acid lipase-deficient mouse, a model for cholesteryl ester storage disease

Lysosomal acid lipase (LAL) plays a critical role in the intracellular handling of lipids by hydrolyzing cholesteryl esters (CE) and triacylglycerols (TAG) contained in newly internalized lipoproteins. In humans, mutations in the LAL gene result in cholesteryl ester storage disease (CESD), or in Wolman disease (WD) when the mutations cause complete loss of LAL activity. A rat model for WD and a mouse model for CESD have been described. In these studies we used LAL-deficient mice to investigate how modulating the amount of intestinally-derived cholesterol reaching the liver might impact its mass, cholesterol content, and function in this model. The main experiment tested if ezetimibe, a potent cholesterol absorption inhibitor, had any effect on CE accumulation in mice lacking LAL. In male Lal(-/-) mice given ezetimibe in their diet (20 mg/day/kg bw) for 4 weeks starting at 21 days of age, both liver mass and hepatic cholesterol concentration (mg/g) were reduced to the extent that whole-liver cholesterol content (mg/organ) in the treated mice (74.3±3.4) was only 56% of that in those not given ezetimibe (133.5±6.7). There was also a marked improvement in plasma alanine aminotransferase (ALT) activity. Thus, minimizing cholesterol absorption has a favorable impact on the liver in CESD.

Risk factors for long-term outcomes after initial treatment in hepatolithiasis

Hepatobiliary complications, such as stone recurrence, recurrent cholangitis, liver abscess, secondary biliary cirrhosis, and cholangiocarcinoma may occur after treatment for hepatolithiasis. However, few previous studies have addressed the risk factors and long-term outcomes after initial treatment. Eighty-five patients with newly diagnosed hepatolithiasis, actively treated for hepatolithiasis, constituted the cohort of this retrospective study. Patients were treated by hepatectomy or nonoperative percutaneous transhepatic cholangioscopic lithotomy. Long-term complications, such as recurrent cholangitis, liver abscess, secondary biliary cirrhosis, and cholangiocarcinoma, and their relationships with clinical parameters were analyzed. The mean follow-up period was 57.4 months. The overall hepatobiliary complication rate after the treatment was 17.6%. Multivariate analysis of suspected risk factors showed that complications were associated with age (HR, 1.046; CI, 1.006-1.089), bile duct stricture (HR, 4.894; CI, 1.295-18.495), and residual stones (HR, 3.482; CI, 1.214-9.981). In conclusion, several long-term hepatobiliary complications occur after hepatolithiasis treatment, and regular observation is necessary in patients with concomitant biliary stricture or residual stones.

Etiology of Portal Hypertension in Children:A Single Center's Experiences

BACKGROUND

All conditions that interfere with blood flow at any level within the portal system can lead to portal hypertension. For better management of this disorder, it is important to determine the underlying cause. In previous studies, extra-hepatic disorders have been reported as the main cause of portal hypertension in children. In this study, we investigate the underlying causes of portal hypertension in children.

METHODS

This prospective, descriptive study investigated the etiology of 45 children with portal hypertension who referred to Nemazee Hospital Pediatric Gastroenterology Ward from 2005 to 2007. The underlying causes of portal hypertension were determined by liver biopsy, abdominal sonography, abdominal computed tomography scan, and liver Doppler sonography.

RESULTS

In this study, 42 of 45 patients (93.3%) developed portal hypertension due to intrahepatic diseases. Extra-hepatic portal hypertension was detected in 3 (6.7%) patients with portal vein thrombosis.

CONCLUSION

Intrahepatic diseases were the most common etiology of portal hypertension among children who referred to our center.

Liver transplantation for caroli disease

Caroli disease is a rare congenital disorder characterized by multifocal, segmental dilatation of intrahepatic bile ducts. Patients with Caroli disease who have recurrent bouts of biliary infection, particularly those who also have complications related to portal hypertension may require liver transplantation. In liver transplant ward of Shiraz University of Medical Science we had 4 patients with Caroli disease who were transplanted. Herein, we describe the demographic characteristics and post-transplant course of the patients. These patients presented with liver failure, recurrent cholangitis and portal hypertension sequelae unresponsive to medical treatment. The mean age of patients was 24.5 (range: 18-36) years, the mean MELD score was 17.5 (range: 11-23), three patients were female; one was male. All of the patients had good post-transplantation course except for one patient who developed post-operative biliary stricture for whom biliary reconstruction was done.