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  • Bioavailability of oral and smoked CBD in humans was found . Oral CBD/ Ketamine. One crossover study examined the effects of oral. Finally, preliminary clinical trials suggest that high-dose oral CBD ( .. Oral CBD/Ketamine. One crossover study examined the effects of oral CBD . Cannabidiol (CBD) oral solution (CBD-OS) is a first-in-class antiepileptic drug ( AED) for the adjunctive treatment exposure to drug, the label states that CBD- OS should be taken with food. Ketamine & Isoflurane.

    Oral CBD/Ketamine 5.1.2.

    Results of Patients. To determine the effectiveness of percutaneous transhepatic removal of bile duct stones when the procedure of endoscopic therapy fails for reasons of anatomical anomalies or is rejected by the patient. Between April and May , patients male patients and female patients; age range, years; mean age, Percutaneous transhepatic cholangiography was performed, and stones were identified.

    Percutaneous transhepatic balloon dilation of the papilla of Vater was performed. If the stone diameter was larger than 15 mm, then basket lithotripsy was performed before balloon dilation. Overall success rate was The procedure was successful in A total of 18 major complications 6.

    There was no mortality. Our experience suggests that percutaneous transhepatic stone expulsion into the duodenum through the papilla is an effective and safe approach in the nonoperative management of the bile duct stones. It is a feasible alternative to surgery when endoscopic extraction fails or is rejected by the patient.

    First, percutaneous transhepatic cholangiography was performed and stones were identified. A total of 18 6. Can bile duct injuries be prevented?

    Background Over the last decade, laparoscopic cholecystectomy has gained worldwide acceptance and considered to be as "gold standard" in the surgical management of symptomatic cholecystolithiasis.

    However, the incidence of bile duct injury in laparoscopic cholecystectomy is still two times greater compared to classic open surgery. The development of bile duct injury may result in biliary cirrhosis and increase in mortality rates.

    The mostly blamed causitive factor is the misidentification of the anatomy, especially by a surgeon who is at the beginning of his learning curve. Biliary tree injuries may be decreased by direct coloration of the cystic duct , ductus choledochus and even the gall bladder. Methods gall bladder fundus was punctured by Veress needle and all the bile was aspirated.

    The same amount of fifty percent methylene blue diluted by saline solution was injected into the gall bladder for coloration of biliary tree. The dissection of Calot triangle was much more safely performed after obtention of coloration of the gall bladder, cystic duct and choledocus.

    Results Between October and December , overall 46 patients of which 9 males with a mean age of 47 between 24 and 74 underwent laparoscopic cholecystectomy with methylene blue injection technique. The diagnosis of chronic cholecystitis the thickness of the gall bladder wall was normal confirmed by pre-operative abdominal ultrasonography in all patients.

    The diameters of the stones were greater than 1 centimeter in 32 patients and calcula of various sizes being smaller than 1 cm. One patient was operated for gall bladder polyp our first case. Successful coloration of the gall bladder, cystic duct and ductus choledochus was possible in 43 patients, whereas only the gall bladder and proximal cystic duct were visualised in 3 cases. In these cases, ductus choledochus visibility was not possible.

    None of the patients developed bile duct injury. Bile duct injuries are the main serious complication of laparoscopy cholecystectomy. The frequency of this type of injuries rangers, between 1 to 3 in 1, cases and although this rate remains stables, their frequency has increased because of the increasing expansion of the indication of cholecystectomy.

    Each lesion is the individual in it's features as well as the scenario in which the surgeon faces it. Several classifications have been developed, but that developed by Strasberg most used nowadays. Intraoperative cholangiography has shown evidence in meta analytic studies that diminishes the frequency of lesions but does not abolish them.

    Conversion from laparoscope's to the open approach with ample and convincent dissection is probably the best maneuver to reduce the frequency of lesions, when any anatomical or technical doubt appears.

    No patient should be operated in critical condition. In this situation, biliary reconstruction has a secondary role and only drainage of the ducts percutaneous or surgical is indicated. Roux en Y hepatoyeyunostomy is the procedure of choice for almost all cases, leaving other types of procedures for selected cases. Transhepatic transanastomotical stents should be used according to the individual status of the patient when small, scared or inflamed ducts are found.

    High quality anastomosis is obtained when proper ducts are found. Sometimes high dissection of the ducts is needed in order to obtain adequate ducts. Nine of each ten cases are completely rehabilitated, obtaining a good quality of life. Effects of partial portal vein arterialization on the hilar bile duct in a rat model.

    Liver revascularization is frequently required during the enlarged radical operation for hilar cholangiocarcinoma involving the hepatic artery.

    Researchers have carried out a number of experiments applying partial portal vein arterialization PVA in clinical practice. In this study we aimed to establish a theoretical basis for clinical application of partial PVA and to investigate the effects of partial PVA on rat hilar bile duct and hepatic functions. Thirty rats were randomly and equally assigned into 3 groups: Proliferation and apoptosis of rat hilar bile duct epithelial cells, arteriolar counts of the peribiliary plexus PBP of the bile duct wall, changes in serum biochemistry, and pathologic changes in the bile duct were assessed 1 month after operation.

    The proliferation of hilar bile duct epithelial cells in group B was greater than in groups A and C P bile duct epithelial cells were detected in any of the groups. Partial PVA can restore the arterial blood supply of the hilar bile duct and significantly extenuate the injury to hilar bile duct epithelial cells resulting from hepatic artery ligation. Isolated segmental, sectoral and right hepatic bile duct injuries.

    The treatment of isolated segmental, sectoral and right hepatic bile duct injuries is controversial. Nineteen patients were treated over a year period. Group one was comprised of 4 patients in whom the injury was primarily repaired during the original surgery; 3 over a T-tube, 1 with a Roux-en-Y. These patients had an uneventful recovery. The second group consisted of 5 patients in whom the duct was ligated; 4 developed infection, 3 of which required drainage and biliary repair. Two patients had good long-term outcomes; the third developed a late anastomotic stricture requiring further surgery.

    The fourth patient developed a small bile leak and pain which resolved spontaneously. The fifth patient developed complications from which he died. The third group was comprised of 4 patients referred with biliary peritonitis; all underwent drainage and lavage, and developed biliary fistulae, 3 of which resolved spontaneously, 1 required Roux-en-Y repair, with favorable outcomes. The fourth group consisted of 6 patients with biliary fistulae. Two patients, both with an 8-wk history of a fistula, underwent Roux-en-Y repair.

    Two others also underwent a Roux-en-Y repair, as their fistulae showed no signs of closure. The remaining 2 patients had spontaneous closure of their biliary fistulae. A primary repair is a reasonable alternative to ligature of injured duct. Patients with ligated ducts may develop complications. Infected ducts require further surgery. Patients with biliary peritonitis must be treated with drainage and lavage.

    In cases where the biliary fistula does not close within 6 to 8 wk, a Roux-en-Y anastomosis should be considered. The study aims to describe the clinical features, microbiology, and associated factors of acute cholangitis AC after bilioenteric anastomosis BEA for biliary duct injury BDI.

    Additionally, we assessed the performance of the Tokyo Guidelines TG13 recommendations in these patients. A propensity score adjustment was performed for the analysis of the independent role of the main factors identified during the univariate logistic regression procedure.

    We identified episodes of AC in 70 patients; A history of post-operative biliary complications OR 2. An empirical treatment for ESBL-producing Enterobacteriaceae may be appropriate in patients living in countries with a high rate of bacterial drug resistance. Early versus late repair of bile duct injuries. Biliary injuries associated with laparoscopic cholecystectomy occur at a constant rate of 0. The spectrum of injures ranges from small leaks of bile to complete section of the main ducts requiring bilioenteric reconstruction.

    The goal of biliary reconstruction is to obtain a high-quality bilioenteric anastomosis that will not malfunction for a long time. No prospective, controlled, randomized trial evidence level 1 has been conducted that shows whether an early repair is better than a late one.

    The timing of the operative procedure should be individualized. A complete examination of the patient should be performed to identify the type of injury and coexistent comorbidities. For septic patients and those with multiple organ dysfunction syndrome, the repair should be delayed. Maneuvers to drain the bile ducts can be performed to relieve jaundice and cholangitis in these patients. For these cases, the surgery should be delayed.

    If a stable patient is found, without comorbidities, the operation can be scheduled earlier. Subhepatic drains should not be left for a long period because of the risk for intestinal fistulization. If needed, they should be changed for transhepatic stents. High-quality bilioenteric anastomoses are performed with fine absorbable sutures for healthy ducts nonscarred, noninflamed, nonischemic in a wide opening, with anastomosis of a tension-free defunctionalized jejunal limb.

    Individualization of the patient is the best rule. Voluntary and involuntary ligature of the bile duct in iatrogenic injuries: Complete obstruction is due to either intentionally or unintentionally placed ligatures or clips. The intentional application is usually performed to "facilitate identification of the duct by bile duct dilation. We reviewed the files of patients with voluntary or involuntary bile duct ligation. Results of preoperative evaluation of the ducts , operative treatment, and postoperative results were analyzed.

    A total of patients were included. Forty-five patients presented with complete obstruction. In 15 cases, the ligature was intentional, and in 30 cases, occlusion was involuntary. In all cases, a Roux-en-Y hepatojejunostomy was performed. Placement of a subhepatic drain and transference of the patient to a qualified center for reconstruction is the best approach if the primary surgeon is not able to do the repair.

    Image-guided intervention in the human bile duct using scanning fiber endoscope system. David; Johnston, Richard S. Bile duct cancers are increasing in frequency while being difficult to diagnose.

    Currently available endoscopic imaging devices used in the biliary tree are low resolution with poor image quality, leading to inadequate evaluation of indeterminate biliary strictures. However, a new ultrathin and flexible cholangioscope system has been successfully demonstrated in a human subject.

    This mini-cholangioscope system uses a scanning fiber endoscope SFE as a forward-imaging guidewire, dimensions of 1. Full color video line resolution at 30Hz is the standard SFE imaging mode using spiral scanning of red, green, and blue laser light at low power. Image-guided operation of the biopsy forceps was demonstrated in healthy human bile ducts with and without saline flushing. The laser-based video imaging can be switched to various modes to enhance tissue markers of disease, such as widefield fluorescence and enhanced spectral imaging.

    In parallel work, biochemical discrimination of tissue health in pig bile duct has been accomplished using fiberoptic delivery of pulsed UV illumination and time-resolved autofluorescence spectroscopic measurements. Implementation of time-resolved fluorescence spectroscopy for biochemical assessment of the bile duct wall is being done through a secondary endoscopic channel.

    The SFE is an ideal mini-cholangioscope for integration of both tissue and molecular specific image contrast in the future. This will provide the physician with unprecedented abilities to target biopsy locations and perform endoscopically-guided therapies. Total rupture of hydatid cyst of liver in to common bile duct: Rupture of hydatid liver cyst into biliary tree is frequent complications that involve the common hepatic duct , lobar biliary branches, the small intrahepatic bile ducts ,but rarely rupture into common bile duct.

    The rupture of hydatid cyst is serious life threating event. The authors are reporting a case of total rupture of hydatid cyst of liver into common bile duct. A year-old male patient who presented with acute cholangitis was diagnosed as a case of totally rupture of hydatid cyst on Abdominal CT Scan. Rupture of hydatid cyst of liver into common bile duct and the gallbladder was confirmed on surgery. Treated by cholecystectomy and T-tube drainage of Common bile duct.

    Hepatic fascioliasis presenting with bile duct obstruction: Fascioliasis is a zoonotic infection caused by a liver trematode: Several cases have been reported in the literature worldwide with a large geographical distribution. We present a case of bile duct obstruction due to a hepatic fascioliasis, successfully treated with both a combined surgical and medical approaches. A high index of suspicion should be kept in mind for all cases of obstructive jaundice, especially in areas in which human fascioliasis infection is repeatedly reported.

    Synchronous double primary cancers of the extrahepatic bile duct: A case report and literature review. Double cancers of the biliary tract system are rare. Most of these cancers are synchronous double cancers of the gall bladder and bile duct , associated with pancreaticobiliary maljunction PBM.

    Synchronous double cancers of the extrahepatic bile duct without PBM are especially rare, and only 4 cases have been reported. A year-old woman was admitted to our hospital for examination of hyperbilirubinemia and liver dysfunction. Contrast-enhanced abdominal computed tomography, Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography revealed 2 stenotic regions in the common bile duct: No findings suggested PBM, such as a markedly long common channel.

    The diagnosis based on endoscopic brush cytology from both stricture portions was adenocarcinoma. The patient had a pylorus-preserving pancreaticoduodenectomy with regional lymph node resection. Macroscopically, there were 2 stenotic regions at the cystic duct junction and in the distal bile duct.

    Microscopically, the tumor at the junction of the cystic duct was a well-to-moderately differentiated adenocarcinoma. On the other hand, the tumor of the distal bile duct was a poorly differentiated adenocarcinoma. There was no evidence of communication between these 2 cancers. Double cancers of the extrahepatic bile duct without PBM are very rare.

    Therefore, an accurate diagnosis prior to surgery is necessary. Furthermore, this rare condition seems to be associated with a poor prognosis. Published by Elsevier Ltd.. In living donor liver transplantation LDLT , the recipient bile duct is thin and short. Bile duct complications often occur in LDLT, with persistent long-term adverse effects. Recently, we began to perform microsurgical reconstruction of the bile duct. The purpose of this study was to investigate the relationship between bile duct reconstruction methods and complications in LDLT.

    From to , we performed LDLTs pediatric: In this study, we retrospectively investigated the initial bile duct complications in LDLT and performed univariate and multivariate analyses to identify the independent risk factors for complications. The most frequent complication was biliary stricture 9. However, there were no risk factors for biliary leakage on univariate analysis in our study. The reconstruction methods hepaticojejunostomy or duct-to-duct anastomosis and reconstruction technique with or without microsurgery were not risk factors for biliary stricture and leakage.

    In this study, the most frequent complication of LDLT was biliary stricture. The independent risk factors for biliary stricture were biliary leakage and recurrent cholangitis. Duct-to-duct anastomosis and microsurgical reconstruction of the bile duct were not risk factors for biliary stricture and leakage. Changing patterns of traumatic bile duct injuries: To summarize the experiences of treating bile duct injuries in 40 years of clinical practice. Based on the experience of more than 40 years of clinical work, cases including a series of 61 bile duct injuries of the Southwest Hospital, Chongqing, and 42 cases and 19 cases of the General Hospital of PLA, Beijing, were reviewed with special reference to the pattern of injury.

    A series of cases of the liver and the biliary tract injuries following interventional therapy for hepatic tumors, most often hemangioma of the liver, were collected. Chinese medical literature from to dealing with traumatic bile duct strictures were reviewed. There was a changing pattern of the bile duct injury. Although most of the cases of bile duct injuries resulted from open cholecystectomy.

    Other types of trauma such as laparoscopic cholecystectomy LC and hepatic surgery were increased in recent years. Moreover, serious hepato-biliary injuries following HAE using sclerotic agents such as sodium morrhuate and absolute ethanol for the treatment of hepatic hemangiomas were encountered in recent years. Experiences in how to avoid bile duct injury and to treat traumatic biliary strictures were presented.

    Traumatic bile duct stricture is one of the serious complications of hepato-biliary surgery, its prevalence seemed to be increased in recent years. The pattern of bile duct injury was also changed and has become more complicated.

    Interventional therapy with sclerosing agents may cause serious hepatobiliary complications and should be avoided. After pancreatic head resection the reconstruction of small and fragile bile ducts is technically demanding, resulting in more postoperative bile leaks. One option for the reconstruction is the placement of a T-tube drainage at the site of the anastomosis. Standard reconstruction after pancreatic head resection was an end-to-side hepaticojejunostomy with PDS 5.

    The reconstruction with a T-tube drainage at the site of the anastomosis is technically easy to perform and offers the opportunity for immediate visualisation of the anastomosis in the postoperative period by application of water soluble contrast medium.

    If a bile leak occurs, biliary deviation through the T-tube drainage can enable a conservative management without revisional laparotomy in selected patients.

    Whether or not a conservative management of postoperative bile leaks will lead to more bile duct strictures is a subject for further investigations. A T-tube drainage at the site of the anastomosis can probably not prevent postoperative bile leaks from a difficult hepaticojejunostomy, but in selected patients it offers the opportunity for a conservative management resulting in less re-operations.

    Therefore we recommend the augmentation of a difficult hepaticojejunostomy with a T-tube drainage. Adult bile duct strictures: Biliary epithelial cells preferentially respond to various insults under chronic pathological conditions leading to reactively atypical changes, hyperplasia, or the development of biliary neoplasms such as biliary intraepithelial neoplasia, intraductal papillary neoplasm of the bile duct , and cholangiocarcinoma.

    Moreover, benign biliary strictures can be caused by a variety of disorders such as IgG4-related sclerosing cholangitis, eosinophilic cholangitis, and follicular cholangitis and often mimic malignancies, despite their benign nature.

    In addition, primary sclerosing cholangitis is a well-characterized precursor lesion of cholangiocarcinoma and many other chronic inflammatory disorders increase the risk of malignancies.

    Because of these factors and the changes in biliary epithelial cells, biliary strictures frequently pose a diagnostic challenge. Although the ability to differentiate neoplastic from non-neoplastic biliary strictures has markedly progressed with the advance in radiological modalities, brush cytology and bile duct biopsy examination remains effective. However, no single modality is adequate to diagnose benign biliary strictures because of the low sensitivity.

    Therefore, understanding the underlying causes by compiling the entire clinical, laboratory, and imaging data; considering the under-recognized causes; and collaborating between experts in various fields including cytopathologists with multiple approaches is necessary to achieve an accurate diagnosis. Laparoscopic cholecystectomy has become the "gold standard" for cholelithiasis. The authors present a series of 18 patients with such lesions, operated between and in the surgical departments of 2 Clinical Hospitals: Cantacuzino" and Coltea, from Bucharest.

    There are analysed the causes and the circumstances in which these injuries have occurred, the clinical signs and imagistic findings and, most of all, their treatment. In complete transections of the common bile duct , a hepatico-jejuno-anastomosis using a Roux en Y-loop appears to be the best solution.

    It is emphasized the fact that an accurate diagnosis and surgical technique are essential for a favourable evolution. That's why these operations must be accomplished by experimented surgeons, from highly specialized departments. Hepatobiliary cystadenoma can protrude and grow into the bile ducts.

    To evaluate the phenomenon and the potential reasons for protrusion and growth of hepatobiliary cystadenoma into the extrahepatic bile ducts in our patients, accomplished by a review of the data regarding hepatobiliary cystadenomas published elsewhere. In a retrospective open study conducted over the last eight years, five patients with hepatobiliary cystadenoma and one patient with hepatobiliary cystadenocarcinoma were operated on.

    All the patients were females aged between 25 to 61 years. Diagnostic procedures, laboratory, operative and histopathological findings and treatment were evaluated. Most of our patients were found to have hepatobiliary cystadenoma located in the left surgical liver. In three out of five patients with HBC mesenchymal stroma was histologically detected. In two of the three, protrusion and growth into the extrahepatic bile ducts was found.

    Considering the pathogenesis, location and the morphology of HBC, the mesenchymal stroma may present the competent potential for intraductal progression of the tumor. Radical excision should be performed for successful treatment of hepatobiliary cystadenomas, because of the potential for reoccurrence.

    Background Choledocholithiasis is defined as presence of at least one gallstone in the bile duct. In case the bile duct is not accessible endoscopically e. Extraction of the stones via PTCD has several risks as are hemorrhage, pancreatitis and injuries of the liver tissue. Methods We here report about our experience with a significant modification of this technique by use of a french hemostasis introducer as a sheath to track the transhepatic access to the bile ducts in order to reduce time and risk.

    Results Three patients were treated by use of the reported modification. In all cases, the stones were successfully removable without complications. Conclusion We demonstrate that the use of a hemostasis introducer for percutaneous extraction of common bile duct stones seems to be promising in terms of shortening hospital stay and increasing patient safety.

    Choledocholithiasis is defined as presence of at least one gallstone in the bile duct. We here report about our experience with a significant modification of this technique by use of a french hemostasis introducer as a sheath to track the transhepatic access to the bile ducts in order to reduce time and risk.

    Three patients were treated by use of the reported modification. We demonstrate that the use of a hemostasis introducer for percutaneous extraction of common bile duct stones seems to be promising in terms of shortening hospital stay and increasing patient safety.

    The article states the results of examination and treatment of 57 patients with stenosis of the common bile duct of various genesis. The main aim of the work is criteria definition and evaluation of diagnostic significance of endosonography in the differential diagnosis of benign and malignant common bile duct stenosis.

    The paper presents a methodology of endoscopic ultrasound and basic criteria for the differential diagnosis of tumors and other lesions of the extrahepatic bile ducts. The sensitivity of endosonography in determining the nature of the common bile duct stenosis was In comprehensive surgical centers endosonography should be used as a method of specifying the final diagnosis to determine the nature of the common bile duct stenosis, particularly at low constriction location.

    Common bile duct stricture as a late complication of upper abdominal radiotherapy. We report the cases of two patients who developed symptomatic common bile duct stricture 10 years after upper abdominal radiotherapy for malignant lymphoma.

    Both patients were in complete remission and presented with marked obstructive jaundice. Endosonography was useful in both cases and showed segmental thickening of the bile duct wall narrowing in the lumen.

    Both patients underwent surgical exploration, confirming biliary obstruction due to intrinsic wall thickening, and had successful biliary drainage by Roux-en-Y hepatico-jejunostomy. Histological examination of the resected bile duct , in one case, and of a bile duct biopsy, in the other, was consistent with late irradiation injury. We conclude that stricture may be a delayed consequence of radiotherapy applied to normal bile ducts.

    Bile duct loss during the course of drug induced liver injury is uncommon but can be an indication of vanishing bile duct syndrome. In this work we assess the frequency, causes, clinical features and outcomes of cases of drug induced liver injury with histologically proven bile duct loss.

    The presenting clinical features of the 26 cases varied, but the most common clinical pattern was a severe cholestatic hepatitis. Five patients died and two others underwent liver transplantation for progressive cholestasis despite treatment with corticosteroids and ursodiol. The most predictive factor of poor outcome was the degree of bile duct loss on liver biopsy. Conclusions Bile duct loss during acute cholestatic hepatitis is an ominous early indicator of possible vanishing bile duct syndrome, for which at present there are no known means of prevention or therapy.

    Papillary bile duct dysplasia in primary sclerosing cholangitis. A year-old man with a year history of chronic ulcerative colitis and a 9-year history of primary sclerosing cholangitis PSC underwent orthotopic liver transplantation because of symptoms related to PSC and cholangiographic features compatible with a biliary neoplasm. Study of the excised liver revealed papillary mucosal lesions in the common hepatic duct and the right and left hepatic ducts as well as cholangiectases and other features typically associated with PSC.

    The papillary lesions consisted of abundant fibrovascular stroma covered by biliary epithelium with low-grade and high-grade dysplasia. Some periductal glands were also dysplastic. These features distinguished papillary dysplasia from classic biliary papillomatosis. Only one focus of microinvasion was found; there were no metastases.

    Among 60 cases of PSC in whom the entire liver could be studied after orthotopic liver transplantation, this was the only instance of unequivocal dysplasia. However, in one specimen, papillary hyperplasia was found. Detailed macroscopic and microscopic rereview of 23 livers from our patients with the longest history of PSC range, years failed to reveal any additional cases with dysplasia.

    Use of biliary stent in laparoscopic common bile duct exploration. It is well supported in the literature that laparoscopic common bile duct exploration LCBDE for choledocholithiasis has equal efficacy when compared to ERCP followed by laparoscopic cholecystectomy.

    Decompression after supra-duodenal choledochotomy is common practice as it reduced the risk of bile leaks. We conducted a prospective non-randomized study to compare outcomes and length of stay in patients undergoing biliary stent insertion versus T-tube drainage following LCBDE via choledochotomy. The study involved patients with choledocholithiasis who underwent LCBDE and decompression of the biliary system by either ante-grade biliary stent or T-tube insertion.

    T-tube insertion was used for 34 patients T-tube group. The length of hospital stay and complications for the selected patients were recorded. All trans-cystic common bile duct explorations were excluded from the study. The mean hospital stay for patients who underwent ante-grade biliary stent or T-tube insertion after LBCDE were 1 and 3.

    This is a statistically significant result with a p value of less than 0. Of the T-tube group, two patients required laparoscopic washout due to bile leaks, one had ongoing biliary stasis and one reported ongoing pain whilst the T-tube was in situ. A complication rate of There were no complications or concerns reported for the Biliary Stent Group.

    Our results show that there is a significant reduction in length of hospital stay and morbidity for patients that have ante-grade biliary stent decompression of the CBD post laparoscopic choledochotomy when compared T-tube drainage.

    This implies that ante-grade biliary stent insertion is likely to reduce costs and increase overall patient satisfaction. Long-term survival after liver transplant for recurrent hepatocellular carcinoma with bile duct tumor thrombus: Hepatocellular carcinoma with bile duct tumor thrombus is considered an aggressive malignancy, and the prognosis of liver transplant for it remains obscure. A year-old man with recurrent hepatocellular carcinoma and a history of surgical resection was admitted to our hospital with a day history of yellowish urine and itchy skin.

    There were 3 lesions in the right lobe with the diameter of 2 cm each. A mass was found in the upper part of common bile duct , and the intrahepatic bile duct was dilated.

    There was no main portal vein thrombus or extrahepatic metastases. Because of his poor liver function, he was listed for a liver transplant. During the wait 30 d , he underwent 9 episodes of plasmapheresis to decrease the serum level of bilirubin.

    He had an orthotopic liver transplant with the graft from a deceased donor. After the liver transplant, he received 5 cycles of chemotherapy with the regimen of oxaliplatin and 5-fluorouracil. This patient has survived without recurrence of hepatocellular carcinoma for more than 82 months and remains in good condition. Liver transplant may have a favorable result for hepatocellular carcinoma patient with a bile duct tumor thrombus, within the Milan criteria.

    Neuroendocrine carcinoma of the extrahepatic bile duct: Neuroendocrine carcinoma NEC originating from the gastrointestinal hepatobiliary-pancreas is a rare, invasive, and progressive disease, for which the prognosis is extremely poor.

    The patient was a year-old man referred with complaints of jaundice. He underwent a right hepatectomy combined with extrahepatic bile duct and portal vein resection after percutaneous transhepatic portal vein embolization. Microscopic examination showed a large-cell neuroendocrine carcinoma according to the WHO criteria for the clinicopathologic classification of gastroenteropancreatic neuroendocrine tumors.

    Currently, the patient is receiving combination chemotherapy with cisplatin and etoposide for postoperative multiple liver metastases. Although NEC is difficult to diagnose preoperatively, it should be considered an uncommon alternative diagnosis.

    A case of cholestasis in a young patient with portal cavernomatosis is reported. This clinical picture is very infrequent and appears as a consequence of extrinsic compression on the common bile duct due to which the derivative venous collaterals. There does not appear to be any relationship between the intensity of the morphologic alteration of the biliary tract and the level of portal hypertension and the degree of extrahepatic obstruction.

    Diagnosis was fundamentally achieved by arteriography and retrograde cholangiography with differential diagnosis with the previously mentioned diseases being required. Chronic cholestasis advises derivative surgery in which difficulties may be found due to the presence of thick collaterals in the hepatic pedicle as occurred in this patient. Iatrogenic bile duct injury with loss of confluence.

    To describe our experience concerning the surgical treatment of Strasberg E-4 Bismuth IV bile duct injuries. In an year period, among patients referred to our hospital for surgical treatment of complex bile duct injuries, 53 presented involvement of the hilar confluence classified as Strasberg E4 injuries. Imagenological studies, mainly magnetic resonance imaging showed a loss of confluence. The files of these patients were analyzed and general data were recorded, including type of operation and postoperative outcome with emphasis on postoperative cholangitis, liver function test and quality of life.

    The mean time of follow-up was of Patients were divided in three groups: Double right and left Roux-en-Y hepatojejunostomy. The pulmonary doctor told me that I was going to die and said there was nothing he could do for me,I started on Health Herbal Clinic IPF Herbal formula treatment in June , i read alot of positive reviews on their success rate treating IPF disease through their Herbal formula and i immediately started on the treatment.

    Just 7 weeks into the Herbal formula treatment I had great improvements with my breath and my chest pain was no more. I am unbelievably back on my feet again, this is a breakthrough for all Pulmonary Fibrosis sufferers, visit Health Herbal Clinic official website www. Be the first to like this. Embeds 0 No embeds. No notes for slide. Paediatrics treatment guidelines Govt of India 1.

    Supraja Chandrashekar and Dr. Dengue Fever 1 Introduction Dengue has a wide spectrum of clinical presentations, often with unpredictable clinical evolution and outcome. Dengue fever is an acute febrile illness with one or more of the following: If not tolerated, start intravenous isotonic fluid therapy with or without dextrose at maintenance. Give only isotonic solutions. IV fluids are usually required for days.

    If the haematocrit remains the same, continue with the same rate for another 2—4 hours and reassess. Frequent recording of vital signs and investigation are essential for evaluating the results of treatment.

    Reassess the clinical status, repeat the haematocrit and review fluid infusion rates accordingly. Intravenous fluids are usually needed for only 24—48 hours.

    Reduce intravenous fluids gradually when the rate of plasma leakage decreases towards the end of the critical phase. Parameters that should be monitored include hourly vital signs and peripheral perfusion. Until the patient is out of the critical phase , urine output hourly. Arterial blood gas monitoring as clinically indicated. Infusion pump will help in precise regulation of fluid input. Internal bleeding is difficult to recognize in the presence of haemo-concentration.

    First correct the component of shock according to standard guidelines with early use of packed cell transfusion. Component transfusion is indicated in cases with significant clinical bleeding. Other causes of respiratory distress include acute pulmonary oedema, severe metabolic acidosis from severe shock, and Acute Respiratory Distress Syndrome ARDS 5.

    Monitor serum potassium and correct the ensuing hypokalaemia. Further infusion of large volumes of intravenous fluids will lead only to a poor outcome. If the patient remains in shock and the haematocrit is elevated, repeated small boluses of a colloid solution may help. Secondly, dextrose is rapidly metabolized resulting in a hypotonic solution that is inappropriate for shock correction.

    Cease infusion and infuse fluid if hypoperfusion occurs. Ventilation vital high risk of mortality , can consider peritoneal dialysis if 24 hour experienced nursing and medical staff available in PICU 6. Start enteral feeds early. Obtain baseline haematocrit, correct hypoglycaemia, hypocalcaemia, Further improvement Discharge Can discontinue fluids over hrs Dengue guidelines for diagnosis, treatment, prevention and control.

    New Edition 2. Manual of Pediatric emergencies and Critical Care. Second Edition, Empyema thoracis is a disease of historical importance with modern menace. Traditionally empyema is being managed empirically. It is an advanced parapneumonic effusion.

    Pleural space infection is a continuum but classically has been divided into three stages: Stage 1 or Exudative or Acute phase lasts upto 3 days: Stage 2 or Fibrinopurulent or Transitional phase 3 to 21 days: The presence of septations fibrinous strands At this stage spontaneous healing may occur or a chronic empyema may develop.

    Further complications which may occur are: It achieves debridement of fibrinous pyogenic material, breakdown of loculations, and drainage of pus from the pleural cavity under direct vision.

    It leaves three small scars. Mini-thoracotomy achieves debridement and evacuation in a similar manner to VATS but it is an open procedure leaving a small linear scar along the rib line. Decortication involves an open posterolateral thoracotomy and excision of the thick fibrous pleural rind with evacuation of pyogenic material. It is a longer and more complicated procedure leaving a larger linear scar along the rib line.

    However cases non secondary to infection viz.. Empyema secondary to bacterial infection eg.. Ensuring widespread vaccination program for predisposing conditions such as measles,Hib,Pneumococcal, chickenpox etc. If a child with pneumonia remains pyrexial or unwell 48 hrs. Febrile response may be blunted in immunocompromised patients.

    Posteroanterior PA view 2 Ultrasound chest: Repeated thoracentesis has no role. Standard operating procedure SOP All the patients of parapneumonic effusion or empyema should be admitted in hospital i e.. Pediatric surgeon or General surgeon familiar with basic thoracic surgery along with paediatrician or respiratory physician should manage these cases.

    Diagnostic imaging, microbiology, pleural fluid analysis should be carried out promptly. Empirical antitubercular therapy should be avoided as far as possible. Oral antibiotics should be continued at discharge for wks. Chest drainage tube ICD insertion: Chest drains should be inserted by adequately trained personnel to reduce the risk of complications. However , if need arises it can be done as a bed side procedure as well.

    A suitable assistant and trained nurse must be available. Routine measurement of the platelet count and clotting studies are only recommended in patients with known risk factors. Where possible, any coagulopathy or platelet defect should be corrected before chest drain insertion. Ultrasound should be used to guide thoracocentesis or drain placement.

    If general anaesthesia is not being used, intravenous sedation should only be given by those trained in the use of conscious sedation, airway management and resuscitation of children, using full monitoring equipment. Substantial force should never be used to insert a drain. A chest radiograph should be performed after insertion of a chest drain.

    A bubbling chest drain should never be clamped. A clamped drain should be immediately unclamped and medical advice sought if a patient complains of breathlessness or chest pain. Patients with chest drains should be managed on wards by staff trained in chest drain management. The drain should be removed once there is clinical resolution. A drain that cannot be unblocked should be removed and replaced by new catheter if significant pleural fluid remains.

    Limited thoracotomy with or without rib resection by cms total incision on either side of chest tube ,if already in situ. To ensure complete lung expansion at the end of the procedure with minimal air leak. If necrotic lung tissue is present then excision of the segment is to be done. Evaluation of underlying condition, if any. Referral criteria If no satisfactory response to conservative management by days.

    Initial presentation as stage 2 or 3 of an empyema Development of complications eg Persistent air leak. Non availability of trained personnel at given time. Patients inadequately treated or responded to previous therapy.

    Complications of an empyema eg.. BPF, lung abscess, empyema necessitans etc. Ultrasound may be used to confirm the presence of a pleural fluid collection, septations, to guide thoracocentesis or drain placement.

    Chest CT scans should not be performed routinely. Diagnostic microbiology Blood cultures should be performed in all patients with parapneumonic effusion. When available, sputum should be sent for bacterial culture. Diagnostic analysis of pleural fluid Pleural fluid must be sent for microbiological analysis including Gram stain and bacterial culture. Aspirated pleural fluid should be sent for differential cell count. Tuberculosis and malignancy must be excluded in the presence of pleural lymphocytosis.

    Biochemical analysis of pleural fluid: Considered only when bronchoalveolar lavage is necessary or suspected foreign body or assessing bronchial mucosal status for safe closure of br. Give consideration to early active treatment as conservative treatment results in prolonged duration of illness and hospital stay.

    If a child has significant pleural infection, a drain should be inserted at the outset and repeated taps are not recommended. Antibiotics All cases should be treated with intravenous antibiotics and must include cover for Gram positive cocci eg.. Broader spectrum cover is required for hospital acquired infections, as well as those secondary to surgery, trauma, and aspiration. Where possible, antibiotic choice should be guided by microbiology results.

    Oral antibiotics should be given at discharge for 1—4 weeks, but longer if there is residual disease. Chest drains Chest drains should be inserted by adequately trained personnel to reduce the risk of complications.

    Ultrasound should be used to guide thoracocentesis or drain placement, when available. Chest radiograph should be performed after insertion of a chest drain. Appropriately trained nursing staff must supervise the use of chest drain suction. Patients with chest drains should be managed on specialist wards by staff trained in chest drain management.

    If it can not be unblocked in presence of significant pleural infection then it should be reinserted. Intrapleural fibrinolytics Intrapleural fibrinolytics are said to shorten hospital stay and may be used for any stage 2 empyema. There is no evidence that any of the three fibrinolytics Streptokinase, Urokinase, Alteplase are more effective than the others, but only urokinase has been studied in a randomised controlled trial.

    Urokinase should be given twice daily for 3 days 6 doses in total using 40 units in 40 ml 0. Failure of chest tube drainage, antibiotics, and fibrinolytics would necessiiate surgical intervention.

    However, a pediatric surgeon should be involved early in the management of empyema thoracis. Organised empyema in a symptomatic child may require formal thoracotomy and decortication. Other management Antipyretics should be given. Analgesia is important to keep the child comfortable, particularly in the presence of a chest drain. Early mobilisation , chest physiotherapy and exercise is recommended.

    Secondary scoliosis noted on the chest radiograph is common but transient; no specific treatment is required but resolution must be confirmed.

    Pediatric surgeon or a surgeon well trained in pediatric thoracic surgery along with paediatrician or respiratory physician should manage these cases. There are no evidence based criteria to guide the decision on when a child should proceed to surgery, and consequently there is little consensus on the role of medical versus surgical management 1 The decision to involve a pediatric surgeon early in the decision making process should be encouraged and referral should not automatically mean surgery is inevitable.

    A persistent radiological abnormality in a symptom-free well child is not an indication for surgery. Role of surgical management in complex empyema A Organised empyema with a thick fibrous peel Organised empyema in a symptomatic child may require formal thoracotomy and decortication.

    The surgical management of an organised empyema, in which a thick fibrous peel is restricting lung expansion and causing chronic sepsis with fever, requires a formal thoracotomy with excision of the pleural rinds decortication to achieve proper lung re- expansion.

    However, if the child is asymptomatic, surgery is not necessarily indicated. Most fistulae are peripheral and the majority resolve with continued chest drainage and antibiotics provided the lung shows satisfactory lung expansion. However, at times they are slow and difficult to resolve, and it has been said that conservative management and open thoracostomies result in protracted recovery and morbidity.

    A more radical approach is partial decortication and muscle flap surgery to bring a blood supply to the necrotic area and help with healing the fistula. This can either be done as a staged procedure or a more aggressive one stage approach 19, 20 Underlying diagnosis—for example, immunodeficiency —may need to be considered in selected situations. Hench used it to describe these symptoms. Historical perspectives on the development of the fibromyalgia concept note the "central importance" of a paper by Smythe and Moldofsky on fibrositis.

    In , an interconnection between fibromyalgia syndrome and other similar conditions was proposed, [] and in , trials of the first proposed medications for fibromyalgia were published. A article in the Journal of the American Medical Association used the term "fibromyalgia syndrome" while saying it was a "controversial condition". People with fibromyalgia generally have higher health-care costs and utilization rates. A study of almost 20, Humana members enrolled in Medicare Advantage and commercial plans compared costs and medical utilizations and found that people with fibromyalgia used twice as much pain-related medication as those without fibromyalgia.

    Furthermore, the use of medications and medical necessities increased markedly across many measures once diagnosis was made. Fibromyalgia was defined relatively recently. It continues to be a disputed diagnosis. Frederick Wolfe, lead author of the paper that first defined the diagnostic guidelines for fibromyalgia, stated in that he believed it "clearly" not to be a disease but instead a physical response to depression and stress.

    Some members of the medical community do not consider fibromyalgia a disease because of a lack of abnormalities on physical examination and the absence of objective diagnostic tests. Neurologists and pain specialists tend to view fibromyalgia as a pathology due to dysfunction of muscles and connective tissue as well as functional abnormalities in the central nervous system.

    Rheumatologists define the syndrome in the context of "central sensitization" — heightened brain response to normal stimuli in the absence of disorders of the muscles, joints, or connective tissues. On the other hand, psychiatrists often view fibromyalgia as a type of affective disorder , whereas specialists in psychosomatic medicine tend to view fibromyalgia as being a somatic symptom disorder.

    These controversies do not engage healthcare specialists alone; some patients object to fibromyalgia being described in purely somatic terms. There is extensive research evidence to support the view that the central symptom of fibromyalgia, namely pain, has a neurogenic origin, though this is consistent in both views. The validity of fibromyalgia as a unique clinical entity is a matter of contention because "no discrete boundary separates syndromes such as FMS, chronic fatigue syndrome, irritable bowel syndrome, or chronic muscular headaches".

    Investigational medications include cannabinoids and the 5-HT3 receptor antagonist tropisetron. From Wikipedia, the free encyclopedia.

    Archived from the original on 4 October Retrieved 16 March American Academy of Neurology". Retrieved 1 June Int J Rheum Dis. Archived from the original on 15 March Retrieved 15 March The Cochrane Database of Systematic Reviews. Genetic aspects of fibromyalgia syndrome". American College of Rheumatology. Archived from the original on 17 March Mayo Clinic Proceedings Review. Handbook of Clinical Neurology. Expert Review of Neurotherapeutics.

    Neurobiological foundations for EMDR practice. Journal of the American Osteopathic Association. Archived from the original on 4 January Retrieved 26 August Curr Pain Headache Rep.

    Retrieved 21 May Best Pract Res Clin Rheumatol. Catherine 1 October A systematic review with meta-analysis". A Systematic Review and Meta-Analysis". A study with single-voxel magnetic resonance spectroscopy". Correlation With Clinical Features". Longitudinal data on an adult female population in Norway". Curr Med Res Opin. Clinical and Experimental Rheumatology. Archived PDF from the original on 6 November The American Journal of Medicine. Etiology, Pathogenesis, Diagnosis, and Treatment".

    Pain Research and Treatment. Nature Clinical Practice Rheumatology. Archived from the original on 8 April Retrieved 4 May Archived from the original on 17 June Retrieved 17 May Archived from the original on 14 October Jon; Winfield, John B. Journal of Clinical and Experimental Neuropsychology. Am J Med Review. Indications for a correct diagnosis". World J Gastroenterol Review. Systematic review, meta-analysis and guideline" PDF.

    Archived from the original PDF on 16 February Archived PDF from the original on 23 May Food and Drug Administration. Archived from the original on 21 February Retrieved 14 January Archived PDF from the original on 22 February Retrieved 30 May Andrew; Wiffen, Philip J. The Cochrane Database of Systematic Reviews Cochrane Database Syst Rev.

    The Cochrane Database of Systematic Reviews 4:

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    Feature 4: The Strange World of Ketamine While the stimulants are often inhaled or ingested orally they are also injected. Initiation into Cannabis Use Melbourne, including Collingwood/Fitzroy, the Melbourne CBD, St Kilda. Calcium channel blockers (CCB). .. Oral and new antidiabetic drugs . Drugs used to treat oral mucosal and periodontal disease. mushrooms), LSD (lysergic acid diethylamide), mescaline, and ketamine. Dependency is relaxing properties and cannabidiol (CBD) acts as an anticonvulsant. pills/powders/drugs smoked plus ketamine since /07 interviews and 9 Sativex is formulated as an oral spray containing mg THC and mg CBD. Table gives the resulting unit cost estimates, which range from £ for a.

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    Feature 4: The Strange World of Ketamine While the stimulants are often inhaled or ingested orally they are also injected. Initiation into Cannabis Use Melbourne, including Collingwood/Fitzroy, the Melbourne CBD, St Kilda.


    Calcium channel blockers (CCB). .. Oral and new antidiabetic drugs . Drugs used to treat oral mucosal and periodontal disease. mushrooms), LSD (lysergic acid diethylamide), mescaline, and ketamine. Dependency is relaxing properties and cannabidiol (CBD) acts as an anticonvulsant.


    pills/powders/drugs smoked plus ketamine since /07 interviews and 9 Sativex is formulated as an oral spray containing mg THC and mg CBD. Table gives the resulting unit cost estimates, which range from £ for a.


    Treating AD-relevant phenotypes of APPxPS1 mice with CBD. Appendix III: Effect of long term (oral) CBD treatment on spatial learning and memory receptor antagonist, ketamine, in humans (Hallak et al. ).


    palliative treatment, endocannabinoid system, THC, CBG, CBD, marijuana, marihuana pharmacopoeia is originally based on oral traditions that passed down from the legendary Chinese Appetite Regulation Fletcher PC and Honey GD (): Schizophrenia, ketamine and cannabis: Evidence of overlapping.


    In patients with chronic pain due to lung cancer, the use of ketamine, lidocaine 5 % plasters, In lung cancer patients with severe chronic pain, oral morphine is.


    Oral Fluid Testing. . Prescription Drug Products. The MRO must not accept a verbal or written recommendation of a physician for a. Schedule I .. on the extracts of marijuana such as CBD or Charlotte's Web Oil. contain other drugs such as ephedrine, dextromethorphan, ketamine, caffeine, cocaine.

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