Pthc Collection 2013 Preview

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The Depthcore Collective is thrilled to release it's 45th Chapter of work "Primal". Consisting of over sixty original works of art, photography and music the collective used this Chapter as a launching pad to explore concepts of nature, beast, instincts and primal origin.

Whilst all of our artists rose admirably to the challenge, Ari Wenkle delivered an especially powerful collection of work, exploring various aspects of the core themes and bringing them to life with in boldly intricate executions. I had the pleasure of interviewing Ari to learn more about him and his artistic life - be sure to check out the transcript here.

Methods: PubMed, Google Scholar, and the Cochrane database were searched to 31 December 2013. Main outcome measurements were therapeutic success rate, 30-day mortality rate, overall complications, cholangitis, and pancreatitis.

Biliary leaks and fistulas are also a common complication after liver and biliary surgery. Leaks and fistulas may take origin from various procedures like bilio-digestive anastomoses, bile or cystic duct stumps or other intraoperative bile duct injury [9, 10]. Despite reduction in mortality for hepatic surgery in the last 2 decades, bile leaks rates have not changed significantly. Most bile leaks from the intra-hepatic biliary tree are transient and managed conservatively by drainage alone or by endoscopic biliary decompression. Minimally invasive percutaneous techniques for the management of biliary leaks and fistulas include percutaneous bile collection drainage, percutaneous trans-hepatic biliary drainage, biliary leak site embolisation sclerosis, ablation of a leaking biliary segment and treatment with a covered stent.

Biliary leaks are an abnormal passage or communication from the biliary system to another location, intra- or extra-hepatic, and most commonly follow gallbladder surgery but can result from ductal injury related to blunt or sharp trauma or iatrogenic injury (e.g. liver biopsy) [15]. The most commonly accepted definition of a bile leak requires the presence of bile discharge from an abdominal wound and/or drain, with a total bilirubin level of >5 mg/ml or three-times the serum level, intra-abdominal collections of bile confirmed by percutaneous aspiration or cholangiographic evidence of dye leaking from the opacified bile ducts [16]. Surgery for hydatid disease may also lead to internal biliary leaks, with a frequency between 4 % and 28 %, mainly when deeply located cysts and right lobe cysts are excised [17].

In the case of bile leaks and fistulas, ultrasound and CT may help in the detection of the localised collections of bile or bile lying free in the peritoneal cavity. CT scanning may be used in conjunction with intravenous cholangiography (CT-IVC) to produce axial and three-dimensional images [22]. This technique is very useful in the detection of stones and in the creation of virtual cholangiographic pictures and may be very valuable in defining sites of leaks as it has the functional dimension that conventional MRCP does not.

a Laceration and obstruction of common hepatic duct post laparoscopic cholecystectomy that led to biloma formation. b Percutaneous CT-guided drainage of the biloma. c Cholangiographic picture that confirms the communication of the collection with the biliary system. Surgical repair of the bile ducts followed

The laparoscopic cholecystectomy has become one of the most common operations for treatment of symptomatic gallbladder disease. However significant postoperative biliary duct injuries can occur, leading to biliary leaks. Here we present a case where multiple abdominal collections are detected in a 64-year-old male patient who underwent laparoscopic cholecystectomy due to gallbladder stones two weeks prior. Percutaneous drainage under computed tomography guidance is implemented to treat the collections which result to be bilomas. After controlling the leak, an endoscopic retrograde cholangiopancreatography with papillotomy and stent placement is performed believing that the problem was settled in the cystic duct. But after observing that the leak increased with this treatment, an anatomical variation is suspected. A percutaneous transhepatic cholangiography is performed which confirm the diagnosis. In case of any deviation of a normal surgical post operatory, a biliary leak must be suspected. Surgeons nowadays must be trained in different diagnosis and treatment methods.

Abdominal ultrasound (US) is performed as first approach, showing intrahepatic and extrahepatic ducts with normal size and without any sign of biliary stones. A fluid collection of 160 mL is detected in the anterior subphrenic space, and free fluid on the right flank and right lower quadrant (Fig. 1, 2).

Due to the relative well clinical status of the patient, it is decided to perform a computed tomography (CT)-scan with percutaneous drainage of the collection. In the CT-scan more collections are detected in the subhepatic space and de Douglas pouch (Fig. 3).

The US is often the initial imaging modality due to the lack of invasion, the cheap cost, and being accessible. It can show from anechoic, well-circumscribed collections to complex fluid with multiple fine internal septa.7 Although the US is useful, further imaging is often necessary to confirm the diagnosis.

The MRI, besides of diagnose the possible free fluid and the collections, can detect the site of the leak and show us the biliary anatomy with the magnetic resonance cholangiopancreatography (MRCP). Specifically, thin-slab MRCP sequences may show the point of communication between the fluid collection and bile ducts. Thin-slab MRCP sequences are also helpful in depicting the detailed anatomy of the biliary tree and in detecting accessory biliary ducts, which could potentially be the source of the bile leak.8,9

Once the diagnosis is done, the surgeon has three main minimal invasive tools to treat the leak: image guided drainage of fluid and collections, PTHC with percutaneous biliary drainage and ERCP with papillotomy or stent placement.

The image guided drainage is usually performed utilizing a 16- to 22-gauge needle with Seldinger technique, under CT or US guidance. Given the lack of radiation exposure, portability, flexibility to angle the probe and real time imaging capability, US is considered the preferred modality to guide diagnostic aspiration and drain placement. Although some collections due to localization or bone or air interposition may require CT guidance. Even though the precise position of the catheter in an isolated biloma is crucial, in an active bile leak, the catheter should be placed in close proximity to the site of the leak.10,11 2b1af7f3a8