Biliary Collection Research Articles

23. SURGICAL MANAGEMENT OF A HIGHLY COMPLEX CASE OF BILIARY LEAK FOLLOWING HEPATOBILIARY SURGERY

Abstract Introduction Biliary leaks are a frequent complication of hepatobiliary surgery. We present a particularly complex case. Clinical case A 46-year-old man underwent S4-8 hepatic bisegmentectomy for hepatocellular carcinoma. Two months later he underwent percutaneous drainage of a liver collection and later endoscopic placement of plastic biliary stents. Due to the persistence of the leak, it was decided to intervene surgically by suturing the biliary leak, draining the main bile duct using a Kehr drain, and cholecystectomy, with apparent resolution. Two months later, sudden dyspnea with yellow-green emission, persistent cough, and episodes of bile vomiting appeared. CT of the chest and abdomen confirmed the presence of a biliobronchial fistula and a subdiaphragmatic biloma connected to the hemidiaphragm and initial parenchymal irritation. Percutaneous drainage of the biliary collection and thoracotomy surgery (transdiaphragmatic repair of biliary fistula, atypical lung resection of the right lower lobe, pleural cleaning, and diaphragmatic plastic surgery) were performed. One month later, with the subdiaphragmatic collection persisting, a Roux-en-Y biliojejunal anastomosis, transjejunal loop, and liver drainage (U tube) were performed, along with drainage of the interhepatodiaphragmatic collection. Subsequently, one month later, due to the persistence of the bile leak with interhepatodiaphragmatic collection, another Roux-en-Y anastomosis of the parenchymal fistula in the residual cavity was performed. After 14 days, the patient was discharged in good clinical condition, which lasted over time, without collections. Discussion This case illustrates the complexity that can be associated with a common complication of hepatobiliary surgery.

Safety of Laparoscopic Cholecystectomy for Cholecystitis during Pregnancy.

The aim of this study is to evaluate the safety of laparoscopic cholecystectomy to treat acute cholecystitis during pregnancy. We conducted a retrospective multicenter study including pregnant women with acute cholecystitis managed in surgery departments in Tunisia from January 1, 2015, to December 31, 2019. Seventeen centers of surgery department participated in this study including 107 cases of acute cholecystitis. The average maternal age was 30.5 years. Nonoperative management was performed in eight patients, whereas 99 other patients had surgery. Postoperative follow-up was uneventful in 93.8% of cases and eventful in 6.2% of cases. There was no mortality as far. A medical complication occurred in two patients with a medical morbidity rate of 1.7%. It was about thromboembolic disease. A surgical complication occurred in two other patients with a surgical morbidity rate of 1.7%. It was about intraperitoneal infection in one case and biliary collection in the other case. In univariate analysis, variables related significantly to maternal complication were: age equal or over 35 years old (P = 0.001), jaundice (P = 0.024), C-reactive protein value equal or over 20 mg/L (P = 0.05), and biliary peritonitis (P = 0.05). In multivariate analysis, independent variable predictive of maternal complications was age equal or over 35 years old (P = 0.003), jaundice (P = 0.003), and biliary peritonitis (P = 0.011). Laparoscopic cholecystectomy for cholecystitis can be safely achieved in pregnant women with low rates of morbidity and mortality. This study showed that independent variable predictive of maternal complications was age equal or over 35 years old, jaundice, and biliary peritonitis.

Continuous or interrupted suture technique for hepaticojejunostomy during pancreatoduodenectomy (HEKTIK trial): study protocol of a randomized controlled multicenter trial

BackgroundHepaticojejunostomy is commonly performed in hepato-bilio-pancreatic surgery, particularly during pancreaticoduodenectomy. The purpose of this study is to evaluate the safety and efficiency of two commonly applied suture techniques (the interrupted versus the continuous suture technique) in patients undergoing a hepaticojejunostomy during pancreatoduodenectomy.MethodsThe HEKTIK trial is a multicenter, randomized controlled, patient-blinded surgical explorative trial with two parallel study groups. An adaptive sample size design was chosen: First, 100 patients scheduled for surgery including a hepaticojejunostomy will be randomized 1:1 either to the interrupted suture technique or the continuous suture technique after informed consent. Based on this data, needed sample size will be adjusted.The primary endpoint will be the occurrence of anastomotic leakage of hepaticojejunostomy, defined as bilirubin concentration in the drain fluid at least 3 times the serum bilirubin concentration on or after postoperative day 3 or as the need for radiologic or operative intervention resulting from biliary collections or bile peritonitis (according to the definition of ISGLS). Further perioperative parameters like other morbidities as well as duration and costs of the hepaticojejunostomy will be analyzed as secondary outcomes.DiscussionUntil now there are no randomized controlled comparative data of these two suture techniques for hepaticojejunostomy. The HEKTIK trial will investigate the yet unanswered question of whether the interrupted suture or the continuous suture technique has advantages performing a hepaticojejunostomy during pancreatoduodenectomy.Trial registrationGerman Clinical Trials Register DRKS00024395. Registered on 01 February 2021.

Biliary collection masquerading as Grey Turner sign

Grey turners sign has been conventionally associated with acute pancreatitis; however, this series is a deviation from the traditional paradigm of the former mentioned sign and describes cases of flank discoloration post cholecystectomy performed for varying indications. The aim of study was to highlight correlation between biliary collection and simultaneous flank discoloration. The study describes a series of 3 cases complicated post operatively by flank discoloration, each with different indication, operative procedure, course of events however united by a common factor (biliary collection). Each case was managed on conservative lines i.e. by MgSO4 glycerine dressing. The above-mentioned cases were admitted in male surgical ward in a Tertiary care hospital over a period spanning from April to Oct 2018 whereby they responded to the conservative management albeit varying in duration of recovery and showed a gradual change in discoloration probably reflecting the sequential degradation of haemoglobin in subcutaneous tissue. In contrast to the classically mentioned Grey Turners sign, there was no evidence of pancreatitis but the mere presence of biliary sanguineous collection which tracked to the skin through a breach in transversalis fascia. To conclude, there are many eponyms describing body wall ecchymosis in relation to intra-abdominal or retroperitoneal pathology, however, there is a dearth of data pertaining to association of Grey Turner sign with biliary collection. From the above 3 cases it’s a sign that highlights itself as an index of morbidity than mortality unlike pancreatitis.

Complication management after bile duct surgery

Bile leakage and postoperative bile duct strictures or anastomotic stenosis after bilioenteric anastomosis are complex surgical complications, which are associated with increased morbidity and mortality. Detailed diagnostics and sophisticated decision-making is always requiered. Complex liver surgery (redo procedures, nonanatomic resections, etc.) and surgery involving the liver hilum or exposure of the intraparenchymal Glissonean sheath are risk factors for postoperative bile leakage. Bile leakage is defined as a bilirubin concentration at least three times greater than the serum bilirubin measured in an abdominal drainage on or after the third postoperative day or as the need for radiologic intervention because of biliary collection or relaparotomy for bile peritonitis. Therapeutic strategies for bile leakage comprise conservative watch and wait, interventional procedures (endoscopic or percutaneous biliary drainage) and relaparotomy and are selected based on the postoperative onset, output volume and anatomic localization of the bile leak. Conservative treatment and interventional procedures show ahigh success rate and should therefore be considered as the treatment of choice in most cases. In contrast to bile leakage, bile duct strictures and anastomotic stenosis are rarely observed after surgery and can usually be treated by interventional procedures. This review article discusses situation-dependent specific treatment of postoperative bile leakage as well as bile duct strictures and anastomotic stenosis in detail.

Management of nonvascular postlaparoscopic bile duct injury

Background and Aim of the Work: Early management of postlaparoscopic nonvascular biliary injuries by an expert team is essential to achieve a good outcome. In this article, we would evaluate the results of this prospective multicentric study in the management of postlaparoscopic nonvascular biliary injuries. Patients and Methods: This prospective multicentric study enrolled 168 patients with iatrogenic nonvascular bile duct injury (BDI). In all cases, endoscopic retrograde cholangiopancreatography (ERCP) was performed, and further management was done according to Strasberg type of injury. Results: Intra-abdominal biliary collection was managed by ultrasound-guided drainage. Type A (19%) was diagnosed and treated by ERCP. Types B and C (20.2%) were treated by duct reconstruction of the isolated segment and Roux-en-Y hepaticojejunostomy (RYHJ), respectively. Strasberg type D nondevascularized partial injury (7.1%) was treated by primary repair around stent. In complete type D patients and E (10.7% and 43%, respectively), Roux en-Y hepaticojejunostomy with lowering the hilar plate was performed. After ERCP, 78% of patients developed hyperamylasemia and only 4.8% developed pancreatitis. After HJ, 9.7% of patients developed stricture and were treated by percutaneous transhepatic cholangial dilatation. Conclusion: This study proved the safety and efficacy of the management of iatrogenic BDI by an expert team implementing different diagnostic and treatment modalities such as ultrasound, computed tomography scan, and ERCP in addition to different surgical options, particularly the use of right end-to-side and left side-to-side RYHJ, with lowering the hilar plate and anterior anastomosis.

Hepatico-Colonic-Cutaneous Fistula: A Rare Entity Treated by ERCP

A 53 year-old woman diagnosed with choledocholithiasis was submitted to an elective laparoscopic cholecystectomy. After two days, presented with abdominal pain, leucocytosis and subhepatic collection in ultrasonography. An emercency laparoscopy was performed and the collection was drained. 35 days later, she presented at the emergency department with bilious enteric secretion through the drain orifice. Transcutaneous fistulography showed contrast media on the colon and the biliary tree. As the patient did not have symptoms of peritonitis, endoscopic retrograde cholangiopancreatography (ERCP) was performed, and confirmed a right hepatic duct fistula with the colon. Papilotomy was performed and a 10Fr/12cm plastic stent was inserted. The patient was submitted to a colonoscopy 35 days later, which showed no signs of fistula. Another 40 days later an ERCP was performed, the stent was removed and no evidence of fistula was seen. The patient had an uneventful evaluation with closure of the cutaneous fistula. The hepaticocolonic fistula is a very rare disease, usually secondary to a local infectious process (cholecystitis), and iatrogenic causes. The most common types are the choledochoduodenal (70%) and choledochocolonic (26%). It is an unusual complication after cholecystectomy, and its mechanism consist in the formation of an internal biliary collection secondary to biliary leak that erodes into the colon, forming the fistula. The clinical signs include right upper quadrant pain, vomiting, nausea, with or without peritoneal signs, and even sepsis. In the diagnostic management are included ultrasound, computed tomography, percutaneous transhepatic cholangiography, magnetic resonance cholangiopancreatography, and ERCP. The gold standard treatment is surgical (open cholecystectomy and segmental colonic resection), however ERCP and sphincterotomy may reduce the intrabiliary pressure and help the fistula close, and this can be the treatment of choice in some cases. There are very few cases of bilio-colonic fistula demonstrated in the literature and most of them were treated by surgery. On the other hand this described case was treated successful by using ERCP approach.

Contrast-enhanced ultrasonography to diagnose complicated acute cholecystitis.

Gangrenous cholecystitis and perforation are severe complications of acute cholecystitis, which have a challenging preoperative diagnosis. Early identification allows better surgical management. Contrast-enhanced computed tomography (ceCT) is the current diagnostic gold standard. Contrast-enhanced ultrasonography (CEUS) is a promising tool for the diagnosis of gallbladder perforation, but data from the literature concerning efficacy are sparse. The aim of the study was to evaluate CEUS findings in pathologically proven complicated cholecystitis (gangrenous, perforated gallbladder, pericholecystic abscess). A total of 8 patients submitted to preoperative CEUS, and with subsequent proven acute complicated cholecystitis at surgical inspection and pathological analysis, were retrospectively identified. The final diagnosis was gangrenous/phlegmonous cholecystitis (n. 2), phlegmonous/ulcerative changes plus pericholecystic abscess (n. 2), perforated plus pericholecystic abscess (n. 3), or perforated plus pericholecystic biliary collection (n. 1). Conventional US findings revealed irregularly thickened gallbladder walls in all 8 patients, with vaguely defined walls in 7 patients, four of whom also had striated wall thickening. CEUS revealed irregular enhancing gallbladder walls in all patients. A distinct wall defect was seen in six patients, confirmed as gangrenous/phlegmonous cholecystitis at pathology in all six, and in four as perforation at macroscopic surgical inspection. CEUS is a non-invasive easily repeatable technique that can be performed at the bedside, and is able to accurately diagnose complicated/perforated cholecystitis. Despite the limited sample size in the present case series, CEUS appears as a promising tool for the management of patients with the clinical possibility of having an acute complicated cholecystitis.

Laparoscopic surgery of benign liver tumours

273 patients underwent elective surgical treatment for benign liver lesions at the 1st Surgical Department of Semmelweis University, Budapest, Hungary between 2004 and 2014. Laparoscopic (LAP) interventions were performed in 83 cases. Cyst fenestration in 52, and hepatic resection in 31 cases. LAP liver resections were set against to open surgery of paired group of patients with comparable demographic and clinical parameters. Data revealed that the operative time in LAP group (113.7 min) was significantly longer than that in the open surgery group (89.5 min). The average postoperative length of hospital stay was shorter after LAP surgery (5.8 vs 9.1 days). There was no postoperative complication in the LAP group, two wound infections and one biliary collection were treated by ultrasonic drainage in the open group. Three patients were given blood transfusion in the LAP, four in the open group. Operative mortality was zero, and no reoperation required. The surgical technique which is described in detail in the text enables safe resection of segments 7-8 which are difficult to approach. Our data support the safety and feasibility of laparoscopic liver resection after adequate preoperative investigations.

Bile Leak Leading to Lesser Sac Bile Collection Masquerading as Stomach in Hepatobiliary Scintigraphy

Images show normal tracer distribution in graft hepatocytes. Abnormal bile collection seen along the inferior margin of the liver which progressively collects at lesser sac (LS) displacing and compressing stomach (S) superolaterally (confirmed in Magnetic Resonance Imaging [MRI] coronal section). There is normal progression of tracer into intestinal loops. The first minute of dynamic image shows a large cold defect at the anatomical site of stomach which is in fact the unlabeled bile collection at LS (thin arrow) (Figure 1). As tracer progresses through biliary tree, radiolabelled bile starts collecting at the above site which is evident in the 15th minute image. The size and location of biliary collection remains unchanged even at 2 h delayed imaging. Normally stomach is not seen on an HBS. Commonest cause of stomach visualization on hepatobiliary scan is enterogastric bile reflux.1 If not careful, one may easily misinterpret and report the LS bile collection to be the stomach (by its size and placement) from an enterogastric reflux. The other teaching point is enterogastric reflux is best noticed in endless cine loop images as a jet of retrograde flow of tracer from duodenum into stomach in the first few minutes after injection which is the time taken for tracer transit through biliary radicles, common bile duct and hepatic outflow tract. Computed tomography (CT) and MR cholangiopancreatography (MRCP) images (Figures 2 and 3) confirm gross collection (12 × 10 cm) in the epigastrium adjacent to the cut surface of liver displacing and compressing the stomach laterally. Single photon emission computed tomography—computed tomography (SPECTCT) or MR correlation may be useful in identifying the displaced stomach. Bile leak collecting in lesser sac of peritoneum is important as it guides clinicians to decide on the site of placement of the drain tube in the abdomen. Biliary complications affect one in five liver transplant recipients.2 Incidence of biliary complications is higher (20–34%) after right-lobe live donor liver transplantation than from cadaveric transplants.3 Endoscopic retrograde cholangiopancreatography is the first-line treatment for biliary complications.4 HBS apart from identifying bile leaks is routinely used in postoperative patients for evaluating biliary-enteric anastomosis patency and in post-cholecystectomy patient with recurrent pain.1 Figure 1 HBS dynamic and static images. (A) Dynamic images (1 min/frame) show a large cold defect at the anatomical site of stomach (thin arrow). There is slow progressive collection of radiolabelled bile at the above site which is evident at 15th minute ... Figure 2 Transaxial CT image showing gross collection (12 × 10 cm) in the epigastrium adjacent to the cut surface of liver (thick arrow) displacing and compressing the stomach laterally (dotted arrow). LS: lesser sac. Figure 3 MRCP coronal images (A & B) show gross collection (12 × 10 cm) in the epigastrium adjacent to the cut surface of liver (thick arrow) displacing and compressing the stomach (S) laterally (thin arrow). ...

Laparoscopic resection for hepatocellular carcinoma: comparison between Middle Eastern and Western experience.

Laparoscopic liver resection (LLR) is growing in popularity, but the short- and long-term outcome of patients undergoing LLR for hepatocellular carcinoma (HCC) has not yet been established. A literature search was performed using PubMed, Scopus, and Web of Science (WoS) from cited English and Chinese publications. Clinical and survival parameters were extracted. The search was last conducted in October 2013. After application of selective criteria, 24 remaining original studies with more than 15 patients were analyzed. In the Western experience, mean operative time was between 150 to 300 minutes, and mean blood loss ranged from 55 to 452 mL. Transfusion was required in all series, ranging from 2.8% to 50%. The conversion rate ranged from 5% to 19.4%. Three cases of death were reported. General morbidity rate ranged from 1.5% to 25%. Specific complications were divided into hemorrhage (2.4% to 25%), ascites (3.7% to 15.3%), and biliary collection (0.6% to 5%). Liver insufficiency was reported in two cases. Mean hospital stay ranged from 5.4 to 15 days. In all case-matched studies, LLR was statistically associated with a shorter hospital stay. The 5-year overall survival rate ranged from 55% to 70%. No trocar-site recurrence was observed. The recurrence rate ranged from 21.4% to 50%. Comparative studies did not demonstrate any significant difference in terms of recurrence between LLR and open liver resection (OLR). In the Middle Eastern experience, mean operative time ranged from 147 to 325 minutes, and mean blood loss ranged from 88 to 808 mL. Transfusion was required, ranging from 1.8% to 19.2%. The conversion rate ranged from 1.8% to 18.6%, and four series reported no conversion. There was no mortality. The main specific complication was ascites (1.7% to 26.6%). A biliary collection was reported in only two series (10.7% and 13.3%), and only one case of postoperative liver insufficiency was reported. Mean hospital stay ranged from 4 to 11.5 days. Statistically, three comparative studies reported a shorter postoperative hospital stay following LLR versus OLR. The 5-year overall survival rate ranged from 50% to 76.6%. Comparative studies did not demonstrate any significant difference in terms of overall survival and recurrence rate between LLR and OLR. No trocar-site recurrence was reported. The recurrence rate ranged from 26.9% to 45.5%, and two series reported no recurrence. Laparoscopic surgery should be considered an acceptable alternative for the treatment of HCC.

Added value of SPECT/CT over planar Tc-99m mebrofenin hepatobiliary scintigraphy in the evaluation of bile leaks

To determine the added value of single-photon emission computed tomography/computed tomography (SPECT/CT) over planar hepatobiliary scintigraphy (HBS) in suspected cases of bile leak. An analysis of the data of all patients who had undergone HBS for suspected bile leak during the last 3 years was carried out. All patients had undergone an initial 45 min dynamic study after an intravenous injection of Tc-99m mebrofenin, following which they underwent multiple static imaging studies for up to 24 h and SPECT/CT imaging whenever needed. A total of 203 patients had undergone an HBS for evaluation of a suspected bile leak. HBS was positive for bile leak in 110 patients, among whom 42 had undergone additional SPECT/CT. In 32 patients SPECT/CT was useful in (i) defining the exact location of collection [intracapsular vs. extracapsular vs. intraparenchymal leak (n=18/25)], (ii) defining the extent of intraparenchymal collections (n=6/6), (iii) characterizing large abdominal collections (n=2/2), and (iv) characterizing suspected contamination (n=4/4), (v) suspected collection (n=0/3), (vi) and other miscellaneous conditions (n=2/2). Defining the extent and exact localization of collection can have therapeutic implications such as the accurate site of placement of the drain for drainage. In approximately one-third of the bile leak-positive HBS studies (32/110), SPECT/CT images were helpful for better characterization of biliary collection. In all, 76% (32/42) of the SPECT/CT studies were found to provide additional useful information over planar imaging. Hybrid SPECT/CT offers the unique advantage of combining the anatomical information from CT with the functional information provided by HBS. It is most useful in characterization of biliary collections, which give important scintigraphic evidence of the severity of bile leak with therapeutic implications such as placement of a drain or surgical exploration.

A few thoughts on “Interventional radiology in the management of benign biliary stenoses, biliary leaks and fistulas: a pictorial review”

Dear Editor, We read with great interest the article by Krokidis and colleagues [1] recently published in Insights into Imaging. In this well-presented pictorial review, the authors point out the crucial role of interventional radiology as a minimally invasive approach to treat benign strictures, to divert the bile away from the site of the fistula, and to seal the leaking tract. Balloon dilation was reported as the strategy of choice in the percutaneous treatment of benign biliary strictures (although burdened by 29–58 % re-stenosis), while the role of stent placement was reported to still be controversial. A different approach can be the use of novel bioabsorbable biliary stents [2], which may limit the number of balloon dilations in bilioplasty, also overcoming the problem of stent withdrawal. Regarding bile leaks, the authors discuss—inter alia—the role of percutaneous drainage of biliary collections, of coil/gelfoam embolisation of bilio-vascular fistulas, and of covered stents. However, we underline that the most commonly used technique for treating postsurgical biliary leak is percutaneous transhepatic biliary drainage, which allow for bile diversion from the site of the fistula [3]. Moreover, an occlusion balloon placed above the site of the fistula has been demonstrated to allow for complete external drainage of the bile, thus representing a valuable option to treat post-surgical biliary leaks [3, 4]. In case of direct communication between a collection and the biliary system, it may happen that percutaneous drainage is not enough to allow for full healing and surgery may be required, as the authors show in Figure 3 [1]. We note that, in this particular setting, percutaneous cyanoacrilyc glue embolisation has been reported as a feasible technique, which may lead to fistula sealing, avoiding the morbidity related to surgical re-intervention [5].

Bile leakage after hepatobiliary and pancreatic surgery: A definition and grading of severity by the International Study Group of Liver Surgery

Despite the potentially severe impact of bile leakage on patients' perioperative and long-term outcome, a commonly used definition of this complication after hepatobiliary and pancreatic operations has not yet been established. The aim of the present article is to propose a uniform definition and severity grading of bile leakage after hepatobiliary and pancreatic operative therapy. An international study group of hepatobiliary and pancreatic surgeons was convened. A consensus definition of bile leakage after hepatobiliary and pancreatic operative therapy was developed based on the postoperative course of bilirubin concentrations in patients' serum and drain fluid. After evaluation of the postoperative course of bilirubin levels in the drain fluid of patients who underwent hepatobiliary and pancreatic operations, bile leakage was defined as bilirubin concentration in the drain fluid at least 3 times the serum bilirubin concentration on or after postoperative day 3 or as the need for radiologic or operative intervention resulting from biliary collections or bile peritonitis. Using this criterion severity of bile leakage was classified according to its impact on patients' clinical management. Grade A bile leakage causes no change in patients' clinical management. A Grade B bile leakage requires active therapeutic intervention but is manageable without relaparotomy, whereas in Grade C, bile leakage relaparotomy is required. We propose a simple definition and severity grading of bile leakage after hepatobiliary and pancreatic operative therapy. The application of the present proposal will enable a standardized comparison of the results of different clinical trials and may facilitate an objective evaluation of diagnostic and therapeutic modalities in the field of hepatobiliary and pancreatic operative therapy.

Outcome of laparoscopic cholecystectomy in acute and chronic cholecystitis.

Background: laparoscopic cholecystectomy is standard treatment in gallbladder disease. Acute cholecystitis has been relative contraindication of laparoscopic cholecystectomy. With theaccumulation of experience in laparoscopic surgery, laparoscopic cholecystectomy is being gradually applied for the treatment of acute cholecystitisObjective: to evaluate and compare the outcome of laparoscopic cholecystectomy in acute and chronic cholecystitis in terms of complications, conversion rates, reason of conversion, need for special modifications of the operative technique, and hospital stay.Methods: A prospective study done Between April 2007 and January 2010, in the department of general surgery, medical city teaching hospital, Baghdad. Evaluation of all patients admitted with symptomatic gall bladder disease, who underwent laparoscopic cholecystectomy were included in this study. They were classified as group A (having acute cholecystitis) and group B (having chronic cholecystitis), The diagnosis of AC was based on clinical, ultrasonographic, and operative finding; also histological diagnosis.Results: A total of 197 patients. 46 (23%) had acute cholecystitis (group A) while 151 patients (76.6%) had chronic cholecystitis (group B). In group A, Gall bladder decompression was required in 4 (8.7%) patients. One patient (2.2%) had wound infection, and one patient (2.2%) developed a subhepatic biliary collection. While epigastric port hernia occurs in one patient (2.2%). In group B, One patient (0.7%) had wound infection, and one patient (0.7%) had umbilical port hernia. Conversion rate was 3(6.5%) for group A and 0% for group B. There was no procedure related mortality in either group. The hospital stay (6-24 hours) was the same for both groups (group A; mean 9.13±6.89 hours, group B; mean 15.77±8.99 hours).Conclusion: laparoscopic cholecystectomy is safe in all patients presented with symptomatic gall bladder disease.

Ruolo diagnostico dell’US color Doppler nel I anno di follow-up posttrapianto epatico (OLT)

This paper discusses the role of colour Doppler ultrasound (CDUS) in the midterm follow-up of patients after orthotopic liver transplantation (OLT). We retrospectively studied 134 patients--102 men and 32 women, age range 21-68 years--who underwent liver transplantation between May 2006 and April 2007. In the first week after OLT, CDUS examination was performed daily in patients with anastomoses at a high risk of thrombosis, and on the basis of clinical and laboratory findings in other patients. After discharge, follow-up was performed 1, 3, 6 and 12 months after transplantation. Any new parenchymal focal lesion was studied by computed tomography (CT) and, where needed, biopsy. CDUS identified the following complications: 22 biliary (B), nine vascular (V) and seven focal lesions (FL). Sensitivity, specificity, positive and negative predictive values and diagnostic accuracy were, respectively: 79.2%, 97.3%, 86.3%, 95.5%, 94% (B), 100%, 99.2%, 88.9%, 100%, 99.3% (V) and 100%, 96.9%, 42.8%, 100%, 97% (FL). CDUS also showed 16 blood collections and eight suspected biliary collections (four of which were confirmed by percutaneous puncture). CDUS is an essential diagnostic tool in the follow-up of OLT. An early diagnosis of complications can improve graft integrity and patient survival.

A dangerous pleural effusion

Bilothorax is a rare complication of biliary peritonitis and, if not treated promptly, can be life-threatening. We report a case of a middle-aged woman who had undergone a bilio-enteric bypass and subsequently a biliary leak developed, which finally led to intra-abdominal biliary collection and spontaneous bilothorax. The clinical course was rapid and mimicked venous thromboembolism, myocardial infarction and pulmonary oedema, which led to a delay in diagnosis and management and finally death. We high-light the fact that bilothorax, although a rare complication of biliary surgery, should always be considered as a probable cause of massive effusion and sudden-onset respiratory and cardiovascular collapse in the postoperative period. A chest X-ray and a diagnostic pleural tap can confirm the diagnosis. Once detected, an aggressive management should be instituted to prevent organ failure and death.

Hypoperfusion of Segment 4 in Right In Situ Split-Liver Transplantation

To expand the donor pool, split-liver transplantation has been implemented in recent years. In the classic technique, the arterial axis with the artery for segment 4 (S4) coming from the left hepatic artery (HA) is included with the right graft. To give a surgical advantage to pediatric recipients in our center, the left HA, the common HA, and the celiac trunk are generally retained with the left liver. Thus the artery for S4 is sacrificed. We compared the outcomes of S4 in 290 whole grafts (WG; group A) with 28 right in situ split-liver grafts (SSLG; group B), which were transplanted over the past 10 years (January 1999–December 2009). The rates of major biliary and of hemorrhagic complications were similar. In most of cases (16/24, 66%) S4, on computerized tomographic scan appeared to show signs of hypoperfusion, sometimes with a peripheral aspect of hyperperfusion in the arterial phase. S1 showed signs of hypoperfusion in only 2 cases. A biliary collection near the resection line present in 8 cases was treated in 6 of them with percutaneous drainage and in 2 with laparotomy. These complications did not influence graft or patient survival. Graft survivals at 1, 5, and 10 years for WG and SSLG were not different among the groups: 85%, 74%, and 66% vs 89%, 79%, and 63%, respectively ( P = .8). Although our technique cannot be considered to be anatomically correct, the ischemia of S4 did not influence the outcome. The rate of retransplantations for hepatic artery thrombosis was 17.9% in RSSG and 3.4% in WG ( P = .001), which was probably due at least in part to the insertion of interposition grafts.

Laparoscopic left hepatectomy with prior vascular control

Laparoscopic major resections remain a challenge for liver surgeons. This video illustrates, step by step, our laparoscopic technique for left hepatectomy. The control of vascular inflow and outflow as well as the division of the left hepatic duct were carried out extraparenchymally before liver transection. Between 2002 and 2008, 11 left hepatectomies were performed by laparoscopy: 7 for liver tumor and 4 for localized Caroli's disease. Mean duration of surgery was 248 +/- 25 min. Mean operative blood loss was 129 +/- 42 ml. Intraoperative blood transfusion or conversion to laparotomy were never required. One postoperative biliary collection occurred and was drained percutaneously. None of the patients died. Mean hospital stay was 7.6 +/- 2.2 days. This technique has proved to be safe and easily reproducible.

Bile duct injuries associated with cholecystectomy

Bile duct injuries associated with cholecystectomy