Biliary-enteric Reconstruction Research Articles

Evaluation of the outcomes of biliary-enteric reconstruction in robotic radical resection of hilar cholangiocarcinoma: a single-center propensity score matching analysis

Although robotic radical resection for hilar cholangiocarcinoma (HCCA) has been reported in some large hepatobiliary centers, biliary-enteric reconstruction (BER) remains a critical step that hampers the operation’s success. This study aimed to evaluate the feasibility and quality of BER in robotic radical resection of HCCA and propose technical recommendations. A retrospective study was conducted on patients with HCCA who underwent minimally invasive radical resection at Zhejiang Provincial People’s Hospital between January 2016 and July 2023. A 1:2 propensity score matching (PSM), widely used to reduce selection bias, was performed to evaluate the outcomes, especially BER-related data, between the robotic and laparoscopic surgery. Forty-six patients with HCCA were enrolled; ten underwent robotic-assisted resection, while the others underwent laparoscopic surgery. After PSM at a ratio of 1:2, 10 and 20 patients were assigned to the robot-assisted and laparoscopic groups, respectively. The baseline characteristics of both groups were generally well-balanced. The average liver resection time was longer in the robotic group than in the laparoscopic group (139.5 ± 38.8 vs 108.1 ± 35.8 min, P = 0.036). However, the former had less intraoperative blood loss [200 (50–500) vs 310 (100–850) ml], despite no statistical difference (P = 0.109). The number of residual bile ducts was 2.6 ± 1.3 and 2.7 ± 1.2 (P = 0.795), and anastomoses were both 1.6 ± 0.7 in the two groups (P = 0.965). The time of BER was 38.4 ± 13.6 and 59.1 ± 25.5 min (P = 0.024), accounting for 9.9 ± 2.8% and 15.4 ± 4.8% of the total operation time (P = 0.001). Although postoperative bile leakage incidence in laparoscopic group (40%) was higher than that in robotic group (10%), there was no significant difference between the two groups (P = 0.204); 6.7 ± 4.4 and 12.1 ± 11.7 days were observed for tube drawing (P = 0.019); anastomosis stenosis and calculus rate was 10% and 30% (P = 0.372), 0% and 15% (P = 0.532), respectively. Neither group had hemorrhage- or bile leakage-related deaths. Robotic radical resection for HCCA may offer perioperative outcomes comparable to conventional laparoscopic procedures and tends to be advantageous in terms of anastomosis time and quality. We are optimistic about its wide application in the future with the improvement of surgical techniques and experience.

Outcome of Biliary-enteric Reconstruction with Hepaticoduodenostomy Following Choledochal Cyst Resection: A Prospective Study.

The two most commonly performed methods of biliary-enteric reconstruction following choledochal cyst resection are Roux-en-Y hepaticojejunostomy (HJ) and hepaticoduodenostomy (HD). There is a lack of consensus regarding the better technique between them. This study aimed to evaluate the outcomes, efficacy and early complications of HD as a mode of biliary reconstruction after surgical resection of a choledochal cyst. This was a multi-institutional prospective study carried out in high-volume tertiary care teaching institutes from January 2010 to December 2022. All children managed with HD following choledochal cyst resection were analysed for their early complications and outcomes. A total of 74 patients were included in this study. There were 59 (79.73%) females and 15 (20.27%) males. Thirty-nine (52.70%) patients had jaundice at the time of presentation. Magnetic resonance cholangiopancreatography was performed in 57 (77.03%) patients following ultrasonography. Intraoperatively, malrotation was present in 2 (2.70%) patients. In our study, operating time ranged from 60 to 195 min (mean: 118 min). Hospital stays ranged from 8 to 17 days (mean: 11.5 days). The post-operative biliary leak was seen in 7 (9.50%) patients, out of which 6 (8.11%) minor leaks were managed conservatively. Roux-en-Y HJ was performed on 1 (1.35%) patient with a major leak. In our series, 4 (5.40%) patients developed cholangitis; post-operative haemorrhagic nasogastric aspirate 5 (6.76%), post-operative pancreatitis 3 (4.05%) and wound infection 4 (5.40%) were observed and managed conservatively. None of the patients in our study developed an anastomotic stricture, bile gastritis and adhesive small bowel obstruction. Resection of choledochal cyst with HD reconstruction is safe and feasible with short operative time. HD is a viable option for operative management of choledochal cyst with low complication rates and faster recovery.

Biliary-enteric reconstruction in laparoscopic radical resection of hilar cholangiocarcinoma: a single-center retrospective cohort study

ObjectiveTo evaluate the feasibility and quality of biliary-enteric reconstruction (BER) in laparoscopic radical resection of hilar cholangiocarcinoma (LsRRH) versus open surgery and propose technical recommendations.MethodsData of 38 LsRRH and 54 radical laparotomy resections of hilar cholangiocarcinoma (LtRRH) cases were collected from our institution. BER was evaluated via biliary residuals numbers, number of anastomoses, anastomosis manner, suture method, time consumption, and postoperative complication.ResultsIn the LsRRH group, patients were relatively younger; Bismuth type I had a higher proportion while type IIIa and IV were less and required no revascularization. In LsRRH and LtRRH groups, respectively, the biliary residuals number was 2.54 ± 1.62 and 2.47 ± 1.46 (p > 0.05); the number of anastomoses was 2.04 ± 1.27 and 2.57 ± 1.33 (p > 0.05); the time of BER was 65.67 ± 21.53 and 42.5 ± 19.77 min (p < 0.05), 15.08 ± 3.64% and 11.76 ± 2.54% of the total operation time (p < 0.05); postoperative bile leakage incidence was 15.79% and 16.67% (p > 0.05); 14 ± 10.28 and 17 ± 9.73 days for healing (p < 0.05); anastomosis stenosis rate was 2.63% and 1.85% (p > 0.05). Neither group had a biliary hemorrhage or bile leakage-related death.ConclusionThe selection bias in LsRRH mainly affects tumor resection than BER. Our cohort study indicates that BER in LsRRH is technically feasible and equals anastomotic quality to open surgery. However, its longer and a more significant proportion of total operation time represent that BER has higher technical requirements and is one of the critical rate-limiting steps affecting the minimal invasiveness of LsRRH.

Laparoscopic excision of congenital choledochal cyst in children and modified hepaticojejunostomy with an unequal length of the jejunal loop

Introduction: Complete excision biliary-enteric reconstruction is necessary for a congenital choledochal cyst (CC) to prevent recurrent cholangitis, acute pancreatitis, and cholangiocarcinoma. Among various reconstructions, this study aims to evaluate the therapeutic effect of unequal length jejunal loop for the biliary reconstruction of congenital choledochal cyst.&#x0D; Method: The clinical data of 56 cases of congenital choledochal cyst treated in the pediatric surgery department of Children's Hospital Affiliated to Zheng Zhou University were retrospectively analyzed. All cases were treated with choledochal cyst resection and unequal length jejunal loop biliary reconstruction, including 51 cases with laparoscopic surgery and 5 cases with traditional surgery.&#x0D; Result: Choledochal cyst resection and unequal length jejunal loop biliary reconstruction were successfully completed in all cases. One case of laparoscopic operation developed biliary fistula on the 3rd day after the operation, and the biliary fistula healed after conservative treatment for 8 days. The other cases recovered smoothly without obvious complications. No contrast agent bile loop reflux was found in upper gastrointestinal angiography.&#x0D; Conclusion: The modified jejunal loop biliary reconstruction has many advantages over the traditional biliary reconstruction, which is worthy of clinical application.

Total Laparoscopic Resection of Hilar Cholangiocarcinoma Type 3b: Applying a Parachute Technique for Hepaticojejunostomy

BackgroundLaparoscopic liver resection for perihilar cholangiocarcinoma (pCCA) is still in its infancy. The biliary-enteric reconstruction represents one of the most delicate parts of this minimally invasive procedure.MethodsIn this study, a 78-year old woman with perihilar cholangiocarcinoma (pCCA) type 3b underwent a hepaticojejunostomy performed by a parachute technique.ResultsThe operation, performed totally by minimally invasive resections, was completed in 386 min, with a blood loss of less than 400 ml and no transfusion requirements. Two intraluminal stents were placed during the hepaticojenunostomy for splinting of the biliary-enteric anastomosis. The patient required prolonged antibiotic treatment for postoperative cholangitis and finally was discharged on postoperative day 15. The histopathologic grading displayed a G 2–3 adenocarcinoma, pT3 pN0, M0, L1, V1, pN1, UICC IIIc R0, and the patient was referred to adjuvant chemotherapy.ConclusionResections of pCCAs, performed totally by minimally invasive techniques, may be feasible and safe for a selected group of patients. With this approach, a running-suture hepaticojejunostomy using the parachute technique represents a worthwhile strategy for biliary-enteric reconstruction.

Biliary Enteric Reconstruction After Biliary Injury: Delayed Repair Is More Costly Than Early Repair

BackgroundBile duct injury (BDI) during cholecystectomy requiring biliary enteric reconstruction (BER) is associated with increased risk of postoperative mortality and substantive increases in costs of care. The impact of the timing of repair on overall costs of care is poorly understood. Materials and methodsThe Healthcare Cost and Utilization Project Florida State databases (2006-2015) were queried to identify patients undergoing BER within 1-y of cholecystectomy performed for benign biliary disease. Patients were then categorized by the time interval between cholecystectomy to BER: early (≤3 d), intermediate (4 d to 6 wk), or delayed (>6 wk). By repair timing strategy, 1-y outcomes were aggregated, including charges, inpatient costs, aggregate length of stay, and inpatient mortality. ResultsOf 563,887 patients undergoing cholecystectomy, 1168 required a BER (0.21%) within 1-y of cholecystectomy. Early BER was performed in 560 patients (47.9%), intermediate BER in 439 patients (37.6%), and delayed BER in 169 (14.5%) patients. On multivariable analysis adjusting for patient, procedure, and facility factors, intermediate BER demonstrated an increased risk of mortality (odds ratio 2.04, 95% confidence interval [CI]: 1.16-3.56) and increased aggregate inpatient cost (+$12,472; 95% CI: $6421-$18,524) relative to early BER. There was no notable difference in adjusted risk of inpatient mortality between the early and delayed BER cohorts (odds ratio 0.90; 95% CI: 0.32-1.25), but delayed BER was associated with increased aggregate inpatient costs (+$45,111; 95% CI: $36,813-$53,409). ConclusionsWhen compared with delayed BER, early repair was associated with shorter aggregate inpatient hospitalization without increased postoperative mortality. Intermediate timing of repair is associated with increased costs and risk of mortality.

Cholangitis following biliary-enteric anastomosis: A systematic review and meta-analysis

BackgroundCholangitis is a serious biliary complication following biliary-enteric anastomosis (BEA). However, the rate of cholangitis in the postoperative period and its associated risk factors are inconclusive. The objective of this systematic review and meta-analysis was to assess the onset and risk factors of cholangitis after biliary-enteric reconstruction in literature. MethodsMEDLINE, EMBASE, and Cochrane databases were searched systematically to identify studies reporting about cholangitis following biliary-enteric anastomosis. Meta-analyses were performed for risk factors using random effects model with odds ratio (OR) and 95% confidence interval (95 %CI) as effect measures. Study quality was assessed by the MINORS (methodological index for non-randomized studies) criteria. Results28 studies involving 6904 patients were included in the study. The pooled rate for postoperative cholangitis (POC) was 10% (95 %CI: 8 %–13%) with studies reporting about an early- and late-onset of cholangitis. Male sex (OR 2.08; 95 %CI: 1.33–3.24; P = 0.001), postoperative hepatolithiasis (OR 137.19; 95 %CI: 29.00–648.97; P < 0.001) and postoperative anastomotic stricture (OR 178.29; 95 %CI: 68.64–463.11; P < 0.001) were associated with a higher risk of a late-onset of POC with a pooled rate of 8% (95 %CI: 6 %–11%) after a median time interval of 12 months. The quality of the included studies was low to moderate. ConclusionCholangitis is a frequent complication after BEA. Consensus definition and prospective trials are required to assess optimal therapeutic strategies. We proposed a standardized definition and grading of POC to enable comparisons between future studies.

Mirizzi syndrome - a reconstruction reconstrued: Technique for bile duct reconstruction using a vascularized gallbladder pedicle

Presenter: Prakash Jayanthi MD | Michigan State University College of Human Medicine Background: Mirizzi’s Syndrome is rare, with < 1% incidence in developed countries. No best treatment algorithm is available. Correct preoperative identification and planning is associated with less morbidity, with operative preference based on surgeon experience. The greater the degree of inflammation/erosion, the more complex the treatment - Csendes Type 1 Mirizzi patients benefit from cholecystectomy alone; Types 2-4 may require subtotal cholecystectomy/choledochoplasty versus biliary-enteric reconstruction; Type 5 usually requires fistula takedown/reconstruction. Methods: A 74-year old female presented with severe RUQ pain. CECT Abd/Pelvis: pneumobilia with air in gallbladder fossa. Perforated, gangrenous cholecystitis was suspected. MRI/MRCP: 3.5 cm gallstone impacted in the gallbladder neck, proximal hepatic duct dilatation, likely adjacent abscess. Bilioenteric fistula was suspected due to pneumobilia. Open cholecystectomy was planned for a diagnosis of Csendes Type V - fistula with complete bile duct wall erosion. Normally, fistula takedown with bilio-enteric reconstruction is preferred; however, the fistula ruptured, with resultant severe inflammation making bilio-enteric reconstruction hazardous. Hence, choledochoplasty using a well-vascularized pedicle of gallbladder neck was performed. Results: Intraoperatively, severe inflammation obscured normal anatomy. The gallbladder was taken dome-down. A broad neck of the gallbladder was attached to the CHD, consistent with Mirizzi’s Syndrome. Subtotal cholecystectomy was performed, leaving a remnant cuff vascularized via cystic artery. Frozen sections were sent, with no evidence of cancer. A pericholecystic abscess, likely from a ruptured bilioenteric fistula, was debrided. A 3.5cm gallstone caused near complete erosion of anterior bile duct - Csendes Type V. The back wall of the duct was identified, with proximal channel towards the liver and distal channel towards duodenum. Choledochoscopy demonstrated no obstruction or lesions. Extensive xanthogranulomatous inflammation precluded biliary-enteric reconstruction, with further dissection concerning for possible Right Hepatic artery compromise. The gallbladder flap approximated easily- therefore choledochoplasty was decided upon. Proximal/distal bile duct was cannulated by 18Fr T-tube; choledochoplasty was performed over it, using interrupted 3-0 Maxon suture without narrowing luminal diameter, re-creating an anterior wall for the bile duct common channel. Pressurized saline through T-tube showed no leak. T-tube cholangiogram confirmed patency and absence of stenosis/obstruction. Several weeks later, a T-tube cholangiogram showed satisfactory repair, with appropriate passage of contrast. Hence, the tube was then removed. The patient did not have any complications. Conclusion: Although rare, Mirizzi’s Syndrome is well-known and historically classified into Type 1 - Gallstone compression of bile duct; Type 2 - Common hepatic/bile duct erosion. Csendes et al. (1989) classified Mirizzi syndrome based on degree of erosion of duct wall into 4 types. Type 5 including cholecystoenteric fistula +/- gallstone ileus was added in 2007. Preoperative suspicion is paramount as bile duct injury approaches 17% incidence, with preoperative diagnosis only made in 62% of patients. Open repair is the gold standard. Cholecystectomy should be sufficient in type 1; any duct wall erosion makes a total cholecystectomy potentially unsafe. Bilioenteric reconstruction, e.g. choledochoplasty or hepaticojejunostomy, may be required for continuity. Choledochoscopy is used to confirm patency, as are cholangiograms in patients with T-tube. This case highlights this disease's unpredictable nature, and the need for familiarity with options for repair.

Biliary reconstruction by isolated jejunal interposition loop: Our experience after excision of choledochal cyst

Background:Choledochal cyst is a fairly common hepatobiliary condition in pediatric surgical practice. For the most common type (type I), it is well established that the total excision of the cyst with an wide biliary-enteric anastomosis is key for long-term good result. Multiple options remain for biliary-enteric reconstruction after excision. Jejunal interposition loop reconstruction is thought to be the most physiologic.Materials and Methods:We have retrospectively reviewed the data of patients of type I choledochal cysts which were operated between January 2010 and September 2018 and undergone jejunal interposition loop reconstruction. Clinical presentation, investigations, operative procedure morbidity and complications were reviewed.Results:There were 33 patients, with a male-to-female ratio of 1:3 and a mean age of 4.63 years (mean ± standard deviation [SD] = 4.63 ± 2.98 years). The follow-up period ranged from 3 to 81 months (mean ± SD = 36.30 ± 19.24 months). There was no stricture or cholangitis. Reoperation required in one due to leak at biliary-enteric anastomosis leading to biliary peritonitis. One each had pancreatitis and prolonged ileus. Two bile leaks stopped spontaneously. Operative time and postoperative hospital stay were 228.78 ± 40.43 min (mean ± SD) and 8.96 ± 3.63 days (mean ± SD), respectively.Conclusion:Jejunal interposition loop reconstruction is safe and reproducible with acceptable morbidity. However, if this procedure is abandoned, the long-term benefits may remain ever elusive.

Short-term and long-term outcomes after Roux-en-Y hepaticojejunostomy versus hepaticoduodenostomy following laparoscopic excision of choledochal cyst in children.

Choledochal cysts are congenital dilations of the biliary tree. Complete cyst excision and biliary-enteric reconstruction have been the standard operations. In our center, more than 95% of choledochal cyst excision is now performed laparoscopically. Majority of current studies describe laparoscopic-assisted reconstruction using Roux-en-Y hepaticojejunostomy (HJ). However, only a few have studied laparoscopic hepaticoduodenostomy (HD) as an alternative method of biliary-enteric reconstruction. In this study, we focused on comparing longer-term outcomes between laparoscopic HJ and HD reconstruction following choledochal cyst excision. We performed retrospective analysis of 54 children who had undergone laparoscopic choledochal cyst excision and biliary-enteric reconstruction between October 2004 and April 2018. Short-term outcomes including operative time, complications such as anastomotic leakage and bleeding, and hospital stays were included. Long-term outcomes including contrast reflux into biliary tree, cholangitis, anastomotic strictures, and need of reoperation were analyzed. Of the 54 patients, 21 of them underwent laparoscopic HD and 33 underwent laparoscopic Roux-en-Y HJ anastomosis reconstruction. There were no significant differences in gestation, gender, age at operation, antenatal diagnosis, and Todani type of choledochal cyst between HD and HJ group. Operative time was significantly shortened in HD group (p = 0.001). Median time to enteral feeding was 3days in both groups. Median intensive care unit (p = 0.001) and hospital stay (p = 0.019) were significantly shorter in HD group. There was no perioperative mortality. There was no significant difference in anastomotic leakage requiring reoperation (p = 0.743). There were no significant differences in long-term outcomes including anastomotic stricture (p = 0.097), cholangitis (p = 0.061), symptoms of recurrent abdominal pain or gastritis (p = 0.071), or need of reoperation (p = 0.326). All patients had normal postoperative serum bilirubin level. Laparoscopic excision of choledochal cyst with HD reconstruction is safe and feasible with better short-term outcomes and comparable long-term outcomes compared to Roux-en-Y HJ reconstruction.

Resection of biliary mucinous cystic neoplasms of the liver: a prospective cohort series of 13 consecutive patients

Biliary mucinous cystic neoplasms (BMCNs) are uncommon neoplastic septated intrahepatic cysts which are often incorrectly diagnosed and have the potential for malignant transformation. To assess the outcome of surgical resection of BMCNs. A prospective liver surgery database was used to identify patients who underwent surgery at Groote Schuur Hospital Complex for BMCN from 1999 to 2015. Demographic variables including age and gender were documented as well as detailed preoperative imaging, location and size, operative treatment, extent of resection, histology, postoperative complications and outcome. Thirteen female patients (median age 45 years) had surgery. Eleven were diagnosed by imaging for symptoms. Two were jaundiced. One cyst was found during an elective cholecystectomy. Five cysts were located centrally in the liver. Before referral three cysts were treated with percutaneous drainage and two were treated with operative deroofing. Six patients had anatomical liver resections and seven patients had non anatomical liver resections of which two needed ablation of residual cyst wall. One patient needed a biliary-enteric reconstruction to treat a fistula. Median operative time was 183 minutes (range: 130-375). No invasive carcinoma was found. There was no operative mortality. One surgical site infection and one intra-abdominal collection were treated. Two patients developed recurrent BMCN after 24 months. BMCNs should be considered in middle aged women who have well encapsulated multilocular liver cysts. Treatment of large central BMCNs adjacent to vascular and biliary structures may require technically complex liver resections and are best managed in a specialised hepato-pancreatico-biliary unit.

Hepatic resection using ultrasonic surgical aspirator

Abstract Background Hepatic resections conducted for malignant tumors can be difficult because of the need to create cancer-free margins. Objectives To examine the outcome of hepatic resections after the introduction of a Cavitron Ultrasonic Surgical Aspirator (CUSA). Methods A retrospective study of patients who underwent hepatic resection by a single surgeon between April 1999 to March 2013. Results We included 101 patients with 104 hepatectomies. Most hepatic parenchymal transections were performed using a CUSA under intermittent hepatic inflow occlusion (Pringle maneuver). Thirty-five patients underwent a right hepatectomy, 11 a left hepatectomy, 6 a right hepatectomy and segment I resection, 6 a right lobectomy, and 46 underwent segmentectomies, wedge resections, or other types of hepatic resections. Biliary-enteric reconstruction with a Roux-en-Y limb of the jejunum to a hepatic duct of the hepatic remnant was performed in 28 patients. Operative time was 90–720 min (median 300 min, mean 327 ± 149 min). Operative blood transfusion was 0–17 units (median 3 units, mean 3.9 ± 3.6 units). Twenty-one hepatectomies were conducted without blood transfusion. Thirty-four postoperative complications occurred in 30 patients with a 9% reoperation rate. Perioperative mortality was 6%. Age, operative time, operative blood transfusion, reoperation, and complications were significantly associated with mortality. Conclusion Careful preoperative diagnosis and evaluation of patients, faultless surgical techniques, and excellent postoperative care are important to avoid potentially serious postoperative complications and mortality. The CUSA is an effective assisting device during hepatic parenchymal transection with a concomitant Pringle maneuver, apparently reducing operative blood loss.

Biliary tract schwannoma:A rare case of obstructive jaundice in a middle aged gentleman.

Schwannomas are derived from Schwann cells, the most common sites being upper extremiteis, trunk, retroperitoneum, head and neck, mediastinum. However they can arise from the gastrointestinal tract too, including the biliary system. We present a case of a 40 year old gentleman, who presented with obstructive jaundice whose computed tomography of the abdomen was suggestive of mass lesion at the porta causing intra hepatic biliary radicle dilatation. And MRCP s/o similar findings with an endosonography s/o hydatid cyst. He underwent local resection with biliary enteric reconstruction and the histopathological examination confirmed a biliary duct schwannoma. On follow at 6 months, the patient is a symptomatic and shows no signs of recurrence. We have also reviewed the literature of biliary tract schwannomas.

Neonatal spontaneous biliary perforation: Case report

Abstract Objective Spontaneous biliary perforation in neonates is rare. The etiology of this pathology is idiopathic and various management strategies ranging from non-operative treatment to complex operations, such as biliary-enteric reconstruction, are performed, with few reported outcomes. Case report A 3-week-old female, born at term, presented fever, abdominal distension, and acholic stool. An ultrasound was performed, which revealed generalized ascites and a poorly-defined collection. An emergency laparotomy confirmed perforation in the distal common bile duct and a biliary-enteric-anastomosis was performed. Discussion Wide drainage has been reported as the best initial management strategy for spontaneous biliary perforation, although it depends on the patient's clinical status and intraoperative findings. Conclusions Spontaneous infantile biliary perforation is rare. Main management is wide drainage with, most perforations being resolved in 2 weeks.

External biliary drainage following major liver resection for perihilar cholangiocarcinoma: impact on development of liver failure and biliary leakage

BackgroundPreoperative biliary drainage is considered essential in perihilar cholangiocarcinoma (PHC) requiring major hepatectomy with biliary-enteric reconstruction. However, evidence for postoperative biliary drainage as to protect the anastomosis is currently lacking. This study investigated the impact of postoperative external biliary drainage on the development of post-hepatectomy biliary leakage and liver failure (PHLF). MethodsAll patients who underwent major liver resection for suspected PHC between 2000 and 2015 were retrospectively analyzed. Biliary leakage and PHLF was defined as grade B or higher according to the International Study Group of Liver Surgery (ISGLS) criteria. ResultsEighty-nine out of 125 (71%) patients had postoperative external biliary drainage. PHLF was more prevalent in the drain group (29% versus 6%; P = 0.004). There was no difference in the incidence of biliary leakage (32% versus 36%). On multivariable analysis, postoperative external biliary drainage was identified as an independent risk factor for PHLF (Odds-ratio 10.3, 95% confidence interval 2.1–50.4; P = 0.004). ConclusionsExternal biliary drainage following major hepatectomy for PHC was associated with an increased incidence of PHLF. It is therefore not recommended to routinely use postoperative external biliary drainage, especially as there is no evidence that this decreases the risk of biliary anastomotic leakage.

Laparoscopic Management of Choledochal Cyst-Technical Modifications and Outcome Analysis.

Choledochal cyst (CDC) is a well described albeit rare clinical entity. Complete cyst excision with biliary-enteric reconstruction is the recommended treatment for Todani type I, II, and IVA cysts to prevent complications. The aim of this study is to evaluate outcomes of laparoscopic CDC excision from a tertiary care center. This is a retrospective analysis of prospectively collected data of 110 patients who underwent laparoscopic cyst excision and biliary-enteric reconstruction for CDC type I and IVA from 1998 to 2013. Out of 110 patients, 55 were children (<16 years) and 55 were adults (>16 years) with mean age 21.19 ± 17.75 years and male:female ratio of 1:2.14. Abdominal pain was the most common presenting symptom (59.09 %). Surprisingly, 32.73 % of adults presented with incidentally detected cyst. Type I cyst was the most common (71.82 %) with mean size of 4.67 ± 1.59 cm. Blood loss (56.0 ± 16.62 vs. 76.55 ± 26.61 ml) and operative time (199.8 ± 44.66 vs. 251.6 ± 54.25 min) were significantly low in pediatric group. Three adults required conversion. Overall complication rate was 10 %. Re-exploration rate was 1.81 % with one patient died post-operatively. Mean hospital stay was significantly low in children (5.9 ± 1.39 vs. 7.0 ± 2.66 days). Median follow-up was 60 months (8-110). Cholangitis developed in six patients with three having anastomotic stricture requiring intervention. Laparoscopic excision of CDC is safe and feasible. Surgery should be performed early as outcomes are better in pediatric age as compared to adults.

Biliary-enteric reconstruction with hepaticoduodenostomy following laparoscopic excision of choledochal cyst is associated with better postoperative outcomes: a single-centre experience.

With the advent of laparoscopic surgery, more choledochal cysts are excised laparoscopically. In this study, we compared the outcomes from laparoscopic hepaticojejunostomy (HJ) and hepaticoduodenostomy (HD) for biliary-enteric reconstruction. A retrospective analysis of patients who had undergone laparoscopic choledochal cyst excision between February 2005 and January 2014 in a tertiary referral centre was performed. Demographics data, operative techniques and surgical outcomes were analysed according to the way of biliary-enteric reconstruction. A total of 31 patients were identified, 20 of whom underwent HJ and 11 underwent HD. There were no significant differences in terms of demographics. Median operative time was significantly shorter in HD group (211.0±96.4 vs. 386.0±90.4min, p=0.001). Although postoperative enteral feeding was initiated later in HD group (5.0±0.8 vs. 4.0±3.6days, p=0.036), postoperative stay in intensive care unit (ICU) (0.7±1.0 vs. 2.4±1.7days, p=0.007) and overall hospital stay (9.1±1.0 vs. 14.4±12.2days, p=0.157) favoured HD group. There was no perioperative mortality. Median follow-up duration was 24.0 (±11.0) months in HD group and 67.5 (±23.7) months in HJ group. One patient in HJ group had postoperative cholangitis related to anastomotic stricture whereas no cholangitis noted in HD group. In total, five patients in HJ group required second operation for complications and residual diseases whereas none in HD group required reoperation. Laparoscopic excision of choledochal cyst with hepaticoduodenostomy reconstruction is safe and feasible with shorter operative time, ICU stay and overall hospital stay. It is not inferior to HJ in terms of short-term postoperative outcomes.

Spontaneous biliary perforation in infancy: Management strategies and outcomes

PurposeInfantile spontaneous biliary perforation is rare with variable management strategies ranging from nonoperative treatment to complex operations such as biliary-enteric reconstruction. Biliary fistula and portal vein thrombosis are known complications, though outcomes are poorly defined. MethodsWe assessed the incidence of spontaneous biliary perforation in infants <1year old using a population database. Next, we describe 4 patients treated at our institution and review all reported cases within the past 25years. ResultsThe incidence of spontaneous biliary perforation is 1.5 in 1,000,000 live births. Over the past 25years, 90 cases were reported, over half of which were initially managed with a surgical drainage procedure. The most common reason for failure of this strategy was CBD obstruction. Our 4 patients were successfully managed without biliary reconstruction despite 2 presenting with CBD obstruction. Reported complications occurred in 22% of patients, most frequently biliary fistula requiring delayed biliary reconstruction. ConclusionsSurgical drainage is an effective method for treatment of infantile spontaneous biliary perforation; however a persistent biliary fistula should prompt evaluation for distal CBD obstruction. Though biliary-enteric anastomosis is the historic procedure of choice for persistent fistula, with improvements in endoscopic and percutaneous treatment, extensive biliary reconstruction may be avoided in the future.

Technical points of total laparoscopic choledochal cyst excision

Background Choledochal cyst excision and biliary enteric reconstruction constitute the best therapy for choledochal cyst. And laparoscopy is currently used to cure this disease now. Methods We retrospectively analyzed the clinical data of 34 cases of total laparoscopic choledochal cyst excision between January 2007 and August 2011. All patients underwent in vitro Roux-en-Y hepatoenterostomy. Results All 34 patients underwent successful total laparoscopic choledochal cyst excision. The operation time was 200-360 minutes. The duration of hospital stay was 3-7 days. Follow-up observations lasted 1-56 months. One patient developed an anastomotic stoma stricture, but no other cases had postoperative complications. No patients died. Conclusion Total laparoscopic choledochal cyst excision is safe and feasible.

Impact of concomitant arterial injury on the outcome of laparoscopic bile duct injury

Background Concomitant injury to the bile duct and hepatic artery is an increasingly recognized complication of laparoscopic cholecystectomy (LC). The impact of a concomitant arterial injury in patients with a bile duct injury (BDI) remains debatable. Early reports described a high incidence of septic complications, difficulty of biliary repair, and increased the risk of recurrent stricture. Data Sources A literature search on the clinical significance and management of a concomitant hepatic artery injury (HAI) to the outcome of biliary-enteric reconstruction following BDI was reviewed. Relevant articles were extracted through MEDLINE, with secondary references obtained from key articles. Conclusions The association between failure of biliary repair and concomitant arterial injuries is not confirmed by the largest studies, which showed no difference in anastomotic stricture rate between patients who had an isolated BDI and those who had a combined HAI and BDI. However, right arterial injury associated with liver necrosis or damage to the right hepatic duct may require right hepatectomy.