Bile Duct Injury Research Articles

Biliary Ablation for Sectoral Duct Injury to Avoid Surgery

AbstractBile duct injury is a common and serious complication of both laparoscopic and open cholecystectomy. The conventional treatment for isolated bile duct injury is hepaticojejunostomy or hepatectomy. We present a case of biliary leak from an isolated right posterior sectoral duct after cholecystectomy treated with percutaneous sclerotherapy using alcohol. Approval and consent waiver were obtained from the Institutional Review Board (IRB 2023-CR-18).

Comparison of the effects of ampulla-guided realignment and conventional gallbladder triangle anatomy in difficult laparoscopic cholecystectomy.

To compare the effects of ampulla-guided realignment and conventional gallbladder triangle anatomy in difficult laparoscopic cholecystectomy (DLC). From June 2021 to August 2022, data from 100 patients undergoing DLC at Nanjing Hospital of Traditional Chinese Medicine were analyzed retrospectively. Patients were divided into two groups: the experimental group (LC with the ampulla-guided realignment) and the control group (conventional LC with triangular gallbladder anatomy), with 50 patients per group. The intraoperative blood loss, operation time, postoperative drainage tube indwelling time, hospitalization time, bile duct injury rate, operation conversion rate, and incidence of postoperative complications were recorded and compared between the two groups. The pain response and daily activities of the patients in the two groups were evaluated 48 h after the operation. The amount of intraoperative blood loss, postoperative drainage tube indwelling time, hospital stay, operation conversion rate, pain degree at 24 and 48 h after operation, bile duct injury incidence, and total postoperative complication rate were shorter or lower in the experimental group than those in the control group (p < 0.05). The Barthel index scores of both groups were higher 48 h after the operation than before the operation, and the experimental group was higher than the control group (p < 0.05). The ampulla-guided alignment in DLC surgery was more beneficial in promoting postoperative recovery, reducing postoperative pain response, reducing the incidence of postoperative complications, and reducing bile duct injury.

OBSTRUCTIVE JAUNDICE: ETIOLOGY AND PATTERN OF PRESENTATION

Surgical jaundice mainly occurs due to obstruction in any duct from the liver to the gall bladder and then the small intestine. It can be divided into intra-hepatic or extra-hepatic causes. Biliary stones, iatrogenic or ischemic biliary stricture, pseudo-pancreatic cysts, carcinoma of the head of the pancreas, and periampullary carcinomas are common pathologies of obstructive jaundice. Common bile duct stones account for 10-15% of biliary stone disease and are the most common cause of obstructive jaundice. Obstructive jaundice presents with a wide range of associated features. Ultrasonography, MRCP, and ERCP are the primary diagnostic tools for diagnosing and managing obstructive jaundice, in addition to blood tests. This study aims to determine the pattern of presentation and causes of obstructive jaundice. This observational, retrospective study was conducted in general surgery and surgical oncology unit 2 of Sheikh Zayed Hospital, Lahore. The study lasted from January 2022 to April 2023. A non-probability convenience sampling technique was used. A total of 55 patients with obstructive jaundice were presented in the study area in a defined period, which included 17 (30.90%) males and 38 (69.09%) females. The mean age was 49 years, with age ranges from 28 years to 80 years. 13 (23.66%) patients were found to have malignant disease, whereas 42 (76.33%) patients presented with benign disease. The most common malignant cause of obstructive jaundice was carcinoma head of the pancreas (10.90%), whereas the least common causes were cholangiocarcinoma (1.82%), carcinoma gall bladder (1.82%) and malignant biliary stricture (1.82%). The most common benign cause and overall most common cause of obstructive jaundice was choledocholithiasis (32.73%), followed by referred biliary injuries (18.18%). The most common clinical feature presented in benign causes of obstructive jaundice was jaundice (100%), followed by itching (71.4%) and abdominal pain (64.28%). The most common clinical feature in malignant causes of obstructive jaundice was jaundice (100%), followed by loss of appetite (84.61%) and weight loss (84.61%). Female was the most common gender presented with obstructive jaundice. The most common benign cause of obstructive jaundice was Choledocholithiasis, while the most malignant cause was carcinoma head of the pancreas.

Clinical and Pathological Features of Immune Checkpoint Inhibitor-induced Liver Injury in Comparison with Drug-induced Liver Injury and Autoimmune Hepatitis.

Immune checkpoint inhibitors may cause various types of organ damage as immune-related adverse events, of which, liver damage is the most common. Herein, we evaluated the clinicopathological features of immune checkpoint inhibitor-related liver injury and investigated the differences between immune checkpoint inhibitor-related liver injury and drug-induced liver injury or autoimmune hepatitis. We selected patients with ≥ grade 3 liver injury who were diagnosed with immune checkpoint inhibitor-related liver injury (n=15). Liver biopsies were performed in 10 of the 15 cases. We also selected cases in which a liver biopsy was performed and drug-induced liver injury (n=7) or autoimmune hepatitis [n=21: acute exacerbation (n=13) was diagnosed and cases of acute onset (n=8), in which liver function test results corresponded to ≥ grade 3]. Portal fibrosis and periportal activity scores were significantly higher in the acute exacerbation autoimmune hepatitis group than in the other groups. Portal and lobular activity were not different between the groups. Plasma cell infiltration showed a higher trend in the autoimmune hepatitis group than in the other groups. Granuloma formations were seen in 90% of immune checkpoint inhibitor-related liver injury cases. The CD4/8 ratio was significantly lower in the immune checkpoint inhibitor-related liver injury group than in the other groups. Patients with bile duct injury had poorer response to corticosteroid therapy than those without. There are some obvious differences among immune checkpoint inhibitor-related liver injury, drug-induced liver injury, and autoimmune hepatitis in liver histology. Liver biopsy is helpful for the diagnosis and severity evaluation of liver injury.

Laparoscopic repair of bile duct injuries: Feasibility and outcomes

IntroductionBile duct injuries (BDI) following laparoscopic cholecystectomy occurs in approximately 0.6% of the cases, often being more severe and complex. Roux-en-Y hepaticojejunostomy (RYHJ) is considered the optimal therapeutic option, with success rates ranging from 75% to 98%. Several series have demonstrated the advancements of the laparoscopic approach for resolving this condition. The objective of this study is to describe our experience in the laparoscopic repair of BDI. MethodsA retrospective, descriptive study was conducted, including patients who underwent laparoscopic repair after BDI. Demographic, clinical, surgical, and postoperative variables were analysed using descriptive statistical analyses. ResultsEight patients with BDI underwent laparoscopic repair (out of 81 surgically repaired patients). Women comprised 75% of the sample. A complete laparoscopic repair was achieved in 75% (6) of cases. The mean age was 40.8 ± 16.61 years (range 19−65). Injuries at or above the confluence (Strasberg-Bismuth ≥ E3) occurred in 25% of cases (2). Primary repair was performed in two cases. Half of the cases underwent a Hepp-Couinaud laterolateral RYHJ, while three patients received a terminolateral RYHJ, and one underwent a bi-terminolateral RYH. The mean operative time was 260 min (range 120−360). Overall morbidity was 37.5% (3 cases): two minor complications (bile leak grade A and drainage-related bleeding) and one major complication (bile leak grade C). No mortality was recorded. The maximum follow-up period reached 26 months (range 6–26). ConclusionsOur study demonstrates the feasibility of laparoscopic RYHJ in a selected group of patients, offering the benefits of a minimally invasive approach.

Mirizzi Syndrome-The Past, Present, and Future.

Mirizzi syndrome is a complication of gallstone disease caused by an impacted gallstone in the infundibulum of the gallbladder or within the cystic duct, causing chronic inflammation and extrinsic compression of the common hepatic duct or common bile duct. Eventually, mucosal ulceration occurs and progresses to cholecystobiliary fistulation. Numerous systems exist to classify Mirizzi syndrome, with the Csendes classification widely adopted. It describes five types of Mirizzi syndrome according to the presence of a cholecystobiliary fistula and its corresponding severity, and whether a cholecystoenteric fistula is present. The clinical presentation of Mirizzi syndrome is non-specific, and patients typically have a longstanding history of gallstones. It commonly presents with obstructive jaundice, and can mimic gallbladder, biliary, or pancreatic malignancy. Achieving a preoperative diagnosis guides surgical planning and improves treatment outcomes. However, a significant proportion of cases of Mirizzi syndrome are diagnosed intraoperatively, and the presence of dense adhesions and distorted anatomy at Calot's triangle increases the risk of bile duct injury. Cholecystectomy remains the mainstay of treatment for Mirizzi syndrome, and laparoscopic cholecystectomy is increasingly becoming a viable option, especially for less severe stages of cholecystobiliary fistula. Subtotal cholecystectomy is feasible if total cholecystectomy cannot be performed safely. Additional procedures may be required, such as common bile duct exploration, choledochoplasty, and bilioenteric anastomosis. Conclusions: There is currently no consensus for the management of Mirizzi syndrome, as the management options depend on the extent of surgical pathology and availability of surgical expertise. Multidisciplinary collaboration is important to achieve diagnostic accuracy and guide treatment planning to ensure good clinical outcomes.

Parenchyma Sparing Anatomic Liver Resections (Bi- and Uni-Segmentectomies) for Liver Tumours in Children-A Single-Centre Experience.

This study included 23 patients that underwent (bi)segmentectomy. There were 15 malignant tumours (hepatoblastoma-13 patients), 7 benign tumours, and 1 calcifying nested stromal epithelial tumour. The median tumour diameter was 52 mm (range 15-170 mm). Bisegmentectomy 2-3 was most frequently performed (seven patients), followed by bisegmentectomy 5-6 (four patients). The median operative time was 225 min (range 95-643 min). Intraoperative complications occurred in two patients-small bowel perforation in one and an injury of the small peripheral bile duct resulting in biloma in the other. The median resection margin in patients with hepatoblastoma was 3 mm (range 1-15 mm). Microscopically negative margin status was achieved in 12 out of 13 patients. There were two recurrences. After a median follow-up time of 38 months (range 12-144 months), all 13 patients with HB were alive with no evidence of disease. Two relapsed patients were alive with no evidence of disease. From the available literature and data presented here, we propose that (bi)segmentectomy can become a viable surgical option in carefully selected paediatric patients and is sufficient to achieve a cure. Further studies evaluating the impact of parenchymal preservation surgery on surgical and oncological outcome should be conducted with a larger dataset.

Elevated serum IL-34 is correlated with disease severity in patients with biliary atresia following Kasai portoenterostomy

BackgroundBiliary atresia (BA) is a severe congenital disorder with progressive obstructive cholangiopathy in young children. The inflammatory process has been recognized as one of the pathological mechanisms driving bile duct injury. Since interleukin-34 (IL-34) has been reportedly linked to several pathological liver disorders, including inflammation, the current study aimed to analyze circulating IL-34 and the association of circulating IL-34 with hepatic deterioration and clinical outcomes in post-Kasai BA children. MethodsCirculating IL-34 levels were analyzed in 89 post-Kasai BA subjects and 45 healthy individuals using an ELISA. Liver stiffness (hardness) was measured by ultrasound elastography. ResultsCirculating IL-34 was substantially higher in BA children than in control individuals, particularly those with unfavorable outcomes including hepatic dysfunction, jaundice, and portal hypertension. In BA group, circulating IL-34 was positively correlated with liver stiffness (r = 0.515, p < 0.001), AST (r = 0.403, p < 0.001), ALT (r = 0.279, p = 0.008), total bilirubin (r = 0.224, p = 0.03), ALP (r = 0.255, p = 0.016), and serum IL-6 (r = 0.590, p < 0.001) but inversely correlated with albumin (r = -0.417, p < 0.001). Kaplan-Meier survival analysis showed that higher circulating IL-34 levels were significantly associated with reduced survival rates in BA subjects (p = 0.002). ConclusionHigher circulating IL-34 values were directly associated with hepatic impairment and the BA severity, implicating thatserum IL-34 could be applied as a noninvasive marker for the monitoring of the severity in BA subjects following Kasai portoenterostomy and therapeutic efficacy.

Laparoscopic Cholecystectomy in Jos: Prospects and Perspectives.

Laparoscopic cholecystectomy is now done in a lot more private and public hospital settings presently in low-income countries, particularly sub-Saharan Africa. Though it is not routinely done in these centres, the percentage of cholecystectomies done laparoscopically has increased over the years. Laparoscopic surgery services were introduced at our hospital in 2011 and this retrospective study reviews our outcomes with the procedure over a 6-year period. A total of 87 cholecystectomies were done in the period under review. Forty-eight (55.2%) were laparoscopic cholecystectomies, 30 (44.8%) were open cholecystectomies, and 9 (10.3%) were mini-laparotomy cholecystectomies. There were 32 (66.7%) women and 16 (33.3%) men who had laparoscopic cholecystectomy giving a male-to-female ratio of 1:2. The mean age of the patients was 41.0 years (SD = 14.3 years). The most common indication for laparoscopic cholecystectomy was calculous cholecystitis. The most common co-morbidity was hypertension in 23 (47.9%) patients, followed by sickle cell anaemia in 10 (20.8%) patients. The operating time ranged from 70 min to 120 min with a mean of 86.6 (SD = 14.5). There were three conversions and two intra-operative complications. Twenty-five patients (52.1%) were discharged within 24 h, 16 (33.3%) within 48 h and the rest (14.6%) were discharged later. The duration of surgery had a significant association with duration of hospital stay. There was 1 mortality in our study. Laparoscopic cholecystectomy offers unique advantages over open such as decreased length of hospital stay and reduced wound complications. Most of the cholecystectomies in our setting are now performed laparoscopically with a low conversion rate and low incidence of bile duct injuries. Patients with sickle cell disease constitute a significant percentage of patients requiring this procedure.

The robotic-assisted laparoscopic approach to biliary tract resection and reconstruction for benign indications: A single-center experience.

Benign biliary disease (BBD) is a prevalent condition involving patients who require extrahepatic bile duct resections and reconstructions due to nonmalignant causes. This study followed all patients who underwent biliary resections for BBD between 2015 and 2023. We excluded those with malignant conditions and patients who had an 'open' operation. Based on the patient's anatomy, the procedures employed were either robotic Roux-en-Y hepaticojejunostomy (RYHJ) or robotic choledochoduodenostomy (CDD). From the 33 patients studied, 23 were female, and 10 were male. Anesthesiology (ASA) class was 3±0.5; the MELD score was 9±4.1; the Child-Pugh score was 6±1.7. The primary indications for undergoing the operation included iatrogenic bile duct injuries, biliary strictures, and type 1 choledochal cysts. The average surgical duration was about 272min, and the average blood loss amounted to 79mL. Postoperatively, three patients experienced major complications, all attributed to anastomotic leaks. The average hospital stay was 4days, with a readmission rate of 15% within 30days. During an average follow-up period of 33months, one patient had to undergo a revision at 18months due to stricture. This necessitated further duct resection and reanastomosis. Notably, there were no reported hepatectomies, no conversion to the 'open' method, no intraoperative complications, and no mortalities. Robotic extrahepatic bile duct resection and reconstruction with Roux-en-Y hepaticojejunostomy or choledochoduodenostomy is safe with an acceptable postoperative morbidity, short hospital length of stay, and low postoperative stricture rate at intermediate duration follow-up.

Differentiated approach in providing care to patients with fresh bile duct injuries

Aim. To demonstrate the efficacy of minimally invasive surgery for bile duct injuries.Materials and methods. The results of combined minimally invasive treatment of 52 patients with fresh bile duct injuries from 2006 to 2023 were analyzed. Bile duct injuries diagnosed within 1–10 days after the operation were referred to as “fresh”. Intraoperative detection of bile duct injury was the criterion of exclusion from the analysis. In 80.8% of observations, combined minimally invasive interventions were performed in the form of percutaneous operations under ultrasound and radiography control. In 19.2% of observations, antegrade percutaneous and retrograde endoscopic access was used.Results. The algorithm for conducting minimally invasive procedures for bile duct injuries and strictures should be selected depending on the terms of injury and the character of injury and complications. In the majority of fresh bile duct injuries, a two-stage algorithm of duct patency restoration was applied. This prevented additional complications and allowed the patient to be prepared for stent biliary drainage after analyzing the primary data of fistula cholangiography. In all observations, minimally invasive procedures of bile duct patency restoration were completed with stent biliary drainage. Complications were noted in eight patients (15.4%).Conclusion. In fresh bile duct injuries, combined minimally invasive methods are an effective alternative to conventional reconstructive surgeries.

Audit of Emergency Laparoscopic Cholecystectomy in a District General Hospital.

Introduction Acute gallstone diseases are common surgical emergencies, accounting for approximately one-third of emergency surgical admissions. Laparoscopic cholecystectomy is thestandard choice of treatment for gallstone diseases and is currently one of the most commonly performed surgical procedures in the United Kingdom.Majority of these procedures are carried out as elective cases. National Institute of Clinical Excellence (NICE) guidelines and other upper gastrointestinal surgery specialty bodies encourage early emergency surgery inacute symptomatic gallstone disease. Weassessed emergency laparoscopic cholecystectomiesperformed at Birmingham Heartlands Hospital, United Kingdom andcompared the practice against NICE and British Benign Upper Gastrointestinal Surgery Society (BBUGSS) recommendations. Methods This is a snapshot retrospective audit, assessing emergency laparoscopic cholecystectomy practice over a nine-month periodfrom November 2022 to July 2023.Variables assessed were demographics, duration of symptoms prior to surgery, imaging modality, indications, C-reactive protein (CRP) levels, operative difficulty, intraoperative and postoperative complications, length of hospital stay and readmission rates. These variables were compared against both NICE and BBUGSS standards.We aimed to establish baseline data to encourage emergency laparoscopic cholecystectomies in our hospital and reduce repeated hospital visits for patients with acute gallbladder disease. Results Forty-eight patients had emergency laparoscopic cholecystectomy in the period reviewed, mean age was 44.3 years and females accounted for approximately 71% (n=34) of the group. 66.7% (n=32) of patients had their surgery within seven days of diagnosiswith acute gallstone disease; 50% (n=24)of patients had no adverse intraoperative event.No patient had biliary tract injury despite a high number of difficult cases. Overall there was no correlation between duration before surgery and intraoperative difficulty or readmission rates.

Laparoscopic Cholecystectomy in Pregnancy: A Seven-Year Retrospective Study From an Australian Tertiary Center.

Background Cholecystectomy is the second most common non-obstetric indication for surgery during pregnancy; however, there is little recent literature specifically exploring perioperative care approaches, and a paucity of Australian data exists. This study investigates the incidence of laparoscopic cholecystectomy (LC) during pregnancy, peri-operative management, and post-operative outcomes in a single Australian tertiary center. Methods A retrospective analysis of LCs performed on pregnant patients between the ages of 16 and 50 years at a tertiary hospital between 2016 and 2023 was completed. Results Twenty-three patients underwent LC. The median gestational age was 17+4weeks (4+3-30+6). Cases were performed in all three trimesters, with the majority in the second trimester (n=12, 52.2%). Surgery indications were recurrent biliary colic (n=11, 47.8%), acute cholecystitis (n=8, 34.8%), and gallstone pancreatitis (n=4, 17.4%). Obstetrics and Gynecology (O&G) consultations occurred in 56.5% (n=13) of cases. Fetal heart rate (FHR) was recorded perioperatively in 82.6% (n=19) of cases. Preoperative steroids were given to 40% of eligible patients. An intraoperative cholangiogram was performed in 12 (52.2%) cases, of which eight (66.7%) utilized abdominal shielding. There was no perioperative maternal mortality nor fetal loss. Surgical morbidities were pancreatitis (n=1), bile leak (n=1), and intraoperatively recognized bile duct injury (n=1). Two threatened preterm labors and five (26.3%) preterm deliveries occurred. Conclusion Performing LC in pregnancy does carry a risk of major morbidity; however, there was no mortality or fetal loss across all trimesters. The decision to perform abdominal shielding during an intraoperative cholangiogram should be approached sensitively in a case-by-case manner, given recent paradigm shifts in radiology. A multidisciplinary approach with standardized local perioperative care policies regarding procedures such as O&G consultation, perioperative steroid use, and FHR monitoring is strongly recommended.

Regulation of CD47 expression on CD14+ monocytes by interferon-α in PBC patients.

Primary biliary cholangitis (PBC) is a chronic intrahepatic cholestatic autoimmune liver disease characterized by inflammatory injury of small and medium-sized bile ducts in the liver. The pathogenesis of PBC has yet to be entirely understood. CD47/signal-regulatory protein alpha (SIRPα) is closely related to developing autoimmune diseases by promoting inflammatory response. However, the effect of CD47/SIRPα on inflammatory response in PBC patients is still unclear. We investigated the expression of CD47/SIRPα and the effect of inflammatory cytokines on the CD47 expression, analyzed potential autoantibodies against CD47 and the effect of anti-CD47 antibody on the inflammatory response in PBC, provided laboratory basis for the study of the pathogenesis and targets for non-invasive diagnosis and treatment on PBC. The expression levels of CD47 and SIRPα on peripheral blood mononuclear cells (PBMC) were measured in 14 patients with PBC (the PBC group) and 13 healthy subjects (the Control group) by flow cytometry (FCM). The PBMC derived from healthy subjects were stimulated with healthy subjects' serum, PBC patients' serum, IFN-α or TNF-α, and the CD47 expression level on CD14+ monocytes was detected by FCM. The level of serum anti-CD47 antibody or IFN-α in PBC patients and healthy subjects was analyzed by ELISA. FCM was used to examine the TNF-α expression level in CD14+ monocytes of healthy subjects stimulated with isotype control antibody, anti-CD47 antibody, LPS or LPS combined with CD47 antibody. The CD47 expression level on the CD14+ monocytes in PBC patients was statistically higher than that in the Control group (P<0.01). Compared with the Control group (PBMC+healthy serum), the CD47 expression on CD14+ monocyte stimulated with the PBC patients' serum (PBMC+PBC patients' serum) was increased (P<0.001); the CD47 expression on CD14+ monocyte stimulated with IFN-α (PBMC + IFN-α) increased gradually with the increased concentration of IFN-α (P<0.05). However, there was no similar trend on CD14+ monocyte stimulated with the TNF-α (PBMC+TNF-α) (P>0.05). The levels of serum anti-CD47 antibody and IFN-α in the PBC patients were higher than those in healthy subjects (P<0.05). The TNF-α expression level in CD14+ monocyte stimulated with the LPS (PBMC+LPS) or anti-CD47 antibody+LPS group (PBMC+LPS+anti-CD47 antibody) was significantly increased than that in the Control group (PBMC+isotype control antibody) (P<0.01 and P<0.001, respectively). The TNF-α expression level in CD14+ monocyte stimulated with the anti-CD47 antibody + LPS was higher than that with the LPS (P< 0.05). The CD47 may be related to the pathogenesis of PBC by inflammatory response. The CD47/SIRPα signal were imbalanced in PBC patients. The presence of serum anti-CD47 antibodies in PBC patients provides a laboratory basis for clinical diagnosis and treatment.

Desarrollo de una Unidad de Cirugía Hepatobiliar Compleja y Trasplante Hepático en un hospital público: a una década de su formación

Background: Centralizing hepatobiliary disease in specialized centers can reduce morbidity and mortality rates and improve long-term outcomes. Objective: The aim of the present study was to describe the clinical and pathological features and surgical outcomes of a series of patients operated on in the Hepatobiliary Surgery and Liver Transplantation Unit of Hospital El Cruce during its first 10 years, as well as the scientific and educational activity of its members. Material and methods: We conducted a descriptive and retrospective study. The information was retrieved from a prospective database. The procedures were classified according to their complexity. An analysis was conducted on liver transplantations (LTs), liver resections and complex biliary procedures, performed from 2013 to 2022. Results: Of 1449 surgical procedures, 832 were high-complexity interventions (58%). A total of 452 LTs were performed, 14 (3%) were combined liver and kidney transplantations; overall transplant survival was 83%, 77% and 75% at 1, 3 and 5 years, respectively. Primary graft dysfunction was observed in 5 cases (1.1%). There were 254 liver resections; 58 cases (23%) were related to benign liver diseases, 155 (61%) to malignancies, and 41 (16%) were associated with living donor transplants. Overall morbidity was 27% and in-hospital mortality was 2%. A total of 106 bilio-digestive bypass procedures were carried out, 53 in patients with bile duct injury. Thirty-day morbidity was 42%, and most cases were minor complications (28%). Other procedures included 17 cephalic pancreaticoduodenectomies and 3 splenectomies and distal pancreatectomies. We have published numerous papers, delivered presentations and courses, and implemented a fellowship program in the specialty since 2015. Conclusion: Centralizing hepatobiliary diseases at a high-complexity center led to comparable outcomes with those reported in international series.

Resección hepática como tratamiento de lesión de vía biliar compleja

Bile duct injury represents a serious health problem, with its incidence doubling since the advent of laparoscopic cholecystectomy. In cases of complex lesions affecting the hepatic confluence, association with vascular injuries, hepatic atrophy, cholangitis or failed repair, treatment is often challenging. We report the case of a female patient with a complex bile duct injury due to vascular involvement of the right hepatic pedicle who developed right liver atrophy. In the presence of septic complications, hepatectomy was necessary, along with a definitive repair of the biliary tract, resulting in positive outcomes.

Beta Thalassemia Presenting with Neonatal Cholestasis and Extensive Hemosiderosis: A Case Report

Neonatal cholestasis is caused by various forms of liver injury and has a complex etiological background. Among these, cases of severe cholestasis due to primary hemolytic disease are rare. Herein, we report a case in which thalassemia-induced severe hemolysis caused bile duct injury by hemosiderosis, with cholestasis occurring shortly after birth and lasting for &gt;4 months. In addition, complete recovery of liver pathology was observed both biochemically and histologically. Hence, clinicians should consider hemolytic disease as a rare cause of neonatal cholestasis in the differential diagnosis of neonates as well as the advisability of conservative treatment based on case progression.

A retrospective study of laparoscopic, robotic-assisted, and open emergent/urgent cholecystectomy based on the PINC AI Healthcare Database 2017–2020

BackgroundRobotic-assisted cholecystectomy (RAC) is becoming increasingly common, but the outcomes of emergent/urgent robotic-assisted cholecystectomies compared to emergent laparoscopic (LC) and open cholecystectomies (OC) remain understudied.MethodsThe PINC AI Healthcare Database was queried to identify adults who underwent emergent or urgent (Em-Ur) cholecystectomy between January 1, 2017, and December 31, 2020. Immediate postoperative and 30-day outcomes were identified including intraoperative complications, transfusion, conversion, postoperative complication, and hospital length of stay. Propensity score matching was done to compare outcomes between Em-Ur robotic-assisted, laparoscopic, and open cholecystectomies Subgroup analyses were performed comparing RAC done with and without fluorescent imaging as well as comparing RAC and LC performed for patients with class 3 obesity (BMI ≥ 40 kg/m2).ResultsRAC Em-Ur cholecystectomies are being performed with increasing frequency and is the most utilized modality for patients with class 3 obesity. There was no difference in intraoperative complications (0.3%), bile duct injury (0.2%), or postoperative outcomes between RAC and LC. LC had significantly shorter operating room times (96 min (75,128)) compared to RAC (120 min (90,150)). There was a significant lower rate of conversion to open in RAC (1.9%) relative to LC (3.2%) in both the overall population and the class 3 obesity sub-analysis (RAC-2.6% vs. LC-4.4%). There was no difference in outcomes in robotic-assisted cholecystectomies done with and without fluorescent imaging.ConclusionsA comparison of propensity score-matched cohorts of emergent/urgent robotic-assisted and laparoscopic cholecystectomy indicates that robotic-assisted cholecystectomy is a safe alternative to laparoscopic cholecystectomy, and that both have superior outcomes to open cholecystectomies.

Selpercatinib-induced hepatotoxicity: A rare case report

Abstract Introduction/Objective Selpercatinib (Retevmo) is a highly selective rearranged during transfection (RET) kinase inhibitor indicated for treatment of solid tumors with RET gene mutation or fusion, such as medullary thyroid carcinoma or non-small cell lung carcinoma. Among selpercatinib’s side effects, severe hepatotoxicity was only seen in 3% of the patients. Here we report a case of selpercatinib-induced hepatotoxicity, which has not been well characterized before. Methods/Case Report The patient was a 56-year-old female who had medullary thyroid carcinoma with RET M918T mutation (pT3aN1b) status post total thyroidectomy. Recurrence occurred and selpercatinib treatment was initiated. Then the patient complained of mouth sores, tongue sensitivity, and lower extremity cramping. The dosage was reduced to half. The magnetic resonance imaging on day 67 of selpercatinib treatment showed heterogeneous enhancement in the right hepatic lobe, compatible with parenchymal liver disease/hepatitis, trace perihepatic ascites, and mild splenomegaly. On day 71, liver function abnormalities were detected (ALK 315 IU/L, ALT 745 IU/L, AST 899 IU/L, total bilirubin 7.7 mg/dL). Workups including autoimmune hepatitis serology, viral hepatitis, or other infections were all negative. She had no history of other drug use. On day 72, a liver biopsy was performed that demonstrated mild to moderate portal lymphocyte-predominant mixed inflammation with interface activity. The lobules showed marked inflammation with hepatocyte disorganization, acidophil bodies, hepatocyte dropout, and rare lipogranulomas. Bile duct injury and patchy canalicular cholestasis were also noted. Trichrome stain showed focal bridging fibrosis. Overall, the histologic findings were acute and chronic hepatitis pattern injury, favor selpercatinib-induced hepatotoxicity. Selpercatinib was discontinued. All liver enzymes gradually returned to normal levels on day 169. Results (if a Case Study enter NA) NA Conclusion Our study suggests that screening patients for abnormal liver function tests prior to and monitoring periodically during selpercatinib treatment is necessary. Based on the severity of hepatotoxicity, withholding, reducing the dose, or permanently discontinuing selpercatinib is recommended.

An interesting case report of delayed presentation of post-cholecystectomy benign biliary stricture

Background The most common cause of benign biliary stricture is bile duct injury after cholecystectomy. Benign biliary strictures are associated with a broad spectrum of signs and symptoms, ranging from subclinical disease with mild elevation of liver enzymes to complete obstruction with jaundice, pruritis, and cholangitis ultimately leading to biliary cirrhosis. The average duration for stricture development after cholecystectomy is around 7 months. This is a case report of a benign biliary stricture presenting 14 years after laparoscopic conversion to open cholecystectomy without the development of recurrent cholangitis and secondary biliary cirrhosis.