Biliary Reconstruction Research Articles

Application of DynaCT biliary soft tissue reconstruction technology in diagnosis and treatment of hepatolithiasis.

Hepatobiliary stone disease involves an intrahepatic bile duct stone that occurs above the confluence of the right and left hepatic ducts. One-step percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) using the percutaneous transhepatic one-step biliary fistulation (PTOBF) technique enables the clearing of intrahepatic stones and the resolution of strictures. However, hepatolithiasis with associated strictures still has high residual and recurrence rates after one-step PTCSL. DynaCT can achieve synchronized acquisition with a flat-panel detector during C-arm rotation. The technical approach and application value of DynaCT biliary soft tissue reconstruction technology for the diagnosis and treatment of hepatolithiasis with bile duct stenosis were evaluated in this study. To explore the value of DynaCT biliary soft tissue reconstruction technology for the diagnosis and treatment of hepatolithiasis with bile duct stenosis, and to assess the feasibility and effectiveness of the PTOBF technique guided by DynaCT biliary soft tissue reconstruction technology. The clinical data of 140 patients with complex biliary stenosis disease combined with bile duct stenosis who received PTOBF and were admitted to the First Affiliated Hospital of Guangzhou Medical University from January 2020 to December 2024 were collected. The patients were divided into two groups: DynaCT-PTOBF group (70 patients) and conventional PTOBF group (70 patients). These groups were compared in terms of the preoperative bile duct stenosis, location of the liver segment where the stone was located, intraoperative operative time, immediate stone retrieval rate, successful stenosis dilatation rate, postoperative complication rate, postoperative reoperation rate, stone recurrence rate, and stenosis recurrence rate. DynaCT biliary soft tissue reconstruction technology was successfully performed in 70 patients. The DynaCT-PTOBF group had a higher detection rate of target bile ducts where bile duct stones and biliary strictures were located than the PTOBF group. Compared with the PTOBF group, the DynaCT-PTOBF group was characterized by a significantly greater immediate stone removal rate (68.6% vs 50.0%, P = 0.025), greater immediate stenosis dilatation success rate (72.9% vs 55.7%, P = 0.034), greater final stenosis release rate (91.4% vs 75.7%, P = 0.012), shorter duration of intraoperative hemorrhage (3.14 ± 2.00 vs 26.5 ± 52.1, P = 0.039), and lower incidence of distant cholangitis (2.9% vs 11.4%, P = 0.49). There were no significant differences between the two groups in terms of the final stone removal rate, reoperation rate, or long-term complication incidence rate. DynaCT biliary soft tissue reconstruction technology guiding the PTOBF technique in patients with hepatolithiasis with bile duct stenosis is feasible and accurate. It may be beneficial for optimizing the preoperative evaluation of the PTOBF technique.

Point-of-care ultrasound in the diagnosis of hepatic gas gangrene.

Hepatic gas gangrene (HGG) is a rare but life-threatening condition typically caused by anaerobic bacteria such as Clostridium perfringens, though Gram-negative bacteria like Escherichia coli and Klebsiella species have also been implicated. Traditionally diagnosed via computed tomography (CT), point-of-care ultrasound (POCUS) has emerged as a valuable tool in critical care settings for its non-invasive, bedside utility. We report the case of a 51-year-old female with choledochal syndrome secondary to cholangiocarcinoma who developed HGG following left extended hepatectomy and biliary reconstruction. POCUS revealed free subhepatic fluid, hypoechogenicity in the right hepatic lobe, and comet-tail artifacts suggestive of intrahepatic gas, leading to prompt surgical intervention. Despite maximal supportive measures, the patient succumbed to refractory shock. This case underscores the utility of POCUS in the rapid diagnosis and management of HGG, offering a non-invasive alternative to traditional imaging, and highlights its potential as a primary diagnostic tool for HGG in critically ill patients.

Multimorbidity in liver surgery

Multimorbidity is characterized by the presence of at least 3 chronic diseases with aprevalence of more than 50% of patients over 60years old. The Charlson comorbidity index (CCI) enables adescription of the severity of the multimorbidity and also provides acorrelation with the postoperative outcome after liver resection. According to this, multimorbid patients are at increased risk of morbidity and mortality after liver resection, mostly due to postoperative liver failure. In particular, open major liver resection with biliary reconstruction and primary liver tumors linked to metabolic associated fatty liver disease (MAFLD) pose an increased risk for multimorbid patients. In contrast, minimally invasive resection leads to aclear reduction in postoperative morbidity and mortality. Preconditioning of the liver and the implementation of perioperative strategies according to the enhanced recovery after surgery (ERAS) concept can also lead to an improvement of the postoperative outcome.

DynaCT biliary reconstruction via a 3D C-arm cholangiography system: clinical application in hepatolithiasis.

Dyna computed tomography (DynaCT) is an innovative clinical imaging tool used to obtain three-dimensional (3D) images of biliary structures via the Artis Zee DSA system (SIEMENS Company, Germany). DynaCT is a type of 3D cone beam computed tomography (CBCT) reconstruction produced from a two-dimensional (2D) cholangiography system by rotating the C-arm without moving the patient. The aim of this study was to evaluate the technical approach and application value of DynaCT to diagnosis hepatolithiasis and biliary stenosis. This was a retrospective single-centre series of 37 hepatolithiasis patients with tubes receiving one-step percutaneous transhepatic cholangioscopic lithotripsy (one-step PTCSL) between October 2021 and October 2022: twenty-one patients were guided by CT (CT group) and sixteen by DynaCT biliary reconstruction (DynaCT group). We compared DynaCT biliary reconstruction technology with computed tomography (CT) in the application of bile ducts. DynaCT biliary reconstruction was successfully performed in 37 patients. Biliary stenosis, including anatomy, morphology, and size, was visualized via DynaCT. Compared with the CT group, the DynaCT group was characterized by significantly more target biliary branches with stones (92 vs. 48, P < 0.05), a higher percentage of secondary stenosis (75.76% vs. 24.24%, p < 0.05), a greater percentage of biliary infection (37.5% vs. 9.5%, P = 0.041), a shorter overall stone clearance time (26.38 ± 13.49 vs. 52.67 ± 30.10, P = 0.001), and a lower rate of reoperation for residual stones (25.00% vs. 66.67%, P = 0.012). DynaCT had a lower contrast agent (25.61 ± 5.13 vs. 42.69 ± 11.15, p < 0.05). However, DynaCT increased radiation exposure (38.12 ± 10.59 vs. 25.79 ± 4.76, p < 0.05). There were no significant differences between the two groups regarding the clearance ratio of the calculus or several postoperative complications. DynaCT for biliary reconstruction has the potential to be a powerful evaluation tool for one-step PTCSL surgery and could lead to new possibilities for hepatobiliary surgery. DynaCT was used for the first time in patients with hepatolithiasis and biliary stenosis. Compared with CT, DynaCT for biliary reconstruction results in higher-quality 3D biliary, blood vessel and liver images. On the basis of the DynaCT biliary model, one-step PTCSL has the potential to improve the stone clearance ratio and shorten the stone clearance time and reoperation ratio.

Matching the opposites: liver transplantation from a situs viscerum inversus totalis donor.

Situs viscerum inversus totalis (SIT) is a rare congenital anomaly. Deceased donors with this condition are often declined because of the technical issues in both the organ's procurement and its transplant. Only eight cases of deceased donor organs with SITwere reported to be used for liver transplantation (LT). We herein present a case of LT using a graft from an SIT donor: a modified retroversus piggyback technique was used. A 15year-old female was referred to our institution as a potential donor. An SIT condition was discovered during standard donor evaluation together with the presence of a complex triple arterial pedicle. Procurement operative time was 125min, from skin incision to cross-clamp. Liver extraction occurred 32min after cold flush. The recipient was a 56year-old male affected by recurrent hepatocellular carcinoma (HCC) on hepatitis C related liver cirrhosis. Position and orientation trials of the graft were made and it was decided to implant it with the retroversus technique. Direct duct-to-duct biliary reconstruction was achieved. The postoperative course was uneventful. To our knowledge, this is the first implant with retroversus technique combined to direct biliary reconstruction and the first repetition of that technique. Cases like this highlight how technical complexity can be overcome leading to successful management of difficult scenarios in a safe manner.

Evolution from laparoscopic to robotic radical resection for gallbladder cancer: a propensity score-matched comparative study.

The use of robotic or laparoscopic surgery for gallbladder cancer (GBC) is increasing, with reported advantages over conventional open surgery. The purpose of this study was to compare the perioperative outcomes and postoperative overall survival (OS) associated with robotic radical resection (RRR) and laparoscopic radical resection (LRR) for GBC. A total of 109 patients with GBC who underwent radical resection with the same surgical team between January 2015 and December 2023 were enrolled, with 21 patients in the RRR group and 88 cases in the LRR group. A 1:1 propensity score matching (PSM) algorithm was used to compare the surgical outcomes and postoperative prognosis between the RRR and LRR groups. Logistic regression analysis was used to identify the risk factors of postoperative overall survival (OS) and complications of Clavien-Dindo (C-D) Grades III-IV. The median follow-up time was 46 (inter-quartile range, IQR 29-70) months for the LRR group and 16 (IQR 12-34) months for the RRR group. After PSM, the baseline characteristics of the RRR and LRR groups were generally well balanced, with 21 patients in each group. RRR was associated with significantly decreased intraoperative bleeding [100.00 (50.00, 200.00) mL vs 200.00 (100.00, 300.00) mL] and higher number of lymph nodes (LNs) yield [12.00 (9.00, 15.50) vs 8.00 (6.00, 12.00)]. The two groups showed comparable outcomes in terms of the incidence of biliary reconstruction, the range of liver resection, the length of operation, the incidence of postoperative morbidity, the incidence of C-D Grades III-IV complications, number of the days of drainage tubes indwelling and postoperative hospital stay, and mortality by postoperative days 30 and 90. After PSM, the 1-, 2-, and 3-year overall survival rates were 78, 70, and 37%, respectively, in the RRR group, and 71, 59, and 48%, respectively, in the LRR group (P = 0.593). Multivariate analysis showed that the preoperative TB level ≥ 72µmol/L and biliary reconstruction were found to be the independent risk factors of C-D Grades III-IV complications. T3 stage was identified to be the risk factor for postoperative OS. Compared with LRR, RRR showed comparable perioperative outcomes in terms of length of operation, and postoperative complications, recovery, and OS. In our case series, RRR of GBC can be accomplished safely and tends to show less intraoperative bleeding and higher LNs yield.

High-Risk Biliary Anastomosis During Robotic Pancreaticoduodenectomy: Initial Experience with Biodegradable Biliary Stent.

Background and Objectives: Biliary fistulas (BFs) occur in approximately 3-8% of patients undergoing pancreaticoduodenectomy (PD), and the bile duct diameter ≤ 5 mm is the most important risk factor. The aim of this study was to evaluate the efficacy of biodegradable biliary stents (BSs) in reducing complications in patients undergoing robotic pancreaticoduodenectomy (RPD) with a bile duct diameter of ≤5 mm. Materials and Methods: A retrospective single-centre observational study was conducted. Patients undergoing RPD after the completion of the robotic biliary anastomosis learning curve were included in this study. Only patients with a bile duct diameter ≤ 5 mm were included in the analysis. A prospectively held database was used. The intraoperative time for biliary anastomosis was extracted from surgical videos. Results: Of 30 patients, 20 received no biliary stent (nBS) and 10 received a biodegradable stent (BS). The decision to use a stent was based on product availability. The median operative time for biliary anastomosis was significantly shorter in the BS group compared to the nBS group, at 15 min versus 24 min (p < 0.001). Three patients in the nBS group developed a BF, whereas none were observed in the BS group. No stent migration was observed in any of the patients. Conclusions: The use of biodegradable biliary stents in high-risk biliary anastomosis in RPD appears to effectively reduce the incidence of BFs and may serve as a viable strategy to mitigate early biliary complications. The use of biodegradable stents facilitates a faster and easier biliary anastomosis. These findings suggest a potential benefit of using biodegradable stents in complex biliary reconstruction. However, larger studies are needed to confirm these results.

Perioperative Complications After Pediatric Liver Transplantation-A Retrospective Analysis of 421 Cases.

Due to the low incidence of pediatric liver transplantations, short- and long-term data regarding their outcome, details on early postoperative complications and their risk factors are under-represented in the literature. We retrospectively reviewed 1645 LTx performed at Hannover Medical School between January 2005 and December 2021. Of these, 421 transplantations were performed in 405 pediatric recipients. Univariate and multivariate binary logistic regressions were performed to identify independent risk factors for the onset of selected perioperative complications requiring intervention within the first 30 days following transplantation and their influence on graft and patient survival. Pleural effusions represent the most common postoperative complication observed in 49.4% (n = 208) of cases, followed by vascular complications in 22.6% (n = 95) and biliary complications in 20.0% (n = 84) of cases. Donor age (OR: 1.019; p = 0.010) and recipient age between 3 and 12 years (OR: 1.849; p = 0.008) were identified as independent risk factors for the onset of pleural effusions. Retransplantations within the first year after LTx were necessary in 11.4% of all cases (n = 48). Twenty (4.8%) patients died within the first year after LTx. Pleural effusions requiring postoperative intervention were observed in approximately half of the pediatric recipients. Therefore, the preemptive intraoperative placement of a chest drain under sterile conditions and general anesthesia should be considered. Our data further indicate that a two-stage procedure for biliary reconstruction may be the preferred procedure in patients at risk of early bile duct complications and retransplantation within the first year.

Technical refinements to reduce the early biliary complication in living donor liver transplantation

BackgroundBiliary reconstruction is a key factor that affects biliary complication rates. Surgical experience plays a pivotal role, but continuous technical refinement is essential for enhancing biliary outcomes. This study aimed to evaluate the biliary outcomes of LDLTs in patients undergoing microsurgical biliary reconstruction with continual technical refinements. Materials and MethodsThis observational cohort study analyzed data was conducted from 2006 to 2022. Microsurgical biliary reconstruction was performed using various refinements, including selective biliary stent insertion, ipsilateral (anatomical) bile duct anastomosis, use of a figure-of-8 suture over the junction of the graft and recipient bile ducts, and centralization techniques for size discrepancies greater than 2 to 1. Comparison and evaluation of early BC within one year post transplant was performed. Results1780 patients (including 1563 adults and 217 paediatric patients) underwent microsurgical biliary reconstruction in LDLTs at KCGMH between 2006 and 2022. The donor grafts comprised 1109 right liver grafts and 671 left liver grafts. Of the grafts, 23.1 % had multiple bile ducts and 16.1 % had bile duct sizes <3 mm. Duct-to-duct anastomosis was performed in most cases 1417 (79.6 %), while 363 (20.4 %) Roux-en-Y hepaticojejunostomies (RY HJ) was performed. The overall early BCs rate was 10 % and notable improvements were observed, decreasing from 10.35 % between 2006 and 2021 to 6.5 % by 2022. Early BS comprised the most part of 6.1 % as compared to 2.7 % one year after transplantation. Stent insertion in selected cases, ipsilateral anastomosis, and the figure-of-8 suture technique significantly reduced early BCs. Although centralization technique showed promising results, its effect was not statistically significant. ConclusionsContinual technical refinements in MBR can contribute to a substantial reduction in early BCs following LDLT, ultimately leading to improved patient outcomes.

Sublingual Administration of Tacrolimus is Safe and Provides Similar Drug Exposure to Per-oral Route in Liver Transplant Recipients During Early Postoperative Period–A Large, Retrospective, Observational Study

BackgroundPer-oral(PO) administration of Tacrolimus(TAC) results in inadequate trough levels in early post-operative period in liver-transplant(LT) recipients who undergo Roux-en-Y hepaticojejunostomy for biliary reconstruction. Sublingual administration(SL) of tacrolimus provides an alternative route in such patients. ObjectiveTo assess feasibility and safety of SL tacrolimus in adult LT-recipients in early post-operative period and to compare therapeutic efficacy of SL administration of tacrolimus vs.PO route. Patients and MethodSingle-centre, retrospective, observational study carried out in adult living donor liver transplant(LDLT) recipients between January 2022 till December 2022. Recipients who underwent Roux-en-Y hepaticojejunostomy for biliary reconstruction, received tacrolimus through SL route till post-operative day(POD)5 as they were kept nil per oral constituted the study group while recipients who underwent duct-to-duct(D-D) anastomosis for biliary reconstruction were allowed orally from POD1 and received PO-tacrolimus were chosen as controls. Feasibility and safety of SL-Tacrolimus was assessed in terms of patient acceptance, need to discontinue SL-Tacrolimus, incidence of local adverse effects and systemic adverse events like neurotoxicity and nephrotoxicity. Therapeutic efficacy was evaluated by comparing median trough levels(TAC level) achieved and incidence of graft rejection between two groups. Results212 patients underwent LT during the study period of which 125 were included(58 in SL-group and 67 in PO-group). Both groups had comparable baseline characteristics. In SL-group, all patients tolerated SL-Tacrolimus well and no local adverse events were observed. Patients with SL-Tacrolimus administration achieved higher median TAC level(ng/ml) vs.PO route(5.85 vs 5(p=0.06)) despite similar median cumulative tacrolimus dose before assessing TAC-level. 50% patients achieved TAC level ≥6ng/ml in SL-group vs. 35.8% in PO-group(p=0.14). Incidence of neurotoxicity, nephrotoxicity and graft rejection during hospital stay were similar in both the groups(p=0.56,0.82 and 0.28 respectively). ConclusionSL-tacrolimus is safe and provides similar trough levels to PO-tacrolimus and may be considered as viable alternative whenever inadequate TAC-levels are anticipated through per-oral route.

Biodegradable internal biliary stenting in orthotopic liver transplantation – A feasibility study

IntroductionBiliary complications remain a common cause of morbidity after liver transplantation and often require invasive interventions to manage. We aimed to assess the technical feasibility and safety of placement of a biodegradable stent across the biliary anastomosis at the time of liver transplantation in patients having a duct to duct biliary reconstruction. MethodsFor this prospective, single-arm, descriptive study, 10 consecutive patients undergoing whole graft, deceased donor, liver transplantation and duct-to-duct biliary tract reconstruction were enrolled and a biodegradable biliary stent was sutured into the bile duct across the anastomosis. ResultsIn all 10 patients it was technically feasible to place and secure the stent safely during the operation. After >6 months (median of 212 days) follow up, no patients had developed biliary anastomotic stricture. One patient had transient bile leak immediately post-operative that was managed conservatively. One patient required endoscopic intervention for non-anastomotic stricture development and biliary cast material that had resulted in stent dysfunction. DiscussionThe results of this study suggest surgical feasibility of placement of an absorbable biliary stent across the biliary anastomosis at the time of liver transplantation, as well as an acceptable safety profile. Further studies are required to confirm these safety and feasibility findings and to assess efficacy in reducing rates of biliary complications and the need for endoscopic intervention in the early post-transplant period.

Outcomes of Retro Colic Retro Pyloric Roux En Y Hepaticojejunostomy In Biliary Reconstruction

OBJECTIVES To assess the effectiveness of retro pyloric Roux-En-Y Hepaticojejunostomy in cases of choledochal cysts and bile duct injuries to reduce complications, such as delayed gastric emptying and acute cholangitis. METHODOLOGY This retrospective cohort study was conducted in the surgical C unit of Hayatabad Medical Complex, Peshawar (January 2019 - December 2022). This study included 37 patients treated for bile duct injuries and choledochal cysts. All patients had an ASA III or above, aged 5 to 36 years. Amongst the 35 patients, 21 patients underwent surgery for choledochal cysts, while 14 patients were treated for bile duct injuries. Patients with type 1choledochal cysts were admitted through OPD after getting diagnosed by ultrasound abdomen and, in some cases, MRCP. RESULTSOut of 36 patients, 23 (63.71%) presented with type I choledochal cysts, while 14 (40%) exhibited bile duct injuries (BDI). Among the 14 BDI cases, 57.14% underwent open cholecystectomy, 42.85% underwent laparoscopic cholecystectomy, and 5.71% received immediate repair during the primary surgery. Conversely, 8.57% of patients with CBD ligation underwent exploration on the 3rd postoperative day upon early detection of the injury. Among the patients diagnosed with BDI after the 7th postoperative day, 25.71% underwent delayed repair at three months. Postoperatively, patients were authorized for fluid consumption within 24-48 hours. Moreover, 4 (11.42%) patients developed a fever of approximately 100°F, managed with intravenous Paracetamol in 2 (5.71%) cases. Patients also presented with subsequent wound infections, which were treated on an outpatient basis through oral antibiotics and wound dressing. CONCLUSION The Retropyloric Roux-en-Y hepaticojejunostomy is a modified biliary reconstruction procedure with minimal morbidity and better outcomes than traditional methods. It reduces complications like delayed gastric emptying and acute cholangitis. We recommend its frequent use for biliary reconstruction when appropriate.

Reconstructive interventions on bile ducts in patients with benign obstructive jaundice

Aim. To evaluate immediate and long-term results of surgical reconstruction of the biliary system in various types of benign obstructive jaundice.Materials and methods. The study enrolled 110 patients with choledocholithiasis, iatrogenic biliary strictures, common bile duct strictures, as well as strictures of biliodigestive and biliobiliary anastomoses. Patients were divided into 3 groups. Group 1 included 43 patients with multiple choledocholithiasis and bile duct dilatation &gt;15 mm. Group 2 enrolled 35 patients with multiple choledocholithiasis and hepaticolithiasis who were intraoperatively diagnosed with stricture, injury, or pressure ulcers of the common bile duct wall. Group 3 included 32 patients with cicatricial and iatrogenic biliary strictures. The immediate and long-term results of surgical treatment were compared.Results. In group 1, the survival rate comprised 89.4%, the average duration of surgery amounted to 137 minutes, complications involved wound infection, bile leakage, bile peritonitis. In group 2, the survival rate accounted for 91.4%, the average duration of surgery comprised 192 minutes; strictures of biliodigestive anastomosis were detected in the remote period, and reconstructive surgeries were performed. Group 3 revealed the survival rate of 100%, the average duration of surgery of 215 minutes, and no complications in the long term.Conclusion. The diameter of the common bile duct, its wall changes, size of gallstones, signs of cholangitis, patency of the bile papilla, and localization of biliary stricture determine the surgical tactics, when performing biliary reconstruction in patients with non-cancerous obstructive jaundice. In case minimally invasive surgery is found impossible under conditions of multiple choledocholithiasis, common bile duct diameter &gt;15 mm, and preservation of its wall, choledocholithotomy with Kerr drainage is considered to be optimal. In case of damage to the CBD wall and patency of the bile papilla, preference shall be given to hepaticoenterostomy. Bile duct reconstruction with stent drainage is indicated for treatment of cicatricial and iatrogenic biliary strictures.

An interesting change in the branching pattern of abdominal aorta artery in abdominal cavity

Anatomical changes of the abdominal aorta artery are highly important in the liver, pancreas, bile ducts, liver transplantation, and abdominal radiological interventions, and knowing about them can reduce the risk of complications from surgery. In this case, an 80-year-old man had anatomical changes in the superior mesenteric and celiac arteries. This person had a celiac arterial trunk, which had a left gastric branch, a splenic branch, and a branch to the diaphragm. In addition to its main branches, the upper mesenteric artery had a hepatic artery (HA) moving toward the liver. Knowing the changes in the celiac trunk and HA is highly essential for designing some abdominal surgeries, including liver transplants, pancreatoduodenectomy, biliary reconstruction, gastrectomy, and other abdominal disorders.

Challenges in Pediatric Liver Retransplantation: A Technical Perspective.

Liver retransplantation (reLT) is the only option for pediatric patients experiencing graft loss. Despite recent advancements in surgical techniques and perioperative management, it remains a high-risk procedure. Our aim is to describe our experience in pediatric reLT, focusing on the technical aspects and surgical challenges. We systematically analyzed surgical reports from pediatric reLT performed at our center between 2006 and 2023 to identify recurrent intraoperative findings and specific surgical techniques. We focused on challenges encountered during different phases of reLT, including hepatectomy, vascular, and biliary reconstruction. Additionally, we compared patient and graft survival rates among different groups. During the study period, 23 children underwent 25 reLT procedures at our center. Major surgical challenges included complex hepatectomy and vascular reconstructions, necessitating tailored approaches. Our analysis shows that patient and graft survival were significantly lower for reLT compared to primary transplantation (p = 0.002). Early reLT had a significantly lower graft survival compared to late reLT (p = 0.002), although patient survival was comparable (p = 0.278). Patient and graft survival rates were comparable between the first and second reLT (p = 0.300, p = 0.597). Patient survival tended to be higher after living-donor liver transplantation (LDLT) compared to deceased-donor liver transplantation (DDLT), although the difference was not statistically significant (p = 0.511). Pediatric reLT involves significant technical challenges and lower survival rates. Advances in perioperative management are crucial for improving outcomes. Further research is needed to optimize surgical strategies and evaluate the long-term benefits of LDLT in pediatric reLT.

223.5: Biodegradable stent for biliary reconstruction in pediatric liver transplantation, surgical approach.

223.5: Biodegradable stent for biliary reconstruction in pediatric liver transplantation, surgical approach.

Safety and efficacy of hepaticoduodenostomy for biliary reconstruction after extrahepatic mid-bile duct cancer surgery.

Bile duct resection and reconstruction for bile duct cancer (BDC) is a complex surgical and oncologic procedure that requires extensive resection and reconstruction of the biliary tract. Hepaticojejunostomy is commonly performed for biliary reconstruction after extrahepatic mid-bile duct resection, while hepaticoduodenostomy (HD) is performed only rarely due to the risk of ascending cholangitis. However, the efficacy of HD has not been well-established in extrahepatic mid-BDC surgery. In this study, we aimed to analyze the outcomes of HD in patients who underwent bile duct resection for extrahepatic mid-BDC. We retrospectively analyzed 38 extrahepatic mid-BDC patients who underwent bile duct resection in our center between January 2018 and June 2023. We compared postoperative outcomes, cancer recurrence, and patient survival between hepaticojejunostomy (n=20) and HD (n=18) groups. Operation time for the HD group was significantly shorter than that of the hepaticojejunostomy group (188 vs. 206 min, P=0.044) with no significant differences in postoperative outcomes. Regression analysis showed that a HD was not associated with a significantly high risk of cancer recurrence or decrease in patient survival. HD appears to have comparable operative benefits, postoperative complications, and oncologic outcomes to hepaticojejunostomy in extrahepatic mid-BDC patients.

Liver and pancreas transplantation in adult donor and recipients with situs inversus totalis: a case series and review of the literature

BackgroundSitus inversus totalis is a rare congenital anomaly characterized by a mirror-image orientation of abdominal, and in some cases, thoracic organs. Here, we report our situs inversus totalis transplantation experience and further review liver transplantations in adult recipients and donors with situs inversus totalis.Case presentationWe describe three cases with situs inversus totalis. The first case was liver transplantation in a recipient (a 61-year-old Iranian man) with situs inversus totalis, the second was a liver transplantation from a donor (a 52-year-old Iranian woman) with situs inversus totalis, and finally, for the first time, a simultaneous pancreas and kidney transplantation in a recipient (a 26-year-old Iranian man) with situs inversus totalis. In patient one, hepatectomy could be performed according to the standard method and on the basis of preoperative studies. Hepatic vein and arterial anastomosis were performed as in every other patient without situs inversus totalis. To prevent biliary complications, a Roux-en-Y hepaticojejunostomy was performed. In patient two, implantation time, suprahepatic vein, portal vein, arterial, and biliary reconstruction could be done as in any other case without situs inversus totalis. Plication of the right-sided diaphragm and fixation of the falciform ligament was done for our patient. In patient three, systemic drainage was preferred to portal flow for establishing the outflow drainage of the pancreas compared with otherwise normal patients.ConclusionAlthough situs inversus totalis is a rare condition, our reported techniques are suitable, considering advantages such as easier accessibility, more acceptable placement of the implanted organs regarding vascular variations, and the appropriate location of the allograft in the proximity of other organs.

Anatomical biliary reconstruction as an ultimum refugium for selective cases-History and current state of knowledge.

Reconstruction of extrahepatic bile ducts is a staple procedure of HPB surgery. The current standard for most cases is a nonanatomical bilioenteric reconstruction, a satisfactory option for the majority of patients. However, it cannot be used for a small number of selective cases (short bowel syndrome, severe abdominal adhesions), where an anatomical reconstruction with or without an interponate can be used. This review summarizes current knowledge about tissue and material usage for experimental and clinical anatomical bile duct reconstruction in the last 100 years. A Pubmed database was searched for published articles about anatomical extrahepatic bile duct reconstruction in experimental and clinical settings ranging from 1920 to 2022. To date, the truly optimal interponate material has not yet been found. However, evidence reveals important properties of such material, most importantly its biodegradability and neovascularization in the recipient's body. The role of internal bile duct stenting for anatomical reconstruction seems important for the outcome. Anatomical reconstruction of extrahepatic bile ducts is an uncommon but usable technique in unique cases when a nonanatomical reconstruction cannot be done. The optimal properties of interponate material for anatomical bile duct reconstruction have been more clarified, although further research is required.

Laparoscopic versus open hepatic resection in patients ≥75 years old: A NSQIP analysis evaluating 2674 patients.

Previous studies report promising outcomes with minimally invasive (MIS) hepatectomy in elderly patients but remain limited by small size. This study aims to comparatively evaluate the demographics and outcomes of geriatric patients undergoing MIS and open hepatectomy. The 2016-2021 NSQIP database was evaluated comparing patients ≥75 undergoing MIS versus open hepatectomy. Patient selection and outcomes were compared using bivariate analysis with multivariable modeling (MVR) evaluating factors associated with serious complications and mortality. Propensity score matched (PSM) analysis further evaluated serious complications, mortality, length of stay (LOS), Clavien Dindo Classification (CDC), and Comprehensive Complication Index (CCI) for cohorts. We evaluated 2674 patients with 681 (25.5%) receiving MIS hepatectomy. MIS approaches were used more for partial lobectomy (85.9% vs. 61.7%; p < 0.001), and required fewer biliary reconstructions (1.6% vs. 10.6%; p < 0.001). Patients were similar with regards to sex, body mass index, and other comorbidities. Unadjusted analysis demonstrated that MIS approaches had fewer serious complications (8.8% vs. 18.7%; p < 0.001). However, after controlling for cohort differences the MIS approach was not associated with reduced likelihood of serious complications (odds ratio [OR]: 0.77; p = 0.219) or mortality (OR: 1.19; p = 0.623). PSM analysis further supported no difference in serious complications (p = 0.403) or mortality (p = 0.446). However, following PSM a significant reduction in LOS (-1.99 days; p < 0.001), CDC (-0.26 points; p = 0.016) and CCI (-2.79 points; p = 0.022) was demonstrated with MIS approaches. This is the largest study comparing MIS and open hepatectomy in elderly patients. Results temper previously reported outcomes but support reduced LOS and complications with MIS approaches.