Bilioenteric Anastomosis Research Articles

Motorized spiral enteroscopy-assisted ERCP after Roux-en-Y reconstructive surgery and bilioenteric anastomosis: first clinical case.

ERCP procedures in patients with surgically altered anatomy are often challenging because Roux-en-Y reconstructive surgery usually excludes the biliopancreatic system from a conventional endoscopic approach. The advent of device-assisted enteroscopy (DAE) using double- and single-balloon enteroscopy and spiral enteroscopy substantially improved the efficacy of endoscopic treatment after all types of Roux-en-Y reconstructions.1,2 However, insertion of the enteroscope is still often cumbersome and time consuming, and therapeutic success rates of ERCP are limited by reduced maneuverability of the endoscope and unstable position in front of the papilla, the limited diameter of the working channel, and availability of instruments with an appropriate length.

Robot-Assisted Pancreatic Surgery: A Structured Approach to Standardization of a Program and of the Operation

Introduction: The use of robots in minimal invasive surgery has become increasingly common in recent years.Robot-assisted pancreatoduodenectomy preponderates against a laparoscopic procedure especially due to the greater flexibility of instruments and therefore a better handling and a better angulation. Furthermore, there are benefits of enlarged 3-D visibility, software-based tremor control, and reduced physical exertion of the surgeon. Methods and Results: This review delivers a point-by-point approach to the setup of a robot-assisted pancreatic program and a detailed approach to robot-assisted pancreatoduodenectomy. Results: In our standardized standard operating procedure approach we use 5 trocars, i.e., 4 robotic trocars and 1 assist trocar. We prefer the position of the robot ports in a straight horizontal line with a distance of 20 cm from the operational field. The operation is dissected into 11 standardized procedural steps as follows: (1) access to the pancreas and visualization, (2) extended Kocher manoeuvre, (3) lower rim and mesentericoportal axis, (4) upper rim and hepatoduodenal ligament, (5) dissection of the pancreatic neck, (6) mesenteric root and pars IV duodeni, (7) mesopancreas, (8) pancreatic anastomosis reconstruction, (9) bilioenteric anastomosis, (10) dudenojejunal anastomosis, and (11) drainage and closure. The setup of the pancreas program and the structured approach to complex pancreatic resections are elucidated. Summary: This review describes the approach to robot-assisted pancreatic surgery in a high-volume pancreas center on a structural and procedural level to support the establishment of such programs at other locations.

Laparoscopic versus open surgery for the management of post-cholecystectomy benign biliary strictures.

Surgical management by a bilioenteric anastomosis is the standard for the repair of post-cholecystectomy benign biliary strictures (BBS). This is traditionally done as an open operation. There are a few reports describing the procedure by a laparoscopic technique. The aim of the present study was to describe our experience of laparoscopic bilio-enteric anastomosis [Roux-en-Y hepaticojejunostomy (LRYHJ)/laparoscopic hepaticoduodenostomy (LHD)] in the management of post-cholecystectomy BBS and compare the outcomes with our patients operated by the open approach. Retrospective analysis of prospective data of post-cholecystectomy BBS patients treated by laparoscopic bilio-enteric anastomosis. The outcomes were compared with patients who underwent an open repair. Between January 2016 and February 2019, 63 patients underwent surgery for post-cholecystectomy BBS. Twenty-nine patients who underwent laparoscopic bilio-enteric anastomosis (LRYHJ-13, LHD-16) were compared with 34 patients who underwent an open repair. The median age (40 vs 39) years, type of index surgery [laparoscopic cholecystectomy (13 vs 15), laparoscopic converted to open cholecystectomy (10 vs 16), and open cholecystectomy (6 vs 3)], type of injury low stricture (7 vs 5) and high stricture (22 vs 29), preoperative biliary fistula (23 vs 30), and time from injury to repair (6 vs 7months) were similar in the 2 groups. The median duration of surgery was also similar (210 vs 200min, p = 0.937); however, the median intraoperative blood loss (50mL vs 200mL, p = 0.001), time to resume oral diet (2 vs 4days p = 0.023),** and median duration of postoperative hospital stay (6 vs 8days, p = 0.001) were significantly less in the laparoscopy group. Overall morbidity rate (within 30days post-surgery) was significantly higher in the open repair group (38% vs 20%). In a subgroup analysis of the laparoscopic repair group, the operative time in patients who underwent an LHD was significantly less than LRYHJ (190 vs 230min, p = 0.034). The other parameters like the mean intraoperative blood loss, time to initiate oral diet, duration of postoperative hospital stay, and incidence of postoperative bile leak were similar. Patients undergoing open repair had a median follow-up of 26months with two developing anastomotic stenosis and those undergoing laparoscopic repair had a median follow-up for 9months with one developing anastomotic stenosis. Laparoscopic surgery for post-cholecystectomy BBS with an LRYHJ or LHD is feasible and safe and compares favourably with the open approach.

3:27 PM Abstract No. 102 Infectious complications and postprocedural antibiotics following initial percutaneous biliary drainage for patients with endoscopically placed stents

To evaluate the risk of cholangitis and role of postprocedural antibiotics for patients with endoscopic biliary stents (EBS) undergoing initial percutaneous biliary cholangiography and drainage (PTC). Retrospective review identified all adult patients undergoing initial PTC without preprocedural evidence of cholangitis over an 18-month period at a large academic center. Cholangitis was defined as fever ≥ 38.5°C within 24 hours of the PTC. Clinical characteristics between patients with and without EBS were compared using chi-squared. 64 patients with a mean age of 62 were included; all patients received preprocedural prophylactic antibiotics. 60 (94%) patients presented with biliary obstruction and 4 (6%) with biliary leak. 45 patients (70%) had a history of endoscopic retrograde cholangiopancreatography (ERCP), 23 (36%) had EBS, and 28 (44%) had a surgical bilioenteric anastomosis. Overall, 9 patients (14%) became cholangitic with one patient developing septic shock. Patients with EBS were more likely to develop cholangitis compared to both the entire cohort (7/23 vs. 2/41, P = 0.005) and patients with history of ERCP alone (7/23 vs. 1/19, P = 0.02). 22 (34.4%) patients were placed on postprocedural empiric antibiotics (i.e., antibiotics without clinical evidence of cholangitis) by their primary team. 6 patients with EBS were placed on empiric post procedure antibiotics and none developed cholangitis, whereas 7 of the 17 (41.2%) not placed on empiric antibiotics developed cholangitis (P = 0.059). These results suggest that patients with EBS may be at high-risk for developing cholangitis after initial PTC beyond the risk conferred to patients with previous ERCP. This may be due to the presence of an indwelling foreign body. The role of routine postprocedural empiric antibiotics for this patient group needs further investigation given the high morbidity associated with cholangitis.

Magnetic recanalization technique for the treatment of alimentray tract stricture: A clinical study

Magnetic compression anastomosis or magnetic recanalization technique is a revolutionary minimally invasive method to perform re-anastomosis in patients with alimentary strictures. We conduct magnetic recanalization for the treatment of severe alimentary strictures that cannot be treated by conventional methods. Data are analysed retrospectively in order to investigate the safety and efficiency of this method. From 2012 January to 2019 October, 17 patients with alimentary stricture after operation were enrolled in the first affiliated hospital of Xi’an Jiaotong University and the Chinese PLA General Hospital. The ages were 47±16.8 years, and 11 cases were men. 17 cases include 14 benign biliary strictures, two esophageal strictures and one colorectal anastomosis strictures. 14 cases are complete strictures, and the others are refractory one. Strictures are found 0–120 months after the last operation. All the patients have undergone 2–8 times unsuccessful standard treatments, including endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangial drainage (PTCD) or endoscopic balloon dilation. Magnetic recanalization technique (MRT) is proposed. The MRT device consists of two identical, nickel-plated NdFeB magnets (rating, N45) termed the parent magnet and the daughter magnet. Each magnet shapes like a cylinder or annular. The daughter and parent magnet are delivered to the proximal and distal end of stricture respectively via different routes. The attraction force between the two magnets leads to necrosis of the fibrotic stricture tissue and the creation of a new transmural anastomosis. Thereafter, stent deployment or balloon dilation is performed to the new anastomosis. Data about stricture length, recanalization time, side effects in 30 days, time to remove the biliary stent and stricture recurrence are collected. All the patients are followed-up to 2019 December by telephone or outpatients service. After the MRT, 1 case fails. Magnets can couple stably in 16 patients (successful rate 94.1%), including 10 cases of choledocho-choledochostomy, 3 cases of bilio-enteric anastomosis, 1 case of esophago-esophagostomy, 1 case of esophago-gastrostomy and 1 case of colo-proctostomy. The delivery routes are per-PTCD/per-ERCP, per-PTCD or drainage tube sinus/per-gastroscope, per-gastroscope/per-gastroscope, per-gastroscope/per-operation and per-enterostomy/per-anus respectively. The daughter and parent magnets detach from each other in 3 patients after days post-MRT. The magnets couple automatically in 2 patients without any interventions. In the other patient, another daughter magnet is added through PTCD, and the magnets are again tightly approximated. Three adverse events are found (cholangitis, 1 patient; biliary bleeding, 1 patient; colon leakage, 1 patient), but are resolved with conservative treatment. The stricture length is 2–7.1 (4±1.9) mm in successful cases, and recanalization occurs after 7–50 (15.5±10.6) days. Biliary multiple plastic stents (4 patients), biliary fully covered self-expandable metallic stent (5 patients), percutaneous trans-hepatic cholangiodrainage catheter (4 patients), balloon dilation plus metallic stent (2 patients), or balloon dilation alone (1 patient) is used after recanalization. Stents are retrieved after 6.9±4.0 months in 14 patients, and 1 patient is still in stent period. During 3–70 months of stent-free follow-up, no stenosis is found in 13 biliary stricture patients, but 2 cases are found biliary stones and cured by endoscopic treatment. Two of three patients with esophageal or colorectal anastomosis stricture experience recurrence in follow up, and are still managed by endoscopic ways. In conclusion, magnetic recanalization technique is a minimally invasive, effective and safe method to complicated alimentary stricture, and can serve as a remedial method when conventional ways fail.

Portal Cavernoma Cholangiopathy in Children and the Management Dilemmas.

Portal cavernoma cholangiopathy (PCC) is one of the most harrowing complications of extrahepatic portal venous obstruction, as it determines the long-term hepatobiliary outcome. Although symptomatic PCC is rare in children, asymptomatic PCC is as common as that in adults. However, there are major gaps in the literature with regard to the best imaging strategy and management modality in children. Moreover, natural history of PCC and effect of portosystemic shunt surgeries in children are unclear. Neglected PCC would lead to difficult or recalcitrant biliary strictures that will require endoscopic therapy or bilioenteric anastomosis, both of which are challenging in the presence of extensive collaterals. There are limited studies on the effect of portosystemic shunt surgeries on the outcome of PCC in children compared to adults. In this review, we aimed to collate all existing literature on PCC in childhood and also compare with adult studies. We highlight the difficulties of this disease to provide a comprehensive platform to foster further research on PCC exclusively in children.

Aberrant right hepatic sectoral ducts injuries after cholecystectomy. Clinical outcomes and management

Background: Anatomical variations of the biliary tree are one of the causes of iatrogenic bile duct injuries (IBDI) during cholecystectomies. One of the most dangerous variants is the anomalous implantation of the aberrant right sectoral duct in the extrahepatic biliary tree and is one of the main risk factors for its injury during surgery.The aim of our review is to report these rarely published injuries, diagnosis and management options. Material and Methods: We reviewed the clinical files of all the patients who suffered a biliary complication after an open and laparoscopic cholecystectomy in our centre between the years 2000-2018. Results: Four consecutive patients were diagnosed with IBDI caused by an aberrant duct and were identified for inclusion.Three of our patients had a right posterolateral sectorial and one had a right anteromedial sectorial bile duct injury. Based on the Strasberg classification three of our patients were classified as are type C (section) and one type B (occlusion). None of these cases were diagnosed during surgery. Two of our patients presented with a persistent biliary fistula, one presented with a bilioma and another with recurrent cholangitis. The time between the primary intervention and the surgical repair of the injury ranged between 2 weeks to 8 years. All of these cases underwent surgery and a bilio-enteric anastomosis was performed. All our patients have shown an asymptomatic postoperative follow up with no signs of cholestasis. Conclusion: The accidental transection or ligation of an aberrant hepatic duct ranges from 5.6% to 17%. The absence of communication between the aberrant duct and the rest of the intrahepatic biliary tree delays the diagnosis despite repeated imaging. A ducto-jejunostomy with a Roux-en-Y reconstruction is considered a relevant treatment.The knowledge of these congenital anatomical variations of the biliary tree is essential for its appropriate and prompt management.

Laparoscopic Left Hepatectomy For Hilar Cholangiocarcinoma

Presenter: Safi Dokmak | Beaujon Hospital Background: Hilar cholangiocarcioma is considered as contraindication to the laparoscopic approach related mainly to the necessity of vascular dissection and a bilioenteric anastomosis. However with the development of minimally invasive pancreatoduodenctomy, we become more familiar with hepatic pedicle dissection, biliary anastomosis and even vascular resection-anastomosis. We present a video of laparoscopic left hepatectomy for hilar cholangiocarcinoma. Methods: Hilar cholangiocarcinoma was discovered on jaundice in a 72 year old male and treated efficiently by endoscopic drainage. Lesion was located on the biliary confluence with left extension and no vascular invasion. The laparoscopic approach was decided and five trocars were used. Results: The operative duration was 360 minutes; the blood loss was 200 ml, with isolated clampage of the portal vein of 30 minutes. The postoperative stay was marked by biliary fistula with spontaneous healing at POD 5 and the patient was discharged home at POD 14. Histology confirmed the diagnosis of a well differentiated cholangiocarcinoma of 3 cm with perineural invasion and no vascular invasion, 15 harvested negative lymph nodes and R0 resection (T2bN0R0). Conclusion: The development and experience with laparoscopic pancreatoduodenctomy will increase the feasibility of some difficult liver resections by the laparoscopic approach including hilar cholangiocarcinoma.

Endoscopic retrograde cholangiopancreatography by double-balloon enteroscopy in patients with surgically altered gastrointestinal anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) allows a diagnostic and therapeutic evaluation of pancreatobiliary diseases. However, the procedure in patients with surgically altered gastrointestinal anatomy represents a technical challenge. to report the diagnostic and therapeutic outcome of device-assisted enteroscopy (DAE) ERCP in patients with a surgically altered gastrointestinal anatomy. a prospective cohort of patients with a history of surgically altered gastrointestinal anatomy undergoing DAE-ERCP in a referral center was used. A double-balloon enteroscope was used to reach the papillary area or the bilio-enteric anastomosis. The clinical and endoscopic characteristics, and technical, diagnostic and therapeutic success were described. Clinical and endoscopic differences were evaluated according to diagnostic success, as well as the biochemical response in those patients with therapeutic success. ninety-six procedures were included in the study in 75 patients. Roux-en-Y hepaticojejunostomy (RYHJ) was the main surgical anatomy (82.3%) and cholangitis was the main indication for ERCP (49%). Diagnostic success was obtained in 69.8% of the participants. Of these, therapeutic success was obtained in 83.6% (overall success 58.3%). Cases with a diagnostic success had a higher frequency of cholangiography compared to those without diagnostic success (94% vs 0%, p < 0.001), as well as a lower probability of a failed cannulation (1.5% vs 100%, p < 0.001). A significant improvement was observed in patients with a therapeutic success in bilirubin, transaminases and alkaline phosphatase levels (p < 0.05). ERCP by means of double-balloon enteroscopy is a useful technique in patients with a surgically altered gastrointestinal anatomy, in whom access to the bile duct is required. However, these procedures are very challenging and diagnostic and therapeutic success where achieved in up to 60% of cases.

Cystocholecystostomy: A new technique for management of hilar biliary disruption due to a large hydatid cyst liver - Ten years of follow-up

A long-standing and large-sized hepatic hydatid cyst located at the liver hilum is likely to rupture into the adjoining major bile ducts. This unusual complication demands preoperative diagnosis at an early stage and adequate surgical management so as to prevent morbidity and mortality. Such cases are managed with bilioenteric anastomosis by doing Roux-en-Y cystojejunostomy. However, one such case was managed by performing side to side anastomosis between disrupted hydatid cyst at the hilum and adjoining gallbladder. This innovative surgical procedure was named “Cysto-cholecystostomy” and was reported for the first time in the English literature. This case report presents ten years of follow up of this patient along with discussion of related cases published in the literature.

Preliminary Results of Spleno-aortic bypass in patients with atheromatous celiac trunk stenosis in pancreaticoduodenectomy

Background: Pancreaticoduodenectomy (PD) is the only curative treatment of pancreatic head cancer. In case of atheromatous stenosis of the origin of the celiac trunk, interventional radiology is the treatment of choice and yield favorable outcomes allowing thus the realization of PD. But in case of failure of interventional radiology, the only left option is surgery. Herein, we would describe the technique of splenoaortic bypass associated to PD to shunt stenosis of the celiac trunk. Methods: During PD, both hepatic and splenic arteries were dissected. A pancreatectomy was performed from right ot left with preservation of the splenic vein and short vessels. Dissection was performed until the distal part of the pancreas leaving about 4 cm from the hilum. The splenic artery is clamped. To shunt the celiac trunk stenosis, we performed a vascular anastomosis between the splenic artery and the aorta. Doppler ultrasound of the hepatic arterial flow was controlled under clampage of the gastroduodenal artery. Then, this latter was ligated. To avoid the risk of pancreatic fistula, no anastomosis was performed and wirsungostomy was done instead. Bilioenteric and gastrojejunal anastomosis were then confectionned. Results: This technique has been used in three patients. Mortality was nil. No graft loss occurred. Only one patient experienced postoperative spleen abscess that required percutaneous drainage. Multidisciplinary approach allowed best management of pancreatic insuffiency. Conslusions: This technique is safe and feasible. It might be considered as an option in patients candidates to PD with stenosis of the celiac trunk non treatable with endovascular techniques.

Treatment strategies of complicated extrahepatic bileduct stones

Complicated extrahepatic bile duct stone is defined as not easy to achieve the treatment standard of total stone clearance, stricture removal, unobstructed drainage and recurrence preventing in a single operation or combined with other liver diseases, which include hepatic hilar bile duct stones incarceration, distal bile duct stone incarceration, Mirizzi syndrome, residual cystic duct stones, recurrent extrahepatic bile duct stones, and combined with portal hypertension or intrahepatic bile duct stones. Through comprehensive and meticulous preoperative evaluation, we can clarify the cause of extrahepatic bile duct stones, the location of stones and bile duct stenosis, the variability of bile duct, the anatomy of the hepatoduodenal ligament, the condition of liver function and biliary tract infection, and make the proper surgery plan. During the surgery, we apply the perihilar surgical techniques, pancreatic hilar plate reduction techniques, Oddi sphincter incision and shaping, and choledochoscopic lithotripsy and lithotomy comprehensively to achieve the goal of reducing residual stone rate and recurrence rate. It is important that reasonably select endoscopic retrograde cholangiopancreatography indications, correctly hold indications of bilioenteric anastomosis, and prevent iatrogenic injury of extrahepatic bile ducts on the premise of clearing stones. Key words: Hepatolithiasis; Extrahepatic bileduct stone; Perihilar surgical techniques; Pancreatic hilar plate reduction techniques; Choledochoscope; Lithotripsy

Treatment strategy for isolated bile leakage after hepatectomy: Literature review.

Isolated bile leakage (IBL) after hepatectomy is intractable, and various treatment methods for it have been reported. This review aimed to clarify the treatment strategy for IBL by summarizing studies on IBL after hepatectomy without extrahepatic bile duct resection. Thirty‐three cases of IBL were reported. The incidence of IBL is very low, accounting for 0.1%–1% of all hepatectomy cases. The risk factors for IBL are unclear; however, several reports mention that biliary anomaly is associated with a high risk of IBL, with preoperative and intraoperative confirmation of biliary tree anatomy being the most important preventive strategy. Treatment methods for IBL include liver resection, bilioenteric anastomosis, endoscopic treatment, bile duct ablation, percutaneous transhepatic portal vein embolization (PTPE), transcatheter arterial embolization, and use of fibrin glue. The therapeutic methods should be chosen depending on remnant liver function, amount of bile leakage, and the liver volume causing the bile leakage. When there is bile leakage from less than one segment, non‐surgical treatment is recommended, whereas when there is bile leakage from one or more segments, surgical treatment can be recommended. Nevertheless, recently, non‐surgical treatment such as PTPE, PTPE with bile duct ablation, and endoscopic methods have been considered as effective treatment approaches.

Surgical approach to benign bile duct alterations

Benign biliary diseases comprise entities, which present with very similar pathognomonic symptoms despite fundamental etiological differences. Obstructions of intrahepatic and extrahepatic bile ducts due to stones, tumors or parasites as well as stenoses and cystic alterations belong to the group of benign biliary diseases. This article provides a systematic overview of the indications and differential treatment of benign biliary diseases with special emphasis on the surgical treatment. The presented recommendations are in accordance with national and international guidelines, current scientific papers and expert opinions. Essentially the surgical options for benign biliary diseases consist of revision, reconstruction through bilioenteric anastomosis, resection and complete organ replacement in the sense of liver transplantation. The location of the affected segment of the biliary tree, the symptoms, the progress of the disease and suspected malignancy essentially determine the level of escalation in the described treatment level scheme. The treatment of benign biliary diseases is complex and requires achievement of unimpaired, unobstructed bile drainage. It serves the purpose of resolving cholestasis and thereby avoiding recurrent cholangitis and long-term complications, such as biliary cirrhosis and malignant transformation; however, in some cases of premalignant lesions of the bile ducts the strategy resembles cancer surgery, including resection of the affected tissue.

Complication management after bile duct surgery

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

Septic Shock and Death after Microwave Ablation of Hepatocellular Carcinoma in a Liver Transplant Patient with a Bilioenteric Anastomosis.

Percutaneous thermal ablation of hepatic tumors continues to play an integral role in the treatment of early-stage primary or secondary hepatic malignancies. Interventional radiologists must be familiar with potential complications of this procedure, associated risk factors, and methods for prevention. The authors report a devastating case of septic shock and death following percutaneous microwave ablation of a solitary hepatocellular carcinoma in a liver transplant patient with a bilioenteric anastomosis (BEA). We review the literature regarding prophylactic antibiotic regimens and bowel preparation prior to performing thermal ablation in patients with BEAs.

Failure Factors to Reach the Blind End Using a Short-Type Single-Balloon Enteroscope for ERCP with Roux-en-Y Reconstruction: A Multicenter Retrospective Study.

Background Failure factors in reaching the blind end (papillae of Vater, bilioenteric anastomosis) during short-type single-balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography (sSBE-assisted ERCP) in patients with Roux-en-Y (R-Y) reconstruction remain to be evaluated. Aims We investigated the failure factors in such patients. Methods We retrospectively studied 253 initial sessions of sSBE-assisted ERCP at three endoscopy centers from April 2008 through September 2017, examining failure factors and complications associated with scope insertion in patients with R-Y reconstruction. Results R-Y reconstruction was performed in 157 patients (with gastrectomy: 122 patients; without gastrectomy plus bilioenteric anastomosis: 35 patients). R-Y without gastrectomy (p = 0.001; odds ratio (OR), 5.73; 95% confidence interval (CI), 2.07 to 16.01) and the presence of peritoneal dissemination (p = 0.021; OR, 4.71; 95% CI, 1.27 to 17.54) were significant failure factors. Insufficient sSBE length was the cause of failure in 17 (11%) of the 157 patients, and 13 (76%) of the 17 patients were with R-Y without gastrectomy. In cases of insufficient short-type length, using a long-type SBE significantly increased the success rate (p = 0.002). Gastrointestinal stenosis was a significant failure factor (p = 0.011) in patients with peritoneal dissemination. Perforation occurred in 2 patients who responded to conservative treatment. Conclusions Failure factors during sSBE-assisted ERCP were R-Y without gastrectomy and the presence of peritoneal dissemination.

Clinical feasibility and effectiveness analysis of robotic pancreatoduodenectomy via a "G"-shaped approach

Objective To analyze the clinical feasibility and effectiveness of the G-shaped surgical approach in robotic pancreatoduodenectomy. Methods The clinical data of 17 patients who were undergoing robotic pancreatoduodenectomy at the First Hospital of Shanxi Medical University from June 2017 to March 2018 was analyzed. Results All the 17 robotic pancreatoduodenectomy operations via the G-shaped surgical approach were successful. The operationtime was (499±146) min (350-825 min), and the blood loss was (119±38) ml (20-500 ml). All surgical margins were negative. All patients recovered well after surgeries, and the postoperative hospital stay was (21±6) (14-36 days). However, one patient experienced secondary surgery due to bilioenteric anastomosis fistula, fortunately the surgical process went successfully. This patient had pancreatic leakage (class B) after surgery and was discharged with tubes after a conservative treatment, another patient had gastroplegia and recovered completely after conservative treatment. Conclusion It is a safe and feasible procedure to use the robotic pancreatoduodenectomy with the G-shaped surgical approach. Key words: Robotics; Pancreatoduodenectomy; Surgical procedures, minimally invasive; G-shaped surgical approach

Laparoscopic radical resection of hilar cholangiocarcinoma: a report of 32 patients

Objective To analyze the clinical outcomes and surgical procedures of 32 patients who underwent laparoscopic radical resection of hilar cholangiocarcinoma. Methods From January 2013 to July 2018, 32 patients who were diagnosed to have hilar cholangiocarcinoma underwent total laparoscopic treatment in Second Hospital of Hebei Medical University. The clinical data of these patients were recorded, including the general data, Bismuth types, AJCC types, postoperative complications, pathological findings, and follow-up results. Results This study included 20 males and 12 females with a mean age of 60.9±8.8 years and a body mass index of 22.6±3.2 kg/m2. According to the preoperative imaging studies, the Bismuth types Ⅰ, Ⅱ, Ⅲa, Ⅲb, and Ⅳ were found in 12, 2, 3, 4 and 11 patients, respectively. Laparoscopic radical resection of hilar cholangiocarcinoma and bilioenteric anastomosis was performed in 12 patients, with radical resection and external bile drainage in 6 patients, extended hemihepatectomy with caudate lobectomy in 6 patients and concomitant portal vein resection in 2 patients. The mean operative time was 365.6±121.9 min and the median intraoperative blood loss was 300 (75, 400) ml. Intraoperative red cell and plasma transfusion were 0-15 U and 400(0, 625)ml, respectively. According to the Clavien-Dindo complication classification system, 5 of 32 (15.6%) patients developed type Ⅱ morbidity. The postoperative pathological findings revealed bile duct adenocarcinoma in 30 patients and mucinous adenocarcinoma in 2 patients. The median size of cancer was 3.0 (1.0, 3.5) cm. According to the 8th AJCC staging system, stage Ⅰ, Ⅱ, Ⅲ, and Ⅳ were found in 6, 13, 11, and 2 patients, respectively. A negative resection margin was achieved in 24 of 32 patients (75%). Up to August 6, 30 of 32 patients (93.8%) were followed up and the overall 1-, 2-, and 3-year survival rates for the patients who underwent laparoscopic radical resection for hilar cholangiocarcinoma were 80.0%, 53.0%, and 53.3%. The median survival time was 21.8 months. Conclusion Total laparoscopic surgery for hilar cholangiocarcinoma was safe and feasible if performed by an experienced surgeon after accurate preoperative evaluation. Key words: Bile duct neoplasms; Surgical procedures, minimally invasive; Laparoscopy; Drainage; Hilar cholangiocarcinoma

Initial single institution experience with robotic biliary surgery and bilio-enteric anastomosis in southeast Asia.

Presently, experience with robotic biliary surgery (RBS) is increasing worldwide although widespread adoption remains limited. In this study, we report our initial experience with RBS. Retrospective review of a single institution prospective database of 95 consecutive robotic hepatopancreatobiliary surgeries performed between 2013 and 2018. Of these, 27 patients who underwent RBS were included in this study. RBS was performed by three principal console surgeons of whom one surgeon performed 23 (85%) and supervised all cases. Additionally, to evaluate our initial outcomes with bilio-enteric anastomoses, eight consecutive pancreatoduodenectomies were included. Of the 27 RBS performed, these included 10 hepaticojejunostomies with bile duct resections (including two concomitant pancreatoduodenectomies and one right hepatectomy) for choledochal cysts, bile duct strictures and biliary malignancies; five liver resections with hilar lymph node clearance for gallbladder cancer; four for Mirizzi syndrome; two cholecystectomies with cholecystoenteric fistula and two bile duct exploration after failed endoscopic treatment of choledocholithiasis. There were no open conversions, no 90-day mortality and four (14.8%) major (>Grade II) morbidities. The median post-operative stay was 6 (range 1-29) days and there was one (3.7%) 30-day readmissions. Of our first 18 robotically constructed bilio-enteric anastomoses, there was only one (5.5%) early anastomotic complication (bile leak requiring reoperation). Our initial experience demonstrated that RBS can be adopted safely with a low open conversion rate. Robotically constructed bilio-enteric anastomosis can be performed safely with a low anastomotic complication rate.