Bilioenteric Reconstruction Research Articles

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.

Modified technique of Hepatojejunostomy for biliary tract reconstruction after resection of tumors affecting the perihilar region: a case series

BackgroundsRadical resection is the most effective treatment for perihilar tumors. Biliary tract reconstruction after resection is one of the key steps in this surgery. Mucosa-to-mucosa cholangiojejunostomy is traditionally performed, in which the bile ducts at the resection margin are separately anastomosed to the jejunum. However, this approach is associated with long operative time and high risk of postoperative complications. The present study presents a modified technique of hepatojejunostomy and its outcomes.MethodsThe data of patients who underwent hepatojejunostomy using the modified technique at the Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, Chongqing, China, from January 2016 to December 2021, were retrospectively analyzed.ResultsA total of 13 patients with perihilar tumors underwent R0 resection and bilioenteric reconstruction using the modified hepatojejunostomy technique during the study period. During the operation, the alignment of the bile duct stumps was improved, the posterior wall of the anastomosis was reinforced, internal stents were placed in the smaller bile ducts, external stents were placed in the larger bile ducts, and hepatojejunostomy was performed using 4 − 0 prolene. No serious postoperative complications, such as death or bile leakage, occurred during the hospitalization. Furthermore, there were no cases of biliary stricture or cholangitis after the six-month follow-up period.ConclusionThe modified hepatojejunostomy technique is a safe and effective technique of biliary reconstruction after the resection of perihilar tumors. This can be easily performed for difficult cases with multiple bile ducts that require reconstruction after resection.

Analysis of minimal access bilio-enteric reconstruction in benign biliary stricture

Analysis of minimal access bilio-enteric reconstruction in benign biliary stricture

Surgical outcomes of robotic-assisted cyst excisions and hepaticojejunostomies in patients with perforated choledochal cysts: a single-centerretrospective study.

Perforated choledochal cysts is usually treated by open approach through a one- or two-stage procedure. Laparoscopic procedures are gradually being used more commonly with advancements in minimally invasive technology, while the level of difficulty and conversion rate are still high due to adhesions and deranged anatomy. Robot-assisted choledochal cyst excisions have been proposed as another minimally invasive procedure that is thought to improve operability and precision compared with laparoscopic surgery. However, there is still a lack about the use of robotic assistance for bilio-enteric reconstruction in pediatric patients with perforated choledochal cyst excisions. The aim of this current study was to investigate the safety and effectiveness of robotic-assisted procedures in pediatric perforated choledochal cyst excisions. Patients suffering from perforated choledochal cysts and treated with surgical procedures including open, laparoscopic, and robotic procedures between January 2009 and December 2021 were retrospectively analyzed. Robotic cyst excisions and hepaticojejunostomies were mainly used to a one-stage procedure (the pseudocyst formation or intra-mural perforation) or in stage 2 of two-stage procedures (complete perforation). Data collection included patient characteristics, intraoperative outcomes, and postoperative complications. There were a total of 64 patients suffering from perforated choledochal cysts were treated at our institution. Thirty-one cases of cyst excisions and hepaticojejunostomies were completed by open procedures. Twenty-two cases of cyst excisions and hepaticojejunostomies were completed by laparoscopic procedures and 11 cases were completed by robotic procedures. The operating times were significantly longer in the laparoscopic procedures group (214.32 ± 51.33min) than found with either the open procedures group (130.55 ± 10.51min) or the robot-assisted procedures group (188.82 ± 16.55min) (p < 0.001). The time to oral intake, total complication, and hospital stay were similar among all three groups (3.53 ± 0.28days vs 3.47 ± 0.30days vs 3.46 ± 0.29days, 19.35% vs 27.27% vs 18.18%, 11.48 ± 1.29days vs 11.95 ± 2.75days vs 11.55 ± 2.38days, respectively) (p > 0.05). The number of biliary complications was higher in the laparoscopic procedures group (18.18%) than in both the open procedures and robot-assisted procedures groups (0.00%) (p = 0.016). Robotic-assisted cyst excision and hepaticojejunostomy procedures in patients with perforated choledochal cysts are both safe and feasible. What is more, they can achieve the same results as open procedures and also reduce the level of difficulty of operations and bring fewer biliary complications compared with laparoscopic procedures.

Incidence and risk factors for anastomotic bile leakage in hepatic resection with bilioenteric reconstruction – A international multicenter study

BackgroundAnastomotic leak (AL) after bilioenteric reconstruction (BR) is a feared complication after bile duct resection, especially in combination with liver resection. Literature on surgical outcome is sparse. This study aimed to determine the incidence and risk factors for AL after combined liver and bile duct resection with a focus on operative or endoscopic reinterventions. MethodsData from consecutive patients who underwent liver resection and BR between 2004 and 2018 in 11 academic institutions in Europe were collected from prospectively maintained databases. ResultsWithin 921 patients, AL rate was 5.4% with a 30d mortality of 9.6%. Pringle maneuver (p<0.001),postoperative external biliary (p=0.007) and abdominal drainage (p<0.001) were risk factors for clinically relevant AL. Preoperative biliary drainage (p<0.001) was not associated with a higher rate of AL. AL was more frequent in stented patients (76.5%) compared to PTCD (17.6%) or PTCD+stent (5.9%,p=0.017). AL correlated with increased incidence of postoperative liver failure (p=0.036), cholangitis, hemorrhage and sepsis (all p<0.001). ConclusionThis multicenter data provides the largest series to date of LR with BR and could help in the management of these patients which are often challenging and hampering the patients’ postoperative course negatively.

Robotic Hepaticojejunostomy After Open Hepaticoduodenostomy

Introduction: Roux-en-Y hepaticojejunostomy (HJ) is the gold standard to repair iatrogenic bile duct injury. Robotic surgery seems a viable surgical approach, as it permits the sophisticated movements required for anastomotic technique through 3D visualization, endowrist manipulation and tremor filtration. This report describes a robotic HJ after open hepaticoduodenostomy (HD). Method: The patient was a 23-year-old female, with a medical history of laparoscopic cholecystectomy followed by an open HD on the right hepatic duct after an iatrogenic bile duct injury. She presented recurrent cholangitis episodes, caused by a stenosis on the HD right hepatic duct anastomosis. After adhesiolysis, the HD stenosis was identified and resected up to the orifice of the right anterior and right posterior sectoral duct. Following resection of the stenotic area the opening at the duodenum was closed. A bilioenteric reconstruction was performed through a Roux-en-Y suprahilar HJ, in which both the posterior and anterior sectoral branch were implanted on the jejunal loop. Continuity of the gastrointestinal tract was restored by a jejunojejunostomy through an end-to-side manual anastomosis. The common limb was tattooed with ink in order to aid orientation in future endoscopic interventions. Results: Operative time was 200 minutes and blood loss 20 cc. No intraoperative complications were encountered. The postoperative course was complicated by a bile leak with spontaneous resolution after one week and gastroparesis requiring temporary placement of a nasogastric tube. Discharge happened on postoperative day 14. Conclusions: Robotic HJ is a safe and feasible technique for complex bile duct reconstructions following open hepatobiliary surgery.

Incidence and Risk Factors for Re-interventions after Liver Resection and Bilioenteric Reconstruction: A International Multicenter Study

Introduction: Biliary leakage after biliary reconstruction (BR) is a common complication.Bile duct resection with combined liver resection (LR) increases the risk of complications even further. Literature on surgical outcome for BR in combination with LR is sparse and clinical management challenging. We therefore aimed to determine the incidence and risk factors for complications after combined liver and bile duct resection with a focus on operative or endoscopic re-interventions. Method: Data from consecutive patients who underwent LR and BR between 2004 and 2018 in 11 academic institutions in Europe were collected from prospectively maintained databases. Results: Within a median follow-up of 34 months, 921 patients underwent LR with concomitant BR. Re-intervention (surgical or endoscopical) rate was 5.4%. Male sex (p=0.048), perineural infiltration (p<0.001), preoperative jaundice (p<0.001), use of preoperative biliary drainage (p<0.001), intraoperative biliary drainage (p=0.007), Pringle maneuver (p<0.001) and postoperative abdominal drainage (p<0.001) increased the risk of re-intervention after LR and BR. Moreover, overall morbidity other than related to BR was 84%. Re-intervention correlated with increased incidence of postoperative liver failure (p=0.036), bile leakage on cut surface, cholangitis, hemorrhage and sepsis (all p<0.001). Median overall survival was comparable for patients with and without need for re-intervention (36 vs. 32months). Conclusions: This multicenter data provides the largest series to date of LR with BR and could help in the management of these patients which are often challenging and hampering the patients` postoperative course negatively.

A narrative review of the modern surgical management of pediatric choledochal cysts.

Choledochal cysts (CC) ae rare congenital dilations of the biliary tract that harbor lifelong malignancy risk. CC are treated with surgical excision and bilioenteric reconstruction. In the modern era, the surgical approach to pediatric patients has enjoyed significant innovation with regards to minimally invasive techniques. In this review, we discuss these advances, including laparoscopic, single-incision laparoscopic, and robotic strategies, with a focus on the clinical outcomes of patients undergoing these procedures. By presenting an overview of the technical pearls emphasized by pioneers of these procedures, we examine the benefits and limitations of various minimally invasive techniques and analyze the utility and effectiveness of laparoscopy and robotics in comparison to each other and open techniques. Additionally, we highlight the importance of surgeon experience and skill in the management of this rare pediatric disease and explore the significance of the surgical learning curve in minimally invasive approaches in the excision of CC. We discuss the challenge of achieving surgical competency along this learning curve, and present proposed strategies to improve skill sets in the face of low case volumes. Finally, the relative dearth of data discussing long-term follow-up in these patients is discussed, and additional research regarding outcomes, malignancy risk and surveillance, and quality of life is necessary to better understand this disease and the implications of its surgical management.

Outcomes of Hepaticoduodenostomy over T-tube against Roux-en-Y Hepaticojejunostomy to Restore Bilio-enteric Continuity after Choledochal Cyst Excision in Children:

Introduction: Any surgical procedure which would restore the bilio-enteric continuity after excision of the choledochal cyst with minimal complications would be a feasible alternative to Hepaticojejunostomy using a Roux loop of jejunum. To determine the outcomes of Hepaticoduodenostomy done over T-Tube against Roux-en-Y Hepaticojejunostomy for bilio-enteric reconstruction after excision of choledochal cyst. Materials and Methods: This study was retrospectively done on all patients of choledochal cysts (Types 1 and 4) operated between January, 2014 and December, 2019. The clinical details, intra-operative and post-operative results of patients who underwent Roux-en-Y Hepatico-Jejunostomy (Group-1) and Hepatico-duodenostomy over T-Tube (Group -2) for establishing bilio-enteric continuity after excision of choledochal cyst were compared and analyzed statistically. Results: 78 patients of choledochal cysts were operated during this period with 31 patients in Group-1 and 47 in Group-2; there was no difference in the mean age or size of the cysts in the two groups; Type 1 cysts were the most common with female preponderance in both groups. Group-2 patients had lesser intra-operative time andfewer numbers of sutures were used during surgery. There was no difference in the incidence of anastomotic leaks, strictures, cholangitis or adhesive obstruction and reoperation rates between the two groups. Group 2 showed increased nasogastric bilious aspirates in 19.15% of cases which improved on conservative management. Conclusion: Bilio-enteric reconstruction using Hepaticoduodenostomy over T-Tube is a simpler, lower pressure and less time taking anastomotic technique with comparable complication rates when compared to Roux-en-Y Hepaticojejunostomy in the management of choledochal cysts.

Long-term follow-up of minimally invasive surgery for the management of major bile duct injury due to cholecystectomy

Presenter: Gabriel Rangel-Olvera MD, MSc | Hospital General "Dr. Manuel Gea Gonzalez" Background: The post-cholecystectomy bile duct injury (BDI) is a life threatening condition, where severe cases require surgical intervention with a bilioenteric reconstruction. The results from minimally invasive (MI) approaches for the BDI repair studies have proven short term safety and feasibility; however they lack of middle long term follow-ups. The aim of the study is to show the patency and follow-up after 5 years of MI BDI repair. Methods: This is a retrospective comparative study of our prospectively collected database of patients with BDI who underwent robotic or laparoscopic hepaticojejunostomy; demographic and surgical variables were collected. Follow-up medical appointments were made at one month, three months, six months, 1 year, and then every year. At each appointment patency evaluation was done by evaluating the patient general condition, signs of cholangitis, stenosis, liver function tests and other postoperative complications. Results: Forty-six bile duct repairs(37, 80.43% by laparoscopic and 9, 19.57% by robotic-assisted approach) treated from June of 2012 to February of 2016 that have completed at least 5 year follow-up were evaluated. 37(80.43%) were female and 9(19.57%) male, the mean age was 41.28(19-77). The types of BDI were as follow: E1 (3,6.52%), E2 (11,23.91%), E3 (17,36.96%), E4 (12,26.09%) and E5 (3,6.52%); dividing the BDI by severity 31(67.39%) were Grade 2 and 15(32.61%) were Grade 3; also 11(23.91%) presented arterial injury and 4(8.7%) bilioenteric fistula (3 to the duodenum and one to the colon). All patients achieved the primary patency after the 90 days of the index treatment; during the follow-up. Three patients lost their primary patency, two of them requiring endoscopic intervention and 1 surgical re-intervention; achieving secondary patency after this intervention and maintaining this condition during the rest of the follow-up. Conclusion: The present study demonstrates good long-term results of bile duct injury reconstructions using laparoscopic and robotic surgery. These approaches are safe and effective alternative giving the benefits of MIS even in this complex entity.

Robotic Single Site Plus One Port: Choledochal Cyst Excision

Introduction: Choledochal cysts in adults are rare and the treatment requires complete excision of the cyst with bilio-enteric reconstruction. Here, we present three cases of robotic single site plus one port choledochal cyst excision with roux-en-Y hepaticojejunostomy.

Minimally invasive surgery for the management of major bile duct injury due to cholecystectomy.

In recent years there has been a growing interest in the application of minimally invasive surgery in the management of cholecystectomy-related injury to the biliary tract. The aim of this analysis was to identify and combine the available evidence on the argument, with particular reference to major injuries to the main bile duct requiring biliodigestive anastomosis. The PubMed/MEDLINE, Embase, and Web of Science electronic databases were queried through May 2019. Inclusion criteria considered all studies reporting detailed data about patients with bile duct injury following cholecystectomy receiving minimally invasive (both laparoscopic and robotic) surgical repair. Clinical outcomes data were pooled and analyzed. A total of 31 studies reporting on the outcomes of 218 patients were eventually included in the analysis, whereby 148 patients with type D or E injury. Of these, there were 31 patients (21%) receiving direct bile duct repair and 117 patients (79%) undergoing bilioenteric reconstruction. Among patients with major bile duct injury, postoperative morbidity was 24%, being 12% the incidence of major complications and 6% the rate of patients requiring subsequent, further surgery. The absence of high-level evidences precludes the possibility to draw definitive conclusions. However, the available data derived from a growing number of centers demonstrate that minimally invasive surgery may offer its well-known advantages on postoperative outcomes also in the setting of severe iatrogenic injury to the bile ducts.

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

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

Technical aspects of surgical repair of complex iatrogenic biliary strictures

Background: Currently, iatrogenic bile duct injury during cholecystectomy remains a major concern in biliary surgery due to associated morbimortality, and optimal management is still a medical challenge. Definitive treatment depends on type of injury and time of diagnosis. Minor injuries can be successfully treated using endoscopic techniques with placement of stents. Nevertheless high-level injuries Bismuth 3 and 4 can accomplish good outcome with surgical reconstruction. At our Unit patients are referred to late repair, either for primary late repair or for retreatment after fail of bilioenteric reconstruction. Our aim is demonstrated the surgical technique to reconstruction of high-level biliary injury. Methods: In this video, it is demonstrated a technique to surgical reconstruction of a biliary stricture, Bismuth type 3-4, that involves the technique described by Machado et al. in 1986 associated to the dissection of right biliary duct as described by Straberg et al. in 2001. Results: A 29-year-old female was diagnosed with bilioenteric anastomosis (BEA) stricture (Bismuth 3). The BEA has been performed initially to repair biliary injury during laparoscopic cholecystectomy by the same team. Later patient was referred to our Center and submitted to a new side-to-side BEA. Patient was submitted to general anesthesia and received prophylactic ceftriaxone and metronidazole. Bilateral subcostal incision was performed. After identification of previous biliary anastomosis, an incision was performed in segment 4B just above hilar plate. Round ligament was dissected, umbilical fissure was opened and the liver bridge between segment 4 and 2/3 was divided until reaching left bile duct underside of segment 4. Left bile duct was opened anteriorly, exposing the entrance of left and right bile ducts. Dissection of hilar plate was performed continuing toward the right, passing into the liver at base of segment 5, circling the right duct in direction of right portal vein. Right duct was opened 0.5-to-1cm anteriorly. MR cholangiography and the final aspect of biliary dissection are showed in the Video. The liver is opened trough round ligament, crossing above hilar plate at the base of segment 4B, and circling right hepatic duct at segment 5. Note the large open of right and left hepatic ducts, exposing a health mucosa, and showing the ostia of posterior and anterior right hepatic ducts and left ducts. A Roux-en-y side-to-side hepaticojejunostomy is performed using a continuous running suture of 5.0 PDS. At the end, bilateral TRU-CUT liver biopsies were performed. A flat silicone drain was placed posteriorly to the anastomosis. Postoperative period was uneventful, without any complications. The pathologic examination revealed periportal non-ductopenic fibrosis, without bridging. Conclusion: Surgical repair of complex biliary strictures highly located can achieve excellent Results even when previous surgery has failed when performed in specialized Centers. Roux-en-Y hepaticojejunostomy should be performed with adequate mucosa apposition without the need of transanatomosis biliary stent.

Evaluating the Outcome of Direct Repair of Bile Duct Injury

AbstractBackground: Bile duct injury (BDI) during laparoscopic cholecystectomy is a surgical catastrophe with an incidence ranging. Between 0.3 to 1,4%. Many surgeons think that direct repair of BDI carries a high risk of stricture that is why the bilioenteric reconstruction is more popular.Aim of Study: Evaluating the results of direct repair in selected cases and compare it to the classic bilioenteric reconstruction.Methods: We had 2 groups, group A had direct bile duct repair and group B had bilioenteric reconstruction. The choice of doing the direct repair was based on the absence of risk factors for biliary complications. Both are compared as regards the presence of postoperative complications either leakage or stricture and hospital stay. All cases were done in Ain Shams university hospitals during the period between January 2013 until December 2017.Results: Bile leakage had happened in one case of group A (11%) and 2 cases of group B (16.7%) with no statistically significant difference, (p-value is 0.72). One case of group A (11.1%) had biliary stricture which was presented at 6 months follow up, managed first by ERCP and stent twice and required reconstruction by Roux en Y after 15 months. For group B, 2 cases had anastomotic strictures presented at 9 and 12 months. They were managed by PTC, dilatation, and stenting and followed by redo reconstruction of the anastomosis at 15 and 17 months after the surgery.Conclusions: Direct repair of the Bile duct can be safely done in properly selected patients with comparable results to bilioenteric reconstruction and no increase in the incidence of postoperative complications.

R1 resection in Hilar cholangiocarcinoma might not translate to inferior patient survival

Introduction: Hilar cholangiocarcinoma (HC) represents an aggressive tumor embedded in an anatomically sensitive area. Surgeons must balance the goal of obtaining negative margins with the need to preserve enough proximal tissue to permit a feasible bilioenteric reconstruction. This study aims to revisit the importance of obtaining an R0 resection when excising HC in the era of modern adjuvant therapy. Methods: A retrospective review of a prospectively maintained database was employed to compile a list of patients with HC who were taken to the operating room with curative intent at our institution from 2008 to 2016. Those cases that resulted in resection were subjected to further analysis, with a focus on oncologic outcomes. Patients with both R0 and R1 margins underwent adjuvant chemoradiation. Results: 100 patients were included in the study. 70 resections were aborted after diagnostic laparoscopy and liver/portal ultrasonography, either because of peritoneal metastasis, or local disease extending beyond what was seen on preoperative imaging. 30 patients underwent resection. Details of their cases and outcomes are included in Figure 1. There were no cases of R2 resection. 2 year overall and progression free survival were similar between R0 and R1 resection groups (p=0.86). Conclusions: As with the resection of any malignancy, principles of oncologic resection should be adhered to when resecting cholangiocarcinoma. Striving for microscopically negative margins is one of those principles; however, given the technical difficulty of obtaining a proximal margin, it should be considered that R1 resection does not preclude comparable outcomes.

Laparoscopic hepaticojejunostomy

Introduction: In laparoscopic pancreaticoduodenectomy (LPD) and resection of choledocal cysts (LRCC), hepaticojejunostomy (LHJ) is required for less invasive surgery. The authors present our procedure and feasibility. Methods: Between June 2014 and December 2017, 25 patients underwent LHJ (19 LPD and 6 LRCC). Synopsis of surgical procedure: Operators were limited to 2 surgeons with experiences more than 250 advanced laparoscopic surgeries. Cauterized jejunal orifice was placed in the ventral side. A polydioxanone surture (PDS II, 5-0) was placed in the 9 o'clock position for suturing the anterior wall. Another PDS II was placed in the 8 o'clock and ligated for continuous suture of the posterior wall toward 3 o'clock positon. Former thread was ligated and sutured continuously from the right side to the left side and tied together accomplishing LHJ. To avoid excessive tension to the anastomosis, jejunum was fixed to the cystic plate. Results: Median age was 62 year-old in LPD and 43.5 in LRCC, and male to female ratio was 12:13 and BMI 23 kg/m2. Although LHJ duration of the first 5 cases were 35 to 50 minutes, median time of the latest 5 cases was 19 (range 17–21) minutes. Anastomosis insufficiency was observed in one (4%) patient of LPD followed by biliary stricture after 11 months. No other biliary complications were observed with median follow-up time of 18 (1–41) months. Conclusion: Laparoscopic bilioenteric reconstruction is feasible within 30 minutes with acceptable morbidity. Further follow-up is required for long time outcomes.

R1 resection in hilar cholangiocarcinoma might not translate to inferior patient survival; an intention to treat analysis

Background: Hilar cholangiocarcinoma (HC) represents an aggressive tumor embedded in an anatomically sensitive area. Surgeons must balance the goal of obtaining negative margins with the need to preserve critical vascular structures as well as enough proximal tissue to permit a feasible bilioenteric reconstruction. This study aims to revisit the importance of obtaining an R0 resection when excising HC in the era of modern adjuvant therapy. Methods: A retrospective review of a prospectively maintained database was employed to compile a list of patients with HC who were taken to the operating room with curative intent at our institution from 2008 to 2016. Those cases that resulted in resection were subjected to further analysis, with a focus on oncologic outcomes. Patients with both R0 and R1 margins underwent adjuvant chemoradiation. Results: 101 patients were included in the study. 71 resections were aborted after diagnostic laparoscopy and liver/portal ultrasonography, either because of peritoneal metastasis, or local disease extending beyond what was seen on preoperative imaging (Bismuth-Corlette T4/MSK T3). 30 patients underwent resection. Details of their cases and outcomes are included in Fig. 1. There were no cases of R2 resection. 2 year overall and progression free survival were similar between R0 and R1 resection groups (p = 0.86). Nodal status, grade, and lymphovascular invasion were also similar between the two groups. Conclusion: As with the resection of any malignancy, principles of oncologic resection should be adhered to when resecting cholangiocarcinoma. Striving for microscopically negative margins is one of those principles; however, given the technical difficulty of obtaining a proximal margin, it should be considered that R1 resection does not preclude a comparable oncologic outcome, provided patients are treated with adjuvant chemoradiation.Table 1Demographics, perioperative data, and complication data for HC resectionCharacteristicQuantityDemographic and procedural data Patients taken to the OR with curative intent101 Procedures where resection was actually performed30Male, No. (%)21 (70%)Female, No. (%)9 (30%)Age in years, median (range)63.5 (39–79)Major hepatectomy performed, No. (%)25 (83.3%)Bile duct resection alone, No. (%)5 (16.7%)Oncologic details AJCC T stage No. (%)T12 (6.7%)T216(53.3%)T312 (40%) Histologic Grade, No. (%)Well differentiated (G1)4(13.3%)Well-moderately differentiated (G1-2)4 (13.3%)Moderately differentiated (G2)12 (40%)Moderate-poorly differentiated (G2-3)7 (23%)Poorly differentiated (G3)3 (10%) Tumor size in mm, median (range)29 (8–70) R0 resection17 (57.7%) R1 resection13 (43.3%) Cases with lymphovascular invasion, No. (%)7 (23.3%) Cases with positive lymph nodes, No. (%)9 (30%) Cases with perineural invasion, No. (%)25 (83%)Outcomes data 30 day mortality, No. (%)2 (6.7%) 90 day mortality, No. (%)3 (10%) Median follow up, months30.5 2 year overall survival (%)90% 2 year progression free survival (%)63.3%2 year PFS with R0 resection64.7%2 year PFS with R1 resection62.0% Time to recurrence in months, median (range)21.3 (3.8–52.1)Abbreviations: HC, hilar Cholangiocarcinoma: AJCC, American Joint Committee on Cancer; PFS, progression free survival Open table in a new tab Abbreviations: HC, hilar Cholangiocarcinoma: AJCC, American Joint Committee on Cancer; PFS, progression free survival

Robotic Roux-en-Y Bilioenteric Reconstruction.

The authors report technical details of robotic bilioenteric reconstruction done for variable indications: choledochal cyst and biliary stricture. Robotic bilioenteric anastomosis as alternative to open reconstruction, offers advantages of minimal access surgery without compromising the precision of open surgery for hilar dissection and reconstruction. Both patients recovered uneventfully and remain symptom-free 18 and 15months after surgery.

Incidence and Risk Factors for Organ/Space Infection after Radiofrequency-Assisted Hepatectomy or Ablation of Liver Tumors in a Single Center: More than Meets the Eye.

Surgical site infections (SSIs) and especially organ/space infection (O/SI) after resection or ablation of liver tumors are associated with increased morbidity and mortality. A secondary blood stream infection (BSI) is considered an O/SI but the exact prevalence is unknown. We aimed to investigate the incidence of O/SI and BSIs in a cohort of consecutive patients after liver resection or ablation, to seek for a possible connection between them and to search for potential risk factors. We reviewed all patients who underwent hepatic resection or intraoperative liver ablation between January 2012 and December 2016 in our department. We focused on age, gender, Child-Pugh score, preoperative biliary drainage, indication for surgery, type of resection, resection or ablation of tumor, need for bilioenteric reconstruction, additional procedure to hepatectomy, blood transfusion, operative time, postoperative admission to ICU, and antibiotic chemoprophylaxis. All positive cultures from intra-abdominal fluids and blood were recorded. O/SI and BSIs were diagnosed by the criteria set by Centers for Disease Control. All variables were compared between the group with O/SI and the group without infection. BSIs were associated with these infections also. Eighty-one consecutive patients with a mean age of 64 years were enrolled. Fifteen patients presented a positive culture postoperatively: intra-abdominal fluid in eight, blood cultures in six, and both blood and intra-abdominal fluid in one patient. The directly estimated incidence of O/SI amounted to 11.1%. Four blood cultures were secondary to O/SI, and the remaining two secondary to central line catheter. O/SI was diagnosed indirectly, through the BSI in an additional 4.9% of the patients, raising the incidence of SSI to 16%. Among the factors studied, only admission to the ICU was found to be statistically significant as a risk factor for the development of O/SI (p = 0.026). O/SI should be actively seeked for after liver surgery including blood cultures. Patients with affected physical status, comorbidities are in greater risk of developing O/SI.