Bilioenteric Anastomosis Research Articles

A Critical Analysis of Postoperative Morbidity and Mortality After Laparoscopic Radiofrequency Ablation of Liver Tumors

Although the laparoscopic approach provides certain advantages over the percutaneous radiofrequency thermal ablation (RFA), the morbidity needs to be defined. The aim of this study is to analyze the morbidity and underlying risk factors after laparoscopic RFA of liver tumors. Between 1996 and 2012, 910 patients underwent 1,207 RFA procedures for malignant liver tumors in a tertiary academic center. The 90-day morbidity and mortality were extracted from a prospective IRB-approved database. Statistical analyses were performed using regression, t, and χ (2) tests. Complications occurred in 50 patients (4%) and were gastrointestinal in 13 patients (1.1%), infections in 10 (0.8%), hemorrhagic in 9 (0.7%), urinary in 7 (0.6%), cardiac in 4 (0.3%), pulmonary in 3 (0.3%), hematologic in 2 (0.2%), and neurologic in 2 (0.2%). The complication rates for an RFA done alone (5%) versus concomitantly with ancillary procedure (6%) were similar (p=.6). In all patients who developed postoperative bleeding from the liver, the ablations had been performed on lesions located in the right posterior sector. Of 9 patients with bleeding, 5 (55%) required a laparotomy. Also, 60% of liver abscesses occurred in patients with a prior bilioenteric anastomosis (BEA). The 90-day mortality was 0.4% (n=5). Hospital stay was 1.2±0.1days and was prolonged to 4.4±0.3days in case of complications. This study describes the morbidity and mortality to be expected after a laparoscopic RFA procedure. Our results show that additional caution should be used to prevent bleeding complications in patients with tumors located in the right posterior sector and infections in patients with a history of BEA.

Needle-Knife Fistulotomy With Percutaneous Transhepatic Cholangioscopy for Managing Complete Bilioenteric Anastomosis Occlusion

Untreated benign biliary stricture can lead to serious complications including recurrent cholangitis, biliary cirrhosis, hepatic failure, and death. Benign stricture of a postoperative anastomosis site is also a problematic issue after biliary surgery. Percutaneous transhepatic cholangioscopy (PTCS) with balloon dilatation is a recently introduced noninvasive therapeutic option for biliary stricture. Guidewire insertion through the stricture site is essential for the success of PTCS treatment. Recently, we treated a difficult case with complete bilioenteric anastomosis stricture that failed to allow passage of the guidewire for balloon dilation. The stricture was treated with artificial bilioenteric fistula using a needle-knife papillotome during the PTCS.

Preservation of the arterial vascularisation after hepatic artery pseudoaneurysm following orthotopic liver transplantation: long-term results.

Hepatic artery pseudoaneurysm (HAP) is a serious complication of orthotopic liver transplantation (OLT). The aim of this study was to determine risk factors for HAP and the best management of this complication. Between 1990 and 2005, 787 OLT were performed at our center. Patients who developed HAP were identified from our prospective database and risk factors of HAP were identified. Management of HAP was analyzed retrospectively. There were 16 OLT (2.5%) complicated by HAP [median delay =13 days; range: 4-100 days]. Presentation was massive bleeding with shock (n=13), pain (n=2), or transient gastrointestinal bleeding (n=1). Bacteriological culture of HAP wall or ascites fluid was positive in 13 (81%) patients. Bilio-enteric anastomosis and biliary leak were identified as risk factors for HAP (p=0.011 and 0.002, respectively), whereas indication for OLT, surgical technique (full-graft OLT versus other techniques), and re-LT were not. Mortality rate after HAP rupture was 53% (7/13), but no deaths occurred in the 3 patients treated before rupture. Treatment included: excision and immediate revascularization [n=7; early mortality =2 (28%), long-term graft survival =4 (57%)], hepatic artery ligation [n=5; early mortality =3 (80%);, long-term graft survival with good liver function =0], and endovascular treatment [n=2; early mortality =0, long-term survival with good liver function =2]. HAP post-OLT carries a high mortality rate when detected after rupture, but recognition before rupture usually allows a successful outcome. Reconstruction with bilio-enteric anastomosis and postoperative biliary leak increase the risk for HAP. In these settings, CT with contrast injection should be performed to screen for HAP when there is any suspicion. Graft revascularization should be attempted whenever possible.

Surgery vs. Endoscopy Competitive or Complementary Tools for Management of Post Cholecystectomy Problems 10 Years’ Experience in Major Referral Center

Purpose: A prospective work to study and evaluate surgical and endoscopic techniques used in management of post cholecystectomy problems. Patients and Methods: In the period from Mars 2000 to October 2009, a random sample of 630 patients (366 females and 264 males) were collected from general surgery department, and gastro-intestinal endoscopy unit, Assuit University hospitals, and managed accordingly using surgery in 143 patients, and endoscopy in 482 patients (plus percutaneous techniques in 25 patients). Results: Endoscopy was very successful as an initial treatment of 457 patients (73%), as being less invasive, low morbidity and mortality, competitive to surgery in treatment of missed stone (88%), mild to moderate biliary leakage (82%), and biliary stricture (74%). Its success increased by addition of percutaneous techniques in 4%, 2.8% & 8.3% for missed stone, leakage, and stricture respectively. But endoscopy was somewhat complementary to surgery in major leakage, and massive stricture, and surgery was resold to in 15%, and 17% of cases. Surgery remain as the treatment of choice in complex problems, and endoscopy play a complementary role in such cases of transection, ligation, combined problems of stones, stricture, and leakage (<40%), compared to 60% for surgery. Bilio-enteric anastomosis was the procedure of choice, done in 86 cases, with stent splintage in unhealthy, or small sized ducts. And stricture complication was encountered in 6% of cases treated by percutaneous rout in 4, and redo surgery in 1 case. The learning curve seems influential in both endoscopy and surgery. The cumulative experience increase the success rate of endoscopy from initial 50% to 95% nowadays, also surgery improved with decreased morbidity and mortality as complications encountered was seen in initial experience and decreased with time. Conclusion: Endoscopy was competitive to surgery in simple problems and advised to be the initial treatment choice, but complementary in major leak, ligation, transection, and complex problems, where surgery plays the main role in treatment with its invasiveness, high morbidity and morbidity. Cumulative experience influence endoscopic and surgical treatment of such problems and it is mandatory with other facility and equipment for management of such challenging cases.

Clinical effects of early postoperative oral feeding versus traditional oral feeding after bilioenteric anastomosis

Clinical effects of early postoperative oral feeding versus traditional oral feeding after bilioenteric anastomosis

Utilidad de la coledocoscopia transquirúrgica en el tratamiento de litos biliares difíciles

Choledocholithiasis presents in 5-10% of the patients with biliary lithiasis. Numerous treatment algorithms have been considered for this disease, however, up to 10% of these therapeutic procedures may fail. Intraoperative choledochoscopy has become a useful tool in the treatment of patients with difficult-to-manage choledocholithiasis.To determine the usefulness of intraoperative choledochoscopy in the laparoendoscopic treatment of difficult stones that was carried out in our service.A cross-sectional study was conducted. The case records were reviewed of the patients that underwent intraoperative choledochoscopy during biliary tree exploration plus laparoscopic choledochoduodenal anastomosis within the time frame of March 1, 2011 and May 31, 2012, at the Hospital General Dr. Manuel Gea González. Transabdominal choledochoscopies were performed with active stone extraction when necessary, followed by peroral choledochoscopies through the recently formed bilioenteric anastomosis. The data were analyzed with descriptive statistics and measures of central tendency.The mean age was 71 years, 57% of the patients were women, and the ASA III score predominated. Active extraction of stones with 7 to 35mm diameters was carried out in 4 of the cases and the absence of stones in the biliary tract was corroborated in all the patients. The mean surgery duration was 18 minutes (range: 4 to 45min).Choledochoscopy is a safe and effective minimally invasive procedure for the definitive treatment of difficult stones.

Modified "Roux en Y" hepaticojejunostomy to permit transgastric endoscopic access.

To present an option technique during the accomplishment of a "Roux-en-Y" hepaticojejunostomy that, allows future transgastric endoscopic access to the biloenteric anastomosis. The side-to-side "Roux-en-Y" hepaticojejunostomy is carried through transmesocolic, retrogastric short tunnel. A distal jejunal loop of approximately 10,0 to 15,0 cm must be kept far from the anastomosis that allows its setting, without tension, in the anterior gastric wall bellow the small bending, between body and of the stomach antrum. Once the jejunal segment is fixed on the anterior gastric wall, this will allow future endoscopic access to the bilioenteric anastomosis, carried through transgastric punction guided by endoscopic-ultrasound (EUS). The modified "Roux en Y" hepaticojejunostomy is a simple and new technique to permit an alternative transgastric endoscopic access to bilioenteric anastomosis.

Intraoperative choledochoscopy usefulness in the treatment of difficult biliary stones

BackgroundCholedocholithiasis presents in 5-10% of the patients with biliary lithiasis. Numerous treatment algorithms have been considered for this disease, however, up to 10% of these therapeutic procedures may fail. Intraoperative choledochoscopy has become a useful tool in the treatment of patients with difficult-to-manage choledocholithiasis. ObjectivesTo determine the usefulness of intraoperative choledochoscopy in the laparoendoscopic treatment of difficult stones that was carried out in our service. Patients and methodsA cross-sectional study was conducted. The case records were reviewed of the patients that underwent intraoperative choledochoscopy during biliary tree exploration plus laparoscopic choledochoduodenal anastomosis within the time frame of March 1, 2011 and May 31, 2012, at the Hospital General Dr. Manuel Gea González. Transabdominal choledochoscopies were performed with active stone extraction when necessary, followed by peroral choledochoscopies through the recently formed bilioenteric anastomosis. The data were analyzed with descriptive statistics and measures of central tendency. ResultsThe mean age was 71 years, 57% of the patients were women, and the ASA III score predominated. Active extraction of stones with 7 to 35mm diameters was carried out in 4 of the cases and the absence of stones in the biliary tract was corroborated in all the patients. The mean surgery duration was 18minutes (range: 4 to 45min). ConclusionsCholedochoscopy is a safe and effective minimally invasive procedure for the definitive treatment of difficult stones.

MR Cholangiopancreatography of the Pancreas and Biliary System: A Review of the Current Applications

MR cholangiopancreatography (MRCP) is still a rapidly evolving technique, but it has been already accepted as clinically useful and is widely used to evaluate biliary or pancreatic diseases. The advantages of this technique are that it does not use contrast media or ionizing radiation, it is noninvasive and complication free, and the examination is relatively short. MRCP has high sensitivity and specificity for diagnosing biliary dilatation and for determining the site and cause of stenosis. With further improvements of hardware and technique, MRCP is expected to replace diagnostic endoscopic retrograde cholangiopancreatography to examine the biliary and pancreatic ducts in the near future. The other applications include evaluation of primary sclerosing cholangitis, stenosis after liver transplantation, and bilioenteric anastomoses. This article reviews the current applications of MRCP in the evaluation of the pancreas and the biliary system.

Portal biliopathy: multidisciplinary management and outcomes of treatment

Portal biliopathy (PB) is a rare condition in which portal hypertension because of extrahepatic portal vein obstruction can lead to biliary abnormalities, with some patients developing obstructive jaundice. At present, there is no international consensus on the management of PB. We present the experience of an Australian tertiary referral hospital with the diagnosis and management of PB, and compare this with reported international experience. The records of nine patients presenting with PB between June 2003 and March 2012 were reviewed and analysed. All patients had portal hypertension because of portal vein thrombosis, with seven patients showing cavernous transformation of the portal vein. Biliary abnormality presented with jaundice (3/9), abdominal pain (2/9) or without symptoms (3/9). All patients developed a cholestatic pattern of liver function tests (LFTs). First-line endoscopic management was employed in 7 of 8 symptomatic patients. Four patients required endoscopic management alone (sphincterotomy alone (1/9), single stent (2/9), repeated stent changes (1/9) ), while four required second-line surgical intervention (portosystemic shunt (1/9), bilioenteric anastomosis (3/9) ). All patients were well, with stable LFTs, at median 18-month follow-up, with two patients undergoing regular stent changes, and the remainder requiring no further intervention. PB can be managed successfully with endoscopic therapy as the first-line option, but a multidisciplinary approach is necessary, with second-line surgical intervention often required. We recommend a management algorithm similar to that presented in the UK PB literature, and confirm that bilioenteric anastomosis can be performed successfully without prior portal decompression.

The efficacy of double-balloon enteroscopy for intrahepatic bile duct stones after Roux-en-Y hepaticojejunostomy for choledochal cysts

Intrahepatic bile duct (IHBD) stones are one of the most complicated morbidities that occur after Roux-en-Y hepaticojejunostomy (RYH); however, the optimal therapeutic approach is controversial. Double-balloon enteroscopy (DBE) has been widely and frequently performed even in pediatric patients. We herein report the successful management of IHBD stones by biliary lithotripsy using DBE after RYH for a choledochal cyst (CC). DBE has made it possible to perform endoscopic therapeutic intervention, including balloon dilatation of an anastomotic stricture and removal of IHBD stones, without any major complications. DBE is a less invasive and safe treatment method for IHBD stones in pediatric patients, which is capable of reaching the bilioenteric anastomosis after RYH for CC.

Intraoperative Placement of External Biliary Drains for Prevention and Treatment of Bile Leaks After Extended Liver Resection Without Bilioenteric Anastomosis

Improved surgical techniques, substantial preoperative diagnostics, and advanced perioperative management permit extensive and complex liver resection. Thus, hepatic malignancies that would have been considered inoperable some years ago may be curatively resected today. Despite all this progress, biliary leakage remains a clinically relevant issue, especially after extended liver resection. Intraoperative decompression of bile ducts by means of distinct biliary drains is controversial. Although drainage is rarely used as a routine procedure, it might be useful in selected patients at high risk for biliary leakage. We describe surgical management of long-segment exposed or injured bile ducts after extended parenchymal resection with concomitant lymphadenectomy. Because blood supply to the bile duct may be impaired, the risk of biliary necrosis and/or leakage is significant. Internal splinting of the bile duct to ensure optimum decompression plus guidance might be helpful. Thus, in selected cases after trisectionectomy we inserted an external-internal or internal-external drain into long-segment exposed bile ducts. For internal-external drains the tube was diverted via the major duodenal papilla into the duodenum and then transfixed after the duodenojejunal flexure through the jejunal wall by means of a Witzel's channel. Because the entire bile duct is splinted, this technique is superior to bile duct decompression with a T-tube. This is supported by the course of a patient suffering biliary leakage after extended right-sided hepatectomy for colorectal metastasis. Initially, a T-tube was inserted for decompression, but biliary leakage persisted. After inserting transhepatic external-internal drainage, bile leakage stopped immediately. The patient's course was then uneventful. Five other patients (mostly with locally advanced hepatocellular or cholangiocellular carcinoma) treated similarly were discharged without complications. Drain removal 6 weeks postoperatively was uncomplicated in five of the 6 patients. In the sixth patient, external-internal drainage was replaced by a Yamakawa-type prosthesis for a biliary stricture. None of the patients suffered severe complications during long-term follow-up. The bile duct drainage technique presented in this study was useful for preventing and treating bile leakage after long-segment exposure of extrahepatic bile ducts during major hepatectomy. Transhepatic or internal-external drains are often used for bilioenteric anastomoses, but similar drainage techniques have not been reported for the native bile duct. T-tubes are generally used in this situation. In particular cases, however, inner splinting of the bile duct and appropriate movement of the bile via a tube can be helpful.

CT Findings of Afferent Loop Varices After Bilioenteric Anastomosis in Patients With Malignant Disease

The purpose of this study was to determine the prevalence and CT findings of afferent jejunal loop varices after bilioenteric anastomosis in patients with malignancy. The study included 99 patients who underwent bilioenteric anastomosis for malignancy and follow-up CT examinations. Two abdominal radiologists reviewed CT images for the presence of afferent loop varices. They also assessed for the presence of extrahepatic portal occlusion or stenosis, other collateral vessels, ascites, splenomegaly, and recurrent tumor. Clinical data regarding age, sex, and histories of pancreaticoduodenectomy and surgery on the portal vein, radiation therapy, and postoperative gastrointestinal bleeding were collected. Univariate and multivariate analyses were performed to discern significant factors associated with afferent loop varices. Cumulative incidence was estimated with the Kaplan-Meier method. Afferent loop varices were found in 22 of the 99 patients (22.2%), and the 48-month cumulative incidence of afferent loop varices was 28.0%. Three of the 22 patients (13.6%) eventually experienced gastrointestinal bleeding. Obstruction in the extrahepatic portal system was the only feature that exhibited a significant difference in multivariate analysis (relative risk, 71.4; 95% CI, 7.4-1000). Afferent loop varices detected after bilioenteric anastomosis on CT images had a prevalence of 22.2% and can result in gastrointestinal bleeding. The presence of obstruction in the extrahepatic portal system was significantly associated with afferent loop varices.

Liver Abscess After Transarterial Chemoembolization in Patients With Bilioenteric Anastomosis: Frequency and Risk Factors

The purpose of this study was to clarify the frequency of and risk factors for liver abscess formation after transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma or metastatic hepatic tumors after undergoing bilioenteric anastomosis. From January 1996 to June 2012, 25 patients (21 men, four women; age range, 34-74 years) with hepatocellular carcinoma (n = 12) or metastatic hepatic tumors (n = 13) with an underlying bilioenteric anastomosis underwent 65 TACE procedures. The incidence of liver abscess, predisposing factors (diabetes, Child-Pugh class, leukopenia, tumor number, tumor size, tumor burden, tumor type, portal vein thrombus, lipiodol dose, particulate embolization, embolization selectivity, oily portogram, antibiotic prophylaxis, and occurrence of liver abscess at initial TACE), and clinical outcome were evaluated. Statistical analysis for relations between liver abscess and predisposing factors was performed by Fisher exact test and linear-by-linear association. Liver abscess developed after 17 of 65 (26.2%) TACE procedures performed on 12 of 25 (48%) patients. Two patients died of progression of liver abscess into sepsis. Univariate and multivariate analyses showed that leukopenia (p = 0.029), occurrence of liver abscess at initial TACE (p = 0.082), and particulate embolization or oily portogram (grade 2) (p = 0.001) were associated with a higher incidence of liver abscess. The incidence of liver abscess was high among patients with bilioenteric anastomoses who underwent TACE. Leukopenia, occurrence of liver abscess at initial session of TACE, and particulate embolization or oily portogram (grade 2) were associated with the development of liver abscess.

Magnetic Compression in Gastrointestinal and Bilioenteric Anastomosis

The concept of compression alimentary anastomosis is well established. Recently, magnetic axial alignment pressures have been encompassed within such device constructs. We quantify the magnetic compression force and pressure required to successfully achieve gastrointestinal and bilioenteric anastomosis by in-depth interrogation of the reported literature. Reports of successful deployment and proof of anastomotic patency on survival were scrutinized to quantify the necessary dimensions and strengths of magnetic devices in (a) gastroenteral anastomosis in live porcine models and (b) bilioenteric anastomosis in the clinical setting. Using a calculatory tool developed for this work (magnetic force determination algorithm, MAGDA), ideal magnetic force and compression pressure were quantified from successful reports with regard to their variance by intermagnet separation. Optimized ranges for both compression force and pressure were determined for successful porcine gastroenteral and clinical bilioenteric anastomoses. For gastroenteral anastomoses (porcine investigations), an optimized compression force between 2.55 and 3.57 kg at 2-mm intermagnet separation is recommended. The associated compression pressure should not exceed 60 N/cm(2). Successful bilioenteric anastomoses is best clinically achieved with intermagnet compression of 18 to 31 g and associated pressures between 1 and 3.5 N/mm(2) (at 2-mm intermagnet separation). The creation of magnetic compression anastomoses using permanent magnets demonstrates a remarkable resilience to variations in magnetic force and pressure exertion. However, inappropriate selection of compression characteristics and magnet dimensions may incur difficulties. Recommendations of this work and the availability of the free online tool (http://magda.ucc.ie/) may facilitate a factor of robustness in the design and refinement of future devices.

Risk Factors for Early Bacterial Infections in Liver Transplantation

ObjectiveOur aim was to determine perioperative risk factors for early bacterial infection after liver transplantation. MethodsRetrospectively examining medical records using Centers for Disease Control and Prevention (CDC) definitions to identify nosocomial infections, we analyzed data on 367 adult patients. ResultsThe incidence of infection was 37.3% (n = 137): namely, surgical site (n = 4; 20.2%), blood stream (n = 64; 17.4%), pulmonary (n = 49; 13.4%), urinary system (n = 26; 7.1%). Significant risk factors within the first 30 days were as follows: deceased donor, Model for End-Stage Liver Disease (MELD) >20, albumin level <2.8 g/dL, intraoperative erythrocyte transfusion >6 U, intraoperative fresh frozen plasma >12 U, bilioenteric anastomosis, postoperative intensive care unit stay >6 days, and postoperative length of stay >21 days. Significant risk factors detected within the first 90 days were as follows: MELD >20, preoperative length of stay >7 days, reoperation, postoperative length of intensive care unit stay >6 days, and postoperative length of stay >21 days. Variability was observed in risk factors according to localization of infection. As a result, except for MELD, type of donor, and biliary anastomosis, the others are preventable factors for early bacterial infection. In addition, the same risk factors showed variability according to the site of infection.

Endoscopic Ultrasound-Guided Antegrade Treatments for Biliary Disorders in Patients with Surgically Altered Anatomy

Endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy is challenging. Several endoscopic ultrasound (EUS)-guided biliary access techniques have been reported as effective alternatives. EUS-guided antegrade treatments (AG) have been developed more recently but have not yet been studied well. To evaluate the feasibility and safety of EUS-AG for biliary disorders in patients with surgically altered anatomies. We retrospectively identified all the patients who underwent EUS-AG. The left intrahepatic bile duct (IHBD) was initially punctured from the intestine followed by cholangiography, antegrade guidewire manipulation, and bougie dilation of the fistula. Either antegrade biliary stenting (ABS) or antegrade balloon dilation (ABD) was performed depending on the biliary disorders. In stone cases, the stones were antegradely pushed out using a balloon. After ABD, a nasobiliary drainage tube was placed to prevent possible bile leak and to keep an access route for any possible repeat procedures. EUS-AG was attempted in seven patients including choledocholithiasis in five, malignant biliary obstruction in one, and bilioenteric anastomosis stricture in one. EUS-AG was not performed in one patient because EUS-cholangiography did not indicate the presence of stones. In the remaining six patients, the IHBD was successfully punctured, followed by cholangiography, guidewire insertion, and bougie dilation. ABS and ABD were successfully performed in one and five patients, respectively. Antegrade procedures with ABD were repeated twice in one patient. Mild complications were observed in two patients. EUS-AG for biliary disorders in patients with surgically altered anatomy is feasible. Further studies are warranted.

Complications and clinical outcomes of microwave ablation for liver metastatic cholangiocarcinoma after bilioenteric anastomosis

To explore the complications and clinical outcome of liver metastatic cholangiocarcinoma after microwave ablation (MWA) in patients with a history of pancreatoduodenectomy or liver resection with bilioenteric anastomosis. Retrospective study was made on 10 lesions of intra-hepatic metastatic cholangiocarcinoma undergoing MWA (range: 1.5 - 3.6 cm, mean: 3.3 ± 1.3 cm) in 6 patients (5 males and 1 female) from February 2008 to October 2011. All had a history of surgical resection for primary neoplasm and bilioenteric anastomosis. Four cases had intrahepatic biliary dilatation pneumatosis. All lesions were completely ablated according to the results of contrast-enhanced ultrasound (CEUS) or contrast-enhanced computed tomography/magnetic resonance imaging (CT/MRI) at Month 1 post-MWA. Liver abscess and fistula occurred in 5 ablation zones (5/10) of 4 patients. Three cases were satisfactorily cured with antibiotic dosing, catheter drainage and supportive care. One case died 13 days after MWA. The overall 1, 2, 3-year survival rates of were 64.8%, 21.6% and 21.0% respectively (median: 15.7 months). A high technical success rate of MWA is obtained in the treatment of intrahepatic metastatic cholangiocarcinoma with bilioenteric anastomosis. However, the incidence of abscess formation remains high due to a coexistence of multiple risk factors.

One‐stage Resection for Bismuth Type IV Hilar Cholangiocarcinoma with High Hilar Resection and Parenchyma‐preserving Strategies: A Cohort Study

Bismuth type IV hilar cholangiocarcinoma (HC) tumors are usually considered unresectable. The strategies of high hilar resection while preserving liver parenchyma can achieve potentially one-stage curative resection for this condition. The aim of the present study was to investigate the feasibility and safety of available strategies. Fifty-one consecutive patients with bismuth type IV HC who underwent one-stage resection were retrospectively reviewed with regard to curative resection rate, remnant liver volume, morbidity, mortality, and survival time. The total median survival time was 29 months. The R(0) (curative resection) rate was 57.8%. The ratio of the remnant liver volume (RLV) to the standard liver volume (SLV) ranged from 35.0 to 60.6%, with a mean of 44.5%. The in-hospital mortality and morbidity rates were 3.9 and 37.2%, respectively. In the R0 patients' survival, there was not a significant difference between bilioenteric anastomosis and hepatoenteric anastomosis (P = 0.714). Combined caudate lobe and high hilar resection (CCHR) is technically safe and oncologically justifiable and could be adopted with a high cure rate as a one-stage resection procedure for most patients with Bismuth type IV HC whose total bilirubin level is less than 20 mg/L and whose direct bilirubin is more than 60% of total bilirubin.

Percutaneous Approach for Removal of Difficult Common Bile Duct Stones

See Usefulness of Percutaneous Transhepatic Cholangioscopic Lithotomy for Removal of Difficult Common Bile Duct Stones by Jae Hyung Lee, Hyung Wook Kim, Dae Hwan Kang, et al., on page 65-70 Bile duct stone disease is one of the most common problems in medical practice. Surgical common bile duct (CBD) exploration was the procedure of choice for the treatment of bile duct stones a few decades ago. However, endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy has become the treatment of choice for bile duct stones after the development of ERCP techniques. Development of devices and techniques used in endoscopic sphincterotomy and stone extraction has increased the success rate of stone removal. Meanwhile, endoscopic sphincterotomy may be difficult or impossible in some clinical situations, including duodenal or pyloric stenosis, unusual biliary anatomy, previous gastrointestinal surgery such as Billroth II and Roux-en-Y gastrojejunostomy reconstruction, bilioenteric anastomosis, and patients' intolerance. As a surgical modality, laparoscopic biliary surgery has been widely used. Laparoscopic CBD exploration (transcystic or transcholedochal) is the most commonly used method for managing difficult CBD stones. However, general anesthesia is necessary to perform the surgery and the cost of the procedure is high. The success rate in performing laparoscopic CBD exploration is approximately 86% to 95% with 5% to 18% complication rates.1 Percutaneous transhepatic stone removal is another important technique among the nonoperative managements of bile duct stones. Percutaneous transhepatic stone extraction and expulsion into the duodenum was first reported in 1979.2 Percutaneous transhepatic cholangioscopy (PTCS) can be combined with these techniques. Balloon dilatation of the sphincter of Oddi has been widely used to facilitate stone removal procedure in order to allow biliary stone passage. Several techniques including basket forceps, electrohydraulic lithotripsy (EHL), and laser lithotripsy are now available for fragmentation of large stones.3 Variable major and minor complications of this technique including cholangitis, biliary pleural effusion, and self-limiting hemobilia have been reported. Lee et al.4 reported 100% success rate of PTCS lithotomy for removal of difficult CBD stones in 33 cases. EHL was used in most patients. Complications related with PTCS lithotomy, including fever, pancreatitis, and hemobilia, occurred in 15 patients (45.5%) but were ameliorated with conservative management. The mean procedure number of PTCS lithotomy was 2.8 and the numbers of EHL session were one session in 16, two sessions in nine, three sessions in five, and more than four sessions in two patients. The major indications of PTCS were altered anatomy due to previous stomach surgery (16 cases) and impacted stones (11 cases). Fifteen patients had prior cholecystectomy, but the paper did not mention the presence of gallbladder stone in another 18 patients with intact gallbladder. Because PTCS is an invasive procedure, declining quality of life and requiring additional time for dilatation, maturation and repeated procedure, this procedure should be considered in really difficult cases in which duodenoscope insertion into ampulla is impossible. If biliary cannulation is possible but stone is impacted in CBD, we should know that there are emerging new techniques such as endoscopic biliary lithotripsy using FREDDY laser5 and direct peroral cholangioscopy (POC) with ultraslim endoscopy.6 Holmium laser lithotripsy under direct POC using an ultrathin upper endoscope was also reported as an effective and safe technique for removal of difficult CBD stones.7 Laparoscopic CBD exploration and cholecystectomy are another options if the patients have both gallbladder and CBD stones and medical conditions which are tolerable to general anesthesia. Lee et al.8 reported that laparoscopic CBD exploration is a safe and effective treatment modality for CBD stones not only for younger patients but also for elderly patients (over 70 years). They suggested the laparoscopic CBD exploration as the first treatment strategy for difficult CBD stones as there were no significant differences in mean operation time, postoperative hospital stay, first meal time, recurrence rate, remnant stone, and complication or mortality rates in both groups. Because this study on PTCS lithotomy4 was a retrospective study conducted between 2008 and 2010, new techniques were not considered and PTCS lithotomy was done in cases with impacted CBD stones regardless of biliary cannulation by conventional ERCP. Nevertheless, this paper confirmed that PTCS lithotomy is a safe and effective treatment modality in difficult CBD stones if conventional ERCP with lithotripsy was impossible.