Bilioenteric Anastomosis Research Articles

Ethanol ablation for refractory bile leakage after complex hepatectomy

BACKGROUND Only a few reports exist on the use of ethanol ablation for posthepatectomy bile leakage. The aim of this study was to assess the value of ethanol ablation in refractory bile leakage. METHODS Medical records of consecutive patients who underwent a first hepatobiliary resection with bilioenteric anastomosis between 2007 and 2016 were reviewed retrospectively, with special attention to bile leakage and ethanol ablation therapy. Bile leakage was graded as A/B1/B2 according to the International Study Group of Liver Surgery definition. Absolute ethanol was injected into the target bile duct during fistulography. RESULTS Of the 609 study patients, 237 (38·9 per cent) had bile leakage, including grade A in 33, grade B1 in 18 and grade B2 in 186. Left trisectionectomy was more often associated with grade B2 bile leakage than other types of hepatectomy (P < 0·001). Of 186 patients with grade B2 bile leakage, 31 underwent ethanol ablation therapy. Ethanol ablation was started a median of 34 (range 15-122) days after hepatectomy. The median number of treatments was 3 (1-7), and the total amount of ethanol used was 15 (3-71) ml. Complications related to ethanol ablation included transient fever (27 patients) and mild pain (13). Following ethanol ablation, bile leakage resolved in all patients and drains were removed. The median interval between the first ablation and drain removal was 28 (1-154) days. CONCLUSION Ethanol ablation is safe and effective, and may be a treatment option for refractory bile leakage.

Laparoscopic left hepatectomy for Klatskin tumour

Introduction: Surgical management of hilar cholangiocarcinoma remains the only treatment option with curative intent and potential influence on overall survival. Methods: In our case report, we describe a complete laparoscopic resection of Klatskin's tumour which consists of left hepatectomy with intracorporeal biliary reconstruction with Roux-en-Y hepaticojejunostomy. Results: A 28-year-old woman presented with obstructive jaundice without other symptoms. Her CEA, Ca-125, AFP and Ca 19-9 values were normal. CT, ERCP and MRCP showed a Bismuth type III.b. neoplastic lesion, without vascular involvement. Diagnostic laparoscopy was performed with ultrasonography. Cholecystectomy with resection of the extrahepatic biliary ductal system and transection of prestenotic right biliary branch was done. Left branches of the hepatic artery and portal vein were clipped and hepatoduodenal lymphadenectomy were performed. Segment II-IV were removed without caudate lobectomy and left hepatic vein was clipped. After removal the specimen through a minilaparotomy and construction a Roux-en-Y loop bilioenteric anastomosis was performed using total laparoscopic procedure. The operation time was 255 minutes with intraoperative blood loss of 200 ml. The pathologic result showed a GII., pT2b, pN0 primary hilar cholangiocarcinoma with all resected margins and nodes free of tumour (0/4), with perineural but no vascular invasion. The postoperative hospital stay was uneventful and the patient was discharged on day 14. The patient had adjuvant gemcitabine, 5-FU combination chemotherapy. The patient is well at 12-month visit with normal results of liver function test and MRCP. Conclusion: Laparoscopic resection is a feasible surgical approach in selected patients with hilar cholangiocarcinoma.

Magnetic compression anastomosis for the complete dehiscence of hepaticojejunostomy in a patient after living-donor liver transplantation

BackgroundMagnetic compression anastomosis (MCA) is a minimally invasive method of anastomosis that does not involve a surgical procedure in patients with stricture, obstruction, or dehiscence of anastomosis after surgery. We experienced a case of complete dehiscence of bilioenteric anastomosis that was successfully treated by MCA.Case presentationA 55-year-old woman received ABO-incompatible right-lobe living-donor liver transplantation with hepaticojejunostomy for the right anterior duct (RAD) and right posterior duct (RPD). Nineteen days after the operation, bilious and bloody discharge was detected from the abdominal drain. We performed an emergency operation and found that the anastomosis was completely dehiscent. We placed bile drainage catheters into the stumps of the RAD and RPD. She repeatedly experienced cholangitis after the surgery, so we added percutaneous transhepatic cholangial drainage (PTCD) tubes. We decided to treat the complete dehiscence of anastomosis by MCA. One year after the liver transplantation, we performed MCA for the RAD. The bilioenteric fistula was completed 21 days after MCA, and the magnets were retrieved by double-balloon endoscopy. Two months later, MCA for the RPD was also performed by the same procedure. The bilioenteric fistula was not completely established, so we performed double-balloon endoscopy and pulled the magnets down 47 days after MCA for the RAD. The internal/external bile drainage tubes were then left in place to maintain the bilioenteric fistula. Twelve months after MCA for the RAD and 19 months after MCA for the RPD, we removed the tubes without any complications.ConclusionMagnetic compression anastomosis for stricture, obstruction, or dehiscence of the anastomosis after living-donor liver transplantation was an effective and safe procedure.

Factores asociados a reingreso hospitalario precoz posterior a resecciones hepáticas y pancreáticas

Aim: T o determine readmission rates and its associated factors in patients undergoing pancreatic and hepatic resections at our center. Matherial and Methods: Perioperative variables of patients undergoing pancreatic and hepatic resections between 2012-2014 were reviewed. Demographic and perioepartive data, as well as up –to postoperative day 30– readmisson rates were analyzed. Emergency cases, postoperative mortality and/or patients undergoing less extensive surgery (less than 2 Couinaud´s segments, non-anatomical resections and non resective cases such as bilioenteric anastomoses) were excluded. Readmission associated factors were identified using both univariate (c2 for categorical and t-student´s/Mann-Whitney for continuous variables) and multivariate (logistic regression) analysis. Results: 116 cases were included, 50.9 % female. Mean postoperative stay was 14 days. Pancreatic adenocarcinoma was the most frequent diagnosis (25.9%), and the 40.5% of surgical procedures were pancreaticoduodenectomy. Overall 30-day readmission rate was 18.1%, with a 23.7% for pancreatic resections and 12.2% for hepatic resections. According to univariate analysis; readmission associated factors were: pancreatic resection, preoperative White cell count, the development of postoperative complications and postoperative length of stay. On Multivariate analysis only postoperative stay was the only significant associate factor [OR 1,2 CI 95% 1.1- 1.5 (p = 0.001)]. Conclussion: Readmission rates after pancreatic and hepatic resections are elevated, even in high-volume centers. Postoperative length of stay is a consistent risk factor for readmission after these type of surgeries. We highly recommend including this parameter as a quality marker of our surgical results in our country.

Pyogenic Liver Abscess of Biliary Origin: The Existing Problems and Their Strategies.

Pyogenic liver abscess (PLA) of biliary origin in Southeast Asia mainly occurs in patients with intrahepatic bile duct stone (IBDS) and extrahepatic bile duct stone (EBDS), bilioenteric anastomosis, or biliary stent. IBDS, as an endemic to Southeast Asia, remains a frequent etiology of acute cholangitis and PLA. PLA related to IBDS is characterized by high incidences of PLA recurrence and death related to infection, and difficulties in diagnosis of concomitant cholangicarcinoma. PLA of biliary origin is more likely caused by Escherichia coli, more often presented as polymicrobial infections, and more associated with extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae isolates. In this review, the authors summarize the differences on the presumed causes, pathogens, multidrug resistance, treatment, and prognosis of PLA between biliary origin and cryptogenic origin, the latter serving as a first and foremost presumed etiology of PLA. The authors also discuss the existing problems on early diagnosis of concomitant cholangicarcinoma related to IBDS.

Role of Interventional Radiology in the Management of Postoperative Biliary Complications

Background: Biliary postoperative complications include biliary stenoses, biliary leaks, fistulas and collection or abscess formation. These complications usually occur due to injury after laparoscopic cholecystectomy, gastric or hepatic resection, bilio-enteric anastomosis and after liver transplantation. In most of the cases a new surgical intervention is not possible. Endoscopic intervention is usually the optimal initial management of these complications; however, in patients with altered enteric passage, tight low biliary stricture, high up obstruction or leakage endoscopic approach becomes impossible. Therefore, the percutaneous trans-hepatic approach is of extreme importance in the diagnosis and treatment of the problem especially in complex cases Objective: This study aimed to highlight the spectrum of percutaneous cholangiographic findings and methods of treatment of postoperative benign biliary stenoses, biliary leaks and to detect its significance in management of these problems. Patients and Methods: This study was conducted in Theodor bilharz research institute (TBRI), Egypt from February 2013 to June 2018. 17 patients with benign postoperative biliary complications (stricture and leak) were treated with a percutaneous transhepatic procedure. Only adult patients (age >18 years) were included in the study. Results: All patients had cholestasis and/or bile leak according to clinical and biologic findings (i.e., jaundice or an episode of cholangitis). Biliary obstruction and/or leak was confirmed by abdominal ultrasonography (US), multidetector computed tomography, and/or magnetic resonance (MR) cholangiography when US results were not conclusive and confirmation of the site & extension of the stricture and/or leak was needed. The results of the present study demonstrated that treatment of post-operative biliary complications (stricture and/or leak) by percutaneous transhepatic procedures was an effective option with acceptable rate of complication. Conclusion: We concluded that the percutaneous treatment of post- operative biliary complications is an effective alternative to surgery. This method should certainly be preferred when the local conditions were not favorable to a surgical repair, failure of endoscopic approach or when a recurrence was observed after an unsuccessful previous repair. Its advantages compared with surgery were its minimally invasive nature, reduced risk of complications, and the fact that all options remain open in case of failure.

Preliminary results of surgical repair of iatrogenic biliary strictures

Introdução: A estenose cicatricial de vias biliares permanece uma complicação crítica de colecistectomias, com consequências devastadoras para o fígado e risco de morte. Objetivo: Avaliar os resultados a longo prazo da correção cirúrgica de lesão iatrogênica de vias biliares realizada em um único centro. Metodologia: Pacientes submetidos a correção cirúrgica de lesão iatrogênica de vias biliares entre 1990 e 2016 foram avaliados retrospectivamente. As informações foram coletadas dos prontuários e da base de dados eletrônica HCMED. Os resultados preliminares foram analisados pela comparação de frequências ou médias aritméticas com desvio-padrão dos parâmetros estudados. Resultados: Foram incluídos 158 casos no estudo, 81% mulheres e com idade média de 45,54 anos. Os sintomas mais frequentemente apresentados foram icterícia (em 79,11% dos casos), dor abdominal (59,49%), colúria (52,53%), acolia ou hipocolia fecal (47,47%), febre (44,3%), prurido (34,18%) e perda de peso (27,22%). A estenose de vias biliares foi secundária a colecistectomia convencional em 63,92% dos casos, a colecistectomia laparoscópica em 22,15%, e a colecistectomia não-especificada em 13,92%. Os pacientes foram divididos de acordo com o diagnóstico de estenose de via biliar (EVB), n=93 casos (58,86%), ou estenose de anastomose bilio-digestiva (EABD), n=65 casos (41,14%). No grupo EVB, níveis de bilirrubina, ALT, AST e GGT eram significativamente mais altos no pré-operatório que no pós-operatório. No grupo EABD, níveis de bilirrubina, AST e GGT eram significativamente mais altos no pré-operatório que no pós-operatório, entretanto não houve diferenças nos níveis de ALT. Recidiva da estenose ocorreu em 5 casos do grupo EVB, e em 7 casos do grupo EABD. A sobrevida no grupo EVB foi de 98,92% em 1 ano e 97,85% em 5 anos; e no grupo EVB, 98,64% e 95,38%, respectivamente. Conclusões: A correção cirúrgica de lesões complexas de vias biliares tem uma taxa de sucesso de 89,87% quando realizada em serviços de referência.

Magnetic Anastomosis for Biliojejunostomy: First Prospective Clinical Trial.

Magnetic compression anastomosis (magnamosis, MCA) has been verified safe and effective by us and others in animal bilioenteric anastomosis (BEA). The objective of the present study was to introduce clinical application of magnetic compression bilioenteric anastomosis (MC-BEA) with a unique device in series of patients. Patients with obstructive jaundice with an indication of BEA were prospectively enrolled from 2012 to 2015. After dissection of bile ducts, the mother ring and drainage tube were placed in the proximal bile duct and the purse-string suture was tightened over the drainage tube. The drainage tube was introduced into the jejunal lumen at the anastomotic site and used to guide the daughter ring to assemble with the mother ring. All the patients were routinely followed up for magnets discharge or any complications associated. Forty-one patients were included. Thirty-four (82.9%) patients had a malignant primary disease, while seven (17.1%) had benign disease. The median time for MC-BEA was 10.5min (interquartile range [IQR] 8.3-13.0min). No perioperative morbidity or mortality associated with MC-BEA was observed. The median time for a patent bilioenteric anastomosis formation was 19.0days (IQR 14.5-23.0days), and the magnets were discharged with a median postoperative duration of 35.0days (IQR 28.0-43.0days). With a median follow-up of 547.5days (range 223-1042days), no patients had biliary fistula, while two (4.9%) developed anastomotic stricture at 4months and 14months after surgery, and underwent reoperation for reconstruction of BEA. MCA is a safe, effective, and time-saving modality for biliojejunostomy.

Minimal Risk of Biliary Tract Complications, Including Hepatic Abscess, After Transarterial Embolization for Hepatocellular Carcinoma Using Concentrated Antibiotics Mixed with Particles.

To assess the incidence of biliary complications, cholecystitis, and abscess formation in HCC patients following transarterial embolization (TAE) using particles mixed with concentrated antibiotics. Retrospective review of HCC patients treated with embolization over a 10-year period revealed 499 procedures in 257 patients. TAE was performed with particles mixed with concentrated antibiotics in addition to IV antibiotics. All follow-up imaging after treatment was retrospectively reviewed for the development of bilomas, biliary strictures, acute cholecystitis, and hepatic abscess. Clinical notes and laboratory tests were also reviewed. Mean follow-up duration was 18.2months. In total, there was one biliary complication consisting of biloma formation. This patient had subsegmental hepatic infarction identified on imaging 8days post-embolization in the setting of subsegmental portal vein thrombus, with subsequent biloma development. There were no cases of new biliary strictures in the embolized portion of the liver at any point after treatment. One patient developed acute gangrenous cholecystitis 10days post-procedure. No patients developed a hepatic abscess, although 10 patients had bilioenteric anastomoses or incompetent sphincters of Oddi. Biliary complications and cholecystitis occurred extremely rarely after TAE, at a markedly lower rate than historical data on TACE. Despite significant risk factors for abscess formation in 10 patients, TAE with particles mixed with concentrated antibiotics resulted in zero abscesses, in contrast to a very high rate after TACE in the literature.

Ethanol ablation for refractory bile leakage after complex hepatectomy.

Only a few reports exist on the use of ethanol ablation for posthepatectomy bile leakage. The aim of this study was to assess the value of ethanol ablation in refractory bile leakage. Medical records of consecutive patients who underwent a first hepatobiliary resection with bilioenteric anastomosis between 2007 and 2016 were reviewed retrospectively, with special attention to bile leakage and ethanol ablation therapy. Bile leakage was graded as A/B1/B2 according to the International Study Group of Liver Surgery definition. Absolute ethanol was injected into the target bile duct during fistulography. Of the 609 study patients, 237 (38·9 per cent) had bile leakage, including grade A in 33, grade B1 in 18 and grade B2 in 186. Left trisectionectomy was more often associated with grade B2 bile leakage than other types of hepatectomy (P < 0·001). Of 186 patients with grade B2 bile leakage, 31 underwent ethanol ablation therapy. Ethanol ablation was started a median of 34 (range 15-122) days after hepatectomy. The median number of treatments was 3 (1-7), and the total amount of ethanol used was 15 (3-71) ml. Complications related to ethanol ablation included transient fever (27 patients) and mild pain (13). Following ethanol ablation, bile leakage resolved in all patients and drains were removed. The median interval between the first ablation and drain removal was 28 (1-154) days. Ethanol ablation is safe and effective, and may be a treatment option for refractory bile leakage.

Percutaneous biliary intervention as an initial treatment for injury of the bile duct

Background: Percutaneous biliary drainage (PTBD) has been used to treat surgical bile duct injuries and as an adjunct to repair surgery.Objective: To present the results of PTDB in a consecutive series of patients with surgical injuries or sequelae of surgical repairs of the bile duct.Material and methods: Patients initially treated with PTBD were analyzed. Strasberg classification was used and recorded: type of operation, surgical approach, number of reoperations, biliary repair attempts and clinical presentation. In patients with bilioenteric continuity, percutaneous biliary treatment was the first option. PTBD was evaluated in the pre, intra and postoperative period and inthe pre dilatation period.Results: At the Hospital Argerich, from 2000 to 2014, 76 patients were included, 68.4% women and 97% post cholecystectomy. The lesions were Type E2 to E5 in 77% of cases. The percentage of patients with controlled symptoms before surgery or percutaneous dilatation was: jaundice 59%, cholestasis 5%, cholangitis 91%, biliary fistula 87%, pruritus 90%, withdrawal hepaticostoma or T-Kehr 91%. In 13 of 16 patients with external biliary fistula, the catheter could be internalized to abdominal cavity. In 70% of 52 operated patients, the catheter facilitated the identification of the proximal biliary duct. In the postoperative period, there were no biliary fistulas of the bilioenteric anastomoses and 3 patients with residual biliary stenosis and 2 with isolated biliary segments were detected and treated.Conclusion: PTBD is helpful in the pre, intra and postoperative treatment of patients with surgical bile duct injuries.

DOUBLE BALLOON ENTEROSCOPY IN THE DIAGNOSTICS AND TREATMENT OF CHRONIC PANCREATITIS SURGERY COMPLICATIONS

Aim. To assess double balloon enteroscopy for diagnostics and treatment of pancreatojejunostomy complications after pancreatic surgery. Material and Methods . For the period 2010–2015 twenty patients with suspected disorders in the area of pancreatojejunostomy underwent transoral (antegrade) examination of the pancreatojejunostomy using double balloon enteroscopy. Results . Pancreatojejunostomy was examined in 17 cases (85.0%). There were no complications. In the 11 cases postoperative complications of pancreatojejunostomy were identified including stricture and failure of pancreatojejunostomy, anastomotic stricture of intrapancreatic bilioenteric anastomosis, residual stones in pancreatic duct. It was performed 9 minimally invasive operations in the area of pancreatojejunostomy using double balloon enteroscopy and surgical laser. Herewith in 4 cases indications for open surgery were established. Conclusion. Double balloon enteroscopy is perspective method in diagnosis and minimally invasive correction of complications of pancreatojejunostomy. It is a useful tool in the survey of pancreatojejunostomy when we have pain recurrence after conventional surgery.

Congenital choledochal malformations in children: management strategies

Background: A Congenital Choledochal Malformations (CCM) is common congenital defect of biliary tree in Asian subcontinent. Presentations of CCM are vague from asymptomatic to life threatening cholangitis or pancreatitis. Complete cyst excision and bilioenteric anastomosis is now accepted surgical treatment.Methods: This is a retrospective study of five years duration. In this study the clinical presentation, haematological, biochemical and radiological findings, operative procedure and outcome were studied from case records.Results: Total of 20 patients were studied, with clinical presentation of recurrent abdominal pain in eight cases, previous history of cholangitis in five cases, acute cholangitis two cases, biliary peritonitis in four cases and previous history of pancreatitis in one case. In 13 cases Roux-en-Y hepaticojejunostomy (RYHJ) and in 4 cases hepaticoduodenostomy (HD) done after cyst excision. One case of type II CCM managed with only cyst excision, in two cases Lilly’s procedure, one case requires temporary external drainage and in two cases temporary internal drainage done in view on cholangitis and jaundice.Conclusions: However, the definitive treatment of CCM is complete cyst excision and bilioenteric anastomosis, though lot of other temporary majors are also required at different stages of disease.

Regression of Low Grade Biliary Dysplasia Following Endoscopic Stent Placement: A Case Report

Choledochoduodenostomy (CDD) is a surgical technique in which the common bile duct (CBD) is anastomosed to the duodenum to create a fistulous tract. We report a case of biliary dysplasia which reversed, and then reoccurred with the placement of an endoscopic fully covered metal stent (FCMS) then its removal in a patient who underwent remote CDD. A 60-year-old woman with history of cholecystectomy and CDD performed in the 1970s for symptomatic episodes of retained biliary stones presented with recurrent epigastric pain and associated unintentional weight loss over a six month period. MRI of the abdomen showed intrahepatic biliary and common hepatic ductal dilation, a focal moderate grade stricture in the mid-portion of the CBD measuring 0.6 cm in length, and a fistulous tract extending posteriorly from the lower portion of the stricture connecting to the first portion of the duodenum. ERCP with cholangioscopy using Spyglass DS was performed and the mucosa of the bile duct was observed to have been replaced by brush border-like small bowel epithelium. Intestinal contents were seen refluxing into the bile duct through the fistulous tract. Biopsies of the stricture revealed intestinal metaplasia, gastric foveolar hyperplasia, and low grade dysplasia. A FCMS was placed to seal the fistulous tract. Subsequently, the patient reported resolution of her abdominal pain, increased tolerance of oral intake, and weight gain. Four months later, a second ERCP was performed, the FCMS was removed, and biopsies of the bile duct were obtained, with findings of resolution of dysplasia while intestinal metaplasia and gastric hyperplasia persisted. The patient underwent a stent-free trial. Two months later, the patient reported the recurrence of her index pain and food intolerance. Repeated ductal biopsies demonstrated recurrence of dysplasia. Again, a FCMS was placed with repeated symptomatic improvement. The patient was then referred to a surgeon for surgical correction. The mechanism for regression of biliary dysplasia following endoscopic stent placement is not well understood, but one explanation is that cholangiocytes normally remain in a persistent mitotically inactive state, but may proliferate depending on the nature of the stimulus. This case report shows that endoscopic FCMS placement may be useful in treatment of biliary dysplasia in patients with bilioenteric anastomosis or fistula.Figure: Top left - MRI of the abdomen demonstrating the bilioenteric fistula and stricture. Top right - Visualization of the biliary stricture on cholangioscopy. Bottom left - Small bowel-like epithelium in the biliary system seen on cholangioscopy.Figure: Slide 1 - tissue section from the bile duct, an area of fistula showing low grade dysplasia. Slide 2 - same tissue section as Slide 1 stained with P53 immunostain. The epithelial cells show increased P53 staining with features supporting low grade dysplasia (4X, P53 immunostain). Slide 3 - tissue section with goblet cell (arrow) indicating intestinal metaplasia of biliary epithelium (40X, H&E stain). Slide 4 - tissue section showing MUC2 staining of goblet cells in biliary epithelium supporting intestinal metaplasia (4X, MUC2 immunostain). Slide 5 - Alcian blue staining of goblet cells supporting intestinal metaplasia (40X, Alcian blue-PAS stain). Slide 6 - increased MUC5AC staining supporting gastric foveolar hyperplasia (4X, MUC5AC immunostain).

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.

Bilioenteric anastomotic stricture in patients with benign and malignant tumors: prevalence, risk factors and treatment

Stricture formation at the bilioenteric anastomosis is a rare but important postoperative complication. However, information on this complication is lacking in the literature. In the present study, we aimed to assess its prevalence and predictive factors, and report our experience in managing bilioenteric anastomotic strictures over a ten-year period. A total of 420 patients who had undergone bilioenteric anastomosis due to benign or malignant tumors between February 2001 and December 2011 were retrospectively reviewed. Univariate and multivariate modalities were used to identify predictive factors for anastomotic stricture occurrence. Furthermore, the treatment of anastomotic stricture was analyzed. Twenty-one patients (5.0%) were diagnosed with bilioenteric anastomotic stricture. There were 12 males and 9 females with a mean age of 61.6 years. The median time after operation to anastomotic stricture was 13.6 months (range, 1 month to 5 years). Multivariate analysis identified that surgeon volume (≤30 cases) (odds ratio: -1.860; P=0.044) was associated with the anastomotic stricture while bile duct size (>6 mm) (odds ratio: 2.871; P=0.0002) had a negative association. Balloon dilation was performed in 18 patients, biliary stenting in 6 patients, and reoperation in 4 patients. Five patients died of tumor recurrence, and one of heart disease. Bilioenteric anastomotic stricture is an uncommon complication that can be treated primarily by interventional procedures. Bilioenteric anastomosis may be performed by a surgeon in his earlier training period under the guidance of an experienced surgeon. Bile duct size >6 mm may play a protective role.

Acute Cholangitis After Bilioenteric Anastomosis for Bile Duct Injuries

Background/PurposeThe study aims to describe the clinical features, microbiology, and associated factors of acute cholangitis (AC) after bilioenteric anastomosis (BEA) for biliary duct injury (BDI). Additionally, we assessed the performance of the Tokyo Guidelines 2013 (TG13) recommendations in these patients. MethodsWe conducted a case-control study of 524 adults with a history of BEA for BDI from January 2000 to January 2014. A propensity score adjustment was performed for the analysis of the independent role of the main factors identified during the univariate logistic regression procedure. ResultsWe identified 117 episodes of AC in 70 patients; 51.3% were definitive AC according to the TG13 diagnostic criteria, and 39.3% did not fulfill the imaging criteria of AC. A history of post-operative biliary complications (OR 2.55, 95% CI 1.38–4.70) and the bile duct confluence preservation (OR 0.46, 95% CI 0.24–0.87) were associated with AC. Eighty-nine percent of the microorganisms were Enterobacteriaceae; of them, 28% were extended spectrum β-lactamase (ESBL) producers. ConclusionsAC is a common complication after BEA and must be suspected even in the absence of imaging findings, particulary in patients with a history of post-operative biliary complications, and/or without bile duct confluence preserved. An empirical treatment for ESBL-producing Enterobacteriaceae may be appropriate in patients living in countries with a high rate of bacterial drug resistance.

Combined anterograde and retrograde method exposing porta hepatis for the treatment of intrahepatic cholangiocarcinoma invading porta hepatis

Objective To explore the surgical safety and clinical efficacy of combined anterograde and retrograde method exposing porta hepatis for the treatment of the intrahepatic cholangiocarcinoma invading porta hepatis. Methods The retrospective descriptive study was conducted. The clinicopathological data of 3 patients with left intrahepatic cholangiocarcinoma invading porta hepatis who were admitted to the Renji Hospital affiliated to Shanghai Jiaotong University School of Medicine from February 2015 to May 2016 was collected. All the 3 patients underwent left hemihepatectomy combined with caudate lobectomy after preoperative lab and imaging examinations and the evaluations of liver function and residual liver volume. The surgical procedures followed as: anterograde dissection of porta hepatis, exposure of hilar plate, left hemihepatectomy combined with caudate lobectomy, right artery resection and reconstruction, hilar cholangioplasty and bilioenteric anastomosis. Observation indicators included: (1) surgical situations: operation time, time of hepatic artery anastomosis and volume of intraoperative blood loss; (2) postoperative pathological examinations; (3) postoperative situations: postoperative complications (biliary fistula, hemorrhage, abnormal liver function, gastroplegia) and postoperative chemotherapy; (4) follow-up: postoperative patients′ survival and carcinoma occurrence. Follow-up was performed to by outpatient examination up to December 2016. The follow-up included clinical symptoms such as abdominal pain, chills, fever and jaundice, liver function and tumor marker examination, and color ultrasound Doppler or abdominal enhanced computed tomography (CT) was performed to detect carcinoma recurrence. Measurement data was represented as average (range). Results (1) Surgical situations: all the 3 patients underwent successful left hemihepatectomy combined with caudate lobectomy using combined antegrade and retrograde method exposing porta hepatis, including 1 combined with right hepatic artery resection and reconstruction, without perioperative death. The average operation time, average time of hepatic artery anastomosis and average volume of intraoperative blood loss of 3 patients were 493 minutes (range, 430-570 minutes), 11 minutes and 526 mL (range, 450-600 mL), respectively. (2) Postoperative pathological examination showed 3 patients were diagnosed with cholangio-carcinoma, 2 with nerve bundles invaded and 2 with No.12 lymph node metastasis, with negative margins of bile duct and hepatic artery. (3) Postoperative situations: 3 patients are not complicated with biliary fistula and gastroplegia. One patient with postoperative liver dysfunction after right artery resection and reconstruction underwent anti-infection, hepatoprotection and anti-hepatic encephalopathy therapies, and then was improved and discharged from hospital at 4 weeks postoperatively. The other 2 patients recovered steadily without complications such as hypohepatia, and then respectively discharged from hospital at 17 and 20 days postoperatively. All the 3 patients underwent chemotherapy of gemcitabine combined with S-1 for 8 courses at week 4 or 5 postoperatively. (4) Follow-up: all the 3 patients were followed up for 7-20 months, with good general conditions and normal liver function and without cholangitis symptoms. One patient received right artery reconstruction, and CT reexamination at postoperative month 3 showed fine imaging of right hepatic artery. There was no sign of carcinoma recurrence. Conclusion The combined anterograde and retrograde method exposing porta hepatis for the treatment of the intrahepatic cholangiocarcinoma invading porta hepatis can increase the radical resection rate and surgical safety. Key words: Biliary neoplasms, perihilar; Intrahepatic cholangiocarcinoma; Combined anterograde and retrograde method exposing porta hepatis; Artery reconstruction

Surgical procedures in liver transplant patients: A monocentric retrospective cohort study

BackgroundPre-existing chronic liver diseases and the complexity of the transplant surgery procedures lead to a greater risk of further surgery in transplanted patients compared to the general population. The aim of this monocentric retrospective cohort study was to assess the epidemiology of surgical complications in liver transplanted patients who require further surgical procedures and to characterize their post-operative risk of complications to enhance their medical care. Patients and methodsFrom January 1997 to December 2011, 1211 patients underwent orthotropic liver transplantation in our center. A retrospective analysis of prospectively collected data was performed considering patients who underwent surgical procedures more than three months after transplantation. We recorded liver transplantation technique, type of surgery, post-operative complications, time since the liver transplant and immunosuppressive regimens. ResultsAmong these, 161 patients (15%) underwent a further 183 surgical procedures for conditions both related and unrelated to the transplant. The most common surgical procedure was for an incisional hernia repair (n = 101), followed by bilioenteric anastomosis (n = 44), intestinal surgery (n = 23), liver surgery (n = 8) and other surgical procedures (n = 7). Emergency surgery was required in 19 procedures (10%), while 162 procedures (90%) were performed electively. Post-operative mortality and morbidity were 1% and 30%, respectively. According to the Dindo-Clavien classification, the most common grade of morbidity was grade III (46%), followed by grade II (40%). ConclusionSurgical procedures on liver transplanted patients are associated with a significantly high risk of complications, irrespective of the time elapsed since transplantation.

Endoscopic rendez-vous reconstruction of complete biliary obstruction

Background and study aimsComplete biliary strictures normally require surgical intervention. We describe an alternative, minimally invasive endoscopic/percutaneous rendez-vous technique for the reconstruction of complete benign biliary strictures. Patients and methodsComplete biliary strictures were reconstructed in four patients using a rendez-vous percutaneous-endoscopic or percutaneous-percutaneous route guided by fluoroscopic and visual (transillumination) control. ResultsAll four patients were treated successfully and safely with the rendez-vous technique. Complications were caused by the preliminary creation, dilatation and maturation of the percutaneous tract. ConclusionThis technique may offer a good alternative to surgical bilio-enteric anastomosis in experienced hands. The long term course of the patients treated remains to be seen.