Bismuth Classification Research Articles

Laparoscopic end-to-end biliary reconstruction with T-tube for transected bile duct injury during laparoscopic cholecystectomy

PurposeThis report describes the laparoscopic end-to-end biliary reconstruction with T-tube for transected bile duct injury (BDI) during laparoscopic cholecystectomy.MethodsWe performed a retrospective descriptive analysis for all patients with a transected BDI at a single institution. We collected and analyzed data for injury site and type, reconstruction methods, conversion rate, previous intervention, and outcomes.ResultsBetween January 2014 and December 2017, 2,901 patients underwent laparoscopic cholecystectomy at a single institution. Among them, 8 patients experienced a transected BDI during laparoscopic cholecystectomy, so the surgeon performed laparoscopic end-to-end biliary reconstruction with T-tube. Our patient series consisted of 6 women (75%) and 2 men (25%) with a mean age of 48.3 years (median, 49 years; range, 29–77 years). Two cases were converted to open surgery. The most common injured site was the common bile duct (5 of 8, 62.5%). The most common injury type, using Bismuth's classification system, was type I (3 of 8, 37.5%). The mean operating time was 136.8 minutes (median, 135.0 minutes; range, 0–180.0 minutes). The mean hospital stay was 7.0 days (median, 4.5 days, range: 3.0–21.0 days). The mean follow-up was 36.4 months (median, 34.0 months; range, 16.0–63.0 months). We observed one postoperative complication during the follow-up period. The patient had an anastomosis site leakage and was cured after reoperation.ConclusionLaparoscopic end-to-end biliary reconstruction with T-tube for transected BDI during laparoscopic cholecystectomy seems to be safe and feasible in selected patients. However, long-term follow-up to identify complications from bile duct stricture remains important.

Outcome of combined complete excision of the caudate lobe with partial hepatectomy for treatment of resectable Klatskin tumors

Background and Aim of the Work: Combination of partial hepatectomy with complete excision of the caudate lobe was found to improve the outcome of resectable Klatskin tumors. In this prospective multicenter study, the outcome of these combined resections would be evaluated. Patients and Methods: This prospective study enrolled 72 patients with resectable Klatskin tumors. The study was conducted in Taif tertiary hospital and Ain Shams University Hospitals from January 2008 to December 2014. All patients underwent partial hepatectomy with complete excision of the caudate lobe after preoperative biliary drainage. The primary outcome was the resection margin (positive or negative), postoperative complications, and patient survival. Other outcomes included; the mean operative time, mean amount of blood loss, and prognostic factors correlated with survival. Results: The number of patients underwent combined resection were 72 patients, 49 males and 23 females with mean age of 58.3 ± 14.2 years. Mean operative time was 243 ± 57 min and the mean blood loss was 896 ± 211 ml. The recorded postoperative complications included; bile leak in 16.7%, wound infection in 15.3%, pleural effusion in 12.5%, liver failure in 4.2%, and liver abscess in 4.2%. Recorded hospital mortality was 5.6%. The resection margin was negative (R0) in 51/72 patients (70.8%). The overall mean survival during the follow-up was 48 ± 10.2 months. The estimated overall 5-year survival rate was 37.5% increased to 50.1% in R0 patients, and it was 4.8% when the margin was positive. There was a significant positive correlation between the patient survival and the negativity of the resection margin, and a negative significant correlation with the pretreatment level of carcinoembryonic antigen. Age, gender, Bismuth classification, and pretreatment level of carbohydrate antigen 19.9 had insignificant correlation with the survival. Conclusion: The excision of the caudate lobe with extended hepatic resection by the experienced hepatobiliary surgeon in properly selected patients survival has been proved to be safe and effective.

The role of percutaneous transhepatic biliary biopsy in the diagnosis of patients with obstructive jaundice: an initial experience.

ObjectiveTo evaluate the accuracy of percutaneous transhepatic biliary biopsy (PTBB) in patients with suspected biliary obstruction.Materials and methods This was a retrospective analysis of 18 patients with obstructive jaundice who underwent PTBB. In each patient, three to ten fragments were collected from the lesion. The final diagnosis was confirmed in the pathology report. We also reviewed analyses of the results of laboratory tests performed before the procedure, as well as the Bismuth classification, clinical outcome, complications occurring during the procedure, access route, and materials used.ResultsTechnical success was achieved in 100% of the PTBB procedures. Among the 18 patients clinically diagnosed with bile duct stenosis, the pathological analysis confirmed that diagnosis in 17. In one case, the pathological findings were considered false-negative. The predominant tumor was cholangiocarcinoma (seen in 50% of the cases). Sixteen of the procedures (88.9%) were performed without complications. Transient hemobilia occurred in one case, and cholangitis occurred in another.ConclusionPTBB is a safe, viable, simple technique with a high rate of true-positive results for the definitive diagnosis of obstructive jaundice.

The anatomical characteristics of patients with posterior bile duct stricture after a liver resection including anterior section

Introduction: When deciding to proceed with anterior sectionectomy or central bisectionectomy, the posterior duct anatomy must be carefully reviewed due to the high variation rate of the duct. Additional procedures or posterior sectionectomy may be needed if injury occurs leading to posterior bile duct stricture. Method: We reviewed the clinical data of patients who received liver resections including the anterior section such as anterior sectionectomy and central bisectionectomy from July of 2009 to September of 2018. We reviewed the type of bile duct anatomy according to the Bismuth classification and the right hepatic duct length was measured if the classification was type A. We excluded patients without MRI and patients who underwent hepaticojejunostomy. We divided patients into 4 groups according to the bile duct anatomy and risk factor analysis for right posterior bile duct stricture. Result: A total of 69 patients received central bisectionectomy or anterior sectionectomy. The type A bile duct was most common (n=42, 60.9%) and type B was the second most type (n=12, 17.4%). Five patient (7.2%) need PTBD or ERCP procedures due to biliary stricture and occurs in only type A. The length of right hepatic duct (RHD) was related to biliary stricture (AUC=0.889) and the sensitivity was 0.8 and specificity was 0.889 when the length of RHD is 12mm. In multivariate analysis, the RHD more than 12mm was significant (OR: 47.068, 1.469 – 1508, P=0.029). The median time to biliary stricture was postoperative 34 day (5-81) and the stricture was managed with ENBD and PTBD and successfully resolved. Conclusion: The RHD more than 12mm was the risk factor of the posterior biliary stricture in anterior or central bisectionectomy.

Lymphovascular invasion and surgical complications predict clinical outcome in patients with perihilar and intrahepatic cholangiocarcinoma

Background: Cholangiocarcinoma (CCC) is a relatively rare malignancy that is typically diagnosed at an advanced disease stage. Major liver resection with portal vein reconstruction has evolved as the mainstay of treatment for patients with perihilar (PHCC) and intrahepatic cholangiocarcinoma (IHCC). Despite recent advancements, the overall- (OS) and recurrence-free survival (RFS) in CCC remains lower than for most other solid tumors. Here we aimed to identify prognostic markers of clinical outcome in CCC-patients that underwent surgical resection in curative intent. Methods: Between 2010 and 2016, 162 patients with CCC (PHCC: n=91, IHCC; n=71) underwent surgery in curative intent at our institution. Preoperative characteristics, perioperative data and oncological follow-up were obtained from a prospectively managed institutional database. The associations of RFS and OS with clinico-pathological characteristics were assessed using univariate and multivariate survival analyses. Results: The median OS and RFS were 38 and 36 months for PHCC and 25 and 13 months for IHCC, respectively. Lymphovascular invasion (LVI) as well as surgical complications as assessed by the comprehensive complication index were independently associated with OS for the PHCC (LVI; Exp(B)=2.28, p=0.042; CCI; Exp(B)=1.04, p< 0.001) and IHCC cohorts (LVI, Exp(B)=5.08, p=0.028; CCI, Exp(B)=1.04, p=0.002), respectively. No other clinical variable including R0-status and Bismuth classification was associated with OS. Conclusions: Surgical resections for CCC are safe in experienced high-volume liver centers. Tumor and patient characteristics were not associated with clinical outcome. In patients with PHCC and IHCC, LVI and CCI are associated with OS, suggesting a similar tumor biology.

Preoperative Risk Score to Predict Occult Metastatic or Locally Advanced Disease in Patients with Resectable Perihilar Cholangiocarcinoma on Imaging

Many patients with resectable perihilar cholangiocarcinoma (PHC) on imaging are diagnosed intraoperatively with occult metastatic or locally advanced disease, precluding a curative-intent resection. This study aimed to develop and validate a preoperative risk score. Patients with resectable PHC on imaging who underwent operations in 2 high-volume centers (US and Europe) between 2000 and 2015 were included. Multivariable logistic regression analysis was used to develop the risk score. Cross-validation was used to validate the score, alternating the 2 centers as "training" and "testing" datasets. Of 566 patients who underwent operations, 309 (55%) patients had a resection, and in 257 (45%) patients, a curative-intent resection was precluded due to distant metastasis (n= 151 [27%]) or locally advanced disease (n= 106 [19%]). Preoperative predictors included bilirubin >2 mg/dL, bile duct involvement on imaging, portal vein involvement on imaging (≥180 degrees), hepatic artery involvement on imaging (≥180 degrees), and suspicious lymph nodes on imaging. The new risk score (c-index 0.75 after cross-validation) provided significantly more accurate predictions than the Bismuth classification (c-index 0.62), Blumgart T-staging (c-index 0.67), and cTNM staging (c-index 0.68). The new risk score identified 4 risk groups for occult metastatic or locally advanced disease: low (14.7%), intermediate (29.5%), high (47.3%), and very high risk (81.3%). The preoperative score groups also predicted survival after operation, irrespective of intraoperative findings (p<0.001). The validated risk score can predict occult distant metastatic or locally advanced PHC basedon 5 preoperatively available factors. The score can be useful in preoperative shared decision making and selection of patients in neoadjuvant clinical trials.

Management of cholecystectomy-induced biliary injuries at Zagazig University Hospital

Objective To evaluate the management strategies following bile duct injuries. Design and duration This was a prospective analysis conducted from March 2015 to March 2017. Setting The study was conducted at the Department of Surgery, Zagazig University Hospitals. Patients and methods The study included all patients who were admitted with iatrogenic biliary injuries during this period. The patients were evaluated according to their clinical features and certain laboratory and imaging investigations. After appropriate preparations, they were managed based on Bismuth Classification. Results A total of 27 patients presented with iatrogenic biliary injuries over a period of 2 years among all 420 cases that underwent cholecystectomy during this period. There were 16 females and 11 males, with a median age of 40 years. A total of 18 patients had laparoscopic cholecystectomy, whereas nine had open cholecystectomy. Twelve cases belonged to our unit whereas 15 were referred from other institutes. Four patients were detected intraoperatively, 15 patients presented with obstructive jaundice, four patients presented with biliary fistula, and four patients presented with collection. Of which, one had ultrasound-guided aspiration and five had endoscopic retrograde cholangiopancreatography (ERCP) stenting done, whereas two underwent peritoneal lavage with drain placement, 16 patients had hepaticojejunostomy, and one patient had choledechodoudenostomy. We had one postoperative mortality owing to hepatorenal failure. Conclusion Strategies need to be developed for dealing with bile duct injuries, with a view to reduce morbidity and mortality, as early recognition and timely management improve the outcome of these patients.

Peribiliary liver metastases MR findings.

We described magnetic resonance (MR) features of peribiliary metastasis and of periductal infiltrative cholangiocarcinoma. We assessed 35 patients, with peribiliary lesions, using MR 4-point confidence scale. T1-weighted (T1-W), T2-weighted (T2-W) and diffusion-weighted images (DWI) signal intensity, enhancement pattern during arterial, portal, equilibrium and hepatobiliary phase were assessed. We identified 24 patients with periductal-infiltrating cholangiocellular carcinoma. The lesions in 34 patients appeared as a single tissue, while in a single patient, the lesions appeared as multiple individual lesions. According to the confidence scale, the median value was 4 for T2-W, 4 for DWI, 3.6 for T1-W in phase, 3.6 for T1-W out phase, 3 for MRI arterial phase, 3.2 for MRI portal phase, 3.2 for MRI equilibrium phase and 3.6 for MRI hepatobiliary phase. According to Bismuth classification, all lesions were type IV. In total, 19 (54.3%) lesions were periductal, 15 (42.9%) lesions were intraperiductal, and 1 (2.8%) lesion was periductal intrahepatic. All lesions showed hypointense signal in T1-W and in ADC maps and hyperintense signal in T2-W and DWI. All lesions showed a progressive contrast enhancement. There was no significant difference in signal intensity and contrast enhancement among all metastases and among all metastases with respect to CCCs, for all imaging acquisitions (p value >0.05). MRI is the method of choice for biliary tract tumors thanks to the possibility to obtain morphological and functional evaluations. T2-W and DW sequences have highest diagnostic performance. MRI does not allow a correct differential diagnosis among different histological types of metastasis and between metastases and CCC.

679 Bismuth Classification of Hilar Cholangiocarcinomas Accurately Predicts the Clinical Outcomes and Survival Rates of Patients that Undergo Unilateral Versus Bilateral Endoscopic Palliative Stenting: Results of the Multicenter, International Collaborative Trial

679 Bismuth Classification of Hilar Cholangiocarcinomas Accurately Predicts the Clinical Outcomes and Survival Rates of Patients that Undergo Unilateral Versus Bilateral Endoscopic Palliative Stenting: Results of the Multicenter, International Collaborative Trial

Resection and Transplantation Technologies in Surgery of High Posttraumatic Cicatricial Strictures of the Bile Ducts

Aim. To improve surgical treatment of high posttraumatic biliary strictures. Material and Methods. The study included 17 patients with high scarry strictures of the bile ducts (SSBD) complicated by recurrent cholangitis and biliary cirrhosis. All of them underwent 3–8 various reconstructive surgeries. The cause of SSBD was iatrogenic injury of the bile ducts in all cases. E.I. Galperin and H. Bismuth classification was used to describe the type of strictures. Results. Various types of liver resection were carried out in 14 out of 17 cases: atypical resection of segment IV followed by bihepaticoenterostomy (4), left-sided (n = 6) and right-sided (n = 4) hemihepatectomy followed by biliodigestive anastomosis with lobar hepatic duct (4), three (3) and two (3) segmental ducts. Postoperative complications were observed in 3 cases with 1 death. Additionally, related right liver lobe transplantation (LT) was performed in 3 cases. Conclusion. Thus, resection and transplantation surgical interventions improve the outcomes in patients with high SSBD complicated by biliary cirrhosis and recurrent cholangitis.

Iatrogenic bile duct injury: experience of a multidisciplinary team in a Federal University in Brazil

Background: Iatrogenic bile duct injury (BDI) is the most feared complication associated with cholecystectomy. Despite laparoscopic improvments, inflammation of the gallbladder, anatomical variations, poor technique employed and bleeding are some of the risk factors associated with this injury. In this study, we aim the results of surgical treatment of BDI, with emphasis on clinical preoperative conditions, results and complications. Methods: Data from thirty three patients who had suffered a BDI were reviewed. The following variables were analyzed: gender, age, conditions of cholecystectomy, type of surgery, symptoms, classification of injury (Bismuth classification), treatment and complications. Results: Twenty two patients were female and eleven were male, with a mean age of 46.1 years. Twenty four patients (72.7%) had an open cholecystectomy and 9 (27.3%) had a laparoscopy approach. Only 1 patient underwent intraoperative cholangiography. Nine injuries (27.3%) were diagnosed intraoperatively. Twenty six patients (78.8%) had cholestasis, 6 (18.2%) had biliary fistula and 9 (27.3%) showed biliary peritonitis. Three patients (9.1%) had a type I injury, 14 (42.4%) type II, 10 (30.3%) type III, 5 (15.1%) type IV, and 1 (3.1%) type V. Hepaticojejunostomy was the most frequently performed surgery as definitive treatment for BDI (84.8%). Nine patients (27.3%) developed late complications, and 2 patients (6.1%) died. Conclusion: Most injuries occurred during open cholecystectomy and intraoperative cholangiography was rarely used. Therefore, few injuries were diagnosed intraoperatively. For most injuries, hepaticojejunostomy was performed as definitive surgical treatment due to the complexity of injuries.

Classification of hilar cholangiocarcinoma: a comparison study between three-dimensional ultrasonography and magnetic resonance cholangiopancreatography

Objective To investigate the accuracy and availability of three-dimensional ultrasonography(3DUS) in the Bismuth-Corlette classification of hilar cholangiocarcinoma(HCCA). Methods Forty-eight patients who underwent surgery and obtained pathologic diagnosis of HCCA were retrospectively analyzed. All patients underwent 3DUS and magnetic resonance cholangiopancreatography(MRCP) before surgery. With surgical outcomes as the gold standard, the diagnostic efficacy of two examinations in classification of HCCA were compared. Results Forty-eight cases of HCCA were divided into 5 types according to surgical results, including type Ⅰ (8 cases), type Ⅱ(13 cases), Ⅲa(8 cases), Ⅲb(11 cases) and type Ⅳ(8 cases) respectively. Among them, 39 cases accepted radical resection and the rest of 9 cases received palliative resection. The accuracy of the Bismuth classification confirmed by 3DUS was 85.4%(41/48). The percentage of underestimated and overestimated classification confirmed by 3DUS were 10.4%(5/48) and 4.2%(2/48) respectively. The accuracy of the classification confirmed by MRCP was 87.4%(42/48). Both of the percentage of underestimated and overestimated classification confirmed by MRCP were samely 6.3%(3/48). The difference between the 3DUS and MRCP was not statistically significant(χ2=0.597, P=0.440). Both the percentage of underestimated and overestimated classification between 3DUS and MRCP were samely not statistically significant (P=0.714, P=1.000, respectively). Conclusions As a new diagnostic technique, 3DUS was feasible and had significant value in evaluating HCCA classification comparable to MRCP. Key words: Ultrasonography, three-dimensional; Bile duct neoplasm; Magnetic resonance cholangiopancreatography

Recanalization of obstructed metallic uncovered biliary stent using endobiliary radiofrequency ablation

We present the case of a 57-year-old woman with a history of hilar cholangiocarcinoma type 3A of the Bismuth classification. A right hepatectomy after right portal embolization was planned. Finally, because peritoneal carcinomatosis was diagnosed during surgery, a palliative strategy was decided. Two uncovered metallic biliary stents (left and right hepatic ducts) were placed, and chemotherapy was started. Four months later, percutaneous placement of another metallic stent was necessary because of stent occlusion. Four months later, she was readmitted because of acute cholangitis resulting from stent re-occlusion. We used radiofrequency ablation for its recanalization (Video 1, available online at www.giejournal.org). After ERCP confirmed tumor ingrowth into the stent (Fig. 1A), a endobiliary radiofrequency ablation (RFA) catheter (Habib, EndoHPB, EMCision, London, UK) was inserted through the endoscope on a 0.035-inch guidewire. The distal tip of the catheter with the 2 electrodes was advanced through the stenosis under fluoroscopic guidance. Two RFA applications were performed (bipolar coagulation mode, maximum 10 W, 90 seconds). Necrotic debris was extracted by use of a balloon catheter. Stent clearance was confirmed by cholangiography (Fig. 1B) and tomography. Chemotherapy was resumed, and no further obstruction of the stent occurred during the following 6 months. Unfortunately, during follow-up, the patient died, but not of a biliary adverse event. This case illustrates the potential benefit and ease of use of endobiliary RFA for stent recanalization. Nevertheless, a cost-effectiveness analysis is warranted.

İnoperabl Klatskin tümörlü hastaların endoskopik tedavi ile uzun dönem sonuçları

Giriş ve Amaç: Klatskin tümörü ana hepatik kanal ya da sağ-sol intrahepatik kanaldan köken alan ve sistik kanalın açılım yerinin proksimalinde görülen epitelyal safra yolu tümörüdür. Hastalığın tanısı geç konur ve yaşam beklentisi düşüktür. Cerrahi için uygun olmayan hastalarda safranın drenajının sağlanması amacıyla endoskopik ya da perkütan drenaj gibi palyatif tedavi seçenekleri kullanılmaktadır. Bu çalışmada, endoskopik stent ve/veya perkütan drenaj tedavisi ile palyatif tedavi edilen inoperabl Klatskin tümörlü hastaların yaşam sürelerini ve işlemlerinin etkinliğini değerlendirmeyi amaçladık. Gereç ve Yöntem: Çalışma, İzmir Atatürk Eğitim ve Araştırma Hastanesi Gastroenteroloji Kliniği'nde Ocak 2008Eylül 2009 tarihlerinde retrospektif olarak yapıldı. Çalışmaya inoperabl hiler kolanjiokarsinomalı 34 hasta dahil edildi. Bismuth sınıflaması göz önüne alınarak hastalığın tipi belirlendi. Bulgular: Çalışmaya 19 kadın, 15 erkek hasta dahil edildi, ortalama yaş 71.8±8.9 olarak bulundu. Yedi hastada (%21) yeterli drenaj olmadı. Drenaj sağlanamayan hastalardan 2'sine (%6) perkütan drenaj kateteri yerleştirildi. Perkütan transhepatik kolanjiografi yapılan hastalarda yeterli bilirubin düşüşü izlenmedi. Endoskopik stent sonrası drenajın yeterli olduğu hastalarda ortalama yaşam süresi 145±138 gündü. Stentleme sonrası yeterli drenaj olmayan ve perkütan transhepatik kolanjiografiyi kabul etmeyen 5 hastada ortalama yaşam süresi 13.2±7 gündü. Stentleme sonrası yeterli drenaj olmaması sebebiyle perkütan transhepatik kolanjiografi ile dren yerleştirilen 2 hastada ortalama yaşam süresi 22±11.3 gündü. Bismuth I hastalarda ortalama yaşam süresi 164.2±19.3, Bismuth II hastalarda 86±125.6, Bismuth III hastalarda 134.7±130.8, Bismuth IV hastalarda 89.3±132.5 gün saptandı. Bismuth'a göre gruplar arasında yaşam süreleri açısından anlamlı fark saptanmadı (p=0.317). Sonuç: Bu çalışmada, palyatif endoskopik tedavi başarı oranının yüksek olduğunu ve tümörün yerleşim yerinin ortalama yaşam süresi üzerinde etkili olmadığını saptadık. Ancak stentlemenin, palyatif anlamda ortalama yaşam süresine katkıda bulunabileceğini ve en az 2 endoskopik retrograd kolanjiografi seansının hastaların palyatif drenajını sağlamak için denenmesi gerektiğini düşünmekteyiz.

Improved surgical outcomes for hilar cholangiocarcinoma: changes in surgical procedures and related outcomes based on 40years of experience at a single institution.

This study aimed to examine the changes in procedures for hilar cholangiocarcinoma (HC) surgery and patient survival following HC surgery over a 40-year period. Between 1974 and 2014, 239 consecutive patients underwent surgery for HC. The changes in perioperative therapy and short- and long-term surgical outcomes were evaluated. The rates of major hepatectomy (in particular, right hepatectomy) and R0 resection significantly increased. Blood loss, transfusion rate, morbidity, and surgical mortality all significantly decreased. The 5-year disease-specific survival was 9.29% (n=38) in 1974-1988, 41.1% (n=88) in 1989-2003 and 55.6% (n=57) in 2004-2008 (p=0.0001: 1974-1988 vs 1989-2003, p<0.0001:1974-1988 vs 2004-2008, p=0.076: 1989-2003 vs 2004-2008). According to a multivariate analysis, Bismuth classification IV (HR vs I, 2.86), period 1989-2003 (HR vs 1974-1988, 0.31), 2004-2008 (HR vs 1974-1988, 0.26), and R1 or R2 resection (HR vs R0, 2.22) were independent prognostic factors. The surgical outcomes for HC over the 40-year period clearly improved as a result of aggressive surgery and progress in surgical techniques, perioperative management, and diagnostic tools.

Biliary drainage strategy of unresectable malignant hilar strictures by computed tomography volumetry.

To identify criteria for predicting successful drainage of unresectable malignant hilar biliary strictures (UMHBS) because no ideal strategy currently exists. We examined 78 patients with UMHBS who underwent biliary drainage. Drainage was considered effective when the serum bilirubin level decreased by ≥ 50% from the value before stent placement within 2 wk after drainage, without additional intervention. Complications that occurred within 7 d after stent placement were considered as early complications. Before drainage, the liver volume of each section (lateral and medial sections of the left liver and anterior and posterior sections of the right liver) was measured using computed tomography (CT) volumetry. Drained liver volume was calculated based on the volume of each liver section and the type of bile duct stricture (according to the Bismuth classification). Tumor volume, which was calculated by using CT volumetry, was excluded from the volume of each section. Receiver operating characteristic (ROC) analysis was performed to identify the optimal cutoff values for drained liver volume. In addition, factors associated with the effectiveness of drainage and early complications were evaluated. Multivariate analysis showed that drained liver volume [odds ratio (OR) = 2.92, 95%CI: 1.648-5.197; P < 0.001] and impaired liver function (with decompensated liver cirrhosis) (OR = 0.06, 95%CI: 0.009-0.426; P = 0.005) were independent factors contributing to the effectiveness of drainage. ROC analysis for effective drainage showed cutoff values of 33% of liver volume for patients with preserved liver function (with normal liver or compensated liver cirrhosis) and 50% for patients with impaired liver function (with decompensated liver cirrhosis). The sensitivity and specificity of these cutoff values were 82% and 80% for preserved liver function, and 100% and 67% for impaired liver function, respectively. Among patients who met these criteria, the rate of effective drainage among those with preserved liver function and impaired liver function was 90% and 80%, respectively. The rates of effective drainage in both groups were significantly higher than in those who did not fulfill these criteria (P < 0.001 and P = 0.02, respectively). Drainage-associated cholangitis occurred in 9 patients (12%). A smaller drained liver volume was associated with drainage-associated cholangitis (P < 0.01). Liver volume drainage ≥ 33% in patients with preserved liver function and ≥ 50% in patients with impaired liver function correlates with effective biliary drainage in UMHBS.

Bismuth classification is associated with the requirement for multiple biliary drainage in preoperative patients with malignant perihilar biliary stricture.

Single preoperative biliary drainage for malignant perihilar biliary stricture occasionally fails to control jaundice and cholangitis. Multiple biliary drainage is required in such cases, but their clinical background is unclear. We determined the clinical characteristics associated with the requirement for multiple biliary drainage. The consecutive 122 patients with malignant perihilar biliary stricture were enrolled in a single-center retrospective study. Preoperative biliary drainage was initially performed on the future remnant hepatic lobe. Additional drainage was performed if jaundice failed to improve or cholangitis developed in undrained hepatic lobes. Detailed clinical characteristics and the number of preoperative biliary drainage procedures required before operation were analyzed. Thirty-one patients (25.4%) initially underwent multiple biliary drainage. However, 69 (56.7%) required multiple biliary drainage by the time of the operation. In the univariate analysis, the initial serum bilirubin level, cholangitis, percutaneous portal vein embolization, history of inserted endoscopic biliary stenting, length of preoperative period, operative procedure, and Bismuth classification were significant factors. In the multivariate analysis using these factors, Bismuth classification was independently associated with the requirement for multiple biliary drainage. The number of patients who required multiple biliary drainage was higher in those with Bismuth-II (91.9%), Bismuth-IIIa (65.7%), and Bismuth-IV (92.9%) than in those with Bismuth-I (22.2%) and Bismuth-IIIb (18.2%). Patients with Bismuth-II, Bismuth-IIIa, and Bismuth-IV are at higher risk for multiple biliary drainage. A strategy based on the Bismuth classification for performing preoperative biliary drainage is important for patients with malignant perihilar biliary stricture.

458 Evaluation of the Safety and Efficacy of Wst11mediated Vascular Targeted Photodynamic Therapy in Inoperable Cholangiocarcinoma

458 Evaluation of the Safety and Efficacy of Wst11mediated Vascular Targeted Photodynamic Therapy in Inoperable Cholangiocarcinoma Emmanuel Ben Soussan*, Jean Francois Lefebvre, Joseph Hardy, Sidney Houry alma clinic, Paris, France Introduction: Interest of PDT in cholangiocarcinoma remains controversial. The aims of this prospective phase II study was to evaluate a new photosensitive agent (WST11) which advantages are: 1) an innovative mechanism of action by vessels occlusion. 2) a short delay between intra-veinous infusion and its penetration of tumoral site (10 minutes) that allowed drug infusion in ERCP room 3) its short half-life (less than 2 hours) reducing the phototoxicity risks and limiting the duration of light protection measures. 4) its deep penetration in tumoral tissues (10-15 mm) without damage of normal tissues. Patients and Methods: From Nov 2009 to Dec 2010, seven pts (42-85 yrs, mean age 65.4) with inoperable cholangiocarcinoma (positive biopsies or cytology) have been treated with WST11. Patients were classified according to Bismuth classification: grade III (3 pts), grade II (3 pts) grade I (1 pts). Six patients were treated during ERCP and one during percutaneous procedure. Plastic stents or biliary drain were inserted after laser treatment in the same procedure. One single procedure with WST11 was performed during the 6 months follow-up for all patients, and 2 received subsequent chemotherapy. Preventive procedure of phototoxicity was made the first day after procedure. Results: No phototoxic or severe secondary effects occured in all patients during the 6 months follow-up, but all patients had an increased D Dimeres level. Two patients are still alive at 36 and 42 months without reccurence of disease in one. This 2 pts received post operative chemotherapy for grade I and III tumor. In four patients, stent ablation was done for stent obstruction. A complete healing of th stricture was found in 3 of the 4 pts. In one, stent have been definitively retriewed without tumoral reccurence at 42 months. Conclusion: This phase II study has shown the safety of WST 11 in non operable cholangiocarcinoma. Advantages of WST 11 are its short half-life and easy use during drainage procedure. Efficacy of this treatment must to be considered in phase III study in association with chemotherapy.

Y-shaped bilateral self-expandable metallic stent placement for malignant hilar biliary obstruction: data from a referral center for palliative care.

Background and Aim. Malignant hilar strictures are a clinical challenge because of the current therapeutic approach and the poor prognosis. In recent years, self-expandable metallic stents have proven more effective than plastic stents for palliation of malignant hilar strictures, with the bilateral stent-in-stent technique registering a high success rate. We report our experience with Y-shaped endoscopic self-expandable metallic stents placement for treatment of advanced malignant hilar strictures. Methods. From April 2009 to August 2012, we prospectively collected data on patients treated with Y-shaped SEMS placement for advanced malignant hilar carcinoma. Data on technical success, clinical success, and complications were collected. Results. Twenty patients (9 males) were treated (mean age 64.2 ± 15.3 years). The grade of malignant hilar strictures according to the Bismuth classification was II in 5 patients (25%), IIIa in 1 (5%), and IV in 14 (70%). The mean bilirubin level was 14.7 ± 4.9 mg/dL. Technical success was achieved in all patients, with a significant reduction in bilirubin levels (2.9 ± 1.7 mg/dL). One patient experienced cholangitis as early complication, while in 2 patients stent ingrowth was observed. No stents migration was recorded. There was no procedure-related mortality. At the end of the follow-up (7.1 ± 3.1 months), 13 of the 20 patients (65%) had died. Conclusions. Our experience confirms endoscopic bilateral self-expandable metallic stents placement with stent-in-stent technique (Y-shaped configuration) as a feasible, effective, and safe procedure for palliation of unresectable malignant hilar strictures.

Incidence and Impact of Concomitant Vascular Injuries on Repair of Post-Cholecystectomy Bile Duct Strictures

Purpose: To study the incidence of associated vascular injuries and their effect on clinical course, intraoperative difficulty and the outcome of repair in patients with post-cholecystectomy bile duct strictures. Methods: Forty consecutive patients referred with a diagnosis of post-cholecystectomy bile duct stricture were prospectively evaluated with Magnetic Resonance Angiography (MRA) along with Magnetic Resonance Cholangiography (MRC). Strictures were classified as per Bismuth's classification and strictures at or above the primary biliary confluence were considered as high strictures. Details of index cholecystectomy, any radiological interventions and surgical repair (Roux-en-Y hepaticojejunostomy) were recorded. Patients were followed up at 6 monthly intervals with clinical examination, liver function tests, abdominal ultrasound and hepatobiliary scintigraphy. Outcome assessment was done using Mcdonald's grading. Results: Four patients in whom MRA could not be completedwere excluded. Vascular injury was present in 22 (61%) and all of them had interruption of right hepatic artery (RHA). Additionally right portal vein injury was also present in one of these patients. RHA injury was noted in 17 (65%) patients with fresh injuries and in 5 (50%) patients who had prior failed repair. Prominent hilar collaterals were demonstrated in 20 (91%) of RHA injuries. Associated hepatic arterial anomalies were noted in 12 patients. Twenty three (64%) patients had high strictures (Type ≥3). There was no significant difference in the incidence of vascular injury between high and low strictures. Thirty four patients underwent stricture repair. There was no significant difference in blood loss, need for blood transfusion and duration of surgery in patients with or without vascular injury. There was no increase in overall complications and bile leak in patients with vascular injury. At median follow-up of 6 months (range 1-24), three failures of stricture repair were encountered. There was no effect of vascular injury on stricture repair in this short duration of follow up. Attempted prior repair and secondary biliary cirrhosis were found to have significant association with failure of stricture repair. Conclusion: On prospective evaluation with MRA post-cholecystectomy bile duct injuries were found to be associated with a very high incidence of asymptomatic vascular injuries mostly injury to the right hepatic artery. Vascular injuries are not associated with increased operative difficulty or post-operative complications. On a short follow-up they also did not have any negative impact on bile duct injury repair, performed by Hepp-Couinaud approach and after allowing adequate time for inflammation to settle.Table: Table. Factors affecting outcome of stricture repair