Cases Of Bile Leakage Research Articles

Surgical management of advanced hepatic alveococcosis using transplantation technologies

Background: Hepatic alveococcosis is extremely aggressive disease. Methods: We examined 41 patients from 2008-2017,36 were operated:31 hepatic resections, 4 liver transplantation(OLT), 1 portosystemic shunting.Among all the cases of hepatic resections (n=1067) alveococcosis accounts for 3.28% Extrahepatic alveococcosis 2(lungs). The complications:9 obstructive jaundice, 4 portal hypertension, 1 viral hepatic cirrhosis. The size of a parasitic node in the liver varied 9.3-21.7cm. Results: 35 radical operated:31 R0-resections,4 OLT,1 portosystemic shunting. 6 were not operated:2 due to marked comorbidity;2 chronic infection+biliary fistulas;1 bile ducts stenting,1 suggested transplantation.Among the surgeries:4 right hepatectomy,16 right extensive hepatectomy,2 left extensive hepatectomy,1 left hepatectomy,1 hepatectomy with reverse autotransplantation of the left lateral segment,1 left hepatectomy “ex situ” with 1 and 8 segmentectomy,1 three-segmentectomy,3 bisegmentectomy,2 segmentectomy. 14 patients have IVC ingrowth:9 IVC prosthetic:4 one-stage left hepatic vein plastic,5–IVC resection.13 portal vein resection,7 resection of extrahepatic ducts,7 resection of diaphragm. 11 cases of bile leakage(ISGLS):grade B–4, С–7. Postoperative complications-16(Clavien-Dindo):typeII–4,IVb–1,IIIb–8,V–3. The long-term results:1 recurrent case,2 fatal cases. Conclusion: Liver resection is a treatment of choice,characterized by large extent of resection,and accompanied by resection plastic operations on major vessels and bile ducts

Comparison of the effect of primary suture and T tube drainage of laparoscopic common bile duct exploration in the treatment of patients with choledocholithiasis

Objective To compare the effect of primary suture and T tube drainage of laparoscopic common bile duct exploration(LCBDE) in the treatment of patients with choledocholithiasis. Methods A total of 57 patients with calculus of extrahepatic bile duct were selected and they were randomly divided into observation group(n=25, treated by LCBDE) and control group(n=32, treated by T tube drainage). The operation time, postoperative recovery time of gastrointestinal tract, abdominal drainage time, postoperative hospital stay, hospitalization expenses and postoperative complications were recorded and compared between the two groups. Results All the patients were successfully completed surgery, and no patients had open surgery.The recovery time and postoperative hospital stay of the observation group were (1.7±0.5)d, (5.3±1.6)d, respectively, which were significantly shorter than (2.1±0.3)d, (9.2±1.9)d of the control group(t=11.73, 6.27, all P 0.05). There were 4 cases of postoperative bile leakage and 1 case of common bile duct residual stones in the observation group, and the incidence rate of complications was 20.00%.There were 2 cases of bile leakage, 3 cases of common bile duct residual stones and 2 cases of biliary peritonitis in the control group, and the incidence rate of complications was 21.87%.There was no statistically significant difference in the incidence rate of complications between the two groups (χ2=0.15, P>0.05). All the patients were followed up for 1 to 2 years, the recurrence rate of stones in the observation group was 12.00%, which was similar to 15.60% in the control group(χ2=0.36, P>0.05). Conclusion Primary suture of laparoscopic common bile duct exploration has the advantages such as less trauma, less pain, faster recovery and shorter hospital stay in the treatment of patients with choledocholithiasis, which is worthy of clinical application and popularization. Key words: Laparoscopy; Choledocholithiasis; Suture techniques; Drainage

Clinical effect of 37 cases of emergency common bile duct exploration and left lateral lobectomy

Objective To investigate the therapeutic effect and safety of acute obstructive cholangitis underwent emergency exploration of common bile duct and left hepatic lobectomy. Methods A retrospective descriptive study was used.The clinical data of 37 cases of acute common bile duct exploration with left lateral lobectomy in the Central Hospital of Shangluo from January 2015 to January 2010 were collected.The patients received emergency common bile duct exploration and left lateral lobectomy of the liver.Outcome measures: (1)patients with surgery; (2)major complications: postoperative bile leakage, residual stones, intraoperative bleeding; (3)postoperative drainage, residual stones and recovery of patients. Results 37 patients was performed in 16 cases, the average operation time was 120min, hepatic left lateral lobe resection average 23min, average amount of bleeding was 80mL.Postoperative stump 1 case of bile leakage, bile duct stones residue in 3 cases, intraoperative bleeding in 3 cases, postoperative return pathology intrahepatic cholangiocarcinoma in 1 case. Conclusion Emergency treatment of common bile duct exploration and left lateral lobectomy is a safe and feasible surgical approach, which can avoid the the reinfection of left lateral lobe. Key words: Cholangitis; Cholestasis; Hepatectomy; Emergency treatment

The outcome of endoscopic management of bile leakage after hepatobiliary surgery.

Background/AimsDespite improvements in surgical techniques and postoperative patient care, bile leakage can occur after hepatobiliary surgery and may lead to serious complications. The aim of this retrospective study was to evaluate the efficacy of endoscopic treatment of bile leakage after hepatobiliary surgery.MethodsThe medical records of 20 patients who underwent endoscopic retrograde cholangiopancreatography because of bile leakage after hepatobiliary surgery from August 2009 to September 2014 were reviewed retrospectively. Endoscopic treatment included insertion of an endoscopic retrograde biliary drainage stent after endoscopic sphincterotomy.ResultsMost cases of bile leakage presented as percutaneous bile drainage through a Jackson-Pratt bag (75%), followed by abdominal pain (20%). The sites of bile leaks were the cystic duct stump in 10 patients, intrahepatic ducts in five, liver beds in three, common hepatic duct in one, and common bile duct in one. Of the three cases of bile leakage combined with bile duct stricture, one patient had severe bile duct obstruction, and the others had mild strictures. Five cases of bile leakage also exhibited common bile duct stones. Concerning endoscopic modalities, endoscopic therapy for bile leakage was successful in 19 patients (95%). One patient experienced endoscopic failure because of an operation-induced bile duct deformity. One patient developed guidewire-induced microperforation during cannulation, which recovered with conservative treatment. One patient developed recurrent bile leakage, which required additional biliary stenting with sphincterotomy.ConclusionsThe endoscopic approach should be considered a first-line modality for the diagnosis and treatment of bile leakage after hepatobiliary surgery.

A randomized controlled trial comparing single-incision laparoscopic cholecystectomy using a novel instrument to that using a common instrument

To evaluate the safety and feasibility of single incision laparoscopic cholecystectomy (SILC) using a novel instrument. From September 2011 to June 2012, eligible patients (150 cases) were divided randomly into three groups: group A, SILC using a novel instrument; group B, SILC using a conventional instrument; and group C, conventional laparoscopic cholecystectomy (LC). Operative and postoperative outcomes were analyzed. The operative times for Group A [mean 40min; rang 30-50min] and Group B [mean 37.5min; rang 25-50min] demonstrated no significant differences (P=0.610), but both times were longer than that in Group C [mean 25min; rang 20-35min] (Z=25.165, P=0.000; Z=16.184, P=0.000). There was no significant difference between the level of blood loss in Group A [mean 10.0ml; range 5.0-20.0ml] and Group B [mean 10.0ml; range 5.0-20.0ml] (P=0.989), but the level in both groups was higher than that in Group C [mean 7.5ml; range 5.0-10.0ml] (Z=12.571, P=0.002; Z=13.619, P=0.001). There were no significant differences in patient satisfaction and pain scores (P=0.519; P=0.691) among the three groups. Complications occurred in 4 cases, including 1 case of bile injury and 3 cases of bile leakage. There were no complications in SILC with a novel instrument. SILC require a longer operative time and more blood loss without benefit of patient satisfaction and pain scores. However, SILC with a novel instrument has fewer complications and a tendency to safer than SILC with a conservative instrument, and it could be a possible alternative in cholecystectomy.

Laparoscopic pancreaticoduodenectomy: right-inferior-posterior "artery first" approach

To discuss the application of right-inferior-posterior "artery first" approach in laparoscopic pancreaticoduodenectomy. Clinical data of 17 patients who underwent laparoscopic pancreaticoduodenectomy through right-inferior-posterior "artery first" approach in our department from February 2014 to April 2015 were retrospectively analyzed. The operation began at the inferior flexure of duodenum. After entering the Toldt's space, the left renal vein (LRV) was revealed and the root of superior mesenteric artery (SMA) was exposed just above the LRV. SMA was dissected along its trunk till the horizontal part of duodenum. Of these 17 cases, adenocarcinoma of pancreatic head was observed in 5 cases, adenosquamous carcinoma in 2 cases, mucinous cycstic neoplasm in 1 case, adenocarcinoma of lower common bile duct in 4 cases, and duodenal papilla cancer in 5 cases. Fifteen cases were accomplished successfully with laparoscopy and 2 cases were converted to open approach. The average operating time was (320 ± 85) min and mean intraoperative blood loss was (305 ± 175) ml. The cutting margins were tumor negative in all the patients. The average number of harvested lymph node was 15.4 ± 6.5. Postoperative complication occurred in 5 cases. Two cases of bile leakage and 2 cases of pancreatic fistula were cured with conservative treatment. One case of delayed abdominal hemorrhage was resolved with reoperation. Right-inferior-posterior "artery first" approach is safe and feasible in laparoscopic pancreaticoduodenectomy.

A Rare Cause of Acute Pancreatitis: Unexpected Travel of the Biliary Catheter.

To the Editor, Biliary leakage is an important complication that occurs after cholecystectomy (1). Unless uncomplicated, it generally closes spontaneously if there is no distal obstruction (2). The therapeutic endoscopic retrograde cholangiopancreatography (ERCP) procedure is helpful in the clearance of biliary flow and lowering the biliary pressure (3). In case of insufficiency of the ERCP procedure, percutaneous biliary drainage maneuvers can help to control biliary fistulas or save time for surgery (4,5). We present a case of bile leakage which occurred after laparoscopic cholecystectomy, where we encountered an interesting cause of acute pancreatitis. A 32 year-old woman who underwent a laparoscopic cholecystectomy two weeks previously was referred to us with a drain placed in the operation wound, suggesting bile leakage. Physical examination revealed disseminated tenderness of the abdomen. Transaminase, amylase and lipase levels were normal. Computed tomography scan showed a 10 cm fluid collection in the sub-hepatic area. We followed her up for two weeks with the drainage of 200 mL of bile daily. A magnetic resonance cholangiopancreatography imaging was obtained showing some sludge and stone of 22 mm in the distal common hepatic duct (CHD). An ERCP was applied, where the pancreatic duct was found to be widened, but CHD could not be cannulated. An 8 F pigtail-locked percutaneous internal-external biliary drainage catheter (Flexima® Drainage Catheters, Boston Scientific; Natick, MA, USA) was placed and a prominent leakage from the cystic duct stump was demonstrated in cholangiography (Figure 1a). Fluid collection diminished by the 24th day. During the second catheter cholangiography, some small stones were pushed into the duodenum by a balloon catheter. One big stone, which remained in place, was extracted on the following day, by a successful ERCP procedure performed with the guidance of a biliary catheter (Figure 1b). Oral feeding was never paused. The intra-abdominal drainage catheter was removed and the patient was discharged on the 33rd day with the biliary catheter. On the 15th day of discharge, she presented with abdominal pain. Laboratory assessment demonstrated a marked elevation in serum amylase and lipase levels. She was re-hospitalized for acute pancreatitis. A control catheter cholangiogram showed an unexpected migration of the catheter into the duct of Virsung, which clarified the etiology of acute pancreatitis (Figure 1c). The catheter was repositioned (Figure 1d) and she was discharged on the following day. A spontaneous closure of the leakage was observed on a consequent catheter cholangiogram obtained a week later. The biliary catheter was removed and the patient visited the outpatient clinic without any complaint after three weeks. FIG. 1. a, b. Cholangiography film obtained after the internal-external biliary drainage catheter is placed. Biliary leakage at the level of cystic duct stump (white arrow). Image of stone or sludge at the level of distal common bile duct (CBD) (white arrow head). ... Biliary drainage catheters are loyal assistants of surgeons. Unless hemobilia or bilhemia occurs, they serve as lifeguards in biliary problems, whereas catheters are foreign bodies and can sometimes make matters worse. When a patient being followed-up with a percutaneous biliary catheter exhibits a state of sudden acute pancreatitis, besides other common reasons, catheter migration through the duct of Virsung must be kept in mind. This case seems to be the first in the literature demonstrating a biliary catheter responsible for acute pancreatitis by migrating into the duct of Virsung.

Evaluation of Therapeutic Effect of Contrast-enhanced Ultrasonography in Hepatic Carcinoma Radiofrequency Ablation and Comparison with Conventional Ultrasonography and Enhanced Computed Tomography

Objective This paper aims to discuss the evaluation of the therapeutic effect of contrast-enhanced ultrasonography (CEUS) in radiofrequency ablation (RFA) for liver cancer and its application value. Methods A total of 80 patients (120 hepatic malignant tumor lesions) were treated using RFA, and CEUS was conducted on the liver before and after the treatment. Sixty-five patients (85/120 tumor lesions) had primary hepatic carcinoma and 11 (30/120 tumor lesions) had metastatic hepatic carcinoma (6 cases of 15 lesions had colorectal carcinoma, 3 cases of 8 lesions had lung carcinoma, and 2 cases of 7 lesions had gastric carcinoma). Four patients (5 lesions) had recurrence. Prior to the treatment, CEUS accurately guided the RFA of lesions, and after the treatment, the accuracy of CEUS was compared with conventional ultrasonography and enhanced computed tomography (CT). Results After the RFA, there were two cases of bile leakage, two cases of bleeding, and three cases of hydrothorax, and 20 cases had fever. In the CEUS performed after the operation, 114 of the 120 lesions (94.6%) were not filled with contrast agent in the arterial phase, venous phase, and delayed phase, indicating that the tumor lesions were totally inactivated. In the remaining six lesions, the arterial phase was enhanced partially on the edge, indicating suspected partial residues of tumor lesions. The final diagnosis was based on the aforementioned two kinds of imaging examinations in combination with the level of tumor markers, needle biopsy, and follow-up visits of over 1 month. Based on the therapeutic effects on the tumor after the operation with the final diagnosis as the standards, the accuracy of CEUS was 94.6%, whereas that of contrast-enhanced CT (CECT) and conventional ultrasonography was 93.4% and 60.5%, respectively. A comparative analysis was performed, which indicated that the difference between CEUS and conventional ultrasonography was of statistical significance (χ 2 = 5.42, p 2 = 5.14, p 2 = 7.54, p > 0.05). Conclusion CEUS has important value of clinical application both prior to and after RFA operations. Prior to the operation, CEUS can accurately guide the RFA treatment, whereas after the operation, CEUS is an important method to evaluate the inactivation after the treatment, and can be an important means for follow-up visits for partial treatment of hepatic carcinoma.

Laparoscopic Choledochojejunostomy in Various Hepatobiliary and Pancreatic Surgeries: A Single Surgeon's Experience

The aims of this study were to measure the learning curve for laparoscopic choledochojejunostomy (LCJ), to describe the technical tips and to report the follow-up data. The results of LCJ performed on 84 patients were analyzed. Patients were divided into eight groups, by surgical order. The plateau of the learning curve was defined as the period during which the operative time showed a dramatic decrease. The exact operative time was recorded using video analysis. Compared with the first three groups, the fourth group showed a significantly shorter LCJ time. The subsequent groups showed a plateau, indicating that there were no more significant changes in the LCJ time. After the plateau of the learning curve was reached, the average LCJ time was 27.4±4.7 minutes. Six cases of postoperative bile leakage occurred, with all occurring before the plateau of the learning curve was reached. Five of the 6 cases of bile leakage had a nondilated common bile duct. Even for a surgeon experienced in laparoscopic surgery, there is a steep learning curve for the performance of LCJ. With careful video review, education of the surgical team, and various technical tips, the learning curve can be shortened. After the learning curve, experienced surgeons can perform LCJ with acceptable results.

One-year experience with single incision laparoscopic cholecystectomy in a single center: without the use of inverse triangulation.

PurposeSingle incision laparoscopic cholecystectomy (SILC) is generally performed with the use of inverse triangulation. In this study, we performed 3-channel or 4-channel SILC without the use of inverse triangulation. We evaluated the adequacy and feasibility of SILC using our surgical method.MethodsWe retrospectively reviewed our series of 309 SILCs performed between March 2014 and February 2015.ResultsAmong 309 SILCs, male were 148 and female were 161 patients, mean age was 48.7 ± 15.3 years old and mean body mass index was 24.8 ± 3.8 kg/m2. Forty patients had previously undergone abdominal surgery including 6 cases of upper abdominal surgery. SILC after percutaneous transhepatic gallbladder (GB) drainage was completed in 8.7% of cases. There were 10 cases of emergency SILC. SILC was performed for noncomplicated GB including symptomatic GB stone and polyp in 66.7% of cases, acute cholecystitis in 33.3%. Overall, 96.8% of procedures were successfully completed without additional port. The reason for addition of an extra port or open conversion included technical difficulties due to severe adhesion and bleeding. The mean operating time was 60.7 ± 22.3 minutes. The overall complication rate was 4.8%: 9 patients of wound seroma, 1 case of bile leakage from GB bed, 4 cases of intra-abdominal abscess or fluid collection, and 1 case of incisional hernia were developed. There was no case of common bile duct injury.ConclusionOur surgical method of SILC without the use of inverse triangulation is safe, feasible and effective technique.

腹腔鏡下胆嚢摘出術後の落下結石嵌頓による胆汁漏の1例

症例は30歳台女性で，上腹部痛を主訴に来院した．胆嚢結石と胆管炎の診断で入院したが，胆管造影で結石は明らかでなかった．腹腔鏡下胆嚢摘出術を行ったが，翌日から胆汁漏が出現した．ERC（endoscopic retrograde cholangiography）で胆嚢管断端から胆汁漏を認め，ENBD（endoscopic nasobiliary drainage）を開始した．再検ERCで胆管結石が明らかとなり，EST（endoscopic sphincterotomy）を行った．胆汁漏は軽快し，術後10日目に退院した．本例は術後落下結石による胆管内圧上昇に伴い，胆嚢管断端に破綻をきたして胆汁漏を生じたものと診断したが，落下結石による胆汁漏の発生はまれである．術後胆汁漏に対する内視鏡的治療の報告が増えている．病態に応じてENBDや胆管ステント，ESTの併用が必要と考えられた．

Is Biliary Drainage Really Necessary after Laparoscopic Common Bile Duct Exploration?

Seung Jae Roh, M.D., In Seok Choi, M.D., Joo Ik Moon, M.D., Dae Sung Yun, M.D., Won Jun Choi, M.D., Sang Eok Lee, M.D., Yu Mi Ra, M.D.. J Minim Invasive Surg 2013;16:27-33. https://doi.org/10.7602/jmis.2013.16.3.27

Multicenter retrospective study of endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction in Japan

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is considered to be an effective salvage procedure for failed endoscopic retrograde cholangiopancreatography in patients with unresectable malignant biliary obstruction. The aim of this retrospective study was to evaluate the efficacy and feasibility of EUS-BD. From November 2006 to May 2012, a total of 64 patients who underwent EUS-BD (44 EUS-guided choledochoduodenostomy [EUS-CDS] and 20 EUS-guided hepaticogastrostomy [EUS-HGS]) at seven tertiary-care referral centers in Japan were included. The primary outcome was the technical success rate, and the secondary outcomes were the incidence of complications, stent dysfunction rate, time to stent dysfunction, and overall survival. The technical success rate for both EUS-CDS and EUS-HGS was 95%. The reasons for technical failure were two failed dilations of the anastomosis in EUS-CDS and one puncture failure in EUS-HGS. The stent dysfunction rate and 3-month dysfunction-free patency rate were 21% and 80% for EUS-CDS and 32% and 51% for EUS-HGS. There were 12 (six in EUS-CDS and six in EUS-HGS) procedure-related complications (19%): five cases of bile leakage (3/2), three stent misplacements (1/2), one pneumoperitoneum (1/0), two cases of bleeding (1/1), one perforation (1/0), and one biloma (0/1). Bile leakage was more frequently observed in patients who underwent plastic stent placement (11%) than in those with covered metal stents (4%). This Japanese multicenter study revealed a high success rate in EUS-BD. However, the complication rate was as high as that in previous series. Covered metal stents may be useful to reduce bile leakage in EUS-BD.

Laparoscopic Pancreaticoduodenectomy Assisted by Mini-Laparotomy

Pancreaticoduodenectomy (PD) is the treatment of choice for periampullary disease. Even with the increasing number of successful reports from around the globe, laparoscopic pancreaticoduodenectomy (LPD) is still not fully accepted. We report the results of our experience of LPD assisted by mini-laparotomy. This retrospective review study included 42 patients who received LPD assisted by mini-laparotomy between March 2009 and April 2012. Clinical outcomes, such as patient age, pathologic diagnosis, pancreas nature, operation time, conversion rate, hospital stay, postoperative complication, and mortality rates, were reviewed. A total of 42 patients (age range, 42 to 70 y ) received LPD assisted by mini-laparotomy. The mean incision length for the laparotomy was 5.2 cm. Mean operative time was 404 minutes, and 3 cases required conversion to open surgery. Mean postoperative hospital stay was 17 days. There were 3 cases of pancreaticogastrostomy leakage, 2 cases of postoperative bleeding, 4 cases of delayed gastric emptying, 1 case of bile leakage, and 5 cases of pulmonary complications. Of the 5 patients with pulmonary complications, 1 died. When performed by a surgeon with ample experience in laparoscopic surgery, LPD assisted by mini-laparotomy is a safe, feasible alternative to conventional PD for select cases. The method described in this study can be used to perform pancreaticoenteric anastomosis in the same manner as an open PD, while taking advantage of the merits of minimally invasive surgery.

Laparoscopic anatomical right hemihepatectomy for liver tumor in 16 patients

To explore the clinical application of laparoscopic anatomical right hemihepatectomy in the treatment of liver tumor. From October 2007 to October 2011, 16 cases of laparoscopic anatomical right hemihepatectomy were performed. The data of operative duration, blood loss volume and postoperative complications, etc, were analyzed retrospectively. Parenchyma was transected with a laparoscopic ultrasonic scalpel and ligature and accomplished with an endoscopic linear stapler. Among them, postoperative pathologic examinations revealed primary liver carcinoma (n = 7), liver hemangioma (n = 6), colon carcinoma with liver metastasis (n = 2) and pancreatic non-function neuroendocrine carcinoma with liver metastasis (n = 1). The mean volume of blood loss was 550 (200 - 1550) ml, mean surgical time 310 (260 - 450) minutes and mean postoperative hospital stay 7 (5 - 14) days. Postoperative complications included 3 cases of bile leakage recovered after 2 - 3 weeks by appropriate draining. The patients with malignant tumor were followed up for 15 (12 - 52) months. Recurrence occurred in 4 cases and another 2 died of recurrence and metastasis. Laparoscopic anatomical right hemihepatectomy is a safe, feasible and effective procedure for the treatment of benign liver disease and malignant liver neoplasms in properly selected patients. It should be recommended for radical resection of hepatocellular carcinoma.

Is Microsurgical Technique Useful in Biliary Reconstruction of Living Donor Liver Transplantation?

Biliary reconstruction remains the "Achilles' heel" of living donor liver transplantation (LDLT). In the last decades, the technical aspects of biliary reconstruction have been debated for their impact on biliary complications in LDLT. A microsurgical technique in biliary reconstruction is more attractive. From December 2010 to June 2011, 15 primary LDLTs underwent duct-to-duct biliary reconstruction using a microscopic technique. External stents were inserted in all patients. All procedures were performed under a microscope by a single transplant microsurgeon. The time consumed for bile duct reconstruction using the microscopic technique was 35 minutes. There were 8 grafts with a single bile duct orifice and seven with two orifices. The average duct size was 3 mm in patients with two orifices and 5 mm in those with a single orifice. There was no bile leak or biliary stricture associated with the biliary reconstruction over a median 5-month follow-up. There were two cases of bile leakage from the cut hepatic surface. The microscopic technique reduced early biliary complications. However, further technical advances are needed to decrease the time consumptions for the procedure.

Roux-en-Y choledochojejunostomy using novel magnetic compressive anastomats in canine model of obstructive jaundice

The traditional hand-sewn Roux-en-Y choledochojejunostomy is technically complicated, and the incidence of postoperative complications has remained high. A set of novel magnetic compressive anastomats was introduced to facilitate choledochojejunostomy and improve the prognosis of patients. After ligating the common bile duct for 7 days, 16 dogs were randomly divided into two groups (n=8 per group). Anastomats were used in the study group, and the traditional hand-sewn method was used in the control group for standard Roux-en-Y choledochojejunostomy. We compared the operation time, incidence of complications, gross appearance, and pathological disparity in stoma between the two groups in 1-month and 3-month follow-up examinations. The time spent on constructing the anastomosis for the study group was significantly shortened. Although no anastomotic stenosis occurred in the two groups, the narrowing rate of biliary-enteric anastomosis was much higher in the control group. There was one case of bile leakage in the control group, whereas no bile leakage occurred in the study group. A smoother surface, an improved layer apposition, and a lower local inflammatory response were identified in the anastomosis of the study group. The structures of the novel magnetic compressive anastomats are simple, and they are time-saving, safe and efficient for performing Roux-en-Y choledochojejunostomy procedures in a canine model of obstructive jaundice.

Laparoscopic and Open Cholecystectomy in Surgical Training

Background: Open cholecystectomy (OC) may still be necessary in surgical training to perform safe conversions of laparoscopic cholecystectomy (LC). Our aim was to study the outcome of LCs and OCs performed by surgical trainees. Methods: All consecutive cholecystectomies (1,581 LCs and 984 OCs) were retrospectively analyzed from 1995 until 2008. Operative complications were compared between the cholecystectomies performed by 20 trainees alone (n = 822), assisted operations (n = 754, trainees/specialist surgeons) and 9 specialists alone (n = 989). Results: Surgical trainees performed 787 (50%) LCs and 789 (80%) OCs either alone or assisted. The conversion rate of LC for trainees and specialist surgeons were 34 (7.0%) and 44 (5.5%), respectively. Complication rates and mortality were similar between the trainees and specialist surgeons. No bile duct injuries were associated with LCs or OCs performed by trainees alone. LCs were associated with 9 (0.57%) cases of bile leakage from cystic stump and 2 (0.13%) other bile duct injuries. Conclusion: Surgical trainees performed over half of our cholecystectomies with good results. The patient selection for LC versus OC was good, because no total transection of the common bile duct was observed in over 1,500 LC operations.

Value of identification of cystic duct, common bile duct, and common hepatic duct in prevention of bile duct injury during laparoscopic cholecystectomy

To explore effective method to avoid iatrogenic bile duct injury during laparoscopic cholecystectomy (LC). 10 492 patients underwent LC from May 1996 to May 2006, 8566 of them were treated by the method to identify the cystic duct, common hepatic duct, and common bile duct during LC (tri-duct method group), and the left 1926 cases whose cystic duct failed to be exposed easily were treated with the method to identify at least two of the 4 structures (cystic lymph node, Hartmann's pouch, cystic artery, and emptiness of cystic triangle) so as to help identify the cystic duct (tri-duct plus tri-structure group). The operating time, amount of blood loss, open conversion rate, and morbidity were compared between these 2 groups. No cases of bile leakage or jaundice because of accidental injury of bile duct were found. The operating time of the tri-duct plus tri-structure group was (28 +/- 12) (15 - 52) min, significantly shorter than that of the tri-duct group [(38 +/- 16) (15 - 92) min, P < 0.05]. The open conversion rate of the tri-duct plus tri-structure group was 1.8%, significantly lower than that of the tri-duct group (8.7%, P < 0.05). There were no significant difference in the amount of blood loss and morbidity between the two groups (both P > 0.05). The tri-structure method can not only confirm the cystic duct correctly, thus preventing iatrogenic bile duct injury, but also shorten the operating time and reduce the open conversion ratio during LC.

Prevention and treatment of biliary tract complications following adult living donor liver transplantation

To investigate the prevention and treatment of biliary tract complications following adult-adult living donor liver transplantation (A-A LDLT). One hundred and eight patients, aged 38 (18 - 63), underwent A-A LDLT, including transplantation of the right liver graft without middle hepatic vein (MHV) in 102 cases and dual graft transplantation in 6 cases (of left lobe from relative in 1 case, of right lobe+left lobe from relative in 3 cases, of right lobe from relative + cadaveric left lobe in 2 cases). Preoperative 3-dimensional computerized tomography (3D CT) and intra-operative cholangiography were employed to reveal the state of the liver, caution was exercised to protect the peripheral vasculature of the right hepatic duct during resection. The bile duct was reconstructed by duct-to-duct (D-D) biliary anastomosis or Roux-en-Y anastomosis of the hepatic duct and jejunum (H-J). Twenty-four of the 108 patients (22.2%) suffered from complications, including bile leakage (n = 4), cutting surface bile leakage (n = 1), and anastomotic biliary stricture (n = 3), etc. Seven donors (6.3%) suffered from complications too, including 2 cases of bile leakage from the remnant cut surface. All the biliary tract complications were properly managed with good outcomes, except for 1 case of recipient death. Measures such as improvement of pre- and intra-surgical examinations and assessments, choice of appropriate approach of biliary tract reconstruction, employment of subtle operations of microscopic procedures, and timely detection and management of complications may reduce the incidence and mortality of biliary tract complications following A-A LDLT.