Cholecystectomy Bile Research Articles

Evolution of bile duct repair in a low and middle-income country (LMIC): a comparison of diagnosis, referral, management and outcomes in repair of bile duct injury after laparoscopic cholecystectomy from 1991 to 2004 and 2005–2017

There is a paucity of data from the developing world regarding laparoscopic cholecystectomy (LC) bile duct injuries (BDIs), despite the fact that most of the world's population live in a developing country. We assessed how referral patterns, management and outcomes after LC-BDI repair have evolved over time in patients treated at a tertiary referral center in a low and middle-income country (LMIC). Patients with LC-BDIs requiring hepaticojejunostomy were identified from a prospective database. Clinical characteristics, geographic distance from referral hospital, timing of referral and repair, and post-operative outcomes were compared in two cohorts treated during 1991-2004 and 2005-2017. Of 125 patients, 32 underwent repair in the early period, 93 in the latter. There was no difference in demographic or clinical characteristics, but a 45.6% increase in geographically distant referrals in the 2005-2017 period. Time from diagnosis to referral and referral to repair increased significantly (p=0.031, p<0.001), necessitating more intermediate repairs. Despite this, the number of severe complications decreased (p=0.022) while long-term outcomes remained unchanged. In this study from an LMIC, geographic and logistic constraints necessitated deviation from accepted algorithms devised for well-resourced countries. When appropriately adapted, results comparable to those reported from developed countries are achievable.

Study of associationship between gall stone composition and bacteriological spectrum in chronic calculous cholecystitis

Background: Chronic calculous cholecystitis is the benign disease affecting the gallbladder, frequently female population of middle age. This study was done with the objective of study the composition of gall stones, microbiological spectrum and their association in chronic calculous cholecystitis patients.Methods: This is a prospective study done on 131 cases of chronic calculous cholecystitis admitted in the department of General Surgery (DNB), K.K. Hospital, Lucknow for cholecystectomy during January 2018 to January 2019. 31 patients were excluded from the study based on exclusion criteria. USG of abdomen was done in all 100 cases. All patients underwent either open cholecystectomy (OC) or laparoscopic cholecystectomy (LC).During cholecystectomy bile was aspirated and was sent to laboratory for culture. Gallstone retrieved from the specimen and was classified based on morphology.Results: Out of 100 cases, 76 cases underwent LC and 24 cases were done with OC. Female dominance was seen in the study (69%). The predominant type of gall stone in present study was cholesterol (68%). The bile culture test was positive in 20% of cases. The most common isolated microorganism was E. coli (50%). No significant association was observed between composition/type of gall stone and isolated microorganisms in bile (p=0.126).Conclusions: The result concluded that chronic calculous cholecystitis was more common in females of middle age group. Bile culture was positive in 20% cases and E. coli was the common organism isolated. Identification of the type of organism is crucial for early management of the disease condition.

Choledochodudenostomy for bile duct injuries: a less demanding option, in a demanding surgical situation

Cholecystectomy is one of the most common surgical procedure performed worldwide and therefore a common cause for iatrogenic biliary tract injury. Bile duct injuries are associated with significant morbidity and are a potentially fatal complication. Choledochodudenostomy in patients of post cholecystectomy bile duct injury can be done safely by experienced surgeons in CBD injuries distal to the confluence of the cystic and common hepatic duct after eradication of sepsis. Choledochoduodenostomy has its own technical advantages and it maintains the normal anatomy. As compared with a routine Roux-en-Y hepaticojejunostomy, CDD is technically easier, faster, requires less manipulation of the CBD, and is more physiological. We present a case report of a patient of laparoscopic cholecystectomy with CBD injury managed with choledochoduodenostomy who did extremely well after procedure with no immediate and delayed postoperative complication.

Clinical analysis of different treatment options for cholecysto-choledocholithiasis

Objective To evaluate the efficacy of different treatment options for cholecysto-choledocholithiasis (CCL), and try to find the ideal treatment. Methods From January 2006 to January 2016, a total of 3 107 patients with CCL from the Affiliated Hospital of Inner Mongolia Medical University were enrolled. Among them, 1 283 patients were in open cholecystectomy (OC) and open common bile duct exploration (OCBDE) group, 964 patients were in laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) group, and 860 patients were in endoscopic retrograde cholangiopancreatography (ERCP)+ LC group. The clinical data of the three groups were analysed. One-way analysis of variance and chi-square test were performed for statistical analysis. Results From 2006 to 2010, the percentage of patients treated with OC+ OCBDE, LC+ LCBDE, and ERCP+ LC were 56.05%(829/1 479), 25.15%(372/1 479) and 18.80%(278/1 479), respectively; from 2011 to 2016, the percentage of patients received the above three treatments were 27.89%(454/1 628), 36.36%(592/1 628) and 35.75%(582/1 628), respectively. The difference in the proportion of the same treatment at different times was statistically significant (χ2=4.775, 4.168 and 0.669, all P 0.05). The hospital stay of the OC+ OCBDE group, the LC+ LCBDE group and the ERCP+ LC group were (6.7±1.3) days, (5.6±1.2) days and (10.9±1.6) days, respectively, and the differences were statistically significant (F=90.010, P<0.01). The hospitalization expenses of OC+ OCBDE group, LC+ LCBDE group and ERCP+ LC group were (13 720±1 910) yuan, (18 150±1 490) yuan and (25 830±2 430) yuan, respectively, and the differences were statistically significant (F=302.991, P<0.01). Conclusion The first choice of patients with CCL is endoscopic minimally invasive treatment and open surgery can be used as a remedial method for endoscopic treatment. Key words: Cholecysto-choledocholithiasis; Endoscopic minimally invasive treatment; Open surgery

Peri Cholecystectomy Bile Analysis for Fasciola hepatica Eggs in Sulaimani Teaching Hospital

Fascioliasis is one of the oldest zoonotic infestations, which returned back to 3000 years B.C., it is caused by Fasciola hepatica or gigantica. It is a widespread disease throughout the world; nearly (2.4 – 17) millions of people is infected. Human is an accidental final host by ingestion of contaminated plants and water by metacircaria. Most of patients suffer from right upper abdominal pain with eosinophilia. Diagnosis is made on clinical background with imaging studies or laboratory (like stool and examinations biliary aspirate, intradermal test or ELISA to detect antibody). It must be taken into consideration as newly emerging infestation in our country. The aim of this study is to highlight on the magnitude of Peri Cholecystectomy Bile Analysis for Fasciola hepatica in Sulaimani province, Kurdistan region and even in Iraq as a whole. A prospective study was performed at Sulaimani Teaching Hospital. Bile samples were collected from who had cholecystectomy. Microscopical analysis was archived for finding egg of the parasite. In 129 samples, there were 7 (5.4%) positive cases of Fasciola hepatica 2 were adult worms, all were swimming in the gall bladder. 5 (3.9%) out of 7 (5.4%) samples were females and only 2 (1.5%) of cases were males. 4 (3.1%) out of 7 were from Sharazur terrain, and 3 (2.3%) of them from the center of Sulaimani city. Fascioliasis is a zoonotic problem. It must be put in differential diagnosis of any vague upper abdominal pain. It is a public health issue, so health worker must give awareness to the society about this disease, which is more easily preventable.

Laparoscopic repair of post – cholecystectomy bile duct injury

Laparoscopic repair of post – cholecystectomy bile duct injury

E-AHPBA multicentre study: post cholecystectomy bile duct injury: early vs late repair with hepaticojejunostomy

E-AHPBA multicentre study: post cholecystectomy bile duct injury: early vs late repair with hepaticojejunostomy

The management of benign biliary strictures

The most common cause of Benign Biliary Stricture is post cholecystectomy bile duct injury. Following introduction of the laparoscopic cholecystectomy procedure the incidence of bile duct injury and stricture has increased. The studies suggest that the incidence remained stable even after the improved learning curve. The early diagnosis and prompt management is the key in preventing devastating sequelae of this benign condition. The management of post cholecystectomy biliary strictures involves a multidisciplinary approach. Our review aims to describe the present strategy in management of post cholecystectomy biliary strictures.

Post-cholecystectomy bile duct injuries: when to repair?

Background: Post cholecystectomy bile duct injury (BDI) though rarely happens; it has its own impact on postoperative outcomes. There is controversy on the optimal time for repair of such injuries. The aim of this study was to analyze the different time modalities used for repair of these injuries and its outcomes.Methods: This was a prospective randomized study conducted at General Surgery Department, Sohag university hospital, from August 2013 to March 2017. It included forty patients diagnosed to have BDI after cholecystectomy divided into 3 groups according to the time of intervention; early, intermediate, and late. We compared them regarding the pre-operative, operative variables and analyzed the post-operative outcomes among groups with one year follow-up after repair. Results: Bile leakage was the main presenting symptom in 100% of patients of early intervention group while there was combination of jaundice (71.43%) and bile leakage (28.57%) in the other two groups, 28.57% of patients of intermediate intervention required ICU admission. In the early intervention group there were tendency towards less severe injuries requiring simpler maneuvers for repair with primary repairs or end to end anastomoses while in late intervention group there were tendency towards more severe injuries requiring more complex maneuvers for reconstruction. In the post-operative course there was a tendency for intermediate intervention group to have higher incidence of complications in the early and late post-operative course (57%, p=0.007). Add to this the intermediate intervention group had the longest hospital stay (p=0.008) and was plagued by mortality rate of 21% (p=0.049).Conclusions: Late repair is superior to other time modalities of intervention in post-cholecystectomy BDI in terms of postoperative outcomes.

The standardisation of minimally invasive methods approaches in treatment of post-laparoscopic cholecystectomy bile leakage

The paper analyses the results of surgical treatment of 10243 patients with cholelithiasis who underwent laparoscopic cholecystectomy. In the early postoperative period 60 patients (0.59%) had bile leakage. Developed surgical technique based on ultrasound data and endoscopic retrograde cholangiopancreatography can improve the results of treatment and avoid septic complications and lethal outcomes. Conservative treatment, minimally invasive endoscopic techniques, ultrasound guided puncture methods and relaparoscopy were effective in 52 patients (86,7%). Postoperative bile leakage is currently one of the most frequent complications of LCE, routine drainage of the subhepatic space facilitates early diagnosis of postoperative complications. When choleo-excretion is more than 200 ml per day, endoscopic retrograde cholangiography is necessary to diagnose damage to the main bile ducts, while confirming the injury of the hepaticocholedochus, a reconstructive surgery with laparotomy is indicated. Drainage bile bleeding, accompanied by symptoms of biliary peritonitis or a significant accumulation of bile in the abdominal cavity in the absence of an injury to the hepaticocholedochus, requires a relaparoscopy for diagnostic and therapeutic purposes. Standardization of the complex application of relaparoscopy, transduodenal endoscopic interventions and puncture techniques can significantly reduce the number of laparotomic operations to correct the complications that have arisen.

Minimally invasive approach (robotic and laparoscopic) to biliary-enteric fistula secondary to cholecystectomy bile duct injury.

Spontaneous biliary-enteric fistula after laparoscopic cholecystectomy bile duct injury is an extremely rare entity. Y-en-Roux hepaticojejunostomy has been demonstrated to be an effective surgical technique to repair iatrogenic bile duct injuries. Seven consecutive patients underwent robotic-assisted (n=5) and laparoscopic (n=2) biliary-enteric fistula resection and bile duct repair at our hospital from January 2012 to May 2017. We reported our technique and described post-procedural outcomes. The mean age was 52.4years, mostly females (n=5). The mean operative time was 240min for laparoscopic cases and 322min for robotic surgery, and the mean estimated blood loss was 300mL for laparoscopic and 204mL for robotic cases. In both groups, oral feeding was resumed between day 2 or 3 and hospital length of stay was 4-8days. Immediate postoperative outcomes were uneventful in all patients. With a median of 9months of follow-up (3-52months), no patients developed anastomosis-related complications. We observed in this series an adequate identification and dissection of the fistulous biliary-enteric tract, a safe closure of the fistulous orifice in the gastrointestinal tract and a successful bile duct repair, providing the benefits of minimally invasive surgery.

Study of morphological spectrum of gallstone and bacteriology of bile in cholelithiasis

Background:Biliary calculus disease is one of the most common disorders of gastrointestinal tract. Gall bladder stone are crystalline structure formed by concretion of bile constituents. Aetiology of gall stone is multifactorial. Bile is found to be sterile in normal patient.Methods: This is a cross sectional study conducted in department of surgery, Lt Lakhiram Agrawal Memorial Medical College, Raigarh, Chhattisgarh, India from October 2015 - October 2016. Total 50 cases were selected and operated by lap /open cholecystectomy were included in this study. During cholecystectomy bile was aspirated and was sent to laboratory for culture. Gallstone retrieved from the specimen was classified based on morphological appearance.Results:Gallstone disease found to be common in female with ratio of 4:1, with maximum no. of cases found in the age group of 35 to 45 year. Bile culture as positive in 40%. The most common organism was E. coli isolated in 14 cases, followed by Klebseilla in 4 cases.Conclusions:The frequency of bile infection in this study area was 40%, in which association with mixed type gallstone was found to be significant and the most common bacteria isolated was E. coli.

Approach to a Patient with Post Laparoscopic Cholecystectomy Bile Leak

With the widespread practice of laparoscopic cholecystectomy and the advancements in imaging and endoscopic therapy the management of bile leaks following cholecystectomy has evolved over the years. Majority of the bile leaks are detected post-operatively. A high index of suspicion should exist for a possible bile leak if a patient presents with abdominal pain, fever, and tenderness within a week following a complicated or converted laparoscopic cholecystectomy, or it may present as an overt external biliary fistula. Leaks which are detected intra-operatively and managed appropriately carry the best prognosis. Interventional radiologists along with expert endoscopists can successfully manage many of the minor bile leaks. Major bile duct injuries should be properly characterized by appropriate imaging studies. One should avoid undue haste while opting for surgical interventions which are invariably required for such major injuries. Such repairs should be undertaken by expert hepatobiliary surgeons as the first repair has the greatest chance of success and failed repairs raises the level of injury making subsequent repairs more difficult.

Ultrathin choledochoscope improves outcomes in the treatment of gallstones and suspected choledocholithiasis

ABSTRACTBackground: We aimed to compare laparoscopic cholecystectomy (LC) and simultaneous laparoscopic transcystic common bile duct exploration (LTCBDE) using an ultrathin choledochoscope with LC followed by endoscopic retrograde cholangiopancreatography (ERC) and endoscopic sphincterotomy (ES) when indicated.Methods: We retrospectively reviewed the records of patients seen between 2004 and 2014 and treated with LC+LTCBDE or LC for gallstones and suspected choledocholithiasis. Postoperative complications and surgical outcomes were compared using t-test, Mann-Whitney U test, or chi-square test.Results: 115 patients underwent successful LC+LTCBDE and 112 LC; follow-up data was available for 103 and 106 patients, respectively. Seventeen patients (16.5%) in the LC+LTCBDE group and 10 (28.6%) in the LC+ERC+ES group developed complications (P = 0.114). The LC+LTCBDE group had a significantly higher rate of satisfactory biliary function outcomes than the LC+ERC+ES group (98.1% vs. 85.7%, respectively) (P = 0.017).Conclusions: Single-step LC+LTCBDE using an ultrathin choledochoscope may provide better outcomes in patients with gallstones and suspected choledocholithiasis.

Predisposing Factors Associated with Post Cholecystectomy Bile Leak

Introduction: Post cholecystectomy bile leak is an uncommon occurrence, but can have significant consequences. Surgical management has shown to have high morbidity and mortality. Endoscopic management via ERCP with sphincterotomy and biliary stent placement has become the mainstay of therapy at this time. To date, little has been described regarding predisposing factors that can lead to a postoperative bile leak. The aim of this study was to assess post cholecystectomy bile leak and determine if there are predisposing factors associated with them. Methods: This retrospective study evaluated patients who underwent cholecystectomy and were found to have a post cholecystectomy bile leak that was treated with ERCP with sphincterotomy and stent placement done at our single center institute. Data from the ERCP cholangiogram was reviewed and included in the data set, including biliary ductal dilatation, stones or sludge in the biliary tract, biliary stenosis, papillary stenosis, duodenal diverticulum, and duct of Luschka. Results: Thirty one patients (17 females, average age 48.3±1.3) with post cholecystectomy bile leak followed by an ERCP were identified from July 2011 to June 2016. Eighteen of the thirty two (56%) patients had at least one of the findings above. Six patients had stones, one additional patient had sludge but no stones, 3 patients had duodenal diverticulum, 1 with biliary stricture, 2 with papillary stenosis, and 6 with a duct of Luschka. Only 6 of these patients had a dilated CBD, 3 associated with stones, 2 with duodenal diverticulum, and 1 without any other obstructive findings. Conclusion: Post cholecystectomy bile leak is an uncommon occurrence, but often (56% of the time) it is accompanied by a predisposing factor. Retained stones and sludge is the most common cause in our small study followed by a duct of Luschka, and duodenal diverticulum. Care should be taken preoperatively to make sure there are no bile duct stones, sludge, or unexplained dilated common bile duct. Further larger studies are needed to assess the utility of pre surgical imaging as well as better describe predisposing factors.

Clinical comparative study of laparoscopic common bile duct exploration versus endoscopic sphincterotomy for choledocholithiasis

Objective To compare the clinical effects between 1aparoscopic cholecystectomy (LC) plus laparoscopic common bile duct exploration (LCBDE) and endoscopic sphincterotomy (EST) plus LC (POEST) for common bile duct stones. Methods 214 patients diagnosed with biliary diseases were included in this study at our institution. The patients were randomized into two groups: LC+ LCBDE group (n=106) and POEST group (n=108). Data including gender, age, number of stones, diameter of bile duct stones, hospitalization time, one-stage cure rate, the residual stone rate and recent complications were collected. Patients were followed up for 12 months, and the data of long-term complications were obtained. Results There were no significant differences between the two groups with respect to gender, age, number of stones, and diameter of bile duct stones. The hospitalization time in LC+ LCBDE group was significantly shorter than that in POEST group [(10.6±4.7) days vs. (13.1±6.8) days, P 0.05). The calculi recurrent rate in LC+ LCBDE group was significantly lower than in POEST group (P 0.05). Conclusion Comparing to POEST, LC+ LCBDE is a better choice of therapy for gallbladder and common bile duct stones. Key words: Choledocholithiasis; Common bile duct exploration; Endoscopic sphincterotomy

Concomitant vascular injuries associated with post-cholecystectomy iatrogenic bile duct injuries: incidence and management in a high volume center

Aims: Concomitant vascular injury with post cholecystectomy bile duct injury is possible. It is considered as an increasing finding during repair. Thus, assessment of those injuries is crucial for defining the optimal surgical management. Methods: One hundred and thirty patients were managed surgically for post cholecystectomy bile duct injury between January 2010 and December 2014 in the department of HPB surgery, National Liver Institute, Menoufiya University in Egypt. Patient's records were revised including preoperative, intraoperative and postoperative data. Follow up visits were also revised. Vascular injury was identified intra-operatively at the beginning of the study while, later, all patients were carried out Computed Topographic hepatic angiography. Results: Twenty eight patients had concomitant vascular injury. Majority were females (75%) with mean age 35years (range, 30–50years). Most of the injuries were post open cholecystectomy (71%). All the patients had right hepatic artery injury while seven had added right portal vein injury. Fifteen patients had right hepatectomy and left hepatico-jejunostomy (53%). Three patients died (11%) due to sepsis and multi-organ failure. The remaining patients had conventional hepatico-jejunostomy. Conclusions: Assessment of vascular injury is an important part in the management of patients with bile duct injuries. Isolated arterial or combined portal injuries may lead to hepatectomy while mortality occurred due to cholangitic abscesses, severe cholangitis with subsequent sepsis.

Increased complexity of post-laparoscopic cholecystectomy bile duct injuries: 22 years experience from a national referral centre in Ireland

Increased complexity of post-laparoscopic cholecystectomy bile duct injuries: 22 years experience from a national referral centre in Ireland

Factors affecting the outcomes of surgical management of post cholecystectomy bile duct strictures

Factors affecting the outcomes of surgical management of post cholecystectomy bile duct strictures

胆囊管にB5胆管が合流し胆囊B5胆管瘻を併発した胆囊結石に対し，腹腔鏡下胆摘兼胆管切除とbiliary ablationを行った1例

症例は70歳の男性で，10年前より胆石を指摘されていたが，今回右季肋部痛を主訴に当院内科を受診した．腹部USでは胆囊の壁肥厚と胆囊内に複数の結石を認め，drip infusion cholangiographic-CT（以下，DIC-CTと略記）でB5胆管は走行異常を認め，胆囊管と共通管を形成していた．術中胆管損傷を防止するために，術前にB5胆管に内視鏡的経鼻胆道ドレナージ（endoscopic nasobiliary drainage；ENBD）留置を施行し，当科で待機的に腹腔鏡下胆囊摘出術を施行した．術中所見では，胆囊頸部で結石が嵌頓しさらに隣接するB5胆管に瘻孔を形成しており，瘻孔部でB5胆管を損傷した．このため，腹腔鏡下に胆囊とB5胆管部分切除を行い，B5末梢側胆管内に無水エタノールを注入するablationを加えた．胆管走行異常を伴い，胆囊結石の嵌頓による胆囊B5胆管瘻に対し，腹腔鏡下に胆囊とB5胆管部分切除に加え，B5末梢胆管のbiliary ablationを加えることで良好な結果が得られた．