Anastomosis Of Common Bile Duct Research Articles

Common bile duct web: Managed with excision and primary anastomosis of bile duct over ERCP stent

Congenital biliary web formations are extremely rare, with only a few cases reported till date in the literature. We report a case of a four years old female child, presented to us for evaluation of jaundice and recurrent attacks of cholangitis. Intra-operatively, we found a nodular mass near the distal end of common bile duct causing extrinsic compression on extra-hepatic biliary tree. Biopsy revealed reactive lymphoid hyperplasia. Four weeks after the first surgery a second procedure was planned. The child then underwent exploratory laparotomy with resection of common bile duct web and anastomosis over an ERCP (Endoscopic retrograde cholangiopancreatography) stent. The reported treatment for biliary web commonly consists of Roux-en-Y hepatico-jejunostomy, excision of the diaphragm with t-tube insertion or excision of the web with a cholecystectomy. However, we performed excision of the web and primary anastomosis of CBD (Common Bile Duct) over an ERCP stent preserving native common bile duct.

S2544 Bile Leak from the Duct of Luschka Following Liver Transplantation

Introduction: Bile leaks following cadaveric orthotropic liver transplantation (OLT) have a reported incidence of 2.7%. Leaks most commonly occur at the choledochocholedochostomy and cholangiojejunostomy sites. Bile leaks from an accessory cystic duct (duct of Luschka) represent the second most common etiology of post-cholecystectomy leaks but a rare etiology following OLT with an incidence of 0.74%. Only 2 cases of bile leaks following OLT from duct of Luschka are reported. Case Description/Methods: We report a case of an infected biloma secondary to a biliary leak from an accessory cystic duct following cadaveric OLT in a 35-year-old male transplanted for alcoholic cirrhosis. Intra-operatively, standard cavo-cavostomy, portal vein, and arterial anastomoses were performed. A donor cholecystectomy was performed by sharp dissection and standard cystic artery and duct ligation. A combined cyst and hepatic donor duct to recipient common bile duct anastomosis eliminated a pre-existing size mismatch. Immunosuppression consisted of a methylprednisolone, tacrolimus, and mycophenolate mofetil. On post-operative day 15, persistent alkaline phosphatase elevation to 185 U/L and hyperbilirubinemia to 5.1 mg/dL prompted evaluation with a magnetic resonance cholangiopancreatogram. This demonstrated fluid collections in the gallbladder fossa (7.3x7.6 cm) and within the porta hepatis (6.2x4.9 cm), no biliary duct dilatation and patent vasculature. He developed a low-grade fever and blood cultures eventually yielded Vancomycin-sensitive E. Faecium (VSE). An endoscopic retrograde cholangiopancreatogram (ERCP) was performed demonstrating no biliary duct stricture but an active leak from an accessory cystic duct (duct of Luschka) (Figure 1). A 5-mm biliary sphincterotomy was followed by a 10 Fr stent placement 9 cm into the common hepatic duct. Ultrasound-guided aspiration of the porta hepatis and gallbladder fossa collections confirmed the biloma diagnosis and fluid cultures of the latter demonstrated VSE. Percutaneous drains were inserted, and intravenous Vancomycin was continued. Four days following ERCP, alkaline phosphatase improved to 155 U/L, aspartate aminotransferase to 19 U/L, alanine aminotransferase to 28 U/L and bilirubin to 3.0 mg/dL. Discussion: An accessory cystic duct occurs in 5-30% of the population and is a critical anatomic variation to consider during cadaveric OLT. We also illustrate the feasibility of a combined endoscopic and radiologic therapeutic approach in case such a leak arises.Figure 1.: Fluoroscopic image demonstrating active extravasation from an accessory cystic duct (duct of Luschka) during the endoscopic retrograde cholangiopancreatogram (ERCP).

Platelet-rich fibrin can accelerate the healing of common bile duct anastomosis in a rat.

This study aimed to evaluate the effect of platelet-rich fibrin (PRF) concentrate on the bile duct anastomosis healing process in rats. Thirty male Sprague Dawley (SD) rats were used for the study. The animals were allocated into three groups: Group I Control Group (n=10): Anastomosis to the common bile duct (CBD) with a stent. Group II PRF Group (n=10): Anastomosis to the CBD with a stent and covered with PRF. Group III Sham Group (n=10): Preparation of the common bile duct, no anastomosis. The animals were followed up for 1 month, then sacrificed. Study parameters were adhesions around the anastomosis, thickness of the bridging bile duct tissue over the stent, and histopathologic examination of the bridging bile duct tissue. CBD anastomosis using a stent caused severe adhesion around the anastomosis, bridging bile duct tissues were weak and histopathologically, healing was incomplete in most of the control animals. However, PRF application significantly reduced the adhesions, increased the quality of the bridging bile duct tissues, and caused complete healing histologically. PRF is an autologous, easily prepared membrane. The present study findings show that PRF prevents local complications and increases the healing capacity of the bile duct after CBD anastomosis. Therefore, it might be a new treatment option for preventing complications following common bile duct anastomosis in liver transplantation patients.

Use of bacterial cellulose film for repair of bile duct injury in pigs.

The aim was to evaluate the use of bacterial cellulose film and bile duct autograft in repairing critical common bile duct injury in pigs. A prospective experimental analytical study was carried out on 20 Sus Domesticus, Piau suidae swine, divided into a control group (n = 10) and an experimental group (n = 10) divided into two subgroups: bacterial cellulose film E1 and bacterial cellulose film E2 to which bacterial cellulose film was randomly allocated. The control group underwent two complete critical common bile duct sections 10 mm apart, while the experimental group with a single critical common bile duct defect underwent a 10 mm section of the longitudinal shaft with edge resection. The defects in the control group were treated with end-to-end conventional anastomosis using polyglycolic 6-0 surgical thread and the experimental group with bacterial cellulose film by continuous suture using the same material. The animals were clinically evaluated throughout the experiment on days D150 (bacterial cellulose film E1), D225 (control group), and D330 (bacterial cellulose film E2) and by intraoperative ultrasound examination related to histopathological and biochemical findings. The intraoperative ultrasonography detected the changes resulting from the common bile duct anastomosis in the control group that produced a considerable incidence of ductal narrowing and obstruction to the biliary flow. In the bacterial cellulose film E2 group, there was an increase in inflammation intensity, granulomatous reaction, fibrosis, and vessels density, without producing bile duct dilation in the ultrasonography assessment. Biochemical analysis of liver enzymes yielded results in the normal range confirming preservation of liver function at the different post-surgery time points. Bacterial cellulose film, when used as a graft for bile duct repair, proved to be a biocompatible material that produced a complete healing process and biliary flow continuity.

Effect of tamoxifen on fibrosis, collagen content and transforming growth factor-β1, -β2 and -β3 expression in common bile duct anastomosis of pigs.

End-to-end anastomosis in the treatment for bile duct injury during laparoscopic cholecystectomy has been associated with stricture formation. The aim of this study was to experimentally investigate the effect of oral tamoxifen (tmx) treatment on fibrosis, collagen content and transforming growth factor-β1, -β2 and -β3 expression in common bile duct anastomosis of pigs. Twenty-six pigs were divided into three groups [sham (n=8), control (n=9) and tmx (n=9)]. The common bile ducts were transected and anastomosed in the control and tmx groups. Tmx (40mg/day) was administered orally to the tmx group, and the animals were euthanized after 60days. Fibrosis was analysed by Masson's trichrome staining. Picrosirius red was used to quantify the total collagen content and collagen type I/III ratio. mRNA expression of transforming growth factor (TGF)-β1, -β2 and -β3 was quantified using real-time polymerase chain reaction (qRT-PCR). The control and study groups exhibited higher fibrosis than the sham group, and the study group showed lower fibrosis than the control group (P=0.011). The control and tmx groups had higher total collagen content than the sham group (P=0.003). The collagen type I/III ratio was higher in the control group than in the sham and tmx groups (P=0.015). There were no significant differences in the mRNA expression of TGF-β1, -β2 and -β3 among the groups (P>0.05). Tmx decreased fibrosis and prevented the change in collagen type I/III ratio caused by the procedure.

Tratamiento endoscópico de afecciones biliopancreáticas en niños. Análisis de 31 pacientes

An observational, descriptive study of the records of 53 endoscopic retrograde cholangiopancreatography (ERCP) performed on 31 patients of paediatric age with suspected biliopancreatic disorders at the National Center for Minimal Access Surgery was performed over a period of 2years and 7months, from 11 February 2013 to 28 July 2015. Of the total, 8 patients (27%) were male, and 22 (73%) female; 14 (26%) were diagnostic and 39 (74%) therapeutic. The primary indication was to study pain with elevated enzymes in 27 (50%), and the main diagnosis was postoperative benign common bile duct-anastomosis stricture in 14 patients (26%), followed by 10 normal ERCP (19%). The intervention used was endoscopic sphincterotomy (16) for placement of prosthesis (7), followed in frequency by stone extraction (6). There were complications in 2 cases, one (2%) in 21 therapeutic procedures, and one (2%) at diagnosis. Mortality was zero. Our results show the high diagnostic usefulness and therapeutic success of ERCP with minimal risk and complications in paediatric patients.

Novel technique for biliary reconstruction using an isolated gastric tube with a vascularized pedicle: a live animal experimental study and the first clinical case

BackgroundBiliary tract reconstruction continues to be a challenging surgical problem. Multiple experimental attempts have been reported to reconstruct biliary defects with different materials and variable outcome. Our aim was to evaluate a new method for biliary reconstruction using an isolated pedicled gastric tube in a live animal trial and also to present the first clinical case.MethodsSeven mongrel dogs underwent biliary reconstruction using gastric tube harvested, completely separated from the greater curvature, and based on a vascularized pedicle with the right gastroepiploic vessels. The tube was interposed between the common bile duct (CBD) and the duodenum. Postoperative mortality, morbidity, liver functions, gross and microscopic histological picture were assessed. The first clinical case was also presented where, in a patient with post-cholecystectomy biliary injury, an isolated pedicled gastric tube was interposed between the proximal and distal ends of the CBD.ResultsOne dog did not recover from anesthesia and another one died postoperatively from septic peritonitis. Five dogs survived the procedure and showed uneventful course and no cholestasis. The mean anastomotic circumference was 4.8 mm (range 4-6) for CBD anastomosis and 6.2 mm (range 5-7) for duodenal anastomosis. Histologically, anastomotic sites showed good evidence of healing. In the first clinical case, the patient showed clinical and biochemical improvement. Endoscopic retrograde cholangiography was feasible and assured patent biliary anastomoses.ConclusionIn mongrel dogs, biliary reconstruction using pedicled gastric tube interposition between CBD and duodenum is feasible with satisfactory clinical results, anastomotic circumference and histological evidence of healing. The technique is also feasible in human and seems to be promising.

Foetus in fetu with common bile duct injury: a case report and review of literature

Six-month-old female child presented with history of abdominal lump of 2 months duration. There was an intra-abdominal mass of about 15 × 10 cm on the right side of the abdomen and laboratory investigations were normal. Roentgenogram showed calcified mass in the region of lumbar vertebrae. Ultrasound of the abdomen revealed a retroperitoneal mass of mixed echogenicity with calcifications. Computerized tomography (CT) scan showed an encapsulated mass with fat densities and rudimentary limbs (Fig. 1). Based on these imaging findings provisional diagnosis of foetus in fetu (FIF) was made preoperatively. Computerized tomography scan image of tumour showing heterogenous mass in upper retroperitonium and showing fat densities and calcifications and early organogenesis. During surgery, the mass was crossing the midline. The duodenum was densely adherent to the mass. During separation of the duodenum, common bile duct thinned out because stretching by the tumour was seen merely as a fold of peritoneum and hence was cut. Single-layer end-to-end anastomosis of the common bile duct was done using vicryl 5-0 and keeping all the knots outside after placing 5 fr infant feeding tube as a stent across the anastomosis (Fig. 2). The feeding tube was cut open along its axis for about 6 cm and one end of the tube was put into distal common bile duct and duodenum and the other end was brought out from the anterior abdominal wall. Complete tumour excision was done. On macroscopic examination, the mass was showing head, trunk and rudimentary limb-like structure (Fig. 3). Histopathology of the specimen confirmed it to be FIF. Common bile duct anastomosed over 5 fr infant feeding tube. Excised specimen showing skull, body and rudimentary limbs of the foetus. Tube cholangiogram was performed on day 14 post-op, and contrast was seen entering into the duodenum without any extravasations. Tube was removed. Hippuran imino diacetic acid scan was performed after 6 weeks showed prompt gut activity. Patient at present is under regular follow-up for the last 1 year and having normal abdominal ultrasound findings. Her liver functions are within normal range and is doing well. Foetus in fetu is a malformed monozygotic diamniotic twin found inside the body of a living child.1-3 Now with CT scan commonly being used, preoperative diagnosis is not difficult. In this case, the common bile duct was so much stretched because of the tumour that it appeared like a thin fold of peritoneum, and it was injured. Once the injury was identified immediately, options were roux – en-y choledocho jejunostomy, choledocho duodenostomy and end-to-end bile duct anastomosis with or without stenting by T tube or by infant feeding tube or cholecystostomy along with common bile duct anastomosis.4 But the placing of stents was difficult because of the small diameter of the bile duct. Same was the reason for not doing other procedures: because of technical difficulties and a high rate of complications of such bilio-enteric anastomosis. Hence, decision for using no. 5 infant feeding tube as a stent and for perfoming end-to-end bile duct repair was made, and it gave us a good result. Literature on such bile duct injury in children was reviewed. Most of the paediatric bile duct injuries are traumatic or iatrogenic but are rare. Transection injury requires surgical repair. Partial tear, avulsion or injuries because of physical trauma can be managed by endoscopic stenting with good results.5 Our case becomes different not only because of its uncommon pathology but also because of management of the complication in such a technically difficult situation and necessitates the importance of versatility of surgical technique.

Hemorrhagic bile pleuritis and peritonitis secondary to traumatic common bile duct rupture, diaphragmatic tear, and rupture of the spleen in a dog

AbstractObjective– To describe the diagnosis and successful treatment of bile pleuritis and peritonitis secondary to traumatic rupture of the common bile duct and a diaphragmatic tear in a young dog.Case Summary– A 1‐year‐old German Shepherd dog was referred for evaluation of vomiting and icterus 4 days after being hit by a car. Thoracic radiographs, thoracic and abdominal ultrasonographic examinations, thoraco‐ and abdominocentesis, and positive contrast celiogram indicated hemorrhagic pleuritis and peritonitis, left dorsal diaphragmatic tear, and rupture and infarct of the spleen. Surgical exploration of the abdomen confirmed these findings in addition to a circumferential tear of the common bile duct, leading to a diagnosis of hemorrhagic bile pleuritis and peritonitis. Aerobic and anaerobic bacterial culture of the abdominal fluid yielded no growth. Surgical correction of the traumatic injuries was achieved via common bile duct anastomosis, cholecystojejunostomy, repair of the diaphragm, and splenectomy. The dog developed postoperative signs consistent with aspiration pneumonia but was successfully treated and discharged from the hospital. Clinical signs and laboratory abnormalities resolved and the dog was alive and healthy 8 months after discharge.New or Unique Information Provided– Bile pleuritis is rare in dogs and cats and is usually associated with penetrating, not blunt, abdominal trauma. Multiple organ injury in cases of traumatic bile duct rupture is uncommon; in this dog, rupture of the common bile duct was accompanied by rupture of the diaphragm and spleen.

Treatment of hepatobiliary calculi combined with cholangitis with orthotopic removal and reconstruction of common bile duct-duodenum anastomosis and first-stage suture of common bile duct in 1 case

Treatment of hepatobiliary calculi combined with cholangitis with orthotopic removal and reconstruction of common bile duct-duodenum anastomosis and first-stage suture of common bile duct in 1 case

Assessment of Early Biliary Complications After Orthotopic Liver Transplantation and Their Relationship to the Technique of Biliary Reconstruction

Introduction Biliary complications are known as the weak point of liver transplantation. Their occurrence can be related to the practice of drainage of the biliary anastomosis, the routine use of which was abandoned in June 2004. The aim of the study was to assess the incidence and type of biliary complications following orthotopic liver transplantation in relation to the technique of biliary anastomosis. Material and methods We compared the results of two groups of adult liver transplant recipients: group I, recent 50 transplantations with biliary drainage (25 women: 25 men of age range: 17 to 63 years), and group II, first 50 transplantations without drainage (19 women and 31 men of age range, 20 to 65 years). We examined the problem of biliary complications and their influence on the further management of the patients. In both groups the main indications for transplantation were various types of cirrhosis as well as cholestatic diseases. In the majority of cases ( n = 86) an end-to-end common bile duct anastomosis was performed and in 14 cases, hepaticojejunal anastomosis. Results In group I, biliary complications requiring surgical or endoscopic intervention occurred in 10 (20%) recipients. In one case, biliary complications resulted in the need for retransplantation. In group II, biliary complications occurred in only four (8%) patients, none of which caused organ loss. Conclusion Cessation of biliary anastomosis drainage has reduced the occurrence of early biliary complications following orthotopic liver transplantation.

Effect of biliary infection on common bile duct healing in the rat

It has been postulated that biliary infection plays a role in bile duct stricture formation. The aim of this study was to verify this hypothesis and to evaluate the effect of biliary infection on common bile duct healing. A 3-mm longitudinal choledochotomy was performed in 120 rats and closed with a continuous 11/0 Ethilon suture. Common bile duct division with end-to-end anastomosis using interrupted 11/0 Ethilon sutures was performed in another 30 rats. Biliary infection was achieved in half of the animals with retrograde injection of living 046:K1:H31 strain Escherichia coli recovered from the rat colonic content. All rats with choledochotomy, including those with biliary infection, showed no bile leakage at the suture line, and the bursting pressure at the site of choledochotomy exceeded 40 mmHg as early as 24 h. Rats with common bile duct anastomosis alone showed no stricture formation for up to 6 months after operation. All rats with biliary sepsis developed complete occlusion at the anastomosis. On scanning electron microscopy, the biliary epithelium was well preserved in all rats. The study suggests that in rats with biliary sepsis the risk of bile leakage after primary closure of the common bile duct is negligible, but biliary infection may play a critical role in common bile duct stricture formation.

Orthotopic liver transplantation: an experimental study on the prevention of infections with Gram-negative organisms.

Infection with Gram-negative bacteria is frequently the cause of death in human liver transplantation. In experimental liver transplantation in mongrel dogs we detected Gram-negative septicaemia in 73% of our first 15 cases; maximal survival was 26 days. In a second series of 27 orthotopic liver transplantations in tissue-typed littermate dogs and littermate pigs the standard surgical technique and aftercare were changed with regard to four factors: an end-to-end common bile duct anastomosis was made instead of a gallbladder to duodenum anastomosis; the continuous postoperative bacteriostatic antibiotic therapy was changed to a single 2-day course of bactericidal antibiotics; preoperative selective bowel decontamination combined with postoperative protective isolation was introduced; the dosage of azathioprine used for immunosuppression was reduced..

External metallic circle in microsurgical anastomosis of common bile duct

Background: Biliary stricture development is one of the most serious problems following biliary tract surgery. Here, we present a new technique for biliary tract reconstruction with an external metallic circle, and the results of this new technique in a rat model. Methods: Twelve male Sprague-Dawley rats (250 to 300 g) were divided into two groups. After transection of the bile duct, standard bile duct reconstruction (without the metallic circle) was performed in group 1 and reconstruction with the external metallic (silver) circle was performed in group 2. At the end of the fourth month, clinical, laboratory biochemical, and histopathologic parameters were compared between the groups. Results: Serum concentrations of alkaline phosphatase (ALP) and operation time were higher in group 1 than in group 2. Differences were statistically significant. In histopathologic examination, biliary duct stricture was seen in group 1. Foreign body reaction and fibrosis in the bile duct wall were seen in group 2. Conclusion: An external metallic circle prevents development of biliary stricture after primary end-to-end bile duct anastomosis in this rat model.

Sutureless and Reduced Suture Anastomosis of Hollow Vessels With Fibrin Glue: A Review

Research in reduced suture fibrin glue (FG) and sutureless FG anastomosis has been lagging behind FG utilization in other surgical fields. A review of the literature for vascular, esophageal, tracheal, gastrointestinal, common bile duct, ureteral, vas deferens, and Fallopian tube FG anastomosis indicates that reduced suture FG and sutureless FG procedures may be performed with less training, reduced operating time, leakage, ischemia, inflammation, and necrosis compared to sutured techniques. Reduced suture FG vasular anastomosis augments early anastomotic strength. Suture number for esophageal, tracheal, and tracheobronchial anastomoses can be reduced with FG. Bursting strength in pig small intestine and rat colon was lower at 4 days postoperatively, but returned to sutured strength at 7 days. Mortality was unaffected, and 18-month follow-up in sutureless FG intestinal anastomosis in pigs showed no stenosis. Preliminary ureteral studies have demonstrated successful sutureless FG and reduced suture FG laparoscopic techniques in pigs. Reduced suture FG and sutureless FG vas deferens anastomosis may reduce sperm granuloma rates, with increased patency and pregnancy rates. Patency and pregnancy rates have been similar for tubal FG, reduced suture FG, autologous fibrin glue (AFG), and sutured anastomosis. Any risk of viral transmission or immune response is eliminated by AFG. While there are few studies in many areas of FG hollow vessel anastomosis, the current literature illustrates many of the advantages of FG over other anastomotic techniques and should provide impetus for continued research in this promising field of surgery.

Infection rates with and without T-tube splintage of common bile duct anastomosis in liver transplantation.

Stenting the bile duct over a T-tube after orthotopic liver transplantation (OLT) is the preferred method of biliary reconstruction. However, because of complications associated with the use of the T-tube, we evaluated the effect of various biliary anastomoses following 100 consecutive OLT (83 records were available for long-term evaluation) and assessed the clinical outcome of abandoning routine T-tube splintage. Of 16 OLT recipients with T-tube splintage (one died immediately following OLT and was excluded from the study), 6 patients (40%) developed six episodes of septicaemia secondary to biliary and/or intra-abdominal sepsis. Four of these six patients had a biliary leak (27%). Of 57 patients with duct-to-duct anastomosis without T-tube splintage, 7 patients developed biliary leak (12.3%) and only 1 developed septicaemia (1.7%) secondary to biliary and intra-abdominal sepsis (P = 0.0002). Of 11 patients with either a gallbladder conduit or Roux loop, only 1 patient had a biliary leak (9%) and there were no septicaemic episodes. In conclusion, direct duct-to-duct anastomosis resulted in significantly less morbidity due to infection without T-tube splintage than the use of a T-tube following OLT, but there were no significant differences in leakage and stricture rates.

Infection rates with and without T-tube splintage of common bile duct anastomosis in liver transplantation

Abstract Stenting the bile duct over a T-tube after orthotopic liver transplantation (OLT) is the preferred method of biliary reconstruction. However, because of complications associated with the use of the T-tube, we evaluated the effect of various biliary anastomoses following 100 consecutive OLT (83 records were available for long-term evaluation) and assessed the clinical outcome of abandoning routine T-tube splintage. Of 16 OLT recipients with T-tube splintage (one died immediately following OLT and was excluded from the study), 6 patients (40 %) developed six episodes of septicaemia secondary to biliary and/or intra-abdominal sepsis. Four of these six patients had a biliary leak (27 %). Of 57 patients with duct-to-duct anastomosis without T-tube splintage, 7 patients developed biliary leak (12.3 %) and only 1 developed septicaemia (1.7%) secondary to biliary and intra-abdominal sepsis (P= 0.0002). Of 11 patients with either a gallbladder conduit or Roux loop, only 1 patient had a biliary leak (9 %) and there were no septicaemic episodes. In conclusion, direct duct-to-duct anastomosis resulted in significantly less morbidity due to infection without T-tube splintage than the use of a T-tube following OLT, but there were no significant differences in leakage and stricture rates.

Laparoscopic management of choledocholithiasis

The authors report on a group of 114 patients with common bile duct (CBD) stones who were treated by laparoscopic surgery. Management through the cystic duct was considered the first option. Choledochotomy was used for those patients in which the cystic approach was not possible or was unsuccessful. Transcystic lithotripsy was considered for patients with CBD stones in disproportion with the size of the cystic duct. Laparoscopic antegrade sphincterotomy was indicated as a drainage procedure. The transcystic approach was used in 89.5% of the patients; choledochotomy was used in 6.2%; and both ways were used in 4.3%. Different procedures were used, including mechanical and electrohydraulic lithotripsy, choledochotomy with T-tube or endoprostheses drainage, laparoscopic sphincterotomy, end-to-end common bile duct anastomosis, and choledochoduodenum anastomosis. One of the patients was in the 21st week of pregnancy. The laparoscopic approach to choledocholithiasis was successfully performed in 94.8% of the patients. Mean hospital stay was 1.7 days. There was a 6.2% incidence of complications and the mortality rate was 0.9%. In 84.3% of the patients, the transcystic approach was used successfully, with a complication rate of 4.9% and a mean hospital stay of 1.6 days. Three patients were converted to open surgery early in this series. Thus far, one patients has presented residual CBD stones. The results obtained suggest that laparoscopic common bile duct exploration is a technically feasible procedure, with low complication and mortality rates, although it requires adequate selection of patients and a variety of techniques and types of equipment.

Technique and Results of Biliary Reconstruction Using Side-to-Side Choledochocholedochostomy in 300 Orthotopic Liver Transplants

The authors evaluated the complication rate and outcome of side-to-side common bile duct anastomosis after human orthotopic liver transplantation. Early and late biliary tract complications after orthotopic liver transplantation remain a serious problem, leading to increased morbidity and mortality. Commonly performed techniques are the end-to-end choledochocholedochostomy and the choledochojejunostomy. Both techniques are known to coincide with a high incidence of leakage and stenosis of the bile duct anastomosis. The side-to-side bile duct anastomosis has been shown experimentally to be superior to the end-to-end anastomosis. The authors present the results of 316 human liver transplants, in which a side-to-side choledochocholedochostomy was performed. Biliary tract complications of 370 transplants in 340 patients were evaluated. Three hundred patients received primary liver transplants with side-to-side anastomosis of donor and recipient common bile duct. Thirty-two patients with biliary tract pathology received a bilioenteric anastomosis, and in eight patients, side-to-side anastomosis was not performed for various reasons. Clinical and laboratory investigations were carried out at prospectively fixed time points. X-ray cholangiography was performed routinely in all patients on postoperative days (PODs) 5 and 42. In patients with suspected papillary stenosis, endoscopic retrograde cholangioscopy and papillotomy were performed. One biliary leakage (0.3%) was observed within the early postoperative period (PODs 0 through 30) after liver transplantation. No stenosis of the common bile duct anastomosis was observed during this time. Late biliary stenosis occurred in two patients (0.6%). T tube-related complications were observed in 4 of 300 primary transplants (1.3%). Complications unrelated to the surgical technique, including papillary stenosis (5.7%) and ischemic-type biliary lesion (3.0%), which must be considered more serious in nature than complications of the anastomosis or T tube-related complications, were observed. Papillary stenosis led to frequent endoscopic interventions and retransplantations in 1.3%. Side-to-side common bile duct anastomosis represents a safe technique of bile duct reconstruction and leads to a low technical complication rate after human orthotopic liver transplantation. Ischemic-type biliary lesion evoked by preservation injury, arterial ischemia, cholestasis, and cholangitis may represent a new entity of biliary complication, which markedly increases the morbidity after human liver transplantation. Therefore, this complication should be the subject of further research.

Primary common bile duct anastomosis in the rat using microsurgical techniques.

In a rat model, we attempted to describe the natural healing course of the common bile duct (CBD) after primary microsurgical repair. Fifty-three rats were divided into experimental groups with CBD microsurgical anastomoses and control groups with CBD mobilization and ligation. Examination of three experimental groups at 1 week, 1 month, and 3 months showed evolving inflammation and stricture changes with eventual patent, healed ducts in 92% of animals at the end of 3 months following transection and repair. There were no histologic abnormalities in the livers. There were fibrotic ducts and hepatic stasis and cirrhosis changes in the control group with CBD ligation. This study demonstrates that microsurgical techniques can achieve successful primary biliary repair in the rat.