Bile Duct Injury Research Articles

Loss of β-catenin reveals a role for glutathione in regulating oxidative stress during cholestatic liver disease.

Cholestasis is an intractable liver disorder that results from impaired bile flow. We have previously shown that the Wnt/β-catenin signaling pathway regulates the progression of cholestatic liver disease through multiple mechanisms, including bile acid metabolism and hepatocyte proliferation. To further explore the impact of these functions during intrahepatic cholestasis, we exposed mice to a xenobiotic that causes selective biliary injury. α-naphthylisothiocyanate (ANIT) was administered to liver-specific knockout (KO) of β-catenin and wild-type mice in the diet. Mice were killed at 6 or 14 days to assess the severity of cholestatic liver disease, measure the expression of target genes, and perform biochemical analyses. We found that the presence of β-catenin was protective against ANIT, as KO mice had a significantly lower survival rate than wild-type mice. Although serum markers of liver damage and total bile acid levels were similar between KO and wild-type mice, the KO had minor histological abnormalities, such as sinusoidal dilatation, concentric fibrosis around ducts, and decreased inflammation. Notably, both total glutathione levels and expression of glutathione-S-transferases, which catalyze the conjugation of ANIT to glutathione, were significantly decreased in KO after ANIT. Nuclear factor erythroid-derived 2-like 2, a master regulator of the antioxidant response, was activated in KO after ANIT as well as in a subset of patients with primary sclerosing cholangitis lacking activated β-catenin. Despite the activation of nuclear factor erythroid-derived 2-like 2, KO livers had increased lipid peroxidation and cell death, which likely contributed to mortality. Loss of β-catenin leads to increased cellular injury and cell death during cholestasis through failure to neutralize oxidative stress, which may contribute to the pathology of this disease.

Recombinant collagen coating 3D printed PEGDA hydrogel tube loading with differentiable BMSCs to repair bile duct injury

Bile duct injury presents a significant clinical challenge following hepatobiliary surgery, necessitating advancements in the repair of damaged bile ducts is a persistent issue in biliary surgery. 3D printed tubular scaffolds have emerged as a promising approach for the repair of ductal tissues, yet the development of scaffolds that balance exceptional mechanical properties with biocompatibility remains an ongoing challenge. This study introduces a novel, bio-fabricated bilayer bile duct scaffold using a 3D printing technique. The scaffold comprises an inner layer of polyethylene glycol diacrylate (PEGDA) to provide high mechanical strength, and an outer layer of biocompatible, methacryloylated recombinant collagen type III (rColMA) loaded with basic fibroblast growth factor (bFGF)-encapsulated liposomes (bFGF@Lip). This design enables the controlled release of bFGF, creating an optimal environment for the growth and differentiation of bone marrow mesenchymal stem cells (BMSCs) into cholangiocyte-like cells. These cells are instrumental in the regeneration of bile duct tissues, evidenced by the pronounced expression of cholangiocyte differentiation markers CK19 and CFTR. The PEGDA//rColMA/bFGF@Lip bilayer bile duct scaffold can well simulate the bile duct structure, and the outer rColMA/bFGF@Lip hydrogel can well promote the growth and differentiation of BMSCs into bile duct epithelial cells. In vivo experiments showed that the scaffold did not cause cholestasis in the body. This new in vitro pre-differentiated active 3D printed scaffold provides new ideas for the study of bile duct tissue replacement.

Biliary atresia: insights into mechanisms using a toxic model of the disease including Wnt and Hippo signaling pathways and microtubules.

Mechanisms underlying bile duct injury in biliary atresia (BA) remain unclear and mechanisms of bile duct repair are unknown. This study aimed to explore the roles of microtubule instability and Wnt and Hippo signaling pathways in a biliatresone-induced BA model. Using primary murine neonatal cholangiocytes in both 2D and 3D cultures, and ex-vivo extra hepatic bile ducts (EHBD) which also has peri-cholangiocyte area, we analyzed injury and recovery processes. Injury was induced by the toxin biliatresone and recovery was induced by toxin wash-out. Microtubule stabilizer paclitaxel prevented biliatresone-induced injury, both to cholangiocytes as well as reduced periductal αSMA stain, this process is mediated by decreased glutathione levels. RhoU and Wnt11 (Wnt signaling) and Pard6g and Amotl1 (Hippo signaling) are involved in both injury and recovery processes, with the latter acting upstream to Wnt signaling. Early stages of biliatresone-induced EHBD injury in cholangiocytes and periductal structures are reversible. Wnt and Hippo signaling pathways play crucial roles in injury and recovery, providing insights into BA injury mechanisms and potential recovery avenues. Microtubule stabilization prevents cholangiocyte injury and lumen obstruction in a toxic model of biliary atresia (biliatresone induced). Early stages of biliatresone-induced injury, affecting both cholangiocytes and periductal structures, are reversible. Both Wnt and Hippo signaling pathways play a crucial role in bile duct injury and recovery, with a noted interplay between the two. Understanding mechanisms of cholangiocyte recovery is imperative to unveil potential therapeutic avenues.

Clinical Evaluation of Primary Suturing of Normal-Diameter Common Bile Ducts After Microincision of Cystic Duct Confluence for Stone Removal.

In patients with gallstones complicated by common bile duct (CBD) stones, both normal and dilated common bile ducts have been reported. The goal of this study was to investigate the efficacy and safety of primary suturing after microincision of the cystic duct confluence in treating these patients. Between July 2018 and December 2021, 104 patients were admitted to the Department of General Surgery at Guannan County People's Hospital with gallstone complications, and their records were reviewed retrospectively. The patients were divided into 2 groups: normal CBD group (n=70, CBD diameter: 6.0 to 8.0mm) and dilated CBD group (n=34, CBD diameter: >8.0mm). In these 104 patients, there were 75 cases of CBD stones with acute cholangitis, 12 cases of CBD stones without cholangitis, and 17 cases of mild biliary pancreatitis with CBD stones (including 2 cases of biliary pancreatitis with cholangitis). Among all patients, there were 37 cases with jaundice, 67 cases without jaundice, and 5 cases of emergency surgery. All patients underwent microincision of the cystic duct confluence followed by primary suturing. Both groups were compared on a variety of general and perioperative indicators. All patients underwent laparoscopy combined with choledochoscopy; there were no cases of biliary tract injury or conversion to laparotomy. There was no statistically significant difference in operation duration ( P =0.286), blood loss ( P =0.06), length of stay ( P =0.821), and time to drainage tube removal ( P =0.096) between the 2 groups. Microincision of the cystic duct confluence, followed by a primary suture, is a safe and effective treatment for CBD stones in patients with a normal CBD diameter, as determined by preoperative imaging.

Impact of an AI-Based laparoscopic cholecystectomy coaching program on the surgical performance: a randomized controlled trial.

Laparoscopic cholecystectomy (LC) is the gold standard for treating symptomatic gallstones but carries inherent risks like bile duct injury (BDI). While critical view of safety (CVS) is advocated to mitigate BDI, its real-world adoption is limited. Additionally, significant variations in surgeon performance impede procedural standardization, highlighting the need for a feasible, innovative, and effective training approach. The aim of this study is to develop an Artificial Intelligence (AI)-assisted coaching program for LC to enhance surgical education and improve surgeon's performance. We conducted a multi-center, randomized controlled trial from May 2022 to August 2023 to assess the impact of an AI-based coaching program, SmartCoach, on novice performing LC. Surgeons and patients meeting specific inclusion criteria were randomly assigned to either a coaching group with AI-enhanced feedback or a self-learning group. The primary outcome was assessed using the Laparoscopic Cholecystectomy Rating Form (LCRF), with secondary outcomes including surgical safety, efficiency, and adverse events. Statistical analyses were performed using SPSS, with significance set at P-value less than 0.05. Between May 2022 and August 2023, 22 surgeons were initially enrolled from 10 hospitals, with 18 completing the study. No demographic differences were noted between coaching and self-learning groups. In terms of surgical performance (LCRF scores), the coaching group showed significant improvement over time (31 to 40, P=0.008), outperforming the self-learning group by study end (40 vs 38, P=0.032). Significant improvements in CVS achievement were also noted in the coaching group (11% to 78%, P=0.021). Overall, the coaching program was well-received, outpacing traditional educational methods in both understanding and execution of CVS and participants in the intervention group expressed strongly satisfaction with the program. The AI-assisted surgical coaching program effectively improved surgical performance and safety for novice surgeons in LC procedures. The model holds significant promise for advancing surgical education.

A deep-learning-based model for assessment of autoimmune hepatitis from histology: AI(H).

Histological assessment of autoimmune hepatitis (AIH) is challenging. As one of the possible results of these challenges, nonclassical features such as bile-duct injury stays understudied in AIH. We aim to develop a deep learning tool (artificial intelligence for autoimmune hepatitis [AI(H)]) that analyzes the liver biopsies and provides reproducible, quantifiable, and interpretable results directly from routine pathology slides. A total of 123 pre-treatment liver biopsies, whole-slide images with confirmed AIH diagnosis from the archives of the Institute of Pathology at University Hospital Basel, were used to train several convolutional neural network models in the Aiforia artificial intelligence (AI) platform. The performance of AI models was evaluated on independent test set slides against pathologist's manual annotations. The AI models were 99.4%, 88.0%, 83.9%, 81.7%, and 79.2% accurate (ratios of correct predictions) for tissue detection, liver microanatomy, necroinflammation features, bile duct damage detection, and portal inflammation detection, respectively, on hematoxylin and eosin-stained slides. Additionally, the immune cells model could detect and classify different immune cells (lymphocyte, plasma cell, macrophage, eosinophil, and neutrophil) with 72.4% accuracy. On Sirius red-stained slides, the test accuracies were 99.4%, 94.0%, and 87.6% for tissue detection, liver microanatomy, and fibrosis detection, respectively. Additionally, AI(H) showed bile duct injury in 81 AIH cases (68.6%). The AI models were found to be accurate and efficient in predicting various morphological components of AIH biopsies. The computational analysis of biopsy slides provides detailed spatial and density data of immune cells in AIH landscape, which is difficult by manual counting. AI(H) can aid in improving the reproducibility of AIH biopsy assessment and bring new descriptive and quantitative aspects to AIH histology.

Indocyanine green fluorescence quantification during normothermic ex situ perfusion for the assessment of porcine liver grafts after circulatory death.

Current graft evaluation during normothermic ex situ liver perfusion lacks real-time parameters for predicting posttransplant hepatocyte and biliary function. Indocyanine green (ICG) imaging has been widely used in liver surgery, enabling the visualization of hepatic uptake and excretion through bile using near-infrared light. In this research, porcine livers under various ischemic conditions were examined during a 5-hour normothermic ex situ liver perfusion procedure, introducing ICG at 1 hour through the hepatic artery. These conditions included livers from heart-beating donors, donation after circulatory death (DCD) with warm ischemic durations of 60 minutes (DCD60) and 120 minutes (DCD120), as well as interventions utilizing tissue plasminogen activator in DCD120 cases (each n = 5). Distinct hepatic fluorescence patterns correlated with different degrees of ischemic injury ( p = 0.01). Low ICG uptake in the parenchyma (less than 40% of maximum intensity) was more prevalent in DCD120 (21.4%) compared to heart-beating donors (6.2%, p = 0.06) and DCD60 (3.0%, p = 0.02). Moreover, ICG clearance from 60 minutes to 240 minutes was significantly higher in heart-beating donors (69.3%) than in DCD60 (17.5%, p < 0.001) and DCD120 (32.1%, p = 0.01). Furthermore, thrombolytic intervention using tissue plasminogen activator in DCD120 resulted in noteworthy outcomes, including significantly reduced ALP levels ( p = 0.04) and improved ICG clearance ( p = 0.02) with a trend toward mitigating fibrin deposition similar to DCD60, as well as enhancements in bile production ( p = 0.09). In conclusion, ICG fluorescence imaging during normothermic ex situ liver perfusion provides real-time classification of hepatic vascular and biliary injuries, offering valuable insights for the more accurate selection and postintervention evaluation of marginal livers in transplantation.

Elimination of bile leakage in liver injuries

Aim. To study the causes and consequences of bile leakage in liver injury and determine the potential ways for its elimination. Materials and methods. The study involved a retrospective analysis of 204 liver injuries of various types. 26 % of cases were detected with isolated abdominal trauma, 74 % – with concomitant abdominal injury. According to the AAST grading scale, 15.7 % of patients got grade II liver injuries, 44.6 % – grade III, 34.3 % – grade IV, and 5.4 % – grade V. Since concomitant injuries predominated, surgical treatment was initially performed in the overwhelming number of cases. 14 % of cases received non-operative management. Results. The incidence of bile leakage amounted to 28.4 % for all liver injuries and reached 54.9 % for III–V grade injuries (AAST). Small bile leakage prevailed, while active leaking was observed in 36.2 %. Damage to peripheral parts of the biliary tract was noted in most cases (68 %). Conservative management of patients with small bile leakage associated with damage to peripheral parts of the biliary tract appeared successful in 48.5 % of cases. Endoscopic biliary drainage of bile ducts proved effective in case of active bile leakage and (or) injuries of the central bile ducts. Conclusion. Endoscopic biliary drainage of bile ducts is considered the most effective for elimination of active biliary leakage in the absence of biliary peritonitis and communication of biliary tract with pleural cavity.

Assessment of Postoperative Complications and Outcomes in Patients Undergoing Laparoscopic Cholecystectomy.

A common surgical technique for gallbladder disorders is laparoscopic cholecystectomy (LC), which has the benefits of less postoperative discomfort and quicker recovery. The purpose of this retrospective research was to assess postoperative outcomes and complications in patients having laparoscopic correction. In total, 200 patients who had LC at the tertiary care center between 2017 and 2022 were the subjects of a retrospective investigation. We gathered and examined data on preoperative conditions, surgical specifics, postoperative results, and demographics. Notable findings from the study were as follows: (1) The average age of the patients was 47.5 years (±12.3), and there were strong correlations (P < 0.001) between age and problems. (2) Significant correlations were found between many covariates and postoperative outcomes, such as a 10% readmission rate and a mean hospital stay of 3.6 days (±1.2) (P < 0.05). (3) Different relationships were seen between the complications (P values ranging from 0.021 to <0.001), including wound infections (6%) and bile duct injuries (2.5%). To enhance patient care, a thorough assessment and focused treatments are required. This study sheds light on the frequency of postoperative problems and outcomes in patients receiving LC.

Robotic-assisted cholecystectomy versus conventional laparoscopic cholecystectomy for benign gallbladder disease: a systematic review and meta-analysis.

Laparoscopic cholecystectomy (LC) is the established gold standard treatment for benign gallbladder diseases. However, robotic cholecystectomy is still controversial. Therefore, we aimed to compare intraoperative and postoperative outcomes in LC and robotic-assisted cholecystectomy (RAC) in patients with nonmalignant gallbladder conditions. PubMed, Scopus, Cochrane Library, and Web of Science were systematically searched for studies comparing RAC to LC in patients with benign gallbladder disease. Only randomized trials and non-randomized studies with propensity score matching were included. Mean differences (MDs) were computed for continuous outcomes and odds ratios (ORs) for binary endpoints, with 95% confidence intervals (CIs). Heterogeneity was assessed with I2 statistics. Statistical analysis was performed using Software R, version 4.2.3. A total of 13 studies comprising 22,440 patients were included, of whom 10,758 patients (47.94%) underwent RAC. The mean age was 48.5years and 65.2% were female. Compared with LC, RAC significantly increased operative time (MD 12.59min; 95% CI 5.62-19.55; p < 0.01; I2 = 79%). However, there were no significant differences between the groups in hospitalization time (MD -0.18days; 95% CI - 0.43-0.07; p = 0.07; I2 = 89%), occurrence of intraoperative complications (OR 0.66; 95% CI 0.38-1.15; p = 0.14; I2 = 35%) and bile duct injury (OR 0.99; 95% CI 0.64, 1.55; p = 0.97; I2 = 0%). RAC was associated with an increase in operative time compared with LC without increasing hospitalization time or the incidence of intraoperative complications. These findings suggest that RAC is a safe approach to benign gallbladder disease.

Avoidance of bile duct injury in laparoscopic cholecystectomy with feasible intraoperative resources: A cohort study.

Laparoscopic cholecystectomy (LC) is one of the most commonly performed surgeries and is considered the standard treatment for cholelithiasis. However, it is associated with a risk of bile duct or hepatic artery injuries. This study evaluated the safety of LCs and the conversion rate (CR) by achieving a critical view of safety (CVS) and identification of Rouviere's sulcus (RS). This was a single-group cohort study that included consecutive patients undergoing LC at Smart Health Tower (Sulaimani, Iraq) from January 2021 to January 2023. The data were prospectively collected from patients' profiles or surgical notes within the hospital's database. A total of 419 patients underwent LC, of which females were the predominant gender (78.5%). The mean and median ages of the cases were 46.3±15.8 and 45 years, with a range of 2-90 years, respectively. The most common indications for surgery were biliary colic (69.5%), followed by acute cholecystitis (23.9%). The duration of the operations was significantly shorter for cases in which the CVS (45.6±17.9 min) or identification of RS (45.6±18.6 min) was achieved compared to those where the CVS (63.7±27.7 min) or RS (50.7±21.7 min) was not observed. Surgeries for patients with both CVS achievement and RS identification were also significantly less time-consuming (44.3±17.6) than counterparts (53.3±22.6). Among the cases without CVS achievement or RS identification (n=97, 23%), eight (8.2%) had adhesions, 12 (12.4%) had a distended gallbladder (GB) and 10 (10.3%) had thick GB walls. In addition, four (4.1%) experienced GB perforation, two (2.1%) had bleeding and one (1%) had stone spillage. There was no conversion. The achievement of CVS and identification of RS are practical landmarks in performing safe LC and decreasing the CR.

Primary cilia as a targetable node between biliary injury, senescence and regeneration in liver transplantation

Biliary complications are a major cause of morbidity and mortality in liver transplantation. Up to 25% of patients that develop biliary complications require additional surgical procedures, re-transplantation or die in the absence of a suitable regraft. Here, we investigate the role of the primary cilium, a highly specialised sensory organelle, in biliary injury leading to post-transplant biliary complications. Human biopsies were used to study the structure and function of primary cilia in liver transplant recipients that develop biliary complications (n= 7) in comparison with recipients without biliary complications (n= 12). To study the biological effects of the primary cilia during transplantation, we generated murine models that recapitulate liver procurement and cold storage, and assessed the elimination of the primary cilia in biliary epithelial cells in the K19CreERTKif3afl/fl mouse model. To explore the molecular mechanisms responsible for the observed phenotypes we used invitro models of ischemia, cellular senescence and primary cilia ablation. Finally, we used pharmacological and genetic approaches to target cellular senescence and the primary cilia, both in mouse models and discarded human donor livers. Prolonged ischemic periods before transplantation result in ciliary shortening and cellular senescence, an irreversible cell cycle arrest that blocks regeneration. Our results indicate that primary cilia damage results in biliary injury and a loss of regenerative potential. Senescence negatively impacts primary cilia structure and triggers a negative feedback loop that further impairs regeneration. Finally, we explore how targeted interventions for cellular senescence and/or the stabilisation of the primary cilia improve biliary regeneration following ischemic injury. Primary cilia play an essential role in biliary regeneration and we demonstrate that senolytics and cilia-stabilising treatments provide a potential therapeutic opportunity to reduce the rate of biliary complications and improve clinical outcomes in liver transplantation. Up to 25% of liver transplants result in biliary complications, leading to additional surgery, retransplants, or death. We found that the incidence of biliary complications is increased by damage to the primary cilium, an antenna that protrudes from the cell and is key to regeneration. Here, we show that treatments that preserve the primary cilia during the transplant process provide a potential solution to reduce the rates of biliary complications.

Multidisciplinary approach to extra-hepatic bile ducts injuries after laparoscopic cholecystectomy

Multidisciplinary approach to extra-hepatic bile ducts injuries after laparoscopic cholecystectomy

Misinterpretation of the severity of bile duct injuries by MRCP

Misinterpretation of the severity of bile duct injuries by MRCP

Outcomes after paclitaxel-coated balloon after iatrogenic biliary injury following single-anastomosis duodeno-ileal bypass: a case report

Outcomes after paclitaxel-coated balloon after iatrogenic biliary injury following single-anastomosis duodeno-ileal bypass: a case report

Laparoscopic Cholecystectomy-Induced Complex Common Bile Duct Injury: Will Rescue ERCP Help?

AbstractA 33-year-old woman presented for laparoscopic cholecystectomy (LC)-induced accidental transection of the common bile duct at the level of confluence and common hepatic duct cutoff (E5–Bismuth type 5 injury) along with transected indwelling biliary stent hanging in the right posterior duct (RPD). At endoscopic retrograde cholangiopancreatography (ERCP), the distal fragment was removed. The RPD stent was cannulated across and retrieved, followed by three plastic stents in the right and left hepatic duct. Prompt referral of a bile duct injury during LC to a specialized center with timely ERCP saved the day and averted the need for surgical intervention.

Elevated Serum KIM-1 in Sepsis Correlates with Kidney Dysfunction and the Severity of Multi-Organ Critical Illness.

The kidney injury molecule (KIM)-1 is shed from proximal tubular cells in acute kidney injury (AKI), relaying tubular epithelial proliferation. Additionally, KIM-1 portends complex immunoregulation and is elevated after exposure to lipopolysaccharides. It thus may represent a biomarker in critical illness, sepsis, and sepsis-associated AKI (SA-AKI). To characterise and compare KIM-1 in these settings, we analysed KIM-1 serum concentrations in 192 critically ill patients admitted to the intensive care unit. Irrespective of kidney dysfunction, KIM-1 serum levels were significantly higher in patients with sepsis compared with other critical illnesses (191.6 vs. 132.2 pg/mL, p = 0.019) and were highest in patients with urogenital sepsis, followed by liver failure. Furthermore, KIM-1 levels were significantly elevated in critically ill patients who developed AKI within 48 h (273.3 vs. 125.8 pg/mL, p = 0.026) or later received renal replacement therapy (RRT) (299.7 vs. 146.3 pg/mL, p < 0.001). KIM-1 correlated with markers of renal function, inflammatory parameters, hematopoietic function, and cholangiocellular injury. Among subcomponents of the SOFA score, KIM-1 was elevated in patients with hyperbilirubinaemia (>2 mg/dL, p < 0.001) and thrombocytopenia (<150/nL, p = 0.018). In univariate and multivariate regression analyses, KIM-1 predicted sepsis, the need for RRT, and multi-organ dysfunction (MOD, SOFA > 12 and APACHE II ≥ 20) on the day of admission, adjusting for relevant comorbidities, bilirubin, and platelet count. Additionally, KIM-1 in multivariate regression was able to predict sepsis in patients without prior (CKD) or present (AKI) kidney injury. Our study suggests that next to its established role as a biomarker in kidney dysfunction, KIM-1 is associated with sepsis, biliary injury, and critical illness severity. It thus may offer aid for risk stratification in these patients.

A comparison of outcomes including bile duct injury of subtotal cholecystectomy versus open total cholecystectomy as bailout procedures for severe cholecystitis: A multicenter real-world study

BackgroundDense inflammation obscuring the hepatocystic anatomy can hinder the ability to perform a safe standard laparoscopic cholecystectomy in severe cholecystitis, requiring use of a bailout procedure. We compared clinical outcomes of laparoscopic and open subtotal cholecystectomy against the traditional standard of open total cholecystectomy to identify the optimal bailout strategy for the difficult gallbladder. MethodsA multicenter, multinational retrospective cohort study of patients who underwent bailout procedures for severe cholecystitis. Procedures were compared using one-way analysis of variance/Kruskal-Wallis tests and χ2 tests with multiple pairwise comparisons, maintaining a family-wise error rate at 0.05. Multiple multivariate linear/logistical regression models were created. ResultsIn 11 centers, 727 bailout procedures were conducted: 317 laparoscopic subtotal cholecystectomies, 172 open subtotal cholecystectomies, and 238 open cholecystectomies. Baseline characteristics were similar among subgroups. Bile leak was common in laparoscopic and open fenestrating subtotal cholecystectomies, with increased intraoperative drain placements and postoperative endoscopic retrograde cholangiopancreatography(P < .05). In contrast, intraoperative bleeding (odds ratio = 3.71 [1.9, 7.22]), surgical site infection (odds ratio = 2.41 [1.09, 5.3]), intensive care unit admission (odds ratio = 2.65 [1.51, 4.63]), and length of stay (Δ = 2 days, P < .001) were higher in open procedures. Reoperation rates were higher for open reconstituting subtotal cholecystectomies (odds ratio = 3.43 [1.03, 11.44]) than other subtypes. The overall rate of bile duct injury was 1.1% and was not statistically different between groups. Laparoscopic subtotal cholecystectomy had a bile duct injury rate of 0.63%. ConclusionLaparoscopic subtotal cholecystectomy is a feasible surgical bailout procedure in cases of severe cholecystitis where standard laparoscopic cholecystectomy may carry undue risk of bile duct injury. Open cholecystectomy remains a reasonable option.

Determining the patency of biliary tracts in dogs with gallbladder mucocele using near-infrared cholangiography with indocyanine green.

Cholecystectomy is indicated for gallbladder mucoceles (GBM). Evaluating the patency of the biliary duct and precise biliary tree visualization is crucial for reducing the risk of compromised bile flow after surgery. Therefore, intraoperative cholangiography (IOC) is recommended during cholecystectomy to prevent biliary tract injury. Although indocyanine green (ICG) cholangiography has been extensively reported in human medicine, only one study has been conducted in veterinary medicine. Therefore, this study aimed to demonstrate the use of ICG for IOC to identify fluorescent biliary tract images and determine the patency of the common bile duct during cholecystectomy in dogs. This study comprised 27 dogs, consisting of 17 with gallbladder mucoceles (GBM) and 10 controls, specifically including dogs that had undergone elective cholecystectomy for GBM. ICG injection (0.25 mg/kg) was administered intravenously at least 45 minutes before surgery. During the operation, fluorescent images from cholangiography were displayed on the monitor and obtained in black-and-white mode for the comparison of fluorescence intensity (FI). The FI values of the gallbladders (GBs) and common bile duct (CBD) were measured using FI analyzing software (MGViewer V1.1.1, MetapleBio Inc.). The results demonstrated successful CBD patency identification in all cases. Mobile GBM showed partial gallbladder visibility, whereas immobile GBM showed limited visibility. Additionally, insights into the adequate visualization of the remaining extrahepatic biliary tree anatomy were provided, extending beyond the assessment of CBD patency and gallbladder intensity. Our study demonstrates the potential of fluorescent IOC using intravenous injection of ICG for assessing the patency of the cystic duct and common bile duct during cholecystectomy in patients with GBM, eliminating the need for surgical catheterization and flushing of the biliary ducts. Further research is warranted to investigate and validate the broader applicability of ICG cholangiography in veterinary medicine.

Efficacy of different indocyanine green doses in fluorescent laparoscopic cholecystectomy: A prospective, randomized, double-blind trial.

Intraoperative bile duct injury is a significant complication in laparoscopic cholecystectomy (LC). Near-infrared fluorescence cholangiography (NIFC) can reduce this complication. Therefore, determining the optimal indocyanine green (ICG) dosage for effective NIFC is crucial. This study aimed to determine the optimal ICG dosage for NIFC. This was a prospective, randomized, double-blind clinical trial at a single tertiary referral center, including 195 patients randomly assigned to three groups: lower dose (0.01 mg/BMI) ICG (n = 63), medium dose (0.02 mg/BMI) ICG (n = 68), and higher dose (0.04 mg/BMI) ICG (n = 64). Surgeon satisfaction and detection rates for seven biliary structures were compared among the three dose groups. Demographic parameters did not significantly differ among the groups. The medium dose (72.1%) and higher dose ICG groups (70.3%) exhibited superior visualization of the common hepatic duct compared to the lower dose group (41.3%) (p < 0.001). No differences existed between the medium and higher dose groups. Similar trends were observed for the common bile duct and cystic common bile duct junction. In patients undergoing fluorescent laparoscopic cholecystectomy, the 0.02 mg/BMI dose of indocyanine green demonstrated better biliary structure detection rates than the 0.01 mg/BMI dose and was non-inferior to the 0.04 mg/BMI dose.