Iatrogenic Bile Duct Injury Research Articles

The Efficacy of Preoperative Cholangiography for Avoiding Bile Duct Injury in Laparoscopic Cholecystectomy

Introduction: Despite the development of surgical technique, iatrogenic bile duct injury (BDI) is one of the most dreadful complication of laparoscopic cholecystectomy (LC). Evidence has suggested that visual misperception accounts for 97% of BDI and aberrant right posterior sectoral hepatic duct (aPHD) is the most common and most vulnerable to BDI. This study aimed to analyze the frequency of each type of variation and efficacy of preoperative imaging. Method: From March 1, 2017 to February 28, 2021, 1477 patients who underwent cholecystectomy at Wonkwang University Hospital were enrolled. Among them, images of the 1429 patients were analyzed with magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and cholangiography using catheter via percutaneous or nasobiliary routes, selectively. Then, the types of patients confirmed to have aPHD were classified and analyzed for the presence of BDI. Results: Of the 1429 patients, 123 patients (8.61%) were found to have aPHD, of which 7 patients (0.49%) were type I, 14 patients (0.98%) were type II, 84 patients (6.97%) were type III, 2 patients (0.14%) were type IV, 7 patients (0.49%) were type IV, 9 patients (0.63%) were miscellaneous type, respectively (Fig. 3). BDI occurred in 3 patients out of 1429 patients (0.21%), and among 123 patients with aPHD, there was only a case of transected aPHD during dissection of posterior wall of gallbladder. Conclusions: It is useful to perform preoperative examination using MRCP, ERCP, cholangiography to reduce BDI through accurate understanding of the anatomy of the biliary tract before laparoscopic cholecystectomy.

A Multicenter Experience of Bile Duct Injury Management from a Single Hepatopancreatobiliary Surgeon in Colombia

Introduction: Iatrogenic bile duct injury is considered a catastrophic postoperative complication after cholecystectomy with a high incidence during laparoscopic approach. This complication has a major impact on morbidity, mortality and quality of life in the short and long term. Standardized management by a hepatobiliary group has shown better results in terms of clinical outcomes

Hepatolithiasis followed by recurrent cholangitis as a consequence of inadequate hepaticojejunostomy for common bile duct injury

Introduction. Hepatolithiasis (HL) is defined as gallstones present in bile ducts above the common bile duct confluence, regardless of the coexistence of gallstones in other parts of the biliary tract. HL is common among patients with recurrent pyogenic cholangitis. Chronic infection can lead to the development of malignancy. Case outline. A 65-year-old woman presented with intermittent fever, jaundice, abdominal pain, and nausea. Eighteen years previously, the patient had an open cholecystectomy due to acute cholecystitis. During the early post-operative days, the patient developed icterus. Intrahepatic biliary ductal dilatation was confirmed by abdominal ultrasound. Due to suspicion of iatrogenic common bile duct injury, the patient underwent a second operation, during which the said injury was confirmed. ?Non-Roux-en-Y? hepaticojejunostomy (HJ) was performed as a problem-resolving procedure. Despite the performed biliary bypass, the patient continued to have episodes of recurrent cholangitis over the 18 years. Given the patient?s recurrent symptoms and results of MRI consistent with HL, surgical treatment was indicated. A left hepatectomy was performed, with Roux-en-Y HJ biliary reconstruction. The post-operative course was uneventful, after which the patient has been symptom-free. Conclusion. The main purpose of treating HL is to eliminate infection which leads to recurrent cholangitis and subsequent hepatic fibrosis. Adequate solution of HL decreases the need for repeated interventions and prevents progression of the disease to cholangiocarcinoma.

Liver transplantation for iatrogenic bile duct injury during cholecystectomy: a French retrospective multicenter study.

Major bile duct injuries (BDI) following cholecystectomy require complex reconstructive surgery. The aim was to collect the liver transplantations (LT) performed in France for major BDI following cholecystectomy, to analyze the risk factors and to report the results. National multicenter observational retrospective study. All the patients who underwent a LT in France between 1994 and 2017, for BDI following cholecystectomy, were included. 30 patients were included. 25 BDI occurred in non hepato-biliary expert centers, 20 were initially treated in these centers. Median time between injury and LT was 3 years in case of an associated vascular injury (11 injuries), versus 11.7 years without vascular injury (p=0.006). Post-transplant morbidity rate was 86.7%, mortality 23.5% at 5 years. Iatrogenic BDI remains a real concern with severe cases, associated with vascular damages or leading to cirrhosis, with no solution but LT. It is associated with high morbidity and not optimal results. This enlights the necessity of early referral of all major BDI in expert centers to prevent dramatic outcome. Decision to perform transplantation should be taken before dismal infectious situations or biliary cirrhosis and access to graft should be facilitated by Organ Sharing Organizations.

A Critical Appraisal of Classification Systems of Iatrogenic Bile Duct Injuries

Introduction: Bile duct injuries represent the most dramatic complications after cholecystectomy either open or laparoscopic. A detrimental effect on patients’ quality of life and overall survival are the obvious consequences of such injuries. An effective treatment strategy after an accurate mapping of the type of the injury represents the only way of averting these morbid consequences. Methods: A systematic literature review in PubMed database was conducted using the terms "Iatrogenic injuries" AND "Bile duct" AND "Classification". Results: Several classification systems have been proposed in an attempt to accurately describe and categorize bile duct injuries. The crucial question is whether we truly need all these systems and whether each of these systems adds something useful to the existing knowledge or just further obscure the field. Each classification system has several advantages to rely its clinical utility upon but entails a reasonable number of limitations as well. Conclusions: A tailored approach by adopting the classification system that can provide the most appropriate guidance either in terms of diagnosis or in terms of treatment decision making appears as the most justified option at present.

Liver transplantation for the treatment of iatrogenic bile duct injury

RESUMO Objetivo: avaliar os resultados dos nossos pacientes que foram submetidos a transplante hepático por lesão iatrogênica do ducto biliar. Métodos: todos os pacientes que foram submetidos a transplante hepático para tratamento de complicações da lesão do ducto biliar foram incluídos no estudo. Os prontuários e protocolos de estudo desses pacientes foram analisados retrospectivamente para determinar características demográficas e clínicas, tratamento e desfecho dos pacientes. Resultados: de um total de 846 transplantes hepáticos realizados, 12 (1,4%) foram por lesão iatrogênica de via biliar: 10 (83,3%) ocorreram durante colecistectomia, 1 (8,3%) após quimioembolização e 1 (8,3%) durante laparotomia para controle de sangramento abdominal. A colecistectomia foi realizada por via aberta em 8 pacientes e por via laparoscópica em dois. Haviam 8 mulheres (66,7%) e 4 homens (33,3%), com média de idade de 50,6 ± 13,1 anos (variação de 23 a 70 anos). Todos os transplantes foram realizados com fígados de doadores cadavéricos. O tempo operatório médio foi de 565,2 ± 106,2 minutos (variação de 400-782 minutos). A reconstrução biliar foi realizada com hepaticojejunostomia em Y de Roux em 11 pacientes e coledococoledocostomia em um. Sete pacientes morreram (58,3%) e cinco (41,7%) estavam vivos durante um seguimento médio de 100 meses (variação de 18 a 118 meses). Conclusão: o transplante hepático em pacientes com lesão iatrogênica das vias biliares é um procedimento complexo com elevada morbimortalidade.

Laparoscopic Approach to the Difficult Gallbladder: Evolution of Technique at a Single Teaching Hospital and Retrospective Review

Laparoscopic cholecystectomy (LC) is the one of the most common procedures in General Surgery but remains challenging in the setting of cystohepatic triangle inflammation and fibrosis secondary to severe cholecystitis. A hostile cystohepatic triangle significantly increases the risk of iatrogenic bile duct injury (BDI). In such cases, early consideration should be given to alternative approaches such as laparoscopic subtotal cholecystectomy (LSC). We have developed a standard approach to difficult LC and delineated an institutional classification system for LSC.

Iatrogenic Bile Duct Injury: Call for Help, Refer Early, Reduce Infection. Invited Commentary: Liver Transplantation as Definitive Treatment of Postcholecystectomy Bile Duct Injury: Experience in a High-volume Repair Center.

Department of Surgery, University of Connecticut School of Medicine, Farmington, CT. [email protected]. The authors report no conflicts of interest.

Progress and Current Limitations of Materials for Artificial Bile Duct Engineering.

Bile duct injury (BDI) and bile tract diseases are regarded as prominent challenges in hepatobiliary surgery due to the risk of severe complications. Hepatobiliary, pancreatic, and gastrointestinal surgery can inadvertently cause iatrogenic BDI. The commonly utilized clinical treatment of BDI is biliary-enteric anastomosis. However, removal of the Oddi sphincter, which serves as a valve control over the unidirectional flow of bile to the intestine, can result in complications such as reflux cholangitis, restenosis of the bile duct, and cholangiocarcinoma. Tissue engineering and biomaterials offer alternative approaches for BDI treatment. Reconstruction of mechanically functional and biomimetic structures to replace bile ducts aims to promote the ingrowth of bile duct cells and realize tissue regeneration of bile ducts. Current research on artificial bile ducts has remained within preclinical animal model experiments. As more research shows artificial bile duct replacements achieving effective mechanical and functional prevention of biliary peritonitis caused by bile leakage or obstructive jaundice after bile duct reconstruction, clinical translation of tissue-engineered bile ducts has become a theoretical possibility. This literature review provides a comprehensive collection of published works in relation to three tissue engineering approaches for biomimetic bile duct construction: mechanical support from scaffold materials, cell seeding methods, and the incorporation of biologically active factors to identify the advancements and current limitations of materials and methods for the development of effective artificial bile ducts that promote tissue regeneration.

Robotic Versus Open Extrahepatic Biliary Reconstruction for Iatrogenic Bile Duct Injury

Robotic Versus Open Extrahepatic Biliary Reconstruction for Iatrogenic Bile Duct Injury

A Novel End-to-End Biliary-to-Biliary Anastomosis Technique for Iatrogenic Bile Duct Injury of Strasberg-Bismuth E1-4 Treatment: A Retrospective Study and in vivo Assessment.

Background: An iatrogenic bile duct injury (IBDI) is a severe complication that has a great impact on the physical and mental quality of life of the patients, especially for patients with postoperative benign biliary stricture. The effective measures for end-to-end biliary-to-biliary anastomosis intraoperative are essential to prevent the postoperative bile duct stricture, but also a challenge even to the most skilled biliary tract surgeon.Objective: A postoperative benign biliary stricture is an extremely intractable complication that occurs following IBDI. This study aimed to introduce a novel end-to-end biliary-to-biliary anastomosis technique named fish-mouth-shaped (FMS) end-to-end biliary-to-biliary reconstruction and determine the safety and effectiveness for preventing the postoperative benign biliary stricture in both rats and humans.Methods: In this study, 18 patients with biliary injury who underwent an FMS reconstruction procedure were retrospectively analyzed. Their general information, disease of the first hospitalization, operation method, and classification of bile duct injury (BDI) were collected. The postoperative complications were evaluated immediately perioperatively and the long-term complications were followed up at the later period of at least 5 years. An IBDI animal model using 18 male rats was developed for animal-based evaluations. A bile duct diathermy injury model was used to mimic BDI. The FMS group underwent an FMS reconstruction procedure while the control group underwent common end-to-end biliary-to-biliary anastomosis, a sham operation group was also established. The blood samples, liver, spleen, and common bile duct tissues were harvested for further assessments.Results: In the retrospective study, there was no postoperative mortality and no patient developed cholangitis during the 5-years postoperation follow-up. In the study of IBDI animal models, compared with the control group, the FMS reconstruction procedure reduced the occurrence of benign biliary stenosis, liver function damage, and jaundice. The blood tests as well as morphological and pathological observations revealed that rats in the FMS reconstruction group had a better recovery than those in the control group.Conclusions: An FMS reconstruction procedure is a safe and efficient BDI treatment method.

Clinical and surgical algorithm for managing iatrogenic bile duct injuries during laparoscopic cholecystectomy: A multicenter study.

The present study was a multicenter, analytical, nonrandomized research on 108 cases of intraoperative vascular and bile duct lesions during laparoscopic cholecystectomies. We selected these cases from 16,559 cholecystectomies performed entirely laparoscopically or debuted laparoscopically and converted to an open approach. The study included two surgical centers labeled as primary, with extensive experience in hepato-biliary reconstructive surgery, and four other centers labeled as secondary that referred cases to the previous two. Our study analyzed several key parameters such as the percentage of iatrogenic lesions recorded, the variability of the main biliary pathway and conformation as well as its relationship to the adjacent critical anatomical landmarks, the anatomical and physiopathological characteristics of pathology requiring surgical intervention, factors related to laparoscopic surgical technique, the surgical technique used to repair the recorded lesions, the duration of survivability and the rate of the occurring complications. Based on the analysis of these parameters, we developed a descriptive algorithm with visual representation relying on several decisional points to guide the surgeons in choosing the optimal treatment method so that patients will benefit from a favorable clinical path.

Long-term outcomes in the repair of intrahepatic iatrogenic bile duct lesions using a combined intraglissonian and extraglissonian approach.

Iatrogenic bile duct injuries (IBDI) with intrahepatic involvement are a serious and challenging surgical complication that can have disastrous consequences in terms of morbidity and mortality. We collected the patients with IBDI type (E4) between January 1991 and March 2020 in our hospital. The objective of the study was to present the long-term results of a extraglissonian approach and intraglissonian biliary reconstruction in a series of patients with intrahepatic bile duct injuries after cholecystectomy. We also detail our preoperative management and the standardization of the technique. An extraglissonian approach with partial hepatic resection of the base of segments 4b and 5 and intraglissonian Roux-en-Y hepaticojejunostomy for biliary reconstruction using to several branches was performed in 10 patients with E4 Strassberg type intrahepatic lesions. Only one patient had postoperative bile leak (Clavien 3a). Surgical time was 260 min (IQR, 210-490). We left transanastomotic catheter (between 2 and 5) in situ for 3 and 6 months after surgery. The patients remained asymptomatic over a median follow-up of 169 months (IQR 129-234). This biliary reconstruction technique obtains positive long-term outcomes in patients with severe intrahepatic lesions.

Iatrogenic Bile Duct Injuries: An Overview and A Review of Literature

Abstract​ Laparoscopic cholecystectomy (LC) is one of the most frequently performed surgical procedures worldwide. Iatrogenic bile duct injury (IBDI) is a serious complication of LC and has an incidence of 0.3 to 0.7%. Since it is associated with a significant and potentially lifelong morbidity as well as mortality, diagnosing IBDI as early as possible is of paramount importance. Management of bile duct injuries and prognosis of their surgical repair depend on the timing of its recognition, type and the extent of the injury. In this paper, we present a case of IBDI and attempt to discuss all its dimensions.

Surgical Management of Post Cholecystectomy Biliary Injuries: A Center Experience.

Abstract: Introduction: Bile duct injury (BDI) is the nightmare sequalae following gallbladder surgery. Ranging from 0.3 to 1.5%. Patients and methods: A retrospective study done from October 2010 till October 2020; including 162 patients suffered from biliary complications post open and laparoscopic cholecystectomy. All the patients were managed surgically and followed up for at least 2 years in advanced hepato-pancreatico-biliary center, Zagazig University, Egypt. Results: Most of our patients were female (69.75%) with median age (33±12.3) years. Biliary leakage presented in in 71 (43.83%) patients, ligated CHD presented in 59 (36.42%) patients. And long-term biliary stricture was in 29 (17.9%) patients and haemobilia in three patients. Roux-en-Y hepatico-jejunostomy (H-J) was the procedure in all patients. No mortality in our patients while Post-operative complications were detected in 31 (19.13%) patients. post-operative H-J stricture was 13/162 (8.02%) patients. Percutaneous Transhepatic Biliary Drainage (PTBD) used successfully in managing anastomotic stricture in 11 patients. Conclusion: Iatrogenic BDIs represent a catastrophic sequalae post cholecystectomy. Proper management requires, early diagnosis, management of intra-abdominal fluid collection and infection, nutritional support, multi-disciplinary team and expert hepato-biliary surgeon.

Organic Dots with Large π-Conjugated Planar for Cholangiography beyond 1500 nm in Rabbits: A Non-Radioactive Strategy.

Iatrogenic extrahepatic bile duct injury remains a dreaded complication while performing cholecystectomy. Although X-ray based cholangiography could reduce the incidence of biliary tract injuries, the deficiencies including radiation damage and expertise dependence hamper its further clinical application. The effective strategy for intraoperative cholangiography is still urgently required. Herein, a fluorescence-based imaging approach for cholangiography in the near-infrared IIb window (1500-1700 nm) using TT3-oCB, a bright aggregation-induced emission luminogen with large π-conjugated planar unit, is reported. In phantom studies, TT3-oCB nanoparticles exhibit high near-infrared IIb emission and show better image clarity at varying penetrating depths. When intrabiliary injected into the gallbladder or the common bile duct of the rabbit, TT3-oCB nanoparticles enable the real-time imaging of the biliary structure with deep penetrating capability and high signal-to-background ratio. Moreover, the tiny iatrogenic biliary injuries and the gallstones in established disease models could be precisely diagnosed by TT3-oCB nanoparticle assisted near-infrared IIb imaging. In summary, we reported a feasible application for aggregation-induced emission dots as biliary contrast agent and realized high-quality cholangiography in the near-infrared IIb window with precise diagnostic ability and nonradioactive damage, which could possibly be applied for intraoperative diagnosis.

Management of Iatrogenic Bile Duct Injuries Following Cholecystectomy in Cipto Mangunkusumo General Hospital Indonesia

Introduction: Iatrogenic bile duct injuries (IBDI) were most common caused by cholecystectomy during laparoscopy than laparotomy. The aim of this study was to evaluate the management of IBDI following cholecystectomy procedure in Cipto Mangunkusumo General Hospital, Jakarta as a tertiary hospital. Methods: The cross-sectional design was used. We collected patient who undergo IBDI repair since January 2015 until December 2019. We retrospectively analyzed the repair technique, and follow up post-operative. Results: There were 13 patients, who undergo IBDI repair. The median age of the patient was 48 years with composition were 6 male and 7 female. There was 3 patients who proceded laparoscopy cholecystectomy. The whole patients referred from secondary hospital. We performed hepaticojejunostomy Roux-en-Y to the 11 patients who experiences IBDI and performed drainage in patients due to bile leakage. There were 6 patients which classified as Strasberg E3 type and the rest of it were classified as E1 type. No mortalities were detected post-operatively. Median length of stay of the patient was 27 days and no jaundice recur reported after long-term follow up. Conclusion: Hepaticojejunostomy Roux-en-Y procedure already becomes the first choice in the management of IBDI in our hospital. The prognosis after the procedure tented to be good. Key words: Iatrogenic bile duct injury, Cholecystectomy

Iatrogenic Bile Duct Injuries: A Critical Appraisal of Classification Systems.

Bile duct injuries represent the most dramatic complications after an open or laparoscopic cholecystectomy. The detrimental effects on patient quality of life and overall survival are the most obvious consequences of such injuries. An effective treatment strategy after accurate mapping of the injury type is the only method of averting these morbid consequences. Several classification systems have been proposed in an attempt to accurately describe and categorize bile duct injuries. The critical question is whether we truly need all these systems and whether each of these systems adds value to the existing knowledge base, or further obscures the field. Each classification system has several advantages to base its clinical utility on, but entails a reasonable number of limitations as well. Currently, a tailored approach adopting the classification system which provides the most appropriate guidance - either in terms of diagnosis or treatment decision making - appears to be the most justified option.

A complex iatrogenic bile duct injury: hilar plate lesion with right hepatic artery section

Presenter: Fabio Vergara MD | IPS Universitaria - Servicios de Salud de la Universidad de Antioquia Background: Iatrogenic bile duct injuries remain an important complication in laparoscopic cholecystectomy, which is one of the commonest surgical procedures in the world. There are numerous mechanisms described in the literature as causes of iatrogenic biliary injuries, among them are: undue dissection in a distorted Calot's triangle, use of diathermy close to bile ducts, local pathology such as acute and chronic inflammation with fibrosed gallbladder. Methods: We presented one case of a complex vascular-biliary lesion. A 30-year-old woman was admitted to the emergency room due to abdominal pain in the right hypochondrium and elevated transaminases. Managed by the general surgery group, they requested an abdominal ultrasound that showed acute cholecystitis with cholelithiasis and slight dilatation of the intrahepatic bile duct. Due to intermediate risk of choledocholithiasis, they request MRI that rules out this pathology. She is programmed to perform laparoscopic cholecystectomy. They found slight inflammation with an infudibulus adhered to the hilar plate. They complete the cholecystectomy and notice bile fluid leakage. They request to our group of hepatopancreatobiliary surgery intraoperative evaluation. Evidence of complete injury to the confluence of the liver that anatomically forms a trifurcation, with complete section of the right hepatic artery. Results: Conversion to open surgery was performed and biliary exploration was carried out, finding three ducts separated by more than 2cm from each other, sectioned: anterior branch of right hepatic duct, posterior branch of right hepatic duct, and left hepatic duct. There is an associated right hepatic artery injury without showing its distal end. Patient has an accessory right hepatic artery. It was decided to perform biliary reconstruction in three separate anastomoses (Roux-en-Y hepaticojejunostomy). Conclusion: Bile duct injuries continue to occur globally and can be life threatening. Early detection of the lesion and management by a group of experienced hepatopancreatobiliary surgery can improve the prognosis of patients.

Outcome of Post Cholecystectomy Bile Duct Injury Management in a High Volume Referral Center in Iran

Introduction: However more than a century pass from first cholecystectomy and iatrogenic bile duct injury, still this is a big problem, here we report our experience in a high volume referral center in Iran about handling of this complication. Methods: We collect data of 59 patient who referred us , suspected to post-cholecystectomy bile duct injury for 3 years since may 2016 both retrospectively through review of charts and calling them and prospectively by regular out-patient visit. Results: In this period 59 patients with age range of 20 to 74y/o referred our center, 15 male and 44 female. 21 patients underwent definite repair in 2 weeks from injury,17 patient after 2 weeks and before 6 weeks and 21 patients after 6 weeks. The most common presenting feature was bilious drain discharge, MRCP and ERCP was falsely negateive in 23.07% and 11.53% repsctively and the most reliable point was primary surgeon think of “something is wrong during surgery”.17% of patients had failed repair in original hospital and 33.9% had exploration ,irrigation and drainage.laboratory abnormality just in 66% of patients detected, most injuries was in Bismuth classII(18%),III(16%)and IV(16%),and Rt hepatic artery injury detected in 27(45.8%)patients.hepatectomy did in two patients and two patients died. No significant deference found when interval from injury to definite surgery compared between groups. Conclusion: Best decision for patients suspected to bile duct injury is referring to a high volume center at any time before exploration and with any interval from injury, HPB surgeon can go for repair.