Intraoperative Cholangiography Research Articles

Near infrared indocyanine green fluorescent cholangiography versus intraoperative cholangiography to improve safety in laparoscopic cholecystectomy for gallstone disease\u2014a systematic review protocol

BackgroundLaparoscopic cholecystectomy has become the standard surgical approach in the treatment of cholelithiasis. Diverse surgical techniques and different imaging modalities have been described to evaluate the biliary anatomy and prevent or early detect bile duct injuries. X-ray intraoperative cholangiography (IOC) and near infrared indocyanine green fluorescent cholangiography (NIR-ICG) are safe and feasible techniques to assess biliary anatomy. The aim of this systematic review will be to evaluate if NIR-ICG can visualize extrahepatic biliary anatomy more efficiently and safer than IOC in minimally invasive cholecystectomy for gallstone disease.MethodsLiterature search will be performed via MEDLINE (PubMed), Embase, Scopus, the Cochrane Central Register of Controlled Trials, and Web of Science Core Collection from 2009 to present. All randomized controlled clinical trials and prospective non-randomized controlled trials which report on comparison of NIR-ICG versus IOC will be included. All patients over 18 years old who require elective or urgent minimally invasive cholecystectomy (undergoing NIR-ICG during this procedure) due to gallstone disease both acute and chronic will be included. Since BDI has a low incidence, the primary outcome will be the ability to visualize extrahepatic biliary anatomy and the time to obtain relevant images of these structures.Two researchers will individually screen the identified records, according to a list of inclusion and exclusion criteria. Bias of the studies will be evaluated with the Newcastle-Ottawa score for non-randomized studies and with The Cochrane Risk of Bias Tool for randomized controlled trials. Quality of evidence for all outcomes will be determined with the GRADE system. The data will be registered in a predesigned database. If selected studies are sufficiently homogeneous, we will perform a meta-analysis of reported results. In the event of a substantial heterogeneity, a narrative synthesis will be provided. Subgroup analysis will be used to investigate possible sources of heterogeneity.DiscussionUnderstanding the benefits of this technique is critical to ensuring policymakers can make informed decisions as to where preventive efforts should be focused regarding specific imaging techniques. If ICG is proven to be faster and non-invasive, its routine use could be encouraged.Systematic review registrationPROSPERO CRD42020177991.

Percutaneous ultrasound-guided cholecystocholangiography with microbubbles combined with liver biopsy for the assessment of suspected biliary atresia.

Percutaneous ultrasound (US)-guided cholecystocholangiography is effective in diagnosing biliary atresia for infants with a gallbladder >1.5cm in length on US. However, whether it is still effective for other types of gallbladders needs further clarification. To evaluate the diagnostic performance and safety of percutaneous US-guided cholecystocholangiography combined with liver biopsy in children with suspected biliary atresia and with different types of gallbladders on US. Sixty-five infants were referred for percutaneous US-guided cholecystocholangiography with microbubbles and liver biopsy after an equivocal (n=39) or highly suspected (n=26) US diagnosis of biliary atresia. Two radiologists evaluated US and percutaneous US-guided cholecystocholangiography images in consensus. One pathologist independently evaluated liver specimens. We used the unpaired t-test, Mann-Whitney U test and chi-square test to analyze the data. Of the 65 infants, 59 (90.8%) underwent a successful percutaneous US-guided cholecystocholangiography, with both sensitivity and specificity of 100%. All six infants for whom puncture failed had contracted gallbladders. The sensitivity and specificity of liver biopsy in the diagnosis of biliary atresia were 89.7% (26/29) and 83.3% (30/36), respectively. When percutaneous US-guided cholecystocholangiography and liver biopsy were combined, all infants gained correct diagnosis, and in 35 infants (97.2%, 35/36) biliary atresia could be excluded without intraoperative cholangiography. Twenty-two of 65 infants (33.8%) had fluid collections around the liver related to puncture. None of these complications needed treatment. Percutaneous US-guided cholecystocholangiography combined with liver biopsy appears safe and effective for excluding or confirming biliary atresia in cholestatic infants with a dilated gallbladder on US.

Evaluation of the Compatibility of Preoperative MRCP and Intraoperative Cholangiography in Imaging of the Bile Ducts in Living Donor Liver Transplantation

Evaluation of the Compatibility of Preoperative MRCP and Intraoperative Cholangiography in Imaging of the Bile Ducts in Living Donor Liver Transplantation

Prevalence of Iatrogenic Bile Duct Injury Following Open and Laparoscopic Cholecystectomy Treatment Outcomes

Background and Aim:Iatrogenic bile duct injuries (IBDI) continue to be a difficult diagnostic and therapeutic problem. The prevalence of iatrogenic IBDI increased with the laparoscopic technique introduction for the cholecystolithiasis treatment. The study's objective was to determine the frequency of iatrogenic bile duct injuries (IBDI) following open and laparoscopic cholecystectomy treatment outcomes. Materials and Methods: This retrospective observational study was carried out on 131 bile duct injuries sustainable patients who underwent laparoscopic cholecystectomy at General Hospital, Lahore for the duration of six months from May 2021 to October 2021. All the patients who satisfied the inclusion criteria were enrolled in this study. Ethical approval and informed consent were taken from the institutional ethical committee and individual respectively. The data outcomes such as time details of laparoscopic cholecystectomy and injuries recognition, injury types, injuries definitive repair time, IBDI management, intraoperative cholangiography use, post-operative complications, laparoscopic cholecystectomy to open cholecystectomy conversion, bile duct injury, morbidity, postoperative outcomes, and mortality rate were recorded. SPSS version 20 was used for data analysis. Results: A total of 131 referred patients were treated for iatrogenic bile duct injury caused by open cholecystectomy (n = 60), and Laparoscopic cholecystectomy (n = 71). During laparoscopic cholecystectomy, bile duct injuries were identified in only 28 (39.4%) patients. Following the LC conversion to open operation, 50%successive procedures were deemed ineffective. In case of no recognizedinjury during LC, bile leak/peritonitis was developed in 70% of patients, with nearly half being referred and the remainder underwentvarious procedures recommended by their surgeon.The rest of the patient’sdeveloped and abnormal liver function, jaundice, cholangitis. About 43% of patients underwent IOC, but two-thirds of patients did not have an injury. Laparoscopic cholecystectomy developed bile duct injury was more severe compared to the IBDI in open cholecystectomy. One patient died during definitive repair and 92% of patients were recovered without any complications. Conclusion:The iatrogenic bile duct injury increasing rate is a major surgical intervention challenge. Multidisciplinary treatment should be followed for iatrogenic bile duct injury prevention and management. Bile duct injury could be effectively treated when suspected and confirmed patients are referred to tertiary care hospitals. Keywords: Iatrogenic bile duct injuries; Laparoscopic Cholecystectomy; Complications

Right hepatectomy with preservation of the entire caudate lobe in patients with metastatic liver tumors: a case of a new hepatectomy technique and treatment strategy for patients with marginal liver function

BackgroundPerforming major hepatectomy for patients with marginal hepatic function is challenging. In some cases, the procedure is contraindicated owing to the threat of postoperative liver failure. In this case report, we present the first case of marginal liver function (indocyanine green clearance retention rate at 15 min [ICGR15]: 28%) successfully treated with right hepatectomy, resulting in total caudate lobe preservation.Case presentationA 71-year-old man was diagnosed with sigmoid colon cancer with three liver metastases (S5, S7, and S8). All of metastatic lesions shrunk after chemotherapy, but his ICGR15 and indocyanine green clearance rate (ICGK) were 21% and 0.12, respectively. Moreover, the remnant liver volume was only 39%. Therefore, portal venous embolism (PVE) of the right portal vein was suggested. Portography showed divergence of the considerably preserved right caudate lobe branch (PV1R) from the root of the right portal vein. The liver function was reevaluated 18 days after PVE was suggested. During this time, the ICGR15 (21–28%) and ICGK rate (0.12–0.10) deteriorated. The right caudate lobe was significantly enlarged; thus, a total caudate lobe-preserving hepatectomy (TCPRx) was performed. Patients eligible for TCPRx included those with (1) hepatocellular carcinoma or metastatic liver cancer, (2) no tumor in the caudate lobe, (3) marginal liver function (ICG Krem greater than 0.05 if TCPRx was adapted; otherwise, less than 0.05) and Child–Pugh classification category A, and (4) preserved PV1R and right caudate bile duct branch. The procedure was performed through (A) precise estimation of the remnant liver volume preoperatively, (B) repeated intraoperative cholangiography to confirm the biliary branch of the right caudate lobe (B1R) conservation, and (C) stapler division of posterior and anterior Glisson’s pedicles laterally to avoid injuries to the PV1R and B1R.ConclusionsRight hepatectomy with total caudate lobe preservation, following PVE, was a safe and viable surgical technique for patients with marginal liver function.

Global trends of indocyanine green fluorescence navigation in laparoscopic cholecystectomy: bibliometrics and knowledge atlas analysis.

Indocyanine green fluorescence cholangiography is a new type of cholangiography that has emerged in recent years. It has many advantages, such as simplicity, safety, and efficiency, and is expected to become a routine procedure for intraoperative cholangiography in the future. However, there is no bibliometric analysis of horizontal generalization in this field. Therefore, this study aims to assess the current research status and developmental trends in this field from a global perspective and to help guide the focus of future research. This study was conducted by retrieving the literature related to ICG fluorescence cholangiography published in English from 2000 to 2021 from Web of Science. The Histcite. Pro tool was used to analyze the bibliometric indicators, and VOSviewer was used to visualize the research trends and hotspots in this field. 192 related studies were finally included. For the past 20years, the number of related publications in this field have increased yearly, with 2010 being a breakthrough point for research in this field. Research has developed rapidly since 2013 and may continue to expand in the next several years. The USA and Japan play leading roles in this field. "SURG ENDOSC", "SURG INNOV", and "J LAPAROENDOSC ADV S" are core journals that publish high-quality literature and the latest developments in this field. Some authors who have a large number of high-quality publications include Ishizawa T and Kokudo N. The current research hotspots in this field are focused on exploring the factors that affect ICG cholangiography and optimization measures. In general, the number of documents related to ICG fluorescence cholangiography is growing rapidly, with the USA and Japan being influential countries and China being one of the major producers of these documents. The optimization of this new technology will affect key developments in future research.

Is Routine Intraoperative Cholangiography Necessary in Patients Undergoing Cholecystectomy? A Systematic Review and Meta-analysis

Introduction: The value of routine intraoperative cholangiography (IOC) for cholecystectomy remains controversial. The objective of this meta-analysis is to investigate the use of routine IOC in comparison to selective and no IOC in patients undergoing cholecystectomy. Methods: PubMed, Embase, Ovid MEDLINE, Cochrane Library and Google Scholar were searched up to June 2021. Two authors selected studies, extracted data and assessed the methodological quality independently. Randomised and longitudinal studies were included. Data were pooled for various outcomes and I2 statistics analysed heterogeneity. Results: Of 38 potential studies identified, 16 studies were included, involving 9196 patients, with 5669 (61.6%) patients undergoing routine IOC and 3527 (38.42%) patients undergoing selective or no IOC during cholecystectomy. There was a trend towards lower bile duct injury (BDI) in the routine IOC group compared to the selective (Odds Ratio (OR)=0.74, p=0.34 95% CI 0.39-1.37) as well as lower ‘other’ complications (OR=0.65, p=0.06, 95%CI=0.41 to 1.02. Choledocholithiasis detection rate was significantly superior for the routine IOC group compared to selective IOC (OR=2.89, p<0.0001, 95% CI 2.09-4.01). There were no differences in retained stones (OR=1.02, p=0.98, 95%CI=0.18-5.79). Conclusion: There were limited methodologically robust studies available. There was a trend towards lower BDI and complication rates in the routine IOC group compared to the selective. Routine IOC has superiority for bile duct stone detection compared to selective IOC or no IOC procedures. There was no significant difference in retained stones between the two groups. More studies are required to build the evidence in this area.

Ultrasound Diagnosis of Asymptomatic Choledochal Lithiasis. Case Report

Choledochal lithiasis can be suspected in some cases due to the presence of micro calculi (<5mm) in the gallbladder, long-standing gallstones or advanced age of the patient, with about 5% having "unsuspected choledochal lithiasis". In some cases, it presents only as biliary colic, and choledochal lithiasis is an incidental finding on imaging studies or during cholecystectomy. Ultrasound is the most widely used initial imaging method, it has high specificity (95%), but low sensitivity (25-30%), so in some cases other imaging methods are required to confirm the diagnosis, such as cholangioresonance or intraoperative cholangiography. Treatment allows ERCP on the one hand followed by laparoscopic cholecystectomy or bile duct exploration during laparoscopy. Male, 60 years old, with biliary colic, no history of jaundice, normal blood count, normal bilirubin, slight elevation of alkaline phosphatase, and normal amylasemia. The ultrasound shows images of gallstones and 4mm and 5mm lithiasis images in the distal third of the common bile duct of normal caliber (5mm). Cholangioresonance confirms the finding. It is performed by ERCP extraction of two 7 mm stones, with clear bile drainage to the papillotomy. At 48 hours laparoscopic cholecystectomy without problems. Hospital discharge 24 hours later in good clinical condition. Ultrasound is a valuable diagnostic method in patients with unsuspected asymptomatic choledochal lithiasis. Regarding treatment, there is still no consensus on the best strategy and when choosing it is advisable to take into account accessible resources and that it be an effective treatment.

Advantages of Extrahepatic Glissonean Approach in the Donor Operation in Living Donor Liver Transplantation

Introduction: To eliminate biliary complications in living donor hepatectomy, we introduced the extrahepatic glissonean approach combined with liver hanging maneuver (GA+LHM) since 2017. Method: Surgical procedures are as follows: Prior to liver transection, we encircle the extrahepatic Glissonean pedicle at the graft liver side with a tape. Then, we introduce a hanging tape from the encircled Glissonean pedicle to the groove between middle hepatic vein and right hepatic vein. Liver parenchymal transection is facilitated with the LHM. After the completion of transection, hepatic artery and portal vein of the graft liver are isolated in the hilum. The remaining structure is the hilar plate including the hepatic duct(s). After intraoperative cholangiography, bile duct, hepatic artery, portal vein, and hepatic vein are divided in this order and the graft liver is procured. We analyzed the short-term outcomes of the donor using Clavien–Dindo classification: For bile leakage, the International Study Group of Liver Surgery definition was used. Results: GA+LHM was successfully performed in a total of 44 consecutive living donor hepatectomy (right lobe graft in 28, left lobe graft in 15, and left trisegmental lobe +S1 graft in 1). There were no Grade Ⅲa≦ complications and bile leakage until discharge. Biliary stricture occurred in 1 (2%) patient who was readmitted and required endoscopic biliary stent placement. Conclusions: GA+LHM presumably prevents heat and mechanical injury of the bile ducts of the remnant liver by minimization of hilar dissection, thereby contributes to eliminating bile leakage in living donor hepatectomy.

Iatrogenic Bile Duct Injuries after Cholecystectomy, Is the Laparoscopic Approach a Good Idea?

Objective: The treatment of iatrogenic bile duct injuries is still a challenge for hepatobiliary and general surgeons. Roux-en-Y hepaticojejunostomy, one of the most appropriate techniques for the treatment of circumferential lesions, either occurring less than 2 cm from the bifurcation or in the bifurcation of the common hepatic duct, requires experience in advanced laparoscopy and hepatobiliary surgery. This study aims to present the results of laparoscopic hepaticojejunostomy (LHJ) for the treatment of iatrogenic bile duct injuries (IBDI). Methods: A retrospective study analyzing the medical records of patients diagnosed with IBDI and treated using LHJ of patients at the Hospital S&#227o José do Avaí (HSJA). Sex, age, previous cholecystectomy technique, signs and symptoms, postoperative complications, length of stay, injury classification, and time elapsed from injury to diagnosis were analyzed. Magnetic resonance cholangiography (MRC), endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiography. Results: From March 2006 to December 2018, six patients underwent LHJ. In five cases (83.33%), the primary operation was a laparoscopic cholecystectomy (LC) and in one patient (13.66%) open cholecystectomy. The most frequent clinical sign was jaundice. The mean surgical time was 153.2 minutes (range: 115 to 206 minutes), and the hospital stay was 3 to 7 days (mean: 4.16 days). One patient had infection of the umbilical trocar incision and one patient presented with stenosis of the hepaticojejunal anastomosis and was treated with radioscopic pneumatic dilatation. Conclusion: LHJ for circumferential and total IBDI either diagnosed early (during surgery) or late, may be a safe and effective option, with similar results to the conventional technique, a low complication rate and all the known advantages of minimally invasive surgery.

Intraoperative Assessment of the Demarcation Line and Intersegmental/Sectional Planes in Liver Surgery

Purpose: Intraoperative assessment of demarcation line (DL) and intersegmental/sectional planes (IP) is essential to perform accurate liver resection without ischemic areas and venous congestion. DL is the most important landmark on the liver surface. The DL is normally formed by means of selective vascular occlusion or portal staining using a dye, and it can be recognized by surgeons’ eye. However, direct visualization with surgeons’ eye suffers from the failing of the evaluation due to an unclear DL, especially in patients with cirrhotic or steatotic livers. Currently, IP, which cannot be recognized by direct visualization, is now in the spotlight during parenchymal transection. Herein, we assessed the DL and IP intraoperatively by several imaging modalities. Method: The DL and IP were intraoperatively detected by means of conventional demarcation techniques and several imaging modalities as follows during liver surgery in a human and an animal model. 1. Direct visualization 2. Indocyanine green fluorescence imaging (ICG-FI) 3. Contrast-enhanced intraoperative ultrasonography (CE-IOUS) 4. Contrast-enhanced intraoperative ultrasonic cholangiography (CE-IOUSC) 5. Augmented Reality using preoperative data (AR) 6. Hyperspectral imaging (HSI) Results: The DL was detected by direct visualization, ICG-FI, and HSI. AR detected virtual DL. On the other hand, the IP was detected by ICG-FI, CE-IOUS, and CE-IOUSC. In this time, we will show the current status and issues with discussion about the strong and weak points of them. Conclusion: New technologies for assessment of DL and IP have a great potential to provide more information to surgeons in order to standardize the surgical approach and develop new surgical approaches.

P-BN59 Danger is there, do we want to know about it? Routine intra operative cholangiography highlights dangerous biliary anatomy for safer cholecystectomy

Abstract Background Normal biliary anatomy is uncommon. Different classification for biliary anatomy has been described, with Huang Types A4 &amp; A5 of great interest for laparoscopic cholecystectomy (LC) due to the proximity of aberrant bile duct to Cystic duct (CD). These types of dangerous anatomy might contribute to bile duct injury. This study aims to analyse the prevalence of dangerous biliary anatomy. Methods Prospectively collected data for all patients who underwent laparoscopic cholecystectomy was analysed. All LC were performed by single surgeon or under his direct supervision, between 01/07/2020 and 20/08/2021. Index admission and single session management of cholelithiasis disease with routine Laparoscopic cholecystectomy + intra operative cholangiography (IOC) +/- LCBD exploration were standard practice. Results Laparoscopic cholecystectomy was performed in 137 patients. Mean age was 56y (17-84). 62% were females. 66% of Laparoscopic cholecystectomies were emergency. IOC was performed in 92% of cases. Abnormal biliary anatomy was found in 54% : Huang A1 - 48%, A2 - 29%, A3 - 12%, A4 - 9.7% and A5 - 0.7%. Dangerous anatomy (A4 and A5) was found in 10.5%, 78 % were females. Female with dangerous anatomy were younger than males 49 y, 60y respectively. Nassar difficulty grading for dangerous anatomy was as follows: G2 28%, G3 42% and G3 28% Abnormal cholangiogram was found in 48%, due to filling defect in 58%, no contrast flow into duodenum in 4%, Cystic duct stone in 4%, and short CD in 8%. CBD stones were treated using transcystic approach in 92% of cases. No intra-operative or post operative complications were recorded for patients with dangerous anatomy. Conclusions This study demonstrates that dangerous biliary anatomy, that could lead to bile duct injury is relatively common, occurring in 10.7% of LCs. Routine intra-operative cholangiography highlights these high-risk variations in biliary anatomy and may prevent inadvertent bile duct injury in such cases.

Unintentional bile duct injuries: prevention and treatment

Presented herein is a rational program of prevention, diagnosis, and the surgical treatment of patients with the unintentional bile duct injuries. Examination results and surgical treatment of 1,117 patients, who underwent laparoscopic cholecystectomy for acute and chronic cholecystitis from 20052020, were studied. The criteria for inclusion in the study were difficult laparoscopic cholecystectomy (181 medical histories) and unintentional bile duct injuries resulting from laparoscopic cholecystectomy (95 patients). Laparoscopic cholecystectomy with a duration of 60 min was considered difficult. A total of 181 (17.7%) medical cases with difficult laparoscopic cholecystectomy and 95 patients with unintentional bile duct injuries were selected for this study. Instrumental studies were performed using X-ray contrast techniques such as: percutaneous fistulography, percutaneous-transhepatic, or intraoperative cholangiography, as well as relaparoscopy, ultrasound, endoscopic retrograde, or magnetic resonance cholangiopancreatography. A program approach to assist the patients with cholelithiasis was developed. Program implementation allows timely prevention and diagnosis of the unintentional bile duct injuries with minimal postoperative complications. The identification of the risk factors for difficult laparoscopic cholecystectomy indicates the need to comply with the preventive measures to prevent unintentional bile duct injuries and dictates the implementation of the surgical intervention by the most experienced surgeons from the second or third-level medical organizations. The rational option of surgical intervention aimed to eliminate the biliary tract injuries based on the following assessment criteria: general somatic condition of the patient, presence of the infectious complications, damage scale, crossed duct diameter, damage mechanism, and damage to the vessel. The right choice of the surgical intervention ensures a reduction in the number of complications and mortality, and quality of life improvement in patients with the unintentional bile duct injuries.

Management of Common Bile Duct Stones Encountered During Cholecystectomy in Patients With Previous Gastric Bypass.

Background: Rapid weight loss following gastric bypass (GBP) predisposes to the development of gallstones, and in those who develop gallstone disease there is a high prevalence of common bile duct stones (CBDS). Furthermore, in these patients, CBDS are difficult to extract due to the altered upper gastrointestinal anatomy following GBP. The aim of the present study was to assess outcome after various management methods applied in the counties of Stockholm and Uppsala, Sweden.Methods: Data from the Swedish Register for Gallstone Surgery and ERCP (GallRiks) and the Swedish Obesity Surgery Register (SoReg) were crossmatched to identify all patients who had undergone gallstone surgery after GBP, where CBDS were found at intraoperative cholangiography, in the Stockholm and Uppsala counties 2009–2013. A retrospective review of patient records was performed for all patients identified.Results: In all, 55 patients were identified. These were managed as follows: expectancy (N = 11); transgastric ERCP (N = 2); laparoscopic choledochotomy (N = 3); open choledochotomy (N = 5); transcystic stone extraction (N = 12); and other approach (N = 13). In nine cases, data on management could not be found. There were nine cases of minor postoperative complication. No retained stones were registered. The operation time was longer for transgastric ERCP (p = 0.002), and the postoperative stay was longer following open and laparoscopic choledochotomy (p < 0.001). There was no statistically significant difference between any of the methods regarding the incidence of postoperative complications (p = 0.098).Discussion: Further development of techniques for managing CBDS discovered in patients undergoing cholecystectomy after previous GBP are needed, as well as more comparative studies with greater statistical power.

Estudio complementario de la patología biliar complicada y el manejo de la litiasis coledociana en dos tiempos

Background: Nowadays, the prevalence of gallstones ranges between 10 and 20% in Western world, and 7-16% of the patients also present choledocholithiasis. The preoperative diagnosis of choledocholithiasis is difficult. Objective: To establish our experience in the evaluation of complicated gallstone disease and twostage management of choledochal lithiasis as standard or care. Material and methods: This prospective and observational study included patients hospitalized with gallstone disease undergoing procedures in the Department of General Surgery of Hospital Vidal from June 30, 2019, to December 30, 2019. Results: Ultrasound of the liver, biliary tract and pancreas was specific, with accuracy of 80.9% and sensitivity of 50%. Magnetic resonance cholangiopancreatography (MRCP) had a sensitivity of 100%, accuracy of 84.6% and sensitivity of 67%. As for endoscopic retrograde cholangiopancreatography (ERCP), the diagnosis of choledocholithiasis was made in 100% of the cases during the first cholangiography while “control” cholangiography had a sensitivity of 0%, specificity of 100% and accuracy of 15.4%. The presence of a dilated cystic duct intraoperatively in association with abnormal biochemical parameters had a sensitivity of 100%, specificity of 90%, and accuracy of 93.6%. Conclusion: Intraoperative cholangiography (IOC) is the gold standard procedure for the management of complicated gallstone disease. The association of biochemical parameters and a dilated cystic duct has high predictive value for choledochal lithiasis.

Transabdominal Ultrasound Evaluation of Pancreaticobiliary Maljunction in Children.

The development of high-frequency ultrasound made the diagnosis of pancreaticobiliary maljunction (PBM) possible. However, no study has been performed to clarify the sensitivity and specificity of transabdominal ultrasound (TAUS) in the diagnosis of PBM. The purpose of this study was to evaluate the accuracy of TAUS in the diagnosis of pediatric PBM and to assess factors that may influence the accuracy of ultrasound. This was a prospective study and 43 patients with suspected PBM were enrolled. All of these patients underwent TAUS examination to detect the pancreaticobiliary ductal union. Final diagnoses were determined by endoscopic retrograde cholangiopancreatography or intraoperative cholangiography. Sensitivity and specificity were calculated. Fisher exact test was used to analyze the difference of sonographic features between false-negative group and true-positive group. Transabdominal ultrasound demonstrated 77.4% (95% confidence interval, 58.5%-89.7%) sensitivity and 100% (95% confidence interval, 69.9%-100%) specificity for PMB diagnosis. In the false-negative group, infant patients (71.4% vs 16.7%, P = 0.012), cystic dilatation of the common bile duct (CBD) (71.4% vs 16.7%, P = 0.012), and stenosis of the distal CBD (71.4% vs 16.7%, P = 0.012) were more frequently observed than in the true-positive group. On the other hand, the true-positive group showed a higher incidence of protein plugs than the false-negative group (62.5% vs 0%, P = 0.007). Transabdominal ultrasound may serve as a potential alternative detection modality for pediatric patients with suspected PBM. Nondetection of the anomaly may be attributed to factors, such as younger age, cystic dilatation of the CBD, and stenosis of the distal CBD.

Application of Embedding Hepaticojejunostomy in Children with Pancreaticobiliary Maljunction Without Biliary Dilatation.

Background: To investigate the effect of embedded hepaticojejunostomy in children with pancreaticobiliary maljunction (PBM) without biliary dilatation. Materials and Methods: The clinical data of 10 patients with nondilated PBM from February 2017 to July 2020 were retrospectively analyzed. Perioperative liver function indexes were compared. Results: All patients were diagnosed by magnetic resonance cholangiopancreatography (MRCP) combined with intraoperative cholangiography. There were 5 cases of Komi type I and 5 cases of type II; the diameter of the common bile duct was 4-9 mm (median: 6 mm); and the length of the common channel was 5-15 mm (median: 9.25 mm). The procedure for one patient with common duct stones was converted to open surgery. Laparoscopic cholecystectomy, common bile duct resection, and embedded hepaticojejunostomy were successfully performed in all 10 cases. The average operation time was 225 ± 96.64 min, and the intraoperative blood loss was 2-5 mL. The mean time to oral intake was 3.5 ± 1.65 days (range: 2-5 days), and the mean hospitalization duration was 6.2 ± 2.44 days (range: 5-8 days). The differences in liver function indexes in the perioperative period were statistically significant (P < .05). The patients were followed-up for 13 to 54 months (median: 40 months). All patients grew well and there was no bile duct dilatation, calculus, or cirrhosis on B-ultrasound examinations. Conclusions: The clinical manifestations of nondilated PBM are often concealed, and preoperative MRCP was important for obtaining a diagnosis. Laparoscopic cholecystectomy, common bile duct resection, and embedded hepaticojejunostomy are feasible for treating nondilated PBM.

Intraoperative cholangiography: a stepping stone to streamlining the treatment of choledocholithiasis

An estimated 8-15% of patients undergoing cholecystectomy have concomitant common bile duct stones. In this 14-year study, we utilize data of patients at a high-volume tertiary care academic center and compare the clinical outcomes of patients undergoing intraoperative cholangiography (IOC) and endoscopic retrograde pancreatography (ERCP). The charts of 1715 patients in the institutional NSQIP database who underwent cholecystectomy between October 1st, 2005 and September 30th, 2019 were retrospectively reviewed. Patients who underwent cholecystectomy in relation to a malignancy diagnosis or who underwent an ERCP in a different index hospitalization were excluded. Main outcomes included hospital length of stay (LOS), post-operative morbidity, and rate of readmissions. Of the 1409 patients included in the final analysis, 185 patients underwent ERCP, while 95 patients underwent IOC. Use of IOC compared to preoperative ERCP resulted in a shorter LOS (2.6 vs. 5.3days, p < 0.001), lower rate of readmission (1.1% vs. 6.5%, p = 0.040), and similar rates of post-operative complications. Mean operative time increased by only 15min in the IOC compared to the ERCP group (129 vs.114min, p = 0.047). Additional variables that increased LOS on multivariable logistic regression included age, ASA classification, post-operative complications, and increased number of preoperative tests. This study demonstrates that use of IOC during cholecystectomy results in shorter LOS and fewer readmissions compared to ERCP. Future studies comparing these two approaches should focus on patient randomization, a cost-effectiveness analysis, and identifying barriers to implementation of a one-stage approach in the management of suspected choledocholithiasis.

SP6.1.6 Rule of systematic intraoperative cholangiogram in patients undergoing emergency cholecystectomy

Abstract Aims Incidence of gall stone disease is estimated at 10-15%of population. Intraoperative cholangiography (IOC) diagnose choledocholithiasis, delineates the anatomy of the biliary ducts, facilitate the dissection and reduces injuries. Our aim is to assess the feasibility and role of IOC and the incidence of choledocholithiasis in acute cholecystitis (ACC). Methods Retrospective analysis of prospectively collected data for patients admitted with ACC and undergoing same-hospital-stay laparoscopic cholecystectomy (LC). IOC was systematically attempted in all cases. Results 475cases included. Female to male ratio1.9:1. Conversion to open was done in 3 cases. Preoperative cholelithiasis was confirmed in 439cases versus 34cases with no stones. USS CBD abnormality (dilated or contain stone) found in 53 cases, out of which 8(15%) cases had CBD stones. Jaundice was found in 69cases, where 25(39%) cases had confirmed choledocholithiasis. IOC was successful in all cases except one. Abnormal IOC was found in 99(21%) cases. Of those; CBD stones were confirmed in 76 (77%) cases regardless the presence of cholelithisasis on USS. Empyema was found in 237 cases and it was associated with higher risk of abnormal IOC in 59(25%) cases where CBD stones were confirmed in 45(76%) cases. Cystic duct (CD) stones found in 80cases, of those 27(34%)cases had choledocholithiasis. Conclusions Females have double the risk of ACC. Preoperative jaundice and CD stones are stronger indicators than CBD diameter for presence of choledocholithiasis. The incidence of choledocholithiasis in ACC is (20-25%) regardless the presence of gall stones on USS. IOC is feasible and highly recommended in emergency LC.

TP6.1.4 Risk factors for post-cholecystectomy bile duct injuries: Systematic review and meta-analysis

Abstract Aims Bile duct injury (BDI) is a major complication of cholecystectomy resulting in long-term consequences. The relatively low incidence (0.23% – 1.5%) of BDI makes the identification of risk factors challenging. The aim of this study was to systematically analyse available literature on BDI post-cholecystectomy to provide an update on the incidence and determine current risk factors. Methods The study was pre-registered on PROSPERO (CRD42020177318). A search was conducted of MEDLINE, EMBASE, Scopus, Cochrane Central, Web of Science databases and the grey literature from inception to February 2020. 1583 unique papers were identified and screened for eligibility. English language, retrospective and prospective studies were included where the population age was &amp;gt; 16 and underwent cholecystectomy. Results Outcomes analysed were incidence of BDI and risk estimates for possible risk factors. 30 studies (6,420,667 patients) were included in the meta-analysis. Gender, BMI&amp;gt;30, acute cholecystitis (AC), emergent surgery, the operative approach, intraoperative cholangiography (IOC) and the impact of surgeon’s experience were analysed. Male gender and AC were determined to be statistically significant risk factors (OR 1.25 (1.13-1.39)) and 1.74 (1.27-2.39) respectively). Furthermore, IOC use was found to be significantly associated with BDI risk (OR 1.27 (1.17 – 1.37), while BMI&amp;gt;30, open surgical approach, emergent surgery and surgeon’s experience were not statistically significant; however, significant heterogeneity among included studies limited the interpretation of these factors. Conclusion Male gender and AC were found to be predictors of BDI, while better quality evidence is needed to show the effect of other factors.