Management Of Benign Biliary Disease Research Articles

ID: 3522338 PERCUTANEOUS ANTEGRADE CHOLANGIOSCOPY FOR MANAGEMENT OF BILIARY DISEASE IN SURGICALLY ALTERED ANATOMY WITH INACCESSIBLE BILIARY TREE

Management of benign biliary disease in patients with surgically altered anatomy (SAA) provides a unique challenge for clinicians. Traditional non-operative management includes percutaneous transhepatic biliary drainage (PTHB) by interventional radiology or balloon-assisted ERCP. With the endoscopic approach, despite balloon and other accessory assistance, the biliary tree may remain out of reach. In these cases of an inaccessible biliary tree (IBT) non-operative options are PTHB or endoscopic ultrasound-guided antegrade intervention.

What Have We Learned From Malpractice Claims Involving the Surgical Management of Benign Biliary Disease?: A 128 Million Dollar Question.

We aimed to study the contributing factors and costs of malpractice claims involving the surgical management of benign biliary disease given the emotional, physical, and financial toll of these claims on patients, providers, and the healthcare system. Cholecystectomy complications carry significant morbidity and rank among the leading sources of surgical malpractice claims. Using the CRICO Strategies' Comparative Benchmarking System database, representing approximately 30% of all paid and unpaid malpractice claims in the United States, 4081 closed claims filed against general surgeons from 1995 to 2015 were reviewed to isolate 745 cholecystectomy-related claims. A multivariable model was used to determine factors associated with claim outcome. The most common associated complications included bile duct injury (n = 397), bowel perforation (n = 96), and hemorrhage (n = 78). Bile duct injuries were recognized intraoperatively only 19% of the time and required biliary reconstruction surgery 77% of the time. The total cost for all claims over the study period was over $128 M and the median time from event to case close was over 3 years. 40% of claims resulted in patient payout; of these, most claims were settled out of court and the median cost per claim was $264,650. For the 60% of claims not resulting in patient payout, most cases were denied, dropped, or dismissed, yet still averaged over $15,000 per claim in legal and administrative fees. On multivariable analysis, bile duct injury, bowel perforation, and high clinical severity were associated with patient payout, while a resident or fellow being named in a claim was negatively associated with patient payout (P < 0.05). Cholecystectomy-related claims are costly and time-consuming. Strategies that reduce the risk and aid in recognition of cholecystectomy complications, as well as advance support of patients and families after poor outcomes, may improve clinical care and reduce claim burden.

What Have We Learned From Malpractice Claims Involving the Surgical Management of Benign Biliary Disease?

What Have We Learned From Malpractice Claims Involving the Surgical Management of Benign Biliary Disease?

What Have We Learned From Malpractice Claims Involving the Surgical Management of Benign Biliary Disease?

What Have We Learned From Malpractice Claims Involving the Surgical Management of Benign Biliary Disease?

Best endoscopic stents for the biliary tree and pancreas.

To determine trends in pancreaticobiliary stents over the past 12-18 months. Metal biliary stents continue to be used for palliation of malignant distal biliary obstruction with superior patency to plastic stents. The use of covered metal biliary stents is increasingly being used for the management of benign biliary disease. Plastic stents predominate in patients with pancreatic disease, with the exception of transmural drainage of pancreatic necrosis. In both biliary and pancreatic disorders, there is a trend towards greater utilization of endoscopic ultrasound-guided interventions. Endoscopic placement of pancreaticobiliary stents plays an important role in the treatment of complex benign and malignant disease. Further comparative trials are needed to determine the optimal role of endoscopic ultrasound-guided transmural stent placement.

Intervention in Benign Biliary Stricture and Biliary Leak

: Benign causes of biliary obstruction are often iatrogenic in nature, and most commonly result from inadvertent damage to the biliary tree during surgical procedures, particularly laparoscopy. Benign biliary obstruction may be associated with trauma, inflammatory processes due to stone disease or pancreatitis, surgery with biliary-enteric anastomoses, liver transplantation, sphincter of Oddi dysfunction, and as a late complication of the treatment of other intra-abdominal processes. The percutaneous treatment of benign biliary strictures by dilatation has a success rate ranging from 67 to 90%, which is higher than that of endoscopic treatment. Common complications of percutaneous biliary drainage and intervention include hemorrhage from puncture of the portal vein or hepatic artery, pleural or gallbladder puncture, injury to bowel or kidney, and sepsis. Placement of metallic stents in the BBS has been tried with no long term promising results. Metallic stents should only be considered for failed attempts at surgical repair. Development of self-expandable covered stents specifically designed to be removed at a later date may change current management strategies. Treatment with covered metal stents or bio absorbable stents warrants further evaluation. Endoscopic biliary sphincterotomy (EBS) is a first-line therapy for various pancreaticobiliary diseases. The endoscopic management of benign biliary diseases typically consists of dilation and insertion of one or more plastic stents followed by elective stent exchange every 3 months to avoid cholangitis caused by stent clogging. Sequential placement of multiple, large diameter stents in patients with distal common bile duct stenosis secondary to chronic pancreatitis appears to be superior to single stent placement and may provide good long-term benefits.

Use of covered self-expandable metal stents for endoscopic management of benign biliary disease not related to stricture (with video)

Covered biliary self-expandable metal stents (CSEMSs) can be partially covered (PCSEMS) or fully covered (FCSEMS) and are U.S. Food and Drug Administration approved for palliation of malignant obstruction. FCSEMSs are increasingly being used for management of benign biliary disorders because of their removability and from promising data from their use for benign biliary strictures.1,2 This has led to their use for benign biliary disorders not related to stricture, such as bile leaks, post-sphincterotomy bleeding, and perforation.

Single Port Access Cholecystectomy: The Initial Learning Curve

Single port surgery is a rapidly advancing technique with a lot of enthusiasm among minimal access surgeons. Single port access cholecystectomy (SPAC) is one of the most commonly performed single port access surgery all over the world. To establish this technique as standard of care for management of benign biliary diseases, it needs strong comparison with traditional laparoscopic cholecystectomy. Initial learning curve, cost effectiveness, post operative pain, post operative recovery and complications rate is yet to be established. SPAC was performed on 19 selected patients for symptomatic gall stone disease by a single surgeon at our institute. The SILS™ port was placed in the umbilicus and combination of articulating and straight instruments were used. Patient characteristics and outcome were reviewed. The main selection criteria for SPAC were based on clinical history, body mass index, and ultrasonographic findings. The SPAC had a mean time of 50 minutes. The first single port cholecystectomy took 120 minutes with sequential improvement in operating time for further cases. The average patient body mass index was 23. No major complications or conversion to traditional technique occurred. One of the largest series to date of SPAC for benign biliary diseases in India, performed by a single surgeon in a single institute is presented. We conclude that it is a safe and reproducible technique with short learning curve for appropriately trained minimal access surgeons with a higher cosmetic satisfaction for patients.

T1519: Use of Fully Covered Self Expanding Metal Stents (FCSEMS) in the Management of Benign Biliary Diseases (BBD)

T1519: Use of Fully Covered Self Expanding Metal Stents (FCSEMS) in the Management of Benign Biliary Diseases (BBD)

Treatment Experience of Subsequent Complications after Roux-en-Y Biliojejunostomy

Purpose: Roux-en-Y biliojejunostomy has been frequently used in the management of benign biliary disease. The aim of this study was to summarize one institute’s experiences in prevention and management of subsequent complications of Roux-en-Y biliojejunostomy. Methods: A retrospective analysis was carried out for patients who underwent reoperation after Roux-en-Y biliojejunostomy from February 1990 through June 2004. Operation history, laboratory test data before the last operation, and images were collected. Results: Sixty-one patients, aged 36–60 years and with a 3.5-year average operation interval, were involved in the study. Anastomotic stricture (47, 80.3%), recurrent calculi (36, 60.7%), and biliary tract infection (all) were the most common complications after Roux-en-Y biliojejunostomy. Other complications (such as calculi of the intrahepatic duct or intrahepatic duct stricture, malformed or twisted jejunum loop, too long or too short proximal jejunum, disappearance of the normal form of anastomosis, and adhesion of the intestinal loop) were also detected by laparotomy. Conclusion: Calculus, stricture, and infection arise as a result of each other. Lessening of the anastomotic stricture, fluent drainage of the distal jejunum below the anastomosis, and relieving pressure of gastrointestinal tract are pivotal in decreasing subsequent complications after Roux-en-Y biliojejunostomy.

Percutaneous management of benign biliary disease.

Thirty-two patients had percutaneous drainage for benign disease of the biliary system, and in 81% of the patients the catheter could be removed. The patients' conditions were of 3 types: choledocholithiasis, biliary strictures, and primary sclerosing cholangitis. Fourteen patients had balloon dilatation of strictures in the biliary tract. As in malignant disease, many patients may be managed entirely by percutaneous methods and surgery avoided, but the results with percutaneous drainage are more gratifying.