Posterior Bile Duct Research Articles

A novel method of bilateral biliary decompression by EUS-guided hepaticogastrostomy with bridging stenting using the partial stent-in-stent method for reintervention of multiple metal stent failure

Video 1A novel method of bilateral biliary decompression by EUS-guided hepaticogastrostomy with bridging stenting using the partial stent-in-stent method for reintervention of multiple metal stent failure.We report a case in which anterior and posterior drainage was performed using the partial stent-in-stent method via the transpapillary approach. The patient had a bismuth type IV biliary obstruction, but only the right hepatic lobe was drained due to obstruction of the left portal vein. For the recurrent stent dysfunction, the patient underwent placement of a plastic stent within an uncovered self-expanding metal stent to correct stent dysfunction. A 7F plastic stent inside a metal stent is shown.The patient later experienced stent failure and jaundice due to tumor progression and was admitted for plastic stent replacement. Neither imaging results nor symptoms suggested duodenal stenosis. The transpapillary approach was attempted first but was unsuccessful. Duodenoscopy was challenging to perform because of duodenal stenosis. Fluoroscopy confirmed the duodenal stenosis. The plastic stent was extracted using an upper endoscope. Multiple uncovered metal stents are shown (1 stent in the anterior bile duct and 2 stents in the posterior bile duct). Jaundice did not resolve despite plastic stent removal.The patient refused to undergo percutaneous biliary drainage, so a decision was made to perform an EUS-guided hepaticogastrostomy (HGS) instead. The left bile duct was observed in the stomach. The left bile duct was punctured with a 19-gauge FNA needle. A 0.025-inch hydrophilic guidewire was directed into the left bile duct. Enhancement of the bile duct showing malignant hilar biliary obstruction (bismuth IV) is seen. Insertion of the guide wire into the posterior bile duct is shown.The stent mesh was then dilated using a balloon dilator. However, there was difficulty inserting the catheter. Additional dilation was performed using a spiral dilator. This instrument is a tapered tip dilator that fits into 0.025-inch guidewires and is expandable to 7F. Insertion of a second guidewire with a larger caliber was done to straighten the bile duct and help stabilize stent insertion. A 0.035-inch hydrophilic guidewire into the posterior bile duct using a double-lumen cannula and insertion of a 0.025-inch hydrophilic guidewire into the anterior bile duct are shown.The stent mesh was then dilated using a spiral dilator. A metal stent was placed through the anterior bile duct at a steep angle. Insertion and deployment of the first uncovered self-expanding metal stent (8× 60mm) from the anterior bile duct into the left bile duct is shown. Multiple metal stents were implanted into the hilar area, and the new stent was placed using the partial stent-in-stent method to prevent overexpansion. Guidewire seeking the posterior bile duct from inside the deployed stent through the stent mesh is shown.The stent mesh was then dilated using a balloon dilator. Insertion and deployment of an uncovered self-expanding metal stent (8× 60mm) from the posterior bile duct to the left bile duct using the partial stent-in-stent method is shown. Enhancement of the bile duct shows drainage from the right bile duct. The fistula of the HGS was only dilated with the spiral dilator. The risk of bile leakage was low, so we decided to implant a plastic stent. A 7F× 15-cm plastic stent was placed from the posterior bile duct into the stomach. Anterior and posterior segment drainage by EUS-HGS with bridging stenting using the partial stent-in-stent method is shown, with left segment drainage by EUS-HGS with the plastic stent.We performed EUS-HGS on a patient with multiple metal stents in place. There were no adverse events, and total bilirubin levels were reduced by more than half within 2 weeks. Six months have passed without stent dysfunction.

EUS-guided hepaticoduodenostomy for posterior bile duct obstruction using a novel plastic stent for isolated posterior bile duct obstruction (with video).

EUS-guided hepaticoduodenostomy for posterior bile duct obstruction using a novel plastic stent for isolated posterior bile duct obstruction (with video).

Intrahepatic cholangiocarcinoma with extensive intraductal extension of high-grade biliary intraepithelial neoplasia: a case report

BackgroundIntrahepatic cholangiocarcinoma (ICC) is frequently associated with precursor lesions, and biliary intraepithelial neoplasia (BilIN) may play a significant role in the development of ICC. However, the exact sequence and progression of these lesions remain to be elucidated. We report a rare case of ICC that exhibited extensive longitudinal intraductal extension of high-grade BilIN in the posterior bile ducts and involved the hepatic hilum and the peripheral hepatic parenchyma.Case presentationA 70-year-old female presented with anorexia. Computed tomography (CT) revealed a 15 mm enhancing intrahepatic tumor extending to the right intrahepatic secondary confluence. This was associated with a 7 mm diameter cystic dilatation of the segment 6 bile duct (B6). Endoscopic retrograde cholangiopancreatography (ERCP) revealed stenosis at the bifurcation of the posterior bile duct branch. Bile cytology confirmed the diagnosis of adenocarcinoma cells. Therefore, the patient was diagnosed with an ICC involving the right glissonean pedicle and underwent a right hepatectomy and lymph node dissection. Histologic examination revealed the tumor consisted of moderately differentiated adenocarcinoma. In connection with this lesion, diffuse intraductal atypical epithelial cells, which were diagnosed as high-grade BilIN, was observed not only in the dilated B6 but in the entire posterior bile ducts, which measured approximately 120 mm in diameter. Furthermore, two distinct foci of adenocarcinomas were identified in the peripheral hepatic parenchyma. A lymph node metastasis was also present. The pathological diagnosis was ICC pT4N1M0 stage IVA. The patient underwent adjuvant chemotherapy and has shown no recurrence 5 years after surgery. Imaging modalities were unable to accurately assess the extent of the intraductal neoplastic lesions due to their low papillary or sessile intraductal tubular growth. No risk factors for BilIN development, which has the potential to predispose to cholangiocarcinoma, were identified in the present case.ConclusionsWe present a case of ICC involving the right hepatic hilum, accompanied by extensive longitudinal extensions of high-grade BilIN and multifocal microscopic invasions in peripheral hepatic parenchyma. Notably, the intraductal lesions involved the entire posterior intrahepatic bile ducts. The presence of biliary neoplasia with extensive intraductal extension, in conjunction with ICC, should be considered as a variant of BilIN.

Clinical value of fluorescent cholangiography for the infraportal type of right posterior bile duct

Background The infraportal type of the right posterior bile duct (infraportal RPBD) is a well-known anatomical variation that increases the potential risk of intraoperative biliary injury. The aim of this study is to clarify the clinical value of fluorescent cholangiography during single-incision laparoscopic cholecystectomy (SILC) for patients with infraportal RPBD. Material and methods Our procedure for SILC utilized the SILS-Port, and another 5-mm forceps was inserted via an umbilical incision. A laparoscopic fluorescence imaging system developed by Karl Storz Endoskope was utilized for fluorescent cholangiography. Between July 2010 and March 2022, 41 patients with infraportal RPBD underwent SILC. We conducted retrospective reviews of patient data, focusing on the clinical value of fluorescent cholangiography. Results Thirty-one patients underwent fluorescent cholangiography during SILC, but the remaining ten did not. Only one patient who did not undergo fluorescent cholangiography developed an intraoperative biliary injury. The detectability of infraportal RPBD before and during the dissection of Calot’s triangle was 16.1% and 45.2%, respectively. These visible infraportal RPBDs were characterized as connections to the common bile duct. The confluence pattern of infraportal RPBD significantly influenced its detectability during the dissection of Calot’s triangle (p < 0.001). Conclusions The application of fluorescent cholangiography can lead to safe SILC, even for patients with infraportal RPBD. Its benefit is emphasized when infraportal RPBD is connected to the common bile duct.

Right posterior bile duct stricture after central bisectionectomy or anterior sectionectomy.

Before performing anterior sectionectomy (AS) or central bisectionectomy (CBS), the anatomy of the right posterior bile duct (RPBD) must be cautiously assessed owing to the many variations of the RPBD and its variations could be related to bile duct injury. Clinical data of patients who underwent AS or CBS from 2009 to 2018 were reviewed. The bile duct anatomy according to Okubo's criteria and the right bile duct (RBD) length were evaluated using MRI, and we performed a risk factor analysis of the RPBD stricture (RPBDS). A total of 68 patients were included. Type A bile ducts were the most common (n = 36, 52.9%). Five (7.2%) patients had RPBDS requiring intervention. RPBDS only occurred in patients with a type A bile duct and a type A portal vein undergoing surgery using the Glissonian sheath approach. Moreover, when the RBD length was > 12mm, the sensitivity and specificity were 0.8 and 0.889, respectively. In multivariate analysis, RBD length of > 12mm was significant. A careful review of RPBD anatomy especially in patient with long RBD and caution when using the anterior Glissonian sheath approach might be helpful to prevent RPBDS during AS or CBS.

Efficacy and superiority between endoscopic retrograde cholangiopancreatography and percutaneous transhepatic biliary drainage as first line intervention of biliary complication after liver transplantation

Biliary complications after liver transplantation (LT) are the most common complications and associated with morbidity and mortality. There has not been a uniform conclusion published on the superiority of the two types of intervention as the first trial. Therefore, we compared the efficacy of endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD) as a first-line treatment of post-LT biliary problems. From January 2013 to December 2016, 565 patients underwent LT in Seoul National University Hospital. Medical records of recipients who were diagnosed with biliary complications after LT retrospectively reviewed. Long-term follow-up was evaluated using cholangiogram, computed tomography (CT) scan, and laboratory parameters. Among 565 LT patients, 85 patients (15.0%) were treated by intervention including ERCP and PTBD with diagnosis of biliary complications. Successful intervention on the first attempt was achieved in 36 of 60 patients (60.0%) with ERCP, and 19 of 25 patients (76.0%) with PTBD, respectively (p = 0.16). We also classified the groups based on the location of the biliary complications and compared the success rate; one with anterior bile duct problems (a-BD, n = 29) and another with posterior bile duct (p-BD, n = 14). In a-BD, there was no difference in the intervention success rate of PTBD and ERCP (25% vs. 24%, p = 0.692). However, in p-BD, PTBD success rate was significantly better than ERCP (75% vs. 18%, p = 0.002). PTBD could be considered as more effective procedure for termination of treatment in patients with post-LT biliary complications, especially posterior posterior duct problems.

Intractable Biliary Strictures After Living Donor Liver Transplantation: A Case Series

Biliary stricture (BS) is a severe complication after liver transplantation. It is difficult to treat, especially after living donor liver transplantation (LDLT). We successfully treated 4 patients for intractable BS after LDLT. All patients had developed cholangitis with stenosis of bile ducts anastomosis. CASE 1: . A 65-year-old woman underwent LDLT with right lobe graft and duct-to-duct biliary reconstruction. Internal plastic stents inserted by endoscopic retrograde cholangiography (ERC) were changed quarterly for the next 2 years. CASE 2: A 55-year-old man underwent LDLT with right lobe graft and duct-to-duct biliary reconstruction. Insertion of internal plastic stents by ERC was attempted; however, the posterior bile duct branch showed complete obstruction. After percutaneous transhepatic biliary drainage (PTCD), the stents were inserted using the rendezvous technique of ERC and were changed by ERC quarterly for the next 3 years. CASE 3: A 22-year-old man underwent LDLT with left lobe graft and hepaticojejunostomy. An external drainage tube was inserted by PTCD, and stents were changed quarterly for the next 2 years. CASE 4: A 60-year-old man underwent LDLT with right lobe graft and hepaticojejunostomy. An external drainage tube was inserted by PTCD, and changed to a metallic stent after 1 year. Three months later the stent was extracted using the rendezvous technique of double balloon enteroscopy. BS of complete obstruction type after LDLT is difficult to treat. Appropriate procedures should be chosen based on the types of strictures and biliary reconstruction methods.

Small bowel obstruction post-living liver transplantation.

A 59-year-old male patient with history of alcoholic cirrhosis with a MELD of 14 underwent right lobe living donor liver transplantation 4 years previously. The graft weighed 1000 g and had a single right portal vein and a single right hepatic artery that were anastomosed in an end-to-end fashion to the recipient’s right portal vein and right hepatic artery, respectively. The right anterior and right posterior bile ducts separated by >1 cm were joined together and anastomosed in an end-to-end fashion to the recipient common hepatic duct. The donor right hepatic vein was anastomosed to the orifice of the right hepatic vein and a reconstructed polytetrafluoroethylene (PTFE) graft draining the anterior sector was anastomosed to the middle hepatic vein orifice. His postoperative course was complicated by a bile leak that failed initial management with endoscopic retrograde cholangiopancreatography (ERCP) and stenting and eventually required creation of a roux en Y hepaticojejunostomy to the two separate ducts on postoperative day 23. He recovered well and was discharged to rehab. He presented a year later with a partial small bowel obstruction secondary to an incisional hernia that was initially managed conservatively and electively repaired with a mesh. He presented 4 years after transplantation with abdominal pain, nausea, and vomiting. His physical exam was significant for diffuse abdominal distension and a reducible recurrent incisional hernia. His laboratory work was notable for a mildly elevated bilirubin (3 mg/dL) and alkaline phosphatase (801 units/L). He underwent a CT scan of the abdomen and pelvis showing a small bowel obstruction (Figures 1 and 2).FIGURE 2Computed tomography of the pelvis on admissionView Large Image Figure ViewerDownload Hi-res image Download (PPT) 1What is the most likely etiology of the small bowel obstruction in this case?aAdhesive small bowel obstructionbFecal impactioncIncarcerated incisional herniadInternal herniaeIntraluminal obstruction2What is the optimal management for this patient?aExploratory laparotomy with lysis of adhesionsbExploratory laparotomy with repair of the incisional herniacExploratory laparotomy with reduction of the internal herniadExploratory laparotomy with small bowel resectioneNothing by mouth, hydration, and nasogastric decompression3Which of the following factors predisposed the patient to develop this complication?aBiliary leak and subsequent interventionsbEtiology of liver diseasecHernia repairdRejectioneUndiagnosed Crohn’s disease4What is the advantage of optimizing the venous outflow of a partial liver graft?aDecrease the risk of bile leakbDecrease the risk of graft rejectioncDecrease the risk of portal vein thrombosisdDecrease the risk of small for size syndromeeDecrease the warm ischemic time5Which of the following could potentially decrease the incidence of this complication?aAutogenous hepatic vein reconstructionbMicrovascular arterial anastomosiscPlacing drainsdPortal vein interposition grafteUsing a smaller liver graft

Three-dimensional visualization technique compared with magnetic resonance cholangiopancreatography for evaluation of anatomic variants of pediatric congenital choledochal cysts.

The aim of this study was to compare the application of a three-dimensional (3D) visualization technique and magnetic resonance cholangiopancreatography (MRCP) for diagnosis of pediatric congenital choledochal cysts. Thin slices of coronal heavily T2-weighted pulse sequences of MRI pertaining to 35 patients were retrospectively used to reconstruct 3D models. Diagnoses and variants of the biliary system were evaluated based on the 3D models and MRCP imaging. The quality of delineation of the biliary duct system and the Todani classification were evaluated. Wilcoxon and Chi-squared tests were used for statistical analysis. Two cases that were diagnosed as type II congenital choledochal cysts using the 3D model were diagnosed as type I using MRCP imaging. Significant differences were observed between the two modalities with respect to the delineation of the right anterior bile duct, right posterior bile duct, and left hepatic duct. The excellent and good rates obtained with the 3D model (65.7%) were much better than that obtained with MRCP (37.1%) imaging. Two cases with accessory hepatic ducts (5.7%), one case with an accessory pancreatic duct (2.8%), and two cases with biliary strictures at the hepatic hilum (5.7%) were detected using the 3D models. In contrast, only one case with an accessory hepatic duct and one case with a biliary stricture at the hepatic hilum were detected using MRCP. The 3D visualization technique facilitated more precise morphological evaluation of congenital choledochal cysts and provided comprehensive spatial anatomic information for diagnosis.

Central hepatopancreatoduodenectomy\u2014oncological effectiveness and parenchymal sparing option for diffusely spreading bile duct cancer: report of two cases

BackgroundHepatopancreatoduodenectomy (HPD) for diffusely spreading bile duct cancer (DSBDC) usually involves a major hepatectomy and a concomitant pancreatoduodenectomy, and is still challenging surgery because of postoperative liver failure. The present case report demonstrated two cases of DSBDC where we could achieve successful HPD with central liver resection (CHPD) as liver parenchymal sparing surgery.Case presentationIn Case 1, endoscopic retrograde cholangiography (ERC) with multiple biopsies revealed that she had DSBDC with Bismuth-Corlette type IIIA. 3D integrated images reconstructed by contrast enhanced CT and CT with drip infusion cholecystocholangiography data revealed the right antero-ventral bile duct (RAVD) confluent to the right hepatic duct and the right antero-dorsal bile duct (RADD) independently confluent to the right posterior bile duct (RPD). Tumor extended common bile duct including intrapancreatic bile duct to the left hepatic duct and RAVD, but the RADD and RPD were spared. Because the future liver remnant (FLR) was assumed not to achieve desirable volume by preoperative portal vein embolization for left or right trisegmentectomy, CHPD including resection of the segments IV and I, and the right antero-ventral segment was done and achieved R0. This procedure is tailored to the anatomical extent of disease in the context of variable biliary anatomy as a modified CHPD, and to our knowledge, this is the first reported case of modified CHPD with antero-dorsal segment preservation. In Case 2, preoperative imaging revealed DSBDC with Bismuth Corlette type IIIA. FLR volume was assumed insufficient for major hepatectomy, CHPD including resection of the segments IV and I, and the right anterior sector was done with R0. The remnant liver volumes of these cases were spared by 55.1% and 25% respectively, and postoperative course was uneventful in both.ConclusionCHPD should be considered a valid option for well-selected cases of DSBDC. This is the first case report of modified CHPD with antero-dorsal segment preservation.

Clinical Value of Fluorescent Cholangiography for the Patients with Infrapotal Type of the Right Posterior Bile Duct during Single-Incision Laparoscopic Cholecystectomy

Introduction: Reports about clinical value of fluorescent cholangiography using indocyanine green (ICG) during single-incision laparoscopic cholecystectomy (SILC) were increasing. We report clinical value and pitfalls of fluorescent cholangiography during SILC for the patients with the infraportal type of the right posterior bile duct.

Conservative Management of Bile Leak Secondary to an Accessory Duct of Luschka

Introduction: Post cholecystectomy bile leaks are rare, have an incidence of 0.1-1%, and regardless of their nature, most cannot be detected during surgery. In 5-30% they correspond to a Luschka duct, which are small ducts that originate in the right hepatic lobe, extend to the gallbladder bed and may or may not drain to the extrahepatic bile ducts. The objective of this publication is to present the experience obtained in the minimally invasive and conservative management of a post-laparoscopic cholecystectomy bilioma due to leakage of the luschka duct. Case: Female patient of 59 years, with Diagnosis : Multiple Myeloma + Cholelithiasis, undergoing laparoscopic cholecystectomy. Two days after surgety, a subphrenic collection is identified, which is drained percutaneously, with ultrasound guidance, and bilious fluid is obtained, approximately 800 cc. Subsequently, in the collagioresonance a bile duct lesion is identified, which is born from the right posterior bile duct and is directed towards the hepatic bed, with indemnity of the main bile duct. The debit decreases progressively during the first week, presenting a negative debit 15 days after placement and the catheter is removed one week later. The evolution 1 month later is favorable, with normal ultrasound controls. Conclusion: The minimally invasive treatment of bile leakage can be considered a safe option in patients with minor injuries, in order to avoid exposure to invasive procedures such as endoscopic retrograde cholangiography and its possible complications.

Management of anatomical challenges during laparoscopic cephalic duodenopancreatectomies

Introduction: Laparoscopic cephalic duodenopancreatectomy (LCDP) is considered a surgery of high technical complexity. It has a long learning curve because of the need of high laparoscopic technical skills, especially in the presence of anatomical variations. The aim of this video is to present three cases of LDCP (pure and hybrid) with difficult anatomical challenges and how to approach them. Case 1: A 76 years old woman presents with painless jaundice and workup reveals an infiltrating 20 mm adenocarcinoma of the Vater´s ampulla. During LCDP, a right posterior bile duct draining independently distal to the common bile duct is found, so two-separated laparoscopic bilio-enteric anastomosis are performed. Case 2: A 70 years old men presents with painless jaundice and workup reveals a 30 mm dysplastic adenoma of the Vater´s ampulla. He had a surgical history of an open gastric antral resection due to a perforated peptic ulcer 40 years ago. During LCDP, multiple lysis adhesions of the hepatic hilium are required and a right hepatic artery arising from the superior mesenteric artery is identified and preserved. Case 3: A 70 years old men with Child-B cirrhosis presents with jaundice and workup reveals an adenocarcinoma of the Vater´s ampulla not suitable for endoscopic resection. Hepatic venous gradient pressure (HVGP) measurement is 7 mmHg, so after multidisciplinary discussion a hybrid LCDP is performed with no complications. Conclusion: anatomical challenges can be safely approached under laparoscopic surgery during LCDP.

Endoscopic ultrasound-guided rendezvous for access to the right posterior bile duct in a surgical candidate.

Endoscopic ultrasound-guided rendezvous for access to the right posterior bile duct in a surgical candidate.

Clinical investigation of the cystic duct variation based on the anatomy of the hepatic vasculature.

Anatomical variation of the cystic duct (CD) is rare but can result in misunderstanding of the CD anatomy during laparoscopic cholecystectomy, potentially leading to bile duct injury. Therefore, the precise preoperative identification of CD variation is important. However, preoperative imaging analyses of the biliary system are not always possible or sufficient. We therefore investigated CD variations based on the anatomy of the hepatic vasculature. This study enrolled 480 patients who underwent imaging before hepatobiliary pancreatic surgery. We assessed the variation of the CD and hepatic vasculature and evaluated the correlations among these variations. A variant CD anatomy was identified in 12 cases (2.5%) as CD draining into the right hepatic bile duct (BD) in 4 cases and into the right posterior BD in 8 cases. CD variation was significantly more common in cases with portal vein (PV) and BD variation than in those without the variation. We developed a scoring system based on the presence of PV and BD variations that showed good discriminatory power for identification of CD variants. Cases with a variant CD anatomy were more likely to exhibit variant PV and BD anatomies than cases with a normal CD anatomy. These findings will be useful for the preoperative identification of CD variants.

Left trisectionectomy plus caudate lobectomy (S1) and resection of biliary duct for Bismuth type IV peri-hilar cholangiocarcinoma

Background: Extended left hemihepatectomy or left trisectionectomy is a challenging procedure that can be applied in patients affected peri-hilar cholangiocarcinoma involvng right second order bile ducts. This procedure requires an extensive preoperative evaluation with future liver volume calculation and liver function assessment. Methods: A 68-years-old male with a peri-hilar cholangiocarcinoma (Bismuth type IV) with jaundice (pre-operational bilirubin 6.8 mg/dL). Future remnant liver volume for S6-7 was 35%A left trisectionectomy plus S1 and common bile duct resection was planned without preoperative biliary drainage. Results: The video shows the surgical technique including en bloc lymphadenectomy, left trisectionectomy with en bloc S1 resection and common bile duct resection. The reconstruction was performed with single bilio-enteric anastomosis of right posterior bile duct. Postoperative course was eventful and patient was discharged in 10th postoperative day. Pathology report confirmed the R0 resection with negative lymph-nodes (0/24). Conclusion: An extended resection with a locoregional lymphadenectomy is the potentially curative option for patients with a peri-hilar Bismuth type IV colangiocarcinoma.

The anatomical characteristics of patients with posterior bile duct stricture after a liver resection including anterior section

Introduction: When deciding to proceed with anterior sectionectomy or central bisectionectomy, the posterior duct anatomy must be carefully reviewed due to the high variation rate of the duct. Additional procedures or posterior sectionectomy may be needed if injury occurs leading to posterior bile duct stricture. Method: We reviewed the clinical data of patients who received liver resections including the anterior section such as anterior sectionectomy and central bisectionectomy from July of 2009 to September of 2018. We reviewed the type of bile duct anatomy according to the Bismuth classification and the right hepatic duct length was measured if the classification was type A. We excluded patients without MRI and patients who underwent hepaticojejunostomy. We divided patients into 4 groups according to the bile duct anatomy and risk factor analysis for right posterior bile duct stricture. Result: A total of 69 patients received central bisectionectomy or anterior sectionectomy. The type A bile duct was most common (n=42, 60.9%) and type B was the second most type (n=12, 17.4%). Five patient (7.2%) need PTBD or ERCP procedures due to biliary stricture and occurs in only type A. The length of right hepatic duct (RHD) was related to biliary stricture (AUC=0.889) and the sensitivity was 0.8 and specificity was 0.889 when the length of RHD is 12mm. In multivariate analysis, the RHD more than 12mm was significant (OR: 47.068, 1.469 – 1508, P=0.029). The median time to biliary stricture was postoperative 34 day (5-81) and the stricture was managed with ENBD and PTBD and successfully resolved. Conclusion: The RHD more than 12mm was the risk factor of the posterior biliary stricture in anterior or central bisectionectomy.

Atherosclerosis of the right posterior hepatic artery in a patient with hilar cholangiocarcinoma undergoing left trisectionectomy: a case report of a therapeutic pitfall

BackgroundWe experienced a rare case of benign arterial stricture of the right posterior hepatic artery (RPHA) caused by atherosclerosis in a patient with hilar cholangiocarcinoma.Case presentationA 75-year-old man was referred to our hospital for the detailed investigation of serum hepatobiliary enzyme elevation. The patient had a history of hypertension, type 2 diabetes mellitus, and an operative history of coronary artery bypass grafting 10 years before. Endoscopic retrograde cholangiography found strictures of the right and left hepatic ducts with involvement of right anterior and posterior bile ducts. Adenocarcinoma was evident by brush cytology. We diagnosed these findings as hilar cholangiocarcinoma and planned left trisectionectomy including bile duct reconstruction. Although the tumor and RPHA were not adjacent, preoperative multidetector computed tomography revealed a stricture of the RPHA that was 5.6 mm in length. We suspected that atherosclerosis caused the stricture, and we performed digital subtraction angiography and intravascular ultrasonography that showed stricture of the RPHA accompanied by thick plaques in the arterial wall. We placed a bare-metal stent in the RPHA and then performed left trisectionectomy. Since this patient developed bile leakage postoperatively, percutaneous drainage was performed. The bile leakage was successfully controlled, and the patient was discharged 3 months after surgery. Unfortunately, 4 months after hepatectomy, he was re-hospitalized with multiple pyogenic liver abscesses. We performed intensive multimodal treatment for the liver abscesses and stabilized the disease; however, we eventually lost this patient due to liver failure 14 months after surgery.ConclusionTo the best of our knowledge, there is no previous literature on atherosclerosis of the RPHA, which was evident preoperatively in our case. Because arterial complications may lead to critical biliary complications in patients who undergo left trisectionectomy, we first performed prophylactic arterial stent placement. We speculate that existing chronic microscopic injury of the peribiliary plexus might have caused the liver abscesses. We successfully diagnosed atherosclerosis of the RPHA preoperatively. However, further investigation of patients is warranted to determine if left trisectionectomy is contraindicated in these patients.

Usefulness of 3D balanced turbo-field-echo MR sequence evaluating the branching pattern of the intrahepatic bile ducts: comparison with drip infusion CT cholangiography.

For liver surgery, it is crucial to preoperatively examine the course of the right posterior bile duct. While MR cholangiopancreatography (MRCP) can only visualize the bile ducts, 3D balanced turbo-field-echo (BTFE) sequence clearly depicts the bile ducts and portal veins as well as drip infusion CT cholangiography (DIC-CT), without contrast media. We evaluated whether BTFE could substitute for DIC-CT. Thirty patients undergoing MRCP and BTFE on 1.5-T MR and DIC-CT were evaluated. Two readers retrospectively evaluated the branching pattern (supra-type: A-C or infra-type: D-E) and scored the degree of confidence and motion artifacts using a 3-point scale for the three 2-mm-thick reconstructed images. The bile duct diameter did not differ between DIC-CT and MRCP (p=0.07). Five patients (17%) had intrahepatic biliary dilatation (>3mm). The A, B, C, D, and E types were diagnosed in 21, 6, 1, 1, and 1 patient, respectively (28 supra-types and 2 infra-types) on DIC-CT. For DIC-CT, MRCP, and BTFE, the mean motion artifact scores were 3.0/3.0, 2.7/2.6, and 2.9/2.8, respectively. The mean diagnostic confidence scores were 2.9/2.9, 2.4/2.4, and 2.9/2.8, respectively, with no difference between DIC-CT and BTFE. The concordance between DIC-CT and BTFE was high (infra- or supra-type: κ=1.00/1.00, A-E: κ=0.86/0.66), but it was poor between DIC-CT and MRCP (infra- or supra-type: κ=0.35/-0.05, A-E: κ=0.33/0.41) for both readers. Similar to DIC-CT, the BTFE MR sequence had high diagnostic accuracy regarding the branching pattern of the intrahepatic bile duct, especially for the supra/infraportal type.

Effect of Right Posterior Bile Duct Anatomy on Biliary Complications in Patients Undergoing Right Lobe Living Donor Liver Transplant.

Our aim was to evaluate the influence of the localization of right posterior bile duct anatomy relative to portal vein of the donors on posttransplant bile duct complications. We retrospectively investigated 141 patients who had undergone living donor liver transplant using right hemiliver grafts. The patients were classified based on the pattern of the right posterior bile duct and divided into infraportal and supraportal types. Clinical donor and recipient risk factors and surgical outcomes were compared for their relationship with biliary complications using logistic regression analyses. The 2 groups were similar according to demographic and clinical features. The biliary complication rate was 23.7% (9/38) in the infraportal group and 47.4% (37/78) in the supraportal group (P = .014). An analysis of risk factors for the development of anastomotic bile leak using logistic regression showed that a supraportal right posterior bile duct anatomy was a statistically significant positive predictor, with odds ratio of 18.905 (P = .012; confidence interval, 1.922-185.967). The distance of the right posterior bile duct from confluence was significantly lower in patients with biliary complications than in those without (mean of 7.66 vs 0.40 mm; P = .044). According to receiver operating characteristic analyses, the cut-off point for the length of right bile duct to right posterior bile duct from the hepatic confluence was 9.5 mm regarding presence of complications. Factors influencing bile duct anastomosis leakage were supraportal-type donor bile duct anatomy and length of the right main bile duct from biliary confluence. Hepatic arterial complications were similarly a risk factor for biliary strictures. Because of the multiple factors leading to complications in living donor liver transplant, it is challenging to group these patients by operative risk; however, establishing risk models may facilitate the prediction of complications.