Previous Biliary Tract Surgery Research Articles

Modern approaches to the diagnosis and treatment of biliary complications after liver transplantation (literature review)

Relevance. The choice of biliary anastomosis is the main factor determining the risk of developing biliary complications after orthotopic liver transplantation. The two most common forms of biliary tract reconstruction are choledocholedochostomy (duct-to-duct anastomosis) and choledochoeunostomy (connection of the bile duct to the jejunum). The choice of biliary tract reconstruction is determined by a variety of factors, including the underlying pathology of the liver, the size of the bile ducts of the donor and recipient, previous transplantation or previous biliary tract surgery, as well as the preferences of the surgeon performing the operation. Despite the correctly chosen method of reconstruction, complications such as strictures, lithiasis, biloma, and bile leakage occur infrequently.Objective: to present a review of the literature on methods of diagnosis and treatment of biliary complications after liver transplantation.Materials and methods. The analysis of literary sources in English and Russian from 2010 to 2023 on this topic in the databases PubMed, MEDLINE, Google Scholar was carried out. The review highlights clinical studies, as well as literature reviews on similar topics with an emphasis on the treatment and diagnosis of biliary complications.Conclusion. The problem of biliary complications of liver transplantation remains relevant and unresolved to the end. Noninvasive imaging techniques for complications arising after biliary tract surgery have prospects for development. The tactics of percutaneous, endoscopic and open interventions on the biliary graft tree require further improvement.

Prevalence of surgical site infection among bile spillage and non-spillage patients undergoing laparoscopic cholecystectomy: A cross-sectional study

Introduction: Laparoscopic cholecystectomy, a common procedure is not without complications, and bile spillage can cause surgical site infection (SSI). There is no local evidence in our hospital setting.
 Objective: The objective of this study was to find the prevalence of surgical site infection among bile spillage and non-spillage patients following laparoscopic cholecystectomy at BMCTH
 Methodology: A hospital-based cross-sectional study was conducted from 25 February 2021 to 25 August 2021 at the surgery department of BMCTH. We enrolled 120 patients through the total enumeration technique who underwent laparoscopic cholecystectomy. We enrolled all the eligible study participants who were more than 18 years excluding patients having age >75 years, acute calculous cholecystitis, evidence of cholangitis and/or obstructive jaundice, previous biliary tract surgery, or previous Endoscopic retrograde cholangiopancreatography, evidence of uncontrolled diabetes mellitus and patients taking immunosuppressive drugs and immunosuppressed conditions like HIV/AIDS. The surgical site infection was assessed on the 7th postoperative day.
 Results: Among 120 patients undergoing laparoscopic cholecystectomy, the majority were female 92(76.7%) and 40-50 years age group 65(54.2%). Bile spillage was found in 27(22.5%) and non-spillage in 93(77.5%). The prevalence of surgical site infection (SSI) was found to be 7.5% which was more in the bile spillage group 25.9% than the non-spillage group 2.2%. The odds of having SSI among the spillage group was 15.9 times more than the non-spillage group and was statistically significant (p <0.05). The pus culture of SSI found the predominant organism as Staphylococcus aureus 6(66.7%) followed by Escherichia coli 3(33.3%). The common indications of laparoscopic cholecystectomy were symptomatic cholelithiasis 95(79.1%) followed by chronic calculus cholecystitis 15(12.5%), gall bladder polyp 8(6.7%) and gall stone pancreatitis 2(1.7%).
 Conclusion: More than two and almost one out of ten had bile spillage and surgical site infection (SSI) respectively. A significantly higher number of SSI among the spillage group should be a concern of surgeons. We need to be extra careful with the spillage group for surgical site infection.

Laparoscopic common bile duct exploration in patients with previous abdominal biliary tract operations

BackgroundA history of abdominal biliary tract surgery has been identified as a relative contraindication for laparoscopic common bile duct exploration (LCBDE), and there are very few reports about laparoscopic procedures in patients with a history of abdominal biliary tract surgery.MethodsWe retrospectively reviewed the clinical outcomes of 227 consecutive patients with previous abdominal biliary tract operations at our institution between December 2013 and June 2019. A total of 110 consecutive patients underwent LCBDE, and 117 consecutive patients underwent open common bile duct exploration (OCBDE). Patient demographics and perioperative variables were compared between the two groups.ResultsThe LCBDE group performed significantly better than the OCBDE group with respect to estimated blood loss [30 (5–700) vs. 50 (10–1800) ml; p = 0.041], remnant common bile duct (CBD) stones (17 vs. 28%; p = 0.050), postoperative hospital stay [7 (3–78) vs. 8.5 (4.5–74) days; p = 0.041], and time to oral intake [2.5 (1–7) vs. 3 (2–24) days; p = 0.015]. There were no significant differences in the operation time [170 (60–480) vs. 180 (41–330) minutes; p = 0.067]. A total of 19 patients (17%) in the LCBDE group were converted to open surgery. According to Clavien’s classification of complications, the LCBDE group had significantly fewer postoperative complications than the OCBDE group (40 vs. 57; p = 0.045). There was no mortality in either group. Multiple previous operations (≥ 2 times), a history of open surgery, and previous biliary tract surgery (including bile duct or gallbladder + bile duct other than cholecystectomy alone) were risk factors for postoperative adhesion (p = 0.000, p = 0.000, and p = 0.000, respectively).ConclusionLCBDE is ultimately the least invasive, safest, and the most effective treatment option for patients with previous abdominal biliary tract operations and is especially suitable for those with a history of cholecystectomy, few previous operations (< 2 times), or a history of laparoscopic surgery.

Ascariasis, the uncommon cause of bile leak, postliving donor liver transplant - A case report

Ascaris lumbricoides is one of the most common parasitic infections in developing countries. History of previous biliary tract surgery risks migration of these worms to the biliary tree. Usually, 10% of patients with living donor liver transplants have biliary complications including bile leak and strictures. Here, we present an unusual case of ascariasis being a cause of biliary obstruction and bile leak in the immediate postoperative period of liver transplant.

Left liver anatomical resection via the left vertical groove and intraoperative antegrade cholangioscopy in patients with left-sided hepatolithiasis and previous biliary tract surgery.

ObjectiveThis study aimed to assess the safety and efficacy of left liver anatomical resection via the left vertical groove following intraoperative antegrade cholangioscopy (biliary exploration through the left hepatic duct orifice) in patients with left-sided hepatolithiasis (LSH) and previous biliary tract surgery.MethodsBetween January 2012 and January 2016, eligible patients with LSH (n = 28) who underwent left liver anatomical resection via the left vertical groove followed by intraoperative antegrade cholangioscopy, were referred to our hospital. Clinical results, such as the overall operative time, length of hospital stay, intraoperative complications, residual stones and postoperative bile leaks, were recorded and analyzed.ResultsNo residual stones and bile leakage occurred in the patients. No patients experienced intraoperative complications or T-tube placement. The mean operative time was 135.1 ± 18.9 minutes. The mean postoperative duration of hospitalization was 7.8 ± 1.8 days.ConclusionsLeft liver anatomical resection via the left vertical groove combined with intraoperative antegrade cholangioscopy is a safe and useful method for patients with LSH and previous biliary tract surgery. This technique simplifies the operative procedure by avoiding dissection of the porta hepatis and subsequent choledochotomy.

Risk factors for recurrence of common bile duct stones after endoscopic biliary sphincterotomy.

ObjectiveLate complications after endoscopic biliary sphincterotomy (EST) include stone recurrence, but no definite risk factors for recurrence have been established. This study was performed to identify the predictors of recurrence and evaluate the clinical outcomes of EST for common bile duct stones.MethodsIn total, 345 eligible patients who successfully underwent EST were evaluated and followed up. Statistical analysis was performed on patients with recurrence or who had undergone at least 6 months of reliable follow-up to detect the risk factors for recurrence.ResultsA total of 57 patients (16.52%) developed recurrence of common bile duct stones. The median length of time until recurrence was 10.25 months (range, 6–54.4 months). Univariate analyses showed that the following factors were associated with recurrence: cholecystectomy prior to EST, prior biliary tract surgery, periampullary diverticulum, diameter of the common bile duct (>15 vs. ≤15 mm), quantity of stones, complete stone removal at the first session, and lithotripsy. Multivariate analysis identified two independent risk factors for recurrence: previous biliary tract surgery and lithotripsy.ConclusionsEST for common bile duct stones is safe as indicated by patients’ long-term outcomes. Patients with a history of biliary surgery or lithotripsy are more prone to recurrence.

Preliminary study of a new pathological evolution-based clinical hepatolithiasis classification.

To investigate clinical features, treatment strategies and outcomes of patients with hepatolithiasis (HL) undergoing surgical treatment, using a new clinical classification. Sixty-eight HL patients were hospitalized and treated surgically from August 2011 to December 2012 and they were classified into four HL types according to pathological evolution of the disease. These four HL types included type I primary type (defined as no previous biliary tract surgery), type II inflammatory type (with previous biliary tract surgery and cholangitis), type III mass-forming type (HL complicated by hepatic mass-forming lesion), and type IV terminal type (with secondary biliary cirrhosis and resultant portal hypertension). The perioperative data including general information, imaging data, postoperative complications, and immediate and final stone clearance rate were obtained and analyzed. In all 68 patients, the proportion of HL type I-IV was 50% (34/68), 36.8% (25/68), 10.3% (7/68) and 2.8% (2/68), respectively. Abdominal pain was the main clinical manifestation in type I (88.2%), fever was predominant in type II (52.0%), the malignancy rate in type III was high (71.4%), and portal hypertension and spleen enlargement were common in type IV (2/2, 100.0%). Liver resection rate for types I-III was 79.4%, 72.0% and 71.4%, respectively. The overall incidence of postoperative complications was 23.5% (16/68). There were no perioperative deaths. The average length of hospital stay was 12.7±7.3 d. Immediate and final stone clearance rate was 73.5% (50/68) and 89.7% (61/68), respectively. Fifty-nine of 68 patients (86.8%) were followed- up for >1 year after surgery, and 96.6% of these patients (57/59) had a good quality of life according to a criterion recommended for postoperative evaluation of quality of life. The pathological evolution-based clinical classification of HL has a role in optimizing treatment strategy, and patients can benefit from this classification when it is used properly.

Cholangiocarcinoma in USA- versus Asian-born Asians: Is viral hepatitis a factor?

Aim: Though liver and biliary tract cancers are more common in Asian countries they are increasing in incidence in the USA. This study attempted to clarify the risk factor profile for immigrant Asians compared with the USA population. Methods: A retrospective review was made of 128 cholangiocarcinoma cases presenting to a tertiary referral center from 1996–2007. Data were collected on patient characteristics, risk factors, tumor characteristics, treatment and survival. We then compared Asian immigrants (n = 40) to USA-born Asians (n = 46). Results: In our cohort, the mean age was 66.7 years, of whom 54% were men, 51% had cholelithiasis, 51% were smokers, 41% used alcohol, 10% had hepatitis C and 27% had hepatitis B. In four patients, one each had sclerosing cholangitis, liver flukes, choledochal cyst and previous biliary tract surgery. The distribution of tumors was as follows: 43 intrahepatic (ICC) and 85 extrahepatic cholangiocarcinoma (ECC) including 43 proximal, nine middle and 33 distal tumors. Immigrants were more likely to be younger (mean age 63 vs 70 years old) and to have ICC than ECC (50% vs 26%) and hepatitis B (46% vs 14%). There was no significant difference between groups in hepatitis C, smoking, alcohol, cholelithasis, resectability or survival. Conclusion: Traditionally described risk factors for cholangiocarcinoma are not as evident in this largely Asian cohort. Asian immigrants were more likely to have ICC and have hepatitis B though whether hepatitis B is directly carcinogenic to the biliary tract is not clear. Immigrant status did not seem to have an effect on outcome from cholangiocarcinoma.

4633 Endoscopic sphincterotomy for common bile duct stones: long-term follow-up and risk analysis for recurrence.

Background. Since its introduction in 1974 ES has become the treatment of choice for CBDS in cholecystectomized and elderly patients unfit for surgery.With further experience, ES has been widely applied also in young and fit patients. Recently, three significant factors for late complications after ES for CBDS were identified (Pereira-Lima 1998): 1) peripapillary diverticulum (recurrence of CBDS); 2) gallbladder in situ (recurrence of biliary symptoms); 3) common bile duct (CBD) diameter ≥ 15 mm (recurrence of CBDS and/or biliary symptoms). Aim of this study was to evaluate the long-term clinical outcome of ES for CBDS, and identify patients at risk for recurrence in a selected group with a follow-up of at least 5-years. Materials and methods. 529 patients (296 females, 233 males, mean age 62 years range 9-88) that underwent successful ES+CBDS extraction between april 1983 and december 1993 were included in the study. Followup data were obtained from our patient records, by mail, telephone call, interview, or ERCP when indicated. The following parameters have been included in statistical analyses: sex, age, gallbladder status, previous biliary tract surgery, prior gastrectomy, clinical presentation, ES-related complications, precut, stone size, number of stones, CBD diameter, duodenal diverticulum, infundibular fistula and liver function tests. Asymptomatic patients with follow-up

Follow-up after Liver Transplantation for Primary Sclerosing Cholangitis: Effects on Survival, Quality of Life, and Colitis

Background: Except for primary biliary cirrhosis, primary sclerosing cholangitis (PSC) is now the commonest indication for liver transplantation in Sweden. There are several specific problems related to post-transplantation life in these patients. Methods: We analyzed a 10-year cohort of 47 patients transplanted at our center. Results: Incidental biliary carcinoma was diagnosed in 13%, with a 2-year survival of only 17%, compared with 70% in the other patients. The 2-year survival has improved considerably (to 82%) in recent years. Quality of life was much or slightly improved in 80%. The colitis was much or slightly improved in 65%, with some deterioration in only 6%. No patient developed colonic carcinoma. Previous biliary tract surgery was identified as a risk factor for a worse 1-year mortality. Conclusions: Liver transplantation for PSC is now associated with a high survival rate and an improvement in the quality of life and course of ulcerative colitis. Previous biliary tract surgery is a risk factor for non-survival.

Orthotopic liver transplantation for primary sclerosing cholangitis. A 12-year single center experience.

The purpose of this study was to analyze a single center's 12-year experience with 127 orthotopic liver transplantations (OLT) for primary sclerosing cholangitis (PSC). Primary sclerosing cholangitis is a chronic cholestatic liver disease of unknown origin that occurs most commonly in young men and is associated frequently (70-80%) with inflammatory bowel disease (IBD). Patients with PSC also are at risk for the development of cholangiocarcinoma (CCA) and those with IBD for colon carcinoma. Although the course of PSC is variable, it frequently is progressive, leading to cirrhosis and requirement for OLT. The medical records of 127 consecutive patients undergoing OLT for PSC from July 1, 1984, to May 30, 1996, were reviewed. Actuarial patient and graft survival was determined at 1,2, and 5 years. The incidence and outcome of patients with CCA, recurrent sclerosing cholangitis, and post-transplant colon carcinoma was determined. Results were analyzed by way of stepwise Cox regression to determine the statistical strength of independent associations between pretransplant covariates and patient survival. The median follow-up period was 3.01 years. Incidental cholangiocarcinoma (ICCA) was defined as a tumor < 1 cm in size that was discovered at the time of pathologic sectioning of the explanted liver. Ninety-two patients (72%) had associated IBD. Seventy-nine (62%) had undergone previous biliary tract surgery. One hundred seven patients (84%) received a single graft, whereas 20 patients (16%) required 22 retransplants. Patients received either cyclosporine- (n = 76) or tacrolimus- (n = 51) based immunosuppression. The 1-, 2-, and 5-year actuarial patient survivals were 90%, 86%, and 85%, respectively, whereas graft survival was 82%, 77%, and 72%, respectively. The presence of previous biliary surgery had no effect on patient survival. Ten patients (8%) had ICCA and their survival was not significantly different from patients without ICCA (100%, 83%, and 83% at 1, 2, and 5 years, respectively). Four patients were known to have CCA at the time of OLT, all recurred within 6 months, and had a significantly worse outcome (p < 0.0001). Recurrent sclerosing cholangitis developed in 11 patients (8.6%). The patient and graft survival in this group was not different from those in whom recurrence did not develop (patient; 100%, 90%, and 90%; graft: 80%, 70%, and 52%). Thirty patients (23%) underwent colectomy after liver transplantation for dysplasia-carcinoma or symptomatic colitis. Of the nine covariates entered into the Cox multivariate regression analysis, only common bile duct frozen section biopsy specimen showing CCA was predictive of a survival disadvantage. Liver transplantation provides excellent patient and graft survival rates for patients affected with PSC independent of pretransplant biliary tract surgery. Incidental cholangiocarcinoma does not affect patient survival significantly. However, known CCA or common duct frozen section biopsy specimen or both showing CCA are associated with poor recipient survival, and OLT should be proscribed in these cases. Recurrent PSC occurs in approximately 9% of cases but does not affect patient survival. Post-transplant colectomy does not affect patient survival adversely.

Spontaneous Perforation of the Common Duct

Rupture of the extrahepatic bile ducts should be considered in the differential diagnosis of bile peritonitis. The following entities have been incriminated in bile duct perforation: (1) previous biliary tract surgery^3,6,7,14,16; (2) abdominal trauma^1,10,12,15; (3) vascular insufficiency with necrosis of the duct wall⁹; (4) choledochal diverticulum²; (5) erosion by tumor⁷; (6) acute pancreatitis.^10,17There is a further group of patients in whom the cause of perforation is unknown. This idiopathic group has been reported most frequently in early infancy and beyond middle age.^8,11,13 At the Philadelphia General Hospital we have recently seen two patients with bile peritonitis due to spontaneous perforation of the common bile duct. <h3>Report of Cases</h3><h3>Case 1.</h3> —A 55-year-old Negro was admitted Nov. 7, 1956, from a local prison with abdominal "fullness" of three weeks' duration. He had lost 40 lb. during the preceding six months. There was associated

Late postcholecystectomy rupture of the common bile duct.

A review of the literature suggests that bile peritonitis may be caused by one of three types of perforation of the common bile duct: so-called spontaneous perforation of the common bile duct occurring without history of abdominal trauma, previous biliary tract surgery, or obstructing stones; late rupture of the extrahepatic ducts subsequent to cholecystectomy, and traumatic rupture of the common bile duct. The last condition occurs very infrequently and is usually fatal because of concomitant injuries to the liver, pancreas, spleen, and intestinal tract. 1 Infrequent reports suggest the rarity of each condition. Report of a Case A man aged 61 was admitted for the first time to the Presbyterian Hospital, Chicago, at midnight on Feb. 15, 1955, complaining of acute epigastric pain of 13 hours' duration. He had awakened early in the morning with a severe cramping abdominal pain. He vomited clear fluid throughout the day. The past history

Surgery of the biliary tract.

Stenosis of the Sphincter of Oddi The validity of the concept that stenosis of the sphincter of Oddi contributes to biliary-tract symptoms is gradually gaining support. It is being recognized with increasing frequency as a pathologic fact both at the time of initial cholecystectomy and as a cause of continued or recurrent symptoms in some patients after cholecystectomy. Cumulative experiences from several sources indicate that stenosis of the sphincter of Oddi may occur in the absence of any demonstrable common-duct stones and in patients who have not had previous biliary-tract surgery. The importance of evaluating the status of the patency . . .

Radiation Therapy of Acute Pancreatitis

It has long been recognized that surgical parotitis responds favorably to radiation treatment. The hope that a similar favorable response might be obtained in cases of acute pancreatitis led to a trial of this agent at the Los Angeles County Hospital. A total of 28 patients were treated from 1941 to 1948, the majority in 1945 and 1946. The cases were unselected, any patient referred with a reasonably substantiated diagnosis being accepted for treatment. A number of these cases were included in the excellent paper of Paxton and Payne, who also described the laboratory methods in use at this hospital in establishing a diagnosis of acute pancreatitis. Survey of Patients Treated by Irradiation Age range was from twenty-four to sixty-eight years. Diastatic activity of the serum ranged from normal (80 to 150) to 4,500. The urinary diastase ranged from normal (less than 1,000) to 37,250. Among the few patients with normal serum amylase, the lowest urinary diastase level was at least four times normal. The temperature range was from normal to 102.4° F. Only 6 patients had a fever of 101° or higher during the course of their disease. Alcoholism, usually of high degree, was present in 11 of the 28 patients. Three patients had delirium tremens during their hospital stay. Gallbladder disease was found in 10 of the 28 patients. Another 3 had had previous biliary tract surgery. Surgery: Two of the patients were submitted to immediate surgery. One of these had an exploratory laparotomy, which confirmed the preoperative diagnosis of acute pancreatitis (and excluded a suspected concomitant perforated peptic ulcer); in the other patient immediate cholecystostomy was done, with removal of gallstones. Seven of the patients underwent delayed surgical procedures (after subsidence of the acute episode). Recurrences: Eight patients had more than one episode of acute pancreatitis managed at this hospital. Of this number, 6 had two bouts of disease; 1 had three; and 1, four. Sequelae and Complications Pancreatic cysts requiring surgical treatment developed in 2 of the 28 patients. Diabetes of moderate severity developed in one patient after three episodes of acute pancreatitis. Multiple gastro-intestinal fistulae with massive gastro-intestinal hemorrhage were found in one patient, who died. In 3 patients pneumonia developed during their hospital stay. Two patients had glaucoma; one of these had an acute exacerbation while receiving atropine. Treatment Data 1. Twenty-eight patients were treated; 2 received a second course for recurrent disease. Thus 30 episodes of the disease were treated (in 28 patients). 2. Of the 30 courses of treatment, 22 were given at 140 kv., with 0.25 mm. Cu filtration (plus 1.0 mm. Al inherent), 5 ma., 20 cm. target-skin distance, half-value layer 0.46 mm. Cu. Seven cases were treated at 200 kv., 4 with 0.25 mm. Cu filter added, and 3 with 0.5 mm. Cu. Other factors were: target-skin distance 52.1 cm. and 20 ma.