Bile Duct Repair Research Articles

Causes of Reintervention of Biliary-Digestive Derivation at UMAE HE 71 from 2015 to 2020

Objective: Describe the causes of biliodigestive bypass reoperation in our center. Material and methods. Retrospective, descriptive and observational study. Results. A total of 64 records were reviewed. 53.1% of the patients underwent reintervention after biliodigestive bypass surgery, in some cases on more than one occasion to the same patient, thus making a total of 61 biliodigestive bypass reintervention surgeries. in unity. The most frequent causes for reintervention were stenosis with a frequency of 70.4%, lithiasis 22.9%, anastomotic dehiscence 4.9% and bilioma 1.6%. In patients who had a diagnosis of stenosis in their first reoperation, it was associated with subsequent reinterventions being for the same diagnosis, with a value of p = 0.087. Conclusions. Any attempt at bile duct repair by inexperienced surgeons or in non-specialized centers should be avoided, in addition to early referral of patients. Avoid instrumentation before bile duct reconstruction due to its possible complications. The surgical technique of hepaticojejunostomy is essential for reducing postoperative complications and better long-term results.

Application of three-dimensional visualization technology in early surgical repair of bile duct injury during laparoscopic cholecystectomy

ObjectiveThis study aimed to explore the application value of three-dimensional (3D) visualization technology in the early surgical repair of bile duct injury during laparoscopic cholecystectomy (LC).MethodsA retrospective analysis was conducted on the clinical data of 15 patients who underwent early surgical repair of bile duct injury during LC with the assistance of 3D visualization technology at the Hepatobiliary Surgery Department of Ningxia Hui Autonomous Region People’s Hospital from January 2019 to December 2022. Postoperative efficacy and long-term follow-up outcomes were summarized.ResultsBefore the repair surgery, 15 cases of bile duct injury during LC were evaluated using 3D visualization technology according to the Strasberg-Bismuth classification: 2 cases of type C, 4 of type E1, 3 of type E2, 3 of type E3, and 3 of type E4. Intraoperative findings were consistent with the 3D visualization reconstruction results, and all patients successfully underwent hepaticojejunostomy using Roux-en-Y anastomosis guided by the 3D visualization navigation. The time interval between LC and bile duct repair surgery ranged from 5 to 28 (14.2 ± 9.7) days. The surgical time was between 120 and 190 (156.40 ± 23.92) min, and estimated blood loss ranged from 80 to 250 (119.66 ± 47.60) mL. The length of hospital stay ranged from 12 to 25 days (median: 16 days). One patient experienced mild bile leakage after the operation, which healed with conservative treatment. All patients were followed up for 12–56 months (median: 34 months) without any loss to follow-up. During the follow-up period, no complications, such as anastomotic stricture or stone formation, were observed.ConclusionThe application of 3D visualization technology for preoperative evaluation and intraoperative navigation can accurately and effectively facilitate early surgical repair of bile duct injury during LC and has clinical value for promotion and application.

Four-Year Report of Iatrogenic Bile Duct Injury Repair from a Referral Hepatobiliary Center.

Iatrogenic bile duct injury (BDI) is one of the most common complications that challenge surgeons performing laparoscopic cholecystectomy (LC). As the number of LC surgeries increases, a pattern of BDI is emerging, but little is known about this matter. The purpose of this study was to assess the pattern of post-LC BDIs directed in a referral center in Iran. Post-BDI patients referred to a hepatobiliary center were studied. Demographic data, clinical status, diagnostic examinations, referral time, post-referral management, and morbidity were analyzed. Nine out of 68 patients had Charcot's cholangitis triad featuring right upper quadrant abdominal pain, fever, and icter. Fever, icter, and itching were the most frequent symptoms. Increased bilirubin, leukocytosis, and abnormal liver function test (LFT) were the most common laboratory abnormalities. 30 patients experienced hepatic artery injury. Out of them, six patients experienced hepatectomy due to hepatic ischemia. Two patients were re-admitted and re-operated, and four patients died. Early and correct treatment by a hepatobiliary surgeon experienced in the management of these types of injuries prevents further complications in patients suffering from iatrogenic BDI. Postoperative complications of bile duct repair, such as anastomosis stricture, are possible; thus, patients need long-term and thorough postoperative observation.

Timely cholecystectomy: important factors to improve guideline adherence and patient treatment

ObjectiveCholecystectomy is one of the most frequently performed surgeries in Germany and is performed as a treatment of acute cholecystitis (guideline S3 IIIB.8) and after endoscopic retrograde cholangiopancreatography for choledocholithiasis...

New advances of NG2-expressing cell subset in marrow mesenchymal stem cells as novel therapeutic tools for liver fibrosis/cirrhosis

BackgroundBone marrow-derived mesenchymal stem cell (BMMSC)-based therapy has become a major focus for treating liver fibrosis/cirrhosis. However, although these cell therapies promote the treatment of this disease, the heterogeneity of BMMSCs, which causes insufficient efficacy during clinical trials, has not been addressed. In this study, we describe a novel Percoll–Plate–Wait procedure (PPWP) for the isolation of an active cell subset from BMMSC cultures that was characterized by the expression of neuroglial antigen 2 (NG2/BMMSCs).MethodsBy using the key method of PPWP and other classical biological techniques we compared NG2/BMMSCs with parental BMMSCs in biological and functional characteristics within a well-defined diethylnitrosamine (DEN)-induced liver fibrosis/cirrhosis injury male C57BL/6 mouse model also in a culture system. Of note, the pathological alterations in the model is quite similar to humans’.ResultsThe NG2/BMMSCs revealed more advantages compared to parentalBMMSCs. They exhibited greater proliferation potential than parental BMMSCs, as indicated by Ki-67 immunofluorescence (IF) staining. Moreover, higher expression of SSEA-3 (a marker specific for embryonic stem cells) was detected in NG2/BMMSCs than in parental BMMSCs, which suggested that the “stemness” of NG2/BMMSCs was greater than that of parental BMMSCs. In vivo studies revealed that an injection of NG2/BMMSCs into mice with ongoing DEN-induced liver fibrotic/cirrhotic injury enhanced repair and functional recovery to a greater extent than in mice treated with parental BMMSCs. These effects were associated with the ability of NG2/BMMSCs to differentiate into bile duct cells (BDCs). In particular, we discovered for the first time that NG2/BMMSCs exhibit unique characteristics that differ from those of parental BMMSCs in terms of producing liver sinusoidal endothelial cells (LSECs) to reconstruct injured blood vessels and sinusoidal structures in the diseased livers, which are important for initiating hepatocyte regeneration. This unique potential may also suggest that NG2/BMMSCs could be an novel off-liver progenitor of LSECs. Ex vivo studies revealed that the NG2/BMMSCs exhibited a similar trend to that of their in vivo in terms of functional differentiation responding to the DEN-diseased injured liver cues. Additionally, the obvious core role of NG2/BMMSCs in supporting the functions of BMMSCs in bile duct repair and BDC-mediated hepatocyte regeneration might also be a novel finding.ConclusionsOverall, the PPWP-isolated NG2/BMMSCs could be a novel effective cell subset with increased purity to serve as a new therapeutic tool for enhancing treatment efficacy of BMMSCs and special seed cell source (BDCs, LSECs) also for bioliver engineering.

Recombinant collagen coating 3D printed PEGDA hydrogel tube loading with differentiable BMSCs to repair bile duct injury

Bile duct injury presents a significant clinical challenge following hepatobiliary surgery, necessitating advancements in the repair of damaged bile ducts is a persistent issue in biliary surgery. 3D printed tubular scaffolds have emerged as a promising approach for the repair of ductal tissues, yet the development of scaffolds that balance exceptional mechanical properties with biocompatibility remains an ongoing challenge. This study introduces a novel, bio-fabricated bilayer bile duct scaffold using a 3D printing technique. The scaffold comprises an inner layer of polyethylene glycol diacrylate (PEGDA) to provide high mechanical strength, and an outer layer of biocompatible, methacryloylated recombinant collagen type III (rColMA) loaded with basic fibroblast growth factor (bFGF)-encapsulated liposomes (bFGF@Lip). This design enables the controlled release of bFGF, creating an optimal environment for the growth and differentiation of bone marrow mesenchymal stem cells (BMSCs) into cholangiocyte-like cells. These cells are instrumental in the regeneration of bile duct tissues, evidenced by the pronounced expression of cholangiocyte differentiation markers CK19 and CFTR. The PEGDA//rColMA/bFGF@Lip bilayer bile duct scaffold can well simulate the bile duct structure, and the outer rColMA/bFGF@Lip hydrogel can well promote the growth and differentiation of BMSCs into bile duct epithelial cells. In vivo experiments showed that the scaffold did not cause cholestasis in the body. This new in vitro pre-differentiated active 3D printed scaffold provides new ideas for the study of bile duct tissue replacement.

Biliary atresia: insights into mechanisms using a toxic model of the disease including Wnt and Hippo signaling pathways and microtubules.

Mechanisms underlying bile duct injury in biliary atresia (BA) remain unclear and mechanisms of bile duct repair are unknown. This study aimed to explore the roles of microtubule instability and Wnt and Hippo signaling pathways in a biliatresone-induced BA model. Using primary murine neonatal cholangiocytes in both 2D and 3D cultures, and ex-vivo extra hepatic bile ducts (EHBD) which also has peri-cholangiocyte area, we analyzed injury and recovery processes. Injury was induced by the toxin biliatresone and recovery was induced by toxin wash-out. Microtubule stabilizer paclitaxel prevented biliatresone-induced injury, both to cholangiocytes as well as reduced periductal αSMA stain, this process is mediated by decreased glutathione levels. RhoU and Wnt11 (Wnt signaling) and Pard6g and Amotl1 (Hippo signaling) are involved in both injury and recovery processes, with the latter acting upstream to Wnt signaling. Early stages of biliatresone-induced EHBD injury in cholangiocytes and periductal structures are reversible. Wnt and Hippo signaling pathways play crucial roles in injury and recovery, providing insights into BA injury mechanisms and potential recovery avenues. Microtubule stabilization prevents cholangiocyte injury and lumen obstruction in a toxic model of biliary atresia (biliatresone induced). Early stages of biliatresone-induced injury, affecting both cholangiocytes and periductal structures, are reversible. Both Wnt and Hippo signaling pathways play a crucial role in bile duct injury and recovery, with a noted interplay between the two. Understanding mechanisms of cholangiocyte recovery is imperative to unveil potential therapeutic avenues.

In Utero Extrahepatic Bile Duct Damage and Repair: Implications for Biliary Atresia.

Biliary atresia (BA) is a cholangiopathy affecting the extrahepatic bile duct (EHBD) of newborns. The etiology and pathophysiology of BA are not fully understood; however, multiple causes of damage and obstruction of the neonatal EHBD have been identified. Initial damage to the EHBD likely occurs before birth. We discuss how different developmental stages in utero and birth itself could influence the susceptibility of the fetal EHBD to damage and a damaging wound-healing response. We propose that a damage-repair response of the fetal and neonatal EHBD involving redox stress and a program of fetal wound healing could-regardless of the cause of the initial damage-lead to either obstruction and BA or repair of the duct and recovery. This overarching concept should guide future research targeted toward identification of factors that contribute to recovery as opposed to progression of injury and fibrosis. Viewing BA through the lens of an in utero damage-repair response could open up new avenues for research and suggests exciting new therapeutic targets.

Bile Duct Injuries During Urgent Cholecystectomy at a Safety Net Teaching Hospital: Attending Experience and Time of Day May Matter.

Background: Bile duct injury (BDI) is one of the most severe complications during cholecystectomy. Early identification of risk factors for BDI may permit risk reduction strategies and inform patient consent.Objective: This study aimed to define patient, provider, and systemic factors associated with BDI; BDI incidence; and short-term outcomes of BDI after urgent cholecystectomy.Methods: Patients who underwent urgent cholecystectomy for acute cholecystitis were retrospectively screened (2020-2022). All patients who sustained BDI were included without exclusions. Demographics, clinical data, and outcomes were collected and compared with descriptive statistics.Results: During the study period, BDI occurred in 4 (0.5%) of 728 patients who underwent urgent cholecystectomy for acute cholecystitis. Most BDI cases (75%) took place overnight or during the weekend. The attending surgeon was almost exclusively (75%) in their first year of practice. BDI was recognized during index operation in 2 cases (50%). Hepatobiliary surgery performed the bile duct repair in all 4 cases. Two complications occurred (50%). All patients were followed by hepatobiliary surgery in the outpatient setting and returned to their baseline level of function within 2 months of hospital discharge.Conclusion: Most BDI occurred in procedures attended by first-year faculty during after hours cholecystectomies, suggesting a role for increased proctorship in early career attendings in addition to in-hours cholecystectomy for acute cholecystitis. The timely return to baseline function experienced by these patients emphasizes the favorable outcomes associated with early recognition of BDI and involvement of hepatobiliary surgery. Further examination with multicenter evaluation would be beneficial to validate these study findings.

Cholangiocyte organoids for bile duct repair and regeneration

Cholangiocyte organoids for bile duct repair and regeneration

Iterative Bile Duct Repair

Bile duct trauma during laparoscopic cholecystectomy, which is responsible for significant morbidity and mortality, reduces survival and long-term quality of life and may cause legal proceedings. The frequency of occurrence is poorly determined due to the fact that most accidents remain undeclared. The circumstances of the trauma, the serious lesions often accompanied by infectious syndromes, biliary peritonitis responsible for visceral failure (hepatic, renal) and malnutrition are indeed often not mentioned in the operative reports. Iterative repair attempts by the same team at the origin of the trauma increase the lesions and make their management more difficult.

MANAGEMENT OF BILE DUCT INJURY IN A REFERRAL CENTER, 10 YEARS OF EXPERIENCE

Abstract Introduction Bile duct injury represents major morbidity and mortality, and in the last two decades in which laparoscopy cholecystectomy has been universally available several factors associated with bile duct injury have been described: one of them being the surgeon's training and experience in laparoscopic cholecystectomy. Some authors have reported that the training curve stabilizes the risk of bile duct injury from 1.7 to 0.17% by procedure number 50. Given that most surgical residency programs don't have enough experience in laparoscopy, this likely contributes to the development of bile duct injury. Therefore, it is important to elucidate the risk factors for bile duct injury in our country. Methods In a referral center we collected the data from 10 years of experience in bile duct repair for bile duct injury. The clinical records for 83 patients were obtained and analyzed. Results High-quality hepaticojejunostomy was performed in all 117 cases, 89.8% open, 8.5% laparoscopic and 1.7% was converted from laparoscopic to open. In 41% of patients, partial resection of the IV segment was necessary. the main post-operatory complication was surgical site infection in 19.6%, overall mortality was 3.4%. according to McDonald Classification for Group A 56.4%, Group B 28.2%, Group C 10.2%, Group D 5.2%, in long-term follow-up. Conclusions Surprisingly, the open cholecystectomy was the most common procedure associated with bile duct injury in our population. Postoperative injury detection was the most frequent, and the most common injury location was near the confluence. We obtained good long-term results even the type of injuries. The disproportion between training centers and hospitals all around the country may impact these results due to the lack of experience of the young surgeons that have only had training in laparoscopic surgery and the lack of universal laparoscopic availability for emergencies. The patients that suffer from this complication are of middle age, and there is a significant disproportion between males and females, with females being the most affected group. It has an impact on their quality of life. High-quality hepaticojejunostomy with Hepp-couinaud technique provides good long-term results, with no difference between the 1–5 year and the 6–10 year groups. The segment IV hepatectomy represents a good option to access the hilar plate. It is important to continue to expose surgeons during their residencies to open cholecystectomy. Prevention is the cheapest and safest way to decrease the incidence of bile duct injury. The implementation of high-volume centers such as ours is important to bring early and high-quality solutions to problems like these.

Bile duct repair after complete intersection

To determine the training period for imposing hepaticojejunostomy for bile duct repair. Reconstructive surgery on the bile ducts was performed in 53 patients. We analyzed the learning curves based on the incidence of anastomotic leakage after hepaticojejunostomy. The learning curve has a downward nature. The number of anastomotic failures decreases by 2 times after 42 procedures. Surgeon had to perform 39-42 operations to reduce the incidence of this complication. Treatment of patients with iatrogenic intersections of the bile ducts should be provided in appropriate hospitals.

Definition and outcomes of postoperative biliary fistula after bile duct injury repair surgery

Background: Bile duct injury remains constant since the introduction of laparoscopic cholecystectomy. In many instances, the placement of a stent is the treatment of choice. Otherwise, a bilioenteric anastomosis is required. Postoperative biliary fistula is a recognized complication of the procedure. The evolution of the leak is variable, it is quite common in the very early postoperative period, and in most cases no more procedures will be necessary. In some instances, on the contrary the leak persists, often requiring the placement of intrahepatic drains to control the fistula. Perpetuation of the leak is an adverse situation for the final result of the anastomosis, and until now there is no definition that adequately refers the volume of output or number of days needed to become a clinically relevant fistula. The aim of this study is to analyze the frequency, management, and outcome in patients with postoperative biliary fistula according to our definition in a high-volume bile duct repair center.

Establishment of a mouse model for bile duct repair and tissue engineering.

Due to the lack of a suitable model, research on biliary biology is far behind that on other organs. A mouse model of common bile duct (CBD) dilation (BDD) was first established and compared with CBD ligation mice (BDL). Then, in a transplantation experiment, the dilated CBD of recipient BDD mice was injured by making an elliptical incision and repaired by transplanting a bile duct patch from donor BDD mice. Biochemical and histological changes were analyzed and cell proliferation of the bile duct grafts was determined. Slightly dilated and unblocked CBD with a diameter of 2.89±0.76 mm was obtained in BDD mice, while the CBD diameter was 0.51±0.08 mm in the Sham group and 4.71±0.64 mm in the BDL group on day 14 after surgery. The liver damage was very mild in BDD mice compared with BDL mice, proving that the BDD model could be further used for bile duct transplantation. By cross transplanting the bile duct patch from enhanced green fluorescence protein and wild-type BDD mice, it was found that the CBD injury was well repaired and the cells of the bile duct patch were completely replaced by recipient-derived cells at 12 week after the repair operation. α Smooth muscle actin, Ki67 and cytokeratin 19 immunofluorescence staining showed that the proliferation of bile duct epithelial cells and abundant active fibroblasts were found within the bile duct patch during the regeneration process. Therefore, a reliable new mouse model of bile duct injury and repair was successfully established and can be used in the study of biliary repair mechanisms and tissue engineering of biliary ducts.

Pitfalls and promises of bile duct alternatives: A narrative review.

Biliodigestive anastomosis between the extrahepatic bile duct and the intestine for bile duct disease is a gastrointestinal reconstruction that abolishes duodenal papilla function and frequently causes retrograde cholangitis. This chronic inflammation can cause liver dysfunction, liver abscess, and even bile duct cancer. Although research has been conducted for over 100 years to directly repair bile duct defects with alternatives, no bile duct substitute (BDS) has been developed. This narrative review confirms our understanding of why bile duct alternatives have not been developed and explains the clinical applicability of BDSs in the near future. We searched the PubMed electronic database to identify studies conducted to develop BDSs until December 2021 and identified studies in English. Two independent reviewers reviewed studies on large animals with 8 or more cases. Four types of BDSs prevail: Autologous tissue, non-bioabsorbable material, bioabsorbable material, and others (decellularized tissue, 3D-printed structures, etc.). In most studies, BDSs failed due to obstruction of the lumen or stenosis of the anastomosis with the native bile duct. BDS has not been developed primarily because control of bile duct wound healing and regeneration has not been elucidated. A BDS expected to be clinically applied in the near future incorporates a bioabsorbable material that allows for regeneration of the bile duct outside the BDS.

A prospective interventional study to compare T-tube placement and primary closure of common bile duct in patients undergoing choledocholithotomy

Background: Primary closure of common bile duct following choledocholithotomy is now being considered as other possibility to the traditional method. This study is designed to analyse the outcome of primary common bile duct repair in terms of mean operation time, duration of hospital stays and post-operative morbidity. The objective of the study was to assess feasibility of safe primary closure in order to achieve early discharge and define case selection for this purpose.Methods: Study was conducted in Sikkim Manipal institute of medical sciences, gangtok on patients operated between January 2017 and April 2018. Primary closure was performed in 16 patients and choledochotomy with T-tube drainage was performed in 16. The primary endpoints were morbidity, the bile drainage quantity, operative time, post-operative stay, time until return to work and postoperative complications and hospital expenses were recorded for each group.Results: Mean total duration of the surgery was 132.44 minutes in primary closure group while it was 146.31 minutes in T-tube group and this difference of around 14 minutes between two groups was statistically significant. Patients were discharged on the 9th day at average in the primary closure group, while in the T-tube they were discharged on the 13th day on average. This difference was statically significant.Conclusions: Primary choledochorraphy is a safe option in selected patients undergoing choledocholithotomy, provided common bile duct patency and clearance can be confirmed intra-operatively.

Bile Duct Injury and Repair: Case Series from 1989 to 2020

BACKGROUND: The benign lesion of the bile duct is a complication of difficult diagnosis and treatment; which has increased due to the use of laparoscopic cholecystectomy (LC) in the management of cholecystolithiasis. Rates of 0.2 to 0.4% of bile duct injuries have been reported, becoming a significant cause of mortality at the time of repair. METHODS: This is an observational, descriptive study, a retrospective case series, based on primary sources of information. The universe of the study are the patients who underwent surgery for bile duct injury from 1989 to 2020, in a private clinic in the city of Cuenca-Ecuador. RESULTS: In more than 30 years, 24 bile duct injury repairs were performed, which occurred: 6 during conventional surgery and 18 during laparoscopic surgery. 54.2% of the lesions occurred less than two centimeters from the confluence of the hepatic ducts. 58.4% of lesions were repaired with Roux-en-Y anastomosis. Antibiotic therapy and drainage were administered to 100% of the patients; 45.83% of the drains placed were tubular drains. 70.8% of the patients didn´t have complications after the repair procedure; the complications that occurred are: bilioma, fistulas, stenosis, cholangitis. CONCLUSION: In most patients who had bile duct injury, the injury occurred during laparoscopic surgery. The injury was most often located less than two centimeters from the confluence of the hepatic ducts. The most frequently performed repair procedure was the Roux-en-Y anastomosis. The most frequent complication after repair was cholangitis.

C-X-C motif chemokine ligand 1 induced by Hedgehog signaling promotes mouse extrahepatic bile duct repair after acute injury.

In extrahepatic bile duct (EHBD) cholangiopathies, including primary sclerosing cholangitis, a reactive cholangiocyte phenotype is associated with inflammation and epithelial hyperproliferation. The signaling pathways involved in EHBD injury response are poorly understood. In this study, we investigated the role of Hedgehog (HH) signaling and its downstream effectors in controlling biliary proliferation and inflammation after EHBD injury. Using mouse bile duct ligation as an acute EHBD injury model, we used inhibitory paradigms to uncover mechanisms promoting the proliferative response. HH signaling was inhibited genetically in Gli1-/- mice or by treating wild-type mice with LDE225. The role of neutrophils was tested using chemical (SB225002) and biological (lymphocyte antigen 6 complex locus G6D [Ly6G] antibodies) inhibitors of neutrophil recruitment. The cellular response was defined through morphometric quantification of proliferating cells and CD45+ and Ly6G+ immune cell populations. Key signaling component expression was measured and localized to specific EHBD cellular compartments by in situ hybridization, reporter strain analysis, and immunohistochemistry. Epithelial cell proliferation peaked 24 h after EHBD injury, preceded stromal cell proliferation, and was associated with neutrophil influx. Indian HH ligand expression in the biliary epithelium rapidly increased after injury. HH-responding cells and neutrophil chemoattractant C-X-C motif chemokine ligand 1 (CXCL1) expression mapped to EHBD stromal cells. Inhibition of HH signaling blocked CXCL1 induction, diminishing neutrophil recruitment and the biliary proliferative response to injury. Directly targeting neutrophils by inhibition of the CXCL1/C-X-C motif chemokine receptor 2/Ly6G signaling axis also decreased biliary proliferation. HH-regulated CXCL1 orchestrates the early inflammatory response and biliary proliferation after EHBD injury through complex cellular crosstalk.

Setting up a surgical complex gallstone service in a non-HPB unit

Complex gallstone disease is associated with a higher risk of complication during laparoscopic cholecystectomy than biliary colic and simple cholecystitis. It is traditionally managed in a hepatopancreaticobiliary (HPB) unit where there is expertise for common bile duct exploration and repair. We developed a mentorship scheme for a busy upper gastro-intestinal (UGI) unit, with support from a specialist HPB unit to treat complex gallstone disease, to reduce the burden on the HPB unit and enable local treatment of patients. Through the creation of a service level agreement, the specialist HPB unit were commissioned to provide mentorship for two surgeons at a large UGI unit with an interest in providing a complex gallstone service to their local population. Eight sessions of mentored operating were supported, with the provision for additional support if complications occurred. There were 14 patients included in the mentorship phase of the programme from November 2015 to May 2017. Cholecystectomies were performed on patients with previously complex histories, which included: previous cholecystostomy; CBD stones and multiple ERCPs; suspected choledochoduodenal fistula; suspected cholecystoduodenal fistula; suspected Mirrizzi's syndrome; previous significant intra-abdominal operation; and significant medical co-morbidities. There was one post-operative complication requiring a return to theatre, and one minor wound infection associated with the complex gallstone lists. We demonstrated a method to reduce the burden on specialist HPB unit for the operative management of complex gallstone disease and safely implement such a service at large UGI unit with an interest in providing a complex gallstone service.