Single Bile Duct Research Articles

A novel approach of intraoperative cholangiography in laparoscopic left lateral sectionectomy in living donor liver transplantation.

Accurate division of bile duct during laparoscopic donor hepatectomy in living donor liver transplantation is essential. We here present a novel approach to achieve cholangiography via the bile duct stump of segment IV (B4 stump) during laparoscopic donor hepatectomy in adult-to-pediatric living donor liver transplantation. Donors who underwent laparoscopic left lateral sectionectomy (LLLS) from January 2022 to April 2022 in our liver transplant center were retrospectively analyzed. A total of 32 donors were eventually enrolled into this study. Cholangiography via the B4 stump was performed in 11 donors (B4 group) while indocyanine green (ICG) fluorescence guiding was performed in 21 donors (ICG group). Perioperative data were collected and compared between groups. Cholangiography by catheterizing the B4 stump was successfully performed in all 11 donors in the B4 group. The mean time of this procedure was 12.82 ± 9.11min. Compared to the ICG group, it was more likely to acquire single bile duct orifice on graft in the B4 group (B4: 10/11, 90.91% vs ICG: 9/21, 42.86%) and it was significantly different (p = 0.030). The donors' complications (Clavien-Dindo grade III-IV) were not significantly different. There was one donor developed intraperitoneal effusion in B4 group, while two donors (one bile leakage and one biliary stricture) developed biliary tract related complications in the ICG group. A Roux-en-Y was performed to solve the biliary stricture in the ICG group. The recipients' outcomes were not significantly different between groups. Cholangiography via the B4 stump catheterization is feasible and safe in identifying the bifurcation of bile duct during LLLS.

Is More Always Better? A Randomised Clinical Trial of One versus Two Bile Duct Flushes during Donor Procurement of Livers

Introduction: Biliary strictures cause significant morbidity after liver transplantation and are thought to be due to bile salt mediated injury occurring at the time of organ procurement. A single bile duct flush is commonly performed after donor hepatectomy to clear any residual bile salts, however, an additional bile duct flush performed during organ procurement may further reduce bile duct injury. This study investigated whether an additional and earlier bile duct flush can reduce bile duct injury and biliary strictures after liver transplantation.

Bile duct anatomical variations: Relevance for liver division and preparing left split liver grafts for pediatric transplantation: Cohort study

Backgroundliver lateral section graft is the most common graft type used for transplantation in children worldwide. Compared to whole liver grafts, a higher rate of biliary complications has been described. Historically, 2 techniques have been described for transection of liver - trans-hilar or trans-umbilical parenchymal transection. Though these techniques allow dividing the biliary system at two distinct positions, the usual surgical strategies do not take advantage of this advantage. Material and methodsA retrospective study was conducted on 40 candidates who volunteered for donation of their left lateral liver section for transplantation, between October 2017 and April 2019. Preoperative imaging was analyzed to depict the arterial and biliary anatomy of the liver and their variations, with a dedicated attention to the left liver (segments 2, 3 and 4). Anatomy of the biliary system was taken into account for defining the optimal surgical strategy - either through a trans-hilar or a trans-umbilical parenchymal transection. ResultsIn 26/40 patients, arterial or biliary variations were much relevant for decision-making on the optimal plane of liver division (trans-umbilical (N = 14) and trans-hilar (N = 26)). This resulted in 23 grafts with a single artery and bile duct, 6 grafts with double arteries and a single bile duct, and 9 grafts with double bile ducts and a single artery; only two grafts had complex anatomy. There was no arterial complication and the overall incidence of biliary problems was 14.7%. All grafts are functioning well at a mean follow-up of 19.6 ± 8.5 months. ConclusionsAnatomical variations are frequent and their knowledge is relevant for procurement of lateral section liver graft. Knowledge of these variation, or -better- preoperative biliary imaging is helpful in guiding parenchymal transection at procurement and preparing optimal liver grafts.

Management of biliary complications after adult-to-adult living donor liver transplantation. Initial experience in a latin american center

Presenter: Sergio Riveros MD | Pontificia Universidad Católica de Chile Background: Living donor liver transplantation (LDLT) is a complex therapeutic alternative that requires a specialized multidisciplinary team with the capacity to resolve complications. The number of anastomosed ducts has an impact on the rate of postoperative biliary complications, but the literature is still scarce. The objective of this study was to describe early and late postoperative biliary complications with a focus on therapeutic management in the initial experience of a LDLT program. Methods: Non-concurrent cohort study at a Pontificia Universidad Católica de Chile. All patients who underwent adult-to-adult LDLT were included from 2016 to 2020. Patients were divided into two groups according to the number of bile duct anastomoses (single duct, group A; and two or three ducts, group B). Demographic, perioperative, postoperative outcomes regarding early and late biliary complications (>2 months), treatment, major complications (Clavien-Dindo III-IV), mortality, and survival were evaluated and compared between groups. Results: single bile duct was anastomosed in 63.3% (n = 19), two bile ducts in 33.3% (n = 10) and three bile ducts in 3.3% (n = 1). Duct-to-duct (DD) anastomosis was performed in 56.7% (n = 17), hepaticojejunostomy (HJ) in 33.3% (n = 10) and combined in 10% (n = 3). Major complications were reported in 46.7% (n = 14), median length of postoperative stay was 15.5 days (7-46) and median follow-up 17 months (0.4-53.5). Overall graft and patient survival was 87% at 24 months. Group A (n = 19) had major complications in 21% (n = 4), early biliary complications in 15.8% (n = 3) and late biliary strictures in 26.7% (n = 4). None required percutaneous drainage, 5.3% surgical drainage (n = 1) and 10.5% re-anastomosis to a Roux-en-Y HJ (n = 2). They underwent ERCP in 26.7% (n = 4) and percutaneous transhepatic internal-external drainage in 6.7% (n = 1). Four patients (21.1%) had early mortality and one patient (6.7%) late mortality, all unrelated to biliary complications. Group B (n = 11) had major complications in 90.9% (n = 10), early biliary complications in 81.8% (n = 9) and late biliary strictures in 54.5% (n = 6). They required percutaneous drainage in 27.3% (n = 3), surgical drainage in 9.1% (n = 1), endoscopic transgastric drainage in 9.1% (n = 1), duct-to-duct reinforcement (n = 1) and re-anastomosis to Roux-en-Y HJ (n = 4). They underwent ERCP in 27.3% (n = 3) and percutaneous transhepatic internal-external drainage in 18.2% (n = 2). All patients are alive with 100% graft and patient survival. Conclusion: Living donor liver transplantation is a challenging treatment that requires a specialized high-volume center with the ability to rescue postoperative complications. The number of reconstructed ducts affects the rate of early biliary complications, without an impact on graft and patient survival. In our experience, patients with 2-3 graft bile ducts had a high rate of biliary complications, but with adequate management, all patients are alive with functioning grafts. Expertise in advanced endoscopy, interventional radiology, and complex reoperations are crucial to achieve excellent outcomes.

A caudate branch as the anatomical landmark for optimal bile duct division during donor hepatectomy

Introduction: Optimal bile duct division line should prevent multiple orifices on the graft and biliary stricture of donors. Magnetic resonance cholagiopancreatography (MRCP) is used most commonly to assess donor bile ducts preoperatively. We have identified caudate branches arising from hilar bifurcation in MRCP. This study evaluated the feasibility of caudate branches shown in MRCP as anatomic landmark during bile duct division by confirming the location using probing method or operative cholangiogram. Method: From February 2016 to December 2017, 57 patients undergoing donor right hepatectomy were evaluated. Prospective data collection for location of caudate branches on MRCP and identification of corresponding caudate branches during operation was performed. Results of probing method or operative cholangiogram were also collected to confirm the anatomic landmark. Clinical characteristics and postoperative outcomes were evaluated. Result: Clinical characteristics showed that median age was 35 years old (range: 17-57). Preoperative evaluation of MRCP showed that 26 patients (87%) were possible candidates for single bile duct opening in the graft. Median distance from hilar bifurcation to right 2nd order division on MRCP was 8.5 mm (range: 3-16 mm). Operative outcomes showed that 20 patients (67%) showed single graft bile duct, 9 patients (30%) showed two graft bile ducts and 1 patient (3%) showed three graft bile ducts. Caudate branches were identified in 29 patients (97%). Probing method was found to be difficult in 10 patients (33%) and operative cholangiogram was performed to confirm the location of the bile duct division line in correlation with the caudate branches. Postoperative outcome showed that median length of hospital stay was 9 days (range: 7-15 days) and there were three cases (10%) of grade I Clavien-Dindo complications. Conclusion: A caudate branch may be used as the anatomical landmark for optimal bile duct division during donor right hepatectomy.

A Review of Double Common Bile Duct and Its Sequelae.

A double or accessory common bile duct (ACBD) is a rare congenital anomaly. We report the case of a 60-year-old American Asian male, who was found to have a double or duplicated common bile duct after being admitted for evaluation of a pancreatic mass. A duplicated bile duct has the same mucosa histologically as a single bile duct. However, the opening of a duplicated bile duct lacks a sphincter allowing retrograde flow of gut contents which results in a higher probability of intraductal calculus formation. On rare occasions, it can predispose to liver abscesses, pancreatitis, pancreatic cancer, gallbladder cancer, gastric cancer, and ampullary cancer depending on the location of the opening of the ACBD. We present an integrative review of the limited cases of ACBD with correlation to the current case and discussion regarding the aspects of diagnosis and management.

Biliary complications among live donors following live donor liver transplantation

IntroductionIn live donor liver transplantation (LDLT), bile duct division is a critical step in donor hepatectomy. Biliary complications hence are a feared sequelae even among donors. Long term data on biliary complications in donors from India are sparse. MethodsProspective evaluation of 452 live donors over 10 years was performed to ascertain the incidence & risk factors of clinically significant biliary complications. ResultsOf the 452 donor hepatectomies (M: F = 114:338, median age = 38), 66.2% (299) were extended right lobe grafts, 24.1% (109) modified right lobe and 9.7% (44) were left lobe grafts. Portal vein anatomy was Type-I in 85% (386), Type-II in 7.5% (34) and Type-III in 7.1% (32). Following donor hepatectomy, a single bile duct opening occurred only in 46.5% (210) of the grafts. Of the remaining 53.5% grafts, 2 ductal openings were noted in 217 (48%) and three ductal openings in 25 (5.5%). Incidence of multiple openings in the duct were more commonly noted in Type II (70.6%) and III (75%) portal vein anatomy than in grafts with Type I (50.4%) portal anatomy (P = 0.001) Bile leak was noted in 15 (3.3%) donors which included one broncho-biliary fistula and bilio-pleural fistula. Analysis revealed no association between post-operative biliary complications and type of graft, portal vein anatomy or biliary anatomy. There was a single mortality in this series secondary to biliary sepsis. On long term follow, there were no biliary strictures in any of the patients. ConclusionsBiliary complications although rare (3.3%), present significant peri-operative morbidity to the donors.

Double Common Bile Duct: An Uncommon Etiology of Gastrointestinal Cancer

A double or accessory common bile duct (ACBD) is a rare congenital anomaly that arises from disturbances in recanalisation of the hepatic primordium with the accessory bile duct opening into a part of the upper gastrointestinal tract (stomach, duodenum, ductus pancreaticus or septum). A duplicated bile duct has the same mucosa histologically as a single bile duct, however, the opening of a duplicated bile duct lacks a sphincter. This results in a higher probability of calculus formation and retrograde flow of gut contents, predisposing patients to liver abscesses, pancreatitis, pancreatic cancer, gallbladder cancer, gastric cancer, and ampullary cancer depending on the location of the opening of the ACBD. Our patient presented with crampy lower abdominal pain associated with an unintentional 40 pound weight loss over four months. Magnetic resonance imaging (MRI) of the abdomen with intravenous contrast demonstrated a 3.9cm heterogeneous solid pancreatic uncinate mass (see Fig. 1) with partial encasement of the superior mesenteric artery. There was no dilation of pancreatic duct. A type II ACBD (see Fig. 2 and Fig. 3) was also noted. Subsequent endoscopic ultrasound with fine needle aspiration of the uncinate mass demonstrated pathology consistent with pancreatic adenocarcinoma. He was eventually referred to a tertiary level center where he underwent chemoradiation. Treatment options vary depending on the presence of malignancy. In instances without gastric or pancreatic cancer but in the presence of unremitting symptoms, surgical resection of the ACBD is recommended to prevent the flow of bilious and pancreatic juices from creating a nidus of continuous inflammation that can progress to neoplastic changes.Figure: MRI of the abdomen with intravenous contrast showing a 3.9cm heterogeneous solid pancreatic uncinate mass.Figure: Choi classification of types of ACBD.Figure: MRI Abdomen showing type II ACBD.

Immunohistochemical Characterization of the Origins of Metastatic Well-differentiated Neuroendocrine Tumors to the Liver.

Metastatic neoplasms of unknown primary site pose a major challenge to patient management. As targeted therapies are now being tailored to neuroendocrine tumors (NETs) of different primary sites, identifying the origin of metastatic NETs has become increasingly important. Compared with more extensive efforts on metastatic adenocarcinomas of unknown primary, the literature on metastatic NETs (often to the liver) is relatively sparse and most studies are based on primary tumors. We sought to study metastatic well-differentiated NETs to the liver to identify markers that predict the site of origin. Eighty-five metastatic NETs to the liver were retrieved from the pathology archive. The primary sites were determined based on either pathologic review of the primary tumors (in most cases) or radiologic/clinical findings. Immunohistochemical labeling for TTF1, CDX2, ISL1, NKX2.2, and PDX1 was performed on either tissue microarrays or whole sections. The primary sites of the NETs in the study cohort included: pancreas (35%), small intestine (32%), rectum (8%), stomach (2%), bile duct (1%), lung (9%), and unknown primary (12%). We found predominant expression of TTF1 in lung carcinoid (63%), CDX2 in small intestinal (89%) and ISL1 in pancreatic NETs (77%), respectively. NKX2.2 was mainly expressed in NETs of the digestive organs. PDX1 was detected in a small percentage of pancreatic, small intestinal and the single bile duct NET. There was no statistically significant association between tumor grade (World Health Organization G1 vs. G2) and the expression of any of the above markers. The 3-marker panel (TTF1, CDX2, and ISL1) had sensitivities of 81%, 89%, and 63%, specificities of 100%, 94%, and 100%, positive predictive values of 100%, 89%, and 100%, and negative predictive values of 84%, 94%, and 96% in separating metastatic NETs into 3 major primary sites: pancreas/rectum, small intestine, and lung, respectively, with an overall accuracy of 82%. Furthermore, this panel predicted a primary site for 6 of the 10 NETs of unknown primary, which reduced the NETs of unknown primary from 12% to 5%. Thus, through immunohistochemical study of a large series of metastatic NETs to the liver, we have demonstrated the utility of a 3-marker panel for the identification of one or more potential primary sites of most metastatic NETs, which could provide practical guidance in patient management.

Biliary sphincterotomy is not required for bile duct stent placement

The aim of the present study was to assess the success and outcome of bile duct stent placement without the use of endoscopic biliary sphincterotomy (EBS). Over a period of 10 years and 9 months, all patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were prospectively identified. Bile duct stent placement was routinely done without EBS unless additional therapy (stone removal, multiple stenting) was anticipated. Of 5020 patients who underwent ERCP, bile duct stents were placed in 1668 patients. After excluding those requiring additional endoscopic therapy, 1112 patients (89.5%) had ERCP and stent placement without a sphincterotomy and 130 patients (10.5%) had ERCP and stent placement with asphincterotomy. Deployed endoprostheses were self-expandable metallic stents in 15.7% and plastic in 77.5%. Caliber of plastic stents was 10 Fr in 78.9% and <10 Fr in 21.1%. All stents were successfully placed in these 1112 patients without the need for EBS. Comparing patients undergoing bile duct stenting with and without sphincterotomy, no difference was seen in rates of pancreatitis (1.54% vs 2.07%, P > 0.9999). Single bile duct stents, both plastic and metal, can be deployed without EBS.

Is Microsurgical Technique Useful in Biliary Reconstruction of Living Donor Liver Transplantation?

IntroductionBiliary reconstruction remains the “Achilles' heel” of living donor liver transplantation (LDLT). In the last decades, the technical aspects of biliary reconstruction have been debated for their impact on biliary complications in LDLT. A microsurgical technique in biliary reconstruction is more attractive. Patients and methodsFrom December 2010 to June 2011, 15 primary LDLTs underwent duct-to-duct biliary reconstruction using a microscopic technique. External stents were inserted in all patients. All procedures were performed under a microscope by a single transplant microsurgeon. ResultsThe time consumed for bile duct reconstruction using the microscopic technique was 35 minutes. There were 8 grafts with a single bile duct orifice and seven with two orifices. The average duct size was 3 mm in patients with two orifices and 5 mm in those with a single orifice. There was no bile leak or biliary stricture associated with the biliary reconstruction over a median 5-month follow-up. There were two cases of bile leakage from the cut hepatic surface. ConclusionThe microscopic technique reduced early biliary complications. However, further technical advances are needed to decrease the time consumptions for the procedure.

Biliary complications after right lobe living donor liver transplantation: a single-centre experience

BackgroundBiliary complications that developed after right lobe liver transplantation from living donors were studied in a single centre. MethodsFrom 2004 to 2010, 200 consecutive living donor right lobe liver transplantations were performed. The database was evaluated retrospectively. Biliary complications were diagnosed according to clinical, biochemical and radiological tests. The number of biliary ducts in the transplanted graft, the surgical techniques used for anastomosis, biliary strictures and bile leakage rates were analysed. ResultsOf a total of 200 grafts, 117 invloved a single bile duct, 77 had two bile ducts and in six grafts there were three bile ducts. In 166 transplants, the anastomosis was performed as a single duct to duct, in 21 transplants double duct to ducts, in one transplant, three duct to ducts and in 12 transplants as a Roux-en-Y reconstruction. In all, 40 bile leakages (20%) and 17 biliary strictures (8.5%) were observed in 49 patients resulting in a total of 57 biliary complications (28.5%). Seventeen patients were re-operated (12 as a result of bile leakages and five owing to biliary strictures). ConclusionIdentification of more than one biliary orifice in the graft resulted in an increase in the complication rates. In grafts containing multiple orifices, performing multiple duct-to-duct (DD) or Roux-en-Y anastomoses led to a lower number of complications.

A Rare Variation of the Biliary Tree of Relevance to Live Liver Donation

To the Editor: An appreciation of the potential anatomical variations of the vascular and biliary systems is essential for donor safety in the context of live donor hepatectomy (1, 2). We previously reported that variant biliary anatomy was present in a substantial proportion of donors with trifurcated portal veins (2, 3). The present report describes two rare cases of biliary anomaly with an independent bifurcation of a branch of segment 2 (B2) from the anterior or posterior bile duct. A 38-year-old male was admitted to our hospital to serve as a live donor for his sister, who had fulminant cryptogenic hepatic failure. Preoperative three-dimensional computed tomography (CT) of the donor did not demonstrate any anomalies of the portal vein, hepatic vein, or hepatic artery. Based on imaging and volume analysis of the liver, the donor underwent left hepatectomy with the caudate lobe. Intraoperative cholangiography demonstrated that B2 bifurcated independently from a branch of segment 7 (B7) (Figure 1A). Therefore, the left-lobe graft contained two bile duct orifices (B2 and B3). Intraoperative cholangiography confirmed that there was no bile leakage and that there was no biliary stenosis of the posterior branch. (A–C) Intraoperative cholangiography demonstrated that B2 independently bifurcated from B7 (case 1, A) or from the anterior branch (case 2, C). Magnetic resonance cholangiography demonstrated variant biliary anatomy, with B2 independently bifurcating from the anterior branch in case 2 (B). A 48-year-old male was admitted to our hospital to serve as a live donor for his wife, who had end-stage primary biliary cirrhosis. Preoperative three-dimensional CT of the donor demonstrated trifurcation of the portal vein, but there were no anomalies of the hepatic vein or hepatic artery. Magnetic resonance cholangiopancreatography (MRCP) demonstrated biliary anomaly with B2 bifurcating independently from an anterior branch (Figure 1B). Based on preoperative volume analysis, the left-lobe graft volume was considered to be too small for the recipient. Further, use of a right-lobe graft was complicated by the possibility that it possesses more than two bile duct orifices as well as two portal veins (anterior and posterior branches), which would increase the complexity of harvesting and of reconstruction. By contrast, the posterior segment graft had one bile duct orifice and portal vein with sufficient liver volume for the recipient. Therefore, the posterior segment graft was utilized for transplantation. The donor underwent posterior segmentectomy. Preoperative MRCP and intraoperative cholangiography demonstrated that B2 bifurcated from anterior branch (Figure 1C). The posterior segment graft had a single bile duct orifice and a single portal vein as well as a hepatic artery of the posterior branch and a right hepatic vein. Live donor liver transplantation requires careful graft selection to reduce the risk of complications. Biliary anomalies, which are sometimes associated with trifurcation of the portal vein, can complicate graft selection and donor surgery. This is the first report to describe independent B2 bifurcation from the anterior or posterior bile duct in a live donor. In donors with this anomaly, both the right and left-lobe grafts have multiple bile ducts. As illustrated in case 2 from the present report, the posterior graft represents a viable alternative for transplantation, provided graft volume is adequate. Preoperative evaluation of the biliary system has not been routinely utilized in our institution. Since dynamic CT may not detect important biliary variations, preoperative MRCP may be required to accurately characterize biliary anatomy, even in donor candidates without trifurcated portal veins. Based on the cost-benefit of this approach, we now routinely perform preoperative MRCP in all live donors in our institution. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

Sa1487 Biliary Sphincterotomy Is Not Required for Bile Duct Stent Placement

Endoscopic biliary sphincterotomy (EBS) is commonly performed prior to bile duct stent placement. However, bile duct stents can be deployed without EBS thereby minimizing the risk of post sphincterotomy bleeding. Over a 9 year period, all patients undergoing ERCP were prospectively identified. During this period, bile duct stent placement was routinely performed without EBS unless additional therapy (stone removal, multiple stenting) was anticipated. Following the procedure, all patients were followed-up at one and four weeks to assess for complications graded by consensus criteria. During the 105 month study period, 4193 patients underwent ERCP. Excluding patients with prior sphincterotomy or precut and those undergoing EBS for additional endoscopic therapy, bile duct stents were placed in 658 patients (42% female, 75% white, mean age 59 years). The most common indications for ERCP were: 40.3% jaundice, 14.7% pancreatic mass, and 8% bile leak after liver transplantation. Stent size was 80% 10 French, 20% 7 French with 15.1% metal stents). 160 of these patients underwent ERCP for stent exchange. Stents were successfully placed in all patients without the need for EBS. Comparing patients undergoing bile duct stenting with and without sphincterotomy, no difference was seen in rates of pancreatitis (1.31% vs 2.34% p=0.228) but post-sphincterotomy bleeding, generally mild to moderate, was noted in 17 of 1407 patients who did undergo EBS during the study period. Single bile duct stents, both plastic and metal, should be deployed without EBS unless additional endoscopic therapy is required.

Duct-to-Duct Biliary Reconstruction Without a Stent in Pediatric Living-Donor Liver Transplantation

Purpose In pediatric liver transplantation, Roux-en-Y hepaticojejunostomy is often preferred for biliary reconstruction, especially in living-donor liver transplantation (LDLT). Limited numbers of duct-to-duct biliary reconstructions have been presented in pediatric recipients. We retrospectively reviewed our experiences with duct-to-duct biliary reconstruction without a stent in pediatric LDLT recipients. Materials and Methods Since September 2006, 32 LDLTs were performed using a duct-to-duct biliary reconstruction without a stent in 31 children (16 boys and 15 girls; overall mean age, 8.3 ± 5.1 years). We transplanted 19 left lobe grafts, 11 left lateral segments, 1 monosegment, and 1 reduced-size right lobe graft. Twenty-eight grafts had a single bile duct; the remaining 4, two bile ducts. We created a single orifice at the back table for the grafts that had 2 bile ducts. Results Two recipients developed bile leakage in the early postoperative period; 3 bile duct stenoses occurred in the late postoperative period. All biliary complications were successfully treated with interventional radiologic or endoscopic approaches. There was no morbidity and no graft loss owing to biliary complications. During a mean follow-up of 23.5 ± 13.6 months (range, 4–44), 4 children died and the remaining 27 (88%) are doing well with satisfactory liver function. Conclusion Our results showed that duct-to-duct biliary reconstruction without a stent was a safe technique for biliary reconstruction even among pediatric cases.

An updated and simplified method for bile duct cannulation of rats

The single bile duct cannulated rat model was used for short-term intestinal absorption studies. Rats were randomly assigned to three groups: (A) bile duct cannulated, (B) control laparotomy and (C) no treatment. The body weight and health of the rats were monitored before and until day 5 after surgery, while bile flow was measured in group A on day 2. On the fifth day, tail vein blood was harvested, and alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase and total bilirubin were quantified. Analysis of variance showed no significant difference between the groups for these parameters. This study demonstrated the suitability of a surgical rat model feasible for evaluation of the impact of bile in pharmacokinetic studies.

Laparoscopic Exploration of the Common Bile Duct with a Rigid Scope in Patients with Problematic Choledocholithiasis

The development of laparoscopic cholecystectomy as a minimally invasive approach to eliminate gallstones, in conjunction with increasingly sophisticated techniques for removal of common bile duct (CBD) stones by endoscopic sphincterotomy, has revolutionized the treatment of choledocholithiasis. We describe a new technical approach to laparoscopic exploration of the CBD after unsuccessful endoscopic stone extraction. Eleven patients were subjected to laparoscopic exploration of the CBD with choledochotomy using a rigid scope (24-Fr nephroscope) during the last 2 years. Of these patients, 10 had unsuccessful preoperative (7 cases) or intraoperative (3 cases) stone extraction, and 1 case had a single impacted stone 2.3 cm in diameter. Five patients had a single bile duct stone and 6 patients had multiple stones. The size of the stones ranged from 9.5 to 24 mm (mean = 12.6 +/- 4 mm). Balloon dilation of the papilla of Vater was done in all patients. Most of the stones were fractured and pushed into the duodenum with rigid grasping forceps but a lithotripter was required in 2 patients. Stone clearance was 100%; complications related to the procedure were not observed. After CBD clearance, primary closure of the choledochotomy was achieved in 10 patients. In 1 patient who had CBD perforation during a previous procedure, choledochotomy was closed over a T-tube. The mean operative time was 124 +/- 26.7 min (range = 84-165 min) and the mean postoperative hospital stay was 4 +/- 1.7 days (range = 3-7 days). Laparoscopic exploration of the CBD with a rigid scope is an efficacious procedure in dealing with unsuccessful endoscopic stone extraction.

Multiple bile duct anastomoses without stent in living-donor liver transplant

Aims: It is unclear whether the presence of multiple bile ducts in the graft increases the risk of biliary complications after living-donor liver transplant. In this study, we present our results to identify risk factors for the development of biliary complications and to determine the effect of multiple bile ducts in the incidence of biliary complications after living-donor liver transplant. Materials & methods: A total of 106 living-donor liver transplants were performed since 2006 and were divided into two groups: those with a single bile duct (n = 70) and those with multiple bile ducts (n = 36). Duct-to-duct biliary anastomosis was used in 79 (75.5%) living-donor liver transplants and a Roux-en-Y-hepaticojejunostomy was used in the remaining 27 (24.5%). Results: The overall biliary complications rate was 12.2% (four leaks, seven stenoses, two leaks plus stenoses). All biliary complications were treated using interventional radiologic techniques. Only hepatic arterial complications were a significant r...

Anatomical Classification of the Peripheral Right Hepatic Duct: Early Identification of a Preventable Source of Morbidity and Mortality in Adult Live Donor Liver Transplantation

Introduction The purpose of this study was to determine the impact of our classification on right graft adult live donor liver transplantation (ALDLT) outcomes. Methods Three-dimensional computed tomography (CT) reconstructions were used to classify the hilar and sectorial biliary anatomy of 71 consecutive live liver donors. Four possible clinical types were defined, based on the normal (N) or abnormal (A) features of the corresponding hilar/sectorial ducts: type I, N/N; type II, N/A; type III, A/N; and type IV, A/A. We subsequently performed an analysis of the operative outcomes based on the donor anatomy. Results Type I was encountered in 47.9% of cases, type II in 29.6%, type III in 19.7%, and type IV in 2.8%. The highest incidence of biliodigestive anastomoses was observed with type III (50%) and type IV (100%) variants. Type I was associated with the highest incidence of single anastomoses (single vs multiple, P = .001) and of single bile duct anastomoses (single vs multiple, P = .004). Type III was associated with more multi-duct reconstructions compared with types I and II ( P = .002 and P = .05, respectively). There were no significant differences in early ( P = .08) or late ( P = .33) biliary complications, or deaths due to a biliary etiology ( P = .55) among the 4 types. Conclusions Complex biliary anatomy in the right liver graft usually requires biliodigestive anastomoses, which are often associated with complicated procedures. The precise delineation of the intrahepatic biliary anatomy provided by our clinical classification may contribute to better morbidity and mortality rates, especially for grafts at greatest anatomical risk.

Costs and Utilization of Intraoperative Cholangiography

BackgroundRoutine intraoperative cholangiography (IOC) has been advocated as a viable strategy to reduce common bile duct injury (CDI) during cholecystectomy. This is predicated, in part, on the low cost of IOC, making it a cost-effective preventive strategy. Using billed hospital charges as a proxy for costs, we sought to estimate costs associated with the performance of IOC. MethodsThe 2001 National Inpatient Survey (NIS) database was assessed for IOC utilization and associated charges. Average charges for hospital admission where the primary procedure was laparoscopic cholecystectomy were compared for those associated with and without the performance of IOC. ResultsEighteen percent of cholecystectomies were performed in facilities that never perform IOC. Routine IOC (defined as >75% of cholecystectomies performed in any one hospital having a concomitant IOC) was performed in only 11% of hospitals. In the remaining 71% of hospitals, selective IOC was performed. IOCs were associated with US $706–739 in additional hospital charges when performed in conjunction with laparoscopic cholecystectomy. We project a cost of US $371,356 to prevent a single bile duct injury by using routine cholangiography. ConclusionWe conclude that only a minority of hospitals performs cholecystectomies with routine IOC. Because of the significant amount of hospital charges attributable to IOC, routine IOC is not cost-effective as a preventative measure against bile duct injury during cholecystectomy.