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Sreepathi V, Srinivasan K, Ahanatha Pillai S, Ramasamy V, Chowdary MBKP, Murugesan TK, Subbareddiar P. Long-Term Outcomes Following Surgical Repair for Post-cholecystectomy Biliary Strictures. Cureus 2024; 16:e64405. [PMID: 39130821 PMCID: PMC11317064 DOI: 10.7759/cureus.64405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2024] [Indexed: 08/13/2024] Open
Abstract
INTRODUCTION Bile duct injuries (BDIs) are a serious complication of cholecystectomy. Strictures that form after major injuries ultimately require surgical repair. This study aimed to analyse our experience with the surgical repair of post-cholecystectomy biliary strictures (PCBS). METHODS Patients who underwent surgical repair for PCBS between January 2013 and March 2020 were retrospectively reviewed. The strictures were classified using the Bismuth system. Delayed repair with Roux-en-Y hepaticojejunostomy was performed using the Hepp-Couinaud technique. Outcomes were graded according to McDonald's criteria. Statistical analysis was performed to identify factors influencing the outcomes. RESULTS Sixty-eight patients underwent repair for PCBS. Forty-five patients presented within one month and eight patients presented late after six months. Presenting symptoms were jaundice, external biliary fistula, biliomas, cholangitis and peritonitis. Portal hypertension was present in two patients. The median interval for definitive repair was 22 weeks. The median hospital stay was 9.5 days. Eighteen patients had postoperative complications. One patient had postoperative mortality due to uncorrectable coagulopathy. With a median follow-up of 54 months, successful outcomes were achieved in 61 (90%) patients. Four patients had anastomotic strictures evident at two, four, five and eight years after repair. Portal hypertension and postoperative complications were the variables associated with poor outcomes. CONCLUSION BDIs following cholecystectomy are a devastating complication. Surgical repair for biliary strictures yields durable long-term outcomes with early identification and timely referral to a tertiary care centre where standardized techniques for biliary reconstruction are followed.
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Affiliation(s)
| | | | | | - Villalan Ramasamy
- Department of Surgical Gastroenterology, Madurai Medical College, Madurai, IND
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2
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Marichez A, Adam JP, Laurent C, Chiche L. Hepaticojejunostomy for bile duct injury: state of the art. Langenbecks Arch Surg 2023; 408:107. [PMID: 36843190 DOI: 10.1007/s00423-023-02818-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/18/2023] [Indexed: 02/28/2023]
Abstract
BACKGROUND Hepaticojejunostomy (HJ) is the gold standard procedure for the reconstruction of the bile duct in many benign and malignant situations. One of the major situation is the bile duct injury (BDI) after cholecystectomy, either for early or late repair. This procedure presents some specificities associated to a debated management of BDI. PURPOSE This article provides a state-of-the-art of the hepaticojejunostomy procedure focusing on bile duct injury including its indications and outcomes CONCLUSION: Performed at the right moment and respecting the technical rules, HJ provides a restoration of the biliary patency in the long term of 80 to 90%. It is the main surgical technique to repair BDI. Complications and failure of this procedure can be difficult to manage. That is why the primary repair requires an appropriate multidisciplinary approach associated with an expert high quality surgical technique.
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Affiliation(s)
- A Marichez
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France.,Inserm UMR 1312 - Team 3 "Liver Cancers and Tumoral Invasion". Bordeaux Institute of Oncology, University of Bordeaux, Bordeaux, France
| | - J-P Adam
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
| | - C Laurent
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
| | - L Chiche
- Department of Hepato-Bilio-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France. .,Inserm UMR 1312 - Team 3 "Liver Cancers and Tumoral Invasion". Bordeaux Institute of Oncology, University of Bordeaux, Bordeaux, France.
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3
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Wiboonkhwan N, Pitakteerabundit T, Thongkan T. Total Hilar Exposure Maneuver for Repair of Complex Bile Duct Injury. Ann Gastroenterol Surg 2022; 6:176-181. [PMID: 35106428 PMCID: PMC8786702 DOI: 10.1002/ags3.12500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/07/2021] [Accepted: 08/18/2021] [Indexed: 12/31/2022] Open
Abstract
The reconstruction of high-level bile duct injury is challenging because exposure of the hilar area is limited and sometimes inaccessible by the Hepp-Couinaud approach. We describe a maneuver for total hilar exposure to perform complex bile duct injury reconstruction. After adhesions surrounding the liver are divided, intraoperative ultrasonography is used to delineate the hilar and intrahepatic biliary anatomy. Surgical exposure of the biliary system is achieved by our maneuver, which consists of four steps: (1) identification of landmark structures, such as the base of the umbilical fissure, the inferior edge of segment 4b, the cystic-hilar plate junction, and the right anterior portal pedicle; (2) lowering of the hilar plate; (3) hepatotomy along the right anterior pedicle; and (4) connection of the hepatotomy to the base of segment 4b. This maneuver allows the liver to be flipped upward, which facilitates clear exposure of the hilar duct and preserves the liver parenchyma. The anterior parts of the right and left hepatic duct are then opened, a wide-hepaticojejunostomy anastomosis is achieved for biliary reconstruction, and a jejunal subcutaneous limb is created. We used this maneuver for treating complex bile duct injury in six cases; none of the patients has died, and two had Clavien-Dindo grade III complications, including surgical site infection and intra-abdominal collection. The total hilar exposure maneuver is thus feasible and safe. It provides excellent exposure of both hepatic ducts and is a good surgical alternative to the Hepp-Couinaud approach in cases of high-level injury.
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Affiliation(s)
- Nan‐ak Wiboonkhwan
- Department of SurgeryFaculty of MedicinePrince of Songkla UniversitySongkhlaThailand
| | | | - Tortrakoon Thongkan
- Department of SurgeryFaculty of MedicinePrince of Songkla UniversitySongkhlaThailand
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4
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Halle-Smith JM, Hall LA, Mirza DF, Roberts KJ. Risk factors for anastomotic stricture after hepaticojejunostomy for bile duct injury-A systematic review and meta-analysis. Surgery 2021; 170:1310-1316. [PMID: 34148708 DOI: 10.1016/j.surg.2021.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/04/2021] [Accepted: 05/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND After major bile duct injury, hepaticojejunostomy can result in good long-term patency, but anastomotic stricture is a common cause of long-term morbidity. There is a need to assimilate high-level evidence to establish risk factors for development of anastomotic stricture after hepaticojejunostomy for bile duct injury. METHODS A systematic review of studies reporting the rate of anastomotic stricture after hepaticojejunostomy for bile duct injury was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Meta-analyses of proposed risk factors were then performed. RESULTS Meta-analysis included 5 factors (n = 2,155 patients, 17 studies). Concomitant vascular injury (odds ratio 4.96; 95% confidence interval 1.92-12.86; P = .001), postrepair bile leak (odds ratio: 8.03; 95% confidence interval 2.04-31.71; P = .003), and repair by nonspecialist surgeon (odds ratio 11.29; 95% confidence interval 5.21-24.47; P < .0001) increased the rate of anastomotic stricture of hepaticojejunostomy after bile duct injury. Level of injury according to the Strasberg Grade did not significantly affect the rate of anastomotic stricture (odds ratio: 0.97; 95% confidence interval 0.45-2.10; P = .93). Owing to heterogeneity of reporting, it was not possible to perform a meta-analysis for the impact of timing of repair on anastomotic stricture rate. CONCLUSION The only modifiable risk factor, repair by a nonspecialist surgeon, demonstrates the importance of broad awareness of these data. Knowledge of these risk factors may permit risk stratification of follow-up, better informed consent, and understanding of prognosis.
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Affiliation(s)
- James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, United Kingdom. https://twitter.com/jameshallesmith
| | - Lewis A Hall
- College of Medical and Dental Sciences, University of Birmingham, United Kingdom
| | - Darius F Mirza
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, United Kingdom. https://twitter.com/DrDariusMirza
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, United Kingdom.
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5
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Lindemann J, Jonas E, Kotze U, Krige JEJ. Evolution of bile duct repair in a low and middle-income country (LMIC): a comparison of diagnosis, referral, management and outcomes in repair of bile duct injury after laparoscopic cholecystectomy from 1991 to 2004 and 2005-2017. HPB (Oxford) 2020; 22:391-397. [PMID: 31427062 DOI: 10.1016/j.hpb.2019.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/30/2019] [Accepted: 07/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is a paucity of data from the developing world regarding laparoscopic cholecystectomy (LC) bile duct injuries (BDIs), despite the fact that most of the world's population live in a developing country. We assessed how referral patterns, management and outcomes after LC-BDI repair have evolved over time in patients treated at a tertiary referral center in a low and middle-income country (LMIC). METHODS Patients with LC-BDIs requiring hepaticojejunostomy were identified from a prospective database. Clinical characteristics, geographic distance from referral hospital, timing of referral and repair, and post-operative outcomes were compared in two cohorts treated during 1991-2004 and 2005-2017. RESULTS Of 125 patients, 32 underwent repair in the early period, 93 in the latter. There was no difference in demographic or clinical characteristics, but a 45.6% increase in geographically distant referrals in the 2005-2017 period. Time from diagnosis to referral and referral to repair increased significantly (p = 0.031, p < 0.001), necessitating more intermediate repairs. Despite this, the number of severe complications decreased (p = 0.022) while long-term outcomes remained unchanged. CONCLUSION In this study from an LMIC, geographic and logistic constraints necessitated deviation from accepted algorithms devised for well-resourced countries. When appropriately adapted, results comparable to those reported from developed countries are achievable.
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Affiliation(s)
- Jessica Lindemann
- Department of Surgery, University of Cape Town Health Sciences Faculty, Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa; Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA.
| | - Eduard Jonas
- Department of Surgery, University of Cape Town Health Sciences Faculty, Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa
| | - Urda Kotze
- Department of Surgery, University of Cape Town Health Sciences Faculty, Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa
| | - Jake E J Krige
- Department of Surgery, University of Cape Town Health Sciences Faculty, Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa
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Lubikowski J, Piotuch B, Stadnik A, Przedniczek M, Remiszewski P, Milkiewicz P, Silva MA, Wojcicki M. Difficult iatrogenic bile duct injuries following different types of upper abdominal surgery: report of three cases and review of literature. BMC Surg 2019; 19:162. [PMID: 31694627 PMCID: PMC6833182 DOI: 10.1186/s12893-019-0619-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/10/2019] [Indexed: 12/14/2022] Open
Abstract
Background Iatrogenic bile duct injuries (BDIs) are mostly associated with laparoscopic cholecystectomy but may also occur following gastroduodenal surgery or liver resection. Delayed diagnosis of type of injury with an ongoing biliary leak as well as the management in a non-specialized general surgical units are still the main factors affecting the outcome. Case presentation Herein we present three types of BDIs (Bismuth type I, IV and V) following three different types of upper abdominal surgery, ie. Billroth II gastric resection, laparoscopic cholecystectomy and left hepatectomy. All of them were complex injuries with complete bile duct transections necessitating surgical treatment. All were also very difficult to treat mainly because of a delayed diagnosis of type of injury, associated biliary leak and as a consequence severe inflammatory changes within the liver hilum. The treatment was carried out in our specialist hepatobiliary unit and first focused on infection and inflammation control with adequate biliary drainage. This was followed by a delayed surgical repair with the technique which had to be tailored to the type of injury in each case. Conclusion We emphasize that staged and individualized treatment strategy is often necessary in case of a delayed diagnosis of complex BDIs presenting with a biliary leak, inflammatory intraabdominal changes and infection. Referral of such patients to expert hepatobiliary centres is crucial for the outcome.
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Affiliation(s)
- Jerzy Lubikowski
- Department of General and Oncological Surgery, Pomeranian Medical University, Szczecin, Poland.,Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, M. Curie Hospital, Szczecin, Poland
| | - Bernard Piotuch
- Department of Surgery, Ministry of the Interior and Administration Hospital, Szczecin, Poland.,Department of General and Hand Surgery, Pomeranian Medical University, Szczecin, Poland
| | - Anna Stadnik
- Department of Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Marta Przedniczek
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland
| | - Piotr Remiszewski
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland
| | - Piotr Milkiewicz
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland.,Translational Medicine Group, Pomeranian Medical University, Szczecin, Poland
| | - Michael A Silva
- Department of Hepatobiliary and Pancreatic Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Maciej Wojcicki
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland.
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7
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Lindemann J, Kloppers C, Burmeister S, Bernon M, Jonas E. Mind the gap! Extraluminal percutaneous-endoscopic rendezvous with a self-expanding metal stent for restoring continuity in major bile duct injury: A case series. Int J Surg Case Rep 2019; 60:340-344. [PMID: 31279238 PMCID: PMC6612668 DOI: 10.1016/j.ijscr.2019.06.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/26/2019] [Accepted: 06/26/2019] [Indexed: 11/27/2022] Open
Abstract
Bile duct injuries with substance loss can be challenging to treat surgically. Morbid obesity, intra-abdominal sepsis and penetrating trauma increase complexity. Endoscopic/percutaneous techniques are alternative treatment options. Combined rendezvous with immediate stenting was successful in two challenging cases.
Introduction Treatment of major iatrogenic and non-iatrogenic bile duct injury (BDI) often requires delayed surgery with interim external biliary drainage. Percutaneous transhepatic cholangiography (PTC) with biliary catheter placement and endoscopic retrograde cholangiography (ERC) with stent placement have been used to bridge defects. In some patients, bridging the defect cannot be achieved through ERC or PTC alone. Materials and methods Two patients with major BDIs, one iatrogenic and one non-iatrogenic underwent an extraluminal PTC/ERC rendezvous with placement of a fully covered self-expandable metal stent (SEMS) for the acute management of BDI with substantial loss of bile duct length. Results In both patients the intraperitoneal PTC/ERC rendezvous with SEMS placement was successful with no complications after 12 and 18 months follow-up, respectively. Discussion This study is the first to report a standardized approach to the acute management of iatrogenic and non-iatrogenic major BDIs using extraluminal intraperitoneal PTC/ERC rendezvous with placement of a fully covered SEMS. The described technique may serve as a “bridge to surgery” strategy for patients where definitive management of BDIs are deferred. However, long-term data of the success of this technique, specifically the use of a SEMS to bridge the defect, are lacking and further investigation is required to determine its role as a definitive treatment of BDIs with substance loss. Conclusion PTC/ERC rendezvous with restoration of biliary continuity and internalization of bile flow is particularly useful for patients who have previously failed ERC and/or PTC alone, and in whom immediate surgical repair is not an option.
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Affiliation(s)
- Jessica Lindemann
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa; Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Christo Kloppers
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa
| | - Sean Burmeister
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa
| | - Marc Bernon
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa
| | - Eduard Jonas
- Surgical Gastroenterology Unit, Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa.
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8
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Risk Factors and Predictors of Poor Outcome Following Hepaticojejunostomy for Postcholecystecomy Bile Duct Injury. Indian J Surg 2019. [DOI: 10.1007/s12262-019-01866-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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9
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Surgical management of laparoscopic cholecystectomy (LC) related major bile duct injuries; predictors of short-and long-term outcomes in a tertiary Egyptian center- a retrospective cohort study. ANNALS OF MEDICINE AND SURGERY (2012) 2018. [PMID: 30505442 DOI: 10.1016/j.amsu.2018.11.006.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objectives Laparoscopic cholecystectomy - associated bile duct injury is a clinical problem with bad outcome. The study aimed to analyze the outcome of surgical management of these injuries. Patients and methods We retrospectively analyzed 69 patients underwent surgical management of laparoscopic cholecystectomy related major bile duct injuries in the period from the beginning of 2013 to the beginning of 2018. Results Regarding injury type; the Leaking, Obstructing, leaking + obstructing, leaking + vascular, and obstructing + vascular injuries were 43.5%, 27.5%, 18.8%, 2.9%, and 7.2% respectively. However, the Strasberg classification of injury was as follow E1 = 25, E2 = 32, E3 = 8, and E4 = 4. The definitive procedures were as follow: end to end biliary anastomosis with stenting, hepaticojejunostomy (HJ) with or without stenting, and RT hepatectomy plus biliary reconstruction with stenting in 4.3%, 87%, and 8.7% of patients respectively. According to the time of definitive procedure from injury; the immediate (before 72 h), intermediate (between 72 h and 1.5months), and late (after1.5 months) management were 13%, 14.5%, and 72.5% respectively. The hospital and/or 1month (early) morbidity after definitive treatment was 21.7%, while, the late biliary morbidity was 17.4% and the overall mortality was 2.9%, on the other hand, the late biliary morbidity-free survival was 79.7%. On univariate analysis, the following factors were significant predictors of early morbidity; Sepsis at referral, higher Strasberg grade, associated vascular injury, right hepatectomy with biliary reconstruction as a definitive procedure, intra-operative bleeding with blood transfusion, liver cirrhosis, and longer operative times and hospital stays. However, the following factors were significantly associated with late biliary morbidity: Sepsis at referral, end to end anastomosis with stenting, reconstruction without stenting, liver cirrhosis, operative bleeding, and early morbidity. Conclusion Sepsis at referral, liver cirrhosis, and operative bleeding were significantly associated with both early and late morbidities after definitive management of laparoscopic cholecystectomy related major bile duct injuries, so it is crucial to avoid these catastrophes when doing those major procedures.
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10
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Gad EH, Ayoup E, Kamel Y, Zakareya T, Abbasy M, Nada A, Housseni M, Abd-Elsamee MAS. Surgical management of laparoscopic cholecystectomy (LC) related major bile duct injuries; predictors of short-and long-term outcomes in a tertiary Egyptian center- a retrospective cohort study. Ann Med Surg (Lond) 2018; 36:219-230. [PMID: 30505442 PMCID: PMC6251332 DOI: 10.1016/j.amsu.2018.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 10/30/2018] [Accepted: 11/06/2018] [Indexed: 02/08/2023] Open
Abstract
Objectives Laparoscopic cholecystectomy - associated bile duct injury is a clinical problem with bad outcome. The study aimed to analyze the outcome of surgical management of these injuries. Patients and methods We retrospectively analyzed 69 patients underwent surgical management of laparoscopic cholecystectomy related major bile duct injuries in the period from the beginning of 2013 to the beginning of 2018. Results Regarding injury type; the Leaking, Obstructing, leaking + obstructing, leaking + vascular, and obstructing + vascular injuries were 43.5%, 27.5%, 18.8%, 2.9%, and 7.2% respectively. However, the Strasberg classification of injury was as follow E1 = 25, E2 = 32, E3 = 8, and E4 = 4. The definitive procedures were as follow: end to end biliary anastomosis with stenting, hepaticojejunostomy (HJ) with or without stenting, and RT hepatectomy plus biliary reconstruction with stenting in 4.3%, 87%, and 8.7% of patients respectively. According to the time of definitive procedure from injury; the immediate (before 72 h), intermediate (between 72 h and 1.5months), and late (after1.5 months) management were 13%, 14.5%, and 72.5% respectively. The hospital and/or 1month (early) morbidity after definitive treatment was 21.7%, while, the late biliary morbidity was 17.4% and the overall mortality was 2.9%, on the other hand, the late biliary morbidity-free survival was 79.7%. On univariate analysis, the following factors were significant predictors of early morbidity; Sepsis at referral, higher Strasberg grade, associated vascular injury, right hepatectomy with biliary reconstruction as a definitive procedure, intra-operative bleeding with blood transfusion, liver cirrhosis, and longer operative times and hospital stays. However, the following factors were significantly associated with late biliary morbidity: Sepsis at referral, end to end anastomosis with stenting, reconstruction without stenting, liver cirrhosis, operative bleeding, and early morbidity. Conclusion Sepsis at referral, liver cirrhosis, and operative bleeding were significantly associated with both early and late morbidities after definitive management of laparoscopic cholecystectomy related major bile duct injuries, so it is crucial to avoid these catastrophes when doing those major procedures. Sepsis at referral was associated with poor outcome after management of LC related MBDIs. Liver cirrhosis and operative bleeding were associated with poor outcome after management of these injuries. It is crucial to avoid these catastrophes when doing those major procedures.
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Affiliation(s)
- Emad Hamdy Gad
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Eslam Ayoup
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Yasmin Kamel
- Anaesthesia, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Talat Zakareya
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Mohamed Abbasy
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Ali Nada
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Mohamed Housseni
- Radioligy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
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11
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Cho JY, Baron TH, Carr-Locke DL, Chapman WC, Costamagna G, de Santibanes E, Dominguez Rosado I, Garden OJ, Gouma D, Lillemoe KD, Angel Mercado M, Mullady DK, Padbury R, Picus D, Pitt HA, Sherman S, Shlansky-Goldberg R, Tornqvist B, Strasberg SM. Proposed standards for reporting outcomes of treating biliary injuries. HPB (Oxford) 2018; 20:370-378. [PMID: 29397335 DOI: 10.1016/j.hpb.2017.10.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/06/2017] [Accepted: 10/21/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is no standard nor widely accepted way of reporting outcomes of treatment of biliary injuries. This hinders comparison of results among approaches and among centers. This paper presents a proposal to standardize terminology and reporting of results of treating biliary injuries. METHODS The proposal was developed by an international group of surgeons, biliary endoscopists and interventional radiologists. The method is based on the concept of "patency" and is similar to the approach used to create reporting standards for arteriovenous hemodialysis access. RESULTS The group considered definitions and gradings under the following headings: Definition of Patency, Definition of Index Treatment Periods, Grading of Severity of Biliary Injury, Grading of Patency, Metrics, Comparison of Surgical to Non Surgical Treatments and Presentation of Case Series. CONCLUSIONS A standard procedure for reporting outcomes of treating biliary injuries has been produced. It is applicable to presenting results of treatment by surgery, endoscopy, and interventional radiology.
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Affiliation(s)
- Jai Young Cho
- Department of Surgery, Seoul National University, Bundang Hospital, Seoul National University College of Medicine, Seongnam, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si 13620, Republic of Korea
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, 130 Mason Farm Road CB 7080, Chapel Hill, NC 27599, USA
| | - David L Carr-Locke
- The Center for Advanced Digestive Care, Weill Cornell Medicine, New York Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY 10021, USA
| | - William C Chapman
- Section of Transplantation, Department of Surgery, Washington University in St Louis, 1 Barnes Hospital Plaza, St Louis, MO 63110, USA
| | - Guido Costamagna
- Digestive Endoscopy Unit, Catholic University of the Sacred Heart, Gemelli Hospital, Largo Agostino Gemelli, 8, Roma, RM 00168, Italy
| | - Eduardo de Santibanes
- Department of Surgery, Hospital Italiano de Buenos Aires, Juan D. Peron 4190, C1181ACH CABA, Buenos Aires, Argentina
| | - Ismael Dominguez Rosado
- Department of Surgery, National Institute of Medical Sciences and Nutrition, Vasco de Quiroga 15 Col. Seccion XVI, Tlalpan C.P. 14000, Mexico City, Mexico
| | - O James Garden
- Clinical Surgery, University of Edinburgh, Royal Infirmary, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - Dirk Gouma
- Department of Surgery, Faculty of Medicine AMC, University of Amsterdam, Sweelincklaan 15, 1217 CK, Hilversum, The Netherlands
| | - Keith D Lillemoe
- Department of Surgery, White 506, 55 Fruit Street, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Miguel Angel Mercado
- Department of Surgery, National Institute of Medical Sciences and Nutrition, Vasco de Quiroga 15 Col. Seccion XVI, Tlalpan C.P. 14000, Mexico City, Mexico
| | - Daniel K Mullady
- Washington University in St Louis, Department of Medicine, Division of Gastroenterology, Campus Box 8124 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Robert Padbury
- Department of Surgery, Flinders Medical Centre and Flinders University, Flinders Dr, Bedford Park SA 5042, Australia
| | - Daniel Picus
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Blvd, St Louis, MO 63110, USA
| | - Henry A Pitt
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3509 N. Broad Street, Boyer Pavilion, E 938, Philadelphia, PA 19140, USA
| | - Stuart Sherman
- Department of Medicine, Division of Digestive and Liver Disorders, Indiana University Health-University Hospital, 550 North University Blvd, Suite 1634, Indianapolis, IN 46202, USA
| | - Richard Shlansky-Goldberg
- Division of Interventional Radiology, Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Silverstein 1st floor, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Bjorn Tornqvist
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Steven M Strasberg
- Section of HPB Surgery, Washington University in St Louis, 1 Barnes Hospital Plaza, St Louis, MO 63110, USA.
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Fonouni H, Kashfi A, Stahlheber O, Konstantinidis L, Kraus TW, Mehrabi A, Oweira H. Analysis of the biliostatic potential of two sealants in a standardized porcine model of liver resection. Am J Surg 2017; 214:945-955. [PMID: 28683896 DOI: 10.1016/j.amjsurg.2017.06.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/28/2017] [Accepted: 06/13/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Improved resection techniques has decreased mortality rate following liver resections(LRx). Sealants are known as effective adjuncts for haemostasis after LRx. We compared biliostatic effectiveness of two sealants in a standardized porcine model of LRx. MATERIAL AND METHODS We accomplished left hemihepatectomy on 27 pigs. The animals were randomized in control group(n = 9) with no sealant and treatment groups (each n = 9), in which resection surfaces were covered with TachoSil® and TissuFleece®/Tissucol Duo®. After 5 days the volume of ascites(ml), bilioma and/or bile leakages and degree of intra-abdominal adhesions were analysed. RESULTS Proportion of ascites was lower in TissuFleece/Tissucol Duo® group. The ascites volume was lower in TachoSil® group. In sealant groups, increased adhesion specially in the TachoSil® group was seen. A reduction of the "bilioma rate" was seen in sealant groups, which was significantly lower in TissuFleece®/Tissucol Duo® group. CONCLUSION In a standardized condition sealants have a good biliostatic effect but with heterogeneous potentials. This property in combination with the cost-benefit analysis should be the focus of future prospective studies.
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Affiliation(s)
- H Fonouni
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
| | - A Kashfi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - O Stahlheber
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - L Konstantinidis
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - T W Kraus
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - A Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - H Oweira
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
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Early Versus Late Cholecystectomy After Clearance of Common Bile Duct Stones by Endoscopic Retrograde Cholangiopancreatography: A Prospective Randomized Study. Surg Laparosc Endosc Percutan Tech 2016; 26:202-7. [DOI: 10.1097/sle.0000000000000265] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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AbdelRafee A, El-Shobari M, Askar W, Sultan AM, El Nakeeb A. Long-term follow-up of 120 patients after hepaticojejunostomy for treatment of post-cholecystectomy bile duct injuries: A retrospective cohort study. Int J Surg 2015; 18:205-10. [PMID: 25965917 DOI: 10.1016/j.ijsu.2015.05.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 03/17/2015] [Accepted: 05/04/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Long-term follow-up is essential for assessment of success of the surgical repair of post-cholecystectomy bile duct injuries (BDI). Factors affecting the long-term outcome and satisfactory length of follow-up have been little reported in the literature. The aim of this study is long-term evaluation of hepaticojejunostomy regarding clinical, radiological, laboratory and quality of life assessment. METHOD Between January 1992 to December 2007, 120 patients with postcholecystectomy bile duct injury surgically treated by hepaticojejunostomy Roux-en-Y were followed up for 20 years in Mansoura Gastro-enterology Center. Long-term outcomes and quality of life (QOL) were evaluated for all patients. Univariate and multivariate analyses were done for detection of factors affecting long-term outcome. RESULTS The median follow up period was 149 months, range (70-246 months). Successful long-term outcome was detected in 106 (88.3%) patients. Long-term complications were detected in 35 (29%) patients. Fourteen (11.6%) patients developed anastomotic stricture within different follow up intervals up to 17 years, of which. Seventeen (14.2%) patients developed recurrent episodes of cholangitis at median interval 48 months, range (2-156 months). Post-ERCP pancreatitis, number of anastomosis, operative time, post-operative early complications, and post-operative bile leak were predictors for poor outcome. Physical component was much more affected than mental component in QOL. CONCLUSION Management of BDI in specialized centers is highly recommended. Longer time for follow-up of the patients of surgical repair of bile duct injury up to 20 years should be adopted to ensure successful outcome. Quality of life assessment is essential component of long-term follow-up.
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Affiliation(s)
- Ahmed AbdelRafee
- Gastroenterology Surgical Center (GEC), Department of Surgery, Mansoura University, Egypt.
| | - Mohamed El-Shobari
- Gastroenterology Surgical Center (GEC), Department of Surgery, Mansoura University, Egypt.
| | - Waleed Askar
- Gastroenterology Surgical Center (GEC), Department of Surgery, Mansoura University, Egypt.
| | - Ahmad M Sultan
- Gastroenterology Surgical Center (GEC), Department of Surgery, Mansoura University, Egypt.
| | - Ayman El Nakeeb
- Gastroenterology Surgical Center (GEC), Department of Surgery, Mansoura University, Egypt.
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Early or Delayed Intervention for Bile Duct Injuries following Laparoscopic Cholecystectomy? A Dilemma Looking for an Answer. Gastroenterol Res Pract 2015; 2015:104235. [PMID: 25722718 PMCID: PMC4333332 DOI: 10.1155/2015/104235] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 01/16/2015] [Indexed: 12/27/2022] Open
Abstract
Background. To evaluate the effect of timing of management and intervention on outcomes of bile duct injury. Materials and Methods. We retrospectively analyzed 92 patients between 1991 and 2011. Data concerned patient's demographic characteristics, type of injury (according to Strasberg classification), time to referral, diagnostic procedures, timing of surgical management, and final outcome. The endpoint was the comparison of postoperative morbidity (stricture, recurrent cholangitis, required interventions/dilations, and redo reconstruction) and mortality between early (less than 2 weeks) and late (over 12 weeks) surgical reconstruction. Results. Three patients were treated conservatively, two patients were treated with percutaneous drainage, and 13 patients underwent PTC or ERCP. In total 74 patients were operated on in our unit. 58 of them underwent surgical reconstruction by end-to-side Roux-en-Y hepaticojejunostomy, 11 underwent primary bile duct repair, and the remaining 5 underwent more complex procedures. Of the 56 patients, 34 patients were submitted to early reconstruction, while 22 patients were submitted to late reconstruction. After a median follow-up of 93 months, there were two deaths associated with BDI after LC. Outcomes after early repairs were equal to outcomes after late repairs when performed by specialists. Conclusions. Early repair after BDI results in equal outcomes compared with late repair. BDI patients should be referred to centers of expertise and experience.
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Sultan AM, Elnakeeb AM, Elshobary MM, El-Geidi AA, Salah T, El-hanafy EA, Atif E, Hamdy E, Elebiedy GK. Management of post-cholecystectomy biliary fistula according to type of cholecystectomy. Endosc Int Open 2015; 3:E91-8. [PMID: 26134781 PMCID: PMC4440382 DOI: 10.1055/s-0034-1390747] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 09/08/2014] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS A study was undertaken to describe the management of post-cholecystectomy biliary fistula according to the type of cholecystectomy. PATIENTS AND METHODS A retrospective analysis of 111 patients was undertaken. They were divided into open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) groups. RESULTS Of the 111 patients, 38 (34.2 %) underwent LC and 73 (65.8 %) underwent OC. Endoscopic retrograde cholangiopancreatography (ERCP) diagnosed major bile duct injury (BDI) in 27 patients (38.6 %) in the OC group and in 3 patients (7.9 %) in the LC group (P = 0.001). Endoscopic management was not feasible in 15 patients (13.5 %) because of failed cannulation (n = 3) or complete ligation of the common bile duct (n = 12). Endoscopic therapy stopped leakage in 35 patients (92.1 %) and 58 patients (82.9 %) following LC and OC, respectively, after the exclusion of 3 patients in whom cannulation failed (P = 0 0.150). Major BDI was more commonly detected after OC (P < 0.001). Leakage was controlled endoscopically in 77 patients (98.7 %) with minor BDI and in 16 patients (53.3 %) with major BDI (P < 0.001). CONCLUSIONS Major BDI is more common in patients presenting with bile leakage after OC. ERCP is the first-choice treatment for minor BDI. Surgery plays an important role in major BDI. Magnetic resonance cholangiopancreatogrphy (MRCP) should be used before ERCP in patients with bile leakage following OC or converted LC.
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Affiliation(s)
- Ahmad M. Sultan
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt ,Corresponding author Ahmad Mohammad Sultan, MD Gastro-enterology Surgical CenterMansoura UniversityGehan StreetMansouraEgypt002050223686
| | - Ayman M. Elnakeeb
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt
| | - Mohamed M. Elshobary
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt
| | - Ahmed A. El-Geidi
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt
| | - Tarek Salah
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt
| | - Ehab A. El-hanafy
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt
| | - Ehab Atif
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt
| | - Emad Hamdy
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt
| | - Gamal K. Elebiedy
- Gastro-enterology Surgical Center, Surgery Department, Mansoura University, Mansoura, Egypt
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Factors Affecting Short-Term and Long-Term Outcomes After Bilioenteric Reconstruction for Post-cholecystectomy Bile Duct Injury: Experience at a Tertiary Care Centre. Indian J Surg 2013; 77:472-9. [PMID: 26730048 DOI: 10.1007/s12262-013-0880-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 01/24/2013] [Indexed: 12/26/2022] Open
Abstract
Bile duct injury following cholecystectomy is an iatrogenic catastrophe associated with significant perioperative morbidity, reduced long-term survival and quality of life. There has been little literature on the long-term outcomes after surgical reconstruction and factors affecting it. The aim of this study was to study factors affecting long-term outcomes following surgical repair of iatrogenic bile duct injury being referred to a tertiary care centre. Between January 2005 to December 2011, 138 patients with bile duct injury were treated in a single surgical unit in a tertiary care referral hospital. Preoperative details were recorded. After initial resuscitation, any intra-abdominal collection was drained and an imaging of biliary anatomy was done. Once the general condition of the patient improved, patients were taken up for a side-to-side extended left duct hepaticojejunostomy. The post-operative outcomes were recorded and a hepatobiliary iminodiacetic acid scan and liver function tests were done, and then the patients were followed up at regular intervals. Clinical outcome was evaluated according to clinical grades described by Terblanche and Worthley (Surgery 108:828-834, 1990). The variables were compared using chi-square, unpaired Student's t test and Fisher's exact test. A two-tailed p value of <0.05 was considered significant. One hundred thirty-eight patients, 106 (76.8 %) females and 32 (23.2 %) males with an age range of 20-63 years (median 40.8 ± SD) with bile duct injury following open or laparoscopic cholecystectomy, were operated during this period. Majority of the patients [83 (60.1 %)] had a delayed presentation of more than 3 months. Based on imaging, Strasburg type E1 was seen in 17 (12.5 %), type E2 in 30 (21.7 %), type E3 in 85 (61.5 %) and type E4 in 6 (4.3 %). On multivariate analysis, only level of injury, longer duration of referral and associated vascular injury were independently associated with an overall poor long-term outcome. This study demonstrates level of injury at or above the confluence; associated vascular injury and delay in referral were associated with poorer outcomes in long-term follow-up; however, almost all patients had excellent outcome in long-term follow-up.
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