Long-term follow-up of 120 patients after hepaticojejunostomy for treatment of post-cholecystectomy bile duct injuries: A retrospective cohort study

A Rare Cause of Pain in a Patient Following Roux-en-Y Choledochojejunostomy

Introduction

Sump syndrome is a rare complication following bilioenteric anastomosis, most commonly following choledochoduodenostomy. This is only the third case in the literature of sump syndrome of the distal common bile duct (CBD) following end-to-side Roux-en-Y choledochojejunostomy (RYCJ). Case Presentation. A 69-year-old man with a history of end-to-side RYCJ for recurrent primary choledocholithiasis presented 3 years postoperatively with right upper quadrant (RUQ) abdominal pain affecting his quality of life. The work up revealed mild leukocytosis and computed tomography (CT) imaging that showed dilation of the distal CBD remnant. He underwent endoscopic retrograde cholangiopancreatography (ERCP) with the removal of large amounts of debris with initial resolution of his pain, but the pain recurred after several months and after two further ERCPs with only short-term resolution of pain, he eventually underwent an open distal CBD excision and the pain has since resolved.

Conclusions

This case report describes a rare case of sump syndrome following RYCJ that presented with abdominal pain alone. Sump syndrome may have a wide array of presenting symptoms, and the pathophysiology of sump syndrome varies based on bilioenteric reconstruction. Although it has rarely been reported to occur in the distal blind CBD remnant following either RYCJ or hepaticojejunostomy, it is important to consider this in the differential for patients with abdominal pain following any bilioenteric reconstruction.

Post-cholecystectomy bile duct injuries: a retrospective cohort study

BACKGROUND

Bile duct injury (BDI) is still a major worrisome complication that is feared by all surgeons undergoing cholecystectomy. The overall incidence of biliary duct injuries falls between 0.2 and 1.3%. BDI classification remains an important method to define the type of injury conducted for investigation and management. Recently, a Consensus has been taken to define BDI using the ATOM classification. Early management brings better results than delayed management. The current perspective in biliary surgery is the laparoscopic role in diagnosing and managing BDI. Diagnostic laparoscopy has been conducted in various entities for diagnostic and therapeutic measures in minor and major BDIs.

METHODS

35 cases with iatrogenic BDI following cholecystectomy (after both open and laparoscopic approaches) both happened in or were referred to Alexandria Main University Hospital surgical department from January 2019 till May 2022 and were analyzed retrospectively. Patients were classified according to the ATOM classification. Management options undertaken were mentioned and compared to the timing of diagnosis, and the morbidity and mortality rates (using the Clavien-Dindo classification).

RESULTS

35 patients with BDI after both laparoscopic cholecystectomy (LC) (54.3%), and Open cholecystectomy (OC) (45.7%) (20% were converted and 25.7% were Open from the start) were classified according to ATOM classification. 45.7% were main bile duct injuries (MBDI), and 54.3% were non-main bile duct injuries (NMBDI), where only one case 2.9% was associated with vasculobiliary injury (VBI). 28% (n = 10) of the cases were diagnosed intraoperatively (Ei), 62.9% were diagnosed early postoperatively (Ep), and 8.6% were diagnosed in the late postoperative period (L). LC was associated with 84.2% of the NMBDI, and only 18.8% of the MBDI, compared to OC which was associated with 81.3% of the MBDI, and 15.8% of the NMBDI. By the Clavien-Dindo classification, 68.6% fell into Class IIIb, 20% into Class I, 5.7% into Class V (mortality rate), 2.9% into Class IIIa, and 2.9% into Class IV. The Clavien-Dindo classification and the patient's injury (type and time of detection) were compared to investigation and management options.

CONCLUSION

Management options should be defined individually according to the mode of presentation, the timing of detection of injury, and the type of injury. Early detection and management are associated with lower morbidity and mortality. Diagnostic Laparoscopy was associated with lower morbidity and better outcomes. A proper Reporting checklist should be designed to help improve the identification of injury types.

Therapeutic Role of Subcutaneous Access Loop Created Adjunct to Hepaticojejunostomy for Management of Bile Duct Injury

BACKGROUND

Roux-en-Y hepaticojejunostomy (RYHJ) is usually required for major bile duct injury (BDI) as a definitive treatment. Hepaticojejunostomy anastomotic stricture (HJAS) is the most feared long-term complication following RYHJ. The ideal management of HJAS remains undefined. The provision of permanent endoscopic access to the bilio-enteric anastomotic site can make endoscopic management of HJAS feasible and attractive option. In this cohort study, we aimed to evaluate short- and long-term outcomes of subcutaneous access loop created adjunct to RYHJ (RYHJ-SA) for management of BDI and its usefulness for endoscopic management of anastomotic stricture if occurred.

MATERIALS AND METHODS

This is a prospective study including patients who were diagnosed with iatrogenic BDI and underwent hepaticojejunostomy with subcutaneous access loop between September 2017 and September 2019.

RESULTS

This study included a total number of 21 patients whom ages ranged between 18 and 68 years. During follow-up, three cases had HJAS. One patient had the access loop in subcutaneous position. Endoscopy was done but failed to dilate the stricture. The other 2 patients had the access loop in subfascial position. Endoscopy of them failed to enter the access loop due to failure of fluoroscopy to identify the access loop. The three cases underwent redo-hepaticojejunostomy. Parajejunal (parastomal) hernia occurs in 2 patients in whom the access loop was fixed subcutaneous position.

CONCLUSION

In conclusion, modified RYHJ with subcutaneous access loop (RYHJ-SA) is associated with reduced quality of life and patient satisfaction. Moreover, its role in endoscopic management of HJAS after biliary reconstruction for major BDI is limited.

Hepaticojejunostomy with gastric access loop versus conventional hepaticojejunostomy: a randomized trial

Roux-en-Y hepaticojejunostomy (RYHJ) with the provision of "gastric access loop" was developed to shorten the distance traveled by the endoscope to reach hepaticojejunostomy (HJ) anastomotic site. The aim of our study was to assess modified RYHJ with gastric access loop (RYHJ-GA) and compare it with conventional RYHJ (RYHJ-C) regarding short- and long-term outcomes and, moreover, to evaluate the feasibility and results of future endoscopic access of the modified bilio-enteric anastomosis. Patients eligible for RYHJ between September 2017 and December 2019 were allocated randomly to receive either RYHJ-C or RYHJ-GA. Fifty-two patients were randomly assigned to RYHJ-C (n = 26) or RYHJ-GA (n = 26). Three cases in RYHJ-C and 4 cases in RYHJ- GA developed HJ anastomotic stricture (HJAS) (P=0.68). 3 cases of RYHJ-GA had successful endoscopic dilation and balloon sweeping of biliary mud (one case) or stones (2 cases). Revisional surgery was needed in 2 cases of RYHJ-C and 1 case in RYHJ-GA (P=0.68). Modified RYHJ with gastric access loop is comparable to the classic hepaticojejunostomy regarding complications. However, gastric access enables easy endoscopic access for the management of future HJAS. This modification should be considered in patients with a high risk of HJAS during long-term follow-up.The trial registration number (TRN) and date of registration:ClinicalTrials.gov (NCT03252379), August 17, 2017.

Clinical presentation, management and outcomes of bile duct injuries after laparoscopic cholecystectomy: a 15-year single-center experience in Vietnam

Objectives

To evaluate the clinical presentation, management, and outcomes of bile duct injuries (BDIs) after laparoscopic cholecystectomy (LC).

Methods

This is a case series of 28 patients with BDIs after LC treated at a tertiary hospital in Vietnam during the 2006-2021 period. The BDI's clinical presentations, Strasberg classification types, management methods, and outcomes were reported.

Results

BDIs were diagnosed intraoperatively in 3 (10.7%) patients and postoperatively in 25 (89.3%). The BDI types included Strasberg A (13, 46.4%), D (1, 3.6%), E1 (1, 3.6%), E2 (4, 14.3%), E3 (5, 17.9%), D + E2 (2, 7.1%), and nonclassified (2, 7.1%). Of the postoperative BDIs, the injury manifested as biliary obstruction (18, 72.0%), bile leak (5, 20.0%), and mixed scenarios (2, 8.0%). Regarding diagnostic methods, endoscopic retrograde cholangiopancreatography (ERCP) was more useful in bile leak scenarios, while multislice computed tomography, magnetic resonance cholangiopancreatography, and percutaneous transhepatic cholangiography were more useful in biliary obstruction scenarios. All 28 BDIs were successfully treated. ERCP with stenting was very effective in the majority of Strasberg A BDIs. For more complex BDI types, hepaticocutaneous jejunostomy was a safe and effective approach. The in-hospital morbidities included postoperative pneumonia (2, 10.7%) and biliary-enteric anastomosis leakage (1, 5.4%). There was no cholangitis or anastomotic stenosis during the follow-up after discharge (median 18 months).

Conclusions

The majority of BDIs are type A and diagnosed postoperatively. ERCP is effective for the majority of Strasberg A BDIs. For major and complex BDIs, hepaticocutaneous jejunostomy is a safe and effective approach.

Outcomes of double-layer continuous suture hepaticojejunostomy in pancreatoduodenectomy and total pancreatectomy

BACKGROUND

This study aims to describe the technique and the results of double-layer continuous suture hepaticojejunostomy (HJ) following pancreatoduodenectomy (PD) and total pancreatectomy (TP).

METHODS

A prospectively maintained database was analyzed retrospectively to identify incidence and severity of biliary leaks (BL) (ISGLS definition), as well as of HJ stenosis (HJS), cholangitis, and need for redo-HJ (in patients with a follow-up ≥3 years) in a consecutive series of 800 procedures (PD = 603; TP = 197). Predictors of biliary complications were also identified.

RESULTS

BLs occurred in 5 patients (0.6%), including 2 (0.3%) combined pancreatic and biliary leaks. Rates of HJS, cholangitis, and need for redo-HJ were 6.1%, 5.4%, and 2.0%, respectively. Incidence of BL was 0.6% in open procedures (4/587) and 0.4% in robotic operations (1/213). Incidence of late biliary complications was also equivalent in open and robotic procedures. Occurrence of BL was predicted by ASA IV status and duodenal cancer, HJS by any associated vascular procedure and hepatic duct size < 8 mm, cholangitis by any associated vascular procedure and normal bilirubin/hepatic enzymes, and redo HJ by history of cholecystectomy and neuroendocrine tumor/cancer.

DISCUSSION

Double layer continuous suture HJ is associated with low BL rates, and an acceptable incidence of late complications.

Biliary Cripple and the Spectrum of Complications following Cholecystectomy: A Case Report

Bile duct injury is a complication seen during cholecystectomy. Here, we highlight the occurrence of bile duct injury (BDI) during an open cholecystectomy who underwent hepaticojejunostomy (HJ), later presenting with a stricture of HJ. Percutaneous transhepatic biliary drainage (PTBD) was performed which led to the development of hepatic artery injury.

Outcome assessment of biliary stricture repair following cholecystectomy in a tertiary care centre

PURPOSE

Bile duct injuries (BDIs) are the potential grievous complications of cholecystectomy that result in substantial morbidity and mortality. Outcomes of BDI management depend on multiple factors such as the type and extent of injury, timing of repair, and surgical expertise. The present retrospective study was conducted to analyse the risk factors associated with the BDI repair outcomes.

METHODS

The data of patients having primary or recurrent bile duct stricture following BDI from 1985 to 2018 were retrospectively evaluated.

RESULTS

A total of 268 patients underwent hepaticojejunostomy (HJ). Of the total, 218 patients had primary bile duct stricture, and 50 patients had HJ stricture. The most commonly performed procedure for primary BDI was Roux-en-Y HJ (RYHJ), followed by right hepatectomy, right posterior sectionectomy, and left hepatectomy. All patients with strictured HJ underwent RYHJ, except one who underwent a right hepatectomy. Outcome assessment using the McDonald grading system showed that 62%, 27%, 5%, and 6% of patients with primary bile duct stricture had grade A, grade B, grade C, and grade D complications, respectively, with a mortality rate of 3.21%, whereas 46%, 34%, and 18% patients with strictured HJ had grade A, grade B, and grade C complications, respectively, with a mortality rate of 2%. High-up biliary strictures, early repair, and blood loss > 350 mL are the surrogate markers for failure of repair.

CONCLUSION

Management of BDI needs a multidisciplinary approach. The outcomes of both primary biliary stricture and strictured HJ can be improved with management of patients in a tertiary care centre. However, attempts to repair within 2 weeks of injury, Strasberg E₄ and E₅, and blood loss of > 350 mL may have an adverse effect on the outcome of HJ.

Outcome of reoperative surgery for late failure of postcholecystectomy bile duct injury repair

The aim of the study is to report the outcomes of reoperative surgery for late failure of postcholecystectomy bile duct injury (BDI) repair. All the patients, who underwent a reoperative surgery for late failure of postcholecystectomy BDI repair at our institution between August 2007 and July 2020, were retrospectively reviewed. Of the total 262 patients of BDI repair, 66 underwent reoperative surgery for late failure. Median duration between last attempt repair and the onset of recurrent symptoms was 18 months. Eighty-five percent of patients with failed repair became symptomatic within 5 years of attempt repair. The most common type of BDI was E3. All the patients underwent Roux-en-Y hepaticojejunostomy. Twenty-nine postoperative complications developed in 23 (35%) patients. Postoperative mortality was 1.5%. Median postoperative hospital stay was 9 (5-61) days. Over a median follow-up of 80 (12-150) months, 5.2% (3/58) of patients developed clinically relevant anastomotic stricture. Three patients with secondary biliary cirrhosis died in the follow-up period due to decompensated liver disease. Overall, excellent or good long-term outcome was achieved in 83% (48/58) of patients which was significantly less satisfactory than primary repair patients (82.8% vs 92.7%, p = 0.039). Reoperative surgery is safe in patients with failed repair after postcholecystectomy BDI and good long-term clinical success can be achieved in most of the patients. The long-term results were less satisfactory in failed-repair group than those who underwent primary repair at our institution. Early referral to a specialized unit for BDI repair may improve long-term outcome.

Long-term postoperative outcomes of Roux-en-Y cholangiojejunostomy in patients with benign biliary stricture

Background

Although there are common postoperative complications, Roux-en-Y cholangiojejunostomy is still broadly used as a standard surgical procedure for patients with biliary stricture. This study aimed to explore long-term risk factors of cholangiojejunostomy in patients with biliary stricture who underwent revisional cholangiojejunostomy.

Methods

Clinical data of 61 patients with biliary stricture undergoing revisional cholangiojejunostomy were retrospectively analyzed. These patients were classified into two groups (patients with traumatic biliary stricture and non-traumatic biliary stricture). Postoperative complications and survival time were successfully followed up.

Results

Among the patients, 34 underwent revisional cholangiojejunostomy due to traumatic biliary stricture, and 27 underwent revisional cholangiojejunostomy due to non-traumatic biliary surgery. Although there was no statistical difference in most clinical data between two groups, biliary dilation or not during the first surgery, cholelithiasis or not during the first surgery, long-term complications after first surgery, cholelithiasis or not during the second surgery, identifying abnormalities during the second surgery and long-term complications after second surgery were significantly different. All patients were successfully followed up and average follow-up time for patients with traumatic and non-traumatic biliary stricture was (88.44 ± 35.67) months and (69.48 ± 36.61) months respectively. Survival analysis indicated that there was no statistical difference in overall survival between two groups. Additionally, cox proportional hazard analysis demonstrated that first preoperative bilirubin level, short-term complication after first surgery and identifying abnormalities during the second surgery were independent risk factors that may have significant effects on patients' overall survival and long-term prognosis after cholangiojejunostomy. Among the intraoperative abnormal findings, residual lesions after the first operation had significant effects on the patients overall survival in the earlier stage. Relatively, anastomotic stoma stricture and biliary output loop problems had obvious effects on patients' overall survival at later stages.

Conclusion

First preoperative bilirubin level, short-term complication after first surgery and abnormal findings during the second surgery were independent risk factors of revisional cholangiojejunostomy, which may affect patients' long-term survival. Therefore, surgeons should minimize incidence of postoperative complications through fully evaluating optimal operative time and standardizing surgical procedures.

Actuarial Patency Rates of Hepatico-Jejunal Anastomosis after Repair of Bile Duct Injury at a Reference Center

Background: Bile duct injury complicates patients’ lives, despite the subsequent repair. Repairing the injury must restore continuity of the bile tree and bring the patient into a state of cure referred to as “patency”. Actuarial primary or actuarial secondary patency rates, depending on whether the patient underwent primary or secondary repair of injury, are proposed to be a proper metric in evaluating outcomes. This study was undertaken to assess outcomes of 669 patients with bile duct injuries Strasberg D and E type referred to the department from public surgical wards between 1990 and 2020. In 442 patients, no attempt was made to repair prior to a referral, and in 227 an attempt to repair was made which failed. Methods: Observations were summarized on December 31st, 2020. The retrospective analysis included: primary patency attained (Grade A result), secondary patency attained (Grade C result), patency loss, and actuarial patency rates of the bile tree at 2, 5, and 10 years. Results: Twenty-five (3.7%) patients died after repair surgery. Actuarial patency rates at 2, 5, and 10 years of follow-up were 93%, 88%, and 74% or 86%, 75%, and 55% in patients attaining Grade A and Grade C outcomes, respectively (p < 0.001). Conclusion: Bile duct injury stands out as a surgical challenge, requiring specialized management at a referral center. Improper proceeding after an injury is the factor leading to faster loss of anastomotic patency.

Simultaneous early surgical repair of post-cholecystectomy major bile duct injury and complex abdominal evisceration: A case report

BACKGROUND

Major bile duct injuries (BDIs) are hazardous complications during 0.4%-0.6% of laparoscopic cholecystectomies. Major BDIs usually require surgical repair, ideally either immediately or at least six weeks after the damage. The complexity of our case lies in the coexistence of early BDI followed by 2-week biliary peritonitis with massive midline evisceration which, in combination, has over 40% mortality risk.

METHODS & CASE REPORT

We describe the case of a 65-year-old male, transferred to our tertiary HPB service on day 14 after common bile duct complete transection during cholecystectomy and postoperative laparotomy. The patient presented with biliary peritonitis along with full wound dehiscence and extensive evisceration. During emergency peritoneal wash-out surgery we deemed immediate BDI repair feasible by primary Roux-en-Y hepaticojejunostomy (HJ), with multi-stage abdominal closure. In the following days we performed progressive abdominal wall closure in multiple sessions under general anesthesia, aided by vacuum-assisted wound closure and intraperitoneal mesh-mediated fascial traction-approximation (VAWCM) with permeable mesh. An expected late incisional hernia was eventually repaired through component separation and biological mesh.

DISCUSSION & CONCLUSION

The simultaneous use of Roux-en-Y HJ and VAWCM has proven safe and effective in the treatment of BDI and 2-week biliary peritonitis with massive midline evisceration.

Enterolith in Roux limb causing extrahepatic biliary obstruction in a patient with a hepaticojejunostomy: case report and relevant literature review

Enterolith in the Roux limb of hepaticojejunostomy causing jaundice is a rare occurrence. A 40-year-old woman had an extrahepatic biliary obstruction and cholangitis 13 years after the Roux-en-Y repair of postcholecystectomy benign biliary stricture. On evaluation, an enterolith was obstructing the Roux limb, which was successfully managed surgically.

Isolated vascularized gastric tube biliary enteric drainage: a paediatric case series experience

Background

Despite the enormous surgical advancements in the last century, access to the biliary system is lost when a Roux-en-Y (RY) biliary drainage procedure is performed. Attempts have been made to overcome this inconvenient sequel using variations in the RY anastomosis, small bowel grafts and vascular grafts. These have been predominantly unsuccessful. An isolated vascularized gastric tube (IVGT) graft has been reported in the literature, which was successfully used for adult patients with common bile duct injuries. We have adopted the technique of using an IVGT graft for bile duct reconstruction in the paediatric patients at our institution. We reviewed our experience at our institution between January 2015 and October 2019. This was a retrospective review of all paediatric patients undergoing an IVGT graft procedure for biliary tract anatomical obstruction in the past 5 years. We looked at the indications for surgery, the demographic profile of the patients and outcomes following surgery and outlined the surgical technique used.

Results

IVGT bile duct reconstruction was performed on eight patients. Patients ranged from 2 months to 7 years, and there was an equal number of males and females. The diagnosis was made on clinical suspicion and confirmed with ultrasound (U/S) and magnetic resonance cholangiopancreatography (MRCP). There was an 87.5% resolution of biliary obstruction, and two patients who had bile leaks postoperatively were managed conservatively. Unfortunately, one patient died in the early postoperative period from sepsis due to pneumonia. Follow-up was for a minimum of 6 months and up to 5 years.

Conclusion

IVGT biliary enteric drainage is a safe, reproducible procedure that allows access to the biliary tree if required in the future. Thus, this procedure serves as an alternative, especially in limited-resource areas where interventional radiology is not available for future interventions.

Risk factors for anastomotic stricture after hepaticojejunostomy for bile duct injury-A systematic review and meta-analysis

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.

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.

Helping the Surgeon Recover: Peer-to-Peer Coaching after Bile Duct Injury

BACKGROUND

Bile duct injury sustained during laparoscopic cholecystectomy is associated with high morbidity and mortality, and can be a devastating complication for a general surgeon. We introduce a novel, individualized surgical coaching program for surgeons who recently injured a bile duct in laparoscopic cholecystectomy. We aim to explore the perception of coaching among these surgeons and to assess surgeons' experiences in the coaching program.

STUDY DESIGN

Six general surgeons who injured a bile duct at an emergency laparoscopic cholecystectomy participated in a 1-on-1 coaching session with a hepatopancreatobiliary surgeon. The session focused on debriefing the index case with video feedback, and discussion of strategies for safe laparoscopic cholecystectomy. The pilot program ran from March to November 2020. Exit interviews were then conducted. Themes covering perception of surgical training, perception of complications, and experience in the coaching program were explored.

RESULTS

Surgeons were generally accepting of the coaching program, especially when the goals aligned with their self-identified areas of development. One-on-1 sessions with a local expert in the area, and the use of video feedback created a unique and interactive coaching opportunity. Peer coaching was identified as a valuable resource in helping surgeons regain confidence and maintain well-being after a bile duct injury. Maintaining a collegial, nonjudgmental relationship is critical in establishing positive coaching experiences.

CONCLUSIONS

An individualized surgical coaching program creates a unique opportunity for professional development and may help promote safe laparoscopic cholecystectomy.

Impact of referral pattern and timing of repair on surgical outcome after reconstruction of post-cholecystectomy bile duct injury: A multicenter study

BACKGROUND

Bile duct injury (BDI) after cholecystectomy remains a significant surgical challenge. No guideline exists to guide the timing of repair, while few studies compare early versus late repair BDI. This study aimed to analyze the outcomes in patients undergoing immediate, intermediate, and delayed repair of BDI.

METHODS

We retrospectively analyzed 412 patients with BDI from March 2015 to January 2020. The patients were divided into three groups based on the time of BDI reconstruction. Group 1 underwent an immediate reconstruction (within the first 72 hours post-cholecystectomy, n = 156); group 2 underwent an intermediate reconstruction (from 4 days to 6 weeks post-cholecystectomy, n = 75), and group 3 underwent delayed reconstruction (after 6 weeks post-cholecystectomy, n = 181).

RESULTS

Patients in group 2 had significantly more early complications including anastomotic leakage and intra-abdominal collection and late complications including anastomotic stricture and secondary liver cirrhosis compared with groups 1 and 3. Favorable outcome was observed in 111 (71.2%) patients in group 1, 31 (41.3%) patients in group 2, and 157 (86.7%) patients in group 3 (P = 0.0001). Multivariate analysis identified that complete ligation of the bile duct, level E1 BDI and the use of external stent were independent factors of favorable outcome in group 1, the use of external stent was an independent factor of favorable outcome in group 2, and level E4 BDI was an independent factor of unfavorable outcome in group 3. Transected BDI and level E4 BDI were independent factors of unfavorable outcome.

CONCLUSIONS

Favorable outcomes were more frequently observed in the immediate and delayed reconstruction of post-cholecystectomy BDI. Complete ligation of the bile duct, level E1 BDI and the use of external stent were independent factors of a favorable outcome.

Impact of iatrogenic biliary injury during laparoscopic cholecystectomy on surgeon's mental distress: a nationwide survey from China

BACKGROUND

Iatrogenic biliary injury (IBI) following laparoscopic cholecystectomy (LC) is the most serious iatrogenic complications. Little is known whether LC-IBI would lead to surgeon's severe mental distress (SMD).

METHODS

A cross-sectional survey in the form of electronic questionnaire was conducted among Chinese general surgeons who have caused LC-IBI. The six collected clinical features relating to mental distress included: 1) feeling burnout, anxiety, or depression, 2) avoiding performing LC, 3) having physical reactions when recalling the incidence, 4) having the urge to quit surgery, 5) taking psychiatric medications, and 6) seeking professional psychological counseling. Univariable and multivariable analyses were performed to identify risk factors of SMD, which was defined as meeting ≥3 of the above-mentioned clinical features.

RESULTS

Among 1466 surveyed surgeons, 1236 (84.3%) experienced mental distress following LC-IBI, and nearly half (49.7%, 614/1236) had SMD. Multivariable analyses demonstrated that surgeons from non-university affiliated hospitals (OR:1.873), patients who required multiple repair operations (OR:4.075), patients who required hepaticojejunostomy/partial hepatectomy (OR:1.859), existing lawsuit litigation (OR:10.491), existing violent doctor-patient conflicts (OR:4.995), needing surgeons' personal compensation (OR:2.531), and additional administrative punishment by hospitals (OR:2.324) were independent risk factors of surgeon's SMD.

CONCLUSION

Four out of five surgeons experienced mental distress following LC-IBI, and nearly half had SMD. Several independent risk factors of SMD were identified, which could help to make strategies to improve surgeons' mental well-being.

Novel case of percutaneous access of afferent limb of Roux-en-Y hepaticojejunostomy for biliary decompression and jejunoplasty in a patient with primary sclerosing cholangitis

Primary sclerosing cholangitis is a rare condition characterized by multifocal fibrotic bile duct strictures and progressive liver disease. Due to its recurrence even after liver transplantation, an alternative surgical procedure, the Roux-en-Y hepaticojejunostomy, is practiced with positive outcomes. We present a case of a 55-year-old female with history of primary sclerosing cholangitis and Roux-en-Y hepaticojejunostomy approximately 25 years ago who presented to the emergency department with acute cholangitis. Computed tomography of the abdomen revealed a dilated loop of small bowel in the right upper quadrant and mid-abdomen with normal bile duct caliber. Interventional radiology was consulted for percutaneous biliary and Roux limb decompression. Ultrasound was utilized to identify and percutaneously access the dilated afferent jejunal limb. With the help of a T-fastener, the jejunal loop was tacked against the anterior abdominal wall and the system was successfully decompressed with a drain left in place. On follow-up, delayed contrast transit through the Roux limb and a stricture in the native jejunum distal to the anastomosis was identified. Hampering of the downstream flow of bile was noted and this was determined to be the likely cause of the initial episode of cholangitis. The strictured bowel segment was balloon-dilated by interventional radiology. Repeat injection of contrast revealed significant improvement in the caliber of the stenotic segment. At 3 weeks' postprocedure, a follow-up enteroscopy of the bowel was performed through the same percutaneous access site. Using this technique, the patient avoided a major invasive surgical procedure.

Quality-of-life after bile duct injury repaired by hepaticojejunostomy: a national cohort study

OBJECTIVES

Reports on quality-of-life (QoL) after bile duct injury (BDI) show conflicting results. The aim of this cohort study was to evaluate QoL stratified according to type of treatment.

METHODS

QoL assessment using the SF-36 (36-item short form health survey) questionnaire. Patients with post-cholecystectomy BDI needing hepaticojejunostomy (HJ) were compared to all other treatments (BDI repair) and to patients without BDI at cholecystectomy (controls).

RESULTS

Patients needing a HJ after BDI reported reduced long-term QoL irrespective of time for diagnosis and repair in both the physical (PCS; p < .001) and mental (MCS; p < .001) domain compared to both controls and patients with less severe BDI. QoL was comparable for BDI repair (n = 86) and controls (n = 192) in both PCS (p = .171) and MCS (p = .654). As a group, patients with BDI (n = 155) reported worse QoL than controls, in both the PCS (p < .001) and MCS (p = .012). Patients with a BDI detected intraoperatively (n = 124) reported better QoL than patients with a postoperative diagnosis. Patients with an immediate intraoperative repair (n = 99), including HJ, reported a better long-term QoL compared to patients subjected to a later procedure (n = 54).

CONCLUSIONS

Patients with postoperative diagnosis and patients with BDIs needing biliary reconstruction with HJ both reported reduced long-term QoL.

Hepaticojejunostomy for Benign Disease: Long-Term Stricture Rate and Management

The objective of the study was to determine the long-term stricture rate of hepaticojejunostiomy (HJ) performed for benign disease, to compare stricture rates for transplant patients and non-transplant patients, and to compare the success rates of procedural and surgical treatment options. Hospital charts of 135 consecutive patients undergoing HJ between 1998 and 2016 were analyzed retrospectively. The primary outcome was stricture formation. Secondary outcomes were time to stricture diagnosis and success rates of various interventions. The anastomotic stricture rate was 13.3 per cent (18). The mean follow-up period was 4.3 years. The mean time to stricture diagnosis was 2.3 years. Stricture rates were similar between the transplant (19.2%) and nontransplant, non-Whipple group (13%). Strictures were treated with radiological intervention with a 44.4 per cent success rate; each required multiple interventions. Mortality from liver disease after failure of nonoperative management of HJ strictures reached 30 per cent (3). Five of ten patients who failed radiological intervention underwent HJ revision; the success rate was 80 per cent. Anastomotic strictures of HJ performed for benign disease occur in 13 per cent of patients and typically develop within 2.5 years postoperatively. Yet, given the dangerous sequelae of chronic biliary obstruction and potential delay in presentation, a follow-up is recommended for up to 10 years. When strictures occur, HJ revision should be considered early, after two failed radiological interventions.

Long-term results of secondary biliary repair for cholecystectomy-related bile duct injury: results of a tertiary referral center

Background: Management of bile duct injury (BDI) after cholecystectomy is challenging. The authors analyzed their center's 49-year experience.Methods: From 1968 to 2016, 120 consecutive patients were managed in a tertiary HBP center, 105 referred from other centers (Group A), 15 from our center (Group B). Surgical strategies and long-term outcomes were retrospectively reviewed.Results: Primary cholecystectomy approach was open in 35% and laparoscopic in 65%. In Group A, intraoperative BDI diagnosis was made in 25/105 patients, including 13 via intraoperative cholangiography (IOC) which was used in 21% of cases. Median time from BDI to referral was 148 days (range 0-10,758), and 3 patients had BDI-related secondary cirrhosis. Ninety-four patients underwent secondary surgical repair, mostly a complex biliary procedure (97%). Postoperative overall and severe morbidity rates were 26% and 6%, respectively. One patient with biliary cirrhosis at referral died postoperatively from hepatic failure. Nine patients (9.6%) developed a secondary biliary stricture after a median of 54 months from repair (6-228 months). In Group B, IOC was performed in 14/15 in whom BDI were intraoperatively detected and immediately repaired. There were 13 minor and 2 major BDIs, all repaired by uncomplex procedures with uneventful postoperative course. One patient had a secondary biliary stricture after 5 months, successfully treated by temporary endoprosthesis.Conclusion: Late follow-up after primary or secondary repair of BDI is recommended to detect recurrent biliary stricture. Bile duct injuries may occur in a tertiary center, but are intraoperatively detected with routine IOC and immediately repaired resulting in satisfactory outcome.

Long-term outcomes of endoscopic treatment of aberrant hepatic duct injuries after cholecystectomy

BACKGROUND AND AIMS

Right aberrant hepatic ducts are an anatomic variant with clinical relevance because of the risk of injury during cholecystectomy. Treatment options for aberrant hepatic duct injuries are not standardized. This study aims to analyze the long-term results of endoscopic treatment of aberrant hepatic duct lesions.

METHODS

Patients who underwent ERCP for aberrant hepatic duct lesions were retrospectively identified. Demographic data, type of aberrant duct lesion according to the Strasberg classification, type of treatment (number of plastic stents inserted, treatment duration, and number of ERCPs), and adverse events were recorded. Follow-up was obtained by telephone contact or medical examinations.

RESULTS

Between January 1996 and March 2019, 32 patients (78% women, mean age 51.7 years) with aberrant hepatic duct injuries underwent ERCP at our Endoscopy Unit. Six patients had Strasberg type B lesions, 11 patients had type C, and 8 patients had type E5, and 7 patients had a stenosis of the aberrant duct. A mean of 3.7 biliary plastic stents per patient were used; mean treatment duration was 6.3 months. All patients with isolated aberrant duct stenosis and 1 of 6 patients (17%) with type B Strasberg lesions achieved patency. Ten of 11 patients (91%) with type C Strasberg lesions achieved duct recanalization. After a mean follow-up of 109.3 ± 61.2 months, 29 of 32 patients (91%) were asymptomatic; 1 underwent surgery for recurrent cholangitis, 1 received a new endoscopic procedure because of cholangitis, and 1 reported episodic biliary colic without an increase in liver function test values and was successfully managed with a low-fat diet.

CONCLUSIONS

An endoscopic approach to aberrant hepatic duct lesions after cholecystectomy can be considered an effective first-line therapy.

Endotherapy of postcholecystectomy biliary strictures with multiple plastic stents: long-term results in a large cohort of patients

BACKGROUND AND AIMS

Endoscopic therapy of benign biliary strictures with multiple plastic stent (MPS) placement has shown satisfactory results. However, the literature describes various benign biliary stricture etiologies. The aim of this study was to evaluate long-term MPS results in patients with postcholecystectomy biliary strictures (PCBSs).

METHODS

PCBS patients without complete bile duct transection were included. ERCP consisted of placing an increasing plastic stent number over time, exchanged at regular intervals (3-4 months), until complete morphologic stricture disappearance. After stent removal, patient follow-up comprised liver function tests and clinical assessment.

RESULTS

One hundred fifty-four patients (43.5% men; mean age, 53 years) were enrolled; in 43% of the cases, PCBSs were involved or were close to the main hepatic confluence. PCBS resolution rate was 96.7% (n = 149). A mean maximum number of 4.3 ± 1.6 stents were placed side-by-side; a mean of 4.2 ± 1.5 ERCPs per patient was needed to obtain PCBS resolution during a mean treatment period of 11.8 ± 6.4 months. Unscheduled stent exchange because of cholangitis, jaundice, or pain occurred in 7.4% of cases. Procedure-related mortality was absent. Follow-up data were available in 85.2% of cases. After a mean follow-up of 11.1 ± 4.9 years, stricture recurrence rate was 9.4% (n = 12). Subsequent to retreatment, 83.3% of patients (n = 10) were asymptomatic after a mean time of 9 years, whereas 2 patients underwent hepaticojejunostomy because of failed retreatment. Statistical analysis revealed no risk factors for PCBS recurrence after MPS.

CONCLUSIONS

Endoscopic therapy of PCBSs with MPSs is safe and effective at long-term follow-up. PCBSs involving or close to the main hepatic confluence were successfully treated with MPSs. PCBS recurrence rate is low and can be successful endoscopically retreated without precluding possible surgical treatment.

Does non-operative management of iatrogenic bile duct injury result in impaired quality of life? A systematic review

BACKGROUND

Several studies have reported the effect of bile duct injury (BDI) on health-related quality of life (HRQOL) with conflicting results. This systematic review aims to study the impact of patient and treatment factors on HRQOL after BDI.

METHODS

A search of the PubMed database was performed and studies were reviewed as per the PRISMA guidelines. Selected studies (n = 11) were then divided into two subgroups depending on whether they found HRQOL to be similar or worse between BDI and control groups. Pooled rates of surgical repair and major BDI were calculated for each of these subgroups.

RESULTS

Surgical repair rates were 99% (95% CI: 96%-99%) in studies where the BDI patients had similar outcomes to controls, compared to 78% (40%-100%) where their outcomes were significantly worse (p = 0.091). The major BDI rate was 51% (95% CI: 42%-61%) in studies where the BDI patients had similar outcomes to controls, compared to 72% (41%-94%) where their outcomes were significantly worse (p = 0.322). Considerable heterogeneity was present within the two subgroups (I²: 68-99%).

DISCUSSION

HRQOL may be adversely affected amongst patients with BDI who do not undergo surgical repair. Significant heterogeneity of data suggests the need for standardised HRQOL tools and injury severity systems when assessing outcomes after BDI.

Utilization of a Modified Roux-en-Y Anastomosis as an Access point for Percutaneous Transjejunal Cholangioplasty of Recurrent Biliary Strictures

INTRODUCTION

Biliary duct injuries pose a significant management challenge due to the propensity for recurrent biliary strictures. Development of a modified Roux-en-Y hepaticojejunostomy known as a Hutson-Russell Pouch (HRP) provides a point of entry for repetitive access to the biliary tree. We aim to highlight the effectiveness of using the HRP as an access point for the long-term management of anastomotic and distal biliary strictures, thereby showcasing the value in potential widespread adoption of this modification to a standard surgical procedure.

MATERIALS AND METHODS

IRB-approved retrospective study of 36 patients (10 M, 26 F; mean age 55.19 ± 13.94; 15-83) underwent a total of 110 transjejunal cholangiograms. Indications for cholangiogram included cholangitis (n = 38), surveillance (n = 36), and elevated liver enzymes (n = 36). Technical success was defined by the ability to access and intervene in the biliary tree via HRP access. In case of stenosis, the ability to successfully dilate (< 30%) residual stenosis was considered a technically successful procedure. Clinical success was defined by normalization of the liver function tests or resolution of cholangitis.

RESULTS

Technical success was achieved in 83/110 (75.45%) of the cases, and clinical success was achieved in 102/110 (98.2%). Transhepatic access was needed in 27/110 (24.5%) of the cases. Interventions performed included balloon cholangioplasty in 104/110 (94.5%), biliary stone removal in 2/110 (1.8%), biliary stent placement in 2/110 (1.8%), and biliary drain placement in 4/110 (3.6%). There were a total of 9/110 complications (8.2%).

CONCLUSION

The HRP was an effective access point in the management of recurrent benign biliary strictures in this cohort.

Bile duct injury repairs: Progressive outcomes in a tertiary referral center

BACKGROUND

Bile duct injury during laparoscopic cholecystectomy persists as a significant problem in general surgery, resulting in complex injuries, arterial damage, and post repair strictures.

METHODS

We performed a retrospective analysis between 2 eras of bile duct injury repairs: 1987 to 2001 (n = 58) and 2002 to 2016 (n = 52) using logistic regression analyses to assess presentation, repair complexity, and outcomes.

RESULTS

No differences in demographics, incidence of cholecystitis, conversion, time to presentation, level of injury, or arterial injury were identified. The second era had an increase in patient age, transhepatic catheter use, prior repair, and utilization of complex repairs. This approach resulted in equivalent complications and mortality rates with increased resource utilization but a lesser incidence of post-repair strictures (P = .004). Regression modeling correlated strictures to prior operative repairs (OR 4.25; P = .016) and a protective effect of repairs performed in the second era (OR 0.23; P = .045).

CONCLUSION

The second era identified a decreasing trend of attempted repairs by referring surgeons but an increase in transhepatic catheters and complex repairs resulting in lesser rates of post-repair stricture. Final regression modeling confirmed increased operative experience decreased post-repair stricture reaffirming the benefits of early identification and referral of bile duct injuries to an experienced hepatobiliary surgeon at a specialty center.

Outcomes of surgery for post-cholecystectomy bile duct injuries: An audit from a tertiary referral center

AIM OF THE STUDY

Bile duct injury (BDI) after cholecystectomy is a serious complication. It often requires surgical repair. The aim of this study was to report on the short and long-term outcomes of surgery for post-cholecystectomy BDI.

PATIENTS AND METHODS

All the patients, who underwent surgery for post-cholecystectomy BDI between August 2007 and September 2017, were retrospectively reviewed. McDonald grading system was used to assess the long-term outcome. The risk factors for unsatisfactory long-term outcome were analyzed by univariate and multivatiate logistic regression analysis.

RESULTS

In total, 228 patients had a Roux-en-Y hepaticojejunostomy. Open cholecystectomy was the major cause of BDI (61%). The median time from injury to definitive repair was 6 months. The types of BDI were as follows: E1 in 13 (5.7%), E2 in 68 (29.82%), E3 in 108 (47.36%), E4 in 28 (12.28%), and E5 in 11 (4.82%) patients respectively. Postoperative morbidity and mortality were 25% and 1.31% respectively. After a median follow-up of 58 months, 90% patients had excellent to good outcome. Recurrent stricture developed in 6 (3%) patients. On multivariate analysis, long injury-repair interval and previous attempt at repair were independent predictors for unsatisfactory long-term outcome.

CONCLUSION

Surgical reconstruction affords excellent to good results for majority of the patients with post-cholecystectomy BDI. As longer delay in definitive repair and previous attempt at repair were associated with unsatisfactory long-term outcome, early referral to a specialized hepatobiliary surgery unit is recommended.

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

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.

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

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.

Klebsiella pneumoniae Liver Abscess

Since the mid 1980s, the prevalence of liver abscess caused by hypervirulent Klebsiella pneumoniae strain has increased in Asia, particularly in Taiwan and Korea. This strain is mostly K1 or K2 serotype, and has hypercapsular and hypermucoid phenotypes. Most infections are community acquired, and patients rarely have a hepatobiliary disease prior to infection. Clinical manifestations are characterized by fever and high C-reactive protein, and metastatic infections, such as septic emboli in the lung and endophthalmitis and meningitis are frequently observed. Antibiotic resistance is rare. Antibiotic treatment and abscess drainage are needed, and early diagnosis and treatment of endophthalmitis is also important.

Long-term follow-up and risk factors for strictures after hepaticojejunostomy for bile duct injury: An analysis of surgical and percutaneous treatment in a tertiary center

BACKGROUND

Hepaticojejunostomy is commonly indicated for major bile duct injury after cholecystectomy. The debate about the timing of hepaticojejunostomy for bile duct injury persists since data on postoperative outcomes, including postoperative strictures, are lacking. The aim of this study was to analyze short- and long-term outcomes of hepaticojejunostomy for bile duct injury, including risk factors for strictures.

METHOD

Analysis of outcome of hepaticojejunostomy in bile duct injury patients referred to a multidisciplinary team.

RESULTS

Between the years1991 and 2016, 281 patients underwent hepaticojejunostomy for bile duct injury. Clavien-Dindo grade III complications occurred in 31 patients (11%) and 90-day mortality occurred in 2 patients (0.7%). After a median follow-up of 10.5 years (interquartile range 6.7-14.8 years), clinically relevant strictures were found in 37 patients (13.2%). Strictures were treated with percutaneous dilatation in 33 patients (89.2%), and 4 patients (1.4%) were reoperated. The stricture rate in patients undergoing hepaticojejunostomy <14 days, between 14-90 days, and >90 days after bile duct injury was 15.8%, 18.7%, and 9.9%, respectively. The stricture rate for early versus intermediate and late repair did not differ (P = 0.766 and 0.431, respectively). The stricture rate for repair after 14-90 days, however, was higher compared with repair >90 days after bile duct injury (P = 0.045). In multivariable analysis male gender was the only independent variable associated with stricture formation (OR 6.7, 95% CI 1.8-25.4, P = 0.005).

CONCLUSION

Hepaticojejunostomy is a relatively safe treatment of bile duct injury. Timing of surgery and intermediate repair affect long-term stricture rate; most anastomotic strictures can be treated successfully with percutaneous dilation.

Quality of Life and Medico-Legal Implications Following Iatrogenic Bile Duct Injuries

In this review we aimed to evaluate quality of life after bile duct injury and the consequent medico-legal implications. A comprehensive English language literature search was performed on MEDLINE, Embase, Science Citation Index and Google™ Scholar databases for articles published between January 2000 and April 2016. The last date of search was 11 April 2016. Key search words included bile duct injury, iatrogenic, cholecystectomy, prevention, risks, outcomes, quality of life, litigation and were used in combination with the Boolean operators AND, OR and NOT. Long-term survival after bile duct injury is significantly impaired (all-cause long-term mortality approximately 21 %) along with the quality of life (especially psychological/mental state remains affected). Bile duct injury is associated with high rates of litigation. Monetary compensation varied from £2500 to £216,000 in the UK, €9826-€55,301 in the Netherlands and $628,138-$2,891,421 in the USA. Bile duct injuries have profound implications for patients, medical personnel and healthcare providers as they cause significant morbidity and mortality, high rates of litigation and raised healthcare expenditure.

Surgeons opinions of legal practice in bile duct injury following cholecystectomy

INTRODUCTION

Litigation for bile duct injury following laparoscopic cholecystectomy places financial strain on the health service, causes significant patient morbidity and adversely affects the patient and surgeon. Claimants argue that the injury itself is evidence of negligence.

METHODS

A questionnaire addressing views on BDI causation was sent to members of AUGIS working in the National Health Service, UK. Response themes and responses were compared between groups of surgeons.

RESULTS

Of 117 respondents, 45% experienced BDI and 22% had medicolegal experience. 47% of respondents identified factors outside the surgeons control as being relevant to BDI. Those that had experienced BDI from their own surgery were less likely to identify surgeon/systems errors as the primary cause for BDI than those that had not (34% vs 74%, p < 0.001). Medicolegal expert surgeons were more likely to report that substandard technique should be presumed (50% vs 19%, p = 0.002), however, 25% of medicolegal experts indicated that not all BDIs caused by their own surgery could have been avoided.

CONCLUSION

A significant number of experienced surgeons indicated that BDI following LC should not be assumed to result from surgeon negligence or institutional failure. This suggests that negligence should not be inferred from the act of BDI alone.

Meta-Analysis of the Long Term Success Rate of Different Interventions in Benign Biliary Strictures

Background

Benign biliary stricture is a rare condition and the majority of the cases are caused by operative trauma or chronic inflammation based on various etiology. Although the initial results of endoscopic, percutaneous and surgical treatment are impressive, no comparison about long term stricture resolution is available.

Aims

The goal of this study was to compare the long term disease free survival in benign biliary strictures with various etiology after surgery, percutaneous transhepatic—and endoscopic treatment.

Methods

PubMed, Embase, and Cochrane Library were searched by computer and manually for published studies. The investigators selected the publications according to the inclusion and exclusion criteria, processed the data and assessed the quality of the selected studies. Meta-analysis of data of 24 publications was performed to compare long term disease free survival of different treatment groups.

Results

Compared the subgroups surgery resulted in the highest long term stricture resolution rate, followed by the percutaneous transhepatic treatment, the multiple plastic stent insertion and covered self-expanding metal stents (SEMS), however the difference was not significant. All compared methods are significantly superior to the single plastic stent placement. Long term stricture resolution rate irrespectively of any therapy is still not more than 84%.

Conclusions

In summary, the use of single plastic stent is not recommended. Further randomized studies and innovative technical development are required for improving the treatment of benign biliary strictures.

Risk factors for increased resource utilization and critical care complications in patients undergoing hepaticojejunostomy for biliary injuries

BACKGROUND

This project aimed to study resource utilization and surgical outcomes after hepaticojejunostomy (HJ) for biliary injuries utilizing data from ACS NSQIP.

METHODS

Data from the Participant Use Data File containing surgical patients submitted to the ACS NSQIP during the period of 1/1/2005-12/31/2014 were analyzed.

RESULTS

During the study period, 320 patients underwent HJ. Mean age was 50 years, and 109 (34%) were male. Forty-four percent of patients met criteria for ASA class III-V. Forty patients (12.5%) developed one or more critical care complications (CCC). Eighty-one patients (25%) experienced morbidity with a perioperative mortality rate of 1.9%. The mean age of these patients was 52 years, and 62% were male. Age and preoperative elevated alkaline phosphatase were independent predictors of CCC (p < 0.001 and 0.042, OR 1.035, OR 4.337, respectively). Patients ASA class III, age, and preoperative hypoalbuminemia were found to increase risk for prolonged LOS (OR 1.87, p = 0.041, OR 1.02, p = 0.049, OR 2.63, p = 0.001).

DISCUSSION

The most significant predictors of morbidity and increased resource utilization after HJ include increasing age, ASA class III or above, and preoperative hypoalbuminemia. Age and ASA class are the strongest predictors of CCC in these patients.

Iatrogenic common bile duct injuries: Increasing complexity in the laparoscopic era: A prospective cohort study

PURPOSE

Iatrogenic bile duct injury (BDI) is the most significant associated complication to laparoscopic cholecystectomy (LC). Little is known about the evolution of the pattern of BDI in the era of laparoscopy. The aim of the study is to assess the pattern of post-LC BDIs managed in a tertiary referral centre.

METHODS

Post-LC BDI referred over two decades were studied. Demographic data, type of BDI (classified using the Strasberg System), clinical symptoms, diagnostic investigations, timing of referral, post-referral management and morbidity were analysed. The pattern of injury, associated vascular injuries rate and their management were compared over two time periods (1992-2004,2005-2014).

RESULTS

78 BDIs were referred. During the second time period Strasberg A injuries decreased from 14% to 0 and Strasberg E1increased from 4% to 23%, the rate of associated vascular injury was six time higher (3.6% versus 22.7%), more patients had an attempted repair at the index hospital (16% versus 35%) sand fewer patients could be managed without surgical intervention at the referral hospital (28% versus 4%).

CONCLUSION

Complexity of referred BDIs and rate of associated vascular injuries have increased over time. These findings led to more patients managed requiring surgical intervention at the referral hospital.

Incidence of hepaticojejunostomy stricture after hepaticojejunostomy

BACKGROUND

Operations requiring biliary-enteric anastomosis are uncommon, and the true incidence of postoperative stricture is unknown. Our goal was to determine the timing, incidence, and management of stricture after biliary-enteric anastomosis.

METHODS

We used 5% Medicare claims data (1996-2011) to identify patients ≥66 years who underwent an operation requiring a biliary-enteric anastomosis. A cumulative incidence curve was used to describe timing of stricture diagnosis. The use of imaging and intervention was evaluated. A Cox proportional hazards model was constructed to identify factors associated with stricture.

RESULTS

A total of 3,374 patients underwent an operation requiring either a hepaticojejunostomy (54.33%; N = 1,833) or choledochojejunostomy (45.67%; N = 1,541); 2-year survival was 57.0%. Overall, 403 (11.9%) patients developed a stricture. The cumulative incidence of stricture was 12.5% at 2 years. Mean time to stricture diagnosis was 16.8 ± 21.6 months (median = 8.5 months); 23% of patients with a stricture required hospitalization for cholangitis (N = 94). Only 18 (4.5%) patients with a stricture required reoperation. Younger age (hazard ratio 0.98; 95% confidence interval 0.98-0.99) was associated with a decreased likelihood of stricture formation; presence of an endostent (hazard ratio 1.66; 95% confidence interval 1.35-2.04) predicted stricture formation.

CONCLUSION

Biliary-enteric anastomotic strictures occur with significant frequency after a biliary-enteric anastomosis. Although many patients are managed nonoperatively, stricture diagnosis remains burdensome.