Open cholecystectomy. A contemporary analysis of 42,474 patients

Surgical quality assessment of critical view of safety in 283 laparoscopic cholecystectomy videos by surgical residents and surgeons

INTRODUCTION

Surgical quality assessment has improved the efficacy and efficiency of surgical training and has the potential to optimize the surgical learning curve. In laparoscopic cholecystectomy (LC), the critical view of safety (CVS) can be assessed with a 6-point competency assessment tool (CAT), a task commonly performed by experienced surgeons. The aim of this study is to determine the capability of surgical residents to perform this assessment.

METHODS

Both surgeons and surgical residents assessed unedited LC videos using a 6-point CVS, a CAT, using an online video assessment platform. The CAT consists of the following three criteria: 1. clearance of hepatocystic triangle, 2. cystic plate, and 3. two structures connect to the gallbladder, with a maximum of 2 points available for each criterion. A higher score indicates superior surgical performance. The intraclass correlation coefficient (ICC) was employed to assess the inter-rater reliability between surgeons and surgical residents.

RESULTS

In total, 283 LC videos were assessed by 19 surgeons and 31 surgical residents. The overall ICC for all criteria was 0.628. Specifically, the ICC scores were 0.504 for criterion 1, 0.639 for criterion 2, and 0.719 for the criterion involving the two structures connected to the gallbladder. Consequently, only the criterion regarding clearance of the hepatocystic triangle exhibited fair agreement, whereas the other two criteria, as well as the overall scores, demonstrated good agreement. In 71% of cases, both surgeons and surgical residents scored a total score either ranging from 0 to 4 or from 5 to 6.

CONCLUSION

Compared to the gold standard, i.e., the surgeons' assessments, surgical residents are equally skilled at assessing critical view of safety (CVS) in laparoscopic cholecystectomy (LC) videos. By incorporating video-based assessments of surgical procedures into their training, residents could potentially enhance their learning pace, which may result in better clinical outcomes.

Development of an artificial intelligence system for real-time intraoperative assessment of the Critical View of Safety in laparoscopic cholecystectomy

BACKGROUND

The Critical View of Safety (CVS) was proposed in 1995 to prevent bile duct injury during laparoscopic cholecystectomy (LC). The achievement of CVS was evaluated subjectively. This study aimed to develop an artificial intelligence (AI) system to evaluate CVS scores in LC.

MATERIALS AND METHODS

AI software was developed to evaluate the achievement of CVS using an algorithm for image classification based on a deep convolutional neural network. Short clips of hepatocystic triangle dissection were converted from 72 LC videos, and 23,793 images were labeled for training data. The learning models were examined using metrics commonly used in machine learning.

RESULTS

The mean values of precision, recall, F-measure, specificity, and overall accuracy for all the criteria of the best model were 0.971, 0.737, 0.832, 0.966, and 0.834, respectively. It took approximately 6 fps to obtain scores for a single image.

CONCLUSIONS

Using the AI system, we successfully evaluated the achievement of the CVS criteria using still images and videos of hepatocystic triangle dissection in LC. This encourages surgeons to be aware of CVS and is expected to improve surgical safety.

Identification and management of subvesical bile duct leakage after laparoscopic cholecystectomy: A systematic review

Bile leak is a rare complication after Laparoscopic Cholecystectomy. Subvesical bile duct (SVBD) injury is the second cause of minor bile leak, following the unsuccessful clipping of the cystic duct stump. The aim of this study is to pool available data on this type of biliary tree anatomical variation to summarize incidence of injury, methods used to diagnose and treat SVBD leaks after LC. Articles published between 1985 and 2021 describing SVBD evidence in patients operated on LC for gallstone disease, were included. Data were divided into two groups based on the intra or post-operative evidence of bile leak from SVBD after surgery. This systematic report includes 68 articles for a total of 231 patients. A total of 195 patients with symptomatic postoperative bile leak are included in Group 1, while Group 2 includes 36 patients describing SVBD visualized and managed during LC. Outcomes of interest were diagnosis, clinical presentation, treatment, and outcomes. The management of minor bile leak is controversial. In most of cases diagnosed postoperatevely, Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is the best way to treat this complication. Surgery should be considered when endoscopic or radiological approaches are not resolutive.

Laparoscopic Cholecystectomy Versus Open Cholecystectomy in Acute Cholecystitis: A Literature Review

Cholecystectomy is a common surgical procedure performed worldwide for acute cholecystitis. Acute cholecystitis occurs when the cystic duct is obstructed by a gallstone, which causes gallbladder distension and subsequent inflammation of the gallbladder. Acute cholecystitis is characterized by pain in the right upper quadrant, anorexia, nausea, fever, and vomiting. Cholecystectomy is the treatment of choice for acute cholecystitis. The two commonly performed types of cholecystectomies are open cholecystectomy and laparoscopic cholecystectomy. However, the approach of choice widely fluctuates with regard to various factors such as patient history and surgeon preference. It is imperative to understand the variations in outcomes of different approaches and how best they fit an individual patient when deciding the technique to be undertaken. This article reviews several studies and compares the two techniques in terms of procedure, mortality rate, complication rate, bile leak/injury rate, conversion rate, and bleeding rate.

Transgastric versus transrectal: Which access route is the best for NOTES gallbladder-preserving gallstone therapy?

OBJECTIVES

To compare the effectiveness and safety of transgastric and transrectal pure natural orifice transluminal endoscopic surgery (NOTES) for cholecystolithotomy.

METHODS

This was a single-center retrospective comparative study of consecutive patients who underwent pure NOTES for either transrectal or transgastric gallbladder-preserving cholecystolithotomy between September 2017 and April 2020. Patients with symptomatic cholelithiasis were assigned for transrectal or transgastric NOTES based on the patients' choice. Treatment success, postoperative pain, peritonitis, time to resume normal diet, and duration of hospitalization were compared.

RESULTS

The technical success rate was 100%. Forty-eight patients underwent successful NOTES cholecystolithotomy via the transrectal (n = 26) or transgastric route (n = 22). One (3.8%) patient in the transrectal NOTES group experienced postoperative abdominal pain compared to 6 (27.3%) in the transgastric NOTES group (P = 0.04). Fever and bile peritonitis developed in one (3.8%) patient in the transrectal NOTES group versus 8 (36.4%) in the transgastric NOTES group (P = 0.005). A postoperative fluid diet was commenced at 6 h with the transrectal approach versus on day 3 for the transgastric NOTES group. The mean postoperative hospitalization for transrectal and transgastric NOTES groups was 4.5 days versus 7 days (P = 0.001). Three patients in the transgastric NOTES group developed postoperative gastric fistula.

CONCLUSIONS

Transrectal NOTES has advantages over transgastric NOTES, including preserved spatial orientation, relatively easier removal of specimens, early food intake, shorter hospitalization, fewer postoperative complications and less pain. Multicenter clinical trials with long-term follow-up are needed to confirm the safety and efficacy of both approaches.

Laparoscopic Surgery with Concomitant Hernia Repair and Cholecystectomy: An Alternative Approach to Everyday Practice

Introduction: Concomitant surgeries have been performed previously in several centers with experience in laparoscopic surgeries. These surgeries are performed in one patient under one operation with anesthesia. Methods: We performed a retrospective unicenter study from October 2021 to December 2021 analyzing patients who underwent laparoscopic hiatal hernia repair with cholecystectomy. We extracted data from 20 patients who underwent hiatal hernia repair together with cholecystectomy. Grouping of data by hiatal hernia type showed 6 type IV hernias (complex hernia), 13 type III hernias (mixed type) and 1 type I hernia (sliding hernia). Out of the 20 cases analyzed, 19 were patients suffering from chronic cholecystitis and 1 patient presented with acute cholecystitis. The average operating time was 179 min. Minimum blood loss was achieved. Cruroraphy was performed in all cases, mesh reinforcement was added in five cases, and fundoplication was performed in all cases, with 3 Toupet, 2 Dor and 15 floppy Nissen fundoplication procedures performed. Fundopexy was routinely performed in cases of Toupet fundoplication. A total of 1 bipolar and 19 retrograde cholecystectomies were performed. Results: All patients had favorable postoperative hospitalization. Patient follow-up took place at 1 month, 3 months and 6 months, with no sign of recurrence of hiatal hernia (anatomical or symptomatic) and no symptoms of postcholecystectomy syndrome. In two patients, we had to perform colostomy. Conclusion: Concomitant laparoscopic hiatal hernia repair and cholecystectomy is safe and feasible.

Use of Critical View of Safety and Proctored Preceptorship in Preventing Bile Duct Injury During Laparoscopic Cholecystectomy-Experience of 3726 Cases From a Tertiary Care Teaching Institute

INTRODUCTION

Bile duct injury (BDI) continues to occur despite technological advances and improvements in surgical training over the past 2 decades. This study was conducted to audit our data on laparoscopic cholecystectomies performed over the past 2 decades to determine the role of Critical View of Safety (CVS) and proctored preceptorship in preventing BDI and postoperative complications.

MATERIALS AND METHODS

All patients undergoing elective laparoscopic cholecystectomy were analyzed retrospectively. The data were obtained from a prospectively maintained database from January 2004 to December 2019. Proctored preceptorship was used in all cases. Intraoperative details included the number of patients where CVS was defined, number of BDI and conversions. Postoperative outcomes, including hospital stay, morbidity, and bile duct stricture, were noted.

RESULTS

Three thousand seven hundred twenty-six patients were included in the final analysis. Trainee surgeons performed 31.6% of surgeries and 9.5% of these surgeries were taken over by the senior surgeon. A CVS could be delineated in 96.6% of patients. The major BDI rate was only 0.05%.

CONCLUSION

This study reiterates the fact that following the basic tenets of safe laparoscopic cholecystectomy, defining and confirming CVS, and following proctored preceptorship are critical in preventing major BDI.

Post cholecystectomy benign biliary stricture-isolated hepatic duct stricture: a proposed modification of the BISMUTH classification

BACKGROUND

Post-cholecystectomy, benign biliary strictures are challenging for both patients and surgeons. Bismuth classified benign biliary strictures into 5 types. This study aimed to review these isolated hepatic duct strictures which were not included in Bismuth classification.

METHODS

The case records of all patients who presented with post-cholecystectomy benign biliary strictures between January 2005 and December 2020 at our centre were reviewed. Data regarding demography, type of stricture, and treatment strategy were entered into the standard proforma.

RESULTS

There were 242 patients [type I-3.7%, type II-41.7%, type III-38.0%, type IV-6.6%, and type V-7.8%]. Five (2.1%) patients did not fit the Bismuth classification and were the focus of this study. In each of these patients, an isolated hepatic duct stricture (first-or second-order hepatic duct) was present, with no involvement of the common hepatic duct or hilar confluence.

CONCLUSIONS

The addition of isolated hepatic duct stricture [type VI] to the Bismuth classification will enhance the original classification, help in reporting and management of this sub-set of patients.

Imaging of benign biliary pathologies

Pathologies of the biliary tree include a wide-spectrum of benign and malignant processes. The differential for benign disease includes congenital and acquired disease with variable prognosis and management pathways. Given the ability to mimic malignancy, benign processes are difficult to diagnose by imaging. Direct cholangiography techniques with tissue sampling are the gold standards for the diagnosis of benign and malignant biliary pathologies. Non-invasive imaging with ultrasound offers a first-line diagnostic tool while MRI/MRCP offers higher specificity for identifying underlying pathology and distinguishing from malignant disease. In this review, we focus on the imaging appearance of dilatation, cystic anomalies obstruction, inflammation, ischemia, strictures, pneumobilia, and hemobilia to help construct a differential for benign processes.

Bile duct injury in laparoscopic cholecystectomy with a posterior infundibular approach

Aims: Bile duct injury (BDI) in laparoscopic cholecystectomy (LC) has a significant impact on morbidity and mortality. Although the critical view of safety (CVS) concept is the most widely supported approach to prevent BDI, alternative approaches are used as well. The aim was to evaluate the incidence, severity, and management of bile duct injury in LC, using a posterior infundibular approach. Methods: This retrospective, monocentric cohort study includes patients who underwent LC for gallstone disease. Data were collected in a prospectively maintained database. Patients with BDI were identified and were analyzed in-depth. Results: Between 1999 and 2018, 8389 consecutive patients were included (M/F 3288/5101; mean age 55 (standard deviation; SD ± 17) years). Mean length of postoperative hospital stay was two days (SD ± 4). Fourteen patients died after LC and 21 patients were identified with BDI. Seventeen BDI (81%) patients were managed minimally invasive (14 endoscopic, 3 laparoscopic), and 4 patients via laparotomy (3 hepaticojejunostomy, 1 primary suture). Severe complications (Clavien-Dindo ≥3) after BDI repair were observed in 6 patients. There was no BDI-related mortality. Median follow-up time was 113 months (range 5–238). Conclusion: A posterior infundibular approach in LC was associated with a low incidence of BDI and no BDI-related mortality.

Management of Major Injuries to the Bile Duct at a Hepatobiliary Specialty Referral Center

INTRODUCTION

Aim is to evaluate geographical and demographic factors influencing management of bile duct injuries occurring during cholecystectomy in a tertiary hepato-pancreato-biliary center in Southeast US.

METHODS

All referrals for biliary injuries during cholecystectomy, between Jan 2017 and December 2020 were included.

RESULTS

19 patients were identified with a median age of 59 (47-65), average BMI of 30.3 (18-49), and the prevalence of diabetes mellitus, hypertension and cardiovascular disease of 11%, 47% and 16%, respectively. The average transfer distance was 76 miles (8-102) and median transfer time was 3 days (1-12). 16 (84%) had Strasberg E injury, with 4 (21%) having a concomitant vascular injury (3 - right hepatic artery, 1 - right portal vein). Two (10.5%) were managed non-operatively, immediate surgical repair was performed in 2 (10.5%) and 15 (78.9%) patients underwent a delayed repair with a median of 87 days (69-118) from injury to repair. Median operative time was 5 hours (4-7), blood loss was 150 mL (100-200) and hospital stay was 8 days (6-12).

DISCUSSION

Factors including distance between hospitals, delays in patient transfer due to bed availability and transportation, play a role in the decision-making towards delayed repair. The delayed repair has the benefit of medical optimization of our high-risk patients' population.

Management of Postcholecystectomy Complications

Cholecystectomy is one of the most common general surgery procedures performed worldwide. Complications include bile duct injury, strictures, bleeding, infection/abscess, retained gallstones, hernias, and postcholecystectomy syndrome. Obtaining a critical view of safety and following the other tenets of the Safe Cholecystectomy Task Force will aid in the prevention of bile duct injury and other morbidity associated with cholecystectomy.

Percutaneous transhepatic cholangiography in the era of magnetic resonance cholangiopancreatography: A prospective comparative analysis in preoperative evaluation of benign biliary stricture

Background and Aim

Accurate anatomical delineation is the key before definitive repair for benign biliary stricture (BBS). The role of percutaneous transhepatic cholangiography (PTC) as a road map is less studied in the era of magnetic resonance cholangiopancreatography (MRCP).

Methods

A prospective observational study, performed between July 2012 and December 2013. All patients of post‐cholecystectomy BBS were evaluated with MRCP and PTC prior to definitive repair. Findings of MRCP and PTC were compared with intraoperative details.

Results

Thirty patients with BBS were included in the study. MRCP was performed in all but PTC was amenable in 28 of 30 (93.3%) patients. PTC was comparable to MRCP in diagnosing stricture type (96.4% vs 89.3%), intrahepatic stones (75% vs 75%), and biliary anomalies (95.6% vs 100%). Additionally, PTC revealed internal biliary fistula in 4 (85.7% vs 61.4%; P value 0.04). PTC‐related minor complications were noted in 2 (7.1%) patients.

Conclusion

PTC is comparable to MRCP in diagnosing the stricture type, intrahepatic biliary stones, and biliary anomalies. Though comparable to MRCP, the authors could not reveal any additional information that could change the course of management in BBS.

Severe case of post cholecystectomy vasculobiliary injury successfully treated by right hepatectomy with a jump graft to the remaining left hepatic lobe

Vasculobiliary injuries (VBI) caused by cholecystectomies are infrequent but extremely serious. We report a case of a severe VBI successfully treated at our center. A 22-year-old woman underwent an open cholecystectomy as treatment for acute cholecystitis and bile duct stones. She was transferred to our center on postoperative Day 4 because of progressive jaundice and encephalopathy. After a proper investigation, we found an extreme VBI with infarction of the right hepatic lobe associated with complete interruption of the portal vein and proper hepatic artery flows and full section of the common hepatic duct. Right hepatectomy with portal—Rex shunt revascularization of the left hepatic lobe and Roux-en-Y hepaticojejunostomy to the left hepatic duct was done. The patient was discharged on the 60th postoperative day.

Discussion: This case shows the successful surgical treatment of a severe cholecystectomy’s VBI, avoiding an emergency liver transplant.

Robotic surgery enables safe and comfortable single-incision cholecystectomy: A comparison of robotic and laparoscopic approaches for single-incision surgery

Background:

Although single-incision robotic cholecystectomy (SIRC) overcomes various limitations of single-incision laparoscopic cholecystectomy (SILC), it is associated with high cost. In this study, we intended to investigate if SIRC is recommendable and advantageous to patients despite its high cost.

Materials and Methods:

We prospectively collected and analysed data of patients who had undergone either SILC (n = 25) or SIRC (n = 50) for benign gallbladder diseases, with identical inclusion criteria, between November 2017 and February 2019.

Results:

SILC and SIRC showed similar operative outcomes in terms of intra- and post-operative complications and verbal numerical rating scale (VNRS) for pain. However, the SIRC group exhibited significantly longer operation time than the SILC group (83.2 ± 32.6 vs. 66.4 ± 32.8, P = 0.002). The SIRC group also showed longer hospital stay (2.4 ± 0.7 vs. 2.2 ± 0.6, P = 0.053). Although the SILC and SIRC groups showed no significant difference in VNRS, the SIRC group required a higher amount (126.0 ± 88.8 mg vs. 87.5 ± 79.7 mg, P = 0.063) and frequency (3.0 ± 2.1 vs. 2.0 ± 1.8, P = 0.033) of intravenous opioid analgesic administration. During surgery, the critical view of safety (CVS), the prerequisite for safe cholecystectomy, was identified in only 24% (n = 6) of patients undergoing SILC and in 100% (n = 50) of patients undergoing SIRC (P < 0.05).

Conclusion:

We conclude that although SILC and SIRC have similar operative outcomes, SIRC is advantageous over SILC because of its potential to markedly enhance the safety of patients by proficiently acquiring CVS.

Outcomes of Endoscopic Management among Patients with Bile Leak of Various Etiologies at a Tertiary Care Center

BACKGROUND/AIMS

Bile leak is a common complication of cholecystectomy, and it is also observed in other conditions such as ruptured liver abscess, hydatid cyst, and trauma. Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line management for such conditions. However, studies on the outcomes of endoscopic management for bile leaks with etiologies other than post-cholecystectomy injury are extremely limited.

METHODS

We conducted a retrospective review of patients with symptomatic bile leak who were referred to a tertiary care center and who underwent ERCP between April 2016 and April 2019. The primary outcome was complete symptomatic resolution without extravasation of the contrast medium during the second ERCP conducted after 6 weeks.

RESULTS

In total, 71 patients presented with symptomatic bile leak. The etiologies of bile leak were post-cholecystectomy injury in 34 (47.8%), liver abscess in 20 (28.1%), and post-hydatid cyst surgery in 11 (15.4%) patients. All patients were managed with ERCP, sphincterotomy, and stent placement for 6 weeks, except for one who underwent surgery. The primary outcome was achieved in 65 (91.5%) of 71 patients. There was no significant difference in terms of outcome in relation to the interval between the diagnosis of bile leak and ERCP.

CONCLUSION

Most patients with bile leak can be successfully managed with ERCP even when performed on an elective basis.

Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy

BACKGROUND

BDI is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI.

METHODS

Literature reviews were conducted for 18 key questions across 6 broad topics around cholecystectomy directed by a steering group and subject experts from 5 surgical societies (Society of Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and European Association for Endoscopic Surgery). Evidence-based recommendations were formulated using the grading of recommendations assessment, development, and evaluation methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.

RESULTS

Consensus was reached on 17 of 18 questions by the guideline development group and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.

CONCLUSIONS

These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

The prevalence of the Rouviere's sulcus: A meta-analysis with implications for laparoscopic cholecystectomy

Rouvière's sulcus (RS) is increasingly being recognized as an important extra-biliary landmark during laparoscopic cholecystectomy (LC). The aim of this study was to conduct a systematic analysis of the prevalence and morphological types of RS. A systematic search was conducted through the major databases PubMed, ScienceDirect, Google Scholar, China National Knowledge Infrastructure (CNKI), SciELO, and the Cochrane Library to identify studies eligible for inclusion. The data were extracted and pooled into a random-effects meta-analysis using STATA software. The primary and secondary outcomes of the study were the pooled prevalence of RS and its morphological types, respectively. A total of 23 studies (n = 4,495 patients) were included. The overall pooled prevalence of RS was 83% (95% confidence interval [CI] [78, 87]). There were no significant differences in prevalence between cadaveric studies (82%, 95% CI [76, 87]) and laparoscopic studies (83%, 95% CI [77, 88]). The open RS constituted 66% (95% CI [61, 71]) of all cases, while the closed type was present in 34% (95% CI [29, 39]). RS is a relatively constant anatomical structure that can be reliably identified in most patients undergoing cholecystectomy. It can therefore be used as a fixed extra-biliary landmark for the appropriate site at which to start dissecting during LC to help prevent iatrogenic bile duct injury.

Epidemiological and clinical assessment of patients undergoing Videolaparoscopic Cholecystectomy at a Curitiba teaching hospital

OBJECTIVE

to assess clinical and epidemiological factors of patients undergoing video cholecystectomy at the Hospital da Cruz Vermelha do Paraná, Curitiba unit, operated from September 2016 to September 2018, as well as the influence of comorbidities, sex and advanced age on the postoperative prognosis, while in the hospital.

METHODS

Analytic retrospective study. The analyzed variables were obtained by the review of medical records. Statistical analyses were performed considering the significance level p < 0.05.

RESULTS

389 patients, of whom 265 were women and 124 men, were included. The mean age was 51.5 years, 58.8% of the patients were diagnosed with at least one comorbidity, and 74.6% were overweight or obese. The incidence of intraoperative complications was 1.3%, postoperative 3.8% and, mortality, 0.3%. Some risk factors were identified as worse postoperative prognosis, such as Diabetes Mellitus, hypertension, presence of one or more comorbidities and mainly, advanced age, which was related to longer hospitalization times (p < 0,001), need of intensive therapy (p < 0,001), conversion to open surgery (p = 0,003) and postoperative complications (p < 0,001). Furthermore, the male sex was predictive of longer hospitalization times (p = 0,003) and need of intensive therapy (p = 0,01).

CONCLUSION

the presence of comorbidities, male sex, and advanced age are predictive factors of bad prognosis for patients undergoing video laparoscopic cholecystectomy.

Safe cholecystectomy multi-society practice guideline and state-of-the-art consensus conference on prevention of bile duct injury during cholecystectomy

BACKGROUND

Bile duct injury (BDI) is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI.

METHODS

Literature reviews were conducted for 18 key questions across six broad topics around cholecystectomy directed by a steering group and subject experts from five surgical societies (SAGES, AHPBA IHPBA, SSAT, and EAES). Evidence-based recommendations were formulated using the GRADE methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.

RESULTS

Consensus was reached on 17 of 18 questions by the Guideline Development Group (GDG) and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.

CONCLUSION

These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

Benign Biliary Strictures: A Systematic Review on Endoscopic Treatment Options

Benign biliary strictures can be difficult to manage. Untreated biliary strictures can lead to complications, such as chronic cholestasis, jaundice, recurrent sepsis, and secondary biliary cirrhosis, which can have severe ramifications. The management landscape is constantly evolving, with the development of modifiable self-expandable metal stents and biodegradable stents. This review critically appraises current endoscopic treatment strategies, in particular focusing on the shortfalls, such as stent migration and stricture recurrence. It also proposes a treatment algorithm based on aetiologias and the location of the strictures.

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.

Endoscopic Retrograde Cholangiopancreatography: Deciphering the Black and White

Endoscopic Retrograde Cholangiopancreatography (ERCP) remains the conventional method of imaging the pancreatic and biliary tree and is performed by direct injection of iodinated contrast material via the major papilla. This diagnostic procedure gained popularity in the 1970s and subsequently paved way for ERCP guided interventions such as sphincterotomy, stone retrieval and stent placement. Currently, therapeutic ERCP is more widespread than diagnostic ERCP primarily due to the availability of noninvasive imaging. Nevertheless, more than half a million ERCPs are performed annually in the United States and radiologists need to be comfortable interpreting them. The following review will familiarize the reader with the imaging appearances of biliary and pancreatic disorders on conventional ERCP, and elaborate on therapeutic ERCP with illustrative examples.

A New Technique of Endoscopic Transpapillary Gallbladder Drainage Combined with Intraductal Ultrasonography for the Treatment of Acute Cholecystitis

Background/Aims:

Endoscopic transpapillary gallbladder drainage (ETGBD) is useful for the treatment of acute cholecystitis; however, the technique is difficult to perform. When intraductal ultrasonography (IDUS) is combined with ETGBD, the orifice of the cystic duct in the common bile duct may be more easily detected in the cannulation procedure. The aim of this study was to evaluate the efficacy of ETGBD with IDUS compared with that of ETGBD alone.

Methods:

A total of 100 consecutive patients with acute cholecystitis requiring ETGBD were retrospectively recruited. The first 50 consecutive patients were treated using ETGBD without IDUS, and the next 50 patients were treated using ETGBD with IDUS. Through propensity score matching analysis, we compared the clinical outcomes between the groups. The primary outcome was the technical success rate.

Results:

The technical success rate of ETGBD with IDUS was significantly higher than that of ETGBD without IDUS (92.0% vs. 76.0%, p=0.044). There was no significant difference in procedure length between the two groups (74.0 min vs. 66.7 min, p=0.310). The complication rate of ETGBD with IDUS was significantly higher than that of ETGBD without IDUS (6.0% vs. 0%, p<0.001); however, only one case showed an IDUS technique-related complication (pancreatitis).

Conclusions:

The assistance of IDUS may be useful in ETGBD.

Postoperative day 1 discharge after anatomic lung resection: A Society of Thoracic Surgeons database analysis

OBJECTIVE

Although minimally invasive techniques have led to shorter hospitalizations, discharge on postoperative day 1 is still uncommon. We hypothesized that day 1 discharge could be performed safely and that there might be significant variation in day 1 discharge rates between hospitals.

METHODS

We identified patients with lung cancer who underwent lobectomy and segmentectomy in the Society of Thoracic Surgeons Database from 2012 to 2017. The 10% longest hospital stay outliers were excluded. A multivariable regression model was created to assess for factors associated with day 1 discharge and readmission.

RESULTS

A total of 46,325 patients were examined, and 1821 patients (3.9%) were discharged on day 1. This rate increased from 3.4% to 5.3% over the course of the study (P < .0001). In multivariable analysis, factors associated with day 1 discharge included age, Zubrod score, body mass index greater than 25, forced expiration value at 1 second, middle or upper lobectomy, minimally invasive technique, and procedure time. Outpatient 30-day mortality was similar (0.3% vs 0.4%, P = .472). Patients discharged on day 1 were not at increased risk of readmission. Readmission after day 1 discharge was associated with male sex, coronary artery disease, chronic obstructive pulmonary disease, and longer procedure time. There was substantial variation in day 1 discharge rate between institutions, with 11 centers (4.0%) discharging more than 20% of their patients on day 1, whereas 102 centers (36.7%) had no day 1 discharges.

CONCLUSIONS

Day 1 discharge after anatomic lung resection is uncommon but is becoming more common. Carefully selected patients may be discharged on day 1 without an increased risk of readmission or death.

Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound-Guided Gallbladder Drainage

"Gallbladder disease is one of the most common gastrointestinal diseases encountered in clinical practice. Surgical removal and percutaneous drainage are both widely available and effective in the management of acute cholecystitis. Several endoscopic approaches exist as an alternative to these interventions. These include transpapillary approaches via endoscopic retrograde cholangiopancreatography (ERCP), transmural drainage and access approaches via endoscopic ultrasound (EUS), and endoscopic surgical approaches using natural orifice transluminal endoscopic surgery (NOTES) techniques. This article reviews the epidemiology and pathophysiology of gallbladder diseases and discusses the various percutaneous, surgical, and endoscopic approaches to managing gallbladder disease."

Management of Segmental Bile Duct Injuries After Cholecystectomy: a Systematic Review

BACKGROUND

Injuries to segmental or aberrant bile ducts are encountered less commonly than their major bile duct counterparts and present a unique diagnostic and therapeutic challenge, since the nature of this injury involves a transected bile duct that loses its communication with the main ductal system. In this systematic review, we aim to pool available data on this particular type of biliary injury in an effort to outline available diagnostic and therapeutic modalities and evaluate their efficacy.

MATERIALS AND METHODS

An extensive literature search was performed on MEDLINE, Scopus, and Web of Science to identify isolated segmental or aberrant bile duct injuries.

RESULTS

A total of 21 studies were included in this systematic report. Ten studies reported non-operative management of patients, while 12 reported operative management of included patients. Outcomes of interest were the choice of treatment interventions and their success. Overall, 23 patients were managed non-operatively with a 91% success rate and 30 patients were managed operatively with a 90% success rate.

CONCLUSION

Non-operative management might be a viable alternative to surgery. Hepatobiliary surgeons should be encouraged to publish their results in treating these rare injuries to further elucidate the role and efficacy of such an approach.

Management of post cholecystectomy vascular injuries

INTRODUCTION

Vasculobiliary and vascular injuries following cholecystectomy are the most serious complications requiring complex surgical management resulting in greater patient morbidity and mortality.

METHODOLOGY

The study was performed at a tertiary teaching hospital of North India. Records of patients referred for biliary or vascular injury sustained during cholecystectomy were reviewed retrospectively to identify patients with vascular injury between January 2009 and March 2018. Clinical profile, hospital course and outcome of these patients were analysed.

RESULTS

Over nine years, 117 patients were referred for cholecystectomy related complications. Total incidence of vascular injury was 5.1% (6/117). Combined vasculobiliary injury (VBI) occurred in 3.4% (4/117) while isolated vascular injury was present in 1.7% patients (2/117). Most (5/6) patients were operated for uncomplicated gall stone disease. Incidences of portal vein (PV) and right hepatic artery (RHA) injuries were equal (3/6). PV injuries were repaired either during cholecystectomy (1/3) or during re-exploration after damage control packing (2/3). RHA injuries presented as pseudoaneurysm and were managed surgically (2/3) or by coil embolization (1/3). All VBI referrals (4/117) were following open cholecystectomy. In VBI patients, vascular injury was diagnosed intra-operatively in two while it was diagnosed several weeks after cholecystectomy in two others. Biliary injury manifested as bile leak post-operatively in all four of them. Nature of biliary injury could be characterized in only 50% (2/4) patients. Definitive repair of biliary injury was performed in one patient only. There was one mortality in our series.

CONCLUSION

Vascular injury is an uncommon complication of cholecystectomy with catastrophic outcome if not managed timely and properly. Adequate surgeon training, keeping the possibility of aberrant vasculobiliary anatomy in all cases, and proper surgical technique is crucial for prevention of such injuries. However in such an event, proper documentation and referral to tertiary centre will help in decreasing morbidity and further litigation.

Emergency Cholecystectomy Versus Percutaneous Cholecystostomy for Treatment of Acute Cholecystitis in High-Risk Surgical Patients

Our aim is to present our experience with laparoscopic cholecystectomy (LC) and percutaneous cholecystostomy (PC) in high-risk patients with acute cholecystitis (AC). The guidelines for AC are still debatable for high-risk patients. We aimed to emphasize the role of LC as a primary treatment method in patients with severe AC instead of a treatment after PC according to the Tokyo Guidelines (TG). AC patients with high surgical risk [American Society of Anesthesiologists (ASA) III-IV] who were admitted to our department between March 2008 and November 2014 were retrospectively evaluated. Disease severity in all patients was assessed according to the 2007 TG for AC. Patients were either treated by emergency LC (group LC) or PC (group PC). Demographic data, ASA scores, treatment methods, rates of conversion to open surgery, duration of drainage, length of hospital stay, and morbidity and mortality rates were compared among groups. Age, ASA score, and TG07 severity scores in the PC group were significantly higher than that in the LC group (P &lt; 0.001, P &lt; 0.001, and P &lt; 0.001, respectively). Sex distribution (P = 0.33), follow-up periods (P = 0.33), and morbidity (P = 0.86) were similar. In the patients with early surgical intervention, mortality was significantly lower (P &lt; 0.001). Length of hospital stay was significantly shorter in the LC group compared with the PC group (P &lt; 0.001). In high-risk surgical patients, PC can serve as an alternative treatment method because of its efficiency in the prevention of sepsis-related complications due to AC. However, LC still should be an option for severe AC with comparable short-term results.

Early discharge after lung resection is safe: 10-year experience

Background

The average hospitalization after lung resection is 6 days, but some patients are discharged early in the post-operative period. The patient factors associated with early discharge (ED) and the safety of this approach are unknown. We hypothesized that specific patient populations are associated with ED, and that complications in this practice are low.

Methods

A prospective database of lung resections performed at an academic medical center between Jan 1, 2007 and Jan 1, 2017 was queried. Demographic and outcome variables were assessed using standard techniques. ED was defined as the length of stay (LOS) for the quintile with the lowest LOS for patients with anatomic resection (AR) or patients with wedge resection (WR). We then compared clinical factors between patients with ED to those patients discharged by day 7, to determine factors associated with ED (relative to "average" discharge).

Results

During the study period, there were 922 AR and 1,150 WR performed. A total of 448 (39.0%) patients had WRED and 211 patients (22.9%) had ARED. The rate of WRED varied by surgeon, but ARED did not. ARED and WRED patients was associated with several factors, including younger age, better lung function, and were less likely to have elevated American Society of Anesthesiologist (ASA) class. Multivariable analysis suggested that patient factors and primary surgeon influence ED. WRED was associated with 30-day mortality of 0.22% vs. 1.14% for longer LOS (P=0.08). After AR, there were no post-operative deaths within 30 days among 211 patients discharged on postoperative day 1 or 2 [(vs. 2/541, 0.4%, P=0.376) with longer LOS, P=0.048].

Conclusions

ED after lung resection is multifactorial but is safe among selected patients. Age, lung function, procedure duration, and surgeon all influence ED. Complications after ED were rare. Individual surgeon comfort with ED likely impacts LOS, and education or enhanced recovery protocols may help overcome this barrier. Standardized pathways would likely help identify low-risk patients for expeditious discharge.

Hepatic ductoplasty for iatrogenic Bismuth type 2 bile duct stricture: A case report

•

The article represents recovering treatment of iatrogenic biliary tract injury by laparoscopic cholecystectomy.

•

Biliary tract stricture like Bismuth type 2 successfully treated by hepatic ductoplasty.

•

To emphasize the importance of avoiding biliary stricture is a key to prevent cholangitis and stone recurrences.

Introduction

Biliary enteric anastomosis is a well-known biliary reconstruction method. Anastomosis stricture is one of the complications of this procedure that occurs in some patients over the long-term. We report a successful case of hepatic ductoplasty combined with hepaticojejunostomy (H–J) for the treatment of iatrogenic Bismuth type 2 stricture.

Presentation of case

The patient was a 68-year-woman who had undergone choledochojejunostomy (C–J) 6 years earlier due to bile duct injury after laparoscopic cholecystectomy for cholelithiasis. She complained of recurrent chills and upper back pain. Cholangiography and computed tomography revealed a C–J anastomotic stricture with hepatolithiasis. The diagnosis was reflux cholangitis with hepatolithiasis due to C–J stricture and a fistula between the reconstructed jejunal limb and duodenum. Exploration was performed, and she underwent hepatic ductoplasty with H–J and hepaticolithotripsy. Surgery was performed uneventfully and the patient has remained well subsequently.

Discussion and conclusion

We propose hepatic ductoplasty as a useful technique for the treatment of selected patients with a C–J stricture or narrow hepatic duct.

Assessing the effect of the critical view of safety criteria on simulated operative decision-making: a pilot study

BACKGROUND

Despite well-established criteria for identifying the critical view of safety (CVS) during laparoscopic cholecystectomy, its impact on intraoperative decision-making among trainees is unclear.

METHODS

General surgery interns (n = 10) viewed a training module on the CVS criteria and then independently reviewed 20 cholecystectomy videos lasting 1 min each edited at various points of CVS dissection to include examples of both adequate and inadequate dissections. Participants were asked to identify the following CVS criteria for each video-(1) clearance of fat from the hepatocystic triangle; (2) exposure of the cystic plate; and (3) two and only two structures entering the gallbladder-and then decide if the structures were safe to divide.

RESULTS

Inter-rater agreement for each CVS criteria varied: (1) (k = 0.2510), (2) (k = 0.2771), and (3) (k = 0.4298) as did the decision to divide critical structures (k = 0.371). Individual mean rate of dividing structures ranged 5-50% and did not correlate with the total number of CVS criteria identified by each participant (Spearman's rho = 0.247, p = 0.492). Division of structures with incomplete CVS identification occurred in 15% of cases and was isolated to one participant in the majority of cases (88%). Among these cases, omission of the cystic plate dissection occurred in every instance.

CONCLUSIONS

Identification of CVS criteria was not uniform with the least amount of agreement on adequate hepatocystic and cystic plate dissection. Individual variation also exists between identification of CVS criteria and likelihood to divide structures. Video-based assessments that include intraoperative decision-making can help assess individual perceptions of safe practices without the risk of harm to the patient.

Bile duct injuries (BDI) in the advanced laparoscopic cholecystectomy era

BACKGROUND

Laparoscopic cholecystectomy is the most commonly performed laparoscopic procedure. It is superior in nearly every regard compared to open cholecystectomies. The one significant aspect where the laparoscopic approach is inferior regards the association with bile duct injuries (BDI). The BDI rate with laparoscopic cholecystectomy is approximately 0.5%; nearly triple the rate compared to the open approach. We propose that 0.5% BDI rate with the laparoscopic approach is no longer accurate.

METHODS

The National Surgical Quality Improvement Program (NSQIP) registry was retrospectively reviewed. All laparoscopic cholecystectomies performed between 2012 and 2016 were extracted. A total of 217,774 cases meeting inclusion criteria were analyzed. The primary data points were the overall BDI incidence rate and time of diagnosis. BDI were identified by ICD-9 and ICD-10 codes. Secondary data points were variables associated with BDI.

RESULTS

The BDI rate was 0.19%. 77% of cases were diagnosed after the index surgical admission. Intra-operative cholangiography (IOC) use was associated with a higher BDI rate and higher identification rate of a BDI intraoperatively (P value < 0.0001). Resident teaching cases were protective with a RR score of 0.56 (P value < 0.0001). The presence of cholecystitis increased the risk of a BDI with a RR score of 1.20 (P value < 0.0001). There was a low conversion rate of 0.04% however converted cases had a nearly hundredfold increase in BDI at 15% (P value < 0.0001).

CONCLUSIONS

The performance of laparoscopic cholecystectomies in North America is no longer associated with higher BDI rates compared to open. IOC use still is not protective against BDI, and cholecystitis continues to be a risk factor for BDI. When a cholecystectomy requires conversion from a laparoscopic to an open approach the BDI increases a hundredfold; which may raise the concern if this approach is still a safe bailout method for a difficult laparoscopic dissection.

Diminished Survival in Patients with Bile Leak and Ductal Injury: Management Strategy and Outcomes

BACKGROUND

The increased incidence of bile duct injuries (BDIs) after the adoption of laparoscopic cholecystectomy has been well documented. However, the longitudinal impact of bile leaks and BDIs on survival and healthcare use have not been studied adequately. The aims of this analysis were to determine the incidence, long-term outcomes, and costs of bile leaks and ductal injuries in a large population.

STUDY DESIGN

The California Office of Statewide Health Planning and Development database was queried from 2005 to 2014. Bile leaks, BDIs, and their management strategy were defined. Survival was calculated by Kaplan-Meier failure estimates with multivariable regression and propensity analyses. Cost analyses used inflation adjustments and institution-specific cost-to-charge ratios.

RESULTS

Of 711,454 cholecystecomies, bile leaks occurred in 3,551 patients (0.50%) and were managed almost exclusively by endoscopists. Bile duct injuries occurred in 1,584 patients (0.22%) with 84% managed surgically. Patients with a bile leak were more likely to die at 1 year (2.4% vs 1.4%; odds ratio 1.85; p < 0.001). Similarly, BDI patients had an increased 1-year mortality (7.2% vs 1.3%; odds ratio 2.04; p < 0.0001). Survival of BDI patients was better with an operative approach (odds ratio 0.19; p < 0.001) when compared with endoscopic management. Operatively managed BDIs were also associated with fewer emergency department visits and readmissions, as well as lower cumulative costs at 1 year ($60,539 vs $118,245; p < 0.001).

CONCLUSIONS

The 0.22% incidence of BDIs observed in California is lower than reported in the first decade after the introduction of laparoscopic cholecystectomy. Bile leaks are 2.3 times more common than BDIs. Patients with a bile leak or BDI have diminished survival. Surgical repair of a BDI leads to enhanced survival and reduced cumulative cost compared with endoscopic management.

IRCAD recommendation on safe laparoscopic cholecystectomy

An expert recommendation conference was conducted to identify factors associated with adverse events during laparoscopic cholecystectomy (LC) with the goal of deriving expert recommendations for the reduction of biliary and vascular injury. Nineteen hepato-pancreato-biliary (HPB) surgeons from high-volume surgery centers in six countries comprised the Research Institute Against Cancer of the Digestive System (IRCAD) Recommendations Group. Systematic search of PubMed, Cochrane, and Embase was conducted. Using nominal group technique, structured group meetings were held to identify key items for safer LC. Consensus was achieved when 80% of respondents ranked an item as 1 or 2 (Likert scale 1-4). Seventy-one IRCAD HPB course participants assessed the expert recommendations which were compared to responses of 37 general surgery course participants. The IRCAD recommendations were structured in seven statements. The key topics included exposure of the operative field, appropriate use of energy device and establishment of the critical view of safety (CVS), systematic preoperative imaging, cholangiogram and alternative techniques, role of partial and dome-down (fundus-first) cholecystectomy. Highest consensus was achieved on the importance of the CVS as well as dome-down technique and partial cholecystectomy as alternative techniques. The put forward IRCAD recommendations may help to promote safe surgical practice of LC and initiate specific training to avoid adverse events.

Liver transplantation in the treatment of severe iatrogenic liver injuries

The place of liver transplantation in the treatment of severe iatrogenic liver injuries has not yet been widely discussed in the literature. Bile duct injuries during cholecystectomy represent the leading cause of liver transplantation in this setting, while other indications after abdominal surgery are less common. Urgent liver transplantation for the treatment of severe iatrogenic liver injury may-represent a surgical challenge requiring technically difficult and time consuming procedures. A debate is ongoing on the need for centralization of complex surgery in tertiary referral centers. The early referral of patients with severe iatrogenic liver injuries to a tertiary center with experienced hepato-pancreato-biliary and transplant surgery has emerged as the best treatment of care. Despite widespread interest in the use of liver transplantation as a treatment option for severe iatrogenic injuries, reported experiences indicate few liver transplants are performed. This review analyzes the literature on liver transplantation after hepatic injury and discusses our own experience along with surgical advances and future prospects in this uncommon transplant setting.

Surgical management for bile duct injury

The management of bile duct injury (BDI) remains a considerable challenge in hepatobiliary surgery. BDI is mainly iatrogenic, and mostly occurs in cholecystectomy. Laparoscopic cholecystectomy (LC) has been performed widely, however, the incidence of BDI associated with LC increases 2-3 times compared to that in open cholecystectomy (OC). BDI also occurs in robotic cholecystectomy. In China, the evidence-based Practice Guideline for Diagnosis and Treatment of BDI was published by the Biliary Surgery Group of Surgery Branch of Chinese Medical Association, with the purpose of reducing the incidence of BDI as well as promoting its optimal diagnosis and treatment. Surgery remains the mainstay of treatment for BDI and traumatic bile duct stricture. The definitive repair involves a series of procedures including exposing the proximal and distal bile duct, anastomotic bile duct tissue preparation, minimally invasive tissue anastomoses, and so on. Successful management is a surgical challenge requiring great specialized experience and precise surgical skill. The application of precision biliary surgery is recommended for promoting standardized management of BDI.

Multidetector CT in detection of troublesome posterior sectoral hepatic duct communicating with cystic duct

OBJECTIVE

To investigate whether multiple detector CT (MDCT) could detect troublesome aberrant posterior sectoral hepatic duct (PHD) communicating with cystic duct (CD).

METHODS

The most troublesome bile duct anomaly during cholecystectomy is an aberrant PHD communicating with CD. It has been suggested that an unenhanced small duct between Rouviere's sulcus and CD on MDCT could be coincident to an aberrant PHD communicating with CD. A total of 224 patients who underwent laparotomy with complete lymph node dissection in the hepatoduodenal ligament for hepatobiliary or pancreatic tumour were enrolled. Retrospective review of preoperative MDCT images and surgical records was performed.

RESULTS

Preoperative MDCT detected 8 (3.6%) unenhanced ducts between Rouviere's sulcus and CD. Surgical records identified 7 (3.1%) cases of aberrant PHD communicating with CD, and all 7 cases showed an unenhanced duct between Rouviere's sulcus and CD on preoperative MDCT imaging. Among the 7 patients, 5 (71%) were without bile duct dilatation.

CONCLUSION

MDCT could detect troublesome aberrant PHD communicating with CD, regardless of the presence or absence of bile duct dilatation. Advances in knowledge: MDCT could detect most troublesome PHD communicating with CD, regardless of the presence or absence of bile duct dilatation.

Bile Duct Injury after Cholecystectomy: Surgical Therapy

BACKGROUND

Iatrogenic bile duct injuries (IBDI) after laparoscopic cholecystectomy (LC), being one of the most common performed surgical procedures, remain a substantial problem in gastrointestinal surgery. The most important aspect regarding this issue is the prevention of IBDI during index cholecystectomy. Once it occurs, early and accurate diagnosis of IBDI is very important for surgeons and gastroenterologists, because unidentified IBDI may result in severe complications such as hepatic failure and death. Laboratory tests, radiological imaging, and endoscopy play an important role in the diagnosis of biliary injuries.

METHODS

This review summarizes and discusses the current literature on the management of IBDI after LC from a surgical point of view.

RESULTS AND CONCLUSION

In general, endoscopic techniques are recommended for the initial diagnosis and treatment of IBDI and are important to classify them correctly. In patients with complete dissection or obstruction of the bile duct, surgical management remains the only feasible option. Different surgical reconstructions are performed in patients with IBDI. According to the available literature, Roux-en-Y hepaticojejunostomy is the most frequent surgical reconstruction and is recommended by most authors. Long-term results are most important in the assessment of effectiveness of IBDI treatment. Apart from that, adequate diagnosis and treatment of IBDI may avoid many serious complications and improve the quality of life of our patients.

A retrospective analysis of endoscopic treatment outcomes in patients with postoperative bile leakage

OBJECTIVE:

Bile leakage, while rare, can be a complication seen after cholecystectomy. It may also occur after hepatic or biliary surgical procedures. Etiology may be underlying pathology or surgical complication. Endoscopic retrograde cholangiopancreatography (ERCP) can play major role in diagnosis and treatment of bile leakage. Present study was a retrospective analysis of outcomes of ERCP procedure in patients with bile leakage.

METHODS:

Patients who underwent ERCP for bile leakage after surgery between 2008 and 2012 were included in the study. Etiology, clinical and radiological characteristics, and endoscopic treatment outcomes were recorded and analyzed.

RESULTS:

Total of 31 patients (10 male, 21 female) were included in the study. ERCP was performed for bile leakage after cholecystectomy in 20 patients, after hydatid cyst operation in 10 patients, and after hepatic resection in 1 patient. Clinical signs and symptoms of bile leakage included abdominal pain, bile drainage from percutaneous drain, peritonitis, jaundice, and bilioma. Twelve (60%) patients were treated with endoscopic sphincterotomy (ES) and nasobiliary drainage (NBD) catheter, 7 patients (35%) were treated with ES and biliary stent (BS), and 1 patient (5%) was treated with ES alone. Treatment efficiency was 100% in bile leakage cases after cholecystectomy. Ten (32%) cases of hydatid cyst surgery had subsequent cystobiliary fistula. Of these patients, 7 were treated with ES and NBD, 2 were treated with ES and BS, and 1 patient (8%) with ES alone. Treatment was successful in 90% of these cases.

CONCLUSION:

ERCP is an effective method to diagnose and treat bile leakage. Endoscopic treatment of postoperative bile leakage should be individualized based on etiological and other factors, such as accompanying fistula.