Bile Duct Injuries

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Incidence of Bile Duct Injuries in Laparoscopic Vs open Cholecystectomy: A Review of Methylene Blue Injection Technique to Prevent Bile Duct Injuries in Laparoscopic Cholecystectomy

Incidence of Bile Duct Injuries in Laparoscopic Vs open Cholecystectomy: A Review of Methylene Blue Injection Technique to Prevent Bile Duct Injuries in Laparoscopic Cholecystectomy

Bile duct injuries are associated with significant morbidity, prolonged hospitalization, increased financial burden, potential litigation and occasional mortality. It is the third most common litigated general surgical complications in western statistics, also it has been reported that average two procedures (between 1 to 8) are required for definitive repair of bile ducts. Bile duct injury if fortunately identified and repaired peroperatively, carry less morbidity and mortality.

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Bile Duct Injuries with Loss of Confluence

Bile Duct Injuries with Loss of Confluence

Abstract: Introduction: Iatrogenic bile duct injuries (IBDI) with loss of confluence are understood as those where right and left hepatic ducts lose continuity with the common biliary tree. These represent 4% of all IBDI and are considered a very demanding surgical challenge. Study design: This is a series of case in a reference center during an eight-year period (2008 – 2016), where all patients with IBDI and loss of confluence submitted to any bilioenteric derivation procedure were included. Results: From a total of 11 cases, 10 of them (90.1%) were treated with double bilioenteric derivation and 1 (9%) with a neo- confluence. In 90.9% (n=10) of the patients a percutaneous catheter of biliary drainage was placed before the surgical procedure. Within a 34.5 months follow-up, the initial approach was successful in 54.5% (n=6), meanwhile accumulated achievement was 81.8% (n=9) considering dilatation and remodeling procedures. From this, 18.2% (n=2) are still with stenosis of derivation in a dilatation protocol with percutaneous catheter. Conclusions: Double hepatojejunostomy with transanastomotic stents and management of eventual stenosis with percutaneous dilatation as a first therapeutic intention results in a standardized practice that leads to reasonable results compared with other high volume centers.
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Managing iatrogenic bile duct injuries through a multidisciplinary team approach: A SIUT case series

Managing iatrogenic bile duct injuries through a multidisciplinary team approach: A SIUT case series

Iatrogenic injury to the bile duct is one of the most serious and feared complication of cholecystectomy, with a high mortality ranging between 3-12%. The management of such injuries of the bile duct is far more complicated and prolonged than the procedure itself. A retrospective analysis of 36 patients with bile duct injuries (BDI) was conducted over a period of 7 years, from January 2007 to December 2014. Most of their injuries occurred during open cholecystectomy, 22 rather than laparoscopic 14 and were mostly elective surgeries 34. Most injuries were identified postoperatively in 33 (91.6%) patients, at a median of 3.0 days. Among the modalities used to diagnose and treat these patients, endoscopy was performed in 32 of the cases (88.8%), followed by surgery on 17 (47.2%) patients and radiology on 16 (44.4%) cases. Surgery remains the gold standard for treatment of complete transection of bile duct injuries and long term outcomes are usually good. Endoscopy and radiology has an increasing role in the diagnosis and treatment of a leaking (non-transected) bile duct injury.
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European Society of Gastrointestinal Endoscopy on Bile Duct Injuries

European Society of Gastrointestinal Endoscopy on Bile Duct Injuries

Abstract: The aim of this article is to describe the pathophysiology, diagnosis, classification, and management of BDI based on the relevant available literature, in particular the recent recommendations from the European Society of Gastrointestinal Endoscopy (ESGE). It is a known fact that bile duct injuries (BDI) are associated with a high morbidity and mortality, posing impaired quality of life along with substantial financial burdens to patients and the society in general. Depending on the type of duct injury, successful management is based upon the time of recognition of injury, patient condition, presence of complications and availability of professional expertise (radiologists, endoscopists and hepato-biliary surgeons). Appropriate management may include endoscopic, per-cutaneous and surgical interventions with imaging playing a significant role in initial diagnosis, assessment and treatment of such injuries.
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Difficult iatrogenic bile duct injuries following different types of upper abdominal surgery: report of three cases and review of literature

Difficult iatrogenic bile duct injuries following different types of upper abdominal surgery: report of three cases and review of literature

As already mentioned, if sepsis and biliary peritonitis predominate, a percutaneous or surgical drainage is ne- cessary as the first line treatment [14, 15]. This was pro- vided in the first two cases giving a good long-term outcome. The external drainage of the left duct for sev- eral weeks in the second patient (following right hepa- tectomy) resulted in nearly complete resolution of all of the inflammatory changes within the liver hilum and the left duct. Therefore, we were able to perform a biliary- enteric reconstruction in a non-inflamed operative field. The problem we encountered during surgery in this pa- tient was a significant, anti-clock wise rotation of the remnant left liver lobe into the right subphrenic space. This made the back wall of hepaticojejunostomy very difficult to perform, resulting most likely in suboptimal suture placement and a biliary leak. Hepatopexy, i.e. su- turing of the divided falciform ligament to the abdom- inal wall following right hepatectomy may prevent or at least diminish the risk of left liver lobe rotation and re- lated to it complications [29]. Additionally, performance of the anastomosis over a transanastomotic external bil- iary drain may have reduced the risk of a biliary leak that occurred in the postoperative period in our patient. This possibly might have prevented the development of a fluid collection in the pouch of Douglas that required another surgery later on.
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Management of major bile duct injury after laparoscopic cholecystectomy:  a case report

Management of major bile duct injury after laparoscopic cholecystectomy: a case report

During cholecystectomy, much emphasis is given to complete exposure of the operating area. During the exposure of peritoneal attachments in Calot's triangle, anatomical variations should be clearly identified, and the cystic duct should not be separated until the junction of the common hepatic and cystic ducts is positively identified. There is no confluence of any other abnormal ducts into the cystic duct. Sometimes the anatomical structure of Calot's triangle is not very clear because of congestion, edema and fragility of the tissues around the cystic duct in acute suppurative or gangrenous cholecystitis. Fibrous tissue scars are often formed in Calot's angle in atrophic cholecystitis. It is more difficult to avoid intraoperative bile duct injuries (IBDI) in such conditions, when correct identification of Calot's triangle is less likely.
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Management of major bile duct injury after laparoscopic cholecystectomy: a case report

Management of major bile duct injury after laparoscopic cholecystectomy: a case report

Injuries to the bile duct system during laparoscopic chole- cystectomy are an unaltered cause for concern not neces- sarily related to the "learning curve" of the operating surgeon as suggested in the past [12]. In recent studies, it was demonstrated that in more than one-third of all bile duct injuries, the basic cause of error is not the inexperi- ence of the surgeon but the use of an improper approach to the fundamental structures of the extrahepatic biliary tree because of a visual perceptual illusion [12]. Corre- spondingly, in most cases, the problem is not recognized at the time of the initial procedure, particularly in the presence of acute inflammation or chronic fibrosis. The role of intraoperative cholangiography and laparoscopic ultrasonography in prevention of MBDI during laparo- scopic cholecystectomy is a matter of ongoing debate [13].
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A comparative study between open and Laparoscopic cholecystectomy in gallstone disease

A comparative study between open and Laparoscopic cholecystectomy in gallstone disease

Some of these ducts may drain substantial portions of the right lobe of the liver, either one of the sectors (two segments) or a segment and may in fact be the sole drainage of that part of the liver in which case they are more precisely termed as 'aberrant' ducts. It has been suggested that most such ducts are aberrant rather than accessory in which case it is even more important to safeguard them. If such a duct is injured it can lead to substantial biliary stasis or leak. The size of the duct may be an indirect indicator of the amount of liver it drains. It has hence been recommended that in case of injury if the duct is more than 3 mm it should always be drained into a Roux loop. Alternatively one can perform a cholangiogram through the duct to assess the amount of liver it drains as well as whether it is accessory or aberrant. With increasing recognition of injury to such ducts these have now been grouped into separate type in the recent Strasberg classification of bile duct injuries.
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CHOLEDOCHAL CYST IN ADULTS - CLINICAL PRESENTATIONS AND MANAGEMENT-SCENARIO FROM EASTERN INDIA.

CHOLEDOCHAL CYST IN ADULTS - CLINICAL PRESENTATIONS AND MANAGEMENT-SCENARIO FROM EASTERN INDIA.

When patients present with the symptoms described, the first step toward making the correct diagnosis is imaging. USG is the first choice. Sensitivity of USG in making the diagnosis is 71%–97%. [25] Furthermore, given that USG is noninvasive and inexpensive, it is the modality of choice for follow-up surveillance. Endoscopic Ultrasound (EUS) has been proven useful as it does not have any of these limitations and allows good visualization of the intrapancreatic portion of the common bile duct. [26]

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Mechanical properties of the porcine bile duct wall

Mechanical properties of the porcine bile duct wall

the biliary system. Few papers have focused on the biome- chanical and morphometric properties of the bile duct wall. The literature on bile duct mechanics mainly con- tains data on ducts tested uni-axially in vitro [6-8]. Uni- axial testing can not be done with preserved tri-dimen- sional structural integrity of the organ wall. Distension of intact segments provides a more physiological-like condi- tion of testing. When the force of inflation is applied, the intact segment deforms [9]. This approach was used in two studies of the normal porcine bile duct [10,11]. How- ever, these studies were limited to measurements only at high pressures or to circumferential tension-strain rela- tions where tension was computed from the transmural pressure and radius but where the wall thickness was not measurable. The stress-strain relation is, however, a more valid measure of the biomechanical properties [12]. Stress is force per unit cross-sectional area. Strain refers to the resulting deformation of the material and is usually expressed as a fraction of the initial length. Strain is non- dimensional which favors comparison between different experiments. The proportionality constant between stress and strain for a linear relationship is called the elastic modulus and is a measure of wall stiffness [9,12]. For non-linear stress-strain relations, an incremental modulus can be computed or mechanical constants determined. In cylindrical tubes the normal stress and strain components are in radial, longitudinal and circumferential directions. If the wall is thin, then the radial component can be ignored and the mechanical problem can be reduced to a two-dimensional one.
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The Effect of Resveratrol on Bone Status in Rats with Bile Duct Obstruction

The Effect of Resveratrol on Bone Status in Rats with Bile Duct Obstruction

Chronic cholestasis was induced by surgical bile duct obstruction (BDO) according to Brcakova et al. [20]. The cannula was inserted into the bile duct, closed and fixed subcutaneously. Obstruction lasted for 28 days. Control rats were either sham-operated, the bile duct was only manipulated and left unobstructed. 1) group: Sham: rats after laparotomy without bile duct obstruction and ve- hiculum application. 2) group: BDO: rats with bile duct obstruction and vehiculum application. 3) group: R-BDO: rats with bile duct obstruction and resveratrol application. The all rats were sacrificed after 28 days of experiment by exsanguination from abdominal aorta in pentobarbital anesthesia.
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Anti fibrotic effect of Holothuria arenicola extract against bile duct ligation in rats

Anti fibrotic effect of Holothuria arenicola extract against bile duct ligation in rats

Histological alterations and an increase in alkaline phosphatase (ALP) levels confirmed the damage pro- duced by the bile duct ligation in rats [58]. In conson- ance with the findings of Nasehi et al. [49] and Kim et al. [57], the data recorded in the present study showed significant enhancement of the ALP activity following BDL in rats. This increase may be attributable to the re- tention of bile salts that damaged the membrane and consequently leads to the passing of the ALP enzyme into circulation [59,60]. It is known that, liver and bile duct disorders are followed by increased activity of ALP which is especially characteristic of the cholestastic syn- drome [56]. Moreover, it has already been proved that in cholestasis the bile salts induce synthesis of new mole- cules of ALP [61]. The present study showed that
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Primary sclerosing cholangitis – The arteriosclerosis of the bile duct?

Primary sclerosing cholangitis – The arteriosclerosis of the bile duct?

Little is known about the potential importance of the extracellular matrix composition in the pathogenesis of both entities and how modifications (e.g. binding of oxLDL/phospholipids to proteoglycans, cleavage and sig- nalling through proteinases, collagenases, gelatinases, resulting advanced glycosylated endproducts or trans- glutamination of collagen fibres) could influence the per- petuation of both diseases. In arteriosclerosis, diminished stability of the matrix scaffold is driven by MMPs, colla- genases, and the recently identified ADAMTSs (a disin- tegrin-like metalloprotease with thrombospondin type-1 motifs) [33]. These enzymes could either play a role in the resolution of vessel stenoses or also destabilize plaques [34,35]. In parallel, these enzymes could also be engaged in the chronic persistent wound-healing process in PSC. It is attractive to speculate that chronic activation of MMPs could further increase duct permeability. In addition, per- sistent activation of ADAMTSs could further increase the inflammatory response through their thrombospondin-1 motive (TSP-1) on TGF-β [36,37] or in the sense of a self- perpetuating process by generating chemotactic/immuno- genic ECM products.
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Morphological and histological study of the liver in migratory starling bird (Sturnus vulgaris)

Morphological and histological study of the liver in migratory starling bird (Sturnus vulgaris)

The liver is one of the accessory organs of the alimentary canal that deliver their secretory products to the small intestine by excretory ducts [3] and is the largest gland of the bird's body which have dark brown or red brown colour. The right side of the liver has both endocrine and exocrine gland, which are releasing several substances directly into the blood stream and secreting bile into the duct system [4 and 5]. The liver is bi-lobed (right and left lobes) that located ventrally and posteriorly to the heart associated with proventriculus and spleen. This organ is one of the most metabolically active organs in the body and serves many vital functions such as plasma proteins synthesis, glycogen storage, decomposition of erythrocytes, hormone production, degradation of alcohol and drugs [6, 7] as well as detoxification of substance [8]. Despite of the avian liver vital functions to our knowledge, few studies have been performed to clarify its structure and most of these studies focused on domestic birds. So the goal of the present study is to investigate the morphology and histology of the liver in starling migratory birds.
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Stimulation of bile duct epithelial secretion by glybenclamide in normal and cholestatic rat liver

Stimulation of bile duct epithelial secretion by glybenclamide in normal and cholestatic rat liver

rent study. However, after gut absorption of glybenclamide, the drug is avidly removed from the portal circulation by the liver, then subjected to enterohepatic recirculation (39, 40). Therefore, cholangiocytes in vivo may be exposed to a much higher concentration of glybenclamide than would be reflected by a serum concentration of 1 m M. Currently, the only treat- ment for cholestasis that is of proven benefit is ursodiol (2). The mechanism whereby ursodiol exerts its beneficial effect is not established, but it may in part result from ursodiol displac- ing more toxic bile acids from the endogenous bile acid pool (41). This could account for the observations that ursodiol of- ten slows the progression of certain cholestatic disorders, rather than inducing actual clinical improvement, and that months to years of treatment are required in any case before a beneficial effect is seen (3, 42). Since many cholestatic disor- ders are the result of biliary dysfunction (6), a rational and per- haps more effective treatment strategy would be to directly stimulate secretion by bile duct cells. Although treatments for such disorders have not yet been directed towards these cells, the current work suggests that it may be practical to selectively stimulate bile ductular secretion, and that this treatment ap- proach would improve bile flow in cholestasis.
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The Experience on Percutaneous Biliary Drainage in Malignant Biliary Obstruction and Associated Bilomas

The Experience on Percutaneous Biliary Drainage in Malignant Biliary Obstruction and Associated Bilomas

The term biloma was introduced in 1979 by Gould and Pater to describe a loculated collection located outside the biliary tree. Kuligowska et al. extended the term biloma to include intrahepatic as well as extrahepatic collections of bile [23]. Bilomas are defined as loculated collections of bile located outside the biliary tree and represent one of the most common and serious complications after cholecystectomy [23]. The formation of biloma related to intrahepatic bile duct injury was first described by Whipple in 1898 [24]. Early use of CT scan and HIDA (hepatobiliary iminodiacetic acid) imaging enables the prompt identification and management of the problem [24]. The diagnosis of traumatic complications (such as biliary complications) is ideally facilitated by the judicious use of CT scans [24]. Patients who require additional workup include those with increasing abdominal distension, worsening or persistent abdominal pain, tachycardia, feeding intolerance, increasing bilirubin levels, and jaundice [24]. Angiography, CT scanning, HIDA imaging, and endoscopic retrograde cholangiopancreatography (ERCP) are valuable tools that can not only help to diagnose, but can treat many of the complications of blunt traumatic liver injuries. Additional radiographic evaluations such as serial CT scans may be helpful, in selected cases, to follow the course of liver injuries. For example, selective arterial angiographic embolization can resolve late life-threatening hepatic hemorrhage. HIDA scans can aid in the localization of the site of bile duct injury. ERCP can be used to stent the common bile duct, and create a sphincterotomy to decompress the biliary system and thereby facilitate healing [24]. El Idrissi-Lamghari et al. have reported that combined endoscopic and transhepatic internal/external drainage that includes an intraduodenal ‘‘rendezvous’’ technique frequently is used for the management of common bile duct obstructions, but not for biloma. They have described an unreported combined technique including an intrabiloma ‘‘rendezvous’’ to treat a large intrahepatic biloma [25].
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Forgotten biliary Stent: A case report

Forgotten biliary Stent: A case report

Endoscopic sphincterotomy and stone extraction is the widely accepted treatment modality for common bile duct stones and this procedure can clear the bile ducts in 85% to 90% of patients. Endoscopic insertion of biliary endoprosthesis has been proposed as an alternative for frail, elderly patients or in those with high surgical risk. Biliary stent plastic is kept for temporary relief of biliary obstruction.It is to be kept for 3 weeks to 3 months maximum, in this patient biliary stent was kept for 5 years which is the longest period a stent remained in biliary tree. We recommend for all ERCP units provide a stent registry system that the stents placed for various therapeutic procedures are not forgotten both by the patient as well as the physician. There sould be a deadline for biliary stents in registry system for each patient.
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Jaundice caused by protrusion of a hepatic cyst into common bile duct that was resolved by choledochoscopic needle-knife electrotomy: a case report

Jaundice caused by protrusion of a hepatic cyst into common bile duct that was resolved by choledochoscopic needle-knife electrotomy: a case report

Backgroud: Hepatic cysts are the most frequent, innocuous, space-occupying lesions of the liver. The majority of solitary liver cysts are nonsymptomatic. When liver cysts reach a large size, there are some complications, including infection, rupture, spontaneous hemorrhage, obstructive jaundice, and neoplastic degeneration. Percutaneous aspiration, fenestration, hepatic resection, and liver transplantation have been proposed for symptomatic patients. Case presentation: In this case report, we describe a 41-year-old woman who presented with persistent liver dysfunction, indolent xanthochromia, and skin itching for 3 months. After a series of tests, she has a 5.0 × 5.3 cm hepatic cyst with many separations in the left medial liver lobe. The obstructive jaundice was caused by a large pedunculated lump protruding into the common bile duct from the left hepatic duct. She was treated with laparotomy and this lump was completely removed from the root by choledochoscopic needle-knife electrotomy with a good clinical response. Postoperative pathology of the lump suggested a hepatic cyst wall without heterocysts or tumor cells.
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Management of Traumatic Bile Leakage

Management of Traumatic Bile Leakage

When patients after BLT are suffering from high fever, persistent abdominal pain or fullness, gross jaundice, we performed abdominal CT to detect intraab- dominal fluid collection. If abnormal intra-abdominal fluid collection was de- tected in abdominal CT, we aspirate intraabdominal fluid by echo. If we aspi- rated bile from intraabdominal fluid, we made a diagnosis of bile duct injury highly possible and ERCP therapy was indicated due to high possibility of major bile leak and to provide early intervention.

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Toothpick inside the Common Bile Duct: A Case Report and Literature Review

Toothpick inside the Common Bile Duct: A Case Report and Literature Review

Copyright © 2017 V. O. Brunaldi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The incidence and prevalence of foreign body (FB) ingestion are difficult to estimate. Unlike other foreign bodies, the ingestion of a toothpick is very uncommon and carries high morbidity and mortality rates. We report a case of a 73-year-old female patient presenting mid-term epigastric pain. Abdominal ultrasound revealed a slightly dilated common bile duct (CBD) and magnetic resonance showed an irregular filling failure in distal CBD and gallstones. Endoscopic Retrograde Cholangiopancreatography revealed major papilla on the edge of a diverticulum and confirmed the distal filling failure. After sphincterotomy, a partially intact toothpick was extracted from the CBD. Neither fistulas nor perforation signs were found. Literature related to foreign bodies and toothpick ingestion was reviewed and some hypotheses to explain the reported case were created. To our knowledge, this is the first report of a toothpick lodged inside the biliary tract.
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