Bile Duct Injury (BDI)

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Reliable reconstruction of the complex high-location bile duct injury: a novel hepaticojejunostomy

Reliable reconstruction of the complex high-location bile duct injury: a novel hepaticojejunostomy

inflammation and non-scarred) bile ducts for tension- free anastomosis is the fundamental principle of high- quality bile duct reconstruction, which must drain all liver segments [8, 9]. Roux-en-Y hepaticojejunostomy (HJ) currently is recognized as the best treatment option for most major BDI to provide excellent long- term outcomes [10]. However, complex high-location bile duct injury (CHBDI) that is defined as a bile duct injury at the conjunction of the left and right hepatic duct or higher plane (classified as Strasberg classifica- tion type E4) in this study is one of the most feared types of injury [9, 11]. For the surgical treatment of CHBDI, the dissection of the hepatoduodenal ligament is inevitable to expose the injured bile duct satisfactorily. To achieve this, surgeons have to lower the hilar plate and remove partial liver parenchyma. The resection of segment IV b base and partial segment V is conducive to exposure
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Original Article Postoperative anastomotic bile duct stricture is affected by the experience of surgeons and the choice of surgical procedures but not the timing of repair after obstructive bile duct injury

Original Article Postoperative anastomotic bile duct stricture is affected by the experience of surgeons and the choice of surgical procedures but not the timing of repair after obstructive bile duct injury

Abstract: Bile duct injury (BDI) is one of the most severe complications of biliary operation. This study is to inves- tigate the correlation between the timing of bile duct repair and anastomotic bile duct stricture. Transverse BDI models were constructed in 60 dogs that were divided randomly into BDI 5 , BDI 10 , BDI 15 , BDI 20 , and BDI 30 groups according to days of injury (5, 10, 15, 20, and 30 days). The morphological and histological changes of anastomotic stoma of hepaticojejunostomy (HJ) were observed after bile duct reconstruction. TGF-β1, α-SMA, and collagen of anastomotic stoma were detected. After HJ, the concentration of direct bilirubin decreased significantly, dropping to 50% after one week, and returning to normal levels after three weeks. The anastomotic diameter shrunk from 1.5 cm to 0.6 cm without significant difference. At 3 months and 6 months after HJ, the expression of TGF-ß in the anastomotic tissue in BDI 5 group was higher than that in BDI 10 , BDI 15 , BDI 20 , and BDI 30 groups. However, no signifi- cant differences were observed (F = 1.282, P > 0.05 at 3 months; F = 1.308, P > 0.05 at 6 months). Similarly, the expression of α-SMA and collagen did not vary significantly. For obstructive BDI, repairing time is not a relevant fac- tor for postoperative anastomotic stenosis, but surgeons and operation methods are the key factors. For patients with BDI, hospitals should focus on the experience of surgeons and the choice of operation methods in order to achieve a good long-term effect.
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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

Pre-operative imaging studies such as magnetic resonance cholangiographies (MRC), ERCP, and PTC correctly delineate the location and nature of MBDI (Rauws, 2004; Csendes et al., 1989). Surgery should only be contemplated when the patient is stabilized and the MBDI has been correctly classified. The success of the operating procedure depends directly on the proper and accurate delineation of the MBDI. If the injury is recognized in the early postoperative period (2 to 7 days), involves a relatively distal lesion below the bifurcation and is not associated with biliary leakage, abscess formation and sepsis, early reconstruction can be considered. When we have involvement of the bifurcation, percutaneous biliary drainage is preferred with elective repair after 6 to 8 weeks (Rauws, 2004). The control of sepsis and the ongoing bile leak are the primary goals of the initial management of a bile duct injury. If this can be accomplished, proceeding with surgical reconstruction is not urgent. In fact, reconstruction in the face of peritonitis portends a statistically poorer outcome in patients.
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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

The duration of laparoscopic cholecystectomy was 150 minutes while the procedure was completed laparoscopi- cally and there is no record of intraoperatively identified biliary injury. From the 2nd postoperative day and up to her referral to our institution, recurrent episodes of cholangitis with severe pain, fever with chills and jaundice began. Magnetic resonance cholangiography (MRC) was performed in order to delineate the biliary anatomy and assess the level of injury. A triple bile duct injury, with right and left hepatic duct ligation and common bile duct cross-section, was revealed (Bismuth type V, Figure 1). Attempts at permanent biliary decompression with repeated endoscopic retrograde cholangiopancreatogra- phies (ERCP), combined with percutaneous transhepatic duct catheterization failed and for 1 year postoperatively bile drained from abdominal drains. On the 13th postop- erative month, she was referred to another hospital for bil- iary draining (Figure 2). Through the left drain, a guidewire was passed only to be found later during ERCP in the duodenum in a place other than the papilla of Vater via a false route. On the next episode of cholangitis, both left and right biliary trees were successfully decompressed and 18 months after LC, she was referred to our hospital for surgical reconstruction.
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Stepwise approach to curative surgery using percutaneous transhepatic cholangiodrainage and portal vein embolization for severe bile duct injury during laparoscopic cholecystectomy: a case report

Stepwise approach to curative surgery using percutaneous transhepatic cholangiodrainage and portal vein embolization for severe bile duct injury during laparoscopic cholecystectomy: a case report

Laparoscopic cholecystectomy (LC) has been recently adapted to acute cholecystitis. Major bile duct injury during LC, especially Strasberg-Bismuth classification type E, can be a critical problem sometimes requiring hepatectomy. Safety and definitive treatment without further morbidities, such as posthepatectomy liver failure, is required. Here, we report a case of severe bile duct injury treated with a stepwise approach using 99m Tc-galactosyl human serum albumin ( 99m Tc-GSA) single-photon emission computed tomography (SPECT)/CT fusion imaging to accurately estimate liver function. A 52-year-old woman diagnosed with acute cholecystitis underwent LC at another hospital and was transferred to our university hospital for persistent bile leakage on postoperative day 20. She had no jaundice or infection, although an intraperitoneal drainage tube discharged approximately 500 ml of bile per day. Recorded operation procedure showed removal of the gallbladder with a part of the common bile duct due to its misidentification, and each of the hepatic ducts and right hepatic artery was injured. Abdominal enhanced CT revealed obstructive jaundice of the left liver and arterial shunt through the hilar plate to the right liver. Magnetic resonance cholangiopancreatography revealed type E4 or more advanced bile duct injury according to the Bismuth-Strasberg classification. We planned a stepwise approach using percutaneous transhepatic cholangiodrainage (PTCD) and portal vein embolization (PVE) for secure right
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Bipartite Laparoscopic Cholecystectomy: New Technique for Avoiding Bile Duct  Injury in Difficult Cases

Bipartite Laparoscopic Cholecystectomy: New Technique for Avoiding Bile Duct Injury in Difficult Cases

The incidence of bile duct injury in laparoscopic cholecystectomy (LC) is still two times greater compared to classic open surgery. This study offers new procedure to avoid this complication during LC. The gall bladder was divided into two parts above the Hartmann pouch and all contents were aspirated. Then, the distal part was dissected for short distance. The proximal part was dis- sected dome down until reaching to cystic duct which was tied or clipped and cut. J-vac drain was put in peritoneal cavity. Between September 2012 and October 2013, overall 77 patients (53 fe- males and 24 males) with mean age of 49 years (between 23 and 67 years) underwent bipartite laparoscopic cholecystectomy. The mean operative time was 60 minutes (between 40 and 90 mi- nutes). The dissection of both parts of gall bladder was safe and easy as close as possible from its wall. No biliary tract injuries were recorded during or after procedure and also at follow-up pe- riod (20 months). Bipartite laparoscopic cholecystectomy is safe, easy to do, and can avoid all com- plications especially bile duct injuries in difficult cases.
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<p>Iatrogenic bile duct injury: impact and management challenges</p>

<p>Iatrogenic bile duct injury: impact and management challenges</p>

contrast material extravasation into fluid collections in addi- tion to demonstrating the anatomical site of the leakage and the type of BDI. For example, in Figure 3 cystic duct leak was demonstrated at MRCP after gadoxetic acid injection. In the same way, hepatobiliary scintigraphy may confirm the presence of an active biliary leak with the progressive accumulation of the radiotracer inside the peritoneal cavity, but this examination is much less reliable. However, if fluid collection is found in ultrasound, CT, or MRCP, an abdominal drain should be placed right away under radiological guidance in order to improve patient’s clinical condition (peritonitis, sepsis, tissue repairing). If there is a delay of more than a week in operative treatment of Stewart-Way Class III or IV injuries, there should be a timeout for 2–3 months before operation. In this time frame, the patient needs to be stabilized and optimized for surgery. An optimal control of any intra- abdominal fluid collection, inflammation, and infection is essential, and is best achieved with percutaneous drainage. 37
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Study of post cholecystectomy biliary leakage and its management

Study of post cholecystectomy biliary leakage and its management

common duct and delayed biliary structure. Other introperative factors that may contribute to bile duct injury include dissection too deep into the liver pafrenchyma, and failure to distinguish betwen the cystic duct and the common hepatic or common bile duct. Since its introduction, laparoscopic cholecystectomy has become the gold standard treatment for gallstone disease. However, the incidence rate of bile duct injury (BDI) has risen from 0.06% to 0.3% (Davidoff et al., 1992). In initial studies on the removal of laparoscopic gallbladder, complications such as bleeding, wound infection, respiratory insufficiency, trocar injury to the intra-abdominal viscera, major vascular injury, and bile leaking accounted for reported morbidity rate ranging from 1.0% to 8.0% (Farquharson’s Text Book Of Operative Surgery, 2014). Despite the completion of the learning curve and the recognition of preventive maneuvers to avoid ductal injury during laparoscopic cholecystectomy, the incidence rate of BDI remains unchanged. (Courtney et al., 2012) In addition, injuries of the bile duct system after laparoscopic cholecystectomy are more complex than that after an open approach, causing significant morbidity and even death (Anand, 2011; Davidoff et al., 1992; Farquharson’s Text Book Of Operative Surgery, 2014)
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An Overview of Near Infrared Fluorescent Cholangiography with Indocyanine Green during Cholecystectomy

An Overview of Near Infrared Fluorescent Cholangiography with Indocyanine Green during Cholecystectomy

Laparoscopic cholecystectomy (LC) is one of the most common surgical procedures performed globally but continues to carry to an unacceptably high risk of iatrogenic bile duct injury (BDI). In recent years several centres have proposed Near Infrared Fluorescent Cholangiography (NIRFC) with Indocyanine Green (ICG) as a potential method of dynamic intraoperative extra hepatic bile duct mapping. We provide an overview of the current problem of BDI during laparoscopic cholecystectomy including the incidence, aetiology and medico legal ramifications. We also provide a short summary of the enduring argument for and against routine intraoperative cholangiogram (IOC) and we discuss the new technology of NIRFC with ICG in detail. We provide an informative summary of the small number of highly heterogeneous clinical trials of NIRFC with ICG currently available and briefly discuss limitations of the technology.
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Management of Traumatic Bile Leakage

Management of Traumatic Bile Leakage

Major bile leak after BLT is uncommon. In addition to a high grade injury, cen- trally-located liver injuries and initial TAE are also a significant risk factor for major bile duct injury. When patients after BLT are suffering from high fever, persistent abdominal pain or fullness, gross jaundice, we perform abdominal CT to detect intraabdominal fluid collection. If we aspirated bile from intraabdo- minal 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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A Comparative study of Bileduct Injuries during Laparoscopic Cholecystectomy With and Without Biliary Mapping using
Methylene Blue

A Comparative study of Bileduct Injuries during Laparoscopic Cholecystectomy With and Without Biliary Mapping using Methylene Blue

Patients suspected of having an iatrogenic bile duct injury should undergo imaging to assess for a fluid collection and to evaluate the biliary tree.ultrasonography can achieve both these goals,but because percutaneous drainage may be required and anatomic delineation is valuable,cross sectional imaging by CT will generally provide more useful data .some surgeons advocate the use of radionuclide scanning to confirm bile leakage,but with any documentation of a leak,CT will be necessary to plan management.also,ischemia is a common cause of bile duct stricture.in the setting of bile duct injury,20% or more of patients will have concomitant unrecognized vascular injuries. (21)
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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

during this method may lead to further anatomical distortion. The Rouviere's sulcus is a fissure on the liver between the right lobe and caudate process and is clearly seen during a LC during the posterior dissection in a majority of patients. It corresponds to the level of the porta hepatis where the right pedicle enters the liver. It has hence been recommended that all dissection be kept to a level above (or anterior) to this sulcus to avoid injury to the bile duct. Also, this being an 'extrabiliary' reference point it does not get affected by distortion due to pathology. Similarly, a clear delineation of the junction of the cystic duct with the gallbladder along with the demonstration of a space between the gallbladder and the liver clear of any other structure other than the cystic artery (safety window or critical view) is also recommended as an essential step to prevent bile duct injury.
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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

If cholangiography is planned, it is to be done at this stage by introducing cholangio catheter via a small opening in cystic duct after placing a clip distally at its junction with gall bladder. Contrast is injected to delineate the biliary tree under fluoroscopic guidance. Though it prevents bile duct injury during further procedure, it cannot prevent injuries which are sustained during dissection described before.

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The role of indocyanine green fluoroscopy for intraoperative bile duct visualization during laparoscopic cholecystectomy: an observational cohort study in 70 patients

The role of indocyanine green fluoroscopy for intraoperative bile duct visualization during laparoscopic cholecystectomy: an observational cohort study in 70 patients

represents the most feared complication following lap- aroscopic cholecystectomy [2]. The lifetime risk bile duct injury following laparoscopic cholecystectomy for gall- bladder stones without acute inflammation in the hands of an experienced surgeon has been reported to be about 0.4% [3]. Laparoscopic cholecystectomy for acute chole- cystitis has been shown to be associated with a much higher risk of bile duct injury with rates as high as 4% being reported in the literature depending on the extent of gallbladder inflammation [4, 5]. Although a large por- tion of bile duct injury consist of minor injuries, exten- sive and complex injuries to the biliary tree during
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Prospective study comparing early versus delayed laparoscopic/ open cholecystectomy for cholecystitis

Prospective study comparing early versus delayed laparoscopic/ open cholecystectomy for cholecystitis

Laparoscopic cholecystectomy is widely established as the standard operation in acute cholecystitis .The traditional teaching has been a two stage treatment for acute cholecystitis with an initial conservative management followed by an interval laparoscopic cholecystectomy.Laparoscopic cholecystectomy is avoided for acute cholecystitis due to concerns about the potential hazards of complications,especially common bile duct injury and a high conversion rate to open cholecystectomy.The conversion rates for elective laparoscopic cholecystectomy range from 3-7 %.However in presence of acute inflammation ,higher conversion rates of up to 30 % have been reported.Several studies have reported favourable outcomes with a low conversion rate if patients are operated within 96 hours of admission.[4,6]
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Safety of primary common Bile Duct Closure

Safety of primary common Bile Duct Closure

and since that time primary suture had been abandoned. Mayo [9], Kiirschner [10], Mirrizzi [11], Edwards and Herriongton [12], Herrington et al. [13], have written articles supportive of primary common bile duct closure. Primary closure of the common bile duct following exploration has been safely and effectively performed, provided no evidence of pancreatitis, cholangitis or ampullary obstruction exists [14]. In majority of surgical centers an external T-tube drainage was carried out in last century, but is an external drainage the best method to be used? [5]. The current study aimed at sharing in returning con idence in primary suture procedure after common bile duct exploration and to establish criteria for including or excluding patients undergoing primary suture of bile duct closure. It is well known that the best treatment of common bile duct stones is ERCP whenever available and our study done on basis of ERCP absence.
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Cholecystectomy for Prevention of Recurrence after Endoscopic Clearance of Bile Duct Stones in Korea

Cholecystectomy for Prevention of Recurrence after Endoscopic Clearance of Bile Duct Stones in Korea

ly, in the present study, cholecystectomy was not associated with a reduction in the recurrence rate of bile duct stones. The cumulative recurrence rate of CBD stones between the chole- cystectomy group and the non-cholecystectomy group was not significantly different. This finding can be explained by the fact that bile duct stone recurrence occurred more frequently due to brown pigment stones than due to cholesterol stones in this study. Brown pigment stones more commonly form in the bile duct, rather than migrate from the GB; thus, cholecystec- tomy would not affect the risk of bile duct stone recurrence in this setting.
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Indications for extrahepatic bile duct resection due to perineural invasion in patients with gallbladder cancer

Indications for extrahepatic bile duct resection due to perineural invasion in patients with gallbladder cancer

Between 2001 and 2017, 68 patients with gallbladder cancer underwent surgical resection at the University of Yamana- shi Hospital. Patients who underwent non-curative resec- tion were excluded from the study. Thus, 50 patients who underwent surgery were included in this retrospective study. We diagnosed all cases as gallbladder cancer using computed tomography (CT), magnetic resonance imaging (MRI), and endoscopic ultrasound (EUS) before surgery; therefore, there was no incidental cancer. None of the pa- tients received preoperative chemotherapy or chemoradio- therapy. In principle, cholecystectomy with EHBD resection was performed in patients with gallbladder cancer except for those patients with mucosal cancer. The clinicopatho- logical features of the cases were reviewed based on data recorded in the hospital database. Tumor specimens and resected lymph nodes were obtained at the time of surgery, fixed immediately in 10% neutral-buffered formalin, and embedded in paraffin. Macroscopic and microscopic classi- fication of gallbladder cancer was based on the Union for International Cancer Control classification, 7th edition. Complications were defined using the Clavien classification, and grade ≥ 2 complications were recorded [10]. Tumors invading the neck or the cystic duct of the gallbladder were defined as proximal-type, and those localized in the body or the fundus were defined as distal-type. Circumferential tumor locations were categorized as hepatic and non- hepatic, and circumferential involvement was recorded as hepatic.
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Effects of Cholestasis on Learning and Locomotor Activity in Bile Duct Ligated Rats

Effects of Cholestasis on Learning and Locomotor Activity in Bile Duct Ligated Rats

subjected to laparotomy as well as bile duct identification and manipulation, but ligation or resection was not performed (with the aim of measuring possible stress induced by surgery). In the bile duct ligation groups, the main bile duct was first ligated using two ligatures approximately 0.5 cm apart and then transected at the midpoint between the two ligatures (31). In the immediate post-operative period, each animal was placed in a cage by itself to prevent wound dehiscence and was moved to its original cage 4 hours after the surgery (32). Post-operative analgesia was achieved with subcutaneous injection of 0.05 mg/ kg rat buprenorphine (33). Passive avoidance tests, locomotor activity analysis and biochemical analysis were performed for all experimental groups, and the results from the sham operated, BDL 7, BDL 14, and BDL 21 groups were compared with those of the control group.
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CHOLEDOCHAL CYST-REPORT OF 4 CASES

CHOLEDOCHAL CYST-REPORT OF 4 CASES

5. Yotsuyanagi, S. Contributions to aetiology and pathogenicity of idiopathic cystic dilatation of common bile duct with report of 3 cases; new aetiological theory based on supposed unequal epithelial proliferation at stage of physiological epithelial occlusion of primitive choledochus. Gann, 1936; 30:601.

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