Different opinions exist related to the best moment to carry on the repair, Strasber  has suggested to wait 3 months in lesions with confluence lost meanwhile ischemia is delimit, as lesion is always higher than originally appreciated. In the same way, Santibañez  considered that repairing should wait 6 to 8 weeks in order to allow inflammation to be limited; on the contrary, recent reports like the ones from Stilling  or Kirk  concluded that the repair moment of a bilioenteric derivation by itself, did not modify the long term result. Stewart and Way  in a multivariate analysis on 307 patients, revealed that a derivation success depends on complete eradication of the abdominal infection, identification of the lesion level through a cholangiography, adequate surgical technique and an experienced biliary team; when these objectives are achieved, repair could be performed at any time with the expectation of a favorable result without any reason to delay the procedure for an arbitrary time .
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 bileductinjuries (IBDI) in such conditions, when correct identification of Calot's triangle is less likely.
Radiological Interventions: The indications of doing percutaneous trans-hepatic cholangiography (PTC) were two folds. Firstly PTC provided excellent images of the proximal biliary tree which were superior to MRCP. Secondly proximal drainage relieved obstructive jaundice and improved patients' feelings of nausea and low appetite so that nutritional optimisation could be achieved. The procedure was done under local anaesthesia and analgesia at angiography suite in over both, dilated and non-dilated bileduct systems. With the guidance of ultrasound, 22 G spinal needle was used to tap secondary radicles of right hepatic duct in mid axillary line. After entering the biliary radicle successfully, guide wire was inserted up to the confluence and cholangiogram images were taken. An attempt to cross the stricture was made in every procedure. An external or interno-external drain was placed depending whether the guide wire crossed the stricture or not. For interno- external drains additional eyes were made in such a way that it could drain the bile pooled proximal to the stricture. The drains were fixed to the skin using silk sutures.
Klatskin tumors are cholangiocarcinomas (CCA) that arise from hilar bile ducts and their confluence. Forty to sixty percent of CCAs are Klatskin tumors making them the most common type [1, 2]. The incidence of CCA is around 2 in 100,000 in the USA  and incidence in Lebanon and the Middle East is unknown. The presenting symptoms range from vague abdominal pain to weight loss, jaundice and pruritus depending on the level and degree of bileduct obstruction . Diagnosing this tumor and classifying it requires multiples imaging modalities starting with the least invasive like ultrasound, Computed tomography (CT) scan and MRI scan, and often necessitates endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). Multiple classification systems exist like the American Joint Committee on Cancer (AJCC), the Bismuth-Corlette, the Memorial Sloan Kettering Cancer Center (MSKCC) and recently the International Cholangiocarcinoma Group Staging System [1, 3, 4–6] , the first one correlating poorly the type with the corresponding treatment.
When all the adhesions to the right upper quadrant were sectioned, the jejunal limb was dissected. Hepatobiliary duct-jejunum single layer anastomosis was performed with interrupted 4/0 absorbable polyglactin (Vicryl) sutures. Liver resection of segment IV base was done when the liver was overhanging the upper ducts, allowing adequate exposure of the left duct. To obtain a complete view of the confluence and/or the isolated right and left hepatic ducts and to allow free placement of the jejunal limb, liver parenchyma could be removed. When the retractors were released, there was no external compression over the jejunum. Partial injuries to the side wall of the bileduct were repaired primarily with T tube placement through a separate choledochotomy when there was no evidence of ductal devascularisation and when the margins of the defect could be approximated without tension. Injuries to isolated sectoral or segmental ducts were repaired or drained into a Roux-en-Y limb of jejunum. Depending on the level of injury and biliary ductal involvement, a median of 2 biliary stents was placed intraoperatively. The Postoperative transcatheter cholangiography was performed routinely (Figure 2). To prevent postoperative biliomas or intra-abdominal collections, a median of 2 drains was placed intraoperatively at the anastomosis. Follow-up and outcome: Of the 92 patients with BDI who underwent biliary reconstruction, three (3.3%) died in the postoperative period due to sepsis and multiple organ failure. Longer-term outcome was assessed by clinical symptoms and liver function tests in outpatient visit. The follow-up protocol for these patients included clinical assessment and liver function test (LFT) every 6 months.
Viewed in conjunction with the finding of Somi et al. , the present study demonstrated that bileduct ligation usually decreases antioxidant enzyme (GST, SOD and CAT) activities in hepatic tissue that may be attributable to mitochondrial toxicity induced by intrahepatocyte con- centration of biliary acids in chronic cholestasis. In accord with our results, Sanzgiri et al.  have reported that the enhanced free radical concentration resulting from the oxidative stress conditions can cause loss of enzymatic activity. Moreover, the enhancements in antioxidant enzyme activities may prevent the accumulation of excessive free radicals and protect liver following BDL. Tissues and cells would be subjected to oxidative injuries when large quantities of inner free radicals are generated or the activities of antioxidant system deteriorate. Accord- ingly, antioxidant therapy represents a potential strategy to prevent liver injury and fibrosis. Treatment with HaE normalized the antioxidant levels through their rich of polyphenolic compound especially chlorogenic acid that has the ability to scavenge free radicals.
5. Yotsuyanagi, S. Contributions to aetiology and pathogenicity of idiopathic cystic dilatation of common bileduct 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.
subjected to laparotomy as well as bileduct identification and manipulation, but ligation or resection was not performed (with the aim of measuring possible stress induced by surgery). In the bileduct ligation groups, the main bileduct 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.
and since that time primary suture had been abandoned. Mayo , Kiirschner , Mirrizzi , Edwards and Herriongton , Herrington et al. , have written articles supportive of primary common bileduct closure. Primary closure of the common bileduct following exploration has been safely and effectively performed, provided no evidence of pancreatitis, cholangitis or ampullary obstruction exists . 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? . The current study aimed at sharing in returning con idence in primary suture procedure after common bileduct exploration and to establish criteria for including or excluding patients undergoing primary suture of bileduct closure. It is well known that the best treatment of common bileduct stones is ERCP whenever available and our study done on basis of ERCP absence.
Laparotomy is performed by a right subcostal incision with the midline upward extension. By gross inspection, there is no peritoneal seed- ing, hepatic metastasis or periaortic node metastasis. Firstly, dissect the hilar vascula- tures carefully and preserve those feeding the left liver. And we found that we need to resect and reconstruct these vasculatures to achieve curative intended resection because of local vascular invasion. Then, the caudate lobe liver and adjacent right liver are resected. After that, the patency of the left common bileduct was explored and the hepaticoplasty was complet- ed. Thirdly, pancreatoduodenectomy is com- pleted and cholangioenterostomy and entero- enterostomy are finished (Figure 2). Finally, the HPD which includes middle lobe and caudate
In conclusion, a CBD diameter of 15 mm or larger and the presence of a periampullary diverticulum were significant pre- dictive factors for recurrence after endoscopic extraction of CBD stones. For patients with risk factors for bileduct stone recurrence, periodic surveillance may be recommended. In addition, prophylactic cholecystectomy after clearance of CBD stones does not appear to reduce the incidence of recurrent CBD stones in Korean patients, in whom pigment stones are more common. Further prospective studies are needed to in- vestigate long-term outcomes in these patients.
glutamyltranspeptidase (543.1 U/L). Total bili- rubin and direct bilirubin were 38.8 μmol/L and 20.6 μmol/L. CA199, CA50 and CA242 were 2715.28 U/ml, 210.78 IU/ml and 142.9 IU/ml respectively. Ultrasonography showed a hypo- echoic heterogeneous mass in the liver. The gallbladder was clear in border with unthick- ened wall (Figure 2). A hyperechoic lesion with acoustic shadow was visualized inside the gall- bladder. CT scan showed a 32×48 mm hypoden- sity lesion with peripheral enhancement in the right lobe of the liver. A single intraluminal pol- ypoidal soft tissue with contrast enhancement could be identified in the confluence of com- mon hepatic duct and cystic duct (Figure 3). Intrahepatic bile ducts were dilated. According to the clinical manifestation and the results of various imaging modalities, we diagnosed the patients having synchronous HC and PLA. After admission, intravenous antibiotics thera- py was applied and ultrasonography-guided catheter drainage as well as liver biopsy was performed (Figure 2). However, the catheter was obstructed by pus and the state did not improve. Pathological examination did not showed any evidence of malignancy of the liver lesion. After all these preparations, this pati- ent underwent operation two weeks after admission.
recommend radical cholecystectomy with extrahepatic bileduct (EHBD) resection in patients with gallbladder cancer even in the absence of direct invasion to the hepatoduodenal ligament based on studies showing that gallbladder cancer cells frequently spread to the tissues surrounding the EHBD via perineural and lymphatic routes [6, 7]. In fact, the dense neural network comprising nerve fibers and plexuses circumvolutes EHBD. Further- more, there is abundant nerve tissue surrounding the gallbladder and the bileduct . Tumor cells can also spread through the perineural space. Importantly, perineu- ral invasion (PNI) was reported as a significant prognostic factor in patients with gallbladder cancer [6, 9].
hilar bileduct tumor, recurrent peritoneal metastasis of ovarian cancer was also detected. The optimal treatment for metastatic ovarian cancer of the bileduct would be chemotherapy. However, in this case, we could not obtain a definite histopathological diagnosis preoperatively. In general, both paclitaxel and carboplatin are not effective in cholangiocarcinoma. There was concern that the tumor was a primary cholangiocarcinoma and these anticancer drugs would not be effective, resulting in a loss of oppor- tunity for curative treatment. In this case, because infiltra- tion to the right hepatic artery was suspected, the preoperative staging of the hepato-hilar tumor was estimated as stage IIIA by International Union Against Cancer (UICC) staging for perihilar cholangiocarcinoma. The overall 5-year survival rate after surgery in stage IIIA hilar cholangiocarcinoma is reported to be approximately 45% , whereas the 5-year survival rate of advanced
Ductal calculi presenting 2 years or more after an operation are generally regarded to be primary or recurrent. One study has identified suture material in 30% of cases. This finding stresses the importance of avoiding non-absorbable material during operation on the biliary tract. Internalization of metal clips used to secure the medial end of the cystic duct during laparoscopic cholecystectomy is now a well-recognized complication of this procedure. The exact pathology remains unclear. The internalized clip becomes covered with calcium bilirubinate to form a brown pigment stone.
The serum markers of the bone metabolism (osteocal- cin, PINP and CTX-1) serve for evaluation of bone turn- over. We therefore determined the local concentrations of these markers in the bone tissue homogenate to exc- lude other influences on the metabolism of the organism. The higher concentration of procollagen type I N-termi- nal propeptide (PINP) in group R-BDO indicates that resveratrol positively stimulate new formation of fibrous tissue locally in bone. This finding is similar to data pre- sented by Singh who reported inhibition of the collagen type I, osteopontin, and bone sialoprotein formation by 2,3,7,8-tetrachlorodibenzo-p-dioxin from cigarette smoke, this effect was antagonized by resveratrol . Moreover, resveratrol is also able to inhibit the receptor activator of nuclear factor-κB ligand (RANKL)-mediated osteoclast differentiation, induces osteoclast apoptosis by inhibition of ROS production , activates osteoblastic activity in vitro by bone transcription of core binding factor α-1 (Cbfa-1) , and reduce rosiglitazone-induced oxidative stress in osteoblast-like cells . The resveratrol induces bone morphogenetic protein-2 through Src kinase-de- pendent estrogen receptor activation  and it could play a role in protecting against bone loss induced by estrogen deficiency , which arose after BDO.
Cholestasis is a cardinal complication of liver disease, but most treatments are merely supportive. Here we report that the sulfonylurea glybenclamide potently stimulates bile flow and bicarbonate excretion in the isolated perfused rat liver. Video-microscopic studies of isolated hepatocyte couplets and isolated bileduct segments show that this stimulatory effect occurs at the level of the bileduct epithelium, rather than through hepatocytes. Measurements of cAMP, cytosolic pH, and Ca2+ in isolated bileduct cells suggest that glybenclamide directly activates Na+-K+-2Cl- cotransport, rather than other transporters or conventional second-messenger systems that link to secretory pathways in these cells. Finally, studies in livers from rats with endotoxin- or estrogen-induced cholestasis show that glybenclamide retains its stimulatory effects on bile flow and bicarbonate excretion even under these conditions. These findings suggest that bileduct epithelia may represent an important new therapeutic target for treatment of cholestatic disorders.
Discussion: The present study showed that a clinically relevant biliary leak after hepaticodigunostomy, and biliary drainage with PTDA occurred after the anastomosis was performed on the segmental ducts that are independent predictors. Early PTDA is a safe and adequate treatment strategy, in patients who had biliary losses within 24 hours e. the rate of relaparotomy has decreased significantly. Confirming as for other authors that the proximal bileduct resections had the highest incidence of leakage. The rate of loss after a bileodigestive bypass procedure for palliation or obstructive jaundice treatment was low, (2%) The surgical palliative of the bile digestive bypass remains an adequate procedure in an unresectable disease Conclusions: The procedures of bile digestive bypass in association with PTDA remain in unresectable neoplasms of the biliary tract a main and safe indication, integrating and ensuring the possibility of carrying out complementary therapies.
After confirming that the patients were adequately se- dated, ERCP was performed using a side-viewing endo- scope (JF-260 V, Olympus Medical Systems, Co. Ltd, Tokyo, Japan). At the time of ERCP, an ERCP catheter (MTW Endoscopy, Goldsbergstraße, Germany) was used for contrast-enhanced catheterization and a jag wire (Boston Scientific Japan, Tokyo, Japan) served as the guide wire. After the common bileduct was selectively imaged, the sizes and number of stones were confirmed and the diameter of the distal bileduct was measured simultaneously (Fig. 1). The diameter of the EPLBD bal- loon (CRE, Boston Scientific Japan, Tokyo, Japan) was selected to correspond to the diameter of the distal bileduct. In all patients, EST was performed before EPLBD (Fig. 2).
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 bileductinjuries.