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.
A 35-year-old female patient was referred to our institution for the management of biliary trauma after laparoscopic cholecystectomy. Due to upper gastrointestinal symptoms she had had an upper abdominal ultrasound (US) that revealed cholelithiasis 4 months before surgery. Laparoscopic cholecystectomy was performed and during surgery as has been mentioned by concerned doctor and confirmed by the DVD provided by hospital, there was a CBD injury (Bismuth II). 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. Common bileduct cross-section, was revealed (Bismuth type II). On the 2nd postoperative month, she was referred to us for biliary draining and surgical reconstruction. Roux en Y hepaticojejunostomy was performed and the patient had no complaints with liver function tests returned results within the normal limits. After 4 years, patient again developed pain epigarium and nausea so MRCP was performed .MRCP showed significant intrahepatic biliary dilatation with obstruction at level of common hepatic ducts. CBD Exploration again planned and Left Hepatic Duct sludge Retrieved and washed aongwith Re Do Roux Anastomosis was performed. Patient recovered well with complete remission of symptoms and normal liver function tests till now.
BACKGROUND: Gall stone is becoming a problem worldwide because of change in life style. Now a days, is a major cause of morbidity among the patients attending the surgical OPD. The last 30 years have seen major developments in the management of gallstone related disease. Endoscopic retrograde cholangio-pancreatography has become a widely available and routine procedure, whilst open cholecystectomy has largely been replaced by a laparoscopic approach, which may or may not include laparoscopic exploration of common bileduct or LCBDE. In this case series, we have studied 25 cases of management of common bileduct stones according to the association with gall stones; pre-operative, intra-operative or post-operative identification of common bileduct stones and its management accordingly. OBJECTIVES:1. To study the various modes of clinical presentation of common bileduct stones. 2. To study the different modalities of management of common bileduct stones. 3. To study the feacibility, success rate, safety and outcome of different modalities. 4. To conclude the outcome of a single-step procedure against combined procedures. METHODS & MATERIALS: Patient selection criteria: 1. Age:15 to 80 years of age 2. BMI of 30 as the upper limit 3. Blood pressure<140/90 mmhg 4. ASA grades 1,2,3 RESULTS: single stage approach preferably laparoscopic common bileduct exploration is adopted if resources are available, otherwise preoperative ERCP plus laparoscopic cholecystectomy is feacible. The length of hospital stay and morbidity is significantly reduced in single stage approach as compared to two stage approach of CBD stones. CONCLUSION: As far as management is concerned, single stage laparoscopic CBD exploration is the best modality. As median hospital stay is significantly lower and rate of complications like recurrence, biliary stricture, leakage, cholangitis and biliary pancreatitis is significantly lower. The LCBDE requires advanced laparoscopic equipment and surgical skills, its application is limited.
Pre-operative imaging studies such as magnetic resonance cholangiographies (MRC), ERCP, and PTC correctly delin- eate the location and nature of MBDI [3,14]. Surgery should only be contemplated when the patient is stabi- lized and the MBDI has been correctly classified. The suc- cess 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 bifurca- tion and is not associated with biliary leakage, abscess for- mation and sepsis, early reconstruction can be considered. When we have involvement of the bifurcation, percutane- ous biliary drainage is preferred with elective repair after 6 to 8 weeks . The control of sepsis and the ongoing bile leak are the primary goals of the initial management of a bileduct injury. If this can be accomplished, proceeding with surgical reconstruction is not urgent. In fact, recon- struction in the face of peritonitis portends a statistically poorer outcome in patients.
Abstract: Iatrogenicbileduct injuries (BDIs) after laparoscopic cholecystectomy, being one of the most common performed surgical procedures, remain a substantial problem in gastrointestinal surgery with a significant impact on patient’s quality of life. The primary aim of this review was to discuss the classification of BDIs, the proposed methods to prevent biliary lesions, the associated risk factors, and the management challenges depending on the timing of recognition of the injury, its extension, the patient’s clinical condition, and the availability of experienced hepatobiliary surgeons. Early recognition of BDI is of paramount importance and limiting the diagnosis delay is crucial for an optimal postoperative outcome. The therapeutic management depends on the type and gravity of the biliary lesion, and includes endoscopic, radiologic, and surgical approaches.
and phospolipid is more rapid than that of bile salts so that bile becomes more lithogenic during this period. Also, high biliary pressure causes cholangiovenous reflux leading to bacteremia as may occur in cholangitis. Complete obstruction of main intrahepatic bile ducts or of a major segmental duct will normally lead to proximal dilation of the bileduct or of intrahepatic biliary radicles. The degree of dilation will depend on the extent, duration and also on the capacity of the bile ducts and surrounding parenchyma to expand. Chronic obstruction may fail to produce significant proximal dilation particularly when associated with marked chronic cholangitis, ductal fibrosis or cirrhosis of the liver.
Iatrogenic injury to the bileduct 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 bileduct is far more complicated and prolonged than the procedure itself. A retrospective analysis of 36 patients with bileduct 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 bileduct 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) bileduct injury.
Iatrogenic (mainly during laparoscopic cholecystectomy) is the most frequent cause of BDI. These are complex situations requiring a multi-disciplinary-radio-medico- surgical collaboration to achieve better management outcome. BDI can be recognized either intra- or post-operatively, this influences the type of diagnostic strategy and therapeutic management needed to deal with such a complication. Depending on the situation characterization of the biliary tree is a must and should be obtained by intra-operative cholangiogram or MRCP to help plan ideal therapeutic management plan. Endoscopy is recommended in the absence of complete trans-section of the main bileduct with insertion of a stent for 4 to 8 weeks as the first-line therapy; it is effective in more than 90% of patients. Sphincterotomy is not recommended as it increases early and late morbidity by 15%.
Preoperative placement of percutaneous transhepatic catheters are a useful tool to be considered and a standardized practice in our team, advantages include cholangitis management (if so), it allows good quality cholangiographies as many times as needed, enables recognition of bile ducts during dissection and helps in fistula control. Some groups consider its routinely use in IBDI with loss of confluence , while others prefer reserve them just for cholangitis cases or inability to establish the level of the lesion .
fistula itself. The tube should be kept for at least two to three months, Csendes reported an increased incidence of bile leak when the tube was bought out through the fistula rather than a fresh choledochotomy. Though choledochoplasty alone may suffice in nearly all cases of CBF, there are patients who present with complete or near complete obstruction of the bileduct at the initial exploration itself in these cases for better long- term results it is safer to perform bilioenteric anastomosis. The various forms of which could be hepaticojejunostomy end to side or side to side, cholecystocholedochoduodenostomy. The other indication for bilioenteric anastomosis could be presence of concomitant multiple CBD stones or distal obstruction of bileduct due to other cause. A well-defined management guideline was provided by Csendes et al who classified MS on the basis of extent or erosion of CD circumference. The recommended procedures for different types are: type I- partial cholecystectomy, type II-suture closure of fistula or choledochoplasty. Type IlI - choledochoplasty, type IV - bilioenteric anastomosis. A satisfactory outcome in a mean follow up of 5.7year is a testimony to the adequacy of these procedures. This management protocol has been followed by other authors too. Bilioenteric anastomosis has been performed in these series for some of type IlI case too, where bileduct erosion was considered significant. Concomitant choledocholithiasis has been reported in35-62% of patients with MS. Routine exploration of the CD should be carried out in all cases with CBF. For type I, cases one can be more selective. The CD exploration is performed through the fistula itself or a fresh choledochotomy.
Background: The indications for extrahepatic bileduct (EHBD) resection remain a major controversy in the surgical management of patients with gallbladder cancer. On the other hand, perineural invasion (PNI) was reported as an important factor in patients with gallbladder cancer because gallbladder cancer cells frequently spread to the tissues surrounding the EHBD via perineural routes. We assessed the correlation of PNI with clinicopathological factors in patients with gallbladder cancer to elucidate EHBD resection indications specifically in patients with PNI. Methods: This retrospective study assessed the PNI status of 50 patients with gallbladder cancer who underwent curative resection and examined the correlation between the presence of PNI and clinicopathological factors. Results: Thirteen patients (26%) were PNI positive. PNI was significantly correlated with male sex, proximal-type tumor, lymphatic and vascular invasion, and advanced T stage. Multivariate analysis found that PNI positivity ( p < 0.001), lymphatic invasion ( p = 0.007), and nodal stage ( p < 0.001) were independent prognostic factors. PNI was never observed in patients with stage T1 cancer. Conversely, PNI was detected rarely in distal-type tumors, all of whom developed various types of recurrences.
Primary closure of the common bileduct following exploration has been safely and effectively performed, as advocated by Halsted, provided no evidence of pancreatitis, cholangitis, or ampullary obstruction exists. This study was to gain back confi dence to primary closure in selected cases. This study was conducted at Beniswaif University Hospital. Between July 2008 to May. 2014. Using this precedent, the operative management and post-operative course of 19 patients undergoing common bileduct (CBD) exploration for choledocholithiasis were studied, twelve had primary closure of the common bileduct following choledochotomy and exploration, and seven had T-tube placement.
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
CASE 3: On 30th January 1985 a thirty years old female was admitted to the hospital with recurrent pain of nine years duration in the right hypochondrium. The pain had increased infrequency over the last 3 months. There was no history of jaundice. On clinical examination there was no palpable mass: Murphy’s sign was positive. Oral cholecystogram showed non-functioning gall bladder. On laparotomy an inflamed gall bladder was found for which cholecystectomy was done. There was also associated cystic mass arising from the lateral wall of the common bileduct. Choledocho-cyst -duodenostomy was performed. Her post operative recovery was uneventful. She was discharged on the seventh day and has remained symptom free for over a year now. CASE 4: On 28th September 1985, a 15 years old female was admitted to the hospital with recurrent pain in the right hypochondrium associated with vomiting off and on for the last 4 years. On examination there was a cystic mass in the right hypochondrium. Intravenous cholangiogram did not outline the gallbladder,nor the cystic mass.
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.
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 . 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.
These injuries usually present within 1 week of laparoscopic cholecystectomy with pain, fever and mild hyper bilirubinaemia ( up to 2.5 mg /dl) from a bilioma or bile peritonitis. Symptoms may be subtle initially. If drain is placed, bile may leak from it or through one of the port sites. Diagnosis should be considered in patients presenting with bloating or anorexia more than few days after laparoscopic cholecystectomy.
Bileduct ligation performed according to Vogel and Vogel . Rats were anesthetized with ketamine and chlorpromazine (100 mg/kg ketamine and 0.75 mg/kg chlorpromazine; ip). Laparotomy was performed under antiseptic conditions. A mid-line incision in the abdo- men was made, exposing the muscle layers and the linea alba, that was then incised over a length corresponding to the skin incision. The edge of the liver was then raised and the duodenum pulled down to expose the common bileduct, which pursues an almost straight course of about 3 cm from the hilum of the liver to its opening into the duodenum. There is no gall bladder, and the duct was embedded for the greater part of its length in the pancreas, which opens into it by numerous small ducts. A blunt aneurysm needle was passed under the part of the duct selected, stripping the pancreas away with care, and the duct was divided between double liga- tures of cotton thread. The peritoneum and the muscle layers as well as the skin wound were closed with cotton stitches. In sham-operated rats, abdominal incision was made without a bileduct ligation.
ed postoperative mortality. The overall mortali- ty rate was 5.6% (ranging from 0% to 40%). Also, there were eleven studies reported post- operative morbidity and the overall morbidity rate was 66.8% (47-100%) (Table 2). All twelve studies reported long-term outcomes. 1-year survival rate ranged from 33.3% reported by Nimura Y to 100% reported by Tsukada K and Hermming A.W. The other nine studies reported 1-year survival was 40%, 42.9%, 50%, 76.9%, 80%, 81.9%, 85.7% (two studies), 94.1%. The mean 1-year survival rate was about 80%. 5-year survival rate for twelve studies was: 0% (three studies), 14.3%, 16.7%, 23%, 32.3%, 37%, 42.9%, 50%, 52.9% and 60%. The mean 5-year survival rate was 31.7% (Table 2). Additionally, the study by Ebata in 2012 report- ed 85 cholangicarcinoma patients with 59 HCC patients underwent HPD. The survival analysis showed that the overall survival rate for the 85 patients was 79.7% at 1 year, 48.5% at 3 years, 37.4% at 5 years, and 32.1% at 10 years after surgery, with a median survival time (MST) of 31.2 months. There were six patients with HCC survived for more than 5 years after HPD and one survived more than 10 years. And in this study, authors compared overall survival of 85 cholangiocarcinoma patients after HPD with 179 patients with unresectable tumor. The sur- vival outcome after HPD (3-, 5-year survival rate, 48.5% and 37.4%) was much better than unresectable tumor (3-, 5-year survival rate, 2.9%and 0%) (P<0.01). The most recent study by Mizuno T in 2015 reported the 5-year sur-
Abstract: Bileduct injury (BDI) is one of the most severe complications of biliary operation. This study is to inves- tigate the correlation between the timing of bileduct repair and anastomotic bileduct 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 afterbileduct 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.