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Kodali R, Anand U, Parasar K, Priyadarshi RN, Kumar R, Singh BN, Kant K. The impact of vascular injuries on the management of bile duct injury following laparoscopic cholecystectomy- insights from a prospective study. HPB (Oxford) 2025; 27:544-552. [PMID: 39824715 DOI: 10.1016/j.hpb.2024.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2024] [Revised: 12/22/2024] [Accepted: 12/30/2024] [Indexed: 01/20/2025]
Abstract
BACKGROUND Our study aimed to compare the clinical presentation and outcomes of post-cholecystectomy bile duct injuries (BDI) with and without arterial injuries. METHODS A prospective analysis of 123 patients with post-cholecystectomy BDI between July 2018 and January 2022 was performed. Multivariate logistic regression analysis was used to assess the impact of vascular injuries on perioperative complications and long-term outcomes after delayed repair. RESULTS Of 123 patients, 42 (34%) had associated vascular injuries, predominantly right hepatic artery disruptions. These patients experienced significantly higher perioperative complications after the index surgery (Cholangiolar abscess- 83.3% vs 32.1% ( p<0.001), recurrent cholangitis- 66.67 % vs 14.81 % ( p<0.001), blood transfusions ³2 - 89.74 % vs 28.57 % ( p<0.001), hospital admissions ³3 - 3.88 ± 1.99 vs 2.49 ± 0.74 ( p<0.001). Delayed Hepp-Couinaud biliary repair was performed in 112 patients. After a median follow-up, of 2 years, 85 (51.43 % vs. 88.16 % ), 12 (25.71 % vs. 3.89 %), 6 (11.43 % vs. 2.59 %), and 9 (11.43 % vs. 6.49 %) patients had excellent, good, fair, and poor outcomes. CONCLUSION Concomitant vasculobiliary injuries were associated with increased morbidity after index surgery; however, the long-term outcomes following definitive biliary repair remained comparable.
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Affiliation(s)
- Rohith Kodali
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India.
| | - Kunal Parasar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Rajeev N Priyadarshi
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna, India
| | - Ramesh Kumar
- Department of Medical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Basant N Singh
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Kislay Kant
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
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Tuncer A, Dirican CD, Sahin E, Ersan V, Unal B, Dirican A. Living Donor Liver Transplantation for Iatrogenic Vascular Injury During Laparoscopic Cholecystectomy: Case Report. Transplant Proc 2025:S0041-1345(25)00155-1. [PMID: 40121120 DOI: 10.1016/j.transproceed.2025.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2024] [Revised: 02/22/2025] [Accepted: 02/25/2025] [Indexed: 03/25/2025]
Abstract
Acute liver failure (ALF) caused by hepatic vascular injury during cholecystectomy is a rare but serious indication of liver transplantation (LT). We present a case of acute liver failure secondary to portal vein, hepatic artery, and common bile duct injury during laparoscopic cholecystectomy, requiring a same-day emergency living donor liver transplantation (LDLT). A 57-year-old man underwent elective laparoscopic cholecystectomy at an external facility. During the operation, uncontrolled bleeding from the liver hilum led to conversion to open surgery. Despite attempts to control the bleeding with sutures, the patient developed abnormal liver enzymes postoperatively. A computed tomography scan revealed necrosis of the right liver lobe and hypoplasia of the left lobe, leading to the patient to be transferred to our center. Upon admission, the patient was found to have encephalopathy, coagulopathy, hypotension, and oliguria, with elevated transaminase levels. Based on these findings, an emergency LT was deemed necessary. Due to the unavailability of a cadaveric organ, the patient's daughter was prepared as a living donor. Exploratory laparotomy revealed a necrotic right liver lobe, atrophic left lobe, transection of the right hepatic artery and common bile duct, and a thrombosed right portal vein. The patient successfully underwent LDLT from his daughter within 24 hours. At the seventh-month follow-up, he had no complications. Hepatic vascular injury during laparoscopic cholecystectomy can lead to ALF, which carries a high mortality risk. In such cases, LDLT may be a life-saving strategy. Early referral of a patient with ALF to a transplant center is life-saving.
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Affiliation(s)
- Adem Tuncer
- Department of General Surgery, Istanbul Aydin University, Istanbul, Türkiye.
| | - Canan Dilay Dirican
- Department of Internal Medicine, New York Medical College, Denville, New Jersey
| | - Emrah Sahin
- Department of General Surgery, Istanbul Aydin University, Istanbul, Türkiye
| | - Veysel Ersan
- Department of General Surgery, Istanbul Aydin University, Istanbul, Türkiye
| | - Bulent Unal
- Department of General Surgery, Istanbul Aydin University, Istanbul, Türkiye
| | - Abuzer Dirican
- Department of General Surgery, Istanbul Aydin University, Istanbul, Türkiye
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Aghamaliyev U, Karimbayli J, Zamparas A, Bösch F, Thomas M, Schmidt T, Krautz C, Kahlert C, Schölch S, Angele MK, Niess H, Guba MO, Werner J, Ilmer M, Renz BW. Bots in white coats: are large language models the future of patient education? A multicenter cross-sectional analysis. Int J Surg 2025; 111:2376-2384. [PMID: 39878073 DOI: 10.1097/js9.0000000000002250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2024] [Accepted: 12/11/2024] [Indexed: 01/31/2025]
Abstract
OBJECTIVES Every year, around 300 million surgeries are conducted worldwide, with an estimated 4.2 million deaths occurring within 30 days after surgery. Adequate patient education is crucial, but often falls short due to the stress patients experience before surgery. Large language models (LLMs) can significantly enhance this process by delivering thorough information and addressing patient concerns that might otherwise go unnoticed. MATERIAL AND METHODS This cross-sectional study evaluated Chat Generative Pretrained Transformer-4o's audio-based responses to frequently asked questions (FAQs) regarding six general surgical procedures. Three experienced surgeons and two senior residents formulated seven general and three procedure-specific FAQs for both preoperative and postoperative situations, covering six surgical scenarios (major: pancreatic head resection, rectal resection, total gastrectomy; minor: cholecystectomy, Lichtenstein procedure, hemithyroidectomy). In total, 120 audio responses were generated, transcribed, and assessed by 11 surgeons from 6 different German university hospitals. RESULTS ChatGPT-4o demonstrated strong performance, achieving an average score of 4.12/5 for accuracy, 4.46/5 for relevance, and 0.22/5 for potential harm across 120 questions. Postoperative responses surpassed preoperative ones in both accuracy and relevance, while also exhibiting lower potential for harm. Additionally, responses related to minor surgeries were minimal, but significantly more accurate compared to those for major surgeries. CONCLUSIONS This study underscores GPT-4o's potential to enhance patient education both before and after surgery by delivering accurate and relevant responses to FAQs about various surgical procedures. Responses regarding the postoperative course proved to be more accurate and less harmful than those addressing preoperative ones. Although a few responses carried moderate risks, the overall performance was robust, indicating GPT-4o's value in patient education. The study suggests the development of hospital-specific applications or the integration of GPT-4o into interactive robotic systems to provide patients with reliable, immediate answers, thereby improving patient satisfaction and informed decision-making.
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Affiliation(s)
- Ughur Aghamaliyev
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Javad Karimbayli
- Division of Molecular Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, National Cancer Institute, Aviano, Italy
| | - Athanasios Zamparas
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Florian Bösch
- Department of Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Michael Thomas
- Department of General, Visceral, Thoracic and Transplant Surgery, University of Cologne, Cologne, Germany
| | - Thomas Schmidt
- Department of General, Visceral, Thoracic and Transplant Surgery, University of Cologne, Cologne, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich Alexander University, Erlangen, Germany
| | - Christoph Kahlert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Sebastian Schölch
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- JCCU Translational Surgical Oncology (A430), German Cancer Research Center (DKFZ), Heidelberg, Germany
- DKFZ Hector Cancer Institute at University Medical Center Mannheim, Mannheim, Germany
| | - Martin K Angele
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Hanno Niess
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Markus O Guba
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Matthias Ilmer
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
- German Cancer Consortium (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bernhard W Renz
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
- German Cancer Consortium (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany
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Zarghami SY, Ghafoury R, Fakhar N, Afrashteh F, Tasa D, Hyder Z. Four-Year Report of Iatrogenic Bile Duct Injury Repair from a Referral Hepatobiliary Center. Middle East J Dig Dis 2024; 16:173-177. [PMID: 39386338 PMCID: PMC11459285 DOI: 10.34172/mejdd.2024.385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 04/26/2024] [Indexed: 10/12/2024] Open
Abstract
Background Iatrogenic bile duct injury (BDI) is one of the most common complications that challenge surgeons performing laparoscopic cholecystectomy (LC). As the number of LC surgeries increases, a pattern of BDI is emerging, but little is known about this matter. The purpose of this study was to assess the pattern of post-LC BDIs directed in a referral center in Iran. Methods Post-BDI patients referred to a hepatobiliary center were studied. Demographic data, clinical status, diagnostic examinations, referral time, post-referral management, and morbidity were analyzed. Results Nine out of 68 patients had Charcot's cholangitis triad featuring right upper quadrant abdominal pain, fever, and icter. Fever, icter, and itching were the most frequent symptoms. Increased bilirubin, leukocytosis, and abnormal liver function test (LFT) were the most common laboratory abnormalities. 30 patients experienced hepatic artery injury. Out of them, six patients experienced hepatectomy due to hepatic ischemia. Two patients were re-admitted and re-operated, and four patients died. Conclusion Early and correct treatment by a hepatobiliary surgeon experienced in the management of these types of injuries prevents further complications in patients suffering from iatrogenic BDI. Postoperative complications of bile duct repair, such as anastomosis stricture, are possible; thus, patients need long-term and thorough postoperative observation.
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Affiliation(s)
- Seyed Yahya Zarghami
- Department of General Surgery, School of Medicine, Firoozgar hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Roya Ghafoury
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Nasir Fakhar
- Tehran University of Medical Sciences, Shariati Hospital, Tehran, Iran
| | - Fatemeh Afrashteh
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Davod Tasa
- Organ Transplantation Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Spiers HVM, Lam S, Machairas NA, Sotiropoulos GC, Praseedom RK, Balakrishnan A. Liver transplantation for iatrogenic bile duct injury: a systematic review. HPB (Oxford) 2023; 25:1475-1481. [PMID: 37633743 DOI: 10.1016/j.hpb.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/17/2023] [Accepted: 08/10/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Bile duct injury (BDI) is an infrequent but serious complication of cholecystectomy, often with life-changing consequences. Liver transplantation (LT) may be required following severe BDI, however given the rarity, few large studies exist to guide management for complex BDI. METHODS A systematic review was performed to assess post-operative complications, 30-day mortality, retransplant rate and 1-year and 5-year survival following LT for BDI in Medline, EMBASE, Web of Science or Cochrane Clinical Trials Database. RESULTS Seven articles met inclusion criteria, describing 179 patients that underwent LT for BDI. Secondary biliary cirrhosis (SBC) was the main indication for LT (82.2% of patients). Median model for end-stage liver disease (MELD) scores at time of LT ranged from 16 to 20.5. Median 30-day mortality was 20.0%. The 1-year and 5-year survival ranges were 55.0-84.3% and 30.0-83.3% respectively, and the overall retransplant rate was 11.5%. CONCLUSION BDI is rarely indicated for LT, predominantly for SBC following multiple prior interventions. MELD scores poorly reflect underlying morbidity, and exception criteria for waitlisting may avoid prolonged LT waiting times. 30-day mortality was higher than for non-BDI indications, with comparable long term survival, suggesting that LT remains a viable but high risk salvage option for severe BDI.
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Affiliation(s)
- Harry V M Spiers
- Department of Surgery, Addenbrooke's Hospital and the University of Cambridge, Cambridge, United Kingdom
| | - Shi Lam
- Department of Surgery, Addenbrooke's Hospital and the University of Cambridge, Cambridge, United Kingdom
| | - Nikolaos A Machairas
- 2nd Department of Propaedeutic Surgery, General Hospital Laiko, National and Kapodistrian University of Athens, Greece
| | - Georgios C Sotiropoulos
- 2nd Department of Propaedeutic Surgery, General Hospital Laiko, National and Kapodistrian University of Athens, Greece
| | - Raaj K Praseedom
- Department of Surgery, Addenbrooke's Hospital and the University of Cambridge, Cambridge, United Kingdom
| | - Anita Balakrishnan
- Department of Surgery, Addenbrooke's Hospital and the University of Cambridge, Cambridge, United Kingdom.
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Symeonidis D, Tepetes K, Tzovaras G, Samara AA, Zacharoulis D. BILE: A Literature Review Based Novel Clinical Classification and Treatment Algorithm of Iatrogenic Bile Duct Injuries. J Clin Med 2023; 12:3786. [PMID: 37297981 PMCID: PMC10253433 DOI: 10.3390/jcm12113786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/18/2023] [Accepted: 05/28/2023] [Indexed: 06/12/2023] Open
Abstract
PURPOSES The management of patients with iatrogenic bile duct injuries (IBDI) is a challenging field, often with dismal medico legal projections. Attempts to classify IBDI have been made repeatedly and the final results were either analytical and extensive but not useful in everyday clinical practice systems, or simple and user friendly but with limited clinical correspondence approaches. The purpose of the present review is to propose a novel, clinical classification system of IBDI by reviewing the relevant literature. METHODS A systematic literature review was conducted by performing bibliographic searches in the available electronic databases, including PubMed, Scopus, and the Cochrane Library. RESULTS Based on the literature results, we propose a five (5) stage (A, B, C, D and E) classification system for IBDI (BILE Classification). Each stage is correlated with the recommended and most appropriate treatment. Although the proposed classification scheme is clinically oriented, the anatomical correspondence of each IBDI stage has been incorporated as well, using the Strasberg classification. CONCLUSIONS BILE classification represents a novel, simple, and dynamic in nature classification system of IBDI. The proposed classification focuses on the clinical consequences of IBDI and provides an action map that can appropriately guide the treatment plan.
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Affiliation(s)
| | | | | | - Athina A. Samara
- Department of Surgery, University Hospital of Larisa, Mezourlo, 41221 Larisa, Greece
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Pesce A, Fabbri N, Feo CV. Vascular injury during laparoscopic cholecystectomy: An often-overlooked complication. World J Gastrointest Surg 2023; 15:338-345. [PMID: 37032796 PMCID: PMC10080601 DOI: 10.4240/wjgs.v15.i3.338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/05/2023] [Accepted: 02/22/2023] [Indexed: 03/27/2023] Open
Abstract
Laparoscopic cholecystectomy is one of the most frequently performed procedures in gastrointestinal surgery worldwide. Bleeding complications due to vascular injuries represent an important cause of morbidity and mortality, especially when facing major bleeding during laparoscopy, where bleeding control can be technically challenging in inexperienced hands. Interestingly, the reported incidence rate of conversion to open surgery due to vascular lesions is approximately 0%-1.9%, with a mortality rate of approximately 0.02%. The primary aim of this article was to perform an up-to-date overview regarding the incidence and surgical management of vascular injuries during laparoscopic cholecystectomy according to the available scientific evidence.
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Affiliation(s)
- Antonio Pesce
- Department of Surgery, University of Ferrara, Azienda USL of Ferrara, Azienda USL of Ferrara, Lagosanto 44023, Ferrara, Italy
| | - Nicolò Fabbri
- Department of Surgery, University of Ferrara, Azienda USL of Ferrara, Azienda USL of Ferrara, Lagosanto 44023, Ferrara, Italy
| | - Carlo Vittorio Feo
- Department of Surgery, University of Ferrara, Azienda USL of Ferrara, Azienda USL of Ferrara, Lagosanto 44023, Ferrara, Italy
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Lopez-Lopez V, Kuemmerli C, Cutillas J, Maupoey J, López-Andujar R, Ramos E, Mils K, Valdivieso A, Valero AP, Martinez PA, Paterna S, Serrablo A, Reese T, Oldhafer K, Brusadin R, Conesa AL, Valladares LD, Loinaz C, Garcés-Albir M, Sabater L, Mocchegiani F, Vivarelli M, Pérez SA, Flores B, Lucena JL, Sánchez-Cabús S, Calero A, Minguillon A, Ramia JM, Alcazar C, Aguilo J, Ruiperez-Valiente JA, Grochola LF, Clavien PA, Petrowsky H, Robles-Campos R. Vascular injury during cholecystectomy: A multicenter critical analysis behind the drama. Surgery 2022; 172:1067-1075. [PMID: 35965144 DOI: 10.1016/j.surg.2022.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/27/2022] [Accepted: 06/27/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The management of a vascular injury during cholecystectomy is still very complicated, especially in centers not specialized in complex hepatobiliary surgery. METHODS This was a multi-institutional retrospective study in patients with vascular injuries during cholecystectomy from 18 centers in 4 countries. The aim of the study was to analyze the management of vascular injuries focusing on referral, time to perform the repair, and different treatments options outcomes. RESULTS A total of 104 patients were included. Twenty-nine patients underwent vascular repair (27.9%), 13 (12.5%) liver resection, and 1 liver transplant as a first treatment. Eighty-four (80.4%) vascular and biliary injuries occurred in nonspecialized centers and 45 (53.6%) were immediately transferred. Intraoperative diagnosed injuries were rare in referred patients (18% vs 84%, P = .001). The patients managed at the hospital where the injury occurred had a higher number of reoperations (64% vs 20%, P ˂ .001). The need for vascular reconstruction was associated with higher mortality (P = .04). Two of the 4 patients transplanted died. CONCLUSION Vascular lesions during cholecystectomy are a potentially life-threatening complication. Management of referral to specialized centers to perform multiple complex multidisciplinary procedures should be mandatory. Late vascular repair has not shown to be associated with worse results.
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Affiliation(s)
- Victor Lopez-Lopez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain.
| | - Christoph Kuemmerli
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland; Department of Surgery, Clarunis - University Center for Gastrointestinal and Liver Diseases Basel, Switzerland. https://twitter.com/ChristophKuemme
| | - Jose Cutillas
- Department of General Surgery, Hospital Francesc de Borja, Gandía, Valencia, Spain
| | - Javier Maupoey
- Department of Hepatobiliary Surgery and Transplants, Hospital Universitario La Fe, Valencia, Spain
| | - Rafael López-Andujar
- Department of Hepatobiliary Surgery and Transplants, Hospital Universitario La Fe, Valencia, Spain
| | - Emilio Ramos
- Department of Hepatobiliary Surgery and Liver Transplant Unit, Hospital Universitari Bellvitge, University of Barcelona, Barcelona, Spain
| | - Kristel Mils
- Department of Hepatobiliary Surgery and Liver Transplant Unit, Hospital Universitari Bellvitge, University of Barcelona, Barcelona, Spain
| | - Andres Valdivieso
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, Bilbao, Spain
| | | | | | - Sandra Paterna
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | - Alejando Serrablo
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | - Tim Reese
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Germany
| | - Karl Oldhafer
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Germany
| | - Roberto Brusadin
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Asunción López Conesa
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Luis Díez Valladares
- Department of Surgery, Hepatopancreatobiliary Unit, Hospital Clínico San Carlos, Madrid, Spain
| | - Carmelo Loinaz
- Department of General Surgery, Digestive Tract and Abdominal Organ Transplantation, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - Marina Garcés-Albir
- Department of Surgery, Hospital Clinico Valencia, University of Valencia, Biomedical Research Institute (INCLIVA), Spain
| | - Luis Sabater
- Department of Surgery, Hospital Clinico Valencia, University of Valencia, Biomedical Research Institute (INCLIVA), Spain
| | - Federico Mocchegiani
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy
| | | | - Benito Flores
- Department of Surgery, Morales University Hospital, Madrid, Spain
| | - Jose Luis Lucena
- Department of Surgery, Puerta del Hierro University Hospital, Madrid, Spain
| | - Santiago Sánchez-Cabús
- Hepatobiliopancreatic Surgery Unit, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain
| | - Alicia Calero
- Department of General Surgery, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | | | - Jose Manuel Ramia
- Department of Surgery, University Hospital of Alicante, Spain; Universidad Miguel Hernandez, Alicante, Spain
| | - Cándido Alcazar
- Department of Surgery, University Hospital of Alicante, Spain; Universidad Miguel Hernandez, Alicante, Spain
| | - Javier Aguilo
- Department of General Surgery, Hospital Lluís Alcanyís Hospital, Xàtiva, Valencia, Spain
| | | | - Lukasz Filip Grochola
- Clinic for Visceral and Thoracic Surgery, Cantonal Hospital of Winterthur, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Ricardo Robles-Campos
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
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9
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Lopez-Lopez V, Maupoey J, López-Andujar R, Ramos E, Mils K, Martinez PA, Valdivieso A, Garcés-Albir M, Sabater L, Valladares LD, Pérez SA, Flores B, Brusadin R, Conesa AL, Cayuela V, Cortijo SM, Paterna S, Serrablo A, Sánchez-Cabús S, Gil AG, Masía JAG, Loinaz C, Lucena JL, Pastor P, Garcia-Zamora C, Calero A, Valiente J, Minguillon A, Rotellar F, Ramia JM, Alcazar C, Aguilo J, Cutillas J, Kuemmerli C, Ruiperez-Valiente JA, Robles-Campos R. Machine Learning-Based Analysis in the Management of Iatrogenic Bile Duct Injury During Cholecystectomy: a Nationwide Multicenter Study. J Gastrointest Surg 2022; 26:1713-1723. [PMID: 35790677 PMCID: PMC9439981 DOI: 10.1007/s11605-022-05398-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/17/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Iatrogenic bile duct injury (IBDI) is a challenging surgical complication. IBDI management can be guided by artificial intelligence models. Our study identified the factors associated with successful initial repair of IBDI and predicted the success of definitive repair based on patient risk levels. METHODS This is a retrospective multi-institution cohort of patients with IBDI after cholecystectomy conducted between 1990 and 2020. We implemented a decision tree analysis to determine the factors that contribute to successful initial repair and developed a risk-scoring model based on the Comprehensive Complication Index. RESULTS We analyzed 748 patients across 22 hospitals. Our decision tree model was 82.8% accurate in predicting the success of the initial repair. Non-type E (p < 0.01), treatment in specialized centers (p < 0.01), and surgical repair (p < 0.001) were associated with better prognosis. The risk-scoring model was 82.3% (79.0-85.3%, 95% confidence interval [CI]) and 71.7% (63.8-78.7%, 95% CI) accurate in predicting success in the development and validation cohorts, respectively. Surgical repair, successful initial repair, and repair between 2 and 6 weeks were associated with better outcomes. DISCUSSION Machine learning algorithms for IBDI are a novel tool may help to improve the decision-making process and guide management of these patients.
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Affiliation(s)
- Victor Lopez-Lopez
- Department of Surgery and Transplantation, Virgen de La Arrixaca Clinic and University Hospital, Murcian Institute of Biosanitary Research (IMIB), Ctra. Madrid-Cartagena, 30120, s/nEl Palmar, Murcia, Spain.
| | - Javier Maupoey
- Department of Hepatobiliary Surgery and Transplants, Hospital Universitario La Fe, Valencia, Spain
| | - Rafael López-Andujar
- Department of Hepatobiliary Surgery and Transplants, Hospital Universitario La Fe, Valencia, Spain
| | - Emilio Ramos
- Department of Hepatobiliary Surgery and Liver Transplant Unit, Hospital Universitari Bellvitge, University of Barcelona, Barcelona, Spain
| | - Kristel Mils
- Department of Hepatobiliary Surgery and Liver Transplant Unit, Hospital Universitari Bellvitge, University of Barcelona, Barcelona, Spain
| | - Pedro Antonio Martinez
- Department of Information and Communication Engineering, Universidad de Murcia, Murcia, Spain
| | - Andres Valdivieso
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, Bilbao, Spain
| | - Marina Garcés-Albir
- Department of Surgery, Hospital Clínico, University of Valencia, Biomedical Research Institute INCLIVA, Valencia, Spain
| | - Luis Sabater
- Department of Surgery, Hospital Clínico, University of Valencia, Biomedical Research Institute INCLIVA, Valencia, Spain
| | - Luis Díez Valladares
- Department of Surgery, Hepatopancreatobiliary Unit, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Benito Flores
- Department of Surgery, Morales University Hospital, Madrid, Spain
| | - Roberto Brusadin
- Department of Surgery and Transplantation, Virgen de La Arrixaca Clinic and University Hospital, Murcian Institute of Biosanitary Research (IMIB), Ctra. Madrid-Cartagena, 30120, s/nEl Palmar, Murcia, Spain
| | - Asunción López Conesa
- Department of Surgery and Transplantation, Virgen de La Arrixaca Clinic and University Hospital, Murcian Institute of Biosanitary Research (IMIB), Ctra. Madrid-Cartagena, 30120, s/nEl Palmar, Murcia, Spain
| | - Valentin Cayuela
- Department of Surgery and Transplantation, Virgen de La Arrixaca Clinic and University Hospital, Murcian Institute of Biosanitary Research (IMIB), Ctra. Madrid-Cartagena, 30120, s/nEl Palmar, Murcia, Spain
| | | | - Sandra Paterna
- Department of Surgery, Miguel Servet University Hospital, Saragossa, Spain
| | - Alejando Serrablo
- Department of Surgery, Miguel Servet University Hospital, Saragossa, Spain
| | - Santiago Sánchez-Cabús
- Hepatobiliopancreatic Surgery Unit, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio González Gil
- Department of Surgery, Los Arcos del Mar Menor University Hospital, Murcia, Spain
| | | | - Carmelo Loinaz
- Department of General Surgery, Digestive Tract and Abdominal Organ Transplantation, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - Jose Luis Lucena
- Department of Surgery, Puerta del Hierro University Hospital, Madrid, Spain
| | - Patricia Pastor
- Department of Surgery, Reina Sofía University Hospital, Murcia, Spain
| | | | - Alicia Calero
- Department of General Surgery, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | - Juan Valiente
- Department of General Surgery, Hellin Hospital, Albacete, Spain
| | | | - Fernando Rotellar
- HPB and Liver Transplant Unit, Department of General Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Jose Manuel Ramia
- HPB Surgery and Liver Transplantation, Dr. Balmis General University Hospital, and Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Cándido Alcazar
- HPB Surgery and Liver Transplantation, Dr. Balmis General University Hospital, and Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Javier Aguilo
- Department of General Surgery, Hospital Lluís Alcanyís Hospital, Xàtiva, Valencia, Spain
| | - Jose Cutillas
- Department of General Surgery, Hospital Francesc de Borja, Gandía, Valencia, Spain
| | - Christoph Kuemmerli
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
- Department of Surgery, Clarunis - University Centre for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | | | - Ricardo Robles-Campos
- Department of Surgery and Transplantation, Virgen de La Arrixaca Clinic and University Hospital, Murcian Institute of Biosanitary Research (IMIB), Ctra. Madrid-Cartagena, 30120, s/nEl Palmar, Murcia, Spain
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Liver transplantation for iatrogenic bile duct injury during cholecystectomy: a French retrospective multicenter study. HPB (Oxford) 2022; 24:94-100. [PMID: 34462215 DOI: 10.1016/j.hpb.2021.08.817] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 07/15/2021] [Accepted: 08/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Major bile duct injuries (BDI) following cholecystectomy require complex reconstructive surgery. The aim was to collect the liver transplantations (LT) performed in France for major BDI following cholecystectomy, to analyze the risk factors and to report the results. METHODS National multicenter observational retrospective study. All the patients who underwent a LT in France between 1994 and 2017, for BDI following cholecystectomy, were included. RESULTS 30 patients were included. 25 BDI occurred in non hepato-biliary expert centers, 20 were initially treated in these centers. Median time between injury and LT was 3 years in case of an associated vascular injury (11 injuries), versus 11.7 years without vascular injury (p = 0.006). Post-transplant morbidity rate was 86.7%, mortality 23.5% at 5 years. CONCLUSION Iatrogenic BDI remains a real concern with severe cases, associated with vascular damages or leading to cirrhosis, with no solution but LT. It is associated with high morbidity and not optimal results. This enlights the necessity of early referral of all major BDI in expert centers to prevent dramatic outcome. Decision to perform transplantation should be taken before dismal infectious situations or biliary cirrhosis and access to graft should be facilitated by Organ Sharing Organizations.
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Bao-Qiang W, Jun H, Wen-Song L, Yong J, Xue-Min C, Dong-Lin S. Laparoscopic repair of transected right hepatic artery during cholecystectomy: A report of two cases. Ann Hepatol 2021; 21:100161. [PMID: 31836423 DOI: 10.1016/j.aohep.2019.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 11/18/2019] [Accepted: 11/20/2019] [Indexed: 02/04/2023]
Abstract
In laparoscopic cholecystectomy (LC), the treatment of iatrogenic biliary tract injury has been given much attention. However, most accidental right hepatic artery (RHA) injuries are treated with simple clipping. The reason is that the RHA has difficulty in revascularization, and it is generally considered that RHA injury does not cause serious consequences. However, some studies suggest that some cases of RHA ligation can cause a series of pathological changes correlated to arterial ischemia, such as liver abscess, bile tumor, liver atrophy and anastomotic stenosis. Theoretically, RHA blood flow should be restored when possible, in order to avoid the complications of right hepatic ischemia. The present study involved two patients, including one male and one female patient. Both patients were admitted to the hospital with the diagnosis of chronic cholecystitis and gallbladder stone, and developed ischemia of the right half hepatic after accidental transection of the RHA. Both patients underwent continuous end-end anastomosis of the RHA with 6-0 Prolene suture. After the blood vessel anastomosis, the right half liver quickly recovered to its original bright red. No adverse complications were observed in follow-ups at three and six months after the operation. Laparoscopic repair of the RHA is technically feasible. Reconstruction of the RHA can prevent complications associated with right hepatic ischemia.
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Affiliation(s)
- Wu Bao-Qiang
- Department of Hepatobiliary and Pancreatic Surgery, The Third Affiliated Hospital of Suzhou University, The First People's Hospital of Changzhou, Changzhou 213003, China
| | - Hu Jun
- Department of Hepatobiliary and Pancreatic Surgery, The Third Affiliated Hospital of Suzhou University, The First People's Hospital of Changzhou, Changzhou 213003, China
| | - Liu Wen-Song
- Department of Hepatobiliary and Pancreatic Surgery, The Third Affiliated Hospital of Suzhou University, The First People's Hospital of Changzhou, Changzhou 213003, China
| | - Jiang Yong
- Department of Hepatobiliary and Pancreatic Surgery, The Third Affiliated Hospital of Suzhou University, The First People's Hospital of Changzhou, Changzhou 213003, China
| | - Chen Xue-Min
- Department of Hepatobiliary and Pancreatic Surgery, The Third Affiliated Hospital of Suzhou University, The First People's Hospital of Changzhou, Changzhou 213003, China.
| | - Sun Dong-Lin
- Department of Hepatobiliary and Pancreatic Surgery, The Third Affiliated Hospital of Suzhou University, The First People's Hospital of Changzhou, Changzhou 213003, China
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12
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Dilek ON, Atay A. Dealing with hepatic artery traumas: A clinical literature review. World J Clin Cases 2021; 9:8425-8440. [PMID: 34754851 PMCID: PMC8554434 DOI: 10.12998/wjcc.v9.i28.8425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/05/2021] [Accepted: 08/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The hepatic artery (HA) is one of the most threatened vascular structures during hepatopancreatobiliary (HPB) surgeries and interventional procedures. It can be affected by many clinical pictures, especially tumors, due to its anatomical position and neighborhood. AIM To reveal the evolution and recent developments in the management of HA traumas in the light of the literature. METHODS In this article, 100 years of MEDLINE (PubMed) literature and articles including cases and series of HA injuries were reviewed, and the types of injury occurrence, treatment, and related complications and their management were compiled. RESULTS The risk of HA injury increases during cholecystectomies and pancreatoduodenectomies, among the most common operations. HA anatomy shows anomalies in approximately 15%-25% of the cases, further increasing this risk. The incidence of HA injury is not precisely known. Approaches that have evolved in recent years in managing patients with HA injury (laceration, transection, ligation, resection) with severe morbidity and mortality risk are reviewed in light of the current literature. CONCLUSION In conclusion, complications and deaths due to HA injury are less common today. The risk of complications increases in patients with hemodynamic instability, jaundice, cholangitis, and sepsis. Revealing the variations in the preoperative radiological evaluation will reduce the risks. In cases where HA injury is detected, arterial flow continuity should be tried to maintain with primary anastomosis, arterial transpositions, or grafts. In cases where bile duct injury develops, patients should be directed to HPB surgery centers, considering the possibility of accompanying HA injury. Large-scale and multicentric studies are needed to understand better the early and long-term results of HA ligation and determine preventive procedures.
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Affiliation(s)
- Osman Nuri Dilek
- Department of General Surgery, Division of Hepatopancreatobiliary Surgery, İzmir Katip Celebi University School of Medicine, İzmir 35150, Turkey
| | - Arif Atay
- Department of Surgery, İzmir Katip Celebi University School of Medicine, İzmir 35150, Turkey
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13
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Mistry J, Vala H. Combined Biliary and Right Hepatic Artery Injury during Laparoscopic Cholecystectomy. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02569-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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14
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de’Angelis N, Catena F, Memeo R, Coccolini F, Martínez-Pérez A, Romeo OM, De Simone B, Di Saverio S, Brustia R, Rhaiem R, Piardi T, Conticchio M, Marchegiani F, Beghdadi N, Abu-Zidan FM, Alikhanov R, Allard MA, Allievi N, Amaddeo G, Ansaloni L, Andersson R, Andolfi E, Azfar M, Bala M, Benkabbou A, Ben-Ishay O, Bianchi G, Biffl WL, Brunetti F, Carra MC, Casanova D, Celentano V, Ceresoli M, Chiara O, Cimbanassi S, Bini R, Coimbra R, Luigi de’Angelis G, Decembrino F, De Palma A, de Reuver PR, Domingo C, Cotsoglou C, Ferrero A, Fraga GP, Gaiani F, Gheza F, Gurrado A, Harrison E, Henriquez A, Hofmeyr S, Iadarola R, Kashuk JL, Kianmanesh R, Kirkpatrick AW, Kluger Y, Landi F, Langella S, Lapointe R, Le Roy B, Luciani A, Machado F, Maggi U, Maier RV, Mefire AC, Hiramatsu K, Ordoñez C, Patrizi F, Planells M, Peitzman AB, Pekolj J, Perdigao F, Pereira BM, Pessaux P, Pisano M, Puyana JC, Rizoli S, Portigliotti L, Romito R, Sakakushev B, Sanei B, Scatton O, Serradilla-Martin M, Schneck AS, Sissoko ML, Sobhani I, ten Broek RP, Testini M, Valinas R, Veloudis G, Vitali GC, Weber D, Zorcolo L, Giuliante F, Gavriilidis P, Fuks D, Sommacale D. 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy. World J Emerg Surg 2021; 16:30. [PMID: 34112197 PMCID: PMC8190978 DOI: 10.1186/s13017-021-00369-w] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/18/2021] [Indexed: 12/16/2022] Open
Abstract
Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.
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Affiliation(s)
- Nicola de’Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, General Regional Hospital “F. Miulli”, Strada Prov. 127 Acquaviva – Santeramo Km. 4, 70021 Acquaviva delle Fonti BA, Bari, Italy
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Fausto Catena
- Department of Emergency and Trauma Surgery of the University Hospital of Parma, Parma, Italy
| | - Riccardo Memeo
- Department of Hepato-Pancreatic-Biliary Surgery, General Regional Hospital “F. Miulli”, Acquaviva delle Fonti, Bari, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Aleix Martínez-Pérez
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Oreste M. Romeo
- Trauma, Burn, and Surgical Care Program, Bronson Methodist Hospital, Kalamazoo, Michigan USA
| | - Belinda De Simone
- Service de Chirurgie Générale, Digestive, et Métabolique, Centre hospitalier de Poissy/Saint Germain en Laye, Saint Germain en Laye, France
| | - Salomone Di Saverio
- Department of Surgery, Cambridge University Hospital, NHS Foundation Trust, Cambridge, UK
| | - Raffaele Brustia
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Rami Rhaiem
- Department of HBP and Digestive Oncologic Surgery, Robert Debré University Hospital, Reims, France
| | - Tullio Piardi
- Department of HBP and Digestive Oncologic Surgery, Robert Debré University Hospital, Reims, France
- Department of Surgery, HPB Unit, Troyes Hospital, Troyes, France
| | - Maria Conticchio
- Department of Hepato-Pancreatic-Biliary Surgery, General Regional Hospital “F. Miulli”, Acquaviva delle Fonti, Bari, Italy
| | - Francesco Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Nassiba Beghdadi
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Ruslan Alikhanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Shosse Enthusiastov, 86, 111123 Moscow, Russia
| | | | - Niccolò Allievi
- 1st Surgical Unit, Department of Emergency, Papa Giovanni Hospital XXIII, Bergamo, Italy
| | - Giuliana Amaddeo
- Service d’Hepatologie, APHP, Henri Mondor University Hospital, Creteil, and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Luca Ansaloni
- General Surgery, San Matteo University Hospital, Pavia, Italy
| | | | - Enrico Andolfi
- Department of Surgery, Division of General Surgery, San Donato Hospital, 52100 Arezzo, Italy
| | - Mohammad Azfar
- Department of Surgery, Al Rahba Hospital, Abu Dhabi, UAE
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Amine Benkabbou
- Surgical Oncology Department, National Institute of Oncology, Mohammed V University in Rabat, Rabat, Morocco
| | - Offir Ben-Ishay
- Department of General Surgery, Rambam Healthcare Campus, Haifa, Israel
| | - Giorgio Bianchi
- Unit of Minimally Invasive and Robotic Digestive Surgery, General Regional Hospital “F. Miulli”, Strada Prov. 127 Acquaviva – Santeramo Km. 4, 70021 Acquaviva delle Fonti BA, Bari, Italy
| | - Walter L. Biffl
- Division of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, California USA
| | - Francesco Brunetti
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | | | - Daniel Casanova
- Hospital Universitario Marqués de Valdecilla, University of Cantabria, Santander, Spain
| | - Valerio Celentano
- Colorectal Unit, Chelsea and Westminster Hospital, NHS Foundation Trust, London, UK
| | - Marco Ceresoli
- Emergency and General Surgery Department, University of Milan Bicocca, Milan, Italy
| | - Osvaldo Chiara
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Roberto Bini
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Raul Coimbra
- Riverside University Health System Medical Center, Comparative Effectiveness and Clinical Outcomes Research Center – CECORC and Loma Linda University School of Medicine, Loma Linda, USA
| | - Gian Luigi de’Angelis
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Decembrino
- Gastroenterology and Endoscopy Unit, General Regional Hospital “F. Miulli”, Acquaviva delle Fonti, Bari, Italy
| | - Andrea De Palma
- General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Philip R. de Reuver
- Department of Surgery, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - Carlos Domingo
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | | | - Alessandro Ferrero
- Department of General and Oncological Surgery, Azienda Ospedaliera Ordine Mauriziano “Umberto I”, Turin, Italy
| | - Gustavo P. Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | - Federica Gaiani
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Federico Gheza
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Gurrado
- Unit of General Surgery “V. Bonomo”, Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Bari, Italy
| | - Ewen Harrison
- Department of Clinical Surgery and Centre for Medical Informatics, Usher Institute, University of Edinburgh, Little France Crescent, Edinburgh, UK
| | | | - Stefan Hofmeyr
- Division of Surgery, Surgical Gastroenterology Unit, Tygerberg Academic Hospital, University of Stellenbosch Faculty of Medicine and Health Sciences, Stellenbosch, South Africa
| | - Roberta Iadarola
- Department of Emergency and Trauma Surgery of the University Hospital of Parma, Parma, Italy
| | - Jeffry L. Kashuk
- Department of Surgery, Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel
| | - Reza Kianmanesh
- Department of HBP and Digestive Oncologic Surgery, Robert Debré University Hospital, Reims, France
| | - Andrew W. Kirkpatrick
- Department of Surgery, Critical Care Medicine and the Regional Trauma Service, Foothills Medical Center, Calgari, Alberta Canada
| | - Yoram Kluger
- Department of General Surgery, Rambam Healthcare Campus, Haifa, Israel
| | - Filippo Landi
- Department of HPB and Transplant Surgery, Hospital Clínic, Universidad de Barcelona, Barcelona, Spain
| | - Serena Langella
- Department of General and Oncological Surgery, Azienda Ospedaliera Ordine Mauriziano “Umberto I”, Turin, Italy
| | - Real Lapointe
- Department of HBP Surgery and Liver Transplantation, Department of Surgery, Centre Hospitalier de l’Université de Montreal, Montreal, QC Canada
| | - Bertrand Le Roy
- Department of Digestive Surgery, University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Alain Luciani
- Unit of Radiology, Henri Mondor University Hospital (AP-HP), Creteil, and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Fernando Machado
- Department of Emergency Surgery, Hospital de Clínicas, School of Medicine UDELAR, Montevideo, Uruguay
| | - Umberto Maggi
- General Surgery and Liver Transplantation Unit, Fondazione IRCCS Ca’Granda, Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Ronald V. Maier
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Alain Chichom Mefire
- Department of Surgery and Obstetrics/Gynecologic, Regional Hospital, Limbe, Cameroon
| | - Kazuhiro Hiramatsu
- Department of General Surgery, Toyohashi Municipal Hospital, Toyohashi, Aichi Japan
| | - Carlos Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundacion Valle del Lili, Universidad del Valle Cali, Cali, Colombia
| | - Franca Patrizi
- Unit of Gastroenterology and Endoscopy, Maggiore Hospital, Bologna, Italy
| | - Manuel Planells
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Andrew B. Peitzman
- Department of Surgery, UPMC, University of Pittsburg, School of Medicine, Pittsburg, USA
| | - Juan Pekolj
- General Surgery, Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Fabiano Perdigao
- Liver Transplant Unit, APHP, Unité de Chirurgie Hépatobiliaire et Transplantation hépatique, Hôpital Pitié Salpêtrière, Paris, France
| | - Bruno M. Pereira
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | - Patrick Pessaux
- Hepatobiliary and Pancreatic Surgical Unit, Visceral and Digestive Surgery, IHU mix-surg, Institute for Minimally Invasive Image-Guided Surgery, University of Strasbourg, Strasbourg, France
| | - Michele Pisano
- 1st Surgical Unit, Department of Emergency, Papa Giovanni Hospital XXIII, Bergamo, Italy
| | - Juan Carlos Puyana
- Trauma & Acute Care Surgery – Global Health, University of Pittsburgh, Pittsburgh, USA
| | - Sandro Rizoli
- Trauma and Acute Care Service, St Michael’s Hospital, Toronto, ON Canada
| | - Luca Portigliotti
- Chirurgia Epato-Gastro-Pancreatica, Azienda Ospedaliera-Universitaria Maggiore della Carità, Novara, Italy
| | - Raffaele Romito
- Chirurgia Epato-Gastro-Pancreatica, Azienda Ospedaliera-Universitaria Maggiore della Carità, Novara, Italy
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Behnam Sanei
- Department of Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Olivier Scatton
- Liver Transplant Unit, APHP, Unité de Chirurgie Hépatobiliaire et Transplantation hépatique, Hôpital Pitié Salpêtrière, Paris, France
| | - Mario Serradilla-Martin
- Instituto de Investigación Sanitaria Aragón, Department of Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Anne-Sophie Schneck
- Digestive Surgery Unit, Centre Hospitalier Universitaire de Guadeloupe, Pointe-À-Pitre, Les Avymes, Guadeloupe France
| | - Mohammed Lamine Sissoko
- Service de Chirurgie, Hôpital National Blaise Compaoré de Ouagadougou, Ouagadougou, Burkina Faso
| | - Iradj Sobhani
- Department of Gastroenterology and Digestive Endoscopy, Henri Mondor Hospital, AP-HP, Creteil, and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
| | - Richard P. ten Broek
- Department of Surgery, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - Mario Testini
- Unit of General Surgery “V. Bonomo”, Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro”, Bari, Italy
| | - Roberto Valinas
- Department of Surgery “F”, Faculty of Medicine, Clinic Hospital “Dr. Manuel Quintela”, Montevideo, Uruguay
| | | | - Giulio Cesare Vitali
- Division of Transplantation, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Dieter Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Luigi Zorcolo
- Department of Surgery, Colorectal Surgery Unit, University of Cagliari, Cagliari, Italy
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Foundation “Policlinico Universitario A. Gemelli”, IRCCS, Rome, Italy
| | - Paschalis Gavriilidis
- Division of Gastrointestinal and HBP Surgery, Imperial College HealthCare, NHS Trust, Hammersmith Hospital, London, UK
| | - David Fuks
- Institut Mutualiste Montsouris, Paris, France
| | - Daniele Sommacale
- Unit of Digestive, Hepatobiliary and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), and Faculty of Medicine, University of Paris Est, UPEC, Creteil, France
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15
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Li L, Li Q, Xie M, Zuo W, Song B. Anatomic Variation of the Cystic Artery: New Findings and Potential Implications. J INVEST SURG 2021; 34:276-283. [PMID: 31238741 DOI: 10.1080/08941939.2019.1631917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Purpose: To determine the anatomy of the cystic artery by dual-source CT, and correlate imaging findings with those patients who had laparoscopic cholecystectomy (LC). Materials and Methods: Following institutional review board approval, a total of 289 consecutive patients (204 men and 85 women) were evaluated with CT for abdominal pain, including 55 patients subsequently underwent LC. Location of the cystic artery termination, distance between the cystic artery origin and the gallbladder, and angle between the cystic artery and its parent artery were evaluated by two radiologists. The laparoscopic surgical video record (gold standard) was similarly evaluated by a surgeon. Results: A total of 256 cystic arteries in the 247 patients were included. Cystic artery terminations are predominately found in ventral Calot triangle plane (50.8%, type II). Cystic artery origin immediately adjacent to the gallbladder surface was seen in 11/256 (4.3%). Zero angle between the cystic artery and its parent artery was found in 17 of 256 cystic arteries (6.6%). The cystic arteries and the Calot triangle were depicted in 49 patients (95% confidence interval: 85%, 97%). For all 49 patients, CT imaging findings were consistent with surgical video records. No case involved vascular and biliary injury occurred. Conclusions: Given the large number of LC performed each year, better knowledge of anatomic variation of the cystic artery could potentially prevent arterial injury and bile duct injury, particularly for patients with unusual anatomy.
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Affiliation(s)
- Li Li
- Department of Radiology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, People's Republic of China
| | - Qiang Li
- College of Ophthalmology, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, People's Republic of China
| | - Mingguo Xie
- Department of Radiology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, People's Republic of China
| | - Wenwei Zuo
- Department of General Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, People's Republic of China
| | - Bin Song
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China
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Yan J, Feng H, Wang H, Yuan F, Yang C, Liang X, Chen W, Wang J. Hepatic artery classification based on three-dimensional CT. Br J Surg 2020; 107:906-916. [PMID: 32057096 DOI: 10.1002/bjs.11458] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/22/2019] [Accepted: 11/12/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Precise classification of the hepatic artery is helpful for preoperative surgical planning in hepatobiliary-pancreatic surgery. However, the anatomy of hepatic arteries is variable. This study investigated anatomical variation using three-dimensional visualization and evaluation (3DVE) to develop a nomenclature system. METHODS The origin and course of the hepatic artery were tracked and analysed by using three-dimensional visualization of CT images acquired between 2013 and 2017. The new classification and nomenclature system, named CRL, was developed based on the origins of the common, right and left hepatic arteries. RESULTS Scans from 770 adults were evaluated. Preoperative 3DVE correlated better with surgical findings than the original CT images alone. Using the CRL classification system, hepatic arteries were divided into nine subtypes. Only 87·4-89·2 per cent of the hepatic arteries of 610 living-donor liver transplant donors were depicted in Michels', Hiatt's or Varotti's classification, compared with 100 per cent identified by the CRL classification. The CRL classification was validated against external data sets from previous studies, with 99·6-100·0 per cent of patients classified by the CRL system. CONCLUSION The CRL classification covers hepatic artery variants and may be used for planning liver surgery.
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Affiliation(s)
- J Yan
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - H Feng
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - H Wang
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, China
- University of Queensland Diamantina Institute, University of Queensland, Woolloongabba, Queensland 4102, Australia
| | - F Yuan
- Graduate School, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - C Yang
- Graduate School, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - X Liang
- University of Queensland Diamantina Institute, University of Queensland, Woolloongabba, Queensland 4102, Australia
| | - W Chen
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - J Wang
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, China
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Tan ZZX, Ch'ng JK. Use of the Gastroduodenal Artery in Hepatic Artery Reconstruction for Iatrogenic Hepatic Artery Injury During Laparoscopic Total Gastrectomy: Case Report and Review of the Literature. Ann Vasc Surg 2020; 66:666.e1-666.e5. [PMID: 31904514 DOI: 10.1016/j.avsg.2019.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 12/15/2019] [Accepted: 12/16/2019] [Indexed: 10/25/2022]
Abstract
Iatrogenic injury of the hepatic artery is a potential hazard of hepatopancreatobiliary and gastric surgery. Prompt recognition and specialist management is paramount to limit morbidity for the patient. Several reconstruction options have been reported in the literature, but the optimum approach should be tailored to the individual patient bearing in mind variations in anatomy, clinical conditions, and other concurrent operative interventions. We report the case of a successful hepatic artery reconstruction using the gastroduodenal artery as a transposition graft for inadvertent transection of the common hepatic artery during laparoscopic total gastrectomy. In expert hands, the use of the gastroduodenal artery for extra-anatomic reconstruction of the hepatic artery is a safe, feasible, and effective option.
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Affiliation(s)
- Zoe Zhuo Xuan Tan
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore.
| | - Jack Kian Ch'ng
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
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Rystedt JM, Kleeff J, Salvia R, Besselink MG, Prasad R, Lesurtel M, Sturesson C, Abu Hilal M, Aljaiuossi A, Antonucci A, Ardito F, Ausania F, Bernon M, Berrevoet F, Björnsson B, Bonsing B, Boonstra E, Bracke B, Brusadin R, Burda L, Caraballo M, Casellas-Robert M, Çoker A, Davide J, De Gelder A, De Rose A, Djokic M, Dudek K, Ekmekçigil E, Filauro M, Fülöp A, Gallagher T, Gastaca M, Gefen R, Giuliante F, Habibeh H, Halle-Smith J, Haraldsdottir K, Hartman V, Hauer A, Hemmingsson O, Hoskovec D, Isaksson B, Jonas E, Khalaileh A, Klug R, Krige J, Lignier D, Lindemann J, López-López V, Lucidi V, Mabrut JY, Månsson C, Mieog S, Mirza D, Oldhafer K, Omoshoro-Jones J, Ortega-Torrecilla N, Otto W, Panaro F, Pando E, Paterna-López S, Pekmezci S, Pesce A, Porte R, Poves I, Prieto Calvo M, Primavesi F, Puleo S, Recordare A, Rizell M, Roberts K, Robles-Campos R, Sanchiz-Cardenas E, Sandström P, Saribeyoglu K, Schauer M, Schreuder M, Siriwardena A, Smith M, Sousa Silva D, Sparrelid E, Stättner S, Stavrou G, Straka M, Strömberg C, Sutcliffe R, Szijártó A, Taflin H, Trotovšek B, van Gulik T, Wallach N, Zieniewicz K. Post cholecystectomy bile duct injury: early, intermediate or late repair with hepaticojejunostomy - an E-AHPBA multi-center study. HPB (Oxford) 2019; 21:1641-1647. [PMID: 31151812 DOI: 10.1016/j.hpb.2019.04.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 03/18/2019] [Accepted: 04/01/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Treatment of bile duct injuries (BDI) during cholecystectomy depends on the severity of injury and the timing of diagnosis. Standard of care for severe BDIs is hepaticojejunostomy. The aim of this retrospective multi-center study was to assess the optimal timing for repair of BDI with hepaticojejunostomy. METHODS Members of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients with hepaticojejunostomy after BDI from January 2000 to June 2016. Patients were stratified according to the timing of biliary reconstruction with hepaticojejunostomy: early (day 0-7), intermediate (1-6 weeks) and late (6 weeks-6 months). Primary endpoint was re-intervention >90 days after the hepaticojejunostomy and secondary endpoints were severe 90-day complications and liver-related mortality. RESULTS In total 913 patients from 48 centers were included in the analysis. In 401 patients (44%) the bile duct injury was diagnosed intraoperatively, and 126 patients (14%) suffered from concomitant vascular injury. In multivariable analysis the timing of hepaticojejunostomy had no impact on postoperative complications, the need for re-intervention after 90 days nor liver-related mortality. The rate of re-intervention more than 90 days after the hepaticojejunostomy was significantly increased in male patients but decreased in older patients. Severe co-morbidity increased the risk for liver-related mortality (HR 3.439; CI 1.37-8.65; p = 0.009). CONCLUSION After BDI occurring during cholecystectomy, the timing of biliary reconstruction with hepaticojejunostomy did not have any impact on severe postoperative complications, the need for re-intervention or liver-related mortality. Individualised treatment after iatrogenic bile duct injury is still advisable.
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Felli E, Mascagni P, Wakabayashi T, Mutter D, Marescaux J, Pessaux P. Feasibility and Value of the Critical View of Safety in Difficult Cholecystectomies. Ann Surg 2019; 269:e41. [PMID: 30418205 DOI: 10.1097/sla.0000000000003096] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Emanuele Felli
- Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - Pietro Mascagni
- Institut Hospitalo-Universitaire (IHU), Institute of Image-Guided Surgery, Strasbourg, France
| | - Taiga Wakabayashi
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
| | - Didier Mutter
- Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
- Institut Hospitalo-Universitaire (IHU), Institute of Image-Guided Surgery, Strasbourg, France
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
| | - Jacques Marescaux
- Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
- Institut Hospitalo-Universitaire (IHU), Institute of Image-Guided Surgery, Strasbourg, France
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
| | - Patrick Pessaux
- Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
- Institut Hospitalo-Universitaire (IHU), Institute of Image-Guided Surgery, Strasbourg, France
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
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Pesce A, Palmucci S, La Greca G, Puleo S. Iatrogenic bile duct injury: impact and management challenges. Clin Exp Gastroenterol 2019; 12:121-128. [PMID: 30881079 PMCID: PMC6408920 DOI: 10.2147/ceg.s169492] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Iatrogenic bile duct 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.
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Affiliation(s)
- Antonio Pesce
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Catania, Italy,
| | - Stefano Palmucci
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Catania, Italy,
| | - Gaetano La Greca
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Catania, Italy,
| | - Stefano Puleo
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Catania, Italy,
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Lindemann J, Jonas E, Kotze U, Krige JE. An analysis of early postoperative complications following biliary reconstruction of major bile duct injuries using the Modified Accordion and Anatomic, Timing Of and Mechanism classifications. Surg Open Sci 2019; 1:2-6. [PMID: 32754686 PMCID: PMC7391892 DOI: 10.1016/j.sopen.2019.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 01/09/2019] [Accepted: 01/30/2019] [Indexed: 11/29/2022] Open
Abstract
Background Few studies have reported patient outcome after surgical repair of bile duct injury using a standardized, validated classification system. This is the first analysis to investigate the correlation between the Anatomic, Timing Of and Mechanism classification of bile duct injury and severity of postoperative complications classified using the Modified Accordion Grading System. Methods Patients undergoing index hepaticojejunostomy repair of bile duct injury in laparoscopic cholecystectomy at a tertiary referral center from 1993-2018 were included. Patient demographics, geographic distance from referral center, time to referral, Anatomic, Timing Of and Mechanism classification and highest Modified Accordion Grade complication were retrieved from a prospective database. The primary outcome was determined using correlation statistics to assess the relationship between level of injury and severity of postoperative complication. Results One hundred and twenty-eight patients were included. There was no correlation between level of injury and severity of postoperative complication (rs(128) = –0.113, P = .203). Seventy (54.7%) patients had an injury less than 2 cm from the hepatic duct bifurcation and 52% of patients developed a postoperative complication, most mild to moderate in severity. Geographic distance resulted in substantial delays in referral (P < .001) but did not affect complication rate (P = .523). Conclusion In this prospective analysis the short-term complication rate was higher than previous retrospective reports, but the distribution of the severity of complications and spectrum of injury type were similar. There was no correlation between severity of injury and postoperative complications. Geographic distance from referral center resulted in substantial differences in referral delay but had no statistically significant effect on outcome.
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Affiliation(s)
- Jessica Lindemann
- Department of Surgery, University of Cape Town Health Sciences Faculty, Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa.,Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Eduard Jonas
- Department of Surgery, University of Cape Town Health Sciences Faculty, Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa
| | - Urda Kotze
- Department of Surgery, University of Cape Town Health Sciences Faculty, Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa
| | - Jake Ej Krige
- Department of Surgery, University of Cape Town Health Sciences Faculty, Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa
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Serna JC, Patiño S, Buriticá M, Osorio E, Morales CH, Toro JP. Incidencia de lesión de vías biliares en un hospital universitario: análisis de más de 1.600 colecistectomías laparoscópicas. REVISTA COLOMBIANA DE CIRUGÍA 2019. [DOI: 10.30944/20117582.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Surgical management of laparoscopic cholecystectomy (LC) related major bile duct injuries; predictors of short-and long-term outcomes in a tertiary Egyptian center- a retrospective cohort study. ANNALS OF MEDICINE AND SURGERY (2012) 2018. [PMID: 30505442 DOI: 10.1016/j.amsu.2018.11.006.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objectives Laparoscopic cholecystectomy - associated bile duct injury is a clinical problem with bad outcome. The study aimed to analyze the outcome of surgical management of these injuries. Patients and methods We retrospectively analyzed 69 patients underwent surgical management of laparoscopic cholecystectomy related major bile duct injuries in the period from the beginning of 2013 to the beginning of 2018. Results Regarding injury type; the Leaking, Obstructing, leaking + obstructing, leaking + vascular, and obstructing + vascular injuries were 43.5%, 27.5%, 18.8%, 2.9%, and 7.2% respectively. However, the Strasberg classification of injury was as follow E1 = 25, E2 = 32, E3 = 8, and E4 = 4. The definitive procedures were as follow: end to end biliary anastomosis with stenting, hepaticojejunostomy (HJ) with or without stenting, and RT hepatectomy plus biliary reconstruction with stenting in 4.3%, 87%, and 8.7% of patients respectively. According to the time of definitive procedure from injury; the immediate (before 72 h), intermediate (between 72 h and 1.5months), and late (after1.5 months) management were 13%, 14.5%, and 72.5% respectively. The hospital and/or 1month (early) morbidity after definitive treatment was 21.7%, while, the late biliary morbidity was 17.4% and the overall mortality was 2.9%, on the other hand, the late biliary morbidity-free survival was 79.7%. On univariate analysis, the following factors were significant predictors of early morbidity; Sepsis at referral, higher Strasberg grade, associated vascular injury, right hepatectomy with biliary reconstruction as a definitive procedure, intra-operative bleeding with blood transfusion, liver cirrhosis, and longer operative times and hospital stays. However, the following factors were significantly associated with late biliary morbidity: Sepsis at referral, end to end anastomosis with stenting, reconstruction without stenting, liver cirrhosis, operative bleeding, and early morbidity. Conclusion Sepsis at referral, liver cirrhosis, and operative bleeding were significantly associated with both early and late morbidities after definitive management of laparoscopic cholecystectomy related major bile duct injuries, so it is crucial to avoid these catastrophes when doing those major procedures.
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24
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Gad EH, Ayoup E, Kamel Y, Zakareya T, Abbasy M, Nada A, Housseni M, Abd-elsamee MAS. Surgical management of laparoscopic cholecystectomy (LC) related major bile duct injuries; predictors of short-and long-term outcomes in a tertiary Egyptian center- a retrospective cohort study. Ann Med Surg (Lond) 2018; 36:219-230. [PMID: 30505442 PMCID: PMC6251332 DOI: 10.1016/j.amsu.2018.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 10/30/2018] [Accepted: 11/06/2018] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVES Laparoscopic cholecystectomy - associated bile duct injury is a clinical problem with bad outcome. The study aimed to analyze the outcome of surgical management of these injuries. PATIENTS AND METHODS We retrospectively analyzed 69 patients underwent surgical management of laparoscopic cholecystectomy related major bile duct injuries in the period from the beginning of 2013 to the beginning of 2018. RESULTS Regarding injury type; the Leaking, Obstructing, leaking + obstructing, leaking + vascular, and obstructing + vascular injuries were 43.5%, 27.5%, 18.8%, 2.9%, and 7.2% respectively. However, the Strasberg classification of injury was as follow E1 = 25, E2 = 32, E3 = 8, and E4 = 4. The definitive procedures were as follow: end to end biliary anastomosis with stenting, hepaticojejunostomy (HJ) with or without stenting, and RT hepatectomy plus biliary reconstruction with stenting in 4.3%, 87%, and 8.7% of patients respectively. According to the time of definitive procedure from injury; the immediate (before 72 h), intermediate (between 72 h and 1.5months), and late (after1.5 months) management were 13%, 14.5%, and 72.5% respectively. The hospital and/or 1month (early) morbidity after definitive treatment was 21.7%, while, the late biliary morbidity was 17.4% and the overall mortality was 2.9%, on the other hand, the late biliary morbidity-free survival was 79.7%. On univariate analysis, the following factors were significant predictors of early morbidity; Sepsis at referral, higher Strasberg grade, associated vascular injury, right hepatectomy with biliary reconstruction as a definitive procedure, intra-operative bleeding with blood transfusion, liver cirrhosis, and longer operative times and hospital stays. However, the following factors were significantly associated with late biliary morbidity: Sepsis at referral, end to end anastomosis with stenting, reconstruction without stenting, liver cirrhosis, operative bleeding, and early morbidity. CONCLUSION Sepsis at referral, liver cirrhosis, and operative bleeding were significantly associated with both early and late morbidities after definitive management of laparoscopic cholecystectomy related major bile duct injuries, so it is crucial to avoid these catastrophes when doing those major procedures.
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Affiliation(s)
- Emad Hamdy Gad
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Eslam Ayoup
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Yasmin Kamel
- Anaesthesia, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Talat Zakareya
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Mohamed Abbasy
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Ali Nada
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Mohamed Housseni
- Radioligy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
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Landolsi S, Landolsi M, Mannai S. Spontaneous right hepatic artery branch gallbladder fistula revealed by haemobilia and upper cataclysmic gastrointestinal bleeding. BMJ Case Rep 2018; 2018:bcr-2017-222134. [PMID: 29298787 DOI: 10.1136/bcr-2017-222134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Spontaneous right hepatic artery branch gallbladder fistula is a rare condition. Our case reported a spontaneous fistula between the right branch of the hepatic artery and the gall bladder. It constitutes a rare cause of haemobilia. In fact, the most common aetiology of haemobilia is traumatic or iatrogenic secondary to hepatobiliary surgery or interventions. Diagnosis of vascular-biliary fistula is not easy. The gallbladder endoluminal clot can mimic a mass, as in our patient. Selective arterial angiography is helpful in identifying the source of gastrointestinal haemorrhage. It can demonstrate the presence of arteriobiliary fistula. The differential diagnosis is arterial pseudoaneurysm in the vicinity of the vessel. Mini-invasive treatment of this fistula constitutes the best treatment. We here report a case of haemobilia with upper cataclysmic gastrointestinal bleeding revealing a spontaneous fistula between the right branch of the hepatic artery and the gall bladder.
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Affiliation(s)
- Sana Landolsi
- Department of Surgery, Universite de Tunis El Manar Faculte de Medecine de Tunis, Tunis, Tunisia
| | - Manel Landolsi
- Department of Radiology, Universite de Tunis El Manar Faculte de Medecine de Tunis, Tunis, Tunisia
| | - Saber Mannai
- Department of Surgery, Universite de Tunis El Manar Faculte de Medecine de Tunis, Tunis, Tunisia
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Rose JB, Hawkins WG. Diagnosis and management of biliary injuries. Curr Probl Surg 2017; 54:406-435. [DOI: 10.1067/j.cpsurg.2017.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 06/20/2017] [Indexed: 12/11/2022]
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LeBedis CA, Bates DDB, Soto JA. Iatrogenic, blunt, and penetrating trauma to the biliary tract. Abdom Radiol (NY) 2017; 42:28-45. [PMID: 27503381 DOI: 10.1007/s00261-016-0856-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Iatrogenic and traumatic bile leaks are uncommon. However, given the overall increase in number of hepatobiliary surgeries and the paradigm shift toward nonoperative management of patients with liver trauma, they have become more prevalent in recent years. Imaging is essential to establishing early diagnosis and guiding treatment as the clinical signs and symptoms of bile leaks are nonspecific, and a delay in recognition of bile leaks portends a high morbidity and mortality rate. Findings suspicious for a bile leak at computed tomography or ultrasonography include free or contained peri- or intrahepatic low density fluid in the setting of recent trauma or hepatobiliary surgery. Hepatobiliary scintigraphy and magnetic resonance cholangiopancreatography (MRCP) with hepatobiliary contrast agents can be used to detect active or contained bile leak. MRCP with hepatobiliary contrast agents has the unique ability to reveal the exact location of bile leak, which often governs whether endoscopic management or surgical management is warranted. Percutaneous transhepatic cholangiography and fluoroscopy via an indwelling catheter that is placed either percutaneously or surgically are useful modalities to guide percutaneous transhepatic biliary drain placement which can provide biliary drainage and/or diversion in the setting of traumatic biliary injury. Surgical treatment of a bile duct injury with Roux-en-Y hepaticojejunostomy is warranted if definitive treatment cannot be accomplished through percutaneous or endoscopic means.
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Hori T, Oike F, Furuyama H, Machimoto T, Kadokawa Y, Hata T, Kato S, Yasukawa D, Aisu Y, Sasaki M, Kimura Y, Takamatsu Y, Naito M, Nakauchi M, Tanaka T, Gunji D, Nakamura K, Sato K, Mizuno M, Iida T, Yagi S, Uemoto S, Yoshimura T. Protocol for laparoscopic cholecystectomy: Is it rocket science? World J Gastroenterol 2016; 22:10287-10303. [PMID: 28058010 PMCID: PMC5175242 DOI: 10.3748/wjg.v22.i47.10287] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 10/16/2016] [Accepted: 11/28/2016] [Indexed: 02/06/2023] Open
Abstract
Laparoscopic cholecystectomy (LC) does not require advanced techniques, and its performance has therefore rapidly spread worldwide. However, the rate of biliary injuries has not decreased. The concept of the critical view of safety (CVS) was first documented two decades ago. Unexpected injuries are principally due to misidentification of human factors. The surgeon's assumption is a major cause of misidentification, and a high level of experience alone is not sufficient for successful LC. We herein describe tips and pitfalls of LC in detail and discuss various technical considerations. Finally, based on a review of important papers and our own experience, we summarize the following mandatory protocol for safe LC: (1) consideration that a high level of experience alone is not enough; (2) recognition of the plateau involving the common hepatic duct and hepatic hilum; (3) blunt dissection until CVS exposure; (4) Calot's triangle clearance in the overhead view; (5) Calot's triangle clearance in the view from underneath; (6) dissection of the posterior right side of Calot's triangle; (7) removal of the gallbladder body; and (8) positive CVS exposure. We believe that adherence to this protocol will ensure successful and beneficial LC worldwide, even in patients with inflammatory changes and rare anatomies.
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Hogan NM, Dorcaratto D, Hogan AM, Nasirawan F, McEntee P, Maguire D, Geoghegan J, Traynor O, Winter DC, Hoti E. Iatrogenic common bile duct injuries: Increasing complexity in the laparoscopic era: A prospective cohort study. Int J Surg 2016; 33 Pt A:151-6. [PMID: 27512909 DOI: 10.1016/j.ijsu.2016.08.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 07/18/2016] [Accepted: 08/04/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE Iatrogenic bile duct injury (BDI) is the most significant associated complication to laparoscopic cholecystectomy (LC). Little is known about the evolution of the pattern of BDI in the era of laparoscopy. The aim of the study is to assess the pattern of post-LC BDIs managed in a tertiary referral centre. METHODS Post-LC BDI referred over two decades were studied. Demographic data, type of BDI (classified using the Strasberg System), clinical symptoms, diagnostic investigations, timing of referral, post-referral management and morbidity were analysed. The pattern of injury, associated vascular injuries rate and their management were compared over two time periods (1992-2004,2005-2014). RESULTS 78 BDIs were referred. During the second time period Strasberg A injuries decreased from 14% to 0 and Strasberg E1increased from 4% to 23%, the rate of associated vascular injury was six time higher (3.6% versus 22.7%), more patients had an attempted repair at the index hospital (16% versus 35%) sand fewer patients could be managed without surgical intervention at the referral hospital (28% versus 4%). CONCLUSION Complexity of referred BDIs and rate of associated vascular injuries have increased over time. These findings led to more patients managed requiring surgical intervention at the referral hospital.
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Affiliation(s)
- N M Hogan
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - D Dorcaratto
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - A M Hogan
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - F Nasirawan
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - P McEntee
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - D Maguire
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - J Geoghegan
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - O Traynor
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - D C Winter
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - E Hoti
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Mercado MA, Vilatoba M, Contreras A, Leal-Leyte P, Cervantes-Alvarez E, Arriola JC, Gonzalez BA. Iatrogenic bile duct injury with loss of confluence. World J Gastrointest Surg 2015; 7:254-260. [PMID: 26527428 PMCID: PMC4621476 DOI: 10.4240/wjgs.v7.i10.254] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 06/25/2015] [Accepted: 09/02/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To describe our experience concerning the surgical treatment of Strasberg E-4 (Bismuth IV) bile duct injuries.
METHODS: In an 18-year period, among 603 patients referred to our hospital for surgical treatment of complex bile duct injuries, 53 presented involvement of the hilar confluence classified as Strasberg E4 injuries. Imagenological studies, mainly magnetic resonance imaging showed a loss of confluence. The files of these patients were analyzed and general data were recorded, including type of operation and postoperative outcome with emphasis on postoperative cholangitis, liver function test and quality of life. The mean time of follow-up was of 55.9 ± 52.9 mo (median = 38.5, minimum = 2, maximum = 181.2). All other patients with Strasberg A, B, C, D, E1, E2, E3, or E5 biliary injuries were excluded from this study.
RESULTS: Patients were divided in three groups: G1 (n = 21): Construction of neoconfluence + Roux-en-Y hepatojejunostomy. G2 (n = 26): Roux-en-Y portoenterostomy. G3 (n = 6): Double (right and left) Roux-en-Y hepatojejunostomy. Cholangitis was recorded in two patients in group 1, in 14 patients in group 2, and in one patient in group 3. All of them required transhepatic instrumentation of the anastomosis and six patients needed live transplantation.
CONCLUSION: Loss of confluence represents a surgical challenge. There are several treatment options at different stages. Roux-en-Y bilioenteric anastomosis (neoconfluence, double-barrel anastomosis, portoenterostomy) is the treatment of choice, and when it is technically possible, building of a neoconfluence has better outcomes. When liver cirrhosis is shown, liver transplantation is the best choice.
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Sugawara G, Ebata T, Yokoyama Y, Igami T, Mizuno T, Nagino M. Management strategy for biliary stricture following laparoscopic cholecystectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:889-95. [PMID: 25159686 DOI: 10.1002/jhbp.151] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Biliary strictures following laparoscopic cholecystectomy (Lap-C), which are often associated with vascular injuries, remain a serious problem to manage. The aim of this study was to review our experiences with postoperative biliary stricture. METHODS This study involved 14 consecutive patients with biliary strictures that resulted from bile duct injuries during Lap-C between 1997 and 2013. Their medical records were retrospectively analyzed. RESULTS Percutaneous transhepatic biliary drainage (PTBD) catheter dilatation was first attempted in eight patients, and five patients were successfully treated. Biliary re-stricture recurred in one patient after 34-month follow-up period. This patient underwent repeated catheter dilatations, which led to recurrent stricture resolution. All five patients maintained biliary tract patency over 72-month follow-up period. The remaining nine patients underwent surgical procedures, including hepaticojejunostomy in two patients, re-hepaticojejunostomy in two patients, and the remaining five patients, with biliary strictures involving the secondary biliary branch and concomitant vascular injuries underwent right hemihepatectomy with cholangiojejunostomy. There were no major postoperative complications. After 80-month follow-up period, all nine patients were alive without biliary stricture. CONCLUSIONS PTBD catheter dilatation is recommended first for postoperative Lap-C-associated biliary strictures. In complicated injury patients with vascular injuries, right hemihepatectomy with cholangiojejunostomy should be indicated.
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Affiliation(s)
- Gen Sugawara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Stewart L. Iatrogenic biliary injuries: identification, classification, and management. Surg Clin North Am 2014; 94:297-310. [PMID: 24679422 DOI: 10.1016/j.suc.2014.01.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Because it offers several advantages over open cholecystectomy, laparoscopic cholecystectomy has largely replaced open cholecystectomy for the management of symptomatic gallstone disease. The only potential disadvantage is a higher incidence of major bile duct injury. Although prevention of these biliary injuries is ideal, when they do occur, early identification and appropriate treatment are critical to improving the outcomes of patients suffering a major bile duct injury. This report delineates the key factors in classification (and its relationship to mechanism and management), identification (intraoperative and postoperative), and management principles of these bile duct injuries.
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Affiliation(s)
- Lygia Stewart
- Department of Surgery (112), University of California San Francisco and San Francisco VA Medical Center, San Francisco, CA 94121, USA.
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Bharathy KGS, Negi SS. Postcholecystectomy bile duct injury and its sequelae: pathogenesis, classification, and management. Indian J Gastroenterol 2014; 33:201-15. [PMID: 23999681 DOI: 10.1007/s12664-013-0359-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Accepted: 07/21/2013] [Indexed: 02/06/2023]
Abstract
A bile duct injury sustained during cholecystectomy can change the life of patients who submit themselves to a seemingly innocuous surgery. It has far-reaching medical, socioeconomic, and legal ramifications. Attention to detail, proper interpretation of variant anatomy, use of intraoperative cholangiography, and conversion to an open procedure in cases of difficulty can avoid/lessen the impact of some of these injuries. Once suspected, the aims of investigation are to establish the type and extent of injury and to plan the timing and mode of intervention. The principles of treatment are to control sepsis and to establish drainage of all liver segments with minimum chances of restricturing. Availability of expertise, morbidity, mortality, and quality of life issues dictate the modality of treatment chosen. Endoscopic intervention is the treatment of choice for minor leaks and provides outcomes comparable to surgery in selected patients with lateral injuries and partial strictures. A Roux-en-Y hepaticojejunostomy (HJ) by a specialist surgeon is the gold standard for high strictures, complete bile duct transection and has been shown to provide excellent long-term outcomes. Percutaneous intervention is invaluable in draining bile collections and is useful in treating post-HJ strictures. Combined biliovascular injuries, segmental atrophy, and secondary biliary cirrhosis with portal hypertension are special circumstances which are best managed by a multidisciplinary team at an experienced center for optimal outcomes.
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Affiliation(s)
- Kishore G S Bharathy
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110 070, India
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Jabłońska B. Hepatectomy for bile duct injuries: when is it necessary? World J Gastroenterol 2013; 19:6348-6352. [PMID: 24151352 PMCID: PMC3801304 DOI: 10.3748/wjg.v19.i38.6348] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 08/30/2013] [Accepted: 09/03/2013] [Indexed: 02/06/2023] Open
Abstract
Iatrogenic bile duct injuries (IBDI) are still a challenge for surgeons. The most frequently, they are caused by laparoscopic cholecystectomy which is one of the commonest surgical procedure in the world. Endoscopic techniques are recommended as initial treatment of IBDI. When endoscopic treatment is not effective, surgery is considered. Different surgical biliary reconstructions are performed in most patients in IBDI. Roux-Y hepaticojejunostomy is the commonest biliary reconstruction for IBDI. In some patients with complex IBDI, hepatectomy is required. Recently, Li et al analyzed the factors that had led to hepatectomy for patients with IBDI after laparoscopic cholecystectomy (LC). Authors concluded that hepatectomy might be necessary to manage early or late complications after LC. The study showed that proximal IBDI (involving hepatic confluence) and IBDI associated with vascular injuries were the two independent risk factors of hepatectomy in this series. Authors distinguished two main groups of patients that require liver resection in IBDI: those with an injury-induced liver necrosis necessitating early intervention, and those in whom liver resection is indicated for treatment of liver atrophy following long-term cholangitis. In this commentary, indications for hepatectomy in patients with IBDI are discussed. Complex biliovascular injuries as indications for hepatectomy are presented. Short- and long-term results in patients following liver resection for IBDI are also discussed. Hepatectomy is not a standard procedure in surgical treatment of IBDI, but in some complex injuries it should be considered.
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Addeo P, Oussoultzoglou E, Fuchshuber P, Rosso E, Nobili C, Souche R, Jaeck D, Bachellier P. Reoperative surgery after repair of postcholecystectomy bile duct injuries: is it worthwhile? World J Surg 2013. [PMID: 23188533 DOI: 10.1007/s00268-012-1847-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Repeat repair of bile duct injuries (BDIs) after cholecystectomy is technically challenging, and its success remains uncertain. We retrospectively evaluated the short- and long-term outcomes of patients requiring reoperative surgery for BDI at a major referral center for hepatobiliary surgery. METHODS Between January 1991 and May 2011, we performed surgical BDI repairs in 46 patients. Among them, 22 patients had undergone a previous surgical repair elsewhere (group 1), and 24 patients had no previous repair (group 2). We compared the early and late outcomes in the two groups. RESULTS The patients in group 1 were younger (48.6 vs. 54.8 years, p = 0.0001) and were referred after a longer interval (>1 month) from BDI (72.7 vs. 41.7%, p = 0.042). Intraoperative diagnosis of BDI (59.1 vs. 12.5%, p = 0.001), ongoing cholangitis (45.4 vs. 12.5%; p = 0.02), and delay of repair after referral to our institution (116 ± 34 days vs. 23 ± 9 days; p = 0.001) were significantly more frequent in group 1 than in group 2. No significant differences were found for postoperative mortality, morbidity, or length of stay between the groups. Patients with associated vascular injuries had a higher postoperative morbidity rate (p = 0.01) and associated hepatectomy rate (p = 0.045). After a mean follow-up of 96.6 ± 9.7 months (range 5-237.2 months, median 96 months), the rate of recurrent cholangitis (6.5%) was comparable in the two groups. CONCLUSIONS This study demonstrates that short- and long-term outcomes after surgical repair of BDI are comparable regardless of whether the patient requires reoperative surgery for a failed primary repair. Associated vascular injuries increase postoperative morbidity and the need for liver resection.
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Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1, Avenue Moliere, 67098, Strasbourg, France
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Wang Z, Yu L, Wang W, Xia J, Li D, Lu Y, Wang B. Therapeutic strategies of iatrogenic portal vein injury after cholecystectomy. J Surg Res 2013; 185:934-9. [PMID: 23859133 DOI: 10.1016/j.jss.2013.06.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 06/11/2013] [Accepted: 06/13/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND The incidence of vascular injury after a cholecystectomy is often underestimated. Although injuries to the portal vein are rare, they are devastating. The aim of the present study was to analyze suitable therapeutic strategies regarding portal vein injury in the absence of biliary injury. MATERIALS AND METHODS Eleven patients with portal vein injuries after laparoscopic or open cholecystectomy were referred to our hospital between 2004 and 2010. The clinical presentation, diagnosis, and management of patients with severe portal vein injuries were reviewed. All the patients were discharged without outstanding clinical conditions. During retrospective analysis, these patients were divided into early, middle, and late stages. RESULTS All the 11 patients had a portal vein and/or right hepatic artery injury, but no biliary injuries were observed. Among these patients, different management strategies were managed according to the stage of the injury. Eight patients received a direct suture at the time of injury by an experienced hepatobiliary surgeon. Two patients received thrombolytic and anticoagulation therapy after cholecystectomy, without additional surgery. One patient received a liver transplant 3 mo after the injury. After long-term follow-up, these patients had no clinical conditions. CONCLUSIONS Direct repair or suture is important during the early stage of portal vein injury. Conservative thrombolytic and anticoagulation therapy may serve an important role in the treatment of acute massive thrombus in portal vein injury during the middle stage. Liver transplantation is a salvage therapy that should be used during the late stage.
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Affiliation(s)
- Zheng Wang
- Department of Hepatobiliary Surgery, First Affiliated Hospital, Medical College, Xi'an Jiaotong University, Xi'an, People's Republic of China
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Priya H, Anshul G, Alok T, Saurabh K, Ranjit N, Romesh L, Deborshi S. Emergency cholecystectomy and hepatic arterial repair in a patient presenting with haemobilia and massive gastrointestinal haemorrhage due to a spontaneous cystic artery gallbladder fistula masquerading as a pseudoaneurysm. BMC Gastroenterol 2013; 13:43. [PMID: 23452779 PMCID: PMC3599389 DOI: 10.1186/1471-230x-13-43] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 02/26/2013] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Haemobilia usually occurs secondary to accidental or iatrogenic hepatobiliary trauma. It can occasionally present with cataclysmal upper gastrointestinal haemorrhage posing as a life threatening emergency. Haemobilia can very rarely be a complication of acute cholecystitis. Here we report a case of haemobilia manifesting as massive gastrointestinal haemorrhage in a patient without any prior history of biliary surgery or intervention and present a brief review of literature. CASE PRESENTATION A 22 year old male admitted with history suggestive of acute cholecystitis subsequently developed waxing waning jaundice and recurrent episodes of upper gastrointestinal bleed. Endoscopy showed an ulcer in the first part of duodenum with a clot, no active bleed was visible. Angiography was suggestive of a ruptured pseudoaneurysm in the vicinity of the right hepatic artery probably originating from the cystic artery. Coil embolization was tried but the coil dislodged into the right branch of hepatic artery distal to the site of pseudoaneurysm. Review of angiographic video in light of operative findings demonstrated a fistulous communication between cystic artery and gallbladder as the cause, a simultaneous cholecystoduodenal fistula was also noted. Retrograde cholecystectomy, closure of cholecystoduodenal fistula and right hepatic arteriotomy with retrieval of the endo-coil and hepatic arterial repair was performed. CONCLUSION Fistula between the cystic artery and gallbladder has been commonly reported to occur after laparoscopic cholecystectomy. Spontaneous fistulous communication, i.e. in the absence of any prior trauma or intervention, between cystic artery and gallbladder is rare with very few reports in literature. Aetiopathogenesis of the disease, in the context of current literature is reviewed. The diagnostic dilemma posed by the confounding finding of an ulcer in the duodenum, the iconic video angiographic depiction as also the therapeutic challenge of a failed embolization with consequent microcoil migration and primary hepatic arterial repair in the emergency situation is discussed.
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Affiliation(s)
- Hazrah Priya
- Department of Surgery, Lady Hardinge Medical College, New Delhi, India
| | - Gupta Anshul
- Department of Surgery, Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Tiwari Alok
- Department of Surgery, Lady Hardinge Medical College, New Delhi, India
| | - Kale Saurabh
- Department of Surgery, Lady Hardinge Medical College, New Delhi, India
| | - Nath Ranjit
- Department of Cardiology, Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Lal Romesh
- Department of Surgery, Lady Hardinge Medical College, New Delhi, India
| | - Sharma Deborshi
- Department of Surgery, Lady Hardinge Medical College, New Delhi, India
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Sarno G, Al-Sarira AA, Ghaneh P, Fenwick SW, Malik HZ, Poston GJ. Cholecystectomy-related bile duct and vasculobiliary injuries. Br J Surg 2012; 99:1129-36. [DOI: 10.1002/bjs.8806] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2012] [Indexed: 12/15/2022]
Abstract
Abstract
Background
Combined vasculobiliary injury is a serious complication of cholecystectomy. This study examined medium- to long-term outcomes after such injury.
Methods
Patients referred to this institution with Strasberg type E bile duct injuries were identified from a prospectively maintained database (1990–2010). Long-term outcomes were evaluated by chart review.
Results
Sixty-three patients were referred with bile duct injury alone (45 patients) or vasculobiliary injury (18). Thirty patients (48 per cent) had septic complications before transfer. Twenty-six patients (41 per cent) had long-term biliary complications over a median follow-up of 96 (range 12–245) months. Nine patients (3 with bile duct injury, 6 with vasculobiliary injury) required further interventions after a median of 22 (8–38) months; five required biliary surgical revision and four percutaneous dilatation of biliary strictures. Vasculobiliary injury and injury-related sepsis were independent risk factors for treatment failure: hazard ratio 7·79 (95 per cent confidence interval 2·80 to 21·70; P < 0·001) and 4·82 (1·69 to 13·68; P = 0·003) respectively.
Conclusion
Outcome following bile duct injury repair was worse in patients with concomitant vasculobiliary injury and/or sepsis.
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Affiliation(s)
- G Sarno
- North Western Hepatobiliary Unit, University Hospital Aintree, Liverpool L7 9AL, UK
| | - A A Al-Sarira
- North Western Hepatobiliary Unit, University Hospital Aintree, Liverpool L7 9AL, UK
| | - P Ghaneh
- North Western Hepatobiliary Unit, University Hospital Aintree, Liverpool L7 9AL, UK
| | - S W Fenwick
- North Western Hepatobiliary Unit, University Hospital Aintree, Liverpool L7 9AL, UK
| | - H Z Malik
- North Western Hepatobiliary Unit, University Hospital Aintree, Liverpool L7 9AL, UK
| | - G J Poston
- North Western Hepatobiliary Unit, University Hospital Aintree, Liverpool L7 9AL, UK
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Timing and risk factors of hepatectomy in the management of complications following laparoscopic cholecystectomy. J Gastrointest Surg 2012; 16:815-20. [PMID: 22068969 DOI: 10.1007/s11605-011-1769-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 10/19/2011] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Complex bile duct injury (BDI) is a serious condition requiring hepatectomy in some instances. The present study was to analyse the factors that led to hepatectomy for patients with BDI after laparoscopic cholecystectomy (LC). METHODS The medical records of patients referred to our department from April 1998 to September 2007 for management of BDI following LC were reviewed, and patients who underwent hepatectomy were identified. The type of BDI, indication for liver resection, interval between LC and liver surgery, histology of the liver specimen, postoperative morbidity and long-term results were analysed. RESULTS Hepatectomy was performed in 10 of 76 patients (13.2%), with BDI either as isolated damage or in combination with vascular injury (VI). Proximal BDI (defined as disruption of the biliary confluence) and injury to the right hepatic artery were found to be independent risk factors of hepatectomy, with odds ratios of 16 and 45, respectively. Five patients required early liver resection (within 5 weeks post-LC) to control sepsis caused by confluent liver necrosis or bile duct necrosis. In five patients, hepatectomy was indicated during long-term follow-up (over 4 months post-LC) to effectively manage recurrent cholangitis and liver atrophy. Despite of high postoperative morbidity (60%) and even mortality (10%), the long-term results (median follow-up of 34 months) were satisfactory, with either no or only transitory symptoms in 67% of the patients. CONCLUSION Hepatectomy may inevitably be necessary to manage early or late complications after LC. Proximal BDI and VI were the two independent risk factors of hepatectomy in this series.
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Management of post-cholecystectomy benign bile duct strictures: review. Indian J Surg 2011; 74:22-8. [PMID: 23372303 DOI: 10.1007/s12262-011-0375-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 11/10/2011] [Indexed: 01/02/2023] Open
Abstract
Cholecystectomy is one of the common surgical procedure performed across the world and bile duct injury is a dreaded complication. The present review addresses the classification of injuries, preoperative preparation and evaluation of these patients and appropriate timing of surgery. A detailed preoperative evaluation combined with a meticulous wide anastomosis by experienced surgeons is the key in achieving long term success. Vascular injuries and its consequences on repair and outcome is also reviewed. Long term results of surgical repair and quality of life in these patients are excellent.
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Robles Campos R, Marín Hernández C, Fernández Hernández JA, Sanchez Bueno F, Ramirez Romero P, Pastor Perez P, Parrilla Paricio P. [Delayed right hepatic artery haemorrhage after iatrogenic gallbladder by laparoscopic cholecystectomy that required a liver transplant due to acute liver failure: clinical case and review of the literature]. Cir Esp 2011; 89:670-676. [PMID: 21880307 DOI: 10.1016/j.ciresp.2011.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 06/14/2011] [Accepted: 07/01/2011] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Right hepatic artery (RHA) injury after laparoscopic cholecystectomy (LC) may go unnoticed clinically, but can sometimes cause necrosis of the right lobe. Exceptionally, when the necrosis spreads to segment IV, fulminant liver failure (FLF) may occur, and an urgent liver transplantation (LT) may be required. PATIENTS AND METHOD We provide a review of the literature on patients with indication for an LT due to vascular damage caused by bile duct injury following LC. The case reported herein is the fourth described in the specialized literature of LT due to RHA injury after LC and the second of FLF after RHA injury. RESULTS LT due to RHA injury was performed in 3 of 13 patients reported in the literature: one LT was performed at 3 months due to FLF, after an extended right hepatectomy was performed, and the remaining two were performed due to secondary biliary cirrhosis. Our patient was transplanted due to FLF 15 days after the injury. CONCLUSIONS RHA injury after LC may require LT due to FLF. Although exceptional, this possibility should be considered when there are RHA complications that may require occlusion.
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Affiliation(s)
- Ricardo Robles Campos
- Unidad de Cirugía Hepática y Transplante Hepático, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain.
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Ardiles V, McCormack L, Quiñonez E, Goldaracena N, Mattera J, Pekolj J, Ciardullo M, de Santibañes E. Experience using liver transplantation for the treatment of severe bile duct injuries over 20 years in Argentina: results from a National Survey. HPB (Oxford) 2011; 13:544-50. [PMID: 21762297 PMCID: PMC3163276 DOI: 10.1111/j.1477-2574.2011.00322.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bile duct injury (BDI) is a severe complication that may arise during the surgical treatment of benign disease and a few patients will develop end-stage liver disease (ESLD) requiring a liver transplant (LT). OBJECTIVE Analyse the experience using LT as a definitive treatment of BDI in Argentina. PATIENTS AND METHODS A national survey regarding the experience of LT for BDI. RESULTS Sixteen out 18 centres reported a total of 19 patients. The percentage of LT for BDI from the total number of LT per period was: 1990-94 = 3.1%, 1995-99 = 1.6%, 2000-04 = 0.7% and 2005-09 = 0.2% (P < 0.001). The mean age was 45.7 ± 10.3 years (range 26-62) and 10 patients were female. The BDI occurred during cholecystectomy in 16 and 7 had vascular injuries. One patient presented with acute liver failure and the others with chronic ESLD. The median time between BDI and LT was 71 months (range 0.2-157). The mean follow-up was 8.3 years (10 months to 16.4 years). Survival at 1, 3, 5 and 10 years was 73%, 68%, 68% and 45%, respectively. CONCLUSIONS The use of LT for the treatment of BDI declined over the review period. LT plays a role in selected cases in patients with acute liver failure and ESLD.
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Affiliation(s)
- Victoria Ardiles
- General Surgery Service and Liver Transplant Unit, Hospital Italiano de Buenos AiresBuenos Aires, Argentina
| | - Lucas McCormack
- General Surgery and Liver Transplant Unit, Hospital Alemán de Buenos AiresBuenos Aires, Argentina
| | - Emilio Quiñonez
- General Surgery and Liver Transplant Unit, Hospital Alemán de Buenos AiresBuenos Aires, Argentina
| | - Nicolás Goldaracena
- General Surgery and Liver Transplant Unit, Hospital Alemán de Buenos AiresBuenos Aires, Argentina
| | - Juan Mattera
- General Surgery Service and Liver Transplant Unit, Hospital Italiano de Buenos AiresBuenos Aires, Argentina
| | - Juan Pekolj
- General Surgery Service and Liver Transplant Unit, Hospital Italiano de Buenos AiresBuenos Aires, Argentina
| | - Miguel Ciardullo
- General Surgery Service and Liver Transplant Unit, Hospital Italiano de Buenos AiresBuenos Aires, Argentina
| | - Eduardo de Santibañes
- General Surgery Service and Liver Transplant Unit, Hospital Italiano de Buenos AiresBuenos Aires, Argentina
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Pulitanò C, Parks RW, Ireland H, Wigmore SJ, Garden OJ. Impact of concomitant arterial injury on the outcome of laparoscopic bile duct injury. Am J Surg 2011; 201:238-44. [PMID: 21266217 DOI: 10.1016/j.amjsurg.2009.07.038] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Revised: 07/09/2009] [Accepted: 07/10/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Concomitant injury to the bile duct and hepatic artery is an increasingly recognized complication of laparoscopic cholecystectomy (LC). The impact of a concomitant arterial injury in patients with a bile duct injury (BDI) remains debatable. Early reports described a high incidence of septic complications, difficulty of biliary repair, and increased the risk of recurrent stricture. DATA SOURCES A literature search on the clinical significance and management of a concomitant hepatic artery injury (HAI) to the outcome of biliary-enteric reconstruction following BDI was reviewed. Relevant articles were extracted through MEDLINE, with secondary references obtained from key articles. CONCLUSIONS The association between failure of biliary repair and concomitant arterial injuries is not confirmed by the largest studies, which showed no difference in anastomotic stricture rate between patients who had an isolated BDI and those who had a combined HAI and BDI. However, right arterial injury associated with liver necrosis or damage to the right hepatic duct may require right hepatectomy.
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Affiliation(s)
- Carlo Pulitanò
- Department of Clinical and Surgical Sciences, Royal Infirmary of Edinburgh, University of Edinburgh, UK
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Strasberg SM, Helton WS. An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB (Oxford) 2011; 13:1-14. [PMID: 21159098 PMCID: PMC3019536 DOI: 10.1111/j.1477-2574.2010.00225.x] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 07/22/2010] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Biliary injuries are frequently accompanied by vascular injuries, which may worsen the bile duct injury and cause liver ischemia. We performed an analytical review with the aim of defining vasculobiliary injury and setting out the important issues in this area. METHODS A literature search of relevant terms was performed using OvidSP. Bibliographies of papers were also searched to obtain older literature. RESULTS Vasculobiliary injury was defined as: an injury to both a bile duct and a hepatic artery and/or portal vein; the bile duct injury may be caused by operative trauma, be ischaemic in origin or both, and may or may not be accompanied by various degrees of hepatic ischaemia. Right hepatic artery (RHA) vasculobiliary injury (VBI) is the most common variant. Injury to the RHA likely extends the biliary injury to a higher level than the gross observed mechanical injury. VBI results in slow hepatic infarction in about 10% of patients. Repair of the artery is rarely possible and the overall benefit unclear. Injuries involving the portal vein or common or proper hepatic arteries are much less common, but have more serious effects including rapid infarction of the liver. CONCLUSIONS Routine arteriography is recommended in patients with a biliary injury if early repair is contemplated. Consideration should be given to delaying repair of a biliary injury in patients with occlusion of the RHA. Patients with injuries to the portal vein or proper or common hepatic should be emergently referred to tertiary care centers.
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Affiliation(s)
- Steven M Strasberg
- Section of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington University in Saint Louis, St Louis, MO 63110, USA.
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Strasberg SM, Helton WS. An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB (Oxford) 2010. [PMID: 21159098 DOI: 10.1111/j.1477-2574.2010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
OBJECTIVES Biliary injuries are frequently accompanied by vascular injuries, which may worsen the bile duct injury and cause liver ischemia. We performed an analytical review with the aim of defining vasculobiliary injury and setting out the important issues in this area. METHODS A literature search of relevant terms was performed using OvidSP. Bibliographies of papers were also searched to obtain older literature. RESULTS Vasculobiliary injury was defined as: an injury to both a bile duct and a hepatic artery and/or portal vein; the bile duct injury may be caused by operative trauma, be ischaemic in origin or both, and may or may not be accompanied by various degrees of hepatic ischaemia. Right hepatic artery (RHA) vasculobiliary injury (VBI) is the most common variant. Injury to the RHA likely extends the biliary injury to a higher level than the gross observed mechanical injury. VBI results in slow hepatic infarction in about 10% of patients. Repair of the artery is rarely possible and the overall benefit unclear. Injuries involving the portal vein or common or proper hepatic arteries are much less common, but have more serious effects including rapid infarction of the liver. CONCLUSIONS Routine arteriography is recommended in patients with a biliary injury if early repair is contemplated. Consideration should be given to delaying repair of a biliary injury in patients with occlusion of the RHA. Patients with injuries to the portal vein or proper or common hepatic should be emergently referred to tertiary care centers.
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Affiliation(s)
- Steven M Strasberg
- Section of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington University in Saint Louis, St Louis, MO 63110, USA.
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Cerdan F, Gabaudan C, Soulier B, Richez P. [Rare complications from laparoscopic cholecystectomy]. JOURNAL DE RADIOLOGIE 2010; 91:1265-1267. [PMID: 21242904 DOI: 10.1016/s0221-0363(10)70186-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Chiruvella A, Sarmiento JM, Sweeney JF, Lin E, Davis SS. Iatrogenic combined bile duct and right hepatic artery injury during single incision laparoscopic cholecystectomy. JSLS 2010; 14:268-71. [PMID: 20932382 PMCID: PMC3043581 DOI: 10.4293/108680810x12785289144593] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Numerous recent reports describe the performance of laparoscopic procedures through a single incision. Although the feasibility of this approach for a variety of procedures is currently being established, little data are available regarding safety. CASE REPORT A 65-year-old female patient who was transferred from an outside institution had undergone a single incision laparoscopic cholecystectomy that resulted in biliary tract and vascular injuries. METHODS The patient was transferred with a known bile duct injury on the first postoperative day following single incision laparoscopic cholecystectomy. Review of her magnetic resonance imaging and percutaneous transhepatic cholangiogram studies showed a Bismuth type 3 bile duct injury. Hepatic angiogram demonstrated an occlusion of the right hepatic artery with collateralization from the left hepatic artery. She was initially managed conservatively with a right-sided external biliary drain, followed 6 weeks later by a Hepp-Couinaud procedure to reconstruct the biliary tract. CONCLUSION As new techniques evolve, it is imperative that safety, or potential side effects, or both safety and side effects, be monitored, because no learning curve is established for these new techniques. In these initial stages, surgeons should have a low threshold to add additional ports when necessary to ensure that procedures are completed safely.
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Affiliation(s)
- Amareshwar Chiruvella
- Department of Surgery, Suite H-124, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA 30322, USA.
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Lau WY, Lai ECH, Lau SHY. Management of bile duct injury after laparoscopic cholecystectomy: a review. ANZ J Surg 2010; 80:75-81. [PMID: 20575884 DOI: 10.1111/j.1445-2197.2009.05205.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Bile duct injury following cholecystectomy is an iatrogenic catastrophe which is associated with significant perioperative morbidity and mortality, reduced long-term survival and quality of life, and high rates of subsequent litigation. The aim of this article was to review the management of bile duct injury after cholecystectomy. METHODS Medline and PubMed database search was undertaken to identify articles in English from 1970 to 2008 using the key words 'bile duct injury', 'cholecystectomy' and 'classification'. Additional papers were identified by a manual search of the references from the key articles. Case report was excluded. RESULTS Early recognition of bile duct injury is of paramount importance. Only 25%-32.4% of injuries are recognized during operation. The majority of patients present initially with non-specific symptoms. Management depends on the timing of recognition, the type, extent and level of the injury. Immediate recognition and repair are associated with improved outcome, and the minimum standard of care after recognition of bile duct injury is immediate referral to a surgeon experienced in bile duct injury repair. There is a growing body of literature supporting the importance of early referral to a tertiary care hospital which can provide a multidisciplinary approach to treat bile duct injury. Inadequate management may lead to severe complications. CONCLUSIONS None of the classification system is universally accepted as each has its own limitation. The optimal management depends on the timing of recognition of injury, the extent of bile duct injury, the patient's condition and the availability of experienced hepatobiliary surgeons.
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Affiliation(s)
- Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China.
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Overby DW, Apelgren KN, Richardson W, Fanelli R. SAGES guidelines for the clinical application of laparoscopic biliary tract surgery. Surg Endosc 2010; 24:2368-2386. [PMID: 20706739 DOI: 10.1007/s00464-010-1268-7] [Citation(s) in RCA: 194] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 05/27/2010] [Indexed: 12/13/2022]
Affiliation(s)
- D Wayne Overby
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.
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50
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Abstract
Bile duct injuries incurred during laparoscopic cholecystectomies remain a major complication in an otherwise safe surgery. These injuries are potentially avoidable with proper techniques and correct interpretation of the anatomy. The scope of the injury can range from a simple cystic duct leak to the injury of the left and right hepatic duct confluence. The key to successful outcomes from these injuries is to know when a referral to a specialized tertiary center is necessary. Evaluation and treatment of bile duct injuries is complex and often requires the expertise of an advanced endoscopist, interventional radiologist, and hepatobiliary surgeons. Before any planned intervention or operative repair, detailed evaluation of the biliary system and its associated vasculature is required. Better outcomes are achieved when patients are referred to centers specialized in biliary injury evaluation, treatment, and performing pretreatment planning early.
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Affiliation(s)
- Yuhsin V Wu
- Division of General Surgery, Department of Surgery, Washington University School of Medicine, Surgery House Staff Office, 1701 West Building, Campus Box 8109, 660 South Euclid Avenue, St Louis, MO 63110, USA
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