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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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Bhusal A, Jha SK, Oli R, Paudel B, Ghimire P. Radiological diagnosis and management of postlaparoscopic cholecystectomy right hepatic arterial pseudoaneurysm: A case report. Radiol Case Rep 2024; 19:6259-6264. [PMID: 39387016 PMCID: PMC11461984 DOI: 10.1016/j.radcr.2024.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 08/31/2024] [Accepted: 09/03/2024] [Indexed: 10/12/2024] Open
Abstract
Injuries to blood vessels occur in 0.8% of the cases following laparoscopic cholecystectomy. They may result from direct penetration while insertion of trocar or by thermal injury (electrocautery). Pseudoaneurysm of hepatic artery is a rare occurrence. It is a serious complication following acute or chronic injuries to hepatic artery, with only 0.06% to 0.6% of the cases being reported. Endovascular embolization is usually the first line treatment in the management of pseudoaneurysm of hepatic artery with high success rate. Surgical intervention should be considered if the embolization fails, pseudoaneurysm are infected or other vascular structures are compressed. Our case highlights a 48-year-old male presenting with complaints of pain abdomen and jaundice later diagnosed to be a case of pseudoaneurysm of right hepatic artery and was successfully managed with angiographic embolization, which is the first line of management.
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Affiliation(s)
- Amrit Bhusal
- Department of Radio-diagnostics and Imaging, BP Koirala Institute of Health Sciences (BPKIHS), Dharan, Sunsari, Nepal
| | - Saurav Kumar Jha
- Department of Radiology, Chitwan Medical College Teaching Hospital, Chitwan, Nepal
| | - Rabindra Oli
- Department of Radiology, Nepal Medical College and Teaching Hospital, Attarkhel, Jorpati, Gokarneshwar, Kathmandu, Nepal
| | - Bigyan Paudel
- Department of Radiology, Chitwan Medical College Teaching Hospital, Chitwan, Nepal
| | - Pradesh Ghimire
- Department of Radiology, Chitwan Medical College Teaching Hospital, Chitwan, Nepal
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Jayasekara A, Tillakaratne SB, Dasanayake U, Gishanthan S, Siriwardana RC. The long-term impact of post-cholecystectomy major bile duct injury on liver stiffness. BMC Gastroenterol 2024; 24:413. [PMID: 39558223 PMCID: PMC11571682 DOI: 10.1186/s12876-024-03505-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 11/12/2024] [Indexed: 11/20/2024] Open
Abstract
INTRODUCTION Iatrogenic bile duct injuries (BDI) are a devastating complication. Long-term impact of corrective hepaticojejunostomy (HJ) for such injuries on post -surgery liver stiffness is lacking. Hence the aim of this study was to explore the extent of hepatic fibrosis in a cohort of patients with Strasberg E bile duct injuries who underwent HJ after a minimum follow-up of six months. METHODS Out of 50 BDI presented over a period of 10-years, 19 patients with Strasberg type E, injuries that underwent HJ and completed a minimum 6-month follow-up [65.5 (7 -108)] period were selected. Data were prospectively collected on liver functions and liver stiffness was assessed using a Fibroscan. Their liver stiffness and degree of fibrosis was compared with (n = 38) age, gender and comorbidity matched controls. RESULTS The median age was 47 (30-70) years, with 63% females. Primary HJ was performed in 84%, with a median time from injury to HJ of 7 (1-39) days. The total bilirubin was 16.5 (11.2) µmol/L, Alkaline Phosphatase was 102 (27.2) U/L, and Platelet count was 256 (77) x 103. Liver stiffness (median 6.4 kPa) did not significantly differ from controls (5.3 kPa). Fibrosis assessment revealed comparable distribution of F0 to F3 fibrosis between the study and control groups (F0/F1: 68.4% vs. 84.4%, F2: 10.5% vs. 9.4%). However, all three patients with right hepatic artery injury (p = 0.003) and three of five patients with bile duct stricture had F3/F4 fibrosis. CONCLUSIONS Major BDI repair demonstrates comparable liver fibrosis in the absence of artery injury and anastomotic strictures. Measuring liver fibrosis could be valuable in the presence of arterial injuries or anastomotic strictures.
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Affiliation(s)
- Avinash Jayasekara
- Colombo North Center for Liver Diseases, Department of Surgery, Faculty of Medicine, University of Kelaniya, Thalagolla Road, P.O. Box 6, Ragama, Sri Lanka
| | - Suchintha B Tillakaratne
- Colombo North Center for Liver Diseases, Department of Surgery, Faculty of Medicine, University of Kelaniya, Thalagolla Road, P.O. Box 6, Ragama, Sri Lanka
| | - Uditha Dasanayake
- Colombo North Center for Liver Diseases, Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Shanthamoorthy Gishanthan
- Colombo North Center for Liver Diseases, Department of Surgery, Faculty of Medicine, University of Kelaniya, Thalagolla Road, P.O. Box 6, Ragama, Sri Lanka
| | - Rohan C Siriwardana
- Colombo North Center for Liver Diseases, Department of Surgery, Faculty of Medicine, University of Kelaniya, Thalagolla Road, P.O. Box 6, Ragama, Sri Lanka.
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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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Meira-Júnior JD, Ramos-Aranda J, Carrillo-Vidales J, Velásquez-Coria ER, Mercado MA, Dominguez-Rosado I. BILE DUCT INJURY REPAIR IN A PATIENT WITH SITUS INVERSUS TOTALIS. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2024; 37:e1795. [PMID: 38511812 PMCID: PMC10949928 DOI: 10.1590/0102-672020240002e1795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 11/30/2023] [Indexed: 03/22/2024]
Abstract
BACKGROUND Bile duct injury (BDI) causes significant sequelae for the patient in terms of morbidity, mortality, and long-term quality of life, and should be managed in centers with expertise. Anatomical variants may contribute to a higher risk of BDI during cholecystectomy. AIMS To report a case of bile duct injury in a patient with situs inversus totalis. METHODS A 42-year-old female patient with a previous history of situs inversus totalis and a BDI was initially operated on simultaneously to the lesion ten years ago by a non-specialized surgeon. She was referred to a specialized center due to recurrent episodes of cholangitis and a cholestatic laboratory pattern. Cholangioresonance revealed a severe anastomotic stricture. Due to her young age and recurrent cholangitis, she was submitted to a redo hepaticojejunostomy with the Hepp-Couinaud technique. To the best of our knowledge, this is the first report of BDI repair in a patient with situs inversus totalis. RESULTS The previous hepaticojejunostomy was undone and remade with the Hepp-Couinaud technique high in the hilar plate with a wide opening in the hepatic confluence of the bile ducts towards the left hepatic duct. The previous Roux limb was maintained. Postoperative recovery was uneventful, the drain was removed on the seventh post-operative day, and the patient is now asymptomatic, with normal bilirubin and canalicular enzymes, and no further episodes of cholestasis or cholangitis. CONCLUSIONS Anatomical variants may increase the difficulty of both cholecystectomy and BDI repair. BDI repair should be performed in a specialized center by formal hepato-pancreato-biliary surgeons to assure a safe perioperative management and a good long-term outcome.
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Affiliation(s)
- José Donizeti Meira-Júnior
- Universidade de São Paulo, Digestive Surgery Division, Department of Gastroenterology - São Paulo (SP), Brazil
| | - Javier Ramos-Aranda
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Hepatopancreatobiliary Surgery Division, Mexico City, Mexico
| | - Javier Carrillo-Vidales
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Hepatopancreatobiliary Surgery Division, Mexico City, Mexico
| | - Erik Rodrigo Velásquez-Coria
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Hepatopancreatobiliary Surgery Division, Mexico City, Mexico
| | - Miguel Angel Mercado
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Hepatopancreatobiliary Surgery Division, Mexico City, Mexico
| | - Ismael Dominguez-Rosado
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Hepatopancreatobiliary Surgery Division, Mexico City, Mexico
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Walha K, Facy O, Kazémi A, Ricolfi F, Krausé D, Loffroy R. RETRACTED ARTICLE: False Aneurysm of the Cystic Artery Stump After Laparoscopic Cholecystectomy: Management with Superselective Coil Embolization. J Gastrointest Surg 2023; 27:3113. [PMID: 19495889 DOI: 10.1007/s11605-009-0942-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Accepted: 05/20/2009] [Indexed: 01/31/2023]
Affiliation(s)
- Kamel Walha
- Department of Vascular and Interventional Radiology, University of Dijon School of Medicine, Bocage Teaching Hospital, Dijon, France
| | - Olivier Facy
- Department of Digestive and Oncologic Surgery, University of Dijon School of Medicine, Bocage Teaching Hospital, Dijon, France
| | - Apolline Kazémi
- Department of Vascular and Interventional Radiology, University of Dijon School of Medicine, Bocage Teaching Hospital, Dijon, France
| | - Frédéric Ricolfi
- Department of Vascular and Interventional Radiology, University of Dijon School of Medicine, Bocage Teaching Hospital, Dijon, France
| | - Denis Krausé
- Department of Vascular and Interventional Radiology, University of Dijon School of Medicine, Bocage Teaching Hospital, Dijon, France
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, University of Dijon School of Medicine, Bocage Teaching Hospital, Dijon, France.
- Division of Interventional Radiology and Endovascular Therapy, University of Dijon School of Medicine, Bocage Teaching Hospital, 2 bd du Maréchal de Lattre de Tassigny, BP 77908, 21079 , Dijon Cedex, France.
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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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Sucandy I, Giovannetti A, Spence J, Ross S, Rosemurgy A. Robotic Roux-en-Y Hepaticojejunostomy for Right Hepatic Duct Transection. Application of Minimally Invasive Technique for High Bile Duct Injury. Am Surg 2023; 89:1309-1310. [PMID: 33787353 DOI: 10.1177/0003134820956358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Minimally Invasive bile duct repair is an emerging modern technique in hepatobiliary surgery. Conventional laparoscopic technique had been sporadically reported by high volume surgeons as an alternative to open operation, however, the majority of those repairs were undertaken for biliary injury below the biliary bifurcation. Roux-en-Y Hepaticojejunostomy below the biliary bifurcation is technically much simpler to complete when compared to that above the hilar plate (high bile duct injury). The risk of long-term anastomotic stricture is also higher as bile duct caliber decreases. This is anatomically inherent as we travel further cranial beyond the hilar plate. In this multimedia article, we describe our minimally invasive technique for high bile duct injury repair using robotic technology.
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Affiliation(s)
| | | | - Janelle Spence
- Digestive Health Institute of AdventHealth Tampa, FL, USA
| | - Sharona Ross
- Digestive Health Institute of AdventHealth Tampa, FL, USA
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Tekant Y, Serin KR, İbiş AC, Ekiz F, Baygül A, Özden İ. Surgical reconstruction of major bile duct injuries: Long-term results and risk factors for restenosis. Surgeon 2023; 21:e32-e41. [PMID: 35321812 DOI: 10.1016/j.surge.2022.03.003] [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: 12/21/2021] [Revised: 02/18/2022] [Accepted: 03/02/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND A single-institution retrospective analysis was undertaken to assess long-term results of definitive surgical reconstruction for major bile duct injuries and risk factors for restenosis. METHODS Patients treated between January 1995 and October 2020 were reviewed retrospectively. The primary outcome measure was patency. RESULTS Of 417 patients referred to a tertiary center, 290 (69.5%) underwent surgical reconstruction; mostly in the form of a hepaticojejunostomy (n = 281, 96.8%). Major liver resection was undertaken in 18 patients (6.2%). There were 7 postoperative deaths (2.4%). Patency was achieved in 97.4% of primary repairs and 88.8% of re-repairs. Primary patency at three months (including postoperative deaths and stents removed afterwards) in primary repairs was significantly higher than secondary patency attained during the same period in re-repairs (89.3% vs 76.5%, p < 0.01). The actuarial primary patency was also significantly higher compared to the actuarial secondary patency 10 years after reconstruction (86.7% vs 70.4%, p = 0.001). Vascular disruption was the only independent predictor of loss of patency after reconstruction (OR 7.09, 95% CI 3.45-14.49, p < 0.001), showing interaction with injuries at or above the biliary bifurcation (OR 9.52, 95% CI 2.56-33.33, p < 0.001). CONCLUSIONS Long-term outcome of surgical reconstruction for major bile duct injuries was superior in primary repairs compared to re-repairs. Concomitant vascular injury was independently associated with loss of patency requiring revision.
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Affiliation(s)
- Yaman Tekant
- Hepatopancreatobiliary Surgery Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Kürşat Rahmi Serin
- Hepatopancreatobiliary Surgery Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Abdil Cem İbiş
- Hepatopancreatobiliary Surgery Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Feza Ekiz
- Hepatopancreatobiliary Surgery Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Arzu Baygül
- Department of Biostatistics, Koç University School of Medicine, Istanbul, Turkey; Koç University Research Center for Translational Medicine, Istanbul, Turkey
| | - İlgin Özden
- Hepatopancreatobiliary Surgery Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Rymbai ML, Paul A, M J A, Anantrao AS, John R, Simon B, Joseph AJ, Raju RS, Sitaram V, Joseph P. Post cholecystectomy benign biliary stricture-isolated hepatic duct stricture: a proposed modification of the BISMUTH classification. ANZ J Surg 2023; 93:1306-1313. [PMID: 36694342 DOI: 10.1111/ans.18281] [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: 06/09/2022] [Revised: 12/11/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Post-cholecystectomy, benign biliary strictures are challenging for both patients and surgeons. Bismuth classified benign biliary strictures into 5 types. This study aimed to review these isolated hepatic duct strictures which were not included in Bismuth classification. METHODS The case records of all patients who presented with post-cholecystectomy benign biliary strictures between January 2005 and December 2020 at our centre were reviewed. Data regarding demography, type of stricture, and treatment strategy were entered into the standard proforma. RESULTS There were 242 patients [type I-3.7%, type II-41.7%, type III-38.0%, type IV-6.6%, and type V-7.8%]. Five (2.1%) patients did not fit the Bismuth classification and were the focus of this study. In each of these patients, an isolated hepatic duct stricture (first-or second-order hepatic duct) was present, with no involvement of the common hepatic duct or hilar confluence. CONCLUSIONS The addition of isolated hepatic duct stricture [type VI] to the Bismuth classification will enhance the original classification, help in reporting and management of this sub-set of patients.
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Affiliation(s)
- Manbha L Rymbai
- Department of HPB Surgery, Christian Medical College, Vellore, India
| | - Anoop Paul
- Department of HPB Surgery, Christian Medical College, Vellore, India
| | - Aparna M J
- Department of HPB Surgery, Christian Medical College, Vellore, India
| | | | - Reetu John
- Department of Radiodiagnosis, Christian Medical College, Vellore, India
| | - Betty Simon
- Department of Radiodiagnosis, Christian Medical College, Vellore, India
| | | | | | | | - Philip Joseph
- Department of HPB Surgery, Christian Medical College, Vellore, India
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Callejas GH, Marques RA, Gestic MA, Utrini MP, Chaim FDM, Chaim EA, Callejas-Neto F, Cazzo E. Relationships of hepatic histopathological findings and bile microbiological aspects with bile duct injury repair surgical outcomes: A historical cohort. Ann Hepatobiliary Pancreat Surg 2022; 26:325-332. [PMID: 35851330 PMCID: PMC9721258 DOI: 10.14701/ahbps.22-003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 12/15/2022] Open
Abstract
Backgrounds/Aims To analyze relationships of hepatic histopathological findings and bile microbiological profiles with perioperative outcomes and risk of late biliary stricture in individuals undergoing surgical bile duct injury (BDI) repair. Methods A historical cohort study was carried out at a tertiary university hospital. Fifty-six individuals who underwent surgical BDI repair from 2014-2018 with a minimal follow-up of 24 months were enrolled. Liver biopsies were performed to analyze histopathology. Bile samples were collected during repair procedures. Hepatic histopathological findings and bile microbiological profiles were then correlated with perioperative and late outcomes through uni- and multi-variate analyses. Results Forty-three individuals (76.8%) were females and average age was 47.2 ± 13.2 years; mean follow-up was 38.1 ± 18.6 months. The commonest histopathological finding was hepatic fibrosis (87.5%). Bile cultures were positive in 53.5%. The main surgical technique was Roux-en-Y hepaticojejunostomy (96.4%). Overall morbidity was 35.7%. In univariate analysis, liver fibrosis correlated with the duration of the operation (R = 0.3; p = 0.02). In multivariate analysis, fibrosis (R = 0.36; p = 0.02) and cholestasis (R = 0.34; p = 0.02) independently correlated with operative time. Strasberg classification independently correlated with estimated bleeding (R = 0.31; p = 0.049). The time elapsed between primary cholecystectomy and BDI repair correlated with hepatic fibrosis (R = 0.4; p = 0.01). Conclusions Bacterial contamination of bile was observed in most cases. The degree of fibrosis and cholestasis correlated with operative time. The waiting time for definitive repair correlated with the severity of liver fibrosis.
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Affiliation(s)
| | - Rodolfo Araujo Marques
- Department of Surgery, School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Martinho Antonio Gestic
- Department of Surgery, School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Murillo Pimentel Utrini
- Department of Surgery, School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | | | - Elinton Adami Chaim
- Department of Surgery, School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Francisco Callejas-Neto
- Department of Surgery, School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Everton Cazzo
- Department of Surgery, School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, Brazil,Corresponding author: Everton Cazzo, MD, PhD Department of Surgery, School of Medical Sciences, State University of Campinas (UNICAMP), Cidade Universitária Zeferino Vaz - Barão Geraldo, Campinas 13085-000, Brazil Tel: +55-1935219450, Fax: +55-1935219448, E-mail: ORCID: https://orcid.org/0000-0002-5804-1580
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12
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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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Postoperative liver function tests can predict anastomotic dysfunction after bile duct injury repair. Updates Surg 2022; 74:937-944. [PMID: 35415799 DOI: 10.1007/s13304-022-01275-9] [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: 10/19/2021] [Accepted: 03/07/2022] [Indexed: 12/07/2022]
Abstract
Liver function tests help in the follow-up of postoperative patients with iatrogenic bile duct injury. There is not clear evidence regarding their predictive role on anastomosis dysfunction. We describe our experience with postoperative liver function tests and a predictive model of long-term patency after repair. This is retrospective cohort study of patients with bilioenteric anastomosis for bile duct injury and their long-term follow-up. A binomial logistic regression model was performed to ascertain the effects of the grade of bile duct injury and liver function test in the postoperative period. A total of 329 patients were considered for the analysis. In the logistic regression model two predictor variables were statistically significant for anastomosis stenosis: type of bilioenteric anastomosis and alkaline phosphatase levels. A ROC curve analysis was made for alkaline phosphatase with an area under the curve of 0.758 (95% CI 0.67-0.84). A threshold of 323 mg/dL was established (OR 6.0, 95% CI 2.60-13.83) with a sensitivity of 75%, specificity of 67%, PPV of 20%, NPV of 96%, PLR of 2.27 and NLR of 0.37. Increased alkaline phosphatase (above 323 mg/dL) after the fourth operative week was found to be a predictor of long-term dysfunction.
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Choudhary SR, Bhujade H, Gupta P, Singh H, Kalra N, Kang M. A Challenging Case of Postcholecystectomy Pseudoaneurysm at an Uncommon Location. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2022. [DOI: 10.1055/s-0042-1742728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractHepatic artery pseudoaneurysm in postcholecystectomy choleduodenal fistula is an extremely rare but clinically significant complication. A 52-year-old male presented with hematemesis and melena several weeks after open cholecystectomy for complicated gallstone disease. Upper gastrointestinal endoscopy revealed bleeding from the choledochoduodenal fistula site. On computed tomography angiography, a small right hepatic artery pseudoaneurysm close to fistula site was identified. Endovascular embolization failed due to nonopacification of the proximal right hepatic artery. Endoscopic ultrasound-guided embolization was also unsuccessful due to the small size of the aneurysm and inadequate visualization. Following this, percutaneous n-butyl cyanoacrylate glue was successfully injected into the pseudoaneurysm. The patient recovered and was planned for hepaticojejunostomy to restore biliary continuity.
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Affiliation(s)
- Shayeri Roy Choudhary
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Harish Bhujade
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Harjeet Singh
- Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Naveen Kalra
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mandeep Kang
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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15
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Lopez-Lopez V, Ferreras D, Lopez-Conesa A, Brusadin R, Cutillas J, Robles-Campos R. Long-term outcomes in the repair of intrahepatic iatrogenic bile duct lesions using a combined intraglissonian and extraglissonian approach. Langenbecks Arch Surg 2022; 407:403-408. [PMID: 33963887 DOI: 10.1007/s00423-021-02188-8] [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] [Received: 03/11/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
PURSPOSE Iatrogenic bile duct injuries (IBDI) with intrahepatic involvement are a serious and challenging surgical complication that can have disastrous consequences in terms of morbidity and mortality. METHODS We collected the patients with IBDI type (E4) between January 1991 and March 2020 in our hospital. The objective of the study was to present the long-term results of a extraglissonian approach and intraglissonian biliary reconstruction in a series of patients with intrahepatic bile duct injuries after cholecystectomy. We also detail our preoperative management and the standardization of the technique. RESULTS An extraglissonian approach with partial hepatic resection of the base of segments 4b and 5 and intraglissonian Roux-en-Y hepaticojejunostomy for biliary reconstruction using to several branches was performed in 10 patients with E4 Strassberg type intrahepatic lesions. Only one patient had postoperative bile leak (Clavien 3a). Surgical time was 260 min (IQR, 210-490). We left transanastomotic catheter (between 2 and 5) in situ for 3 and 6 months after surgery. The patients remained asymptomatic over a median follow-up of 169 months (IQR 129-234). CONCLUSION This biliary reconstruction technique obtains positive long-term outcomes in patients with severe intrahepatic lesions.
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Affiliation(s)
- Víctor Lopez-Lopez
- Department of Surgery. HBP Unit, Virgen de la Arrixaca University Hospital, IMIB-Arrixaca, Murcia, Spain.
| | - David Ferreras
- Department of Surgery. HBP Unit, Virgen de la Arrixaca University Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Asuncion Lopez-Conesa
- Department of Surgery. HBP Unit, Virgen de la Arrixaca University Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Roberto Brusadin
- Department of Surgery. HBP Unit, Virgen de la Arrixaca University Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Jose Cutillas
- Department of Surgery. HBP Unit, Virgen de la Arrixaca University Hospital, IMIB-Arrixaca, Murcia, Spain
| | - Ricardo Robles-Campos
- Department of Surgery. HBP Unit, Virgen de la Arrixaca University Hospital, IMIB-Arrixaca, Murcia, Spain
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16
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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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Cirocchi R, Panata L, Griffiths EA, Tebala GD, Lancia M, Fedeli P, Lauro A, Anania G, Avenia S, Di Saverio S, Burini G, De Sol A, Verdelli AM. Injuries during Laparoscopic Cholecystectomy: A Scoping Review of the Claims and Civil Action Judgements. J Clin Med 2021; 10:5238. [PMID: 34830520 PMCID: PMC8622805 DOI: 10.3390/jcm10225238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND To define what type of injuries are more frequently related to medicolegal claims and civil action judgments. METHODS We performed a scoping review on 14 studies and 2406 patients, analyzing medicolegal claims related to laparoscopic cholecystectomy injuries. We have focalized on three phases associated with claims: phase of care, location of injuries, type of injuries. RESULTS The most common phase of care associated with litigation was the improper intraoperative surgical performance (47.6% ± 28.3%), related to a "poor" visualization, and the improper post-operative management (29.3% ± 31.6%). The highest rate of defense verdicts was reported for the improper post-operative management of the injury (69.3% ± 23%). A lower rate was reported in the incorrect presurgical assessment (39.7% ± 24.4%) and in the improper intraoperative surgical performance (21.39% ± 21.09%). A defense verdict was more common in cystic duct injuries (100%), lower in hepatic bile duct (42.9%) and common bile duct (10%) injuries. CONCLUSIONS During laparoscopic cholecystectomy, the most common cause of claims, associated with lower rate of defense verdict, was the improper intraoperative surgical performance. The decision to take legal action was determined often for poor communication after the original incident.
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Affiliation(s)
- Roberto Cirocchi
- Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (R.C.); (M.L.); (S.A.)
| | - Laura Panata
- Legal Medicine and Insurance Office, Santa Maria della Misericordia Hospital, 06129 Perugia, Italy; (L.P.); (A.M.V.)
| | - Ewen A. Griffiths
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham B15 2GW, UK;
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Giovanni D. Tebala
- Surgical Emergency Unit, John Radcliffe Hospital, Oxford University NHS Foundation Trust, Oxford OX3 9DU, UK;
| | - Massimo Lancia
- Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (R.C.); (M.L.); (S.A.)
| | - Piergiorgio Fedeli
- School of Law, Legal Medicine, University of Camerino, 62032 Camerino, Italy;
| | - Augusto Lauro
- Department of Surgical Sciences, Hospital “Policlinico Umberto I”, “Sapienza” University of Rome, 00161 Rome, Italy;
| | - Gabriele Anania
- Department of Medical Science, University of Ferrara, 44121 Ferrara, Italy;
| | - Stefano Avenia
- Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (R.C.); (M.L.); (S.A.)
| | - Salomone Di Saverio
- Department of General Surgery, ASUR Marche, AV5, Hospital of San Benedetto del Tronto, 63074 San Benedetto del Tronto, Italy;
| | - Gloria Burini
- Department of General and Emergency Surgery, Hospital “Ospedali Riuniti di Ancona”, 60126 Ancona, Italy
| | - Angelo De Sol
- Department of General Surgery, St. Maria Hospital, 05100 Terni, Italy;
| | - Anna Maria Verdelli
- Legal Medicine and Insurance Office, Santa Maria della Misericordia Hospital, 06129 Perugia, Italy; (L.P.); (A.M.V.)
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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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19
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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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20
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Anand U, Kumar R, Priyadarshi RN, Kumar M, Kumar R, Ahmed N, John AG, Parasar K, Kumar B. Analysis of outcomes of biliary reconstruction after post-cholecystectomy bile duct injuries. ANZ J Surg 2021; 91:1542-1548. [PMID: 34184389 DOI: 10.1111/ans.17047] [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] [Received: 01/12/2021] [Revised: 06/10/2021] [Accepted: 06/17/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Post-cholecystectomy bile duct injury (BDI) is a serious complication that often requires surgical repair. This study aimed to analyze the outcomes of surgery performed for BDI and to determine the factors associated with post-surgical complications. METHODS A retrospective analysis was conducted using a prospectively maintained database of 105 patients who underwent surgical repair for post-cholecystectomy BDI between March 2013 and March 2020. BDI was classified based on the Strasberg-Bismuth system, and the outcomes were graded using the McDonald criteria. Multivariable logistic regression was used to identify the significant variables associated with postoperative complications. RESULTS In a cohort of 105 patients with post-cholecystectomy BDI who underwent bilioenteric repair, 71 (67.6%), 25 (23.8%), 2 (1.9%), and 7 (6.7%) patients had excellent, good, fair, and poor outcomes, respectively, during a median follow-up of 64 months. The incidence of recurrent biliary stricture after definitive surgical hepaticojejunostomy was 6.7% (n = 7). The presence of cholangitis, choledochoduodenal fistula, and hilar biliary strictures was among the significant variables associated with the development of both short-term and long-term complications following surgery. CONCLUSIONS Surgical repair of BDIs with bilioenteric anastomosis can yield excellent results when managed in a tertiary care center where expertise in the reconstruction of the biliary tree is prioritized.
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Affiliation(s)
- Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | | | - Manoj Kumar
- Department of General Surgery, All India Institute of Medical Sciences, Patna, India
| | - Rakesh Kumar
- Senior Specialist Medical Officer, CHC Minapur, Muzaffarpur, India
| | - Nehal Ahmed
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Aaron George John
- 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
| | - Bindey Kumar
- Department of Paediatric Surgery, All India Institute of Medical Sciences, Patna, India
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21
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Burasakarn P, Higuchi R, Yazawa T, Uemura S, Izumo W, Matsunaga Y, Yamamoto M. Hepatic artery resection without reconstruction in pancreatoduodenectomy. Langenbecks Arch Surg 2021; 406:2081-2090. [PMID: 33932159 DOI: 10.1007/s00423-021-02178-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 04/18/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE It has been reported that there are left and right hepatic arterial arcades via the blood vessels around the hilar bile duct; therefore, when the hilar bile duct is preserved, hepatic artery reconstruction may not be necessary. We compared the short-term and long-term outcomes in patients with distal cholangiocarcinoma who underwent pancreatoduodenectomy (PD) with right hepatic artery resection without right hepatic artery reconstruction (RHAR group) with those patients who underwent conventional PD. METHODS All data were retrospectively collected from patient records. A 1:4-propensity score-matched case-control study was conducted in patients with distal cholangiocarcinoma who received treatment at Tokyo Women's Medical University from February 1985 to April 2015. RESULTS There was no statistical difference in the overall morbidity rate between the two groups. No patient in the RHAR group (10 patients) had liver failure, liver abscess, or cholangitis in the postoperative period; one patient died postoperatively because of a bleeding pseudoaneurysm in the gastroduodenal artery. The PD group (40 patients) had a significantly better median time regarding the recurrence (34 vs. 11 months, p=0.027) and 5-year disease-free survival (35% vs. 10%, p=0.027) rates than the RHAR group, which may be attributed to the presence of a more severe disease in patients in the RHAR group. CONCLUSION We concluded that pancreaticoduodenectomy with right hepatic artery resection without reconstruction has a comparable overall morbidity rate with that of a conventional pancreaticoduodenectomy surgery and may be performed as an alternative procedure when tumor invasion of the right hepatic artery is suspected.
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Affiliation(s)
- Pipit Burasakarn
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.,Division of HPB Surgery, Department of Surgery, Phramongkutklao Hospital, Bangkok, Thailand
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Takehisa Yazawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shuichiro Uemura
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Wataru Izumo
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yutaro Matsunaga
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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22
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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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El Nakeeb A, Sultan A, Ezzat H, Attia M, Abd ElWahab M, Kayed T, Hassanen A, AlMalki A, Alqarni A, Mohammed MM. Impact of referral pattern and timing of repair on surgical outcome after reconstruction of post-cholecystectomy bile duct injury: A multicenter study. Hepatobiliary Pancreat Dis Int 2021; 20:53-60. [PMID: 33268245 DOI: 10.1016/j.hbpd.2020.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 10/09/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Bile duct injury (BDI) after cholecystectomy remains a significant surgical challenge. No guideline exists to guide the timing of repair, while few studies compare early versus late repair BDI. This study aimed to analyze the outcomes in patients undergoing immediate, intermediate, and delayed repair of BDI. METHODS We retrospectively analyzed 412 patients with BDI from March 2015 to January 2020. The patients were divided into three groups based on the time of BDI reconstruction. Group 1 underwent an immediate reconstruction (within the first 72 hours post-cholecystectomy, n = 156); group 2 underwent an intermediate reconstruction (from 4 days to 6 weeks post-cholecystectomy, n = 75), and group 3 underwent delayed reconstruction (after 6 weeks post-cholecystectomy, n = 181). RESULTS Patients in group 2 had significantly more early complications including anastomotic leakage and intra-abdominal collection and late complications including anastomotic stricture and secondary liver cirrhosis compared with groups 1 and 3. Favorable outcome was observed in 111 (71.2%) patients in group 1, 31 (41.3%) patients in group 2, and 157 (86.7%) patients in group 3 (P = 0.0001). Multivariate analysis identified that complete ligation of the bile duct, level E1 BDI and the use of external stent were independent factors of favorable outcome in group 1, the use of external stent was an independent factor of favorable outcome in group 2, and level E4 BDI was an independent factor of unfavorable outcome in group 3. Transected BDI and level E4 BDI were independent factors of unfavorable outcome. CONCLUSIONS Favorable outcomes were more frequently observed in the immediate and delayed reconstruction of post-cholecystectomy BDI. Complete ligation of the bile duct, level E1 BDI and the use of external stent were independent factors of a favorable outcome.
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Affiliation(s)
- Ayman El Nakeeb
- Gastrointestinal Surgical Center, Mansoura University, Mansoura, Egypt.
| | - Ahmad Sultan
- Gastrointestinal Surgical Center, Mansoura University, Mansoura, Egypt
| | - Helmy Ezzat
- Gastrointestinal Surgical Center, Mansoura University, Mansoura, Egypt
| | - Mohamed Attia
- Gastrointestinal Surgical Center, Mansoura University, Mansoura, Egypt
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Sarasammal S, Thampi S, Krishnapillai R, Murugesan R, vilakom Govindapillai U. Clinical Significance of Origin of Cystic Artery and its Relations to Calot's Triangle. NATIONAL JOURNAL OF CLINICAL ANATOMY 2021. [DOI: 10.4103/njca.njca_48_20] [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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Ma KW, So H, Cho DH, Oh JS, Cheung TT, Park DH. Durability and outcome of endoscopic ultrasound-guided hepaticoduodenostomy using a fully covered metal stent for segregated right intrahepatic duct dilatation. J Gastroenterol Hepatol 2020; 35:1753-1760. [PMID: 32365417 DOI: 10.1111/jgh.15089] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/04/2020] [Accepted: 04/27/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Segregated right intrahepatic duct dilatation (IHD) results from complete obstruction of the biliary tract proximal to the hilar level. We aimed to evaluate long-term efficacy and safety of endoscopic ultrasound (EUS) hepaticoduodenostomy (HDS) in segregated right IHD. METHODS Consecutive patients who had undergone EUS-guided HDS with a fully covered self-expandable metal stent (FCSEMS) in an academic tertiary center were recruited. All patients had segregated right hepatic duct and failed drainage by endoscopic retrograde cholangiopancreatography (ERCP). Demographic data, endoscopic findings, procedure details, and outcome data were extracted from a prospectively maintained database. RESULTS From 2013 to 2017, there were 35 patients who had undergone EUS-guided HDS with a median follow-up duration of 169 (3-2091) days. Malignancy accounted for 71.4% of the ductal segregation, followed by surgical complication (17.1%). Technical and clinical success rate was 97.1% and 80%, respectively. Early adverse event (AE) happened in seven patients (20%), two of them required endoscopic reintervention, and no percutaneous transhepatic biliary drainage (PTBD) or surgery was performed because of AE. The median stent patency duration was 331 (3-1202) days. The median duration of fistula tract keeping was 1280 (3-1280) days. There was no significant difference in terms of patency rate with respect to whether the underlying pathology was benign or malignant (P = 0.776). EUS-guided HDS for right posterior sectional duct segregation was associated with higher 3-month stent patency rate when compared with right anterior sectional duct (79.1% vs 38.1%, P = 0.012). CONCLUSION Endoscopic ultrasound-guided HDS with an FCSEMS appears to be a safe and effective treatment as a viable alternative option to PTBD after failed ERCP. It creates a durable and reliable fistula tract for permanent access to an isolated ductal system, and this application deserves more attention.
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Affiliation(s)
- Ka Wing Ma
- Department of Surgery, The University of Hong Kong, Hong Kong
| | - Hoonsub So
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea
| | - Dong Hui Cho
- Division of Gastroenterology, Department of Internal Medicine, Hyundae General Hospital, Chung-Ang University, Namyangju, Korea
| | - Jin Sun Oh
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea
| | - Tan To Cheung
- Department of Surgery, The University of Hong Kong, Hong Kong
| | - Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea
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Tidjane A, Boudjenan Serradj N, Ikhlef N, Benmaarouf N, Tabeti B. Factors influencing the occurrence of biliary stricture above the confluence in major bile ducts injuries: Analysis of a case series. Ann Med Surg (Lond) 2020; 57:334-338. [PMID: 32874566 PMCID: PMC7452105 DOI: 10.1016/j.amsu.2020.07.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/08/2020] [Indexed: 11/30/2022] Open
Abstract
Background bile duct injury is a complication that occurs mainly after cholecystectomy. Outcomes of biliary repair surgery are worse when the stricture level is above the biliary confluence. Method A single centred retrospective study was carried out on patients operated in our department for biliary stricture after a major bile duct injury over the period from January 2010 to May 2018. Only patients operated for biliary stricture were included. This study aimed to determine the independent factors influencing the occurrence of a stricture above de biliary confluence. Univariate and multivariate binary regression was used for data analysis. Results Fifty-three patients were included, they were 43 women and 10 men, sex-ratio was 0.23. Thirty-one patients had Grade E3-E4-E5 stricture (58,5%), and patients who had a failure of a previous repair surgery accounted for 36% (n = 19) of our patients.After univariate and multivariate analysis, only laparoscopic cholecystectomy (OR = 7.58, CI = [1.47-38, 91], P = 0.015) and failure of anterior biliary repair surgery (OR = 7, 12, CI = [1.29-39.42], P = 0.025) were independent factors associated with more frequent occurrence of biliary strictures above the confluence. Conclusion Failure of biliary repair surgery makes the pre-existing biliary stricture progress and compromises subsequent surgery's outcomes. It is important to refer all cases of bile duct injury to specialized centers to increase the chances of success of the first biliary repair surgery.
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Affiliation(s)
- Anisse Tidjane
- Department of Hepatobiliary Surgery and Liver Transplantation, EHU-1st November 1954, Department of Medicine, University of Oran 1, Oran, Algeria
| | - Nabil Boudjenan Serradj
- Department of Hepatobiliary Surgery and Liver Transplantation, EHU-1st November 1954, Department of Medicine, University of Oran 1, Oran, Algeria
| | - Nacim Ikhlef
- Department of Hepatobiliary Surgery and Liver Transplantation, EHU-1st November 1954, Department of Medicine, University of Oran 1, Oran, Algeria
| | - Noureddine Benmaarouf
- Department of Hepatobiliary Surgery and Liver Transplantation, EHU-1st November 1954, Department of Medicine, University of Oran 1, Oran, Algeria
| | - Benali Tabeti
- Department of Hepatobiliary Surgery and Liver Transplantation, EHU-1st November 1954, Department of Medicine, University of Oran 1, Oran, Algeria
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Nasa M, Sharma ZD, Gupta M, Puri R. Bile Duct Injury—Classification and Prevention. JOURNAL OF DIGESTIVE ENDOSCOPY 2020. [DOI: 10.1055/s-0040-1709949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractIatrogenic bile duct injuries (BDI) are commonly encountered after laparoscopic cholecystectomy. Timely recognition of these injuries is important as the outcome depends on the optimal management and there is significant impact on the patient’s quality of life. Therapeutic management is guided by the type and extent of the bile duct injury and availability of expertise, and includes involvement of endoscopic, surgical, and radiological approaches.
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Affiliation(s)
- Mukesh Nasa
- Institute of Digestive and Biliary Sciences, Medanta—The Medicity, Gurugram, India
| | - Zubin Dev Sharma
- Institute of Digestive and Biliary Sciences, Medanta—The Medicity, Gurugram, India
| | - Mahesh Gupta
- Institute of Digestive and Biliary Sciences, Medanta—The Medicity, Gurugram, India
| | - Rajesh Puri
- Institute of Digestive and Biliary Sciences, Medanta—The Medicity, Gurugram, India
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[Hematochezia and right-sided upper abdominal pain after puncture of a liver abscess in a 75-year-old male]. Internist (Berl) 2020; 61:513-517. [PMID: 32246182 DOI: 10.1007/s00108-020-00781-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This article presents the case of a 75-year-old male patient, who underwent a percutaneous abscess puncture of a liver abscess. A few days after the puncture and drainage there was a sudden onset of right upper quadrant abdominal pain accompanied by hematochezia. The patient presented with markedly elevated liver enzyme levels and a significant drop in hemoglobin concentration. After gastroscopy and abdominal computed tomography (CT) in the portal venous phase no bleeding source could be identified. A false aneurysm of the cystic artery was identified only after a CT angiography of the abdomen. Due to spontaneous cessation of the bleeding a cholecystectomy was subsequently performed for definitive treatment of the false aneurysm.
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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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Gupta V, Gupta V, Joshi P, Kumar S, Kulkarni R, Chopra N, Pavankumar G, Chandra A. Management of post cholecystectomy vascular injuries. Surgeon 2019; 17:326-333. [PMID: 30396859 DOI: 10.1016/j.surge.2018.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 09/30/2018] [Accepted: 10/05/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Vasculobiliary and vascular injuries following cholecystectomy are the most serious complications requiring complex surgical management resulting in greater patient morbidity and mortality. METHODOLOGY The study was performed at a tertiary teaching hospital of North India. Records of patients referred for biliary or vascular injury sustained during cholecystectomy were reviewed retrospectively to identify patients with vascular injury between January 2009 and March 2018. Clinical profile, hospital course and outcome of these patients were analysed. RESULTS Over nine years, 117 patients were referred for cholecystectomy related complications. Total incidence of vascular injury was 5.1% (6/117). Combined vasculobiliary injury (VBI) occurred in 3.4% (4/117) while isolated vascular injury was present in 1.7% patients (2/117). Most (5/6) patients were operated for uncomplicated gall stone disease. Incidences of portal vein (PV) and right hepatic artery (RHA) injuries were equal (3/6). PV injuries were repaired either during cholecystectomy (1/3) or during re-exploration after damage control packing (2/3). RHA injuries presented as pseudoaneurysm and were managed surgically (2/3) or by coil embolization (1/3). All VBI referrals (4/117) were following open cholecystectomy. In VBI patients, vascular injury was diagnosed intra-operatively in two while it was diagnosed several weeks after cholecystectomy in two others. Biliary injury manifested as bile leak post-operatively in all four of them. Nature of biliary injury could be characterized in only 50% (2/4) patients. Definitive repair of biliary injury was performed in one patient only. There was one mortality in our series. CONCLUSION Vascular injury is an uncommon complication of cholecystectomy with catastrophic outcome if not managed timely and properly. Adequate surgeon training, keeping the possibility of aberrant vasculobiliary anatomy in all cases, and proper surgical technique is crucial for prevention of such injuries. However in such an event, proper documentation and referral to tertiary centre will help in decreasing morbidity and further litigation.
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Affiliation(s)
- Vishal Gupta
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
| | - Vivek Gupta
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
| | - Pradeep Joshi
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
| | - Saket Kumar
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
| | - Rugved Kulkarni
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
| | - Nikhil Chopra
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
| | - G Pavankumar
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
| | - Abhijit Chandra
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
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Abstract
Bile duct injuries can occur after abdominal trauma, postoperatively after cholecystectomy, liver resection or liver transplantation and also as a complication of endoscopic retrograde cholangiopancreatography (ERCP). The clinical appearance of bile duct injuries is highly variable and depends primarily on the underlying cause. In addition to the high perioperative morbidity, following successful initial complication management, bile duct injuries can lead to significant long-term complications. The treatment requires close interdisciplinary cooperation between surgery, interventional gastroenterology and interventional radiology. The treatment of bile duct injuries depends primarily on the time of diagnosis (intraoperative/postoperative) as well as the extent of the injury and is discussed in this review.
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Lubikowski J, Piotuch B, Stadnik A, Przedniczek M, Remiszewski P, Milkiewicz P, Silva MA, Wojcicki M. Difficult iatrogenic bile duct injuries following different types of upper abdominal surgery: report of three cases and review of literature. BMC Surg 2019; 19:162. [PMID: 31694627 PMCID: PMC6833182 DOI: 10.1186/s12893-019-0619-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/10/2019] [Indexed: 12/14/2022] Open
Abstract
Background Iatrogenic bile duct injuries (BDIs) are mostly associated with laparoscopic cholecystectomy but may also occur following gastroduodenal surgery or liver resection. Delayed diagnosis of type of injury with an ongoing biliary leak as well as the management in a non-specialized general surgical units are still the main factors affecting the outcome. Case presentation Herein we present three types of BDIs (Bismuth type I, IV and V) following three different types of upper abdominal surgery, ie. Billroth II gastric resection, laparoscopic cholecystectomy and left hepatectomy. All of them were complex injuries with complete bile duct transections necessitating surgical treatment. All were also very difficult to treat mainly because of a delayed diagnosis of type of injury, associated biliary leak and as a consequence severe inflammatory changes within the liver hilum. The treatment was carried out in our specialist hepatobiliary unit and first focused on infection and inflammation control with adequate biliary drainage. This was followed by a delayed surgical repair with the technique which had to be tailored to the type of injury in each case. Conclusion We emphasize that staged and individualized treatment strategy is often necessary in case of a delayed diagnosis of complex BDIs presenting with a biliary leak, inflammatory intraabdominal changes and infection. Referral of such patients to expert hepatobiliary centres is crucial for the outcome.
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Affiliation(s)
- Jerzy Lubikowski
- Department of General and Oncological Surgery, Pomeranian Medical University, Szczecin, Poland.,Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, M. Curie Hospital, Szczecin, Poland
| | - Bernard Piotuch
- Department of Surgery, Ministry of the Interior and Administration Hospital, Szczecin, Poland.,Department of General and Hand Surgery, Pomeranian Medical University, Szczecin, Poland
| | - Anna Stadnik
- Department of Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Marta Przedniczek
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland
| | - Piotr Remiszewski
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland
| | - Piotr Milkiewicz
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland.,Translational Medicine Group, Pomeranian Medical University, Szczecin, Poland
| | - Michael A Silva
- Department of Hepatobiliary and Pancreatic Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Maciej Wojcicki
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland.
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Pereira F, Venales Y, Salazar F. Detalles técnicos de la doble hepático – yeyuno anastomosis en Y de Roux, con base en la descripción de un caso. REVISTA COLOMBIANA DE CIRUGÍA 2019. [DOI: 10.30944/20117582.112] [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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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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Otto W, Sierdziński J, Smaga J, Dudek K, Zieniewicz K. Long-term effects and quality of life following definitive bile duct reconstruction. Medicine (Baltimore) 2018; 97:e12684. [PMID: 30313064 PMCID: PMC6203466 DOI: 10.1097/md.0000000000012684] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The study covered a cohort of 236 patients with transection of hepatic duct. It aimed to assess the long-term outcome of the reconstruction and a patient's quality of life.The literature contains many controversies over timing of biliary reconstruction and who ought to repair the injury but just few reports on the long-term outcomes and patient's quality of life.The bile duct system was reconstructed by hepaticojejunostomy in 236 patients. Of these, 139 patients were initially repaired at a public hospital and referred because of stricture (Group A, N = 59) or of an anastomosis dehiscence (Group B, N = 80); 97 were unrepaired and referred because of a surgical clip occluding the duct (Group C, N = 39) or bile leakage from an open duct (Group D, N = 58). All patients were surveyed in 2015 for quality of life using WHOQOL-BREF.The mean time of follow-up was 150 months. The time without symptoms amounted to >5 years in 78.6% of patients. The mean time before anastomosis renewal ranged from 8.9 to 4.7 years (P < .04). Multivariate analysis showed infection, failure of reconstruction in public hospital, and female sex as factors responsible for poor long-term outcome.Patients in Group C had better quality of life than the others (P < .001) with respect to physical health (median 67.85) and psychological condition (median 79.16). The overall mortality was 15.2%.The long-term result of reconstruction depends on the cause of referral which, in turn, arises from subsequent intervention taken in local hospitals.
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Affiliation(s)
| | | | - Justyna Smaga
- Central Teaching Hospital, Medical University of Warsaw, Poland, Warsaw, Banacha 1a, Poland
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Balla A, Quaresima S, Corona M, Lucatelli P, Fiocca F, Rossi M, Bezzi M, Catalano C, Salvatori FM, Fingerhut A, Paganini AM. ATOM Classification of Bile Duct Injuries During Laparoscopic Cholecystectomy: Analysis of a Single Institution Experience. J Laparoendosc Adv Surg Tech A 2018; 29:206-212. [PMID: 30256167 DOI: 10.1089/lap.2018.0413] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Bile duct injuries (BDIs) are more frequent during laparoscopic cholecystectomy (LC). Several BDI classifications are reported, but none encompasses anatomy of damage and vascular injury (A), timing of detection (To), and mechanism of damage (M). Aim was to apply the ATOM classification to a series of patients referred for BDI management after LC. METHODS From 2008 to 2016, 26 patients (16 males and 10 females, median age 63 years, range 34-82 years) with BDIs were observed. Fifteen patients were managed by percutaneous transhepatic cholangiography (PTC)+endoscopic retrograde cholangiopancreatography (ERCP); five and six underwent PTC and ERCP alone, respectively. Median overall follow-up duration was 34 months. Three patients died from sepsis. RESULTS Out of 26 patients, 20 presented with main bile duct and six with nonmain bile duct injuries. Using the ATOM classification, every aspect of the BDI in every case was included, unlike with other classifications (Neuhaus, Lau, Strasberg, Bergman, and Hanover). CONCLUSIONS The all-inclusive European Association for Endoscopic Surgery (EAES) classification contains objective data and emphasizes the underlying mechanisms of damage, which is relevant for prevention. It also integrates vascular injury, necessary for ultimate management, and timing of discovery, which has diagnostic implications. The management complexity of these patients requires specialized referral centers.
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Affiliation(s)
- Andrea Balla
- 1 Department of General Surgery and Surgical Specialties "Paride Stefanini," Sapienza University of Rome , Rome, Italy
| | - Silvia Quaresima
- 1 Department of General Surgery and Surgical Specialties "Paride Stefanini," Sapienza University of Rome , Rome, Italy
| | - Mario Corona
- 2 Vascular and Interventional Radiology Unit, Department of Radiologic Sciences, Sapienza University of Rome , Rome, Italy
| | - Pierleone Lucatelli
- 2 Vascular and Interventional Radiology Unit, Department of Radiologic Sciences, Sapienza University of Rome , Rome, Italy
| | - Fausto Fiocca
- 1 Department of General Surgery and Surgical Specialties "Paride Stefanini," Sapienza University of Rome , Rome, Italy
| | - Massimo Rossi
- 1 Department of General Surgery and Surgical Specialties "Paride Stefanini," Sapienza University of Rome , Rome, Italy
| | - Mario Bezzi
- 2 Vascular and Interventional Radiology Unit, Department of Radiologic Sciences, Sapienza University of Rome , Rome, Italy
| | - Carlo Catalano
- 2 Vascular and Interventional Radiology Unit, Department of Radiologic Sciences, Sapienza University of Rome , Rome, Italy
| | - Filippo M Salvatori
- 2 Vascular and Interventional Radiology Unit, Department of Radiologic Sciences, Sapienza University of Rome , Rome, Italy
| | - Abe Fingerhut
- 3 Section for Surgical Research, Department of Surgery, Medical University of Graz , Graz, Austria
| | - Alessandro M Paganini
- 1 Department of General Surgery and Surgical Specialties "Paride Stefanini," Sapienza University of Rome , Rome, Italy
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Renz BW, Bösch F, Angele MK. Bile Duct Injury after Cholecystectomy: Surgical Therapy. Visc Med 2017; 33:184-190. [PMID: 28785565 PMCID: PMC5527188 DOI: 10.1159/000471818] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Iatrogenic bile duct injuries (IBDI) after laparoscopic cholecystectomy (LC), being one of the most common performed surgical procedures, remain a substantial problem in gastrointestinal surgery. The most important aspect regarding this issue is the prevention of IBDI during index cholecystectomy. Once it occurs, early and accurate diagnosis of IBDI is very important for surgeons and gastroenterologists, because unidentified IBDI may result in severe complications such as hepatic failure and death. Laboratory tests, radiological imaging, and endoscopy play an important role in the diagnosis of biliary injuries. METHODS This review summarizes and discusses the current literature on the management of IBDI after LC from a surgical point of view. RESULTS AND CONCLUSION In general, endoscopic techniques are recommended for the initial diagnosis and treatment of IBDI and are important to classify them correctly. In patients with complete dissection or obstruction of the bile duct, surgical management remains the only feasible option. Different surgical reconstructions are performed in patients with IBDI. According to the available literature, Roux-en-Y hepaticojejunostomy is the most frequent surgical reconstruction and is recommended by most authors. Long-term results are most important in the assessment of effectiveness of IBDI treatment. Apart from that, adequate diagnosis and treatment of IBDI may avoid many serious complications and improve the quality of life of our patients.
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Affiliation(s)
| | | | - Martin K. Angele
- Department of General, Visceral, Vascular and Transplantation Surgery, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
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Timing of Surgical Repair After Bile Duct Injury Impacts Postoperative Complications but Not Anastomotic Patency. Ann Surg 2017; 264:544-53. [PMID: 27433902 DOI: 10.1097/sla.0000000000001868] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Our goal was to determine the optimal timing for repair of bile duct injuries sustained during cholecystectomy. BACKGROUND Bile duct injury during cholecystectomy is a serious complication that often requires surgical repair. There is heterogeneity in the literature regarding the optimal timing of surgical repair, and it remains unclear to what extent timing determines postoperative morbidity and long-term anastomotic function. METHODS A single institution prospective database was queried for all E1 to E4 injuries from 1989 to 2014 using a standardized tabular reporting format. Timing was stratified into 3 groups [early (<7 days), intermediate (8 days until 6 weeks), and late (>6 weeks) after injury]. Analysis was stratified between those who had a previous bile duct repair or not, including postoperative complications and anastomotic failure as outcome variables in 2 separate multivariate logistic regression models. RESULTS There were 614 patients included in the study. The mean age was 41 years (range, 15-85 yrs), and the majority were female (80%). The mean follow-up time was 40.5 months. Side-to-side hepaticojejunostomy was performed in 94% of repairs. Intermediate repair was associated with a higher risk of postoperative complications [odd ratio = 3.7, 95% confidence interval (1.3-10.2), P = 0.01] when compared with early and late in those with a previous repair attempt. Sepsis control and avoidance of biliary stents were protective factors against anastomotic failure. CONCLUSIONS Adequate sepsis control and delayed repair of biliary injuries should be considered for patients presenting between 8 days and 6 weeks after injury to prevent complications, if a previous bile duct repair was attempted.
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Dralle H, Kols K, Weimann A, Paul A, Hoyer DP. [Intraoperatively unrecognized central bile duct injury : In open converted, laparoscopically begun cholecystectomy]. Chirurg 2017; 88:442-445. [PMID: 28405716 DOI: 10.1007/s00104-017-0410-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- H Dralle
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Sektion Endokrine Chirurgie, Medizinisches Zentrum, Universitätsklinikum Essen, Hufelandstraße 55, 45147, Essen, Deutschland.
| | - K Kols
- Schlichtungsstelle für Arzthaftpflichtfragen, Norddeutsche Ärztekammern, Hans Böckler Allee 3, 30173, Hannover, Deutschland.
| | - A Weimann
- Klinik für Allgemein-, Viszeral- und Onkologische Chirurgie, Klinikum St. Georg gGmbH, Delitzscher Str. 141, 04129, Leipzig, Deutschland.
| | - A Paul
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Hufelandstraße 55, 45147, Essen, Deutschland.
| | - D P Hoyer
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Hufelandstraße 55, 45147, Essen, Deutschland
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Lee J, Lim DH, Park HC, Yu JI, Choi DW, Choi SH, Heo JS. Predictive factors of gastroduodenal bleeding after postoperative radiotherapy in biliary tract cancer. Jpn J Clin Oncol 2017; 47:328-333. [PMID: 28064203 DOI: 10.1093/jjco/hyw205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/22/2016] [Indexed: 12/20/2022] Open
Abstract
Objective To identify predictive factors for gastroduodenal bleeding after postoperative radiation therapy in patients with biliary tract cancer. Methods We identified 186 patients with biliary tract cancer who completed scheduled postoperative radiation therapy from March 2000 to August 2013. To isolate the effects of radiation on gastroduodenal bleeding, patients with pylorus-preserving pancreaticoduodenectomy, pylorus-resecting pancreaticoduodenectomy or Whipple surgery (n = 67) were excluded from this analysis. Postoperative radiation therapy was started at a median 5 weeks (range: 4-12 weeks) after surgery with a median dose of 44 Gy (range: 44-54), and chemotherapy was also concurrently administered to 102 patients. Results The median age of the patients was 59 years (range: 36-76 years). Of the 119 patients, 26 had intrahepatic cholangiocarcinoma, 29 had hilar cholangiocarcinoma, while 64 had extrahepatic tumors (gallbladder cancer, n = 53; proximal bile duct cancer, n = 10; choledochal cyst cancer, n = 1). Of all, 11 patients (9%) developed gastroduodenal bleeding. In univariate analyses, hepatic artery resection and gastroduodenal wall thickening on postoperative radiation therapy simulation computed tomography were statistically significant factors for gastroduodenal bleeding. Multivariate analysis by a logistic regression model using those two variables revealed that both parameters were independent predictors for gastroduodenal bleeding. Conclusions Concomitant hepatic artery resection and presence of gastroduodenal wall thickening on postoperative radiation therapy simulation computed tomography were predictive factors for gastroduodenal bleeding after postoperative radiation therapy in biliary tract cancer. In such cases, patients should be informed of the high risk of gastroduodenal bleeding, and should be closely observed during and after postoperative radiation therapy.
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Affiliation(s)
- Jieun Lee
- Departments of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Hoon Lim
- Departments of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Chul Park
- Departments of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Il Yu
- Departments of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Wook Choi
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Ho Choi
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Heo
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Senthilkumar MP, Battula N, Perera M, Marudanayagam R, Isaac J, Muiesan P, Olliff SP, Mirza DF. Management of a pseudo-aneurysm in the hepatic artery after a laparoscopic cholecystectomy. Ann R Coll Surg Engl 2017; 98:456-60. [PMID: 27580308 DOI: 10.1308/rcsann.2016.0182] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Introduction Symptomatic hepatic-artery pseudoaneurysm (HAP) after bile-duct injury (BDI) is a rare complication with a varied (but clinically urgent) presentation. Methods A prospectively maintained database of all patients with BDI at laparoscopic cholecystectomy (LC) referred to a tertiary specialist hepatobiliary centre between 1992 and 2011 was searched systematically to identify patients with a symptomatic HAP. Care and outcome of these patients was studied. Results Eight (6 men) of 236 patients with BDI (3.4%) with a median age of 65 (range: 54?6) years presented with symptomatic HAP. Median time of presentation of the HAP from the index LC was 31 (range: 13?16) days. Bleeding was the dominant presentation in 7 patients. One patient presented late (>2 years) with abdominal pain alone. Computed tomography angiography was the most useful investigation. Angioembolisation was successful in 7 patients. One patient died, and another patient developed liver infarction. Three patients (38%) developed biliary strictures after embolisation. Seven patients are alive and well at a median follow-up of 66 months. Conclusions Presentation of HAP is often delayed. A high index of suspicion is necessary for the diagnosis. Computed tomography angiography is the first-line investigation and selective angioembolisation can yield successful outcomes.
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Affiliation(s)
| | - N Battula
- Queen Elizabeth Hospital Birmingham , UK
| | | | | | - J Isaac
- Queen Elizabeth Hospital Birmingham , UK
| | - P Muiesan
- Queen Elizabeth Hospital Birmingham , UK
| | - S P Olliff
- Queen Elizabeth Hospital Birmingham , UK
| | - D F Mirza
- Queen Elizabeth Hospital Birmingham , UK
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Rubio-Manzanares-Dorado M, Marín-Gómez LM, Aparicio-Sánchez D, Suárez-Artacho G, Bellido C, Álamo JM, Serrano-Díaz-Canedo J, Padillo-Ruiz FJ, Gómez-Bravo MÁ. Implication of the presence of a variant hepatic artery during the Whipple procedure. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 107:417-22. [PMID: 26140634 DOI: 10.17235/reed.2015.3701/2015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The anatomical variants of the hepatic artery may have important implications for pancreatic cancer surgery. The aim of our study is to compare the outcome following a pancreatoduodenectomy (PD) in patients with or without a variant hepatic artery arising from superior mesenteric artery. MATERIAL AND METHODS We reviewed 151 patients with periampullary tumoral pathology. All patients underwent oncological PD between January 2005 and February 2012. Our series was divided into two groups: Group A: Patients with a hepatic artery arising from superior mesenteric artery; and Group B: Patients without a hepatic artery arising from superior mesenteric artery. We expressed the results as mean +/- standard deviation for continuous variables and percentages for qualitative variables. Statistical tests were considered significant if p < 0.05. RESULTS We identified 11 patients with a hepatic artery arising from superior mesenteric artery (7.3%). The most frequent variant was an aberrant right hepatic artery (n = 7), following by the accessory right hepatic artery (n = 2) and the common hepatic artery trunk arising from the superior mesenteric artery (n = 2). In 73% of cases the diagnosis of the variant was intraoperative. R0 resection was performed in all patients with a hepatic artery arising from superior mesenteric artery. There were no significant differences in the tumor resection margins and the incidence of postoperative complications. CONCLUSION Oncological PD is feasible by the presence of a hepatic artery arising from superior mesenteric artery. The complexity of having it does not seem to influence in tumor resection margins, complications and survival.
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Abbasoğlu O, Tekant Y, Alper A, Aydın Ü, Balık A, Bostancı B, Coker A, Doğanay M, Gündoğdu H, Hamaloğlu E, Kapan M, Karademir S, Karayalçın K, Kılıçturgay S, Şare M, Tümer AR, Yağcı G. Prevention and acute management of biliary injuries during laparoscopic cholecystectomy: Expert consensus statement. Turk J Surg 2016; 32:300-305. [PMID: 28149133 PMCID: PMC5245728 DOI: 10.5152/ucd.2016.3683] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 09/13/2016] [Indexed: 12/17/2022]
Abstract
Gallstone disease is very common and laparoscopic cholecystectomy is one of the most common surgical procedures all over the world. Parallel to the increase in the number of laparoscopic cholecystectomies, bile duct injuries also increased. The reported incidence of bile duct injuries ranges from 0.3% to 1.4%. Many of the bile duct injuries during laparoscopic cholecystectomy are not due to inexperience, but are the result of basic technical failures and misinterpretations. A working group of expert hepatopancreatobiliary surgeons, an endoscopist, and a specialist of forensic medicine study searched and analyzed the publications on safe cholecystectomy and biliary injuries complicating laparoscopic cholecystectomy under the organization of Turkish Hepatopancreatobiliary Surgery Association. After a series of e-mail communications and two conferences, the expert panel developed consensus statements for safe cholecystectomy, management of biliary injuries and medicolegal issues. The panel concluded that iatrogenic biliary injury is an overwhelming complication of laparoscopic cholecystectomy and an important issue in malpractice claims. Misidentification of the biliary system is the major cause of biliary injuries. To avoid this, the "critical view of safety" technique should be employed in all the cases. If biliary injury is identified intraoperatively, reconstruction should only be performed by experienced hepatobiliary surgeons. In the postoperative period, any deviation from the expected clinical course of recovery should alert the surgeon about the possibility of biliary injury.
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Affiliation(s)
- Osman Abbasoğlu
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Yaman Tekant
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Aydın Alper
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Ünal Aydın
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Ahmet Balık
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Birol Bostancı
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Ahmet Coker
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Mutlu Doğanay
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Haldun Gündoğdu
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Erhan Hamaloğlu
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Metin Kapan
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Sedat Karademir
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Kaan Karayalçın
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Sadık Kılıçturgay
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Mustafa Şare
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Ali Rıza Tümer
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Gökhan Yağcı
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
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Bile Duct Injuries Associated With 55,134 Cholecystectomies: Treatment and Outcome from a National Perspective. World J Surg 2016; 40:73-80. [PMID: 26530691 DOI: 10.1007/s00268-015-3281-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Bile duct injury (BDI) is a rare complication associated with cholecystectomy, and recommendations for treatment are based on publications from referral centers with a selection of major injuries and failures after primary repair. The aim was to analyze the frequency, treatment, and outcome of BDIs in an unselected population-based cohort. METHODS This was a retrospective cohort study including all BDIs registered in GallRiks (Swedish quality register for gallstone surgery and ERCP) during 2007-2011. Data for this study were based on a national follow-up survey where medical records were scrutinized and BDIs classified according to the Hannover classification. RESULTS A total of 174 BDIs arising from 55,134 cholecystectomies (0.3%) identified at 60 hospitals were included with a median follow-up of 37 months (9-69). 155 BDIs (89%) were detected during cholecystectomy, and immediate repair was attempted in 140 (90%). A total of 27 patients (18%) were referred to a HPB referral center. Hannover Grade C1 (i.e., small lesion <5 mm) dominated (n = 102; 59%). The most common repair was "suture over T-tube" (n = 78; 45%) and reconstruction with hepaticojejunostomy was performed in 30 patients (17%). A total of 31 patients (18 %) were diagnosed with stricture, 19 of which were primarily repaired with "suture over T-tube." The median in-hospital-stay was 14 days (1-149). CONCLUSIONS The majority of BDIs were detected during the cholecystectomy and repaired by the operating surgeon. Although this is against most current recommendations, short-term outcome was surprisingly good.
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Heits N, Mueller L, Koops A, Koops S, Herrmann J, Hendricks A, Kabar I, Arlt A, Braun F, Becker T, Wilms C. Limits of and Complications after Embolization of the Hepatic Artery and Portal Vein to Induce Segmental Hypertrophy of the Liver: A Large Mini-Pig Study. Eur Surg Res 2016; 57:155-170. [DOI: 10.1159/000447511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 06/06/2016] [Indexed: 11/19/2022]
Abstract
Background: The aim of this study was to compare arterial embolization (AE) with portal vein embolization (PVE) for the induction of segmental hypertrophy regarding procedural efficacy, safety and outcome. Methods: A total of 29 mini pigs were subjected to PVE, AE or assigned to the sham (SO) group. Correspondingly, 75% of the hepatic artery or portal vein branches were embolized. Growth and atrophy of the liver lobes, calculating the liver-to-body weight index (LBWI), laboratory data, arteriography, portography, Doppler ultrasound (US) and histopathology were analyzed. Results: After PVE, 2 animals had to be excluded due to technical problems. After AE, 4 animals had to be excluded because of technical problems and early sacrifice. Postprocedural US demonstrated effective AE and PVE of the respective lobes. Four weeks after PVE, portography showed a slow refilling of the embolized lobe by collateral portal venous vessels. Four weeks after AE, arteriography revealed a slight revascularization of the embolized lobes by arterial neovascularization. Segmental AE led to extensive necrotic and inflammatory alterations in the liver and bile duct parenchyma. Significant hypertrophy of the non-embolized lobe was only noted in the PVE group (LBWI: 0.91 ± 0.28%; p = 0.001). There was no increase in the non-embolized lobe in the AE (LBWI: 0.45 ± 0.087%) and SO group (LBWI: 0.45 ± 0.13%). Conclusion: PVE is safe and effective to induce segmental hypertrophy. Portal reperfusion by collateral vessels may limit hypertrophy. AE did not increase the segmental hepatic volume but carries the risk of extensive necrotic inflammatory damage.
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Prognostication of Learning Curve on Surgical Management of Vasculobiliary Injuries after Cholecystectomy. Int J Hepatol 2016; 2016:2647130. [PMID: 27525124 PMCID: PMC4971320 DOI: 10.1155/2016/2647130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 06/19/2016] [Accepted: 06/22/2016] [Indexed: 02/08/2023] Open
Abstract
Background. Concomitant vascular injury might adversely impact outcomes after iatrogenic bile duct injury (IBDI). Whether a new HPB center should embark upon repair of complex biliary injuries with associated vascular injuries during learning curve is unknown. The objective of this study was to determine outcome of surgical management of IBDI with and without vascular injuries in a new HPB center during its learning curve. Methods. We retrospectively reviewed patients who underwent surgical management of IBDI at our center. A total of 39 patients were included. Patients without (Group 1) and with vascular injuries (Group 2) were compared. Outcome was defined as 90-day morbidity and mortality. Results. Median age was 39 (20-80) years. There were 10 (25.6%) vascular injuries. E2 injuries were associated significantly with high frequency of vascular injuries (66% versus 15.1%) (P = 0.01). Right hepatectomy was performed in three patients. Out of these, two had a right hepatic duct stricture and one patient had combined right arterial and portal venous injury. The number of patients who developed postoperative complications was not significantly different between the two groups (11.1% versus 23.4%) (P = 0.6). Conclusion. Learning curve is not a negative prognostic variable in the surgical management of iatrogenic vasculobiliary injuries after cholecystectomy.
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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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Stilling NM, Fristrup C, Wettergren A, Ugianskis A, Nygaard J, Holte K, Bardram L, Sall M, Mortensen MB. Long-term outcome after early repair of iatrogenic bile duct injury. A national Danish multicentre study. HPB (Oxford) 2015; 17:394-400. [PMID: 25582034 PMCID: PMC4402049 DOI: 10.1111/hpb.12374] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 11/08/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this retrospective study was to evaluate the peri-operative and long-term outcome after early repair with a hepaticojejunostomy (HJ). METHODS Between 1995 and 2010, a nationwide, retrospective multi-centre study was conducted. All iatrogenic bile duct injury (BDI) sustained during a cholecystectomy and repaired with HJ in the five Hepato-Pancreatico-Biliary centres in Denmark were included. RESULTS In total, 139 patients had an HJ repair. The median time from the BDI to reconstruction was 5 days. A concomitant vascular injury was identified in 26 cases (19%). Post-operative morbidity was 36% and mortality was 4%. Forty-two patients (30%) had a stricture of the HJ. The median follow-up time without stricture was 102 months. Nineteen out of the 42 patients with post-reconstruction biliary strictures had a re-HJ. Twenty-three patients were managed with percutaneous transhepatic cholangiography and dilation. The overall success rate of re-establishing the biliodigestive flow approached 93%. No association was found between timing of repair, concomitant vascular injury, level of injury and stricture formation. CONCLUSION In this national, unselected and consecutive cohort of patients with BDI repaired by early HJ we found a considerable risk of long-term complications (e.g. 30% stricture rate) and mortality in both the short- and the long-term perspective.
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Affiliation(s)
- Nicolaj M Stilling
- Department of Surgery, Odense University HospitalOdense C, Denmark,Correspondence, Nicolaj Markus Stilling, Department of Surgery, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark. Tel.: +45 2830 8020. Fax: +45 6591 9872. E-mail:
| | - Claus Fristrup
- Department of Surgery, Odense University HospitalOdense C, Denmark
| | - André Wettergren
- Department of Surgical Gastroenterology C, RigshospitaletCopenhagen Ø, Denmark
| | - Arnas Ugianskis
- Department of Surgical Gastroenterology A1, Aalborg Hospital, Aarhus University HospitalAalborg, Denmark
| | - Jacob Nygaard
- Department of Surgical Gastroenterology L, Aarhus University HospitalAarhus, Denmark
| | - Kathrine Holte
- Department of Surgical Gastroenterology C, RigshospitaletCopenhagen Ø, Denmark
| | - Linda Bardram
- Department of Surgical Gastroenterology C, RigshospitaletCopenhagen Ø, Denmark
| | - Mogens Sall
- Department of Surgical Gastroenterology A1, Aalborg Hospital, Aarhus University HospitalAalborg, Denmark
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Incidence, diagnostics and management of iatrogenic bile duct injuries: 20 years experience in a high volume centre. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s13126-015-0199-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Raashed S, Chandrasegaram MD, Alsaleh K, Schlaphoff G, Merrett ND. Vascular coil erosion into hepaticojejunostomy following hepatic arterial embolisation. BMC Surg 2015; 15:51. [PMID: 25925841 PMCID: PMC4423092 DOI: 10.1186/s12893-015-0039-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 04/24/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Right hepatic arterial injury (RHAI) is the most common vascular injury sustained during laparoscopic cholecystectomy, occurring in up to 7% of cholecystectomies. RHAI is also the most common vascular injury associated with a bile duct injury (BDI) and is reported to occur in up to 41 - 61% of cases when routine angiography is employed following a BDI. We present an unusual case of erosion of vascular coils from a previously embolised right hepatic artery into bilio-enteric anastomoses causing biliary obstruction. This is on a background of biliary reconstruction following a major BDI. CASE PRESENTATION A 37-year old man underwent a bile duct reconstruction following a major BDI (Strasberg-Bismuth E4 injury) sustained at laparoscopic cholecystectomy. He had two separate bilio-enteric anastomoses of the right and left hepatic ducts and had a modified Terblanche Roux-en-Y access limb formed. Approximately three weeks later he was admitted for significant gastrointestinal bleeding and was hypotensive and anaemic. Selective computed tomography angiography revealed a 2 x 2 centimetre right hepatic artery pseudoaneurysm, which was urgently embolised with radiological coils. Two months later he developed intermittent fevers, rigors, jaundice, and right upper quadrant pain with evidence of intrahepatic biliary dilatation on magnetic resonance cholangiopancreatography. The degree of intrahepatic biliary dilatation progressively increased on subsequent imaging over several months, suggesting stricturing of the bilio-enteric anastomoses. Several attempts to traverse these strictures with a percutaneous transhepatic approach had failed. Then, approximately ten months after the initial BDI repair, choledochoscopy through the Terblanche access limb revealed multiple radiological coils within the bilio-enteric anastomoses, which had eroded from the previously embolised right hepatic artery. A laparotomy was performed to remove the coils, take down the existing obstructed bilio-enteric anastomoses and revise this. Following this the patient recovered uneventfully. CONCLUSION Obstructive jaundice and cholangitis secondary to erosion of angiographically placed embolisation coils is a rarely described complication. In view of the relative frequency of arterial injury and complications following major bile duct injury, we suggest that these patients be formally assessed for associated arterial injury following a major BDI.
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Affiliation(s)
- Soondoos Raashed
- />Upper Gastrointestinal Unit, Bankstown Hospital, Sydney, Australia
| | - Manju D Chandrasegaram
- />Upper Gastrointestinal Unit, Bankstown Hospital, Sydney, Australia
- />Division of Surgery, School of Medicine, University of Western Sydney, Sydney, Australia
| | - Khaled Alsaleh
- />Upper Gastrointestinal Unit, Bankstown Hospital, Sydney, Australia
| | - Glen Schlaphoff
- />Interventional and Diagnostic Radiology, Liverpool Hospital, Sydney, Australia
| | - Neil D Merrett
- />Upper Gastrointestinal Unit, Bankstown Hospital, Sydney, Australia
- />Division of Surgery, School of Medicine, University of Western Sydney, Sydney, Australia
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