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Blohm M, Sandblom G, Enochsson L, Cengiz Y, Bayadsi H, Hennings J, Diaz Pannes A, Stenberg E, Bewö K, Österberg J. Ultrasonic dissection versus electrocautery dissection in laparoscopic cholecystectomy for acute cholecystitis: a randomized controlled trial (SONOCHOL-trial). World J Emerg Surg 2024; 19:34. [PMID: 39538278 PMCID: PMC11562708 DOI: 10.1186/s13017-024-00565-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2024] [Accepted: 11/03/2024] [Indexed: 11/16/2024] Open
Abstract
BACKGROUND Laparoscopic cholecystectomy with ultrasonic dissection presents a compelling alternative to conventional electrocautery. The evidence for elective cholecystectomy supports the adoption of ultrasonic dissection, citing advantages such as reduced operating time, diminished bleeding, shorter hospital stays and decreased postoperative pain and nausea. However, the efficacy of this procedure in emergency surgery and patients diagnosed with acute cholecystitis remains uncertain. The aim of this study was to compare outcomes of electrocautery and ultrasonic dissection in patients with acute cholecystitis. METHODS A randomized, parallel, double-blinded, multicentre controlled trial was conducted across eight Swedish hospitals. Eligible participants were individuals aged ≥ 18 years with acute cholecystitis lasting ≤ 7 days. Laparoscopic cholecystectomy was performed in the emergency setting as soon as local circumstances permitted. Random allocation to electrocautery or ultrasonic dissection was performed in a 1:1 ratio. The primary endpoint was the total complication rate, analysed using an intention-to-treat approach. The primary outcome was analysed using logistic generalized estimated equations. Patients, postoperative caregivers, and follow-up personnel were blinded to group assignment. RESULTS From September 2019 to March 2023, 300 patients were enrolled and randomly assigned to electrocautery dissection (n = 148) and ultrasonic dissection (n = 152). No significant difference in complication rate was observed between the groups (risk difference [RD] 1.6%, 95% confidence interval [CI], - 7.2% to 10.4%, P = 0.720). No significant disparities in operating time, conversion rate, hospital stay or readmission rates between the groups were noted. Haemostatic agents were more frequently used in electrocautery dissection (RD 10.6%, 95% CI, 1.3% to 19.8%, P = 0.025). CONCLUSIONS Ultrasonic dissection and electrocautery dissection demonstrate comparable risks for complications in emergency surgery for patients with acute cholecystitis. Ultrasonic dissection is a viable alternative to electrocautery dissection or can be used as a complementary method in laparoscopic cholecystectomy for acute cholecystitis. TRIAL REGISTRATION The trial was registered prior to conducting the research on http://clinical. TRIALS gov , NCT03014817.
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Affiliation(s)
- My Blohm
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
- Centre for Clinical Research Dalarna, Uppsala University, Falun, Sweden.
- Department of Surgery, Mora Lasarett, Mora, Sweden.
| | - Gabriel Sandblom
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Lars Enochsson
- Department of Diagnostics and Intervention, Surgery, Umeå University, Umeå, Sweden
- Division of Orthopedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Yücel Cengiz
- Department of Diagnostics and Intervention, Surgery, Umeå University, Umeå, Sweden
| | - Haytham Bayadsi
- Department of Diagnostics and Intervention, Surgery, Umeå University, Umeå, Sweden
| | - Joakim Hennings
- Department of Diagnostics and Intervention, Surgery, Umeå University, Umeå, Sweden
| | | | - Erik Stenberg
- Department of Surgery, Faculty of Medicine, and Health, Örebro University Hospital, Örebro, Sweden
| | - Kerstin Bewö
- Department of Surgery, Falu Lasarett, Falun, Sweden
| | - Johanna Österberg
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Dalarna, Uppsala University, Falun, Sweden
- Department of Surgery, Mora Lasarett, Mora, Sweden
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Blitzkow ACB, Freitas ACTD, Coelho JCU, Campos ACL, Costa MARD, Buffara-Junior VA, Matias JEF. CRITICAL VIEW OF SAFETY: A PROSPECTIVE SURGICAL AND PHOTOGRAPHIC ANALYSIS IN LAPAROSCOPIC CHOLECYSTECTOMY - DOES IT HELP TO PREVENT IATROGENIC LESIONS? ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2024; 37:e1827. [PMID: 39475862 PMCID: PMC11506944 DOI: 10.1590/0102-6720202400034e1827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 05/08/2024] [Indexed: 11/02/2024]
Abstract
BACKGROUND The incidence of biliary duct injuries remains higher in laparoscopic cholecystectomy (LC) in comparison to open surgery. The Critical View of Safety (CVS) was introduced by Strasberg as a strategy for reducing this catastrophic complication. AIM: The aim of this study was to evaluate how often an adequate CVS is achieved during LC, the determining factors for its success, and the associated surgical outcomes. METHODS This is a prospective study. CVS photographs of all patients who underwent LC by the same surgeon between 2020 and 2023 were taken. Success in achieving CVS was analyzed by the surgeon herself and posteriorly by hepatobiliary specialists. Patients were classified into two groups: CVS achieved and CVS not achieved. Finally, multivariable logistic regression was used to examine the association between preoperatory factors and surgical complications. RESULTS Three hundred and nine consecutive patients were submitted to LC. There were 73.5% elective CL and 26.5% acute cholecystitis. The age ranged from 14 to 87 years, and 76.8% were female. The median body mass index was 26.7. Previous abdominal surgeries were present in 64%, and 26% were obese. The CVS was achieved in 79.9% of the patients, and there were no surgical complications in this group. The factors associated with nonachievement were acute cholecystitis (p=0.007), male sex (p=0.014), and previous surgeries (p=0.021). Three patients needed a subtotal cholecystectomy due to severe inflammation. There was no statistical correlation between the identification of CVS and surgical complications. CONCLUSIONS The CVS is achieved in most patients. Acute cholecystitis, male sex, and previous abdominal operations are associated with difficulties in obtaining CVS.
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Affiliation(s)
| | | | | | | | | | - Victor Assad Buffara-Junior
- Hospital Santa Cruz - Rede D'or, Department of Surgery - Curitiba, Paraná (PR), Brazil
- Pilar Hospital, Department of Surgery - Curitiba (PR), Brazil
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Merenzon MA, Bhatia S, Levy A, Di L, Gurses ME, Rivera C, Daggubati L, Luther E, Shah AH, Komotar RJ, Ivan ME. The Learning Curve and Clinical Outcomes With 250 Laser Ablations for Brain Tumors: A Pathway to Experience. Oper Neurosurg (Hagerstown) 2024; 27:205-212. [PMID: 38385677 DOI: 10.1227/ons.0000000000001101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/03/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Laser interstitial thermal therapy (LITT) has gained popularity as a minimally invasive technique for treating brain tumors. Despite its proven safety profile, LITT is not yet widely available, and there is a lack of data on the learning curve required to achieve proficiency. This study analyzes a 250-patient cohort of laser-ablated tumors to describe changes in patient selection and clinical outcomes over time and experience, with the aim of providing insight into the learning curve for incorporating LITT into a neuro-oncology program and identifying a cutoff point that distinguishes novice from expert performance. METHODS We retrospectively reviewed 250 patients with brain tumor who underwent LITT between 2013 and 2022. Demographic and clinical data were analyzed. Kaplan Meier curves were used for survival analysis. Operative time was evaluated using exponential curve-fit regression analysis to identify when consistent improvement began. RESULTS The patients were divided into quartiles (Q) based on their date of surgery. Mean tumor volume increased over time (Q1 = 5.7 and Q4 = 11.9 cm 3 , P = .004), and newly diagnosed lesions were more frequently ablated ( P = .0001). Mean operative time (Q1 v Q4 = 322.3 v 204.6 min, P < .0001) and neurosurgical readmission rate (Q1 v Q4 = 7.8% v 0%, P = .03) were reduced over time. The exponential curve-fit analysis showed a sustained decay in operative time after case #74. The extent of ablation ( P = .69), the recurrence ( P = .11), and the postoperative complication rate ( P = .78) did not vary over time. CONCLUSION After treating 74 patients, a downward trend in the operative time is observed. Patient selection is broadened as experience increases.
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Affiliation(s)
- Martín A Merenzon
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, Miami , Florida , USA
| | - Shovan Bhatia
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, Miami , Florida , USA
| | - Adam Levy
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, Miami , Florida , USA
| | - Long Di
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, Miami , Florida , USA
| | - Muhammet Enes Gurses
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, Miami , Florida , USA
| | - Cameron Rivera
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, Miami , Florida , USA
| | - Lekhaj Daggubati
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, Miami , Florida , USA
| | - Evan Luther
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, Miami , Florida , USA
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, Miami , Florida , USA
- Sylvester Comprehensive Cancer Center, Brain Tumor Initiative, University of Miami Miller School of Medicine, Miami , Florida , USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, Miami , Florida , USA
- Sylvester Comprehensive Cancer Center, Brain Tumor Initiative, University of Miami Miller School of Medicine, Miami , Florida , USA
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, Miami , Florida , USA
- Sylvester Comprehensive Cancer Center, Brain Tumor Initiative, University of Miami Miller School of Medicine, Miami , Florida , USA
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Sreepathi V, Srinivasan K, Ahanatha Pillai S, Ramasamy V, Chowdary MBKP, Murugesan TK, Subbareddiar P. Long-Term Outcomes Following Surgical Repair for Post-cholecystectomy Biliary Strictures. Cureus 2024; 16:e64405. [PMID: 39130821 PMCID: PMC11317064 DOI: 10.7759/cureus.64405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2024] [Indexed: 08/13/2024] Open
Abstract
INTRODUCTION Bile duct injuries (BDIs) are a serious complication of cholecystectomy. Strictures that form after major injuries ultimately require surgical repair. This study aimed to analyse our experience with the surgical repair of post-cholecystectomy biliary strictures (PCBS). METHODS Patients who underwent surgical repair for PCBS between January 2013 and March 2020 were retrospectively reviewed. The strictures were classified using the Bismuth system. Delayed repair with Roux-en-Y hepaticojejunostomy was performed using the Hepp-Couinaud technique. Outcomes were graded according to McDonald's criteria. Statistical analysis was performed to identify factors influencing the outcomes. RESULTS Sixty-eight patients underwent repair for PCBS. Forty-five patients presented within one month and eight patients presented late after six months. Presenting symptoms were jaundice, external biliary fistula, biliomas, cholangitis and peritonitis. Portal hypertension was present in two patients. The median interval for definitive repair was 22 weeks. The median hospital stay was 9.5 days. Eighteen patients had postoperative complications. One patient had postoperative mortality due to uncorrectable coagulopathy. With a median follow-up of 54 months, successful outcomes were achieved in 61 (90%) patients. Four patients had anastomotic strictures evident at two, four, five and eight years after repair. Portal hypertension and postoperative complications were the variables associated with poor outcomes. CONCLUSION BDIs following cholecystectomy are a devastating complication. Surgical repair for biliary strictures yields durable long-term outcomes with early identification and timely referral to a tertiary care centre where standardized techniques for biliary reconstruction are followed.
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Affiliation(s)
| | | | | | - Villalan Ramasamy
- Department of Surgical Gastroenterology, Madurai Medical College, Madurai, IND
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Booyse K, Lindemann J, Calitz M, Bernon M, Jonas E, Kloppers C. Laparoscopic subtotal cholecystectomy outcomes across a low-and middle-income country metropolitan health service. World J Surg 2024; 48:1323-1330. [PMID: 38581358 DOI: 10.1002/wjs.12180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/26/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Laparoscopic subtotal cholecystectomy (LSC) is a safe alternative for difficult cholecystectomies to prevent bile duct injury and open conversion. The primary aim was to detail the use and outcomes on LSCs. METHODS Retrospective analysis of a prospectively maintained database of laparoscopic cholecystectomy (LC). Relative clinical factors, outcomes, and 30-day follow-up between LSC and LC were compared using univariate and multivariate analyses. RESULTS Six hundred and twenty four cholecystectomies were performed and 53 (8.5%) required LSC. 81.8% were fenestrating LSC. Male sex was significantly overrepresented in the LSC group (p < 0.01) and patients requiring LSC were significantly older (p < 0.01). Same admission cholecystectomy was associated with a higher risk of LSC (p < 0.01). Patients with a history of previous surgery, preoperative ERCP, or percutaneous cholecystostomy had an increased risk of undergoing LSC (p < 0.01). A necrotic gallbladder was the most significant predictor of the need for a LSC (p < 0.001). A contracted gallbladder, extensive adhesions, gallbladder empyema, and severe inflammation were significant predictors of difficulty (all p < 0.01). Postoperative complications occurred in 26.4% of LSC patients. There were ten (18.9%) Clavien-Dindo Grade III complications, 5.7% required ERCPs, and 9.4% required relook laparotomies. Significantly, more patients in the LSC group developed bile leaks (n = 8, 15%) (p < 0.001). There were two readmissions within 30 days, one mortality, and no BDIs occurred in the LSC cohort. CONCLUSION LSC provides a feasible surgical option that should be utilized in complex cholecystitis.
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Affiliation(s)
- Karien Booyse
- Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa
| | - Jessica Lindemann
- Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Mariska Calitz
- Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa
| | - Marc Bernon
- Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa
| | - Eduard Jonas
- Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa
| | - Christo Kloppers
- Division of General Surgery, University of Cape Town Health Sciences Faculty and Groote Schuur Hospital, Cape Town, South Africa
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Zidan MHED, Seif-Eldeen M, Ghazal AA, Refaie M. Post-cholecystectomy bile duct injuries: a retrospective cohort study. BMC Surg 2024; 24:8. [PMID: 38172774 PMCID: PMC10765830 DOI: 10.1186/s12893-023-02301-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 12/23/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Bile duct injury (BDI) is still a major worrisome complication that is feared by all surgeons undergoing cholecystectomy. The overall incidence of biliary duct injuries falls between 0.2 and 1.3%. BDI classification remains an important method to define the type of injury conducted for investigation and management. Recently, a Consensus has been taken to define BDI using the ATOM classification. Early management brings better results than delayed management. The current perspective in biliary surgery is the laparoscopic role in diagnosing and managing BDI. Diagnostic laparoscopy has been conducted in various entities for diagnostic and therapeutic measures in minor and major BDIs. METHODS 35 cases with iatrogenic BDI following cholecystectomy (after both open and laparoscopic approaches) both happened in or were referred to Alexandria Main University Hospital surgical department from January 2019 till May 2022 and were analyzed retrospectively. Patients were classified according to the ATOM classification. Management options undertaken were mentioned and compared to the timing of diagnosis, and the morbidity and mortality rates (using the Clavien-Dindo classification). RESULTS 35 patients with BDI after both laparoscopic cholecystectomy (LC) (54.3%), and Open cholecystectomy (OC) (45.7%) (20% were converted and 25.7% were Open from the start) were classified according to ATOM classification. 45.7% were main bile duct injuries (MBDI), and 54.3% were non-main bile duct injuries (NMBDI), where only one case 2.9% was associated with vasculobiliary injury (VBI). 28% (n = 10) of the cases were diagnosed intraoperatively (Ei), 62.9% were diagnosed early postoperatively (Ep), and 8.6% were diagnosed in the late postoperative period (L). LC was associated with 84.2% of the NMBDI, and only 18.8% of the MBDI, compared to OC which was associated with 81.3% of the MBDI, and 15.8% of the NMBDI. By the Clavien-Dindo classification, 68.6% fell into Class IIIb, 20% into Class I, 5.7% into Class V (mortality rate), 2.9% into Class IIIa, and 2.9% into Class IV. The Clavien-Dindo classification and the patient's injury (type and time of detection) were compared to investigation and management options. CONCLUSION Management options should be defined individually according to the mode of presentation, the timing of detection of injury, and the type of injury. Early detection and management are associated with lower morbidity and mortality. Diagnostic Laparoscopy was associated with lower morbidity and better outcomes. A proper Reporting checklist should be designed to help improve the identification of injury types.
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Affiliation(s)
- Mohamed Hossam El-Din Zidan
- Faculty of Medicine, Alexandria University, Alexandria, Egypt.
- Alexandria Main University Hospital, Alexandria University, Alexandria, Egypt.
| | - Mostafa Seif-Eldeen
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Alexandria Main University Hospital, Alexandria University, Alexandria, Egypt
| | - Abdelhamid A Ghazal
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Alexandria Main University Hospital, Alexandria University, Alexandria, Egypt
| | - Mustafa Refaie
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Alexandria Main University Hospital, Alexandria University, Alexandria, Egypt
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Hristov B, Doykov D, Stanchev D, Kraev K, Uchikov P, Kostov G, Valova S, Tilkiyan E, Doykova K, Doykov M. Hepatico-Duodenal Fistula Following Iatrogenic Strasberg Type E4 Bile Duct Injury: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1621. [PMID: 37763740 PMCID: PMC10537085 DOI: 10.3390/medicina59091621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/31/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Gallstone disease (GSD) is among the most common disorders worldwide. Gallstones are established in up to 15% of the general population. Laparoscopic cholecystectomy (LC) has become the "gold standard" for treatment of GSD but is associated with a higher rate of certain complications, namely, bile duct injury (BDI). Biliary fistulas (BF) are a common presentation of BDI (44.1% of all patients); however, they are mainly external. Post-cholecystectomy internal BF are exceedingly rare. CASE REPORT a 33-year Caucasian female was admitted with suspected BDI after LC. Strasberg type E4 BDI was established on endoscopic retrograde cholangiopancreatography (ERCP). Urgent laparotomy established biliary peritonitis. Delayed surgical reconstruction was planned and temporary external biliary drains were positioned in the right and left hepatic ducts. During follow-up, displacement of the drains occurred with subsequent evacuation of bile through the external fistula, which resolved spontaneously, without clinical and biochemical evidence of biliary obstruction or cholangitis. ERCP established bilio-duodenal fistula between the left hepatic duct (LHD) and duodenum, with a stricture at the level of the LHD. Endoscopic management was chosen with staged dilation and stenting of the fistulous tract over 18 months until fistula maturation and stricture resolution. One year after stent extraction, the patient remains symptom free. DISCUSSION Management of post-cholecystectomy BDI is challenging. The optimal approach is determined by the level and extent of ductal lesion defined according to different classifications (Strasberg, Bismuth, Hannover). Type E BDI are managed mainly surgically with a delayed surgical approach generally deemed preferable. Only three cases of choledocho-duodenal fistulas following LC BDI currently exist in the literature. Management is controversial, with expectant approach, surgical treatment (biliary reconstruction), or liver transplantation being described. Endoscopic treatment has not been described; however, in the current paper, it proved to be successful. More reports or larger case series are needed to confirm its applicability and effectiveness, especially in the long term.
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Affiliation(s)
- Bozhidar Hristov
- Section "Gastroenterology", Second Department of Internal Diseases, Medical Faculty, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria
- Gastroenterology Clinic, University Hospital "Kaspela", 4001 Plovdiv, Bulgaria
| | - Daniel Doykov
- Section "Gastroenterology", Second Department of Internal Diseases, Medical Faculty, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria
- Gastroenterology Clinic, University Hospital "Kaspela", 4001 Plovdiv, Bulgaria
| | - Desislav Stanchev
- Section "Gastroenterology", Second Department of Internal Diseases, Medical Faculty, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria
- Gastroenterology Clinic, University Hospital "Kaspela", 4001 Plovdiv, Bulgaria
| | - Krasimir Kraev
- Department of Propedeutics of Internal Diseases, Medical Faculty, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria
- Rheumatology Clinic, St. George University Hospital, 6000 Plovdiv, Bulgaria
| | - Petar Uchikov
- Department of Special Surgery, Faculty of Medicine, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria
- Second Department of Surgery, St. George University Hospital, 4000 Plovdiv, Bulgaria
| | - Gancho Kostov
- Department of Special Surgery, Faculty of Medicine, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria
- Department of Surgery, University Hospital "Kaspela", 4001 Plovdiv, Bulgaria
| | - Siyana Valova
- Section "Nephrology", Second Department of Internal Diseases, Medical Faculty, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria
- Clinic of Nephrology, University Hospital "Kaspela", 4001 Plovdiv, Bulgaria
| | - Eduard Tilkiyan
- Section "Nephrology", Second Department of Internal Diseases, Medical Faculty, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria
- Clinic of Nephrology, University Hospital "Kaspela", 4001 Plovdiv, Bulgaria
| | - Katya Doykova
- Department of Diagnostic Imaging, Medical Faculty, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria
- Department of Diagnostic Imaging, University Hospital "Kaspela", 4001 Plovdiv, Bulgaria
| | - Mladen Doykov
- Department of Urology and General Medicine, Medical Faculty, Medical University of Plovdiv, 6000 Plovdiv, Bulgaria
- Clinic of Urology, University Hospital "Kaspela", 4001 Plovdiv, Bulgaria
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Haney CM, Kowalewski KF, Schmidt MW, Lang F, Bintintan V, Fan C, Wehrtmann F, Studier-Fischer A, Felinska EA, Müller-Stich BP, Nickel F. Robotic-assisted versus laparoscopic bowel anastomoses: randomized crossover in vivo experimental study. Surg Endosc 2023; 37:5894-5901. [PMID: 37072638 PMCID: PMC10338398 DOI: 10.1007/s00464-023-10044-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/25/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Initial learning curves are potentially shorter in robotic-assisted surgery (RAS) than in conventional laparoscopic surgery (LS). There is little evidence to support this claim. Furthermore, there is limited evidence how skills from LS transfer to RAS. METHODS A randomized controlled, assessor blinded crossover study to compare how RAS naïve surgeons (n = 40) performed linear-stapled side-to-side bowel anastomoses in an in vivo porcine model with LS and RAS. Technique was rated using the validated anastomosis objective structured assessment of skills (A-OSATS) score and the conventional OSATS score. Skill transfer from LS to RAS was measured by comparing the RAS performance of LS novices and LS experienced surgeons. Mental and physical workload was measured with the NASA-task load index (NASA-Tlx) and the Borg-scale. OUTCOMES In the overall cohort, there were no differences between RAS and LS for surgical performance (A-OSATS, time, OSATS). Surgeons that were naïve in both LS and RAS had significantly higher A-OSATS scores in RAS (Mean (Standard deviation (SD)): LS: 48.0 ± 12.1; RAS: 52.0 ± 7.5); p = 0.044) mainly deriving from better bowel positioning (LS: 8.7 ± 1.4; RAS: 9.3 ± 1.0; p = 0.045) and closure of enterotomy (LS: 12.8 ± 5.5; RAS: 15.6 ± 4.7; p = 0.010). There was no statistically significant difference in how LS novices and LS experienced surgeons performed in RAS [Mean (SD): novices: 48.9 ± 9.0; experienced surgeons: 55.9 ± 11.0; p = 0.540]. Mental and physical demand was significantly higher after LS. CONCLUSION The initial performance was improved for RAS versus LS for linear stapled bowel anastomosis, whereas workload was higher for LS. There was limited transfer of skills from LS to RAS.
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Affiliation(s)
- Caelán Max Haney
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
- Department of Urology, University Hospital Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Karl-Friedrich Kowalewski
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
- Department of Urology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Mona Wanda Schmidt
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Franziska Lang
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Vasile Bintintan
- Department of Surgery, University Hospital Cluj Napoca, Cluj-Napoca, Romania
| | - Carolyn Fan
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Fabian Wehrtmann
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Alexander Studier-Fischer
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Eleni Amelia Felinska
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Beat Peter Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
- Department of Surgery, Clarunis University Center for Gastrointestinal and Liver Disease, University Hospital and St. Clara Hospital Basel, Basel, Switzerland
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Gómez DA, Mendoza Zuchini A, Pedraza M, Salcedo Miranda DF, Mantilla-Sylvain F, Pérez Rivera CJ, Lozada-Martínez ID, Domínguez-Alvarado G, Cabrera-Vargas LF, Narvaez-Rojas A. Long-Term Outcomes of Laparoscopic Common Bile Duct Exploration Through Diathermy, Choledochotomy, and Primary Closure: A 6-Year Retrospective Cohort Study. J Laparoendosc Adv Surg Tech A 2023; 33:281-286. [PMID: 36576507 DOI: 10.1089/lap.2022.0453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background and Objective: Choledocholithiasis is a frequent pathology, unfortunately when its endoscopic management fails, there is no consensus of how it should be addressed. The aim of this study was to evaluate the safety, feasibility, and long-term outcomes of laparoscopic common bile duct exploration (LCBDE) using electrosurgery (coagulation) for choledochotomy followed by primary closure after endoscopic treatment failure. Materials and Methods: A retrospective cohort study of patients who underwent LCBDE from 2013 to 2018 was conducted in Bogotá, Colombia. Clinical demographics, operative outcomes, recurrence rate of common bile duct stones, and long-term bile duct complications were analyzed. A descriptive analysis was performed. Results: A total of 168 patients were analyzed. Most of the patients were males (53.37%) with a median age of 73 years with no comorbidities (65%). Stone clearance was successful in 167 patients (99.4%). Nonlethal complications were noted in 3 patients during the surgery or in the immediate postoperative (1.79%) and managed with T-tube or endoscopically. No cases of mortality surgery related were observed. There were no signs of any type of biliary injury or stricture observed in any of the patients during the 24-month follow-up period. Conclusions: LCBDE with diathermy and primary closure is a safe and effective treatment option for choledocholithiasis for failed endoscopic retrograde cholangiopancreatography in terms of long-term outcome as well as short-term outcome.
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Affiliation(s)
| | | | | | | | | | | | - Ivan David Lozada-Martínez
- Research Unit, Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia.,Research Unit, International Coalition on Surgical Research, Universidad Nacional Autónoma de Nicaragua, Managua, Nicaragua
| | - Gonzalo Domínguez-Alvarado
- Research Unit, Grupo de Innovación e Investigación Quirúrgica, School of Medicine, Universidad Autónoma de Bucaramanga, Bucaramanga, Colombia
| | - Luis Felipe Cabrera-Vargas
- Department of Surgery, Universidad El Bosque, Bogotá, Colombia.,Research Unit, Medical and Surgical Research Center, Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia
| | - Alexis Narvaez-Rojas
- Research Unit, International Coalition on Surgical Research, Universidad Nacional Autónoma de Nicaragua, Managua, Nicaragua
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10
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Abdelgawad MS, Eid M, Abokoura S, Elmazaly MA, Aly RA. Iatrogenic bile duct injuries after laparoscopic cholecystectomy: evaluation by MRCP before management. EGYPTIAN LIVER JOURNAL 2023. [DOI: 10.1186/s43066-023-00238-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Abstract
Background
Iatrogenic bile duct injuries are unusual but possibly associated with fatal complications with increased incidence since the introduction of laparoscopic cholecystectomy. Appropriate estimation of these injuries is essential for proper management. Imaging is vital for the initial diagnosis, extent assessment and consequently, treatment guidance of bile duct injury with an ideal outcome. In this study, MRCP was carried out in 37 cases (28 females and 9 males, age range from 19 to 58 years) with suspected BDI following laparoscopic cholecystectomy. MRCP images were assessed for bile duct transection injury, strictures, biliary leakage, and intrahepatic biliary radicles (IHBR) dilatation. In positive cases, Strasberg classification system was used with the definitive diagnosis was done regarding the surgical findings and/or findings on endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC).
Results
Our study includes 37 cases with biliary injuries. On MRCP our cases were stratified regarding the Strasberg-Bismuth classification into five types (A to E). Most BDIs were type E2 (29.7%), followed by type E1 (18.9%), type A (16.2%), type E3 (10.8%), type E4 (8.2%), type C (5.4%), and type D and finally type E5 and B injuries with each one representing 2.7%. Twenty cases presented with biliary leakage and seventeen with bile duct obstruction, whether duct ligation or stricture.
Conclusion
MRCP is an essential imaging modality for assessment of iatrogenic BDIs enabling the radiologists to classify these injuries and helps to govern the management.
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11
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Blohm M, Sandblom G, Enochsson L, Cengiz Y, Austrums E, Abdon E, Hennings J, Hedberg M, Gustafsson U, Diaz-Pannes A, Österberg J. Learning by doing: an observational study of the learning curve for ultrasonic fundus-first dissection in elective cholecystectomy. Surg Endosc 2022; 36:4602-4613. [PMID: 35286473 PMCID: PMC9085702 DOI: 10.1007/s00464-021-08976-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 12/31/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Surgical safety and patient-related outcomes are important considerations when introducing new surgical techniques. Studies about the learning curves for different surgical procedures are sparse. The aim of this observational study was to evaluate the learning curve for ultrasonic fundus-first (FF) dissection in elective laparoscopic cholecystectomy (LC). METHODS The study was conducted at eight hospitals in Sweden between 2017 and 2019. The primary endpoint was dissection time, with secondary endpoints being intra- and postoperative complication rates and the surgeon's self-assessed performance level. Participating surgeons (n = 16) were residents or specialists who performed LC individually but who had no previous experience in ultrasonic FF dissection. Each surgeon performed fifteen procedures. Video recordings from five of the procedures were analysed by two external surgeons. Patient characteristics and data on complications were retrieved from the Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). RESULTS Dissection time decreased as experience increased (p = 0.001). Surgeons with limited experience showed more rapid progress. The overall complication rate was 14 (5.8%), including 3 (1.3%) potentially technique-related complications. Video assessment scores showed no correlation with the number of procedures performed. The self-assessed performance level was rated lower when the operation was more complicated (p < 0.001). CONCLUSIONS Our results show that dissection time decreased with increasing experience. Most surgeons identified both favourable and unfavourable aspects of the ultrasonic FF technique. The ultrasonic device is considered well suited for gallbladder surgery, but most participating surgeons preferred to dissect the gallbladder the traditional way, beginning in the triangle of Calot. Nevertheless, LC with ultrasonic FF dissection can be considered easy to learn with a low complication rate during the initial learning curve, for both residents and specialists.
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Affiliation(s)
- My Blohm
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institute, Stockholm, Sweden.
- Department of Surgery, Mora Hospital, Mora, Sweden.
- Centre for Clinical Research Dalarna - Uppsala University, Falun, Sweden.
| | - Gabriel Sandblom
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Stockholm, Sweden
| | - Lars Enochsson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Yücel Cengiz
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Edmunds Austrums
- Department of Surgery, Central Hospital Kristianstad, Kristianstad, Sweden
| | - Elisabeth Abdon
- Department of Surgery, Östersund Hospital, Östersund, Sweden
| | - Joakim Hennings
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Mats Hedberg
- Department of Surgery, Mora Hospital, Mora, Sweden
- Centre for Clinical Research Dalarna - Uppsala University, Falun, Sweden
| | - Ulf Gustafsson
- Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | | | - Johanna Österberg
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, Mora Hospital, Mora, Sweden
- Centre for Clinical Research Dalarna - Uppsala University, Falun, Sweden
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12
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Pareek T, R R, R P, Chidambaranathan S, O L NB. A Single Centre Experience With Routine Magnetic Resonance Cholangiopancreatography in the Management of Patients With Gall Stone Disease. Cureus 2021; 13:e18743. [PMID: 34790490 PMCID: PMC8588194 DOI: 10.7759/cureus.18743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 11/05/2022] Open
Abstract
AIM To evaluate the role of preoperative magnetic resonance cholangiopancreatography (MRCP) in detection of common bile duct stone (CBDS) in cases of gall stone disease (GSD). METHODS This is a retrospective study with a prospectively maintained database, carried out in 116 patients who underwent laparoscopic cholecystectomy (LC) for GSD, from October 2017 to September 2020. Preoperative MRCP was performed in all cases. RESULTS MRCP detected CBDS in 23 out of 116 patients (19.8%) including silent CBDS in seven patients (6%). In situations of normal biochemical parameters and USG abdomen, 30.4% unnoticed CBDS out of all 23 CBDS, were discovered by MRCP. The sensitivity and specificity of aspartate aminotransferase (AST) or alanine aminotransferase (ALT) [positive predictive value (PPV): 24%; negative predictive value (NPV): 81.3%], alkaline phosphatase (ALP) (PPV: 63.2%; NPV: 88.7%), serum total bilirubin (PPV: 57.1%; NPV: 88.4%) and CBD diameter (PPV: 61.5%; NPV: 85.4%) were, respectively, 26.1% and 79.6%, 52.2% and 92.5%, 52.2% and 90.3%, and 34.8% and 94.6%. Cystic duct variations found in nine patients (7.75%). There was no bile duct injury (0%) noted in post operative patients. CONCLUSION With normal biochemical and USG parameters, MRCP is a valuable non-invasive investigation to detect the overlooked CBDS. After recognising the cystic duct variants, it may be possible to prevent bile duct injury. Before performing a laparoscopic cholecystectomy (LC) in GSD, a routine preoperative MRCP is highly recommended.
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Affiliation(s)
- Tanmay Pareek
- Surgical Gastroenterology, Madras Medical College, Chennai, IND
| | - Rajkumar R
- Surgical Gastroenterology, Madras Medical College, Chennai, IND
| | - Prabhakaran R
- Surgical Gastroenterology, Madras Medical College, Chennai, IND
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13
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Aspart F, Bolmgren JL, Lavanchy JL, Beldi G, Woods MS, Padoy N, Hosgor E. ClipAssistNet: bringing real-time safety feedback to operating rooms. Int J Comput Assist Radiol Surg 2021; 17:5-13. [PMID: 34297269 PMCID: PMC8739308 DOI: 10.1007/s11548-021-02441-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/17/2021] [Indexed: 12/18/2022]
Abstract
Purpose Cholecystectomy is one of the most common laparoscopic procedures. A critical phase of laparoscopic cholecystectomy consists in clipping the cystic duct and artery before cutting them. Surgeons can improve the clipping safety by ensuring full visibility of the clipper, while enclosing the artery or the duct with the clip applier jaws. This can prevent unintentional interaction with neighboring tissues or clip misplacement. In this article, we present a novel real-time feedback to ensure safe visibility of the instrument during this critical phase. This feedback incites surgeons to keep the tip of their clip applier visible while operating. Methods We present a new dataset of 300 laparoscopic cholecystectomy videos with frame-wise annotation of clipper tip visibility. We further present ClipAssistNet, a neural network-based image classifier which detects the clipper tip visibility in single frames. ClipAssistNet ensembles predictions from 5 neural networks trained on different subsets of the dataset. Results Our model learns to classify the clipper tip visibility by detecting its presence in the image. Measured on a separate test set, ClipAssistNet classifies the clipper tip visibility with an AUROC of 0.9107, and 66.15% specificity at 95% sensitivity. Additionally, it can perform real-time inference (16 FPS) on an embedded computing board; this enables its deployment in operating room settings. Conclusion This work presents a new application of computer-assisted surgery for laparoscopic cholecystectomy, namely real-time feedback on adequate visibility of the clip applier. We believe this feedback can increase surgeons’ attentiveness when departing from safe visibility during the critical clipping of the cystic duct and artery. Supplementary Information The online version supplementary material available at 10.1007/s11548-021-02441-x.
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Affiliation(s)
- Florian Aspart
- Caresyntax GmbH, Komturstraße 18A, 12099, Berlin, Germany.
| | - Jon L Bolmgren
- Caresyntax GmbH, Komturstraße 18A, 12099, Berlin, Germany
| | - Joël L Lavanchy
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Guido Beldi
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | | | - Nicolas Padoy
- ICube, University of Strasbourg, CNRS, IHU, Strasbourg, France
| | - Enes Hosgor
- Caresyntax GmbH, Komturstraße 18A, 12099, Berlin, Germany
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14
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Halle-Smith JM, Hall LA, Mirza DF, Roberts KJ. Risk factors for anastomotic stricture after hepaticojejunostomy for bile duct injury-A systematic review and meta-analysis. Surgery 2021; 170:1310-1316. [PMID: 34148708 DOI: 10.1016/j.surg.2021.05.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/04/2021] [Accepted: 05/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND After major bile duct injury, hepaticojejunostomy can result in good long-term patency, but anastomotic stricture is a common cause of long-term morbidity. There is a need to assimilate high-level evidence to establish risk factors for development of anastomotic stricture after hepaticojejunostomy for bile duct injury. METHODS A systematic review of studies reporting the rate of anastomotic stricture after hepaticojejunostomy for bile duct injury was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Meta-analyses of proposed risk factors were then performed. RESULTS Meta-analysis included 5 factors (n = 2,155 patients, 17 studies). Concomitant vascular injury (odds ratio 4.96; 95% confidence interval 1.92-12.86; P = .001), postrepair bile leak (odds ratio: 8.03; 95% confidence interval 2.04-31.71; P = .003), and repair by nonspecialist surgeon (odds ratio 11.29; 95% confidence interval 5.21-24.47; P < .0001) increased the rate of anastomotic stricture of hepaticojejunostomy after bile duct injury. Level of injury according to the Strasberg Grade did not significantly affect the rate of anastomotic stricture (odds ratio: 0.97; 95% confidence interval 0.45-2.10; P = .93). Owing to heterogeneity of reporting, it was not possible to perform a meta-analysis for the impact of timing of repair on anastomotic stricture rate. CONCLUSION The only modifiable risk factor, repair by a nonspecialist surgeon, demonstrates the importance of broad awareness of these data. Knowledge of these risk factors may permit risk stratification of follow-up, better informed consent, and understanding of prognosis.
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Affiliation(s)
- James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, United Kingdom. https://twitter.com/jameshallesmith
| | - Lewis A Hall
- College of Medical and Dental Sciences, University of Birmingham, United Kingdom
| | - Darius F Mirza
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, United Kingdom. https://twitter.com/DrDariusMirza
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, United Kingdom.
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15
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Martínez-Martínez JA, Cómbita-Rojas HA, Pinillos Navarro PC, Casallas-Cristancho D, Paez-Sosa LA, Ruiz-Gómez SM. Impacto de la participación del residente y su rol en desenlaces clínicos de los pacientes llevados a colecistectomía en un hospital universitario. REVISTA COLOMBIANA DE CIRUGÍA 2021. [DOI: 10.30944/20117582.859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Introducción. La colecistectomía es uno de los procedimientos quirúrgicos más realizados a nivel mundial, por lo que su aprendizaje es cada vez más necesario para los médicos residentes en entrenamiento, pero sin comprometer la seguridad de los pacientes. El objetivo de este estudio fue determinar el impacto de la participación de los médicos residentes en los principales desenlaces clínicos de la colecistectomía.
Métodos. Se realizó un estudio prospectivo de cohortes, donde se incluyeron los pacientes llevados a colecistectomía laparoscópica, desde junio de 2019 hasta julio de 2020. Se llevó a cabo el análisis estadístico para describir medidas de frecuencia, tendencia central, dispersión y análisis bivariados para los desenlaces de interés.
Resultados. Se incluyeron 482 pacientes a quienes se les practicó colecistectomía, 475 de ellas por vía laparoscópica. El 62,5 % fueron mujeres y el 76,2 % se realizaron de carácter urgente. En el 96 % de los procedimientos se contó con la participación de un residente. En el análisis bivariado no se encontró una diferencia estadísticamente significativa entre la participación del residente y un impacto negativo en los desenlaces clínicos de las variables relevantes.
Discusión. No hay evidencia de que la participación de médicos residentes en la colecistectomía laparoscópica se asocie con desenlaces adversos en los pacientes, lo que sugiere estar en relación con una introducción temprana y responsable a este procedimiento por parte de los docentes, permitiendo que la colecistectomía sea un procedimiento seguro.
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16
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Chik I, Khoo H, Azman A, Zuhdi Z, Harunarashid H, Jarmin R. Virtual reality laparoscopic simulator: Training tool for surgical trainee in Malaysia. FORMOSAN JOURNAL OF SURGERY 2021. [DOI: 10.4103/fjs.fjs_59_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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17
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Revisional surgery for recurrent benign bile duct strictures. Eur Surg 2020. [DOI: 10.1007/s10353-020-00667-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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18
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Tsaparas P, Machairas N, Ardiles V, Krawczyk M, Patrono D, Baccarani U, Cillo U, Aandahl EM, Cotsoglou C, Espinoza JL, Claría RS, Kostakis ID, Foss A, Mazzaferro V, de Santibañes E, Sotiropoulos GC. Liver transplantation as last-resort treatment for patients with bile duct injuries following cholecystectomy: a multicenter analysis. Ann Gastroenterol 2020; 34:111-118. [PMID: 33414630 PMCID: PMC7774661 DOI: 10.20524/aog.2020.0541] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/20/2020] [Indexed: 11/22/2022] Open
Abstract
Background Liver transplantation (LT) has been used as a last resort in patients with end-stage liver disease due to bile duct injuries (BDI) following cholecystectomy. Our study aimed to identify and evaluate factors that cause or contribute to an extended liver disease that requires LT as ultimate solution, after BDI during cholecystectomy. Methods Data from 8 high-volume LT centers relating to patients who underwent LT after suffering BDI during cholecystectomy were prospectively collected and retrospectively analyzed. Results Thirty-four patients (16 men, 18 women) with a median age of 45 (range 22-69) years were included in this study. Thirty of them (88.2%) underwent LT because of liver failure, most commonly as a result of secondary biliary cirrhosis. The median time interval between BDI and LT was 63 (range 0-336) months. There were 23 cases (67.6%) of postoperative morbidity, 6 cases (17.6%) of post-transplant 30-day mortality, and 10 deaths (29.4%) in total after LT. There was a higher probability that patients with concomitant vascular injury (hazard ratio 10.69, P=0.039) would be referred sooner for LT. Overall survival following LT at 1, 3, 5 and 10 years was 82.4%, 76.5%, 73.5% and 70.6%, respectively. Conclusion LT for selected patients with otherwise unmanageable BDI following cholecystectomy yields acceptable long-term outcomes.
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Affiliation(s)
- Peter Tsaparas
- 2 Department of Propaedeutic Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece (Peter Tsaparas, Nikolaos Machairas, Ioannis D. Kostakis, Georgios C. Sotiropoulos)
| | - Nikolaos Machairas
- 2 Department of Propaedeutic Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece (Peter Tsaparas, Nikolaos Machairas, Ioannis D. Kostakis, Georgios C. Sotiropoulos)
| | - Victoria Ardiles
- Division of Hepatobiliary Surgery, Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina (Victoria Ardiles, Johana Leiva Espinoza, Rodrigo Sanchez Claría, Eduardo de Santibañes)
| | - Marek Krawczyk
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Poland (Marek Krawczyk)
| | - Damiano Patrono
- General Surgery 2U, Liver Transplant Center, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Turin, Italy (Damiano Patrono)
| | - Umberto Baccarani
- Liver Transplant Unit, Department of Medicine, University of Udine, Udine, Italy (Umberto Baccarani)
| | - Umberto Cillo
- Hepatobiliary and Liver Transplant Unit, University of Padova School of Medicine, Padova, Italy (Umberto Cillo)
| | - Einar Martin Aandahl
- Surgical Department, Section of Transplant Surgery, Oslo University Hospital, Oslo, Norway (Einar Martin Aandahl, Aksel Foss)
| | - Christian Cotsoglou
- Department of Gastrointestinal Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori, University of Milan, Milan, Italy (Christian Cotsoglou)
| | - Johana Leiva Espinoza
- Division of Hepatobiliary Surgery, Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina (Victoria Ardiles, Johana Leiva Espinoza, Rodrigo Sanchez Claría, Eduardo de Santibañes)
| | - Rodrigo Sanchez Claría
- Division of Hepatobiliary Surgery, Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina (Victoria Ardiles, Johana Leiva Espinoza, Rodrigo Sanchez Claría, Eduardo de Santibañes)
| | - Ioannis D Kostakis
- 2 Department of Propaedeutic Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece (Peter Tsaparas, Nikolaos Machairas, Ioannis D. Kostakis, Georgios C. Sotiropoulos)
| | - Aksel Foss
- Surgical Department, Section of Transplant Surgery, Oslo University Hospital, Oslo, Norway (Einar Martin Aandahl, Aksel Foss)
| | - Vincenzo Mazzaferro
- Department of Gastrointestinal Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori, University of Milan, Milan, Italy (Christian Cotsoglou)
| | - Eduardo de Santibañes
- Division of Hepatobiliary Surgery, Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina (Victoria Ardiles, Johana Leiva Espinoza, Rodrigo Sanchez Claría, Eduardo de Santibañes)
| | - Georgios C Sotiropoulos
- 2 Department of Propaedeutic Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece (Peter Tsaparas, Nikolaos Machairas, Ioannis D. Kostakis, Georgios C. Sotiropoulos).,Department of General Visceral and Transplantation Surgery, University Hospital Essen, Germany (Georgios C. Sotiropoulos)
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19
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Abstract
Every year approximately 750,000 cholecystectomies are performed in the United States, most of those are performed laparoscopically. Postcholecystectomy complications are not uncommon and lead to increased morbidity and financial burden. Some of the most commonly encountered complications with laparoscopic cholecystectomy include biliary injury (0.08%-0.5%), bile leak (0.42%-1.1%), retained common bile duct stones (0.8%-5.7%), postcholecystectomy syndrome (10%-15%), and postcholecystectomy diarrhea (5%-12%). Endoscopy has an important role in the diagnosis and management of biliary complications and in many cases can provide definitive management. There is no consensus on the best therapeutic approach for biliary complications. Therefore, biliary complications should be approached by an experienced multidisciplinary team. It is important for the gastroenterologist to be familiar with the management of such complications (Visual Abstract, Supplemental Digital content 1, http://links.lww.com/AJG/B544).
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20
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Biodegradable versus multiple plastic stent implantation in benign biliary strictures: A systematic review and meta-analysis. Eur J Radiol 2020; 125:108899. [DOI: 10.1016/j.ejrad.2020.108899] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 02/04/2020] [Accepted: 02/11/2020] [Indexed: 12/12/2022]
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21
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Halle-Smith JM, Hodson J, Stevens LG, Dasari B, Marudanayagam R, Perera T, Sutcliffe RP, Muiesan P, Isaac J, Mirza DF, Roberts KJ. A comprehensive evaluation of the long-term clinical and economic impact of minor bile duct injury. Surgery 2020; 167:942-949. [PMID: 32183995 DOI: 10.1016/j.surg.2020.01.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/24/2020] [Accepted: 01/31/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Outcomes after Strasberg grade E bile duct injury have been widely reported. However, there are comparatively few reports of outcomes after Strasberg A to D bile duct injury. Therefore, the aim of this study was to comprehensively evaluate the long-term clinical and economic impact of Strasberg A to D bile duct injury. METHODS Patients with Strasberg A to D bile duct injury were identified from a prospectively collected and maintained database. Long-term biliary complication rates, as well as treatment costs were then estimated, and compared across Strasberg injury grades. RESULTS A total of N = 120 patients were identified, of whom N = 49, 13, 20, and 38 had Strasberg grade A, B, C, and D bile duct injury, respectively. Surgical repair was most commonly performed in Strasberg grade D injuries (74% vs 8%-20% in lower grades, P < .001). By 5 years post bile duct injury, the estimated long-term biliary complication rate was 40% in Strasberg grade D injuries, compared with 15% in Strasberg grade A (P = .022). A significant difference in total treatment and follow-up costs was also detected (P < .001), being highest in Strasberg grade D injuries (mean £11,048/US$14,252 per patient) followed by the Strasberg grade B group (mean £10,612/US$13,689 per patient). DISCUSSION Strasberg grade A to D injuries lead to considerable long-term morbidity and cost. Strasberg grade D injuries are typically managed surgically and result in the highest complication rate and treatment costs. Strasberg grade B injuries lead to a similar complication rate and treatment cost but are often managed without surgery.
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Affiliation(s)
- James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - James Hodson
- Institute of Translational Medicine, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Lewis G Stevens
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Bobby Dasari
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Ravi Marudanayagam
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Thamara Perera
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Robert P Sutcliffe
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Paolo Muiesan
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - John Isaac
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Darius F Mirza
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom.
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22
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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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23
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Halle-Smith JM, Hodson J, Stevens LG, Dasari B, Marudanayagam R, Perera T, Sutcliffe RP, Muiesan P, Isaac J, Mirza DF, Roberts KJ. A comprehensive evaluation of the long-term economic impact of major bile duct injury. HPB (Oxford) 2019; 21:1312-1321. [PMID: 30862441 DOI: 10.1016/j.hpb.2019.01.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/17/2019] [Accepted: 01/31/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Complications and litigation after bile duct injury (BDI) result in clinical and economic burden. The aim of this study was to comprehensively evaluate the long-term clinical and economic impact of major BDI. METHOD Patients with long-term follow-up after Strasberg E BDI were identified. Costs of treatment and litigation were the primary outcome. Relationships between these outcomes and repair factors, like timing of repair and surgeon expertise, were secondary outcomes. RESULTS Among 139 patients with a median follow up of 10.7 years, 40% of patients developed biliary complications. Repairs by non-specialist surgeons had significantly higher follow up and treatment costs than those by specialists (£25,814 vs. £14,269, p < 0.001). Estimated litigation costs were higher in delayed than immediate repairs (£23,295 vs. £12,864). As such, the lowest average costs per BDI are after immediate specialist repair and the highest after delayed non-specialist repair (£27,133 vs. £49,109, ×1.81 more costly, p < 0.001). Repair by a non-specialist surgeon (HR: 4.00, p < 0.001) and vascular injury (HR: 2.35, p = 0.013) were significant independent predictors of increased complication rates. CONCLUSION Costs of major BDI are considerable. They can be reduced by immediate on-table repair by specialist surgeons. This must therefore be considered the standard of care wherever possible.
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Affiliation(s)
- James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - James Hodson
- Medical Statistics, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Lewis G Stevens
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Bobby Dasari
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Ravi Marudanayagam
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Thamara Perera
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Robert P Sutcliffe
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Paolo Muiesan
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - John Isaac
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Darius F Mirza
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom.
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24
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Petrillo M, Ierardi AM, Tofanelli L, Maresca D, Angileri A, Patella F, Carrafiello G. Gd-EOB-DTP-enhanced MRC in the preoperative percutaneous management of intra and extrahepatic biliary leakages: does it matter? Gland Surg 2019; 8:174-183. [PMID: 31183327 DOI: 10.21037/gs.2019.03.09] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Postoperative bile leakage is a common complication of abdominal surgical procedures and a precise localization of is important to choose the best management. Many techniques are available to correctly identify bile leaks, including ultrasound (US), computed tomography (CT) or magnetic resonance imaging (MRI), being the latter the best to clearly depict "active" bile leakages. This paper presents the state of the art algorithm in the detection of biliary leakages in order to plan a percutaneous biliary drainage focusing on widely available and safe contrast agent, the Gb-EOB-DPA. We consider its pharmacokinetic properties and impact in biliary imaging explain current debates to optimize image quality. We report common sites of leakage after surgery with special considerations in cirrhotic liver to show what interventional radiologists should look to easily detect bile leaks.
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Affiliation(s)
- Mario Petrillo
- Diagnostic and Interventional Radiology Department, San Paolo Hospital, University of Milan, Milan, Italy
| | - Anna Maria Ierardi
- Diagnostic and Interventional Radiology Department, San Paolo Hospital, University of Milan, Milan, Italy
| | - Laura Tofanelli
- Diagnostic and Interventional Radiology Department, San Paolo Hospital, University of Milan, Milan, Italy
| | - Duilia Maresca
- Diagnostic and Interventional Radiology Department, San Paolo Hospital, University of Milan, Milan, Italy
| | - Alessio Angileri
- Diagnostic and Interventional Radiology Department, San Paolo Hospital, University of Milan, Milan, Italy
| | - Francesca Patella
- Diagnostic and Interventional Radiology Department, San Paolo Hospital, University of Milan, Milan, Italy
| | - Gianpaolo Carrafiello
- Diagnostic and Interventional Radiology Department, San Paolo Hospital, University of Milan, Milan, Italy
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25
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Ekmekcigil E, Ünalp Ö, Uğuz A, Hasanov R, Bozkaya H, Köse T, Parıldar M, Özütemiz Ö, Çoker A. Management of iatrogenic bile duct injuries: Multiple logistic regression analysis of predictive factors affecting morbidity and mortality. Turk J Surg 2018; 34:264-270. [PMID: 30216168 DOI: 10.5152/turkjsurg.2018.3888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 11/30/2017] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Iatrogenic bile duct injuries remain a challenge for the surgeons to overcome. The predictive factors affecting morbidity and mortality are important for determining the best management modality. MATERIAL AND METHODS The patients who referred to Ege University Faculty of Medicine after laparoscopy associated iatrogenic bile duct injury are grouped according to Strasberg-Bismuth classification system. The type and number of prior attempts, concomitant complications, and treatment modalities are analyzed using the SPSS version 18 (IBM, Chicago, IL, USA). The variables with p<0.10 were considered for univariate analysis and then evaluated for predictive factors by forward Logistic Regression method using multiple logistic regression analysis. RESULTS According to the analysis of 105 patients who were referred during 2004-2014, the type and number of prior attempts are considered predictive factors in sepsis. In multiple logistic regression analysis, abscess formation, concomitant vascular injury, and serum bilirubin level are significantly effective in predicting mortality. CONCLUSION The management of iatrogenic bile duct injuries should be carefully planned with a multidisciplinary approach. The predictive factors affecting morbidity and mortality are important in determining the best modality for managing iatrogenic bile duct injuries. Abscess formation, vascular injury, and serum bilirubin level are the potential risk factors. Therefore, we can strongly recommend immediate assessment of patients for prompt diagnosis and referring to an HPB center, to avoid further injuries.
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Affiliation(s)
- Ela Ekmekcigil
- Department of General Surgery, Ege University University School of Medicine, İzmir, Turkey
| | - Ömer Ünalp
- Department of General Surgery, Ege University University School of Medicine, İzmir, Turkey
| | - Alper Uğuz
- Department of General Surgery, Ege University University School of Medicine, İzmir, Turkey
| | - Ruslan Hasanov
- Department of General Surgery, Ege University University School of Medicine, İzmir, Turkey
| | - Halil Bozkaya
- Department of Interventional Radiology, Ege University University School of Medicine, İzmir, Turkey
| | - Timur Köse
- Department of Biostatistics and Medical Informatics, Ege University University School of Medicine, İzmir, Turkey
| | - Mustafa Parıldar
- Department of Interventional Radiology, Ege University University School of Medicine, İzmir, Turkey
| | - Ömer Özütemiz
- Department of Gastroenterology, Ege University University School of Medicine, İzmir, Turkey
| | - Ahmet Çoker
- Department of General Surgery, Ege University University School of Medicine, İzmir, Turkey
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26
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Mangieri CW, Hendren BP, Strode MA, Bandera BC, Faler BJ. Bile duct injuries (BDI) in the advanced laparoscopic cholecystectomy era. Surg Endosc 2018; 33:724-730. [PMID: 30006843 DOI: 10.1007/s00464-018-6333-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/06/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy is the most commonly performed laparoscopic procedure. It is superior in nearly every regard compared to open cholecystectomies. The one significant aspect where the laparoscopic approach is inferior regards the association with bile duct injuries (BDI). The BDI rate with laparoscopic cholecystectomy is approximately 0.5%; nearly triple the rate compared to the open approach. We propose that 0.5% BDI rate with the laparoscopic approach is no longer accurate. METHODS The National Surgical Quality Improvement Program (NSQIP) registry was retrospectively reviewed. All laparoscopic cholecystectomies performed between 2012 and 2016 were extracted. A total of 217,774 cases meeting inclusion criteria were analyzed. The primary data points were the overall BDI incidence rate and time of diagnosis. BDI were identified by ICD-9 and ICD-10 codes. Secondary data points were variables associated with BDI. RESULTS The BDI rate was 0.19%. 77% of cases were diagnosed after the index surgical admission. Intra-operative cholangiography (IOC) use was associated with a higher BDI rate and higher identification rate of a BDI intraoperatively (P value < 0.0001). Resident teaching cases were protective with a RR score of 0.56 (P value < 0.0001). The presence of cholecystitis increased the risk of a BDI with a RR score of 1.20 (P value < 0.0001). There was a low conversion rate of 0.04% however converted cases had a nearly hundredfold increase in BDI at 15% (P value < 0.0001). CONCLUSIONS The performance of laparoscopic cholecystectomies in North America is no longer associated with higher BDI rates compared to open. IOC use still is not protective against BDI, and cholecystitis continues to be a risk factor for BDI. When a cholecystectomy requires conversion from a laparoscopic to an open approach the BDI increases a hundredfold; which may raise the concern if this approach is still a safe bailout method for a difficult laparoscopic dissection.
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Affiliation(s)
- Christopher W Mangieri
- Dwight D. Eisenhower Army Medical Center (DDEAMC), Fort Gordon, GA, USA. .,General Surgery Department, Dwight D. Eisenhower Army Medical Center (DDEAMC), 300 East Hospital Road, Fort Gordon, GA, 30905, USA.
| | - Bryan P Hendren
- Dwight D. Eisenhower Army Medical Center (DDEAMC), Fort Gordon, GA, USA
| | - Matthew A Strode
- Dwight D. Eisenhower Army Medical Center (DDEAMC), Fort Gordon, GA, USA.,Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Bradley C Bandera
- Dwight D. Eisenhower Army Medical Center (DDEAMC), Fort Gordon, GA, USA
| | - Byron J Faler
- Dwight D. Eisenhower Army Medical Center (DDEAMC), Fort Gordon, GA, USA
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27
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Virzì V, Ognibene NMG, Sciortino AS, Culmone G, Virzì G. Routine MRCP in the management of patients with gallbladder stones awaiting cholecystectomy: a single-centre experience. Insights Imaging 2018; 9:653-659. [PMID: 29978345 PMCID: PMC6206385 DOI: 10.1007/s13244-018-0640-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/25/2018] [Accepted: 05/28/2018] [Indexed: 01/14/2023] Open
Abstract
Objectives To assess the frequency of choledocolithiasis and the role of preoperative laboratory findings, ultrasound (US) and magnetic resonance cholangio-pancreatography (MRCP) in the detection of choledocolithiasis in patients with gallbladder stones awaiting cholecystectomy. Methods A consecutive sample of 104 patients underwent MRCP prior to cholecystectomy. The patients were classified into different groups on the basis of the risk of choledocolithiasis. A specialised doctor with more 10 years of experience performed the US interpretation and a radiologist performed the MRCP interpretation blinded to US or aspartate aminotransferase (AST)/alanine aminotransferase (ALT)/alkaline phosphatase (ALP) results. A chi-square (χ2) test was performed to assess the statistical significance of differences in the frequency of choledocolithiasis based on laboratory findings, choledocal diameter on US and group risk. Results MRCP showed calculi in 7 out of 104 patients (6.7%), with no statistically significant differences between the high/moderate risk and low/no risk groups and between the patients with normal and altered laboratory findings or choledocal diameter on preoperative US. The sensitivity and specificity of AST/ALT [positive predictive value (PPV): 12%; negative predictive value (NPV): 94%], ALP (PPV: 7%; NPV: 94%), total serum bilirubin (PPV: 6%; NPV: 93%) and choledocal diameter (PPV: 20%; NPV: 94%) were, respectively, 28.6 and 94.8%, 85.7 and 17.5%, 14.3 and 93.8%, and 14.3 and 95.9%. Conclusions MRCP is a reliable evaluation for the detection of common bile duct (CBD) stones, reducing the misdiagnosis of retained choledocholithiasis with normal biochemical predictors and US examination. Main messages • MRCP is a non-invasive method for the detection of CBD stones. • Preoperative MRCP reduces the misdiagnosis of retained choledocholithiasis. • Detection of choledocholithiasis is mandatory prior to cholecystectomy to avoid surgical morbidity
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Affiliation(s)
- Valentina Virzì
- Department of Radiology, "Regina Pacis" Clinic, via Principe Lanza di Scalea 3/5, 93017, San Cataldo, CL, Italy
| | | | - Antonio Salvatore Sciortino
- Department of Surgery, "Regina Pacis" Clinic, via Principe Lanza di Scalea 3/5, 93017, San Cataldo, CL, Italy
| | - Glenda Culmone
- "Regina Pacis" Clinic, Skema Iniziative Sanitarie, via Principe Lanza di Scalea 3/5, 93017, San Cataldo, CL, Italy
| | - Giuseppe Virzì
- Department of Surgery, "Regina Pacis" Clinic, via Principe Lanza di Scalea 3/5, 93017, San Cataldo, CL, Italy
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28
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Migliore M, Arezzo A, Arolfo S, Passera R, Morino M. Safety of single-incision robotic cholecystectomy for benign gallbladder disease: a systematic review. Surg Endosc 2018; 32:4716-4727. [PMID: 29943057 DOI: 10.1007/s00464-018-6300-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 06/18/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Multiport laparoscopic cholecystectomy (MLC) is the gold standard technique for cholecystectomy. In order to reduce postoperative pain and improve cosmetic results, the application of the single-incision laparoscopic cholecystectomy (SILC) technique was introduced, leading surgeons to face important challenges. Robotic technology has been proposed to overcome some of these limitations. The purpose of this review is to assess the safety of single-incision robotic cholecystectomy (SIRC) for benign disease. METHODS An Embase and Pubmed literature search was performed in February 2017. Randomized controlled trial and prospective observational studies were selected and assessed using PRISMA recommendations. Primary outcome was overall postoperative complication rate. Secondary outcomes were postoperative bile leak rate, total conversion rate, operative time, wound complication rate, postoperative hospital stay, and port site hernia rate. The outcomes were analyzed in Forest plots based on fixed and random effects model. Heterogeneity was assessed using the I2 statistic. RESULTS A total of 13 studies provided data about 1010 patients who underwent to SIRC for benign disease of gallbladder. Overall postoperative complications rate was 11.6% but only 4/1010 (0.4%) patients required further surgery. A postoperative bile leak was reported in 3/950 patients (0.3%). Conversion occurred in 4.2% of patients. Mean operative time was 86.7 min including an average of 42 min should be added as for robotic console time. Wound complications occurred in 3.7% of patients. Median postoperative hospital stay was 1 day. Port site hernia at the latest follow-up available was reported in 5.2% of patients. CONCLUSIONS The use of the Da Vinci robot in single-port cholecystectomy seems to have similar results in terms of incidence and grade of complications compared to standard laparoscopy. In addition, it seems affected by the same limitations of single-port surgery, consisting of an increased operative time and incidence of port site hernia.
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Affiliation(s)
- Marco Migliore
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy.
| | - Simone Arolfo
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
| | - Roberto Passera
- Division of Nuclear Medicine, University of Torino, Torino, Italy
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
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29
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Kaprin AD, Kostin AA, Nikiforov PV, Egorov VI, Grishin NA, Lozhkin MV, Petrov LO, Bykasov SA, Sidorov DV. [Pancreatoduodenectomy: learning curve within single multi-field center]. Khirurgiia (Mosk) 2018:17-23. [PMID: 29697678 DOI: 10.17116/hirurgia2018417-23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIM To analyze learning curve by using of immediate results of pancreatoduodenectomy at multi-field oncology institute. MATERIAL AND METHODS For the period 2010-2016 at Abdominal Oncology Department of Herzen Moscow Oncology Research Institute 120 pancreatoduodenal resections were consistently performed. All patients were divided into two groups: the first 60 procedures (group A) and subsequent 60 operations (group B). Herewith, first 60 operations were performed within the first 4.5 years of study period, the next 60 operations - within remaining 2.5 years. RESULTS Learning curves showed significantly variable intraoperative blood loss (1100 ml and 725 ml), surgery time (589 min and 513 min) and postoperative hospital-stay (15 days and 13 days) in group A followed by gradual improvement of these values in group B. Incidence of negative resection margin (R0) was also significantly improved in the last 60 operations (70 and 92%, respectively). CONCLUSION Despite pancreatoduodenectomy is one of the most difficult surgical interventions in abdominal surgery learning curve will differ from one surgeon to another.
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Affiliation(s)
- A D Kaprin
- Herzen Moscow Oncology Research Institute of Healthcare Ministry of the Russian Federation - branch of National Medical Research Radiology Center
| | - A A Kostin
- Herzen Moscow Oncology Research Institute of Healthcare Ministry of the Russian Federation - branch of National Medical Research Radiology Center
| | - P V Nikiforov
- Herzen Moscow Oncology Research Institute of Healthcare Ministry of the Russian Federation - branch of National Medical Research Radiology Center
| | - V I Egorov
- Br. Bakhrushiny City Clinical Hospital of Moscow Healthcare Department, Moscow, Russia
| | - N A Grishin
- Herzen Moscow Oncology Research Institute of Healthcare Ministry of the Russian Federation - branch of National Medical Research Radiology Center
| | - M V Lozhkin
- Herzen Moscow Oncology Research Institute of Healthcare Ministry of the Russian Federation - branch of National Medical Research Radiology Center
| | - L O Petrov
- Herzen Moscow Oncology Research Institute of Healthcare Ministry of the Russian Federation - branch of National Medical Research Radiology Center
| | - S A Bykasov
- Herzen Moscow Oncology Research Institute of Healthcare Ministry of the Russian Federation - branch of National Medical Research Radiology Center
| | - D V Sidorov
- Herzen Moscow Oncology Research Institute of Healthcare Ministry of the Russian Federation - branch of National Medical Research Radiology Center
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30
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Ortiz-Brizuela E, Sifuentes-Osornio J, Manzur-Sandoval D, Terán-Ellis SMY, Ponce-de-León S, Torres-González P, Mercado MÁ. Acute Cholangitis After Bilioenteric Anastomosis for Bile Duct Injuries. J Gastrointest Surg 2017; 21:1613-1619. [PMID: 28744740 DOI: 10.1007/s11605-017-3497-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 07/03/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND/PURPOSE The study aims to describe the clinical features, microbiology, and associated factors of acute cholangitis (AC) after bilioenteric anastomosis (BEA) for biliary duct injury (BDI). Additionally, we assessed the performance of the Tokyo Guidelines 2013 (TG13) recommendations in these patients. METHODS We conducted a case-control study of 524 adults with a history of BEA for BDI from January 2000 to January 2014. A propensity score adjustment was performed for the analysis of the independent role of the main factors identified during the univariate logistic regression procedure. RESULTS We identified 117 episodes of AC in 70 patients; 51.3% were definitive AC according to the TG13 diagnostic criteria, and 39.3% did not fulfill the imaging criteria of AC. A history of post-operative biliary complications (OR 2.55, 95% CI 1.38-4.70) and the bile duct confluence preservation (OR 0.46, 95% CI 0.24-0.87) were associated with AC. Eighty-nine percent of the microorganisms were Enterobacteriaceae; of them, 28% were extended spectrum β-lactamase (ESBL) producers. CONCLUSIONS AC is a common complication after BEA and must be suspected even in the absence of imaging findings, particulary in patients with a history of post-operative biliary complications, and/or without bile duct confluence preserved. An empirical treatment for ESBL-producing Enterobacteriaceae may be appropriate in patients living in countries with a high rate of bacterial drug resistance.
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Affiliation(s)
- Edgar Ortiz-Brizuela
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, Mexico
| | - José Sifuentes-Osornio
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Avenida Vasco de Quiroga No. 15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan, C.P.14080, México, Distrito Federal, Mexico.
| | - Daniel Manzur-Sandoval
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Avenida Vasco de Quiroga No. 15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan, C.P.14080, México, Distrito Federal, Mexico
| | - Santiago Mier Y Terán-Ellis
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Avenida Vasco de Quiroga No. 15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan, C.P.14080, México, Distrito Federal, Mexico
| | - Sergio Ponce-de-León
- Clinical Epidemiology Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, Mexico
| | - Pedro Torres-González
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, Mexico
| | - Miguel Ángel Mercado
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Avenida Vasco de Quiroga No. 15, Colonia Belisario Domínguez Sección XVI, Delegación Tlalpan, C.P.14080, México, Distrito Federal, Mexico.
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31
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Lauterio A, De Carlis R, Di Sandro S, Ferla F, Buscemi V, De Carlis L. Liver transplantation in the treatment of severe iatrogenic liver injuries. World J Hepatol 2017; 9:1022-1029. [PMID: 28932348 PMCID: PMC5583534 DOI: 10.4254/wjh.v9.i24.1022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/19/2017] [Accepted: 07/14/2017] [Indexed: 02/06/2023] Open
Abstract
The place of liver transplantation in the treatment of severe iatrogenic liver injuries has not yet been widely discussed in the literature. Bile duct injuries during cholecystectomy represent the leading cause of liver transplantation in this setting, while other indications after abdominal surgery are less common. Urgent liver transplantation for the treatment of severe iatrogenic liver injury may-represent a surgical challenge requiring technically difficult and time consuming procedures. A debate is ongoing on the need for centralization of complex surgery in tertiary referral centers. The early referral of patients with severe iatrogenic liver injuries to a tertiary center with experienced hepato-pancreato-biliary and transplant surgery has emerged as the best treatment of care. Despite widespread interest in the use of liver transplantation as a treatment option for severe iatrogenic injuries, reported experiences indicate few liver transplants are performed. This review analyzes the literature on liver transplantation after hepatic injury and discusses our own experience along with surgical advances and future prospects in this uncommon transplant setting.
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Affiliation(s)
- Andrea Lauterio
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy.
| | - Riccardo De Carlis
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Stefano Di Sandro
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Fabio Ferla
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Vincenzo Buscemi
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Luciano De Carlis
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
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LeBedis CA, Bates DDB, Soto JA. Iatrogenic, blunt, and penetrating trauma to the biliary tract. Abdom Radiol (NY) 2017; 42:28-45. [PMID: 27503381 DOI: 10.1007/s00261-016-0856-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Iatrogenic and traumatic bile leaks are uncommon. However, given the overall increase in number of hepatobiliary surgeries and the paradigm shift toward nonoperative management of patients with liver trauma, they have become more prevalent in recent years. Imaging is essential to establishing early diagnosis and guiding treatment as the clinical signs and symptoms of bile leaks are nonspecific, and a delay in recognition of bile leaks portends a high morbidity and mortality rate. Findings suspicious for a bile leak at computed tomography or ultrasonography include free or contained peri- or intrahepatic low density fluid in the setting of recent trauma or hepatobiliary surgery. Hepatobiliary scintigraphy and magnetic resonance cholangiopancreatography (MRCP) with hepatobiliary contrast agents can be used to detect active or contained bile leak. MRCP with hepatobiliary contrast agents has the unique ability to reveal the exact location of bile leak, which often governs whether endoscopic management or surgical management is warranted. Percutaneous transhepatic cholangiography and fluoroscopy via an indwelling catheter that is placed either percutaneously or surgically are useful modalities to guide percutaneous transhepatic biliary drain placement which can provide biliary drainage and/or diversion in the setting of traumatic biliary injury. Surgical treatment of a bile duct injury with Roux-en-Y hepaticojejunostomy is warranted if definitive treatment cannot be accomplished through percutaneous or endoscopic means.
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Mellinger JD, Williams RG, Sanfey H, Fryer JP, DaRosa D, George BC, Bohnen JD, Schuller MC, Sandhu G, Minter RM, Gardner AK, Scott DJ. Teaching and assessing operative skills: From theory to practice. Curr Probl Surg 2016; 54:44-81. [PMID: 28212782 DOI: 10.1067/j.cpsurg.2016.11.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 11/22/2016] [Indexed: 11/22/2022]
Affiliation(s)
- John D Mellinger
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL.
| | - Reed G Williams
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL; Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Hilary Sanfey
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL; American College of Surgeons, Chicago, IL
| | - Jonathan P Fryer
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Debra DaRosa
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Brian C George
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jordan D Bohnen
- Department of General Surgery, Massachussetts General Hospital and Harvard University, Boston, MA
| | - Mary C Schuller
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Gurjit Sandhu
- Department of Surgery, University of Michigan, Ann Arbor, MI; Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI
| | - Rebecca M Minter
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Aimee K Gardner
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX; UT Southwestern Simulation Center, University of Texas Southwestern Medical Center, Dallas, TX
| | - Daniel J Scott
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX; UT Southwestern Simulation Center, University of Texas Southwestern Medical Center, Dallas, TX
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Elmasry M, Lindop D, Dunne DF, Malik H, Poston GJ, Fenwick SW. The risk of malignancy in ultrasound detected gallbladder polyps: A systematic review. Int J Surg 2016; 33 Pt A:28-35. [PMID: 27465099 DOI: 10.1016/j.ijsu.2016.07.061] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/11/2016] [Accepted: 07/19/2016] [Indexed: 02/08/2023]
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Increasing resident utilization and recognition of the critical view of safety during laparoscopic cholecystectomy: a pilot study from an academic medical center. Surg Endosc 2016; 31:1627-1635. [PMID: 27495348 DOI: 10.1007/s00464-016-5150-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/21/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is a commonly performed surgical procedure; however, it is associated with an increased rate of bile duct injury (BDI) when compared to the open approach. The critical view of safety (CVS) provides a secure method of ductal identification to help avoid BDI. CVS is not universally utilized by practicing surgeons and/or taught to surgical residents. We aimed to pilot a safe cholecystectomy curriculum to demonstrate that educational interventions could improve resident adherence to and recognition of the CVS during LC. METHODS Forty-three general surgery residents at Thomas Jefferson University Hospital were prospectively studied. Fifty-one consecutive LC cases were recorded during the pre-intervention period, while the residents were blinded to the outcome measured (CVS score). As an intervention, a comprehensive lecture on safe cholecystectomy was given to all residents. Fifty consecutive LC cases were recorded post-intervention, while the residents were empowered to "time-out" and document the CVS with a doublet photograph. Two independent surgeons scored the videos and photographs using a 6-point scale. Residents were surveyed pre- and post-intervention to determine objective knowledge and self-reported comfort using a 5-point Likert scale. RESULTS In the 18-week study period, 101 consecutive LCs were adequately captured and included (51 pre-intervention, 50 post-intervention). Patient demographics and clinical data were similar. The mean CVS score improved from 2.3 to 4.3 (p < 0.001). The number of videos with CVS score >4 increased from 15.7 to 52 % (p < 0.001). There was strong inter-observer agreement between reviewers. The pre- and post-intervention questionnaire response rates were 90.7 and 83.7 %, respectively. A greater number of residents correctly identified all criteria of the CVS post-intervention (41-93 %, p < 0.001) and offered appropriate bailout techniques (77-94 %, p < 0.001). Residents strongly agreed that the CVS education should be included in general surgery residency curriculum (mean Likert score = 4.71, SD = 0.54). Residents also agreed that they are more comfortable with their LC skills after the intervention (4.27, σ = 0.83). CONCLUSION The combination of focused education along with intraoperative time-out significantly improved CVS scores and knowledge during LC in our institution.
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Functional gallbladder disease: Operative trends and short-term outcomes. Surgery 2016; 160:100-105. [DOI: 10.1016/j.surg.2016.03.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 02/19/2016] [Accepted: 03/03/2016] [Indexed: 12/19/2022]
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Karanikas M, Bozali F, Vamvakerou V, Markou M, Memet Chasan ZT, Efraimidou E, Papavramidis TS. Biliary tract injuries after lap cholecystectomy-types, surgical intervention and timing. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:163. [PMID: 27275476 DOI: 10.21037/atm.2016.05.07] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Bile duct lesions, including leaks and strictures, are immanent complications of open or laparoscopic cholecystectomy (LC). Endoscopic procedures have gained increasing potential as the treatment of choice in the management of postoperative bile duct injuries. Bile duct injury (BDI) is a severe and potentially life-threatening complication of LC. Several series have described a 0.5% to 0.6% incidence of BDI during LC. Early recognition and an adequate multidisciplinary approach are the cornerstones for the optimal final outcome. Suboptimal management of injuries often leads to more extensive damage to the biliary tree and its vasculature. Early referral to a tertiary care center with experienced hepatobiliary surgeons and skilled interventional radiologists would appear to be necessary to assure optimal results.
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Affiliation(s)
- Michail Karanikas
- 1 1st Department of Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Dragana, Alexandroupolis, 68100 Thrace, Greece ; 2 1st Propedeutic Surgical Clinic, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, 54655 Macedonia, Greece
| | - Ferdi Bozali
- 1 1st Department of Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Dragana, Alexandroupolis, 68100 Thrace, Greece ; 2 1st Propedeutic Surgical Clinic, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, 54655 Macedonia, Greece
| | - Vasileia Vamvakerou
- 1 1st Department of Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Dragana, Alexandroupolis, 68100 Thrace, Greece ; 2 1st Propedeutic Surgical Clinic, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, 54655 Macedonia, Greece
| | - Markos Markou
- 1 1st Department of Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Dragana, Alexandroupolis, 68100 Thrace, Greece ; 2 1st Propedeutic Surgical Clinic, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, 54655 Macedonia, Greece
| | - Zeinep Tzoutze Memet Chasan
- 1 1st Department of Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Dragana, Alexandroupolis, 68100 Thrace, Greece ; 2 1st Propedeutic Surgical Clinic, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, 54655 Macedonia, Greece
| | - Eleni Efraimidou
- 1 1st Department of Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Dragana, Alexandroupolis, 68100 Thrace, Greece ; 2 1st Propedeutic Surgical Clinic, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, 54655 Macedonia, Greece
| | - Theodossis S Papavramidis
- 1 1st Department of Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Dragana, Alexandroupolis, 68100 Thrace, Greece ; 2 1st Propedeutic Surgical Clinic, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, 54655 Macedonia, Greece
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Li T, Kim G, Chang S. Tips and tricks to avoid bile duct injury in SILC: an experience of 500 cases. Surg Endosc 2016; 30:4750-4755. [PMID: 26932550 DOI: 10.1007/s00464-016-4802-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/03/2016] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Conventional laparoscopic cholecystectomy is the gold standard surgical treatment for symptomatic gallstones. Surgeons have attempted to minimize the number of incisions via single-incision laparoscopic cholecystectomy (SILC), which offers benefits including improved cosmesis, possibly less postoperative pain, and improved patient satisfaction. However, studies show that there is an increased risk of operative complications-in particular bile duct injuries. We report 500 consecutive cases of SILC performed without bile duct injury. METHODS A retrospective study of 500 continuous cases of SILC performed by the same surgeon at a single institution was conducted. Data on patient demographics, operative details, and postoperative outcomes were collected and evaluated. Detailed analysis of surgical techniques specifically to reduce bile duct injury was performed and described in this study. RESULTS In total, 500 patients underwent SILC during the study period. Eight patients needed additional ports to complete the surgery, while one was converted to an open surgery. No serious intraoperative complications, such as bile duct injury, were encountered. CONCLUSION Our experience shows that with due care and caution during SILC, with particular attention towards achieving the critical view of safety and a standardized technique, bile duct injury in SILC can be avoided.
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Affiliation(s)
- Tony Li
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Guowei Kim
- Department of Surgery, National University Hospital, Singapore, Singapore
| | - Stephen Chang
- Division of Hepatobiliary and Pancreatic Surgery and Liver Transplant Program, University Surgical Cluster, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore.
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Abstract
Biliary strictures frequently present a diagnostic challenge during pre-operative evaluation to determine their benign or malignant nature. A variety of benign conditions, such as primary sclerosing cholangitis (PSC) and IgG4-related sclerosing cholangitis, frequently mimic malignancies. In addition, PSC and other chronic biliary diseases increase the risk of cholangiocarcinoma and so require ongoing vigilance. Although traditional methods of evaluation including imaging, detection of circulating tumour markers, and sampling by endoscopic ultrasound and endoscopic retrograde cholangiopancreatography have a high specificity, they suffer from low sensitivity. Currently, up to 20% of biliary strictures remain indeterminate after pre-operative evaluation and necessitate surgical intervention for a definitive diagnosis. The discovery of novel biomarkers, new imaging modalities and advanced endoscopic techniques suggests that a multimodality approach might lead to better diagnostic accuracy.
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Day-care laparoscopic cholecystectomy with diathermy hook versus fundus-first ultrasonic dissection: a randomized study. Surg Endosc 2015; 30:3867-72. [DOI: 10.1007/s00464-015-4691-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 11/17/2015] [Indexed: 10/22/2022]
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Tao L, Li Q, Ren H, Chen B, Hou X, Mou L, Zhou S, Zhou J, Sun X, Dai J, Ding Y. Repair of extrahepatic bile duct defect using a collagen patch in a Swine model. Artif Organs 2015; 39:352-360. [PMID: 25345752 DOI: 10.1111/aor.12388] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Extrahepatic bile duct (EBD) injury can happen during surgery. To repair a defect of the EBD and prevent postoperative biliary complications, a collagen membrane was designed. The collagen material was porous, biocompatible, and degradable and could maintain its shape in bile soaking for about 4 weeks. The goal was to induce rapid bile duct tissue regeneration. Twenty Chinese experimental hybrid pigs were used in this study and divided into a patch group and a control group. A spindle-shaped defect (20 mm × 6 mm) was made in the anterior wall of the lower EBD in the swine model, and then the defect was reconstructed using a collagen patch with a drainage tube and wrapped with greater omentum. Ultrasound was performed at 2, 4, 8, and 12 weeks postoperatively. Liver function tests and white blood cell count (WBC) were measured. Hematoxylin-eosin staining, cytokeratin 7 immunohistochemical staining, and Van Gieson's staining of EBD were used. The diameter and thickness of the EBD at the graft site were measured. There was no significant difference in liver function tests or WBC in the patch group compared with the control group. No evidence of leakage or stricture was observed, but some pigs developed biliary sludge or stone at 4 and 8 weeks. The drainage tube was lost within 12 weeks. The neo-EBD could withstand normal biliary pressure 2 weeks after surgery. Histological study showed the accessory glands and epithelial cells gradually regenerated at graft sites from 4 weeks, with increasing vessel infiltration and decreasing inflammation. The collagen fibers became regular with full coverage of epithelial cells. The statistical analysis of diameter and thickness showed no stricture formation at the graft site, but the EBD wall was slightly thicker than in the normal bile duct due to collagen fiber deposition. The structure of the neo-EBD was similar to that of the normal EBD. The collagen membrane patch associated with a drainage tube and wrapped with greater omentum effectively induced the regeneration of the EBD defect within 12 weeks.
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Affiliation(s)
- Liang Tao
- Department of Hepatobiliary Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
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Felekouras E, Petrou A, Neofytou K, Moris D, Dimitrokallis N, Bramis K, Griniatsos J, Pikoulis E, Diamantis T. Early or Delayed Intervention for Bile Duct Injuries following Laparoscopic Cholecystectomy? A Dilemma Looking for an Answer. Gastroenterol Res Pract 2015; 2015:104235. [PMID: 25722718 PMCID: PMC4333332 DOI: 10.1155/2015/104235] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 01/16/2015] [Indexed: 12/27/2022] Open
Abstract
Background. To evaluate the effect of timing of management and intervention on outcomes of bile duct injury. Materials and Methods. We retrospectively analyzed 92 patients between 1991 and 2011. Data concerned patient's demographic characteristics, type of injury (according to Strasberg classification), time to referral, diagnostic procedures, timing of surgical management, and final outcome. The endpoint was the comparison of postoperative morbidity (stricture, recurrent cholangitis, required interventions/dilations, and redo reconstruction) and mortality between early (less than 2 weeks) and late (over 12 weeks) surgical reconstruction. Results. Three patients were treated conservatively, two patients were treated with percutaneous drainage, and 13 patients underwent PTC or ERCP. In total 74 patients were operated on in our unit. 58 of them underwent surgical reconstruction by end-to-side Roux-en-Y hepaticojejunostomy, 11 underwent primary bile duct repair, and the remaining 5 underwent more complex procedures. Of the 56 patients, 34 patients were submitted to early reconstruction, while 22 patients were submitted to late reconstruction. After a median follow-up of 93 months, there were two deaths associated with BDI after LC. Outcomes after early repairs were equal to outcomes after late repairs when performed by specialists. Conclusions. Early repair after BDI results in equal outcomes compared with late repair. BDI patients should be referred to centers of expertise and experience.
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Affiliation(s)
- Evangelos Felekouras
- 1st Department of Surgery, University of Athens Medical School, Laikon General Hospital, Agiou Thoma 17 Street, 11527 Athens, Greece
| | - Athanasios Petrou
- 1st Department of Surgery, University of Athens Medical School, Laikon General Hospital, Agiou Thoma 17 Street, 11527 Athens, Greece
| | - Kyriakos Neofytou
- 1st Department of Surgery, University of Athens Medical School, Laikon General Hospital, Agiou Thoma 17 Street, 11527 Athens, Greece
| | - Demetrios Moris
- 1st Department of Surgery, University of Athens Medical School, Laikon General Hospital, Agiou Thoma 17 Street, 11527 Athens, Greece
| | - Nikolaos Dimitrokallis
- 1st Department of Surgery, University of Athens Medical School, Laikon General Hospital, Agiou Thoma 17 Street, 11527 Athens, Greece
| | - Konstantinos Bramis
- 1st Department of Surgery, University of Athens Medical School, Laikon General Hospital, Agiou Thoma 17 Street, 11527 Athens, Greece
| | - John Griniatsos
- 1st Department of Surgery, University of Athens Medical School, Laikon General Hospital, Agiou Thoma 17 Street, 11527 Athens, Greece
| | - Emmanouil Pikoulis
- 1st Department of Surgery, University of Athens Medical School, Laikon General Hospital, Agiou Thoma 17 Street, 11527 Athens, Greece
| | - Theodoros Diamantis
- 1st Department of Surgery, University of Athens Medical School, Laikon General Hospital, Agiou Thoma 17 Street, 11527 Athens, Greece
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Andersen P, Andersen LM, Iversen LH. Iatrogenic ureteral injury in colorectal cancer surgery: a nationwide study comparing laparoscopic and open approaches. Surg Endosc 2014; 29:1406-12. [DOI: 10.1007/s00464-014-3814-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 08/14/2014] [Indexed: 01/21/2023]
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Hepatic subcapsular biloma: a rare complication of laparoscopic cholecystectomy. Case Rep Surg 2014; 2014:186819. [PMID: 25177507 PMCID: PMC4142546 DOI: 10.1155/2014/186819] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 07/28/2014] [Indexed: 12/16/2022] Open
Abstract
The development of an intra-abdominal bile collection (biloma) is an infrequent complication of laparoscopic cholecystectomy (LC). These bilomas develop in the subhepatic space most often secondary to iatrogenic injury of the extrahepatic ducts. We present a case of hepatic subcapsular biloma following LC and we discuss its etiology and management. Early diagnosis is crucial and percutaneous drainage under CT guidance should be employed to resolve this complication.
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Smereczyński A, Starzyńska T, Kołaczyk K, Kładny J. Role of sonography in assessing complications after laparoscopic cholecystectomy. J Ultrason 2014; 14:152-62. [PMID: 26674247 PMCID: PMC4579702 DOI: 10.15557/jou.2014.0015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 05/28/2013] [Accepted: 06/20/2013] [Indexed: 01/04/2023] Open
Abstract
Laparoscopic cholecystectomy, which was introduced to the arsenal of surgical procedures in the middle of the 1980s, is a common alternative for conventional cholecystectomy. Its primary advantage is less invasive character which entails shorter hospitalization and faster recovery. Nevertheless, the complications of both procedures are comparable and encompass multiple organs and tissues. The paper presents ultrasound presentation of the surgical bed after laparoscopic cholecystectomy and of complications associated with this procedure. In the first week following the surgery, the presence of up to 60 ml of fluid in the removed gallbladder bed should be considered normal in certain patients. The fluid will gradually absorb. In single cases, slight amounts of fluid are detected in the peritoneal cavity, which also should not be alarming. Carbon dioxide absorbs from the peritoneal cavity within two days. Ultrasound assessment of the surgical bed after cholecystectomy is inhibited by hemostatic material left during the surgery. Its presentation may mimic an abscess. In such cases, the decisive examination is magnetic resonance imaging but not computed tomography. On the other hand, rapidly accumulating fluid around the liver is an alarming symptom, particularly when there is inadequate blood supply or when peritoneum irritation symptoms develop. Depending on the suspected cause of the patient's deteriorating condition, it is essential to perform urgent computed tomography angiography, celiac angiography or endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography. The character of the fluid collection may be determined by its ultrasound-guided puncture. This procedure allows for aspiration of fluid and placement of a drain. Moreover, transabdominal ultrasound examination after laparoscopic cholecystectomy may contribute to the identification of: dropped stones in the right hypochondriac region, residual fragment of the gallbladder with possible concretions, undiagnosed choledocholithiasis, existing cholestasis, pseudoaneurysm of the hepatic artery, portal vein thrombosis and hematoma as well as hernias of the abdominal walls. Moreover, ultrasound examination helps to identify optimal sites in the abdominal integuments, which enables collision-free access to the peritoneal cavity.
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Affiliation(s)
| | - Teresa Starzyńska
- Klinika Gastrologii, Pomorski Uniwersytet Medyczny, Szczecin, Polska
| | - Katarzyna Kołaczyk
- Zakład Diagnostyki Obrazowej i Radiologii Interwencyjnej, Pomorski Uniwersytet Medyczny, Szczecin, Polska
| | - Józef Kładny
- Klinika Chirurgii Ogólnej i Onkologicznej, Pomorski Uniwersytet Medyczny, Szczecin, Polska
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Connor SJ, Perry W, Nathanson L, Hugh TB, Hugh TJ. Using a standardized method for laparoscopic cholecystectomy to create a concept operation-specific checklist. HPB (Oxford) 2014; 16:422-9. [PMID: 23961737 PMCID: PMC4008160 DOI: 10.1111/hpb.12161] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 06/07/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Prevalences of bile duct injury (BDI) following laparoscopic cholecystectomy (LC) remain unacceptably high. There is no standardized method for performing an LC. This study aims to describe a standardized technique for LC that will allow for the development of a concept LC checklist, the use of which, it is hoped, will decrease the prevalence of BDI. METHODS A standardized method for LC was developed based on previously published expert analysis supplemented by video error analysis of operations in which BDI occurred. Established checklist methodology was then used to construct an LC-specific concept checklist. RESULTS A five-step technique for the safe establishment of the critical view was created to guide the development of the checklist. The five steps are: (i) confirm the gallbladder lies in the hepatic principal plane and is retracted to the 10 o'clock position; (ii) confirm Hartmann's pouch is lifted up and toward the segment IV pedicle; (iii) identify Rouvière's sulcus; (iv) confirm the release of the posterior leaf of the peritoneum covering the hepatobiliary triangle, and (v) confirm the critical view with or without intraoperative cholangiography. CONCLUSIONS A standardized approach to LC would allow for the creation of an LC-specific checklist that has the potential to lower the prevalence of BDI.
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Affiliation(s)
- Saxon J Connor
- Department of Surgery, Christchurch HospitalChristchurch, New Zealand,Correspondence Saxon J. Connor, Department of Surgery, Christchurch Hospital, Christchurch 8000, New Zealand. Tel: + 64 3 364 0640. Fax: + 64 3 364 0352. E-mail:
| | - William Perry
- Department of Surgery, Christchurch HospitalChristchurch, New Zealand
| | - Leslie Nathanson
- Department of Surgery, Royal Brisbane and Women's HospitalBrisbane, Qld, Australia
| | - Thomas B Hugh
- Department of Surgery, St Vincent's HospitalSydney, NSW, Australia
| | - Thomas J Hugh
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, University of SydneySydney, NSW, Australia
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Desai NS, Khandelwal A, Virmani V, Kwatra NS, Ricci JA, Saboo SS. Imaging in laparoscopic cholecystectomy--what a radiologist needs to know. Eur J Radiol 2014; 83:867-879. [PMID: 24657107 DOI: 10.1016/j.ejrad.2014.02.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 02/16/2014] [Accepted: 02/18/2014] [Indexed: 12/13/2022]
Abstract
Laparoscopic cholecystectomy is the gold standard treatment option for cholelithiasis. In order to properly assess for the complications related to the procedure, an understanding of the normal biliary anatomy, its variants and the normal postoperative imaging is essential. Radiologist must be aware of benefits and limitations of multiple imaging modalities in characterizing the complications of this procedure as each of these modalities have a critical role in evaluating a symptomatic post-cholecystectomy patient. The purpose of this article is describe the multi-modality imaging of normal biliary anatomy and its variants, as well as to illustrate the imaging features of biliary, vascular, cystic duct, infectious as well as miscellaneous complications of laparoscopic cholecystectomy. We focus on the information that the radiologist needs to know about the radiographic manifestations of potential complications of this procedure.
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Affiliation(s)
- Naman S Desai
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis street, Boston, MA, 02115, USA.
| | - Ashish Khandelwal
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis street, Boston, MA, 02115, USA.
| | - Vivek Virmani
- Department of Radiology, Dr. Everett Chalmers Hospital, Priestman St, Fredericton, 700, NB E3B 5N5, Canada.
| | - Neha S Kwatra
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis street, Boston, MA, 02115, USA.
| | - Joseph A Ricci
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA.
| | - Sachin S Saboo
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis street, Boston, MA, 02115, USA.
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Parrilla P, Robles R, Varo E, Jiménez C, Sánchez-Cabús S, Pareja E. Liver transplantation for bile duct injury after open and laparoscopic cholecystectomy. Br J Surg 2014; 101:63-68. [PMID: 24318962 PMCID: PMC4253129 DOI: 10.1002/bjs.9349] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Bile duct injury (BDI) after cholecystectomy is a serious complication. In a small subset of patients with BDI, failure of surgical or non-surgical management might lead to acute or chronic liver failure. The aim of this study was to review the indications and outcome of liver transplantation (LT) for BDI after open and laparoscopic cholecystectomy. METHODS Patients with BDI after cholecystectomy who were on the waiting list for LT between January 1987 and December 2010 were identified from LT centres in Spain. A standardized questionnaire was sent to each unit for extraction of data on diagnosis, previous treatments, indication and outcome of LT for BDI. RESULTS Some 27 patients with BDI after cholecystectomy in whom surgical and non-surgical management for BDI failed were scheduled for LT over the 24-year interval. Emergency LT for acute liver failure was indicated in seven patients, all after laparoscopic cholecystectomy. Two patients died while on the waiting list and only one patient survived more than 30 days after LT. Elective LT for secondary biliary cirrhosis after a failed hepaticojejunostomy was performed in 13 patients after open and seven after laparoscopic cholecystectomy. One patient from the elective transplantation group died within 30 days of LT. The estimated 5-year overall survival rate was 68 per cent. CONCLUSION Emergency LT for acute liver failure was more common in patients with BDI after laparoscopic cholecystectomy, and associated with a poor outcome.
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Affiliation(s)
- P Parrilla
- Department of Surgery, Virgen de la Arrixaca University Hospital, Murcia, Spain
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Macedo FIB, Casillas VJ, Davis JS, Levi JU, Sleeman D. The Value of Cholangiography through Jackson-Pratt Drains in the Management of Postoperative Biliary Injuries. Am Surg 2014. [DOI: 10.1177/000313481408000126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Iatrogenic biliary injury is the most significant complication after laparoscopic cholecystectomy. We present our experience with an alternative diagnostic approach using transcatheter cholangiography (TCC) through a Jackson-Pratt (JP) drain and discuss potential benefits and limitations of the technique. From March 2002 to February 2012, 40 patients with major postoperative biliary injury underwent biliary reconstruction at our institution. Mean age was 51.7 ± 18.1 years (range, 19 to 86 years) with 30 (75%) females. Seventeen (42.5%) injuries were detected intraoperatively and in 13 (32.5%) cases, JP drains were placed for biliary drainage. Lesions were classified according to Bismuth grade: I (10 patients [25%]), II (10 patients [25%]), III (six patients [15%]), IV (10 patients [25%]), and V (four patients [10%]). TCC was performed in seven patients with JP drains (53.8%). It fully defined the injury site in three cases of limited magnetic resonance cholangiopancreatography (MRCP) such as common hepatic duct and common bile duct leaks and in four cases (57.1%) that endoscopic retrograde cholangiopancreatography (ERCP) was limited as a result of clipping of the distal common bile duct. TCC showed promising results in cases of limited MRCP and ERCP such as fistulous orifices or leakage. It may represent an alternative adjunct in the diagnostic armamentarium of complex biliary injuries.
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Affiliation(s)
- Francisco Igor B. Macedo
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center/Jackson Memorial Hospital, Miami, Florida
| | - Victor J. Casillas
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center/Jackson Memorial Hospital, Miami, Florida
| | - James S. Davis
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center/Jackson Memorial Hospital, Miami, Florida
| | - Joe U. Levi
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center/Jackson Memorial Hospital, Miami, Florida
| | - Danny Sleeman
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center/Jackson Memorial Hospital, Miami, Florida
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Gurusamy KS, Rossi M, Davidson BR. Percutaneous cholecystostomy for high-risk surgical patients with acute calculous cholecystitis. Cochrane Database Syst Rev 2013:CD007088. [PMID: 23939652 DOI: 10.1002/14651858.cd007088.pub2] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The management of people at high risk of perioperative death due to their general condition (high-risk surgical patients) with acute calculous cholecystitis is controversial, with no clear guidelines. In particular, the role of percutaneous cholecystostomy in these patients has not been defined. OBJECTIVES To compare the benefits (temporary or permanent relief of symptoms) and harms (recurrence of symptoms, procedure-related morbidity) of percutaneous cholecystostomy in the management of high-risk individuals with symptomatic gallstones. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded to December 2012 to identify the randomised clinical trials. We also handsearched the references lists of identified trials. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or publication status) addressing this issue. DATA COLLECTION AND ANALYSIS Two review authors collected data independently. For each outcome, we calculated the P values using Fisher's exact test or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS We included two trials with 156 participants for this review. The comparisons included in these two trials were percutaneous cholecystostomy followed by early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy (1 trial; 70 participants) and percutaneous cholecystostomy versus conservative treatment (1 trial; 86 participants). Both trials had high risk of bias. Percutaneous cholecystostomy with early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy: There was no significant difference in mortality between the two intervention groups (0/37 versus 1/33; Fisher's exact test: P value = 0.47). There was no significant difference in overall morbidity between the two intervention groups (1/31 versus 2/30; Fisher's exact test: P value = 0.61). This trial did not report on quality of life. There was no significant difference in the proportion of participants requiring conversion to open cholecystectomy between the two intervention groups (2/31 percutaneous cholecystostomy followed by early laparoscopic cholecystectomy versus 4/30 delayed laparoscopic cholecystectomy; Fisher's exact test: P value = 0.43). The mean total hospital stay was significantly lower in the percutaneous cholecystostomy followed by early laparoscopic cholecystectomy group compared with the delayed laparoscopic cholecystectomy group (1 trial; 61 participants; MD -9.90 days; 95% CI -12.31 to -7.49). The mean total costs were significantly lower in the percutaneous cholecystostomy followed by early laparoscopic cholecystectomy group compared with the delayed laparoscopic cholecystectomy group (1 trial; 61 participants; MD -1123.00 USD; 95% CI -1336.60 to -909.40). Percutaneous cholecystostomy versus conservative treatment: Nine of the 44 participants underwent delayed cholecystectomy in the percutaneous cholecystostomy group. Seven of the 42 participants underwent delayed cholecystectomy in the conservative treatment group. There was no significant difference in mortality between the two intervention groups (6/44 versus 7/42; Fisher's exact test: P value = 0.77). There was no significant difference in overall morbidity between the two intervention groups (6/44 versus 3/42; Fisher's exact test: P value = 0.49). The number of participants who underwent laparoscopic cholecystectomy was not reported in this trial. Therefore, we were unable to calculate the proportion of participants who underwent conversion to open cholecystectomy. The other outcomes, total hospital stay, quality of life, and total costs, were not reported in this trial. AUTHORS' CONCLUSIONS Based on the current available evidence from randomised clinical trials, we are unable to determine the role of percutaneous cholecystostomy in the clinical management of high-risk surgical patients with acute cholecystitis. There is a need for adequately powered randomised clinical trials of low risk of bias on this issue.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Department of Surgery, Royal Free Campus, UCL Medical School, Royal Free Hospital,, Rowland Hill Street, London, UK, NW3 2PF
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