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Cirilo Neto O, Moutinho LER, Melo PSVDE, Rabêlo PJM, Amorim AG, Melo CML. Liver transplantation for the treatment of iatrogenic bile duct injury. Rev Col Bras Cir 2023; 50:e20233565. [PMID: 37531504 PMCID: PMC10508668 DOI: 10.1590/0100-6991e-20233565-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 05/01/2023] [Indexed: 08/04/2023] Open
Affiliation(s)
- Olival Cirilo Neto
- - Universidade de Pernambuco, Faculdade de Ciências Médicas - Recife - PE - Brasil
- - Hospital Universitário Oswaldo Cruz, Unidade de Transplante de Fígado - Recife - PE - Brasil
| | | | | | | | - Americo Gusmão Amorim
- - Hospital Universitário Oswaldo Cruz, Unidade de Transplante de Fígado - Recife - PE - Brasil
| | - Cláudio Moura Lacerda Melo
- - Universidade de Pernambuco, Faculdade de Ciências Médicas - Recife - PE - Brasil
- - Hospital Universitário Oswaldo Cruz, Unidade de Transplante de Fígado - Recife - PE - Brasil
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2
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Lopez-Lopez V, Kuemmerli C, Cutillas J, Maupoey J, López-Andujar R, Ramos E, Mils K, Valdivieso A, Valero AP, Martinez PA, Paterna S, Serrablo A, Reese T, Oldhafer K, Brusadin R, Conesa AL, Valladares LD, Loinaz C, Garcés-Albir M, Sabater L, Mocchegiani F, Vivarelli M, Pérez SA, Flores B, Lucena JL, Sánchez-Cabús S, Calero A, Minguillon A, Ramia JM, Alcazar C, Aguilo J, Ruiperez-Valiente JA, Grochola LF, Clavien PA, Petrowsky H, Robles-Campos R. Vascular injury during cholecystectomy: A multicenter critical analysis behind the drama. Surgery 2022; 172:1067-1075. [PMID: 35965144 DOI: 10.1016/j.surg.2022.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/27/2022] [Accepted: 06/27/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The management of a vascular injury during cholecystectomy is still very complicated, especially in centers not specialized in complex hepatobiliary surgery. METHODS This was a multi-institutional retrospective study in patients with vascular injuries during cholecystectomy from 18 centers in 4 countries. The aim of the study was to analyze the management of vascular injuries focusing on referral, time to perform the repair, and different treatments options outcomes. RESULTS A total of 104 patients were included. Twenty-nine patients underwent vascular repair (27.9%), 13 (12.5%) liver resection, and 1 liver transplant as a first treatment. Eighty-four (80.4%) vascular and biliary injuries occurred in nonspecialized centers and 45 (53.6%) were immediately transferred. Intraoperative diagnosed injuries were rare in referred patients (18% vs 84%, P = .001). The patients managed at the hospital where the injury occurred had a higher number of reoperations (64% vs 20%, P ˂ .001). The need for vascular reconstruction was associated with higher mortality (P = .04). Two of the 4 patients transplanted died. CONCLUSION Vascular lesions during cholecystectomy are a potentially life-threatening complication. Management of referral to specialized centers to perform multiple complex multidisciplinary procedures should be mandatory. Late vascular repair has not shown to be associated with worse results.
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Affiliation(s)
- Victor Lopez-Lopez
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain.
| | - Christoph Kuemmerli
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland; Department of Surgery, Clarunis - University Center for Gastrointestinal and Liver Diseases Basel, Switzerland. https://twitter.com/ChristophKuemme
| | - Jose Cutillas
- Department of General Surgery, Hospital Francesc de Borja, Gandía, Valencia, Spain
| | - Javier Maupoey
- Department of Hepatobiliary Surgery and Transplants, Hospital Universitario La Fe, Valencia, Spain
| | - Rafael López-Andujar
- Department of Hepatobiliary Surgery and Transplants, Hospital Universitario La Fe, Valencia, Spain
| | - Emilio Ramos
- Department of Hepatobiliary Surgery and Liver Transplant Unit, Hospital Universitari Bellvitge, University of Barcelona, Barcelona, Spain
| | - Kristel Mils
- Department of Hepatobiliary Surgery and Liver Transplant Unit, Hospital Universitari Bellvitge, University of Barcelona, Barcelona, Spain
| | - Andres Valdivieso
- Hepatobiliary Surgery and Liver Transplant Unit, Cruces University Hospital, Bilbao, Spain
| | | | | | - Sandra Paterna
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | - Alejando Serrablo
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | - Tim Reese
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Germany
| | - Karl Oldhafer
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Germany
| | - Roberto Brusadin
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Asunción López Conesa
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Luis Díez Valladares
- Department of Surgery, Hepatopancreatobiliary Unit, Hospital Clínico San Carlos, Madrid, Spain
| | - Carmelo Loinaz
- Department of General Surgery, Digestive Tract and Abdominal Organ Transplantation, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - Marina Garcés-Albir
- Department of Surgery, Hospital Clinico Valencia, University of Valencia, Biomedical Research Institute (INCLIVA), Spain
| | - Luis Sabater
- Department of Surgery, Hospital Clinico Valencia, University of Valencia, Biomedical Research Institute (INCLIVA), Spain
| | - Federico Mocchegiani
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy
| | | | - Benito Flores
- Department of Surgery, Morales University Hospital, Madrid, Spain
| | - Jose Luis Lucena
- Department of Surgery, Puerta del Hierro University Hospital, Madrid, Spain
| | - Santiago Sánchez-Cabús
- Hepatobiliopancreatic Surgery Unit, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain
| | - Alicia Calero
- Department of General Surgery, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | | | - Jose Manuel Ramia
- Department of Surgery, University Hospital of Alicante, Spain; Universidad Miguel Hernandez, Alicante, Spain
| | - Cándido Alcazar
- Department of Surgery, University Hospital of Alicante, Spain; Universidad Miguel Hernandez, Alicante, Spain
| | - Javier Aguilo
- Department of General Surgery, Hospital Lluís Alcanyís Hospital, Xàtiva, Valencia, Spain
| | | | - Lukasz Filip Grochola
- Clinic for Visceral and Thoracic Surgery, Cantonal Hospital of Winterthur, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Henrik Petrowsky
- Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Ricardo Robles-Campos
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de La Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
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3
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Furtado R, Yoshino O, Muralidharan V, Perini MV, Wigmore SJ. Hepatectomy after bile duct injury: a systematic review. HPB (Oxford) 2022; 24:161-168. [PMID: 34702627 DOI: 10.1016/j.hpb.2021.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/24/2021] [Accepted: 09/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bile duct injury (BDI) after cholecystectomy can lead to recurrent cholangitis, even after biliary reconstruction. This necessitates hepatectomy in a minority of patients. A systematic review was conducted, summarizing the pattern of biliary injury sustained in this group and their outcomes after hepatectomy. METHODS A literature search included the MEDLINE, EMBASE, PubMed and Cochrane libraries. Retrospective cohort studies describing outcomes for hepatectomy after BDI, and the nature of the antecedent BDI, published between 1999 and 2019, were selected. RESULTS Eight articles described a cohort of 2110 patients with BDI. Of these, 84 underwent hepatectomy. Complex vasculo-biliary injuries had been sustained in most cases. The mean time to hepatectomy was between 26 and 224 months after BDI. A right hepatectomy was performed in 67-89% of cases. Post hepatectomy, intra-abdominal infection (range 0-50%) and bile leaks (range 0-45%) occurred variably. Mortality occurred in three series. Nineteen percent of patients (16 of 84) developed recurrent symptoms at follow up. CONCLUSION Hepatectomy after bile duct injury is an uncommon procedure and represents a salvage strategy when vasculo-biliary injury happens. Liver resection leads to resolution of symptoms in the majority of the cases however postoperative bile leaks and intra-abdominal infection are common.
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Affiliation(s)
- Ruelan Furtado
- Austin Health, Department of Surgery, Heidelberg, Victoria, Australia
| | - Osamu Yoshino
- Austin Health, Department of Surgery, Heidelberg, Victoria, Australia
| | - Vijayaragavan Muralidharan
- Austin Health, Department of Surgery, Heidelberg, Victoria, Australia; The University of Melbourne, Department of Surgery, Austin Health, Victoria, Australia
| | - Marcos V Perini
- Austin Health, Department of Surgery, Heidelberg, Victoria, Australia; The University of Melbourne, Department of Surgery, Austin Health, Victoria, Australia.
| | - Stephen J Wigmore
- University Department of Clinical Surgery, University of Edinburgh, Little France Crescent, Edinburgh, UK.
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Wiboonkhwan N, Pitakteerabundit T, Thongkan T. Total Hilar Exposure Maneuver for Repair of Complex Bile Duct Injury. Ann Gastroenterol Surg 2022; 6:176-181. [PMID: 35106428 PMCID: PMC8786702 DOI: 10.1002/ags3.12500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/07/2021] [Accepted: 08/18/2021] [Indexed: 12/31/2022] Open
Abstract
The reconstruction of high-level bile duct injury is challenging because exposure of the hilar area is limited and sometimes inaccessible by the Hepp-Couinaud approach. We describe a maneuver for total hilar exposure to perform complex bile duct injury reconstruction. After adhesions surrounding the liver are divided, intraoperative ultrasonography is used to delineate the hilar and intrahepatic biliary anatomy. Surgical exposure of the biliary system is achieved by our maneuver, which consists of four steps: (1) identification of landmark structures, such as the base of the umbilical fissure, the inferior edge of segment 4b, the cystic-hilar plate junction, and the right anterior portal pedicle; (2) lowering of the hilar plate; (3) hepatotomy along the right anterior pedicle; and (4) connection of the hepatotomy to the base of segment 4b. This maneuver allows the liver to be flipped upward, which facilitates clear exposure of the hilar duct and preserves the liver parenchyma. The anterior parts of the right and left hepatic duct are then opened, a wide-hepaticojejunostomy anastomosis is achieved for biliary reconstruction, and a jejunal subcutaneous limb is created. We used this maneuver for treating complex bile duct injury in six cases; none of the patients has died, and two had Clavien-Dindo grade III complications, including surgical site infection and intra-abdominal collection. The total hilar exposure maneuver is thus feasible and safe. It provides excellent exposure of both hepatic ducts and is a good surgical alternative to the Hepp-Couinaud approach in cases of high-level injury.
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Affiliation(s)
- Nan‐ak Wiboonkhwan
- Department of SurgeryFaculty of MedicinePrince of Songkla UniversitySongkhlaThailand
| | | | - Tortrakoon Thongkan
- Department of SurgeryFaculty of MedicinePrince of Songkla UniversitySongkhlaThailand
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Liver transplantation for iatrogenic bile duct injury during cholecystectomy: a French retrospective multicenter study. HPB (Oxford) 2022; 24:94-100. [PMID: 34462215 DOI: 10.1016/j.hpb.2021.08.817] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 07/15/2021] [Accepted: 08/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Major bile duct injuries (BDI) following cholecystectomy require complex reconstructive surgery. The aim was to collect the liver transplantations (LT) performed in France for major BDI following cholecystectomy, to analyze the risk factors and to report the results. METHODS National multicenter observational retrospective study. All the patients who underwent a LT in France between 1994 and 2017, for BDI following cholecystectomy, were included. RESULTS 30 patients were included. 25 BDI occurred in non hepato-biliary expert centers, 20 were initially treated in these centers. Median time between injury and LT was 3 years in case of an associated vascular injury (11 injuries), versus 11.7 years without vascular injury (p = 0.006). Post-transplant morbidity rate was 86.7%, mortality 23.5% at 5 years. CONCLUSION Iatrogenic BDI remains a real concern with severe cases, associated with vascular damages or leading to cirrhosis, with no solution but LT. It is associated with high morbidity and not optimal results. This enlights the necessity of early referral of all major BDI in expert centers to prevent dramatic outcome. Decision to perform transplantation should be taken before dismal infectious situations or biliary cirrhosis and access to graft should be facilitated by Organ Sharing Organizations.
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Long-term outcomes in the repair of intrahepatic iatrogenic bile duct lesions using a combined intraglissonian and extraglissonian approach. Langenbecks Arch Surg 2021; 407:403-408. [PMID: 33963887 DOI: 10.1007/s00423-021-02188-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
PURSPOSE Iatrogenic bile duct injuries (IBDI) with intrahepatic involvement are a serious and challenging surgical complication that can have disastrous consequences in terms of morbidity and mortality. METHODS We collected the patients with IBDI type (E4) between January 1991 and March 2020 in our hospital. The objective of the study was to present the long-term results of a extraglissonian approach and intraglissonian biliary reconstruction in a series of patients with intrahepatic bile duct injuries after cholecystectomy. We also detail our preoperative management and the standardization of the technique. RESULTS An extraglissonian approach with partial hepatic resection of the base of segments 4b and 5 and intraglissonian Roux-en-Y hepaticojejunostomy for biliary reconstruction using to several branches was performed in 10 patients with E4 Strassberg type intrahepatic lesions. Only one patient had postoperative bile leak (Clavien 3a). Surgical time was 260 min (IQR, 210-490). We left transanastomotic catheter (between 2 and 5) in situ for 3 and 6 months after surgery. The patients remained asymptomatic over a median follow-up of 169 months (IQR 129-234). CONCLUSION This biliary reconstruction technique obtains positive long-term outcomes in patients with severe intrahepatic lesions.
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Chang JG, Yoon YI, Lee SG, Hwang S, Kim KH, Ahn CS, Moon DB, Ha TY, Song GW, Jung DH, Park GC, Park JI. Single-Center Experience of Living Donor Liver Transplantation for Patients With Secondary Biliary Cirrhosis. Transplant Proc 2020; 53:98-103. [PMID: 33339650 DOI: 10.1016/j.transproceed.2020.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/09/2020] [Accepted: 10/30/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Secondary biliary cirrhosis (SBC) represents a unique form of cirrhosis that develops in the liver secondary to persistent biliary obstruction. This study aimed to review the living donor liver transplants (LDLTs) performed at our center for patients with SBC and end-stage liver disease and to share the perioperative strategies undertaken to achieve satisfactory outcomes. METHODS The medical records of 29 patients who underwent LDLT for SBC between December 1994 and July 2018 at the Asan Medical Center (Seoul, South Korea) were retrospectively reviewed. Their clinical data were extracted and statistically analyzed. Survival curves were computed. RESULTS The perioperative and in-hospital morbidity rates were 72.4% and 10.3%, respectively. The overall mean recipient follow-up was 80.0 (SD, 66.4) months (range, 0.8-246.8 months). Patient survival rates after 1, 3, 5, and 10 years after transplant were 82.8%, 79.3%, 79.3%, and 79.3%, respectively. For liver grafts, the survival rates were 82.8%, 75.8%, 75.8%, and 75.8% at 1, 3, 5, and 10 years, respectively. CONCLUSIONS LDLT is potentially a final lifesaving resort for patients with SBC with portal hypertension. However, considering the difficulty of surgery and perioperative management, LDLT should be performed by experienced transplant surgeons in a center where a multidisciplinary approach is possible.
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Affiliation(s)
- Jin-Gi Chang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - S Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Chul-Soo Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Tae-Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jeong-Ik Park
- Department of Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea
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Tsai CY, Chen MY, Yeh TS. Hemi-hepatectomy for E4 major bile duct injury following laparoscopic cholecystectomy. Asian J Surg 2020; 43:1212-1213. [PMID: 33144030 DOI: 10.1016/j.asjsur.2020.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/28/2020] [Indexed: 12/01/2022] Open
Affiliation(s)
- Chun-Yi Tsai
- Departments of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Yang Chen
- Departments of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ta-Sen Yeh
- Departments of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan.
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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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 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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10
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Ferrada PISM, Morales HFL, Abarca JAS, Muñoz PIF. Major biliovascular injury associated with cholecystectomy with the need for percutaneous arterial revascularization and staged right hepatectomy: case report. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2020; 33:e1493. [PMID: 32428133 PMCID: PMC7236335 DOI: 10.1590/0102-672020190001e1493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 12/10/2019] [Indexed: 08/30/2023]
Affiliation(s)
| | - Héctor Fabio Losada Morales
- Departamento de Cirugia, Anestesia y Traumatologia, Universidad de la Fontera, Temuco, Region de la Araucania (IX), Chile
| | - Jorge Alberto Silva Abarca
- Departamento de Cirugia, Anestesia y Traumatologia, Universidad de la Fontera, Temuco, Region de la Araucania (IX), Chile
| | - Paula Inés Flores Muñoz
- Departamento de Cirugia, Anestesia y Traumatologia, Universidad de la Fontera, Temuco, Region de la Araucania (IX), Chile
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11
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Shammout R, Al Habbal R, Rayya F. Porta Hepatis Injury during Laparoscopic Cholecystectomy. Case Rep Gastroenterol 2020; 14:234-241. [PMID: 32399008 PMCID: PMC7204780 DOI: 10.1159/000507431] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/20/2020] [Indexed: 01/22/2023] Open
Abstract
Iatrogenic porta hepatis injury is a rare but devastating surgical complication of laparoscopic cholecystectomy. There are no systematic studies examining the best treatment strategy in patients with this injury. We present a case of a 23-year-old woman with a large abscess in the right hepatic lobe due to an extreme vasculobiliary injury after laparoscopic cholecystectomy. Although rare, the impact of vasculobiliary injuries after cholecystectomy highlights the need for constant alertness and prompt management in order to minimize mortality and morbidity usually associated with the routine operative procedure.
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Affiliation(s)
- Reem Shammout
- Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
| | - Raiean Al Habbal
- Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
| | - Fadi Rayya
- Department of General Surgery, Al-Assad University Hospital, Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
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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: 0.6] [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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Surgical management of laparoscopic cholecystectomy (LC) related major bile duct injuries; predictors of short-and long-term outcomes in a tertiary Egyptian center- a retrospective cohort study. ANNALS OF MEDICINE AND SURGERY (2012) 2018. [PMID: 30505442 DOI: 10.1016/j.amsu.2018.11.006.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objectives Laparoscopic cholecystectomy - associated bile duct injury is a clinical problem with bad outcome. The study aimed to analyze the outcome of surgical management of these injuries. Patients and methods We retrospectively analyzed 69 patients underwent surgical management of laparoscopic cholecystectomy related major bile duct injuries in the period from the beginning of 2013 to the beginning of 2018. Results Regarding injury type; the Leaking, Obstructing, leaking + obstructing, leaking + vascular, and obstructing + vascular injuries were 43.5%, 27.5%, 18.8%, 2.9%, and 7.2% respectively. However, the Strasberg classification of injury was as follow E1 = 25, E2 = 32, E3 = 8, and E4 = 4. The definitive procedures were as follow: end to end biliary anastomosis with stenting, hepaticojejunostomy (HJ) with or without stenting, and RT hepatectomy plus biliary reconstruction with stenting in 4.3%, 87%, and 8.7% of patients respectively. According to the time of definitive procedure from injury; the immediate (before 72 h), intermediate (between 72 h and 1.5months), and late (after1.5 months) management were 13%, 14.5%, and 72.5% respectively. The hospital and/or 1month (early) morbidity after definitive treatment was 21.7%, while, the late biliary morbidity was 17.4% and the overall mortality was 2.9%, on the other hand, the late biliary morbidity-free survival was 79.7%. On univariate analysis, the following factors were significant predictors of early morbidity; Sepsis at referral, higher Strasberg grade, associated vascular injury, right hepatectomy with biliary reconstruction as a definitive procedure, intra-operative bleeding with blood transfusion, liver cirrhosis, and longer operative times and hospital stays. However, the following factors were significantly associated with late biliary morbidity: Sepsis at referral, end to end anastomosis with stenting, reconstruction without stenting, liver cirrhosis, operative bleeding, and early morbidity. Conclusion Sepsis at referral, liver cirrhosis, and operative bleeding were significantly associated with both early and late morbidities after definitive management of laparoscopic cholecystectomy related major bile duct injuries, so it is crucial to avoid these catastrophes when doing those major procedures.
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14
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Gad EH, Ayoup E, Kamel Y, Zakareya T, Abbasy M, Nada A, Housseni M, Abd-Elsamee MAS. Surgical management of laparoscopic cholecystectomy (LC) related major bile duct injuries; predictors of short-and long-term outcomes in a tertiary Egyptian center- a retrospective cohort study. Ann Med Surg (Lond) 2018; 36:219-230. [PMID: 30505442 PMCID: PMC6251332 DOI: 10.1016/j.amsu.2018.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 10/30/2018] [Accepted: 11/06/2018] [Indexed: 02/08/2023] Open
Abstract
Objectives Laparoscopic cholecystectomy - associated bile duct injury is a clinical problem with bad outcome. The study aimed to analyze the outcome of surgical management of these injuries. Patients and methods We retrospectively analyzed 69 patients underwent surgical management of laparoscopic cholecystectomy related major bile duct injuries in the period from the beginning of 2013 to the beginning of 2018. Results Regarding injury type; the Leaking, Obstructing, leaking + obstructing, leaking + vascular, and obstructing + vascular injuries were 43.5%, 27.5%, 18.8%, 2.9%, and 7.2% respectively. However, the Strasberg classification of injury was as follow E1 = 25, E2 = 32, E3 = 8, and E4 = 4. The definitive procedures were as follow: end to end biliary anastomosis with stenting, hepaticojejunostomy (HJ) with or without stenting, and RT hepatectomy plus biliary reconstruction with stenting in 4.3%, 87%, and 8.7% of patients respectively. According to the time of definitive procedure from injury; the immediate (before 72 h), intermediate (between 72 h and 1.5months), and late (after1.5 months) management were 13%, 14.5%, and 72.5% respectively. The hospital and/or 1month (early) morbidity after definitive treatment was 21.7%, while, the late biliary morbidity was 17.4% and the overall mortality was 2.9%, on the other hand, the late biliary morbidity-free survival was 79.7%. On univariate analysis, the following factors were significant predictors of early morbidity; Sepsis at referral, higher Strasberg grade, associated vascular injury, right hepatectomy with biliary reconstruction as a definitive procedure, intra-operative bleeding with blood transfusion, liver cirrhosis, and longer operative times and hospital stays. However, the following factors were significantly associated with late biliary morbidity: Sepsis at referral, end to end anastomosis with stenting, reconstruction without stenting, liver cirrhosis, operative bleeding, and early morbidity. Conclusion Sepsis at referral, liver cirrhosis, and operative bleeding were significantly associated with both early and late morbidities after definitive management of laparoscopic cholecystectomy related major bile duct injuries, so it is crucial to avoid these catastrophes when doing those major procedures. Sepsis at referral was associated with poor outcome after management of LC related MBDIs. Liver cirrhosis and operative bleeding were associated with poor outcome after management of these injuries. It is crucial to avoid these catastrophes when doing those major procedures.
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Affiliation(s)
- Emad Hamdy Gad
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Eslam Ayoup
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Yasmin Kamel
- Anaesthesia, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Talat Zakareya
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Mohamed Abbasy
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Ali Nada
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Mohamed Housseni
- Radioligy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
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15
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Gupta V, Gupta V, Joshi P, Kumar S, Kulkarni R, Chopra N, Pavankumar G, Chandra A. Management of post cholecystectomy vascular injuries. Surgeon 2018; 17:326-333. [PMID: 30396859 DOI: 10.1016/j.surge.2018.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 09/30/2018] [Accepted: 10/05/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Vasculobiliary and vascular injuries following cholecystectomy are the most serious complications requiring complex surgical management resulting in greater patient morbidity and mortality. METHODOLOGY The study was performed at a tertiary teaching hospital of North India. Records of patients referred for biliary or vascular injury sustained during cholecystectomy were reviewed retrospectively to identify patients with vascular injury between January 2009 and March 2018. Clinical profile, hospital course and outcome of these patients were analysed. RESULTS Over nine years, 117 patients were referred for cholecystectomy related complications. Total incidence of vascular injury was 5.1% (6/117). Combined vasculobiliary injury (VBI) occurred in 3.4% (4/117) while isolated vascular injury was present in 1.7% patients (2/117). Most (5/6) patients were operated for uncomplicated gall stone disease. Incidences of portal vein (PV) and right hepatic artery (RHA) injuries were equal (3/6). PV injuries were repaired either during cholecystectomy (1/3) or during re-exploration after damage control packing (2/3). RHA injuries presented as pseudoaneurysm and were managed surgically (2/3) or by coil embolization (1/3). All VBI referrals (4/117) were following open cholecystectomy. In VBI patients, vascular injury was diagnosed intra-operatively in two while it was diagnosed several weeks after cholecystectomy in two others. Biliary injury manifested as bile leak post-operatively in all four of them. Nature of biliary injury could be characterized in only 50% (2/4) patients. Definitive repair of biliary injury was performed in one patient only. There was one mortality in our series. CONCLUSION Vascular injury is an uncommon complication of cholecystectomy with catastrophic outcome if not managed timely and properly. Adequate surgeon training, keeping the possibility of aberrant vasculobiliary anatomy in all cases, and proper surgical technique is crucial for prevention of such injuries. However in such an event, proper documentation and referral to tertiary centre will help in decreasing morbidity and further litigation.
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Affiliation(s)
- Vishal Gupta
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
| | - Vivek Gupta
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
| | - Pradeep Joshi
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
| | - Saket Kumar
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
| | - Rugved Kulkarni
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
| | - Nikhil Chopra
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
| | - G Pavankumar
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
| | - Abhijit Chandra
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow, 226003, Uttar Pradesh, India.
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16
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Liver Transplantation for the Treatment of Complicated Iatrogenic Biliary Injuries: A National Review from the UNOS Data Set. Transplantation 2017; 101:2883-2887. [PMID: 28834863 DOI: 10.1097/tp.0000000000001922] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Liver transplantation (LT) is rarely indicated in the management of iatrogenic bile duct injuries (IBDI), but occasionally, it becomes the only remaining therapy. The purpose of this study is to evaluate potential complications of IBDI and their impact on perioperative mortality, graft, and patient survival after LT. METHODS The United Network for Organ Sharing database was queried for all LT performed in the United States between 1994 and 2014. Of the 101 238 liver transplants performed, 61 were related to IBDI. We performed a case matched analysis in a 5:1 ratio. RESULTS The median age for patients with IBDI was 50.16 ± 11.7 years with a mean Model End-Stage Liver Disease score of 22.6 ± 9.8. Patients receiving LT for IBDI were more likely women (54.1%, P = 0.001), had lower incidence of hepatitis C virus infection (4.9%, P = 0.001) and longer cold ischemic time (P = 0.001). The mean body mass index was 25.5 ± 5.2 in patients transplanted for IBDI. IBDI was recognized as the strongest independent predictor associated with eightfold increased risk of early graft loss (P = 0.001; odds ratio, 8.4) and a 2.9-fold increased risk of 30-day mortality after LT in a case matched analysis (P = 0.03). CONCLUSIONS IBDI is an uncommon but challenging indication for LT. These patients have significantly increased rates of early graft loss. IBDI is an independent factor related to increased risk of perioperative death after LT. Further studies are needed to determine the causes of perioperative complications and identify potential modifiable factors to improve outcomes in patients undergoing transplantation for IBDI.
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17
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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: 8] [Impact Index Per Article: 1.1] [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: 07/17/2017] [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
- Department of Surgical Sciences, University of Pavia, 27100 Pavia, Italy
| | - Stefano Di Sandro
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
- Department of Experimental Medicine, University of Pavia, 27100 Pavia, 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
- Department of Surgical Sciences, University of Pavia, 27100 Pavia, Italy
| | - Luciano De Carlis
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
- School of Medicine, University of Milan-Bicocca, 20162 Milan, Italy
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18
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Rose JB, Hawkins WG. Diagnosis and management of biliary injuries. Curr Probl Surg 2017; 54:406-435. [DOI: 10.1067/j.cpsurg.2017.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 06/20/2017] [Indexed: 12/11/2022]
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19
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Sultana A, Powell JJ, Oniscu GC. Pushing the boundaries in liver graft utilisation in transplantation: Case report of a donor with previous bile duct injury repair. Int J Surg Case Rep 2017; 37:248-249. [PMID: 28715721 PMCID: PMC5514494 DOI: 10.1016/j.ijscr.2017.06.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 06/23/2017] [Accepted: 06/25/2017] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Liver transplantation is a recognised treatment for extensive bile duct injuries with secondary biliary cirrhosis or recurring sepsis. However, there have been no reports of successful liver transplantation from a donor who sustained a previous bile duct injury. PRESENTATION OF CASE Here we discuss the case of a liver transplant from a 51-year-old brain dead donor who had suffered a Strasberg E1 bile duct injury and had undergone a Roux-en-Y hepaticojejunostomy 24 years prior to donation. The liver was successfully recovered and transplanted into a 56-year-old male recipient with end stage liver disease consequent to alpha 1 antitrypsin deficiency. The graft continues to function well 36 months post-transplant, with normal liver function tests and imaging revealing a patent hepaticojejunostomy. DISCUSSION The potential associated vascular injuries should be identified during bench preparation whilst the management of biliary reconstruction at the time of transplant should follow the principles of biliary reconstruction in cases with biliary injuries, extending the hilar opening into the left duct. CONCLUSION This case highlights the successful utilisation of a post bile duct injury repair liver, employing an experienced procurement team and careful bench assessment and reconstruction.
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Affiliation(s)
- Asma Sultana
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom.
| | - James J Powell
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Gabriel C Oniscu
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
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20
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Leale I, Moraglia E, Bottino G, Rachef M, Dova L, Cariati A, De Negri A, Diviacco P, Andorno E. Role of Liver Transplantation in Bilio-Vascular Liver Injury After Cholecystectomy. Transplant Proc 2017; 48:370-6. [PMID: 27109958 DOI: 10.1016/j.transproceed.2015.12.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/30/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to report 2 cases of liver transplantation (LT) for iatrogenic bile-vascular injury (BVI) sustained during cholecystectomy and to review the literature for LT after cholecystectomy. METHODS Between March 2001 and July 2013, within our institution, 12 patients were treated after cholecystectomy, 3 of 12 received LT, 1 for acute de-compensation in a cirrhotic patient and 2 after iatrogenic lesions. RESULTS The majority of iatrogenic injury occurred during video-laparocholecystectomy (63,6%; 7/11). Three patients of 12 (25%) received LT: the first patient developed acute de-compensation in chronic and after liver failure. The second patient developed recurrent cholangitis and secondary biliary cirrhosis. The third patient had undergone emergency hepatectomy because of bleeding and subsequent total hepatectomy with porto-caval shunt. Five of 12 (42%) patients were treated with bilio-digestive anastomosis: 1 patient with direct repair on T-tube; 2 patients (17%) with arterial vascular lesion requiring surgical treatment; and 1 patient treated with medical therapy. No deaths occurred. The post-operative morbidity included 1 re-intervention, 3 recurrent cholangitis, 1 anastomotic biliary stricture, 1 anastomotic bile leak, and cholestasis in 3 patients. The overall hospital stays were higher after LT. Median follow-up was 8.25 years (range, 2-14). CONCLUSIONS The management of iatrogenic injury during cholecystectomy depends on the time of recognition, extent of injury, experience of the surgeon, and the patient's general condition. If safe repair is possible, BVI should be treated promptly, otherwise all patients should be treated in an experienced center.
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Affiliation(s)
- I Leale
- HBP Surgery and Liver Transplant, IRCCS San Martino-IST, Genoa, Italy.
| | - E Moraglia
- Emergency Department, IRCCS San Martino-IST, Genoa, Italy
| | - G Bottino
- HBP Surgery and Liver Transplant, IRCCS San Martino-IST, Genoa, Italy
| | - M Rachef
- HBP Surgery and Liver Transplant, IRCCS San Martino-IST, Genoa, Italy
| | - L Dova
- HBP Surgery and Liver Transplant, IRCCS San Martino-IST, Genoa, Italy
| | - A Cariati
- HBP Surgery and Liver Transplant, IRCCS San Martino-IST, Genoa, Italy
| | - A De Negri
- HBP Surgery and Liver Transplant, IRCCS San Martino-IST, Genoa, Italy
| | - P Diviacco
- HBP Surgery and Liver Transplant, IRCCS San Martino-IST, Genoa, Italy
| | - E Andorno
- HBP Surgery and Liver Transplant, IRCCS San Martino-IST, Genoa, Italy
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Honmyo N, Kuroda S, Kobayashi T, Ishiyama K, Ide K, Tahara H, Ohira M, Ohdan H. Stepwise approach to curative surgery using percutaneous transhepatic cholangiodrainage and portal vein embolization for severe bile duct injury during laparoscopic cholecystectomy: a case report. Surg Case Rep 2016; 2:27. [PMID: 26989053 PMCID: PMC4798688 DOI: 10.1186/s40792-016-0154-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 03/15/2016] [Indexed: 12/07/2022] Open
Abstract
Laparoscopic cholecystectomy (LC) has been recently adapted to acute cholecystitis. Major bile duct injury during LC, especially Strasberg-Bismuth classification type E, can be a critical problem sometimes requiring hepatectomy. Safety and definitive treatment without further morbidities, such as posthepatectomy liver failure, is required. Here, we report a case of severe bile duct injury treated with a stepwise approach using 99mTc-galactosyl human serum albumin (99mTc-GSA) single-photon emission computed tomography (SPECT)/CT fusion imaging to accurately estimate liver function. A 52-year-old woman diagnosed with acute cholecystitis underwent LC at another hospital and was transferred to our university hospital for persistent bile leakage on postoperative day 20. She had no jaundice or infection, although an intraperitoneal drainage tube discharged approximately 500 ml of bile per day. Recorded operation procedure showed removal of the gallbladder with a part of the common bile duct due to its misidentification, and each of the hepatic ducts and right hepatic artery was injured. Abdominal enhanced CT revealed obstructive jaundice of the left liver and arterial shunt through the hilar plate to the right liver. Magnetic resonance cholangiopancreatography revealed type E4 or more advanced bile duct injury according to the Bismuth-Strasberg classification. We planned a stepwise approach using percutaneous transhepatic cholangiodrainage (PTCD) and portal vein embolization (PVE) for secure right hemihepatectomy and biliary-jejunum reconstruction and employed 99mTc-GSA SPECT/CT fusion imaging to estimate future remnant liver function. The left liver function rate had changed from 26.2 % on admission to 26.3 % after PTCD and 54.5 % after PVE, while the left liver volume rate was 33.8, 33.3, and 49.6 %, respectively. The increase of liver function was higher than that of volume (28.3 vs. 15.8 %). On postoperative day 63, the curative operation, right hemihepatectomy and biliary-jejunum reconstruction, was performed, and posthepatectomy liver failure could be avoided. Careful consideration of treatment strategy for each case is necessary for severe bile duct injury with arterial injury requiring hepatectomy. The stepwise approach using PTCD and PVE could enable hemihepatectomy, and 99mTc-GSA SPECT/CT fusion imaging was useful to estimate heterogeneous liver function.
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Affiliation(s)
- Naruhiko Honmyo
- Department of Gastroenterological and Transplant Surgery, Hiroshima University Hospital, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Shintaro Kuroda
- Department of Gastroenterological and Transplant Surgery, Hiroshima University Hospital, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Tsuyoshi Kobayashi
- Department of Gastroenterological and Transplant Surgery, Hiroshima University Hospital, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kohei Ishiyama
- Department of Gastroenterological and Transplant Surgery, Hiroshima University Hospital, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Kentaro Ide
- Department of Gastroenterological and Transplant Surgery, Hiroshima University Hospital, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Hiroyuki Tahara
- Department of Gastroenterological and Transplant Surgery, Hiroshima University Hospital, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Masahiro Ohira
- Department of Gastroenterological and Transplant Surgery, Hiroshima University Hospital, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Hiroshima University Hospital, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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22
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Major bile duct injury requiring operative reconstruction after laparoscopic cholecystectomy: a follow-on study. Surg Endosc 2015; 30:1839-46. [PMID: 26275556 DOI: 10.1007/s00464-015-4469-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 07/23/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Bile duct injury (BDI) after laparoscopic cholecystectomy (LC) has significant cost impact and is a significant source of morbidity and mortality. We undertook a population-based assessment of the national experience with BDI between 2001 and 2011 and compared this to our report for the prior decade. METHODS Using the nationwide inpatient sample (NIS) for 2001-2011, we identified patients who underwent LC or partial cholecystectomy, with and without biliary reconstruction. Data were analyzed using methods that accounted for the hierarchical, stratified random sampling of the NIS. Both univariate modeling and multivariate modeling were performed. RESULTS LCs increased from 71.1 % in 2001 to 79.0 % in 2011 (p < 0.0001). Annual mortality decreased from 0.56 to 0.38 % (p = 0.002). In 2001, 0.11 % of LCs were associated with biliary reconstruction versus 0.09 % in 2011 (p = 0.15) with rates ranging from 0.08 to 0.12 %. The need for reconstruction was associated with an average in-hospital mortality rate of 4.4 %. Mortality rates from LC remained consistent across the study period (average mortality, 0.10 %, p = 0.57). Under multivariate analysis, admission to rural or urban non-teaching centers was associated with a decreased rate of injury; the majority of major BDIs were admitted from clinic or outpatient settings. These results are consistent with results from the prior decade. Neither emergent admission nor race was associated with increased odds of BDI, and this differs from our prior analysis. CONCLUSION LC continued to increase in utilization between 2001 and 2011. Although rates of BDI have decreased, the need for reconstruction continues to be associated with a significant mortality. In addition, mortality related to biliary reconstruction is also higher than previously published series and may reflect the complexity of managing biliary injury as well as the higher likelihood of these patients having comorbid conditions.
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Perini MV, Herman P, Montagnini AL, Jukemura J, Coelho FF, Kruger JA, Bacchella T, Cecconello I. Liver resection for the treatment of post-cholecystectomy biliary stricture with vascular injury. World J Gastroenterol 2015; 21:2102-2107. [PMID: 25717244 PMCID: PMC4326146 DOI: 10.3748/wjg.v21.i7.2102] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Accepted: 12/01/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To report experience with liver resection in a select group of patients with postoperative biliary stricture associated with vascular injury.
METHODS: From a prospective database of patients treated for benign biliary strictures at our hospital, cases that underwent liver resections were reviewed. All cases were referred after one or more attempts to repair bile duct injuries following cholecystectomy (open or laparoscopic). Liver resection was indicated in patients with Strasberg E3/E4 (hilar stricture) bile duct lesions associated with vascular damage (arterial and/or portal), ipsilateral liver atrophy/abscess, recurrent attacks of cholangitis, and failure of previous hepaticojejunostomy.
RESULTS: Of 148 patients treated for benign biliary strictures, nine (6.1%) underwent liver resection; eight women and one man with a mean age of 38.6 years. Six patients had previously been submitted to open cholecystectomy and three to laparoscopic surgery. The mean number of surgical procedures before definitive treatment was 2.4. All patients had Strasberg E3/E4 injuries, and vascular injury was present in all cases. Eight patients underwent right hepatectomy and one underwent left lateral sectionectomy without mortality. Mean time of follow up was 69.1 mo and after long-term follow up, eight patients are asymptomatic.
CONCLUSION: Liver resection is a good therapeutic option for patients with complex postoperative biliary stricture and vascular injury presenting with liver atrophy/abscess in which previous hepaticojejunostomy has failed.
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Major Liver Resection as Definitive Treatment in Post-cholecystectomy Common Bile Duct Injuries. World J Surg 2015; 39:1216-23. [DOI: 10.1007/s00268-014-2933-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Jadrijevic S, Sef D, Kocman B, Mrzljak A, Matasic H, Skegro D. Right hepatectomy due to portal vein thrombosis in vasculobiliary injury following laparoscopic cholecystectomy: a case report. J Med Case Rep 2014; 8:412. [PMID: 25481385 PMCID: PMC4295332 DOI: 10.1186/1752-1947-8-412] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 09/16/2014] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Vasculobiliary injury composed of bile duct, portal vein and hepatic artery injury is a rare, but the most severe, complication after cholecystectomy that may require hepatectomy or even urgent liver transplantation. CASE PRESENTATION We present a case of a 36-year-old Caucasian woman with a biliary sepsis and a large right liver lobe abscess due to an extreme vasculobiliary injury after laparoscopic cholecystectomy. Bismuth type IV biliary duct injury, portal vein thrombosis and injury of right hepatic artery were identified, resulting in life-threatening septic episodes. Right hepatectomy with Roux-en-Y hepaticojejunostomy and reconstruction of her portal vein with a vein allograft were performed. She fully recovered and remained well during 3 years of follow-up. CONCLUSIONS Although rare, the impact of vasculobiliary injuries after cholecystectomy highlights the need for constant alertness and prompt management in order to minimize the risk of the routine operative procedure. Hepatectomy with biliary and vascular reconstruction should be considered early in the management of vasculobiliary injury to avoid the development of life-threatening consequences.
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Affiliation(s)
- Stipislav Jadrijevic
- Department of Surgery, Division of Transplantation Surgery, University Hospital Merkur, Zagreb, Croatia
| | - Davorin Sef
- Department of Surgery, Division of Transplantation Surgery, University Hospital Merkur, Zagreb, Croatia
| | - Branislav Kocman
- Department of Surgery, Division of Transplantation Surgery, University Hospital Merkur, Zagreb, Croatia
| | - Anna Mrzljak
- Department of Medicine, University Hospital Merkur, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Hrvoje Matasic
- Department of Anesthesiology and Critical Care, University Hospital Merkur, Zagreb, Croatia
| | - Dinko Skegro
- Department of Medicine, University Hospital Merkur, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
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Sugawara G, Ebata T, Yokoyama Y, Igami T, Mizuno T, Nagino M. Management strategy for biliary stricture following laparoscopic cholecystectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:889-95. [PMID: 25159686 DOI: 10.1002/jhbp.151] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Biliary strictures following laparoscopic cholecystectomy (Lap-C), which are often associated with vascular injuries, remain a serious problem to manage. The aim of this study was to review our experiences with postoperative biliary stricture. METHODS This study involved 14 consecutive patients with biliary strictures that resulted from bile duct injuries during Lap-C between 1997 and 2013. Their medical records were retrospectively analyzed. RESULTS Percutaneous transhepatic biliary drainage (PTBD) catheter dilatation was first attempted in eight patients, and five patients were successfully treated. Biliary re-stricture recurred in one patient after 34-month follow-up period. This patient underwent repeated catheter dilatations, which led to recurrent stricture resolution. All five patients maintained biliary tract patency over 72-month follow-up period. The remaining nine patients underwent surgical procedures, including hepaticojejunostomy in two patients, re-hepaticojejunostomy in two patients, and the remaining five patients, with biliary strictures involving the secondary biliary branch and concomitant vascular injuries underwent right hemihepatectomy with cholangiojejunostomy. There were no major postoperative complications. After 80-month follow-up period, all nine patients were alive without biliary stricture. CONCLUSIONS PTBD catheter dilatation is recommended first for postoperative Lap-C-associated biliary strictures. In complicated injury patients with vascular injuries, right hemihepatectomy with cholangiojejunostomy should be indicated.
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Affiliation(s)
- Gen Sugawara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Abstract
Late complications arising after bile duct injury (BDI) include biliary strictures, hepatic atrophy, cholangitis and intra-hepatic lithiasis. Later, fibrosis or even secondary biliary cirrhosis and portal hypertension can develop, enhanced by prolonged biliary obstruction associated with recurrent cholangitis. Secondary biliary cirrhosis resulting in associated hepatic failure or digestive tract bleeding due to portal hypertension is a substantial risk factor for morbidity and mortality after bile duct repair. Parameters that determine the management of late complications of BDI include the type of biliary injury, associated vascular injury, hepatic atrophy, the presence of intra-hepatic strictures or lithiasis, repetitive infectious complications, the quality of underlying parenchyma (fibrosis, secondary biliary cirrhosis) and the presence of portal hypertension. Endoscopic drainage is indicated for patients with uncontrolled acute sepsis, patients at high operative risk, patients with cirrhosis who are not eligible for liver transplantation and patients who have previously undergone several attempts at repair. Roux-en-Y hepaticojejunostomy, whether de novo or as an iterative repair, is the technique of reference for post-cholecystectomy BDI. Hepatic resection is indicated in only rare instances, mainly in case of extended hilar stricture, multiple stone retention in one sector of the liver or in patients for whom the repair is deemed technically difficult. Liver transplantation is indicated only in exceptional circumstances, when secondary biliary cirrhosis is associated with liver failure and portal hypertension.
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Affiliation(s)
- L Barbier
- Chirurgie Digestive et Transplantation Hépatique, Hôpital La Conception, Assistance publique-Hôpitaux de Marseille, Aix-Marseille Université, 147, boulevard Baille, 13385 Marseille cedex 5, France.
| | - R Souche
- Chirurgie Digestive A, Hôpital Saint-Éloi, Centre Hospitalo-Universitaire, Montpellier, France
| | - K Slim
- Service de Chirurgie Digestive, Unité de Chirurgie Ambulatoire, CHU Estaing, Clermont-Ferrand, France
| | - P Ah-Soune
- Gastro-Entérologie et Hépatologie, Centre Hospitalier Régional de Toulon, Toulon, France
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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 2013; 101:63-8. [PMID: 24318962 PMCID: PMC4253129 DOI: 10.1002/bjs.9349] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [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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Patrono D, Mazza E, Paraluppi G, Strignano P, David E, Romagnoli R, Salizzoni M. Liver transplantation for "mass-forming" sclerosing cholangitis after laparoscopic cholecystectomy. Int J Surg Case Rep 2013; 4:907-10. [PMID: 23995476 DOI: 10.1016/j.ijscr.2013.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 06/03/2013] [Accepted: 07/22/2013] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Chronic biliary obstruction consequence of a bile duct injury may require liver transplantation (LT) in case of secondary biliary cirrhosis, intractable pruritus or reiterate episodes of cholangitis. "Mass-forming" sclerosing cholangitis leading to secondary portal vein thrombosis and pre-sinusoidal portal hypertension has not been reported so far. PRESENTATION OF CASE We present the case of a patient who underwent laparoscopic cholecystectomy for Mirizzi syndrome. The persistent bile duct obstruction due to a residual gallstone fragment was treated by a prolonged biliary stenting. Following repeated bouts of cholangitis, a fibrous centrohepatic scar developed, conglobating and obstructing the main branches of the portal vein and of the biliary tree. The patient developed secondary portal vein thrombosis and portal hypertension. After an extensive diagnostic work-up, including surgical exploration to rule out malignancy, the case was successfully managed by liver transplantation. DISCUSSION Mass-forming sclerosis of the bile duct and biliary bifurcation may develop as a consequence of chronic biliary obstruction and prolonged stenting. Secondary portal vein thrombosis and pre-sinusoidal portal hypertension represents an unusual complication, mimicking Klatskin tumor. CONCLUSION A timely and proper management of post-cholecystectomy complications is of mainstay importance. Early referral to a specialized hepato-biliary center is strongly advised.
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Affiliation(s)
- Damiano Patrono
- General Surgery 2 and Liver Transplantation Center, University of Turin, A. O. Città della Salute e della Scienza di Torino, Corso Bramante 88, 10126 Turin, Italy
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Addeo P, Saouli AC, Ellero B, Woehl-Jaegle ML, Oussoultzoglou E, Rosso E, Cesaretti M, Bachellier P. Liver transplantation for iatrogenic bile duct injuries sustained during cholecystectomy. Hepatol Int 2013. [DOI: 10.1007/s12072-013-9442-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Bile Duct Injury-from Injury to Repair: an Analysis of Management and Outcome. Indian J Surg 2013; 77:536-42. [PMID: 26730060 DOI: 10.1007/s12262-013-0915-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 04/08/2013] [Indexed: 12/28/2022] Open
Abstract
Despite advances in speciality care, mortality and morbidity remain the most important issues in the management of post-cholecystectomy bile duct injuries. We analysed the peri-operative management of post-cholecystectomy bile duct injuries to assess their outcomes. Of 150 patients with post-cholecystectomy bile duct injuries, 13 patients who presented with strictured hepaticojejunostomy were excluded from the analysis. The records of the remaining 137 patients were analysed for type of presentation, management and follow-up. Of 137 injuries, 88 were open and 49 were laparoscopic. Various presentations include acute bile duct injury (n = 5), bile collection (n = 45), external biliary fistula (n = 46) and stricture (n = 41). After initial management, three patients died (sepsis, n = 2; pseudoaneurysmal bleed, n = 1). Of 107 patients who underwent definitive repair, three died (portal hypertension, n = 2; sepsis, n = 1). At median follow-up of 30 months, 100 patients had good outcome (grade A, B), and only 4 had bad outcome (grade C, D) as per McDonald grading. Peritonitis and sepsis in the early phase and portal hypertension and cirrhosis in the late phase are the main causes of mortality in patients sustaining bile duct injury during cholecystectomy. Successful management in a specialist hepatobiliary centre can limit the morbidity in more than 90 % cases.
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Benkabbou A, Castaing D, Salloum C, Adam R, Azoulay D, Vibert E. Treatment of failed Roux-en-Y hepaticojejunostomy after post-cholecystectomy bile ducts injuries. Surgery 2013; 153:95-102. [DOI: 10.1016/j.surg.2012.06.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 06/14/2012] [Indexed: 11/29/2022]
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Timing and risk factors of hepatectomy in the management of complications following laparoscopic cholecystectomy. J Gastrointest Surg 2012; 16:815-20. [PMID: 22068969 DOI: 10.1007/s11605-011-1769-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 10/19/2011] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Complex bile duct injury (BDI) is a serious condition requiring hepatectomy in some instances. The present study was to analyse the factors that led to hepatectomy for patients with BDI after laparoscopic cholecystectomy (LC). METHODS The medical records of patients referred to our department from April 1998 to September 2007 for management of BDI following LC were reviewed, and patients who underwent hepatectomy were identified. The type of BDI, indication for liver resection, interval between LC and liver surgery, histology of the liver specimen, postoperative morbidity and long-term results were analysed. RESULTS Hepatectomy was performed in 10 of 76 patients (13.2%), with BDI either as isolated damage or in combination with vascular injury (VI). Proximal BDI (defined as disruption of the biliary confluence) and injury to the right hepatic artery were found to be independent risk factors of hepatectomy, with odds ratios of 16 and 45, respectively. Five patients required early liver resection (within 5 weeks post-LC) to control sepsis caused by confluent liver necrosis or bile duct necrosis. In five patients, hepatectomy was indicated during long-term follow-up (over 4 months post-LC) to effectively manage recurrent cholangitis and liver atrophy. Despite of high postoperative morbidity (60%) and even mortality (10%), the long-term results (median follow-up of 34 months) were satisfactory, with either no or only transitory symptoms in 67% of the patients. CONCLUSION Hepatectomy may inevitably be necessary to manage early or late complications after LC. Proximal BDI and VI were the two independent risk factors of hepatectomy in this series.
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Strasberg SM, Gouma DJ. 'Extreme' vasculobiliary injuries: association with fundus-down cholecystectomy in severely inflamed gallbladders. HPB (Oxford) 2012; 14:1-8. [PMID: 22151444 PMCID: PMC3252984 DOI: 10.1111/j.1477-2574.2011.00393.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Extreme vasculobiliary injuries usually involve major hepatic arteries and portal veins. They are rare, but have severe consequences, including rapid infarction of the liver. The pathogenesis of these injuries is not well understood. The purpose of this study was to elucidate the mechanism of injury through an analysis of clinical records, particularly the operative notes of the index procedure. METHODS Biliary injury databases in two institutions were searched for data on extreme vasculobiliary injuries. Operative notes for the index procedure (cholecystectomy) were requested from the primary institutions. These notes and the treatment records of the tertiary centres to which the patients had been referred were examined. Radiographs from the primary institutions, when available, as well as those from the tertiary centres, were studied. RESULTS Eight patients with extreme vasculobiliary injuries were found. Most had the following features in common. The operation had been started laparoscopically and converted to an open procedure because of severe chronic or acute inflammation. Fundus-down cholecystectomy had been attempted. Severe bleeding had been encountered as a result of injury to a major portal vein and hepatic artery. Four patients have required right hepatectomy and one had required an orthotopic liver transplant. Four of the eight patients have died and one remains under treatment. CONCLUSIONS Extreme vasculobiliary injuries tend to occur when fundus-down cholecystectomy is performed in the presence of severe inflammation. Contractive inflammation thickens and shortens the cystic plate, making separation of the gallbladder from the liver hazardous.
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Affiliation(s)
- Steven M Strasberg
- Section of Hepatopancreatobiliary Surgery, Washington University in St LouisSaint Louis, MO, USA
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdamthe Netherlands
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Management of post-cholecystectomy benign bile duct strictures: review. Indian J Surg 2011; 74:22-8. [PMID: 23372303 DOI: 10.1007/s12262-011-0375-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 11/10/2011] [Indexed: 01/02/2023] Open
Abstract
Cholecystectomy is one of the common surgical procedure performed across the world and bile duct injury is a dreaded complication. The present review addresses the classification of injuries, preoperative preparation and evaluation of these patients and appropriate timing of surgery. A detailed preoperative evaluation combined with a meticulous wide anastomosis by experienced surgeons is the key in achieving long term success. Vascular injuries and its consequences on repair and outcome is also reviewed. Long term results of surgical repair and quality of life in these patients are excellent.
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Robles Campos R, Marín Hernández C, Fernández Hernández JA, Sanchez Bueno F, Ramirez Romero P, Pastor Perez P, Parrilla Paricio P. Hemorragia diferida de la arteria hepática derecha tras iatrogenia biliar por colecistectomía laparoscópica que precisó trasplante hepático por insuficiencia hepática aguda: caso clínico y revisión de la literatura. Cir Esp 2011; 89:670-6. [DOI: 10.1016/j.ciresp.2011.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 06/14/2011] [Accepted: 07/01/2011] [Indexed: 01/14/2023]
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Ardiles V, McCormack L, Quiñonez E, Goldaracena N, Mattera J, Pekolj J, Ciardullo M, de Santibañes E. Experience using liver transplantation for the treatment of severe bile duct injuries over 20 years in Argentina: results from a National Survey. HPB (Oxford) 2011; 13:544-50. [PMID: 21762297 PMCID: PMC3163276 DOI: 10.1111/j.1477-2574.2011.00322.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bile duct injury (BDI) is a severe complication that may arise during the surgical treatment of benign disease and a few patients will develop end-stage liver disease (ESLD) requiring a liver transplant (LT). OBJECTIVE Analyse the experience using LT as a definitive treatment of BDI in Argentina. PATIENTS AND METHODS A national survey regarding the experience of LT for BDI. RESULTS Sixteen out 18 centres reported a total of 19 patients. The percentage of LT for BDI from the total number of LT per period was: 1990-94 = 3.1%, 1995-99 = 1.6%, 2000-04 = 0.7% and 2005-09 = 0.2% (P < 0.001). The mean age was 45.7 ± 10.3 years (range 26-62) and 10 patients were female. The BDI occurred during cholecystectomy in 16 and 7 had vascular injuries. One patient presented with acute liver failure and the others with chronic ESLD. The median time between BDI and LT was 71 months (range 0.2-157). The mean follow-up was 8.3 years (10 months to 16.4 years). Survival at 1, 3, 5 and 10 years was 73%, 68%, 68% and 45%, respectively. CONCLUSIONS The use of LT for the treatment of BDI declined over the review period. LT plays a role in selected cases in patients with acute liver failure and ESLD.
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Affiliation(s)
- Victoria Ardiles
- General Surgery Service and Liver Transplant Unit, Hospital Italiano de Buenos AiresBuenos Aires, Argentina
| | - Lucas McCormack
- General Surgery and Liver Transplant Unit, Hospital Alemán de Buenos AiresBuenos Aires, Argentina
| | - Emilio Quiñonez
- General Surgery and Liver Transplant Unit, Hospital Alemán de Buenos AiresBuenos Aires, Argentina
| | - Nicolás Goldaracena
- General Surgery and Liver Transplant Unit, Hospital Alemán de Buenos AiresBuenos Aires, Argentina
| | - Juan Mattera
- General Surgery Service and Liver Transplant Unit, Hospital Italiano de Buenos AiresBuenos Aires, Argentina
| | - Juan Pekolj
- General Surgery Service and Liver Transplant Unit, Hospital Italiano de Buenos AiresBuenos Aires, Argentina
| | - Miguel Ciardullo
- General Surgery Service and Liver Transplant Unit, Hospital Italiano de Buenos AiresBuenos Aires, Argentina
| | - Eduardo de Santibañes
- General Surgery Service and Liver Transplant Unit, Hospital Italiano de Buenos AiresBuenos Aires, Argentina
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Perera MTPR, Monaco A, Silva MA, Bramhall SR, Mayer AD, Buckels JAC, Mirza DF. Laparoscopic posterior sectoral bile duct injury: the emerging role of nonoperative management with improved long-term results after delayed diagnosis. Surg Endosc 2011; 25:2684-91. [DOI: 10.1007/s00464-011-1630-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 11/16/2010] [Indexed: 01/11/2023]
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Specialist Early and Immediate Repair of Post-laparoscopic Cholecystectomy Bile Duct Injuries Is Associated With an Improved Long-term Outcome. Ann Surg 2011; 253:553-60. [DOI: 10.1097/sla.0b013e318208fad3] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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40
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Nordin A, Grönroos JM, Mäkisalo H. Treatment of Biliary Complications after Laparoscopic Cholecystectomy. Scand J Surg 2011; 100:42-8. [DOI: 10.1177/145749691110000108] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The incidence of iatrogenic bile duct injury remains high despite increased awareness of the problem. This major complication following laparoscopic cholecystectomy (LC) has a significant impact on patient's well-being and even survival despite seemingly adequate therapy. The management of bile duct injury (BDI) includes education to avoid the insult, proper and early diagnosis and preferably early treatment. It is of utmost importance to involve experienced hepatobiliary surgeon early enough to perform corrective reconstruction or to plan other therapies with a multidisciplinary team including interventional radiologist and advanced endoscopist. The selection of correct therapy at the earliest possible phase has significant effect on patient outcome. The treatment options are surgery and endoscopy, either immediately or delayed. By constant and continuous analysis of the problem and information to the surgical community it should be possible to decrease the prevalence of iatrogenic BDI and even to avoid it.
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Affiliation(s)
- A. Nordin
- Transplantation and Liver Surgery Department, Helsinki University Hospital, Helsinki, Finland
| | - J. M. Grönroos
- Departments of Surgery and Emergency, Turku University Hospital, Turku, Finland
| | - H. Mäkisalo
- Transplantation and Liver Surgery Department, Helsinki University Hospital, Helsinki, Finland
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Pulitanò C, Parks RW, Ireland H, Wigmore SJ, Garden OJ. Impact of concomitant arterial injury on the outcome of laparoscopic bile duct injury. Am J Surg 2011; 201:238-44. [PMID: 21266217 DOI: 10.1016/j.amjsurg.2009.07.038] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Revised: 07/09/2009] [Accepted: 07/10/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Concomitant injury to the bile duct and hepatic artery is an increasingly recognized complication of laparoscopic cholecystectomy (LC). The impact of a concomitant arterial injury in patients with a bile duct injury (BDI) remains debatable. Early reports described a high incidence of septic complications, difficulty of biliary repair, and increased the risk of recurrent stricture. DATA SOURCES A literature search on the clinical significance and management of a concomitant hepatic artery injury (HAI) to the outcome of biliary-enteric reconstruction following BDI was reviewed. Relevant articles were extracted through MEDLINE, with secondary references obtained from key articles. CONCLUSIONS The association between failure of biliary repair and concomitant arterial injuries is not confirmed by the largest studies, which showed no difference in anastomotic stricture rate between patients who had an isolated BDI and those who had a combined HAI and BDI. However, right arterial injury associated with liver necrosis or damage to the right hepatic duct may require right hepatectomy.
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Affiliation(s)
- Carlo Pulitanò
- Department of Clinical and Surgical Sciences, Royal Infirmary of Edinburgh, University of Edinburgh, UK
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Surgical management and outcome of bile duct injuries following cholecystectomy: a single-center experience. Langenbecks Arch Surg 2011; 396:699-707. [PMID: 21336816 DOI: 10.1007/s00423-011-0745-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2010] [Accepted: 01/26/2011] [Indexed: 01/29/2023]
Abstract
PURPOSE Biliary injury is a severe complication of cholecystectomy. The Hepp-Couinaud reconstruction with the hepatic duct confluence and the left duct may offer best long-term outcome as long as the confluence remains intact (Bismuth I-III). Complex liver surgery is usually indicated in most proximal (Bismuth IV) injuries in non-cirrhotic patients. The aim of this study was to evaluate the surgical treatment and outcome of bile duct injuries managed in a referral hepatobiliary unit. METHODS We retrospectively analyzed surgical management and outcome of biliary injuries following cholecystectomy in 35 patients (27 laparoscopic) referred to our center between June 2001 and December 2009. There was no liver cirrhosis diagnosed in any patient. High injuries (Bismuth III-IV) were found in 14 patients. Management after referral included the Hepp-Couinaud hepaticojejunostomy in 32 patients with Bismuth I-III injuries, which in four cases with biliary peritonitis was preceded by abdominal lavage and prolonged external biliary drainage. Liver transplantation was performed in two patients with Bismuth IV injuries. RESULTS After median follow-up of 59 months (range, 6-102), 34 (97%) patients are alive and 32 (92%) remain in good general condition with normal liver function. One patient who had combined biliary and colonic injury died of sepsis before repair. Recurrent strictures following the Hepp-Couinaud repair developed in two (6%) patients with high injuries combined with right hepatic arterial injury. CONCLUSION The Hepp-Couinaud hepaticojejunostomy offers durable results, even after previous interventions have failed. In case of diffuse biliary peritonitis, delayed biliary reconstruction following external biliary drainage may be the best option.
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Geng L, Luo D, Zhang HC, Zhao LS, Qing DK. Microvessel density at different levels of normal or injured bile duct in dogs and its surgical implications. Hepatobiliary Pancreat Dis Int 2011; 10:83-7. [PMID: 21269940 DOI: 10.1016/s1499-3872(11)60012-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Ischemic recurrent stricture after surgical repair for iatrogenic bile duct injury (BDI) remains a challenge in clinical practice. The present study was designed to investigate whether ischemia is universal and of varied severity at different levels of the proximal bile duct after BDI. METHODS A total of 30 beagle dogs were randomly divided into control, BDI, and BDI-repaired groups. The BDI animal model was established based on the classic pattern of laparoscopic cholecystectomy-related BDI. The animals were sacrificed on postoperative day 15, and bile duct tissue was harvested to assess microvessel density (MVD) at selected levels of the normal, post-BDI and BDI-repaired bile duct with the CD34 immunohistochemistry technique. RESULTS In the control group, MVD at level H (high level) was remarkably higher than that at level L (low level). No significant difference was found between MVDs at levels H and M (middle level), as well as at levels M and L. However, the tendency was noted that the closer the level to the hilus, the greater the MVD at that level. In both the BDI and BDI-repaired groups, MVDs at level H were generally greater than those at level L, despite the unremarkable differences between MVDs at neighboring levels. In these two groups, a similar tendency of MVD distribution to that in the control group was found; the closer the level to the injury site, the lower was the MVD at that level. Moreover, compared with the MDVs at the levels M and L in the control group, MVDs at the corresponding levels in the BDI and BDI-repaired groups were all remarkably reduced (P<0.05). In addition, MVDs at all three levels in the BDI group significantly declined further after BDI repair. CONCLUSIONS After BDI, universal ischemic damage in the injured proximal bile duct develops close to the injury site, while close to the hilus, ischemia is relatively slight. High hepaticojejunostomy, rather than low biloenterostomy or end-to-end duct anastomosis, should be recommended for BDI repair. Great care should be taken to protect the peribiliary plexus during repair.
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Affiliation(s)
- Lin Geng
- Department of Hepatobiliary Surgery, Kunming General Hospital of PLA, Kunming 650032, China
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Strasberg SM, Helton WS. An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB (Oxford) 2011; 13:1-14. [PMID: 21159098 PMCID: PMC3019536 DOI: 10.1111/j.1477-2574.2010.00225.x] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 07/22/2010] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Biliary injuries are frequently accompanied by vascular injuries, which may worsen the bile duct injury and cause liver ischemia. We performed an analytical review with the aim of defining vasculobiliary injury and setting out the important issues in this area. METHODS A literature search of relevant terms was performed using OvidSP. Bibliographies of papers were also searched to obtain older literature. RESULTS Vasculobiliary injury was defined as: an injury to both a bile duct and a hepatic artery and/or portal vein; the bile duct injury may be caused by operative trauma, be ischaemic in origin or both, and may or may not be accompanied by various degrees of hepatic ischaemia. Right hepatic artery (RHA) vasculobiliary injury (VBI) is the most common variant. Injury to the RHA likely extends the biliary injury to a higher level than the gross observed mechanical injury. VBI results in slow hepatic infarction in about 10% of patients. Repair of the artery is rarely possible and the overall benefit unclear. Injuries involving the portal vein or common or proper hepatic arteries are much less common, but have more serious effects including rapid infarction of the liver. CONCLUSIONS Routine arteriography is recommended in patients with a biliary injury if early repair is contemplated. Consideration should be given to delaying repair of a biliary injury in patients with occlusion of the RHA. Patients with injuries to the portal vein or proper or common hepatic should be emergently referred to tertiary care centers.
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Affiliation(s)
- Steven M Strasberg
- Section of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington University in Saint Louis, St Louis, MO 63110, USA.
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Strasberg SM, Helton WS. An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB (Oxford) 2010. [PMID: 21159098 DOI: 10.1111/j.1477-2574.2010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
OBJECTIVES Biliary injuries are frequently accompanied by vascular injuries, which may worsen the bile duct injury and cause liver ischemia. We performed an analytical review with the aim of defining vasculobiliary injury and setting out the important issues in this area. METHODS A literature search of relevant terms was performed using OvidSP. Bibliographies of papers were also searched to obtain older literature. RESULTS Vasculobiliary injury was defined as: an injury to both a bile duct and a hepatic artery and/or portal vein; the bile duct injury may be caused by operative trauma, be ischaemic in origin or both, and may or may not be accompanied by various degrees of hepatic ischaemia. Right hepatic artery (RHA) vasculobiliary injury (VBI) is the most common variant. Injury to the RHA likely extends the biliary injury to a higher level than the gross observed mechanical injury. VBI results in slow hepatic infarction in about 10% of patients. Repair of the artery is rarely possible and the overall benefit unclear. Injuries involving the portal vein or common or proper hepatic arteries are much less common, but have more serious effects including rapid infarction of the liver. CONCLUSIONS Routine arteriography is recommended in patients with a biliary injury if early repair is contemplated. Consideration should be given to delaying repair of a biliary injury in patients with occlusion of the RHA. Patients with injuries to the portal vein or proper or common hepatic should be emergently referred to tertiary care centers.
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Affiliation(s)
- Steven M Strasberg
- Section of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington University in Saint Louis, St Louis, MO 63110, USA.
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Lau WY, Lai ECH, Lau SHY. Management of bile duct injury after laparoscopic cholecystectomy: a review. ANZ J Surg 2010; 80:75-81. [PMID: 20575884 DOI: 10.1111/j.1445-2197.2009.05205.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Bile duct injury following cholecystectomy is an iatrogenic catastrophe which is associated with significant perioperative morbidity and mortality, reduced long-term survival and quality of life, and high rates of subsequent litigation. The aim of this article was to review the management of bile duct injury after cholecystectomy. METHODS Medline and PubMed database search was undertaken to identify articles in English from 1970 to 2008 using the key words 'bile duct injury', 'cholecystectomy' and 'classification'. Additional papers were identified by a manual search of the references from the key articles. Case report was excluded. RESULTS Early recognition of bile duct injury is of paramount importance. Only 25%-32.4% of injuries are recognized during operation. The majority of patients present initially with non-specific symptoms. Management depends on the timing of recognition, the type, extent and level of the injury. Immediate recognition and repair are associated with improved outcome, and the minimum standard of care after recognition of bile duct injury is immediate referral to a surgeon experienced in bile duct injury repair. There is a growing body of literature supporting the importance of early referral to a tertiary care hospital which can provide a multidisciplinary approach to treat bile duct injury. Inadequate management may lead to severe complications. CONCLUSIONS None of the classification system is universally accepted as each has its own limitation. The optimal management depends on the timing of recognition of injury, the extent of bile duct injury, the patient's condition and the availability of experienced hepatobiliary surgeons.
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Affiliation(s)
- Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR, China.
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Ruiz Gómez F, Ramia Ángel JM, García-Parreño Jofré J, Figueras J. Lesiones iatrogénicas de la vía biliar. Cir Esp 2010; 88:211-21. [DOI: 10.1016/j.ciresp.2010.03.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Revised: 02/21/2010] [Accepted: 03/12/2010] [Indexed: 12/20/2022]
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Truant S, Boleslawski E, Lebuffe G, Sergent G, Pruvot FR. Hepatic resection for post-cholecystectomy bile duct injuries: a literature review. HPB (Oxford) 2010; 12:334-41. [PMID: 20590909 PMCID: PMC2951822 DOI: 10.1111/j.1477-2574.2010.00172.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This study seeks to identify factors for hepatectomy in the management of post-cholecystectomy bile duct injury (BDI) and outcome via a systematic review of the literature. METHODS Relevant literature was found by searching the PubMed database and the bibliographies of extracted articles. To avoid bias selection, factors for hepatectomy were analysed in series reporting both patients undergoing hepatectomy and patients undergoing biliary repair without hepatectomy (bimodal treatment). Relevant variables were the presence or absence of additional hepatic artery and/or portal vein injury, the level of BDI, and a previous biliary repair. RESULTS Among 460 potentially relevant publications, only 31 met the eligibility criteria. A total of 99 hepatectomies were reported among 1756 (5.6%) patients referred for post-cholecystectomy BDI. In eight series reporting bimodal treatment, including 232 patients, logistic regression multivariate analysis showed that hepatic arterial and Strasberg E4 and E5 injuries were independent factors associated with hepatectomy. Patients with combined arterial and Strasberg E4 or E5 injury were 43.3 times more likely to undergo hepatectomy (95% confidence interval 8.0-234.2) than patients without complex injury. Despite high postoperative morbidity, mortality rates were comparable with those of hepaticojejunostomy, except in urgent hepatectomies (within 2 weeks; four of nine patients died). Longterm outcome was satisfactory in 12 of 18 patients in the largest series. CONCLUSIONS Hepatectomies were performed mainly in patients showing complex concurrent Strasberg E4 or E5 and hepatic arterial injury and provided satisfactory longterm outcomes despite high postoperative morbidity.
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Affiliation(s)
- Stéphanie Truant
- Department of Digestive Surgery and Transplantation, University HospitalsLille, France
| | - Emmanuel Boleslawski
- Department of Digestive Surgery and Transplantation, University HospitalsLille, France
| | - Gilles Lebuffe
- Department of Anaesthesiology and Intensive Care Medicine, University HospitalsLille, France
| | | | - François-René Pruvot
- Department of Digestive Surgery and Transplantation, University HospitalsLille, France
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Schmidt SC, Fikatas P, Denecke T, Schumacher G, Aurich F, Neumann U, Seehofer D. Hepatic resection for patients with cholecystectomy related complex bile duct injury. Eur Surg 2010. [DOI: 10.1007/s10353-010-0524-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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