Iatrogenic bile duct injuries

Near-infrared fluorescence cholangiography in dogs: A pilot study

OBJECTIVE

To determine the effect of indocyanine green (ICG) dose and timing of administration on near-infrared fluorescence (NIRF) imaging of the normal canine biliary tree.

STUDY DESIGN

Preclinical prospective study.

ANIMALS

Eight purpose-bred beagles.

METHODS

The dogs were randomized to receive two of four intravenous ICG dose (low [L]:0.05 mg/kg or high [H]:0.25 mg/kg)/time (0 and 3 h prior to NIRF) combinations. NIRF images were collected every 10 min for 120 min. Target (cystic duct)-to-background (liver) ratios were calculated for all timepoints and compared.

RESULTS

ICG cholangiography was successful in all dogs. The contrast ratio was above 1 in the L0 group by 20 min and reached its peak at 100 min. In the H0 group, the ratio was above 1 by 60 min and reached its peak at 90 min. Contrast ratios above 2 (fluorescence twice as bright in the cystic duct compared to the liver) were maintained from 180 to 300 min for L3 and H3 and was achieved after 80 min for L0.

CONCLUSION

Low dose ICG provided better ratios early after injection compared to the high dose which remained highly concentrated in the liver tissue after injection. Both doses provided excellent visualization of the biliary tree at 3 h post injection, low dose ICG provided better ratios from 3 to 5 h post injection. Based on these results, 0.05 mg/kg of ICG administered at anesthetic premedication, or as early as 3 h prior to laparoscopic surgery should yield optimal fluorescence images.

CLINICAL SIGNIFICANCE

This study provides guidelines for NIRF cholangiography in clinically normal dogs.

How much is the long-term quality of life impaired in cholecystectomy-related biliary tract injury?

Objectives

Iatrogenic bile duct injury (IBDI) is a serious complication of cholecystectomy that may crucially affect long-term quality of life and have major morbidities. Furthermore, even after reconstructive surgical treatment, such injuries still reduce the long-term quality of life. Therefore, there remains a need to investigate long-term quality of life of the patients since it is considered that there is a long-term decrease in both physical and mental quality of life. Accordingly, this study aimed to investigate the clinical evaluations and long-term quality of life of the patients who had undergone reconstructive surgery for iatrogenic bile duct injury.

Material and Methods

This clinical study included 49 patients (38 females/11 males) with cholecystectomy-associated bile duct injury and who underwent reconstruction surgery. Several parameters, including the type of bile duct injury, reconstructive surgical procedures, length of hospital stay, and complications were evaluated. Moreover, the effects of reconstructive surgical timing (perioperative, early postoperative, late postoperative) on quality of life were assessed. Long term quality of life (LTQL) levels were evaluated using the SF-36 questionnaire in patients whose follow-ups ranged from two to nine years. The SF-36 questionnaire scores were compared to the average SF-36 norm values of the healthy Turkish population.

Results

Our results showed that 73.5% of biliary tract injuries occurred after a laparoscopic surgery while 26.5% after open cholecystectomy. Of the injuries, 32.7% developed in patients with acute cholecystitis. Thirty of the patients were treated with hepaticojejunostomy. When SF-36 questionnaire scores of the study were compared to those of the healthy Turkish population, energy-vitality was found to be lower significantly in male patients (p= 0.041). However, there was no significant deterioration in female patients. Although general health perception was better in hepaticojejunostomy according to the type of reconstructive surgery performed, no significant difference was observed in the quality of life. Mental health, energy-vitality (p= 0.019), and general health perception (p= 0.026) were found to be lower in women who had E¹ -E² injuries. Only seven of the injuries were detected perioperatively. Physical function (p= 0.033) and general health perception (p= 0.035) were found to be lower in the early postoperative treatment group in male patients in terms of the time of reconstructive surgery.

Conclusion

IBDIs cause serious morbidity. Furthermore, even after reconstructive surgical treatment, such injuries still reduce LTQL. Our results suggest that LTQL is lower, especially in male patients undergoing postoperative early biliary repair for Strasberg E³ -E⁴ type injuries.

Presence of Aberrant Anatomy Is an Independent Predictor of Bile Duct Injury During Cholecystectomy

The aim of this study is to investigate the impact of an aberrant anatomy diagnosed with MR cholangiography on the occurrence of bile duct injury. Although many authors report that aberrant anatomy is a strong risk factor for the occurrence of bile duct injury during cholecystectomy, no reports have examined the incidence of aberrant anatomy and its association as an independent risk factor for bile duct injury while controlling for potential confounding factors. This study involved 1289 patients. All images of MR cholangiography were reviewed and the findings, including the presence of aberrant anatomy, thickening of the gallbladder wall, and cystic duct stones—which may be related to the occurrence of bile duct injury—were recorded. The surgical outcome was compared according to the presence or absence of an aberrant anatomy and the predictive factors for bile duct injury were investigated. Aberrant anatomy was present in 11.2% of cases. The incidence of bile duct injury was significantly higher in patients with aberrant anatomy compared with patients without (3.5% versus 0.3%). By multivariate analysis, the presence of an aberrant anatomy and thickening of the gallbladder wall was an independent predictor for bile duct injury occurrence [odds ratio (OR) =16.56, P = 0.001; OR = 10.96, P = 0.006, respectively]. The presence of an aberrant anatomy and thickening of the gallbladder wall is an independent risk factor for the occurrence of bile duct injury.

Long-term outcomes of patients with common bile duct injury following laparoscopic cholecystectomy

INTRODUCTION

Common bile duct (CBD) injury is a serious and dreaded complication of cholecystectomy. A paucity of data assessing long-term outcomes exists. This study aimed to determine long-term mortality and liver transplantation rates following CBD injury requiring operative intervention.

METHODS

Patients were identified via the New York State (NYS) Planning and Research Cooperative System longitudinal administrative database which captures patient-level data from every inpatient and outpatient hospital discharge in NYS. In total, 125 patients with CBD injuries were identified following 156,958 laparoscopic cholecystectomies for cholelithiasis performed in NYS from 2005 to 2010. Patients were then tracked by unique identifier to obtain rate of liver transplantation. Follow-up ranged from 4 to 9 years from surgery.

RESULTS

There were 125 patients with CBD injuries detected. No mortalities occurred within 30 days. All-cause mortality was 20.8 % (n = 26) with mean time to death 1.64 ± 1.08 years. One patient who underwent hepaticoenterostomy required a liver transplant 4.3 years after surgery. Significant factors predictive of all-cause mortality included: age >61, Medicare insurance, male gender, White race, diabetes, hypertension and pulmonary complications following surgery. Overall 30-day morbidity, timing to and type of operative intervention did not influence mortality.

CONCLUSION

Considerable long-term mortality, 20.8 %, is associated with common bile duct injury requiring operative intervention. This was an increase of 8.8 % above the cohort's expected age-adjusted rate of death. The mortality rate is appreciably higher than quoted previously. No difference was demonstrated by type of repair required. Liver transplant rate was 0.8 %. These data have significant implications for patient and family counseling both prior to cholecystectomy and following CBD injury.

Beyond the learning curve: incidence of bile duct injuries following laparoscopic cholecystectomy normalize to open in the modern era

BACKGROUND

Early reports of higher complication rates, specifically bile duct injuries, raised concerns over the safety of laparoscopy over open cholecystectomy. This study aims to ascertain the rate, management, and perioperative outcomes of bile duct injury in an era beyond the laparoscopic learning curve.

METHODS

The New York State (NYS) Planning and Research Cooperative System longitudinal administrative database was used to identify patients. From 2005 to 2010, 156,315 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis. Patients were then tracked with unique identifiers for common bile duct injury. Common bile duct injury was identified by ICD-9 and CPT diagnosis and procedure codes for patients who subsequently underwent hepatectomy, hepaticojejunostomy, or other bile duct surgery.

RESULTS

From 2005 to 2010, 156,958 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis. Of the total patients, 149 patients underwent a biliary duct procedure within a year. Twenty-four of them were diagnosed with gallbladder cancer and excluded, leaving 125 for further analysis. The biliary injuries were identified at a rate of 0.080 %. Thirty-one of those patients (24.8 %) underwent hepatectomy, 40 patients (32.0 %) underwent hepaticoenterostomy, and 54 patients (43.2 %) underwent primary repair of the bile duct. Thirty-two (26 %) patients were repaired on the same day of their initial procedure. Of the remaining 93 patients, 38 (30 %) were repaired within 10 days, seven (6 %) repaired between 11 and 20 days, and 48 (38 %) patients over 21 days from injury.

CONCLUSION

In NYS, the rate of bile duct injury has now decreased to 0.08 % and mirrors the historical figures quoted for open cholecystectomy. This improvement likely reflects increased experience, improved instrumentation, and movement beyond the "learning curve."

Laparoscopic reconstruction of the extrahepatic bile duct using a jejunal tube: an innovative, more physiological and anatomical technique for biliodigestive derivation†

The incidence of bile duct injuries has increased as a consequence of the increasing number of cholecystectomies. However, the results of biliodigestive derivation currently used for bile duct reconstruction are unsatisfactory. We report here the case of a patient with iatrogenic Bismuth II bile duct injury and propose a new technique that permits more anatomical and physiological reconstruction of extensive bile duct injuries using transverse retubularization of a pedicled jejunal segment interposed between the bile duct and duodenum.

Video-assisted surgery implementation in the public health system of a developing country

BACKGROUND

Over the last two decades, video-assisted surgery has become the preferential access route for many procedures. Despite cholecystectomy being the laparoscopic procedure most frequently performed in Brazilian public hospitals from 2008 to 2012, the lack of population-based studies led us to conduct a survey on the prevalence of video-assisted surgery in the treatment of patients using the Sistema Único de Saúde (SUS) (Unified Health System), which is the universal, free, and public healthcare system of Brazil.

METHODS

By analyzing the DATASUS (national public health registry database), the prevalence of laparoscopic cholecystectomy and open cholecystectomy (OC) was calculated in the period from January to December in 2008, 2010 and 2012, taking into consideration their geographic distribution throughout Brazil.

RESULTS

At the end of the study period, an increase in the number of laparoscopic cholecystectomies was observed, with a variation of 125.7%. However, OC was more prevalent despite an increase in the use of video-assisted surgery over the 5-year study period, increasing from 12 to 25% in 2012.

CONCLUSIONS

In spite of a trend toward increased use of video-assisted surgery for treating SUS patients during the period under study, the data from 2012 are still far from being ideal. For this population, OC via laparotomy is still the most prevalent option in all regions. This information must encourage the Brazilian surgical societies to push for an improvement in the supply of the treatment provided by the public health system.

Single-port cholecystectomy versus multi-port cholecystectomy: a prospective cohort study with 222 patients

BACKGROUND

The aim of this study was to compare single-port access cholecystectomy (SPA) with the standard laparoscopic technique (LC) regarding the duration of the operation, complications, learning curve, late postoperative quality of life (QoL) and the incidence of incisional hernias.

METHODS

Between June 2009 and December 2011, a total of 122 SPA cholecystectomies were performed in our hospital. Simultaneously, 310 patients were operated on with the LC technique. In the LC group, 100 patients met the same criteria defined for SPA surgery. The two groups (SPA and LC) were compared by multivariable regression analysis. Endpoints of this study were quality of life (QoL) after 6 months by the EQ-5D questionnaire 5L and the incidence of incisional hernia 1 year after surgery. Operating time, hospital stay, and perioperative complications were also measured and compared. The median follow-up was 9.2 months (3-25 months).

RESULTS

The patients in the SPA group were younger and more often female. The mean operating time for group SPA was 73 min (35-136 min)-significantly longer than that for group LC with 60 min (33-190 min) (p < 0.001). Additional trocars were used in 8 of 122 (6.5 %) SPA patients. A conversion to open cholecystectomy was not necessary in SPA patients. The conversion rate in the LC group to open cholecystectomy was 2 % (2/100). The perioperative and postoperative complications and incisional hernia (5.5 %) were the same in both groups. QoL was significantly better in the SPA group in terms of mobility (p = 0,002), usual activity (p = 0.036), and overall anxiety (p = 0.026).

CONCLUSIONS

SPA cholecystectomy is safe, although the operation is significantly longer. No differences in terms of major complications or the incidence of incisional hernia were seen after 1 year. QoL was significantly better in patients operated on with the SPA technique.

Primary versus delayed repair for bile duct injuries sustained during cholecystectomy: results of a survey of the Association Francaise de Chirurgie

BACKGROUND

Bile duct injuries (BDIs) sustained during a cholecystectomy still remain a major surgical problem, and it is still not clear whether the injury should be repaired immediately or a delayed repair is preferred.

METHODS

A retrospective national French survey was conducted to compare the results of immediate (at time of cholecystectomy), early (within 45 days after a cholecystectomy) and late (beyond 45 days after a cholecystectomy) surgical repair for BDI sustained during a cholecystectomy.

RESULTS

Forty-seven surgical centres provided 640 cases of bile duct injury sustained during a cholecystectomy of which 543 were analysed for the purpose of the present study. The timing of repair was immediate in 194 cases (35.7%), early in 216 cases (39.8%) and late in 133 cases (24.5%). The type of repair was a suture repair in 157 cases (81%), and a bilio-digestive reconstruction in 37 cases (19%) for immediate repair; a suture repair in 119 cases (55.1%) and a bilio-digestive anastomosis in 96 cases (44.9%) for the early repair; and a bilio-digestive reconstruction in 129 cases (97%) and a suture repair in 4 cases (3%) for late repair. A second procedure was required in 110 cases (56.7%) for immediate repair, 80 cases (40.7%) for early repair (P < 0.05) and in 9 cases (6.8%) for late repair (P < 0.001).

CONCLUSION

The timing of surgical repair for a bile duct injury sustained during a cholecystectomy influences significantly the rate of a second procedure and a late repair should be preferred option.

Visibility enhancement of common bile duct for laparoscopic cholecystectomy by vivid fiber-optic indication: a porcine experiment trial

Bile duct injury (BDI) is the most serious iatrogenic complication during laparoscopic cholecystectomy (LC) and occurs easily in inexperienced surgeons since the position of common bile duct (CBD) and its related ductal junctions are hard to precisely identify in the hepatic anatomy during surgery. BDI can be devastating, leading to chronic morbidity, high mortality, and prolonged hospitalization. In addition, it is the most frequent injury resulting in litigation and the most likely injury associated with a successful medical malpractice claim against surgeons. This study introduces a novel method for conveniently and rapidly indicating the anatomical location of CBD during LC by the direct fiber-optic illumination of 532-nm diode-pumped solid state laser through a microstructured plastic optical fiber to avoid the wrong identification of CBD and the injury from mistakenly cutting the CBD that can lead to permanent and even life threatening consequences. Six porcine were used for preliminary intra-CBD illumination experiments via laparotomy and direct duodenal incision to insert the invented CBD illumination laser catheter with nonharmful but satisfactory visual optical density.

Does increased experience with laparoscopic cholecystectomy yield more complex bile duct injuries?

BACKGROUND

Two decades since the advent of laparoscopic cholecystectomy, the rate of bile duct injuries still remains higher than in the open cholecystectomy era.

METHODS

The rate and complexity of bile duct injuries was evaluated in 83,449 patients who underwent laparoscopic cholecystectomy between 1995 and 2008 in the Kaiser Permanente Northern California system. Fifty-six surgeons who performed a laparoscopic cholecystectomy in the past were surveyed to determine factors that predispose to bile duct injuries.

RESULTS

The overall incidence of bile duct injuries was .10%; 59.5% of the 84 injuries were cystic duct leaks. Incidence varied slightly from .10% (1995-1998) to .08% (1999-2003) and .12% (2004-2008). There was a trend toward more proximal injuries (injury <2 cm from the bifurcation: 14.3% to 44.4% to 50.0% of major injuries). The misinterpretation of anatomy was cited by 92.9% of surgeons as the primary cause of bile duct injuries; 70.9% cited a lack of experience as a contributing factor.

CONCLUSIONS

Laparoscopic cholecystectomy has an overall low risk of bile duct injuries; the rate remains constant, but injury complexity may have increased over time.

Associated Vascular Injury in Patients with Bile Duct Injury During Cholecystectomy

Cholecystectomy remains one of the most commonly performed procedures in general surgery. Although the incidence, diagnosis, and treatment of bile duct (BD) injuries have been well described, studies characterizing associated vascular injuries are limited. The objective of this study was to analyze the frequency and management of associated vascular and BD injury after cholecystectomy. A total of 50 patients were referred to a tertiary institution for BD injuries from 1996 to 2010. Thirty-nine (78%) of the patients were female with the mean age of 49 years (range, 14 to 86 years). Seventy-five per cent of the injuries were Strasberg Type E. Nine patients (18%) had associated vascular injuries. Six patients had injuries to the right hepatic artery; in one patient, both the right and left hepatic arteries were damaged. Five patients had right portal vein injuries; three of these subsequently died. In conclusion, as a result of the high incidence of associated vascular injury, a thin-collimation CT angiogram and/or mesenteric angiogram with portal venous imaging should be considered as part of the preoperative evaluation in patients with BD injury.

Real-time intra-operative near-infrared fluorescence identification of the extrahepatic bile ducts using clinically available contrast agents

BACKGROUND

Iatrogenic bile duct injuries are serious complications with patient morbidity. We hypothesized that the invisible near-infrared (NIR) fluorescence properties of methylene blue (MB) and indocyanine green (ICG) could be exploited for real-time, intraoperative imaging of the extrahepatic bile ducts during open and laparoscopic surgeries.

METHODS

In all, 2.0 mg/kg of MB and 0.05 mg/kg of ICG were injected intravenously into 35-kg female Yorkshire pigs and the extrahepatic bile ducts were imaged over time using either the Fluorescence-Assisted Resection and Exploration (FLARE) image-guided surgery system (open surgery) or a custom NIR fluorescence laparoscopy system. Surgical anatomy was confirmed using x-ray cholangiography. The contrast-to-background ratio (CBR), contrast-to-liver ratio (CLR), and chemical concentrations in the cystic duct (CD) and common bile duct (CBD) were measured, and the performance of each agent was quantified.

RESULTS

Using NIR fluorescence of MB, the CD and CBD could be identified with good sensitivity (CBR and CLR > or =4), during both open and laparoscopic surgeries, from 10 to 120 min postinjection. Functional impairment of the ducts, including constriction and injury were immediately identifiable. Using NIR fluorescence of ICG, extrahepatic bile ducts did not become visible until 90 min postinjection because of strong residual liver retention; however, between 90 and 240 min, ICG provided exquisitely high sensitivity for both CD and CBD, with CBR > or =8 and CLR > or =4.

CONCLUSION

We demonstrate that 2 clinically available NIR fluorophores, MB fluorescing at 700 nm and ICG fluorescing at 800 nm, provide sensitive, prolonged identification of the extrahepatic bile ducts and assessment of their functional status.

Triangle of safety technique: a new approach to laparoscopic cholecystectomy

Backgrounds and Study Aims. Common bile duct (CBD) injury is one of the most serious complications of laparoscopic cholecystectomy (LC). Misidentification of the CBD during dissection of the Calot's triangle can lead to such injuries. The aim of the authors in this study is to present a new safe triangle of dissection. Patients and Method. 501 patients under went LC in the following approach; The cystic artery is identified and mobilized from the gall bladder (GB) medial wall down towards the cystic duct which would simultaneously divide the medial GB peritoneal attachment. This is then followed by dividing the lateral peritoneal attachment. The GB will be unfolded and the borders of the triangle of safety (TST) are achieved: cystic artery medially, cystic duct laterally and the gallbladder wall superiorly. The floor of the triangle is then divided to delineate both cystic duct and artery in an area relatively far from CBD. Results. There were little significant immediate or delayed complications. The mean operating time was 68 minutes, nearly equivalent to the conventional method. Conclusions. Dissection at TST appears to be a safe procedure which clearly demonstrates the cystic duct and may help to reduce the CBD injuries.

Paediatric cholecystectomy: Shifting goalposts in the laparoscopic era

BACKGROUND

Laparoscopic cholecystectomy is the treatment of choice in symptomatic paediatric cholelithiasis. However, controversy exists about its role in asymptomatic cholelithiasis and biliary dyskinesia. We have reviewed the experiences of two UK paediatric centres with laparoscopic cholecystectomy over an 8.5 year period and critically evaluated the indications and outcomes of surgery.

METHODS

Patients who underwent laparoscopic cholecystectomy by a single surgeon at the Royal Aberdeen and Royal Alexandra Hospitals between May 1996 to August 2003 and September 2003 to December 2005, respectively, were studied. Information was extracted from prospectively held databases and analysed.

RESULTS

A total of 27 cholecystectomies were performed during the period of study. The mean age of patients was 11.7 years with a female preponderance. Symptomatic idiopathic cholelithiasis was the main indication for surgery (14). Cholecystectomy was also performed for haemolytic disease (3), acute recurrent pancreatitis of unknown cause (2), gallbladder trauma (1), and for asymptomatic calcific non-resolving stones (7). All patients were investigated with ultrasound scans with four patients undergoing magnetic resonance cholangiopancreatography (MRCP) for suspected common bile duct (CBD) stones. A standard four-port approach was used with the gallbladder extracted through the umbilical port. The mean operative time in the latter 13 cases was 105 minutes with a median postoperative stay of one day for the whole series. Histology revealed chronic cholecystitis in all but three cases. All patients were discharged after a six-month follow-up period.

CONCLUSIONS

The advent of laparoscopy has resulted in an expansion of the traditional indications for cholecystectomy. MRCP is a useful investigation in selected children to exclude choledocholithiasis and avoid intraoperative cholangiography. There appears to be no clear correlation between histology and presenting symptoms. The natural history of asymptomatic gallstones in children is not known although a consensus is emerging to support cholecystectomy for all calcific non-resolving gallstones.

Surgical options in the management of cystic duct avulsion during laparoscopic cholecystectomy

BACKGROUND

Avulsion of cystic duct during laparoscopic cholecystectomy (LC) is not a common intraoperative complication, but may be encountered by any laparoscopic surgeon. Surgeons are rarely familiar with management of this condition.

METHODS

Patients with gall stone related problems who were scheduled for LC at the minimal invasive surgery unit of a tertiary referral hospital during a 5 years period (April 2002-April 2007) were prospectively enrolled.

RESULTS

12 cases were identified (incidence: 1.15%). All 12 patients had gallbladder inflammation. Five patients had acute and seven patients had chronic cholecystitis. The avulsed cystic duct (ACD) was managed by clipping in 4, intracorporeal suturing in 3, converting to open surgery with suture ligation in 2, and lonely external drainage in 3 patients. Bile leakage had ceased within 3 days in 2, 14 days in one, and 20 days in the other patient. Bile volume increased gradually in one of the patients, which stopped only after endoscopic sphincterotomy (ES) at 25th postoperative day. No major late complication or mortality occurred.

CONCLUSION

ACD during LC is a rare complication. Almost all standard methods of treatment yield to successful outcomes with low morbidity. According to the situation, ACD may be successfully managed laparoscopically. Available cystic stump remnant was clipped. Intracorporeal suture ligation was performed when short length of stump precluded clipping. Deeply retracted cystic duct with active bile leak led to conversion to open surgery. With minimal or no bile leak at ACD stump, closed tube drainage of sub-hepatic area was attempted. Persistent bile leak was assumed to be controlled by ES, successfully accomplished in one patient.

Risk factors for bile duct injury during laparoscopic cholecystectomy: a case-control study

Common bile duct injury is a serious but uncommon complication of laparoscopic cholecystectomy. A case-control epidemiologic study of patients who had undergone cholecystectomy in Ontario, Canada, between 1991 and 1997 was performed. Four patients who had undergone a laparoscopic cholecystectomy at the same hospital 2 months prior to a case were selected as controls. The risk of bile duct injury associated with various exposures was estimated by unconditional logistic regression. There were 28 cases and 88 controls. Emergency operation (adjusted odds ratio = 5.0; 95% confidence interval, 1.4-17.8) and failure to identify the cystic duct (adjusted odds ratio = 13.7; 95% confidence interval, 2.5-76.3) were statistically significant risk factors for operative bile duct injury. No other characteristics were independent risk factors for bile duct injury. Failure to identify the cystic duct and the emergency surgery are independent risk factors for bile duct injury.

Proposal of a new technique for bile duct reconstruction after iatrogenic injury: study in dogs and review of the literature

PURPOSE: Interposition of a jejunal tube between the common bile duct and duodenum. METHODS: Five adult mongrel dogs of both sexes, weighing on average 22.3 kg (18 to 26.5 kg), were used. Obstructive jaundice was induced by ligation of the distal common bile duct. After one week, a 2.5-cm long jejunal tube was fabricated from a segment of the loop removed 15 cm from the Treitz angle and interposed between the common bile duct and duodenum. RESULTS: The animals presented good clinical evolution and no complications were observed. After 6 weeks, complete integration was noted between the bile duct mucosa, tube and duodenum and a significant reduction in total bilirubin and alkaline phosphatase was observed when compared to the values obtained one week after ligation of the common bile duct. CONCLUSION: The jejunal tube interposed between the dilated bile duct and duodenum showed good anatomic integration and reduced total bilirubin and alkaline phosphatase levels in the animals studied.

Bile duct injuries during laparoscopic cholecystectomy: primary and long-term results from a single institution

BACKGROUND

Iatrogenic bile duct injury carries high morbidity. After the introduction of laparoscopic cholecystectomy the incidence of these injuries has at least doubled, and even after the learning curve, the incidence has plateaued at the level of 0.5%.

METHODS

A total of 32 patients sustained biliary tract injuries of the 3736 laparoscopic cholecystectomies performed in and around Turku University Central Hospital between January 1995 and April 2002. The data concerning primary treatment and long-term results were collected and analyzed retrospectively.

RESULTS

The overall incidence for bile duct injuries, including all the minor injuries (cystic duct leaks and bile duct strictures), was 0.86%; for major injuries alone the incidence was 0.38%. Nineteen percent of the injuries were detected intraoperatively. All the cystic duct leaks were treated endoscopically with a 90% success rate. Of the bile duct strictures 88% were treated successfully with endoscopic techniques. Ninety-three percent of the major injuries, including tangential lesions of common bile duct and total transections, were treated operatively. The operation of choice was either hepaticojejunostomy or cholangiojejunostomy in 69% of the cases; the rest were treated with simple suturing over a T-tube or an endoscopically placed stent. The long-term results, with a median follow-up period of 7.5 years, are good in 79% of the operated patients and in 84% of the whole study population. Mortality rate was 3% and acute or chronic cholangitis was seen in 13% of the patients during follow-up.

CONCLUSION

Most of the minor bile duct injuries, including cystic duct leaks and bile duct strictures, are well treatable with endoscopic techniques, whereas most of the major injuries require operative treatment, which at optimal circumstances gives good results.

Conversions during laparoscopic cholecystectomy: risk factors and effects on patient outcome

In view of the substantial, at times conflicting, literature on conversion to open surgery during laparoscopic cholecystectomy (LC), we have considered it timely to review the subject to identify the risk factors for conversion and its consequences. The review is based on a complete literature search covering the period 1990 to 2005. The search identified 109 publications on the subject: 68 retrospective series, 16 prospective nonrandomized studies, 8 prospective randomized clinical trials, 5 prospective case-controlled studies, 5 reviews and 7 others (3 observational, 2 population-based studies, 1 national survey, and 1 editorial). As the majority of reported studies are retrospective, firm conclusions cannot be reached. Single factors that appear to be important include male gender, extreme old age, morbid obesity, cirrhosis, previous upper abdominal surgery, severe/advanced acute and chronic disease, and emergency LC. The combination of patient- and disease-related risk factors increases the conversion risk. In the training of residents, the number of cases needed for reaching proficiency exceeds 200 cases. The value of predictive scoring systems is important in the selection of cases for resident training. Conversion exerts adverse effects on operating time, postoperative morbidity, and hospital costs, especially when it is enforced. There appears to be no absolute contraindication to LC that is agreed upon by all. There is consensus on certain individual risk factors and their additive effect on the likelihood of conversion. Predictive systems based on these factors appear to be useful in selection of cases for resident training.

A Population Based Study on Mishaps During Laparoscopic Cholecystectomy in Qatar: 10 Years Experience

In order to determine the national incidence of adverse events following laparoscopic cholecystectomy (LC) the records were reviewed retrospectively of4861 patients who underwent LC over a period often years (1993-2003).

The most serious non-biliary complication was trocar injury of major vessels in three cases. Other non-biliary complications included duodenal perforation during dis-section of the Calot's triangle, small bowel injury while inserting the umbilical port and trocar site hernia. Adverse biliary events included common bile duct injury, common hepatic duct injury, bile leakage from the cystic duct and one instance of the migration of an endoloop into the com-mon bile duct. Conversion to open cholecystectomy was required in 109 cases.

Although LC may be associated with various adverse sequelae, these are rare and should not deter surgeons and patients.

Laparoscopic End-to-End Choledochocholedochostomy for Bile Duct Injury During Laparoscopic Cholecystectomy

Bile duct injury is one of the serious complications associated with laparoscopic cholecystectomy. If the bile duct injury is circumferential or the bile duct is transected, conversion to open surgery is usually done. With the continuing development of laparoscopic techniques, procedures that previously seemed implausible can now be performed laparoscopically. We describe a case of successful laparoscopic end-to-end choledochocholedochostomy after the common bile duct was mistaken for the cystic duct intraoperatively and transected.

Informed consent and choice in cholecystectomy

As patients and parents seek more information and the threat of litigation increases, the process of informed consent has assumed greater importance. Data from large adult experiences indicate that the risk of bile duct injury, although small, is greater with laparoscopic cholecystectomy (LC) than open cholecystectomy. This complication has not yet been documented in pediatric practice, where cholecystectomy is relatively uncommon. What method do parents and patients choose if consent is truly informed? Of 57 consecutive children undergoing cholecystectomy, an open procedure was specifically indicated in 20 (previous major gastrointestinal surgery in 11, concomitant major abdominal operation in four, and complex biliary tract disease in five) and LC in two (cystic fibrosis, severe autism). The remaining 35 patients were counseled in a standard manner about the relative merits of LC versus mini-cholecystectomy (MC) and allowed to choose. Specifically, they were informed that LC offers better cosmesis, less postoperative discomfort, and a shorter hospital stay, but in adults is associated with a slightly increased rate of bile duct injury (0.3-0.5% vs. 0.2%). All MCs were performed through a 4-cm incision. Parents chose LC in 23 cases and MC in 12. The median age of both groups was similar. No surgical complications occurred, and there were no conversions in the LC group. No patient had retained stones. LC patients were discharged home after a mean of 1.7 days and MC patients after 2.3 days (0.1 > p > 0.05). If an open or laparoscopic technique is not specifically indicated and if parents/patients are fully informed, a significant minority may opt for mini-cholecystectomy.

Laparoscopic Bile Duct Injuries: Management at a Tertiary Liver Center

Bile duct injury is a rare but morbid complication of laparoscopic cholecystectomy (LC). This study was undertaken to evaluate the management of 20 patients with bile duct injuries during LC who were referred to a tertiary center with expertise in hepatobiliary surgery and liver transplantation. Sixteen (80%) were female. Mean age was 44 (range 13–70) years. Half of the injuries were distal (Bismuth I), and nearly half were diagnosed at LC. Reoperative repair was attempted in 30 per cent. Mean interval between injury and operation was 6.55 months (range 0 to 36 months). Eighteen patients underwent Roux-en-Y hepaticojejunostomy (HJ). Of the two patients who did not undergo HJ (both Bismuth I), one was treated with transhepatic cholangiography only, and one died of multiorgan failure. There were four minor complications and one late reoperation for stricture. We conclude that bile duct injury after LC is successfully managed in a tertiary center by a hepatobiliary-liver transplant team. Principles of management include anatomic definition of injury, control of sepsis, staged approach involving interventional radiology, and operative techniques refined in liver transplantation including magnification, fine sutures, selective use of internal stent, and liver biopsy.

A new method of preventing bile duct injury in laparoscopic cholecystectomy

AIM: Of all the complications of laparoscopic cholectecystomy, bile duct injury (BDI) is the most serious complication. The prevention of injury to the common bile duct (CBD) remains a significant concern in laparoscopic cholecystectomy (LC). Different kinds of methods have been advanced to avoid this injury but no single method has gained wide acceptance. Because of various limitations of current methodologies we began a study using cold light illumination of the extrahepatic biliary system (light cholangiography LCP) to better visualize this area and thereby reduce the risk of bile duct injury.

METHODS: Thirty-six patients with cholelithiasis were divided into two groups. Group I (16 cases) received LCP and group II (20 cases) received methelenum coeruleum cholangiography (MCCP). In group I cold light was used to illuminate the common bile duct by leading an optical fiber into the common duct with a duodenoscope at the time of LC. The light coming from the fiber in the CBD could clearly illuminate the location of CBD and hepatic duct establishing its location relative to the cystic duct. This method was compared with the dye injection technique using methelenum coeruleum.

RESULTS: In group I thirteen cases were successfully illuminated and three failed. The cause of three failed cases was due to the difficulty in inserting the fiber into the ampulla of Vater. No complications occurred in the thirteen successful cases. In each of these successful cases the location of the common and hepatic ducts was clearly seen differentiating the ductal system from surrounding anatomy. In ten cases both the left and right hepatic ducts could be seen and in three only the right hepatic ducts were seen. In four of the thirteen cases, cystic ducts were also seen. In group II, eighteen of the twenty cases were successful. The location of extrahepatic ducts became blue differentiating the ductal system from surrounding anatomy. Two cases failed due to a stone obstructing the cystic duct, and extravisation of the dye turned the entire area blue. LCP showed the common and hepatic ducts more clearly than MCCP.

CONCLUSION: LCP is the only technique that can clearly and directly show the location of the extrahepatic biliary system and may be useful in selecting cases of uncertain anatomy in the prevention of bile duct injury.