Techniques of biliary reconstruction following bile duct resection (with video)

Modified technique of Hepatojejunostomy for biliary tract reconstruction after resection of tumors affecting the perihilar region: a case series

BACKGROUNDS

Radical resection is the most effective treatment for perihilar tumors. Biliary tract reconstruction after resection is one of the key steps in this surgery. Mucosa-to-mucosa cholangiojejunostomy is traditionally performed, in which the bile ducts at the resection margin are separately anastomosed to the jejunum. However, this approach is associated with long operative time and high risk of postoperative complications. The present study presents a modified technique of hepatojejunostomy and its outcomes.

METHODS

The data of patients who underwent hepatojejunostomy using the modified technique at the Department of Hepatobiliary Surgery, Daping Hospital, Army Medical University, Chongqing, China, from January 2016 to December 2021, were retrospectively analyzed.

RESULTS

A total of 13 patients with perihilar tumors underwent R0 resection and bilioenteric reconstruction using the modified hepatojejunostomy technique during the study period. During the operation, the alignment of the bile duct stumps was improved, the posterior wall of the anastomosis was reinforced, internal stents were placed in the smaller bile ducts, external stents were placed in the larger bile ducts, and hepatojejunostomy was performed using 4 - 0 prolene. No serious postoperative complications, such as death or bile leakage, occurred during the hospitalization. Furthermore, there were no cases of biliary stricture or cholangitis after the six-month follow-up period.

CONCLUSION

The modified hepatojejunostomy technique is a safe and effective technique of biliary reconstruction after the resection of perihilar tumors. This can be easily performed for difficult cases with multiple bile ducts that require reconstruction after resection.

Utility of modified pancreaticoduodenectomy (Hi-cut PD) for middle-third cholangiocarcinoma: an alternative to hepatopancreaticoduodenectomy

BACKGROUND

The standard procedure for middle-third cholangiocarcinoma (MCC) is pancreaticoduodenectomy (PD); hepatopancreaticoduodenectomy (HPD) is often performed despite its high risk. There is no clear selection guidance for these procedures.

METHODS

Patients with MCC who underwent HPD or PD were retrospectively evaluated. The conventional PD was modified (mPD) to transect the bile duct beyond or close to the cranial level of the portal bifurcation.

RESULTS

The mPD group (n = 55) was characterized by older age, shorter operation time, less blood loss, and less frequent complications than were observed in the HPD group (n = 34). The median grossly tumor-free margin of the proximal bile duct (GM) was 13 mm vs 20 mm (P = 0.006). Overall survival did not differ significantly between groups (48% vs 53% at 5 years, P = 0.399). Multivariate analysis identified positive surgical margin as a sole independent prognostic factor (hazard ratio, 1.89; P = 0.043), which was statistically associated with GM length. Five-year survival for mPD patients with GM ≥15 mm was significantly better than that for those who had GM <15 mm (69% vs 33%, P = 0.011) and comparable to that of HPD patients (53%, P = 0.450).

CONCLUSION

The mPD may be recommended in patients with MCC, provided that GM ≥15 mm is expected from the preoperative radiological imaging. Otherwise, HPD should be considered.

The Short- and Long-Term Surgical Results of Consecutive Hepatopancreaticoduodenectomy for Wide-Spread Biliary Malignancy

BACKGROUND

Cancer-free resection (R0) is one of the most important factors for the long-term survival of biliary carcinoma. For some patients with widespread invasive cancer located between the hilar and intrapancreatic bile duct, hepatopancreaticoduodenectomy (HPD) is considered a radical surgery for R0 resection. However, HPD is associated with high morbidity and mortality rates. Furthermore, previous reports have not shown lymph node metastasis (LNM) status, such as the location or number, which could influence the prognosis after HPD. In this study, first, we explored the prognostic factors for survival, and second, we evaluated whether the LNM status (number and location of LNM) would influence the decision on surgical indications in patients with widely spread biliary malignancy.

METHODS

We retrospectively reviewed the medical records of 54 patients who underwent HPD with hepatectomy in ≥2 liver sectors from January 2003 to December 2021 (HPD-G). We also evaluated 54 unresectable perihilar cholangiocarcinoma patients who underwent chemotherapy from January 2010 to December 2021 (CTx-G).

RESULTS

R0 resection was performed in 48 patients (89%). The median survival time (MST) and 5-year overall survival rate of the HPD-G and CTx-G groups were 36.9 months and 31.1%, and 19.6 months and 0%, respectively. Univariate and multivariate analyses showed that pathological portal vein involvement was an independent prognostic factor for survival (MST: 18.9 months). Additionally, patients with peripancreatic LNM had worse prognoses (MST: 13.3 months) than CTx-G.

CONCLUSIONS

Patients with peripancreatic LNM or PV invasion might be advised to be excluded from surgery-first indications for HPD.

Interrupted versus continuous suture technique for biliary-enteric anastomosis: randomized clinical trial

BACKGROUND

Biliary-enteric anastomosis (BEA) can be performed using continuous or interrupted suture techniques, but high-quality evidence regarding superiority of either technique is lacking. The aim of this study was to compare the suture techniques for patients undergoing BEA by evaluating the suture time as well as short- and long-term biliary complications.

METHODS

In this single-centre randomized clinical trial, patients scheduled for elective open procedure with a BEA between 21 January 2016 and 20 September 2017 were randomly allocated in a 1:1 ratio to have the BEA performed with continuous suture (CSG) or interrupted suture technique (ISG). The primary outcome was the time required to complete the anastomosis. Secondary outcomes were BEA-associated postoperative complications with and without operative revision of the BEA, including bile leakage, cholestasis, and cholangitis, as well as morbidity and mortality up to day 30 after the intervention and survival.

RESULTS

Altogether, 82 patients were randomized of which 80 patients received the allocated intervention (39 in ISG and 41 in CSG). Suture time was longer in the ISG compared with the CSG (median (interquartile range), 22.4 (15.0-28.0) min versus 12.0 (10.0-17.0) min, OR 1.26, 95 per cent c.i. 1.13 to 1.40; unit of increase of 1 min; P < 0.001). Short-term and long-term biliary complications were similar between groups. The incidence of bile leakage (6 (14.6 per cent) versus 4 (10.3 per cent), P = 0.738) was comparable between groups. No anastomotic stenosis occurred in either group.

CONCLUSION

Continuous suture of BEA is equally safe, but faster compared with interrupted suture.

REGISTRATION NUMBER

NCT02658643 (http://www.clinicaltrials.gov).

Meta-analysis of interrupted versus continuous suturing for Roux-en-Y hepaticojejunostomy and duct-to-duct choledochocholedochostomy

AIMS

To compare outcomes of interrupted (IS) and continuous (CS) suturing techniques for Roux-en-Y hepaticojejunostomy and duct-to-duct choledochocholedochostomy.

METHODS

The study protocol was prospectively registered in PROSPERO (registration number: CRD42021286294). A systematic search of MEDLINE, CENTRAL, and Web of Science and bibliographic reference lists were conducted (last search: 14th March 2022). All comparative studies reporting outcomes of IS and CS in hepaticojejunostomy and choledochocholedochostomy were included and their risk of bias was assessed using ROBINS-I tool. Overall biliary complications, bile leak, biliary stricture, cholangitis, liver abscess, and anastomosis time were the evaluated outcome parameters.

RESULTS

Ten comparative studies (2 prospective and 8 retrospective) were included which reported 1617 patients of whom 1186 patients underwent Roux-en-Y hepaticojejunostomy (IS: 789, CS: 397) and the remaining 431 patients underwent duct-to-duct choledochocholedochostomy (IS: 168, CS: 263). Although use of IS for hepaticojejunostomy was associated with significantly longer anastomosis time (MD: 14.15 min, p=0.0002) compared to CS, there was no significant difference in overall biliary complications (OR: 1.34, p=0.11), bile leak (OR: 1.64, p=0.14), biliary stricture (OR: 0.84, p=0.65), cholangitis (OR: 1.54, p=0.35), or liver abscess (OR: 0.58, p=0.40) between two groups. Similarly, use of IS for choledochocholedochostomy was associated with no significant difference in risk of overall biliary complications (OR: 0.92, p=0.90), bile leak (OR: 1.70, p=0.28), or biliary stricture (OR: 1.07, p=0.92) compared to CS.

CONCLUSIONS

Interrupted and continuous suturing techniques for Roux-en-Y hepaticojejunostomy or duct-to-duct choledochocholedochostomy seem to have comparable clinical outcomes. The available evidence may be subject to confounding by indication with respect to diameter of bile duct. Future high-quality research is encouraged to report the outcomes with respect to duct diameter and suture material.

Clinical and oncological benefits of left hepatectomy for Bismuth type I/II perihilar cholangiocarcinoma

PURPOSE

This retrospective study aimed to clarify whether the postoperative prognosis differs between right and left hepatectomy for Bismuth type I/II perihilar cholangiocarcinoma.

METHODS

Preoperative images of 195 patients with perihilar cholangiocarcinoma were reexamined. Patients with Bismuth type I/II perihilar cholangiocarcinoma without a difference in extraductal tumor invasion between the right and left sides of the hepatic portal region were classified into those undergoing left (L group) or right (R group) hepatectomy.

RESULTS

Twenty-three patients (11.8%) were classified into the L group and 33 (16.9%) into the R group. All eight patients with pTis/1 belonged to the L group. The L group had significantly less liver failure than the R group (p = 0.001). One patient (4.3%) in the L group and four patients (12.1%) in the R group died from postoperative complications. Among 48 patients with pT2, the L group tended to have better overall survival (median, 12.2 vs. 5.6 years; p = 0.072), but not recurrence-free survival (median, 9.1 vs. 3.6 years; p = 0.477), in comparison to the R group.

CONCLUSIONS

Postoperative survival after left hepatectomy for Bismuth type I/II perihilar cholangiocarcinoma is expected to be as long as that after right hepatectomy.

Therapeutic Effect of Combining Anisodamine With Neostigmine on Local Scar Formation Following Roux-en-Y Choledochojejunostomy in a Novel Rat Model

Background: The present study aimed to explore the potential effect of combining anisodamine with neostigmine on local scar formation following Roux-en-Y choledochojejunostomy (RCJS) in a novel rat model.

Methods: The biliary obstruction model of Sprague Dawley (SD) rats was established in advance, and 54 rats were divided into nine groups randomly (sham operation group, anisodamine group, neostigmine group, combination group, and control group). Anisodamine (25 mg/kg) and neostigmine (50 μg/kg) were injected to the abdominal cavity separately or simultaneously for 1 week since the first day after surgery according to their allocated intervention, while the same amount of saline (0.5 ml) was injected intraperitoneally in the control group. Indexes including body weight, the diameter of the common bile duct, liver function, inflammatory indexes, and the condition of scar formation in different groups at certain time were evaluated in our study.

Results: Recovery of liver function (ALT, AST, TB, DB, and GGT) and systematic inflammation indexes (CRP, TNF-α, and IL-1β) in the combination group was prior to that in the control group (p < 0.05), while no statistical difference in the serum level of IL-10 was observed among groups. Rats in the combination group represented a wider anastomotic diameter and lower expression of α-SMA and TGF-β1 at anastomotic stoma compared to the control group (p < 0.05). Histopathological staining showed slighter proliferation of collagen and smooth muscle fibers in rats’ bile duct wall and less local scar formation at anastomotic stoma compared to the control group.

Conclusion: The combination of anisodamine and neostigmine can alleviate local and systemic inflammatory response, promote the recovery of liver function, and reduce scar formation in rats after the RCJS procedure.

Coledocolitiasis y exploración laparoscópica de la vía biliar. Un estudio de cohorte

Introducción. La coledocolitiasis es la presencia de cálculos en las vías biliares. En la mayoría de los casos se trata mediante la colangio pancreatografía retrógrada endoscópica y menos comúnmente por intervención quirúrgica laparoscópica. El objetivo de este estudio fue describir una cohorte retrospectiva de pacientes sometidos a exploración laparoscópica de la vía biliar. Métodos. Se incluyeron pacientes intervenidos entre los años 2014 y 2018, en dos instituciones de nivel III en Cali, Colombia, referidos para valoración por cirugía hepato-biliar, por dificultad para la extracción de los cálculos por colangio pancreatografia retrograda endoscópica, debido al tamaño, la cantidad, o la dificultad para identificar o canular la papila duodenal. Resultados. De los 100 pacientes incluidos, se encontró que el 72 % fueron mujeres, con rango de edad entre 14 y 92 años. Al 39 % de los pacientes se les extrajo un solo cálculo y al 16 % 10 cálculos. Un 12 % presentaron cálculos gigantes (mayores de 2,5 cm de ancho) y un 44 % presentaron litiasis múltiple. Al 69 % de los pacientes se les realizó colecistectomía. El porcentaje de éxito de limpieza de la vía biliar por laparoscopia fue del 95 %. Discusión. La exploración laparoscópica de la vía biliar es una técnica posible, reproducible, segura y con excelentes resultados para el manejo de la coledocolitiasis.

Mechanism of scar formation following Roux-en-Y choledochojejunostomy in a novel rat model of obstructive jaundice

Background

The present study aimed to analyze the scar formation mechanism following Roux-en-Y choledochojejunostomy (CJS) in a novel rat model of obstructive jaundice.

Methods

The biliary obstruction model of Sprague-Dawley (SD) rats was established in advance, and 24 rats were randomly divided into 4 groups (control group, 1-day ligation group, 3-day ligation group, and 5-day ligation group). Changes in postoperative weight, common bile duct diameter, and laboratory indexes were analyzed to determine the best operation time. Roux-en-Y CJS in rats was studied based on the model, and the rats were randomly divided into 4 groups [control group, 3-day choledochojejunostomy (CJS) group, 7-day CJS group, and 30-day CJS group]. The same indexes were analyzed, and the characteristics of scar formation were evaluated by histopathology and polymerase chain reaction examination.

Results

The third day after common bile duct ligation is the best time for a Roux-en-Y CJS. The common bile duct diameter expands to 4.2 mm on average, and these physiological characteristics are consistent with current standard clinical findings. After completing CJS, the rats’ weight returned to normal levels, and alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TB), direct bilirubin (DB), and C-reactive protein (CRP) indexes gradually decreased (P<0.05). Anastomotic stoma diameter tended to narrow with time and was significantly narrower on day 30 than preoperation. After CJS, the expression of α-smooth muscle actin (α-SMA) peaked in the early stage and was still higher than that of the control group in the bile duct wall 1 month postoperatively (P<0.05). Transforming growth factor-β1 (TGF-β1) expression gradually increased and was higher than that of the control group at each stage postoperatively (P<0.05).

Conclusions

The rat Roux-en-Y CJS model is more in line with our surgical model, and the clinical condition has potential applicability for the study of CJS scar formation. Scar formation following CJS in rats is characterized by the activation of fibroblasts caused by early inflammatory stimulation, which leads to the proliferation of collagen and smooth muscle fibers, resulting in scars.

The Role of Portoenterostomy with Aggressive Hilar Dissection in Biliary Tract Tumors: Report of Case Series and Review of the Literature

Hepaticojejunostomy is a challenging and complex procedure to be done with confidence in conditions that contain a large number of segmental bile ducts. Portoenterostomy can be defined as the joining of multiple bile ducts into a single cavity using segmenter bile duct ends, stents, and surrounding connective tissues. During surgery, in cases with advanced stage biliary tract tumors that cannot be performed hepatectomy, after aggressive dissections to provide a negative surgical margin, a large number of segmental bile ducts can be revealed and needs to ensure the continuity of bile flow. Here, our clinical series of portoenterostomy (PE) in which we applied in patients who had aggressive hilar dissection and resection for hilar cholangiocarcinomas and biliary tract tumors were discussed. The study included 15 patients who underwent PE for biliary tract tumors and hilar cholangiocarcinomas between 2015 and 2019. Six of the patients had a tumor-negative surgical margin, with a mean follow-up of 14.4 months (range 2 to 28 months). Nine of the patients had a tumor-positive surgical margin, with a mean follow-up of 7.7 months (range 2 to 17 months). Portoenterostomy instead of hepaticojejunostomy in small and multiple biliary radicles and bile duct cancers has been successfully performed in 15 patients of bile duct cancer and Klatskin tumor. In the presence of active inflammation, fibrosis, major bile duct trauma, and thin bile duct radicles, this method, which is described in detail, provides an excellent salvage surgical procedure with less morbidity.

Choledochal cyst- unusual presentation in the adult phase: Case report

INTRODUCTION

Bile duct cysts are congenital malformations characterized by bile duct dilatation with intra and/or extrahepatic localization. About 80% of cases are diagnosed in childhood, so their presentation in adults is rare and repeatedly associated with complications.

PRESENTATION OF CASE

A 38-year-old female patient complained of severe abdominal pain for one month, with no associated cholestatic signs. She underwent abdominal ultrasonography that showed cholelithiasis with extrahepatic bile duct dilatation and underwent cholangiography (MRI), which revealed fusiform dilatation of the proximal portion of the hepatocholedochal, compatible with choledochal cyst.

DISCUSSION

In adult patients, clinical manifestations are usually nonspecific, and the diagnosis is established by medical imaging. Magnetic resonance cholangiopancreatography (MRCP) is the gold standard diagnostic today. Treatment with better prognosis consists of total cyst resection with hepaticojejunal anastomosis and intestinal transit reconstruction with Roux-en-Y.

CONCLUSION

Bile duct cysts are a rare condition in adults. Currently, increasing access to more accurate medical imaging enables early diagnosis, contributing to the use of therapeutic methods in appropriate time, avoiding development of complications.

Two-in-one method: Novel pancreaticojejunostomy technique for the bifid pancreas

The bifid pancreas is a rare anatomical variation of the pancreatic duct in which double main pancreatic ducts in the body and tail of the pancreas join at the pancreas head and drain through the major papilla. When pancreaticoduodenectomies are carried out on bifid pancreases, close attention must be paid to the reconstruction because of the possibility that there may be two pancreatic ducts that need to be reconstructed. We present a case of pancreaticoduodenectomy for the bifid pancreas and a novel technique named the 'two-in-one' method for double pancreatic duct to jejunum anastomosis. Using the two-in-one method, we anastomosed one jejunal hole to a double pancreatic duct. Pancreatic texture was normal and postoperative volumes of pancreatic juice from the two external pancreatic duct stents were 250 mL and 100 mL/day, respectively. Postoperative recovery went well although the patient needed a slightly longer hospital stay as a result of surgical site infection. This novel anastomotic technique was as simple to carry out as a normal pancreaticojejunostomy and may be useful for reconstruction of the bifid pancreas.

Comparison between hepaticojejunostomy and hepaticoduodenostomy after excision of choledochal cyst in children: a cohort study

Objective

Hepaticojejunostomy (HJ) and hepaticoduodenostomy (HD) are commonly used biliary reconstruction techniques after choledochal cyst excision. HD has been suggested to be a more physiologic alternative during reconstruction. The objective of this study is to compare operative time, hospital stay, morbidity (leak, cholangitis, ileus, and obstruction), and mortality between HJ and HD after cyst excision.

Methods

This is a 14-year retrospective cohort study of pediatric patients (≤18 years old) who underwent choledochal cyst excision and subsequent biliary reconstruction at the Philippine Children’s Medical Center. Data were taken from inpatient charts, operative technique, OPD logbook, readmission, and OPD charts.

Results

There were 122 patients: 56% HD and 44% HJ. Majority were female (72%), with 1:2.6 male to female ratio. The average age was 36.1 months, with a mean follow-up of 32.8 months (range 6 months–14 years). The most common cyst was type I (87%). Operative time was longer for HJ compared with HD (321.3 vs 203.6 min; p=0.000). Hospital stay was longer with HJ compared with HD (7.7 vs 6.8 days; p=0.002). Mortality rate was low at 1.6% while morbidity was at 13.9% in both groups. Although morbidity was higher among those who underwent HD, there was no significant difference between the two procedures. Anastomotic leak (4%) and cholangitis (7.4%) were observed in HD, and ileus (7.4%) was observed in the HJ group.

Conclusions

In our series, HD provided less operative time and hospital stay than with HJ. We did not observe bile gastritis after HD as compared with others. It is suggested that longer follow-up is needed to confirm such findings.

Short- and long-term outcomes of choledochojejunostomy during pancreaticoduodenectomy and total pancreatectomy: interrupted suture versus continuous suture

PURPOSE

Choledochojejunostomy can be performed with either interrupted sutures (IS) or continuous sutures (CS). No reports have compared the short- or long-term patient outcomes resulting from these two methods.

METHODS

A total of 228 consecutive patients who underwent pancreaticoduodenectomy or total pancreatectomy were prospectively enrolled in this study. All patients were alternately (by turns) assigned to the IS and CS groups. Among those patients, 161 patients who received regular postoperative follow-up for more than 2 years were eligible for analysis (IS group, n = 81; CS group, n = 80). A comparative analysis was performed between these groups regarding short-term (e.g., anastomotic leakage) and long-term complications (e.g., anastomotic stricture), time required to complete the anastomosis, and cost.

RESULTS

The incidence of anastomotic leakage and anastomotic stricture was comparable between the IS and CS groups (1.2% vs. 1.2%, p = 0.993; 8.6% vs. 6.2%, p = 0.563). The groups did not differ regarding the incidence of any short- or long-term complications. The time required to complete the anastomosis in the IS group was 27.0 ± 6.6 min, compared with 16.2 ± 5.0 min in the CS group (p < 0.001). The cost was $144.7 ± 34.6 in the IS group vs. $11.7 in the CS group (p < 0.001).

CONCLUSIONS

The IS and CS groups did not differ regarding short- and long-term outcomes. The anastomosis was completed in significantly less time in the CS group. The CS method was also superior in terms of cost.

Risk factors for a high Comprehensive Complication Index score after major hepatectomy for biliary cancer: a study of 229 patients at a single institution

BACKGROUND

The Comprehensive Complication Index (CCI) is a new tool to evaluate the postoperative condition by calculating the sum of all complications weighted by their severity. The aim of this study was to identify independent risk factors for a high CCI score (≥40) in 229 patients after major hepatectomies with biliary reconstruction for biliary cancers.

METHODS

The CCI was calculated online via www.assessurgery.com. Independent risk factors were identified by multivariable analysis.

RESULTS

57 (25%) patients were classified as having CCI ≥ 40. On multivariable analysis, volume of intraoperative blood loss (≥2.5 L) (p = 0.004) and combined pancreatoduodenectomy (PD) (p = 0.006) were independent risk factors for CCI ≥ 40. A high level of maximum serum total bilirubin was identified as independent risk factors for a high volume of intraoperative blood loss. Liver failure (p = 0.046) was more frequent in patients with combined PD than in those without.

DISCUSSION

Patients who undergo preoperative external biliary drainage for severe jaundice might have impaired production of coagulation factors. When blood loss during liver transection becomes difficult to control, surgeons should consider various strategies, such as second-stage biliary or pancreatic reconstruction. In patients planned to undergo major hepatectomy with combined PD, preoperative portal vein embolization is mandatory to prevent postoperative liver failure.

Prognostic impact of the site of portal vein invasion in patients with surgically resected perihilar cholangiocarcinoma

BACKGROUND

The aim of this study was to determine the impact of the site of portal vein invasion on survival after hepatectomy for perihilar cholangiocarcinoma.

METHODS

This study classified 168 patients undergoing resection for perihilar cholangiocarcinoma histologically as without portal vein resection or tumor invasion to the portal vein (PV0), with tumor invasion to unilateral branches of the portal vein (PVt3), or with tumor invasion to the main portal vein or its bilateral branches, or to unilateral second-order biliary radicals with contralateral portal vein involvement (PVt4). Patients in PVt4 were subclassified into the A-M group (cancer invasion limited to the tunica adventitia or media) or the I group (cancer invasion reaching the tunica intima).

RESULTS

Of the patients, 121 were in PV0, 21 were in PVt3, and 26 were in PVt4. There was no difference in survival between the PV0 and PVt3 groups (P = .267). The PVt4 group had a worse prognosis than the PVt3 group (P = .046). In addition, the A-M (n = 19) and I subgroups (n = 7) of PVt4 had worse prognoses than the PV0 or PVt3 groups (P = .005 and < .001, respectively). All patients in the I subgroup of PVt4 died within 9 months after resection. On multivariate analysis, PVt4 (P = .029) was identified as an independent prognostic factor.

CONCLUSIONS

In perihilar cholangiocarcinoma, postoperative survival was no different between patients with and without ipsilateral portal vein invasion, although patients with tumor invasion to the main or contralateral branches of the portal vein, especially with tunica intima invasion, had extremely poor prognoses.

[Restoration and reconstruction of extrahepatic bile ducts in high strictures using enteric autotransplant of variable diameter]

AIM

To develop technique incorporating favorable aspects of gastroenterostomy in common hepatic duct anastomosis, providing bile drainage into duodenum and preventing duodenobiliary reflux.

MATERIAL AND METHODS

It is presented developed operations for high strictures of extrahepatic bile ducts using enteric autotransplant of variable diameter.

RESULTS

Good remote postoperative results were observed in 10 survived patients. There were no recurrence of stricture, cholangitis and normal biochemical parameters were observed. It has been proved that suggested methods may be alternative to Roux-en-Y hepaticojejunostomy.

Anastomotic leakage after gastrointestinal surgery: diagnosis and management

Anastomotic leakage represents a major complication of gastrointestinal surgery, leading to increased postoperative morbidity; it the foremost cause of mortality after intestinal resection. Identification of risk factors is essential for the prevention of AL. AL can present with various clinical pictures, ranging from the absence of symptoms to life-threatening septic shock. Contrast-enhanced CT scan is the most complete investigation to define AL and its consequences. Early and optimal multidisciplinary management is based on three options: medical management, radiologic or endoscopic intervention, or surgical re-intervention. Prompt treatment should help decrease postoperative morbidity and mortality, with the choice depending on the septic status of the patient. If the patient is asymptomatic, treatment can be medical only, coupled with close surveillance. Interventional management is indicated when the fistula is symptomatic but not life-threatening. On the other hand, when the vital prognosis is engaged, surgery is indicated, emergently, associated with intensive care. Even more than their prevention, early and appropriate management counts most to decrease their consequences.

Post-operative depletion of platelet count is associated with anastomotic insufficiency following intrahepatic cholangiojejunostomy: a case-control study from the results of 220 cases of intrahepatic cholangiojejunostomy

Background

Post-operative anastomotic insufficiency following major hepato-biliary surgery has significant impacts on the post-operative course. Recent reports have revealed that platelets play an important role in liver regeneration and wound healing. From these experimental and clinical results on platelet function, we hypothesized that post-operative platelet depletion (to <10 × 10⁴/μL) would be associated with delayed liver regeneration as well as anastomotic insufficiency of intrahepatic cholangiojejunostomy. However, little information is available regarding correlations between platelet count and these complications. The purposes of the present study were, firstly, to evaluate the incidence of anastomotic insufficiency following intrahepatic cholangiojejunostomy and, secondly, to evaluate whether platelet depletion represents a risk factor for anastomotic insufficiency in intrahepatic cholangiojejunostomy.

Methods

Participants in this study comprised 220 consecutive patients who underwent intrahepatic cholangiojejunostomy following hepato-biliary resection for biliary malignancies between September 1998 and December 2010. Anastomotic insufficiency was confirmed by cholangiographic demonstration of leakage from the anastomosis using contrast medium introduced via a biliary drainage tube or prophylactic drain placed during surgery.

Results

Anastomotic insufficiency of the intrahepatic cholangiojejunostomy occurred in 13 of 220 patients (6%). Thirteen of the 220 patients, including one with anastomotic insufficiency, died during the study. Uni- and multivariate analyses both revealed that platelet depletion on post-operative day 1 (<10 × 10⁴/μL) correlated with anastomotic insufficiency.

Conclusion

Post-operative platelet depletion was closely associated with anastomotic insufficiency following intrahepatic cholangiojejunostomy. This correlation has been established, but the underlying mechanisms have not.

Surgical outcome of hilar plate resection: extended hilar bile duct resection without hepatectomy

BACKGROUND

We have done curative or palliative extended extrahepatic bile duct resection at the level of the hilar plate for selected patients with cholangiocarcinoma with hilar spreading, calling this procedure "hilar plate resection" (HPR), but the results of evaluating the clinical benefits of HPR for cholangiocarcinoma with hilar spreading have not been reported.

PATIENTS AND METHODS

Fifty-two patients with cholangiocarcinoma underwent HPR: the curative procedure was performed in 28 patients (cHPR group) and the palliative in 24 patients (pHPR group). In the same period, 128 patients with cholangiocarcinoma underwent major hepatectomy with intrahepatic cholangiojejunostomy (Hx group). These groups were compared in terms of post-operative complications and survival.

RESULTS

There were no significant differences in the rate of patients with post-operative complications and in post-operative hospital stay. The overall cumulative 5-year survival rates for each procedure (Hx group, cHPR group and pHPR group) were 40, 38 and 11 %, respectively. There was no significant difference between the Hx and cHPR groups in survival rates (p = 0.87).

CONCLUSION

In conclusion, HPR appears to be safe and feasible for selected patients with cholangiocarcinoma. However, the indications for HPR should be restricted.

Concise review: clinical programs of stem cell therapies for liver and pancreas

Regenerative medicine is transitioning into clinical programs using stem/progenitor cell therapies for repair of damaged organs. We summarize those for liver and pancreas, organs that share endodermal stem cell populations, biliary tree stem cells (hBTSCs), located in peribiliary glands. They are precursors to hepatic stem/progenitors in canals of Hering and to committed progenitors in pancreatic duct glands. They give rise to maturational lineages along a radial axis within bile duct walls and a proximal-to-distal axis starting at the duodenum and ending with mature cells in the liver or pancreas. Clinical trials have been ongoing for years assessing effects of determined stem cells (fetal-liver-derived hepatic stem/progenitors) transplanted into the hepatic artery of patients with various liver diseases. Immunosuppression was not required. Control subjects, those given standard of care for a given condition, all died within a year or deteriorated in their liver functions. Subjects transplanted with 100-150 million hepatic stem/progenitor cells had improved liver functions and survival extending for several years. Full evaluations of safety and efficacy of transplants are still in progress. Determined stem cell therapies for diabetes using hBTSCs remain to be explored but are likely to occur following ongoing preclinical studies. In addition, mesenchymal stem cells (MSCs) and hematopoietic stem cells (HSCs) are being used for patients with chronic liver conditions or with diabetes. MSCs have demonstrated significant effects through paracrine signaling of trophic and immunomodulatory factors, and there is limited evidence for inefficient lineage restriction into mature parenchymal or islet cells. HSCs' effects are primarily via modulation of immune mechanisms.