Novel technique for biliary reconstruction using an isolated gastric tube with a vascularized pedicle: a live animal experimental study and the first clinical case

Gastric sleeve as an extra-anatomical roux for biliary reconstruction in a pediatric third liver transplant

BACKGROUND

Sir Roy Calne in 1976 described "Biliary reconstruction is the Achilles heel of liver transplantation," and it remains true. In some patients, such as those with short-gut syndrome and concomitant biliary atresia, neither duct to duct nor Roux biliary reconstruction is feasible.

METHODS

We present a case of child's third liver transplant (LT), where an innovative extra-anatomical biliary bypass was created using a sleeve from greater curvature of the stomach.

RESULTS

The patient is well nearly 10 years following the LT.

CONCLUSIONS

This technique could prove to be an important addition to the armamentarium of a surgeon in difficult retransplants and in patients with short-gut syndrome as it provides a viable option with good long-term outcome.

Fabrication of 3D printed PCL/PEG artificial bile ducts as supportive scaffolds to promote regeneration of extrahepatic bile ducts in a canine biliary defect model

In this study, a 3D porous poly(ε-caprolactone)/polyethylene glycol (PCL/PEG) composite artificial tubular bile duct was fabricated for extrahepatic bile duct regeneration. PCL/PEG composite scaffolds were fabricated by 3D printing, and the molecular structure, mechanical properties, thermal properties, morphology, and in vitro biocompatibility were characterized for further application as artificial bile ducts. A bile duct defect model was established in beagle dogs for in vivo implantation. The results demonstrated that the implanted PE1 ABD, serving as a supportive scaffold, effectively stimulated the regeneration of a new bile duct comprising CK19-positive and CK7-positive epithelial cells within 30 days. Remarkably, after 8 months, the newly formed bile duct exhibited an epithelial layer resembling the normal structure. Furthermore, the study revealed collagen deposition, biliary muscular formation, and the involvement of microvessels and fibroblasts in the regenerative process. In contrast, the anastomotic area without ABD implantation displayed only partial restoration of the epithelial layer, accompanied by fibroblast proliferation and subsequent bile duct fibrosis. These findings underscore the limited inherent repair capacity of the bile duct and underscore the beneficial role of the PE1 ABD artificial tubular bile duct in promoting biliary regeneration.

Isolated vascularized gastric tube biliary enteric drainage: a paediatric case series experience

Background

Despite the enormous surgical advancements in the last century, access to the biliary system is lost when a Roux-en-Y (RY) biliary drainage procedure is performed. Attempts have been made to overcome this inconvenient sequel using variations in the RY anastomosis, small bowel grafts and vascular grafts. These have been predominantly unsuccessful. An isolated vascularized gastric tube (IVGT) graft has been reported in the literature, which was successfully used for adult patients with common bile duct injuries. We have adopted the technique of using an IVGT graft for bile duct reconstruction in the paediatric patients at our institution. We reviewed our experience at our institution between January 2015 and October 2019. This was a retrospective review of all paediatric patients undergoing an IVGT graft procedure for biliary tract anatomical obstruction in the past 5 years. We looked at the indications for surgery, the demographic profile of the patients and outcomes following surgery and outlined the surgical technique used.

Results

IVGT bile duct reconstruction was performed on eight patients. Patients ranged from 2 months to 7 years, and there was an equal number of males and females. The diagnosis was made on clinical suspicion and confirmed with ultrasound (U/S) and magnetic resonance cholangiopancreatography (MRCP). There was an 87.5% resolution of biliary obstruction, and two patients who had bile leaks postoperatively were managed conservatively. Unfortunately, one patient died in the early postoperative period from sepsis due to pneumonia. Follow-up was for a minimum of 6 months and up to 5 years.

Conclusion

IVGT biliary enteric drainage is a safe, reproducible procedure that allows access to the biliary tree if required in the future. Thus, this procedure serves as an alternative, especially in limited-resource areas where interventional radiology is not available for future interventions.

Case Report: Surgical Correction of a Cystic Duct Stump Leakage Following Cholecystectomy Using an Autologous Rectus Sheath Graft in a Dog

A 2.7 kg, 13-year-old, castrated male Yorkshire Terrier was presented with bile peritonitis after cholecystectomy. Exploratory coeliotomy to identify and correct bile leakage revealed that the transected end of the cystic duct was open with no in-situ ligatures or vascular clips. The residual cystic duct stump was too short to ligate or seal directly. An autologous rectus sheath graft, harvested from the internal leaf of the rectus sheath, was used to patch the cystic duct stump. The graft was secured over the open duct using several simple interrupted sutures and covered with an omentalization. The clinical signs resolved after surgery, except for a transient increase in hepatobiliary enzyme levels and intrahepatic bile duct dilatation. The enzyme levels returned to near normal on day 25 after surgery. No intrahepatic bile duct dilatation was detected on day 55 after surgery. The owner was contacted for 3 years post-operatively and reported that the dog remained healthy without any long-term complications. Grafting using autologous rectus sheath can be used to treat cystic duct stump leakage that cannot be managed with direct closure using traditional modalities due to spatial constraints.

Effect of tamoxifen on fibrosis, collagen content and transforming growth factor-β1, -β2 and -β3 expression in common bile duct anastomosis of pigs

End-to-end anastomosis in the treatment for bile duct injury during laparoscopic cholecystectomy has been associated with stricture formation. The aim of this study was to experimentally investigate the effect of oral tamoxifen (tmx) treatment on fibrosis, collagen content and transforming growth factor-β1, -β2 and -β3 expression in common bile duct anastomosis of pigs. Twenty-six pigs were divided into three groups [sham (n = 8), control (n = 9) and tmx (n = 9)]. The common bile ducts were transected and anastomosed in the control and tmx groups. Tmx (40 mg/day) was administered orally to the tmx group, and the animals were euthanized after 60 days. Fibrosis was analysed by Masson's trichrome staining. Picrosirius red was used to quantify the total collagen content and collagen type I/III ratio. mRNA expression of transforming growth factor (TGF)-β1, -β2 and -β3 was quantified using real-time polymerase chain reaction (qRT-PCR). The control and study groups exhibited higher fibrosis than the sham group, and the study group showed lower fibrosis than the control group (P = 0.011). The control and tmx groups had higher total collagen content than the sham group (P = 0.003). The collagen type I/III ratio was higher in the control group than in the sham and tmx groups (P = 0.015). There were no significant differences in the mRNA expression of TGF-β1, -β2 and -β3 among the groups (P > 0.05). Tmx decreased fibrosis and prevented the change in collagen type I/III ratio caused by the procedure.

Repair of Bile Duct Injury With Autologous Vein Graft and Stent

OBJECTIVES

We investigated the effects of autologous vein transplant on bile duct injury repair, through observation of the hepatic and biliary system tissue morphology changes and animal survival after bile duct injury repair.

MATERIALS AND METHODS

Rabbits were equally divided into groups. Group A had cholecystectomy and common bile duct resection (length of 0.5 cm), transplant of an autologous vein (length of 0.5 cm), and stent implant. Group B had cholecystectomy and common bile duct resection (length of 1.0 cm), transplant of an autologous vein (length of 1.0 cm), and stent implant. The third group (group C) had cholecystectomy only.

RESULTS

Two rabbits died in group A and group B; all experimental animals from group C survived. Regarding liver biochemical indexes at preoperative week 1, at postoperative month 1, and at postoperative month 3, we found no significant differences (paired t test, P > .05). Liver biochemical indexes between groups were also not significantly different (P > .05). At month 3, postoperative liver pathology of experimental animals showed no significant changes and no cholestasis; biliary epithelial cells were seen in the transplant vascular.

CONCLUSIONS

We conclude that autologous vein graft can effectively repair bile duct injury for a short coloboma.

Repair of a common bile duct defect with a decellularized ureteral graft

AIM

To evaluate the feasibility of repairing a common bile duct defect with a decellularized ureteral graft in a porcine model.

METHODS

Eighteen pigs were randomly divided into three groups. An approximately 1 cm segment of the common bile duct was excised from all the pigs. The defect was repaired using a 2 cm long decellularized ureteral graft over a T-tube (T-tube group, n = 6) or a silicone stent (stent group, n = 6). Six pigs underwent bile duct reconstruction with a graft alone (stentless group). The surviving animals were euthanized at 3 mo. Specimens of the common bile ducts were obtained for histological analysis.

RESULTS

The animals in the T-tube and stent groups survived until sacrifice. The blood test results were normal in both groups. The histology results showed a biliary epithelial layer covering the neo-bile duct. In contrast, all the animals in the stentless group died due to biliary peritonitis and cholangitis within two months post-surgery. Neither biliary epithelial cells nor accessory glands were observed at the graft sites in the stentless group.

CONCLUSION

Repair of a common bile duct defect with a decellularized ureteral graft appears to be feasible. A T-tube or intraluminal stent was necessary to reduce postoperative complications.

Tamoxifen decreases the myofibroblast count in the healing bile duct tissue of pigs

OBJECTIVE

The aim of this study was to evaluate the effect of oral tamoxifen treatment on the number of myofibroblasts present during the healing process after experimental bile duct injury.

METHODS

The sample consisted of 16 pigs that were divided into two groups (the control and study groups). Incisions and suturing of the bile ducts were performed in the two groups. Tamoxifen (20 mg/day) was administered only to the study group. The animals were sacrificed after 30 days. Quantification of myofibroblasts in the biliary ducts was made through immunohistochemistry analysis using anti-alpha smooth muscle actin of the smooth muscle antibody. Immunohistochemical quantification was performed using a digital image system.

RESULTS

In the animals treated with tamoxifen (20 mg/day), there was a significant reduction in immunostaining for alpha smooth muscle actin compared with the control group (0.1155 vs. 0.2021, p = 0.046).

CONCLUSION

Tamoxifen reduced the expression of alpha smooth muscle actin in the healing tissue after bile duct injury, suggesting a decrease in myofibroblasts in the scarred area of the pig biliary tract. These data suggest that tamoxifen could be used in the prevention of biliary tract stenosis after bile duct surgeries.