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Rey Rubiano AM, González-Teshima LY, Arango L, Blanco-Avellaneda C, Carvajal Gutiérrez JJ, Castaño-Llano R, Gómez Zuleta MA, González C, Peñaloza-Ramírez A, Pinilla Morales R, Pinto Carta R, Polanía Liscano HA, Rincón Sánchez RA, Sepúlveda Copete M, Vargas-Rubio R, Avendaño Capriles CA, García-Sierra AM, Yepes-Nuñez JJ. Clinical practice guideline on the use of single-operator cholangioscopy in the diagnosis of indeterminate biliary stricture and the treatment of difficult biliary stones. Surg Endosc 2024; 38:499-510. [PMID: 38148404 PMCID: PMC10830582 DOI: 10.1007/s00464-023-10569-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 10/23/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND AND AIMS Single-operator cholangioscopy (SOC) offer a diagnostic and therapeutic alternative with an improved optical resolution over conventional techniques; however, there are no standardized clinical practice guidelines for this technology. This evidence-based guideline from the Colombian Association of Digestive Endoscopy (ACED) intends to support patients, clinicians, and others in decisions about using in adults the SOC compared to endoscopic retrograde cholangiopancreatography (ERCP), to diagnose indeterminate biliary stricture and to manage difficult biliary stones. METHODS ACED created a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. Universidad de los Andes and the Colombia Grading of Recommendations Assessment, Development and Evaluation (GRADE) Network supported the guideline-development process, updating and performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The GRADE approach was used, including GRADE Evidence-to-Decision frameworks. RESULTS The panel agreed on one recommendation for adult patients with indeterminate biliary strictures and one for adult patients with difficult biliary stones when comparing SOC versus ERCP. CONCLUSION For adult patients with indeterminate biliary strictures, the panel made a conditional recommendation for SOC with stricture pattern characterization over ERCP with brushing and/or biopsy for sensitivity, specificity, and procedure success rate outcomes. For the adult patients with difficult biliary stones the panel made conditional recommendation for SOC over ERCP with large-balloon dilation of papilla. Additional research is required on economic estimations of SOC and knowledge translation evaluations to implement SOC intervention in local contexts.
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Affiliation(s)
- Adriana Margarita Rey Rubiano
- School of Medicine, Universidad de los Andes, Carrera 1 # 18a-12, Bogotá, D.C., Colombia
- Department of Gastroenterology, Fundación Santa Fe de Bogotá, Bogotá, D.C., Colombia
| | | | - Lázaro Arango
- Department of Clinical Surgical Gastroenterology, University of Caldas, Manizales, Caldas, Colombia.
- Department of Endoscopy and Gastroenterology, University of Caldas, Manizales, Caldas, Colombia.
- Union of surgeons, Zentria Group, Manizales, Caldas, Colombia.
| | - Camilo Blanco-Avellaneda
- Department of Gastrointestinal Surgery and Digestive Endoscopy, Pontificia Universidad Javeriana, Bogotá, D.C, Colombia
- Education and Research Group, Faculty of Education, Universidad El Bosque, Bogotá, D.C., Colombia
- Videoendoscopy Unit of Restrepo Ltda, Bogotá, D.C, Colombia
| | - Jhon Jaime Carvajal Gutiérrez
- Department of Gastroenterology, Hospital Pablo Tobón Uribe, Medellín, Antioquia, Colombia
- Department of Internal Medicine, Universidad de Antioquia, Medellín, Antioquia, Colombia
| | - Rodrigo Castaño-Llano
- Department of Gastroenterology, Universidad de Antioquia, Medellín, Antioquia, Colombia
- Institute of Cancerology, Clínica las Américas Auna, Medellín, Antioquia, Colombia
| | - Martin Alonso Gómez Zuleta
- Department of Internal Medicine, Universidad Nacional de Colombia, Bogotá, D.C., Colombia
- Department of Internal Medicine, Gastroenterology Section, Hospital Universitario Nacional de Colombia, Bogotá, D.C., Colombia
| | - Carlos González
- Department of Gastroenterology and Digestive Endoscopy, Clínica Reina Sofia, Bogotá, D.C., Colombia
- Department of Gastroenterology and Digestive Endoscopy, Fundación Universitaria Sanitas, Bogotá, D.C., Colombia
- Department of Gastroenterology, Clínica Colombia, Bogotá, D.C., Colombia
| | - Arecio Peñaloza-Ramírez
- Department of Gastroenterology, Fundación Universitaria de Ciencias de la Salud, Bogotá, D.C., Colombia
- Department of Gastroenterology, Hospital de San José, Bogotá, D.C., Colombia
| | - Raúl Pinilla Morales
- Department of Gastroenterology and Oncological Digestive Endoscopy, Instituto Nacional de Cancerología, Bogotá, D.C., Colombia
- School of Medicine, Universidad Nacional de Colombia, Bogotá, D.C., Colombia
| | - Renzo Pinto Carta
- Colombian Association of Digestive Endoscopy, Bogotá, D.C., Colombia
- American Society for Gastrointestinal Endoscopy, Rochester, USA
| | - Héctor Adolfo Polanía Liscano
- Department of Gastroenterology, Universidad Surcolombiana, Neiva, Huila, Colombia
- Endotek Ltda, Hospital Universitario Neiva, Neiva, Huila, Colombia
| | - Reinaldo Andrés Rincón Sánchez
- Department of Internal Medicine and Gastroenterology, Pontificia Universidad Javeriana - Hospital Universitario San Ignacio, Bogotá, D.C., Colombia
- Department of Gastroenterology, Fundación Clínica Shaio, Bogotá, D.C., Colombia
| | | | - Rómulo Vargas-Rubio
- Department of Gastroenterology, Hospital Universitario de San Ignacio, Pontificia Universidad Javeriana, Bogotá, D.C., Colombia
| | - Camilo Andrés Avendaño Capriles
- School of Medicine, Universidad del Norte, Barranquilla, Colombia
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Andrés Mauricio García-Sierra
- School of Medicine, Universidad de los Andes, Carrera 1 # 18a-12, Bogotá, D.C., Colombia
- School of Global Health Management and Informatics, University of Central Florida, Orlando, USA
| | - Juan José Yepes-Nuñez
- School of Medicine, Universidad de los Andes, Carrera 1 # 18a-12, Bogotá, D.C., Colombia.
- Pulmonology Service, Internal Medicine Section, Fundación Santa Fe de Bogotá University Hospital, Bogotá, D.C., Colombia.
- Colombia GRADE Network, Bogotá, D.C., Colombia.
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Pardo Aranda F, Gené Škrabec C, López-Sánchez J, Zarate Pinedo A, Espin Álvarez F, Cremades Pérez M, Navinés López J, Herrero Vicente C, Vidal Piñeiro L, Cugat Andorrà E. Indocyanine green (ICG) fluorescent cholangiography in laparoscopic cholecystectomy: Simplifying time and dose. Dig Liver Dis 2023; 55:249-253. [PMID: 36404235 DOI: 10.1016/j.dld.2022.10.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/15/2022] [Accepted: 10/23/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND This article aims to analyze and to simplify the optimal dose and time of intravenous indocyanine green (ICG) administration to achieve the identification of the cystic duct and the common bile duct (CBD). METHODS A consecutive series of 146 patients was prospectively analyzed and divided into three groups according to the time of ICG administration: at induction of anesthesia group (20-30 min); hours before group (between 2 and 6 h); and the day before group (≥6 h); and two groups according to the dose of ICG: 1 cc (2.5 mg) or weight-based dose (0.05 mg/kg). RESULTS The CBD was better visualized in the at induction of anesthesia group (85.4%), in the hours before group (97.1%) (p = 0.002) and in the 1cc group (p = 0.011). When we analyzed the 1 cc group (n = 126) a greater visualization of the CBD was observed in the at induction of anesthesia group (86.7%) and in the hours before group (97.1%) (p = 0.027). CONCLUSION Due to its simplicity and reproducibility, we suggest a dose of 2.5 mg administered 2-6 h before the procedure is the optimal. However, ICG administered 30 min prior to the surgery is enough for adequate visualization of biliary structures.
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Affiliation(s)
- Fernando Pardo Aranda
- Department of General and Digestive Surgery, HPB Unit, Hospital Germans Trias i Pujol, Ctra. del Canyet s/n, Badalona, Barcelona 08916, Spain
| | - Clara Gené Škrabec
- Department of General and Digestive Surgery, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain.
| | - Jaime López-Sánchez
- Department of General and Digestive Surgery, Hospital Universitario de Salamanca, Spain
| | - Alba Zarate Pinedo
- Department of General and Digestive Surgery, HPB Unit, Hospital Germans Trias i Pujol, Ctra. del Canyet s/n, Badalona, Barcelona 08916, Spain
| | - Francisco Espin Álvarez
- Department of General and Digestive Surgery, HPB Unit, Hospital Germans Trias i Pujol, Ctra. del Canyet s/n, Badalona, Barcelona 08916, Spain
| | - Manel Cremades Pérez
- Department of General and Digestive Surgery, HPB Unit, Hospital Germans Trias i Pujol, Ctra. del Canyet s/n, Badalona, Barcelona 08916, Spain
| | - Jordi Navinés López
- Department of General and Digestive Surgery, HPB Unit, Hospital Germans Trias i Pujol, Ctra. del Canyet s/n, Badalona, Barcelona 08916, Spain
| | - Christian Herrero Vicente
- Department of General and Digestive Surgery, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Laura Vidal Piñeiro
- Department of General and Digestive Surgery, HPB Unit, Hospital Germans Trias i Pujol, Ctra. del Canyet s/n, Badalona, Barcelona 08916, Spain
| | - Esteban Cugat Andorrà
- Department of General and Digestive Surgery, HPB Unit, Hospital Germans Trias i Pujol, Ctra. del Canyet s/n, Badalona, Barcelona 08916, Spain; Department of General and Digestive Surgery, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
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张 铃, 侯 纯, 徐 智, 王 立, 凌 晓, 王 港, 崔 龙, 修 典. [Clinical effect of laparoscopic transcystic drainage combined with common bile duct exploration for the patients with difficult biliary stones]. Beijing Da Xue Xue Bao Yi Xue Ban 2022; 54:1185-1189. [PMID: 36533353 PMCID: PMC9761809 DOI: 10.19723/j.issn.1671-167x.2022.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To explore the feasibility and efficacy of laparoscopic transcystic drainage and common bile duct exploration in the treatment of patients with difficult biliary stones. METHODS Between April 2020 and December 2021, eighteen patients with difficult biliary stones received laparoscopic transcystic drainage (C-tube technique) and common bile duct exploration. The clinical characteristics and outcomes were retrospectively collected. The safety and effectiveness of laparoscopic transcystic drainage and common bile duct exploration were analyzed. RESULTS Among the eighteen patients with difficult biliary stones, thirteen patients received traditional laparoscopic transcystic drainage, and the remaining five received modified laparoscopic transcystic drainage. The mean surgical duration were (161±59) min (82-279 min), no bile duct stenosis or residual stone was observed in the patients receiving postoperative cholangiography via C-tube. The maximum volume of C-tube drainage was (500±163) mL/d (180-820 mL/d). Excluding three patients with early dislodgement of C-tube, among the fifteen patients with C-tube maintained, the median time of C-tube removal was 8 d (5-12 d). The duration of hospital stay was (12±3) d (7-21 d) for the 18 patients. Five C-tube related adverse events were observed, all of which occurred in the patients with traditional laparoscopic transcystic drainage, including two abnormal position of the C-tube, and three early dislocation of the C-tube. All the 5 adverse events caused no complications. Only one grade one complication occurred, which was in a patient with modified laparoscopic transcystic drainage. The patient demonstrated transient fever after C-tube removal, but there was no bile in the drainage tube and the subsequent CT examination confirmed no bile leakage. The fever spontaneously relieved with conservative observation, and the patient recovered uneventfully with discharge the next day. All the 18 patients were followed up for 1-20 months (median: 9 months). Normal liver function and no recurrence of stone were detected with ultrasonography or magnetic resonance cholangiopancreatography (MRCP). CONCLUSION Laparoscopic transcystic drainage combined with common bile duct exploration is safe and feasible in the treatment of patients with difficult biliary stones. The short-term effect is good. Modified laparoscopic transcystic drainage approach may reduce the incidence of C-tube dislocation and bile leak.
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Affiliation(s)
- 铃福 张
- />北京大学第三医院普通外科,北京 100191Department of General Surgery, Peking University Third Hospital, Beijing 100191, China
| | - 纯升 侯
- />北京大学第三医院普通外科,北京 100191Department of General Surgery, Peking University Third Hospital, Beijing 100191, China
| | - 智 徐
- />北京大学第三医院普通外科,北京 100191Department of General Surgery, Peking University Third Hospital, Beijing 100191, China
| | - 立新 王
- />北京大学第三医院普通外科,北京 100191Department of General Surgery, Peking University Third Hospital, Beijing 100191, China
| | - 晓锋 凌
- />北京大学第三医院普通外科,北京 100191Department of General Surgery, Peking University Third Hospital, Beijing 100191, China
| | - 港 王
- />北京大学第三医院普通外科,北京 100191Department of General Surgery, Peking University Third Hospital, Beijing 100191, China
| | - 龙 崔
- />北京大学第三医院普通外科,北京 100191Department of General Surgery, Peking University Third Hospital, Beijing 100191, China
| | - 典荣 修
- />北京大学第三医院普通外科,北京 100191Department of General Surgery, Peking University Third Hospital, Beijing 100191, China
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Uzun MA, Tilki M, Alkan Kayaoğlu S, Çiçek Okuyan G, Kılıçoğlu ZG, Gönültaş A. Long-term results and prognostic factors after surgical treatment for gallbladder cancer. Turk J Surg 2022; 38:334-344. [PMID: 36875276 PMCID: PMC9979551 DOI: 10.47717/turkjsurg.2022.5861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 11/10/2022] [Indexed: 01/12/2023]
Abstract
Objectives Gallbladder cancer is relatively rare and traditionally regarded as having poor prognosis. There is controversy about the effects of clinicopathological features and different surgical techniques on prognosis. The aim of this study was to investigate the effects of clinicopathological characteristics of the patients with surgically treated gallbladder cancer on long-term survival. Material and Methods We retrospectively analyzed the database of gallbladder cancer patients treated at our clinic between January 2003 and March 2021. Results Of 101 evaluated cases, 37 were inoperable. Twelve patients were determined unresectable based on surgical findings. Resection with curative intent was performed in 52 patients. The one-, three-, five-, and 10-year survival rates were 68.9%, 51.9%, 43.6%, and 43.6%, respectively. Median survival was 36.6 months. On univariate analysis, poor prognostic factors were determined as advanced age; high carbohydrate antigen 19-9 and carcinoembryonic antigen levels; non-incidental diagnosis; intraoperative incidental diagnosis; jaundice; adjacent organ/structure resection; grade 3 tumors; lymphovascular invasion; and high T, N1 or N2, M1, and high AJCC stages. Sex, IVb/V segmentectomy instead of wedge resection, perineural invasion, tumor location, number of resected lymph nodes, and extended lymphadenectomy did not significantly affect overall survival. On multivariate analysis, only high AJCC stages, grade 3 tumors, high carcinoembryonic antigen levels, and advanced age were independent predictors of poor prognosis. Conclusion Treatment planning and clinical decision-making for gallbladder cancer requires individualized prognostic assessment along with standard anatomical staging and other confirmed prognostic factors.
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Affiliation(s)
- Mehmet Ali Uzun
- Clinic of General Surgery, Haydarpaşa Numune Training and Research Hospital, University of Health Sciences, İstanbul, Türkiye.,Clinic of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, İstanbul, Türkiye
| | - Metin Tilki
- Clinic of General Surgery, Haydarpaşa Numune Training and Research Hospital, University of Health Sciences, İstanbul, Türkiye
| | - Sevcan Alkan Kayaoğlu
- Clinic of General Surgery, Haydarpaşa Numune Training and Research Hospital, University of Health Sciences, İstanbul, Türkiye
| | - Gülten Çiçek Okuyan
- Clinic of General Surgery, Haydarpaşa Numune Training and Research Hospital, University of Health Sciences, İstanbul, Türkiye
| | - Zeynep Gamze Kılıçoğlu
- Clinic of Radiology, Haydarpaşa Numune Training and Research Hospital, University of Health Sciences, İstanbul, Türkiye
| | - Aylin Gönültaş
- Clinic of Pathology, Haydarpaşa Numune Training and Research Hospital, University of Health Sciences, İstanbul, Türkiye
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Yaghi M, Jaafar R, Kanso M, Khalife M, Faraj W. Choledochal anomalies in adults: A 20-year single-center retrospective cohort experience in the Middle East. Arab J Gastroenterol 2022; 23:235-240. [PMID: 36371373 DOI: 10.1016/j.ajg.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 03/31/2022] [Accepted: 10/14/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND STUDY AIMS Choledochal cysts are rare congenital cystic dilatations of the bile ducts that occur in fewer than 1% of individuals. The disease is common in East Asia, and most of the literature concerns those populations, but some data about Western populations have been published recently. Long-term reports about the disease in Middle Eastern populations, however, are currently lacking. We report a single-center 20-year experience in diagnosing and managing choledochal anomalies. PATIENTS AND METHODS Participants were adult patients in whom choledochal cysts were diagnosed over a 20-year (2000-2019) period at a single tertiary academic care center. Clinical data, including radiologic imaging findings, were retrieved from the patients' medical records. To describe the baseline characteristics of the population, we calculated descriptive statistics. RESULTS Choledochal anomalies were diagnosed in 19 adult patients, whose median age was 30 years (interquartile range [IQR], 23-67 years). Of the choledochal cysts 13 (68.4%) were classified as Todani type I, 4 (21.1%) as Todani type IV, and 3 (15.8%) as Todani type V (Caroli's disease). No patient had underlying chronic liver disease, and liver synthetic function was preserved in all. Eighteen patients (94.7%) underwent surgery: cyst excision with Roux-en-Y hepaticojejunostomy in 17 and liver transplantation in 1. All 18 survived surgery, and the median postoperative hospital stay was 11 days (IQR, 5-34 days). All 18 were alive 90 days after surgery, and the median follow-up period was 40 months (IQR, 12-140 months). Seven patients (36.8%) developed postoperative surgical complications; 2 patients required rehospitalization, and 1 required reoperation. CONCLUSION This description of adults with choledochal cysts is the latest long-term report about this disease in the Middle East. In our 20-year experience, the disease characteristics in our patients were moderately consistent with those described previously.
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Affiliation(s)
- Marita Yaghi
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon
| | - Rola Jaafar
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon
| | - Mariam Kanso
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon
| | - Mohamed Khalife
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon
| | - Walid Faraj
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut, Lebanon.
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Jeong HT, Lee J, Jo HH, Kim HG, Han J. The effect and therapeutic compliance of adjuvant therapy in patients with cholangiocarcinoma after R0 resection: a retrospective study. J Yeungnam Med Sci 2022; 40:65-77. [PMID: 35615785 PMCID: PMC9946916 DOI: 10.12701/jyms.2022.00213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/25/2022] [Indexed: 11/04/2022]
Abstract
BACKGRUOUND This study aimed to compare clinical outcomes between surveillance and adjuvant therapy (AT) groups after R0 resection for cholangiocarcinoma (CCA). METHODS A total of 154 patients who underwent R0 resection for CCA at the Daegu Catholic University Medical Center between January 2010 and December 2019 were included. Overall survival (OS) and progression-free survival (PFS) were analyzed. RESULTS The median follow-up duration was 899 days. There were 109 patients in the AT group and 45 patients in the surveillance group. The patients in the AT group were younger (67 years vs. 74 years, p<0.001) and included more males (64.2% vs. 46.7%, p=0.044). The proportion of patients with stage III CCA was larger in the AT group than in the surveillance group (13.8% vs. 2.2%, p=0.005). In addition, AT did not improve OS (5-year OS rate, 69.3% in the AT group vs. 64.2% in the surveillance group, p=0.806) or PFS (5-year PFS rate, 42.6% in the AT group vs. 48.9% in the surveillance group, p=0.113). In multivariate analysis using the Cox proportional hazards model, stage III CCA (hazard ratio [HR], 10.81; 95% confidence interval [CI], 2.92-40.00; p<0.001) was a significant predictor of OS. American Society of Anesthesiologists classification II (HR, 0.50; 95% CI, 0.31-0.81; p=0.005), and American Joint Committee on Cancer stages II (HR, 3.14; 95% CI, 1.25-7.89; p=0.015) and III (HR, 8.08; 95% CI, 2.80-23.32; p<0.001) were independent predictors of PFS. CONCLUSION AT after R0 resection for CCA did not improve OS or PFS.
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Affiliation(s)
- Han Taek Jeong
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Joonkee Lee
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Hyeong Ho Jo
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Ho Gak Kim
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Jimin Han
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea,Correspondence author: Jimin Han, MD, PhD Department of Internal Medicine, Daegu Catholic University School of Medicine, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 42472, Korea Tel: +82-53-650-3442 • Fax: +82-53-621-4487 • E-mail:
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Morrell DJ, Pauli EM, Hollenbeak CS. Inpatient Choledocholithiasis Management: a Cost-Effectiveness Analysis of Management Algorithms. J Gastrointest Surg 2022; 26:837-48. [PMID: 35083722 DOI: 10.1007/s11605-022-05249-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/08/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Choledocholithiasis is commonly encountered. It is frequently managed with laparoscopic common bile duct exploration or endoscopic retrograde cholangiopancreatography (either preoperative, intraoperative, or postoperative relative to laparoscopic cholecystectomy). The purpose of this study is to determine the most cost-effective method to manage inpatient choledocholithiasis. METHODS A decision tree model was created to evaluate the cost-effectiveness of laparoscopic common bile duct exploration and preoperative, intraoperative, and postoperative endoscopic retrograde cholangiopancreatography. The primary outcome was incremental cost-effectiveness ratio with a ceiling willingness to pay threshold assumed of $100,000 per quality-adjusted life year. Model parameters were determined through review of published literature and institutional data. Costs were from the perspective of the healthcare system with a time horizon of 1 year. Sensitivity analyses were performed on model parameters. RESULTS In the base case analysis, laparoscopic common bile duct exploration was cost-effective, resulting in 0.9909 quality-adjusted life years at an expected cost of $18,357. Intraoperative endoscopic retrograde cholangiopancreatography yielded more quality-adjusted life years (0.9912) at a higher cost ($19,717) with an incremental cost-effectiveness ratio of $4,789,025, exceeding the willingness to pay threshold. Both preoperative and postoperative endoscopic retrograde cholangiopancreatographies were eliminated for being both more costly and less effective. Laparoscopic common bile duct exploration remained cost-effective if the probability of successful biliary clearance was above 0.79, holding all other variables constant. If its base cost remained below $18,400 and intraoperative endoscopic retrograde cholangiopancreatography base cost rose above $18,200, then laparoscopic common bile duct exploration remained cost-effective. CONCLUSION Laparoscopic common bile duct exploration is the most cost-effective method to manage choledocholithiasis. Efforts to ensure availability of local expertise and resources for this procedure are warranted.
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Restrepo DJ, Moreau C, Edelson CV, Dev A, Saligram S, Sayana H, Patel SN. Improving Diagnostic Yield in Indeterminate Biliary Strictures. Clin Liver Dis 2022; 26:69-80. [PMID: 34802664 DOI: 10.1016/j.cld.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Indeterminate biliary strictures are defined as a narrowing of the bile duct that cannot be differentiated as malignant or benign after performing cross-sectional imaging and an ERCP. Identifying the etiology of a bile duct stricture is the single most important step in determining whether a complex and potentially morbid surgical resection is warranted. Due to this diagnostic and therapeutic dilemma, new technologies, laboratory tests, and procedures are emerging to solve this problem.
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Shima Y, Sugiyama H, Ogasawara S, Kan M, Maruta S, Yamada T, Miura Y, Asano K, Sensui M, Nagashima H, Yokoyama M, Kusakabe Y, Yasui S, Ohno I, Mikata R, Tsuyuguchi T, Horikoshi T, Mishima T, Kuboki S, Takayashiki T, Ohtsuka M, Kato J, Kato N. Diagnostic value of peroral cholangioscopy in addition to computed tomography for indeterminate biliary strictures. Surg Endosc 2021. [PMID: 34370123 DOI: 10.1007/s00464-021-08661-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Peroral cholangioscopy (POCS) has been used to overcome the difficulty in diagnosing indeterminate biliary stricture or tumor spread. However, the value of adding POCS to computed tomography (CT) remains unclear. Our aim was to evaluate the diagnostic value of adding POCS to CT for indeterminate biliary stricture and tumor spread by interpretation of images focusing on the high diagnostic accuracy of visual findings in POCS. METHODS We retrospectively identified 52 patients with biliary stricture who underwent endoscopic retrograde cholangiography (ERC) at our institution between January 2013 and December 2018. Two teams, each composed of an expert endoscopist and surgeon, performed the interpretation independently, referring to the CT findings of the radiologist. The CT + ERC + POCS images (POCS group) were evaluated 4 weeks after the evaluation of CT + ERC images (CT group). A 5-point scale (1: definitely benign to 5: definitely malignant) was used to determine the confident diagnosis rate, which was defined as an evaluation value of 1 or 5. Tumor spread was also evaluated. RESULTS In the evaluation of 45 malignant diagnoses, the score was significantly closer to 5 in the POCS group than in the CT group in both teams (P < 0.001). The confident diagnosis rate was significantly higher for the POCS group (92% and 73%) than for the CT group (25% and 12%) in teams 1 and 2, respectively (P < 0.001). We found no significant difference in diagnostic accuracy for tumor spread between the groups. CONCLUSION Visual POCS findings confirmed the diagnosis of biliary strictures. POCS was useful in cases of indefinite diagnosis of biliary strictures by CT.
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Maatman TK, Loncharich AJ, Flick KF, Simpson RE, Ceppa EP, Nakeeb A, Nguyen TK, Schmidt CM, Zyromski NJ, House MG. Transient Biliary Fistula After Pancreatoduodenectomy Increases Risk of Biliary Anastomotic Stricture. J Gastrointest Surg 2021; 25:169-77. [PMID: 32671799 DOI: 10.1007/s11605-020-04727-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 06/30/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Biliary fistula after pancreatoduodenectomy (PD) is associated with significant morbidity and mortality. The aim of this study was to determine the risk of early postoperative biliary fistula for developing biliary anastomotic stricture after PD. METHODS Retrospective review of all PD performed for various indications at a single institution between 2013 and 2018. Postoperative biliary fistulae were graded according to the International Study Group of Liver Surgery (ISGLS) as grade A-C. Multivariable analysis was performed for all comparative patient subgroups. RESULTS A total of 843 patients underwent PD for malignant (68%) and benign (32%) indications. Postoperative biliary fistula developed in 66 (8%) patients; ISGLS grade A in 29 (3%), grade B in 32 (4%), and grade C in 5 (0.6%). Ninety-day mortality was 3% (25 patients). The remaining 818 patients were evaluated with a median follow-up of 16 months (IQR, 5-32 months). Biliary anastomotic stricture developed in 41 (5%) patients at a median of 10 months (IQR, 6-18 months) postoperatively. Strictures were managed with percutaneous (27 patients, 66%) or endoscopic (14 patients, 34%) stenting. No biliary stricture required operative anastomotic revision. Postoperative biliary fistula (HR, 4.4; 95% CI, 2.0-9.9; P = 0.0002) was associated with biliary anastomotic stricture; an increased risk for biliary anastomotic stricture was seen in patients with grade A (HR, 6.4; 95% CI, 2.4-16.9; P = 0.0002) and grade B (HR, 3.6; 95% CI, 1.2-10.9; P = 0.02) postoperative biliary fistula. CONCLUSION Postoperative biliary fistula after pancreatoduodenectomy, including clinically insignificant, transient biliary fistula, is associated with an increased risk of a late biliary anastomotic stricture requiring stenting.
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11
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Chen PH, Tung CF, Peng YC, Yeh HZ, Chang CS, Chen CC. Duodenal major papilla morphology can affect biliary cannulation and complications during ERCP, an observational study. BMC Gastroenterol 2020; 20:310. [PMID: 32988368 PMCID: PMC7520951 DOI: 10.1186/s12876-020-01455-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/15/2020] [Indexed: 12/12/2022] Open
Abstract
Background We investigated whether duodenal major papilla morphology could be a risk factor for failure of selective biliary cannulation (SBC) and post endoscopic retrograde cholangiography and pancreatography (ERCP) complications. Methods A prospectively recorded database was reviewed retrospectively. Patients were included if they received therapeutic ERCP and had naïve major duodenal papilla. We used Haraldsson’s classification for papilla morphology, as follows: Regular (Type 1), Small (Type 2), Protruding or Pendulous (Type 3) and Creased or Ridged (Type 4). Risk factors for failing SBC and post-ERCP complications were analyzed by multivariate analysis. Results A total of 286 cases were included. Age, gender, indications and therapeutic procedures were not different among the four types of papillae. The failure rates of SBC with Type 3 papilla and Type 4 papilla were 11.11% and 6.25%, respectively. In the multivariate analysis, Type 2 papilla (odd ratio 7.18, p = 0.045) and Type 3 papilla (odd ratio 7.44, p = 0.016) were associated with greater SBC failure compared with Type 1 papilla. Malignant obstruction compared to stone (odds ratio 4.45, p = 0.014) and age (odd ratio = 1.06, p = 0.010) were also risk factors for cannulation failure. Type 2 papilla was correlated with a higher rate of post-ERCP pancreatitis (20%, p = 0.020) compared to the other types of papilla However, papilla morphology was not a significant risk factor for any complications in the multivariate analysis. Conclusion Small papilla and protruding or pendulous papilla are more difficult to cannulate compared to regular papilla. Small papilla is associated with a higher rate of post-ERCP pancreatitis.
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Affiliation(s)
- Po-Han Chen
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Taiwan Boulevard, Taichung, 40705, Taiwan
| | - Chun-Fang Tung
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Taiwan Boulevard, Taichung, 40705, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yen-Chung Peng
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Taiwan Boulevard, Taichung, 40705, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hong-Zen Yeh
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Taiwan Boulevard, Taichung, 40705, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chi-Sen Chang
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Taiwan Boulevard, Taichung, 40705, Taiwan
| | - Chia-Chang Chen
- Division of Gastroenterology, Department of Internal Medicine, Taichung Veterans General Hospital, 1650, Taiwan Boulevard, Taichung, 40705, Taiwan.
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Passeri MJ, Baimas-George MR, Sulzer JK, Iannitti DA, Martinie JB, Baker EH, Ocuin LM, Vrochides D. Prognostic impact of the Bismuth-Corlette classification: Higher rates of local unresectability in stage IIIb hilar cholangiocarcinoma. Hepatobiliary Pancreat Dis Int 2020; 19:157-162. [PMID: 32088126 DOI: 10.1016/j.hbpd.2020.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 02/01/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Bismuth-Corlette (BC) classification is used to categorize hilar cholangiocarcinoma by proximal extension along the biliary tree. As the right hepatic artery crosses just behind the left bile duct, we hypothesized that BC IIIb tumors would have a higher likelihood of local unresectability due to involvement of the contralateral artery. METHODS A retrospective review of a prospectively maintained database identified patients with hilar cholangiocarcinoma taken to the operating room for intended curative resection between April 2008 and September 2016. Cases were assigned BC stages based on preoperative imaging. RESULTS Sixty-eight patients were included in the study. All underwent staging laparoscopy after which 16 cases were aborted for metastatic disease. Of the remaining 52 cases, 14 cases were explored and aborted for locally advanced disease. Thirty-eight underwent attempt at curative resection. After excluding cases aborted for metastatic disease, the chance of proceeding with resection was 55.6% for BC IIIb staged lesions compared to 80.0% of BC IIIa lesions and to 82.4% for BC I-IIIa staged lesions (P < 0.05). About 44.4% of BC IIIb lesions were aborted for locally advanced disease versus 17.6% of remaining BC stages. CONCLUSIONS When hilar cholangiocarcinoma is preoperatively staged as BC IIIb, surgeons should anticipate higher rates of locally unresectable disease, likely involving the right hepatic artery.
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Affiliation(s)
- Michael J Passeri
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Dr., Suite 600, Charlotte, NC 28204, USA
| | - Maria R Baimas-George
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Dr., Suite 600, Charlotte, NC 28204, USA
| | - Jesse K Sulzer
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Dr., Suite 600, Charlotte, NC 28204, USA
| | - David A Iannitti
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Dr., Suite 600, Charlotte, NC 28204, USA
| | - John B Martinie
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Dr., Suite 600, Charlotte, NC 28204, USA
| | - Erin H Baker
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Dr., Suite 600, Charlotte, NC 28204, USA
| | - Lee M Ocuin
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Dr., Suite 600, Charlotte, NC 28204, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Dr., Suite 600, Charlotte, NC 28204, USA.
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13
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Li M, Tao Y, Shen S, Song L, Suo T, Liu H, Wang Y, Zhang D, Ni X, Liu H. Laparoscopic common bile duct exploration in patients with previous abdominal biliary tract operations. Surg Endosc 2020; 34:1551-60. [PMID: 32072280 DOI: 10.1007/s00464-020-07429-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/10/2020] [Indexed: 12/30/2022]
Abstract
Background A history of abdominal biliary tract surgery has been identified as a relative contraindication for laparoscopic common bile duct exploration (LCBDE), and there are very few reports about laparoscopic procedures in patients with a history of abdominal biliary tract surgery. Methods We retrospectively reviewed the clinical outcomes of 227 consecutive patients with previous abdominal biliary tract operations at our institution between December 2013 and June 2019. A total of 110 consecutive patients underwent LCBDE, and 117 consecutive patients underwent open common bile duct exploration (OCBDE). Patient demographics and perioperative variables were compared between the two groups. Results The LCBDE group performed significantly better than the OCBDE group with respect to estimated blood loss [30 (5–700) vs. 50 (10–1800) ml; p = 0.041], remnant common bile duct (CBD) stones (17 vs. 28%; p = 0.050), postoperative hospital stay [7 (3–78) vs. 8.5 (4.5–74) days; p = 0.041], and time to oral intake [2.5 (1–7) vs. 3 (2–24) days; p = 0.015]. There were no significant differences in the operation time [170 (60–480) vs. 180 (41–330) minutes; p = 0.067]. A total of 19 patients (17%) in the LCBDE group were converted to open surgery. According to Clavien’s classification of complications, the LCBDE group had significantly fewer postoperative complications than the OCBDE group (40 vs. 57; p = 0.045). There was no mortality in either group. Multiple previous operations (≥ 2 times), a history of open surgery, and previous biliary tract surgery (including bile duct or gallbladder + bile duct other than cholecystectomy alone) were risk factors for postoperative adhesion (p = 0.000, p = 0.000, and p = 0.000, respectively). Conclusion LCBDE is ultimately the least invasive, safest, and the most effective treatment option for patients with previous abdominal biliary tract operations and is especially suitable for those with a history of cholecystectomy, few previous operations (< 2 times), or a history of laparoscopic surgery.
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14
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[A consensus statement on the standardized application of antibacterial agents in biliary tract surgery (2019)]. Zhonghua Wai Ke Za Zhi 2019; 57:481-487. [PMID: 31269607 DOI: 10.3760/cma.j.issn.0529-5815.2019.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The standardized application of antibacterial agents in the treatment of biliary tract diseases is of great significance.On the basis of international and domestic guidelines and consensuses, combining with the actual situation of Chinese biliary tract infection, Study Group of biliary Tract Surgery in Chinese Society of Surgery of Chinese Medical Association and Enhanced Recovery After Surgery Committee of Chinese Research Hospital Association and Editorial Board of Chinese Journal of Surgery organized experts to make recommendations which adopted a problem-oriented approach on the severity grade of biliary tract infection, the protocol of specimen examination, the use of antibiotics, the indication of drug withdrawal, the agents application strategy of drug-resistant bacteria infection and special situation to guide surgeons getting the accurate judgement of the severity of biliary tract infection and the formulation of standard protocols for the use of antibacterial agents on the premise of following the bacteriological and drug resistance monitoring information.
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15
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Platt T, Smith K, Nixon M, Sinha S, Srinivas G, Andrews S. Success of intraoperative imaging and management of suspected choledocholithiasis without pre-operative bile duct imaging - A case series. Ann Med Surg (Lond) 2018; 36:173-177. [PMID: 30505436 PMCID: PMC6249395 DOI: 10.1016/j.amsu.2018.10.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/27/2018] [Accepted: 10/29/2018] [Indexed: 01/14/2023] Open
Abstract
Background Laparoscopic common bile duct exploration (LCBDE) is gaining popularity over endoscopic retrograde cholangiopancreatography (ERCP) for the management of common bile duct stones. However, its application has been almost exclusively following preoperative stone confirmation via magnetic retrograde cholangiopancreatography (MRCP), endoscopic ultrasound (EUS) or ERCP. We present our series of LCBDE following detection of common bile duct stones with intraoperative imaging (IOI) alone, in consecutive elective and emergency patients with suspected choledocholithiasis. Materials and methods All patients with suspected but unconfirmed choledocholithiasis undergoing LC with intention to proceed to LCBDE between January 2015 and June 2017 were included. LCBDE was performed following the discovery of choledocholithiasis on IOI. Results 371 patients with suspected choledocholithiasis underwent LC with IOI. CBD stones or obstructing sludge was identified in 107 patients (29%), with sensitivity of 96.2% and specificity of 98.5%. 100 patients, median age 59, went on to have LCBDE as indicated by intraoperative imaging. 76% were performed as emergency cases and conversion to open rate was 2%. There were no mortalities. Bile leak and retained stones occurred in 4% and 3% respectively. 7/100 patients required re-intervention, with re-look laparoscopy (n = 4) and ERCP (n = 3). Median length of stay was 1.5 and 3 days for elective and emergency cases respectively, and 30 readmission rate was 8%. Discussion and conclusion Traditionally patients presenting with suspicion of choledocholithiasis undergo preoperative MRCP/EUS and/or ERCP prior to eventual LC. We propose an alternative, more streamlined, pathway of treatment without requiring preoperative cholangiography, applicable to both elective and emergency patients. Laparoscopic common bile duct exploration is a safe and effective treatment for bile duct stones. Intraoperative cholangiography is sensitive and specific in identification of bile duct stones. Bile duct exploration can be safely performed on the basis on intraoperative imaging alone. Intraoperative imaging provides sufficient information for real time decision making.
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Affiliation(s)
- Timothy Platt
- General Surgery, South Devon NHS Foundation Trust, United Kingdom
| | - Kristy Smith
- Core Surgical Trainee, Norfolk and Norwich University Hospitals NHS Foundation Trust, United Kingdom
| | - Martha Nixon
- StR General Surgery, Plymouth Hospitals NHS Trust, United Kingdom
| | - Surajit Sinha
- Locum Consultant Upper GI Surgery, South Devon NHS Foundation Trust, United Kingdom
| | - Gandrapu Srinivas
- Consultant Upper GI Surgeon, South Devon NHS Foundation Trust, United Kingdom
| | - Stuart Andrews
- Consultant Upper GI Surgeon, South Devon NHS Foundation Trust, United Kingdom
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Abstract
The definition of ambulatory surgery is that the patient is admitted, operated and discharged within a day (24 hours) , but does not include outpatient surgery. It can shorten the average hospital stay, reduce medical expenses, accelerate the recovery of patients, and has been approved to have great social and economic benefits.The main contents of this consensus include: (1)the establishment of ambulatory biliary surgery system, which involves the facilities building, team building, the construction of management systems, operation management, operation state analysis and benefit evaluation; (2)Patient selection criteria, pre-hospital assessment, surgical scheduling, preoperative education, anesthesia and management of adverse reactions after anesthesia, intraoperative application of general surgical principles and postoperative emergency plans, perioperative nursing; (3)Discharge criteria and pre-discharge assessment, post-discharge follow-up and rehabilitation guidance; (4) quality and safety control index system of ambulatory biliary surgery.The publication of this consensus is conducive to the establishment of ambulatory biliary surgery system, the evaluation of effectiveness and quality control, and the promotion of ambulatory biliary surgery.
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17
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Horvat N, Godfrey EM, Sadler TJ, Hechtman JF, Tang LH, Sigel CS, Monti S, Mannelli L. Subclinical focal Cholangitis mimicking liver metastasis in asymptomatic patients with history of pancreatic Ductal Adenocarcinoma and Biliary tree intervention. Cancer Imaging 2017; 17:21. [PMID: 28709465 PMCID: PMC5512934 DOI: 10.1186/s40644-017-0124-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 07/05/2017] [Indexed: 11/30/2022] Open
Abstract
Background Cholangitis is an inflammatory process of the biliary tract with a wide range of clinical manifestations and it is not always considered in the differential diagnosis in asymptomatic patients. To the best of our knowledge there is no previous report in the English literature of focal cholangitis manifesting exclusively as liver parenchymal changes mimicking liver metastasis in asymptomatic patients with pancreatic ductal adenocarcinoma (PDAC) and history of manipulation of the biliary tree. The purpose of this article is to present six cases of subclinical focal cholangitis mimicking liver metastasis in asymptomatic patients with history of PDAC and biliary tree intervention. Case presentation There are six cases with new hepatic lesions detected on follow-up scans in asymptomatic patients with history of PDAC and manipulation of biliary tree. Overall seven lesions were detected, all of them were on the liver periphery, five were hypovascular and two were hypervascular. None of those patients had elevation of CA 19.9 compared with the previous exams. The three patients that had magnetic resonance imaging presented restriction on diffusion weighted imaging and high signal intensity on T2-weighted image. Two patients underwent liver biopsy, which showed only inflammatory changes. All patients were treated with antibiotics and underwent imaging follow-up, which demonstrated resolution of the lesions. None of the patients showed imaging or clinical signs of disease progression during this interval. Conclusion Radiologists and oncologists need to be aware of the possibility of focal cholangitis causing hepatic lesions mimicking neoplasia in patients with history of biliary tree intervention, even in the absence of clinical symptoms.
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Affiliation(s)
- Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10021, USA.,Department of Radiology, Hospital Sírio-Libanês, Adma Jafet 91, São Paulo, SP, 01308050, Brazil.,Department of Radiology, Universidade de São Paulo, Dr. Enéas de Carvalho Aguiar, São Paulo, SP, 05403900, Brazil
| | - Edmund M Godfrey
- Department of Radiology, Addenbrooke's Hospital, Cambridge University NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Timothy J Sadler
- Department of Radiology, Addenbrooke's Hospital, Cambridge University NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Jaclyn F Hechtman
- Department of Pathology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Laura H Tang
- Department of Pathology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Carlie S Sigel
- Department of Pathology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Serena Monti
- IRCCS SDN, Via E. Gianturco, 113, 80143, Naples, Italy
| | - Lorenzo Mannelli
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, 10021, USA.
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Kaselas C, Patoulias D, Patoulias I, Spyridakis I. Dilatation of the Proximal Cystic Duct: Is It a Variant to "Type VI" Choledochal Cyst? J Clin Diagn Res 2016; 10:PD07-9. [PMID: 27504348 DOI: 10.7860/jcdr/2016/20630.8000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 05/13/2016] [Indexed: 11/24/2022]
Abstract
Choledochal cysts are rare congenital malformations, comprising of dilatation of the biliary tree of different localization. Classically, classification of choledochal cysts describes five variants of the disease. Type VI choledochal cyst is considered by many authors as the sixth variant of this classification and is described either as a dilatation of the cystic duct or as a cystic duct cyst. We present a rare case of cystic duct dilatation that presented with acute cholangiopancreatitis and a clinical picture consistent of a choledochal cyst in a 10-year-old female patient. Cholecystectomy with excision of the cystic duct was performed. Histopathologic examination did not reveal any findings consistent with choledochal cyst. Based on these findings we speculate that in our case the dilatation of the cystic duct is a variant to type VI choledochal cyst, based on the fact that no cystic-like malformation has been identified in histology. We provide details of the pre-operative work-up and compare them with intraoperative findings in order to increase awareness of the condition.
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Affiliation(s)
- Christos Kaselas
- Pediatric Surgeon, 1 Department of Pediatric Surgery, "G. Gennimatas" University Hospital, "Aristotle" University of Thessaloniki , Thessaloniki, Greece
| | - Dimitrios Patoulias
- Medical Student, 1 Department of Pediatric Surgery, "G. Gennimatas" University Hospital, "Aristotle" University of Thessaloniki , Thessaloniki, Greece
| | - Ioannis Patoulias
- Consultant Pediatric Surgeon, 1 Department of Pediatric Surgery, "G. Gennimatas" University Hospital, "Aristotle" University of Thessaloniki , Thessaloniki, Greece
| | - Ioannis Spyridakis
- Consultant Pediatric Surgeon, 1 Department of Pediatric Surgery, "G. Gennimatas" University Hospital, "Aristotle" University of Thessaloniki , Thessaloniki, Greece
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Komorowski AL, Li WF, Millan CA, Huang TS, Yong CC, Lin TS, Lin TL, Jawan B, Wang CC, Chen CL. Temporary abdominal closure and delayed biliary reconstruction due to massive bleeding in patients undergoing liver transplantation: an old trick in a new indication. J Hepatobiliary Pancreat Sci 2016; 23:118-24. [PMID: 26692574 PMCID: PMC4764012 DOI: 10.1002/jhbp.311] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 12/17/2015] [Indexed: 12/27/2022]
Abstract
Background Massive bleeding during liver transplantation (LT) is difficult to manage surgical event. Perihepatic packing (PP) and temporary abdominal closure (TAC) with delayed biliary reconstruction (DBR) can be applied in these circumstances. Method A prospective database of LT in a major transplant center was analyzed to identify patients with massive uncontrollable bleeding during LT that was resolved by PP, TAC, and DBR. Results From January 2009 to July 2013, 20 (3.6%) of 547 patients who underwent LT underwent DBR. Mean intraoperative blood loss was 20,500 ml at the first operation. The DBR was performed with a mean of 55.2 h (16–110) after LT. Biliary reconstruction included duct‐to‐duct (n = 9) and hepatico‐jejunostomy (n = 11). Complications occurred in eight patients and included portal vein thrombosis, cholangitis, severe bacteremia, pneumonia. There was one in‐hospital death. In the follow‐up of 18 to 33 months we have seen one patient died 9 months after transplantation. The remaining 18 patients are alive and well. Conclusions In case of massive uncontrollable bleeding and bowel edema during LT, the combined procedures of PP, TAC, and DBR offer an alternatively surgical option to solve the tough situation.
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Affiliation(s)
- Andrzej L Komorowski
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan.,Department of Surgical Oncology, Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Kraków, Poland
| | - Wei-Feng Li
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Carlos A Millan
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Tun-Sung Huang
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan.,Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chee-Chien Yong
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Tsan-Shiun Lin
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Ting-Lung Lin
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Bruno Jawan
- Liver Transplantation Program and Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Chi Wang
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan. .,Department of Surgery, Chang Gung Memorial Hospital Chiayi, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Chao-Long Chen
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
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20
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Zago TM, Pereira BMT, Calderan TRA, Hirano ES, Fraga GP. Extrahepatic duct injury in blunt trauma: two case reports and a literature review. Indian J Surg 2014; 76:303-7. [PMID: 25278655 DOI: 10.1007/s12262-013-0885-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 02/03/2013] [Indexed: 11/28/2022] Open
Abstract
Traumatic injuries of the extrahepatic biliary tract are rare. Associated injuries are usually responsible for immediate indication for surgical treatment, the time when an injury to the extrahepatic biliary ducts may be diagnosed. However, missed injuries are often common. The primary aim of this paper is to describe the clinical features, diagnosis, treatment, and outcome of two patients with left hepatic duct injury after blunt abdominal trauma. As a secondary objective, a literature review is presented. The two cases presented in this study are as follows: (1) A young male, involved in a motor vehicle crash, was admitted with blunt hepatic trauma in a general hospital. Endoscopic retrograde cholangiography was conducted 3 weeks later and revealed a large leakage at the left hepatic duct. Exploratory laparotomy was performed 26 days after the initial traumatic event and identified a complete section of the left hepatic duct, treated with anastomosis. (2) A male fell from a height. On exploratory laparotomy, a 30 % partial injury of the left hepatic duct was found in addition to hemoperitoneum, liver injury, gallbladder detachment together with cystic duct rupture, retroperitoneal hematoma to the right, and cecum hematoma. A high level of suspicion is necessary to identify injuries to the hepatic ducts. Early diagnosis that occurs during laparotomy due to associated injuries is important to reduce complications.
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Affiliation(s)
- Thiago Messias Zago
- Division of Trauma Surgery, University of Campinas, Campinas, Brazil ; Cidade Universitaria "Prof. Zeferino Vaz", Rua Alexander Fleming, 181, 13.083-970 Campinas, São Paulo Brazil
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