Outcomes of endoscopic sclerotherapy for jejunal varices at the site of choledochojejunostomy (with video): Three case reports

BACKGROUND

Hemorrhage associated with varices at the site of choledochojejunostomy is an unusual, difficult to treat, and often fatal manifestation of portal hypertension. So far, no treatment guidelines have been established.

CASE SUMMARY

We reported three patients with jejunal varices at the site of choledochojejunostomy managed by endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoacrylate injection at our institution between June 2021 and August 2023. We reviewed all patient records, clinical presentation, endoscopic findings and treatment, outcomes and follow-up. Three patients who underwent pancreaticoduodenectomy with a Whipple anastomosis were examined using conventional upper gastrointestinal endoscopy for suspected hemorrhage from the afferent jejunal loop. Varices with stigmata of recent hemorrhage or active hemorrhage were observed around the choledochojejunostomy site in all three patients. Endoscopic injection of lauromacrogol/α-butyl cyanoacrylate was carried out at jejunal varices for all three patients. The bleeding ceased and patency was observed for 26 and 2 months in two patients. In one patient with multiorgan failure and internal environment disturbance, rebleeding occurred 1 month after endoscopic sclerotherapy, and despite a second endoscopic sclerotherapy, repeated episodes of bleeding and multiorgan failure resulted in eventual death.

CONCLUSION

We conclude that endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoacrylate injection can be an easy, effective, safe and low-cost treatment option for jejunal varicose bleeding at the site of choledochojejunostomy.

An improved laparoscopic choledochojejunostomy technique (with video)

TECHNIQUE

Choledochojejunostomy is an important procedure in hepatobiliary pancreatic surgery. It is used in pancreaticoduodenectomy, biliary strictures, liver transplantation, and other surgical reconstructions involving bile duct resection. Safe and reliable anastomosis under laparoscopic guidance is important for good postoperative recoveries. There are some difficulties owing to the limited angle of laparoscopic instruments. Standardized anastomosis methods are currently lacking, especially for cases with thin bile duct walls and small diameters. We modified the traditional laparoscopic choledochojejunostomy by combining the advantages of interrupted and continuous sutures using continuous sutures of the posterior and anterior walls followed by intermittent knot-tying of the anterior walls. The technical aspects of this anastomosis method and the related experiences of high-volume centers are summarized.

RESULTS

An experienced laparoscopic surgeon can safely perform laparoscopic choledochojejunostomy by following a programmed anastomosis procedure.

CONCLUSIONS

This modified anastomotic technique simplifies the procedure, reduces the difficulty of laparoscopic anastomosis, and yields satisfactory results. Larger-scale studies are necessary to validate whether it can definitively reduce complications and enhance outcomes.

IL-10 dependent modulatory effect of regulatory B10 cells on local scar formation following Roux-en-Y choledochojejunostomy in a novel rat model

Choledochojejunostomy has been common surgical treatment of biliary tract disease. Scar formation at anastomotic often results in postoperative complications associated with bleak post-operative recovery, in which local inflammation may be a potential target to modulate local scar formation. This study investigated the effect of regulatory B10 cells on local scar formation through interleukin-10 signal pathway following Roux-en-Y choledochojejunostomy (RCJS) in a novel rat model. Sprague-Dawley (SD) rats with RCJS were randomly divided into blank group, experimental group, IL-10 blocking group, control group, and received different interventions and duration. Injected through dorsal vein of penis, rats in different groups were treated respectively according to scheme. These interventions were performed during surgery, on 1st day, and 2nd day after surgery. Related indexes, including blood examination, specimen tissue of anastomotic detection, were recorded and compared in different interventional groups. Rats in experimental groups had more rapid recovery in liver function and inflammatory index, and higher in IL-10 level. Flow cytometry analysis showed that rats in experimental groups had highest content of B10 cells and lowest content of CD4+CD25- T cells in peripheral blood. Wider anastomotic by macroscopical observation, and slighter proliferation of collagen fiber and smooth muscle fiber, lower α-SMA and TGF-β1 levels by pathological staining were detected in experimental groups. Higher expression of the IL-10 gene and lower expression of TGF-β1 at anastomotic were detected in experimental groups. B10 cells may relieve local inflammation of anastomotic following RCJS in rats through IL-10-dependent modulatory effect, and improve local scar formation.

Instructional Video For Hepaticojejunostomy Anastomosis Ensuring Evenly Spaced Sutures

OBJECTIVE

We demonstrate a surgical technique involving construction of a hepaticojejunostomy (HJ) anastomosis that ensures even spacing between the sutures regardless of the size of the common bile duct. This is demonstrated via a series of illustrations followed by live demonstration of a HJ anastomosis created during a Whipple procedure.

VIDEO DESCRIPTION

Overall, this technique results in the creation of a tension-free hepaticojejunostomy anastomosis, that typically does not require stenting, is highly reliable and replicable regardless of the size of the common bile duct. It is also easily reproducible and easy to teach trainees.

Development and evaluation of a portable and soft 3D-printed cast for laparoscopic choledochojejunostomy model in surgical training

BACKGROUND

Laparoscopic choledochojejunostomy (LCJ) is an essential basic skill for biliary surgeons. Therefore, we established a convenient and effective LCJ 3D printing model to evaluate whether the model could simulate the actual operation situation and determine its effectiveness and validity in surgical training.

METHODS

A 3D printing dry laboratory model was established to simulate LCJ. The face and content validity of the model were evaluated by six experienced biliary surgeons based on 5-point Likert scale questionnaires. A total of 15 surgeons with different levels of experience performed LCJ on the model and evaluated the structural validity of the model using the objective structured assessment of technical skills (OSATS). Simultaneously, the operation time of each surgery was also recorded. A study was also performed to further evaluate the learning curve of residents.

RESULTS

The operating space score of the model was 4.83 ± 0.41 points. The impression score of bile duct and intestinal canal was 4.33 ± 0.52 and 4.17 ± 0.41 points, respectively. The tactile sensation score of bile duct suture and intestinal canal suture was 4.00 ± 0.63 and 3.83 ± 0.41points, respectively. The OSATS score for model operation in the attending group was 29.20 ± 0.45 points, which was significantly higher than that in the fellow group (26.80 ± 1.10, P = 0.007) and the resident group (19.80 ± 1.30, P < 0.001). In addition, there was a statistical difference in operation time among surgeons of different experience levels (P < 0.05). Residents could significantly improve the surgical score and shorten the time of LCJ through repeated training.

CONCLUSIONS

The 3D printing LCJ model can simulate the real operation scenes and distinguish surgeons with different levels of experience. The model is expected to be one of the training methods for biliary tract surgery in the future.

Choledochoduodenostomy continues to be a safe alternative for biliary reconstruction in deceased-donor liver transplantation

Debate continues as to whether choledochoduodenostomy (CDD) can be used instead of Roux-en-Y choledochojejunostomy (CDJ) when duct-to-duct (DTD) is not an option. We hypothesized that CDD and CDJ had similar rates of complications. All deceased-donor liver transplantations from September 2011 to March 2020 were categorized by biliary reconstruction. Primary outcomes were bleeding, bile leak, anastomotic stricture, and cholangitis. Of the 1,086 patients, 812 (74.8%) received a DTD; 225 (20.7%) received a CDD; and 49 (4.5%) received a CDJ. Cholangitis was significantly higher in CDJ compared to DTD and CDD (26.5% vs 6% vs 13.8%, p < 0.0001). When controlling for significant confounders, CDJ had 10.2 higher odds of cholangitis (95% CI 4.4-23.2) compared to DTD, and 3.3 higher odds compared to CDD (95% CI 1.4-7.8). When compared to DTD, CDJ and CDD had significantly lower odds of stricture. CDD continues to be a safe alternative for biliary reconstruction in deceased-donor liver transplantation.

5G-Assisted Remote Guidance in Laparoscopic Simulation Training Based on 3D Printed Dry Lab Models

This is a pilot study to assess the utility of applying 5G-assisted remote guidance in laparoscopic simulation training. A single trainee of a junior surgeon was recruited to complete three steps of tasks including basic task 1, basic task 2, and model task, and the performance was recorded and evaluated. The operator completed each task three times. Except for basic task 1, all tasks were remotely guided by a more experienced surgeon using 5G technology. Tasks completion time and a 30-point objective structured assessment of technical skills (OSATS) score were utilized to assess the results of simulation training. All remote guidance processes were successfully completed without significant network latency. Through basic task 1, the operator quickly became familiar with the trained laparoscopic instruments. For basic task 2, OSATS scores increased from 16 to 24 points, and completion time decreased from 1500 to 986 s after training under 5G-assisted remote guidance. For model tasks, OSATS scores increased from 15 to 26 points, and completion time decreased from 1734 to 1142 s. This is a novel mode of laparoscopic simulation training to increase the convenience of training. Perhaps in the near future, surgeons can simulate difficult operations at home or in the office, and accurately grasp the possible situations that may occur in actual operations in advance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12262-022-03590-2.

Palliative laparoscopic Roux-en-Y choledochojejunostomy as a feasible treatment option for malignant distal biliary obstruction

PURPOSES

The advantages of surgical bypass for patients with distal biliary obstruction caused by advanced periampullary cancer include a low risk of recurrent biliary obstruction; however, the highly invasive nature of the operation limits its use. Herein, we present the clinical findings of patients who underwent laparoscopic Roux-en-Y choledochojejunostomy (LRYCJ) compared with those who underwent endoscopic stent insertion.

METHODS

We reviewed, retrospectively, the palliative care outcomes for malignant bile duct obstruction according to the type of intervention: LRYCJ vs. endoscopic stenting. After initial intervention, the factors predisposing to recurrent biliary obstruction (RBO) were identified via multiple regression analysis.

RESULTS

The final analysis included 28 patients treated with LRYCJ (22.4%) and 97 patients who underwent endoscopic stent insertion (77.6%). The two groups did not differ in the incidence of early or late complications and mortality; however, the LRYCJ group had a lower incidence of RBO (4 patients, 14.3% vs. 73 patients, 75.3%; p < 0.001). As a predisposing factor for RBO, endoscopic stenting was the only highly significant predictor (OR 16.956, CI 5.140-55.935, p < 0.001).

CONCLUSIONS

LRYCJ represents an attractive option for palliation of malignant distal biliary obstruction, with improved biliary-tract patency and less need for subsequent interventions such as additional stenting.

Perpendicular duodenum jejunum anastomosis for conventional postoperative endoscopic access in biliodigestive diversions in Roux in Y

BACKGROUND

Cholecystectomy is one of the most performed abdominal surgical procedures, with approximately 1.5 million procedures performed annually in the United States of america. Most of the biliary duct injuries during laparoscopic cholecystectomy are due to a wrong perception of the anatomy. Two thirds of postsurgical stenosis develop within two and three years after repairing and the other third in the following ten years.

OBJECTIVE

To show the adequacy for postoperative endoscopic access in Roux-in-Y biliodigestive diversions.

METHOD

The best technique to repair biliary duct injuries is the Roux-in-Y hepaticojejunostomy or choledochojejunostomy, from this procedure we propose a surgical technique that consists to perform a perpendicular anastomosis between the defunctionalized jejunum loop and the duodenum for later endoscopic access of the Roux-en-Y biliodigestive diversion.

RESULTS

The duodenal-jejunal perpendicular anastomosis procedure was performed in four patients with Roux-Y biliodigestive diversion.

CONCLUSIONS

With the technique that is proposed, we have that advantage of keeping the anastomosis permanently open due to its rhomboidal design and because of the pylorus is kept intact alkaline reflux would not be a problem.

Indication and surgical techniques of bypass choledochojejunostomy for intractable choledocholithiasis

Despite development in endoscopic treatment and minimally invasive surgery for choledocholithiasis, there remains a small number of patients who require bypass Roux-en-Y choledochojejunostomy (RYCJ) because of the intractable occurrence of common bile duct (CBD) stones. We herein present the detailed procedures of open RYCJ customized for intractable choledocholithiasis. The first method is a side-to-end choledochojejunostomy with intraluminal closure of the distal CBD. This method was applied to a 79-year-old female patient who underwent endoscopic retrograde cholangiopancreatography (ERCP) more than 10 times in the past 14 years (Case No. 1). The distal CBD was explored through choledochotomy and then the distal CBD lumen was occluded with internal running sutures. A large-sized choledochojejunostomy was performed. The patient recovered uneventfully and has been doing well for the past 2 years. The second method is an end-to-end choledochojejunostomy with segmental CBD resection. It was applied to a 75-year-old male patient who underwent ERCP 9 times in the past 10 years (Case No. 2). The CBD was resected segmentally and a large-sized choledochojejunostomy was performed. The patient also recovered uneventfully and has been doing well for the past 2 years. In conclusion, the primary indication of bypass RYCJ is intractable choledocholithiasis which requires numerous sessions of endoscopic stone removal over a long period. Open RYCJ is the preferred procedure to date. If the papilla is patulous, the distal CBD should be occluded or resected to prevent reflux ascending cholangitis. We recommend to resect the intrapancreatic distal CBD if it is markedly dilated like choledochal cyst.

Impact of previous history of choledochojejunostomy on the incidence of organ/space surgical site infection after hepatectomy

PURPOSE

Impact of previous history of choledochojejunostomy (PCJ) on the incidence of organ/space surgical site infection (SSI) after hepatectomy remains unclear. The aim of this study was to investigate the incidence and causes of SSI after hepatectomy.

METHODS

Patients who underwent hepatectomy of ≤1 Couinaud's sector between January 2011 and September 2019 were retrospectively analyzed. Incidence of and risk factors for organ/space SSI (Clavien-Dindo grade ≥2) after hepatectomy were investigated.

RESULTS

Among 750 hepatectomies, 18 patients (2.4%) had a medical history of PCJ. Incidence of organ/space SSI was higher in patients with PCJ (50%) than in those without PCJ (3%, P < 0.001), and the trend was consistent even after estimated propensity score matched cohort. Multivariate analysis showed PCJ was a strong risk factor for organ/space SSI (grade ≥2), with the highest odds ratios (OR) among all other clinicopathological risk factors (OR, 32.25; P < 0.001). Among hepatectomies with PCJ, pneumobilia (OR, 12.25; P = 0.015), operation time ≥171 min (OR, 12.25; P = 0.016), and liver steatosis (OR, 24.00; P ≤ 0.005) were associated with organ/space SSI after hepatectomy.

CONCLUSION

Previous history of choledochojejunostomy was a strong risk factor for organ/space SSI after hepatectomy. The high rate of organ/space SSI after hepatectomy with PCJ might be attributed to intrahepatic bile duct contamination, increased operation time, and histological liver steatosis.

A potential intraoperative disaster averted: Preduodenal portal vein compressing a preduodenal common bile duct

Familiarity with the anatomy is paramount for conduct of safe surgery for a surgeon. Anomalies with the biliary and hepatic arterial system are common but portal vein anomalies are least common. A preduodenal portal vein has been reported in about 100 cases but a combination of preduodenal portal vein with preduodenal common bile duct is extremely rare with only 9 cases being reported. We report a one such case and discuss the embryological basis for the peculiar anatomy observed in our case which has never been reported earlier. We also reviewed the reported cases in literature.

What is the better surgical treatment option for recurrent common bile duct stones?

Purpose

Repeating endoscopic retrograde cholangiopancreatography (ERCP) in patients with recurrent common bile duct (CBD) stones is problematic in many ways. Choledochoduodenostomy (CDS) and choledochojejunostomy (CJS) are 2 surgical treatment options for recurrent CBD stones, and each has different advantages and disadvantages. The aim of this study was to compare the 2 surgical options in terms of the recurrence rate of CBD stones after surgical treatment.

Methods

This retrospective multicenter study included all patients who underwent surgical treatment due to recurrent CBD stones that were not effectively controlled by medical treatment and repeated ERCP between January 2006 and March 2015. We collected data from chart reviews and medical records. A recurrent CBD stone was defined as a stone found 6 months after the complete removal of a CBD stone by ERCP. Patients who underwent surgery for other reasons were excluded.

Results

A total of 27 patients were enrolled in this study. Six patients underwent CDS, and 21 patients underwent CJS for the rescue treatment of recurrent CBD stones. The median follow-up duration was 290 (180–1,975) days in the CDS group and 1,474 (180–6,560) days in the CJS group (P = 0.065). The postoperative complications were similar and tolerable in both groups (intestinal obstruction; 2 of 27, 7.4%; 1 in each group). CBD stones recurred in 4 patients after CDS (4 of 6, 66.7%), and 3 patients after CJS (3 of 21, 14.3%) (P = 0.010).

Conclusion

CJS may be a better surgical option than CDS for preventing further stone recurrence in patients with recurrent CBD stones.

Laparotomy-assisted transcatheter variceal embolization for bleeding jejunal varices formed at the site of choledochojejunostomy: Report of a case and review of the literature

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Jejunal varices should be included in the differential diagnosis of melena in patients with a bilioenteric anastomosis and portal vein hypertension.

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Laparotomy-assisted transcatheter variceal embolization is one of the options for the treatment of jejunal varices.

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A multidisciplinary approach is critical for timely management of the unstable patient with bleeding from jejunal varices.

Introduction

Bleeding from jejunal varices formed at the site of a bilioenteric anastomosis due to portal vein hypertension is relatively rare and difficult to treat.

Presentation of case

An 80-year-old man with melena, slight fever, and abdominal pain was referred to our hospital. He had undergone subtotal stomach-preserving pancreaticoduodenectomy for cancer of the ampulla of Vater six years earlier. Follow-up computed tomography (CT) three years earlier showed occlusion of the extrahepatic portal vein and the growth of collateral flow into the lateral segment of the liver, but there were no signs of recurrence of the cancer of the ampulla of Vater. The patient underwent prophylactic endoscopic variceal ligation for esophageal varices one year earlier. On admission, blood tests showed anemia and elevated liver enzyme and bilirubin levels. Esophagogastroduodenoscopy and colonoscopy failed to identify the site of bleeding. Double-balloon endoscopy showed the dilated blood vessels around the stenotic anastomosis of the choledochojejunostomy. A CT scan was consistent with total occlusion of the portal vein and varices around the choledochojejunostomy site. With a diagnosis of jejunal varices, laparotomy-assisted transcatheter variceal embolization was performed. Double-balloon endoscopy performed one month after laparotomy-assisted transcatheter variceal embolization showed no varices, and dilation of the stenotic anastomosis of the choledochojejunostomy was performed safely.

Conclusion

Jejunal varices should be included in the differential diagnosis of melena in patients with a previous history of surgery with a bilioenteric anastomosis and portal vein hypertension. Laparotomy-assisted transcatheter variceal embolization is one of the options for the treatment of jejunal varices.

Magnetic Compression Anastomosis in Laparoscopic Pancreatoduodenectomy: A Preliminary Study

BACKGROUND

Laparoscopic pancreatoduodenectomy (LPD) is a minimally invasive technique widely developed in the last few decades. Although magnetic compression anastomosis (magnamosis) is used during cholangiojejunostomy, its applicability in LPD has not yet been reported. Herein, we evaluated the feasibility and effectiveness of magnamosis in LPD.

METHODS

Between January 2018 and December 2019, seven patients who underwent laparoscopic magnetic compression choledochojejunostomy (LMC-CJ) or laparoscopic magnetic compression pancreatojejunostomy (LMC-PJ) in LPD were enrolled. After LPD, a parent magnet with or without a drainage tube was placed in the proximal bile duct and pancreatic duct of each patient. Daughter magnets were introduced to couple with the parent magnets at the desired sites. A close postoperative surveillance of magnet movements was performed. Various relevant data were collected, and all patients were followed up until February 2020.

RESULTS

LPD was successfully completed in all seven patients, of which seven underwent LMC-CJ and two received LMC-PJ. The median time needed for completion of LMC-CJ was 11 min (range, 8-16). The cost time for the two cases of LMC-PJ was 12 and 15 min, respectively. After a median time of 50 d (range, 40-170) postoperation, all magnets were expelled. No leakages of LMC-CJ or LMC-PJ were observed after operation. After a median follow-up period of 11 mo (range, 4-18), there was no incidence of anastomotic stricture.

T-tube drainage versus choledochojejunostomy in hepatolithiasis patients with sphincter of Oddi laxity: study protocol for a randomized controlled trial

Background

Residual and recurrent stones remain one of the most important challenges of hepatolithiasis and are reported in 20 to 50% of patients treated for this condition. To date, the two most common surgical procedures performed for hepatolithiasis are choledochojejunostomy and T-tube drainage for biliary drainage. The goal of the present study was to evaluate the therapeutic safety and perioperative and long-term outcomes of choledochojejunostomy versus T-tube drainage for hepatolithiasis patients with sphincter of Oddi laxity (SOL).

Methods/design

In total, 210 patients who met the following eligibility criteria were included and were randomized to the choledochojejunostomy arm or T-tube drainage arm in a 1:1 ratio: (1) diagnosed with hepatolithiasis with SOL during surgery; (2) underwent foci removal, stone extraction and stricture correction during the operation; (3) provided written informed consent; (4) was willing to complete a 3-year follow-up; and (5) aged between 18 and 70 years. The primary efficacy endpoint of the trial will be the incidence of biliary complications (stone recurrence, biliary stricture, cholangitis) during the 3 years after surgery. The secondary outcomes will be the surgical, perioperative and long-term follow-up outcomes.

Discussion

This is a prospective, single-centre and randomized controlled two-group parallel trial designed to demonstrate which drainage method (Roux-en-Y hepaticojejunostomy or T-tube drainage) can better reduce biliary complications (stone recurrence, biliary stricture, cholangitis) in hepatolithiasis patients with SOL.

Trial registration

Clinical Trials.gov: NCT04218669. Registered on 6 January 2020.

Anterograde bile duct drainage for intractable bile leakage after hepatectomy in a patient with previous pancreatoduodenectomy: A case report

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Endoscopic retrograde drainage is effective for managing bile leakage.

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Bile drainage after pancreatoduodenectomy with choledochojejunostomy is difficult.

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Post-hepatectomy bile leakage in a patient with prior pancreatoduodenectomy.

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Selective anterograde bile duct drainage was successful in treating the condition.

Introduction

Endoscopic retrograde drainage is effective for managing bile leakage, which is relatively common after hepatectomy without bile duct reconstruction. However, the procedure is difficult to perform after pancreatoduodenectomy with choledochojejunostomy. We present a case of anterograde bile duct drainage for intractable bile leakage after hepatectomy in a patient with previous pancreatoduodenectomy.

Presentation of case

An 80-year-old woman with a history of pancreatoduodenectomy for distal biliary cancer and adjuvant chemotherapy presented with bile leakage. Six years after the pancreatoduodenectomy, she underwent partial hepatectomy for suspected metastasis or intrahepatic cholangiocarcinoma. On the 9th postoperative day, bile leaked from her drainage tube forming an abscess cavity; this continued until the 28th postoperative day. We attempted selective anterograde drainage from the cut surface of the liver under fluoroscopic guidance using a guidewire and Cobra-type catheter. We selectively cannulated the entrance hole of the bile duct. Twenty days after the drainage, the abscess cavity disappeared. After 41 days, the tube was removed, and the patient was discharged. We suggest this procedure as a possible treatment option for difficult bile leakage cases.

Discussion

A case of intractable bile leakage after hepatectomy in a patient with a previous history of pancreatoduodenectomy is difficult to manage, and usually needs surgical intervention. The effect of selective cannulation of the entrance hole of the bile duct has not been studied.

Conclusion

Selective anterograde bile duct drainage for intractable bile leakage after hepatectomy in a patient with a previous history of pancreatoduodenectomy successfully resolved bile duct leakage in our patient.

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.

Hepatic ductoplasty for iatrogenic Bismuth type 2 bile duct stricture: A case report

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The article represents recovering treatment of iatrogenic biliary tract injury by laparoscopic cholecystectomy.

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Biliary tract stricture like Bismuth type 2 successfully treated by hepatic ductoplasty.

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To emphasize the importance of avoiding biliary stricture is a key to prevent cholangitis and stone recurrences.

Introduction

Biliary enteric anastomosis is a well-known biliary reconstruction method. Anastomosis stricture is one of the complications of this procedure that occurs in some patients over the long-term. We report a successful case of hepatic ductoplasty combined with hepaticojejunostomy (H–J) for the treatment of iatrogenic Bismuth type 2 stricture.

Presentation of case

The patient was a 68-year-woman who had undergone choledochojejunostomy (C–J) 6 years earlier due to bile duct injury after laparoscopic cholecystectomy for cholelithiasis. She complained of recurrent chills and upper back pain. Cholangiography and computed tomography revealed a C–J anastomotic stricture with hepatolithiasis. The diagnosis was reflux cholangitis with hepatolithiasis due to C–J stricture and a fistula between the reconstructed jejunal limb and duodenum. Exploration was performed, and she underwent hepatic ductoplasty with H–J and hepaticolithotripsy. Surgery was performed uneventfully and the patient has remained well subsequently.

Discussion and conclusion

We propose hepatic ductoplasty as a useful technique for the treatment of selected patients with a C–J stricture or narrow hepatic duct.

Endoscopic balloon dilatation for benign hepaticojejunostomy anastomotic stricture using short double-balloon enteroscopy in patients with a prior Whipple's procedure: a retrospective study

Background

Endoscopic retrograde cholangiography using a short double-balloon endoscope (DB-ERC) is a promising minimally-invasive method for accessing hepaticojejunostomy (HJ) anastomosis in patients with surgically altered anatomy. We aimed to evaluate the immediate and long-term outcomes of balloon dilatation for benign HJ anastomotic stricture (HJAS) in patients who had previously undergone Whipple’s procedure using a DB-ERC.

Methods

We conducted a retrospective analysis of 46 patients who underwent balloon dilatation alone with a DB-ERC for benign HJAS between November 2008 and November 2014. The median follow-up duration was 3.5 (interquartile range [IQR], 1.9–5.1) years.

Results

The technical and clinical success rates were 100%, and adverse events occurred in 7% (3/46, cholangitis). The median hospitalization period was seven (IQR, 5–10) days. Of 42 patients (91%) followed-up for > 1 year, 24 (51%) had recurrent HJAS at a median of 1.2 (IQR, 0.6–2.9) years after balloon dilatation. The cumulative anastomotic patency rates at 1, 2, and 3 years were 73, 55, and 49%, respectively. In univariate analysis, early stricture formation (< 1 year) was a risk factor for recurrent stenosis, although no statistically significant risk factors were observed in multivariate analysis.

Conclusions

Endoscopic balloon dilatation with DB-ERC for benign HJAS is effective and safe, having good immediate technical success and few adverse events. Further improvements to this procedure are needed to prevent recurrent HJAS.

Utility of hepatobiliary scintigraphy for recurrent reflux cholangitis following choledochojejunostomy: A case report

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Reflux cholangitis is a common complication of Roux-en-Y choledochojejunostomy.

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The patient had recurrent postoperative reflux cholangitis.

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There was no stenosis or calculus in choledochojejunostomy anastomosis.

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Hepatobiliary scintigraphy detected that the blind loop caused the cholangitis.

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Hepatobiliary scintigraphy could be adjunct to other examination in diagnosing reflux cholangitis.

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Hepatobiliary scintigraphy is useful to clarify the mechanism of reflux cholangitis.

Introduction

Reflux cholangitis is a frequent complication of Roux-en-Y choledochojejunostomy.

Presentation of case

A 68-year-old male underwent left lobectomy of the liver, bile duct resection and choledochojejunostomy for intrahepatic cholangiocarcinoma located in Segment 2 of the liver, 40 mm in diameter with a lymph node metastasis 5 years ago. He had frequent recurrences of postoperative reflux cholangitis and hepatic abscesses and was treated with antibiotics each time. Postoperative adjuvant chemotherapy was scheduled, but due to recurrent cholangitis it was difficult. Although double balloon endoscopy for endoscopic retrograde cholangiography was performed, no stenosis was found in the choledochojejunostomy anastomosis, and no defect suspected of calculus and stenosis were found by contrast. Antibiotics had to be administered for a long time because it recurred when antibiotics were discontinued. This time, a tumor 2.0 cm in diameter was detected in segment 7 of the liver on follow – up computed tomography. The preoperative diagnosis was recurrent Intrahepatic cholangiocarcinoma. Hepatobiliary scintigraphy was carried out in preparation for concomitant treatment of his reflux cholangitis. Retention in the blind loop of the choledochojejunostomy was retarded, and the excretion was delayed. Therefore, hepatectomy and resection of the blind loop were performed. We confirmed improvement of stasis in the blind loop on postoperative hepatobiliary scintigraphy. The postoperative course was uneventful, and antibiotics were not required.

Discussion

Hepatobiliary scintigraphy may be able to clarify the mechanism underlying reflux cholangitis.

Conclusion

Hepatobiliary scintigraphy was useful for the treatment of recurrent reflux cholangitis in this case.

Choledochojejunostomy with an innovative magnetic compressive anastomosis: How to determine optimal pressure?

AIM: To investigate the optimal magnetic pressure and provide a theoretical basis for choledochojejunostomy magnetic compressive anastomosis (magnamosis).

METHODS: Four groups of neodymium-iron-boron magnets with different magnetic pressures of 0.1, 0.2, 0.3 and 0.4 MPa were used to complete the choledochojejunostomy magnamosis. Twenty-six young mongrel dogs were randomly divided into five groups: four groups with different magnetic pressures and 1 group with a hand-suture anastomosis. Serum bilirubin levels were measured in all groups before and 1 wk, 2 wk, 3 wk, 1 mo and 3 mo after surgery. Daily abdominal X-ray fluoroscopy was carried out postoperatively to detect the path and the excretion of the magnet. The animals were euthanized at 1 or 3 mo after the operation, the burst pressure was detected in each anastomosis, and the gross appearance and histology were compared according to the observation.

RESULTS: The surgical procedures were all successfully performed in animals. However, animals of group D (magnetic pressure of 0.4 MPa) all experienced complications with bile leakage (4/4), whereas half of animals in group A (magnetic pressure of 0.1 MPa) experienced complications (3/6), 1 animal in the manual group E developed anastomotic stenosis, and animals in group B and group C (magnetic pressure of 0.2 MPa and 0.3 MPa, respectively) all healed well without complications. These results also suggested that the time required to form the stoma was inversely proportional to the magnetic pressure; however, the burst pressure of group A was smaller than those of the other groups at 1 mo (187.5 ± 17.7 vs 290 ± 10/296.7 ± 5.7/287.5 ± 3.5, P < 0.05); the remaining groups did not differ significantly. A histologic examination demonstrated obvious differences between the magnamosis groups and the hand-sewn group.

CONCLUSION: We proved that the optimal range for choledochojejunostomy magnamosis is 0.2 MPa to 0.3 MPa, which will help to improve the clinical application of this technique in the future.

In vivo porcine training model for laparoscopic Roux-en-Y choledochojejunostomy

Purpose

The purpose of this study was to develop a porcine training model for laparoscopic choledochojejunostomy (CJ) that can act as a bridge between simulation models and actual surgery for novice surgeons. The feasibility of this model was evaluated.

Methods

Laparoscopic CJ using intracorporeal sutures was performed on ten animals by a surgical fellow with no experience in human laparoscopic CJ. A single layer of running sutures was placed in the posterior and anterior layers. Jejunojejunostomy was performed using a linear stapler, and the jejunal opening was closed using absorbable unidirectional sutures (V-Loc 180).

Results

The average operation time was 131.3 ± 36.4 minutes, and the CJ time was 57.5 ± 18.4 minutes. Both the operation time and CJ time showed a steady decrease with an increasing number of cases. The average diameter of the CBD was 6.4 ± 0.8 mm. Of a total of ten animals, eight were sacrificed after the procedure. In two animals, a survival model was evaluated. Both pigs recovered completely and survived for two weeks, after which both animals were sacrificed. None of the animals exhibited any signs of bile leakage or anastomosis site stricture.

Conclusion

The porcine training model introduced in this paper is an adequate model for practicing laparoscopic CJ. Human tissue simulation is excellent.

Double-balloon-enteroscopy-based endoscopic retrograde cholangiopancreatography in post-surgical patients

AIM: To evaluate double balloon enteroscopy (DBE) in post-surgical patients to perform endoscopic retrograde cholangiopancreatography (ERCP) and interventions.

METHODS: In 37 post-surgical patients, a stepwise approach was performed to reach normal papilla or enteral anastomoses of the biliary tract/pancreas. When conventional endoscopy failed, DBE-based ERCP was performed and standard parameters for DBE, ERCP and interventions were recorded.

RESULTS: Push-enteroscopy (overall, 16 procedures) reached enteral anastomoses only in six out of 37 post-surgical patients (16.2%). DBE achieved a high rate of luminal access to the biliary tract in 23 of the remaining 31 patients (74.1%) and to the pancreatic duct (three patients). Among all DBE-based ERCPs (86 procedures), 21/23 patients (91.3%) were successfully treated. Interventions included ostium incision or papillotomy in 6/23 (26%) and 7/23 patients (30.4%), respectively. Biliary endoprosthesis insertion and regular exchange was achieved in 17/23 (73.9%) and 7/23 patients (30.4%), respectively. Furthermore, bile duct stone extraction as well as ostium and papillary dilation were performed in 5/23 (21.7%) and 3/23 patients (13.0%), respectively. Complications during DBE-based procedures were bleeding (1.1%), perforation (2.3%) and pancreatitis (2.3%), and minor complications occurred in up to 19.1%.

CONCLUSION: The appropriate use of DBE yields a high rate of luminal access to papilla or enteral anastomoses in more than two-thirds of post-surgical patients, allowing important successful endoscopic therapeutic interventions.

Sphincter of Oddi laxity: An important factor in hepatolithiasis

AIM: To evaluate the importance of sphincter of Oddi laxity (SOL) in hepatolithiasis (HL).

METHODS: Subjects included 98 patients diagnosed with HL between 2002 and 2007. Detailed histories were taken and the subjects were monitored until July 2008. HL patients were divided into two groups: Group I included 45 patients with SOL, and Group II included 53 patients without. Recurrence and reoperation indices of both groups were calculated and compared.

RESULTS: The recurrence index was 0.135 in Group I and 0.018 in Group II (P < 0.001). The reoperation index was 0.070 in Group I and 0.010 in Group II (P < 0.001). The mean frequency of biliary operation was 2.07 in Group I and 1.21 in Group II (P = 0.001). Differences between the two groups are significant.

CONCLUSION: HL patients with SOL tend to have a higher risk of recurrence and a larger demand for reoperation than those without this condition.