Bile duct varices in the absence of portal hypertension signs

Previous reports have shown that unrecognized or incidental bile duct varices have been reported as being related to hazardous complications and difficulties during surgery or other interventional procedures. A 32-year-old Indian female patient with no previous symptoms and signs suggestive of portal hypertension was admitted for an elective laparoscopic cholecystectomy for biliary colic. Bile duct varices were incidentally recognized during the operation. For the sake of safety, the surgery was converted to a conventional approach. Postoperatively, a detailed history revealed catheterization of the umbilical vein during the newborn period. Subsequently, contrast-enhanced computer tomography scanning showed extrahepatic portal vein thrombosis and cavernous transformation, while an upper gastrointestinal tract endoscopy did not reveal any evidence of esophageal varices. Bile duct varices should be excluded in patients with symptoms and signs suggestive for portal hypertension. Moreover, the present case addresses the fact that bile duct varices should also be suspected in asymptomatic patients with a history suggestive for extrahepatic portal vein thrombosis. Intraoperative recognition of bile duct varices requires a careful anatomical approach to the hepatoduodenal ligament to avoid hazardous complications.     

Bile duct cysts

Bile duct cysts are uncommon lesions that are found in adult and pediatric patients. Current concepts regarding epidemiology, etiology, classification, clinical diagnosis, and surgical treatment are reviewed. Bile duct cysts are associated with abnormal junctional anatomy of the pancreatic and bile ducts and with biliary tract cancer. When possible, complete cyst excision is the recommended treatment.     

Bile duct cysts in adults

BACKGROUND: Bile duct cysts are rare and of uncertain origin. Most have been reported in young females of Asian descent, but an increasing number have occurred in Western adults. METHODS: A Medline literature search was performed to locate articles on the pathophysiological concepts, clinical behaviour and management controversies pertaining to bile duct cysts in adults. Emphasis was placed on reports from the past two decades. RESULTS AND CONCLUSION: An increasing rate of occurrence of bile duct cyst is reported in adults. Type IV cysts are more frequent in adults than children. Presentation tends to be non-specific abdominal discomfort. Related hepatobiliary or pancreatic disease frequently precedes recognition, and may complicate the postoperative course. Surgical treatment aims to relieve complications deriving from the cysts and to reduce the significant risk of malignant change within the biliary tree. Complete cyst resection, cholecystectomy and Roux-en-Y hepaticojejunostomy reconstruction is standard. Controversy exists about the role of hepatic resection in type IV and V cysts, and the role of minimally invasive and laparoscopic treatment. In general, the outcome is good and a near-zero mortality rate has been reported in institutional series over the past decade.     

腹腔镜胆囊切除致胆道损伤26例分析

目的 探讨腹腔镜抻囊切除术(laparoscopic cholecystectomy,LC)致胆管损伤的原因、类型、临床表现、诊断及处理原则. 方法回顾性分析1997-2007年收治的26例LC致胆管损伤的临床资料.结果 胆管损伤Ⅰ型5例、Ⅱ型13例、Ⅲ型2例、Ⅳ型6例;3例术中发现胆管损伤并中转开腹,23例术后发现胆管损伤,其中13例为LC术后1周内发现,8例为术后20～60 d发现,2例在术后2年表现反复胆管炎发作的症状;24例接受介入治疗,其中5例获得治愈,19例在胆管炎和黄疸控制后获得手术;切除毁损胆管20例,行肝总管或左右肝管的胆肠吻合术.结论 胆道损伤是严重的LC术后并发症,应高度警惕.合理运用介入或手术的方法及时进行必要的胆管内支撑和通畅的胆汁外引流,应避免再次医源性损伤和修补术后胆道再狭窄.     

Bile duct disruption by blunt trauma

The rarity of bile duct injury secondary to blunt abdominal trauma leads to frequent delays in diagnosis and inappropriate management. An illustrative case is therefore described and 94 reported cases are reviewed. In 53% of patients, operation was delayed more than 24 hours. Early clinical findings of hypovolemia and acute abdomen are related to associated injuries. Late findings are abdominal distention and jaundice due to the biliary injury. Early diagnosis is facilitated by diagnostic paracentesis. Patients operated on during the first 24 hours after the injury had a statistically higher incidence of bile duct injury distal to the cystic duct (p less than 0.05) and of complete ductal severance (p less than 0.05). The association of location distal to the cystic duct and complete severance was highly significant (p less than 0.001). Management should include biliary exploration. Cholangiography using concentrated water-soluble contrast agents may help to find the anatomy of obscure injuries. The choice of surgical repair must be individualized according to the location and the magnitude of the injury.     

Bile duct complications after laparoscopic cholecystectomy

Summary A retrospective review and analysis of patients referred to the Division of Gastroenterology and the Section of Gastrointestinal Surgery with common bile duct complications after laparoscopic cholecystectomy was undertaken in order to identify injury patterns, management, and outcome. Sixteen patients were identified over a 20-month period. Twelve patients had major common bile duct injuries and four had minor injuries (cystic duct leaks). Seventy-one percent of injuries occurred with surgeons who had done more than 13 laparoscopic cholecystectomies. Eighty-three percent of patients who had major ductal injury did not have a cholangiogram prior to the injury. Sixteen percent of patients with major common bile duct injuries had findings of acute cholecystitis and 58% of these major injuries were easy gallbladders. One-third of major injuries were recognized at operation. Two-thirds of immediate repairs failed. All cystic duct leaks were managed nonoperatively.It appears that bile duct complications after laparoscopic cholecystectomy are more common in the community than is reported. Bile duct complications occur with surgeons who are experienced and inexperienced with laparoscopic cholecystectomy. Common bile duct injuries, unrecognized at laparoscopic cholecystectomy in the majority of cases, usually occur with easy gallbladders. Operative cholangiography is not utilized in the majority of common bile duct injuries. When immediate repair of common bile duct injuries is undertaken, the majority are unsuccessful. Endoscopic retrograde cholangiopancreatography (ERCP) is invaluable in the diagnosis and management of bile duct complications. Cystic duct leaks may be managed successfully with endoscopic stents.Presented at the annual SAGES meeting, April 10–12, 1992, Washington, D.C.     

Bile duct reconstruction in liver transplantation

Complications of the biliary anatomosis are common after liver transplantation. Even with improved techniques the frequency of biliary complications is approximately ten percent. Main reason for this high morbidity rate is the unfavourable blood supply to the biliary tract. A variant of reconstructions has been described and recommended. The end-to-end-choledochocholedochostomy over a T tube turned out to be the preferred technique in most centers. In cases of different diameter of donor and recipient biliary tract, the side-to-side-choledochocholedochostomy provides a relayable alternative method. When the length of the bile duct doesn't allow direct anastomosis, the gallbladder-conduit may help to overcome this problem. The choledochojejunostomy with Roux-en-Y loop has become a frequently used biliary anastomosis, especially when the recipients bile duct is absent or otherwise destroyed. - Our own experience with fourteen liver transplantations shows biliary tract complications in three cases: a leakage and a stenosis of the anastomosis after choledochocholedochostomy were successfully transformed to a hepaticojejunostomy. In the third case, intrahepatic biliary stenosis were treated by percutaneous transhepatic dilatation.     

胆道疾病与肝脏移植

一些胆道疾病是肝移植的主要适应证，在国外约占肝移植总数的40%。近些年，肝胆系统恶性肿瘤行肝移植的比例明显减少，各种难治愈性良性胆道疾病的比例显著增加。随着胆道外科和移植外科的发展，两者的关系日益密切。一些胆道疾病既是肝移植的主要适应证，也是肝移植后常见并发症。本文将重点讨论肝移植对胆道疾病的治疗效果。     

Bile duct injuries during laparoscopic cholecystectomy

Surgical Endoscopy -     

Bile duct injury after laparoscopic cholecystectomy

Background: Forty series reporting experience with laparoscopic cholecystectomy in the United States from 1989 to 1995 were reviewed. A total of 114,005 cases were analyzed and 561 major bile duct injuries (0.50%) and 401 bile leaks from the cystic duct or liver bed (0.38%) were recorded. Intraoperative cholangiography (IOC) was attempted in 41.5% of the laparoscopic cholecystectomies and was successful in 82.7%. In major bile duct injuries, the common bile duct/common hepatic duct were the most frequently injured (61.1%) and only 1.4% of the patients had complete transection. Methods: When reported, most of the bile duct injuries were managed surgically with a biliary-enteric anastomosis (41.8%) or via laparotomy and t-tube or stent placement (27.5%). The long-term success rate could not be determined because of the small number of series reporting this information. The management for bile leaks usually consisted of a drainage procedure (55.3%) performed endoscopically, percutaneously, or operatively. Results: The morbidity for laparoscopic cholecystectomy, excluding bile duct injuries or leaks, was 5.4% and the overall mortality was 0.06%. It was also noted that the conversion rate to an open procedure was 2.16%. Conclusions: It is concluded based on this review of laparoscopic cholecystectomies that the morbidity and mortality rates are similar to open surgery. In addition, the rate of bile duct injuries and leaks is higher than in open cholecystectomy. Furthermore, bile duct injuries can be minimized by lateral retraction of the gallbladder neck and careful dissection of Calot's triangle, the cystic duct–gallbladder junction, and the cystic duct–common bile duct junction. Received: 24 September 1996/Accepted: 28 July 1997     

Bile duct injuries during laparoscopic cholecystectomy

Background: With the introduction of laparoscopic cholecystectomy, an increase in the incidence of bile duct injury two to three times that seen in open cholecystectomy was witnessed. Although some of these injuries were blamed on the ``learning curve,' many occurred long after the surgeon had passed his initial experience. We are still seeing these injuries today. Methods: To better understand the mechanism behind these injuries, in the hope of reducing the injury rate, 177 cases of bile duct injury during laparoscopic cholecystectomy were reviewed. All records were studied, including the initial operative reports and all subsequent treatments. Videotapes of the procedures were available for review in 45 (25%) of the cases. All X-ray studies, including interoperative cholangiograms and ERCPs, were reviewed. Results: The vast majority of the injuries seen in this review (71%) were a direct result of the surgeon misidentifying the anatomy. This misidentification led to ligation and division of the common bile duct in 116 (65%) of the cases. Cholangiograms were performed in only 18% (32 patients) of cases, and in only two patients was the bile duct injury recognized as a result of the cholangiogram. Review of the X-rays showed that in each instance of common bile duct ligation and transection in which a cholangiogram was performed the impending injury was in evidence on the X-ray films but ignored by the surgeon. Conclusions: From this review, several conclusions can be drawn. First and foremost, the majority of bile duct injuries seen with laparoscopic cholecystectomy can either be prevented or minimized if the surgeon adheres to a simple and basic rule of biliary surgery; NO structure is ligated or divided until it is absolutely identified! Cholangiography will not prevent bile duct injury, but if performed properly, it will identify an impending injury before the level of injury is extended. And lastly, the incidence of bile duct injury is not related to the laparoscopic technique but to a failure of the surgeon to translate his knowledge and skills from his open experience to the laparoscopic technique. Received: 14 May 1996/Accepted: 1 July 1996