Management of biliary duct confluence injuries produced by hepatic hydatidosis

From 1978 to 1999 a total of 850 patients underwent surgical treatment for hydatid disease of the liver at our surgical department. Biliary duct confluence injuries produced by hepatic hydatidosis (HH) were founded in six patients (0.7%). Surgical intervention was undertaken to relieve the obstructive jaundice and clinical manifestations of cholangitis and to treat the hydatid cyst. A partially open cystopericystectomy technique was used in three patients with a double bilioenteric Roux-en-Y reconstruction. The remaining three patients (two with prehepatic portal hypertension and one with triple hepatic duct confluence) were subjected to a cystojejunostomy. There were no hospital deaths. Two cases of anastomotic leakage following a high bilioenteric anastomosis occurred but did not require surgical treatment. During the follow-up (5–19 years) one patient suffered local recurrence of the hydatid disease 7 years after cystojejunostomy. The site of intrahepatic biliary and vascular involvement, the presence of biliary duct anomalies, and the presence of portal hypertension are decisive factors when choosing the “ideal” procedure for reconstruction. Conservative surgical approaches (partial cystectomy and cystojejunostomy) are the treatments of choice. Radical surgery is often a serious matter.     

Early versus late repair of bile duct injuries

Biliary injuries associated with laparoscopic cholecystectomy occur at a constant rate of 0.3% to 0.6%. The spectrum of injures ranges from small leaks of bile to complete section of the main ducts requiring bilioenteric reconstruction. The goal of biliary reconstruction is to obtain a high-quality bilioenteric anastomosis that will not malfunction for a long time. No prospective, controlled, randomized trial (evidence level 1) has been conducted that shows whether an early repair is better than a late one. The timing of the operative procedure should be individualized. A complete examination of the patient should be performed to identify the type of injury and coexistent comorbidities. For septic patients and those with multiple organ dysfunction syndrome, the repair should be delayed. Maneuvers to drain the bile ducts can be performed to relieve jaundice and cholangitis in these patients. For these cases, the surgery should be delayed. If a stable patient is found, without comorbidities, the operation can be scheduled earlier. Subhepatic drains should not be left for a long period because of the risk for intestinal fistulization. If needed, they should be changed for transhepatic stents. High-quality bilioenteric anastomoses are performed with fine absorbable sutures for healthy ducts (nonscarred, noninflamed, nonischemic) in a wide opening, with anastomosis of a (tension-free) defunctionalized jejunal limb. Individualization of the patient is the best rule.     

Operative ultrasonic bile duct scanning.

The concept of operative echography is introduced. A technique of operative ultrasonic bile duct visualization is presented as an alternative to contrast cholangiography during surgery. The technique is rapid, sensitive, provides immediate results, and does not involve the use of ionizing radiation.     

Laparoscopic bile duct injuries. Risk factors, recognition, and repair.

Records of 11 patients undergoing biliary reconstruction after laparoscopic cholecystectomy are reviewed. Ductal injuries resulted from failure to define the anatomy of Calot's triangle. Risk factors include scarring, acute cholecystitis, and obesity. Presenting findings included anorexia, ileus, failure to thrive, pain, ascites, and jaundice. All patients required hepaticojejunostomies, which were multiple and above the hepatic bifurcation in four patients. Given the extensive nature of these injuries and the frequent need for intrahepatic anastomosis and early stenosis of repairs by referring physicians, we recommend reconstruction be undertaken by an experienced hepatobiliary surgeon. To avoid injuries, a greater appreciation of risk factors and anatomic distortion and variance and strict adherence to principles of dissection and identification of anatomic structures are suggested. The use of cholangiography and a low threshold for conversion to the open procedure are advised.     

Iatrogenic bile duct injury with loss of confluence

AIM: To describe our experience concerning the surgical treatment of Strasberg E-4(Bismuth Ⅳ) bile duct injuries. METHODS: In an 18-year period, among 603 patients referred to our hospital for surgical treatment of complex bile duct injuries, 53 presented involvement of the hilar confluence classified as Strasberg E4 injuries. Imagenological studies, mainly magnetic resonance imaging showed a loss of confluence. The files of these patients were analyzed and general data were recorded, including type of operation and postoperative outcome with emphasis on postoperative cholangitis, liver function test and quality of life. The mean time of follow-up was of 55.9 ± 52.9 mo(median = 38.5, minimum = 2, maximum = 181.2). All other patients with Strasberg A, B, C, D, E1, E2, E3, or E5 biliary injuries were excluded from this study.RESULTS: Patients were divided in three groups: G1(n = 21): Construction of neoconfluence + Roux-en-Y hepatojejunostomy. G2(n = 26): Roux-en-Y portoenterostomy. G3(n = 6): Double(right and left) Rouxen-Y hepatojejunostomy. Cholangitis was recorded in two patients in group 1, in 14 patients in group 2, and in one patient in group 3. All of them required transhepatic instrumentation of the anastomosis and six patients needed live transplantation.CONCLUSION: Loss of confluence represents a surgicalchallenge. There are several treatment options at different stages. Roux-en-Y bilioenteric anastomosis(neoconfluence, double-barrel anastomosis, portoenterostomy) is the treatment of choice, and when it is technically possible, building of a neoconfluence has better outcomes. When liver cirrhosis is shown, liver transplantation is the best choice.     

Operative choledochoscopy in common bile duct surgery.

Surgical exploration of the common bile duct for gallstones is a common operation but carries a high residual stone rate. Conventional techniques for exploring the bile ducts are blind procedures. The surgeon cannot see what he is doing. Also there has been no reliable method for a postexploratory check of the bile ducts before closure, usually around a T-tube. Operative choledochoscopy allows the surgeon to see stones in the duct, may aid the removal of stones and provides visual postexploratory checks that the common bile duct and the hepatic ducts are clear, that papilla is patent and that no stone is left behind before closure. A personal series of 150 patients had operative choledochoscopy using a flexible fibreoptic choledochoscope. If there was a clear indication on preoperative investigations that the ducts should be explored, an operative cholangiogram was omitted and the choledochoscope used as the exploring instrument. In 127 patients with a diagnosis of gallstone disease, choledochoscopy was used at the primary operation. In 12 patients choledochoscopy was used at a secondary operation for recurrent gallstone disease, and 11 patients had malignant obstruction of the biliary tract. In 70 of the 127 patients, gallstones were found and extracted using the choledochoscope. In 53 patients the ducts were clear, and in 4, other lesions were found: 3 papillomas and one polycystic disease. One hundred and six of the patients had the common bile duct closed primarily with no T-tube drainage. There was no increase in complications and no deaths associated with choledochoscopy or primary closure of the common bile duct.(ABSTRACT TRUNCATED AT 250 WORDS)     

Iatrogenic bile duct injuries

During a 25-year period (1959–1984), 42 patients with iatrogenic bile duct damage were referred. Before referral, 11 patients had no attempt at reconstruction, while 31 had undergone 41 operations to repair the damage. At admission, 4 patients had secondary biliary cirrhosis, 1 had portal vein thrombosis, and 1 had sepsis. The entire extrahepatic duct system had been resected in 1 patient, and operative treatment includes 41 patients. Fifty-two operations have been performed, and 34 patients (83%) have had an excellent long-term result, median 13 years. Five patients had 4 operations or more (before and after referral), and 3 are alive in good condition. Various methods of repair were employed, and 8 patients (20%) had recurrence of stricture. Restricture was lowest for hepaticojejunostomy Roux-en-Y (15%), in particular when no stent was used across the anastomosis (8%). The hospital mortality rate was 2 (5%) of 41 and overall mortality, 7 (17%) of 41. The lowest mortality rate (9%) was associated with hepaticojejunostomy Roux-en-Y. Low rate of recurrence and mortality are correlated to early referral. Patients who had restricture or died were referred a median 5 and 7 months, respectively, later than those who did well. Mortality was also related to serious complications at the time of referral and lack of follow-up. Patients with iatrogenic bile duct injury should be referred early to a competent center, where adequate treatment of infection, reconstruction with a hepaticoje-junostomy Roux-en-Y without stenting, and lifelong follow-up can be performed.

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Resumen En el curso de un período de 25 años (1959-1984), fueron referidos 42 pacientes con lesión iatrogénica del conducto biliar. Anterior a la referencia, 11 no habfan sido sometidos a reconstruction, mientras 31 habfan sido sometidos a 41 operaciones para reparar la lesión. En el momento de la admisión, 4 pacientes presentaban cirrosis biliar secundaria, 1 presentaba trombosis de la vena porta, y 1, sepsis. La totalidad del sistema ductal extrahepático había sido resecado en 1 paciente; el tratamiento operatorio fue realizado en los 41 pacientes. Cincuenta y dos operaciones fueron realizadas, y 34 pacientes (83%) han tenido un excelente resultado a largo plazo, en un seguimiento promedio de 13 años. Cinco pacientes recibieron 4 operaciones o más (antes y después de la referencia), y 3 están vivos y en buena conditión. Varios métodos de reparatión han sido empleados; 8 pacientes (20%) desarrollaron recurrencia de la estrechez. La tasa de recurrencia fue más baja para la hepaticoyeyunostomía de Roux-en-Y (15%), particularmente cuando no se utilizó una prótesis a través de la anastomosis (8%). La mortalidad hospitalaria fue de 2 entre 41 casos (5%) y la mortalidad global de 7 entre 41 (17%). La menor mortalidad (9%) se observó en los pacientes sometidos a hepaticoyeyunostomía de Roux-en-Y. Bajas tasas de recurrencia y de mortalidad aparecen correlacionadas con una referencia temprana. Los pacientes con estrechez recurrente y aquellos que murieron, tuvieron una referencia promedio de 5 y 7 meses respectivamente, más tardía que aquella de los pacientes que evolucionaron bien. La mortalidad también aparece relacionada con complicaciones serias en el momento de la referencia y con falta de seguimiento. Los pacientes con lesión iatrogénica del conducto biliar deben ser referidos precozmente a un centro de reconocida competencia, donde se pueda realizar el tratamiento adecuado de la infectión, la reconstrucción mediante hepáticoyeyunostomía de Roux-en-Y sin prótesis intraluminales, y un seguimiento por el resto de la vida del paciente.

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Résumé Pendant une période de 25 ans (1959 à 1984), 42 patients présentant une lésion biliaire iatrogénique ont été adressés aux auteurs. Auparavant, 11 n'avaient subi aucune intervention réparatrice alors que 31 d'entre eux avaient subi une ou plusieurs interventions (41 opérations pour 31 malades). Lors de l'admission, 4 malades présentaient une cirrhose biliaire secondaire, 1 accusait une thrombose de la veine porte, 1 était en proie à une infection. Chez 1 des 41 sujets la totalité de l'arbre biliaire extra-hépatique avait été réséqué. Au total 41 malades sur 42 ont été opérés. Cinquante-deux opérations ont été accomplies. Trente-quatre opérés (83%) ont eu un bon résultat à long terme (médiane: 13 ans), cinq patients ont subi 4 opérations ou plus (avant ou après l'admission), et 3 sont en excellente santé. Différentes opérations reconstructives ont été pratiquées et 8 malades (20%) ont été victimes d'une récidive de la sténose. La nouvelle sténose fut plus rare après hépaticojé-junostomie sur anse en Y à la Roux, en particulier lorsque l'anastomose avait été effectuée sans drain interne (8%). La mortalité hospitalière a été de 5% (2 malades décédés) et la mortalité globale de 17% (7 malades décédés). La mortalité la plus basse (9%) a été observée après hépatico-jéjunostomie. Le taux le plus bas de récidive et de mortalité a été constaté quand le malade a été adressé rapidement, en effet les malades qui ont présenté une récidive ou qui sont morts, ont été reÇus respectivement 5 à 7 mois plus tard après l'origine de la lésion que ceux qui eurent des suites favorables. La mortalité fut fonction aussi de l'existence de complications au moment de l'admission ou de l'absence de suivi après l'intervention initiale. En conclusion, les malades qui sont victimes d'une lésion iatrogénique des voies biliaires doivent Être adressés rapidement à un centre spécialisé ou un traitement adéquat de l'infection, une reconstruction biliaire par hépatico-jéjunostomie sans drain tuteur et un suivi prolongé toute la vie peuvent Être entrepris.

     

Iatrogenic bile duct injuries

Background: The real incidence of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is not known. Methods: Using questionnaires, we analyzed 91,232 LC performed by 170 surgical units in Brazil between 1990 and 1997. Results: A total of 167 BDI occurred (0.18%); the most frequent were Bismuth type 1 injuries (67.7%). Most injuries (56.8%) occurred at the hands of surgeons who had surpassed the learning curve (50 operations). However, the incidence dropped with increasing experience; it was 0.77% at surgical departments with <50 operations vs 0.16% at departments with >500 operations. The diagnosis was made intraoperatively in 67.7%, but it was based on intraoperative cholangiography in only 19.5%. The procedure was converted to open surgery in 85.8% when the diagnosis of injury occurred intraoperatively, and laparotomy was performed in 90.7% when the injury was diagnosed postoperatively. The mean hospitalization time was 7.6 ± 5.9 days, the major complications were stenosis and fistulas, and the mortality rate was 4.2%. Conclusion: The incidence of BDI after LC is similar to that reported for the open procedure. BDI increases mortality and morbidity and prolongs hospitalization; therefore, all efforts should be made to reduce its incidence.     

Granular cell myoblastoma involving the common bile duct.

Three cases of granular cell myoblastoma involving the large bile ducts are reported. Two of the patients were proved to have multifocal tumors. These tumors may clinically simulate sclerosing adenocarcinomas. Technical difficulties with these tumors for the consulting pathologist are discussed.     

胆道损伤的处理

目的 探讨胆道损伤的分类和临床特点。方法 回顾性分析临床资料，72例胆道损伤中，医源性49例，外伤性23例(胆总管下段损伤5例，胆总管上段／肝总管损伤50例，肝内胆管损伤17例)，经局部缝合、组织修补、胆肠吻合等方式治疗。结果 全组发生胆漏2例，死于胆道感染、出血2例；随访66例，发现胆道狭窄4例，结石复发3例。结论 应努力避免和及时发现胆道损伤，根据损伤部位、类型、程度、特点分类，采取不同方式修复胆道损伤，并保证修复后胆道血供良好。     

Repair of bile duct injuries

Twenty-two patients with surgical injury to the common hepatic duct or common bile duct were evaluated. In 20 patients the injury occurred during cholecystectomy and resulted from mistaken identification of the common duct for the cystic duct. Roux-en-Y hepaticojejunostomy was performed in 21 patients. Three of the anastomoses were end-to-side, while 18 were side-to-side. Choledochoduodenostomy was performed in 1 patient. There were no operative deaths in the 22 patients. Four (18%) patients developed wound infections and in 2 (9%) patients there was a transient bile leak. Two patients died of liver failure due to irreversible biliary cirrhosis 2 and 3 years after the initial injury. All patients in whom side-to-side Roux-en-Y hepaticojejunostomy was performed as a first procedure (14 cases) had a successful long-term result with no signs of cholangitis or anastomotic stenosis. The 3 patients with end-to-side hepaticojejunostomy developed anastomotic stricture with repeated attacks of cholangitis and required secondary operations. The patient treated by choledochoduodenostomy had a satisfactory result. Patients with iatrogenic bile duct injury can be managed with a high degree of success if referred early and treated appropriately.

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Resumen Veintidos pacientes con lesiones quirÚrgicas del canal hepático comÚn o del canal colédoco fueron evaluados. En 20 pacientes la lesión ocurrió en el curso de una colecistectomía y fue el resultado de error en la identificación del hepático comÚn o del cístico. Se realizó hepático-yeyunostomía de Roux-en-Y en 21 casos; tres de las anastomosis fueron término-laterales, mientras 18 fueron látero-laterales.No se presentó mortalidad operatoria en los 22 pacientes. Cuatro (18%) casos desarrollaron infección de la herida y en 2 (9%) casos ocurrió escape transitorio de bilis. Dos pacientes murieron de falla hepática debida a cirrosis biliar irreversible, dos y très años después de la lesión inicial. Todos los pacientes en quienes se realizó hepático-yeyunosto-mía látero-lateral de Roux-en-Y como procedimiento primario (14 casos) presentaron un resultado exitoso a largo plazo, sin signos de colangitis o de estrechez de la anastomosis. Los 3 casos con hepático-yeyunostomía término-lateral desarrollaron estrechez de la anastomosis con ataques repetidos de colangitis que requirieron una segunda operación. El caso tratado con colédoco-duodenostomía tuvo un resultado satisfactorio.Los pacientes con lesión iatrogénica del conducto biliar pueden ser manejados con un alto grado de éxito si son prontamente referidos y tratados en forma apropiada.

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Résumé Les lésions traumatiques iatrogènes des voies biliaires extra-hépatiques sont le fait le plus souvent des cholecystectomies mais elles peuvent s'observer également lors des cholédocotomies ou des gastrectomies difficiles pour ulcère duodénal postérieur térébrant. Il est capital de prévenir ces complications redoutables pour l'exposition méticuleuse de la voie biliaire principale au cours de la chirurgie biliaire ou de la chirurgie gastrique. La blessure des voies biliaires extra-hépatiques doit être traitée précocément avant la constitution de lésions irréversibles du parenchyme. Pour ce faire il convient d'adresser le blessé dans un centre spécialisé où sera pratiquée une hépatico-jéjunostomie sur une anse jéjunale longue montée en Y, l'anastose portant sur le moignon sain du canal hépatique commun et le canal hépatique gauche suivant la technique de Hepp.

     

Truncoumbilical bypass of the portal vein in radical resection of biliary tract tumour involving the hepatic duct confluence

Before combined resection of the right hepatic lobe and the hepatoduodenal ligament, an autogenous external iliac vein was interposed between the root of the portal vein trunk and the umbilical portion of the vein in four patients with biliary tract tumour. The left hepatic arterial pathway was preserved, except in one case in whom resection of this artery was followed by reconstruction. This procedure allowed successful and safe extended right hepatic lobe resection and combined en bloc resection of the hepatoduodenal ligament while preserving hepatic blood perfusion.     

Ten-year trend in the national volume of bile duct injuries requiring operative repair

Background The objectives of this study were to determine the national proportions and mortality rate for bile duct injuries resulting from laparoscopic cholecystectomy (LC) that required operative reconstruction for repair over a 10-year period and to investigate the major factors associated with the mortality rate in this group of patients.Methods Using the Nationwide Inpatient Sample (NIS) of >7 million patient records per year, we extracted and analyzed data for LC during the years 1990–2000. Procedures that involved biliary reconstructions performed as part of another primary procedure were excluded. Using the Statistical Package for the Social Sciences (SPSS), we used procedure-specific codes that enabled us to calculate national estimates for LC for the time period under review. We then calculated biliary reconstruction procedures that occurred after LC for this cohort of patients. Finally, we analyzed in-hospital mortality, as well as the patient, institutional, and outcome characteristics associated with biliary reconstructions.Results The percentage of cholecystectomies performed laparoscopically has increased over the years for which data are available (from 52% in 1991 to 75% in 2000). Despite this increase, the mortality rate for this group of patients has remained consistently low over the study period (mean, 0.45%; range 0.33–0.58%). Within this group of patients, the average rate of bile duct injuries requiring operative repair was 0.15% for the years under study. The reconstruction rates ranged from 0.25% in 1992 to 0.09% in 1999. For 2000, the most recent year for which data are available, biliary reconstruction was performed in 0.10% of all patients who underwent LC. The average mortality rate for patients undergoing biliary reconstruction for the years 1991 to 2000 was 4.5%. After multivariate analysis, age, African American ethnicity, type of admission, source of admission, and hospital location, and teaching status were all found to correlate significantly with death after-biliary reconstruction.Conclusions These data show an increase in the percentage of cholecystectomies performed laparoscopically over the years under study and an associated low mortality rate. In contrast, although the number of bile duct injuries appears to be decreasing, these procedures continue to be associated with a significant mortality rate.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Scientific Session, Denver, CO, USA, 31 March–4 April 2004     

Long-term results of surgical repair of bile duct injuries following laparoscopic cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy (LC) is associated with an increased incidence of bile duct injuries when compared with the open surgical technique. Long-term results of repaired injuries and hepatic damage associated with chronic biliary obstruction are lacking. METHODS: From Aug 1, 1991 until Dec 1, 1999, there were 27 patients referred for management of complex biliary injuries that occurred during LC. Patients underwent percutaneous transhepatic cholangiography and placement of transhepatic catheters with computed tomography-guided biloma drainage when indicated. On the basis of the cholangiography findings, patients underwent Roux-en-Y hepaticojejunostomy (HJ) and liver biopsy or were treated with nonsurgical interventions. RESULTS: Twenty-one of 27 patients (77. 8%) underwent HJ, and 16 of these 21 patients (76.2%) also underwent hepatic biopsy. In 1 patient, a recurrent stricture developed at 20 months after the initial repair; and, in a second patient, an episode of cholangitis developed in the postoperative period with the transhepatic catheters in place. Five of 16 patients (31.2%) demonstrated marked hepatic fibrosis with 4 (25%) of these patients showing evidence of evolving cirrhosis at the time of HJ. CONCLUSIONS: In this series with 55 months of follow-up, HJ repair of LC injuries was associated with an initial 95.2% success rate and an ultimate success rate of 100%. Despite this, delayed referral, averaging 12 months, was associated with significant hepatic injury in 5 of 16 (31.3%) patients who underwent biopsy.     

Complications following repair of extrahepatic bile duct injuries after blunt abdominal trauma

Extrahepatic bile duct traumatic injuries are extremely rare and their treatment is difficult and with several controversies. The aim of this study was to offer some more clinical information on their surgical repair and outcome. We present seven patients with extrahepatic biliary tract lesions after blunt abdominal trauma, (isolated gallbladder lesions were excluded) four males and three females from 23 to 51 years of age (mean age 35.1 years). All patients had suffered high-energy blunt abdominal trauma and presented associated injuries, mostly liver trauma and lung contusions. Six gallbladder lesions and six common bile duct injures were identified; a right hepatic duct laceration and a left hepatic duct transection were also present. Injuries were treated either with primary repair or with duct-jejunal anastomoses with Roux-en-Y reconstruction. Principal complications were postoperative anastomotic leakage (1 case) and recurrent cholangitis (3 cases) with or without stricture. Not-diagnosed injuries caused substantial morbidity. We prefer and recommend the use of primary repair in partial ruptures with no significant tissue loss and biliary-enteric anastomoses in large injuries and complete transections because they offer the best long-term drainage with less risk of stricture formation than end-to-end anastomoses. We defend the use of long duration (6 to 9 months) transanastomotic stents.