New classification of the anatomic variations of cystic artery during laparoscopic cholecystectomy

AIM： To investigate the anatomic variations in the cystic artery by laparoscopy, and to provide a new classification system for the guidance of laparoscopic surgeons.METHODS： Six hundred patients treated with laparoscopic cholecystectomy from June 2005 to May 2006 were studied retrospectively, The laparoscope of 30° （Stryker, American） was applied, Anatomic structures of cystic artery and conditions of Calot＇s triangle under laparoscope were recorded respectively,RESULTS： Laparoscopy has revealed there are many anatomic variations of the cystic artery that occur frequently. Based on our experience with 600 laparoscopic cholecystectomies, we present a new classification of anatomic variations of the cystic artery, which can be divided into three groups： （1） Calot＇s triangle type, found in 513 patients （85.5%）; （2） outside Calot＇s triangle, found in 78 patients （13%）; （3） compound type, observed in 9 patients （1.5%）.CONCLUSION： Our classification of the anatomic variations of the cystic artery uncontrollable cystic artery extrahepatic bile duct injury. will be useful for decreasing hemorrhage, and avoiding extrahepatic bile duct injury.     

A three‐step conceptual roadmap for avoiding bile duct injury in laparoscopic cholecystectomy: an invited perspective review

Bile duct injuries are the most common serious complication of cholecystectomy. Avoidance of bile duct injury is a key aim of biliary surgery. The purpose of this paper is to describe laparoscopic cholecystectomy from the viewpoint of three conceptual goals. Three conceptual goals of cholecystectomy are: (1) getting secure anatomical identification of key structures; (2) making the right decision not to perform a total cholecystectomy when conditions are too dangerous to get secure identification – the “inflection point”; and (3) finishing the operation safely when secure anatomical identification of cystic structures is not possible. The Critical View of Safety (CVS) has been shown to be a good way of getting secure anatomical identification. Conceptually, CVS is a method of target identification, the targets being the two cystic structures. Sometimes, anatomic identification is not possible because the risk of biliary injury is judged to be too great. Then a decision is made to abandon the attempt to do a complete cholecystectomy – and instead to “bail‐out”. This “inflection point” is defined as the moment at which the decision is made to halt the attempt to perform a total cholecystectomy laparoscopically and to finish the operation by a different method. Currently the best bail‐out procedure seems to be subtotal fenestrating cholecystectomy. Application of conceptual goals of cholecystectomy can help the surgeon to avoid biliary injury.     

Pre-operative endoscopic ultrasonography can optimise the management of patients undergoing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocholithiasis: a prospective study

BACKGROUND: Pre-operative endosonography has been proposed as a cost-effective procedure in the management of patients who undergo laparoscopic cholecystectomy having an intermediate risk of common bile duct stones. We prospectively evaluated the impact of pre-operative endosonography on the management of patients facing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocolithiasis. METHODS: Among 587 consecutive patients scheduled for laparoscopic cholecystectomy, 47 (8%) patients having one or more abnormal liver function tests but a normal appearance of common bile duct at abdominal ultrasound, underwent pre-operative endosonography. In patients with endosonography-detected common bile duct stones, a pre-operative endoscopic retrograde cholangiography was performed, or an intra-operative endoscopic retrograde cholangiography was scheduled. In all endosonography-negative patients, an intra-operative trans-cystic cholangiography was performed. RESULTS: Endosonography detected common bile duct stones in nine patients (19%) but only in five of them stones were radiologically confirmed (PPV 0.55). Endosonography-detected stones were confirmed in four of four (100%) patients in whom cholangiography was performed within 1 week, but only in one of five (20%) patients in whom radiology was further delayed (P < 0.05). In three of four cases (75%), stones detected at endosonography but not confirmed at X-rays, were smaller than 2.0 mm. Among 38 patients with negative endosonography, common bile duct stones were found in two patients (NPV 0.95), whereas unplanned endoscopic stone extraction was needed only in one patient (NPV 0.97). CONCLUSIONS: Pre-operative endosonography can spare unnecessary pre-operative endoscopic retrograde cholangiography as well as inappropriate scheduling of intra-operative endoscopic retrograde cholangiography in patients undergoing laparoscopic cholecystectomy with abnormal liver function tests. To maximise the impact of endosonography on the management of these patients, the procedure should be performed immediately before laparoscopic cholecystectomy.     

Managing injuries of hepatic duct confluence variants after major hepatobiliary surgery： An algorithmic approach

AIM：To investigate injuries of anatomy variants of hepatic duct confluence during hepatobiliary surgery and their impact on morbidity and mortality of these procedures. An algorithmic approach for the management of these injuries is proposed.
METHODS：During a 6-year period 234 patients who had undergone major hepatobiliary surgery were retrospectively reviewed in order to study postoperative bile leakage. Diagnostic workup included endoscopic and magnetic retrograde cholangiopancreatography （E/MRCP）, scintigraphy and fistulography.
RESULTS：Thirty （12.8%） patients who developed postoperative bile leaks were identified. Endoscopic stenting and percutaneous drainage were successful in 23 patients with bile leaks from the liver cut surface. In the rest seven patients with injuries of hepatic duct confluence, biliary variations were recognized and a stepwise therapeutic approach was considered. Conservative management was successful only in 2 patients. Volume of the liver remnant and functional liver reserve as well as local sepsis were used as criteria for either resection of the corresponding liver segment or construction of a biliary-enteric anastomosis. Two deaths occurred in this group of patients with hepatic duct confluence variants （mortality rate 28.5%）.
CONCLUSION：Management of major biliary fistulaethat are disconnected from the mainstream of the biliary tree and related to injury of variants of the hepatic duct confluence is extremely challenging. These patients have a grave prognosis and an early surgical procedure has to be considered.     

Common bile duct injury by fibrin glue: Report of a rare complication

Fibrin glue is widely used in clinical practice and plays an important role in reducing postoperative complications.We report a case of a 65-year-old man, whose common bile duct was injured by fibrin glue, with a history of failed laparoscopic cholecystectomy and open operation for uncontrolled laparoscopic bleeding.In view of thepersistent liver dysfunction, xanthochromia and skin itching, the patient was admitted to us for further management.Ultrasound, computed tomography, and magnetic resonance cholangiopancreatography(MRCP) revealed multiple stones in the common bile duct, and liver function tests confirmed the presence of obstructive jaundice and liver damage.Endoscopic retrograde cholangiopancreatography was unsuccessfully performed to remove choledocholithiasis, but a small amount of tissue was removed and pathologically confirmed as calcified biliary mucosa.This was followed by open surgery for suspicious cholangiocarcinoma.There was no evidence of cholangiocarcinoma, but the common bile duct wall had a defect of 8 mm × 10 mm at Calot’s triangle.A hard, grid-like foreign body was removed, which proved to be solid fibrin glue.Subsequently, the residual choledocholithiasis was removed by a choledochoscopic procedure, and the common bile duct deletion was repaired by liver round ligament with T-tube drainage.Six months later, endoscopy was performed through the T-tube fistula and showed a well-repaired bile duct wall.Eight months later, MRCP confirmed no bile duct stenosis.A review of reported cases showed that fibrin glue is widely used in surgery, but it can also cause organ damage.Its mechanism may be related to discharge reactions.     

Experience using liver transplantation for the treatment of severe bile duct injuries over 20 years in Argentina: results from a National Survey

BackgroundBile duct injury (BDI) is a severe complication that may arise during the surgical treatment of benign disease and a few patients will develop end-stage liver disease (ESLD) requiring a liver transplant (LT).ObjectiveAnalyse the experience using LT as a definitive treatment of BDI in Argentina.Patients and MethodsA national survey regarding the experience of LT for BDI.ResultsSixteen out 18 centres reported a total of 19 patients. The percentage of LT for BDI from the total number of LT per period was: 1990–94 = 3.1%, 1995–99 = 1.6%, 2000–04 = 0.7% and 2005–09 = 0.2% (P < 0.001). The mean age was 45.7 ± 10.3 years (range 26–62) and 10 patients were female. The BDI occurred during cholecystectomy in 16 and 7 had vascular injuries. One patient presented with acute liver failure and the others with chronic ESLD. The median time between BDI and LT was 71 months (range 0.2–157). The mean follow-up was 8.3 years (10 months to 16.4 years). Survival at 1, 3, 5 and 10 years was 73%, 68%, 68% and 45%, respectively.ConclusionsThe use of LT for the treatment of BDI declined over the review period. LT plays a role in selected cases in patients with acute liver failure and ESLD.National survey showing a declining use for liver transplantation in the treatment of bile duct injury but highlighting a key role in selected patients with acute liver failure and end stage liver disease     

Laparo-endoscopic “Rendezvous” to treat cholecysto-choledocolithiasis： Effective,safe and simplifies the endoscopist’s work

AIM： To investigate our clinical experience with combined laparo-endoscopic Rendezvous （RV） for the treatment of patients affected by gallstones and common bile duct （CBD） stones and especially to study the never evaluated opinion of the endoscopist concerning the difficulty of the intraoperative endoscopic procedure during the RV in comparison with standard endoscopic retrograde cholangio-pancreatography （ERCP）.
METHODS： Eighty consecutive patients affected by cholecystolithiasis and diagnosed or suspected CBD stones were treated with a standardized ＂tailored＂ RV. The relevant technical features, the feasibility, the effectiveness in stone clearance, the safety but also the simple evaluation of difficulty and agreement of the endoscopist were analyzed with a questionnaire.
RESULTS： The feasibility was 97.5% and the effectiveness 100% concerning CBD clearance and solution of coexisting problems at the papilla. Minor morbidity was 3.3%, the operating time was prolonged by a mean of 14 min, the mean hospital stay was 3.8 d and only one stone’s recurrence occurred. The endoscopist evaluated the procedure to be simpler than standard ERCP-ES in 81.2% of the cases.
CONCLUSION： Simultaneous RV carries higheffectiveness and safety at least comparable to those reported for other options. The endoscopist is very often satisfied with this approach because of the minimization of some steps of the endoscopic procedure and avoidance of relevant iatrogenic risk factors. If the mandatory collaboration between surgeons and endoscopists is guaranteed, this approach can often be preferable for the patient, the surgeon, the endoscopist and the hospital.     

Indocyanine green-based fluorescence imaging in visceral and hepatobiliary and pancreatic surgery: State of the art and future directions

In recent years, the use of fluorescence-guided surgery(FGS) to treat benign and malignant visceral, hepatobiliary and pancreatic neoplasms has significantly increased. FGS relies on the fluorescence signal emitted by injected substances(fluorophores) after being illuminated by ad hoc laser sources to help guide the surgical procedure and provide the surgeon with real-time visualization of the fluorescent structures of interest that would be otherwise invisible. This review surveys and discusses the most common and emerging clinical applications of indocyanine green(ICG)-based fluorescence in visceral, hepatobiliary and pancreatic surgery. The analysis, findings, and discussion presented here rely on the authors' significant experience with this technique in their medical institutions, an up-to-date review of the most relevant articles published on this topic between 2014 and 2018, and lengthy discussions with key opinion leaders in the field during recent conferences and congresses. For each application, the benefits and limitations of this technique, as well as applicable future directions, are described. The imaging of fluorescence emitted by ICG is a simple, fast,relatively inexpensive, and harmless tool with numerous different applications in surgery for both neoplasms and benign pathologies of the visceral and hepatobiliary systems. The ever-increasing availability of visual systems that can utilize this tool will transform some of these applications into the standard of care in the near future. Further studies are needed to evaluate the strengths and weaknesses of each application of ICG-based fluorescence imaging in abdominal surgery.     

Management of biliary complications after orthotopic liver transplantation： The role of endoscopy

Biliary complications are significant causes of morbidity and mortality after orthotopic liver transplantation （OLT）. The estimated incidence of biliary complications after OLT ranges between 10%-25%, however, these numbers continue to decline due to improvement in surgical techniques. The most common biliary complications are strictures （both anastomotic and non-anastomotic） and bile leaks. Most of these problems can be appropriately managed with endoscopic retrograde colangiography （ERC）. Other complications such as bile duct stones, bile casts, sphincter of Oddi dysfunction, and hemobilia, are less frequent and also can be managed with ERC. This article will review the risk factors, diagnosis, and endoscopic management of the most common biliary complications after OLT.