Extrahepatic bile duct measurement by using transabdominal ultrasound in Japanese adults: multi-center prospective study

Background

In adults, less than 10-mm bile duct has idiomatically been recognized as “non-dilated bile duct” though there was no obvious evidence. The aim of this study was to prospectively examine the maximum inner diameter of extrahepatic bile duct (MDEBD) in consecutive adults.

Methods

Transabdominal ultrasound (US) was performed to measure the MDEBD of 8840 cases (4420 male) in five institutions. The frequency of ultrasound probe ranged from 3.5 to 5 MHz.

Results

The mean diameter of MDEBD was 4.5 ± 1.4 mm (range 1–14 mm). The relationship between the MDEBD and age was shown as follows: MDEBD = 2.83 + 0.03 × age. Multiple regression analysis was analyzed between 6 groups and significant α level is 0.008 in this analysis. In all age groups but 20s and 30s, there was statistically significant MDEBD among each age group (p < 0.0001). Mean, mode value and median MDEBD is increasing according to the age as follows: 20s: 3.9 ± 1.0 mm, 30s: 3.9 ± 1.2 mm, 40s: 4.3 ± 1.2 mm, 50s: 4.6 ± 1.3 mm, 60s: 4.9 ± 1.4 mm, >70s: 5.3 ± 1.6 mm.

Conclusion

The present study revealed that MDEBD positively correlates with age. Therefore, when we examine the presence of dilation of the bile duct, our calculating formula appears to be suitable for accurate evaluation.     

Preoperative evaluation of the longitudinal spread of extrahepatic bile duct cancer using multidetector computed tomography

Background/Purpose

The aim of this study was to compare the diagnostic accuracy of multidetector computed tomography (MDCT) and direct cholangiography in evaluating the longitudinal spread of extrahepatic bile duct cancer.

Methods

Images obtained from a 16-detector row scanner (MDCT) and from direct cholangiography (via either endoscopic naso-biliary drainage or percutaneous transhepatic biliary drainage) of 47 patients with histopathologically proven extrahepatic bile duct cancer were retrospectively interpreted. Differences between measures of longitudinal tumor spread determined by each modality and measures of macroscopic spread in resected specimens were assessed and compared.

Results

Assessments carried out using MDCT differed significantly less from the macroscopic measurements than those made using direct cholangiography (P < 0.0001). Provided the diagnosis was defined as being accurate, based on a diagnostic difference of within ±5 mm, the diagnostic accuracy of MDCT (96%) was significantly higher than that of direct cholangiography (70%) (P = 0.028). Preoperative evaluation with direct cholangiography resulted in a 30% underestimation of the incidence.

Conclusion

MDCT is superior to direct cholangiography for evaluating the preoperative longitudinal extent of bile duct cancer. Consequently, the utility of MDCT for preoperative evaluation of extrahepatic bile duct cancer warrants further examination.     

Development of a novel reflux-free bilioenteric anastomosis procedure by using a bioabsorbable polymer tube

Background

Bilioenteric anastomosis allows reflux of bowel fluid into bile ducts, resulting in reflux cholangitis. We sought to develop a reflux-free procedure of bilioenteric anastomosis endowed using an artificial bile duct (ABD).

Methods

The study was performed in four groups of pigs. In Group A, end-to-side choledochoduodenostomy using the interposed ABD with its distal end wrapped by the duodenal seromuscular layer was performed. In Group B, conventional end-to-side choledochoduodenostomy using the ABD was performed. In Group C, conventional end-to-side choledochoduodenostomy was performed. In Group D, sham operation was performed. In each groups, 12 weeks later, animals were evaluated.

Results

Bile amylase levels were significantly lower in Group A (36.9 ± 21.7 U/L) compared with Group B (469 ± 140.9 U/L). No significant differences were observed in bile amylase levels between Groups A and D or between Groups B and C. On histology, the neo-bile duct in Group A was covered with the duodenal muscular layer at the orifice into the intestinal tract.

Conclusion

This study suggests that the ABD is useful in the regeneration of extrahepatic bile ducts and that to bury the ABD in the duodenum can be a preventive measure against reflux of bowel fluid to bile ducts.     

Endoscopic Balloon Dilation Lithotripsy for Difficult Bile Duct Stones

Background/Aim

Endoscopic treatment for removal of large or impacted bile duct stones is challenging, and may not be successful. The aim of this study was to evaluate the safety and efficacy of endoscopic balloon dilation lithotripsy (EBDL) as a means of treating difficult extrahepatic bile duct stones refractory to failed conventional endoscopic treatments.

Patients and Methods

The patients were included in the indication of EBDL only if stones were confirmed as brown-pigmented stones or recurrent. Balloon dilation was performed using a balloon dilation catheter in order to crush large and/or impacted stones at the common hepatic duct or common bile duct level in seven cases, and then fragmented stones were removed using a basket and/or an extraction balloon catheter.

Results

The median diameter of the balloons used for EBDL was 32.4 ± 10.5 mm (range, 12.4–52.1). Balloon dilation was performed for 60 s per session. The mean number of EBDL sessions required to crush stones was two (range, 1–5), the mean number of ERCP sessions required for complete stone removal was 2.4 ± 0.8 (range, 1–3), the overall procedure-related complication rate was 0 % (0/7), and the success rate was 100 % (7/7).

Conclusion

EBDL might be a safe and effective option for the treatment of large and impacted extrahepatic bile duct stones refractory to conventional endoscopic treatments.     

Clinical Significance and Long-Term Outcome of Incidentally Found Bile Duct Dilatation

Background and Aim

The significance of incidentally detected bile duct dilatation has not yet been elucidated and there are only a few studies on asymptomatic patients with a dilated bile duct. This study aimed to investigate the causes and natural course of bile duct dilatation in asymptomatic patients.

Methods

A retrospective review of medical records was conducted for individuals in whom bile duct dilatation was detected by routine screening abdominal ultrasound at a health promotion center in Samsung Medical Center from January 2005 to April 2008.

Results

A total of 514 patients were included; the mean age was 60.1 ± 9.9 and the median follow-up period was 72 (interquartile range 56–85) months. Thirty-eight individuals who had a definite cause or biliary disease requiring treatment at the time of detection of bile duct dilatation were compared with 476 individuals who did not have a definitive cause or who did not need treatment. Both common bile duct (CBD) dilatation and intrahepatic bile duct (IHBD) dilatation were significantly related to the presence of a definitive causative lesion (OR 3.95; 95 % CI 1.77–8.82; p = 0.001). In the IHBD dilatation group, the severity of dilatation was also associated with the presence of a definitive causative lesion (OR 5.77; 95 % CI 1.32–25.26; p = 0.020).

Conclusion

Incidentally found biliary dilatation could be a prodrome of significant biliary tree disease. Therefore, further evaluation and regular follow up should be considered especially for marked IHBD dilatation or concomitant dilatation of CBD and IHBD detected on ultrasound.     

Preventive Saline Irrigation of the Bile Duct After the Endoscopic Removal of Common Bile Duct Stones

Background

Small stone fragments after an endoscopic stone extraction for choledocholithiasis may act as the nidus for recurrent choledocholithiasis. Therefore, efforts to eliminate the nidus might reduce the recurrence of choledocholithiasis and cholangitis related to choledocholithiasis.

Aims

The purpose of this study was to determine whether an additional preventive saline irrigation of the bile duct after the endoscopic removal of common bile duct stones would decrease residual stones and the recurrence of cholangitis.

Methods

A retrospective analysis was performed for the consecutively collected data about the patients who underwent the complete endoscopic treatment for common bile duct stone.

Results

Among 99 patients, 45 patients underwent saline irrigation. Residual stones were detected in 18 patients (18.2 %). The incidences of residual stones were 8.9 % (4 of 45 patients) in the irrigation group and 25.9 % (14 of 54 patients) in the non-irrigation group (P = 0.037). In multivariate analysis, preventive saline irrigation was found to be the only significant factor for the decrease of residual stones (HR = 0.258, P = 0.039). When analyzing the occurrence of recurrent cholangitis and the procedure related to complications, there were no significant differences according to the performance of preventive saline irrigation of the bile duct.

Conclusions

Preventive saline irrigation could reduce the residual common bile duct stones without complications.     

Erythropoietin (EPO) Affords More Potent Cardioprotection by Activation of Distinct Signaling to Mitochondrial Kinases Compared with Carbamylated EPO

Purpose

Erythropoietin (EPO) and its non-erythrogenic derivative, carbarmylated EPO (CEPO), have been reported to activate different receptors (homomeric EPO receptor vs. heteromeric receptor consisting of EPO receptor monomer and common β-subunit). The aim of this study was to examine differences between EPO and CEPO in efficacy of cardioprotection against infarction and in activation of pro-survival kinases.

Methods

In isolated rat hearts, infarction was induced by global ischemia followed by reperfusion. Infarct size was determined 2 h after reperfusion, and ventricular tissues for immunoblotting were sampled at 5 min after reperfusion.

Results

Pretreatment with EPO (10 units/ml) before ischemia reduced infarct size (% of risk area; %IS/AR) from 47.0?±?2.1% of the control after 20-min ischemia to 24.7?±?4.3% and from 62.0?±?3.0% after 25-min ischemia to 45.5?±?4.1%. Desialylated EPO (asialoEPO, 100 ng/ml) mimicked the protection by EPO. However, CEPO (100 ng/ml) failed to reduce infarct size after 20-min ischemia (%IS/AR?=?47.5?±?5.9%) and that after 25-min ischemia (%IS/AR?=?56.1?±?4.2%). The infarct size-limiting effect of CEPO was not shown either by increasing CEPO dose to 500 ng/ml or by shortening ischemia to 15 min. Both EPO and CEPO enhanced phosphorylation of cytosolic GSK-3β upon reperfusion. In contrast, phosphorylation of GSK-3β, Akt, and PKC-ε in mitochondria upon reperfusion was significantly enhanced by EPO but not by CEPO.

Conclusion

EPO affords more potent protection against infarction than does CEPO by distinct activation of signaling leading to phosphorylation of pro-survival protein kinases in mitochondria upon reperfusion.     

Initial experience of three-minute freeze cycles using the second-generation cryoballoon ablation: acute and short-term procedural outcomes

Background

The second-generation cryoballoon (CB-A) (Arctic Front Advance, Cryocath, Medtronic, MN, USA) might significantly improve procedural outcome with respect to the first-generation balloon. These technological improvements might also question the current recommendation of the need a 4-min freeze to achieve durable pulmonary vein isolation (PVI).

Objective

The main aim of the study was to analyze the procedural efficacy of a 3-min freeze–thaw cycles with the CB-A balloon in the terms of rates of acute PVI and 6-month outcome.

Methods

Patients having undergone CB-A for PAF or early persistent AF, with 3-min freeze–thaw cycles were consecutively included in our analysis. Acute procedural success was measured in terms of the rate of PVI. Short-term follow-up was evaluated by the means of 24-h Holters and clinical examinations at regular intervals.

Results

Fifty-two consecutive patients (35 male (67 %); mean age, 59.8?±?10.5) were included. Mean procedure and fluoroscopy times were 96?±?15 and 13.2?±?8.3 min, respectively. Mean time from groin puncture to catheter extraction was 60.4?±?20 min. After a mean of 1.5 freeze cycles per vein of 3 min in duration, all 208 (100 %) PVs could be isolated with the CB-A. A total 192 (91 %) veins were isolated during the first freeze. At a mean of 5.7-month follow-up, 82 % of patients were free of AF.

Conclusion

CB-A is effective in producing PVI by using 3-min-duration freeze cycles. After a mean of 1.5 freeze per vein, freedom from AF was achieved in 82 % of patients at 6-month follow-up.     

Evaluation of Endoscopic Transpapillary Brushing Cytology for the Diagnosis of Bile Duct Cancer Based on the Histopathologic Findings

Background and Aim

Diagnosis of the bile duct cancer still needs more accuracy. Studies on endoscopic retrograde cholangiopancreatography (ERCP)-guided brushing cytology were carried to evaluate the role of the endoscopic transpapillary brushing cytology for the diagnosis of bile duct cancer.

Patients and Method

The study involved 76 consecutive patients who underwent ERCP-guided bile duct cytology for the diagnosis of bile duct cancer from 2008 to August 2012. Three types of cytological specimens were obtained using different sampling methods, i.e., bile aspiration cytology (BAC), brush tip cytology (BTC), and post brushing bile cytology (PBC), to investigate their diagnostic abilities, and comparatively studied with each macroscopic type of the surgically resected specimens.

Results

The cancer-positive rate was 67.1 % (BAC alone: 41.9 %), and the use of BTC and PBC in addition to BAC yielded a statistically significant increase of the cancer-positive rate (p = 0.0031). In 34 resected cases, the cancer-positive rate in relation to the macroscopic type was improved by the addition of BTC and PBC to BAC alone for the papillary (87.5 vs. 40.0 %, p = 0.071) and nodular (100 vs. 70.0 %, p = 0.0603) types, but not for the flat type (62.5 vs. 57.1 %; p = 0.7651).

Conclusion

The diagnostic ability of ERCP-guided brushing cytology could be improved by the addition of PBC. However, the cancer-positive rate was the lowest for the flat type of bile duct cancer.     

Impact of respiration on electroanatomical mapping of the right atrium: implication for cavotricuspid isthmus ablation

Purpose

Cavotricuspid isthmus (CTI) ablation for typical atrial flutter (AFL) has become the preferred treatment for this arrhythmia. The aims of this study were to assess the impact of respiratory gating (RG) on electroanatomical mapping of CTI and to assess the efficiency of CTI ablation guided by the Carto3® system equipped with the new respiration gating software.

Methods

Forty-four consecutive patients (mean age, 60?±?13 years; 25 male) undergoing cavotricuspid ablation for symptomatic common AFL were randomly assigned to CARTO? mapping with or without enabling RG module (Group A, RG OFF, Group B, RG ON).

Results

A significant reduction in mean RA volume, CTI central length and CS ostium maximum diameter has been observed in the RG maps. The mean total procedural, fluoroscopy and radiofrequency (RF) time were 102.9?±?35.3, 10.6?±?3.3, 22.9?±?14.2 min in group A and 75.3?±?21.7, 3.6?±?4.5, 10.4?±?5.7 min in group B, respectively (p?<?0.05).

Conclusions

Electroanatomical mapping systems’ accuracy may be strongly influenced by respiration movements. The current study showed that automatic respiratory gated acquisition resulted in a better visualization of CTI, and this determines a relevant reduction in fluoroscopy and RF times.     

Usefulness of Intraductal Ultrasonography in Icteric Patients with Highly Suspected Choledocholithiasis Showing Normal Endoscopic Retrograde Cholangiopancreatography

Background

Choledocholithiasis is one of the causes of jaundice and may require urgent treatment. Endoscopic retrograde cholangiopancreatography (ERCP) has been the primary management strategy for choledocholithiasis. However, small stones can be overlooked during ERCP.

Aim

The aim of this study was to evaluate the accuracy of intraductal ultrasonography (IDUS) for detecting choledocholithiasis in icteric patients with highly suspected common bile duct (CBD) stones without definite stone diagnosis on ERCP.

Methods

Ninety-five icteric (bilirubin ≥3 mg/dL) patients who underwent ERCP for highly suspected choledocholithiasis without definite filling defects on cholangiography were prospectively enrolled in the present study. We evaluated the bile duct using IDUS for the presence of stones or sludge. Reference standard for choledocholithiasis was endoscopic extraction of stone or sludge.

Result

Bile duct stones were detected with IDUS in 31 of 95 patients (32.6 %). IDUS findings were confirmed by endoscopic stone extraction in all patients. The mean diameter of CBD stones detected by IDUS was 2.9 mm (range 1–7 mm). IDUS revealed biliary sludge in 24 patients (25.2 %) which was confirmed by sludge extraction in 21 patients (87.5 %). In dilated CBD, detection rate of bile duct stone/sludge based on IDUS was significantly higher than in non-dilated CBD (p = 0.004).

Conclusion

IDUS is useful for the detection of occult CBD stone on ERCP in icteric patients with highly suspected CBD stones.     

Safety and Efficacy of Laser Lithotripsy for Complicated Biliary Stones Using Direct Choledochoscopy

Background

The first-line therapy for choledocholithiasis is endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction, which is successful in over 90 % of cases. However, large biliary stones often require extracorporeal shockwave lithotripsy, electrohydraulic lithotripsy (EHL), or laser lithotripsy. The objective of our study was to assess the safety and efficacy of laser lithotripsy with choledochoscopy guidance.

Methods

Between March 2001 and November 2009, laser lithotripsy with a holmium laser was used for complicated bile stones in 20 patients. All patients included had failed standard stone extraction techniques after a mean of 2.1 ± 1.1 ERCP sessions. Main outcome measures included complete stone clearance and complications post-procedure.

Results

Twenty patients (mean age 61.0 ± 22.3 years, six men) underwent laser lithotripsy with a mean stone size was 2.2 cm (range 1.1–3.5 cm) and a mean number of stones of 2.2 (range 1–6). A mean of 0.25 ± 0.20 kJ was applied during laser lithotripsy sessions with a mean procedure time of 85.3 ± 23.0 min. The majority (18/20, 90 %) achieved final clearance after a mean of 1.4 ± 0.8 (29 total) laser sessions and a mean of 1.9 ± 0.8 (38 total) ERCP sessions. Five complications occurred: two patients required post-procedure admission for pain and three patients had bile leaks. All bile leaks were minor and resolved after biliary stenting.

Conclusions

Laser lithotripsy using the holmium laser is safe and effective with direct cholangioscopic guidance. Further prospective studies are warranted.     

Learning curve of single port laparoscopic cholecystectomy determined using the non-linear ordinary least squares method based on a non-linear regression model

Introduction

Single port laparoscopic surgery has come to the forefront of minimally invasive surgery. For those familiar with conventional techniques, however, this type of operation demands a different type of eye/hand coordination and involves unfamiliar working instruments. Herein, the authors describe the learning curve and the clinical outcomes of single port laparoscopic cholecystectomy for 150 consecutive patients with benign gallbladder disease.

Method

All patients underwent single port laparoscopic cholecystectomy using a homemade glove port by one of five operators with different levels of experiences of laparoscopic surgery. The learning curve for each operator was fitted using the non-linear ordinary least squares method based on a non-linear regression model.

Results

Mean operating time was 77.6 ± 28.5 min. Fourteen patients (6.0%) were converted to conventional laparoscopic cholecystectomy. Complications occurred in 15 patients (10.0%), as follows: bile duct injury (n = 2), surgical site infection (n = 8), seroma (n = 2), and wound pain (n = 3). One operator achieved a learning curve plateau at 61.4 min per procedure after 8.5 cases and his time improved by 95.3 min as compared with initial operation time. Younger surgeons showed significant decreases in mean operation time and achieved stable mean operation times. In particular, younger surgeons showed significant decreases in operation times after 20 cases.

Conclusion

Experienced laparoscopic surgeons can safely perform single port laparoscopic cholecystectomy using conventional or angled laparoscopic instruments. The present study shows that an operator can overcome the single port laparoscopic cholecystectomy learning curve in about eight cases.     

The distance of tumor spread in the main pancreatic duct of an intraductal papillary-mucinous neoplasm: where to resect and how to predict it

Background

The surgical decision regarding where to resect the pancreas is an important judgement that is directly linked to the surgical procedure. An appropriate surgical margin to resect intraductal papillary-mucinous neoplasm (IPMN) of the pancreas based on the distance of tumor spread (DTS) in the main pancreatic duct has not been adequately documented. We analyzed the appropriate surgical margin based on the DTS in the main pancreatic duct of IPMN and the positive rate at the pancreatic cut end margin.

Methods

Forty patients with main duct- or mixed-type IPMN diagnosed histopathologically who underwent surgery at Tokai University Hospital between 1991 and 2008 were retrospectively analyzed. The resection line was determined to achieve a 2-cm surgical margin in patients with main duct- or mixed-type IPMN and as limited a resection as possible to remove the dilated branch duct in patients with branch duct-type IPMN according to macroscopic type. The dysplastic state of the epithelium was judged as positive for carcinoma in situ (high-grade dysplasia) or adenoma (very low to moderate dysplasia) and judged as negative for hyperplasia or normal.

Results

The mean DTS in the main pancreatic duct was 41.6 ± 30.0 mm, and that of the distance of tumor absence was 13.6 ± 12.4 mm. The positive rate at the pancreatic cut end margin in frozen sections was 29.7%. The final positive rate at the pancreatic cut end margin was 26.2%. There has been no evidence of local recurrence in the remnant pancreas. DTS in the main pancreatic duct of IPMN was correlated with the maximum diameter of the duct (R = 0.678).

Conclusion

Distance of tumor spread offered important insights about the appropriate site to resect the pancreas and the positive rate at the cut end margin in IPMN.     

Single-institution validation of the international consensus guidelines for treatment of branch duct intraductal papillary mucinous neoplasms of the pancreas

Background

The international consensus guidelines (the guidelines) for management of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas recommend surgical resection of branch duct IPMNs with any of the following features: cyst size >30 mm, mural nodules, main pancreatic duct diameter >6 mm, positive cytology, and symptoms. The aim of this study was to evaluate the usefulness of these guidelines for resection of branch duct IPMNs.

Methods

We reviewed 84 consecutive patients with branch duct IPMNs who underwent surgical resection at our hospital between January 1984 and December 2007.

Results

Sixty-nine patients had indications for resection according to the guidelines. Malignant IPMNs had significantly larger cysts than benign tumors (P = 0.026). Patients with malignant IPMNs had significantly more indications for resection than those with benign IPMNs (2.6 ± 1.0 vs. 1.7 ± 0.9, P < 0.001), and 36 of the 37 patients with malignant IPMNs had indications. The sensitivity of the guidelines for predicting malignancy was 97.3%. One of 15 patients without indications had malignancy, and the specificity was low (29.8%).

Conclusions

The guidelines show a high sensitivity for predicting malignancy of branch duct IPMNs, but the specificity is low. The cyst size and the total number of indications in each patient should be taken into account when predicting the risk of malignancy for branch duct IPMNs.     

Clinical features of pancreaticobiliary maljunction: update analysis of 2nd Japan-nationwide survey

Introduction

Pancreaticobiliary maljunction (PBM) is a congenital anomaly, which can be defined as a union of the pancreatic and biliary ducts located outside off the duodenal wall. We herein investigate clinical features of PBM including as the 2nd report of a Japanese nationwide survey.

Patients and methods

During a period of 18 years (from 1990 to 2007), 2,561 patients with PBM were registered at 141 medical institutions in Japan. Among them, eligible patients (n = 2,529) were divided into two groups: adult (n = 1,511) and pediatric patients (n = 1,018). Comparisons of clinical features including associated biliary cancers were performed according to the biliary dilatation (BD), age factor, and time era.

Results

Only one case in pediatric patients with BD combined with a bile duct cancer (0.1 %). In adult patients, the bile duct cancer and the gallbladder cancer was seen in 6.9 and 13.4 % patients with BD and in 3.1 and 37.4 % patients without BD, respectively. In adult patients with BD, the occurrence rates of biliary cancers were increased in latter period (00’–07’) compared with former period (90’–99’). The ratio of biliary cancer localization was changed between former and latter period, and the bile duct cancer was increased in latter period (from 5.5 to 9.3 %).

Conclusions

The largest series of PBM were evaluated to clarify the clinical features including the associated biliary cancer in this Japan-nationwide survey. This report could be widely used in the future as a reference data for diagnosis and treatment of PBM.     

Liver transplantation for iatrogenic bile duct injuries sustained during cholecystectomy

Purpose

The aim of this study was to report a single-center experience and review the literature on liver transplantation (LT) for iatrogenic bile duct injury (BDI) sustained during cholecystectomy.

Methods

A retrospective review of a prospectively maintained database of LT between 1990 and December 2012 was performed. For the same period, a review of the literature on LT for BDI was undertaken.

Results

Six patients, with a mean age of 55.3 years (range 52–65), referred at a mean interval of 206 months (range 96–384) from BDI underwent LT. All patients had class E Strasberg BDIs and were referred with end-stage liver disease after multiple previous attempts at BDI repairs. Mortality, morbidity, and retransplantation rates were 16.6, 50, and 16.6 %, respectively. Five patients were alive at a mean follow-up time of 80.4 ± 92 months. Fifty-eight patients listed or transplanted for BDI were identified and reviewed. Indications for LT included chronic or acute liver failure (22.4 %) and the delay between BDI and referral for LT ranged from 1 day to 180 months. Associated vascular injuries were present in 41.3 % of the patients, and 72.4 % of the patients had previous failed BDI repairs. The overall postoperative mortality was 34.4 %, and the morbidity ranged from 60 to 100 %. The overall 5-year survival reached 75 %.

Conclusions

A long interval of time between BDI and referral to tertiary centers for repair, a high rate of associated vascular injuries, and multiple failed previous repair attempts characterize the clinical history of patients undergoing LT for BDI. Operative morbidity and mortality rates of LT in the setting of BDI are particularly high for patients with bilio-vascular injuries presenting with acute liver failure and for patients with chronic liver disease due to multiple previous repair attempts and recurrent preoperative biliary infection.     

A laparoscopic approach to benign retrorectal tumors

Background

Retrorectal tumors (RTs) are rare in adults. Their surgical excision is often difficult because of their anatomic location. The aim of this study was to evaluate the results of straight laparoscopic resection of RTs in our institution.

Methods

Eight patients (six women and two men) with benign RTs were treated by laparoscopic resection in our tertiary care center between September 2012 and June 2013. Exclusion criteria included malignant tumors, lesions with fistula formation, and anterior sacral meningoceles. Clinical data, imaging features, operative details, pathological results, and treatment outcomes were reviewed and analyzed.

Results

Eight cases of benign RT with an average diameter of 8.9 ± 1.7 cm were treated by a straight laparoscopic procedure. The mean operative time was 122 ± 36 min, and the average intraoperative blood loss was 46 ± 33 ml. The median postoperative stay was 5 days (range 3–8 days), and all patients were discharged without serious complications. During a median follow-up of 11 months, no tumor recurrence was observed.

Conclusions

In our experience, a laparoscopic approach is safe for removing benign tumors in the retrorectal space. This approach may provide access to this difficult-to-reach space and has the advantages of allowing excellent visualization, meticulous dissection, less morbidities, and fast recuperation.     

Intraoperative exploration of biliary anatomy using fluorescence imaging of indocyanine green in experimental and clinical cholecystectomies

Background/purpose

We evaluated the usefulness of intraoperative exploration of the biliary anatomy using fluorescence imaging with indocyanine green (ICG) in experimental and clinical cholecystectomies.

Methods

The experimental study was done using two 40-kg pigs and the clinical study was done in 12 patients for whom cholecystectomy was planned from January 2009 to June 2009. Initially we used a laparoscopic approach for the evaluation of fluorescence imaging of the biliary system in the two pigs. Then the clinical study was started on the basis of these experimental results. ICG (1.0 ml/body of 2.5 mg/ml ICG) was infused 1–2 h before surgery. With the subjects under general anesthesia we observed in real time the condition of the biliary tract under the guidance of fluorescence imaging employing an infrared camera or a prototype laparoscope. ICG was added intravenously to observe the location or flow condition of the cystic artery.

Results

We obtained a clear view of the biliary tract and the location of the cystic duct in the two pigs. Local compression with a transparent hemispherical plastic device was effective for offering a clearer view. The biliary tract, except for the gallbladder, was clearly recognized in all clinical subjects. Local compression with a transparent hemispherical plastic device for open cholecystectomy and a flat plastic device for laparoscopy provided clearer visualization of the confluence between the cystic duct and common bile duct or common hepatic duct. The location of the cystic artery was revealed after division of the connective tissues, and the flow condition of the cystic artery was confirmed 7–10 s after intravenous re-infusion of ICG. There were no adverse events related to the intraoperative procedure or the ICG itself.

Conclusions

This method is safe and easy for the identification of the biliary anatomy, without requiring cannulation into the cystic duct, X-ray equipment, or the use of radioactive materials. Although fluorescence imaging is still at an early stage of application in comparison with ordinary intraoperative cholangiography, we expect that this method will become routine, offering a lower degree of invasiveness that will help avoid bile duct injury.