Lesión quirúrgica de vía biliar compleja. Manejo conservador / Complex bile duct injury. Conservative management

RESUMEN La colecistectomía laparoscópica es el tratamiento de elección para la litiasis vesicular sintomática. Aunque la tasa de complicaciones es baja, las lesiones de la vía biliar representan un grave problema. La asociación con una lesión vascular (lesión compleja) genera un impacto adicional, disminuyendo la calidad de vida y la sobrevida a largo plazo. Presentamos el caso de una paciente con lesión compleja por compromiso vascular del pedículo hepático derecho que desarrolló una atrofia del parénquima correspondiente. Ante la ausencia de complicaciones sépticas, el tratamiento no operatorio pudo realizarse en forma exitosa.

ABSTRACT Laparoscopic cholecystectomy is considered the standard of care for symptomatic cholelithiasis. Although the rate of complications is low, bile duct injuries represent a serious problem. The association with vascular injury (complex injury) poses an additional impact by reducing the quality of life and long-term survival. We report the case of a female patient with complex injury due to vascular involvement of the right hepatic pedicle who developed right liver atrophy. Non-operative management was successful due to the absence of septic complications.

A new strategy of laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein combined with transhepatic duct lithotomy for complex hemihepatolithiasis: A propensity score matching study.

BACKGROUND: There have been no studies on laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein combined with transhepatic duct lithotripsy for the treatment of complex hemihepatolithiasis. This study aimed to investigate the safety and efficacy of laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein combined with transhepatic duct lithotomy to treat complex hemihepatolithiasis. METHODS: The clinical data for patients who underwent laparoscopic anatomical hemihepatectomy for complex intrahepatic bile duct stones with or without common bile duct stones from January 2016 to June 2020 were prospectively collected. Patients were divided into 2 groups according to surgical approach: laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein (middle hepatic vein group) or laparoscopic anatomical hemihepatectomy not guided by the middle hepatic vein (nonmiddle hepatic vein group). The safety and short-term and long-term efficacy outcomes of the 2 groups were compared with 1:1 propensity score matching. RESULTS: With only a slightly longer operative time (P = .006), the initial and final stone residual rates in the middle hepatic vein group (n = 70) were significantly lower than those in the nonmiddle hepatic vein group (n = 70) (P = .002, P = .009). The bile leakage rate and stone recurrence rate were also significantly lower (P = .001, P = .001). CONCLUSION: Laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein is safe and effective for treating intrahepatic bile duct stones and can decrease the stone residual rate, reduce the bile leakage rate and stone recurrence rate, and accelerate early recovery. However, owing to the complicated technical requirements for surgeons and anesthesiologists, use of the procedure is limited to large and experienced medical centers.

Perihilar clear cell cholangiocarcinoma: an often-diagnostic challenge.

Cholangiocarcinomas are rare and often diagnosed late. Clear cell histology is a rare variant of such cancers. We report one such case of a man in his late 60s, with a history of excess alcohol intake, who was found to have deranged liver biochemical tests incidentally during an admission for an allergic reaction. Subsequent imaging to investigate this suggested a diagnosis of perihilar cholangiocarcinoma (ultrasound, CT, MRI, cholangiogram). Biopsy confirmed this to be of clear cell type on histology and immunohistochemistry. Diagnosis and further management of this rare entity was conducted in multidisciplinary meetings with the regional hepatobiliary centre. The patient was deemed unsuitable for surgical resection, underwent chemotherapy but died 1 year later.

[Right hepatic bile duct injury: a single stage combined laparoscopic-endoscopic treatment]. / Lesión quirúrgica del conducto hepá tico derecho: tratamiento combinado laparoscópico-endoscópico.

Treatment of bile ducts injuries (BDI) treatment, combining minimally access surgical techniques, although their benefits, has been scarcely reported. We described a combined laparoscopic-endoscopic procedure, carried out in a patient with postoperative right hepatic duct (RHD) injury associated to laparoscopic cholecystectomy. Based on a clinical case description, we illustrate the surgical technique and assess their applicability and results. A biliary fistula was identified employing laparoscopic cholangiography and a metallic clip applied, producing RHD occlusion, was retrieved under fluoroscopic guidance. A biliary "rendezvous" maneuver was done for positioning an endoscopic biliary stent. The biliary fistula disappeared within two weeks and during 40-months of follow-up the patient remains asymptomatic. Laparoscopic-endoscopic approach, although technically demanding, resulted effective to treat this patient. A Continuous follow-up is essential for evaluating the long-term results.

Primary neuroendocrine tumour of the common hepatic duct: An unexpected Klatskin-like lesion.

The biliary system is an uncommon location for neuroendocrine tumours (NETs), and within this system, the common hepatic duct is an even more rare site for NETs. Clinical and radiological presentations are challenging because these tumours may be preoperatively confused with Klatskin-like lesions. Here we report a well-differentiated grade 2 NET arising from the common hepatic duct in a 64-year-old female. Curative surgery was performed, and no evidence of recurrent disease was observed at the 2-months follow-up.

A novel classification of aberrant right hepatic ducts ensures a critical view of safety in laparoscopic cholecystectomy.

BACKGROUND: Based on the spatial relationship of an aberrant right hepatic duct (ARHD) with the cystic duct and gallbladder neck, we propose a practical classification to evaluate the specific form predisposing to injury in laparoscopic cholecystectomy (LC). METHODS: We retrospectively investigated the preoperative images (mostly magnetic resonance cholangiopancreatography) and clinical outcomes of 721 consecutive patients who underwent LC at our institute from 2015 to 2018. We defined the high-risk ARHD as follows: Type A: communicating with the cystic duct and Type B: running along the gallbladder neck or adjacent to the infundibulum (the minimal distance from the ARHD < 5 mm), regardless of the confluence pattern in the biliary tree. Other ARHDs were considered to be of low risk. RESULTS: A high-risk ARHD was identified in 16 cases (2.2%): four (0.6%) with Type A anatomy and 12 (1.7%) with Type B. The remaining ARHD cases (n = 34, 4.7%) were categorized as low risk. There were no significant differences in the operative outcomes (operative time, blood loss, hospital stay) between the high- and low- risk groups. Subtotal cholecystectomy was applied in four cases (25%) in the high-risk group, a significantly higher percentage than the low-risk group (n = 1, 2.9%). In all patients with high-risk ARHD, LC was completed safely without bile duct injury or conversion to laparotomy. CONCLUSIONS: Our simple classification of high-risk ARHD can highlight the variants located close to the dissecting site to achieve a critical view of safety and may contribute to avoiding inadvertent damage of an ARHD in LC.

Lesión quirúrgica del conducto hepático derecho: tratamiento combinado laparoscópico-endoscópico / Right hepatic bile duct injury: a single stage combined laparoscopic-endoscopic treatment

RESUMEN El tratamiento de las lesiones quirúrgicas de las vías biliares (LQVB), empleando procedimientos quirúrgicos de mínimo acceso en forma conjunta, a pesar de sus beneficios, ha sido escasamente reportado. Describimos el tratamiento combinado láparoendoscópico, en una paciente con fístula biliar y estenosis postoperatoria del conducto hepático derecho (CHD). Con base en la descripción de un caso clínico, ilustramos la técnica quirúrgica y evaluamos su aplicabilidad y resultados. Empleando colangiografía laparoscópica, identificamos la fistula biliar y demostramos la oclusión del CHD por un clip metálico, el cual fue retirado mediante guía fluoroscópica. Realizamos maniobra de "rendezvous" biliar y colocamos de prótesis plástica endoscópica. La fístula biliar resolvió en 12 días y a 40 meses de seguimiento, la paciente permanece sin alteraciones. El abordaje láparo-endoscópico, aunque técnicamente demandante, resultó efectivo para el tratamiento de esta paciente. Su seguimiento es fundamental y de especial interés, a fin de evaluar los resultados a largo plazo.

ABSTRACT Treatment of bile ducts injuries (BDI) treatment, combining minimally access surgical techniques, although their benefits, has been scarcely reported. We described a combined laparoscopic-endoscopic procedure, carried out in a patient with postoperative right hepatic duct (RHD) injury associated to laparoscopic cholecystectomy. Based on a clinical case description, we illustrate the surgical technique and assess their applicability and results. A biliary fistula was identified employing laparoscopic cholangiography and a metallic clip applied, producing RHD occlusion, was retrieved under fluoroscopic guidance. A biliary "rendezvous" maneuver was done for positioning an endoscopic biliary stent. The biliary fistula disappeared within two weeks and during 40-months of follow-up the patient remains asymptomatic. Laparoscopic-endoscopic approach, although technically demanding, resulted effective to treat this patient. A Continuous follow-up is essential for evaluating the long-term results.

Hilar cholangiocarcinoma: Value of high-resolution enhanced magnetic resonance imaging for preoperative evaluation.

OBJECTIVES: The objective is to assess the accuracy of high-resolution (HR) enhanced magnetic resonance imaging (MRI) images in the preoperative evaluation of biliary and vascular invasion in hilar cholangiocarcinomas. METHODS: This retrospective study included 36 patients with hilar cholangiocarcinoma who underwent enhanced HR-MRI with an effective section thickness of 1.2 mm at 3.0 T before surgery. Combined HR-MRI and magnetic resonance cholangiopancreatography (MRCP) images were compared with MRCP in evaluating the extent of biliary infiltration according to the Bismuth-Corlette classification. To determine the suitable criterion for HR-MRI in predicting vessel invasion, Labeling 180 and 90 of circumferential contact of the tumor with the vessel were used to predict the invasion. The correlation between imaging findings and surgical and histopathological records was statistically analyzed. RESULTS: The accuracy in detecting biliary neoplastic invasion was higher for combined HR-MRI images (97.2%) than MRCP images (86.1%). HR-MRI images increased the accuracy in delineation of the tumor biliary extent (P < 0.05). The accuracy of Labeling 90 (98.6% in portal venous system and 98.0% in hepatic arterial system) was higher than that of Labeling 180 (96.5% in portal venous system and 94.6% in hepatic arterial system). However, there was no significant statistic difference between them (P > 0.05). Interobserver agreement was high with respect to biliary tract, portal venous, and hepatic arterial system involvement. CONCLUSIONS: Enhanced HR-MRI images showed excellent capability for assessing tumor extent and vascular invasion in hilar cholangiocarcinomas. More than 90° of circumferential contact of the tumor with the vessel on HR-MRI may be an appropriate criterion for predicting invasion.

Long-term outcomes of endoscopic treatment of aberrant hepatic duct injuries after cholecystectomy.

BACKGROUND AND AIMS: Right aberrant hepatic ducts are an anatomic variant with clinical relevance because of the risk of injury during cholecystectomy. Treatment options for aberrant hepatic duct injuries are not standardized. This study aims to analyze the long-term results of endoscopic treatment of aberrant hepatic duct lesions. METHODS: Patients who underwent ERCP for aberrant hepatic duct lesions were retrospectively identified. Demographic data, type of aberrant duct lesion according to the Strasberg classification, type of treatment (number of plastic stents inserted, treatment duration, and number of ERCPs), and adverse events were recorded. Follow-up was obtained by telephone contact or medical examinations. RESULTS: Between January 1996 and March 2019, 32 patients (78% women, mean age 51.7 years) with aberrant hepatic duct injuries underwent ERCP at our Endoscopy Unit. Six patients had Strasberg type B lesions, 11 patients had type C, and 8 patients had type E5, and 7 patients had a stenosis of the aberrant duct. A mean of 3.7 biliary plastic stents per patient were used; mean treatment duration was 6.3 months. All patients with isolated aberrant duct stenosis and 1 of 6 patients (17%) with type B Strasberg lesions achieved patency. Ten of 11 patients (91%) with type C Strasberg lesions achieved duct recanalization. After a mean follow-up of 109.3 ± 61.2 months, 29 of 32 patients (91%) were asymptomatic; 1 underwent surgery for recurrent cholangitis, 1 received a new endoscopic procedure because of cholangitis, and 1 reported episodic biliary colic without an increase in liver function test values and was successfully managed with a low-fat diet. CONCLUSIONS: An endoscopic approach to aberrant hepatic duct lesions after cholecystectomy can be considered an effective first-line therapy.

Effectiveness of near-infrared fluorescent cholangiography in the identification of cystic duct-common hepatic duct anatomy in comparison to magnetic resonance cholangio-pancreatography: a preliminary study.

INTRODUCTION: Bile duct injury represents the most serious complication of LC, with an incidence of 0.3-0.7% resulting in a significant impact on quality-of-life, overall survival, and frequent medico-legal litigations. Near-infrared fluorescent cholangiography (NIRF-C) represents a novel intra-operative imaging technique that allows a real-time enhanced visualization of the extrahepatic biliary tree by fluorescence. The role of routine use of pre-operative magnetic resonance cholangio-pancreatography (MRCP) to better clarify the biliary anatomy before laparoscopic cholecystectomy is still a matter of debate. The primary aim of this study was to evaluate the effectiveness of NIRF-C in the detection of cystic duct-common hepatic duct anatomy intra-operatively in comparison with pre-operative MRCP. METHODS: Data from 26 consecutive patients with symptomatic cholelithiasis or chronic cholecystitis, who underwent elective laparoscopic cholecystectomy with intra-operative fluorescent cholangiography and pre-operative MRCP examination between January 2018 and May 2018, were analyzed. Three selected features of the cystic duct-common hepatic duct anatomy were identified and analyzed by the two different imaging methods: insertion of cystic duct, cystic duct-common hepatic duct junction, and cystic duct course. RESULTS: Fluorescent cholangiography was performed successfully in all twenty-six patients undergoing elective laparoscopic cholecystectomy. The visualization of cystic duct was reported in 23 out of 26 cases, showing an overall diagnostic accuracy of 86.9%. The level of insertion, course, and wall implantation of cystic duct were achieved by NIRF-C with diagnostic accuracy values of 65.2%, 78.3%, and 91.3%, respectively in comparison with MRCP data. No bile duct injuries were reported. CONCLUSION: Fluorescent cholangiography can be considered a useful imaging diagnostic tool comparable to MRCP for detailed intra-operative visualization of the cystic duct-common hepatic duct anatomy during elective laparoscopic cholecystectomies.

Intraductal papillary mucinous neoplasm of the biliary tract: a lesion of the bile duct lumen.

Intraductal papillary neoplasm of the bile duct (IPNB) is a rare entity characterized by papillary growth within the bile duct lumen1, currently regarded as a biliary counterpart of intraductal papillary mucinous neoplasm of the pancreas. The most common clinical findings are abdominal pain, jaundice or cholangitis, although some patients are asyntomatic. The diagnosis requires careful assessment of imaging findings and cito-histological evaluation, with endoscopic ultrasound guided fine needle aspiration (EUS-FNA) playing a very important role. IPNB is a premalignant lesion which can evolve into invasive cholangiocarcinom. A radical treatment strategy should be planned accordingly.

A Rare Case of Ciliated Foregut Cyst of the Common Hepatic Duct.

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Pure laparoscopic living donor hepatectomy using the Glissonean pedicle approach (with video).

BACKGROUND: The use of pure laparoscopic donor hepatectomy has been increasing, with various advantages reported. However, the Glissonean approach has not been adopted despite its usefulness. The aim of this study was to introduce the Glissonean pedicle approach for laparoscopic living donor hepatectomy. METHODS: We retrospectively reviewed data from 11 patients who underwent pure laparoscopic donor hepatectomy for adult living donor liver transplantation. In this novel operative procedure, after mobilization of the liver, the right or left Glissonean pedicle was encircled, and then the liver parenchymal transection was completed. Next, the right or left hepatic artery, portal vein, and hepatic duct were dissected out. The right or left hepatic duct was divided under intraoperative cholangiography guidance using indocyanine green fluorescence, and the hepatic artery and the portal vein were cut. Finally, the hepatic vein was divided using the laparoscopic stapler, and the graft liver was procured via a suprapubic incision. RESULTS: The overall median surgical time was 387 min (range 280-563 min), and the volume of blood loss was 75 mL (21-1228 mL). The warm ischemic time was 5 min (2-10 min). A conversion to open procedure was occurred in 1 patient. A complication, a grade IIIa bile leakage according to the Clavien-Dindo classification, was noted in 1 patient. CONCLUSION: This is the first report of the Glissonean pedicle approach for pure laparoscopic donor hepatectomy; our results demonstrate the safety and feasibility of this technique.

Left-sided gallbladder: a systematic review of a rare biliary anomaly.

BACKGROUND: A left-sided gallbladder (LSGB) is a rare anatomical anomaly that is often not discovered until surgery. Two cases of LSGB managed with laparoscopic cholecystectomy (LC) stimulated this systematic review. The aims of this study were in LSGB to define the rate of pre-operative detection, variations in biliary anatomy, laparoscopic techniques employed and outcomes of surgery for symptomatic gallstones. METHODS: A systematic review was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses principles. RESULTS: Fifty-three studies with 112 patients of which 90 (80.4%) had symptomatic gallstones. Pre-operative imaging was performed in 108 patients (96.4%) with an LSGB reported on imaging in 32 (29.6%) patients. The remainder of LSGB were discovered at surgery. Ultrasound detected an LSGB in three (2.7%) patients. Five variants of cystic union with the common hepatic duct (CHD) were identified. The most common (67.8%) was union on the right side of the CHD after a hairpin bend anterior to the CHD. A cholecystectomy for gallstone disease was performed in 90 patients, 23.3% open and 76.7% LC. Common variations in LC technique were different port site placement and techniques related to the falciform ligament to improve exposure. Common bile duct injury occurred in four (4.4%) patients. CONCLUSION: LSGB is a rare anatomical variation that in patients with symptomatic gallstones is usually discovered at surgery. Cholecystectomy is associated with a higher incidence of common bile duct injury.

Effect of scheduled endoscopic dilatation of dominant strictures on outcome in patients with primary sclerosing cholangitis.

OBJECTIVE: Scheduled endoscopic dilatation of dominant strictures (DS) in primary sclerosing cholangitis (PSC) might improve outcome relative to endoscopic treatment on demand, but evidence is limited. Since randomisation is difficult in clinical practice, we present a large retrospective study comparing scheduled versus on-demand endoscopic retrograde cholangiopancreatography (ERCP) based on patient preferences. DESIGN: Between 1987 and 2017, all new patients with PSC had been offered scheduled ERCP with dilatation of a DS if diagnosed; the latter was repeated at defined intervals until morphological resolution, independent of clinical symptoms (treatment group). Patients who refused participation were clinically evaluated annually and received endoscopic treatment only on demand (control group). The primary clinical endpoint was transplantation-free survival. Secondary outcomes were overall survival, bacterial cholangitis episodes, hepatic decompensation of liver cirrhosis and endoscopy-related adverse events. RESULTS: The final study included 286 patients, 133 (46.5%) receiving scheduled ERCP and 153 (53.5%) receiving on-demand ERCP. After a mean follow-up of 9.9 years, the rate of transplantation-free survival was higher in patients receiving scheduled ERCP (51% vs 29.3%; p<0.001), as was transplantation-free survival time (median: 17.9 vs 15.2 years; log-rank: p=0.008). However, the benefit of scheduled ERCP was significant only in patients with the initial (17.1%) or later (45.5%) diagnosis of a DS (17.8 vs 11.1 years; log-rank: p<0.001). IBD (p=0.03), DS (p=0.006), higher Mayo Risk Score (p=0.02) and non-adherence to scheduled endoscopy (p=0.005) were independently associated with transplantation-free survival. CONCLUSION: In our large retrospective study, regular ERCP with endoscopic balloon dilatation significantly benefits patients with PSC with DS, diagnosed both at initial presentation and during surveillance, even if asymptomatic. Further studies have to find out how to best identify stricture patients non-invasively.

Todani Ic cystic dilatation of the bile duct.

The congenital dilation of the bile duct is an infrequent pathology in western countries and is associated with the female sex. It is usually diagnosed clinically with complementary tests and evaluated at an early age and also appears frequently in adults. These dilatations are grouped into five types according to Todani's classification, including type Ic (Figure 1). The treatment of choice for dilatations of the biliary duct Todani type I is the complete excision of the biliary tract due to the susceptibility of malignant degeneration. A reconstruction is performed via a hepaticojejunostomy with a Roux-en-Y loop. Although in non-malignant cases, a papillotomy with prophylactic stent placement using ERCP can be performed as an alternative. We present the case of a 54-year-old female with a history of high blood pressure, she was examined due to generalized abdominal pain which was unrelated to food intake. The blood test did not identify any alterations of interest. Ultrasound identified a fusiform dilation of the common bile duct occupied by lithiasis. ERCP was attempted due to choledocholithiasis, but the procedure was abandoned as it was not feasible to channel the duodenal papilla. The study was completed with NMR cholangiography (transverse plane [Figure 2] and coronal plane [Figure 3]), identifying a diffuse fusiform dilatation of the common bile duct and common hepatic duct, compatible with congenital cystic lesion Todani type Ic. Finally, the patient underwent a hepaticojejunostomy after sectioning of the main bile duct and extraction of choledocholithiasis.