Establishing consensus on the perioperative management of cholecystectomy in public hospitals: a Delphi study with an expert panel in Mexico.

BACKGROUND: Several guidelines have put forward recommendations about the perioperative process of cholecystectomy. Despite the recommendations, controversy remains concerning several topics, especially in low- and middle-income countries. The aim of this study was to develop uniform recommendations for perioperative practices in cholecystectomy in Mexico to standardize this process and save public health system resources. METHODS: A modified Delphi method was used. An expert panel of 23 surgeons anonymously completed two rounds of responses to a 29-item questionnaire with 110 possible answers. The consensus was assessed using the percentage of responders agreeing on each question. RESULTS: From the 29 questions, the study generated 27 recommendations based on 20 (69.0%) questions reaching consensus, one that was considered uncertain (3.4%), and six (20.7%) items that remained open questions. In two (6.9%) cases, no consensus was reached, and no recommendation could be made. CONCLUSIONS: This study provides recommendations for the perioperative management of cholecystectomy in public hospitals in Mexico. As a guide for public institutions in low- and middle-income countries, the study identifies recommendations for perioperative tests and evaluations, perioperative decision making, postoperative interventions and institutional investment, that might ensure the safe practice of cholecystectomy and contribute to conserving resources.

Choices of Therapeutic Strategies for Colorectal Liver Metastases Among Expert Liver Surgeons: A Throw of the Dice?

OBJECTIVE: To test the degree of agreement in selecting therapeutic options for patients suffering from colorectal liver metastasis (CRLM) among surgical experts around the globe. SUMMARY/BACKGROUND: Only few areas in medicine have seen so many novel therapeutic options over the past decades as for liver tumors. Significant variations may therefore exist regarding the choices of treatment, even among experts, which may confuse both the medical community and patients. METHODS: Ten cases of CRLM with different levels of complexity were presented to 43 expert liver surgeons from 23 countries and 4 continents. Experts were defined as experienced surgeons with academic contributions to the field of liver tumors. Experts provided information on their medical education and current practice in liver surgery and transplantation. Using an online platform, they chose their strategy in treating each case from defined multiple choices with added comments. Inter-rater agreement among experts and cases was calculated using free-marginal multirater kappa methodology. A similar, but adjusted survey was presented to 60 general surgeons from Asia, Europe, and North America to test their attitude in treating or referring complex patients to expert centers. RESULTS: Thirty-eight (88%) experts completed the evaluation. Most of them are in leading positions (92%) with a median clinical experience of 25 years. Agreement on therapeutic strategies among them was none to minimal in more than half of the cases with kappa varying from 0.00 to 0.39. Many general surgeons may not refer the complex cases to expert centers, including in Europe, where they also engage in complex liver surgeries. CONCLUSIONS: Considerable inconsistencies of decision-making exist among expert surgeons when choosing a therapeutic strategy for CRLM. This might confuse both patients and referring physicians and indicate that an international high-level consensus statements and widely accepted guidelines are needed.

Liver transplantation center in México with low-volume and excellent results / Centro de trasplante hepático en México con bajo volumen y excelentes resultados

Background: Orthotopic liver transplantation (OLT) is the treatment of choice for end stage liver disease. Many studies show an inverse relationship between the number of procedures and operative mortality. Objective: The objective of the study is to show the results of our center and determine if it can have comparable results to high volumen centers. Method: This is a retrospective study which analyzed the information of patients with OLT at our institution from 1985 to December 31, 2012. Depending on date of transplantation, the study was divided into three stages. Stage 1: from 1985 to 1999. Stage 2: from 2000 to 2007. Stage 3: from 2008 to 2012. In the 1, 2 and 3 stage 22, 37 and 56 OLT were performed respectively. Results: Perioperative mortality was significantly lower between Stage 3 vs. Stage 1 and 2 (3.5% vs. 50% and 21.7%, p = 0.001). Patient survival was also better at 1 and 5 years at Stage 3 (94.4%, 87.8%) vs. era 2 (77.6%, 66.17%) and Stage 1 (47% and 29%) (p = 0.001). Conclusion: In conclusion, the present results of OLT at our program are excellent despite being a low-volume center.

Antecedentes: El trasplante hepático ortotópico (THO) es el tratamiento de elección para la insuficiencia hepática terminal. Numerosos estudios muestran una relación inversa entre el número de procedimientos y la mortalidad operatoria. Objetivo: El objetivo de este estudio es mostrar los resultados de nuestro centro y determinar si puede tener resultados equiparables a los obtenidos en centros de alto volumen. Método: Es un estudio retrospectivo en el que se analizó la información de pacientes con THO en nuestra institución, de 1985 al 31 de diciembre de 2012. Dependiendo de la fecha del THO, el estudio se dividió en tres etapas: etapa 1, de 1985 a 1999; etapa 2, de 2000 a 2007; y etapa 3, de 2008 a 2012. En las etapas 1, 2 y 3 se realizaron 22, 37 y 56 THO, respectivamente. Resultados: La mortalidad perioperatoria fue menor de manera significativa en la etapa 3 en comparación con las etapas 1 y 2 (3.5 vs. 50 y 21.7%; p = 0.001). La supervivencia de los pacientes a 1 y 5 años fue mejor en la etapa 3 (94.4 y 87.8%) que en la etapa 2 (77.6 y 66.17%) y en la etapa 1 (47 y 29%) (p = 0.001). Conclusión: En conclusión, los resultados actuales en THO en nuestro programa son excelentes, a pesar de ser un centro de bajo volumen.

BILE DUCT INJURY REPAIR IN A PATIENT WITH SITUS INVERSUS TOTALIS.

BACKGROUND: Bile duct injury (BDI) causes significant sequelae for the patient in terms of morbidity, mortality, and long-term quality of life, and should be managed in centers with expertise. Anatomical variants may contribute to a higher risk of BDI during cholecystectomy. AIMS: To report a case of bile duct injury in a patient with situs inversus totalis. METHODS: A 42-year-old female patient with a previous history of situs inversus totalis and a BDI was initially operated on simultaneously to the lesion ten years ago by a non-specialized surgeon. She was referred to a specialized center due to recurrent episodes of cholangitis and a cholestatic laboratory pattern. Cholangioresonance revealed a severe anastomotic stricture. Due to her young age and recurrent cholangitis, she was submitted to a redo hepaticojejunostomy with the Hepp-Couinaud technique. To the best of our knowledge, this is the first report of BDI repair in a patient with situs inversus totalis. RESULTS: The previous hepaticojejunostomy was undone and remade with the Hepp-Couinaud technique high in the hilar plate with a wide opening in the hepatic confluence of the bile ducts towards the left hepatic duct. The previous Roux limb was maintained. Postoperative recovery was uneventful, the drain was removed on the seventh post-operative day, and the patient is now asymptomatic, with normal bilirubin and canalicular enzymes, and no further episodes of cholestasis or cholangitis. CONCLUSIONS: Anatomical variants may increase the difficulty of both cholecystectomy and BDI repair. BDI repair should be performed in a specialized center by formal hepato-pancreato-biliary surgeons to assure a safe perioperative management and a good long-term outcome.

Hepatolithiasis with secondary cholangitis and supernumerary left hepatic lobe.

We report the case of a 31-year old woman with recurrent cholangitis secondary to hepatolithiasis. The stones were composed of calcium bilirubinate. The patient also had a supernumerary hepatic lobe connected to the inferior aspect of the segment III of the liver. The role of the supernumerary hepatic lobe in the development of hepatolithiasis is unclear and may be coincidental.

Transition from a low: to a high-volume centre for bile duct repair: changes in technique and improved outcome.

BACKGROUND: Improvements in bile duct injury repairs have been shown in centres with specialized surgeons. The aim of the present study was to demonstrate the temporal change in the pattern of referral, technical variation associated with repair and long-term outcome of bile duct injuries at a tertiary referral centre in Mexico City. METHODS: A retrospective case note review was performed. Patients were divided into two groups: group I (GI) 1990 to 2004 and group II (GII) 2005-2008, and appropriate statistical analysis undertaken. RESULTS: Over a 20-year period, 312 patients with iatrogenic bile duct injuries required surgical treatment (GI = 169, GII = 140 patients). All injuries were reconstructed using a Roux-en-Y hepaticojejunostomy. The proportion of patients who had undergone a laparoscopic cholecystectomy increased from 24% to 36% (P = 0.017) over the two time periods. In the second time period there was an increase in segment IV and V partial resections (P = 0.020), a reduction in the use of transanastomotic stents (42% to 2%, P = 0.001) and an increase in the proportion of patients requiring a neoconfluence (2% to 11%, P = 0.003). In the second time period, the number of patients requiring a hepatectomy during repair (2% to 1%, P = 0.001), a portoenterostomy (16% to 9%, P = 0.060) or a double-barrel hepatico-jejunostomy (5% to 1%, P = 0.045) significantly decreased. During follow-up, patients in the second time period had a reduction in the incidence of post-operative cholangitis (11% to 6%, P = 0.310) and the frequency of post-operative anastomotic stenoses (13% to 5%, P = 0.010). Mortality remained low throughout the series but was absent in the second group. CONCLUSIONS: Changes in technique and growing experience of the multidisciplinary team improved operative and long-term results of bile duct injury repair.

Subtotal Cholecystectomy After Failed Critical View of Safety Is an Effective and Safe Bail Out Strategy.

BACKGROUND: Bile duct injury (BDI) is accompanied by significant morbidity and long-term impact in quality of life. Subtotal cholecystectomy (STC) is an alternative to prevent this outcome but is associated with other complications. The aim of this work is to demonstrate that BDI associated morbidity exceeds STC associated morbidity, underscoring STC as a reasonable bail out strategy. METHODS: We compared 115 patients who underwent STC with 293 patients who were referred to our center with BDI type E1-E3 and underwent surgical repair. The groups were comparable because in both instances the surgeon had the opportunity to decide not to perform a total cholecystectomy once critical view of safety (CVS) was not achieved. RESULTS: Bile leakage was found in 21% of the STC group with only one BDI (0.9%). More Accordion ≥ 4 were found in the STC group (10.4% vs 4.8%, p = 0.035); however, reoperations were more frequent in the BDI group (8.2% vs 0.9%, p = 0.006). No patient in the STC group required reintervention for completion cholecystectomy. After 3.8 years follow-up, 2.4% of patients had secondary biliary cirrhosis in the BDI group; none in the STC group. CONCLUSIONS: Despite complications of STC, morbidity associated with BDI is much higher due to high long-term reoperation rate, in addition to secondary biliary cirrhosis. STC is a safe alternative that can prevent BDI if properly and timely performed in the context of difficult cholecystectomy.

Perfusion Decellularization of Extrahepatic Bile Duct Allows Tissue-Engineered Scaffold Generation by Preserving Matrix Architecture and Cytocompatibility.

Reconstruction of bile ducts damaged remains a vexing medical problem. Surgeons have few options when it comes to a long segment reconstruction of the bile duct. Biological scaffolds of decellularized biliary origin may offer an approach to support the replace of bile ducts. Our objective was to obtain an extracellular matrix scaffold derived from porcine extrahepatic bile ducts (dECM-BD) and to analyze its biological and biochemical properties. The efficiency of the tailored perfusion decellularization process was assessed through histology stainings. Results from 4'-6-diamidino-2-phenylindole (DAPI), Hematoxylin and Eosin (H&E) stainings, and deoxyribonucleic acid (DNA) quantification showed proper extracellular matrix (ECM) decellularization with an effectiveness of 98%. Immunohistochemistry results indicate an effective decrease in immunogenic marker as human leukocyte antigens (HLA-A) and Cytokeratin 7 (CK7) proteins. The ECM of the bile duct was preserved according to Masson and Herovici stainings. Data derived from scanning electron microscopy (SEM) and thermogravimetric analysis (TGA) showed the preservation of the dECM-BD hierarchical structures. Cytotoxicity of dECM-BD was null, with cells able to infiltrate the scaffold. In this work, we standardized a decellularization method that allows one to obtain a natural bile duct scaffold with hierarchical ultrastructure preservation and adequate cytocompatibility.

Right and left partial iatrogenic injuries of the biliary tree. Therapeutic options.

BACKGROUND: Bile duct injuries (BDI) have a wide array of presentation. Left partial injuries (Strasberg D) of the hepatic duct are the result of excessive traction, which dissects the hepatic hilum and provokes medial perforations without continuity loss. Right partial injuries (Strasberg A, B and C) are produced by direct damage to the hepatic duct or isolated injury to the right and accessory ducts. It is important to determine frequency, spectrum and treatment outcome of this BDI in the surgical scenario. METHODS: Patients with BDI who underwent surgical treatment in our hospital were reviewed, right and left partial injuries were selected. Demographic, clinical and therapeutic data were analyzed. RESULTS: In a 16-year period, 405 patients underwent surgical treatment of BDI. 31 (8%) were classified as a left partial injury (Strasberg D): 23 injuries at the common hepatic duct treated with a Hepatojejunostomy (HJ); four at the confluence level which received a HJ with neoconfluence construction; two partial injuries in the left hepatic duct underwent a selective left HJ; and two complete occlusions of the left hepatic duct, one treated with a partial hepatectomy and the last case underwent a partial HJ. Right partial injuries (Strasberg A, B or C) were identified in 21 cases (5%), their treatment was tailored according to the type of BDI (conservative, selective HJ, or hepatectomy). CONCLUSIONS: In our series the frequency of left and right partial BDI injuries was 8% and 5%, respectively. The spectrum of analyzed injuries included four subtypes for the left partial and eight for the right partial lesions. Most BDI in the two analyzed groups presented concomitant devascularization of the extra-hepatic ducts, therefore receiving surgical treatment rather than endoscopic treatment was done.

Bile duct injury repair in a patient with situs inversus totalis / Tratamento de lesão de via biliar em paciente com situs inversus totalis

ABSTRACT BACKGROUND: Bile duct injury (BDI) causes significant sequelae for the patient in terms of morbidity, mortality, and long-term quality of life, and should be managed in centers with expertise. Anatomical variants may contribute to a higher risk of BDI during cholecystectomy. AIMS: To report a case of bile duct injury in a patient with situs inversus totalis. METHODS: A 42-year-old female patient with a previous history of situs inversus totalis and a BDI was initially operated on simultaneously to the lesion ten years ago by a non-specialized surgeon. She was referred to a specialized center due to recurrent episodes of cholangitis and a cholestatic laboratory pattern. Cholangioresonance revealed a severe anastomotic stricture. Due to her young age and recurrent cholangitis, she was submitted to a redo hepaticojejunostomy with the Hepp-Couinaud technique. To the best of our knowledge, this is the first report of BDI repair in a patient with situs inversus totalis. RESULTS: The previous hepaticojejunostomy was undone and remade with the Hepp-Couinaud technique high in the hilar plate with a wide opening in the hepatic confluence of the bile ducts towards the left hepatic duct. The previous Roux limb was maintained. Postoperative recovery was uneventful, the drain was removed on the seventh post-operative day, and the patient is now asymptomatic, with normal bilirubin and canalicular enzymes, and no further episodes of cholestasis or cholangitis. CONCLUSIONS: Anatomical variants may increase the difficulty of both cholecystectomy and BDI repair. BDI repair should be performed in a specialized center by formal hepato-pancreato-biliary surgeons to assure a safe perioperative management and a good long-term outcome.

RESUMO RACIONAL: As lesões de via biliar (LVB) impõem sequelas significativas ao paciente em termos de morbidade, mortalidade e qualidade de vida a longo prazo, devendo ser manejadas em centros especializados. Variantes anatômicas podem contribuir para um maior risco de LVB durante colecistectomia. OBJETIVOS: Relatar paciente com lesão de via biliar associado a situs inversus totalis. MÉTODOS: Paciente do sexo feminino, 42 anos, com histórico prévio de situs inversus totalis e LVB inicialmente reparada simultaneamente à lesão, há 10 anos, por um cirurgião não especializado. Ela foi encaminhada a um centro especializado devido a episódios recorrentes de colangite e um padrão laboratorial colestático. Colangiressonância revelou uma grave estenose anastomótica. Devido à sua idade jovem e colangites recorrentes, foi submetida a uma revisão cirúrgica da hepaticojejunostomia com técnica de Hepp-Couinaud. Até onde sabemos, este é o primeiro relato de reparo de LVB em um paciente com situs inversus totalis. RESULTADOS: A hepaticojejunostomia realizado prèviamente foi desfeita e refeita empregando a técnica de Hepp-Couinaud, alta na placa hilar, com uma ampla abertura na confluência dos ductos biliares em direção ao ducto hepático esquerdo. A alça de roux anterior foi mantida. A recuperação pós-operatória transcorreu sem intercorrências, o dreno foi removido no sétimo dia pós-operatório, e a paciente está agora assintomática, com bilirrubina e enzimas canalículares normais, e sem mais episódios de colestase ou colangite. CONCLUSÕES: Variantes anatômicas podem aumentar a dificuldade tanto da colecistectomia quanto do reparo de LVB, o qual deve ser realizado em um centro especializado por cirurgiões hepatobiliares para garantir um manejo perioperatório seguro e um bom resultado a longo prazo.

Voluntary and involuntary ligature of the bile duct in iatrogenic injuries: a nonadvisable approach.

BACKGROUND: Bile duct injuries related to laparoscopic and/or open cholecystectomy are a frequent finding and require surgical treatment. Complete obstruction is due to either intentionally or unintentionally placed ligatures or clips. The intentional application is usually performed to "facilitate identification of the duct by bile duct dilation." Considering that we are a national referral center for such injuries, we decided to analyze our cases of voluntary and involuntary duct ligation after iatrogenic bile duct injury. METHODS: We reviewed the files of patients with voluntary or involuntary bile duct ligation. Results of preoperative evaluation of the ducts, operative treatment, and postoperative results were analyzed. RESULTS: A total of 413 patients were included. Forty-five patients presented with complete obstruction. In 15 cases, the ligature was intentional, and in 30 cases, occlusion was involuntary. Bile duct dilation (>10 mm) was demonstrated in one case of voluntary (6%) and three cases of involuntary ligations (10%). The remaining cases in both groups had no duct dilation and developed necrosis at the blinded duct and leakage proximal to the ligature, with different degrees of bilioperitoneum and/or biloma. In all cases, a Roux-en-Y hepatojejunostomy was performed. CONCLUSION: Bile duct ligature produces dilation in a very small number of patients (less than 10%) and usually produces necrosis of the blinded stump with subsequent bile leakage. Placement of a subhepatic drain and transference of the patient to a qualified center for reconstruction is the best approach if the primary surgeon is not able to do the repair.

Intrahepatic repair of bile duct injuries. A comparative study.

INTRODUCTION: The frequency of bile duct injuries associated to cholecystectomy remains constant (0.3-0.6%). A multidisciplinary approach (endoscopical, radiological, and surgical) is necessary to optimize the outcome of the patient. Surgery is indicated when complete section of the duct is identified (Strasberg's E injuries) requiring a bilioenteric anastomosis as treatment. Nowadays, the most frequent technique used for reconstruction is a Roux-en-Y hepatojejunostomy. Long-term results of reconstruction are related to several technical and anatomic factors, but an ischemic duct (with subsequent scarring) plays a mayor role. In this paper, we report the results of biliary reconstructions comparing the extrahepatic-probably ischemic -- to intrahepatic -- non ischemic -- repairs. METHODS: We reviewed the files of patients referred to our hospital (third-level teaching hospital) for bile duct repair after iatrogenic injury from 1990 to July 2006. Injury classification, time lapse since injury, surgical repair technique, and long-term follow-up were noted. In all cases, a Roux-en-Y hepatojejunostomy was done. Partial resection of segment IV was performed in 136 patients to obtain noninflamed, nonscarred, nonischemic biliary ducts with the purpose of reaching the confluence and achieving a high-quality bilioenteric anastomosis. An anastomosis at the level of the confluence was attempted in 293 patients (in 198 the confluence was preserved and in 95 it was lost). In the remaining 80 patients, a low bilioenteric anastomosis was done at the level of the common hepatic duct. We compared intrahepatic (198) and extrahepatic (80) repairs. RESULTS: A total of 405 cases (88 males, 317 females) were identified, with a mean age of 42 years (range 17-75). All of the injuries were classified as Strasberg E1, E2, E3, E5 (less frequent); those with E4 classification (separated ducts) were excluded. In all cases, the confluence was preserved (N = 293). Thirty-two cases were repaired minutes to hours after the injury occurred. The remaining 373 patients arrived weeks after the injury. In 198 cases, an intrahepatic repair was done, including the 136 in which resection of segments IV and V was part of the surgery. In the remaining 80 cases (operated between 1990 and 1997), an extrahepatic repair was done at the level of the common hepatic duct where the surgeon found a healthy duct. Twelve (15%) of the 80 cases with extrahepatic anastomosis required a new intervention (surgical or radiological), compared to only 8 of the 198 (3%) that had an intrahepatic anastomosis (P = 0.00062). Good results were obtained in 85% and 97% of the cases with extrahepatic anastomosis and intrahepatic anastomosis, respectively. Both groups had a reintervention rate of 7% (20/278). CONCLUSIONS: An intrahepatic anastomosis requires finding nonscarred, nonischemic ducts, thus allowing a safe and high-quality anastomosis with significantly better results when compared to the low-level anastomosis group.

Acute Cholangitis After Bilioenteric Anastomosis for Bile Duct Injuries.

BACKGROUND/PURPOSE: The study aims to describe the clinical features, microbiology, and associated factors of acute cholangitis (AC) after bilioenteric anastomosis (BEA) for biliary duct injury (BDI). Additionally, we assessed the performance of the Tokyo Guidelines 2013 (TG13) recommendations in these patients. METHODS: We conducted a case-control study of 524 adults with a history of BEA for BDI from January 2000 to January 2014. A propensity score adjustment was performed for the analysis of the independent role of the main factors identified during the univariate logistic regression procedure. RESULTS: We identified 117 episodes of AC in 70 patients; 51.3% were definitive AC according to the TG13 diagnostic criteria, and 39.3% did not fulfill the imaging criteria of AC. A history of post-operative biliary complications (OR 2.55, 95% CI 1.38-4.70) and the bile duct confluence preservation (OR 0.46, 95% CI 0.24-0.87) were associated with AC. Eighty-nine percent of the microorganisms were Enterobacteriaceae; of them, 28% were extended spectrum ß-lactamase (ESBL) producers. CONCLUSIONS: AC is a common complication after BEA and must be suspected even in the absence of imaging findings, particulary in patients with a history of post-operative biliary complications, and/or without bile duct confluence preserved. An empirical treatment for ESBL-producing Enterobacteriaceae may be appropriate in patients living in countries with a high rate of bacterial drug resistance.

A rare case of choledochal cyst with pancreas divisum: case presentation and literature review.

Choledochal cysts are rare congenital malformations of the bile duct characterized by dilatations of the intrahepatic and/or extrahepatic portion of the biliary tree, they are associated to an anomalous arrangement of the pancreaticobiliary duct. Pancreas divisum results from a fusion failure of the pancreatic buds. The coexistence of pancreas divisum and choledochal cyst in adults has been reported in less than 10 well documented cases. This article presents a case of a 42-year-old Peruvian man with intermittent episodes of abdominal pain, initially diagnosed with choledocholithiasis, who underwent open cholecystectomy. During surgery, a diagnosis of choledochal cyst and pancreas divisum was made, and therefore a hepaticoduodenostomy was performed. The patient was referred to our hospital due to persistence of abdominal pain. After admission, a papillectomy was achieved without further complications. A cyst resection and dismantling of hepaticoduodenostomy with Roux-en-Y was performed 8 years later. During the subsequent 18-month follow-up, the patient remains asymptomatic.

Long-term evaluation of biliary reconstruction after partial resection of segments IV and V in iatrogenic injuries.

Roux-en-Y hepatojejunostomy is the procedure of choice for biliary reconstruction after complex iatrogenic injury that is usually associated with vascular injuries and concomitant ischemia of the ducts. To avoid the ischemic component, our group routinely performs a high repair to assure an anastomosis in noninflamed, nonscarred, and nonischemic ducts. If the duct bifurcation is preserved, the Hepp-Couinaud approach for reconstruction is an excellent choice. Partial liver resection of segments IV and V allows adequate exposure of the bile duct at its bifurcation with an anterior approach of the ducts (therefore not jeopardizing the circulation), allowing a high quality anastomosis. Long-term results of bile duct reconstruction using this approach are described. Two hundred eighty-five bile duct reconstructions were done between 1989 and 2004 in a tertiary care university hospital. The first partial-segment IV resection was done in 1994; 94 cases have been reconstructed since then using this approach. All of them had a complex injury (Strasberg E1-E5), and although in many cases the bifurcation was preserved (E1-E3), a high bilioenteric anastomosis was done to facilitate the reconstruction. In 70 cases, the bifurcation was identified, and in the 24 in which the confluence was not preserved, the right and left ducts were found except in one case. In three patients, the right duct was found unsuitable for anastomosis, and a liver resection was done. In the remaining 21, an anastomosis was done using a stent (transhepatic, transanastomotic) through the right duct. According to Lillemoe's criteria, 86 cases had good results (91%). In four of the eight remaining patients, there was the need to operate again due to the presence of an obstruction and/or cholangitis. In the rest, radiological instrumentation was done. Four of these cases have developed secondary biliary cirrhosis, two of which have died while waiting for a liver transplant, four and six years after reconstruction. Partial segments IV and V resection allows adequate exposure of the confluence and the isolated left or right hepatic ducts. Anterior exposure of the ducts allows an anastomosis in well-preserved, nonischemic, nonscarred, or noninflamed ducts. Parenchyma removal also allows the free placement of the jejunal limb, without external compression and tension, obtaining a high quality anastomosis with excellent long-term results.

Bile duct growing factor: an alternate technique for reconstruction of thin bile ducts after iatrogenic injury.

A variant of bilioenteric anastomosis, laterolateral hepatojejunostomy, is described in which the opened anterior aspect of the common hepatic duct and left hepatic duct is anastomosed to a Roux jejunal limb. This technique is specially designed for thin, injured bile ducts in which a conventional anastomosis is difficult due to the small diameter of the ducts. A wide anastomosis is obtained, leaving the posterior wall as a conduit for bile, ensuring an adequate anastomotic diameter.

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.

An unusual cause of bilioenteric anastomotic dysfunction after iatrogenic bile duct injury.

Roux en Y hepatojejunostomy is the surgery of choice for bile duct repair. Anastomotical dysfunction after reconstruction has several etiopathologies. Besides technical factors, ischemia of the duct is responsible for late obstruction. Bile colonization with secondary stones and sludge can also be identified as a cause. An unusual cause of anastomotical dysfunction secondary to ascaris biliary infestation after biliary reconstruction is reported herein. The patient had intermittent cholangitis and eosinophilia. At operation, the worm was found obstructing the anastomosis.