Complex Intrahepatic Lithiasis: A Case Report of Combined Treatment With Surgical Exploration of the Bilioenteric Anastomosis and Laser Lithotripsy by Cholangioscopy.

Intrahepatic lithiasis, or hepatolithiasis, is an endemic disease in southeast Asia, although, with immigration from Eastern countries, the incidence of this pathology is rising worldwide. The Latin American experience demonstrates morbidity and mortality compatible with other Western countries, but minimally invasive procedures are lacking. We demonstrate a case of a combined surgical and endoscopic approach for stone clearance. We present a case of a 47-year-old female patient with biliary enteric anastomosis to treat recurrent pyogenic cholangitis resulting from intrahepatic lithiasis. The patient was admitted to the emergency room, presented with a new episode of cholangitis, and submitted to transcutaneous hepatobiliary drainage. The multidisciplinary approach, including the endoscopic and surgical teams, successfully performed the stone clearance with laser lithotripsy and stone removal by open access. The postoperative period was uneventful, and the patient did not present any sign of recurrence after one year. A combined surgical and endoscopic approach achieved short-term clinical and technical success in this novel case. Moreover, individualizing cases requiring open surgical access is feasible, which allows a combined endoscopic approach with safety.

Biliary-enteric reconstruction in laparoscopic radical resection of hilar cholangiocarcinoma: a single-center retrospective cohort study.

OBJECTIVE: To evaluate the feasibility and quality of biliary-enteric reconstruction (BER) in laparoscopic radical resection of hilar cholangiocarcinoma (LsRRH) versus open surgery and propose technical recommendations. METHODS: Data of 38 LsRRH and 54 radical laparotomy resections of hilar cholangiocarcinoma (LtRRH) cases were collected from our institution. BER was evaluated via biliary residuals numbers, number of anastomoses, anastomosis manner, suture method, time consumption, and postoperative complication. RESULTS: In the LsRRH group, patients were relatively younger; Bismuth type I had a higher proportion while type IIIa and IV were less and required no revascularization. In LsRRH and LtRRH groups, respectively, the biliary residuals number was 2.54 ± 1.62 and 2.47 ± 1.46 (p > 0.05); the number of anastomoses was 2.04 ± 1.27 and 2.57 ± 1.33 (p > 0.05); the time of BER was 65.67 ± 21.53 and 42.5 ± 19.77 min (p < 0.05), 15.08 ± 3.64% and 11.76 ± 2.54% of the total operation time (p < 0.05); postoperative bile leakage incidence was 15.79% and 16.67% (p > 0.05); 14 ± 10.28 and 17 ± 9.73 days for healing (p < 0.05); anastomosis stenosis rate was 2.63% and 1.85% (p > 0.05). Neither group had a biliary hemorrhage or bile leakage-related death. CONCLUSION: The selection bias in LsRRH mainly affects tumor resection than BER. Our cohort study indicates that BER in LsRRH is technically feasible and equals anastomotic quality to open surgery. However, its longer and a more significant proportion of total operation time represent that BER has higher technical requirements and is one of the critical rate-limiting steps affecting the minimal invasiveness of LsRRH.

A novel micromagnetic ring used for biliary-enteric anastomosis in rats.

BACKGROUND: To explore the feasibility of micromagnetic ring in establishing biliary-enteric anastomosis in a rat model. METHODS: A new micromagnetic ring suitable for rat biliary-enteric anastomosis model was designed and fabricated. The common bile ducts of 20 Sprague-Dawley albino rats were ligated and dilated after 2 weeks. Surgery for biliary-enteric anastomosis was completed by using micromagnetic ring. The anastomosis time, postoperative survival rate, liver function, liver histopathology, and complications were recorded. After 28 days, anastomotic specimens were obtained to observe healing with the naked eye and light microscopy. RESULTS: Among the 20 Sprague-Dawley albino rats, one rat showed bile leakage and died one week after ligation of the common bile duct and another rat was removed from the experiment because there was no obvious dilatation of the common bile duct. The remaining 18 rats successfully underwent surgery for biliary-enteric anastomosis using micromagnetic ring, with an average anastomosis time of 7.10 ± 1.15 min (range, 5.17-9.50 min). The expulsion time of micromagnetic anastomosis rings was 11.94 ± 2.48 days (range, 8-17 days). The bilirubin level dropped to normal 1 week after surgery. Biliary-enteric anastomotic specimens were obtained 28 days after surgery, and microscopic observation showed that the mucosal layer of the anastomosis had good continuity and the anastomosis was smooth. CONCLUSION: A micromagnetic ring can be used to construct a rat biliary-enteric anastomosis model, and it offers advantages, such as simple operation and reliable anastomosis effect.

Findings encountered in percutaneous cholangiography in a case of post-transplant recurrence of hepatic Langerhans cell histiocytosis with biliary involvement.

This case report describes a four-year-old boy who presented with the diagnosis of LCH with liver involvement. This required a living-related liver transplant one year later. The primary disease recurred in the transplanted liver 6 months post-transplant and led to progressive biliary dilatation. A percutaneous trans-hepatic cholangiogram was performed five years after transplant, showing a pattern of multifocal biliary duct strictures mimicking the pattern of primary sclerosing cholangitis and a stenosis of the biliary-enteric anastomosis. Despite management with an internal-external biliary drain, the stenosis of the biliary-enteric anastomosis evolved to an occlusion one year after drain removal. This was associated with progression of the changes in the biliary tree, this time associated with significant saccular dilatations secondary to the multiple areas of stenosis. Due to these findings and progressive deterioration of the function of the graft, the patient required re-transplantation. This report illustrates the findings in imaging of the biliary tree secondary to the recurrence of LCH after liver transplantation, which may help to recognize this complication to physicians facing a similar clinical scenario.

Gadoxetate Disodium-Enhanced MR Cholangiography for Evaluation of Biliary-Enteric Anastomoses: Added Value Beyond Conventional T2-Weighted Images.

OBJECTIVE. The objective of our study was to evaluate image quality and reader confidence in MR cholangiography of bile ducts using conventional T2-weighted MR cholangiography alone in comparison with T2-weighted MR cholangiography and gadoxetate disodium-enhanced MR cholangiography in a series of patients with biliary-enteric anastomosis (BEA). SUBJECTS AND METHODS. Fifty patients with BEA and clinically and sonographically suspected complications underwent 1.5-T MRI. After acquisition of T1- and T2-weighted images, conventional MR cholangiography was performed using 3D fast relaxation fast spin-echo (FRFSE) and single-shot fast spin-echo (SSFSE) T2-weighted sequences (image set 1). In each patient, a 3D fat-suppressed Liver Acquisition with Volume Acceleration (LAVA) sequence was performed before and 15, 20, 25, 30, and 40 minutes after IV administration of 0.1 mL/kg of gadoxetate disodium (Primovist) (image set 2). Two radiologists in consensus evaluated image quality in the anatomic segments of the biliary tract and recorded diagnostic confidence scores for image set 1 alone and image sets 1 and 2 together. MRI findings were compared with postsurgical specimen if surgery was performed, conventional cholangiography, or 12 months of imaging follow-up. RESULTS. A significant improvement in image quality for visualization of all biliary segments was found using gadoxetate disodium-enhanced MR cholangiography in comparison with T2-weighted MR cholangiography alone. Readers judged diagnostic confidence of image set 1 alone and image sets 1 and 2 together as very confident in three and 37 cases, confident in 30 and 11, not confident in 14 and one, and not confident at all in three and 1, respectively. Concordance between image set 1 alone and image sets 1 and 2 together and the reference standard results was present in 23 of 50 cases (46%) and 47 of 50 cases (94%), respectively (p < 0.0001). CONCLUSION. Gadoxetate disodium-enhanced MR cholangiography can improve image quality for visualization of the biliary tract and further enhanced the diagnostic performance of conventional T2-weighted MR cholangiography in the evaluation of patients with BEA.

Antireflux Status Post Roux-en-Y anastomosis: An Experimental Study for Optimal Antireflux Technique.

BACKGROUND: Roux-en-Y hepaticojejunostomy has been a gold standard to establish biliary-enteric anastomosis for various surgical indications, but associated with variable incidences of cholangitis. This experimental study was conducted to report a modification in Roux-en-Y anastomosis for possible better alternative to provide antireflux procedure after Roux-en-Y biliary-enteric anastomosis with the aim to minimize the possibility of reflux and its consequences. MATERIALS AND METHODS: For experimental study, the required fresh segment of Lamb's small intestine was procured. Three sets of Roux-en-Y anastomosis were created for each experiment. In set 1, there was simple Roux-en-Y anastomosis. In set 2, Roux-en-Y anastomosis along with 4-5 cm long spur between the hepatic and duodenal limbs was created. In set 3, in addition to Roux-en-Y with creation of spur, additional antireflux mechanism was created at the junction of upper two-third and lower one-third of the hepatic limb. Saline mixed contrast was infused by infusion pump to raise the intraluminal pressure to more than 10 cm of H2O. X-ray was taken at that time. RESULTS: In set 1, all preparations demonstrated reflux of contrast in the hepatic limb. The set 2 also demonstrated the same findings of 100% reflux in the hepatic limb. In set 3, No reflux was observed in 8 (80%) preparations while remaining 2 (20%) preparations reveal partial reflux. CONCLUSION: This experimental study suggests that the provision of spur and additional valve may be able to decrease the possibility of reflux in Roux-en-Y biliary-enteric anastomosis.

Preventing intrahepatic infection after ablation of liver tumours in biliary-enteric anastomosis patients.

PURPOSE: To assess the value of bowel preparation plus targeted antibiotics for preventing intrahepatic infections after MWA of liver tumours in BEA patients. MATERIALS AND METHODS: This retrospective study included 21 patients (divided into two groups) with a history of BEA undergoing ultrasound-guided MWA of liver tumours from November 2008 to June 2014. Group A (n = 10) received single-antibiotic therapy (cefazedone 2 g bid 4, amoxicillin and flucloxacillin sodium 2 g bid 3, levofloxacin 0.5 g qd 3) after ablation, and group B (n = 11) received bowel preparation before ablation plus combined antibiotic therapy (imipenem and cilastatin sodium 1 g 1/12 h, linezolid 0.6 g 1/12 h). Patients were followed for 3 months. Incidences of fever, bacteraemia, and intrahepatic infections were compared, including the duration of fever and length of hospital stay. RESULTS: Following ablation, in group A, 90% of the patients (9/10) had fever, 60% (6/10) had bacteraemia, 60% (6/10) had liver abscess, and 10% (1/10) had biliary tract infection. In group B, no cases of bacteraemia or intrahepatic infection were reported, and the incidences of fever, bacteraemia, and liver abscess were substantially lower than group A (p = 0.002, 0.004, 0.004). Duration of fever and length of hospital stay were markedly shorter than group A (p = 0.002 0.003). CONCLUSIONS: Bowel preparation plus targeted antibiotic therapy can significantly reduce the incidences of fever, bacteraemia, and intrahepatic infections in BEA patients undergoing MWA of liver tumours. These preliminary results need to be further validated in randomised trials.

Modified laparoscopic biliary enteric anastomosis procedure using handmade double-armed needles.

INTRODUCTION: Laparoscopic biliary enteric anastomosis (BEA) offers several advantages, including good visualization, which helps to overcome the compromised visual field resulting from the biliary tract being located on the right anterior side of the body at some distance from the surgical opening. Laparoscopic BEA, however, requires skillful manipulation of the forceps over a limited range to achieve optimal outcomes. Here we describe a modified and reorganized BEA technique that increases the simplicity and feasibility of the procedure. MATERIALS AND SURGICAL TECHNIQUES: After biliary tract surgery for benign diseases such as laparoscopic choledocholithotomy, handmade double-sided needles were used for BEA in 20 patients. First, one of the needles was placed at the right edge of the bile duct wall from the outside to the inside, while the other arm of the needle entered the right edge of the intestine from the outside to the inside. Next, continuous sutures were placed on the posterior wall with the needle that was placed on the intestine. Then, continuous sutures were placed on the anterior wall with a second needle. Finally, both threads were laparoscopically tied. DISCUSSION: This relatively simple and feasible method has demonstrated excellent results and will be beneficial in the clinical setting.

Extrahepatic cyst excision and partial hepatectomy for Todani type IV-A cysts.

BACKGROUND: Extrahepatic cyst excision and Roux-en-Y hepaticojejunostomy is not satisfactory in many patients with complex Todani type IV-A choledochal cysts. AIMS: To report the results of combined extrahepatic cyst excision, partial hepatectomy, and Roux-en-Y hepaticojejunostomy for type IV-A choledochal cysts. METHODS: The records of patients who received extrahepatic cyst excision, partial hepatectomy, and Roux-en-Y hepaticojejunostomy for type IV-A choledochal cysts from January 2002 to December 2011 were retrospectively reviewed, and surgical outcomes analysed. RESULTS: 59 patients (30.5% males; mean age, 43.2 ± 18.4 years) were included. Radical excision of cystically dilated bile ducts was achieved in 53 patients (89.8%). Bile leakage, delayed wound healing, and abdominal infection occurred in 5 (8.47%), 7 (11.86%), and 3 (5.08%) patients, respectively. Forty-nine patients (83.1%) were followed for an average of 42.6 ± 15.3 months. During the follow-up, 6 patients (12.2%) experienced recurrent cholangitis. Long-term biliary function was excellent in 33 (67.4%), good in 9 (18.4%), fair in 5 (10.2%), and poor in 2 (4.1%) patients. CONCLUSION: Combined extra-hepatic cyst excision, partial hepatectomy, and Roux-en-Y hepaticojejunostomy is effective for the treatment of complex Todani type IV-A choledochal cysts with substantial intrahepatic bile duct involvement and hilar bile duct stenosis.

Iatrogenic biliary injuries: identification, classification, and management.

Because it offers several advantages over open cholecystectomy, laparoscopic cholecystectomy has largely replaced open cholecystectomy for the management of symptomatic gallstone disease. The only potential disadvantage is a higher incidence of major bile duct injury. Although prevention of these biliary injuries is ideal, when they do occur, early identification and appropriate treatment are critical to improving the outcomes of patients suffering a major bile duct injury. This report delineates the key factors in classification (and its relationship to mechanism and management), identification (intraoperative and postoperative), and management principles of these bile duct injuries.