Lesiones de la vía biliar

La finalidad de esta revisión es mostrar el estado actual de las lesiones de vía biliar (LVB), producidas especialmente durante la colecistectomía laparoscópica. Revisaremos la etiopatogenia, los grados de compromiso biliar, las lesiones vasculares asociadas, las clasificaciones utilizadas y los factores de riesgo. Además la forma como evaluar oportunamente la magnitud de la lesión, tanto en la misma cirugía como en el postoperatorio. Igualmente se muestran las diversas alternativas terapéuticas empleadas. Todo con la finalidad de evitar graves complicaciones.

The purpose of this review is to show the current status of bile duct injury, specially produced during laparoscopic cholecystectomy. We will review etiopathogenesis, degrees of bile commitment, associated vascular lesions, classifications used and risk factors. In addition, how to assess the extent of the injury in a timely manner, both in the same surgery and in the postoperative surgery. The various therapeutic alternatives used are also shown. All in order to avoid serious complications.

Mejoría de la calidad de vida después de la reparación definitiva de la lesión de la vía biliar, evaluada con el cuestionario SF-36 / Improvement on quality of life after bile duct injury repair using the SF-36 Health Survey

RESUMEN Antecedentes: diferentes publicaciones han estudiado la fisiopatología de la lesión de la vía biliar (LVB), pero pocas han investigado los efectos psicosociales y de calidad de vida relacionados con su reparación. Objetivo: comparar la calidad de vida de pacientes antes y después de la reparación definitiva de una LVB. Material y métodos: se usó como instrumento para evaluar la calidad de vida relacionada con la salud (CVRS) el cuestionario de salud SF-36 en una serie de pacientes operados entre diciembre de 2015 y junio de 2019 para la reparación de LVB. Resultados: sobre 48 casos de reparaciones de LVB, contestaron la encuesta 22 (46%). Se compararon los ítems del formulario SF 36: diferencia en la función física, el rol físico, el dolor corporal, la salud general, la vitalidad, la función social, el rol emocional, la salud mental y el ítem de transición de salud, y todos mostraron una mejoría estadísticamente significativa (p < 0,001) después de la reparación. En el análisis univariado se observó que la salud mental se vio afectada por la presencia de una lesión compleja (p = 0,019), el rol físico y el rol emocional antes de la reparación, y mostró relación con el tipo de lesión según Strasberg (p = 0,001 y p = 0,032). Aquellos que asociaron lesión vascular presentaron una asociación negativa con la función física (p = 0,019), la vitalidad (p = 0,033), la salud mental (p = 0,005) y el dolor (p = 0,026) antes de la reparación. Conclusión: la resolución definitiva de la LVB en un centro especializado en patología hepatobiliopancreática mostró producir una significativa mejoría en la calidad de vida.

ABSTRACT Background: Different publications have examined the pathophysiology of bile duct injury (BDI), bur few studies have investigated the effects of BDIs and their subsequent repair on psychosocial and health-related quality of life Objective: The aim of this study was to compare the quality of life of patients before and after definitive BDI repair. Material and methods: The SF-36 Health Survey was used as an instrument to assess health-related quality of life (HRQL) in a series of patients operated on between December 2015 and June 2019 for BDI repair. Results: Of 48 patients who underwent BDI repair, 22 (46%) responded to the survey. The SF-36 items, which includes different domains (physical functioning, physical role functioning, bodily pain, general health, vitality, social functioning, emotional role functioning, mental health, and health transition) were compared. All domains demonstrated statistically significant improvement (p < 0.001) following repair. On univariate analysis, mental health was affected by the presence of a complex injury (p = 0.019), and physical and emotional role functioning before BDI repair were associated with the type of injury of the Strasberg classification (p = 0.001 and p = 0.032, respectively). An associated vascular injury had a negative correlation with physical functioning (p = 0.019), vitality (p = 0.033), mental health (p = 0.005), and pain (p = 0.026) prior to repair. Conclusion: The definitive resolution of BDIs at a center specialized in hepatobiliary and pancreatic surgery resulted in a significant improvement of patients' quality of life.

Resección hepática como tratamiento de lesión de vía biliar compleja / Liver resection for the treatment of complex bile duct injury

RESUMEN La lesión de la vía biliar constituye un problema de salud importante, ya que su incidencia se ha duplicado desde el advenimiento de la colecistectomía laparoscópica. En casos de lesiones complejas con afectación de la confluencia, asociación a lesiones vasculares, atrofia hepática, colangitis o intentos fallidos de reparación, el tratamiento suele ser un desafío. Presentamos el caso de una paciente con lesión compleja por compromiso vascular del pedículo hepático derecho que desarrolló una atrofia del parénquima hepático. Ante la presencia de complicaciones sépticas debió realizarse una hepatectomía asociada a la reparación definitiva de la vía biliar, con buenos resultados.

ABSTRACT Bile duct injury represents a serious health problem, with its incidence doubling since the advent of laparoscopic cholecystectomy. In cases of complex lesions affecting the hepatic confluence, association with vascular injuries, hepatic atrophy, cholangitis or failed repair, treatment is often challenging. We report the case of a female patient with a complex bile duct injury due to vascular involvement of the right hepatic pedicle who developed right liver atrophy. In the presence of septic complications, hepatectomy was necessary, along with a definitive repair of the biliary tract, resulting in positive outcomes.

Advances in the treatment of iatrogenic bile duct injury / 临床肝胆病杂志

Iatrogenic bile duct injury (IBDI) refers to bile duct injury accidentally caused by medical factors such as surgical operation or other invasive operations during treatment. With the gradual maturity of surgical operation and minimally invasive techniques, the treatment of bile duct injury now includes endoscopic treatment, bile duct jejunum Roux-en-Y anastomosis, bile duct end-to-end anastomosis, hepatectomy, and liver transplantation. For IBDI, the selection of reasonable and effective treatment methods is currently an important and difficult issue in biliary surgery. Through a systematic review of the literature on the treatment of IBDI, this article analyzes and summarizes the different treatment modalities for IBDI.

Indocyanine green fluorescence navigation in obese patients undergoing laparoscopic cholecystectomy / 国际外科学杂志

Objective:To investigate the feasibility and potential of fluorescent cholecystic bile duct visualization with direct intravenous injection of indocyanine green(ICG) in obese patients undergoing laparoscopic cholecystectomy(LC).Methods:The clinical data of 132 patients with LC combined with obesity admitted to the Department of Hepatobiliary and Pancreatic Surgery of the Second People′s Hospital of Changzhou City, affiliated to Nanjing Medical University, from January 2023 to July 2023 were retrospectively analyzed. They were divided into fluorescence group( n=65) and control group( n=67) according to whether indocyanine green fluorescence navigation was used or not. There were 50 males and 82 females, and all the enrolled patients body mass index≥28 kg/m 2. Two groups identify the time of the three tubes, intraoperative bleeding, operation time, postoperative hospitalization time, white blood cell count(WBC), C-reactive protein(CRP), alanine aminotransferase(ALT), gamma-glutamyl transferase(GGT), and postoperative follow-up in the fluorescent and control groups were counted respectively. Measurement data with skewed distribution were expressed as M( Q1, Q3), and intergroup comparisons were performed using the Mann-Whitney U test; counting data were described by frequency(rate), and intergroup comparisons were made by applying the chi-square test, Fisher′s exact probability method, and chi-square corrected test according to the difference in the minimum frequency. Results:Surgery was successfully completed in both groups. Preoperative inflammatory indicators and liver function levels were also not statistically significant( P>0.05). The time to identify the three tubes, operation time, intraoperative bleeding, and postoperative hospitalization in the fluorescence group were 18.00(13.50, 20.00) min, 40.00(30.00, 50.00) min, 5.00(5.00, 10.00) mL, and 2.00(1.50, 3.00) d, and in the control group were 32.00(25.00, 45.00) min, 65.00(50.00, 85.00) min, 41.00(41.00, 46.00) mL, and 4.00(3.00, 5.00) d. The differences between the two groups were statistically significant( P<0.05). The postoperative leukocyte count, postoperative CRP, and postoperative GGT were 9.15(7.10, 11.75)×10 9/L, 7.19(3.22, 20.00) mg/L, and 34.0(20.0, 49.0) U/L in the fluorescence group, and 13.05(11.02, 15.59)×10 9/L, and 18.78(12.90, 32.95) mg/L in the control group, respectively, 82.5(68.5, 114.5) U/L, and the differences between the two groups were statistically significant ( P<0.05). None of the patients showed abdominal pain, abnormal liver function and hepatobiliary ultrasound in the follow-up findings within 2 months after surgery. Conclusion:The effect of obesity, a factor that interferes with ICG fluorescence, is extremely limited, and ICG fluorescence cholangiography is a useful technique in the obese population that not only improves the efficiency of the procedure, but also increases intraoperative safety, with results superior to those of conventional laparoscopic cholecystectomy.

Research advances in the diagnosis and treatment of benign gallbladder disease / 中华肝胆外科杂志

Benign gallbladder diseases are common in general surgery practice, and laparoscopic cholecystectomy (LC) has become the standard treatment for these conditions. With the widespread adoption of LC and the improved understanding of gallbladder disease, it is necessary to re-evaluate the diagnosis and treatment of benign gallbladder disease. Based on the latest expert consensus on the diagnosis and treatment of benign gallbladder disease, this review aims to provide an overview of the diagnostic and treatment strategies for benign gallbladder diseases. Specifically, it focuses on enhancing our understanding of the role of benign gallbladder diseases in the development of gallbladder cancer, the impact of congenital biliary anomalies on the diagnostic and treatment processes of benign gallbladder diseases, and the significance of the preoperative examinations.

Evaluating and repairing biliary injury during normothermic liver perfusion / 中华器官移植杂志

A widening gap between demand and availability of donor livers for transplantation has stimulated the use of extended-criteria donor(ECD)livers, including donation after circulatory death liver grafts.However, these types of donor livers carry an elevated risk of developing such postoperative complication as ischemic type biliary lesions(ITBL).Although the pathogenesis of ITBL has remained elusive, severity of histological bile duct injury(BDI)at the time of transplantation has been identified as a strong predictor of the development of ITBL post-transplantation.In recent years, significant advances have been achieved in the field of liver machine perfusion.Normothermic machine perfusion(NMP)is primarily utilized for determining the quality of ECD organs.To evaluate the extent of biliary injury during NMP, some reliable criteria of BDI are required.This review focused upon different approaches of assessing damage to biliary tree and current understandings of potential effects of NMP on biliary system and biliary injury.Also it offered an overview of novel biomarkers and emerging therapeutic strategies.

Research progress of intraoperative cholangiography in laparoscopic cholecystectomy / 国际外科学杂志

With the widespread implementation of laparoscopic cholecystectomy in various levels of medical institutions, surgical complications have also increased. Among them, the incidence of bile duct injury remains high in complex laparoscopic cholecystectomy. The reason for this is that surgeons cannot effectively and accurately identify the relationship between the aberrant bile duct and the cystic duct and the common bile duct, resulting in the accidental injury of the bile duct, resulting in long hospital stays, increased medical costs, and decreased long-term quality of life for patients. Intraoperative cholangiography, as a real-time visual method of biliary presentation, can effectively reduce the incidence of iatrogenic bile duct injury. However, most surgeons do not fully understand the technology of intraoperative cholangiography during cholecystectomy. This article reviews the application of intraoperative cholangiography in laparoscopic cholecystectomy based on the clinical experience of the author′s team and the literature in recent years, with the aim of deepening the understanding of surgeons about intraoperative cholangiography, so as to better apply it to clinical practice and benefit patients.

Lesiones de vía biliar poscolecistectomía: conducta terapéutica actual / Post Cholecystectomy Bile Duct Injuries: Current Therapeutic Option

Resumen La colecistolitiasis es una condición común en Chile. La complicación más frecuente de esta condición es la colecistitis aguda. Aproximadamente 60.000 colecistectomías son realizadas anualmente en nuestro país, convirtiéndola en una de las patologías digestivas más frecuentes. El tratamiento de la colelitiasis ha evolucionado las últimas dos décadas. Con el desarrollo de la laparoscopía a final de 1980, la colecistectomía abierta fue definitivamente sustituida en los 90 por la vía laparoscópica. Desafortunadamente, la generalización de este procedimiento produjo un aumento en la incidencia de lesiones de vía biliar, aumentando desde una 0,1-0,2% hasta un 0,5-0,7%. Si bien, con el progresivo entrenamiento de los cirujanos en la cirugía mínimamente invasiva esta cifra ha disminuido nuevamente, la LVB aún constituye una de las complicaciones más graves en cirugía, generando gran impacto en la calidad de vida del paciente, e incluso costos en salud que pueden llegar a ser devastadores. El manejo de una lesión de vía biliar es, para muchos cirujanos, un desafío quirúrgico, que para su resolución requiere de las habilidades y experiencia de un cirujano hepatobiliar y derivación a centros de salud especializados. Sin duda, la acción más importante es extremar de manera rutinaria las medidas de prevención. Sin embargo, una vez que la lesión se ha producido, el futuro del paciente depende, directamente, del buen criterio del cirujano, tanto para realizar un diagnóstico temprano, como del enfrentamiento terapéutico que realice. El objetivo de este trabajo es dar a conocer diferentes conductas preventivas y terapéuticas cuando esta complicación se presenta.

Calculous biliary disease is a common condition in Chile. Over 60.000 cholecystectomies are performed annually, making gallstone disease one of the most common digestive health problems. The treatment of calculous biliary disease has evolved over the last 2 decades. With the development of laparoscopic technology in the late 1980s, new techniques for cholecystectomy were introduced. By the early 1990s, laparoscopic cholecystectomy had replaced open cholecystectomy in the operative management of gallbladder stone disease. Unfortunately, the widespread application of laparoscopic cholecystectomy has led to a concurrent rise in the incidence of major bile duct injuries. Reports have estimated the incidence has risen from 0.1-0.2 to 0.5-0.7%. Although, exponential training of surgeons in minimally invasive surgery has led to decrease this numbers again, bile duct injuries still constitute one of the most serious complications in surgery, generating a great impact on the patient's quality of life, and even health costs that can be devastating. The management of patients following major bile duct injurie is a surgical challenge, often requiring the skills of experienced hepatobiliary surgeons at tertiary referral centers. In this setting, the most important action is to routinely maximize prevention measures. However, once injury has occurred, patient's future depends directly on the correct judgment of the surgeon, both to make an early diagnosis and to choose the best therapeutic confrontation. The objective of this article is to present the different preventive and therapeutic options available when this complication occurs.

Application of intraoperative intravenous injection of indocyanine green in endoscopic surgery for chronic atrophic cholecystitis / 国际外科学杂志

Objective:To investigate the clinical value of intraoperative intravenous injection of indocyanine green in differentiating extrahepatic bile duct structure in chronic atrophic cholecystitis.Methods:A retrospective analysis was performed on the data of 110 patients diagnosed with chronic AC who underwent laparoscopic cholecystectomy (LC) admitted to the Department of Hepatobiliary and pancreatic Surgery of Changzhou Second People′s Hospital from January 2020 to July 2021. All patients were confirmed by abdominal B-ultrasound before surgery. The patients in the experimental group were divided into experimental group ( n=55) and control group ( n=55) according to whether indocyanine green was intravenously injected during the operation. The experimental group was intravenously injected with 5 mg indocyanine green during the operation, and LC was navigated by indocyanine green fluorescence imaging technique during the operation. The control group received routine LC. The imaging rate and imaging time of the cystic duct, common bile duct, and common hepatic duct in the experimental group were compared. The clinical data, identify three tube time, operation time, intraoperative blood loss, abdominal cavity drainage placement and extubation time, transfer laparotomy and bile duct injury, postoperative hospital stay, postoperative first review of alanine aminotransferase (ALT), glutamine transferase (GGT) of leveling and follow-up were compared between the two groups. The measurement data subject to normal distribution were expressed by Mean±standard deviation ( ± s), and the two groups were compared by independent sample t test. The measurement data of skewness distribution were described by M( Q1, Q3)and the manhui method in nonparametric test was used Mann-whitney U test.The chi-square test or Fisher′s exact probability method was used for comparison between groups of count data. Results:Operation was performed successfully in both groups. In the experimental group, the common hepatic duct, common bile duct and gallbladder duct were developed successfully in all patients, 54 cases and 52 cases respectively, and the developing time of the three tubes was (15.8±1.2) min. In the experimental group, the time of three tubes, operation time, intraoperative blood loss and abdominal drainage tube placement were (18.5±1.3) min, (64.0±6.8) min, (16.3±6.7) mL, 43 cases, respectively. In the control group, there were (46.3±8.1) min, (98.7±10.5) min, (53.6±14.9) mL and 55 cases, respectively. The experimental group was significantly lower than the control group, and the difference between the two groups was statistically significant ( P< 0.05). There was no case of conversion to laparotomy and bile duct injury in the experimental group, and 1 case of conversion to laparotomy and 1 case of bile duct injury in the control group, and there was no statistical significance between the two groups ( P>0.05). There were significant differences in postoperative extubation time and postoperative hospital stay between the two groups ( P<0.05). ALT and GGT levels were 47(31, 75) U/L and 38(19, 114) U/L in the experimental group and 62(53, 92) U/L and 76(63, 96) U/L in the control group at the first postoperative review, with statistically significant differences between the two groups ( P<0.05). Patients in both groups were followed up for 3 months after discharge. There were no obvious complications in the experimental group, and 1 case had a small amount of peritoneal effusion 7 days after discharge in the control group. Conclusion:In the face of LC with chronic AC, intraoperative intravenous injection of indocyanine green to develop extrahepatic bile duct can help to distinguish its anatomical structure and avoid bile duct injury, improve the safety and progress of surgery, and maximize training and improve the level of the surgeon.

Endoscopic surgery strategies of delayed iatrogenic bile duct injury / 中华消化外科杂志

The treatment of iatrogenic bile duct injury is complex, especially for delayed iatrogenic bile duct injury, and the timing and treatment measures are crucial. Endoscopic surgery treatment, interventional treatment and surgery all play important roles. Endoscopic surgery treatment has become the main choice for iatrogenic bile duct injury because of its advantages of small trauma, fast recovery, short operation time and precise efficacy, etc. At the same time, endoscopic surgery treatment can create opportunities and conditions for secondary bile duct repair surgery, and can also control the occurrence of post-repair complications. With the further populari-zation and application of endoscopic technology, the development of imaging three-dimensional reconstruction technology and visualization analysis, endoscopic surgery treatment will definitely become the main treatment for delayed iatrogenic bile duct injury.

Hepatectomía derecha para lesión del conducto biliar posterior a colecistectomía / Right hepatectomy for post-cholecystectomy bile duct injury

Mujer de 54 años sometida a colecistectomía laparoscópica programada por colecistolitiasis sintomática, el procedimiento fue convertido a abordaje abierto por presencia de bilirragia perioperatoria no localizada, tratada con sutura primaria del lecho vesicular bajo sospecha de un conducto aberrante de Luschka. Al vigésimo día postoperatorio se diagnostica una fístula biliar tras la aparición de bilirragia a través de la herida quirúrgica. Una colangiografía transhepática percutánea mostró una pérdida completa de continuidad con fuga a ese nivel, confirmando la lesión del conducto hepático derecho, con un extremo cortado retraído del conducto hepático. Debido a la compleja lesión de la vía biliar proximal, a los 3 meses de la primera cirugía se realiza una hepatectomía derecha. Aunque la hepatectomía no es un procedimiento estándar para pacientes con lesiones quirúrgicas de la via biliar, debe considerarse como parte del arsenal quirúrgico para la reparación de un grupo seleccionado de pacientes en lesiones postcolecistectomía

A 54-year-old female underwent a planned laparoscopic cholecystectomy due to a symptomatic cholecystolithiasis, the procedure was converted to an open approach due to the presence of a not located perioperative bilirhagia, treated with a primary suture of the gallbladder bed under the suspicion of an aberrant duct of Luschka. On the 20th postoperative day, the patient is diagnosed with a biliary fistula after the appearance of bilirhagia through the surgical wound. A percutaneous transhepatic cholangiography showed a complete loss of continuity with leakage at that level, confirming the right hepatic duct injury, with a retracted cut end from the hepatic duct. Due to the complex proximal bile duct injury, 3 months after the first surgery, a right hepatectomy is performed. Although an hepatectomy is not a standard procedure for patients with IBDI, it should be considered as a part of the surgical armamentarium for the repair of a selected group of patients in postcholecystectomy injuries

Cómo evitar la lesión de vía biliar en colecistectomía laparoscópica: más allá de la visión crítica de seguridad / How to avoid bile duct injury in laparoscopic cholecystectomy: beyond the critical safety view

Resumen La colecistectomía laparoscópica (CL) es el estándar de tratamiento para la patología benigna como la colelitiasis y los pólipos de la vesícula biliar y es uno de los procedimientos más frecuentes de la cirugía general. Esta intervención tiene un riesgo de 0,1%-0,3% de causar una lesión quirúrgica de la vía biliar (LQVB). En la actualidad, existen programas de sociedades científicas, estrategias de abordaje y tecnologías que nos permiten reducir las LQVB mejorando la seguridad clínica de este procedimiento. El objetivo de este documento es realizar una revisión de las estrategias, tecnologías y maniobras para realizar una CL segura más allá de la visión crítica de seguridad.

Laparoscopic cholecystectomy (LC) is the standard of treatment for benign pathologies such as cholelithiasis and gallbladder polyps. The LC is one of the most frequent procedures in general surgery, with a 0.1%-0.3% associated risk of bile duct injury. Currently, scientific society programs, surgical strategies, and new technologies allow us to reduce the risk of bile duct injuries and to increase the clinical safety of this procedure. This document aims to review the strategies, technologies, and tactics to carry out a safe LC beyond the critical vision of security.

Colecistitis aguda en vesícula biliar izquierda. Presentación de un caso resuelto en forma segura por vía laparoscópica / Acute cholecystitis in a left sided gallbladder safely managed by laparoscopic surgery

RESUMEN La vesícula izquierda (VI) es una rara anomalía de la vía biliar que, cuando enferma, no suele dar sín tomas diferentes de aquella normoposicionada, haciendo infrecuente su diagnóstico preoperatorio. Presentamos el caso de una colecistitis aguda en un paciente con VI, resuelto en forma segura por vía laparoscópica. Un paciente ingresa por un cuadro típico de colecistitis aguda. Como hallazgo in traoperatorio se constata una vesícula biliar inflamada, ubicada en posición siniestra. Se modificó la ubicación de los puertos de trabajo y se realizó colangiografía transvesicular por punción, antes de iniciar la disección del hilio vesicular. Luego de identificar el conducto cístico, se realizó colangiografía transcística que confirmó la anatomía de la vía biliar completa y expedita. Se completó la colecistec tomía laparoscópica en forma segura. El hallazgo de una VI obliga al cirujano a cambiar la técnica de una colecistectomía laparoscópica. Esta anomalía incrementa el riesgo de lesiones de la vía biliar. La disección cuidadosa del hilio vesicular logrando una visión crítica de seguridad y el uso de colangiogra fía intraoperatoria son de extrema importancia para una colecistectomía segura.

ABSTRACT Left-sided gallbladder (LSGB) is a rare bile duct abnormality, usually found during a cholecystectomy. Symptoms usually do not differ from those of a normally positioned gallbladder, making the preoperative diagnosis extremely uncommon. We report the case of an acute cholecystitis in a patient whit LSGB, safely managed with laparoscopic surgery. A 24-year-old male patient was admitted to our institution with clinical and radiological signs of acute cholecystitis. The intraoperative finding of an acute cholecystitis in a LSGB made us modify ports positioning and a cholangiograhy was done by direct puncture of the gallbladder before hilum dissection. After the cystic duct was identified, a transcystic cholangiography was performed which confirmed a complete and clear bile duct anatomy and laparoscopic cholecystectomy was safely completed. The intraoperative finding of a LSGB makes the surgeon change some aspects of the usual technique to perform a safe cholecystectomy as LSGB significantly increases the risk of common bile duct injuries. Meticulous dissection of the gallbladder hilum to achieve a critical view of safety and the systematic use of intraoperative cholangiography are extremely important to perform a safe laparoscopic cholecystectomy.

Risk factors analysis and prevention and intervention measures of bile duct injury in laparo-scopic cholecystectomy / 中华消化外科杂志

Laparoscopic cholecystectomy (LC) is the first preferred treatment of benign gallbladder diseases such as gallbladder stones and gallbladder polyps, however bile duct injury is a serious complication of LC. Although bile duct injury is a rare complication, improper treatments will seriously affect the quality of life or even threaten life. Therefore, the prevention and correct treatments of bile duct injury in LC are crucial. Based on domestic and overseas researches, the authors investigate risk factors for bile duct injury in LC, share experiences of timely detection, diagnosis and treatment, so as to provide references for hepatic and biliary surgeons.

Lesión quirúrgica de la vía biliar: experiencia en el Hospital José Ramón Vidal de Corrientes / Bile duct injury after cholecystectomy: the experience of Hospital José Ramón Vidal de Corrientes

RESUMEN Antecedentes: la lesión quirúrgica de la vía biliar representa un gran problema de salud y puede surgir ante cualquier cirujano que realice una colecistectomía. Objetivos: el objetivo del trabajo fue presentar nuestra experiencia en reparación de la vía biliar, ana lizando la morbimortalidad y la incidencia de dicha patología en nuestro Servicio. Material y métodos: estudio retrospectivo descriptivo; se tomaron las variables de las historias clínicas de los pacientes en un período de 8 años, de enero de 2011 a julio de 2019 donde fueron admitidos 19 pacientes que presentaron lesión quirúrgica de la vía biliar en el Hospital José Ramón Vidal de la provincia de Corrientes, Argentina. Resultados: 12 pacientes fueron tratados quirúrgicamente mediante hepático-yeyuno anastomosis, 2 por bihepático-yeyuno anastomosis y dos mediante sutura término-terminal bilio-biliar sobre tubo de Kehr. Tres pacientes fueron tratados mediante colocación de stent y dilatación posterior mediante colangiopancreatografia retrógrada endoscópica. Conclusión: los cirujanos deben entrenarse para disminuir al mínimo la posibilidad de una lesión. El objetivo de una colecistectomía debería ser no lesionar la vía biliar.

ABSTRACT Background: Bile duct injury represents a serious health problem and can occur after any cholecystectomy. Objectives: The aim of this study was to report our experience in repairing bile duct injuries analyzing morbidity, mortality and its incidence in our department. Material and Methods: We conducted a retrospective and descriptive study. The information was retrieved form the medical records of 19 patients with bile duct injury hospitalized at the Hospital José Ramón Vidal, Corrientes, Argentina, between January 2011 and July 2019. Results: A Roux-en-Y hepaticojejunostomy was performed in 12 patients, double hepaticojejunostomy in two patients, and two patients were treated with end-to-end ductal anastomosis with suture over a T tube. Three patients underwent endoscopic retrograde cholangiopancreatography with stent placement and dilation. Conclusion: Surgeons should be trained to avoid the possibility of bile duct injury. The main goal of cholecystectomy should be to avoid this complication.

Extra hepatic bile duct injury after laparoscopic cholecystectomy: a retrospective study

Background: Laparoscopic cholecystectomy (LC), being one of the most common performed surgical procedure among the basic surgeries. Incidence of common bile duct (CBD) injury as high as 1.4-3% has been reported in some studies. The aim of this study was to estimate the incidence and predictors of CBD injury who underwent elective laparoscopic cholecystectomy.Methods: A retrospective observational study conducted at Heritage Institute of Medical Sciences, Varanasi, Uttar Pradesh India. Data was collected for a period of 1 year between March 2019 till 2020.Results: In majority of laparoscopic cholecystectomy we encountered moderate degree of difficulty. Extra hepatic bile duct injuries occurred in 1.4% of cases and were classified according to Strasberg classification. Type A injury was most common followed by type E2. Most major bile duct injuries were recognized intraoperatively. No mortality was noted in our study.Conclusions: Bile duct injuries is a major complication of laparoscopic cholecystectomy with significant morbidity and mortality, reduced survival impaired quality of life and subsequent litigations. Majority of bile duct injuries, results mainly from the surgeon’s inexperience, misinterpretation of anatomy and poor surgical techniques.

Effects of definitive repair surgery on health-related quality of life in patients with bile duct injury after laparoscopic cholecystectomy / 中华消化外科杂志

Objective@#To investigate the effects of definitive repair surgery on health-related quality of life (HRQOL) in patients with bile duct injury after laparoscopic cholecystectomy (LC).@*Methods@#The retrospective case-control study was conducted. The clinicopathological data of 181 patients with bile duct injury caused by LC for benign gallbladder diseases who underwent definitive repair surgery and 50 patients without complications after LC for benign gallbladder diseases in the Mianyang Central Hospital from January 2000 to December 2017 were collected. There were 82 males and 99 females of 181 patients with bile duct injury, aged from 31 to 68 years, with an average age of 47 years. Definitive repair surgery was performed according to different types of bile duct injury, and questionnaire of HRQOL was conducted preoperatively and one year after operation. There were 18 males and 32 females of 50 patients without complications after LC, aged from 35 to 69 years, with an average age of 41 years. Questionnaire of HRQOL was conducted on LC patients without complications one year after operation. Observation indicators: (1) classification of bile duct injury; (2) intraoperative situations of definitive repair surgery; (3) postoperative situations of definitive repair surgery; (4) follow-up; (5) results of the SF-36 scale assessment. Follow-up was conducted by outpatient examination and telephone interview up to December 2018. Patients were reexamined liver function and color Doppler ultrasonography once every 6-12 months, and further magnetic resonance cholangiopancreatography (MRCP) or computed tomography examination to detect recurrence of anastomotic biliary stricture and cholangitis. Measurement data with normal distribution were expressed as Mean±SD, and comparison between groups was analyzed by the paired t test. Measurement data with skewed distribution were described as M (range), and count data were described as absolute numbers.@*Results@#(1) Classification of bile duct injury: of the 181 patients with bile duct injury, there were 64 cases of E1 type, 70 cases of E2 type, 35 cases of E3 type, 9 cases of E4 type, and 3 cases of E5 type. (2) Intraoperative situations of definitive repair surgery: all the 181 patinets with bile duct injury underwent definitive repair surgery successfully, including 61 undergoing end-to-end biliary anastomosis, 109 undergoing Roux-en-Y choledojejunostomy, 11 undergoing hemi-hepatectomy combined with Roux-en-Y anastomosis. There were 52 patients combined with hilar cholangioplasty. The operation time and volume of intraoperative blood loss of 181 patients were (190±126) minutes and 601.5 mL (range, 150.0-2 100.0 mL). There were 24 cases with blood transfusion and 18 cases with T-tube stent. (3) Postoperative situations of definitive repair surgery: 40 of 181 patients had complications, including 14 cases of incisional infection, 10 cases of bile leakage, 8 cases of perihepatic effusion, 7 cases of pulmonary infection, and 1 case of abdominal hemorrhage. The patient with postoperative abdominal hemorrhage underwent reoperation for hemostasis, and other patients with complications were cured after ultrasound-guided puncture and drainage or conservative treatment. Duration of postoperative hospital stay of 181 patients with bile duct injury was 12.6 days (range, 6.0-34.0 days). There was no perioperative death occurred. (4) Follow-up: 157 of 181 patients were followed up for 8.2-201.3 months, with a median follow-up time of 92.7 months. Twenty-eight patients had anastomotic stricture recurred, 16 of which were treated with reoperation, 10 were treated with endoscopic stent implantation, and 2 cases were treated with balloon dilatation in interventional department; the stricture was repaired again in all cases. Thirteen patients had recurrent cholangitis, showing no obvious anastomotic stricture on MRCP, and symptoms can be effectively controlled after conservative treatment. (5) Results of the SF-36 scale assessment: 181 patients with bile duct injury completed the SF-36 scales before definitive repair surgery, and 157 completed one year after definitive repair surgery. All the 50 patients without complications completed SF-36 scales one year after LC. The scores of HRQOL in physiological function, role functioning, somatic pain, general health, vitality, social function, emotional function, mental health, the scores of physical component summary, and mental component summary of 181 patients with bile duct injury before surgery were 79±15, 65±12, 40±17, 42±14, 59±20, 27±15, 48±23, 56±22, 60±11, and 56±11, respectively. The above indices one year after definitive repair surgery were 87±10, 78±15, 71±20, 64±20、68±19, 70±25, 67±21, 69±23, 71±13, 68±15, respectively. The above indices of 50 patients without complications one year after LC were 90±13, 81±20, 87±16, 72±20, 73±15, 86±17, 79±22, 77±19, 82±18, 79±18, respectively. The 181 patients with bile duct injury had significant elevation in above indices one year after definitive repair surgery (t=2.051, 2.016, 3.875, 3.014, 2.563, 3.225, 2.964, 2.357, 2.150, 2.203, P<0.05). The 50 patients without complications also had significant elevation in above indices one year after definitive repair surgery (t=2.817, 2.206, 3.641, 3.112, 3.202, 3.310, 3.011, 2.899, 2.150, 2.118, P<0.05). There were significant differences in the general health and mental health one year after definitive repair surgery between 181 patients with bile duct injury and 50 patients without complications (t=2.014, 2.011, P<0.05), and no significant difference in the physiological function, role functioning, somatic pain, vitality, social function, or emotional function between the two groups (t=0.852, 0.915, 0.907, 1.102, 1.284, 1.120, 0.863, 1.109, P>0.05).@*Conclusion@#Definitive repair surgery can significantly improve HRQOL in patients with bile duct injury caused by LC.

Effects of definitive repair surgery on health-related quality of life in patients with bile duct injury after laparoscopic cholecystectomy / 中华消化外科杂志

Objective To investigate the effects of definitive repair surgery on health-related quality of life (HRQOL) in patients with bile duct injury after laparoscopic cholecystectomy (LC).Methods The retrospective case-control study was conducted.The clinicopathological data of 181 patients with bile duct injury caused by LC for benign gallbladder diseases who underwent definitive repair surgery and 50 patients without complications after LC for benign gallbladder diseases in the Mianyang Central Hospital from January 2000 to December 2017 were collected.There were 82 males and 99 females of 181 patients with bile duct injury,aged from 31 to 68 years,with an average age of 47 years.Definitive repair surgery was performed according to different types of bile duct injury,and questionnaire of HRQOL was conducted preoperatively and one year after operation.There were 18 males and 32 females of 50 patients without complications after LC,aged from 35 to 69 years,with an average age of 41 years.Questionnaire of HRQOL was conducted on LC patients without complications one year after operation.Observation indicators:(1) classification of bile duct injury;(2) intraoperative situations of definitive repair surgery;(3) postoperative situations of definitive repair surgery;(4) follow-up;(5) results of the SF-36 scale assessment.Follow-up was conducted by outpatient examination and telephone interview up to December 2018.Patients were reexamined liver function and color Doppler ultrasonography once every 6-12 months,and further magnetic resonance cholangiopancreatography (MRCP) or computed tomography examination to detect recurrence of anastomotic biliary stricture and cholangitis.Measurement data with normal distribution were expressed as Mean±SD,and comparison between groups was analyzed by the paired t test.Measurement data with skewed distribution were described as M (range),and count data were described as absolute numbers.Results (1) Classification of bile duct injury:of the 181 patients with bile duct injury,there were 64 cases of E1 type,70 cases of E2 type,35 cases of E3 type,9 cases of E4 type,and 3 cases of E5 type.(2) Intraoperative situations of definitive repair surgery:all the 181 patinets with bile duct injury underwent definitive repair surgery successfully,including 61 undergoing end-to-end biliary anastomosis,109 undergoing Roux-en-Y choledojejunostomy,11 undergoing hemi-hepatectomy combined with Roux-en-Y anastomosis.There were 52 patients combined with hilar cholangioplasty.The operation time and volume of intraoperative blood loss of 181 patients were (190±126) minutes and 601.5 mL (range,150.0-2 100.0 mL).There were 24 cases with blood transfusion and 18 cases with T-tube stent.(3) Postoperative situations of definitive repair surgery:40 of 181 patients had complications,including 14 cases of incisional infection,10 cases of bile leakage,8 cases of perihepatic effusion,7 cases of pulmonary infection,and 1 case of abdominal hemorrhage.The patient with postoperative abdominal hemorrhage underwent reoperation for hemostasis,and other patients with complications were cured after ultrasound-guided puncture and drainage or conservative treatment.Duration of postoperative hospital stay of 181 patients with bile duct injury was 12.6 days (range,6.0-34.0 days).There was uo perioperative death occurred.(4) Follow-up:157 of 181 patients were followed up for 8.2-201.3 months,with a median follow-up time of 92.7 months.Twenty-eight patients had anastomotic stricture recurred,16 of which were treated with reoperation,10 were treated with endoscopic stent implantation,and 2 cases were treated with balloon dilatation in interventional department;the stricture was repaired again in all cases.Thirteen patients had recurrent cholangitis,showing no obvious anastomotic stricture on MRCP,and symptoms can be effectively controlled after conservative treatment.(5) Results of the SF-36 scale assessment:181 patients with bile duct injury completed the SF-36 scales before definitive repair surgery,and 157 completed one year after definitive repair surgery.All the 50 patients without complications completed SF-36 scales one year after LC.The scores of HRQOL in physiological function,role functioning,somatic pain,general health,vitality,social function,emotional function,mental health,the scores of physical component summary,and mental component summary of 181 patients with bile duct injury before surgery were 79±15,65±12,40±17,42±14,59±20,27±15,48±23,56±22,60±11,and 56±11,respectively.The above indices one year after definitive repair surgery were 87±10,78±15,71±20,64±20、68± 19,70 ± 25,67 ± 21,69 ± 23,71 ± 13,68 ± 15,respectively.The above indices of 50 patients without complications one year after LC were 90±13,81±20,87±16,72±20,73±15,86±17,79±22,77±19,82±18,79 ± 18,respectively.The 181 patients with bile duct injury had significant elevation in above indices one year after definitive repair surgery (t=2.051,2.016,3.875,3.014,2.563,3.225,2.964,2.357,2.150,2.203,P＜0.05).The 50 patients without complications also had significant elevation in above indices one year after definitive repair surgery (t=2.817,2.206,3.641,3.112,3.202,3.310,3.011,2.899,2.150,2.118,P＜0.05).There were significant differences in the general health and mental health one year after definitive repair surgery between 181 patients with bile duct injury and 50 patients without complications (t =2.014,2.011,P＜0.05),and no significant difference in the physiological function,role functioning,somatic pain,vitality,social function,or emotional function between the two groups (t=0.852,0.915,0.907,1.102,1.284,1.120,0.863,1.109,P＞0.05).Conclusion Definitive repair surgery can significantly improve HRQOL in patients with bile duct injury caused by LC.

Protective effect of salvianolate against bile duct injury after dcd donor liver transplantation / 解放军医学杂志

Objective To investigate the protective effect of salvianolate against bile duct injury after donation after cardiac death (DCD) liver transplantation and its clinical application prospect. Methods Sixty recipients of DCD liver transplantation were randomly divided into two groups with 30 cases in each group. Salvianolate (250mg/d) was given daily for 14 days after operation in treatment group, and the same amount of normal saline was given in control group. The therapeutic regimen of anti-rejection and anti-infection is the same between the two groups. The incidence of early graft dysfunction (EAD), and the serous levels of total bilirubin (TB), alkaline phosphatase (ALP), γ-glutamyltransferase (GGT), total bile acid (TBA) 1 month, 6 months and 12 months after liver transplantation were compared between the two groups. Also, the platelets (PLT), prothrombin time (PT), activated partial prothrombin time (APTT) and fibrinogen (FIB) were compared between the two groups at 2 weeks after operation. Results There was no significant difference in baseline parameters between the two groups (P>0.05). Compared with the control group, the incidence of EAD was decreased in treatment group, but there was no significant difference [10.0%(3/30) vs. 23.3%(7/30), P=0.166]. The serous levels of TB, ALP, GGT and TBA in treatment group were lower than those in control group 1 month, 6 months and 12 months after operation: [TB: 1 month, (28.5±17.0)μmol/L vs. (39.8±20.1)μmol/L, P=0.025; 6 months, (24.5±10.6)μmol/L vs. (33.3±16.4) μmol/L, P=0.018; 12 months, (19.8±9.5)μmol/L vs. (26.4±14.1)μmol/L, P=0.037, ALP: 1 month, (147.3±76.9)U/L vs. (187.6±70.9)U/L, P=0.039; 6 months, (163.0±61.4)U/L vs. (198.1±51.6)U/L, P=0.020; 12 months, (167.9±59.9)U/L vs. (200.2±56.2)U/L, P=0.036, GGT: 1 month, (83.9±49.5)U/L vs. (113.6±61.1)U/L, P=0.043; 6 months, (130.9±48.7)U/L vs. (169.7±77.0)U/L, P=0.023; 12 months, (154.7±45.1)U/L vs. (182.5±59.8)U/L, P=0.047, TBA: 1 month, (6.6±2.1)μmol/L vs. (8.0±2.4)μmol/L, P=0.016; 6 months, (9.5±2.2)μmol/L vs. (12.1±3.4)μmol/L, P=0.001; 12 months, (12.5±2.7)μmol/L vs. (5.6±3.8)μmol/L, P=0.001]. However, there was no significant difference in PLT, PT, APTT and FIB between two groups [PLT: (148.6±88.6)×109/L vs. (152.8±74.4)×109/L, P=0.843; PT: (12.9±1.1)s vs. (13.0±1.1)s, P=0.617; APTT: (34.6±3.7)s vs. (34.9±3.4)s, P=0.716; FIB: (3.4±0.6)g/L vs. (3.2±0.6)g/L, P=0.270, repectively]. Conclusions Salvianolate has a protective effect against bile duct injury after DCD liver transplantation, and does not increase the risk of postoperative bleeding.