Endoscopy for treating minor post-cholecystectomy biliary fistula A review of the literature.

AIM: Laparoscopic cholecystectomy for gallstone disease is the most common surgical procedures performed in Western countries and bile leaks remain a significant cause of morbidity. A recognized treatment for minor biliary injury is internal biliary decompression by endoscopic retrograde cholangiopancreatography. The aim of this study was to assess the effectiveness of endoscopic strategy in the management of minor biliary injuries. MATERIAL OF STUDY: Twenty-two patients with a bile leak following laparoscopic cholecystectomy were recorded consecutively between 2007 and 2017 and they were all treated with endoscopic approach, with ERCP in order to confirm the nature of the injury and decompress the bile duct with sphincterotomy, stent insertion, or the placement of nasobiliary drains. In 15 patients, the leak was diagnosed by persistent bile drainage, in the other 7 patients without a drain the biliary leak was suspected because of symptoms in the immediate postoperative period. RESULTS: Controlled biliary fistulae were established in all 22 patients (100%), without further intervention. A complete cholangiogram was obtained in all patients (100%). The most common sites of minor leak were the cystic duct stump and the Luschka duct, but in one patients the site of the leak was unclear. DISCUSSION: Early in the series, sphincterotomy alone or nasobiliary tube placement was performed. Subsequently patients underwent sphincterotomy with stent insertion, in order to promote preferential drainage of bile into the duodenum. The median time to resolution after successful ERCP was 4 days. Two patients underwent ERCP complicated by mild pancreatitis. The median hospital stay was 15 days (range, 10-31 days) post-laparoscopic cholecystectomy. ERCP was performed 4-6 weeks later to document healing of the leaking point and to remove the stent. Routine follow was at median 50 days. CONCLUSIONS: This review confirms that postoperative minor biliary injuries can be successful managed by endoscopic ERCP biliary decompression. KEY WORDS: Bile leak, Bile duct injury, Biliary fistula, Endoscopy, ERCP, Laparoscopic cholecystectomy.

Clinical outcomes in patients with bile leaks treated via ERCP with regard to the timing of ERCP: a large multicenter study.

BACKGROUND AND AIMS: Postsurgical or traumatic bile duct leaks (BDLs) can be safely and effectively managed by endoscopic therapy via ERCP. The early diagnosis of BDL is important because unrecognized leaks can lead to serious adverse events (AEs). Our aim was to evaluate the relationship between timing of endotherapy after BDL and the clinical outcomes, AEs, and long-term results of endoscopic therapy. METHODS: We conducted a multicenter, retrospective study on patients with BDLs who underwent ERCP between 2006 and 2014. Data were assembled on patient demographics, etiology of BDL, and procedural details. Endotherapy for BDLs were classified a priori into 3 groups based on timing of ERCP from time of biliary injury: within 1 day of BDL, on day 2 or 3 after BDL, and greater than 3 days after BDL. The relationship among timing of ERCP after BDL injury and outcomes, procedure-related AEs, and patient AEs and mortality were evaluated. RESULTS: From February 2006 to June 2014, 518 patients (50% male; mean age, 51.7 years) underwent ERCP for therapy of BDLs. The etiology of the BDL was laparoscopic cholecystectomy (70.7%), post-liver transplantation (11.2%), liver resection (14.1%), trauma (2.5%), and other causes (1.5%). Endotherapy was performed by placing a transpapillary stent alone (73.5%) or with a sphincterotomy (26.5%). The timing of ERCPs was as follows: ≤1 day = 57 patients, day 2 or 3 = 140 patients, and >3 days = 321 patients. There was no statistical difference in patient demographics, etiology/site of BDL, or type of endotherapy performed among the 3 groups. On multivariate analysis there was no statistically significant difference in BDL success rate for ERCPs performed within 1 day compared with those performed on day 2 or 3 or after 3 days of bile duct injury (91.2%, 90%, and 88.5%, respectively; P = .77). Similarly, there was no significant difference in the overall patient AE rate among the 3 groups (21.1%, 22.9%, and 24.6%, respectively; P = .81). AEs in men occurred significantly more frequently when compared with women, even after adjusting for age, BDL etiology, and location of leak (27.6% vs 19.9%; OR, 1.53; P = .04). Patients whose BDL was due to a cholecystectomy had a lower AE and mortality rate compared with those who had biliary injury from other etiologies (OR, .42; P < .001). CONCLUSIONS: The overall success rates and AEs after ERCP were not dependent on the timing of the procedure relative to the discovery of the bile leak. This suggests that ERCP in these patients can usually be performed in an elective, rather than an urgent, manner.

A rare case of gangrene of cystic duct due to the insertion of endoscopic nasobiliary drainage (ENBD) tube into the cystic duct by mistake.

This is the first case report of Gangrenous cholecystitis due to the insertion of endoscopic nasobiliary drainage (ENBD) tube into the cystic duct by mistake,The reason why it happened may be related to Inflammation and hypoimmunity.

Morbidity and mortality after minor bile duct injury following laparoscopic cholecystectomy.

BACKGROUND AND STUDY AIMS: Cystic duct and Luschka duct leakage after laparoscopic cholecystectomy are often classified as minor injuries because the outcome of endoscopic stenting and percutaneous drainage is generally reported to be good. However, the potential associated early mortality and risk factors for mortality are scarcely reported. The aim of this study was to describe the outcome, mortality, and risk factors for poor survival of patients with type A bile duct injury (BDI) referred to a tertiary center. PATIENTS AND METHODS: Between January 1990 and January 2012, 800 patients were referred for BDI treatment and included in a prospective database. RESULTS: Type A BDI, according to the Amsterdam and Strasberg classifications, was diagnosed in 216 patients. Treatment after referral was mainly endoscopic (n = 192 [88.9 %]) and radiologic (n = 14 [6.5 %]). Complications related to endoscopic retrograde cholangiopancreatography (ERCP) occurred in 14 patients (6.5 %). Other complications were sepsis (n = 34 [15.7 %]), cardiopulmonary (n = 22 [10.2 %]), and abscess formation (n = 15 [6.9 %]). BDI-related mortality was 4.2 % (9/216). Multivariate analysis showed age (hazard ratio [HR] = 1.04, 95 % confidence interval [CI] 1.00 - 1.07) and American Society of Anesthesiologists class 3 or 4 (HR = 5.64, 95 %CI 2.31 - 13.77) to be independent factors significantly associated with mortality. CONCLUSIONS: Type A "minor" BDI after laparoscopic cholecystectomy is associated with considerable short-term mortality related to the patient's condition at referral. Older patients and patients with ASA 3 or 4 have a significantly higher risk of mortality.

[Right hepatic artery pseudoaneurysm fistulating to the biliary tract responsible for recurrent upper gastrointestinal tract bleeding]. / Pseudoaneuryzma jaterní tepny fistulující do zlucových cest jako prícina opakovaných melén.

The paper presents a case of 51 years old patient suffering from repetitive upper intestinal tract bleedings following several months after uncomplicated laparoscopic cholecystectomy for acute cholecystitis. After a difficult diagnostic algorithm the diagnosis is set as a right hepatic artery pseudoaneurysm fistulating into the cystic duct stump. Several attempts of intraarterial embolisation (coiling) were done with only temporary effect. Finally an open surgical procedure with transligation of the aneurysm was performed with an immediate and definitive effect. No clinical signs of bleeding appeared within 6 months after the procedure. Key words: haemobilia, hepatic artery pseudoaneurysm, complication of cholecystectomy, coiling.

Cystic duct leaks after laparoendoscopic single-site cholecystectomy.

BACKGROUND: Leakage from the clipped cystic duct stump (cystic duct stump leak [CDSL]) as a cause of biliary peritonitis has not been emphasized enough. It deserves special mention because it is not an uncommon cause and it is easier to treat. With the advent of laparoendoscopic single-site (LESS) cholecystectomy, its occurrence in relation to other causes of biliary peritonitis needs reexamination. SUBJECTS AND METHODS: Details of 756 patients undergoing LESS cholecystectomy were analyzed, and patients presenting with biliary peritonitis were identified. The investigative profile included an ultrasound, contrast-enhanced computed tomography scan, and endoscopic retrograde cholangiopancreatography (ERCP) to identify the site of leak. The management in addition to stenting included abdominal tube drainage. RESULTS: There were 5 (0.66%) patients, all female, with biliary peritonitis, and 4 of them (0.53%) had cystic stump leakage as identified by ERCP. The usual time of presentation was in the first week after surgery, with acute abdominal pain and vomiting. Common bile duct stenting was carried out, after choledocholithotomy where required, at the same ERCP session. Tube abdominal drain was required in 2 patients, and 1 patient had to undergo exploratory laparotomy for an associated acute intestinal obstruction. All the patients recovered completely. The stent was removed between 4 and 6 weeks after ERCP. CONCLUSIONS: Effective CDSL management requires early recognition and management. ERCP is the cornerstone for correct identification, and common bile duct stenting was curative in all patients.

Stray bullet in inferior vena cava.

A young boy presented in emergency with history of being hit by a stray bullet injuring the right hypochondrium. Ultrasound of abdomen showed hemoperitoneum and the radiograph showed bullet in the pelvis. Exploratory laparotomy showed injuries to liver and cystic duct with tract leading retroperitoneally into the inferior vena cava. The bullet was found wandering inside the vena caval lumen. Stray bullets are presumed to remain limited to the soft tissues. However, the trajectory, impact velocity and the involved region ultimately determine the outcome and influence management.

Endoscopic therapy for type B surgical biliary injury in a patient with short cystic duct.

Anatomical variations of the cystic duct are well-defined. The presence of short or absent cystic duct is unusual and represents a co-factor of biliary injury especially during laparoscopic cholecystectomy. Thus, its knowledge is important to avoid ductal injury in hepato-biliary surgery. We experienced the case of a 40-year-old woman with symptomatic cholelitiasis, who underwent to laparoscopic cholecystectomy. At surgery, an accidental bile duct lesion was carried, during Calot's triangle dissection, due the particular difficulties in dissecting an extremely short cystic duct found at the junction of the common hepatic duct and common bile duct. No vascular anomalies were present. The biliary leakage from the common bile duct was intraoperative identified and subsequentially treated by the endoscopic method. Laparoscopic cholecystectomy with sequential biliary endoprosthesis insertion was completed without conversion to open surgery. The endoscopic stenting was the definitive treatment for the leakage. No evidence of biliary stent complication was observed during the follow-up. This report documents a case of short cystic duct with particular emphasis to the biliary injury risk during the laparoscopic dissection of "unusual" Calot's triangle, and examines our mini-invasive therapeutic strategies in the management of bile leakage after laparoscopic cholecystectomy.

Exploración laparoscópica de la vía biliar y manejo actual de la coledocolitiasis: análisis de los primeros 30 casos / Laparoscopic common bile duct exploration and current management of choledocholithiasis

Se trata de un estudio descriptivo, prospectivo, longitudinal que incluyó a 30 pacientes que consultaron con indicaciones de exploración laparoscópica de la vía biliar. Se describe la técnica utilizada para la exploración transcística y por coledocotomía, tanto con guía fluoroscópica como el uso del coledocoscopio. Se estudiaron las variables, efectividad, conversión, tiempo quirúrgico, complicaciones tiempo de hospitalización, litiasis residual. La exploración laparoscópica de la vía biliar fue efectiva en el 84% de los casos. Las causas de conversión fueron cálculos enclavados y cálculos intrahepáticos. El 32% de los casos se resolvió por la vía transcística , mientras que el resto (68%) se resolvió mediante coledocotomía. La morbilidad asociada la técnica fue de 6,6% dada por diarrea postoperatoria y biliperitoneo luego del retiro del tubo en “t”. El tiempo promedio de hospitalización fue de 3,5 días. Sin casos reportados de litiasis residual. La exploración laparoscópica de la vía biliar (ELVB) es una alternativa terapéutica segura y efectiva en el tratamiento de la obstrucción de la vía biliar principal por cálculos. Sin embargo, queda claro que el éxito del procedimiento depende del dominio de técnicas endoscópicas y laparoscópicas avanzadas y la disponibilidad de recursos tecnológicos de primera.

Report the experience in laparoscopic common bile duct exploration in the Surgery Department III of the Hospital Universitario de Caracas. Descriptive, prospective, longitudinal study of patients admitted with indication of laparoscopic common bile duct exploration. We describe the transcystic approach and choledochotomy technique, using fluoroscopic guidance or choledochoscope. Success rate, conversion, operative time, complications, length of stay and residual lithiasis were studied. Laparoscopic common bile exploration was successful in 84% of the patients. Conversión causes were embedded stones and intrahepatic lithiasis. Transcystic approach was used in 32% of the cases and choledochotomy was performed in 68% of the patients. Morbidity rate was 6,6% due to diarrhea and biliary peritonitis after "t" tube removal. Median length of stay was 3,5 days. No cases of residual stones were reported. Laparoscopic common bile duct exploration is a safe and effective procedure in patients with common bile duct obstruction due to choledocholithiasis However, the success rate is in relation with endoscopic and advanced laparoscopic techniques mastery and technologic resources availability.

The pedicle effect and direct coupling: delayed thermal injuries to the bile duct after laparoscopic cholecystectomy.

Electrothermal energy, especially in the form of monopolar diathermy, is used widely for dissection during laparoscopic cholecystectomy. While this is largely safe, occasionally there can be unrecognized transfer of energy in the operating area, resulting in electrothermal injury. We report a series of 3 patients who underwent uneventful laparoscopic cholecystectomies but were readmitted 4 to 5 days later with pinhole leaks from the common bile duct as a result of coagulative necrosis caused by unrecognized energy transfer. We suggest that surgeons keep the use of monopolar diathermy to a minimum while dissecting near vital structures.

Double cystic duct in a child with VACTERL association: a case report.

Double cystic duct is an extremely rare anomaly of the biliary tract not described in the pediatric literature. We report the first pediatric case born with VACTERL association found to have double cystic ducts during gallbladder surgery for symptomatic cholelithiasis. Description of the anatomic variability, cholangiography images, and pathologic findings along with review of the literature is included.

Endoscopic sphincterotomy alone in the management of low-grade biliary leaks due to cholecystectomy.

AIM: Endoscopic retrograde cholangiopancreatography (ERCP) is important in the diagnosis and management of postoperative bile leaks. Endoscopic sphincterotomy (ES) alone, ES with stent or nasobiliary drain (NBD) placement and stent or NBD without ES are the methods of choice. In the present study, we aimed to show the efficacy of ES alone in the management of low-grade (LGL) cystic duct stump (CDS) leaks due to cholecystectomy. METHODS: Between September 2005 and January 2008, ES was carried out on 31 patients with LGL from the CDS due to cholecystectomy who were referred to the endoscopy unit of Izmir Ataturk Training and Research Hospital. Biliary leakage was detected by biliary discharge from a tube drain inserted during the operation. In cases of retaining common bile duct stones, balloon extraction was carried out. If bile discharge continued, a stent was introduced for cessation of the leak as a second procedure. RESULTS: The success rate of ES alone was 87.1% (27 of 31 patients). In four patients (12.9%), ES alone was inadequate, therefore a stent was placed. The biliary leak ceased gradually and stopped in all patients at a mean of 11 (7-21) days. Balloon extraction of retained stones was carried out in six patients (19.6%). In two (6.5%) patients, mild hemorrhage and in two patients self-limited pancreatitis was seen (6.5%) as complications. CONCLUSION: Endoscopic retrograde cholangiopancreatography is essential in the management of postoperative biliary leaks. Endoscopic sphincterotomy alone can be the initial procedure in the treatment of LGL from the CDS due to cholecystectomy.