Management of Postcholecystectomy Biliary Complications: A Narrative Review.

Every year approximately 750,000 cholecystectomies are performed in the United States, most of those are performed laparoscopically. Postcholecystectomy complications are not uncommon and lead to increased morbidity and financial burden. Some of the most commonly encountered complications with laparoscopic cholecystectomy include biliary injury (0.08%-0.5%), bile leak (0.42%-1.1%), retained common bile duct stones (0.8%-5.7%), postcholecystectomy syndrome (10%-15%), and postcholecystectomy diarrhea (5%-12%). Endoscopy has an important role in the diagnosis and management of biliary complications and in many cases can provide definitive management. There is no consensus on the best therapeutic approach for biliary complications. Therefore, biliary complications should be approached by an experienced multidisciplinary team. It is important for the gastroenterologist to be familiar with the management of such complications (Visual Abstract, Supplemental Digital content 1, http://links.lww.com/AJG/B544).

Prevalence of anatomic landmarks for orientation during elective laparoscopic cholecystectomies.

BACKGROUND: We sought to determine the prevalence of common anatomic landmarks around the gallbladder that may be useful in orienting surgeons during laparoscopic cholecystectomy. METHODS: The subhepatic anatomy of 128 patients undergoing elective cholecystectomy was recorded. We searched and recorded the presence of five anatomic landmarks: the bile duct (B), the Sulcus of Rouviere (S), the left hepatic artery (A), the umbilical fissure (F), and the duodenum (E). These are the previously described B-SAFE landmarks. RESULTS: We found that the duodenum and umbilical fissure were present reliably in almost all patients. The position of the left hepatic artery could be reliably determined by its pulsation in 84% of patients. A portion of the bile duct could be seen in 77% and the Sulcus of Rouviere was present in 80%. Furthermore, the hepatobiliary triangle was always found superior or at the same level as the Sulcus of Rouviere. CONCLUSIONS: We found that these five anatomic landmarks were reliably present. This suggest that using the B-SAFE landmarks may allow a surgeon to more easily orient before and during laparoscopic cholecystectomy and prevent bile duct injuries.

[A consensus statement on the standardized application of antibacterial agents in biliary tract surgery (2019)].

The standardized application of antibacterial agents in the treatment of biliary tract diseases is of great significance.On the basis of international and domestic guidelines and consensuses, combining with the actual situation of Chinese biliary tract infection, Study Group of biliary Tract Surgery in Chinese Society of Surgery of Chinese Medical Association and Enhanced Recovery After Surgery Committee of Chinese Research Hospital Association and Editorial Board of Chinese Journal of Surgery organized experts to make recommendations which adopted a problem-oriented approach on the severity grade of biliary tract infection, the protocol of specimen examination, the use of antibiotics, the indication of drug withdrawal, the agents application strategy of drug-resistant bacteria infection and special situation to guide surgeons getting the accurate judgement of the severity of biliary tract infection and the formulation of standard protocols for the use of antibacterial agents on the premise of following the bacteriological and drug resistance monitoring information.

Hypothermic machine perfusion reduces the incidences of early allograft dysfunction and biliary complications and improves 1-year graft survival after human liver transplantation: A meta-analysis.

BACKGROUND: The worldwide organ shortage continues to be the main limitation of liver transplantation. To bridge the gap between the demand and supply of liver grafts, it becomes necessary to use extended criteria donor livers for transplantation. Hypothermic machine perfusion (HMP) is designed to improve the quality of preserved organs before implantation. In clinical liver transplantation, HMP is still in its infancy. METHODS: A systematic search of the PubMed, EMBASE, Springer, and Cochrane Library databases was performed to identify studies comparing the outcomes in patients with HMP versus static cold storage (SCS) of liver grafts. The parameters analyzed included the incidences of primary nonfunction (PNF), early allograft dysfunction (EAD), vascular complications, biliary complications, length of hospital stay, and 1-year graft survival. RESULTS: A total of 6 studies qualified for the review, involving 144 and 178 liver grafts with HMP or SCS preservation, respectively. The incidences of EAD and biliary complications were significantly reduced with an odds ratio (OR) of 0.36 (95% confidence interval [CI] 0.17-0.77, P = .008) and 0.47 (95% CI 0.28-0.76, P = .003), respectively, and 1-year graft survival was significantly increased with an OR of 2.19 (95% CI 1.14-4.20, P = .02) in HMP preservation compared to SCS. However, there was no difference in the incidence of PNF (OR 0.30, 95% CI 0.06-1.47, P = .14), vascular complications (OR 0.69, 95% CI 0.29-1.66, P = .41), and the length of hospital stay (mean difference -0.30, 95% CI -4.10 to 3.50, P = .88) between HMP and SCS preservation. CONCLUSIONS: HMP was associated with a reduced incidence of EAD and biliary complications, as well as an increased 1-year graft survival, but it was not associated with the incidence of PNF, vascular complications, and the length of hospital stay.

Can we reduce ischemic cholangiopathy rates in donation after cardiac death liver transplantation after 10 years of practice? Canadian single-centre experience

Background: Outcomes in liver transplantation with organs obtained via donation after cardiocirculatory death (DCD) have been suboptimal compared to donation after brain death, attributed mainly to the high incidence of ischemic cholangiopathy (IC). We evaluated the effect of a 10-year learning curve on IC rates among DCD liver graft recipients at a single centre. Methods: We analyzed all DCD liver transplantation procedures from July 2006 to July 2016. Patients were grouped into early (July 2006 to June 2011) and late (July 2011 to July 2016) eras. Those with less than 6 months of follow-up were excluded. Primary outcomes were IC incidence and IC-free survival rate. Results: Among the 73 DCD liver transplantation procedures performed, 70 recipients fulfilled the selection criteria, 32 in the early era and 38 in the late era. Biliary complications were diagnosed in 19 recipients (27%). Ischemic cholangiopathy was observed in 8 patients (25%) in the early era and 1 patient (3%) in the late era (p = 0.005). The IC-free survival rate was higher in the late era than the early era (98% v. 79%, p = 0.01). The warm ischemia time (27 v. 24 min, p = 0.049) and functional warm ischemia time (21 v. 17 min, p = 0.002) were significantly lower in the late era than the early era. Conclusion: We found a significant reduction in IC rates and improvement in ICfree survival among DCD liver transplantation recipients after a learning curve period that was marked by more judicious donor selection with shorter procurement times.

Contexte: L'issue des greffes de foie suite à un don d'organe après décès cardiocirculatoire (DDC) a été sous-optimale comparativement aux dons suivant la mort cérébrale. Cela serait surtout attribuable à une forte incidence de cholangiopathie ischémique (CI). Nous avons évalué l'effet d'une courbe d'apprentissage échelonnée sur 10 ans sur les taux de CI chez des receveurs de greffe de foie après DDC dans un seul centre. Méthodes: Nous avons analysé toutes les greffes de foie consécutives à des DDC entre juillet 2006 et juillet 2016. Les patients ont été regroupés en 2 époques, la première, de juillet 2006 à juin 2011, et la seconde, de juillet 2011 à juillet 2016. Ceux pour lesquels on disposait de moins de 6 mois de suivi ont été exclus. Les paramètres principaux étaient l'incidence de CI et le taux de survie sans CI. Résultats: Parmi les 73 greffes de foie par suite de DDC, 70 receveurs répondaient aux critères de sélection, 32 pour la première époque et 38 pour la seconde époque. Des complications biliaires ont été diagnostiquées chez 19 receveurs (27 %). La cholangiopathie ischémique a été observée chez 8 patients (25 %) de la première époque et 1 patient (3 %) de la seconde (p = 0,005). Le taux de survie sans CI a été plus élevé pendant la seconde époque que pendant la première (98 % c. 79 %, p = 0,01). Le temps d'ischémie chaude (27 minutes c. 24, p = 0,049) et le temps d'ischémie chaude fonctionnelle (21 minutes c. 17, p = 0,002) ont été significativement plus courts durant la seconde époque que durant la première. Conclusion: Nous avons observé une réduction significative des taux de CI et une amélioration de la survie sans CI chez les receveurs de greffes de foie par DDC après une courbe d'apprentissage qui a été marquée par une sélection plus judicieuse des donneurs et des délais d'obtention plus courts.

In situ normothermic perfusion of livers in controlled circulatory death donation may prevent ischemic cholangiopathy and improve graft survival.

Livers from controlled donation after circulatory death (DCD) donors suffer a higher incidence of nonfunction, poor function, and ischemic cholangiopathy. In situ normothermic regional perfusion (NRP) restores a blood supply to the abdominal organs after death using an extracorporeal circulation for a limited period before organ recovery. We undertook a retrospective analysis to evaluate whether NRP was associated with improved outcomes of livers from DCD donors. NRP was performed on 70 DCD donors from whom 43 livers were transplanted. These were compared with 187 non-NRP DCD donor livers transplanted at the same two UK centers in the same period. The use of NRP was associated with a reduction in early allograft dysfunction (12% for NRP vs. 32% for non-NRP livers, P = .0076), 30-day graft loss (2% NRP livers vs. 12% non-NRP livers, P = .0559), freedom from ischemic cholangiopathy (0% vs. 27% for non-NRP livers, P < .0001), and fewer anastomotic strictures (7% vs. 27% non-NRP, P = .0041). After adjusting for other factors in a multivariable analysis, NRP remained significantly associated with freedom from ischemic cholangiopathy (P < .0001). These data suggest that NRP during organ recovery from DCD donors leads to superior liver outcomes compared to conventional organ recovery.

Safe laparoscopic cholecystectomy: A systematic review of bile duct injury prevention.

BACKGROUND: Since the introduction of laparoscopic cholecystectomy (LC), a substantial increase in bile duct injury (BDI) incidence was noted. Multiple methods to prevent this complication have been developed and investigated. The most suitable method however is subject to debate. In this systematic review, the different modalities to aid in the safe performance of LC and prevent BDI are delineated. MATERIALS AND METHODS: A systematic search for articles describing methods for the prevention of BDI in LC was conducted using EMBASE, Medline, Web of science, Cochrane CENTRAL and Google scholar databases from inception to 11 June 2018. RESULTS: 90 studies were included in this systematic review. Overall, BDI preventive techniques can be categorized as dedicated surgical approaches (Critical View of Safety (CVS), fundus first, partial laparoscopic cholecystectomy), supporting imaging techniques (intraoperative radiologic cholangiography, intraoperative ultrasonography, fluorescence imaging) and others. Dedicated surgical approaches demonstrate promising results, yet limited research is provided. Intraoperative radiologic cholangiography and ultrasonography demonstrate beneficial effects in BDI prevention, however the available evidence is low. Fluorescence imaging is in its infancy, yet this technique is demonstrated to be feasible and larger trials are in preparation. CONCLUSION: Given the low sample sizes and suboptimal study designs of the studies available, it is not possible to recommend a preferred method to prevent BDI. Surgeons should primarily focus on proper dissection techniques, of which CVS is most suitable. Additionally, recognition of hazardous circumstances and knowledge of alternative techniques is critical to complete surgery with minimal risk of injury to the patient.

Mirizzi's syndrome: A scoring system for preoperative diagnosis.

BACKGROUND/AIM: Mirizzi's syndrome (MS) is an unusual complication of gallstone disease and occurs in approximately 1% of patients with cholelithiasis. Majority of cases are not identified preoperatively, despite the availability of modern imaging techniques. A preoperative diagnosis can forewarn the operating surgeon and avoid bile duct injuries in cases of complicated cholecystitis. A preoperative scoring system helpful and hence, we aim to devise a scoring system based on clinical, biochemical, and imaging features to predict the diagnosis of MS in cases of complicated cholecystitis. PATIENTS AND METHODS: From January 2000 to July 2013, 1,539 patients with cholelithiasis underwent cholecystectomy. Of these, 96 patients had complicated cholecystitis. Records of these patients were analyzed retrospectively. In these, 32 patients were found to be having MS that formed the study group. A scoring system was devised based on clinical, biochemical, and imaging parameters to predict the diagnosis of MS. Every positive parameter was given 1 point and patients rated on a scale of 0-10. RESULTS: Score of 3 or more was found to have a 90% sensitivity of predicting MS among complicated cholecystitis. Similarly, a score of 6 or more had an 80% sensitivity of predicting Mirizzi's types II, III, and IV indicating fistulization. Jaundice, leucocytosis, associated choledocholithiasis/hepatolithiasis, intrahepatic biliary radical dilatation, meniscus sign and mass at confluence were found to be significant parameters. CONCLUSION: We propose a simple scoring system based on clinical, biochemical, and imaging parameters that can be useful for predicting MS in patients with complicated cholecystitis.

Heparin but not tissue plasminogen activator improves outcomes in donation after circulatory death liver transplantation in a porcine model.

Ischemic-type biliary lesions (ITBLs) arise most frequently after donation after circulatory death (DCD) liver transplantation and result in high morbidity and graft loss. Many DCD grafts are discarded out of fear for this complication. In theory, microvascular thrombi deposited during donor warm ischemia might be implicated in ITBL pathogenesis. Herein, we aim to evaluate the effects of the administration of either heparin or the fibrinolytic drug tissue plasminogen activator (TPA) as means to improve DCD liver graft quality and potentially avoid ITBL. Donor pigs were subjected to 1 hour of cardiac arrest (CA) and divided among 3 groups: no pre-arrest heparinization nor TPA during postmortem regional perfusion; no pre-arrest heparinization but TPA given during regional perfusion; and pre-arrest heparinization but no TPA during regional perfusion. In liver tissue sampled 1 hour after CA, fibrin deposition was not detected, even when heparin was not given prior to arrest. Although it was not useful to prevent microvascular clot formation, pre-arrest heparin did offer cytoprotective effects during CA and beyond, reflected in improved flows during regional perfusion and better biochemical, functional, and histological parameters during posttransplantation follow-up. In conclusion, this study demonstrates the lack of impact of TPA use in porcine DCD liver transplantation and adds to the controversy over whether the use of TPA in human DCD liver transplantation really offers any protective effect. On the other hand, when it is administered prior to CA, heparin does offer anti-inflammatory and other cytoprotective effects that help improve DCD liver graft quality. Liver Transplantation 24 665-676 2018 AASLD.

An Improved Suture Technique for Perform Biliary Reconstruction in Orthotopic Liver Transplantation.

BACKGROUND: The biliary anastomosis remains to be the Achilles' heel of liver transplantation. The incidence of biliary complications (e.g., stenosis and leakage) is immanent and the optimal type of reconstruction is unclear. The aim of this study was to compare 2 different bile duct suture techniques regarding their benefits in the prevention of biliary complications. MATERIAL AND METHODS: From 1992 to 2012, the transplanted patients (n=394) of our center were analyzed retrospectively in terms of suture techniques and consecutive biliary complications. Secondary, possible risk factors (cold ischemic time, donor age, and preoperative liver function) were examined. An end-to-end choledocho-choledochostomy without T-tube was performed during orthotopic liver transplantation whenever possible. In group 1 (n=123) the biliary reconstruction was performed completely by continuous-suture technique. In group 2 (n=164) continuous-suture technique was also performed in posterior wall of the bile duct, but the anterior wall was closed by interrupted-suture technique. RESULTS: The overall biliary complication rate was 19.6%. There were no significant differences in biliary complications between the groups. Analysis of risk factors showed no influence on the complication rate. CONCLUSIONS: The argument for the interrupted-suture technique is a better overview and a lower risk to grab the posterior wall during the anastomotic realization. The threads of the anterior wall can be presented individually and then be knotted.

Fibrin Sealant with Polyglycolic Acid Felt vs Fibrinogen-Based Collagen Fleece at the Liver Cut Surface for Prevention of Postoperative Bile Leakage and Hemorrhage: A Prospective, Randomized, Controlled Study.

BACKGROUND: The incidence of postoperative biliary leakage and hemorrhage is low, but these factors remain important in liver surgery, and this study's objective was to explore the efficacy of fibrin sealant (FS) with polyglycolic acid (PGA) vs fibrinogen-based collagen fleece (CF) at the liver cut surface. Fibrinogen-based collagen fleece is generally used for hemostasis; PGA-FS has reduced biliary leakage in several retrospective studies. STUDY DESIGN: We designed a multicenter, randomized, controlled trial. The primary outcome was the rate of biliary leakage and hemorrhage. Secondary outcomes included morbidities and effusion at the liver cut surface at 3 months post-surgery. Biliary leakage was diagnosed when the drain/serum bilirubin ratio was >5. Hemorrhage was diagnosed when relaparotomy or transfusion was needed. RESULTS: Of 786 patients from 11 institutions enrolled from 2009 to 2014, a total of 391 were randomly assigned to PGA-FS and 395 to CF. Regarding primary outcomes, rates of biliary leakage were 4.1% with PGA-FS and 5.1% with CF, and rates of hemorrhage were 1.0% in each group; groups did not differ significantly. For secondary outcomes, morbidity rates were 18.7% in the PGA-FS group and 24.6% in the CF group (p = 0.0450). Effusion at the cut liver surface was less with PGA-FS (22.2%) than with CF (32.9%) (p = 0.0142). Regarding morbidity, infection around the liver, jaundice, and abdominal paracentesis were less in the PGA-FS group. CONCLUSIONS: Compared with CF, PGA-FS did not reduce biliary leakage and hemorrhage. Surgical site infection around the liver, effusion at the liver cut surface, and abdominal paracentesis were less in the PGA-FS group.

Blunt Dissection: A Solution to Prevent Bile Duct Injury in Laparoscopic Cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) has been a standard operation and replaced the open cholecystectomy (OC) rapidly because the technique resulted in less pain, smaller incision, and faster recovery. This study was to evaluate the value of blunt dissection in preventing bile duct injury (BDI) in laparoscopic cholecystectomy (LC). METHODS: From 2003 to 2015, LC was performed on 21,497 patients, 7470 males and 14,027 females, age 50.3 years (14-84 years). The Calot's triangle was bluntly dissected and each duct in Calot's triangle was identified before transecting the cystic duct. RESULTS: Two hundred and thirty-nine patients (1.1%) were converted to open procedures. The postoperative hospital stay was 2.1 (0-158) days, and cases (46%) had hospitalization days of 1 day or less, and 92.8% had hospitalization days of 3 days or less; BDI was occurred in 20 cases (0.09%) including 6 cases of common BDI, 2 cases of common hepatic duct injury, 1 case of right hepatic duct injury, 1 case of accessory right hepatic duct, 1 case of aberrant BDI 1 case of biliary stricture, 1 case of biliary duct perforation, 3 cases of hemobilia, and 4 cases of bile leakage. CONCLUSION: Exposing Calot's triangle by blunt dissection in laparoscopic cholecystectomy could prevent intraoperative BDI.

End-ischemic machine perfusion reduces bile duct injury in donation after circulatory death rat donor livers independent of the machine perfusion temperature.

A short period of oxygenated machine perfusion (MP) after static cold storage (SCS) may reduce biliary injury in donation after cardiac death (DCD) donor livers. However, the ideal perfusion temperature for protection of the bile ducts is unknown. In this study, the optimal perfusion temperature for protection of the bile ducts was assessed. DCD rat livers were preserved by SCS for 6 hours. Thereafter, 1 hour of oxygenated MP was performed using either hypothermic machine perfusion, subnormothermic machine perfusion, or with controlled oxygenated rewarming (COR) conditions. Subsequently, graft and bile duct viability were assessed during 2 hours of normothermic ex situ reperfusion. In the MP study groups, lower levels of transaminases, lactate dehydrogenase (LDH), and thiobarbituric acid reactive substances were measured compared to SCS. In parallel, mitochondrial oxygen consumption and adenosine triphosphate (ATP) production were significantly higher in the MP groups. Biomarkers of biliary function, including bile production, biliary bicarbonate concentration, and pH, were significantly higher in the MP groups, whereas biomarkers of biliary epithelial injury (biliary gamma-glutamyltransferase [GGT] and LDH), were significantly lower in MP preserved livers. Histological analysis revealed less injury of large bile duct epithelium in the MP groups compared to SCS. In conclusion, compared to SCS, end-ischemic oxygenated MP of DCD livers provides better preservation of biliary epithelial function and morphology, independent of the temperature at which MP is performed. End-ischemic oxygenated MP could reduce biliary injury after DCD liver transplantation.

The White-test helps to reduce biliary leakage in liver resection: a systematic review and meta-analysis.

BACKGROUND: Bile leakage testing may help to detect and reduce the incidence of biliary leakage after hepatic resection. This review was performed to investigate the value of the White-test in identifying intraoperative biliary leakage and avoiding postoperative leakage. MATERIAL AND METHODS: A systematic review and meta-analysis was performed. Two researchers performed literature research. Primary outcome measure was the incidence of post-hepatectomy biliary leakage; secondary outcome measure was the ability of detecting intraoperative biliary leakage with the help of the White-test. RESULTS: A total of 4 publications (including original data from our center) were included in the analysis. Evidence levels of the included studies had medium quality of 2b (individual cohort studies including low quality randomized controlled trials). Use of the White-test led to a significant reduction of post-operative biliary leakage [OR: 0.3 (95% CI: 0.14, 0.63), p = 0.002] and led to a significant higher intraoperative detection of biliary leakages [OR: 0.03 (95%CI: 0.02, 0.07), p < 0.00001]. CONCLUSION: Existing evidence implicates the use of the White-test after hepatic resection to identify bile leaks intraoperatively and thus reduce incidence of post-operative biliary leakage. Nonetheless, there is a requirement for a high-quality randomized controlled trial with adequately powered sample-size to confirm findings from the above described studies and further increase evidence in this field.

An evaluation of the protective effect of an infusion of chilled glucose solution on thermal injury of the bile ducts caused by radiofrequency ablation of the liver.

PURPOSE: To evaluate the protective effects of chilling the bile ducts with cold (5°C) 5% glucose solution (GS) during radiofrequency (RF) administration. METHODS: Twenty male pigs (3 mos. old; 25-30 kg) were subjected to RF delivery with chilling (experimental group, N=10) or without chilling (control group, N=10). Half of the animals in each group were euthanized immediately after the operation, and half were euthanized one week later. The following histological variables in relation to the bile ducts were evaluated by a pathologist (blind examiner): degenerative changes to the epithelium; epithelial necrosis; ulceration, regenerative changes of the epithelium; polymorphonuclear neutrophil infiltration; and thermal effects. RESULTS: The experimental group (88 bile ducts examined) showed reduced thermal damage relative to the control group (86 bile ducts examined) as demonstrated by significant differences in the following histopathological parameters: epithelial detachment of biliary epithelium (84.1% vs. 59.3%; p<0.006); elongation/palisade arrangement of nuclei (65.1% vs. 87.5%; p<0.001); pseudo-goblet cells (32.9% vs. 56.8%; p<0.001). CONCLUSION: Infusion of 5% glucose solution (5°C) has a protective effect on bile ducts subjected to heat (95-110°C, 12 min) from radiofrequency thermal ablation device.

An evaluation of the protective effect of an infusion of chilled glucose solution on thermal injury of the bile ducts caused by radiofrequency ablation of the liver

PURPOSE: To evaluate the protective effects of chilling the bile ducts with cold (5°C) 5% glucose solution (GS) during radiofrequency (RF) administration. METHODS: Twenty male pigs (3 mos. old; 25-30 kg) were subjected to RF delivery with chilling (experimental group, N=10) or without chilling (control group, N=10). Half of the animals in each group were euthanized immediately after the operation, and half were euthanized one week later. The following histological variables in relation to the bile ducts were evaluated by a pathologist (blind examiner): degenerative changes to the epithelium; epithelial necrosis; ulceration, regenerative changes of the epithelium; polymorphonuclear neutrophil infiltration; and thermal effects. RESULTS: The experimental group (88 bile ducts examined) showed reduced thermal damage relative to the control group (86 bile ducts examined) as demonstrated by significant differences in the following histopathological parameters: epithelial detachment of biliary epithelium (84.1% vs. 59.3%; p<0.006); elongation/palisade arrangement of nuclei (65.1% vs. 87.5%; p<0.001); pseudo-goblet cells (32.9% vs. 56.8%; p<0.001). CONCLUSION: Infusion of 5% glucose solution (5°C) has a protective effect on bile ducts subjected to heat (95-110°C, 12 min) from radiofrequency thermal ablation device. .

Single-stage cholecystectomy at the time of pancreatic necrosectomy is safe and prevents future biliary complications: a 20-year single institutional experience with 217 consecutive patients.

INTRODUCTION: Current guidelines recommend cholecystectomy (CCY) during the index admission for mild to moderate biliary pancreatitis as delayed CCY is associated with a substantial risk of recurrent biliary events. Delayed CCY is recommended in severe pancreatitis. The optimal timing of CCY in necrotizing pancreatitis, however, has not been well studied. We sought to determine the safety of single-stage CCY performed at the time of necrosectomy and its effectiveness in preventing subsequent biliary complications. METHODS: We retrospectively queried our institutional database of patients who underwent pancreatic necrosectomy for necrotizing pancreatitis from 1992 to 2012. RESULTS: We identified 217 consecutive patients who underwent pancreatic necrosectomy during the study period. The most common etiologies of pancreatitis were biliary (41 %) and alcoholic (24%), with a median computed tomography (CT) severity index score of 6 ± 1.6 and a 63.6% incidence of infected necrosis. Ninety-eight patients had undergone CCY prior to necrosectomy. Seventy patients (59% of those with gallbladders in situ) underwent CCY at the time of pancreatic necrosectomy. CCY was not performed in the remaining 49 due to a clear non-biliary etiology (35%), technical difficulty (29%), intraoperative hemodynamic instability (18%), or surgeon preference (18%). Postoperative morbidity and mortality was no different between the CCY and no CCY groups, with no bile duct injury or bile leaks in patients undergoing CCY at the time of necrosectomy. Of the patients undergoing CCY, 43% of patients without cholelithiasis or biliary sludge on preoperative imaging had gallstones or sludge identified pathologically after single-stage CCY. Of those who did not receive a single-stage CCY, biliary complications developed in 17 (35%) of patients (21% cholecystitis, 14% recurrent gallstone pancreatitis) at a median time to incidence of 10 months. Seventeen (35%) patients eventually received a postnecrosectomy cholecystectomy, of which 75% required an open procedure. CONCLUSION: Single-stage CCY at the time of pancreatic necrosectomy is safe in selected patients and should be performed if technically feasible to prevent future biliary complications and reduce the need for a subsequent separate, often open, CCY.

Prevention and management of biliary anastomotic stricture in right-lobe living-donor liver transplantation.

Biliary strictures can be categorized according to technical factor as anastomotic or nonanastomotic strictures. Biliary anastomotic stricture is a common complication after living-donor liver transplantation, occasionally causing deaths. The two most commonly used methods for biliary anastomosis are duct-to-duct anastomosis and hepaticojejunostomy. Before presenting a description of the latest techniques of duct-to-duct anastomosis and hepaticojejunostomy, this review first relates the technique of donor right hepatectomy, as most biliary complications suffered by recipients of living-donor liver transplantation originate from donor operations. Three possible causes of biliary anastomotic stricture, namely impaired blood supply, biliary anomaly, and technical flaw, are then discussed. Lastly, the review focuses on the latest management of biliary anastomotic stricture. Treatment modalities include endoscopic retrograde cholangiography with dilatation, percutaneous transhepatic biliary drainage with dilatation, conversion of duct-to-duct anastomosis to hepaticojejunostomy, and revision hepaticojejunostomy. End-to-side versus side-to-side hepaticojejunostomy is also discussed.