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

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

Classification and management of bile duct injuries.

To review the classification and general guidelines for treatment of bile duct injury patients and their long term results. In a 20-year period, 510 complex circumferential injuries have been referred to our team for repair at the Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán" hospital in Mexico City and 198 elsewhere (private practice). The records at the third level Academic University Hospital were analyzed and divided into three periods of time: GI-1990-99 (33 cases), GII- 2000-2004 (139 cases) and GIII- 2004-2008 (140 cases). All patients were treated with a Roux en Y hepatojejunostomy. A decrease in using transanastomotic stents was observed (78% vs 2%, P = 0.0001). Partial segment IV and V resection was more frequently carried out (45% vs 75%, P = 0.2) (to obtain a high bilioenteric anastomosis). Operative mortality (3% vs 0.7%, P = 0.09), postoperative cholangitis (54% vs 13%, P = 0.0001), anastomosis strictures (30% vs 5%, P = 0.0001), short and long term complications and need for reoperation (surgical or radiological) (45% vs 11%, P = 0.0001) were significantly less in the last period. The authors concluded that transition to a high volume center has improved long term results for bile duct injury repair. Even interested and tertiary care centers have a learning curve.

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

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

Malignant insulinoma arising from intrasplenic heterotopic pancreas.

CONTEXT: Heterotopic pancreas is defined as ectopic pancreatic tissue without vascular or anatomic continuity with the normal pancreas. The spleen is a rare site of origin. This case report describes a patient with a malignant insulinoma which originated from an intrasplenic heterotopic pancreas. CASE REPORT: A 46-year-old man with three previous episodes of neuroglucopenic and adrenergic symptoms was referred to our hospital. A fasting test was performed and discontinued due to hypoglycemic symptoms. Preoperative studies failed to demonstrate any pancreatic lesions. However, a heterogeneous encapsulated tumor in the spleen was found on MRI. During surgery, only the splenic tumor was found, with neither vascular nor anatomical connections to the normal pancreas. Pathology reported a malignant insulinoma. Insulin and proinsulin were documented by immunohistochemistry. After one year of follow up, the patient is free of symptoms and no recurrent disease has been documented. DISCUSSION: Only seven cases of splenic heterotopic pancreas have been reported, six with cystic mucinous neoplasms. In addition, only one case of a malignant insulinoma arising from heterotopic pancreas has previously been described. This is the second case reported of an insulinoma arising from heterotopic pancreas and the first to originate from intrasplenic heterotopia.

[Accessory spleen as a differential diagnosis of intrapancreatic tumors. Case report and review of the literature]. / Bazo accesorio como diagnóstico diferencial de tumores intrapancreáticos. Reporte de un caso y revisión de la literatura.

There are few reports of intrapancreatic accessory spleen. Most cases have been reported in Japan and some refer epithelial cysts within it. Most of these lesions are asymptomatic and may be misdiagnosed as a non-functioning neuroendocrine tumor due to their radiological characteristics and lack of symptomatology. We report a case of a 46 year old woman with an incidentally diagnosed intrapancreatic accessory spleen. Because of a history of weight loss and a severe acanthosis nigricans a hidden neoplasia was sought. A 2.5 x 1 cm lesion was found in the tail of the pancreas on computed tomography scan and later confirmed with endoscopic ultrasound. A non-diagnostic biopsy was undertaken. A distal pancreatectomy with splenectomy was performed and a final pathological diagnosis of intrapancreatic accessory spleen was given. The 99mTc-denatured RBC scan in addition to the octreotide scintigraphy have been proposed to differentiate it from other intrapancreatic tumors and avoid unnecessary surgery. Intrapancreatic accessory spleen should be considered as a differential diagnosis for pancreatic tumors.

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

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

Bile duct injuries related to misplacement of "T tubes".

INTRODUCTION: T tubes can be placed in the bile ducts either open or laparoscopically for several reasons such as: extraction of stones, biliary reconstruction after liver transplant and in end-to-end anastomosis in iatrogenic injuries. Inadequate placement of the T tube, long term stay and technical difficulties that can affect the outcome, can lead to an injury that usually requires a biliodigestive reconstruction. METHODS: In a 15-year period (1990-2005) a total of 343 patients have been referred to our university hospital for biliary reconstruction. Files of those patients in which the injury was due to misplacement of a T tube or associated with a long-term stay were reviewed. We evaluated the type of injury, technique used for the reconstruction, longterm staying of the T tubes (1-6 months), hospital in stay, long term outcomes as well as associated comorbidities. RESULTS: In 42 cases a biliary injury related to a T tube was identified (13%). All the injuries were classified as Strasberg E, with demonstration of a fistula (internal or external); 18 to the duodenum, 5 to the jejunum-ileum and 3 to the colon. A hepatojejunostomy was done to all patients; the duodenum and small gut fistulas were closed and in the 3 cases with colonic injury a right hemicolectomy was performed. The postoperative evolution was adequate without major complications but with a longer hospital stay. In 39 of the 42 patients (92%), good postoperative results were obtained. Only one case required a new surgery (22 months after the first one), due to recidivant cholangitis. CONCLUSION: Inadequate placement of the T tubes and long-term stay can produce complex biliary injuries with associated comorbidities such as fistulas to the adjacent viscera. Placement of T tubes need a careful surgical technique and their indication must be carefully assessed.