[Clinical and economic justification of icg-cholangiography in «difficult¼ laparoscopic cholecystectomy]. / Kliniko-ekonomicheskoe obosnovanie kholangiografii s indotsianinom zelenym pri «trudnoi¼ laparoskopicheskoi kholetsistektomii.

OBJECTIVE: To prove from a clinical and economic point of view the expediency of using ICG cholangiography in patients with «difficult¼ laparoscopic cholecystectomy for the prevention of damage to the bile ducts. MATERIAL AND METHODS: The results of treatment of 173 patients with cholelithiasis at various levels of health care providing were analyzed with regard to assessment of indicators of surgery complexity, developed complications and economic costs. RESULTS: The effectiveness of the original scale of «difficult¼ laparoscopic cholecystectomy has been proved. The financial and economic costs of treatment of patients with damage of biliary ducts and patients with cholelithiasis without development of complications have been analyzed and evaluated. A comparative description of financial costs for patients with «difficult¼ laparoscopic cholecystectomy with the use of ICG-cholangiography has been given. A program on care delivery for patients suffering from cholelithiasis in the conditions of region with regard to safety and economic effectiveness has been developed. CONCLUSION: The implementation of this program provides the minimization of postoperative complications and fatality at all levels of surgical care delivery. It has been established that a rational approach to reducing the number of biliary ducts damages is their prevention by prediction of «difficult¼ laparoscopic cholecystectomy and performance of such interventions in medical organizations of III level with the possibility of modern technologies use.

Diseases of bile duct in children.

Several diseases originate from bile duct pathology. Despite studies on these diseases, certain etiologies of some of them still cannot be concluded. The most common disease of the bile duct in newborns is biliary atresia, whose prognosis varies according to the age of surgical correction. Other diseases such as Alagille syndrome, inspissated bile duct syndrome, and choledochal cysts are also time-sensitive because they can cause severe liver damage due to obstruction. The majority of these diseases present with cholestatic jaundice in the newborn or infant period, which is quite difficult to differentiate regarding clinical acumen and initial investigations. Intraoperative cholangiography is potentially necessary to make an accurate diagnosis, and further treatment will be performed synchronously or planned as findings suggest. This article provides a concise review of bile duct diseases, with interesting cases.

[Preliminary clinical application of novel magnetic navigation and ultrasound-guided percutaneous transhepatic cholangiography drainage through the right liver duct for malignant obstructive jaundice].

Objective: To analyze the clinical application value of a novel magnetic navigation ultrasound (MNU) combined with digital subtraction angiography (DSA) dual-guided percutaneous transhepatic biliary drainage (PTCD) through the right hepatic duct for the treatment of malignant obstructive jaundice. Methods: Randomized controlled trial. The clinical data of 64 patients with malignant obstructive jaundice requiring PTCD through the right hepatic duct at the Hepatobiliary Center of the First Affiliated Hospital of Nanjing Medical University (Jiangsu Province People's Hospital) from December 2018 to December 2021 were retrospectively analyzed. The MNU group (n=32) underwent puncture guided by a novel domestic MNU combined with DSA, and the control group (n=32) underwent puncture guided by traditional DSA. The operation time, number of punctures, X-ray dose after biliary stenting as shown by DSA, patients' tolerance of the operation, success rate of the operation, pre- and post-operative total bilirubin, and incidence of postoperative complications were compared between the two groups. Results: The operation time of the MNU group was significantly shorter than that of the control group [(17.8±7.3) vs. (31.6±9.9) min, t=-6.35,P=0.001]; the number of punctures in the MNU group was significantly lower [(1.7±0.6) vs. (6.3±3.9) times, t=-6.59, P=0.001]; and the X-ray dose after biliary stenting as shown by DSA in the MNU group was lower than that in the control group [(132±88) vs. (746±187) mGy, t=-16.81,P<0.001]; Five patients in the control group were unable to tolerate the operation, and two stopped the operation, however all patients in the MNU group could tolerate the operation, and all completed the operation, with a success rate of 100% (32/32) in the MNU group compared to 93.8%(30/32) in the control group; the common complications of PTCD were biliary bleeding and infection, and the incidence of biliary bleeding (25.0%, 8/32) and infection (18.8%, 6/32) in the MNU group was significantly lower than that in the control group, 53.1% (17/32) and 28.1% (9/32), respectively. Conclusion: Magnetic navigation ultrasound combined with DSA dual-guided PTCD through the right biliary system for the treatment of malignant obstructive jaundice is safe and feasible.

Duplicación del colédoco asociado a unión biliopancreática anómala: Reporte de caso / Common bile duct duplication associated with anomalous biliopancreatic junction: A case report

Introducción. La duplicación del colédoco es una anomalía congénita poco frecuente. En la mayoría de los casos este defecto se asocia a cálculos en la vía biliar, unión pancreatobiliar anómala, pancreatitis, cáncer gástrico o colangiocarcinoma. Por esta razón, el diagnóstico y el tratamiento temprano son importantes para evitar las complicaciones descritas a futuro. Métodos. Se presenta el caso de una paciente de 30 años, con antecedente de pancreatitis aguda, con cuadro de dolor abdominal crónico, a quien se le realizaron varios estudios imagenológicos sin claro diagnóstico. Fue llevada a manejo quirúrgico en donde se documentó duplicación del colédoco tipo II con unión pancreatobiliar anómala. Resultados. Se hizo reconstrucción de las vías biliares y hepatico-yeyunostomía, con adecuada evolución postoperatoria y reporte final de patología sin evidencia de tumor. Conclusión. El diagnóstico se hace mediante ecografía endoscópica biliopancreática, colangiorresonancia o colangiopancreatografía retrógrada endoscópica. El tratamiento depende de si está asociado o no a la presencia de unión biliopancreática anómala o cáncer. Si el paciente no presenta patología neoplásica, el tratamiento quirúrgico recomendado es la resección del conducto con reconstrucción de las vías biliares.

Introduction. Double common bile duct is an extremely rare congenital anomaly. This anomaly may be associated with bile duct stones, anomalous biliopancreatic junction, pancreatitis, bile duct cancer, or gastric cancers. Thus, early diagnosis and treatment is important to avoid complications. Clinical case. We report a rare case of double common bile duct associated with an anomalous biliopancreatic junction in a 30-year-old female, with prior history of acute pancreatitis, who presented with chronic abdominal pain. She underwent several imaging studies, without clear diagnosis. She was taken to surgical management where duplication of the type II common bile duct was documented with anomalous pancreatobiliary junction. Results. Reconstruction of the bile ducts and hepatico-jejunostomy were performed, with adequate postoperative evolution and final pathology report without evidence of tumor. Conclusion. Diagnosis is usually performed by an endoscopic ultrasound, magnetic resonance cholangiopancrea-tography, or endoscopic retrograde cholangiopancreatography. Treatment depends on the presence of anomalus biliopancreatic junction or concomitant cancer. In cases without associated malignancy, resection of bile duct and biliary reconstruction is the recommended surgical treatment.

How I Do It: Robotic Choledochoscopy.

BACKGROUND: As the use of the robotic platform increases among general surgeons, the amount of robotic cholecystectomies is expected to increase as well. The use of intraoperative cholangiography is valuable in assessing for choledocholithiasis. We describe our technique of performing robotic intraoperative cholangiograms with choledochoscopy. Out technique aids in efficiency since no undocking is required. METHODS: Preoperatively, the decision to perform a cholangiogram is made based on physical exam, labs, and imaging findings. The procedure begins with obtaining a critical view of safety. The robotic arms are positioned in a manner that allows all 4 robotic arms to remain docked. A ductotomy is made and the cholangiocatheter is introduced. The cholangiogram images are then interpreted and if a stone is seen in the common bile duct we will then perform a transcystic common bile duct exploration using the SpyGlass Discover digital. A complete cholangiogram is then performed. The cystic duct is secured and the gallbladder is removed from the liver bed. The patients are watched overnight and discharged on postoperative day 1. CONCLUSIONS: A robotic approach to performing a transcystic common bile duct exploration is a safe and reproducible treatment method for choledocholithiasis. Our approach offers an advantage since no undocking is required.

An atypical case of isolated immunoglobulin G4-related sclerosing cholangitis with a cholangiogram resembling primary sclerosing cholangitis.

An asymptomatic 77-year-old man with intrahepatic bile duct dilation was referred to our hospital. Cholangiography revealed alternations between strictures and dilated segments from the right and left hepatic ducts to the lower bile ducts, with findings of a pruned tree, beaded, shaggy appearance, and diverticulum-like outpouching. Histopathology revealed abundant immunoglobulin G4 (IgG4)-positive plasma cells (> 10 per high-power field) with an IgG4/IgG-positive cell ratio of 40-50%. After 2 weeks of steroid therapy, the cholangiography markedly improved. Because the cholangiographic findings resembled those of primary sclerosing cholangitis, steroid therapy proved useful in differentiating IgG4-related sclerosing cholangitis from primary sclerosing cholangitis.

Intrahepatic biloma after intraoperative cholangiography.

A woman in her 30s presented to the emergency department with a month-long history of postprandial epigastric pain radiating to her back. The diagnosis of cholecystolithiasis and suspected choledocholithiasis was made, and the patient underwent cholecystectomy with cholangiography using standard technique. The surgery was complicated by an intrahepatic bile duct injury attributed to high injection pressure during cholangiography. She developed an intrahepatic collection that was drained and confirmed the diagnosis of biloma. In this case report, we discuss a rare complication of intraoperative cholangiography during laparoscopic cholecystectomy and consider a way to prevent it.

Indocyanine green fluorescent cholangiography: The new standard practice to perform laparoscopic cholecystectomy in pediatric patients. A comparative study with conventional laparoscopic technique.

BACKGROUND: This study aimed to compare outcomes of standard laparoscopic cholecystectomy and indocyanine green fluorescent cholangiography laparoscopic cholecystectomy over a 10-year period. METHODS: From 2013 to 2023, 173 laparoscopic cholecystectomies were performed in 2 pediatric surgery units: 83 using standard technique (G1) and 90 using indocyanine green fluorescent cholangiography (G2). Patients included 96 girls and 77 boys, with a median age of 12.3 years (range 4-17) and a median weight of 51 kg (range 19-114). The 2 groups were compared regarding the following: (1) perioperative complications rate; (2) overall length of surgery (T1); (3) length of cystic duct isolation, clipping, and sectioning (T2); (4) time of gallbladder removal (T3); (5) degree of visualization of biliary tree; (6) safety and feasibility of indocyanine green fluorescent cholangiography; (7) incidence of anatomical anomalies detected intraoperatively. RESULTS: All laparoscopic cholecystectomies were accomplished without conversion to open. The perioperative complications rate was significantly higher in G1 compared with G2 (12% vs 0%; P = .0007). Median T1, T2, and T3 were significantly longer in G1 (90, 37, 35 minutes) compared with G2 (55, 17, 19 minutes) (P = .0001), respectively. The visualization rate of the complete biliary tree was significantly higher in G2 (98.8%) than in G1 (80.7%) (P = .0001). No adverse reactions to indocyanine green were recorded. The incidence of biliary anomalies detected intraoperatively was significantly higher in G2 (7.8%) than in G1 (1.2%) (P = .03). CONCLUSION: Indocyanine green fluorescent cholangiography can be considered the new standard practice to perform laparoscopic cholecystectomy in pediatrics. Indocyanine green fluorescence provided superior visualization of biliary anatomy, increased detection of anatomic variants, faster procedure, and fewer complications compared with conventional technique. Indocyanine green fluorescent cholangiography was safe, feasible, simple, inexpensive, and a timesaving tool.

Safety of laparoscopic cholecystectomy performed by trainee surgeons with different cholangiographic techniques (SCOTCH): a prospective non-randomized trial on the impact of fluorescent cholangiography during laparoscopic cholecystectomy performed by trainees.

AIMS: The identification of the anatomical components of the Calot's Triangle during laparoscopic cholecystectomy (LC) might be challenging and its difficulty may increase when a surgical trainee (ST) is in charge, ultimately allegedly affecting also the incidence of common bile duct injuries (CBDIs). There are various methods to help reach the critical view of safety (CVS): intraoperative cholangiogram (IOC), critical view of safety in white light (CVS-WL) and near-infrared fluorescent cholangiography (NIRF-C). The primary objective was to compare the use of these techniques to obtain the CVS during elective LC performed by ST. METHODS: This was a multicentre prospective observational study (Clinicalstrials.gov Registration number: NCT04863482). The impact of three different visualization techniques (IOC, CVS-WL, NIRF-C) on LC was analyzed. Operative time and time to achieve the CVS were considered. All the participating surgeons were also required to fill in three questionnaires at the end of the operation focusing on anatomical identification of the general task and their satisfaction. RESULTS: Twenty-nine centers participated for a total of 338 patients: 260 CVS-WL, 10 IOC and 68 NIRF-C groups. The groups did not differ in the baseline characteristics. CVS was considered achieved in all the included case. Rates were statistically higher in the NIR-C group for common hepatic and common bile duct visualization (p = 0.046; p < 0.005, respectively). There were no statistically significant differences in operative time (p = 0.089) nor in the time to achieve the CVS (p = 0.626). Three biliary duct injuries were reported: 2 in the CVS-WL and 1 in the NIR-C. Surgical workload scores were statistically lower in every domain in the NIR-C group. Subjective satisfaction was higher in the NIR-C group. There were no other statistically significant differences. CONCLUSIONS: These data showed that using NIRF-C did not prolong operative time but positively influenced the surgeon's satisfaction of the performance of LC.

Laparoscopic cholecystectomy assisted by combined intravenous and intracholecystic fluorescent cholangiography: a case report.

This case report describes a laparoscopic approach using fluorescence imaging guidance to treat gangrenous cholecystitis with perforation (GCP). A male patient in his early 60s presented with 3 days of right upper abdominal pain. Computed tomography and ultrasonography findings were consistent with a stone incarcerated in the gallbladder neck, GCP, and localized peritonitis. Percutaneous gallbladder drainage was initially performed, followed by laparoscopic cholecystectomy 7 days later, using combined intravenous and intracholecystic fluorescent cholangiography. This technique allowed visualization of the cystic and common bile ducts during surgery and enabled safe removal of the diseased gallbladder. The patient recovered well without complications, and reported no pain or discomfort at a 2-month follow-up.

Treatment of complex iatrogenic common hepatic duct injury following laparoscopic cholecystectomy.

We report the case of a woman in her 40s, with no significant medical history, submitted to a laparoscopic cholecystectomy in our institution for symptomatic gallbladder lithiasis. On postoperative day 4, she presented to our emergency room with severe abdominal pain and elevated inflammatory markers. Abdominal CT scan revealed a mass filled with liquid and air in the gallbladder fossa. Surgical exploration was performed revealing a major common hepatic duct iatrogenic injury, which was managed using suture over a T-tube. Three months after surgery, cholangiography showed a biliary stenosis, and a biodegradable stent was inserted through percutaneous transhepatic access. The difficulties in the management of this condition and its outcomes are discussed in this report.

[Modern possibilities of fluorescent imaging in liver surgery]. / Sovremennye vozmozhnosti flyuorestsentnoi vizualizatsii v khirurgii pecheni.

The article presents a literature review of modern methods of fluorescent navigation in liver surgery. The technique of tumor «staining¼, mapping of liver segments, fluorescent cholangiography is covered. The own results of the use of indocyanine green in liver surgery are presented.

[Integration of ICG-fluorescence cholangiography into the safety system of laparoscopic cholecystectomy]. / Integratsiya ICG-fluorestsentnoi kholangiografii v sistemu bezopasnosti laparoskopicheskoi kholetsistektomii.

THE AIM OF THE STUDY: Is evaluating the possibility of integrating ICG-fluorescent cholangiography into the general safety system for laparoscopic cholecystectomy to prevent damage to the extrahepatic bile ducts by working out the methodological aspects of navigation technologies. MATERIALS AND METHODS: The analysis of literature data on various approaches to improve the perioperative identification of anatomical structures during laparoscopic cholecystectomy, including the ICG-fluorescent cholangiography, was carried out. This program was implemented during the provision of elective surgical care to 24 patients with cholelithiasis who underwent laparoscopic cholecystectomy with ICG-fluorescent navigation. RESULTS AND DISCUSSION: The developed program included: preoperative assessment of the anatomy of the biliary tree using MRCP; intraoperative technique of safe laparoscopic cholecystectomy with mandatory application of the concept of «critical view of safety¼ (CVS), which allows the most effective identification of the necessary anatomical structures; the use of ICG-fluorescent cholangiography, which allows to improve the control of anatomical structures at all stages of the operations. CONCLUSIONS: The first experience of using ICG-fluorescent cholangiography testifies to the high informative value of the method, the possibility and prospects of integrating the technology into a comprehensive safety system during laparoscopic cholecystectomy.

Percutaneous Ultrasound Cholangiography With Microbubbles in Children With Biliary Diseases.

ABSTRACT: The application of intracavity contrast-enhanced ultrasound in the evaluation of biliary disease has been confirmed valuable among pediatric population. This pictorial essay aims to demonstrate the role of percutaneous ultrasound cholangiography (PUSC) with microbubbles in the diagnosis of different pediatric biliary diseases in our center. The biliary system's morphologic characteristics in PUSC mode of neonatal hepatitis, biliary atresia, choledochal cysts, and biliary complications of hepatobiliary surgery are presented.

Lesión quirúrgica de la vía biliar en residentes. Experiencia de un Centro Formador Universitario / Surgical injury of the biliary tract in residents. Experience of a University Training Center

La lesión quirúrgica de la vía biliar es una complicación peligrosa de la colecistectomía, con importantes secuelas postoperatorias para el paciente en términos de morbilidad, mortalidad y calidad de vida. Tienen una incidencia laparoscópica estimada del 0,4% al 1,5% y del 0,2% al 0,3% en la colecistectomía convencional. El objetivo de este estudio fue evaluar la incidencia de LQVB durante la formación del cirujano y la importancia de realizar colangiografía intraoperatoria (COI) durante esta etapa

Bile duct surgical injury is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality and quality of life. These have an estimated laparoscopic incidence of 0.4% to 1.5% and 0.2% to 0.3% in conventional cholecystectomy. The aim of this study was to evaluate the incidence of LQVB during surgeon training and the importance of performing intraoperative cholangiography (IOC) during this stage

How to avoid iatrogenic injuries of the biliary tract in urgent surgery? The use of indocianine green is an alternative.

Iatrogenic bile duct injury is a rare complication, although feared due to its morbidity and mortality. In urgent surgeries, its incidence can be doubled, so in selected cases we must assess the use of resources such as indocyanine green to minimize the risk of biliary or arterial lesions by allowing the correct identification of the structures. We present the case of a 57-year-old patient with acute cholecystitis who underwent laparoscopic cholecystectomy. Given the difficulty in differentiating structures in Calot's triangle, the decision was made to use indocyanine green, which identifies a very short cystic duct, thus avoiding iatrogenic bile duct injury.

La lesión iatrogénica de vía biliar es una complicación infrecuente, aunque temida por su morbimortalidad. En cirugías urgentes, su incidencia puede duplicarse, por lo que en casos seleccionados debemos valorar la utilización de recursos como el verde de indocianina para minimizar el riesgo de lesiones biliares o arteriales, al permitir una correcta identificación de las estructuras. Presentamos el caso de una paciente de 57 años con colecistitis aguda a la que realizamos colecistectomía laparoscópica. Ante la dificultad en la diferenciación de estructuras en el triángulo de Calot, se decidió utilizar verde de indocianina, que identificó un conducto cístico muy corto, evitando así una lesión iatrogénica de vía biliar.