Hypothermic oxygenated machine perfusion reduces bile duct reperfusion injury after transplantation of donation after circulatory death livers.

Dual hypothermic oxygenated machine perfusion (DHOPE) of the liver has been advocated as a method to reduce ischemia/reperfusion injury (IRI). This study aimed to determine whether DHOPE reduces IRI of the bile ducts in donation after circulatory death (DCD) liver transplantation. In a recently performed phase 1 trial, 10 DCD livers were preserved with DHOPE after static cold storage (SCS; www.trialregister.nl NTR4493). Bile duct biopsies were obtained at the end of SCS (before DHOPE; baseline) and after graft reperfusion in the recipient. Histological severity of biliary injury was graded according to an established semiquantitative grading system. Twenty liver transplantations using DCD livers not preserved with DHOPE served as controls. Baseline characteristics and the degree of bile duct injury at baseline (end of SCS) were similar between both groups. In controls, the degree of stroma necrosis (P = 0.002) and injury of the deep peribiliary glands (PBG; P = 0.02) increased after reperfusion compared with baseline. In contrast, in DHOPE-preserved livers, the degree of bile duct injury did not increase after reperfusion. Moreover, there was less injury of deep PBG (P = 0.04) after reperfusion in the DHOPE group compared with controls. In conclusion, this study suggests that DHOPE reduces IRI of bile ducts after DCD liver transplantation. Liver Transplantation 24 655-664 2018 AASLD.

Effects of the administration of pentoxifylline and prednisolone on the evolution of portal fibrogenesis secondary to biliary obstruction-an experimental study in growing animals.

BACKGROUND: Many chronic liver diseases lead to progressive hepatic fibrosis, a condition that can ultimately result in loss of organ function and severe portal hypertension necessitating hepatic transplantation. Within the last few decades, studies have been conducted to demonstrate the possibility of drug modulation of hepatic fibrogenesis. Regarding biliary obstruction, it has been suggested that administration of corticosteroids could promote better late outcomes for children with biliary atresia submitted to Kasai's portoenterostomy. Models used to test potential antifibrogenic drugs such as pentoxifylline (PTX) have not included growing animals. METHODS: In this experimental study, 119 young rats (21st or 22nd days) were submitted to laparotomy and common bile duct ligation (CBDL) or to sham surgery (SHAM). Animals were allocated into 5 groups, according to surgical procedure, and administered the following solutions: (1) CBDL + distilled water, (2) SHAM + distilled water, (3) CBDL + PTX, (4) CBDL + prednisolone (PRED), and (5) CBDL + PTX + PRED (PTX + PRED). Each group was further divided into 2 subgroups according to the length of the experiment (15 or 30 days). At the end of the defined period, animals were weighed, and a hepatic fragment was collected from each one for analyses. RESULTS: The PTX animals exhibited increased weight gain compared to animals in the PRED or PTX + PRED groups. Animals from the 3 therapeutic groups (PTX, PRED, and PTX + PRED) showed diminished collagen-filled area in portal spaces. Total portal space area was increased in the PTX group. CONCLUSIONS: Hepatic fibrosis induced by bile duct ligation in young rats could be modulated by pharmacologic interventions. Administration of PTX or PRED, or the combination of both, resulted in diminished collagen-filled areas in portal spaces.

Operative strategy can reduce the incidence of major bile duct injury in laparoscopic cholecystectomy.

Major bile duct injury (BDI) rates remain in the range of 0.3 to 0.5 per cent for laparoscopic cholecystectomy (LC). The dominant surgical technique worldwide continues to be the "infundibular" technique of dissection that was popularized in the early 1990s. Proponents of the "critical view of safety" (CV) technique have suggested that most of these injuries are avoidable. The objective of our study was to determine whether routine use of the CV technique reduced the observed/expected single-institution rate of major BDI over a 5-year period in a teaching hospital. All patients (n = 3042) who underwent LC for any indication at one institution over a 60-month period were identified by database search. Major BDI was identified by Common Procedural Terminology codes indicating operative repair and confirmed by review of medical records. One patient sustained a transection-excision of the common duct requiring hepaticoduodenostomy. Based on published data, the observed BDI rate was one in nine to one in 15 of the expected rate. This represents an order-of-magnitude improvement in the safety of LC at a single institution where the majority of cases were performed by residents. We suggest that the "critical view" technique should be widely adopted.

Polyethylene stent blockage: a porcine model.

BACKGROUND: Endoscopic insertion of biliary stents is a useful treatment for obstructive jaundice resulting from unresectable tumors of the pancreas and biliary tree. The main drawback is the recurrence of jaundice due to clogging. The aim of this study was to establish an experimental model of polyethylene stent clogging in large white pigs. METHODS: A straight polyethylene stent of 5F (group I), 7F (group II) or 10F size (group III) was inserted in the common bile duct. Animals were killed at 2 months, or earlier if physical signs suggesting stent clogging occurred. Chemicophysical analysis of stent deposition combined stereomicroscopy and identification of the contents by means of Fourrier transform infrared spectroscopy. Bacteriologic analyses included identification of aerobic and anaerobic bacteria and measurement of beta-glucuronidase, lecithinase and lipase activities. RESULTS: Physical signs suggesting stent obstruction or death occurred in 8 of 8 animals in group I, 11 of 12 in group II, and 2 of 8 in group III (p < 0.001). The proportion of mucoprotein in the stent contents tended to fall with increasing stent diameter (mean 82%, 58% and 47% for 5F, 7F and 10F, respectively), whereas wheat starch and calcium bilirubinate content increased with increasing stent diameter (9% and 4%, 18% and 10%, and 29% and 23% for 5F, 7 F, and 10F, respectively), although none of these differences were statistically significant. A variety of bacteria were cultured from the stent deposits, including anaerobic strains. Clostridium species were associated with the highest enzyme activities. CONCLUSIONS: In this model the major component of early stent deposits was mucoprotein, and numerous aerobic and anaerobic bacteria were isolated. Formation of calcium bilirubinate was a late phenomenon and poorly related to bacterial enzymatic activities.

Long-term ciprofloxacin treatment for the prevention of biliary stent blockage: a prospective randomized study.

OBJECTIVE: In vitro experimental and animal studies have shown that quinolones reduce the adherence of bacteria on a polyethylene tube and prevent stent blockage. Our aim was to see whether ciprofloxacin prevents stent blockage in patients with malignant stricture of the biliary tract. METHODS: Patients with inoperable biliary or pancreatic tumor not involving the bifurcation of the common hepatic duct were recruited. They were randomized to receive either endoscopic stenting alone or stenting with prophylactic treatment of ciprofloxacin (200 mg i.v. before stenting, followed by 250 mg orally twice per day). In each follow-up visit, clinical symptoms of cholangitis were documented and blood samples taken for blood counts, serum levels of bilirubin, and alkaline phosphatase. Stent blockage was defined as clinical symptom(s) of cholangitis with biochemical or radiological evidence of stent dysfunction. RESULTS: Fifty-eight patients were recruited into the study. Three patients in the stenting group and three in the ciprofloxacin group were excluded after randomization. Eleven patients received stenting alone and five patients receiving ciprofloxacin had previous endoscopic stenting. Thirteen patients (50%) in the ciprofloxacin group and eight patients (31%) in the stenting group died before stent blockage. Ten patients (38%) in each group had stent blockage during the follow-up at 20 wk. The median stent patency was 11.6 wk and 11.9 wk in the ciprofloxacin group and the stenting group, respectively. Kaplan-Meier analysis of stent patency showed no difference between the two groups. Among patients who received endoscopic stenting for the first time, there was a trend favoring ciprofloxacin treatment, but the difference was not significant. The 30-day and 20-wk mortality between the groups were comparable. CONCLUSION: Long-term use of ciprofloxacin does not prevent blockage of polyethylene biliary stents.

New retraction technique to allow better visualization of Calot's triangle during laparoscopic cholecystectomy.

BACKGROUND: Bile duct injuries during laparoscopic cholecystectomy (LC) are thought to occur because surgeons tend to confuse the common bile duct (CBD) with the cystic duct. Among reasons for this misidentification, the difference in the way the operating field is exposed in LC compared to open cholecystectomy should be noticed. Using Dr. Reddick's technique, which is commonly practiced, the upward and the lateral traction of the gallbladder results in a narrower Calot's triangle and angulation of the CBD. These anatomical distortions are thought to contribute to ductal injuries during LC. METHODS: We propose a new method to expose Calot's triangle during LC. The principle of this technique is to expose the hepatic hilus by retracting the caudal surfaces of the quadrate and lateral lobes of the liver using an atraumatic curved instrument. RESULTS: The advantages of this technique are that one gains wide exposure of the hepatic hilus, leaves Calot's triangle undistorted, and avoids tenting the CBD. CONCLUSIONS: This new technique may make LC safer and decrease the number of bile duct injuries associated with the misidentification of the anatomy.

[Methods of correction and prevention of cicatricial strictures and fistulas of the bile ducts]. / Metody korrektsii i profilaktika rubtsovykh striktur i svishchei zhelchnykh protokov.

Two hundred and eighty one patients with cicatricial biliary strictures were examined to reveal external biliary fistulas in 72 of the patients. The strictures and fistulas developed after surgery on the stomach and biliary ducts due to an accidental surgical injury to these organs, or at later terms after a ++hepato-choledochal intervention. The biliary lesions were repaired with 149 operations with formation of a biliodigestive anastomosis without tube drainage, 117 with tube drainage (mostly transhepatic), six plastic operations with reconstruction of the ++hepato-choledochal integrity, and 47 ++radio-endoscopically guided interventions. Complications after cavitary++ operations were observed in 36.9 per cent cases with the fatal outcome in 13 of the patients (4.7 per cent). ++Radio-endoscopically guided interventions included: radioendobiliary prosthetics of the biliary ducts, recanalization, balloon dilatation of short strictures with endoscopic guidance, elimination of concretions by means of external drainage, and endoscopic papillosphincterotomy in distal choledochal strictures. Long-term findings were related to the level of the biliary lesion, the period that had elapsed since the stricture formation, and the number of operations in the medical history. Good or satisfactory results were achieved in 87.9 per cent cases. Considering the results of treatment for biliary strictures and fistulas disappointing, the main effort should be aimed at their prophylaxis. With this purpose, measures to prevent surgical injury to the biliary tract have been elaborated.

Iatrogenic bile duct injuries: avoidance, recognition, and treatment.

Common bile duct injury has potential catastrophic implications if unrecognized or inadequately managed at the time of initial surgical intervention. Every precaution necessary to avoid operative injury to the common duct should be taken, and with experience and meticulous attention to detail, this complication should rarely be encountered in the career of a well-trained general surgeon. If ever this unexpected occurrence happens, adherence to certain principles of recognition and management may preclude significant morbidity and mortality. Two patients with injured common bile ducts are discussed. One patient presented with an iatrogenic stricture due to previous operative trauma. A second patient suffered a complete transection of the common duct while undergoing a routine cholecystectomy; the transection was recognized and repaired primarily. The fundamental principles of bile duct reconstruction and biliary-enteric anastomoses are discussed. The prevention of stricture formation is explained, with specific guidelines presented to minimize this potentially lethal complication.