[Choledochal cysts: surgical treatment in newborns and infants]. / Kisty kholedokha: osobennosti khirurgicheskogo lecheniya u detei pervykh trekh mesyatsev zhizni.

OBJECTIVE: To improve postoperative outcomes in newborns and infants with choledochal cysts and to determine the indications for surgery. MATERIAL AND METHODS: There were 13 children aged 0-3 months with choledochal cyst who underwent reconstructive surgery between 2019 and 2023. In all children, choledochal cyst was associated with cholestasis. Acholic stool was observed in almost half of the group (n=7). All children underwent cyst resection and Roux-en-Y hepaticoenterostomy. RESULTS: Symptoms of cholestasis regressed in all patients. Mean surgery time was 128±27 min. There were no complications. Enteral feeding was started after 1-2 postoperative days, abdominal drainage was removed after 6.2±1.6 days. Mean length of hospital-stay was 16±3.7 days. Adequate bile outflow is one of the main principles. For this purpose, anastomosis with intact tissues of hepatic duct should be as wide as possible. Roux-en-Y loop should be at least 40-60 cm to prevent postoperative cholangitis. CONCLUSION: Drug-resistant cholestasis syndrome and complicated choledochal cysts (cyst rupture, bile peritonitis) are indications for surgical treatment in newborns and infants. When forming Roux-en-Y hepaticoenterostomy, surgeon should totally excise abnormal tissues of the biliary tract to prevent delayed malignant transformation.

An unusual presentation of a rare formation of the common hepatic duct and right hepatic artery in a case of pediatric congenital biliary dilatation.

A 15-year-old girl with recurrent upper abdominal pain was diagnosed with congenital biliary dilatation. Abdominal enhanced computed tomography (CT) showed the anterior segmental branch of the right hepatic artery (RHA) running across the ventral aspect of the dilated common hepatic duct (CHD). Laparoscopic extrahepatic dilated biliary duct excision and Roux-en-Y hepaticojejunostomy were planned. Intraoperatively, the dilated CHD was observed to bifurcate into the ventral and dorsal ducts, between which the anterior segmental branch of the RHA crossed through the CHD. The CHD rejoined on the distal side as one duct. We transected the CHD just above the cystic duct. The patency of the ventral and dorsal sides of the bifurcated CHD was confirmed. Laparoscopic hepaticojejunostomy was performed at the distal side of the rejoined CHD, without sacrificing the anterior segmental branch of the RHA. There was no postoperative blood flow impairment in the right hepatic lobe or anastomotic stenosis.

Recognition and Surgical Management of Aberrant Right Hepatic Duct Originating From the Cystic Duct.

An aberrant right hepatic duct is a rare congenital anomaly of the biliary system. Failure to recognize these anomalies can result in serious complications. In this case, we present a patient who underwent laparoscopic cholecystectomy for chronic cholecystitis. Post-operatively she developed a bile leak for which she underwent reoperation. On re-exploration, she was discovered to have a cystic stump leak and a rare Hisatsugu type V anatomic anomaly of the right hepatic duct originating from the cystic duct. She was subsequently managed with oversewing of the cystic duct stump and drainage. This case demonstrates the importance of recognizing these rare anomalies and the challenges of management in a rural, resource-limited setting.

Bile duct injury with formation of right hepatic duct-duodenal fistula after cholecystectomy: A case report.

RATIONALE: The management of bile duct injury (BDI) remains a considerable challenge in the department of hepatobiliary and pancreatic surgery. BDI is mainly iatrogenic and mostly occurs in laparoscopic cholecystectomy (LC). After more than 2 decades of development, with the increase in experience and technological advances in LC, the complications associated with the procedure have decreased annually. However, bile duct injuries (BDI) still have a certain incidence, the severity of BDI is higher, and the form of BDI is more complex. PATIENT CONCERNS: We report the case of a patient who presented with bile duct injury and formation of a right hepatic duct-duodenal fistula after LC. DIAGNOSES: Based on the diagnosis, a dissection was performed to relieve bile duct obstruction, suture the duodenal fistula, and anastomose the right and left hepatic ducts to the jejunum. INTERVENTION: Based on the diagnosis, a dissection was performed to relieve bile duct obstruction, suture the duodenal fistula, and anastomose the right and left hepatic ducts to the jejunum. OUTCOMES: Postoperative recovery was uneventful, with normal liver function and no complications, such as anastomotic fistula or biliary tract infection. The patient was hospitalized for 11 days postoperatively and discharged. LESSONS: The successful diagnosis and treatment of this case and the summarization of the imaging features and diagnosis of postoperative BDI have improved the diagnostic understanding of postoperative BDI and provided clinicians with a particular clinical experience and basis for treating such diseases.

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.

A case of accessory hepatic duct entering cystic duct successfully treated by laparoscopic cholecystectomy for cholecystolithiasis.

Although laparoscopic cholecystectomy is a well-established surgical procedure, an accessory hepatic duct (AcHD) entering the cystic duct is poorly understood. A 77-year-old woman with symptomatic cholecystlithiasis was referred to our hospital. Abdominal ultrasonography indicated several small stones in the gall bladder. Magnetic resonance cholangiopancreatography (MRCP) did not reveal an anomalous cystic duct. Dissecting the gall bladder bed at operation, AcHD entering the cystic duct was suspected. Intraoperative cholangiography revealed that B5 branch entered the cystic duct. We ligated the AcHD, and divided it. Laparoscopic cholecystectomy was completed, and the patient was discharged without any complication. A week after the operation, MRCP showed that ventral branch of B5 was dilated. The patient showed no symptom for more than a year. The present case exhibited extremely rare AcHD entering the cystic duct, which was hardly recognized before surgery. It is possible to recognize such anomalous variants with standard laparoscopic approach based on 2018 Tokyo Guidelines and with attention to the possibilities of AcHD entering the cystic duct.

Post cholecystectomy benign biliary stricture-isolated hepatic duct stricture: a proposed modification of the BISMUTH classification.

BACKGROUND: Post-cholecystectomy, benign biliary strictures are challenging for both patients and surgeons. Bismuth classified benign biliary strictures into 5 types. This study aimed to review these isolated hepatic duct strictures which were not included in Bismuth classification. METHODS: The case records of all patients who presented with post-cholecystectomy benign biliary strictures between January 2005 and December 2020 at our centre were reviewed. Data regarding demography, type of stricture, and treatment strategy were entered into the standard proforma. RESULTS: There were 242 patients [type I-3.7%, type II-41.7%, type III-38.0%, type IV-6.6%, and type V-7.8%]. Five (2.1%) patients did not fit the Bismuth classification and were the focus of this study. In each of these patients, an isolated hepatic duct stricture (first-or second-order hepatic duct) was present, with no involvement of the common hepatic duct or hilar confluence. CONCLUSIONS: The addition of isolated hepatic duct stricture [type VI] to the Bismuth classification will enhance the original classification, help in reporting and management of this sub-set of patients.

Variations in extra-hepatic biliary tree morphology and morphometry: a narrative review of literature with focus on cystohepatic triangle.

The morphometry and morphology of the components of extrahepatic biliary tree show extensive variations. A beforehand recognition of these variations is very crucial to prevent unintended complications while performing surgeries in this region. This study was conducted to analyse the configuration of the extrahepatic biliary tree and its possible variations, as well as measure the components that limit the cystohepatic triangle. Articles were searched in major online indexed databases (Medline and PubMed, Scopus, Embase, CINAHL Plus, Web of Science and Google Scholar) using relevant key words. A total of 73 articles matched the search criteria of which 55 articles were identified for data extraction. The length of left and right hepatic duct in majority of studies was found to be > 10 mm. A wide range of diameters of hepatic ducts were observed between 5 and 43 mm. The average length of cystic duct is around 20 mm. The length and diameter of the common bile duct are 50-150 mm and 3-9 mm, respectively. The most frequently observed pattern of insertion of cystic duct into common hepatic duct is right lateral, rarely anterior, or posterior spiral insertion can present. The results of this study will provide a standard reference range which instead will help to differentiate the normal and pathological conditions.

Robotic versus laparoscopic surgery for choledochal cyst in children with aberrant hepatic ducts: A retrospective study.

BACKGROUND: The aim of this current study was to compare the safety and effectiveness between robotic and laparoscopic surgery in pediatric patients suffered from choledochal cysts associated with aberrant hepatic duct. METHODS: Patients suffered from choledochal cysts associated with aberrant hepatic duct who were treated with laparoscopic or robotic procedures between January 2009 and June 2022 were retrospectively analyzed. The patients were divided into laparoscopic and robotic group according to different surgical methods. The data collected included the demographic information, imaging information, operative details and postoperative complications. RESULTS: Twenty-two patients were included in the analysis consisting of 14 cases in laparoscopic group and 8 cases in robotic group. The male to female ratio was 1:6.33. The median age of the patients was 40.00 months with a mean weight of 16.99 kg. There were no significant differences in patient characteristics between the two groups. The operation and anesthesia time were significantly longer in the laparoscopic procedures group (238.14 ± 17.24 min, 265.93 ± 19.51 min, respectively) than robotic procedures group (208.00 ± 9.24 min, 230.13 ± 12.87 min, respectively) (p < 0.001). The time to take water and hospital stay were longer in laparoscopic group (3.33 ± 0.44 days, 8.92 ± 0.52 days, respectively) than robotic group (3.01 ± 0.22 days, 7.88 ± 1.13 days, respectively) (p < 0.05). There was no statistical difference in total complications between the two groups (p = 0.912). CONCLUSIONS: Robotic surgery can achieve the same results as laparoscopic surgery in the management of patients suffered from choledochal cysts associated with aberrant hepatic duct, at the same time reducing the difficulty of operation and recovering faster.

Biliary Tract Exploration After Laparoscopic Left-sided Hepatectomy: A Comparative Study of Left Hepatic Duct Orifice Versus Common Bile Duct Approach.

BACKGROUND: Laparoscopic left-sided hepatectomy (LLH) and additional biliary tract exploration are effective methods to treat left-sided hepatolithiasis (LSH) combined with extrahepatic bile duct stones. Although biliary tract exploration through common bile duct (CBD) incision has been widely accepted, the safety and effectiveness of the left hepatic duct (LHD) orifice approach after LLH is still in debate. METHODS: One hundred and forty-four patients with LSH who underwent LLH and biliary tract exploration in our institution from April 2014 to September 2021 were enrolled in the retrospectively study. They were divided into 3 groups: LHD group (n=67), CBD/T-tube group (n=58), and CBD/PC group (n=19). Patients' demographic characteristics, intraoperative, and postoperative outcomes were retrospectively analyzed. RESULTS: LHD group exhibited a shorter operative time (202.8±42.2 vs. 232.7±47.5 min, P =0.000), time to first bowel movement (2.3±0.5 vs. 2.9±0.7 d, P =0.000) and postoperative hospital stay (7.5±2.1 vs. 9.8±5.2 d, P =0.001) compared with the CBD/T-tube group. The lithotomy time in the LHD group was significantly longer than that in the CBD/T-tube group (33.6±7.3 vs. 29.0±6.3 min, P =0.000) and CBD/PC group (33.6±7.3 vs. 28.7±3.7, P =0.006). Intraoperative blood loss, blood transfusion rate, initial stone clearance rate, and stone recurrence rate all had no significant differences between the 3 groups (all P >0.05). LHD group showed less rate of electrolyte imbalance than that of the CBD/T-tube group (3.0% vs. 19.0%, P =0.004) but it was equivalent to the CBD/PC group ( P >0.05). The type of biliary tract exploration (odds ratio: 5.43, 95% confidence interval: 0.04-0.95, P =0.032) as independent predictors of electrolyte imbalance. No reoperation and mortality occurred in the 3 groups. The conversion rate was comparable among 3 groups (1.5% vs. 1.7% vs. 0, all P >0.05). No significant difference in stone recurrence rate was seen (1.5% vs. 3.4% vs. 0, all P >0.05). CONCLUSION: Biliary tract exploration through LHD orifice after LLH is a safe and effective treatment for selected patients with LSH, with an advantage over the T-tube drainage in the field of operative time, the incidence of electrolyte imbalance, recovery of gastrointestinal function, and postoperative hospital stay.

Cholecysto-hepatic duct serving as the only drainage pathway of bile from the intrahepatic to the extrahepatic biliary system in an infant: a case report.

BACKGROUND: Cholecystohepatic duct is a rare anomaly of the biliary system which involves drainage of bile into the gallbladder which may be associated with agenesis of the common hepatic duct or common bile duct. CASE PRESENTATION: A 2.5-month-old infant presented to our emergency department with icterus. He had a history of esophageal atresia and imperforate anus which had been treated surgically by thoracotomy, esophagostomy, gastrostomy and colostomy placement. Following imaging studies by ultrasound and MRCP, the diagnosis of common hepatic duct agenesis was made. Cholecystohepatic duct was present as the solitary drainage pathway of bile from the intrahepatic to extrahepatic biliary system. CONCLUSIONS: Cholecystohepatic ducts need a high index of suspicion to be diagnosed on preoperative hepatobiliary imaging. As they may be asymptomatic, they are predisposed to iatrogenic injury during hepatobiliary surgeries.

The Outcome of Patients With Cystic Biliary Atresia With Intact Proximal Hepatic Ducts Following Hepatic-Cyst-Jejunostomy.

OBJECTIVES: To determine the outcomes of patients with cystic biliary atresia by correlating the anatomy of the hepatic ducts with the choice of biliary reconstruction surgery. BACKGROUND: The Kasai hepatoportoenterostomy (Kasai) is the initial surgical procedure offered to most patients with biliary atresia. In contrast, a hepatic-cyst-jejunostomy has been reported to be effective in patients with the cystic form of biliary atresia. METHODS AND RESULTS: We performed an international multicenter retrospective review. Two hundred eighty-seven patients were included, and 33 cases of cystic biliary atresia were identified. Outcomes were the serum total bilirubin level 3 months post-surgery and native liver survival at 2 years of age and were compared between cases who received the Kasai versus hepatic-cyst-jejunostomy in correlation to the anatomy of proximal hepatic ducts. The patients were categorized into 3 anatomical groups: patent intact hepatic ducts (n = 10), patent hypoplastic hepatic ducts (n = 13), and obliterated hepatic ducts (n = 10). All 10 patients with patent intact hepatic duct group underwent hepatic-cyst-jejunostomy, and 9 experienced bile drainage and native liver survival. Among the 13 patients with hypoplastic hepatic ducts, 11 underwent the Kasai procedure, and 9 had bile drainage, whereas 2 underwent hepatic-cyst-jejunostomy, and one survived with the native liver. All of the patients with obliterated hepatic ducts underwent the Kasai procedure; 5 established biliary drainage and survived with the native liver. Of 5 who did not drain, 3 underwent liver transplantation. CONCLUSIONS: In patients with cystic biliary atresia, the subset with a connection between cyst and intrahepatic bile ducts via intact proximal hepatic ducts had favorable clinical outcomes following hepatic-cyst-jejunostomy.

Biliary tract exploration via left hepatic duct stump versus the common bile duct incision in left-sided hepatolithiasis: a meta-analysis.

BACKGROUND: Left lateral hepatic resection is the preferred surgical approach for treating left hepatolithiasis. However, it is not clear whether cholangioscopy via left hepatic duct (LHD) orifice can replace conventional common bile duct (CBD) approach during laparoscopic procedures. METHODS: We performed a comprehensive literature search by screening medical databases, then compared perioperative outcomes and occurrence of recurrent stones between LHD and CBD approaches. RESULTS: A total of five studies, comprising 345 patients, were included in this meta-analysis. The reported operative times, intra-operative blood loss and incidence of post-operative complications were comparable between the approaches. Pooled results revealed a positive correlation between LHD approach with shorter length of hospital stay (standard mean difference = -1.36; 95% confidence interval: -2.10, -0.61; P < 0.001). Additionally, bile duct exploration via LHD orifice was associated with similar rate of recurrent stones and cholangitis across both groups. CONCLUSIONS: Our results demonstrated that biliary tract exploration via LHD stump can be safely performed in left-sided hepatolithiasis. Additionally, the LHD approach was associated with comparable intra-operative outcomes and shorter post-operative hospitalization relative to CBD approach, and does not increase incidence of stone recurrence.

A new strategy of laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein combined with transhepatic duct lithotomy for complex hemihepatolithiasis: A propensity score matching study.

BACKGROUND: There have been no studies on laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein combined with transhepatic duct lithotripsy for the treatment of complex hemihepatolithiasis. This study aimed to investigate the safety and efficacy of laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein combined with transhepatic duct lithotomy to treat complex hemihepatolithiasis. METHODS: The clinical data for patients who underwent laparoscopic anatomical hemihepatectomy for complex intrahepatic bile duct stones with or without common bile duct stones from January 2016 to June 2020 were prospectively collected. Patients were divided into 2 groups according to surgical approach: laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein (middle hepatic vein group) or laparoscopic anatomical hemihepatectomy not guided by the middle hepatic vein (nonmiddle hepatic vein group). The safety and short-term and long-term efficacy outcomes of the 2 groups were compared with 1:1 propensity score matching. RESULTS: With only a slightly longer operative time (P = .006), the initial and final stone residual rates in the middle hepatic vein group (n = 70) were significantly lower than those in the nonmiddle hepatic vein group (n = 70) (P = .002, P = .009). The bile leakage rate and stone recurrence rate were also significantly lower (P = .001, P = .001). CONCLUSION: Laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein is safe and effective for treating intrahepatic bile duct stones and can decrease the stone residual rate, reduce the bile leakage rate and stone recurrence rate, and accelerate early recovery. However, owing to the complicated technical requirements for surgeons and anesthesiologists, use of the procedure is limited to large and experienced medical centers.

Comparison and Selection of Three Methods of Minimally Invasive External Drainage for Children with Congenital Choledochal Cysts.

Aim: Emergent biliary drainage is necessary due to acute symptoms of choledochal cysts. Percutaneous biliary drainage (PBD), laparoscopic bile duct drainage (LBD), and laparoscopic cholecystostomy (LC) are the three most common drainage treatments. So far, there is no comparative study on these three approaches, which all have been applied in our hospital. This article compares the drainage effects of these three approaches and illustrates their respective merits and demerits, with the aim of providing a reference for clinical application. Materials and Methods: We conducted a retrospective study of 20 children who underwent biliary drainage before their definitive surgery due to acute symptoms of choledochal cysts between June 2008 and May 2015. Among them, 6 underwent PBD, 8 underwent LBD, and 6 underwent LC. Results: Preoperative abdominal pain, fever, and jaundice symptoms were effectively relieved by the three approaches. There were no significant differences in terms of the recovery of liver functions. The average interval and duration of procedures of three groups were PBD (25.00 ± 4.47 minutes and 262.50 ± 35.74 minutes), LBD (84.37 ± 24.99 minutes and 283.75 ± 39.62 minutes), and LC (50.83 ± 13.57 minutes and 218.33 ± 28.58 minutes), respectively. Conclusions: LC has advantages of a comparatively simple operation and no foreign body sensation (external drain) in the hepatic duct, which is beneficial for relieving inflammation of the common bile duct, and thus is suitable for majority of patients needing external bile drainage. Meanwhile, PBD and LBD also have their respective applicable patients.

Transhepatic Direct Approach to the "Limit of the Division of the Hepatic Ducts" Leads to a High R0 Resection Rate in Perihilar Cholangiocarcinoma.

BACKGROUND: Previous studies have shown that curative resection (R0 resection) was among the most crucial factors for the long-term survival of patients with PHCC. To achieve R0 resection, we performed the transhepatic direct approach and resection on the limits of division of the hepatic ducts. Although a recent report showed that the resection margin (RM) status impacted PHCC patients' survival, it is still unclear whether RM is an important clinical factor. OBJECTIVE: To describe a technique of transhepatic direct approach and resection on the limit of division of hepatic ducts, investigate its short-term surgical outcome, and validate whether the radial margin (RM) would have a clinical impact on long-term survival of perihilar cholangiocarcinoma (PHCC) patients. METHODS: Consecutive PHCC patients (n = 211) who had undergone major hepatectomy with extrahepatic bile duct resection, without pancreaticoduodenectomy, in our department were retrospectively evaluated. RESULTS: R0 resection rate was 92% and 86% for invasive cancer-free and both invasive cancer-free and high-grade dysplasia-free resection, respectively. Overall 5-year survival rate was 46.9%. Univariate analysis showed that preoperative serum carcinoembryonic antigen level (> 7.0 mg/dl), pathological lymph node metastasis, and portal vein invasion were independent risk factors, but R status on both resection margin and bile duct margin was not an independent risk factor for survival. CONCLUSION: The transhepatic direct approach to the limits of division of the bile ducts leads to the highest R0 resection rate in the horizontal margin of PHCC. Further examination will be needed to determine the adjuvant therapy for PHCC to improve patient survival.