Impact of referral pattern and timing of repair on surgical outcome after reconstruction of post-cholecystectomy bile duct injury:A multicenter study

Background:Bile duct injury(BDI)after cholecystectomy remains a significant surgical challenge.No guideline exists to guide the timing of repair,while few studies compare early versus late repair BDI.This study aimed to analyze the outcomes in patients undergoing immediate,intermediate,and delayed repair of BDI.Methods:We retrospectively analyzed 412 patients with BDI from March 2015 to January 2020.The patients were divided into three groups based on the time of BDI reconstruction.Group 1 underwent an immediate reconstruction(within the first 72 hours post-cholecystectomy,n=156);group 2 underwent an intermediate reconstruction(from 4 days to 6 weeks post-cholecystectomy,n=75),and group 3 underwent delayed reconstruction(after 6 weeks post-cholecystectomy,n=181).Results:Patients in group 2 had significantly more early complications including anastomotic leakage and intra-abdominal collection and late complications including anastomotic stricture and secondary liver cirrhosis compared with groups 1 and 3.Favorable outcome was observed in 111(71.2%)patients in group 1,31(41.3%)patients in group 2,and 157(86.7%)patients in group 3(P=0.0001).Multivariate analysis identified that complete ligation of the bile duct,level E1 BDI and the use of external stent were independent factors of favorable outcome in group 1,the use of external stent was an independent factor of favorable outcome in group 2,and level E4 BDI was an independent factor of unfavorable outcome in group 3.Transected BDI and level E4 BDI were independent factors of unfavorable outcome.Conclusions:Favorable outcomes were more frequently observed in the immediate and delayed reconstruction of post-cholecystectomy BDI.Complete ligation of the bile duct,level E1 BDI and the use of external stent were independent factors of a favorable outcome.

Diagnosis and management of choledochal cyst: 20 years of single center experience

We report the first case series from Africa and the Middle East on choledochal cyst, a disease which shows significant geographical distribution with high incidence in the Asian population. In this study, the epidemiological data of the patients are presented and analyzed. Attention was paid to diagnostic imaging and its accuracy in the diagnosis and classification of choledochal cyst. Most cases of choledochal cyst disease have type I and IV-A cysts according to the Todani classification system, which support the etiological theories of choledochal cyst, especially Babbitt’s theory of the anomalous pancreaticobiliary duct junction, which are clearly stated. The difficulties and hazards of surgical management and methods used to avoid operative complications are clarified. Early and late postoperative complications are also included. This study should be followed by multicenter studies throughout Egypt to help assess the incidence of choledochal cysts in one of the largest populations in Africa and the Middle East.

Problem of living liver donation in the absence of deceased liver transplantation program:Mansoura experience

We report our experience with potential donors for living donor liver transplantation(LDLT), which is the first report from an area where there is no legalized deceased donation program. This is a single center retrospective analysis of potential living donors(n = 1004) between May 2004 and December 2012. This report focuses on the analysis of causes, duration, cost, and various implications of donor exclusion(n = 792).Most of the transplant candidates(82.3%) had an experience with more than one excluded donor(median = 3). Some recipients travelled abroad for a deceased donor transplant(n = 12) and some died before finding a suitable donor(n = 14). The evaluation of an excluded donor is a time-consuming process(median = 3 d, range 1 d to 47 d). It is also a costly process with a median cost of approximately 70 USD(range 35 USD to 885 USD). From these results, living donor exclusion has negative implications on the patients and transplant program with ethical dilemmas and an economic impact. Many strategies are adopted by other centers to expand the donor pool; however, they are not all applicable in our locality. We conclude that an active legalized deceased donor transplantation program is necessary to overcome the shortage of available liver grafts in Egypt.