Is there a place for endoscopic management in postcholecystectomy iatrogenic bile duct injuries?

In this editorial we comment on the article by Emara et al published in the recent issue of the World Journal of Gastrointestinal Surgery.Previously,surgery was the primary treatment for bile duct injuries(BDI).The treatment of BDI has advanced due to technological breakthroughs and minimally invasive procedures.Endoscopic and percutaneous treatments have largely supplanted surgery as the primary treatment for most instances in recent years.Patient management,including the specific technique,is typically impacted by local knowledge and the kind and severity of the injury.Endoscopic therapy is a highly successful treatment for postoperative benign bile duct stenosis and offers superior long-term outcomes compared to surgical correction.Based on the damage features of BDI,therapeutic options include endoscopic duodenal papillary sphincterotomy,endoscopic nasobiliary drainage,and endoscopic biliary stent implantation.

Post-cholecystectomy iatrogenic bile duct injuries:Emerging role for endoscopic management

Post-cholecystectomy iatrogenic bile duct injuries(IBDIs),are not uncommon and although the frequency of IBDIs vary across the literature,the rates following the procedure of laparoscopic cholecystectomy are much higher than open cholecystectomy.These injuries caries a great burden on the patients,physicians and the health care systems and sometime are life-threatening.IBDIs are associated with different manifestations that are not limited to abdominal pain,bile leaks from the surgical drains,peritonitis with fever and sometimes jaundice.Such injuries if not witnessed during the surgery,can be diagnosed by combining clinical manifestations,biochemical tests and imaging techniques.Among such techniques abdominal US is usually the first choice while Magnetic Resonance Cholangio-Pancreatography seems the most appropriate.Surgical approach was the ideal approach for such cases,however the introduction of Endoscopic Retrograde Cholangio-Pancreatography(ERCP)was a paradigm shift in the management of such injuries due to accepted success rates,lower cost and lower rates of associated morbidity and mortality.However,the literature lacks consensus for the optimal timing of ERCP intervention in the management of IBDIs.ERCP management of IBDIs can be tailored according to the nature of the underlying injury.For the subgroup of patients with complete bile duct ligation and lost ductal continuity,transfer to surgery is indicated without delay.Those patients will not benefit from endoscopy and hence should not do unnecessary ERCP.For low–flow leaks e.g.gallbladder bed leaks,conservative management for 1-2 wk prior to ERCP is advised,in contrary to high-flow leaks e.g.cystic duct leaks and stricture lesions in whom early ERCP is encouraged.Sphincterotomy plus stenting is the ideal management line for cases of IBDIs.Interventional radiologic techniques are promising options especially for cases of failed endoscopic repair and also for cases with altered anatomy.Future studies will solve many unsolved issues in the management of IBDIs.

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 Médicasy 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), G Ⅱ2000-2004 (139 cases) and GⅢ2004-2008 (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.

Isolated right posterior bile duct injury following cholecystectomy:Report of two cases

Anatomic variations of the right biliary system are one of the most common risk factors for sectoral bile duct injury(BDI)during cholecystectomy.Isolated right posterior BDI may in particular be a challenge for both diagnosis and management.Herein we describe two cases of isolated right posterior sectoral BDI that took place during laparoscopic cholecystectomy.Despite effective external biliary drainage from the liver hilum in both cases,there was a persistent biliary leak observed which was not visible on endoscopic retrogradecholangiogram.Careful evaluation of images from both endoscopic and magnetic resonance cholangiograms revealed the diagnosis of an isolated right posterior sectoral BDI.These were treated with a delayed bisegmental(segments 6 and 7)liver resection and a Roux-en-Y hepaticojejunostomy respectively with good outcomes at 24 and 4 mo of follow-up.This paper discusses strategies for prevention of such injuries along with the diagnostic and therapeutic challenges it offers.

Classification of iatrogenic bile duct injury

BACKGROUND: Iatrogenic bile duct injury continues to be an important clinical problem, resulting in serious morbidity, and occasional mortality, to patients. The ease of management, operative risk, and outcome of bile duct injuries vary considerably, and are highly dependent on the type of injury and its location. This article reviews the various classification systems of bile duct injury. DATA SOURCES: A Medline, PubMed database search was performed to identify relevant articles using the keywords 'bile duct injury', 'cholecystectomy', and 'classification'. Additional papers were identified by a manual search of the references from the key articles. RESULTS: Traditionally, biliary injuries have been classified using the Bismuth's classification. This classification, which originated from the era of open surgery, is intended to help the surgeons to choose the appropriate technique for the repair, and it has a good correlation with the final outcome after surgical repair. However, the Bismuth's classification does not encompass the whole spectrum of injuries that are possible. Bile duct injury during laparoscopic cholecystectomy tends to be more severe than those with open cholecystectomy. Strasberg's classification made Bismuth's classification much more comprehensive by including various other types of extrahepatic bile duct injuries. Our group, Bergman et al, Neuhaus et al, Csendes et al, and Stewart et al have also proposed other classification systems to complement the Bismuth's classification. CONCLUSIONS: None of the classification system is universally accepted as each has its own limitation. Hopefully, a universally accepted comprehensive classification system will be published in the near future.

Iatrogenic bile duct injuries from biliary tract surgery

BACKGROUND:Cholecystectomy is the most commonly performed procedure in general surgery.However,bile duct injury is a rare but still one of the most common complications.These injuries sometimes present variably after primary surgery.Timely detection and appropriate management decrease the morbidity and mortality of the operation. METHODS:Five cases of iatrogenic bile duct injury(IBDI) were managed at the Department of Surgery,First Affiliated Hospital,Xi’an Jiaotong University.All the cases who underwent both open and laparoscopic cholecystectomy had persistent injury to the biliary tract and were treated accordingly. RESULTS:Recovery of the patients was uneventful.All patients were followed-up at the surgical outpatient department for six months to three years.So far the patients have shown good recovery. CONCLUSIONS:In cases of IBDI it is necessary to perform the operation under the supervision of an experienced surgeon who is specialized in the repair of bile duct injuries,and it is also necessary to detect and treat the injury as soon as possible to obtain a satisfactory outcome.

Management of bile duct injuries combined with accessory hepatic duct during laparoscopic cholecystectomy

Bile duct injuries(BDIs)are difficult to avoid absolutely when the biliary tract has a malformation,such as accessory hepatic duct.Here,we investigated the management strategies for BDI combined with accessory hepatic duct during laparoscopic cholecystectomy.

Hepatectomy for bile duct injuries: When is it necessary?

Iatrogenic bile duct injuries(IBDI)are still a challenge for surgeons.The most frequently,they are caused by laparoscopic cholecystectomy which is one of the commonest surgical procedure in the world.Endoscopic techniques are recommended as initial treatment of IBDI.When endoscopic treatment is not effective,surgery is considered.Different surgical biliary reconstructions are performed in most patients in IBDI.Roux-Y hepaticojejunostomy is the commonest biliary reconstruction for IBDI.In some patients with complex IBDI,hepatectomy is required.Recently,Liet al analyzed the factors that had led to hepatectomy for patients with IBDI after laparoscopic cholecystectomy(LC).Authors concluded that hepatectomy might be necessary to manage early or late complications after LC.The study showed that proximal IBDI(involving hepatic confluence)and IBDI associated with vascular injuries were the two independent risk factors of hepatectomy in this series.Authors distinguished two main groups of patients that require liver resection in IBDI:those with an injury-induced liver necrosis necessitating early intervention,and those in whom liver resection is indicated for treatment of liver atrophy following long-term cholangitis.In this commentary,indications for hepatectomy in patients with IBDI are discussed.Complex biliovascular injuries as indications for hepatectomy are presented.Short-and long-term results in patients following liver resection for IBDI are also discussed.Hepatectomy is not a standard procedure in surgical treatment of IBDI,but in some complex injuries it should be considered.

Non-image diagnosis of bile duct injury during laparoscopic cholecystectomy

Objective: To evaluate the role of simple non-imagetechnique in intraoperative diagnosis of bile duct in-jury (BDI).Methods: BDI was highly suspected at the original la-paroscopic cholecystectomy (LC) when the following 3abnormal findings were noted: the 'cystic duct' stump(the common bile duct stump actually) markedly re-tracted down to the duodenum; bile leakage from theporta hepatis; abnormal mucosal patch attached to the'cystic duct' stump of the removed gallbladder. Allcases of suspected BDI were converted to have laparo-tomy. Image techniques such as intraoperative cholan-giography or ultrasonography were not utilized forrecognition of BDI in all 9 patients.Results: BDI in 4 of the 9 patients was suspected ac-cording to 1-3 abnormal intraoperative findings de-scribed above. The four patients were subjected imme-diately to converted laparotomy. Abnormal findingswere not observed or misinterpreted in the other 5misdiagnosed patients.Conclusions: Timely recognizing whether BDI occursshould be considered as a routine procedure ofLC. Negligence of operators to the abnormalities of theoriginal LC, is the main cause of misdiagnosis forBDL. Simple non-image approaches such as close ob-servation of these abnormalities can make timely diag-nosis for most BDIs during the original LC.

Iatrogenic bile duct injury with loss of confluence

AIM: To describe our experience concerning the surgical treatment of Strasberg E-4(Bismuth Ⅳ) bile duct injuries. METHODS: In an 18-year period, among 603 patients referred to our hospital for surgical treatment of complex bile duct injuries, 53 presented involvement of the hilar confluence classified as Strasberg E4 injuries. Imagenological studies, mainly magnetic resonance imaging showed a loss of confluence. The files of these patients were analyzed and general data were recorded, including type of operation and postoperative outcome with emphasis on postoperative cholangitis, liver function test and quality of life. The mean time of follow-up was of 55.9 ± 52.9 mo(median = 38.5, minimum = 2, maximum = 181.2). All other patients with Strasberg A, B, C, D, E1, E2, E3, or E5 biliary injuries were excluded from this study.RESULTS: Patients were divided in three groups: G1(n = 21): Construction of neoconfluence + Roux-en-Y hepatojejunostomy. G2(n = 26): Roux-en-Y portoenterostomy. G3(n = 6): Double(right and left) Rouxen-Y hepatojejunostomy. Cholangitis was recorded in two patients in group 1, in 14 patients in group 2, and in one patient in group 3. All of them required transhepatic instrumentation of the anastomosis and six patients needed live transplantation.CONCLUSION: Loss of confluence represents a surgicalchallenge. There are several treatment options at different stages. Roux-en-Y bilioenteric anastomosis(neoconfluence, double-barrel anastomosis, portoenterostomy) is the treatment of choice, and when it is technically possible, building of a neoconfluence has better outcomes. When liver cirrhosis is shown, liver transplantation is the best choice.

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.

Factors influencing the results of treatment of bile duct injuries during laparoscopic cholecystectomy

BACKGROUND: The short-term results of repair of lapa- roscopic bile duct injuries have been well discussed, but the long-term results have been rarely reported. This study was undertaken to evaluate the factors influencing the outcome of repair of bile duct injuries caused by laparoscopic chole- cystectomy. METHODS: The outcomes of repair of bile duct injuries caused by laparoscopic cholecystectomy in 31 patients were reviewed retrospectively, and the effects of injury recogni- tion, cholangiography, repair modality and techniques on the long-term results were analyzed. RESULTS: Bile duct injuries were repaired successfully in 19 (95%) of 20 patients with injuries who had been recog- nized intraoperatively, and in 10 (90%) of 11 patients with injuries who had been recognized postoperatively. Repair was successful in 29 (93% ) of the 31 patients after complete cholangiography. Closure of partial division, laceration, or small perforation of the bile duct with or without T tube drainage was satisfactory in the 23 patients. End to end re- pair over T tube was successful in 2 transection patients, who were detected intraoperatively. Roux-en-Y hepatico- jejunostomy was used successfully to repair transection, ex- cision or stricture of the bile duct in 4 of 5 patients (80% ). CONCLUSION: Early detection of bile duct injuries caused by laparoscopy, complete evaluation of the biliary duct, and appropriate surgical modality and techniques are help- ful to improve the results of repair for laparoscopic bile duct injuries.

Isolated segmental,sectoral and right hepatic bile duct injuries

The treatment of isolated segmental,sectoral and right hepatic bile duct injuries is controversial.Nineteen patients were treated over a 26-year period.Group one was comprised of 4 patients in whom the injury was primarily repaired during the original surgery;3 over a T-tube,1 with a Roux-en-Y.These patients had an uneventful recovery.The second group consisted of 5 patients in whom the duct was ligated;4 developed infection,3 of which required drainage and biliary repair.Two patients had good long-term outcomes;the third developed a late anastomotic stricture requiring further surgery.The fourth patient developed a small bile leak and pain which resolved spontaneously.The fifth patient developed complications from which he died.The third group was comprised of 4 patients referred with biliary peritonitis;all underwent drainage and lavage,and developed biliary fistulae,3 of which resolved spontaneously,1 required Roux-en-Y repair,with favorable outcomes.The fourth group consisted of 6 patients with biliary fistulae.Two patients,both with an 8-wk history of a fistula,underwent Roux-en-Y repair.Two others also underwent a Roux-en-Y repair,as their fistulae showed no signs of closure.The remaining 2 patients had spontaneous closure of their biliary fistulae.A primary repair is a reasonable alternative to ligature ofinjured duct.Patients with ligated ducts may develop complications.Infected ducts require further surgery.Patients with biliary peritonitis must be treated with drainage and lavage.There is a 50% chance that a biliary fistula will close spontaneously.In cases where the biliary fistula does not close within 6 to 8 wk,a Roux-en-Y anastomosis should be considered.

Timing of surgical repair of bile duct injuries after laparoscopic cholecystectomy: A systematic review

BACKGROUND The surgical management of bile duct injuries(BDIs)after laparoscopic cholecystectomy(LC)is challenging and the optimal timing of surgery remains unclear.The primary aim of this study was to systematically evaluate the evidence behind the timing of BDI repair after LC in the literature.AIM To assess timing of surgical repair of BDI and postoperative complications.METHODS The MEDLINE,EMBASE,and The Cochrane Library databases were systematically screened up to August 2021.Risk of bias was assessed via the Newcastle Ottawa scale.The primary outcomes of this review included the timing of BDI repair and postoperative complications.RESULTS A total of 439 abstracts were screened,and 24 studies were included with 15609 patients included in this review.Of the 5229 BDIs reported,4934(94%)were classified as major injury.Timing of bile duct repair was immediate(14%,n=705),early(28%,n=1367),delayed(28%,n=1367),or late(26%,n=1286).Standardization of definition for timing of repair was remarkably poor among studies.Definitions for immediate repair ranged from<24 h to 6 wk after LC while early repair ranged from<24 h to 12 wk.Likewise,delayed(>24 h to>12 wk after LC)and late repair(>6 wk after LC)showed a broad overlap.CONCLUSION The lack of standardization among studies precludes any conclusive recommendation on optimal timing of BDI repair after LC.This finding indicates an urgent need for a standardized reporting system of BDI repair.

Iatrogenic bile duct injuries:Etiology,diagnosis and management

Iatrogenic bile duct injuries (IBDI) remain an important problem in gastrointestinal surgery. They are most frequently caused by laparoscopic cholecystectomy which is one of the commonest surgical procedures in the world. The early and proper diagnosis of IBDI is very important for surgeons and gastroenterologists, because unrecognized IBDI lead to serious complications such as biliary cirrhosis, hepatic failure and death. Laboratory and radiological investigations play an important role in the diagnosis of biliary injuries. There are many classifications of IBDI. The most popular and simple classification of IBDI is the Bismuth scale. Endoscopic techniques are recommended for initial treatment of IBDI. When endoscopic treatment is not effective, surgical management is considered. Different surgical reconstructions are performed in patients with IBDI. According to the literature, Roux- en-Y hepaticojejunostomy is the most frequent surgical reconstruction and recommended by most authors. In the opinion of some authors, a more physiological and equally effective type of reconstruction is end- to-end ductal anastomosis. Long term results are the most important in the assessment of the effectiveness of IBDI treatment. There are a few classifications for the long term results in patients treated for IBDI; the Terblanche scale, based on clinical biliary symptoms, is regarded as the most useful classification. Proper diagnosis and treatment of IBDI may avoid many serious complications and improve quality of life.

Mechanism of Dynamic Near-infrared Fluorescence Cholangiography of Extrahepatic Bile Ducts and Applications in Detecting Bile Duct Injuries Using Indocyanine Green in Animal Models

Fluorescence intraoperative cholangiography（IOC） is a potential alternative for identifying anatomical variation and preventing iatrogenic bile duct injuries by using the near-infrared probe indocyanine green（ICG）. However, the dynamic process and mechanism of fluorescence IOC have not been elucidated in previous publications. Herein, the optical properties of the complex of ICG and bile, dynamic fluorescence cholangiography and iatrogenic bile duct injuries were investigated. The emission spectrum of ICG in bile peaked at 844 nm and ICG had higher tissue penetration. Extrahepatic bile ducts could fluoresce 2 min after intravenous injection, and the fluorescence intensity reached a peak at 8 min. In addition, biliary dynamics were observed owing to ICG excretion from the bile ducts into the duodenum. Quantitative analysis indicated that ICG-guided fluorescence IOC possessed a high signal to noise ratio compared to the surrounding peripheral tissue and the portal vein. Fluorescence IOC was based on rapid uptake of circulating ICG in plasma by hepatic cells, excretion of ICG into the bile and then its interaction with protein molecules in the bile. Moreover, fluorescence IOC was sensitive to detect bile duct ligation and acute bile duct perforation using ICG in rat models. All of the results indicated that fluorescence IOC using ICG is a valid alternative for the cholangiography of extrahepatic bile ducts and has potential for measurement of biliary dynamics.

Surgical management in biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury

AIM: To discuss the surgical method and skill of biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury. METHODS: From November 2005 to December 2006, eight patients with biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury were admitted to our hospital. Their clinical data were analyzed retrospectively. RESULTS: Bile duct injury was caused by cholecys- tectomy in the eight cases, including seven cases with laparoscopic cholecystectomy and one with mini- incision choleystectomy. According to the classification of Strasberg, type E1 injury was found in one patient, type E2 injury in three, type E3 injury in two and type E4 injury in two patients. Both of the type E4 injury patients also had a vascular lesion of the hepatic artery. Six patients received Roux-en-Y hepaticojejunostomy for the second time, and one of them who had type E4 injury with the right hepatic artery disruption received right hepatectomy afterward. One patient who had type E4 injury with the proper hepatic artery lesion underwent liver transplantation, and the remaining one with type E3 injury received external biliary drainage. All the patients recovered fairly well postoperatively. CONCLUSION: Roux-en-Y hepaticojejunostomy is still the main approach for such failed surgical cases with bile duct injury. Special attention should be paid to concomitant vascular injury in these cases. The optimal timing and meticulous and excellent skills are essential to the success in this surgery.

New classification of acute bile duct injuries

The Editor welcomes submissions for possible publication in the Letters to the Editor section that consist of commentary on an article published in the Journal or other relevant issues.Letters commenting on an article published in the Journal will be considered if they are received within 6 weeks of the time the article was published. Authors of the article being commented on will be given an opportunity to offer a timely response to the letter.Authors of letters will be notified that the letter has been received. Unpublished letters cannot be returned.

Iatrogenic extrahepatic bile duct injury in 182 patients: causes and management

Objective: To describe the causes and treatment ofiatrogenic bile duct injury caused by cholecystecto-my.Methods: 182 patients with iatrogenic extrahepaticbile duct injury from 4 university hospitals of Chinawere reviewed. Details of primary cholecystectomy,biliary reconstruction as well as postoperative ma-nagement were recorded. All patients were followedup for at least 6 months (6 months to 9 years, medi-an 3.5 years). The adequacy of repair was assessedby regular evaluation of the patients clinical statusand liver function variables. Hepatobiliary B-ultra-sonography was used routinely in the follow up of pa-tients, and magnetic resonance cholangiopancreatog-raphy was applied in the patients suggestive of abnor-mality.Results: In 152 patients, bile duct injury happenedduring open cholecystectomy, and in 30 patients dur-ing laparoscopic cholecystectomy. All the injuries de-veloped during anterograde cholecystectomy (at theCalot’s triangle). All the patients with these injuriesunderwent choledochocholedochostomy or Roux-en-Ycholedochojejunostomy with good results (161 pa-tients), recurrent stricture (11), and death (10).Conclusions: During cholecystectomy, the Calot’s tri-angle should be identified anatomically, but retro-grade cholecystectomy is the optimal choice. Bileduct injury should be discovered as soon as possibleand be managed timely. Different operative methodsare optional according to the degree of injury and thepostoperative period.

Rare isolated extra-hepatic bile duct injury: A case report

BACKGROUND Extra-hepatic bile duct injury(EHBDI)is very rare among all blunt abdominal injuries.According to literature statistics,it only accounts for 3%-5%of abdominal injuries,most of which are combined injuries.Isolated EHBDI is more rare,with a special injury mechanism,clinical presentation and treatment strategy,so missed diagnosis easily occurs.CASE SUMMARY We report a case of unexplained abdominal effusion and jaundice following blunt abdominal trauma in our department.Of which,surgical exploration of the case was performed and a large amount of bile leakage in the abdominal cavity was found.No obvious abdominal organ damage or bile duct rupture was found.Surgery was terminated after the common bile duct indwelled with a T tube.After 2 wk,a T-tube angiography revealed the lesion in the common bile duct pancreatic segment,confirming isolated EHBDI.And 2 mo later,the T tube was pulled out with re-examined magnetic resonance cholangiopancreatography,indicating narrowing of the common bile duct injury,with no special treatment due to no clinical symptoms and no abnormality in the current follow-up.CONCLUSION This case was featured by intraoperative bile leakage and no EHBDI.This type of rare isolated EHBDI is prone to missed and delayed diagnosis due to its atypical clinical manifestations and imaging features.Surgery is still the main treatment,and the indications and principles of bile duct injury repair must be followed.