Iatrogenic bile-duct injury post-laparoscopic cholecystectomy remains a major serious complication with unpredictable long-term results. We present a patient who underwent laparoscopic cholecystectomy for gallstones, ...Iatrogenic bile-duct injury post-laparoscopic cholecystectomy remains a major serious complication with unpredictable long-term results. We present a patient who underwent laparoscopic cholecystectomy for gallstones, in which the biliary injury was recognized intraoperatively. The surgical procedure was converted to an open one. The first surgeon repaired the injury over a T-tube without recognizing the anatomy and type of the biliary lesion, which led to an unusual biliary mal-repair. Immediately postoperatively, the abdominal drain brought a large amount of bile. A T-tube cholangiogram was performed. Despite the contrast medium leaking through the abdominal drain, the mal-repair was recognized intraoperatively. The surgical procedure was converted to an open one. The first surgeon repaired the injury over a T-tube without recognizing the anatomy and type of the biliary lesion, which led to an unusual biliary mal-repair. Immediately postoperatively, the abdominal drain brought a large amount of bile. A T-tube cholangiogram was performed. Despite the contrast medium leaking through the abdominal drain, the mal-repair was unrecognized. The patient was referred to our hospital for biliary leak. Ultrasound and cholangiography was repeated, which showed an unanatomical repair （right to left hepatic duct anastomosis over the T-tube）,with evidence of contrast medium coming out through the abdominal drain. Eventually the patient was subjected to a definitive surgical treatment. The biliary continuity was re-established by a Roux-en-Y hepaticojejunostomy, over transanastomotic external biliary stents. The patient is now doing well 4 years after the second surgical procedure. In reviewing the literature, we found a similar type of injury but we did not find a similar surgical real-repair. We propose an algorithm for the treatment of early and late biliary injuries.展开更多
BACKGROUND: Biliary tract injuries are mostly iatrogenic Related data are limited in developing countries. There are lessons to be learned by revisiting the clinical profiles management issues and outcome of patients ...BACKGROUND: Biliary tract injuries are mostly iatrogenic Related data are limited in developing countries. There are lessons to be learned by revisiting the clinical profiles management issues and outcome of patients referred to a tertiary care center in Sri Lanka, compared with the previous data from the same center published in 2006. Such a review is particularly relevant at a time of changing global perceptions of iatrogenic biliary injuries. This study aimed to analyze and compare the changes in the injury pattern, management and outcome following biliary tract injury in a Sri Lankan study population treated at a tertiary care center. METHODS: A retrospective analysis was made of 67 patients treated between May 2002 and February 2011. The profiles of the last 38 patients treated from October 2006 to February 2011 were compared with those of the first 29 patients treated from May 2002 to September 2006. Definitive management options included endoscopic biliary stenting, reconstructive hepaticojejunostomy with creation of gastric access loops and biliary stricture dilation. Post-treatment jaundice cholangitis and abdominal pain needing intervention were considered as treatment failures. RESULTS: In the 67 patients, 55 were women and 12 men Their mean age was 40.6 (range 19-80) years. Five patients had traumatic injuries. Thirty-seven injuries (23 during the second study period) were due to laparoscopic cholecystectomy and 25 (10 during the second study period) to open cholecystectomy The identification rate of intra-operative injury was 19% in the laparoscopic group and 8% in the open group. Bismuth typeI, II, III and IV injuries were seen in 18, 18, 15 and 12 patients, respectively. Endoscopic stenting was the definitive treatment in 20 patients. In 35 patients who had hepaticojejunostomy, 33 underwent creation of the gastric access loop. Twenty- two reconstructions were performed during the second study period. A gastric access loop was used for endotherapy in three patients with anastomotic occlusion at the site of hepaticojejunostomy. The overall outcome was satisfactory in the majority of patients. There were four injury-related deaths. CONCLUSIONS: Biliary tract injuries associated with laparoscopic cholecystectomy have become the most frequent cause of biliary injury management at our center. Although endotherapy was useful in selected patients, in the majority, surgical reconstruction with hepaticojejunostomy was required as the definitive treatment. Creation of the gastric access loop was found to be a useful adjunct in the management of hepaticojejunostomy strictures.展开更多
AIM: To summarize the experience in diagnosis, management and prevention of iatrogenic bile duct injury (IBDI). METHODS: A total of 210 patients with bile duct injury occurred during cholecystectomy admitted to Hunan ...AIM: To summarize the experience in diagnosis, management and prevention of iatrogenic bile duct injury (IBDI). METHODS: A total of 210 patients with bile duct injury occurred during cholecystectomy admitted to Hunan Provincial People’s Hospital from March 1990 to March 2006 were included in this study for retrospective analysis. RESULTS: There were 59.5% (103/173) of patients with IBDI resulting from the wrong identification of the anatomy of the Calot’s triangle during cholecystectomy. The diagnosis of IBDI was made on the basis of clinical features, diagnostic abdominocentesis and imaging findings. Abdominal B ultrasonography (BUS) was the most popular way for IBDI with a diagnostic rate of 84.6% (126/149). Magnetic resonance cholangiography (MRC) could reveal the site of injury, the length of injured bile duct and variation of bile duct tree with a diagnostic rate 100% (45/45). According to the site of injury, IBDI could be divided into six types. The most common type (type 3) occurred in 76.7% (161/210) of the patients and was treated with partial resection of the common hepatic duct and common bile duct. One hundred and seventy-six patients were followed up. The mean follow-up time was 3.7 (range 0.25-10) years. Good results were achieved in 87.5% (154/176) of the patients. CONCLUSION: The key to prevention of IBDI is to follow the "identifying-cutting-identifying" principle during cholecystectomy. Re-operation time and surgical procedure are decided according to the type of IBDI.展开更多
The place of liver transplantation in the treatment of severe iatrogenic liver injuries has not yet been widely discussed in the literature. Bile duct injuries during cholecystectomy represent the leading cause of liv...The place of liver transplantation in the treatment of severe iatrogenic liver injuries has not yet been widely discussed in the literature. Bile duct injuries during cholecystectomy represent the leading cause of liver transplantation in this setting, while other indications after abdominal surgery are less common. Urgent liver transplantation for the treatment of severe iatrogenic liver injury may-represent a surgical challenge requiring technically difficult and time consuming procedures. A debate is ongoing on the need for centralization of complex surgery in tertiary referral centers. The early referral of patients with severe iatrogenic liver injuries to a tertiary center with experienced hepato-pancreatobiliary and transplant surgery has emerged as the best treatment of care. Despite widespread interest in the use of liver transplantation as a treatment option for severe iatrogenic injuries, reported experiences indicate few liver transplants are performed. This review analyzes the literature on liver transplantation after hepatic injury and discusses our own experience along with surgical advances and future prospects in this uncommon transplant setting.展开更多
Laparoscopic cholecystectomy(LC) does not require advanced techniques, and its performance has therefore rapidly spread worldwide. However, the rate of biliary injuries has not decreased. The concept of the critical v...Laparoscopic cholecystectomy(LC) does not require advanced techniques, and its performance has therefore rapidly spread worldwide. However, the rate of biliary injuries has not decreased. The concept of the critical view of safety(CVS) was first documented two decades ago. Unexpected injuries are principally due to misidentification of human factors. The surgeon's assumption is a major cause of misidentification, and a high level of experience alone is not sufficient for successful LC. We herein describe tips and pitfalls of LC in detail and discuss various technical considerations.Finally, based on a review of important papers and our own experience, we summarize the following mandatory protocol for safe LC:(1) consideration that a high level of experience alone is not enough;(2) recognition of the plateau involving the common hepatic duct and hepatic hilum;(3) blunt dissection until CVS exposure;(4) Calot's triangle clearance in the overhead view;(5) Calot's triangle clearance in the view from underneath;(6) dissection of the posterior right side of Calot's triangle;(7) removal of the gallbladder body; and(8) positive CVS exposure. We believe that adherence to this protocol will ensure successful and beneficial LC worldwide, even in patients with inflammatory changes and rare anatomies.展开更多
文摘Iatrogenic bile-duct injury post-laparoscopic cholecystectomy remains a major serious complication with unpredictable long-term results. We present a patient who underwent laparoscopic cholecystectomy for gallstones, in which the biliary injury was recognized intraoperatively. The surgical procedure was converted to an open one. The first surgeon repaired the injury over a T-tube without recognizing the anatomy and type of the biliary lesion, which led to an unusual biliary mal-repair. Immediately postoperatively, the abdominal drain brought a large amount of bile. A T-tube cholangiogram was performed. Despite the contrast medium leaking through the abdominal drain, the mal-repair was recognized intraoperatively. The surgical procedure was converted to an open one. The first surgeon repaired the injury over a T-tube without recognizing the anatomy and type of the biliary lesion, which led to an unusual biliary mal-repair. Immediately postoperatively, the abdominal drain brought a large amount of bile. A T-tube cholangiogram was performed. Despite the contrast medium leaking through the abdominal drain, the mal-repair was unrecognized. The patient was referred to our hospital for biliary leak. Ultrasound and cholangiography was repeated, which showed an unanatomical repair （right to left hepatic duct anastomosis over the T-tube）,with evidence of contrast medium coming out through the abdominal drain. Eventually the patient was subjected to a definitive surgical treatment. The biliary continuity was re-established by a Roux-en-Y hepaticojejunostomy, over transanastomotic external biliary stents. The patient is now doing well 4 years after the second surgical procedure. In reviewing the literature, we found a similar type of injury but we did not find a similar surgical real-repair. We propose an algorithm for the treatment of early and late biliary injuries.
文摘BACKGROUND: Biliary tract injuries are mostly iatrogenic Related data are limited in developing countries. There are lessons to be learned by revisiting the clinical profiles management issues and outcome of patients referred to a tertiary care center in Sri Lanka, compared with the previous data from the same center published in 2006. Such a review is particularly relevant at a time of changing global perceptions of iatrogenic biliary injuries. This study aimed to analyze and compare the changes in the injury pattern, management and outcome following biliary tract injury in a Sri Lankan study population treated at a tertiary care center. METHODS: A retrospective analysis was made of 67 patients treated between May 2002 and February 2011. The profiles of the last 38 patients treated from October 2006 to February 2011 were compared with those of the first 29 patients treated from May 2002 to September 2006. Definitive management options included endoscopic biliary stenting, reconstructive hepaticojejunostomy with creation of gastric access loops and biliary stricture dilation. Post-treatment jaundice cholangitis and abdominal pain needing intervention were considered as treatment failures. RESULTS: In the 67 patients, 55 were women and 12 men Their mean age was 40.6 (range 19-80) years. Five patients had traumatic injuries. Thirty-seven injuries (23 during the second study period) were due to laparoscopic cholecystectomy and 25 (10 during the second study period) to open cholecystectomy The identification rate of intra-operative injury was 19% in the laparoscopic group and 8% in the open group. Bismuth typeI, II, III and IV injuries were seen in 18, 18, 15 and 12 patients, respectively. Endoscopic stenting was the definitive treatment in 20 patients. In 35 patients who had hepaticojejunostomy, 33 underwent creation of the gastric access loop. Twenty- two reconstructions were performed during the second study period. A gastric access loop was used for endotherapy in three patients with anastomotic occlusion at the site of hepaticojejunostomy. The overall outcome was satisfactory in the majority of patients. There were four injury-related deaths. CONCLUSIONS: Biliary tract injuries associated with laparoscopic cholecystectomy have become the most frequent cause of biliary injury management at our center. Although endotherapy was useful in selected patients, in the majority, surgical reconstruction with hepaticojejunostomy was required as the definitive treatment. Creation of the gastric access loop was found to be a useful adjunct in the management of hepaticojejunostomy strictures.
文摘AIM: To summarize the experience in diagnosis, management and prevention of iatrogenic bile duct injury (IBDI). METHODS: A total of 210 patients with bile duct injury occurred during cholecystectomy admitted to Hunan Provincial People’s Hospital from March 1990 to March 2006 were included in this study for retrospective analysis. RESULTS: There were 59.5% (103/173) of patients with IBDI resulting from the wrong identification of the anatomy of the Calot’s triangle during cholecystectomy. The diagnosis of IBDI was made on the basis of clinical features, diagnostic abdominocentesis and imaging findings. Abdominal B ultrasonography (BUS) was the most popular way for IBDI with a diagnostic rate of 84.6% (126/149). Magnetic resonance cholangiography (MRC) could reveal the site of injury, the length of injured bile duct and variation of bile duct tree with a diagnostic rate 100% (45/45). According to the site of injury, IBDI could be divided into six types. The most common type (type 3) occurred in 76.7% (161/210) of the patients and was treated with partial resection of the common hepatic duct and common bile duct. One hundred and seventy-six patients were followed up. The mean follow-up time was 3.7 (range 0.25-10) years. Good results were achieved in 87.5% (154/176) of the patients. CONCLUSION: The key to prevention of IBDI is to follow the "identifying-cutting-identifying" principle during cholecystectomy. Re-operation time and surgical procedure are decided according to the type of IBDI.
文摘The place of liver transplantation in the treatment of severe iatrogenic liver injuries has not yet been widely discussed in the literature. Bile duct injuries during cholecystectomy represent the leading cause of liver transplantation in this setting, while other indications after abdominal surgery are less common. Urgent liver transplantation for the treatment of severe iatrogenic liver injury may-represent a surgical challenge requiring technically difficult and time consuming procedures. A debate is ongoing on the need for centralization of complex surgery in tertiary referral centers. The early referral of patients with severe iatrogenic liver injuries to a tertiary center with experienced hepato-pancreatobiliary and transplant surgery has emerged as the best treatment of care. Despite widespread interest in the use of liver transplantation as a treatment option for severe iatrogenic injuries, reported experiences indicate few liver transplants are performed. This review analyzes the literature on liver transplantation after hepatic injury and discusses our own experience along with surgical advances and future prospects in this uncommon transplant setting.
文摘Laparoscopic cholecystectomy(LC) does not require advanced techniques, and its performance has therefore rapidly spread worldwide. However, the rate of biliary injuries has not decreased. The concept of the critical view of safety(CVS) was first documented two decades ago. Unexpected injuries are principally due to misidentification of human factors. The surgeon's assumption is a major cause of misidentification, and a high level of experience alone is not sufficient for successful LC. We herein describe tips and pitfalls of LC in detail and discuss various technical considerations.Finally, based on a review of important papers and our own experience, we summarize the following mandatory protocol for safe LC:(1) consideration that a high level of experience alone is not enough;(2) recognition of the plateau involving the common hepatic duct and hepatic hilum;(3) blunt dissection until CVS exposure;(4) Calot's triangle clearance in the overhead view;(5) Calot's triangle clearance in the view from underneath;(6) dissection of the posterior right side of Calot's triangle;(7) removal of the gallbladder body; and(8) positive CVS exposure. We believe that adherence to this protocol will ensure successful and beneficial LC worldwide, even in patients with inflammatory changes and rare anatomies.
