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 c...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.展开更多
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 ...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.展开更多
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 high...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.展开更多
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 ...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.展开更多
目的建立犬胆总管横断损伤、胆道支架管引流、胆总管端端吻合的动物模型,探讨胆总管端端吻合的自然愈合过程。方法将25只犬随机分成对照组(n=5)与实验组(n=20),实验组分为4组,于术后3 d5、d、7 d9、d,胆道造影、取吻合处胆总管作羟脯氨...目的建立犬胆总管横断损伤、胆道支架管引流、胆总管端端吻合的动物模型,探讨胆总管端端吻合的自然愈合过程。方法将25只犬随机分成对照组(n=5)与实验组(n=20),实验组分为4组,于术后3 d5、d、7 d9、d,胆道造影、取吻合处胆总管作羟脯氨酸、断裂强度、HE染色、Masson染色检测。结果实验组术后无一例胆漏;羟脯氨酸(mg):术后第3 dvs 5 d7、d、9 d、对照组差异有统计学意义(9±1.87 vs 20.6±2.302、2.6±2.70、27±4.121、6.54±2.22,均P<0.05),术后第5d vs 7 d差异无统计学意义(P=0.265)。断裂强度(N):术后第3 d vs 5 d、7 d、9 d差异有统计学意义(2.5±0.94 vs 5.72±1.057、.76±0.72、8.68±0.92,均P<0.05),术后第7 d vs 9 d差异无统计学意义(P=0.131)。术后5~7 d,HE染色见胆管壁增厚;Masson染色见大量胶原纤维增生、排列杂乱。结论胆总管横断损伤、胆道支架管引流、胆总管端端吻合术后,胆管壁胶原含量、断裂强度迅速升高,术后5~7 d,接近正常胆管组织水平;胆管壁增厚、胆管壁胶原纤维增生。展开更多
Robotic-assisted cholecystectomy(RC)is increasingly common.However,its exact role remains unde-fined,with multiport conventional laparoscopic cholecystectomy(LC)being regarded as the established gold standard.This rev...Robotic-assisted cholecystectomy(RC)is increasingly common.However,its exact role remains unde-fined,with multiport conventional laparoscopic cholecystectomy(LC)being regarded as the established gold standard.This review aims to provide an overview of the evidence for RC and to define its current and future role.A literature search was performed on the PubMed and Medline databases to identify relevant articles published between 1994 and February 2022.The evidence obtained was summarised in a narrative style.Greater emphasis was placed on recent 10-year articles and studies of higher meth-odological quality.RC is noninferior to LC.The robotic platform facilitates the application of minimally invasive surgery in a way conventional laparoscopy cannot.LC remains appropriate for the majority of patients requiring cholecystectomy.The advantages of RC include inherent technical benefits,facilitating the learning of new surgical technology and its potential to reduce the risk of open conversion and bile leakage in certain populations(Mirizzi syndrome,complicated calculous disease,chronic liver disease and possibly malignancy).It also has increasing applicability to related biliary surgery.The limitations include cost,loss of tactile feedback and the learning curve associated with initial implementation.Future applications of robotic surgical systems include utilisation in difficult cholecystectomy,cases of biliary malignancy,telerobotic surgery and telementoring.展开更多
文摘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.
文摘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.
文摘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.
文摘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.
文摘目的建立犬胆总管横断损伤、胆道支架管引流、胆总管端端吻合的动物模型,探讨胆总管端端吻合的自然愈合过程。方法将25只犬随机分成对照组(n=5)与实验组(n=20),实验组分为4组,于术后3 d5、d、7 d9、d,胆道造影、取吻合处胆总管作羟脯氨酸、断裂强度、HE染色、Masson染色检测。结果实验组术后无一例胆漏;羟脯氨酸(mg):术后第3 dvs 5 d7、d、9 d、对照组差异有统计学意义(9±1.87 vs 20.6±2.302、2.6±2.70、27±4.121、6.54±2.22,均P<0.05),术后第5d vs 7 d差异无统计学意义(P=0.265)。断裂强度(N):术后第3 d vs 5 d、7 d、9 d差异有统计学意义(2.5±0.94 vs 5.72±1.057、.76±0.72、8.68±0.92,均P<0.05),术后第7 d vs 9 d差异无统计学意义(P=0.131)。术后5~7 d,HE染色见胆管壁增厚;Masson染色见大量胶原纤维增生、排列杂乱。结论胆总管横断损伤、胆道支架管引流、胆总管端端吻合术后,胆管壁胶原含量、断裂强度迅速升高,术后5~7 d,接近正常胆管组织水平;胆管壁增厚、胆管壁胶原纤维增生。
文摘Robotic-assisted cholecystectomy(RC)is increasingly common.However,its exact role remains unde-fined,with multiport conventional laparoscopic cholecystectomy(LC)being regarded as the established gold standard.This review aims to provide an overview of the evidence for RC and to define its current and future role.A literature search was performed on the PubMed and Medline databases to identify relevant articles published between 1994 and February 2022.The evidence obtained was summarised in a narrative style.Greater emphasis was placed on recent 10-year articles and studies of higher meth-odological quality.RC is noninferior to LC.The robotic platform facilitates the application of minimally invasive surgery in a way conventional laparoscopy cannot.LC remains appropriate for the majority of patients requiring cholecystectomy.The advantages of RC include inherent technical benefits,facilitating the learning of new surgical technology and its potential to reduce the risk of open conversion and bile leakage in certain populations(Mirizzi syndrome,complicated calculous disease,chronic liver disease and possibly malignancy).It also has increasing applicability to related biliary surgery.The limitations include cost,loss of tactile feedback and the learning curve associated with initial implementation.Future applications of robotic surgical systems include utilisation in difficult cholecystectomy,cases of biliary malignancy,telerobotic surgery and telementoring.