Near-infrared cholangiography with intragallbladder indocyanine green injection in minimally invasive cholecystectomy

Laparoscopic cholecystectomy(LC)remains one of the most commonly performed procedures in adult and paediatric populations.Despite the advances made in intraoperative biliary anatomy recognition,iatrogenic bile duct injuries during LC represent a fatal complication and consist an economic burden for healthcare systems.A series of methods have been proposed to prevent bile duct injury,among them the use of indocyanine green(ICG)fluorescence.The most commonly reported method of ICG injection is the intravenous administration,while literature is lacking studies investigating the direct intragallbladder ICG injection.This narrative mini-review aims to assess the potential applications,usefulness,and limitations of intragallbladder ICG fluorescence in LC.Authors screened the available international literature to identify the reports of intragallbladder ICG fluorescence imaging in minimally invasive cholecystectomy,as well as special issues regarding its use.Literature search retrieved four prospective cohort studies,three case-control studies,and one case report.In the three case-control studies selected,intragallbladder near-infrared cholangiography(NIRC)was compared with standard LC under white light,with intravenous administration of ICG for NIRC and with standard intraoperative cholangiography(IOC).In total,133 patients reported in the literature have been administered intragallbladder ICG administration for biliary mapping during LC.Literature includes several reports of intragallbladder ICG administration,but a standardized technique has not been established yet.Published data suggest that NIRC with intragallbladder ICG injection is a promising method to achieve biliary mapping,overwhelming limitations of IOC including intervention and radiation exposure,as well as the high hepatic parenchyma signal and time interval needed in intravenous ICG fluorescence.Evidence-based guidelines on the role of intragallbladder ICG fluorescence in LC require the assessment of further studies and multicenter data collection into large registries.

Prospective evaluation of magnetic resonance cholangiography in patients with suspected common bile duct stones before laparoscopic cholecystectomy

OBJECTIVE: To evaluate the predictive value of magnetic resonance cholangiography (MRC) in selected patients before laparoscopic cholecystectomy (LC). METHODS: Patients with risk factors for common bile duct (CBD) stones scheduled for elective LC from March 1999 to May 2001, underwent MRC followed by endoscopic retrograde cholangiography (ERC) to detect the stones and the accuracy of MRC. Selection of suspected patients was based on clinical, ultrasonographic, and laboratory criteria. RESULTS: During a 26-month period, a total of 267 patients were studied. Seventy-eight MRC identified patients were found to have CBD stones by ERC or laparoscopic cholangiography in the study. Seven of 78 patients were misdiagnosed as having CBD stones by MRC. In this study, MRC had a sensitivity of 100%, a specificity of 96.3%, a positive predictive value of 91.8%, and a negative predictive value of 100% for the detection of common bile duct stones. CONCLUSIONS: With the use of LC, ERC is frequently performed before LC to detect CBD stones; but it is invasive with a well-documented complication rate. MRC is a simple non-invasive method for preoperative screening for CBD stones in at-risk patients. In this study if ERC had been limited to patients with a positive MRC, it would have reduced the need for ERC by 68.2%, and the complications of preoperative examination would be minimized significantly.

Routine magnetic resonance cholangiography compared to intra-operative cholangiography in patients with suspected common bile duct stones

BACKGROUND:Magnetic resonance cholangiography (MRC)is a non-invasive method for imaging biliary ducts.When used to exclude common bile duct(CBD) stones,MRC may obviate the need for intra-operative cholangiography(IOC).In this prospective study,MRC and IOC were compared for the diagnosis of suspected stones of the CBD. METHODS:Thirty patients with gallstones and suspected CBD lithiasis(abnormal serum liver tests and CBD>7 mm on ultrasound)had MRC followed by open cholecystectomy and IOC.MR imaging was done using a 1.5-T whole body scanner(Signa,General Electric Medical Systems).A torso phased-array coil with a 4-channel receiver was used for data acquisition. RESULTS:Over a period of 18 months,30 patients(average age 53.9±13.3 years;range 38-76 years)were enrolled in this study.Eleven patients were male(36.7%)and 19 female(63.3%).MRC revealed CBD stones in 19 patients, while IOC revealed CBD stones in 22.The sensitivity of MRC in detecting CBD stones was 81.8%,and the specificity was 87.5%.The positive predictive value was 94.7%,and the negative predictive value was 63.3%. CONCLUSIONS:Pre-operative MRC may obviate the need for IOC.MRC reduces operative time,is less invasive, and may also alleviate damage to the CBD that can occurduring IOC.MRC can identify CBD stones pre-operatively and can help surgeons plan safe procedures.Pre-operative MRC should be done routinely in patients whose clinical or biochemical findings suggest the possibility of CBD stones.

Utility of fluorescent cholangiography during laparoscopic cholecystectomy: A systematic review

AIM: To verify the utility of fluorescent cholangiography for more rigorous identification of the extrahepatic biliary system.METHODS: MEDLINE and Pub Med searches were performed using the key words "fluorescent cholangiography", "fluorescent angiography", "intraoperative fluorescent imaging", and "laparoscopic cholecystectomy" in order to identify relevant articles published in English, French, German, and Italian during the years of 2009 to 2014. Reference lists from the articles were reviewed to identify additional pertinent articles. For studies published in languages other than those mentioned above, all available information was collected from their English abstracts. Retrieved manuscripts(case reports, reviews, and abstracts) concerning the application of fluorescent cholangiography were reviewed by the authors, and the data were extracted using a standardized collection tool. Data were subsequently analyzed with descriptive statistics. In contrast to classic meta-analyses, statistical analysis was performed where the outcome was calculated as the percentages of an event(without comparison) in pseudo-cohorts of observed patients.RESULTS: A total of 16 studies were found that involved fluorescent cholangiography during standard laparoscopic cholecystectomies(n = 11), singleincision robotic cholecystectomies(n = 3), multiport robotic cholecystectomy(n = 1), and single-incision laparoscopic cholecystectomy(n = 1). Overall, these preliminary studies indicated that this novel technique was highly sensitive for the detection of important biliary anatomy and could facilitate the prevention of bile duct injuries. The structures effectively identified before dissection of Calot's triangle included the cystic duct(CD), the common hepatic duct(CHD), the common bile duct(CBD), and the CD-CHD junction. A review of the literature revealed that the frequenciesof detection of the extrahepatic biliary system ranged from 71.4% to 100% for the CD, 33.3% to 100% for the CHD, 50% to 100% for the CBD, and 25% to 100% for the CD-CHD junction. However, the frequency of visualization of the CD and the CBD were reduced in patients with a body mass index > 35 kg/m2 relative to those with a body mass index < 35 kg/m2(91.0% and 64.0% vs 92.3% and 71.8%, respectively).CONCLUSION: Fluorescent cholangiography is a safe procedure enabling real-time visualization of bile duct anatomy and may become standard practice to prevent bile duct injury during laparoscopic cholecystectomy.

Preoperative assessment of hilar cholangiocarcinoma:combination of cholangiography and CT angiography

BACKGROUND: Hilar cholangiocarcinoma is one of the most difficult carcinomas to manage because of the location of the main tumor at the hepatic hilus and the complex anatomy of the biliary, arterial, and portal systems. To plan an operation, it is important to acquire accurate information about the relationship between hilar cholangiocarcinoma and adjacent vessels. This study aimed to evaluate the clinical value of cholangiography combined with spiral CT three-dimensional (3D) angiography for a preoperative assessment of hilar cholangiocarcinoma. METHODS: From March 2007 to August 2009, cholangiography was performed in 13 patients with hilar cholangiocarcinoma. Meanwhile, contrast-enhanced abdominal scanning was performed using 16-slice spiral CT, and the 3D images of the hepatic artery and portal vein were acquired. The level and range of invasion of the hepatic artery, the portal vein, and the bile duct, the preoperative Bismuth classification, and T-staging were recorded and compared with those after surgical exploration. RESULTS: The hepatic artery and portal vein were reconstructed successfully in all these patients. Percutaneous transhepatic cholangiography was performed in 9 patients, endoscopic retrograde cholangiopancreatography in 1, and magnetic resonance cholangiopancreatography in 3. The CT angiography records of invasion of the hepatic artery were consistent with the results of explorations in these patients. The data from 5 of the 13 patients were consistent with those on invasion of the portal vein. The results of the Bismuth classification and the T-staging system were consistent with those of surgical exploration in 12 of the 13 patients. Seven of 8 patients who were estimated to be suitable for operation based on images were curatively treated and 5 who were judged to be unsuitable for curative operation by cholangiography and CT angiography were confirmed intraoperatively and underwent palliative procedures. CONCLUSIONS: Cholangiography combined with multi-slice spiral 3D CT angiography can satisfactorily delineate the local invasion of hilar cholangiocarcinoma and accurately evaluate the resectability. This approach, therefore, contributes to the planning of safe operation. (Hepatobiliary Pancreat Dis Int 2010; 9: 186-191)

Multi-slice three-dimensional spiral CT cholangiography: a new technique for diagnosis of biliary diseases

Objective: To validate multi-slice three-dimensional spiral CT cholangiography (3-D CTC) in clinical di- agnosis of biliary diseases. Methods: This study included 146 patients with bili- ary diseases, involving 73 cases of biliary tumor, 87 cases of radioparent calculus, 12 cases of post cholan- gio-jejunostomy and one case of congenital choledo- chocyst. The data of thin-slice volumetric CT scan were sent to the workstation (GE Advantage Win- dows 3. 1). Rational 3-D CTC including maximum intensity projection, minimum intensity projection, surface shaded display, CT virtual endoscopy and ray sumption was performed. The diagnostic accura- cy of 3-D CTC was compared with that of conven- tional CT, ultrasonography and endoscopic retro- grade cholangiopancreaticography (ERCP). Results: Different biliary diseases showed distinct ima- ging manifestations on 3-D CTC, As a new technique for assessing the status of post cholangio-jejunosto- my, 3-D CTC was superior to conventional CT, ul- trasonography and ERCP in diagnosis of negative bil- iary calculus, extrahepatic cholangiocarcinoma, cancer embolus of the biliary duct, carcinoma of the pancreas head and periampullar carcinoma. It was also superior to conventional CT, ultrasonography or equal to ERCP in diagnosis of hilar cholangiocarcino- ma, but inferior to conventional CT and ultrasonog- raphy in diagnosis of gallbladder cancer. Conclusion: 3-D CTC as a non-invasive and sensitive technique for the diagnosis of biliary diseases with high diagnostic accuracy will greatly increase the de- tection rate of biliary diseases.

Is intraoperative cholangiography necessary during laparoscopic cholecystectomy for cholelithiasis?

AIM:To determine the efficacy and safety benefits of performing intraoperative cholangiography(IOC)during laparoscopic cholecystectomy(LC)to treat symptomatic cholelithiasis.METHODS:Patients admitted to the Minimally Invasive Surgery Center of Tianjin Nankai Hospital between January2012 and January 2014 for management of symptomaticcholelithiasis were recruited for this prospective randomized trial.Study enrollment was offered to patients with clinical presentation of biliary colic symptoms,radiological findings suggestive of gallstones,and normal serum biochemistry results.Study participants were randomized to receive either routine LC treatment or LC+IOC treatment.The routine LC procedure was carried out using the standard four-port technique;the LC+IOC procedure was carried out with the addition of meglumine diatrizoate(1:1 dilution with normal saline)injection via a catheter introduced through a small incision in the cystic duct made by laparoscopic scissors.Operative data and postoperative outcomes,including operative time,retained common bile duct(CBD)stones,CBD injury,other complications and length of hospital stay,were recorded for comparative analysis.Inter-group differences were statistically assessed by theχ2 test(categorical variables)and Fisher’s exact test(binary variables),with the threshold for statistical significance set at P<0.05.RESULTS:A total of 371 patients were enrolled in the trial(late-adolescent to adult,age range:16-70 years),with 185 assigned to the routine LC group and 186 to the LC+IOC group.The two treatment groups were similar in age,sex,body mass index,duration of symptomology,number and size of gallstones,and clinical symptoms.The two treatment groups also showed no significant differences in the rates of successful LC(98.38%vs97.85%),CBD stone retainment(0.54%vs 0.00%),CBD injury(0.54%vs 0.53%)and other complications(2.16%vs 2.15%),as well as in duration of hospital stay(5.10±1.41 d vs 4.99±1.53 d).However,the LC+IOC treatment group showed significantly longer mean operative time(routine LC group:43.00±4.15 min vs 52.86±4.47 min,P<0.01).There were no cases of fatal complications in either group.At the one-year follow-up assessment,one patient in the routine LC group reported experiencing diarrhea for three months after the LC and one patient in the LC+IOC group reported ongoing intermittent epigastric discomfort,but radiologicalexamination provided no abnormal findings.CONCLUSION:IOC addition to the routine LC treatment of symptomatic cholelithiasis does not improve rates of CBD stone retainment or bile duct injury but lengthens operative time.

Predictive value and main determinants of abnormal features of intraoperative cholangiography during cholecystectomy

BACKGROUND:The major issue with intraoperative cholangiography (IOC) is whether its diagnostic accuracy for common bile duct (CBD) stones matches that of other diagnostic procedures,and thus,whether it will become a routine diagnostic procedure.The current study aimed to address the main determinants of CBD stone diagnosis in IOC among an Iranian population.METHODS:In a retrospective review database-based study conducted in Taleghani Hospital in Tehran between 2006 and 2008,baseline data and perioperative information of 2060 patients (male to female ratio 542:1518,mean age 53.7 years) who were candidates for cholecystectomy and underwent concomitant IOC for confirming CBD stones were reviewed.The predictive power of this procedure for diagnosis of abnormal biliary ducts with the focus on biliary stones was determined.RESULTS:Overall mortality and morbidity following cholecystectomy in the study population were 0.6% and 2.6%,respectively.Both early mortality and morbidity due to cholecystectomy were higher in male than female.The prevalence of CBD stones in IOC was 3.4% (5.2% in male and 2.8% in female,P=0.008).Among those without gallstones,8.7% had CBD stones and only 3.1% had concomitant gallstones and CBD stones.The main predictors of stone appearance as an abnormal feature of IOC during cholecystectomy were:advanced age (OR=1.022,P=0.001),male gender (OR=1.498,P=0.050),history of abdominal surgery (OR=1.543,P=0.040) and preoperative endoscopic retrograde cholangiopancreatography (OR=5.400,P<0.001).CONCLUSIONS:IOC is a safe and accurate method for the assessment of bile duct anatomy and stones.Therefore,the routine use of IOC within cholecystectomy seems reasonable and is recommended.

Endoscopic retrograde cholangiography for pediatric choledocholithiasis: Assessing the need for endoscopic intervention

AIM:To assess pediatric patients for choledocholithiasis.We applied current adult guidelines to identify predictivefactors in children.METHODS:A single-center retrospective analysis was performed at a tertiary children's hospital.We evaluated 44 consecutive pediatric patients who underwent endoscopic retrograde cholangiography(ERCP) for suspected choledocholithiasis.Patients were stratified into those with common bile duct stones(CBDS) at ERCP vs those that did not using the American Society of Gastrointestinal Endoscopy(ASGE) guidelines(Very Strong and Strong criteria) for suspected CBDS.RESULTS:CBDS were identified in 84% at the time of ERCP.Abdominal ultrasound identified CBDS in 36% of patients.Conjugated bilirubin ≥ 0.5 mg/d L was an independent risk factor for CBDS(P = 0.003).The Very Strong(59.5%) and Strong(48.6%) ASGE criteria identified the majority of patients(P = 0.0001).A modified score using conjugated bilirubin had a higher sensitivity(81.2% vs 59.5%) and more likely to identify a stone than the standard criteria,odds ratio of 25.7 compared to 8.8.Alanine aminotransferase and gamma-glutamyl transferase values identified significant differences in a subset of patients with odds ratio of 4.1 and 3.25,respectively.CONCLUSION:Current adult guidelines identified the majority of pediatric patients with CBDS,but specific pediatric guidelines may improve detection,thus decreasing risks and unnecessary procedures.

Fluorescent cholangiography: An up-to-date overview twelve years after the first clinical application

Laparoscopic cholecystectomy(LC)is one of the most frequently performed gastrointestinal surgeries worldwide.Bile duct injury(BDI)represents the most serious complication of LC,with an incidence of 0.3%-0.7%,resulting in significant perioperative morbidity and mortality,impaired quality of life,and high rates of subsequent medico-legal litigation.In most cases,the primary cause of BDI is the misinterpretation of biliary anatomy,leading to unexpected biliary lesions.Near-infrared fluorescent cholangiography is widely spreading in clinical practice to delineate biliary anatomy during LC in elective and emergency settings.The primary aim of this article was to perform an up-to-date overview of the evolution of this method 12 years after the first clinical application in 2009 and to highlight all advantages and current limitations according to the available scientific evidence.

MR Cholangiography and Dynamic Examination of Duodenal Fluid inthe Differential Diagnosis between Extrahepatic Biliary Atresia and Infantile Hepatitis Syndrome

In order to evaluate the value of magnetic resonance cholangiography （MRC） and dynamic examination of duodenal fluid in the differential diagnosis between extrahepatic biliary atresia （EHBA） and infantile hepatitis syndrome （IHS）, 52 patients with infantile cholestatic jaundice were examined by MRC and duodenal fluid examination. Original interpretations were compared with clinical outcome. Calculated sensitivity of duodenal fluid examination in diagnosis of EHBA was 100 %, and specificity was 91.1%. Sensitivity of MRC in the diagnosis of EHBA was 94.4 % and specificity 88.24 %. The sensitivity of MRC and examination of duodenal fluid combined in diagnosis of EHBA was 94.4 % and specificity 97.06 %. We are led to conclude that MRC and dynamic examination of duodenal fluid are useful in the differential diagnosis between IHS and EHBA and the combined use of the two techniques yield better resutls.

Magnetic resonance cholangiography in the assessment and management of biliary complications after OLT

Despite advances in patient and graft management,biliary complications(BC)still represent a challenge both in the early and delayed period after orthotopic liver transplantation(OLT).Because of unspecific clinical presentation,imaging is often mandatory in order to diagnose BC.Among imaging modalities,magnetic resonance cholangiography(MRC)has gained widespread acceptance as a tool to represent the reconstructed biliary tree noninvasively,using both the conventional technique(based on heavily T2-weighted sequences)and contrast-enhanced MRC(based on the acquisition of T1-weighted sequences after the administration of hepatobiliary contrast agents).On this basis,MRC is generally indicated to:(1)avoid unnecessary procedures of direct cholangiography in patients with a negative examination and/or identify alternative complications;and(2)provide a road map for interventional procedures or surgery.As illustrated in the review,MRC is accurate in the diagnosis of different types of biliarycomplications,including anastomotic strictures,nonanastomotic strictures,leakage and stones.

Single balloon enteroscopy for endoscopic retrograde cholangiography in patients with Roux-en-Y hepaticojejuno anastomosis

AIM:To evaluate single balloon enteroscopy in diagnostic and therapeutic endoscopic retrograde cholangiography(ERC)in patients with Roux-en-Y hepaticojejunoanastomosis(HJA).METHODS:The study took place from January 2009to December 2011 and we retrospectively assessed 15patients with Roux-en-Y HJA who had signs of biliary obstruction.In total,23 ERC procedures were performed in these patients and a single balloon videoen-teroscope(Olympus SIF Q 180)was used in all of the cases.A transparent overtube was drawn over the videoenteroscope and it freely moved on the working part of the enteroscope.Its distal end was equipped with a silicone balloon that was inflated by air from an external pump at a pressure of≤5.4 kPa.The technical limitations or rather the parameters of the single balloon enteroscope(working length-200 cm,diameter of the working channel-2.8 mm,absence of Albarran bridge)showed the need for special endoscopic instrumentation.RESULTS:Cannulation success was reached in diagnostic ERC in 12 of 15 patients.ERC findings were normal in 1 of 12 patients.ERC in the remaining 11 patients showed some pathological changes.One of these(cystic bile duct dilation)was subsequently resolved surgically.Endoscopic treatment was initialized in the remaining 10 patients(5 with HJA stenosis,2 with choledocholithiasis,and 3 with both).This treatment was successful in 9 of 10 patients.The endoscopic therapeutic procedures included:balloon dilatation of HJA stenosis-11 times(7 patients);choledocholitiasis extraction-five times(5 patients);biliary plastic stent placement-six times(4 patients);and removal of biliary stents placed by us-six times(4 patients).The mean time of performing a single ERC was 72 min.The longest procedure took 110 min and the shortest took34 min.This shows that it is necessary to allow for more time in individual procedures.Furthermore,these procedures require the presence of an anesthesiologist.We did not observe any complications in these 15 patients.CONCLUSION:This method is more demanding than standard endoscopic retrograde cholangiopancreatography due to altered postsurgical anatomy.However,it is effective,safe,and widens the possibilities of resolving biliary pathology.

Electrohydraulic lithotripsy and rendezvous nasal endoscopic cholangiography for common bile duct stone: A case report

BACKGROUND In patients with large stones in the common bile duct(CBD),advanced treatment modalities are generally needed.Here,we present an interesting case of a huge CBD stone treated with electrohydraulic lithotripsy(EHL)by the percutaneous approach and rendezvous endoscopic retrograde cholangiography(ERC)using a nasal endoscope.CASE SUMMARY A 91-year-old woman underwent ERC for a symptomatic large CBD stone with a diameter of 50 mm.She was referred to our institution after the failure of lithotomy by ERC,and after undergoing percutaneous transhepatic biliary drainage.We attempted to fragment the stone by transhepatic cholangioscopy using EHL.However,the stones were too large and partly soft clay-like for lithotripsy.Next,we attempted lithotomy with ERC and cholangioscopy by the rendezvous technique using a nasal endoscope and achieved complete lithotomy.No complication was observed at the end of this procedure.CONCLUSION Cholangioscopy by rendezvous technique using a nasal endoscope is a feasible and safe endoscopic method for removing huge CBD stones.

Improving rehabilitation and quality of life after percutaneous transhepatic cholangiography drainage with a rapid rehabilitation model

BACKGROUND Percutaneous transhepatic cholangiography drainage(PTCD)effectively treats biliary obstruction.However,patients must maintain the drainage tube after hospital discharge,which may interfere with daily life and work,potentially causing psychological distress.Postoperative rehabilitation is crucial,and strengthened nursing interventions can shorten recovery time.AIM The aim was to evaluate an inpatient model to shorten rehabilitation duration and improve quality of life after PTCD.METHODS A total of 118 patients with malignant obstructive jaundice who were admitted to our hospital between May 2018 and January 2021 were included and divided into observational(with therapy)and control(no therapy)groups of 59 each.RESULTS The observational group had fewer hospitalization days than the control group.The complication,the PTCD fixed-tube prolapse,and tube-related admission rates within 3 mo after PTCD were significantly lower in the observation group than in the control group(P<0.05).The fatigue,pain,nausea,vomiting,pruritus,emaciation,and fever scores after PTCD decreased in both groups compared with the scores before PTCD(P<0.05).The quality of life scores after the intervention were higher in the observation than in the control group(P<0.05).CONCLUSION The model promoted rehabilitation after PTCD,reduced post-PTCD complications,and the tube-related admissions in the 3 mo after the procedure,and improved the quality of life.

Magnetic resonance cholangiography in assessing biliary anatomy in living donors:A meta-analysis

AIM:To establish the role of magnetic resonance cholangiography(MRC)in diagnosis of biliary anatomy in living-donor liver transplantation(LDLT)donors.METHODS:A systematic review was performed by searching electronic bibliographic databases prior to March 2013.Studies with diagnostic results and fulfilled inclusion criteria were included.The methodological quality of the studies was assessed.Sensitivity,specificity and other measures of the accuracy of MRC for diagnosis of biliary anatomy in LDLT donors were summarized using a random-effects model or a fixed-effects model.Summary receiver operating characteristic(SROC)curves were used to summarize overall test performance.Publication bias was assessed using Deek’s funnel plot asymmetry test.Sensitivity analysis was adopted to explore the potential sources of heterogeneity.RESULTS:Twelve studies involving 869 subjects were eligible to the analysis.The scores of Quality Assessment of Diagnostic Accuracy Studies for the included studies ranged from 11 to 14.The summary estimates of sensitivity,specificity,positive likelihood ratio,negative likelihood ratio,diagnostic OR of MRC in diagnosis of biliary anatomy in LDLT donor were 0.88(95%CI:0.84-0.92),0.95(95%CI:0.93-0.97),15.33(95%CI:10.70-21.95),0.15(95%CI:0.11-0.20)and 130.77(95%CI:75.91-225.27),respectively.No significant heterogeneity was detected in all the above four measures.Area under SROC curve was 0.971.Little publication bias was noted across the studies(P=0.557).Sensitivity analysis excluding a study with possible heterogeneity got a similar overall result,which suggested the little influence of this study on the overall results.CONCLUSION:Our results suggest that MRC is a high specificity but moderate sensitivity technique in diagnosis of biliary anatomy in LDLT donors.

Intraoperative cholangiography 2020:Quo vadis? A systematic review of the literature

Background: There are few randomized controlled trials with sufficient statistical power to assess the effectiveness of intraoperative cholangiography(IOC) in the detection and treatment of common bile duct injury(BDI) or retained stones during cholecystectomy. The best evidence so far regarding IOC and reduced morbidity related to BDI and retained common bile duct stones was derived from large populationbased cohort studies. Population-based studies also have the advantage of reflecting the outcome of the procedure as it is practiced in the community at large. However, the outcomes of these population-based studies are conflicting. Data sources: A systematic literature search was conducted in 2020 to search for articles that contained the terms “bile duct injury”, “critical view of safety”, “bile duct imaging” or “retained stones” in combination with IOC. All identifed references were screened to select population-based studies and observational studies from large centers where socioeconomic or geographical selections were assumed not to cause selection bias. Results: The search revealed 273 references. A total of 30 articles fulflled the criteria for a large observational study with minimal risk for selection bias. The majority suggested that IOC reduces morbidity associated with BDI and retained common bile duct stones. In the short term, IOC increases the cost of surgery. However, this is offset by reduced costs in the long run since BDI or retained stones detected during surgery are managed immediately. Conclusions: IOC reduces morbidity associated with BDI and retained common bile duct stones. The reports reviewed are derived from large, unselected populations, thereby providing a high external validity. However, more studies on routine and selective IOC with well-defned outcome measures and sufficient statistical power are needed.

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.

Percutaneous transhepatic cholangiography vs endoscopic ultrasound-guided biliary drainage:A systematic review

BACKGROUND Percutaneous transhepatic cholangiography is a diagnostic and therapeutic procedure that involves inserting a needle into the biliary tree,followed by the immediate insertion of a catheter.Endoscopic ultrasound-guided biliary drainage(EUS-BD)is a novel technique that allows BD by echoendoscopy and fluoroscopy using a stent from the biliary tree to the gastrointestinal tract.AIM To compare the technical aspects and outcomes of percutaneous transhepatic BD(PTBD)and EUS-BD.METHODS Different databases,including PubMed,Embase,clinicaltrials.gov,the Cochrane library,Scopus,and Google Scholar,were searched according to the guidelines for Preferred Reporting Items for Systematic reviews and Meta-Analyses to obtain studies comparing PTBD and EUS-BD.RESULTS Among the six studies that fulfilled the inclusion criteria,PTBD patients underwent significantly more reinterventions(4.9 vs 1.3),experienced more postprocedural pain(4.1 vs 1.9),and experienced more late adverse events(53.8%vs 6.6%)than EUS-BD patients.There was a significant reduction in the total bilirubin levels in both the groups(16.4-3.3μmol/L and 17.2-3.8μmol/L for EUSBD and PTBD,respectively;P=0.002)at the 7-d follow-up.There were no significant differences observed in the complication rates between PTBD and EUSBD(3.3 vs 3.8).PTBD was associated with a higher adverse event rate than EUSBD in all the procedures,including reinterventions(80.4%vs 15.7%,respectively)and a higher index procedure(39.2%vs 18.2%,respectively).CONCLUSION The findings of this systematic review revealed that EUS-BD is linked with a higher rate of effective BD and a more manageable procedure-related adverse event profile than PTBD.These findings highlight the evidence for successful EUS-BD implementation.

Intraductal ultrasonography and endoscopic retrograde cholangiography in diagnosis of extrahepatic bile duct stones: a comparative study

BACKGROUND: Intraductal ultrasonography (IDUS) is highly accurate in detection of extrahepatic bile duct stones. This study was to compare the accuracy of IDUS and endo- scopic retrograde cholangiography (ERC) in the diagnosis of extrahepatic bile duct stones. METHODS: Thirty patients suspected of extrahepatic bile duct stones on B ultrasonography, CT, or MRI were en- rolled for study. ERC was performed using a Fujinon duo- denoscope (ED-410XT, ED-410Xu), then IDUS was done by inserting a Fujinon microprobe (PL2220-15) through the endoscopic biopsy channel to detect the extrahepatic bile duct. Finally stones in the extrahepatic bile duct were detected and extracted by endoscopic sphincterotomy (EST). RESULTS: Among the 30 patients, 26 were diagnosed as having cholelithiasis accurately through ERC. In one pa- tient the stone detected by ERC was really floccule. Mis- diagnosis happened in 2 patients with extrahepatic bile duct stones. So the overall accuracy and sensitivity of ERC in the diagnosis of extrahepatic bile duct stones were 86.7% (26/30) and 92.9% (26/28) respectively. In contrast, IDUS showed the results of diagnosis were in consistent with those of EST stone extraction. Its accuracy and sensi- tivity in the diagnosis of extrahepatic bile duct stones were 100% (30/30) and 100% (28/28) respectively. CONCLUSION: IDUS which is superior to ERC in diagno- sing extrahepatic bile duct stones can avoid the visual error of ERC.