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.

Comparison of brush and basket cytology in differential diagnosis of bile duct stricture at endoscopic retrograde cholangiopancreatography

BACKGROUND： A previous report has identified a significantly higher sensitivity of cancer detection for dedicated grasping basket than brushing at endoscopic retrograde cholangiopancreato- graphy （ERCP）. This study aimed to compare the diagnostic accuracy of Geenen brush and Dormia basket cytology in the differential diagnosis of bile duct stricture. METHOD： The current study enrolled one hundred and fourteen patients who underwent ERCP with both Geenen brush and Dormia basket cytology for the differential diagnosis of bile duct stricture at our institution between January 2008 and December 2012. RESULTS： We adopted sequential performances of cytologic samplings by using initial Geenen brush and subsequent Dormia basket cytology in 59 patients and initial Dormia basket and subsequent Geenen brush cytology in 55 patients. Presampling balloon dilatations and biliary stentings for the stricture were performed in 17 （14.9%） and 107 patients （93.9%）, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of Geenen brush cytology for the diagnosis of malignant bile duct stricture were 75.0%, 100.0%, 100.0%, 66.7% and 83.3%, respectively, and those of Dormia basket cytology were 64.5%, 100.0%, 100.0%, 58.5% and 76.3%, respectively （P=0.347 and 0.827 for sensitivity and accuracy, respectively）. The good and excellent cellular yields （≥grade 2） were obtained by Geenen brush and Dormia basket cytology in 88 （77.2%） and 79 （69.3%） patients, respectively.CONCLUSION： The sensitivity, specificity and accuracy of biliary sampling with a Dormia basket are comparable to those with conventional Geenen brush cytology in the detection of malignant bile duct stricture.

Frey procedure for the treatment of chronic pancreatitis associated with common bile duct stricture

BACKGROUND:The Frey procedure(FP)is the treatment of choice for symptomatic chronic pancreatitis(CP).In cases of biliary stricture,biliary derivation can be performed by choledochoduodenostomy,Roux-en-Y choledochojejunostomy or,more recently,reinsertion of the common bile duct(CBD)into the resection cavity.The objective of the present study was to evaluate the outcomes associated with each of these three types of biliary derivation.METHODS:We retrospectively analyzed demographic,CPrelated,surgical and follow-up data for patients having undergone FP for CP with biliary derivation between 2004and 2012 in our university medical center.The primary efficacy endpoint was the rate of CBD stricture recurrence.The secondary endpoints were surgical parameters,postoperative complications,postoperative follow-up and the presence of risk factors for secondary CBD stricture.RESULTS:Eighty patients underwent surgery for CP during the study period.Of these,15 patients received biliary derivation with the FP.Eight of the FPs(53.3%)were combined with choledochoduodenostomy,4(26.7%)with choledochojejunostomy and 3(20.0%)with reinsertion of the CBD into the resection cavity.The mean operating time was 390minutes.Eleven complications(73.3%)were recorded,including one major complication(6.7%)that necessitated radiologicallyguided drainage of an abdominal collection.The mean(range)length of stay was 17 days(8-28)and the median(range)follow-up time was 35.2 months(7.2-95.4).Two patients presented stricture after CBD reinsertion into the resection cavity;one was treated with radiologically-guided dilatation and the other underwent revisional Roux-en-Y choledochojejunostomy.Three patients presented alkaline reflux gastritis(37.5%),one(12.5%)cholangitis and one CBD stricture after FP with choledochoduodenostomy.No risk factors for secondary CBD stricture were identified.CONCLUSIONS:As part of a biliary derivation,the FP gave good results.We did not observe any complications specifically related to surgical treatment of the biliary tract.However,CBD reinsertion into the resection cavity appeared to be associated with a higher stricture recurrence rate.In our experience,choledochojejunostomy remains the"gold standard"for the surgical treatment for CBD strictures.

Endoscopic diagnosis and treatment of biliary leak in patients following liver transplantation:a prospective clinical study

BACKGROUND: Orthotopic liver transplantation has been widely used in patients with end-stage liver disease within the last two decades. However, the prevalence of biliary complications after liver transplantation remains high. The most common short-term biliary complication may be biliary leak. So, we examined 13 patients with biliary leak after liver transplantation, attempting to evaluate the role of endoscopic diagnosis and treatment of biliary leak and the incidence of bile duct stricture after healing of the leak. METHODS: Six cases of T-tube leak and seven cases of anastomosis leak complicating liver transplantation were enrolled in this prospective study. Six patients were treated by endoscopic plastic stent placement, two by nasobiliary catheter drainage, two by papillosphincterotomy, and three by nasobiliary catheter drainage combined with plastic stent placement. Some patients received growth hormone treatment. RESULTS: The bile leak resolution time was 10-35 days in 10 patients with complete documentation. The median time of leak resolution was 15.3 days. Four cases of anastomosis stricture, three cases of common hepatic duct and one case of multiple bile duct stenosis were detected by follow-up nasobiliary catheter cholangiography or endoscopic retrograde cholangiopancreatography. CONCLUSIONS: Endoscopic nasobiliary catheter or plastic stent placement is a safe and effective treatment for bile duct stricture occurring after bile leak resolution in most liver transplantation patients. Nasobiliary catheter combined with plastic stent placement may be the best choice for treating bile leak, because, theoretically, it may prevent the serious condition resulting from accidental nasobiliary catheter dislocation, and it may have prophylactic effects on upcoming bile duct stricture, although this should be further confirmed.