Although rare,iatrogenic bile duct injury(BDI)after laparoscopic cholecystectomy may be devastating to the patient.The cornerstones for the initial management of BDI are early recognition,followed by modern imaging an...Although rare,iatrogenic bile duct injury(BDI)after laparoscopic cholecystectomy may be devastating to the patient.The cornerstones for the initial management of BDI are early recognition,followed by modern imaging and evaluation of injury severity.Tertiary hepato-biliary centre care with a multidisciplinary approach is crucial.The diagnostics of BDI commences with a multiphase abdominal computed tomography scan,and when the biloma is drained or a surgical drain is put in place,the diagnosis is set with the help of bile drain output.To visualize the leak site and biliary anatomy,the diagnostics is supplemented with contrast enhanced magnetic resonance imaging.The location and severity of the bile duct lesion and concomitant injuries to the hepatic vascular system are evaluated.Most often,a combination of percutaneous and endoscopic methods is used for control of contamination and bile leak.Generally,the next step is endoscopic retrograde cholangiography(ERC)for downstream control of the bile leak.ERC with insertion of a stent is the treatment of choice in most mild bile leaks.The surgical option of re-operation and its timing should be discussed in cases where an endoscopic and percutaneous approach is not sufficient.The patient's failure to recover properly in the first days after laparoscopic cholecystectomy should immediately raise suspicion of BDI and this merits immediate investigation.Early consultation and referral to a dedicated hepatobiliary unit are essential for the best outcome.展开更多
Background: Cholecystectomy is one of the most now common abdominal surgeries performed every day. The incidence of bile duct injury (BDI) following open cholecystectomy is only 0.1% - 0.2%. After the introduction of ...Background: Cholecystectomy is one of the most now common abdominal surgeries performed every day. The incidence of bile duct injury (BDI) following open cholecystectomy is only 0.1% - 0.2%. After the introduction of laparoscopic cholecystectomy, the incidence has gone up to 0.4% - 0.7%. The present study is a prospective analysis of all patients with bile duct injury who were admitted to Dhaka Medical College Hospital during or at a variable period following cholecystectomy. Methods: To determine the pattern of presentation of iatrogenic biliary injury following cholecystectomy in the department of surgery of Dhaka Medical College Hospital, a total of 30 patients were purposively selected from May 2018 to November 2018. Patient particulars, records of physical and clinical evaluation, and operative details were collected by individual researchers. Data analysis was done by SPSS for windows version 21. Results: BDI was found very common among the age group 21 - 30 yrs (36%) and female dominant (60%). Majority of the patients presented with abdominal pain (96%), intra-abdominal collection (88%), biliary peritonitis (68%), cholangitis (60%), and obstructive jaundice (40%), and biliary fistula (40%). Laparoscopic cholecystectomy (84%) was the principal cause of biliary injury in our study. 48% of patients experienced clinical features within 7 days post-cholecystectomy. Per-operative diagnosis was done in only 12% of cases. 44% of patients in this study were recognized as Bismuth grade-3, followed by 36%, grade-2 patients. Management outcomes included wound infection (41.66%), minor bile leak (25%), peritonitis (8.33%), and renal impairment (8.33%). Conclusion: The effect of BDI is an extremely distressful clinical condition for the patients and their family members, hence proper care and management protocol should be followed.展开更多
BACKGROUND: Laparoscopic cholecystectomy (LC) has become the 'gold standard' in treating benign gallbladder diseases. Increasing laparoscopic experience and techniques have made laparoscopic subtotal cholecyst...BACKGROUND: Laparoscopic cholecystectomy (LC) has become the 'gold standard' in treating benign gallbladder diseases. Increasing laparoscopic experience and techniques have made laparoscopic subtotal cholecystectomy (LSC) a feasible option in more complex procedures. In recent years, few studies with a few cases of LSC have reported good results in patients with various types of cholecystitis. This study was designed to evaluate the feasibility, indications, characteristics and benefits of LSC in patients with complicated cholecystitis. METHODS: Altogether, 3485 patients were scheduled to receive LC during the past 4 years at our institute. Among them, 168 patients with various complicated forms of cholecystitis were treated by LSC. Meanwhile, the other 3317 patients who received standard LC were enrolled as the control group. Perioperative data from the two groups were collected and retrospectively analyzed. RESULTS: In the LSC group, 135 patients suffered from acute calculic cholecystitis, 18 from chronic calculic cholecystitis with cirrhotic portal hypertention, and 15 from chronic calculic atrophy cholecystitis with severe fibrosis. These patients constituted 4.8% of the total patients who underwent LC (168/3485) in the same period at our institute. In 122 patients, the cystic duct and artery were clipped before division. In another 46 patients, the gallbladder was initially incised at Hartmann's pouch. Five patients (3.0%) were converted to open subtotal cholecystectomy. The median operation time for LSC was 65.5±15.2 minutes, estimated operative blood loss was 71.5±15.5 ml, and the time to resume diet was 20.4±6.3 hours. Thirteen patients (7.7%) had local complications. The mean postoperative hospital stay was 4.2±2.6 days. In the LC group, 2887 had chronic calculic cholecystitis, 312had acute calculic cholecystitis, 47 had chronic calculic atrophy cholecystitis, and 71 had polypus. Seventeen patients (0.5%) were converted to open cholecystectomy. The median operation time was 32.6±10.2 minutes, the estimated operative blood loss was 24.5±8.5 ml, and the time to resume diet was 18.3±4.5 hours. Thirty- nine patients (1.2%) had local complications. Mean postoperative hospital stay was 3.8±1.4 days. There was no bile duct injury or mortality in either group. CONCLUSIONS: LSC for patients with complicated cholecystitis is difficult, with a longer operation time, more operative blood loss and higher conversion and complication rates than LC. However, it is feasible and relatively safe. LSC is advantageous over open surgery, but it remains a non-routine choice. It is important to know the technical characteristics of LSC, and pay attention to perioperative bleeding and bile leak.展开更多
医源性胆管损伤(iatrogenic bile duct injuries,IBDI)是胆囊切除术的一种严重并发症,其不仅损害病人的身心健康,同时也对外科医生及医保系统造成严重负面影响。IBDI核心在于预防,关键在于及时诊断。把握手术时机,选择合理手术方式,IBD...医源性胆管损伤(iatrogenic bile duct injuries,IBDI)是胆囊切除术的一种严重并发症,其不仅损害病人的身心健康,同时也对外科医生及医保系统造成严重负面影响。IBDI核心在于预防,关键在于及时诊断。把握手术时机,选择合理手术方式,IBDI亦可取得良好的远期治疗效果。本文将从预防、诊断及治疗三方面对IBDI的诊治现状与趋势进行阐述。展开更多
文摘Although rare,iatrogenic bile duct injury(BDI)after laparoscopic cholecystectomy may be devastating to the patient.The cornerstones for the initial management of BDI are early recognition,followed by modern imaging and evaluation of injury severity.Tertiary hepato-biliary centre care with a multidisciplinary approach is crucial.The diagnostics of BDI commences with a multiphase abdominal computed tomography scan,and when the biloma is drained or a surgical drain is put in place,the diagnosis is set with the help of bile drain output.To visualize the leak site and biliary anatomy,the diagnostics is supplemented with contrast enhanced magnetic resonance imaging.The location and severity of the bile duct lesion and concomitant injuries to the hepatic vascular system are evaluated.Most often,a combination of percutaneous and endoscopic methods is used for control of contamination and bile leak.Generally,the next step is endoscopic retrograde cholangiography(ERC)for downstream control of the bile leak.ERC with insertion of a stent is the treatment of choice in most mild bile leaks.The surgical option of re-operation and its timing should be discussed in cases where an endoscopic and percutaneous approach is not sufficient.The patient's failure to recover properly in the first days after laparoscopic cholecystectomy should immediately raise suspicion of BDI and this merits immediate investigation.Early consultation and referral to a dedicated hepatobiliary unit are essential for the best outcome.
文摘Background: Cholecystectomy is one of the most now common abdominal surgeries performed every day. The incidence of bile duct injury (BDI) following open cholecystectomy is only 0.1% - 0.2%. After the introduction of laparoscopic cholecystectomy, the incidence has gone up to 0.4% - 0.7%. The present study is a prospective analysis of all patients with bile duct injury who were admitted to Dhaka Medical College Hospital during or at a variable period following cholecystectomy. Methods: To determine the pattern of presentation of iatrogenic biliary injury following cholecystectomy in the department of surgery of Dhaka Medical College Hospital, a total of 30 patients were purposively selected from May 2018 to November 2018. Patient particulars, records of physical and clinical evaluation, and operative details were collected by individual researchers. Data analysis was done by SPSS for windows version 21. Results: BDI was found very common among the age group 21 - 30 yrs (36%) and female dominant (60%). Majority of the patients presented with abdominal pain (96%), intra-abdominal collection (88%), biliary peritonitis (68%), cholangitis (60%), and obstructive jaundice (40%), and biliary fistula (40%). Laparoscopic cholecystectomy (84%) was the principal cause of biliary injury in our study. 48% of patients experienced clinical features within 7 days post-cholecystectomy. Per-operative diagnosis was done in only 12% of cases. 44% of patients in this study were recognized as Bismuth grade-3, followed by 36%, grade-2 patients. Management outcomes included wound infection (41.66%), minor bile leak (25%), peritonitis (8.33%), and renal impairment (8.33%). Conclusion: The effect of BDI is an extremely distressful clinical condition for the patients and their family members, hence proper care and management protocol should be followed.
文摘BACKGROUND: Laparoscopic cholecystectomy (LC) has become the 'gold standard' in treating benign gallbladder diseases. Increasing laparoscopic experience and techniques have made laparoscopic subtotal cholecystectomy (LSC) a feasible option in more complex procedures. In recent years, few studies with a few cases of LSC have reported good results in patients with various types of cholecystitis. This study was designed to evaluate the feasibility, indications, characteristics and benefits of LSC in patients with complicated cholecystitis. METHODS: Altogether, 3485 patients were scheduled to receive LC during the past 4 years at our institute. Among them, 168 patients with various complicated forms of cholecystitis were treated by LSC. Meanwhile, the other 3317 patients who received standard LC were enrolled as the control group. Perioperative data from the two groups were collected and retrospectively analyzed. RESULTS: In the LSC group, 135 patients suffered from acute calculic cholecystitis, 18 from chronic calculic cholecystitis with cirrhotic portal hypertention, and 15 from chronic calculic atrophy cholecystitis with severe fibrosis. These patients constituted 4.8% of the total patients who underwent LC (168/3485) in the same period at our institute. In 122 patients, the cystic duct and artery were clipped before division. In another 46 patients, the gallbladder was initially incised at Hartmann's pouch. Five patients (3.0%) were converted to open subtotal cholecystectomy. The median operation time for LSC was 65.5±15.2 minutes, estimated operative blood loss was 71.5±15.5 ml, and the time to resume diet was 20.4±6.3 hours. Thirteen patients (7.7%) had local complications. The mean postoperative hospital stay was 4.2±2.6 days. In the LC group, 2887 had chronic calculic cholecystitis, 312had acute calculic cholecystitis, 47 had chronic calculic atrophy cholecystitis, and 71 had polypus. Seventeen patients (0.5%) were converted to open cholecystectomy. The median operation time was 32.6±10.2 minutes, the estimated operative blood loss was 24.5±8.5 ml, and the time to resume diet was 18.3±4.5 hours. Thirty- nine patients (1.2%) had local complications. Mean postoperative hospital stay was 3.8±1.4 days. There was no bile duct injury or mortality in either group. CONCLUSIONS: LSC for patients with complicated cholecystitis is difficult, with a longer operation time, more operative blood loss and higher conversion and complication rates than LC. However, it is feasible and relatively safe. LSC is advantageous over open surgery, but it remains a non-routine choice. It is important to know the technical characteristics of LSC, and pay attention to perioperative bleeding and bile leak.
文摘医源性胆管损伤(iatrogenic bile duct injuries,IBDI)是胆囊切除术的一种严重并发症,其不仅损害病人的身心健康,同时也对外科医生及医保系统造成严重负面影响。IBDI核心在于预防,关键在于及时诊断。把握手术时机,选择合理手术方式,IBDI亦可取得良好的远期治疗效果。本文将从预防、诊断及治疗三方面对IBDI的诊治现状与趋势进行阐述。
