Is there a place for endoscopic management in postcholecystectomy iatrogenic bile duct injuries?

In this editorial we comment on the article by Emara et al published in the recent issue of the World Journal of Gastrointestinal Surgery.Previously,surgery was the primary treatment for bile duct injuries(BDI).The treatment of BDI has advanced due to technological breakthroughs and minimally invasive procedures.Endoscopic and percutaneous treatments have largely supplanted surgery as the primary treatment for most instances in recent years.Patient management,including the specific technique,is typically impacted by local knowledge and the kind and severity of the injury.Endoscopic therapy is a highly successful treatment for postoperative benign bile duct stenosis and offers superior long-term outcomes compared to surgical correction.Based on the damage features of BDI,therapeutic options include endoscopic duodenal papillary sphincterotomy,endoscopic nasobiliary drainage,and endoscopic biliary stent implantation.

Post-cholecystectomy iatrogenic bile duct injuries:Emerging role for endoscopic management

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.

Iatrogenic extrahepatic bile duct injury in 182 patients: causes and management

Objective: To describe the causes and treatment ofiatrogenic bile duct injury caused by cholecystecto-my.Methods: 182 patients with iatrogenic extrahepaticbile duct injury from 4 university hospitals of Chinawere reviewed. Details of primary cholecystectomy,biliary reconstruction as well as postoperative ma-nagement were recorded. All patients were followedup for at least 6 months (6 months to 9 years, medi-an 3.5 years). The adequacy of repair was assessedby regular evaluation of the patients clinical statusand liver function variables. Hepatobiliary B-ultra-sonography was used routinely in the follow up of pa-tients, and magnetic resonance cholangiopancreatog-raphy was applied in the patients suggestive of abnor-mality.Results: In 152 patients, bile duct injury happenedduring open cholecystectomy, and in 30 patients dur-ing laparoscopic cholecystectomy. All the injuries de-veloped during anterograde cholecystectomy (at theCalot’s triangle). All the patients with these injuriesunderwent choledochocholedochostomy or Roux-en-Ycholedochojejunostomy with good results (161 pa-tients), recurrent stricture (11), and death (10).Conclusions: During cholecystectomy, the Calot’s tri-angle should be identified anatomically, but retro-grade cholecystectomy is the optimal choice. Bileduct injury should be discovered as soon as possibleand be managed timely. Different operative methodsare optional according to the degree of injury and thepostoperative period.

Iatrogenic Bile Duct Injuries after Cholecystectomy, Is the Laparoscopic Approach a Good Idea?

Objective: The treatment of iatrogenic bile duct injuries is still a challenge for hepatobiliary and general surgeons. Roux-en-Y hepaticojejunostomy, one of the most appropriate techniques for the treatment of circumferential lesions, either occurring less than 2 cm from the bifurcation or in the bifurcation of the common hepatic duct, requires experience in advanced laparoscopy and hepatobiliary surgery. This study aims to present the results of laparoscopic hepaticojejunostomy (LHJ) for the treatment of iatrogenic bile duct injuries (IBDI). Methods: A retrospective study analyzing the medical records of patients diagnosed with IBDI and treated using LHJ of patients at the Hospital S?o José do Avaí (HSJA). Sex, age, previous cholecystectomy technique, signs and symptoms, postoperative complications, length of stay, injury classification, and time elapsed from injury to diagnosis were analyzed. Magnetic resonance cholangiography (MRC), endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiography. Results: From March 2006 to December 2018, six patients underwent LHJ. In five cases (83.33%), the primary operation was a laparoscopic cholecystectomy (LC) and in one patient (13.66%) open cholecystectomy. The most frequent clinical sign was jaundice. The mean surgical time was 153.2 minutes (range: 115 to 206 minutes), and the hospital stay was 3 to 7 days (mean: 4.16 days). One patient had infection of the umbilical trocar incision and one patient presented with stenosis of the hepaticojejunal anastomosis and was treated with radioscopic pneumatic dilatation. Conclusion: LHJ for circumferential and total IBDI either diagnosed early (during surgery) or late, may be a safe and effective option, with similar results to the conventional technique, a low complication rate and all the known advantages of minimally invasive surgery.

Iatrogenic bile duct injuries from biliary tract surgery

BACKGROUND:Cholecystectomy is the most commonly performed procedure in general surgery.However,bile duct injury is a rare but still one of the most common complications.These injuries sometimes present variably after primary surgery.Timely detection and appropriate management decrease the morbidity and mortality of the operation. METHODS:Five cases of iatrogenic bile duct injury(IBDI) were managed at the Department of Surgery,First Affiliated Hospital,Xi’an Jiaotong University.All the cases who underwent both open and laparoscopic cholecystectomy had persistent injury to the biliary tract and were treated accordingly. RESULTS:Recovery of the patients was uneventful.All patients were followed-up at the surgical outpatient department for six months to three years.So far the patients have shown good recovery. CONCLUSIONS:In cases of IBDI it is necessary to perform the operation under the supervision of an experienced surgeon who is specialized in the repair of bile duct injuries,and it is also necessary to detect and treat the injury as soon as possible to obtain a satisfactory outcome.

Iatrogenic bile duct injuries:Etiology,diagnosis and management

Iatrogenic bile duct injuries (IBDI) remain an important problem in gastrointestinal surgery. They are most frequently caused by laparoscopic cholecystectomy which is one of the commonest surgical procedures in the world. The early and proper diagnosis of IBDI is very important for surgeons and gastroenterologists, because unrecognized IBDI lead to serious complications such as biliary cirrhosis, hepatic failure and death. Laboratory and radiological investigations play an important role in the diagnosis of biliary injuries. There are many classifications of IBDI. The most popular and simple classification of IBDI is the Bismuth scale. Endoscopic techniques are recommended for initial treatment of IBDI. When endoscopic treatment is not effective, surgical management is considered. Different surgical reconstructions are performed in patients with IBDI. According to the literature, Roux- en-Y hepaticojejunostomy is the most frequent surgical reconstruction and recommended by most authors. In the opinion of some authors, a more physiological and equally effective type of reconstruction is end- to-end ductal anastomosis. Long term results are the most important in the assessment of the effectiveness of IBDI treatment. There are a few classifications for the long term results in patients treated for IBDI; the Terblanche scale, based on clinical biliary symptoms, is regarded as the most useful classification. Proper diagnosis and treatment of IBDI may avoid many serious complications and improve quality of life.

The Clinical Analysis of Bile Duct Injury during Laparoscopic Cholecystectomy

The study was to improve surgical safety and reduce the incidence of bile duct injury (BDI) during laparoscopic cholecystectomy. The clinical information of 31 cases with bile duct injury during Laparoscopic Cholecystectomy (LC) was analyzed retrospectively. Thirty patients with bile duct injury were divided into 5 types according to Bismuth typing, including: type I 9 cases, type II 12 cases, type III 4 cases, type IV 3 cases, type V 3 cases. After median follow-up of 48 months, 30 (97%) patients are alive and 29 (94%) remain in good general condition with normal liver function. One patient died from acute obstructive suppurative cholangitis (AOSC). One patient appeared to have pain under the xiphoid that was resolved after 3 months. Recurrent strictures following repair have developed in two (6%) patients with high injuries combined with right hepatic arterial injury. Appropriate surgical indications, handling Calot triangle carefully and correctly, and conversion to open surgery at the right moment are the keys of prevention and treatment of bile duct injury during LC.

Isolated segmental,sectoral and right hepatic bile duct injuries

The treatment of isolated segmental,sectoral and right hepatic bile duct injuries is controversial.Nineteen patients were treated over a 26-year period.Group one was comprised of 4 patients in whom the injury was primarily repaired during the original surgery;3 over a T-tube,1 with a Roux-en-Y.These patients had an uneventful recovery.The second group consisted of 5 patients in whom the duct was ligated;4 developed infection,3 of which required drainage and biliary repair.Two patients had good long-term outcomes;the third developed a late anastomotic stricture requiring further surgery.The fourth patient developed a small bile leak and pain which resolved spontaneously.The fifth patient developed complications from which he died.The third group was comprised of 4 patients referred with biliary peritonitis;all underwent drainage and lavage,and developed biliary fistulae,3 of which resolved spontaneously,1 required Roux-en-Y repair,with favorable outcomes.The fourth group consisted of 6 patients with biliary fistulae.Two patients,both with an 8-wk history of a fistula,underwent Roux-en-Y repair.Two others also underwent a Roux-en-Y repair,as their fistulae showed no signs of closure.The remaining 2 patients had spontaneous closure of their biliary fistulae.A primary repair is a reasonable alternative to ligature ofinjured duct.Patients with ligated ducts may develop complications.Infected ducts require further surgery.Patients with biliary peritonitis must be treated with drainage and lavage.There is a 50% chance that a biliary fistula will close spontaneously.In cases where the biliary fistula does not close within 6 to 8 wk,a Roux-en-Y anastomosis should be considered.

Initial management of suspected biliary injury after laparoscopic cholecystectomy

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.

Mirizzi syndrome:Problems and strategies

Mirizzi syndrome is a serious complication of gallstone disease.It is caused by the impacted stones in the gallbladder neck or cystic duct.One of the features of Mirizzi syndrome is severe inflammation or dense fibrosis at the Calot’s triangle.In our clinical practice,bile duct,branches of right hepatic artery and right portal vein clinging to gallbladder infundibulum are often observed due to gallbladder infundibulum adhered to right hepatic hilum.The intraoperative damage of branches of right hepatic artery occurs more easily than that of bile duct,all of which are hidden pitfalls for surgeons.Magnetic resonance cholangiopancreatography(MRCP)and endoscopic retrograde cholangiopancreatography(ERCP)are the preferable tools for the diagnosis of Mirizzi syndrome.Anterograde cholecystectomy in Mirizzi syndrome is easy to damage branches of right hepatic artery and bile duct due to gallbladder infundibulum adhered to right hepatic hilum.Subtotal cholecystectomy is an easy,safe and definitive approach to Mirizzi syndrome.When combined with the application of ERCP,a laparoscopic management of Mirizzi syndrome by well-trained surgeons is feasible and safe.The objective of this review was to highlight its existing problems:(1)low preoperative diagnostic rate,(2)easy to damage bile duct and branches of right hepatic artery,and(3)high concomitant gallbladder carcinoma.Meanwhile,the review aimed to discuss the possible therapeutic strategies:(1)to enhance its preoperative recognition by imaging findings,and(2)to avoid potential pitfalls during surgery.

腹腔镜胆囊切除术后胆道损伤治疗现状

虽然腹腔镜胆囊切除术(LC)已在各大医院得到普遍开展,经验技术得到不断提高,以及腹腔镜器械不断更新,但其引起的胆道损伤偶有发生。LC造成的胆道损伤是最常见的医源性胆道损伤。胆道损伤的发生机制复杂多样,其严重的后果对医患双方都造成了巨大的影响,因此临床上遇到胆道损伤应及时采取有效措施,最大程度地减轻患者痛苦。本文通过查阅近几年的相关文献,对胆道损伤治疗情况进行综述。

Biloma Post-Cholecystectomy: A Prudent “Wait-and-See” Approach

Bile duct injury (BDI) is a well-known complication of cholecystectomy and can lead to the formation of a variety of complications, including biloma. Once diagnosed, the appropriate treatment depends on the severity of the condition and can range from minimally invasive procedures to more invasive procedures. We report the case of a 31-year-old woman who exhibited postoperative bile leakage after a cholecystectomy and a CT scan revealed a left hepatic subcapsular biloma. The patient was managed conservatively with close monitoring. The biloma resolved on its own without any intervention. Bilomas are rare complication of cholecystectomy that can be managed conservatively with a wait and see approach, especially in asymptomatic patients. Close monitoring with imaging and laboratory parameters is crucial in the management of these patients.

医源性胆道损伤外科处理27例分析

目的探讨医源性胆道损伤的原因和处理原则。方法回顾性分析和总结近8年来该科收治的27例医源性胆道损伤的临床资料。结果损伤的27例中有16例是开腹胆囊切除术,11例为腹腔镜胆囊切除术(LC),其中23例发生在二级以下医院,术中发现并行胆管修补的2例,术后发现的25例中,梗阻型有18例,胆漏型2例,梗阻胆漏型5例,术后一个半月内发现再手术处理的16例,胆道损伤处理后胆道狭窄的9例,23例行胆肠内引流,其他行胆管引流术,全部患者获得随访,总体效果优良率达93%(25/27)。结论医源性胆道损伤主要集中在基层医院,胆囊切除术是造成损伤的主要手术,技术水平是重要因素,损伤后的处理需根据类型不同区别对待,良好的胆肠内引流是处理胆道损伤的主要术式。

腹腔镜胆囊切除术中胆管损伤的原因、类型和处理

目的探讨腹腔镜胆囊切除术(LC)中胆管损伤的原因、类型及处理措施。方法回顾分析本科1993年3月￣2004年7月腹腔镜胆囊切除术的临床资料。结果LC9200例中,胆管损伤11例,发生率0.12%。其中急诊LC475例,急诊率5.16%,无一胆管损伤;中转开腹193例,中转率为2.09%,中转开腹胆管损伤2例,损伤率1.05%。胆管损伤术中发现8例、术后诊断3例;胆管修补(端端吻合)+T管支撑引流6例、胆肠Roux-en-y吻合4例,腹腔穿刺+鼻胆管引流1例(ENBD);再次胆道手术1例,再手术率9.09%。结论遵循辨-切-辨手术程序是避免LC胆管损伤的关键;严格掌握LC和急诊LC的适应证,果断及时中转开腹是避免胆管损伤的重要手段;及时发现实时处理胆管损伤能有效降低胆管损伤的再手术率。

医源性胆管损伤的手术时机与手术方式的选择

目的探讨医源性胆管损伤的原因、类型、手术时机和方式。方法回顾性总结分析2002~2007年间对26例胆管损伤的诊治过程。其中腹腔镜胆囊切除术（LC）术中损伤18例,开腹胆囊切除术（OC）8例。所有胆管损伤患者均行手术治疗,分别行胆管修补术,胆管对端吻合术,胆管空肠Roux-Y吻合术,肝门部空肠Roux-Y吻合。结果胆管修复失败的主要原因为：术式选择不当,支架放置的部位或时间不合理,延期修复的时间过长或过短。结论术中发现胆管损伤者（Ⅰ~Ⅱ型）尽可能地行胆管对端吻合术。凡是不适合于胆管对端吻合术者,首选胆管空肠Roux-Y吻合术。无胆瘘或胆汁型腹膜炎存在,术中未能及时发现者,可以行延迟性手术。吻合口〈10mm应放置支架（或支撑管,另戳孔引出体外）,拔支架时间为9~12个月。

医源性胆管损伤156例的处理体会

目的 探讨医源性胆管损伤后的处理方法。方法 对 2 0年中 15 6例医源性胆管损伤病例进行回顾性分析 ,以修复后再手术作为判断疗效标准。结果 总的再手术率为 85 .71%(12 6/ 14 7) ,LC、OC、OC +胆管探查术胆管损伤修复后再手术率分别为 95 .2 4%、87.2 7%、62 .5 0 % ,三组间两两比较差异显著 (P <0 .0 5 )。再手术率与患者性别、年龄无显著关系 (P >0 .0 5 ) ,与损伤原因、修复手术时机和手术操作等因素有关。结论 胆管损伤修复术后 ,疗效较差 ,再手术率较高。修复术力争术中、术后早期 (<48h内 )或 4周后处理 ,可减少术后胆管狭窄的发生率 。

腹腔镜胆囊切除术中医源性胆道损伤的处理策略

目的:探讨腹腔镜胆囊切除术(LC)中医源性胆管损伤的诊断及处理策略。方法:回顾分析2009年1月至2018年12月19例LC导致的医源性胆管损伤患者的临床资料。按Strasberg-Bismuth胆管损伤分型,胆囊管残端漏或胆囊床小胆管漏(A型)3例(15.8%);副右肝管损伤导致胆漏(C型)2例(10.5%);肝外胆管侧壁损伤导致胆漏(D型)7例(36.8%);肝外胆管横断损伤导致胆管梗阻(E型)7例(36.8%)。术后发现并处理7例,其中行胆管空肠Roux-en-Y吻合治疗4例,行内镜鼻胆管引流、腹腔引流3例。术中发现并处理12例,其中腹腔镜胆管修补1例,腹腔镜胆管修补+T管引流3例,腹腔镜胆囊床小胆管夹闭处理2例,中转开腹行胆管空肠Roux-en-Y吻合3例,胆管端-端吻合+T管引流1例,副右肝管空肠Roux-en-Y吻合2例。结果:19例患者失访2例,随访率89.5%,术后中位随访时间49个月。1例患者经过内镜鼻胆管引流、腹腔引流后胆漏消失,但拔管后出现胆管狭窄、黄疸,于术后5个月再次行胆管空肠Roux-en-Y吻合治愈。全组均无严重并发症及死亡病例。结论:LC相关医源性胆管损伤应根据损伤发现时间、原因、部位及程度等因素进行个体化治疗,及时诊断并由经验丰富的专科医师进行确定性修复手术是改善预后的关键。

医源性胆管损伤修复后再手术原因分析及防治

目的 :探讨医源性胆管损伤修复后再手术的原因及防治 .方法 :对 2 0a中 12 9例医源性胆管损伤 ,12 0例修复后10 8例再手术患者 ,损伤部位和修复时机进行回顾性分析 .结果 :再手术率 90 %(10 8/ 12 0 ) ;再手术率与患者性别、年龄无显著关系 ;再手术率与损伤原因、损伤部位、修复时机、手术方式和手术操作等因素有关 ;腹腔镜胆囊切除术 (LC)胆管损伤修复后再手术率最高 (10 0 %) ,开腹胆囊切除术 (OC)次之(91 3 0 %)、OC +胆管探查术最低 (71 4 3 %) ,三组间相差显著 (P <0 0 5 ) ;损伤部位再手术率 :肝总管、肝门部胆管、高位胆管分别为 92 3 1%,91 67%,94 5 2 %三者无显著差异 ,而胆总管损伤再手术率最低 5 5 5 6%,与前三个部位再手术率相差非常显著 (P <0 0 1) .结论 :胆管损伤力争手术中、术后早期 (<4 8h)确诊并修复 ,短期内 (<4wk)修复应慎用 ,4wk后行近端胆管与空肠Roux y端侧 侧吻合较合适 ,并内置T管支撑 6mo以上 ,可降低术后胆管狭窄及返流性胆管炎的发生率 ,从而降低再手术率 。

医源性高位胆管损伤狭窄的处理

目的 探讨医源性高位胆管损伤后狭窄的处理方法 ,以期提高疗效、减少并发症。方法 对 2 3年中 183例医源性胆管损伤病例资料进行回顾性分析 ,以修复后再手术作为判断疗效标准。结果 183例中有 173例行不同方式修复术 ,有 14 4例因高位胆管狭窄再行 1～ 5次手术 ,再手术率 83 .2 4% ( 14 4/173 )。结论 采用狭窄以上正常胆管进行胆肠Roux Y吻合术 ,注意吻合方法和质量 ,可减少术后胆管再狭窄复发的发生率 。

医源性胆道损伤的预防及治疗措施

目的探讨医源性胆道损伤的预防和治疗措施.方法对36例医源性胆道损伤的临床资料进行回顾性分析.结果36例共施行手术41次,其中2次手术者5例.最后1次手术方式为胆管端端吻合2例,胆管壁缺损修补4例,单纯缝线拆除3例,胆管空肠Roux-en-Y吻合27例.28例随访1～8年,优良率90%.结论胆囊切除术是医源性胆道损伤的主要原因,是可以避免的.胆管空肠Roux-en-Y吻合术是医源性胆道损伤或损伤性狭窄修复重建的首选方法.