role of surgery in the management of latrogenic bile duct injuries in the era of minimally invasive techniques

The management of postoperative bile duct strictures and major bile duct injuries remains a challenge. A multidisciplinary approach is advocated for diagnosis and appropriate management. Thirty-six patients constituted the subject of this retrospective study, conducted at Ain Shams University hospitals, Menoufyia University hospitals [Egypt] and Croix Rousse University hospital [Lyon, France] in between March 1998 and March 2003. All the patients suffered bile duct injury diagnosed in the postoperative period after a hepatobiliary operation. Overall, management pursued three paths; endoscopic, radiological or surgical or a combination of the three. Intraperitoneal bile leakage whether contained as biloma or diffuse as peritonitis can be relieved by Ultrasound-guided aspiration [USGA]. Re-laparoscopy with peritoneal toilet and drainage is another alternative. Endoscopic management in the form of ERCP sphincterotomy and stent insertion is to be carried out if the leak does not resolve. Bergman type A lesions more likely resulted in biloma formation that was successfully treated by USGA in most cases. For patients with Bergman type B lesions resulting in external biliary fistula, surgical intervention is indicated to repair the underlying bile duct injury with bilio-enteric bypass. For minimally invasive techniques, the failure rate was 23.5% for the radiological approach [4/17] and 33.3% [5/15] for the endoscopic approach. Failure of the biliary-enteric bypass occurred in 7 out of 22 bypasses [31.9%] done in 16 patients. Five patients underwent multiple anastomoses. Bypass surgery was the most appropriate management adopted in the presence of complete CBD division. We may be able to draw the conclusion that the higher the lesion the less likely the Endoscopic Approach meets success. Major bile duct injuries can be managed successfully by combined surgical and radiological techniques. A minimally invasive approach could be pursued for the management of postoperative bile duct injuries as long as the general condition of the patient permits and in the absence of complete CBD division. High bile duct lesions more likely require surgical correction. Of all the bypass procedures, hepatico-jejunostomy performed under optimal conditions by an experienced surgeon yields the best results

Preoperative versus postoperative 5 FU-based chemoradiation in the management of resectable rectal carcinoma

Forty-eight patients with resectable rectal carcinoma [stages II and III] were randomized to receive either preoperative concomitant 2 cycles of 5-FU/LV and pelvic radiation followed 4-6 weeks later by surgery then additional 4 cycles of the same chemotherapy [group A = 23 patients] or the standard surgical procedure to be followed by 6 cycles of 5-FU/LV and concomitant pelvic irradiation during cycle 3 and 4 [group B = 25 patients]. In preoperative group, objective response was seen in 47.8% of patients 4 weeks after chemoradiation. The remaining patients had stable disease. Ten patients [43.5%] and 16 patients [64%] in preoperative group and postoperative group, respectively, underwent abdominoperineal resection [APR]; while 13 patients [56.5%] in preoperative group and 9 patients [36%] in postoperative group underwent sphincter saving surgery. Seven out of 17 patients [41%] in preoperative group who were initially candidates for APR saved their anal sphincter after preoperative chemoradiation, 85.7% of these patients had excellent to good sphincter function. No pathologic complete response had been recorded. Hematologic grade 3+ toxicity was recorded in 17.4% of patients in preoperative group and in 28% in postoperative group. Grade 3+ diarrhea was recorded in 17.4% in preoperative group and in 20% of patients in postoperative group. The differences were not statistically significant. Eight patients [34.8%] in preoperative group and 9 patients [36%] in postoperative group had one or more components of failure. The difference was not statistically significant. The 2-year overall survival was 69.6% in preoperative group and 72% in postoperative group. The 2-year disease free survival was 65.2% in preoperative group and 64% in postoperative group. The differences in survival and disease free survival between the two groups were not statistically significant. The study concluded that treatment with preoperative combined modality therapy, followed by surgery and postoperative chemotherapy in resectable rectal carcinoma is an attractive alternative to the standard postoperative combined modality therapy. The local control, survival rates and toxicity are comparable to postoperative combined modality therapy. Preoperative chemoradiation offers an additional potential advantage of sphincter preservation. This work needs to be confirmed on a larger number of patients with longer follow up