Management of bile duct injuries

The incidence of bile duct injuries increased with the wide spread shift from open to laparoscopic cholecystectomy. The estimated incidence of major bile duct injuries, which was 0.1% to 0.3% [Strasberg et al, 1995 and Roslyn et al, 1993] during the open cholecystectomy era, has risen to an estimated 0.4% to 0.6% [Fletcher et al, 1999, Adamsen et al, 1997, and Wherry et al, 1996] for laparoscopic cholecystectomy. This increase has led to substantial patient morbidity and major financial implications [Misra et al, 2004 and Savader et al, 1997]. Proper management of iatrogenic bile duct injury is mandatory to avoid immediate or later life-threatening sequelae. The results of surgery depend mainly on the type of injury, prompt detection of the injury, and timing of the surgery [Tsalis et al, 2002]. A review of our experience with bile duct injuries was performed to determine the optimal management and outcomes of patients presented with biliary tract injuries. The present study included 11 patients with cystic and/or bile duct injuries. They were collected from inpatients of Ain Shams University and Specialized Hospitals in Egypt and Al Jedani Hospitals in Saudi Arabia, between August 1999 and January 2004. They were 7 females and 4 males whose age ranged from 25 to 68 years [mean 40.5]. All patients were subjected to the following: History, Clinical Examination, Laboratory investigations, Radiological investigations [Abdominal U/S. ERCP, MRCP], Preoperative Preparation, and Operative and / or nonoperative management according to the case and type of injury. A total of II patients were treated for a bile duct injury. Eight patients presented after laparoscopic cholecystectomy [72.7%] and 3 patients after open cholecystectomy [27.3%]. The majority of patients were operated on for chronic cholecystitis [72.7%]. An intra operative diagnosis of a biliary injury was determined in 4 patients [36.4%]. Two different groups of patients can be identified according to the clinical presentation and this is mainly dependent on the time interval between the procedure, the start of the first symptoms and the detection of injury. Injury detected during laparoscopic cholecystectomy [intraoperatively]: An intra operative diagnosis of a biliary injury was determined in 4 patients [36.4%]. One patient had avulsed cystic duct and three had injury of CBD. The four patients diagnosed intra operatively with bile duct injury were treated by: Roux-en-Y choledechojejunostomy in 2 cases with CBD injuries. Direct CBD repair in one patient with CBD injury, Stitching of avulsed cystic duct in one patient. Delayed identification of a bile duct injury in the postoperative period: Seven patients [63.6%] presented with jaundice, fever, biliary peritonitis, biliary fistula, vomiting, and abdominal pain. Four of them were diagnosed as ligated common bile duct and managed surgically by Roux-en-Y hepatico-jejunostomy [36.4%]. While 3 patients [27.3%] were managed by endoscopic stenting, 2 with cystic duct leakage and 1 with lacerated right hepatic duct. Morbidity occurred in 1 patient [9.1%] in the form of wound infection. And there was one mortality case [9.1%] from biliary peritonitis. Bile duct injury represents a serious life threatening problem that represents a challenge even to the experienced biliary surgeon. Early referral to specialist center gives the best chance of long term success. Patients with bile duct injury should be investigated very thoroughly by laboratory tests radiological investigations and must be managed very carefully preoperatively by correction of the anemia and hypoalbuminemia and the clotting abnormalities. The results of this study showed that surgical exploration and hepaticojejunostomy played the main role in management of patients with ligated common bile duct. Also choledechojejunostomy or direct repair of CBD injuries was the main surgical strategy for cases diagnosed intraoperatively. Meanwhile, ERCP sphincterotomy and/or stenting played a role in management of patients with cystic duct leakage

Neoadjuvant chemotherapy using vinorelbine,epirubicin, and methotrexate [VEM] in locally advanced breast cancer

To evaluate the role of VEM regimen in downstaging patients with locally advanced breast cancer to allow surgery

Patients and Methods: Between January 2000 to January 2002, 16 patients with locally advanced breast cancer were enrolled, they received VEM regimen [Vinorelbine 25 mg/irf, epirubicin 35 mg/rrf, and methotrexate 20 mg/m" given at day 1 and 8 every 28 days]. Responding patients after 4 courses received 2 more courses and then referred to surgery

Results: Downstaging was obtained in 86% of the patients with a pathological complete response ;raite of 8%. At 3D months mf follow-up, median survival Unas not teen reached. The most common lhematoI0jpc loxicity was neutropenia grade %

Conclusion: VEM represents an effective and well tolerated regimen for patients with locally advanced breast cancer