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RESUMEN: Las lesiones iatrogénicas de las vías biliares (LIVB), en el curso de una colecistectomía laparoscópica (CL), son complicaciones que causan resultados inesperados para cirujanos un incremento en los riesgos de los pacientes (morbilidad y mortalidad), afectando su calidad de vida. Asimismo, causan situaciones difíciles desde el punto de vista técnico para el cirujano que debe repararlas desde un punto de vista técnico. El objetivo de este manuscrito fue resumir la información referente a las LIVB y describir su morfología y opciones diagnóstico-terapéuticas.
SUMMARY: Iatrogenic Bile duct injuries (IBDI), during laparoscopic cholecystectomy (CL), are complications that cause unexpected results for surgeons, an increment in patient risks (morbidity and mortality), and affect the patient´s quality of life. At the same time, they create difficult situations for the repairing surgeon from a technical point of view. The aim of this manuscript was to summarize the information regarding IBDI and to describe its morphology and diagnostic-therapeutic options.
Subject(s)
Humans , Wounds and Injuries/etiology , Bile Ducts/pathology , Cholecystectomy, Laparoscopic/adverse effects , Wounds and Injuries/classification , Wounds and Injuries/diagnosis , Wounds and Injuries/therapy , Bile Ducts/injuries , Risk Factors , Iatrogenic DiseaseABSTRACT
Proper timing of repair is one of key factors predicting long-term prognosis of iatrogenic biliary injury.Local inflammation is proved related to long-term biliary stricture.This article introduces pathological procedure of biliary injury based on pathophysiological mechanism and animal model rescarch of wound healing,and how to increase intraoperative repair rate based on the clinical evidences.The preoperative active inflammation control and systemic management could create necessary conditions for the the subsequent early repair.At the same time,authors suggest to set individual strategy regarding timing of repair.Delayed repair is recommended for combined vascular injury or severe biliary injury with terrible contamination.
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Objective To investigate the effective strategies to prevent and treat biliary complications after orthotopic liver transplantation.Methods The clinical data of 316 patients who received orthotopic liver transplantation at the Fuzhou General Hospital of Nanjing Military Command from November 2001 to March 2012 were retrospectively analyzed.Cold perfusion with HTK + UW solution was applied when obtaining the liver graft,and then the liver graft was preserved in the UW solution.The bile duct was perfused with UW solution thereafter.Orthotopic liver transplantation or piggyback liver transplantation were adopted in the cadaver liver transplantation.Left liver transplantation and right liver transplantation were adopted in the living donor liver transplantation.Choledochojejunal Roux-en-Y anastomosis or duct-to-duct choledochostomy were used for biliary reconstruction.Ordinary T tubes were used for drainage before 2006,and then 6 F pediatric suction catheter or epidural catheter were applied for drainage thereafter.The Ttube was pulled out 3-6 months after the operation.Enteral nutrition was applied to patients at the early phase after operation.The immunosuppressive agents used including tacrolimus + mycophenolatemofetil + adrenal cortical hormone,and for some patients,tacrolimus + mycophenolatemofetil + sirolimus + hormone were used.Patients were followed up for 2 years to learn the incidence of biliary complications and guide the medication.The difference in the incidence of bile leakage between patients who wcrc admitted before 2006 and those admitted after 2006 were compared using the chi-square test.Results The warm ischemia time was 2-6 minutes,and the cold ischemia time was 3-10 hours.For patients who received cadaver liver transplantation,orthotopic liver transplantation was carried out for 291 times and piggyback liver transplantation for 24 times; biliojejunal Roux-en-Y anastomosis was carried out for 5 times and bile duct end-to-end anastomosis for 310 times.For patients who received living donor liver transplantation,1 received left liver transplantation and 1 received right liver transplantation,and they received bile duct end-to-end anastomosis.A total of 311 patients received immunosuppressive treatment with tacrolimus + mycophenolatemofetil + adrenal cortical hormone,and 5 patients reveived tacrolimus + mycophenolatemofetil + sirolimus + hormone.Of the 316 patients who received orthotopic liver transplantation,38 had biliary complications after the operation,including bile leakage in 18 patients,intra-and extra-hepatic bile duct stricture in 6 patients,anastomotic stricture in 6 patients,biliarycomplications included cholangitis in the portal area and cholestasis in 4 patients,choledocholithiasis and cholangitis in 2 patients and biliary infection in 2 patients.The incidence of bile leakage before 2006 was 14.00％ (7/50),which was significantly higher than 4.12％ (11/267) of bile leakage after 2006 (x2-7.676,P ＜ 0.05).Of the 38 patients with biliary complications,the condition of 35 patients was improved,and 3 patients died.Of the 18 patients with bile leakage,15 was cured by conservative treatment,3 received surgical treatment (the condition of 1 patient was improved by drainage,anti-infection treatment and nutritional support,but died of peritoneal hemorrhage at postoperative 1 month; 2 patients received peritoneal drainage,1 was cured and 1 died of peritoneal infection).For the 6 patients with intra-and extra-hepatic bile duct stricture,1 was cured by liver retransplantation and 5 were cured by conservative treatment,endoscopic retrograde cholangio-pancreatography (ERCP) or balloon dilation.For the 6 patients with anastomotic stricture,the condition of 3 patients was improved by conservative treatment,balloon dilation or stent implantation,1 gave up treatment due to hepatic cancer recurrence and died thereafter,1 received anastomosis + T tube drainage,1 was cured by recurrent tumor resection and choledochojejunostomy.Four patients with cholangitis in the portal area and cholestasis were cured by conservative treatment.For the 2 patients with choledocholithiasis and cholangitis,1 was cured by stent implantation with ERCP,and 1 received conservative treatment,and the level of total bilirubin was decreased.Two patients with biliary infection were cured by anti-infection treatment.Conclusions Most of the biliary complications could be treated by non-surgical treatments.For patients with severe biliary complications or those could not be treated by non-surgical treatment,re-exploration of the bile duct is effective.Liver re-transplantation is the only choice for patients with dysfunction of liver graft caused by severe ischemic biliary injury.
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We report a case of bile fistula after cholecystectomy in a patient with severe right liver atrophy, which was managed by endoscopic nasobiliary drainage and conservative treatment. The patient was a 76-year-old man with a sudden onset in the right flank and abdominal pain. Computed tomography revealed calculous cholecystitis and severely atrophied right lobe of the liver. Gallbladder was located in the superior-posterior portion of the liver as opposed to the normal position. The patient underwent cholecystectomy and showed massive bleeding and bile leakage at the gallbladder bed during operation. A bile fistula was detected three days after surgery, which was managed by interventional bile drainage. Right liver agenesis or severe atrophy is rare. Additionally, the report of combined bile duct injury after cholecystectomy in these settings is extremely rare.
Subject(s)
Humans , Abdominal Pain , Atrophy , Bile , Bile Ducts , Cholecystectomy , Cholecystitis , Drainage , Fistula , Gallbladder , Hemorrhage , LiverABSTRACT
Iatrogenic traumatic biliary stricture is one of the difficult points in the biliary surgery,and operation is the only definitive treatment. The operative opportunity,surgical procedure and techniques are important for the prognosis.From January 1998 to December 2011,173 patients with iatrogenic traumatic stricture were admitted to the Eastern Hepatobiliary Surgery Hospital. According to the Bismuth classification of traumatic biliary stricture,10 patients were in type Ⅰ,22 in type Ⅱ,87 in type Ⅲ,38 in type Ⅳ and 16 in type Ⅴ.Excision of the traumatic stricture with end-to-end anastomosis was performed on 19 patients.Of the 173 patients,154 were treated by Roux-en-Y duodenojejunostomy, and 8 of them received additional hemihepatectomy or partial hepatectomy.A total of 155patients were followed up,with a median time of 74 months,the total excellent and good rate was 94.8％ ( 147/155 ).Surgery is the most effective therapy for iatrogenic traumatic biliary stricture. Optimal timing, reasonable surgical methods, strictly following the principle of biliary surgery and perfect operative skills are key points for a better prognosis.
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Biliary stricture after cholecystectomy poses difficult management problems to surgeons because of high and stable incidence.In contrast to malignant stricture,benign stricture requires durable repair.Repeated operations may not only increase the suffering of the patient,but also reduce the likelihood of a better outcome. A 56-year-old woman with biliary stricture after cholecystectomy who had undergone several operations in other hospitals was admitted to Chinese PLA General Hospital.Computed tomography (CT) scan showed a dilated biliary tree and localized the level of ductal obstruction in the hepatic hilar stricture.In addition,CT identified fluid collections in the left upper quadrant and no artery injury was detected. Ultrasound-guided percutaneous abdominal drainage was performed to control the abdominal infection. Magnetic resonance cholangiopancreatography classified the injury as Bismuth Ⅲ.The patient with bile leakage and severe abdominal infection was treated with antibiotics before the final operation.On June 1,2012,the patient received Roux-en-Y hepaticojejunostomy.After operation,the patient recovered smoothly without severe complications,such as bile leakage,cholangitis and recurrent stricture.Liver function of the patient was back to normal and T tube drainage was pulled out at the end of 3 months of follow up.
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Objective To explore the effective molecular mechanism of PPAR-γligands rosiglitazone to biliary ischemia-reperfusion injury in autologous liver transplantation. Method A total of 40 SD rats were randomly (random number) divided into sham operation group (SO), ischemia - reperfusion group (Ⅰ/R), rosiglitazone (ROS) and GW9662 group, with 10 ones in each. The models, rat biliary ischemiareperfusion injury of autologous liver transplantation, were made by modified two-cuff technique. Tissues of the liver and bile ducts and blood of those models were evaluated by pathological and biochemical methods to make sure the models were made successfully or not. SO group suffered autologous orthotopic liver transplantation, and L/R group suffered both that and ischemia-reperfusion. ROS group were injected rosiglitazone (0.3mg/kg) via portal vein after having been done all as I/R. GW9662 group suffered all as ROS, and 10min later ,they were injected GW9662(0.3mg/kg) via portal vein. 4h after the experiment, tissues of livers and bilary ducts were taken to be tested by immunohistochemistry method, and the blood punctured from the right ventricular were taken to be determined by ELISA. ANOVA was used for statistical analysis.Results IL-1β, TNF-α and IL-6 were mainly expressed in the cytoplasm of hepatocytes and bile duct cells,while NF-κB was expressed both in the cytoplasm and nuclei. Expression of those proteins in L/R and GW9662 group was increased, significantly higher when compared to the SO and ROS (P ＜ 0.05). IL-1β,TNF-α and IL-6 in rat serum were simultaneously increased, and significantly higher than SO(P ＜0.05).Compared with the SO, expressions of the IL-1 β,TNF-α and IL-6 were not significantly changed in ROS (P＞ 0.05 )but significantly increased in GW9662. Conclusions PPAR-γ ligand rosiglitazone took protective role in biliary ischemia-reperfusion injury in autologous liver transplantation. The mechanism correlates with the release of the IL-lα, IL-1β and TNF-α and other inflammatory mediators, which decreased as the expression of NF-κB inhibited by its antagonist.
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Objective To study the effect of applying gastro-bile duct drainage in iatrogentic injury in the bile duct and reasons of iatrogentic injury in the bile duct. Methods Clinical data of 9 cases with iatrogentic injury in the bile duct were studied retrospectively. Results Nine patients with iatrogentic injury in the bile duct were found in time by affnsion examination, choledochoendoscopy or cholangiography intraoperation, including 5 cases in-jured by metal divining rod,2 cases caused by lithotomy, 1 case injured by laparoscopic elastic separating plier and 1 case injured by common hepatic duct transection. The gastro-bile duct was placed into common bile duct through pa-pilla of duodenum, pylorus and the former wall of gastric. All the cases recovered smoothly. The gastro-bile duct was removed in 8 cases in 6 to 10 days later,in 1 cases in 30 days later,who were followed up for 9 months to 5 years, finding no complications such as stricture of bile duct and retroperitoneal infection. Conclusions Intraoperative cho-ledochoendoacopy,affusion examination and cholangiography are helpful to diagnosis. The better results are achieved by appling gastro-bile duct drainage in iatrogentic injury in the bile duct.
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Objective To assess the surgical treatment of iatrogenic biliary strictures. Methods The clinical data of 235 patients with iatrogenic biliary injuries and strictures who had been admitted to our hospital from January 1989 to December 2006 were reviewed retrospectively. Cholangio-jejunal Roux-en-Y anastomosis (n=182), surgical repair with pediele flap of autogenous tissues (n=34), end-to-end choledocho-choledo-chostomy (n= 12), common bile duct incision and figuration +T-tube drainage ( n =6) and liver transplanta-tion ( n = 1 ) were applied to the patients. Results A total of 189 patients were followed up for 1 to 10 years. The total excellent and good rate was 94.7% (179/189). The recurrence rate of the biliary stricture was 5.3% (10/189), and the main cause of which were biliary cirrhosis, selerosing cholangitis and calculus. One patient with severe biliary cirrhosis and portal hypertension died of liver failure postoperatively. Conclusions The cholangio-jejunal Roux-en-Y anastomosis is a reliable and effective method. Surgical repair of the bile duet with pedicle flap of autogenous tissues could preserve the function of the sphincter of Oddi, but the long-term effect needs further investigation. Biliary stent is not usually necessary to install. Liver transplantation is efficient for the patients with end stage of biliary diseases caused by biliary stricture.