Development of a biodegradable prosthesis through tissue engineering, for the organ-replacement or substitution of the extrahepatic bile duct.

INTRODUCTION AND OBJECTIVES: There are different situations in which an extrahepatic bile duct replacement or substitute is needed, such as initial and localized stages of bile duct cancer, agenesis, stenosis, or bile duct disruption. MATERIALS AND METHODS: A prosthesis obtained by electrospinning composed of Poly (D,L-lactide-co-glycolide) (PGLA) - Polycaprolactone (PCL) - Gelatin (Gel) was developed, mechanical and biological tests were carried out to evaluate resistance to tension, biocompatibility, biodegradability, cytotoxicity, morphological analysis and cell culture. The obtained prosthesis was placed in the extrahepatic bile duct of 15 pigs with a 2-year follow-up. Liver function tests and cholangioscopy were evaluated during follow-up. RESULTS: Mechanical and biological evaluations indicate that this scaffold is biocompatible and biodegradable. The prosthesis implanted in the experimental model allowed cell adhesion, migration, and proliferation, maintaining bile duct permeability without altering liver function tests. Immunohistochemical analysis indicates the presence of biliary epithelium. CONCLUSIONS: A tubular scaffold composed of electrospun PGLA-PCL-Gel nanofibers was used for the first time to replace the extrahepatic bile duct in pigs. Mechanical and biological evaluations indicate that this scaffold is biocompatible and biodegradable, making it an excellent candidate for use in bile ducts and potentially in other tissue engineering applications.

Clinical value of preferred endoscopic ultrasound-guided antegrade surgery in the treatment of extrahepatic bile duct malignant obstruction.

OBJECTIVES: To explore the clinical value of preferred ultrasound endoscopic guided biliary drainage in patients with extrahepatic biliary obstruction with intrahepatic biliary ectasis. METHODS: A total of 58 patients with malignant obstruction and intrahepatic bile duct expansion, including 32 males, 26 females and median age 65 (58‒81) were selected. A prospective randomized controlled study was randomized into EUS-AG and ERCP-BD, with 28 patients in EUS-AG and 30 in ERCP-BD. The efficacy of the two treatments, operation success rate, operation time, the incidence of complications, hospitalization days, cost, unimpeded stent duration, and survival time were compared. RESULTS: 1) The surgical success rate in group EUS-AG was 100%, and in group, ERCP-BD was 96.67%. There was no statistical difference in surgical success rate in the two groups (p>0.05). 2) Average operating time in EUS-AG was (23.69±11.57) min, and in ERCP-BD was (36.75±17.69) min. The difference between the two groups has statistical significance (p<0.05). 3) The clinical symptoms of successful patients were significantly relieved. Compared with the preoperative procedure, the differences in group levels had statistical significance (p<0.05); TBIL, ALP, WBC and CRP levels, no statistical significance difference in groups (p>0.05). CONCLUSION: EUS-AG operation has short time, low incidence of complications, safe, effective, and can be used as the preferred treatment plan for patients with extrahepatic biliary duct malignant obstruction associated with intrahepatic biliary duct expansion; EUS-AG operation has more unique clinical advantages for patients with altered gastrointestinal anatomy or upper gastrointestinal obstruction.

Dilataciones quísticas congénitas de las vías biliares (segunda parte). Vías biliares extrahepáticas / Congenital bile duct cystic dilatations (part 2). Extrahepatic bile ducts

RESUMEN Las dilataciones quísticas congénitas de la vía biliar extrahepática son infrecuentes, principalmente en Occidente, y afectan sobre todo a niños pero son poco comunes en adultos. El diagnóstico requiere un alto índice de sospecha y suele llevarse a cabo con estudios colangiográficos de los cuales la CRMN es, en la actualidad, el de mayor utilidad. Es conocido el aumento de malignización de estas dilataciones, por lo que el tratamiento completo de la bolsa quística es obligatorio.

ABSTRACT Congenital dilatation of extrahepatic bile ducts is rare in the Western countries and is more common in children than in adults. The diagnosis requires high level of suspicion and is made by cholangiography tests, among which MRCP is the most useful nowadays. Malignant transformation of these cystic dilatations is well-known; therefore, complete resection of the cystic pouch is mandatory.

Hepatectomía derecha asociada a resección de la confluencia de la vía biliar por cáncer de vesícula biliar: presentación de un caso clínico / Right hepatectomy in block with hiliar extra hepatic bile duct for gallbladder cancer: clinical case

El cáncer de vesícula biliar es la neoplasia maligna más común del tracto biliar. Suele presentarse en estadios clínicos avanzados. El tratamiento quirúrgico ha ido evolucionando y en la actualidad equipos dedicados pueden realizar resecciones multiorgánicas extensas y complejas en el afán de lograr resecciones R0 (no enfermedad residual), que podrían ofrecer a los pacientes la posibilidad de curación. En el presente reporte se describe el caso de una paciente con cáncer de vesícula estadio clínico IV, la cual fue sometida a hepatectomía derecha ampliada a segmento IV B en bloque con la confluencia de la vía biliar, lográndose una resección R0

Gallbladder cancer is the most common malignancy of the biliary tract. Usually seen in advanced stages. There are still many controversies about the type of curative surgical treatment for each stage of the disease. The only chance of long term survival for patients with advanced tumors is aggressive, large surgeries that implies multiorgan resection.We report the case of a patient with gallbladder cancer with jaundice at diagnosis, who underwent extended hepatectomy (segment IV B, segment I and extra hepatic hilar bile duct included)

[Right hepatectomy in block with hiliar extra hepatic bile duct for gallbladder cancer: clinical case]. / Hepatectomía derecha asociada a resección de la confluencia de la vía biliar por cáncer de vesícula biliar: presentación de un caso clínico.

Gallbladder cancer is the most common malignancy of the biliary tract. Usually seen in advanced stages. There are still many controversies about the type of curative surgical treatment for each stage of the disease. The only chance of long term survival for patients with advanced tumors is aggressive, large surgeries that implies multiorgan resection.We report the case of a patient with gallbladder cancer with jaundice at diagnosis, who underwent extended hepatectomy (segment IV B, segment I and extra hepatic hilar bile duct included).

[Syncrhonous carcinosarcoma of the extrahepatic bile duct and gallbladder.] / Carcinosarcoma sincrónico de la vesícula y la via biliar extrahepática.

Carcinosarcoma is a malignant neoplasm characterized for intermingled epithelial and mesenchymal components. CASE REPORT: A preoperative suspected diagnosis will allow a radical therapy avoiding a very bad prognosis. We report on a male patient who was operated in our Service with diagnosis of synchronous carcinosarcoma of gallbladder and extrahepatic bile duct and a review of the Medical Literature. DISCUSSION: A gallblader carcinosarcoma showing extension into common bile duct is very rare, a carcinosarcoma of the bile duct is exceptional, and a synchronous carcinosarcoma ofthe bile duct and gallbladder has not been reported previously.

Outcomes of choledochal cysts with or without intrahepatic involvement in children after extrahepatic cyst excision and Roux-en-Y hepaticojejunostomy.

BACKGROUND: Type I and type IV-A choledochal cysts (CC) in Todani's classification are the most frequent types of CC. Unlike type I cyst, in which the dilatation is confined to the extrahepatic bile duct, type IV-A affects both extra and intrahepatic ducts. AIM: To review our experience of complete cyst excision with Roux-en-Y hepaticojejunostomy for the treatment of type I and type IV-A CC in childhood, in order to better characterize these entities. MATERIAL AND METHODS: Data was collected retrospectively from a cohort of children who underwent cyst resection for CC from 1989 to 2011 in our institution. RESULTS: Twelve patients were submitted to surgical excision of extrahepatic cyst and hepaticojejunostomy for treatment of type I (n = 6) and type IV-A (n = 6) cysts, with a complication rate of 25% (n = 3) and no mortality. Long term follow-up was available in 92% of patients, with a median of 10 years (2-22 years). Morbidities consisted of bile leak (2 patients) and late-onset cholestasis (1 patient); two of these required anastomotic revision. The results did not reveal any significant differences between the groups regarding postoperative outcomes (P > 0.05). Preoperative intrahepatic dilatation was found to permanently vanish in 83% of patients diagnosed with type IV-A cyst after operative repair. CONCLUSIONS: Intrahepatic dilatation of type IV-A cyst in children did not adversely affect the postoperative outcome after conventional surgical repair. This operative approach was effective in the management of type I and type IV-A cysts.

Right trisectionectomy with principle en bloc portal vein resection for right-sided hilar cholangiocarcinoma: no-touch technique.

BACKGROUND: The most favorable long-term survival rate for hilar cholangiocarcinoma is achieved by a R0 resection. A surgical concept involving a no-touch technique, with extended right hepatic resections and principle en bloc portal vein resection was described by Neuhaus et al. According to Neuhaus et al., their technique may increase the chance of R0, because the right branch of the portal vein and hepatic artery is in close contact with the tumor and is frequently infiltrated. The left artery runs on the left margin of the hilum and often is free. The 5-year survival rate for their patients is 61% but 60-day mortality rate is 8%. Given the increased morbidity, some authors do not agree with routine resection of portal vein and may perform the resection of portal vein only on demand, after intraoperative assessment and confirmation of portal vein invasion. This video shows en bloc resection of extrahepatic bile ducts, portal vein bifurcation, and right hepatic artery, together with extended right trisectionectomy (removal of segments 1, 4, 5, 6, 7, and 8). METHODS: A 75-year-old man with progressive jaundice due to right-sided hilar cholangiocarcinoma underwent percutaneous biliary drainage with metallic stents for palliation. The patient was referred for a second opinion. Serum bilirubin levels were normal, and CT scan showed a resectable tumor, but volumetry showed a small left liver remnant. Right portal vein embolization was then performed, and CT scan performed after 4 weeks showed adequate compensatory hypertrophy of the future liver remnant (segments 2 and 3). Surgical decision was to perform a right trisectionectomy with en bloc portal vein and bile duct resection using the no-touch technique. RESULTS: The operation began with hilar lymphadenectomy. The common bile duct is sectioned. Right hepatic artery is ligated. Left hepatic artery is encircled. Portal vein is dissected and encircled. Right liver is mobilized and detached from retrohepatic vena cava. Right and middle hepatic veins are divided. A right trisectionectomy along with segment 1 is performed, leaving specimen attached only by the portal vein. Portal vein is severed above and below the tumor, and specimen is removed. Portal vein anastomosis is done end-to-end with 6-0 Prolene. Doppler confirms normal portal flow. The procedure ends with Roux-Y hepaticojejunostomy. The patient recovered uneventfully, without transfusion, and was discharged on the tenth postoperative day. Final pathology confirmed hilar cholangiocarcinoma and R0 resection. Portal vein showed microscopic invasion. Patient is well with no evidence of the disease 14 months after the procedure. CONCLUSIONS: Right trisectionectomy with en bloc portal vein and bile duct resection is feasible and may enhance chance for R0 resection and a better late outcome, especially in cases when portal vein is microscopically involved. Although described in 1999, there are few detailed descriptions of this procedure, and to the best of our knowledge, no multimedia articles are available. This video may help oncological surgeons to perform and standardize this challenging procedure.

Ictericia obstructiva secundaria a tumor de células granulares de la vía biliar extrahepática / Obstuctive jaundice secondary to extrahepatic bile ducts granular cell tumor

Bile ducts granular cell tumor is a rare entity. Of neural origin, mostly benign, may, however, present mimicking malignancy. We report a 32 years old female presenting with painless jaundice and extrahepatic bile ducts stenosis confirmed with MRC. Extrahepatic bile ducts resection is performed. Reconstruction involves four independent ducts to a Roux en Y enteric loop. She has a good postoperative outcome, with no evidence of complications nor recurrence at 17 months of follow up.

El tumor de células granulares en la vía biliar es una neoplasia rara de origen neural, en su mayoría benigna y cuya presentación puede sugerir patología maligna. Objetivo: Se presenta el caso clínico, características anatomopatológicas, manejo y evolución de una paciente joven que se presenta con ictericia obstructiva por estenosis subcarinal biliar. Paciente y Método: Paciente 32 años, sexo femenino, con ictericia, coluria y prurito. Diagnóstico de estenosis biliar y dilatación de vía biliar intrahepática se confirma con colangiorresonancia magnética. Se realiza resección de vía biliar extrahepática desde supracarinal que incluye vía biliar distal. Reconstitución bilioentérica a Y de Roux que involucra cuatro conductos intrahepáticos. Evoluciona en forma satisfactoria en el postoperatorio. El seguimiento alejado a 17 meses revela una satisfactoria condición de la paciente, sin signos de complicación o recidiva. Conclusión: El manejo por un equipo de experiencia multidisciplinario nos permitió ayudar a una paciente con rara patología, benigna en lo histológico, pero que puede representar un gran desafío técnico.

Antegrade papillary balloon dilation for extrahepatic bile duct stone clearance: lessons learned from treating 300 patients.

PURPOSE: To report the authors' experience with percutaneous papillary balloon dilation for extrahepatic bile duct stone clearance to the duodenum in 300 patients. MATERIALS AND METHODS: During a 16-year period, 300 patients with extrahepatic bile duct stones who underwent papillary balloon dilation were retrospectively evaluated. Two hundred eighty-six patients with retained extrahepatic bile duct stones were treated through a postoperative drain placed during cholecystectomy; 245 patients were treated through a T-tube route and 41 through a transcystic approach. In the remaining 14 patients, the procedure was performed through a newly created percutaneous transhepatic route. Success rates, technical features, reasons for failure, and complications were evaluated. RESULTS: Biliary duct stone removal after papillary dilation was successful in 288 patients (96%). In 244 patients, the procedure was successfully completed on the first attempt. Forty-three patients needed two sessions, and in one patient it took three sessions. Stone diameters ranged from 4 mm to 18 mm (mean, 8 mm). Two hundred fourteen patients had four or fewer stones (mean, 2.3), and 86 patients had more than four (mean, 8.8; range, 5-25). Two patients required surgical intervention after loss of transcystic drainage, with subsequent development of peritonitis. During the follow-up period (mean, 26.6 months), no clinical or laboratory abnormalities were observed. CONCLUSIONS: Percutaneous antegrade papillary balloon dilation and stone clearance is a safe and effective tool in removing common bile duct stones. Some technical issues should be considered to achieve complete stone removal while minimizing the incidence of complications.

Monopolar electrosurgery on the extrahepatic bile ducts during laparoscopic cholecystectomy: an experimental controlled trial.

INTRODUCTION: The purpose of this study is to investigate the occurrence of thermal injury in the extrahepatic bile ducts when monopolar electrosurgery is used to perform dieresis of the cystic duct and cystic vessels in laparoscopic cholecystectomy. METHODS: Female pigs (n=40) of the Large White breed were separated into 2 groups of 20 animals. In the experimental groups, dieresis of the cystic duct and cystic vessels was performed with monopolar electrosurgery using a hook-like dissector using a power setting of 20 W, whereas in the control group this procedure was performed with a pair of Metzenbaum scissors disconnected from any kind of thermal energy source. Occurrence of distal thermal injury was evaluated on 2 occasions, on the 3rd and 28th days postoperatively. It consisted of exploratory laparotomy, cholangiography and both macroscopic and microscopic examination of the surgical specimen, which included cystic duct stump, hepatic duct and choledochus. RESULTS: The presence of distal thermal injury, classified as second degree, 1.2 mm in the portion near the clipping area, was observed in only one of the cystic duct stumps after microscopic examination, without statistical significance. No thermal injury was observed in the extrahepatic bile ducts. CONCLUSIONS: Monopolar electrosurgery produced negligible thermal injury in the extrahepatic bile ducts after laparoscopic cholecystectomy.

Colecistectomía Laparoscópica: resultados de seis años en el Hospital "Sor Juana Inés de la Cruz", Mérida / Laparoscopic cholecystectomy: results of six years in the Hospital \"Sor Juana Inés de la Cruz\", Mérida

Informar los resultados de un estudio de 262 pacientes de colecistectomía por video-laparoscópica. El presente trabajo expone los resultados de la experiencia de la colecistectomía laparoscópica durante siete años. Se realizó un estudio retrospectivo de las historias médicas de todos aquellos pacientes sometidos a colecistectomía laparoscópica a partir del 1 de Mayo de 1996 hasta el 31 de diciembre de 2002. Se realizó un total de 262 colecistectomías, con un predominio de pacientes del sexo femenino con un (80.92 por ciento), la edad promedio fue de 42 años. Las indicaciones quirurgicas fueron: colecistitis crónica litiásica (93.13 por ciento), colecistitis aguda (3.44 por ciento), colecistopatía alitiásica sintomática (0.76 por ciento) y pólipos vesiculares (2.67 por ciento). Hubo 33 casos de conversión a cirugía abierta para un (12.59 por ciento) y 2 casos de lesión de vía biliar extrahepática para un (0.76 por ciento). Las principales causas de conversión fueron: dificultad en la disección, anomalías anatómicas, sangrado transoperatorio y lesión de vía biliar. Se presentaron 33 complicaciones (12.59 por ciento), de las cuales 18 son transoperatorias y 15 postoperatorias. El promedio de estancia hospitalaria fue 58.78 por ciento, con menos de 48 horas siguientes al procedimiento quirúrgico. El tiempo quirúrgico promedio fue de 75 minutos. Hospital Sor Juana Inés de la Cruz en Mérida-Venezuela. La colecistectomía laparoscópica es un procedimiento seguro, confiable en manos experimentadas, que puede realizarse con seguridad en colecistopatía litiásica, sin embargo, dicho procedimiento no está exento de complicaciones, lo cual requiera convertir el procedimiento a cirugía abierta. Es importante que el cirujano este capacitado para resolver estas complicaciones, e igualmente en el momento oportuno decidir a conversión. Colecistectomía laparoscópica, litiasis vasicular, complicaciones quirúrgicas.

[Bile duct laparoscopic exploration]. / Exploración laparoscópica de vías biliares.

The use of ERCP with endoscopic esphincterotomy (ES) for the management of choledocholithiasis has replaced almost completely common bile duct exploration in the era of laparoscopic cholecystectomy. Once the procedure is completed it is followed by laparoscopic cholecystectomy in the same hospitalization. During the last few years, the development of new technology and equipment with possibilities of minimal invasive procedures and diagnosis, as well as the ongoing surgical skills has allowed surgeons to solve the problem of choledocholithiasis in one minimal invasive procedure, decreasing effectively morbidity with a high success rate, changing again ERCP with ES as a complement and not as a substitute for surgery. Nevertheless the initial step in the use of these techniques require of a special technical support and what is most important capacitation to achieve the desire objectives. Transcystic technique seems to be the most promising and choledochotomy with primary closure in cases that cannot be solved with the transcystic approach. Regardless of the approach the surgeon must be familiar with both and increasingly with the use of the endoscope in order to provide patients with advantages of minimal invasive surgery and all its advantages. We also discuss our series of 81 patients operated on with laparoscopic surgery with a high rate of success, low morbidity and mortality.

Variaciones anatómicas del conducto cístico / Anatomic variations of the cystic duct

Las intervenciones quirúrgicas de la zona hepatoboliar, conllevan, además de los riesgos inherentes a toda cirugía mayor, la complejidad estructural y la presencia de anomalías de dicha zona. En el presente trabajo sobre la descripción de las variaciones anatómicas del conducto cístico, se estudiaron 50 cadáveres de adultos (Material Cadavérico) y 50 Colecistopancreatografías Retrógradas Endoscópicas de adulto (Material Radiológico). Basándonos en las características específicas: diámetro externo distal, longitud y número de conductos, forma, sitio y nivel de unión hepatocística, obtuvimos los siguientes resultados Material Cadavérico diametro externo distal, 3 a4 mm (56 por ciento); presencia de un solo conducto (92 por ciento); longitud máxima, 13 a 18 mm (26 por ciento); forma de unión angular (72 por ciento); sitio de implantacion hepatocística, cara derecha del Conducto Hepático Común (84 por ciento); nivel alto (90 por ciento). Material Radiológico diámetro externo distal, 3 a 4 mm; un solo conducto (100 por ciento); longitud máxima, 6 a 12 mm; forma de unión angular (68 por ciento); sitio de implantación hepatocística, cara derecha del Conducto Hepático Común (76 por ciento); nivel alto (84 por ciento). Con tales resultados se recomienda al cirujano, tener un amplio conocimiento de la anatomía de la zona hepatobiliar y suficiente experiencia práctica, para evitar y prevenir posibles complicaciones pre y postoperatorias, que redundarán en beneficio de él y sus pacientes.

Lesiones quirúrgicas de la vía biliar secundarias a colecistectomía laparoscópica: encuesta nacional / Major biliary injuries following laparoscopic cholecystectomy

Se presentan 117 lesiones de la vía biliar principal provocadas en el curso de la cirugía videoasistida reparadas por 42 cirujanos encuestados, ya fuera por ellos mismos o en el centro en que actúan. Se hace mención que en la bibliografía argentina es escaso el número de lesiones del hepatocolédoco durante cirugía laparoscópica. Se afirma, en base a ello, que las estadísticas nacionales no son confiables en lo que se refiere al porcentaje real de las lesiones de las vías biliares durante la cirugía videoasistida

Lesiones quirúrgicas de la vía biliar secundarias a colecistectomía laparoscópica: encuesta nacional / Major biliary injuries following laparoscopic cholecystectomy

Se presentan 117 lesiones de la vía biliar principal provocadas en el curso de la cirugía videoasistida reparadas por 42 cirujanos encuestados, ya fuera por ellos mismos o en el centro en que actúan. Se hace mención que en la bibliografía argentina es escaso el número de lesiones del hepatocolédoco durante cirugía laparoscópica. Se afirma, en base a ello, que las estadísticas nacionales no son confiables en lo que se refiere al porcentaje real de las lesiones de las vías biliares durante la cirugía videoasistida (AU)