Laparoscopic Cholecystectomy: Bile Duct and Vascular Injuries: Management and Outcome

Background: This is a retrospective study of 32 consecutive patients referred in the period 1992-2000 for management of serious bile duct injuries caused by elective laparoscopic cholecystectomy. Methods: The patients were referred on median 29 days (0 days to 34 months). Only 7 patients were referred immediately after discovery of the injury. At the local hospital, 25 patients underwent various procedures in attempts at repair. Ten of the patients were treated for bile duct strictures after previous repairs in other hospitals. Results: At referral, 23 patients (72%) had complete transection of the bile duct, while 9 had bile leakage injuries. Additional complications were occlusion of the right hepatic artery in 8 patients (24%) and occlusion of the mesenteric superior artery in 1 patient. Infectious complications were prominent in 21 patients (70%), 6 of whom had septicaemia. Operative management with hepaticojejunostomy Roux-Y was employed in 22 patients. Various non-operative strategies were chosen, including endoscopically or transhepatic stenting of the bile duct and embolization of the right hepatic artery. There was no difference in hospital stay between operative and non-operative procedures which on median was 16 days ( range 7-69 days). Three patients died: one had thrombosis of the superior mesenteric artery, while the other two died of complications to bile peritonitis. Median observation period is 5 years (5 months to 8 years). Two patients have cholangitis; both had injury to the right hepatic artery. The other patients all had normal ultrasonograms of the liver and normal/almost normal liver function tests. Conclusions: Bile duct injuries continue to occur, are serious and may result in death. Injury to the right hepatic artery is present in many cases. Patients are referred late to a competent center, resulting in serious infection in 70%.     

Right liver necrosis: complication of laparoscopic cholecystectomy

Although bile duct injuries are common among the complications of laparoscopic cholecystectomy, hepatic vascular injuries are not well described. Between January 1990 to December 1999, 83 patients with bile duct injuries have been referred to our clinic. Two of them had liver necrosis due to hepatic arterial occlusion. These two women had laparoscopic cholecystectomy for symptomatic cholelithiasis in district hospitals 4 and 15 days prior to their referral to our clinic. Serum aspartate aminotransferase and alanine aminotransferase levels were found to be 30 to 40-fold higher than normal levels. Ultrasonography, computed tomography and Doppler sonography showed necrosis in the right liver lobe and no flow in the right hepatic artery. Patients were also complicated with liver abscess and biliary peritonitis, respectively. Emergency right hepatectomy was performed in both cases and one of them needed Roux-Y-hepaticojejunostomy (to the left hepatic duct). One patient died of peritonitis in the postoperative period. The other one has no problem in her third postoperative year. The earliest and the simplest method for diagnosis or ruling out hepatic arterial occlusion is detecting the blood biochemistry and Doppler ultrasonography. In some cases emergency hepatectomy can be necessary. Postoperative complications should be expected higher than elective cases.     

Pseudoaneurysm following laparoscopic cholecystectomy

BACKGROUND:Laparoscopic cholecystectomy(LC)is the operation of choice for removal of the gallbladder. Unrecognized bile duct injuries present with biliary peritonitis and systemic sepsis.Bile has been shown to cause damage to the vascular wall and therefore delay the healing of injured arteries leading to pseudoaneurysm formation.Failure to deal with bile leak and secondary infection may result in pseudoaneurysm formation. This study was to report the incidence and outcomes of pseudoaneurysm in patients with bile leak following LC referred to our hospital. METHODS:A retrospective analysis of our prospectively maintained liver database using pseudoaneurysm, bile leak and bile duct injury following laparoscopic cholecystectomy from January 2000 to December 2005 was performed. RESULTS:A total of 86 cases were referred with bile duct injury and bile leak following LC and of these,4 patients (4.5%)developed hepatic artery pseudoaneurysm(HAP) presenting with haemobilia in 3 and massive intra- abdominal bleed in 1.Selective visceral angiography confirmed pseudoaneurysm of the right hepatic artery in 2 cases,cystic artery stump in one and an intact but ectatic hepatic artery with surgical clips closely applied to the right hepatic artery at the origin of the cystic artery in the fourth case.Effective hemostasis was achieved in 3 patients with coil embolization and the fourth patient required emergency laparotomy for severe bleeding and hemodynamic instability due to a ruptured right hepatic artery.Of the 3 patients treated with coil embolization, 2 developed late strictures of the common hepatic duct. . (CHD)requiring hepatico-jejunostomy and one developed a stricture of left hepatic duct.All the 4 patients are alive at a median follow up of 17 months(range 1 to 65)with normal liver function tests. CONCLUSIONS:HAP is a rare and potentially life- threatening complication of LC.Biloma and subsequent infection are reported to be associated with pseudoaneurysm formation.Late duct stricture is common either due to unrecognized injury at LC or secondary to ischemia after embolization.     

An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy

Objectives

Biliary injuries are frequently accompanied by vascular injuries, which may worsen the bile duct injury and cause liver ischemia. We performed an analytical review with the aim of defining vasculobiliary injury and setting out the important issues in this area.

Methods

A literature search of relevant terms was peformed using OvidSP. Bibliographies of papers were also searched to obtain older literature.

Results

Vasculobiliary injury was defined as: an injury to both a bile duct and a hepatic artery and/or portal vein; the bile duct injury may be caused by operative trauma, be ischaemic in origin or both, and may or may not be accompanied by various degrees of hepatic ischaemia. Right hepatic artery (RHA) vasculobiliary injury (VBI) is the most common variant. Injury to the RHA likely extends the biliary injury to a higher level than the gross observed mechanical injury. VBI results in slow hepatic infarction in about 10% of patients. Repair of the artery is rarely possible and the overall benefit unclear. Injuries involving the portal vein or common or proper hepatic arteries are much less common, but have more serious effects including rapid infarction of the liver.

Conclusions

Routine arteriography is recommended in patients with a biliary injury if early repair is contemplated. Consideration should be given to delaying repair of a biliary injury in patients with occlusion of the RHA. Patients with injuries to the portal vein or proper or common hepatic should be emergently referred to tertiary care centers.     

Unilateral hepatic artery reconstruction is unnecessary in biliary tract carcinomas involving lobar hepatic artery: implications of interlobar hepatic artery and its preservation

BACKGROUND/AIMS: The interruption of hepatic arterial flow when performing a bilioenteric anastomosis has been reported to usually bring about serious postoperative complications, such as anastomotic leakage, hepatic abscess and infarction. We aimed to evaluate the surgical implications of the interlobar hepatic artery when patients with advanced biliary tract carcinomas undergo surgical resection with a bilioenteric anastomosis. METHODOLOGY: In 7 patients with advanced biliary tract carcinomas, the combined resection of the liver (greater than hemihepatectomy in 2 and less than hemihepatectomy in 5), extrahepatic bile duct, hepatic artery (right hepatic artery in 5, right and left hepatic artery in 1, left hepatic artery in 1), and the portal vein was performed in 4 patients. The portal vein was reconstructed in all 4 patients. The hepatic artery was reconstructed in only one patient, with combined resection of both right and left hepatic arteries, but was not reconstructed in 2 other patients, even though they underwent resection greater than hemihepatectomy. RESULTS: The interlobar hepatic artery running into the Glissonian sheath around the hepatic duct confluence could be preserved in 5 patients, as shown by angiography, but could not be preserved in 2 patients who underwent greater than hemihepatectomy. Moderate and transient ischemic liver damage occurred, but no serious postoperative complications were induced in any of the 5 patients in the unilateral hepatic artery preserved group. However, both cases without preservation of the hepatic artery encountered liver failure, liver abscess and leakage of bilioenteric anastomosis, and one patient died of multiple organ failure. CONCLUSIONS: One major lobar branch of the hepatic artery involved by cancer invasion could be safely resected without reconstruction in patients with advanced biliary tract carcinomas when the interlobar hepatic artery running into the Glissonian sheath around the hepatic duct confluence is preserved.     

Right hepatic lobectomy for bile duct injury associated with major vascular occlusion after laparoscopic cholecystectomy

A 57-year-old woman underwent laparoscopic cholecystectomy (LC) for cholelithiasis. Continuous bile leak was observed beginning on the first postoperative day. Postoperative endoscopic retrograde cholangiography revealed bile leak through the common hepatic duct, and severe stenosis of the hepatic confluence. A total of three percutaneous transhepatic biliary drainage (PTBD) catheters were inserted to treat obstructive jaundice and cholangitis. The patient was referred to our hospital for surgery 118 days after LC. Cholangiography through the PTBD catheters demonstrated a hilar biliary obstruction. Celiac arteriography revealed obstruction of the right hepatic artery, and transarterial portography showed occlusion of the right anterior portal branch. On the basis of the cholangiographic and angiographic findings, we performed a right hepatic lobectomy with hepaticojejunostomy to resolve the bile duct obstruction and address the problem of major vascular occlusion. The patient's postoperative recovery was uneventful and she remains well 25 months after hepatectomy. We discuss a treatment strategy for bile duct injury suspected after LC, involving early investigation of the biliary tree and prompt intervention.     

Management of postoperative arterial hemorrhage after pancreato-biliary surgery according to the site of bleeding: re-laparotomy or interventional radiology

Background/Purpose

Intra-abdominal arterial hemorrhage is still one of the most serious complications after pancreato-biliary surgery. We retrospectively analyzed our experiences with 15 patients in order to establish a therapeutic strategy for postoperative arterial hemorrhage following pancreato-biliary surgery.

Methods

Between August 1981 and November 2007, 15 patients developed massive intra-abdominal arterial bleeding after pancreato-biliary surgery. The initial surgery of these 15 patients were pylorus-preserving pancreatoduodenectomy (PPPD) (7 patients), hemihepatectomy and caudate lobectomy with extrahepatic bile duct resection or PPPD (4 patients), Whipple’s pancreatoduodenectomy (PD) (3 patients), and total pancreatectomy (1 patient). Twelve patients were managed by transcatheter arterial embolization and three patients underwent re-laparotomy.

Results

Patients were divided into two groups according to the site of bleeding: SMA group, superior mesenteric artery (4 patients); HA group, stump of gastroduodenal artery, right hepatic artery, common hepatic artery, or proper hepatic artery (11 patients). In the SMA group, re-laparotomy and coil embolization for pseudoaneurysm were performed in three and one patients, respectively, but none of the patients survived. In the HA group, all 11 patients were managed by transcatheter arterial embolization. None of four patients who had major hepatectomy with extrahepatic bile duct resection survived. Six of seven patients (85.7%) who had pancreatectomy survived, although hepatic infarction occurred in four.

Conclusions

Management of postoperative arterial hemorrhage after pancreato-biliary surgery should be done according to the site of bleeding and the initial operative procedure. Careful consideration is required for indication of interventional radiology for bleeding from SMA after pancreatectomy and hepatic artery after major hepatectomy with bilioenteric anastomosis.     

Changing Patterns of traumatic bile duct injuries：areviw of forty years experience

AIM: To summarize the experiences of treating bile duct injuries in 40 years of clinical practice. METHODS: Based on the experience of more than 40 years of clinical work, 122 cases including a series of 61 bile duct injuries of the Southwest Hospital, Chongqing, and 42 cases (1989-1997) and 19 cases (1998-2001) of the General Hospital of PLA, Beijing, were reviewed with special reference to the pattern of injury. A series of cases of the liver and the biliary tract injuries following interventional therapy for hepatic tumors, most often hemangioma of the liver, were collected. Chinese medical literature from 1995 to 1999 dealing with 2742 traumatic bile duct strictures were reviewed. RESULTS: There was a changing pattern of the bile duct injury. Although most of the cases of bile duct injuries resulted from open cholecystectomy, other types from other type of trauma such as laparoscopic cholecystectomy (Lc) and hepatic surgery were increased in recent years. Moreover, serious hepato-biliary injuries following HAE using sclerotic agents such as sodium morrhuate and absolute ethanol for the treatment of hepatic hemangiomas were encountered in recent years.Experiences in how to avoid bile duct injury and to treat traumatic biliary strictures were presented. CONCLUSION: Traumatic bile duct stricture is one of the serious complications of hepato-biliary surgery, its prevalence seemed to be increased in recent years. The pattern of bile duct injury was also changed and has become more complicated.Interventional therapy with sclerosing agents may cause serious hepatobiliary complications and should be avoided.     

Successful treatment of postoperative acute hepatic artery obstruction with mesenteric arterioportal shunt

Fatal biliary complications and liver abscesses are likely in cases of acute hepatic arterial occlusion after hepatobiliary surgery with bilioenteric anastomosis. A 60-year-old man with hilar hepatic metastasis of gastric cancer underwent curative surgery. While the recurrent nodule was removed with the involved bile duct, vascular structures were preserved. Massive bleeding from the hepatic artery occurred suddenly on postoperative day 3, and the hepatic artery was ligated to stop bleeding. As Doppler ultrasonography indicated no arterial flow in the liver, a side-to-side mesenteric arterioportal shunt was created to prevent ischemic complications. Postoperative angiography showed fine patency of the shunt, and ischemic complications were avoided. However, the patient suddenly experienced massive hematemesis and fell into shock four months after the shunt operation. Upper gastrointestinal fiberoscopy showed serious varices throughout the whole esophagus. Angiographic examination indicated excessive shunt flow and markedly expanded mesenteric veins. The shunt was then occluded by coil embolization, but the patient did not recover from shock and eventually died. In the present case, the mesenteric arterioportal shunt appeared to be effective in relieving postoperative acute hepatic arterial occlusion. However, the shunt should be closed as soon as collateral blood flow is completed.     

Extrahepatic bile duct injury due to abdominal trauma

The diagnosis of bile duct injury due to abdominal trauma is usually not feasible preoperatively, but it must be suspected interoperatively with the presence of bile staining fluid in the subhepatic area. Four patients with bile duct injuries were encountered; these were the results of blunt injury in three and penetrating injury in one. The injury sites were in the common bile duct in two patients, and in the right hepatic duct just proximate to the bifurcation in two patients. One patient was diagnosed on the finding of bile stain discharged from the drainage tube after the first abdominal exploration. The other three patients were diagnosed by the amount of bile stained fluid collected in the subhepatic area during the primary laparotomy. The injuries of the common bile duct were treated by primary repairs and T-tube choledochostomy in two patients. The other two patients with right hepatic duct injuries were treated by right lobectomy because of extensive liver parenchyma injury. The postoperative courses were smooth and there were no deaths. We reviewed 27 reports (1984–1994) from around the world. The total operative mortality of the 75 patients in these reports was 18.67% (14/75) for the primary operation, and 7.14% (1/14) for re-operation in patients in whom reoperation was performed due to overlooked injuries or biliary complications.     

Comparison of pre-operative exams and per-operative findings in living donor liver transplantation

BACKGROUND: Success in living donor liver transplantation is associated to donor vascular and biliar anatomy. AIM: Compare pre-operative and per-operative findings in living liver donors related to portal vein, hepatic artery, bile duct and hepatic venous drainage anatomy. METHODS: Donors charts of living donor liver transplants done at Clinics Hospital of the Federal University of Paraná, Curitiba, PR, Brazil, were reviewed between March 1998 and August 2005. On the pre-operative period the anatomy was analysed through: celiac and mesenteric arteriography of the hepatic artery and portal vein (venous phase); magnetic resonance imaging of the venous drainage, portal vein and bile duct. Normality was determined based on data of the literature. Pre-operative findings were compared to per-operative findings. RESULTS: Portal vein and hepatic artery were studied in 44 patients, 16 females and 28 males, mean age of 33 years old. In 8 cases the left liver lobe was used to pediatric receptor, in 36 cases the right liver lobe was used to adult receptor. Bile duct anatomy was studied in 37 cases and venous drainage in 32. Over all, the findings related to pre-operative and per-operative anatomy were not coincident in 36.36% of the cases. In the case of hepatic artery, they were not coincident in 11.36%, in the case of the portal vein in 9.1%, in the case of the venous drainage in 9.37% and in the case of the bile duct in 21.6%. CONCLUSION: The pre-operative and per-operative findings related to vascular and bile duct donor anatomy are frequently different in living donor liver transplantation.     

Bile duct injuries during laparoscopic cholecystectomy: an audit of 1522 cases

BACKGROUND/AIMS: Bile duct injuries during laparoscopic cholecystectomy are serious complications. The incidence of this complication increases compared with open cholecystectomy. The aim of this paper has been to audit the incidence and nature of bile duct injuries during laparoscopic cholecystectomy in a single center. METHODOLOGY: From January 1991 to September 2000, all laparoscopic cholecystectomy attempts performed in Rajavithi Hospital were analyzed. RESULTS: Of the 1522 procedures performed, there were 9 (0.59%) cases of bile duct injuries. These involved the common hepatic duct (n=3) and the common bile duct (n=6). The underlying gallbladder pathology included chronic cholecystitis (n=6), Mirizzi's syndrome (n=2), and acute cholecystitis (n=1). Transection of the duct accounted for the majority of the injuries. Six bile duct injuries were identified at the time of operation. These were primarily repaired by direct suture (n=1) or by a biliary-enteric anastomosis (n=5). In the remaining three patients, the diagnosis was delayed. Two patients presented with a large amount of bile from the drain after surgery and one patient presented with jaundice. These were repaired by direct suture over a T tube (n=1) or biliary-enteric anastomosis (n=2). One patient developed recurrent cholangitis following biliary-enteric anastomosis after delayed diagnosis. CONCLUSIONS: The experience of a 0.59% incidence of bile duct injury is comparable to the best results from most large series in the West. Inflammation/adhesion at Calot's triangle is an important associated factor for injury. Injuries identified and repaired at the time of the first operation afford good results.     

Clinical, virological, and pathological significance of hepatic bile duct injuries in Chinese patients with chronic hepatitis C

Purpose. Hepatic bile duct injuries are characteristic histological findings in patients with chronic hepatitis C virus (HCV) infection. However, the pathogenesis and clinical significance of this phenomenon remain unclear. The aims of this study were to evaluate the prevalence and clinical significance of hepatic bile duct injuries in Chinese patients with chronic hepatitis C. Methods. One hundred and seventeen Chinese patients with chronic hepatitis C were enrolled. Clinical, biochemical, immunological (serum autoantibodies and cryoglobulinemia), histological, and virological data (serum HCV RNA titer and HCV genotype) were compared between patients with and without hepatic bile duct injuries. Results. Eighty-three (71%) of the 117 patients with chronic hepatitis C had hepatic bile duct injuries. Patients with hepatic bile duct injuries had a significantly higher frequency of HCV genotype 1b; a higher mean serum globulin level; significantly higher mean scores for histological periportal necro-inflammation, portal inflammation, and fibrosis; and more severe portal lymphoid aggregation/follicles when compared with patients without hepatic bile duct injuries (P < 0.05, all). No significant differences in the presence of serum autoantibodies, cryoglobulinemia, mean serum HCV RNA titer, or response to interferon treatment were noted between the two groups. Multivariate logistic regression analysis showed that HCV genotype 1b infection, portal inflammation, and lymphoid aggregation/follicles were significant independent predictors associated with hepatic bile duct injuries. Conclusions. The presence of hepatic bile duct injuries in Chinese patients with chronic hepatitis C was significantly correlated with HCV genotype 1b infection, and the patients with these injuries had more severe portal inflammation and formation of lymphoid aggregates/follicles. Received: September 8, 2000 / Accepted: January 26, 2001     

Ischemic bile duct injury as a serious complication after transarterial chemoembolization in patients with hepatocellular carcinoma

BACKGROUND: Bile duct injuries after transarterial chemoembolization (TACE) have been reported; however, the exact pathogenic mechanisms and clinical implications of the injuries remain to be clarified. STUDY: A total of 950 consecutive patients with hepatocellular carcinoma (HCC) were studied. Among them, 807 were treated with TACE and the remaining 143 were treated with transarterial chemoinfusion (TACI) of cisplatin. RESULTS: None of 143 patients with HCC treated with TACI were found to have any radiographic evidence of biliary injury. In contrast, of the 807 patients treated with TACE, 17 (2%) developed biliary complications. Of all complications, 12 (71%) were subcapsular bilomas; 3 (17%), focal strictures of the common hepatic duct or common bile duct; and 2 (12%), diffuse mild dilatation of the intrahepatic bile ducts. Interestingly, 2 of the 12 bilomas were found in the lobe that was not embolized with gelatin sponge particles. The median numbers of TACE tended to be greater in the patients with focal stricture than in those with bilomas (6.0 vs. 2.5; p = 0.08). All 3 patients with focal strictures and 4 of the 12 patients with bilomas had associated serious bacterial infections at presentation. CONCLUSIONS: Bilomas seem to be caused by iodized oil rather than gelatin sponge particles; focal strictures of large bile ducts seem to be caused by gelatin sponge particles. We suggest that adjustments in the amounts of iodized oil or gelatin sponge particles and in the sites of embolization may reduce ischemic biliary injuries after TACE.     

Endoscopic therapy for biliary strictures complicating living donor liver transplantation: Factors predicting better outcome

AIM To identify factors predicting outcome of endoscopic therapy in bile duct strictures(BDS) post living donor liver transplantation(LDLT).METHODS Patients referred with BDS post LDLT, were retrospectively studied. Patient demographics, symptoms(Pruritus, Jaundice, cholangitis), intra-op variables(cold ischemia time, blood transfusions, number of ducts used, etc.), peri-op complications [hepatic artery thrombosis(HAT), bile leak, infections], stricture morphology(length, donor and recipient duct diameters) and relevant laboratory data both pre-and post-endotherapy were studied. Favourable response to endotherapy was defined as symptomatic relief with 80% reduction in total bilirubin/serum gamma glutamyl transferase. Statistical analysis was performed using SPSS 20.0.RESULTS Forty-one patients were included(age: 8-63 years). All had right lobe LDLT with duct-to-duct anastomosis. Twenty patients(48.7%) had favourable response to endotherapy. Patients with single duct anastomosis, aggressive stent therapy(multiple endoscopic retrogradecholagiography, upsizing of stents, dilatation and longer duration of stents) and an initial favourable response to endotherapy were independent predictors of good outcome(P 0.05). Older donor age, HAT, multiple ductal anastomosis and persistent bile leak( 4 wk post LT) were found to be significant predictors of poor response on multivariate analysis(P 0.05). CONCLUSION Endoscopic therapy with aggressive stent therapy especially in patients with single duct-to-duct anastomosis was associated with a better outcome. Multiple ductal anastomosis, older donor age, shorter duration of stent therapy, early bile leak and HAT were predictors of poor outcome with endotherapy in these patients.     

Endoscopic management of postoperative bile leak

Significant bile leak is an uncommon but serious complication of biliary tract surgery. Of twenty-five patients presenting with postoperative bile leak, 11 had complete tie-off of common bile duct and required surgery, while the remaining 14 had injury without complete obstruction and could be managed by endoscopic methods. Of these 14 cases, bile leak occurred from the cystic duct in 11 patients and from the common hepatic duct, right hepatic duct and left hepatic duct in one patient each. Endoscopic procedures performed included sphincterotomy alone (four patients), sphincterotomy and stent placement (seven patients) and sphincterotomy followed by nasobiliary catheter drainage (three patients). There was no technical failure and bile leak was stopped in all patients. One patient died of haemobilia 5 days after stent placement. When technically feasible, postoperative bile leak can be managed safely and effectively by endoscopic methods, obviating the need for surgical reexploration.     

Handling of biliary complications following laparoscopic cholecystectomy in the setting of Tripoli Central Hospital

BackgroundLaparoscopic cholecystectomy (LC) has an increased incidence of bile duct injury and bile leak when compared with open cholecystectomy. This study reviews management of these complications in a general hospital setting. Data collected from patients diagnosed and treated in one surgical unit for biliary complications after LC between 1992 and 1996 were analysed.MethodA total of 14 patients were examined. Diagnosis was defined mainly by Endoscopic retrograde cholangiopancreatography (ERCP) and undetected choledocholitiasis was discovered in association with two of these complications. 43% of patients presented after LC with early postoperative bile leak or jaundice due to partial or complete bile duct excision or slippage of clips from the cystic duct. 57% presented with late biliary strictures. Thirteen patients were treated surgically, with biliary reconstruction (11 patients), direct repair (one) and cystic duct ligation in combination with clearance of bile duct from large multiple stones (one). One patient,who had clip displacement from cystic duct in combination with misplaced clip on right hepatic duct, was treated elsewhere. Postoperatively, one patient developed anastomotic leak and another died from sequellaie of bile duct transection requiring staged operations.ConclusionsIt is concluded that, in an environment similar to that where the authors had to work, LC should be performed in hospitals with facility to perform ERCP or when access for this technique is available in a nearby institution. Early recognition and immediate management of biliary injuries is dependent on individual resources and circumstances but, if required, consultation with colleagues or referral of patients with suspected or established biliary complications should not be delayed.     

胰十二指肠切除术中肝动脉变异及意义

目的 探讨胰十二指肠切除术中肝动脉变异及意义.方法 回顾性分析100例胰十二指肠切除术患者的肝动脉变异情况,分析其变异类型以及术中所采取的针对性措施.结果 通过术前腹腔干动脉、肠系膜上动脉(DSA)造影及术中对肝十二指肠韧带骨骼化,100例患者发现16例肝动脉变异.14例(14%)患者出现替肝动脉,其中10例为替肝右动脉(10%),8例发自肠系膜上动脉,2例发自胃十二指肠动脉;4例(4%)为替肝左动脉,3例发自胃左动脉,1例发自肝右动脉.14例变异血管直径0.3～0.6 cm,平均0.47 cm,术中均予以保留.1例(1%)于肝十二指肠韧带后方伴行门静脉出可触及变异动脉进入肝脏,血管直径0.4 cm,术中予以保留.1例(1%)变异动脉发自胰头方向进入右肝,血管直径0.2 cm,动脉夹闭1 h后离断该血管.结论 针对胰十二指肠切除术中发现的肝动脉变异,必须根据血管直径、阻断变异血管时肝脏变化及血管科建议,判断是否保留变异血管.     

Surgical strategy for the management of biliary injury in laparoscopic cholecystectomy

BACKGROUND/AIMS: The incidence of biliary injury during laparoscopic cholecystectomy remains high and several complications resulting from injuries have recently been reported. The aim of this study is to elucidate the surgical strategy for the management of biliary injury during laparoscopic cholecystectomy. METHODOLOGY: Ten patients with biliary injury during laparoscopic cholecystectomy are retrospectively reviewed. RESULTS: Second operations as initial repair were performed in five patients in our institute. Duct-to-duct anastomosis for one and duct-enterostomies for two were performed in three common bile duct transections. Simple closures were performed for the other two biliary injuries. Another five cases underwent both laparoscopic cholecystectomies and second operations for initial repair when they were referred to our service. Four were treated by a third operation in our institution including hilar bile duct resections and duct-enterostomies in two, and right hepatic lobectomies in the other two cases. The last patient could not be treated because of his poor condition and he died of hepatic failure soon after the consultation. CONCLUSIONS: Complications resulting from biliary injury have recently been reported, necessitating liver transplantation. Laparoscopic surgeons should avoid biliary injury and must not perform inadequate biliary reconstruction, which leads to secondary biliary cirrhosis, cholangitis, liver failure, and finally patient death.     

Preoperative assessment of extrahepatic bile duct carcinoma using three-dimensional intraductal US.

BACKGROUND: We investigated the utility of a new imaging modality, three-dimensional intraductal ultrasonography (US), for staging bile duct cancer. METHODS: In eight patients with extrahepatic bile duct carcinoma, two- and three-dimensional intraductal US was used to assess tumor invasion of the right hepatic artery, portal vein, and pancreatic parenchyma before resection. The findings were correlated with histologic information from the resected specimen. RESULTS: Three-dimensional intraductal US enabled accurate assessment of tumor invasion of the right hepatic artery in 88% of cases, the portal vein in 100%, and pancreatic parenchyma in 100%. Two-dimensional intraductal US enabled accurate assessment of invasion of these structures in 88%, 88%, and 88% of cases. CONCLUSIONS: Three-dimensional intraductal US is useful in assessing tumor stage in bile duct carcinoma.