Laparoscopic cholecystectomy is now a gold standard treatment modality for gallstone diseases. However, the incidence rate of bile duct injury has not been changed for many years. From initial classification published by Bismuth, there have been many classifications of common bile duct injury. The initial classification, levels and types of bile duct injury, and currently combined vascular injuries are reviewed here.
Bile Ducts ; Bismuth ; Cholecystectomy, Laparoscopic ; Classification* ; Common Bile Duct* ; Gallstones ; Incidence ; Vascular System Injuries

PURPOSE: It is difficult to preoperatively determine the extent of surgery for extrahepatic cholangiocarcinoma due to its proximity to vital structures. Recently the tendency of combined resection of liver and pancreas for the treatment of this appears to be increasing, although, in spite of the expected survival benefit, this radical surgery cannot be applied to all extrahepatic cholangiocarconoma because of the high rate of operative complications. We reviewed patients who had undergone segmental resection of the bile duct vice radical surgery for extrahepatic cholangiocarconoma in order to study their clinical features and to analyze the prognostic factors for survival. METHODS: Thirty-four patients who underwent segmental resection for extrahepatic cholangiocarcinoma, excepting GB cancer, at our center between 1994 to 2000 were included in this study and their medical records were reviewed retrospectively. RESULTS: The mean age of the patients was 63 years and they underwent segmental resection of bile duct and skeletalization of the hepatoduodenal ligament with hepatico-jejunostomy. The mean length of hospital stay after operation was 17.2 days (8~44) and no operative mortality was encountered. Postoperative complications including 5 wound dehiscences, 1 intraperitoneal abscess, 1 pyloric obstruction and 1 case of gastric ulcer bleeding were all improved following conservative management. The mean size of tumors was 2.6 cm and 11 tumors (32%) involved the resection margin. The estimated 2 and 4 year survival rates of the 34 patients following resection was 64% and 22% respectively and the only significant predictive factor for survival following resection was the tumor involvement of resection margin (P=0.045). The 2-year survival rate of the positive margin group was 34%, although that of the free margin group was 74%. CONCLUSION: Segmental resection for extrahepatic cholangiocarconoma may be a reasonable option offering relatively low morbidity and mortality if the resection margin is tumor- free. Additionally, segmental resection may be more beneficial to patients with high operative risk in particular.
Abscess ; Bile Ducts ; Bile Ducts, Extrahepatic* ; Cholangiocarcinoma ; Hemorrhage ; Humans ; Length of Stay ; Ligaments ; Liver ; Medical Records ; Mortality ; Pancreas ; Postoperative Complications ; Retrospective Studies ; Stomach Ulcer ; Survival Rate ; Wounds and Injuries

A 6-year-old male who lived with a mother in a single-parent family was referred to the emergency room with multiple traumas. There was no specific finding on CT scan of the other hospital performed 55 days before admission. However, CT scan at the time of admission showed common bile duct (CBD) stenosis, proximal biliary dilatation and bile lake formation at the segment II and III. Endoscopic retrograde biliary drainage was performed, but the tube had slipped off spontaneously 36 days later, and follow-up CT scan showed aggravated proximal biliary dilatation above the stricture site. He underwent excision of the CBD including the stricture site, and the bile duct was reconstructed with Roux-en-Y hepaticojejunostomy. Pathologic report of the resected specimen revealed that the evidence of trauma as a cause of bile duct stricture. While non-iatrogenic extrahepatic biliary trauma is uncommon, a level of suspicion is necessary to identify injuries to the extrahepatic bile duct. The role of the physicians who treat the abused children should encompass being suspicious for potential abdominal injury as well as identifying visible injuries.
Abdominal Injuries ; Bile Ducts ; Bile Ducts, Extrahepatic ; Bile ; Child ; Child Abuse ; Child ; Common Bile Duct ; Constriction, Pathologic ; Dilatation ; Drainage ; Emergency Service, Hospital ; Follow-Up Studies ; Humans ; Lakes ; Male ; Mothers ; Multiple Trauma ; Single-Parent Family ; Tomography, X-Ray Computed ; Wounds, Nonpenetrating

INTRODUCTIONBile duct perforation (BDP) with resultant biliary ascites in children is a rare clinical condition. The aetiopathogenesis is still an enigma, with increasing evidence suggesting anomalous union of pancreaticobiliary ductal (AUPBD) system as the prime causative factor.

CLINICAL PICTUREWe report 2 cases of spontaneous perforation of the bile duct confirmed on histopathological examination as choledochal cyst, in a 6-month-old female child and a 4-year-old boy who presented with subtle clinical symptoms.

TREATMENT AND OUTCOMEBoth patients were successfully managed by excision of the gall bladder and common bile duct and Roux-en- Y hepaticojejunostomy. This procedure was performed following initial cholecystostomy drainage in the second case.

CONCLUSIONSFrom the available literature and experience with our patients, BDP is not merely spontaneous but may be related to AUPBD and choledochal cyst.

Ascites ; etiology ; surgery ; Bile Ducts ; injuries ; Child, Preschool ; Cholangiography ; Cholecystectomy ; Choledochal Cyst ; complications ; surgery ; Common Bile Duct ; diagnostic imaging ; injuries ; surgery ; Female ; Humans ; Infant ; Jejunostomy ; Laparoscopy ; Male ; Tomography, X-Ray Computed

OBJECTIVETo summarize the reasons for bile duct injury (BDI) after laparoscopic cholecystectomy (LC), and to determine the effect of multiple treatment after BDI.

METHODSA retrospective cohort study was performed. The medical records of 110 patients diagnosed with BDI after LC from October 1993 to November 2007, in ten large hospitals in Guangdong of China, were reviewed.

RESULTSAmong 110 patients with BDI, 58 cases (52.7%) were local patients, whereas 52 cases (47.3%) were transferred from outside hospitals. Reasons for BDI following LC were: (1) Lack of experience of the LC operator (48.2%); (2) LC performed during acute cholecystitis (20.0%); (3) The structure of Calot triangle was unclear (15.5%); (4) Variable anatomical position (11.8%); (5) Intra-operation bleeding (4.5%). The commonest sites of injury were the choledochus and common hepatic duct (76.4%). Following BDI, endoscopic stenting or operative repair was performed in 106 patients. The overall success rate was 95.3% (101/106), with a mortality rate was 0.9% (1/106). Cholangitis occurred in 3.8% (4/106) cases. Choledocho-enterostomy operation was performed in almost 60.0% (63/106) cases, and the success rate was 93.7% (59/63). Endoscopic stenting or operative repair was performed immediately following BDI in 23.6% (25/106) patients, the success rate was 100%; and within 30 days in 63.2% (67/106) patients. Eighty-eight out of 106 patients who underwent repair were successful following the first operative procedure.

CONCLUSIONSFactors such as an un-experienced operator and unclear anatomical position were causes of BDI following LC. Early operative repair should be regarded as the treatment of choice, in patients diagnosed with BDI. Early refer to an experienced hepatobiliary operator ensures a high success rate.

Adolescent ; Adult ; Aged ; Aged, 80 and over ; Bile Ducts ; injuries ; surgery ; Cholecystectomy, Laparoscopic ; adverse effects ; Female ; Humans ; Iatrogenic Disease ; Intraoperative Complications ; diagnosis ; etiology ; surgery ; Male ; Middle Aged ; Retrospective Studies

OBJECTIVETo discuss the feasibility of biliary reconstruction and rehabilitation after transection injury of biliary duct by laparoscopy.

METHODSThe clinical data of 24 cases receiving biliary reconstruction after transection injury of biliary duct by laparoscopy were analyzed retrospectively from August 2002 to April 2008, including operation indications, contraindications, related operation skills and so on. In these 24 cases, the reasons of transection of biliary duct as followed: 15 cases were pancreaticoduodenectomy, 6 cases were resection of the choledochal cyst, 1 case was resection of high cholangiocarcinoma, 1 case was cholecystectomy and 1 case was resection of gastric cancer.

RESULTSBiliary reconstruction and rehabilitation was successfully completed in 24 cases by laparoscopy. There was 1 case of bile leakage and no duct stenosis complications.

CONCLUSIONSBiliary reconstruction and rehabilitation by laparoscopy was feasible and safe procedure, has a high successful rate, and deserves further clinical trials in hospitals.

Adolescent ; Adult ; Aged ; Anastomosis, Surgical ; methods ; Bile Ducts ; injuries ; surgery ; Child ; Child, Preschool ; Feasibility Studies ; Female ; Follow-Up Studies ; Humans ; Laparoscopy ; Male ; Middle Aged ; Retrospective Studies

BACKGROUND/AIMS: Bile duct injury is the most serious complication of cholecystectomy. The aim of this study was to evaluate the outcome of endoscopic treatment in bile duct injury after cholecystectomy. METHODS: We reviewed the results of endoscopic treatments in the patients diagnosed as bile duct injury after cholecystectomy on cholangiographic examinations, retrospectively. Endoscopic treatment included insertion of nasobiliary drainage catheter or plastic stent after endoscopic sphicterotomy. RESULTS: A total of twenty-two patients (9 male, 13 female; median age of 59 years) with bile duct injury were included. Endoscopic treatment was successfully performed in 12 of 13 patients with bile leak only. In patients with both bile leak and stricture, endoscopic treatment was successful in 2 of 3 patients. In 6 patients with complete obstruction of bile duct, endoscopic treatment failed and surgical approach was needed. In our series, transpapillary endoscopic treatment was not successful when proximal bile duct above the injured site was not visualized by endoscopic retrograde cholangiopancreatography (ERCP) and surgery was performed in all cases. Overall success rate of endoscopic treatment in 22 patients with bile duct injury was 64% (14/22). There was no complication associated with endoscopic treatment. CONCLUSIONS: ERCP is useful for the treatment of bile leakage after cholecystectomy and can be used for the treatment prior to surgery. Surgical intervention is needed in case of endoscopic treatment failure.
Adult ; Aged ; Bile Ducts/*injuries ; Cholangiopancreatography, Endoscopic Retrograde ; Cholecystectomy/*adverse effects ; *Endoscopy, Digestive System ; English Abstract ; Female ; Humans ; Male ; Middle Aged ; Treatment Outcome

BACKGROUND: Laparoscopic cholecystectomy has become the gold-tandard treatment for symptomatic gallbladder diseases. The evaluation and the treatment of common duct pathology is an essential component in the surgical management of biliary tract disease. The purpose of the present study was to identify the value and the importance of laparoscopic cholangiography compared to endoscopic retrograde cholangiography (ERC) in a laparoscopic cholecystectomy and to suggest the role of laparoscopic cholangiography in the management of patients undergoing laparoscopic cholecystectomy. METHODS: A laparoscopic cholecystectomy was attempted in two hundred six consecutive patients treated at Hallym University between January 1993 and December 1996. Patients were divided into three groups: In group I, 167 patients were examined with preoperative ERC while in group II, 17 patients were examined with laparoscopic cholangiography; Group III included 22 patients who were not examined with preoperative ERC or laparoscopic cholangiography. RESULTS: The average age was 52.78 years in group I, 45.62 years in group II, and 49.22 years in group III. The average operative time was 76.88 minutes in group I, 131.47 minutes in group II, and 85.22 minutes in group III. The operative time in group II was longer than that in group I (p<0.001). The duration of postoperative hospitalization was 4.9 days in group I and 4.11 days in group II, but this difference was not statistically significant (p=0.166). Conversion to an open cholecystectomy was 17/167 (10%) in group I, 1/17 (5%) in group II and 5/22 (22%). No complications or deaths occurred that were due to laparoscopic cholangiography. The postoperative complications in group I/II/III included bile leakage (3/0/2), bleeding in the bed of the gallbladder (5/0/0), wound bleeding (2/1/1), recurrent common duct stones (2/0/0), subcutaneous emphysema (4/1/0), shoulder pain (12/3/0), and wound infections (15/2/1). CONCLUSIONS: Although cholangiography may not be indicated for all patients undergoing a laparoscopic cholecystectomy, it will eventually be required. We conclude that laparoscopic cholangiography, as well as ERC, is a good method for evaluating the biliary tree. Laparoscopic cholangiography is clinically useful in patients who have negative ultrasonography and a dilated bile duct. Also, laparoscopic cholangiography has many advantages, especially at a teaching hospital: it outlines the anatomy of the extrahepatic biliary tree, identifies anomalies of surgical importance in time before iatrogenic damage is inflicted, detects stones in the cystic duct, discovers unsuspected stones, and develops experience with the technique. However, it is technically diffult to cannulate cystic duct and extends the operating time.
Bile ; Bile Ducts ; Biliary Tract ; Biliary Tract Diseases ; Cholangiography* ; Cholecystectomy ; Cholecystectomy, Laparoscopic* ; Cystic Duct ; Gallbladder ; Gallbladder Diseases ; Hemorrhage ; Hospitalization ; Hospitals, Teaching ; Humans ; Operative Time ; Pathology ; Postoperative Complications ; Shoulder Pain ; Subcutaneous Emphysema ; Ultrasonography ; Wound Infection ; Wounds and Injuries

The extrahepatic bile duct cancers(EBDC) are rare and are found late stage in their course. Because of their location in close proximity to the liver, hepatic artery, and portal vein, they are often unresectable. However, high survival rates after an aggressive surgical resection has been reported lately. This report presents the results of 62 cases with EBDC operated at the Department of Surgery, Pusan National University Hospital, from 1988 to 1997. EBDC usually occurs in older age group. especially between 60~70 years of age, and the mean age was 56.6 years. Sex ratio(male:female) was 5.2:1 with male predominance. Frequent clinical manifestations in order of frequency were jaundice(82.3%), abdominal pain(69.4%), pruritus(35.5%), anorexia(33.9%), fever and chill(32.3%), weight loss(22.6%). The laboratory findings were increased alkaline phosphatase(93.5%), bilirubin(77.4%), SGOT(77.4%), SGPT(69.4%). Elevated CEA(>5ng/dl) was 28.6%. The preoperative diagnostic accuracy was 100.0% in ERCP and PTC, 96.4% in abdominal CT, and 95.3% in ultrasonogram. The most common site of the cancer was lower third of the bile duct(61.3%), followed by upper third(27.4%) and middle third(11.3%). Curative resection was possible in 33 cases(53.2%) and the other 29 cases were received palliative biliary decompression. Postoperative complications were bile leakage(30.6%), wound infection( 25.8%), intraabdominal hematoma(19.4%), cholangitis(17.7%), and UGI bleeding(11.3%). The dead cases were 5 cases(8.0%) of all 62 cases and the causes of death were sepsis in 3 cases(4.8%) and UGI bleeding 2 cases(3.2%). By TNM classification(AJCC, 1992) stage IV(64.5%) was most common and stage II(25.9%) was next in order. Among the 62 adenocarcinoma, 25 cases were poorly-differentiated lesion(40.3%), 19 cases were moderately-differentiated lesion(30.6%), and 18 cases were well-differentiated lesion(29.0%). In conclusion, the survival rates of EBDC were higher low staged, curative resected, well differentiated and lower third located groups than high staged, palliative resected, poorly differentiated and upper third located groups.
Adenocarcinoma ; Bile ; Bile Ducts, Extrahepatic* ; Busan ; Cause of Death ; Cholangiopancreatography, Endoscopic Retrograde ; Decompression ; Fever ; Hemorrhage ; Hepatic Artery ; Humans ; Liver ; Male ; Portal Vein ; Postoperative Complications ; Sepsis ; Survival Rate* ; Tomography, X-Ray Computed ; Ultrasonography ; Wounds and Injuries

Laparoscopic cholecystectomy is the newest treatment modality to be introduced for the management of the gallstone disease and is gaining rapid acceptance elsewhere. Despite its rapid and widespread acceptance, early data suggest that some complications and limitations are common when compared to standard cholecystectomy. The aim of this study was to identify problems in laparoscopic cholecystectomy and the reasons for secondary or operative conversion. From August 1991 to December 1994, 195 consecutive patients were treated with laparoscopic cholecystectomy at the Department of General Surgery, Kangdong Sacred Heart Hospital, College of Medicine, Hallym University. The results were as follows; 1) The most prevalent age group was the 5th decade (24.6%) and the sex ratio (M : F) was 1 : 1.4. 2) The most common symptom was right upper quadrant pain (66.2%). 3) The majority (66.7%) of the admitted patient came to our hospital within 6 months of the onset of symptoms. 4) The number of patients with previous abdominal operations was 44 patients (22.6%), and the most common operation was an appendectomy (8.2%). 5) The patients with associated diseases were 124 patients (63.6%), gastritis being noted in 35 patients (17.9%). 6) The preoperative diagnostic rate was 96% by abdominal ultrasonography and 23.6% by ERCP 7) The average operative time was 103 minutes. 8) The most frequent operative finding was adhesion (72.3%). 9) The mean period of hospitalization after operation was 3.5 days. 10) The most dominant type in pathologic classification was chronic cholecystitis (86.7%). 11) The number of conversions to an open cholecystectomy was 14 (7.2%). 12) Among 195 patients, complications were noted in 10 patients (5.1%) : bile leakage from the bile duct or the liver bed(3 patients), bile duct injury (2 patients), subphrenic abscess (2 patients), atelectasis (1 patient), wound hematoma (1 patient), and drain site bleeding (1 patient).
Appendectomy ; Bile ; Bile Ducts ; Cholangiopancreatography, Endoscopic Retrograde ; Cholecystectomy ; Cholecystectomy, Laparoscopic* ; Cholecystitis ; Classification ; Gallstones ; Gastritis ; Heart ; Hematoma ; Hemorrhage ; Hospitalization ; Humans ; Liver ; Operative Time ; Pulmonary Atelectasis ; Sex Ratio ; Subphrenic Abscess ; Ultrasonography ; Wounds and Injuries