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1.  Total Laparoscopic Roux-en-Y Cholangiojejunostomy for the Treatment of Biliary Disease 
Total laparoscopic Roux-en-Y cholangiojejunostomy may be a first choice for patients with biliary disease that requires biliary-jejunal anastomosis.
Background and Objectives:
Roux-en-Y cholangiojejunostomy (RCJS) has been widely used in biliary bypass surgeries, but in most reported literature, an assisted mini-incision was needed, and studies reporting total laparoscopic Roux-en-Y cholangiojejunostomy (TLRCJS) are rare. The goal of this study was to investigate how to treat hepatic portal bile duct diseases and perform jejunojejunostomy and cholangiojejunostomy totally laparoscopically. We evaluated the feasibility of TLRCJS in treating biliary tract diseases.
TLRCJS were performed in 103 patients from January 2000 to August 2011. There were 28 cases of recurrent choledocholithiasis combined with stricture of the common bile duct (CBD) after several stone extractions, 3 patients with iatrogenic bile duct injury, 24 patients with choledochal cyst, 36 patients with hepatic portal cholangiocarcinoma, and 12 patients with cancer of the pancreatic head and periampullary cancer. All surgeries were performed through 5 trocars. First, laparoscopic surgery on the CBD was performed according to the original disease. The CBD was opened and stones were extracted in choledocholithiasis patients. In iatrogenic injury patients, strictured CBD was resected and repaired. Dilated CBD or choledochal cyst with tumor was transected. In patients with malignant jaundice, the CBD was opened longitudinally. At the same time, the bile duct was prepared for cholangiojejunostomy. Second, the positions of the laparoscope and surgeons were altered. The jejunal mesentery and jejunum were transected, and side-to-side jejunojejunostomy (JJS) was performed. The laparoscope and surgeon positions were exchanged again; the Roux-en-Y biliary limb was lifted close to the residual bile duct; and side-to-side or end-to-side choledochojejunostomy (CJS) was performed. Finally, an abdominal drainage tube was placed.
All the surgeries were performed successfully. The diameter of the residual bile duct ranged from 0.4 to 3.2 cm (average, 0.9 cm). Three patients had postoperative bile leakage and were treated from 1 week to approximately 1 month with abdominal drainage. Postoperative intraperitoneal hemorrhage and stress ulcer of the stomach occurred in 2 patients with biliary tract injury combined with obstructive jaundice. One with intraperitoneal hemorrhage was cured by another laparoscopic surgery. The other patient was cured after 2 days of abdominal drainage, antacids, and hemostatic drug therapy. The follow-up duration of 95 patients was 4 to 93 months (average, 48.3 months). The follow-up rate was 92.2% (95/103). Patients with cancer died of metastasis or cachexia during 14-month follow-up with no postoperative complication. Reflux cholangitis occurred in 3 patients 2, 3, and 5 years after the operation, respectively. No anastomotic stricture or other complication was found in other patients during the follow-up.
TLRCJS is the best and first choice for patients with biliary tract diseases that need biliary-jejunal anastomosis. But it is essential that the surgeon has proficiency in laparoscopic surgeries.
PMCID: PMC3771782  PMID: 23815976
Laparoscopy; Roux-en-Y cholangiojejunostomy; Common bile duct stone; Bile duct injury; Congenital choledochal cyst; Hepatic portal cholangiocarcinoma; Cancer of pancreatic head; Periampullary cancer
2.  Segmental Liver Transplantation From Living Donors Report of the Technique and Preliminary Results in Dogs  
HPB Surgery  1990;2(3):189-204.
A technique of orthotopic liver transplantation using a segmental graft from living donors was developed in the dog. Male mongrel dogs weighing 25–30 kg were used as donors and 10–15 kg as recipients. The donor operation consists of harvesting the left lobe of the liver (left medial and left lateral segments) with the left branches of the portal vein, hepatic artery and bile duct, and the left hepatic vein. The grafts are perfused in situ through the left portal branch to prevent warm ischemia. The recipient operation consists of two phases: 1total hepatectomy with preservation of the inferior vena cava using total vascular exclusion of the liver and veno-venous bypass, 2implantation of the graft in the orthotopic position with anastomosis of the left hepatic vein to the inferior vena cava and portal, arterial and biliary reconstruction. Preliminary experiments consisted of four autologous left lobe transplants and nine non survival allogenic left lobe transplants. Ten survival experiments were conducted. There were no intraoperative deaths in the donors and none required transfusions. One donor died of sepsis, but all the other donor dogs survived without complication. Among the 10 grafts harvested, one was not used because of insufficient bile duct and artery. Two recipients died intraoperatively of air embolus and cardiac arrest at the time of reperfusion. Three dogs survived, two for 24 hours and one for 48 hours. They were awake and alert a few hours after surgery, but eventually died of pulmonary edema in 2 cases and of an unknown reason in the other. Four dogs died 2–12 hours postoperatively as a result of hemorrhage for the graft's transected surface. An outflow block after reperfusion was deemed to be the cause of hemorrhage in these cases. On histologic examination of the grafts, there were no signs of ischemic necrosis or preservation damage.
This study demonstrates the technical feasibility of living hepatic allograft donation. It shows that it is possible, in the dog, to safely harvest non ischemic segmental grafts with adequate pedicles without altering the vascularization and the biliary drainage of the remaining liver. We propose that this technique is applicable to human anatomy.
PMCID: PMC2423581  PMID: 2278916
3.  Successful Treatment of Recurrent Cholangitis by Constructing a Hepaticojejunostomy with Long Roux-en-Y Limb in a Long-term Surviving Patient after a Whipple Procedure for Pancreatic Adenocarcinoma 
Patient: Female, 74
Final Diagnosis: Recurrent cholangitis
Symptoms: —
Medication: —
Clinical Procedure: —
Specialty: Gastroenterology and Hepatology
Unusual clinical course
Cholangitis may result from biliary obstruction (e.g., biliary or anastomotic stenosis, or foreign bodies) or occur in the presence of normal biliary drainage. Although reflux of intestinal contents into the biliary tree after hepaticojejunostomy appears to be a rare complication, it is important to emphasize that there are few available surgical therapeutic techniques.
Case Report:
A 74-year-old woman presented to our hospital after 17 years of episodes of cholangitis. The patient had undergone a pancreatoduodenectomy (Whipple procedure) 18 years earlier due to pancreatic adenocarcinoma. The reconstruction was achieved through the sequential placement of pancreatic, biliary, and retrocolic gastric anastomosis into the same jejunal loop. The postoperative course was uneventful and the patient received adjuvant chemotherapy. Approximately 6 months after the initial operation, the patient started having episodes of cholangitis. Over the next 17 years she experienced several febrile episodes presumed to be secondary to cholangitis. A computing tomography (CT) scan of the abdomen revealed intrahepatic bile ducts partially filled with orally administered contrast material (Gastrografin). Magnetic resonance cholangiopancreatography (MRCP) showed dilatation of the left intrahepatic bile ducts. A percutaneous transhepatic cholangiography showed that the bilioenteric anastomosis was normal, without stenosis. Based on these findings, a diagnosis of a short loop between the hepaticojejunostomy and the gastrojejunostomy permitting the reflux of intestinal juice into the biliary tree was made. During the re-operation, a new hepaticojejunal anastomosis in a 100-cm long Roux-en-Y loop was performed to prevent the reflux of the intestinal fluid into the biliary tree. The patient was discharged on postoperative day 10. One year after the second procedure, the patient enjoys good health and has been free of fever and abdominal pain and has not received any antibiotic therapy.
Lengthening the efferent Roux-en-Y limb should be considered as a therapeutic option when treating a patient with recurrent episodes of cholangitis after hepaticojejunostomy.
PMCID: PMC4152249  PMID: 25150551
Anastomosis, Roux-en-Y – methods; Cholangitis – therapy; Pancreatic Neoplasms – pathology; Pancreatic Neoplasms – surgery
4.  Pancreaticoduodenectomy with preservation of gastric tube blood flow after esophagectomy: Report of a case 
•We performed a pancreaticoduodenectomy in which the gastroduodenal artery was preserved.•The patient who had previously undergone esophagectomy, was diagnosed as middle bile duct cancer.•In order to prevent gastric tube ischemia, the gastroduodenal artery and gastroepiploic artery had to be preserved.
During pancreaticoduodenectomy (PD), the gastroduodenal artery (GDA) is commonly divided. In this study, we described the clinical features of PD in which the GDA was preserved in order to avoid gastric tube ischemia in a patient who had previously undergone esophagectomy.
A 70-year-old man had previously undergone esophagectomy. Esophagectomy and gastric tube reconstruction were performed 10 years earlier due to superior thoracic esophageal cancer. The patient was referred to our hospital for the treatment of obstructive jaundice and was diagnosed with middle bile duct cancer. We performed PD and preserved the GDA. The postoperative course was uneventful, and the gastric tube continued functioning well.
In a patient with a prior esophagectomy and gastric tube reconstruction, the blood flow to the gastric tube is supplied only by the GDA via the right gastroepiploic artery (RGEA). Therefore, we carefully chose a technique that would preserve the GDA and avoid gastric tube ischemia. Oncologically, this procedure may be debatable because the efficiency of lymph node dissection along the GDA and RGEA may be compromised. PD involving GDA preservation in common bile duct (CBD) cancer may be acceptable because the CBD is behind the pancreatic head, and the CBD lymph flows into the para-aorta lymph nodes behind the pancreas.
This procedure is suitable for patients who have previously undergone esophagectomy and this procedure prevents digestive function disorders. Using this method, preoperative angiographic assessment and meticulous surgical technique may lead to successful outcomes.
PMCID: PMC4189085  PMID: 25240214
Bile duct cancer; Pancreaticoduodenectomy; Gastroduodenal artery; Esophagectomy; Gastric tube
5.  Repair of bile duct defect with degradable stent and autologous tissue in a porcine model 
AIM: To introduce and evaluate a new method to repair bile duct defect with a degradable stent and autologous tissues.
METHODS: Eight Ba-Ma mini-pigs were used in this study. Experimental models with common bile duct (CBD) defect (0.5-1.0 cm segment of CBD resected) were established and then CBD was reconstructed by duct to duct anastomosis with a novel degradable stent made of poly [sebacic acid-co-(1,3-propanediol)-co-(1,2-propanediol)]. In addition, a vascularized greater omentum was placed around the stent and both ends of CBD. Cholangiography via gall bladder was performed for each pig at postoperative months 1 and 3 to rule out stent translocation and bile duct stricture. Complete blood count was examined pre- and post-operatively to estimate the inflammatory reaction. Liver enzymes and serum bilirubin were examined pre- and post-operatively to evaluate the liver function. Five pigs were sacrificed at month 3 to evaluate the healing of anastomosis. The other three pigs were raised for one year for long-term observation.
RESULTS: All the animals underwent surgery successfully. There was no intraoperative mortality and no bile leakage during the observation period. The white blood cell counts were only slightly increased on day 14 and month 3 postoperatively compared with that before operation, the difference was not statistically significant (P = 0.652). The plasma level of alanine aminotransferase on day 14 and month 3 postoperatively was also not significantly elevated compared with that before operation (P = 0.810). Nevertheless, the plasma level of γ-glutamyl transferase was increased after operation in both groups (P = 0.004), especially 2 wk after operation. The level of serum total bilirubin after operation was not significantly elevated compared with that before operation (P = 0.227), so did the serum direct bilirubin (P = 0.759). By cholangiography via gall bladder, we found that the stent maintained its integrity of shape and was still in situ at month 1, and it disappeared completely at month 3. No severe CBD dilation and stricture were observed at both months 1 and 3. No pig died during the 3-mo postoperative observation period. No sign of necrosis, bile duct stricture, bile leakage or abdominal abscess was found at reoperation at month 3 postoperatively. Pigs had neither fragments of stent nor stones formed in the CBD. Collagen deposit was observed in the anastomosis by hematoxylin and eosin (HE) and Masson’s trichrome stains. No severe cholestasis was observed in liver parenchyma by HE staining. Intestinal obstruction was found in a pig 4 mo after operation, and no bile leakage, bile duct stricture or biliary obstruction were observed in laparotomy. No sign of bile duct stricture or bile leakage was observed in the other two pigs.
CONCLUSION: The novel method for repairing bile duct defect yielded a good short-term effect without postoperative bile duct stricture. However, the long-term effect should be further studied.
PMCID: PMC3468852  PMID: 23066314
Degradable stent; Bile duct defect; Biliary reconstruction; Autologous tissue; Omentum
6.  Techniques of biliary reconstruction following bile duct resection (with video) 
In several clinical situations, including resection of malignant or benign biliary lesions, reconstruction of the biliary system using the Roux-en-Y jejunum limb has been adopted as the standard procedure. The basic technique and the procedural knowledge essential for most gastroenterological surgeons are described in this article, along with a video supplement. Low complication rates involving anastomotic insufficiency or stricture can be achieved by using proper surgical techniques, even following small bile duct reconstruction. Using the ropeway method to stabilize the bile duct and jejunal limb allows precise mucosa-to-mucosa anastomosis with interrupted sutures of the posterior row of the anastomosis. Placement of a transanastomotic stent tube is the second step. The final step involves suturing the anterior row of the anastomosis. In contrast to the lower extrahepatic bile duct, the wall of the hilar or intrahepatic bile duct can be recognized within the fibrous connective tissue in the Glissonean pedicle. The portal side of the duct should be selected for the posterior wall during anastomosis owing to its thickness. Meticulous inspection to avoid overlooking small bile ducts could decrease the chance of postoperative intractable bile leakage. In reconstruction of small or fragile branches, a transanastomotic stent tube could work as an anchor for the anastomosis.
Electronic supplementary material
The online version of this article (doi:10.1007/s00534-011-0475-5) contains supplementary material, which is available to authorized users.
PMCID: PMC3311849  PMID: 22081253
Biliary reconstruction; Bilioenteric anastomosis; Choledochojejunostomy; Hepaticojejunostomy; Hepatobiliary resection
7.  Bilio-entero-gastrostomy: prospective assessment of a modified biliary reconstruction with facilitated future endoscopic access 
BMC Surgery  2012;12:9.
Hepaticojejunostomy (HJ) is the classical reconstruction for benign biliary stricture. Endoscopic management of anastomotic complications after hepaticojejunostomy is extremely difficult. In this work we assess a modified biliary reconstruction in the form of bilio-entero-gastrostomy (BEG) regarding the feasibility of endoscopic access to HJ and management of its stenosis if encountered.
From October 2008 till February 2011 all patients presented to the authors with benign biliary stricture who needed bilio-enteric shunt were considered. For each patient bilio-entero-gastrostomy (BEG) of either type I, II or III was constructed. In the fourth week postoperatively, endoscopy was performed to explore the possibility to access the biliary anastomosis and perform cholangiography.
BEG shunt was performed for seventeen patients, one of whom, with BEG type I, died due to myocardial infarction leaving sixteen patients with a diagnosis of postcholecystectomy biliary injury (9), inflammatory stricture with or without choledocholithiasis (5) and strictured biliary shunt (2). BEG shunts were either type I (3), type II (3) or type III (10). Endoscopic follow up revealed successful access to the anastomosis in 14 patients (87.5%), while the access failed in one type I and one type II BEG (12.5%). Mean time needed to access the anastomosis was 12.6 min (2-55 min). On a scale from 1–5, mean endoscopic difficulty score was 1.7. One patient (6.25%), with BEG type I, developed anastomotic stricture after 18 months that was successfully treated endoscopically by stenting. These preliminary results showed that, in relation to the other types, type III BEG demonstrated the tendency to be surgically simpler to perform, endoscopicall faster to access, easier and with no failure.
BEG, which is a modified biliary reconstruction, facilitates endoscopic access of the biliary anastomosis, offers management option for its complications, and, therefore, could be considered for biliary reconstruction of benign stricture. BEG type III tend to be surgically simpler and endoscopically faster, easier and more successful than type I and II.
PMCID: PMC3411507  PMID: 22720668
8.  Clinical application of laser treatment for cardiovascular surgery 
Laser Therapy  2011;20(3):217-232.
Background: Recently, several kinds of lasers have been widely employed in the field of medicine and surgery. However, laser applications are very rare in the field of cardiovascular surgery throughout the world. So, we have experimentally tried to use lasers in the field of cardiovascular surgery. There were three categories: 1) Transmyocardial laser revascularization (TMLR), 2) Laser vascular anastomosis, and 3) Laser angioplasty in the peripheral arterial diseases.
By the way, surgery for ischemic heart disease has been widely performed in Japan. Especially coronary artery bypass grafting (CABG) for these patients has been done as a popular surgical method. Among these patients there are a few cases for whom CABG and percutaneous coronary intervention (PCI) could not be carried out, because of diffuse stenosis and small caliber of coronary arteries.
Materials and methods of TMLR: A new method of tranasmyocardial revascularization by CO2 laser (output 100 W, irradiation time 0.2 sec) was experimentally performed to save severely ill patients. In this study, a feasibility of transmyocardial laser revascularization from left ventricular cavity through artificially created channels by laser was precisely evaluated. Results: In trials on dogs laser holes 0.2mm in diameter have been shown microscopically to be patent even 3 years after their creation, thus this procedure could be used as a new method of transmyocardial laser revascularization.
Clinical application of TMLR: Subsequently, transmyocardial laser revascularization was employed in a 55-year-old male patient with severe angina pectoris who had undergone pericardiectomy 7 years before. He was completely recovered from severe chest pain. Conclusions of TMLR: This patient was the first successful case in the world with TMLR alone. This method might be done for the patients who percutaneous coronary intervention and coronary artery bypass grafting could be carried out.
Laser vascular anastomosis: At present time, in vascular surgery there are some problems to keep long-term patency after anastomosis of the conventional suture method, especially for small-caliber vessels.
Materials and methods of Laser vascular anastomosis: From these standpoints, a low energy CO2 laser was employed experimentally in vascular anastomosis for small-caliber vessels.
Resullts of Laser vascular anastomosis: From preliminary experiments it could be concluded that the optimal laser output was 20–40 mW and irradiation time was 6–12 sec/mm for vascular anastomosis of small-caliber vessels in the extremities. And then, histologic findings and intensity of the laser anastomotic sites were investigated thereafter. Subseqently, good enough intensity and good healing of laser anastomotic sites as well as the conventional suture method could be observed. There were no statistic differences between laser and suture methods. A feasibility of laser anastomosis could be considered and clinical application could be recognized.
Clinical applications of Laser vascular anastomosis: On February 21, 1985, arterio-venous laser anastomosis for the patient with renal failure was smoothly done and she could accept hemodialysis.
Conclusions of Laser vascular anastomosis: This patient was the first clinical successful case in the world. Thereafter, Laser vascular anastomosis were in 111 patients with intermittent claudication, refractory crural ulcer, and coronary disorders. Thereafter, they are going well. Laser angioplasty: Laser angioplasty for peripheral arterial diseases. There are many methods to treat peripheral arterial diseases such as balloon method, atherectomy, laser technique and stenting graft in the field of endovascular treatment. Recent years, minimal invasive treatment should be employed even in the surgical treatment. However, there are different images between these methods.
Materials and methods of Laser angioplasty: We have chosen to use laser for endovascular treatment for peripheral arterial diseases. We have tried to check between laser energy and vessel wall.
Results of Laser angioplasty: Subsequently, it could be concluded that optimal conditions for laser angioplasty were 6 W in output and irradiation time was 5 sec. And with another method of feedback control system, temperature of metal tip probe was 200°C and irradiation time was 5 sec for each shot. And histological study and feasibility of angioscopic guidance could be done and clinical application was started. Until now, 115 patients were successfully treated with their life longevity.
Conclusions of Laser angioplasty: Thus, laser applications were useful methods to treat a lot of patients with some ischemic problems.
PMCID: PMC3799031  PMID: 24155531
9.  Failure of sequential biliary stenting for unsuccessful common bile duct stone removal 
AIM: To determine the factors associated with the failure of stone removal by a biliary stenting strategy.
METHODS: We retrospectively reviewed 645 patients with common bile duct (CBD) stones who underwent endoscopic retrograde cholangiography for stone removal in Siriraj GI Endoscopy center, Siriraj Hospital from June 2009 to June 2012. A total of 42 patients with unsuccessful initial removal of large CBD stones that underwent sequential biliary stenting were enrolled in the present study. The demographic data, laboratory results, stone characteristics, procedure details, and clinical outcomes were recorded and analyzed. In addition, the patients were classified into two groups based on outcome, successful or failed sequential biliary stenting, and the above factors were compared.
RESULTS: Among the initial 42 patients with unsuccessful initial removal of large CBD stones, there were 37 successful biliary stenting cases and five failed cases. Complete CBD clearance was achieved in 88.0% of cases. The average number of sessions needed before complete stone removal was achieved was 2.43 at an average of 25 wk after the first procedure. Complications during the follow-up period occurred in 19.1% of cases, comprising ascending cholangitis (14.3%) and pancreatitis (4.8%). The factors associated with failure of complete CBD stone clearance in the biliary stenting group were unchanged CBD stone size after the first biliary stenting attempt (10.2 wk) and a greater number of endoscopic retrograde cholangio-pancreatography sessions performed (4.2 sessions).
CONCLUSION: The sequential biliary stenting is an effective management strategy for the failure of initial large CBD stone removal.
PMCID: PMC3680618  PMID: 23772266
Endoscopic retrograde cholangiography; Common bile duct stone; Biliary stenting; Large common bile duct stone; Biliary stenting failure
10.  Therapeutic transjejunal endoscopy for the treatment of biliary complications after choledochojejunostomy 
The present study aimed to assess the value of endoscopic jejunostomy for post-biliary intestinal anastomosis biliary complications. The clinical data of the endoscopic therapies by jejunal approach for post-biliary intestinal anastomosis biliary complications in 13 patients (16 surgeries in total) were retrospectively analyzed. The surgical success rate was 100% (16/16). Nasobiliary tube detention was performed for 2 patients, plastic stent placement for 5 and biliary metal stent placement for 4. The remaining two patients did not retain any drainage tube or bracket after surgery. The incidence rate of intraoperative anastomotic stenostomia was 76.9% (10/13). A noticeable postoperative decrease in bilirubin levels was observed in 10 patients. The level of gallstone-free patients was 75% (3/4). There were 10 cases in which cholangitis remission or no attack was identified. Post-operative incisional infection occurred in 3 patients, hepatophyma in 1 and an intestinal fistula in 1. Endoscopic therapy by jejunal approach for post-biliary intestinal anastomosis biliary complications has the virtue of being safe, effective and minimally invasive. It has extensive potential applications in clinical practice.
PMCID: PMC3570081  PMID: 23403492
jejunum; endoscope; biliary intestinal anastomosis; jejunostomy
11.  Risk factors and prevention of biliary anastomotic complications in adult living donor liver transplantation 
AIM: To evaluate risk factors of biliary anastomotic complications (BACs) and outcomes according to type of biliary reconstruction.
METHODS: A total of 33 consecutive adult living donor liver transplantation (LDLT) were reviewed, 17 of which had undergone Duct-to-Duct anastomosis (D-D). The remaining 16 patients received Roux-en-Y anastomosis (R-Y). The perioperative factors, such as the type of graft and the number of graft bile ducts, were analyzed retrospectively.
RESULTS: The overall incidence of BACs was 39.4%. The incidence of BACs was significantly higher in the patients with than without neoadjuvant chemotherapy (71.4% vs 10%, P = 0.050). There was no significant difference in the incidence of biliary leakage in patients with D-D vs those with R-Y. The incidence of biliary strictures following the healing of biliary leakage was significantly higher in D-D (60%) than in R-Y (0%) (P = 0.026). However, the incidence of BACs related bacteremia was significantly higher in R-Y than in D-D (71.4% vs 0%, P = 0.008). In D-D, use of T-tube stent remarkably reduced the incidence of BACs, compared with straight tube stent (0% vs 50%, P = 0.049).
CONCLUSION: Our experience showed an increase of BACs related bacteremia in the patients with R-Y. Therefore, D-D might be a preferred biliary reconstruction. However, the surgical refinement of D-D should be required because of the high incidence of biliary strictures. Use of the T-tube stent might lead to a significant reduction of BACs in D-D.
PMCID: PMC4250624  PMID: 17696254
Living donor; Liver transplantation; Biliary anastomotic complication; Duct-to-Duct anastomosis; Roux-en-Y anastomosis
12.  T-tube bridging for the management of biliary tree injuries 
Injuries of the biliary tree, which mainly occur as a complication of laparoscopic cholecystectomy, are a potentially life threatening cause of high morbidity and mortality. The reported frequency of biliary injuries after laparoscopic cholecystectomy is from 0.5–0.8%. Such injuries may sometimes become too complicated for surgical repair. Presented here is the case of a patient with a major bile duct injury for whom bile duct continuity was achieved using a T-tube.
Case Report:
A 53-year-old man, who developed bile duct injury following a laparoscopic cholecystectomy performed in another center for cholelithiasis, was referred to our clinic. A Roux-en-Y hepaticojejunostomy was performed in the early postoperative period. However, ensuing anastomotic leakage prompted undoing of the hepaticojejunostomy followed by placement of a T-tube by which bile duct continuity was achieved.
For injuries with tissue loss requiring external drainage, T-tube bridging offers a feasible option in that it provides bile duct continuity with biliary flow into the duodenum, as well as achieving external drainage, thus alleviating the need for further definitive surgery.
PMCID: PMC3615961  PMID: 23569540
iatrogenic bile duct injury; T-tube bridging; external and internal biliary drainage
13.  Indocyanine green fluorescence and three-dimensional imaging of right gastroepiploic artery in gastric tube cancer 
A 79-year-old male was admitted to our hospital for the treatment of cancer of the gastric tube. Gastrointestinal examination revealed a T1b Union for International Cancer Control (UICC) tumor at the pyloric region of the gastric tube. Laparotomy did not reveal infiltration into the serosa, peritoneal dissemination, regional lymph node swelling, or distant metastasis. We performed a distal gastrectomy preserving the right gastroepiploic artery by referencing the preoperative three-dimensional computed tomoangiography. We also evaluated the blood flow of the right gastroepiploic artery and in the proximal gastric tube by using indocyanine green fluorescence imaging intra-operatively and then followed with a gastrojejunal anastomosis with Roux-en-Y reconstruction. The definitive diagnosis was moderately differentiated adenocarcinoma of the gastric tube, pT1bN0M0, pStage IA (UICC). His postoperative course was uneventful. Three-dimensional computed tomographic imaging is effective for assessing the course of blood vessels and the relationship with the surrounding structures. Intraoperative evaluation of blood flow of the right gastroepiploic artery and of the gastric tube in the anastomotic portion is very valuable information and could contribute to a safe gastrointestinal reconstruction.
PMCID: PMC4284357  PMID: 25574113
Gastrectomy; Indocyanine green; Computed tomography; Mediastinum; Metachronous cancer
14.  Electrohydraulic lithotripsy as an highly effective method for complete large common bile duct stone clearance 
The removal of common bile duct (CBD) stones is commonly performed by endoscopic retrograde cholangiography (ERC), which has an 85–90% success rate. Thus, 10–15% of CBD stones, specifically large ones, cannot be completely removed using standard techniques and are therefore managed conservatively by sequential biliary stenting or using other techniques such as electrohydraulic lithotripsy (EH L). The aim of the present paper was to determine the outcomes of these different methods for the removal of large CBD stones in the patients who failed to clear the CBD after initial attempt and to identify the factors which might associated with patients who would fail for sequential biliary stenting. We retrospectively reviewed 439 patients who underwent ERC for stone removal in our institute. In this study, 36 cases and 7 cases were included in the sequential biliary stenting and intraductal EH L groups, respectively, with rates of complete CBD clearance of 86.1% and 100%, respectively. On average, 2.8 and 1.3 sessions were required before complete stone removal in the biliary stenting and EH L groups, respectively. The number of complications during follow-up was higher in biliary stenting than in intraductal EH L patients. The factors associated with failure to complete CBD stone clearance in the biliary stenting group were no change in CBD stone size 9 weeks after the first biliary stenting attempt and failure of balloon sphincteroplasty. EH L was an effective and safe procedure for acheivement of complete CBD clearance especially for large CBD stone.
PMCID: PMC3791527  PMID: 24147232
common bile duct stone; intraductal electrohydraulic lithotripsy; biliary stenting; electrohydraulic lithotripsy; outcomes
15.  Post-operative depletion of platelet count is associated with anastomotic insufficiency following intrahepatic cholangiojejunostomy: a case–control study from the results of 220 cases of intrahepatic cholangiojejunostomy 
BMC Surgery  2014;14:81.
Post-operative anastomotic insufficiency following major hepato-biliary surgery has significant impacts on the post-operative course. Recent reports have revealed that platelets play an important role in liver regeneration and wound healing. From these experimental and clinical results on platelet function, we hypothesized that post-operative platelet depletion (to <10 × 104/μL) would be associated with delayed liver regeneration as well as anastomotic insufficiency of intrahepatic cholangiojejunostomy. However, little information is available regarding correlations between platelet count and these complications. The purposes of the present study were, firstly, to evaluate the incidence of anastomotic insufficiency following intrahepatic cholangiojejunostomy and, secondly, to evaluate whether platelet depletion represents a risk factor for anastomotic insufficiency in intrahepatic cholangiojejunostomy.
Participants in this study comprised 220 consecutive patients who underwent intrahepatic cholangiojejunostomy following hepato-biliary resection for biliary malignancies between September 1998 and December 2010. Anastomotic insufficiency was confirmed by cholangiographic demonstration of leakage from the anastomosis using contrast medium introduced via a biliary drainage tube or prophylactic drain placed during surgery.
Anastomotic insufficiency of the intrahepatic cholangiojejunostomy occurred in 13 of 220 patients (6%). Thirteen of the 220 patients, including one with anastomotic insufficiency, died during the study. Uni- and multivariate analyses both revealed that platelet depletion on post-operative day 1 (<10 × 104/μL) correlated with anastomotic insufficiency.
Post-operative platelet depletion was closely associated with anastomotic insufficiency following intrahepatic cholangiojejunostomy. This correlation has been established, but the underlying mechanisms have not.
PMCID: PMC4274695  PMID: 25323783
Biliary reconstruction; Intrahepatic cholangiojejunostomy; Platelet depletion; Liver regeneration
16.  Postoperative biliary adverse events following orthotopic liver transplantation: Assessment with magnetic resonance cholangiography 
World Journal of Gastroenterology : WJG  2014;20(32):11080-11094.
Biliary adverse events following orthotopic liver transplantation (OLT) are relatively common and continue to be serious causes of morbidity, mortality, and transplant dysfunction or failure. The development of these adverse events is heavily influenced by the type of anastomosis during surgery. The low specificity of clinical and biologic findings makes the diagnosis challenging. Moreover, direct cholangiographic procedures such as endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography present an inadmissible rate of adverse events to be utilized in clinically low suspected patients. Magnetic resonance (MR) maging with MR cholangiopancreatography is crucial in assessing abnormalities in the biliary system after liver surgery, including liver transplant. MR cholangiopancreatography is a safe, rapid, non-invasive, and effective diagnostic procedure for the evaluation of biliary adverse events after liver transplantation, since it plays an increasingly important role in the diagnosis and management of these events. On the basis of a recent systematic review of the literature the summary estimates of sensitivity and specificity of MR cholangiopancreatography for diagnosis of biliary adverse events following OLT were 0.95 and 0.92, respectively. It can provide a non-invasive method of imaging surgical reconstruction of the biliary anastomoses as well as adverse events including anastomotic and non-anastomotic strictures, biliary lithiasis and sphincter of Oddi dysfunction in liver transplant recipients. Nevertheless, conventional T2-weighted MR cholangiography can be implemented with T1-weighted contrast-enhanced MR cholangiography using hepatobiliary contrast agents (in particular using Gd-EOB-DTPA) in order to improve the diagnostic accuracy in the adverse events’ detection such as bile leakage and strictures, especially in selected patients with biliary-enteric anastomosis.
PMCID: PMC4145751  PMID: 25170197
Liver transplantation; Bile ducts; Biliary adverse events; Magnetic resonance cholangiography; Contrast-enhanced magnetic resonance cholangiography
17.  In vitro study of accuracy of cervical pedicle screw insertion using an electronic conductivity device (ATPS part III) 
European Spine Journal  2009;18(9):1300-1313.
Reconstruction of the highly unstable, anteriorly decompressed cervical spine poses biomechanical challenges to current stabilization strategies, including circumferential instrumented fusion, to prevent failure. To avoid secondary posterior surgery, particularly in the elderly population, while increasing primary construct rigidity of anterior-only reconstructions, the authors introduced the concept of anterior transpedicular screw (ATPS) fixation and plating. We demonstrated its morphological feasibility, its superior biomechanical pull-out characteristics compared with vertebral body screws and the accuracy of inserting ATPS using a manual fluoroscopically assisted technique. Although accuracy was high, showing non-critical breaches in the axial and sagittal plane in 78 and 96%, further research was indicated refining technique and increasing accuracy. In light of first clinical case series, the authors analyzed the impact of using an electronic conductivity device (ECD, PediGuard) on the accuracy of ATPS insertion. As there exist only experiences in thoracolumbar surgery the versatility of the ECD was also assessed for posterior cervical pedicle screw fixation (pCPS). 30 ATPS and 30 pCPS were inserted alternately into the C3–T1 vertebra of five fresh-frozen specimen. Fluoroscopic assistance was only used for the entry point selection, pedicle tract preparation was done using the ECD. Preoperative CT scans were assessed for sclerosis at the pedicle entrance or core, and vertebrae with dense pedicles were excluded. Pre- and postoperative reconstructed CT scans were analyzed for pedicle screw positions according to a previously established grading system. Statistical analysis revealed an astonishingly high accuracy for the ATPS group with no critical screw position (0%) in axial or sagittal plane. In the pCPS group, 88.9% of screws inserted showed non-critical screw position, while 11.1% showed critical pedicle perforations. The usage of an ECD for posterior and anterior pedicle screw tract preparation with the exclusion of dense cortical pedicles was shown to be a successful and clinically sound concept with high-accuracy rates for ATPS and pCPS. In concert with fluoroscopic guidance and pedicle axis views, application of an ECD and exclusion of dense cortical pedicles might increase comfort and safety with the clinical use of pCPS. In addition, we presented a reasonable laboratory setting for the clinical introduction of an ATPS-plate system.
PMCID: PMC2899545  PMID: 19575244
Cervical pedicle screw fixation; Accuracy; Electronic conductivity device; Insertion technique; ATPS
18.  Anomalous opening of the common bile duct into the duodenal bulb: endoscopic treatment 
BMC Gastroenterology  2007;7:26.
Anomalous biliary opening especially the presence of the ampulla of Vater in the duodenal bulb is a very rare phenomenon. We report clinical implications, laboratory and ERCP findings and also therapeutic approaches in 53 cases.
The data were collected from the records of 12.158 ERCP. The diagnosis was established as an anomalous opening of the common bile duct (CBD) into the duodenal bulb when there is an orifice observed in the bulb with the absence of a papillary structure at its normal localization and when the CBD is visualized by cholangiography through this orifice without evidence of any other opening.
A total of 53 cases were recruited. There was an obvious male preponderance (M/F: 49/4). Demographic data and ERCP findings were available for all, but clinical characteristics and laboratory findings could be obtained from 39 patients with full records. Thirty – seven of 39 cases had abdominal pain (95%) and 23 of them (59%) had cholangitis as well. Elevated AP and GGT were found in 97.4% (52/53). History of cholecystectomy was present in 64% of the cases, recurrent cholangitis in 26% and duodenal ulcer in 45%. Normal papilla was not observed in any of the patients and a cleft-like opening was evident instead. The CBD was hook shaped at the distal part that opens to the duodenal bulb. Pancreatic duct (PD) was opening separately into the bulb in all the cases when it was possible to visualize. Dilated CBD in ERCP was evident in 94% and the CBD stone was demonstrated in 51%. PD was dilated in four of 12 (33%) cases. None of them has a history of pancreatitis. Endoscopically, Papillary Balloon Dilatation instead of Sphincterotomy carried out in 19 of 27 patients (70%) with choledocholithiazis. Remaining eight patients had undergone surgery (30%). Clinical symptoms were resolved with medical treatment in 16(32%) patients with dilated CBD but no stone. Perforation and bleeding were occurred only in two patients, which stones extracted with sphincterotomy (each complication in 1 patient).
The opening of the CBD into the duodenal bulb is a rare event that may be associated with biliary and gastric/duodenal diseases. To date, surgical treatment has been preferred. In our experience, sphincterotomy has a high risk since it may lead to bleeding and perforation by virtue of the fact that a true papillary structure is absent. However, we performed balloon dilatation of the orifice successfully without any serious complication and suggest this as a safe therapeutic modality.
PMCID: PMC1933541  PMID: 17610747
19.  Obstructive jaundice and cholangitis caused by an arterial ring of the proper hepatic artery around the common bile duct 
Many different benign and malignant diseases can cause obstruction of the extrahepatic biliary duct. One of the more serious complications of biliary obstruction is cholangitis leading to emergency decompression. Anatomic variations are frequent in this region; however, it has rarely been reported that the extrahepatic bile duct is compressed by the arterial vessels.
Case Report
We present the case of a 68-year-old woman who was admitted through the emergency department of our hospital with jaundice, abdominal pain and fever. Biochemical analyses of liver function showed increased value of AST (113 IU/L) and AST (128 IU/L). Total bilirubin was 5.88 mg/dl, conjugated bilirubin was 3.00 mg/dl, and alkaline phosphatase was 393 IU/L. We performed abdominal ultrasound (US), magnetic resonance cholangiopancreatography (MRCP), and computed tomography (CT) imaging. Multislice CT angiography showed that the arterial ring of the common hepatic artery around the common bile duct (CBD) originated from the superior mesenteric artery. Cholecystectomy and intraoperative cholangiography were performed, as well as decompression and lavage of the biliary tree. Escherichia coli was identified from bile. Dissection of the hepatoduodenal ligament confirmed that the proper hepatic artery made a vascular ring around the CBD. Finally, a T tube was placed into the CBD. During 5 years of follow-up the patient has been without recurrent episodes of jaundice. In such cases dissection of the proper hepatic artery from the common hepatic duct is the treatment of choice.
If there are signs of cholangitis decompression and lavage of the biliary tree with “T”, drainage should be performed. Vascular malformations should be considered as a possible cause of extrahepatic biliary obstruction. CT angiography may be helpful in identifying these malformations.
PMCID: PMC3539617  PMID: 21804468
cholangitis; benign obstructive jaundice; vascular malformation
20.  Antegrade common bile duct (CBD) stenting after laparoscopic CBD exploration 
Laparoscopic common bile duct exploration (LCBDE) has been found to be a safe, efficient and cost-effective treatment for choledocholithiasis. Following LCBDE, the clearance may be ascertained by a cholangiogram or choledochoscopy. The common bile duct (CBD) may be closed primarily with or without a stent in situ or may be drained by means of a T-tube or a biliary enteric anastomosis.
Materials and Methods:
In our series of 464 patients of choledocholithiasis, 100 patients underwent closure of the CBD with an indwelling antegrade stent following LCBDE. LCBDE was performed by direct massage of CBD, saline lavage, direct pickup with choledocholithotomy forceps or by basketing. Fragmentation of impacted stones in situ was performed in a few patients. Completion choledochoscopy was performed by means of a pediatric bronchoscope. A 10-cm, 7 Fr. double-flap biliary stent was placed in situ after LCBDE.
There was no mortality in the series. There was no conversion either. The median duration of the operation was 75 min. The mean postoperative hospital stay was 3.5 days. One patient had a minor postoperative biliary leak. One patient had a right sub-hepatic collection. Four patients developed postoperative port infection. The stents were removed endoscopically after 4 weeks. Sixty-eight patients could be followed up till 1 year. There has been no incidence of residual disease and the patients on follow-up are asymptomatic.
In our experience, a single stage laparoscopic treatment of cholelithiasis with choledocholithiasis is a safe, viable and cost-effective option. Closure of the CBD over an antegrade stent is a feasible option but requires advanced skills in minimal access surgical techniques, especially endosuturing. The procedure may be performed safely in expert hands without mortality and with negligible morbidity.
PMCID: PMC2910375  PMID: 20668614
Antegrade stenting; choledochoduodenostomy; choledocholithiasis; laparoscopic common bile duct exploration; T-tube drainage
21.  Comparision of modified and conventional delta-shaped gastroduodenostomy in totally laparoscopic surgery 
World Journal of Gastroenterology : WJG  2014;20(30):10478-10485.
AIM: To evaluate the safety and feasibility of a modified delta-shaped gastroduodenostomy (DSG) in totally laparoscopic distal gastrectomy (TLDG).
METHODS: We performed a case-control study enrolling 63 patients with distal gastric cancer (GC) undergoing TLDG with a DSG from January 2013 to June 2013. Twenty-two patients underwent a conventional DSG (Con-Group), whereas the other 41 patients underwent a modified version of the DSG (Mod-Group). The modified procedure required only the instruments of the surgeon and assistant to complete the involution of the common stab incision and to completely resect the duodenal cutting edge, resulting in an anastomosis with an inverted T-shaped appearance. The clinicopathological characteristics, surgical outcomes, anastomosis time and complications of the two groups were retrospectively analyzed using a prospectively maintained comprehensive database.
RESULTS: DSG procedures were successfully completed in all of the patients with histologically complete (R0) resections, and none of these patients required conversion to open surgery. The clinicopathological characteristics of the two groups were similar. There were no significant differences between the groups in the operative time, intraoperative blood loss, extension of the lymph node (LN) dissection and number of dissected LNs (150.8 ± 21.6 min vs 143.4 ± 23.4 min, P = 0.225 for the operative time; 26.8 ± 11.3 min vs 30.6 ± 14.8 mL, P = 0.157 for the intraoperative blood loss; 4/18 vs 3/38, P = 0.375 for the extension of the LN dissection; and 43.9 ± 13.4 vs 39.5 ± 11.5 per case, P = 0.151 for the number of dissected LNs). The anastomosis time, however, was significantly shorter in the Mod-Group than in the Con-Group (13.9 ± 2.8 min vs 23.9 ± 5.6 min, P = 0.000). The postoperative outcomes, including the times to out-of-bed activities, first flatus, resumption of soft diet and postoperative hospital stay, as well as the anastomosis size, did not differ significantly (1.9 ± 0.6 d vs 2.3 ± 1.5 d, P = 0.228 for the time to out-of-bed activities; 3.2 ± 0.9 d vs 3.5 ± 1.3 d, P = 0.295 for the first flatus time; 7.5 ± 0.8 d vs 8.1 ± 4.3 d, P = 0.489 for the resumption of a soft diet time; 14.3 ± 10.6 d vs 11.5 ± 4.9 d, P = 0.148 for the postoperative hospital stay; and 30.5 ± 3.6 mm vs 30.1 ± 4.0 mm, P = 0.730 for the anastomosis size). One patient with minor anastomotic leakage in the Con-Group was managed conservatively; no other patients experienced any complications around the anastomosis. The operative complication rates were similar in the Con- and Mod-Groups (9.1% vs 7.3%, P = 1.000).
CONCLUSION: The modified DSG, an alternative reconstruction in TLDG for GC, is technically safe and feasible, with a simpler process that reduces the anastomosis time.
PMCID: PMC4130856  PMID: 25132765
Stomach neoplasms; Totally laparoscopic surgery; Digestive tract reconstruction; Modified anastomosis; Treatment outcome
22.  Management of Injury to the Common Bile Duct in a Patient with Roux-en-Y Gastric Bypass 
Case Reports in Surgery  2014;2014:938532.
Introduction. Most surgeons prefer Roux-en-Y hepaticojejunostomy (RYHJ) for biliary reconstruction following a common bile duct (CBD) injury. However, in patients with a Roux-en-Y gastric bypass (RYGB) a RYHJ may be technically challenging and can interfere with bowel physiology induced by RYGB. The use of a hepaticoduodenostomy (HD) resolves both these issues. Presentation of Case. We present a case of CBD injury during laparoscopic cholecystectomy one year after laparoscopic RYGB for morbid obesity. Due to adhesions and previous surgery with RYGB, we did not want to interfere with the RYGB physiology by anastomosing the CBD to the jejunum or ileum. Succeeding a full Kocher's maneuver we performed biliary reconstruction by a tension-free end-to-side HD. The postoperative recovery was uneventful and the patient was discharged after eight days. At four-month follow-up, the patient had stable weight and normal laboratory test results. MRCP demonstrated normal intra- and extrahepatic bile ducts with status after HD. Discussion. We propose that HD should be considered in treatment of CBD injury in post-RYGB patients as it may reduce the risk of interfering with the post-RYGB physiology.
PMCID: PMC4139029  PMID: 25161795
23.  Mirizzi syndrome type Va: A rare coexistence of double cholecysto-biliary and cholecysto-enteric fistulae 
World Journal of Radiology  2010;2(10):410-413.
Mirizzi syndrome is a rare cause of intermittent obstructive jaundice, where an impacted stone in the cystic duct or Hartmann’s pouch mechanically obstructs the common bile duct (CBD). We report a rare case of double cholecysto-biliary and cholecysto-enteric fistulae, in a 75-year-old female patient, presenting with a right upper quadrant abdominal pain and intermittent obstructive jaundice. Endoscopic retrograde cholangiopancreatography suggested Mirizzi syndrome. Operative findings included erosions of the lateral wall of the CBD and the second portion of the duodenum due to impacted gallstones. The defects were reconstructed primarily and a Kehr tube was inserted. The patient had an uneventful postoperative course and was discharged on the 14th postoperative day.
PMCID: PMC2999013  PMID: 21161027
Mirizzi syndrome; Obstructive jaundice; Gallstone; Cholecysto-enteric fistula; Endoscopic retrograde cholangiopancreatography
24.  Percutaneous Treatment of Extrahepatic Bile Duct Stones Assisted by Balloon Sphincteroplasty and Occlusion Balloon 
Korean Journal of Radiology  2005;6(4):235-240.
To describe the technical feasibility and usefulness of extrahepatic biliary stone removal by balloon sphincteroplasty and occlusion balloon pushing.
Materials and Methods
Fifteen patients with extrahepatic bile duct stones were included in this study. Endoscopic stone removal was not successful in 13 patients, and two patients refused the procedure due to endoscopy phobia. At first, all patients underwent percutaneous transhepatic biliary drainage (PTBD). A few days later, through the PTBD route, balloon assisted dilatation for common bile duct (CBD) sphincter was performed, and then the stones were pushed into the duodenum using an 11.5 mm occlusion balloon. Success rate, reason for failure, and complications associated with the procedure were evaluated.
Eight patients had one stone, five patients had two stones, and two patients had more than five stones. The procedure was successful in 13 patients (13/15). In 12 of the patients, all stones were removed in the first trial. In one patient, residual stones were discovered on follow-up cholangiography, and were subsequently removed in the second trial. Technical failure occurred in two patients. Both of these patients had severely dilated CBD and multiple stones with various sizes. Ten patients complained of pain in the right upper quadrant and epigastrium of the abdomen immediately following the procedure, but there were no significant procedure-related complications such as bleeding or pancreatitis.
Percutaneous extrahepatic biliary stone removal by balloon sphincteroplasty and subsequent stone pushing with occlusion balloon is an effective, safe, and technically feasible procedure which can be used as an alternative method in patients when endoscopic extrahepatic biliary stone removal was not successful.
PMCID: PMC2684970  PMID: 16374081
Extrahepatic bile duct, calculi; Extrahepatic bile duct, stone extraction
25.  Isolated segmental, sectoral and right hepatic bile duct injuries 
The treatment of isolated segmental, sectoral and right hepatic bile duct injuries is controversial. Nineteen patients were treated over a 26-year period. Group one was comprised of 4 patients in whom the injury was primarily repaired during the original surgery; 3 over a T-tube, 1 with a Roux-en-Y. These patients had an uneventful recovery. The second group consisted of 5 patients in whom the duct was ligated; 4 developed infection, 3 of which required drainage and biliary repair. Two patients had good long-term outcomes; the third developed a late anastomotic stricture requiring further surgery. The fourth patient developed a small bile leak and pain which resolved spontaneously. The fifth patient developed complications from which he died. The third group was comprised of 4 patients referred with biliary peritonitis; all underwent drainage and lavage, and developed biliary fistulae, 3 of which resolved spontaneously, 1 required Roux-en-Y repair, with favorable outcomes. The fourth group consisted of 6 patients with biliary fistulae. Two patients, both with an 8-wk history of a fistula, underwent Roux-en-Y repair. Two others also underwent a Roux-en-Y repair, as their fistulae showed no signs of closure. The remaining 2 patients had spontaneous closure of their biliary fistulae. A primary repair is a reasonable alternative to ligature of injured duct. Patients with ligated ducts may develop complications. Infected ducts require further surgery. Patients with biliary peritonitis must be treated with drainage and lavage. There is a 50% chance that a biliary fistula will close spontaneously. In cases where the biliary fistula does not close within 6 to 8 wk, a Roux-en-Y anastomosis should be considered.
PMCID: PMC2665134  PMID: 19322912
Segmental bile duct; Sectoral bile duct; Right hepatic bile duct; Injury; Treatment

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