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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.

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.

Introduction

Operations on the common bile duct may lead to potentially serious complications such as biliary peritonitis. T-tube insertion is performed to reduce the risk of this occurring postoperatively. Biliary leakage at the point of insertion into the common bile duct, or along the fistula, can sometimes occur after T-tube removal and this has been reported extensively in the literature. We report a case where the site at which the T-tube fistula leaked proved to be the point of contact between the fistula and the anterior abdominal wall, a previously unreported complication.

Case presentation

A 36-year-old sub-Saharan African woman presented with gallstone-induced pancreatitis and, once her symptoms settled, laparoscopic cholecystectomy was performed, common bile duct stones were removed and a T-tube was inserted. Three weeks later, T-tube removal led to biliary peritonitis due to the disconnection of the T-tube fistula which was recannulated laparoscopically using a Latex drain.

Conclusion

This case highlights a previously unreported mechanism for bile leak following T-tube removal caused by detachment of a fistula tract at its contact point with the anterior abdominal wall. Hepatobiliary surgeons should be aware of this mechanism of biliary leakage and the use of laparoscopy to recannulate the fistula.

T-tube usage is common following common bile duct exploration for calculi and other complex biliary surgeries to ensure proper biliary diversion and healing. A 25-year-old woman was referred from a surgical unit with a history of open cholecystectomy and common bile duct exploration for cholelithiasis and choledocholithiasis with T-tube placement in the common bile duct for postoperative biliary diversion. While retrieving the T-tube, it got fractured and the fragment remained in the bile duct. We report a rare case of retained T-tube fragment after T-tube removal that was retrieved endoscopically.

Iatrogenic bile-duct injury post-laparoscopic cholecystectomy remains a major serious complication with unpredictable long-term results. We present a patient who underwent laparoscopic cholecystectomy for gallstones, in which the biliary injury was recognized intraoperatively. The surgical procedure was converted to an open one. The first surgeon repaired the injury over a T-tube without recognizing the anatomy and type of the biliary lesion, which led to an unusual biliary mal-repair. Immediately postoperatively, the abdominal drain brought a large amount of bile. A T-tube cholangiogram was performed. Despite the contrast medium leaking through the abdominal drain, the mal-repair was unrecognized. The patient was referred to our hospital for biliary leak. Ultrasound and cholangiography was repeated, which showed an unanatomical repair (right to left hepatic duct anastomosis over the T-tube), with evidence of contrast medium coming out through the abdominal drain. Eventually the patient was subjected to a definitive surgical treatment. The biliary continuity was re-established by a Roux-en-Y hepatico-jejunostomy, over transanastomotic external biliary stents. The patient is now doing well 4 years after the second surgical procedure. In reviewing the literature, we found a similar type of injury but we did not find a similar surgical mal-repair. We propose an algorithm for the treatment of early and late biliary injuries.

Common bile duct stones (CBDSs) may occur in up to 3%–14.7% of all patients for whom cholecystectomy is preformed. Patients presenting with CBDS have symptoms including: biliary colic, jaundice, cholangitis, pancreatitis or may be asymptomatic. It is important to distinguish between primary and secondary stones, because the treatment approach varies. Stones found before, during, and after cholecystectomy had also differing treatments. Different methods have been used for the treatment of CBDS but the suitable therapy depends on conditions such as patient' satisfaction, number and size of stones, and the surgeons experience in laparoscopy. Endoscopic retrograde cholangiopancreatography with or without endoscopic biliary sphincterotomy, laparoscopic CBD exploration (transcystic or transcholedochal), or laparotomy with CBD exploration (by T-tube, C-tube insertion, or primary closure) are the most commonly used methods managing CBDS. We will review the pathophysiology of CBDS, diagnosis, and different techniques of treatment with especial focus on the various surgical modalities.

Introduction

Nonoperative management (NOM) of hemodynamically stable patients with blunt hepatic injuries is considered the current standard of care. However, it is associated with several in-hospital complications. In selected cases laparoscopy could be proposed as diagnostic and therapeutic means.

Case report

A 28 years-old male was admitted in the Emergency Unit following a motor vehicle crash. CT-scan showed an isolated stade II hepatic injury at the level of the segment IV. Firstly a NOM was decided. Laparoscopic exploration was then performed at day 4 due to a biliary peritonitis. Intraoperative trans-cystic duct cholangiography showed a biliary leaks of left hepatic biliary tract, involving sectioral pedicle to segment III. Cholecystectomy, trans-cystic biliary drainage, application of surgical tissue sealing patch and abdominal drainage were performed. Postoperative outcome was uneventful, with fast patient recovery.

Conclusion

Laparoscopy has gained a role as diagnostic and therapeutic means in treatment of complications following NOM of blunt liver trauma. This approach seems feasible and safety, with satisfactory postoperative outcome.

The biliary excretion of a new derivative of cephalosporin, cephacetrile (CIBA 36 278 Ba), was studied (i) in the isolated perfused rabbit liver, (ii) in humans with a duodenal tube, and (iii) in patients after cholecystectomy with a Kehr's drain in the common bile duct. The biliary excretion of the antibiotic was very low in the perfused liver, and no antibiotic activity was found in liver tissue at the end of the experiment. This observation, together with the finding of a rapid decline of the antibiotic concentration in the circulating blood serum, favors the assumption that a metabolic transformation of CIBA 36 278 Ba in liver tissue takes place. In humans, the antibiotic concentration was found to be low both in the duodenal juice and in the bile obtained by external drainage. The biliary concentrations found in these subjects seem to be inferior to those required for the inhibition of the common bacteria of biliary infections. In renal failure, however, the biliary excretion of CIBA 36 278 Ba increased considerably.

Background

Benign biliary postoperative stenoses and biliary leaks and fistulas usually occur due to injury after laparoscopic cholecystectomy, gastric or hepatic resection, bilio-enteric anastomoses and after liver transplantation. In most of the cases a new surgical intervention is not possible and the percutaneous trans-hepatic approach is of paramount importance in the diagnosis and treatment of the problem. This review aims to highlight the spectrum of percutaneous cholangiographic findings and methods of treatment of postoperative benign biliary stenoses and biliary leaks and fistulas. In the case of stenosis, dilation of the narrow tract is the usually the first approach, whereas in the case of leaks and fistulas bile diversion with drainage is usually attempted in order to seal the fistulous tract. However, a great variety of combination of materials and techniques may be used on a “case-by case” approach

Methods

A selection of cases of benign biliary postoperative stenoses and biliary leaks and fistulas that were managed percutaneously are presented and the most common lines of approach are discussed.

Conclusion

The imaging spectrum of percutaneous treatment of benign biliary postoperative stenoses and biliary leaks and fistulas is presented in order to aid interpretation and management with image guided procedures.

Teaching Points

• Treatment of benign biliary stenosis is performed with cholangioplasty and stents.

• The main goal of fistula treatment is to divert the bile away from the site of bile wall defect.

• Drain collection and tract embolisation are the other options for bile leak percutaneous treatment.

Background

Combined iatrogenic vascular and biliary injury during cholecystectomy resulting in ischemic hepatic necrosis is a very rare cause of acute liver failure. We describe a patient who developed fulminant liver failure as a result of severe cholestasis and liver gangrene secondary to iatrogenic combine injury or the hepatic pedicle (i.e. hepatic artery, portal vein and bile duct) during laparoscopic cholecystectomy.

Case presentation

A 40-years-old woman underwent laparoscopic cholecystectomy for acute cholecystitis. During laparoscopy, a severe bleeding at the liver hilum motivated the conversion to open surgery. Many sutures were placed across the parenchyma for bleeding control. After 48 hours, she rapidly deteriorated with encephalopathy, coagulopathy, persistent hypotension and progressive organ dysfunction including acute renal failure requiring hemodialysis and mechanical ventilation. An angiography documented an occlusion of right hepatic artery and right portal vein. In the clinical of acute liver failure secondary to liver gangrene, severe coagulopathy and progressive secondary multi-organ failure, the patient was included in the waiting list for liver transplantation. Two days later, the patient was successfully transplanted with initial adequate liver graft function. However, she developed bilateral pneumonia and severe gastrointestinal bleeding and finally died 24 days after transplantation due to bilateral necrotizing pneumonia.

Conclusion

The occurrence of acute liver failure due to portal triad injury during laparoscopic cholecystectomy is a catastrophic complication. Probably, the indication of liver transplantation as a life-saving strategy in patients with late diagnosis, acute liver failure, severe coagulopathy and progressive secondary multi-organ failure could be considered but only minimizing immunosuppressive regimen to avoid postoperative infections.

BACKGROUND

Complete reports of biliary and vascular injuries after laparoscopic cholecystectomy are rare.

STUDY DESIGN

Fifteen patients with complex laparoscopic cholecystectomy injuries underwent corrective operations. The injuries consisted of 14 bile duct injuries and one large laceration of a cirrhotic liver. Five of the bile duct injuries were accompanied by inadvertent occlusion of the right hepatic artery, and one was further complicated by portal vein occlusion. One hepatic artery occlusion and one portal vein occlusion were successfully reconstructed. Two patients with arterial occlusion required right hepatic lobectomy. Corrective biliary operations consisted of common hepaticojejunostomy (seven cases), right and left hepaticojejunostomies (one case), right anterior and left hepaticojejunostomies (two cases), right hepaticojejunostomy (one case), right posterior hepaticojejunostomy (one case), and left hepaticojejunostomy after right lobectomy (two cases).

RESULTS

Except for a patient with a severe laceration of a cirrhotic liver who died as a result of hepatic failure, the remaining 14 patients are alive and well with normal hepatic function tests at six and 37 months after corrective operations.

CONCLUSIONS

A knowledge of anatomy is critical to the prevention of injuries to the hepatobiliary tree and related structures during laparoscopic cholecystectomy. J. Am. Coll. Surg., 1994, 179: 321–325.

Background

Biliary complications continue to be an important determinant of the recipient's survival rate after orthotopic liver transplantation (OLT). The objective of this study was to evaluate the incidence of early biliary complications in OLT in the presence or absence of a T‐tube.

Methods

This retrospective study, based on inpatient data, focused on the relationship between T‐tube placement and early biliary complications of 84 patients after OLT, from November 2002 to June 2005. Patients were divided into two groups based on whether or not a T‐tube was used following bile duct reconstruction: T‐tube group (group I, n = 33); non‐T‐tube group (group II, n = 51).

Results

45.2% of OLT recipients had a malignant neoplasm. There were no significant differences in the demographic characteristics or operation data between the two groups. Overall, early biliary tract complications developed in 19.0% (16/84) of patients. The rate of early biliary complications was 30.3% (10/33) and 11.8% (6/51) in groups I II, respectively (p = 0.035). Biliary complications which were directly caused by T‐tube placement occurred in 12.1% (4/33) of patients in group I. Overall, the percentage of malignant neoplasms, chronic viral cirrhosis, fulminant liver failure and other primary disease recipients with early biliary complications were 6.2%, 37.5%, 43.8% and 12.5%, respectively.

Conclusion

This study suggests that the use of a T‐tube in Chinese patients undergoing OLT causes a higher incidence of early biliary complications. Most of the early biliary complications occurred in chronic viral cirrhosis and fulminant liver failure recipients.

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.

A case of esophageal ulcer caused by nasobiliary tube is described. This tool is not routinely considered to be a cause of major complications in the literature and to our knowledge, this is the first report of this kind of complication in nasobiliary tube placement. A 72-year-old patient presented with Charcot's triad and was demonstrated to have cholangitis with multiple biliary stones in the common bile duct. Biliary drainage was achieved through endoscopic retrograde cholangiography, endoscopic sphincterotomy, biliary tree drainage and nasobiliary tube with double pigtail. The patient presented odynophagia, dysphagia and retrosternal pain 12 h after the procedure and upper endoscopy revealed a long esophageal ulcer, which was treated conservatively. This report provides corroboration of evidence that nasobiliary tube placement has potential complications related to pressure sores. In our opinion this is a possibility to consider in informed consent forms.

Radiographic assessment of the biliary tract is often essential in patients who have undergone liver transplantation. T- or straight-tube cholangiography, percutaneous transhepatic cholangiography, and endoscopic retrograde cholangiography all may be used. A total of 264 cholangiograms in 79 adult liver transplant patients (96 transplants) was reviewed. Normal radiographic features of biliary reconstructive procedures, including choledochocholedochostomy and choledochojejunostomy, are demonstrated. Complications diagnosed by cholangiography included obstruction, bile leaks, and tube problems, seen in eight, 24, and 12 transplants respectively. Stretching and incomplete filling of intrahepatic biliary ducts were frequently noted and may be associated with rejection and other conditions. Transhepatic biliary drainage, balloon catheter dilatation of strictures, replacement of dislodged T-tubes, and restoring patency of obstructed T-tubes using interventional radiologic techniques were important in avoiding complications and additional surgery in selected patients.

A 29 year old morbidly obese patient suffered injury to his common bile duct during cholecystectomy. Subsequent access to the biliary tree was obtained by using a long heavy gauge needle after first opacifying the system with contrast injection through a nasobiliary tube. It is now twenty six months after initial percutaneous biliary drainage placement and eighteen months after removal of all biliary access. The patient is asymptomatic and has normal liver function tests. This technique can be useful in morbidly obese patients who are at increased risk from surgical repair of biliary duct injuries.

A 43-year old woman was admitted 11 days after open cholecystectomy with a iatrogenic bile duct injury. On admission the patient showed an uncontrolled biliary fistula through an external drain placed at an emergency laparotomy for biliary peritonitis with fever and jaundice. PTC showed a biliary stricture type II (Bismuth). A percutaneous drainage was performed to decompress the biliary system. Three weeks later, percutaneous balloon dilatation of the stricture was performed. However, bile leakage persisted. In a combined transhepatic/ endoscopic procedure, the percutaneous biliary drainage was replaced by a nasobiliary tube. One week later, no stricture was found and the biliary leak was sealed. The patient could be discharged without symptoms or signs of cholestasis. The multidisciplinary management of post-operative biliary fistula is presented, comparing the role of interventional radiology, endoscopy and surgery.

We propose a method of reconstruction after pancreaticoduodenectomy consisting of a double Roux en Y on the same jejunal loop without interruption of the mesentery and a third anatomical Roux en Y to reconstitute the alimentary tract.

The construction of the double Roux en Y draining pancreas and bile ducts separately, requires a linear Stapler 3-4 centimeters from the biliary anastomosis. In this way, by employing the same loop without mesenteric interruption, two functional excluded loops will be ’obtained. The rationale of the suggested model is based on the separation of biliary and pancreatic secretions. This makes it possible to avoid a stagnant cul-de-sac coinciding with the pancreaticojejunal anastomosis and to obtain in the case of leakage, a pure biliary and/or pancreatic fistula as far as is possible.

99mTc HIDA scans demonstrated the efficiency, of the biliopancreatic limbs of the reconstruction, showing normal emptying time for the gastric remnant and the absence of radionuclide stagnation or any alkaline enterogastric reflux.

Introduction

Blunt duodenal injuries do not occur often. A patient with damage to the duodenal tissue around the pancreatic and common bile duct presents a challenge to surgeons. The choice of procedure must be tailored to the nature of the defect and the amount of tissue lost.

Case presentation

We describe the case of a 16-year-old Caucasian boy with a blunt duodenal injury after a motor vehicle accident. On admission, the patient had stable vital signs and a normal laboratory workup. Gradually his clinical condition deteriorated and a computed tomography scan showed a retroperitoneal haematoma at the level of his duodenum. A fully circumferential rupture of the second part of his duodenum was found during laparotomy, with the intact Vater's papilla lying adjacent to the defect and a superficial laceration of the head of his pancreas. The retroperitoneal haematoma was thoroughly drained and a pedicled ileal loop was interposed between the duodenal stumps to restore the continuity of the patient's duodenum. Apart from a mild postoperative pancreatitis, the patient's postoperative course evolved with no further problems. The patient was discharged on the 22nd postoperative day in excellent condition and has remained so to date (after five years).

Conclusion

In our case report, where the second part of the patient's duodenum was completely transected, our choices for reconstruction were limited. Important factors for the successful management of this patient were prompt surgical intervention and the accurate assessment of the nature of the duodenal and associated injuries. We believe that the technique we used was a reasonable choice because the anatomical continuity of the patient's duodenum was restored.

Introduction

Management of the biliary ducts during liver resection is one of the most important challenges for hepatobiliary surgeons. Here, we report the case of a left hepatic trisectionectomy for hilar cholangiocarcinoma with a rare aberrant biliary duct of segment 5, which, to the best of our knowledge, has never been reported in previous literature.

Case presentation

A 56-year-old Asian female initially presented with intrahepatic bile duct dilatation in the left lateral sector, left paramedian sector, and right paramedian sector. Simultaneous cholangiography from a percutaneous transhepatic biliary drainage tube in biliary duct of segment 8 and endoscopic nasobiliary drainage tube in biliary duct of segment 3 revealed drainage of the right lateral sectoral branch into the common hepatic duct and the aberrant drainage of segment 5 into the right lateral sectoral branch. The left hepatic duct, right paramedian sectoral duct, and the confluence of the right lateral sectoral duct were narrowed. Left hepatic trisectionectomy was successfully performed with careful dissection and division of the aberrant biliary duct of segment 5.

Conclusion

For safe liver resection, it is important to perform a detailed anatomic evaluation of the intrahepatic ducts, both preoperatively and intraoperatively.

Purpose

Biliary reconstruction remains the Achilles’ heel of adult live donor liver transplantation (LDLT). The study aims to investigate the feasibility of duct-to-duct hepaticocholedochostomy in LDLT.

Methods

Perioperative data from 30 consecutive LDLT aiming at duct-to-duct reconstruction of the biliary tract using a continuous suture technique were prospectively collected. Nineteen recipients (63.3%) had one graft bile duct. Eleven recipients (36.7%) had two or three graft bile ducts. The median follow-up was 50 months.

Results

The overall biliary complication rate was 23.3%. Two recipients developed biliary stricture (6.7%), and two recipients (6.7%) presented with biliary leakage in early posttransplant phase (<90 days). One recipient suffered from bilioma (3.3%), and two recipients (6.7%) presented with biliary stricture in later posttransplant phase (>90 days). No correlation was found between the number of graft bile ducts and the incidence of biliary complications. No biliary complication-associated necessity for re-transplantation or mortality was observed. On multivariate analysis, no single risk factor associated with biliary complication could be identified. All biliary complications were successfully treated with Roux-en-hepaticojejunostomy and/or with endoscopic interventions.

Conclusion

Duct-to-duct hepaticocholedochostomy with continues suture represents a safe and feasible procedure for biliary reconstruction in LDLT. Recipients may benefit from aggressive management of biliary complications with Roux-en-hepaticojejunostomy as compared with repeated endoscopic interventions in early posttransplant phase.

Introduction

Spontaneous intraperitoneal rupture with biliary peritonitis in a case of hepatic hydatid cyst is extremely rare but serious complication. It is a surgical emergency with high morbidity and mortality rates. Very few cases have been reported in the literature.

Case presentation

We report an unusual case of a biliary peritonitis due to spontaneous rupture of hepatic hydatid cyst in a male patient of 34 years of age. He presented with acute peritonitis. Contrast enhanced computed tomography 2 days prior to laparotomy showed a dumbbell shaped hydatid cyst of right lobe of the liver with perihepatic fluid collection. At operation 1.5 L bile was found in the peritoneal cavity with rupture of the anterior wall of the cyst and large cystobiliary communication. He was managed with deroofing of the cyst, cholecystectomy, and placement of T tube in the cystobiliary communication and in the extrahepatic bile duct. He developed biliary fistula which was closed over a period of 34 days with conservative therapy. At 6 months follow up patient is well and free of recurrence.

Conclusion

Though rare, ruptured hydatid cyst should be considered in the differential diagnosis of acute abdomen in a patient residing in the endemic zone.

Background

Mirizzi syndrome is a rare complication of prolonged cholelithiasis with presence of large, impacted gallstone into the Hartman's pouch, causing chronic extrinsic compression of common bile duct (CBD). Fistula formation between the CBD and the gallbladder may represent an outcome of that condition. According to Mirizzi's classification and Csendes's subclassification, Mirizzi syndrome type IV represents the most uncommon type (4%).

Spontaneous biliary-enteric fistulas have also been rarely reported (1.2–5%) in a large series of cholecystectomies. Cholecystocolic fistula is the most infrequent biliary enteric fistula, causing significant morbidity and representing a diagnostic challenge.

Case presentation

We describe a very rare, to our knowledge, combination of Mirizzi syndrome type IV and cholecystocolic fistula. A 52 year old male, presented to our clinic complaining of episodic diarrhea (monthly episodes lasting 16 days), high temperature (38°C–39°C), right upper quadrant pain without jaundice. The definitive diagnosis was made intraoperatively. Magnetic Resonance Imaging (MRI) and Endoscopic Retrograde Cholangiopancreatography (ERCP) demonstrated the presence of Mirizzi syndrome with cholecystocolic fistula formation. The patient was operated upon, and cholecystectomy, cholecystocolic fistula excision and Roux-en-Y biliary-enteric anastomosis were undertaken with excellent post-operative course.

Conclusion

Appropriate biliary tree imaging with ERCP and MRI/MRCP is essential for the diagnosis of Mirizzi syndrome and its complications. Cholecystectomy, fistula excision and biliary-enteric anastomosis with Roux-en-Y loop appears to be the most appropriate surgical intervention in order to avoid damage to Calot's triangle anatomic elements. Particularly in our case, ERCP was a valuable diagnostic tool that Mirizzi syndrome type IV and cholecystocolic fistula.

AIM: To investigate how to reduce the incidence of biliary complications in rat orthotopic liver transplantation.

METHODS: A total of 165 male Wistar rats were randomly divided into three groups: Group A, orthotropic liver transplantation with modified “two-cuff” technique; Group B, bile duct was cut and reconstructed without transplantation; and Group C, only laparotomy was performed. Based on the approaches used for biliary reconstruction, Group A was divided into two sub-groups:A1 (n = 30), duct-duct reconstruction, and A2 (n = 30), duct-duodenum reconstruction. To study the influence of artery reconstruction on bile duct complication, Group B was divided into four sub-groups: B1 (n = 10), duct-duct reconstruction with hepatic artery ligation, B2 (n = 10), duct-duct reconstruction without hepatic artery ligation, B3 (n = 10), duct-duodenum reconstruction with hepatic artery ligation, and B4 (n = 10), duct-duodenum reconstruction without hepatic artery ligation. The samples were harvested 14 d after operation or at the time when significant biliary complication was found.

RESULTS: In Group A, the anhepatic phase was 13.7 ± 1.06 min, and cold ischemia time was 50.5 ± 8.6 min. There was no significant difference between A1 and A2 in the operation duration. The time for biliary reconstruction was almost the same among all groups. The success rate for transplantation was 98.3% (59/60). Significant differences were found in the incidence of biliary complications in Groups A (41.7%), B (27.5%) and C (0%). A2 was more likely to have biliary complications than A1 (50% vs 33.3%). B3 had the highest incidence of biliary complications in Group B.

CONCLUSION: Biliary complications are almost inevitable using the classical “two cuff” techniques, and duct-duodenum reconstruction is not an ideal option in rat orthotopic liver transplantation.

Encapsulated collections of bile (“biloma”) may be a sequela of liver trauma, operative injury or disease. Such collections may be intrahepatic or extrahepatic and usually in the supramesocolic compartment of the abdomen. This is a report of a retroperitoneal biloma, an entity that has been reported only twice to date but this is the first secondary to an operative common bile duct lesion.

Evacuation of the biloma and reconstruction of the associated biliary stricture were successfully carried out. The patient remains sympton free with normal clinical and laboratory data more than 14 months after surgery.

Operative common bile duct (CBD) injury may be followed by a number of complications. To our knowledge retroperitoneal biloma secondary to a CBD lesion has not been previously reported.