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Background: Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction is generally accepted as first line management for common bile duct (CBD) stones. CBD exploration, either by open or laparoscopic approach nowadays, is usually reserved for ERCP failures, complicated stone locations, along with altered anatomical situations. The aim of this study was to highlight the increasing role of laparoscopic choledochoduodenostomy which is not only a reliable but also as a rescue procedure for those failed ERCP cases due to complicated bile duct stones.Materials and Methods: It is a retrospective review of the database, from a tertiary care teaching institution from India, from Jan 2012 up to December 2016.Results: Out of total 30 patients who underwent laparoscopic choledochoduodenostomy, 28 had failed ERC stone clearance while two patients were directly offered drainage in view of unfavorable anatomy. The major reasons for failed ERC stone clearance were as follows-multiple large calculi (42.8%), recurrent stones (21.4%), and associated stricture (21.4%). Mean operating time was 130 (± 27) minutes with mean blood loss of 60 (± 19) ml. Stone extraction was successful, primarily by milking in 13 (43.33%) patients, rest required augmentation by Dormia basket/balloon. Two patients (6.66%) developed controlled bile leak which resolved with conservative treatment. The median length of hospital stay was 5 days (IQR 3-9). Mean duration of follow-up was 17 (± 3.2) months.Conclusion: Laparoscopic common bile duct exploration with choledochoduodenostomy has been shown to be a safe, reliable, and efficient method for treating complex CBDS, especially after failed ERCP procedures. [ABSTRACT FROM AUTHOR]

Background: Bile duct injury (BDI) remains the most dreaded complication following cholecystectomy with serious repercussions for the surgeon, patient and entire healthcare system. In the absence of registries, the true incidence of BDI in the United States remains unknown. We aim to identify the incidence of BDI requiring operative intervention and overall complications after cholecystectomy.Methods: Utilizing the Truven Marketscan® research database, 554,806 patients who underwent cholecystectomy in calendar years 2011-2014 were identified using ICD-9 procedure and diagnosis codes. The final study population consisted of 319,184 patients with at least 1 year of continuous enrollment and who met inclusion criteria. Patients were tracked for BDI and other complications. Hospital cost information was obtained from 2015 Premier data.Results: Of the 319,184 patients who were included in the study, there were a total of 741 (0.23%) BDI identified requiring operative intervention. The majority of injuries were identified at the time of the index procedure (n = 533, 72.9%), with 102 (13.8%) identified within 30-days of surgery and the remainder (n = 106, 14.3%) between 31 and 365 days. The operative cumulative complication rate within 30 days of surgery was 9.84%. The most common complications occurring at the index procedure were intestinal disorders (1.2%), infectious (1%), and shock (0.8%). The most common complications identified within 30-days of surgery included infection (1.5%), intestinal disorders (0.7%) and systemic inflammatory response syndrome (SIRS) (0.7%) for cumulative rates of infection, intestinal disorders, shock, and SIRS of 2.0, 1.9, 1.0, and 0.8%, respectively.Conclusion: BDI rate requiring operative intervention have plateaued and remains at 0.23% despite increased experience with laparoscopy. Moreover, cholecystectomy is associated with a 9.84% 30-day morbidity rate. A clear opportunity is identified to improve the quality and safety of this operation. Continued attention to educational programs and techniques aimed at reducing patient harm and improving surgeon skill are imperative. [ABSTRACT FROM AUTHOR]

Objective: The current treatment options available for patients with unresectable hilar cholangiocarcinoma [CCA] are endoscopic biliary drainage [EBD] using a metal stent, percutaneous transhepaticbiliary drainage [PTBD], and palliative care. However, information regarding their cost-effectiveness is not available.This study aimed to compare the cost utility between palliative biliary drainage [EBD or PTBD] and palliative care. Materials and Methods: We used 2 methods for evaluation, direct calculation and the Markov decision analysis model. The cost of treatment and quality-adjusted life years [QALY] in the EBD, PTBD and palliative care groups were collected from the cohorts of unresectable hilar CCA database at a tertiary care hospital in Thailand. Transition probabilities were derived from international literature and the cohorts. Base-case and sensitivity analysis was also performed. Results: Compared with palliative care, the incremental cost per additional QALY gained from EBD and PTBD using the direct calculation method were 422,822 baht (US$ 12,622) and 490,578 baht (US$ 14,644) per QALY gained, respectively. This result was in concordance with the Markov model. The ICER from EBD and PTBD were 655,520 baht (US$19,568) and 6,548,398 baht (US$195,475) per QALY gained, respectively. According to probabilistic sensitivity analysis using the Markov model, EBD is preferable to palliative care if the willingness to pay [WTP] is higher than 650,000 baht (US$19,403) per QALY gained. PTBD is not cost-effective compared to palliative care at any WTP threshold. At a WTP threshold of 160,000 Thai baht (the threshold of Thailand; US$ 4,776 per QALY gained) neither EBD nor PTBD were found to be cost-effective. At this threshold, only palliative care is cost-effective. Conclusion: EBD is more cost-effective than PTBD when compared with palliative care in cases of unresectable hilar CCA, but at the WTP threshold of Thailand only palliative care is cost-effective. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study is to evaluate the clinical outcomes and cost-effectiveness of elective, robot-assisted choledochotomy and common bile duct exploration (RCD/CBDE) compared to open surgery for ERCP refractory choledocholithiasis.Method: A prospective database of all RCD/CBDE has been maintained since our first procedure in April 2007 though April 2016. With ethics approval, this database was compared with all contemporaneous elective open procedures (OCD/CBDE) performed since March 2005. Emergency procedures were excluded from analysis. Cost analysis was calculated using a micro-costing approach. Outcomes were analyzed on the basis of intent-to-treat. A p value of 0.05 denoted statistical significance.Results: A total of 80 cases were performed since 2005 compromising 50 consecutive, unselected RCD/CBDE and 30 OCD/CBDE. Comparing RCD/CBDE to OCD/CBDE there were no significant differences between groups with respect to age (65 ± 20 vs. 67 ± 18 years, p = 0.09), gender (14/30 vs. 16/25 male/female, p = 0.52), ASA class or co-morbidities. The mean duration of surgery for RCD/CBDE trended longer compared to OCD/CBDE (205 ± 70 min vs. 174 ± 73 min, p = 0.08). However, there was significant reduction in postoperative complications with RCD/CBDE versus OCD/CBDE (22% vs. 56%, p = 0.002). Median hospital stay was also significantly reduced (6 vs 12 days, p = 0.01). The net overall hospital cost for RCD/CBDE was lower ($8449.88 CAD vs. $11671.2 CAD).Conclusion: In this single-centre, cohort study, robotic-assisted CD/CBDE for ERCP refractory common bile duct stones provides the dominating strategy of improved patient outcomes with a reduction of overall cost. [ABSTRACT FROM AUTHOR]

Purpose: Extrahepatic bile duct (EHBD) resection is performed as part of radical cholecystectomy for gallbladder (GB) cancer. However, the indication for EHBD resection is still controversial. The aim of the present study was to evaluate the prognostic value of this procedure.Methods: Patients who underwent surgical resection for GB cancer with curative intent were enrolled. We divided GB cancer into two categories based on the tumor location: proximal-type and distal-type tumors. The former refers to tumors involving the neck or cystic duct, while the latter comprises tumors located between the body and fundus.Results: This study included 80 patients, 40 each with proximal- and distal-type tumors. Proximal tumor location, lymph node metastasis, and a serum carcinoembryonic antigen level > 5.0 ng/mL were independent predictors of poor prognosis. The 5-year survival rates of patients with proximal-type and distal-type tumors were 33.3 and 73.5%, respectively. Patients with proximal-type tumors showed significantly lower rates of R0 resection, more frequently had ≥ 3 metastatic lymph nodes, and exhibited a higher rate of perineural invasion. EHBD resection improved prognoses only in patients with proximal-type tumors but not in those with distal-type tumors. In the former group, EHBD resection significantly reduced the rate of local or regional lymph node recurrence.Conclusions: Extended cholecystectomy with EHBD resection should be performed for patients with GB cancer involving the neck and cystic duct to reduce local and regional lymph node recurrence and achieve better prognosis. [ABSTRACT FROM AUTHOR]

Background: Iatrogenic bile duct injury (BDI) is a common complication after cholecystectomy. Patients are mainly treated endoscopically, but the optimal treatment method has remained unclear.Aims: The aim was to analyze endoscopic treatment in BDI after cholecystectomy and to explore endoscopic sphincterotomy (ES), with or without stenting, as the primary treatment for an Amsterdam type A bile leak.Methods: All patients referred to Helsinki University Hospital endoscopy unit due to a suspected BDI between the years 2004 and 2014 were included in this retrospective study. To collect the data, all ERC reports were reviewed.Results: Of the 99 BDI patients, 94 (95%) had bile leak of whom 11 had concomitant stricture. Ninety-three percent of all patients were treated endoscopically. Seventy-one patients had native papillae and a leak in the cystic duct or peripheral radicals. They were treated with ES (ES group, n = 50) or with sphincterotomy and stenting (EST group, n = 21). There was no difference between the closure time of the fistula (p = 0.179), in the time of discharge from hospital (p = 0.298), or in the primary healing rate between the ES group and the EST group (45/50 vs 19/21 patients, p = 0.951).Conclusion: After the right patient selection, the success rate of endoscopic treatment can approach 100% for Amsterdam type A bile leak. ES is an effective and cost-effective single procedure with success rate similar to EST. It may be considered as a first-line therapy for the management of Amsterdam type A leaks. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy (LC) for symptomatic gallstone disease is one of the most common surgical procedures. Concomitant common bile duct (CBD) stones are detected with an incidence of 4-20% and the ideal management is still controversial. The frequent practice is to perform endoscopic sphincterotomy pre-operatively (POES) followed by LC, to allow subsequent laparoscopic or open exploration if POES fails. However, POES has shown different drawbacks such as need for two hospital admissions, need of two anesthesia inductions, higher rate of pancreatitis, and longer hospital stay. Hence, an intra-operative endoscopic sphincerotomy (IOES) has been proposed.Objective: To compare the 1 stage laparoscopic cholecystectomy (LC) combined with IOES versus 2-stage POES followed by LC for the management of pre-operatively known cholecystocholedocholithiasis.Search Strategy: The search terms bile duct stones/calculi, ERCP, endoscopic sphincterotomy, laparoendoscopic rendezvous (LERV), and laparoscopic ductal clearance/choledochotomy/exploration were used. A comprehensive hand-based search of reference lists of published articles and review articles was performed to ensure inclusion of all possible studies and exclude duplicates.Selection Criteria: RCTs comparing 1 stage LC combined with IOES versus 2-stage POES followed by LC for the management of pre-operatively known cholecystocholedocholithiasis in adults.Data Collection& Analysis: Three reviewers assessed trial quality and extracted the data. Data were entered in revman version 5.3. The trials were grouped according to the outcome measure assessed such as success rate of CBD stone clearance, incidence of pancreatitis, overall morbidity, and length of hospital stay.Main Results: A total of 629 patients in 5 RCTs met the inclusion criteria. The success rate of CBD clearance (IOES = 93%, POES = 92%) was the same in both groups (OR 1.34; 95% CI 0.45-0.97; p = 0.60). Findings showed that IOES was associated with less pancreatitis (0.6%) than POES (4.4%) (OR 0.19; 95% CI 0.06-0.67; p = 0.01; I 2 = 43%). The incidence of overall morbidity was lower in the IOES group (6%) than the POES group (11%) (OR 0.54; 95% CI 0.31-0.96; p = 0.03; I 2 = 20%). The mean days of hospital stay for IOES group (M = 3.52, SD = 1.434, N = 5) was significantly less than the POES group (M = 6.10, SD = 2.074, N = 5), t(8) = 2.29, p <= 0.051.Conclusion: IOES is at par with two-stage POES in terms of CBD clearance, with less incidence of post-operative pancreatitis, overall morbidity, and less hospital stay. [ABSTRACT FROM AUTHOR]

Background: Endoscopic sphincterotomy or endoscopic papillary balloon dilatation during endoscopic retrograde cholangiopancreatography (ERCP) are associated with a high risk of bleeding in patients receiving dual antiplatelet agents (APAs). However, the discontinuation of antiplatelet agents increases the risk of thromboembolic events in these patients. To date, the placement of self-expandable metal stents (SEMSs) in patients receiving dual APAs has not been well investigated. The aim of this study was to evaluate the feasibility and safety of SEMS placement for the removal of common bile duct (CBD) stones in patients in whom APAs were not discontinued.Methods: Ten consecutive patients who were suspected of having CBD stones and who were receiving dual APAs were prospectively enrolled and underwent temporary SEMS placement, followed by stone extraction and SEMS removal. The patients continued taking dual APAs at the time of undergoing the procedure.Results: SEMS placement was successful in all ten patients. Complete duct clearance with the SEMSs was achieved in a single session in all patients with CBD stones (9/9, 100%). One patient had cholangitis, but ERCP did not reveal biliary stones. There were no cases of bleeding during or after the procedure, even though all patients continued to take dual APAs. There were no new thromboembolic events.Conclusions: SEMSs can be used for the extraction of CBD stones in patients on dual APAs, and does not lead to hemorrhagic or thromboembolic events. [ABSTRACT FROM AUTHOR]

Covered self-expandable metallic stents (CSEMS) may provide palliative drainage for unresectable distal malignant biliary strictures. Laser-cut CSEMS allows easy positioning due to its characteristic of minimal stent shortening. Endoscopic stent removal is sometimes recommended for recurrent biliary obstruction (RBO). However, there are no previous reports of endoscopic removal of laser-cut CSEMS. The current study presents data from 6 patients who were placed a laser-cut CSEMS for unresectable distal malignant biliary strictures, and later endoscopic stent removal was attempted for RBO at the present institute. The duration of stent placement, the procedural success rate, the procedural duration, and accidental complications were evaluated. The mean duration of stent placement was 156±37.9 days (range, 117-205). The procedural success rate was 100%. The mean procedural duration was 11.8±7.5 min (range, 5-24). No complications were reported. Laser-cut CSEMS were safely removed from all patients. The present case report is the first to demonstrate that Endoscopic stent removal of laser-cut CSEMS was safely performed. [ABSTRACT FROM AUTHOR]

Introduction: Pre-operative evaluation of biliary strictures remains challenging. The dilemma that exists is how to balance the risk of failing to detect malignancy and the potential morbidity caused by unnecessary surgery in patients with benign etiologies. With emerging novel diagnostic modalities, this study aims to assess the efficacy of diagnostic techniques and facilitate a clinical approach to indeterminate biliary strictures. Areas covered: Conventional imaging modalities are crucial in identifying the location of a stricture and are helpful for choosing further diagnostic modalities. Utilization of endoscopic techniques, including endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS), is key in establishing a diagnosis. The emergence of novel diagnostic modalities, such as fluorescence in-situ hybridization (FISH), peroral cholangioscopy (POC), intraductal endoscopic ultrasound (IDUS) and confocal laser endomicroscopy (CLE), enhance the diagnostic yield in the evaluation of indeterminate biliary strictures. Expert commentary: More reliable and validated visual criteria for differentiating malignancy from benign biliary conditions, utilizing advanced imaging modalities such as POC and CLE, need to be established. It is of significance to further evaluate these novel diagnostic modalities through ongoing trials and to develop a diagnostic algorithm that reconciles cost-effectiveness with diagnostic accuracy. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic surgery for choledocholithiasis is still evolving. Only a few reports of single-incision laparoscopic common bile duct exploration (LCBDE) have been published.Methods: One hundred and one consecutive patients underwent single-incision LCBDE (SILCBDE) by one surgeon with straight instruments during a 42-month period.Results: Choledochotomies were performed on 61 patients (60.4%). The success rate of intrahepatic duct exploration was 68.0% (17/25) for patients undergoing transcystic choledochoscopic bile duct explorations following longitudinal cystic ductotomies. The ductal clearance rate was 100%. Eighteen procedures (17.8%) were converted, including one open surgery. Nineteen patients (18.8%) experienced 26 episodes of complications; the majority (19 episodes) were classified as Clavien-Dindo grade I. Excluding those patients with Mirizzi syndrome (McSherry type II), multivariate logistic regressions showed that patients who were older or had complicated cholecystitis had higher procedure conversion rates and that higher modified APACHE II scores, higher white blood cell counts, and longer operative times were independent risk factors for complications. Based on operative times, 20 successful SILCBDEs were needed to get through the learning phase. A higher transcystic approach rate (46.5 vs. 8.3%; P < 0.01) and a shorter operative time (207 ± 62 vs. 259 ± 66 min; P < 0.01) were observed in the experienced phase. Compared with our early series of multi-incision LCBDE, the SILCBDE group had a higher bile duct stone clearance rate (100 vs. 94.4%; P < 0.05) and a higher proportion of patients with concomitant acute cholecystitis (59.6 vs. 22.2%; P < 0.01).Conclusions: LCBDE with a 100% ductal clearance rate is possible following an algorithm for various approaches. SILCBDE is feasible under a low threshold for procedure conversion. A transcystic approach should be tried first if indicated, and a longitudinal cystic ductotomy to the cystocholedochal junction is beneficial. Prospective, randomized trials comparing single-incision and multi-incision LCBDE are anticipated. [ABSTRACT FROM AUTHOR]

Background and Aim In patients with irretrievable or intractable bile duct stone, temporary insertion of a plastic stent ( PS) followed by further endoscopic retrograde cholangiopancreatography ( ERCP) or surgery has been recommended as a 'bridge' therapy. However, the exact mechanism of stone fragmentation has not been discovered. The aim of the present study was to evaluate whether PS shape can facilitate stone fragmentation. Methods Using a new in vitro bile flow phantom model, we compared the friction effect among three different PS groups (straight PS group, double pigtail-shaped PS group, and screw-shaped PS group) and a control group. Each group had 10 silicon tube blocks that separately contained one stone and two PS. The control group had 10 blocks each with only a stone and no PS. We carried out analysis of the friction effect by stone weight and volume changes among the groups, excluding fragmented stones. Results After 8 weeks, complete fragmentation was noted in one out of 34 cholesterol stones (2.9%) and in four out of six pigmented stones (66.7%). Fragmentation tended to be more prominent in the screw-shaped PS group than in the straight PS group, double pigtail-shaped group, and control group (volume change: −11.33%, 7.94%, 4.43%, and 2.05%, respectively, P = 0.1390; weight change: −9.30%, 0.71%, −0.10%, and −1.23%, respectively, P = 0.3553). Conclusion Stone fragmentation may be induced by PS friction effect. Also, screw-shaped plastic stents may improve friction effect. These results may help guide future PS development and clinical decisions. [ABSTRACT FROM AUTHOR]

B Video 1 b External and internal magnets were used to facilitate bile duct cannulation by changing the position of the papilla. However, as the angle between the bile duct and cannulation was almost a right angle, possibly caused by a diverticulum, an experienced endoscopist failed to complete biliary cannulation after several attempts (Fig. [Extracted from the article]

Background: Biliary complications continue to be the "Achilles heel" of living-donor liver transplantation (LDLT). The use of biliary stents in LDLT to reduce biliary complications is a controversial issue. We performed a randomized trial to study the impact of intraductal biliary stents on postoperative biliary complications after LDLT.Study Design: Of the 94 LDLTs that were performed during a period of 16 months, ABO-incompatible transplants, left lobe grafts, 3 or more bile ducts on the graft, and those requiring bilioenteric drainage were excluded. Eligible patients were randomized to either a study arm (intraductal stent, n = 31) or a control arm (no stent, n = 33) by block randomization. Stratification was done, based on the number of ducts on the graft requiring anastomosis, into single (n = 20) or 2 ducts (n = 44). Ureteric stents of 3F to 5F placed across the biliary anastomosis and exiting into the duodenum for later endoscopic removal at 3 months were used. The primary end point was postoperative bile leak.Results: Bile leak occurred in 15 of 64 (23.4%), the incidence was higher in the stented group compared with the control group (35.5% vs 12.1%; p = 0.03). Multiplicity of bile ducts and stenting were identified as risk factors for bile leak on multivariate analysis (p = 0.031 and p = 0.032). During a median follow-up of 2 years, biliary stricture developed in 9 patients (14.1%). Postoperative bile leak is a significant risk factor for the development of biliary stricture (p = 0.003).Conclusions: Intraductal transanastomotic biliary stenting and multiplicity of graft ducts were identified as independent risk factors for the development of postoperative biliary complications. [ABSTRACT FROM AUTHOR]

Background and study aims No standard procedure for endoscopic retrograde cholangiopancreatography is available for patients with Roux-en-Y hepaticojejunostomy (RYHJ) with side-to-end hepaticojejunostomy. We therefore explored methods of efficient scope insertion at a hepaticojejunostomy site. Patients and methods Patients with suspected biliary disease were prospectively enrolled. Based on two fluoroscopic images obtained on scope insertion into each lumen of a two-pronged Roux-en-Y anastomosis, we selected the lumen in which the distal end of the scope progressed toward the patient's liver or head. The accuracy of this method for selecting the correct lumen leading to the hepaticojejunostomy site was investigated. Results Of the 33 included patients, successful insertion to the hepaticojejunostomy site was achieved in 32 (97 %), 26 (81 %) of whom had undergone the imaging method. The accuracy of the method was 88 % (23/26). The time required for insertion between the anastomotic site and the hepaticojejunostomy site was shorter when the lumen selection had been correct (13 minutes [7 - 30] (n = 23) vs. 18 minutes [8 - 28] (n = 9); P = 0.95). Conclusion This method based on two fluoroscopic images was useful for achieving efficient scope insertion in patients with RYHJ.Trial registered at University Hospital Medical Information Network Clinical Trials Registry (UMIN000014183). [ABSTRACT FROM AUTHOR]

Background: Intrahepatic biliary cystadenomas are rare hepatic neoplasms, which are usually cystic. These tumors are often misdiagnosed as simple liver cysts and hydatid cysts clinically and radiologically owing to nonspecific clinical and radiologic features. These tumors require complete resection, as recurrence and malignant transformation can occur following incomplete excision. It is essential that these tumors be diagnosed accurately so that they can be adequately excised.Methods: Clinical and radiological features of six cases of biliary cystadenoma are described.Results: All of these cases were resected with the clinical and/or radiological impression of simple liver cysts and/or hydatid cysts. Out of the six patients, five were female and one was male. Ages of the patients ranged from 28 to 60 years (mean 45 years). The patients presented with nonspecific symptoms. Internal septations were seen on preoperative imaging (when available). On gross examination, all tumors were cystic; their sizes varied from 5.5 to 14 cm, mean size was 9.0 cm. On histopathologic examination, cystic spaces were lined by cuboidal to columnar mucin-secreting epithelium with underlying ovarian-type stroma. In one case, ovarian-type stroma was not seen. Recurrence was seen in three cases at 1 to 5 years of follow up.Conclusions: Owing to their malignant potential and high recurrence rate following incomplete resection, an aggressive surgical approach is recommended. Prognosis is excellent after complete resection. [ABSTRACT FROM AUTHOR]

Background: The objective of the current study was to investigate both short- and long-term outcomes of patients undergoing curative-intent resection for intrahepatic cholangiocarcinoma (ICC) stratified by extent of hepatic resection relative to overall final pathological margin status.Methods: One thousand twenty-three patients with ICC who underwent curative-intent resection were identified from a multi-institutional database. Demographic, clinicopathological, and operative data, as well as overall (OS) and recurrence-free survival (RFS) were compared among patients undergoing major and minor resection before and after propensity score matching.Results: Overall, 608 (59.4%) patients underwent major hepatectomy, while 415 (40.6%) had a minor resection. Major hepatectomy was more frequently performed among patients who had large, multiple, and bilobar tumors. Roughly half of patients (n = 294, 48.4%) developed a postoperative complication following major hepatectomy versus only one fourth of patients (n = 113, 27.2%) after minor resection (p < 0.001). In the propensity model, patients who underwent major hepatectomy had an equivalent OS and RFS versus patients who had a minor hepatectomy (median OS, 38 vs. 37 months, p = 0.556; and median RFS, 20 vs. 18 months, p = 0.635). Patients undergoing major resection had comparable OS and RFS with wide surgical margin (≥10 and 5-9 mm), but improved RFS when surgical margin was narrow (1-4 mm) versus minor resection in the propensity model. In the Cox regression model, tumor characteristics and surgical margin were independently associated with long-term outcome.Conclusions: Major hepatectomy for ICC was not associated with an overall survival benefit, yet was associated with increased perioperative morbidity. Margin width, rather than the extent of resection, affected long-term outcomes. Radical parenchymal-sparing resection should be advocated if a margin clearance of ≥5 mm can be achieved. [ABSTRACT FROM AUTHOR]

Background: "Hilar en bloc resection" using a no-touch technique has been advocated as a standard procedure in right-sided hepatectomies for treatment of perihilar cholangiocarcinoma (PHC). In principle, it has never been reported for left-sided tumors. The aim is to describe the procedures of total hilar en bloc resection with left hemihepatectomy and caudate lobectomy (THER-LH) for advanced PHC and discuss feasibility and clinical significance of this novel technique.Methods: A retrospective study using a prospectively maintained database was performed to identify eight patients who had received THER-LH for advanced PHC from January 2013 to December 2015. The clinicopathological features, surgical procedures, and outcomes of these patients form the basis this study.Results: The operative time was 546 ± 158 (380-870) min, and estimated blood loss was 875 ± 690 (400-2500) ml. Time of vessel resection and reconstruction was 25.6 ± 12.3 min for the portal vein and 19.1 ± 4.9 min for the hepatic artery. Time of hilum clamping was 27.3 ± 11.9 (15-41) min. Two patients had Clavien-Dindo grade II and IVa complications of bile leakage with one developing intraabdominal abscess and bleeding. There was no perioperative mortality. Histopathologic examination revealed that all of eight patients had tubular adenocarcinoma with microscopic invasion to the resected hepatic arteries and portal veins in seven patients. Negative bile duct margins were achieved in all of them. Three patients developed recurrence and died at 11, 18, and 24 months postoperatively. The remaining patients were alive at the time of last follow-up. The median survival was 24 months with one patient achieving a disease-free survival of 50 months.Conclusion: THER-LH is a technically demanding procedure that is safe and feasible that may have some beneficial effects on the prognosis of these patients with advanced PHC. Further studies are required to confirm the oncological superiority and survival benefits of this novel technique. [ABSTRACT FROM AUTHOR]

Background: Surgical site infections (SSI) are one of the most common complications after hepato-pancreato-biliary surgery. Infectious complications may lead to an associated immune-modulatory effect that inhibits the body's response to cancer surveillance. We sought to define the impact of SSI on long-term prognosis of patients undergoing surgical resection of extrahepatic biliary malignancies (EHBM).Methods: Patients undergoing surgery for EHBM between 2000 and 2014 were identified using a large, multi-center, national cohort dataset. Recurrence free survival (RFS) was calculated and a multivariable Cox proportional hazards model was utilized to identify potential risk factors for RFS including SSI.Results: Seven hundred twenty-eight patients included in the analytic cohort; 236 (32.4%) patients had perihilar cholangiocarcinoma, 241 (33.1%) gallbladder cancer, and 251 (34.5%) distal cholangiocarcinoma. A major resection, liver resection, was performed in 205 (28.3%) patients, while 110 (15.2%) patients had a pancreaticoduodenectomy. The overall incidence of morbidity was 55.8%; among the 397 patients who experienced a complication, 161 patients specifically had an SSI. The SSI occurred as an infection of the surgical site (n = 70, 9.6%) or formation of an abscess in the operative bed (n = 91, 12.5%). SSI was associated with long-term survival as patients who experienced an SSI had a median RFS of 19.5 months compared with 30.5 months for those patients who did not have an SSI (HR 1.40, 95% CI 1.08-1.80; p = 0.01). Among 279 patients who had EHBM that had no associated lymph node metastases, well-to-moderate tumor differentiation, as well as an R0 resection margin, SSI remained associated with worse RFS (HR 1.84, 95% CI 1.03-3.29; p = 0.038), as well as overall survival (HR 1.87, 95% CI 1.18-2.97; p = 0.008).Conclusion: SSI was a relatively common occurrence following surgery for EHBM as 1 in 10 patients experienced an SSI. In addition to standard tumor-specific factors, the occurrence of postoperative SSI was adversely associated with long-term survival. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic common bile duct exploration (LCBDE) has been widely promoted in recent years as a safe and effective treatment for choledocholithiasis. However, there are no standard guidelines for the treatment of patients who have concomitant hepatolithiasis of the left liver and abdominal adhesions. The aim of the current research was to compare the outcomes of open versus laparoscopic common bile duct exploration with left hepatectomy (OCBDH vs. LCBDH) in patients with choledocholithiasis concomitant with left-sided hepatolithiasis, and to evaluate the safety and feasibility of laparoscopic surgery for choledocholithiasis in patients with abdominal adhesions.Methods: Between October 2012 and October 2015, a total of 321 consecutive patients with choledocholithiasis underwent surgical treatment. LCBDE was performed in 107 patients, and open common bile duct exploration (OCBDE) was performed in 111 patients. Further, 31 patients and 72 patients underwent LCBDH and OCBDH, respectively. A total of 133 patients who underwent LCBDE or OCBDE had abdominal adhesions, which were classified as mild, moderate, or severe according to an abdominal adhesion scoring system, which was validated in the LCBDE group and OCBDE group. The perioperative results were reviewed and analyzed retrospectively.Results: In the mild adhesion group, blood loss, postoperative recovery in the LCBDE group was lesser than those in the OCBDE group. In the moderate adhesion group, the postoperative recovery was significantly shorter in the LCBDE group than in the OCBDE group. In the severe adhesion group, the operation time and blood loss in the LCBDE group were higher than those in the OCBDE group. The postoperative recovery was significantly better in the LCBDH group than in the OCBDH group.Conclusion: LCBDH can obviously improve recovery and shorten the hospitalization period. Further, LCBDE is safe and feasible for patients of choledocholithiasis with mild and moderate abdominal adhesions. [ABSTRACT FROM AUTHOR]

Background This study examines the usefulness of early post-operative liver function test ( LFT) monitoring in predicting retained choledocholithiasis after laparoscopic common bile duct exploration ( LCBDE). Methods Data on patients who had LCBDE over a 3-year period were collected retrospectively. Patients who had ongoing choledocholithiasis after unsuccessful LCBDE were considered for the test group and patients who had successful LCBDE were considered for the control group. Preoperative, day 1 post-operative and day 2 post-operative alkaline phosphatase ( ALP), gamma glutamyl transferase ( GGT), alanine transaminase ( ALT) and bilirubin levels were recorded. Proportions of patients who had worsening LFTs were analysed in each group. Results Proportions of patient who had worsening LFTs on day 1 were not statistically different between two groups and they were statistically equal on equivalence testing (two one-sided tests). On day 2, proportions of patient were again not statistically different. Bilirubin and ALT were statistically equivalent ( P = 0.022 and P = 0.025 respectively) but GGT and ALP failed to achieve statistical equivalence ( P = 0.062 and P = 0.138 respectively) on day 2. Twelve patients with normal appearing final intraoperative cholangiogram needed reintervention due to retained choledocholithiasis diagnosed subsequently. LFTs progressively improved despite presence of choledocholithiasis in eight of these 12 patients (75%) and only four were diagnosed by worsening post-operative LFTs during index admission. Conclusion LFTs in the early post-operative period are not useful in determining which patients require biliary imaging or intervention after an apparently successful LCBDE. [ABSTRACT FROM AUTHOR]

Background: Recent advances in technology and accumulation of surgical experience have expanded the indications for laparoscopic liver resection (LLR). However, compared to open liver resection (OLR), the feasibility of laparoscopic anatomical liver resection for centrally located tumor (CLT) has not been clearly established. The aim of our study was to assess the feasibility and safety of laparoscopic anatomical major liver resection for CLT. Methods: From April 2011 to March 2016, 20 cases of anatomical LLR and 86 cases of OLR for CLTs such as central hepatectomy (CH) and right anterior sectionectomy (RAS) were performed at a single institution. We performed one-to-one propensity score matching and analyzed short-term outcomes between the LLR ( n = 20) and OLR ( n = 20) groups. Results: Among 20 cases in the LLR group, two cases underwent open conversion due to common bile duct injury and anatomical distortion, respectively. There were no statistically significant difference between the LLR and OLR groups regarding clamping time of the Pringle maneuver ( p = 0.502), blood loss ( p = 0.746), surgical margin ( p = 0.198), or length of hospital stay ( p = 0.110). However, surgical time was significantly longer in the LLR group than in the OLR group (388 vs 268 min; p < 0.001). There were no significant differences between the two groups with regard to morbidity rate or mean comprehensive complication index ( p = 0.716 and p = 0.819, respectively). Conclusion: Total anatomical LLR can be performed safely in selected CLT patients by experienced surgeons. Laparoscopic CH or RAS appears feasible with non-inferior perioperative outcomes compared to OLR. [ABSTRACT FROM AUTHOR]

Context: The extent of hepatectomy and lymph node dissection (LND) in the treatment of hepatolithiasis-associated intrahepatic cholangiocarcinoma (HL-iCCA) is still controversial.Aims: The aim of this retrospective study was to evaluate the role of surgical treatment for HL-iCCA.Methods: The clinical data of 63 patients with HL-iCCA who undergoing surgery between January 2005 and December 2015 were analyzed retrospectively.Statistical Analysis Used: All data were analyzed by the SPSS 17.0 software program (IMB Inc., Chicago, IL, USA). Survival curves were analyzed by the Kaplan-Meier method and compared by the Log-rank test. A P < 0.05 was considered statistically significant.Results: Forty-nine patients (77.8%) underwent surgical resection including 35 with LND and 14 without LND. The overall 1-, 3-, and 5-year survival rates were 58.1%, 28.2%, and 10.6%, respectively, and the median survival time was 19 months. The 1-, 3-, and 5-year survival rates of resection group were 78.9%, 36.3%, and 13.5%, respectively, while the 1-year survival rate of exploratory laparotomy group was 0 (P < 0.0001). The 1-, 3-, and 5-year survival rates of patients with LND were significantly superior to those of without LND (75.9%, 39.4%, and 20.2% vs. 71.4%, 17.9%, and 0, P = 0.043). According to the N status, the 1-, 3-, and 5-year survival rates of pN0 subgroup were 81.8%, 49.2%, and 28.1%; pN1 subgroup were 65.3%, 18.6%, and 0%; and pNx subgroup were 71.4%, 17.9%, and 0%, respectively (pN0 vs. pN1, P = 0.005; pN0 vs. pNx, P = 0.004; pN1 vs. pNx, P = 0.653). The 1-, 3-, and 5-year survival rates of R0 resection (n = 42) were 80.2%, 36.7%, and 14.9%, respectively, and those of R1 resection (n = 7) were 71.4%, 0%, and 0%, respectively (P = 0.028).Conclusions: Radical resection is the most effective therapy for HL-iCCA. Regional lymphadenectomy is strongly recommended in resectable HL-iCCA, which is helpful in tumor staging and long-term survival. [ABSTRACT FROM AUTHOR]

Background/purpose: The study aims to describe the clinical features, microbiology, and associated factors of acute cholangitis (AC) after bilioenteric anastomosis (BEA) for biliary duct injury (BDI). Additionally, we assessed the performance of the Tokyo Guidelines 2013 (TG13) recommendations in these patients.Methods: We conducted a case-control study of 524 adults with a history of BEA for BDI from January 2000 to January 2014. A propensity score adjustment was performed for the analysis of the independent role of the main factors identified during the univariate logistic regression procedure.Results: We identified 117 episodes of AC in 70 patients; 51.3% were definitive AC according to the TG13 diagnostic criteria, and 39.3% did not fulfill the imaging criteria of AC. A history of post-operative biliary complications (OR 2.55, 95% CI 1.38-4.70) and the bile duct confluence preservation (OR 0.46, 95% CI 0.24-0.87) were associated with AC. Eighty-nine percent of the microorganisms were Enterobacteriaceae; of them, 28% were extended spectrum β-lactamase (ESBL) producers.Conclusions: AC is a common complication after BEA and must be suspected even in the absence of imaging findings, particulary in patients with a history of post-operative biliary complications, and/or without bile duct confluence preserved. An empirical treatment for ESBL-producing Enterobacteriaceae may be appropriate in patients living in countries with a high rate of bacterial drug resistance. [ABSTRACT FROM AUTHOR]

Biliary tract disease remains a common indication for operative intervention. The incidence of concurrent biliary tract disease (>2 biliary tract disease processes) is unknown and the impact of more than one biliary tract diagnosis on outcomes remains to be defined. The objective of this study was to determine the effect of concurrent biliary tract disease on conversion rate and outcomes after laparoscopic cholecystectomy. A 5-year retrospective analysis of all patients who underwent a laparoscopic cholecystectomy was performed comparing those with a single biliary diagnosis to patients with concurrent biliary tract disease. Variables analyzed were conversion to open cholecystectomy, incidence of bile duct injury, use of endoscopic retrograde cholangiopancreatography and/or intraoperative cholangiogram, length of surgery, and duration of hospitalization. The incidence of concurrent biliary tract disease was 9 per cent and a conversion to open cholecystectomy was performed in 16 per cent of patients. After adjusting for confounding factors, concurrent biliary tract disease was predictive of conversion (odds ratio 1.6, 95% confidence interval 1.1-2.3, P = 0.03) and bile duct injury (odds ratio 2.5, 95% confidence interval 0.8-5, P = 0.01). Concurrent biliary tract disease patients were more likely to undergo intraoperative cholangiogram or endoscopic retrograde cholangiopancreatography, as well as longer operation and length of stay. [ABSTRACT FROM AUTHOR]

End-to-end anastomosis in the treatment for bile duct injury during laparoscopic cholecystectomy has been associated with stricture formation. The aim of this study was to experimentally investigate the effect of oral tamoxifen (tmx) treatment on fibrosis, collagen content and transforming growth factor-β1, -β2 and -β3 expression in common bile duct anastomosis of pigs. Twenty-six pigs were divided into three groups [sham ( n = 8), control ( n = 9) and tmx ( n = 9)]. The common bile ducts were transected and anastomosed in the control and tmx groups. Tmx (40 mg/day) was administered orally to the tmx group, and the animals were euthanized after 60 days. Fibrosis was analysed by Masson's trichrome staining. Picrosirius red was used to quantify the total collagen content and collagen type I/ III ratio. mRNA expression of transforming growth factor ( TGF)-β1, -β2 and -β3 was quantified using real-time polymerase chain reaction ( qRT- PCR). The control and study groups exhibited higher fibrosis than the sham group, and the study group showed lower fibrosis than the control group ( P = 0.011). The control and tmx groups had higher total collagen content than the sham group ( P = 0.003). The collagen type I/ III ratio was higher in the control group than in the sham and tmx groups ( P = 0.015). There were no significant differences in the mRNA expression of TGF-β1, -β2 and -β3 among the groups ( P > 0.05). Tmx decreased fibrosis and prevented the change in collagen type I/ III ratio caused by the procedure. [ABSTRACT FROM AUTHOR]

Background: Imaging techniques that enhance visualisation of the anatomy may help prevent bile duct injury. Near-Infrared Fluorescence Imaging is such a technique. Previous experiments with ICG have shown that illumination of the extra-hepatic bile ducts is feasible. Yet, there is room for improvement in the visualisation of the target as compared to the background. Experiments with IRDye® 800CW show promising results. However, this dye is too expensive for routine clinical use. The aim of this study is to test the first applicability of two newly developed preclinical dyes regarding intraoperative imaging of the cystic duct and cystic artery, compared with IRDye® 800CW.Methods: Laparoscopic cholecystectomy was performed in three pigs, using a laparoscopic fluorescence imaging system. Each pig received 6 mg of one of the fluorescent dyes (1 mg/mL; IRDye® 800CW, IRDye® 800BK or IRDye® 800NOS) by intravenous injection. Intraoperative recognition of the biliary system and cystic artery was registered at set time points. All procedures were digitally recorded, and the target to background ratio (TBR) was determined to assess the fluorescence signal.Results: With all three fluorescent dyes, the cystic artery was directly visualised. For the visualisation of the cystic duct, 15, 34 and 30 min were needed using IRDye® 800BK, IRDye® 800NOS and IRDye® 800CW, respectively. The maximum TBR of the cystic duct was the highest with IRDye® 800NOS (4.20) after 36 min, compared to 2.45 for IRDye® 800BK and 2.15 for IRDye® 800CW, both after 45 min. There were no adverse events.Conclusion: IRDye® 800BK and IRDye® 800NOS seem to be good alternatives for IRDye® 800CW for the visualisation of the cystic duct and cystic artery in pigs. [ABSTRACT FROM AUTHOR]

Lateral injury of the bile duct can occur after cholecystectomy, bile duct dissection, or exploration. If direct repair is not possible, conversion to bilioenteric anastomosis can be needed with the risk of long-term bile duct infections and associated complications. We developed a new surgical technique which consist of reconstructing the bile duct with the round ligament. The vascularized round ligament is completely mobilized until its origin and used for lateral reconstruction of the bile duct to cover the defect. T tube was inserted and removed after few months. Patency of the bile duct was assessed by cholangiography, the liver function test and magnetic resonance imaging (MRI). Two patients aged 33 and 59 years old underwent lateral reconstruction of the bile duct for defects secondary to choledocotomy for stone extraction or during dissection for Mirizzi syndrome. The defects measured 2 and 3 cm and occupied half of the bile duct circumference. The postoperative course was marked by low output biliary fistula resolved spontaneously. In one patient, the T tube was removed at 3 months after surgery and MRI at 9 months showed strictly normal aspect of the bile duct with normal liver function test. The second patient is going very well 2 months after surgery and the T tube is closed. Lateral reconstruction of the bile duct can be safely achieved with the vascularized round ligament. We will extend our indications to tubular reconstruction. [ABSTRACT FROM AUTHOR]

Extension of ampulloma into the lower common bile duct (CBD) is observed in up to 30% of cases. This biliary extension can prevent complete tumor resection thus is considered as a contraindication for endoscopic and even surgical ampullectomy. For ampullomas associated with a prolonged biliary extension, a pancreaticoduodenectomy is associated with a high morbidity and can be considered as an overtreatment for a benign neoplasm. The present study describes a new surgical approach including ampullectomy with complete resection of the intrapancreatic CBD and restoration of both biliary and pancreatic flow by two separate anastomoses. This procedure was performed in seven patients for a non-invasive ampulloma with a 25- to 70-mm CBD involvement. No patients died and three developed postoperative complications. Resection was R0 in all patients but one. With a 24-month median follow-up (range = 3-84), no patients developed pancreatic insufficiency or tumor recurrence. [ABSTRACT FROM AUTHOR]

Background: Common bile duct (CBD) stones exist among 12% of patients with cholelithiasis. They may result in some complications including pancreatitis and cholangitis. The common therapeutical method is endoscopic sphincterotomy during ERCP(Endoscopic Retrograde Cholangio-Pancreatography) and stones removal. This method does not have a reasonable success rate for stones with a diameter larger than 15 mm and may cause serious complications. The aim of this study was to evaluate the CBD stenting method in the treatment of large CBD stones. Materials and Methods: This study was performed on 32 patients who presented to the ERCP unit of Shahid Beheshti hospital in Qom with large CBD stones. Success rate in CBD clearing and rate of some complications including rupture of CBD, pancreatitis, and cholangitis were evaluated after the first ERCP for stent replacement, and the second for its removal. Results: The success rate in complete CBD clearing was 93.8%. A reduction in size and number of stones was seen during a 2-month period, which was statistically significant. No case of CBD rupture and cholangitis was detected and the incidence of pancreatitis was 18.8%. Conclusion: CBD stenting has a reasonable success rate for reducing the size and number of CBD stones. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic common bile duct exploration (LCBDE) has gained wide popularity in the treatment of choledocholithiasis. Bile leakage remains a major cause of postoperative morbidity. The aim of this study was to report 5-year results of 500 LCBDEs and identify risk factors associated with bile leakage.Methods: Five hundred consecutive LCBDEs performed in one institution from September 2011 to June 2016 were reviewed. Patients' clinical data were retrospectively collected and analyzed. Univariable and multivariable analysis of bile leakage was performed by logistic regression.Results: We found stones (n = 388) or bile sludge (n = 71) in 459 patients (92%) on exploration, leaving 41 patients (8%) without stones. Operative time was 128 min in the first 250 LCBDEs, and this decreased to 103 min in the second 250 LCBDEs (P = 0.0004). Four hundred and eight (82%) procedures were completed with primary closure after choledochotomy; the rate of primary closure increased significantly in the second 250 patients compared with the first (88 vs 76%; P = 0.0005), whereas T-tube placement (2 vs 6%; P = 0.0225) and transcystic approach (7 vs 12%; P = 0.0464) decreased, respectively. Stone clearance was successful in 495 patients (99%). Overall morbidity was 5%, and bile leakage occurred in 17 patients (3.4%). Two patients died from bile leakage. The median follow-up was 24 months with stone recurrence occurred in two patients and bile duct stricture in one patient. Univariable analysis identified diameter of the common bile duct (CBD), stone clearance, and T-tube insertion as risk factors related to bile leakage. Multivariable analysis taking these three factors into account identified non-dilated CBD (risk ratio (RR) = 9.87; P = 0.007) and failure in stone clearance (RR = 11.88; P = 0.024) as significant risk factors.Conclusions: Bile leakage following LCBDE is associated with diameter of the CBD and stone clearance. LCBDE would be safer in proficient laparoscopic surgeons with a careful selection of patients. [ABSTRACT FROM AUTHOR]

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) has been proven to be a safe and effective method for diagnosis and treatment of biliary and pancreatic disorders. Major complications of ERCP include pancreatitis, hemorrhage, cholangitis, and duodenal perforation. We report a third case in literature of pneumoperitoneum after ERCP due to rupture of intrahepatic bile ducts and Glisson's capsule in a peripheral hepatic lesion. Case Report: A 50-year-old male with a history of metastatic pancreatic neuroendocrine tumor and who had a partially covered metallic stent placed in the biliary tree 1 year ago presented to the oncology clinic with fatigue, abdominal pain, and hypotension. He was planned for ERCP for possible cholangitis secondary to obstructed previously placed biliary stent. However, the duodenoscope could not be advanced to the level of the major papilla because of narrowed pylorus and severely strictured duodenal sweep. Forward-view gastroscope was then passed with careful manipulation to the severely narrowed second part of the duodenum where the previously placed metallic stent was visualized. Balloon sweeping of stenting was done. Cholangiography did not show any leak. Following the procedure, the patient underwent CT scan of the abdomen that showed pneumoperitoneum which was communicating with pneumobilia through a loculated air collection in necrotic hepatic metastasis perforating Glisson's capsule. The patient was managed conservatively. Conclusion: In our case, pneumoperitoneum resulted from rupture of intrahepatic bile ducts and Glisson's capsule in hepatic metastasis. This case emphasizes the need for close clinical and radiological observation of patients with hepatic masses (primary or metastatic) subjected to ERCP. [ABSTRACT FROM AUTHOR]

Background and study aims We present the first clinical results of a new tandem technique for direct peroral cholangioscopy using a standard ultraslim upper gastrointestinal endoscope and a guide probe that was originally developed for the non-transendoscopic placement of biliary endoprostheses (guide probe of Kautz; MTW, Wesel, Germany). Patients and methods Twenty direct peroral cholangioscopy procedures were performed with the new anchor-assisted method using the guide probe of Kautz in a single center and were retrospectively analyzed. Results  Indications for anchor-assisted cholangioscopy procedures included indeterminate bile duct strictures (n = 14), filling defects that remained after stone extraction (n = 4), and complex stone extractions (n = 2). Biliary access and visualization of the target region were achieved in 18/20 procedures (90 %). The interventional success rate was 85 % (11 /13 interventions). One case of postinterventional cholangitis occurred (5 %), along with one case of minor peri-interventional papillary bleeding (5 %). Conclusions The anchor-assisted cholangioscopy technique is feasible and safe for direct cholangioscopy and provides reliable success rates in clinical practice. This technique represents an alternative approach for direct cholangioscopy on a single-operator basis using standard endoscopes. [ABSTRACT FROM AUTHOR]

Liver resection remains the cornerstone of curative treatment for hepatocellular carcinoma and colorectal cancer liver metastases. Its success is dependent upon the extent of resection achieved. To this end, intra-operative imaging techniques have been experimented with to aid the surgeon. Fluorescence guided surgery (FGS) utilises the properties of near infrared light emitting molecules to identify malignant tissue, enabling the surgeon to maximise resection of diseased tissue and minimise collateral damage. Data from early trials showed increased superficial lesion detection when using fluorescence to guide liver resection. However, with far greater tissue penetration, intra-operative ultrasound (IOUS) remains the gold-standard intra-operative imaging modality. Subsequent trials have shown that the concomitant use of both FGS and IOUS may increase tumour detection rates intra-operatively. This review provides a comprehensive analysis of the most compelling evidence regarding fluorescence in hepatobiliary surgery and addresses the challenges faced introducing it into common practice. [ABSTRACT FROM AUTHOR]

Background: Hepaticojejunostomy may be used for biliary reconstruction in certain cases of liver transplantation. In this occasion, Roux-en-Y biliary reconstruction is predominantly performed. Petersen's hernia is an internal hernia that can occur after Roux-en-Y reconstruction, and it may lead to extensive ischemic changes affecting incarcerated portions of the small bowel or Roux limb resulting in severe complications with a poor prognosis. Case presentation: The present case was a 44-year-old male who underwent living donor liver transplantation (LDLT) for familial amyloid polyneuropathy and in whom biliary reconstruction was performed with Roux-en-Y hepaticojejunostomy. Two years after liver transplantation, symptomatic bowel strangulation was diagnosed by CT examination and emergent surgery was performed accordingly. On exploration, an ischemic limb associated with Petersen's hernia was observed. Although repositioning of the incarcerated bowel loop gradually improved the color of the limb, the limb failed to completely recover to a normal color. To allow accurate evaluation for the viability of the limb, we decided to perform a second-look operation after 48 h. On re-exploration, the surface of the limb remained a dark color; however, intraoperative endoscopic findings revealed only partial necrosis of the mucosa. Next, we resected the portion of ischemic damaged limb only following side-to-side jejunojejunostomy. Consequently, redoing of biliary reconstruction could be avoided and the original hepaticojejunostomy site was preserved. Although the stricture of the remnant Roux limb occurred 1 month thereafter, it was successfully managed by balloon dilation via percutaneous transhepatic biliary drainage route. Conclusions: The occurrence of Petersen's hernia should always be considered in cases of liver transplantation with Roux-en-Y biliary reconstruction. On the basis of an accurate assessment of the extent of jejunal limb injury, reanastomosis of the hepaticojejunostomy, a potentially high-risk surgical procedure, can be avoided in emergent situations. [ABSTRACT FROM AUTHOR]

The management of bile duct injury (BDI) remains a considerable challenge in hepatobiliary surgery. BDI is mainly iatrogenic, and mostly occurs in cholecystectomy. Laparoscopic cholecystectomy (LC) has been performed widely, however, the incidence of BDI associated with LC increases 2-3 times compared to that in open cholecystectomy (OC). BDI also occurs in robotic cholecystectomy. In China, the evidence-based Practice Guideline for Diagnosis and Treatment of BDI was published by the Biliary Surgery Group of Surgery Branch of Chinese Medical Association, with the purpose of reducing the incidence of BDI as well as promoting its optimal diagnosis and treatment. Surgery remains the mainstay of treatment for BDI and traumatic bile duct stricture. The definitive repair involves a series of procedures including exposing the proximal and distal bile duct, anastomotic bile duct tissue preparation, minimally invasive tissue anastomoses, and so on. Successful management is a surgical challenge requiring great specialized experience and precise surgical skill. The application of precision biliary surgery is recommended for promoting standardized management of BDI. [ABSTRACT FROM AUTHOR]

Adequate biliary drainage with endoscopic or percutaneous placement of self-expandable metal stents represents the goal of palliation in patients with inoperable malignant obstruction of the biliary tree. As an adjunct to stenting, various tissue ablation treatments have been proposed with conflicting results. The aim of this study was to test the effect on biliary tissue of a new ablation technique based on Nd:YAG laser light delivery. The study was conducted on ex vivo specimens of 18 healthy farm pigs, using cystic ducts that are the simplest biliary structures to isolate and cannulate ex vivo. A 22G cannula was positioned into the cystic duct and a quartz optical fibre, with a prototypal cooling system, was inserted into the cannula. Nd:YAG laser output powers of 10, 12, and 15 W were tested, with a total delivered energy of 1000 J in continuous mode in each case. After laser treatment, histological analysis was performed. At macroscopical examination, no lesions of the external wall of the cystic ducts were detected. At histopathological examination, a coagulative necrosis involving the entire mucosa up to the muscolaris propria without significant changes of periductal tissues was observed in all specimens. This study shows the possibility of using Nd:YAG laser on ex vivo porcine biliary ducts with the effect of obtaining a coagulative necrosis involving the whole mucosa. [ABSTRACT FROM AUTHOR]

Background: Endoscopic nasobiliary drainage (ENBD) was often used for preoperative biliary drainage in cases like cholangiocarcinoma or acute obstructive suppurative cholangitis, reports on endoscopic nasobiliary drainage (ENBD) over primary closure of the common bile duct (CBD) are limited. This study compares outcomes of laparoscopic cholecystectomy (LC) + laparoscopic CBD exploration (LCBDE) + intraoperative ENBD + primary closure of CBD with equivalent patients who underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) and subsequent LC.Methods: From January 2013 to December 2015, 829 consecutive patients with choledocholithiasis combined with cholecystolithiasis underwent surgery in our department. 211 patients underwent LC + LCBDE + intraoperative ENBD + primary closure of CBD (group A) and 117 preoperative ERCP + subsequent LC (group B). A total of 501 patients (355 who underwent T-tube drainage and 146 who underwent transcystic exploration) were excluded from the analysis. Clinical records, operative findings, and postoperative follow-up were analyzed.Results: Age and sex distribution, comorbidity, presentations, CBD diameter, and size and number of stones were similar in the two groups, and there was no postoperative mortality. Duration of surgery in group A was shorter (83 vs. 104 min, P < 0.01), as was postoperative hospital stay (6 vs. 9 days, P < 0.01). Average operative expenditure in group A was less than that of group B ($ 3816 vs. $ 4015, P < 0.01). The success rate in group A was higher (100 vs. 91%, P < 0.01). Ten patients in group B converted to LCBDE. The postoperative complication rate was higher in group B but without significant difference (1.9 vs. 4.2%, P = 0.29). Median follow-up time was 24 (3-28) months (n = 302 patients). Two patients in group B reported residual stones.Conclusion: LC + LCBDE + intraoperative ENBD + primary closure of CBD should have priority over preoperative ERCP + subsequent LC for choledocholithiasis combined with cholecystolithiasis. [ABSTRACT FROM AUTHOR]

Background. Gallstone disease affects 15–20% of the general population and up to 20% of these patients present common bile duct stones. Aim. This observational study reports our experience on routine cysticotomy and flushing of the cystic duct in patients with low risk of common duct stones. Materials and Methods. We analyzed 731 patients who underwent laparoscopic cholecystectomy between September 2013 and September 2015. Results. Patients were preoperatively stratified on the clinical risk; those presenting with low preoperative risk of common bile duct stones were referred to undergo laparoscopic cholecystectomy and routine cysticotomy with bile duct flushing. Patients presenting thick bile sludge, solid debrides, and/or increased tension of bile outflow underwent unplanned cholangiography. No intraoperative complications or conversion to open technique occurred. Average follow-up time was 22,8 months (range 12 to 37). Rate of retained ductal stones accounted for 0,3%. Conclusions. Routine cysticotomy and bile flushing in our experience is a valid, simple, and not time consuming manoeuvre that can help decompressing and flushing CBD. Moreover, it is a valid tool for extending selective IOC approach in a focused manner. Further evaluations have to be conducted to evaluate risks and effectiveness of this manoeuvre. [ABSTRACT FROM AUTHOR]

Aims Bile duct ligation (BDL) model is used to study hepatic encephalopathy accompanied by cognitive impairment. We employed the proteomic analysis approach to evaluate cognition-related proteins in the prefrontal cortex of young BDL rats and analyzed the effect of minocycline on these proteins and spatial memory. Main methods BDL was induced in young rats at postnatal day 17. Minocycline as a slow-release pellet was implanted into the peritoneum. Morris water maze test and two-dimensional liquid chromatography-tandem mass spectrometry were used to evaluate spatial memory and prefrontal cortex protein expression, respectively. We used 2D/LC-MS/MS to analyze for affected proteins in the prefrontal cortex of young BDL rats. Results were verified with Western blotting, immunohistochemistry, and quantitative real-time PCR. The effect of minocycline in BDL rats was assessed. Key findings BDL induced spatial deficits, while minocycline rescued it. Collapsin response mediator protein 2 (CRMP2) and manganese-dependent superoxide dismutase (MnSOD) were upregulated and nucleoside diphosphate kinase B (NME2) was downregulated in young BDL rats. BDL rats exhibited decreased levels of brain-derived neurotrophic factor (BDNF) mRNA as compared with those by the control. However, minocycline treatment restored CRMP2 and NME2 protein expression, BDNF mRNA level, and MnSOD activity to control levels. Significance We demonstrated that BDL altered the expression of CRMP2, NME2, MnSOD, and BDNF in the prefrontal cortex of young BDL rats. However, minocycline treatment restored the expression of the affected mediators that are implicated in cognition. [ABSTRACT FROM AUTHOR]

Background: Choledocholithiasis or the presence of common bile duct stones (CBDS) is one of the medical conditions that requires surgical intervention. The management of choledocholithiasis has evolved from open common bile duct exploration (OCBDE) to therapeutic endoscopic retrograde cholangiopancreatography (ERCP) to laparoscopic common bile duct exploration (LCBDE). Each entails a degree of difficulty. In this review we aim to assess and compare the benefits and pitfalls of open surgery (OCBDE) versus endoscopic retrograde cholangiopancreatography (ERCP) in management of common bile duct stones. Methods: A systematic review of the electronically searched publications of the scientific literature. We searched the Cochrane HepatoBiliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE (1946 to 2016), EMBASE (1974 to 2016), and Science Citation Index Expanded (1900 to 2016). Initially all randomized clinical trials which compared the results from open surgery versus endoscopic clearance for common bile duct stones were included, articles were selectively screened according to the eligibility criteria. Results: eight publications were selectively included with 761 participants compared to open surgical clearance with ERCP. All trials had a high risk of bias. There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data. Conclusion: open surgery intervention in order to remove the gallbladder and trapped gallstones appears to be as safe as endoscopy and further suggested to be more successful than the endoscopic technique in clearing the duct stones. [ABSTRACT FROM AUTHOR]

Background: Endoscopic sphincterotomy (EST) combined with balloon catheters and/or baskets are the routine endoscopic techniques for stone extraction in the great majority of patients. Whereas large common bile duct (CBD) stones are treated conventionally with mechanical lithotripsy, large balloon papillary dilation after endoscopic sphincterotomy (ELPBD) represents the onset of an era in large CBD stone extraction and the management of -impactionl That is because it seems effective, inexpensive, less traumatic, safe and easy method that does not require sophisticated apparatus and can be performed widely by skillful endoscopists. Studies comparing the efficacy and safety of EPLBD with EST have reported mixed outcomes. The aim of the study to compare the success and complications rates between endoscopic papillary balloon dilation and endoscopic sphincterotomy for enlargement of papillary opening during endoscopic removal of common bile duct stones. Methods: Randomized prospective comparative study was conducted on seventy four patients with CBD stone(s), subjective to therapeutic ERCP procedures for endoscopic extraction of common CBD(s). The enrolled patients were randomly divided into two groups according to the maneuver for dilate the papillary orifice into: Group I: Thirty one patients underwent EPLBD technique combined with balloon catheters and/or baskets for stone extraction. Group II: Forty three patients underwent EST combined with balloon catheters and/or baskets, which is considered as conventional endoscopic technique for stone extraction in the great majority of patients. Results: Complete extraction CBD stones among the patients of group1; EPLBD was effective for clearance of (92.5%) of CBD stones in patients with the stone sized < 1cm and in (83%) of patients with stone size ≥ 1cm, (overall clearance rate=87%). Overall adverse effects of patients of group1 was (29%) as mild self-limiting post ERCP pain occurred in (9.6%) and mild intra-procedure bleeding occurred in (9.6%), whereas more serious complication as melena which occurred in (3.2%), and mild pancreatitis occurred in (6.4%). Whereas complete CBD stones clearance among the patients of group 2; EST was effective in (96%) of patients with the stone sized < 1 cm, while stone clearance occurred in (56%) in patient with stone size≥ 1cm, (overall clearance rate=79%). Overall adverse effects of patients of group 2 was (18.5%) as mild self-limiting post ERCP pain occurred in (7%) and mild intra-procedure bleeding occurred in (4.6%), whereas more serious complications as mild pancreatitis developed in (4.6%), and post ERCP cholangitis in (2.3%). The comparison between the two groups regarding the extraction of CBD stones revealed combination of papillary large balloon dilation after EST is not required in patients whose the CBD stone size < 1 cm. Whereas the clearance rate of CBD stones in the patients with stone size ≥ 1cm among the group 1 was (83%) which better than among the group 2 which was (56%) with nearly statistical difference (P value=0.07). Conclusion: Conventional EST is an effective method for removal of common bile duct stones < 1cm in diameter whereas the use of large papillary balloon dilation after endoscopic sphincterotomy improve the clearance rate of bile duct stones≥ 1cm which is difficult to be extracted by conventional sphincterotomy and extraction devices. Endoscopic papillary large balloon dilation is an adjunctive tool to endoscopic sphincterotomy for removing large or difficult CBD stones. [ABSTRACT FROM AUTHOR]

Background: Endoscopic sphincterotomy (ES) is the standard technique for common bile duct (CBD) stone removal. Recently, endoscopic papillary large balloon dilation (EPLBD) has been shown to be a safe and effective technique for the removal of large CBD stone. The aim of this study was to determine the therapeutic outcomes and safety of EPLBD compared with ES for large CBD stone extraction.Patients and Methods: One hundred twenty-four patients with large bile duct stones were randomized into two groups, the first group included 61 patients subjected to EPLBD and the second group included 63 patients who underwent ES. We compared the success rate of stone removal, frequency of mechanical lithotripsy requirement, morbidity, and mortality.Results: Baseline characteristics were not significantly different. The overall ductal clearance rate was ultimately similar between the EPLBD group (96.7%) and the ES group (93.7%) (P = .53), the one session ductal clearance rate was significantly different (86.9% versus 71.4%; P = .01). Requirement of mechanical lithotripsy was significantly different between the EPLBD and ES group (9.8% versus 17.5%, P = .04). There were no differences in complication rates between the EPLBD and ES group; pancreatitis, 4.9% versus 6.3%; minor hemorrhage, 1.6% versus 6.3%; acute cholangitis, 3.3% versus 1.9%; and recurrent stones, 3.3% versus 3.2%.Conclusions: The therapeutic outcomes of EPLBD for removal of large bile duct stones are better than those of ES with comparable complication rate. EPLBD is also recommended for removal of large CBD stone in patients with an underlying coagulopathy or need for anticoagulation following endoscopic retrograde cholangiopancreaticography. [ABSTRACT FROM AUTHOR]

Background: Wait-and-see policy after endoscopic sphincterotomy (ES) for common bile duct (CBD) stones in patients with concomitant gallbladder stones may lead to recurrent biliary complications. The aim of this study was to assess the short and long-term results of wait-and-see policy in patients with intact gallbladder after endoscopic clearance of CBD stones.Materials and Methods: From January 1999 to December 2014 a total of 181 consecutive patients with intact gallbladder underwent ES for CBD stones. The main measures of outcome were long-term biliary complications, biliary related mortality, CBD stone recurrence and need for surgical interventions. Secondary outcomes were 30-day mortality and 30-day morbidity. Clinical data were retrospectively collected from hospital records and from the National Registry of Death.Results: During the median follow-up of 3.9 years (IQR 1.6-6.6) late biliary complications were observed in 24 (13.8%) patients. Cumulative biliary related morbidity at 3 and 5 years was 7.6% and 10.8%, respectively. CBD stone recurrence was observed in 9 (5.2%) patients. On-demand cholecystectomy was performed in 6 (3.3%) patients. 30-day mortality was 3.9% and 30-day morbidity 9.4%. Overall cumulative mortality rate at 3 and 5 years after ES was 31.4% and 49.7%, respectively. Long-term biliary related mortality was 1.7%. No significant difference in long term complications or biliary mortality was observed between patients< 75 or ≥75 years of age.Conclusion: Prophylactic cholecystectomy after ES has been shown to reduce mortality even in high-risk patients. In our series late biliary related mortality and morbidity were relatively low, because a considerable number of patients died from non-biliary related causes.However, most biliary-related events seem to occur evenly during the follow-up after ES. A prompt risk assesment and consideration of surgical treatment during index admission may prevent late biliary -related complications. [ABSTRACT FROM AUTHOR]

Epithelial response to injury is critical to the pathogenesis of biliary cirrhosis, and IL-6 has been suggested as a mediator of this phenomenon. Several liver cell types can secrete IL-6 following activation by various signaling molecules including circulating adenosine. The aims of this study were to assess whether adenosine can induce IL-6 secretion by cholangiocytes via the A2b adenosine receptor (A2bAR) and to determine the effect of A2bAR-sensitive IL-6 release on injury response in biliary cirrhosis. Human normal cholangiocyte H69 cells were used for in vitro studies to determine the mechanism by which adenosine and the A2bAR induce release of IL-6. In vivo, control and A2bAR-deficient mice were used to determine the roles of A2bAR-sensitive IL-6 release in biliary cirrhosis induced by common bile duct ligation (BDL). Additionally, the response to exogenous IL-6 was assessed in C57BL/6 and A2bAR-deficient mice. Adenosine induced IL-6 mRNA expression and protein secretion via A2bAR activation. Although activation of A2bAR induced cAMP and intracellular Ca2+ signals, only the Ca2+ signals were linked to IL-6 upregulation. After BDL, A2bAR-deficient mice have impaired survival, which is further impaired by exogenous IL-6; however, decreased survival is not due to changes in fibrosis and no changes in inflammatory cells. Exogenous IL-6 is associated with the increased presence of bile infarcts. Extracellular adenosine induces cholangiocyte IL-6 release via the A2bAR. This signaling pathway is important in the pathogenesis of injury response in biliary cirrhosis but does not alter fibrosis. Adenosine upregulates IL-6 release by cholangiocytes via the A2bAR in a calcium-sensitive fashion. Mice deficient in A2bAR experience impaired survival after biliary cirrhosis induced by common bile duct ligation independent of changes in fibrosis. [ABSTRACT FROM AUTHOR]

Background: It remains controversial whether preoperative cholangitis affects long-term outcomes after resection in patients with extrahepatic bile duct cancer.Methods: A total of 107 patients with extrahepatic bile duct cancer who underwent resection with curative intent from 2008 to 2014 were retrospectively reviewed. Patients were categorized into two groups according to the presence or absence of preoperative cholangitis. Clinicopathological variables and long-term outcomes were compared in the two groups.Results: In the preoperative cholangitis group, the rate of preoperative biliary drainage, the number of tube changes and/or additions, and the rate of lymph node metastasis were higher compared to the no-cholangitis group. Overall survival and disease-free survival were significantly worse in the cholangitis group compared to the no-cholangitis group (p = 0.022, p = 0.007). A poorer prognosis was not observed with an increasing grade of cholangitis in Tokyo Guidelines 2013 (p = 0.09). A multivariate logistic regression analysis revealed that the preoperative cholangitis was an independent prognostic factor for extrahepatic bile duct cancer.Conclusion: Preoperative cholangitis is an independent prognostic factor in patients with extrahepatic bile duct cancer regardless of the severity of the cholangitis. [ABSTRACT FROM AUTHOR]

Introduction: Hepaticojejunostomy leaks are less frequent than pancreatic leaks after pancreatoduodenectomy, and the current literature suggests comparable outcomes. The purpose of this study was to determine if the hepaticojejunostomy leak adversely affected patient outcomes.Methods: Consecutive cases of pancreatoduodenectomy (n = 924) were reviewed at a single high-volume institution over an 8-year period (2006-2014).Results: Pancreaticojejunostomy leaks were identified in 217 (23%) patients and hepaticojejunostomy leaks were identified in 24 patients (3%); combined hepaticojejunostomy/pancreaticojejunostomy leaks were identified in 31 patients (3%). Those with hepaticojejunostomy leaks or combined leaks had a significantly increased risk of morbidity when compared to pancreaticojejunostomy leaks or no leak (54 and 58 vs. 34 and 24%, respectively, p < 0.05). The median length of stay was significantly greater for hepaticojejunostomy leaks or combined leaks when compared to pancreatojejunostomy leaks (17 or 14 vs. 9 days, p = 0.001) and those with no leak (17 or 14 vs. 7 days, p = 0.001). Ninety-day mortality for all patients was 3.6%. Hepaticojejunostomy leaks and combined leaks significantly increased 90-day mortality rate (17 and 32%, respectively, p < 0.05).Conclusions: Hepaticojejunostomy and combined leaks after pancreatoduodenectomy are rarer than pancreaticojejunostomy leaks; these patients are at a significantly increased risk of major morbidity and mortality. [ABSTRACT FROM AUTHOR]

Background: Common bile duct (CBD) stone is one of the most common diseases among elderly people. In recent decades, there are numerous studies regarding the safety and efficacy of laparoscopic common bile duct exploration (LCBDE). Elderly patients are often regarded as high-risk patients because they are more likely to present with age-specific deterioration of organ function and coexisting chronic diseases, which may reduce their tolerance of laparoscopic surgery. Although laparoscopic surgery for choledocholithiasis is now widely accepted as the treatment for CBD stone, its appropriateness for the treatment of elderly patients or those with coexisting high-risk patients has not been well established. Therefore, the objective of this paper is to analyze the safety and efficacy of LCBDE in elderly patients.Methods: Between January 2012 and November 2015, 376 patients underwent LCBDE in our center. Based on their ages, they were divided into two groups, and a retrospective study was performed. By making comparisons between younger group who were younger than 70 years (n = 253) and elderly group who were 70 years old or older (n = 123), the demographics, clinical characteristics, laboratory data, operative parameters and outcomes were analyzed.Results: Before operation, elderly patients had more coexisting chronic diseases and risk factors, such as arterial hypertension, heart diseases, pulmonary diseases and previous abdominal surgery (P < 0.05). In both groups, LCBDE was equally successful with a high clearance rate (100 % in elderly patients vs. 98.8 % in younger group, P = 0.554). Besides, the operating time, intraoperative blood loss, postoperative hospital stay, total costs and overall complication showed no significant difference between two groups (P > 0.05). There was no major bile duct injury or death in either group.Conclusion: Although elderly patients are frequently confronted with coexisting disorders, LCBDE can be considered as a safe and effective technique in choledocholithiasis treatment for elderly patients. [ABSTRACT FROM AUTHOR]

Background and Purpose: Dihydrotanshinone I (DHI), a lipophilic component of traditional Chinese medicine Salvia miltiorrhiza Bunge, has various therapeutic effects. We investigated the anti-fibrotic effect of DHI and its underlying mechanisms in vitro and in vivo.Experimental Approach: Rats subjected to bile duct ligation (BDL) were treated with DHI (25 mg·kg-1 ·day-1 , i.p.) for 14 days. Serum biochemical and liver tissue morphological analyses were performed. The human hepatic stellate cell line LX-2 served as a liver fibrosis model in vitro. Liver fibrogenic genes, yes-associated protein (YAP) downstream genes and autophagy markers were examined using western blot and real-time PCR analyses. Similar analyses were done in rat primary hepatic stellate cells (pHSCs). Autophagy flux was assessed by immunofluorescence.Key Results: In BDL rats, DHI administration attenuated liver necrosis, bile duct proliferation and collagen accumulation and reduced the expression of genes associated with fibrogenesis, including Tgfb1, Mmp-2, Acta2 and Col1a1. DHI (1, 5, 10 μmol·L-1 ) time- and dose-dependently suppressed the protein level of COL1A1, TGFβ1 and α-SMA in LX-2 cells and rat pHSCs. Furthermore, DHI blocked the nuclear translocation of YAP, which inhibited the YAP/TEAD2 interaction and its downstream fibrogenic genes, connective tissue growth factor, SOX4 and survivin. This stimulated autophagic flux and accelerated the degradation of liver collagen.Conclusions and Implications: DHI exerts anti-fibrotic effects in BDL rats, LX-2 cells and rat pHSCs by inhibiting the YAP and TEAD2 complex and stimulating autophagy. These findings indicate that DHI may be a potential therapeutic for the treatment of liver fibrosis. [ABSTRACT FROM AUTHOR]

Minimal hepatic encephalopathy (MHE), which represents the early stage of this condition, is not clinically apparent and is prevalent in up to 80% of patients. The poor outcomes of MHE encouraged us to identify more simple methods for early diagnosis of MHE. To this purpose, we evaluated the contemporary manifestations of motor, cognitive and sensorimotor gaiting deficits following bile duct-ligation (BDL). Male Wistar rats were undergone BDL to induce cirrhosis and locomotor, spatial learning and memory and sensorimotor gating were assessed 2, 3, and 4 weeks after the operation by rotarod, Morris water-maze and prepulse inhibition (PPI) tests. PPI was examined 6 weeks after BDL until appearance of hepatic encephalopathy. Results showed that although PPI was significantly enhanced in the 6-week BDL animals, locomotor activity reduced in 4-week BDL rats compared to the BDL rats after a 2-week period. The total distance travelled and swimming time to reach the platform increased in the 4-week BDL rats and, in contrast, the percentage of time spent and space travelled in correct quadrant decreased. Moreover, memory index decreased in the 3-week BDL group compared to sham-operated group. It was observed an increase in global PPI in 3- and 4-week BDL animals in comparison with either 2-week BDL or sham-operated rats. Consequently, it is indicated that BDL animals manifest spatial learning and memory deficits and PPI disruption in early stage of HE and evaluation of these factors can be considered as indices for simple and early diagnosis of MHE. [ABSTRACT FROM AUTHOR]