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Background: Early reports suggested that previous abdominal surgery was a relative contraindication to laparoscopic cholecystectomy (LC) on account of difficulty and potential access complications. This study analyses different types/systems of previous surgery and locations of scars and how they affect access difficulties. As modified access techniques to minimise risk of complications are under-reported the study details and evaluates them. Method: Prospectively collected data from consecutive LC and common bile duct explorations (LCBDE) performed by a single surgeon over 30 years was analysed. Previous abdominal surgery was documented and peri-operative outcomes were compared with patients who had no previous surgery using Chi-squared analysis. Results: Of 5916 LC and LCBDE, 1846 patients (31.2%) had previous abdominal surgery. The median age was 60 years. Those with previous surgery required more frequent duodenal (RR 1.07; p = 0.023), hepatic flexure (RR 1.11; p = 0.043) and distal adhesiolysis (RR 3.57; p < 0.001) and had more access related bowel injuries (0.4% vs. 0.0%; p < 0.001). Previous upper gastrointestinal and biliary surgery had the highest rates of adhesiolysis (76.3%), difficult cystic pedicles (58.8%), fundus-first approach (7.2%), difficulty grades (64.9% Grades 3–5) and utilisation of abdominal drains (71.1%). Previous open surgery resulted in longer operative time compared to previous laparoscopic procedures (65vs.55 min; p < 0.001), increased difficulty of pedicle dissection (42.4% vs. 36.0%; p < 0.05) and required more duodenal, hepatic flexure and distant adhesiolysis (p < 0.05) and fundus-first dissection (4% vs 2%; p < 0.05). Epigastric and supraumbilical access and access through umbilical and other hernias were used in 163 patients (8.8%) with no bowel complications. Conclusion: The risks of access and adhesiolysis in patients with previous abdominal scars undergoing biliary surgery are dependent on the nature of previous surgery. Previous open, upper gastrointestinal and biliary surgery carried the most significant risks. Modified access techniques can be adopted to safely mitigate these risks. [ABSTRACT FROM AUTHOR]

Background: Biliary obstruction before liver resection is a known risk factor for post-operative complications. The aim of this study was to determine the impact of persistent hyperbilirubinemia following preoperative biliary drainage before liver resection. Methods: The ACS-NSQIP (2016–2021) database was used to extract patients with cholangiocarcinoma who underwent anatomic liver resection with preoperative biliary drainage comparing those with persistent hyperbilirubinemia (> 1.2 mg/dL) to those with resolution. Patient characteristics and outcomes were compared with bivariate analysis. Multivariable modeling evaluated factors including persistent hyperbilirubinemia to evaluate their independent effect on serious complications, liver failure, and mortality. Results: We evaluated 463 patients with 217 (46.9%) having hyperbilirubinemia (HB) despite biliary stenting. Bivariate analysis demonstrated that patients with HB had a higher rate of serious complications than those with non-HB (80.7% vs 70.3%; P = 0.010) including bile leak (40.9% vs 31.8%; P = 0.045), liver failure (26.7% vs 17.9%; P = 0.022), and bleeding (48.4% vs 36.6%; P = 0.010). Multivariable analysis demonstrated that persistent HB was independently associated with serious complications (OR 1.88, P = 0.020) and mortality (OR 2.39, P = 0.049) but not post-operative liver failure (OR 1.65, P = 0.082). Conclusions: Failed preoperative biliary decompression is a predictive factor for post-operative complications and mortality in patients undergoing hepatectomy and may be useful for preoperative risk stratification. [ABSTRACT FROM AUTHOR]

Background and aim: Balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) is an emerging procedure for pancreatobiliary diseases in patients with surgically altered anatomy. However, data on BE-ERCP for hepatolithiasis after hepaticojejunostomy (HJS) are still limited. Methods: Stone removal success, adverse events and recurrence were retrospectively studied in consecutive patients who underwent BE-ERCP for hepatolithiasis after HJS between January 2011 and October 2022. Subgroup analysis was performed to compare clinical outcomes between patients who had undergone HJS over 10 years before (past HJS group) and within 10 years (recent HJS group). Results: A total of 131 patients were included; 39% had undergone HJS for malignancy and 32% for congenital biliary dilation. Scope insertion and complete stone removal were successful in 89% and 73%, respectively. Early adverse events were observed in 9.9%. Four patients (3.1%) developed gastrointestinal perforation but could be managed conservatively. Hepatolithiasis recurrence rate was 17%, 20% and 31% in 1-year, 3-year, and 5-year after complete stone removal. The past HJS group was the only risk factor for failed stone removal (odds ratio 10.4, 95% confidence interval 2.99–36.5) in the multivariable analysis. Failed scope insertion (20%) and failed guidewire or device insertion to the bile duct (22%) were two major reasons for failed stone removal in the past HJS group. Conclusions: BE-ERCP for hepatolithiasis was effective and safe in cases with HJS but the complete stone removal rate was low in the past HJS group. Recurrent hepatolithiasis was common and careful follow up study is needed even after complete stone removal. [ABSTRACT FROM AUTHOR]

Simple Summary: In this review, first, the history of EUS-guided biliary drainage (EUS-BD) is summarized. In the following chapters controversies arising from various approaches and challenges in EUS-BD, EUS-guided gallbladder drainage (EUS-GBD) and alternatively performed procedures are discussed from different points of view on the background of the available evidence. In addition, for all topics arguments in favor and against the techniques are described and reflected. The topics include "Why do we need procedures other than ERCP?"; "Should EUS-BD and ERCP be performed by the same operator?"; rendezvous techniques, including "Should rendezvous be used first?" and "Which rendezvous route should be used?"; percutaneous transhepatic cholangiography and biliary drainage (PTBD); "Should PTBD and EUS-BD be performed by the same physician?"; "Do we need cystotomes?"; "Do we need bougies?"; "Are all EUS needles the same for EUS-BD?"; "Plastic or metal stents?"; and adverse events. In this 14th document in a series of papers entitled "Controversies in Endoscopic Ultrasound" we discuss various aspects of EUS-guided biliary drainage that are debated in the literature and in practice. Endoscopic retrograde cholangiography is still the reference technique for therapeutic biliary access, but EUS-guided techniques for biliary access and drainage have developed into safe and highly effective alternative options. However, EUS-guided biliary drainage techniques are technically demanding procedures for which few training models are currently available. Different access routes require modifications to the basic technique and specific instruments. In experienced hands, percutaneous transhepatic cholangiodrainage is also a good alternative. Therefore, in this paper, we compare arguments for different options of biliary drainage and different technical modifications. [ABSTRACT FROM AUTHOR]

Introduction: Enhanced recovery after surgery (ERAS) is a multidisciplinary approach to optimize patient care. The goal of this approach is to reduce the body's reaction to surgical stress by optimizing the perioperative nutritional status, promoting analgesia without opioids, and early postoperative feeding. In pediatric patients, very limited literature is available for the application of ERAS protocol. This study was done to evaluate the application of ERAS protocol in pediatric hepatobiliary and pancreatic patients. Materials and Methods: This is a randomized prospective study conducted over a period of 2 years at a tertiary center in North India. A total of 40 hepatobiliary and pancreatic patients who were willing to participate in the study were included in the study. Patients were randomized by computer-generated method and data were collected regarding demography, clinical diagnosis, preoperative and postoperative workup, and peri-operative care including analgesia, pain scores, postoperative recovery, hospital stay, and complications. These patients were followed for 6 months postoperatively and the results were evaluated using SPSS software. Results: The study included 20 patients each in both the conventional and ERAS group with median ages of 11.5 years and 7.1 years, respectively. The data analysis showed that the ERAS group of patients had better outcomes in terms of hospital stay and drain removal time with significant statistical differences. Pain scores and complications are almost the same in both groups. Conclusion: Principles of ERAS can be safely applied in pediatric patients undergoing major surgery in the present era of emerging infections and also increasing patient burden without morbidity. [ABSTRACT FROM AUTHOR]

BACKGROUND: Postoperative healthcare use and readmissions are common among the hepatopancreatobiliary (HPB) population. We evaluated the surgical volume required to sustain advanced practice providers (APPs) in the perioperative setting for cost reduction. STUDY DESIGN: Using decision analysis modeling, we evaluated costs of employing dedicated perioperative APP navigators compared with no APPs navigators. Simulated subjects could: (1) present to an emergency department, with or without readmission, (2) present for direct readmission, (3) require additional office visits, or (4) require no additional care. We informed our model using the most current available published data and performed sensitivity analyses to evaluate thresholds under which dedicated perioperative APP navigators are beneficial. RESULTS: Subjects within the APP navigator cohort accumulated $1,270 and a readmission rate of 6.9%, compared with $2,170 and 13.5% with no APP navigators, yielding a cost savings of $905 and 48% relative reduction in readmission. Based on these estimated cost savings and national salary ranges, a perioperative APPs become financially self-sustaining with 113 to 139 annual HPB cases, equating to 2 to 3 HPB cases weekly. Sensitivity analyses revealed that perioperative APP navigators were no longer cost saving when direct readmission rates exceeded 8.9% (base case 3.7%). CONCLUSIONS: We show that readmissions are reduced by nearly 50% with an associated cost savings of $900 when employing dedicated perioperative APPs. This position becomes financially self-sufficient with an annual HPB case load of 113 to 139 cases. High-volume HPB centers could benefit from postdischarge APP navigators to optimize outcomes, minimize high-value resource use, and ultimately save costs. [ABSTRACT FROM AUTHOR]

Background: Patients with percutaneous transhepatic biliary drainage (PTBD) need regular drainage tube care after discharge, and transitional care can help solve this problem. However, few studies have focused on the quality of transitional care, the perceptions of patients with drainage tubes after discharge and those of healthcare professionals. Aim: This study is aimed at exploring the real experience and perceptions of transitional care services among healthcare professionals and PTBD patients who have been discharged with tubes and at providing references for future transitional care service development. Design: The study uses a qualitative descriptive design. The reporting method followed Consolidated Criteria for Reporting Qualitative Research guidelines. Methods: Semistructured interviews were conducted with PTBD patients who had been discharged with tubes and multicentre healthcare professionals using the purpose sampling method. The thematic analysis method was used for analysis. Results: Thirteen PTBD patients from one hospital and 12 healthcare professionals from three hospitals were interviewed. The analysis of the patient interview data revealed three themes, namely, recognition of the value of transitional care services, patients have some unmet needs and perception of transitional care service pathways. Six subthemes were also identified. The analysis of the interview data of healthcare professionals revealed two themes, namely, harvest and challenges in transitional care services work and expectations for future development of transitional care services. Four subthemes were also identified. Conclusions: The transitional care of discharged patients with PTBD tubes deserves the attention of clinical workers, and a series of measures should be taken to improve transitional care services. Patient/Public Contribution: Patients were involved in the formulation of interview questions for this study, and during the interviews, patients presented their suggestions for transitional care services. Healthcare professionals participated in this study as interviewees, and no members of the public were involved in this study. [ABSTRACT FROM AUTHOR]

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred technique for treating pathologies of the bile duct. It has been suggested that this procedure, combined with sphincterotomy, may influence the subsequent development of long-term complications. The main objective of this study was to determine the long-term complications of biliopancreatic disease after ERCP and their potential association with the development of biliopancreatic neoplasms. Methods: This retrospective cohort study included 576 patients who underwent ERCP (referred to as index ERCP) with sphincterotomy for benign biliary disease, with a minimum follow-up period of more than 2 years. Results: The incidence of long-term benign and neoplastic pathologies after ERCP was analyzed. The most common findings were recurrence of choledocholithiasis in 70 patients (12.1%), cholangitis "sine materia" in 27 patients (4.7%), and acute pancreatitis in 8 patients (1.4%). Eight patients (1.4%) developed hepatobiliopancreatic neoplasms, including 4 cases of pancreatic neoplasms (0.7%), 1 cholangiocarcinoma (0.2%), 1 ampulloma (0.2%), and 2 intrahepatic neoplasms (0.3%). Multivariate analysis revealed that factors such as age over 50 years, previous biliary surgery, diversion of the bile duct (BD) to the digestive tract, dilation of the BD, stent placement, biopsy, and cholecystectomy were factors associated with an increased risk of long-term benign complications. Conclusion: Endoscopic retrograde chola ngiop ancre atogr aphy with sphincterotomy is associated with an increased long-term risk of subsequent benign biliopancreatic disease. However, our data do not allow us to establish a direct relationship with the development of biliopancreatic neoplasms. [ABSTRACT FROM AUTHOR]

Whether prophylactic abdominal drainage tube is routinely placed in patients after hepatobiliary surgery remains controversial. To evaluate the effect of prophylactic abdominal drainage tube placement after hepatobiliary surgery on postoperative infection. Randomized controlled trials on the placement of prophylactic abdominal drainage tube after hepatobiliary surgery were collected through a computerized search of PubMed, Embase, Conchrane Library and Web of Science databases, with a time range from the establishment of the database to August 2023. After two researchers independently screened the literature, extracted information, and evaluated the quality of the included studies. Finally, 13 studies were included, including 3620 patients, and the results showed that there was no statistically significant difference in postoperative infection rate between the drainage group (1840 patients and the non‐drainage group [1783 patients] [relative risk, RR = 1.17, 95% confidence interval, CI: 0.94–1.47, p = 0.16]. Compared with the drainage group, the incidence of infectious abdominal fluid in the non‐drainage group was lower (RR = 2.09, 95% CI: 1.57–2.80, p < 0.00001), and the incidence of postoperative bile leakage was lower (RR = 1.77, 95% CI: 1.27–2.47, p < 0.001) and shorter hospital stays after surgery (mean difference = 1.27, 95% CI: 0.32–2.22, p = 0.009). In conclusion, placing a prophylactic abdominal drainage tube after hepatobiliary surgery does not reduce postoperative infection rates compared with no drainage. [ABSTRACT FROM AUTHOR]

The article focuses on study about the capecitabine compared with observation in resected biliary tract cancer (BILCAP) trial and the importance of going beyond the P-value and examining the entire data, including the effect size. Topics discussed include primary outcome of BILCAP, problem with the per-protocol analysis, and importance of the difference in median survival in the case of the BILCAP study.

Background and aims: Self-expandable metal stent (SEMS) insertion is the standard palliative treatment for unresectable malignant extrahepatic biliary obstruction (MBO). Drawbacks of conventional fully covered SEMS (FCSEMS) and uncovered SEMS (USEMS) include stent migration and tumor ingrowth, respectively. This study aimed to compare stent patency in MBO with the newly design multi-hole SEMS (MHSEMS), which has multiple small side holes in the stent membrane, with conventional FCSEMS and UCSEMS. Patients and methods: This retrospective study using a propensity score matching design and stent patency times of 40 patients with MHSEMS was compared to 40 and 34 patients with FCSEMS and UCSEMS during the same period, respectively. Secondary outcomes were procedure-related adverse events, clinical success rate, time to recurrent biliary obstruction (RBO), and etiology of RBO. RBO was compared using Kaplan–Meier analysis. Results: Baseline characteristics after matching were comparable among the 3 groups. RBO rates were 21%, 37%, and 55% for MHSEMS, FCSEMS, and UCSEMS, respectively (p = 0.014), at a mean time of 479, 353, and 306 days, respectively (MHSEMS vs UCSEMS, p = 0.002). Rate of tumor ingrowth was highest in the UCSEMS group (42.4% vs 13.2% in MHSEMS; p = 0.005 and vs 0% in FCSEMS; p < 0.001). Stent migration rate was highest in the FCSEMS group at 15.8% vs 2.6% in MHSEMS (p = 0.047) and 0% in UCSEMS (p = 0.005). Conclusion: MHSEMS provided the longest stent patency time with lowest RBO rate compared to conventional SEMS by showing a lower stent migration rate than FCSEMS and a lower tumor ingrowth rate than UCSEMS. [ABSTRACT FROM AUTHOR]

Intracholecystic papillary neoplasm of the gallbladder is a rare and relatively new entity in the fifth edition of the World Health Organization classification of tumors of the digestive system. It mainly occurs in elderly women. It is an exophytic, granular, and friable mass seen in gallbladder mucosa, often mistaken clinically as sludge. We report a middle-aged female with abdominal pain and a vague mass in the right hypochondrium. A computed tomography scan of the abdomen and pelvis showed a heterogeneously enhancing lesion in the gallbladder lumen extending from the fundus to the neck, causing an irregular luminal obstruction. Histopathological examination of the cholecystectomy specimen showed features of intracholecystic papillary neoplasm of biliary and oncocytic type with low-grade dysplasia. [ABSTRACT FROM AUTHOR]

Hepatoblastoma has a PRETEXT staging depending on the degree of hepatic involvement; stage IV is an indication for transplantation. At the same time, it has sought to reduce the occurrence of posttransplant complications by not using a Kehr’s T tube during the choledocho‑choledochostomy, obtaining interesting results. A 16-month-old girl diagnosed with a PRETEXT IV hepatoblastoma, who received four courses of chemotherapy (CTX) with cisplatin plus doxorubicin, after she received a liver transplant and during surgery it was decided not to use a Kehr T-tube. She remained stable and had a favorable evolution, leaving on day 19 posttransplant. One month later, she received two cycles of adjuvant CTX with CAV scheme. Currently, she is free of disease. Even though the technique of choice is hepaticojejunostomy, it was decided to perform a choledocho‑choledochostomy without a Kehr’s T tube, without the development of complications. Results in the literature show that the use of this technique prevents the appearance of complications in up to half of the cases, compared to when the tube is used. [ABSTRACT FROM AUTHOR]

Background. There are few studies comparing recurrences between endoscopic retrograde cholangiopancreatography (ERCP) and open choledochotomy (OCT). Aims. To compare the effect of different surgical methods on single and multiple recurrences of choledocholithiasis. Methods. A total of 1255 patients with choledocholithiasis who underwent ERCP or OCT were retrospectively studied. The recurrence of choledocholithiasis was calculated by the Kaplan–Meier method with the log-rank test. Multivariate analyses of recurrent choledocholithiasis were performed by introducing variables with P < 0.20 in univariate analysis into the logistic regression model. Results. A total of 204 (16.7%, 204/1225) patients relapsed. Among the 204 patients, 74.5% relapsed within three years after surgery, of whom 39.7% (81/204) had multiple relapses (≥ 2). The recurrence rate of ERCP (17.2%, 119/692) was higher than that of OCT (15.1%, 85/563), but the difference was not statistically significant. The independent risk factors for a single recurrence of choledocholithiasis were diabetes, stone number ≥ 2 , maximum stone diameter ≥ 15 mm , sedentary occupation, the approach of ERCP (EST or EPBD), periampullary diverticulum, primary suture, high-fat diet (postoperative), frequency of weekly vegetable intake (< 4, postoperative), and drinking (postoperative). However, the ERCP approach (EST or EPBD), OCT approach (LCBDE), primary suture, high-fat diet (postoperative), and frequency of weekly vegetable intake (< 4, postoperative) were independent risk factors for multiple recurrences of choledocholithiasis. Conclusion. Patients with choledocholithiasis should be followed up regularly for one to three years after treatment. Stone number ≥ 2, diabetes mellitus, periampullary diverticulum, surgical methods, and lifestyle are all risk factors for the recurrence of choledocholithiasis. ERCP is still the preferred surgical method based on the advantages of low risk of cholangitis recurrence, less hospital stay, minimally invasive surgery, fewer postoperative complications, and easier acceptance by elderly patients. In addition to optimizing the treatment plans, postoperative lifestyle management is also vital. [ABSTRACT FROM AUTHOR]

Simple Summary: Biliary tract cancer (BTC) is a highly aggressive malignancy with a poor prognosis; currently, limited biomarkers are available for early diagnosis and effective disease management. Therefore, it is essential to investigate reliable biomarkers for BTC patients. Peptidylarginine deiminase type 2 (PADI2) is a vital factor for post-translational modification (PTM) that catalyzes arginine to citrulline. It is crucial in several pathophysiological processes, such as autoimmune diseases and cancers. We evaluated the clinical significance of PADI2 expression in pathological stage I–III BTC patients. We observed that patients with high PADI2 protein expression are associated with poorer survival, including progress-free survival (PFS), disease-specific survival (DSS), and overall survival (OS). Our study highlighted, for the first time, a significant correlation between the PADI2 higher expression levels and unfavorable prognosis in BTC, which can be used to predict patients' survival outcomes. (1) Background: PADI2 is a post-translational modification (PTM) enzyme that catalyzes citrullination, which then triggers autoimmune disease and cancer. This study aimed to evaluate the prognostic value of peptidylarginine deiminase 2 (PADI2) protein expression in biliary tract cancer (BTC) patients. (2) Methods: Using immunohistochemistry, the PADI2 protein expression in BTC tissues was analyzed. The correlations between PADI2 protein expression and clinicopathologic characteristics were analyzed using Chi-square tests. The Kaplan–Meier procedure was used for comparing survival distributions. We used Cox proportional hazards regression for univariate and multivariate analyses. From 2014 to 2020, 30 resected BTC patients were enrolled in this study. (3) Results: Patients with high PADI2 protein expression were associated with shorter progress-free survival (PFS; p = 0.041), disease-specific survival (DSS; p = 0.025), and overall survival (OS; p = 0.017) than patients with low PADI2 protein expression. (4) Conclusions: The results indicated that PADI2 protein expression was an independent poor prognostic factor for BTC patients regarding PFS, DSS, and OS. [ABSTRACT FROM AUTHOR]

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An intraductal papillary mucinous neoplasm of the biliary tract (BT-IPMN) in the caudate lobe of the liver is a rare tumor originating from the bile duct. Approximately 40% of the intraductal papillary neoplasms of the biliary tract (IPNB) secrete mucus and can grow in the intrahepatic or extrahepatic bile ducts. A 65-year-old woman presented with recurrent episodes of right upper pain. She developed her first episode 8 years ago, which resolved spontaneously. The frequency of symptoms has increased in the last 2 years. She underwent laparoscopic hepatectomy and choledochal exploration and was pathologically diagnosed with a rare BT-IPMN of the caudate lobe after admission. Here, we review studies on IPNB cases and systematically describe the pathological type, diagnosis, and treatment of IPNB to provide a valuable reference for hepatobiliary surgeons in the diagnosis and treatment of this disease. [ABSTRACT FROM AUTHOR]

Background: Severe pruritus caused by progressive familial intrahepatic cholestasis (PFIC) and Alagille syndrome (AGS) is refractory to medical treatment. Surgical interruption of the enterohepatic circulation is considered the mainstay of alleviating distressing symptoms and delaying cirrhosis. Aim and Objectives: This study aims to evaluate the short-term effect of partial external biliary diversion (PEBD) on pruritus, liver disease progression, patient's growth, and quality of life. Material and Methods: This prospective cohort study enrolled children with PFIC and AGS from July 2019 to July 2021, whose guardians consented to the PEBD procedure. A standard surgical approach was performed by a single surgeon. Outcomes were measured subjectively and objectively pre- and post-procedure using the pruritus 5-D itching score, Paediatric Quality of Life Inventory scale (PedsQL), growth parameters, bile acids level, and liver function tests. Patients' follow-up period ranged from 6 to 12 months. Results: Seven patients had PEBD procedure; five with PFIC and two with AGS. A significant improvement was detected in the 5-D itching score (p-value < 0.001), PedsQL (p-value < 0.001), and bile acids level (p-value 0.013). The preexisting growth failure was ameliorated. The downward trend in the bilirubin level was not significant. No influential difference in the other liver function tests occurred. No intra-operative complications encountered. Only one case had a post-operative stoma prolapse which was managed surgically. Conclusion: PEBD procedure could be considered as an effective and safe treatment options for intractable pruritus in patients with PFIC or AGS, providing preserved synthetic liver functions. [ABSTRACT FROM AUTHOR]

Biliary fistula and bile leak are known complications following hepatobiliary surgery, trauma, and percutaneous biliary interventions. In the case of an isolated biliary system with a prolonged indwelling percutaneous transhepatic biliary drainage (PTBD) catheter, a biliary-cutaneous fistula (BCF) may develop after catheter blockage or its accidental slippage. Due to the absence of internal drainage, secreted bile flows through the matured PTBD tract to form a fistula. If left untreated, chronic BCF will result in malabsorption, infection, and delayed wound healing. Here, we report a case of left-sided BCF following prolonged PTBD for Bismuth type II cholangiocarcinoma (metastatic disease), which was initially managed by bile duct ablation using N-butyl cyanoacrylate. The patient further needed fistulous tract embolization to obliterate the BCF. [ABSTRACT FROM AUTHOR]

Aim: Nurse‐led transitional care programmes (TCPs) have been shown to facilitate patient recovery in several illness settings, but its role among patients discharged with T‐tubes remains uncertain. The aim of the study was to investigate the effects of a nurse‐led TCP among patients discharged with T‐tubes. Design: This retrospective cohort study was conducted at a tertiary medical centre. Methods: From January 2018 to December 2020, a total of 706 patients discharged with T‐tubes after biliary surgery were included in the study. Patients were divided into a TCP group (n = 255) and a control group (n = 451) based on whether they participated in a TCP. The baseline characteristics, discharge readiness, self‐care ability, transitional care quality and quality of life (QoL) were compared between the groups. Results: Self‐care ability and transitional care quality were significantly higher in the TCP group. Patients in the TCP group also exhibited improved QoL and satisfaction. The results suggest that the incorporation of a nurse‐led TCP among patients discharged with T‐tubes after biliary surgery is feasible and effective. No Patient or Public Contribution. [ABSTRACT FROM AUTHOR]

Bardet–Biedl syndrome is an autosomal-recessive ciliopathic disorder affecting multiple organ systems. Characteristic features include progressive retinal dystrophy, obesity, polydactyly hypogonadism, mental retardation, and renal disorders. Other manifestations include congenital heart diseases, hepatic fibrosis, ataxia, and diabetes. Approximately 30% of patients with Biedl–Bardet syndrome (BBS) have hepatobiliary disorders such as periportal fibrosis, nonalcoholic fatty liver disease, and cystic dilation of the bile ducts. The association of BBS with choledochal cysts (CDC) is extremely rare. Here, we report a case of a 14-year-old boy with a novel variant of BBS and associated type IV CDC. The patient was managed surgically with CDC excision and Roux-en-Y hepaticojejunostomy. [ABSTRACT FROM AUTHOR]

Objective: Cholangiocarcinomas (CC) are rare tumors that develop from the biliary tract and surgery is the gold standard for them. All efforts have been made by surgeons from past to present to obtain R0 resection. The aim of the study was to examine the surgical therapy of CCs, which we have applied various surgical treatments in our clinic in the last three years. Methods: Patients whose pathological examination yielded Hiler CC and underwent surgical operation at our clinic between February 2019 and February 2022 were retrospectively evaluated. Results: Twenty five patients were found suitable for the study. Nine were male and 16 were female, with a mean age of 61.72±11.12 (minimummaximum: 29-76) years. The overall morbidity rate in the postoperative period was 52%, and liver failure in the postoperative period was seen in 4 patients. Bile leakage developed in 2 patients. Portal vein thrombosis was detected in 2 patients and surgical site infection was detected in 5 patients. No mortality was seen in the intraoperative and postoperative periods. In the follow-up period, recurrence was observed in 3 patients and mortality was observed in 3 patients. Conclusion: Advanced surgical techniques have induced extended indications in surgery and reduced mortality and morbidity ratios, and oncologic outcomes were more acceptable than before. The most significant purpose is to perform R0 resection to maintain adequate remnant liver volume. Such complex surgeries require multidisciplinary treatment in specialized hepatopancreaticobiliary and liver transplant services to optimize surgical and oncological outcomes. [ABSTRACT FROM AUTHOR]

Introduction. Bile duct ligation (BDL) and subsequent cholestasis are associated with oxidative stress and liver injury and fibrosis. Hesperidin (3,5,7-trihydroxyflavanone 7-rhamnoglucoside) is a flavanone glycoside abundant in citrus fruits. It has positive effects on diabetic retinopathy, reduced platelet aggregation, and blood flow alterations and has the potential to reduce liver injury in oxidative stress. The aim of this study was to evaluate the hepatoprotective effects of hesperidin on BDL-induced liver injury in rats. Methods. A total of 48 adult male Wistar rats were equally allocated to six eight-rat groups, namely, a healthy group, a sham group, a BDL+Vehicle group (BDL plus treatment with distilled water), a BDL+VitC group (BDL plus treatment with vitamin C 4.25 μg/kg), a BDL+Hesp100 group (BDL plus treatment with hesperidin 100 mg/kg/day), and a BDL+Hesp200 group (BDL plus treatment with hesperidin 200 mg/kg/day). Treatments were orally provided for 21 consecutive days. Finally, rats were sacrificed through heart blood sampling. Blood samples were centrifuged, and liver function, oxidative stress, and antioxidant parameters were assessed. Liver tissue was also assessed for oxidative stress, antioxidant, and histological parameters. The expression of inflammatory genes, namely, TGFβ1, iNOS, Caspase-3, and α-SMA, was measured through polymerase chain reaction. Findings. Hesperidin supplementation was associated with significant decrease in the levels of liver enzymes, bilirubin, nitric oxide, malondialdehyde, protein carbonyl, and inflammatory gene expression; significant increase in the levels of total antioxidant capacity, glutathione, and superoxide dismutase and catalase enzyme activity; and significant improvement in the histological morphology and structure of the liver parenchyma. Conclusion. Hesperidin has significant positive effects on liver morphology and structure, inflammation, fibrosis, and oxidative stress in rats with BDL-induced cholestatic liver injury. [ABSTRACT FROM AUTHOR]

BACKGROUND: Near-infrared fluorescence imaging using intravenous indocyanine green (ICG) facilitates intraoperative identification of biliary anatomy. We hypothesize that a much lower dose of ICG than the standard decreases hepatic and background fluorescence and improves bile duct visualization. STUDY DESIGN: In this multicenter randomized controlled trial, 55 adult patients undergoing laparoscopic cholecystectomy were randomized to low-dose (0.05 mg) or standard-dose (2.5 mg) ICG preoperatively on the day of surgery. A quantitative assessment was performed on recorded videos from the operation using ImageJ software to quantify the fluorescence intensity of the bile duct, liver, and surrounding/background fat. Operating surgeons blinded to ICG dose provided a qualitative assessment of various aspects of the visualization of the extrahepatic biliary tree comparing near-infrared fluorescence to standard visible light imaging using a scale of 1 to 5 (1, unsatisfactory; 5, excellent). Quantitative and qualitative scores were compared between the groups to determine any significant differences between the doses. RESULTS: The bile duct--to--liver and bile duct--to--background fat fluorescence intensity ratios were significantly higher for the low-dose group compared with the standard-dose group (3.6 vs 0.68, p < 0.0001; and 7.5 vs 3.3, p < 0.0001, respectively). Low-dose ICG had a slightly higher (ie better) mean score on the qualitative assessment compared to the standard dose, although the differences were not statistically significant. CONCLUSIONS: Low-dose ICG leads to quantitative improvement of biliary visualization using near-infrared fluorescence imaging by minimizing liver fluorescence; this further facilitates routine use during hepatobiliary operations. [ABSTRACT FROM AUTHOR]

Simple Summary: There is a paucity of evidence assessing the impact of bile duct stenting at the time of EUS-guided tissue sampling, either using fine-needle biopsy (EUS-FNB) or fine-needle aspiration (EUS-FNA) in patients with head of pancreas (HOP) masses. Our main aim was to assess the diagnostic accuracy of endoscopic ultrasound-guided tissue acquisition (EUS-TA) in patients with or without concurrent bile duct stents. Pooled accuracy was not statistically different between both patient subsets. However, we found that, compared to plastic stents, patients with biliary metal stents had a significantly lower yield of EUS-TA for pancreatic head lesions. There is a paucity of evidence regarding whether biliary stents influence endoscopic ultrasound-guided tissue acquisition using either fine-needle biopsy (EUS-FNB) or fine-needle aspiration (EUS-FNA), among patients with head of pancreas (HOP) lesions. We aimed at assessing the diagnostic accuracy of endoscopic ultrasound-guided tissue sampling in patients with or without bile duct stents. A total of seven studies with 2458 patients were included. The main aim was to assess overall pooled diagnostic accuracy. A pairwise meta-analysis was performed using a random effects model. Outcomes were expressed as odds ratios (ORs) with 95% confidence intervals (CIs). We found that pooled accuracy was 85.4% (CI 78.8–91.9) and 88.1% (CI 83.3–92.9) in patients with and without stents, respectively. There was no statistically significant difference between the two (OR 0.74; p = 0.07). Furthermore, patients with metal stents demonstrated a significant difference (OR 0.54, 0.17–0.97; p = 0.05), which was not seen with plastic stents. EUS-FNB showed poorer diagnostic accuracy with concurrent biliary stenting (OR 0.64, 0.43–0.95; p = 0.03); however, the same was not observed with EUS-FNA. Compared to plastic stents, metal biliary stenting further impacted the diagnostic accuracy of EUS-guided tissue acquisition for pancreatic head lesions. There was no difference in the rate of procedure-related adverse events between the stent and no-stent groups. [ABSTRACT FROM AUTHOR]

Hepaticojejunostomy is an essential component of many surgical procedures, including pancreaticoduodenectomy. Biliary leaks after HJS represent a major complication leading to relevant clinical problems: the postoperative mortality rate could reach 70% for surgical re-intervention, whereas endoscopic management is technically difficult due to the postoperative anatomy. Interventional Radiology plays a pivotal role for these patients. The case of a percutaneous biliary rendez-vous procedure performed to treat an HJA dehiscence after duodeno-cephalo-pancreasectomy is presented, which is successfully guaranteed to avoid a new surgical approach. [ABSTRACT FROM AUTHOR]

Patients with common bile duct stones (CBDS) are susceptible to recurrence after complete stone removal with endoscopic retrograde cholangiopancreatography (ERCP). Our study aims to analyze the potential risk factors for the recurrence of choledocholithiasis after endoscopic treatment. From January 2016 to January 2018, a total of 315 eligible patients who underwent ERCP at Nantong First People's Hospital were evaluated and followed up. The clinical data recorded in this study included general characteristics, medical history, ERCP-related factors, CBDS-related factors, and laboratory/imaging indicators. The patients were divided into a recurrence group and a nonrecurrence group, and then, logistic regression analysis and Kaplan–Meier analysis were used to identify the risk factors for stone recurrence after ERCP. CBDS recurred after ERCP in 48 patients (15.24%). The data from the recurrence group and nonrecurrence group showed significant differences in age, common bile duct diameter (≥ 15 mm), number of stones (≥ 2), periampullary diverticulum (PAD), history of biliary surgery, bile duct stenosis, and duodenal papillary stenosis (p < 0.05). Patients with the following risk factors were found to be more susceptible to recurrence after ERCP treatment: wider common bile duct, multiple stones, PAD, biliary surgery history, bile duct stricture, and duodenal papilla stenosis. [ABSTRACT FROM AUTHOR]

Percutaneous transhepatic cholangiodrainage (PTCD) and percutaneous transhepatic biliary stenting (PTBS) may be used as a palliative treatment for inoperable patients with malignant biliary obstruction (MBO) to improve the prognosis and their quality of life. However, acute pancreatitis is a common and severe complication that cannot be ignored after PTCD and PTBS in patients with MBO. A few cases may develop severe pancreatitis with a higher mortality rate. In this study, we summarize the known risk factors for acute pancreatitis after percutaneous biliary interventional procedures and investigate possible risk factors to reduce its occurrence by early identifying high-risk patients and taking appropriate measures. [ABSTRACT FROM AUTHOR]

Background and aim: Severe cholangitis secondary to biliary obstruction carries high mortality unless biliary drainage is performed urgently. Owing to various patient-related and logistical issues, bedside biliary drainage is considered a salvage therapeutic option. This study aims to evaluate the safety and efficacy of ultrasonography (USG)-guided biliary drainage at the bedside in patients with severe cholangitis admitted to the intensive care unit (ICU). Materials and methods: A total of 20 patients of severe cholangitis admitted to ICU who underwent bedside percutaneous transhepatic biliary drainage (PTBD) under USG guidance were retrospectively evaluated. Clinical outcomes, details about the PTBD procedure, and complications were recorded and analyzed. Results: Among 20 patients, 13 were male and 7 were female with a mean age of 50.5 years. A most common cause of biliary obstruction was gall bladder malignancy (45%, n = 9) followed by cholangiocarcinoma (25%, n = 5). Left- and right-sided PTBD was performed in 40% (n = 8) and 35% (n = 7) patients, respectively, while 25% (n = 5) of patients underwent bilateral PTBD. The technical success rate was 100%. A total of 65% (n = 13) of patients were discharged from ICU upon improvement while the remaining 35% (n = 7) died despite bedside PTBD. None of the patients had any major procedure-related complications. Conclusions: Ultrasound-guided bedside PTBD seems to be a safe and effective option in critically ill patients with severe cholangitis when shifting of patients is not feasible. [ABSTRACT FROM AUTHOR]

Drug-induced hemolytic anemia (DIHA) is a rare complication of drug therapy and usually underdiagnosed. Cefoperazone/sulbactam is a compound prepared from the third generation of cephalosporin and β-lactamase inhibitor. There are limited data of DIHA induced from cefoperazone/sulbactam. A 93-year-old female patient, who had an operation on the biliary tract 3 months ago, was admitted to our hospital with an abdominal infection. After cefoperazone/sulbactam was given as anti-infection treatment, the patient developed hemolytic anemia on the third day. Cefoperazone/sulbactam was discontinued and replaced with meropenem. Subsequently the level of red blood cells, hemoglobin, and hematocrit returned to normal. Clinicians should pay attention to monitoring the possible adverse reactions during the use of cefoperazone/sulbactam and should be aware of the occurrence of DIHA, so as to give timely treatment. [ABSTRACT FROM AUTHOR]

Introduction: In hepatobiliary surgery, intra-operative indocyanine green (ICG) fluorescence imaging use started in the late 2000s with Japanese surgical teams and is now gaining popularity among surgeons all over the world to improve accuracy and safety of surgical procedures. However, even if ICG fluorescence has been shown to be a safe imaging modality, only a few clinical efficacity studies have been performed and no guidance has been established. This narrative review aims at assessing the potential applications of ICG fluorescence imaging in hepatobiliary surgery. Methods: We screened the available international literature to identify the most used applications of ICG fluorescence imaging in hepatobiliary surgery. Results: Three main fields were identified: biliary duct visualization, hepatic segments' delimitation, and liver tumor detection. Comments, application protocols, prospects, and limitations of each technique were described. Discussion: These results could guide hepatobiliary surgeons in their use of ICG fluorescence imaging; nevertheless, further prospective studies are needed to assess the sensitivity and specificity of this modality. [ABSTRACT FROM AUTHOR]

Background: Progressive Familial Intrahepatic cholestasis type I (PFIC1) is a rare congenital hepatopathy causing cholestasis with progressive liver disease. Surgical interruption of the enterohepatic circulation, e.g., surgical biliary diversion (SBD) can slow down development of liver cirrhosis. Eventually, end stage liver disease necessitates liver transplantation (LT). PFIC1 patients might develop diarrhea, graft steatosis and inflammation after LT. SBD after LT was shown to be effective in the alleviation of liver steatosis and graft injury. Case report: Three PFIC1 patients received LT at the ages of two, two and a half and five years. Shortly after LT diarrhea and graft steatosis was recognized, SBD to the terminal ileum was opted to prevent risk for ascending cholangitis. After SBD, inflammation and steatosis was found to be reduced to resolved, as seen by liver biochemistry and ultrasounds. Diarrhea was reported unchanged. Conclusion: We present three PFIC1 cases for whom SBD to the terminal ileum successfully helped to resolve graft inflammation and steatosis. [ABSTRACT FROM AUTHOR]

Finding intraoperatively an advanced perihilar bile duct tumor involving both hepatic ducts is a difficult situation for a surgeon to perform biliary drainage. We propose a simplified biliary drainage technique by a combined intraoperative biliary stent with choledochoduodenostomy and report the long-term outcomes of four patients who underwent biliary drainage using this technique. This technique is less technically demanding and provides an acceptable patency rate. Choledochoduodenostomy anastomosis also allows the surgeon to reassess and perform additional interventions of the biliary tract. [ABSTRACT FROM AUTHOR]

Background: Type III choledochal cysts (CCs) are the rarest and least well-characterized of the five variants of biliary cysts. Only a few relevant studies have been conducted and a gold standard treatment for type III CCs is still lacking because of their scarcity. An unusual case of type III CC with choledochocele at the end of the distal common bile duct (CBD) with no bulging of the duodenum is presented here.Case Presentation: A 61-year-old woman presented to our department with repeated upper abdominal pain for one year. Laboratory examination revealed abnormal liver function and a slight increase in the white blood cell (WBC) count and proportion of neutrophils. In an MRCP of the patient, the distal CBD was found to have a cystic structure indicative of a type III CC. Endoscopic retrograde cholangiopancreatograpy (ERCP) revealed cystic findings compatible with Todani type III CCs. However, duodenoscopy did not show a bulge in the duodenum so laparoscopic cholecystectomy and Roux-en-Y hepaticojejunostomy were performed. In her 6-month follow-up, the patient reported that recovery from the operation was uneventful.Conclusions: ERCP has become the gold standard for diagnosing type III CCs. Type III CCs can be treated minimally invasively with laparoscopic cholecystectomy and Roux-en-Y hepaticojejunostomy. [ABSTRACT FROM AUTHOR]

Simple Summary: With the widespread use of EUS-guided procedures, several methods are available in order to achieve biliary drainage when endoscopic retrograde cholangiopancreatography (ERCP) fails. Together with the well established role of percutaneous trans-hepatic biliary drainage (PTBD) and surgical hepaticojejunostomy, EUS-choledochoduodenostomy (EUS-CD) and EUS-hepaticogastrostomy (EUS-HG) have provided good results to date, representing valuable alternatives. However, no definite indications have been provided about which should be the best way of drainage. In this network meta-analysis, we compared all these techniques, showing how, considering the available studies, none of these methods seems to be superior to another, although PTBD seems to have a slightly higher rate of adverse events. So, when dealing with patients affected by distal malignant biliary obstruction (DMBO) and when ERCP fails, all these methods seem to be equally effective, although possibly EUS-guided approaches could be less invasive and affected by fewer adverse events. There is scarce evidence on the comparison between different methods for the drainage of distal malignant biliary obstruction (DMBO) after endoscopic retrograde cholangiopancreatography (ERCP) failure. Therefore, we performed a network meta-analysis to compare the outcomes of these techniques. We searched main databases through September 2021 and identified five randomized controlled trials. The primary outcome was clinical success. The secondary outcomes were technical success, overall and serious adverse event rate. Percutaneous trans-hepatic biliary drainage was found to be inferior to other interventions (PTBD: RR 1.01, 0.88–1.17 with EUS-choledochoduodenostomy (EUS-CD); RR 1.03, 0.86–1.22 with EUS-hepaticogastrostomy (EUS-HG); RR 1.42, 0.90–2.24 with surgical hepaticojejunostomy). The comparison between EUS-HG and EUS-CD was not significant (RR 1.01, 0.87–1.17). Surgery was not superior to other interventions (RR 1.40, 0.91–2.13 with EUS-CD and RR 1.38, 0.88–2.16 with EUS-HG). No difference in any of the comparisons concerning adverse event rate was detected, although PTBD showed a slightly poorer performance on ranking analysis (SUCRA score 0.13). In conclusion, all interventions seem to be effective for the drainage of DMBO, although PTBD showed a trend towards higher rates of adverse events. [ABSTRACT FROM AUTHOR]

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is the first line treatment for choledocholithiasis. In many occasions, several attempts of ERCP are performed until failure is declared and surgical treatment is applied, in many times following procedure-related complications. We present the results of surgical management of patients with choledocholithiasis following repeated failures of ERCP due to impaction of multiple large stones.Methods: Patients that underwent surgical treatment for choledocholithiasis following repeated ERCP attempts between January 2006 and December 2018 were retrospectively assessed. Post-ERCP complications were evaluated and the surgical approach, technique, and outcomes were assessed.Results: One hundred and two patients were operated on for choledocholithiasis following repeated failed ERCP. All the patients had at least 2 failed attempts (mean = 3.2 ± 1.7), and 25 (23.5%) suffered major ERCP-related complications. Following choledochotomy and stone extraction, bilioenteric anastomosis was done in the vast majority of patients (90.2%), most commonly choledochoduodenostomy (62%). Thirty-eight (37%) patients had minimally invasive procedure (laparoscopic n = 26, robotic assisted n = 12). Major post-operative complications (Clavien-Dindo ≥ 3) occurred in 24 patients (23.5%). Nine patients (8.8%) were re-operated and 10 (9.8%) were readmitted within 30 days from surgery. Three patients died within 30 days from surgery. Older patients had significantly more ERCP attempts and suffered higher post-operative mortality. During a median follow-up of 70 months, the only biliary complication was an anastomotic stricture in one patient.Conclusion: Surgery for CBDS after failure of ERCP is safe and provides a highly effective long-term solution. [ABSTRACT FROM AUTHOR]

To evaluate the efficacy of stent-in-stent (SIS) and side-by-side (SBS) bilateral stenting for treating malignant hilar biliary obstruction (MHBO). Relevant studies in Pubmed, Embase, and Cochrane Library were identified through June 2020. This meta-analysis was conducted using RevMan v5.3, using relevant endpoint data relating to clinical and technical success, complications, stent dysfunction, and overall survival (OS) rates extracted from these studies. We identified six relevant studies which included 315 MHBO patients treated with either SBS (n = 161) or SIS bilateral (n = 154) stenting. We saw no significant difference between these two groups with respect to clinical success (OR: 1.07; 95% CI: 0.46, 2.49, p =.87), complication (HR: 0.12; 95% CI: −0.04, 0.27, p =.15), stent dysfunction (OR: 0.68; 95% CI: 0.42, 1.10, p =.11), or OS (HR: 0.97; 95% CI: 0.82, 1.16, p =.74). However, the SBS group exhibited significantly lower technical success rates (OR: 6.55; 95% CI: 1.10, 38.83, p =.04). Significant heterogeneity was only detected for the endpoint of complication rates (I2 = 60%). These results suggest that SIS bilateral stenting yields better rates of technical success than does SBS bilateral stenting in MHBO patients. [ABSTRACT FROM AUTHOR]

Background: The aim of the current study was to evaluate the efficacy of one- and two-stage single-incision laparoscopic hepaticojejunostomy (SILH) for perforated CDCs with good medical conditions.Methods: Between June 2015 and December 2020, 57 patients were reviewed: Group 1: patients who underwent one-stage SILH (n = 16); Group 2: patients who underwent two-stage SILH (n = 41). The demographic characteristics, operational details, postoperative outcomes and postoperative complications were evaluated.Results: The mean follow-up durations of group 1 and 2 were 39.3 and 38.6 months, respectively. One patient (6.3%) in group 1, and 4 patients (9.8%) in group 2 were converted to laparotomy (p = 0.67). No statistical significance was found in operative time, blood transfusion, time to resume full diet, duration of drainage after definitive surgery and postoperative hospital stays between the two groups. Four patients in group 2 developed bile leakage, which was higher than that in group 1 (9.8% vs 0, p = 0.20). None suffered incidental injury, bleeding, anastomotic stenosis, cholangitis, cholelithiasis, pancreatic leakage, pancreatitis, Roux-loop obstruction, adhesive intestinal obstruction or wound infection. Liver function normalized within 1 year postoperatively in both groups.Conclusions: In experienced hands, one-stage single-incision laparoscopic hepaticojejunostomy is safe and effective for patients with complete perforations and good medical conditions. [ABSTRACT FROM AUTHOR]

The article presents a case study of a successful management of biliary atresia in an 834 gram preterm infant, emphasizing the challenges in early diagnosis and the importance of timely surgical intervention, specifically Kasai portoenterostomy (KPE). Topics discussed include the rarity of biliary atresia in preterm infants, the diagnostic dilemma in extremely-low-birthweight infants, and the significance of early KPE in improving outcomes and native liver survival.

Endoscopic ultrasound (EUS)-guided biliary drainage is a therapeutic alternative method in patients with cholestasis where the ampulla of Vater cannot be reached because several reasons. An unfortunate complication during EUS-guided biliary drainage was presented in this report. A 53-year-old male patient presented with jaundice and pruritus. He had a history of total gastrectomy due to gastric cancer. An abdominal tomography scan detected a tumoral mass in the common bile duct due to the recurrence of gastric cancer. We decided to perform EUS-guided hepaticojejunostomy because biliary drainage cannot be obtained by conventional methods and percutaneous drainage impairs patient comfort. A double pigtail plastic stent was placed from the jejunum into the segment-3 bile duct towards the hilus. After that echoduodenoscope was removed to the outside gently. We noticed that the stent was stuck in the echoduedonoscope elevator. We reached into the bile duct again and placed a doublepigtail plastic stent successfully. [ABSTRACT FROM AUTHOR]

This document is a summary of the French intergroup guidelines of the management of biliary tract cancers (BTC) (intrahepatic, perihilar and distal cholangiocarcinomas, and gallbladder carcinomas) published in September 2023, available on the website of the French Society of Gastroenterology (SNFGE) (www.tncd.org). This collaborative work was conducted under the auspices of French medical and surgical societies involved in the management of BTC. Recommendations were graded in three categories (A, B and C) according to the level of scientific evidence until August 2023. BTC diagnosis and staging is mainly based on enhanced computed tomography, magnetic resonance imaging and (endoscopic) ultrasound-guided biopsy. Treatment strategy depends on BTC subtype and disease stage. Surgery followed by adjuvant capecitabine is recommended for localised disease. No neoadjuvant treatment is validated to date. Cisplatin-gemcitabine chemotherapy combined to the anti-PD-L1 inhibitor durvalumab is the first-line standard of care for advanced disease. Early systematic tumour molecular profiling is recommended to screen for actionable alterations (IDH1 mutations, FGFR2 rearrangements, HER2 amplification, BRAF V600E mutation, MSI/dMMR status, etc.) and guide subsequent lines of treatment. In the absence of actionable alterations, FOLFOX chemotherapy is the only second-line standard-of-care. No third-line chemotherapy standard is validated to date. These guidelines are intended to provide a personalised therapeutic strategy for daily clinical practice. Each individual BTC case should be discussed by a multidisciplinary team. • Surgical management of BTC depends on subtype. • CISGEM plus anti-PD1/PDL1 inhibitor is the first-line standard-care in advanced BTC. • Tumor molecular profiling should be performed at the diagnosis of advanced BTC. • Molecular profiling should search for actionable alterations (IDH1, FGFR2, etc.). [ABSTRACT FROM AUTHOR]

3 Imaging findings before the procedure. a Computed tomography (CT) showing dilated intrahepatic bile duct, with multiple liver metastases and ascites due to pancreatic cancer. b CT showing occluded duodenal and distal bile duct stent. 2 Hepatic parenchymal metal stent placement with plastic stent in the bile duct prevented obstructive cholangitis and biliary peritonitis. However, when EUS-HGS is performed in patients with cholangitis and ascites, metal stent placement may cause peripheral obstructive cholangitis (Fig. [Extracted from the article]

Sump syndrome is a rare complication of a side to side choledochoduodenostomy (CDD). After the introduction of endoscopic retrograde cholangiopancreatography (ERCP) in 1968 Kozarek (Gastroenterol Hepatol (N Y) 13(10):620-622, 2017), choledochoduodenostomy and its complications are seldom seen. The diagnosis of sump syndrome is further befogged by the lack of characteristic clinical or laboratory findings, the inability of the patient to provide medical records of their CDD, and the fact that sump syndrome only presents decades after a CDD. In this article, we will present a case of a 39-year-old female patient who presented as a case of ascending cholangitis with an initially unknown past surgical history. A detailed medical history was thoroughly taken, and her previous medical reports were presented after which an ERCP was done with extraction of debris was preformed. In a time where choledochoduodenostomy is rarely being chosen as a choice of treatment and its complications are infrequently encountered, this case serves as a reminder that even in the ERCP era, complications of choledochoduodenostomy should still be well understood. [ABSTRACT FROM AUTHOR]

Common bile duct (CBD) stones are present in 5–15% of patients with gallstones. Some of these patients are candidates for a definitive biliary drainage procedure for prevention of stone recurrence. The aim of our study was to ascertain the outcome of laparoscopic choledochoduodenostomy in choledocholithiasis. After obtaining ethical clearance from the institutional ethical committee, the present prospective and observational study was conducted on 32 patients over a period from September 2017 to September 2020 in the tertiary care hospital. In our study, the total number of patients was 32, of whom 26 (81%) were females. The mean and range of age were 54.44 SD 10.827 and 24–70 years, respectively. The most common presenting feature was jaundice (53.125%). The mean CBD diameter was 24.59 SD 2.564 mm with multiple stones in CBD in 90.625% of our patients. The mean duration of surgery and intraoperative blood loss was 147.94 SD 9.732 and 76.25 SD 12.636 ml, respectively. The mean hospital stay was 6.34 SD 0.827 days with 90.6% of the patients returning to work in the 3rd week. In our study, there was no conversion to open and a single patient developed postoperative ileus which was managed conservatively. There was complete resolution of symptoms on follow-up. Laparoscopic choledochoduodenostomy is safe for benign bile duct diseases. It is physiological, with minimal intraoperative blood loss, less operative time, and fewer postoperative complications and is safe with faster recovery. [ABSTRACT FROM AUTHOR]

Robotic surgery is being increasingly used for complex benign and malignant hepato-pancreato-biliary (HPB) cases. As use of robotics increases, fellowships to excel in complex robotic procedures will be sought after. With this dedicated training, attending surgeon positions can be obtained that can incorporate and teach this skill set. Unfortunately, there are no evidence-based approaches for constructing a curriculum for an HPB robotic surgery fellowship. This paper describes a technique to develop a structured curriculum to ensure competence and fulfil the learning and practice needs for robotic HPB fellows. [ABSTRACT FROM AUTHOR]

Background: There is no consensus on the optimal drainage technique in the management of biliary anastomotic strictures occurring after right-lobe living-donor liver transplantation (RL LDLT). Aims: To investigate whether there is a superiority between unilateral and bilateral drainage groups in terms of efficacy and safety of biliary drainage in RL LDLT patients undergoing double-biliary reconstruction. Study Design: Retrospective Cohort Methods: Between January 2009 and August 2019, 1693 patients underwent RL LDLT. Of these, 182 patients who developed biliary anastomotic strictures out of the 306 patients who had double-biliary reconstruction, were included in the study. One hundred fifty-five patients with technical success were divided into 2 groups as unilateral (n=116) and bilateral (n=39) drainage groups. The groups were compared in terms of variable parameters such as clinical success, additional procedure, post-ERCP complication, procedures after clinical failure, hospital stay, mortality, and survival. Results: The clinical success was higher in the bilateral group (70% vs. 82%, P = .201). In the initial and the follow-up periods, a total of 44 (38%) patients in the unilateral group were switched to the bilateral drainage group due to the increased need for stenting. The placement of a stent successfully solved the problem only in 28% (32/117) of the patients in the unilateral group, while this rate was 44% (17/39) in the bilateral group. The median follow-up time of both groups was 42 months, and was equal. The number of stent-free follow-up patients in the unilateral drainage group was less than that in the bilateral drainage group (4 and 7, respectively). Conclusion: An active attempt should be made for bilateral drainage in patients with biliary anastomotic stricture following RL LDLT. However, for patients in whom bilateral drainage is not possible, unilateral drainage may be recommended, with the placement of a maximum number of stents following primary biliary balloon dilatation, depending on the degree of stricture. [ABSTRACT FROM AUTHOR]

This study reviews bile duct injuries (BDI) most commonly found in our setup and a novel technique of endobiliary stent usage for management in emergency situations leading to significantly less morbidity and mortality. A total of 211 patients were analyzed out of 214 BDI. All the data regarding demographic details, time of injury, time to referral, surgeons' perception of anatomy, anatomical variance, and the type of presentation were collected. We propose a new technique and management guideline in the current era of endoscopy and surgery together for the treatment of BDI and benign biliary stricture. We have observed that the mean age was 45.5 years. Out of 211 cases, 175 were after laparoscopic cholecystectomy. Exploration and external drainage of bile was done in initial 12 patients, out of which 3 patients had a combined endobiliary surgical internal stent and T tube. Later on, all patients (38) were internally drained with endobiliary stents. All patients of minor bile duct injury were managed with endoscopic retrograde cholangiography and papillotomy, and endobiliary plastic stenting. Overall, 76% of patients with biliary laceration and segmental injury (less than 1 cm) were managed with endoscopic stent techniques, without definitive surgery. Only 24% of the patient with minor or less than 1-cm laceration group of patients needed hepatico jejunostomy (HJ) along with all major-type bile duct injuries. We propose the use of an endobiliary plastic stents for internal drainage and repair of BDI in emergency and intraoperative situations in order to avoid long-term external drains as well as nutritional and electrolytes issues following high-output biliary fistula. Furthermore, it prevents the progression of biliary stricture. [ABSTRACT FROM AUTHOR]

Background: Endoscopic ultrasound (EUS)-guided biliary drainage is becoming an option for palliation of malignant biliary obstruction. Lumen-apposing metal stents (LAMS) are replacing self-expandable metal stents (SEMS). The aim of this meta-analysis was to evaluate the efficacy and safety of LAMS and SEMS for EUS-guided choledochoduodenostomy (EUS-CDS).Methods: A meta-analysis was performed using PRISMA protocols. Electronic databases were searched for studies on EUS-CDS. The primary outcome was clinical success. Secondary outcomes were technical success, reintervention, and adverse events. We used the random effects model with the DerSimonian-Laird estimation, and the results were depicted using forest plots. Subgroup analyses were also performed with data stratified by selected variable.Results: Overall, 31 studies (820 patients) were included. The pooled rates of clinical and technical success were 93.6 % (95 % confidence interval [CI] 88.6 %-96.5 %) and 94.8 % (95 %CI 90.2 %-97.3 %) for LAMS, and 91.7 % (95 %CI 88.1 %-94.2 %) and 92.7 % (95 %CI 89.9 %-94.9 %) for SEMS, respectively. The pooled rates of adverse events were 17.1 % (95 %CI 12.5 %-22.8 %) for LAMS and 18.3 % (95 %CI 14.3 %-23.0 %) for SEMS. The pooled rates of reintervention were 10.9 % (95 %CI 7.7 %-15.3 %) for LAMS and 13.9 % (95 %CI 9.6 %-19.7 %) for SEMS. Subgroup analyses confirmed these results.Conclusions: This meta-analysis showed that LAMS and SEMS are comparable in terms of efficacy for EUS-CDS. Clinical and technical success, post-procedure adverse events, and reintervention rates were similar between LAMS and SEMS use; however, adverse events require further investigation. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to evaluate the potential effects of biliary drainage before pancreaticoduodenectomy on postoperative outcomes. Methods: This study was conducted retrospectively on data from 820 cases of pancreaticoduodenectomy performed in the Gastrointestinal Surgery Department of Ankara City Hospital between April 1999 and August 2019. Twenty years of collected patient data were re-examined and 805 patients were divided into two groups as those who underwent preoperative biliary drainage (PBD) and those who did not (non-PBD). Demographic data of patients, and preoperative, operative and postoperative details, including morbidity, were collected and compared between the two groups. Results: There were 574 (71.3%) patients in the PBD group and 231 (28.6%) patients in the non-PBD group. Total complications according to Clavien-Dindo classification were significantly higher in the PBD group (P < 0.001). Intraabdominal hemorrhage, delayed gastric emptying and wound infection were found to be higher in the PBD group but the rate of pancreatic fistula was similar in both groups. There was no difference between the two groups in terms of complications according to preoperative bilirubin levels. In drained patients with normal bilirubin levels, wound infections were significantly higher in a group with diameter of common bile duct > 8 mm (P = 0.020). Conclusion: PBD is not associated with anastomotic leakage after pancreaticoduodenectomy. Wound infection, delayed gastric emptying and intraabdominal hemorrhage were significantly associated with PBD. Preoperative bilirubin level had no effect on these results. In subgroup analysis, in patients undergoing drainage, if bilirubin falls below 5 mg/dL, the risk of wound infection was still high in patients with bile duct diameter > 8 mm. [ABSTRACT FROM AUTHOR]